| User | Post |
|---|
|
2:05 pm
September 11, 2008
|
MaX
Member
| | Washington D.C, USA | |
|
| posts 37 |
|
|
Hi,
Can anyone suggest the treatment protocol for a chronic (pain since 4years) tennis elbow case 46y Female
Her case is like this: 2 years back she underwent medications and Physio for 1 month and recovered fully with SWD and US + exercises. But 6 months later she felt pain once again.
Now the symptoms are felt on and off.
I am in need of good advice regarding this case. Please give your suggestions I will be greatful.
Which one is more effective???
Also, can anyone tell me that which manipulation is more effective in tennis elbow???
Mills' manipulation or MWM???
|
|
|
7:26 pm
September 11, 2008
|
Liz
Member
| | | |
|
| posts 38 |
|
|
Fryette – Manipulative varus technique for chronic cases of abducted ulna
Cyriax – Initially championed use of varus technique. Later abandoned in favor of Mills maneuver
Kusher and Reid – Kaltenborn technique
Stoddard – Fixation over knee ….momentum into adduction
Mills manipulation (Kaufman, 2000) – Positive outcomes in lateral elbow pain of non- traumatic origin
Struijs et al (2003) – Repetitive thrusts to the wrist
Mulligan (1993) - Sustained lateral glides
– Vincenzino 2001
– Paungmali 2003
No literature found on manipulation in cases of traumatic onset elbow pain.
MWM Vs Mill's Manipulation - MWM is a recent development while Mill's Manip has been used for quite some time and has been well documented.
There have been 8 studies so far assessing the short term effects of MWM and all have documented immediate relief from pain and quicker return to function.
|
|
|
7:32 pm
September 11, 2008
|
Tears
Member
| | | |
|
| posts 36 |
|
|
Evidence based practice (EBP): Is “Mobilisation with Manipulation – MWM” more effective in treating patients with lateral epicondylalgia?
Introduction: EBP represents a constantly evolving state of information “new evidences from clinical research both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious and safer” (Thyer, 2004). EBP involves five steps (1) convert one’s need for information into an answerable question (2) track down the best clinical evidence to answer that question (3) critically appraise that evidence in terms of its validity, clinical significance and usefulness (4) integrate the critical appraisal of research evidence with one’s clinical expertise, patient values and circumstances
|
|
|
7:34 pm
September 11, 2008
|
Tears
Member
| | | |
|
| posts 36 |
|
|
(5) Evaluate one’s effectiveness and efficiency in
undertaking the four steps and strive for self-improvement.
Step 1: converting one’s need for information into an
answerable question
Peer group discussion provides an excellent opportunity to
frame a question for the information that needs an answer. In this case also,
an online discussion forum served as the source where, one of the members
questioned whether Mills manipulation or MWM is the effective treatment for
tennis elbow (lateral epicondylalgia). Majority of members who replied felt
that MWM is more effective than Mills manipulation. This lead to framing the
question: Is “Mobilisation with Manipulation – MWM” more effective in treating
patients with lateral epicondylalgia?
|
|
|
7:38 pm
September 11, 2008
|
Tears
Member
| | | |
|
| posts 36 |
|
|
Step 2: Tracking down the best clinical evidence to answer
that question
A search was done using a combination of key words
across various databases and articles that were thought to have relevant
information retrieved. Limiters were set so that the information retrieved is
the latest and the whole purpose of EBP is to explore the latest developments.
For example, the key word “lateral epicondylalgia” retrieved 49 abstracts.
Subsequent searches with specific key words and limiters narrowed down the
number of extracts received and finally seven abstracts which were thought to
have relevant information to the topic under question were extracted and read
through.
|
|
|
7:41 pm
September 11, 2008
|
Tears
Member
| | | |
|
| posts 36 |
|
|
Step 3: critically appraise that evidence in terms of its
validity, clinical significance and usefulness
This includes critical exploration and appraisal of the
seven studies that were retrieved. The studies were reviewed in terms of their
sample size, sample characteristics, randomization, blinded-ness, data
analytical techniques used internal and external validity of the findings,
generalizability of the findings and lack of any biasness in reporting the
findings.
Abbott, Patla and Jensen, 2001. The initial effects of an
elbow mobilization with movement technique on grip strength in subjects with
lateral epicondylalgia. Man Ther. 2001 Aug;6(3):163-9.
In this study 25 subjects with lateral epicondylalgia
were treated by MWM, the outcome measure being: Favourable response to MWM, pain-free
grip strength and maximum grip strength of the affected elbow
|
|
|
7:48 pm
September 11, 2008
|
Tears
Member
| | | |
|
| posts 36 |
|
|
Ninety- two percent (92% )of the subjects were
able to perform a previously painful motion pain-free, further MWM resulted in
significant increase in both pain-free and maximum grip strength and the
authors opine that MWM may be a useful modality in treating LE. However the
study is an uncontrolled, quasi-experimental one group pretest- posttest
design. Hence, the validity (internal and external) and the generalisability of
the findings are not free from potential bias. The sampling technique used
(purposive) lacks randomization. Further, the study has only measured the
immediate effects of MWM, with no importance given to the long term outcome
which serves as another constraint to the generalisability of the findings
|
|
|
7:58 pm
September 11, 2008
|
Tears
Member
| | | |
|
| posts 36 |
|
|
The authors themselves recommend randomized controlled studies investigating the long term efficacy of MWM as a treatment modality for LE.
