The are stated plainly, with the eccentric-concentric paired

The
article being reviewed is titled, “Comparison of effects of eccentric training,
eccentric-concentric training, and eccentric-concentric training combined with
isometric contraction in the treatment of lateral elbow tendinopathy” by
Dimitrios Stasinopoulos PhD and Ioannis Stasinopoulos MD, taken from the
Journal of Hand Therapy. This article looks into the comparative training
methods available for treatment post-diagnosis. There are three forms of
treatment explored; an eccentric, eccentric-concentric, and
eccentric-concentric training method with an isometric contraction.

 

In
the abstract for the article, Stasinopoulos and Stasinopoulos clearly state
that all three approaches to rehabilitation have been shown to have value, but now
want to produce a trial to compare their effectiveness. The abstract outlines concisely
the main points of the method, results and a brief conclusion. Bisset et al
(2011) indicate the validity of the study, with around 3% of the population
suffering from lateral elbow pain, with at least 20% of these chronically.

 

An
RCT (randomised control trial) was used to explore this research, with 34
patients participating, split into 3 groups; A, B and C. Bulpitt (2013) states
the RCT study design is “necessary to prove the effectiveness of new healthcare
strategies or treatment and to prevent the introduction of new but useless
treatments”. Bulpitt (2013) also suggests that the RCT has been present
throughout the history of medicine in differing forms, and has throughout this
time shown its necessity. The determination of results, through using the VAS
(visual analogue scale) for pain and function, in addition to using a pain-free
grip strength test are also clearly indicated in the abstract. Regarding the
VAS scale, Van den Broeck and Brestoff (2013) suggest “The VAS scale is very
easy to apply, is usually considered cognitively easy to respond to, and
provides results that can be interpreted straightforwardly”. However, the same
editors also reason that, “…VAS scales are considered to be overly simplistic
by researchers”, and “…VAS scales tend to result in disease states being
weighed as more severe than with other instruments”. This may cast doubt on this
form of assessment, with the VAS scale potentially being overly subjective. The
results of the trial are stated plainly, with the eccentric-concentric paired
with isometric contraction treatment yielding the best results. A potential
oversight in this section could be the inclusion of a hypothesis and null
hypothesis, a very important factor in qualitative data and the production of a
good study result (Gad, 2009).

 

In
the introduction, there are supported references relating to the causes of
lateral elbow tendinopathy (LET), both anatomically and physiologically. The
researchers also give a good insight into clinical presentations and potential triggers
of LET, for example, work or sport-related repetitive strain movements. The
introduction shows further necessity of the trial, with the researchers
stating, “such a variety of treatment options suggests that the optimal
treatment strategy is not known, and more research is needed”. Stasinopoulos
and Stasinopoulos also indicate the preferred treatment of the LET condition
currently lies with an eccentric training programme, which is echoed in conditions
similar to LET such as patellar and Achilles tendinopathies. Hans Hoppeler
(2014) agrees, suggesting that “eccentric exercise is recognised to be the
conservative treatment of choice for tendinopathies”. Stasinopoulos and
Stasinopoulos also summarise with references, two alternative treatments and previous
studies surrounding them, showing their relevance to the study. They also
outlined this physiological movement, “forceful grip activities requiring
isometric contraction” which would validate the grip test as a meaningful test
for outcomes. Overall, the introduction states the relevance of this trial,
presenting well-informed scientific knowledge, supporting references and
clinical relevance; early indicators that the method may also be well
considered and precise.

 

Stasinopoulos
and Stasinopoulos explain in the method, their reasoning for using the
parallel-group design for their RCT over the crossover design. With the
crossover design, there is the possibility of all treatment types having an
effect on participants, potentially confusing results. Therefore, there is
justification that each participant randomly receives one of three treatments
simultaneously. This will give a more controlled set of results, and reduces
the possibility of attrition due to being ‘cured’ before completion. There were
two external professionals assigned for the trial; a doctor who was responsible
for diagnosis, baseline and follow-up assessments, as well as collecting informed
consent, and a therapist carrying out all of the selected treatments for each
group. This minimalizes external factors affecting results. For example, the therapist
will have a practised routine of treatment and will have a very low percentage
of variance in technique. However, under scrutiny, the therapist may have a
particular bias toward a form of treatment and may be more practised in this
area, giving a better treatment. A proposed alternative could be to use three
specialist physiotherapists for the three differing treatments.

 

Stasinopoulos
and Stasinopoulos took many precautions through testing and eliminating
alternate pathologies from the trial, which could affect treatment outcomes. A
condition such as LET can be very common and not always related to articular surfaces
(Koot et al, 2016). Due to the population pool of the study being simply over
the age of 18, with no maximum age, influences such as sensitivity of growth
plates during puberty, and increases in onset of poorer health conditions in
later life are minimalised due to the researcher’s rigorous testing.
Additionally, the researchers show good, referenced knowledge of pathologies
that could have an effect on the study, which aided to filter them from the
trial. Dawe and Poulter (2011) state that elbow pain, although very common, may
well reveal itself as a “multisystem disorder”, meaning it can be very
difficult to diagnose a definitive pathology without extensive testing, which
is evidently achieved in the study.

