“EFFICACY OF FARADIC ELECTRICAL
STIMULTION IN REDUCING PAIN AND
RANGE OF MOTION IN PATIENTS WITH
CHRONIC LATERAL EPICONDYLITIS’’
INTRODUCTION
Lateral epicondilitis is most common over use syndrome which is a
classic repetitive strain injury seen all over the world. Though it is not a
complicated problem it had exposed to light due to problems associated
with it. It got importance because of its frequent incidence in all age
groups précising people in manual works
LATERAL EPICONDILITIS:
It is a pathological condition of common extensor muscles
at its origin on lateral humeral condyle.
Lateral epicondilitis is a painful condition affecting the
tendinous origin of common wrist extensor from lateral
epicondyle.
It is also called as LATERAL EPICONDYLAGIA, (OR) LATERAL
EPICONDYLOSIS (OR) TENNIS ELBOW. It is a combination of chronic
exhaustion and irritation in muscles and tendons on back of forearm
and outside of elbow today this condition is better called as
‘’COMPUTER ELBOW’’
FARADIC CURRENT:
Faradic current is a low frequency pulsed current which is
asymmetrically biphasic of frequency between 30 and 70 HZ.
This faradic current in both unipolar and bipolar does the
great deal in reducing pain, swelling, increasing venous and
lymphatic drainage. Comparative to galvanic current this is
best in stimulating long muscles and creating lot of
advantages to patients
SURGING:
The process of giving relaxation to the tetanic contraction
produced by faradic current is called surging.
i. Trapezoidal surging:
The impulses increases and decreases gradually forming
trapezoidal shape
ii. Triangular surging:
The impulses increases and decreases gradually forming
triangular shape
iii. Saw Tooth:
The impulses increases gradually but suddenly fall.
In this study I am going to find the efficacy of electrical stimulation with
surged faradic currents in tennis elbow
NEED FOR STUDY:
It is generally a work related or sport related pain disorder usually
caused by excessive quick, monotonous, repetitive eccentric
contractions and gripping activities of the wrist. Many of the studies are
done on effective of electrotherapy in tennis elbow but none had a
practical based study on surged faradic current efficacy on tennis so this
study proves that.
AIM OF STUDY:
To find the efficacy of surged faradic current stimulation in tennis elbow.
.Objectives of the Study:
To reduce pain
To improve range of motion of elbow and wrist
To improve ADL’S
HYPOTHESIS
Null Hypothesis
There is no significant reduction of pain and improvement of range of
motion in tennis elbow with surged faradic currents
Alternative Hypothesis
There is significant reduction of pain and improvement of range of
motion in tennis elbow with surged faradic currents
AETIOLOGY
The major aetiology of tennis elbow are divided into extrinsic and
intrinsic factors
TENNIS ELBOW
EXTRENSIC FACTORS INTRENSIC FACTORS
Repetitive stress anatomical factors
Forceful activity age related factors
Manual labour systemic factors
Other:
Epicondilitis
Calcific deposits
Painful annular ligament
PERSONS IN RISK:
-athletes
-plumbers
Painters
cooks
-butchers
Carpenters
House wife
Person works on computer
RISK FACTORS:
Obesity
Manual labour
Repetitive movements
Forceful activities
EPIDEMIOLOGY
An epidemiological study of the incidence and recurrence of the
tennis elbow among over 500 tennis players (278 men, 254
women age range between 20 & 50 years) that is 39.7%oftennis
players and total annual incidence is 1 – 3%
persons affected
male
48% female
52%
ANATOMY
The main joint here is Elbow joint which is synovial joint of hinge type
Lower end of humerus:
The lower end of humerus formed the condyle which is
expanded from two sides and has articular and non-articular parts. In
articular part includes “capitulum” or “trochela” where as in non-articular
part includes lateral epicondyle, lateral supracondular, medial supra
condylar ridge, coronoid fossa, radial fossa, olecranon fossa.
Lateral epicondyle
It is smaller than the medical epicondyle. Its antero- lateral part has a
muscular impression.
