Effectiveness of physiotherapy for lateral epicondylitis: a systematic review

Clinical implications of reconsideration of enthesitis/enthesopathy/enthesial erosion, as tendon attachment-localized avulsions and stress fracture equivalents

Recognizing the mechanical origin of enthesitis/enthesopathy and the avulsion-nature of what had previously been considered erosions, it seems inappropriate to attribute it to stresses related to a person’s normal activities. Conversely, sudden or unconditioned repetitive stresses appears the more likely culprit. Studies of enthesial reaction have lacked standardization as to findings present among individuals who appear to be healthy. Clinical evaluation by palpation and manipulation may be as effective as application of radiologic techniques. Recognition of the mechanical nature of the disease, including individuals with inflammatory arthritis suggests prescription of mechanical solutions that reduce stresses across the involved enthesis.

Platelet-Rich Plasma Has Better Results for Long-term Functional Improvement and Pain Relief for Lateral Epicondylitis: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Corticosteroids (CS) have shown good short-term performance in terms of pain relief and functional improvement. However, the safety and long-term efficacy of this treatment remains controversial. Several studies have reported good results of platelet-rich plasma (PRP) in the treatment of tendinopathies. However, whether its use in the treatment of lateral epicondylitis (LE) is superior to that of CS remains controversial.

PURPOSE

To perform a systematic review and meta-analysis of original studies to determine whether the prognosis of LE patients treated with PRP is better than that of CS.

STUDY DESIGN

Meta-analysis; Level of evidence, 2.

METHODS

Two independent reviewers searched online databases from January 2000 to July 2022 according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to evaluate prospective studies of PRP versus CS injection for LE. A third author addressed any discrepancies. Evidence quality was assessed using the Cochrane risk of bias tool. Risk ratios for dichotomous variables and mean differences (MDs) for continuous variables were used to compare clinical outcomes. P values <.05 were considered statistically significant.

RESULTS

Eleven randomized controlled trials with 730 patients were included in this review. PRP provided a significantly worse short-term (<2 months) improvement in the visual analog scale (VAS) pain score (MD, 0.93 [95% CI, 0.42 to 1.44]; I2 = 85%; P = .0003) and Disabilities of the Arm, Shoulder and Hand (DASH) score (MD, 10.23 [95% CI, 9.08 to 11.39]; I2 = 67%; P < .0001) but better long-term (≥6 months) improvement in the VAS score (MD, -2.18 [95% CI, -3.13 to -1.22]; I2 = 89%; P < .0001), DASH score (MD, -8.13 [95% CI, -9.87 to -6.39]; I2 = 25%; P < .0001), and Mayo Elbow Performance Score (MD, 16.53 [95% CI, 1.52 to 31.53]; I2 = 98%; P = .03) than CS. The medium-term (2-6 months) reduction in the VAS score was not significantly different between the 2 groups. After sensitivity analysis, none of the results changed except for the short-term VAS scores (MD, 0.53 [95% CI, -0.13 to 1.19]; I2 = 78%; P = .12).

CONCLUSION

Both PRP and CS injections are effective treatments for patients with LE. CS provides better short-term (<2 months) functional improvement and may be more advantageous in terms of short-term pain relief, while PRP provides better long-term (≥6 months) functional improvement and better performance regarding long-term pain relief.

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.

Conservative Management of Lateral Epicondylalgia: A Review

A common overuse injury to the elbow is called tennis elbow or lateral epicondylitis (LE). LE is a condition that causes substantial discomfort and dysfunction in the upper extremity. Thermal and electrical agents are examples of conservative techniques. It is a significant public health concern since it frequently occurs due to occupation. It also happens in recurrent upper extremity motions including desktop use, weight training, forceful forearm movements, and repetitive vibratory movements, which are the most common activities performed by an engineer. LE leads to lateral epicondylar pain, which is irritating due to inflammation of the extensor muscle origin, and also activities of daily living are restricted. It is not only seen in players with racquet sports but then most of the males and females are affected in the fourth and fifth decades, leading to limitations in daily work, activity, and household work. Rehabilitation seems the most effective treatment yet in acute and chronic conditions if later the pain does not subside then rest, injectables, and nonsteroidal anti-inflammatory drugs are the options to be taken. Physiotherapeutic rehabilitation plays a significant role in LE.

Rehabilitation of the painful elbow

Although lateral elbow pain and medial ulnar collateral ligament injury are common musculoskeletal pathologies in overhead athletes, the evidence supporting specific interventions for managing these conditions is scarce. Management of these conditions has been guided mostly by expert opinion rather than empirical evidence, yet the lack of comparative data in the literature has not negatively affected return-to-play rates following surgery. However, an understanding of what is known regarding unimodal and multimodal treatments for lateral elbow pain and medial ulnar collateral ligament injury is needed for clinicians to select evidence-based treatment pathways and highlight what is not known to develop future high-quality investigations.

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.

The 100 most cited articles in lateral epicondylitis research: A bibliometric analysis

Introduction

Lateral epicondylitis is a significant clinical problem in orthopaedics. There have been numerous articles written about this. Bibliometric analysis is critical for determining a field's most influential study. We attempt to identify and analyze the top 100 citations in lateral epicondylitis research.

Materials and methods

On December 31, 2021, an electronic search was conducted in the Web of Science Core Collection and the Scopus search engine with no restrictions on publication years, language, or study design. We reviewed each article's title and abstract until the top 100 were documented and evaluated in various ways.

Results

Between 1979 and 2015, the 100 most cited articles were published in 49 journals. The total number of citations ranged from 75 to 508 (mean ± SD, 145.5 ± 90.9), with citation densities ranging from 2.2 to 37.6 citations per year (mean ± SD, 8.7 ± 6.5). The United States is the most productive country, and the 2000s witnessed a surge in lateral epicondylitis research. The year of publication had a moderately positive correlation with citation density.

Conclusion

Our findings offer readers a fresh perspective on historical development hotspot areas of lateral epicondylitis research. Disease progression, diagnosis, and management have always been topics of discussion in articles. PRP-based biological therapy has emerged as a promising area for future research.

Lateral Elbow Pain and Muscle Function Impairments

Although often described as a self-limiting condition and likely to resolve on its own, high recurrence rates and extended sick leave frame a need for effective non-surgical treatment for people with lateral elbow tendinopathy. The interrelationship of histological and structural changes to the tendon, the associated impairments in motor control, and potential changes in pain processing may all drive symptoms. This clinical practice guideline covers the epidemiology, functional anatomy and pathophysiology, risk factors, clinical course, prognosis, differential diagnosis, tests and measures, and interventions for managing lateral elbow tendinopathy in the physical therapy clinic. J Orthop Sports Phys Ther 2022;52(12):CPG1-CPG111. doi:10.2519/jospt.2022.0302.

