Efficacy of Shortwave Diathermy in Ulnar Nerve Entrapment on the Elbow
Condition: Ulnar Nerve Entrapment at Elbow
MeSH terms: Nerve Compression Syndromes; Ulnar Nerve Compression Syndromes; Cubital Tunnel Syndrome; Hyperthermia
Study type: Interventional

Summary: 
      It was aimed to see if there is any efficacy of short wave diathermy (SWD) in the treatment
      of ulnar nerve entrapment at the elbow (UNE). Ulnar nerve entrapment, following carpal tunnel
      syndrome (CTS), is the second most common upper extremity entrapment neuropathy. Ulnar nerve
      is compressed mostly in elbow region because of its anatomy. Conservative treatment choices
      are limited in ulnar nerve entrapment neuropathy and very few studies about UNE, are
      available in literature.

      The aim of this study was researching the efficacy of SWD which is a deep heating modality in
      treatment of UNE. SWD is used either continuous or pulsed mode. Continuous SWD is used for
      the purpose of heating.

      MATERIALS AND METHODS: 61 adult patients, who had been diagnosed with UNE clinically and
      electrophysiologically, were randomly assigned into two groups. Ten sessions of SWD was
      applied to the patients in the treatment group as 5 sessions per week for 2 weeks. Ten
      sessions of placebo SWD was applied to the patients in the control group as 5 times a week,
      for 2 weeks. All patients in both groups were given elbow splints and were informed to avoid
      symptom provocating activities. Patients were evaluated at baseline, at the end of the
      treatment and,1 and 3 months after the treatment. Besides physical examination, quick-DASH
      (disabilities of arm, shoulder, hand) and SF-36 were used to evaluate activities of daily
      life, dynamometer was used to evaluate grip force and VAS was used to evaluate pain severity.
    

Detailed description: 
      efficacy of short wave diathermy in ulnar nerve entrapment on the elbow

      ABSTRACT

      OBJECTIVE: Efficacy of short wave diathermy (SWD) in the treatment of ulnar nerve entrapment
      at the elbow (UNE).

      MATERIALS AND METHODS: 61 adult patients, who had been diagnosed with UNE clinically and
      electrophysiologically, were randomly assigned into two groups. Ten sessions of SWD was
      applied to the patients in the treatment group as 5 sessions per week for 2 weeks. Ten
      sessions of placebo SWD was applied to the patients in the control group as 5 times a week,
      for 2 weeks. All patients in both groups were given elbow splints and were informed to avoid
      symptom provocating activities. Patients were evaluated at baseline, at the end of the
      treatment and,1 and 3 months after the treatment. Besides physical examination, quick-DASH
      (disabilities of arm, shoulder, hand) and SF-36 were used to evaluate activities of daily
      life, dynamometer was used to evaluate grip force and VAS was used to evaluate pain severity.

      INTRODUCTION

      Ulnar nerve entrapment, following carpal tunnel syndrome (CTS), is the second most common
      upper extremity entrapment neuropathy. Ulnar nerve is compressed mostly in elbow region
      because of its anatomy. Ulnar nerve entrapment neuropathy diagnosis depends on symptoms,
      physical examination and electrodiagnostical tests (1). The incidence of ulnar nerve
      entrapment in elbow (UNE) was found as 25.2/100000 in Siena, a district of Italy (2). It is
      3-8 times more common in males than females (3).

      Conservative treatment choices are limited in ulnar nerve entrapment neuropathy and very few
      studies about UNE, are available in literature. Among the evidence-based treatments the first
      choice is elbow splint (4). It is very important to avoid the movements that provoke the
      symptoms of UNE, the splint that is used in treatment allows the elbow to rest and lessens
      the inflammation and symptoms (4). During daytime elbow pads and/ or splints which keep the
      elbow in 30- 45 degree flexion position may be used (5-6). To prevent elbow flexion during
      sleep time a pillow /towel may be put on antecubital fossa or the elbow splint may be used
      during sleep time (4).

