Effectiveness of Acupuncture for Lateral Epicondylitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Percutaneous tendon dry needling and thrust manipulation as an adjunct to multimodal physical therapy in patients with lateral elbow tendinopathy: A multicenter randomized clinical trial

OBJECTIVE

The purpose of this study was to assess the effects of adding electrical dry needling and thrust manipulation into a multimodal program of exercise, mobilization, and ultrasound in patients with lateral elbow tendinopathy.

DESIGN

Randomized, single-blinded, multicenter, parallel-group trial.

SETTING

Thirteen outpatient physical therapy clinics in nine different US states.

PARTICIPANTS

One hundred and forty-three participants (n = 143) with lateral elbow tendinopathy were randomized.

INTERVENTION

Cervical spine manipulation, extremity manipulation, and percutaneous tendon electrical dry needling plus multimodal physical therapy (n = 73) or multimodal physical therapy (n = 70) alone.

MAIN MEASURES

The primary outcome was elbow pain intensity and disability as measured by the Patient-Rated Tennis Elbow Evaluation at baseline, 1 week, 4 weeks, and 3 months. Secondary outcomes included the Numeric Pain Rating Scale, Tennis Elbow Functional Scale, Global Rating of Change, and medication intake.

RESULTS

The 2 × 4 analysis of covariance demonstrated that individuals with lateral elbow tendinopathy receiving electrical dry needling and thrust manipulation plus multimodal physical therapy experienced significantly greater improvements in disability (Patient-Rated Tennis Elbow Evaluation: F = 19.675; P < 0.001), elbow pain intensity (Numeric Pain Rating Scale: F = 22.769; P < 0.001), and function (Tennis Elbow Function Scale: F = 13.269; P < 0.001) than those receiving multimodal physical therapy alone at 3 months. The between-group effect size was large for pain and disability (Patient-Rated Tennis Elbow Evaluation: standardized mean difference = 1.13; 95% confidence interval: 0.78, 1.48) in favor of the electrical dry needling and thrust manipulation group.

CONCLUSIONS

The inclusion of percutaneous tendon electrical dry needling and thrust manipulation into a multimodal program of exercise, mobilization and ultrasound was more effective than multimodal physical therapy alone in individuals with lateral elbow tendinopathy.Trial Registration: www.clinicaltrials.gov NCT03167710 May 30, 2017.

Treating Lateral Epicondylopathy With Dry Needling and Exercise: A Case Series

CONTEXT

Lateral epicondylopathy (LE) is a common overuse injury affecting elbow, wrist, and hand function. It is characterized by weakness and pain in the muscles and tendons of the forearm responsible for the extension of your wrist and fingers. Trigger point dry needling is a technique reported to be beneficial in managing pain and dysfunction after LE diagnosis. LE is also commonly treated with conservative treatment, such as joint and soft tissue mobilization, self-care home programs, and anti-inflammatory use. We explored a different dry needling approach consisting of in situ dry needling with electric stimulation combined with targeted therapeutic exercise to treat LE in 3 cases.

CASE PRESENTATION

Three patients were referred for dry needling once a week for 6 weeks and home-based exercise therapy for LE. They were clinically evaluated using grip strength, a visual analog scale to assess pain, and Patient-Rated Tennis Elbow Evaluation Test scores. These were measured at 4 time points (weeks 0, 2, 4, and 6).

MANAGEMENT AND OUTCOMES

The dry needling intervention incorporated 8 locations in the upper-extremity with 2 electric stimulation channels. The patients had reduced pain as measured by a visual analog scale, increased function as measured by the Patient-Rated Tennis Elbow Evaluation Test, and increased grip strength over 6 weeks.

CONCLUSIONS

This case series illustrates the use of dry needling and a home exercise program to provide a favorable outcome in a patient with LE. Patients had an 80% to 100% reduction in pain and similar improvements in function that were significantly beyond the minimum clinically important difference. This dry needling approach is a safe and effective treatment of LE in the short term.

