Friday, February 3, 2012

Parkour

Parkour (sometimes abbreviated PK) is a method of movement focused on moving around obstacles with speed and efficiency. Originally developed in France, the main purpose of the discipline is to teach participants how to move through their environment by vaulting, rolling, running, climbing and jumping. Traceurs (parkour practitioners) train to be able to identify and utilize alternate or the more efficient paths. Parkour can be practiced anywhere, but areas dense with obstacles offer many different training opportunities.

Overview

Two primary characteristics of parkour are efficiency and speed. Traceurs take the most direct path through an obstacle as rapidly as that route can be traversed safely. Developing one's level of spatial awareness is often used to aid development in these areas. Also, efficiency involves avoiding injuries, both short and long term. This idea embodying parkour's unofficial motto is être et durer ("to be and to last").
Traceurs say that parkour also influences one's thought processes by enhancing self-confidence and critical-thinking skills that allow one to overcome everyday physical and mental obstacles.[1][2][3] A study by Neuropsychiatrie de l'Enfance et de l'Adolescence (Neuropsychiatry of Childhood and Adolescence) in France reflects that traceurs seek more excitement and leadership situations than do gymnastic practitioners.[4]

Terminology

The first terms used to describe this form of training were "l'art du déplacement" and "le parcours".[5] The term "parkour" (French pronunciation: [paʁˈkuʁ]) was coined by Hubert Koundé. It derives from "parcours du combattant", the classic obstacle course method of military training proposed by Georges Hébert.[6][7][8]
A practitioner of parkour is called a "traceur" [tʁasœʁ], with the feminine form being "traceuse" [tʁasøz]. They are substantives derived from the French verb "tracer", which normally means "trace",[9] or "trail" (as in "he escaped without a trace").[10]

Historical precedents

In the film Jump London, Sébastien Foucan states that "Le Parkour has always existed, free running has always been there, the thing is that no one gave it a name, we didn’t put it in the box. It is an ancient art [...] The Neanderthals, to hunt, or to chase, or to move around, they had to practice the free run." The latter was also an inspiration for the famous on-foot chase scenes of Hong Kong stuntman, martial artist and actor Jackie Chan.[11] In Eastern martial arts such as Ninjutsu and Qing Gong, movements similar to those of Parkour have been taught for centuries and with a similar aim. In Jump London, Foucan does acknowledge the influence of martial arts movies on the development of Parkour: "We also climbed onto the roof of our school. We pretended we were Ninja warriors".

A "traceur" performing a "passe muraille"

[edit] Hébert's legacy

Before World War I, former naval officer Georges Hébert travelled throughout the world. During a visit to Africa, he was impressed by the physical development and skills of indigenous tribes that he met:[12] He noted, "their bodies were splendid, flexible, nimble, skillful, enduring, and resistant but yet they had no other tutor in gymnastics but their lives in nature." [12]
On May 8, 1902, Saint-Pierre, Martinique, where Hébert was stationed, suffered from a volcanic eruption of Mount Pelée. Hébert coordinated the escape and rescue of some 700 people. This experience had a profound effect on him, and reinforced his belief that athletic skill must be combined with courage and altruism. He eventually developed this ethos into his motto "être fort pour être utile" (" be strong to be useful").[12] Inspired by indigenous tribes, Hébert became a physical education tutor at the college of Reims in France. He began to define the principles of his own system of physical education and to create various apparatuses and exercises to teach his "méthode naturelle"[12] which he defined as: "Methodical, progressive and continuous action, from childhood to adulthood, that has as its objective: assuring integrated physical development; increasing organic resistances; emphasizing aptitudes across all genres of natural exercise and indispensable utilities (walking, running, jumping, quadrupedal movement, climbing, equilibrium (balancing), throwing, lifting, defending and swimming); developing one's energy and all other facets of action or virility such that all assets, both physical and virile, are mastered; one dominant moral idea: altruism."[13]
Hébert set up a "méthode naturelle" session consisting of ten fundamental groups: walking, running, jumping, quadrupedal movement, climbing, balancing, throwing, lifting, self-defense, swimming, which are part of three main forces:[13]
  • Energetic or virile sense: energy, willpower, courage, coolness, and firmness
  • Moral sense: benevolence, assistance, honor, and honesty
  • Physical sense: muscles and breath
During World War I and World War II, Hébert's teaching continued to expand, becoming the standard system of French military education and training. Thus, Hébert was one of the proponents of "parcours", an obstacle course, developed by a Swiss architect,[14] which is standard in the military training and led to the development of civilian fitness trails and confidence courses.[12] Also, French soldiers and firefighters developed their obstacle courses known as "parcours du combattant" and parcours SP".[15]

[edit] Belle family


David Belle, parkour founder, at The New Yorker Festival
Raymond Belle was born in Vietnam, at the time part of French Indochina. His father died during the First Indochina War and Raymond was separated from his mother during the division of Vietnam in 1954. He was taken by the French Army in Da Lat and received a military education and training that shaped his character.[16] After the Battle of Dien Bien Phu, Raymond was repatriated to France and completed his military education in 1958. At age 19, his dedication to fitness helped him serve in Paris's regiment of "sapeurs-pompiers" (the French fire service).[16]
David participated in activities such as martial arts and gymnastics and sought to apply his athletic prowess for some practical purpose. He trained extremely hard mostly to try to win the approval of his father (Raymond).[15] At age 17, David left school seeking freedom and action. He continued to develop his strength and dexterity in order to be useful in life, as Raymond had advised him.[15]

[edit] Development in Lisses

After moving to Lisses commune, David Belle continued his journey with others who would later form the group the Yamakasi.[15] Sébastien Foucan noted in Jump London "From then on we developed and really the whole town was there for us; there for parkour. You just have to look, you just have to think, like children." This, as he describes, is "the vision of parkour."
In 1997, Yann Hnautra, Charles Perriere, Chau Belle, David Belle, Laurent Piemontesi, Sébastien Foucan, Guylain Perriere, Malik Diouf and Williams Belle created the group Yamakasi,[17] whose name comes from the Lingala language of Congo, and means "strong spirit, strong body, strong man, endurance". After the musical show Notre Dame de Paris, Belle and Foucan split up due to money and disagreements over the definition of "l'art du déplacement",[18] The film Yamakasi (2001), and the French documentary Génération Yamakasi were created without Belle and Foucan.[citation needed]

[edit] Philosophy and theories

According to Williams Belle, the philosophies and theories behind parkour are an integral aspect of the art, one that many non-practitioners have never been exposed to. Belle trains people because he wants "it to be alive" and for "people to use it".[3] Châu Belle explains it is a "type of freedom" or "kind of expression"; that parkour is "only a state of mind" rather than a set of actions, and that it is about overcoming and adapting to mental and emotional obstacles as well as physical barriers.[3]
A newer convention of parkour philosophy has been the idea of "human reclamation".[19] Andy (Animus of Parkour North America) clarifies it as "a means of reclaiming what it means to be a human being. It teaches us to move using the natural methods that we should have learned from infancy. It teaches us to touch the world and interact with it, instead of being sheltered by it."[19]"It is as much as a part of truly learning the physical art as well as being able to master the movements, it gives you the ability to overcome your fears and pains and reapply this to life as you must be able to control your mind in order to master the art of parkour."[20]
A point has been made about the similarities between the martial arts philosophy of Bruce Lee and Parkour.[21] In an interview with The New Yorker, David Belle acknowledges the influence of Lee's thinking: "There’s a quote by Bruce Lee that’s my motto: ‘There are no limits. There are plateaus, but you must not stay there, you must go beyond them. A man must constantly exceed his level.’ If you’re not better than you were the day before, then what are you doing—what’s the point?".[22]

