Current Evidence for Effectiveness of Interventions for Cubital Tunnel Syndrome, Radial Tunnel Syndrome, Instability, or Bursitis of the Elbow

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Current Evidence for Effectiveness of Interventions forCubital Tunnel Syndrome, Radial Tunnel Syndrome,

Instability, or Bursitis of the Elbow

A Systematic Review

Willem D. Rinkel, MSc,* Ton A.R. Schreuders, PhD,* Bart W. Koes, PhD,wand Bionka M. A. Huisstede, PhD*w

Objective: To provide an evidence-based overview of the effec-tiveness of interventions for 4 nontraumatic painful disorderssharing the anatomic region of the elbow: cubital tunnel syndrome,radial tunnel syndrome, elbow instability, and olecranon bursitis.

Methods: The Cochrane Library, PubMed, Embase, PEDro, andCINAHL were searched to identify relevant reviews and random-ized clinical trials (RCTs). Two reviewers independently extracteddata and assessed the quality of the methodology. A best-evidencesynthesis was used to summarize the results.

Results: One systematic review and 6 RCTs were included. For thesurgical treatment of cubital tunnel syndrome (1 review, 3 RCTs),comparing simple decompression with anterior ulnar nerve trans-position, no evidence was found in favor of either one of these.Limited evidence was found in favor of medial epicondylectomyversus anterior transposition and for early postoperative therapyversus immobilization. No evidence was found for the effect oflocal steroid injection in addition to splinting. No RCTs werefound for radial tunnel syndrome. For olecranon bursitis (1 RCT),limited evidence for effectiveness was found for methylprednisoloneacetate injection plus naproxen. Concerning elbow instability,including 2 RCTs, one showed that nonsurgical treatment resultedin similar results compared with surgery, whereas the other foundlimited evidence for the effectiveness in favor of early mobilizationversus 3 weeks of immobilization after surgery.

Discussion: In this review no, or at best, limited evidence was foundfor the effectiveness of nonsurgical and surgical interventions totreat painful cubital tunnel syndrome, radial tunnel syndrome,elbow instability, or olecranon bursitis. Well-designed and well-conducted RCTs are clearly needed in this field.

Key Words: radial tunnel syndrome, cubital tunnel syndrome,

instability of the elbow, bursitis, elbow, musculoskeletal disorders

(Clin J Pain 2013;00:000–000)

Nontraumatic musculoskeletal upper-extremity dis-orders have been classified in a model of Complaints

of the Arm, Neck, and/or Shoulder (CANS).1 CANS was

defined as “musculoskeletal complaints of the arm, neck,and/or shoulder not caused by acute trauma or by anysystemic disease.” Symptoms meeting this definition aredivided into specific and nonspecific complaints. In contrastwith nonspecific complaints, a specific disorder can be seenas an entity that is recognizable by unique characteristicsincluding case history, physical examination, imaging, and/or laboratory testing. The CANS model includes 6 specificpainful elbow disorders: lateral and medial epicondylitis,cubital and radial tunnel syndrome, elbow instability, andelbow bursitis. The latter 4 are included in this review.Evidence regarding the effectiveness of interventions totreat lateral and medial epicondylitis has been publishedelsewhere.2,3

Cubital tunnel syndrome is the second most commonentrapment neuropathy after carpal tunnel syndrome.4,5

Compression of the ulnar nerve causes pain or paresthesiainvolving the fourth and fifth finger, and pain in the medialaspect of the elbow, which may extend proximally or dis-tally.6 Several work-related factors can increase the occur-rence of specific elbow disorders.7 The occurrence of cubitaltunnel syndrome is associated with “holding a tool inposition” (OR, 3.53).

Radial tunnel syndrome is another nerve entrapment.8

The characteristic feature is pain over the radial proximalforearm with little or no motor weakness. Pain is oftenlocated at the lateral epicondyle over the radial tunnel,making it difficult to differentiate this syndrome from lat-eral epicondylitis. The occurrence of radial tunnel syn-drome is associated with “handling loads >1kg” (OR, 9.0;95% CI, 1.4, 56.9), “static work of the hand during themajority of the cycle time” (OR, 5.9), and “full extension (0to 45 degrees) of the elbow” (OR, 4.9).7

Elbow instability is usually caused by a posterolateralrotatory instability.9–11 Symptoms range from vaguesymptoms in the elbow to recurrent posterolateral dis-locations. Besides pain at the lateral side, clicking andsnapping may be reported. Diagnosis is mainly clinical anddepends on a combination of findings from the history, andactive and passive tests. Examination of the elbow (whileunder general anesthesia) is sometimes necessary.9

Regarding bursitis of the elbow, the olecranon bursitisis the most common.12 This may be caused by relativelytrivial activities, such as habitually leaning on the elbowduring work or daily activities.13

Many different interventions for specific CANS areapplied in clinical practice: ranging from oral medicationand physiotherapy14,15 to corticosteroid injections andsurgery.15,16 To help health professionals in choosing the

Received for publication September 11, 2012; accepted February 4,2013.

From the Departments of *Rehabilitation Medicine; and wGeneralPractice, Erasmus MC—University Medical Center Rotterdam,Rotterdam, The Netherlands.

