Extracorporeal shock wave therapy for lateral epicondylitis--a double blind randomised controlled trial

Long-term follow-up of open and endoscopic Hohmann procedures for lateral epicondylitis

PURPOSE

The long-term outcome of this new endoscopic technique was compared with that of the classical open Hohmann procedure.

TYPE OF STUDY

Retrospective cohort study.

METHODS

During 1992 and 1995, 37 patients were surgically treated with the Hohmann procedure after failed intensive conservative treatment. At an average of 92 months after the operation, 30 patients (81%) could be clinically re-examined and were evaluated with a standard questionnaire including the scores of Roles and Maudsley and Morrey et al.

RESULTS

Twenty of these patients were treated endoscopically and 10 with the open technique. There were no differences in demographic data between the 2 groups. At follow-up in both groups, similar results were seen for the function of the elbow, the scores of Roles and Maudsley and Morrey et al., the subjective rating of pain and function of the elbow, and complication rate. The results in the score of Morrey showed an average scoring of 93.2 for the endoscopic group and 87.5 for the open group (P > .05).

CONCLUSIONS

The endoscopic technique showed results comparable to the open technique and can therefore be recommended for wider surgical use so as to learn more details concerning possible complications and results of the new technique.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The effectiveness of extra corporeal shock wave therapy for plantar heel pain: a systematic review and meta-analysis

BACKGROUND

There is considerable controversy regarding the effectiveness of extracorporeal shock wave therapy in the management of plantar heel pain. Our aim was to conduct a systematic review of randomised controlled trials to investigate the effectiveness of extracorporeal shock wave therapy and to produce a precise estimate of the likely benefits of this therapy.

METHODS

We conducted a systematic review of all randomised controlled trials (RCTs) identified from the Cochrane Controlled trials register, MEDLINE, EMBASE and CINAHL from 1966 until September 2004. We included randomised trials which evaluated extracorporeal shock wave therapy used to treat plantar heel pain. Trials comparing extra corporeal shock wave therapy with placebo or different doses of extra corporeal shock wave therapy were considered for inclusion in the review. We independently applied the inclusion and exclusion criteria to each identified randomised controlled trial, extracted data and assessed the methodological quality of each trial.

RESULTS

Six RCTs (n = 897) permitted a pooled estimate of effectiveness based on pain scores collected using 10 cm visual analogue scales for morning pain. The estimated weighted mean difference was 0.42 (95% confidence interval 0.02 to 0.83) representing less than 0.5 cm on a visual analogue scale. There was no evidence of heterogeneity and a fixed effects model was used.

CONCLUSION

A meta-analysis of data from six randomised-controlled trials that included a total of 897 patients was statistically significant in favour of extracorporeal shock wave therapy for the treatment of plantar heel pain but the effect size was very small. A sensitivity analysis including only high quality trials did not detect a statistically significant effect.

Extracorporeal shock wave therapy in calcific tendinitis of the shoulder

OBJECTIVE

To investigate clinical (pain, mobility) and radiological (resolution of calcium deposits) efficacy of different energy levels of extracorporeal shock wave therapy (ESWT) in calcific tendinitis of the shoulder.

DESIGN AND PATIENTS

There were 90 study subjects with radiographically verified calcific tendinitis of one shoulder, mean age 52+/-6 years (range 29-65 years; females:males=55:35), all of whom had had symptoms for at least 6 months and substantial restriction of shoulder mobility and pain that required taking anti-inflammatory drugs. Calcium deposits were of type I or type II (clearly circumscribed and dense) and ranged from 1 cm to 3 cm in diameter. Subjects were divided into three groups to receive ESWT at one of two energy levels (E1=0.15 mJ/mm2, E2=0.44 mJ/mm2) or sham treatment. Treatment was given at 6 weekly intervals until symptoms resolved, five treatments had been given or the subject dropped out of the programme.

RESULTS

All subjects in groups E1 and E2 completed the programme. Those in group E1 had significantly less pain during treatment but more treatments than those in group E2, and at 6 month follow-up had residual calcification and recurrence of pain (87%). Subjects in group E2 had no residual calcification or recurrence of pain. Sham treatment had no effect. There were no side effects except a small number of haematomas (2 in E1, 6 in E2; maximum size 2 cm).

CONCLUSION

ESWT in calcific tendinitis of the shoulder is very effective. It does not have significant side effects at an energy level of E=0.44 mJ/mm2, which can therefore be recommended.

