HMNU- Information about MSK Kinesis and HMNU Devices

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Information about MSK Kinesis and HMNU Devices Like- Medical, Wellness and Aesthetic MSK Kinesis Therapies in collaboration with HMNU


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2 HUMAN UNITEC INTERNATIONAL is a Project Financing development and management Corporation Nasdaq OTC:HMNU developing a project for the realization and management of innovative MSK KINESIS Health and Wellness Centers and the exclusive commercialization and distribution of the DIT and MSK KINESIS TECHNOLOGY and related FDA and EU recorded MSK KINESIS devices. MSK KINESIS HEALTH WELLNESS CENTERS: The Company is in now opening MSK KINESIS Health and Wellness Centers in Arizona Sedona Florida Miami Aventura and New York Manhattan offering the exclusive MSK KINESIS Pain Therapies. MEDICAL WELLNESS AND AESTHETIC MSK KINESIS THERAPIES: Certified Licenses Operators are providing a complete range of medical and wellness evaluations assistance and treatments including classes for pre and post rehabilitation. MSK KINESIS POWER PAIN THERAPY : Non invasive back and neck pain treatment and remedy Tendinopathy Sciatic and Lumbago Rachialgie Fibromyalgia Sport injuries and sport capacity improvement multiple other applications. MSK KINESIS MAX THERAPY: Non invasive deep pain therapy of Tendinopathy Rachialgy Fibrobromialgy Sport Injuries and or Improvement Osteoporosis treatment for reduction of severe cellulite multiple other applications. MSK KINESIS DEVICES: - MSK KINESIS POWER: 16.00000 including 4 accessories and case - MSK KINESIS POWER D: 12.00000 including 3 accessories and case - MSK KINESIS POWER V: 18.00000 including 4 accessories and case - MSK KINESIS MAX: 16.00000 including 5 accessories and case 110v/220v - MSK KINESIS MAX PORTABLE: 9.00000 including 5 accessories and case 110v/220v The cost of the devices include 5 days mandatory MSK KINESIS training and MSK KINESIS Certification 3 years equipment’s limited warranty and 6 months limited MSK KINESIS accessory warranty. Photos can not depict the actual MSK KINESIS Technology: for reference only. Prices are subject to the terms and condition of the sale contract.

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3 MSK KINESIS POWER THERAPY: PROTOCOLS MSK KINESIS therapy addresses Musculoskeletal disorders MSDs which are injuries or pain in the musculo-skeletal system including the joints ligaments muscles nerves tendons and structures that support limbs neck and back. BACK PAIN: Low back pain is manifested as pain in the lower back area that can relate to problems with the lumbar spine the discs between the vertebrae the ligaments around the spine and discs the spinal cord and nerves muscles of the low back internal organs of the pelvis and abdomen or the skin covering the lumbar area. With the onset of acute pain MSK KINESIS THERAPY will initiate a 4 week protocol consisting of a three step process. Each painful point of origin will be focused with gradual and constant pressure for about 20 seconds ranging between 1.2kg and 2.4kg per square centimeter followed by a maneuver toward the periphery in a longitudinal manner at a pressure of 2kg per square centimeter. These steps are repeated on eIch painful point. Therapy should be administered three times a week. SCIATICA: Sciatica is a common type of pain affecting the sciatic nerve a large nerve extending from the lower back down the back of each leg. The first step of the procedure is to apply MSK KINESIS on painful points in a gradual and constant manner ranging from 2kg to 4kg per square centimeter. Each step is repeated 3 times with pressure maintained for at least 20 seconds for each point per session. NECK PAIN: Neck pain although felt in the neck can be caused by numerous other spinal problems. Neck pain may arise due to muscular tightness in both the neck and upper back or pinching of the nerves emanating from the cervical vertebrae. Joint disruption in the neck creates pain as does joint disruption in the upper back. The MSK KINESIS treatment should be performed as follows: painful points should be initially treated with a gradual and constant pressure ranging from 0 5 to 1kg per square centimeter with three steps for each sore spot. Following these three steps we proceed to a comprehensive treatment of the cervical spine with a constant pressure of 2 kg repeating the treatment three times a week. TENDINOPATHY: Tendinopathy refers to a disease of a tendon. The clinical presentation includes tenderness on palpation and pain often when exercising or with movement. In the case of intersectional tendinopathy proceed through the MSK KINESIS treatments on affected areas from pain with a gradual and constant pressure ranging from 3kg to 5kg per square centimeter. The pressure is maintained for 20 seconds and follows the same protocol repeated three times a week.