The authors declare no conflict of interest.Reprints: Bionka M. A. Huisstede, PhD, Department of Rehabilitation

Medicine, Erasmus MC—University Medical Center Rotterdam,Room H-016, P.O. Box 2040, 3000 CA Rotterdam, The Nether-lands (e-mail: [email protected]).

Copyright r 2013 by Lippincott Williams & Wilkins

REVIEW ARTICLE

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best treatment, and to decide in which area more research isneeded, an overview of the evidence for effectiveness of thetreatments is required. In this study we systematicallyreviewed literature concentrating on the effectiveness ofinterventions for cubital and radial tunnel syndrome, elbowinstability, and elbow bursitis.

METHODS

Search StrategyA search of relevant systematic reviews on the 4 above-

mentioned disorders was performed in the CochraneLibrary. In addition, relevant reviews and randomizedclinical trials (RCTs) in PubMed, Embase, PEDro, andCINAHL were searched for: (1) interventions included inthe systematic reviews from the date of search strategy ofthe review at issue up to January 2012 (ie, recent RCTs)and, (2) from the beginning of the database up to January2012 (ie, additional RCTs). Keywords related to the dis-orders and interventions were included in the literaturesearch. The search strategies are listed in Appendix A.

Inclusion CriteriaSystematic reviews and/or RCTs were considered eli-

gible for inclusion if they fulfilled all of the following cri-teria: (1) the study included patients with cubital tunnelsyndrome, radial tunnel syndrome, elbow instability, orelbow bursitis; (2) the disorder was not caused by an acutetrauma or any systemic disease as described in the defi-nition of CANS; (3) an intervention for treating 1 of the 4disorders was evaluated; (4) results on pain, function, or

recovery were reported; and (5) the article was written inEnglish, French, German, or Dutch.

Study SelectionTwo authors (S.G./W.D.R., B.M.A.H.) independently

applied the inclusion criteria to select potentially relevantstudies from the title and abstracts of the referencesretrieved by the literature search. A consensus method wasused to solve any disagreements concerning the inclusion ofstudies, and a third reviewer (B.W.K.) was consulted ifdisagreement persisted.

Categorization of the Relevant LiteratureIn this review, the relevant literature is categorized

under 3 different headings: systematic reviews, recentRCTs, and additional RCTs. The heading Systematicreviews describes all Cochrane and Cochrane-based sys-tematic reviews. The heading Recent RCTs contains allRCTs published after the search date of the systematicreview on the same intervention. Finally, the headingAdditional RCTs describes all RCTs concerning an inter-vention that has not yet been described in a systematicreview.

Data ExtractionTwo authors (S.G./W.D.R., B.M.A.H.) independently

extracted the data from the included articles. Informationwas collected on the study population, interventions, andoutcome measures. A consensus method was used to solveany disagreements concerning the data extraction, and athird reviewer (B.W.K.) was consulted if disagreementpersisted. The follow-up period was categorized as short

FIGURE 1. Flowchart of the literature search.

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term (0 to 3mo), midterm (4 to 6mo), and long term(>6mo).

Methodological Quality AssessmentTo identify potential risks of bias of the included

RCTs, 3 authors (T.A.R.S./W.D.R., B.M.A.H.) independ-ently assessed the quality of the methodology of each RCT.The 12 quality criteria and operationalization of these cri-teria were adapted from Furlan et al.17 Each item wasscored as “yes,” “no,” or “unsure.” High quality wasdefined as a score of Z50% (ie, a “yes” score on Z50% ofthe criteria) on the methodological quality assessment. Aconsensus procedure was used to solve any disagreementbetween the reviewers.

Data SynthesisA quantitative analysis of the studies was not possible

due to the use of diverse outcome measures and otherclinical heterogeneity. Therefore, we decided not to performa meta-analysis but to summarize the results using a ratingsystem that consisted of 5 levels of scientific evidence,taking into account the quality of the methodology and theoutcome of the original studies (best-evidence synthesis).The number of RCTs found in the reviews summarizedtogether with the recent RCTs or the number of additionalRCTs determined the number of RCTs for a certainintervention. A particular article was included in the best-evidence synthesis only if a comparison was made betweenthe groups (treatment vs. placebo, treatment vs. control, ortreatment vs. treatment) and the level of significance wasreported. The results of the study were labeled “significant”if 1 of the 3 outcome measures reported significant results.

The level of evidence was ranked and divided in thefollowing levels:(1) Strong evidence for effectiveness: consistent (ie, Z75%

of the trials report the same findings) positive (signifi-cant) findings within multiple higher quality RCTs.

(2) Moderate evidence for effectiveness: consistent (ie,Z75% of the trials report the same findings) positive(significant) findings within multiple lower qualityRCTs and/or 1 high-quality RCT.

(3) Limited evidence for effectiveness: positive (significant)findings within 1 low-quality RCT.

(4) Conflicting evidence for effectiveness: provided byconflicting (significant) findings in the RCTs (ie,<75% of the studies report consistent findings).

(5) No evidence found in favor of the effectiveness of theinvention: RCT(s) available, but no (significant) differ-ences between intervention and control groups werereported.

(6) No systematic review or RCT found.

RESULTS

Study SelectionThe initial literature search in the databases resulted

in, after deduplication, 1912 potentially relevant studies(483 from PubMed, 81 from Embase, 48 from Cochrane,1293 from CINAHL, and 7 from PEDro). Finally, afterapplication of the selection criteria, for cubital syndrome 3RCTs and 1 systematic review were included, 2 RCTs forelbow instability, and 1 RCT for bursitis. No RCTs werefound for radial tunnel syndrome (Fig. 1). The character-istics of the included studies are listed in Appendix B.

