Laser therapy: a randomized, controlled trial of the effects of low intensity Nd:YAG laser irradiation on lateral epicondylitis

Comparative Effectiveness of Physical Therapy and Electrophysiotherapy for the Treatment of Lateral Epicondylitis: A Network Meta-Analysis

BACKGROUND

Lateral epicondylitis (LE) is a common enthesopathy, possibly caused by overuse and repetitive activity. Although non-operative management is the primary approach for treating LE, clinical guidelines and the literature fail to identify the most effective non-operative treatment. Therefore, we conducted a network meta-analysis to compare the effectiveness of physical therapy and electrophysiotherapy treatments for the treatment of LE.

METHODS

We searched MEDLINE, EMBASE, Web of Science, and Scopus for peer-reviewed, randomized controlled trials evaluating the effectiveness of physical therapy and electrophysiotherapy treatments. Data related to article characteristics and outcomes (grip strength and pain VAS) were collected.

RESULTS

Twenty-three clinical trials, including 1,363 participants (mean [SD] age, 47.4 [7.5], 53.1% women) were eligible in this study. Pain VAS demonstrated significant reductions in scores following treatment with magnetic field (mean difference (MD) [95% CI],-1.88 [-2.66 to -1.11]), exercise (MD [95% CI], -0.90 [-1.69 to -0.1]), and acoustic waves (MD [95% CI], -0.83 [-1.37 to -0.29]) compared to placebo. For grip strength, no treatment modality was found to be significantly effective. A sensitivity analysis that excluded studies with high publication bias and high degrees of heterogeneity produced similar results to the main analysis with the exception of statistically improved grip strength after light therapy (MD [95% CI], 5.38 [1.71 to 9.04]) and acoustic wave therapy (MD [95% CI], 7.79 [2.44 to 13.15]).

CONCLUSION

Overall, electrophysiotherapy treatments should be prioritized over physical therapy. Magnetic field therapy was associated with pain reduction, whereas acoustic wave and light therapy were associated with increased grip strength.

Effect of class IV laser therapy and Pilates exercises on bone density and pain in primary osteoporosis: a randomised controlled trial

Background/aims

Osteoporosis is a systemic disorder characterised by a decrease in bone quality and density. This causes the bones to become weak and unable to withstand mild stresses, and the associated pain is made worse with activities. The aim of this study was to investigate the effect of class IV laser therapy and Pilates exercises on bone mineral density and pain in patients with primary osteoporosis.

Methods

A total of 60 patients with osteoporosis (40 women and 20 men) participated in this study. Their age ranged between 40 and 60 years. They were allocated randomly to three groups: Group A (n=20) received multiwave locked system laser therapy, group B (n=20) patients received Pilates exercises and group C (n=20) received multiwave locked system laser therapy and Pilates exercises. The treatment programme took place three times a week for 8 weeks. Bone mineral density of the lumbar spine (L1–L4) was measured by dual-energy X-ray absorptiometry and pain intensity during activities was measured by using the Numeric Pain Rating Scale. Evaluation of lumbar bone mineral density and pain intensity were performed before and after 8 weeks.

Results

The statistical analysis of this study revealed there was a significant increase of T-scores post-treatment compared to pre-treatment within group A (P=0.0001; P<0.05), group B (P=0.0001; P<0.05), and group C (P=0.0001), with improvement percentages of 19.59, 34.69 and 50.66% respectively. There was a decrease of pain intensity during activities post-treatment compared to pre-treatment within group A (P=0.0001; P<0.05), group B (P=0.0001; P<0.05) and group C (P=0.0001), with improvement percentages of 41.28, 54.39 and 70.09% respectively.

Conclusions

Class IV laser therapy and Pilates exercises are useful therapeutic modalities to increase bone mineral density and decrease pain in patients with osteoporosis, but combining them is more effective than using them separately.

Efficacy of Nonoperative Treatments for Lateral Epicondylitis: A Systematic Review and Meta-Analysis

BACKGROUND

Lateral epicondylitis is a common overuse injury affecting approximately 1 to 3 percent of the population. Although symptoms may disappear spontaneously within 1 year, the clinical guidelines for conservative treatment are not clear. The authors' objective was to examine the outcomes of nonsurgical treatments for lateral epicondylitis through a meta-analysis and provide a treatment recommendation using the available evidence.

METHODS

The authors searched the PubMed, EMBASE, Scopus, and Web of Science databases to identify primary research articles studying conservative treatments (electrophysiotherapy, physical therapy, and injections) for lateral epicondylitis. The authors included randomized controlled trials published in peer-reviewed journals. Data related to outcomes (pain, grip strength, Patient-Rated Tennis Elbow Evaluation score, and Disabilities of the Arm, Shoulder and Hand score) and complications were extracted.

RESULTS

Fifty-eight randomized controlled trials were included in the meta-analysis. Electrophysiotherapy was effective in improving pain [mean difference, -10.0 (95 percent CI, -13.8 to -6.1)], Patient-Rated Tennis Elbow Evaluation score [mean difference, -10.7 (95 percent CI, -16.3 to -5.0)], and Disabilities of the Arm, Shoulder and Hand score [mean difference, -11.9 (95 percent CI, -15.8 to -7.9)]; and physical therapy improved pain [mean difference, -6.0 (95 percent CI, -9.7 to -2.3)] and Patient-Rated Tennis Elbow Evaluation scores [mean difference, -7.5 (95 percent CI, -11.8 to -3.2)] compared to placebo. Injections did not improve any outcome measures. Patients who received electrophysiotherapy and injections reported higher adverse effects than physical therapy patients.

CONCLUSIONS

Patients who received electrophysiotherapy and physical therapy reported statistically and clinically improved scores in pain and function compared to placebo. Injections may put patients at higher risk for adverse effects compared to other conservative treatments. When managing lateral epicondylitis conservatively, electrophysiotherapy and physical therapy should be prioritized before other interventions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Comparative Efficacy and Safety of Nonsurgical Treatment Options for Enthesopathy of the Extensor Carpi Radialis Brevis: A Systematic Review and Meta-analysis of Randomized Placebo-Controlled Trials

BACKGROUND

Numerous treatment options have been proposed for enthesopathy of the extensor carpi radialis brevis (eECRB).