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4 WELLNESS: For Health and Wellness the procedure will initially maintain a constant pressure of 2kg per square centimeter in areas near the spine focused mostly on the muscles. Subsequently the steps maneuver out at a distance of about 3 cm each. With a gradual and constant pressure points in the central part of the thigh and calf are addressed. The femoral quadriceps are treated until malleable. Wellness treatment for the front part of the body proceeds with a gradual and constant pressure on points in the chest while maintaining the pressure of 4kg per square centimeter for about 20/25 seconds. The front and rear parts of the body will focus on points in the thighs with the pressure of about 5kg per square centimeter for about 30/35 seconds. SPORT INJURY: Sport injuries account for a multitude of musculo-skeletral injuries. In cases such as gymnastics sports injuries can be broad and undifferentiated. MSK therapy is a great help in speeding up and improving the natural processes of healing in the body. MSK KINESIS intensive treatments also increase the physical sport performances capacity up to 70 improvement for athletes. DISC DESEASE: In the case of degenerative disc disease and small disc hernia production MSK KINESIS treatment creates a constant pressure along the paravertebral muscles that are affected by pain using a gradual and constant pressure of 2kg per square centimeter for up to 30 seconds. The treatment should be repeated in the same session for about 5 times the results are expected to appear over the next 48 hours. PATHOLOGY OF ACUTE TENDONITIS: MSK KINESIS treatment must be performed by a gradual and constant pressure in the inflamed area for about 30 seconds with constant pressure of 1.8 kg 3 times in the same session. PATHOLOGY OF CHRONIC DISEASE TENDONITIS: Treatment protocol must maintain an alternating pressure for about 40 seconds on the tendon insertion points twice in the same session. PATHOLOGY PUBALGICA: Pubalgica also known as a sports hernia or athletics pubalgia is a chronic groin lesion. Athletes with pubalgia have an imbalance of the adductor and abdominal muscles at the pubis that leads to an increase of the weakness of the posterior wall of the groin. This imbalance leads to a deep groin pain. MSK KINESIS therapy procedure calls for gradual and constant compression up to 4kg with intermittent pauses of about 20 seconds to be repeated 4 times over the same session. The process is repeated after 24 hours. If there are other areas that are afflicted by radiating pain with a constant pressure of 2 kg. up to 4 times per session.

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5 CARPAL TUNNEL SYNDROME: is a disorder caused by compression at the wrist of the median nerve. When the median nerve is compressed it will often cause pain numbness and weakness affecting the hand to the thumb index and middle finger. Because of the mobility of the structures that are concerned treatment should be done exclusively on the damaged areas with a gradual and constant pressure from 0.5 / 0.8 kg three times in the same session. MUSCLE DISEASES: in the case of acute injury expect a 24/48 hours delay before intervention. MSK KINESIS treatment the damaged area must be treated with a gradual and constant pressure of 0.5 / 0.8 KG for 5 seconds treatment should be repeated three times in the same session. A respite of 48 hours is recommended and then the entire treatment should be repeated. In the case of chronic lesions involving various muscles to a large extent MSK KINESIS treatment calls for constant pressure of 4.0 / 4.5 kg with pressure to be maintained for 30 seconds. The treatment must be repeated three times in the same session. LUMBAGO: Is pain in the muscles and joints of the lower back. The lumbar region has the responsibility of bearing a considerable amount of the body’s weight. Forces can sometimes be too much for the structures such as the muscles ligaments and tendons MSK KINESIS treatment focuses on remediating the disruption to the way joints in the area work and reducing inflammation and pain. MSK KINESIS provides a first treatment which targets the area affected by pain with gradual and constant pressure to the para spinal muscles and the adjacent area. Each sore point should be treated three times for about 20 seconds with a constant pressure of 0.5 kg to 1.2 kg. Consequently support structures must be reestablished to the joints of the back with a gradual and constant pressure from 0.7kg to 2.3 kg. and the underlying structures with a gradual and constant pressure throughout the belly muscle with a constant pressure of 2.5 Kg to 2. 7 kg. Subsequently treatment will be repeated at the patients request or in the case in which the pain symptoms were continuing to occur. CERVICALIA: Neck pain although felt in the neck can be caused by numerous other spinal problems. Neck pain may arise due to muscular tightness in both the neck and upper back or pinching of the nerves emanating from the cervical vertebrae. Joint disruption in the neck creates pain as does joint disruption in the upper back. In the case of chronic lesions involving various muscles to a large extent MSK KINESIS treatment calls for constant pressure of 4.0 / 4.5 kg with pressure to be maintained for 30 seconds. The treatment must be repeated three times in the same session.

