EFFECTIVENESS OF SCAPULAR MUSCLE TRAINING IN IMPROVING GRIP STRENGTH AMONG LATERAL EPICONDYLITIS PATIENT
Main Article Content
Keywords
Grip strength, Lateral Epicondylitis, Patient rated Tennis Elbow Evaluation, Scapular Strengthening exercises
Abstract
Background: Overuse injuries including lateral epicondylitis (LE) affect functional activities and quality of life. Medications and Physiotherapy help in reducing pain, and improving muscular imbalance and functional status.
Objective: To determine the effectiveness of scapular muscular training along with conventional physiotherapy in improving the grip strength of patients suffering from lateral epicondylitis.
Methodology: The Randomized control trial was conducted on 56 patients who were selected by using a convenience sampling technique. Patients were randomly divided into two groups Group A (n=28) was treated with conventional physiotherapy treatment and Group B (n=28) was treated with Scapular strengthening and conventional physiotherapy protocol. Modified Sphygmomanometer and Patient Tennis Elbow Evaluation (PRTEE)
were used for assessing grip strength and functional status levels among patients. Data analyzed by using SPSS 26 was presented in the form of mean+S.D and percentage %, frequency tables Paired T-test and Independent T-test were used for within and between the group difference with significant value<0.05.
Result: The results showed that Grip strength and Total PRTEE scoring in the Scapular group were 143.57±7.54 and 56.03±9.37 while in the control group was 135.61±7.02 and 68.03±7.40 respectively with p<0.05 showing that showing that Scapular strengthening was significantly effective than alone Conventional treatment.
Conclusion: The study concluded that Scapular strength training with Conventional Physiotherapy treatment was statistically significant in improving urinary grip strength and functional status in patients who suffered from LE having a p-value <0.05.
References
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2. Bazancir, Z., & Fırat, T. (2019). A potential factor in the pathophysiology of lateral epicondylitis: The long sarcomere length of the extensor carpi radialis brevis muscle and implications for physiotherapy. Medical Hypotheses, 130, 109278. https://doi.org/10.1016/j.mehy.2019.109278
3. Bisset, L. M., & Vicenzino, B. (2015). Physiotherapy management of lateral epicondylalgia. Journal of Physiotherapy, 61(4), 174-181. https://doi.org/10.1016/j.jphys.2015.08.004
4. Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of lateral elbow tendinopathy: One size does not fit all. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 938-949. https://doi.org/10.2519/jospt.2015.5986
5. Sayampanathan, A. A., Basha, M., & Mitra, A. K. (2020). Risk factors of lateral epicondylitis: A meta-analysis. The Surgeon, 18(2), 122-128. https://doi.org/10.1016/j.surge.2019.10.002
6. Sandhu, K., Kahal, K. S., Singh, J., Singh, J., & Grewal, H. (2020). A comparative study of activated platelet rich plasma versus local corticosteroid injection for the treatment of lateral epicondylitis: A randomized study. International Journal of Orthopaedics, 6(1), 1274-1276. https://doi.org/10.18044/jioh.6.1.1274
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8. Degen, R. M., Conti, M. S., Camp, C. L., Altchek, D. W., Dines, J. S., & Werner, B. C. (2018). Epidemiology and disease burden of lateral epicondylitis in the USA: Analysis of 85,318 patients. HSS Journal, 14(1), 9-14. https://doi.org/10.1007/s11420-018-9698-7
9. Pluim, B. M., Clarsen, B., & Verhagen, E. (2018). Injury rates in recreational tennis players do not differ between different playing surfaces. British Journal of Sports Medicine, 52(9), 611-615. https://doi.org/10.1136/bjsports-2017-098805
10. Bhalara, A. S., & Sheth, M. S. (2020). Comparison of scapular muscle strength and endurance in subjects with lateral epicondylitis and healthy individuals. International Journal of Health Sciences & Research, 10(2), 43-48. https://doi.org/10.52403/ijhsr.20200206
11. Park, H. B., Gwark, J. Y., Im, J. H., & Na, J. B. (2021). Factors associated with lateral epicondylitis of the elbow. Orthopaedic Journal of Sports Medicine, 9(5), 23259671211007734. https://doi.org/10.1177/23259671211007734
12. Johns, N., & Shridhar, V. (2020). Lateral epicondylitis: Current concepts. Australian Journal of General Practice, 49(11), 707-709. https://doi.org/10.31128/AJGP-10-20-5706
13. Lenoir, H., Mares, O., & Carlier, Y. (2019). Management of lateral epicondylitis. Orthopaedics & Traumatology: Surgery & Research, 105(8), S241-S246. https://doi.org/10.1016/j.otsr.2019.07.002
14. Pathan, A. F., Sharath, H., & Sharath, H. (2023). A review of physiotherapy techniques used in the treatment of tennis elbow. Journal of Clinical Rehabilitation, 15(10).
