Rehabilitation for patients with lateral epicondylitis: a systematic review

Rehabilitation for Patients with Lateral Epicondylitis: A Systematic Review

Daniel Trudel, BSc, MSc, PT Canadian Forces Base Kingston, Ontario, Canada

Jennifer Duley, BHSC, MSc, PT Grand River Hospital Kitchener, Ontario, Canada

Ingrid Zastrow, BA, MSc (PT) West Lincoln Memorial Hospital Grimsby, Ontario, Canada

Erin W. Kerr, BSc, MSc, PT West Vancouver Orthopaedic and Sports Physical Therapy Vancouver, Britsh Columbia, Canada

Robyn Davidson, BSc, BPHE, Bed, MSc, PT School of Rehabilitation Science McMaster University Hamilton, Ontario, Canada

ABSTRACT: The purpose of this systematic review was to determine the effectiveness of conservative treatments for lateral epicondylitis and to provide recommendations based on this evidence. Five reviewers searched computerized bibliographic databases for articles on the conservative treatment of lateral epicondylitis from the years 1983 to 2003. A total of 209 studies were located; however, only 31 of these met the study inclusion criteria. Each of the articles was randomly allocated to reviewers and critically appraised using a structured critical appraisal tool with 23 items. Treatment recommendations were based on this rating and Sackett’s Level of Evidence. This review has determined, with at least level 2b evidence, that a number of treatments, including acupuncture, exercise therapy, manipulations and mobilizations, ultrasound, phonophoresis, Rebox, and ionization with diclofenac all show positive effects in the reduction of pain or improvement in function for patients with lateral epicondylitis. There is also at least level 2b evidence showing laser therapy and pulsed electromagnetic field therapy to be ineffective in the management of this condition. Practitioners should use the treatment techniques that have strongest evidence and ensure that studies findings are generalized to patients who are similar to those reported in primary research studies in terms of patient demographics and injury presentation. J HAND THER. 2004;17:243–266.

Joy C. MacDermid, BScPT, PhD School of Rehabilitation Science McMaster University Hamilton, Ontario, Canada Clinical Research Lab Hand and Upper Limb Centre St. Joseph’s Health Centre London, Ontario, Canada Career Scientist of the Ontario Ministry of Health Health Research Personnel Development Program

Lateral epicondylitis, often termed ‘‘tennis elbow,’’ is defined as a syndrome of pain in the wrist extensor muscles at or near their lateral epicondyle origin or pain directly over the epicondyle.1 The primary clinical features of this syndrome are discomfort of the lateral elbow, pain and tenderness at or slightly Research funding was provided by the Ontario Workplace Safety and Insurance Board (WSIB). Correspondence and reprint requests to Joy C. MacDermid, BScPT, PhD, School of Rehabilitation Science, IAHS, 1400 Main Street West, 4th Floor, Hamilton, Ontario, Canada L8S 1C7; e-mail: . doi:10.1197/j.jht.2004.02.011

distal to the lateral epicondyle, and tenderness of the proximal muscle mass. A clinical diagnosis is often founded on an appropriate history and confirmatory physical signs, i.e., pain reproduced by resisted wrist extension.1 Fibroblastic and vascular degeneration often associated with repetitive activity, particularly with rotation of the forearm and forceful gripping, are accepted as key features.1–3 The extensor carpi radialis brevis is consistently involved, although approximately 30% of patients also have involvement of the extensor digitorum communis.1 Individuals at high risk for this type of overuse injury are those in the occupations of construction, assembly, April–June 2004 243

manufacturing, food processing, and forestry.1,4 Pain relief, preservation of movement, and muscle conditioning are the primary objectives of the rehabilitation of lateral epicondylitis. Despite extensive research on the topic, a clear understanding of the role for conservative management remains elusive. Chronic or recurrent cases and treatment failures are common. The purpose of this article is to provide a comprehensive systematic review of the current evidence on the conservative treatment for lateral epicondylitis (excluding splinting and extracorporal shock wave) with a goal of guiding practice and identifying research gaps.

MacDermid, which is published in this issue, then critically appraised each article. A consensus was then reached on the methodologic quality of the studies as per the scores on the appraisal form and as rated by Sackett’s Levels of Evidence (see introductory article in this issue). If a consensus could not be reached, then a third independent evaluator was brought in to settle the difference. During this evaluation process, seven articles were found not to meet the inclusion criteria once full study information was available and were therefore excluded at this stage.

OBJECTIVES

Previous Relevant Literature

Using a group consensus process the following question was defined: What is the current evidence to support or refute the use of conservative rehabilitation treatment interventions for lateral epicondylitis?

There have been a number of systematic reviews previously published looking at the effectiveness of various treatments on lateral epicondylitis. In 1996, Assendelft et al.5 looked at the effectiveness of corticosteroid injections for lateral epicondylitis. This review found that at that time, no conclusive reports could be made on the effectiveness of the injections. This was due to the serious methodologic flaws found in the studies. In 2002, Smidt et al.6 conducted another systematic review on the effectiveness of corticosteroid injections for lateral epicondylitis. This review found that corticosteroid injections had a positive short-term effect; however, due to the lack of high-quality studies, it was not possible to draw definitive conclusions. In 1999, van der Windt et al.7 looked at the treatment effects of ultrasound therapy for musculoskeletal disorders. Thirty-eight studies were included in this review; however, only six of these studies looked at lateral epicondylitis. This review concluded that there was little evidence to support the use of ultrasound therapy in the treatment of musculoskeletal disorders. In 2002, Struijs et al.8 conducted a systematic review looking at the effects of orthotic devices for lateral epicondylitis. This study also found that no definitive conclusions could be drawn due to the methodologic flaws present in the studies reviewed. In 2001, Bernstein9 conducted a review to determine how effective surgical and injection therapy was in the management of chronic pain. This review found that local triamcinolone injection (greater than or equal to 12 weeks) is effective for the relief of pain due to lateral epicondylitis (level 2). It was also found that there was limited evidence of effectiveness (level 3) for local glycosaminoglycan polyphosphate injection for lateral epicondylitis. Bernstein also stated that overall there was a lack of methodologically sound studies for surgery and injection therapies. In 2001, Mior10 looked at the effects of exercise in the treatment of chronic pain. This review included only one study looking at the upper extremity. This

Search Strategy A search of Medline, CINAHL, EMBASE, PEDro, and the Cochrane database from January 1983 up to and including March 2003 was conducted. Search terms used for inclusion were: physical therapy techniques, rehabilitation, tennis elbow, elbow, lateral epicondylitis, epicondylalgia, rehabilitation, complementary therapies, conservative treatment, tendonitis, ultrasound, acupuncture, TENS, electrical stimulation, friction massage, manual therapy techniques, mobilizations, exercise, laser, wait and see, shortwave diathermy, steroid injections, injections, and exercise movement techniques, Studies with an emphasis on surgery, splints (see issue review on this topic), shock wave therapy, or casts were excluded. Additionally, the search was limited to English only, adults (age 18+), humans, and randomized controlled trials (RCTs) or quasi-RCTs. The electronic search was complemented by hand searches of bibliographic references. Two hundred three references were retrieved by search; however, only 31 of these articles were included in this review.

