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.

Botulinum Toxin in Chronic Lateral Epicondylitis, from Tendon to Muscle Approach-A Review

BACKGROUND

Chronic lateral epicondylitis challenges the therapeutical approach; underlying mechanisms are incompletely understood; neuropathic pain and central and peripheral sensitization may explain the fact that botulinum toxin has been found to play a role in pain and function management.

METHODS

We searched the literature for MeSH terms: lateral epicondylitis or synonyms and botulinum toxin.

RESULTS

We found 14 papers containing trials on botulinum toxin injection into the tendon or into the extensor muscles (specifically, extensor carpi radialis brevis and extensor communis digitorum). We followed the administration pathways, doses, timing, and side effects.

CONCLUSIONS

With a chronic course, the focus of the therapy shifts from the afflicted tendon to the inserting muscles, as muscle contracture may create a vicious loop to perpetuate and aggravate the disease. Doses, timing, and side effects are discussed.

Clinical efficacy of botulinum toxin in lateral elbow tendinopathy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Botulinum toxin injections for lateral elbow tendinopathy have been used as an alternative therapeutic option. However, few studies have quantitatively summarized the effect of botulinum toxin as well as its clinical significance. We aimed to evaluate the clinical efficacy (based on pain and grip strength) and adverse events of botulinum toxin on lateral elbow tendinopathy.

PATIENTS AND METHODS

The MEDLINE, EMBASE, Web of Science, and Scopus databases were searched until March 2023 for randomized controlled trials reporting the effects of botulinum toxin injections on lateral elbow tendinopathy. A random- or fixed-effects model (depending of inter-study variability) and generic inverse variance method were used to pool quantitative data from outcomes. The risk of bias was assessed with the Cochrane Risk of Bias 2.0 tool.

RESULTS

A total of 8 clinical trials recruiting 438 subjects were included for meta-analysis. Pooled analysis revealed that botulinum toxin significantly reduced pain (mean difference [MD] -0.95, 95% CI [-1.63, -0.26], p=0.007) but it was not clinically relevant. No significant effect was detected for grip strength (MD-0.62kg, 95% CI [-2.25, 1.02], p=0.46) or in the risk for adverse events (odds ratio [OR] 0.41, 95% CI [0.05, 3.56], p=0.42) between botulinum toxin injection and control interventions.

DISCUSSION

The use of botulinum toxin reached greater pain relief than control interventions and normal saline after a period of 12 to 24 weeks. However, changes in pain relief did not reach clinical significance. The studies that had the greatest reduction in pain used higher doses of botulinum toxin (60 U). Additionally, differences in grip strength and adverse events did not reach statistical or clinical importance. A subanalysis indicated that botulinum toxin outperformed corticosteroid injections in terms of improving grip strength. Botulinum toxin only causes local and minimal side effects such as irritation, ecchymosis, and paralysis.

LEVEL OF EVIDENCE

I.

Nonoperative Management of Lateral Epicondyle Tendinopathy: An Umbrella Review

Objective

The primary objective of this review was to summarize systematic reviews and meta-analyses reporting on nonoperative management of lateral epicondyle tendinopathy.

Methods

An umbrella review of all published systematic reviews and meta-analyses was performed. Three databases were searched using the key words "tennis elbow," "lateral epicondylitis," "non-operative," and "non-surgical modalities." The search was limited to English-language systematic reviews and meta-analyses between the years of 2000 and 2022.

Results

There were 114 systematic reviews/meta-analyses, of which 35 met our inclusion criteria. These articles reviewed the following nonoperative management strategies: ultrasound, shockwave therapy, injection procedures, low-level laser therapy, joint mobilizations, exercise therapy, and electrophysical modalities. Exercise therapy was beneficial in decreasing pain regardless of dosage or type. Conflicting results were seen with ultrasound, laser, and shockwave therapy. Corticosteroid injections provided the most short-term pain relief, and platelet-rich plasma and autologous blood injections were most effective in the long term.

Conclusion

A variety of nonoperative interventions were found to be effective for short- and long-term pain relief as well as functional improvement, with most interventions indicating mixed results. Due to variations in study populations and study quality, results should be interpreted with caution.

