Downloaded from http://bjsm.bmj.com/ on March 12, 2015 - Published by group.bmj.com
BJSM Online First, published on February 17, 2015 as 10.1136/bjsports-2015-094640 PEDro systematic review update This section features a recent systematic review that is indexed on PEDro, the Physiotherapy Evidence Database (http://www.pedro. org.au). PEDro is a free, web-based database of evidence relevant to physiotherapy.
The effect of eccentric exercise in improving function or reducing pain in lateral epicondylitis is unclear ▸ Cullinane F, Boocock M, Trevelyan F. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil 2014;28:3–19.
BACKGROUND Lateral epicondylitis has an annual incidence up to 3% in the general population.1 Resistance exercise reduces pain intensity and improves grip strength in lateral epicondylitis.2 Eccentric exercise is successfully used in the rehabilitation of mid-portion Achilles and patellar tendon injuries and seems promising in the treatment of other tendinopathies such as lateral epicondylitis.3
AIM This systematic review aimed to evaluate the effectiveness of eccentric exercise for lateral epicondylitis.
SEARCHES AND INCLUSION CRITERIA Electronic database searches of ProQuest, MEDLINE, AMED, Scopus, Web of Science and CINAHL were conducted. Randomised controlled studies and controlled clinical trials (non-randomised) were included if they were written in English. Previous, concurrent or comparative treatment with corticosteroid injections was an exclusion criterion. Owing to the high risk of bias in non-randomised trials, this commentary focuses on evidence from randomised controlled trials only.
INTERVENTIONS Studies compared (1) eccentric exercise versus other therapy (electrotherapy and stretching), (2) eccentric exercise and ‘adjunct therapies’ (other types of exercise, ultrasound, deep friction massage, heat, ice, forearm band, transcutaneous electrical nerve stimulation or combinations of these) versus the same adjunct therapies and (3) eccentric exercise and adjunct therapies versus different therapies. Among the included studies eccentric exercise was prescribed in different positions, with different amounts of resistance, frequency (ranging from 3 to 7 times per week), duration (ranging from 4 to 14 weeks), sets (generally 3) and repetitions (ranging from 5 to 15).
MAIN OUTCOME MEASURES To be included in the review, studies had to report on one or more functional or disability outcome measures, for example the disability of the arm and shoulder questionnaire or grip strength. Although not part of the eligibility criteria, the review also reported pain outcomes (measured by the visual analogue scale).
STATISTICAL METHODS Data were reported descriptively; no meta-analysis was conducted.
RESULTS Eight randomised controlled trials with a total of 334 participants were included. Quality ratings of these trials ranged from 11 to 20 of 26 points using a modified Cochrane Musculoskeletal Injuries Group score; one study was rated as low, six studies as medium, and one study as high quality. In all studies the visual analogue scale was used to measure pain, in six studies grip strength was measured, and five studies used questionnaires on functional or disability outcomes. One low quality study4 compared eccentric exercise with electrotherapy and stretching. Both groups reported a significant reduction of pain, but there was no significant difference between the groups at 4 weeks. Two5 6 of three randomised controlled studies which compared eccentric exercise and adjunct therapy to the same adjunct therapy showed an improvement in grip strength and a greater reduction in pain in the groups where eccentric exercise was added. In addition one of these studies reported reduced disability also in the eccentric exercise group.5 In contrast, one medium quality study7 reported no differences in functional measures, pain, and grip strength between groups. Three of four randomised controlled trials showed greater benefits on function,8 9 grip strength,8 10 and reduced pain8–10 in the group that received eccentric exercise and adjunct therapy, compared with the group that received a different therapy. In contrast, a medium quality study11 reported Cyriax physiotherapy was more effective than eccentric exercise combined with phonophoresis on pain, function and grip strength.
LIMITATIONS/CONSIDERATIONS This review is limited by the lack of a meta-analysis, small sample size of the included studies (ranging from 20 to 94 participants), low number of studies and inconsistent findings between studies of the same comparison. The authors relied on ‘vote counting’ to estimate the benefits of eccentric exercise; however this method does not take in to account the sample size of studies and the treatment effect size,12 therefore the clinical importance of the findings is unknown. Furthermore, although three of four trials showed that eccentric exercise and adjunct therapy improved function and reduced pain compared with a different therapy, all studies used a different combination of treatments in the intervention arm. As the effective component(s) of the combined treatments cannot be identified, such findings should not be interpreted as evidence showing eccentric exercise is effective as part of a multimodal therapy programme. The review followed the PRISMA statement13 for reporting systematic reviews, however there were some limitations in reporting. For example, the authors did not report the procedures on study selection or data extraction. Findings of this review demonstrate that the effect of eccentric exercise in lateral epicondylitis is unclear. Another recent systematic review also found a low number of studies investigating the effect of eccentric exercise in lateral epicondylitis.14 Their results suggest that eccentric exercise may be more beneficial compared with no intervention, but appear to be no more effective when compared with another intervention.
