Role of strengthening during nonoperative treatment of lateral epicondyle tendinopathy

Manual therapy and exercise for lateral elbow pain

BACKGROUND

Manual therapy and prescribed exercises are often provided together or separately in contemporary clinical practice to treat people with lateral elbow pain.

OBJECTIVES

To assess the benefits and harms of manual therapy, prescribed exercises or both for adults with lateral elbow pain.

SEARCH METHODS

We searched the databases CENTRAL, MEDLINE and Embase, and trial registries until 31 January 2024, unrestricted by language or date of publication.

SELECTION CRITERIA

We included randomised or quasi-randomised trials. Participants were adults with lateral elbow pain. Interventions were manual therapy, prescribed exercises or both. Primary comparators were placebo or minimal or no intervention. We also included comparisons of manual therapy and prescribed exercises with either intervention alone, with or without glucocorticoid injection. Exclusions were trials testing a single application of an intervention or comparison of different types of manual therapy or prescribed exercises.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted trial characteristics and numerical data, and assessed study risk of bias and certainty of evidence using GRADE. The main comparisons were manual therapy, prescribed exercises or both compared with placebo treatment, and with minimal or no intervention. Major outcomes were pain, disability, heath-related quality of life, participant-reported treatment success, participant withdrawals, adverse events and serious adverse events. The primary endpoint was end of intervention for pain, disability, health-related quality of life and participant-reported treatment success and final time point for adverse events and withdrawals.

MAIN RESULTS

Twenty-three trials (1612 participants) met our inclusion criteria (mean age ranged from 38 to 52 years, 47% female, 70% dominant arm affected). One trial (23 participants) compared manual therapy to placebo manual therapy, 12 trials (1124 participants) compared manual therapy, prescribed exercises or both to minimal or no intervention, six trials (228 participants) compared manual therapy and exercise to exercise alone, one trial (60 participants) compared the addition of manual therapy to prescribed exercises and glucocorticoid injection, and four trials (177 participants) assessed the addition of manual therapy, prescribed exercises or both to glucocorticoid injection. Twenty-one trials without placebo control were susceptible to performance and detection bias as participants were not blinded to the intervention. Other biases included selection (nine trials, 39%, including two quasi-randomised), attrition (eight trials, 35%) and selective reporting (15 trials, 65%) biases. We report the results of the main comparisons. Manual therapy versus placebo manual therapy Low-certainty evidence, based upon a single trial (23 participants) and downgraded due to indirectness and imprecision, indicates manual therapy may reduce pain and elbow disability at the end of two to three weeks of treatment. Mean pain at the end of treatment was 4.1 points with placebo (0 to 10 scale) and 2.0 points with manual therapy, MD -2.1 points (95% CI -4.2 to -0.1). Mean disability was 40 points with placebo (0 to 100 scale) and 15 points with manual therapy, MD -25 points (95% CI -43 to -7). There was no follow-up beyond the end of treatment to show if these effects were sustained, and no other major outcomes were reported. Manual therapy, prescribed exercises or both versus minimal intervention Low-certainty evidence indicates manual therapy, prescribed exercises or both may slightly reduce pain and disability at the end of treatment, but the effects were not sustained, and there may be little to no improvement in health-related quality of life or number of participants reporting treatment success. We downgraded the evidence due to increased risk of performance bias and detection bias across all the trials, and indirectness due to the multimodal nature of the interventions included in the trials. At four weeks to three months, mean pain was 5.10 points with minimal treatment and manual therapy, prescribed exercises or both reduced pain by a MD of -0.53 points (95% CI -0.92 to -0.14, I2 = 43%; 12 trials, 1023 participants). At four weeks to three months, mean disability was 63.8 points with minimal or no treatment and manual therapy, prescribed exercises or both reduced disability by a MD of -5.00 points (95% CI -9.22 to -0.77, I2 = 63%; 10 trials, 732 participants). At four weeks to three months, mean quality of life was 73.04 points with minimal treatment on a 0 to 100 scale and prescribed exercises reduced quality of life by a MD of -5.58 points (95% CI -10.29 to -0.99; 2 trials, 113 participants). Treatment success was reported by 42% of participants with minimal or no treatment and 57.1% of participants with manual therapy, prescribed exercises or both, RR 1.36 (95% CI 0.96 to 1.93, I2 = 73%; 6 trials, 770 participants). We are uncertain if manual therapy, prescribed exercises or both results in more withdrawals or adverse events. There were 83/566 participant withdrawals (147 per 1000) from the minimal or no intervention group, and 77/581 (126 per 1000) from the manual therapy, prescribed exercises or both groups, RR 0.86 (95% CI 0.66 to 1.12, I2 = 0%; 12 trials). Adverse events were mild and transient and included pain, bruising and gastrointestinal events, and no serious adverse events were reported. Adverse events were reported by 19/224 (85 per 1000) in the minimal treatment group and 70/233 (313 per 1000) in the manual therapy, prescribed exercises or both groups, RR 3.69 (95% CI 0.98 to 13.97, I2 = 72%; 6 trials).

