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\def\RunningAuthor{Rayees Unnisa et al.}
\firstPage{1914}
\articleType{Original Article}
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\title{Mets and oscillating energy manual therapy in chronic lateral epicondylosis: a comparative study}
\author{Rayees~Unnisa\textsuperscript{*}\textsuperscript{1},  
            N.~Sivajyothi\textsuperscript{2},  
            G.Yatheendra~kumar\textsuperscript{3},  
            M.A~Wajid~Ur~Rahman\textsuperscript{1}, 
            Imaduddin~Ahmed\textsuperscript{1}~\\[5pt]{\textsuperscript{1}Deccan College of Physiotherapy, Hyderabad, Telangana, India}~\\{\textsuperscript{2}School of Physiotherapy, VELS University, Chennai, Tamil Nadu, India}~\\{\textsuperscript{3}Susrutha Institute of Physical Medicine and Rehabilitation, Hyderabad, Telangana, India}}

\begin{abstract}
Lateral Epicondylitis (LT) term was used previously thinking that it as an inflammatory condition, but it is tendinosis of Common extensor tendons of the forearm due to overuse. The incidence of the condition is about 4000 - 7000 per year in the general population in the United States. Conventional treatments practiced on the concept of inflammation have shown forty to eighty percent of unsuccessful results. Individuals with lateral epicondylosis may have symptoms like pain during activity, weakness, swelling and functional disability. The primary objective of the study is to find out the effectiveness of oscillating energy manual therapy (OEMT) compared with muscle energy technique (MET) on functional outcome in subjects with lateral epicondylosis. Total of 30 subjects with unilateral lateral epicondylosis was selected and was divided into two groups of 15 each in a group. Group A (received oscillating energy manual therapy) and Group B (received muscle energy technique). NRS (Numerical Rating Scale), Grip Strength and PRTEE (Patient Rated Tennis Elbow Evaluation) scale were measured pre and post-treatment for both the groups and also at follow up of the sixth week. Muscle energy technique group showed improvement in pain levels, muscle strength and functional activities. The statistical analysis demonstrated that results were more significant in group B at 4\ensuremath{^{th}} week and also at follow up with a mean difference of (2.3) for NRS, (57.4) for PRTEE and (5.9) for grip strength than group A. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}functional activities,\newline grip strength,\newline manual therapy,\newline pain,\newline lateral epicondylosis
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Rayees~Unnisa~\\ Phone:\ 9700140032~\\  Email:\ physio.therapy08@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{Introduction}
Lateral epicondylosis is one of the most common non-traumatic elbow disorders. It was first described by \unskip~\citep{548698:12547206}. The incidence of lateral epicondylosis in the general population is about 4 to 7 per 1,000 per year and about 9.1\% in tennis players \unskip~\citep{548698:12547200}\ensuremath{^{. }} Most commonly occurs in the fourth or fifth decade with equal incidence in men and women\unskip~\citep{548698:12547207}. \textit{Extensor carpi radialis brevis} (ECRB) is the most commonly affected muscle, but up to 50\% of patients will also have degeneration of the \textit{extensor digitorum communis} \textit{.} Initially, the pathology was assumed to be tendinitis, but now it is known as tendinosis with degeneration and angiofibroblastic hyperplasia \unskip~\citep{548698:12547201} and as such the correct terminology of the condition is lateral epicondylosis. If it is micro trauma of muscle fiber, as previously assumed pathophysiology of lateral epicondylosis, must heal in 3-5 days of the injury but the tendon injuries may take 5 weeks for healing. Because of reduced blood supply, many cases cross the expected healing time leading it to a chronic condition. Because of the absence of inflammatory cells shown in histopathological studies, it is evident that it is chronic degeneration with the presence of fibroblasts, collagen in a disorganized way and increased blood cells\unskip~\citep{548698:12547213} Causing it an angiofibroblastic condition. Conventional treatments practiced on the basis of inflammation have shown thirty-nine to eighty percent of unsuccessful results. Rest, ultrasound, stretching, strengthening exercises, steroid injection, iontophoresis, friction message, counterforce bracing, extracorporeal shock wave therapy, Platelet-rich plasma injection, phototherapy and surgery are the commonly used interventions either in single or in combination. Another approach suggests that it could be due to the presence of active tender points on hand and wrist extensor muscles. Oscillating energy Manual Therapy (OEMT), also known as V-spread, is a craniosacral manual technique \unskip~\citep{548698:12547210} it has been shown effective for chronic lateral epicondylosis \unskip~\citep{548698:12547202}. Muscle Energy Technique (MET) is a manual therapy involving isometric contraction\unskip~\citep{548698:12547301} which aims in improving musculoskeletal function, and decreasing pain levels in lateral epicondylosis are shown to be effective \unskip~\citep{548698:12547217}. \ensuremath{^{}}

