A Newly Designed Tennis Elbow Orthosis With a Traditional Tennis Elbow Strap in Patients With Lateral Epicondylitis

BACKGROUND

Lateral epicondylitis is a common cause of pain and upper limb dysfunction. The use of counterforce straps for treatment of lateral epicondylitis is widespread. This kind of orthosis can be modified to have a greater effect on relieving pain by reducing tension on the origin of the extensor pronator muscles.

OBJECTIVES

To determine the immediate effects of a newly designed orthosis on pain and grip strength in patients with lateral epicondylitis.

MATERIALS AND METHODS

Twelve participants (six men and six women) were recruited (mean age = 41 ± 6.7 years) and evaluated for pain and grip strength in three sessions. A 48-hour break was taken between each session. The first session was without any orthosis, the second session was with the new modified tennis elbow orthosis, and the third session was with a conventional tennis elbow strap.

RESULTS

Both counterforce straps were effective. However, significantly more improvement was observed in pain and grip strength after using the newly modified orthosis (P < 0.05).

CONCLUSIONS

The newly designed strap reduces pain more effectively and improves grip strength by causing greater localized pressure on two regions with different force applications (two component vectors versus one).

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.

FOREARM BAND VERSUS ELBOW TAPING: AS A MANAGEMENT OF LATERAL EPICONDYLITIS

Purpose: There are several treatments available for the management of lateral epicondylitis, but there is a dearth of clinical trials compared to the efficacy of a forearm band over supportive elbow taping technique as an adjunct measure in the management of lateral epicondylitis. Materials and Methods: Totally 45 subjects with the mean age of 30±5 years diagnosed with lateral epicondylitis participated in the study based upon inclusion and exclusion criteria. Subjects were randomly allocated to three groups (n = 15 in each); Group-A (forearm band), Group-B (elbow taping) and Group-C (control), provided with a forearm band, supportive elbow taping technique and as a control group, respectively, although all groups received the conventional physiotherapy in addition to these adjunct measures. The outcome measurements included pain-free grip strength and functional improvement, assessed by using hand-held dynamometer and patient-rated forearm evaluation questionnaire (PRFEQ), respectively. Total duration of study was four weeks. Results: Although all the groups showed improvement with respect to increase in the pain-free grip strength and enhancement of functional independence, however, Group-A has shown the maximum improvement followed by Group-B which in turn proved to be more effective than conventional physiotherapy alone. Conclusion: The application of the forearm band produced a significant increase in the grip strength and function as compared to the elbow taping and control groups. The study implies the potential use of a forearm band in the future in addition to the conventional therapy in the management of patients with lateral epicondylitis.

Evidence supporting the use of physical modalities in the treatment of upper extremity musculoskeletal conditions

PURPOSE OF REVIEW

To evaluate recent trials and reviews of physical modalities and conservative treatments for selected upper extremity musculoskeletal conditions for evidence supporting their use.

RECENT FINDINGS

Recent evidence suggests that many localized tendinopathies are related more to degenerative than inflammatory processes. With this realization, there is increased emphasis on finding new modalities to treat tendinopathies and other localized musculoskeletal conditions that rely on other than anti-inflammatory mechanisms. Although there is good evidence to support the short-term benefits of corticosteroid injections, convincing evidence in support of other conservative treatments and modalities is generally lacking. Extracorpal shock wave therapy may have significant clinical benefit for calcific tendinitis; however, it requires intravenous sedation in most cases and does not appear to be effective in lateral epicondylitis. The most consistent positive treatment effects for rotator cuff tendinitis were achieved by ultrasound-guided subacromial corticosteroid injection as well as manual therapy in conjunction with therapeutic exercise.

SUMMARY

Although there is evidence supporting the use of several different physical modalities and conservative treatments for upper extremity musculoskeletal conditions, there is a strong need for larger, higher quality randomized controlled trials. Although most studies are able to demonstrate short-term benefits, there is a lack of high-quality data demonstrating that these conservative treatments have long-term benefits, particularly, with regard to functional outcomes.

Strain reduction of the extensor carpi radialis brevis tendon proximal origin following the application of a forearm support band

STUDY DESIGN

Experimental laboratory design.

OBJECTIVES

To measure the strain at the proximal origin of the extensor carpi radialis brevis (ECRB), and to determine the influence of a forearm support band.

BACKGROUND

A forearm support band is often used with the intent to decrease stresses around the origin of the wrist extensors. However, the influence of the location of the band has not been studied.

