Extracorporeal shock-wave treatment for tennis elbow

Abstract

he efficacy of extracorporeal shock-wave therapy for tennis elbow was investigated using a single fractionated dosage in a randomised, double-blind study. Outcomes were assessed using the Disabilities of Arm, Shoulder and Hand questionnaire, measurements of grip strength, levels of pain, analgesic usage and the rate of progression to surgery. Informed consent was obtained before patients were randomised to either the treatment or placebo group. In the final assessment, 74 patients (31 men and 43 women) with a mean age of 43.4 years (35 to 71), were included.None of the outcome measures showed a statistically significant difference between the treatment and control groups (p > 0.05). All patients improved significantly over time, regardless of treatment. Our study showed no evidence that extracorporeal shock-wave therapy for tennis elbow is better than placebo. Tennis elbow (lateral epicondylitis) is a condition whose aetiology is poorly understood. The principal symptom is pain located at the lateral epicondyle of the humerus and the common extensor origin just distal to it. The pain quite commonly radiates distally over the extensor surface of the forearm and tends to worsen with activities which require action of the extensor muscles. The onset of symptoms is usually abrupt after an unaccustomed activity, but it may T also be gradual. It usually follows a protracted course, with the degree of pain increasing and decreasing. The principal methods of treatment include splinting, physiotherapy, ultrasound and functional bracing, as with a tennis elbow clasp. If these measures fail, injection of corticosteroids into the common extensor origin is usually given. Surgery is reserved for persistent cases. The commonly used term 'lateral epicondylitis' implies inflammation, but it has not been possible to demonstrate inflammation in pathological specimens, either in the acute or chronic form, because most patients had previously received local injections. Although extracorporeal shock wave therapy (ESWT) has been used extensively for a variety of orthopaedic conditions, the mechanism of its effect on bone and soft tissues remains controversial. Its effect on tennis elbow and on other orthopaedic conditions is unproven because of the lack of randomised, double-blind studies with adequate power. We have attempted to address this deficiency in this study. Patients and MethodsWe recruited 158 patients (70 men and 88 women) into the study all of whom had received extensive conservative treatment and were awaiting surgery. They were sent information about the planned study by post and 141 (63 men and 78 women) who responded were invited to an initial screening clinic. The senior author (LCB) examined each patient to apply the inclusion and exclusion criteria (Table I). He excluded 55 patients (28 men and 27 women), either because it was not possible to make a firm diagnosis of tennis elbow, or because they had a criterion for exclusion. An in-depth discussion of the design of the study and the proposed form of treatment was ...

What is the clinical effectiveness and cost-effectiveness of conservative interventions for tendinopathy? An overview of systematic reviews of clinical effectiveness and systematic review of economic evaluations

“…Buchbinder et al 58 performed searches up to and including February 2005. A total of 10 RCTs were included in their review, [84][85][86][87][88][89][90][91][92][93] with nine RCTs [85][86][87][88][89][90][91][92][93] (1006 participants) comparing ESWT with placebo and one 94 comparing ESWT with a steroid injection (93 participants). Data from six trials were pooled.…”

“…87,89,90,95 Results from two placebo-controlled trials could not be pooled because of inadequate reporting of results. 91,93 Further information is available in the Cochrane review of ESWT for LET (published online 2005). 96 Electrocorporeal shock wave therapy compared with placebo The nine placebo-controlled trials [85][86][87][88][89][90][91][92][93] reported conflicting results, with three trials [85][86][87] reporting significant differences in favour of ESWT for pain and function, whereas four trials reported no benefit of ESWT over placebo for these outcomes.…”

“…91,93 Further information is available in the Cochrane review of ESWT for LET (published online 2005). 96 Electrocorporeal shock wave therapy compared with placebo The nine placebo-controlled trials [85][86][87][88][89][90][91][92][93] reported conflicting results, with three trials [85][86][87] reporting significant differences in favour of ESWT for pain and function, whereas four trials reported no benefit of ESWT over placebo for these outcomes. [88][89][90][91] However, when the available data were pooled, the authors found that most benefits observed in the positive trials were no longer statistically significant.…”

Treatment of Refractory Lateral Epicondylitis of Humerus with Local Autologous Plasma Injection

“…In our study this sort of complication did not occur as this is abiologic form of treatment. Extracorporial shock wave therapy was shown to be no better than placebo in a recent study 18 .in present day orthopaedics biological treatment modalities are gaining popularity.bone morphogenic protin and other growth factors have been studied in vitro and presently are being tested in vivo also 19 .the study by Edwards and calandrucciio showed that 22/28 pts responded to autologous blood injection 20 .we used autologous plasma instead of blood to decrease the volume of injection and also to avoid the deposition of iron locally following breakdown of Rbcs .Mishra and pavelko introduced platelet rich plasma technique in the treatment of chronic elbow tendonitis. 21 klein et al 23 reported in their study that TGF ß increase type 1 collagen production in tendon sheath fibroblasts.these mechanism may be work in our study also.further study of autologous plasma versus whole blood or steroid should also be performed in the future.the data suggests autologous plasma may be an alternative to surgery in patients with this disorder of its kind.To conclude the use of autologous plasma injection method provides biologic healing and is an effective solution for refractory lateral epicondylitis of humerus and similar disorders.…”

Treatment of Refractory Lateral Epicondylitis with Platelet-Rich Plasma

“…국소화된 냉요법이 도움이 될 수 있 으며, 직류전기 자극용법이 통증을 완화 시킬 수 있다 5,7,8,13) . 이온 삼투 요법 또한 통증 완화에 사용될 수 있 지만, 이중 맹검 위약-대조군 연구에서는 효과가 의미 없는 것으로 보고된 바 있다 16) . 혈소판 풍부 혈장은 말 초혈액에 비해 5~10배 농축된 양의 혈소판을 함유 하 고 있으며, 혈소판 내에는 여러 성장인자 (growth factor)를 비롯하여 손상된 조직의 회복 및 재생에 필 요한 생활성화 인자가 풍부하게 포함되어 있다 15) .…”