Review of tennis elbow was biased
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《英国医生杂志》
EDITOR—In their review of tennis elbow last year Assendelft et al say that topical non-steroidal anti-inflammatory drugs (NSAIDs) in gel form are beneficial and NSAIDs given orally are likely to be beneficial, whereas local steroid injections are a trade-off between harms and benefits.1 Physiotherapeutic modalities were deemed as interventions with "unknown effectiveness" and not recommended.
The evidence for NSAIDs consists of five randomised controlled trials, where the patient experiences a short duration of symptoms and few, if any, prior treatments. No steps were taken to exclude poor quality NSAID trials, although one trial was listed as non-randomised in the Cochrane Library, and the blinding procedure of another trial was described as "unclear, if blinded at all." Of the remaining three, one trial reported no significant effect from NSAIDs compared with placebo, and another stated: "Difficult to recommend the use of diclofenac in the treatment of lateral epicondylitis."
The reviewers' conclusion on the effectiveness of physiotherapy is based on an old review that excluded nine randomised controlled trials for low method scores.2 It did not address the question of optimal dose and treatment procedures, although optimal doses of ultrasound, laser, and joint mobilisation have been established recently.3-5 Most patients in physiotherapy randomised controlled trials had experienced little relief from previous NSAID or steroid injections and had longer symptom duration. Still, 13 out 15 randomised controlled trials with adequate doses presented significant results in favour of physiotherapy.
In view of the important differences in review methods and patients, we consider the recommendations made by Assendelft et al to be biased towards NSAID treatment.
Jan M Bjordal, research fellow
Bergen University College, 5020 Bergen Physiotherapy Department
Jan Hendrik Demmink, assistant professor
Section of Physiotherapy Science, University of Bergen, 5020 Bergen, Norway jmb@hib.no
Competing interests: None declared.
References
Assendelft W, Green S, Buchbiner R, Strujis P, Smidt N. Tennis elbow. BMJ 2003;327: 329.
Smidt N, Assendelft WJ, Arola H, Malmivaara A, Greens S, Buchbinder R, et al. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Ann Med 2003;35: 51-62.
Bjordal J, Couppé C, Ljunggreen A. Low level laser therapy for tendinopathy. Evidence of a dose-response pattern. Phys Ther Rev 2001;6: 91-9.
McLean S, Naish R, Reed L, Urry S, Vicenzino B. A pilot study of the manual force levels required to produce manipulation induced hypoalgesia. Clin Biomech (Bristol, Avon) 2002;17: 304-8.
Kroling P, Kober L, Wimmer G. Ultrasound therapy of epicondylopathia humeri—immediate and serial treatment effects on the pressure pain threshold. Physikalische Medizin Rehabilitationsmedizin Kurortmedizin 2001;10: 1-5.
The evidence for NSAIDs consists of five randomised controlled trials, where the patient experiences a short duration of symptoms and few, if any, prior treatments. No steps were taken to exclude poor quality NSAID trials, although one trial was listed as non-randomised in the Cochrane Library, and the blinding procedure of another trial was described as "unclear, if blinded at all." Of the remaining three, one trial reported no significant effect from NSAIDs compared with placebo, and another stated: "Difficult to recommend the use of diclofenac in the treatment of lateral epicondylitis."
The reviewers' conclusion on the effectiveness of physiotherapy is based on an old review that excluded nine randomised controlled trials for low method scores.2 It did not address the question of optimal dose and treatment procedures, although optimal doses of ultrasound, laser, and joint mobilisation have been established recently.3-5 Most patients in physiotherapy randomised controlled trials had experienced little relief from previous NSAID or steroid injections and had longer symptom duration. Still, 13 out 15 randomised controlled trials with adequate doses presented significant results in favour of physiotherapy.
In view of the important differences in review methods and patients, we consider the recommendations made by Assendelft et al to be biased towards NSAID treatment.
Jan M Bjordal, research fellow
Bergen University College, 5020 Bergen Physiotherapy Department
Jan Hendrik Demmink, assistant professor
Section of Physiotherapy Science, University of Bergen, 5020 Bergen, Norway jmb@hib.no
Competing interests: None declared.
References
Assendelft W, Green S, Buchbiner R, Strujis P, Smidt N. Tennis elbow. BMJ 2003;327: 329.
Smidt N, Assendelft WJ, Arola H, Malmivaara A, Greens S, Buchbinder R, et al. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Ann Med 2003;35: 51-62.
Bjordal J, Couppé C, Ljunggreen A. Low level laser therapy for tendinopathy. Evidence of a dose-response pattern. Phys Ther Rev 2001;6: 91-9.
McLean S, Naish R, Reed L, Urry S, Vicenzino B. A pilot study of the manual force levels required to produce manipulation induced hypoalgesia. Clin Biomech (Bristol, Avon) 2002;17: 304-8.
Kroling P, Kober L, Wimmer G. Ultrasound therapy of epicondylopathia humeri—immediate and serial treatment effects on the pressure pain threshold. Physikalische Medizin Rehabilitationsmedizin Kurortmedizin 2001;10: 1-5.