A study by Seradge18 was initially included but, aftercorrespondence with the authors, it seemed that the studywas designed as a prospective cohort study based onpatients choosing between 2 treatment protocols themselvesand that the patients were not randomized.

Methodological Quality AssessmentThe results of the methodological quality assessment

are presented in Table 1. All but one of the studies had a“low risk of bias” profile, that is, they met >50% of theFurlan criteria.17 Methodologically, flaws in all the studieswere related to blinding to the intervention of both thepatient and care provider.

Effectiveness of InterventionsThe evidence for the effectiveness on the outcome

measures for the various treatment options for cubitaltunnel syndrome, elbow instability, and bursitis of theelbow is presented in Table 2. As mentioned before, nostudies were found regarding the radial tunnel syndrome.

TABLE 1. Methodological Quality Scores of the Included RCTs

References

Adequate

Randomi-

zation?

Allocation

Conceal-

ment?

Blinding

Patients?

Blind-

ing

Care-

giver?

Blinding

Outcome

Assessors?

Incomplete

Outcome

Data

Addressed?

Dropouts?

Participants

Analyzed in

the

Allocated

Group?

Free of

Suggestions

of Selective

Outcome

Reporting?

Similarity

of

Baseline

Character-

istics?

Cointer-

ventions

Avoided

or

Similar?

Compliance

Acceptable

in all

Groups?

Timing of

the

Outcome

Assessment

Similar?

Maxi-

mum

Score

Study

Score

Percent-

age

Cubital tunnel syndromeSvernlov

et al19+ ? � � + + � + + ? ? + 12 6 50

Geutjenset al20

+ ? � � + + � + ? ? NA � 11 4 36

Honget al21

? ? � � ? + + + ? ? � + 12 4 33

Instability of elbowJosefsson

et al22+ ? � � ? + � + ? ? ? � 12 3 25

Rafaiet al23

? ? � � ? � ? + ? ? ? + 12 2 17

Bursitis of elbowSmith

et al12? ? � � + ? ? + + ? ? + 12 4 33

+ indicates yes; � , no;?, unsure; NA, not applicable; RCT, randomized controlled trial.

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Cubital Tunnel SyndromeOne systematic review and 3 additional RCTs were

found. In the systematic review of Zlowodzki et al,24 4RCTs25–28 were included that compared anterior trans-position with simple decompression for treating cubitaltunnel syndrome. Furthermore, the additional RCT ofGeutjens et al20 compared medial epicondylectomy toanterior transposition.

The additional RCT of Hong et al21 compared non-surgical treatment (splinting) with the effect of a steroidinjection in addition to splinting. The additional RCT ofSvernlov et al19 compared the elbow brace to nerve glidingand to information only.

Surgical TreatmentSimple Decompression Compared With Anterior

Transposition of the Ulnar Nerve, Systematic Review:Zlowodzki et al24 included 4 RCTs (n=261),25–28 com-paring simple decompression to transposition of which thefirst 2 performed subcutaneous transpositions and the other2 submuscular transpositions. The follow-up period rangedfrom 9 months27 to almost 4 years.25 In 3 of the 4 studies, aclinical scoring system was used as the primary outcomemeasure. No significant differences were found in terms ofthe clinical scores between simple decompression andanterior transposition: standard mean difference in effect�0.04 (95% CI, �0.36 to 0.28).

Medial Anterior Epicondylectomy Compared WithUlnar Nerve Transposition, Additional RCT: Geutjens et al20

(n=34, high risk of bias) compared medial anterior epi-condylectomy to ulnar nerve transposition. At 4.7 yearsfollow-up, a significant difference was found between the2 techniques on the pain score in the hand. Theepicondylectomy group scored significantly better com-pared with the anterior transposition group. No significantdifferences were found in range of motion or grip strength.Therefore, we conclude that there is limited evidencethat medial anterior epicondylectomy offers a significantlybetter pain score than ulnar nerve transposition in thetreatment of cubital tunnel syndrome at long-termfollow-up.

Nonsurgical TreatmentSplinting Compared With Local Steroid Injections Plus

Splinting, Additional RCT: Hong et al21 (n=12, high riskof bias) compared the effect of local steroid injections inaddition to splinting. At 6 months follow-up, no significantdifferences were found between the 2 techniques in terms ofsymptoms, signs, and nerve conduction studies. Therefore,we conclude that there is no evidence that steroid injectionoffers any additional benefit to splinting in the treatment ofcubital tunnel syndrome at long-term follow-up.

Elbow Brace Compared With Nerve Gliding to Infor-mation Only, Additional RCT: Svernlov et al19 (n=51, lowrisk of bias) compared the elbow brace to nerve gliding andto information only. At the 6 months follow-up, no sig-nificant differences were found between the 3 groups interms of performance, satisfaction, pain, strength, or neu-rophysiological parameters. Therefore, we conclude thatthere is no evidence of superiority of technique between anelbow brace, nerve gliding, or information only at long-term follow-up.

Radial Tunnel SyndromeBecause no RCTs were found for radial tunnel syn-

drome, we conclude that there is currently no evidence ofeffectiveness in its treatment.

