Eccentric Tyler Twist Wrist Extensor Strengthening in Lateral Epicondylitis
Condition: Lateral Epicondylitis
MeSH terms: Tennis Elbow
Study type: Interventional

Summary: 
      The purpose of the study is to compare the effects of Tyler twist wrist extensor
      strengthening exercises in patients with lateral epicondylitis. A randomized control trial
      was conducted at Cina medical center Rawalpindi and Midland Doctors Medical institute. The
      sample size was 52 calculated through open-epi tool. The participants were divided into two
      groups: the treatment group and the control group. The study duration was 1 year. Sampling
      technique applied was non-probability purposive sampling. Only 20 to 40 years participants
      with diagnosed condition were included in the study. Tools used in this study are Jamar
      dynamometer for grip strength and PRTEE Questionnaire for pain and disability. Data was
      collected at baseline, mid and immediately after the application of interventions. Data
      analyzed through SPSS version 25
    

Detailed description: 
      Lateral epicondylitis is the most common cause of pain in elbow, due to repetitive wrist
      extension or gripping activities. This condition is also described as a chronic symptomatic
      degeneration of the extensor tendon of forearm commonly extensor carpi radialis brevis at the
      attachment area of humeral epicondyle. (1) Tennis elbow is common in individuals who undergo
      repetitive wrist extension, radial deviation, and forearm supination. The histological
      findings of lateral epicondylitis consist of granulation tissue, micro-rupture, fibroblasts
      abundance, UN structured collagen, vascular hyperplasia, and lack of inflammatory cells
      within the tissue (lymphocytes, macrophages, neutrophils). (2) Lateral epicondylitis can
      occur in any age group but is more common between 30-50 years of age. (3) Many previous
      reports conducted in different countries described that there is 2-14% prevalence of lateral
      epicondylitis in working population and only 5% of people suffering from tennis elbow relate
      this injury to the tennis. (4) Evidence from a systematic review published in 2019 described
      the prevalence rate of 1-3% in the general population and 7% in the handy workers group with
      equal gender distribution. (5) There are many treatment options for lateral epicondylitis.
      Initially it is treated by conservative treatment (1) Recently in 2021, R Manandhar et al
      conducted an RCT reported positive results using combination of Movement with mobilization
      and Eccentric exercises regarding pain and functional disability.(8) BL Woodley et al in 2018
      published his systematic review which concluded that limited level of evidence exists on the
      effectiveness of eccentric strengthening exercises to standard physiotherapy protocols.
      Twenty relevant studies were sourced, 11 of which met the inclusion criteria. These included
      studies of tendinopathy of the common wrist extensor tendon of the lateral elbow (LET. (9) If
      pain do not resolve with conservative treatment then further treatment options will be
      extracorporeal shock wave therapy, cortisone injections and surgery.(6) In an RCT of Ju-hyun
      Lee et all in 2018 ,the effects of eccentric control exercise for tennis elbow showed useful
      effects for pain and functional activity was improved with a p value of 0.05.(7) Timothy
      Tyler et al recently conducted a cross sectional study in 2021 to compare standard
      physiotherapy treatment to Tyler twist exercises which are a new treatment protocol for wrist
      extensor strengthening using 2-3 colored twistable rubber bands This study suggested that
      Tyler twist exercise could be effective strength training protocol and once learnt can be
      performed by the patient at home without any supervision.(9)

      To treat lateral epicondylitis platelet rich plasma has gained popularity. To enhance wound
      healing, bone healing and tendon healing, platelets release high concentration of
      platelet-derived growth factors. It is difficult to draw clear conclusions on PRP for lateral
      epicondylitis because some available studies have reported conflicting results. Manipulative
      techniques fall into two basic varieties in the treatment of lateral epicondylitis; those
      that will produce a thrust and those that seek full extension. To effect the contractile
      element the manipulations performed in extension with pronation have the greatest chance.
      Forced extension of elbow with the wrist and fingers fixed and the forearm promoted is the
      most common procedure known as mill's manipulation. Manipulations are painful procedures and
      require 2 weeks of rest after application.(11) With a high success rate, injections are one
      of the most popular methods utilized .Physical therapy is initiated when the condition
      becomes chronic or not responding to initial treatment. Ultrasound, phonophoresis, electrical
      stimulation,, manipulation, soft tissue mobilization , neural tension, friction massage ,
      augmented soft tissue mobilization and stretching and strengthening techniques are the common
      rehabilitation modalities utilized for the treatment. (12) Proper evidence behind Tyler twist
      wrist extensor exercises in the management of lateral epicondylitis is sparse and there are
      less number of studies with limited methodological designs. There are no previous randomized
      control trials conducted to see the effects of Tyler twist exercises in contrast to standard
      physiotherapy treatment using combined tools for pain , grip strength and functional activity
      According to the literature review, there had been lack of reporting of compliance and
      adherence to the exercise programs, with only four studies documenting exercise adherence,
      So, the additional benefit of this protocol is that it can be performed as part of a home
      program and does not involve continued medical supervision when learned properly. So, this
      study will focus on effects of Tyler twist exercise to standard physiotherapy protocol.
    

Intervention name(s): Tyler Twist Exercises; conventional physical therapy
Intervention type(s): Other; Other
Intervention description(s): Tyler twist exercises are the group of exercises which are used to strengthen wrist ex tensors.The protocol consists of several steps using colored twist-able bands and patients are guided to actively perform the steps for their grip strength development.; Conventional physiotherapy (Ultrasound + Cross Friction Massage for 10 minutes + Wrist extensor stretching and Isotonic wrist extensor strengthening.)
Other intervention name(s): control group
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Lateral Epicondylitis, Tyler Twist Exercises, Elbow