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PHYSIOTHERAPYTREATMENT APPROACHESFOR TENNIS ELBOWVicente Lloretviernes 24 de mayo de 13
KEY WORDS:- Clinical picture ≠ Diagnosis- Subclassification- Pain ≠ Damageviernes 24 de mayo de 13
CLINICAL PICTUREWhat are we talking about when we talk about...?PFG: Pain Free Gripviernes 24 de mayo de 13
1. Pain does not provide a measure of thestate of the tissues2. Pain is modulated by many factors:somatic, psychological a...
1. Pain does not provide a measure of thestate of the tissues2. Pain is modulated by many factors:somatic, psychological a...
SUBCLASSIFICATION...low level evidence......need of further research...EVIDENCE BASED PHYSIOTHERAPYviernes 24 de mayo de 13
COMPLAINS OF- Limited range of movement- Pain- Limited range of movement associated with painviernes 24 de mayo de 13
COMPLAINS OF- Limited range of movement- Pain- Limited range of movement associated with painMovement disfunction{viernes ...
Painsystem(s)changesLocaltendonpathologyMANAGEMENTMotorsystemimpairmentsviernes 24 de mayo de 13
Bisset L, Russell, Ha B, Bradley S,Vicenzino B (2006)Bilateral sensorimotor abnormalities in unilateral epicondylalgia.Arc...
Motor system impairmentsPienimakiT, Kauranen K,Vanharanta H (1997) Bilaterally decreasedmotor performance of arms in patie...
Kelly JD, Lombardo SJ, Pink M, Perry J, Giangarra CE (1994)EMG and cinematographic analysis of elbow function in tennis pl...
Motorsystemimpairmentsmorphological deficitssensori-motor (bilateral)strength imbalanceglobal changesviernes 24 de mayo de 13
Pain systems changesSlater H,Arendt-Nielsen L,Wright A, Graven-NielsenT (2004)Sensory and motor effects of experimental mu...
Pain systems changesAlfredson H, Ljung BO,Thorsen K, Lorentz R (2000) In vivo investigation of ECRB tendons withmicrodyaly...
Painsystem(s)changesPain systems changesmechanical hyperalgesiadeep tissue sensitivitycentral sensitizationlocal neurotran...
Local tendon pathologyZezig E, Ohberg L,Alfredson H. Extensor origin vascularity related to pain in patients withTE.Knee S...
Local tendon pathologyLocaltendonpathologycollagen fibrils disarrayNeovascularisationincreased matrix proteinviernes 24 de ...
ManagementPainsystem(s)changesMotorsystemimpairmentsLocaltendonpathologymorphological deficitssensori-motor (bilateral)stre...
Exercise, Prolotherapy, PolydocinalExercise,Exercise,ExerciseMWM,gradedmotorimageryManagementMotorsystemimpairmentsPainsys...
Leanne Bisset, Elaine Beller, Gwendolen Jull, Peter Brooks, Ross Darnell, and BillVicenzinoMobilisation with movement and ...
NNT=3NNT=2viernes 24 de mayo de 13
Leanne Bisset, Elaine Beller, Gwendolen Jull, Peter Brooks, Ross Darnell, and BillVicenzinoMobilisation with movement and ...
¿What is a MWM?- MWM = hypoalgesia and rapidly function recoveryVicenzino B.Wright A. Effects of a novel manipulative phys...
Observación clínica:Patient presents with Pain & Disability Pain free & recoveredObservation 1:Retrospective interpretatio...
Hsieh C-Y,Vicenzino B,Yang C-H, Hu M-H,Yang C. Mulligan ́s mobilization with movement for thethumb: a single case report u...
Hsieh C-Y,Vicenzino B,Yang C-H, Hu M-H,Yang C. Mulligan ́s mobilization with movement for thethumb: a single case report u...
viernes 24 de mayo de 13
viernes 24 de mayo de 13
MWMTransient changein bone position &increase ROMNEUROPHYSIOLOGICPain effectsAssociated systems &modelingSensory motor sys...
viernes 24 de mayo de 13
viernes 24 de mayo de 13
MotorsystemimpairmentsPainsystem(s)changesLocaltendonpathologyviernes 24 de mayo de 13
THANK YOU!viernes 24 de mayo de 13
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Physiotherapy treatment approaches for tennis elbow - Vicente Lloret Vicedo

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Physiotherapy treatment approaches for tennis elbow

Enfoques de tratamiento para el codo de tenista en fisioterapia

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Physiotherapy treatment approaches for tennis elbow - Vicente Lloret Vicedo

