You are on page 1of 13

Clinical Rehabilitation

http://cre.sagepub.com/

Comparison of effects of Cyriax physiotherapy, a supervised exercise programme and
polarized polychromatic non-coherent light (Bioptron light) for the treatment of lateral
epicondylitis
Dimitrios Stasinopoulos and Ioannis Stasinopoulos
Clin Rehabil 2006 20: 12
DOI: 10.1191/0269215506cr921oa

The online version of this article can be found at:
http://cre.sagepub.com/content/20/1/12

Published by:

http://www.sagepublications.com

Additional services and information for Clinical Rehabilitation can be found at:

Email Alerts: http://cre.sagepub.com/cgi/alerts

Subscriptions: http://cre.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

Citations: http://cre.sagepub.com/content/20/1/12.refs.html

>> Version of Record - Jan 1, 2006

What is This?

Downloaded from cre.sagepub.com at UNIV OF ILLINOIS URBANA on October 2, 2014

com at UNIV OF ILLINOIS URBANA on October 2. fcd s re. radialis brevis (ECRB)i the most commonly af matolory and Rehabilitation Centre. Orfanidou 16. Leeds Metropolitan University. Athens. commonly referred to as condition is a degenerative or failed healing tendon tennis elbow.sagepub. I 191/0269215506cr921 oa Downloaded from cre.1.Clinical Rehabilitation 2006. Athens. Greece and School of Health and Human Sciences.3 -6 The Lateral epicondylitis. Setting: Rheumatology and rehabilitation centre.3 It is usually defined as a syndrome of pain in the area of the lateral epicondyle.7 ItCis generally awl Athens 11 141. a supervised exercise programme.05). 20: 12-23 Comparison of effects of Cyriax physiotherapy. If this is not possible. Subjects: This study was carried out with 75 patients who had lateral epicondylitis. 2014 .05) and at any of the follow-up time points (P<0. one month (week 8). Greece Received 12th March 2005. vascular hyperplasia and disorga- nized collagen in the origin of the extensor carpi Address for correspondence: Dimitrios I Stasinopoulos. Interventions: Group A (n = 25) was treated with Cyriax physiotherapy. e-mail: d_stasinopoulos@yahoo. All patients received three treatments per week for four weeks. returned for revisions 25th May 2005. They were allocated to three groups by sequential allocation. Introduction of the arm. Cyriax physiotherapy and polarized polychromatic non-coherent light (Bioptron light) may be suitable. Design: Controlled clinical trial. Patissia. Objective: To compare the effectiveness of Cyriax physiotherapy. Group C (n = 25) received polarized polychromatic non-coherent light (Bioptron light).gr fected structure. a supervised exercise programme and polarized polychromatic non-coherent light (Bioptron light) for the treatment of lateral epicondylitis Dimitrios Stasinopoulos Rheumatology and Rehabilitation Centre. Leeds. Rheu. It is generally a work-related or (D 2006 Edward Arnold (Publishers) Ltd 10. and polarized polychromatic non-coherent light (Bioptron light) in the treatment of lateral epicondylitis. Outcomes: Pain was evaluated using a visual analogue scale and function using a visual analogue scale and pain-free grip strength at the end of the four-week course of treatment (week 4). UK and loannis Stasinopoulos Rheumatology and Rehabilitation Centre. A supervised exercise programme was given to group B (n = 25). Greece. Results: The supervised exercise programme produced the largest effect in the reduction of pain and in the improvement of function at the end of the treatment (P<0. Conclusion: The supervised exercise programme should be the first treatment option for therapists when they manage lateral epicondylitis patients. revised manuscript accepted 20th June 2005. is one of the most common lesions response characterized by the increased presence of fibroblasts. three months (week 16) and six months (week 28) after the end of treatment.

daily living. affected arm and dominant exercise programmes are rarely effective because arm. cross-over designs are limited in situations where Indeed. Methods peutic modalities. patients fail to comply with the regimen.12.4 supervised exercise programme and polarized No ideal treatment has emerged for the manage. IS interviewed each siotherapy and exercise programmes.com at UNIV OF ILLINOIS URBANA on October 2. physiotherapists are able statistical clinical significance for all outcome to use a new modality called polarized polychro. duration of symptoms. Home ment. such as palpation over the lateral epicondylitis is not known. Therefore. a super- that the optimal physiotherapy treatment strategy vised exercise programme.10. 6 confirm these early findings and demon. to the patients' therapy group. with a light devices (Bioptron light. advocate a conservative approach.8'9 turers of polarized polychromatic non-coherent The dominant arm is commonly affected. previous treat- grammes carried out in a clinical setting.'9 More recently. measures on lateral epicondylitis. 22 suggest that a sample size of 25 supervised exercise programmes appear to be at all subjects per group is sufficient to demonstrate effective. patients are cured by the intervention and do not vealed a systematic review published in 1992 that have the opportunity to receive the other treat- concluded that there was a lack of scientific ments following cross-over. a cursory search of the literature re. had over 25 years' experience and who evaluated strate the importance of improving the the patients to confirm the lateral epicondylitis current physiotherapy management of lateral epi.2 Manufac- contractions and gripping activities of the wrist. Many clinicians of lateral epicondylitis. 2014 . the sheer A controlled. assessments were conducted by IS who was blind ments for lateral epicondylitis are Czriax phy.sagepub. massage and manual techniques.' Two recently published investigator who administered the treatments systematic reviews by Smidt et al.' -16 There patient to ascertain baseline demographic and are two types of exercise programme: home clinical characteristics. cover a wide years.6 However. including patient name. and gained informed consent. resisted middle finger extension and ison of the effects of Cyriax physiotherapy. All Two of the most common physiotherapy treat. sex.19 Only Abbott et al. and polarized polychro- is not known and more research to establish the matic non-coherent light (Bioptron light). diagnosis. polychromatic non-coherent light for the treatment ment of lateral epicondylitis. A most effective physiotherapy treatment in lateral parallel-group design was employed because epicondylitis patients is needed.2' Two investigators evidence supporting physiotherapy treatments were involved in the study: (1) the primary for lateral epicondylitis. the facet of the lateral epicondyle. a passive wrist flexion. Clinical effects Downloaded from cre. prevalence of 1-3% in the general populationl0 Switzerland) claim that the waves of this light and the peak prevalence is between 30 and 60 move in parallel planes (polarization).3. age. resisted wrist aim of the present article was to make a compar- extension. exercise programmes and supervised exercise pro.2'6'14'15 Phy- siotherapy is a conservative treatment that is usually recommended6"16'17 and a wide array of physiotherapy treatments are used: electrothera. assessments. who et al. 18 and Trudel (DS). both of which may affect activities of ency). Wollerau. repetitive eccentric management of lateral epicondylitis. monotonous. monocentre trial was conducted in a variety of physiotherapy treatments with such clinical setting over an 18-month period to assess different theoretical mechanisms of action suggests the effectiveness of Cyriax physiotherapy. Treatment of lateral epicondylitis 13 sport-related pain disorder.14. performed all baseline and follow-up condylitis. and are not synchronized (incoher- function. Bioptron. Diagnosis can be confirmed by tests The clinical value of these three treatments for that reproduce the pain.3' 1'2 Lateral epicondylitis appears to be of range of wavelengths (480-3400 nm) including longer duration and severity in women. exercise programmes.13 visible light and part of the infrared range (poly- The main complaints are pain and decreased chromy). occupation. (2) a specialized rheumatologist (IS). usually caused by matic non-coherent light (Bioptron light) for the excessive quick.