PURPOSE

To (1) compare the efficacy and safety of nonsurgical treatment options for eECRB described in randomized placebo-controlled trials at short-term, midterm, and long-term follow-up and (2) evaluate outcomes in patients receiving placebo.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Following PRISMA guidelines, 4 electronic databases were searched for randomized placebo-controlled trials for eECRB. Studies reporting visual analog scale (VAS) for pain scores and/or grip strength were included. Random- or fixed-effects meta-analysis was employed to compare treatments with at least 2 eligible studies using the standardized mean difference and odds ratio. The study protocol was registered at PROSPERO (ID: CRD42018075009).

RESULTS

Thirty-six randomized placebo-controlled trials, evaluating 11 different treatment modalities, with a total of 2746 patients were included. At short-term follow-up, only local corticosteroid injection improved pain; however, it was associated with pain worse than placebo at long-term follow-up. At midterm follow-up, laser therapy and local botulinum toxin injection improved pain. At long-term follow-up, extracorporeal shock wave therapy provided pain relief. With regard to grip strength, only laser therapy showed better outcomes in comparison with placebo. While there was no difference among various treatments in the odds ratio of an adverse event, they all increased adverse events compared with placebo. In placebo-receiving patients, a sharp increase in the percentage of patients reporting mild pain or less was observed from 2% at short-term follow-up to 92% at midterm follow-up.

CONCLUSION

Most patients experienced pain resolution after receiving placebo within 4 weeks of follow-up. At best, all treatments provided only small pain relief while increasing the odds of adverse events. Therefore, if clinicians are inclined to provide a treatment for particular patients, they may consider a pain relief regimen for the first 4 weeks of symptom duration. Patient-specific factors should be considered when deciding on treatment or watchful waiting.

Short-term Efficacy Comparison of High-intensity and Low-intensity Laser Therapy in the Treatment of Lateral Epicondylitis: A Randomized Double-blind Clinical Study

Objectives

This study aims to evaluate and compare the short-term efficacies of high-intensity laser therapy (HILT) and low-intensity laser therapy (LILT) in the treatment of lateral epicondylitis (LE).

Patients and methods

Sixty patients (16 males, 44 females; mean age 44.2±9.3 years; range, 18 to 65 years) with unilateral elbow pain were randomized into two groups as 30 patients treated with HILT (9 males and 21 females) and 30 patients treated with LILT (7 males and 23 females). The HILT (1,064 nm) and LILT (904 nm) were administered three times a week for three weeks, and each treatment was combined with an epicondylitis bandage. A visual analog scale (VAS), quick Disabilities of the Arm, Shoulder, and Hand (QDASH) questionnaire, Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36), and hand grip strength test were used to evaluate the patients before and three weeks after treatment.

Results

The two groups had similar demographic characteristics, including age, sex, occupation, and body mass index (p>0.05). There were no statistically significant differences between the two groups in terms of the pretreatment VAS, QDASH, hand grip strength, and SF-36 scores (p>0.05). After three weeks, both groups showed significant improvements in all of the parameters (p<0.05). However, in the HILT group, the QDASH, hand grip strength, and SF-36 physical component summary (PCS) scores showed superior improvement compared to the LILT group (p<0.05).

Conclusion

Each treatment modality was found to be effective and safe for the short-term treatment of LE. However, the HILT exhibited more significant effects on the hand grip strength, QDASH, and SF-36 PCS scores than the LILT.

Effectiveness of Low Level Laser Therapy (LLLT) in the treatment of Lateral elbow tendinopathy (LET): an umbrella review

PURPOSE

The aim of this umbrella review is to determine the effectiveness of LLLT in the treatment of LET and to provide recommendations based on this evidence.

METHODS

A comprehensive and systematic review was undertaken using Medline, EBSCO and EMBASE. Systematic reviews or meta-analysis were included if they compared Laser with at least one of the following: (i) placebo, (ii) no treatment, (iii) another treatment, conservative (physical therapy intervention or medical) or operative of LET. Principal outcomes included the assessment of short and long-term effect on functional status, pain, grip strength (pain-free or maximum) and a global measure (overall improvement).

RESULTS

Seven papers met the inclusion criteria for the umbrella review, Five papers were of moderate and two of low methodological quality. All reviews reported benefits associated with laser therapy Vs other intervention or placebo, however the significance of the identified benefits differed between studies and reviews. No review reported negative effects of laser therapy or harm to patients. All reviews noted significant variance between included studies with 2 reviews citing statistically significant heterogeneity. It is essential to consider this in the interpretation of these data.

CONCLUSION

This umbrella review found poor results for the effectiveness of LLLT in the management of LET. Therefore, further research with well-designed RCTs is required to provide meaningful evidence on the effectiveness (absolute and relative) of LLLT for the management of LET.

Comparison of effects of Cyriax physiotherapy, a supervised exercise programme and polarized polychromatic non-coherent light (Bioptron light) for the treatment of lateral epicondylitis

Objective: To compare the effectiveness of Cyriax physiotherapy, a supervised exercise programme, and polarized polychromatic non-coherent light (Bioptron light) in the treatment of lateral epicondylitis.

Design: Controlled clinical trial.

Setting: Rheumatology and rehabilitation centre.

Subjects: This study was carried out with 75 patients who had lateral epicondylitis. They were allocated to three groups by sequential allocation.

Interventions: Group A ( n=25) was treated with Cyriax physiotherapy. A supervised exercise programme was given to group B ( n=25). Group C ( n=25) received polarized polychromatic non-coherent light (Bioptron light). All patients received three treatments per week for four weeks.

Outcomes: Pain was evaluated using a visual analogue scale and function using a visual analogue scale and pain-free grip strength at the end of the four-week course of treatment (week 4), one month (week 8), three months (week 16) and six months (week 28) after the end of treatment.