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6 ANKLE: The ankle is an intricate network of bones ligaments tendons and muscles. Strong enough to bear the body weight that enables a person to move the ankle can be prone to injury and pain. MSK KINESIS treatment should focus initially on the area affected by pain with a pressure that shall not exceed 1.5 kg. Followed by focus on the foot in its entirety with a pressure that does not exceed 2.4kg. Pressure on the muscles of the upper part of the ankle articulation is then applied to restore perfect connection of the foot with the rest of the body. The MSK KINESIS treatment should be performed as follows: first the painful para-spinal muscles and the muscle bellies of the muscles adjacent to the para-vertebral second the movement of the pressure must always be gradual and constant never abrupt and should never exceed 2kg. Third the hand piece of the equipment must always remain perpendicular to the axis of treatment and never oblique. The motion during treatment should be gradual and constant from the bottom to the top the patient should remain in a sitting position. Treatment is focused on the painful points and on those that are adjacent to the paravertebral musculature both in the upper part of the muscle belly and that of the lower one of the muscle belly for about 15 minutes during 3 consecutive sessions.

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7 MSK KINESIS MAX SET MANUAL MSK KINESIS MAX PORTABLE SET MANUAL 1. Place the pump on a clean dust-free stable and flat surface. Check the filter monthly and replace if dirty clogged or wet to ensure proper operation. 2. Make sure cups and accessories have been cleaned before use. 3. Take the power cord out and plug into an electrical outlet. 4. Connect Silicone hose to Vacuum valve. 5. Turn on Power Switch lamp is on 6. Set up the vacuum pressure w/ control knob you desire 7. You can choose one of the tubing hose - w/ air outlet or w/o air outlet w/ air outlet you can also control pressure by open and close w/o air outlet you can apply cups with constant pressure. 8. Select an appropriate size or type of cup. 9. You can use appropriate amount of oil or skin cream onto the target area. 10. The cups can be used individually or in combination per your preference. 11. Insert Pressure Control Part Black piece to top of the cupping cup 12. Therapy Time: It depends on the condition of the skin but we recommend total operation normally 5 to 20 min. 13. Pigment reaction will be dissipated in 4 to 7 days. It is normal for darkening to appear on the skin where cups are applied. 14. To use MSK KINESIS MAX and MSK KINESIS MAX PORTABLE with pointer: Put pointer inside of cup silver pointer to the bottom skin side. MSK KINESIS MAX Pressure Pointer helps to make more circulation and release pain. 15. If you want to use Disposable cup you can put disposable cup as picture of page 3 and you dont need to clean regular cups Disposable cups can be used only for Size 1 which is most frequent use cups. 16. Oval size cupping cup can be used area of Knee Ankle Elbow Wrist etc. 17. Bottom piece of Massage cup helps to press wide area of pain. 18. Size2 3 4 5 cups can be used to proper area which hand neck face shoulders etc. 19. To detach cups from body simple pull up the top of the blue tip valve of cups. Then negative pressure inside cups will be released. Always use this method to release cup gently rather than wrenching it away suddenly to prevent skin damage. 20. It is possible that sometimes blisters may appear on the skin where the cup has been attached. When the blistering is serious routine sterilization is necessary. Prick the blisters and apply disinfectant. 21. Unplug the power cord from the electrical outlet detach the Silicone hose and tuck it into cord storage cavity. 22. Clean and sterilize cups and accessories. Cups can be clean by alcohol or sterilizing liquid or boiling with water. Do not boil cups.