Elbow InstabilityTwo additional RCTs were included. Josefsson et al22

compared surgery to immobilization by plaster. Rafaiet al23 compared early mobilization of the elbow toimmobilization.

Nonsurgical Treatment Versus SurgeryComparing Surgery to Immobilization Treatment,

Additional RCT: Josefsson et al22 (n=28, high risk of bias)compared surgery to 3 weeks of immobilization in a plastercast. At the 1-year follow-up, no significant differences werefound between the 2 techniques in terms of mobility, sta-bility, and grip and elbow strength. Therefore, we concludethat there is no evidence of surgery differing from immo-bilization at long-term follow up.

Nonsurgical TreatmentEarly Mobilization Compared With 3-Week Immobili-

zation After Surgery, Additional RCT: Rafai et al23 (n=50,high risk of bias) compared early mobilization of the elbowto immobilization for 3 weeks after surgery. At 1-year fol-low-up, a significantly better range of motion of elbowextension, 96% good (normal extension) versus 81%,respectively, was found in the early mobilization group.Significantly fewer problems with stiffness, that is, 19% inthe immobilization group versus 4%, respectively, werefound in the early mobilization group. The comparison ofpain or instability revealed no significant differences at the1-year follow-up. Therefore, we conclude that there islimited evidence that at long-term follow-up, early mobi-lization offers a significantly better range of motion and lessstiffness than immobilization after surgery for elbowinstability.

Olecranon BursitisOne additional RCT was included. Smith et al12

compared injection with methylprednisolone acetate andoral naproxen to injection with methylprednisolone acetateand oral placebo to oral naproxen to oral placebo.

Nonsurgical TreatmentAdditional RCT: Smith et al12 (n=42, high risk of

bias) compared patients assigned to 1 of 4 possible treat-ments: group 1, injection with methylprednisolone acetate(20mg) and oral naproxen (1 g/d); group 2, injection withmethylprednisolone acetate (20mg) and oral placebo;group 3, oral naproxen (1 g/d); and group 4, oral placebo.This study reported on swelling of the elbow and thenumber of patients requiring reaspirations in addition totenderness, because they were determined as the most sig-nificant outcome measures.

At the 6-week follow-up, there was a significantlygreater decrease in swelling and a lower number of reaspi-rations in the patients treated with an intrabursal methyl-prednisolone acetate injection plus oral naproxen. At 6months, an examination and/or a questionnaire was usedfor the outcome measures of tenderness and the number ofaspirations performed. No differences in tenderness scoreswere found, and the number of reaspirations was higher inthe groups without the injection. Therefore, we conclude




that there is limited evidence for the effectiveness of intra-bursal methylprednisolone acetate injection plus oral nap-roxen for the treatment of nonseptic olecranon bursitis.

DISCUSSIONThis review evaluated the effectiveness of interventions

in the treatment of cubital tunnel syndrome, radial tunnelsyndrome, and instability or bursitis of the elbow. Weincluded 1 systematic review and 6 RCTs, all evaluating theeffectiveness of several surgical and nonsurgical treatmentoptions.

For the surgical treatment of cubital tunnel syndrome,no difference in clinical outcome scores between simpledecompression and transposition of the ulnar nerve wasfound. Comparing 2 other surgical procedures, it was foundthat medial epicondylectomy gave significantly betterresults regarding pain, than anterior transposition. On thebasis of these results, it seems worthwhile to perform astudy in which simple decompression is compared withmedial epicondylectomy. Nevertheless, for the most effec-tive treatment of cubital tunnel syndrome, the debate con-tinues as to what are the actual indications for surgery.There is no evidence for the surgical approach being moreor less effective than (prolonged) nonsurgical treatment,whereas some have a personal view that it can be a suc-cessful treatment in up to 90% of cases.29

The studies on elbow instability showed that the out-comes after surgery were not significantly different fromimmobilization treatment. Early immobilization after sur-gery should be advocated.

The only RCT on olecranon bursitis showed that thereis a significant advantage of naproxen as surplus in themethylprednisolone injection treatment of this disorder.Unfortunately, no reviews or RCTs were found for radialtunnel syndrome. In the literature, a systematic review thatincluded observational studies on treatment options forradial tunnel syndrome was found.8 Although no

observational studies on nonsurgical treatment could beincluded in this review, a tendency was determined forsurgical decompression in patients with radial tunnelsyndrome.

In all the included RCTs, the type of clinical scorediffered and was largely based on subjective criteria,including a clinical assessment of sensation and strength(McGowan score and LSUMC score, Bishop score, andMRC score), severity of residual symptoms, subjectiveimprovement, and preoperative and postoperative workstatus (Bishop score). Some of the tests used to evaluateentrapments need to be critically appraised. For example,manual muscle strength testing is performed using theMRC 0-5 scale, which is not a numerical but an ordinalscale, implying that mean grades on the MRC scale need tobe avoided. Consensus on a classification or grading systemfor the severity of symptoms is required for the evaluationof outcome in cubital tunnel syndrome.

To compare results from different studies, it seemslogical to present the original data and then combine theminto a grading score. Most agree that outcome shouldconsist of measures that identify clinically relevantimprovements in function,30 possibly with the use of aquestionnaire similar to the Levine or the specific UNEquestionnaire.31 In addition, there is a need to include apain measurement and nerve function assessment, andtesting for muscle strength and sensation.

