A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia

Tendinopathies of the elbow, wrist, and hand: histopathology and clinical considerations

This article reviews the current opinion of the histopathological findings of common elbow, wrist, and hand tendinopathies. Implications for client management including examination, diagnosis, prognosis, intervention, and outcomes are addressed. Concepts for further research regarding common therapeutic interventions are discussed.

Two cases of work-related lateral epicondylopathy treated with Graston Technique® and conservative rehabilitation

OBJECTIVE

To chronicle the conservative treatment and management of two work-related cases of lateral elbow pain diagnosed as lateral epicondylopathy.

CLINICAL FEATURES

PATIENT 1: A 48-year old female presented with gradual onset of right lateral elbow pain over the course of six weeks related to work activities of repetitive flexion/extension movements of the wrist and finger keying. PATIENT 2: A 47-year old female presented with gradual onset of left lateral elbow pain over the course of four weeks related to work activities of repetitive squeezing and gripping.

INTERVENTION AND OUTCOME

The conservative treatment approach consisted of activity modification, bracing, medical acupuncture with electrical stimulation, Graston Technique®, and rehabilitative exercise prescription. Outcome measures included verbal pain rating scale (VPRS), QuickDASH Work Module Score (QDWMS), and a return to regular work activities. Both patients attained resolution of their complaints, and at eight month follow-up reported no recurrence of symptoms.

CONCLUSION

A combination of conservative rehabilitation strategies may be used by chiropractors to treat work-related lateral epicondylopathy and allow for individuals to minimize lost time related to this condition.

Obstacles to obtaining optimal physiotherapy services in a rural community in southeastern Nigeria

Background. Many people continue to live with physical disabilities across the globe, especially in rural Africa despite expertise of Physiotherapists and available evidence of effectiveness of Physiotherapy. Objective. To determine the obstacles to obtaining Optimal Physiotherapy services in a rural community in Southeastern Nigeria. Methods. Population-based cross-sectional study of individuals and health facilities in a rural community in Southeastern Nigeria. Results. The obstacles to obtaining optimal physiotherapy services in this community were unavailability of physiotherapy services, poor knowledge of health workers and community dwellers of the roles and scope of physiotherapy, poor health care seeking behavior of community dwellers, patronage of traditional health workers, and poor referral practices by health workers. Conclusion. Rural health workers in Nkanu West Local Government and other rural communities in Nigeria and Africa should be educated on the roles and scope of physiotherapy. There is a need for raising awareness of the management options for movement/functional problems for rural indigenous communities in Nigeria in particular and Africa in general. Physiotherapists should be made aware of the growing need for physiotherapy in rural areas of Nigeria and Africa largely comprising of the elderly.

Selective 360° percutaneous extensor carpi radialis brevis tendon release for tennis elbow: an experimental study

OBJECTIVES

The purpose of this study was to define in volunteers and cadavers the positions of structures at risk and the extensor carpi radialis brevis (ECRB) origin limits for sonographically guided percutaneous tendon release in tennis elbow.

METHODS

First, in volunteers, we used Doppler sonography to determine the position (danger zone) of the structures at risk (neurovascular bundle and radial collateral ligament) from the most lateral point of the epicondyle (point of entry). Second, in cadavers, we studied the footprint of the ECRB's origin for finally performing sonographically guided tendon release (1- to 2-mm incision) away from the danger zone. Efficacy was measured in terms of detachment ratios for the ECRB and safety as the absence of neurovascular bundle or radial collateral ligament injuries.

RESULTS

In 10 volunteers (20 elbows), the neurovascular bundle was located 18.1 mm or greater anteromedially from the point of entry. The neurovascular bundle was not in direct contact with the bone. In 13 formaldehyde-embalmed cadaver elbows, the distance between the origin of the ECRB and the radial collateral ligament was 0 mm or greater. The anterior origin of the ECRB did not contact the neurovascular bundle. The maximum attachment limits of the ECRB were at 15, 5, 15, and 16 mm from the point of entry (anterior, posterior, proximal, and distal margins, respectively). Average detachment ratios were excellent for anterior and distal margins and good for posterior and proximal margins, without neurovascular bundle or radial collateral ligament injuries.

CONCLUSIONS

This study determined a danger zone to avoid and an area of probability in which to enclose most of the ECRB's origin for sonographically guided percutaneous tendon release. A 360° ECRB detachment can be performed safely and effectively. Clinically, sonographically guided percutaneous tendon release should selectively target pathologic regions.

Physical therapies for Achilles tendinopathy: systematic review and meta-analysis

BACKGROUND

Achilles tendinopathy (AT) is a common condition, causing considerable morbidity in athletes and non-athletes alike. Conservative or physical therapies are accepted as first-line management of AT; however, despite a growing volume of research, there remains a lack of high quality studies evaluating their efficacy. Previous systematic reviews provide preliminary evidence for non-surgical interventions for AT, but lack key quality components as outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Statement. The aim of this study was to conduct a systematic review and meta-analysis (where possible) of the evidence for physical therapies for AT management.

