Effect of Vibration on Epicondylalgia: A Pilot Study

Lateral epicondylitis (LE) is a common overuse injury of the elbow. It has been reported to influence up to 3% of the population with a greater preponderance in the prime range of 30 to 55 years of age [1-6]. Nearly 40% to 50% of recreational tennis players will experience this condition in their lifetime [5]. However, one does not have to play a racquet sport to develop this overuse syndrome. Playing an instrument, manual labor, and repetitive keyboard activities are contributing factors. LE is often the result of microtrauma associated with tasks that involve gripping and wrist extension with forearm supination. The proximal attachment of the extensor carpi radialis brevis (ECRB) to the lateral aspect of the capitellum places the tendon at risk for undersurface abrasions with elbow flexion and extension [7]. Originally the repetitive microtrauma was believed to produce an inflammatory reaction. However, histological studies have shown inflammatory cells are absent in chronic LE [8,9]. Repetitive stretching and strain upon the tendon can cause denaturing of the protein matrix and proliferation of fibrous tissue [10]. Cyclic trauma and immature repairs result in failure of the musculotendinous biomechanics [11]. Pain symptoms will then result in under-usage which can lead to structural weakening of the tendon to make it more susceptible to injury [12].

Clinical presentation includes pain at the musculotendinous junction of the ECRB when gripping and twisting of the wrist/ hand. Reduced wrist range of motion and a decrease in wrist extension strength may also be present [1,13-15]. Clinical tests such as the Cozen sign and Maudsley sign are often positive [16]. These symptoms are attributed to histological changes in the tendon (angiofibroblastic hyperplasia), changes in the pain system (sensitization), and motor system impairments [14,15,16]. LE is generally a clinical diagnosis so radiographs are not typically needed but they may help identify bone disease, osteochondral defects, loose bodies, and calcification of the ECRB [18,1,14,5]. Ultrasound can be valuable in identifying degenerative changes in the tendon and neovascularization [19,20]. MRI can provide information about ECRB partial or full-thickness tears.

Although no universal treatment regime has been adopted for LE, non-operative treatment is a priority. In fact, it has been estimated that 90% of LE cases resolve without surgery [21,22]. Non-operative interventions include bracing/splinting, nonsteroidal anti-inflammatories (NSAIDs), thermal modalities, electrotherapeutics, acupuncture, biological injections (autologous blood injections/platelet-rich plasma injections), and therapeutic exercises (emphasis on eccentric muscle activation). All have been reported to provide varying degrees of symptom relief. While LE is often considered to be self-limiting it can last 12 to 18 months [23].

In previous studies, corticosteroid injections initially relieved pain but with recurrence in 18-54% of patients [1]. Platelet-richplasma [15] and hyaluronic acid injection [6] studies reported relief for 8-12 weeks, with hyaluronic acid showing ongoing improvements up to 12 months. Mulligan mobilization with movement techniques with exercise and ice had positive effects on pain and functional tasks [24]. Kinesiotaping has revealed varying results. One study reported no change in strength [25] while another [26] reported a decrease in pain and an increase in grip strength. Dry needling effectively decreased pain pressure threshold and increased grip strength across a systematic review [27,28].

Counterforce braces have been used for many decades. The intent of the brace is to reduce pain via ECRB inhibition and the dispersion of stress on the musculotendinous junction across a wider surface area to facilitate the repair process [29]. Bisset et al reported an immediate positive effect but no lasting relief [30]. Whereas, Kachanathu et al stated a forearm band increased grip strength and function when compared to elbow taping [31]. In a recent randomized controlled study comparing counterforce bracing to placebo, pain frequency and severity was reduced for 2-12 weeks and elbow function was improved at 26 weeks for the bracing group [32]. The only vibration study published specifically on tennis elbow used a convex unit (low surface area contact) and failed to reveal the frequency of the vibration. The authors did not report statistically significant improvement [33], although two outliers with resolved pain in the vibration group were not included in analysis. Likewise, frequency, amplitude and surface area contact are important components of the intervention not reported in the study.

