Background
Methods
Registration of review
Eligibility criteria
Population
Interventions
Comparison groups
Outcomes
Study characteristics
Data sources and searches
Study selection
Quality assessment and data extraction
Data synthesis and analysis
Statistical analyses
Reporting
Results
Study selection
Study characteristics
Education | Exercise | Manual Therapy | Soft Tissue Therapy | Acupuncture | Passive Modalities | Medication | Usual Care | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Author, year | Treatment provider | Number of visits | Treatment period (weeks) | Manipulation | Mobilisation | Traction | Ultrasound | Splint | Heat/Cold | ||||||
PTc
| 8 | 6 | ✓ | ✓ | ✓ | ||||||||||
GPe
| 2 | 6 | ✓ | ✓ | |||||||||||
GPd
| 1 | 6 | ✓ | ||||||||||||
Smidt [66] | PTc
| 9 | 6 | ✓ | ✓ | ✓ | |||||||||
GPe
| 3 | 6 | ✓ | ||||||||||||
GPd
| 1 | 6 | ✓ | ✓ | |||||||||||
Haahr [64] | GP, Ergonomistd
| 1 | UK | ✓ | ✓ | ✓ | |||||||||
GPd
| 1 | UK | ✓ | ||||||||||||
Nagrale [65] | PTc
| 12 | 4 | ✓ | ✓ | ✓ | |||||||||
PTe
| 12 | 4 | ✓ | ✓ | ✓ | ||||||||||
Struijs [67] | PTd
| 9 | 6 | ✓ | ✓ | ✓ | |||||||||
PTd
| 1 | 6 | ✓ | ||||||||||||
PTd
| 9 | 6 | ✓ | ✓ | ✓ | ✓ |
Education | Exercise | Manual Therapy | Soft Tissue Therapy | Acupuncture | Passive Modalities | Surgery | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Author, Year | Treatment Provider | Number of Visits | Treatment Period (weeks) | Manipulation | Mobilisation | Traction | Ultrasound | Splint | |||||
Jarvik [61] | GP, HTc
| 30 | 12 | ✓ | ✓ | ✓ | ✓ | ||||||
Surgeon, HTd
| UK | UK | ✓ | ✓ |
Risk of bias within studies
Author, Year | Research Question | Randomization | Concealment | Blinding | Similarity at baseline | Similarities between arms | Outcome measurement | Percent drop-out | Intention to treat | Multiple sites |
---|---|---|---|---|---|---|---|---|---|---|
Y | Y | Y | Y | Y | N | Y | 6 Weeks: Multimodal Care: 5 % Corticosteroid Injection: 0 % Reassurance and advice: 10 % 52 Weeks: Multimodal Care: 5 % Corticosteroid Injection: 0 % Reassurance and advice: 7 % | Y | CS | |
Haahr et al., 2003 [64] | Y | Y | Y | Y | N | N | Y | 3 Months: Multimodal GP/Ergonomist: 16 % GP: 14 % 6 Months: Multimodal GP/Ergonomist: 19 % GP: 16 % 12 Months: Multimodal GP/Ergonomist: 22 % GP: 18 % | Y | CS |
Jarvik et al., 2009 [61] | Y | Y | Y | Y | Y | Y | Y | 12 Months: Multimodal Care: 11.9 % Surgery: 14.0 % | Y | Y |
Nagrale et al., 2009 [65] | Y | Y | Y | Y | Y | N | Y | No drop outs | NA | CS |
Smidt et al., 2002 [66] | Y | Y | Y | CS | N | N | Y | Multimodal PT: no drop outs Reassurance and advice: no drop outs Corticosteroid injection: 12 weeks: 1.6 % 26 weeks: 1.6 % | Y | CS |
Struijs et al., 2004 [67] | Y | Y | CS | Y | Y | Y | Y | 6 Weeks: Multimodal PT: 3.6 % Brace: 1.5 % Multimodal PT + Brace: 1.8 % 26 Weeks: Multimodal PT: 3.6 % Brace: 5.9 % Multimodal PT + Brace: 3.6 % 52 Weeks: Multimodal PT: 5.4 % Brace: 5.4 % Multimodal PT + Brace: 3.6 % | Y | NA |
Summary of evidence
Carpal tunnel syndrome of persistent duration
Author(s), Year | Subjects and Setting; Number (n) Enrolled | Interventions; Number (n) of Subjects | Comparisons; Number (n) of Subjects | Follow-up | Outcomes | Key Findings |
---|---|---|---|---|---|---|
