Evidence Based Rehabilitation Principles for Tennis Elbow. Patricia H. Koehne, OTR/L, CHT Ability Rehabilitation SST/OOC

Transcription

1 Evidence Based Rehabilitation Principles for Tennis Elbow Patricia H. Koehne, OTR/L, CHT Ability Rehabilitation SST/OOC

2 Basic Stats on Tennis Elbow: aka Lateral Epicondylalgia 1-3% population ages (middle age malady) self-limiting moderate effect on daily life activities and function (most specifically lifting and carrying) lasts 6-24 months

3 Evidence Based Treatment Disclaimer: Not a research expert! o Read a lot! (literature reviews, meta-analyses, randomized controlled studies ) but not exhaustive Well documented for therapeutic interventions (PREs {mostly eccentric}, modalities {heat, US, Ionto, TENs}, splinting {wcs, counterforce}, rest/behavior mod, manual mob, taping...) Not well documented for specific clinical practice guidelines (ie. frequency, duration, sessions..) No standardized, universally accepted program for LE

4 It all starts with Education.. Minimal EB literature, but all were conclusive in importance of pt. ed. for decreasing immed. pain and decreasing recurrence rate. o 10 yr review- only 3 articles o A structured therapy program that included ergonomic advice was more effective than injections and NSAIDs to decrease pain, increase function, lower recurrence and fewer sick days o Educating referral sources, esp. PCPs for early referral

5 BEHAVIOR MODIFICATION Changing the way you lift and carry o palm up and close to side Work/ergonomic changes o position of wrist when typing o MF extension with using mouse Sport Adaptations 2-handed back stroke size of racquet handle Lifetime of managing symptoms

6 EB for splints Counterforce strap decreases strain in ECRB (if worn correctly) a working splint (NEVER at night/rest) prefab WCS at night/rest on computer for wrist support Some Md s request LAS: for complete rest and immobilization if small tear & trying to avoid surgery 2005 Meta-Analysis: no one brace better than other...

7 EB for Modalities Iontophoresis good pain relief at initial onset blocking of pain signals vs. antiinflammatory good tissue penetration of meds (Dex) US increased blood circulation for healing good diagnostic use by MDs (help classify) TENS good pain relief;; self-management;; cost-effective;; decreased NSAID use;; less time off work

8 Newer modalties, less EB.. LLLT (cold laser) showing some good results (if used with correct parameters for diagnosis);; mixed meta-analysis Effects: decreased inflammation;; increased collagen & tensile strength HILT (thermal laser) pulsed emission;; high peak power;; high level of fluency;; short duration for decreased pain, increased blood flow, collagen & tensile strength 2015: using diagnostic US to evaluate CET thickness: No change comparing HILT, bracing & sham HILT

9 EB for Resistive Exercises Good support throughout literature showing increased grip with decreased pain (a 20 year review & 10 year review) Eccentric exercises most documented Effective because of the possible effects of stretching, lengthening & increased tensile strength in the tendons Lack of research comparing types of exercise (eccentric, concentric, isometric, isokinetic) Optimal dosing not clearly defined (freq, duration )

10 More EB literature to support Acute vs. Chronic classification Acute (0-6 mos) o high intensity strain o Athletes o Heavy Laborers o weekend warriors Chronic (>6 mos) slower, repetitive strain low demand jobs (computer) due to general deconditioning, poor posture, poor ergonomics at work station, sedentary lifestyle

11 Additional Classification System needed?? In 2010, a published HT practice pattern revealed more than 16 different practice patterns used in various combinations in both acute and chronic LE JHT (2012): A Potential Classification Model for Individuals with Tennis Elbow (Wixom & LaStayo) A classification system compiled from previous authors which attempts to stratify patients based on specific signs and symptoms: Mild, Moderate or Severe

12 Along with classification of Acute vs Chronic??

13 Treatment for Severe LE Pain Management meds;; modalities STM;; upper quadrant MTPs consider central sensitization Rest/Immobilization splints Progress to moderate level when pain decreases

14 Treatment for Moderate to Mild LE A more restorative exercise program PREs progressively increase as they transition from moderate to mild Pt s can transition from one classification to another;; adapt treatment accordingly

15 So, what is best practice?? Definite lack of prospective, randomized trials to guide treatment choices Little consensus exists regarding management;; No clear protocols due to poor classification system, but some good guidelines;; are protocols feasible? Need better details in research regarding dosage parameters EB to support wait & see approach

16 EB Rehab: An Evolving Expectation for Therapists WHY? Reimbursements becoming more dependent on EB interventions Limited number of Insurance visits Higher pt. expectations (consumer vs. patient) Professional competition

17 Knowledge Translation: How do we put research into action?? Membership in Professional Organizations gain access to journal articles & latest research Participate in Journal Clubs Start a Learning Lunch at work Build relationships with researchers

18 Thank You