Lateral Epicondylosis Research Paper

Introduction
Lateral epicondylosis (LE) is a musculoskeletal condition that causes elbow dysfunction to the soft tissue surrounding the lateral epicondyle of the humerus. The aetiology of this condition is still unclear, however it is assumed to occur from over-stretching or excessive use of extensor muscles.1 Diagnosis is often based on the patients history and physical signs such as, pain radiating over the outer compartment and down the posterior arm where the extensor muscles (extensor carpi radialis brevis) run, muscle weakness, and decreased wrist extension.2 Some treatment methods include: R.I.C.E., massage, steroidal injections, concentric and eccentric strengthening exercises, stretching, and surgery.1 However, due to the uncertainty of the aetiology of this condition there is no clear efficacious treatment method for LE.3

Analysis
Martinez-Silvestrini et al. 4 used a randomised controlled trial to investigate whether stretching exercises
alone versus stretching exercises supplemented with eccentric and concentric exercises was more effective in treating LE. The objective of this 6 week program was to determine the significance of eccentric strengthening exercises. The participants were randomised into the 3 groups which increases internal validity however, the assessors were not blinded during the baseline assessment or during the follow-up which may have left the study vulnerable to expectation bias. The exclusion criteria was extensive for this study which may limit the source population because it was not very generalisable. The results from this study show a significant improvement over the 3 groups (p=0.01), however between each group there was no significant difference in outcomes at 6 weeks (p=0.05). Therefore, there was no evidence proving the efficacy of one treatment over the other. Nevertheless, it was an important finding that eccentric training was not significantly worse than the other forms of treatment and was not associated with symptom exacerbation.

The control group received home stretching exercises while the other 2 groups received either eccentric or concentric exercises in addition to stretching exercises. A control group without an intervention would be useful to differentiate between spontaneous healing and the response to the intervention,4 but there is a question of ethics by not providing treatment to a patient, therefore this ‘pseudo-control group’ receives a standard form of treatment.5 Cofounding factors that may have contributed to measurement errors and affected the outcomes include the other types of treatments participants had access to such as; education, icing and stretching, which may have aided in the patients improvement. They were also not excluded from receiving other forms of treatment/interventions which also may have affected the internal validity of the study. Other factors include; the exercise program was done unsupervised which can lead to noncompliance not being reported and poor exercise technique, subjects were instructed to not exercise through pain which could have affected the results, patients with LE do improve over time so we cannot be sure if improvement is due to the natural course of the condition, and measurements were done by using questionnaires which are subjective as participants have different pain thresholds.4

Although there was some statistical significance being that the p-value for the difference from baseline to six weeks within groups using a paired t-test was <0.01). However at the other succeeding follow-ups there was no statistically significant outcomes measured by the VAS. There was also no statistically significant differences between groups at any time using VAS, and the overall patient satisfaction was not significant. Due to the very limited evidence supporting the hypothesis this study does not show any benefit of eccentric strengthening over other forms of treatment for LE.6

This study had many limitations to it including the small number of participants, the short duration of symptoms, variation in control group, and uncontrolled concurrent treatments.6 This study did however have generalisability as it had high levels of internal validity and minimal exclusion criteria allowing the study and source population to be connected.7 Ultimately, this study showed no clinical significance supporting the use of eccentric strengthening to treat LE.

Conclusion
Overall it cannot be deduced from these articles whether eccentric strengthening exercise is more superior than other forms of treatment for LE.
Martinez-Silvestrini et al.4 showed improvement in eccentric, concentric and stretching, but none of them were more efficacious than the other. This may have been because the control group was not a placebo but a ‘psuedo-control group’5 or because of the short duration of the study. Wen et al.6 displayed minimal evidence to support their hypothesis that eccentric exercises would show greater improvement in LE, and had too many limitations.

Based on the findings from these articles I would not include eccentric strengthening in my treatment regime for LE because, there is not enough statistically or clinically significant evidence to support this form of treatment over stretching and other modalities. Ultimately I would take into consideration the individuals response to certain treatments and work out a management strategy that was tailored specifically for
them.