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Rehabilitation for Patients with LateralEpicondylitis:

A Systematic Review

Daniel Trudel, BSc, MSc, PTCanadian Forces BaseKingston, Ontario, Canada

Jennifer Duley, BHSC, MSc, PTGrand River HospitalKitchener, Ontario, Canada

Ingrid Zastrow, BA, MSc (PT)West Lincoln Memorial HospitalGrimsby, Ontario, Canada

Erin W. Kerr, BSc, MSc, PTWest Vancouver Orthopaedic and Sports Physical TherapyVancouver, Britsh Columbia, Canada

Robyn Davidson, BSc, BPHE, Bed, MSc, PTSchool of Rehabilitation Science

McMaster University Hamilton, Ontario, Canada

Joy C. MacDermid, BScPT, PhDSchool of Rehabilitation Science

McMaster University Hamilton, Ontario, CanadaClinical Research Lab

Hand and Upper Limb CentreSt. Josephs Health CentreLondon, Ontario, CanadaCareer Scientist of the Ontario Ministry of Health

Health Research Personnel Development Program

ABSTRACT: The purpose of this systematic review was todetermine the effectiveness of conservative treatments for lateralepicondylitis and to provide recommendations based on thisevidence. Five reviewers searched computerized bibliographicdatabases for articles on the conservative treatment of lateralepicondylitis from the years 1983 to 2003. A total of 209 studieswere located; however, only 31 of these met the study inclusioncriteria. Each of the articles was randomly allocated to reviewersand critically appraised using a structured critical appraisal tool

with 23 items. Treatment recommendations were based on thisrating and Sacketts Level of Evidence. This review has de-termined, with at least level 2b evidence, that a number oftreatments, including acupuncture, exercise therapy, manipula-tions and mobilizations, ultrasound, phonophoresis, Rebox, andionization with diclofenac all show positive effects in thereduction of pain or improvement in function for patients withlateral epicondylitis. There is also at least level 2b evidenceshowing laser therapy and pulsed electromagnetic field therapy to

be ineffective in the management of this condition. Practitionersshould use the treatment techniques that have strongest evidenceand ensure that studies findings are generalized to patients whoare similar to those reported in primary research studies in termsof patient demographics and injury presentation.

J HAND THER. 2004;17:243266.

Lateral epicondylitis, often termed tennis elbow,

is defined as a syndrome of pain in the wrist extensormuscles at or near their lateral epicondyle origin orpain directly over the epicondyle.1 The primaryclinical features of this syndrome are discomfort ofthe lateral elbow, pain and tenderness at or slightly

distal to the lateral epicondyle, and tenderness of the

proximal muscle mass. A clinical diagnosis is oftenfounded on an appropriate history and confirmatoryphysical signs, i.e., pain reproduced by resisted wristextension.1 Fibroblastic and vascular degenerationoften associated with repetitive activity, particularlywith rotation of the forearm and forceful gripping,are accepted as key features.13 The extensor carpiradialis brevis is consistently involved, althoughapproximately 30% of patients also have involve-ment of the extensor digitorum communis.1 Individ-uals at high risk for this type of overuse injury arethose in the occupations of construction, assembly,

Research funding was provided by the Ontario Workplace Safetyand Insurance Board (WSIB).

Correspondence and reprint requests to Joy C. MacDermid,BScPT, PhD, School of Rehabilitation Science, IAHS, 1400 MainStreet West, 4th Floor, Hamilton, Ontario, Canada L8S 1C7; e-mail:.

doi:10.1197/j.jht.2004.02.011

AprilJune 2004 243
mailto:[email protected]:[email protected]

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manufacturing, food processing, and forestry.1,4 Painrelief, preservation of movement, and muscle condi-tioning are the primary objectives of the rehabilita-tion of lateral epicondylitis. Despite extensiveresearch on the topic, a clear understanding of therole for conservative management remains elusive.Chronic or recurrent cases and treatment failures arecommon. The purpose of this article is to providea comprehensive systematic review of the current

evidence on the conservative treatment for lateralepicondylitis (excluding splinting and extracorporalshock wave) with a goal of guiding practice andidentifying research gaps.

OBJECTIVES

Using a group consensus process the followingquestion was defined: What is the current evidence tosupport or refute the use of conservative rehabilita-tion treatment interventions for lateral epicondylitis?

Search Strategy

A search of Medline, CINAHL, EMBASE, PEDro,and the Cochrane database from January 1983 up toand including March 2003 was conducted. Searchterms used for inclusion were: physical therapytechniques, rehabilitation, tennis elbow, elbow, lat-eral epicondylitis, epicondylalgia, rehabilitation,complementary therapies, conservative treatment,tendonitis, ultrasound, acupuncture, TENS, electricalstimulation, friction massage, manual therapy tech-niques, mobilizations, exercise, laser, wait and see,shortwave diathermy, steroid injections, injections,

and exercise movement techniques, Studies with anemphasis on surgery, splints (see issue review on thistopic), shock wave therapy, or casts were excluded.Additionally, the search was limited to English only,adults (age 18+), humans, and randomized con-trolled trials (RCTs) or quasi-RCTs.

The electronic search was complemented by handsearches of bibliographic references.

Two hundred three references were retrieved bysearch; however, only 31 of these articles wereincluded in this review.

Methods of Review

Five independent reviewers examined titles andabstracts of the studies identified by the searchstrategy to select trials that met the inclusion criteria.All trials classified as relevant by at least one of thereviewers were retrieved. The retrieved articles werereexamined to ensure that they met the inclusioncriteria.

Thirty-eight articles were randomized by a num-bering system; the evaluators were all blinded to therandomization process. Two independent evaluators,using the appraisal form developed by Dr. Joy

MacDermid, which is published in this issue, thencriticallyappraised each article. A consensuswas thenreached on the methodologic quality of the studies asper the scores on the appraisal form and as rated bySacketts Levels of Evidence (see introductory articlein this issue). If a consensus could not be reached, thena third independent evaluator was brought in to settlethe difference. During this evaluation process, sevenarticles were found not to meet the inclusion criteria

once full study information was available and weretherefore excluded at this stage.

RESULTS

Previous Relevant Literature

There have been a number of systematic reviewspreviously published looking at the effectiveness ofvarious treatments on lateral epicondylitis. In 1996,Assendelft et al.5 looked at the effectiveness ofcorticosteroid injections for lateral epicondylitis. This

review found that at that time, no conclusive reportscould be made on the effectiveness of the injections.This was due to the serious methodologic flawsfound in the studies. In 2002, Smidt et al.6 conductedanother systematic review on the effectiveness ofcorticosteroid injections for lateral epicondylitis. Thisreview found that corticosteroid injections hada positive short-term effect; however, due to the lackof high-quality studies, it was not possible to drawdefinitive conclusions.

In 1999, van der Windt et al.7 looked at thetreatment effects of ultrasound therapy for musculo-skeletal disorders. Thirty-eight studies were in-cluded in this review; however, only six of thesestudies looked at lateral epicondylitis. This reviewconcluded that there was little evidence to supportthe use of ultrasound therapy in the treatment ofmusculoskeletal disorders.

In 2002, Struijs et al.8 conducted a systematicreview looking at the effects of orthotic devices forlateral epicondylitis. This study also found that nodefinitive conclusions could be drawn due to themethodologic flaws present in the studies reviewed.

In 2001, Bernstein9 conducted a review to de-termine how effective surgical and injection therapy

was in the management of chronic pain. This reviewfound that local triamcinolone injection (greater thanor equal to 12 weeks) is effective for the relief of paindue to lateral epicondylitis (level 2). It was also foundthat there was limited evidence of effectiveness (level3) for local glycosaminoglycan polyphosphate in-

jection for lateral epicondylitis. Bernstein also statedthat overall there was a lack of methodologicallysound studies for surgery and injection therapies.

