Reliability of a patient-rated forearm evaluation questionnaire for patients with lateral epicondylitis

Manual therapy and exercise for lateral elbow pain

BACKGROUND

Manual therapy and prescribed exercises are often provided together or separately in contemporary clinical practice to treat people with lateral elbow pain.

OBJECTIVES

To assess the benefits and harms of manual therapy, prescribed exercises or both for adults with lateral elbow pain.

SEARCH METHODS

We searched the databases CENTRAL, MEDLINE and Embase, and trial registries until 31 January 2024, unrestricted by language or date of publication.

SELECTION CRITERIA

We included randomised or quasi-randomised trials. Participants were adults with lateral elbow pain. Interventions were manual therapy, prescribed exercises or both. Primary comparators were placebo or minimal or no intervention. We also included comparisons of manual therapy and prescribed exercises with either intervention alone, with or without glucocorticoid injection. Exclusions were trials testing a single application of an intervention or comparison of different types of manual therapy or prescribed exercises.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted trial characteristics and numerical data, and assessed study risk of bias and certainty of evidence using GRADE. The main comparisons were manual therapy, prescribed exercises or both compared with placebo treatment, and with minimal or no intervention. Major outcomes were pain, disability, heath-related quality of life, participant-reported treatment success, participant withdrawals, adverse events and serious adverse events. The primary endpoint was end of intervention for pain, disability, health-related quality of life and participant-reported treatment success and final time point for adverse events and withdrawals.

MAIN RESULTS

Twenty-three trials (1612 participants) met our inclusion criteria (mean age ranged from 38 to 52 years, 47% female, 70% dominant arm affected). One trial (23 participants) compared manual therapy to placebo manual therapy, 12 trials (1124 participants) compared manual therapy, prescribed exercises or both to minimal or no intervention, six trials (228 participants) compared manual therapy and exercise to exercise alone, one trial (60 participants) compared the addition of manual therapy to prescribed exercises and glucocorticoid injection, and four trials (177 participants) assessed the addition of manual therapy, prescribed exercises or both to glucocorticoid injection. Twenty-one trials without placebo control were susceptible to performance and detection bias as participants were not blinded to the intervention. Other biases included selection (nine trials, 39%, including two quasi-randomised), attrition (eight trials, 35%) and selective reporting (15 trials, 65%) biases. We report the results of the main comparisons. Manual therapy versus placebo manual therapy Low-certainty evidence, based upon a single trial (23 participants) and downgraded due to indirectness and imprecision, indicates manual therapy may reduce pain and elbow disability at the end of two to three weeks of treatment. Mean pain at the end of treatment was 4.1 points with placebo (0 to 10 scale) and 2.0 points with manual therapy, MD -2.1 points (95% CI -4.2 to -0.1). Mean disability was 40 points with placebo (0 to 100 scale) and 15 points with manual therapy, MD -25 points (95% CI -43 to -7). There was no follow-up beyond the end of treatment to show if these effects were sustained, and no other major outcomes were reported. Manual therapy, prescribed exercises or both versus minimal intervention Low-certainty evidence indicates manual therapy, prescribed exercises or both may slightly reduce pain and disability at the end of treatment, but the effects were not sustained, and there may be little to no improvement in health-related quality of life or number of participants reporting treatment success. We downgraded the evidence due to increased risk of performance bias and detection bias across all the trials, and indirectness due to the multimodal nature of the interventions included in the trials. At four weeks to three months, mean pain was 5.10 points with minimal treatment and manual therapy, prescribed exercises or both reduced pain by a MD of -0.53 points (95% CI -0.92 to -0.14, I2 = 43%; 12 trials, 1023 participants). At four weeks to three months, mean disability was 63.8 points with minimal or no treatment and manual therapy, prescribed exercises or both reduced disability by a MD of -5.00 points (95% CI -9.22 to -0.77, I2 = 63%; 10 trials, 732 participants). At four weeks to three months, mean quality of life was 73.04 points with minimal treatment on a 0 to 100 scale and prescribed exercises reduced quality of life by a MD of -5.58 points (95% CI -10.29 to -0.99; 2 trials, 113 participants). Treatment success was reported by 42% of participants with minimal or no treatment and 57.1% of participants with manual therapy, prescribed exercises or both, RR 1.36 (95% CI 0.96 to 1.93, I2 = 73%; 6 trials, 770 participants). We are uncertain if manual therapy, prescribed exercises or both results in more withdrawals or adverse events. There were 83/566 participant withdrawals (147 per 1000) from the minimal or no intervention group, and 77/581 (126 per 1000) from the manual therapy, prescribed exercises or both groups, RR 0.86 (95% CI 0.66 to 1.12, I2 = 0%; 12 trials). Adverse events were mild and transient and included pain, bruising and gastrointestinal events, and no serious adverse events were reported. Adverse events were reported by 19/224 (85 per 1000) in the minimal treatment group and 70/233 (313 per 1000) in the manual therapy, prescribed exercises or both groups, RR 3.69 (95% CI 0.98 to 13.97, I2 = 72%; 6 trials).

AUTHORS' CONCLUSIONS

Low-certainty evidence from a single trial in people with lateral elbow pain indicates that, compared with placebo, manual therapy may provide a clinically worthwhile benefit in terms of pain and disability at the end of treatment, although the 95% confidence interval also includes both an important improvement and no improvement, and the longer-term outcomes are unknown. Low-certainty evidence from 12 trials indicates that manual therapy and exercise may slightly reduce pain and disability at the end of treatment, but this may not be clinically worthwhile and these benefits are not sustained. While pain after treatment was an adverse event from manual therapy, the number of events was too small to be certain.

Treating Lateral Epicondylopathy With Dry Needling and Exercise: A Case Series

CONTEXT

Lateral epicondylopathy (LE) is a common overuse injury affecting elbow, wrist, and hand function. It is characterized by weakness and pain in the muscles and tendons of the forearm responsible for the extension of your wrist and fingers. Trigger point dry needling is a technique reported to be beneficial in managing pain and dysfunction after LE diagnosis. LE is also commonly treated with conservative treatment, such as joint and soft tissue mobilization, self-care home programs, and anti-inflammatory use. We explored a different dry needling approach consisting of in situ dry needling with electric stimulation combined with targeted therapeutic exercise to treat LE in 3 cases.

CASE PRESENTATION

Three patients were referred for dry needling once a week for 6 weeks and home-based exercise therapy for LE. They were clinically evaluated using grip strength, a visual analog scale to assess pain, and Patient-Rated Tennis Elbow Evaluation Test scores. These were measured at 4 time points (weeks 0, 2, 4, and 6).

MANAGEMENT AND OUTCOMES

The dry needling intervention incorporated 8 locations in the upper-extremity with 2 electric stimulation channels. The patients had reduced pain as measured by a visual analog scale, increased function as measured by the Patient-Rated Tennis Elbow Evaluation Test, and increased grip strength over 6 weeks.

CONCLUSIONS

This case series illustrates the use of dry needling and a home exercise program to provide a favorable outcome in a patient with LE. Patients had an 80% to 100% reduction in pain and similar improvements in function that were significantly beyond the minimum clinically important difference. This dry needling approach is a safe and effective treatment of LE in the short term.

Comparison of Interventions for Lateral Elbow Tendinopathy: A Systematic Review and Network Meta-Analysis for Patient-Rated Tennis Elbow Evaluation Pain Outcome

PURPOSE

There is controversy regarding the optimal treatment for lateral elbow tendinopathy (LET), and not all available treatment options have been compared directly with placebo/control. A network meta-analysis was conducted to compare the effectiveness of different LET treatments directly and indirectly against control/placebo based on a validated outcome, the Patient-Rated Tennis Elbow Evaluation (PRTEE) pain score.

METHODS

Randomized, controlled trials comparing different treatment methods for LET were included, provided they reported outcome data using the PRTEE pain score. A network meta-analysis with random effect was used to combine direct and indirect evidence between treatments compared with placebo in the short term (up to six weeks) and midterm (more than six weeks and up to six months) after intervention.

RESULTS

Thirteen studies with 12 comparators including control/placebo were eligible. The results indicated no significant improvement in PRTEE pain score in the short term across all treatments compared with control/placebo. In the midterm, physiotherapy/exercise showed benefit against placebo (mean difference: -4.32, 95% confidence interval: -7.58 and -1.07). Although steroid injections, dry needling, and autologous blood also exhibited potential treatment effects, it is crucial for the clinician to consider certain pitfalls when considering these treatments. The limited number of small studies and paucity of data call for caution in interpreting the results and need for further evidence.

