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Chronic Tennis Elbow: Aspects on Pathogenesis and Treatment in a Soft Tissue Pain Condition
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Clinical Epidemiology.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Objectives: To study the treatment practice of chronic tennis elbow (TE) among general practitioners (GPs) and physiotherapists (PTs), the effects of a simple, graded home exercise regime versus expectation, the effects of eccentric versus concentric exercise, and the involvement of the substance P – NK1 receptor system in the peripheral, painful tissue of chronic TE patients by positron emission tomography (PET).

Materials and methods: A postal survey regarding therapeutic methods used in patients with chronic TE was sent to 129 GPs and 77 PTs, 81 subjects with chronic TE were randomly and blindly assigned to either an exercise group or a wait list group, 120 subjects were randomly assigned to either eccentric or concentric exercise and ten subjects were examined by PET and the NK1 specific radioligand [11C]GR205171.

Results: High proportions of GPs and PTs used ergonomic counselling and stretching in the treatment of chronic TE. The majority of GPs prescribed passive anti-inflammatory measures such as sick leave and anti-inflammatory medication. Many PTs prescribed dynamic, particularly eccentric, exercise. Graded dynamic exercise according to a simple low-cost protocol, has better effect on pain than a wait-and-see attitude. Adjusted for outcome affecting variables, eccentric graded exercise has quicker effect than concentric graded exercise. During PET scan with the NK1 specific radioligand [11C]GR205171, voxel volume and signal intensity of this volume was significantly higher in the affected than the unaffected arm in subjects with unilateral chronic TE.

Conclusions: GPs and PTs used many treatments to a similar extent but differed regarding the use of exercise. Chronic TE responds favourably to graded dynamic exercise aimed specifically at the painful tissue. The exercise should stress the eccentric work phase. The substance P – NK1 receptor system seems to play a part in the peripheral, painful tissue of a chronic, soft tissue pain condition such as chronic TE.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2011. , p. 65
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 712
Keywords [en]
tennis elbow, pain, chronic, soft tissue, imaging, PET, RCT, survey, treatment, exercise, eccentric, concentric, epicondylosis, epicondylitis, tendinosis, tendinitis
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-160051ISBN: 978-91-554-8187-2 (print)OAI: oai:DiVA.org:uu-160051DiVA, id: diva2:447989
Public defence
2011-11-25, Rudbecksalen, Rudbecklaboratoriet, Dag Hammarskjölds väg 20, Uppsala, 13:15 (Swedish)
Opponent
Supervisors
Projects
Epi-XAvailable from: 2011-11-03 Created: 2011-10-13 Last updated: 2011-11-10Bibliographically approved
List of papers
1. Treatment practice in chronic epicondylitis: a survey among general practitioners and physiotherapists in Uppsala County, Sweden
Open this publication in new window or tab >>Treatment practice in chronic epicondylitis: a survey among general practitioners and physiotherapists in Uppsala County, Sweden
2005 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 23, no 4, p. 239-41Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To investigate treatment practice among general practitioners (GPs) and physiotherapists (PTs) in chronic epicondylitis of 3 months' duration or more. DESIGN: Postal survey. SETTING AND SUBJECTS: All 129 GPs and all 77 PTs at 35 primary health care centres in Uppsala County, Sweden, received the questionnaire. MAIN OUTCOME MEASURES: Proportion of responders using various treatments (five specified alternatives + open question). RESULTS: The questionnaire was answered by 70% of the GPs and 61% of the PTs. Ergonomic counselling, stretching, and orthotic devices were common, and used to a similar extent by GPs and PTs. Acupuncture was also common, but less so among GPs than PTs. Transcutaneous electric nerve stimulation was used by relatively few GPs and PTs. The open question revealed that dynamic exercise, particularly eccentric, was used by most PTs but only one GP. A majority of GPs prescribed sick leave and anti-inflammatory treatment with an NSAID or cortisone injections. CONCLUSION: A large number of treatment methods in chronic epicondylitis were reported, none of which is properly evidence-based and some of which are even known to be ineffective. There is a need for randomized controlled studies of potentially effective treatments in this condition.

Keywords
Anti-Inflammatory Agents; Non-Steroidal/therapeutic use, Chronic Disease, Family Practice, Humans, Physical Therapy (Specialty), Physical Therapy Modalities/utilization, Physician's Practice Patterns, Questionnaires, Referral and Consultation, Research Support; Non-U.S. Gov't, Sweden, Tennis Elbow/drug therapy/rehabilitation/*therapy
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-75207 (URN)10.1080/02813430510031333 (DOI)16272073 (PubMedID)
Available from: 2007-03-21 Created: 2007-03-21 Last updated: 2017-12-14Bibliographically approved
2. A randomized controlled trial of exercise versus wait list in chronic tennis elbow (lateral epicondylosis)
Open this publication in new window or tab >>A randomized controlled trial of exercise versus wait list in chronic tennis elbow (lateral epicondylosis)
2011 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 116, no 4, p. 269-279Article in journal (Refereed) Published
Abstract [en]

Background.

Chronic tennis elbow (lateral epicondylosis) is a common disorder. Like other chronic soft tissue pain conditions it is often difficult to treat successfully. The effects of exercise have been discussed but no convincing evidence has been put forward so far, and a simple protocol for exercise is lacking.