  1. 1. PHYSIOTHERAPYTREATMENT APPROACHESFOR TENNIS ELBOWVicente Lloretviernes 24 de mayo de 13
  2. 2. KEY WORDS:- Clinical picture ≠ Diagnosis- Subclassification- Pain ≠ Damageviernes 24 de mayo de 13
  3. 3. CLINICAL PICTUREWhat are we talking about when we talk about...?PFG: Pain Free Gripviernes 24 de mayo de 13
  4. 4. 1. Pain does not provide a measure of thestate of the tissues2. Pain is modulated by many factors:somatic, psychological and social3. Relationship between pain and the stateof the tissues is less predictable as painpersist4. Conscious correlate of the implicitperception that tissue is in danger.PAIN ≠ DAMAGEviernes 24 de mayo de 13
  5. 5. 1. Pain does not provide a measure of thestate of the tissues2. Pain is modulated by many factors:somatic, psychological and social3. Relationship between pain and the stateof the tissues is less predictable as painpersist4. Conscious correlate of the implicitperception that tissue is in danger.Moseley GL. Reconceptualising Pain. PhysicalTherapy Reviews. 2007 Aug 25;3(12):169-78.viernes 24 de mayo de 13
  6. 6. SUBCLASSIFICATION...low level evidence......need of further research...EVIDENCE BASED PHYSIOTHERAPYviernes 24 de mayo de 13
  7. 7. COMPLAINS OF- Limited range of movement- Pain- Limited range of movement associated with painviernes 24 de mayo de 13
  8. 8. COMPLAINS OF- Limited range of movement- Pain- Limited range of movement associated with painMovement disfunction{viernes 24 de mayo de 13
  9. 9. Painsystem(s)changesLocaltendonpathologyMANAGEMENTMotorsystemimpairmentsviernes 24 de mayo de 13
  10. 10. Bisset L, Russell, Ha B, Bradley S,Vicenzino B (2006)Bilateral sensorimotor abnormalities in unilateral epicondylalgia.Arch Phys Med Rehabil. 87:490-5.Motor system impairments150175250225250275300325350375Tiempodereacción(mseg)Control EpicondilalgiaRT1RT28090100120130VelocidaddelmovimientoControl Epicondilalgiaviernes 24 de mayo de 13
  11. 11. Motor system impairmentsPienimakiT, Kauranen K,Vanharanta H (1997) Bilaterally decreasedmotor performance of arms in patients with CLE,Archives Phys Med Rehab 78 (10): 1092-5Results: Compared to normal the patient had:-19-36% slower reaction times for both arms-31-32% slower speed of movement for both arms- There was no difference between affected and unaffected arm.Conclusión:- Unclear mechanims at play.- What comes first the pain of tennis elbow or motorcontrol deficit?- May be indicative of altered central processingviernes 24 de mayo de 13
  12. 12. Kelly JD, Lombardo SJ, Pink M, Perry J, Giangarra CE (1994)EMG and cinematographic analysis of elbow function in tennis players with LE,AJSM 22:359-630102030405060708090100NormalLesionadoPREPARATION1º 2ºACCELERATIONBALLIMPACTFOLLOW-THOUGH1º 2ºMotor system impairmentsviernes 24 de mayo de 13
  13. 13. Motorsystemimpairmentsmorphological deficitssensori-motor (bilateral)strength imbalanceglobal changesviernes 24 de mayo de 13
  14. 14. Pain systems changesSlater H,Arendt-Nielsen L,Wright A, Graven-NielsenT (2004)Sensory and motor effects of experimental muscle pain in patientswith LE and controls with DOMS. Pain 114:118:30Pain was quicker in onset and over larger areas bilaterally.Indicative of involvement of central sensitizationA number of interacting neurophys mechanisms:facilitation of quiescent or latent synapsisexpansion of receptive fieldsactivation of mor WDR neuronsPain lasted longer in sore arm of patients.Bilateral hyperalgesiaviernes 24 de mayo de 13
  15. 15. Pain systems changesAlfredson H, Ljung BO,Thorsen K, Lorentz R (2000) In vivo investigation of ECRB tendons withmicrodyalysis technique - no signs of inflammation but high amounts of glutamate in tenniselbow.Acta Orthop Scand 71(5):475-9- 4 patients with chronic pain ECRB origin & 4 control- Microdyalysis under LA and resting conditions over 2 hourperiod (15 min samplings)- Sampled glutamate and prostablandin E2 (PGE2)- Glutamate higher in patients- PGE2 no differentviernes 24 de mayo de 13
  16. 16. Painsystem(s)changesPain systems changesmechanical hyperalgesiadeep tissue sensitivitycentral sensitizationlocal neurotransmittersviernes 24 de mayo de 13