CONCLUSIONS

Patients should be informed that there is currently no strong evidence that any treatment produces more rapid improvement in pain symptoms when compared with control/placebo in the short and medium terms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

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.

Demonstrating the relationship of ultrasonographic parameters with disease activity and pain in lateral epicondylitis

To evaluate the relationship of ultrasonographic evaluation parameters with pain, muscle strength and disease severity in lateral epicondylitis (LE). 64 people were included in present retrospective, cross-sectional study. Activity and rest pain was questioned with Visual Analog Scale (VAS). Also, Patient Rated Tennis Elbow Evaluation (PRTEE) and the maximum grip strength were evaluated. Hypoechoic region, neovascularity, cortical irregularity, enthesopathy and peritendinous fluid or bursitis were evaluated by ultrasonography. 48 of the patients were female and 16 were male. Mean age was 48.53 ± 6.12, body mass index was 27.70 ± 4.75. 55 (85.9%) hypoechoic region, 31 (48.4%) neovascularity, 21 (32.8%) cortical irregularity, 19 (29,7%) enthesopathy, and 18 (28.1%) peritendinous fluid or bursitis were detected by ultrasonography. When the ultrasonographic findings and clinical findings of the patients were compared, no significant difference was found between the hypoechoic region, cortical irregularity, enthesopathy and clinical findings (P > .05), while the extension grip strength was found to be significantly lower in patients with neovascularity (P = .045). In addition, patients with peritendinous fluid or bursitis, were found to be significantly lower in both flexion (P = .033) and extension (P = .023) grip strength, while PRTEE function (P = .021) subgroup and total (P = .038) scores were significantly higher. Hypoechoic region, cortical irregularities and enthesopathy were not evaluated to be associated with disease severity, pain and muscle strength. Neovascularity was found to be associated only with extension grip strength. Peritendinous fluid or bursitis was found to be associated with both flexion and extension grip strength and disease activity, but not associated with pain.

Chronic lateral elbow tendinopathy with a supervised graded exercise protocol

STUDY DESIGN

Prospective Case Series.

BACKGROUND

Variety of studies inquired the effectiveness of exercise treatment in LET (Lateral Elbow Tendinopathy). The research on the effectiveness of these approaches are still ongoing and very much needed due to the uncertainty of the subject.

PURPOSE

We aimed to understand how the application of exercises in a graded manner affect the treatment outcomes in terms of pain and function.

METHODS

This study is completed by 28 patients with LET and it was planned as a prospective case series. Thirty participants were included to participate in the exercise group. Basic Exercises (Grade 1) were performed for four weeks. Advanced Exercises (Grade 2) were performed for another four weeks. The VAS (Visual Analog Scale), pressure algometer, the PRTEE (Patient-Rated Tennis Elbow Evaluation) and a grip strength dynamometer were used to measure outcomes. The measurements were performed at baseline, at the end of four weeks and at the end of eight weeks.

RESULTS

Investigation of the pain scores revealed that all VAS scores (p < 0.05, ES = 1.35; 0.72; 0,73 activity, rest, and night respectively) and pressure algometer results were improved both during basic (p < 0.05, ES = 0.91) and advanced exercises (p < 0.05, ES = 0,41). PRTEE scores were found to be improved in patients with LET after basic and advanced exercises (p > 0.001, ES = 1.15; p > 0.001, ES = 1.56 respectively). The grip strength only changed after basic exercises (p = 0.003, ES = 0.56).

CONCLUSIONS

The basic exercises were beneficial for both pain and function. However, advanced exercises are required for obtaining further improvements in terms of pain, function, and grip strength.

Effect of premodulated interferential current versus diadynamic current on the management of lateral elbow tendinopathy

Study aim: To compare the effect of premodulated interferential current (PREMOD IFC) and diadynamic current (DD) with exercise training on the management of lateral elbow tendinopathy (LET).

Material and methods: One hundred and four patients with unilateral LET from both genders (55 females and 49 males) were randomly allocated into two groups. Group A received PREMOD IFC in addition to the exercises, and group B received DD with the same exercises. The outcomes were maximum grip strength assessed by the hand dynamometer, the pinch strength assessed by the pinch gauge dynamometer, and pain and functional disability of the forearm assessed by a patient-rated tennis elbow evaluation (PRTEE) questionnaire. All participants received electrical stimulation, consisting of three sessions per week for six weeks.

Results: The mean PRTEE score, and grip strength were significantly improved after six weeks in favour of group A, while there was no significant difference between the two groups in pinch strength. (p < 0.05).

Conclusion: The results revealed that the combination of PREMOD IFC with exercises could improve pain, functional disability, and grip strength compared to DD with exercises in LET patients without a significant difference between the two groups in pinch strength.

Lateral Elbow Pain and Muscle Function Impairments

Although often described as a self-limiting condition and likely to resolve on its own, high recurrence rates and extended sick leave frame a need for effective non-surgical treatment for people with lateral elbow tendinopathy. The interrelationship of histological and structural changes to the tendon, the associated impairments in motor control, and potential changes in pain processing may all drive symptoms. This clinical practice guideline covers the epidemiology, functional anatomy and pathophysiology, risk factors, clinical course, prognosis, differential diagnosis, tests and measures, and interventions for managing lateral elbow tendinopathy in the physical therapy clinic. J Orthop Sports Phys Ther 2022;52(12):CPG1-CPG111. doi:10.2519/jospt.2022.0302.

A randomized controlled trial on pain, grip strength, and functionality in lateral elbow pain: Mulligan vs muscle energy techniques

BACKGROUND

Lateral elbow tendinopathy (LET) is one of the most common lesions of the upper extremity. The level of evidence from studies on LET treatment protocols is insufficient.

OBJECTIVE

The aim of this study was to compare the acute effects of mobilization with movement (MWM) and muscle energy technique (MET) on pain, grip strength, and functionality in patients diagnosed with LET.

METHODS

Forty-five patients with LET aged 30-55 years were enrolled in this study. Patients were divided into three groups: MWM, MET, and control group. The control group received a 4-week home exercise program. In addition to the home exercise program in the MWM group, 12 sessions of MWM and 12 sessions of MET were performed in the MET group. Participants' pain, grip strength, and functionality were assessed before and after the study.

RESULTS

After the treatment period, greater improvement in pain, grip strength, finger strength, and functionality were observed in the MWM and MET groups than in the control group (p< 0.05), but no statistically significant difference was found between the MWM and MET groups (p> 0.05).

CONCLUSIONS

This study shows that MWM and MET, used in addition to home exercises, can be used to relieve pain and increase grip strength, finger strength, and functionality.

Comparison of the effectiveness of peloid therapy and kinesio taping in tennis elbow patients: a single-blind controlled study

This study aimed to compare the peloid therapy and kinesio tape treatments in chronic lateral epicondylitis. While home exercise program and cold application were applied to the control group, peloid therapy (5 days a week for 3 weeks at 45 °C for 30 min each day, a total of 15 treatment days) was applied in addition to the first group, and kinesio taping (6 treatment days 2 times a week) was applied to the second group. Patients were evaluated with visual analog scale (VAS), grip strength with Jamar hydraulic dynamometer, Arm, Shoulder, and Hand Disabilities (DASH), quality of life in Short Form-36 (SF-36), and Patient-Rated Forearm Evaluation Questionnaire (PRFEQ) was recorded before treatment, after treatment (third week), and 1 month after the end of treatment. In this study, 156 patients with chronic lateral epicondylitis were included. In the follow-up of the patients, there was a statistically significant improvement in the hand grip strength, DASH, PRFEQ, VAS, and SF-36 scores in the 1st month follow-up after the treatment compared to the pre-treatment control in all groups (p < 0.001). At the end of the treatment, the hand grip strength (p = 0.002), DASH (p < 0.001), PRFEQ pain (p < 0.001) and function (p = 0.007), SF-36 physical health (p = 0.002) scores were statistically significant in the peloid therapy group compared to the control group. At the 1st month after the end of treatment, hand grip strength, VAS, DASH, PRFEQ pain, function, daily activities, and SF-36 physical health scores (all of p < 0.001) were statistically significant in the peloid treatment group compared to the control group. Peloid treatment was found to be more effective than kinesio taping in SF-36 physical health (p = 0.007) and PRFEQ pain (p = 0.003) scores in the 1st month follow-up after treatment. Peloid therapy in addition to exercise seems more effective in chronic lateral epicondylitis. Randomized controlled long-term studies are needed.ClinicalTrials ID: NCT04687943.