In 2001, Mior10 looked at the effects of exercise inthe treatment of chronic pain. This review includedonly one study looking at the upper extremity. This

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study found positive effects for exercise in thetreatment of chronic lateral epicondylitis and forspecific soft tissue shoulder disorders. However, dueto the poor methodologic quality of the study (level3), definitive conclusions could not be given.

The most recent review was conducted in 2003 bySmidt et al.11This review looked at the effectiveness ofphysiotherapy for lateral epicondylitis. The studyincluded 23 RCTs and found that two of the studies

that compared ultrasound with a placebo ultrasoundshow statistically significant and clinically relevantdifferences in favor of ultrasound.There was, however,insufficient evidence to demonstrate benefit or lack ofeffect for laser therapy, electrotherapy, exercises, andmobilization techniques for lateral epicondylitis.

Cochrane Reviews

In 2002, the Cochrane Library published a number ofreviews looking at various treatments for lateralepicondylitis. One review by Buchbinder et al.12

examined the effects of surgery for the treatment oflateralelbowpain.Thisreviewfoundthattherewerenocontrolled trials investigating the effect of surgery onlateral elbow pain. Therefore, no conclusions could bedrawn on the value of this type of treatment.

Another review by Green et al.13 examined theeffects of nonsteroidal anti-inflammatory drugs(NSAIDs) for the treatment of lateral elbow pain(tennis elbow) in adults. This review found that thereis some support for the use of topical NSAIDs torelieve lateral elbow pain at least in the short term.There was, however, insufficient evidence to recom-mend or discourage the use of oral NSAIDs, althoughit appeared that injection may be more effective thanoral NSAIDs in the short term. There also had beenno studies found directly comparing topical to oralNSAIDs, so no conclusions could be drawn re-garding the best method of administration.

The Cochrane Library also examined the effects ofshock wave therapy for lateral elbow pain. Thisreview by Buchbinder et al.14 found that the twostudies that were included yielded different results.One study demonstrated highly significant differ-ences in favor of shock wave therapy, whereas theother study found no benefits of shock wave therapy

over the placebo.A review on the effectiveness of orthotic devices

for the treatment of tennis elbow was conducted. Theresults of this review have already been reported inthe previous relevant literature section.8

Another review that was conducted in 2002 byGreen et al.15 examined the effectiveness of acupunc-ture in the treatment of lateral elbow pain. Thisreview found that there was insufficient evidence toeither support or refute treatment of acupuncture(either needle or laser) in the treatment of lateralelbow pain. This review demonstrated needle acu-

puncture to be of short-term benefit with respect topain; however, this conclusion was based on findingsfrom two small trials. There was no treatment benefitfound to last more than 24 hours.

Current Review

Study results are summarized in Tables 13.

Ultrasound

Six studies ranging from level 1b to 2b16 usinga total of 332 subjects examined the use of ultrasoundin the treatment of lateral epicondylits.1722 Qualityscores for these studies ranged from 25 to 41 out of48. Four studies found that using ultrasound aloneand ultrasound in combination with other treatmentscould decrease pain from lateral epicondylitis. Thestudies by Stratford et al.,17 Binder et al.,19 andLundeberg et al.20 found significant short-termeffects in reducing pain using ultrasound alone.Stratford et al.17 also examined ultrasound in

combination with friction massage, phonophoresisalone, and phonophoresis with friction massage, andfound all treatments to be beneficial for decreasingpain; however, no one treatment was superior toanother. Halles et al.18 looked at the effects ofultrasound in combination with hydrocortisone andfound a significant reduction in pain. The studies byPienimaki et al.21,22 both found that progressiveexercise therapy is more beneficial than ultrasoundin acute and chronic lateral epicondylitis.

Acupuncture

Five level 1b and 2b16

studies with quality scoresranging from 19 to 39 out of 48 were examined.2327

These studies included 308 subjects with lateralepicondylitis and revealed that acupuncture helpedto decrease pain associated with this condition. Finket al.23,24 found that the experimental group who hadacupuncture at six sites (One Ash point, LI 10 and LI11, Lu 5, LI 4 and SJ 5) had significantly greaterreduction in pain over the control group at the two-week follow up. Molsberger et al.24 found significantpain relief in the acupuncture group who receivedneedling at a nonsegmental distal point of the

fibulotibial joint of the homolateral leg (GB 34) overthe control group 72 hours posttreatment. Whenexamining different methods of needling, Younget al.26 found that floating acupuncture produced

better initial analgesic responses than routine acu-puncture. Haker et al.27 reported that for short-termpain relief, classic deep acupuncture was superior tosuperficial needling.

Rebox

One level 2b16 study by Johannsen et al.28 exam-ined the effects of Rebox on lateral epicondylitis. This

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study scored 31 out of 48 and included 35 subjects. Itwas concluded that Rebox produced significant

beneficial effects on pain, grip strength, and func-tional performance for individuals with lateralepicondylitis.

Wait and See

The level 2b16 study by Smidt et al.29 examineda total of 185 individuals and obtained a quality score

of 37 out of 48. Results revealed that corticosteroidinjections were superior for short-term relief of painand improvement of function in patients with lateralepicondylitis. However, physiotherapy treatment(ultrasound, friction massage, and exercise) was the

best option for long-term improvement, followed bya wait-and-see treatment.

Exercise

Four level 1b and 2b16 studies examined the effectsof exercise in the treatment of lateral epicondy-

lits.

21,22,30,31

These studies contained a total of 125participants and their scores ranged from 25 to 37 outof 48. All four studies found that progressivestrengthening and stretching programs had signifi-cantly greater reductions in pain than the alternativetreatment state. The studies by Newcomer et al.,30

Pienimaki et al.,22 and Svernlov et al.31 also founda statistically significant increase in grip strength inthose who participated in the strengthening andstretching programs.

Ionization

Two level 2b16 studies examined the effects ofionization on a total of 64 individuals with lateralepicondylitis.32,33 These studies quality scores were

both 25 out of 48. The study by Vecchini et al.32 foundthat 20 (30-minute) treatments of ionization withdiclofenac for one month resulted in a significantlygreater reduction in pain compared with placeboionization with saline. The study by Demirtas et al.33

found that ionization with sodium diclofenac for 20minutes, one time per day, five days per week for tendays followed by 20 minutes of infrared treatmenthad a significantly greater reduction in pain com-

pared with ionization with sodium salicylate andinfrared treatment.

Pulsed Electromagnetic Field

One level 2b16 study by Devereaux et al.34

examined the effects of electromagnetic field ther-apy on 30 subjects with lateral epicondylitis. Thisstudy was given a quality score of 36 out of 48. Itwas found that there was no significant difference

between the experimental group and the placebogroup with respect to pain and grip strength.

Researchers were unable to show an advantage inrecovery for those treated with pulsed electromag-netic field therapy.

Mobilization and Manipulations

Two level 2b16 studies examined the effects ofmobilization as a treatment for lateral epicondyli-tis.35,36 These studies looked at a total of 42

participants and were given quality scores rangingfrom 30 to 37 out of 48. The study by Drechsler et al.35

found that a combination of mobilizations of theradial head and neural tension techniques wassuperior to the standard physiotherapy treatment(ultrasound, stretching, strengthening, and friction)for both recreational and occupational status. Thestudy by Vincenzio et al.36 used a mobilization withmovement technique and found that this demon-strated a hypoanalgesic effect during and aftertreatment. Two level 2b16 studies examined theeffects of manipulation as a treatment for lateral

epicondylitis.37,38 The studies were given qualityscores that ranged from 23 to 30 out of 48. Thesestudies included a total of 139 subjects. The first study

by Burton et al.37 looked at manipulation alonecompared with manipulation in addition to a forearmstrap, manipulation with the use of an antiinflamma-tory cream, or manipulation with a strap and cream.It was found that the use of an antiinflammatorycream and/or forearm strap, in addition to manipu-lation, was no more effective than manipulationalone. The second study by Verhaar et al.38 foundthat corticosteroid injections were superior to Cyriax

physiotherapy (deep transverse friction massage andMills manipulation) for short-term pain reduction.