Ligaments of the elbow joint:
CAPSULAR LIGAMENT:
Superiorly it is attached to lower end of humerus in such a
way that the capitulum, trochled, the medial fossa, coronoid fossa
& olecranon fossa is intracapsular
ANTERIOR AND POSTERIOR LIGAMENTS:
These ligaments are thickening of capsule
ULNAR COLLETERAL LIGAMENT:
It is triangular in shape. Its apex of attached to medial
epicondyle of humerus and its base to ulna.
RADIAL COLLTERAL LIGAMENT:
It is a foot shaped band extending from lateral epicondyle to
angular ligament.
Relationships of the elbow joint:
Anteriorly : Brachialis and median nerve
Posteriorly: Triceps and anconeus
Medially: Ulnar nerve
laterally: Supinator muscles
Blood supply:
Brachial artery
Radial artery
Ulnar artery
Nerve supply:
Median nerve
radial nerve
musculo cutaneous nerve
Muscles originated:
Brachioradialis
Anconeus
Extensor Carpi radialis longus
Extensor Carpi radialis brevis
Extensor digitorum
Extensor digiti minimi
Extensor Carpi ulnaris
PATHOPHYSIOLOGY
Due to repetitive stress or over use the tendinous origin of extensors get
damaged followed by tear which occurs at teno periosteal junction
resulting in inflammation producing exudates granulation tissue finally
tenodesis.
Injury or repeated stress
granulation tissue and degenerative changes at teno
microrupture peri osteal junction
calcification as a result of hypovascularisation
intrasubstance tear tendinitis
irregularities of epicondyle
Lateral epicondylitis
BIOMECHANICS
Elbow stability and stabilizing structures:
Stabilizers
Passive stabilizers Active stabilizers
Passive bony stabilizers
Passive soft tissue stabilizers
Force transmission through
Interplay between passive stabilizers elbow
(1)PASSIVE STABILIZERS:
The passive and active stabilizers provide biomechanical stability in the
elbow joint.
(a)PASSIVE BONY STABILIZERS:
The ulna humeral joint is a highly congruous joint and is a dominant
factor as a passive bony stabilizer. The contact areas in the elbow joint
vary with the type of applies stress. Contact areas occur at four facets in
the sigmoid fossa, 2 at coronoid and 2 at the olecranon with virus and
valgus, the contact changes medially laterally. 4 separate areas of
contact in sigmoid fossa. Contact moves towards the centre of the
sigmoid during flexion. The carrying angle orientation changes from a
valgus orientation in extension to varus orientation in flexion.
(b) Passive soft tissue stabilizers:
It is include the medial & lateral collateral ligament complexes and the
anterior capsule.
(C)INTERPLAY BETWEEN PASSIVE STABILIZERS:
The contributions of the articular geometry and ligaments to varus
& valgus loads were studied.
(2)ACTIVE STABILIZERS:
These balanced forces likely function as dynamic stabilizers of the
joint.
From the muscles crossing the elbow joint, the brachialis and
triceps muscles have the largest work capacity and contractile
strength.
(3)MOVEMENTS:
SUPINATION AND PRONATION:
The 1* motion of the forearm is supinaton and pronation, with the axis of
rotation passing from the proximal radial head to the convex articular
surface of the ulna at the distal radio Ulnar joint (in ADL 50* pronation &
50* supinaton).
FLEXION AND EXTENSION:
In elbow flexion and extension (in ADL 30* and 130*), the deviation of
joint rotation is minimal, and elbow motion can be thought of as a
uniaxial joint
(4)RANGE OF MOTION:
Normal range of motion is from 0-150 degrees and forearm rotation
averages 75 degrees pronation and 85 degrees supinaton.