Results: The supervised exercise programme produced the largest effect in the reduction of pain and in the improvement of function at the end of the treatment ( P<0.05) and at any of the follow-up time points ( P<0.05).

Conclusion: The supervised exercise programme should be the first treatment option for therapists when they manage lateral epicondylitis patients. If this is not possible, Cyriax physiotherapy and polarized polychromatic non-coherent light (Bioptron light) may be suitable.

The use of Bioptron light (polarized, polychromatic, non-coherent) therapy for the treatment of acute ankle sprains

Purpose The purpose of this study was to investigate the efficacy of Bioptron light therapy for the treatment of acute ankle sprains. Method A parallel group, single-blind, controlled study was carried out in patients with grade II acute ankle sprains. Patients were randomly allocated into two treatment groups (n = 25 for each). Both groups received cryotherapy, and the test group also received Bioptron light therapy. All treatments were performed daily for 5 d. Evaluations included self-reported pain via a visual analogue scale, degree of ankle edema, and ankle range of motion via goniometry carried out before the treatment and at the end of the treatment. Results The test group showed the largest magnitude of improvement for all evaluations at treatment five, and the between-group differences observed were statistically significant (p < 0.0005 for each). Conclusions These data provide preliminary evidence of the efficacy of Bioptron light therapy supplemented with cryotherapy for the treatment of acute ankle sprains; however, larger studies are required to confirm these results. Implications for Rehabilitation Ankle sprains are common acute injuries among professional and recreational sports players but also among people in general. Cryotherapy is the first-standard treatment of acute ankle sprains. Phototherapy such as Bioptron light has been recommended supplement to cryotherapy to reduce the symptoms of ankle sprains. The results of the present trial showed that using BIOPTRON LIGHT and cryotherapy the rehabilitation period of acute ankle sprains can be reduced.

What is the clinical effectiveness and cost-effectiveness of conservative interventions for tendinopathy? An overview of systematic reviews of clinical effectiveness and systematic review of economic evaluations

BACKGROUND

Lateral elbow tendinopathy (LET) is a common complaint causing characteristic pain in the lateral elbow and upper forearm, and tenderness of the forearm extensor muscles. It is thought to be an overuse injury and can have a major impact on the patient's social and professional life. The condition is challenging to treat and prone to recurrent episodes. The average duration of a typical episode ranges from 6 to 24 months, with most (89%) reporting recovery by 1 year.

OBJECTIVES

This systematic review aims to summarise the evidence concerning the clinical effectiveness and cost-effectiveness of conservative interventions for LET.

DATA SOURCES

A comprehensive search was conducted from database inception to 2012 in a range of databases including MEDLINE, EMBASE and Cochrane Databases.

METHODS AND OUTCOMES

We conducted an overview of systematic reviews to summarise the current evidence concerning the clinical effectiveness and a systematic review for the cost-effectiveness of conservative interventions for LET. We identified additional randomised controlled trials (RCTs) that could contribute further evidence to existing systematic reviews. We searched MEDLINE, EMBASE, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, Web of Science, The Cochrane Library and other important databases from inception to January 2013.

RESULTS

A total of 29 systematic reviews published since 2003 matched our inclusion criteria. These were quality appraised using the Assessment of Multiple Systematic Reviews (AMSTAR) checklist; five were considered high quality and evaluated using a Grading of Recommendations, Assessment, Development and Evaluation approach. A total of 36 RCTs were identified that were not included in a systematic review and 29 RCTs were identified that had only been evaluated in an included systematic review of intermediate/low quality. These were then mapped to existing systematic reviews where further evidence could provide updates. Two economic evaluations were identified.

LIMITATIONS

The summary of findings from the review was based only on high-quality evidence (scoring of > 5 AMSTAR). Other limitations were that identified RCTs were not quality appraised and dichotomous outcomes were also not considered. Economic evaluations took effectiveness estimates from trials that had small sample sizes leading to uncertainty surrounding the effect sizes reported. This, in turn, led to uncertainty of the reported cost-effectiveness and, as such, no robust recommendations could be made in this respect.

CONCLUSIONS

Clinical effectiveness evidence from the high-quality systematic reviews identified in this overview continues to suggest uncertainty as to the effectiveness of many conservative interventions for the treatment of LET. Although new RCT evidence has been identified with either placebo or active controls, there is uncertainty as to the size of effects reported within them because of the small sample size. Conclusions regarding cost-effectiveness are also unclear. We consider that, although updated or new systematic reviews may also be of value, the primary focus of future work should be on conducting large-scale, good-quality clinical trials using a core set of outcome measures (for defined time points) and appropriate follow-up. Subgroup analysis of existing RCT data may be beneficial to ascertain whether or not certain patient groups are more likely to respond to treatments.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003593.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Efficacy of physical therapy for the treatment of lateral epicondylitis: a meta-analysis

Background

Physical therapy for the treatment of lateral epicondylitis (LE) often comprises movement therapies, extracorporeal shockwave therapy (ECSWT), low level laser therapy (LLLT), low frequency electrical stimulation or pulsed electromagnetic fields. Still, only ECSWT and LLLT have been meta-analytically researched.

Methods

PUBMED, EMBASE and Cochrane database were systematically searched for randomized controlled trials (RCTs). Methodological quality of each study was rated with an adapted version of the Scottish Intercollegiate Guidelines Network (SIGN) checklist. Pain reduction (the difference between treatment and control groups at the end of trials) and pain relief (the change in pain from baseline to the end of trials) were calculated with mean differences (MD) and 95 %-Confidence intervals (95 % CI).

Results

One thousand one hundred thirty eight studies were identified. One thousand seventy of those did not meet inclusion criteria. After full articles were retrieved 16 studies met inclusion criteria and 12 studies reported comparable outcome variables. Analyses were conducted for overall pain relief, pain relief during maximum handgrip strength tests, and maximum handgrip strength. There were not enough studies to conduct an analysis of physical function or other outcome variables.