Laser

Six level 1a and 2b16 studies3944 examined a totalof 294 subjects and collectively investigated theeffects of laser therapy versus placebo laser therapyin the treatment of lateral epicondylitis. The scoresfor the studies ranged from 29 to 44 out of 48. Theoutcomes used in these studies included gripstrength, pain severity, and an incremental lifting

test. The findings of all six studies suggest that laseris not significantly better than placebo laser for any ofthese outcomes in the treatment of lateral epicondy-litis. When used in combination with traditionalphysiotherapy, Vasseljen et al.45 found that laserprovided no greater benefit for pain and gripstrength. This study included 30 subjects and hada quality score of 30 of 48. Alternatively, two level2b16 studies46,47 with a total of 93 subjects and scoresranging from 31 to 39 out of 48 indicated that therewas significant short- and long-term improvementon pain, grip strength, and incremental lifting.


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TABLE 1. Background Information of Studies

Study Patients Interventions Evaluations

No. of Subjects (n)Sex (M/F)Age Type and

Duration of

symptoms Type Time Frequency

dWhen

Administered

Stratford PW,et al., 1989

n = 4020 M; 20 FAge: 31.854.4 yrsSymptom

duration: 0.912.4months

1. Ultrasound andplacebo ointmentwithout frictionmassage

US/Phonophoresis:6 minFriction:10 min

33per week 1. D ichotomousrating of successor failure

2. Ultrasound andplacebo ointment

with frictionmassage

2. VAS pain

3. Phonophoresiswithout frictionmassage

3. VAS function

4. Phonophoresis withfriction massage

4. Grip strength

dAdministeredpre- andpost-treatmentand withinfive weeks ofinitial visit

Halle JS, et al.,1986

n = 4822 M; 26 F

Age: 2059 yrsSymptom duration:N/A

1. US with couplingagent and home

program

US: N/ATENS: N/A

Injection: N/ATennis elbow

cuff: duringall normal dayactivityremovedat night

Homeice massage:23day

Five consecutivework days with

all protocolsexcept injection

Injection wereinjected once,then reevaluatedafter one week

1. McGillPain

Questionnaire2. US with a 10%

hydrocortisone-coupling agent andhome program

3. TENS and homeprogram

4. Injection withlidocaine andhydrocortisone andhome program

dHome programconsists of tenniselbow cuff, avoidingstrenuous activity,and home icemassage

Binder A, et al.,1985

n = 76 1. Ultrasound US: pulsed 1:4;1.0 MHz;510 min

US: 12 Rx weregiven (23 perwk) over46 wks

1. VAS pain28 M; 48 F 2. Placebo 2. Lifting testAge: 29-65 yrs 3. Grip strengthSymptom

duration:at least onemonth

dAdministered atbaseline andevery two wks,as well as atone-monthfollow up, oneyear later asquestionnaire

or reexaminedto assessnatural history

Lundeberg T,et al., 1988

n = 99 1. US US: continuous;1 mHz; 10 min

10 Rx: 23/wkover 56 wks

1.VAS pain63 M; 43 F 2. Placebo 2. Resisted wrist DFAge: 2168 yrs 3. Rest 3. Lifting testSymptom

duration:at least onemonth

4. Grip strength5. Patient satisfactiondAdministered at

baseline and everytwo weeks for onewk; follow-up examat three months

(continued on next page

)

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TABLE 1. (continued)


Fink M,et al.

Rheumatology.2002;41:2059

n = 80 1. Acupuncture Acupuncture:six needles:Ash point, LI10,LI11, Lu5, LI4,SJ5; twistingneedles until a DeQi sensationwas induced;

25 minSham: six

needles: Puncturesites five cm awayfrom the classicpoints and theirinterconnectingmeridians and alsoclear of painfulpressure points(Ah-Shi ortrigger points),25 min

23per weekfor two weeks

1. Peak muscleforceSymptom duration

3+ months2.Sham

Acupuncture 2. Pain at rest,in motion,during exertion,duration,frequency)

Acupuncturegroup:19 M;23 F

3.DASH

questionnaire:functionalimpairment

Age: 52.568.7 yrs

Symptom duration:median eightmonths

Sham acupuncturegroup:12 M; 26 FAge: 51.6610.0 yrs

Symptomduration:median 10.5months

Fink M, et al.

ForschKomplementarmedKlassNaturheilkd.2002;9:2105

n = 45 at baseline

At follow-up 1:

1.Acupuncture Acupuncture:

(six needles)LI10, LI11,on pointover muscular originof lateral extensorgroup of forearm,L5, LI4, SJ5; 25 min

Sham acupuncture:(six needles) siteswere 5 cm awayfrom traditionalsites, needlesinserted in same wasand stimulated,

25 min

10 Rx; 23/wk 1. s ix point VRS

Pain: at rest,on motion,on exertion

n = 422.Sham

acupuncture

2. Subjectivefrequencyand durationof pain periods

19 M; 23 F

dAssessed atbaseline, twowks, two months,12 months

Age Rx: 52.58.7 yrs

Age sham:51.6610.0 yrs

Mediansymptomduration(months):Rx8;Sham10.5

Molsberger A,et al., 1994

n = 48 1. Verum group Verum group:Needle onfibulatibial joint ofhomolateral leg,inserted 2 cm;needlemanipulated untilfelling ofdull pressureand warmth;5 min

Placebo group:Pencil-like probe

stimulated a point1.5 cm lateral to T3(mock acupuncture);five min

1 Rx 1. Physicalpressure,load, movementsof forearmwhich werecausing elbowpain; degree ofpain recordedon what soundslike a VAS orNRS durationof pain

22 M; 26 F 2. Placebo group

dAssessments

before, after,and 12 hourspost-Rx

Symptomduration:at least twomonths

Yong H, et al.,1998

n = 93 1. Floatingacupuncture(FA)

2. Routineacupuncture(RA)

FA: locate a nontender point 5080mm below the tenderpoint. The needle isin for 12 days; thisis followed byone day of restwhen a onefinger massageRx is applied for

10 min

FA: N/RRA: 7 courses

of Rx

1. The initialresponse toacupuncture:immediatelyafter the firstRx, the subjectswere askedto evaluate theirresponse in termsof percentage

of pain relief(continued)


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RA: Points: tender(point), LI11, SI9,SJ5, electrodesfor a G6805-1electrostimulatorwere connected tothe needles;stimulated at 4v,

20-Hz squarewave; 1.0 mAmp wasgiven once persix days; eachRx followed by aone-finger massagefor 10 min; this wasfollowed by one daywithout acupunctureand withoutmassage, completingone course of Rx; thenext course of sixacupuncture and

massage Rx wererepeated

2. The number ofelapseddays requiredto bringabout recoveryduring the20 days of thestudy period

Haker E, et al.Clin J Pain

1990;6:2216

n = 82 1. Traditionalacupuncturegroup

Traditionalacupuncture group:Needles insertedcorrespondingto traditionalChinese acupuncture(LI10, LI11, LI12,Lu5, SJ5), inserted todepth of 1.252.5 cm;all rotated to illicitThe Chi every fivemin during 20 min

Rx

All treated2-33/wk; 10Rx in all

1.FourDiagnosticcriteria

52 M; 30 F

2. Superficialacupuncturegroup

Superficialacupuncture group:Needles insertedsuperficially at samepoints as Rx group;20 min; The Chi notobtained