(2) local or generalized arthritis. (8) an in placebo-controlled studies measuring pain relief installed pacemaker. patients were given no indication of the potentially beneficial effects of the treatments or any feedback Patients were excluded from the study if they on their performance in the pre. For example. weeks (one month). neck and/or Cyriax physiotherapy was applied as presented thoracic region. The formula that used to estimate tan University Research Ethics Committee and the appropriate sample size was: access to patients was authorized by the manager N = 16c&2/d2 of the rheumatology and rehabilition centre. lifting.com at UNIV OF ILLINOIS URBANA on October 2. knitting.sagepub. the fourth from lateral elbow pain were examined and patient with lateral epicondylitis to the Cyriax evaluated in the rheumatology and rehabilitation physiotherapy group. (1) dysfunction in the shoulder. equivalent to 25% with 80% of power and a 5% The study was approved by the Leeds Metropoli- significant level. (7) pregnancy. Patients Patients between 30 and 60 years old were were informed to refrain from taking anti-inflam- included in the study if. (6) limita. matory medication throughout the course of study. the first patient where C2 is the variability of the data and d2 is the with lateral epicondylitis was assigned to the effect size.14 D Stasinopoulos and I Stasinopoulos of 20% had been reported as clinically meaningful tions in arm functions. The patients were allocated to three groups by sequential allocation. grasping.8 5 lations suggested that a sample size of 25 patients All patients received a written explanation of the per group was sufficient to detect a 20% change in trial prior to entry into the study. at the time of presentation. All patients lived in Athens. and so on.and postapplica- had one or more of the following conditions: tion measurements. they had been evaluated as having clinically Patient compliance to this request was monitored diagnosed lateral epicondylitis for at least four using a treatment diary. assuming that variance was signed informed consent to participate in the study. in at least two of the following four tests4: Communication and interaction (verbal and non-verbal) between the therapist and patient 1) Tomsen test (resisted wrist extension) was kept to a minimum and behaviours sometimes 2) Resisted middle finger test used by therapists to facilitate positive treatment 3) Mill's test (full passive flexion of the wrist) outcomes were purposefully avoided. All patients gave outcome measures. (2) less pain during orthopaedic medicine on Cyriax principles (DS). For example.7 and (3) pain four weeks. been operated on and (10) had received any therapeutic interventions such as low-power laser conservative treatment for the management of light. (5) bilateral lateral epicondylitis. activities that irritated the elbow such as shaking referred or referred by their physician or phy. Therefore the above formula is with lateral epicondylitis to the supervised exercise N = 16(252)/(202) = 16 x 625/400 = 25 programme group. Power calcu. (4) radial nerve entrap. driving a car and using a screwdriver. resistance supination with the elbow in 900 of Each treatment was given three times per week for flexion rather than in full extension. handwriting. For example in our trial a=25 and Cyriax physiotherapy group. centre located in Athens between January 2003 and All patients were instructed to use their arm January 2004. sisted of 10 min of deep transverse friction im- ment. the second patient d = 20. by a recently published review article24 and con- (3) neurological deficit.4. (9) the affected elbow had and functional outcomes in response to physio. siotherapist. during the course of the study but to avoid were native speakers of Greek. Greece. mediately followed by one intervention of Mill's Downloaded from cre. 2014 . before entering the study. baseline variance for pain and lateral epicondylitis in the preceding four weeks functional outcomes was set at 25%. hands. Patients were included in the All treatments were administered at the centre trial if they reported (1) pain on the facet of lateral by a qualified physiotherapist with a certificate in epicondyle when palpated. the third patient with lateral epicondylitis to the polarized polychromatic non- Patients over 18 years old who were suffering coherent light (Bioptron light) group.23 In this study. and were either self. 4) Handgrip dynamometer test.