A systematic review on the efficacy of different types of platelet-rich plasma in the management of lateral epicondylitis

BACKGROUND

Platelet-rich plasma (PRP) is reported as an effective treatment for lateral epicondylitis (LE). Theoretically, different types of PRP have different therapeutic effects. However, there is controversy on the effects of different types of PRP in the treatment of LE. The purpose of this study was to systematically compare pain relief, functional improvement, and the success rate of treatment using 2 different types of PRP by reviewing and summarizing the data available in the current literature on LE after PRP injection.

METHODS

The PubMed, MEDLINE, Embase, Cochrane Library, and Web of Science databases were reviewed. A computerized literature search was performed for related studies published from database inception to August 2021 using the following terms: lateral epicondylitis, tennis elbow, tendinopathy, lateral elbow pain, PRP, and platelet-rich plasma. The PRP patients included in our study were divided into those receiving leukocyte-poor PRP (LP-PRP) and those receiving leukocyte-rich PRP (LR-PRP) according to the different preparation methods. Outcomes of interest included patient characteristics, types and preparations of PRP, clinical outcomes, success rates, and the safety of treatment at short- and long-term follow-up.

RESULTS

A total of 33 studies were evaluated in our analysis, including 2420 LE patients. LP-PRP was used in 19 of these studies, LR-PRP was used in 13, and both LP-PRP and LR-PRP were used in 1. Patients in both PRP groups showed significantly improved clinical outcomes after treatment compared with before treatment. The mean visual analog scale scores ranged from 6.1 to 8.0 before treatment, ranged from 1.5 to 4.0 at short-term follow-up, and ranged from 0.6 to 3.3 at long-term follow-up in the LR-PRP group. The mean visual analog scale scores ranged from 4.2 to 8.4 before treatment, 1.6 to 5.9 at short-term follow-up, and 0.7 to 2.7 at long-term follow-up in the LP-PRP group. The Disabilities of the Arm, Shoulder and Hand scores in the LR-PRP and LP-PRP groups ranged from 47.0 to 54.3 and 30.0 to 67.7, respectively, before treatment and ranged from 20.0 to 22.0 and 5.5 to 19.0, respectively, at long-term follow-up. The success rates in the LR-PRP and LP-PRP groups ranged from 70% to 100% and 36% to 100%, respectively. The complication rate was lower in the LP-PRP group (3.9%) than in the LR-PRP group (6.4%, P = .029), with the main complication being temporary pain after PRP treatment.

CONCLUSION

PRP treatment demonstrated significant improvements in terms of pain relief and functional improvement in LE patients regardless of the type of PRP. There were no significant differences in pain relief and functional improvement between LR-PRP and LP-PRP. The main complication was temporary pain after PRP injection, and the complication rate in the LP-PRP group was lower than that in the LR-PRP group.

Hyaluronic acid injections for chronic tennis elbow

Background

For most patients, tennis elbow (TE) resolves within 6 months of onset. For those with persistent and painful TE, nonsurgical treatment options are limited. Thousands of studies have tried to find effective treatments for TE but have usually failed. In this study, we tested the hypothesis that injections with hyaluronic acid (HA) would be effective at reducing pain from chronic TE.

Methods

Patients with a minimum of six months of pain from TE and with a pain level of 50 or greater (out of 100) were included in the study. They were randomized equally into one of two treatment groups: injection with HA or injection with saline control. Follow-up was conducted at 3, 6 and 12 months from the initial injection. Both the patient and the examiner at the follow-up visits were blinded to the treatment arm. The primary outcome measure was the visual analog scale (VAS pain) score at one year. Additional outcome measures included the shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) and Patient Rated Tennis Elbow Evaluation (PRTEE) scores.

Results

Eighteen patients were randomized into the HA injection treatment arm, and 17 (94%) completed the study. The average age was 51.9 years, and 10 of the subjects were male. Patients had an average of 28.1 months of pain before entering the study. The VAS score in the HA group decreased from a baseline of 76.4–14.3 at 12 months. All 17 patients in the HA group showed VAS score reductions above the minimal clinically important difference (MCID) of at least 18. The PRTEE score improved from 67 to 28.1. The QuickDASH score improved from 53.7 to 22.5. Follow-up in the saline group was less than 50% and was therefore not used as a comparator.

Conclusions

HA injections yielded significant success in pain relief by three months. Patients continued to improve for the 12-month duration of the study. This study indicates that patients with chronic lateral epicondylitis may benefit from receiving injections of hyaluronic acid rather than having to undergo surgery.

The impact of a hand therapy workplace-based educational approach on the management of lateral elbow tendinopathy: A randomized controlled study

BACKGROUND

Lateral elbow tendinopathy (LET) is one of the most prevalent work-related musculoskeletal conditions. Management strategies for LET rarely consider patients' work environments and have limited focus on education regarding occupational risk factors. Workplace-based rehabilitation has shown benefits in the return to work processes for injured workers with other health conditions, but no studies have investigated the impact of a workplace-based educational approach in the management of LET.

PURPOSES

First, to identify the impact of an additional workplace-based educational intervention to standard hand therapy care on the outcomes of pain, grip strength, and function. Second, to identify the effectiveness of standard hand therapy on the same clinical outcomes.

STUDY DESIGN

A randomized controlled trial.

METHODS

Forty-nine participants were randomized to the control group (n = 25) or intervention group (n == 24). The control group received standard hand therapy for 12 weeks. The intervention group received standard hand therapy for the first 12 weeks plus an additional workplace-based educational intervention, "Working Hands-ED," delivered by a hand therapist. Pain levels for provocative tests, grip strength, and function were measured using a Numeric Rating Scale, Jamar Dynamometer, and the Patient-Rated Tennis Elbow Evaluation questionnaire at baseline, weeks 6 and 12. The Patient-Specific Functional Scale was also used for the intervention group.

RESULTS

There were no statistical differences between both groups for all clinical outcomes by 12 weeks (P> .05). Pain levels for all provocative tests and Patient-Rated Tennis Elbow Evaluation scores statistically improved within both groups (P < .05), however with small effect sizes observed. The Patient-Specific Functional Scale scores statistically improved for the intervention group by 12 weeks (P < .05).

CONCLUSION

The addition of a hand therapy workplace-based intervention did not result in superior clinical outcomes for pain, grip strength, and function. The study identified that a multimodal self-management approach used by hand therapists improved their patients' pain and function regardless of whether the education was given in the clinic or the workplace.

Autologous blood and platelet-rich plasma injection therapy for lateral elbow pain

BACKGROUND

Autologous whole blood or platelet-rich plasma (PRP) injections are commonly used to treat lateral elbow pain (also known as tennis elbow or lateral epicondylitis or epicondylalgia). Based on animal models and observational studies, these injections may modulate tendon injury healing, but randomised controlled trials have reported inconsistent results regarding benefit for people with lateral elbow pain.