METHODS AND MEASURES

The forearm support band was applied on 8 cadaver arms (mean +/- SD age, 78.4 +/- 10.3 years) and 2 experimental conditions were performed. First, strain measurements were made without applying tension to the distal ECRB tendon, then strain measurements were made with a traction force of 21.5 N being applied to the distal ECRB tendon. Strain of the proximal origin of the ECRB, 1.0 cm distal from the lateral epicondyle, was recorded using a strain gauge. The band was mounted on the forearm at distances equal to 80%, 70%, 60%, 50%, 40%, 30%, and 20% of the forearm length as measured from the wrist. Testing order was randomized. Tension applied to the band was 19.6 N.

RESULTS

When no tension was applied to the ECRB, there was no statistically significant difference (P>.05) in strain values at the ECRB origin by mounting the band at any of the forearm positions. In the tension condition, the average (SD) strain with no band was 2.40% (1.40%). The average strain value of 0.85% (0.65%), when the band was mounted 80% of the forearm length proximal to the wrist, was statistically smaller than that obtained without the band (P<.05).

CONCLUSIONS

The strain on the ECRB origin was less when the forearm support band was applied 80% proximal from the wrist joint.

LEVEL OF EVIDENCE

Therapy, level 5.

Physiotherapy, steroid injections, or rest for lateral epicondylosis? What the evidence suggests

OBJECTIVE

To identify effective lateral epicondylosis interventions and assess the quality of research over time.

METHODS

Relevant MEDLINE and EMBASE searches respectively yielded 226 and 187 potential studies. Additional citations were extracted from bibliographies. Thirty controlled trials met inclusion criteria. The Cochrane Collaboration guidelines "quality score" served to rate studies.

RESULTS

In the short term (<2 to 3 months) steroid injections and physiotherapy outperformed relative rest. Physiotherapy appears efficacious regardless of time frame. After 3 months, active physiotherapy outperforms injections, but does not appear significantly better than rest. Evidence was neutral or insufficient regarding ultrasound, splinting, or manipulation. Nonsignificant correlations between publication year and study quality score were found.

CONCLUSIONS

Overall research quality has not improved with time. Steroid injections appear the most successful short-term intervention for pain relief. Active physiotherapy appears efficacious regardless of time frame.

Elbow orthoses: a review of literature

The objective of this study is to review the available literature on elbow orthoses in patients with various diagnoses to assess the scientific base of the prescription of elbow orthoses. A search of literature in Medline, Embase, Cochrane and Recal was performed using the keyword "elbow" combined with "orthosis related keywords". Abstracts were read to select the papers dealing primarily with monoarticular elbow orthoses. References of the selected papers were also examined. A total of 57 papers were read of which 18 met the selection criteria. Both the quality and quantity of the studies appeared to be low, so in this study no definitive conctusions can be drawn about the efficacy of monoarticular elbow orthoses. Current prescriptions of elbow orthoses cannot be evidence based, because no scientific evidence on elbow orthoses is available.

The efficacy of splinting for lateral epicondylitis: a systematic review

To determine the efficacy of using splinting as a treatment for lateral epicondylitis (LE), a systematic review of the literature was conducted on Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, PEDro, and Cochrane databases using pertinent key words and phrases. Hand searches of article references were also used to ensure that as many relevant articles as possible were identified. Searches were limited to articles published in English. Articles that did not involve splinting (or terminology derivative thereof) as treatment intervention for LE were excluded. From 98 potential articles, 58 were considered strong inclusion candidates. These articles were copied and further triaged according to predefined criteria, resulting in 22 articles that were numbered randomly and blinded. Three reviewers appraised these articles, eliminating 11 of the articles because they did not meet essential criteria of randomization, control group, and/or inferential statistical analysis. Using MacDermid quality scores, the 11 remaining articles were rated by three reviewers. Consensus between the three reviewers was achieved for all quality scores for all 11 articles included in the review. Adjusted quality scores ranged from 44.5 to 16.5 with a mean of 26.3 points. For accurate comparison and consistency of terminology, splints described in the included articles were first classified according to the ASHT Splint Classification, expanded and refined version, and next according to their inherent material properties. Six splints in five classification categories were identified. Discussion of the results from the 11 included studies was organized according to splint category and further separated into strength, pain, and load applied sections. This review identified one Sackett level 1b study and ten Sackett level 2b studies that offer early positive, but not conclusive, support for the effectiveness of splinting lateral epicondylitis. None of the reviewed studies received a perfect quality score, and the wide range of quality scores attests to the fact that considerable improvement of future studies is essential.

Orthotic devices for tennis elbow

BACKGROUND

Lateral epicondylitis (tennis elbow) is a frequently reported condition. A wide variety of treatment strategies has been described. As of yet, no optimal strategy has been identified.

