Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials

Abstract

ObjectiveTo evaluate the effectiveness of exercise compared with other conservative interventions in the management of lateral elbow tendinopathy (LET) on pain and function.DesignSystematic review and meta-analysis.MethodsWe used the Cochrane risk-of-bias tool 2 for randomised controlled trials (RCTs) to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation methodology to grade the certainty of evidence. Self-perceived improvement, pain intensity, pain-free grip strength (PFGS) and elbow disability were used as primary outcome measures.Eligibility criteriaRCTs assessing the effectiveness of exercise alone or as an additive intervention compared with passive interventions, wait-and-see or injections in patients with LET.Results30 RCTs (2123 participants, 5 comparator interventions) were identified. Exercise outperformed (low certainty) corticosteroid injections in all outcomes at all time points except short-term pain reduction. Clinically significant differences were found in PFGS at short-term (mean difference (MD): 12.15, (95% CI) 1.69 to 22.6), mid-term (MD: 22.45, 95% CI 3.63 to 41.3) and long-term follow-up (MD: 18, 95% CI 11.17 to 24.84). Statistically significant differences (very low certainty) for exercise compared with wait-and-see were found only in self-perceived improvement at short-term, pain reduction and elbow disability at short-term and long-term follow-up. Substantial heterogeneity in descriptions of equipment, load, duration and frequency of exercise programmes were evident.ConclusionsLow and very low certainty evidence suggests exercise is effective compared with passive interventions with or without invasive treatment in LET, but the effect is small.PROSPERO registration numberCRD42018082703.

Development of an optimised physiotherapist-led treatment protocol for lateral elbow tendinopathy: a consensus study using an online nominal group technique

“…Indeed, even more consistently used treatments, such as exercise therapy, lack a consistent approach to delivery with no consensus on the types of exercise to include, dose of exercise to prescribe and whether exercise should provoke pain or be pain free. [12][13][14][15][16] Physiotherapy treatment packages are complex interventions involving a combination of verbal and non-verbal communication, patient education and delivery of therapeutic modalities. When designing complex interventions, the purpose should be clear and the intervention should be informed by evidence prior to pilot and feasibility testing.…”

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

“…Despite that shockwave therapy is rarely applied as a monotherapy in clinical practice, an optimal management for patients with lateral elbow tendinopathy remains inconclusive. 8 Contemporary evidence suggests that exercise is the primary treatment option; 7 however, only a few trials 37,40,41,43,44,55,56,59 have used an exercise programme along with extracorporeal shockwave therapy. Therefore, transferability of the present findings in pragmatic clinical situations is somewhat limited.…”

“…In the area of grading the certainty of evidence and when one trial was available, we started from ‘low certainty’ and then downgraded certainty in the case of ‘low’ or ‘moderate quality’ on PEDro scale. Although similar methods have been used in previous meta-analysis, 7,9,69 validity of the described method is lacking.…”

“…15 When one trial was available, the evidence was graded as low certainty, and if it also had low quality was graded as very low certainty. 7,9…”

“…A variety of therapeutic techniques have been proposed for the appropriate management of patients with lateral elbow tendinopathy including exercise, orthotics, manual therapy, passive modalities, acupuncture or a combination of them. 5,7,8 However, the effectiveness of each treatment option remains debatable. 8 Extracorporeal shockwave therapy is a popular method in the management of common tendinopathies and has been proposed as an effective supplement to other non-invasive therapies.…”