Unsupervised isometric exercise versus wait-and-see for LET

(Vuvan, Vicenzino, Mellor, Heales, & Coombes, 2019)

Aims: To investigate the effect of an 8-week unsupervised program of isometric exercise compared to a wait-and-see approach on pain, disability, global improvement, and pain-free grip strength in participants with unilateral LET.

Methods: RCT in Australia. Inclusion: 18-70 years old, unilateral LET >6 weeks, pain >2 on average, provoked by 2 of grip, palpation, stretch, resisted contraction, reduced pain free grip strength. Exclusion: other diagnosis, other MSK complaint > to LET, major neurologic inflammatory, systemic condition, treatment in preceding 3 months, major trauma, fracture, or surgery in the last year. All participants were provided written and verbal general advice regarding self-management and ergonomics. Ex group: additional information about 8 week daily progressive isometric exercise program standardized and tailored to max voluntary contraction of each subject. Recording of exercises on a diary with adherence and symptoms. Adherence measured by % of 56 sessions done. Blinding of assessor, computer randomization (stratified <5 or >6 pain at baseline). PRTEE, GROC, and pain-free grip strength (3 measures 30 sec rest, mean). 20 / group = enough power to detect change. Stat analysis. 533 responders, 40 included n=21 exercise n=19 wait-and-see. Follow-up 98%.

Results: The exercise group had better PRTEE scores at 8 weeks compared to the wait–and-see group (SMD -0.92, 95% CI -1.58 to -0.26, P = 0.006). No ≠ in GROC nor in pain-free grip strength. 90% completed greater than 71% of prescribed sessions. No participants reported a serious adverse event. Use of co-interventions was similar between groups

Limitations: Power enough for PRTEE unknown for GROC & PFGS. Only non-severe patients. Program <10min / day.

In practice: This protocol of self-management isometrics for LET has moderate effect on PRTEE when compared to wait and see, but not on GROC nor pain-free grip strength at 8 weeks.

Vuvan, V., Vicenzino, B., Mellor, R., Heales, L. J., & Coombes, B. K. (2019). Unsupervised Isometric Exercise versus Wait-and-See for Lateral Elbow Tendinopathy. Medicine and Science in Sports and Exercise, 52(2), 287–295. https://doi.org/10.1249/MSS.0000000000002128

Does effectiveness of exercise therapy and mobilization techniques offer guidance for treatment of L & M epicondylitis?

(Hoogvliet, Randsdorp, Dingemanse, Koes, & Huisstede, 2013)

Aims: To assess the evidence for effectiveness of exercise therapy and mobilisation techniques for both medial and lateral epicondylitis.

Methods: SR on 4 DB, 2 reviewers independently extracted data and assessed the methodological quality. English, German, French, Dutch language. Quality assessed according to a scale (Furlan). Heterogeneity made synthesis impossible, hence best evidence synthesis.

Results: Moderate evidence for a short-term effect of stretching plus strengthening exercises compared to ultrasound plus friction massage. Short-term and mid-term effect of manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilisation of the wrist and forearm in patients with LE. For all other interventions, only limited, conflicting or no evidence was found

Limitations: No meta-analysis, poor level of evidence (1 paper high, other moderate low).

In practice: We do not have strong evidence for treatment of epicondylitis. To our current knowledge the best available option is exercise therapy + stretching +/- manual therapy as adjunct.

Hoogvliet, P., Randsdorp, M. S., Dingemanse, R., Koes, B. W., & Huisstede, B. M. A. (2013). Does effectiveness of exercise therapy and mobilization techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. British Journal of Sports Medicine, 47(17), 1112–1119. https://doi.org/10.1136/bjsports-2012-091990

Management of lateral elbow tendinopathy

(Coombes, Bisset, & Vicenzino, 2015)

Aims: To collate evidence and expert opinion on the pathophysiology, clinical presentation, and differential diagnosis of LET. Factors that might provide prognostic value or direction for physical rehabilitation are canvassed. Clinical recommendations for physical rehabilitation are provided, including the prescription of exercise and adjunctive physical therapy and pharmacotherapy.

Methods: Not mentioned. Authors’ literature analysis

Results: Frequent pathology among 35- 54 years old people, 1-3% of general population, with increased risk if smokers, tennis player, or manual workers. Self-limiting pathology 83% to 90% of people without treatment improve, even though not fully recover after 1 year. 1/3 of patients may still experience symptoms after 1 year even with treatment. Large proportion of recurrence. 5% de not have benefits of conservative treatment and undergo surgery with variable outcomes.

