I became interested in this topic due to a personal acquaintance who faced a similar issue. There was a 45-year-old male friend of mine who complained of pain in his right elbow joint. He had been diagnosed with Tennis elbow a year ago. As a professional Lawn Tennis player, he used to practice for 4 to 5 hours daily. Over the past year, he underwent medical and physiotherapy treatment. The physiotherapy treatment included ultrasound, strengthening exercises, stretching exercises, and manual techniques.
However, the pain did not completely go away, and whenever he resumed practice, the pain would worsen. This happened two to three times within the last year. After returning to the sport, he experienced increased pain and had to go back to the physiotherapy department. After the fourth physiotherapy session, he no longer wanted to resume practice. Despite negative test results for tennis elbow and having good wrist and elbow strength, he refused to start practicing again due to a fear of experiencing pain after performing backhand actions and rallies. He didn't want to quit Lawn Tennis, but he also hesitated to return to the sport due to the fear of reinjury or pain. Hence, it was suspected that he might be suffering from kinesiophobia.
To thoroughly assess his right elbow joint, we examined him in detail. Kinesiophobia refers to a condition in which a patient experiences an excessive, irrational, and disabling fear of engaging in physical movement and activities due to a perceived vulnerability to painful injury or reinjury. Kinesiophobia is commonly observed among patients with musculoskeletal pain and should be taken into consideration when designing and implementing rehabilitation programs. As part of the assessment, we administered the Tampa scale of Kinesiophobia to determine the level of kinesiophobia. The patient scored 52 on the scale.
Since the conservative rehabilitation procedure was not effective for him, we decided to incorporate Graded Motor Imagery (GMI) into the treatment, as suggested by Rayner and Smale (2017) in their blog on Lateral Epicondylalgia. GMI offers a novel approach to retrain the brain's cortical representation of the elbow and movements of the wrist and lower arm. By altering a patient's perception of pain, we can improve neuromuscular function.
Several studies have demonstrated the positive effects of GMI on kinesiophobia, pain, function in other conditions such as Osteoarthritis, Post radius fracture, and Elbow stiffness. However, there is limited research specifically focused on kinesiophobia treatment during rehabilitation. To provide effective rehabilitation for lateral epicondylalgia, it is necessary to consider both physiological and psychological factors as predictors of disability and rehabilitative outcomes. Instead of the traditional "bottom-up" approach that focuses on peripheral sources of pain, we need to acknowledge the "top-down" perspective, which emphasizes central processing in the cortex.
GMI is a treatment technique derived from this new perspective, aiming to normalize central processing and alleviate chronic pain. By incorporating GMI for kinesiophobia alongside conventional treatment, we can improve rehabilitation outcomes for Lateral Epicondylalgia patients.
Considering all the aforementioned factors, we provided the patient with Graded Motor Imagery along with other conventional treatments for a duration of six weeks following the GMI protocol by Mosley. After the second week, there was a noticeable change in the kinesiophobia score. However, by the fourth week, there was a significant clinical difference in the kinesiophobia score. The patient was able to resume practice, including backhand rallies, and expressed eagerness to participate in competitions. He had a district competition scheduled in two weeks, so we continued training him with the GMI protocol for an additional two weeks. Clinically, all his symptoms subsided, and he was able to fully engage in his activities. This case study serves as evidence for the success of this approach. Further research can be conducted to validate these findings statistically.
If kinesiophobia had been diagnosed early, the patient could have achieved complete recovery much earlier.
Take Away Message
Holistic management strategies that incorporate biomedical, psychosocial, and neuroscience aspects of pain and dysfunction should be included in the rehabilitation of patients with Lateral Epicondylalgia. The fear of not being able to return to a specific activity should not be overlooked, as a higher degree of kinesiophobia predicts the progression of disability over time.
A greater degree of kinesiophobia is associated with more pain, disability, and lower quality of life. Fear of movement leads to inactivity and a sedentary lifestyle, resulting in the loss of functional ability, strength, and quality of life, which can exacerbate pain. Therefore, screening for kinesiophobia should be a part of the basic musculoskeletal assessment for patients with Lateral Epicondylalgia. When designing and implementing rehabilitation programs for Lateral Epicondylalgia, kinesiophobia should be taken into consideration.