Study LimitationsThere is always the possibility that potentially relevant

studies will have been missed in the selection procedureand, of course, the above-mentioned studies are prone topublication bias. In Rehabilitation Medicine, it is now wellaccepted that outcome measures should be reportedaccording to the International Classification of Function-ing, disability, and health (ICF),32 and should preferably beperformed at 3 levels: activity, function, and participationlevel. For this review we only included studies, which

TABLE 2. Evidence for Effectiveness: Overview of the Cubital Tunnel Syndrome, Instability of the Elbow, Olecranon Bursitis, and theRadial Tunnel Syndrome

Nonsurgical TreatmentSurgical Treatment

Disorders (Physio)therapy Oral Treatment Injection

Cubital tunnelsyndrome

Elbow brace vs. nerve gliding vs.information only

cNE at long-term follow-up

X Splinting vs. splintingplus injection

cNE at long-termfollow-up

Simple decompression vs. anteriortransposition

cNE at long-term follow-up

Medial anterior epicondylectomy* vs.anterior transposition

c+at long-term follow-up

Instability of theelbow

Early mobilization* vs.immobilization

c+at long-term follow-up

X X Surgery vs. immobilizationcNE at long-term follow-up

Olecranonbursitis

X Naproxen* vs.placebo

cNE at long-termfollow-up

Prednisolone* vs.placebo injection

c+at long-termfollow-up

X

Radial tunnelsyndrome

X X X X

Randomized clinical trial(s) (RCT) available, but no differences between intervention and control groups were found.*In favor of+ , limited evidence found; NE, no evidence found for effectiveness of the treatment; X, no systematic review or RCT found.




reported on outcomes related to pain and function. It seemsthat, for example, return to work would be a valuableevaluation parameter at the participation level, but this isseldom reported in studies. In some studies the number ofincluded patients was low, resulting in low statistical powerto detect significant differences between treatments. In allbut one of the included studies the quality of the method-ology was low.

CONCLUSIONSThis study reviewed the effectiveness of interventions

used in the treatment of the painful conditions of cubitaltunnel syndrome, radial tunnel syndrome, elbow instability,or olecranon bursitis. Despite the abundance of published

studies, there is no, or at best, limited evidence for theeffectiveness of nonsurgical and surgical interventions totreat the above-mentioned elbow disorders. Well-designedand well-conducted RCTs are clearly needed in this field.The information emerging from this study also stresses theneed for a more standardized set of outcome assessment forevaluation after intervention.

ACKNOWLEDGMENT

The authors thank Suzanne Glerum, MD from theDepartment of General Practice, Erasmus MC—UniversityMedical Center Rotterdam, Rotterdam, the Netherlands forher contribution to the literature search and data extraction.




TABLE A. Search String for the Different Databases

Database Full Search String

PubMed Radial Tunnel Syndrome: “Radial neuropathy” [mh] OR “radial tunnel” OR “supinator syndrome” OR (posterior ANDinterosseous AND (nervus OR nerve)) OR PINS OR RTS OR (radial* AND (nervus OR nerve) AND (compress* ORentrapment)) OR (“radial nerve”[mh] AND (compress* OR entrapment))

Cubital Tunnel Syndrome: “cubital tunnel syndrome”[mh] OR (ulnar* AND (nervus OR nerve) AND (compress* ORentrapment)) OR (“ulnar nerve”[mh] AND (compress* OR entrapment)) OR “cubital tunnel”

Bursitis of elbow: (bursitis[mh:noexp] AND elbow) OR “students elbow” OR “bursitis olecrani”

Instability of elbow: (instability OR dislocation OR subluxation OR unstable OR “Joint instability”[mh]) AND elbow

For RCT(s) and CCT(s): (randomized controlled trial [pt] OR controlled clinical trial [pt] OR randomized controlled trials [mh]OR random allocation [mh] OR double-blind method [mh] OR single-blind method [mh] OR clinical trial [pt] OR clinical trials[mh] OR “clinical trial” [tw] OR ((singl* [tw] OR doubl* [tw] OR trebl* [tw] OR tripl* [tw]) AND (mask* [tw] OR blind* [tw]))OR “latin square” [tw] OR placebos [mh] OR placebo* [tw] OR random* [tw] OR research design [mh:noexp] OR comparativestudy [mh] OR evaluation studies [mh] OR follow-up studies [mh] OR prospective studies [mh] OR cross-over studies [mh] ORcontrol* [tw] OR prospectiv* [tw] OR volunteer* [tw]) NOT (animal [mh] NOT human [mh])

For therapy: (randomized controlled trial[Publication Type] OR (randomized[Title/Abstract] AND controlled[Title/Abstract]AND trial[Title/Abstract]))

Embase Radial Tunnel Syndrome: ((radial NEAR/3 (palsy* OR neuropath* OR tunnel OR compress* OR entrap*)) AND “radialnerve”) OR (supinat* NEAR/3 syndrom*) OR (“posterior interosseus” NEAR/3 (nerv* OR neur*))

Cubital Tunnel Syndrome: “cubital tunnel syndrome”/ OR “cubital tunnel” OR ((ulnar* AND nerv*) AND (compress* ORentrapment OR “nerve compression”/exp)) OR ((nerve/exp AND ulnar*) AND (compress* OR entrapment OR “nervecompression”/exp))