 Limited studies were present on oscillating energy manual therapy and muscle energy technique in lateral epicondylosis; the present study aimed at finding out the effectiveness of oscillating energy manual therapy versus muscle energy technique on pain, grip strength and functional abilities in individuals with chronic lateral epicondylosis.
    
\section{Materials and Methods}
\textbf{Procedure}


  
  \begin{enumerate}
  \item \relax The study was conducted on 30 subjects with lateral epicondylosis at Susrutha Institute of Physical Medicine and Rehabilitation, Hyderabad, India after informed consent and institutional ethical committee approval. The subjects were randomly selected according to the inclusion (both gender ,age 25-45 years with chronic lateral epicondylosis and presence of tender points) and exclusion criteria(cervical spine disorders, peripheral neuropathy, Fractures , major upper limb surgeries, use of steroid injection during the last six months for severe pain, tumor and wounds around the involved elbow joint). The patients were divided into two groups (Group A and Group B) by convenient sampling. 
  \end{enumerate}
  

\begin{itemize}
  \item \relax  Group A : oscillating energy manual therapy e
  \item \relax  Group B : muscle energy technique
\end{itemize}
  The study was carried on for a period of 4 weeks. Both the groups were evaluated for pain by NRS, grip strength by a dynamometer and functional ability of the elbow joint by PRTEE pre-treatment and post-treatment and also at follow up of the 6\ensuremath{^{th}} week.

\textbf{ Group A}

 treated with oscillating energy manual therapy

\textbf{Technique}

 It is also known as V-spread and is performed as described in many osteopathic books\unskip~\citep{548698:12547210}. The subject was asked to sit on a chair with the affected painful arm resting on the treatment table. Tender points were palpated. Then the therapist places the index and middle fingers of one hand in a V-shape around the tender point and placed the index finger of the other hand in the medial side of the elbow, diagonally across the located tender point. Gentle pressure was applied a few times using fingertips to the tissues alternatively from the medial and lateral sides to start the oscillations. On the initiation of oscillations, the application of pressure should be stopped and allow the oscillations to continue between the two points of contact on the subject's elbow. This technique was repeated until there were no tender points on palpation \unskip~\citep{548698:12547202}. The duration varied from 30 seconds to 2 minutes. The same technique was repeated for all tender points, each session lasting for 20-30 minutes applied in 2 sessions for a week for 4 weeks. After 4 weeks of treatment pain, grip strength and functional status of the elbow joint was measured by using NRS, Dynamometer and PRTEE and follow up was done at 6\ensuremath{^{th}} week.

