BESS patient care pathway: Tennis elbow

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.

United Kingdom physiotherapists injection therapy practice for musculoskeletal complaints: A cross-sectional survey

BACKGROUND

Physiotherapists in the United Kingdom (UK), who have received additional training can adopt injection therapy for the treatment of musculoskeletal (MSK) disorders.

OBJECTIVES

The objective of this practice survey was to explore (i) the frequency of use of injection therapy by UK physiotherapists for MSK disorders; and (ii) the clinical reasoning for selection of injectate, dose and pre/post injection practice.

DESIGN

Cross-sectional online survey.

METHODS

The online survey was disseminated via social media and professional networks over a 3-month period. Responses to closed multiple choice survey questions were analysed with descriptive data, with reporting of confidence intervals at 95%. Open questions were analysed using content analysis.

RESULTS

The survey received 320 responses. The majority (86.6%, n = 277) used landmark guided approaches. The highest frequency of injections administered were for trigger digits, sub acromial pain and the knee joint. Corticosteroid drugs were widely used (99.7%, n = 319, CI 95% 98 to 100) with Triamcinolone (Kenalog) being the most frequently utilised for both joints (58.8%, n = 160, 53 to 65) and soft tissues (46.3%, n = 126, 40 to 52). Drug choice was largely based on availability in clinic (47.1%, n = 128, 41 to 53). Drug doses for common injection sites varied among the respondents with variation also evident in pre and post-injection practice.

CONCLUSION

Marked variation across some elements of injection therapy practice was evident. Notable differences in corticosteroid preparation used, the doses of drug injected, and the use of local anaesthetic were reported by respondents. Injecting physiotherapists should endeavour to ensure practice is aligned to best available evidence.