Pain Modulation in Chronic Musculoskeletal Disorders: Botulinum Toxin, a Descriptive Analysis

Botulinum neurotoxin (BoNT), a product of Clostridium botulinum, reversibly inhibits the presynaptic release of the neurotransmitter acetylcholine at the neuromuscular junction. In addition, BoNT blocks the transmission of other substances involved in pain perception and, together with a soft-tissue anti-inflammatory effect, may play a role in analgesia. When first-line treatment fails, second-line therapies might include BoNT. Studies on chronic and recurrent pain using different mechanisms offer heterogenous results that must be validated and standardized. Plantar fasciitis, severe knee osteoarthritis, painful knee and hip arthroplasty, antalgic muscular contractures, and neuropathic and myofascial pain syndromes may benefit from the administration of BoNT. Research on this topic has revealed the main musculoskeletal conditions that can benefit from BoNT, stressing the effects, modalities of administration, doses, and schedule.

[Infiltration therapies for lateral epicondylopathy]

The therapy of the lateral epicondylopathy (tennis elbow) includes drug injection into the extensor tendon insertion in chronic cases. The choice of medication and the type of injection is decisive for the success of therapy. Furthermore, accurate application is indispensable for therapy success (e.g. peppering injection technique, ultrasound-supported injection technique). Corticosteroid injection is often associated with short-term success, so that other options have found their way into everyday practice. Objectification of treatment success is usually defined by Patient-Reported Outcome Measurements (PROM). With the introduction of Minimal Clinically Important Differences (MCID), statistically significant results are put into perspective in terms of clinical significance. Therapy for lateral epicondylopathy was considered effective if the mean difference in score results between baseline and follow-up exceeded 1.5 points for the Visual Analogue Scale (VAS), 16 points for Disabilities of Arm, Shoulder and Hand Score (DASH), 11 points for Patient-Rated Tennis Elbow Evaluation (PRTEE), and 15 points for Mayo Elbow Performance Score (MEPS). However, the effectiveness must still be critically questioned according to meta-analytical evaluations, in which healing within 12 months was found in 90% of the cases of untreated chronic tennis elbow in the placebo groups. The use of substances, such as Traumeel (Biologische Heilmittel Heel GmbH, Baden-Baden, Germany), hyaluronic acid, botulinum toxin, platelet rich plasma (PRP), autologous blood or polidocanol, are based on various mechanisms. In particular, the use of PRP or autologous blood for the treatment of musculotendinous and degenerative articular pathologies has become popular, although the studies regarding effectiveness are inconsistent. PRP can be divided into leukocyte-rich (LR-PRP) and leukocyte-poor plasma (LP-PRP) according to its preparation. In contrast to LP-PRP, LR-PRP incorporates the middle and intermediate layers, but there is no standardized preparation described in the literature. Conclusive data regarding effective efficacy are still pending.

Effectiveness of different doses of botulinum neurotoxin in lateral epicondylalgia: A network meta-analysis

BACKGROUND

Previous studies have investigated the role of botulinum neurotoxin (BoNT) in lateral epicondylalgia, with controversial results. We hypothesized that BoNT would be effective and safe for the treatment of lateral epicondylalgia.

OBJECTIVE

To investigate the effectiveness and safety of different doses of BoNT in participants with lateral epicondylalgia.

METHODS

PubMed, Embase, and Cochrane Library were searched up to August 27, 2022, for randomized controlled trials (RCTs) of BoNT treatment for epicondylalgia. The Cochrane risk of bias tool was used for quality assessment. A network meta-analysis and a trial sequential analysis (TSA) were conducted on pain, grip strength and adverse events. Meta-regression was applied for high heterogeneity comparisons.

RESULTS

We included 8 RCTs consisting of 448 participants. Four studies scored low risk of bias in all categories, whereas the other 4 studies had unclear risk only in the selection bias category. The network meta-analysis and TSA revealed that corticosteroid (standardized mean difference [SMD]: -1.32, 95% CI: -2.13; -0.50), high-dose BoNT (SMD -1.32, -2.04; -0.61), and low-dose BoNT (SMD -0.52, -0.93; -0.10), relieved pain significantly better than placebo for up to 7 to 10 weeks. High-dose BoNT demonstrated a significantly greater reduction in pain than low-dose BoNT for up to 7 to 10 weeks (SMD -0.81, -1.39; -0.22). Finally, after low-dose BoNT, younger participants (p = 0.023) and women (p = 0.012) showed more pain decrease than older individuals and men at 2 to 6 weeks. As for grip strength and adverse events, only grip strength after low-dose BoNT versus placebo (SMD -0.49, -0.88; -0.10) and corticosteroid (SMD -1.36, -2.15; -0.57) at 2 to 6 weeks reached significance after threshold adjustment in TSA.

