SCIENTIFIC/CLINICAL ARTICLES
JHT READ
FOR
CREDIT ARTICLE #077.
The Effect of Oscillating-energy Manual Therapy
on Lateral Epicondylitis: A Randomized,
Placebo-control, Double-blinded Study
Mohammad Reza Nourbakhsh, PT, PhD, OCS
Frank J. Fearon, PT, DHSc, OCS, FAAOMPT
Department of Physical Therapy, North Georgia College
and State University, Dahlonega, Georgia
Correspondence and reprint requests to Mohammad Reza
Nourbakhsh, PT, PhD, OC, Department of Physical Therapy,
North Georgia College and State University, Dahlonega, GA
30597; e-mail: <[email protected]>.
0894-1130/$ e see front matter Ó 2008 Hanley & Belfus, an imprint
of Elsevier Inc. All rights reserved.
doi:10.1197/j.jht.2007.09.005
4
JOURNAL OF HAND THERAPY
ABSTRACT: Symptoms of lateral epicondylitis (LE) are attributed
to degenerative changes and inflammatory reactions in the common extensor tendon induced by microscopic tears in the tissue after repetitive or overload functions of the wrist and hand extensor
muscles. Conventional treatments, provided on the premise of inflammatory basis of LE, have shown 39e80% failure rate. An alternative approach suggests that symptoms of LE could be due to
active tender points developed in the origin of hand and wrist
extensor muscles after overuse or repetitive movements. Oscillating-energy Manual Therapy (OEMT), also known as V-spread, is
a craniosacral manual technique that has been clinically used for
treating tender points over the suture lines in the skull. Considering symptoms of LE may result from active tender points, the purpose of this study was to investigate the effect of OEMT on pain,
grip strength, and functional abilities of subjects with chronic LE.
Twenty-three subjects with chronic LE (.3 mo) between ages of
24 and 72 years participated in this study. Before their participation, all subjects were screened to rule out cervical and other pathologies that could possibly contribute to their lateral elbow
pain. Subjects who met the inclusion criteria were randomized
into treatment and placebo treatment groups by a second (treating)
therapist. Subjects were blinded to their group assignment. Subjects in the treatment group received OEMT for six sessions. During each treatment session, first a tender point was located
through palpation. After proper hand placement, the therapist focused the direction of the oscillating energy on the localized tender
point. Subjects in the placebo group underwent the same procedure, but the direction of the oscillating energy was directed to
an area above or below the tender points, not covering the affected
area. Jamar Dynamometer, Patient Specific Functional Scale (PSFS),
and Numeric Rating Scale (NRS) were used to measure grip
strength, functional status, and pain intensity and limited activity
due to pain, respectively. The screening therapist who was blinded
to the subjects’ group assignment performed pretest, posttest, and
six-month follow-up measurements. Subjects in the treatment
group showed both clinically and statistically significant improvement in grip strength (p ¼ 0.03), pain intensity (p ¼ 0.006), function
(p ¼ 0.003), and limited activity due to pain (p ¼ 0.025) compared
with those in the placebo group. Follow-up data, collected after
six months, showed no significant difference between posttest
and follow-up measurements in functional activity (p ¼ 0.35),
pain intensity (p ¼ 0.72), and activity limitation due to pain
(p ¼ 0.34). Of all the subjects contacted for follow-up assessment,
91% maintained improved function and 73% remained pain free
for at least six months. OEMT seems to be a viable, effective, and
efficient alternative treatment for LE.
J HAND THER. 2008;21:4–14.
