Hand Works Occupational Therapy Lateral Epicondylitis. By Sath Segran

Transcription

1 Hand Works Occupational Therapy Lateral Epicondylitis By Sath Segran

2 Outline of presentation What is Lateral Epicondylitis Anatomy Epidemiology Aetiology Definitions Symptoms and presentation Assessment of Lateral Epicondylitis Goals of Treatment Available treatments Outcome measures Conclusion

3 What is Lateral Epicondylitis? Also known as Tennis Elbow First used in 1883 Most common Upper Extremity Tendonitis Overuse phenomenon of the wrist extensor muscles during repetitive upper extremity motions. Pathological changes occurring at the common extensor tendon origin which attaches to the lateral epicondyle.

4 Muscles involved Number one culprit = ECRB ECRB has a small origin Vulnerable to shearing stress during all movements of the forearm. Changes can also occur at the Common Extensor tendon origin, EDC and ECRL.

5 Epidemiology 1:1 male to female years old Tennis players = 5% Majority are work related injuries

6 Repetitive movements of the wrist and forearm into supination /pronation Aetiology Microtearing stimulates inflammation Tendon degeneration Micro trauma/ tears to the tendon at the common extensor origin Repetitive micro trauma leads to incomplete healing

7 Tendon Degeneration This tendon degeneration is characterized as angiofibroblastic hyperplasia.

8 Definitions Tendonitis : Acute inflammatory response to injury of a tendon that produces the classical signs of heat, swelling and pain. Tenosynovitis is inflammation of the lining of the sheath that surrounds a tendon.

9 Definitions Tendinosis= The term Tendinosis has been used to describe the histopathologic findings identified in Tennis Elbow. The findings included : Absence of inflammatory infiltrates and tenocyte Fibroblast hyperplasia Collagen synthesisation Endothelial cell hyperplasia Disorganised collagen Cell necrosis Calcification Hand Works Occupational Therapy

10 Symptoms/Clinical presentation Pain over the lateral epicondyle of the humerus or during movements: gripping, resisted wrist extension, supination, digital extension and wrist radial deviation. May present with referred pain. Reduced grip strength with elbow extended Mild stages: Symptoms will develop after completion of an activity. Severe stages: Symptoms will occur with minimal activity such as brushing teeth and shaking hands.

11 Initial Interview Assessment Patient s history on symptoms. Previous Treatment Work duties Patient s hobby and interest

12 Clinical Assessment Wrist AROM: Secondary to pain, ROM may be limited in wrist extension or flexion and elbow extension. Grip strength: Patient is instructed to squeeze the handle to the point where the pain starts and then stop. In elbow flexion/extension

13 Coven s test: I. Examiner s thumb stabilizes the client s elbow at the lateral epicondyle. II. With forearm pronated, the client makes a fist and then actively extends and radially deviateswith examiner resisting this motion. Positive: Severe sudden pain in the area of the lateral epicondyle.

14 Mill s tennis elbow test Originally described as a manipulation maneuver, but can be used as a clinical test. I. Examiner palpates the the lateral epicondyle. II.Elbow pronated, the examiner fully flexes the wrist while moving the elbow from flexion to extension. Positive: Pain at Lateral Epicondyle. *Test should not be used on patients with significant muscular pain in the region.

15 Resisted Middle Finger Extension Test A positive test is pain with resisted middle finger. May elicit pain due to the extensor digitorum sharing a common tendon with the ECRB. Pain on palpation over the common extensor tendon origin.

16 Assessment Patient Rated Tennis Elbow Evaluation Easy to use 15 Questions 2 subscales: Pain and Function. High test-retest reliability.

17 Assessment/Questionnaire Disability of the Arm, Shoulder and Hand: Self-report questionnaire Measures physical function and symptoms Scored out of 100 Higher score indicating a greater level of disability Visual analogue scale

18 Assessment/Questionnaire These two written assessment are useful: It allows clinician to quickly assess pain and function in patients with LE. Identify jobs/tasks that could be changed to decrease pain. Occupation focused.

19 Imaging Determines the severity of injury. Can show thickening of the ECRB tendon and degenerative tendinosis. Demonstrates increased signal intensity of the origin of the ECRB.