\textbf{Group B }

\textbf{\space }treated with muscle energy technique

\textbf{Technique}

This technique was applied by allowing the subject to sit comfortably and then stabilize the subject's distal humerus with one hand, then the forearm was supinated with the therapist another hand until resistance appeared. Holding the position the subject was asked to slowly pronate the forearm that is Isometric contraction against resistance for a period of five seconds, followed by slightly increasing supination until resistance was met once again. After five seconds of relaxation, the procedure was repeated 5 times during a single treatment session; this technique was applied in 2 sessions for a week for 4 weeks. After 4 weeks of treatment pain, grip strength and functional status of the elbow joint was measured by using NRS, Dynamometer and PRTEE and follow up was done at 6\ensuremath{^{th}} week. Figure~\ref{f-79bb8c60ac6b} shows that,


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\egroup
\textbf{Statistical analysis}

Statistical analysis was performed by using SPSS 9, MS EXEL. Descriptive analysis was used to analyses the data in each subject [Group A \& Group B]. WILCOXON SIGNED RANKS TEST was performed Inter (within) groups (Group A \& Group B). For strength, PAIRED-T-TEST was performed. MANN-WHITNEY TEST was performed Intra (between) groups (Group A \& Group B), and for strength, INDEPENDENT-T-TEST was performed.  
    
\section{Results and Discussion}
The present study has compared the muscle energy technique with oscillating energy manual therapy to evaluate pain intensity, grip strength and functional ability in subjects with lateral epicondyosis. Group A was given oscillating energy manual therapy, and group B was given a muscle energy technique. The analysis of mean NRS score within the group that measured at baseline, post-treatment, and after 6weeks follow up of intervention in both the groups found that there is a significant difference in post-treatment means. The participants in Group B found significant improvements in NRS from a baseline score of mean 7.4 to 2.3(4\ensuremath{^{th }} week) and 2.6 (6\ensuremath{^{th}} week). The participants of Group A also showed improvements in NRS with a baseline score of mean 7.6 to 4.4 (4\ensuremath{^{th}} week) and 4.6 (6\ensuremath{^{th}} week). But there was more statistically significant difference in pain levels in Group B than Group A. Decrease in the level of pain perceived is due to the decrease in neurophysiological pain. We hypothesized that during the treatment session, manual contact with the patient might have resulted in alteration of pain, through the neurophysiological mechanisms of movement performed. The decrease in pain perception in the group can be correlated with this effect of clinical touch.

The activation of agonist and antagonist muscles, along with clinician touch, seems to alter the perception of pain. 

Even though the literature on MET intervention for the management of LE is lacking, our study results are correlated with the results of the study done by \unskip~\citep{548698:12547203} on the short-term effects of MET on pain in individuals with nonspecific lumbopelvic pain, has also shown improvements in pain levels.  

 However, the results of VAS were contradictory to the results of the study done by\unskip~\citep{548698:12547208} where METS was less effective compared to mulligan even though it has a prognostic effect. 

According to Chaitow, MET is an active isometric contraction method in which normal blood circulation is increased, which removes nociceptive stimulants from the site of pain and reduces pain levels \unskip~\citep{548698:12547301}.

 The analysis of grip strength and functional ability within both groups found that there is a significant difference in post-treatment means and follow up. In group B, there is a significant improvement in grip strength from a baseline score of mean 2.4 to 5.6 (4\ensuremath{^{th}} week) and 5.9 (6\ensuremath{^{th}} week). Table~\ref{tw-5d0a88dd7cae} shows,


\begin{table*}[!htbp]
\caption{\boldmath {Group Statistics for NRS} }
\label{tw-5d0a88dd7cae}
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\tbltoprule \rowcolor{kwdboxcolor} & Group & \cAlignHack  Number of subjects & Mean & SD & Std. Error Mean\\
\tblmidrule 
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  OEMT &
  \cAlignHack 15 &
  7.4667 &
  1.18723 &
  .30654\\
 &
  METS &
  \cAlignHack 15 &
  7.4000 &
  1.35225 &
  .34915\\
\multicolumn{1}{p{\dimexpr(.1697\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{Post\_NRS}} &
  OEMT &
  \cAlignHack 15 &
  4.6000 &
  1.35225 &
  .34915\\
 &
  METS &
  \cAlignHack 15 &
  2.3333 &
  .97590 &
  .25198\\
\multicolumn{1}{p{\dimexpr(.1697\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{FollowUp\_NRS}} &
  OEMT &
  \cAlignHack 12 &
  4.5000 &
  1.08711 &
  .31382\\
 &
  METS &
  \cAlignHack 12 &
  2.6667 &
  .98473 &
  .28427\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
There were also improvements in scores of PRTEE in both the groups, but it was more significant in Group B with baseline mean value of 82.7 to 57.4 (4\ensuremath{^{th}} week) and 60.6 (6\ensuremath{^{th}} week) and at follow up respectively.