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MSK KINESIS MAX PORTABLE •3 years limited warranty: vacuum pump is warranted to be free defects in materials and workmanship for 3 years of the original consumer purchaser. This device was built to exacting standards and carefully inspected prior to shipment. This 3-years limited warranty is an expression of our confidence in the materials and workmanship of our products and our assurance to the consumer of years of dependable service. This warranty does not cover device failure due to owner misuse or negligence or normal wear and tear. The warranty does not extend to non-durable components such as rubber accessories which are subject to normal wear and need periodic replacement. • MSK KINESIS MAX Cups: 6-months warranty MSK KINESIS MAX and MSK KINESIS MAX PORTABLE Equipment Includes:

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5 5 Original Article INTRODUCTION Lateral epicondylalgia LE also known as tennis elbow is a tendinopathy taking place in the insertion of the extensor carpi radialis brevis ECRB with one third of patients also having extensor digitorum communis EDC involvement 1. LE is a very common condition affecting 1 to 3 of the general population and up to 15 of labour workers in northern European countries 2-5. This represents a public health issue in terms of work leave of absence compensation and re-training. LE is an overuse condition typically caused by repetitive micro traumatic events resulting from elastic and eccentric loading required by various sports e.g.: tennis golf and manual work. Histologic examination has failed to exhibit the classic features of inflammatory disease but instead exhibits degenerative changes with a dense population of fibroblasts vascular hyperplasia and disorganized collagen 6. Numerous treatments have been proposed: Physical intervention 7 injections of corticoid or platelet rich plasma immobilization 8 acupuncture shock-wave therapy 910 and surgery. Manipulative therapies are a growing interest in conditions involving chronic pain especially LE 1112. Deep transverse friction DTF developed empirically by J.H.Cyriax 13-17 has shown good results. It technically should be referred to as a massage hence should be precisely applied to the affected soft tissue structure. Four tissues can benefit from DTF: the enthesis the bulk of the tendon the musculo-tendinous junction and the muscle belly. Superficial layers will be mobilized with increasing pressure to reach a painful point estimated around 50 to 100 Newtons and that pressure must be kept for at least 20 minutes. The expected effects are softening of scar tissues and at the microscopic level breaking of pathological collagen cross linking and adhesion. The analgesic effect results from removal of pro-inflammatory substance by the immediate hyperemia gate control and releases of endogenous opiates. The technique as described by Cyriax puts the mechanical stress on the physician’s fingers which over time would result in less effective technical execution loss of precision and intensity. Another shortcoming of the manual DTF technique is the lack of standardization in its execution which is dependent on the physician’s physical strength his or her habits and on patient perception. This lack of standardization leads to inter and intra operator variability which renders its evaluation in clinical trials perilous. The MSK KINESIS device allows pressure monitoring without putting undue physical stress on the physician. Because the device shields unusually high continuous pressure that are not reached by manual therapy a prospective cases series study should validat its safety and efficacy for a chronic musculosketal disease before realization of a randomized control trial. The purpose of this article is to evaluate the safety and efficacy of the MSK KINESIS device for deep transverse pressure DTP in the treatment of Chronic lateral epicondylalgia in a prospective case series pilot study. MATERIALS AND METHODS Study design All patients gave written inform consent and approval was obtained by local ethics committee. This is a single centre cross sectional prospective study with inclusion starting from 2007 until 2009 evaluating the efficacy of a standardized protocol of continuous pressure using the MSK KINESIS device for treatment of LE. Description of the population enrolled: Thirty patients aged 