OBJECTIVES

To review current evidence on the benefit and safety of autologous whole blood or platelet-rich plasma (PRP) injection for treatment of people with lateral elbow pain.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase for published trials, and Clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal for ongoing trials, on 18 September 2020.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs comparing autologous whole blood or PRP injection therapy to another therapy (placebo or active treatment, including non-pharmacological therapies, and comparison between PRP and autologous blood) for lateral elbow pain. The primary comparison was PRP versus placebo. Major outcomes were pain relief (≥ 30% or ≥ 50%), mean pain, mean function, treatment success, quality of life, withdrawal due to adverse events, and adverse events; the primary time point was three months.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 32 studies with 2337 participants; 56% of participants were female, mean age varied between 36 and 53 years, and mean duration of symptoms ranged from 1 to 22 months. Seven trials had three intervention arms. Ten trials compared autologous blood or PRP injection to placebo injection (primary comparison). Fifteen trials compared autologous blood or PRP injection to glucocorticoid injection. Four studies compared autologous blood to PRP. Two trials compared autologous blood or PRP injection plus tennis elbow strap and exercise versus tennis elbow strap and exercise alone. Two trials compared PRP injection to surgery, and one trial compared PRP injection and dry needling to dry needling alone. Other comparisons include autologous blood versus extracorporeal shock wave therapy; PRP versus arthroscopic surgery; PRP versus laser; and autologous blood versus polidocanol. Most studies were at risk of selection, performance, and detection biases, mainly due to inadequate allocation concealment and lack of participant blinding. We found moderate-certainty evidence (downgraded for bias) to show that autologous blood or PRP injection probably does not provide clinically significant improvement in pain or function compared with placebo injection at three months. Further, low-certainty evidence (downgraded for bias and imprecision) suggests that PRP may not increase risk for adverse events. We are uncertain whether autologous blood or PRP injection improves treatment success (downgraded for bias, imprecision, and indirectness) or withdrawals due to adverse events (downgraded for bias and twice for imprecision). No studies measured health-related quality of life, and no studies reported pain relief (> 30% or 50%) at three months. At three months, mean pain was 3.7 points (0 to 10; 0 is best) with placebo and 0.16 points better (95% confidence interval (CI) 0.60 better to 0.29 worse; 8 studies, 523 participants) with autologous blood or PRP injection, for absolute improvement of 1.6% better (6% better to 3% worse). At three months, mean function was 27.5 points (0 to 100; 0 is best) with placebo and 1.86 points better (95% CI 4.9 better to 1.25 worse; 8 studies, 502 participants) with autologous blood or PRP injection, for absolute benefit of 1.9% (5% better to 1% worse), and treatment success was 121 out of 185 (65%) with placebo versus 125 out of 187 (67%) with autologous blood or PRP injection (risk ratio (RR) 1.00; 95% CI 0.83 to 1.19; 4 studies, 372 participants), for absolute improvement of 0% (11.1% lower to 12.4% higher). Regarding harm, we found very low-certainty evidence to suggest that we are uncertain whether withdrawal rates due to adverse events differed. Low-certainty evidence suggests that autologous blood or PRP injection may not increase adverse events compared with placebo injection. Withdrawal due to adverse events occurred in 3 out of 39 (8%) participants treated with placebo versus 1 out of 41 (2%) treated with autologous blood or PRP injection (RR 0.32, 95% CI 0.03 to 2.92; 1 study), for an absolute difference of 5.2% fewer (7.5% fewer to 14.8% more). Adverse event rates were 35 out of 208 (17%) with placebo versus 41 out of 217 (19%) with autologous blood or PRP injection (RR 1.14, 95% CI 0.76 to 1.72; 5 studies; 425 participants), for an absolute difference of 2.4% more (4% fewer to 12% more). At six and twelve months, no clinically important benefit for mean pain or function was observed with autologous blood or PRP injection compared with placebo injection.

AUTHORS' CONCLUSIONS

Data in this review do not support the use of autologous blood or PRP injection for treatment of lateral elbow pain. These injections probably provide little or no clinically important benefit for pain or function (moderate-certainty evidence), and it is uncertain (very low-certainty evidence) whether they improve treatment success and pain relief > 50%, or increase withdrawal due to adverse events. Although risk for harm may not be increased compared with placebo injection (low-certainty evidence), injection therapies cause pain and carry a small risk of infection. With no evidence of benefit, the costs and risks are not justified.

Do hand therapists have a role in workplace-based education to manage tennis elbow? Beliefs about effective treatments among Australian hand therapists and medical practitioners

BACKGROUND

Lateral elbow tendinopathy (LET), commonly known as tennis elbow, is a prevalent work-related upper extremity musculoskeletal disorder. Medical practitioners and hand therapists manage LET with commonly available clinic-based treatments, despite no sound evidence to suggest long-term relief and functional restoration for workers with LET. Workplace-based rehabilitation is effective for injured workers with other health conditions, but no studies have investigated this rehabilitation approach in the management of LET.

OBJECTIVES

(i) Identify, compare, and contrast Australian hand therapists' and medical practitioners' perceptions about the effectiveness of common treatments for LET, and (ii) obtain their views towards a hand therapist delivered workplace-based education approach.

METHODS

In this cross-sectional study, 38 medical practitioners from Western Australia and 104 hand therapists around Australia completed online surveys. Independent t-tests were used to identify between-group differences in responses.

RESULTS

Despite some between-group differences regarding the perceived effectiveness of common LET treatments, both groups believed education about LET pathology, activity modification, postures, and workplace recommendations were most effective. Most medical practitioners (81%) and hand therapists (71%) believed workplace-based education delivered by a hand therapist would be beneficial for patients with acute and chronic LET.

CONCLUSION

Australian hand therapists and medical practitioners believed educational approaches were the most important component in the management of LET, and supported workplace-based educational interventions provided by hand therapists in the management of LET.

Epicondylopathia humeri radialis

BACKGROUND

Lateral epicondylitis is a common orthopaedic condition often massively restricting the quality of life of the affected patients. There are a wide variety of treatment options - with varying levels of evidence.

METHOD

The following statements and recommendations are based on the current German S2k guideline Epicondylopathia radialis humeri (AWMF registry number: 033 - 2019). All major German specialist societies participated in this guideline, which is based on a systematic review of the literature and a structured consensus-building process.