2. Pain elicited onLE by isometricpronation/supinationof forearm

Age:2570 yrs

3. Grip strengthwithvigorimeter(pain-limiting)

Symptomduration:mean 9months;range 1120months

4. Lifting test5. Clinical

subjective reportof improvement

Johannsen F,et al., 1993

n = 16 1. ReboxPlacebo Rebox: Current0300 mAmps;020v; 2005000 Hz;no indicationwhere electrodeswere placed

or length ofeach Rx session

10 Rx in3 weeks

1. Power grip withVAS for pain10 M; 6 F 2. PlaceboRebox

Placebo: Same asabove butcurrent wasinhibited

2. Lifting test withVAS pain

Age:Reboxplacebo45 (3655) yrs;

PlaceboRebox

41 (3758) yrsSymptom duration:

six (312)months

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Smidt N,et al., 2002

n = 185 1. Wait andsee group

Wait and seegroup: VisitedMD once duringsix-weekintervention todiscuss activities thatprovoked pain andpractical solutions;

medications wereprescribed ifnecessary

six weeks 1. six-pointLikertScalegeneralimprovement

92 M; 93 F2. Injection

group

Injection group:Injections givenuntil spotswere pain-free onresisted DF; amountof medication usedwas recorded;patients asked toavoid painprovoking activities(absolute rest not

necessary);maximum ofthree injectionsrecommended overa six-week period

2. 11 pointNRS: Severity ofmain complaint,pain during

day andinconvenience

Age: 4154

3. PT group

PT group: nine Rxs ofpulsed US 20% dutycycle at 2W/cm2 for7.5 mins per session;deep frictionmassage; exerciseprogram consistingof progressive, slow,repetitive wrist andforearm stretches,

muscle conditioning,and occupationalexercises for 6 weeks

3. PT scored overallseverity ofelbow complaintson 11-pointscale aftertaking historyand physicalexamination

Symptomduration:821 weeks

4. Pain-free/grip strength

5. Maximum gripstrength

6. Pressurepain thresholdwith algometer

Newcomer KL,et al., 2001

n = 39 Control: 5 mLinjection of0.25%

bupivacainehydrochoride

Not reported One injectionOne injection

1. VASpain2. Functional pain

questionnaire19 M; 20 FMean age

controlgroup44.667.6,

Rx group 46.067.0Symptom duration

controlgroup 3.460.9,Rx group 3.26 0.8

Experimental: 5 mLof a 4:1 solutionof 0.25% bupivacainehydrochlorideand betamethasoneBoth groups:

ice massage,home stretching,and strengthening

Ice massage: 57min, 353/day

Stretchingand strengtheningN/R

3. Grip strength-pain-freegrip strength -maximalgrip strength

d Measured atbaseline, fourweeks, eight

weeks,and six months

Pienimaki T,et al., 1998

n = 308M; 15FMean age in exercise

group is 45(range 3654),ultrasound group

Exercise group:four stepprogressivestretching andstrengtheningprogram

Not reported Exercise group:N/R

1. Retrospective:postalquestionnaire,hospital register

(continued)


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44 (range 3857)Symptom duration:

N/R

Ultrasound group:local pulsed 1:5,0.5 W/cm2

Ultrasound group:up to 15treatment visits

2. Prospective:-baselineand two months:painquestionnaire,pain drawing,clinicalevaluation,

musclefunctioning -12 months:painquestionnaire,pain drawing

Pienimaki TT,et al., 1996

n = 39 Exercise group:progressive slowrepetitive wrist andforearm stretching,muscle conditioning,occupationalexercises

six to eightweeks

Exercise group: 10reps 3 23 setsfor each exercise,463/day

1. VAS: pain14 M; 25 F

Ultrasound group:

pulsed 1:5, 1 MHz,0.30.7 W/cm2

Ultrasound group:1015 minutes,233/week

2. Pain andDisabilityQuestionnaire

3. Isokinetic testingof wrist/forearm

4. Isometric gripstrength

d Evaluated pre-and posttest

Mean age 43(range 3353)

Symptomduration:

\6 months9, >6 months 11

Svernlov B,et al., 2001

n = 3019 M; 11 FAverage age in

group S 43years, Group E42.1 years

Symptoms duration ingroup S 8.4 months(range 320), GroupE 10.7 months (range724)

Group S:contract-relaxstretch program

Group E:eccentricregimen

Both groupsused an elbow

band duringactivity andwrist supportat night

12 weeks Group S:contract forearmextensors 10s,relax 2s, stretch1520s, repeat353 , 23/day

Group E: warm-up23 min, staticstretch 1530s,repeat353 , eccentricexercises 10s,3 sets, 5repsall done13/day

1. SubjectiveAssessment

a) VAS: painb) Change in

symptomsc) Back to normal

work andleisure activities

2. Objectiveassessment

a) Grip strength:function

d Assessed atbaseline, afterthree, six and12 months

Vecchini L,et al., 1984

n = 2410 M; 14 FMean age

in experimentalgroup 35.45618.04,placebo group45.92612.12

Symptom duration:N/R

Ionizationdiclofenac group:150 mgdiclofenacsodium,48 mA intensity

Placebo group:150 mg saline

Cycle of atleast 20daily session

2530 minsessions

1. Pain: four-pointscale

2. Functionalimpairment:four-point scale

3. Swelling: four-point scale

4. Tolerability:four-point scale

d Evaluations

performedat baselinefour, 10, and20 days oftreatment

Demirtas RN,et al., 1998

n = 4014 M; 26 FMean age group

1 45.3561.71(range 2860),group 242.6562.12(range 2561)

Group 1:iontophoresissodium diclofenac

Group 2:iontophoresisof sodiumsalicylate

Maximum of18 days

Iontophoresis-Current intensity

six and 11 mA20-min Rx

Infrared-250 W-20-min Rx

1. Pain: four-point scale

2. Pain producedby pressure onlateral epicondyle

3. Pain producedon resistingwrist extension


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Symptom durationin group 1 5.2,group 2 4.8

Both groupshad infrared Rx

13/day,fivedays/week

4. Pain duringfunction

5. Spontaneouspain at rest

Devereaux MD,et al., 1985

n = 3017 M; 13 FMean age in

treatment group43.762.0,placebogroup 43.962.5

Symptom durationin activegroup10.161.8months,placebo group9.862.0months

Pulsedelectromagneticfield therapy

regimePlacebo:dummy coils

eight12 weeks At least eighthours/dayin 12 Rx

sessionsNo Rx sessionwas to beless thanone hour

1. Pain induced bylifting

2. Incremental lifting

test3. Pain with wrist DF4. Effect on work5. Pain on routine

daily tasks6. Tenderness over

lateral epicondyle7. Grip strength:

function8. Thermal gradientd Evaluated every

two weeks fortreatment period

Drechsler WI,

et al., 1997

n = 18

8 M; 10 FAverage age

3057(range 3057)

Symptom duration:N/R

Neural tension

group:-ULTT IIb:radial nerve-home exerciseprogrammimickingULTT-Anteriorand posteriormobilizationsof radial head

six8 weeks Neural tension

group:23/week,home program10 reps 123/day

1. Self-report

questionnaires:recreationaland occupational

2. Grip strength:function

3. Isometric testing:pain

4. Radial headmobility: anteriorand posteriorglides,elbowextension ROM

Standard Rx group-Continuousultra sound1.01.5 W/cm2,3 MHz-Friction massage-Stretching andstrengtheningof wrist extensors