Methods of Review Five independent reviewers examined titles and abstracts of the studies identified by the search strategy to select trials that met the inclusion criteria. All trials classified as relevant by at least one of the reviewers were retrieved. The retrieved articles were reexamined to ensure that they met the inclusion criteria. Thirty-eight articles were randomized by a numbering system; the evaluators were all blinded to the randomization process. Two independent evaluators, using the appraisal form developed by Dr. Joy 244

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RESULTS

study found positive effects for exercise in the treatment of chronic lateral epicondylitis and for specific soft tissue shoulder disorders. However, due to the poor methodologic quality of the study (level 3), definitive conclusions could not be given. The most recent review was conducted in 2003 by Smidt et al.11 This review looked at the effectiveness of physiotherapy for lateral epicondylitis. The study included 23 RCTs and found that two of the studies that compared ultrasound with a placebo ultrasound show statistically significant and clinically relevant differences in favor of ultrasound. There was, however, insufficient evidence to demonstrate benefit or lack of effect for laser therapy, electrotherapy, exercises, and mobilization techniques for lateral epicondylitis.

Cochrane Reviews In 2002, the Cochrane Library published a number of reviews looking at various treatments for lateral epicondylitis. One review by Buchbinder et al.12 examined the effects of surgery for the treatment of lateral elbow pain. This review found that there were no controlled trials investigating the effect of surgery on lateral elbow pain. Therefore, no conclusions could be drawn on the value of this type of treatment. Another review by Green et al.13 examined the effects of nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of lateral elbow pain (tennis elbow) in adults. This review found that there is some support for the use of topical NSAIDs to relieve lateral elbow pain at least in the short term. There was, however, insufficient evidence to recommend or discourage the use of oral NSAIDs, although it appeared that injection may be more effective than oral NSAIDs in the short term. There also had been no studies found directly comparing topical to oral NSAIDs, so no conclusions could be drawn regarding the best method of administration. The Cochrane Library also examined the effects of shock wave therapy for lateral elbow pain. This review by Buchbinder et al.14 found that the two studies that were included yielded different results. One study demonstrated highly significant differences in favor of shock wave therapy, whereas the other study found no benefits of shock wave therapy over the placebo. A review on the effectiveness of orthotic devices for the treatment of tennis elbow was conducted. The results of this review have already been reported in the previous relevant literature section.8 Another review that was conducted in 2002 by Green et al.15 examined the effectiveness of acupuncture in the treatment of lateral elbow pain. This review found that there was insufficient evidence to either support or refute treatment of acupuncture (either needle or laser) in the treatment of lateral elbow pain. This review demonstrated needle acu-

puncture to be of short-term benefit with respect to pain; however, this conclusion was based on findings from two small trials. There was no treatment benefit found to last more than 24 hours.

Current Review Study results are summarized in Tables 1–3. Ultrasound Six studies ranging from level 1b to 2b16 using a total of 332 subjects examined the use of ultrasound in the treatment of lateral epicondylits.17–22 Quality scores for these studies ranged from 25 to 41 out of 48. Four studies found that using ultrasound alone and ultrasound in combination with other treatments could decrease pain from lateral epicondylitis. The studies by Stratford et al.,17 Binder et al.,19 and Lundeberg et al.20 found significant short-term effects in reducing pain using ultrasound alone. Stratford et al.17 also examined ultrasound in combination with friction massage, phonophoresis alone, and phonophoresis with friction massage, and found all treatments to be beneficial for decreasing pain; however, no one treatment was superior to another. Halles et al.18 looked at the effects of ultrasound in combination with hydrocortisone and found a significant reduction in pain. The studies by Pienimaki et al.21,22 both found that progressive exercise therapy is more beneficial than ultrasound in acute and chronic lateral epicondylitis. Acupuncture Five level 1b and 2b16 studies with quality scores ranging from 19 to 39 out of 48 were examined.23–27 These studies included 308 subjects with lateral epicondylitis and revealed that acupuncture helped to decrease pain associated with this condition. Fink et al.23,24 found that the experimental group who had acupuncture at six sites (One Ash point, LI 10 and LI 11, Lu 5, LI 4 and SJ 5) had significantly greater reduction in pain over the control group at the twoweek follow up. Molsberger et al.24 found significant pain relief in the acupuncture group who received needling at a nonsegmental distal point of the fibulotibial joint of the homolateral leg (GB 34) over the control group 72 hours posttreatment. When examining different methods of needling, Young et al.26 found that floating acupuncture produced better initial analgesic responses than routine acupuncture. Haker et al.27 reported that for short-term pain relief, classic deep acupuncture was superior to superficial needling. Rebox One level 2b16 study by Johannsen et al.28 examined the effects of Rebox on lateral epicondylitis. This April–June 2004 245

study scored 31 out of 48 and included 35 subjects. It was concluded that Rebox produced significant beneficial effects on pain, grip strength, and functional performance for individuals with lateral epicondylitis. Wait and See The level 2b16 study by Smidt et al.29 examined a total of 185 individuals and obtained a quality score of 37 out of 48. Results revealed that corticosteroid injections were superior for short-term relief of pain and improvement of function in patients with lateral epicondylitis. However, physiotherapy treatment (ultrasound, friction massage, and exercise) was the best option for long-term improvement, followed by a wait-and-see treatment. Exercise Four level 1b and 2b16 studies examined the effects of exercise in the treatment of lateral epicondylits.21,22,30,31 These studies contained a total of 125 participants and their scores ranged from 25 to 37 out of 48. All four studies found that progressive strengthening and stretching programs had significantly greater reductions in pain than the alternative treatment state. The studies by Newcomer et al.,30 Pienimaki et al.,22 and Svernlov et al.31 also found a statistically significant increase in grip strength in those who participated in the strengthening and stretching programs. Ionization Two level 2b16 studies examined the effects of ionization on a total of 64 individuals with lateral epicondylitis.32,33 These studies’ quality scores were both 25 out of 48. The study by Vecchini et al.32 found that 20 (30-minute) treatments of ionization with diclofenac for one month resulted in a significantly greater reduction in pain compared with placebo ionization with saline. The study by Demirtas et al.33 found that ionization with sodium diclofenac for 20 minutes, one time per day, five days per week for ten days followed by 20 minutes of infrared treatment had a significantly greater reduction in pain compared with ionization with sodium salicylate and infrared treatment. Pulsed Electromagnetic Field One level 2b16 study by Devereaux et al.34 examined the effects of electromagnetic field therapy on 30 subjects with lateral epicondylitis. This study was given a quality score of 36 out of 48. It was found that there was no significant difference between the experimental group and the placebo group with respect to pain and grip strength. 246

