Primary studies included in this systematic review

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Systematic review

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Counterforce Orthosis In The Management Of Lateral Epicondylitis.

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Journal Journal of Ayub Medical College, Abbottabad : JAMC
Year 2017
Links Pubmed

This article includes 19 Primary studies 19 Primary studies (19 references)

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BACKGROUND: Lateral Epicondylitis (LE), is a condition characterized by the pain and tenderness over the lateral epicondyle of the humerus. LE is commonly seen among people who are involved in sports such as tennis and golf. Any activity that repeatedly overstrains the extensor carpi radialis brevis tendon can lead to LE. The management of lateral epicondylitis generally involves the use of counterforce orthosis. The aim of this review is to summarize the evidence regarding the effectiveness of counterforce orthoses on the clinical outcomes of patients with lateral epicondylitis. METHODS: The PubMed, Ovid, and ProQuest databases were searched for potential studies which explored the use of counterforce orthosis in the management of lateral epicondylitis. RESULTS: To have a better understanding of the effectiveness of various types of orthoses, the review is organized into four sections. The first section explores the use of a single orthotic device, the second section focuses on the combined use of orthotic devices, the third section explore studies that compared the effect of local steroid injection along with orthosis and the last section narrate the studies that compared various types of orthotic devices. The studies support the use of orthotic devices as a treatment modality for lateral epicondylitis. There is rising evidence which supports the use of a comprehensive approach, (by combining routine physiotherapy with orthotic devices) in the management of LE. CONCLUSIONS: Orthosis alone or in combination with routine physical therapy can be considered as an evidence-based treatment strategy for patients with lateral epicondylitis. However, on the basis of the literature review conducted, the authors recommend that further high-quality clinical trials regarding the management of lateral epicondylitis are necessary to strengthen the evidence-based physiotherapy practice.

Systematic review

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Non‐steroidal anti‐inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults

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Journal Cochrane Database of Systematic Reviews
Year 2013
Links Pubmed DOI PubMed Central

This article includes 15 Primary studies 15 Primary studies (15 references)