OUTCOMES

Lateral epicondylitis should be diagnosed clinically and can be confirmed by imaging modalities. The Guidelines Commission issues recommendations on clinical and radiological diagnostic workup. The clinical condition results from the accumulated effect of mechanical overload, neurologic irritation and metabolic changes. Differentiating between acute and chronic disorder is helpful. Prognosis of non-surgical regimens is favourable in most cases. Most cases spontaneously resolve within 12 months. In case of unsuccessful attempted non-surgical management for at least six months, surgery may be considered as an alternative, if there is a corresponding structural morphology and clinical manifestation. At present, it is not possible to recommend a specific surgical procedure.

CONCLUSION

This paper provides a summary of the guideline with extracts of the recommendations and statements of its authors regarding the pathogenesis, prevention, diagnostic workup as well as non-surgical and surgical management.

Musculoskeletal ultrasonographic evaluation of perineural injection therapy versus therapeutic ultrasound in chronic lateral epicondylitis

Background

Lateral epicondylitis (LE) is a common disorder causing pain and functional limitations especially in athletes and manual workers. There is a growing interest in regenerative injection therapies in chronic LE. One of those suggested is perineural injection (PNI) therapy. The present study aims to find out the efficacy of PNI therapy in the treatment of chronic LE as compared to therapeutic ultrasound (TUS) and to detect if any changes have happened after treatment to the common extensor tendon (CEO) as detected by diagnostic ultrasound (US) examination.

Results

Statistical analysis between the 2 groups at the start of the study as regards age, sex, and clinical parameters including visual analog scale (VAS), tenderness grading scale, and Patient-Rated Tennis Elbow Evaluation (PRTEE) Questionnaire revealed a non-significant difference between both groups (p > 0.05). After 12 weeks, within-group analysis showed significant improvement in all clinical outcome measures in both groups compared to the initial assessment.

Between-group analysis after 12 weeks showed that the tenderness grading scale and PRTEE score had more significant improvement in the PNI therapy group. However, the two groups were comparable regarding VAS. Within-group US evaluation at the 12th week post-treatment showed a highly significant decrease in hypoechoic areas (p < 0.001) and a decrease in distributed fibrillar pattern in PNI group, while the TUS group demonstrated a significant decrease in hypoechoic areas and tendon thickness (p < 0.005). Between-group US evaluation after 12 weeks showed no significant difference in all assessed US parameters. No complications were observed in both groups.

Conclusions

A short-term follow-up regimen of 1 session/week of PNI therapy is significantly more effective than 3 sessions/week of TUS regarding the improvement of pain and functional status. Yet both therapeutic modalities were able to produce significantly positive structural changes in the CEO. The current study highlights the neurogenic inflammation as the primary pain generator in chronic LE and the advantage of its treatment with PNI therapy in chronic and refractory cases.

Comparison of low level laser therapy and extracorporeal shock wave in treatment of chronic lateral epicondylitis

OBJECTIVE

The aim of this study was to compare the efficacy of extracorporeal shock wave therapy (ESWT) ver-sus low-level laser therapy (LLLT) in treating chronic lateral epicondylitis (CLE).

METHODS

In this prospective study, 52 patients (24 males, 28 females; mean age=48 years; age range=30-70 years) with a diagnosis of CLE were included and randomized into two groups (26 in each group): ESWT group (14 males, 12 females; mean age=48±10 years) or LLLT group (10 males, 16 females; mean age=48±11 years). ESWT was applied for 5 weeks with one session per week, while LLLT was applied with 15 sessions on consecutive days. All patients were evaluated using Disability of the Arm, Shoulder and Hand Questionnaire (DASH), Patient-Related Lateral Epicondy-litis Evaluation (PRTEE), and the 36-Item Short-Form Health Survey (SF-36) before and after the treatments.

RESULTS

In the comparison of baseline data between treatment groups, significant differences were observed only in SF-Physical functioning and SF-Energy/fatigue scores (p=0.035 and p=0.038, re-spectively), which were 77.1±17.2 and 56.3±17.2 in ESWT group and 66.5±18.0 and 44.8±21.5 in LLLT group, respectively. In the comparison of post-treatment data between groups, there were sig-nificant differences in all scores (p<0.05) except two subscales of SF-36, which were SF-role limita-tions due to emotional problems (p=0.092) and physical health (p=0.147), respectively. The other subscales of SF-36, PRTEE and DASH scores obtained after the treatments were better in ESWT group than in LLLT group. The comparison of pre-and post-treatment scores in each group revealed significant improvements in all scores (p<0.05), except SF-36 subscales, including energy/fatigue, emotional well-being, social functioning, and general health scores (p>0.05).

CONCLUSION

Evidence from this study revealed that although both treatment modalities were effective in the treatment of CLE, ESWT seemed to more effective in pain relief and functional recovery than LLLT.

LEVEL OF EVIDENCE

Level II, Therapeutic study.

Comparative Study between Scales: Subjective Elbow Value and Patient-rated Tennis Elbow Evaluation Applied to Patients Affected by Lateral Epicondylitis

Objective  To verify if the subjective elbow value (SEV) scale presents similar results to those of the Patient-rated Tennis Elbow Evaluation (PRTEE) scale in the evaluation of patients with lateral elbow epicondylitis (LEE).

Methods  Thirty-seven patients were diagnosed with LEE in the outpatient service of our hospital through clinical history, physical examination, X-ray, and ultrasonography. The SEV and PRTEE scales were used and their results were compared using a significance level ≥ 5% ( p ≥0.05).

Results  A statistically significant relationship was found between the values of SEV and PRTEE in the group of patients studied ( p  = 0.017).

Conclusion  Subjective elbow value presented similar results to PRTEE in the evaluation of patients with diagnosis of LEE.

The Role of Ultrasound Therapy in the Management of Musculoskeletal Soft Tissue Pain

Ultrasound is an invaluable physical modality widely used for diagnosis and therapy in humans and animals. It is noninvasive, atraumatic, and may be used repeatedly. As a therapeutic tool, ultrasound has been in use for some 6 decades. Therapeutic ultrasound (TUS) is used for the treatment of musculoskeletal disorders, including acute soft tissue injuries, overuse syndromes, as well as chronic orthopedic and rheumatologic conditions. The aim of this review was to investigate the clinical effectiveness of TUS in musculoskeletal acute and chronic pain, mainly through the control of inflammation and the promotion of soft tissue injury healing. Based on the evidence presented, TUS is clinically effective in some musculoskeletal soft tissue pain conditions, but due to conflicting results in some studies, no specific positive recommendations can be made, nor does it permit exclusion of TUS from clinical practice. In phonophoresis, TUS plays a significant role, without reported adverse effects. There is scope for improving the evidence base with better designed studies.

The effects of Mulligan's mobilization with movement technique in patients with lateral epicondylitis

BACKGROUND

Lateral epicondylitis (LE) is a common problem of the arm. Mulligan has proposed the use of mobilization with movement for LE.

OBJECTIVES

To investigate the effects of Mulligan's mobilization with movement (MWM) in LE.

