Comparison of an epicondylitis bandage with a wrist orthosis in patients with lateral epicondylitis

Clinical and Ultrasonographic Effectiveness of Two Different Splints Used for the Treatment of Lateral Epicondylitis: A Prospective Randomized Controlled Study

OBJECTIVE

This study compares the clinical and ultrasonographic efficacy of 2 splint types, the lateral epicondylitis band (LEB) and the wrist extensor splint (WES), for treatment of lateral epicondylitis (LE).

DESIGN

Randomized controlled single-blind trial.

SETTING

Outpatient clinic.

PARTICIPANTS

159 participants diagnosed with unilateral LE based on clinical and ultrasonographic findings, and 2-12 weeks from symptom onset, were included (N=159).

INTERVENTIONS

One group received joint-protection education-only (wait-and-see), while the other 2 groups were fit with splints: one the LEB and the other the WES. Both splint groups received joint-protection education.

MAIN OUTCOME MEASURES

The primary outcome measure was the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire. Secondary outcome measures were the Visual Analog Scale (VAS) for pain, hand grip strength by dynamometry, algometric measurements, patient satisfaction, and selected ultrasonographic parameters (maximum tendon thickness measurements (MTTM) in the capitellar-radiocapitellar region and total ultrasonography scale score [TUSS]). All outcomes were assessed at baseline, 3-weeks, and 6-weeks post intervention initiation.

RESULTS

Participants' mean age was 46.85±8.63 years. Of the participants, 40.88% (n=65) were male and 59.12% (n=94) were female. The baseline median (1Q-3Q) values of PRTEE-total scores were 58.5 (51-68) for the LEB, 63.5 (56.25-70.25) for the WES and 57 (48-68) for the education-only groups. At 6-weeks, the PRTEE-total scores had decreased by 44 points for those randomized to the LEB, 46 points to the WES and 7 points in the education-only groups(P<.001). While the LEB and WES approaches were superior to the wait-and-see approach in algometric measurements, VAS, and PRTEE scores (P<.05), no significant changes were found in MTTM and TUSS values. The LEB group was superior to the WES group in hand grip strength and patient satisfaction (P<.05).

CONCLUSION

Using either splint for 6 weeks can be considered effective for the relief of pain and increased functionality in persons with subacute LE, although the LEB had a more positive effect on grip strength and patient satisfaction than the WES.

Comparative analysis of the therapeutic effects of extracorporeal shock wave therapy and high-intensity laser therapy in lateral epicondylitis: a randomised clinical trial

Lateral epicondylitis (LE) presents a substantial obstacle due to the pain and functional decline, frequently requiring non-surgical treatments. This study contrasts the efficacy of high-ıntensity laser therapy (HILT) and extracorporeal shock wave therapy (ESWT) in managing LE. A prospective, randomized comparative trial was conducted with 50 participants assigned to either HILT or ESWT groups. Both groups received standard physiotherapy (exercise program and LE bandages), and outcomes, including tenderness, Visual Analog Scale (VAS), Quick Disabilities of the Arm, Shoulder, and Hand scale (Q-DASH), and grip strength, were assessed at baseline, 3rd weeks, and 12th weeks. The baseline features of the groups exhibited similarities (p > 0.05). In intra-group comparisons, both HILT and ESWT groups exhibited significant enhancements in tenderness, VAS, Q-DASH, and grip strength (p < 0.05). In inter-group comparisons, the HILT group exhibited superior outcomes in tenderness reduction, pain alleviation, and disability improvement compared to the ESWT group (p < 0.05). Grip strength did not differ significantly across the groups (p > 0.05). Both HILT and ESWT, when combined with standard physiotherapy, showed effectiveness in treating LE. However, HILT demonstrated greater efficacy in terms of tenderness reduction, pain relief, and disability improvement. This study suggests that non-invasive techniques, particularly HILT, can be preferable for managing LE.

Comparison of two different orthoses used in the treatment of lateral epicondylitis

BACKGROUND

Lateral epicondylitis (LE) is one of the most common causes of lateral elbow pain, and orthoses are often used in its conservative treatment. However, the number of studies examining the effectiveness of the orthoses used and their differences compared to each other is limited.

OBJECTIVE

To determine the effects of 2 orthoses types, wrist orthosis (WO) and counterforce brace (CB), commonly used in the treatment of lateral epicondylitis on muscle activation, grip strength, hand function, and satisfaction level in healthy individuals.

