Shock wave therapy for lateral elbow pain

Abstract

Background: This review is one in a series of reviews of interventions for lateral elbow pain.

Objectives: To determine the effectiveness and safety of extracorporeal shock wave therapy (ESWT) for lateral elbow pain.

Search strategy: Searches of the Cochrane Controlled Trials Register (Cochrane Library Issue 2, 2004), MEDLINE, EMBASE, CINAHL, and Science Citation Index (SCISEARCH) were conducted in February 2005, unrestricted by date.

Selection criteria: We included nine trials that randomised 1006 participants to ESWT or placebo and one trial that randomised 93 participants to ESWT or steroid injection.

Data collection and analysis: For each trial two independent reviewers assessed the methodological quality and extracted data. Methodological quality criteria included appropriate randomisation, allocation concealment, blinding, number lost to follow up and intention to treat analysis. Where appropriate, pooled analyses were performed. If there was significant heterogeneity between studies or the data reported did not allow statistical pooling, individual trial results were described in the text.

Main results: Eleven of the 13 pooled analyses found no significant benefit of ESWT over placebo. For example, the weighted mean difference for improvement in pain (on a 100-point scale) from baseline to 4-6 weeks from a pooled analysis of three trials (446 participants) was -9.42 (95% CI -20.70 to 1.86) and the weighted mean difference for improvement in pain (on a 100-point scale) provoked by resisted wrist extension (Thomsen test) from baseline to 12 weeks from a pooled analysis of three trials (455 participants) was -9.04 (95% CI -19.37 to 1.28). Two pooled results favoured ESWT. For example, the pooled relative risk of treatment success (at least 50% improvement in pain with resisted wrist extension at 12 weeks) for ESWT in comparison to placebo from a pooled analysis of two trials (192 participants) was 2.2 (95% CI 1.55 to 3.12). However this finding was not supported by the results of four other individual trials that were unable to be pooled. Steroid injection was more effective than ESWT at 3 months after the end of treatment assessed by a reduction of pain of 50% from baseline (21/25 (84%) versus 29/48 (60%), p<0.05). Minimal adverse effects of ESWT were reported. Most commonly these were transient pain, reddening of the skin and nausea and in most cases did not require treatment discontinuation or dosage adjustment.

Authors' conclusions: Based upon systematic review of nine placebo-controlled trials involving 1006 participants, there is "Platinum" level evidence that shock wave therapy provides little or no benefit in terms of pain and function in lateral elbow pain. There is "Silver" level evidence based upon one trial involving 93 participants that steroid injection may be more effective than ESWT.

Conflict of interest statement

None known

Figures

1.1. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 1 Mean pain at rest (100 point scale).

1.2. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 2 Mean pain with resisted wrist extension (Thomsen test)(100 point scale).

1.3. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 3 Mean pain with typical daily activities.

1.4. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 4 Mean pain with resisted middle finger extension (100 point scale).

1.5. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 5 Mean pain with resisted supination of the wrist (Mills test)(100 point scale).

1.6. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 6 Number of patients with significant improvement.

1.7. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 7 Failure of treatment defined by Roles and Maudsley score of 4.

1.8. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 8 Failure of treatment defined by Roles and Maudsley score of 3 or 4 and/or additional therapy.

1.9. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 9 Number of patients who eventually underwent surgical release of common extensor origin.

1.10. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 10 Mean grip strength.

1.11. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 11 Mean Upper Extremity Function Scale (range 8‐80).

1.12. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 12 Mean patient‐specific activity score.

1.13. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 13 Mean patient evaluation of their disease status (100mm VAS).

1.14. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 14 Mean pain with palpation over the lateral epicondyle (100 point scale).

1.15. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 15 Mean pain with Chair test (100 point scale).

1.16. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 16 Mean pain at night (100 point scale).

1.17. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 17 Number of patients satisfied with their treatment.

1.18. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 18 Mean investigator assessment of pain to pressure over lateral epicondyle (10 cm VAS).

1.19. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 19 Number of patients reported pain during treatment.

1.20. Analysis

Comparison 1 ESWT VERSUS PLACEBO, Outcome 20 Number of patients reported nausea during treatment.

2.1. Analysis

Comparison 2 ESWT VERSUS STEROID INJECTION, Outcome 1 Number of patients with successful treatment (defined as reduction in pain of 50% or greater at 3 months).