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BACKGROUND: Lateral elbow pain, or tennis elbow, is a common condition that causes pain in the elbow and forearm. Although self-limiting, it can be associated with significant disability and often results in work absence. It is often treated with topical and oral non-steroidal anti-inflammatory drugs (NSAIDs). This is an update of a review first published in 2002 (search date October 11, 2012). OBJECTIVES: To assess the benefits and harms of topical and oral NSAIDs for treating people with lateral elbow pain. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, EMBASE and SciSearch up to October 11, 2012. No language restriction was applied. SELECTION CRITERIA: Studies were included if they were randomised or quasi-randomised controlled trials (RCTs or CCTs) that compared topical or oral NSAIDs with placebo or another intervention, or compared two NSAIDs in adults with lateral elbow pain. Outcomes of interest were pain, function, quality of life, pain-free grip strength, overall treatment success, work loss and adverse effects. DATA COLLECTION AND ANALYSIS: Two review authors independently selected the studies for inclusion, extracted the data, and performed a risk of bias assessment. MAIN RESULTS: Fifteen trials, involving 759 participants and reporting 17 comparisons, were included in the review. Four new trials identified from the updated search were included, along with 11 of 14 trials included in the original review (three trials included in the previous review were found not to meet inclusion criteria). Of eight trials that studied topical NSAIDs (301 participants), five compared topical NSAIDs with placebo, one compared manipulative therapy and topical NSAIDs with manipulative therapy alone, one compared leech therapy with topical NSAIDs and one compared two different topical NSAIDs. Of seven trials that investigated oral NSAIDs (437 participants), two compared oral NSAIDs with placebo, one compared oral NSAIDs and bandaging with bandaging alone, three compared oral NSAIDs with glucocorticoid injection, one compared oral NSAIDs with a vasodilator and two compared two different oral NSAIDs. No trials directly compared topical NSAIDs with oral NSAIDs. Few trials used intention-to-treat analysis, and the sample size of most was small. The median follow-up was 2 weeks (range 1 week to 1 year). Low-quality evidence was obtained from three trials (153 participants) suggesting that topical NSAIDs were significantly more effective than placebo with respect to pain in the short term (mean difference -1.64, 95% confidence interval (CI) -2.42 to -0.86) and number needed to treat to benefit (7 (95% CI 3 to 21) on a 0 to 10 scale). Low-quality evidence was obtained from one trial (85 participants) indicating that significantly more participants report fair, good or excellent effectiveness with topical NSAIDs versus placebo at 28 days (14 days of therapy) (risk ratio (RR) 1.49, 95% CI 1.04 to 2.14). No participants withdrew as the result of adverse events, but some studies reported mild adverse effects such as rash in 2.5% of those exposed to topical NSAIDs compared with 1.3% of those exposed to placebo. Low-quality and conflicting evidence regarding the benefits of oral NSAIDs obtained from two trials could not be pooled. One trial found significantly greater improvement in pain compared with placebo, and the other trial found no between-group differences; neither trial found differences in function. One trial reported a withdrawal due to adverse effects for a participant in the NSAIDs group. Use of oral NSAIDs was associated with increased risk of gastrointestinal side effects compared with placebo in one trial in the review. Another trial reported discontinuation of treatment due to gastrointestinal side effects in four participants taking NSAIDs, and another participant developed an allergic reaction in response to oral NSAIDs. Very scant and conflicting evidence regarding the comparative effects of oral NSAIDs and glucocorticoid injection was obtained. One trial reported a significant improvement in pain with glucocorticoid injection, and another found no between-group differences; treatment success was similar between groups (RR of fair, good or excellent effectiveness 0.74; 95% CI 0.43 to 1.26). Transient pain may occur following injection. AUTHORS' CONCLUSIONS: There remains limited evidence from which to draw firm conclusions about the benefits or harms of topical or oral NSAIDs in treating lateral elbow pain. Although data from five placebo-controlled trials suggest that topical NSAIDs may be beneficial in improving pain (for up to 4 weeks), non-normal distribution of data and other methodological issues precluded firm conclusions. Some people may expect a mild transient skin rash. Evidence about the benefits of oral NSAIDs has been conflicting, although oral NSAID use may result in gastrointestinal adverse effects in some people. No direct comparisons between oral and topical NSAIDs were available. Some trials demonstrated greater benefit from glucocorticoid injection than from NSAIDs in the short term, but this was not apparent in all studies and was not apparent by 6 months in the only study that included longer-term outcomes.

Systematic review

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Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials

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Journal Lancet
Year 2010
Links Pubmed DOI

This article is included in 2 Structured summaries of systematic reviews 41 Structured summaries of systematic reviews (2 references)

This article includes 41 Primary studies 41 Primary studies (41 references)

