School of Health & Social Care

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2 School of Health & Social Care Evaluation of the effectiveness of elbow orthotic devices compared to physiotherapeutic interventions for the treatment of patients with lateral epicondylitis (tennis elbow) A systematic Review Claudia Köckritz Module title: Dissertation Module code: RMH4009-N A Dissertation submitted in partial fulfilment of the requirements of the University of Teesside for the Degree of the Master of Science Advanced Clinical Practice of Manipulative Therapy. Supervisor: John Dixon Date of Submission: 3 rd May 2011 Word count: 14999

3 This research programme was conducted in the School of Health & Social Care, University of Teesside. The copyright of this Dissertation belongs to the author under the terms of the United Kingdom Copyright acts as qualified by the University of Teesside Regulations and Polices. Due acknowledgement must always be made of the use of any material contained in, or derived from, this Dissertation.

4 Abstract Lateral epicondylitis is one of the most diagnosed musculoskeletal disorders at the upper extremity with increasing incidences. The aim of this review was to synthesise the best available evidence on the effectiveness of physiotherapeutic interventions compared to orthotic devices for the treatment of lateral epicondylitis, hence to identify the more effective treatment in reducing pain and improving function. Both treatment approaches are commonly used and recommended by the literature for patients suffering from lateral epicondylitis. Published research provides relevance for both treatment options, nevertheless their effectiveness in comparison seems not to be assessed in previous research, and no systematic review was found which assessed and specifically focused on this objective/comparison. Published research provides relevance for both treatment options, nevertheless their effectiveness in comparison seems not to be assessed in previous research, and no systematic review was found which assessed and specifically focused on this objective/comparison. Exhaustive electronic searches were conducted until November 2010 in PEDro, Cochrane, EMBASE, MEDLINE, AMED and Cinahl databases, supplemented with screening of reference lists and searches in journals and websites. Finally, four RCTs and one CCT were included in this review. For assessing methodological quality of trials the PEDro-scale was implemented. Additionally, reporting quality, methodological and overall issues were critically discussed and judged. Data analysis was performed descriptively, no statistical calculations were included. Appraisal of the trials revealed considerable flaws in reporting and methodological quality. Furthermore, heterogeneity among the trials was detected mainly related to interventions and outcomes characteristics and partly to study population. Overall, there is evidence that physiotherapeutic approaches of exercises with or without supplementary physical therapy are more effective in reducing pain and improving function or activities compared to orthotic devices. This conclusion relates to the efficacy at short-term. Further high-quality research is required with improved methodology, reporting quality and conduction.

5 Zusammenfassung Epicondylitis lateralis ist eine der häufigst diagnostizierten muskoloskeletalen Erkrankung der oberen Extremität, mit steigender Inzidenz. Die Zielsetzung dieses Reviews war es die beste verfügbare Evidenz bezüglich der Effektivität physiotherapeutischer Interventionen im Vergleich zu Orthesen für die Behandlung von epicondylitis lateralis zu synthetisieren, und demzufolge die effektivere Behandlung zur Schmerzlinderung und Funktionsverbesserung zu ermitteln. Beide sind häufig angewendete und von der Literatur empfohlene Behandlungsansätze für Patienten, die an epicondylitis lateralis leiden. Relevanz wird anhand veröffentliche Forschung für beide Behandlungsoptionen vermittelt, dennoch scheint deren Effektivität im Vergleich in vorangegangener Forschung noch nicht bewertet/untersucht worden zu sein. Es wurde kein systematischer Review, welcher diesen Ansatz bzw. Vergleich beurteilt und fokussiert, gefunden. Ausgiebige elektronische Suchen wurden bis November 2010 in den Datenbanken PEDro, Cochrane, EMBASE, MEDLINE, AMED und Cinahl durchgeführt und ergänzt durch Screening von Referenzlisten und Suchen in Journalen und Webseiten. Letztendlich wurden 4 RCTs und 1 CCT in diesen Review einbezogen. Zur Bewertung der Studien bezüglich methodologischer Qualität wurde die PEDro- Skala implementiert. Außerdem, wurden die berichtende Qualität, methodologische und allgemeine Aspekte diskutiert und bewertet. Die Datenanalyse wurde deskriptiv ausgeführt und es wurden keine statistischen Berechnungen eingeschlossen. Die Beurteilung der Studien enthüllte beachtliche Schwachstellen bezüglich der berichtenden und methodologischen Qualität. Des Weiteren, wurde eine Heterogenität zwischen den Studien bemerkt hauptsächlich bezogen auf die Interventionen und Charakteristik der Ergebnissmessungen und teilweise bezüglich der Studienpopulation. Allumfassend, gibt es Evidenz, dass physiotherapeutische Ansätze mittels Übungen, mit oder ohne ergänzende physikalische Therapie, effektiver zur Schmerzreduzierung und Funktions- oder Aktivitätsverbesserung sind im Vergleich zu Orthesen. Diese Schlussfolgerung bezieht sich auf die Kurzzeitwirksamkeit. Weitere Forschung von hoher Qualität mit verbesserter Methodologie, berichtenden Qualität und Durchführung ist erforderlich.