METHODS

Forty patients were included in the study and randomly assigned to group 1 (n= 20), who received MWM, exercise and cold therapy, or group 2 (n= 20), who received exercise and cold therapy. The sessions were conducted five times a week for two weeks. All measures were conducted at baseline, after treatment, at 1st and 3rd months follow-ups. Mann-Whitney U test, a visual analogue scale (VAS) for pain intensity, Patient-rated Tennis Elbow Evaluation (PRTEE) Questionnaire for pain intensity and functional disability and a dynamometer for hand grip strength were applied.

RESULTS

VAS activity pain significantly decreased in group 1 after treatment (p= 0.001), at the 1st (p< 0.001) and 3rd months (p= 0.040). There was a significant decrease in VAS night pain in group 1 (p= 0.024), and a significant increase in pain-free grip strength (p= 0.002) after treatment. PRTEE-Pain scores decreased in group 1 after treatment (p< 0.001), 1st (p< 0.001) and 3rd months (p= 0.001).

CONCLUSIONS

MWM plus exercise and cold therapy is a safe and effective alternative with positive effects on elbow pain, functional capacity, and pain-free, maximum grip strength.

Comparing the efficiency of ultrasound, ketoprofen, and mucopolysaccharide polysulfate phonophoresis in the treatment of lateral epicondylitis: A randomized-controlled clinical study

Objectives

In this study, we aimed to compare the efficiency of ultrasound, mucopolysaccharide polysulfate phonophoresis, ketoprofen phonophoresis and exercise combinations in terms of pain, functionality, disability, and strength in patients with lateral epicondylitis (LE).

Patients and methods

This prospective, parallel-group, randomized-controlled clinical study included a total of 60 patients (42 males, 18 females; mean age 38.08 years; range, 21 to 50 years) with LE between April 2016 and October 2017. The patients were equally randomized into four groups based on the time of admission to the outpatient clinic. The Visual Analog Scale (VAS), painless weight lifting, the Patient- Rated Tennis Elbow Evaluation (PRTEE), and Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) were used to measure the outcomes. The measurements were performed at baseline, at the end of 10 daily sessions, and after a six-week follow-up period.

Results

The resting VAS scores in the ketoprofen phonophoresis group and lifted weights in the MPS and ketoprofen phonophoresis groups showed a significant improvement both after 10 days of treatment and at six-week follow-up visits (p<0.001). In the QuickDASH model, there was no significant improvement in the control group after 10 days of treatment (p>0.05); however, a significant improvement was observed after six weeks (p<0.001). Except for these variables, significant improvements were found in all groups for all variables at six-week follow-up (p<0.05). However, improvements were similar in all groups (p>0.05).

Conclusion

Based on our study results, for LE patients who are unable to adhere to exercise and splint use and are given a physical treatment plan, inclusion of ketoprofen and MPS phonophoresis in the treatment program may yield additional benefits in their daily living activities, functionality, and working life.

The Effectiveness of Shockwave Therapy in Patients with Lateral Epicondylitis

Shockwave therapy is based on generating a very intense energy in a very short period of time. It creates a mechanical pressure over the affected tissues that leads to an increased cellular permeability, thus increasing the microcirculation and the cellular metabolism. Therefore, the healing process is accelerated. Lateral epicondylitis represents a common arm injure, which usually affects early to late middle-aged patients, more common and with a longer evolution period in women, characterized by inflammation of the arm muscles’ tendon insertion and manifests with pain on elbow extension and forearm rotation. Our study aims to investigate the efficacity of the shockwave therapy in comparison with a classical treatment of local and systemic drugs. The 50 patients were evenly split into two groups. The diagnosis of lateral epicondylitis was based on exhaustive physical examination. Enthesis evaluation was performed through power Doppler ultrasound. The pain was quantified using the visual analogue scale for pain intensity. All parameters were evaluated at diagnosis and after 30 days, following treatment. One group received shockwave therapy, while the other group received nonsteroidal anti-inflammatory drugs and local topics associated with laser and ultrasound application. The results of our study report that both groups experienced significant improvement after treatment. The shockwave therapy recorded a higher improvement rate in all the parameters. Consequently, this new non-invasive, effective and safe technique can be successfully used in the treatment of abarticular pathology of the elbow.

Chronic lateral epicondylitis: challenges and solutions

Lateral epicondylitis (LE) is a significant source of pain and dysfunction resulting from repetitive gripping or wrist extension, radial deviation, and/or forearm supination. Although most cases are self-limiting over several years, controversy exists regarding the best treatment strategy for chronic LE. Nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), shockwave therapy, and injections with corticosteroids or biologics are all conservative treatment options for LE. For refractory cases, surgical options include open, arthroscopic, and percutaneous techniques. In this review, the current evidence behind these treatment strategies is presented. The data demonstrate that NSAIDs, PT, bracing, and shockwave therapy provide limited benefit for treating LE. Biologics such as platelet-rich plasma and autologous whole-blood injections may be superior to steroid injections in the long-term management of LE. Although the initial results are promising, larger comparative studies on stem cell injections are needed. For refractory LE, open, arthroscopic, and percutaneous techniques are all highly effective, with no method seemingly superior over another. Arthroscopic and percutaneous approaches may result in faster recovery and earlier return to work.

Classification of Tendon Matrix Change Using Ultrasound Imaging: A Systematic Review and Meta-analysis

Ultrasound imaging (US) is an accurate and reliable method used to diagnose tendinopathy. This systematic review was aimed at identifying common criteria and parameters used to diagnose tendinopathy, the methodological quality of studies and the predictive value of US. Nineteen studies met the inclusion criteria, with the Achilles, quadriceps and patella tendons being investigated. Overall, there was significant heterogeneity between the criteria used to diagnose tendinopathy utilising US. The methodological quality of included studies was "good." Additionally, meta-analysis revealed that US-identified abnormalities were predictive of future symptoms, and classification of tendinopathy using three US defined parameters indicated a higher relative risk of developing clinical tendinopathy compared with the use of two US-defined parameters. Further research into the development of a standardised US criterion that incorporates both clinical and US findings is required to allow for greater consistency in the diagnosis of tendinopathy.

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.

Kinesio taping reduces elbow pain during resisted wrist extension in patients with chronic lateral epicondylitis: a randomized, double-blinded, cross-over study

Background

Lateral epicondylitis is frequently seen in racquet sport players and the treatments are usually symptomatic rather than curative. Taping therapy is cheap and easy to apply in the sport field. In this study we valued the effectiveness of Kinesio taping (KT) on immediate pain control for patients with chronic lateral epicondylitis.

Methods

We conducted a randomized, double-blinded, cross-over study with 15 patients with chronic lateral epicondylitis. All participants received two taping sessions in a random order with a 3-day interval in between: one with KT and the other with sham taping (ST). Pain perceived during resisted wrist extension and at rest using numeric rating scale (NRS), the pain-free grip strength, and the pressure pain threshold, were measured before and 15 min after the tape was applied.