Jarvik et al., 2009 [61] | Participants (≥18 y.o.) recruited from Washington State and New Hampshire. Case definition: symptoms ≥2 weeks in at least 2 digits including thumb, index, ring finger; CTS on hand pain diagram, electrodiagnostic testing (motor latency, ulnar sensory difference, radial sensory difference); night pain waking; positive flick test. (n = 116). | Multimodal Care by physician and hand therapist: NSAIDS (ibuprofen 200 mg/3x /day), opioid, corticosteroid; hand therapy (6 visits/6 weeks): educational booklet, exercises, stretching, tendon gliding, wrist splint and work/activity modifications; ultrasound if no improvement 6 weeks after randomization (maximum 12 15-min sessions; 2–4 per week/6 weeks): 1Mhz, 1.0 W/cm2 in 1:4 pulsed mode. (n = 59) | Surgery: open or endoscopic decompression, followed by hand therapy (median nerve and tendon gliding exercises). (n = 57) | 6 and 12 months | Primary Outcome: Function (CTSAQ Functional Status Scale) Secondary Outcomes: Symptom severity (CTSAQ Symptom Severity Scale); hand/wrist pain intensity (NRS 0–10); hand/wrist pain interference (NRS 0–10); work days lost (0–28); limited activity days; general health-related quality of life (SF-36 0–100). Successful outcome: ≥0.5 points improvement from baseline CTSAQ function; ≥0.5 points CTSAQ symptom severity; and a score of 0 or 1 on hand/ wrist pain interference with work or housework Adverse events. |
*Difference in Mean Change Score (Multimodal Care-Surgery) CTSAQ Function 6 months: -0.46 (95 % CI -0.72; -0.20) 12 months: -0.40 (95 % CI -0.70; -0.11) CTSAQ Symptom Severity 6 months: -0.42 (95 % CI -0.77; -0.07) 12 months: -0.34 (95 % CI -0.65; -0.02) There were no clinically or statistically differences between groups in days of reduced work/housework, work days lost, pain intensity, pain interference or SF-36 at any follow-up point. Successful Outcomea
6 months: Multimodal Care: RR 0.51 (95 % CI 0.25; 1.05) 12 months: Multimodal Care: RR 0.62 (95 % CI 0.35; 1.08) Adverse Events: No clinically important adverse events; no surgical complications. |
Lateral epicondylitis of persistent duration
Author(s), Year | Subjects and Setting; Number (n) Enrolled | Interventions; Number (n) of Subjects | Comparisons; Number (n) of Subjects | Follow-up | Outcomes | Key Findings |
---|---|---|---|---|---|---|
Participants (18–65 y.o.) from Brisbane, Australia. Case definition: lateral elbow pain increased with palpation of the lateral epicondyle, gripping, resisted wrist or second or third finger extension of >6 weeks duration. (n = 198) | Multimodal care by a PT (8 visits/6 weeks): elbow manipulation, exercise (supervised and home-based), self-manipulation, educational booklet (disease process, self management advice, ergonomics). (n = 66) | Corticosteroid injection by a GP (1 ml 1 % lidocaine with 10 mg triamcinolone acetonide in 1 ml); 1 injection at painful points and second injection after two weeks if necessary; advice to return gradually to normal activities; educational booklet (disease process, self management advice, ergonomics) (n = 65) Reassurance and Advice: reassurance (ADL modifications, analgesic drugs, heat, cold, braces), educational booklet (disease process, self