Lateral epicondylitis (LE), also known as tennis elbow, is a pathology characterized by pain over the
lateral aspect of the elbow, occurring in 1e3% of the
population.1 Although about 40e50% of tennis
players report experiencing LE in their lifetime, less
than 5% of all LE cases overall is related to playing
tennis.1,2 The highest incidence of diagnosed LE,
about 64%, was associated with work-related activities, which involve repetitive and high-load wrist
and hand functions.3e5
In spite of extensive research on this ailment, there
is no general agreement on the precise etiology and
pathophysiology of LE. Cyriax attributed the symptoms of LE to tissue inflammatory responses to
microscopic tears of common extensor tendon at its
attachment to the lateral epicondyle.6 This theory is
still viewed as a common cause of LE.2,7e9 It is believed that macro- or microscopic tear in the muscular or tendinous tissue initiates an inflammatory
response, which can be the source of symptoms in patients with LE.2 Others have indicated that the symptoms of LE could also be due to other factors such as
tissue deterioration, degenerative changes,10,11 and
scar tissue formation9 after injuries induced by repetitive and high-load motions, which were beyond the
adaptive capacity of the involved tissues.1,10,11
More than 40 treatment methods have been
recommended for LE.12 Common treatment approaches for LE include a single or a combination
intervention including ultrasound, stretching,
strengthening exercises, steroid injection, iontophoresis, friction message, and counterforce bracing.
Overall, conventional treatments emphasizing the reduction of tissue inflammatory reactions, have failed
in 10e30% of the cases.2,11,13 The use of ultrasound to
reduce pain and improve healing time in LE14 has
produced conflicting results.15e21 The effects of counterforce bracing on LE have been questioned.22
Counterforce bracing has been shown to be less effective than stretching and12 strengthening exercises,23
and to be no better than placebo braces.24 Steroid injections, which are widely used in chronic LE,25,26
have a 69% success rate reported in a 52-week
follow-up study.27 Different surgical procedures are
used in LE5,28,29 with an 8e17% reported failure
rates.29,30 Microscopic muscle fiber tears, as the assumed pathophysiology of LE,6 are expected to heal
in three to five days after the injury,31 whereas the
tendon injuries, due to decreased vascularization,
may take up to five weeks to heal.31 LE due to the inflammation secondary to soft tissue tears as the cause
should therefore resolve within a five-week period.
However, many cases of LE extend beyond the
normal tissue healing timeline into the chronic stages.
As an alternative pathophysiology, Chop2 suggests
that some of the symptoms of LE could be due to trigger point developed in the origin of the muscles attached to the lateral epicondyle after overuse or
localized fibrositis. Chaitow32 attributes development of such trigger points to increased sensitivity
of neural receptors in the muscle and its related connective tissue in response to overuse or sudden
changes in muscle length after prolonged contractions in a shortened position. Localized trigger points
could elicit pain when palpated, overloaded during a
strong contraction, or stretched during wrist and elbow movements.32,33 A previous study by the authors showed that treating the tender points in the
lateral elbow area with Neuroprobe could effectively
reduce symptoms of LE.34
Oscillating-energy Manual Therapy (OEMT), also
known as V-spread, is a standard technique for
treating tender points and dysfunctional sutures in
the skull in osteopathic manual medicine. In osteopathic literature, this technique is being defined as
‘‘Using force transmitted across the diameter of the
skull to accomplish sutureal gapping.’’35
This technique involves inducing a gentle oscillating impulse (energy), through a specific hand placement, across the cranium.36 Upledger37 described the
hand placements as being two electrodes, passing a
back-and-forth biomagnetic energy between them.
Recipients of such treatment report feeling an impulse
going back-and-forth between the practitioner’s hands
placed on their limb. The nature of such impulse, if they
are actually generated by the practitioner, has not been
investigated through scientific methods. Some have
speculated that the oscillating energy is due to
changes in direction of tissue fluid induced by hand
placement.38 Chaitow36 indicated that the oscillating
energy could be due to application of a very light (in
grams) alternating force to the contact areas by the
practitioner. Others have speculated that the oscillating energy could be due to interaction between the
patient’s and the practitioner’s biomagnetic fields.39
Despite anecdotal evidence from clinicians, the
effects of OEMT on somatic tender points have not
been scientifically investigated. The purpose of this
study was to investigate the effects of OEMT on LE.
Considering previous reports, attributing the symptoms of LE to somatic tender points,2,34 and the effects of OEMT on tender points, we hypothesized
that OMET would also improve grip strength, pain
intensity, functional ability, and limited arm activities
due to pain in patients with chronic LE. The results of
this study could validate the effects of OMET on somatic tender points and could provide evidence for
a viable alternative treatment for LE.
