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Tennis Elbow Treatment

Approaches
a
Invited Topical Review
Physiotherapy management of lateral epicondylalgia
Leanne M Bisset
Menzies Health Institute Queensland, Grif?th University, Gold Coast;
KEY WORDS
Tennis elbow
Physiotherapy
Lateral elbow
Physical therapy
Introduction
b
a
, Bill Vicenzino
b
University of Queensland, School of Health and Rehabilitation Sciences:
Physiotherapy and the
NHMRC Centre for Research Excellence[ 7 _ T D $ D I F F ] in Spinal Pain, Injury
and Health, Brisbane, Australia
Lateral epicondylalgia (LE), more commonly known as tennis
elbow, is the most common chronic musculoskeletal pain
condition affecting the elbow, causing signi?cant pain, disability
and lost productivity. Despite decades of research investigating
treatments and the underlying mechanisms of LE, it remains a
challenging condition for physiotherapy clinicians and researchers
alike. This topical review outlines the prevalence, burden and risk
factors associated with LE. Diagnosis, assessment and the
principles of management are also presented. The contemporary
evidence for treatment ef?cacy and directions for future research
are also discussed.
Prevalence of lateral epicondylalgia
Approximately 40% of people will experience LE at some point in
their life.
1
It most commonly presents in men and women aged
between 35 and 54 years.
24
The reported point prevalence of LE is
between1 and3%withinthe general population,
57
and four to seven
per [ 8 _ T D $ D I F F ] 1000 patients visiting general medical practitioners.
Up to
50% of all tennis players also experience some type of elbow pain,
with 75 to 80% of these elbow complaints attributable to LE.
The burden of lateral epicondylalgia
LE most commonly affects the dominant arm, particularly when
performing repetitive activity, so it is not surprising that the
greatest burden of LE is among manual working populations where
musculoskeletal upper limb injuries account for some of the
longest work absences.
12
Up to 17% of workers within industries
that involve highly repetitive hand tasks, such as meat processing
and factory workers, experience LE.
1316
This results in an absence
from work of up to 219 workdays, with direct costs of US$8099 per
person.
17,18
3,6,8,9
Data from Workcover Queensland indicates that upper
limb (shoulder and elbow) injuries account for 18% of all workrelated
claims (2009 to 2013), which is equal to the prevalence of
back injuries.
19
Journal of Physiotherapy 61 (2015) 174181
Journal of
PHYSIOTHERAPY
journal homepage: www.elsevier.com/locate/jphys
[Bisset LM, Vicenzino B (2015) Physiotherapy management of lateral epicondylalgia.
Journal of
Physiotherapy 61: 174181]
_ 2015 Australian Physiotherapy Association. Published by Elsevier B.V. This is an
open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1,10,11
Clinical course and risk factors for lateral epicondylalgia
In his seminal paper on tennis elbow in 1936, Dr James Cyriax
proposed that the natural history of LE was between 6 months and
2 years,
20
which has since been widely cited. In contrast, recent
reports have shown that symptoms may persist for many years and
recurrence is common.
2125
Over 50% of patients attending general
practice for their elbow pain report not being recovered at
12 months.
21,26
Follow-up of participants in a clinical trial
of
non-surgical treatments for LE identi?ed that 20% of respondents
(27/134) reported ongoing pain after 3 to 5 years (mean 3.9 years)
regardless of the treatment received, and that those with high
baseline severity were 5.5 times more likely to still have symptoms
of LE. Therefore, LE is not self-limiting and is associated with
ongoing pain and disability in a substantial proportion of sufferers.
Workers in manual occupations involving repetitive arm and
wrist movements are at increased risk of LE
27,28
and are more
resistant to treatment, with a poorer prognosis.
29,30
Of?ce work,
older age, being female,
31
previous tobacco use and concurrent
rotator cuff pathology are also signi?cantly associated with LE.
One plausible reason for persistent pain in LE is the presence of
sensitisation of the nervous system,
thresholds to nociceptive withdrawal
33,34
35
23
given the reduced
and greater temporal
summation.
36
It has previously been shown that people with LE
exhibit widespread hyperalgesia (ie, enhanced pain response to
various stimuli), which is associated with high pain scores,
decreased function and longer symptom duration.
Diagnosis and assessment
33,34,37,38
LE is a diagnosis based on clinical history and physical
examination, with diagnostic imaging best used when a differential
diagnosis is likely. LE is typically diagnosed by the presence of pain
over the lateral humeral epicondyle that may radiate distally into the
forearm. This pain is aggravated by palpation, gripping and resisted
wrist and/or second or third ?nger extension.
2,39
While LE is thought
to result from an overload of the forearm extensor muscles,
the
pain may have an insidious onset with no speci?c causal activity.
http://dx.doi.org/10.1016/j.jphys.2015.07.015
1836-9553/_ 2015 Australian Physiotherapy Association. Published by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
11
32
21
To assist prognosis,[ 9 _ T D $ D I F F ] assessment of pain and disability[ 1 _ T
D $ D I F F ] should be
performed at baseline, as there is some evidence to show that
people who present with higher pain and disability are more likely
to have ongoing pain at 12 months.
37,40
The Patient Rated Tennis
Elbow Evaluation is a condition-speci?c questionnaire that
includes both pain and function subscales, which are aggregated
to give one overall score of 0 (no pain or disability) to 100 (worst
possible pain and disability).
41,42
A minimumchange of 11 points or
37% of the baseline score is considered to be clinically important.
The most commonfunctional limitationin LE is pain ongripping, and
this can be measured as pain-free grip strength, which is a reliable
and valid measure that is more sensitive to change than maximal
grip strength.
44
With the patient lying supine, the elbow in relaxed
extension and the forearm pronated, the patient is asked to grip a
dynamometer until the ?rst onset of pain, and the mean of three
tests at 1-minute intervals is then calculated.
45
Elbow, wrist, and forearm range of motion, stress testing of the
medial and lateral collateral elbow ligaments, and speci?c tests for
elbow instability (eg, Posterolateral Rotary Drawer Test,
and
Table Top Relocation Test
47
) should be assessed to aid the
differential diagnosis of intra-articular and ligamentous pathology.
The clinician needs to be aware that there may be co-pathologies
and an overlap in symptoms, particularly in patients presenting
with signs of central sensitisation, which may be sensory in nature,
or associated with neuropathic lesions such as posterior interosseous
nerve entrapment as it passes between the two heads of the
supinator muscle. In patients with posterior interosseous nerve
entrapment, they may report pain over the dorsal aspect of the
forearm and exhibit muscle weakness of the ?nger and thumb
extensors without sensory loss.
48,49
Evaluation of the cervical and thoracic spine and neurodynamic
testing of the radial nerve are also helpful in identifying spinal
contribution to pain. While it is currently unclear as to what impact