AUTHORS' CONCLUSIONS

Low-certainty evidence from a single trial in people with lateral elbow pain indicates that, compared with placebo, manual therapy may provide a clinically worthwhile benefit in terms of pain and disability at the end of treatment, although the 95% confidence interval also includes both an important improvement and no improvement, and the longer-term outcomes are unknown. Low-certainty evidence from 12 trials indicates that manual therapy and exercise may slightly reduce pain and disability at the end of treatment, but this may not be clinically worthwhile and these benefits are not sustained. While pain after treatment was an adverse event from manual therapy, the number of events was too small to be certain.

Efficacy of extension wrist hand orthosis on pain, grip strength and electromyographic activities in lateral epicondylitis: A randomized single-blind clinical trial

BACKGROUND

Lateral epicondylitis (LE) is one of the most common work-related complications characterized by pain, decreased grip strength and dysfunction of upper limb. Although conservative management such as physiotherapy and orthosis is reported as first line of treatment, sufficient evidence to decide their effectiveness is lacking and remains controversial.

PURPOSE

The current study evaluated and compared the efficacy of a custom-made extension wrist hand orthosis adjunct to usual physiotherapy and therapeutics alone for subjects with LE.

STUDY DESIGN

Prospective randomized single-blinded clinical trial.

METHODS

62 subjects with LE were selected as samples using convenience method in this experimental study. They were randomly divided into two groups: usual physiotherapy only and its combination with orthosis. Pain and grip strength were measured using Visual Analog Scale and Jamar hydraulic digital hand dynamometer. Muscle activity of extensor carpi radialis brevis during hand gripping was measured using surface electro-myographic by PowerLab electromyography (AD Instruments, Castle Hill, Australia). Data analysis and comparison were performed for baseline and post-intervention (12weeks).

RESULTS

After 12weeks of treatment, there were significant differences in mean scores of pain (1.22 ± 0.51, p = 0.001), maximum voluntary grip strength (5.82 ± 7.84, p = 0.04), and extensor carpi radialis brevis muscle activation (0.082 ± 0.094, p = 0.02) between the therapeutics alone group and the therapeutics plus orthosis group. Compared to therapeutics alone, those getting a combination of physiotherapy and orthosis had greater treatment efficacy (p < 0.05).

CONCLUSIONS

Both postintervention (12-week) treatments could affect pain scores, grip strength, and extensor muscle activation. Custom-made extension wrist hand orthosis adjunct to usual physiotherapy is more effective than therapeutics alone in subjects with LE. Therefore, the use of wrist orthosis adjunct to physiotherapy should be recommended in rehabilitation settings for LE.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Position statement: nonoperative management of lateral epicondylitis in adults

We sought to compare methods of nonsurgical treatment of lateral epicondylitis in men and women older than 18 years to develop a guideline intended for orthopedic surgeons and other health care providers who assess, counsel and care for these patients. We searched Medline, Embase and Cochrane through to Mar. 9, 2021, and included all English-language studies comparing nonsurgical approaches. We compared physiotherapy versus no active treatment, corticosteroids versus placebo, platelet-rich plasma (PRP) versus placebo, and autologous blood injection versus placebo. Outcomes of interest were pain outcomes (visual analogue scale scores) and functional outcomes. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. This guideline will benefit patients seeking nonsurgical intervention for lateral epicondylitis by improving counselling on nonsurgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various nonsurgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making.

