Effectiveness of Manual Therapy in the Management of Elbow Joint Dysfunctions.

Effectiveness of Manual Therapy in the Management of Elbow Joint Dysfunctions.

Dr. Kanchan koul (PT) Assistant professor at Dayananda Sagar University Bangalore.

Elbow joint is a compound synovial modified hinge joint. It is 2 nd largest joint to get easily dislocated. Complex elbow trauma, close head injuries, overuse injuries, serious burns, complex fractures and dislocations of elbow these entire conditions put patient on the risk of elbow dysfunction. Evaluation of elbow pain causing dysfunction can be a challenging because of joint complexity[ CITATION Ran95 \l 1033 ]. It is important to identify the specific structures (musculotendinous) that are always on a risk of overuse or has been injured through overuse Normal upper limb function depends on a freely mobile, strong and stable elbow joint complex.

Humeroulnar joint a modified hinge joint that allow flexion and extension where as humeroradial joint permits flexion, extension and rotation on capitulum of the humerus .The proximal radioulnar joint facilitates rotation during supination and pronation. Stability of these entire joint are provided by medial and lateral ligament complexes[ CITATION SBr09 \l 1033 ].

Deep branch of radial nerve also passes through the “Orcade of Frohse” a fibrous arch made by superficial head of supinator muscle, can be harmed by injury leading to peripheral nerve dysfunction of elbow.

The most common elbow dysfunction is “repetitive trauma syndrome” in simple words “overuse” commonly occur in muscle attached to medial or lateral epicondyles in response to stressful repetitive sporting activities involving wrist motion[ CITATION Meh97 \l 1033 ].

“Mayer” 1883 coined the terms “lawn tennis” for tennis elbow or lateral epicondylitis (L.E).It is commonly seen in sports and clinical practice. In 1800’s it was describe as “occupational condition”.

Prevalence of lateral epicondylitis is (2.8%) in general population, (7.4%) in engineering industry, in 89% of population it is considered as self-limiting condition, (40%) diagnosed population experience reoccurrence and enhanced symptoms leading to impaired function[ CITATION Cal97

\l 1033 ]. Pain is felt all over the lateral epicondyle, irritated by work or recreational activities involving hand and wrist movements[ CITATION And93 \l 1033 ].

The physiotherapy treatment approaches available till now to treat L.E[ CITATION Bis05 \l 1033 ] are manual therapy which includes (soft tissue techniques, elbow MWM, wrist MWM, spinal MWM, cervical MWM oscillating energy manual therapy, joint manipulation, Cyriax cross friction massage, mills manipulation, scaphoid thrust manipulation, neurofascial mobilization, myofascial trigger point therapy, lymphatic drain therapy, instrument assisted mobilization),

exercisetherapy,

acupuncture,

ultrasound,

extracorporeal

soft tissue

shock

wave

therapy,iontophoresis with NSAIDS/dexamethasone, low level laser therapy, orthotic device, taping[ CITATION Vic03 \l 1033 ] based on different school of thoughts like Maitland, Mills, Cyriax[ CITATION Cyr97 \l 1033 ], Kaltenborn[ CITATION Kal76 \l 1033 ], Mennel[ CITATION Men64 \l 1033 ], Stoddard, and Mulligans[ CITATION Mur06 \l 1033 ].

Among all available treatment options manual therapy is one of the approaches, followed worldwide and is considered by most of the physiotherapist as current treatment option to treat L.E[ CITATION Smi03 \l 1033 ]. Manual therapy implies “hand on therapy� that includes joint stretching or mobilization to improve muscles dysfunction and joint mobility based on the concept that joint restriction contribute to pain.

Types of manual therapy[ CITATION SBr09 \l 1033 ]: 1- Biomechanical model (osteopathic approach).

Here by using muscle energy there is voluntary contraction of the subjects muscle in a precisely controlled direction against an opposite force applied by the therapist.

2-Manipulation Therapist passively, often forcefully moves or thrusts a bone through its physiological barriers to improve R.O.M or to correct alignment of a joint.

3-Norwegian approach (Kaltenborn)[ CITATION Kal76 \l 1033 ]

In this approach hypo-mobility, normal, hypermobility and range and quality of movement are evaluated using translatory movement in addition to rotation movement.

4-Mulligans Mobilization[ CITATION Mul99 \l 1033 ]: Concept was introducing by brain mulligan in 1970. It was based on kalternborns principle of passive mobilization, concave convex rule and treatment plane rule glides can be applied to joint in 2 ways first at right angle to the joint movement and appropriate glide can be determined by applying the concave and convex rule.

4- Maitland’s (Australian) approach[ CITATION Dar04 \l 1033 ] In this approach, there is ongoing assessment and reassessment of the patient’s conditions and considerations of anatomy and pathology in relation to sign and symptoms.

Recent studies concluded that in the management of acute and chronic musculoskeletal pain, manual therapy is considered as effective. With manual therapy, there is increased circulation via local effects sympathetic reflex and increased lymphatic and venous drainage that lead to decrease oedema and local swelling. There were high level of evidences indicating the importance of using elbow MWM as treatment technique, reported the immediate effect of pain and grip strength. One study concludes that with MWM on elbow joint 92% of patients were able to perform a pain free movement immediately after treatment. It was suggested that MWM has physiological sympatho-excitatory and hypoalgesic (improvement in pressure pain threshold and pain free grip) on comparison of all that scores had showed significant improvement when compared with placebo or controlled group.

Over last two decades numerous researchers have contribute towards treatment methods of L.E. Mulligan’s MWM have been frequently studied and proven effective method to relief pain and improve grip strength in L.E subjects. However it is very important to know that whether these effects translate to an improvement in clinical outcomes for patients. Effect of MWM concluded from previous research are reduction in pain, reduced need for analgesic, promotion

of healing through circulatory effects, maintance of tone and muscle length, enhanced healing process due to increased protein synthesis, improved cytological well-being. From clinical point of view, each subject should be categories into acute and chronic conditions. Mulligan’s concept should be given with other methods like low level laser therapy, soft tissue mobilization, strengthening, agility, power training, proprioception flexibility drills, and aerobic endurance training for better clinical outcome. Future research should be done in direction to make a “pragmatic approach” to treat elbow dysfunctions including Bio-psycho-social impact of dysfunction on patient pain perception.

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