      2-3 times a day the splint should be removed, and passive range of motion exercises should be
      performed. In a study it was found that using the splint at night does not only relieve the
      symptoms, but it also heals the ulnar nerve functions (7). On the other hand another study
      showed that using splint at night does not provide any additional benefit on avoiding symptom
      provoking positions (8).

      Non-steroidal anti-inflammatory drugs (NSAID) are prescribed to relieve pain and inflammation
      in UNE. In case of there is no benefit of conservative treatment, when there is progressive
      paralysis in hand muscles and claw hand sign surgical treatment should be taken into
      consideration. Different surgical techniques are performed depending on the ulnar nerve
      entrapment region and elbow anatomy.

      Conservative treatment choices of UNE are limited; since elbow splint limits daily living
      activities patient compliance is low and the results of elbow splint efficacy are
      controversial. While it was shown literaturally that physical medicine treatment modalities
      are effective in treatment of carpal tunnel syndrome (CTS) which is the most common upper
      extremity entrapment neuropathy (9, 10), there are a few studies about UNE treatment with
      physical medicine treatment modalities. It was shown in literature that continuous short-wave
      diathermy (SWD) application in CTS was effective on pain, function and symptom relief and
      this provided a basis for our study as CTS is an entrapment neuropathy similar to UNE. The
      aim of this study is researching the efficacy of SWD which is a deep heating modality in
      treatment of UNE. SWD is used either continuous or pulsed mode. Both thermal and non-thermal
      effects are seen due to absorption of electromagnetic energy in tissue. Among the thermal
      effects are; increase in blood flow, cell metabolism, tissue elasticity, changes in muscle
      relaxation and enzyme reactions due to increase in temperature. Superficial wound healing,
      decrease in edema, lymphedema, venous stasis ulcer are the result of non-thermal effects.
      Continuous SWD is used for the purpose of heating. It is essential to be precautious to avoid
      any kind of burn case. Pulsed-mode SWD is preferred for non-thermal effects although there is
      not enough evidence about its effects (11).

      METHODS Patients and study design

      The study was designed as randomized placebo controlled double blind research. 76 patients
      who applied İstanbul Fatih Sultan Mehmet Research and Training Hospital Physical Medicine and
      Rehabilitation clinic between February 2013- August 2013 and were diagnosed as UNE
      electrophysiologically according to criteria suggested by American Neurology Society were
      included into the study. 61 patients completed the study ( 1 patient continued the treatment
      in another hospital because of transportation, 3 patient left the treatment because of not
      being allowed by job boss, 4 patient left the treatment without giving any information, 7
      patient completed the treatment but didn't come to the control examination). The hospital
      ethical committee permission was taken (FSMEAH-KAEK 2013/18 - 28.02.2013).

      UNE Diagnosis Criteria suggested by American Neurology Society (12);

        1. Ulnar nerve motor conduction velocity lower than 50 m/sec in elbow region

        2. Elbow region ulnar nerve motor conduction velocity 10 m/sec lower than forearm region

        3. More than 20% decrease in compound muscle action potential (CMAP) amplitude in above
           elbow stimulation compared to below elbow

        4. Evident difference in configuration of above elbow CMAP compared to below elbow

      If 2 of the criteria are positive it is a possible UNE diagnosis, and it is certain UNE
      diagnosis in case 3 criteria are positive.

      Exclusion Criteria;

        1. cervical radiculopathy

        2. brachial plexopathy

        3. ulnar nerve cut and trauma

        4. sensation deficit in application region

        5. diabetes mellitus

        6. polyneuropathy

        7. wound, burn, scar mark on forearm research region

        8. presence of implant, prothesis, pin in tissue

        9. not having well general health

       10. epilepsy

       11. presence of intrauterine device

       12. presence of hearing instrument

       13. presence of tumor, inflammatory states

       14. pregnancy or pregnancy suspicion

       15. being gotten radiotherapy ( during the last 6 months)

      The patients were divided into two groups by coin toss randomization. The patients in the
      first group were applied continuous SWD treatment in 27.12 Hz frequency and for 20 minutes on
      elbow region by placing the elbow in 2 cm distance far from the condansator electrodes of SWD
      while the elbow is in 90 degree flexion. The second group patients were applied placebo SWD,
      the patients positioned same as the first group without turning on SWD. Both groups were
      given treatment 5 days a week and 10 session in total for two consecutive weeks. The
      physiotherapist that was applying the treatment on patients was not blind to treatment.

