Physiotherapy alone or in combination with corticosteroid injection for acute lateral epicondylitis in general practice: A protocol for a randomised, placebo-controlled study

<p>Abstract</p> <p>Background</p> <p>Lateral epicondylitis is a painful condition responsible for loss of function and sick leave for long periods of time. In many countries, the treatment guidelines recommend a wait-and-see policy, reflecting that no conclusions on the best treatment can be drawn from the available research, published studies and meta-analyses.</p> <p>Methods/Design</p> <p>Randomized double blind controlled clinical trial in a primary care setting. While earlier trials have either compared corticosteroid injections to physical therapy or to naproxen orally, we will compare the clinical effect of physiotherapy alone or physiotherapy combined with corticosteroid injection in the initial treatment of acute tennis elbow. Patients seeing their general practitioner with lateral elbow pain of recent onset will be randomised to one of three interventions: 1: physiotherapy, corticosteroid injection and naproxen or 2: physiotherapy, placebo injection and naproxen or 3: wait and see treatment with naproxen alone. Treatment and assessments are done by two different doctors, and the contents of the injection is unknown to both the treating doctor and patient. The primary outcome measure is the patient's evaluation of improvement after 6, 12, 26 and 52 weeks. Secondary outcome measures are pain, function and severity of main complaint, pain-free grip strength, maximal grip strength, pressure-pain threshold, the patient's satisfaction with the treatment and duration of sick leave.</p> <p>Conclusion</p> <p>This article describes a randomized, double blind, controlled clinical trial with a one year follow up to investigate the effects of adding steroid injections to physiotherapy in acute lateral epicondylitis.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov Identifier: NCT00826462</p

Which spinal levels are identified by palpation of the iliac crests and the posterior superior iliac spines?

The line joining the superior aspect of the iliac crests posteriorly (the intercristal line) is commonly stated to cross the midline at the L4 or L4–5 spinal level on imaging. This study aimed to assess the spinal level identified through palpation of surface anatomy (iliac crests and posterior superior iliac spines) in adults and the level of agreement compared with the intercristal line identified through imaging. The study participants included consecutive adult patients undergoing prone fluoroscopically guided spinal injections for chronic low back pain at the Royal Orthopaedic Hospital, Birmingham, between April and July 2004. Prior to fluoroscopic imaging, each patient's surface anatomy was palpated by two examiners and lines created to form the palpated intercristal line and the posterior superior iliac spine line. Following imaging, the mid-line spinal levels identified by these palpated lines were recorded and the level of agreement (kappa coefficient) with the intercristal line formed by imaging of the iliac crests was assessed. The results showed that although the L4 or L4–5 spinal levels were identified on imaging of the intercristal line in 86.7% of 75 patients (49 female), the intercristal line formed through palpation tended to identify higher levels; the L3 or L3–4 spinal levels in 77.3% of cases and more commonly in females than in males (85.7 vs. 61.5%) and in patients with higher body mass indices. The level of agreement between the two lines was poor (κ = 0.05). The posterior superior iliac spine line identified the S2 spinous process in 51% and the S1 in 44% of 60 (45 female) patients. The results suggest that formation of the intercristal line by palpation of the iliac crests identifies different spinal levels to those identified by imaging and that both methods should be regarded as different instruments. In the clinical situation, it may be more appropriate to consider that palpation of the intercristal line is a guide for identifying the L3 or L3–4 spinal levels rather than the L4 or L4–5 levels, particularly in females and patients with higher body mass indices

Transverse Frictional Massage For Plantar Fasciitis: A Clinical Pilot Trial.

Objectives To test the feasibility of a clinical trial comparing the effects of transverse friction massage (TFM) and a home exercise programme (HEP) and a HEP alone in the treatment of plantar fasciitis. Design Prospective, non-blinded, different subject design experimental pilot study. Setting Physiotherapy clinic within a community health centre clinic. Participants Twenty-four participants (14 females) aged 43–77 years (X = 58), with plantar fasciitis of greater than 4 weeks duration. Interventions Six treatment sessions of TFM in the first 4 weeks for the experimental group together with a HEP for 6 weeks. The control group was given a HEP only for 6 weeks. Main outcome measures Visual Analogue Pain Scale (VAPS) and a Lower Extremity Functional Scale (LEFS) measured on assessment and every 2 weeks for 6 weeks. Results Subjects demonstrated a reduction in both outcome measures for pain at the end of the 6-week treatment (P < 0.05), but there was no statistically significant difference between the two groups. The outcome measures were found to be suitable for subjects with plantar fasciitis and the methodology appropriate for the research design chosen. Conclusion This study has demonstrated the feasibility of a clinical trial for the treatment of plantar fasciitis with TFM and a HEP. A retrospective power calculation suggests that recruitment of more than 274 patients would be required to achieve an 80% chance of a clinically significant difference being detected between these two groups (α = 0.05). It is recommended that another pilot study with a longer follow-up is carried out first prior to any full-scale studies

Cervical spine reposition errors after cervical flexion and extension

Background: Upright head and neck position has been frequently applied as baseline for diagnosis of neck problems. However, the variance of the position after cervical motions has never been demonstrated. Thus, it is unclear if the baseline position varies evenly across the cervical joints. The purpose was to assess reposition errors of upright cervical spine. Methods: Cervical reposition errors were measured in twenty healthy subjects (6 females) using video-fluoroscopy. Two flexion movements were performed with a 20 s interval, the same was repeated for extension, with an interval of 5 min between flexion and extension movements. Cervical joint positions were assessed with anatomical landmarks and external markers in a Matlab program. Reposition errors were extracted in degrees (initial position minus reposition) as constant errors (CEs) and absolute errors (AEs). Results: Twelve of twenty-eight CEs (7 joints times 4 repositions) exceeded the minimal detectable change (MDC), while all AEs exceeded the MDC. Averaged AEs across the cervical joints were larger after 5 min' intervals compared to 20 s intervals (p &lt; 0.05). Conclusions: This is the first study to demonstrate single joint reposition errors of the cervical spine. The cervical spine returns to the upright positions with a 2° average absolute difference after cervical flexion and extension movements in healthy adults.</p