Procedures used in Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;333:939.

We used 8 physiotherapy sessions of 30 minutes each, consisting of mobilisation with movements (MWM) and exercise,¹ which were applied in order to address key physical impairments of lateral epicondylitis (LE) that cause reduced functional ability in day to day living (ie, lateral elbow pain and reduced capacity to grip without pain).

THE MOBILISATION TECHNIQUE

The 2 MWM techniques primarily used were the lateral glide of the elbow (LAT) and posterio-anterior glide of the radiohumeral joint (PA). MWM are a family of techniques with a common theme,² which is the application of a joint glide (mobilisation) that is sustained during the performance of an active physical task (movement) by the patient. The physical task in LE is usually a pain free grip measured in units of force by a dynamometer. The treatment technique is performed without any pain and a substantial improvement in grip force is expected during its execution. In the case of a patient with LE of the right elbow, the LAT is performed with the patient supine and the affected upper limb fully supported on a treatment table in relaxed elbow extension and forearm pronation (figure 1). The therapist, standing by the patient’s right side and facing the patient’s head, stabilises the patient’s distal humerus laterally with the heel of his or her left hand and 1^st web space. The therapist then applies, from the medial side, a laterally directed glide to the ulna through the 1^st web space of his or her right hand. While sustaining the glide, the therapist asks the patient to perform a pain free grip. The change in force with the glide in-situ is noted. It is important to note that ongoing use of this technique is contingent upon a substantial change in pain free grip force during the application of the technique. If successful, the technique may be repeated 6–10 times during a single treatment session.

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Figure 1

 The lateral glide MWM.

Patients should be warned of the possibility of an exacerbation of pain 48 hours after first treatment. Minor adjustments in the direction of the glide³ and force applied⁴ can be made to the technique to optimise outcome. The same principles apply to the PA technique. With the patient positioned as described above, the therapist applies a posterio-anteriorally directed glide to the head of the radius with his/her thumbs (figure 2). In addition to these MWMs, taping was applied in such a way as to replicate the force applied by the MWM.¹ Taping was encouraged to further sustain the pain relieving effects between treatment bouts,² but more critical to the condition’s resolution was ongoing self treatment by the patient.

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Figure 2

 The postero-anterior glide of the radio-humeral joint MWM.

THE EXERCISES

A progressive resistance exercise programme for the wrist extensors (figure 3), flexors, radial and ulnar deviators, as well as the forearm supinators and pronators, was used to restore muscle condition, as it is poor in LE. General upper limb conditioning exercises were also included.¹ There were 4 key prescription criteria: (i) pain free exercise, (ii) slow movements (eg, 8 seconds per repetition), (iii) regular review by the physiotherapist, and (iv) exercises performed with correct form. Concentric, eccentric, and isometric modes of contraction were used; the latter was used if the former were not pain free. Resistance was supplied mainly in the form of rubber bands, but free weights and manual resistance may also be used. With regards to exercise parameters, we used a 3 set structure of approximately 12–18 repetitions performed daily, which is in line with an endurance-strength adaptation protocol. The overriding principle was a structure that encouraged adherence to regular exercise and no exacerbation of the elbow pain. One pragmatic aspect of the physiotherapy protocol was that therapists were able to modify the MWM and exercises in response to patient feedback and response during and in between sessions.

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Figure 3

 Exercise for the wrist extensors with rubber band resistance.