Extracorporeal shock wave therapy for calcific and noncalcific tendonitis of the rotator cuff: a systematic review

The authors conducted a systematic review to assess the effectiveness of extracorporeal shock wave therapy (ESWT) for the treatment of calcific and noncalcific tendonitis of the rotator cuff. Conservative treatment for rotator cuff tendonitis includes physiotherapy, nonsteroidal antiinflammatory drugs, and corticosteroid injections. If symptoms persist with conservative treatment, surgery is often considered. Extracorporeal shock wave therapy has been suggested as a treatment alternative for chronic rotator cuff tendonitis, which may decrease the need for surgery. Articles for this review were identified by electronically searching Medline, EMBASE, Cumulative Index to Nursing & Allied Health Literature (CINAHL), and Evidence Based Medicine (EBM) and hand-screening references. Two reviewers selected the trials that met the inclusion criteria, extracted the data, and assessed the methodological quality of the selected trials. Finally, the strength of scientific evidence was appraised. Evidence was classified as strong, moderate, limited, or conflicting. Sixteen trials met the inclusion criteria. There were only five randomized, controlled trials and all involved chronic (>/=3 months) conditions, three for calcific tendonitis and two for noncalcific tendonitis. For randomized, controlled trials, two (40%) were of high quality, one (33%) for calcific tendonitis and one (50%) for noncalcific tendonitis. The 11 nonrandomized trials included nine that involved calcific tendonitis and two that involved both calcific and noncalcific tendonitis. Common problem areas were sample size, randomization, blinding, treatment provider bias, and outcome measures. There is moderate evidence that high-energy ESWT is effective in treating chronic calcific rotator cuff tendonitis when the shock waves are focused at the calcified deposit. There is moderate evidence that low-energy ESWT is not effective for treating chronic noncalcific rotator cuff tendonitis, although this conclusion is based on only one high-quality study, which was underpowered. High-quality randomized, controlled trials are needed with larger sample sizes, better randomization and blinding, and better outcome measures.

Effectiveness of extracorporeal shock wave therapy in the treatment of previously untreated lateral epicondylitis: a randomized controlled trial

BACKGROUND

Extracorporeal shock wave therapy is a relatively new therapy used in the treatment of chronic tendon-related pain. Few randomized controlled trials have been performed on it, and no studies have examined the effectiveness of extracorporeal shock wave therapy as a frontline therapy for tendon-related pain.

HYPOTHESIS

Subjects treated with active extracorporeal shock wave therapy will have higher rates of treatment success than subjects treated with sham extracorporeal shock wave therapy.

DESIGN

Double-blind randomized controlled trial.

METHODS

Sixty subjects who had previously untreated lateral epicondylitis for less than 1 year and more than 3 weeks were included in this study. Subjects were randomly allocated to receive 1 session per week for 3 weeks of either sham or active extra-corporeal shock wave therapy. Subjects in the active therapy group received 2000 pulses (energy flux density, 0.03-0.17 mJ/mm(2)). All subjects were provided with a forearm-stretching program. After 8 weeks of therapy, subjects were classified as either treatment successes or treatment failures according to fulfillment of all 3 criteria: (1) at least a 50% reduction in the overall pain visual analog scale score, (2) a maximum allowable overall pain visual analog scale score of 4.0 cm, and (3) no use of pain medication for elbow pain for 2 weeks before the 8 week follow-up. Visual analog scale scores were also collected for pain at rest, during sleep, during activity, at its worst, and at its least, as well as for quality of life (using the EuroQoL questionnaire) and grip strength.

RESULTS

Success rates in the sham and active therapy groups were 31% and 39%, respectively. No significant difference was detected between groups (chi(2)(1)= 0.3880, P = .533). Mean change in quality of life over 8 weeks was an increase of 1.3 and 3.3 for sham and active therapy groups, respectively, and mean change in grip strength over 8 weeks was an increase of 7.4 kg and 6.8 kg for sham and active therapy groups, respectively.

CONCLUSIONS

Despite improvement in pain scores and pain-free maximum grip strength within groups, there does not appear to be a meaningful difference between treating lateral epicondylitis with extracorporeal shock wave therapy combined with forearm-stretching program and treating with forearm-stretching program alone, with respect to resolving pain within an 8-week period of commencing treatment.

Comparison of two ultrasonographic localization techniques for the treatment of lateral epicondylitis with extracorporeal shock wave therapy: a randomized study

OBJECTIVE

To describe and compare two ultrasonographic localization techniques for the treatment of lateral epicondylitis with extracorporeal shock wave therapy (ESWT).

DESIGN

Forty-one subjects selected through clinical examination were randomly assigned to two groups of treatment.

INTERVENTIONS

Each subject received a three-session ultrasound-guided ESWT (performed weekly). Lateral tangential focusing was used in group A, whereas back tangential focusing was used for group B.

MAIN OUTCOME MEASURES

Total Elbow Scoring System (TESS) and a visual analogue scale (VAS) were used to evaluate each subject before the treatment and at six months follow-up.