20 MRI Findings

21 Goals of Treatment Reduce pain Reduce inflammation (for acute conditions) Regain muscle strength and AROM Return to normal ADL and Occupation

22 Treatment Options Little evidence out there More than 40 types of available management. Occupational Therapy key treatment s: Educating patient regarding their injury. Ergonomic counselling Activity modifications Other lifestyle changes to reduce aggravating activities.

23 Example of Activity Modifications Avoid lifting with palm turn down. Hand turned up is better. Avoid lifting with a straight elbow. Maintain a bent elbow and keep item close to body when lifting.

24 Orthotic Intervention Can be used in the acute phase. Can be a custom made or prefabricated. Purpose of splinting: Unload and rest muscles to promote tendon recovery. Significant reduction in electrical activity with wrist in extension during lifting activities.

25 Counter- force brace Prevents full muscular expansion Applied distal to ECRB origin Provides a compressive force Significant reduction in ECRB and EDC muscle force Creates a secondary origin of the extensor tendons Thus unloading the true origin at the Lateral Epicondyle. Hand Works Occupational Therapy

26 Kinesio Tape Provides increased low-threshold excitement to somatosensory receptors, thereby increasing somatosensory input to CNS. Applied on a pronated arm, with wrist flexed. Not stretching the tape, apply from the origin to the insertion of ECRB.

27 K-tape is believed to have therapeutic benefits: Gather fascia to align the tissue in its desired position Lift the skin over areas of inflammation, pain and oedema. Decrease pressure over the lymphatic channels that provide a path for the removal of exudates.

28 Eccentric Exercises Remodelling at the musculotendinous junction. Increase fibroblast activity Facilitate tendon remodelling and healing. Evidence suggests that exercise programs can reduce pain, but the improvement in grip strength is still unclear.

29 Myofascial Release Low load pressure and stretch to a muscle unit. Pressure is applied on restricted fascia. Using thumb to slowly sink into fascia, contacting the restricted fascia. Fascial restrictions undue tension in the other parts of the body due to fascial continuity.

30 Myofascial Release Resulting in stress on structures that are enveloped, divided, or supported by fascia. By restoring length, pressure can be relieved on pain sensitive structures. Significantly more effective than a placebo treatment.

31 Laser treatment Widespread but controversial treatment. Not carried out by Occupational Therapist. Produces clinically meaningful improvements in a variety of soft tissue injuries. Alteration at cellular function occurs in absence of significant heating in cells after irradiation.

32 Acupuncture Treatment of musculoskeletal conditions in Western countries. Thought to confer an analgesic effect By increasing the release of b- endorphins in the lumbar spine.

33 Acupuncture Overriding of the pain stimulus by the biochemical lines of acupuncture in the transmitting process of the CNS. Significant longer duration of pain relief compared to a placebo treatment. Also not carried out by OT s however they are some who perform dry needling.

34 Non- streroidal anti-inflammatory drugs Proven to relief pain Temporary solution No literature evidence on long term benefits

35 Medical Management Corticosteroid Injections Greater perception of benefit at 4 weeks than receiving oral NSAIDs Short term benefits in: -Pain reduction -Grip strength Long term effectiveness and advantages over other conservative management are still uncertain.

36 Medical Management cont. Autologous blood injection May trigger the inflammatory cascade and initiate healing. No significant differences in pain, grip strength and general improvement between ABI and placebo.

37 Platelet Rich Plasma Injection Slightly similar to the ABI. Difference = Blood is placed in a centrifuge. Platelets are then selectively removed and used for injection.

38 Platelet Rich Plasma Injection cont. A greater concentration of platelets delivered into the damaged body part Platelets play a significant role in the repair and regeneration of connective tissue. No scientific research documenting this benefit at the moment

39 Surgical Management Option ONLY after 6 to 12 months of conservative management. 8% will require surgery. Excision of abnormal tissue within the CETO, release and/or reattachment of the tendon Still no consensus on which operative procedure offers the best results.

40 Due to the lack of methodological sound studies, researchers have been unable to identify a single treatment that has provided significant improvements for patients with Lateral Epicondylitis.

