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Are Passive Physical Modalities Effective for the Management of Common Soft Tissue Injuries of the Elbow?

A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

Dion, Sarah DC; Wong, Jessica J. BSc, DC, FCCS(C); Côté, Pierre DC, PhD; Yu, Hainan MBBS, MSc; Sutton, Deborah BScOT, MEd, MSc; Randhawa, Kristi BHSc, MPH; Southerst, Danielle BScH, DC, FCCS(C); Varatharajan, Sharanya BSc, MSc; Stern, Paula J. BSc, DC, FCCS(C); Nordin, Margareta Dr.Med.Sci.; Chung, Chadwick BSc, DC, FCCS(C); D’Angelo, Kevin BSc(Hons), DC; Dresser, Jocelyn BPhEd, DC; Brown, Courtney DC, BSc, MSc; Menta, Roger BKin, DC; Ammendolia, Carlo DC, PhD; Shearer, Heather M. DC, MSc, FCCS(C); Stupar, Maja DC, PhD; Ameis, Arthur MD, FRCPC, DESS, FAAPM&R; Mior, Silvano DC, PhD; Carroll, Linda J. PhD; Jacobs, Craig BFA, DC, MSc, FCCS(C); Taylor-Vaisey, Anne MLS

doi: 10.1097/AJP.0000000000000368
Review Articles

Objective: To evaluate the effectiveness of passive physical modalities for the management of soft tissue injuries of the elbow.

Methods: We systematically searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials from 1990 to 2015. Studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis.

Results: We screened 6618 articles; 21 were eligible for critical appraisal and 9 (reporting on 8 randomized controlled trials) had a low risk of bias. All randomized controlled trials with a low risk of bias focused on lateral epicondylitis. We found that adding transcutaneous electrical nerve stimulation to primary care does not improve the outcome of patients with lateral epicondylitis. We found inconclusive evidence for the effectiveness of: (1) an elbow brace for managing lateral epicondylitis of variable duration; and (2) shockwave therapy or low-level laser therapy for persistent lateral epicondylitis.

Discussion: Our review suggests that transcutaneous electrical nerve stimulation provides no added benefit to patients with lateral epicondylitis. The effectiveness of an elbow brace, shockwave therapy, or low-level laser therapy for the treatment of lateral epicondylitis is inconclusive. We found little evidence to inform the use of passive physical modalities for the management of elbow soft tissue injuries.

*Department of Graduate Studies

Graduate Education and Research Programs

§Undergraduate Education

#Graduate Education Program

¶¶Division of Clinical Education, Canadian Memorial Chiropractic College

UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology and Canadian Memorial Chiropractic College

††Institute for Health Policy, Management and Evaluation, University of Toronto

‡‡Institute for Work and Health, Toronto

Canada Research Chair in Disability Prevention and Rehabilitation

Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON

∥∥Department of Public Health Sciences and Alberta Centre for Injury Prevention and Research, School of Public Health, University of Alberta, Edmonton, AB

§§Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of Medicine, University of Montreal, Montreal, QC, Canada

**Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, New York, NY

Systematic Review Registration Number: CRD42014008900.

Supported by the Ontario Ministry of Finance and the Financial Services Commission of Ontario, Canada (RFP No.: OSS_00267175) and the Canada Research Chairs program to P.C. The funding agency was not involved in the collection of data, data analysis, interpretation of data, or drafting of the manuscript. Dr Côté has received a grant from the Ontario Government, Ministry of Finance; grant from AVIVA Canada, funding from the Canada Research Chairs program, past consultancy with Canadian Chiropractic Protective Association, and reimbursement for speaking/teaching from the European Spine Society, Société des experts en évaluation médico-légale du Québec, and National Judicial Institute, outside submitted work. Dr Ammendolia reports honorarium and support for travel; and grant from The Arthritis Society, outside submitted work. Dr Mior reports personal fees (honorarium for expert panel work) from University of Ontario Institute of Technology; past consultancy with Ontario Chiropractic Association, and grant from Ontario Chiropractic Association, outside submitted work. Dr Nordin reports support for travel as Visiting Professor; consultancy with Palladian Healthcare (support for travel), and grant for World Spine Care Global Spine Care Initiative (support for travel), outside submitted work. The remaining authors declare that they have no competing interests.

Reprints: Jessica J. Wong, BSc, DC, FCCS(C), UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, 6100 Leslie Street, Toronto, ON, Canada, M2H 3J1 (e-mail:

Received April 1, 2015

Accepted February 14, 2016

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