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

Comparing the efficacy of Agnikarma with therapeutic ultrasound in the management of tennis elbow - A randomised controlled preliminary study

BACKGROUND

Tennis elbow is a common musculoskeletal disease of elbow and causes restricted movement of forearm. Various treatment modalities like NSAID, corticosteroid injection, counter bracing, physiotherapy, surgery etc are available but safety and efficacy of one treatment over another is under research. Ayurveda classifies this condition as Snayugata vata. According to Sushruta, Agnikarma (thermal cautery) is the one among the treatment modalities for Snayugata vata. Previously published randomised controlled trials have shown that therapeutic ultrasound is safe and effective for tennis elbow. However, the comparative efficacy of these two treatment modalities is unknown.

OBJECTIVE

This study compares the effects of Agnikarma (AGK) with Therapeutic Ultrasound (TUS) in reducing pain, tenderness and restores the ability to do various tasks.

MATERIALS AND METHODS

A total of 30 patients were enrolled in the study as an open-label, double-armed, prospectively designed comparative clinical study, with 15 patients in each group. Group AGK received two sittings of Agnikarma and Group TUS received therapeutic ultrasound. To analyze the patients, three outcome measures were adopted: pain intensity, assessed with a Numerical Pain Rating Scale, tenderness - Grade 0 to Grade 4 (mentioned in Hutchinson's clinical methods) and pain and functional Disability assessed with the Patient Rated Tennis Elbow Evaluation (PRTEE) questionnaire. Assessment was done on 0th, 8th, 15th, 30th and 60th day.

RESULT

Tennis elbow can be effectively treated with AGK and TUS. (p < 0.001 for pain, tenderness and PRTEE). While comparing between the groups, on 8th day and 15th day statistically significant difference in pain and PRTEE (p < 0.05) was noted between AGK and TUS groups. Agnikarma showed better results than therapeutic ultrasound in pain management and showed an improved quality of life from 8th day onwards and for a period up to 2 months.

CONCLUSION

Both Agnikarma and therapeutic ultrasound have roles in the management of tennis elbow. However, starting on the 8th day and continuing for up to 2 months, Agnikarma showed a significant benefit in pain management and improved status for quality of life.

Investigation of the effects of a short opponens splint and structured hand exercise program in computer engineers with wrist pain: a randomized controlled trial

Objectives. This study aimed to examine the effects of a short opponens splint and hand exercise program on pain, hand functionality, daily activities, and work efficacy in computer engineers with wrist pain. Methods. Forty-five engineers were randomized into three groups: group 1 (n = 15) utilized both splints and exercises, group 2 (n = 15) engaged in exercises only and group 3 (n = 15) received no treatment, across 8 weeks, thrice weekly. Only exercises were applied to group 2 (n = 15). No treatment was applied for group 3 (n = 15). The progress of subjects was controlled periodically each week. Outcome measurements including the Jamar hand dynamometer, pinchmeter, nine-hole peg test (9-NHPT), visual analog scale, Boston carpal tunnel syndrome questionnaire and Michigan hand outcome questionnaire (MHQ) were evaluated pre and post treatment during the study period. Results. Comparing the outcome measurements of the three groups showed a statistically significant difference between them except for the 9-NHPT and MHQ pain and esthetics (p < 0.05). According to post-hoc tests, groups 1 and 2 had more significant differences than group 3. Also, there was no statistically significant difference in any parameter between group 1 and group 2 (p > 0.017). Conclusion. Non-restrictive minimal orthosis or exercise programs are advisable for individuals with wrist pain.