METHODS

A comprehensive strategy was used to search 11 electronic databases from inception to September 2011. Search terms included Achilles, tendinopathy, pain, physical therapies, electrotherapy and exercise (English language full-text publications, human studies). Reference lists of eligible papers were hand-searched. Randomised controlled trials (RCTs) were included if they evaluated at least one non-pharmacological, non-surgical intervention for AT using at least one outcome of pain and/or function. Two independent reviewers screened 2852 search results, identifying 23 suitable studies, and assessed methodological quality and risk of bias using a modified PEDro scale. Effect size calculation and meta-analyses were based on fixed and random effects models respectively.

RESULTS

Methodological quality ranged from 2 to 12 (/14). Four studies were excluded due to high risk of bias, leaving 19 studies, the majority of which evaluated midportion AT. Effect sizes from individual RCTs support the use of eccentric exercise. Meta-analyses identified significant effects favouring the addition of laser therapy to eccentric exercise at 12 weeks (pain VAS: standardised mean difference -0.59, 95% confidence interval -1.11 to -0.07), as well as no differences in effect between eccentric exercise and shock wave therapy at 16 weeks (VISA-A:-0.55,-2.21 to 1.11). Pooled data did not support the addition of night splints to eccentric exercise at 12 weeks (VISA-A:-0.35,-1.44 to 0.74). Limited evidence from an individual RCT suggests microcurrent therapy to be an effective intervention.

CONCLUSIONS

Practitioners can consider eccentric exercise as an initial intervention for AT, with the addition of laser therapy as appropriate. Shock wave therapy may represent an effective alternative. High-quality RCTs following CONSORT guidelines are required to further evaluate the efficacy of physical therapies and determine optimal clinical pathways for AT.

Effectiveness of different methods of resistance exercises in lateral epicondylosis--a systematic review

STUDY DESIGN

Systematic Review.

INTRODUCTION

Lateral epicondylosis (LE) is relatively common with an annual incidence in the general population of 1% to 3%. Systematic reviews have identified exercise is effective, but have not established specific exercise parameters.

PURPOSE

The purpose of this systematic review was to synthesize the quality and content of clinical research addressing type and dosage of resistance exercises in lateral epicondylosis.

METHODS

Computerized bibliographic databases (1990-2010) were searched using relevant keywords; bibliographies of included papers were hand searched. Of 594 screened abstracts, 11 articles (12 studies) met inclusion criteria. Articles were randomly allocated to pairs of reviewers who independently verified data extraction and appraised the full text, using a structured critical appraisal tool with 24 items. Data extraction was limited by a lack of consistent reporting of elements of exercise dosage.

RESULTS

The mean quality rating of the studies was 72%, with 2 papers exceeding 75% quality. Of the 12 studies, 9 addressed the effects of isotonic (eccentric/concentric) exercises, 2 studied the effect of isometric and one studied isokinetic exercises. The exercise programs ranged over a period of 4 to 52 weeks. Exercises were prescribed 1 to 6 times per day, with an average duration of 15 minutes per session, and average of 15 repetitions (range: 3 to 50), with 1 to 4 sets per session.

CONCLUSION

All the studies reported that resistance exercise resulted in substantial improvement in pain and grip strength; eccentric exercise was most studied. Strengthening using resistance exercises is effective in reducing pain and improving function for lateral epicondylosis but optimal dosing is not defined.

LEVEL OF EVIDENCE

2a.

Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial

OBJECTIVE

To compare the effectiveness of supervised exercise program and Cyriax physiotherapy in the treatment of tennis elbow (lateral epicondylitis).

DESIGN

Randomized clinical trial.

SETTING

Physiotherapy and rehabilitation centre.

SUBJECTS

This study was carried out with 20 patients, who had tennis elbow (lateral epicondylitis).

INTERVENTION

Group A (n = 10) had received supervised exercise program. Group B (n = 10) was treated with Cyriax physiotherapy. All patients received three treatment sessions per week for four weeks (12 treatment sessions).

OUTCOME MEASURES

Pain was evaluated using a visual analogue scale (VAS), and functional status was evaluated by completion of the Tennis Elbow Function Scale (TEFS) which were recorded at base line and at the end of fourth week.

RESULTS

Both the supervised exercise program and Cyriax physiotherapy were found to be significantly effective in reduction of pain and in the improvement of functional status. The supervised exercise programme resulted in greater improvement in comparison to those who received Cyriax physiotherapy.

CONCLUSION

The results of this clinical trial demonstrate that the supervised exercise program may be the first treatment choice for therapist in managing tennis elbow.

