A Systematic Review of Randomized Control Trials to Assess Exercise Prescription Practice in Tennis Elbow

¹European Society for Shoulder and Elbow Rehabilitation, Kent Community Health NHS Foundation Trust, United Kingdom

²European Society for Shoulder and Elbow Rehabilitation, United Kingdom

^3,4,5Lincolnshire Community Health Services, Lincolnshire, United Kingdom

⁶European Society for Shoulder and Elbow Rehabilitation, Ashford and St Peters Hospital, United Kingdom

⁷European Society for Shoulder and Elbow Rehabilitation, Liverpool Hope University, Liverpool, United Kingdom

⁸European Society for Shoulder and Elbow Rehabilitation, Lincolnshire Community Health Services, Lincolnshire, United Kingdom

*Corresponding author: Jayanti Rai, PT, MSc, European Society for Shoulder and Elbow Rehabilitation, Kent Community Health NHS Foundation Trust, United Kingdom; E-mail: [email protected].

Received Date: February 03, 2023

Published Date: March 13, 2023

Citation: Jayanti R, et al. (2023). A Systematic Review of Randomized Control Trials to Assess Exercise Prescription Practice in Tennis Elbow. Mathews J Sports Med. 3(1):07.

Copyrights: Jayanti R, et al. © (2023).

ABSTRACT

Context: There are concerns about the appropriate integration of underpinning scientific rationale and methodology when designing exercise programmes for Tennis Elbow (TE) rehabilitation. Objective: To systematically review the exercise prescription practices in the management of TE. Data Source: A systematic search of MEDLINE, EMBASE, AMED, and SCOPUS (2015-2021). Study Selection: A comprehensive literature search was conducted applying recommended methods and Boolean logic with the following terms: physiotherapy; physical therapy; rehabilitation; exercise; tennis elbow; lateral epicondylitis; and lateral elbow tendinopathy. Out of the total of 848 articles that were identified from the initial search, 21 RCTs were shortlisted for the current systematic review. Study Design: Systematic Review. Level of Evidence: Level 4. Data Extraction: The Preferred Reporting Items for Systematic Reviews (PRISMA) was used to guide the search and report the process of synthesizing the results. The quality of the RCTs was assessed using The Physiotherapy Evidence Database (PEDro) scale. Information regarding the exercise prescription practice and study characteristics were extracted from the included articles. Results: On the PEDro scale, 2 RCTs were scored excellent, 11 good, 7 fair and 1 poor. The majority of the studies failed to provide sufficient scientific justification for either the exercises chosen, or the progressions implemented in order to achieve optimal results. Conclusions: There is clearly a paucity of high-quality evidence to guide physiotherapists in designing and progressing exercise programmes for patients with TE. Further research in the field of exercise prescription and related progression is required to provide more robust evidence in prescribing exercise-based interventions for the management of TE in clinical practice.

Keywords: Tennis Elbow, Exercise Dosage, Exercise Prescription, Physiotherapy.

INTRODUCTION

The term “the lawn tennis arm” from the 1880s, and today's Tennis Elbow (TE) also known as lateral epicondylitis and lateral elbow tendinopathy has been a topic of interest for decades among both sports and non-sports-related health care providers due to its impact on patients in terms of  pain severity, functional limitations, and health-related quality of life [1,2]. The publication by Dr. Ferdinand Runge is widely regarded as the first to describe the symptoms, pathology, and treatment of lateral epicondylitis (tennis elbow). However, the primary objective of his work was to provide insight into the causes and treatments of writer's cramp, elegantly illustrated by four case reports^. He described lateral humeral condylar tenderness and difficulty in writing [3]. In 1882, Morris coined the term “lawn tennis elbow” as he found the condition was associated with the tennis backhand stroke [4]. TE accounts for two-thirds of cases seen in general practice, with the population prevalence estimated up to 3% and an incidence of 4–7 per 1000 individuals a year [5]. While the exact underlying pathophysiological mechanism remains unclear, a multifactorial aetiology is proposed to lead to the development of TE [6].