Bisett et al. (2006). Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomized trial.BMJ.
This single blinded randomized trial investigates the efficacy of physiotherapy compared with wait and see approach or corticosteroid injections over 52 weeks in tennis elbow. 196 patients were randomly allocated to any of the three groups and were followed up for 52 weeks. The interventions consisted of corticosteroid injection or 8 sessions of physiotherapy or wait and see respective to which group they participated.
|
|
|
2:10 am
September 12, 2008
|
Tears
Member
| | | |
|
| posts 36 |
|
|
The main outcome measures were global improvement, grip force, and assessor’s rating of severity measured at baseline, 6 weeks and 52 weeks.
He study reports that physiotherapy combining elbow manipulation and exercise has a superior benefit to wait and see in the first six weeks and to corticosteroid injections after six weeks. However after 52 weeks there was no significant difference between wait and see and physiotherapy groups. There are minimal methodological flaws with the study design and the data analysis techniques used seems to be appropriate. The authors have clearly acknowledged the potential areas of bias and have backed it up with proper reasoning
|
|
|
2:11 am
September 12, 2008
|
Tears
Member
| | | |
|
| posts 36 |
|
|
However, the elbow manipulation was vaguely used in this study with no direct terms such as Mulligan’s “MWM” being mentioned anywhere. Hence it is difficult whether to correlate the manipulation mentioned as MWM or whether we should assume that as MWM. Barring this, the study seems to be of superior quality.
Kochar and Dogra (2002). Effectiveness of a Specific Physiotherapy Regimen on Patients with Tennis Elbow. Physiotherapy, 88 (6), 333-341.
In this study the effect of a combination of Mulligan mobilization and therapeutic ultrasound has been compared with that of therapeutic ultrasound alone. The sample size of this study is small for generalisability of the results
|
|
|
2:12 am
September 12, 2008
|
Tears
Member
| | | |
|
| posts 36 |
|
|
Moreover the study combines ultrasound and MWM has treatment technique which may lead to the question “why not MWM alone”? How sure can one associate the outcome (positive or otherwise) to MWM alone? Hence the findings of this study can’t be considered as an evidence supporting MWM for LE.
Paungamali et al (2003 & 2004)
All the three studies done by these authors investigate and explore the physiological explanation for the hypoalgesic effects of MWM. It can be said that the authors strongly hypothesize that MWM has a hypoalgesic effect and are investigating how MWM works at a physiological level
|
|
|
2:13 am
September 12, 2008
|
Tears
Member
| | | |
|
| posts 36 |
|
|
After going through the articles it can be seen that they are not directly relevant to the topic under question as I was exploring whether MWM is the effective treatment modality for LE.
Slater et al (2006). Effects of a manual therapy technique in experimental lateral epicondylalgia. Man Ther, 11 (12), 107-117.
This study also explores the mechanism underlying the analgesic effects of MWM. 24 participants were randomly allocated into 2 groups. Delayed onset muscle soreness (DOMS) and pain through saline injections were induced experimentally. The participants were then administered MWM and the outcome measured. The results of this study suggest that the lateral glide-MWM does not activate mechanisms associated with analgesia or force augmentation in subjects with experimentally induced features simulating lateral epicondylalgia
|
|
|
2:14 am
September 12, 2008
|
Tears
Member
| | | |
|
| posts 36 |
|
|
As explained previously, the full text of this article couldn’t be retrieved and hence am in no position to comment on the quality or generalisability of the studies finding.
Discussion:
From the search, evidences suggest that MWM may have short term pain relief (immediately following treatment) in treating LE and is a treatment modality of choice among PT practitioners across various countries. However the long term effect of MWM on LE is still debatable and the only study (Bisset et al, 2006) which has investigated on the long term effect of MWM has reported in the negative. Further, the validity and generalisability of the findings of other studies are a major constraint to support that “MWM is an effective treatment modality for LE”.
|
|
|
2:15 am
September 12, 2008
|
Tears
Member
| | | |
|
| posts 36 |
|
|
Hence it can be argued that more RCT’s investigating the long term efficacy of MWM as a treatment modality in LE is the need of the hour.
(4) Integrate the critical appraisal of research evidence with one’s clinical expertise, patient values and circumstances
Well, doing this search and going through various studies done was in itself a good learning experience. Having gone through the latest available evidences, I would definitely integrate MWM as a treatment modality for short term pain relief for patients with LE. However that wouldn’t stop me using other manual techniques that I use, considering the long term prognosis of the patient and my treatment plan
|
|
|
2:17 am
September 12, 2008
|
Tears
Member
| | | |
|
| posts 36 |
|
|
Further, each patient is unique and reliance on one particular technique wouldn’t be advisable.
(5) Evaluate one’s effectiveness and efficiency in undertaking the four steps and strive for self-improvement
Having been doing research activities using internet, I can to an extent say that the searches were done in an efficient way. However, it doesn’t mean that I have retrieved all relevant information’s as human errors are always a significant factor to be considered. This discussion served a good learning experience for me and will definitely strive for self-improvement with feedbacks from fellow professionals.
Conclusion:
MWM seems to be a treatment modality of choice among PT practitioners in treating patients with LE. Thought there are a number of studies which have recorded and reported the short term analgesic effects of MWM, more studies investigating the long term effects of MWM are highly recommended.
Oops…that has become very long than what even I intended to. Sorry! And thanks for reading (if anyone had the patience heheh…lol, :))
|
|
Forums