Multimodal pathology (tendon continuum model + neuro-motor & nociceptive changes).

Examination: Symptom reproduction with loading of tendon (palpation, resisted contraction, stretching). Rule-out other causes. Check elbow, shoulder, neck, thoracic spine. PRTEE & Pain-free grip test & PSFS to measure function.

Imagery can rule out not diagnose. Lack of association between severity of imaging and symptoms. Prognostic factors: location on continuum tendon model, initial severity and functional impairment, central sensitization, associated with shoulder / neck pain, associated neuromuscular impairments, psychosocial / work factors. Treatments: oral NSAIDS in acute phase, injections not recommended (delay in recovery), antidepressant or antiepileptic drugs if central sensitization, PRP no evidence of effectiveness, prolotherapy and nitric oxide patches if associated with load may help if limited outcomes at 6 months. Manual therapy: short term benefits if adjunct to exercises. No data on type, intensity, frequency, or duration of exercise. Currently it is recommended to gradually increase load with focus on wrist extensors. Heterogeneity in presentations => tailored dosage according to severity, stages, and functional demand. Education to reassure, inform, and advice.

Low risk: Education, advice, self-medication = wait & see, + physio after 6-12 week if no improvement.

Moderate risk: 8 to 12 weeks of physiotherapy recommended.

High risk (PRTEE >54): Central sensitization: pain management then physio.

Imagery if not responding to physiotherapy, if not other diagnostic found then try patches or prolotherapy.

Limitations: Guidelines (not a study, methodology unknown)

Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 938–949. https://doi.org/10.2519/jospt.2015.5841

Should exercises be painful in the management of chronic MKS pain? A SR with MA

(Smith, Hendrick, O Smith, & Al., 2017)

Aims: To compare the effect of exercises where pain is allowed / encouraged compared with non-painful exercises on pain, function or disability in patients with chronic musculoskeletal pain within randomised controlled trials.

Method: Systematic review on exercises into pain vs non-pain exercises on pain, function or disability. 9 papers included, total of 385 participants with pain > 3 months (chronic).

Results: Small but significant difference favouring exercises into pain in the short-term, moderate quality evidence, small effect size (-0,27) on patient reported pain.

Appears to be no difference in patient reported pain on medium and long-term due to moderate to low quality evidence. The instructions regarding pain were different, not clear if that had an effect.

Limitations: None of the studies recorded levels of pain during exercise.
The framing of pain vs no pain can potentially affect the outcome, the effects are unclear.
Studies included different areas, LBP, shoulder pain, Achilles pain, plantar heel pain.

In practice: Affects advice / conversations with patients. Pain during exercises in chronic pain not harmful, does not prevent improvements.

Smith, B., Hendrick, P., O Smith, T., & Al., E. (2017). Should Exercises be painful in the management of chronic msk pain. BJSM, 1–10. https://doi.org/10.1136/bjsports-2016097383

Normal kinematics of the upper cervical spine during the Flexion-Rotation Test – In vivo measurements using magnetic resonance imaging

(Takasaki et al., 2011)

Aims: The purpose of this study was 1) to examine measurement reliability of segmental upper cervical movements using magnetic resonance imaging and 2) to investigate the content validity of the FRT

Methods: MRI study measurement on 19 healthy women.

Results: FRT is a valid and reliable (substantial reliability) measure of Upper Cervical Spine UCS Rotation (Better if taken 2 times than one). Normal range 45° each side. Positive test if <33°.

Limitations: Small sample, healthy, only women, young 22yo, 141m average height.

In Practice: FRT is a valid and reliable method to measure C1-C2 rotation.

Takasaki, H., Hall, T., Oshiro, S., Kaneko, S., Ikemoto, Y., & Jull, G. (2011). Normal kinematics of the upper cervical spine during the Flexion-Rotation Test – In vivo measurements using magnetic resonance imaging. Manual Therapy, 16(2), 167–171. https://doi.org/10.1016/j.math.2010.10.002

Induction of nocebo and placebo effects on itch and pain by verbal suggestions

(Van Laarhoven et al., 2011)

Aims: To study verbally induced nocebo and placebo effects on itch and pain.

Methods: 105 healthy female subjects were randomly assigned to one of 4 groups: (Itch nocebo n=36 vs Control n=20 or Pain nocebo n=33 vs Control n=16). In itch / pain nocebo groups patients were told a verbal suggestion stating that 95% of healthy people will experience Itch / pain and in control groups a neutral suggestion stating only 5% may experience Itch, 5% pain otherwise nothing. All groups tested for mechanical stimuli (Von Frey), electrical stimuli, ionophoresis of Histamine. Then all nocebo group undertook another ionophoresis stimuli. With either placebo suggestion of reduction of itch / pain or control with suggestion of same gel and that everyone feels itch or pain but not the other according to the group. All group rated pain and itch on VAS scales before and every 30 seconds during test, and after.