A recent randomized controlled study by \unskip~\citep{548698:12547217} compared METS with corticosteroid injection and demonstrated significant improvements in grip strength and functional ability in METS group, similar results were observed in our study also.

Statistical analysis of grip strength depicts that strength improved significantly in METS group than oscillatory technique group and the results are correlated with results of \unskip~\citep{548698:12547198} following the application of 8 treatment sessions of METS within 2 weeks. Table~\ref{tw-bdca9d01b935} andTable~\ref{tw-9b43a6400da2} Shows,


\begin{table*}[!htbp]
\caption{\boldmath {Group Statistics for PRTEE} }
\label{tw-bdca9d01b935}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.178\linewidth-2\tabcolsep}p{\dimexpr.142\linewidth-2\tabcolsep}p{\dimexpr.1794\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.17099999999999998\linewidth-2\tabcolsep}p{\dimexpr.1696\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor} & Group & \cAlignHack Number of subjects & Mean & SD & Std. Error Mean\\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(.178\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{Pre\_PRTEE}} &
  OEMT &
  \cAlignHack 15 &
  88.2000 &
  8.07288 &
  2.08441\\
 &
  METS &
  \cAlignHack 15 &
  82.7333 &
  8.11935 &
  2.09641\\
\multicolumn{1}{p{\dimexpr(.178\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{Post\_PRTEE}} &
  OEMT &
  \cAlignHack 15 &
  76.8667 &
  9.03064 &
  2.33170\\
 &
  METS &
  \cAlignHack 15 &
  57.4667 &
  8.14920 &
  2.10412\\
\multicolumn{1}{p{\dimexpr(.178\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{FollowUp\_PRTEE}} &
  OEMT &
  \cAlignHack 12 &
  74.8333 &
  7.82575 &
  2.25910\\
 &
  METS &
  \cAlignHack 12 &
  60.6667 &
  9.12871 &
  2.63523\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Group Statistics for GRIP STRENGTH} }
\label{tw-9b43a6400da2}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1918\linewidth-2\tabcolsep}p{\dimexpr.1489\linewidth-2\tabcolsep}p{\dimexpr.167\linewidth-2\tabcolsep}p{\dimexpr.1586\linewidth-2\tabcolsep}p{\dimexpr.1641\linewidth-2\tabcolsep}p{\dimexpr.1696\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor} & Group & \cAlignHack Number of subjects & Mean & SD & Std. Error Mean\\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(.1918\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{Pre\_strength}} &
  OEMT &
  \cAlignHack 15 &
  1.6000 &
  .50709 &
  .13093\\
 &
  METS &
  \cAlignHack 15 &
  2.6667 &
  .97590 &
  .25198\\
\multicolumn{1}{p{\dimexpr(.1918\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{Post\_strength}} &
  OEMT &
  \cAlignHack 15 &
  3.1333 &
  .91548 &
  .23637\\
 &
  METS &
  \cAlignHack 15 &
  5.9333 &
  1.16292 &
  .30026\\
\multicolumn{1}{p{\dimexpr(.1918\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{FollowUp\_strength}} &
  OEMT &
  \cAlignHack 12 &
  3.0833 &
  .99620 &
  .28758\\
 &
  METS &
  \cAlignHack 12 &
  5.6667 &
  1.07309 &
  .30977\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
In the METS group, significant improvement occurs in the functional outcome, which was depicted in the statistical analysis of the PRTEE scale. Hence, the improvement in the efficiency to do their routine work occurs. This reduction in pain levels enhanced in the performance of activities, which were earlier painful.