All substances vibrate at a unique resonance frequency, including tissues of the human body. Focal (local) vibration [34,35] can be generated with off-center motors or air forced by diaphragms, acting on frequency-sensitive mechanoreceptors or force-gated ion channels to achieve a variety of clinical effects. Focal vibration has been used to produce analgesic action in a variety of clinical conditions via central, neurotransmitter, and inhibitory mechanisms [36]. The best described analgesic effect of vibration has been attributed to spinal gating, previously called “gate control theory” [35]. Stimulation of the Pacinian mechanoreceptors carried along Aβ afferent fibers release adenosine in the substantia gelatinosa (dorsal horn of the spinal cord), blocking glutamate from nociceptive fibers from activating the ascending spinothalamic tract [10,37,38]. Electrical devices activate Meissner corpuscles sensitive to 20 – 50 Hz, while vibration is optimally activating Pacinian corpuscles at 150-240 Hz [39,40]. The mechanical activity of vibration has been theorized to decrease muscle guarding via reduced actin-myosin bond coupling and increased range of motion [41,34,35], potentially via recalibrating the neuromotor reflex [42]. Finally, increased blood flow from vibratory nitric oxide-mediated vasodilation may also facilitate the removal of pain-inducing cytokines [41,34]. The VibraCool® device provides focal stimulation at a frequency of 200 Hz, pressed in a concave casing devised to maximize Pacinian exposure directly to affected muscles. The purpose of this study was to compare the effectiveness of vibration with the VibraCool® device to that of a known intervention (counterforce strap) on pain relief in individuals with epicondylalgia.

All procedures in this study were performed in compliance with relevant laws and institutional guidelines and were approved by the University Office of Institutional Review Board (#154-23) on November 10, 2023. Participants were recruited via social media and flyers. All participants provided written informed consent prior to the collection of any data. A total of 27 participants meet the inclusion criteria: over 18 years of age, lateral elbow pain, free of sensory deficits in the arms, no history of elbow, wrist, or hand surgery, no history of fibromyalgia or diabetes, and no cold sensitivity (if in VibraCool® group).

Baseline data included: wrist flexion and extension range of motion, grip strength at five positions on a Jamar hand dynamometer (Performance Health, Indianapolis, IN), pain pressure threshold, Cozen test, and Maudsley test. These measures were made to confirm the diagnosis of lateral epicondylitis. In addition, three questionnaires were administered: Patient Rated Tennis Elbow Evaluation (PRTEE), Quick Disabilities of the Arm, Shoulder, and Hand (DASH), and Visual Analog Scale (VAS). These questionnaires have been used extensively in prior studies: PRTEE Interclass correlation (ICC) is 0.89-0.99 (Pain ICC = 0.89-0.99, Function ICC = 0.83-0.99); Dash reliability is 0.91 with a minimal detectable change at the 90% confidence level being 12.85; VAS reliability is 0.94 [43].

This study was an intention to treat design. Thus, we asked about prior treatments. If a person had a negative experience with a counterforce strap, we offered them the VibraCool® option. If they never used a counterforce strap, we offered them both options. The counterforce strap (Figure 1) was a polyester, nylon, spandex blend adjustable to fit each forearm (Sleeve Stars, Santa Barbara, CA). The VibraCool® device (Figure 2) was a small device that fits in a pouch to strap onto the elbow (PainCareLabs, Atlanta, GA). VibraCool® is pre-set to vibrate at 200 Hz. While packaging of the VibraCool® includes an ice pack which can be used concurrently, this study only evaluated vibration. All participants were provided a color-coded treatment diary to log the daily treatment and write any notes about their activity levels. Each treatment was performed for 30-minutes each day. After the first treatment the VAS was completed (posttreatment 1). After 21 consecutive days of treatment, the PRTEE, DASH, and VAS were completed (post-test data). Each participant was then to refrain from using any treatments for two weeks and the 3 questionnaires were repeated (follow-up data).

Data analysis included descriptive statistics run for demographic variables and for the dependent variables. Chisquare analysis was run to determine if there were between-group differences on those who had pain for greater than one year versus those who experienced pain for less than one year. A repeatedmeasures MANOVA was conducted to examine the effects of three levels of time (pre-test, post-test, and two-week follow-up) and two groups (VibraCool® or Counterforce Strap) on the dependent variables VAS, DASH, and PRTEE. A Mann-Whitney U was run to evaluate between-group differences for the VAS post one treatment. The Mann-Whitney U was run due to unequal group sizes.

