Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38961.584653.AE (Published 02 November 2006) Cite this as: BMJ 2006;333:939All rapid responses
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Dear Editor,
I have a major issue with the published article, which appears to ignore
whole body function and addresses Tennis Elbow as a single localised
condition.
While researching Pain and Low Back Pain (1, 2) our group started at
the basic questions of 1) Why does a muscle not rip out of its
attachments? 2) How Ivan Pavlov’s 1910 Lecture identified the orienting
response activating whole body functions to internal and external
environmental changes, results in coordinated body activity and not
isolated muscle actions.
Adding the simple concept that a new born baby is a complete
neuromuscular system, responding by orienting to environmental changes;
which learns each and every movement by repetition of combined actions,
until they pass to unconscious complex conditioned reflexes, (eg, standing
to walking to driving and writing, musicianship, craftsmanship, etc). Pain
management is similarly learnt, but as a subservient, parallel neural
system. (2)
Obviously the functional adult body operates as one single unit in
Pavlov’s learnt coordinated manner, responding to both internal and
external environmental changes. 'Tennis elbow' is a classical example of
this as a whole body function.
Injury/pain produces internal environment change to the
mechanoreceptor and nociceptor inputs from the muscle attachments at the
periosteum, which causes afferent dorsal horn stimulation, leading to
midbrain activation of the autonomic and sensory-motor systems; resulting
in efferent feedback modulation to prevent increased muscle
contraction/damage, often before conscious awareness of the injury occurs.
Tennis Elbow is an excellent example of this process.
We found that after injecting patients with chronic low back pain (2)
it often relieved their neck pain, carpal tunnel syndrome and tennis or
golfer's elbow.
We considered the issue from the above first principles and published(3)
our surprising findings with a proposed explanation, supported by over 300
clinical cases.
Tennis Elbow must be considered as a whole body response to strain or
injury at the lateral epicondyle attachments resulting in secondary
activation of the autonomic and other nervous system areas with the
efferent result being the clinically perceived syndrome. The published
article appears to have considered Tennis Elbow as a localised condition
without appreciating the whole body mechanisms and as such must be
challenged.
References:
1. McKay AB, Wall D, The orienting response and the functional whole human
body. Australasian Musculoskeletal Med. November 2003,8(2):86-99.
2. McKay AB, Pain and chronic low back pain: a new model? Part 1 and Part
2 Australasian Musculoskeletal Med. May 2004, 9(1):14-25
3. McKay AB. Tennis Elbow Everywhere, Australasian Musculoskeletal
Med. November 2005, 10(2:127-130
These references are available in .pdf if required for assessment.
Competing interests:
None declared
Competing interests: No competing interests
Congratulations on your paper: very helpful. I decline to inject
tennis elbows
even when one is postively requested, unless the patient undertakes to
completely discontinue the offending activities for at least 2 weeks. I
have found
any less rigorous advice results in inevitable recurrence. Since you
allowed
'gradual' return to normal activities and also permitted a second
injection 2
weeks after the first, I suspect that you did not optimise the response to
injection.
Just a thought.
Michael Snaith
Competing interests:
None declared
Competing interests: No competing interests
Re: tennis elbow: What is it?
Surely we should carefully define what the problem is before we
treat/research anything. The references attached to Bisset et al
demonstrates a very confused concept with respect to Tennis Elbow
aetiology and pathophysiology.
1. Is it a purely local phenomenon and no other part of the body
is involved as per reductionist medicine; OR
2. Is it a whole body response to damage via mechanoreceptive/
nociceptive activations passing via dorsal horn amplification to mid-brain
and then either/and higher centres for conscious recognition and via
autonomic and modulated motor mid-brain efferents back for attempted self
repair, resulting in swelling, chemical changes and increased afferent
responses again... causing nocioceptive wind-up?
This whole body response was originally identifed by Pavlov 1904-1916
in his Lectures, then defined neurophysiologically by de Bono in his
Mechanism of Mind 1969 and seemingly forgotten by modern reductionists!
Once the 'Tennis Elbow' definition problem is clarified then and only
then can we make logically and useful EBM findings and not merely add to
the current confused literature.
Competing interests:
None declared
Competing interests: No competing interests