Standard Rxgroup: 23/week,5-min ultrasound,threeonemin sessionsof friction massage,510 reps, hold eachstretch 30 sstretchingand strengthening

d Measurementstaken at baseline,duringandpostapplicationof intervention

Vincenzino B,et al., 2001

n = 2414 M; 10 FAge: 3466 yrsSymptoms:

236 months

Mobilizationwith movementtechnique(Mulligan:lateral glide

of proximalforearm whilepatient performspain-freegrip exercise)vs placebo(firm manualcontact onsubjects elbow)vs control(no manualcontact)

Mobilization withmovement: sixrepetitions wereperformed with15-sec rest interval

betweenrepetitions

Each subjectattended threeexperimentalsessions onthree different

days, at least48 hrs apart, atabout the sametime of day

At each session,the subjectreceived oneof thetreatmentconditions

1. Pain-freegrip strength

2. Pressurepain threshold

(continued)


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Burton AK,1988

n = 3317 M; 16 FMean age:

45.1 yrsSymptoms:

mean duration4.8 wks

Manipulationalone

Manipulationwith forearmstrap

Manipulationwithtopical

antiinflammatorycream

Manipulationwith strap andcream

Number ofmanipulationsperformed in asingle treatmentnot mentioned

Manipulation: 2X/wk in firstweek andonce infollowing twowks

Straps worn allday for

three wksCream applied 5X/

day for three wks


2. VAS for functionalcapacity ofpatients chosenfunction (rated05; 0 = nopain, 5 = severe

pain)d Measurements taken

at baseline,three days, oneweek, andthree weeks

Verharr JAN,et al., 1995

n = 10659 M; 49 FMean age 43Symptom

duration:33 wks

Corticosteroidinjections

PT according toCyriax

Injection group:one injection

Patients were thenseen two andfour weeksafter thestart ofRx and a second

or third injectionwas given

Cyriax group:12 Rxsover fourweeks

d Administered at 0,six, and 52 weeks

1. Severity of pain2. Occurrence of

pain3. Subjective loss of

grip strength4. Resumption of

labor5. Resisted

dorsiflexion ofthe wrist

6. Resisteddorsiflexionof middle fingers

7. Local tenderness8. Mean grip strengthd Administered at

six and 52weeks post-Rx

9. Change in gripstrength

10. Patientsatisfaction level

11. Result rating

Lundeberg T,et al., 1987


at least threemos

Ga-As pulse wavelaser vs.He-Ne continuouswave laservs. placebo

Laser held at surfaceof skin for60-sec/acupuncture point

(acupuncture points:Li 10, 11, 12; SJ5, 10; SI 4, 8; H3,4; P3)

10 Rxs (2X/wk)over 56 wks

1. VAS pain2. Grip strength3. Functional

strength(incrementallifting)

d Measures weretaken everytwo weeks;follow upcontinued forthree months

Haker E, et al.,1991

n = 63; 49completed

31 M; 18 FAge: 2266 yrsSymptoms:

135 months

Ga-As laser vsmock radiation(placebo)

Laser applied toone point atanterior aspect ofLE, and fivepoints around thissite at 1.52 cm

Each point treated for30 sec with laser held1 mm from skin

23X/ wkfor 10 treatments

1. Palpation of LE2. Resisted

wrist extension3. Passive stretching

of extensormuscle group

4. Resistedfinger extension

5. Isometricpronation/supination



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7. Incrementallifting(1, 2, 3, 4, 5 kg)

d Measured atbaseline, after10 treatments,and at threeand 12-month

follow up

KraheninnikoffM, et al., 2003

n = 48Age: 3764 yrsSymptoms: at

leastfour wks

Ga-Al-As laservs placebo

Applied to tenderpoints on lateralepicondyle and inforearm extensorsfor 120 sec(3.6 J/point)

23/wk formaximumof eighttreatments

d Measured atbaseline andbeforeeach treatmentFollow updone 10 wksafter lasttreatment

1. Four-pointverbal scalepain score

2. VAS pain3. Tender points

on LE and inforearm extensors

4. Forearmmuscle strength

Basford JR,et al., 2000

n = 52; analysisfor 47

28 F; 19 MSymptoms:

>30 days

Laser vs.placebo

60 sec at seven sitesalong forearm (threesites immediatelyabove, at and belowLE; at distal wristextensors, volarwrist; two siteson medialepicondyle)

33/ wk forfour wks

1. VAS pain(last 24 hrs)

2. Grip strength3. Pinch strengthd Measurements

taken beforefirst treatment,after 10th treatment,and at threemonths follow up

Haker E, et al.Pain.

1990;43:2437

n = 4928 M, 21 FAge: 2470 yrsSymptoms:

between oneand 36 months

Ga-As laser vs.placebo

Each point treatedfor 30 sec(L1, 10, 11, 12,Lu5, SJ 5) withwand held1 mm from skin

233/wkfor 10treatments

1. Grip strength2. Incremental

lifting (14 kg)with presenceor absence ofpain

3. Subjective reportof improvement(scale of15;1 = excellent,5 = worse)

d Measurementstaken at first,

fourth, andsixth visits

Papadopoulos ES,et al., 1996

n = 29(31 elbows)

10 M; 21 FAge: 45.3 yrs

(mean)Symptoms:

25 wks (mean)

Ga-Al-As laservs placebo

Laser applied tomost tenderspot for 60 sec

33/wk fortwo wks

1. VAS pain2. Marcy Wedge

Pro exerciser(exercise ofthe forearmmuscles butstopping whenpain reached)

(continued)


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Vasseljen O Jr,et al., 1992

n = 3015 M; 15 FMean age of

active lasergroup 47.1 years(range 3463) andplacebo group43.9 years (range

2561)Symptom duration

of active lasergroup 4.1 months(range 112)and placebogroup 2.9 months(range 110)

Infrared lasergroup: 880 Hz,175 ns, 1.5 mW

Placebo group:laser disconnected

eight treatments 10-minutetreatments,3X/week

1. Vigorimeter(grip strength):function

2. Incremental liftingtest: function

3. Goniometricmeasurements of

wrist flexion:

point ofaggravationof pain

4. VAS: paind Patient assessment:

assess statusd Measurements

taken before andafter treatmentperiod, andat three,six, 12 months

Haker EHK,et al., 1991

n = 5843 M; 15 F

Age: 3365 yrsSymptoms:

160 monthspain

Ga-As, He-Nelaser vs

placebo

Probe was usedto radiate the

area over LE foreight minutes

Then pen laser wasapplied toacupuncture pointsLI 11, 12 for twomin per point

Same procedure forplacebo group

but with noemission

34 X/ wkfor 10

treatmentsin all

1. Palpation of LE2. Resisted

wrist extension3. Passive stretching

of theextensormuscle group

4. Resistedfinger extension

5. Isometricpronation/supinationof forearm


lifting(1, 2, 3, 4 kgs)with gripdiameters of2.53 cm

8. Subjectiveassessment

d Measurementstaken at baseline,end of treatmentand four weeksposttreatment

Vasseljen O,et al., 1992


112 months

Ga-As laser vsplacebo vstraditionalphysiotherapy

(ultrasoundand frictionmassage)

Ultrasound: 1 MHz,1.5 W/cm2

pulsed mode(2 ms ON, 8 msOFF), stationaryhead

Massage to originof ECRB; methodused by Cyriax

Laser: 10 minUltrasound:

seven minFriction

massage: 10 min

3X/ wk fortotal ofeighttreatments


lifting (1, 2, 3 kg)3.ROM

(assessingpoint of painin wrist flexion)

4. VAS pain(last 24 hours)

5. Subjectiveassessment(change in pain)

N/R = not reported; US = ultrasound; M = male; F = female; VAS = visual analog scale; TENS = transcutaneous electrical nervestimulation; DF = dorsiflexion; DASH = Disabilities of the Arm, Shoulder, and Hand [questionnaire], n = number of patients; Rx =treatment.