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Researchers were unable to show an advantage in recovery for those treated with pulsed electromagnetic field therapy. Mobilization and Manipulations Two level 2b16 studies examined the effects of mobilization as a treatment for lateral epicondylitis.35,36 These studies looked at a total of 42 participants and were given quality scores ranging from 30 to 37 out of 48. The study by Drechsler et al.35 found that a combination of mobilizations of the radial head and neural tension techniques was superior to the standard physiotherapy treatment (ultrasound, stretching, strengthening, and friction) for both recreational and occupational status. The study by Vincenzio et al.36 used a mobilization with movement technique and found that this demonstrated a hypoanalgesic effect during and after treatment. Two level 2b16 studies examined the effects of manipulation as a treatment for lateral epicondylitis.37,38 The studies were given quality scores that ranged from 23 to 30 out of 48. These studies included a total of 139 subjects. The first study by Burton et al.37 looked at manipulation alone compared with manipulation in addition to a forearm strap, manipulation with the use of an antiinflammatory cream, or manipulation with a strap and cream. It was found that the use of an antiinflammatory cream and/or forearm strap, in addition to manipulation, was no more effective than manipulation alone. The second study by Verhaar et al.38 found that corticosteroid injections were superior to Cyriax physiotherapy (deep transverse friction massage and Mills manipulation) for short-term pain reduction. Laser Six level 1a and 2b16 studies39–44 examined a total of 294 subjects and collectively investigated the effects of laser therapy versus placebo laser therapy in the treatment of lateral epicondylitis. The scores for the studies ranged from 29 to 44 out of 48. The outcomes used in these studies included grip strength, pain severity, and an incremental lifting test. The findings of all six studies suggest that laser is not significantly better than placebo laser for any of these outcomes in the treatment of lateral epicondylitis. When used in combination with traditional physiotherapy, Vasseljen et al.45 found that laser provided no greater benefit for pain and grip strength. This study included 30 subjects and had a quality score of 30 of 48. Alternatively, two level 2b16 studies46,47 with a total of 93 subjects and scores ranging from 31 to 39 out of 48 indicated that there was significant short- and long-term improvement on pain, grip strength, and incremental lifting.

TABLE 1. Background Information of Studies Study

Patients No. of Subjects (n) Sex (M/F) Age Duration of symptoms

Stratford PW, et al., 1989

n = 40 20 M; 20 F Age: 31.8–54.4 yrs Symptom duration: 0.9–12.4 months

Interventions

Evaluations

Type and When Administered

d

Type

Time

Frequency

1. Ultrasound and placebo ointment without friction massage 2. Ultrasound and placebo ointment with friction massage 3. Phonophoresis without friction massage 4. Phonophoresis with friction massage

US/Phonophoresis: 6 min Friction: 10 min

3 3 per week

1. Dichotomous rating of success or failure 2. VAS pain 3. VAS function 4. Grip strength d

Administered pre- and post-treatment and within five weeks of initial visit

Halle JS, et al., 1986

n = 48 22 M; 26 F Age: 20–59 yrs Symptom duration: N/A

1. US with coupling agent and home program 2. US with a 10% hydrocortisonecoupling agent and home program 3. TENS and home program 4. Injection with lidocaine and hydrocortisone and home program d Home program consists of tennis elbow cuff, avoiding strenuous activity, and home ice massage

US: N/A TENS: N/A Injection: N/A Tennis elbow cuff: during all normal day activity–removed at night Home ice massage: 2 3 day

Five consecutive work days with all protocols except injection Injection were injected once, then reevaluated after one week

1. McGill Pain Questionnaire

Binder A, et al., 1985

n = 76 28 M; 48 F Age: 29-65 yrs Symptom duration: at least one month

1. Ultrasound 2. Placebo

US: pulsed 1:4; 1.0 MHz; 5–10 min

US: 12 Rx were given (2–3 per wk) over 4–6 wks

1. VAS pain 2. Lifting test 3. Grip strength d Administered at baseline and every two wks, as well as at one-month follow up, one year later as questionnaire or reexamined to assess natural history

Lundeberg T, et al., 1988

n = 99 63 M; 43 F Age: 21–68 yrs Symptom duration: at least one month

1. US 2. Placebo 3. Rest

US: continuous; 1 mHz; 10 min

10 Rx: 2 3 /wk over 5–6 wks

1.VAS pain 2. Resisted wrist DF 3. Lifting test 4. Grip strength 5. Patient satisfaction d Administered at baseline and every two weeks for one wk; follow-up exam at three months (continued on next page)

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TABLE 1. (continued) Study Fink M, et al. Rheumatology. 2002;41:205–9

Patients n = 80 Symptom duration 3+ months Acupuncture group: 19 M; 23 F Age: 52.568.7 yrs Symptom duration: median eight months Sham acupuncture group: 12 M; 26 F Age: 51.6610.0 yrs

Interventions 1. Acupuncture 2. Sham Acupuncture

Acupuncture: six needles: Ash point, LI10, LI11, Lu5, LI4, SJ5; twisting needles until a De Qi sensation was induced; 25 min Sham: six needles: Puncture sites five cm away from the classic points and their interconnecting meridians and also clear of painful pressure points (Ah-Shi or trigger points), 25 min

Symptom duration: median 10.5 months

Evaluations 2 3 per week for two weeks

1. Peak muscle force 2. Pain at rest, in motion, during exertion, duration, frequency) 3. DASH questionnaire: functional impairment

Fink M, et al. Forsch Komplementa¨rmed Klass Naturheilkd. 2002;9:210–5

n = 45 at baseline At follow-up 1: n = 42 19 M; 23 F Age Rx: 52.5 8.7 yrs Age sham: 51.6610.0 yrs Median symptom duration (months): Rx—8; Sham—10.5

1. Acupuncture 2. Sham acupuncture

Acupuncture: (six needles) LI10, LI11, on point over muscular origin of lateral extensor group of forearm, L5, LI4, SJ5; 25 min Sham acupuncture: (six needles) sites were 5 cm away from traditional sites, needles inserted in same was and stimulated, 25 min

10 Rx; 2 3 /wk

1. six point VRS Pain: at rest, on motion, on exertion 2. Subjective frequency and duration of pain periods d Assessed at baseline, two wks, two months, 12 months

Molsberger A, et al., 1994

n = 48 22 M; 26 F Symptom duration: at least two months

1. Verum group 2. Placebo group

Verum group: Needle on fibulatibial joint of homolateral leg, inserted 2 cm; needle manipulated until felling of dull pressure and warmth; 5 min Placebo group: Pencil-like probe stimulated a point 1.5 cm lateral to T3 (mock acupuncture); five min

1 Rx

1. Physical pressure, load, movements of forearm which were causing elbow pain; degree of pain recorded on what sounds like a VAS or NRS duration of pain d Assessments before, after, and 12 hours post-Rx

Yong H, et al., 1998

n = 93

1. Floating acupuncture (FA) 2. Routine acupuncture (RA)

FA: locate a non tender point 50–80 mm below the tender point. The needle is in for 1–2 days; this is followed by one day of rest when a one finger massage Rx is applied for 10 min

FA: N/R RA: 7 courses of Rx

1. The initial response to acupuncture: immediately after the first Rx, the subjects were asked to evaluate their response in terms of percentage of pain relief

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(continued)

TABLE 1. (continued) Study

Patients

Interventions

Evaluations

RA: Points: tender (point), LI11, SI9, SJ5, electrodes for a G6805-1 electrostimulator were connected to the needles; stimulated at 4v, 20-Hz square wave; 1.0 mAmp was given once per six days; each Rx followed by a one-finger massage for 10 min; this was followed by one day without acupuncture and without massage, completing one course of Rx; the next course of six acupuncture and massage Rx were repeated

2. The number of elapsed days required to bring about ‘‘recovery’’ during the 20 days of the study period

Haker E, et al. Clin J Pain 1990;6:221–6

n = 82 52 M; 30 F Age: 25–70 yrs Symptom duration: mean 9 months; range 1–120 months