Results: Subjects who received verbal suggestions to induce high pain expectations reported significantly more pain than subjects who received verbal suggestions inducing low pain expectations. Subjects who received verbal suggestions inducing high itch expectations experienced significantly higher levels of itch evoked by the somatosensory stimuli than subjects who received verbal suggestions inducing low itch expectations. The nocebo effects induced by verbal suggestions appeared to be stronger for itch than for pain.

Itch levels decreased to a greater extent when suggestions of itch reduction were given than when suggestions of pain reduction were given, while the decrease in itch was not significantly different when it was suggested that itch would be reduced in comparison to neutral suggestions and same for pain.

Limitations: Only women, from one university of Netherlands, small sample. Part 2 habituation of histamine effect possible. Lab setting can be a cofounding factor. Lack control group with no expectations at all. Healthy subjects only. Small effect: MIDC not reached, low levels of itch / pain in general.

In practice: Itch and pain can be induced by only giving verbal suggestions. The perception of different ambiguous stimuli can be influenced by negative suggestions, in such a way that negative expectations can adversely influence the intensity of itch or pain experienced.

Van Laarhoven, A. I. M., Vogelaar, M. L., Wilder-Smith, O. H., Van Riel, P. L. C. M., Van De Kerkhof, P. C. M., Kraaimaat, F. W., & Evers, A. W. M. (2011). Induction of nocebo and placebo effects on itch and pain by verbal suggestions. Pain, 152(7), 1486–1494. https://doi.org/10.1016/j.pain.2011.01.043

Reliability, validity and diagnostic accuracy of palpation of the sciatic, tibial and common peroneal nerves in the exam of LB related leg pain.

(Walsh & Hall, 2009)

Aim: The aim of this study was to determine the reliability, validity and diagnostic accuracy of manual palpation of the sciatic, tibial and common peroneal nerves in the examination of low-back related leg pain.

Methods: 45 subjects. Palpation compared to SLR + Slump. Inclusion: presence of unilateral low-back related leg pain, 18 to 70yo, English speaking. Exclusion: signs of serious pathology, history of spinal surgery or neurological disease, unable to tolerate testing process.

Palpation at the sciatic nerve at the midway point of a line from ischial tuberosity to the greater trochanter of the femur; the tibial nerve where it bisects the popliteal fossa at the mid-point of the popliteal crease; and the common peroneal nerve where it passes behind the head of fibula to wind around the neck of fibula. Bilateral simultaneous palpation. Positive if pain or discomfort on one leg or more on one leg if bilaterally. Following palpation: PPT measured at same spots. 3 measures 10 s rest, asymptomatic leg then symptomatic, mean of 3 measures taken. Proximal to distal. 2nd blinded examiner did Slump and SLR. For each test, reproduction of presenting symptoms, which was made worse by dorsiflexion, was recorded as a positive finding. Positive if +ve Slump AND +ve SLR. First 20 subjects did the exact same procedure with a 3rd examiner to measure inter tester reliability.

Results: Reliability: Substantial agreement was found for all palpation tests. K=0,7-0,8. PPT reliability demonstrated excellent inter-tester reliability.

Validity: There were no significant differences in PPTs between sides at any of the nerves in subjects who were negative on manual palpation. In subjects who were positive on manual palpation, mean PPTs were significantly lower on the symptomatic side compared to the asymptomatic side for each of the nerves

Limitations: Small sample from Australia, SLR and Slump non gold standard.

In Practice: This study provides support for the use of nerve palpation in clinical examination, with evidence of excellent reliability and diagnostic accuracy as well as validity of manual palpation for three lower limb nerve sites.

Walsh, J., & Hall, T. (2009). Reliability, validity and diagnostic accuracy of palpation of the sciatic, tibial and common peroneal nerves in the examination of low back related leg pain. Manual Therapy, 14(6), 623–629. https://doi.org/10.1016/j.math.2008.12.007

Patellofemoral Pain

(Willy et al., 2019)

Aims: Guidelines on PFP

Methods: Review of literature & experts’ consensus.

Limitations: May be bias in experts’ opinion. Broad topic. Expert consensus

In Practice:

Diagnosis: The presence of retro-patellar or peri-patellar pain, (2) reproduction of retro-patellar or peri-patellar pain with squatting, stair climbing, prolonged sitting, or other functional activities loading the PFJ in a flexed position, and (3) exclusion of all other conditions that may cause anterior knee pain.