three times before surface with the elbow in 900 of flexion and the and three times after the eccentric exercises with a forearm in pronation. Bioptron 2 was held at a 90° angle 5-10 cm above centric exercises of wrist extensors were performed the clean bare skin of the bellies of the extensors with elbow on bed in full extension.25'26 Bioptron the amount of force each patient is able to generate 2 is a product from Harrier Inc. (anterior) with the elbow in extension and the ing exercises of ECRB tendon were repeated six forearm in supination and (2) from the lateral times at each treatment session. Ec. at the end of treatment (week Patients were told to continue with the exercise 4). The emission of type of connective tissue massage applied precisely light may be administered in 1-min steps and to the soft-tissue structures such as tendons. Static stretch. then returned to the in the present study. However. Each patient was evaluated at starting position with the help of the other hand. In addition.24 controlled by an integrated soft-start/soft-stop Mill's manipulation is a passive movement per. Bioptron enced during the procedure.e. the baseline (week 0). the load was increased using and 10 (cm) was 'worst pain imaginable'. The probe of the Bioptron 2 was held at progressive eccentric exercises of wrist extensors a 900 angle 5 -10 cm above the clean bare skin of at each treatment session were performed with the lateral condyle (1) from the upper surface 1 min rest interval between each set.27 (Bioptron light) therapy was administered using a In addition. disabling. specific power density = basis of the patient's description of pain experi. the probe of 30-s rest interval between each repetition. EEC and carries an ISO 9001 certificate and tensors and static stretching exercises of ECRB EN 46001 as a patented medically approved tendon. of elbow extension has been taken up). 40 mW/cm2. USA. in which 0 according to the patient's tolerance. there is a characteristic sound (beep it consists of minimal amplitude high-velocity tone). The output characteristics of Bioptron 2. 2 is approved by the US Food and Drug Admin- The supervised exercise programme consisted of istration. Pain-free grip strength is defined as in each location (i.24 Cyriax are: light wavelength = 480-3400 nm. forearm in full pronation be valid and sensitive of the VAS. electronic switch. From this position patients flexed their Pain. degree of physiotherapy treatment was individualized on the polarization = 95%. energy density = 2. Three sets of 10 repetitions of slow product. Patients were instructed to report their The supervised exercise programme treatment was overall level of elbow function over the previous individualized one the basis of the patient's de. tron 2 is over. When patients were able to perform the Pain was measured on a visual analogue scale eccentric exercises without experiencing any minor (VAS). and with an isometric gripping action before eliciting Downloaded from cre.27 and the wrist in flexion and ulnar deviation Function was measured using a VAS.e. lia. The pain free weights. Static stretching exercises of the VAS was used to measure the patient's worst level ECRB tendon were performed with the help of of pain over the previous 24 h prior to each the therapist. where 0 (cm) was 'least pain imaginable' pain or discomfort. extension thrust at the elbow once the full range according to the manufacturer's user guide. function'. 24 h prior to each evaluation and this approach scription of pain experienced during the procedure.supination. at one month (week 8). The therapist placed the elbow of evaluation and this approach has been shown to patient in full extension. function and drop-out rate were measured wrist. wrist in extended position (as high as flexion and the forearm in mid-position of possible) and the hand hanging over the edge of pronation . forearm in muscles of the wrist with the elbow in 900 of pronation.4 J/cm2. 2014 .com at UNIV OF ILLINOIS URBANA on October 2. Treatment of lateral epicondylitis 15 manipulation. function was measured by pain-free Bioptron 2 device to three locations for 6 min grip strength. Deep transverse friction is a specific was developed in Switzerland.sagepub. slowly counting to 30. at three months (week even if they experienced mild pain. has been shown to be valid and sensitive of the Polarized polychromatic non-coherent light VAs. they 16) and at six months (week 28) after the end of were told to stop the exercise if the pain became treatment. This position (cm) was taken as 'no function' and 10 (cm) as 'full was held for 30-45 s each time and then released. 18 min in total). the bed. When the treatment with Biop- formed at the end of the elbow extension range (i. Therapeutic Goods Association Austra- slow progressive eccentric exercises of wrist ex.

