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Systematic review

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Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials.

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Authors Mi B , Liu G , Zhou W , Lv H , Liu Y , Wu Q , Liu J
Journal The Physician and sportsmedicine
Year 2017
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This article is included in 2 Broad syntheses 8 Broad syntheses (2 references)

This article includes 8 Primary studies 8 Primary studies (8 references)

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OBJECTIVES: Lateral epicondylitis (LE) is a common tendinopathy for which an effective treatment is still unknown. The purpose of this meta-analysis was to compare the effectiveness of platelet rich plasma (PRP) vs steroid in reducing pain and improving function of the elbow in the treatment of LE. METHODS: A systematic search of the literature was conducted to identify related articles published from January 1980 to September 2016 in Pubmed, Embase, the Cochrane Library and SpringerLink. All studies that compared PRP with steroid administration on LE were included. Main outcomes were collected and analyzed by the Review Manager 5.1. RESULTS: Eight randomized controlled trials (RCTs) that involved 511 patients met the criteria. This meta-analysis showed that there was no significant difference in pain relief in the short-term (2 to 4 weeks: SMD = 1.02, P = .03; 6 to 8 weeks: SMD = .73, P = .24) and the intermediate-term (12 weeks: SMD = -0.28, P = .35). Steroid exhibited a better efficacy of function in the short-term (2 to 4 weeks: SMD = .61, P < .001; 6 to 8 weeks: SMD = .53, P < .001). However, PRP was superior to steroid for pain relief in the long-term (half year: SMD = -1.6, P < .001; one year: SMD = -1.45, P < .001), and also for function improving in the intermediate-term (12 weeks: SMD = -0.53, P < .001) and the long-term (half year: SMD = -0.56, P < .001; one year: SMD = -0.7, P < .001). No serious adverse effects of treatment were observed in the two groups. CONCLUSION: Treatment of patients with LE by steroid could slightly relieve pain and significantly improve function of elbow in the short-term (2 to 4 weeks, 6 to 8 weeks). PRP appears to be more effective in relieving pain and improving function in the intermediate-term (12 weeks) and long-term (half year and one year). Considering the long-term effectiveness of PRP, we recommend PRP as the preferred option for LE.

Systematic review

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Local corticosteroid versus autologous blood injections in lateral epicondylitis: meta-analysis of randomized controlled trials.

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Journal European journal of physical and rehabilitation medicine
Year 2017
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INTRODUCTION: Lateral epicondylitis is a common painful elbow disorder. Several approaches to treatment have been proposed, with a local injection of corticosteroids being the most frequently used. Recent insights into the pathophysiology encouraged the introduction of autologous blood injections as an alternative treatment method. The aim of this meta-analysis is to summarize quantitatively the evidence regarding the efficacy of corticosteroids and autologous blood injections for treatment of pain in lateral epicondylitis. EVIDENCE ACQUISITION: Studies were considered eligible based on the following inclusion criteria: adult human, diagnosis of lateral epicondylitis, randomized controlled trials comparing corticosteroids versus autologous blood injections, pain assessment. Exclusion criteria were previous surgery for lateral epicondylitis or for other elbow disorders, concurrent treatment with drugs or physiotherapy, diagnosis of musculoskeletal systemic disorder. A systematic search of literature was performed according to the PRISMA statement. Effect size of each included study was calculated and analyzed in a random-effects model. EVIDENCE SYNTHESIS: Four studies, enrolling total of 218 patients (139 females and 79 males), were included in quantitative analysis. At 2 weeks, there was a trend towards a reduction of VAS score in the corticosteroid group (WMD=2.12 [95% CI: 4.38 to 0.14], P=0.07). No significant differences were recorded in the medium-term (4-12 weeks; WMD=0.85 [95% CI: -0.44 to 2.15], P=0.19) and long-term (24 weeks; WMD=0.63 [95% CI: -2.40 to 3.66], P=0.68) follow-up. CONCLUSIONS: Few high-quality trials compare the efficacy of corticosteroid and autologous blood injections in the control of pain related to lateral epicondylitis. Available data indicate that corticosteroids tend to reduce VAS score in short-term follow-up, although these data are not statistically significant. No differences were recorded in the medium and long term. Contrary to popular opinion among medical professionals, and despite pathophysiological cues, the currently available data offer no support for the effectiveness of autologous blood injections in medium- and long-term follow-up. Further studies are necessary to establish which treatment has more impact on pain in lateral epicondylitis. These data could be then used as a basis for practical guidelines and new protocols of treatment.