Demographic data - Of the 22 VibraCool® participants, 16 were right and 6 were left involved elbows. Of these, 16 had the dominant and 6 non-dominant elbows involved. The age was 53.7 ± 11.5 years with 11 experiencing pain for over one-year and 11 less than 1-year. The distribution of the groups is displayed in Table 1.

Table 1:Demographic Data by Group and Duration of Symptoms.

Screening Data - Of the 22 VibraCool® participants, 14 had a positive Cozen test, 10 had a positive Maudsley test, 17 had decreased wrist flexion/extension, 14 had decreased grip strength, and 22 had a diminished pain pressure threshold. In summary, 19 participants had 3 or more of these deficits.

Of the 5 counterforce strap participants, 2 had a positive Cozen test, 3 had a positive Maudsley test, 4 had decreased wrist flexion/ extension, 3 had decreased grip strength, and 5 had a diminished pain pressure threshold. In summary, 4 participants had 3 or more of these deficits. Outcome Data - A summary of the outcomes data is provided in Table 2. Deltas over time and Minimal Clinically Important Differences (MCID) are displayed in Table 3. Chi square was significant (p = .04) for between-group differences in pain duration. All five members of the counterforce strap group had pain of less than 1 year; the VibraCool® group had 11 participants who had pain of less than and 11 that had pain for greater than one year.

Table 2:Dependent Variable Means and Standard Deviations for Each Group and Time Point.

Table 3:Delta Values Over Time & Minimal Clinically Important Differences (MCID).

For the repeated-measures ANOVA, sphericity was violated for within-subjects’ effects for time for the VAS (p < 0.01), DASH (p < 0.02), and PRTEE (p < 0.01). The violation of sphericity was likely due to unequal group sizes and thus the Pillai’s trace correction was applied for overall between- and within-subjects’ tests. There were no between group differences found (p = 0.76) or time by group interaction (p = 0.58). However, there was a significant overall within-subjects effect of time (p = 0.001). Univariate effects were examined for the impact of time using the Huynh-Feldt correction, as epsilon was > 0.75.

For the VAS scores, the main effect of time was not statistically significant (p = 0.13), with a small effect size (partial η² = 0.08). DASH scores showed a significant main effect of time (p < 0.01) with a medium effect size (partial η² = 0.20). PRTEE scores demonstrated a significant main effect of time (p < 0.01), with a large effect size (partial η² = 0.46). Post-hoc testing for time with Bonferroni correction found that there was no significant difference in DASH from pre-test to post-test (p = 0.07) or from post-test to two-week follow-up (p = 0.67). DASH scores significantly improved from pre-test to two-week follow-up (p = 0.02). The results indicate that disability significantly decreased over time. PRTEE scores significantly improved from pre-test to post-test (p < 0.01) and pretest to two-week follow-up (p < 0.01), but not between post-test and two-week follow-up (p = 0.07). This indicates that elbow-related disability significantly decreased over time and the treatment effect was retained over the 2-week follow-up. Mann-Whitney U testing demonstrated significant between-group differences for the VAS (p = 0.02), with the VibraCool® demonstrating significant pain reduction, compared to the counterforce strap. Cohen’s d was 0.94, indicating a large effect size.

As a pilot study interested in learning about the impact of the VibraCool® device on pain and disability, a secondary data analysis was performed. A Friedman’s ANOVA with Wilcoxon signed-ranks post-hoc tests were run on just the VibraCool® data. Friedman ANOVA results indicated significant differences between time points (p < 0.01). Wilcoxon signed ranks post-hoc testing affirmed that upper extremity disability measured by the DASH reduced from pre-test to post-test (p = 0.01) and from pre-test to follow-up (p < 0.01), but not from post-test to two-week follow-up (p = 0.93). Elbow-related disability as measured by the PRTEE also improved from pre-test to post-test (p < 0.01) and pre-test to two-week follow-up (p < 0.01), but not from two-week follow-up to posttest (p = 0.41). Pain as measured by the VAS was not significantly different from pre-test to post-test (p = 0.09), from pre-test to twoweek follow-up (p = 0.07), or from post-test to follow-up (p = 0.90). These results indicate that disability improvements are sustained from a post-test to two-week follow-up (Table 2). Likewise, Table 3 also reveals the PRTEE was the only measure to reach the MCID value.

