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BMC Musculoskeletal Disorders

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01-12-2020 | Musculoskeletal Pain | Research article

The effect of manual therapy to the thoracic spine on pain-free grip and sympathetic activity in patients with lateral epicondylalgia humeri. A randomized, sample sized planned, placebo-controlled, patient-blinded monocentric trial

Authors: Philipp Zunke, Alexander Auffarth, Wolfgang Hitzl, Mohamed Moursy

Published in: BMC Musculoskeletal Disorders | Issue 1/2020

Abstract

Background

The treatment of first choice for lateral epicondylalgia humeri is conservative therapy. Recent findings indicate that spinal manual therapy is effective in the treatment of lateral epicondylalgia. We hypothesized that thoracic spinal mobilization in patients with epicondylalgia would have a positive short–term effect on pain and sympathetic activity.

Methods

Thirty patients (all analyzed) with clinically diagnosed (physical examination) lateral epicondylalgia were enrolled in this randomized, sample size planned, placebo-controlled, patient-blinded, monocentric trial. Pain-free grip, skin conductance and peripheral skin temperature were measured before and after the intervention. The treatment group (15 patients) received a one-time 2-min T5 costovertebral mobilization (2 Hz), and the placebo group (15 patients) received a 2-min one-time sham ultrasound therapy.

Results

Mobilization at the thoracic spine resulted in significantly increased strength of pain-free grip + 4.6 kg ± 6.10 (p = 0.008) and skin conductance + 0.76 μS ± 0.73 (p = 0.000004) as well as a decrease in peripheral skin temperature by − 0.80 °C ± 0.35 (p < 0.0000001) within the treatment group.

Conclusion

A thoracic costovertebral T5 mobilization at a frequency of 2 Hz shows an immediate positive effect on pain-free grip and sympathetic activity in patients with lateral epicondylalgia.

Clinical trial registration

German clinical trial register DRKS00013964, retrospectively registered on 2.2.2018.

Roquelaure Y, Ha C, Leclerc A, Touranchet A, Sauteron M, Melchior M, Imbernon E, Goldberg M. Epidemiologic surveillance of upper-extremity musculoskeletal disorders in the working population. Arthritis Rheum. 2006;55(5):765–78 https://doi.org/10.1002/art.22222.CrossRefPubMed

Ahmad Z, Siddiqui N, Malik SS, Abdus-Samee M, Tytherleigh-Strong G, Rushton N. Lateral epicondylitis: a review of pathology and management. Bone Joint J. 2013;95-B(9):1158–64 https://doi.org/10.1302/0301-620X.95B9.29285.CrossRefPubMed

Haker E. Lateral epicondylalgia: diagnosis, treatment and evaluation. Crit Rev Phys Rehabil Med. 1993;3:129–54.

Gruchow HW, Pelletier D. An epidemiologic study of tennis elbow. Incidence, recurrence, and effectiveness of prevention strategies. Am J Sports Med. 1979;7(4):234–8 https://doi.org/10.1177/036354657900700405.CrossRefPubMed

Cyriax JH. The pathology and treatment of tennis elbow. JBJS. 1936;18(4):921–40.

Hong QN, Durand MJ, Loisel P. Treatment of lateral epicondylitis: where is the evidence? Joint Bone Spine. 2004;71(5):369–73. https://doi.org/10.1016/j.jbspin.2003.05.002.CrossRefPubMed

Bisset LM, Vicenzino B. Physiotherapy management of lateral epicondylalgia. J Physiother. 2015;61(4):174–81. https://doi.org/10.1016/j.jphys.2015.07.015.CrossRefPubMed

Kane SF, Lynch JH, Taylor JC. Evaluation of elbow pain in adults. Am Fam Physician. 2014;89(8):649–57.PubMed

Sims SE, Miller K, Elfar JC, Hammert WC. Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials. Hand (N Y). 2014;9(4):419–46. https://doi.org/10.1007/s11552-014-9642-x.CrossRef

10.

Cullinane FL, Boocock MG, Trevelyan FC. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil. 2014;28(1):3–19 https://doi.org/10.1177/0269215513491974.CrossRefPubMed

11.

Hoogvliet P, Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med. 2013;47(17):1112–9. https://doi.org/10.1136/bjsports-2012-091990.CrossRefPubMed

12.

Herd CR, Meserve BB. A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia. J Man Manip Ther. 2008;16(4):225–37 https://doi.org/10.1179/106698108790818288.CrossRefPubMedPubMedCentral

13.

Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain. 1996;68(1):69–74.CrossRefPubMed

14.