Effectiveness of non-invasive therapies on pain, maximum grip strength, disability, and quality of life for lateral elbow tendinopathy: A systematic review and meta-analysis

BACKGROUND

Lateral elbow tendinopathy is a common musculoskeletal disorder. Effectiveness of non-invasive therapies for this health condition are unclear.

OBJECTIVE

To investigate the effectiveness of non-invasive therapies on pain, maximum grip strength, disability, and quality of life for lateral elbow tendinopathy.

METHODS

Searches were conducted on MEDLINE, Embase, CINAHL, AMED, PEDro, Cochrane Library, SPORTDiscus and PsycINFO without language or date restrictions up to May 3rd, 2023. Randomized trials investigating the effectiveness of any non-invasive therapy compared with control or other invasive interventions were included. Two independent reviewers screened eligible trials, extracted data, and assessed the risk of bias of included trials and certainty of the evidence.

RESULTS

Twenty-two different therapies investigated in 47 randomized trials were included in the quantitative analysis. Moderate certainty evidence showed that betamethasone valerate medicated plaster may reduce disability (mean difference -6.7; 95% CI -11.4, -2.0) in the short-term when compared with placebo. Low certainty evidence showed that acupuncture may reduce disability (MD -9.1; 95% CI -11.7, -6.4) in the short-term when compared with sham. Moderate to very low certainty of evidence also showed small to no effect of non-invasive therapies on pain intensity, maximum grip strength, and disability outcomes in the short-term compared to control or invasive interventions. Most therapies had only very low certainty of evidence to support their use.

CONCLUSIONS

Decision-making processes for lateral elbow tendinopathy should be carefully evaluated, taking into consideration that most investigated interventions have very low certainty of evidence. There is an urgent call for larger high-quality trials.

Lateral epicondylitis of the elbow: an up-to-date review of management

Lateral epicondylitis, also known as tennis elbow, is an overuse tendinopathy of the common extensor origin of the elbow in patients involved in repetitive movement of the wrist and forearm. Lateral epicondylitis is a self-limiting condition, with operative management only recommended in severe, recalcitrant cases. This article reviews the recent updates on operative and non-operative management of lateral epicondylitis.

Comparison between acupotomy and corticosteroid injection for patients diagnosed with different classifications of tennis elbow: a randomized control trial

BACKGROUND

Tennis elbow has long been one of the most controversial subjects in orthopaedics. Many scholars thought the use of open or arthroscopic surgery was reserved for patients with refractory symptoms. Therapy with percutaneous acupotomy performed under local anaesthesia also removes degenerated tissue, releases strain, and therefore provides an alternative treatment option to surgical excision.

METHODS

The aim of this single-blinded randomized control trial was to examine the long-term clinical effectiveness of a nonsurgical percutaneous release technique (acupotomy) and the current recommended treatment (steroid injection) in people diagnosed with a refractory tennis elbow. Ninety patients with refractory symptoms were included. The intervention period was 6 weeks. According to the classification, 38 patients had extra-articular tennis elbow, 36 patients had intraarticular tennis elbow, and 16 patients had mixed type tennis elbow. Forty-five patients were randomly assigned to treatment with percutaneous release by acupotomy according to their classified condition, and 45 patients were randomly assigned to treatment with steroid injection alone. The visual analogue scale (VAS), a tenderness assessment, a grip assessment, and the Nirschl staging system were used for outcome evaluation at pretreatment and the posttreatment timepoints from 12 to 48 weeks.

RESULTS

During the first weeks, there were no differences observed between the groups. By 6, 24 and 48 weeks, significant differences were observed between the two groups. The acupotomy group scored significantly better in visual analogue scale score (VAS) of pain, tenderness during palpation, pain-free grip strength (PFGS) and Nirschl staging than the corticosteroid group.

CONCLUSIONS

For patients with lateral epicondylitis, acupotomy is just as effective as corticosteroid injections in the short term (< 6 weeks). In the long term, acupotomy has greater efficacy and is associated with a lower rate of recurrence than corticosteroid injections in the management of lateral epicondylitis.

TRIAL REGISTRATION

The National Health Commission announced the "ethical review measures for biomedical research involving people" in 2019, which was not mandatory in previous studies.