STUDY DESIGN

Quasi-experimental study.

METHODS

Thirty-seven healthy individuals were recruited. Muscle activation was evaluated by surface electromyography, and maximum grip strength was evaluated with a handheld dynamometer. Hand function and satisfaction level were evaluated with Jebsen Taylor Hand Function Test and Orthotics and Prosthetics Users Survey, respectively. All evaluations were conducted for each individual in 3 conditions (no orthosis, WO, and CB).

RESULTS

Extensor carpi radialis (ECR) muscle activation was greater when using CB compared with that when without orthosis (p = 0.036). There was no significant difference in extensor digitorum communis (EDC) muscle activation and maximum grip strength among the conditions (p > 0.05). Hand function was worse when using the WO compared with the other conditions (p < 0.001). In terms of orthosis satisfaction, individuals were found to be significantly more satisfied with the use of CB (p = 0.001).

CONCLUSIONS

In our study highlight the use of CB in terms of EDC muscle activity, grip strength, hand function, and satisfaction, while the use of WO is prominent in terms of keeping extensor carpi radialis muscle activity low, which has been shown to be important for LE. To obtain definitive results on the effectiveness of different orthoses in the treatment of LE, more research is needed to compare the muscular activation in the extensor carpi radialis brevis (ECRB) and EDC muscles with objective methods.

Efficacy of extension wrist hand orthosis on pain, grip strength and electromyographic activities in lateral epicondylitis: A randomized single-blind clinical trial

BACKGROUND

Lateral epicondylitis (LE) is one of the most common work-related complications characterized by pain, decreased grip strength and dysfunction of upper limb. Although conservative management such as physiotherapy and orthosis is reported as first line of treatment, sufficient evidence to decide their effectiveness is lacking and remains controversial.

PURPOSE

The current study evaluated and compared the efficacy of a custom-made extension wrist hand orthosis adjunct to usual physiotherapy and therapeutics alone for subjects with LE.

STUDY DESIGN

Prospective randomized single-blinded clinical trial.

METHODS

62 subjects with LE were selected as samples using convenience method in this experimental study. They were randomly divided into two groups: usual physiotherapy only and its combination with orthosis. Pain and grip strength were measured using Visual Analog Scale and Jamar hydraulic digital hand dynamometer. Muscle activity of extensor carpi radialis brevis during hand gripping was measured using surface electro-myographic by PowerLab electromyography (AD Instruments, Castle Hill, Australia). Data analysis and comparison were performed for baseline and post-intervention (12weeks).

RESULTS

After 12weeks of treatment, there were significant differences in mean scores of pain (1.22 ± 0.51, p = 0.001), maximum voluntary grip strength (5.82 ± 7.84, p = 0.04), and extensor carpi radialis brevis muscle activation (0.082 ± 0.094, p = 0.02) between the therapeutics alone group and the therapeutics plus orthosis group. Compared to therapeutics alone, those getting a combination of physiotherapy and orthosis had greater treatment efficacy (p < 0.05).

CONCLUSIONS

Both postintervention (12-week) treatments could affect pain scores, grip strength, and extensor muscle activation. Custom-made extension wrist hand orthosis adjunct to usual physiotherapy is more effective than therapeutics alone in subjects with LE. Therefore, the use of wrist orthosis adjunct to physiotherapy should be recommended in rehabilitation settings for LE.

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.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Scoping Review of Psychological and Psychosocial Constructs and Outcome Measures Reported in Tendinopathy Clinical Trials

OBJECTIVE

To identify and describe the psychological and psychosocial constructs and outcome measures used in tendinopathy research.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched the PubMed, EMBASE, Scopus, Web of Science, PEDro, CINAHL, and APA PsychNet databases on July 10, 2021, for all published studies of tendinopathy populations measuring psychological and psychosocial factors.

STUDY SELECTION

Studies using a clinical diagnosis of tendinopathy or synonyms (eg, jumper's knee or subacromial impingement) with or without imaging confirmation.

DATA SYNTHESIS

We described the volume, nature, distribution, and characteristics of psychological and psychosocial outcomes reported in the tendinopathy field.