18 to 75 with diagnostic epicondylalgia presenting at the physical medicine clinic within a period of one year and willing to participate were eligible for a possible inclusion in the study. Chronic epicondylalgia was defined as pain at the epicondyle insertion of the ECRB either at rest under palpation or at resisted contraction for at least 12 weeks in duration since first symptoms. Our Exclusion Criteria were: Patient undergoing a different form of physical treatment at the time of enrollment mild to severe cognitive impairment non-French speaker inability to comply with the follow- Keywords: Epicondylalgia treatment Manual therapy Transverse pressure The Use of the MSK KINESIS for Mechanical Pressure in the Treatment of Chronic Lateral Epicondylalgia: A Pilot Study ABSTRACT Introduction: Chronic Lateral Epicondylalgia CLE is potentially associated with a sign ificant reduction of the patient’s quality of life its treatment by manual Deep Transverse Friction DTF although widely accepted lacks standardization. The pur pose of our study was to evaluate the efficacy of the MSK KINESIS device which a llows deep tran sverse pres sure DTP monitoring f or treatment of CLE. Materials and Methods: This is a single centre observational study for treatment of CLE by the MSK KINESIS device. In a given year all patients who appeared at our institution with a diagnostic of CLE were screened for possible inclusion. Exclusion criteria were: confounding factors on pain and function of the upper limb cognitive impairment inability or unwilling to give informed consent or to comply with treatment protocol. Our primary outcome measure was the pain reduction measured by the VAS pain scale VAS at 6 weeks. Our intervention consisted in applying a pressure from 0.5 to 10kg/100mm 2 for 20 minutes once a week for 6 weeks using the MSK KINESIS device. Results: Thirty patients were screened. Two were excluded for incomplete protocol remaining 28 for analysis. Mean age was 47.3 23 were male 82.1 24 were affected on their dominant side 85.7. We had a sign ificant reduction in VAS pain score at 12 weeks 80.8 vs 13.0 p0.01. There were no side effects reported. Conclusion: Our study showed the safety of the use of a standard protocol using the MSK KINESIS device for treatment of CLE. We believe that further controlled studies will establish the MSK KINESIS as a reliable option for treatment of CLE.

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6 6 up inability for the patient or their legal representative to provide informed consent. Standardized continous pressure protocol: Treatment was administered by a physiotherapist o r a me dical doctor. A progressively increasing pressure using MSK KINESIS dynamometer was applied to the epicondyle insertion of the ECRB until the pain pressure threshold PPT defined as unbearable pain was reached. The PPT minus one third of its value was then sustained for 90 seconds. The common insertion and the bulk of ECRB and ECB were treated. The process was repeated 10 times to reach a total treatment time of 20 minutes. The pressure applied started at 0.5kg/100mm 2 and the PPT was usually reached after 3 seconds at 1.5 kg/100mm 2 with 0.5kg/100mm 2 /s increments. The initial PPT was used as a reference as the minimal pressure to reach and to surpass in following visits. The patients received treatment once a week for a total of 6 treatment sessions. Dynamometer: The MSK KINESIS is a medical device that can quantify the amount of pressure kg/100mm 2 applied onto a patient’s body using a dynamometer. The Dynamometer is located directly on the divide between the physician and the patient Table/Fig-1 with practitioner’s body weight used as the pressure source. DATA COLLECTION AND ANALYSIS Data regarding demographics activity level patient’s history previous treatment received were collected upon first clinical encounter. VAS was collected at the first patient visit at 3 weeks and at 6 weeks. The need to switch to another treatment modality was assessed at te fina foo- up isit Data analysis was completed using SYSTAT ® 9 for Windows ® . Results will be expressed as a mean for continuous variables VAS pain score at each time point age BMI height weight and as a percentage for categorical variables gender laterality. To assess a difference in our primary outcome measure we used a paired T-test comparing the mean of the differences between the initial VAS and VAS at 3 and 6weeks. A value of p0.05 was considered statisticay significant RESULTS During a one year period we enrolled 30 patients 2 patients were lost to follow-up between their initial visit and their 6 week visit and were not included in the statistical analysis. The mean age was 47.3 ranging from 30 to 64 mean BMI was 25.2 ranging from 19 to 37.3. Twenty-three 82.1 were male 26 92.8 were affected on the right . 