Epicondylalgia is a musculoskeletal disorder that is characterized by pain at the lateral epicondyle. It frequently includes limited wrist range of motion, wrist/grip weakness, positive Cozen Sign (incriminating the ECRB muscle; sensitivity 84-91%), positive Maudsley Sign (incriminating the extensor digitorum longus muscle; sensitivity 66-88%), and/or increased tenderness to palpation (reduced pain pressure threshold) at the musculotendinous junction of the proximal elbow extensors [43]. These signs and symptoms were used as screening tools to confirm the presence of epicondylalgia for participation in the study [44]. The original intent of the study was to randomize the assignment of participants to the VibraCool® device or counterforce strap intervention. However, many participants had unsuccessfully used a counterforce strap in the past and did not want to use it again. They were interested in using the VibraCool® device so this led to a very unequal sample size.

One of the pre-screening questions asked about the duration of the participant’s signs/symptoms. When viewing this data, there was an interest in seeing if symptom duration made a difference in the response to treatment. A period of one-year appeared to be a reasonable break point since Bisset et al identified “tennis elbow” as a self-limiting condition with up to 80% cases recovering within one year[45]. It would have been helpful to differentiate by tissue pathology instead of time, i.e. epicondylitis (inflammation of ECRB) versus epicondylosis (chronic degenerative process of the proximal common extensor tendon). However, this would have required imaging or an invasive process. Coincidentally, this one-year differentiation resulted in 11 participants in each group. A study by Kraushaar and Nirschl (1999) evaluated cadaveric specimens of nine people who failed conservative management for lateral epicondylitis. Histology and electron microscopy found a paucity of evidence to suggest an inflammatory response. Since their study did not evaluate the tissue in the early stages of epicondylalgia, it is unclear when the elbow dysfunction transitions from an inflammatory to a degenerative status [9]. In fact, this could happen at different times in different people. Nonetheless, out of curiosity, the current data was analyzed by three groups: VibraCool® with symptoms less than one year, VibraCool® with symptoms more than one year, and counterforce strap. The intent was to see if people with a longer period of symptoms responded differently, i.e. were the tissues histologically dissimilar. Although there were differences over time, there were no significant differences between groups. It is possible the one-year mark was not an appropriate breakpoint but without imaging, this is not known.

In evaluating the effectiveness of the counterforce strap, prior studies examined the impact on various parameters with a single application [18,45,31,32,23,46]. A study [45] comparing a forearm strap to a forearm-elbow strap (counterforce band with an additional elbow strap) and control demonstrated slight increases in pain-free grip strength and pressure pain threshold for both braces compared to control. However, the increases were less than the MCID. The rationale offered for this pain reduction was a decrease in the muscle/tendon forces (ECRB) on the lateral epicondyle to offload the pain. Likewise, the integrated EMG activity with an Aircast band was found to be less than a standard strap and a control but a rationale for this outcome was reported to be perplexing [46]. While the literature [31] has supported the use of a counterforce strap as a standard of care, there are no recommendations for the “wear-time.” Thus, despite trying to establish research parity by rendering equal treatment times with the two interventions, it might have been better to use the counterforce strap longer each day. Clinicians often suggest people wear the strap during active periods of their day to achieve the above stated outcomes. This tends to be for periods greater than the 30-minutes per day in this study. Further studies are needed to provide clinically relevant “wear-time,” precise placement, and magnitude of compression to allow for comparisons of best treatment options.

When outcome measures for all VibraCool® data were compared to the counterforce strap, improvement was identified in both groups over time. Pain (VAS) was reduced in both groups and neither achieved a minimal clinically important difference (MCID) as identified in Table 3 [47]. The disability questionnaires (DASH and PRTEE) indicated significant improvement over time for both groups. Although there were no differences between the groups, a MCID was achieved for the PRTEE questionnaire. So, what would be the physiological rationale for these outcomes? Given that the duration of the symptoms for numerous participants was many months to years, it would make sense that the stage of injury was degenerative/failed tendon healing and a mechanical device might help the symptoms as compared to an anti-inflammatory product. The physiology of the counterforce strap has been discussed. The VibraCool® device delivered a 200 Hz vibration blocking significant a-delta nociceptor pain [48,49]. Single-motor 200 Hz devices have been found to be effective for pain reduction in over 100 studies [50-52]. This study administered a 30-minute treatment daily over three weeks but a recent study by Fattorini et al recommended 30-minutes, three-times per day [42]. Unfortunately, the Fattorini study (2023) was published after the current study was initiated. Furthermore, active muscle contractions have been suggested to be used with vibration to reset dysfunctional reflexed and asynchronous proprioception [9]. Exercise also stimulates regional hyperemia and the delivery of cyclic loading can stimulate collagen remodeling [9]. The inclusion of therapeutic exercise is consistant with multi-modal interventions that typically happen in the clinical setting. However, the isolation of individual treatments was performed in the current study to identify a causeand- effect relationship of the interventions. Given this expanded data, a decision to stop this study, report the results, and make modifications to the methodology seemed reasonable.