Conclusions

Differences between treatment and control groups were larger than differences between treatments. Control group gains were 50 to 66 % as high as treatment group gains. Still, only treatment groups with their combination of therapy specific and non-therapy specific factors reliably met criteria for clinical relevance. Results are discussed with respect to stability and their potential meaning for the use of non-therapy specific agents to optimize patients’ gain.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0665-4) contains supplementary material, which is available to authorized users.

Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials

BACKGROUND

Non-surgical approaches to treatment of lateral epicondylitis are numerous. The aim of this systematic review is to examine randomized, controlled trials of these treatments.

METHODS

Numerous databases were systematically searched from earliest records to February 2013. Search terms included "lateral epicondylitis," "lateral elbow pain," "tennis elbow," "lateral epicondylalgia," and "elbow tendinopathy" combined with "randomized controlled trial." Two reviewers examined the literature for eligibility via article abstract and full text.

RESULTS

Fifty-eight articles met eligibility criteria: (1) a target population of patients with symptoms of lateral epicondylitis; (2) evaluation of treatment of lateral epicondylitis with the following non-surgical techniques: corticosteroid injection, injection technique, iontophoresis, botulinum toxin A injection, prolotherapy, platelet-rich plasma or autologous blood injection, bracing, physical therapy, shockwave therapy, or laser therapy; and (3) a randomized controlled trial design. Lateral epicondylitis is a condition that is usually self-limited. There may be a short-term pain relief advantage found with the application of corticosteroids, but no demonstrable long-term pain relief. Injection of botulinum toxin A and prolotherapy are superior to placebo but not to corticosteroids, and botulinum toxin A is likely to produce concomitant extensor weakness. Platelet-rich plasma or autologous blood injections have been found to be both more and less effective than corticosteroid injections. Non-invasive treatment methods such as bracing, physical therapy, and extracorporeal shockwave therapy do not appear to provide definitive benefit regarding pain relief. Some studies of low-level laser therapy show superiority to placebo whereas others do not.

CONCLUSIONS

There are multiple randomized controlled trials for non-surgical management of lateral epicondylitis, but the existing literature does not provide conclusive evidence that there is one preferred method of non-surgical treatment for this condition. Lateral epicondylitis is a condition that is usually self-limited, resolving over a 12- to 18-month period without treatment.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions to Authors for a complete description of level of evidence.

Humeral lateral epicondylitis complicated by hydroxyapatite dihydrite deposition disease: a case report

OBJECTIVE

The aim of this case report is to differentiate the recovery timeline expected for patients with simple lateral epicondylitis from an abnormal recovery period, in which case an underlying condition should be suspected.

CLINICAL FEATURES

A 49-year-old woman presented to a chiropractic clinic with posterolateral right elbow pain. The history included chronic recurrent lateral elbow pain, followed by a traumatic event leading to sustained pain and disability.

INTERVENTION AND OUTCOMES

Following a trial of conservative therapy including activity restrictions, soft tissue therapy, joint mobilizations, and therapeutic ultrasonography that led to no significant improvement, the patient was referred for diagnostic imaging that revealed hydroxyapatite dihydrite deposition disease.

CONCLUSION

This report describes a case for which lateral epicondylitis symptoms failed to resolve because of an underlying condition (hydroxyapatite dihydrite deposition disease). This case emphasizes that primary care practitioners treating lateral epicondylitis should consider referral for further investigations when positive results are not achieved.

Current concepts in examination and treatment of elbow tendon injury

Context:

Injuries to the tendons of the elbow occur frequently in the overhead athlete, creating a significant loss of function and dilemma to sports medicine professionals. A detailed review of the anatomy, etiology, and pathophysiology of tendon injury coupled with comprehensive evaluation and treatment information is needed for clinicians to optimally design treatment programs for rehabilitation and prevention.

Evidence Acquisitions:

The PubMed database was searched in January 2012 for English-language articles pertaining to elbow tendon injury.

Results:

Detailed information on tendon pathophysiology was found along with incidence of elbow injury in overhead athletes. Several evidence-based reviews were identified, providing a thorough review of the recommended rehabilitation for elbow tendon injury.

Conclusions:

Humeral epicondylitis is an extra-articular tendon injury that is common in athletes subjected to repetitive upper extremity loading. Research is limited on the identification of treatment modalities that can reduce pain and restore function to the elbow. Eccentric exercise has been studied in several investigations and, when coupled with a complete upper extremity strengthening program, can produce positive results in patients with elbow tendon injury. Further research is needed in high-level study to delineate optimal treatment methods.

Tratamento fisioterapêutico para epicondilite lateral: uma revisão sistemática

INTRODUÇÃO: Embora o tratamento conservador ainda seja a melhor conduta inicial para a epicondilite lateral do cotovelo, há pouca evidência científica de que o tratamento fisioterapêutico altere o curso natural da doença e seja efetiva no tratamento dessa patologia. OBJETIVO: Avaliar a efetividade e a segurança das diversas intervenções fisioterapêuticas utilizadas no tratamento conservador da epicondilite lateral. MATERIAIS E MÉTODOS: Foram incluídos apenas ensaios clínicos aleatorizados e quase aleatorizados que utilizaram pelo menos uma modalidade fisioterapêutica como uma das intervenções. Foi realizada uma busca nas bases de dados eletrônicos MEDLINE; Embase; LILACS e SciELO até dezembro de 2010. Não houve restrição do período de publicação dos artigos. Com o objetivo de aumentar a sensibilidade e a precisão, a estratégia de busca utilizada foi adaptada para cada base de dados. Foi utilizada a pontuação da escala PEDro para avaliação da qualidade metodológica dos ensaios clínicos aleatorizados. RESULTADOS: 26 artigos foram incluídos na revisão sistemática e a avaliação da maioria desses artigos apresentou qualidade metodológica satisfatória (6,4 pontos). Em relação aos aspectos mensurados, todos os artigos avaliaram a dor, 18 (69%) examinaram a força de preensão e 11 (42%) a função dos pacientes. Quanto à duração do acompanhamento dos pacientes apenas nove (35%) artigos realizaram acompanhamento a longo prazo. CONCLUSÃO: A melhor opção para o tratamento da epicondilite lateral parece ser a combinação de modalidades terapêuticas, o que condiz com a realidade clínica do fisioterapeuta. Porém, mais ensaios clínicos com boa qualidade metodológica são necessários para determinar a efetividade da maioria das modalidades terapêuticas encontradas.

Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: a systematic review

BACKGROUND

Several treatments are available to treat epicondylitis. Among these are instrumental electrophysical modalities, ranging from ultrasound, extracorporeal shock wave therapy (ESWT), transcutaneous electrical nerve stimulation (TENS) to laser therapy, commonly used to treat epicondylitis.

OBJECTIVES

To present an evidence-based overview of the effectiveness of electrophysical modality treatments for both medial and lateral epicondylitis (LE).

METHODS

Searches in PubMed, EMBASE, CINAHL and Pedro were performed to identify relevant randomised clinical trials (RCTs) and systematic reviews. Two reviewers independently extracted data and assessed the methodological quality. A best-evidence synthesis was used to summarise the results.

RESULTS

A total of 2 reviews and 20 RCTs were included, all of which concerned LE. Different electrophysical regimes were evaluated: ultrasound, laser, electrotherapy, ESWT, TENS and pulsed electromagnetic field therapy. Moderate evidence was found for the effectiveness of ultrasound versus placebo on mid-term follow-up. Ultrasound plus friction massage showed moderate evidence of effectiveness versus laser therapy on short-term follow-up. On the contrary, moderate evidence was found in favour of laser therapy over plyometric exercises on short-term follow-up. For all other modalities only limited/conflicting evidence for effectiveness or evidence of no difference in effect was found.

CONCLUSIONS

Potential effectiveness of ultrasound and laser for the management of LE was found. To draw more definite conclusions high-quality RCTs examining different intensities are needed as well as studies focusing on long-term follow-up results.

Evidence-based soft tissue rheumatology: epicondylitis and hand stenosing tendinopathy

Lateral and medial epicondylitis represent overuse tendinopathies of wrist extensor and wrist flexor muscles, respectively. In lateral epicondylitis, a short-term therapeutic efficacy of glucocorticoid injection and limited evidence on the efficacy of acupuncture has been shown. De Quervain tendinopathy is caused by tendinous impingement by a thickened retinaculum. There is limited evidence on the efficacy of glucocorticoid injection in this condition.Trigger finger usually results from tendon entrapment beneath a thickened A1 flexor pulley. An association with hand tool use and diabetes has been shown in this condition, and there is evidence on the therapeutic efficacy of glucocorticoid injection. No other therapeutic modality has shown efficacy or has been assessed in a placebo-controlled clinical trial in these conditions.It can be concluded that epicondylitis and stenosing tendinopathy are readily diagnosed, and most patients recover with current therapies. However, still unsolved issues preclude a purely evidence-based approach to these entities.

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.

Low level laser treatment of tendinopathy: a systematic review with meta-analysis

OBJECTIVES

To assess the clinical effectiveness of Low Level Laser Therapy (LLLT) in the treatment of tendinopathy. Secondary objectives were to determine the relevance of irradiation parameters to outcomes, and the validity of current dosage recommendations for the treatment of tendinopathy.

BACKGROUND

LLLT is proposed as a possible treatment for tendon injuries. However, the clinical effectiveness of this modality remains controversial, with limited agreement on the most efficacious dosage and parameter choices.

METHOD

The following databases were searched from inception to 1(st) August 2008: MEDLINE, PubMed, CINAHL, AMED, EMBASE, All EBM reviews, PEDro (Physiotherapy Evidence Database), SCOPUS. Controlled clinical trials evaluating LLLT as a primary intervention for any tendinopathy were included in the review. Methodological quality was classified as: high (> or =6 out of 10 on the PEDro scale) or low (<6) to grade the strength of evidence. Accuracy and clinical appropriateness of treatment parameters were assessed using established recommendations and guidelines.

RESULTS

Twenty-five controlled clinical trials met the inclusion criteria. There were conflicting findings from multiple trials: 12 showed positive effects and 13 were inconclusive or showed no effect. Dosages used in the 12 positive studies would support the existence of an effective dosage window that closely resembled current recommended guidelines. In two instances where pooling of data was possible, LLLT showed a positive effect size; in studies of lateral epicondylitis that scored > or =6 on the PEDro scale, participants' grip strength was 9.59 kg higher than that of the control group; for participants with Achilles tendinopathy, the effect was 13.6 mm less pain on a 100 mm visual analogue scale.

CONCLUSION

LLLT can potentially be effective in treating tendinopathy when recommended dosages are used. The 12 positive studies provide strong evidence that positive outcomes are associated with the use of current dosage recommendations for the treatment of tendinopathy.

Defocused CO2 laser on equine skin: a histological examination

REASONS FOR PERFORMING STUDY

No studies have been published on effects of treatment with a defocused beam carbon dioxide (CO2) laser on equine skin histology. A better understanding of this will help to define how lasers should be used, in order to reduce potential side effects.

OBJECTIVE

To describe the acute effects of different doses of defocused CO2 laser, ranging from therapeutic to surgical levels, on equine skin.

METHODS

Defocused CO2 laser was administered to the skin in the hamstrings (91 J/cm2), fetlock (137 J/cm2) and loin (450 J/cm2) areas of 13 Standardbred horses. The acute effects on skin histology were examined 90 min after the end of therapy.

RESULTS

Mild changes with focal spongiosis and subepidermal clefts were found after 91 J/cm2 irradiation and more severe changes with diffuse subepidermal clefts after the 137 J/cm2 dose. A homogeneous eosinophilic acellular zone of dermis and destruction of adnexal structures, and significant thinning of the epidermis was observed after the 450 J/cm2 dose.

CONCLUSIONS

The present study indicates acute dose-dependent changes in equine skin histology after laser treatment Severe tissue damage was induced using a 450 J/cm2 dose.