the presence of cervical and thoracic impairments have on the
condition, exploratory research indicates that neck pain is more
common in people with LE compared with their healthy counterparts.
50
Furthermore, people with LE who also report shoulder or
neck pain have a poorer prognosis in both the short term and long
term,
40
and impairment at C4 to C5 spinal levels has been
identi?ed on manual examination in people with localised
symptoms of LE.
51
The role of cervical and thoracic spine
impairments in the prognosis of LE requires validation; however,
in light of these exploratory studies, the clinician should include
cervical and thoracic spine assessment in their examination of the
patient presenting with LE.
Imaging studies, such as ultrasound (US) and magnetic
resonance imaging, have high sensitivity but [ 1 0 _ T D $ D I F F ] lower speci?
city in
detecting LE.
5254
Structural abnormalities identi?ed on imaging
tend to be consistent across all tendinopathies, and include focal
hypoechoic regions, tendon thickening, neovascularisation, disruption
of ?brils and intrasubstance tears.
5255
Importantly, structural
changes on imaging are present in approximately 50% of healthy,
asymptomatic age-matched and gender-matched individuals,
indicating that caution must be applied in interpreting the relevance
of such ?ndings. Notwithstanding this, negative image ?ndings can
be used to rule out LE as a diagnosis
52,53
and assist with alternative
diagnoses such as instability and/or joint pathology.
54,56
A notable
differential diagnosis is the presence of a large tear (_ 6 mm) within
the tendon or lateral collateral ligament, which has been linked to
failed conservative treatment.
57
Management of lateral epicondylalgia
Physical interventions for LE have been widely investigated,
with the publication of more than 200 clinical trials and several
systematic reviews. Conservative management is recommended as
the ?rst line of treatment for LE.
In order to facilitate summary and interpretation of this volume
of literature, the present review has focused on summarising the
Invited Topical Review 175
46
43
53,54
?ndings for conservative interventions that have been compared to
a control, placebo or other interventions in randomised, controlled
trials (RCTs) of sound methodological quality (de?ned for this
review as a rating _ 5/10 on the PEDro scale). It has predominantly
focused on physical therapies and has not comprehensively
reviewed other medical interventions, including injection therapies
(see Coombes et al
58
for further [ 1 1 _ T D $ D I F F ] information).
A prevailing notion in tendinopathy management is to regard
exercise and load management
59,60
as the key element, with all
other physical modalities being adjuncts to speed the recuperation
or to enhance the effects of exercise and outcomes. While
acknowledging that a variety of outcomes and follow-up times
are reported in the literature, this review has focused on shortterm
follow-up data, wherein the primary aim of adjunctive
treatment is to speed up recovery. Outcomes of pain (converted to
a 0 to 100 scale; 0 = no pain, 100 = worst pain imaginable) and
global rating of success are presented in terms of point estimates of
effect (eg, MD, RR), whereas other outcomes are qualitatively
reported. A summary of the ?ndings from English language papers
(or reports therein of non-English original papers), along with the
level of evidence that underpins their use, is provided. The
interventions reported in this review include exercise, manual
therapy/manipulation, orthoses, laser, US, acupuncture, shock
wave therapy (SWT), and multimodal physiotherapy treatment
many of which have been compared to placebo or control.
Figure 1 is a graphic representation of the number of patients in
RCTs that have investigated the effects of different interventions in
LE, which interventions have demonstrated a superior effect
compared to the comparator group, as well as where interventions
have not yet been compared head-to-head.
Exercise
Exercise is rarely delivered as a treatment in isolation, with
many RCTs studying a variety of exercise types in combination
with other interventions. This review identi?ed eight RCTs of
sound methodological quality from ?ve systematic reviews
that investigated the effects of isometric, isokinetic, concentric and
eccentric exercises in LE. Three of the trials compared eccentric
exercise to other treatments. Tyler et al (n = 21)
found a
signi?cant bene?t of 9 (SD 2) sessions of eccentric exercise over
10 (SD 2) sessions of isotonic extensor exercises, with participants
in both groups receiving a multimodal program of stretches, US,
friction massage, heat and ice. The eccentric exercises produced
greater pain relief and functional improvement, with nine of the
11 participants reporting at least 50% improvement in their pain
following eccentric exercise, compared to three out of 10 reporting
the same level of improvement in the comparator group. Viswas
et al (n = 20)
67
also found that a supervised program of eccentric
exercises improved pain and function more than friction massage
with Mills manipulation at short-term follow-up. Similarly, a
program of eccentric exercises with an elbow orthosis may provide
greater global improvement at the end of treatment (6 weeks RR
4.7, 95% CI 1.1 to 19.8) but no difference in pain relief compared
with an elbow orthosis alone (n = 37).
68
In contrast, a 3-month
home program of eccentric exercises produced variable results
when compared with a program of concentric forearm exercises,
with both exercise interventions demonstrating signi?cant improvement
over short-term and long-term follow-up.
For exercise programs other than eccentric-only regimens,
there was evidence from one RCT that isometric, concentric and
eccentric exercises may be superior to US for pain relief (MD 21,
95% CI 1 to 41) and grip strength (MD 101 N, 95% CI 11 to 1914) at
8 weeks.
70
Compared to placebo US, Selvanetti et al (n = 62)
found a signi?cant bene?t after 4 weeks of eccentric exercises in
combination with contract/relax stretching for pain relief at the
end of treatment (MD, 95% CI 17 to 21). A 3-month home program
of concentric/eccentric forearm exercises reportedly produced
greater reductions in pain but not function, when compared with a
wait-and-see approach.
72
66
69
However, one other study found no
6165
71
[ ( F i g u r e _ 1 ) T D $ F I G ]
Bisset and Vicenzino: Physiotherapy management of lateral epicondylalgia
176
difference in pain and function outcomes at 6 weeks between
concentric exercises, eccentric exercises and stretching (n = 81).
In summary, despite con?icting ?ndings, there was evidence
from several RCTs of sound methodological quality that exercise
may be more effective at reducing pain and improving function
[ 1 2 _ T D $ D I F F ] than other interventions such as US, placebo US, and
friction
massage, but there may be no difference in effect between different
types of exercises.
Manual therapy and manipulation
Six RCTs,
7479
reported within four systematic reviews,
investigated the effects of manual therapy techniques on a range of
outcomes in people with LE, but importantly, most of these
measured the immediate effects of a single treatment session or
the short-term effects after several sessions of manual therapy.
Three of the RCTs studied elbow treatments, two studied neck