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TABLE 2. Results and Level of Evidence of Studies

Study Results Modifiers Level

Absolute Changes and pValues (if available) forAll Outcomes and RTW

if Noted

Factors Affecting Time todReturn to Work,dNonresponse, anddComplications

Sacketts Level of

Evidence

Stratford PW, et al., 1989 1.No one therapy wassuperior to another, thus,authors recommended US

because it is more cost-effective thanphonophoresis

Return to workdN/RNonresponse

dN/RComplicationsdN/R

1b

Halle JS, et al., 1986 1. I n each case, at least twoof the pain indexesindicated that thetreatment rendered wasstatistically significant,and with the patientsreceiving an injection,effective pain reductionwas demonstrated overall four pain indexes; thisdata was p\.05

Return to workdN/RNonresponsedN/RComplicationsdN/R

2b

Binder A, et al., 1985 1. The US group hadsignificantly moreparticipants withsatisfactory outcome onobjective testing than theplacebo group (p\.01)

Return to workdN/RNonresponsed 41 patients (14 US and 27

placebo) still showed anunsatisfactory outcomeat the end of thecontrolled study andwere offered US (inplacebo group), steroidinjections, or both

2b

ComplicationsdAt one year, minor

intermittent pain in the

elbow wasstillpresent inover 50% of the patients

Lundeberg T, et al., 1988 1. 36% US group, 30%placebo group, 24% restshowed satisfactoryoutcome on objectivetesting both at end oftreatment and threemonths follow up; thedifference between the USgroup and the rest groupwas significant (p\.01);there was no difference

between the US group

and the placebo group


2b

Fink M, et al. Rheumatology.2002;41:2059

1. In both groups, the Rx ledto significant changes inthe outcome measurementand the changes were alsoclinically relevant at thefirst follow up

2. There was a significantreduction in distability(DASH) at the secondfollow up in favor of theRx group

Return to workdN/RNonresponsedN/RComplicationsd No side effects occurred

apart from pain resultingfrom needling, which ledto one dropout

2b

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3. Under sham acupunctureRx, the subgroups with highor varying occupationalstrain show significantlyless improvement thanpatients with low strain(p\.05)

4. There was a significant

difference between Rxeffects in subgroup one

between real and shamacupuncture (p\.05)

Fink M, et al. ForschKomplementarmed KlassNaturheilkd. 2002;9:2105

1. In both groups, the Rx led tosignificant changes in theoutcome parameters

between the first andsecond follow up and again

between the third and finalfollow up (p\.05)

Return to work 1b

2. Significant differencesbetween the two groupscould be detected for pain

on motion and pain onexertion at the first followup

dN/RNonresponsedN/RComplicationsd Intolerable pain from

acupuncture

Molsberger A, et al., 1994 1. In Verum group, 79% of patients reported at least50% relief of pain; placebogroup reported 15% relief ofpain

Return to work 2b

2. Average duration of pain inVerum group was 20.2hours as opposed to 1.4hours in placebo group

dN/RNonresponsedN/RComplicationsdN/R

Yong H, et al., 1998 1. The initial therapeuticresponse in the FA groupwas greater (p\.01) thanthe RA group

Return to workdN/R

2b

2. Statistical analysisshowed a significantdifference (p\.01) betweenthe two methods used inthis study in terms ofrecovery

NonresponsedN/R

3. FA was more effective thanRA in producing pain relief,especially during the firstRx; FA took less time andfewer Rxs to producecomplete recovery from the

symptoms of lateralepicondylitis

ComplicationsdN/R

Haker E, et al. Clin J Pain1990;6:2216

1. Pain threshold on gripstrength increased intraditional acupuncturegroup compared withsuperficial acupuncturegroup (p\.05); nodifferences at follow up


2b

2. After 10 Rxs, smallernumber in traditional groupsuffered pain than insuperficial group whilelifting 3 kg (p\.05)


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3. Pain threshold on grippinghad significant increase intraditional group comparedwith superficial group(p\.05): no significantdifferences were found atfollow up

Johannsen F, et al., 1993 1.Significant improvement forgrip strength with elbow in90 flex Rebox vs. placebo(p = .02); similar result forgrip strength in elbowextension (p = .07)

Return to workdN/RNonresponsedN/R

2b

2. VAS pain in flexion andextension showedsignificantimprovements (p = .02,p = .07) in Reboxgroup; VAS pain whenlifting 2-kg weightsignificant improvement(p = .001); Rebox

groups diary recordedsignificantimprovements inimpairments (p = .001)

ComplicationsdN/R

Smidt N, et al., 2002 1. At six weeks, significantdifferences in favor ofcorticosteroid injectionswere seen for all outcomes

Return to workdN/RNonresponsedN/R

2b

2. At 26 and 52 weeks,significant differences fornearly all outcomemeasures were noted infavor of PT compared withinjections

ComplicationsdPain post-Rx for PT and

injection (47%, but mild)

Newcomer KL, et al., 2001 1. Changes in outcomemeasurements from

baseline to four weeks, eightweeks, and six months werenot significantly different

Return to workdN/R

1b

2. No significant difference ingrip strength betweengroups

NonresponsedN/RComplicationsdN/R

3. Both groups hadsignificant improvementin outcome measuresover time

4. Because there was nosignificant difference

between groups, canconclude that injectionsadded very little toa standardrehabilitation program

Pienimaki T, et al., 1998 1. Individuals in exercisegroup has significantly lesspain and pain and theirdrawings were not sowidespread as theultrasound group

Return to workd eight individuals (67%)

in the exercise groupand five individuals(45%) in the ultrasoundgroup still held theirprevious job

2b

(continued)


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2. Individuals in theexercise group had

better outcomes andprognosis at the 36-monthfollow up

d two individuals in theultrasound group andnone in the exercisegroup were absent fromwork because of tenniselbow

NonresponsedN/R

ComplicationsdN/R

Pienimaki TT, et al., 1996 1. P ain at rest and understrain significantlyincreased in theultrasound group anddecreased in the exercisegroup

Return to workdN/R

1b

2. Sleeping disturbanceswere alleviatedsignificantly more in theexercise group then inthe ultrasound group

NonresponsedN/R

3. Isokinetic strengthincreased in exercise group,torque decreased inultrasound group,differences between thegroup, and changes inexercise group werestatistically significant

ComplicationsdN/R

4. Maximum grip strengthsignificantly increased inthe exercise group andremained unchanged in theultrasound group

Svernlov B, et al., 2001 1. No significant difference

between the groupswere seen in the fiveVAS pain scales

Return to work 2b

2. Both groups foundstatistically significantimprovements in four of theVAS pain scales

3. In group S, all but two andin group E all but oneparticipants reportedcomplete relief of pain atrest after six months

4. Grip strengthsignificantly increased in

both groups after six

months5. Increase in grip strength

was significantly larger ingroup E at six months

d

All participants wereback to work andprevious leisure activity

by three monthsNonresponsedN/RComplicationsdN/R

Vecchini L, et al., 1984 1. Ionization withdiclofenac treatmentproduced a significantreduction for all targetsymptoms

Return to workdN/R

2b

2. Placebo treatment led toa significantimprovement of pain onmovement andfunctional impairment

NonresponsedN/RComplicationsdOne case of local

irritation in patient inIonization treatmentwith diclofenac group


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3. Ionization withdiclofenac treatmentwere significantly moreimproved for pain onmovement andfunctional impairment atfinal evaluation

Demirtas RN, et al., 1998 1. S tatistically significantreduction in the scores ofpain produced by pressureon lateral epicondyle, onresisting wrist extension,during function, andspontaneous pain at restwere seen in bothgroups