A review of modern management of lateral epicondylitis

Lateral epicondylitis, or tennis elbow, is the most common cause of elbow pain. This degenerative condition can manifest as an acute process lasting < 3 months or a chronic process often refractory to treatment. Symptom resolution occurs in 70% to 80% of patients within the first year. A "watch-and-wait" approach can be an appropriate treatment option, although physical therapy has been shown to be an effective first-line therapy. Corticosteroids, while providing relief of pain in the acute setting, may be detrimental to recovery in the long term. Platelet-rich plasma injections, although recently well publicized, have not been proven by well-controlled clinical trials to be effective therapy. For patients with symptoms refractory to conservative management, surgical intervention has shown to be a successful treatment modality.

Elbow tendinopathy

Lateral epicondylosis is a common pathology of the upper extremity. The origin of the ECRB is the most commonly cited anatomic location of lateral epicondylosis pathology. Histologic examination shows the features of a failed healing response, with absence of acute inflammatory cells. The typical patient with lateral epicondylosis is an adult in the fourth or fifth decade of life, with no difference about the sex. Diagnosis is based on history and physical examination. The role of imaging is to confirm the diagnosis. The most consistent symptom of lateral epicondylosis is pain over the lateral aspect of the elbow. Therapeutic modalities for lateral epicondylosis vary widely and lack definitive evidence. Open, percutaneous or arthroscopic surgery is recommended when functional disability and pain persist after 6 to 12 months of nonoperative management. Future studies using validated clinical measures and imaging are needed to determine the best management for patients with lateral epicondylosis.

A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis

PURPOSE

We designed a prospective, randomized study to evaluate the effects of iontophoresis delivery of dexamethasone versus corticosteroid injection therapy on patient outcomes.

METHODS

We randomized 82 patients to 10 mg dexamethasone via iontophoresis using a self-contained patch with a 24-hour battery; 10 mg dexamethasone injection; or 10 mg triamcinolone injection. All patients received the same hand therapy protocol. Primary outcomes tracked were change in grip strength (flexion vs extension), pain, and function scores on a validated questionnaire. The secondary outcome was return-to-work status. Patients were evaluated at baseline, completion of physical therapy, and 6-month follow-up.

RESULTS

The iontophoresis patients had statistically significant improvement in grip strength at the conclusion of hand therapy compared with baseline. They were also more likely to get back to work without restriction. By 6-month follow-up, all groups had equivalent results for all measured outcomes.

CONCLUSIONS

Dexamethasone via iontophoresis produced short-term benefits because for this group grip strength and unrestricted return to work were significantly better. This study suggests that this iontophoresis technique for delivery of corticosteroid may be considered a treatment option for patients with lateral epicondylitis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Joint manipulation in the management of lateral epicondylalgia: a clinical commentary

Lateral epicondylalgia or tennis elbow is a prevalent musculoskeletal disorder that is characterized by lateral elbow pain often associated with gripping tasks. The underlying pathology remains to be fully elucidated; however, evidence indicates that the disorder does not involve an inflammatory process but rather impairments of the pain and motor systems as well as morphological changes in the structure of both the extensor carpi radialis brevis muscle and tendon. Although the most efficient management approach remains controversial, there is a growing body of literature reporting the effects and underlying mechanisms of joint manipulation in the management of lateral epicondylalgia. Evidence exists demonstrating that joint manipulation directed at the elbow and wrist as well as at the cervical and thoracic spinal regions results in clinical alterations in pain and the motor system. In addition to presenting this evidence, this paper describes proposed underlying physiological mechanisms of joint manipulation associated with the observed clinical effects. We propose that this information will be useful for the physical therapist in making clinical decisions regarding the selection of treatment technique for the management of patients with lateral epicondylalgia.

A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia

Lateral epicondylalgia is a commonly encountered musculoskeletal complaint. Currently, there is no agreement regarding the exact underlying pathoanatomical cause or the most effective management strategy. Various forms of joint manipulation have been recommended as treatment. The purpose of this study was to systematically review available literature regarding the effectiveness of manipulation in treating lateral epicondylalgia. A comprehensive search of Medline, CINAHL, Health Source, SPORTDiscus, and the Physiotherapy Evidence Database ending in November 2007 was conducted. Thirteen studies, both randomized and non-randomized clinical trials, met inclusion criteria. Articles were assessed for quality by one reviewer using the 10-point PEDro scale. Quality scores ranged from 1-8 with a mean score of 5.15 +/- 1.85. This score represented fair quality overall; however, trends indicated the presence of consistent methodological flaws. Specifically, no study achieved successful blinding of the patient or treating therapist, and less than 50% used a blinded outcome assessor. Additionally, studies varied significantly in terms of outcome measures, follow-up, and comparison treatments, thus making comparing results across studies difficult. Results of this review support the use of Mulligan's mobilization with movement in providing immediate, short-, and long-term benefits. In addition, positive results were demonstrated with manipulative therapy directed at the cervical spine, although data regarding long-term effects were limited. Currently, limited evidence exists to support a synthesis of any particular technique whether directed at the elbow or cervical spine. Overall, this review identified the need for further high-quality studies using larger sample sizes, valid functional outcome measures, and longer follow-up periods.

