Elbow and Forearm Tendinopathy Evidence Based Medicine Literature Review and Protocol

1. Elbow and Forearm Tendinopathy Evidence Based Medicine Literature Review and Protocol Peggy C. Haase, OTR, CHT

2. Level IV Advancing Project – Peggy C. Haase, OTR, CHT • Completed evidence based medicine review of current therapy choices for upper extremity tendinopathy, focusing on the elbow and forearm, including proximal forearm muscle belly as well as insertional lateral tendinopathy, insertional medial tendinopathy, and insertional triceps tendinopathy • Articles reviewed and placed in research summary grid • Developed conservative management treatment protocol for elbow and forearm tendinopathy, including forearm muscle belly and elbow insertional tendinopathy • Developed patient education handouts for active, resistive, eccentric, and eccentric resistive exercises • Presented findings to Hand & UE Focus Group at the June 22, 2009 meeting

3. Evidence Based Literature Review • Reviewed 18 articles on tendinopathy, evidence-based practice for hand therapists, wrist & hand overuse, elbow & forearm tendinopathy • 9 Level 1 evidence articles • 2 Level 2 evidence articles • 2 Level 3 evidence articles • 5 Level 5 evidence articles

4. Literature Review Reveals Support for Use Level 1 and Level 2 Evidence for: • Ultrasound • Phonophoresis • Electrical Stimulation • Iontophoresis • Manual Therapy • Stretching • Concentric Exercises • Eccentric Exercises • Strengthening Exercises • Counterforce Brace • Consider 6 weeks of home therapy

5. Literature Review Reveals Weak or No Evidence for Use • Low-Intensity Laser • Transverse Friction Massage

6. Progressing to Return to Normal Activity Level Level 3 and Level 5 Evidence for use of: • Rest • Supportive devices as splint, brace • Assessment of total mechanics of body, not just the local area presenting with the discomfort • Activity assessment for activity modification • Progressive reconditioning program for strength, flexibility, endurance, and eccentric exercises

7. Nirschl Pain Phase Scale • Phase 1. Stiffness or mild soreness after activity. Pain is usually gone within 24 hours. • Phase 2. Stiffness or mild soreness before activity that is relieved by warm-up. Symptoms are not present during activity, but return afterward, lasting up to 48 hours. • Phase 3. Stiffness or mild soreness before specific sport or occupational activity. Pain is partially relieved by warm-up. It is minimally present during activity, but does not cause the person to alter activity. • Phase 4. Similar to phase 3 pain but more intense, causing the person to alter performance of the activity. Mild pain occurs with activities of daily living, but does not cause a major change in them. • Phase 5. Significant (moderate or greater) pain before, during, and after activity, causing alteration of activity. Pain occurs with activities of daily living, but does not cause a major change in them. • Phase 6. Phase 5 pain that persists even with complete rest. Pain disrupts simple activities of daily living and prohibits doing household chores. • Phase 7. Phase 6 pain that also disrupts sleep consistently. Pain is aching in nature and intensifies with activity.

8. Elbow and Forearm Tendinopathy Conservative Treatment Guide March 2009 • Phase 1 - Acute Phase (1-3 weeks) Rest, use of cool, may use splint for pain management, PAMs include 20% pulsed ultrasound, ultrasound-electrical stimulation combo, iontophoresis with dexamethasone Rehabilitation Phase (2 weeks – 12 months) • Phase II - Early Rehab Phase most patients enter treatment now Activity (ADL, sport, work) assessment for possible aggravating activities with suggestions for activity adjustments to decrease pain and increase function May add use of counterforce brace Warming up/cooling down with activity and exercises Active motion exercises for elbow, forearm, wrist Active eccentric exercises for affected muscle May add passive stretches PAMs include 50% pulsed ultrasound, phonophoresis with dexamethasone gel, iontophoresis with dexamethasone May progress to overall conditioning program as VOI Fitness Center • Phase III - Late Rehab Phase Continue with warming up/cooling down with activity and exercises Continue with active exercises and active eccentric exercises Add conditioning/strengthening exercises – eccentric to concentric exercises Pain is guide to decrease repetitions, decrease weight, decrease speed, decrease time with activity – seen Nirschl Pain Phase Scale - as pain is decreased, then may increase program Progress to concentric resistive exercises when no pain with two consecutive sessions with active and active eccentric exerciss Progress to return to activity as pain remains decreased May progress to overall conditioning program as VOI Fitness Center

9. Resources • Journal of Hand Therapy • American Journal of Sports Medicine • British Journal of Sports Medicine • Clinic Orthopaedics Related Research • Rheumatology Journal • Clinics in Sports Medicine • Modalities for Therapeutic Intervention, 4th Edition • Evidence-Based Guide to Therapeutic Physical Agents • Arm Care, Robert Nirschl

10. Thank You