6 years). There were no signifi- request for an alternative treatment.0005. Table 3). Reasons for patient drop-out Baseline pain on VAS was 6.05 one-way ANOVA.0005.13) for the whole sample (n = 75) (Table 2). The other 75 patients were significant difference between Cyriax physiother- allocated by sequential allocation into one of the apy and polarized polychromatic non-coherent three possible groups: (1) Cyriax physiotherapy light at week 28 (P < 0. Differ. 15 male.28 Force was measured in pounds with a ized polychromatic non-coherent light (Bioptron Jamar hand dynamometer that had adjustable light) (n = 25. There was a described above. 15 male. The magnitude of the one-way ANOVA were significant to determine reduction was significantly larger for the super- how the three groups differed. Lat- until they first experienced pain and then to release eral epicondylitis was in the dominant arm in 90% their grip.9 cm (95% CI +SD = 5. mean age = 40. treatment outcome.0005. change in mately 4 units in all groups when compared with function on the VAS and change in pain-free grip the pretreatment baseline (P <0. 16 male.6 years) and (3) polar. Table 3).05. of patients. There were no significant differences in quently recorded and the reading was not visible to mean age (P <0. forearm pronation and internal (Figure 1). (2) not returned for follow-up. 10 female.4 years +SD = 5. (2) a supervised exercise 3. mean age = 40. Three measures of pain-free grip mean duration of complaints (P <0.4 VAS units.5 statistical software polychromatic non-coherent light (+1.com at UNIV OF ILLINOIS URBANA on October 2. cant differences between the groups for baseline The change from baseline was calculated for pain (P > 0. at weeks 8. Table 3). Bonferroni.2 years). programme (n = 25.05. 2014 .6 VAS units) and polarized signif'icance. Table 2).1) for the whole reason. 1).0 VAS was used for the statistical analysis. Drug therapy had been tried by 30-45%.9 cm (95% con- were categorized as follows: (1) a withdraw without fidence interval (CI) = 6. rotation of the upper limb such that the palmar At baseline there were more males in the groups aspect of the hand faced posteriorly with the upper (17 in total). Bonferroni post-hoc (P < 0. Similarly. week 4 there was a decline in VAS of approxi- ences in this change pain on the VAS. Table 3). P <0. (n = 25. A 5% level of vised exercise programme than for Cyriax phy- probability was adopted as the level for statistical siotherapy (+0. Bonferroni.05. Bonferroni. The mean age of patients was limb placed by the patient's side. groups for baseline function (P > 0.sagepub. Table 3).74-4. Some A drop-out rate was also used as an indicator of 4-8% of patients were athletes (Table 1).0005 one-way ANOVA. Patients were then approximately 40 years and the duration of lateral instructed to squeeze the dynamometer handles epicondylitis was approximately five months. so post- comparisons were conducted when the results from hoc tests were performed. There was no significant difference between Cyriax phy- siotherapy and polarized polychromatic non-co- herent light (+0. 9 female. P >0. 16 and 28 there were comparable magnitudes of One hundred and twenty-one patients eligible for reduction with larger reduction for the supervised inclusion visited the clinic within the trial period.1 handles to accommodate different hand sizes. There was a significant difference in was determined using a one-way analysis of the magnitude of reduction between the groups variance (one-way ANOVA).28 The attained grip force was subse. paired t- strength was calculated between the groups and test. units.05. Patient flow through the The arm was placed in a standardized position of trial is summarized in a CONSORT flow chart elbow extension. one- strength were recorded with a 30-s rest interval way ANOVA) between the groups. 10 female. mean There were no significant differences between the age = 40. At each follow-up for each outcome measure.7-7.4 years Baseline function on VAS was 3. Results Bonferroni. years + SD = 6. exercise programme than for Cyriax physiotherapy Twenty-five were unwilling to participate in the and polarized polychromatic non-coherent light study and 21 did not meet the inclusion criteria (P <0. one-way ANOVA) or the the patient.16 D Stasinopoulos and I Stasinopoulos pain. and (3) sample (n = 75) (Table 2). Table 3). Patients had between each measurement and the mean value of received a wide range of previous treatments (Table these repetitions was calculated.05. one-way Downloaded from cre. SPSS version 11.

4 Potential participants (n=96) Inclusion criteria Not meeting inclusion criteria (n=21) Under 30 (n=7) Over 60 (n=5) Equal pain during resistance supination with elbow in 90° of flexion and extension (n=4) Lateral epicondylitis less than 4 weeks (n=5) Eligible patients (n=75)| Sequential allocation (n=75) Cyriax physiotherapy (n=25) Supervised exercise programme (n=25) Bioptron light (n=25)1 1 47 47 Completed trial (n=25) Completed trial (n =25)1 Completed trial (n=25)1 Figure 1 Flowchart of the study. 2014 . Table 1 Previous treatments.com at UNIV OF ILLINOIS URBANA on October 2. occupations and duration of symptoms (n (%)) Cyriax physiotherapy Supervised exercise Bioptron light programme Previous treatments Low-power laser light 4 (16%) 4 (16%) 4 (16%) Drugs 10(40%) 11 (44%) 9(36%) Ultrasound 5 (20%) 3 (12%) 5 (20%) lontophoresis 3 (12%) 2 (8%) 2 (8%) Heat 0 (0%) 2 (8%) 2 (8%) Injection 3 (12%) 3 (12%) 3 (12%) Occupations Housework 9 (36%) 7 (28%) 7 (28%) Manual work 7 (28%) 7 (28%) 8 (32%) Secretarial 8 (32%) 9 (36%) 8 (32%) Sport 1 (4%) 2 (8%) 2 (8%) Duration of symptoms Under 5 months 7 (28%) 7 (28%) 6 (24%) Over 5 months 18 (72%) 18 (72%) 19 (76%) Downloaded from cre.sagepub. Treatment of lateral epicondylitis 17 All lateral epicondylitis patients presenting the clinic (n=121) Unwillingness (n=25) .

