Get your chronic LE clients to feel some pain with exercise! They will thank you after six weeks

Investigating the effects of neuromobilization in lateral epicondylitis. Yilmaz, K., K. Yigiter Bayramlar, C. Ayhan and O. Tufekci (2020) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - Radial nerve gliding This is a randomised controlled trial assessing the effectiveness of radial nerve tensioners plus eccentric exercises vs eccentric exercises only for lateral epicondylalgia (LE). A total of 34 participants were included in the study. To be included, participants had to present with LE (no details on the diagnostic process were provided), and have experienced symptoms for more than three months. Participants were excluded if they presented with neck or arm symptoms, if they presented with neurological symptoms, if they reported bilateral LE or wide spread pain, or if they had received treatment for their LE in the last 6 months. Participant were randomised to radial nerve tensioners plus eccentric exercises (eperimental group, n = 18), or eccentric exercises only (control group, n = 16). Both groups performed three sets of ten repetitions of graded eccentric exercises for the wrist extensor every day. Participants started with no resistance and progressed to eccentric exercises with weight when there was no pain during the exercise. Each week, the participants in the eccentric exercise only, attended a physiotherapy session during which the eccentric exercises were progressed (total of 6 sessions). The nerve tensioner group performed the same exercises described above plus 10 repetitions (3 seconds holds) of radial nerve tensioners (see picture below). The nerve tensioner group also attended 3 physiotherapy sessions per week for 3 weeks after which they continued with their tensioners exercises at home (total of 9 sessions). Efficacy of intervention was assessed through pain severity (VAS) at baseline, 3 weeks, and 6 weeks. Compliance with the home exercise program was self-reported. The results showed that both groups improved over the course of the six weeks to a statistically and clinically significant level. The radial tensioner group consistently reported clinical significant improvements in pain at rest, night, and during activity. The eccentric only group improved to a clinically significant level in the pain during activity only. The self reported compliance was 88% and 80% in the experimental and control group respectively. There results of this study need to be considered in light of a few limitations. First, the pain level in the control group was overall lower at baseline compared to the radial tensioner group, which has the potential for greater improvements in the tensioner group. Second, there was an imbalance in the number of physiotherapy sessions provided between groups. In particular, 6 session were provided to the eccentric only group and 9 sessions to the radial tensioner group. Finally, symptoms reduction through radial tensioners may be due to a Condition Pain Modulation response (artificially inducing pain with treatment can provide pain relief after treatment - pain inhibits pain). Unfortunately, the eccentric exercises were performed pain-free and we cannot exclude the effect of this confounding variable on the treatment effect. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, the adjunct of a radial nerve tensioners to eccentric exercises may provide additional pain relief compared to eccentric exercises alone in clients with chronic lateral epicondylalgia (symptoms for more than 3 moths). It is also possible that performing resistance exercises that cause some pain during their execution may provide similar effects through what we call Condition Pain Modulation. This approach would probably be most appropriate during the disrepair/degenerative phase of tendinopathy. Radial tensioners or resistance exercises may be inappropriate during the reactive phase (acute phase) of LE. URL: Available through The Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract STUDY DESIGN: Randomized controlled study. INTRODUCTION: Lateral epicondylitis (LE) causes pain and loss of function in the affected limb. Different exercises have been used for the treatment of LE. In recent years, the technique of neuromobilization has been frequently used to treat tendinopathy. However, there is no study that demonstrates the effects of neuromobilization techniques on patients with LE. PURPOSE OF THE STUDY: The aim of the present study was to determine the effects of neuromobilization techniques on pain, grip strength, and functional status in LE patients and to compare them with conservative rehabilitation treatment. METHODS: A total of 40 patients (26 females and 14 males; age: 42.80 ± 8.91 years) with a history of LE participated in the study. The patients were randomly assigned to two groups: the neuromobilization group and the control group. The neuromobilization group completed a 6-week conservative rehabilitation and radial nerve mobilization program, whereas the control group received conservative rehabilitation therapy only. Both groups underwent a 7-day weekly conservative home rehabilitation program. Pain severity, grip strength, pinch strength, joint motions, and upper extremity functional level were assessed before treatment, at the third week after treatment, and at the sixth week after treatment. RESULTS: There was a significant decrease in all pain scores in favor of the neuromobilization group at week 6 after treatment (at rest: P = .001, effect size (ES) = 0.84; at night: P = .001, ES = 0.91 and during activity: P = .004, ES = 1.06). No significant differences were found for grip strength, pinch strength, joint motions, and functional level in the neuromobilization group, although trends toward better improvement were observed. CONCLUSIONS: Radial nerve mobilization techniques are more effective on pain than conservative rehabilitation therapy in LE patients, and this effect continues after treatment.