Fernandez-Carnero J, Cleland JA, Arbizu RL. Examination of motor and hypoalgesic effects of cervical vs thoracic spine manipulation in patients with lateral epicondylalgia: a clinical trial. J Manip Physiol Ther. 2011;34(7):432–40 https://doi.org/10.1016/j.jmpt.2011.05.019.CrossRef

15.

Schmid A, Brunner F, Wright A, Bachmann LM. Paradigm shift in manual therapy? Evidence for a central nervous system component in the response to passive cervical joint mobilisation. Man Ther. 2008;13(5):387–96 https://doi.org/10.1016/j.math.2007.12.007.CrossRefPubMed

16.

Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009;14(5):531–8 https://doi.org/10.1016/j.math.2008.09.001.CrossRefPubMed

17.

Wright A. Hypoalgesia post-manipulative therapy: a review of a potential neurophysiological mechanism. Man Ther. 1995;1(1):11–6 https://doi.org/10.1054/math.1995.0244.CrossRefPubMed

18.

Ogawa T, Low PA. Autonomic regulation of temperature and sweating. 2nd ed. Philadephia: Lippincott-Raven Press; 1999.

19.

Sato K. Normal and abnormal sweat glan function. 2nd ed. Philadelphia: Lippincott-Raven Press; 1999.

20.

Kingston L, Claydon L, Tumilty S. The effects of spinal mobilizations on the sympathetic nervous system: a systematic review. Man Ther. 2014;19(4):281–7 https://doi.org/10.1016/j.math.2014.04.004.CrossRefPubMed

21.

Reynolds DV. Surgery in the rat during electrical analgesia induced by focal brain stimulation. Science. 1969;164:444–5.CrossRefPubMed

22.

Schiller Y. The anatomy and physiology of the sympathetic innervation to the upper limbs. Clin Auton Res. 2003;13(Suppl 1):I2–5. https://doi.org/10.1007/s10286-003-1102-6.CrossRefPubMed

23.

Paxinos G, Mai JK. The human nervous system. 2nd ed. Bosten: Elsevier Academic Press, Amsterdam; 2004.

24.

Behbehani MM. Functional characteristics of the midbrain periaqueductal gray. Prog Neurobiol. 1995;46(6):575–605 doi: 10.1016/0301-0082(95)00009-K.CrossRefPubMed

25.

Jowsey P, Perry J. Sympathetic nervous system effects in the hands following a grade III postero-anterior rotatory mobilisation technique applied to T4: a randomised, placebo-controlled trial. Man Ther. 2010;15(3):248–53. https://doi.org/10.1016/j.math.2009.12.008.CrossRefPubMed

26.

Lovick TA. Interactions Between Descending Pathways from the Dorsal and Ventrolateral Periaqueductal Gray Matter in the Rat. In: Depaulis A, Bandler R, editors. The Midbrain Periaqueductal Gray Matter: Functional, Anatomical, and Neurochemical Organization. Boston: Springer US; 1991. p. 101–20.CrossRef

27.

Benarroch EE. Periaqueductal gray: an interface for behavioral control. Neurology. 2012;78(3):210–7 https://doi.org/10.1212/WNL.0b013e31823fcdee.CrossRefPubMed

28.

Trepel M. Neuroanatomie. 4th ed. München: Elsevier GmbH, Urban & Fischer Verlag; 2008.

29.

Wancura-Kampik I. Segment-Anatomie. 2nd ed. München: Elsevier GmbH, Urban & Fischer Verlag; 2010.

30.

Jewson JL, Lambert GW, Storr M, Gaida JE. The sympathetic nervous system and tendinopathy: a systematic review. Sports Med. 2015;45(5):727–43 https://doi.org/10.1007/s40279-014-0300-9.CrossRefPubMed

31.

Jewson JL, Lambert EA, Docking S, Storr M, Lambert GW, Gaida JE. Pain duration is associated with increased muscle sympathetic nerve activity in patients with Achilles tendinopathy. Scand J Med Sci Sports. 2017;27(12):1942–9 https://doi.org/10.1111/sms.12820.CrossRefPubMed

32.

Petersen N, Vincenzino B, Wright A. The effects of a cervical mobilisation technique on the sympathetic outflow of the upper limb in normal subjects. Physiother Theory Pract. 1993;9:149–56.CrossRef

33.

Moulson A, Watson T. A preliminary investigation into the relationship between cervical snags and sympathetic nervous system activity in the upper limbs of an asymptomatic population. Man Ther. 2006;11(3):214–24 https://doi.org/10.1016/j.math.2006.04.003.CrossRefPubMed

34.

Bessler J, Beyerlein C. Manuelle Therapie nach mulligan: mobilisation with movement. Stuttgart: Georg Thieme Verlag KG; 2015.CrossRef

35.