treatments and another treatment to the wrist. There was evidence
from two within-subject lab-based studies (n = 48)
that
Mulligans Mobilisation-with-Movement at the elbow is superior
to placebo in providing immediate improvement in pain-free grip
(WMD 43 N, 95% CI 30 to 57) and pain on palpation measured as
the pressure pain threshold (WMD 25 kPa, 95% CI 6 to 45).
A
study of 23 participants in which six sessions of a craniosacral
technique called oscillating-energy manual therapy (the therapist
delivers oscillating energy to the affected elbow via movement of
his/her ?ngertips) reported a signi?cantly greater improvement in
pain severity at the end of treatment (2 to 3 weeks in total),
compared to placebo (MD 21, 95% CI 1 to 42).
76
Two further studies of sound methodological quality investigated
the effects of spinal manual therapy in the management of
LE.
74,75
Placebo
/control
One small pilot trial (n = 10) investigated the effects of local
elbow treatment (stretching, concentric/eccentric strengthening
exercises, joint mobilisations to the elbow and wrist), alone and in
combination with cervical and thoracic manual therapy techniques
(Maitland mobilisations).
74
Extraction of data found a
signi?cant difference between groups for pain-free grip strength
at the end of treatment (MD 15 kg, 95% CI 10 to 19) but no
difference on pain or function outcomes. Another small study
investigated the immediate effects of a single cervical spine
manipulation versus placebo (manual contact) in a within-subjects
study design of 10 people with LE.
75
SWT
n = 1376
Manual
therapy
Exercise
n = 674
n=
156
n= 87
Orthoses
Multimodal
73
61,62,64,80
77,79
There was a signi?cant
62
n= 321
n= 427
immediate improvement in pressure pain threshold of the affected
arm (MD 77 kPa, 95% CI 37 to 116) following cervical manipulation
compared with the placebo, but there was no difference between
interventions for heat or cold pain threshold.
75
In a separate trial, a maximum of nine treatments of
manipulation/mobilisation of the wrist (posteroanterior glide of
the scaphoid) provided superior improvement in pain during the
day (MD 20, 95% CI 3 to 37) but not global assessment (RR 1.3, 95%
CI 0.8 to 1.9) compared at 6 weeks with a multimodal program of
US, friction massage and exercise.
78
In summary, manual therapy techniques to the elbow, wrist and
cervicothoracic spine may reduce pain and increase pain-free grip
strength immediately following treatment, although in many
instances, meta-[ 1 3 _ T D $ D I F F ] analysis was not possible due to
heterogeneity
between manual therapy techniques and timing of follow-up
assessment. There was insuf?cient evidence of any long-term
clinical effects for manual therapy alone.
Orthotics and taping
n= 208
Acupuncture
n= 206
n= 266
Due to differences in the types of orthoses, comparator groups,
timing of follow-up and outcome measures used, pooling of data
was not possible for studies investigating the effects of orthoses in
LE. The reported effects of an orthosis compared with placebo or
control were contrasting between studies. Data from two RCTs
suggested that a dynamic wrist extensor brace
a
or a forearm
counterforce orthosis might provide signi?cant improvement in
pain and function at 4 to 12 weeks follow-up compared with no
treatment or elbow taping (n = 63).
81,82
In contrast, both a
standard counterforce orthosis
b
and a forearm-elbow orthosis
provided no immediate improvement in pain or grip strength
compared with no treatment
83
Laser
US
Figure 1. Network comparison of interventions for lateral epicondylalgia.
Note: The size of the circle represents the total number of participants (n) for
each intervention, the solid line and direction of the arrow indicates the
intervention with known
superior effect over the comparator, and the dotted line represents head-to-head
comparisons reported in the literature but with no clear bene?t of one intervention
over
another.
SWT = shock wave therapy, US = ultrasound.
or placebo.
84
Similarly, there
appeared to be little or no added bene?t of one orthosis over
another in improving pain and function in the short term, when
comparing a standard counterforce orthosis against a counterforce
orthosis with the addition of a wrist splint
d
, (n = 43)
85
or a forearm
extension bar that limits supination.
86
Although this latter study
found a statistically signi?cant difference in the pain subscale of
the Patient Rated Tennis Elbow Evaluation, the between-group
difference was too small to be clinically relevant.
43
[ 1 4 _ T D $ D I F F ] Unpooled data from two RCTs revealed that compared with
corticosteroid injection, an elbow orthosis might be as effective at
c
relieving pain, improving function or in?uencing self-perceived
improvement in the short term (2 to 6 weeks).
87,88
Compared with
a multimodal program of friction massage plus US and exercise, an
elbow orthosis
e
alone was inferior in relieving pain and overall
satisfaction, but was superior in improving function (ability to
perform daily activities) at 6 weeks. There was no difference in
overall success between treatments at 6 weeks (RR 1.2, 95% CI
0.9 to 1.7),
89
but adding an elbow brace to the multimodal program
did not provide additional pain relief or risk of a successful
outcome at 6 weeks (RR 1.1, 95% CI 0.8 to 1.7).
In summary, there was con?icting evidence for the effectiveness
of orthoses in providing pain relief or improvement in
function compared with placebo or no treatment. Elbow orthoses
may be as effective as corticosteroid injection in the short term;
however, there was only one study to support this claim. There was
no compelling evidence that any one orthosis is superior to another
in the short term, or that adding an orthosis to another treatment
provides any additional bene?t.
Acupuncture/dry needling
Results from four studies indicated that acupuncture may be
more effective than placebo in providing pain relief and improvement
in function at the end of treatment,
9093
but this effect was
equivocal at 2 to 3 months of follow-up.
90,91
Acupuncture may
provide superior pain relief and functional improvement compared
with other interventions such as US, where results from two
studies suggest that acupuncture was more effective at the end of
treatment and at the 6-month follow-up.
94,95
One other study
(n = 86) compared acupuncture plus corticosteroid injection with
corticosteroid injection alone. Extracted data indicated a signi?cant
difference in success (RR 1.5, 95% CI 1.0 to 2.3) but not pain
relief (MD 0, 95% CI 1 to 1) between treatments immediately after
treatment.
96
While there appears to be con?icting evidence,
acupuncture might be more effective than placebo and more
effective than US at relieving pain and improving self-assessed
treatment bene?t in the short term.
Laser
In one systematic review,
97
a subgroup of ?ve trials that used
904 nm lasers and doses from 0.5 to 7.2 Joules, reported
signi?cantly improved pain relief (MD 17, 95% CI 9 to 26) and
likelihood of global improvement (RR 1.5, 95% CI 1.3 to 1.8) for
laser compared with placebo. The present review found an
additional three RCTs that used a 904 nm laser, all of which found
no bene?t from laser compared with the comparator groups in the
short term, perhaps because the comparison groups received
active interventions such as exercise.
98,99
Two recent RCTs not
included in the earlier systematic review
97