Return to workdN/R 2b

2. The reduction in painproduced on resisting wristextension and painproduced bypressure on lateralepicondyle was

statistically moresignificant in group 1


Devereaux MD, et al., 1985 1. No significant differencefor all assessments

between the treatment andplacebo groups


2b

Drechsler WI, et al., 1997 1. Recreational statussignificantly improved inthe NTG at discharge andthree months

Return to workdN/R

2b

2. Recreational statussignificantly improved inSTG at discharge, but notat three months

NonresponsedN/R

3. Occupational statusunchanged for both groups

ComplicationsdN/R

4. No significant change ingrip strength

5. ULTT IIb was significantlydifferent for the NTG atdischarge and follow up,

but not for STG6. Therefore, mobilizations

and neural tensionexercises are superior tostandard Rx

Vincenzino B, et al., 2001 1. S ignificant differencebetween treatment groupand placebo and controlgroups with respect toincreased pain-free gripstrength

Return to work 2b

2. Pressure-pain thresholdincreased significantly inthe treatment groupcompared with theplacebo and control groups

dN/RNonresponsedN/RComplicationsdN/R

(continued)


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Burton AK, 1988 1. Mean grip strengthincreased significantlyfor all groups at three wks

Return to workdN/R

2b

2. No significant differencesfound between groups atreassessment

NonresponsedN/R

3. Significant decrease in meanVAS scores, but

no significantdifferences found

between groups

ComplicationsdN/R

Verharr JAN, et al., 1995 1.At six wks, results based onhistory and physicalexamination showed thatthe injection group wassignificantly better

2. At one yr, no significantdifference b/w groups

3. No significant difference b/w groups for meangrip strength

4. Satisfaction was

significantly lower in the PTgroup

Return to workdAt six weeks, in the PT

group four resumed, 14still working, 13 unableto work, 20 notapplicable

2b

dAt six weeks in theinjection group, nineresumed, 15 stillworking, nine unable towork, 19 not applicable

dAt 52 weeks, in the PTgroup, 19 resumed, eightstill working, six unableto work, 20 not applicable

dAt 52 weeks, in theinjection group, sevenresumed, 13 stillworking, two unable towork, 17 not applicable

NonresponsedN/RComplicationsdone patient discontinued

PT b/c of severe pain

Lundeberg T, et al., 1987 1.No significant differencesnoted for any outcome;therefore, laser is notsignificantly better thanplacebo for treating LE

Return to workdN/RNonresponsedMinor or intermittent

pain still present in 60%of patients

ComplicationsdNo difference in

incidence of recurrenceof severe pain noted

2b

Haker E, et al., 1991 1. Pain-free grippingthreshold significantlyincreased in laser group vs.placebo after 10

treatments and at three-month follow up

Return to workdN/R

2b

2. Incremental lifting (3, 4 kgs)changed favorably after 10treatments for the lasergroup;outcome of 3-kg lifting testalso changedfavourably at three months

NonresponsedN/R

3. Significantly fewerpatients in laser groupreported pain at middlefinger test after 10treatments

ComplicationsdN/R


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Kraheninnikoff M, et al.,2003

1. No statisticallysignificant differences

between laser andplacebo group 10 weeksafter treatment

Return to workdN/R

2b

2. A nonsignificant trendtoward pain alleviationduring treatment and after

10 wks in both groups


Basford JR, et al., 2000 1. No statistically significantdifferences between groupsin any outcome


1b

Haker E, et al. Pain.1990;43:2437


between groups in anyoutcome after 10treatments or at follow up

Return to workdN/RNonresponsedN/RComplicationsd six of 23 in laser group

and five of 26 in placebogroup reported that theyfelt unchanged orworse

2b

dNo side effects reported

Papadopoulos ES, et al.,1996


between the groups ineither outcome

Return to workdN/RNonresponsedN/RComplicationsdThese findings may

indicate that low-levellaser therapy delaysspontaneous remission

2b

Vasseljen O Jr, et al. , 1992 1.Significant decrease inpain in the laser group overthe placebo group

Return to workdN/R

2b

2. Significant improvementonly in grip strength in thelaser over the placebo group


Haker EHK, et al., 1991 1. No statisticallysignificant differencesfound in subjective orobjective outcomes after 10treatments

Return to workdN/R

2b

2. The grip strength did showa difference

favouring the placebo group(p\.06)

NonresponsedN/R

3. No differences foundbetween the groups at anyof the follow ups

ComplicationsdNo side effects reported

during or after the

treatment period

Vasseljen O, et al., 1992 1. Low-level laser in no betterthan traditionalphysiotherapy in thetreatment of LE


2b

N/R = not reported.


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Limitations

Although our database search revealed an adequatenumber of RCTs evaluated at level 2b or above,methodologic limitations were not absent (Table 3).Many of thestudies failed to provideadequate follow-up, blinding procedures, and did not use eithersample or power calculations or sample size justifica-tion. The use of standardized outcome measures was

another area of particular deficit. Recruitment strat-egies were also often not described, making it difficultto generalize results; furthermore, the size andsignificance of effects were often absent. In addition,acute and chronic cases, which are typically consid-ered quite different from a clinical standpoint, arerarely considered separately, either through stratifi-cation of sampling or in statistical analyses. Finally,a lack of discussion on clinical and practical issuesrelating to the interventions themselves, includingclear descriptions of the techniques, dosage, andprogression, as well as training or experience require-

ments, makes it difficult for therapists to replicatestudy interventions.

A wide variety of interventions have been de-scribed as conservative management techniques forlateral epicondylitis: ultrasound, phonophoresis,electrical stimulation, manipulation of joints/softtissues, neural tension, friction massage, joint mobi-lizations, augmented soft tissue massage, stretching,strengthening, and work hardening. Not all of thesehave been studied in comparison to control, and fewhead-to-head comparisons are available. Therefore,constructing the optimal treatment approach is dif-

ficult based on current evidence. Despite the assump-tion that activity or work can be primary factors inthe development of lateral epicondylitis, little atten-tion has been paid to secondary prevention. The rolefor modification of workplace or recreation expo-sures needs to be rigorously evaluated.

CONCLUSIONS ANDRECOMMENDATIONS

Much research has been conducted in the area ofconservative treatment for lateral epicondylitis;

however, there have been no high-quality compre-hensive systematic reviews to summarize the evi-dence available on this topic. Our review hasdetermined, with at least level 2b evidence, thatacupuncture, exercise therapy, manipulations/mobi-lizations, ultrasound, phonophoresis, Rebox, andionization with diclofenac all show positive effectsin the reduction of pain and in the improvement offunction for those with lateral epicondylitis. There isalso at least level 2b evidence showing laser therapyand pulsed electromagnetic field therapy to beineffective in the management of this condition.

Therefore, our recommendations would be thatpractitioners use the treatment techniques that havethe strongest evidence supporting their outcomes.Given the lack of evidence on the relative benefits ofthese treatment options, therapists must constructa treatment plan and progression from these options

based on clinical practicalities and experience. It isimperative that patients are matched according to thespecific treatment study participants characteristics

and injury presentations to obtain the best results.

Research Gaps/Directions

Future research should involve the completion ofmore rigorous study designs to reduce methodologiclimitations and to produce higher-quality evidence.In particular, randomized trials are needed whentreatment outcomes are measured independently,chronicity is accounted for, and blinding of treatmentproviders and patients is implemented when possi-

ble. Descriptions of treatment interventions should

be more explicit to facilitate the transference oftechniques into practice. Given the role for exercisetherapy defining the optimal approach to progressivestrengthening and endurance in this pathologywould help guide therapists in designing exerciseprograms.

