Brooke K. Coombes

Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials

BACKGROUND Few evidence-based treatment guidelines for tendinopathy exist. We undertook a systematic review of randomised trials to establish clinical efficacy and risk of adverse events for treatment by injection. METHODS We searched eight databases without language, publication, or date restrictions. We included randomised trials assessing efficacy of one or more peritendinous injections with placebo or non-surgical interventions for tendinopathy, scoring more than 50% on the modified physiotherapy evidence database scale. We undertook meta-analyses with a random-effects model, and estimated relative risk and standardised mean differences (SMDs). The primary outcome of clinical efficacy was protocol-defined pain score in the short term (4 weeks, range 0-12), intermediate term (26 weeks, 13-26), or long term (52 weeks, ≥52). Adverse events were also reported. FINDINGS 3824 trials were identified and 41 met inclusion criteria, providing data for 2672 participants. We showed consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms. For example, in pooled analysis of treatment for lateral epicondylalgia, corticosteroid injection had a large effect (defined as SMD>0·8) on reduction of pain compared with no intervention in the short term (SMD 1·44, 95% CI 1·17-1·71, p<0·0001), but no intervention was favoured at intermediate term (-0·40, -0·67 to -0·14, p<0·003) and long term (-0·31, -0·61 to -0·01, p=0·05). Short-term efficacy of corticosteroid injections for rotator-cuff tendinopathy is not clear. Of 991 participants who received corticosteroid injections in studies that reported adverse events, only one (0·1%) had a serious adverse event (tendon rupture). By comparison with placebo, reductions in pain were reported after injections of sodium hyaluronate (short [3·91, 3·54-4·28, p<0·0001], intermediate [2·89, 2·58-3·20, p<0·0001], and long [3·91, 3·55-4·28, p<0·0001] terms), botulinum toxin (short term [1·23, 0·67-1·78, p<0·0001]), and prolotherapy (intermediate term [2·62, 1·36-3·88, p<0·0001]) for treatment of lateral epicondylalgia. Lauromacrogol (polidocanol), aprotinin, and platelet-rich plasma were not more efficacious than was placebo for Achilles tendinopathy, while prolotherapy was not more effective than was eccentric exercise. INTERPRETATION Despite the effectiveness of corticosteroid injections in the short term, non-corticosteroid injections might be of benefit for long-term treatment of lateral epicondylalgia. However, response to injection should not be generalised because of variation in effect between sites of tendinopathy. FUNDING None.

A new integrative model of lateral epicondylalgia

Tennis elbow or lateral epicondylalgia is a diagnosis familiar to many within the general community and presents with an uncomplicated clinical picture in most cases. However, the underlying pathophysiology presents a more complex state and its management has not been conclusively determined. Research on this topic extends across anatomical, biomechanical and clinical literature; however, integration of findings is lacking. We propose that the current understanding of the underlying pathophysiology of lateral epicondylalgia can be conceptualised as encompassing three interrelated components: (i) the local tendon pathology, (ii) changes in the pain system, and (iii) motor system impairments. This paper presents a model that integrates these components on the basis of a literature review with the express aim of assisting in the targeting of specific treatments or combinations thereof to individual patients.

Thermal Hyperalgesia Distinguishes Those With Severe Pain and Disability in Unilateral Lateral Epicondylalgia

