A randomized controlled, monocentre trial was conducted in the Cyprus Musculoskeletal and Sports Trauma Research Centre (CYMUSTREC) over 4 months to assess the effectiveness of an eccentric-concentric training of wrist extensors and an eccentric - concentric training of wrist extensors combined with strengthening of supinator. Two investigators were involved in the study: (1) a physiotherapist - lecturer (DS) who evaluated the subjects, performed all baseline and follow - up assessments, and gained informed consent and (2) a physiotherapist - M.Sc in sports physiotherapy student, the primary investigator (MT), who administered the treatments. All assessments were conducted by DS who was blind to the subjects’ therapy group. DS interviewed each subject to ascertain baseline demographic and clinical characteristics, including patient name, sex, age, duration of symptoms, previous treatment, occupation, affected arm and dominant arm.
Subjects between 18 and 45 years old (5) were examined and evaluated in the CYMUSTREC located in Nicosia/Cyprus (European University Cyprus) between January 2016 and April 2016. All subjects lived in Nicosia, Cyprus, were native speakers of Greek and were either self-referred or referred by their physician or physiotherapist.
The inclusion criteria of the study were (5):
1. No history of LET
2. No dysfunction in the shoulder, neck (radiculopathy) and/or thoracic region
3. No history of the fracture in the upper limb in the last 12 months
4. Athletes who did not use their upper limbs in their sport
Subjects were excluded from the study if they had one or more of the following conditions: (a) local or generalized arthritis; (b) neurological deficit; (c) radial, ulnar or median nerve entrapment; (d) limitations in arm functions; (e) the affected elbow had been operated on and (f) osteoarthritis in the wrist .
All subjects received a written explanation of the trial prior to entry into the study. All subjects gave signed informed consent to participate in the study. The study was approved by the Cyprus Bioethical Research Ethics Committee (ΕΤΑΒΚ ΕΠ 2016.01.11) and access to subjects was authorised by the manager of the CYMUSTREC (DS).
The subjects were randomly allocated to two groups by drawing lots. Subjects in group A were treated with eccentric - concentric training of wrist extensors and subjects in group B were treated with eccentric - concentric training of wrist extensors combined with supinator strengthening.
All subjects were instructed to use their arm during the course of the study but to avoid activities that irritated the elbow such as grasping, lifting, knitting, handwriting, driving a car and using a screwdriver. They were also told to refrain from taking anti-inflammatory drugs throughout the course of the study. Patient compliance with this request was monitored using a treatment diary.
Communication and interaction (verbal and non-verbal) between the therapist and subject was kept to a minimum, and behaviors sometimes used by therapists to facilitate positive treatment outcomes were purposefully avoided. For example, subjects were given no indication of the potentially beneficial effects of the treatments or any feedback on their performance in the pre-application and post-application measurements .
In the eccentric - concentric training group (Group A), eccentric - concentric exercises of the wrist extensors were performed in the non-dominant hand with the elbow on the bed in full extension, the forearm in pronation, the wrist in an extended position (as high as possible), and the hand hanging over the edge of the bed. From this position, patients flexed their wrist slowly (Figure 1) while counting to 15 (20 - 22) using chronometer, then returned to the starting position (extension). In the eccentric - concentric exercises of the wrist extensors combined with strengthening of supinator (Group B), eccentric - concentric training performed in the same way. Strengthening exercises of the supinator were performed in the non-dominant hand with the elbow on the bed in full extension, the forearm in pronation, the wrist in mid - position and the hand hanging over the edge of the bed. From this position, patients supinated their arm slowly (Figure 2) while counting to 15 (20 - 22) using chronometer, then returned to the starting position (pronation).Figure 1:
Eccentric - concentric training of wrist extensors.
In both groups three sets of 15 repetitions of slow progressive exercises of the wrist extensors and supinator respectively, at each treatment session were performed, with 1-min rest interval between each set. Subjects were told to continue with the exercise even if they experienced mild pain. However, they were told to stop the exercise if the pain became disabling. The mild and disabling pain was monitored asking the subject to rate the pain on VAS before and after treatment. Mild pain was defined below 4 on VAS whereas disabling pain was defines above 8 on VAS [20-22]. When subjects were able to perform the exercises without experiencing any minor pain or discomfort, the load was increased using free weights.
All the above reported exercise programmes were given five times a week for 6 weeks and were individualized on the basis of the subject’s description of pain experienced during the procedure.
Function was measured in the present study. Each subject was evaluated at the baseline (week 0), at the end of treatment (week 6) and at 1 month (week 10) after the end of treatment. Function was measured by grip strength. Grip strength is defined as the amount of force each subject is able to generate with an isometric gripping action . Force was measured in pounds with a Jamar hand dynamometer (Figure 3) that had adjustable handles to accommodate different hand sizes. The arm was placed in a standardized position of elbow extension, forearm pronation and internal rotation of the upper limb such that the palmar aspect of the hand faced posterior with the upper limb placed by the subject’s side. Subjects were then instructed to squeeze the dynamometer handles and then to release their grip . The attained grip force was subsequently recorded, and the reading was not visible to the subject. Three measures of pain-free grip strength were recorded with a 30 seconds rest interval between each measurement, and the mean value of these repetitions was calculated. It is a valid and reliable outcome measure in LET patients.Figure 3:
Hand grip dynamometer JAMAR.