[edit] Non-rivalry

A campaign was started on 1 May 2007 by Parkour.NET portal[23] to preserve parkour's philosophy against sport competition and rivalry.[24] In the words of Erwan LeCorre: "Competition pushes people to fight against others for the satisfaction of a crowd and/or the benefits of a few business people by changing its mindset. Parkour is unique and cannot be a competitive sport unless it ignores its altruistic core of self development. If parkour becomes a sport, it will be hard to seriously teach and spread parkour as a non-competitive activity. And a new sport will be spread that may be called parkour, but that won't hold its philosophical essence anymore."[23] According to LeCorre, those who truly practice Parkour have the same mind aspect of each other, therefore it brings people to work together rather than compete, it allows them to be united internationally and forget the social and economical problems which separated them globally, ultimately leading one giant community working and growing together.

[edit] Free running

Free running is a form of urban acrobatics in which participants, known as free runners, use the city and rural landscape to perform movements through its structures. The term free running was coined during the filming of Jump London, as a way to present parkour to the English-speaking world. Parkour's emphasis on efficiency distinguishes it from the similar practice of free running, which places more emphasis on freedom of movement and creativity.
The man who coined the phrase, Sébastien Foucan, defines free running as a discipline for self development, of following your own way[citation needed]. His dissatisfaction with the limited creativity and self-expression in Parkour was the motivation for Sebastian Foucan to develop a similar but also very different art of movement that became known as free running.[25] He notes "Understand that this form of art has been created by few soldiers in Vietnam to escape or reach: and this is the spirit we'd like parkour to keep. You have to make the difference between what is useful and what is not in emergency situations. Then you'll know what is parkour and what is not. So if you do acrobatics things on the street with no other goal than showing off, please don't say it's parkour. Acrobatics existed a long time ago before parkour."[6]
When questions are raised between the differences of parkour and free running, the Yamakasi group deny the differences and say: "parkour, l'art du deplacement, free running, the art of movement... they are all the same thing. They are all movement and they all came from the same place, the same nine guys originally. The only thing that differs is each individual's way of moving". [26]

[edit] Military training

After the attention that parkour received following the film Casino Royale, militaries from different countries began looking for ways to incorporate parkour into training. The British Royal Marines hired parkour athletes to train their members.[27] Colorado Parkour began a project to introduce parkour into the U.S. military[28] and parkour is slowly being introduced into the United States Marine Corps.[29]

[edit] Criticism

Parkour is not widely practiced in dedicated public facilities such as skateparks. Although efforts are being made to create places for it, most Traceurs do not like the idea as it is contradictory to the philosophy of freedom. [30] Traceurs practice parkour in urban areas such as gyms, parks, playgrounds, offices, and abandoned structures. Concerns have been raised regarding trespassing, damage of property,[31] and the practice in inappropriate places.[32] However, most traceurs will take care of their training spots and will remove themselves quickly and quietly from a public place if asked.[33][34] The Magpie Youth Centre free running club in Glen Parva, Leicester has raised 40,000 Euros to build a free running park/training utility on the park opposite the youth center.
Concerns have been raised by law enforcement and fire and rescue teams of the risk in jumping off high buildings.[35] They argue that practitioners are needlessly risking damage to both themselves and rooftops by practicing at height, with police forces calling for practitioners to stay off the rooftops. [36][37][38] Some figures within the parkour community agree that this sort of behaviour is not to be encouraged.[37][39][40][41]
American traceur Mark Toorock says that injuries are rare "because participants rely not on what they can't control – wheels or the icy surfaces of snowboarding and skiing – but their own hands and feet," but Lanier Johnson, executive director of the American Sports Medicine Institute, notes that many of the injuries are not reported.[42] Even when injuries do occur, many members in the parkour community encourage pursuing the most scientifically sound method to recovery and future prevention. [43]
Comedian Daniel Tosh made fun of the discipline on one episode of his show, Tosh.0, calling it "Nothing more than extreme walking."

[edit] Movements

There are fewer pre-defined movements in parkour than in gymnastics, as there is no list of "moves". Each obstacle a traceur faces presents a unique challenge, committed Tracuers tend to shy away from defining movement. The ability to overcome the challenge depends on multiple factors, for example, on body type, speed, angle of approach, the physical make-up of the obstacle. Parkour is about training the body and mind to react to those obstacles appropriately with a technique that is effective. Often that technique cannot and need not be classified and given a name. In many cases effective parkour techniques depend on fast redistribution of body weight and the use of momentum to perform seemingly difficult or impossible body maneuvers at great speed. Absorption and redistribution of energy is also an important factor, such as body rolls when landing which reduce impact forces on the legs and spine, allowing a traceur to jump from greater heights than those often considered sensible in other forms of acrobatics and gymnastics.
According to David Belle, the practice is to move in such a way that will help you gain the most ground as if escaping or chasing something. Also, if you go from A to B, you need to be able to get back from B to A,[44] but not necessarily with the same movements or "passements". Despite this, there are many basic versatile and effective techniques that are emphasized for beginners. Most important are good jumping and landing techniques. The roll, used to limit impact after a drop and to carry one's momentum onward, is often stressed as the most important technique to learn.


 


 

 

 

Basic movements

Some movements defined in parkour are:[45]
Synonym Description
French French pronouncation English
Atterrissage [ateʁisaʒ] Landing Bending the knees when toes make contact with ground (never land flat footed; always land on toes and ball of your foot, or whole footed).
réception [ʁesɛpsjɔ̃]
Équilibre [ekilibʁ] Balance Walking along the crest of an obstacle; literally "balance."
Équilibre de chat
Cat Crawl Quadrupedal movement along the crest of an obstacle.
Franchissement [fʁɑ̃ʃismɑ̃]Z Underbar Jumping or swinging through a gap between obstacles; literally "to cross" or "to break through."
Lâché [laʃe] Lache Hanging drop; lâcher literally meaning "to let go." To hang or swing (on a bar, on a wall, on a branch) and let go, dropping to the ground or to hang from another object. This can refer to almost all hanging/swinging type movements.
swing
Passe muraille [pas myʁaj] Pop vault, wall hop, Wallpass, wallrun Overcoming a tall structure, usually by use of a step off the wall to transform forward momentum into upward momentum, then using the arms to climb onto and over the object.

Dyno (shortened from "Dynamic[clarification needed]", opposite to "Static") This movement comes from climbing terminology, and encompasses leaping from a position similar to an armjump, then grabbing an obstacle usually higher than the initial starting place, often used for an overhang. This movement is used when a simpler movement is not possible.
Passement [pasmɑ̃] Vault, Pass To move over an object with one's hand(s) on an object to ease the movement.
Demitour [dəmi tuʁ] Turn vault A vault or dropping movement involving a 180° turn; literally "half turn." This move is often used to place yourself hanging from an object in order to shorten a drop or prepare for a jump.
Turn Down
Passement
Speed vault To overcome an obstacle by jumping side-ways first, then placing one hand on the obstacle to self-right your body and continue running.