  17. 17. Local tendon pathologyZezig E, Ohberg L,Alfredson H. Extensor origin vascularity related to pain in patients withTE.Knee Surg SportsTraumatol Arthrosc (2006) 14:659-63- 17 patient: 22 elbows (5 bilateral) v 11 controls- US + Doppler studyNeovessels closely related to neural structuresviernes 24 de mayo de 13
  18. 18. Local tendon pathologyLocaltendonpathologycollagen fibrils disarrayNeovascularisationincreased matrix proteinviernes 24 de mayo de 13
  19. 19. ManagementPainsystem(s)changesMotorsystemimpairmentsLocaltendonpathologymorphological deficitssensori-motor (bilateral)strength imbalanceglobal changesmechanical hyperalgesiadeep tissue sensitivitycentral sensitizationlocal neurotransmitterscollagen fibrils disarrayNeovascularisationincreased matrix proteinviernes 24 de mayo de 13
  20. 20. Exercise, Prolotherapy, PolydocinalExercise,Exercise,ExerciseMWM,gradedmotorimageryManagementMotorsystemimpairmentsPainsystem(s)changesLocaltendonpathologyviernes 24 de mayo de 13
  21. 21. Leanne Bisset, Elaine Beller, Gwendolen Jull, Peter Brooks, Ross Darnell, and BillVicenzinoMobilisation with movement and exercise, corticosteroid injection, or wait and see fortennis elbow: randomised trialBMJ Nov 2006; 333: 939Physical treatmentviernes 24 de mayo de 13
  22. 22. NNT=3NNT=2viernes 24 de mayo de 13
  23. 23. Leanne Bisset, Elaine Beller, Gwendolen Jull, Peter Brooks, Ross Darnell, and BillVicenzinoMobilisation with movement and exercise, corticosteroid injection, or wait and see fortennis elbow: randomised trialBMJ Nov 2006; 333: 939viernes 24 de mayo de 13
  24. 24. ¿What is a MWM?- MWM = hypoalgesia and rapidly function recoveryVicenzino B.Wright A. Effects of a novel manipulative physiotherapy technique on tenniselbow: a single case study. ManualTherapy 1995; 1(1):30-5.Abbott JH, Patla CE, Jensen RH.The initial effects of an elbow mobilization with movementtechnique on grip strength in subjects with lateral epicondylalgia. ManualTherapy 2001;6(3):163-9.Positional fault =biomechanical correction?viernes 24 de mayo de 13
  25. 25. Observación clínica:Patient presents with Pain & Disability Pain free & recoveredObservation 1:Retrospective interpretation of clinical observations:Observation 2:Observation 3:The Mobilisation exerts a force to a joint that glides joint surgaces.The force needs to be specific for the technique to be effective.The MWM reverses a positional fault.Inferred clinical aplicationAntecedent event:Traumatic (injury) or Non-traumatic (postural, overuse)Positional FaultPatient experiencesPain & DisabilityIdentification of positionalfault by practitionerMWM applied to reversepositional faultMWM reversespositional faultMWMviernes 24 de mayo de 13
  26. 26. Hsieh C-Y,Vicenzino B,Yang C-H, Hu M-H,Yang C. Mulligan ́s mobilization with movement for thethumb: a single case report using magnetic resonance imaging to evaluate the positional faulthypothesis. ManualTherapy 2002; 7(1):44-9.Gal et al. Movements of vertebrae during manipulative thrust to unembalmed human cadavers..1997 J of Manipulative PhysTher 20:30-40.viernes 24 de mayo de 13
  27. 27. Hsieh C-Y,Vicenzino B,Yang C-H, Hu M-H,Yang C. Mulligan ́s mobilization with movement for thethumb: a single case report using magnetic resonance imaging to evaluate the positional faulthypothesis. ManualTherapy 2002; 7(1):44-9.Gal et al. Movements of vertebrae during manipulative thrust to unembalmed human cadavers..1997 J of Manipulative PhysTher 20:30-40.viernes 24 de mayo de 13
  28. 28. viernes 24 de mayo de 13
  29. 29. viernes 24 de mayo de 13
  30. 30. MWMTransient changein bone position &increase ROMNEUROPHYSIOLOGICPain effectsAssociated systems &modelingSensory motor systemInitial non-opioidhypo-algesia:DPIS-PAG mediated?Sensorimotor integrationBIOMECHANICSviernes 24 de mayo de 13
  31. 31. viernes 24 de mayo de 13
  32. 32. viernes 24 de mayo de 13
  33. 33. MotorsystemimpairmentsPainsystem(s)changesLocaltendonpathologyviernes 24 de mayo de 13
  34. 34. THANK YOU!viernes 24 de mayo de 13

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