Chiu TW, Wright A. To compare the effects of different rates of application of a cervical mobilisation technique on sympathetic outflow to the upper limb in normal subjects. Man Ther. 1996;1(4):198–203. https://doi.org/10.1054/math.1996.0269.CrossRefPubMed

36.

Maitland GD. Vertebral manipulation. 5th ed. Oxford: Butterworth Heinemann; 1986.

37.

Tsirakis V, Perry J. The effects of a modified spinal mobilisation with leg movement (SMWLM) technique on sympathetic outflow to the lower limbs. Man Ther. 2015;20(1):103–8 https://doi.org/10.1016/j.math.2014.07.002.CrossRefPubMed

38.

Lascurain-Aguirrebena I, Newham DJ, Galindez-Ibarbengoetxea X, Casado-Zumeta X, Lertxundi A, Critchley DJ. Association between sympathoexcitatory changes and symptomatic improvement following cervical mobilisations in participants with neck pain. A double blind placebo controlled trial. Musculoskelet Sci Pract. 2019;42:90–7. https://doi.org/10.1016/j.msksp.2019.05.001.CrossRefPubMed

39.

Sterling M, Jull G, Wright A. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. Man Ther. 2001;6(2):72–81. https://doi.org/10.1054/math.2000.0378.CrossRefPubMed

40.

La Touche R, Paris-Alemany A, Mannheimer JS, Angulo-Diaz-Parreno S, Bishop MD, Lopez-Valverde-Centeno A, von Piekartz H, Fernandez-Carnero J. Does mobilization of the upper cervical spine affect pain sensitivity and autonomic nervous system function in patients with cervico-craniofacial pain?: a randomized-controlled trial. Clin J Pain. 2013;29(3):205–15. https://doi.org/10.1097/AJP.0b013e318250f3cd.CrossRefPubMed

41.

Vicenzino B, Collins D, Benson H, Wright A. An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation. J Manip Physiol Ther. 1998;21(7):448–53.

42.

Perry J, Green A, Singh S, Watson P. A randomised, independent groups study investigating the sympathetic nervous system responses to two manual therapy treatments in patients with LBP. Man Ther. 2015. https://doi.org/10.1016/j.math.2015.04.011.

43.

Navarro-Santana MJ, Gomez-Chiguano GF, Somkereki MD, Fernandez-de-las-Penas C, Cleland J, Plaza-Manzano G. Effects of joint mobilisation on clinical manifestations of sympathetic nervous system activity: a systematic review and meta-analysis. Physiotherapy. 2019. https://doi.org/10.1016/j.physio.2019.07.001.

44.

Online A: Epicondylopathia radialis humeri. Berlin; 2020. https://www.awmf.org/leitlinien/detail/ll/033-019.html. Accessed 10 Jan 2020.

45.

Brummel J, Baker CL 3rd, Hopkins R, Baker CL Jr. Epicondylitis: lateral. Sports Med Arthrosc Rev. 2014;22(3):e1–6. https://doi.org/10.1097/JSA.0000000000000024.CrossRefPubMed

46.

Vaquero-Picado A, Barco R, Antuna SA. Lateral epicondylitis of the elbow. EFORT Open Rev. 2016;1(11):391–7. https://doi.org/10.1302/2058-5241.1.000049.CrossRefPubMedPubMedCentral

47.

Paungmali A, O'Leary S, Souvlis T, Vicenzino B. Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Phys Ther. 2003;83(4):374–83.CrossRefPubMed

48.

Lim EC. Pain free grip strength test. J Physiother. 2013;59(1):59. https://doi.org/10.1016/S1836-9553(13)70152-8.CrossRefPubMed

49.

Stratford PW, Levy DR, Gowland C. Evaluative properties of measures used to assess patients with lateral epicondylitis at the elbow. Physiother Can. 1993;45:160–4.

50.

VaezMousavi SM, Barry RJ, Rushby JA, Clarke AR. Evidence for differentiation of arousal and activation in normal adults. Acta Neurobiol Exp. 2007;67(2):179–86.

51.

Lipschitz M, Bernstein-Lipschitz L, Nathan H. Thoracic sympathetic trunk compression by osteophytes associated with arthritis of the costovertebral joint. Anatomical and clinical considerations. Acta Anat (Basel). 1988;132(1):48–54.CrossRef

52.

Farrokhyar F, Reddy D, Poolman RW, Bhandari M. Why perform a priori sample size calculation? Can J Surg J. 2013;56(3):207–13. https://doi.org/10.1503/cjs.018012.CrossRef

53.