1. Traditional acupuncture group 2. Superficial acupuncture group

Traditional acupuncture group: Needles inserted corresponding to traditional Chinese acupuncture (LI10, LI11, LI12, Lu5, SJ5), inserted to depth of 1.25–2.5 cm; all rotated to illicit The Chi every five min during 20 min Rx Superficial acupuncture group: Needles inserted superficially at same points as Rx group; 20 min; The Chi not obtained

All treated 2-3 3 /wk; 10 Rx in all

1. Four Diagnostic criteria 2. Pain elicited on LE by isometric pronation/ supination of forearm 3. Grip strength with vigorimeter (pain-limiting) 4. Lifting test 5. Clinical subjective report of improvement

Johannsen F, et al., 1993

n = 16 10 M; 6 F Age: Rebox–placebo 45 (36–55) yrs; Placebo–Rebox 41 (37–58) yrs Symptom duration: six (3–12) months

1. Rebox–Placebo 2. Placebo–Rebox

Rebox: Current 0–300 mAmps; 0–20v; 200–5000 Hz; no indication where electrodes were placed or length of each Rx session Placebo: Same as above but current was inhibited

10 Rx in 3 weeks

1. Power grip with VAS for pain 2. Lifting test with VAS pain

(continued on next page)

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TABLE 1. (continued) Study

Patients

Interventions

Evaluations

Smidt N, et al., 2002

n = 185 92 M; 93 F Age: 41–54 Symptom duration: 8–21 weeks

1. Wait and see group 2. Injection group 3. PT group

Wait and see group: Visited MD once during six-week intervention to discuss activities that provoked pain and practical solutions; medications were prescribed if necessary Injection group: Injections given until spots were pain-free on resisted DF; amount of medication used was recorded; patients asked to avoid pain provoking activities (absolute rest not necessary); maximum of three injections recommended over a six-week period PT group: nine Rxs of pulsed US 20% duty cycle at 2W/cm2 for 7.5 mins per session; deep friction massage; exercise program consisting of progressive, slow, repetitive wrist and forearm stretches, muscle conditioning, and occupational exercises for 6 weeks

six weeks

1. six-point Likert Scale—general improvement 2. 11 point NRS: Severity of main complaint, pain during day and inconvenience 3. PT scored overall severity of elbow complaints on 11-point scale after taking history and physical examination 4. Pain-free/ grip strength 5. Maximum grip strength 6. Pressure pain threshold with algometer

Newcomer KL, et al., 2001

n = 39 19 M; 20 F Mean age control group 44.6 6 7.6, Rx group 46.0 6 7.0 Symptom duration control group 3.4 6 0.9, Rx group 3.2 6 0.8

Control: 5 mL injection of 0.25% bupivacaine hydrochoride Experimental: 5 mL of a 4:1 solution of 0.25% bupivacaine hydrochloride and betamethasone Both groups: ice massage, home stretching, and strengthening

Not reported

One injection One injection Ice massage: 5–7 min, 3–5 3 /day Stretching and strengthening N/R

1. VAS–pain 2. Functional pain questionnaire 3. Grip strength -pain-free grip strength maximal grip strength d Measured at baseline, four weeks, eight weeks, and six months

Pienimaki T, et al., 1998

n = 30 8M; 15F Mean age in exercise group is 45 (range 36–54), ultrasound group

Exercise group: four step progressive stretching and strengthening program

Not reported

Exercise group: N/R

1. Retrospective: postal questionnaire, hospital register

(continued)

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TABLE 1. (continued) Study

Pienimaki TT, et al., 1996

Patients

Interventions

44 (range 38–57) Symptom duration: N/R

Ultrasound group: local pulsed 1:5, 0.5 W/cm2

n = 39 14 M; 25 F

Exercise group: progressive slow repetitive wrist and forearm stretching, muscle conditioning, occupational exercises Ultrasound group: pulsed 1:5, 1 MHz, 0.3–0.7 W/cm2

Mean age 43 (range 33–53) Symptom duration: \6 months 9, >6 months 11

Evaluations Ultrasound group: up to 15 treatment visits

2. Prospective: -baseline and two months: pain questionnaire, pain drawing, clinical evaluation, muscle functioning 12 months: pain questionnaire, pain drawing

six to eight weeks

Exercise group: 10 reps 3 2–3 sets for each exercise, 4–6 3 /day Ultrasound group: 10–15 minutes, 2–3 3 /week

1. VAS: pain 2. Pain and Disability Questionnaire 3. Isokinetic testing of wrist/forearm 4. Isometric grip strength d Evaluated preand posttest

Svernlov B, et al., 2001

n = 30 19 M; 11 F Average age in group S 43 years, Group E 42.1 years Symptoms duration in group S 8.4 months (range 3–20), Group E 10.7 months (range 7–24)

Group S: contract-relax stretch program Group E: eccentric regimen Both groups used an elbow band during activity and wrist support at night

12 weeks

Group S: contract forearm extensors 10s, relax 2s, stretch 15–20s, repeat 3–5 3 , 2 3 /day Group E: warm-up 2–3 min, static stretch 15–30s, repeat 3–5 3 , eccentric exercises 10s, 3 sets, 5 reps—all done 1 3 /day

1. Subjective Assessment a) VAS: pain b) Change in symptoms c) Back to normal work and leisure activities 2. Objective assessment a) Grip strength: function d Assessed at baseline, after three, six and 12 months

Vecchini L, et al., 1984

n = 24 10 M; 14 F Mean age in experimental group 35.45618.04, placebo group 45.92612.12 Symptom duration: N/R

Ionization diclofenac group: 150 mg diclofenac sodium, 4–8 mA intensity Placebo group: 150 mg saline

Cycle of at least 20 daily session

25–30 min sessions

1. Pain: four-point scale 2. Functional impairment: four-point scale 3. Swelling: fourpoint scale 4. Tolerability: four-point scale d Evaluations performed at baseline four, 10, and 20 days of treatment

Demirtas RN, et al., 1998

n = 40 14 M; 26 F Mean age group 1 45.3561.71 (range 28–60), group 2 42.6562.12 (range 25–61)

Group 1: iontophoresis sodium diclofenac Group 2: iontophoresis of sodium salicylate

Maximum of 18 days

Iontophoresis -Current intensity six and 11 mA 20-min Rx Infrared -250 W -20-min Rx

1. Pain: fourpoint scale 2. Pain produced by pressure on lateral epicondyle 3. Pain produced on resisting wrist extension (continued on next page)

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TABLE 1. (continued) Study

Patients

Interventions

Symptom duration in group 1 5.2, group 2 4.8

Both groups had infrared Rx

Devereaux MD, et al., 1985

n = 30 17 M; 13 F Mean age in treatment group 43.762.0, placebo group 43.962.5 Symptom duration in active group 10.161.8 months, placebo group 9.862.0 months

Pulsed electromagnetic field therapy regime Placebo: dummy coils

Drechsler WI, et al., 1997

n = 18 8 M; 10 F Average age 30–57 (range 30–57) Symptom duration: N/R

Neural tension group: -ULTT IIb: radial nerve -home exercise program mimicking ULTT -Anterior and posterior mobilizations of radial head

1 3 /day, five days/week

4. Pain during function 5. Spontaneous pain at rest

eight–12 weeks

At least eight hours/day in 1–2 Rx sessions No Rx session was to be less than one hour