pain-free grip strength units.3 (8.6-1. Table 3).6 (72.0005. There was no larized polychromatic non-coherent light (+ 3.05.3 (6. so post-hoc tests were per.3-81) 77.6-7.3 (7.2) 6.7-27.3) 7. Table 3). P <0. There was a ANOVA.05.0005.1 pain-free grip strength units) nificantly larger for the supervised exercise and polarized polychromatic non-coherent light programme when compared with Cyriax phy.9 (3.6 significant difference between Cyriax physiother.5) 75.8 (2.6) Bioptron light 26 (24.7) Supervised exercise programme 25.8-8.2) 63.2) 7. paired t-test. so post-hoc tests were per- significant difference in the magnitude of improve.9 (24.6) 1.5) Pain-free strength (lb) Cyriax physiotherapy 25.8-27.2) 2.7) 65.4-67.8 (2.1 -81.6-72. Bonferroni. There was a VAS of approximately 3 units in all groups when significant difference in the magnitude of improve- compared with the pretreatment baseline (P < ment between the groups (P < 0.1 (60.9) for the whole sample (n = 75) (Table 2).1 -2.4 (2. formed. There were no significant differences between the groups for baseline pain-free grip Discussion strength (P > 0. Table 2).6-7. Table 3). function and pain-free grip strength week 0 week 4 week 8 week 16 week 28 Pain Cyriax physiotherapy 6.05.18 D Stasinopoulos and I Stasinopoulos Table 2 Pain.2 (6.2 (7.7 VAS units) and polarized poly. At week 4 there was a rise in (P < 0.6 (2. Bonferroni. Similarly. There was no and polarized polychromatic non-coherent light significant difference between Cyriax physiother- (P <0.3-74. Table 3). paired t-test. programme when compared with Cyriax phy- formed.8) 69 (63. P > 0. Baseline pain-free grip strength was 25.6-7. 16 and 28 there were larger improvements for the supervised exercise comparable magnitudes of improvement with lar.9) 7.3) Values are means (95% Cl).2) 2.4) 76. Table 3). 2014 .1 -7.3 (3.4) 1. Table comparable magnitudes of improvement.1) 2.9 (3.05.4-67.3 (61.1 (6.4 (61.3-2.2 (1. Bonferroni.4(63. with 3).8 (7.05.9-7. at weeks 8.9 (6.4 VAS units. Similarly. siotherapy (+0.9-2.0005.6) 3. Table 3).6 (7.8 (7.4-2.1) Supervised exercise programme 3.8) Function Cyriax physiotherapy 3.2-73.8 (23.9 (0.9 (1. Bonferroni. siotherapy ( +7.3) 0.3) 2.6-4.8-3.1 -27) 73.5 (60.8) 2.1 -8.3) 3.6) 8.6-2.6) 64.4-4.5) 7.6-65.9 (6. The magnitude of improvement was sig- ment between the groups (P <0.5-7.2) 7.8-1.-3.8) 66.4-7.9-66. There was no apy and polarized polychromatic non-coherent significant difference between Cyriax physiother. Table 3). difference between Cyriax physiotherapy and po- P <0. (+ 10. Bonferroni. At week 4 there was a rise in pain-free grip The results obtained from this controlled clinical strength of approximately 40 units in all groups trial are novel. Bonferroni. as to date there have been no data when compared with the pretreatment baseline comparing the effectiveness of Cyriax physiother- Downloaded from cre.4-7) 7 (6. light at any of the follow-up time points There were no drop-outs and all patients suc- (P > 0. Table 3).4 (73. There was no significant chromatic non-coherent light (+ 1.0005.com at UNIV OF ILLINOIS URBANA on October 2.1 VAS units.6 (2. one-way nificantly larger for the supervised exercise ANOVA.0-26. ANOVA.1 (0.9-78. cessfully completed the study.2) Bioptron light 7 (6. Bonferroni.4 (8.6 (70.2-8. one-way ANOVA.0) 2. apy and polarized polychromatic non-coherent Table 3). one-way 0.5-8) 8.05. The magnitude of improvement was sig.5) 65.3) 67.6-4.9-7.4-2) 1.7) Bioptron light 3. Table 2). at week 8.05. Bonferroni.9-73) 68 (62.4-8.4 (63. Table 3).7 (68.05.sagepub.0 (2. light at any of the follow-up time points apy and polarized polychromatic non-coherent (P > 0.9 lb (95% CI 25. Table 3).5-3.6-3.5) 8. programme than for Cyriax physiotherapy ger improvements for the supervised exercise and polarized polychromatic non-coherent light programme than for Cyriax physiotherapy (P <0.4) 7.7 (1.05. P > 0. 16 and 28 there were light (+0.9 (3.7 (6.3) Supervised exercise programme 6.3) 7.7 pain-free grip strength units.7-80.7-7.

I_ I_ I_ x . o " o + + . (0C ) C ° o o o-o 4-Q c: )oCO0 (D 0 6 ~N6(. o(.0o. °°(D °CY) 4°N (9c). 4 CY) 0 C)- 0 co 0 IC) LC LI LI OI) ci -O 0 4 )( 46 f (0 0 0 0 0 a) C: (0 0 o 40-i10 IC0 Lo o 0 (N o 4- 0 4. 2014 . +(N~+( +(N + 0 Q C) 00(3 c c. c.0 r-o-t M-- > t) 0*.(N4. 0) 0 0 0 0Z 0L IC 0 0 IC 0 0 C0 IC 0 I) 0< . - co C -C e C) c 08) co CN CY) 0)N 4 c C) a) (0 C 0 4t- 0 4- LO LO <o c) (N C1 t 4. 0 0 6( 0 +0+0+0+0 +S +c +r +j 0 0 0 xD 0. _CY 1a)c0 co 0 IC) N ( _ _ 0 _ 0 o o U) *CD Cl C. r-C 4 C-) 't(0 0 00 00 EU) CD. Lo o. q) Oa) a) ° a) a~~~~~~~~) a) (1 - U) ) a) a) a * NL L U) 0 U) (U I. 4. o 0 0 0 4. +1 t. - _ 01)0) *C)Q c-0-c . CL CL Q.0 D CD CD r 0 0 0 0 U1) (0) ao 0) +N. 4-) 4-1 4 L o co 4=) a U) V LO LO LO U .02. N 0 0) (0 N~ 4 (0D 4( N 4.com at UNIV OF ILLINOIS URBANA on October 2.( X 0 0 0 0 -C CN cs M' L Y' 0) o01= C 0) Cy) cyN q0-(o0L0 (-0 (N . . 0.sagepub.+ + C1) c 0 CN~~~~( (N) (0 (. C c r.6 4 1 CD r.0 0 a3 x 0_ __ 0) *0_ 0 C 4.vZt IO o 0o C) o 0)o C) IC) 0o= 0 o I 0 0 ( C 0 O 0 IC IC) IC) ' IC) 0 0 0 0 E 0 0 0) 0 4. c o y s Io N o{n-r-L * LO 00 0 0 0 0 0 0 co 0 0-0y "I _0~ IC) IC N ICN ro o) c. I 0 00- 0D o o0 op00 (0 >U)c _ ___ _ )< 0-C 0-. . r. 0. -I C) s u) 0) 0 0 0) . cN + zz + z. Treatment of lateral epicondylitis 19 N _ _C 0 O.+N +N +c +j +!LY + !e + CY 0 0 (D E 0 0 0 0 0 0 0 a 4C) . CL L~~L Downloaded from cre.