CONCLUSIONS

Our meta-analysis confirmed the effectiveness of low-dose BoNT in the reduction of pain for lateral epicondylalgia. Further conclusions cannot be drawn due to insufficient available data.

The efficacy and safety of intra-articular botulinum toxin type A injection for knee osteoarthritis: A meta-analysis of randomized controlled trials

The purpose of this study was to investigate the efficacy and safety of intra-articular Botulinum Toxin type A (BTA) injection in the management of patients with knee osteoarthritis (KOA). The literature retrieval was conducted based on PRISMA guidelines. Databases including Pubmed, Web of science, EMBASE, and Cochrane Library were searched to identify RCTs that comparing the effects of intra-articular BTA injection with control interventions on patients with KOA. The primary outcomes involved pain and function improvements as well as the occurrence of adverse events. Seven RCTs comprising 548 participants were included in this meta-analysis. Compared with the control group, BTA injection exhibited greater pain reduction at 4 weeks posttreatment (SMD = -0.86, 95% CI [-1.52, -0.19], p = 0.011), but not 8-24 weeks posttreatment (wk 8, SMD = -0.53, 95% CI [-1.21, 0.15], p = 0.127; wk 12, SMD = -0.34, 95% CI [-0.73, 0.04], p = 0.081; wk 24, SMD = -0.65, 95% CI [-1.52, 0.22], p = 0.144). Additionally, no differences were found between BTA injection versus control intervention on functional improvement at all time points assessed (wk 4, WMD = -5.16, 95% CI [-12.31, 2.00], p = 0.158; wk 8, WMD = -0.98, 95% CI [-5.66, 3.71], p = 0.683; wk 12, WMD = -2.52, 95% CI [-7.54, 2.50], p = 0.325); wk 24, WMD = -3.66, 95% CI [-14.09, 6.76], p = 0.491). There was no significant difference in adverse event rate between the BTA and control group (OR = 0.88, 95% CI [0.24, 3.18], p = 0.843). This meta-analysis suggests that intra-articular BTA injection could be an efficious and safe strategy for analgesic treatment of KOA. However, evidence is limited due to the small number and heterogeneity of included studies, this urges further and stronger trials to confirm our findings.

Lateral Epicondylitis: Critical Analysis Review of Current Nonoperative Treatments

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Lateral epicondylitis (LE) or tennis elbow is a common cause of elbow pain in the general population, especially women in the fourth and fifth decades of life who participate in repetitive forceful movements involving the wrist and forearm.

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The pathogenesis of this overuse injury is believed to start from an overload event leading to a microtear in or near the origin of the extensor carpi radialis brevis that is subsequently prone to additional injury and structural weakness over time.

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Treatment of LE often begins with a wide variety of nonoperative modalities including rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies are implemented; however, there remains a lack of comparative efficacy between these adjunct treatments.

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In this article, we examine the available literature regarding nonoperative management of LE and provide supplementary insight into the effectiveness of current modalities.