1. Pain induced by lifting 2. Incremental lifting test 3. Pain with wrist DF 4. Effect on work 5. Pain on routine daily tasks 6. Tenderness over lateral epicondyle 7. Grip strength: function 8. Thermal gradient d Evaluated every two weeks for treatment period

six–8 weeks

Neural tension group: 2 3 /week, home program 10 reps 1–2 3 /day

1. Self-report questionnaires: recreational and occupational 2. Grip strength: function 3. Isometric testing: pain 4. Radial head mobility: anterior and posterior glides, elbow extension ROM d Measurements taken at baseline, during and postapplication of intervention

Standard Rx group -Continuous ultra sound 1.0–1.5 W/cm2, 3 MHz -Friction massage -Stretching and strengthening of wrist extensors

Vincenzino B, et al., 2001

n = 24 14 M; 10 F Age: 34–66 yrs Symptoms: 2–36 months

Mobilization with movement technique (Mulligan: lateral glide of proximal forearm while patient performs pain-free grip exercise) vs placebo (firm manual contact on subject’s elbow) vs control (no manual contact)

Evaluations

Standard Rx group: 2 3 /week, 5-min ultrasound, three–one min sessions of friction massage, 5–10 reps, hold each stretch 30 s stretching and strengthening Mobilization with movement: six repetitions were performed with 15-sec rest interval between repetitions

Each subject attended three experimental sessions on three different days, at least 48 hrs apart, at about the same time of day At each session, the subject received one of the treatment conditions

1. Pain-free grip strength 2. Pressure pain threshold

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TABLE 1. (continued) Study

Patients

Interventions

Evaluations

Burton AK, 1988

n = 33 17 M; 16 F Mean age: 45.1 yrs Symptoms: mean duration 4.8 wks

Manipulation alone Manipulation with forearm strap Manipulation with topical antiinflammatory cream Manipulation with strap and cream

Verharr JAN, et al., 1995

n = 106 59 M; 49 F Mean age 43 Symptom duration: 33 wks

Corticosteroid injections PT according to Cyriax

Lundeberg T, et al., 1987

n = 82 31 M; 26 F Age: 25–62 yrs Symptoms: at least three mos

Ga-As pulse wave laser vs. He-Ne continuous wave laser vs. placebo

Laser held at surface of skin for 60-sec/ acupuncture point (acupuncture points: Li 10, 11, 12; SJ 5, 10; SI 4, 8; H3, 4; P3)

10 Rxs (2X/wk) over 5–6 wks

1. VAS pain 2. Grip strength 3. Functional strength (incremental lifting) d Measures were taken every two weeks; follow up continued for three months

Haker E, et al., 1991

n = 63; 49 completed 31 M; 18 F Age: 22–66 yrs Symptoms: 1–35 months

Ga-As laser vs mock radiation (placebo)

Laser applied to one point at anterior aspect of LE, and five points around this site at 1.5–2 cm Each point treated for 30 sec with laser held 1 mm from skin

2–3X/ wk for 10 treatments

1. Palpation of LE 2. Resisted wrist extension 3. Passive stretching of extensor muscle group 4. Resisted finger extension 5. Isometric pronation/ supination 6. Pain-free grip strength

Number of manipulations performed in a single treatment not mentioned

Manipulation: 2X/ wk in first week and once in following two wks Straps worn all day for three wks Cream applied 5X/ day for three wks

1. Pain-free grip strength 2. VAS for functional capacity of patient’s chosen function (rated 0–5; 0 = no pain, 5 = severe pain) d Measurements taken at baseline, three days, one week, and three weeks Administered at 0, six, and 52 weeks 1. Severity of pain 2. Occurrence of pain 3. Subjective loss of grip strength 4. Resumption of labor 5. Resisted dorsiflexion of the wrist 6. Resisted dorsiflexion of middle fingers 7. Local tenderness 8. Mean grip strength d Administered at six and 52 weeks post-Rx 9. Change in grip strength 10. Patient satisfaction level 11. Result rating

Injection group: one injection Patients were then seen two and four weeks after the start of Rx and a second or third injection was given Cyriax group: 12 Rxs over four weeks

d

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TABLE 1. (continued) Study

Patients

Interventions

Evaluations 7. Incremental lifting (1, 2, 3, 4, 5 kg) d Measured at baseline, after 10 treatments, and at three and 12-month follow up

Kraheninnikoff M, et al., 2003

n = 48 Age: 37–64 yrs Symptoms: at least four wks

Ga-Al-As laser vs placebo

Applied to tender points on lateral epicondyle and in forearm extensors for 120 sec (3.6 J/point)

2 3 /wk for maximum of eight treatments

Basford JR, et al., 2000

n = 52; analysis for 47 28 F; 19 M Symptoms: >30 days

Laser vs. placebo

60 sec at seven sites along forearm (three sites immediately above, at and below LE; at distal wrist extensors, volar wrist; two sites on medial epicondyle)

3 3 / wk for four wks

1. VAS pain (last 24 hrs) 2. Grip strength 3. Pinch strength d Measurements taken before first treatment, after 10th treatment, and at three months follow up

Haker E, et al. Pain. 1990;43:243–7

n = 49 28 M, 21 F Age: 24–70 yrs Symptoms: between one and 36 months

Ga-As laser vs. placebo

Each point treated for 30 sec (L1, 10, 11, 12, Lu5, SJ 5) with wand held 1 mm from skin

2–3 3 /wk for 10 treatments

1. Grip strength 2. Incremental lifting (1–4 kg) with presence or absence of pain 3. Subjective report of improvement (scale of 1–5; 1 = excellent, 5 = worse) d Measurements taken at first, fourth, and sixth visits

Papadopoulos ES, et al., 1996

n = 29 (31 elbows) 10 M; 21 F Age: 45.3 yrs (mean) Symptoms: 25 wks (mean)

Ga-Al-As laser vs placebo

Laser applied to most tender spot for 60 sec

3 3 /wk for two wks

1. VAS pain 2. Marcy Wedge Pro exerciser (exercise of the forearm muscles but stopping when pain reached)

Measured at baseline and before each treatment Follow up done 10 wks after last treatment 1. Four-point verbal scale pain score 2. VAS pain 3. Tender points on LE and in forearm extensors 4. Forearm muscle strength d

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TABLE 1. (continued) Study

Patients

Interventions

Evaluations

Vasseljen O Jr, et al., 1992

n = 30 15 M; 15 F Mean age of active laser group 47.1 years (range 34–63) and placebo group 43.9 years (range 25–61) Symptom duration of active laser group 4.1 months (range 1–12) and placebo group 2.9 months (range 1–10)

Infrared laser group: 880 Hz, 175 ns, 1.5 mW Placebo group: laser disconnected

eight treatments

10-minute treatments, 3X/week

1. Vigorimeter (grip strength): function 2. Incremental lifting test: function 3. Goniometric measurements of wrist flexion: point of aggravation of pain 4. VAS: pain d Patient assessment: assess status d Measurements taken before and after treatment period, and at three, six, 12 months

Haker EHK, et al., 1991

n = 58 43 M; 15 F Age: 33–65 yrs Symptoms: 1–60 months pain

Ga-As, He-Ne laser vs placebo

Probe was used to radiate the area over LE for eight minutes Then pen laser was applied to acupuncture points LI 11, 12 for two min per point Same procedure for placebo group but with no emission

