International Journal of Health Sciences and Research

www.ijhsr.org ISSN: 2249-9571

Original Research Article

Comparative Efficacy of Wrist Manipulation, Progressive Exercises and

Both Treatments in Patients with Tennis Elbow
Dr Tanusree Basak1, Dr Tapas Kumar Pal2, Mr Biswajit Saha3, Dr Shabnam Agarwal1, Dr Tirthadeep Das4
1
Associate Professor, 2Assistant Professor, 3Post graduate Scholar,
Nopany Institute of Healthcare Studies, Kolkata- 700006
4
Physiotherapist, Dept. of Neuro Rehabilitation, Institute of Neurosciences, Kolkata- 700017
Corresponding Author: Dr Tanusree Basak

ABSTRACT

Background: Tennis elbow is an overuse injury of common Extensor tendon of wrist which occurs
due to repetitive micro trauma. Although the uses of Wrist Manipulation and Progressive Exercises
have been established as suitable treatment methods separately in Tennis Elbow Patients in terms of
pain relief and rapid restoration of function, but the benefit of one over the other has not been
exclusively explored and also the combined efficacy of Wrist Manipulation and Progressive Exercises
is yet to be established. Therefore, the aim of the study is to compare the efficacy of Wrist
Manipulation versus Progressive Exercises versus both together to improve Pain, Grip Strength and
Functional Disability of Tennis Elbow.
Methods: Both gender (n = 90), age 30-65 years, presented with Chronic Tennis Elbow were selected
based on inclusion and exclusion criteria and randomly allocated into 3 groups. All groups received
treatment for total duration of 6 weeks. The outcome measures were assessed using 101 Numerical
Pain Rating Scale, Jamar Hand-held Dynamometer and Patient Rated Tennis Elbow Evaluation to
measure difference between pre and post intervention Pain intensity, Grip Strength and Functional
Disability of Tennis Elbow.
Result: ANOVA was used to compare the difference among three groups. The level of significance
was set at critical F-value >4. Within group analysis showed significant improvement over elbow Pain
and Functional Disability after 6 weeks of intervention who received combined of wrist manipulation
and progressive exercise program.
Conclusion: This study concluded that both group showed improvement in Elbow Pain, Grip
Strength and Functional Disability in Tennis Elbow patients. However it was found that the Group
who received combined treatment showed better improvement than the group of Wrist Manipulation
and group of Progressive Exercises.

Key words: Tennis Elbow, Wrist Manipulation, Progressive Exercises program, 101 NPRS, Jamar
hand held dynamometer, PRTEE.

INTRODUCTION pronation or supination and aggravated by

Tennis Elbow is a painful gripping. [2]
musculoskeletal condition, which provides The most commonly affected
significant challenges to the healthcare structure is the origin of the Extensor Carpi
industry. [1] Radialis Brevis (ECRB) but up to 50% of
Tennis elbow is a syndrome patients will also have degeneration of
characterized by an insidious onset of elbow the extensor digitorum communis. Although
pain brought on by wrist extension with the pathology was initially thought to be
tendinitis, it is now known as tendinosis
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Tanusree Basak et al. Comparative Efficacy of Wrist Manipulation, Progressive Exercises and Both Treatments
in Patients with Tennis Elbow