METHODS
Design of the Study
A randomized, placebo-controlled, double-blinded
design was used in this study. Two separate physical
therapists performed measurements and treatments.
One (the examiner therapist) conducted all the examination and measurements and the other (treating
therapist) performed the treatments. Subjects were
first examined by the examiner therapist; then subjects were randomly assigned into treatment or placebo groups by the treating therapist. Randomization
was performed by having subjects to draw a card out
JanuaryeMarch 2008
5
the last 24 hours before testing.42e46 For pain intensity, subjects rated their pain level on an 11-point
scale, with zero indicating no pain and ten indicating intolerable pain. According to Spadoni et al.,47
pain reduction greater than 3.0 units in the NRS
are considered clinically significant. A similar 11point scale was used for assessment of activity limitation due to pain, with zero representing severely
limited and ten representing no limited activities
due to elbow pain. These NRS scales are modeled
after pain questions from the SF36 and are identical to those used by Westaway et.al.42 in their
study validating the use of the PSFS with neck
patients.
of a set of cards marked as ‘‘Group A’’ or ‘‘Group B.’’
Subjects in group A received real treatments. Both
subjects and the measuring therapist were blinded to
the subjects’ group assignments. The treating therapist was blinded to the treatment outcomes throughout the entire data collection period.
Subjects
A total of twenty-three subjects with unilateral LE,
recruited through advertisement in the North-East
Georgia community, between the ages of 24 and 72
years participated in this study (Table 1). Almost all
subjects were involved in heavy or repetitive arm
movements either as part of their job or during recreational activities.
PROCEDURE
MATERIAL
Reliability Assessment for PSFS
The following instruments were used in this study:
A testeretest reliability of the PSFS adapted for use
with elbow injuries was conducted in ten subjects
(seven males and three females). After the initial
functional assessment, subjects were asked to complete a second PSFS survey at a different scheduled
time before initiation of their treatment.
1. A Calibrated Jamar Hand Dynamometer was used
to measure grip strength in the affected arm in the
standardized recommended position. The reliability and validity of this method have previously
been established.40,41 Grip strength was measured
three times. The average value of the measurements was used for data analysis.
2. An adopted PSFS was used to measure changes in
subjects’ functional abilities.42 The scale requires
the subjects to list three of their activities most affected by the injury. The level of difficulty for
each activity is rated on a scale of zero to ten,
with zero indicating having most difficulty and
ten denoting their ability of performing the task
as before the injury. The sum of the scores for the
three activities quantifies their functional status
at each testing period. Good-to-excellent reliability
and validity have been reported for the PSFS in
patients with neck, low back, and knee injuries.42e44 Using the PSFS in patients with knee problems, a minimum of 2.5 points in the PSFS score is
considered as Minimum Clinically Important
Difference.43 The reliability of the PSFS for elbow
injuries has not been previously reported.
Therefore, a within-study reliability assessment
was conducted, the results of which are reported
in Results.
3. The NRS was used to assess subjects’ pain intensity and limitation of activities due to pain during
Screening Process and Group Assignment
Before their participation, all subjects were
screened by an orthopedic clinical specialist for
proper diagnosis of LE and for ruling out other
pathologies that could possibly contribute to lateral
elbow pain. Each subjects’ diagnosis was confirmed
through conformation of area of pain to the origin of
the wrist and hand extensors on the lateral epicondyle. Distal radiation of symptoms into the forearm
was acceptable. Proximal upper extremity or neck
symptoms, however, were considered as exclusion
criteria. Additionally, three commonly used clinical
pain provocation tests, Cozen’s, Mill’s, and third
finger extension tests,48 were used to confirm diagnosis of LE. Subjects with a history of cervical pathology,
nerve entrapment syndromes, nonunion fractures,
surgical treatments for LE, and steroid injection for
elbow pain during the last six months before the
study were excluded.
Subjects who met the inclusion criteria and agreed
to participate in the study were randomly assigned
into a treatment or a placebo groups. Regardless of
TABLE 1. Descriptive Statistics
Number of Subjects
Groups
Treatment
Placebo
Duration of Symptoms (in Months)
Males
Females
Mean (SD)
Min
Max
Mean (SD)
Min
Max
6
8
5
4
51.7 (9.4)
52.4 (7.17)
39
44
72
63
17.1 (17.7)
20.3 (22.1)
3
3
60
60
Min ¼ Minimum; Max ¼ Maximum.