3–4 X/ wk for 10 treatments in all

1. Palpation of LE 2. Resisted wrist extension 3. Passive stretching of the extensor muscle group 4. Resisted finger extension 5. Isometric pronation/ supination of forearm 6. Grip strength 7. Incremental lifting (1, 2, 3, 4 kgs) with grip diameters of 2.5–3 cm 8. Subjective assessment d Measurements taken at baseline, end of treatment and four weeks posttreatment

Vasseljen O, et al., 1992

n = 30 13 M; 17 F Age: 25–70 yrs Symptoms: 1–12 months

Ga-As laser vs placebo vs traditional physiotherapy (ultrasound and friction massage) Ultrasound: 1 MHz, 1.5 W/cm2 pulsed mode (2 ms ON, 8 ms OFF), stationary head Massage to origin of ECRB; method used by Cyriax

Laser: 10 min Ultrasound: seven min Friction massage: 10 min

3X/ wk for total of eight treatments

1. Grip strength 2. Incremental lifting (1, 2, 3 kg) 3. ROM (assessing point of pain in wrist flexion) 4. VAS pain (last 24 hours) 5. Subjective assessment (change in pain)

N/R = not reported; US = ultrasound; M = male; F = female; VAS = visual analog scale; TENS = transcutaneous electrical nerve stimulation; DF = dorsiflexion; DASH = Disabilities of the Arm, Shoulder, and Hand [questionnaire], n = number of patients; Rx =treatment.

April–June 2004 255

TABLE 2. Results and Level of Evidence of Studies Study

Results Absolute Changes and p Values (if available) for All Outcomes and RTW if Noted

Modifiers

Level

Factors Affecting Time to Return to Work, d Nonresponse, and d Complications

Sackett’s Level of Evidence

d

Stratford PW, et al., 1989

1. No one therapy was superior to another, thus, authors recommended US because it is more costeffective than phonophoresis

Return to work d N/R Nonresponse d N/R Complications d N/R

1b

Halle JS, et al., 1986

1. In each case, at least two of the pain indexes indicated that the treatment rendered was statistically significant, and with the patients receiving an injection, effective pain reduction was demonstrated over all four pain indexes; this data was p\.05

Return to work d N/R Nonresponse d N/R Complications d N/R

2b

Binder A, et al., 1985

1. The US group had significantly more participants with satisfactory outcome on objective testing than the placebo group (p\.01)

Return to work d N/R Nonresponse d 41 patients (14 US and 27 placebo) still showed an unsatisfactory outcome at the end of the controlled study and were offered US (in placebo group), steroid injections, or both Complications d At one year, minor intermittent pain in the elbow was still present in over 50% of the patients

2b

Lundeberg T, et al., 1988

1. 36% US group, 30% placebo group, 24% rest showed satisfactory outcome on objective testing both at end of treatment and three months follow up; the difference between the US group and the rest group was significant (p\.01); there was no difference between the US group and the placebo group

Return to work d N/R Nonresponse d N/R Complications d N/R

2b

Fink M, et al. Rheumatology. 2002;41:205–9

1. In both groups, the Rx led to significant changes in the outcome measurement and the changes were also clinically relevant at the first follow up 2. There was a significant reduction in distability (DASH) at the second follow up in favor of the Rx group

Return to work d N/R Nonresponse d N/R Complications d No side effects occurred apart from pain resulting from needling, which led to one dropout

2b

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TABLE 2. (continued) Study

Results

Modifiers

Level

3. Under sham acupuncture Rx, the subgroups with high or varying occupational strain show significantly less improvement than patients with low strain (p\.05) 4. There was a significant difference between Rx effects in subgroup one between real and sham acupuncture (p\.05) Fink M, et al. Forsch Komplementa¨rmed Klass Naturheilkd. 2002;9:210–5

1. In both groups, the Rx led to significant changes in the outcome parameters between the first and second follow up and again between the third and final follow up (p\.05) 2. Significant differences between the two groups could be detected for pain on motion and pain on exertion at the first follow up

Return to work N/R Nonresponse d N/R Complications d Intolerable pain from acupuncture

1b

Molsberger A, et al., 1994

1. In Verum group, 79% of patients reported at least 50% relief of pain; placebo group reported 15% relief of pain 2. Average duration of pain in Verum group was 20.2 hours as opposed to 1.4 hours in placebo group

Return to work d N/R Nonresponse d N/R Complications d N/R

2b

Yong H, et al., 1998

1. The initial therapeutic response in the FA group was greater (p\.01) than the RA group 2. Statistical analysis showed a significant difference (p\.01) between the two methods used in this study in terms of recovery 3. FA was more effective than RA in producing pain relief, especially during the first Rx; FA took less time and fewer Rxs to produce complete recovery from the symptoms of lateral epicondylitis

Return to work N/R Nonresponse d N/R Complications d N/R

2b

1. Pain threshold on grip strength increased in traditional acupuncture group compared with superficial acupuncture group (p\.05); no differences at follow up 2. After 10 Rxs, smaller number in traditional group suffered pain than in superficial group while lifting 3 kg (p\.05)

Return to work d N/R Nonresponse d N/R Complications d N/R

2b

Haker E, et al. Clin J Pain 1990;6:221–6

d

d

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TABLE 2. (continued) Study

Results

Modifiers

Level

3. Pain threshold on gripping had significant increase in traditional group compared with superficial group (p\.05): no significant differences were found at follow up 1. Significant improvement for grip strength with elbow in 90 flex Rebox vs. placebo (p = .02); similar result for grip strength in elbow extension (p = .07) 2. VAS pain in flexion and extension showed significant improvements (p = .02, p = .07) in Rebox group; VAS pain when lifting 2-kg weight significant improvement (p = .001); Rebox group’s diary recorded significant improvements in impairments (p = .001)

Return to work N/R Nonresponse d N/R Complications d N/R

2b

1. At six weeks, significant differences in favor of corticosteroid injections were seen for all outcomes 2. At 26 and 52 weeks, significant differences for nearly all outcome measures were noted in favor of PT compared with injections

Return to work N/R Nonresponse d N/R Complications d Pain post-Rx for PT and injection (47%, but mild)

2b

1. Changes in outcome measurements from baseline to four weeks, eight weeks, and six months were not significantly different 2. No significant difference in grip strength between groups 3. Both groups had significant improvement in outcome measures over time 4. Because there was no significant difference between groups, can conclude that injections added very little to a standard rehabilitation program

Return to work N/R Nonresponse d N/R Complications d N/R

1b

Return to work eight individuals (67%) in the exercise group and five individuals (45%) in the ultrasound group still held their previous job

2b

Johannsen F, et al., 1993

Smidt N, et al., 2002

Newcomer KL, et al., 2001

Pienimaki T, et al., 1998

1. Individuals in exercise group has significantly less pain and pain and their drawings were not so widespread as the ultrasound group

d

d

d

d

(continued)

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TABLE 2. (continued) Study

Results

Modifiers

Level

2. Individuals in the exercise group had better outcomes and prognosis at the 36-month follow up

two individuals in the ultrasound group and none in the exercise group were absent from work because of tennis elbow Nonresponse d N/R Complications d N/R

Pienimaki TT, et al., 1996

1. Pain at rest and under strain significantly increased in the ultrasound group and decreased in the exercise group 2. Sleeping disturbances were alleviated significantly more in the exercise group then in the ultrasound group 3. Isokinetic strength increased in exercise group, torque decreased in ultrasound group, differences between the group, and changes in exercise group were statistically significant 4. Maximum grip strength significantly increased in the exercise group and remained unchanged in the ultrasound group