Lateral Ulnar Collateral Ligament Reconstruction for Posterolateral Rotatory Instability After Failed Common Extensor Origin Release: Outcomes at Minimum 2-Year Follow-up

Background:

In patients with chronic lateral epicondylitis who have failed nonoperative treatment, open or percutaneous release of the common extensor origin (CEO) without subsequent reconstruction tends to result in good clinical outcomes. However, surgery can lead to iatrogenic injuries of the lateral collateral ligamentous complex, causing posterolateral rotatory instability (PLRI).

Purpose:

To determine the clinical outcomes of lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon graft after failed open CEO surgery.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 103, patients underwent revision surgery at a single institution because of PLRI after failed open release of the CEO (Hohmann procedure) between January 2007 and October 2016. The primary surgery had been performed at other institutions in all cases. Of these patients, 72 were available for follow-up (49 by clinical examination, 23 by telephone interview). Standardized clinical examination; Mayo Elbow Performance Score (MEPS); 11-item version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH); subjective elbow value (SEV); and patient satisfaction were assessed at least 2 years after LUCL reconstruction.

Results:

The mean age of patients in the study was 46.9 years (range, 21-74 years), and the mean follow-up was 2.8 years after revision surgery. The mean MEPS was 78.9, and the mean QuickDASH score reached 20.4. The mean SEV was 78.6%, and 75% of the patients rated the surgery as good to excellent. Complications were detected in 14% of the patients, and 9 needed revision surgery, primarily owing to graft failure with recurrent instability (n = 5).

Conclusion:

LUCL reconstruction in patients with PLRI after release of the CEO can restore elbow stability and achieve high patient satisfaction. However, outcome scores and revision rates in this cohort were inferior to published outcomes of primary LUCL reconstruction for treatment of noniatrogenic or traumatic PLRI.

Pain-free grip strength in individuals with lateral elbow tendinopathy: Between- and within-session reliability of one versus three trials

BACKGROUND

Pain-free grip strength is an important outcome measure in lateral elbow tendinopathy (LET); yet, the reliability and minimum detectable change (MDC) in functional positions are unknown.

PURPOSE

The purpose of this study is to examine the between- and within-session pain-free grip strength reliability and MDC in LET.

METHODS

Twenty-three individuals with LET completed three pain-free grip strength trials with the elbow flexed and extended. The first trial and the mean of three trials were analyzed. Between-session data were collected 2-28 days apart. Within-session data were collected 20-30 min apart.

RESULTS

Between-session intraclass correlation coefficients (ICCs) were good (ICC_2,1 = 0.75) for single trials (flexed), excellent (ICC_2,1 = 0.89-0.94) for single trials (extended), and excellent for the mean of three trials (both positions). Within-session ICCs were excellent for single (ICC_2,1 = 0.89-0.91) and the mean of three trials (ICC_2,3 = 0.96-0.98) in both positions. Between-session flexed MDCs were 133 N (single) versus 90 N (mean) and extended MDCs were 118 N (single) versus 92 N (mean). Within-session flexed MDCs were 79 N (single) versus 52 N (mean) and extended MDCs were 125 N (single) versus 46 N (mean).

CONCLUSIONS

Using the mean of three trials is recommended, and clinicians can be confident of true change if between-session differences are >92 N and within-session differences are >52 N.

Cross-cultural adaptation of the Activities of Daily Living Questionnaire-Brazil in Parkinson's disease

BACKGROUND

Culturally adapted measures to assess the performance of activities of daily living (ADL) in individuals with Parkinson's disease (PD) are limited in Brazil.

OBJECTIVE

To adapt the ADL Questionnaire to the Brazilian culture and to analyze its reproducibility in individuals with PD.

METHODS

The ADL Questionnaire was translated and cross-culturally adapted to Brazilian Portuguese language. Reproducibility was analyzed using test-retest reliability and agreement values. The test-retest reliability of the individual items and total scores were calculated. The limits of agreement were verified using the Bland-Altman plot. The standard error of measurement (SEM) and the minimum detectable change (MDC) were calculated. Patients who were classified on a score of 1-4 on the modified Hoehn and Yahr scale were eligible.

RESULTS

No divergence was identified between the original and the adapted version, which demonstrated adequate semantic and conceptual equivalence. The Bland-Altman plot showed no systematic changes in the mean test-retest scores. The intraclass correlation coefficient (ICC) was 0.98 (95% confidence interval [95%CI] 0.93-0.99), and all individual items showed good levels of reliability (>0.60). The SEM (SEM%) and MDC (MDC%) values were 3.0 (6.75%) and 8.2 (18.7%), respectively. These values are within the recommended values.

CONCLUSIONS

The ADL-Brazil Questionnaire is a reliable instrument to be used for clinical and research purposes to assess self-perceptions of ADL performance in individuals with PD.

Test-retest reliability and measurement error of the modified gait efficacy scale in individuals with stroke

PURPOSE

To investigate the test-retest reliability and measurement error of the Brazilian version of the modified Gait Efficacy scale (mGES-Brazil) in individuals who have had stroke.

METHODS

The mGES-Brazil was applied on two occasions, five to seven days apart, in a research laboratory setting. Test-retest reliability and measurement error, which included the standard error of measurement (SEM), smallest detectable change (SDC), and analysis of the limits of agreement by the Bland-Altman plots, were examined.

RESULTS

Fifty individuals who have had stroke (18 men), with a mean age of 64 ± 11 years, were evaluated. All individual items showed good reliability (Intra-class Correlation Coefficient - ICC_2,1 > 0.90). The ICC was 0.98 (95% CI 0.97 to 0.99) and the Bland and Altman plots revealed no systematic changes in the mean test-retest scores. The SEM (SEM%) was 3 (5%), within the recommended values, while the SDC was 8 points.

CONCLUSION

The mGES-Brazil demonstrated to be reliable to be applied within clinical and research contexts for the assessment of changes in walking confidence of individuals who have had stroke. Changes in mGES scores ≥8 points reflect real changes.

Psychometric properties and cross-cultural adaptation of the Patient-Rated Tennis Elbow Evaluation (PRTEE); a systematic review and meta-analysis

PURPOSE

To synthesize and appraise the evidence on the translation, cross-cultural adaptation, and psychometric properties of the Patient-Rated Tennis Elbow Evaluation (PRTEE).

METHOD

Five electronic databases were searched from 1999 to 2021. Two independent reviewers assessed the risk of bias and quality of the included studies using the COSMIN recommended guidelines. The overall quality of the evidence on each psychometric property was provided using the GRADE approach.

RESULTS

Twenty-one studies met the criteria for inclusion in this review. The PRTEE was translated and cross-culturally adapted to 13 languages and cultures. High quality of evidence supports sufficient pooled results for test-retest reliability (0.96(CI: 0.94-0.97)), construct validity (against Disabilities of the Arm, Shoulder, and Hand (DASH): 0.81(CI: 0.76-0.85), against Visual Analogue Scale (VAS): 0.70 (0.62-0.74)), and responsiveness of the PRTEE. The overall rating of the structural validity and internal consistency (0.96(CI: 0.94-0.97)) was indeterminate, and the quality of evidence was low and moderate, respectively. Regarding measurement error, the overall rating of the summarized results (Standard error of measurement (SEM): 3.1 (1.8 to 4.4) and Minimal Detectable Change (MDC₉₅): 8.9 (5.3-12.5)) was sufficient, and the quality of evidence was moderate.

CONCLUSION

Moderate to high quality evidence supports adequate psychometric properties of the PRTEE in terms of internal consistency, test-retest reliability, measurement error, hypothesis testing for construct validity, and responsiveness.Implications for RehabilitationThe PRTEE can measure the construct of pain and disability at a single time-point and detect changes over time precisely.The PRTEE can be used in clinical setting for patients with acute, subacute, and chronic Lateral Elbow Tendinopathy (LET), athletes who suffer from elbow pain and tennis players.

The patient-rated tennis elbow evaluation questionnaire was successfully translated to Korean

INTRODUCTION

Lateral epicondylitis is a common tendinopathy of the elbow. An adequately validated questionnaire is essential to compare the various treatment options, because there is still controversy regarding the best treatment for lateral epicondylitis.

PURPOSE OF THE STUDY

The patient-rated tennis elbow evaluation (PRTEE) was introduced to measure the degree of symptoms and the limitation of function in these patients. This English questionnaire was previously translated into several languages and validated; however, it has not been translated into Korean. The aim of this study was to translate and cross-culturally adapt the PRTEE questionnaire into Korean, and to assess the reliability and validity of the translated questionnaire.

METHODS

Eighty-three patients were asked to complete the Korean version of the PRTEE and other questionnaires related to the upper extremity or to the general health condition (the Disabilities of Arm, Shoulder, and Hand questionnaire, Short Form-12, and EQ-5D). The PRTEE responses were recorded twice to evaluate test-retest reliability. Internal consistency, test-retest reliability, concurrent validity, and ceiling and flooring effects were evaluated.