Thief To overcome an obstacle by using a one-handed vault, then using the other hand at the end of the vault to push oneself forwards in order to finish the move.
Lazy vault
Saut de chat [sod ʃa] Cat pass/jump, (king) kong vault, monkey vault The saut de chat involves diving forward over an obstacle so that the body becomes horizontal, pushing off with the hands and tucking the legs, such that the body is brought back to a vertical position, ready to land.
Passement assis Dash vault This vault involves using the hands to move oneself forwards at the end of the vault. One uses both hands to overcome an obstacle by jumping feet first over the obstacle and pushing off with the hands at the end. Visually, this might seem similar to the saut de chat, but reversed. Allegedly David Belle has questioned the effectiveness of this movement.
Saut de chat inversé Reverse vault A vault involving a 180° rotation such that the traceur's back faces forward as they pass the obstacle. The purpose of the rotation is ease of technique in the case of otherwise awkward body position or loss of momentum prior to the vault.


Kash vault This vault is a combination of two vaults; the kong vault and the dash vault. After pushing off with the hands in a kong vault, the body continues past vertical over the object until the feet are leading the body. The kash vault is then finished by pushing off the object at the end, as in a dash vault.
Planche [plɑ̃ʃ] Muscle-up To get from a hanging position (wall, rail, branch, arm jump, etc.) into a position where your upper body is above the obstacle, supported by the arms. This then allows for you to climb up onto the obstacle and continue.
climb-up
Roulade [ʁulad] Roll A forward roll where the hands, arms and diagonal of the back contact the ground, often called breakfall. Used primarily to transfer the momentum/energy from jumps and to minimize impact, preventing a painful landing. It is similar to the basic kaiten or ukemi and it was taken from martial arts such as judo, ninjutsu, jujutsu, hapkido and aikido.
Saut de bras [sodbra] Arm jump To land on the side of an obstacle in a hanging/crouched position, the hands gripping the top edge, holding the body, ready to perform a muscle up.
cat leap
cat grab
Saut de fond [sodfɔ̃] Drop Literally 'jump to the ground' / 'jump to the floor'. To jump down, or drop down from something.
Saut de détente [sodə detɑ̃t] Gap jump, running jump To jump from one place/object to another, over a gap/distance. This technique is most often followed with a roll.
Saut de précision [so d presiziɔ̃] Precision Static or moving jump from one object to a precise spot on another object. This term can refer to any form of jumping however. Often abbreviated to "pre"
précision [presiziɔ̃]
Saut de mur
Wall Jump To step off a wall in order to overcome another obstacle or gain height to grab something
Tic-Tac
Saut de rotation
Rotary jump Similar to a kong vault, the person dives and then rotates their lower body around the obstacle. Used for shorter to medium obstacles. For people that have trouble with kong vaults.
Rotary vault


Side vault A vault where the person is parallel to the obstacle and places one hand on the obstacle. When performing the vault, the person's back should be facing down.

பரோட்டா பிரியர்களுக்கு ஓர் எச்சரிக்கை



பரோட்டா பிரியர்களுக்கு ஓர் எச்சரிக்கை !!!!!!!!!!!!!
தினமும் இரவு பரோட்டா சாப்பிட்டால் தான் சாப்பிட்ட திருப்தி கிடைக்கிறதா?
இன்று தமிழகம் முழுவதும் பரவலாக காணபடுகிறது பரோட்டா கடை ,அந்த பரோடாவும் ஊருக்கு ஊர் எத்தனை வகை ,அளவிலும் சுவையிலும் எத்தனை வேறுபாடு
விருதுநகர் பரோட்டா ,தூத்துக்குடி பரோட்டா ,கொத்து பரோட்டா ,சில்லி பரோட்டா ,சொல்லும்போதே நாவில் நீர் ஊறுமே .
பரோட்டாவின் கதை என்ன தெரியுமா
பரோட்டா என்பது மைதாவால் செய்யப்படும் உணவாகும். இது தமிழகம் எங்கும் கிடைக்கிறது. இரண்டாம் உலகப் போரின் போது ஏற்பட்ட கோதுமைப் பற்றாக்குறையால், மைதா மாவினால் செய்யப்பட்ட உணவுகள் தமிழகத்தில் பரவலாகப் பயன்படத் தொடங்கின; பரோட்டாவும் பிரபலமடைந்தது.
பரோட்டா பொதுவாக எப்படி செய்வார்கள்?
மைதா மாவுல உப்பு போட்டு, தண்ணி விட்டு பிசைஞ்சு, அப்புறம் எண்ணெய் விட்டு, உருட்டி, ஒவ்வொரு உருண்டையையும் தட்டி, அடித்து, பெரிய கைக்குட்டை போல் பறக்க விட்டு, அதை அப்படியே சுருட்டி, திரும்ப வட்ட வடிவில் உருட்டி, தோசைக்கல்லில் போடுவார்கள்.

இப்போது பரோட்டாவின் மூலபொருளான மைதாவில் தான் பிரச்சனை துடங்குகிறது.
பரோட்டா மட்டும் இல்லது இன்னும் பல வகை உணவு வகைகள் இந்த கொடிய மைதா வில் இருந்து தயாரிக்கபடுகிறது ,நம் பிறந்த நாளுக்கு கொண்டாட வாங்கும் கேக் உட்பட .

மைதா எப்படி தயாரிகிறார்கள் ?

நன்றாக மாவாக அரைக பற்ற கோதுமை மாவு மஞ்சள் நிறத்தில் இருக்கும் அதை பனசாயல் பெரோசிடே (benzoyl peroxide ) என்னும் ரசாயினம் கொண்டு வெண்மை யாகுகிறார்கள்,அதுவே மைதா .


Benzoyl peroxide நாம் முடியில் அடிக்கும் டை யில் உள்ள ரசாயினம்
இந்த ராசாயினம் மாவில் உள்ள protein உடன் சேர்ந்து நிரழிவு க்கு காரணியாய் அமைகிறது .


இது தவிர Alloxan என்னும் இரசாயனம், மாவை மிருதுவாக கலகபடுகிறது மேலும் Artificial colors, Mineral oils, Taste Makers, Preservatives , Sugar, Saccarine , Ajinomotto போன்ற உப பொருட்களும் சேர்க்க படுகிறது ,இது மைதாவை இன்னும் அபயகரமகுகிறது .


இதில் Alloxan சோதனை கூடத்தில் எலிகளுக்கு நிரழிவு நோய் வரவைபதற்கு பயன்படுகிறது ,ஆக பரோட்டா வில் உள்ள Alloxan மனிதனுக்கும் நிரழிவு வர துணை புரிகிறது .

மேலும் மைதாவில் செய்யும் பரோட்டா சீரணத்துக்கு உகந்தது அல்ல ,மைதாவில் நார் சத்து கிடையாது , நார் சத்து இல்லா உணவு நம் சிரண சக்தியை குறைத்து விடும் .