Tennis elbow

INTRODUCTION

Lateral pain in the elbow affects up to 3% of the population, and is considered an overload injury of the extensor tendons of the forearm where they attach at the lateral epicondyle. Although usually self-limiting, symptoms may persist for over 1 year in up to 20% of people.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for tennis elbow? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 80 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, autologous whole blood injections, corticosteroid injections, combination physical therapies, exercise, extracorporeal shock wave therapy, iontophoresis, low-level laser therapy, manipulation, non-steroidal anti-inflammatory drugs (oral and topical), orthoses (bracing), platelet-rich plasma injections, pulsed electromagnetic field treatment, surgery, and ultrasound.

Management of tennis elbow

CLINICAL QUESTION

What is the best treatment for tennis elbow?

RESULTS

Despite a wealth of research, there is no true consensus on the most efficacious management of tennis elbow especially for effective long-term outcomes. Corticosteroid injections do show large pain-relieving effects in the short term but are associated with risks of adverse events and long-term reoccurrence. Advice with a "wait and see" approach is recommended as the first-line treatment in primary care for most cases. In the medium term physiotherapy and or low-level laser therapy may be effective.

IMPLEMENTATION

Rule out alternative diagnosis. Onward referral may be indicated if the condition does not resolve after 12 months.

Surgery for lateral elbow pain

BACKGROUND

Surgery is sometimes recommended for persistent lateral elbow pain where other less invasive interventions have failed.

OBJECTIVES

To determine the benefits and safety of surgery for lateral elbow pain.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL and Web of Science unrestricted by date or language (to 15 December 2010).

SELECTION CRITERIA

Randomised and controlled clinical trials assessing a surgical intervention compared with no treatment or another intervention including an alternate surgical intervention, in adults with lateral elbow pain.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials for inclusion, assessed risk of bias and extracted data.

MAIN RESULTS

We included five trials involving 191 participants with persistent symptoms of at least five months duration and failed conservative treatment. Three trials compared two different surgical procedures and two trials compared surgery to a non-surgical treatment. All trials were highly susceptible to bias. Meta-analysis was precluded due to differing comparator groups and outcome measures. One trial (24 participants) reported no difference between open extensor carpi radialis brevis (ECRB) surgery and radiofrequency microtenotomy, although reanalysis found that pain was significantly lower in the latter group at three weeks (MD -2.80 points on 10 point scale, 95% CI -5.07 to -0.53). One trial (26 participants) reported no difference between open ECRB surgery and decompression of the posterior interosseous nerve in terms of the number of participants with improvement in pain pain on activity, or tenderness on palpation after an average of 31 months following surgery. One trial (45 participants) found that compared with open release of the ERCB muscle, percutaneous release resulted in slightly better function. One trial (40 participants) found comparable results between open surgical release of the ECRB and botulinum toxin injection at two years, although we could not extract any data for this review. One trial (56 participants) found that extracorporeal shock wave therapy (ESWT) improved pain at night compared with percutaneous tenotomy at 12 months (MD 5 points on 100 point VAS, 95% CI 1.12 to 8.88), but there were no differences in pain at rest or pain on applying pressure.

AUTHORS' CONCLUSIONS

Due to a small number of studies, large heterogeneity in interventions across trials, small sample sizes and poor reporting of outcomes, there was insufficient evidence to support or refute the effectiveness of surgery for lateral elbow pain. Further well-designed randomised controlled trials and development of standard outcome measures are needed.

Systematic Review and Analysis of Work-Related Injuries to and Conditions of the Elbow

This systematic review of literature examines and synthesizes research findings related to interventions for people with work-related elbow injuries, particularly epicondylitis. It was carried out as part of the Evidence-Based Literature Review Project of the American Occupational Therapy Association. The 11 articles included in this review suggest multiple approaches to intervention but do not provide sufficient evidence to determine which methods or approaches are best practice. Research has provided little evidence to support the use of commonly prescribed interventions for epicondylitis, the most frequently reported work-related elbow injury. Collectively, the evidence to support the use of splinting, exercise, or physical agent modalities is weak and provides little guidance for approaching management of elbow injuries. The implications for education and research are discussed, as is the application of the evidence to clinical practice in occupational therapy.

A new exercise for tennis elbow that works!

Eccentric exercise has been effectively used in the management of tendinopathies in multiple regions of the body. Lateral epicondylosis ("tennis elbow") is a common tendinopathy that has shown improvement following treatment utilizing isokinetic eccentric exercise. A novel exercise was developed for home-based eccentric exercise that has shown promise for use with patients with lateral epicondylosis. Clinicians should be aware of this exercise and consider it as an evidence-based intervention.