A spectrum of clinical trials and an article have attempted to address the management of TE over the years in relation to with arguments for and against conservative and operative management, interventions [7-9]. Some studies have even suggested no intervention to be as effective as conservative or surgical management [10,11]. The physiotherapy (PT) management of TE has largely consisted of a combination of different interventions including but not limited to exercise modalities, manual therapy (joint mobilisations, soft tissue massage, trigger point, and transverse frictions), acupuncture, injections, electrotherapy modalities (therapeutic ultrasound, laser, extracorporeal shockwave therapy), splinting, bracing, taping, and nerve stimulation [12-15]. Although there is no universal gold standard interventional approach or general consensus among healthcare professionals for the optimal management of TE, potentially due to multifactorial underlying etiology exercise prescription has been broadly considered and implemented as the core component of conservative management [6]. Furthermore, the National Institute for Health and Care Excellence (NICE) guidelines recommend stretching and strengthening exercises along with eccentric loading of the wrist extensor muscles for the management of TE (NICE 2020) [16]. This has led to a considerable number  of research outputs  in relation to wide-ranging exercise modalities [17,18]. Amongst exercise-based protocols, eccentric exercise prescription has been   suggested  by a number of  studies to be superior in reducing pain and improving function in tendinopathies including TE when compared to taping, ultrasound therapy, ice, heat, stretches, concentric strengthening, and friction massage [19,20]. It has been proposed that eccentric exercises positively influence tendon remodeling by means of structural adaptations, tendon length changes, reduced nerve ingrowth, and enhanced tenocyte activity [21,22]. In addition to eccentric exercises there have been an increasing number of studies investigating other potential exercise modalities and protocols such as 4-stage progressive tendon loading exercises (PTLE) and scapular muscle exercises, considering shoulder girdle weakness in patients with TE, with preliminary positive results in managing pain and function in TE [23-25]. Although exercise-based interventions are broadly practiced by healthcare professionals in various musculoskeletal settings for the management of TE and despite growing number of related studies, there remains major uncertainties in relation to underpinning scientific rationale, optimal exercise specifications and implementation methods, and appropriate outcome assessments [26,27]. A systematic review of 30 RCTs covering a total of 2123 participants reported a very low evidence in relation to the effectiveness of exercise prescription compared with passive interventions with or without invasive treatment [28]. Furthermore, while it has been reported that eccentric exercise has more efficacy in improving pain, there is no convincing evidence to support its superiority on muscle strength and function compared with concentric or isotonic exercises. This could potentially be contributed to the heterogeneity of studies, inconsistent exercise specifications and parameters, and diverse range of implementation methods [29]. Addressing these requires systematic evaluation of the literature to provide further insights into what constitutes an evidence-based exercise treatment programme particularly in relation to the exercise modality and applied dosage (i.e. the intensity, duration, frequency, and progression) of existing exercise prescription practices.

Therefore, this study aimed to systematically review common exercise prescription practices applied for the management of TE in order to underpin level of existing evidence and highlight potential future research avenues.

METHODS

A structured approach underpinned by well-established guidelines for systematic reviews was employed to ensure appropriateness of the literature search [30]. The database included PUBMED, MEDLINE, EMBASE, AMED and SCOPUS. An electronic search was undertaken to cover the period between 2015 to 2021 using Boolean logic using the following terms: physiotherapy; physical therapy; rehabilitation; exercise; tennis elbow; lateral epicondylitis; and lateral elbow tendinopathy. Text word and thesaurus searches were used to minimize chances of missing relevant articles. Identified articles were manually searched for additional references. Inclusion and exclusion criteria are summarized in Table 1. The study was registered to PROSPERO (CRD42021281976) For the benefit of the readers, Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) has been utilized to describe the search and process of elimination. (Figure 1).

Table 1. Study inclusion and exclusion criteria.

Figure 1. PRISMA flow chart.

Articles that did not meet eligibility criteria were identified from abstracts and disregarded. Full texts were obtained for remaining articles and information was extracted with regard to the Population, Intervention, Comparison, Outcome (PICO) as outlined in Table 2.

Table 2. Population, Intervention, Comparison, Outcome (PICO).