Results

A significant reduction of 2.1 ± 1.6 (Z = − 3.081, P = 0.002) and 0.7 ± 0.8 (Z = − 2.428, P = 0.015) was found on a NRS with KT and ST, respectively, indicating that both taping sessions produced immediate pain relief for resisted wrist extension. Both taping sessions significantly improved the pain-free grip strength with increases of 3.31 ± 5.05 (Z = − 2.615, P = 0.009) and 2.43 ± 3.31 (Z = − 2.783, P = 0.005) kg found with KT and ST, respectively. Compared with ST, KT exhibited superiority in controlling pain experienced during resisted wrist extension (Z = − 2.168, P = 0.030).

Conclusions

Taping produced unneglectable placebo effects on pain relief and painf-free grip strength for patients with lateral epicondylitis, and KT seemed to have additional effects on controlling pain that was elicited by resisted wrist extension.

Trial registration

ISRCTN13618356 (retrospectively registered on 13/02/2017).

What Is the Most Effective Eccentric Stretching Position in Lateral Elbow Tendinopathy?

Background

A variety of treatment options suggest that the optimal treatment strategy for lateral elbow tendinopathy (LET) is not known, and further research is needed to discover the most effective treatment for LET. The purpose of the present study was to verify the most effective position of eccentric stretching for the extensor carpi radialis brevis (ECRB) in vivo using ultrasonic shear wave elastography.

Methods

A total of 20 healthy males participated in this study. Resting position was defined as 90° elbow flexion and neutral position of the forearm and wrist. Elongation of the ECRB was measured for four stretching maneuvers (forearm supination/pronation and wrist extension/flexion) at two elbow angles (90° flexion and full extension). The shear elastic modulus, used as the index of muscle elongation, was computed using ultrasonic shear wave elastography for the eight aforementioned stretching maneuverangle combinations.

Results

The shear elastic modulus was the highest in elbow extension, forearm pronation, and wrist flexion. The shear elastic moduli of wrist flexion with any forearm and elbow position were significantly higher than the resting position. There was no significant difference associated with elbow and forearm positions except for elbow extension, forearm pronation, and wrist flexion positions.

Conclusions

This study determined that elbow extension, forearm pronation, and wrist flexion was the most effective eccentric stretching for the ECRB in vivo.

Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy

STUDY DESIGN

RCT.

INTRODUCTION

Lateral elbow tendinopathy is a common clinical condition. eccentric exercises. eccentric-concentric loading and, isometric exercises are indicated to reduce and manage tendon pain.

PURPOSE OF THE STUDY

To compare the effectiveness of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy.

METHODS

A randomized clinical trial was carried out in a rheumatology and rehabilitation center. A group of 34 patients with later elbow tendinopathy was randomly allocated to Group A (n = 11) who underwent eccentric training, Group B had eccentric-concentric and Group C who had eccentric-concentric and isometric training. All patients received 5 treatments per week for 4 weeks. Pain was evaluated using a visual analog scale and function using a visual analog scale and pain-free grip strength at the end of the 4-week course of treatment (week 4) and 1 month (week 8) after the end of treatment.

RESULTS

The eccentric-concentric training combined with isomentric contractions produced the largest effect in the reduction of pain and improvement of function at the end of the treatment (P < .05) and at any of the follow-up time points (P < .05).

CONCLUSION

The eccentric-concentric training combined with isomentric contractions was the most effective treatment. Future well-designed studies are needed to confirm the results of the present trial.

LEVEL OF EVIDENCE

III.

Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation: a systematic review

QUESTION

What is the effect of exercise on increasing participation and activity levels and reducing impairment in the rehabilitation of people with upper limb fractures?

DESIGN

Systematic review of controlled trials.

PARTICIPANTS

Adults following an upper limb fracture.

INTERVENTION

Any exercise therapy program, including trials where exercise was delivered to both groups provided that the groups received different amounts of exercise.

OUTCOME MEASURES

Impairments of body structure and function, activity limitations and participation restrictions.

RESULTS

Twenty-two trials were identified that evaluated 1299 participants with an upper limb fracture. There was insufficient evidence from 13 trials to support or refute the effectiveness of home exercise therapy compared with therapist-supervised exercise or therapy that included exercise following distal radius or proximal humeral fractures. There was insufficient evidence from three trials to support or refute the effectiveness of exercise therapy compared with advice/no exercise intervention following distal radius fracture. There was moderate evidence from five trials (one examining distal radius fracture, one radial head fracture, and three proximal humeral fracture) to support commencing exercise early and reducing immobilisation in improving activity during upper limb rehabilitation compared with delayed exercise and mobilisation. There was preliminary evidence from one trial that exercise to the non-injured arm during immobilisation might lead to short-term benefits on increasing grip strength and range of movement following distal radius fracture. Less than 40% of included trials reported adequate exercise program descriptions to allow replication according to the TIDieR checklist.

CONCLUSION

There is emerging evidence that current prescribed exercise regimens may not be effective in reducing impairments and improving activity following an upper limb fracture. Starting exercise early combined with a shorter immobilisation period is more effective than starting exercise after a longer immobilisation period.

REGISTRATION

CRD42016041818. [Bruder AM, Shields N, Dodd KJ, Taylor NF (2017) Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation: a systematic review. Journal of Physiotherapy 63: 205-220].

Ultrasonographic Evaluation of Acupuncture Effect on Common Extensor Tendon Thickness in Patients with Lateral Epicondylitis: A Randomized Controlled Study

OBJECTIVE

To explore the effect of acupuncture on common extensor tendon (CET) thickness in patients with lateral epicondylitis (LE). Additionally, to identify whether clinical and ultrasonographic changes showed any correlation.

METHODS

Forty-one patients were randomly assigned to acupuncture and control groups. Conventional treatment (rest, NSAİİ, bracing, exercise) methods for LE were applied to all patients. In addition to this, the acupuncture treatment was applied to the acupuncture group. The visual analog scale (VAS) for pain, the Duruoz Hand Index (DHI) for functioning of the affected limb, the pressure pain threshold, and CET thickness (via ultrasound imaging) were assessed before and end of the treatment in both groups.

RESULTS

The VAS and DHI scores in both groups decreased. The pressure pain threshold and CET thickness only demonstrated improvement in the acupuncture group.

CONCLUSION

These findings show that the CET thickness was reduced after 10 sessions of acupuncture treatment in LE patients.