management advice, ergonomics) (n = 67) | 6, 12, 26 and 52 weeks | Primary Outcome: Global improvement (6 point Likert Scale); success = “completely recovered” or “much improved”; recurrence (“successful” to “unsuccessful”); pain-free grip force (digital grip dynamometer, affected side/unaffected side x 100) Secondary Outcome: pain severity (VAS 0–100 mm); elbow disability (Pain Free Function Questionnaire (PFFQ)); Sensorimotor function: SRT(ms); RT1(ms); RT2(ms); S1(cm/s); S2(cm/s) Adverse events. | Relative Risk (Multimodal Care vs. Corticosteroid Injection):a
Success 6 weeks: RR 0.79 (95 % CI 0.63; 0.99) 12 weeks: RR 1.53 (95 % CI 1.11; 2.10) 26 weeks: RR 1.73 (95 % CI 1.28; 2.34) 52 weeks: RR 1.32 (95 % CI 1.09; 1.59) Recurrence After 6 weeks: RR 0.11 (95 % CI 0.05; 0.25) Difference in Mean Change from Baseline: (Multimodal Care - Corticosteroid Injectionb) Pain-free Grip Force 6 weeks:--17.4 (99 % CI -22.4; -12.4) 12 weeks: 13.1 (99 % CI 7.6; 18.6) 26 weeks: 28.2 (99 % CI 21.6; 34.8) 52 weeks: 12.3 (99 % CI 6.7; 17.9) Pain Severity 6 weeks: -13.4 (99 % CI -18.8; -8.0) 12 weeks: 19.4 (99 % CI 13.6; 25.2) 26 weeks: 20.0 (99 % CI 14.6; 25.4) 52 weeks: 18.2 (99 % CI 12.6; 23.8) PFFQ 6 weeks: -20.3 (99 % CI -26.9; -13.6) 12 weeks: 12.4 (99 % CI 5.1; 19.7) 26 weeks: 21.4 (99 % CI 15.1; 27.6) 52 weeks: 18.8 (99 % CI 11.9; 25.7) Sensorimotor Function There were no clinical or statistical differences between groups in SRT, RT1, RT2, S1 or S2 at any follow-up point. Relative Risk Reduction (Multimodal Care vs. Reassurance and Advice):a
Success 6 weeks: RR 2.60 (99 % CI 1.63; 4.15) 12 weeks: RR 1.31 (99 % CI 0.98; 1.73) 26 weeks: RR 1.08 (99 % CI 0.88; 1.32) 52 weeks: RR 1.07 (99 % CI 0.93; 1.22) Recurrence 6 weeks: RR 0.85 (95 % CI 0.27; 2.65) Difference in Mean Change from Baseline (Multimodal care – Reassurance and Adviceb): Pain-free Grip Force 6 weeks: 24.0 (99 % CI 19.0; 29.0) 12 weeks: 14.3 (99 % CI 9.5; 19.1) 26 weeks: 15.4 (99 % CI 9.9; 20.9) 52 weeks: 10.0 (99 % CI 4.4; 15.6) Pain Severity 6 weeks: 12.2 (99 % CI 7.3; 17.1) 12 weeks: 5.8 (99 % CI 0.8; 10.8) 26 weeks: 4.9 (99 % CI -0.5; 10.3) 52 weeks 1.4 (99 % CI -4.2; 7.0) PFFQ 6 weeks: 15.7 (99 % CI 9.9; 21.5) 12 weeks: 17.4 (99 % CI 11.2; 23.6) 26 weeks: 5.0 (99 % CI -1.1; 11.1) 52 weeks: 10.4 (99 % CI 4.1; 16.7) Sensorimotor Function There were no clinical or statistical differences between groups in SRT, RT1, RT2, S1 or S2 at any follow-up point. Adverse Events Minor: pain following treatment, loss of skin pigment; subcutaneous tissue atrophy. Multimodal Care: 10.6 %; Corticosteroid Injection: 20.0 %; Wait and See: 0.0 %. | |
Haahr et al., 2003 [64] | Adults (18–66 y.o.) with lateral epicondylitis consulting with GP in Ringkjoebing County, Denmark. Case definition: new episode (<1 year) of lateral epicondylitis (i.e., indirect tenderness at or within 2 cm from lateral humeral epicondyle on resisted extension of wrist and/or third finger (n = 289). | Multimodal Intervention by GP and ergonomist: reassurance and advice (against complete rest, stay active, avoid aggravating activities, adjust work conditions) by GP. Graded exercises by ergonomist. OTC analgesics, (n = 148) | Usual care provided by GP. (n = 141) | 1 year | Primary Outcome: Self-reported overall development of condition (5 point Likert; ‘much better’ to ‘much worse’); 50 % reduction in combined pain and function score Secondary Outcome: sickness absence, ceased or changed job, start education or rehabilitation activity, labour compensation claim. | Perceived unchanged or worse overall developmentc: Control: OR 1.0 Multimodal Care: OR 1.0 (95 % CI 0.4; 2.3) |