with degeneration characterised by the strength is increased when the muscles of

presence of dense fibroblasts, vascular the proximal forearm are compressed. [13]
hyperplasia and disorganised collagen. [3] Wrist manipulation, Strengthening
Tennis Elbow is a chronic overuse Exercises and Stretching the Wrist
injury of the extensor tendons of the elbow, Extensors had been effectively used to treat
which occurs due to repeated micro trauma patients suffering from Tennis Elbow.
to the ECRB tendon. [4] Manipulation is thought to cause muscle
Tennis Elbow affects 1-3% of the relaxation and free the motion segments that
population, only 5% of all patients seen are have undergone disproportionate
recreational tennis players. [5] 75% of displacement or are felt to be hypo mobile.
Tennis Elbow patients are symptomatic in Wrist Manipulation has a direct effect on
their dominant arms. [6,7] the articular surface, modulation of
Although the syndrome has been nociceptive afferent transmission to the
identified in patients ranging from 12 to 80 central nervous system is influenced. [14]
years old, there is a prevalence of 19% Active rehabilitation program may
increase in 30 to 60 years old population, it be effective in the treatment of chronic
predominantly occurs in the fourth and fifth Tennis Elbow. Stretching may improve the
decades. [7-9] Male and female prevalence tissue healing in damaged connective tissue
rates are reportedly equal. [10] and strengthening the attachment of the
Pain arising from Tennis Elbow may Wrist Extensors might increase the
be acute or insidious. In cases with a more tolerance to repetitive movements.
acute onset, there is often a recent change in Progressive exercises can promote
mechanical load, technique or equipment. healing without traumatisation of soft
The severity of pain ranges from minor in a tissues. The progressive exercise includes
specific situation, to more severe pain with slow soft tissue stretching and slow and
disturbed sleep. Pain is aggravated by repetitive movements for strengthening of
gripping activities, from more forceful soft tissues. The whole program exercises
gripping during industrial work, to gripping muscles, tendons, ligaments and
[15]
during trivial daily activities such as osteotendinal insertions.
gripping the milk bottle in the fridge and the Wrist Manipulation and Progressive
tooth brush. The most painful position is Exercises have been established as suitable
with straight elbow and the second most treatment methods in treating Tennis Elbow
painful position is with the elbow in Patients, but the benefit of any one
maximal flexion. Stiffness may occur after combination over the other has not been
keeping the elbow in the same position for a exclusively explored. Hence this study has
longer period of time; especially after been undertaken to evaluate whether there is
sleeping or carrying load. [11,12] any additional benefit of the combined
The orthopedic clinical examination effect of Wrist Manipulation and
of Tennis elbow is simple and can be Progressive Exercises in patients with
conducted with the help of Mills’ test- A Tennis Elbow.
passive stretch of the extensor tendons
produced by full elbow extension, forearm MATERIALS AND METHODS
pronation, wrist flexion and ulnar deviation This study was randomised clinical
and Cozen’s Test- Resisted extension of the trial conducted in the physiotherapy
wrist performed with the elbow and wrist department of Nopany Institute of
fully extended and pronated reproduces the healthcare studies (NIHS) and other
pain on the lateral side of the elbow with. A physiotherapy clinics in Kolkata between
positive test for Tennis elbow is indicated if June 2015 to December 2015, all the
the induced pain is reduced and the grip procedures were carried out after obtaining
approval from Institutional Human Research

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Tanusree Basak et al. Comparative Efficacy of Wrist Manipulation, Progressive Exercises and Both Treatments
in Patients with Tennis Elbow