15. Ma, K. L., & Wang, H. Q. (2020). Management of lateral epicondylitis: A narrative literature review. Pain Research and Management, 2020. https://doi.org/10.1155/2020/2835681
16. Zwerus, E. L., Somford, M. P., Maissan, F., Heisen, J., Eygendaal, D., & Van Den Bekerom, M. P. J. (2018). Physical examination of the elbow: What is the evidence? A systematic literature review. British Journal of Sports Medicine, 52(19), 1253-1260. https://doi.org/10.1136/bjsports-2018-099187
17. Scher, D. L., Wolf, J. M., Owens, B. D., & Maj, M. C. (2009). Lateral epicondylitis. Orthopedics, 32(4). https://doi.org/10.3928/01477447-20090401-25
18. Di Giacomo, G., Ellenbecker, T. S., & Kibler, W. B. (2019). Tennis medicine: A complete guide to evaluation, treatment, and rehabilitation. Springer. https://doi.org/10.1007/978-3-030-23835-7
19. Bateman, M., Titchener, A. G., Clark, D. I., & Tambe, A. A. (2019). Management of tennis elbow: A survey of UK clinical practice. Shoulder & Elbow, 11(3), 233-238. https://doi.org/10.1177/1758573219835693
20. Coombes, B. K., Connelly, L., Bisset, L., & Vicenzino, B. (2016). Economic evaluation favors physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: Evidence from a randomized clinical trial. British Journal of Sports Medicine, 50(22), 1400-1405. https://doi.org/10.1136/bjsports-2016-096971
21. Bhalara, A. S., & Sheth, M. S. (2020). Comparison of scapular muscle strength and endurance in subjects with lateral epicondylitis and healthy individuals. International Journal of Health Sciences & Research, 10(2), 43-48. https://doi.org/10.52403/ijhsr.20200206
22. Weber, C., Thai, V., Neuheuser, K., Groover, K., & Christ, O. (2015). Efficacy of physical therapy for the treatment of lateral epicondylitis: A meta-analysis. BMC Musculoskeletal Disorders, 16, 1-13. https://doi.org/10.1186/s12891-015-0683-5
23. Menta, R., Randhawa, K., Cote, P., Wong, J. J., Yu, H., Sutton, D., & others. (2015). The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. Journal of Manipulative and Physiological Therapeutics, 38(7), 507-520. https://doi.org/10.1016/j.jmpt.2015.04.008
24. Mostafaee, N., Divandari, A., Negahban, H., Kachooei, A. R., Moradi, A., Ebrahimzadeh, M. H., & others. (2022). Shoulder and scapula muscle training plus conventional physiotherapy versus conventional physiotherapy only: A randomized controlled trial of patients with lateral elbow tendinopathy. Journal of Rehabilitation Research and Development, 38(9), 1153-1164. https://doi.org/10.1682/JRRD.2021.03.0023
25. Fazal, A. I. A., Kibria, M. G., Akter, S., Salek, S., & Rahman, M. M. (2023). Activation of middle and lower trapezius and strengthening of serratus anterior muscle for the rehabilitation of a patient with chronic lateral epicondylalgia: A case report. European Journal of Physical and Rehabilitation Medicine, 9, 1-7. https://doi.org/10.23736/S1973-9087.23.08273-8
26. Srinivas, M. R., & Babu, J. H. K. (2022). The effect of middle and lower trapezius strengthening on hand grip strength in athletes with chronic lateral epicondylitis. Journal of Physical Therapy Science, 6(9), 4231-4243. https://doi.org/10.1298/jpts.2022.4223