POTENTIAL RELEVANCE

To reduce the potential side effects of defocused CO2 laser treatment, the laser parameters must be carefully evaluated. Caution should be taken if doses higher than 91 J/cm2 (16 W, 4 min, and 42 cm2) are used in irradiation of equine skin.

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.

The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: a prospective, randomized, controlled trial

The aims of this study were to evaluate the effects of low-level laser therapy (LLLT) and to compare these with the effects of brace or ultrasound (US) treatment in tennis elbow. The study design used was a prospective and randomized, controlled, single-blind trial. Fifty-eight outpatients with lateral epicondylitis (9 men, 49 women) were included in the trial. The patients were divided into three groups: 1) brace group-brace plus exercise, 2) ultrasound group-US plus exercise, and 3) laser group-LLLT plus exercise. Patients in the brace group used a lateral counterforce brace for three weeks, US plus hot pack in the ultrasound group, and laser plus hot pack in the LLLT group. In addition, all patients were given progressive stretching and strengthening exercise programs. Grip strength and pain severity were evaluated with visual analog scale (VAS) at baseline, at the second week of treatment, and at the sixth week of treatment. VAS improved significantly in all groups after the treatment and in the ultrasound and laser groups at the sixth week (p<0.05). Grip strength of the affected hand increased only in the laser group after treatment, but was not changed at the sixth week. There were no significant differences between the groups on VAS and grip strength at baseline and at follow-up assessments. The results show that, in patients with lateral epicondylitis, a brace has a shorter beneficial effect than US and laser therapy in reducing pain, and that laser therapy is more effective than the brace and US treatment in improving grip strength.

Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic achilles tendinopathy

BACKGROUND

Eccentric exercises (EEs) are recommended for the treatment of Achilles tendinopathy, but the clinical effect from EE has a slow onset.

HYPOTHESIS

The addition of low-level laser therapy (LLLT) to EE may cause more rapid clinical improvement.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 52 recreational athletes with chronic Achilles tendinopathy symptoms were randomized to groups receiving either EE + LLLT or EE + placebo LLLT over 8 weeks in a blinded manner. Low-level laser therapy (lambda = 820 nm) was administered in 12 sessions by irradiating 6 points along the Achilles tendon with a power density of 60 mW/cm(2) and a total dose of 5.4 J per session.

RESULTS

The results of the intention-to-treat analysis for the primary outcome, pain intensity during physical activity on the 100-mm visual analog scale, were significantly lower in the LLLT group than in the placebo LLLT group, with 53.6 mm versus 71.5 mm (P = .0003) at 4 weeks, 37.3 mm versus 62.8 mm (P = .0002) at 8 weeks, and 33.0 mm versus 53.0 mm (P = .007) at 12 weeks after randomization. Secondary outcomes of morning stiffness, active dorsiflexion, palpation tenderness, and crepitation showed the same pattern in favor of the LLLT group.

CONCLUSION

Low-level laser therapy, with the parameters used in this study, accelerates clinical recovery from chronic Achilles tendinopathy when added to an EE regimen. For the LLLT group, the results at 4 weeks were similar to the placebo LLLT group results after 12 weeks.

Management of lateral epicondylitis: current concepts

Lateral epicondylitis, or tennis elbow, is a common cause of elbow pain in the general population. Traditionally, lateral epicondylitis has been attributed to degeneration of the extensor carpi radialis brevis origin, although the underlying collateral ligamentous complex and joint capsule also have been implicated. Nonsurgical treatment, the mainstay of management, involves a myriad of options, including rest, nonsteroidal anti-inflammatory drugs, physical therapy, cortisone, blood and botulinum toxin injections, supportive forearm bracing, and local modalities. For patients with recalcitrant disease, the traditional open débridement technique has been modified by multiple surgeons, with others relying on arthroscopic or even percutaneous procedures. Without a standard protocol (nonsurgical or surgical), surgeons need to keep abreast of established and evolving treatment options to effectively treat patients with lateral epicondylitis.

Lateral epicondylitis: review and current concepts

Lateral epicondylitis is a painful and functionally limiting entity affecting the upper extremity and is frequently treated by hand surgeons. The anatomic basis of the injury to the extensor carpi radialis brevis origin appears to be multifaceted, involving hypovascular zones, eccentric tendon stresses, and a microscopic degenerative response. Although many treatments have been advocated, there is little clear consensus on which modality works best, for both conservative and operative options. In this article, we present an overview of this difficult problem and an evidence-based review of treatment choices.

Blinding techniques in randomized controlled trials of laser therapy: an overview and possible solution

Low-level laser therapy has evidence accumulating about its effectiveness in a variety of medical conditions. We reviewed 51 double blind randomized controlled trials (RCTs) of laser treatment. Analysis revealed 58% of trials showed benefit of laser over placebo. However, less than 5% of the trials had addressed beam disguise or allocation concealment in the laser machines used. Many of the trials used blinding methods that rely on staff cooperation and are therefore open to interference or bias. This indicates significant deficiencies in laser trial methodology. We report the development and preliminary testing of a novel laser machine that can blind both patient and operator to treatment allocation without staff participation. The new laser machine combines sealed preset and non-bypassable randomization codes, decoy lights and sound, and a conical perspex tip to overcome laser diode glow detection.

Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example

BACKGROUND

The Oxford Levels of Evidence are now routinely assigned at many orthopaedic journals. One disadvantage of this approach is that study designs with a higher level of evidence may be given greater weight than the overall quality of the study merits. In other words, there is no guarantee that research is scientifically valid simply because a more sophisticated study design was employed. The aim of this study was to review Level-I and II therapeutic studies on lateral epicondylitis to measure variation in quality among the highest-level study designs.

METHODS

Fifty-four prospective randomized therapeutic trials involving patients with lateral epicondylitis were evaluated by two independent reviewers according to the Oxford Levels of Evidence, a modification of the Coleman Methodology Score (a 0 to 100-point scale), and the revised CONSORT (Consolidated Standards of Reporting Trials) score.