6
Age
JOURNAL OF HAND THERAPY
their group assignment, all the subjects were told that
if their symptoms did not improve, they would
receive an alternative treatment after being posttested. All subjects signed an informed consent
form approved by the Institutional Review Board of
North Georgia College and State University.
Oscillating-energy Manual Therapy
The OEMT (V-spread) was administered based on
the standard method described in many osteopathic
texts.36,37 During the OEMT treatments, the subject
was seated comfortably on a chair with the affected
arm resting on the treatment table. First, the point
of greatest tenderness on the subject’s lateral epicondyle was located through palpation. Then, the
therapist (orthopedic clinical specialist, trained in
craniosacral therapy) placed the index and middle
fingers of one hand, spread in a V-shape, around
the detected tender point, and placed the index finger
of the other hand in the medial side of the elbow, diagonally across the located tender point (Figure 1).
After hand placement, the therapist applied a very
gentle pressure, via his finger tips, to the tissue alternatively from the medial and lateral sides a few times
to initiate the back-and-forth impulse (energy) oscillation between the medial and lateral hands. At this
point (upon start of the oscillating movement), the
therapist stopped pressing on the tissue and allowed
the oscillatory impulse to continue, with no further
efforts from the therapist part, between the two
points of contact on the subject’s elbow (Figure 2).
At this point, the therapist could feel continued
back-and-forth oscillation of the impulse (energy) between the two points of contact on the limb. The therapist focused the direction of the oscillating energy
on the tender point by slightly moving the index finger on the medial side of the elbow. Treatment was
FIGURE 1. Hand position for OEMT. Therapist places
one hand with the fingers spread in a ‘‘V’’ shape around
the tender point over the lateral epicondyle and places
the index of the other hand over the medial side of the
elbow.
FIGURE 2. Arrows represent the direction of the oscillating energy between the two practitioner’s hand. By adjusting the hand position, the oscillating energy is focused on
the tender point (marked by X) surrounded by the practitioner’s index and middle fingers.
repeated a few times until the treated tender point
was not tender with palpation. Most of the subjects
were able to sense the oscillating energy across their
elbow. Most subjects described the sensation as feeling something moving back-and-forth across their
elbow between the points of contact. Subjects reported an initial increase in tenderness followed by
a decrease in pain over the treated area. Treatment
duration varied from point to point ranging from 30
seconds to 2 minutes. Treatment was repeated several
times until the treated point was not tender with palpation. The same procedure was repeated for all
identified tender points during each session. Each
treatment session, depending on the number of tender points explored and treated, took about 20e30
minutes. All subjects received six treatment sessions
in a two- to three-week period.
Placebo OEMT Treatment
Subjects in the placebo group underwent the exact
procedure explained above. The only difference was
that after locating the point of greatest tenderness,
therapist placed his index and middle finger, spread
in V-shape, away from the located tender point and
no oscillating energy was directed to the affected
area. For subjects to have a sense of a treatment being
provided, the therapist applied a very gentle pressure to the tissue and imparted periodic short-duration (about 5 seconds) oscillation to the nonaffected
areas. Due to subtle nature of the treatment, subjects
in the placebo group were also asked if they felt the
oscillating energy across their limb. Most of the
subjects could feel the oscillation. However, in contrast to the treatment group, this oscillating energy
had a short duration and it was not focused on
the tender points. Subjects in the placebo group had
the same number of treatment sessions as those in the
treatment group.
JanuaryeMarch 2008
7
Data Analysis
In addition to random assignment of subjects into
treatment and placebo group, to assure equality of
baseline measures, independent t-tests were used to
compare baseline grip strength, functional level, pain
intensity, and pain limited activity between the
treatment and placebo groups.
We performed repeated measure analysis to compare pretest and posttest data for grip strength, pain
intensity, limited activity due to pain, and functional
ability variables within treatment and placebo groups.