27. Lee, J.-H., Kim, T.-H., & Lim, K.-B. (2018). Effects of eccentric control exercise for wrist extensor and shoulder stabilization exercise on the pain and functions of tennis elbow. Journal of Physical Therapy Science, 30(4), 590-594. https://doi.org/10.1589/jpts.30.590
28. Kirithika, G., Kamalakannan, M., Ramana, K., & Anitha, A. (2024). Efficacy of scapular strengthening exercise and eccentric forearm exercise on functional recovery in subjects with lateral epicondylitis. Indian Journal of Physiotherapy & Occupational Therapy, 18. Retrieved from [URL]
29. Raithatha, K., Khant, A., & Ved, V. (2018). Effectiveness of scapular muscle strengthening in management of lateral epicondylalgia. International Journal of Advance Research, Ideas and Innovations in Technology, 4(3). Retrieved from [URL]
30. Farzad, M., MacDermid, J. C., Shafiee, E., Beygi, A. S., Vafaei, A., Varahra, A., & others. (2022). Clinimetric testing of the Persian version of the Patient-Rated Tennis Elbow Evaluation (PRTEE) and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires in patients with lateral elbow tendinopathy. Journal of Rehabilitation Research and Development, 44(12), 2902-2907. https://doi.org/10.1682/JRRD.2022.03.0030
31. Day, J. M., Lucado, A. M., Dale, R. B., Merriman, H., Marker, C. D., & Uhl, T. L. (2021). The effect of scapular muscle strengthening on functional recovery in patients with lateral elbow tendinopathy: A pilot randomized controlled trial. Journal of Sport Rehabilitation, 30(5), 744-753. https://doi.org/10.1123/jsr.2020-0142
32. Silva, B. B., Venturato, A. C., Aguiar, L. T., Luiz Filho, F., Faria, C. D., & Polese, J. C. (2019). Validity and reliability of the modified sphygmomanometer test with fixed stabilization for clinical measurement of muscle strength. Journal of Bodywork and Movement Therapies, 23(4), 844-849. https://doi.org/10.1016/j.jbmt.2019.03.010
33. Gutiérrez-Espinoza, H., Estrella-Flores, E., Cuyul-Vásquez, I., Jorquera-Aguilera, R., Francisco López-Gil, J., & Araya-Quintanilla, F. (2024). Effects of a conventional treatment plus scapular exercises program in patients with chronic lateral elbow tendinopathy: A pre–post single-group study. Journal of Sport Rehabilitation, 33(2), 106-113. https://doi.org/10.1123/jsr.2023-0104
34. Yuksel, E., & Yesilyaprak, S. S. (2024). Scapular stabilization exercise training improves treatment effectiveness on shoulder pain, scapular dyskinesis, muscle strength, and function in patients with subacromial pain syndrome: A randomized controlled trial. Journal of Bodywork and Movement Therapies, 37, 101-108. https://doi.org/10.1016/j.jbmt.2024.02.003
35. Day, J. M., Bush, H., Nitz, A. J., & Uhl, T. L. (2015). Scapular muscle performance in individuals with lateral epicondylalgia. Journal of Orthopaedic & Sports Physical Therapy, 45(5), 414-424. https://doi.org/10.2519/jospt.2015.5828
36. Ramteke, S., & Samal, S. (2020). To study the effect of rotator cuff exercises on tennis elbow. Indian Journal of Public Health Research & Development, 11(3), 610-614. https://doi.org/10.37506/ijphrd.v11i3.11612
37. Stasinopoulos, D. (2019). The role of proprioception in the management of lateral elbow tendinopathy. Journal of Hand Therapy, 32(1), e2-e3. https://doi.org/10.1016/j.jht.2018.11.007