Meta-Analysis of Effectiveness and Safety of Botulinum Toxin in the Treatment of Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS) is characterized by pain, limited range of motion, swelling, skin changes, vasomotor instability, and patchy bone demineralization. Conservative management strategies for CRPS include physical and occupational therapy, psychosocial and behavioral therapy, and pharmacotherapy. However, some patients still experience CRPS symptoms after receiving conventional treatments. Therefore, botulinum toxin (BoNT) has been applied to patients with CRPS in several trials considering its analgesic effect in musculoskeletal and neuropathic pain; however, the results were controversial. We conducted the study to explore the effectiveness and safety of BoNT in patients with complex regional pain syndrome (CRPS). A search was performed using the following electronic databases up to 19 October 2022: PubMed, Embase, and Cochrane Library. We included both randomized controlled trials and nonrandomized controlled studies involving patients with complex regional pain syndrome managed with botulinum toxin. Cochrane risk-of-bias tool and Joanna Briggs Institute Critical Appraisal Checklist were used for quality assessment for randomized controlled trials and quasi-experimental studies. Only randomized controlled trials entered the meta-analysis. The primary outcome was the visual analogue scale of pain presented as a weighted mean difference (WMD) and 95% confidence interval (CI). The secondary outcome was the risk of adverse events presented as an odds ratio (OR) with 95% CI. We analyzed eight articles with 176 patients, including three randomized controlled trials with 62 participants. The age of the patients ranged from 23.8 to 51 years old. The duration of the disease ranged from 2.2 to 11.8 years. The proportion of females ranged from 16.6% to 100%. The route of administration of BoNT included: (1) lumbar sympathetic block (LSB), (2) intramuscular injection, (3) subcutaneous or intradermal injection (SC/ID). Improvement in pain was revealed in six studies, and adverse events were all self-limited and temporary. Meta-analysis revealed a significant reduction in pain at the first follow-up between 3 weeks to 1 month after intervention (WMD, -1.036, 95% CI, -1.673 to -0.400) but not at the second follow-up between 2 to 3 months after treatment (WMD, -0.895, 95% CI, -2.249 to 0.458). Subgroup analyses between LSB and SC/ID were nonsignificant at both follow-up periods (p = 0.422, 0.139). The risk of adverse events was similar between the BoNT and control group (OR, 0.698, 95% CI, 0.136 to 3.581). In conclusion, BoNT may be effective and safe for alleviating pain in patients with CRPS. However, we could not draw definite conclusions due to small sample size and high between-study heterogeneity. The limited number of participants may conceal the possibility of serious adverse events. Further large-scale randomized controlled trials are warranted to delineate the role of BoNT in CRPS.

Treatment, Diagnostic Criteria and Variability of Terminology for Lateral Elbow Pain: Findings from an Overview of Systematic Reviews

Background: Lateral elbow pain (LEP) represents a musculoskeletal disorder affecting the epicondyloid region of the elbow. The terminological framework of this problem in literature, to date, is confusing. This systematic review (SR) aims to analyse the panorama of the scientific literature concerning the pathogenetic framework, treatment, and clinical diagnosis of LEP. Methods: We conducted an SR according to the guidelines of the PRISMA statement. We performed research using the electronic Medline, Epistemonikos, and Cochrane Library databases. The research started on 12 January 2022 and finished on 30 April 2022. We included all systematic reviews and meta-analyses published, in English, between 1989 and 2022. The articles’ selection was based on critical appraisal using Amstar 2. In the selected reviews we obtained the etiopathogenic terminology used to describe the symptoms, treatment, and diagnostic criteria of LEP. Results: Twenty-five SRs met the eligibility criteria and were included in the study. From these SRs, 227 RCT articles were analysed and different treatments proposals were extracted, such as exercise, manipulation corticosteroid injection, and surgery. In the selected articles, 10 different terms emerged to describe LEP and 12 different clinical tests. The most common treatments detected in this SR were a conservative multimodal approach (e.g., eccentric exercises, manual therapy, acupuncture, ultrasound), then surgery or other invasive treatments (e.g., corticosteroid injection, tenotomy). The most common term detected in this SR was “lateral epicondylitis” (n = 95, 51.6%), followed by “tennis elbow” (n = 51, 28.1%) and “lateral epicondylalgia” (n = 18, 9.4%). Among the diagnostic tests were painful palpation (n = 101, 46.8%), the Cozen test (n = 91, 42.1%), the pain-free grip-strength test (n = 41, 19.0%), and the Maudsley test (n = 48, 22.2%). A total of 43.1% of RCTs (n = 96) included subjects with LEP > 3 months, 40.2% (n = 85) included patients with LEP < 3 months, and 16.7% of the items (n = 35) were not specified by the inclusion criteria on the onset of symptoms. Conclusions: In this SR, a considerable terminological heterogeneity emerged in the description of LEP, associated with the lack of clear and recognised diagnostic criteria in evaluating and treating patients with lateral elbow pain.

Effects of onabotulinumtoxin A in patients concurrently diagnosed with chronic migraine encephalalgia and temporomandibular disorders: A retrospective case series

OBJECTIVE

Chronic migraine encephalalgia (CME) with concomitant temporomandibular disorder (TMD) is a serious illness with limited effective treatment options. This study explores the effectiveness of onabotulinumtoxinA (BtxA) as an adjunct therapeutic to TMJ arthroscopy in the relief of CME.

METHODS

A retrospective cohort study of patients receiving TMJ arthroscopy, with or without BtxA injections for CME, was conducted. Variables assessed include pain using a visual analog scale (VAS), maximal incisal opening (MIO), muscle soreness, and headache frequency and duration.