Ethics Committee considering the protection The Jamar dynamometer is useful for
of rights of patients and safeguarding their handgrip strength testing and measurements.
welfare. All the patients were informed A Spearman Construct validity testing was
about the procedures that would be carried performed to determine validity of the
out and the patients who agreed signed an Sphygmomanometer compared with the
informed consent form. Patients were free to Jamar dynamometer produced a 0.75
withdraw their participation without correlation. [18]
prejudice. PRTEE is a 15-item questionnaire
Patients of both genders (n=90) aged designed to measure forearm pain and
between 30-65 years, who presented with disability in patients with lateral
symptoms persisting more than 6 weeks, epicondylitis. The PRTEE allows patients to
tenderness over the lateral epicondyle, pain rate their levels of tennis elbow pain and
with gripping, passive wrist flexion and disability from 0 to 10, and consists of 2
resisted wrist extension, positive Cozen’s subscales: Pain and function. It is high on
test and Mill’s test [16] were included for the reliability, validity, and sensitivity in
study. At the start of the study, all 3 group chronic Tennis elbow patient. The pain
were homogeneous (p>0.05) in relation to (ICC = 0.89), function (1CC=0.83), and the
age, weight, height and BMI. The criteria of total (ICC = 0.89) scores all demonstrated
patient exclusion consisted of patient with excellent reliability. [19-21]
history of Rheumatoid arthritis,
Degenerative arthritis, Polyarthritis, Carpal Methods
tunnel syndrome, Peripheral neuropathy, Wrist Mobilization
Radial nerve entrapment, Space occupying Patient: The patient sat on a chair with
lesion over the affected area, Cubitus his/her affected hand resting on a table with
Valgus and Varus deformity, patient on palmer aspect of hand facing downwards.
NSAIDS, systemic and local corticosteroids Technique: Facing the patient’s affected
or analgesic within 3 days of study side therapist gripped the patient’s scaphoid
participation. Baseline measurements of bone between the thumb and index finger.
Pain intensity, grip strength and functional Therapist’s grip was more strengthened by
disability were measured by 101 NPRS, placing the thumb and index finger of
Jamar hand held dynamometer and Patient- his/her other hand on top of them. The
Rated Tennis Elbow Evaluation therapist then extends the patient’s wrist
questionnaire (PRTEE). Group A (n=30) dorsally at the same time the scaphoid bone
received wrist manipulation, Group B was manipulated ventrally. Wrist
(n=30) performed progressive exercise, Manipulation was performed 15 times for
Group C (n=30) received both wrist 20 sets, twice weekly for total 6 weeks
manipulation and progressive exercise. duration. [22]
Outcome Measures:
101 NPRS is advantageous for
quantifying the pain intensity. It is valid,
reliable and appropriate for use in clinical
practice. The 101 NPRS were translated into
Zulu to determine the concurrent validity of
the Zulu translation of the English
numerical pain rating scale 101. The Zulu
translation of the scale that was tested
revealed a high level of correlation (p=
0.001). NPRS have good sensitivity and
generated data than can be statistically Figure 1 Wrist mobilization in neutral position
analysed. [17]

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Vol.8; Issue: 4; April 2018
Tanusree Basak et al. Comparative Efficacy of Wrist Manipulation, Progressive Exercises and Both Treatments
in Patients with Tennis Elbow

Patients received Progressive Exercises for

6 weeks.
The exercises started with slow fist-
clenching, resisted wrist movements and
wrist rotations with a stick, followed by
movements against a band and two-way
resisted wrist rotations and pressing hands
against a wall. The final step included
occupational training program like twisting
a towel, compressing a soft ball, transferring
buttons from cup into another. Every
Figure 2 Wrist mobilization in extension position exercise period ended with stretching
exercises were performed for 30 seconds.
Progressive Exercise:

Figure 3 Progressive exercises

Pain Rating scale (101 NPRS), Jamar Hand-

held dynamometer and Patient Related
Tennis Elbow Evaluation (PRTEE) within
groups. Analysis of variance was used to
compare the difference among the three
groups changes in pre-intervention and post-
intervention scores of elbow pain, grip
strength and functional disability. The level
of significance was set at critical F-value >4
and the analysis were performed using the
Figure 4 Occupational training SPSS version 21.0
The exercises were performed 4-6 times Comparison of effectiveness among
daily at home. Each exercise included 10 Group A, Group B and Group C in pain
repetitions in 2-3 sets. Post intervention scores (101 NPRS), Grip Strength (Jamar
assessment period for Pain intensity, grip Hand-held dynamometer) and Functional
strength and functional disability were done Disability (PRTEE) in pre and post-
after six weeks training. [15] intervention.
101 NPRS is used to measure the Elbow
RESULT Pain. If pain decreases, the value of NPRS
STATISTICAL ANALYSIS will decrease.
Analysis of variance was used to compare
significance difference in 101 Numerical

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Tanusree Basak et al. Comparative Efficacy of Wrist Manipulation, Progressive Exercises and Both Treatments
in Patients with Tennis Elbow

