Original Article
Bilateral Cervical Dysfunction in Patients With Unilateral Lateral Epicondylalgia Without Concomitant Cervical or Upper Limb Symptoms: A Cross-Sectional Case-Control Study

https://doi.org/10.1016/j.jmpt.2013.12.005Get rights and content

Abstract

Objective

The purposes of this study were to examine the prevalence and distribution of spinal and neurodynamic dysfunction in a population with unilateral lateral epicondylalgia (LE) without concomitant cervical or upper limb symptoms, compare with cervical examination in a healthy control population, and investigate potential associations with clinical and demographic factors.

Methods

This cross-sectional study included 165 patients with LE along with 62 healthy controls. Manual examination (C4-T2) was performed by an unblinded examiner with dysfunction defined as pain of 3 or higher on a numerical rating scale in the presence of a severe or moderate hypomobility or hypermobility. Neurodynamic testing (radial nerve) was classified positive if LE symptoms were reproduced and altered by sensitization maneuver. Repeated-measures analysis of variance was used to compare sides, segmental levels, and groups. Regression analysis was used to determine associations between variables.

Results

Thirty-six percent of patients had dysfunction of at least 1 spinal palpation site, and 41% had a positive neurodynamic test. Significant group-by-level (P = .02) and group-by-side (P = .04) interactions were found for spinal examination, with greater dysfunction bilaterally at C4-7 (P < .01) in LE compared with control arms. The number of positive palpation sites was associated with injury duration (P = .03), whereas neurodynamic response was associated with severity of resting pain (P = .04).

Conclusions

Cervical dysfunction is evident in individuals with LE without obvious neck pain and may reflect central sensitization mechanisms. Further study of the nature of the relationship between cervical dysfunction and LE is required.

Section snippets

Design

This cross-sectional, comparative study investigated the prevalence of abnormal findings from a clinical examination of the cervical and thoracic spine and radial nerve in individuals with and without unilateral LE (Fig 1). Data for the LE group were collected before enrollment into a randomized controlled trial,13 the methodology for which is described in detail elsewhere.14

Participants

All patients were recruited from the greater Brisbane region of Australia through community media advertisements.

Results

Analysis was possible using data from 164 patients with LE and 62 controls without LE. Cervical examination was not performed in 1 hearing-impaired patient, due to communication difficulties associated with testing in prone lying. Table 1 provides a summary of the baseline characteristics of the population. The groups were comparable in demographics. Lateral epicondylalgia patients had an average (± SD) duration of injury of 25.1 ± 29.8 weeks (range, 6-25 weeks), with worst pain over the

Discussion

The results of this study indicate that cervical spine dysfunction, as determined by pain of 3 or more on an 11-point numerical rating scale with severe or moderate hypomobility or hypermobility on manual palpation, exists in LE patients who do not have additional neck or upper limb pain. Dysfunction was evident bilaterally at the cervical spine in unilateral LE and localized to the lower cervical spine (C4-7) but not the thoracic spine. A longer duration of LE symptoms was associated with a

Limitations

Before drawing clinical implications from this study, it is important to consider several points. First, the population studied was self-referred via community media announcements as a part of a randomized controlled trial and underwent a thorough interview and clinical examination. The examination sought to exclude other comorbid upper limb or cervical symptoms in the experimental sample. This needs to be considered in translation of the findings into clinical practice, that is, the findings

Future Studies

Despite growing recognition of a relationship between the cervical spine and LE, much needs to be done in this area to better understand the mechanisms linking the 2 and determine its influence on prognosis. There is a need for more detailed and universally agreed classification systems for pain, which presents over the lateral elbow, taking into account that a continuum of concomitant cervical spine pathology may exist. This is particularly relevant for nonspecific arm pain, in which symptoms

Conclusion

Cervical dysfunction is evident in individuals with LE without obvious neck pain and may reflect central sensitization mechanisms. Further study of the nature of the relationship between cervical dysfunction and LE is required.

Funding Sources and Potential Conflicts of Interest

This trial was supported by the Australian National Health and Medical Research Council grant 511238 awarded to Drs Bisset and Vicenzino. Coombes was a recipient of a University of Queensland Research Scholarship. No conflicts of interest were reported for this study.

Practical Applications

  • In patients with unilateral lateral epicondylalgia without concomitant cervical or upper limb symptoms, cervical impairment is reasonably common (36%) on manual examination.

  • Impairment was prevalent bilaterally at C4-7 compared with

Contributorship Information

  • Concept development (provided idea for the research): BKC, LB, BV

  • Design (planned the methods to generate the results): BKC, LB, BV

  • Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): LB, BV

  • Data collection/processing (responsible for experiments, patient management, organization, or reporting data): BKC, BV

  • Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): BKC, LB, BV

  • Literature

References (40)

  • H Slater et al.

    Sensory and motor effects of experimental muscle pain in patients with lateral epicondylalgia and controls with delayed onset muscle soreness

    Pain

    (2005)
  • LM Bisset et al.

    Bilateral sensorimotor abnormalities in unilateral lateral epicondylalgia

    Arch Phys Med Rehabil

    (2006)
  • C Cook et al.

    Diagnostic utility of clinical tests for spinal dysfunction

    Man Ther

    (2011)
  • J Fernandez-Carnero et al.

    Examination of motor and hypoalgesic effects of cervical vs thoracic spine manipulation in patients with lateral epicondylalgia: a clinical trial

    J Manipulative Physiol Ther

    (2011)
  • RJ Nee et al.

    Neural tissue management provides immediate clinically relevant benefits without harmful effects for patients with nerve-related neck and arm pain: a randomised trial

    J Physiother

    (2012)
  • JH Villafane et al.

    Radial nerve mobilization decreases pain sensitivity and improves motor performance in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial

    Arch Phys Med Rehabil

    (2012)
  • JH Villafane et al.

    Short-term effects of neurodynamic mobilization in 15 patients with secondary thumb carpometacarpal osteoarthritis

    J Manipulative Physiol Ther

    (2011)
  • AI De-la-Llave-Rincon et al.

    Response of pain intensity to soft tissue mobilization and neurodynamic technique: a series of 18 patients with chronic carpal tunnel syndrome

    J Manipulative Physiol Ther

    (2012)
  • H Vernon

    The Neck Disability Index: state-of-the-art, 1991-2008

    J Manipulative Physiol Ther

    (2008)
  • RP Nirschl et al.

    Tennis elbow. The surgical treatment of lateral epicondylitis

    J Bone Joint Surg Am

    (1979)
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