For between group assessments, first the amount of
improvement in each variable was determined by
subtracting the posttest score from the pretest score.
Considering group and improvement in each variable
as the two factors for statistical analysis, we used twoway Multivariate Analysis of Variance (MANOVA),
followed by Tukey post hoc analysis, to compare
mean improvement in the four dependent variables
between the treatment and placebo groups.
functional abilities of subjects with LE in this study.
Statistical analysis of pretest data showed no significant difference in any of the baseline measures for
grip strength (p ¼ 0.22), functional level (p ¼ 0.89),
pain intensity (p ¼ 0.85), and pain limited activity
(p ¼ 0.80) between the treatment and placebo groups.
Pretest and Posttest Analysis
Figures 2e6 compare the mean values of pretest
and posttest measurements for grip strength, pain intensity, limitation of activity due to pain, and functional ability in treatment and placebo groups. In
the treatment group, a significant improvement was
found in grip strength (p ¼ 0.04), pain intensity
(p ¼ 0.000), functional abilities (p ¼ 0.004), and in limited activity due to pain (p ¼ 0.000). None of these
variables showed a significant change in the placebo
group (p . 0.05). Detailed descriptive statistics are
presented in Table 2.
Treatment and Placebo Group Comparison
Follow-up Study
RESULTS
The amount of improvement (posttest measures
minus pretest measures) observed for each dependent
variable in the treatment and placebo groups are presented in Figure 7. Post hoc analysis, following the
two-way MANOVA, showed a significant difference
in grip strength (p ¼ 0.03), pain intensity (p ¼ 0.006),
limited activity due to pain (p ¼ 0.025), and functional
level (p ¼ 0.003) between the treatment and placebo
groups.
Subjects
Follow-up Analysis
Descriptive statistics related to the subjects in the
treatment and placebo groups are presented in Table
1. Eleven subjects were randomly assigned to the
treatment; and 12 subjects to the placebo group. It
should be noted that, although not intentional, the
sample recruited for this study represents a population of chronic LE subjects. The typical subject reported a mean duration of symptoms greater than
12 months. Therefore, the results may be limited to
treatment of chronic LE. All subjects reported previous, unsuccessful treatment, ranging from rest, physical therapy, and cortisone injections. None of the
subjects, however, were involved in any other form
of treatments during the course of this study. There
was no significant difference (p . 0.05) in baseline
values (pretest) for grip strength, pain intensity, functional level, and limited activity due to pain between
the treatment and control groups.
Of the 11 subjects contacted for follow-up assessment, ten subjects (91%) maintained improved function and eight subjects (73%) remained pain free
for at least six months. Paired t-test did not show
any significant difference between posttest and
Reliability Assessment
Intraclass correlation coefficient analysis, ICC (3,1)
showed a high reliability (ICC ¼ 0.91; 95% confidence
interval ¼ 0.57e0.98) of using PSFS survey to assess
8
JOURNAL OF HAND THERAPY
120
Grip Strength (lb/in2)
Follow-up data were collected six months posttreatment from subjects in the treatment group. The
same questionnaire related to functional (PSFS), pain
intensity (NRS), and limitation of activity due to pain
(NRS) assessments was used to collect follow-up data.
Pretest
Posttest
100
80
60
40
20
0
OEMT
POEMT
Treatment
FIGURE 3. Pretest and posttest measurements for grip
strength in treatment and placebo groups. OEMT ¼
Oscillating-energy Manual Therapy; POEMT ¼ Placebo
Oscillating-energy Manual Therapy.
10
Pretest
Posttest
8
30
7
6
PSFS Score
Pain Intensity
(Numeric Rating Scale)
40
Pretest
Posttest
9
5
4
3
2
20
10
1
0
OEMT
POEMT
Treatment
FIGURE 4. Pretest and Posttest measurements for pain
intensity strength in treatment and placebo groups.