      All patients were informed about UNE before the treatment, elbow positions and movements that
      might worsen the symptoms were being taught and recommended to avoid these positions, written
      consent was taken. The two group patients were prescribed elbow splint that keeps elbow in
      30° flexion, to be used at night during the treatment period. Patient evaluation,before
      treatment, after treatment, first month after the treatment and third month after the
      treatment, was done by one physician (NBB) who was blind to all patients. The patients did
      not know if they were in treatment group or in control group until the study was completed.

      The primary endpoint of this study is evaluation of pain intensity with VAS, secondary
      endpoint of this study is evaluation of changes in hypoesthesia and Tinel sign with
      quick-DASH, SF-36, dynamometer.

      Assessments

      In order to have a 15% relief in VAS there has to be 34 patients in each group according to
      power analysis. The study was designed with 76 patients, because of some of the volunteers
      not completing the treatment, 31 patients participate in treatment group and 30 patients
      participate in control group, as a total studt was completed with 61 patients.

      The age, height, weight, gender, occupation, education level, dominant hand, affected
      extremity, history of repetitive trauma of patients were recorded. BMI (body mass index) has
      been calculated by using the data of height and weight with the formula of BMI= body mass
      (kg)/ (height)² (m²). The patients with BMI > 30 were accepted as obese.

      The patients were evaluated by physical examination, daily living activities, pain and grip
      strength before treatment, after treatment, one month after treatment and three months after
      treatment. In order to evaluate the patients Visiual Analogue Scale (VAS), Short Form 36,
      Quick -DASH, muscle assessment scale, grip strength with dynamometer used, and if it was
      present of claw hand deformity, hypothenar atrophy, Tinel sign, hypoesthesia (thenar/
      hypothenar), Froment sign, Wartenberg sign recorded. McGowen classification has been
      performed before treatment.

      Statistical analysis For statistical analysis NCSS (Number Cruncher Statistical System)
      2007&PASS (Power Analysis and Sample Size) 2008 Statistical Software (Utah, USA) softwares
      were used. Besides descriptive statistical methods ( mean, standard deviation, median,
      frequency, rate, minimum, maximum), for comparison of quantitative data between two groups;
      if parameters were normally distributed student t test, if they were not normally distributed
      Mann Whitney U test were used. To compare qualitative data Fisher's exact test and Yates
      Continuity Corection Test (Yates Corected chi-square) were used. For in-group analysis in
      follow-ups; comparison of normally distributed parameters were done by paired samples Test,
      and Wilcoxon Signed Ranks Test was preferred for parameters that were not normally
      distributed. Statistical significance was measured with p<0,01 and p<0,05.

      DISCUSSION

      UNE is an upper extremity disease which is second most common peripheral neuropathy after
      CTS, that causes functional insufficiency in daily living activities and praxis requiring
      works and therefore results in work loss. The main goal in UNE treatment is; increasing the
      life quality in the long term by relieving the symptoms, lessening the compression on the
      nerve, preventing the nerve damage, stopping the present nerve damage, preservation of
      physical function and social participation.