Hintze J. PASS 13 power analysis and sample size software. Kaysville: NCSS, LLC; 2014.

54.

Piantadosi S. Clinical trials - a methodological perspective. New Jersey: John Wiley & Sons; 2005.CrossRef

55.

Hintze J. NCSS 10 statistical software. Kaysville: NCSS, LCC; 2015.

56.

Hill T, Lewicki P. Statistics: methods and applications. Tulsa: Statsoft; 2006.

57.

Perry J, Green A. An investigation into the effects of a unilaterally applied lumbar mobilisation technique on peripheral sympathetic nervous system activity in the lower limbs. Man Ther. 2008;13(6):492–9 https://doi.org/10.1016/j.math.2007.05.015.CrossRefPubMed

58.

Berglund KM, Persson BH, Denison E. Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. Man Ther. 2008;13(4):295–9 https://doi.org/10.1016/j.math.2007.01.015.CrossRefPubMed

59.

Edmondston SJ, Ferguson A, Ippersiel P, Ronningen L, Sodeland S, Barclay L. Clinical and radiological investigation of thoracic spine extension motion during bilateral arm elevation. J Orthop Sports Phys Ther. 2012;42(10):861–9 https://doi.org/10.2519/jospt.2012.4164.CrossRefPubMed

60.

McDevitt A, Young J, Mintken P, Cleland J. Regional interdependence and manual therapy directed at the thoracic spine. J Man Manip Ther. 2015;23(3):139–46. https://doi.org/10.1179/2042618615Y.0000000005.CrossRefPubMedPubMedCentral

61.

Sueki DG, Cleland JA, Wainner RS. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. J Man Manip Ther. 2013;21(2):90–102. https://doi.org/10.1179/2042618612Y.0000000027.CrossRefPubMedPubMedCentral

62.

Cleland JA, Flynn TW, Palmer JA. Incorporation of manual therapy directed at the Cervicothoracic spine in patients with lateral Epicondylalgia: a pilot clinical trial. J Man Manip Ther. 2005;13(3):143–51. https://doi.org/10.1179/106698105790824932.CrossRef

63.

Kardouni JR, Shaffer SW, Pidcoe PE, Finucane SD, Cheatham SA, Michener LA. Immediate changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with subacromial impingement syndrome: a randomized controlled study. Man Ther. 2015;20(4):540–6 https://doi.org/10.1016/j.math.2014.12.003.CrossRefPubMed

64.

Kardouni JR, Pidcoe PE, Shaffer SW, Finucane SD, Cheatham SA, Sousa CO, Michener LA. Thoracic spine manipulation in individuals with subacromial impingement syndrome does not immediately Alter thoracic spine kinematics, thoracic excursion, or scapular kinematics: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(7):527–38 https://doi.org/10.2519/jospt.2015.5647.CrossRefPubMed

65.

Arendt-Nielsen L, Fernandez-de-Las-Penas C, Graven-Nielsen T. Basic aspects of musculoskeletal pain: from acute to chronic pain. J Man Manip Ther. 2011;19(4):186–93. https://doi.org/10.1179/106698111X13129729551903.CrossRefPubMedPubMedCentral

66.

Bishop MD, Torres-Cueco R, Gay CW, Lluch-Girbes E, Beneciuk JM, Bialosky JE. What effect can manual therapy have on a patient's pain experience? Pain Manag. 2015;5(6):455–64. https://doi.org/10.2217/pmt.15.39.CrossRefPubMedPubMedCentral

67.

Pourhoseingholi MA, Vahedi M, Rahimzadeh M. Sample size calculation in medical studies. Gastroenterol Hepatol Bed Bench. 2013;6(1):14–7.PubMedPubMedCentral

Title: The effect of manual therapy to the thoracic spine on pain-free grip and sympathetic activity in patients with lateral epicondylalgia humeri. A randomized, sample sized planned, placebo-controlled, patient-blinded monocentric trial
Authors: Philipp Zunke
Alexander Auffarth
Wolfgang Hitzl
Mohamed Moursy
Publication date: 01-12-2020
Publisher: BioMed Central
Keyword: Musculoskeletal Pain
Published in: BMC Musculoskeletal Disorders / Issue 1/2020
Electronic ISSN: 1471-2474
DOI: https://doi.org/10.1186/s12891-020-3175-y

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

The effect of manual therapy to the thoracic spine on pain-free grip and sympathetic activity in patients with lateral epicondylalgia humeri. A randomized, sample sized planned, placebo-controlled, patient-blinded monocentric trial

Abstract

Background

Methods

Results

Conclusion

Clinical trial registration

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Clinical trial registration

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