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Three Part Question

In [adults with chronic tennis elbow] is [electrotherapy better than conservative therapies] at improving [pain and function]

Clinical Scenario

A 28 year old female presents with a four month history of ‘tennis elbow’ (lateral epicondylitis). You want to treat her with a form of electrotherapy and you wonder if one form is better than another.

Search Strategy

MEDLINE 1966-02/09, CINAHL 1982 – 02/09, AMED 1985-02/09, SPORTDiscus 1830-02/09, EMBASE 1996-02/09, via the OVID interface. In addition the Cochrane database and PEDro database were also searched
Medline, CINAHL, AMED, EMBASE, SPORTSDiscus: [{exp (‘tennis elbow’ OR lateral elbow pain OR lateral epicondylitis OR epicondylitis OR epicondylagia OR lateral epicondylosis) AND (electrotherapy OR electrophysiotherapy OR electrophysical agents OR EPAs OR laser OR LLLT OR ultrasound OR ultrasonic therapy OR TENS OR Transcutaneous Electrical Therapy OR interferential therapy OR IFT OR low intensity laser therapy OR pulsed shortwave therapy OR PSWT OR Megapulse OR Electromagnetic Energy Or PEME OR shockwave therapy OR shock wave therapy)}] LIMIT to human AND English language.

Search Outcome

A total of 10 papers were found which were relevant to the question. One paper was disregarded as it was not a systematic review based on clinical trials, and 2 were Cochrane protocols and therefore had not been completed.

The remaining articles therefore included 1 Cochrane review and 2 systematic reviews on shock wave therapy; 1 systematic review on laser therapy; and 2 RCTs on ultrasound therapy. There was also an RCT on electrical stimulation.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kochar M and Dogra A, 2002, UK	1) U/S & MWM 2)U/S 3)Control n= 66	1b RCT	Pain (VAS)	In U/S & MWM group by 5.9cm (p<0.01). In U/S group by 1.67cm (p<0.01) Both groups better than control and MWM significantly better than U/S alone (p<0.05) Patient assessment score p<0.05 improved for MWM. At 3 weeks U/S significantly better but not at 12/52.	Reduced internal validity. No allocation concealment. No randomisation of control. No blinding of patient, assessor, treater. Not specified drop out rate or change groups therefore ITT not known.
Bisset et al, 2005, Australia	2 studies ESWT vs Placebo 1 study n=246 1 study n=71	1a Systematic review and Meta-analysis	Pain scale (PVAS)	Both studies found no significant difference in pain scores or global improvement 4 - 6 weeks after Rx.	Haake et al (2002) n = 246 did not state intention to treat analysis. Had 30 participants drop out. Pooled data presented show no evidence of effect over that of placebo in either the short or long term.
			Global improvement	No added benefit of ESWT over placebo
Buchbinder et al, 2005, Australia	9 RCT n = 1006 ESWT	1a (Cochrane)	Pain	Conflicting. 3 RCT n = 446 significant at end point whereas 4 trials reported no benefits	Heterogenous data therefore not all data from the trials could be pooled
			Function DASH UEFS	UEFS statistical significance ESWT over placebo no p value
Rompe, J. and Maffulli, N, 2007, Germany	10 studies n = 948 SWT vs placebo	1a Systematic review	Pain scales	6 studies in favour of SWT over placebo. 4 studies no difference.	No p value stated. Data not pooled due to clinical and methodological heterogeneity.
Bjordal et al, 2008, Norway	13 RCT (n = 730) Laser therapy	1a Systematic review	Pain (VAS 0-100mm)	10.2mm LLLT better than placebo	Does not specify PEDro score for level of acceptance. Meta-analysis done but no forest plots.
			Improved global health status (3 trials only)	RR 1.68 in favour of LLLT over placebo
Oken et al, 2008, Turkey	n = 59 patients with lateral epicondylitis. 3 groups: 1.) Brace plus exercise 2.) Ultrasound plus exercise 3.) Laser plus exercise	1b RCT	Pain (VAS)	Significant improvement (p<0.05) within groups for laser and ultrasound groups at end of treatment and 1 month follow up. In the brace group, significant improvement within the group at end of treatment only. Between all 3 groups there was no statistical significance. Pain increased after discontinuing brace at 1 month follow up.	Reported 1 drop out but no mention of ITT analysis. No reports of allocation concealment.
			Grip Strength	At 1 month follow up, for both U/S and brace groups there was no statistical significant improvement within the groups. For laser group there was within group significance. Between all 3 groups there was no statistical significance.
			Global assessment of improvement	Improved in the laser group, but not statistically significant. No change in the ultrasound group. Worsened in the brace group. Between group and within group difference was not statistically significant for all 3 groups.
Nourbakhsh, M.R. and Fearon, F.J, 2008, USA	n = 18 RCT patients with chronic lateral epicondylitis. Group 1) Low frequency electrical stimulation (4Hz) Group 2) placebo	1b RCT	Grip strength	Significant difference (p=0.04) between groups 1 and 2	Small sample (n=10 in group a, 8 in group b) 10 people only were used for reliability study for patient specific functional scale, therefore ?reduced reliability of function outcome measure.
			Function	Significant difference (p=0.01) between groups 1 and 2
			Pain	Significant difference (p=0.01) between groups 1 and 2
			Limited activity due to pain	Significant difference (p=0.003) between groups 1 and 2

Comment(s)

Only 2 studies (Kochar and Dogra 2002 and Oken et al 2008) examined the use of ultrasound for tennis elbow. Kochar and Dogra (2002)had reduced internal validity. Oken et al (2008) found there was no statistically significant difference between groups. For laser, there was a systematic review which contained 13 RCTs and found laser is better than placebo. For ESWT, three systematic reviews found conflicting results possibly due to heterogenous data. Electrical stimulation (4Hz) found significant improvements in pain, strength and function.

Clinical Bottom Line

There is some weak evidence for the benfits of laser over placebo. There is inconclusive evidence for SWT. There is weak evidence for the effects of US and electrical stimulation (4Hz) over placebo.

References

1. Kochar M and Dogra A. Effectiveness of a specific Physiotherapy Regimen on Patients with Tennis Elbow . Physiotherapy June 2002 Vol 88: No 6 333-341.
2. Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med 2005; 39:411-422.
3. Buchbinder R, Green S, Youd J, Assendelft W, Barnsley L, Smidt N. Shock wave therapy for lateral elbow pain. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No: CD003524. DOI: 10.1002/14651858.CD0.
4. Rompe, J. and Maffulli, N. Repetitive shock wave therapy for lateral elbow tendinopathy (tennis elbow): a systematic and qualitative analysis. British Medical Bulletin 2007, 83: 355-378.
5. Bjordal, J, Lopes-Martins, R, Joensen, J, Couppe, C, Ljunggren, A, Stergioulas, A. and Johnson, M. A systematic review with procedural assessments and meta-analysis of Low Level Laser Therapy in lateral elbow tendinopathy (tennis elbow). BMC Musculoskeletal Disorders 2008 9:75.
6. Oken, O. Kashraman, Y. Ayhan, F. Canpolat, S. Yorgancioglu, Z. The Short-term Efficacy of Laser, Brace, and Ultrasound Treatment in Lateral Epicondylitis: A Prospective, Randomized, controlled trial. Journal of Hand Therapy 2008: 63-68.
7. Nourbakhsh, M.R. and Fearon, F.J. An alternative approach to treating lateral epicondylitis; A randomized placebo-controlled, double-blinded study Clinical Rehabilitation 2008; 22: 601-609.