PATHOMECHANICS
Due to hyper vascularisation and degenerative process there is
pyramidal slope formation by deformation of lateral epicondyle, resulting
in pulling of origin of extensor Carpi radialis brevis resulting inactive
insufficiency. Muscle spasm resulting in limited extension movements
granulation tissue
degenrative changes
formation
deformation of
shape of lateral
muscle spasm
epicondye to
pyramidal shape
limited randge of
active insufficiency
extension and
of ECRB
supination
EXTENSORS OF ELBOW:
Triceps is main extensor of elbow weakness of triceps has
profund effect on elbow extension. Functional implications of
zero elbow extension strength must be considered carefully in
upright position weight of fore arm and hand causes elbow to
extent pushing an object or using the upper extremity to
assist in raising from a chair requires active contraction of
triceps
Tightness of triceps results in limited elbow flexion and
contribute to diminished shoulder elevation
SUPINATOR:
Weakness of supinator results in weakened supination where
as tightness causes limited movement
CLASSIFICATION
OF
TENNIS ELBOW
There are two types of classification of lateral epicondilitis
1. PATTERNS BASIS:
a) PATTERN 4 D: there is impaired joint mobility, motor
function and range of motion associated with connective
tissue dysfunction
b) PATTERN 4 E: there is impaired joint mobility, motor function
and range of motion associated with localised inflammation
2. SEVEARITY BASIS:
a. ACUTE LATERAL EPICONDYLITIS
b. CHRONIC LATERAL EPICONDILITIS
CLINICAL FEATURES
The most common presenting features are
1. Pain
2. Spasm on dorsal fore arm muscles
3. Fatigue
4. Restricted extension and supinaton movements
5. Tenderness
6. Effusion
Common complaints are:
1. Diffuse pain
2. Morning stiffness
3. Occasional night pain
4. Dropping of objects
5. Pain at resisted extension
6. Popping or clicking sound heard on movement
INVESTIGATIONS
SPECIAL TESTS:
1. COZEN’S TEST:
The patient is asked to make a fist, pronate the forearm, radially
deviated and the wrist against resistance.
-A positive test is indicated by pain in the lateral epicondyle
region or muscle weakness and may be indicative of lateral epicondilitis.
2, MILL’S TEST:
Therapist palpates the lateral epicondyle and pronates the patients
forearm, flexes the wrist and extends the elbow.
-A positive test is indicated by pain in the lateral epicondyle S
3, MAUDSLEYS LATERAL EPICONDYLITISN TEST:
Therapist resists extension of 3rd digit of the hand, stressing the extensor
digitorum muscle and tendon, while palpating the patient’s lateral
epicondyle.
A positive test is indicated by pain over the lateral epicondyle.
REGULAR INVESTIGATIONS:
X – RAY
CT SCAN
MRI SCAN
NERVE CONDUCTION STUDIES
ULTRASONOGRAPHY
MEDICAL MANEGEMENT
DRUGS:
NSAIDS
ANALGESIS
CORTICOSTEROIDS
INJECTIONS:
BOTULIN
CORTICOSTEROIDS
PLATELET RICH PLASMA INJECTIONS
CORTISONE
CONSERVATIVE BRACING
DRY NEEDLING/ ACUPUNCTURE
NITRATE PATCHES
SURGICAL MANAGEMENT
OPEN SURGERY:
This is most common approach; this involves making an
incision over the elbow. Open surgery is usually performed as an
outpatient surgery.
ARTHROSCOPIC SURRGERY:
Tennis elbow can also be repaired using tiny instruments and
small incisions.
PHYSIOTHERAPY MANAGEMENT
SURGED FARADIC CURRENTS:
Surged faradic currents are low frequency currents used to
stimulate muscle groups nerve trunks. Due to surging property
patient is most comfortable without any burning sensation or
irritation which in a mean while produces relaxation
THERAPEUTIC EFFECTS OF FARADICS CURRENTS:
Stimulation of sensory nerves by vasodilatation
Stimulation of motor nerves and produces repeated tetanic
conctrations of muscles supplied by corresponding nerve.
Reduces swelling and pain
Increases venous and lymphatic drainage
Prevention and loosening of adhesions
The technique we are following here group muscle stimulation. As
we discussed earlier 4D PATTERN cases need to attend session
6-24 weeks and 4E PATTERN CASES should attend 3-36 weeks
of physiotherapy with other interventions but by use of surged
faradic currents the time period reduces by 6- 8 weeks
MATERIALS AND METHODS
. METHOD OF COLLECTING DATA:
Sampling technique : Random sampling technique.