Evidence-supported rehabilitation of patellar tendinopathy

Chronic tendinopathy is a common musculoskeletal disorder that frequently affects athletes who train and compete at all levels. This Clinical Commentary presents a review of the etiology, incidence, and contributory factors related specifically to patellar tendinopathy. Examination and differential diagnosis considerations are provided, and an evidence-based, staged rehabilitation program is described.

Inter-rater reliability for measurement of passive physiological range of motion of upper extremity joints is better if instruments are used: a systematic review

QUESTION

What is the inter-rater reliability for measurements of passive physiological or accessory movements in upper extremity joints?

DESIGN

Systematic review of studies of inter-rater reliability.

PARTICIPANTS

Individuals with and without upper extremity disorders.

OUTCOME MEASURES

Range of motion and end-feel using methods feasible in clinical practice.

RESULTS

Twenty-one studies were included of which 11 demonstrated acceptable inter-rater reliability. Two studies satisfied all criteria for internal validity while reporting almost perfect reliability. Overall, the methodological quality of studies was poor. ICC ranged from 0.26 (95% CI -0.01 to 0.69) for measuring the physiological range of shoulder internal rotation using vision to 0.99 (95% CI 0.98 to 1.0) for the physiological range of finger and thumb flexion/extension using a goniometer. Measurements of physiological range of motion using instruments were more reliable than using vision. Measurements of physiological range of motion were also more reliable than measurements of end-feel or of accessory range of motion.

CONCLUSIONS

Inter-rater reliability for the measurement of passive movements of upper extremity joints varies with the method of measurement. In order to make reliable decisions about joint restrictions in clinical practice, we recommend that clinicians measure passive physiological range of motion using goniometers or inclinometers.

Proximal wrist extensor tendinopathy

Proximal wrist extensor tendinopathy, which is also known as tennis elbow, is pain at or just distal to the lateral humeral epicondyle within the proximal wrist extensor tendon. It occurs commonly in certain athletes but can also occur in people with jobs that require repetitive movements of the hand and upper limb. In most cases the tendon involved shows no signs of inflammation or tendonitis, but instead shows fibroblasts, vascular hyperplasia, and disorganized collagen. Diagnosis is often made by history and physical exam alone. Most people respond to conservative measures including activity modification, analgesics, manipulation of tissue, and exercise. In some cases, an injection of corticosteroid or botulinum toxin may be used. Surgery is rarely needed.

A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis

BACKGROUND

The outcome is unknown for 2 common bracing treatments utilized for patients with lateral epicondylitis. The purpose of this study was to compare the clinical outcomes of a wrist splint with that of a counterforce forearm strap for the management of acute lateral epicondylitis.

MATERIALS AND METHODS

Forty-two patients (44 elbows) received either a wrist extension splint (Group I-24 elbows) or a counterforce forearm strap (Group II-20 elbows). Measures on the Mayo Elbow Performance (MEP) and American Shoulder and Elbow Society (ASES) Elbow Assessment Form were collected prior to treatment and at 6 weeks. A total score was derived, utilizing the ASES Elbow Assessment, as was a score utilizing the standard scoring system for the MEP.

RESULTS

Group I's score derived from the ASES form improved 16 points and Group II's score improved 13 points. Group I's score on the MEP improved 13 points and Group II's score improved 12 points. There was no significant difference measured between the Groups with the ASES (P = .60) nor MEP (P = .63) scores. However, within the ASES derived score, pain relief was significantly better with the extension splint group (P = .027). No other variables were statistically significantly different.

DISCUSSION

Significant pain relief with the wrist extension splint may be due to improved immobilization of the wrist extensor muscles in a resting position.

CONCLUSION

The wrist extension splint allows a greater degree of pain relief than does the forearm strap brace for patients with lateral epicondylitis.

Hand therapist management of the lateral epicondylosis: a survey of expert opinion and practice patterns

Lateral epicondylosis (LE) is a common condition. Knowledge on practice patterns underlies identification of knowledge to practice gaps. The purpose was to determine the practice patterns and beliefs of hand therapists in managing LE. The study design used was a descriptive survey. A survey of Certified Hand Therapists and members of the American Society of Hand Therapists was conducted (n=693). Questions were framed around frequency and perceived effectiveness of interventions, examination techniques, outcome measures, and prognostic factors. More than 80% of therapists use education/activity modification, home exercise, LE orthoses, and stretching for both the acute and chronic LE. Therapists perceive education, orthoses and home exercise are the most effective for acute cases, whereas in chronic cases, orthoses dropped to ninth in ranked perceived effectiveness. Grip strength (80%) and numeric pain rating (71%) were the most commonly used outcome measures. Most (>70%) therapists perceived occupation and duration of symptoms are prognostic in terms of resolution of symptoms, whereas compliance with exercise (78%) and work factors are important for return to work. Therapists rely on impairment measures to evaluate hand therapy outcomes in patients with LE. Hand therapists are aligned with a number of recommendations from the available systematic reviews, although the use of outcome measures and optimal definition of education and exercise exhibit evidence to practice gaps.