இதில் சத்துகள் எதுவும் இல்லை குழந்தைகளுக்கு இதனால் அதிக பாதிப்பு உள்ளது , எனவே குழந்தைகளை மைதா வினால் செய்த bakery பண்டங்களை உன்ன தவிர்பது நல்லது.

Europe union,UK,China இந்த மைதா பொருட்கள் விற்க தடை விதித்துள்ளன .


மைதா நாம் உட்கொள்ளும் போது சிறுநிரக கள் ,இருதய கோளறு ,நிரழிவு போன்றவை வருவதற்கு பல வாய்ப்புகள் உண்டு .
நமது அண்டை மாநிலமான கேரளத்தில் பரோட்டாவின் தீமைகள் குறித்து இப்போதே பிரச்சாரம் செய்ய தொடங்கி விட்டனர்.மேலும் மைதாவை அதன் தீமைகள் குறித்து ஆராச்சி செய்து ஆய்வறிக்கையும் சமர்ப்பித்துள்ளனர்.


இப்போது ஆவது நாமும் விழித்து கொள்வோம் நம் தலைமுறை காப்போம்.

நண்பர்களே ஆரோக்கியமான நம் பாரம்பரிய கேப்பை, கேள்வரகு ,கம்பு உட்கொண்டு அந்நிய உணவான பரோட்டாவை புறம் தள்ளுவோம் .
இந்த பதிவை உங்கள் நண்பர்களுடன் பகிர்ந்து விழிப்புணர்வு செய்யுங்கள் .

Saturday, January 28, 2012

Joint Manipulation in the Management of Lateral Epicondylalgia: A Clinical Commentary

Joint Manipulation in the Management of Lateral Epicondylalgia: A Clinical Commentary
Bill Vicenzino, PT, PhD, Joshua A. Cleland, PT, PhD, OCS, FAAOMPT, and Leanne Bisset, PT, MPhty (Sports)
Address all correspondence and request for reprints to: Bill Vicenzino, Division of Physiotherapy, University of Queensland, QLD 4072 Australia. E-mail: b.vicenzino@uq.edu.au
Lateral epicondylalgia or tennis elbow is a prevalent musculoskeletal disorder that is characterized by lateral elbow pain often associated with gripping tasks. The underlying pathology remains to be fully elucidated; however, evidence indicates that the disorder does not involve an inflammatory process but rather impairments of the pain and motor systems as well as morphological changes in the structure of both the extensor carpi radialis brevis muscle and tendon. Although the most efficient management approach remains controversial, there is a growing body of literature reporting the effects and underlying mechanisms of joint manipulation in the management of lateral epicondylalgia. Evidence exists demonstrating that joint manipulation directed at the elbow and wrist as well as at the cervical and thoracic spinal regions results in clinical alterations in pain and the motor system. In addition to presenting this evidence, this paper describes proposed underlying physiological mechanisms of joint manipulation associated with the observed clinical effects. We propose that this information will be useful for the physical therapist in making clinical decisions regarding the selection of treatment technique for the management of patients with lateral epicondylalgia.
Key Words: Tennis Elbow, Joint Mobilization, Joint Manipulation, Manual Therapy
Lateral epicondylalgia (LE), epicondylitis, or tennis elbow is a musculoskeletal disorder often encountered by healthcare practitioners, such as physical therapists, and is characterized by pain over the lateral elbow that is typically aggravated by gripping activities1. The syndrome is most prevalent (35–64% of all cases) in jobs requiring repetitive manual tasks, it results in restricted function, and it is one of the more costly of all work-related illnesses24. The peak incidence of this condition occurs between the ages of 35 and 50 and usually affects the dominant arm5.
Formerly called lateral epicondylitis, lateral epicondylalgia or epicondylar tendinopathy are more appropriate terms considering that numerous studies69 have shown the absence of inflammatory cells in this disorder. It has, therefore, been suggested that the term epicondylitis be abandoned in favor of ‘epicondylalgia1,10,11. Recent evidence suggests that the symptoms associated with LE might be related to a constellation of changes in the extensor carpi radialis brevis and common extensor tendon mechanism. These have been reported to include signs of neurogenic involvement12 as a result of chemical mediators of pain located in myelinated sensory fibers (e.g., substance P and calcitonin gene-related peptide)12,13 and increased levels of glutamate (an excitatory amino acid)14, neovascularisation15, and changes in muscle fiber morphology (e.g., fiber necrosis, higher percentage of fast twitch oxidative fibers, and moth eaten fibers)16. Impairments in the sympathetic nervous system (e.g., absent vasomotor response)17 and the presence of mechanical but not thermal hyperalgesia further point to the involvement of the pain and/or sensory systems in this condition18,19.
Currently, no general consensus exists as to the most appropriate management strategy for LE, even though several systematic reviews have been published. A review conducted by Bisset et al20 identified evidence for the use of elbow manipulation2122 and therapeutic exercise23 in the short term and recommended that the long-term effects of joint manipulation be studied. Other limitations with the current literature include poor methodological quality (i.e., lack of experimental rigor), a finding that has changed little since an earlier systematic review by Labelle24.
Interestingly, in a recent commentary on management of LE, Ashe et al25 listed a number of treatment approaches that included patient education, splinting, modalities (e.g., ice, LASER, and high-voltage galvanic stimulation), strengthening, and stretching. Noteworthy was the omission of joint manipulation from their list. Perhaps this may be related to the fact that LE has long been conceptualized as a musculotendinous disorder and the traditional focus of joint manipulation has been the direct influence upon joint structures rather than musculotendinous tissues26.
Since the last clinical commentary on a manual therapist's perspective on LE27, a significant number of studies21,22,2844 have investigated the effects of joint manipulation of the elbow and wrist as well as of the cervical and thoracic spines. The purpose of this paper is to comment on current research investigating the effects of joint manipulation, to elaborate on the hypothesized physiological mechanisms contributing to these clinical effects, and to present a clinical reasoning process to the technique selection that is based on the patient's clinical presentation. The commentary will provide clinicians with a rationale to refine decision-making regarding the incorporation of joint manipulation for the management of LE.

Manipulation of the Elbow
Mill's manipulation, which is reported to be in widespread use45, is a small-amplitude high-velocity thrust performed at the end of elbow extension while the wrist and hand are held flexed46. It targets the common extensor tendon and is usually coupled with transverse friction massage with a view to freeing scar tissue. Stasinopoulos and Stasinopoulos47 recently evaluated the clinical efficacy of this manipulation and friction massage compared to a supervised eccentric exercise program or treatment by polarized polychromatic non-coherent (Bioptron) light in 75 patients with tennis elbow. Their data showed that the manipulation/friction massage combination is no better than the Bioptron light, which are both substantially inferior to the exercise program. This finding is in line with that of a previous study48.
One particular manipulative therapy technique that has been receiving considerable attention in the literature in the management of LE is Mulligan's Mobilization with Movement (MWM)49. The MWM technique is a non-thrust manipulative technique performed in the following fashion: The therapist first identifies a physical activity that the patient reports to be painful. Most often this entails the patient clenching the fist, a task that is frequently impaired in LE26. The patient is next instructed to perform the identified painful task while the therapist provides a laterally directed glide to the elbow (Figure (Figure1).1). Preliminary findings have suggested that the orientation of the lateral glide and the amount of manual force applied by the therapist is critical to the effective application of this technique29,33. Directing the lateral glide force somewhat posterior or directly lateral is most effective29. A manual force of 1.9N/cm applied during the glide (standardized to the circumference of the patient's proximal forearm in cm), which was approximately two-thirds of the maximum force that the practitioner was willing to apply, has been shown to maximize the hypoalgesic effect33. The MWM is typically repeated for 6 to 10 repetitions per visit and then repeated over several follow-up sessions. Perhaps most critically, the MWM should be repeated as part of a home exercise program between physical therapy visits26,29,49.

