Colleagues:
A few comments on EBP. We do not have all the answers to our research questions
by a long shot, but we do have a wealth of evidence that is available to us now.
Do we not agree that it is our responsibility to synthesize the evidence that
exists and incorporate that evidence into our current practice? I believe we
should practice according to the best evidence that is available to us at the
time. While there is an important place for "intuitive" approaches in practice,
that "intuitiveness" should be based on the best available evidence. This is
what truly makes us experts and skilled clinicians. PT educational programs and
continuing education providers should present in the context of the research
that is currently available.
In response to the two messages below.
Lynda: You mentioned that the medication is "ointment" based. What is the
chemical make up of the ointment? Most such ointments (in the USA) are petroleum
based. We know from the literature that US does not penetrate petroleum. In fact
there are very few bases that allow for adequate dose delivery. Unless the
medication is compounded with a base that has been specifically shown to allow
for adequate dose delivery the treatment will not be at all effective. This is a
beautiful example of where we should (and I don't mean to imply Lynda has not in
this case) be applying the literature to practice.
Henry: Lateral epicondylitis has been shown to be a misnomer. The literature
shows there is no inflammatory process with this condition. Hence many authors
now use tendinosis. [Tendinosis of the elbow (tennis elbow). Clinical features
and findings of histological, immunohistochemical, and electron microscopy
studies. Kraushaar BS, Nirschl RP, J Bone Joint Surg Am.1999 Feb;81(2):259-78.
Review.] However, there is clearly no consensus as to treatment approaches as
the citation below articulates. From the studies I have read, and I haven't read
them all, exercise seems to be the only PT intervention that has been shown to
be effective.
I am curious as to why you choose to use US. Was the increase in strength
temporary?
TITLE:
Lateral tennis elbow: "Is there any science out
there?"
AUTHORS:
Boyer MI; Hastings H 2nd
AUTHOR AFFILIATION:
Department of Orthopaedic Surgery, Washington
University School of
Medicine, St Louis, MO, USA.
SOURCE:
J Shoulder Elbow Surg 1999 Sep-Oct;8(5):481-91
CITATION IDS:
PMID: 10543604 UI: 20008949
ABSTRACT:
As orthopaedic surgeons, we are besieged by myths
that guide our treatment
of lateral epicondylitis, or "tennis elbow." This
extends from the term used to
describe the condition to the nonoperative and
operative treatments as well.
The term epicondylitis suggests an inflammatory
cause; however, in all but 1
publication examining pathologic specimens of
patients operated on for this
condition, no evidence of acute or chronic
inflammation is found. Numerous
nonoperative modalities have been described for the
treatment of lateral
tennis elbow. Most are lacking in sound scientific
rationale. This has led to a
therapeutic nihilism with respect to the
nonoperative management of this
condition. An examination of the literature can only
lead us to believe that
most, if not all, common nonoperative therapeutic
modalities used for the
treatment of tennis elbow are unproven at best or
costly and time-consuming
at worst. Most of the published literature on the
nonoperative treatment of
patients with lateral tennis elbow consists of
poorly designed trials. The
selection criteria are nebulous, the control group
is questionably designed, and
the number of patients is often too low to avoid a
serious loss of study power.
These studies therefore have a high beta error,
implying an inability to detect
a difference between groups, even if one truly
existed. If clinical signs and
symptoms persist beyond the limit of acceptability
of both patient and surgeon,
then an array of surgical options are available.
These range from a 10-minute
office procedure (the percutaneous release of the
extensor origin with the
patient under local anesthetic) to an extensive
joint denervation, in which all
radial nerve branches ramifying to the lateral
epicondyle are directly or
indirectly divided. How is the surgeon to choose,
given the fact that most of
the published surgical studies are case series of
one type of operation or
another, consisting of patients operated on and
evaluated by the same
surgeon, who has a vested interest in his or her own
patients' successful
outcome? The orthopaedic surgeon therefore has very
little on which to "hang
his hat" when it comes to objective data to guide
treatment of patients with
lateral tennis elbow syndrome. In the final analysis
we are guided simply by
our own subjective viewpoint and clinical
experience. In 1999, to have such a
common clinical condition have such a paucity of
peer-reviewed published data
of acceptable scientific quality is disappointing.