Assessment: Clinicians should use the Anterior Knee Pain Scale (AKPS), the patellofemoral pain and osteoarthritis sub-scale of the Knee injury and Osteoarthritis Outcome Score (KOOS-PF), or the (VAS) for activity, for worst pain, for usual pain, or the numeric pain-rating scale (NPRS) to measure pain.

Treatment: Should include exercise therapy with combined hip- and knee-targeted exercises to reduce pain and improve patient-reported outcomes and functional performance in the short, medium, and long term.

Clinicians may use tailored patellar taping in combination with exercise therapy to assist in immediate pain reduction, and to enhance outcomes of exercise therapy in the short term (4 weeks).

Clinicians should prescribe prefabricated foot orthoses for patients with greater than normal pronation to reduce pain, but only in the short term (up to 6 weeks).

Willy, R. W., Hoglund, L. T., Barton, C. J., Bolgla, L. A., Scalzitti, D. A., Logerstedt, D. S., … Torburn, L. (2019). Patellofemoral Pain. Journal of Orthopaedic & Sports Physical Therapy, 49(9), CPG1–CPG95. https://doi.org/10.2519/jospt.2019.0302

Validity of clinical small-fiber sensory testing to detect small-fiber degeneration

(Ridehalgh, Sandy-Hindmarch, & Schmid, 2018)

Aims: To examine the validity of clinical tests to assess small nerve fibers degeneration using Carpal Tunnel Syndrome (CST) as a model neuropathy.

Methods: Prospective cross-sectional. Presence of CTS was assessed with skin biopsies. 85 patients with CTS were evaluated with Neurotip and Quantitative sensory testing (T°). A subgroup of 51 CTS was tested with toothpick and coins.

Results: None of the test in isolation has sufficient validity in isolation. However, reduced pinprick has LR+3,94 and Sp=0,88 and can help rule in small fiber degeneration (not toothpick). Negative cold and warm with coin has LR-0,14, Se=0,98 and can help rule out small fibers degeneration. More severe easier to rule in, less severe more difficult to rule out.

Issues: Tested only on upper arm and may be different in ≠ areas of body less innervated. Excluded other small nerve neuropathies, or other issues that may be present in clinical practice. + and – LR are weak, the study shows which is the best indicator but among relatively weak tools. Use of control may inflate Sp and LR+.

Practice: Use pinprick test first, if positive then we can rule in pathology. If negative, cold warm coin detection is needed to rule out small-fiber degeneration. Just clinical suspicion: Gold standard in needed to confirm diagnosis.

Ridehalgh, C., Sandy-Hindmarch, O. P., & Schmid, A. B. (2018). Validity of Clinical Small–Fiber Sensory Testing to Detect Small–Nerve Fiber Degeneration. Journal of Orthopaedic & Sports Physical Therapy, 48(10), 767–774. https://doi.org/10.2519/jospt.2018.8230

Movement control tests of the LBP; evaluation of the difference between P with LBP and healthy controls

(Luomajoki, Kool, de Bruin, & Airaksinen, 2008)

Aims: To determine whether the number of positive tests out of six active MC tests was different in patients LBP VS healthy controls + if ≠ according to the duration of LBP.

Methods: Case control study, Non blinded, 108 P and 102 controls, consecutive Germans, LBP (excluded radiculopathy), 12 ratters. 3 trials, oral explanation + if needed demonstration. 6 Motor control tests performed (Luomajoki tests) in the same order. Statistical analysis.

Results: Comparable groups, 2,21 (P) vs 0,75 (C) positive tests. Statistical difference, large effect size. There was a significant difference between acute and chronic, as well as between subacute and chronic but not between acute and subacute patient groups. The more chronic the more +ve tests.

Limitations: Case control no search of cofounding factors? Small clinical difference. Results not shown (which test + wich – on the 6). No blinding + subjective diag.

In Practice: There may be a difference, in the number of MC tests in LBP patients and the more chronic the more positive tests. MC evaluation through Luomajoki tests may be of use in LBP patients. Although tests have not been studied for validity, and the effect of MC treatment strategies have not been proven effective.

Luomajoki, H., Kool, J., de Bruin, E. D., & Airaksinen, O. (2008). Movement control tests of the low back; evaluation of the difference between patients with low back pain and healthy controls. BMC Musculoskeletal Disorders, 9(1), 170. https://doi.org/10.1186/1471-2474-9-170