RESULTS

The two reviewers were consistent in their use of the Oxford Levels of Evidence (kappa = 0.73, p < 0.01), the modified Coleman Methodology Score (kappa = 0.73; p < 0.01), and the CONSORT score (kappa = 0.53; p < 0.01). Both reviewers rated the majority of studies as Level II (91% and 94%) and as unsatisfactory according to the Coleman Methodology Score (87% and 89%) and the CONSORT score (62% and 63%). Areas of deficiency included poor descriptions of recruitment (>90% of the trials), power-level calculations (73%), randomization (58%), blinding (90%), and participant flow (50%) as well as inadequate follow-up, sample size, and blinding.

CONCLUSIONS

The use of the gold-standard trial design, the prospective randomized therapeutic study (Level-I or II evidence), does not ensure quality research or reporting. Critical analysis of scientific work is important regardless of the study design. Clinical scientists should be familiar with the CONSORT criteria and adhere to them when reporting clinical trials.

A prospective pilot study of a multidisciplinary home training programme for lateral epicondylitis

OBJECTIVE

To evaluate a new multidisciplinary structured home training programme for patients with lateral epicondylitis compared to conventional attendance.

DESIGN

This study utilized a prospective non-randomized design to compare the effect of a home exercise programme against a pragmatic approach to managing patients with lateral epicondylitis in a primary care setting in Sweden.

SUBJECTS

A total of 78 patients, presenting to their general practitioner with lateral epicondylitis were recruited from two separate geographical areas. The patients were divided into two group, 51 entered the intervention group and 27 entered the control group.

METHODS

The intervention group was treated with a specific home training programme, ergonomic advice and when necessary wrist and/or night bandages. The control group was treated with conventional treatment, e.g. corticosteroid injections, stretching or no intervention. Pain and function were evaluated by the PRFEQ. An electronic hand-power gauge measured strength and stamina. Sick-leave absence was collected via the regional Social Insurance Office.

RESULTS

After four weeks the intervention group experienced less sick-leave, less pain, better function and returned to work earlier than the control group. After 16 weeks the intervention group still had significantly better function than the control group and were taking less sick-leave. Pain decreased more in the intervention group but this was not significant. There was no difference in grip strength between the two groups.

CONCLUSION

A structured home training programme can improve function and reduce sick leave in patients with lateral epicondylitis.

Evidenz zur Laserakupunktur bei orthopädischen Erkrankungen

BACKGROUND AND OBJECTIVES

The aim of this review is to evaluate the evidence for laser acupuncture in selected orthopaedic diseases.

MATERIAL AND METHODS

Randomized controlled studies, meta-analyses and systematic reviews were identified by a systematic search strategy in Medline and the Cochrane library. The studies were evaluated using the quality criteria of the Oxford Centre of Evidence Based Medicine.

RESULTS

For the selected orthopedic diseases (medial and lateral epicondylitis, myofascial pain syndrome of the neck, back and shoulder and osteoarthritis), meta-analyses, systematic reviews and eight randomized controlled studies were found. All other published studies used laser therapy without consideration of classical acupuncture points. All studies had significant drawbacks in methodological quality and the number of patients included. In more recent trials, improvement towards higher methodological quality was obvious. Although current evidence is equivocal, positive effects can be assumed in myofascial pain syndromes of the neck, back and shoulder. Laser acupuncture is advantageous in terms of side effects compared to classical acupuncture techniques.

CONCLUSION

Better, well designed randomized studies with higher power are mandatory in orthopedic diseases.

Short-Time Effects of Laser Needle Stimulation on the Peripheral Microcirculation Assessed by Laser Doppler Spectroscopy and Near-Infrared Spectroscopy

OBJECTIVE

The aim of the present study was to evaluate immediate effects of a standardized laser needle stimulation over a defined acupuncture point on the microvascular blood flow and muscle oxygenation in the human forearm.

BACKGROUND DATA

Recently, it has been shown that laser stimulation improves tissue perfusion. This is relevant since adequate blood supply is an important factor in the treatment of pain syndromes.

METHODS

The study was designed as a randomized, double-blinded, placebo-controlled trial. Thirty-three healthy non-smoking males were randomly assigned to a control group (n = 15) with no laser irradiation and to an intervention group (n = 18) for which laser needle irradiation was performed on the right forearm at acupuncture point Pe6. Non-invasive blood flow measurements (laser Doppler spectroscopy [LDS]) were performed before, during, and after intervention. Additionally, the dynamic changes in muscle oxygenation of the m. flexor carpi ulnaris were investigated using near-infrared spectroscopy (NIRS).

RESULTS

Repeated measures MANOVA demonstrated a statistically significant interaction between time and group (p = 0.034, effect size = 0.39), indicating that peripheral blood flow was influenced by laser needle application. In contrast, tissue oxygenation was not affected by the experimental treatment.

CONCLUSION

It has been demonstrated that laser needle stimulation may improve peripheral microcirculation under standardized conditions, whereas tissue oxygenation remained unchanged. Further research is required to determine the influence of various parameter settings and irradiation treatments on the peripheral microcirculation. Moreover, different acupuncture points should be investigated in order to appraise the clinical effectiveness of laserneedle stimulation.

Effectiveness of low-level laser therapy for lateral elbow tendinopathy

OBJECTIVE

Our aim was to determine the effectiveness of low-lever laser therapy (LLLT) in the management of lateral elbow tendinopathy (LET) and to provide recommendations based on this evidence.

BACKGROUND DATA

LET is a common clinical condition, and a wide array of physiotherapy treatments is used for treating LET.

METHODS

Randomized controlled trials (RCTs) identified by a search strategy in six databases were used in combination with reference checking. RCTs that included LLLT, patients with LET, and at least one of the clinically relevant outcome measure were selected. Aqualitative analysis of the selected studies was conducted using the Chalmers' technique.

RESULTS

Nine RCTs fulfilled the criteria and were included in the review. Although these studies had satisfactory methodology, shortcomings were not absent; poor results were revealed as to the effectiveness of LLLT for LET management.