The normal function of hand provides us with the ability to perceive and manipulate objects in the environment, to achieve the normal function of hand; proximal joints and musculatures should be optimal enough to stabilize the hand and wrist which helps to obtain precision and prehensile functions. In LE due to Extensor carpi radialis brevis tendinitis, handgrip and movements are severely compromised. In any rehabilitation of the upper limbs, complete recovery must be achieved; if not, it can limit the quality of life and functional independence. 

\unskip~\citep{548698:12547204} Lateral epicondylosis can be due to tendinogenic, articular, or neurogenic causes. Several theories have been laid down, and the most recent theory suggests that compression of posterior branch of the radial nerve at the elbow occurs during the repeated actions of the wrist extensor muscles, especially the extensor carpi radialis \unskip~\citep{548698:12547199} examined the anatomic factors related to the causes of lateral epicondylosis. When the elbow was extended, the undersurface of the extensor carpi radialis brevis rubbed against the lateral edge of the capitellum while the extensor carpi radialis longus compressed the brevis against the underlying bone. The results of these afore mentioned studies may help us to understand the pathomechanics of Lateral epicondylosis and supports the explanation of the mechanism of MET. Because of the combination of creep and plastic change in the connective tissue MET can release articular restrictions, elongate muscle fibers, and increase the joint range of motion.

The oscillating energy manual therapy (v-spread) was used to treat restricted cranial sutures in olden days, a modified version was proposed for treatment of somatic tender points. It is believed that biomagnetic energy is released from the therapist's hand, as soft tissue healing is frequency-specific and respond well with a human touch. The electromagnetic fields have an effect on tissue healing, bone healing, synthesis of growth factor and connective tissue repair and healing \unskip~\citep{548698:12547214}. According to \unskip~\citep{548698:12547205} electromagnetic signals range from 0.3htz to 30 hz and with most signals of 7 to 8 hz can be omitted from therapist touch. The improvements in subjects receiving oscillatory technique could be due to the release of these electromagnetic fields from the therapist's hand and increase in the synthesis of collagen by fibroblast may occur as the cause is angiofibroblastic. This therapy is shown effective in the treatment of fibromyalgia patients\unskip~\citep{548698:12684377}. In Group B individuals receiving muscle energy technique, according to L.chaitow, the Musculoskeletal system is the primary machinery of life, because of repetitive biomechanical stress on soft tissues pathological changes occur. Golgi tendon organ activates when the patient performs an isometric contraction, which results in direct inhibition of agonist's muscles and a reflexive, reciprocal inhibition occurs at the antagonistic muscles. During relaxation, both muscle groups are inhibited, and a new range of motion is achieved. The muscles are stretched, and viscoelastic changes occur there is increased blood flow to the area, and lymphatic drainage is increased because of this possible mechanism there is a reduction in pain levels and functional improvement in many patients. Many researchers have used METS in the treatment of musculoskeletal disorders in their study showed that METS is effective in reducing pain and in increasing cervical range of motion in sub-acute neck pain.

\unskip~\citep{548698:12547209}  investigated the effect of METS on horizontal abductors and showed improvement in the gleno humeral Joint adduction and internal rotation in the tightness of posterior shoulder. 

In speculation of the results obtained, METS is more effective than oscillating energy manual therapy. This is due to the fact that METS addresses the pathology directly by correcting muscle imbalance, which was not obtained with oscillating energy manual therapy. Hence, METS should be the superior treatment approach in the management of LE complimented by oscillating energy manual therapy and other interventions\textbf{.}

Limitations of the study are, despite the significant effects demonstrated in this study, the larger sample size may improve reliability and gives more precision. Effective use of OEMT requires some skill and experience. Need to find out the consistency of technique. Further clinical studies are needed to explore the mechanism.
    
\section{Conclusion}
The results of the present study concluded that oscillating energy manual therapy and muscle energy technique had shown the improvement in NRS, grip strength and PRTEE in lateral epicondylosis subjects, but more significant improvement was observed in the subjects who were treated with muscle energy technique than oscillating energy manual therapy. 
    

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