studied dual wavelength
980/810 nm (versus placebo)
100
or 820 nm (versus US)
and reported no differences. The lack of bene?t from laser might be
due to an inappropriate selection of wavelength or, in one study, a
type II error (n = 16).
100,101
In summary, 904 nm laser might be bene?cial in the short term
compared with placebo, but there is likely no difference between
laser and other active interventions in the short term or long term.
Laser wavelengths other than 904 nm do not appear to have any
bene?t over that of a placebo.
Ultrasound and phonophoresis
Pooled data from four RCTs (n = 266)
102105
found no difference
in the likelihood of global improvement in the short term (up to
12 weeks) between US and placebo (RR 1.3, 95% CI 0.9 to 1.9). There
was low-level evidence from three RCTs that US is no different to
phonophoresis alone,
acupuncture,
94
106,107
combined with an elbow orthosis,
or friction massage in relieving pain.
The
conclusions drawn from previous systematic reviews
remain
unchanged: US appears to be no more effective than placebo for
61,62
Invited Topical Review 177
107
101
106
pain relief or self-perceived global improvement in the short
term.
61,62
Shock wave therapy
Based on the results of nine placebo-controlled trials (1006 participants),
a 2005 Cochrane review concluded the SWT provides
little or no bene?t in reducing pain or improving function in LE.
There is clinical controversy as to which method of application for
SWT is most ef?cacious (eg, radial or extracorporeal, with or
without local anaesthetic), but no studies could be found that have
validated one technique over another. The present review found an
additional ?ve RCTs comparing SWT with placebo,
109,110
US with
hot pack and friction massage,
and surgery.
113
111
corticosteroid injection,
One study reported signi?cant differences in
favour of SWT over a placebo for pain and function measures after
treatment and at a 6-month follow-up, but that data were not
included in pooled analyses due to a lack of clarity in the statistics
reported therein.
109
Gunduz et al found no difference in pain relief
or function between SWT, US with friction massage and
corticosteroid injection at any time point.
111
Shock wave therapy
appeared to be no different to corticosteroid injection or
autologous blood injections in improving pain or function at
12 weeks
112
and no better than surgical percutaneous tenotomy in
providing pain relief or functional improvement.
113
Pooled data
from the Cochrane review plus one additional study
110
found that
compared with placebo, SWT induced no greater pain relief (MD
8, 95% CI 17 to 3) at 6 weeks. Similarly, the pooled mean
difference for pain on resisted wrist extension (Thomsen test) at
4 to 6 weeks follow-up was not signi?cantly different between
SWT and placebo (MD 15, 95% CI 36 to 6).
In summary, pooling data from a previous review and new data
supports the conclusion that SWT is no more effective than placebo
or other treatments for relieving pain in LE.
Multimodal programs
[ 1 5 _ T D $ D I F F ] Several studies [ 1 6 _ T D $ D I F F ] have [ 1 7 _ T D $
D I F F ] combined a range of physical modalities in
the rehabilitation program. A commonly reported multimodal
program involving friction massage in various combinations with
Mills manipulation, US, and stretches has been compared with
exercise,
66,67,114
laser,
115
wrist manipulation,
78
manual therapy,
116
elbow brace,
89
wait-and-see,
117
and corticosteroid injection.
117,118
While the heterogeneity between comparator groups
limits pooling, in almost all studies, this approach was either
inferior or no different to the comparison. One study (n = 60) did
show superior pain relief and functional improvement after
4 weeks of a Cyriax program (friction massage plus Mills
manipulation) compared with phonophoresis plus supervised
exercise.
114
A second study (n = 125) found equivocal results
between a program of friction massage, US and exercise compared
with an elbow orthosis
f
at a 6-week follow-up, with the
multimodal treatment delivering superior pain relief and functional
improvement, but the brace treatment favoured ability of
daily activities and less inconvenience, with no difference between
groups for measures of success (RR 1.2, 95% CI 0.9 to 1.7), severity
of complaints, pain-free grip strength, maximum grip strength and
pressure pain threshold.
89
Despite the diversity of comparisons
and outcomes, it seems that on balance, the majority of the
evidence does not support the use of friction massage in
combination with other treatments in the management of LE.
Two large RCTs compared a multimodal program of Mulligans
Mobilisation-with-Movement and exercise (one with placebo
injection) with wait-and-see (or placebo injection) and corticosteroid
injection.
22,23
Pooled data (n = 205) revealed that physiotherapy
was superior to wait-and-see in providing a successful
outcome in the short term (6 to 8 weeks, RR 2.3, 95% CI 1.6 to 3.3).
At 52 weeks there was a signi?cant, but very small, bene?t of
physiotherapy over wait-and-see in terms of the number of
participants deeming their treatment a success (pooled data RR
108
111,112
1.1, 95% CI 1.0 to 1.1). Physiotherapy was similar to corticosteroid
injection in providinga successful outcomein the short term(pooled
data RR 0.9, 95% CI 0.7 to 1.1), but was superior to corticosteroid
injection at 52 weeks follow-up (RR 1.3, 95% CI 1.1 to 1.5).
In summary, a multimodal program of Mobilisation-withMovement
and exercise is likely superior to wait-and-see and
placebo injection in the short term, and superior to corticosteroid
injection in the long term. Multimodal treatment involving friction
massage may be no different or worse than other treatments in
providing pain relief.
Evidence-informed clinical reasoning
While many treatments for LE have been researched, many
have small effects that occur in the short term (eg, 6 to 12 weeks)
and few have shown consistent effectiveness over other treatments.
Figure 1 highlights the lack of between-intervention
superiority, with signi?cant treatment effects largely seen only
when an intervention is compared with placebo or control (no
treatment). It is also apparent fromFigure 1 that several treatments
have not yet been compared head-to-head. Notwithstanding these
limitations, the current evidence suggests that exercise may be
bene?cial in the short termcompared with other interventions such
as US, friction massage, and stretches for reducing pain and
improving function. The issue with exercise for the clinician is that
there is insuf?cient evidence tosupport any one typeof exercise over
another, and the optimal dose of exercise for LE has yet to be
established. Elbow orthoses may also be useful in providing pain
relief and improvement in function compared with placebo or doing
nothing; however, as with exercise, the typeof orthosis appears to be
less critical. Manual therapy techniques to the elbow, wrist and
cervicothoracic spine may be helpful in providing immediate pain
relief and improvement in function in people with LE. A multimodal
program of Mulligans Mobilisation-with-Movement and exercise
[ ( F i g u r e _ 2 ) T D $ F I G ]
Bisset and Vicenzino: Physiotherapy management of lateral epicondylalgia
178
Good prognosis
PRTEE < 54/100
Pain duration < 3 mth
No adverse prognostic indicators
Education and advice:
tendinopathy explanation
load management