Systematic review

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Autologous whole blood or corticosteroid injections for the treatment of epicondylopathy and plantar fasciopathy? A systematic review and meta-analysis of randomized controlled trials.

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Journal Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine
Year 2016
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Objectives To compare the efficacy of autologous whole blood with that of corticosteroid injections on epicondylopathy and plantar fasciopathy. Design Systematic review and meta-analysis. Methods The databases of PubMed, Web of Science, CENTRAL, and Scopus were searched up to 6th May 2015. Randomized trials comparing the effects of autologous whole blood and corticosteroid injections on epicondylopathy or plantar fasciopathy were included. Trials exploring the efficacy of platelet-rich plasma were excluded. The primary outcome was pain relief. The secondary outcome included the assessment of composite outcomes. All outcomes were assessed at 2–6 (short-term) weeks, 8–13 (intermediate-term) weeks and 24–26 (medium-term) weeks. Quality assessment was performed with the Cochrane risk of bias tool. Results Nine trials were included. For pain relief, there was a statistically significant difference in favour of corticosteroids in the short term (SMD 0.52; 95%CIs 0.18 to 0.86; I 2 = 53%; p &lt; 0.01). A statistically significant difference in favour of autologous whole blood was indicated in the medium-term assessment of pain relief on epicondylopathy. Conclusions Corticosteroids were marginally superior to autologous whole blood in relieving pain on plantar fasciopathy at 2–6 weeks. Autologous whole blood provided significant clinical relief on epicondylopathy at 8–24 weeks. Conclusions were limited by the risk of bias.

Systematic review

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Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis.

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Journal Journal of orthopaedics and traumatology : official journal of the Italian Society of Orthopaedics and Traumatology
Year 2016
Links Pubmed DOI PubMed Central

This article is included in 1 Broad synthesis 10 Broad syntheses (1 reference)

This article includes 10 Primary studies 10 Primary studies (10 references)

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BACKGROUND: Clinical outcomes between the use of platelet-rich plasma (PRP), autologous blood (AB) and corticosteroid (CS) injection in lateral epicondylitis are still controversial. MATERIALS AND METHODS: A systematic review and network meta-analysis of randomized controlled trials was conducted with the aim of comparing relevant clinical outcomes between the use of PRP, AB and CS injection. Medline and Scopus databases were searched from inception to January 2015. A network meta-analysis was performed by applying weight regression for continuous outcomes and a mixed-effect Poisson regression for dichotomous outcomes. RESULTS: Ten of 374 identified studies were eligible. When compared to CS, AB injection showed significantly improved effects with unstandardized mean differences (UMD) in pain visual analog scale (VAS), Disabilities of Arm Shoulder and Hand (DASH), Patient-Related Tennis Elbow Evaluation (PRTEE) score and pressure pain threshold (PPT) of -2.5 (95 % confidence interval, -3.5, -1.5), -25.5 (-33.8, -17.2), -5.3 (-9.1, -1.6) and 9.9 (5.6, 14.2), respectively. PRP injections also showed significantly improved VAS and DASH scores when compared with CS. PRP showed significantly better VAS with UMD when compared to AB injection. AB injection has a higher risk of adverse effects, with a relative risk of 1.78 (1.00, 3.17), when compared to CS. The network meta-analysis suggested no statistically significant difference in multiple active treatment comparisons of VAS, DASH and PRTEE when comparing PRP and AB injections. However, AB injection had improved DASH score and PPT when compared with PRP injection. In terms of adverse effects, AB injection had a higher risk than PRP injection. CONCLUSIONS: This network meta-analysis provided additional information that PRP injection can improve pain and lower the risk of complications, whereas AB injection can improve pain, disabilities scores and pressure pain threshold but has a higher risk of complications. LEVEL OF EVIDENCE: Level I evidence.