OBJECTIVES

The objective of this review was to assess the effectiveness of orthotic devices for treatment of tennis elbow.

SEARCH STRATEGY

An electronic database search was conducted using Medline, Embase, Cinahl, the Cochrane Controlled Trial Register, Current Contents and reference lists from all retrieved articles. Experts on the subjects were approached for additional trials.

SELECTION CRITERIA

All randomised clinical trials (RCT) describing individuals with diagnosed lateral epicondylitis and comparing the use of an orthotic device as a treatment strategy were evaluated for inclusion.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the validity of the included trials and extracted data on relevant outcome measures. Dichotomous outcomes were expressed as Relative Risks (RRs) and continuous outcomes as Standardised Mean Differences (SMD), both with corresponding 95% confidence intervals (95% CI). Statistical pooling and subgroup analyses were intended

MAIN RESULTS

Five small-size RCTs (N per group 7-49) were included. Validity score ranged from 3-9 positive items out of 11. Subgroup analyses were not performed due to the small number of trials. The limited number of included trials present few outcome measures and limited long-term results. Pooling was not possible due to large heterogeneity amongst trials.

REVIEWER'S CONCLUSIONS

No definitive conclusions can be drawn concerning effectiveness of orthotic devices for lateral epicondylitis. More well-designed and well-conducted RCTs of sufficient power are warranted.

The Wharfedale Epicondylar Clasp: A Treatment for Lateral and Medial Epicondylitis

Pain in the elbow impinges on many activities of daily living, both at work and at home, and can severely limit the ability to cope. This article demonstrates the use of a small, practical orthosis, made to measure to relieve lateral and medial epicondylitis, better known as tennis or golfer's elbow. An audit showed that for 84% of the 52 patients who responded, the use of the clasp was considered a success in both the short-term and the long-term results.

Strength and pain measures associated with lateral epicondylitis bracing

OBJECTIVE

To determine the effect of bracing on measures of pain-free grip strength and pain scores in individuals with unilateral lateral epicondylitis through a comparison of two elbow braces, a placebo brace, and a no-brace situation.

DESIGN

Repeated-measures design in which the subjects acted as their own controls.

SETTING

A clinical research laboratory at a hand and upper limb clinic.

PATIENTS

Fifty individuals diagnosed by a physician with unilateral lateral epicondylitis, having symptoms for at least 3 weeks, were recruited from the community.

INTERVENTIONS

The braces studied were the Count'R-Force Tennis Elbow Brace, the Body Glove Airprene Elbow Support, and a placebo brace that consisted of a modified DePuy Levy Clinic Patella Strap.

MAIN OUTCOME MEASURES

Pain-free grip strength measured using an NK Biotechnical Corporation Hand Assessment System DIGIT-grip Device and pain scores measured on a visual numeric rating scale.

RESULTS

No significant differences in pain-free grip strength or pain were observed between any of the test situations (p > .05). Pain during the test, however, was greater than pain before or after the test (p < .05).

CONCLUSIONS

When tests were completed on one occasion with the brace on, no advantages of elbow bracing were detected. Whether bracing is effective when used as a treatment technique for an extended period of time should be addressed in future research.

The treatment of lateral epicondylitis by iontophoresis of sodium salicylate and sodium diclofenac

OBJECTIVE

To investigate the effectiveness of sodium diclofenac and sodium salicylate applied by topical iontophoresis and to compare them in the treatment of lateral epicondylitis.

SUBJECTS

Forty patients with lateral epicondylitis were randomized into two groups of 20 patients who were matched for age and sex.

INTERVENTIONS

The patients in one group were treated by iontophoresis of sodium diclofenac and the other group were treated by iontophoresis of sodium salicylate. Then infrared treatment was applied to patients in both groups.

MAIN OUTCOME MEASURES

Pain scores obtained before and after treatment were compared.

RESULTS

Pain produced by pressure on the lateral epicondyle, on resisting wrist extension, during function and spontaneous pain at rest significantly decreased in both groups after treatment (p < 0.001). When pain scores obtained after treatment were compared, greater decrease was observed in the pain produced on resisting wrist extension (p < 0.01) and by pressure on the lateral epicondyle (p < 0.05) in the group treated with sodium diclofenac than in the group treated with sodium salicylate.

CONCLUSIONS

The results suggest some benefits from the process of iontophoresis and the use of infrared in the treatment of lateral epicondylitis and indicate that iontophoresis of sodium diclofenac is more effective than that of sodium salicylate.