Self-perceived recovery, pain intensity, pain-free grip strength and elbow disability (PRTEE, PFFQ and modified PFFQ) for exercise with or without physiotherapy or HEP compared with corticosteroid injection(s)
| Outcomes | No of studies | Comparisons | Effects estimate (95% CI) P value | Certainty (GRADE) | Heterogeneity | |
| Average estimate/assumed risk in Exercise (PT±HEP) group | Average estimate/assumed risk in cortisone injection group | |||||
|
GROC
Short-term follow-up | 2 | 88 of 122 (72.0%) participants reported satisfactory recovery | 63 of 127 (49.6%) participants reported satisfactory recovery |
RR 1.45*
(1.03 to 2.05) p=0.03 |
⊕
Very low†††‡‡ | χ2=2.73, I2=63%, p=0.10 |
|
GROC
Mid-term follow-up | 3 | 142 of 164 (86.6%) participants reported satisfactory recovery | 84 of 169 (49.7%) participants reported satisfactory recovery |
RR 1.73*
(1.47 to 2.03) p<0.001 |
⊕⊕
Low††‡‡ | χ2=0.86, I2=0%, p=0.65 |
|
GROC
Long-term follow-up | 3 | 158 of 168 (94.0%) participants reported satisfactory recovery | 123 of 170 (72.3%) participants reported satisfactory recovery |
RR 1.27*
(1.16 to 1.40)p<0.001 |
⊕⊕
Low††‡‡ | χ2=1.79, I2=0%, p=0.41 |
|
Mean change in pain rating
Short-term follow-up | 3 | Mean pain score was 18.9 (range 16.7 to 20.8) in 163 participants | Mean pain score was 26.3 (range 25.3 to 30.6) in 166 participants |
SMD −0.27‡
(−0.59 to 0.05) p=0.09 |
⊕
Very low†††‡‡ | χ2=4.15, I2=52%, p=0.13 |
|
Mean change in pain rating
Mid-term follow-up | 3 | Mean pain score was 12.5 (range 9.0 to 14.0) in 164 participants | Mean pain score was 29.7 (range 29.3 to 30.0) in 168 participants |
SMD −0.69*‡
(-0.91 to –0.47) p<0.001 |
⊕⊕
Low††‡‡ | χ2=0.42, I2=0%, p=0.81 |
|
Mean change in pain rating
Long-term follow-up | 3 | Mean pain score was 6.5 (range 3.7 to 8.1) in 168 participants | Mean pain score was 18.4 (range 9.8 to 21.6) in 169 participants |
SMD −0.56*‡
(-0.78 to –0.34) p<0.001 |
⊕⊕
Low††‡‡ | χ2=0.94, I2=0%, p=0.62 |
|
PFGS ratio
Short-term follow-up | 2 | Mean ratio was 73.2 (range 66.3 to 80.8) in 122 participants | Mean ratio was 61.9 (range 59.9 to 63.7) in 122 participants |
MD 12.15*§¶
(1.69 to 22.60) p=0.02 |
⊕
Very low††‡‡† | χ2=2.27, I2=56%, p=0.13 |
|
PFGS ratio
Mid-term follow-up | 2 | Mean ratio was 87.6 (range 79.5 to 96.3) in 122 participants | Mean ratio was 65.2 (range 64.1 to 66.5) in 121 participants |
MD 22.45*§ ¶
(3.63 to 41.30) p=0.02 |
⊕⊕
Low††† | χ2=6.92, I2=85%, p=0.009 |
|
PFGS ratio
Long-term follow-up | 2 | Mean ratio was 96.7 (range 92.6 to 100.9) in 126 participants | Mean ratio was 78.8 (range 72.6 to 84.6) in 125 participants | MD 18.00*§ ¶(11.17 to 24.84) p<0.001 |
⊕⊕
Low††† | χ2=0.28, I2=0%, p=0.60 |
|
Elbow disability
Short-term follow-up | 4 | Mean score was 24.1 (range 10.9 to 34.9) in 188 participants | Mean score was 32.4 (range 12.5 to 52.7) in 190 participants |
SMD −0.28**
(−0.50 to –0.06)p=0.01 |
⊕
Very low††‡‡§§ | χ2=3.42, I2=12%, p=0.33 |
|
Elbow disability
Mid-term follow-up | 3 | Mean score was 16.1 (range 6.2 to 26.5) in 164 participants | Mean score was 35.0 (range 18.6 to 53.3) in 167 participants |
SMD −0.80**
(−1.03 to –0.58) p<0.001 |
⊕
Very low††‡‡§§ | χ2=0.99, I2=0%, p=0.61 |
|
Elbow disability
Long-term follow-up | 3 | Mean score was 9.0 (range 3.1 to 12.9) in 168 participants | Mean score was 24.3 (range 7.5 to 37.1) in 168 participants |
SMD −0.64**
(−0.86 to –0.42) p<0.001 |
⊕
Very low††‡‡§§ | χ2=1.84, I2=0%, p=0.40 |
Data for two studies (48, 61) were requested and provided from authors as means and SDs.
*In favour of exercise (PT±HEP) compared with CI(s).
†Inconsistent results between included studies.
‡Pooled weighted baseline pain 57.2—clinically significant difference 17.2 points change on pain scale (0–100); pooled weighted SDs at short-term, mid-term and long-term follow-up were 23.8, 24.6 and 20.1 points, respectively.
§Clinically significant differences.
¶Pooled weighted baseline PFGS ratio 37.0—clinically significant difference 7.4 points change.
**Pooled weighted disability score at baseline was 57.7—clinically significant difference 37% or 21.3 points change; pooled weighted SDs at short-term, mid-term and long-term follow-up were 20.6, 22.1 and 21.6 points, respectively.
††High risk of bias.
‡‡Indirect comparison in one or more included studies.
§§Substantial differences at baseline disability scores among included studies.
GRADE, Grading of Recommendations Assessment, Development and Evaluation; GROC, Global Rating of Change Scale; HEP, home exercise programme; IV, inverse variance; MD, mean difference; PFGS, Pain Free Grip Strength; PRFQ, Pain Free Function Questionnaire; PRTEE, Patient-Rated Tennis Elbow Evaluation; PT, physiotherapy; RR, risk ratio; SMD, standardised mean difference.