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BACKGROUND: Few evidence-based treatment guidelines for tendinopathy exist. We undertook a systematic review of randomised trials to establish clinical efficacy and risk of adverse events for treatment by injection. METHODS: We searched eight databases without language, publication, or date restrictions. We included randomised trials assessing efficacy of one or more peritendinous injections with placebo or non-surgical interventions for tendinopathy, scoring more than 50% on the modified physiotherapy evidence database scale. We undertook meta-analyses with a random-effects model, and estimated relative risk and standardised mean differences (SMDs). The primary outcome of clinical efficacy was protocol-defined pain score in the short term (4 weeks, range 0-12), intermediate term (26 weeks, 13-26), or long term (52 weeks, ≥52). Adverse events were also reported. FINDINGS: 3824 trials were identified and 41 met inclusion criteria, providing data for 2672 participants. We showed consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms. For example, in pooled analysis of treatment for lateral epicondylalgia, corticosteroid injection had a large effect (defined as SMD>0·8) on reduction of pain compared with no intervention in the short term (SMD 1·44, 95% CI 1·17-1·71, p<0·0001), but no intervention was favoured at intermediate term (-0·40, -0·67 to -0·14, p<0·003) and long term (-0·31, -0·61 to -0·01, p=0·05). Short-term efficacy of corticosteroid injections for rotator-cuff tendinopathy is not clear. Of 991 participants who received corticosteroid injections in studies that reported adverse events, only one (0·1%) had a serious adverse event (tendon rupture). By comparison with placebo, reductions in pain were reported after injections of sodium hyaluronate (short [3·91, 3·54-4·28, p<0·0001], intermediate [2·89, 2·58-3·20, p<0·0001], and long [3·91, 3·55-4·28, p<0·0001] terms), botulinum toxin (short term [1·23, 0·67-1·78, p<0·0001]), and prolotherapy (intermediate term [2·62, 1·36-3·88, p<0·0001]) for treatment of lateral epicondylalgia. Lauromacrogol (polidocanol), aprotinin, and platelet-rich plasma were not more efficacious than was placebo for Achilles tendinopathy, while prolotherapy was not more effective than was eccentric exercise. INTERPRETATION: Despite the effectiveness of corticosteroid injections in the short term, non-corticosteroid injections might be of benefit for long-term treatment of lateral epicondylalgia. However, response to injection should not be generalised because of variation in effect between sites of tendinopathy. FUNDING: None.

Systematic review

Unclassified

Physiotherapy, steroid injections, or rest for lateral epicondylosis? What the evidence suggests.

Authors Nimgade A , Sullivan M , Goldman R
Journal Pain practice : the official journal of World Institute of Pain
Year 2005
Links Pubmed DOI

This article is included in 1 Structured summary of systematic reviews 27 Structured summaries of systematic reviews (1 reference)

This article includes 27 Primary studies 27 Primary studies (27 references)

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OBJECTIVE: To identify effective lateral epicondylosis interventions and assess the quality of research over time. METHODS: Relevant MEDLINE and EMBASE searches respectively yielded 226 and 187 potential studies. Additional citations were extracted from bibliographies. Thirty controlled trials met inclusion criteria. The Cochrane Collaboration guidelines "quality score" served to rate studies. RESULTS: In the short term (<2 to 3 months) steroid injections and physiotherapy outperformed relative rest. Physiotherapy appears efficacious regardless of time frame. After 3 months, active physiotherapy outperforms injections, but does not appear significantly better than rest. Evidence was neutral or insufficient regarding ultrasound, splinting, or manipulation. Nonsignificant correlations between publication year and study quality score were found. CONCLUSIONS: Overall research quality has not improved with time. Steroid injections appear the most successful short-term intervention for pain relief. Active physiotherapy appears efficacious regardless of time frame.

Systematic review

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Complications associated with the use of corticosteroids in the treatment of athletic injuries.

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Authors Nichols AW
Journal Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine
Year 2005
Links Pubmed DOI

This article includes 43 Primary studies 43 Primary studies (43 references)