Tendinopathies around the Elbow Part 1: Lateral Elbow Tendinopathy

Tendinopathies of the elbow and in particular of the common extensor origin are a common cause of elbow pain. Part one of this two part review of tendinopathies of the elbow will focus on the pathophysiology and management of lateral elbow tendinopathy, frequently referred to as tennis elbow. Lateral elbow tendinopathy is a common condition with an incidence of 1 – 2%. The pathology arises from the origin of extensor carpi radialis brevis where changes, consistent with all tendinopathies, of angiofibroblastic hyperplasia occur secondary to repetitive micro trauma. It is not an inflammatory condition. Clinical history and examination is usually sufficient for diagnosis although MRI and ultrasound can be used. The many treatment options that have been proposed have a mixed quality of supporting evidence. Thus management protocols are difficult to define. Treatment depends on the length of symptoms. Acute presentation is managed through conservative measures including activity modification, topical NSAIDs and physiotherapy. For patients with recalcitrant symptoms, injection therapy with, for example, platelet rich plasma can be used. Alternatively surgical excision of the diseased tissue can be performed. This review article will consider the available evidence in order to identify both treatments that are effective and those that are not.

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.

Autologous whole blood or corticosteroid injections for the treatment of epicondylopathy and plantar fasciopathy? A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To compare the efficacy of autologous whole blood with that of corticosteroid injections on epicondylopathy and plantar fasciopathy.

DESIGN

Systematic review and meta-analysis.

METHODS

The databases of PubMed, Web of Science, CENTRAL, and Scopus were searched up to 6th May 2015. Randomized trials comparing the effects of autologous whole blood and corticosteroid injections on epicondylopathy or plantar fasciopathy were included. Trials exploring the efficacy of platelet-rich plasma were excluded. The primary outcome was pain relief. The secondary outcome included the assessment of composite outcomes. All outcomes were assessed at 2-6 (short-term) weeks, 8-13 (intermediate-term) weeks and 24-26 (medium-term) weeks. Quality assessment was performed with the Cochrane risk of bias tool.

RESULTS

Nine trials were included. For pain relief, there was a statistically significant difference in favour of corticosteroids in the short term (SMD 0.52; 95%CIs 0.18 to 0.86; I² = 53%; p < 0.01). A statistically significant difference in favour of autologous whole blood was indicated in the medium-term assessment of pain relief on epicondylopathy.

CONCLUSIONS

Corticosteroids were marginally superior to autologous whole blood in relieving pain on plantar fasciopathy at 2-6 weeks. Autologous whole blood provided significant clinical relief on epicondylopathy at 8-24 weeks. Conclusions were limited by the risk of bias.

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.

Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All

Synopsis Clear guidelines for the clinical management of individuals with lateral elbow tendinopathy (LET) are hampered by many proposed interventions and the condition's prognosis, ranging from immediate resolution of symptoms following simple advice in some patients to long-lasting problems, regardless of treatment, in others. This is compounded by our lack of understanding of the complexity of the underlying pathophysiology of LET. In this article, we collate evidence and expert opinion on the pathophysiology, clinical presentation, and differential diagnosis of LET. Factors that might provide prognostic value or direction for physical rehabilitation, such as the presence of neck pain, tendon tears, or central sensitization, are canvassed. Clinical recommendations for physical rehabilitation are provided, including the prescription of exercise and adjunctive physical therapy and pharmacotherapy. A preliminary algorithm, including targeted interventions, for the management of subgroups of patients with LET based on identified prognostic factors is proposed. Further research is needed to evaluate whether such an approach may lead to improved outcomes and more efficient resource allocation. J Orthop Sports Phys Ther 2015;45(11):938-949. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5841.

Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis

BACKGROUND

Clinical outcomes between the use of platelet-rich plasma (PRP), autologous blood (AB) and corticosteroid (CS) injection in lateral epicondylitis are still controversial.

MATERIALS AND METHODS

A systematic review and network meta-analysis of randomized controlled trials was conducted with the aim of comparing relevant clinical outcomes between the use of PRP, AB and CS injection. Medline and Scopus databases were searched from inception to January 2015. A network meta-analysis was performed by applying weight regression for continuous outcomes and a mixed-effect Poisson regression for dichotomous outcomes.

RESULTS

Ten of 374 identified studies were eligible. When compared to CS, AB injection showed significantly improved effects with unstandardized mean differences (UMD) in pain visual analog scale (VAS), Disabilities of Arm Shoulder and Hand (DASH), Patient-Related Tennis Elbow Evaluation (PRTEE) score and pressure pain threshold (PPT) of -2.5 (95 % confidence interval, -3.5, -1.5), -25.5 (-33.8, -17.2), -5.3 (-9.1, -1.6) and 9.9 (5.6, 14.2), respectively. PRP injections also showed significantly improved VAS and DASH scores when compared with CS. PRP showed significantly better VAS with UMD when compared to AB injection. AB injection has a higher risk of adverse effects, with a relative risk of 1.78 (1.00, 3.17), when compared to CS. The network meta-analysis suggested no statistically significant difference in multiple active treatment comparisons of VAS, DASH and PRTEE when comparing PRP and AB injections. However, AB injection had improved DASH score and PPT when compared with PRP injection. In terms of adverse effects, AB injection had a higher risk than PRP injection.

CONCLUSIONS

This network meta-analysis provided additional information that PRP injection can improve pain and lower the risk of complications, whereas AB injection can improve pain, disabilities scores and pressure pain threshold but has a higher risk of complications.

LEVEL OF EVIDENCE

Level I evidence.

The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration

OBJECTIVE

The purpose of this systematic review was to evaluate the effectiveness of exercise compared to other interventions, placebo/sham intervention, or no intervention in improving self-rated recovery, functional recovery, clinical, and/or administrative outcomes in individuals with musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand.

METHODS

We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers independently screened studies for relevance and assessed the risk of bias using the Scottish Intercollegiate Guidelines Network criteria. We synthesized the evidence using the best evidence synthesis methodology.

RESULTS

We identified 5 studies with a low risk of bias. Our review suggests that, for patients with persistent lateral epicondylitis, (1) adding concentric or eccentric strengthening exercises to home stretching exercises provides no additional benefits; (2) a home program of either eccentric or concentric strengthening exercises leads to similar outcomes; (3) home wrist extensor strengthening exercises lead to greater short-term improvements in pain reduction compared to "wait and see"; and (4) clinic-based, supervised exercise may be more beneficial than home exercises with minimal improvements in pain and function. For hand pain of variable duration, supervised progressive strength training added to advice to continue normal physical activity provides no additional benefits.

CONCLUSION

The relative effectiveness of stretching vs strengthening for the wrist extensors remains unknown for the management of persistent lateral epicondylitis. The current evidence shows that the addition of supervised progressive strength training does not provide further benefits over advice to continue normal physical activity for hand pain of variable duration.