Table 1 Comparison of 101NPRS Table 3 Comparison of PRTEE

Analysis of Variance Analysis of Variance
Source of Variation df Sum of Sq. Mean Sq. Source of Variation df Sum of Sq. Mean Sq.
Between 2 1015.717 507.8583 Between 2 601.1556 300.5778
Within 87 271.0083 3.115038 Within 87 711.0667 8.17318
Total 89 1286.725 14.45758 Total 89 1312.222 14.74407

Method df F-Value Probability Method df F-Value Probability

Anova F-test (2, 87) 163.0344 0 Anova F-test (2, 87) 36.7761 0

The difference among base line and post The difference between base line
intervention elbow pain with Group A, and post intervention functional disability
Group B and Group C were measured by with Group A was measured by Analysis of
Analysis of Variance. The calculated F Variance. The calculated F value (36.7761)
value (163.0344) is greater than critical F- is greater than critical F-value (4, as found
value (4, found in F-table). The difference in F-table). The difference was found to be
was found to be statically significant statically significant (critical F-Value>4).
(critical F-Value >4) From the above tables, it is clear that
Group C (combination of wrist
Comparison of effectiveness among manipulation and progressive exercises)
Group A, Group B and Group C showed more improvement in elbow pain,
increasing Grip Strength (Jamar Hand- grip strength and functional disability.
held dynamometer) in pre and post-
intervention DISCUSSION
Jamar Hand-held dynamometer is used to The findings of the study support
measure Grip Strength. If Grip Strength that there is significant difference within pre
increases, reading of Jamar Hand-held and post intervention scores of elbow pain,
dynamometer increases. grip strength and functional disability in
Group C. This study supports the alternative
Table 2 Comparison of Grip Strength
Analysis of Variance
hypothesis that there is significant
Source of Variation df Sum of Sq. Mean Sq. difference in elbow pain, grip strength and
Between 2 420 210 functional disability using wrist
Within 87 2980.5 34.25862
Total 89 3400.5 38.20787 manipulation and progressive exercises.
The mean difference in elbow pain
Method df F-Value Probability
Anova F-test (2, 87) 6.1298 0.0032 scores of Group C patients (wrist
manipulation and progressive exercise) is
The difference among base line and post higher than Group B (progressive exercise)
intervention grip strength Group A, Group and Group A (wrist manipulation) patients
B and Group C were measured by Analysis at the end of 6 weeks. Statistically there is a
of Variance. The calculated F value significant difference (critical F Value=
(6.1298) is greater than critical F-value (4, 163.0344) in elbow pain in Group C patients
as found in F-table). The difference was (wrist manipulation and progressive
found to be statically significant (critical F- exercise). This indicates that wrist
Value >4). manipulation and progressive exercises
were the most effective intervention in
Comparison of effectiveness among reducing Pain in patients with Tennis
Group A, Group B and Group C Elbow. Our study supports the findings by
decreasing Functional Disability Struijis et al, who have also shown in their
(PRTEE) in pre and post-intervention study that wrist manipulation is more
PRTEE is used to measure the Functional effective method to decrease elbow pain. [14]
Disability. If the Functional Disability Goyal et al has also shown in their study
decreases, the value of PRTEE will also that wrist manipulation is most effective
decrease. method to decrease pain and increase grip

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Tanusree Basak et al. Comparative Efficacy of Wrist Manipulation, Progressive Exercises and Both Treatments
in Patients with Tennis Elbow

strength. Wrist manipulation consisted of were effective intervention in decreasing the