Objectives: To evaluate if sensory, motor, and psychological factors are different in severe lateral epicondylalgia compared with less severe cases and control. Methods: A total of 164 patients with unilateral lateral epicondylalgia and 62 healthy control participants of comparable age and sex underwent the following testing: quantitative sensory testing (pressure, thermal pain thresholds), pain-free grip, quality of life (EuroQol), and psychological (Hospital Anxiety and Depression Scale, Tampa Scale for Kinesiophobia) testing. Cluster analysis classified patients into mild, moderate, or severe subgroups using the Patient Rated Tennis Elbow Evaluation. Data were then evaluated to determine differences between control and lateral epicondylalgia subgroups. Results: Bilateral cold hyperalgesia (affected elbow, standardized mean difference (SMD) −1.14, P=0.000; unaffected elbow SMD −0.94, P=0.000) and unilateral heat hyperalgesia (SMD −1.06, P=0.001) were evident in severe lateral epicondylalgia in comparison to healthy controls. All patient groups regardless of severity demonstrated bilateral and widespread mechanical hyperalgesia relative to controls (P<0.003); however, only those with moderate and severe symptoms showed large differences (Absolute SMD>0.8) at all sites. Quality of life was significantly poorer in patients with severe symptoms, whereas anxiety, depression, and kinesiophobia did not differ between subgroups. Discussion: Lateral epicondylalgia patients presenting with severe pain and disability could be distinguished by hypersensitivity to thermal stimuli, notably bilateral cold hyperalgesia. Findings may implicate a combination of central, peripheral, and sympathetic nervous system processes and may help explain the poorer outcomes found in this subpopulation.

Optimising corticosteroid injection for lateral epicondylalgia with the addition of physiotherapy: A protocol for a randomised control trial with placebo comparison

BackgroundCorticosteroid injection and physiotherapy are two commonly prescribed interventions for management of lateral epicondylalgia. Corticosteroid injections are the most clinically efficacious in the short term but are associated with high recurrence rates and delayed recovery, while physiotherapy is similar to injections at 6 weeks but with significantly lower recurrence rates. Whilst practitioners frequently recommend combining physiotherapy and injection to overcome harmful effects and improve outcomes, study of the benefits of this combination of treatments is lacking. Clinicians are also faced with the paradox that the powerful anti-inflammatory corticosteroid injections work well, albeit in the short term, for a non-inflammatory condition like lateral epicondylalgia. Surprisingly, these injections have not been rigorously tested against placebo injections. This study primarily addresses both of these issues.MethodsA randomised placebo-controlled clinical trial with a 2 × 2 factorial design will evaluate the clinical efficacy, cost-effectiveness and recurrence rates of adding physiotherapy to an injection. In addition, the clinical efficacy and adverse effects of corticosteroid injection beyond that of a placebo saline injection will be studied. 132 participants with a diagnosis of lateral epicondylalgia will be randomly assigned by concealed allocation to one of four treatment groups – corticosteroid injection, saline injection, corticosteroid injection with physiotherapy or saline injection with physiotherapy. Physiotherapy will comprise 8 sessions of elbow manipulation and exercise over an 8 week period. Blinded follow-up assessments will be conducted at baseline, 4, 8, 12, 26 and 52 weeks after randomisation. The primary outcome will be a participant rating of global improvement, from which measures of success and recurrence will be derived. Analyses will be conducted on an intention-to-treat basis using linear mixed and logistic regression models. Healthcare costs will be collected from a societal perspective, and along with willingness-to-pay and quality of life data will facilitate cost-effectiveness and cost-benefit analyses.ConclusionThis trial will utilise high quality trial methodologies in accordance with CONSORT guidelines. Findings from this study will assist in the development of evidence based practice recommendations and potentially the optimisation of resource allocation for rehabilitating lateral epicondylalgia.Trial registrationAustralian New Zealand Clinical Trials Register ACTRN12609000051246

Cold hyperalgesia associated with poorer prognosis in lateral epicondylalgia: a 1-year prognostic study of physical and psychological factors