38. Kachanathu, S. J., Zedan, A. M. E., Hafez, A. R., Alodaibi, F. A., Alenazi, A. M., & Nuhmani, S. (2019). Effect of shoulder stability exercises on hand grip strength in patients with shoulder impingement syndrome. Somatosensory & Motor Research, 36(2), 97-101. https://doi.org/10.1080/08990220.2019.1619637
2. Bazancir, Z., & Fırat, T. (2019). A potential factor in the pathophysiology of lateral epicondylitis: The long sarcomere length of the extensor carpi radialis brevis muscle and implications for physiotherapy. Medical Hypotheses, 130, 109278. https://doi.org/10.1016/j.mehy.2019.109278
3. Bisset, L. M., & Vicenzino, B. (2015). Physiotherapy management of lateral epicondylalgia. Journal of Physiotherapy, 61(4), 174-181. https://doi.org/10.1016/j.jphys.2015.08.004
4. Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of lateral elbow tendinopathy: One size does not fit all. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 938-949. https://doi.org/10.2519/jospt.2015.5986
5. Sayampanathan, A. A., Basha, M., & Mitra, A. K. (2020). Risk factors of lateral epicondylitis: A meta-analysis. The Surgeon, 18(2), 122-128. https://doi.org/10.1016/j.surge.2019.10.002
6. Sandhu, K., Kahal, K. S., Singh, J., Singh, J., & Grewal, H. (2020). A comparative study of activated platelet rich plasma versus local corticosteroid injection for the treatment of lateral epicondylitis: A randomized study. International Journal of Orthopaedics, 6(1), 1274-1276. https://doi.org/10.18044/jioh.6.1.1274
7. Raithatha, K., Khant, A., & Ved, V. (2018). Effectiveness of scapular muscle strengthening in management of lateral epicondylalgia. International Journal of Advance Research, Ideas and Innovations in Technology, 4(3). Retrieved from [URL]
8. Degen, R. M., Conti, M. S., Camp, C. L., Altchek, D. W., Dines, J. S., & Werner, B. C. (2018). Epidemiology and disease burden of lateral epicondylitis in the USA: Analysis of 85,318 patients. HSS Journal, 14(1), 9-14. https://doi.org/10.1007/s11420-018-9698-7
9. Pluim, B. M., Clarsen, B., & Verhagen, E. (2018). Injury rates in recreational tennis players do not differ between different playing surfaces. British Journal of Sports Medicine, 52(9), 611-615. https://doi.org/10.1136/bjsports-2017-098805
10. Bhalara, A. S., & Sheth, M. S. (2020). Comparison of scapular muscle strength and endurance in subjects with lateral epicondylitis and healthy individuals. International Journal of Health Sciences & Research, 10(2), 43-48. https://doi.org/10.52403/ijhsr.20200206
11. Park, H. B., Gwark, J. Y., Im, J. H., & Na, J. B. (2021). Factors associated with lateral epicondylitis of the elbow. Orthopaedic Journal of Sports Medicine, 9(5), 23259671211007734. https://doi.org/10.1177/23259671211007734
12. Johns, N., & Shridhar, V. (2020). Lateral epicondylitis: Current concepts. Australian Journal of General Practice, 49(11), 707-709. https://doi.org/10.31128/AJGP-10-20-5706
13. Lenoir, H., Mares, O., & Carlier, Y. (2019). Management of lateral epicondylitis. Orthopaedics & Traumatology: Surgery & Research, 105(8), S241-S246. https://doi.org/10.1016/j.otsr.2019.07.002
14. Pathan, A. F., Sharath, H., & Sharath, H. (2023). A review of physiotherapy techniques used in the treatment of tennis elbow. Journal of Clinical Rehabilitation, 15(10).