Nagrale et al., 2009 [65] | Outpatient clinic, Wardha, Maharashtra, India (30–60 y.o.). Case definition: tenderness to palpation over the lateral humeral epicondyle, pain with gripping, passive wrist flexion with elbow extension and resisted wrist extension lasting ≥1 month (n = 60) | Cyriax physiotherapy (deep transverse friction massage plus Mill’s manipulation), education (ergonomics, activity modification) (3/week; 4 weeks). (n = 30) | Phonophoresis (5 min) over lateral epicondyle (Voveran Emulgel frequency 1 MHz, 0.8 W/cm2 intensity), supervised exercise, education (ergonomics, activity modification) (3/week; 4 weeks) (n = 30) | 4 and 8 weeks | Primary Outcome: pain severity (VAS 0–10 cm); pain-free grip strength (dynamometer, pounds); Tennis Elbow Function Scale (TEFS) (0–40) | Cyriax Physiotherapy – Phonophoresis + Exercise Difference in Mean Change Score a,d
Pain severity 4 weeks: 1.8 8 weeks: 2.5 Pain-free Grip Strength 4 weeks: 12.4 8 weeks: 14.5 TEFS 4 weeks: 7.7 8 weeks: 8.9 |
Smidt et al., 2002 [66] | Primary care setting (85 family doctors), referred to 5 research centres, Netherlands (18–70 y.o.). Case definition: lateral epicondylitis ≥6 weeks duration (n = 185) | Multimodal Care: provided by a PT (9visits/6 weeks): pulsed ultrasound, massage, exercise; home exercise equipment and instruction booklet.(n = 64) | Corticosteroid Injection (1 mL of 10 mg/mL triamcinolone cetonide + 1 mL 2 % lignocaine) at each tender spot; maximum 3 injections in 6 weeks, avoid pain-provoking activities provided by family doctor (n = 62) Reassurance and Advice: 1 visit with family doctor in 6 weeks. Advice (pain provoking activities, ergonomic), paracetamol or NSAIDs if necessary, await spontaneous improvement (n = 59) | 6, 12, 26 and 52 weeks | Primary Outcome: Global improvement (“completely recovered“to “much worse”); success = “completely recovered” or “much improved”; severity of main complaint (NRS 0–10); pain during day (NRS 0–10); inconvenience (NRS 0–10); functional disability (modified pain-free function questionnaire, 0–40); PT rated overall severity (0–10). Secondary Outcomes: pain-free grip strength (kg); maximum grip strength (kg); pressure pain threshold; satisfaction with intervention. All scales transformed to 0–100. Adverse events. | Multimodal Care – Reassurance and Advice Difference in Mean Change Score a
Success rate 6 weeks:
RR 1.46 (95 % CI 0.93; 2.29) 52 weeks:
RR 1.09 (95 % CI 0.95; 1.25) Multimodal Care - Corticosteroid injection Success rate 6 weeks: RR 0.51 (95 % CI 0.39; 0.67) 52 weeks: RR 1.31 (95 % CI 1.09; 1.57) Adverse events: increased pain; radiating pain; facial flush; skin irritation; red swollen elbow; skin colour change; other minor or temporary adverse reactions. Multimodal: 64 %; Corticosteroid Injection:58 %; Reassurance and Advice: 17 % |