Comparison of extracorporeal shock wave therapy and high-intensity laser therapy on pain, grip strength, and function in patients with lateral epicondylalgia: a randomized controlled study

This study aimed to compare the effects of extracorporeal shockwave therapy (ESWT) and high-intensity laser therapy (HILT) on pain, grip strength, and function in patients with lateral epicondylalgia. This prospective randomized controlled study included 42 patients (22 women and 20 men, mean age: 37) divided into 3 groups. The first group received physiotherapy (n = 14), the second received physiotherapy combined with ESWT (n = 14), and the third received physiotherapy combined with HILT (n = 14). All participants underwent 10 physiotherapy sessions for 2 weeks, 5 sessions per week. In addition to physiotherapy, the ESWT group received 4 ESWT sessions, 2 sessions per week, and the HILT group received 4 HILT sessions, 2 sessions per week. The outcomes were pain intensity as assessed by Visual Analog Scale, grip strength by hand dynamometer, and function by the Duruoz Hand Index and Patient-Rated Tennis Elbow Evaluation-Turkish version questionnaire. The participants were assessed at the beginning of the study (T1/week 0), at the end of treatment (T2/2nd week), and at follow-up (T3/6th week). At follow-up (T3), a significant improvement was observed in all outcomes compared to baseline (T1) in all groups (P < 0.05). Inter-group comparison of the mean differences between baseline and end values showed that the HILT group was superior in all outcomes (P < 0.05). This study showed that physiotherapy alone combined with ESWT and HILT positively affected the treatment of lateral epicondylalgia. Physiotherapy combined with HILT was found to be the most effective for improving pain, grip strength, and function. Clinical trial number: NCT674325.

Healthcare Utilization for Lateral Epicondylitis: A 9-Year Analysis of the 2010–2018 Health Insurance Review and Assessment Service National Patient Sample Data

This retrospective cross-sectional study examined healthcare utilization among 213,025 patients with lateral epicondylitis over a nine-year period using the 2010–2018 Health Insurance Review and Assessment Service (HIRA) data (ICD code M771). Healthcare utilization, types of treatment, and the route of the visit were analyzed with frequency analysis for Western medicine (WM) and Korean medicine (KM). The findings revealed that the number of patients visiting WM and KM facilities for lateral epicondylitis rose every year from 2010 to 2018. Over this period, the age distribution of patients was 45–54 years (39.93%), 55–64 (23.12%), and 35–44 years (21.07%), and there were slightly more female patients (53.66%) than male patients (46.34%). The number of claims for lateral epicondylitis tended to increase with decreasing average monthly temperature; an increased proportion of middle-aged patients (45–64 years) was the most evident. The most frequently performed interventions in WM were subcutaneous or intramuscular injection (injection), deep heat therapy (physical therapy), and spinal peripheral nerve block-axillary nerve block (treatment/operation); the most frequently performed intervention in KM was acupuncture (injection). For pharmacological treatment, analgesics and anti-inflammatory medications were most frequently prescribed. The findings can be useful for health policymakers and as foundational data for clinicians and researchers.

Lateral epicondylosis: A literature review to link pathology and tendon function to tissue-level treatment and ergonomic interventions

BACKGROUND

Common treatments for lateral epicondylosis (LE) focus on tissue healing. Ergonomic advice is suggested broadly, but recommendations based on biomechanical motion parameters associated with functional activities are rarely made. This review analyzes the role of body functions and activities in LE and integrates the findings to suggest motion parameters applicable to education and interventions relevant to activities and life roles for patients.

PURPOSE

This study examines LE pathology, tendon and muscle biomechanics, and population exposure outlining potentially hazardous activities and integrates those to provide motion parameters for ergonomic interventions to treat or prevent LE. A disease model is discussed to align treatment approaches to the stage of LE tendinopathy.

STUDY DESIGN

Integrative review METHODS: We conducted in-depth searches using PubMed, Medline, and government websites. All levels of evidence were included, and the framework for behavioral research from the National Institutes of Health was used to synthesize ergonomic research.