RESULTS

Twenty-nine constructs were identified, including 16 psychological and 13 psychosocial constructs. The most frequently-reported constructs were work-related outcomes (32%), quality of life (31%), depression (30%), anxiety (18%), and fear (14%). Outcome measures consisted of validated and nonvalidated questionnaires and 1-item custom questions (including demographics). The number of different outcome measures used to assess an individual construct ranged between 1 (emotional distress) and 11 (quality of life) per construct.

CONCLUSION

There was a large variability in constructs and outcome measures reported in tendinopathy research, which limits conclusions about the relationship between psychological and psychosocial constructs, outcome measures, and tendinopathies. Given the wide range of psychological and psychosocial constructs reported, there is an urgent need to develop a core outcome set in tendinopathy. J Orthop Sports Phys Ther 2022;52(6):375-388. doi:10.2519/jospt.2022.11005.

Development of an optimised physiotherapist-led treatment protocol for lateral elbow tendinopathy: a consensus study using an online nominal group technique

OBJECTIVES

There are a wide range of physiotherapy treatment options for people with lateral elbow tendinopathy (LET); however, previous studies have reported inconsistent approaches to treatment and a lack of evidence demonstrating clinical effectiveness. This study aimed to combine the best available research evidence with stakeholder perspectives to develop key components of an optimised physiotherapist-led treatment protocol for testing in a future randomised controlled trial (RCT).

DESIGN

Online consensus groups using nominal group technique (NGT), a systematic approach to building consensus using structured multistage meetings.

SETTING

UK National Health Service (NHS).

PARTICIPANTS

10 physiotherapists with special interest in LET, 2 physiotherapy service managers and 3 patients who had experienced LET.

INTERVENTIONS

Two consensus groups were conducted; the first meeting focused on agreeing the types of interventions to be included in the optimised treatment protocol; the second meeting focused on specific details of intervention delivery. Participants were sent an evidence summary of available treatments for LET prior to the first meeting. All treatment options were discussed before anonymous voting and ranking of priority. Consensus for inclusion of each treatment option was set at ≥70% based on OMERACT guidelines. Options with 30%-69% agreement were discussed again, and a second vote was held, allowing for a change of opinion.

RESULTS

The optimised physiotherapist-led treatment package included: advice and education, exercise therapy and orthotics. Specific components for each of these interventions were also agreed such as: condition-specific advice, health-promotion advice, exercise types, exercise into 'acceptable' levels of pain, exercise dosage and type of orthoses. Other treatment options including electrotherapy, acupuncture and manual therapy were excluded.

CONCLUSION

An optimised physiotherapist-led treatment protocol for people with LET was successfully developed using an online NGT consensus approach. This intervention is now ready for testing in a future pilot/feasibility RCT to contribute much needed evidence about the treatment of LET.

TRIAL REGISTRATION NUMBER

This is the pre-cursor to the OPTimisE Pilot and Feasibility Randomised Controlled Trial. Registration: https://www.isrctn.com/ISRCTN64444585.

Corticosteroids vs autologous blood injection for lateral epicondylitis: Study protocol for a cohort trial

BACKGROUND

There is limited evidence to assess the evaluation of the safety and effectiveness of autologous blood injections in the treatment of lateral epicondylitis patients. For this study, the aim was to compare the efficiency of corticosteroid and autologous blood injections for the treatment of lateral epicondylitis in a retrospective cohort trial in our single center.

METHODS

After being approved by the institutional review committee of Chongqing General Hospital (IRB# 2018.417.C, November 9, 2018), we performed a single-center, retrospective study between November 2018 and January 2020. All participants provided written informed consent. The criteria for inclusion in our experiment are as follows: over 18 years old; with the history of at least 6 months of lateral epicondylitis; and the palpation of lateral epicondyle tenderness; visual analog scale (≥4). In the group A, the patient were injected the autologous blood. In group B, the patients were immersed with 0.5% of bupivacaine (1 ml) and local corticosteroids (2 ml) at lateral epicondyle. The outcomes were composed of a visual analog scores of subjective pain severity over the past 24 hours as the primary result; and limb function in various tasks of daily activity measured with disabilities of the arm, shoulder, and hand quick questionnaire scores, the maximum grip strength and the modified scores of Nirschl, as secondary results. All the results were assessed before the injection and at 4 weeks and 8 weeks after the injection. For all examination, when the P value was less than .05, it would be defined to be a statistically significant difference.

RESULTS

The results of this study would provide new information about the influence of autologous blood injections in treating the lateral epicondylitis.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry6263).