Notes: TE; Tennis Elbow, ADL; Activities of Daily Living.

RESULTS

A total of 848 articles were identified and after screening for the titles, abstracts and full text articles 21 RCTs were shortlisted for the present systematic review. The age of the participants varied between 24 to 65 years. The interventions covered across the 21 studies were stretching exercises, strengthening exercises, ultrasound therapy, transverse friction massage, splinting, continuous shortwave diathermy, gyroscopic device, isometric exercises, corticosteroid injection, joint manipulation, kinesiology taping, elbow band, functional task exercises, iontophoresis, cyriax exercises, eccentric control exercises, wait and see, and deep friction massage.

The Physiotherapy Evidence Database (PEDro) scale was used to score the quality of studies [31]. The PEDro scale was developed to help PEDro users rapidly identify the trials that are likely to be internally valid and have sufficient statistical information to guide clinical decision making. The PEDro score ranges from 0 to 10. The agreement between the two reviewers was 93.3 %. Disagreement was solved in a consensus meeting. The RCTs were scored 0 to 3 (poor), 4 to 5 (fair), 6 to 8 (good), and 9 to 10 (excellent) [32]. Out of the 21 articles 2 [33,34] scored as excellent, 11 [35-45] as good, 7 [46-52] as fair and 1 [53] as poor. Table 3 summarizes the PEDro Score for the included studies. Furthermore, the authors appraised the questions to help understand the exercise prescription practices in this patient group (Table 4). Characteristics of the studies presented in Table 5.

Table 3. The Physiotherapy Evidence Database (PEDro) score for the RCTs included in the systematic review.

Table 5. Characteristics of the studies.

According to the NICE guidelines [16], failure to respond to a course of conservative management (6-12-month) including exercise-based interventions requires referring TE patients for orthopedic consultation and the consideration of surgical intervention. It is therefore vital that conservative management follows a targeted exercise prescription approach supported by best evidence with an aim to achieve optimal results. This should then reduce the likelihood of patient referral for potentially invasive procedures and the risks that come with this, and to minimize unnecessary burdens on NHS resources. The current systematic review identified gaps in the exercise prescription practice in TE patients, highlighting the need for more robust randomised clinical trials using appropriate scientific justification to support the development and implementation of evidence-based rehabilitation programmes.

Quality of Trials

Following PEDro evaluation [34,54] of the 21 trials were classed as ‘excellent’, although the majority of studies [35-45] were classed as ‘good’. Cashin [32] cites that trials involving complex treatment interventions such as exercise, should ideally score a minimum of 8/10 on the PEDro scale. Of the trials evaluated, only 3 [33,34,44] scored 8/10 or above. Further high-quality studies are required to enhance the existing evidence base in support of use of exercise regimens in patients with TE.

Justification for Overall Exercise Prescription

‘Exercise is medicine’ is the mantra we have been hearing and preaching as healthcare professionals all our practicing life. However, Swisher (2010) [55] brings home a very important point that much needs to done when it comes to exercise prescription and as one would not simply advise patient to take medicine ‘willy nilly’, the same analogy between ‘Exercise’ &  ‘Medicine’ is that exercise needs to be prescribed to the patient as a specific dosage, designed as per individual patient needs, the frequency, intensity and other parameters maters when providing a patient with an exercise program.  Only 16 of the 21 articles provided a rationale for the base-line exercise prescription and only two studies tailored the exercise programme in relation to individual participants, basing decision-making upon repetitions to fatigue [36] and participants’ own judgment [42]. Wegener et al. [45] considered individual patient tolerance in their exercise intervention, however, it was unclear if any adjustments were made to personalise the programme. Vuvan [44] set the intensity of exercise intervention based upon the strength of each participant’s unaffected limb without apparent consideration of the response to exercise in the affected limb. A surprisingly low number of studies tailored their programme to the individual participants and even fewer reported monitoring methods and exercise progression dose in relation to exercise training principles such as FITT (Frequency, Intensity, Timing, and Types) [54]. Without clear evidence on how best to monitor, adapt, and progress exercise intervention for TE patients, clinicians, and physiotherapists would potentially extrapolate literature from other conditions which may not yield the same benefits as approaches specifically targeting the TE population. Future high-quality studies are required to be more explicit in outlining exercise prescription and related justification in order to guide clinicians in formatting exercise intervention plans for individual patients.