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BACKGROUND: The potent anti-inflammatory pharmacologic effects of the corticosteroids (cortisone and synthetic derivatives) has led to their extensive usage in the management of rheumatologic diseases and athletic musculoskeletal injuries. The efficacy and risks of locally injected or systemically administered corticosteroids in the treatment of athletic injuries are unclear. OBJECTIVE: To review critically the medical literature and determine complications and risks associated with corticosteroid treatment of athletic injuries. DATA SOURCES: A search of 3 databases-MEDLINE, CINAHL, and Cochrane Clinical Trial Register-was performed using the OVID interface for all years between 1966 and 2003. The search first combined all references under the medical subject headings adrenal cortex hormones, glucocorticoids, and glucocorticoids, synthetic. A second search combined all references under the medical subject headings athletic injuries, sprains and strains, tendon injuries, shoulder injuries, rotator cuff disease, tennis elbow, and lateral epicondylitis. The references identified by these 2 searches were intersected and limited to human only to produce 130 articles. Relevant review articles were scanned, references reviewed, and additional articles retrieved for consideration of inclusion. STUDY SELECTION: For inclusion in this critical review, articles must meet the following criteria: (1) subjects were human, (2) subjects had athletic-related injuries, and (3) subjects received corticosteroid treatment. Ultimately, 43 studies met inclusion criteria. DATA EXTRACTION AND SYNTHESIS: Selected articles were then categorized as to whether the primary focus was usage/efficacy of corticosteroid injection therapy, occurrence of complications of corticosteroid injection therapy, or usage or complications of systemic corticosteroid therapy. MAIN RESULTS: Twenty-five selected studies primarily examined the usage/efficacy of corticosteroid injections in the treatment of various athletic injuries. Of the 983 total subjects who received corticosteroid injections among these studies, only minor complications of treatment were reported. Eighteen selected studies primarily described complications of corticosteroid injections in the treatment of athletic injuries. Of these, tendon and fascial ruptures were the predominant complications reported. The search identified no articles that addressed the usage of or complications of systemic corticosteroids in the treatment of athletic injuries, although tibial stress fracture and multifocal osteonecrosis occurred in individuals being treated for nonathletic injury conditions. CONCLUSIONS: This critical review reveals that the existing medical literature does not provide precise estimates for complication rates following the therapeutic use of injected or systemic corticosteroids in the treatment of athletic injuries. Tendon and fascial ruptures are often reported complications of injected corticosteroids, whereas tibial stress fractures and multifocal osteonecrosis were described with systemic corticosteroids.

Systematic review

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The efficacy of splinting for lateral epicondylitis: a systematic review.

Authors Borkholder CD , Hill VA , Fess EE
Journal Journal of hand therapy : official journal of the American Society of Hand Therapists
Year 2004
Links Pubmed DOI

This article is included in 1 Structured summary of systematic reviews 11 Structured summaries of systematic reviews (1 reference)

This article includes 11 Primary studies 11 Primary studies (11 references)

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To determine the efficacy of using splinting as a treatment for lateral epicondylitis (LE), a systematic review of the literature was conducted on Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, PEDro, and Cochrane databases using pertinent key words and phrases. Hand searches of article references were also used to ensure that as many relevant articles as possible were identified. Searches were limited to articles published in English. Articles that did not involve splinting (or terminology derivative thereof) as treatment intervention for LE were excluded. From 98 potential articles, 58 were considered strong inclusion candidates. These articles were copied and further triaged according to predefined criteria, resulting in 22 articles that were numbered randomly and blinded. Three reviewers appraised these articles, eliminating 11 of the articles because they did not meet essential criteria of randomization, control group, and/or inferential statistical analysis. Using MacDermid quality scores, the 11 remaining articles were rated by three reviewers. Consensus between the three reviewers was achieved for all quality scores for all 11 articles included in the review. Adjusted quality scores ranged from 44.5 to 16.5 with a mean of 26.3 points. For accurate comparison and consistency of terminology, splints described in the included articles were first classified according to the ASHT Splint Classification, expanded and refined version, and next according to their inherent material properties. Six splints in five classification categories were identified. Discussion of the results from the 11 included studies was organized according to splint category and further separated into strength, pain, and load applied sections. This review identified one Sackett level 1b study and ten Sackett level 2b studies that offer early positive, but not conclusive, support for the effectiveness of splinting lateral epicondylitis. None of the reviewed studies received a perfect quality score, and the wide range of quality scores attests to the fact that considerable improvement of future studies is essential.

Systematic review

Unclassified

Rehabilitation for patients with lateral epicondylitis: a systematic review.

Journal Journal of hand therapy : official journal of the American Society of Hand Therapists
Year 2004
Links Pubmed DOI

This article is included in 1 Structured summary of systematic reviews 31 Structured summaries of systematic reviews (1 reference)

This article includes 31 Primary studies 31 Primary studies (31 references)

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

Systematic review

Unclassified

Corticosteroid injections for lateral epicondylitis: A systematic review.