Aims of the study.

This study is a randomized, controlled, clinical trial of the effect of exercise versus expectation (wait-list) on pain, muscle strength, function, and quality of life in patients with longstanding lateral epicondylosis.

Methods.

Eighty-one subjects with tennis elbow lasting for more than three months were randomly allocated to an exercise group (n=40) or a reference group (n=41). The exercise group performed daily exercise, with weekly load increase, for three months. The reference group was wait listed, but otherwise followed in the same way. Outcome measures were pain during maximum voluntary muscle contraction (Cozen´s test) and pain during maximum muscle elongation with a load (modified Empty-can-test), muscle strength measured with a Chatillon MSE 100 hand-held dynamometer, and the Disability of the Arm, Shoulder and Hand (DASH) and the Gothenburg Quality of Life questionnaires.

Results

.The exercise group had greater and faster regression of pain, both during muscle contraction and muscle elongation, than the reference group (p=0.0005 and p=0.0016, respectively). There was a non-significant muscle strength difference between the groups, but no differences regarding DASH scores or quality of life measures.

Conclusions

.Exercise appears to be superior to expectation in reducing pain in chronic lateral epicondylosis.

Keywords
exercise, chronic, pain, tennis elbow, epicondylitis, RCT, epicondylosis, tendinosis, tendinitis
National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:uu:diva-159954 (URN)10.3109/03009734.2011.600476 (DOI)000296794100008 ()
Available from: 2011-10-13 Created: 2011-10-12 Last updated: 2017-12-08Bibliographically approved
3. A randomized controlled trial of eccentric versus concentric exercise in chornic tennis elbow (lateral epicondylosis)
Open this publication in new window or tab >>A randomized controlled trial of eccentric versus concentric exercise in chornic tennis elbow (lateral epicondylosis)
2011 (English)In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149Article in journal (Refereed) Submitted
Abstract [en]

Chronic tennis elbow was used in this paper as a model for chronic soft tissue pain, which is a common problem, often difficult to treat. Exercise has been shown to have positive effects in chronic pain, but whether eccentric or concentric exercise should be used is controversial. The aim of this study was to test the effects of eccentric versus concentric exercise on pain, strength, function and quality of life in chronic tennis elbow. One hundred and twenty subjects with tennis elbow lasting for more than three months were randomly allocated to eccentric exercise (n=60) or to concentric exercise (n=60), performed at home daily for three months with increasing load. The subjects were seen at baseline and after one, two, three, six, and twelve months of follow up, where the outcome measures pain during maximum voluntary muscle contraction (Cozen’s test), pain during maximum muscle elongation (modified Empty can test), and muscle strength were measured. Function was measured with the Disability of the Arm, Shoulder and Hand questionnaire (DASH) and quality of life with the Gothenburg Quality of Life questionnaire at baseline and after three, six, and twelve months. The eccentric exercise group had faster regression of pain, both during muscle contraction and elongation, as well as greater increase of muscle strength than the concentric group (p<0.0001, p=0.006, and p<0.02, respectively). The differences persisted throughout the follow-up period. There were no significant differences between the groups regarding DASH scores or quality of life measures.

Keywords
eccentric, exercise, concentric, RCT, tennis elbow, epicondylosis, tendinosis, tendinitis, chronic, pain
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-160038 (URN)
Available from: 2011-10-13 Created: 2011-10-13 Last updated: 2017-12-08Bibliographically approved
4. PET-scan shows peripherally increased neurokinin 1 receptor availability in chronic tennis elbow: a picture of neurogenic inflammation?
Open this publication in new window or tab >>PET-scan shows peripherally increased neurokinin 1 receptor availability in chronic tennis elbow: a picture of neurogenic inflammation?
Show others...
2011 (English)In: Pain, ISSN 0304-3959, E-ISSN 1872-6623Article in journal (Refereed) Submitted
Abstract [en]

In response to pain, neurokinin 1 (NK1) receptor availability in the central nervous system is altered in the dorsal horn of the spinal cord as well as in the brain. But the NK1 receptor and its primary agonist, substance P, also play a crucial role in peripheral tissue in response to pain, as part of neurogenic inflammation. However, little is known about alterations in NK1 receptor availability in peripheral tissue in chronic pain conditions and very few studies have been performed on human beings. We therefore performed positron emission tomography (PET) with the NK1 specific radioligand [11C]GR205171 in ten subjects with chronic tennis elbow. We demonstrated increased NK1 receptor availability in the affected arm as compared with the unaffected arm, measured as differences between the arms in number and volume of pixels > 2.5 SD above reference as well as signal intensity of this volume. We conclude that in addition to alteration of the NK1 receptor in the CNS, there is also activation, or up-regulation of the NK1 receptor in the peripheral, painful tissue in a chronic pain condition. We interpret this increased NK1 receptor availability as part of ongoing neurogenic inflammation and suggest that this is part of the cause of chronic tennis elbow.

Keywords
PET, chronic, pain, substance P, neurokinin 1, tennis elbow, epicondylitis, epicondylosis
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-160048 (URN)
Available from: 2011-10-13 Created: 2011-10-13 Last updated: 2017-12-08Bibliographically approved

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