RESULTS

The Korean version of the PRTEE showed high internal consistency (Cronbach's alpha = 0.968). The overall test-retest reliability was good (intra-class correlation score = 0.94). High correlation efficiencies between the PRTEE and other questionnaires were observed, supporting high concurrent validity (Spearman's correlation = 0.83 for the Disabilities of Arm, Shoulder, and Hand questionnaire; -0.73 for Short Form-12; and -0.57 for EQ-5D). Ceiling and floor effects were not observed on this test.

CONCLUSION

We successfully translated the PRTEE into the Korean language; this version of the PRTEE showed good reliability and construct validity in Korean-speaking patients with lateral epicondylitis.

Clinical effectiveness of shockwave therapy in lateral elbow tendinopathy: systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of extracorporeal shockwave therapy compared with other interventions on pain, grip strength and disability in patients with lateral elbow tendinopathy.

DATA SOURCES

MEDLINE, PubMed, CINAHL, EMBASE, PEDro, ScienceDirect, Cochrane Library and clinical trial registries.

REVIEW METHODS

We included randomized controlled trials assessing the effectiveness of extracorporeal shockwave therapy alone or as an additive intervention compared with sham or other interventions. Pain intensity, grip strength and elbow disability were used as primary outcome measures. We assessed methodological quality with the PEDro score and quality of evidence with the GRADE approach.

RESULTS

Twenty-seven studies with 1871 patients were finally included. Extracorporeal shockwave therapy reduced pain intensity at mid-term follow-up (standardized mean difference: -1.21, 95% confidence interval:-1.53, -0.89, P < 0.001) and improved grip strength at very short- (mean difference:3.92, 95% confidence interval: 0.91, 6.94, P = 0.01) and short-term follow-up (mean difference:4.87, 95% confidence interval:2.24, 7.50, P < 0.001) compared with sham treatment. However, no clinically significant results were found between comparators in all outcomes and follow-up times. Extracorporeal shockwave therapy presented clinically better compared to Laser in grip strength at short-term (mean difference:3.50, 95% confidence interval:2.40, 4.60, P < 0.001) and ultrasound in pain intensity at very-short-term follow-up (standardized mean difference: -1.54, 95% confidence interval: -2.60, -0.48, P = 0.005).

CONCLUSION

Low to moderate certainty of evidence suggests that there are no clinical benefits of extracorporeal shockwave therapy compared to sham interventions or corticosteroid injections. Based on very-low and moderate certainty of evidence, extracorporeal shockwave therapy outperforms against Laser and ultrasound, respectively.Level of Evidence: Therapy, level 1a.

Comparing the efficacy of continuous and pulsed ultrasound therapies in patients with lateral epicondylitis: A double-blind, randomized, placebo-controlled study

Objectives

The aim of this study was to investigate the efficacy of continuous and pulsed ultrasound therapies in lateral epicondylitis.

Patients and methods

A total of 51 patients (18 males, 33 females; mean age: 46.52±6.16 years; range, 27 to 64 years) who were diagnosed with lateral epicondylitis between February 2013 and October 2014 were included. The patients were randomized to either continuous ultrasound (n=17), pulsed ultrasound (n=17), or placebo (n=17) groups. First group received 10 sessions of continuous ultrasound therapy. The second group received 10 sessions of pulsed ultrasound therapy in a ratio of 1:4. The third group received 10 sessions of placebo treatment. The pain levels of the patients were evaluated using Visual Analog Scale (VAS). The muscle strength was evaluated using a dynamometer. For functional evaluation, Duruöz’s Hand Index (DHI) and Patient-Rated Tennis Elbow Evaluation (PRTEE) scales were used. Assessments were made at baseline, at the end of therapy, and one month after therapy. The thickness of the common extensor tendon was also measured using ultrasonic imaging at baseline and at the end of therapy.

Results

At the end of the study, there was a statistically significant improvement in the rest and activation VAS scores, and DHI and PRTEE scores in both continuous and pulsed ultrasound therapy groups, compared to placebo (p<0.05). However, no superiority was found between the continuous and pulsed ultrasound therapy groups (p>0.05). A statistically significant reduction in the common extensor tendon thickness was found only in the pulsed ultrasound therapy group (p<0.05).

Conclusion

Our study results show that both continuous and pulsed ultrasound applications are effective in the treatment of lateral epicondylitis.

The Effect of Scapular Muscle Strengthening on Functional Recovery in Patients With Lateral Elbow Tendinopathy: A Pilot Randomized Controlled Trial

CONTEXT

There is a lack of consensus on the best management approach for lateral elbow tendinopathy (LET). Recently, scapular stabilizer strength impairments have been found in individuals with LET.

OBJECTIVE

The purpose of this study was to compare the effectiveness of local therapy (LT) treatment to LT treatment plus a scapular muscle-strengthening (LT + SMS) program in patients diagnosed with LET.

DESIGN

Prospective randomized clinical trial.

SETTING

Multisite outpatient physical therapy.

PATIENTS

Thirty-two individuals with LET who met the criteria were randomized to LT or LT + SMS.

INTERVENTIONS

Both groups received education, a nonarticulating forearm orthosis, therapeutic exercise, manual therapy, and thermal modalities as needed. Additionally, the LT + SMS group received SMS exercises.

MAIN OUTCOME MEASURE

The primary outcome measure was the patient-rated tennis elbow evaluation; secondary outcomes included global rating of change (GROC), grip strength, and periscapular muscle strength. Outcomes were reassessed at discharge, 6, and 12 months from discharge. Linear mixed-effect models were used to analyze the differences between groups over time for each outcome measure.

RESULTS

The average duration of symptoms was 10.2 (16.1) months, and the average total number of visits was 8.0 (2.2) for both groups. There were no significant differences in gender, age, average visits, weight, or height between groups at baseline (P > .05). No statistical between-group differences were found for any of the outcome measures. There were significant within-group improvements in all outcome measures from baseline to all follow-up points (P < .05).

CONCLUSION

The results of this pilot study suggest that both treatment approaches were equally effective in reducing pain, improving function, and increasing grip strength at discharge as well as the 6- and 12-month follow-ups. Our multimodal treatment programs were effective at reducing pain and improving function up to 1 year after treatment in a general population of individuals with LET.

Adaptation and transcultural translation into Spanish of the Patient-Rated Tennis Elbow Evaluation Questionnaire

The purpose of this study was to perform the translation and cross-cultural adaptation of the Patient-Rated Tennis Elbow Evaluation Questionnaire to Spanish language and evaluate its reliability and validity. The translation and cultural adaptation into Spanish was done in accordance with the published guidelines. One-hundred fifty Spanish-speaking patients with unilateral chronic lateral epicondylalgia competed the questionnaire. Test-retest reliability was established by the intraclass correlation coefficient. Internal consistency was established with Cronbach's α. To establish convergent validity, we used the Disabilities of the Arm, Shoulder, and Hand Questionnaire using the Spearman's correlation coefficient. Error estimation in the measurements was calculated with the standard error of measurement. Our results showed a high internal consistency (Cronbach's α = .96) and high test-retest reliability (intraclass coefficient = .9; .89-.94; P < .001). The Spearman's correlation coefficient (r = .765; P < .001) showed a good relationship between the Spanish version of the Patient-Rated Tennis Elbow Evaluation Questionnaire and the Disabilities of the Arm, Shoulder, and Hand Questionnaire. The standard error of measurement (11.9%) showed little variability of measurements. In conclusion, the Spanish version of the Patient-Rated Tennis Elbow Evaluation Questionnaire is a valid and reliable tool that can be used to assess lateral epicondylalgia in Spanish-speaking individuals in order to implement the best treatment and reduce time with pain and disability.

Comparative Study between Scales: Subjective Elbow Value and Patient-rated Tennis Elbow Evaluation Applied to Patients Affected by Lateral Epicondylitis

Objective  To verify if the subjective elbow value (SEV) scale presents similar results to those of the Patient-rated Tennis Elbow Evaluation (PRTEE) scale in the evaluation of patients with lateral elbow epicondylitis (LEE).

Methods  Thirty-seven patients were diagnosed with LEE in the outpatient service of our hospital through clinical history, physical examination, X-ray, and ultrasonography. The SEV and PRTEE scales were used and their results were compared using a significance level ≥ 5% ( p ≥0.05).

Results  A statistically significant relationship was found between the values of SEV and PRTEE in the group of patients studied ( p  = 0.017).