Journal Pain
Year 2002
Links Pubmed DOI

This article is included in 1 Structured summary of systematic reviews 13 Structured summaries of systematic reviews (1 reference)

This article includes 13 Primary studies 13 Primary studies (13 references)

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Reviews 13 studies concerning the effectiveness of corticosteroid injections for lateral epicondylitis, that is, tennis elbow. Results show that almost all studies had poor internal validity scores. For short-term outcomes of &lt; 6 wks, statistically significant and clinically relevant differences were observed regarding pain, global improvement, and grip strength for corticosteroid injection Ss compared to those receiving placebo, local anaesthetic, or conservative treatments. For intermediate outcomes of 1.5-6 mo and long-term outcomes of &gt;6 mo, no statistically significant or clinically relevant results were observed. It is concluded that it is not possible to draw firm conclusions on the effectiveness of corticosterone injections for lateral epicondylitis, although the available evidence shows superior short-term effects. (PsycInfo Database Record (c) 2020 APA, all rights reserved)

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Struijs PA 2002

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Systematic review

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Corticosteroid injections for lateral epicondylitis: a systematic overview.

Journal The British journal of general practice : the journal of the Royal College of General Practitioners
Year 1996
Links Pubmed PubMed Central

This article is included in 1 Structured summary of systematic reviews 11 Structured summaries of systematic reviews (1 reference)

This article includes 11 Primary studies 11 Primary studies (11 references)

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BACKGROUND: Lateral epicondylitis (tennis elbow) is a common complaint, for which corticosteroid injections are a frequently applied therapy. However, there were no up-to-date reviews available that systematically addressed the effectiveness and adverse effects, including questions concerning optimal timing of injections and composition of the injection fluid. AIM: The aim of the study was to assess the effectiveness of corticosteroid injections in the treatment of lateral epicondylitis (tennis elbow) by systematic review of the available randomized clinical trials. DATA SOURCES: The data sources used were randomized clinical trials identified by literature searches of the MedLine (1966-1994) and Embase (Exerpta Medica) (1980-1994) databases for the keywords epicondylitis, tendinitis and elbow, injection. References given in relevant publications were further examined. STUDY SELECTION: The criteria for selecting studies were as follows: randomized clinical trials (treatment allocation in random or alternate order); one of the treatments to include one or more corticosteroid injections (additional interventions were allowed); participants suffering from lateral epicondylitis; and publication in English, German or Dutch. Abstracts and unpublished studies were not included. DATA SYNTHESIS: Methodological quality was assessed by means of a standardized criteria list (range 1-100 points). The extracted outcomes were the general conclusion drawn by the authors of the reports on the trials, and the success rates at the various follow-up points as (re)calculated by us. The success rates were subsequently graphically displayed and statistically pooled. Separate stratified analyses were conducted according to a predetermined analysis plan. RESULTS: Twelve randomized clinical trials were identified. The median methodological score was 40 points, indicating an overall poor to moderate quality. The pooled analysis indicated short-term effectiveness (2-6 weeks): pooled odds ratio (OR) = 0.15 [95% confidence interval (CI) 0.10-0.23], chi 2 [degrees of freedom (df = 5) = 13.3], indicating statistical heterogeneity. At longer term follow-up, no difference could be detected. The studies of better methodological quality indicated more favourable results than those of lesser methodological quality. The most suitable corticosteroid to use as well as dosage, injection interval and injection volume could not be derived from the various trials. CONCLUSION: The existing evidence on corticosteroid injections for the treatment of tennis elbow is not conclusive. Many trials were conducted in a secondary care setting and clearly had serious methodological flaws, and there was statistical heterogeneity among the trials. Corticosteroid injections appear to be relatively safe and seem to be effective in the short term (2-6 weeks). Although the treatment seems to be suitable for application in general practice, further trials in this setting are needed. As yet, questions regarding the optimal timing, dosage, injection technique and injection volume remain unanswered.