Efficacy of PowerBall Versus Mulligan Mobilization With Movement on Pain and Function in Patients With Lateral Epicondylitis: A Randomized Clinical Trial

Background Lateral epicondylitis (LE), sometimes referred to as tennis elbow or lateral elbow tendinopathy (LET), is one of the most common repetitive stress disorders in the elbow joint. Often, this involves the attachment of the extensor carpi radialis brevis muscle. This study's primary focus is on treating people with LE, a condition that causes repetitive movements of the upper extremities. There is currently no research on how PowerBall gadget workouts affect the function and pain of individuals with lateral epicondylitis. Exercises using the "PowerBall device," which applies both intrinsic and extrinsic pressure to the wrist, elbow, and shoulder muscles, are thought to be beneficial forms of resistance training. It has been shown that there are improvements in strength, function, range of motion (ROM), discomfort, and quality of life (QOL). On the other side, it has been demonstrated that LE patients have reduced discomfort while using Mulligan Mobilization with Movement (MMWM). Methods The 50 patients with LE were split into two groups for the single-blinded, randomized clinical study after baseline assessment and randomization: Group A was the intervention group, and Group B was the conventional group. The "PowerBall device" exercise was provided to participants in Group A, and MMWM was given to those in Group B. Both groups can benefit from basic workouts and ultrasonography by following the prescribed routine. Quantification of pain, function, grip strength, and range of motion was done at the start and finish of therapy using the Visual Analogue Scale (VAS), Patient Rated Tennis Elbow Evaluation (PRTEE), portable dynamometer, and goniometer. Results After therapy, both groups showed considerable improvement (p<0.05). Both descriptive and inferential statistics were employed in the data analysis. Numerous statistical tests were employed, such as the student's paired and unpaired t-test and the chi-square test. From a statistical and clinical perspective, Group A's outcomes were more significant. On the visual analog scale, there was a decrease in pain intensity for wrist and elbow mobility at rest (p<0.0003), activity (p<0.003), PRTEE (p<0.001), grip strength (p<0.03), and range of motion (p<0.01). Both groups' assessments after rehabilitation indicated increases in pain and function; however, Group A (0.03) benefited more and saw early success with the PowerBall device. Conclusion Findings show that a three-week program incorporating resistance training exercises mediated by a "PowerBall device" enhances upper limb performance beyond traditional exercise treatment and increases grip strength, wrist extension strength, internal and external rotator concentric and eccentric strength. The findings and observations indicate that both groups have significantly improved.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Prospective randomized single-blinded clinical trial.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Comparative Effectiveness of Physical Therapy and Electrophysiotherapy for the Treatment of Lateral Epicondylitis: A Network Meta-Analysis

BACKGROUND

Lateral epicondylitis (LE) is a common enthesopathy, possibly caused by overuse and repetitive activity. Although non-operative management is the primary approach for treating LE, clinical guidelines and the literature fail to identify the most effective non-operative treatment. Therefore, we conducted a network meta-analysis to compare the effectiveness of physical therapy and electrophysiotherapy treatments for the treatment of LE.

METHODS

We searched MEDLINE, EMBASE, Web of Science, and Scopus for peer-reviewed, randomized controlled trials evaluating the effectiveness of physical therapy and electrophysiotherapy treatments. Data related to article characteristics and outcomes (grip strength and pain VAS) were collected.

RESULTS

Twenty-three clinical trials, including 1,363 participants (mean [SD] age, 47.4 [7.5], 53.1% women) were eligible in this study. Pain VAS demonstrated significant reductions in scores following treatment with magnetic field (mean difference (MD) [95% CI],-1.88 [-2.66 to -1.11]), exercise (MD [95% CI], -0.90 [-1.69 to -0.1]), and acoustic waves (MD [95% CI], -0.83 [-1.37 to -0.29]) compared to placebo. For grip strength, no treatment modality was found to be significantly effective. A sensitivity analysis that excluded studies with high publication bias and high degrees of heterogeneity produced similar results to the main analysis with the exception of statistically improved grip strength after light therapy (MD [95% CI], 5.38 [1.71 to 9.04]) and acoustic wave therapy (MD [95% CI], 7.79 [2.44 to 13.15]).

CONCLUSION

Overall, electrophysiotherapy treatments should be prioritized over physical therapy. Magnetic field therapy was associated with pain reduction, whereas acoustic wave and light therapy were associated with increased grip strength.