CONCLUSIONS

LLLT need not be ruled out for LET as it is a dose-response modality, and the optimal treatment dose has obviously not yet have been discovered. Further research with well-designed RCTs is needed to establish the absolute and relative effectiveness of this intervention for LET.

Low-Power Laser Treatment for Shoulder Pain

OBJECTIVE

The objective of this study is to investigate the effect of low-power gallium-arsenide laser treatment on the patients with shoulder pain.

BACKGROUND DATA

Low-energy laser therapy has recently been popularized in the treatment of various rheumatologic, neurologic, and musculoskeletal disorders such as osteoarthritis, rheumatoid arthritis, fibromyalgia, carpal tunnel syndrome, rotator cuff tendinitis, and chronic back pain syndromes.

METHODS

A total of 40 patients who applied to our clinic with shoulder pain and complied with the selection criteria were included in the study. The patients were randomly assigned into Group I (n = 20, laser treatment) and Group II (n = 20, control). In Group I, patients were given laser treatment and an exercise protocol for 10 sessions during a period of 2 weeks. Laser was applied over tuberculum majus and minus, bicipital groove, and anterior and posterior faces of the capsule, regardless of the existence of sensitivity, for 1 min at each location at each session with a frequency of 2000 Hz using a GaAs diode laser instrument (Roland Serie Elettronica Pagani, wavelength 904 nm, frequency range of 5-7000 Hz, and maximum peak power of 27 W, 50 W, or 27 x 4 W). In Group II, placebo laser and the same exercise protocol was given for the same period. Patients were evaluated according to the parameters of pain, palpation sensitivity, algometric sensitivity, and shoulder joint range of motion before and after treatment.

RESULTS

Analysis of measurement results within each group showed a significant posttreatment improvement for some active and passive movements in both groups, and also for algometric sensitivity in Group I (p < 0.05-0.01). Posttreatment palpation sensitivity values showed improvement in 17 patients (85%) for Group I and six patients (30%) for Group II. Comparison between two groups showed superior results (p < 0.01 and p < 0.001) in Group I for the parameters of passive extension and palpation sensitivity but no significant difference for other parameters.

CONCLUSIONS

The results of our study have shown better results in palpation sensitivity and passive extension, but no significant improvement in pain, active range, and algometric sensitivity in laser treatment group compared to the control group in the patients with shoulder pain.

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

A systematic review of the literature on the effectiveness of physical interventions for lateral epicondylalgia (tennis elbow) was carried out. Seventy six randomised controlled trials were identified, 28 of which satisfied the minimum criteria for meta-analysis. The evidence suggests that extracorporeal shock wave therapy is not beneficial in the treatment of tennis elbow. There is a lack of evidence for the long term benefit of physical interventions in general. However, further research with long term follow up into manipulation and exercise as treatments is indicated.

The Use of Polarized Polychromatic Non-coherent Light as Therapy for Acute Tennis Elbow/Lateral Epicondylalgia: A Pilot Study

OBJECTIVE

The aim of this study was to assess the efficacy of polarized, polychromatic, non-coherent, low energy light (Bioptron 2, Bioptron AG, Switzerland) in the treatment of acute tennis elbow.

BACKGROUND

Tennis elbow, or lateral epicondylitis, is one of the most common lesions affecting the arm. A plethora of treatment regimes have been described for this condition, but no specific therapy has emerged as a gold standard.

METHODS

A pilot study was carried out with 25 patients who had acute tennis elbow. Bioptron 2 device was applied over lateral epicondyle three times per week for 4 weeks. Pain on VAS, function on VAS, and painfree grip strength were measured at the beginning (week 0) and at the end of the study (week 4).

RESULTS

The pain on VAS was reduced at the end of treatment (t(24) = 3.84, p = 0.001). Function on VAS was increased at the end of treatment (t(24) = 4.23, p < 0.001). Pain-free grip strength was increased at the end of treatment (t(24) = 4.23, p < 0.004).

CONCLUSION

Although the results suggested that the Bioptron 2 could reduce patients' symptoms with acute tennis elbow, future controlled studies are needed to establish the relative and absolute effectiveness of Bioptron 2.

Rehabilitation for patients with lateral epicondylitis: a systematic review

The purpose of this systematic review was to determine the effectiveness of conservative treatments for lateral epicondylitis and to provide recommendations based on this evidence. Five reviewers searched computerized bibliographic databases for articles on the conservative treatment of lateral epicondylitis from the years 1983 to 2003. A total of 209 studies were located; however, only 31 of these met the study inclusion criteria. Each of the articles was randomly allocated to reviewers and critically appraised using a structured critical appraisal tool with 23 items. Treatment recommendations were based on this rating and Sackett's Level of Evidence. This review has determined, with at least level 2b evidence, that a number of treatments, including acupuncture, exercise therapy, manipulations and mobilizations, ultrasound, phonophoresis, Rebox, and ionization with diclofenac all show positive effects in the reduction of pain or improvement in function for patients with lateral epicondylitis. There is also at least level 2b evidence showing laser therapy and pulsed electromagnetic field therapy to be ineffective in the management of this condition. Practitioners should use the treatment techniques that have strongest evidence and ensure that studies findings are generalized to patients who are similar to those reported in primary research studies in terms of patient demographics and injury presentation.

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.

Agents physiques antalgiques

Analgesic electrotherapy is now based on more consistent scientific data; the biological action of the electric current, of the electromagnetic radiations and of the mechanical vibrations is better approached. But the randomized control trials still provide contradictory results concerning the analgesic efficiency of the cryotherapy, the TENS, the pulsed electro-magnetic fields, the ultrasound and laser therapy, the shock waves; iontophoresis, short waves, microwaves, infrasound vibrations are very few investigated. The analgesic electrotherapy cannot be recommended nor prohibited; physical agents represent only therapeutic options. On the basis of the scientific data and of their personal experience, the therapists can use them. More controlled clinical investigations of higher methodological levels are still required.