In this review article we will
examine the "myths" of tennis elbow: the name, the
salient features on
history and physical examination, the diagnostic
modalities, the pathology of
the "lesion," the anatomy of the lateral elbow and
extensor origin and why it
has led to such confusion in differential diagnosis,
the nonoperative and
operative treatment of tennis elbow, and finally the
various studies that have
been carried out on elbow biomechanics as it relates
to the pathoetiology of
true "tennis elbow." It is our hope that the reader
will emerge with a clearer
picture of the pathoetiology of the condition and
the scientific rationale (or
lack thereof) of the various operative and
nonoperative treatment modalities.
Henry Tsao wrote:
> Lynda and others,
>
> I am a strong believer in the fact that if it works for your patient and
> makes them better, then why not use it?? Much of physiotherapy had been
> without research, and yet we used the techniques knowing that clinically it
> worked. So in Lynda's case, I believe one day, the evidence will come, but
> in the mean time, if it works clinically and is legal, and the patients are
> attaining relief without side effects, then I don't see why Lynda should not
> continue using this. I think sometimes too much emphasis is placed on
> evidence that we overlook the importance of clinical experience and results.
>
> As well, we tend to generalize treatment modalities as a "cure for all." For
> instance, in the field of electrotherapy. We should not use electrotherapy
> for every condition... applied at the correct region and set on the optimal
> settings, it can have great beneficial relief. Recently, I have tried using
> U/S with lateral epicondylitis, and it is amazing how much grip strength
> improves just with this application. Try it next time and you will be
> surprised!
>
> Henry***
>
> >From: "Lynda Bennett" <[log in to unmask]>
> >Reply-To: [log in to unmask]
> >To: [log in to unmask]
> >Subject: RE: EPA and evidence based practice
> >Date: Sat, 04 Nov 2000 09:31:32 GMT
> >
> >My initial posting was mainly as a reaction to the loss of respect for
> >intuitive trials when one insists on only using EBP ( yet I accept the
> >possibility of inherent legal and ethical risks.)
> >I do notpropose that anyone should use this treatment. I will relay my
> >experience for interest. Maybe someone would like to conduct a research
> >project . I am not against research, in fact it fascinates me. But I do get
> >very tired of reading so-called research which seems to be only looking
> >backwards and can only come up with "nothing works" because there isn't
> >enough proof to say that it does work.
> >I want to use research to trial and prove ideas. I don't want research
> >dictating treatment and preventing the development of new ideas.
> >Anyway...
> >I have used arnica as a homeopathic remedy in my family for 23 years. The
> >ointment is not a homeopathic strength, it is a tincture in a base. I buy
> >it
> >from various pharmacies and have my preferred brands usually based on the
> >least added ingredients.
> >I tried it with the ultrasound almost accidentally at first. My husband had
> >not long applied the arnica for his gout (Ist MTP) and was still in pain. I
> >had the ultrasound nearby and suggested it might help, as we had no usual
> >medications on hand and it was Saturday!
> >The reported relief was greater than ultrasound had given previously, plus
> >the visual reduction in redness was apparent within 10 minutes.
> >Having read articles on phonophoresis I thought I would trial this again,
> >with a similar outcome. I treated him morning and night for 2 days, then
> >night only for two more days. On this occasion, the treatment was at the
> >initial acute phase of the "flare up". He did not need to get the tablets
> >after all as it continued to settle well. I think we were probably just
> >lucky and since then when the ultrasound is not handy, and the medication
> >is, then it is the tablets first.
> >Other patients asked me to trial it and I did so after consulting their
> >physicians. With healthy scepticism we proceeded - patients had
> >significant
> >relief after each treatment and only needed it for a few days for that
> >initial inflammation thaaat causes so much pain that it inhibits walking.
> >We
> >did not alter the medications. The arnica and ultrasound were only to give
> >an immediate relief. I have only applied it once daily and not on very many
> >people as it is usually not worth the explanation time. Most patients I see
> >would have already commenced medication and would be obtaining enough
> >relief.
> >No I have never tried anything else.
> >Arnica should be used with care with any patient as it has similar
> >properties to other NSAIDS. Believe it or not I am a very cautious person.
> >Hope you find this interesting.
> >Lynda.
> >
> *******************************************************
Douglas M. White, PT, OCS
Physical Therapist, Consultant
191 Blue Hills Parkway
Milton, MA USA 02186
P: 617.696.1974
[log in to unmask]
http://DouglasWhite.tripod.com
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