time than the home exercise programme. 8 for other conditions similar to lateral epicondylitis. Cyriax physiother. However. the home exercise programme question why a similar manipulative manoeuvre is was performed for about three months in all not recommended for the management of these previously published studies. Again.com at UNIV OF ILLINOIS URBANA on October 2. The findings of these three trials Downloaded from cre. Deep transverse friction and los29 administered a supervised exercise pro. using polarized polychromatic non-coherent light The only previously published RCT that studied (Bioptron light) on lateral epicondylitis. 37 in acute lateral epicondylitis26 and in carpal tunnel They found that Cyriax physiotherapy was a less syndrome. lack of trials is that polarized polychromatic non- term follow-up (six weeks after the end of treat. invalid outcome measures. There is clearly all previously published studies. intermediate and long term. in frequency. but they did not report whether either in the physiotherapy area. Two pilot the effectiveness of Cyriax physiotherapy on lateral studies assessed the effectiveness of this treatment epicondylitis was conducted by Verhaar et a. one might tively.31-36 respec. Thus. matic non-coherent light treatment based on ment). All previously reported treatment were effective or ineffective in long. Future studies to rendered effective. Pienimaki et al. apy was an effective treatment in the present ized polychromatic non-coherent light for pain and controlled clinical trial. for which deep transverse friction alone was conducted by Stasinopoulos and Stasinopou. the other overuse conditions similar to lateral epicon- present controlled clinical trial and the study that dylitis. these previously which was administered in a totally different published studies had methodological shortcom- manner than the supervised exercise programme ings such as small sample size. lack of fol- ment in which the exercise programmes were low-ups and lack of randomization. The most If a similar manipulation technique is found for likely explanation for this difference may be that a other overuse injuries. the short.29'38'39 ment in only one previously published RCT. compare the effects of these two exercise pro. the ineffective Cyriax phy- supervised exercise programme achieves a higher siotherapy treatment of these conditions may be degree of patient compliance. physiotherapy cannot be drawn. leaving the reader with questions about manufacturers' claims may improve patients' their effectiveness. Research on the effectiveness of Cyriax phy- A home exercise programme was the sole treat. intensity. In contrast. However. lack of blinding employed in the present controlled clinical (therapists. transverse friction only and not of deep transverse lar29'30 and Achilles tendinopathy. a supervised exercise programme and polar.sagepub. siotherapy on overuse injuries is sparse. it seems that the lateral epicondylitis in the present study and it is supervised exercise programme may give good concluded that the effectiveness of Cyriax phy- long-term clinical results in a shorter period of siotherapy is based mostly on Mill's manipulation. trials found that a course of polarized polychro- term follow-up (one year after the end of treat. analysis. The present controlled clinical trial was the first grammes are required to confirm the findings of study to examine the effectiveness of light therapy the present controlled clinical trial. Mill's manipulation showed positive effects on gramme for a month. One might question why. symptoms. Cyriax physiother- a need for a future clinical trial to compare the apy consisted of 10 min of deep transverse friction effects of the present study's supervised exercise only.8 showing poor outcomes. The supervised than the supervised exercise programme in the exercise programme produced the largest effect in short. though Cyriax physiotherapy for lateral programme treatment protocol with the home epicondylitis consists of deep transverse friction exercise programme treatment protocol used by and Mill's manipulation.20 D Stasinopoulos and I Stasinopoulos apy. duration of treatment). but also in the development of conclusions about the effectiveness of Cyriax treatment protocol (type of exercises. lack of power trial. friction plus Mill's manipulation.40 The most likely explanation for the effective treatment than steroid injection in short. In contrast. assessors). but it was less effective function in lateral epicondylitis. Thus. coherent light has only become recently available ment). Previously published trials found that a home Cyriax physiotherapy should consist of deep exercise programme reduced the pain in patel. In addition. The differences were not only in the environ. definite administered. intermediate and long term. seems ineffective. patients. 2014 .