15. Ma, K. L., & Wang, H. Q. (2020). Management of lateral epicondylitis: A narrative literature review. Pain Research and Management, 2020. https://doi.org/10.1155/2020/2835681
16. Zwerus, E. L., Somford, M. P., Maissan, F., Heisen, J., Eygendaal, D., & Van Den Bekerom, M. P. J. (2018). Physical examination of the elbow: What is the evidence? A systematic literature review. British Journal of Sports Medicine, 52(19), 1253-1260. https://doi.org/10.1136/bjsports-2018-099187
17. Scher, D. L., Wolf, J. M., Owens, B. D., & Maj, M. C. (2009). Lateral epicondylitis. Orthopedics, 32(4). https://doi.org/10.3928/01477447-20090401-25
18. Di Giacomo, G., Ellenbecker, T. S., & Kibler, W. B. (2019). Tennis medicine: A complete guide to evaluation, treatment, and rehabilitation. Springer. https://doi.org/10.1007/978-3-030-23835-7
19. Bateman, M., Titchener, A. G., Clark, D. I., & Tambe, A. A. (2019). Management of tennis elbow: A survey of UK clinical practice. Shoulder & Elbow, 11(3), 233-238. https://doi.org/10.1177/1758573219835693
20. Coombes, B. K., Connelly, L., Bisset, L., & Vicenzino, B. (2016). Economic evaluation favors physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: Evidence from a randomized clinical trial. British Journal of Sports Medicine, 50(22), 1400-1405. https://doi.org/10.1136/bjsports-2016-096971
21. Bhalara, A. S., & Sheth, M. S. (2020). Comparison of scapular muscle strength and endurance in subjects with lateral epicondylitis and healthy individuals. International Journal of Health Sciences & Research, 10(2), 43-48. https://doi.org/10.52403/ijhsr.20200206
22. Weber, C., Thai, V., Neuheuser, K., Groover, K., & Christ, O. (2015). Efficacy of physical therapy for the treatment of lateral epicondylitis: A meta-analysis. BMC Musculoskeletal Disorders, 16, 1-13. https://doi.org/10.1186/s12891-015-0683-5
23. Menta, R., Randhawa, K., Cote, P., Wong, J. J., Yu, H., Sutton, D., & others. (2015). The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. Journal of Manipulative and Physiological Therapeutics, 38(7), 507-520. https://doi.org/10.1016/j.jmpt.2015.04.008
24. Mostafaee, N., Divandari, A., Negahban, H., Kachooei, A. R., Moradi, A., Ebrahimzadeh, M. H., & others. (2022). Shoulder and scapula muscle training plus conventional physiotherapy versus conventional physiotherapy only: A randomized controlled trial of patients with lateral elbow tendinopathy. Journal of Rehabilitation Research and Development, 38(9), 1153-1164. https://doi.org/10.1682/JRRD.2021.03.0023
25. Fazal, A. I. A., Kibria, M. G., Akter, S., Salek, S., & Rahman, M. M. (2023). Activation of middle and lower trapezius and strengthening of serratus anterior muscle for the rehabilitation of a patient with chronic lateral epicondylalgia: A case report. European Journal of Physical and Rehabilitation Medicine, 9, 1-7. https://doi.org/10.23736/S1973-9087.23.08273-8
26. Srinivas, M. R., & Babu, J. H. K. (2022). The effect of middle and lower trapezius strengthening on hand grip strength in athletes with chronic lateral epicondylitis. Journal of Physical Therapy Science, 6(9), 4231-4243. https://doi.org/10.1298/jpts.2022.4223
27. Lee, J.-H., Kim, T.-H., & Lim, K.-B. (2018). Effects of eccentric control exercise for wrist extensor and shoulder stabilization exercise on the pain and functions of tennis elbow. Journal of Physical Therapy Science, 30(4), 590-594. https://doi.org/10.1589/jpts.30.590
28. Kirithika, G., Kamalakannan, M., Ramana, K., & Anitha, A. (2024). Efficacy of scapular strengthening exercise and eccentric forearm exercise on functional recovery in subjects with lateral epicondylitis. Indian Journal of Physiotherapy & Occupational Therapy, 18. Retrieved from [URL]
29. Raithatha, K., Khant, A., & Ved, V. (2018). Effectiveness of scapular muscle strengthening in management of lateral epicondylalgia. International Journal of Advance Research, Ideas and Innovations in Technology, 4(3). Retrieved from [URL]