OEMT ¼ Oscillating-energy Manual Therapy;
POEMT ¼ Placebo Oscillating-energy Manual Therapy.
follow-up measurements for functional activity (mean
posttest ¼ 29.2 6 6.0, mean follow-up ¼ 27.0 6 7.7;
p ¼ 0.35); pain intensity (mean posttest ¼ 1.41 6 1.16,
mean follow-up ¼ 1.16 6 1.85; p ¼ 0.72); and limited
activity due to pain (mean posttest ¼ 8.83 6 1.02,
mean follow-up ¼ 9.16 6 1.19; p ¼ 0.34).
DISCUSSION
Grip Strength
During grip, wrist extensor muscles originating
from the lateral epicondyle work, as wrist fixators, in
synergy with the finger flexor muscles.3,49 The impairment of these muscles due to LE, therefore, could
result in decreased grip strength.15e17,19,23,50 In this
10
Pretest
Posttest
Activity Level
(Numeric Rating Scale)
9
8
7
6
5
4
3
2
1
0
OEMT
POEMT
Treatment
FIGURE 5. Pretest and posttest measurements for activity
limitation due to pain in the treatment and placebo groups.
Higher scores indicate improved overall activity with no
pain. OEMT ¼ Oscillating-energy Manual Therapy;
POEMT ¼ Placebo Oscillating-energy Manual Therapy.
0
OEMT
POEMT
Treatment
FIGURE 6. Pretest and Posttest measurements for functional activity level in treatment and placebo groups.
OEMT ¼ Oscillating-energy Manual Therapy;
POEMT ¼ Placebo Oscillating-energy Manual Therapy.
study, subjects in the treatment group showed a significant improvement (p ¼ 0.04) in grip strength
(16% increase) after two weeks of treatment with
OEMT. Other investigators, using conventional
physical therapy treatments16,23,27,51e56 or steroid injection57,58 for treatment of LE, have reported significant improvement in grip strength after six to weeks
of interventions.23,27 According to Vicenzino51 early
pain relief, as was found in this study, could have
motivated the subjects to use their arm more often
during daily activities, resulting in improved muscle
strength. Similar early recovery of grip strength, in
patients with LE, has been reported by Tsui and
Leung,59 using electro-acupuncture treatments.
Other investigators, however, have reported no significant changes in grip strength in patients treated
for LE.24,58,60e65
Controversial reports of improvement in grip
strength after providing different treatments or
even in studies using the same treatments57,58,60
may suggest that the possibility of improvement
in grip strength could be pathology related.
Pienimaki et al.50 showed that, in subjects with
LE, changes in grip strength were more associated
with having a positive wrist extension test than
with having a positive Mill’s test in the preliminary
evaluation. Contraction of wrist extensors is required to contrast with flexion moment acting on
the wrist, induced by finger flexors, maintaining
the functional position of the wrist during forceful
grip. Reduced pain in the origin of the wrist extensor muscles enhances mechanical advantage of the
finger flexor muscles, resulting in a stronger grip.
Therefore, it can be speculated that grip strength
measurements with LE are likely measuring pain
rather than true changes in muscle strength. More
JanuaryeMarch 2008
9
TABLE 2. Statistics for Dependent Variables in the Treatment and Placebo Groups
Group
Variables
Pretest (Mean 6 SD)
Posttest Mean (SD)
p-Value*
Treatment group
Grip strength
Pain intensity
Functional level
Pain limited activity
61.3 6 38.7
5.1 6 2.66
14.7 6 8.9
5.2 6 2.8
73.6 6 30.9
2.0 6 1.8
29.2 6 6.0
8.5 6 1.1
0.04
0.000
0.000
0.004
Placebo group
Grip strength
Pain intensity
Functional level
Pain limited activity
81.1 6 26.6
4.6 6 2.3
17.6 6 9.2
6.1 6 2.2
79.2 6 28.0
4.1 6 3.1
22.3 6 10.3
6.0 6 2.9
0.50
0.44
0.055
0.94
*p-Values reported from repeated measure analysis.
studies are needed to determine factors involved in
grip strength after treatments for LE.
Pain Intensity
In this study, subjects in the treatment group
showed 3.1 units of pain reduction, based on the
NRS, compared with almost no improvement in pain
intensity in the placebo group (Table 2). According to
Spadoni et al.,47 pain reduction greater than 3.0 units
in the NRS are considered clinically significant.