RESULTS

The review broadened the diagnosis of LE from a tendon ailment to one affecting the enthesis of the capitellum. It reinforced the continuum of severity to encompass degeneration as well as regeneration. Systematic reviews confirmed the availability of evidence for tissue-based treatments, but evidence of well-defined harm reducing occupational interventions was scattered amongst evidence levels. Integration of biomechanical studies and population information gave insight into types of potentially hazardous activities and provided a theoretical basis for limiting hazardous exposures to wrist extensor tendons by reducing force, compression, and shearing during functional activities.

CONCLUSIONS

These findings may broaden the first treatment approach from a passive, watchful waiting into an active exploration and reduction of at-risk activities and motions. Including the findings into education modules may provide patients with the knowledge to lastingly reduce potentially hazardous motions during their daily activities, and researchers to define parameters of ergonomic interventions.

Effects of manual acupuncture and electroacupuncture for lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis

OBJECTIVE

The aim of this study was to evaluate the effect of acupuncture/electroacupuncture, alone or combined with other interventions, on pain intensity, pain-related disability, and strength in lateral epicondylalgia (LE) of musculoskeletal origin.

DATABASES AND DATA TREATMENT

Electronic databases were searched for randomized clinical trials, where at least one group received acupuncture or electroacupuncture for LE of musculoskeletal origin. To be eligible, trials had to include humans and collect outcomes on pain intensity or pain-related disability in LE. Data were extracted by two reviewers. The risk of bias (RoB) of the trials was assessed using the Cochrane RoB tool, methodological quality was assessed with the Physiotherapy Evidence Database (PEDro) score, and the level of evidence was summarized using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Standardized mean differences (SMDs) using random effects were calculated.

RESULTS

A total of 14 trials (10 acupuncture) were included. The meta-analysis found a moderate effect size of acupuncture (SMD = -0.66, 95% confidence interval (CI) = -1.22 to -0.10), but not electroacupuncture (SMD = -0.08, 95% CI = -0.99 to 0.83), in the reduction of elbow pain as compared to a comparative group. Acupuncture exhibited a significant moderate effect size (SMD = -0.51, 95% CI = -0.91 to -0.11) in the improvement of related-disability. Acupuncture (SMD = 0.36, 95% CI = 0.16 to 0.57), but not electroacupuncture (SMD = 0.34, 95% CI = -0.29 to 0.98), exhibited a significant but small effect size on strength. Most significant effects were in the short term. The RoB was low but the heterogeneity of trial results led to a downgrading of the GRADE evidence level.

CONCLUSION

Low-level evidence suggests positive effects of acupuncture, but not electroacupuncture, for pain, related-disability, and strength, in LE of musculoskeletal origin, in the short term.

Acupuncture for lateral epicondylitis: A prisma-compliant protocol for a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Acupuncture has been widely used for relieving pain associated with musculoskeletal disorders, such as lateral epicondylitis. Although the effect of acupuncture on pain has been demonstrated in previous reviews, it is still under debate. This study is aimed at evaluating the efficacy of acupuncture to treat lateral epicondylitis and establishing the evidence systematically.

METHODS

Nine databases will be searched from their inception to May 2020 without language or publication status restrictions, including 3 English databases (MEDLINE, Embase, the Cochrane Central Register of Controlled Trials), 5 Korean databases (Korean Medical Database, KoreaMed, Korean Studies Information Service System, Research Information Service System, Oriental Medicine Advanced Searching Integrated System), and 1 Chinese database (China Knowledge Network Database). Only randomized controlled trials will be included. Pain intensity will be considered as the primary outcome. Secondary outcomes will include the grip strength, total effective rate, and adverse events. Two independent researchers will perform the study selection, data extraction, and quality assessment. The methodological quality of the identified studies will be assessed using the Cochrane Collaboration's risk-of-bias tool. In the meta-analysis, continuous data will be expressed as mean and 95% confidence interval, and dichotomous data will be expressed as risk ratio and 95% confidence interval.

RESULTS

The results of this study will be submitted to a peer-reviewed journal for publication.

CONCLUSION

The results of this study would provide the evidence of whether acupuncture is effective for lateral epicondylitis.

REGISTRATION NUMBER

PROSPERO CRD42020186824.