Conclusion  Subjective elbow value presented similar results to PRTEE in the evaluation of patients with diagnosis of LEE.

Physical therapy for tendinopathy: An umbrella review of systematic reviews and meta-analyses

OBJECTIVE

To summarize evidence in the last decade regarding the efficacy of physical therapy interventions to treat tendinopathy, as a single disease entity, as determined in systematic reviews (SRs) and/or meta-analyses (MAs).

METHODS

Electronic search of PubMed, PEDro, and Scopus database was performed from year 2010 to January 2020. The methodological quality of the identified studies was assessed using the AMSTAR 2 tool. Studies scoring 9 points or higher were further analyzed using GRADE principles.

RESULTS

40 SRs and/or MAs were included in qualitative synthesis, whereas only 5 MAs were included in quantitative synthesis. Low-level laser therapy (LLLT) intervention showed a pooled improvement in pain reduction of 1.53 cm; 95% CI, [1.14, 1.91] (I² = 1.9%, p = 0.361) on visual analogue scale, and grip strength of 9.59 kg; 95% CI, [5.90, 13.27].

CONCLUSIONS

Moderate-quality evidence may support these following interventions: LLLT revealed a statistically and potentially clinically significant improvement in pain and function on the short-term. Extracorporeal shockwave therapy showed a statistically significant enhancement in pain and function at all follow-up durations; however, its clinical significance was undetermined. Eccentric exercise was supported by qualitative evidence only. Caution is advised when interpreting results due to possible pathological differences in tendinopathy at each region.

The Association Between Conditioned Pain Modulation and Manipulation-induced Analgesia in People With Lateral Epicondylalgia

OBJECTIVES

Conditioned pain modulation (CPM) and manipulation-induced analgesia (MIA) may activate similar neurophysiological mechanisms to mediate their analgesic effects. This study assessed the association between CPM and MIA responses in people with lateral epicondylalgia.

MATERIALS AND METHODS

Seventy participants with lateral epicondylalgia were assessed for CPM followed by MIA. A single assessor measured pressure pain thresholds (PPT) before, during, and after cold water immersion (10°C) of the asymptomatic hand and contralateral lateral glide (CLG) mobilization of the neck. For analyses, linear mixed models evaluated differences in CPM and MIA responses. Pearson partial correlations and regression analyses evaluated the association between CPM and MIA PPT.

RESULTS

There was a significant increase (CPM and MIA, P<0.001) in PPT from baseline during the interventions (CPM mean: 195.84 kPa for elbow and 201.87 kPa for wrist, MIA mean: 123.01 kPa for elbow and 126.06 kPa for wrist) and after the interventions (CPM mean: 126.06 kPa for elbow, 114.24 kPa for wrist, MIA mean: 123.50 kPa for elbow and 122.16 kPa for wrist). There were also significant moderate and positive partial linear correlations (r: 0.40 to 0.54, P<0.001) between CPM and MIA measures, controlling for baseline measures. Regression analyses showed that CPM PPT was a significant predictor of MIA PPT (P<0.001) and the models explained between 73% and 85% of the variance in MIA PPT.

DISCUSSION

This study showed that CPM and MIA responses were significantly correlated and that the CPM response was a significant predictor of MIA response.

Extracorporeal Shock Wave Therapy for Lateral Epicondylitis, Lonely or in Combination with Topical Corticosteroid; Which Approach is Superior?

Background

Lateral epicondylitis (LE) is a common musculoskeletal disorder. Although varieties of modalities have been proposed for its treatment, the outcomes are uncertain, and the responses would diminish early by the time passage. The current study was aimed to assess the efficacy of extracorporeal shock wave therapy (ESWT) merely and in combination with topical corticosteroid for the treatment of LE.

Materials and Methods

In the current double-blinded randomized clinical trial, 70 patients with the diagnosis of LE were randomly allocated to two intervention groups of ESWT merely (control group) (n=35) or ESWT plus topical corticosteroid (intervention group) (n=35). The ESWT was performed weekly for three weeks. Topical clobetasol was utilized within 30 minutes before ESWT for the intervention group, while Vaseline gel was used in a similar pattern for controls. Pain based on a visual analog scale (VAS), handgrip strength (HGS) and the Patient-Rated Tennis Elbow Evaluation (PRTEE) were assessed for the patients before the intervention, following the intervention cessation, and within two months post-intervention.

Results

Statistically significant improvement was found following both interventions in terms of pain, HGS, and function (P-value<0.001 for all), while the comparison of the two interventions, ESWT, merely versus in combination with topical clobetasol, revealed insignificant difference (P-value>0.05).

Conclusion

The findings of our study are in favor of ESWT use either merely or in combination with topical steroids for the treatment of LE, while the comparison of the two techniques revealed insignificant differences.

Patient-Rated Tennis Elbow Evaluation (PRTEE)

BACKGROUND

The Patient-Rated Tennis Elbow Evaluation questionnaire (PRTEE) is a specific questionnaire available for assessing the health status of patients with lateral epicondylitis. An official German translation does not yet exist.

OBJECTIVES

The aim of this study was to translate and cross-culturally adapt the English version of the PRTEE into German.

MATERIAL AND METHODS

The translation and cross-cultural adaptation was completed by an expert committee comprising people of varying professional and linguistic backgrounds. According to international guidelines, the English original was first translated into German, then back-translated and the final version was pre-tested on patients.

RESULTS

No major difficulties were encountered during the translation process and smaller linguistic discrepancies could be resolved in the expert committee. For the pre-validation testing, 11 patients with extensor repair due to persistent lateral epicondylitis were included. They rated the questionnaire as easy to understand and complete. The final version was approved by the developers of the original questionnaire as the official German translation.

CONCLUSIONS

Although the measurement properties of the German version were not evaluated in this study, the original shows good reliability, validity and responsiveness. In summary, the PRTEE is a questionnaire quick and easy to complete for patients with lateral epicondylitis. Therefore, it is suitable for the clinical routine assessment of subjective health status or the outcome after an intervention.

The short-term effectiveness of low-level laser, phonophoresis, and iontophoresis in patients with lateral epicondylosis

STUDY DESIGN

Randomized parallel group trial.

INTRODUCTION

Various treatment options for lateral epicondylosis have been reported in the literature.

PURPOSE OF STUDY

We aimed to compare the effectiveness of low-level laser therapy (LLLT), phonophoresis, and iontophoresis in terms of pain, function, and grip strength.

METHODS

This study that comprised 37 patients with lateral epicondylosis was planned as a prospective randomized parallel group trial. Twelve participants were randomized to the LLLT group, 12 to the phonophoresis group, and 13 to the iontophoresis group. The Visual Analog Scale (VAS), pressure algometer, the Patient-Rated Tennis Elbow Evaluation, and grip strength dynamometer were used to measure outcomes. The measurements were performed at baseline and at the end of 15 sessions.

RESULTS

Investigation of the pain scores revealed that all VAS scores were improved in both the laser and iontophoresis groups (VAS at rest: P = .015, effect size (ES) = 1.49 and P = .016, ES = 0.58, respectively; VAS during activity: P = .008, ES = 1.05 and P = .008, ES = 1.16, respectively; VAS at night: P = .013, ES = 1.01 and P = .016, ES = 0.72, respectively). Only advance in function and grip strength was associated with the iontophoresis group (Patient-Rated Tennis Elbow Evaluation P = .006, ES = 0.78; grip strength with elbow extension P = .011, ES = 1.03; with elbow flexion P = .003, ES = 0.52).

DISCUSSION

The most effective approach could not be highlighted among the existing studies in the literature as they were applied in combination with other therapies.

CONCLUSION

In our study, we observed that LLLT provides a benefit only for pain, whereas iontophoresis is beneficial for both pain and function. If the effect size is evaluated, LLLT is more influential than iontophoresis for decreasing pain. However, when we compared phonophoresis and iontophoresis in terms of effectiveness, we found that iontophoresis has better effects for pain, function, and grip strength.

The search for translational pain outcomes to refine analgesic development: Where did we come from and where are we going?

Pain measures traditionally used in rodents record mere reflexes evoked by sensory stimuli; the results thus may not fully reflect the human pain phenotype. Alterations in physical and emotional functioning, pain-depressed behaviors and facial pain expressions were recently proposed as additional pain outcomes to provide a more accurate measure of clinical pain in rodents, and hence to potentially enhance analgesic drug development. We aimed to review how preclinical pain assessment has evolved since the development of the tail flick test in 1941, with a particular focus on a critical analysis of some nonstandard pain outcomes, and a consideration of how sex differences may affect the performance of these pain surrogates. We tracked original research articles in Medline for the following periods: 1973-1977, 1983-1987, 1993-1997, 2003-2007, and 2014-2018. We identified 606 research articles about alternative surrogate pain measures, 473 of which were published between 2014 and 2018. This indicates that preclinical pain assessment is moving toward the use of these measures, which may soon become standard procedures in preclinical pain laboratories.