Fig. 1
Fig. 1
The lateral glide Mobilization With Movement treatment technique for lateral epicondylalgia being applied during the performance of a grip force test on a dynamometer.
Several placebo-controlled studies22,34 and a case-series29 have demonstrated that a single application of the MWM for LE results in an immediate increase in pain-free grip force (strength). Pain-free grip force has been shown to be a valid and sensitive method of assessing clinically important change over time and correlates with the patient's perceived rating of change in those with LE50. These studies have also reported an initial reduction in pressure pain thresholds over the lateral epicondyle22,34, improved range during upper limb neurodynamic testing (using the radial nerve bias test)34, and sympathoexcitation34 with the MWM technique.
Vicenzino and Wright44 initially investigated the effects of a course of MWM treatments on the outcomes of pain and function in a patient with LE using a single-subject design. The results were encouraging and demonstrated that the MWM technique, in addition to a self-MWM technique performed at home, resulted in rapid reduction in pain and the improved function that followed. In a quasi-randomized clinical trial, Kochar and Dogra32 assigned 66 patients with LE to receive ultrasound and exercise therapy or ultrasound, exercise, and MWM for a period of 3 weeks. At the conclusion of treatment, the group receiving joint manipulation demonstrated a reduction in pain over the past 24 hours as measured by a visual analog scale score of 5.9 cm, which was significantly greater than the ultrasound and exercise group (1.7 cm). A 5.9 cm reduction in pain exceeds the clinically meaningful level of improvement in acute pain conditions by 4-fold5154. The difference in pain scores between groups remained significant at the 12-week follow-up.
Recently, Bisset et al55 studied the short-term (6 weeks) and long-term (3 to 12 months) effects of 8 sessions of MWM and exercise in a randomized clinical trial of 198 patients with LE. MWM and exercise was compared to a corticosteroid injection group and a group who followed a wait-and see policy. There was a significant advantage of MWM and exercise over wait-and-see at 6 weeks with a Number Needed to Treat (NNT) of 3. That is, the practitioner would have to treat 3 patients with MWM and exercise in order to have one more successful outcome than if they advised the patient to adopt the wait and see approach. The NNT varied from 2 to 4 for MWM and exercise over injection in the long term. Over the entire 12-month period on an area-under-the-curve analysis (i.e., the product of outcome data by time over the entire 12 months), a blinded assessor judged the MWM and exercise to maximally reduce the severity of LE compared to the other treatments. Pain-free grip force was also optimally improved by MWM and exercises over the entire year. Patients in the MWM and exercise group were apparently more satisfied with their treatment since they sought out fewer other treatments. MWM and exercise also had significantly fewer recurrences (5/66) than did the injection group (47/65), which represents a 90% reduction in the risk of recurrence following corticosteroid injection. The relative risk reduction rate provides an estimate of the probability of a particular event (in this case recurrence of the condition) in one group divided by the probability of the same event in another group. In this case the relative risk reduction of recurrence was 90% for patients receiving MWM and exercise.

Manipulation of the Wrist
Preliminary evidence exists for the use of a scaphoid thrust manipulation technique in the treatment of LE. In a pilot study, Struijs et al36 randomly assigned 31 patients with LE to receive either scaphoid thrust manipulation or a multi modal treatment approach consisting of ultrasound, friction massage, and strengthening exercises. All patients underwent 9 treatments over a 6-week period. At the termination of physical therapy, the group receiving scaphoid manipulation exhibited significantly less pain during the day measured by visual analogue scale. The success rates (i.e., the proportion of patients reporting complete recovery or much improvement) in the two groups were not significantly different (i.e., manipulation 85% versus comparison 67%), but this is possibly a type II error.

Manipulation of the Cervicothoracic Spine
Studies describing involvement of the cervicothoracic spine in patients with LE have either reported the prevalence of cervical spine impairments in patients with LE (mostly made as observations or comments in clinical trials), or have investigated the clinical effectiveness of spinal manipulation treatment31,41,56,57. In one of the first studies to consider addressing cervical spine impairments in patients with LE, Gunn and Milbrandt31 treated 50 patients with a multimodal treatment package that included non-thrust manipulation and traction of the cervical spine, isometric neck exercises, and hot packs/ultrasound to the cervical spine, for an average period of 5.3 weeks. The results demonstrated that 86% (43/50) of patients reported a good (resuming previous occupation) or satisfactory (light duties or other occupation) improvement following treatment, which persisted at a 6-month follow-up. It should be recognized that all these patients exhibited recalcitrant LE, having failed other management approaches, even surgery in some cases. However, this study was not randomized, nor did it control for the possible natural history of the disorder, and thus it represents a low level of evidence.
More recently, in a pilot study by Cleland et al58, 10 patients with LE were randomly assigned to receive treatment solely directed at the elbow or treatment directed at the elbow plus manipulation (non-thrust) of the cervicothoracic spine. All patients underwent 10 physical therapy sessions over 6 weeks, and the outcomes were captured at baseline as well as at 6 and 26 weeks. The results at discharge (6 weeks) showed improvements in pain-free grip force and on the Disability of the Arm, Shoulder, and Hand questionnaire but not on the pain rating scale; the results favored the group receiving the cervicothoracic spine manipulation. No inferential statistical analyses were performed as a result of the small sample size. Interestingly, a previous retrospective audit30 of the outcome in 112 patients with LE revealed that the addition of spinal manipulation treatment (in 51 patients) resulted in significantly fewer visits (P<0.01), despite a similar success rate in both groups (80% and 75%). The spinal manipulation techniques directed at the cervical spine included passive physiological intervertebral mobilization techniques (80% of patients), MWM techniques (30% of patients), and muscle energy techniques (52% of patients). In contrast, Rompe et al56 have shown that adding spinal manipulative therapy (passive mobilization therapy and traction of cervical and cervico-thoracic spine) to low-energy shock wave therapy did not alter the outcome of treatment56. However, the LE patients were not randomized to the manipulation group in that study56; therefore, it cannot be confidently stated that the spinal manipulation did not provide added benefit.
In a number of randomized control trials of the initial effects of neck manipulation (non-thrust) for LE, Vicenzino and colleagues22,3743 investigated the lateral cervical glide technique described by Elvey59. The technique is performed with the patient in supine and with the involved upper limb placed in a neurodynamic test position purported to preferentially stress or load the radial nerve59,42. With the arm in this position, the therapist applies lateral cervical glides at a frequency of 1.3HZ42 at C5/C6 toward the contra-lateral side of symptoms (Figure (Figure2).2). In an initial study41, this technique was shown to result in an improved range of motion of the neurodynamic test, reductions in 24-hour pain on a visual analogue scale, and an increase in pressure pain thresholds (digital pressure algometry) to a significantly greater magnitude than the placebo group. In a follow-up study38, the cervical lateral glide technique not only resulted in significant improvements in pressure pain threshold and increases in pain-free grip force, but it also produced a sympathoexcitatory response across sudomotor, cutaneous vasomotor, cardiac, and respiratory functions. It should be emphasized that, with the exception of the 24-hour follow-up for pain measures, both of the aforementioned studies only investigated effects immediately post-application of the cervical lateral glide techniques; therefore, long-term follow-ups are needed.