LEVEL OF EVIDENCE

Level 5.

Effectiveness of manual therapies: the UK evidence report

BACKGROUND

The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions.

METHODS

The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories. The strength/quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs.

RESULTS

By September 2009, 26 categories of conditions were located containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. We identified 49 recent relevant systematic reviews and 16 evidence-based clinical guidelines plus an additional 46 RCTs not yet included in systematic reviews and guidelines.Additionally, brief references are made to other effective non-pharmacological, non-invasive physical treatments.

CONCLUSIONS

Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.

Transcutaneous electrical nerve stimulation for the management of tennis elbow: a pragmatic randomized controlled trial: the TATE trial (ISRCTN 87141084)

Background

Tennis elbow is a common and often extremely painful musculoskeletal condition, which has considerable impact on individuals as well as economic implications for healthcare utilization and absence from work. Many management strategies have been studied in clinical trials. Whilst corticosteroid injections offer short term pain relief, this treatment is unpleasant and is used with caution due to an associated high risk of pain recurrence in the long term. Systematic reviews conclude that there is no clear and effective treatment for symptoms of pain in the first 6 weeks of the condition. There is a clear need for an intervention that is acceptable to patients and provides them with effective short-term pain relief without increasing the risk of recurrence. Transcutaneous electrical nerve stimulation (TENS) is an inexpensive, non-invasive, non-pharmacological form of analgesia that is commonly used in the treatment of pain. TENS has very few contraindications and is simple to apply. It also benefits from being patient controlled, thereby promoting self-management. This study aims to assess the effectiveness, in terms of pain relief, and cost-effectiveness of a self-management package of treatment that includes TENS.

Methods/Design

The design of the study will be a two-group pragmatic randomized clinical trial. 240 participants aged 18 years and over with tennis elbow will be recruited from 20-30 GP practices in Staffordshire, UK. Participants are to be randomized on a 1:1 basis to receive either primary care management (standard GP consultation, medication, advice and education) or primary care management with the addition of TENS, over 6 weeks. Our primary outcome measure is average intensity of elbow pain in the past 24 hours (0-10 point numerical rating scale) at 6 weeks. Secondary outcomes include pain and limitation of function, global assessment of change, days of sick leave, illness perceptions, and overall health status. A cost-effectiveness analysis will also be performed. Patient adherence and satisfaction data will be collected at 6 weeks, 6 months and 12 months by postal questionnaire. A diary will also be completed for the first 2 weeks of treatment. Clinical effectiveness and cost-effectiveness analyses will be carried out using an intention-to-treat approach as the primary analysis.

Discussion

This paper presents detail on the rationale, design, methods and operational aspects of the trial.

Trial registration

Current Controlled Trials. ISRCTN87141084

Physiotherapy alone or in combination with corticosteroid injection for acute lateral epicondylitis in general practice: a protocol for a randomised, placebo-controlled study

Background

Lateral epicondylitis is a painful condition responsible for loss of function and sick leave for long periods of time. In many countries, the treatment guidelines recommend a wait-and-see policy, reflecting that no conclusions on the best treatment can be drawn from the available research, published studies and meta-analyses.

Methods/Design

Randomized double blind controlled clinical trial in a primary care setting. While earlier trials have either compared corticosteroid injections to physical therapy or to naproxen orally, we will compare the clinical effect of physiotherapy alone or physiotherapy combined with corticosteroid injection in the initial treatment of acute tennis elbow. Patients seeing their general practitioner with lateral elbow pain of recent onset will be randomised to one of three interventions: 1: physiotherapy, corticosteroid injection and naproxen or 2: physiotherapy, placebo injection and naproxen or 3: wait and see treatment with naproxen alone. Treatment and assessments are done by two different doctors, and the contents of the injection is unknown to both the treating doctor and patient. The primary outcome measure is the patient's evaluation of improvement after 6, 12, 26 and 52 weeks. Secondary outcome measures are pain, function and severity of main complaint, pain-free grip strength, maximal grip strength, pressure-pain threshold, the patient's satisfaction with the treatment and duration of sick leave.

Conclusion

This article describes a randomized, double blind, controlled clinical trial with a one year follow up to investigate the effects of adding steroid injections to physiotherapy in acute lateral epicondylitis.

Trial Registration

ClinicalTrials.gov Identifier: NCT00826462

A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma

OBJECTIVE

To appraise existing evidence for prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injection therapies for lateral epicondylosis (LE).

DESIGN

Systematic review.

DATA SOURCES

Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine.