Background:Predictors of outcome in lateral epicondylalgia, which is mainly characterized as a mechanical hyperalgesia, are largely limited to sociodemographic and symptomatic factors. Quantitative sensory testing is used to study altered pain processing in various chronic pain conditions and may be of prognostic relevance. Methods:The predictive capacity of early measures of physical and psychological impairment on pain and disability and mechanical hyperalgesia, were examined using data from 41 patients assigned to placebo in a prospective randomized controlled trial of unilateral lateral epicondylalgia. Quantitative sensory testing (pressure, cold pain thresholds), motor function (pain-free grip), and psychological factors (Tampa Scale of Kinesiophobia, Hospital Anxiety and Depression Scale) were measured at baseline. The outcome measures were the Patient-rated Tennis Elbow Evaluation (PRTEE) scale and pressure pain threshold (PPT) measured by digital algometry at the affected elbow. Backward stepwise linear regression was used to predict PRTEE and PPT scores at 2 and 12 months. Results:Cold pain threshold was the only consistent predictor for both PRTEE (P<0.034) and PPT (P<0.048). Initial PRTEE was the strongest single predictor of PRTEE at 2 months, whereas female sex was the strongest single predictor of PPT (P<0.002). At 1 year, final models explained 9% to 52% of the variability in pain and disability and mechanical hyperalgesia, respectively. Discussion:Early assessment of cold pain threshold could be a useful clinical tool to help identify patients at risk of poorer outcomes and might provide direction for future research into mechanism-based treatment approaches for these patients.

Evidence of Spinal Cord Hyperexcitability as Measured With Nociceptive Flexion Reflex (NFR) Threshold in Chronic Lateral Epicondylalgia With or Without a Positive Neurodynamic Test

UNLABELLED There is emerging evidence of altered pain signal processing as a likely underlying mechanism in chronic lateral epicondylalgia (LE), yet this remains to be assessed. Furthermore, it has been proposed that neurodynamic tests reflect nociceptive withdrawal responses. Therefore, the objective was to improve our understanding of spinal cord excitability as measured by nociceptive flexion reflex (NFR) threshold in chronic LE with and without a positive neurodynamic test. NFR threshold, pain-free grip, and pressure pain threshold were measured in 30 LE participants and 31 healthy controls. Test of neural tissue involvement (using upper limb neural tension, radial bias) was used to differentiate LE participants with or without a positive neurodynamic test. There were significant differences in NFR threshold between the control and LE with or without a positive neurodynamic test (F[2,54] = 5.68, P = .006), after adjusting for age, sex, pain rating at NFR threshold, and reflex size (NFR interval peak z score). The mean differences (95% confidence interval) in NFR threshold between the control and LE with or without a positive neurodynamic test were 3.74 mA (.637, 6.84) and 3.38 mA (.0245, 6.74) respectively. PERSPECTIVE The results suggest evidence of spinal cord hyperexcitability, particularly sensory hypersensitivity, in LE with or without a positive neurodynamic test. Our data appear to support the hypothesis that continued peripheral afferent stimulation results in facilitation of nociceptive pathways in this patient population.

Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All

Synopsis Clear guidelines for the clinical management of individuals with lateral elbow tendinopathy (LET) are hampered by many proposed interventions and the conditions prognosis, ranging from immediate resolution of symptoms following simple advice in some patients to long-lasting problems, regardless of treatment, in others. This is compounded by our lack of understanding of the complexity of the underlying pathophysiology of LET. In this article, we collate evidence and expert opinion on the pathophysiology, clinical presentation, and differential diagnosis of LET. Factors that might provide prognostic value or direction for physical rehabilitation, such as the presence of neck pain, tendon tears, or central sensitization, are canvassed. Clinical recommendations for physical rehabilitation are provided, including the prescription of exercise and adjunctive physical therapy and pharmacotherapy. A preliminary algorithm, including targeted interventions, for the management of subgroups of patients with LET based on identified prognostic factors is proposed. Further research is needed to evaluate whether such an approach may lead to improved outcomes and more efficient resource allocation. J Orthop Sports Phys Ther 2015;45(11):938-949. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5841.