CLINICAL IMPLICATIONS The majority of the studies included in this systematic review suggest that eccentric exercise may be more effective in improving function and reducing pain in lateral epicondylitis, but this evidence is limited. Future well-designed and adequately powered studies are needed to confirm the effectiveness and
Heijnders ILC, et al. Br J Sports Med Month 2015 Vol 0 No 0
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://bjsm.bmj.com/ on March 12, 2015 - Published by group.bmj.com
PEDro systematic review update establish the treatment effect size of eccentric exercise for lateral epicondylitis.
4 5
Irene L C Heijnders, Chung-Wei Christine Lin Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia Correspondence to Dr Chung-Wei Christine Lin, Musculoskeletal Division, The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Sydney, NSW 2000, Australia; [email protected] Contributors ILCH and C-WCL selected the systematic review. ILCH wrote the first draft of the manuscript. ILCH and C-WCL contributed to interpretation of the data and revision of the final manuscript.
6
7
8 9
Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
10
To cite Heijnders ILC, Lin C-WC. Br J Sports Med Published Online First: [ please include Day Month Year] doi:10.1136/bjsports-2015-094640
11
Accepted 22 January 2015 Br J Sports Med 2015;0:1–2. doi:10.1136/bjsports-2015-094640
12
REFERENCES
13
1
2 3
2
Hoogvliet P, Randsdorp MS, Dingemanse R, et al. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med 2013;47:1112–19. Raman J, MacDermid JC, Grewal R. Effectiveness of different methods of resistance exercises in lateral epicondylosis—a systematic review. J Hand Ther 2012;25:5–25. Friezziero A, Trainito S, Oliva F, et al. The role of eccentric exercise in sport injuries rehabilitation. Br Med Bull 2014;110:47–75.
14
Wen D, Schultz B, Schaal B, et al. Eccentric strengthening for chronic lateral epicondylosis: a prospective randomized study. Sports Health 2011;3:500–3. Tyler T, Thomas G, Nicholas S, et al. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. J Shoulder Elbow Surg 2010;19:917–22. Söderberg J, Grooten WJ, Äng BO. Effects of eccentric training on hand strength in subjects with lateral epicondylalgia: a randomized-controlled trial. Scand J Med Sci Sports 2012;22:797–803. Martinez-Silvestrini J, Newcomer K, Gay R, et al. Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening. J Hand Ther 2005;18:411–19. Pienimaki T, Tarvainen T, Siira P. Progressive strengthening and stretching exercises and ultrasound for chronic lateral epicondylitis. Physiotherapy 1996;82:522–30. Viswas R, Ramachandran R, Korde Anantkumar P. Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial. Scientific World J 2012;2012:939645. Svernlov B, Adolfsson L. Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia. Scand J Med Sci Sports 2001;11:328–34. Nagrale A, Herd C, Gamvir S, et al. Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: a randomized clinical trial. J Man Manip Ther 2009;17:171–8. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. m8/Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. http://www.cochrane-handbook.org Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic review and meta-analyses: the PRISMA statement. BMJ 2009;339:b2535. Olaussen M, Holmedal O, Lindbaek M, et al. Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review. BMJ Open 2013;3:e003564.
Heijnders ILC, et al. Br J Sports Med Month 2015 Vol 0 No 0
Downloaded from http://bjsm.bmj.com/ on March 12, 2015 - Published by group.bmj.com
The effect of eccentric exercise in improving function or reducing pain in lateral epicondylitis is unclear Irene L C Heijnders and Chung-Wei Christine Lin Br J Sports Med published online February 17, 2015
Updated information and services can be found at: http://bjsm.bmj.com/content/early/2015/02/17/bjsports-2015-094640
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This article cites 13 articles, 4 of which you can access for free at: http://bjsm.bmj.com/content/early/2015/02/17/bjsports-2015-094640 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Physiotherapy (135) Physiotherapy (188) Injury (854) Trauma (767)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
BJSM Online First, published on February 17, 2015 as 10.1136/bjsports-2015-094640 PEDro systematic review update This section features a recent systematic review that is indexed on PEDro, the Physiotherapy Evidence Database (http://www.pedro. org.au). PEDro is a free, web-based database of evidence relevant to physiotherapy.