Strength-Duration Curves of Radial Nerve in Patients With Lateral Elbow Pain

CONTEXT

Lateral epicondylalgia (LE) refers to a painful condition at or around the lateral epicondyle of the humerus. LE is one of the most common injuries of the elbow; however, the cause of the pathology is not clear. Patients often experience symptoms consistent with a radial nerve injury; however, data on the involvement of the radial nerve are needed.

OBJECTIVE

To analyze the relationship between electrophysiologic excitability and morphology of the radial nerve in patients with unilateral chronic LE.

DESIGN

Cross-sectional study.

SETTING

Department of Physiotherapy, University of Seville.

PATIENTS

A total of 56 elbows (28 right, 28 left) in 28 patients (12 females, 16 males; age 49 [7.37] y) were recruited by convenience sampling.

MAIN OUTCOME MEASURES

Strength-duration curves (chronaxia and accommodation index) and cross-sectional area (CSA) of the radial nerve were made in all participants. All parameters were compared between both limbs. Also, pain with palpation in the lateral epicondyle and functional pain of involved extremities was assessed using visual analog scale and the Patient-Rated Tennis Elbow Evaluation, respectively.

RESULTS

Symptomatic limb showed higher CSA values of the radial nerve when compared with the asymptomatic limb (P < .001). On the symptomatic limb, duration of symptoms was positively correlated with CSA values. Chronaxia values were all normal and similar between both limbs (P = .35). Regarding accommodation index, 14 (54%) patients showed accommodation indices that suggested pathological radial nerve on the right limb, 4 (14%) on the left limb, 5 (18%) on both limbs, and 4 (14%) had none of the affected nerves. Eight-six percent of patients showed accommodation indices that suggested pathological radial nerve, independently of symptomatic limb. In these cases, affected nerves had higher CSA than the unaffected nerve (P = .01). On the affected nerves, duration of symptoms was positively correlated with accommodation indices.

CONCLUSIONS

These findings suggest that patients with unilateral chronic LE show a decreased excitability in any radial nerve, independently of the symptomatic limb, and that pathological nerves have higher CSA than the nonpathological nerves.

Autologous US-guided PRP injection versus US-guided focal extracorporeal shock wave therapy for chronic lateral epicondylitis: A minimum of 2-year follow-up retrospective comparative study

PURPOSE

To compare the efficacy of two independent groups of patients treated with ultrasound (US)-guided extracorporeal shock wave (ESW) therapy and with US-guided injection of platelet-rich plasma (PRP) for chronic lateral epicondylitis (LE) with a minimum of 2-year follow-up.

METHODS

We retrospectively evaluated 63 patients treated for chronic LE (31 patients with autologous US-guided PRP injection and 32 patients with US-guided focal ESW therapy) from 2009 to 2014. All the patients were evaluated by means of Roles-Maudsley (RM) score, quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) score, visual analogic scale (VAS) and patient-rated tennis elbow evaluation (PRTEE) to retrospectively assess the pain relief, level of activity, the self-reported function and subjective satisfaction at minimum of 2-year follow-up.

RESULTS

Both US-guided autologous PRP injection and US-guided focal ESW administration proved effective in chronic LE with significant improvement in the QuickDASH, VAS, RM and PRTEE scores ( p < 0.0001). No adverse effects or complications were recorded in any groups. No differences were found in recurrence rate and final results of the QuickDASH, VAS, RM and PRTEE scores between the two groups ( p > 0.05). The mean time between treatment and symptom resolution was significantly shorter for the PRP treatment ( p = 0.0212); furthermore, the mean time to return to the normal activities was quicker for PRP group ( p = 0.0119).

CONCLUSION

Both PRP injection and ESW therapy are feasible and safe options for the treatment of chronic LE with low risk of complications and with good long-term follow-up results. US-guided PRP injection has quick efficacy when compared with US-guided focal ESW therapy.

Therapeutic effects of acupuncture plus fire needle versus acupuncture alone in lateral epicondylitis: A randomized case-control pilot study

BACKGROUND

The aim of this study was to compare the short-term and intermediate-term efficacy of acupuncture plus fire needle therapy with that of acupuncture alone in the treatment of lateral epicondylitis (LE).

METHODS

Thirty-eight patients with LE who had persisted for at least 2 months were enrolled in this prospective, assessor-blinded, randomized controlled pilot trial. Twenty-one patients were randomized to the acupuncture plus fire needle group and 17 to the acupuncture-only group. The primary outcome was the visual analog scale pain score for the previous 24 hours and the secondary outcomes were the maximum grip strength, Patient-rated Forearm Evaluation Questionnaire score, and Medical Outcomes Study 36-Item Short-form Health Survey score. The values at baseline (pretreatment), at the end of treatment, and at 3 months after treatment were used to assess the short-term and intermediate-term effects of treatment. The data were analyzed using the Chi-square test and t test.

RESULTS

Within-group analyses showed better results for acupuncture plus fire needle therapy in the short term and intermediate term. Differences in the severity of pain and secondary outcomes were significant in the intermediate term in the acupuncture group. At the end of treatment, none of the differences in outcome scores were significant, except for maximum grip strength in the affected hand in the acupuncture group. No significant between-group differences in short-term or intermediate-term outcomes were observed.

CONCLUSION

Acupuncture plus fire needle therapy was effective in the short term in patients seeking improvement of LE. Twelve treatments were effective for relieving pain and improving disability in the intermediate term in patients with chronic LE in both study groups. The findings of the pilot study confirm the feasibility of proceeding to a larger randomized controlled study of the longer-term effects of acupuncture plus fire needle therapy in patients with LE.

Assessing Patient-Centred Outcomes in Lateral Elbow Tendinopathy: A Systematic Review and Standardised Comparison of English Language Clinical Rating Systems

Background

Lateral elbow tendinopathy (LET) is a common condition affecting adults. Although a lack of treatment consensus continues to prompt numerous effectiveness studies, there is a paucity of clear guidance on the choice of outcome measure. Our aim was to undertake a standardised evaluation of the available clinical rating systems that report patient-centred outcomes in LET.

Methods

A systematic review of studies reporting the development, assessment of metric properties and/or use of instruments aiming to quantify LET-specific patient-centred outcome measures was conducted in MEDLINE, Embase and CINAHL (inception-2017) adhering to PRISMA guidance. The evidence for each instrument was independently assessed by two reviewers using the standardised evaluating measures of patient-reported outcomes (EMPRO) method evaluating overall and attribute-specific instrument performance (metric properties and usability). EMPRO scores > 50/100 were considered indicative of high performance.

Results

Out of 7261 references, we identified 105 articles reporting on 15 instruments for EMPRO analysis. Median performance score was 41.6 (range 21.6–72.5), with four instruments meeting high-performance criteria: quick Disabilities of the Arm Shoulder and Hand score (qDASH) (72.5), DASH (66.9), Oxford Elbow Score (OES) (66.6) and Patient-Rated Tennis Elbow Evaluation (PRTEE) (57.0). One hundred seventy-nine articles reported instrument use internationally with DASH as the most frequent (29.7% articles) followed by PRTEE (25.6%), MEPS (15.1%) and qDASH (8.1%). The correlation between frequency of use and performance was r = 0.35 (95%CI − 0.11; 0.83).

Conclusions

This is the first study to provide standardised guidance on the choice of measures for LET. A large number of clinical rating systems are both available and being used for patients with LETs. Robust evidence is available for four measures, the DASH, QDASH, PRTEE and OES. The use of instruments in the literature is only in part explained by instrument performance.

Electronic supplementary material

The online version of this article (10.1186/s40798-019-0183-2) contains supplementary material, which is available to authorized users.