Therefore, our findings of 3.1 units (p ¼ 0.000) decrease in pain intensity in the treatment group compared with almost no improvement (0.5 units,
p ¼ 0.44) in the placebo group indicate both statistically and clinically significant effect of OEMT on
reducing pain intensity in subjects with LE.
Functional Improvement
Improvement
(Mean Postetest - Mean Pretest)
In this study, the treatment group as a whole demonstrated remarkable significant improvement in functional activities (mean of 14.7 at pretest vs. 29.3 at
posttest, p ¼ 0.000) and in limited activity due to pain
(mean of 5.2 at pretest vs. 8.6 at posttest, p ¼ 0.002).
A positive effect of OEMT treatment on function
abilities was assessed using two methods: PSFS and
the global limitation of activities during the previous
24 hours. It is worth noting that Westaway et al.42
30
OEMT
POEMT
20
10
0
-10
Grip Strength
Pain Intensity
Activity Level
PSFS Score
Dependent Variables
FIGURE 7. Level of improvements in the tested variables
between treatment and placebo groups. OEMT ¼ Oscillating-energy Manual Therapy; POEMT ¼ Placebo Oscillating-energy Manual Therapy. Error bars present standard
errors.
10
JOURNAL OF HAND THERAPY
recommended that a generic- or condition-specific
functional rating tool be used in conjunction with
the PSFS when group decision making is a goal.
Therefore, the authors used the 24-hour limitation
of activity NRS scale to measure generic activity limitation along with the PSFS. The global scale provides
a standardized and reliable method to quantify activity limitations due to pain and has demonstrated
good reliability and validity with a number of
pathologies.42,45,46
Stratford et al.44 and others42,43 have demonstrated
usefulness of the PSFS in assessment of functional
improvements in neck, low back, and knee rehabilitation. This study is the first to demonstrate testeretest
reliability of using PSFS for measuring functional
changes with an elbow pathology (refer to Results).
The PSFS provides what may be more impressive
evidence of functional improvement. Caution,
however, must be used when interpreting PSFS
scores. The scale is intended to measure changes
within an individual and not between groups.
Nevertheless, Stratford et al.44 have demonstrated
the tool’s usefulness in measuring meaningful functional improvement.
Effects of OEMT
This study showed that OEMT could significantly
improve the symptoms of chronic LE in a relatively
short period of time. It is worth noting that all the
subjects had a history of previous unsuccessful conventional treatments before their participation in this
study. These findings indicate that OMET could be a
viable, effective, and efficient alternative treatment
for LE.
Several mechanisms, although highly speculative,
have been proposed to explain the effects of OEMT
(V-spread) on somatic pain and dysfunction.
Traditionally, this technique has been used in osteopathic craniosacral therapy for releasing restricted
cranial sutures. This technique involves specific hand
positioning and inducing a gentle oscillating impulse
across the cranium. Upledger37 described the therapist hand placement as being two electrodes passing
a fluctuating energy across the head, causing CSF
fluctuation within the cranium. It is proposed that
with appropriate hand placement, the fluctuating
CSF is directed toward the treatment area to release
articular restrictions.37 This mechanism of effect, although being advocated by craniosacral therapist,
cannot explain the effects of OEMT on somatic tender
points in other areas besides the cranium.
Dowling66 proposed a modified version of this technique called Progressive Inhibition of Neuromuscular
Structures (PINSs). Dowling,66 presenting a few case
studies supporting effectiveness of PINS technique in
treating somatic tender points after car accidents, suggested that this technique could be used for treating
tender points and somatic dysfunctions in the skull,
trunk, and extremities. Dowling66 attributed the effects
of PINS to the mild pressure applied to the tissue,
working as a counter irritant, leading to muscle relaxation via tissue accommodation and habituation or via
reflexive inhibition of motor neuron pool of the hypertonic muscle. These assumptions, however, cannot explain our findings of improved pain and function in
subjects with LE. If the effects of OEMTwere due to habituation or reflexive inhibition of the muscles, similar
improvements would have been expected in subjects in
the control group. These subjects acquired the same
hand placement and application of mild pressure to
the tissue, as the treatment group, but did not receive
any oscillating energy.