The effects of counterforce brace on pain in subjects with lateral elbow tendinopathy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Lateral elbow tendinopathy, also known as "tennis elbow" or "lateral epicondylitis," is a common disease leading to pain in the lateral side of the elbow and disability during hand gripping. A counterforce brace is one of the most conventional treatments. However, its effects on outcomes remain inconclusive.

OBJECTIVES

To investigate the effects of counterforce braces on pain in subjects with lateral elbow tendinopathy. Grip strength was reviewed as a secondary outcome.

STUDY DESIGN

Systematic review and meta-analysis of randomized controlled trials.

METHODS

PubMed, Embase, Scopus, Web of Science, CENTRAL, PEDro, ProQuest, RECAL, and RehabData were searched from January 1, 1995, through June 15, 2019.

RESULTS

Seventeen studies were included with a total of 1145 participants. A small improvement in pain over the short term (standardized mean difference -0.02; 95% confidence interval: -0.85 to 0.80) and a moderate-to-large improvement in pain in subjects 45 years or younger (standardized mean difference -0.86; 95% confidence interval: -2.45 to 0.72) in favor of the brace versus physiotherapy interventions were found. In contrast, over the long-term physiotherapy interventions (standardized mean difference 1.17; 95% confidence interval: -0.00 to 2.34), wrist splint (standardized mean difference 0.35; 95% confidence interval: -0.07 to 0.76), and laser therapy (standardized mean difference 0.58; 95% confidence interval: -0.44 to 1.59) had better effects on pain improvement versus the brace.

CONCLUSION

The results indicated that physiotherapy interventions compared to counterforce braces have better effects, especially over the long-term. However, counterforce braces may have better effects on pain in younger people (<45 years old) over the short term (<6 weeks).

CLINICAL RELEVANCE

The results suggest that counterforce bracing is a reasonable strategy to alleviate pain over the short term. However, the subgroup analysis suggests that factors such as age may have a role in their effectiveness.

Prospective randomized controlled trial in the treatment of lateral epicondylitis with a new dynamic wrist orthosis

BACKGROUND

In the treatment of lateral epicondylitis (LE), the role of a new dynamic wrist orthosis is unclear.

PATIENTS AND METHODS

Patients suffering from a LE longer than 3 months were multicentrically and prospectively randomized into a physiotherapeutic group (PT group) and in a physiotherapy group plus wrist orthosis (PT + O group). Physiotherapy consisted of daily eccentric strengthening exercises under initial professional supervision. Inclusion criteria were a Placzek score greater than 4. Exclusion criteria were previous surgery, rheumatic arthritis, elbow instability, radicular symptoms, higher-grade extensor tendon rupture, or cervical osteoarthritis. The clinical evaluation was performed after 12 weeks and 12 months. The Patient-Rated Tennis Elbow Evaluation (PRTEE) scale, Placzek Score, the pain rating (VAS), range of motion and the Subjective Elbow Score were evaluated.

RESULTS

Of the initially 61 patients, 31 were followed up after 12 weeks and 22 after 12 months. Twenty-nine patients (43%) were male, the mean age was 46, and 44 patients (66%) had the right elbow involved. At 12 weeks, there was a pain reduction on the VAS in both groups (PT + O: 6.5-3.7 [p = .001]; PT: 4.7-4.1 [p = .468]), albeit it was only significant for the PT + O group. At 12 months, reduction was significant in both groups (PT + O: 1.1 [p = .000]; PT: 1.3 [p = .000]). The painless maximum hand strength in kg improved in both groups significant after 3 and 12 months. The Placzek score was reduced from 8.25 to 3.5 [p = .001] after 12 weeks for the PT + O group and from 8.1 to 3.8 [p = .000] in the PT group, as well as after 12 months in the PT + O group to 0 [p = .000] and in the PT group to 2.0 [p = .000]. The PRTEE improved in both groups after 12 weeks (PT + O: 52.8--31.3 [p = .002]; PT: 48.6-37.6 [p = .185]) and 12 months (PT + O: 16.15 [p = .000]; PT: 16.6 [p = .000]), although the reduction at 12 weeks was not significant for the PT group.

CONCLUSION

The elbow orthosis appears to accelerate the healing process with respect to the PRTEE and pain on the VAS (12 weeks follow-up), although there is an adjustment after 12 months in both groups and a significant improvement of symptoms is achieved in all endpoints.