tools and work station


self-management
counsel regarding injections
Not improved
after 6 to 12 wk
22,23
may be superior to wait-and-see and placebo injection in the
short term, and superior to corticosteroid injection in the long
term. In contrast, multimodal treatment involving friction
massage may be no different or worse than other treatments
in providing pain relief. For electrophysical agents, laser using
904 nm wavelengths may be bene?cial in the short term
compared to placebo; however, there is likely no difference
between laser and other active interventions in the short or long
term. Laser wavelengths other than 904 nm do not appear to
have any bene?t over that of a placebo. Ultrasound appears to be
no more effective than placebo in the short term[ 1 8 _ T D $ D I F F ] ;
however[ 1 9 _ T D $ D I F F ] ,
acupuncture may be more effective than US and/or placebo in
the short term. Lastly, despite the addition of new RCTs, the
conclusions drawn from a previous Cochrane review remain
unchanged for SWT, which appears to be no more effective than
placebo for relieving pain in LE.
It is proposed that when consulting a patient with LE, there
might be merit in considering treatment recommendations on the
basis of presenting patient characteristics that are known to be
associated with the risk of a good or poor prognosis (Figure 2). It is
recommended that patients with features indicating a good
prognosis (eg, pain duration of < 3 months, no concomitant neck
or other arm pain, Patient-Rated Tennis Elbow Evaluation (PRTEE)
< 54/100) be counselled on their condition, load management
including tools and work station, self-management and that
adopting a wait-and-see approach is likely to be of bene?t within
12 weeks. This approach is likely of merit for those patients who
are unwilling to perform exercises or visit the physiotherapist for a
number of sessions of Mobilisation-with-Movement with exercise.
In contrast, if the patient would prefer to speed up the process,
then exercise and Mobilisation-with-Movement would be undertaken
because there is evidence of its bene?t.
If a patient presents with features that are known to be
associated with poorer outcomes (eg, concomitant neck and arm
prognos_c con_
nuum
Education and advice:
tendinopathy explanation
load management

tools and work station


self-management
counsel regarding injections
Add exercise (8 wk):
isometric, concentric,
eccentric
general upper limb strengthening
MWM (pain management)
Not improved after 6 to 8 wk or
high pain/disability persists
Add
adjun
ctive physical modalities
(limited number
of sessions):
laser, acupuncture,
elbow and/or spinal
manual therapy
taping, orthoses

not friction massage, US, SWT


Poor prognosis
PRTEE > 54/100
Multiple adverse prognostic
indicators
Consider:
chronic pain management
pain education
referral / medication
differential diagnoses
(imaging, pathology tests)
Not improved
after 8 to 12 wk
Figure 2. Evidence-based clinical pathway for the physiotherapy management of
lateral epicondylalgia (assuming accurate clinical diagnosis at outset). The green
arrows
represent the clinical pathway for patients with characteristics indicative of a
good prognosis; the orange arrows represent the clinical pathway for patients with
characteristics highly indicative[ 6 _ T D $ D I F F ] of a poor prognosis; the
blue arrows represent the initial clinical pathway for patients that fall within
the prognostic continuum (ie, exhibit
one or more poor prognostic indicators); the yellow arrows represent the additional
treatment options for patients at risk of a poor prognosis who fail to respond to
evidencebased
treatment with education, advice, exercise therapy and Mobilisation-with-Movement
manual therapy techniques.
MWM = Mobilisation-with-Movement, PRTEE = Patient-Rated Tennis Elbow Evaluation,
SWT = shock wave therapy, US = ultrasound.
pain, highly repetitive manual work, higher levels of pain and
disability such as a PRTEE > 54/100, cold hyperalgesia with cold
pain thresholds above 13 8C) then a more involved process ought to
be considered. The approach should be more in line with
management of persistent or chronic pain, possibly involving
pain education, referral for medication and in severe protracted
cases the involvement of pain clinic specialists, in addition to the
education and advice that all patients with LE should receive. In
addition, there should be a con?rmation of the diagnosis/
differential diagnosis through use of diagnostic imaging. It is
important to understand that patients are likely to present along a
continuum of prognostic features, which requires the clinician to
use clinical reasoning skills to navigate the management approach
in consultation with the patient. For example, a patient that
appeared to have a good prognosis at the initial consultation but is
no better at 6 to 12 weeks could be encouraged to undertake
exercise and Mobilisation-with-Movement. If the condition does
not improve with a graduated progressive exercise program, other
passive pain relieving techniques might be introduced to speed up
the resolution (eg, Mobilisation-with-Movement (if not already
trialled), laser, acupuncture, spinal manipulation, orthoses). When
introducing passive interventions it is important not to engender a
patients reliance on these interventions, as most of them have only
small effects of short-term duration and they do not facilitate selfmanagement
by the patient. A patients failure to respond when
incorporating passive techniques and exercises over 8 to 12 weeks
should be regarded by the clinician as an indication to escalate the
management program to one like that for the patient presenting
with features associated with a poor prognosis (Figure 2).
Future directions for research and practice
A signi?cant gap in the current literature, and an area of
growing interest, is the effect of potentially confounding variables
on treatment outcomes. Certain clinical characteristics and/or
underlying pathophysiological characteristics may modify treatment
effects. For example, one study has found that the presence of a
tear in the lateral collateral ligament and the size of an
intrasubstance tendon tear detected by US were each signi?cantly
associated with poorer prognosis in patients with LE, and indicated
greater likelihood of failing conservative management, including an
eccentric exercise program.
57
While certain characteristics are
known prognostic factors for long-term pain and disability, the
questionremains: what is the optimal treatment for individuals who
exhibit one or more of these characteristics? Prognostic factors that
have been identi?ed through retrospective data analysis obtained
from clinical trials require con?rmation of their role in modifying
treatment effects through prospective evaluation. If clinical outcomes
for LE are to be improved, it is important to understand how
these prognostic factors modify treatment effects.
The role of exercise in managing LE across the severity spectrum
should be clari?ed, including optimal dosage and type of exercise
for people with mild, moderate or severe symptoms of LE. Given
that exercise is considered to be the cornerstone of rehabilitation,
it is [ 2 0 _ T D $ D I F F ] understudied compared with other interventions. There
is a
need for further well-controlled RCTs investigating the effects of
exercise and the role that supervision of exercise has to play in
terms of patient compliance. Recent work on patellar tendinopathy
has highlighted the effectiveness of isometric exercises compared
with isotonic exercises in producing pain relief in the short term,
which corresponded to normalising cortical inhibition.
While
exercise is generally considered to have an analgesic effect and
prevent the development of chronic pain, exercise-induced
analgesia is impaired in some musculoskeletal conditions that
exhibit central sensitisation, and in some cases, may even increase
pain.
120
The effectiveness of alternative exercise regimens such as
isometric exercise in people with LE is worthy of investigation, as
are other treatments that speci?cally target central sensitisation.
LE is a challenging tendinopathic condition with a complex
underlying aetiology. There is a growing body of evidence that
5,37,40,51
119
Invited Topical Review 179
60
provides some clarity as to what we should and should not be
considering in our management of the patient with LE. With
contemporary knowledge of pain processes as well as local tendon
changes, physiotherapists who use a clinical-reasoning-based
approach to managing musculoskeletal conditions are well placed
to manage patients with LE, as conservative treatment remains the
best practice approach for this population.
Footnotes: www.pedro.org.au.
a
Carp-X, The Netherlands.
Thermoskin, Australia or CountR-Force Tennis elbow brace,
Arlington, USA.
c
Go-strap, Australia.
d
Tha