Struijs et al., 2004 [73] | Patients referred from GP and primary care PT to outpatient clinic, the Netherlands. Case definition: pain aggravated by pressure on lateral epicondyle and resisted wrist dorsiflexion (≥6 weeks duration) (n = 180) | Multimodal Care by PT (9 visits/6 weeks): pulsed ultrasound, friction massage, strengthening and stretching exercise, home exercise with diary. (n = 56) | Brace: provided by PT (1 visit): Epipoint elbow brace worn over common extensor tendon. (n = 68) Combination Group: Multimodal Care plus Brace intervention. (n = 56) | 6, 26 and 52 weeks | Primary Outcome: Global improvement (6 point Likert Scale) (“completely recovered“to “much worse”); success = “completely recovered” or “much improved”; severity of complaints (0–11 NRS); pain intensity of most severe complaint (0–11 NRS); modified PFFQ (10 item, 0–4) Secondary Outcome: Inconvenience during daily activities (0–10); pain-free grip strength (kg); maximum grip strength (kg); pressure pain threshold at lateral epicondyle (kg/cm2); satisfaction with treatment (0–10). All outcomes transformed to 100 point scale. | Multimodal Care – Brace Success rate 6 weeks: RR 1.22 (95 % CI 0.9; 1.7) 26 weeks: RR 0.89 (95 % CI 0.5; 1.6) 52 weeks: RR 1.26 (95 % CI 0.5; 3.3) Difference in Mean Change Score Severity of Complaints 6 weeks: 5 (95 % CI -2; 12) 52 weeks: -1 (95 % CI -10; 5) Pain Intensity 6 weeks: 13 (95 % CI 3; 21) 26 weeks: -1 (95 % CI -12; 10) 52 weeks: 0 (95 % CI -10; 11) PFFQ 6 weeks: 7 (95 % CI 1; 12) 26 weeks: 0 (95 % CI -6; 7) 52 weeks: -3 (95 % CI -9; 3) There were no clinical or statistical differences between groups in inconvenience during daily activities, pain-free grip strength, maximum grip strength or pressure pain threshold at any follow-up point. Satisfaction 6 weeks: 9 (95 % CI 1, 18) Multimodal Care – Combination Success rate 6 weeks: RR 0.90 (95 % CI 0.6; 1.3) 26 weeks: RR 1.31 (95 % CI 0.7; 2.4) 52 weeks: RR 0.87 (95 % CI 0.3; 2.4) Difference in Mean Change Score Severity of Complaints 6 weeks: -6 (95 % CI -12; 1) 52 weeks: -3 (95 % CI -11; 4) Pain Intensity 6 weeks: 7 (95 % CI -4; 17) 26 weeks: -4 (95 % CI -14; 7) 52 weeks: 2 (95 % CI -8; 13) PFFQ 6 weeks: -2 (95 % CI -8; 4) 26 weeks: -6 (95 % CI -12; 1) 52 weeks: -5 (95 % CI -12; 1) There were no clinical or statistical differences between groups in inconvenience during daily activities, pain-free grip strength, maximum grip strength or satisfaction at any follow-up point. Pressure pain threshold 6 weeks: −13 (95 % CI −25; −1) Combination--Brace Success rate 6 weeks: RR 1.11 (95 % CI 0.8; 1.5) 26 weeks: RR 1.17 (95 % CI 0.6; 2.2) 52 weeks: RR 1.10 (95 % CI 0.4; 2.8) Difference in Mean Change Score Severity of Complaints 6 weeks: 11 (95 % CI 6; 18) 52 weeks: 1 (95 % CI −6; 8) Pain Intensity 6 weeks: 6 (95 % CI −15; 4) 26 weeks: 5 (95 % CI −7; 17) 52 weeks: −2 (95 % CI −12; 8) PFFQ 6 weeks: 9 (95 % CI 2; 15) 26 weeks: 6 (95 % CI −1; 13) 52 weeks: 2 (95 % CI −5; 9) There were no clinical or statistical differences between groups in inconvenience during daily activities, pain-free grip strength, maximum grip strength or pressure pain threshold at any follow-up point. Satisfaction 6 weeks: 11 (95 % CI 3; 19) |