Digital Rehabilitation for Elbow Pain Musculoskeletal Conditions: A Prospective Longitudinal Cohort Study

Elbow musculoskeletal pain (EP) is a major cause of disability. Telerehabilitation has shown great potential in mitigating musculoskeletal pain conditions, but EP is less explored. This single-arm interventional study investigates clinical outcomes and engagement levels of a completely remote multimodal digital care program (DCP) in patients with EP. The DCP consisted of exercise, education, and cognitive-behavioral therapy for 8 weeks. Primary outcome: disability change (through the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), treatment response cut-offs: 12.0-point reduction and 30% change). Secondary outcomes: pain, analgesic intake, surgery intent, mental health, fear-avoidance beliefs, work productivity, and patient engagement. Of the 132 individuals that started the DCP, 112 (84.8%) completed the intervention. Significant improvements were observed in QuickDASH with an average reduction of 48.7% (11.9, 95% CI 9.8; 14.0), with 75.3% of participants reporting ≥30% change and 47.7% reporting ≥12.0 points. Disability change was accompanied by reductions in pain (53.1%), surgery intent (57.5%), anxiety (59.8%), depression (68.9%), fear-avoidance beliefs (34.2%), and productivity impairment (72.3%). Engagement (3.5 (SD 1.4) sessions per week) and satisfaction 8.5/10 (SD 1.6) were high. The significant improvement observed in clinical outcomes, alongside high engagement, and satisfaction suggests patient acceptance of this care delivery mode.

Nonoperative treatment of lateral epicondylitis: a systematic review and meta-analysis

Background

There is an ongoing controversy regarding the nonoperative treatment of lateral epicondylitis. Given that the evidence surrounding the use of various treatment options for lateral epicondylitis has expanded, an overall assessment of nonoperative treatment options is required. The purpose of this systematic review and meta-analysis was to compare physiotherapy (strengthening), corticosteroids (CSIs), platelet-rich plasma (PRP), and autologous blood (AB) with no active treatment or placebo control in patients with lateral epicondylitis.

Methods

MEDLINE, Embase, and Cochrane were searched through till March 8, 2021. Additional studies were identified from reviews. All English-language randomized trials comparing nonoperative treatment of patients >18 years of age with lateral epicondylitis were included.

Results

A total of 5 randomized studies compared physiotherapy (strengthening) with no active treatment. There were no significant differences in pain (mean difference: −0.07, 95% confidence interval [CI]: −0.56 to 0.41) or function (standardized mean difference [SMD]: −0.08, 95% CI: −0.46 to 0.30). Seven studies compared CSI with a control. The control group had statistically superior pain (mean difference: 0.70, 95% CI: 0.22 to 1.18) and functional scores (SMD: −0.35, 95% CI: −0.54 to −0.16). Two studies compared PRP with controls, and no differences were found in pain (SD: −0.15, 95% CI: −1.89 to 1.35) or function (SMD: 0.14, 95% CI: −0.45 to 0.73). Three studies compared AB with controls, and no differences were observed in pain (0.49, 95% CI: −2.35 to 3.33) or function (−0.07, 95% CI: −0.64 to 0.50).

Discussion

The available evidence does not support the use of nonoperative treatment options including physiotherapy (strengthening), CSI, PRP, or AB in the treatment of lateral epicondylitis.

"I didn't know what I could do": Behaviors, knowledge and beliefs, and social facilitation after distal radius fracture

BACKGROUND

Biomedical models have limitations in explaining and predicting recovery after distal radius fracture (DRF). Variation in recovery after DRF may be related to patients' behaviors and beliefs, factors that can be framed using a lens of self-management. We conceptualized the self-management process using social cognitive theory as reciprocal interactions between behaviors, knowledge and beliefs, and social facilitation. Understanding this process can contribute to needs identification to optimize recovery.

PURPOSE

Describe the components of the self-management process after DRF from the patient's perspective.

STUDY DESIGN

Qualitative descriptive analysis.

METHODS

Thirty-one adults aged 45-72 with a unilateral DRF were recruited from rehabilitation centers and hand surgeons' practices. They engaged in one semi-structured interview 2-4 weeks after discontinuation of full-time wrist immobilization. Data were analyzed using qualitative descriptive techniques, including codes derived from the data and conceptual framework. Codes and categories were organized using the three components of the self-management process.

RESULTS

Participants engaged in medical, role, and emotional management behaviors to address multidimensional sequelae of injury, with various degrees of self-direction. They described limited knowledge of their condition and its medical management, naive beliefs about their expected recovery, and uncertainty regarding safe movement and use of their extremity. They reported informational, instrumental, and emotional support from health care professionals and a broader circle.

CONCLUSIONS

Descriptions of multiple domains of behaviors emphasized health-promoting actions beyond adherence to medical recommendations. Engagement in behaviors was reciprocally related to participants' knowledge and beliefs, including illness and pain-related perceptions. The findings highlight relevance of health behavior after DRF, which can be facilitated by hand therapists as part of the social environment. Specifically, hand therapists can assess and address patients' behaviors and beliefs to support optimal recovery.