2 - g i F / e l b a T e d i s t n a n i m o d r i e h t n o d e t c e f f a e r e w 7 . 5 8 4 2 d n a e d i s VAS Handicap PPT at the initial visit 3 weeks and 6 weeks is shown in T able/Fig-3. The results of our comparison between endpoints are summarized in T able/Fig-4. No patients needed or asked to be switched to another treatment modality. DISCUSSION A recently updated meta-analysis by Loew 17 does not find sufficient evidence in favor of DTF on pain improvement of grip strength and fonctional status. One randomized controlled trial with 40 patients with lateral epicondylalgia was included in the analysis and did not show statistically significant result in favor DTF. Many Table/Fig-1: Dynamometer Outcome measures: Our primary outcome measure was the difference in the pain during activities the last 2 days between the patient’s first clinic visit and his last visit at the end of the treatment period at 6 weeks. For each evaluation of pain Visual Analoguous Scale VAS was used and graded from 0 to 100 0 representing “no pain” and 100 “the worst pain imaginable”. Primary outcome: Pain by VAS during activities evaluated patient global pain during last 48 hours on activities with VAS Pain Scale. Secondary outcome measures: Number of patient lost to follow- up Pain by VAS under pressure evaluated pain during the application of initial PPT at the insertion of ECRB. Pain by VAS during contraction evaluated pain during a maximal hand griped resisted contraction VAS Handicap evaluated fonctional limitation on daily living evaluated by the patient graded from 0 to 100 0 representing no fonctionnal limitation et 100 maximal fontionnal limitation. Our null hypothesis was that there will be no difference in the patient’s VAS during activities between their first and last clinic visit at 12 weeks. Table/Fig-2: Baseline caracteristics Values Gender Male 82.1 Age years 473 ± 9.2 30 64 Weigth kg 70 ± 15.2 45 100 Height cm 166 ± 10.7 154.194 BMI 25.2 ± 4.4 19 37.3 Side right 9208 Dominant Hand affected right 85.7 Table/Fig-3: Comparison of VAS during activities VAS Pain under pressure VAS Pain during contraction VAS Handicap and PPT at the initial visit with visit at 3 weeks and at 6 weeks time period mean ± SD range No patients needed or asked to be switched to another treatment modality Initial n28 3 weeks n28 6 weeksn28 VAS during activities 80.8 ±19.6 25 100 35.4 ± 17.1 4 76 13.0 ± 10.1 2 54 VAS Pain under pressure 87.3 ± 14.3 54 100 47.8 ± 13.0 25 78 13.2 ± 8.5 2 34 VAS Pain during contraction 76.6 ± 21.1 19 98 33.8 ± 16.6 8 80 10.6 ± 7.1 1 29 VAS Handicap 70.8 ± 20.0 28 98 30.6 ± 17.3 11 64 8.5 ± 8.2 2 30 PPT 0.4 ± 0.3 0 1 2.2 ± 1.5 0 4.1 3.7 ± 2.1 0.5 8.2 Table/Fig-4: Comparison in VAS at rest between endpoints by mean of the differences p0.01 Initial-3 weeks 3 weeks-6 weeks Inital-6 weeks VAS during activities - 44.5 - 23.5 - 66.2 VAS Pain under pressure - 39.0 - 35.4 - 73.2 VAS Pain during contraction - 39.4 - 23.7 - 62.0 VAS Handicap -22.8 -22.7 -61.2

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7 7 studies are excluded from analysis for insufficient methodological quality but no studies include a DTP technique in their protocol. Our pilot study show a significant benefit of the use of the MSK KINESIS for DTP in lateral epicondylalgia. We were able to show a significant reduction in pain using DTP at both 3 and 6 weeks follow ups. Moreover only 2 patients were lost to follow-up and no patient asked or needed to be switched to another treatment modality which make the use of the MSK KINESIS for a standardized DTF protocol a very well tolerated and accepted treatment. The treatment is safe because perpendicular application of pressure causes no shear stress on the different layers of tissue with therefore very low risk of lesion. Moreover this can also explain why this treatment modality is much more tolerated than DTF. After a few sessions pressure superior to 6 kg/100mm 2 could be applied. Our study is the first to address