Fig. 2
Fig. 2
The cervical spine lateral glide (oscillation at approximately 1.3Hz) applied to the C5/6 motion segment.
A noteworthy observation is that patients with LE who have concomitant cervical articular impairments or neck pain have a poorer prognosis. One reason for this is that the impairments and neck pain are often neglected in the treatment of a patient with LE57,60. Waugh et al57 conducted a multi-center prospective cohort study of 83 patients with LE and reported that although the practitioners identified cervical impairment in 57% of patients, only 37% actually received treatment directed at the cervical spine57. Smidt et al60 followed 349 patients from two randomized clinical trials61,62 in order to better understand prognostic indicators of outcome; they found, that at the 12-month follow-up, one of the strongest contributors to persistent symptoms identified by the multivariate prediction model was concomitant neck pain. Interestingly, the patient's neck pain was not treated in these randomized clinical trials. The foregoing evidence highlights to practitioners that the cervicothoracic spine region should be considered in the clinical assessment and management of LE.

Physiological Rationale
While the true physiological effects of manipulative therapy may not yet be clearly elucidated, it is tempting to speculate on the physiological rationale as to why patients with LE respond favorably to such techniques directed at different anatomical regions. First, it is speculated that the pain associated with LE might be associated with altered neuronal afferent input to the spine19,63. Perhaps applying manipulation techniques to the elbow, wrist, and cervicothoracic spine may assist in reducing abnormal afferent input64, resulting in a reduction of the symptoms associated with LE.
A number of double-blind, placebo-controlled, repeated measures studies34,3740,6568 have assessed sympathetic nervous system activity in an attempt to quantify the physiological effects of spinal and extremity manipulation techniques. Many of these studies34,38,68 have demonstrated that spinal manipulation produces a statistically significant hypoalgesic effect and a concomitant sympathoexcitatory response when compared to a placebo or control group. Interestingly, there was a strong association between the hypoalgesic and sympathoexcitatory effects, with a confirmatory factor analysis correlation of 0.82 (P=0.05)38. A similar response has also been demonstrated with MWM of the elbow joint35. In a number of follow-up studies, which used methods to discern involvement of endogenous opioids, such as naloxone blockade and tolerance34,35,43,69,70, the hypoalgesic effect was found to be non-opioid in nature. Subsequently, an animal study of knee manipulation for capsaicin-induced foot hyperalgesia reported that the substrates of the hypoalgesic effect were non-opioid in nature, involving both serotonergic- and noradrenergic-mediated descending pain inhibition pathways71. This was further supported by the finding that spinal gammaaminobutyric acid receptors were not involved in the hypoalgesia71. The evidence of a concomitant effect38 and the data from the animal study71 provide a reasonable level of support for the dorsal periaquaductal gray area of the midbrain as a coordinating center for the manipulation-induced pain relieving effects and for the idea that the studied techniques constitute an adequate stimulus for a non-opioid, endogenous descending pain inhibition system69.
The notion that there exists only one physiological mechanism for manipulative therapy is improbable; the most reasonable explanation is that joint manipulation techniques result in a complex multi-system physiological response69,72,73. In support of this statement, Abbot et al28 in a single-group repeated-measures design, showed that an MWM applied to the elbow in patients with LE resulted in a significant increase of shoulder external rotation immediately following the procedure, inferring that the treatment has also a somewhat distributed neuro-motor effect. Application of the MWM technique to the unaffected elbow of sufferers of unilateral LE resulted in a small reduction in grip strength22,29, implying that the effect on the neuro motor system is not present in pain-free elbows and that it may not be, as proposed by Slater et al72, a post-exercise motor facilitation in response to the repeated muscle contractions performed during the MWM treatment. Further research is required to explore the significance of these initial findings in terms of the underlying mechanism of joint manipulation.

Using Pain System Impairments in Manipulation Technique Selection
Regardless of the fact that the theoretical constructs underlying manipulative therapy are not yet clearly understood, the evidence of benefit in the use of these techniques continues to expand. The question then arises as to when should various manipulative techniques be directed at the elbow and when should they be directed at the cervicothoracic spine? We speculate that possible subgroups of patients with homogenous clinical presentations may exist, who will respond differently to various forms of manipulative therapy. Under this schema, the practitioner has essentially three choices when incorporating manipulative therapy into the management of LE: peripheral (elbow ± wrist), spinal (cervical, thoracic), or a combination of both peripheral and spinal manipulations. Based on current evidence and clinical observation, we speculate that LE patients can be classified into different subgroups, which will determine their response to each of the manipulations.
The first classification is those patients who are likely to respond positively to peripheral treatments. We propose that patients exhibiting greater affected to unaffected side-to-side deficits in pain-free grip force relative to pressure pain thresholds are candidates for the MWM technique directed at the elbow22,26,74. This is based on studies that showed that the effects of the MWM technique22,34 produced a much greater improvement in pain-free grip force relative to pressure pain thresholds. Vicenzino et al34 demonstrated that the MWM technique resulted in a increase in pain-free grip force of 58% compared to an increase in pressure pain threshold of only 10%. Similarly, in a study by Paungmali et al34, patients who were treated with the MWM technique experienced a 47% increase in painfree grip force following the treatment while the pressure pain threshold only exhibited a 9% change.
The second classification is patients who are likely to respond to a cervical lateral glide manipulation. Vicenzino et al38 demonstrated that patients receiving this treatment exhibited an improvement in pressure pain threshold of 29% while pain-free grip force only improved to a magnitude of 11%. Perhaps patients presenting with greater pressure pain threshold deficits relative to pain-free grip force deficits should first be treated with manipulative therapy techniques directed at the cervical spine.
The third classification of patients would be those who exhibit similar deficits in both pressure pain threshold and pain-free grip force and who might require treatment directed at both the peripheral and spinal joints. In this case continued re-examination would be especially warranted to ascertain if one treatment should take precedence over another26. Clearly, this classification system is in its infancy and must be investigated further prior to widespread clinical implementation.

Future Research
Future research studies should further investigate the long term effects of manipulative therapy techniques directed at the spine as well as at the periphery. In addition, these studies should incorporate exercises that have shown to be beneficial and may serve to augment the rehabilitation process23. Future studies should identify predictor variables identifying which patients are most likely to respond rapidly and favorably to joint manipulation techniques directed to either the peripheral or spinal joints. In addition, only one of the studies36 reported in this commentary used any form of high-velocity techniques with purported effects at the joint and was solely directed at the wrist. Future studies should compare the outcomes associated with thrust techniques directed at the elbow and cervicothoracic spine.