Modulation by Sigma-1 Receptor of Morphine Analgesia and Tolerance: Nociceptive Pain, Tactile Allodynia and Grip Strength Deficits During Joint Inflammation

Sigma-1 receptor antagonism increases the effects of morphine on nociceptive pain, even in morphine-tolerant animals. However, it is unknown whether these receptors are able to modulate morphine antinociception and tolerance during inflammatory pain. Here we used a mouse model to test the modulation of morphine effects by the selective sigma-1 antagonist S1RA (MR309), by determining its effect on inflammatory tactile allodynia (von Frey filaments) and on grip strength deficits induced by joint inflammation (a measure of pain-induced functional disability), and compared the results with those for nociceptive heat pain recorded with the unilateral hot plate (55°C) test. The subcutaneous (s.c.) administration of morphine induced antinociceptive effects to heat stimuli, and restored mechanical threshold and grip strength in mice with periarticular inflammation induced by Complete Freund’s Adjuvant. S1RA (80 mg/kg, s.c.) administered alone did not induce any effect on nociceptive heat pain or inflammatory allodynia, but was able to partially reverse grip strength deficits. The association of S1RA with morphine, at doses inducing little or no analgesic-like effects when administered alone, resulted in a marked antinociceptive effect to heat stimuli and complete reversion of inflammatory tactile allodynia. However, S1RA administration did not increase the effect of morphine on grip strength deficits induced by joint inflammation. When S1RA (80 mg/kg, s.c.) was administered to morphine-tolerant animals, it rescued the analgesic-like effects of this opioid in all three pain measures. However, when S1RA was repeatedly given during the induction of morphine tolerance (and not on the day of behavioral evaluation) it failed to affect tolerance to the effects of morphine on nociceptive heat pain or inflammatory allodynia, but completely preserved the effects of this opioid on grip strength deficits. These effects of S1RA on morphine tolerance cannot be explained by pharmacokinetic interactions, given that the administration of S1RA did not modify concentrations of morphine or morphine-3-glucuronide (a major morphine metabolite) in morphine-tolerant animals in plasma or brain tissue. We conclude that sigma-1 receptors play a pivotal role in the control of morphine analgesia and tolerance in nociceptive and inflammatory pain, although in a manner dependent on the type of painful stimulus explored.

Comparison of ultrasound and extracorporeal shock wave therapy in lateral epicondylosis

OBJECTIVE

The aim of this study was to compare the efficacy of extracorporeal shock wave therapy (ESWT) and therapeutic ultrasound (US) in the treatment of lateral epicondylosis (LE).

METHODS

Our study enrolled 50 patients with LE. Patients were randomized into two groups. Group 1 underwent therapeutic US (n = 24; 5 males and 15 females; mean age: 43.75 ± 4.52) Group 2 underwent ESWT (n = 20; 8 males and 16 females; mean age: 46.04 ± 9.24). Patients were evaluated at baseline, after treatment,and 1 month following treatment. The outcome measures were the visual analog scale (VAS), algometer, grip dynamometer, quick-disability of the arm,shoulder,and hand (QDASH), patient-rated tennis elbow evaluation (PRTEE), and Short Form-36 (SF-36) health survey questionnairre.

RESULTS

Both groups showed significant improvements in terms of VAS (all p values < 0.0001), dynamometer (p = 0.001 vs p = 0.015), algometer (all p values < 0.0001), PRTEE (all p values < 0.0001), QDASH (all p values < 0.0001), and SF-36 scores (p = 0.001 vs p = 0.005) within time. There was no significant difference between the two groups, except algometer scores in favor of ESWT (p = 0.029).

CONCLUSION

ESWT and therapeutic US are equally effective in treating LE. ESWT is an alternative therapeutic intervention and as effective as US.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Does Kinesiotaping improve pain and functionality in patients with newly diagnosed lateral epicondylitis?

PURPOSE

This study aimed to compare the short-term effects of kinesiotaping and extracorporeal shock wave therapy (ESWT) along with physiotherapy on pain, functionality, and grip strength in patients with newly diagnosed lateral epicondylitis undergoing rehabilitation.

METHODS

Forty-five voluntary patients (mean age 48 years) were randomly assigned to three groups. Patients in all groups received physiotherapy consisting of a cold pack and transcutaneous electrical nerve stimulation five times per week for a total of 15 sessions and a home exercise programme including stretching and eccentric strength exercises. In the second group, patients received kinesiotaping 5 days a week for 3 weeks. In the third group, ESWT was applied three times for 3 weeks. Patients were assessed by visual analogue scale for pain intensity, pain-free grip strength using a hand dynamometer, Cyriax Resisted Muscle Test, and Patient-Rated Tennis Elbow Evaluation Scale. All measurements were collected at baseline and after treatment.

RESULTS

There were no significant differences in the demographic characteristics of the patients in all groups at baseline. Intra-group analysis revealed that pain intensity decreased, whereas maximum grip strength and functionality increased in all groups at the end of the treatment (p < 0.05). Inter-group analysis revealed that the kinesiotaping group yielded better results in decreasing pain intensity than the other groups (p < 0.05). The kinesiotaping group (p < 0.001) and ESWT group (p = 0.002) yielded better results in improving functionality than the physiotherapy group. There were significant differences in recovering pain-free grip strength in the kinesiotaping group (p < 0.05).

CONCLUSION

Kinesiotaping was found to be effective for decreasing pain intensity, recovering grip strength, and improving functionality in patients with lateral epicondylitis undergoing rehabilitation.

LEVEL OF EVIDENCE

Therapeutic study, Level II.

Cross-cultural adaptation and validation of the Patient-Rated Tennis Elbow Evaluation Questionnaire on lateral elbow tendinopathy for French-speaking patients

STUDY DESIGN

Translation and validation of algo-functional questionnaire.

INTRODUCTION

The lateral elbow tendinopathy is a common injury in tennis players and physical workers. The Patient-Rated Tennis Elbow Evaluation (PRTEE) Questionnaire was specifically designed to measure pain and functional limitations in patients with lateral epicondylitis (tennis elbow). First developed in English, this questionnaire has since been translated into several languages.

PURPOSE OF THE STUDY

The aims of the study were to translate and cross-culturally adapt the PRTEE questionnaire into French and to evaluate the reliability and validity of this translated version of the questionnaire (PRTEE-F).

METHODS

The PRTEE was translated and cross-culturally adapted into French according to international guidelines. To assess the reliability and validity of the PRTEE-F, 115 participants were asked twice to fill in the PRTEE-F, and once the Disabilities of Arm, Shoulder and Hand Questionnaire (DASH) and the Short Form Health Survey (SF-36). Internal consistency (using Cronbach's alpha), test-retest reliability (using intraclass correlation coefficient (ICC), standard error of measurement and minimal detectable change), and convergent and divergent validity (using the Spearman's correlation coefficients respectively with the DASH and with some subscales of the SF-36) were assessed.

RESULTS

The PRTEE was translated into French without any problems. PRTEE-F showed a good test-retest reliability for the overall score (ICC 0.86) and for each item (ICC 0.8-0.96) and a high internal consistency (Cronbach's alpha = 0.98). The correlation analyses revealed high correlation coefficients between PRTEE-F and DASH (convergent validity) and, as expected, a low or moderate correlation with the divergent subscales of the SF-36 (discriminant validity). There was no floor or ceiling effect.

DISCUSSION AND CONCLUSIONS

The PRTEE questionnaire was successfully cross-culturally adapted into French. The PRTEE-F is reliable and valid for evaluating French-speaking patients with lateral elbow tendinopathy.

Randomised, prospective, non-blinded pilot study comparing the effect of intramuscular steroid injections and intralesional steroid injections in the management of tennis elbow

Background

Tennis elbow is an overuse injury affecting people performing repetitive forearm movements. It is a soft tissue disorder that causes significant disability and pain.

The aim of the study was to establish that an intramuscular steroid injection is effective in the short-term pain relief and functional improvement of tennis elbow. The severity of pain at the injection site was monitored to determine whether the intramuscular injection is better tolerated than the intralesional injection.

Methods and results

19 patients, who had no treatment for tennis elbow in the preceding 3 months, were recruited from Whipps Cross University Hospital, London, and were randomised to receive either 80 mg of intramuscular Depo-Medrone or 40 mg of intralesional Depo-Medrone injection. Blinding proved difficult as the injection sites differed and placebo arms were not included in the study. A Patient-Rated Tennis Elbow Evaluation (PRTEE) Questionnaire and a 10-point Likert scale were used to assess primary outcome. Six weeks after the treatment, there was a reduction in pain, improvement in function and total PRTEE scores in both intramuscular and intralesional groups (p=0.008) using a 95% CI for mean treatment difference of −26 to +16 points. A statistically significant result (p=0.001) in favour of intramuscular causing less pain at the injection site was noted.

Conclusion

Non-inferiority of intramuscular to intralesional injections was not confirmed; however, the intramuscular injection proved to be effective in reducing tennis elbow-related symptoms and was found less painful at the site of injection at the time of administration.

Trial registration number

EUDRACT Number: 2010-022131-11.

REC Number: 10/H0718/76 (NRES, Central London REC 1).

Comparison Between Corticosteroid and Lidocaine Injection in the Treatment of Tennis Elbow: A Randomized, Double-Blinded, Controlled Trial

OBJECTIVE

The aim of the study was to compare the effects of corticosteroid injection with lidocaine injection in treating tennis elbow.

