• 
• 

Three Part Question

In [adults with lateral epicondylitis] is [eccentric exercise more beneficial than other non invasive treatments] at [decreasing pain and improving function]

Clinical Scenario

A 31 year old male presents with a 3 month history lateral epicondylitis. You are planning to use standard treatments of electrotherapy, ICE, and exercises to improve his symptoms. You have heard from a colleague about an exercise regime based on eccentric muscle contractions and you wonder if there is any evidence of greater efficacy than the usual treatments.

Search Strategy

MEDLINE 1966-02/07, CINAHL 1982 –02/07, AMED 1985-02/07, SPORTDiscus 1830-02/07, EMBASE 1996-02/07, via the OVID interface. Cochrane Database Feb 2007; PEDro database Feb 2007
MEDLINE, CINAHL, AMED, SPORTSDiscus EMBASE, the Cochrane database: [{(lateral epicondylitis.mp OR exp tendinopathy OR exp tennis elbow] AND [(exp eccentric contraction OR exp exercise OR exp therapeutic exercise OR exp physical therapy techniques or physiotherapy.mp)] LIMIT to human AND English language
Cochrane Database and PEDro database: lateral epicondylitis

Search Outcome

7 papers and 1 abstract were retrieved. Only 3 papers and the abstract were relevant to the 3 part question. There is a Cochrane protocol registered but not converted to a review (Smidt 2004).

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Svernlov,B. Adolfsson,L 2001 Sweden	Gp 1 (n=15) Stretching Exercise Gp 2 (n=15) Eccentric Exercise	Pilot, RCT	1. VAS	1. NSS Between Gps	Main study follow on (n=129) observational only. Results @3,6,12 mths
			2. Self report change	2. NSS Between Gps@ 3 – 6mth, @ 12mth all pts improved or resolved.
			3. Grip (Kg)	3. @ 6mth Gp 1 54.2 v Gp 2 67.9Kg (P<.05). Other test times NSS
Croisier et al. 2001 France	N = 15 lateral epicondylitis All received Eccentric exercise	Single group study comparing to uninjured side.	1. Pain VAS	1. mean decrease of 5/10	Generally insufficient data to perform detailed analysis
			2. Strength	2. torque diff between injured/uninjured side = NSS
			3. Return to activity	3. 13/15 subjects moderate/marked/ complete decrease in symptoms
			4. Ultrasound scan	4. no data available
Croisier et al. 2005 France	N = 76 lateral epicondylitis 2 groups of treatment Eccentric exercise v conventional physio treatment (TENS, ICE, ultrasound therapy, frictions, stretching)	Abstract	1. VAS	1. After 20 treatments Eccentric group less pain than control (P < 0.01)	Abstract only. Patients assigned, not randomised. Control group had other multiple treatments No detailed results data available
			2. Return to offending activity	2. Return with complete or marked relief of symptoms 74% of treatment group v 33% control group
			3. Strength	3. No data available
			4. Ultrasound scan	4. Improved tendon structure 89% treatment group v 60% control group.
Manias & Stasinopoulos 2006 UK/Greece	N = 40 lateral epicondylitis Gp 1 = Eccentric Exercise Gp 2 = Ecc Exercise & ICE	Clinical trial. Parallel group design	1.VAS	1. Gp 1= 8.8 – 1.9@wk4 +1.5@wk16; Gp. 2 = 8.6 - 1.7 @ Wk4 + 1.6@wk16. NSS between Gps. But within Gps p < 0.0005	Sequential allocation not randomisation No power calculation

Comment(s)

There is one study in abstract form directly comparing eccentric exercise with standard physiotherapy for tennis elbow. This reveals some limited evidence of the benefit of eccentric exercise, but detailed critique cannot be made on the abstract. There is some other limited data from full papers that eccentric training is no better than either ICE and/or stretching treatments.

Clinical Bottom Line

Present limited evidence suggests that eccentric exercise is no better than other standard physiotherapy treatments for chronic lateral epicondylitis.

References

1. Svernlov,B. Adolfsson,L Non-operative treatment regime including eccentric training for lateral humeral epicondyalgia. Scand.J.Med.Sci.Sports 2001;11:328-334
2. Croisier JL, Forthomme, B., Foidart-Dessalle,M. Godon,B, Crielaard,JM. Treatment of recurrent tendinitis by isokinetic eccentric exercises. Isokin.Exerc. Sci. 2001;9:133-141
3. Croisier, Jl., Foidart,M. Crielaard,JM., Forthomme,B Adapted eccentric training in chronic lateral epicondylitis rehabilitation Computer Methods in Biomechanics and Biomedical Engineering. 2005; Suppl.1: 55-56
4. Manias P, Stasinopoulos,D A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy Br.J.Sports Med. 2006; 40:81-85