The effect of eccentric exercise in improving function or reducing pain in lateral epicondylitis is unclear ▸ Cullinane F, Boocock M, Trevelyan F. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil 2014;28:3–19.
BACKGROUND Lateral epicondylitis has an annual incidence up to 3% in the general population.1 Resistance exercise reduces pain intensity and improves grip strength in lateral epicondylitis.2 Eccentric exercise is successfully used in the rehabilitation of mid-portion Achilles and patellar tendon injuries and seems promising in the treatment of other tendinopathies such as lateral epicondylitis.3
AIM This systematic review aimed to evaluate the effectiveness of eccentric exercise for lateral epicondylitis.
SEARCHES AND INCLUSION CRITERIA Electronic database searches of ProQuest, MEDLINE, AMED, Scopus, Web of Science and CINAHL were conducted. Randomised controlled studies and controlled clinical trials (non-randomised) were included if they were written in English. Previous, concurrent or comparative treatment with corticosteroid injections was an exclusion criterion. Owing to the high risk of bias in non-randomised trials, this commentary focuses on evidence from randomised controlled trials only.
INTERVENTIONS Studies compared (1) eccentric exercise versus other therapy (electrotherapy and stretching), (2) eccentric exercise and ‘adjunct therapies’ (other types of exercise, ultrasound, deep friction massage, heat, ice, forearm band, transcutaneous electrical nerve stimulation or combinations of these) versus the same adjunct therapies and (3) eccentric exercise and adjunct therapies versus different therapies. Among the included studies eccentric exercise was prescribed in different positions, with different amounts of resistance, frequency (ranging from 3 to 7 times per week), duration (ranging from 4 to 14 weeks), sets (generally 3) and repetitions (ranging from 5 to 15).
MAIN OUTCOME MEASURES To be included in the review, studies had to report on one or more functional or disability outcome measures, for example the disability of the arm and shoulder questionnaire or grip strength. Although not part of the eligibility criteria, the review also reported pain outcomes (measured by the visual analogue scale).
STATISTICAL METHODS Data were reported descriptively; no meta-analysis was conducted.
RESULTS Eight randomised controlled trials with a total of 334 participants were included. Quality ratings of these trials ranged from 11 to 20 of 26 points using a modified Cochrane Musculoskeletal Injuries Group score; one study was rated as low, six studies as medium, and one study as high quality. In all studies the visual analogue scale was used to measure pain, in six studies grip strength was measured, and five studies used questionnaires on functional or disability outcomes. One low quality study4 compared eccentric exercise with electrotherapy and stretching. Both groups reported a significant reduction of pain, but there was no significant difference between the groups at 4 weeks. Two5 6 of three randomised controlled studies which compared eccentric exercise and adjunct therapy to the same adjunct therapy showed an improvement in grip strength and a greater reduction in pain in the groups where eccentric exercise was added. In addition one of these studies reported reduced disability also in the eccentric exercise group.5 In contrast, one medium quality study7 reported no differences in functional measures, pain, and grip strength between groups. Three of four randomised controlled trials showed greater benefits on function,8 9 grip strength,8 10 and reduced pain8–10 in the group that received eccentric exercise and adjunct therapy, compared with the group that received a different therapy. In contrast, a medium quality study11 reported Cyriax physiotherapy was more effective than eccentric exercise combined with phonophoresis on pain, function and grip strength.
LIMITATIONS/CONSIDERATIONS This review is limited by the lack of a meta-analysis, small sample size of the included studies (ranging from 20 to 94 participants), low number of studies and inconsistent findings between studies of the same comparison. The authors relied on ‘vote counting’ to estimate the benefits of eccentric exercise; however this method does not take in to account the sample size of studies and the treatment effect size,12 therefore the clinical importance of the findings is unknown. Furthermore, although three of four trials showed that eccentric exercise and adjunct therapy improved function and reduced pain compared with a different therapy, all studies used a different combination of treatments in the intervention arm. As the effective component(s) of the combined treatments cannot be identified, such findings should not be interpreted as evidence showing eccentric exercise is effective as part of a multimodal therapy programme. The review followed the PRISMA statement13 for reporting systematic reviews, however there were some limitations in reporting. For example, the authors did not report the procedures on study selection or data extraction. Findings of this review demonstrate that the effect of eccentric exercise in lateral epicondylitis is unclear. Another recent systematic review also found a low number of studies investigating the effect of eccentric exercise in lateral epicondylitis.14 Their results suggest that eccentric exercise may be more beneficial compared with no intervention, but appear to be no more effective when compared with another intervention.