OEMT is based on the belief that the therapist is
imparting oscillating biomagnetic energy; therefore,
its mechanism of effect could be speculated through
the effects of such energy, projected from the therapist hands,39 on tender points and tissue healing. The
effects of electromagnetic fields on tissue healing,67
synthesis of growth factor,68 bone healing,69 and
connective tissue repair70 have be documented.
Oschman,71 however, indicated that the healing effect
of electromagnetic fields on tissue healing is frequency specific. According to Sickens and Walker72
for optimum healing, nerves respond to 2 Hz, bones
to 7 Hz, ligaments to 10 Hz, skin to 15 Hz, and capillaries to 20 and 75 Hz electromagnetic signals.
Oschman asserted that electromagnetic signals ranging in frequency from 0.3 to 30 Hz, with most signal
having a frequency of 7e8 Hz, can be omitted from
the hands of practitioners of therapeutic touch.39
The frequency of the electromagnetic fields emitted
from the practitioner’s hands corresponds well with
the electromagnetic frequency for soft tissue healing.
We speculate the improved symptoms of LE in this
study could be attributed to the effects of such frequency-specific electromagnetic signals on soft tissue
healing. Considering significant findings of this
study, OEMT could be a potential effective technique
for treating musculoskeletal dysfunctions. However,
further research is needed to explain the mechanism
of effect and to confirm the therapeutic effects of electromagnetic signals emitted from a practitioner’s
hands on other musculoskeletal problems.
Conclusion
This randomized, placebo-controlled, doubleblinded study has demonstrated both clinically
and statistically significant improvements in grip
strength, pain intensity, function, and activity tolerance in subjects with chronic LE after OEMT treatment compared with placebo treatment. These
findings indicate that OEMT could be a viable, effective, and efficient alternative treatment for symptoms
of chronic LE.
Limitations
Despite the significant effects demonstrated in this
study, a larger sample size would improve the generalizability of the findings.
Due to subtle nature of the imparted oscillating
energy, effective use of OEMT requires some training
and experience. A novice practitioner in this field
might have difficulty sensing the oscillating energy
and properly administering the technique without
adequate training. In this study, all treatments were
provided by an experienced therapist. More studies
are needed to establish consistency of technique
across multiple practitioners.
More scientific and clinical studies are needed to
explore the mechanism of effect and to further assess
the effects of OMET on somatic pain and dysfunction
associated with other pathologies.
Acknowledgment
The authors would like to thank the following graduate
students at North Georgia College and State University for
their assistance in this research: Alexis Gaines, Matthew R.
Marchman, Leon Romero, and John Stuart.
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JHT Read for Credit
Quiz: Article # 077
Record your answers on the Return Answer Form
found on the tear-out coupon at the back of this
issue. There is only one best answer for each
question.
#1. The subjects in this study were
a. consecutively assigned into 2 groups all of
whom had lateral epicondylitis for less than
3 months
b. randomly placed into one of 2 groups all of
whom had lateral epicondylitis for 3 months
or longer
c. divided into 3 groups: a chronic, an acute, and
a sub acute group
d. all treated with a steroid injection plus
OEMT
#2. The subjects were evaluated with the following
instruments
a. Jamar Dynamometer, MMT, and EMG
b. NRS, PSFS, and MMT
c. MMT, EMG, and PSFS
d. NRS, PSFS, and the Jamar Dynamometer
14
JOURNAL OF HAND THERAPY
#3. At 6 months posttesting the subjects demonstrated ___vs scores at the end of treatment
a. a significant increase in function
b. a significant decrease in function
c. no significant change in function
d. significant anesthesia over the lateral elbow
area
#4. At 6 months posttesting the subjects demonstrated ___vs scores at the end of treatment
a. an increase in pain
b. no significant change in pain
c. a decrease in pain
d. an increase in ROM
#5. The authors present conclusive evidence as to the
pathological process responsible for the pain of
lateral epicondylitis
a. true
b. false
When submitting to the HTCC for re-certification,
please batch your JHT RFC certificates in groups
of 3 or more to get full credit.