RESULTS

Sixty patients (44 BtxA, 16 Control), consisting of 56 (93.3%) females, met inclusion criteria. A significant reduction in pain is reported with patients receiving BtxA (p < 0.0001) on VAS as compared to Control group. BtxA treatment also significantly reduced headache frequency and duration (p < 0.05).

CONCLUSION

These results support the use of adjunctive BtxA treatment with arthroscopy for the treatment of CME in the context of TMD.

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.

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.

Do we need to improve the reporting of evidence in tendinopathy management? A critical appraisal of systematic reviews with recommendations on strength of evidence assessment

Objective

To critically appraise the quality of published systematic reviews (SRs) of randomised controlled trials (RCTs) in tendinopathy with regard to handling and reporting of results with special emphasis on strength of evidence assessment.

Data sources

Medline from inception to June 2020.

Study eligibility

All SRs of RCTs assessing the effectiveness of any intervention(s) on any location of tendinopathy.

Data extraction and synthesis

Included SRs were appraised with the use of a 12-item tool devised by the authors arising from the Preferred Reporting Items in Systematic Reviews and Meta-Analyses statement and other relevant guidance. Subgroup analyses were performed based on impact factor (IF) of publishing journals and date of publication.

Results

A total of 57 SRs were included published in 38 journals between 2006 and 2020. The most commonly used risk-of-bias (RoB) assessment tool and strength of evidence assessment tool were the Cochrane Collaboration RoB tool and the Cochrane Collaboration Back Review Group tool, respectively. The mean score on the appraisal tool was 46.5% (range 0%–100%). SRs published in higher IF journals (>4.7) were associated with a higher mean score than those in lower IF journals (mean difference 26.4%±8.8%, p=0.004). The mean score of the 10 most recently published SRs was similar to that of the first 10 published SRs (mean difference 8.3%±13.7%, p=0.54). Only 23 SRs (40%) used the results of their RoB assessment in data synthesis and more than half (n=30; 50%) did not assess the strength of evidence of their results. Only 12 SRs (21%) assessed their strength of evidence appropriately.

Conclusions

In light of the poor presentation of evidence identified by our review, we provide recommendations to increase transparency and reproducibility in future SRs.

[Evidence in Infiltrative Pain Therapy of the Musculoskeletal System]

Musculoskeletal pain symptoms frequently generate limitations in daily work and life in many patients. Usually, symptomatic treatment is possible before clarifying the in depth diagnosis. A symptom-based infiltration therapy will never replace a thoroughly done physical examination and thoughtful collection of patient history, however, it can be of great benefit for the patient when done focused on the point of pain and executed with profound anatomical knowledge. Furthermore, the knowledge of the level of evidence of therapeutic infiltrations improves their outcomes and shapes realistic patients' expectations. Ultrasound-guided therapeutic infiltrations improve the outcome despite the use of lower amounts of active agents by pinpointed applications. This article provides an overview of the scientific evidence of effectiveness of (ultrasound-guided) infiltration techniques in diverse musculoskeletal regions.

Botulinum toxin injections for shoulder and upper limb pain: a narrative review

Botulinum toxin (BoNT) has been widely employed to treat poststroke spasticity, cervical dystonia and muscle hyperactivity. Recently, BoNT injections are increasingly used in treating musculoskeletal pain. The mechanism of BoNT in pain relief comprises relaxation of overused muscles and inhibition of inflammatory nociceptive cytokines/neurotransmitters. As BoNT injections seem promising in treating painful musculoskeletal disorders, we aimed to investigate its effectiveness in shoulder and upper limb pain. Although the present article is a narrative review, we employed a systematic approach to search for relevant articles in PubMed. A total of 19 clinical studies were included. Here, we observed that intramuscular BoNT injections were helpful in stroke patients with hemiplegic shoulder pain. In shoulder joint pain, intra-articular and intrabursal BoNT injections achieved a longer period of pain relief than corticosteroid injections. Similarly, a more durable effect of intramuscular BoNT than saline injections was seen in shoulder myofascial pain. Its use in complex regional pain syndrome and persistent upper limb pain in breast cancer survivors was insufficient, necessitating more studies. Since not all of the included studies could provide Class I of evidence based on the efficacy criteria used by American Academy of Neurology, controlled clinical trials in a larger number of patients are necessary to verify validity of these findings in the future.