mert ortho?ex brace,


Netherlands.
e
Epipoint, Zeulenroda, Germany.
f
Epipoint, Bauerfeind,
Germany[ 2 1 _ T D $ D I F F ] .
Ethics approval: Not applicable.
Competing interests: Nil.
Source(s) of support: Nil[ 5 _ T D $ D I F F ] .
Acknowledgements: Aoife Stephenson for conducting the
database searches, Prue Tilley for assistance with data extraction
and Brooke Coombes for collaborating on the concepts of clinical
pathways[ 2 2 _ T D $ D I F F ] .
Provenance: Commissioned. Not peer-reviewed.
Correspondence: Bill Vicenzino, University of Queensland,
School of Health and Rehabilitation Sciences: Physiotherapy and
the NHMRC Centre for Research Excellence Spinal Pain, Injury and
Health, Brisbane, Australia. Email: b.vicenzino@uq.edu.au
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Effectiveness of Cyriax Physiotherapy in Subjects with Tennis Elbow
Prabhakar et al., J Nov Physiother 2013, 3:3
http://dx.doi.org/10.4172/2165-7025.1000156
Novel Physiotherapies
Research Article Open Access
Ashish J Prabhakar
1
2
1
*, Vijay Kage
PDVVPFs, COPT, Ahmednagar, KLEU, India
Institute of Physiotherapy, Belgaum, India
2
and Deepak Anap
Keywords: Pain; Epicondylitis; Handling tools
Introduction
Abstract
1
Pain over the lateral epicondyle, which is exacerbation by work or recreational
activities that involves gripping action
of the hand, such as holding tools, shaking hands, and lifting a kettle, usually
signals that the individuals has a condition
termed lateral epicondylalgia, epicondylitis, or what is more commonly known as
tennis elbow.
Pain over the lateral epicondyle, which is exacerbation by work or
recreational activities that involves gripping action of the hand, such
as holding tools, shaking hands, and lifting a kettle, usually signals
that the individuals has a condition termed lateral epicondylalgia,
epicondylitis, or what is more commonly known as tennis elbow [1].
This condition was first named by Morris (1882) who called it lawn
tennis arm [2].
Tennis elbow is a syndrome characterized by an insidious onset
of elbow pain brought on by wrist extension with pronation or
supination and aggravated by gripping [3].
Lateral epicondylalgia affects 1-3% of the population, only 5%
of all patients seen are recreational tennis players [4]. Although the
syndrome has been identified in patients ranging from 20 to 60 years
old, it predominantly occurs in the fourth and fifth decades. Male and
female prevalence rates are reportedly equal. Seventy-five percent of
patients are symptomatic in their dominant arms [5-7].
The specific muscle most often implicated clinically and surgically
is the extensor carpi radialisbrevis with occasional involvement of the
extensor digitorum communis, extensor carpi radialis longus, and
extensor carpi ulnaris. The possible reason for this more frequent
involvement of the extensor carpi radialisbrevis is its location as one
of the most laterally situated muscles on the lateral epicondyle with
slips taking origin from the radial collateral ligament. The extensor
carpi radialisbrevis is intimately attached to the joint capsule, which
is continuous with the radial collateral ligament and because of this
proximity adhesions are more likely [3].
Cyriax advocated the use of deep transverse friction massage
in combination with mills manipulation in treating lateral
epicondylalgia [5,8].
Deep transverse friction (DTF) is also known as deep friction
massage is a specific type of connective tissue massage applied
precisely to the soft tissue structures such as tendons. It was developed
in an empirical way by cyriax and is currently used extensively in
rehabilitation practice [5].
Mills manipulation is the most common manipulative technique
used by physiotherapists. Cyriax stated that it should be performed
immediately after the DTF is provided that the patient has a full range
of passive elbow extension. If passive elbow extension is limited,
the manipulative thrust will affect the elbow joint, rather than the
common extensor tendon, possibly causing traumatic arthritis. It is
defined as a passive movement performed at the end of rangethat is,
once all the slack has been taken up-and is a minimal amplitude, high
velocity thrust. The aim of this technique, again without properly
designed controlled studies to prove this, is to elongate the scar tissue
by rupturing adhesions within the teno-oseous junction, making the
area mobile and pain free [5].
Cyriax physiotherapy is the technique where DTF and Mills are
used, but very few studies on cyriax physiotherapy using various
outcome measures havebeen conducted. However, the present study
is been undertaken to study the effect of cyriax on pain, grip strength
and to see change in functional activities level fallowing treatment in
cases of tennis elbow.
Method
Design
This study was conducted at the physiotherapy OPD of KLE Dr.
Prabhakar Kore hospital and MRC, Belgaum Karnataka.
Participants were referred by public and private medical
practitioners for treatment of chronic tennis elbow. 20 subjects were
recruited and received Cyriax physiotherapy, Therapeutic ultrasound
and exercisers. The intervention was provided at 7 visits occurring
over 1 week. Measurements were recorded once pretreatment i.e 1