Downloaded from cre. Patients' diaries is not possible to administer the supervised exercise suggested that patients were compliant to the study programme. this modality points. Cyriax physiotherapy and polarized instructions. Third. the lack of placebo (sham)/no treatment group is important standardization of treatment protocols for Cyriax when the absolute effectiveness of a treatment is physiotherapy and exercise programmes might be a determined. There were several shortcomings of the present incorrect details to please the investigators. The effects of needed. in the supervised exercise programme should be the this case lateral epicondylitis. exercise programmes and polarized polychro. First. information as to which is the most appropriate This means that. If for some reason it in the clinic were not monitored. Therefore. Second. cannot be ruled out as a target for research because * The supervised exercise programme pro- this is a dose-response modality and the optimal duced the largest effect in the short. a supervised exercise Several trials have assessed the effectiveness of programme and polarized polychromatic low-power laser light for the treatment of lateral non-coherent light (Bioptron light) reduced epicondylitis. example. treatment for the management of a condition. Although reviews of the literature pain and improved function at the end of the found that low-power laser light is an ineffective treatment and at any of the follow-up time treatment for lateral epicondylitis. mediate and long term and should be the mined. due in part to difficulties in In conclusion. there is strong evidence that lateral matic non-coherent light reduced pain and epicondylitis is not a self-limiting condition and improved function at the end of the treatment patients' symptoms cannot be reduced without and at any of the follow-up time points. inter- treatment dosage has not yet have been deter. such as analgesic medications contribute to the ment group was included in the present trial. the effects of * Further studies on the possible mechanisms low-power laser light on lateral epicondylitis that can explain the effects of these treat- cannot be translated into those for polarized ments on lateral epicondylitis are also polychromatic non-coherent light. although patients may have given polychromatic non-coherent light may be suitable. impossible to devise. However. In vised exercise programme. radiation characteristics. Clinical messages tiveness of polarized polychromatic non-coherent light on overuse injuries. because a good and trustworthy placebo generalized. (sham)/no treatment control for Cyriax physiother. Therefore. sufficiently described in order to make it possible matic non-coherent light appears to be difficult or to replicate the therapy elsewhere. polarized polychromatic non-coherent light are yet to be confirmed by other researchers. In order that study findings be tigate.6'4' Low-power laser light and polarized first treatment option for therapists when polychromatic non-coherent light differ in their they manage lateral epicondylitis. The appropriate 'active' treatment. the use of sequential allocation to same time. choosing among these treatments. 2014 . it was possible that patients followed the since no genuine randomization procedure was treatment but took analgesic medications at the followed. first treatment option for therapists when they ities treatments patients might be getting when not manage lateral epicondylitis. should be found to measure how other treatments strated. Finally. no placebo (sham) or no treat. frequency and duration of the treatment be apy. Treatment of lateral epicondylitis 21 encourage the design of future well-designed RCTs that might produce strong evidence for the effec. the absolute effectiveness of possible shortcoming of the present controlled technique-based interventions is difficult to inves. and polarized polychro- addition. supervised exercise programme produced the lar- tiveness also does not provide the therapists with gest effect in the short. intensity. The improvement of symptoms. For trial. although this study was not a RCT. Cyriax physiotherapy. intermediate and long term. ways a true cause-and-effect relationship to be demon. and the improvement of symptoms may allocate patients to treatment groups allowed for be due to those medications. other activ. it is essential that the type.com at UNIV OF ILLINOIS URBANA on October 2.9'37 Absolute effec. a super- defining the active element of these treatments. clinical trial.sagepub. * Cyriax physiotherapy.

Phys Ther Rev 2000. tennis elbow: the evidence: BMJ 15 September Smidt N. Letter. 7410: 327. response to Mellor S. Newman N. a cost-effectiveness analysis should be Phys Med Rehabil 2004. 10 Allander E. Keller A. Arch Phys Med Rehabil 2000. 19: 357-66. J HIand Arch Phys Med Rehabil 1993. Cieslac K. (2002) article Time to abandon the epidemiology. Miseferi D. In addition to M. Buchbinder R. Phys Ther Rev 1997. Wright A.22 D Stasinopoulos and I Stasinopoulos Further well-designed RCTs are needed to confirm 13 Waugh E. Ann Med 2003. 15 Pienimaki T. (2003) article Treatment of 5 Assendelft W. further studies on the possible 39-48. (2003) article Tennis treatment of lateral epicondylitis of the elbow: an elbow: BMJ. Factors associated with prognosis of lateral the analysis of the effectiveness of the compared epicondylitis after 8 weeks of physical therapy. Lateral epicondylalgia II: important issues for the recommendation of a therapeutic management. Tennis elbow: anatomical. Rapid M. Siira P. 17 Stasinopoulos D. J Bone Joint Surg Am 1999. Lateral epicondylalgia: diagnosis. incidence and remission 25 Stasinopoulos I. Tarvainen T. Guibert R. Lack of scientific evidence for the response to Assendelft et al. Vanharanta H. polychromatic non-coherent light (Bioptron light) treatment and evaluation. 5: 129-54.com at UNIV OF ILLINOIS URBANA on October 2. 1990. Rehabilitations for patients with Jensen L. Rev Phys Rehabil Med 2000. Jensen R. Gam A. Rapid Med 1993. Cyriax physiotherapy in the treatment of tennis elbow. of physiotherapy for lateral epicondylitis: a 2 Noteboom T. Davidson R. 2: treatment. Kerr E. Hauschild B. 9 Vasseljen 0. Joncas J. Tennis elbow: a review. 17: 243-66. epicondylitis. 81: Physiotherapy 1996. Mathiesen B. rheumatology. 5: References 117-24. Patla C. Levy K. Levy D. epidemiological and therapeutic aspects. Br J Sports Med 2004. Sheffield C. Kellog F. 6 Trudel D. an elbow mobilization with movement technique on tendinosis of the elbow (tennis elbow). Johnson MI Polarised 4 Haker E. 6: 163-69. Nirschl R. The initials effects of 7 Kraushaar B. Assendelft W. 1504-10. Physiotherapy 1992. Phys Ther Rev 1996. The use of polarised polychromatic rates of some common rheumatic diseases and non-coherent light (Bioptron light) in syndromes. Lateral epicondylalgia I: Khan et al. J Orthop Sports Phys Ther 19 Stasinopoulos D. Tennis elbow.sagepub. Tomlinson G. J R Coll polychromatic non-coherent light as Therapy for Gen Pract 1986. 22 Abbott J. Wilson J. 2004. 6 September 2004. Int Orthop 27 Stratford P. Prevalence. incorporated in the trial. MacDermid J. features and findings of histological Man Ther 2001. 16 Selvier T. 20 Stasinopoulos D. Low-level laser versus traditional 24 Stasinopoulos D. Struijs P. Johnson MI. acute tennis elbow/lateral epicondylalgia: a pilot 12 Verhaar J. 12: 213-28. J Bone Joint Surg 1992. Progressive strengthening and stretching exercises intensity Nd:YAG laser irradiation on lateral and ultrasound for chronic lateral epicondylitis. Verrier the effectiveness of the treatments. Crit lateral epicondylitis are also needed. management for tendinopathy. physiotherapy for tennis elbow/lateral epicondylitis. 18 Smidt N. Zastrow I. 1: 23 -34. Physiotherapy and 1 Labelle H. randomized controlled trial of the effects of low 8 Pienimaki T. 21 Johannsen F. Conservative treatment and mechanisms the effects of these treatments on rehabilitation of tennis elbow: a review article. Cruver S. Rapid response to 3 Vicenzino B. study. systematic review. 81: 259-85. The use of polarised epicondylitis: a survey in general practice. Jaglal S. 36: 464-65. Gauldie S. Duley J. 85: 308-18. 3: 145-53. Treatment/ 1994. Letter. 23: 66-69. 35: 51-62. attempted meta-analysis. 74: 438-40. 38: 675-77. aetiology and 'tendinitis' myth: BMJ 22 September 2004. Rivard C. Effectiveness 74: 646-51. Methods utilized in treating lateral epicondylitis. 1994. Davis A. 18: 263-67. The prevalence of humeral 26 Stasinopoulos D. Arola H et al. because reduced costs are 14 Wright A. Vicenzino B. 2014 . pathophysiology. Green S. Current concepts review . Johnson MI. Rebox: an adjunct in physical medicine? lateral epicondylitis: a systematic review. BMJ 2003. Laser therapy: a studies. 1 1 Hamilton G. Johnson MI. 78: 329-34. Extensor carpi radialis tendonitis: a validation of Downloaded from cre. Clinical grip strength in subjects with lateral epicondylalgia. natural history. Ther 2004. Arch treatments. Scand J Rheumatol 1974. Bioptron light therapy booklet. Crit Rev Phys Rehabil and tennis elbow/lateral epicondylitis. Finally. Photomed Laser Surg 2005. immunohistochemical and electron microscopy 23 Basford J. Nitz A. 82: 522-30. Fallaha tennis elbow/lateral epicondylitis.