The Effect of Botulinum Toxin Injection into the Common Extensor Tendon in Patients with Chronic Lateral Epicondylitis: A Randomized Trial

BACKGROUND

Botulinum toxin (BTX) is widely used for pain control in various musculoskeletal disorders.

OBJECTIVES

We evaluated the analgesic effect of botulinum toxin type A (BTX-A) in chronic lateral epicondylitis and compared the effect between 10 and 50 IU of BTX-A.

METHODS

Sixty subjects with chronic lateral epicondylitis were included and underwent a BTX-A injection in the common extensor tendon. The subjects were randomly allocated into two groups: the small-dose group (SD group; 30 subjects, 10 IU) and large-dose group (LD group; 30 subjects, 50 IU). Treatment outcomes were evaluated by measuring the pain level using the numeric rating scale (NRS) and measuring grip strength before and one, two, three, four, five, and six months after treatment.

RESULTS

Subjects in both groups showed a significant decrease in NRS scores at all evaluation time points after treatment. The reduction in NRS scores was significantly greater in the LD group at one, two, three, and four months after treatment. Six months after treatment, 19 subjects (63.3%) in the SD group and 21 (70%) in the LD group reported successful pain relief (pain relief ≥50%). The rate of successful pain relief was not significantly different between the two groups. Grip strength was more increased in the LD group at one, two, three, four, and six months after treatment.

CONCLUSIONS

BTX-A injection into the common extensor tendon can be a good treatment option for chronic lateral epicondylitis. The 50-IU BTX-A injection achieved a better outcome than the 10-IU injection.

Botulinum Toxin for Chronic Lateral Epicondylitis (LE)

Lateral epicondylitis is a common disease in orthopaedic practice. Although the majority of cases do not become chronic, patients who do not respond to the initial treatment may suffer from pain in the long term and effective treatment is challenging. The off-label use of botulinum toxin is one of the common potential indications for the substance in orthopaedics and traumatology. In a literature review of 2000 - 2019, eight EBM ≥ level 3 studies evaluating the use of botulinum toxin in lateral epicondylitis were found. Five of these studies evaluated botulinum toxin versus placebo in chronic cases; two other studies compared botulinum toxin with corticosteroids in acute cases and classic Hohmann surgery in chronic cases; the eighth study compared botulinum toxin in two different injection sites and corticosteroids by classic injection. Our findings suggest that the use of this substance may be a treatment option in refractory chronic cases before surgery is indicated. The working group on botulinum toxin in O & T of the International Musculoskeletal Pain Society (IMPS/IGOST) introduced an alternative injection schedule, which combines findings from the recent clinical literature with practical experience in order to reduce the risk of side effects while ensuring treatment effectiveness. Using 2 simple tests of function and, if necessary, sonographic verification, 2 separate injection sites in the extensor carpi radialis or the extensor digitorum can be identified by palpation. The tendon level on the lateral epicondyle acts as the third injection site. With optimal use of the ampoule content, the 3 injection sites can be infiltrated individually, depending on the muscle status. On the one hand, this enables treatment to take place after a dual therapy approach and, on the other hand, the risk of overdose in a muscle with subsequent unnecessary muscle weakening can be reduced.

Utilization of Botulinum Toxin for Musculoskeletal Disorders

Rehabilitation from musculoskeletal injuries is challenging with multiple intrinsic and extrinsic factors influencing athletes, conditions, and length of recovery. Multidisciplinary treatment strategies aim to address pathophysiology, mechanical, and psychosocial factors of injuries. An essential element in the recovery from musculoskeletal injuries is pain control and the return of physiologic function. There have been significant advancements in the understanding of pain and, therefore, new techniques and management strategies are being used. Botulinum neurotoxin (BoNT) has demonstrated valuable biopharmaceutical properties to provide neuromuscular blockade, which, in some cases, can help to return biomechanical and functional physiologic loss. There is developing literature in BoNT's ability to block pain in the treatment of painful musculoskeletal conditions. Critical analysis of the literature is necessary given the paucity of high-quality, evidence-based literature in the treatment of these conditions. This article reviews the utilization of BoNT in chronic exertional compartment syndrome, osteoarthritis, lateral epicondylosis, plantar fasciopathy, and myofascial pain syndrome.

Management of lateral epicondylitis

Lateral epicondylitis is the most common cause of lateral elbow pain. Although also known as tennis elbow, lateral epicondylitis often develops as a work-related condition and therefore constitutes a major public health issue. This article reviews the pathophysiological factors involved in lateral epicondylitis, as well as the tools available for establishing the diagnosis and ruling out other causes of lateral elbow pain. Finally, the non-operative and surgical treatment options are discussed in detail.