day and once post treatment i.e 7


Participants
th
day.
People entering the trial had to meet the following inclusion
criteria, both male and female between 20 to 50 years of age, pain
on the lateral side of the elbow, tenderness over the forearm extensor
origin, pain with 1 of the following tests: Mills test, Cozens test,
all subjects with symptoms for duration of more than 3 months.
Exclusion criteria were previous surgical history for elbow, fractures
around elbow, restricted extension and laxity at elbow, sensitive
skin, allergies to adhesive tape, a recent steroid injection for same
complaints (3 months).
Intervention
The purpose of this study was explained and a written informed
*Corresponding author: Ashish J Prabhakar, PDVVPFs, COPT, Ahmednagar,
KLEU, India, E-mail: ashp22@gmail.com
Received
April 24, 2013; Accepted May 30, 2013; Published June 02, 2013
Citation: Prabhakar AJ, Kage V, Anap D (2013) Effectiveness of Cyriax
Physiotherapy in Subjects with Tennis Elbow. J Nov Physiother 3: 156.
doi:10.4172/2165-7025.1000156
Copyright: 2013 Prabhakar AJ, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Volume 3 Issue 3 1000156
J Nov Physiother
ISSN:2165-7025 JNP, an open access journal
st
consent was obtained from all the participants. The subjects were
screened based on the inclusion and exclusion criteria. Demographic
data was collected along with initial assessment of VAS, grip
strength, Patient rated forearm evaluation questionnaire for lateral
epicondylitis.
Citation: Prabhakar AJ, Kage V, Anap D (2013) Effectiveness of Cyriax Physiotherapy
in Subjects with Tennis Elbow. J Nov Physiother 3: 156.
doi:10.4172/2165-7025.1000156
The subjects received the selected treatment for 7 sessions at 1
session per day.
Therapeutic Ultrasound: Subject received ultrasound and exercises
before performing deep friction massage and manipulation. Subject
were seated on the chair with shoulder in neutral position, elbow in
right angle and fully supported. The ultrasound was administered for
10 minutes in pulsed mode at 1 w/cm
with ultrasound gel Binder,
over the later epicondyle or area of tenderness.
Exercises
J Nov Physiother
ISSN:2165-7025 JNP, an open access journal
2
Each exercise were repeated 10 times in 3 series, Clenching fist
strongly, resisted wrist flexion and extension, wrist rotation with a
stick and end range stretching for wrist flexors and extensors for at
least 30 sec.
Following these subjects received Cyriax physiotherapy.
Cyriax physiotherapy
Position of the patient-the patient sits with elbow bent to right
angle and full supination. The physiotherapist places one hand at the
patients wrist and holds the forearm in supination.
The pad of the index finger, middle finger or thumb is placed
directly over the involved site, the remaining fingers should be used to
provide further stabilization of the therapists hand, no lubrication is
used, the patients skin must move along with the therapists fingers.
Beginning with light pressure, the therapist moves the skin over
the site of the lesion back and forth in a direction perpendicular to the
normal orientation of the fibers of the involved part.
The massage is given for 2 minutes then stopped for 1 to 2 minutes
then repeated of 2 minutes, working up to 12 to 15 minutes, followed
by the manipulation.
Manipulation
Position of patient- patient sits upright with the arm abducted
to the horizontal and so far medially rotated that the olecranon faces
upward. The physiotherapist stand behind the patient, the patients
forearm must be fully pronated and the wrist flexed.
The physiotherapist now places his left hand on the olecranon,
thus extending the elbow, while the tension is strongly maintained;
he suddenly forces full extension at the elbow with his left hand with
a smart jerk.
This is carried out once each visit, immediately after friction.
Outcome Measures
Pain intensity
By Visual analogue scale-A scale of 10 cm to evaluate intensity of
pain where 0 represents no pain and 10 represent unbearable pain.
Grip strength
Grip strength was measured by hand held dynamometer.
Physical function outcome
Patient rated forearm evaluation questionnaire for lateral
epicondylitis.
Statistical Analysis
Statistical analysis for the present study was done using statistical
package of social sciences (SPSS) version 14 so as to verify the results
obtained. For this purpose data was entered into an excel spread
sheet, tabulated and subjected to statistical analysis. Comparison of
the pre and post intervention outcome measures within the group
was done by using paired-t test. Probability values less than 0.05 were
considered statistically significant and probability values less than
0.0001 were considered highly significant.
Results
VAS-VAS score presession on 1
st
Page 2 of 4
day and post session on 7
day
was 6.0 1.3 and 1.3 1.0 respectively. On comparing these values
there was significant difference.
day
and post session on 7
Grip strength-The mean grip strength score presession on 1
day was 15.3 2.3 which increased to 18.3
2.3 respectively.
th
Finally on comparing the pre and post treatment values of
PRTEEQ i.e, pre 55.4 14.0 fallowing which post treatment decreased
to 21.0 6.2.
Discussion
The present experimental trial was conducted to study the effect
of, Cyriax physiotherapy with conservative treatment of therapeutic
ultrasound and supervised exercise in subjects with lateral
epicondylitis (Tennis elbow). Results of this study were focused on
pain relief where Pain assessment was done by visual analogue scale
(VAS), [9] improvement of grip strength, grip strength was measured
with the help of hand held dynamometer, [10] and reduction in
function activity impairment scores based on Patient rated forearm
evaluation questionnaire for lateral epicondylitis. It was noticed that
there was improvement in all the above parameters.
In this study the age group of the participants was between 20 to
50 years, the mean was 41.15 7.73. According to a study by Halpren
it was stated that, peak age at which tennis elbow occurs is 40 to 50
years [11]. There is a decrease in the occurrence of tennis elbow cases
after 50 years of age, this may be due to diminished intensity of play
or activity at these older ages as suggested in a study by Gruchow et
al. [12].
Subjects of present study consisted of 11 males and 09 females.
According to a study by Alireza Shamsoddini et al. [8] and few
others, tennis elbow is equally distributed between men and women.
But according to Gruchow et al. [12] there was a fourfold increase in
prevalence among men and nearly two fold increases among women.
In this study men had a marginally higher prevalence rate than
women, but there was no statistically significant difference between
men and women prevalence.
The mean values of data from present study showed reduction in
pain score on VAS, improved grip strength on hand held dynamometer
and functional improvement graded on PRFEQ.
When the intra group mean values of VAS were analyzed it was
found statistically significant. In the present study reduction in
th
st
Volume 3 Issue 3 1000156
pain level, as quantified by the VAS with the application of Cyriax is
consistent with the findings of previous studies.
Citation: Prabhakar AJ, Kage V, Anap D (2013) Effectiveness of Cyriax Physiotherapy
in Subjects with Tennis Elbow. J Nov Physiother 3: 156.
doi:10.4172/2165-7025.1000156
It is a common clinical observation that application of DTF leads
to immediate pain relief. The patient experiences numbing effect
during the session and reassessment immediately after the application
of DTF shows reduction in pain and increase in strength and mobility
[13] several theories have been put forth to explain the pain relieving
effect of DTF. According to Cyriax and Cyriax, DTF also leads to
increased destruction of pain provoking metabolites such as Lewiss
substances [5]. Another mechanism by which reduction in pain may
be achieved is through diffused noxious inhibitory controls, a pain
suppression mechanism that releases endogenous opiates.
The latter are inhibitory neurotransmitters which diminish the
intensity of pain transmitted by higher centres [5].
Mills manipulation is performed immediately after DTF, where
it is done to elongate the scared tissue by rupturing adhesions within
the teno-osseous junction making the area mobile and pain free [5,8].
Amit V Nagrale et al. in his study between Cyriax and
phonophorosis found Cyriax physiotherapy to be superior treatment
approach compared to phonophrosis in terms of pain, pain-free grip,
and functional status [14].
It is important to note that all participants were given ultrasound
and supervised exercises as a common conventional method.
Ultrasound refers to mechanical vibrations which are essentially
the same as sound waves but of a higher frequency. Such waves are
beyond the range of human hearing and can therefore also be called
ultrasonic [15].
In a study by DVazet al. [16], they studied the effect of pulsed lowintensity