In summary, all outcome measures improved over time regardless of the data analysis performed. It appears that the longer the duration of the symptoms, the more likely the participant was to have tried a variety of other interventions, including a counterforce strap. Thus, the counterforce strap group reported epicondylagia for shorter periods of time. This disparity and the potential indication for increased duration of the VibraCool® treatment time resulted in the researchers deciding to stop data collection, review the results to date, and begin to design an alternative approach. However, the results to date are worth sharing. This is the best way to enhance research protocols to determine best treatment options. Future research with the VibraCool® device should follow Fattorini et al and compare three 30-minute treatments daily for three days with active exercise compared to active exercise only [42]. The outcome measures used in the current study were consistent with other studies and should be used again [27,28,24,47]. Overall, vibration has the potential to be a valuable, convenient, and inexpensive treatment technique for a common but challenging diagnosis like epicondylalgia.

a) Identification of the stage of lateral epicondylgia can play a significant role in determining effective treatment(s).

b) Vibration has the potential to be a valuable, convenient, and inexpensive treatment technique for a common but challenging diagnosis like epicondylalgia.

c) Precise treatment parameters are in the process of being established.

d) The combination of vibration with active exercise needs to be explored.

All procedures in this study were performed in compliance with relevant laws and institutional guidelines and were approved by the University Office of Institutional Review Board.

The authors received no financial support for the research, authorship, and/or publication of this article.

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Thank you to Penny Zimmerman, PT, AT, for her assistance in subject recruitment. Thank you to Dr Christopher H Wise and Dr Todd Everett for initial study development.