the problem of pressure measurement during treatment in epicondylalgia. By defining and recording the pain threshold at the location of the epicondylalgia at each visit we were able to apply consistent pressure and show the patient his progress. The procedure has allowed great adherence of the patients with low rate lost to follow up. There hasn’t been any adverse effect reported although the treatment protocol was reaching pain thresholds at each study. To our knowledge the maximum amount of pressure that can be reached by applying pressure perpendicularly to a tendon hasn’t been study. However Kukulka has reached 10 kg N/mm 2 on Achille tendon 18 Having a numeric value for the pressure applied allows for low inter and intra operator variability which is fundamental for the evaluation of new techniques and solves for a major shortcoming in the evaluation of any manual therapy. High pressure are difficut to reach for the therapist because they put tremendous pressure on his/her hands most notably the trapeziometacarpal joint and can result in trapeziometacarpal joint degenerative disease over the long term 19. Moreover those high are rarely reached and most probably never sustained because of human biomecanic physiological limitation. The MSK KINESIS device allows the application of high pressure on the treatment area using the physician’s body weight and eliminating pressure from the physician’s hand. This is of significant importance in the treatment of obese patients or athletes with high muscular density and to avoid physician chronic hand pain. Our pressure protocol is similar to DTF but is less painful because there are no transverse friction and is therefore closer to manual ischemic compression. The emergence of the myofascial trigger point concept as a potential generator of myosfascial pain in epicondylalgia was reviewed by Shmushkevich 20 and offers a insightful approach to the relevance of ischemic compression technique for the treatment of musculo-skeletal pain. Contrary to ischemic compression the device allows modulation of the pressure applied during the treatment probably modulating ischemic pressures. Perpendicular pressure or DTF has the ability to modify tissue intrinsic property by increasing tolerance to strech. At the microscopic level those techniques probably modifies collagen cross-linking 6. At the difference of stretching manipulation as in the glinding technique direct pressure techniques probably have the potential to modify collagen hydratation and collagen unfolding 2122. Physical therapy literature offers one pilot study by McLean and al. 23 that aimed to physically evaluate the pressure required to produce analgesia during manual therapy. The manipulative treatment aimed to realize a lateral glide and was to be associated with voluntary movement of the patient. They found the best results were obtained with higher pressure applied. Similarly each treatment in our study aimed to reach higher pressure and was a criterion for follow-up during the course of the treatment. Kukulka and et al. 18 found that by doing perpendicular pressure on Achille tendon H refle was decreased in soleus muscle but there was not difference between 5 and 10 kg pressure 18. Pain regulating mechanism i.e diffuse noxious inhibitory control by treating arm at different locations are present but we believe there is poor if any neurological sustained effect 182024. In this study the use of the MSK KINESIS for DTF in the treatment of LE had favorable results as we were able to significanty improve patient pain using a reliable and reproducible protocol. In this study chronic patient can be considered their own control if we consider the length of symptoms. Our next steps in the evaluation of this new technique are to compare the MSK KINESIS for DTP to other treatments modalities in a randomized-controlled trial and allow us to better define te indications for tis interention CONCLUSION The use of the MSK KINESIS for DTF of chronic lateral epicondylalgia showed good tolerability with no side effect. Besides significant pain reduction at 3 and 6 weeks were observed. The use of MSK KINESIS allows reproducible pressure application for standardization of treatment ie significanty reducing stress to the physician’s hand. REFERENCES Verhaar JA. Tennis elbow. Anatomical epidemiological and therapeutic aspects. International orthopaedics. 