Return to work d N/R Nonresponse d N/R Complications d N/R

1b

Svernlov B, et al., 2001

1. No significant difference between the groups were seen in the five VAS pain scales 2. Both groups found statistically significant improvements in four of the VAS pain scales 3. In group S, all but two and in group E all but one participants reported complete relief of pain at rest after six months 4. Grip strength significantly increased in both groups after six months 5. Increase in grip strength was significantly larger in group E at six months

Return to work d All participants were back to work and previous leisure activity by three months Nonresponse d N/R Complications d N/R

2b

Vecchini L, et al., 1984

1. Ionization with diclofenac treatment produced a significant reduction for all target symptoms 2. Placebo treatment led to a significant improvement of pain on movement and functional impairment

Return to work d N/R Nonresponse d N/R Complications d One case of local irritation in patient in Ionization treatment with diclofenac group

2b

d

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April–June 2004 259

TABLE 2. (continued) Study

Results

Modifiers

Level

3. Ionization with diclofenac treatment were significantly more improved for pain on movement and functional impairment at final evaluation Demirtas RN, et al., 1998

Devereaux MD, et al., 1985

Drechsler WI, et al., 1997

Vincenzino B, et al., 2001

1. Statistically significant reduction in the scores of pain produced by pressure on lateral epicondyle, on resisting wrist extension, during function, and spontaneous pain at rest were seen in both groups 2. The reduction in pain produced on resisting wrist extension and pain produced by pressure on lateral epicondyle was statistically more significant in group 1

Return to work N/R Nonresponse d N/R Complications d N/R

2b

1. No significant difference for all assessments between the treatment and placebo groups

Return to work N/R Nonresponse d N/R Complications d N/R

2b

Return to work N/R Nonresponse d N/R Complications d N/R

2b

Return to work N/R Nonresponse d N/R Complications d N/R

2b

1. Recreational status significantly improved in the NTG at discharge and three months 2. Recreational status significantly improved in STG at discharge, but not at three months 3. Occupational status unchanged for both groups 4. No significant change in grip strength 5. ULTT IIb was significantly different for the NTG at discharge and follow up, but not for STG 6. Therefore, mobilizations and neural tension exercises are superior to standard Rx 1. Significant difference between treatment group and placebo and control groups with respect to increased pain-free grip strength 2. Pressure-pain threshold increased significantly in the treatment group compared with the placebo and control groups

d

d

d

d

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TABLE 2. (continued) Study Burton AK, 1988

Verharr JAN, et al., 1995

Lundeberg T, et al., 1987

Haker E, et al., 1991

Results 1. Mean grip strength increased significantly for all groups at three wks 2. No significant differences found between groups at reassessment 3. Significant decrease in mean VAS scores, but no significant differences found between groups

Modifiers

Level

Return to work N/R Nonresponse d N/R Complications d N/R

2b

1. At six wks, results based on history and physical examination showed that the injection group was significantly better 2. At one yr, no significant difference b/w groups 3. No significant difference b/ w groups for mean grip strength 4. Satisfaction was significantly lower in the PT group

Return to work At six weeks, in the PT group four resumed, 14 still working, 13 unable to work, 20 not applicable d At six weeks in the injection group, nine resumed, 15 still working, nine unable to work, 19 not applicable d At 52 weeks, in the PT group, 19 resumed, eight still working, six unable to work, 20 not applicable d At 52 weeks, in the injection group, seven resumed, 13 still working, two unable to work, 17 not applicable Nonresponse d N/R Complications d one patient discontinued PT b/c of severe pain

2b

1. No significant differences noted for any outcome; therefore, laser is not significantly better than placebo for treating LE

Return to work N/R Nonresponse d Minor or intermittent pain still present in 60% of patients Complications d No difference in incidence of recurrence of severe pain noted

2b

Return to work N/R Nonresponse d N/R Complications d N/R

2b

1. Pain-free gripping threshold significantly increased in laser group vs. placebo after 10 treatments and at threemonth follow up 2. Incremental lifting (3, 4 kgs) changed favorably after 10 treatments for the laser group; outcome of 3-kg lifting test also changed favourably at three months 3. Significantly fewer patients in laser group reported pain at middle finger test after 10 treatments

d

d

d

d

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TABLE 2. (continued) Study

Results

Modifiers

Level

Kraheninnikoff M, et al., 2003

1. No statistically significant differences between laser and placebo group 10 weeks after treatment 2. A nonsignificant trend toward pain alleviation during treatment and after 10 wks in both groups

Return to work N/R Nonresponse d N/R Complications d N/R

2b

Basford JR, et al., 2000

1. No statistically significant differences between groups in any outcome

Return to work d N/R Nonresponse d N/R Complications d N/R

1b

Haker E, et al. Pain. 1990;43:243–7

1. No statistically significant differences between groups in any outcome after 10 treatments or at follow up

Return to work d N/R Nonresponse d N/R Complications d six of 23 in laser group and five of 26 in placebo group reported that they felt ‘‘unchanged’’ or ‘‘worse’’ d No side effects reported

2b

Papadopoulos ES, et al., 1996

1. No statistically significant differences between the groups in either outcome

Return to work d N/R Nonresponse d N/R Complications d These findings may indicate that low-level laser therapy delays spontaneous remission

2b

Vasseljen O Jr, et al., 1992

1. Significant decrease in pain in the laser group over the placebo group 2. Significant improvement only in grip strength in the laser over the placebo group

Return to work d N/R Nonresponse d N/R Complications d N/R

2b

Haker EHK, et al., 1991

1. No statistically significant differences found in subjective or objective outcomes after 10 treatments 2. The grip strength did show a difference favouring the placebo group (p\.06) 3. No differences found between the groups at any of the follow ups

Return to work d N/R Nonresponse d N/R Complications d No side effects reported during or after the treatment period

2b

Vasseljen O, et al., 1992

1. Low-level laser in no better than traditional physiotherapy in the treatment of LE

Return to work d N/R Nonresponse d N/R Complications d N/R

2b

N/R = not reported.

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d

Limitations Although our database search revealed an adequate number of RCTs evaluated at level 2b or above, methodologic limitations were not absent (Table 3). Many of the studies failed to provide adequate followup, blinding procedures, and did not use either sample or power calculations or sample size justification. The use of standardized outcome measures was another area of particular deficit. Recruitment strategies were also often not described, making it difficult to generalize results; furthermore, the size and significance of effects were often absent. In addition, acute and chronic cases, which are typically considered quite different from a clinical standpoint, are rarely considered separately, either through stratification of sampling or in statistical analyses. Finally, a lack of discussion on clinical and practical issues relating to the interventions themselves, including clear descriptions of the techniques, dosage, and progression, as well as training or experience requirements, makes it difficult for therapists to replicate study interventions. A wide variety of interventions have been described as conservative management techniques for lateral epicondylitis: ultrasound, phonophoresis, electrical stimulation, manipulation of joints/soft tissues, neural tension, friction massage, joint mobilizations, augmented soft tissue massage, stretching, strengthening, and work hardening. Not all of these have been studied in comparison to control, and few head-to-head comparisons are available. Therefore, constructing the optimal treatment approach is difficult based on current evidence. Despite the assumption that activity or work can be primary factors in the development of lateral epicondylitis, little attention has been paid to secondary prevention. The role for modification of workplace or recreation exposures needs to be rigorously evaluated.