Systematic review

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Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis.

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Journal British journal of sports medicine
Year 2016
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This article is included in 1 Broad synthesis 27 Broad syntheses (1 reference)

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

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BACKGROUND: There are many injection therapies for lateral epicondylalgia but there has been no previous comprehensive comparison, based on the Bayesian method. METHODS: The MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for appropriate literature. The outcome measurement was the pain score. Direct comparisons were performed using the pairwise meta-analysis, and network meta-analysis, based on a Bayesian model, was used to calculate the results of all of the potentially possible comparisons and rank probabilities. A sensitivity analysis was performed by excluding low-quality studies. The inconsistency of the model was assessed by means of the node-splitting method. Metaregression was used to assess the relationship between the sample size and the treatment effect. RESULTS: All of the injection treatments showed a trend towards better effects than placebo. Additionally, the peppering technique did not add additional benefits when combined with other treatments. No significant changes were observed by excluding low-quality studies in the sensitivity analysis. No significant inconsistencies were found according to the inconsistency analysis, and metaregression revealed that the sample size was not associated with the treatment effects. CONCLUSIONS: Some commonly used injection therapies can be considered treatment candidates for lateral epicondylalgia, such as botulinum toxin, platelet-rich plasma and autologous blood injection, but corticosteroid is not recommended. Hyaluronate injection and prolotherapy might be more effective, but their superiority must be confirmed by more research. The peppering technique is not helpful in injection therapies.

Systematic review

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Autologous blood injection for treatment of lateral epicondylosis: A meta-analysis of randomized controlled trials.

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Journal Physical Therapy in Sport
Year 2016
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OBJECTIVES: To appraise existing evidence of autologous blood injection in treating lateral epicondylosis. DESIGN: Meta-analysis of randomized controlled trials. SETTING: A comprehensive search of the PubMed, Cochrane, SCOPUS, and CINAHL databases was performed to identify randomized controlled trials that reported the efficacy of autologous blood injection in treating lateral epicondylosis. The selected studies were subjected to a meta-analysis and risk of bias assessment. PARTICIPANTS: Patients with lateral epicondylosis. MAIN OUTCOME MEASURES: Pain-related measurement in each selected randomized controlled trial was pooled into meta-analysis. RESULTS: Nine randomized controlled trials were included in the analysis. The results of the meta-analysis including the pain scores indicated that autologous blood injection is more effective compared with corticosteroid injection (standard mean difference: -0.75; 95% confidence interval: -1.14 to -0.37) but not more effective compared with platelet-rich plasma injection (standard mean difference: 0.09; 95% confidence interval: -0.66 to 0.84). The risk of bias assessment indicated that all the included trials exhibited a moderate to high risk of bias. CONCLUSION: Autologous blood injection is more effective than corticosteroid injection but not more effective than platelet-rich plasma injection in treating lateral epicondylosis. However, this evidence is limited by the potential risk of bias.

Systematic review

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Efficacy and Safety of Autologous Blood Products Compared With Corticosteroid Injections in the Treatment of Lateral Epicondylitis: A Meta-Analysis of Randomized Controlled Trials

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Authors Qian X. , Lin Q. , Wei K. , Hu B. , Jing P. , Wang J.
Journal PM and R
Year 2016
Links Pubmed DOI

This article is included in 1 Broad synthesis 10 Broad syntheses (1 reference)

This article includes 10 Primary studies 10 Primary studies (10 references)