30. Farzad, M., MacDermid, J. C., Shafiee, E., Beygi, A. S., Vafaei, A., Varahra, A., & others. (2022). Clinimetric testing of the Persian version of the Patient-Rated Tennis Elbow Evaluation (PRTEE) and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires in patients with lateral elbow tendinopathy. Journal of Rehabilitation Research and Development, 44(12), 2902-2907. https://doi.org/10.1682/JRRD.2022.03.0030
31. Day, J. M., Lucado, A. M., Dale, R. B., Merriman, H., Marker, C. D., & Uhl, T. L. (2021). The effect of scapular muscle strengthening on functional recovery in patients with lateral elbow tendinopathy: A pilot randomized controlled trial. Journal of Sport Rehabilitation, 30(5), 744-753. https://doi.org/10.1123/jsr.2020-0142
32. Silva, B. B., Venturato, A. C., Aguiar, L. T., Luiz Filho, F., Faria, C. D., & Polese, J. C. (2019). Validity and reliability of the modified sphygmomanometer test with fixed stabilization for clinical measurement of muscle strength. Journal of Bodywork and Movement Therapies, 23(4), 844-849. https://doi.org/10.1016/j.jbmt.2019.03.010
33. Gutiérrez-Espinoza, H., Estrella-Flores, E., Cuyul-Vásquez, I., Jorquera-Aguilera, R., Francisco López-Gil, J., & Araya-Quintanilla, F. (2024). Effects of a conventional treatment plus scapular exercises program in patients with chronic lateral elbow tendinopathy: A pre–post single-group study. Journal of Sport Rehabilitation, 33(2), 106-113. https://doi.org/10.1123/jsr.2023-0104
34. Yuksel, E., & Yesilyaprak, S. S. (2024). Scapular stabilization exercise training improves treatment effectiveness on shoulder pain, scapular dyskinesis, muscle strength, and function in patients with subacromial pain syndrome: A randomized controlled trial. Journal of Bodywork and Movement Therapies, 37, 101-108. https://doi.org/10.1016/j.jbmt.2024.02.003
35. Day, J. M., Bush, H., Nitz, A. J., & Uhl, T. L. (2015). Scapular muscle performance in individuals with lateral epicondylalgia. Journal of Orthopaedic & Sports Physical Therapy, 45(5), 414-424. https://doi.org/10.2519/jospt.2015.5828
36. Ramteke, S., & Samal, S. (2020). To study the effect of rotator cuff exercises on tennis elbow. Indian Journal of Public Health Research & Development, 11(3), 610-614. https://doi.org/10.37506/ijphrd.v11i3.11612
37. Stasinopoulos, D. (2019). The role of proprioception in the management of lateral elbow tendinopathy. Journal of Hand Therapy, 32(1), e2-e3. https://doi.org/10.1016/j.jht.2018.11.007
38. Kachanathu, S. J., Zedan, A. M. E., Hafez, A. R., Alodaibi, F. A., Alenazi, A. M., & Nuhmani, S. (2019). Effect of shoulder stability exercises on hand grip strength in patients with shoulder impingement syndrome. Somatosensory & Motor Research, 36(2), 97-101. https://doi.org/10.1080/08990220.2019.1619637
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Sep 3, 2024
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EFFECTIVENESS OF SCAPULAR MUSCLE TRAINING IN IMPROVING GRIP STRENGTH AMONG LATERAL EPICONDYLITIS PATIENT. (2024). Journal of Population Therapeutics and Clinical Pharmacology, 31(9), 67-76. https://doi.org/10.53555/x20kfy90
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Author Biographies
Dr. Ujala Asghar
MS Scholar, Department of Physical Therapy and Rehabilitation Science, Superior University, Lahore.
Dr. Muhammad Junaid Gondal
Associate Professor, Department of Physical Therapy and Rehabilitation Science, Superior University, Lahore
Dr. Somia Nawab
MS Scholar, Department of Physical Therapy and Rehabilitation Science, Superior University, Lahore
Dr. Sumbal Salik
Consultant Physiotherapist, DHQ Hospital, Okara
Dr. Shazia Rafiq
Senior Physiotherapist, Punjab Institute of Neuroscience
How to Cite
EFFECTIVENESS OF SCAPULAR MUSCLE TRAINING IN IMPROVING GRIP STRENGTH AMONG LATERAL EPICONDYLITIS PATIENT. (2024). Journal of Population Therapeutics and Clinical Pharmacology, 31(9), 67-76. https://doi.org/10.53555/x20kfy90