CONCLUSIONS AND RECOMMENDATIONS Much research has been conducted in the area of conservative treatment for lateral epicondylitis; however, there have been no high-quality comprehensive systematic reviews to summarize the evidence available on this topic. Our review has determined, with at least level 2b evidence, that acupuncture, exercise therapy, manipulations/mobilizations, ultrasound, phonophoresis, Rebox, and ionization with diclofenac all show positive effects in the reduction of pain and in the improvement of function for those with lateral epicondylitis. There is also at least level 2b evidence showing laser therapy and pulsed electromagnetic field therapy to be ineffective in the management of this condition.

Therefore, our recommendations would be that practitioners use the treatment techniques that have the strongest evidence supporting their outcomes. Given the lack of evidence on the relative benefits of these treatment options, therapists must construct a treatment plan and progression from these options based on clinical practicalities and experience. It is imperative that patients are matched according to the specific treatment study participants’ characteristics and injury presentations to obtain the best results.

Research Gaps/Directions Future research should involve the completion of more rigorous study designs to reduce methodologic limitations and to produce higher-quality evidence. In particular, randomized trials are needed when treatment outcomes are measured independently, chronicity is accounted for, and blinding of treatment providers and patients is implemented when possible. Descriptions of treatment interventions should be more explicit to facilitate the transference of techniques into practice. Given the role for exercise therapy defining the optimal approach to progressive strengthening and endurance in this pathology would help guide therapists in designing exercise programs. Outcome measurement has been an area of particular deficit, despite the availability of at least some methodologic evidence. Self-report scales designed specifically for patients with lateral epicondylitis are available and are likely to be most responsive to changes in lateral epicondylitis symptoms.48–50 The Patient-Rated Forearm Scale has pain and function (specific and usual activity) subscales, which are weighted equal to provide a global score. The Pain-free Function Questionnaire is a pain scale that focuses on pain with activity.51 Both were developed with items specific to lateral epicondylitis. Other self-report measures with sound psychometric properties such as the Disability of the Arm, Shoulder, and Hand (DASH), Visual Analog Scale (VAS), or the McGill Pain Questionnaire might also contribute to a more comprehensive comparison of treatment interventions but are less specific to the condition. However, because head-to-head evaluations of these different outcome measures have not yet been performed, the relative value of these is unknown. In terms of measuring physical impairments, both range of motion and strength measures have been studied.50–52 Pain-free grip (measured with the elbow extended) has been shown to be reliable, valid, and responsive in this patient population.51 Pain threshold can be measured by algometry, although this may be less reliable than other physical measures.42 Adoption of a core set of outcome measures would facilitate future trials and allow for meta-analyses of smaller studies. Although April–June 2004 263

TABLE 3. Quality Scores of Studies Study

?

Design

Subjects

Items Stratford PW, et al., 1989 Halle JS, et al., 1986 Binder A, et al., 1985 Lundeberg T, et al., 1988 Fink M, et al. Rheumatology. 2002;41:205–9 Fink M, et al. Forsch Komplementa¨rmed Klass Naturheilkd. 2002;9:210–15 Molsberger A, et al., 1994 Yong H, et al., 1998 Haker E, et al. Clin J Pain. 1990;6:221–26 Johannsen F, et al., 1993 Smidt N, et al., 2002 Newcomer KL, et al., 2001 Pienimaki T, et al., 1998 Pienimaki TT, et al., 1996 Svernlov B, et al., 2001 Vecchini L, et al., 1984 Demirtas RN, et al., 1998 Devereaux MD, et al., 1985 Drechsler WI, et al., 1997 Vincenzino B, et al., 2001 Burton AK, 1988 Verharr JAN, et al., 1995. Lundeberg T, et al., 1987 Haker E, et al., 1991 Kraheninnikoff M, et al., 2003 Basford JR, et al., 2000 Haker E, et al. Pain. 1990;43:243–47 Papadopoulos ES, et al., 1996 Vasseljen O Jr, et al., 1992 Haker EHK, et al., 1991 Vasseljen O, et al., 1992

1 2 3 4 5 6 7 8 2 2 2 1 2 1 1 2

9 2

10 2

11 0

12 2

13 2

14 2

15 2

16 2

17 2

18 1

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0 1 1

2 1 2

0 0 0

2 1 2

0 1 2

1 2 1

1 2 2

2 1 1

0 1 1

0 2 2

1 1 2

0 1 0

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1 1 2

1 0 1

2 28 2 32 2 35

2 2 2 2 2 2 1 2

1

2

2

1

2

2

2

1

1

2

2

1

1

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1

2 39

2 2 2 2 2 2 1 2

1

2

2

1

2

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1

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1

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0

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2 39

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1

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2 31

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0 19 2 35

1 1 2 2 1 2 2 2 2 2 2 2 2 1 1 0 2 2 2 2 1 2 2 2

0 1 2

2 2 2

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1 2 2

2 2 2

0 0 0

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1 1 1

1 31 2 37 2 37

2 2 2 0 1 1 1 0

1

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2 25

2 2 2 2 1 1 1 2

2

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2 1 2 2

29 25 25 36

1 2 2 1 2 2 2

2 2 2 2 2 2 2

2 2 2 2 2 2 2

2 2 1 2 2 2 2

1 2 1 2 1 1 2

1 1 1 1 2 2 2

1 1 1 1 2 2 2

0 2 0 0 2 2 2

2 1 0 2 0 1 2

2 2 1 2 2 2 2

0 0 0 0 0 0 0

2 2 0 2 0 1 1

1 2 1 1 1 2 2

0 0 0 1 2 2 2

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1 2 2 1 1 1 1

1 2 1 1 1 1 1

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1 0 0 0 0 0 0

1 2 1 1 0 1 2

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30 37 23 30 29 31 38

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1 2

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2 1 1

2 2 2

0 0 0

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2 39 2 34 1 30

a consensus process is advisable for this, a reasonable strategy at this time is that all studies should include the following. Short-term Outcomes 1. Pain relief (self-reported using either the Patientrated Forearm Scale, Pain-free Function Scale, or a VAS) 2. Function (Patient-rated Forearm Scale) 3. Muscle Function a. Functional grip—Pain-free grip strength 264

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Intervention

Outcomes

Analysis

R

T

19 20 21 22 23 24 25 2 2 2 1 2 2 41

b. Tendon integrity—Wrist extensor strength c. Endurance for activity Long-term Outcomes 1. Reoccurrence of symptoms a. Pain/function (Patient-rated Forearm Scale) b. Requiring additional treatment 2. Work outcomes (lost time, the Work subscale of the DASH or a scale similar to the Work Limitation Scale,53 which describes the difficulty at work) 3. Resumption of regular recreational activity

CONCLUSIONS There are a number of good-quality studies on various therapeutic interventions for lateral epicondylitis that demonstrate a variety of effective treatment options that will enable conservative management of lateral epicondylitis. However, the evidence is still incomplete and does not permit strong conclusions to be made on a number of commonly used approaches. At this time, none of the used treatments can be refuted. Additional RCTs that focus on quality research designs and use appropriate outcomes are needed to provide a stronger foundation for hand therapy management of these patients. At present, use of selected modalities and stretching/strengthening are indicated. Hand therapists should work to define these treatment approaches more clearly and demonstrate outcomes more objectively.

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