Current Trends for Treating Lateral Epicondylitis

Lateral epicondylitis, also known as 'tennis elbow', is a degenerative rather than inflammatory tendinopathy, causing chronic recalcitrant pain in elbow joints. Although most patients with lateral epicondylitis resolve spontaneously or with standard conservative management, few refractory lateral epicondylitis are candidates for alternative non-operative and operative modalities. Other than standard conservative treatments including rest, analgesics, non-steroidal anti-inflammatory medications, orthosis and physical therapies, nonoperative treatments encompass interventional therapies include different types of injections, such as corticosteroid, lidocaine, autologous blood, platelet-rich plasma, and botulinum toxin, which are available for both short-term and long-term outcomes in pain resolution and functional improvement. In addition, newly emerging biologic enhancement products such as bone marrow aspirate concentrate and autologous tenocyte injectates are also under clinical use and investigations. Despite all non-operative therapeutic trials, persistent debilitating pain in patients with lateral epicondylitis for more than 6 months are candidates for surgical treatment, which include open, percutaneous, and arthroscopic approaches. This review addresses the current updates on emerging non-operative injection therapies as well as arthroscopic intervention in lateral epicondylitis.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

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

RESULTS

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

CONCLUSION

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

Shock-wave therapy versus corticosteroid injection on lateral epicondylitis: a meta-analysis of randomized controlled trials

Background: Shock-wave (SW) therapy has been widely promoted and proven to be effective in ameliorating symptoms of lateral epicondylitis (LE) during recent years. Corticosteroid (CS) injection is another common treatment of LE, and several researches have documented its significant effect in the treatment of LE. Despite this, few studies have focused on comparing the use of SW and CS in the treatment of LE. The aim of this meta-analysis is to assess whether SW is superior to CS in managing LE, both in terms of ameliorating pain and improving functionality. Methods: A systematic search of the literature was conducted to identify relevant articles that were published in Pubmed, Medline, Embase, the Cochrane Library, SpringerLink, Clinical Trials.gov and OVID from the databases' inception to December 2018. All studies comparing the efficacy of SW and CS in terms of pain levels and functionality improvement were included. Data on the two primary outcomes were collected and analyzed using the Review Manager 5.3. Results: Four studies were included in the current meta-analysis. A significant difference in VAS score (SMD = 1.13, Cl 0.72-1.55 P < 0.00001, I² = 0) was noted between the SW group and the CS group. Furthermore, Significant difference was also seen in the term of grip strength (including HGS and GSS scoring system) (SMD = -1.42, Cl -1.85--0.98 P < 0.00001, I² = 0). Conclusions: In light of the better improvement in the terms of VAS and grip strength with follow-up more than 12 weeks, we assume that SW may be a superior alternative for the treatment of LE.

Is sarcopenia associated with hepatic encephalopathy in liver cirrhosis? A systematic review and meta-analysis

BACKGROUND/PURPOSE

Hepatic encephalopathy (HE), a major neuropsychiatric complication in advanced liver disease, is associated with poor prognosis. Sarcopenia, characterized by a decline in muscle mass, strength, and physical performance, is prevalent in liver cirrhosis. This study aims to explore whether sarcopenia is associated with HE in cirrhotic patients.

METHODS

PubMed and EMBASE were searched for relevant cohort and case-control studies investigating the association between sarcopenia and HE up to July 2018. Data of patients' characteristics, definition of low muscle mass, and protocols of grading/diagnosing HE were retrieved. The primary outcome was estimated by a pooled odds ratio (OR) and its 95% confidence interval (CI), using a random effect model.

RESULTS

The meta-analysis enrolled 6 studies, comprising 1795 patients. Sarcopenia was positively associated with the presence of HE (OR 2.74 with a 95% CI, 1.87 to 4.01). The association was less likely to be influenced by differences in research designs, focused study outcomes, muscle mass measurements, and protocols of grading/diagnosing HE. There was lack of evidence supporting higher serum ammonia levels in patients with sarcopenia.

CONCLUSION

In patients with liver cirrhosis, there is a significant association between sarcopenia and HE. A greater number of prospective studies are necessary to clarify whether the association remains even after adjusting relevant confounders and to suggest effective prevention of HE in patients with coexisting sarcopenia.