The purpose of study was explained to all the subjects and an
informed concert was taken followed by demographic data from
each subject.
Research design : Experimental study.
Source of data : Narayana College of physiotherapy,
outpatient department.
Sampling size : This study includes sample of 40
subjects.
Study duration : Total duration of study is 4-15weeks.
Study population : Both male and female 35-55 years of age
SELECTION CRITERIA:
INCLUSIVE CRITERIA:
Both male and female.
Patient with age group of 35-45 years.
Patients with tennis elbow diagnosis will confirm by special
tests.
Patient with tennis elbow diagnosed by orthopeadician.
Lateral elbow chronic pain.
Positive Cozens test and Mill’s test.
Unilateral case (dominant extremity)
EXCLUSION CRITERIA:
Cases with bilateral symptoms.
All extraneous cases like shoulder and cervical involvement.
Recent history of trauma in upper limb.
Recent history of surgery in upper limb.
History of immobilization of elbow.
History of inflammatory arthritis like rheumatoid arthritis.
Recent steroid injection and anti-inflammatory drugs.
Fibromyalgia.
Myositis ossificans.
Radial and posterior interrosseus nerve entrapment syndrome.
Joint pathology like elbow arthritis.
Carpal tunnel syndrome.
Malignancy.
Cardiovascular disease.
Systemic disease such DM
OUTCOME MEASURES:
Pain
ROM
Muscle strength
OUTCOME MEASUREMENTS SCALES:
Visual analogue scale
Goniometry
Manual muscle testing.
MATERIALS USED:
Functional electrical stimulator
Chair
Goniometer
Cotton
Water
Pillows
Velcro’s
Cotton
METHODOLOGY:
STEP 1: all the patients were assessed with a pre assessment
sheet and were informed about the study and got a consent
form
STEP 2: all the patients were given surged faradic currents for a
session of 15- 20 min
STEP 3 : for every 3 weeks assessment of outcome measures
were taken
STEP 4: treatment is continued and final post assessment is
taken
All the patients were given treatment for 15- 20 minutes stimulating each
and every muscle for 25-30 times with weekly four days excluding
holidays and patients comfort until 4-15 weeks
CASE STUDY
CASE 1
SUBJECTIVE ASSESMENT:
NAME : K. ravi kumar
AGE : 28
SEX : Male
Occupation : soft ware engineer
ADDRESS : Subedarpet Nellore
CHIEF COMPLAINTS:
Restricted movements
Lateral elbow pain
swelling
MEDICAL HISTORY : elbow fracture
SUBJECTIVE ASSESMENT:
PAIN:
Site of pain :lateral epicondyle
Side of pain :right elbow
Character of pain :pricing pain
Aggravating factors :actives , prolonged compression
Relieving factors : rest medications
ON OBSERVATION:
Redness : present
Swelling : present
Posture : normal
ON PALPATION:
Tempature : normal
Tenderness : present
Muscle spasm : present
ON EXAMINATION:
Range of motion
Movement Active ROM Passive ROM
Elbow extension 135 - 50 135- 0
Supination 0 - 70 0 -90
Wrist extension 0 - 40 0 - 70
CASE 2
SUBJECTIVE ASSESMENT:
NAME : v.parandammaiah
AGE : 50
SEX : Male
Occupation : carpenter
ADDRESS : sarvepalli
CHIEF COMPLAINTS:
Restricted movements
Lateral elbow pain
Swelling
MEDICAL HISTORY : nil
SUBJECTIVE ASSESMENT:
PAIN:
Site of pain :lateral epicondyle
Side of pain :right elbow
Character of pain :pricing pain
Breveting factors :activies , prolonged compression
Relieving factors : rest medications
ON OBSERVATION:
Redness : present
Swelling : present