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OBJECTIVE: To compare the efficacy and safety of autologous blood products (ABPs) and corticosteroid injections (CSIs) in the treatment of lateral epicondylitis. TYPE OF STUDY: Meta-analysis. LITERATURE SURVEY: We systematically searched EMBASE, PubMed, the Cochrane Library, and Web of Science to identify randomized controlled trials (RCTs) that compared ABPs with CSIs for the treatment of lateral epicondylitis without language and publication date restriction through April 2015. METHODOLOGY: Two investigators independently included and assessed the quality of each eligible study according to the method recommended by the Cochrane Collaboration. Available data about the main outcomes were extracted from each study and heterogeneity was assessed using the Q statistic and the inconsistency index (I2). We also evaluated the publication bias and conducted a subgroup analysis. Review Manager 5.2 software was used for data syntheses and analyses, and the standardized mean difference (SMD) or mean difference (MD) was estimated by using random effects models with a 95% confidence interval (CI). To investigate the efficacy among different trial durations, the follow-up times were divided into short periods (2-4 weeks), intermediate periods (6-24 weeks) and long-term periods (≥24 weeks). SYNTHESIS: Ten RCTs (n = 509) were included in this meta-analysis. The pooled analysis showed that CSIs were more effective than ABPs for pain relief in the short term (SMD = 0.88; 95% CI = 0.31-1.46%; P = .003). However, in the intermediate term, ABPs exhibited a better therapeutic effect for pain relief (SMD = −0.38; 95% CI = −0.70 to −0.07%; P = .02), function (SMD = −0.60; 95% CI = −1.13 to −0.08%; P = .03), disabilities of the arm, shoulder, and hand (MD = −11.04; 95% CI = −21.72 to −0.36%; P = .04), and Nirschl stage (MD = −0.81; 95% CI = −1.11 to −0.51%; P < .0001). In the long term, ABPs were superior to CSIs for pain relief (SMD = −0.94; 95% CI = −1.32 to −0.57%; P < .0001) and Nirschl stage (MD = −1.04; 95% CI = −1.66 to −0.42%; P = .001). Moreover, for grip strength recovery, no significant difference was found between the 2 therapies (P > .05). CONCLUSIONS: Limited evidence supports the conclusion that CSIs are superior to ABPs for pain relief in the short term; however, this result was reversed in the intermediate and long term. ABPs seemed to be more effective at restoring function in the intermediate term. Because of the small sample size and the limited number of high-quality RCTs, more high-quality RCTs with large sample sizes are required to validate this result.

Systematic review

Unclassified

Does nonsurgical treatment improve longitudinal outcomes of lateral epicondylitis over no treatment? A meta-analysis.

Authors Sayegh ET , Strauch RJ
Journal Clinical orthopaedics and related research
Year 2015
Links Pubmed DOI PubMed Central

This article is included in 1 Broad synthesis 22 Broad syntheses (1 reference)

This article includes 22 Primary studies 22 Primary studies (22 references)

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BACKGROUND: Lateral epicondylitis is a painful tendinopathy for which several nonsurgical treatment strategies are used. Superiority of these nonsurgical treatments over nontreatment has not been definitively established. QUESTIONS/PURPOSES: We asked whether nonsurgical treatment of lateral epicondylitis compared with observation only or placebo provides (1) better overall improvement, (2) less need for escape interventions, (3) better outcome scores, and (4) improved grip strength at intermediate- to long-term followup. METHODS: The English-language literature was searched using PubMed and the Cochrane Central Register of Controlled Trials. Randomized-controlled trials (RCTs) comparing any form of nonsurgical treatment with either observation only or placebo at followup of at least 6 months were included. Nonsurgical treatments included injections (corticosteroid, platelet-rich plasma, autologous blood, sodium hyaluronate, or glycosaminoglycan polysulfate), physiotherapy, shock wave therapy, laser, ultrasound, corticosteroid iontophoresis, topical glyceryl trinitrate, or oral naproxen. Methodologic quality was assessed with the Consolidated Standards of Reporting Trials (CONSORT) checklist, and 22 RCTs containing 2280 patients were included. Pooled analyses were performed to evaluate overall improvement; requirement for escape interventions (treatment of any kind, outside consultation, and surgery); outcome scores (Patient-Rated Tennis Elbow Evaluation [PRTEE]; DASH; Pain-Free Function Index [PFFI]; EuroQoL [EQ]-5D; and overall function); and maximum and pain-free grip strength. Sensitivity analyses were performed using only trials of excellent or good quality. Heterogeneity analyses were performed, and funnel plots were constructed to assess for publication bias. RESULTS: Nonsurgical treatment was not favored over nontreatment based on overall improvement (risk ratio [RR] = 1.05 [0.96-1.15]; p = 0.32), need for escape treatment (RR = 1.50 [0.84-2.70]; p = 0.17), PRTEE scores (mean difference [MD] = 1.47, [0.68-2.26]; p < 0.001), DASH scores (MD = -2.69, [-15.80 to 10.42]; p = 0.69), PFFI scores (standardized mean difference [SMD] = 0.25, [-0.32 to 0.81]; p = 0.39), overall function using change-from-baseline data (SMD = 0.11, [-0.14 to 0.36]; p = 0.37) and final data (SMD = -0.16, [-0.79 to 0.47]; p = 0.61), EQ-5D scores (SMD = 0.08, [-0.52 to 0.67]; p = 0.80), maximum grip strength using change-from-baseline data (SMD = 0.12, [-0.11 to 0.35]; p = 0.31) and final data (SMD = 4.37, [-0.65 to 9.38]; p = 0.09), and pain-free grip strength using change-from-baseline data (SMD = -0.20, [-0.84 to 0.43]; p = 0.53) and final data (SMD = -0.03, [-0.61 to 0.54]; p = 0.91). CONCLUSIONS: Pooled data from RCTs indicate a lack of intermediate- to long-term clinical benefit after nonsurgical treatment of lateral epicondylitis compared with observation only or placebo. LEVEL OF EVIDENCE: Level II, therapeutic study.