6 Acknowledgements I would like to thank my supervisor, John Dixon, for the excellent support and supervision during the last eight months. Your relaxed and reassuring nature helped me through the period of dissertation and made it far easier for me. I have taken great advantage of your professional knowledge and experience as well as of your very helpful comments and suggestions. Thank you very much for all your motivations and patience! Furthermore, I thank the module leader Dr Katherine Sanderson for the good guidance throughout the module and the provided support to occurring queries. It is very important for me to thank my best friend Jana for the tireless assistance, patience and endurance. You have never got tired to encourage me in many respects throughout the last 2 ½ years and helped me to conquer my language limitations. Thank you very much! I would like to give special thanks to Rosita Boose. Your encouragement and understanding at all times and under any circumstances helps me and means a lot to me and made the Master programme far easier for me. Furthermore, I would like to thank Andrea for always being there on our long way, for providing help and support at any time and for being my Peng you know what I mean.

7 Contents Title page Abstract Acknowledgements Contents List of contents List of tables List of figures i ii iii iv v viii ix

8 List of contents content page 1. Introduction Evidence in current situation 2 2. Specific background Lateral epicondylitis Aetiology Clinical presentation and diagnosing Physiotherapeutic treatment and orthotic interventions Area of research Research question and aims Methods Methodology of review Ethical consideration General approach Design of review Criteria for considering trials for review Types of participants Types of intervention and comparison Types of outcome measures Types of studies Search strategy Data sources Search terms, keywords and strings Data collection and analysis Study selection Data extraction Appraising the quality Data analysis Results Process of search and selection 32

9 st stage of the process nd stage of the process Characteristics of included studies Description of participants Description of interventions and comparison interventions Description of outcomes Quality of methodology and risk of biases Summary of results from included studies Exercise interventions versus orthotic devices Mixed physiotherapeutic approaches versus orthotic devices Discussion Consideration of methodolocial quality and risk of biases of the trials Overall synthesis and implication for practice Critical discussion and limitation of available evidence Implication for future research Strength, weakness and limitation of this review Declaration and conflicts of interest Authors conclusion References 83 Appendices Appendix 1: Ethics release/confirmative letter 96 Appendix 2: Review planning process protocol 97 Appendix 3: Search strategy for the trials 125 Appendix 4: 1 st screening form of literature selection 133 Appendix 5: 2 nd screening form of literature selection 134 Appendix 6: Features of excluded trials 135 Appendix 7: Data extraction form for trials 145 Appendix 8: PEDro Scale form 151

10 Appendix 9: Publication details of included trials 154 Appendix: 10: Results of included studies, complete reporting 155 Consent form for Learning Resource Centre 172 Agreement for Authorship 173

11 List of Tables 4.1. Electronic search results of title and abstract Outcome measures of included trials Characteristics of included trials Results of assessment by PEDro rating criteria Results of included studies of exercise interventions versus orthotic devices Results of included studies of mixed physiotherapeutic approaches versus orthotic devices 61

12 List of Figures Figure 3.1: Flow chart: Procedure of the review 16 Figure 4.1: Flow chart: Search of trials and process of selection 34

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