Rotation 1 Fourth Year - Evidence Based Practice STARES

Situation
A 26 year old female was referred to the Outpatient Department at Armadale hospital by her GP for ‘tennis elbow’. The injury resulted at a game of ten pin bowling 3 months earlier where the woman bowled on an unusual angle. She played ten pin bowling on a weekly basis and had never experienced an injury such as this before. The patient took two weeks off work initially as her work was manual in nature and the pain was limiting the tasks she was able to complete. She had also stopped ten pin bowling after the initial injury and had not yet returned.

Task
I was asked in the referral letter to assess and treat her accordingly.

Action
When the patient arrived I performed a full subjective and objective assessment, completely disregarding the diagnosis given in the referral, to ensure that I was unbiased in my own diagnosis. The patient did indeed have an extensor tendinopathy which was started to resolve on its own with the patient stopping the aggravating activities of ten pin bowling and work. However, there were still quite marked limitations in terms of elbow, forearm, wrist and grip strength and some pain especially with grip. I remembered from 2nd year the benefits of eccentric strength exercises in tendinopathy and prescribed the patient eccentric wrist flexion, extension, radial deviation and ulnar deviation with weights, education on continuing to avoid the aggravating activities where possible and wearing a tennis elbow brace when doing the tasks she cannot avoid. I also gave her general elbow and grip strengthening exercises and stretches for the wrist.

Before I next saw the patient I decided to look at the evidence on extensor tendinopathy treatment to ensure I was giving her the best treatment I could. I found an article called Lateral epicondylalgia: a musculoskeletal physiotherapy perspective by B.Vicenzino (Manual Therapy 2003, 8 (2), 66-79) which is a masterclass article on tennis elbow. It outlines appropriate treatments depending on the presentation of the patient. I found it especially interesting as my patient fit very nicely into one of the classifications given; pain-free grip strength deficit is much larger than pain elicited on direct palpation of the lateral epicondyle (i.e. the pressure pain threshold). It spoke about the Mulligan’s (1999) MWM and how it is extremely beneficial in the treatment of patients with this presentation, specifically the sustained lateral glide with pain-free grip. This technique can be done manually and then reinforced with taping of the lateral glide to continue improvements once the patient leaves the physiotherapist, as well as self mobilization techniques for home. Due to the strength of the evidence supporting these techniques I decided to try them on my patient when she returned if she still fit into the same clinical picture.

When the patient returned the techniques I had prepared were still relevant, so, I performed a sustained lateral glide while she performed pain-free gripping movements. She felt that the grip she could maintain with the glide was much stronger than without, and this was then confirmed with a handheld dynamometer. The treatment therefore seemed to be a successful one. I taped the patient before she left and she felt this helped the pain substantially. I decided not to teach her self-mobilizations as I was not confident she would be able to perform them correctly at home.

When the patient returned a week later she had significant improvements in pain and functional level and no longer had pain on grip. I was then able to focus more on improving her strength functionally to allow her to return to ten pin bowling.

Result
I believe that the patient recovered much faster with the evidence-based intervention that was chosen due to her specific clinical pattern rather than a recipe treatment for every tennis elbow available. Whilst I was treating her initially with eccentric exercises which are backed by strong exercises, I was able to incorporate even more specific treatments that really targeted her problems.

Evaluation
Whilst I believe that there was little that I could have done in this situation to have prepared or performed any better, it has definitely taught me the importance of evidence-based practice. We are taught over and over again at university the importance of knowing the evidence and using treatments that are backed by evidence, but until you experience it for yourself it is a hard concept to grasp. Just saying that you are doing a treatment because it was what you were taught to do just does not cut it in the real world with real patients, you must be able to back yourself up with hard evidence.

Strategies
I now know that when I graduate I am really only just beginning to learn. University has given me my base knowledge but I must continue the learning by keeping up to date with the literature in order to be the best physiotherapist I can be. I will definitely keep up to date once I graduate, as my supervisor is a great clinician and it is due to his very comprehensive knowledge of the evidence that is available.