      Although UNE is the second most common peripheral neuropathy there is no consensus about its
      treatment according to currently present studies. The present treatment options are divided
      into two as; conservative treatment and surgery. Conservative treatment option is composed
      of; patient education, exercise, splinting, physical medicine modalities, pharmacological
      treatments. In case there is no enough clinical relief in conservatively treated patients,
      surgery is preferred. In a study was made by Hong et al; 10 patients ( 12 ulnar nerve
      neuropathy cases) were divided into two groups. Group A which was composed of 5 cases were
      given an elbow splint that keeps elbow in 30-35° flexion position, group B which was composed
      of 7 cases were given splint and administered single dose of 40 mg triamsinolone injection in
      elbow near ulnar nerve (6). In first month control examination there was an increase in nerve
      conduction velocity of group A, there was same amount increase in both group A and group B in
      sixth month control examination. Svernlöv et al. studied 51 UNE patients by dividing them
      into 3 groups (13). Group 1 was given splint and recommended to avoid symptom provoking
      activities, group 2 was given nerve gliding exercises and recommended to avoid symptom
      provoking activities, group 3 was recommended only to avoid symptom provoking activities. It
      was found that splint and nerve gliding exercises did not provide any additional benefit on
      clinical outcome. In our study we recommend every patient elbow splint that keeps elbow in
      30° flexion. Despite some studies showing the night splint is beneficial, some other studies
      show that it has no effect on clinical outcome.

      In a study of Nakamichi et al. 77 patients ( 80 ulnar neuropathy cases) were told to avoid
      positions that causes mechanical pressure on ulnar nerve (14). The cases that had relief in
      complaints were followed up until 1 year. It was concluded that mild and moderate cases of
      UNE could be treated b avoiding smptom provoking activities compared to severe cases.
      According to our study; the similar improvement in VAS, quick-DASH, dynamometer, SF-36
      results were related to avoidance of symptom provoking activites.

      In a study made by Özkan et al., 32 cases of UNE were divided into two groups and first group
      was given ultrasound treatment, second group was given low level laser treatment for 2 weeks,
      5 days per week (15). It was found that there was clinical and electrophysiological
      improvement in both groups in first month control examination and there was no significant
      difference between groups. Guiseppina et al. divided 22 patients (34 cases) of CTS into two
      equal groups, and studied effect of deep heating modality (7). First group was treated 20
      minutes per session, 2 session per week with a microwave energy producing physical therapy
      modality and in total 6 sessions of treatment were given. Second group was placebo treatment
      group, was given same duration and same times sham treatment. It was found that deep heating
      had a significant effect on pain and function compared to placebo group. İncebıyık et al.
      studied effect of SWD on 31 patients (58 cases) of mild or moderate CTS dividing into two
      groups (16). The treatment was designed as 5 sessions per week, 15 sessions in total. First
      group was given superficial heating treatment, SWD, nerve and tendon gliding exercises,
      second group was given superficial heat treatment, placebo SWD, nerve and tendon gliding
      exercises. It was found that SWD was effective in CTS on pain, function, clinical symptoms
      improvement. We studied effectiveness of SWD, which is a deep heating modality similar to US,
      microwave, by controlling with a placebo group. Because of having a few studies about UNE and
      small sample sizes there are different results about deep heating effectiveness.

      Our study is important because of being randomized placebo controlled double blind, getting
      patients evaluated in many aspects, being the first studying SWD effectiveness on UNE. Having
      a small sample size and short follow up period are limitations of our study. Because of not
      having many studies about SWD effectiveness in UNE treatment, the session number was decided
      depending on the clinical experiences which is another limitation of our study. In our
      opinion; it will be useful to show the effect of physical medicine modalities in UNE
      treatment with studies which are planned with more patients, more sessions and longer period
      of follow ups with different physical medicine modalities which are organized as placebo
      controlled.

      Financial Support There was no any support from any foundation or settlement. The patients
      were not paid for volunteering the study.
    

Intervention name(s): shortwave diathermy treatment; placebo shortwave diathermy treatment
Intervention type(s): Other; Other
Intervention description(s): shortwave diathermy is a deep heating physical therapy agent. It was found efficiaous in carpal tunnel syndrome which is an entrapment neuropathy like ulnar nerve entrapment so it was hypothesised that shortwave diathermy could be an effective treatment method in ulnar nerve entrapment.; shortwave device was not turned on while participants were asked to put their elbow into the device
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: this study has 2 groups of participants. treatment group and control group. It is designed as randomized controlled double blind clinical trial.
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: shortwave diathermy, ulnar nerve entrapment at elbow