The literature, and in particular that reporting research of joint manipulation techniques in LE, has greatly increased over the 20 years. This growth in the literature provides an opportunity for practitioners to base clinical decisions on data that is more advanced in its inferential capabilities. For example, practitioners may approach the application of joint manipulations to the spine and peripheral joints with greater confidence of at least deriving short-term effects in pain-free grip force and pressure pain thresholds. The physiological rationale for these effects has also progressed and can now be more plausibly used in explaining clinically observable effects. Despite these advances, there remains much to be studied before there is solid evidence to support the use of joint manipulations in the treatment of LE. Until such data becomes available, we propose that practitioners base clinical decisions on a sound clinical examination and evidence from the literature as presented herein.
1. Waugh EJ. Lateral epicondylalgia or epicondylitis: What's in a name? J Orthop Sports Phys Ther. 2005;35:200–202. [PubMed]
2. Dimberg L. The prevalence and causation of tennis elbow (lateral humeral epicondylitis) in a population of workers in an engineering industry. Ergonomics. 1987;30:573–580. [PubMed]
3. Feuerstein M, Miller VL, Burrell LM, Berger R. Occupational upper extremity disorders in the federal workforce: Prevalence, health care expenditures, and patterns of work disability. J Occup Environ Med. 1998;40:546–555. [PubMed]
4. Kivi P. The etiology and conservative treatment of humeral epicondylitis. Scand J Rehabil Med. 1982;15:37–41. [PubMed]
5. Haker E. Lateral epicondylalgia: Diagnosis, treatment and evaluation. Critical Rev Phys Rehabil Med. 1993;5(2):129–154.
6. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow): Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999;81:259–278. [PubMed]
7. Nirschl R, Pettrone F. Tennis elbow: The surgical treatment of lateral epicondylitis. J Bone Joint Surg. 1979;61A:832–839. [PubMed]
8. Potter HG, Hannafin JA, Morwessel RM, DiCarlo EF, O'Brien SJ, Altchek DW. Lateral epicondylitis: Correlation of MR imaging, surgical, and histopathologic findings. Radiology. 1995;196:43–46. [PubMed]
9. Regan W, Wold LE, Coonrad R, Morrey BF. Microscopic histopathology of chronic refractory lateral epicondylitis. Am J Sports Med. 1992;20:746–749. [PubMed]
10. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the “tendinitis” myth: Painful, overuse tendon conditions have a noninflammatory pathology. BMJ. 2002;324(7338):626–627. [PMC free article] [PubMed]
11. Vicenzino B, Wright A. Lateral epicondylalgia I: A review of epidemiology, pathophysiology, aetiology and natural history. Phys Ther Rev. 1996;1:23–34.
12. Ljung BO, Alfredson H, Forsgren S. Neurokinin 1-receptors and sensory neuropeptides in tendon insertions at the medial and lateral epicondyles of the humerus: Studies on tennis elbow and medial epicondylalgia. J Orthop Res. 2004;22:321–327. [PubMed]
13. Ljung BO, Forsgren S, Friden J. Substance P and calcitonin gene-related peptide expression at the extensor carpi radialis brevis muscle origin: Implications for the etiology of tennis elbow. J Orthop Res. 1999;17:554–559. [PubMed]
14. Alfredson H, Ljung BO, Thorsen K, Lorentzon R. In vivo investigation of ECRB tendons with microdialysis technique: No signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop Scand. 2000;71:475–479. [PubMed]
15. Zeisig E, Ohberg L, Alfredson H. Extensor origin vascularity related to pain in patients with tennis elbow. Knee Surg Sports Traumatol Arthroscopy. 2006;14:659–663.
16. Ljung BO, Lieber RL, Friden J. Wrist extensor muscle pathology in lateral epicondylitis. J Hand Surg. 1999;24B:177–183.
17. Smith RW, Papadopolous E, Mani R, Cawley MI. Abnormal microvascular responses in a lateral epicondylitis. Br J Rheumatol. 1994;33:1166–1168. [PubMed]
18. Sran M, Souvlis T, Vicenzino B, Wright A. Characterisation of chronic lateral epicondylalgia using the McGill pain questionnaire, visual analog scales, and quantitative sensory tests. Pain Clinic. 2002;13:251–259.
19. Wright A, Thurnwald P, Smith J. An evaluation of mechanical and thermal hyperalgesia in patients with lateral epicondylalgia. Pain Clinic. 1992;5:221–227.
20. Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005;39:411–422. [PMC free article] [PubMed]
21. Paungmali A, O'Leary S, Souvlis T, Vicenzino B. Naloxone fails to antagonise initial hypoalgesic effect of a manual therapy treatment for lateral epicondylalgia. J Manipulative Physiol Ther. 2003;27:180–185. [PubMed]
22. Vicenzino B, Paungmali A, Buratowski S, Wright A. Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia. Man Ther. 2001;6:205–212. [PubMed]
23. Pienimaki T, Tarvainen T, Siira P, Vanharanta H. Progressive strengthening and stretching exercises and ultrasound for chronic lateral epicondylitis. Physiother. 1996;82:522–530.
24. Labelle H, Guibert R, Joncas J, Newman N, Fallaha M, Rivard C. Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow: An attempted meta-analysis. J Bone Joint Surg. 1992;74B:646–651.
25. Ashe M, McCauley T, Khan K. Tendinopathies in the upper extremity: A paradigm shift. J Hand Ther. 2004;17:329–334. [PubMed]
26. Vicenzino B. Lateral epicondylalgia: A musculoskeletal physiotherapy perspective. Man Ther. 2003;8:66–79. [PubMed]
27. Lee D. Tennis elbow: A manual therapist's perspective. J Orthop Sports Phys Ther. 1986;8:134–142. [PubMed]
28. Abbott JH. Mobilization with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylalgia. Man Ther. 2001;6:170–177. [PubMed]
29. Abbott JH, Patla CE, Jensen RH. The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia. Man Ther. 2001;6:163–169. [PubMed]
30. Cleland JA, Whitman JA, Fritz JM. Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: A retrospective analysis. J Orthop Sports Phys Ther. 2004;34:713–722. [PubMed]
31. Gunn C, Milbrandt W. Tennis elbow and the cervical spine. Can Med Assn J. 1976;114:803–809.
32. Kochar M, Dogra A. Effectiveness of a specific physiotherapy regimen on patients with tennis elbow. Physiother. 2002;88:333–341.
33. McLean S, Naish R, Reed L, Urry S, Vicenzino B. A pilot study of the manual force level required to produce manipulation induced hypoalgesia. Clin Biomech. 2002;17:304–308.
34. Paungmali A, O'Leary S, Souvlis T, Vicenzino B. Hypoalgesia and sympathoexcitatory effects of mobilisation with movement for lateral epicondylalgia. Phys Ther. 2003;83:374–383. [PubMed]
35. Paungmali A, Vicenzino B, Smith M. Hypoalgesia induced by elbow manipulation in chronic lateral epicondylalgia does not exhibit tolerance. J Pain. 2003;4:448–454. [PubMed]