SEARCH STRATEGY

names and descriptors of the therapies and LE.

STUDY SELECTION

All human studies assessing the four therapies for LE.

MAIN RESULTS

Results of five prospective case series and four controlled trials (three prolotherapy, two polidocanol, three autologous whole blood and one platelet-rich plasma) suggest each of the four therapies is effective for LE. In follow-up periods ranging from 9 to 108 weeks, studies reported sustained, statistically significant (p<0.05) improvement in visual analogue scale primary outcome pain score measures and disease-specific questionnaires; relative effect sizes ranged from 51% to 94%; Cohen's d ranged from 0.68 to 6.68. Secondary outcomes also improved, including biomechanical elbow function assessment (polidocanol and prolotherapy), presence of abnormalities and increased vascularity on ultrasound (autologous whole blood and polidocanol). Subjects reported satisfaction with therapies on single-item assessments. All studies were limited by small sample size.

CONCLUSIONS

There is strong pilot-level evidence supporting the use of prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injections in the treatment of LE. Rigorous studies of sufficient sample size, assessing these injection therapies using validated clinical, radiological and biomechanical measures, and tissue injury/healing-responsive biomarkers, are needed to determine long-term effectiveness and safety, and whether these techniques can play a definitive role in the management of LE and other tendinopathies.

Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: a randomized clinical trial

Cyriax and Cyriax advocated the use of deep transverse friction massage in combination with Mill's manipulation in treating lateral epicondylalgia. Evidence comparing this approach with other physical therapies is lacking. The purpose of this randomized clinical trial was to compare the effectiveness of deep transverse friction massage with Mill's manipulation versus phonophoresis with supervised exercise in managing lateral epicondylalgia. Sixty patients age 30-60, presenting with the teno-periosteal variety of lateral epicondylalgia with symptom duration greater than one month, were randomized into two groups. The control group received phonophoresis with diclofenac gel over the area of the lateral epicondyle for 5 minutes combined with supervised exercise. The experimental group received 10 minutes of deep transverse friction massage followed by a single application of Mill's manipulation. Both groups received treatment 3 times per week for 4 weeks. Outcomes of interest included pain via visual analog scale (VAS), pain-free grip strength, and functional status measured with the Tennis Elbow Function Scale. Data were analyzed using a one-way ANOVA. Whereas both groups improved significantly from the initiation of treatment, a between-group comparison revealed significantly greater (p<0.05) improvements regarding pain, pain-free grip, and functional status for the experimental group compared to the control group. The results of this study demonstrate that Cyriax physiotherapy is a superior treatment approach compared to phonophoresis and exercise in managing lateral epicondylalgia.

Neuropeptides in tendinopathy

Overuse tendinopathy remains a major clinical burden for sports medicine and general practitioners. Recent studies have highlighted the role of sensory and autonomic nerves in generating or perpetuating the symptoms and tissue abnormalities associated with tendinopathy. We outline the neuroanatomy and potential roles of nerves and associated neuropeptides in tendinopathy. In addition, intriguing new data is reviewed which suggests that there may be a substantial intrinsic source of neuropeptides within tendons - namely, the tenocytes themselves. The potential roles of Substance P and mast cells are highlighted in particular. We discuss the implications for conservative management including sclerosing injections and exercise training.

An alternative approach to treating lateral epicondylitis. A randomized, placebo-controlled, double-blinded study

OBJECTIVE

To investigate the effect of noxious level electrical stimulation on pain, grip strength and functional abilities in subjects with chronic lateral epicondylitis.

DESIGN

Randomized, placebo-control, double-blinded study.

SETTING

Physical Therapy Department, North Georgia College and State University.

SUBJECTS

Eighteen subjects with chronic lateral epicondylitis between the ages of 24 and 72 years participated in this study. Subjects were randomly assigned into treatment or placebo groups.

INTERVENTIONS

Subjects received six sessions of low-frequency electrical stimulation over the palpated tender points. The intensity of electrical stimulation was set at 0 in the placebo group.

MAIN MEASUREMENTS

Grip strength, functional status, pain intensity and limited activity due to pain were assessed before and after treatment. Six-month follow-up data were collected in treatment group only.

RESULTS

Both clinically and statistically significant improvements in average grip strength were found (treatment group: 28% increase; placebo group: 2.5% decrease; P=0.04), functional activity (treatment group: 110% increase; placebo group: 22% increase; P= 0.003), pain intensity (treatment group: 3.1 point decrease; placebo group: 0.2 point increase; P=0.01) and activity limitation due to pain (treatment group: 4.1 points increase; placebo group: 1.9 point decrease; P= 0.003) between the treatment and placebo groups. Follow-up data showed that 100% of subjects maintained the improved function, and 83% remained pain-free for at least six months post treatment.

CONCLUSION

The results of this study indicated that symptoms of chronic lateral epicondylitis could be effectively treated by noxious level low-frequency electrical stimulation.