Bursitis of elbow: (bursitis/exp AND (elbow/exp OR elbow)) OR “students elbow” OR “bursitis olecrani”

Instability of elbow: “elbow dislocation”/exp OR ((instability OR “joint instability”/exp OR dislocation OR “dislocation”/expOR subluxation OR subluxation/exp OR unstable) AND (elbow OR elbow/exp))

For RCT(s) and CCT(s): (“controlled clinical trial”/exp OR “randomized controlled trial”:ti OR “controlled clinical trial”:it OR“randomization”/ OR “double blind procedure”/ OR “single blind procedure”/ OR “crossover procedure”/ OR “clinicaltrial”:it OR ((“clinical trial” OR (singl* OR doubl* OR tripl*)) AND (mask* OR blind*)) OR (“Latin square design”/ OR“latin square” OR “latin-square”) OR “placebo”/ OR placebo* OR “random sample”/ OR “comperative study”:it OR“evaluation study”:it OR evaluation/exp OR “follow up”/exp OR “prospective study”/ OR control* OR prospectiv* ORvolunteer*) NOT (animals/exp NOT humans/exp)

For therapy: “randomized controlled trial”:it OR (randomized:ti,ab AND controlled:ti,ab AND trial:ti,ab)

CINAHL Radial Tunnel Syndrome: (radial* and neuropathy) or “radial tunnel” or “supinator syndrome” or (posterior and interosseousand nerv*) or PINS or RTS or (radial* and nerv* and (compress* or entrapment)) or ((MH “radial nerve”) and (compress* orentrapment))

Cubital Tunnel Syndrome: (ulnar* and nerv* and (compress* or entrapment)) or ((MH “ulnar nerve”) and (compress* orentrapment)) or “cubital tunnel”

Bursitis of elbow: ((MH “bursitis”) and (elbow or (MH “elbow”) or (MH “elbow joint”))) or “students elbow” or “bursitisolecrani”

Instability of elbow: (instability OR dislocation OR subluxation OR unstable OR (MH “Joint instability”)) AND (elbow or (MH“elbow”) or (MH “elbow joint”))

Clinical trial(s) (MH “Clinical Trials+”) Systematic review(s) (MH “Systematic Review”)

PEDro Radial Tunnel Syndrome radial tunnel syndrome Cubital Tunnel Syndrome cubital tunnel syndrome Bursitis of elbow bursitiselbow Instability of elbow instability elbow

Cochrane Radial Tunnel Syndrome radial tunnel syndrome Cubital Tunnel Syndrome cubital tunnel syndrome Bursitis of elbow bursitiselbow Instability of elbow instability elbow

APPENDIX




TABLE B. Data Extraction of the Included Systematic Review and RCTs

References Treatment

Control/Comparison

Group

Outcome

Measures (Follow-

Up Period) Results Results by Outcome Measure

Cubital tunnel syndromeZlowodzkiet alw24

Reviewmeta-analysis

Transposition vs. simpledecompression (n=130)

Clinical scores(pain, strength,change insensation)

Nerve-conductionvelocities

P=0.81P=0.22

Transposition vs. simpledecompression: SMD= �0.04(�0.36 to 0.28) [effect size (CI)]

Transposition vs. simpledecompression: SMD=0.24(�0.15 to 0.63)

Geutjenset al20

RCT

Medial epicondylectomy(n=25 nerves)

Anterior transposition(AT) (n=22 nerves)

Pain score in hand(0-5 y)

(mean 4.5 y, min.1 y)

Grip strength (kg)(4.5 y)

Range of movement(4.5 y)

P=0.029P=0.259P=0.906

Baseline: no data givenEpicondylectomy group: 0 (0)*

[mean (SD)] at final follow-up vs.0.45 (0.86) in AT group at finalfollow-up.

Baseline: no data givenEpicondylectomy group: 18.5 (9.19)

at final follow-up vs. AT group:22.6 (8.26) in AT group at finalfollow-up

Baseline: no data givenEpicondylectomy group: 5-122

degrees at final follow-up vs. ATgroup: 3-125 degrees at finalfollow-up

Honget al21

RCT

40mg triamcinolone/2mLlidocaine+ splinting(n=7 nerves)

Elbow splinting(n=5 nerves)

Symptoms (6mo)Signs (6mo)Change in NCV(6mo)

Change in motoramplitudedecrease (6mo)

Change in distalsensory latency(6mo)

Change in sensoryamplitude (6mo)

NS (no P-valuegiven)

Splint+ injection group: �58%(24) [mean (SD)] at 1mo vs. splintgroup: �50% (35) at 1mo

Splint+ injection group: �61%(32) at 6mo vs. splint group:�45% (29) at 6mo

Splint+ injection group: �39%(34) at 1 mo vs. splint group:�30% (24) at 1mo




Splint+ injection group: �55%(78) at 1mo vs. splint group: 50%(168) at 1mo




Splint+ injection group: 30% (62)at 1mo vs. splint group: 20% (60)at 1mo

Splint+ injection group: 84% (75)at 6mo vs. splint group: 59%(114) at 6mo

Svernlovet al19

RCT

Elbow brace (n=21)Nerve gliding (n=15)

Information only(n=15)