ultrasound therapy for chronic lateral epicondylitis. They


concluded that low-intensity ultrasound (LIUS) was no more effective
for a large treatment effect than placebo for recalcitrant LE. This is in
keeping with other interventional studies for the condition.
Ultrasound has been used over a period of time to control acute and
chronic pain over a localized area. Several studies have demonstrated
the effectiveness of ultrasound in reducing pain. In study by Binder et
al., where they checked for the effectiveness of ultrasound in treating
soft tissue lesions, where they conclude that Ultrasound enhances
recovery in most patients with lateral epicondylitis [17].
Timnoteboom et al. [18], in his study mentioned that chronic
symptoms are commonly associated with inadequate muscle power
and endurance. Reduction in grip strength was noted in these subjects
and to overcome supervised exercises were prescribed.
This strengthening of these muscles strengthening the damaged
attachment of wrist extensors resulted in better repetitive wrist
movements performed by the subjects with tennis elbow [19].
It was claimed that the eccentric training results in tendon
strengthening by stimulating mechanoreceptors in tenocytes to
produce collagen, which is the key cellular mechanism that determines
recovery from tendon injuries. Strengthening may improve collagen
alignment of the tendon and stimulate cross linkage formation both
of which improve the tensile strength of tendon [19].
Literatures suggest that strengthening and stretching both are
main components of exercise program, because tendons must be
flexible along with strong. Positive effects of exercise program for
tendon injuries may be attributable to lengthening of muscle tendon
unit by stretching and strengthening exercise which could achieve
loading effect within muscle tendon unit along with hypertrophy and
increased tensile strength of the tendon [20].
The results of this study showed significant increase in grip
strength.
PRTEE Formerly known as the Patient-Rated Forearm Evaluation
Questionnaire (PRFEQ) seems to be a reliable tool for assessing pain
and function in patients with chronic lateral epicondylitis. The PRTEE
has shown greater reliability and has sufficient width scale to reliably
detect improvement or worsening in most subjects. For these reasons,
the PRTEE appears to be the one of most commonly reported measure
of health status in patients with Tennis elbow [21].
In the present study the means of PRTEE were analyzed, where
intra group analyses showed significant improvement.
On comparing pre and post values it showed significant
improvement in terms of pain, grip strength and functional
performance in subjects with tennis elbow. Therefore it can be
concluded that Cyrix physiotherapy can be incorporated with
conservative physiotherapy management for better results.
Limitations of the study were, subjects could not be followed up
for longer period of time, to assess long term benefit, and occupation
relevance was not compared.
Future Scope of the Study, studies with longer follow-up period
are recommended to assess long term benefits, Conduct the study with
larger sample size, Range of Motion could be taken in to consideration
Conclusion
The present study provided evidence to support the use of
Cyriax physiotherapy in relieving pain, improving grip strength and
functional performance in subject with tennis elbow.
Conflict of Interest
The authors report no conflict of interest.
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Citation: Prabhakar AJ, Kage V, Anap D (2013) Effectiveness of Cyriax Physiotherapy
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Subjects with Tennis Elbow. J Nov Physiother 3: 156. doi:10.4172/2165-7025.1000156
Volume 3 Issue 3 1000156
J Nov Physiother
ISSN:2165-7025 JNP, an open access journal
Page 4 of 4

This course was edited and developed from the document: Physiotherapy Management
of
Lateral Epicondylalgia Bisset LM, Vicenzino B (2015), Journal of Physiotherapy
61: 1741,
(DOI: http://dx.doi.org/10.1016/j.jphys.2015.07.015), used under the Creative
Commons Attribution License.

This course was edited and developed from the document: Effectiveness of Cyriax
Physiotherapy
In Subjects with Tennis Elbow Prabhakar AJ, Kage V, Anap D (2013), J Nov
Physiother 3: 156.
(DOI:10.4172/2165-7025.1000156), used under the Creative Commons Attribution
License.