Chronic Lateral Epicondylalgia

I recently had the pleasure of attending a workshop given by Professor Bill Vicenzino of Queensland University.  As many of you will know Bill has been a prolific researcher and pioneer in the field of treating chronic lateral epicondylalgia using physiotherapy intervention.  Bill is a strong believer in results based intervention and discussed in great detail some of the persistent failings with traditional management regimes of chronic lateral epicondylalgia.

Current treatment options

May involve modalities such as;

Ultrasound

Interferrential

Laser

Deep transverse frictions

Acupuncture

Manipulation

Strengthening exercises

Epicondylar clasps

Corticosteroid

Surgery

Not surprisingly most of the modalities do not come out particularly favorably when subjected to rigorous critical review with the exception of indication’s that laser may be beneficial.

There was definitive and important research regarding the role of corticosteroids in chronic lateral epicondylalgia.  Suffice it to say in summary that the initial acute symptomatic relief frequently obtained with corticosteroid infiltration is associated with a relapse rate of up to 70% at six month review.

In essence, Professor Vicenzino highlighted the role of specific manual therapy interventions to continuously assess function on a test / re-test basis using a grip strength measure following the application of manual therapy techniques.  We have discussed in previous posts the relevance of using grip strength measure and there was particular emphasis on the use of pain free grip strength as opposed to maximal grip strength as a measure of treatment effectiveness.

The preferred manual therapy interventions involve the use of mobilisation with movement (MWM) as originally pioneered by Brian Mulligan.  Bill has developed a manual therapy intervention protocol based on a sequence of specific MWM techniques with the assessment of pre and post treatment pain free grip strength as the measure of effectiveness.

If you get a chance I strongly recommend attending one of these workshops to learn the specific handling techniques and the sequence for application, which he has developed.  Some of these techniques were described in a master class paper published in Manual Therapy in 2003.  We also covered soft tissue taping techniques to unload painful tissues for cases in which the condition was so irritable that manual therapy did not offer significant relief of symptoms.

Much of the conventional wisdom regarding the etiology and pathology of this notoriously resistant condition was challenged in discussion and certainly provided an ample volume of data from which to review our clinical practice.

Some interesting concepts regarding muscle imbalance between wrist extensors and long finger extensors was also presented with a tantalising observation that chronic lateral epicondylalgia sufferers display reduced wrist extension bilaterally on grip assessment.  I wonder if this will become part of a pre-employment/pre-participation screening profile?

We also covered specific exercise prescription as part of a corrective regime and reviewed the convincing data indicating that six to eight weeks of weekly, structured, supervised, progressive exercise is an essential component for effective outcomes.

The day concluded with a lively Q&A session and Bill fielding questions with great efficiency and refreshing Australian directness.  Some of this discussion veered into topics we have discussed before on this blog, regarding therapist creditability and the delivery of effective care.

Suffice to say it is essential that our interventions demonstrate measurable effect and are associated with a positive response (even if we don’t fully understand the response mechanism). The implication is that we therapists must wisely choose the selection of techniques on the basis of their most likely efficacy. In the real world we do not have the luxury of repeatedly trying different techniques in the hope of improving a patient’s well being.  They simply won’t hang around to allow us to run this type of experiment.

All in all a very worthwhile day, some excellent practical clinical information obtained.  Again I recommend you keep an eye out for Bill’s work and also for his forthcoming coming publication on mobilisation with movement, which is due out in the end of 2010, published by Elsevier.

Enjoy the clinical challenge.

David

GHTime Code(s): 7561f 

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