1. Banffy MB, ElAttrache NS (2012) Injection therapy in the management of musculoskeletal injuries: The elbow. Oper Tech in Sports Med 20(2): 124-131.
2. George CE, Heales LJ, Stanton R, Wintour S-A, Kean CO (2019) Sticking to the facts: A systematic review of the effects of therapeutic tape in lateral epicondylalgia. Phys Ther Sport 40: 117-127.
3. Landesa-Piñeiro L, Leirós-Rodríguez R (2022) Physiotherapy treatment of lateral epicondylitis: A systematic review. J Back Musculoskelet Rehabil 35(3): 463-477.
4. Smidt N, van der Windt DAWM (2006) Tennis elbow in primary care. BMJ 333(7575): 927-928.
5. Taylor SA, Hannafin JA (2012) Evaluation & management of elbow tendinopathy. Sports Health 4(5): 384-393.
6. Waseem M, Nuhmani S, Ram CS, Sachin Y (2012) Lateral epicondylitis: A review of the literature. J Back Musculoskelet Rehabil 25(2): 131-142.
7. Walz DM, Newman JS, Konin GP, Glen Ross (2010) Epicondylitis pathogenesis, imaging, and treatment. Radiographics 30(1): 167-184.
8. Kannus P, Jozsa L (1991) Histopathological changes preceding spontaneous rupture of a tendon: a controlled study of 891 patients. J Bone Joint Surg Am 73(10): 1507-1525.
9. Kraushaar BS, Nirschl RP (1999) Tendinosis of the elbow: clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am 81(2): 259-278.
10. Patterson-Kane JC, Becker DL, Rich T (2012) The pathogenesis of tendon microdamage in athletes: the horse as a natural model for basic cellular research. J Comp Pathol 147(2-3): 227-247.
11. Kannus P (1997) Etiology and pathophysiology of chronic tendon disorders in sports. Scand J Med Sci Sports 7(2): 78-85.
12. Sharma P, Maffulli N (2005) Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am 87(1): 187-202.
13. Gabriel TI, Alexandra IDM, Florin V, Florin C (2021) Lateral epicondylitis of the elbow in athletes. Science, Movement and Health 21(2): 507-511.
14. Georgieva D, Poposka A, Samardziski M, Bozinovski Z, Dzoleva-Tolevska R, et al. (2016) Tennis elbow: Its origins & treatment. Research in Physical Education, Sport, & Health 5(1): 83-86.
15. Kemp JA, Olson MA, Tao MA, Burcal CJ (2021) Platelet-Rich Plasma versus corticosteroid injection for the treatment of lateral epicondylitis: A systematic review. IJSPT 16(3): 597-605.
16. Zwerus EL, Somford MP, Maissan F, Jelle Heisen, Denise Eygendaal, et al. (2018) Physical examination of the elbow, what is the evidence? A systematic literature review. Br J Sports Med 52(19): 1253-1260.
17. Jespersen A, Amris K, Graven-Nielsen T, Arendt-Nielsen L, Bartels EM, et al. (2013) Assessment of pressure-pain thresholds and central sensitization of pain in lateral epicondylalgia. Pain Med 14(2): 297-304.
18. Ahmad Z, Siddiqui N, Malik SS, M Abdus-Samee, G Tytherleigh-Strong, ET AL. (2013) Lateral epicondylitis: a review of pathology and management. Bone Joint J 95(9): 1158-1164.
19. Connell D, Burke F, Coombes P, S McNealy, D Freeman, et al. (2001) Sonographic examination of lateral epicondylitis. AJR Am J Roentgenol 176(3): 777-782.
20. Du Toit C, Stieler M, Saunders R, L Bisset, Vicenzino B (2008) Diagnostic accuracy of power Doppler ultrasound in patients with chronic tennis elbow. Br J Sports Med 42(11): 872-876.
21. Hay EM, Paterson SM, Lewis M, G Hosie, P Croft (1999) Pragmatic randomized controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of the elbow in primary care. BMJ 319(7215): 964-968.
22. Hoogvliet P, Randsdorp M, Dingemanse R, Koes BW, Huisstede BMA (2013) Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med 47(17): 1112-1119.
23. Ma K-L, Wang H-Q (2020) Management of lateral epicondylitis: a narrative literature review. Pain Res Manag 2020(1): 6965381.
24. Reyhan AC, Sindel D, Dereli EE (2020) The effects of Mulligan’s mobilization with movement technique in patients with lateral epicondylitis. J Back Musculoskelet Rehabil 33(1): 99-107.
25. Martínez-Beltrán MJ, Rodríguez-Sanz D, Pérez-Mallada N (2021) Are there any changes in strength after the application of Kinesio taping in lateral epicondylalgia? J Back Musculoskelet Rehabil 34(5): 775-781.
26. Eraslan L, Yuce D, Erbilic A, Baltaci G (2018) Does Kinesiotaping improve pain and functionality in patients with newly diagnosed lateral epicondylitis? Knee Surg Sports Traumatol Arthrosc 26(3): 938-945.
27. Navarro-Santana MJ, Sanchez-Infante J, Gomez-Chiguano GF, Cleland JA, Lopez-de-Uralde-Villanueva I, et al. (2020) Effects of trigger point dry needling on lateral epicondylalgia of musculoskeletal origin: A systematic review and meta-analysis. Clin Rehabil 34(11): 1327-1340.