COPM (6mo)PerformanceSatisfactionPain (VAS) (6mo)DiurnalNocturnal

NS (no P-valuegiven)

P=0.0001P=0.0003P=0.039

No significant differences betweenthe groups at 6mo

Elbow brace: 4.8 (1.4) [mean (SD)]at BL vs. 6.7 (2.3) at 6mo

Nerve gliding: 5.1 (1.6) at BL vs. 7.9(1.7) at 6mo

(Continued )




TABLE B. (continued)


Control/Comparison

Group

Outcome

Measures (Follow-


Strengthmeasurements(6mo)

Neurophysiologicalexamination(6mo)

NSP=0.0001P=0.0001NSNSP=0.011P=0.002P=0.001P=0.0007P=0.012NSNS

Information: 4.4 (1.3) at BL vs. 6.5(1.8) at 6mo

Elbow brace: 3.3 (1.4) at BL vs. 6.5(2.7) at 6mo











No significant differences betweenor within the groups at BL and6mo

Elbow instabilityJosefssonet al22

RCT

Surgical repair (n=14) Splinting 3wk (n=14) Loss of extension(>2 y)

Loss of flexion(>2 y)

Limited motion(extension)(>2 y)

WeaknessWeather-relateddiscomfort

Pain on effortTendernessPain at restFeeling in instability

NS (noP-valuegiven)

NS (noP-valuegiven)

Surgical repair: 55 degrees (21) at5wk vs. splinting: 44 degrees (22)at 5wk


Surgical repair: 18 degrees (15) at>1y vs. splinting: 10 degrees (14)at >1y



Surgical repair: 1 degree (2) at >1yvs. splinting: 1 degree (2) at >1y

Surgical repair: 7 pt at >1y vs.splinting: 4 pt at >1y







Rafaiet al23

RCT

Postsurgery plaster 3wk(n=26)

Postsurgery earlymobilization (n=24)

Pain (1 y)ROM (extension)(3mo)

NS (noP-valuegiven)

Plaster: at 1 y vs. early mobility at1 y

Plaster: 81% good at 3mo vs. earlymobilization*: 96% good at 3mo

(Continued )




REFERENCES1. Huisstede BM, Miedema HS, Verhagen AP, et al. Multi-

disciplinary consensus on the terminology and classification ofcomplaints of the arm, neck and/or shoulder. Occup EnvironMed. 2007;64:313–319.

2. Dingemanse R, Randsdorp M, Koes BW, et al. Evidence forthe ffectiveness of electrophysical modalities of medial andlateral epicondylitis: a systematic review. Br J Sports Med.2013 [Epub ahead of print]. PMID: 23335238.

3. Hoogvliet P, Randsdorp M, Dingemanse R, et al. Doeseffectiveness of exercise therapy and mobilization techniquesoffer guidance for treatment of lateral and medical epicondy-litis? A systematic review. Article in press.

4. Bartels RHMA, Termeer EH, Van Der Wilt GJ, et al. Simpledecompression or anterior subcutaneous transposition forulnar neuropathy at the elbow: a cost-minimization analysis—Part 2. Neurosurgery. 2005;56:531–535.

5. Cutts S. Cubital tunnel syndrome. Postgrad Med J.2007;83:28–31.

6. Piligian G, Herbert R, Hearns M, et al. Evaluation andmanagement of chronic work-related musculoskeletal dis-orders of the distal upper extremity. Am J Ind Med. 2000;37:75–93.

7. van Rijn RM, Huisstede BM, Koes BW, et al. Associationsbetween work-related factors and specific disorders at theelbow: a systematic literature review. Rheumatology (Oxford).2009;48:528–536.

8. Huisstede B, Miedema HS, van Opstal T, et al. Interventionsfor treating the radial tunnel syndrome: a systematic review ofobservational studies. J Hand Surg Am. 2008;33:72–78.

9. Charalambous CP, Stanley JK. Posterolateral rotatory insta-bility of the elbow. J Bone Joint Surg Br. 2008;90:272–279.

10. O’Driscoll SW. Elbow instability. Acta Orthop Belg.1999;65:404–415.

11. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatoryinstability of the elbow. J Bone Joint Surg Am. 1991;73:440–446.

12. Smith DL, McAfee JH, Lucas LM, et al. Romney DMA.Treatment of nonseptic olecranon bursitis. A controlled, blindedprospective trial. Arch Intern Med. 1989;149:2527–2530.

13. McAfee JH, Smith DL. Olecranon and prepatellarbursitis. Diagnosis and treatment. West J Med. 1988;149:607–610.

14. Favejee MM, Huisstede BM, Koes BW. Frozen shoulder: theeffectiveness of conservative and surgical interventions–system-atic review. Br J Sports Med. 2011;45:49–56.