Systematic review

Unclassified

Comparative effectiveness of injection therapies in lateral epicondylitis: A systematic review and network meta-analysis of randomized controlled trials

Journal Annals of the Rheumatic Disease
Year 2013
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Background Injection therapy with glucocorticoids has been used since the 1950s as a treatment strategy for lateral epicondylitis (tennis elbow). Lately several other injection therapies have become available. Objectives Using a systematic review and network meta-analysis, our objective was to assess the comparative effectiveness of different injection therapies used for pain reduction. Methods Structured literature searches in Medline, Embase, Cinahl, Web of Science, and the Cochrane Clinical Trials Database. Selected studies were randomized controlled trials comparing different injection therapies and/or placebo injections for lateral epicondylitis. Risk of bias was assessed in each of the included trials. The outcome measures were change in pain intensity at the end of the masked trial period (i.e., endpoint) and adverse events. Network (random effects) meta-analysis was applied to combine direct and indirect evidence within and across trial data. Following the arm-based network meta-analysis standardized mean differences (SMDs) were used as the effect size based on differences between means divided by the pooled standard deviation. Results Seventeen trials (1381 patients) allocating individuals to injection with glucocorticoid, botulinum toxin, platelet-rich plasma, autologous blood, hyaluronic acid, prolotherapy, polidocanol, glycosaminoglycan polysulfate, and/or placebo, fulfilled the inclusion criteria. Only 3 (18%) of the trials were judged to be at low risk of bias: one trial of glucocorticoid compared to platelet-rich plasma, and placebo-controlled trials of prolotherapy and polidocanol. Pooled results from all included studies showed that glucocorticoid injection (investigated in 12 treatment arms with 310 patients) was no more effective than placebo with respect to improvement in pain (SMD -0.04 [95% CI -0.45 to 0.35], P=0.81); Botulinum toxin injection (4 treatment arms with 130 patients) was statistically significant but clinically only marginally more effective than placebo (-0.50 [-0.91 to -0.08], P=0.023); whereas autologous blood injection investigated in three treatment arms with 96 patients (-1.43 [-2.15 to -0.71], P =0.001) and platelet-rich plasma with two treatment arms and 114 patients (-1.13 [-1.77 to -0.49], P =0.002) were both clearly more efficacious than placebo. Neither polidocanol (one treatment arm, 18 patients) nor glycosaminoglycan polysulfate (one treatment arm, 32 patients) were found to be superior to placebo, while prolotherapy (one treatment arm, 10 patients) and hyaluronic acid (one treatment arm, 165 patients) were both found to be much more efficacious than placebo (-2.71 [-4.60 to -0.82], P =0.009, and -5.58 [-6.35 to -4.82], P <0.0001 respectively). Conclusions Our study found that most trials that have assessed the value of injection therapy for lateral epicondylitis are at high risk of bias and that their results therefore need to be interpreted with caution. Further high quality trials are needed in this area.