The 21st Annual Clinical Meeting of the American Academy entitled Exploring the Science, Practicing the Art: Integrative Pain Management for Optimal Patient Care, in Las Vegas, Nevada, from September 21-24, 2010. This poster was presented on Wednesday, September 22, and Thursday, September 23

1. Combined of HVLA manipulation, exercise and physical therapy for treatment of Lateral
multimodal therapies for chronic tennis elbow: pilot study
Combination
to test protocols for a randomized clinical trials
epicondylitis
1,
Radpasand
Over View
Lateral epicondylitis, also known as tennis elbow is
defined as pain over the lateral aspect of the elbow
which is aggravated by active wrist extension and
direct palpation over either the lateral epicondyle of
the humerus, the radio-humeral joint space or the
proximal muscle bellies. The incidence and
prevalence is approximately 1%-3%. Women are
more often affected than men, of 9% and 3%
respectively, with a peak prevalence at age 42-44.
At least 40 different treatment modalities aiming to
reduce pain and increase function have been
described, but the optimal treatment remains
undefined.
Hard-padded elbow brace knob was placed
exactly on top of the most painful area
4. Ice: Small amount, just to cover the
lateral epicondyle
5. Exercises (4 Types): Isometric end
point contraction
Exercise
A) Forearm Extensor
Muscle
Objective
Has two parts 1) pure extension
at the wrist, 2) radial deviation
and extension
To develop and test protocols for a randomized
clinical trial (RCT) of 2 multimodal package therapies
for chronic lateral epicondylitis (CLE).
B) Forearm Flexor
Muscle
Methods
Six participants were enrolled after case review
and randomized to 1 of 2 groups (4 in group A
and 2 in group B) for 12 weeks of treatment.
Group A: high-velocity-low-amplitude
manipulation (HVLA), high-voltage pulse
galvanic stimulation (HVPGS), counterforce
bracing, ice, and exercise.
Group B: ultrasound, counterforce bracing,
and exercise. Both groups had suggestion to
restrict usage of the affected elbow.
All participants were asked to complete a visual
analog scale questionnaire (VAS_24hs) and a
patient-rated tennis elbow evaluation (PRTEE)
every week. Pain-free grip strength (PFGS) was
measured at baseline, and at Weeks 3, 6,9,and
12.
Multimodal package A
Multimodal package A
1. Manipulation - HVLA Type
A quick thrust using the pad of the thumb in a posterior to
anterior direction over the posterior aspect of the radial
head, approximately on top of the extensor tendon
attachment to the lateral epicondyle. The patient sat on a
chair with the upper body in postural alignment. The
provider’s opposite hand holds the dorsum of the
patient’s wrist. The provider starts with the elbow slightly
flexed, takes it to full extension and applies the thrust at
the end-range while extending the elbow and pronating
the forearm
2. High-voltage pulse galvanic stimulation
(HVPGS): 150 Hz ; 19-29mA
Positive pad was over the lateral epicondyle
Negative pad was at the base of involved elbow’s
scapula
3. Hard-padded elbow brace
Has two parts 1) pure flexion
at the wrist, 2) radial
deviation, and flexion
Multimodal package B
1.
2.
3.
Ultrasound
Time: set at 8 minutes
Dosage: 3 MHz, 1.5 W/cm²
Pulse mode: 20%
Transducer head area: 2 cm²
Hard-padded elbow brace
Exercises (1Type ): Isometric end point contraction
 Putty therapeutic
Result
One participant in group A dropped out before the end of care.
Both groups demonstrated changes in all of the outcome
variables from baseline to the endpoint of treatment. In group A,
there was a 59% change for PRTEE total, a 3.2% change for
PFGS, and a 51.4% change for VAS_24hs worst pain felt
compared to 9.5%, 169.0%, and 65.1%, respectively, for group
B. The painful elbow showed less strength than the non-painful
one, and there was an inverse relationship between PRTEE
and PFGS. The sample size for a larger RCT calculated post
ad hoc was 246 participants.
Pain Free Grip Strength
Patient-Rated Tennis Elbow Evaluation
VAS 24hs Worst Pain
Group A
70
90
60
50
80
50
C) Exercise for Supinator and
Pronator Muscle
40
70
40
30
20
10
D) Putty Therapeutic
The arm and forearm should make a 90° angle
with each other, with the wrist extended as far as
it can, while holding the putty. The putty will be
pushed toward the thenar surface of the palm of
the hand by flexing the four digits of 2 to 5 as
hard as possible.
30
20
10
0
Pre
-20
Time Point
40
20
Post
Post
-10
50
0
-10
Pre
60
30
10
Pre
0
The participant has the full active
control of the weight. The elbow is
supported at the edge of the table,
while the arm and forearm make a 90°
angle. All of the exercises had duration
per repetition of 10s, with 10
repetitions maximum.
Group A
Group B
100
Group A
Group B
60
Group B
Kilograms
Background
2 Northwestern Health Sciences University, Bloomington, MN
Department, D’Youville College, Buffalo, NY
Palmer Center for Chiropractic Research, Davenport, IA, USA
PRTEE Score (0-50)
1Chiropractic
VAS (0-100)
1
Mohsen
E.F. Owens
Mohsen Radpasand, DC, MD Jr
2
Time Point
Post
Time Point
Conclusions: This pilot study demonstrated that the study
design is feasible and that patients could be recruited for a 12week trial of multimodal treatment. A larger, multicenter trial is
warranted to evaluate these treatment strategies.
Disclosure: Supported by a grant from the NIH (K30-AT-0097704). This study was conducted at the Palmer Center for
Chiropractic Research (PCCR), which was constructed with
support of a Research Facilities Improvement Grant
(C06RR15433) from the National Center for Research Resources
at the NIH. The NCMIC provided financial support for the program,
and the Chattanooga Group provided the ultrasound unit for this
study. J Manipulative Physiol Ther. 2009;32(7):571-585