The impact of onsite workplace health-enhancing physical activity interventions on worker productivity: a systematic review

The aim of this study is to investigate the effects of onsite workplace health-enhancing physical activity (HEPA) programmes on worker productivity. The PROSPERO registration number is CRD42014008750. A search for controlled trials or randomised controlled trials (RCTs) that investigated the effects of onsite workplace HEPA programmes on productivity levels of working adults was performed. Risk of bias of included studies was assessed, and the inter-rater reliability of the quality assessment was analysed. Qualitative synthesis of available evidence is presented. Eight studies were included in the review. There is consistent evidence that onsite workplace HEPA programmes do not reduce levels of sick leave. There appears to be inconsistent evidence of the impact of onsite workplace HEPA programmes on worker productivity. A high-quality study of an onsite combination (aerobic, strengthening and flexibility) HEPA regime and a moderate-quality study of a Tai Chi programme improved worker productivity measured with questionnaires in female laundry workers and older female nurses, respectively. Two high-quality studies and four moderate-quality studies did not show benefit. Studies that showed benefit were mainly those designed with productivity measures as primary outcomes, delivered to occupations involved with higher physical loads, and had higher compliance and programme intensity. The small number of studies and the lack of consistency among studies limited further analyses. There is inconsistent evidence that onsite workplace HEPA programmes improve self-reported worker productivity. Future high-quality RCTs of onsite workplace HEPA programmes should be designed around productivity outcomes, target at-risk groups and investigate interventions of sufficient intensity. High attendance with improved recording is needed to achieve significant results in augmenting worker productivity.

One-week time course of the effects of Mulligan's Mobilisation with Movement and taping in painful shoulders.

Previous research suggests that Mulligans Mobilisation-with-Movement (MWM) technique for the shoulder produces an immediate improvement in movement and pain. The aims of this study were to investigate the time course of the effects of a single MWM technique and to ascertain the effects of adding tape following MWM in people with shoulder pain. Twenty-five participants (15 males, 10 females), who responded positively to an initial application of MWM, were randomly assigned to MWM or MWM-with-Tape. Range of movement (ROM), pressure pain threshold (PPT) and current pain severity (PVAS) were measured pre- and post-intervention, 30-min, 24-h and one week follow-up. Following a one-week washout period, participants were crossed over to receive a single session of the opposite intervention with follow-up measures repeated. ROM significantly improved with MWM-with-Tape and was sustained over one week follow-up (p < 0.001; 18.8°, 95% confidence intervals (CI) 7.3-30.4), and in PVAS up to 30-min follow-up (38.4 mm, 95% CI 20.6-56.1 mm). MWM demonstrated an improvement in ROM (11.8°, 95% CI 1.9-21.7) and PVAS (40.4 mm, 95% CI 27.8-53.0 mm), but only up to 30-min follow-up. There was no significant improvement in PPT for either intervention at any time point. MWM-with-Tape significantly improved ROM over the one-week follow-up compared to MWM alone (15.9°, 95% CI 7.4-24.4). Both MWM and MWM-with-Tape provide a short-lasting improvement in pain and ROM, and MWM-with-Tape also provides a sustained improvement in ROM to one-week follow-up, which is superior to MWM alone.

Elbow flexor and extensor muscle weakness in lateral epicondylalgia

Objective To evaluate whether deficits of elbow flexor and extensor muscle strength exist in lateral epicondylalgia (LE) in comparison with a healthy control population. Design Cross-sectional study. Participants 150 participants with unilateral LE were compared with 54 healthy control participants. Main outcome measures Maximal isometric elbow flexion and extension strength were measured bilaterally using a purpose-built standing frame such that gripping was avoided. Results The authors found significant side differences in elbow extensor (−6.54 N, 95% CI −11.43 to −1.65, p=0.008, standardised mean difference (SMD) −0.45) and flexor muscle strength (−11.26 N, 95% CI −19.59 to −2.94, p=0.009, SMD −0.46) between LE and control groups. Within the LE group, only elbow extensor muscle strength deficits between sides was significant (affected–unaffected: −2.94 N, 95% CI −5.44 to −0.44). Conclusion Small significant deficits of elbow extensor and flexor muscle strength exist in the affected arm of unilateral LE in comparison with healthy controls. Notably, comparing elbow strength between the affected and unaffected sides in unilateral epicondylalgia is likely to underestimate these deficits. Trial Registration Australian New Zealand Clinical Trials Register ACTRN12609000051246.