RESULTS

TESS and VAS pretreatment scores were homogeneous between the groups (p > 0.05). In both groups there was a significant (p < 0.05) increase in the TESS score and a decrease in the VAS score but there was no resolution of the pain. TESS and VAS follow-up scores were homogeneous between the two groups (p > 0.05).

CONCLUSIONS

There was no difference between the two techniques of using ESWT.

Les traitements non chirurgicaux de la tendinopathie des épicondyliens

OBJECTIVE

To review the literature on nonsurgical treatment of tennis elbow.

METHODS

We searched Medline for all randomized controlled trials (RCTs), controlled clinical trials (CCTs) and literature reviews published from 1966 to December 2003 on nonsurgical treatment of tennis elbow. We used the keys words controlled clinical trial, tennis elbow on lateral epicondylitis, and treatment. We found 46 reports of RCTs and CCTs on 14 nonsurgical treatments and 11 literature reviews.

RESULTS

Corticosteroid injection is the best treatment option for the short term. However, beneficial effects persisted only for a short time, and the long-term outcome could be poor. For the long term, physiotherapy (pulsed ultrasound, deep friction massage and exercise programme) was the best option but was not significantly different from the "wait-and-see" approach. Some support is offered for the use of topical nonsteroid anti-inflammatory drugs, at least for the short term. There is insufficient evidence to support or refute the use of acupuncture, extracorporeal shock wave therapy, manipulation, orthoses, low-energy laser, glycosaminoglycan polysulfate injection, botulinum toxin injection, or topical nitric oxide application.

CONCLUSION

Further trials, with use of appropriate methods and adequate sample sizes, are needed before conclusions can be drawn about the effects of many of the treatments for tennis elbow and their ability to change the condition's natural course.

Repetitive low-energy shock wave treatment for chronic lateral epicondylitis in tennis players

BACKGROUND

There is conflicting evidence regarding extracorporeal shock wave treatment for chronic tennis elbow.

HYPOTHESIS

Treatment with repetitive low-energy extracorporeal shock wave treatment is superior to repetitive placebo extra-corporeal shock wave treatment.

METHODS

Seventy-eight patients enrolled in a placebo-controlled trial. All patients were tennis players with recalcitrant MRI-confirmed tennis elbow of at least 12 months' duration. Patients were randomly assigned to receive either active low-energy extracorporeal shock wave treatment given weekly for 3 weeks (treatment group 1) or an identical placebo extracorporeal shock wave treatment (sham group 2). Main outcome measure was pain during resisted wrist extension at 3 months; secondary measures were >50% reduction of pain and the Upper Extremity Function Scale.

RESULTS

At 3 months, there was a significantly higher improvement in pain during resisted wrist extension in group 1 than in group 2 (mean [SD] improvement, 3.5 [2.0] and 2.0 [1.9]; P =.001 for between-group difference of improvement) and in the Upper Extremity Function Scale (mean [SD] improvement, 23.4 [14.8] and 10.9 [14.9]; P <.001 for between-group difference of improvement). In the treatment group, 65% of patients achieved at least a 50% reduction of pain, compared with 28% of patients in the sham group (P =.001 for between-group difference).

CONCLUSION

Low-energy extracorporeal shock wave treatment as applied is superior to sham treatment for tennis elbow.

Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits

Despite the success in clinical application, the exact mechanism of shock wave therapy remains unknown. We hypothesized that shock wave therapy induces the ingrowth of neovascularization and improves blood supply to the tissues. The purpose of this study was to investigate the effect of shock wave therapy on neovascularization at the tendon-bone junction. Fifty New Zealand white rabbits with body weight ranging from 2.5 to 3.5 kg were used in this study. The right limb (the study side) received shock wave therapy to the Achilles tendon near the insertion to bone. The left limb (the control side) received no shock wave therapy. Biopsies of the tendon-bone junction were performed in 0, 1, 4, 8 and 12 weeks. The number of neo-vessels was examined microscopically with hematoxylin-eosin stain. Neovascularization was confirmed by the angiogenic markers including vessel endothelial growth factor (VEGF) and endothelial nitric oxide synthase (eNOS) expressions and endothelial cell proliferation determined by proliferating cell nuclear antigen (PCNA) expression examined microscopically with immunohistochemical stains. The results showed that shock wave therapy produced a significantly higher number of neo-vessels and angiogenesis-related markers including eNOS, VEGF and PCNA than the control without shock wave treatment. The eNOS and VEGF began to rise in as early as one week and remained high for 8 weeks, then declined at 12 weeks; whereas the increases of PCNA and neo-vessels began at 4 weeks and persisted for 12 weeks. In conclusion, shock wave therapy induces the ingrowth of neovascularization associated with early release of angiogenesis-related markers at the Achilles tendon-bone junction in rabbits. The neovascularization may play a role to improve blood supply and tissue regeneration at the tendon-bone junction.