extending the subject’s wrist dorsally at the Functional Disability in patients with Tennis
same time the scaphoid bone is manipulated Elbow
ventrally. Pain reduction may be due to The advantages of wrist
mechanical effect of wrist manipulation and manipulation are the potential effectiveness
modulation of nociceptive afferent over the short term and the ability for the
transmission to the central nervous system. patients to maintain his or her daily
[22]
Paungmali et al, found similar results activities without restrictions. [25] Tipton et
with improved pain-free grip, pressure pain al say that exercises increases the forces
threshold, and sympatho-excitation being transmitted to ligaments, tendons and
following mobilization with movement. [23] bones which help to maintain and increase
According to Rompe, mobilization is the strength and functional capacity of these
thought to produce sensory input sufficient structures. [26] Strengthening the damaged
to recruit and activate descending pain attachment of wrist extensors results in
inhibitory systems that result in some or all better repetitive wrist movements performed
of the pain relieving effects. [24] by the patients. Stretching minimizes
The mean difference in the Grip excessive internal strain to the tendon by
Strength of Group C patients (wrist optimizing tissue extensibility during
manipulation and progressive exercise) is stressful activity. According to
higher than Group B (progressive exercise) Stasinopoulous et al both strengthening and
and Group A (wrist manipulation) patients stretching are the main components of
at the end of 6 weeks. Statically there is exercise program because tendon must have
significant difference (critical F value= flexibility along with strength. [27]
6.1298) in the grip strength among Group Patients who were treated with
A, Group B and Group C patients with combination of Wrist Manipulation and
Tennis Elbow. This indicates that Progressive Exercises reported
combination of wrist manipulation and improvement in Pain, Grip Strength and
progressive exercises were effective Functional Disability score.
intervention methods. Pienimaki et al [15] has Positive effects of exercise program
also shown in their study that progressive for tendon injuries may be attributable to
exercises are more effective to decrease lengthening of muscle tendon unit by
pain, increase grip strength and improve stretching and strengthening exercise which
patient’s ability to work. The slow, could achieve loading effect within muscle
repetitive wrist and forearm stretching, tendon unit along with hypertrophy and
muscle conditioning and occupational increased tensile strength of the tendon.
exercises which is a more intensive program It may also improve collagen alignment of
to promote patients’ daily living and ability the tendon and stimulate collagen cross-
to work. linkage formation, both of which improve
The mean difference in the tensile strength. [28]
Functional Disability scores of Group C
patients (wrist manipulation and progressive CONCLUSION
exercise) is higher than Group B The result of the study shows that
(progressive exercise) and Group A (wrist combination of wrist manipulation and
manipulation) patients at the end of 6 progressive exercises were effective in
weeks. Statically there is a significant improving elbow pain and functional
difference (critical F value= 36.776) in disability related to Tennis Elbow. However
functional disability scores in Group C no statistically significant improvement in
Patients (wrist manipulation and progressive the Grip strength was found among the three
exercise). This indicates that wrist groups. Hence we can conclude that
manipulation and progressive exercises combination of wrist manipulation and

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Tanusree Basak et al. Comparative Efficacy of Wrist Manipulation, Progressive Exercises and Both Treatments
in Patients with Tennis Elbow

progressive exercises were better treatment Romanian Journal of Physical Therapy.

method in reducing elbow pain and 2013; 19 (31).
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ACKNOWLEDGEMENT(S) 10. Shiri R, Vikari-Junata E, Veronen H,
Our heartiest gratitude to Dr Shabnam Agarwal, HelioVarra M. Prevalence and
Director-Education, NIHS for providing the determinants of lateral and medial
continuous guidance for framing this epicondylitis: A population study.
manuscript. I would also like to express my American Journal of Epidemiology.
sincere thanks to all the faculty members of 2006;164(11):1065-1074.
NIHS and our family for their constant support 11. Brukner P and K. Khan. Clinical Sports
during preparation of this manuscript. Medicine. 4th edition. Sydney, McGraw-
Hill Book Company.1993.
Conflict of Interest: None declared 12. Vicenzino B. Lateral epicondylalgia: a
Source of funding: Nil musculoskeletal physiotherapy
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How to cite this article: Basak T, Pal TK, Saha B et al. Comparative efficacy of wrist
manipulation, progressive exercises and both treatments in patients with tennis elbow. Int J Health
Sci Res. 2018; 8(4):87-94.

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