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Systematic Review of the Efficacy and Safety of Shock Wave Therapy for Lateral Elbow Pain
RACHELLE BUCHBINDER, SALLY E. GREEN, JOANNE M. YOUD, WILLEM J.J. ASSENDELFT, LESLEY BARNSLEY, and NYNKE SMIDT ABSTRACT. Objective. To determine the efficacy and safety of extracorporeal shock wave therapy (ESWT) for lateral elbow pain. Methods. Systematic review of randomized controlled trials using Cochrane Collaboration methodology. Results. Nine placebo-controlled trials (1006 participants) and one trial of ESWT versus steroid injection (93 participants) were included. The 9 placebo-controlled trials reported conflicting results, although 11 of 13 pooled analyses found no significant benefit of ESWT over placebo, e.g., weighted mean difference for improvement in pain (on a 100-point scale) from baseline to 4–6 weeks (pooled analysis of 3 trials, 446 participants) was –9.42 (95% CI –20.70 to 1.86). Two pooled results favored ESWT, e.g., relative risk of treatment success (at least 50% improvement in pain with resisted wrist extension at 12 weeks) for ESWT in comparison to placebo (pooled analysis of 2 trials, 192 participants) was 2.2 (95% CI 1.55 to 3.12). However, this finding was not supported by the results of 4 other 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%) vs 29/48 (60%); p < 0.05]. Minimal adverse effects of ESWT were reported. Conclusion. Based upon systematic review of 9 placebo-controlled trials, there is "platinum" level evidence that ESWT provides little or no benefit in terms of pain and function in lateral elbow pain. There is "silver" level evidence based upon one trial that steroid injection may be more effective than ESWT. (J Rheumatol 2006;33:1351–63) Key Indexing Terms:
TENNIS ELBOW
From the Monash Department of Clinical Epidemiology, Cabrini Hospital, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne; Australasian Cochrane Centre, Monash Institute of Health Services Research, Melbourne; Department of General Practice and Nursing Home Medicine, Leiden University Medical Center, Leiden, The Netherlands; Department of Rheumatology, Concord Hospital, Sydney, Australia; Department of Medicine, Sydney University, Sydney; and the Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands. This review is published as a Cochrane Review in The Cochrane Library 2006, Issue 1. Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library should be consulted for the most recent version of the Review. R. Buchbinder, MBBS (Hons), MSc, FRACP, Director, Department of Clinical Epidemiology, Cabrini Hospital, Associate Professor, Department of Epidemiology and Preventive Medicine, Monash University; S.E. Green, PhD, BAppSci (Physiotherapy), Associate Professor, Director, Australasian Cochrane Centre, Monash Institute of Health Services Research; J.M. Youd, BSc (Hons), PhD, Research Associate, Department of Clinical Epidemiology, Cabrini Hospital, Department of Epidemiology and Preventive Medicine, Monash University; W.J.J. Assendelft, MD, PhD, Professor, Head, Department of General Practice and Nursing Home Medicine, Leiden University Medical Center; L. Barnsley, BMed (Hons), GradDipEpi, PhD, FRACP, FAFRM (RACP), Head, Senior Staff Specialist, Department of Rheumatology, Concord Hospital, Associate Professor, Department of Medicine, Sydney University; N. Smidt, PhD, PT, Senior Research Fellow, Institute for Research in Extramural Medicine, VU University Medical Center. Address reprint requests to Ass. Prof. R. Buchbinder, Monash Department of Clinical Epidemiology, Suite 41, Cabrini Medical Centre, 183 Wattletree Road, Malvern, Victoria, Australia 3144. E-mail: rachelle.buchbinder@med.monash.edu.au Accepted for publication January 20, 2006.
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