Land- and water-based exercise therapies for musculoskeletal conditions

This chapter summarizes current evidence from recently published systematic reviews of land- and water-based exercise therapies for musculoskeletal conditions. The aim is to present an overview of the evidence and highlight gaps where more research is still needed. This is not a systematic review, but a systematic search of the literature and a summary of results of the best, most recent systematic reviews evaluating interventions for musculoskeletal conditions. There have been two previous summaries of systematic reviews of evidence for exercise therapies in musculoskeletal conditions. We have updated these searches, and additionally considered the evidence for the clinical effectiveness of exercise in fibromyalgia and chronic widespread pain and of hydrotherapy and water-based exercise treatments on pain and disability.

VEGF expression in patellar tendinopathy: a preliminary study

Vascular function and angiogenesis are regulated by vascular endothelial growth factor-A (VEGF). The purpose of this preliminary study was to address the following questions: Is VEGF expression in the patellar tendon more prevalent in patients with patellar tendinopathy than in individuals with normal, pain-free patellar tendons? Which cell populations express VEGF in normal and tendinopathic tendon? Is there a difference in symptom duration between VEGF+ and VEGF- tendons? We collected patellar tendon tissue from 22 patients undergoing open débridement of the patellar tendon and from 10 patients undergoing intramedullary nailing of the tibia. VEGF expression was assessed immunohistochemically. Relevant inflammatory and repair cell types were immunolabeled. VEGF expression was absent from control tendons, but was present in a subset of patients with histopathological evidence of angiofibroblastic tendinosis. VEGF was expressed in the intimal layer of tendon vessels, but was absent in other cell types. Patients demonstrating VEGF expression in the patellar tendon had a shorter symptom duration (12 +/- 7.8 months) than patients with no detectable VEGF (32.8 +/- 23.5 months). VEGF may contribute to the vascular hyperplasia that is a cardinal feature of symptomatic tendinosis, particularly in cases with more recent onset.

Treatment of tendinopathy: what works, what does not, and what is on the horizon

Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear.

LEVEL OF EVIDENCE

Level II, systematic review.

A systematic review with procedural assessments and meta-analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow)

Background

Recent reviews have indicated that low level level laser therapy (LLLT) is ineffective in lateral elbow tendinopathy (LET) without assessing validity of treatment procedures and doses or the influence of prior steroid injections.

Methods

Systematic review with meta-analysis, with primary outcome measures of pain relief and/or global improvement and subgroup analyses of methodological quality, wavelengths and treatment procedures.

Results

18 randomised placebo-controlled trials (RCTs) were identified with 13 RCTs (730 patients) meeting the criteria for meta-analysis. 12 RCTs satisfied half or more of the methodological criteria. Publication bias was detected by Egger's graphical test, which showed a negative direction of bias. Ten of the trials included patients with poor prognosis caused by failed steroid injections or other treatment failures, or long symptom duration or severe baseline pain. The weighted mean difference (WMD) for pain relief was 10.2 mm [95% CI: 3.0 to 17.5] and the RR for global improvement was 1.36 [1.16 to 1.60]. Trials which targeted acupuncture points reported negative results, as did trials with wavelengths 820, 830 and 1064 nm. In a subgroup of five trials with 904 nm lasers and one trial with 632 nm wavelength where the lateral elbow tendon insertions were directly irradiated, WMD for pain relief was 17.2 mm [95% CI: 8.5 to 25.9] and 14.0 mm [95% CI: 7.4 to 20.6] respectively, while RR for global pain improvement was only reported for 904 nm at 1.53 [95% CI: 1.28 to 1.83]. LLLT doses in this subgroup ranged between 0.5 and 7.2 Joules. Secondary outcome measures of painfree grip strength, pain pressure threshold, sick leave and follow-up data from 3 to 8 weeks after the end of treatment, showed consistently significant results in favour of the same LLLT subgroup (p < 0.02). No serious side-effects were reported.

Conclusion

LLLT administered with optimal doses of 904 nm and possibly 632 nm wavelengths directly to the lateral elbow tendon insertions, seem to offer short-term pain relief and less disability in LET, both alone and in conjunction with an exercise regimen. This finding contradicts the conclusions of previous reviews which failed to assess treatment procedures, wavelengths and optimal doses.

Tennis elbow

INTRODUCTION

Lateral pain in the elbow affects up to 3% of the population, and is considered an overload injury of the extensor tendons of the forearm where they attach at the lateral epicondyle. Although usually self-limiting, symptoms may persist for over 1 year in up to 20% of people.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for tennis elbow? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 30 systematic reviews, RCTs or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, corticosteroid injections, exercise and mobilisation, extracorporeal shock wave therapy, non-steroidal anti-inflammatory drugs (oral and topical), orthoses (bracing), and surgery.