Outcome measurement has been an area ofparticular deficit, despite the availability of at leastsome methodologic evidence. Self-report scales de-signed specifically for patients with lateral epicon-dylitis are available and are likely to be mostresponsive to changes in lateral epicondylitis symp-toms.4850 The Patient-Rated Forearm Scale has painand function (specific and usual activity) subscales,which are weighted equal to provide a global score.The Pain-free Function Questionnaire is a pain scalethat focuses on pain with activity.51 Both weredeveloped with items specific to lateral epicondylitis.Other self-report measures with sound psychometricproperties such as the Disability of the Arm,Shoulder, and Hand (DASH), Visual Analog Scale(VAS), or the McGill Pain Questionnaire might alsocontribute to a more comprehensive comparison oftreatment interventions but are less specific to thecondition. However, because head-to-head evalua-

tions of these different outcome measures have notyet been performed, the relative value of these isunknown. In terms of measuring physical impair-ments, both range of motion and strength measureshave been studied.5052 Pain-free grip (measuredwith the elbow extended) has been shown to bereliable, valid, and responsive in this patient pop-ulation.51 Pain threshold can be measured byalgometry, although this may be less reliable thanother physical measures.42 Adoption of a core set ofoutcome measures would facilitate future trials andallow for meta-analyses of smaller studies. Although

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a consensus process is advisable for this, a reasonable

strategy at this time is that all studies should includethe following.

Short-term Outcomes

1. Pain relief (self-reported using either the Patient-rated Forearm Scale, Pain-free Function Scale, ora VAS)

2. Function (Patient-rated Forearm Scale)3. Muscle Functiona. Functional gripPain-free grip strength

b. Tendon integrityWrist extensor strength

c. Endurance for activity

Long-term Outcomes

1. Reoccurrence of symptomsa. Pain/function (Patient-rated Forearm Scale)

b. Requiring additional treatment2. Work outcomes (lost time, the Work subscale of

the DASH or a scale similar to the WorkLimitation Scale,53 which describes the difficultyat work)

3. Resumption of regular recreational activity

TABLE 3. Quality Scores of Studies

Study ? Design Subjects Intervention Outcomes Analysis R T

Items 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Stratford PW, et al.,1989

2 2 2 1 2 1 1 2 2 2 0 2 2 2 2 2 2 1 2 2 2 1 2 2 41

Halle JS, et al., 1986 2 2 2 2 2 1 2 2 0 2 0 2 0 1 1 2 0 0 1 0 0 1 1 2 28Binder A, et al., 1985 1 2 2 2 1 2 2 2 1 1 0 1 1 2 2 1 1 2 1 1 1 1 0 2 32Lundeberg T, et al.,1988

1 2 2 2 1 2 2 1 1 2 0 2 2 1 2 1 1 2 2 0 1 2 1 2 35

Fink M, et al.

Rheumatology.2002;41:2059

2 2 2 2 2 2 1 2 1 2 2 1 2 2 2 1 1 2 2 1 1 1 1 2 39

Fink M, et al.Forsch KomplementarmedKlass Naturheilkd.2002;9:21015

2 2 2 2 2 2 1 2 1 2 2 1 2 2 2 1 1 2 2 1 2 0 1 2 39

Molsberger A, et al.,1994

1 2 1 1 1 2 1 2 1 1 1 2 2 2 2 1 0 1 1 0 1 1 1 2 31

Yong H, et al., 1998 0 2 0 1 1 1 1 0 1 1 0 2 1 0 1 1 1 0 1 0 1 2 0 0 19Haker E, et al. Clin JPain. 1990;6:22126

2 2 2 2 1 1 1 2 1 2 0 2 2 1 2 1 1 2 1 1 1 1 2 2 35

Johannsen F, et al., 1993 1 1 2 2 1 2 2 2 0 2 0 2 1 2 2 2 1 1 2 0 0 1 1 1 31Smidt N, et al., 2002 2 2 2 2 2 1 1 0 1 2 2 2 1 1 2 1 2 2 2 0 2 2 1 2 37Newcomer KL, et al.,

2001

2 2 2 2 1 2 2 2 2 2 0 1 0 2 2 2 2 2 2 0 2 0 1 2 37

Pienimaki T, et al.,1998

2 2 2 0 1 1 1 0 1 2 0 1 1 0 1 1 1 1 2 0 2 0 1 2 25

Pienimaki TT, et al.,1996

2 2 2 2 1 1 1 2 2 2 0 2 0 0 2 1 2 1 2 0 2 2 1 2 34

Svernlov B, et al., 2001 2 2 2 2 1 1 1 0 0 2 0 1 2 1 1 1 1 2 2 0 1 1 1 2 29Vecchini L, et al., 1984 1 2 2 2 1 1 1 0 0 1 0 2 1 1 1 1 1 1 2 0 1 1 1 1 25Demirtas RN, et al., 1998 2 2 2 1 1 2 0 0 0 1 0 2 1 0 1 1 0 1 2 0 1 2 1 2 25Devereaux MD, et al.,1985

2 2 2 2 1 2 2 2 1 2 0 2 2 2 2 1 1 0 2 0 1 2 1 2 36

Drechsler WI, et al., 1997 1 2 2 2 1 1 1 0 2 2 0 2 1 0 2 1 1 1 2 1 1 2 1 1 30Vincenzino B, et al., 2001 2 2 2 2 2 1 1 2 1 2 0 2 2 0 2 2 2 1 2 0 2 2 1 2 37Burton AK, 1988 2 2 2 1 1 1 1 0 0 1 0 0 1 0 2 2 1 1 1 0 1 0 1 2 23Verharr JAN, et al., 1995. 1 2 2 2 2 1 1 0 2 2 0 2 1 1 2 1 1 1 1 0 1 1 1 2 30Lundeberg T, et al., 1987 2 2 2 2 1 2 2 2 0 2 0 0 1 2 2 1 1 1 2 0 0 0 1 1 29

Haker E, et al., 1991 2 2 2 2 1 2 2 2 1 2 0 1 2 2 2 1 1 1 1 0 1 0 0 1 31Kraheninnikoff M,et al., 2003

2 2 2 2 2 2 2 2 2 2 0 1 2 2 2 1 1 2 2 0 2 0 1 2 38

Basford JR, et al., 2000 2 2 2 2 2 2 2 2 1 2 1 2 2 2 2 2 1 2 2 2 2 1 2 2 44Haker E, et al.Pain. 1990;43:24347

2 2 2 2 1 2 2 1 2 2 0 2 2 1 2 1 1 2 1 0 0 2 1 2 36

Papadopoulos ES,et al., 1996

2 2 2 2 1 2 2 2 1 1 0 2 2 2 2 1 1 1 2 0 1 2 2 2 37

Vasseljen O Jr, et al., 1992 2 2 2 2 2 2 2 2 2 2 0 2 1 2 2 1 1 2 2 0 1 2 1 2 39Haker EHK, et al., 1991 2 2 2 2 1 2 2 2 1 2 0 2 1 2 2 1 1 1 2 0 1 0 1 2 34Vasseljen O, et al., 1992 2 2 2 1 2 1 1 0 1 2 0 2 2 1 2 1 1 1 1 0 1 2 1 1 30


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CONCLUSIONS

There are a number of good-quality studies onvarious therapeutic interventions for lateral epicon-dylitis that demonstrate a variety of effectivetreatment options that will enable conservativemanagement of lateral epicondylitis. However, theevidence is still incomplete and does not permitstrong conclusions to be made on a number of

commonly used approaches. At this time, none of theused treatments can be refuted. Additional RCTs thatfocus on quality research designs and use appropri-ate outcomes are needed to provide a strongerfoundation for hand therapy management of thesepatients. At present, use of selected modalities andstretching/strengthening are indicated. Hand thera-pists should work to define these treatment ap-proaches more clearly and demonstrate outcomesmore objectively.

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