 

Once
all diagnoses were confirmed and informed consent was gained to make the study
legitimate, the control group of 43 was then randomly split into 3 separate groups
so no selection bias was shown (Kennes et al, 2011). All individuals were given
instructions to continue using the affected arm, with the following actions to
be avoided; grasping, lifting, knitting, handwriting, driving a car and using a
screwdriver. All heavily activate the extensor carpi radialis which will
provoke their symptoms and affect the study. However, there were no absolute
checks undertaken to ensure compliance with this.

 

For
the avoidance of potential bias, the participants weren’t given any prognosis
regarding each of the treatments before entering into the study, and
communication between therapist and patient was minimal. Hróbjartsson et al
(2011) said of response bias, “Patients may desire to please the researcher, or
just give a “correct” or expected answer that fits with the experimental
situation”. The doctor responsible for initial testing and diagnosis was also
kept blind in relation to which patient received which treatment type, meaning
there was also no professional bias in relation to assessment when determining
results.

 

All three forms of treatment began with the same
instructed starting position, as well as the same amount of sets, reps and
frequency per week, showing continuity within this section. However, it could
be argued that the technique of the individual treatments will differ in
workload, most notably from the purely eccentric movement to the
eccentric-concentric with the addition of isometric being the largest shift in
effort load, including a potential progressive inclusion of hand-held weights.
This has the potential to affect results/attrition, as the higher the workload,
the more aggravation and fatigue to the injured site, leading to a higher
injury risk factor (McCall, 2016). Drew, Cook and Finch (2016), however,
suggest by their Tertiary Prevention concept, that although training loads and
injury incidence are linked, a phased return programme is recommended for
future injury prevention rather than ruling out all but the lightest exercise
variations.

 

Gathering
the results of the trial, as mentioned in the abstract, was taken in the form
of patient experienced function and pain over the course of 24 hours previous
to the final assessment, measured on a VAS scale (0 – 10). Kersten et al (2012)
published an article arguing the point regarding the VAS scale that “VAS change
scores may seriously over or underestimate changes resulting from
rehabilitation”, as well as “a given change in one patient may be of different
magnitude than the same apparent change in another”. This may lead to the
results process, and subsequent findings not given the credit intended. The
pain-free grip strength test in the results can be determined as more credible,
with a physical piece of equipment giving a reading. However, this is only
given after the patient experiences their subjective pain level. It can be
determined that there is a high factor of subjectivity in regard to the
recorded results, only from the patients, not the assessor. A more dependable
feature of the pain-free grip strength test was that the patients weren’t
allowed to see their results, so as to prevent a potentially forced result.

 

The results were produced by comparing the initial
tests carried out before treatments began, to those taken once a course of
treatments had been completed (4 weeks) and again at 8 weeks. Due to the same
scales being used in both instances, this a logical and consistent way of
producing results. The mean average was calculated from each group’s given
scores, giving each group one mean total for each test. Stasinopoulos and
Stasinopoulos indicate well the relevant differing statistics of the group,
from the average age of the participants (43), their approximate timescale of
the condition upon treatment (6 months) and the percentage of participants
suffering with the tendinopathy in their dominant arm (85%). The most relevant
statement being that between the three groups, the mean average age and
timescale of condition was very similar. These factors aid in the results being
more dependable.

 

Attrition was monitored by use of a flow chart,
with the patients that dropped out doing so before the treatment phase began.
This means that attrition bias is not applicable here (Hróbjartsson et al, 2011). Stasinopoulos
and Stasinopoulos indicate their results clearly in a table showing a
definitive decrease in pain on the VAS scale, a definitive increase in function
(VAS) and pain-free grip strength (lbs) for all treatment types. There are a
few clear points highlighted by the table; the eccentric-concentric alongside
isometric contraction treatment has yielded the largest threshold of
improvement, and that the largest improvement was recorded after week 4, with a
very slight improvement made in comparison when results were taken at week 8.
There was less than 0.5 units of statistical significance in results between
eccentric and eccentric-concentric treatment methods, with Stasinopoulos and
Stasinopoulos basing their p-level at 5%. Generally, the lower the p-value, the
stronger the evidence (du Prel et al, 2009). However, due to the apparent lack
of a hypothesis, the p-value cannot be based on an appropriate source.

 

During
the discussion, the researchers openly admit that “future well-designed studies
are needed to confirm the results of the present trial”. This would suggest
that, although there is some well-thought evidence shown in this trial,
Stasinopoulos and Stasinopoulos may not be truly confident that their results
be concrete findings until further trials concur with their result. This could
be a causality of their decision to only have a target group of 34 people, as
smaller trial results cannot be truly reliable until further testing of larger
groups can confirm the same conclusion (Hackshaw, 2009). Another issue with the
target group could be that they were all amateur athletes taking part, and it
is suggested that when treating athletes, “all aspects of the kinetic chain” be
taken into consideration (Ellenbecker et al, 2010), which may be a further
progression of this particular study. Alongside this, although it can be up for
ethical debate, it is recommended that a placebo/sham component be introduced
to test the legitimacy of the trial and its results (Brim and Miller 2013).

 

In
conclusion, although the trial itself has been well thought out in its validity,
it has been now suggested there are many components lacking before this trial
can be fully accepted for the results it has produced.

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