Physiotherapy treatment of lateral epicondylitis: A systematic review

BACKGROUND

Lateral epicondylitis is a tendinopathy with a prevalence of between 1-3% of the population aged 35-54 years. It is a pathology with a favorable evolution, but with frequent recurrences (which imply an economic extra cost).

OBJECTIVE

The objective of this review was to determine the efficacy of physiotherapy treatment for the treatment of epicondylitis and, if any, to identify the most appropriate techniques.

METHODS

A systematic search was carried out in October 2020 in the databases of PubMed, Cinahl, Scopus, Medline and Web of Science using the search terms: Physical therapy modalities, Physical and rehabilitation medicine, Rehabilitation, Tennis elbow and Elbow tendinopathy.

RESULTS

Nineteen articles were found, of which seven applied shock waves, three applied orthoses, three applied different manual therapy techniques, two applied some kind of bandage, one applied therapeutic exercise, one applied diacutaneous fibrolysis, one applied high intensity laser, and one applied vibration.

CONCLUSIONS

Manual therapy and eccentric strength training are the two physiotherapeutic treatment methods that have the greatest beneficial effects, and, furthermore, their cost-benefit ratio is very favorable. Its complementation with other techniques, such as shock waves, bandages or Kinesio® taping, among others, facilitates the achievement of therapeutic objectives, but entails an added cost.

Efficacy of Nonoperative Treatments for Lateral Epicondylitis: A Systematic Review and Meta-Analysis

BACKGROUND

Lateral epicondylitis is a common overuse injury affecting approximately 1 to 3 percent of the population. Although symptoms may disappear spontaneously within 1 year, the clinical guidelines for conservative treatment are not clear. The authors' objective was to examine the outcomes of nonsurgical treatments for lateral epicondylitis through a meta-analysis and provide a treatment recommendation using the available evidence.

METHODS

The authors searched the PubMed, EMBASE, Scopus, and Web of Science databases to identify primary research articles studying conservative treatments (electrophysiotherapy, physical therapy, and injections) for lateral epicondylitis. The authors included randomized controlled trials published in peer-reviewed journals. Data related to outcomes (pain, grip strength, Patient-Rated Tennis Elbow Evaluation score, and Disabilities of the Arm, Shoulder and Hand score) and complications were extracted.

RESULTS

Fifty-eight randomized controlled trials were included in the meta-analysis. Electrophysiotherapy was effective in improving pain [mean difference, -10.0 (95 percent CI, -13.8 to -6.1)], Patient-Rated Tennis Elbow Evaluation score [mean difference, -10.7 (95 percent CI, -16.3 to -5.0)], and Disabilities of the Arm, Shoulder and Hand score [mean difference, -11.9 (95 percent CI, -15.8 to -7.9)]; and physical therapy improved pain [mean difference, -6.0 (95 percent CI, -9.7 to -2.3)] and Patient-Rated Tennis Elbow Evaluation scores [mean difference, -7.5 (95 percent CI, -11.8 to -3.2)] compared to placebo. Injections did not improve any outcome measures. Patients who received electrophysiotherapy and injections reported higher adverse effects than physical therapy patients.

CONCLUSIONS

Patients who received electrophysiotherapy and physical therapy reported statistically and clinically improved scores in pain and function compared to placebo. Injections may put patients at higher risk for adverse effects compared to other conservative treatments. When managing lateral epicondylitis conservatively, electrophysiotherapy and physical therapy should be prioritized before other interventions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Minimally invasive treatment of lateral epicondylitis

Lateral epicondylitis (LE), also known as tennis elbow, is the most common cause of elbow pain in adults, with approximately 1-3% of the general population being afflicted. Although the condition is usually self-limiting, pain can be a major hindrance, limiting daily activity and the work capacity of patients. As a result, many treatment options have become available with the aim to shorten the duration of the disease and increase the quality of life. Steroid injections, NSAIDs, topical creams, platelet-rich plasma, physical therapy, and kinesiotaping are considered conservative treatments, while surgical options are last-resort treatments reserved for refractory LE. In this review, we will provide a brief summary of LE and focus on addressing conservative and minimally invasive interventional options for the treatment of LE.