Posture : normal
ON PALPATION:
Tempature : normal
Tenderness : present
Muscle spasm : present
ON EXAMINATION:
Range of motion
Movement Active ROM Passive ROM
Elbow extension 135 - 60 135- 0
Supination 0 - 50 0 -90
Wrist extension 0 - 50 0 - 70
CASE 3
SUBJECTIVE ASSESMENT:
NAME : v.ramanaiah
AGE : 54
SEX : Male
Occupation : butcher
ADDRESS : dicous road , Nellore
CHIEF COMPLAINTS:
Restricted movements
Lateral elbow pain
swelling
MEDICAL HISTORY : nil
SUBJECTIVE ASSESMENT:
PAIN:
Site of pain :lateral epicondyle
Side of pain :right elbow
Character of pain :pricing pain
Breveting factors :activites , prolonged compression
Relieving factors : rest medications
ON OBSERVATION:
Redness : present
Swelling : present
Posture : normal
ON PALPATION:
Tempature : normal
Tenderness : present
Muscle spasm : present
ON EXAMINATION:
Range of motion
Movement Active ROM Passive ROM
Elbow extension 135 – 40 135- 0
Supination 0 – 70 0 -90
Wrist extension 0 – 50 0 - 70
DATA ANALYSIS
ELBOW EXTENSION
S.NO PRE TEST POST TEST
1 135 - 40 135 - 0
2 135 - 50 135 – 0
3 135 – 30 135 – 0
4 135 – 60 135 – 10
5 135 – 70 135 – 10
6 135 – 40 135 – 10
7 135 - 80 135 – 20
8 135 – 50 135 – 0
9 135 – 30 135 – 0
10 135 - 40 135 – 10
AVERAGE PRE TEST POST TEST
MEAN 49.0 6.0
MEDIAN 45 5
MODE 40 0,10
SUPINATION
S.NO PRE TEST POST TEST
1 0 – 70 0 – 90
2 0 – 60 0 – 90
3 0 – 70 0 – 90
4 0 – 65 0 -90
5 0 – 50 0 – 82
6 0 – 50 0 – 85
7 0 – 48 0 – 80
8 0 – 60 0 – 90
9 0 – 80 0 – 90
10 0 – 60 0 – 90
AVERAGE PRE TEST POST TEST
MEAN 61.3 87.7
MEDIAN 60 90
MODE 60 90
WRIST EXTENSION
S.NO PRE TEST POST TEST
1 0 – 60 0 – 70
2 0 – 40 0 – 68
3 0 – 50 0 – 70
4 0 – 30 0 -50
5 0 – 30 0 – 50
6 0 – 60 0 – 70
7 0 – 46 0 – 60
8 0 – 38 0 – 50
9 0 – 60 0 – 70
10 0 – 52 0 – 70
AVERAGE PRE TEST POST TEST
MEAN 46.6 62.8
MEDIAN 48 69
MODE 60 70
% OF IMPROVEMENT FOR ELBOW EXTENSION =
Pre mean- post mean/ pre mean x 100
49.0-6/49 x 100 = 36.755
100
90 87.7
80
70
61.3 62.8
60
movement
50 46.6 pre mean
40 post mean
30
20
10
0
RESULT:
The pre and post mean values for elbow extension is 40.9 & 6.0. For
Supination pre mean and post mean is 61.3 and 87.7 where as for wrist
extension is 46.6 and 62.8.
DISCCUSSION:
Surged faradic current has got great improvement in improving
range of motion and reducing pain there is great improvement in many
subjects with in short time for both 4E & 4D PATTERNS. There is a clear
evidence of reduction in tissue inflammation and gradual improvement
by correcting biomechanics of joint without causing any discomfort to
patient.
CONCLUSION:
To identify the varying results in two different regimes in all
patients were selected using simple random sampling technique
and were taken
The VISUAL ANALOUGE SCAL FOR PAIN & GONOIOMETRY
reports were taken after their respective protocols, to expose the
facts regarding their effectiveness
The study was experimental design. The collected data was
analyzed and interpreted, which showed a significant variation in
both scales
Finally my study concluded that surged faradic currents are
effective in lateral epicondilitis patients
BIBILOGRAPHY:
B D CHAURASIA’S TEXT BOOK OF HUMAN ANATOMY
JOHN EBNEZAR text book of orthopaedics
JOHN LOW ANN REED text book of electrotherapy
CLATON’S text book of electro therapy
APLEY’S text book of orthopaedic surgery