DESIGN

It is a prospective, double-blinded, randomized controlled trial. Patients with tennis elbow for more than 1 mo were recruited from a hospital-based rehabilitation outpatient clinic. A total of 70 patients were recruited, and 61 patients completed the study. Patients received an injection of either 10 mg (1 ml) of triamcinolone (corticosteroid group, n = 30) or 1 ml of 1% lidocaine (lidocaine group, n = 31). All of the outcome measures were evaluated before the intervention and at 2 wks and 2 mos after treatment.

RESULTS

No significant group differences were observed between the corticosteroid and lidocaine groups regarding Patient-Rated Tennis Elbow Evaluation, Disability of the Arm, Shoulder, and Hand, visual analog scale for pain, and grip strength at baseline and at 2 wks and 2 mos after treatment (P > 0.05). However, within-group comparison showed significant improvement after injection with regard to Patient-Rated Tennis Elbow Evaluation, Disability of the Arm, Shoulder, and Hand, visual analog scale for pain, and grip strength in both groups (P > 0.05).

CONCLUSIONS

No differences in the short-term outcomes were found between lidocaine and corticosteroid injection in a small sample of people with tennis elbow with mean duration of 3.8 mos.

Grip strength in mice with joint inflammation: A rheumatology function test sensitive to pain and analgesia

Grip strength deficit is a measure of pain-induced functional disability in rheumatic disease. We tested whether this parameter and tactile allodynia, the standard pain measure in preclinical studies, show parallels in their response to analgesics and basic mechanisms. Mice with periarticular injections of complete Freund's adjuvant (CFA) in the ankles showed periarticular immune infiltration and synovial membrane alterations, together with pronounced grip strength deficits and tactile allodynia measured with von Frey hairs. However, inflammation-induced tactile allodynia lasted longer than grip strength alterations, and therefore did not drive the functional deficits. Oral administration of the opioid drugs oxycodone (1-8 mg/kg) and tramadol (10-80 mg/kg) induced a better recovery of grip strength than acetaminophen (40-320 mg/kg) or the nonsteroidal antiinflammatory drugs ibuprofen (10-80 mg/kg) or celecoxib (40-160 mg/kg); these results are consistent with their analgesic efficacy in humans. Functional impairment was generally a more sensitive indicator of drug-induced analgesia than tactile allodynia, as drug doses that attenuated grip strength deficits showed little or no effect on von Frey thresholds. Finally, ruthenium red (a nonselective TRP antagonist) or the in vivo ablation of TRPV1-expressing neurons with resiniferatoxin abolished tactile allodynia without altering grip strength deficits, indicating that the neurobiology of tactile allodynia and grip strength deficits differ. In conclusion, grip strength deficits are due to a distinct type of pain that reflects an important aspect of the human pain experience, and therefore merits further exploration in preclinical studies to improve the translation of new analgesics from bench to bedside.

Evaluation of the reliability and validity of the Persian version of Patient-Rated Elbow Evaluation questionnaire

Elbow joint pathologies are highly prevalent in Persian-speaking countries. A reliable low-cost method like an appropriate questionnaire is mandatory for the early diagnosis of elbow joint disorders. Among designed questionnaires, Patient-Rated Elbow Evaluation (PREE) is an accepted commonly used scale evaluating pain and dysfunction of the patients. The aims of the study were to cross-culturally adapt and also to identify the psychometric properties of the Persian PREE. The original version of the PREE was translated and cross-culturally adapted to Persian according to the guidelines by Beaton et al. Seventy-three patients and thirty-nine healthy people were enrolled in the study. Test-retest reliability and internal consistency were evaluated using ICC, Cronbach's alpha, and item-total correlation, respectively. Construct validity was investigated using Disability of Arm, Shoulder, and Hand (DASH) questionnaire and physical component scale of SF-36 (PCS). To determine a cutoff point for discriminating patients from non-patients, receiver operating characteristic curve was plotted. The Persian PREE displayed high internal consistency (Cronbach's alpha = 0.91) and had acceptable ICC values in the subscales and total score (ICC > 0.90). A positive moderate correlation with DASH (r = 0.66, P < 0.001) and a negative moderate correlation with PCS of SF-36 (r = -0.44, P < 0.001) were observed. The cutoff point equal to 13.16 was determined for Persian PREE. The Persian PREE exhibited promising validity and reliability. The findings supported its applicability in clinical situations that were consistent with the original version.

Kinesio taping in patients with lateral epicondylitis

BACKGROUND

Lateral epicondylitis (LE) is a painful condition that affects the tendinous tissue of the lateral epicondyle of the humerus and leads to loss of function of the affected limb. Therefore it can have a major impact on the patient's social and personal life. Many treatments are recommended for lateral epicondylitis; unfortunately the evidence is limited.

OBJECTIVES

The aim of study was to investigate the effect of kinesio taping (KT) on pain, grip strength and function in patients LE.

METHODS

Thirty-one (23 females, 8 males) patients with LE were included. KT was applied twice a week for 2 weeks. Pain at rest, activity of daily living (ADL), night and palpation on lateral epicondyle was evaluated with the visual analog scale (VAS 0-10 cm), and the grip strength was measured with a hand held dynamometer. The stage of the disease was evaluated by the Nirschl score and the functional status was assessed with Patient-Rated Forearm Evaluation Questionnaire (PRTEQ) score. These parameters were evaluated before, at 2 weeks and 6 weeks after treatment. Patients' satisfaction was also recorded on a Likert scale after treatment at 2 weeks and 6 weeks.

RESULTS

The average age of the patients was 43.58 ± 9.02. The dominant limb was affected in 64.5% (20) of the patients. After the application of KT on lateral epicondyle, there was a significant improvement in all parameters in terms of pain, Nirschl score, hand grip strength, patient satisfaction, and PRTEQ scores at 2 and 6 weeks.

CONCLUSIONS

Kinesio taping can be an effective treatment method in LE. This application improves pain, grip strength and functional status of the patients with LE.

Greek adaptation and validation of the Patient-Rated Tennis Elbow Evaluation (PRTEE)

PURPOSE OF THE STUDY

To cross-culturally adapt and validate the Greek version of the Patient-Rated Tennis Elbow Evaluation (PRTEE-G) Questionnaire.

METHODS

Four bi-lingual translators were involved in the translation and cultural adaptation procedures. Eighty-two patients (61 women and 21 men) with Lateral Elbow Tendinopathy (LET) participated in the study. To establish test - retest reliability, the patients were asked to complete the PRTEE-G Questionnaire before and after the first physiotherapy treatment. Internal consistency of the translated instrument was measured using Cronbach 'alpha'. An intraclass correlation coefficient was used to assess the test - retest reliability of the PRTEE-G Questionnaire. Concurrent validity was measured by correlating the PRTEE-G Questionnaire scores with the Greek version of the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) scores using Pearson's correlation coefficient.

RESULTS

The Greek PRTEE questionnaire has acceptable internal consistency (Cronbach 'alpha' = 0.95), excellent test - retest reliability (ICC = 0.94) and demonstrates expected concurrent validity (r > 0.72).

CONCLUSION

The Greek version of PRTEE Questionnaire is a reliable and valid measure when administered to patients with LET.

Cross-cultural adaptation, reliability and validity of the Turkish version of the Upper Limb Functional Index (ULFI)

STUDY DESIGN

Clinical measurement.

BACKGROUND

The Upper Limb Functional Index (ULFI) is a patient reported outcome (PRO) measure with sound clinimetric properties and clinical viability for determination of upper limb function.

PURPOSE-METHODS

The aims of this study were to cross-culturally adapt the ULFI for Turkish-speaking patients (ULFI-Tk) and investigate the reliability and validity in patients with upper limb problems. Patients (n=l02, age 49.1±16.6) with upper limb disorders were consecutively recruited. All participants completed the ULFI-Tk and the Disability of Arm, Shoulder and Hand Turkish-version (DASH-Tk) criterion at baseline and day-three.

RESULTS

The ULFI-Tk demonstrated good internal consistency (α=0.87), moderate criterion validity (DASH-Tk:r=0.68;p<0.05), moderate reliability (ICC2:1=0.72,CI=0.58-0.80) and strong error measurement (SEM=2.94;MDC90=5.35). Exploratory factor analysis demonstrated a dual factor structure that explained 31.2% of total variance.

CONCLUSIONS

The ULFI-Tk is a reliable and valid PRO that could be used to assess upper limb musculoskeletal disorders in Turkish speaking patients

LEVEL OF EVIDENCE

Class 2.