41 Conclusion Key points: LE is usually not an inflammatory condition, it involves tendinosis and tendon degeneration. Imperative to provide patient education on appropriate lifting techniques and other activity modifications to prevent exacerbation and re-injury. Our role is to facilitate healing, increase or maintain patient s function and return patients to their daily occupations.

42 Questions?

43 References Ajimsha, M. S., Chithra, S., & Thulasyammal, R. P. (2012). Effectiveness of Myofascial Release in the Management of Lateral Epicondylitis in Computer Professionals. Archives of physical medicine and rehabilitation, 93(4), Blanchette, M.-A., & Normand, M. C. (2011). Augmented Soft Tissue Mobilization vs Natural History in the Treatment of Lateral Epicondylitis: A Pilot Study. Journal of Manipulative and Physiological Therapeutics, 34(2), doi: /j.jmpt Coleman, B., Quinlan, J. F., & Matheson, J. A. (2010). Surgical treatment for lateral epicondylitis: A long-term follow-up of results. Journal of Shoulder and Elbow Surgery, 19(3), doi: /j.jse Derebery, V. J., Devenport, J. N., Giang, G. M., & Fogarty, W. T. (2005). The Effects of Splinting on Outcomes for Epicondylitis. Archives of physical medicine and rehabilitation, 86(6), doi: /j.apmr Dorf, E. R., Chhabra, A. B., Golish, S. R., McGinty, J. L., & Pannunzio, M. E. (2007). Effect of Elbow Position on Grip Strength in the Evaluation of Lateral Epicondylitis. The Journal of Hand Surgery, 32(6), doi: /j.jhsa Greco, S., Nellans, K. W., & Levine, W. N. (2009). Lateral Epicondylitis: Open Versus Arthroscopic. Operative Techniques in Orthopaedics, 19(4), doi: /j.oto Green Sally, Buchbinder Rachelle, Barnsley Les, Hall Stephen, White Millicent, Smidt Nynke, & Assendelft Willem Jj. Acupuncture for lateral elbow pain. Cochrane Database of Systematic Reviews. Greenfield, C., & Webster, V. (2002). Chronic Lateral Epicondylitis: Survey of current practice in the outpatient departments in Scotland. Physiotherapy, 88(10), doi: /s (05)60510-x Hong, Q. N., Durand, M.-J., & Loisel, P. (2004). Treatment of lateral epicondylitis: where is the evidence? Joint Bone Spine, 71(5), doi: /j.jbspin Lattermann, C., Romeo, A. A., Anbari, A., Meininger, A. K., McCarty, L. P., Cole, B. J., & Cohen, M. S. (2010). Arthroscopic debridement of the extensor carpi radialis brevis for recalcitrant lateral epicondylitis. Journal of Shoulder and Elbow Surgery, 19(5), doi: /j.jse Smidt, N., Assendelft, W. J. J., van der Windt, D. A. W. M., Hay, E. M., Buchbinder, R., & Bouter, L. M. (2002). Corticosteroid injections for lateral epicondylitis: a systematic review. Pain, 96(1 2), doi: /s (01) Struijs Peter Aa, Smidt Nynke, Arola H, van Dijk C N, Buchbinder Rachelle, & Assendelft Willem Jj. Orthotic devices for the treatment of tennis elbow. Cochrane Database of Systematic Reviews. Trudel, D., Duley, J., Zastrow, I., Kerr, E. W., Davidson, R., & MacDermid, J. C. (2004). Rehabilitation for patients with lateral epicondylitis: a systematic review. Journal of Hand Therapy, 17(2), doi: /j.jht Wolf, J. M., Ozer, K., Scott, F., Gordon, M. J. V., & Williams, A. E. (2011). Comparison of Autologous Blood, Corticosteroid, and Saline Injection in the Treatment of Lateral Epicondylitis: A Prospective, Randomized, Controlled Multicenter Study. The Journal of Hand Surgery, 36(8), doi: /j.jhsa Wuori, J. L., Overend, T. J., Kramer, J. F., & MacDermid, J. (1998). Strength and pain measures associated with lateral epicondylitis bracing. Archives of physical medicine and rehabilitation, 79(7),