CLINICAL IMPLICATIONS The majority of the studies included in this systematic review suggest that eccentric exercise may be more effective in improving function and reducing pain in lateral epicondylitis, but this evidence is limited. Future well-designed and adequately powered studies are needed to confirm the effectiveness and
Heijnders ILC, et al. Br J Sports Med Month 2015 Vol 0 No 0
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://bjsm.bmj.com/ on March 12, 2015 - Published by group.bmj.com
PEDro systematic review update establish the treatment effect size of eccentric exercise for lateral epicondylitis.
4 5
Irene L C Heijnders, Chung-Wei Christine Lin Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia Correspondence to Dr Chung-Wei Christine Lin, Musculoskeletal Division, The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Sydney, NSW 2000, Australia; [email protected] Contributors ILCH and C-WCL selected the systematic review. ILCH wrote the first draft of the manuscript. ILCH and C-WCL contributed to interpretation of the data and revision of the final manuscript.
6
7
8 9
Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
10
To cite Heijnders ILC, Lin C-WC. Br J Sports Med Published Online First: [ please include Day Month Year] doi:10.1136/bjsports-2015-094640
11
Accepted 22 January 2015 Br J Sports Med 2015;0:1–2. doi:10.1136/bjsports-2015-094640
12
REFERENCES
13
1
2 3
2
Hoogvliet P, Randsdorp MS, Dingemanse R, et al. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med 2013;47:1112–19. Raman J, MacDermid JC, Grewal R. Effectiveness of different methods of resistance exercises in lateral epicondylosis—a systematic review. J Hand Ther 2012;25:5–25. Friezziero A, Trainito S, Oliva F, et al. The role of eccentric exercise in sport injuries rehabilitation. Br Med Bull 2014;110:47–75.
14
Wen D, Schultz B, Schaal B, et al. Eccentric strengthening for chronic lateral epicondylosis: a prospective randomized study. Sports Health 2011;3:500–3. Tyler T, Thomas G, Nicholas S, et al. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. J Shoulder Elbow Surg 2010;19:917–22. Söderberg J, Grooten WJ, Äng BO. Effects of eccentric training on hand strength in subjects with lateral epicondylalgia: a randomized-controlled trial. Scand J Med Sci Sports 2012;22:797–803. Martinez-Silvestrini J, Newcomer K, Gay R, et al. Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening. J Hand Ther 2005;18:411–19. Pienimaki T, Tarvainen T, Siira P. Progressive strengthening and stretching exercises and ultrasound for chronic lateral epicondylitis. Physiotherapy 1996;82:522–30. Viswas R, Ramachandran R, Korde Anantkumar P. Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial. Scientific World J 2012;2012:939645. Svernlov B, Adolfsson L. Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia. Scand J Med Sci Sports 2001;11:328–34. Nagrale A, Herd C, Gamvir S, et al. Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: a randomized clinical trial. J Man Manip Ther 2009;17:171–8. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. m8/Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. http://www.cochrane-handbook.org Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic review and meta-analyses: the PRISMA statement. BMJ 2009;339:b2535. Olaussen M, Holmedal O, Lindbaek M, et al. Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review. BMJ Open 2013;3:e003564.
Heijnders ILC, et al. Br J Sports Med Month 2015 Vol 0 No 0
Downloaded from http://bjsm.bmj.com/ on March 12, 2015 - Published by group.bmj.com
The effect of eccentric exercise in improving function or reducing pain in lateral epicondylitis is unclear Irene L C Heijnders and Chung-Wei Christine Lin Br J Sports Med published online February 17, 2015
Updated information and services can be found at: http://bjsm.bmj.com/content/early/2015/02/17/bjsports-2015-094640
These include:
References Email alerting service
Topic Collections
This article cites 13 articles, 4 of which you can access for free at: http://bjsm.bmj.com/content/early/2015/02/17/bjsports-2015-094640 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Physiotherapy (135) Physiotherapy (188) Injury (854) Trauma (767)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