Justification for Exercise Type

Stretching Exercise

Murtezani et al. [50] utilized stretches as the sole exercise component in their control group, delivered alongside therapeutic ultrasound. Furthermore, stretches were reported to produce favorable results by Hassan et al. [48] in a comparison study. While both authors provided justification for the use of stretches in terms of pain relief, the quoted evidence was based on a study combining stretches with strengthening, not stretches in isolation [56]. Kachanathu et al. [37] incorporated stretching exercises as part of standard care in combination with ultrasound and cross-friction massage with limited rationalization for their approach as to why this was considered standard cares. Stretching exercises were combined with eccentric loading with minimal justification [40] and a strengthening programme by Giray et al. [36] who provided more substantive justification. Stretching in the absence of strength-based exercises is not supported by national guidance (NICE, 2020) [57] or by current clinical practice [11]. This may reflect why authors were not able to provide adequate explanation in support of their stretch-based interventions which in turn raises questions about their choice of intervention in the first place.

Eccentric Exercise

The benefits of eccentric exercise have been investigated and reported by a number of authors and the rationale for this form of intervention is generally well justified. Sevier et al. [42] justified their intervention based on them being considered the gold standard intervention. Lee et al. [38] and Wegener et al. [45] each provided substantive support for the use of eccentric exercises, describing collagen changes and improvements in tensile strength; enabling tendons to gain more power during activities. Despite clear evidence and rationale to support the use of eccentric exercises, some studies lacked sufficient reasoning for utilising eccentric exercises [49]. The majority of studies opting to investigate eccentric training did not make it clear if their applied protocol was based on clinical experience or scientific rationale as it is difficult to gauge an optimal eccentric loading protocol from the current available research pool [58].

Strengthening and Functional Exercise

Early evidence is available to support the application of exercises targeting global upper limb musculature to manage patients with TE [59,60]. Some articles included in the present systematic review provided further support to this approach. Ramteke et al. [41] investigated the application of global upper limb strengthening and isometric exercises in a small RCT. Despite favorable results, they failed to provide a clear rationale for the chosen approach or acknowledge pre-existing literature. Furthermore, despite acknowledging the paucity of literature to support the use of functional upper limb exercises to manage TE, Deshak et al. [53] also failed to provide any robust rationale for the applied approach. Lee et al. [38] used shoulder stabilization exercises to optimise function in their comparison study. Whilst the study rightly recognised a paucity of evidence to justify examining the intervention, it failed to highlight the existing literature in relation to the use of shoulder exercise in the management of TE.

Variability was observed with how specific exercise approaches were justified. On some occasions, authors provided a rationale based on pathology of TE, and on others it was based on cited existing research. Across several of the studies included the justification provided was either very poor or absent altogether. In several instances where approaches or aims of intervention were not justified, it impacted upon the choice of outcome measures leading to the unclarity around the optimal targets of the intervention. The findings of this study may explain the variability in both type and dose of exercise-based interventions commonly used in clinical practice for the management of TE, which is in line with results of a multi-centre service evaluation [11]. Innovative approaches to improve exercise prescription would help to support health professionals in their clinical practice. Health APPs are available to support patients and clinicians in tailoring rehabilitation, however further work is required with validation against specific protocols [61].

CONCLUSIONS

There is clearly a paucity of high-quality evidence available to guide physiotherapists and other health care providers in first designing and then suitably monitoring and progressing exercise programmes in TE patients. Based on the present systematic review, authors made the strongest and most consistent justification in relation to eccentric exercises, which could reflect the strength of the evidence base surrounding this particular approach. We recommend authors to ensure that exercise interventions are fully justified while also considering how the most appropriate outcome measures are utilised to measure and demonstrate the effects of their chosen intervention. Further research in the field of exercise prescription in terms of repetitions, load, dosage, and related progression is required in order to provide more robust evidence in prescribing exercise for the management of TE in clinical practice.

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