Objective To evaluate the effectiveness of exercise compared with other conservative interventions in the management of lateral elbow tendinopathy (LET) on pain and function. Design Systematic review and meta-analysis. Methods We used the Cochrane risk-of-bias tool 2 for randomised controlled trials (RCTs) to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation methodology to grade the certainty of evidence. Self-perceived improvement, pain intensity, pain-free grip strength (PFGS) and elbow disability were used as primary outcome measures. Eligibility criteria RCTs assessing the effectiveness of exercise alone or as an additive intervention compared with passive interventions, wait-and-see or injections in patients with LET. Results 30 RCTs (2123 participants, 5 comparator interventions) were identified. Exercise outperformed (low certainty) corticosteroid injections in all outcomes at all time points except short-term pain reduction. Clinically significant differences were found in PFGS at short-term (mean difference (MD): 12.15, (95% CI) 1.69 to 22.6), mid-term (MD: 22.45, 95% CI 3.63 to 41.3) and long-term follow-up (MD: 18, 95% CI 11.17 to 24.84). Statistically significant differences (very low certainty) for exercise compared with wait-and-see were found only in self-perceived improvement at short-term, pain reduction and elbow disability at short-term and long-term follow-up. Substantial heterogeneity in descriptions of equipment, load, duration and frequency of exercise programmes were evident. Conclusions Low and very low certainty evidence suggests exercise is effective compared with passive interventions with or without invasive treatment in LET, but the effect is small. PROSPERO registration number CRD42018082703.

OBJECTIVE: To evaluate the effect of low-load resistance training with blood flow restriction (LLRT-BFR) when compared to LLRT with sham-BFR in patients with lateral elbow tendinopathy (LET). DESIGN: Randomized controlled trial. METHODS: Forty-six patients with LET were randomly assigned to a LLRT-BFR or a LLRT with sham-BFR treatment group. All patients received soft tissue massage, supervised exercises with BFR or sham intervention (twice a week for 6 weeks), advice, and a home exercise program. The primary outcome measures were pain intensity, patient-rated tennis elbow evaluation (PRTEE) score, pain-free grip strength, and global rating of change, measured at baseline, 6 weeks, and 12 weeks. Between-group differences were evaluated using mixed-effects models with participant-specific random effects for continuous data. Global rating of change was analyzed using logistic regression. RESULTS: Statistically significant between-group differences were found in favor of LLRT-BFR compared to LLRT with sham-BFR in pain intensity at 12-week follow-up (−1.54, 95% CI: −2.89 to −0.18; P = .026), pain-free grip strength ratio at 6-week follow-up (0.20, 95% CI: 0.06 to 0.34; P = .005), and PRTEE at 6- and 12-week follow-up (−11.92, 95% CI: −20.26 to −3.59; P = .006, and −15.23, 95% CI: −23.57 to −6.9; P<.001, respectively). At 6- and 12-weeks, patients in the LLRT-BFR group had greater odds of reporting complete recovery or significant improvement (OR = 6.0, OR = 4.09, respectively). CONCLUSION: Low-load resistance training with blood flow restriction produced significantly better results compared to the LLRT with sham-BFR for all primary outcomes. Considering the clinically significant between-group improvement in function (>11 points in PRTEE) and the better success rates in the LLRT-BFR group, this intervention may improve recovery in LET. J Orthop Sports Phys Ther 2022;52(12):803–825. Epub: 14 September 2022. doi:10.2519/jospt.2022.11211

The precise calculation of arterial occlusive pressure is essential to accurately prescribe individualized pressures during blood flow restriction training. Arterial occlusion pressure in the lower limb varies significantly between different body positions while similar reports for the upper limb are lacking. Body position has a significant effect in upper limb arterial occlusive pressure. Using cuffs with manual pump and a handheld Doppler ultrasound can be a reliable method to determine upper limb arterial blood flow restriction. A randomized repeated measures design. Level 3. Forty-two healthy participants (age mean ± SD = 28.1 ± 7.7 years) completed measurements in supine, seated, and standing position by 3 blinded raters. A cuff with a manual pump and a handheld acoustic ultrasound were used. The Wilcoxon signed-rank test with Bonferroni correction was used to analyze differences between body positions. A within-subject coefficient of variation and an intraclass correlation coefficient (ICC) test were used to calculate reproducibility and reliability, respectively. A significantly higher upper limb arterial occlusive pressure was found in seated compared with supine position (P < 0.031) and in supine compared with standing position (P < 0.031) in all raters. An ICC of 0.894 (95% CI = 0.824-0.939, P < 0.001) was found in supine, 0.973 (95% CI = 0.955-0.985, P < 0.001) in seated, and 0.984 (95% CI = 0.973-0.991, P < 0.001) in standing position. ICC for test-retest reliability was found 0.90 (95% CI = 0.814-0.946, P < 0.001), 0.873 (95% CI = 0.762-0.93, P < 0.001), and 0.858 (95% CI = 0.737-0.923, P < 0.001) in the supine, seated, and standing position, respectively. Upper limb arterial occlusive pressure was significantly dependent on body position. The method showed excellent interrater reliability and repeatability between different days. Prescription of individualized pressures during blood flow restriction training requires measurement of upper limb arterial occlusive pressure in the appropriate position. The use of occlusion cuffs with a manual pump and a handheld Doppler ultrasound showed excellent reliability; however, the increased measurement error compared with the differences in arterial occlusive pressure between certain positions should be carefully considered for the clinical application of the method. B.

To evaluate the effectiveness of extracorporeal shockwave therapy compared with other interventions on pain, grip strength and disability in patients with lateral elbow tendinopathy. MEDLINE, PubMed, CINAHL, EMBASE, PEDro, ScienceDirect, Cochrane Library and clinical trial registries. We included randomized controlled trials assessing the effectiveness of extracorporeal shockwave therapy alone or as an additive intervention compared with sham or other interventions. Pain intensity, grip strength and elbow disability were used as primary outcome measures. We assessed methodological quality with the PEDro score and quality of evidence with the GRADE approach. Twenty-seven studies with 1871 patients were finally included. Extracorporeal shockwave therapy reduced pain intensity at mid-term follow-up (standardized mean difference: −1.21, 95% confidence interval:−1.53, −0.89, P < 0.001) and improved grip strength at very short- (mean difference:3.92, 95% confidence interval: 0.91, 6.94, P = 0.01) and short-term follow-up (mean difference:4.87, 95% confidence interval:2.24, 7.50, P < 0.001) compared with sham treatment. However, no clinically significant results were found between comparators in all outcomes and follow-up times. Extracorporeal shockwave therapy presented clinically better compared to Laser in grip strength at short-term (mean difference:3.50, 95% confidence interval:2.40, 4.60, P < 0.001) and ultrasound in pain intensity at very-short-term follow-up (standardized mean difference: −1.54, 95% confidence interval: −2.60, −0.48, P = 0.005). Low to moderate certainty of evidence suggests that there are no clinical benefits of extracorporeal shockwave therapy compared to sham interventions or corticosteroid injections. Based on very-low and moderate certainty of evidence, extracorporeal shockwave therapy outperforms against Laser and ultrasound, respectively. Level of Evidence: Therapy, level 1a.