TABLE B. (continued)


Control/Comparison

Group

Outcome

Measures (Follow-


Stiffness (1 y)Instability (1 y)

S (noP-valuegiven)

S (no P-valuegiven)

NS (noP-valuegiven)

Plaster: 19% at 1 y vs. earlymobilizationa: 4% at 1 y

Plaster: 0 pt at 1 y vs. earlymobilization: 0 pt at 1 y

Olecranon bursitisSmithet al12

RCT

Methylprednisolone acetate20mg intrabursalinjection plus oralnaproxen 1 g/d (n=11)

Oral naproxen 1 g/d(n=10)

Methylprednisoloneacetate 20mgintrabursal injectionplus oral placebo(n=10)

Oral placebo(n=11)

Tenderness (6mo)Swelling (6wk)Number ofreaspirations(6mo)

NS, P>0.05

P=0.05P=0.025

No data

Methylprednisolone acetateinjection+oral naproxen*: 4.3(1.8) [mean (SD)]mm at BL vs.�12.5 (4.3)mm at 6wk

Methylprednisolone acetateinjection+oral placebo: 4.5(2.0)mm at BL vs. �9.5 (7.7)mmat 6wk

Oral naproxen: 5.0 (2.4)mm at BLvs. 0.2 (17)mm at 6wk

Oral placebo: 3.8 (2.2)mm at BL vs.�1.0 (15) mm at 6wk

Methylprednisolone acetateinjection+oral naproxen*: 0.1(0.3) at 6mo

Methylprednisolone acetateinjection+oral placebo: 0.1 (0.3)at 6mo

Oral naproxen: 1.0 (1.2) at 6moOral placebo: 0.4 (0.7) at 6mo

Radial tunnel syndromeNo reviews or RCTs found

*In favor ofwSystematic reviewBL, baseline; COPM, Canadian Occupational Performance Measure; min., minimal; NCV, nerve conduction velocity; NS, not significant; pt, patient(s);

RCTs, randomized controlled trials; ROM, range of motion; S, significant; SMD, standard mean difference; VAS, visual analog scale.




15. Huisstede BM, Koes BW, Gebremariam L, et al. Currentevidence for effectiveness of interventions to treat rotatorcuff tears. Man Ther. 2011;16:217–230.

16. Gebremariam L, Hay EM, Koes BW, et al. Effectiveness ofsurgical and postsurgical interventions for the subacromialimpingement syndrome: a systematic review. Arch Phys MedRehabil. 2011;92:1900–1913.

17. Furlan AD, Pennick V, Bombardier C, et al. 2009 updatedmethod guidelines for systematic reviews in the Cochrane BackReview Group. Spine. 2009;34:1929–1941.

18. Seradge HA. Cubital tunnel release and medial epicondylec-tomy: effect of timing of mobilization. J Hand Surg Am.1997;22:863–866.

19. Svernlov B, Larsson M, Rehn K, et al. Conservative treatmentof the cubital tunnel syndrome. J Hand Surg Eur Vol.2009;34:201–207.

20. Geutjens GG, Langstaff RJ, Smith NJ, et al. Medialepicondylectomy or ulnar-nerve transposition for ulnar neuro-pathy at the elbow? J Bone Joint Surg Br. 1996;78:777–779.

21. Hong CZ, Long HA, Kanakamedala RV, et al. Splinting andlocal steroid injection for the treatment of ulnar neuropathy atthe elbow: clinical and electrophysiological evaluation. ArchPhys Med Rehabil. 1996;77:573–577.

22. Josefsson PO, Gentz CF, Johnell O, et al. Surgical versus non-surgical treatment of ligamentous injuries following dislocationof the elbow joint. A prospective randomized study. J BoneJoint Surg Am. 1987;69:605–608.

23. Rafai M, Largab A, Cohen D, et al. Pure posterior luxation of theelbow in adults: immobilization or early mobilization. A random-ized prospective study of 50 cases. Chir Main. 1999;18:272–278.

24. Zlowodzki M, Chan S, Bhandari M, et al. Anterior trans-position compared with simple decompression for treatment ofcubital tunnel syndrome. A meta-analysis of randomized,controlled trials. J Bone Joint Surg Am. 2007;89:2591–2598.

25. Bartels RH, Verhagen WI, van der Wilt GJ, et al. Prospectiverandomized controlled study comparing simple decompressionversus anterior subcutaneous transposition for idiopathicneuropathy of the ulnar nerve at the elbow: Part 1. Neuro-surgery. 2005;56:522–530; discussion 522–530.

26. Biggs M, Curtis JAA. Randomized, prospective study compar-ing ulnar neurolysis in situ with submuscular transposition.Neurosurgery. 2006;58:296–304; discussion 296–304.

27. Gervasio O, Gambardella G, Zaccone C, et al. Simpledecompression versus anterior submuscular transposition ofthe ulnar nerve in severe cubital tunnel syndrome: aprospective randomized study. Neurosurgery. 2005;56:108–117.

28. Nabhan A, Ahlhelm F, Kelm J, et al. Simple decompression orsubcutaneous anterior transposition of the ulnar nervefor cubital tunnel syndrome. J Hand Surg Br. 2005;30:521–524.

29. Szabo RM, Kwak C. Natural history and conservativemanagement of cubital tunnel syndrome. Hand Clin.2007;23:311–318, v-vi.

30. Caliandro P, La Torre G, Padua R, et al. Treatment for ulnarneuropathy at the elbow. Cochrane Database Syst Rev.2011;CD006839.

31. Mondelli M, Padua L, Giannini F, et al. A self-administeredquestionnaire of ulnar neuropathy at the elbow. Neurol Sci.2006;27:402–411.

32. International classification of functioning d, and health (ICF).2001.



Current Evidence for Effectiveness of Interventions for Cubital Tunnel Syndrome, Radial Tunnel Syndrome, Instability, or Bursitis of the Elbow

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