1994185:263-67. Allander E. Prevalence incidence and remission rates of some common rheumatic diseases or syndromes. Scandinavian journal of rheumatology. 197433:145-53. Herquelot E Gueguen A Roquelaure Y Bodin J Serazin C Ha C et al. Work-related risk factors for incidence of lateral epicondylitis in a large working population. Scandinavian Journal of Work Environment Health. 2013396:578-88. Kurppa K Viikari-Juntura E Kuosma E Huuskonen M Kivi P . Incidence of tenosynovitis or peritendinitis and epicondylitis in a meat-processing factory. Scandinavian Journal of Work Environment Health. 1991171:32-37. Rosenbaum DA Grzywacz JG Chen H Arcury TA Schulz MR Blocker JN et al. Prevalence of epicondylitis rotator cuff syndrome and low back pain in Latino poultry workers and manual laborers. American Journal of Industrial Medicine. 2013562:226-34. Kraushaar BS Nirschl RP . Tendinosis of the elbow tennis elbow. Clinical features and findings of histological immunohistochemical and electron microscopy studies. The Journal of Bone and Joint Surgery American volume. 1999812:259-78. Bisset L Paungmali A Vicenzino B Beller E. A systematic review and meta- analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine. 2005397:411-22 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. 2006:43337575:939. Extracorporeal shock wave therapy for the treatment of lateral epicondylitis. Orthopedics. 2011341:37. Buchbinder R Green SE Youd JM Assendelft WJ Barnsley L Smidt N. Systematic review of the efficacy and safety of shock wave therapy for lateral elbow pain. The Journal of Rheumatology. 2006337:1351-63. Herd CR Meserve BB. A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia. The Journal of Manual Manipulative therapy. 2008164:225-37. Hoogvliet P Coert JH Friden J Huisstede BM European Hg. How to treat Guyons canal syndrome Results from the European HANDGUIDE study: a multidisciplinary treatment guideline. British Journal of Sports Medicine. 20134717:1063-70. Nagrale AV Herd CR Ganvir S Ramteke G. Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: a randomized clinical trial. The Journal of Manual Manipulative Therapy. 2009173:171-78. Stasinopoulos D Johnson MI. Cyriax physiotherapy for tennis elbow/lateral epicondylitis. British Journal of Sports Medicine. 2004386:675-77. Viswas R Ramachandran R Korde Anantkumar P . Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow lateral epicondylitis: a randomized clinical trial. The Scientific World Journal. 20122012:939645. Joseph MF Taft K Moskwa M Denegar CR. Deep friction massage to treat tendinopathy: a systematic review of a classic treatment in the face of a new paradigm of understanding. Journal of Sport Rehabilitation. 2012214:343-53. Loew. Deep transverse friction massage for treating lateral elbow or lateral knee tendinitis. Cochrane Database Syst Rev. 201411:CD003528 Kukulka CG Haberichter PA Mueksch AE Rohrberg MG A Special Communication Muscle Pressure Effects on Motoneuron Excitability: Phys Ther. 1987 67:1720-22. Chevalier X Maheu E. Rhizarthrosis. Rev Prat. 2012625:639. Shmushkevich Y Kalichman L. Myofascial pain in lateral epicondylalgia: a review. J Bodyw Mov Ther. 2013174:434-39. Schleip and al. 2012 Strain hardening of fascia: static stretching of dense fibrous connective tissues can induce a temporary stiffness increase accompanied by enhanced matrix hydration. J Bodyw Mov Ther. 2012161:94-100

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8 8 g n i d l o f n u n e g a l l o C 3 1 0 2 . L a t n e g r A J n o t l e h S M s a w k y r o M 1 P M e e G c M 22 accelerates water influ determining hydration in the interstitial matri Biophys J. 201210310:2157-66. l a u n a m e h t f o y d u t s t o l i p A . B o n i z n e c i V S y r r U L d e e R R h s i a N S n a e L c M 23 force levels required to produce manipulation induced hypoalgesia. Clinical Biomechanics. 2002174:304-08. Lee HM1 Wu SK You JY.2009 Quantitative application of transverse friction 24 massage and its neurological effects on fleor carpi radialis. Man Ther. 2009145:501-07. PARTICULARS OF CONTRIBUTORS: 1. Medical Practionner Departement of Musculo-skeletal Rehabilitation Leukerbad Clinic Leukerbad Switzerland. 2. Hospital Surgeon Departement of Orthopedic Surgery and Traumatology Centre Hospitalier dArgenteuil Argenteuil France. 3. Faculty Departement of Internal Medecine LSU Shreveport USA.

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