band friction syndrome in athletes: a clinical trial. Buratowski S.sagepub. Scand J 39: 250-55. 28 Vicenzino B. Stasinopoulos I. Mackintosh L. Johnsson P. Clin Rehabil 2004. reliability testing of the evaluation methods. 2: 109-13. Comparison of 36 Roos EM. Heavy-Load eccentric calf muscle training for the 38 Pallechia L. Surg Sports Traumatol Arthrosc 2001. Lorentzon R. Wright 35 Ohberg L. Johnson MI. Clement DB. Am J infrapatellar tendonitis: a combination of Sports Med 1998. Br J Sports Med 2004. Kester A.com at UNIV OF ILLINOIS URBANA on October 2. effects of exercise programme. 14: 286- 30 Purdam CR. 9: 42-47.a randomized controlled study with Surg 23: 425-30. Med Sci Sports 2001. Photomed Laser Surg 23: 225-28. patients with chronic Achilles tendinosis. A pilot study of the 37 Verhaar J. Mosher RE. 18: tendinopathy. modalities and transverse friction massage versus 32 Niesen-Vertommen SL. Lorentzon R. iontophoresis. Lorentzon R. Mee J. Alfredson H.a randomised trial with 1-year 347-52. The effect of eccentric versus 39 Schwellnus P. Behnke P. Alfredson H. Khan KM. Eccentric A. 26: 360-66. Treatment of lateral epicondylitis 23 selected outcome measures. 11: 197-206. Lagerquist A. follow-up. Local corticosteroid injection versus painful chronic patellar tendinopathy. Mameren H. 3: 135-45. Physiother Can 1987. 38: 395-97. 41 Stasinopoulos D. eccentric decline squat in the management of Linden A. Thomee R. Stasinopoulos I. R. Soderberg B. Effectiveness of Eccentric overload training with chronic Achilles laser for tennis elbow: a review. Treatment of treatment of chronic Achilles tendinosis. Joint Surg Br 1996. 38: 205-12. Taunton JE. 33 Mafi N. 34 Silbernager KG. 78: 564-68. Pietila T. Clin J Sports Med 1992. Scand J Med Sci Sports 2004. short-term results with eccentric calf muscle 40 Stasinopoulos D. 6: thickness at follow up. J Bone 31 Alfredson H. Johnson P. Photomed Laser tendon pain . Br J Sports Med 2004. Karlsson J. 78: 128-32. Thomee P. Alfredson H. 8-11. Downloaded from cre. Deep concentric exercise in the management of Achilles transverse frictions in the treatment of iliotibial tendonitis. Walenkamp H. Paungmali A. Hamel H. Johnson MI. training compared to concentric training in a Treatment of carpal tunnel syndrome with polarised randomized prospective multicenter study on polychromatic non-coherent light (Bioptron light). Knee A preliminary prospective open clinical trial. Cyriax-type physiotherapy for tennis elbow. Specific manipulative therapy treatment for training in patients with Achilles tendinosis: chronic lateral epicondylalgia produces unique normalized tendon structure and decreased characteristic hypoalgesia. Lorentzon 95. J Sports Rehabil 1994. Superior Physiotherapy 1992. Cook JL. 2014 . pulsed ultrasound Clinical improvement after 6 weeks of eccentric and transverse friction in the treatment of chronic exercises in patients with mid-portion Achilles patellar tendinopathy. Engstrom M. Man Ther 2001. 29 Stasinopoulos D.