36. Struijs PAA, Damen PJ, Bakker EWP, Blankevoort L, Assendelft WJJ, Van Dijk CN. Manipulation of the wrist for management of lateral epicondylitis: A randomized pilot study. Phys Ther. 2003;83:608–616. [PubMed]
37. Vicenzino B, Cartwright T, Collins D, Wright A. An investigation of stress and pain during manual therapy in asymptomatic subjects. Eur J Pain. 1999;3:13–18. [PubMed]
38. Vicenzino B, Collins D, Benson H, Wright A. An investigation of the interrelationship between manipulative therapy induced hypoalgesia and sympathoexcitation. J Manipulative Physiol Ther. 1998;21:448–453. [PubMed]
39. Vicenzino B, Collins D, Cartwright T, Wright A. Cardiovascular and respiratory changes produced by lateral glide mobilisation of the cervical spine. Man Ther. 1998;3:67–71.
40. Vicenzino B, Collins D, Wright A. Sudomotor changes induced by neural mobilisation techniques in asymptomatic subjects. J Manual Manipulative Ther. 1994;2:66–74.
41. Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain. 1996;68:69–74. [PubMed]
42. Vicenzino B, Neal R, Collins D, Wright A. The displacement, velocity and frequency profile of the frontal plane motion produced by the cervical lateral glide treatment technique. Clin Biomech. 1999;14:515–521.
43. Vicenzino B, O'Callaghan J, Kermode F, Wright A. The influence of naloxone on the initial hypoalgesic effect of spinal manual therapy. In: Devor M, Rowbotham M, Wiesenfeld-Hallin Z, editors. Proceedings of the 9th World Congress on Pain. Vol 16. Seattle, WA: IASP Press; 2000. pp. 1039–1044.
44. Vicenzino B, Wright A. Effects of a novel manipulative physiotherapy technique on tennis elbow: A single case study. Man Ther. 1995;1:30–35. [PubMed]
45. Stasinopoulos D, Johnson MI. Cyriax physiotherapy for tennis elbow/ lateral epicondylitis. Br J Sports Med. 2004;38:675–677. [PMC free article] [PubMed]
46. Cyriax J. Cyriax's Illustrated Manual of Orthopaedic Medicine. 2nd ed. Butterworth Heinemann: Oxford, UK; 1983.
47. Stasinopoulos D, Stasinopoulos I. Comparison of effects of Cyriax physiotherapy, a supervised exercise programme and polarized polychromatic non-coherent light (Bioptron light) for the treatment of lateral epicondylitis. Clin Rehabil. 2006;20:12–23. [PubMed]
48. Verhaar JAN, Walenkamp G, Van Mameren H, Kester ADM, Van der-Linden AJ. Local corticosteroid injection versus Cyriax-type physiotherapy for tennis elbow. J Bone Joint Surg. 1996;78B:128–132.
49. Mulligan B. Manual Therapy: “NAGS”, “SNAGS”, MWMS” etc. 4th ed. Plane View Services: Wellington, NZ; 1999.
50. Stratford P, Levy D. Assessing valid change over time in patients with lateral epicondylitis at the elbow. Clin J Sport Med. 1994;4:88–91.
51. Bird SB, Dickson EW. Clinically significant changes in pain along the visual analog scale. Ann Emergency Med. 2001;38:639–643.
52. Gallagher EJ, Liebman M, Bijur PE. Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Ann Emergency Med. 2001;38:633–638.
53. Kelly AM. Does the clinically significant difference in visual analog scale pain scores vary with gender, age, or cause of pain? Academic Emerg Med. 1998;5:1086–1090.
54. Kelly AM. The minimum clinically significant difference in visual analogue scale pain score does not differ with severity of pain. Emergency Med J. 2001;18:205–207.
55. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006:bmj.38961.584653.AE. [PMC free article] [PubMed]
56. Rompe JD, Riedel C, Betz U, Fink C. Chronic lateral epicondylitis of the elbow: A prospective study of low-energy shockwave therapy and low–energy shockwave therapy plus manual therapy of the cervical spine. Arch Phys Med Rehabil. 2001;82:578–582. [PubMed]
57. Waugh EJ, Jaglal SB, Davis AM, Tomlinson G, Verrier MC. Factors associated with prognosis of lateral epicondylitis after 8 weeks of physical therapy. Arch Phys Med Rehabil. 2004;85:308–318. [PubMed]
58. Cleland J, Flynn T, Palmer J. Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: A pilot clinical trial. J Manual Manipulative Ther. 2005;13:143–151.
59. Elvey R. Treatment of arm pain associated with abnormal brachial plexus tension. Aust J Physiother. 1986;32:225–230.
60. Smidt N, Lewis M, Van der Windt D, Hay EM, Bouter LM, Croft P. Lateral epicondylitis in general practice: Course and prognostic indicators of outcome. J Rheumatol. 2006;33:1–7. [PubMed]
61. Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ. 1999;319(7215):964–968. [PMC free article] [PubMed]
62. Smidt N, Van der Windt D, Assendelft WJJ, Deville W, Korthals-de Bos IBC, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomised controlled trial. Lancet. 2002;359(9307):657–662. [PubMed]
63. Wright A, Thurnwald P, O'Callaghan J, Smith J, Vicenzino B. Hyperalgesia in tennis elbow patients. J Musculoskeletal Pain. 1994;2(4):83–97.
64. Zusman M. Spinal manipulative therapy: Review of some proposed mechanisms and a new hypothesis. Aust J Physiother. 1986;32:89–99.
65. Chiu T, Wright A. To compare the effects of different rates of application of a cervical mobilisation technique on sympathetic outflow to the upper limb in normal subjects. Man Ther. 1996;1:198–203. [PubMed]
66. Cleland J, Durall C, Scott S. Effects of slump long sitting on peripheral sudomotor and vasomotor function: A pilot study. J Manual Manipulative Ther. 2002;10:67–75.
67. Simon R, Vicenzino B, Wright A. The influence of an anteroposterior accessory glide of the glenohumeral joint on measures of peripheral sympathetic nervous system function in the upper limb. Man Ther. 1997;2:18–23. [PubMed]
68. Sterling M, Jull G, Wright A. Cervical mobilisation: Concurrent effects on pain, sympathetic nervous system activity and motor activity. Man Ther. 2001;6:72–81. [PubMed]
69. Souvlis T, Vicenzino B, Wright A. The neurophysiological mechanisms of spinal manual therapy. In: Boyling G, Jull G, editors. Grieve's Modern Manual Therapy. 3rd ed. Elsevier Churchill Livingstone: Edinburgh, UK; 2005. pp. 367–379.
70. Souvlis T, Wright A. The tolerance effect: Its relevance to analgesia produced by physiotherapy interventions. Phys Ther Rev. 1997;2:227–237.
71. Skyba DA, Radhakrishnan R, Rohlwing JJ, Wright A, Sluka KA. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain. 2003;106(1–2):159–168. [PMC free article] [PubMed]
72. Slater H, Arendt-Nielsen L, Wright A, Graven-Nielsen T. Effects of a manual therapy technique in experimental lateral epicondylalgia. Man Ther. 2006;11:107–117. [PubMed]
73. Wright A, Vicenzino B. Cervical mobilisation techniques, sympathetic nervous system effects and their relationship to analgesia. In: Shacklock M, editor. Moving in on Pain. Adelaide, Australia: Butterworth-Heinemann Australia; 1995. pp. 164–173.
74. Vicenzino B. Commentary: Cleland J, Whitman JM, Fritz JM. Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: A retrospective analysis. J Orthop Sports Phys Ther. 2005;34:722–723.