28. Nuhmani S, Khan MH, Ahsan M, Abualait TS, Muaisi Q (2023) Dry needling in the management of tendinopathy: A systematic review of randomized control trials. J Bodyw Mov Ther 33: 128-135.
29. Nirschl RP, Ashman ES (2003) Elbow tendinopathy: tennis elbow. Clin Sports Med 22(4): 813-836.
30. Bisset L, Beller E, Jull G, Peter Brooks, Ross Darnell, et al. (2006) Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 333(7575): 939.
31. Kachanathu SJ, Miglani S, Grover D, Zakaria AR (2013) Forearm band versus elbow taping: As a management of lateral epicondylitis. Journal of Musculoskeletal Research 16(1): 1-9.
32. Kroslak M, Pirapakaran K, Murrell GAC (2019) Counterforce bracing of lateral epicondylitis: a prospective, randomized, double-blinded, placebo-controlled clinical trial. J Shoulder Elbow Surg 28(2): 288-295.
33. Furness ND, Phillips A, Gallacher S, Beazley JCS, Evans JP, et al. (2018) Vibration therapy versus standard treatment for tennis elbow: A randomized controlled study. J Orthop Surg 26(3): 2309499018792744.
34. Cerciello S, Rossi S, Visona E, Corona K, Oliva F (2016) Clinical applications of vibration therapy in orthopaedic practice. Muscles Ligaments Tendons J 6(1): 147-156.
35. Saggini R, Carmignano SM, Palermo T, Bellomo RG (2016) Mechanical vibration in rehabilitation: State of the art. Journal of Novel Physiotherapies 6(60): 314.
36. Casale R, Hansson P (2022) The analgesic effect of localized vibration: a systematic review. Part 1: the neurophysiological basis. Eur J Phys Rehabil Med 58(2): 306-315.
37. Salter MW, DeKoninck Y, Henry JL (1993) Physiological roles for adenosine and ATP in synaptic transmission in the spinal dorsal horn. Prog Neurobiol 41(2): 125-156.
38. Salter MW, De Koninck Y, Henry JL (1992) ATP-sensitive K+ channels mediate an IPSP in dorsal horn neurones elicited by sensory stimulation. Synapse 11(3): 214-20.
39. Poenaru D, Cintez D, Petrusca I, Cioc L, Dumitrascu D (2016) Local application of vibration in motor rehabilitation-Scientific and practical considerations. Maedica 11(3): 227-231.
40. Salter MW, Henry JL (1987) Evidence that adenosine mediates the depression of spinal dorsal horn neurons induced by peripheral vibration in the cat. Neuroscience 22(2): 631-50.
41. Baxter AL, Anderson Thrasher, Jena L Etnoyer-Slaski, Lindsey L Cohen (2023) Multimodal mechanical stimulation reduces acute and chronic low back pain: Pilot data from a HEAL phase 1 study. Front Pain Res 4: 1114633.
42. Fattorini L, Rodio A, Filippi GM, Pettorossi VE (2023) Effectiveness of Focal Muscle Vibration in the Recovery of Neuromotor Hypofunction: A Systematic Review. J Funct Morphol Kinesiol 8(3): 103.
43. Saroja G, Antony Leo, Pm venkata sai (2014) Diagnostic accuracy of provocative tests in lateral epicondylitis. Int J Physiother Research 2(6): 815-823.
44. Lucado AM, Day JM, Vincent JI, Joy C MacDermid, Jane Fedorczyk, et al. (2022) Lateral elbow pain and muscle function impairments. J Orthop Sports Phys Ther 52(12): CPG1-CPG111.
45. Bisset LM, Collins NJ, Offord SS (2014) Immediate effects of 2 types of braces on pain and grip strength in people with lateral epicondylalgia: A randomized controlled trial. JOSPT 44(2): 120-128.
46. Snyder-Mackler L, Epler M (1989) Effect of standard and Aircast tennis elbow bands on integrated electromyography of forearm extensor musculature proximal to the bands. Am J Sports Med 17(2): 278-281.
47. Zinger G, Bregman A, Safranz O, Beyth S, Peyser A (2022) Hyaluronic acid injections for chronic tennis Elbow. BMC Sports Sci Med Rehabil 14(1): 8.
48. Su HC, Hsieh CW, Lai NM, Chou PY, Lin PH, et al. (2021) Using Vibrating and Cold Device for Pain Relieves in Children: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Pediatr Nurs 61: 23-33.
49. Zhao L, Qi P, Wang X, Su X, Liao L (2025) Local analgesia for the relief of pain in children undergoing venipuncture and intravenous cannulation: a systematic review and network meta-analysis. BMC Anesthesiol 25(1): 115.
50. Ballard A, Khadra C, Adler S, Trottier ED, Le May S (2019) Efficacy of the Buzzy Device for Pain Management during Needle-Related Procedures: A Systematic Review and Meta-analysis. Clin J Pain 35(6): 532-543.
51. Jin F, Wang X, Qi M, Zhang W, Zhang Y (2024) Effectiveness and safety of Buzzy device in needle-related procedures for children under twelve years of age: A systematic review and meta-analysis. Medicine 103(15): e37522.
52. Beers SR, De Bellis MD (2002) Neuropsychological function in children with maltreatment-related posttraumatic stress disorder. Am J Psychiatry 159(3): 483-486.