Comparação de dois tratamentos fisioterapêuticos na redução da dor e aumento da autonomia funcional de idosos com gonartrose

Objetivo: Comparar o tratamento da terapia manual, associada ao ultrassom, com o tratamento da cinesioterapia convencional, associada ao laser de arseneto de galium (AsGa), na redução da dor e no aumento da autonomia funcional em idosos com gonartrose. Métodos: Estudo clínico, de delineamento quase-experimental. A amostra foi dividida aleatoriamente em dois grupos: grupo experimental 1 (GE1; n=44; idade=68±7,64 anos; índice de massa corporal: 26,77±4,74Kg/m2) - idosos com gonartrose submetidos ao tratamento fisioterapêutico com terapia manual e ultrassom; e grupo experimental 2 (GE2; n=20; idade=70±5,49 anos; índice de massa corporal: 27,11±4,63Kg/m 2 ) - idosos com gonartrose submetidos ao tratamento fisioterápico com cinesioterapia convencional e laserterapia. Foram analisados a autonomia funcional (protocolo do Grupo de Desenvolvimento Latino-Americano para a Maturidade - GDLAM) e o quadro álgico (escala CR10 de Borg). Ambos os GEs participaram de sessões de treinamento com duração de 45 minutos, duas vezes semanais, durante oito semanas consecutivas. O nível de significância foi de p<0,05. Resultados: Observou-se melhora da autonomia funcional pela redução significativa do índice de GDLAM (p<0,001) tanto no GE1 (Δ=16,14) quanto no GE2 (Δ=9,32). Semelhantemente, houve diminuição significativa (p<0,001) do nível de dor tanto no GE1 (Δ=5,09) quanto no GE2 (Δ=7,1). O poder do experimento foi de 98%. Conclusão: Infere-se, assim, que ambos os tratamentos sugeridos neste estudo são eficazes no aumento da autonomia funcional e na redução do quadro álgico de idosos com gonartrose.

Comparison of the effect of intra-tendon applications of recombinant human platelet-derived growth factor-BB, platelet-rich plasma, steroids in a rat achilles tendon collagenase model

This study compared the effect of intra-tendon (IT) delivery of recombinant human platelet-derived growth factor-BB (rhPDGF-BB), platelet-rich plasma (PRP) and corticosteroids in a rat tendinopathy model. Seven days after collagenase induction of tendinopathy, a 30-µl IT injection was administered. Treatments included: saline; 3 µg rhPDGF-BB; 10 µg rhPDGF-BB; PRP; and 300 µg triamcinolone acetonide (TCA). Outcomes were assessed 7 and 21 days after treatment. All groups exhibited good to excellent repair. Relative to saline, cell proliferation increased 65% in the 10 µg rhPDGF-BB group and decreased 74% in the TCA group; inflammation decreased 65% in the TCA group. At 7 days, maximum load-to-failure was increased in the 3 µg rhPDGF-BB group relative to saline, PRP, and TCA (p < 0.025). On day 21, maximum load-to-rupture was increased in the 10 µg rhPDGF-BB group relative to saline, PRP, and TCA (p < 0.035) and in the 3 µg rhPDGF-BB group compared to saline and TCA (p < 0.027). Stiffness in the 10 µg rhPDGF-BB group was increased compared to saline, PRP, and TCA (p < 0.038). Histology demonstrated similar repair in all groups. PRP and TCA did not improve mechanical properties compared to saline. Injections of rhPDGF-BB increased maximum load-to-failure (3 and 10 µg) and stiffness (10 µg) relative to controls and commonly used treatments. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:145-150, 2014.

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.

Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review

OBJECTIVES

To evaluate the current evidence for the efficacy of corticosteroid injection and non-electrotherapeutic physiotherapy compared with control for treating lateral epicondylitis.

DESIGN

Systematic review.

PARTICIPANTS

We searched five databases in September 2012 for randomised controlled studies with a minimum quality rating. Of the 640 studies retrieved, 11 were included, representing 1161 patients of both sexes and all ages.

INTERVENTIONS

Corticosteroid injection and non-electrotherapeutic physiotherapy.

OUTCOME MEASURES

Relative risk (RR) or standardised mean difference (SMD) for overall improvement, pain and grip strength at 4-12, 26 and 52 weeks of follow-up.

RESULTS

Corticosteroid injection gave a short-term reduction in pain versus no intervention or non-steroidal anti-inflammatory drugs (SMD -1.43, 95% CI -1.64 to -1.23). At intermediate follow-up, we found an increase in pain (SMD 0.32, 95% CI 0.13 to 0.51), reduction in grip strength (SMD -0.48, 95% CI -0.73 to -0.24) and negative effect on the overall improvement effect (RR 0.66 (0.53 to 0.81)). For corticosteroid injection versus lidocaine injection, the evidence was conflicting. At long-term follow-up, there was no difference on overall improvement and grip strength, with conflicting evidence for pain. Manipulation and exercise versus no intervention showed beneficial effect at short-term follow-up (overall improvement RR 2.75, 95% CI 1.30 to 5.82), but no significant difference at intermediate or long-term follow-up. We found moderate evidence for short-term and long-term effects of eccentric exercise and stretching versus no intervention. For exercise versus no intervention and eccentric or concentric exercise and stretching versus stretching alone, we found moderate evidence of no short-term effect.

CONCLUSIONS

Corticosteroid injections have a short-term beneficial effect on lateral epicondylitis, but a negative effect in the intermediate term. Evidence on the long-term effect is conflicting. Manipulation and exercise and exercise and stretching have a short-term effect, with the latter also having a long-term effect.

Mechanical solution for a mechanical problem: Tennis elbow

Lateral epicondylitis is a relatively common clinical problem, easily recognized on palpation of the lateral protuberance on the elbow. Despite the “itis” suffix, it is not an inflammatory process. Therapeutic approaches with topical non-steroidal anti-inflammatory drugs, corticosteroids and anesthetics have limited benefit, as would be expected if inflammation is not involved. Other approaches have included provision of healing cytokines from blood products or stem cells, based on the recognition that this repetitive effort-derived disorder represents injury. Noting calcification/ossification of tendon attachments to the lateral epicondyle (enthesitis), dry needling, radiofrequency, shock wave treatments and surgical approaches have also been pursued. Physiologic approaches, including manipulation, therapeutic ultrasound, phonophoresis, iontophoresis, acupuncture and exposure of the area to low level laser light, has also had limited success. This contrasts with the benefit of a simple mechanical intervention, reducing the stress on the attachment area. This is based on displacement of the stress by use of a thin (3/4-1 inch) band applied just distal to the epicondyle. Thin bands are required, as thick bands (e.g., 2-3 inch wide) simply reduce muscle strength, without significantly reducing stress. This approach appears to be associated with a failure rate less than 1%, assuming the afflicted individual modifies the activity that repeatedly stresses the epicondylar attachments.