Effects of Tendon Neuroplastic Training (TNT) in Lateral Epicondylitis.
Condition: Lateral Epicondylitis
MeSH terms: Tennis Elbow
Study type: Interventional

Summary: 
      The aim of this research is to determine effects tendon neuroplastic training on strength,
      pain, and function in lateral epicondylitis. Randomized controlled trials will be conduct in
      National Institute of Rehabilitation Medicine Islamabad and Lady Reading Hospital Peshawar.
      The sample size is 34. The subjects will be divided in two groups, 17 subjects in tendon
      neuroplastic training group and 17 subjects will be assigned to conventional exercises group.
      Study duration is of one year. Sampling technique applied will be non-probability convenient
      sampling technique. Only 20-45 years old patients diagnosed with lateral epicondylitis will
      be included. Tools used in the study are Numeric pain scale, Dynamometer for grip strength
      and Patient rated tennis elbow evaluation for functional status.
    

Detailed description: 
      Lateral epicondylitis or tennis elbow is the common musculoskeletal degenerative disorder of
      the extensor origin at the lateral humeral epicondyle. It is the most common overuse syndrome
      seen in the primary care with the annual incidence of 1% to 3% in general population. This
      condition is most prevalent in age group of 45-54 years. The condition effect men and women
      equally. It mostly effects individuals with the history of repetitive wrist extension
      activities. Lateral epicondylitis is the chronic symptomatic degeneration (tendinosis) of the
      tendon of extensor muscles of forearm. According to cyriax most common effected muscle in
      lateral epicondylitis is extensor carpi radialis brevis (ECRB). Patients with lateral
      epicondylitis present to clinic with chief complaints of decrease grip strength and increase
      pain which may have a significant effect on their daily life activities.

      Conventional treatment primarily focuses on pain management by anti-inflammatory medicine,
      Ultrasound, phonophoresis, ionophoresis and corticosteroid injection. In literature other
      physiotherapy approaches documented which includes manual therapy, stretching and
      strengthening exercises, electrotherapy, taping, shock-wave therapy, and acupuncture. There
      is greater evidence in favor of strengthening exercises in patients who have symptoms for
      more than 6 months. Other approaches also focus on eccentric exercises combined with static
      stretching exercises in treatment of tendinopathies. Isometric exercises are used to manage
      and reduce tendon pain. But all these interventions merely focus on the peripheral tissue and
      not address neuromuscular and complex corticospinal adaptation associated with the persistent
      pain and therefore lead to chronicity and less desirable outcomes. Tendon neuroplastic
      training (TNT) is proposed to address the central nervous system component and motor deficit
      of tendinopathies. It combines isometric or isotonic strengthening training with externally
      paced audio or visual cue provided by metronome rather than self-paced exercise and strongly
      focus on neuromuscular control with the aim to induce neuroplasticity. Corticospinal
      excitability and short interval cortical inhibition are factors through which we can measure
      motor control and is found altered in tendinopathy.
    

Intervention name(s): Tendon neuroplastic training (TNT); group B Conventional treatment
Intervention type(s): Other; Other
Intervention description(s): Subjects will attend physical therapy for three non-consecutive days per week for a total 4 consecutive weeks. Exercise would involve isolated flexion, extension with a dumbbell. This exercise would be paced with external audio/visual cue on smart phone using proMetronome app. Patients will listen to the sound and track the movement of metronome with the eyes. Pace of metronome will be set at 20 beats per minute such that each beat will be 3 sec apart. This will allow a 3sec concentric and 3 sec eccentric phases.4 sets of 8 repetitions would be completed with a 2-minute rest between each set. Exercise will begin with 3 pounds weight, but it would be made sure that this wouldn't cause pain during exercise (more than 5/10), gradual progression in weight to 5 pounds after 2nd weeks.; Subjects assigned to this group will undergo static stretching of Extensor carpi radialis brevis and myofascial release for 4 weeks, 3 sessions a week. Myofascial release technique will be applied for 5 minutes and 2 reptations per session
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary purpose: Treatment
Keywords: Lateral Epicondylitis; Tendon neuroplastic training; strength training