Kortikosteroidinjektionen, Physiotherapie oder eine Abwartestrategie bei lateraler Epikondylitis: randomisierte kontrollierte Studie

Laterale Epikondylitis wird allgemein mit Kortikosteroidinjektionen oder mit Physiotherapie behandelt. Holländische klinische Richtlinien empfehlen eine Abwartestrategie. Die Wirksamkeit dieser Ansätze wurde miteinander verglichen. Die Patienten sollten gut über Vor- und Nachteile von Behandlungsoptionen bei lateraler Epikondylitis informiert sein. Die Entscheidung, mit Physiotherapy zu behandeln oder eine Abwartestrategie einzunehmen, kann von den vorhandenen Ressourcen abhängen, da der relative Vorteil der Physiotherapie gering ist. Abstract Lateral epicondylitis is generally treated with corticosteroid injections or physiotherapy. Dutch clinical guidelines recommend a wait-and-see policy. The efficacy of these approaches was compared. Patients should be properly informed about the advantages and disadvantages of the treatment options for lateral epicondylitis. The decision to treat with physiotherapy or to adopt a wait-and-see policy might depend on available resources, since the relative gain of physiotherapy is small

Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial

OBJECTIVE: To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain. DESIGN: Economic evaluation alongside a randomised controlled trial. SETTING: Primary care. PARTICIPANTS: 183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n=60, spinal mobilisation), physiotherapy (n=59, mainly exercise), or general practitioner care (n=64, counselling, education, and drugs). MAIN OUTCOME MEASURES: Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques. RESULTS: The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (447 euro; 273 pounds sterling; 402 dollars) were around one third of the costs of physiotherapy (1297 euro) and general practitioner care (1379 euro). These differences were significant: P <0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P=0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care. CONCLUSIONS: Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitione

Manual therapy, physical therapy, or continued care by the general practitioner for patients with neck pain - Long-term results from a pragmatic randomized clinical trial

OBJECTIVES: The authors' goals were to compare the effectiveness of manual therapy (MT; mainly spinal mobilization), physical therapy (PT; mainly exercise therapy), and continued care by the general practitioner (GP; analgesics, counseling and education) over a period of 1 year. METHODS: One hundred eighty-three patients suffering for at least 2 weeks from nonspecific neck pain were randomized to receive a 6-week treatment strategy of MT once a week, PT twice a week, or GP care once every 2 weeks. The primary outcome measures were perceived recovery, severity of physical dysfunctioning, pain intensity, and functional disability. RESULTS: The differences between groups considered over 1 year were statistically significant (repeated measurements analyses P <0.001 to P=0.02) for all outcomes but borderline for the Neck Disability Index (P=0.06). Higher improvement scores were observed for MT for all outcomes, followed by PT and GP care. The success rate, based on perceived recovery after 13 weeks, was 72% for MT, which was significantly higher than the success rate for continued GP care (42%, P=0.001) but not significantly higher compared with PT treatment (59%, P=0.16). The difference between PT and GP approached statistical significance (P=0.06). After 1 year the success rates were 75%, 63%, and 56%, respectively, and no longer significantly different. CONCLUSIONS: Short-term results (at 7 weeks) have shown that MT speeded recovery compared with GP care and, to a lesser extent, also compared with PT. In the long-term, GP treatment and PT caught up with MT, and differences between the three treatment groups decreased and lost statistical significance at the 13-week and 52-week follow-u

Economic evaluations and Randomized trials in spinal disorders: Principles and methods

Study Design. Descriptive methodologic recommendations. Objective. To help researchers designing, conducting, and reporting economic evaluations in the field of back and neck pain. Summary of Background Data. Economic evaluations of both existing and new therapeutic interventions are becoming increasingly important. There is a need to improve the methods of economic evaluations in the field of spinal disorders. Materials and Methods. To improve the methods of economic evaluations in the field of spinal disorders, this article describes the various steps in an economic evaluation, using as example a study on the cost-effectiveness of manual therapy, physiotherapy, and usual care provided by the general practitioner for patients with neck pain. Results. An economic evaluation is a study in which two or more interventions are systematically compared with regard to both costs and effects. There are four types of economic evaluations, based on analysis of: (1) cost-effectiveness, (2) cost-utility, (3) cost-minimization, and (4) cost-benefit. The cost-utility analysis is a special case of cost-effectiveness analysis. The first step in all these economic evaluations is to identify the perspective of the study. The choice of the perspective will have consequences for the identification of costs and effects. Secondly, the alternatives that will be compared should be identified. Thirdly, the relevant costs and effects should be identified. Economic evaluations are usually performed from a societal perspective and include consequently direct health care costs, direct nonhealth care costs, and indirect costs. Fourthly, effect data are collected by means of questionnaires or interviews, and relevant cost data with regard to effect measures and health care utilization, work absenteeism, travel expenses, use of over-the-counter medication, and help from family and friends, are collected by means of cost diaries, questionnaires, or (telephone) interviews. Fifthly, real costs are calculated, or the costs are estimated on the basis of real costs, guideline prices, or tariffs. Finally, in the statistical analysis the mean direct, indirect, and total costs of the alternatives are compared, using bootstrapping techniques. Incremental cost-effectiveness ratios are graphically presented on a cost-effectiveness plane and acceptability curves are calculated. Conclusion. Economic evaluations require specific methods. These recommendations may be helpful in improving the quality of economic evaluations of new and existing therapeutic interventions in the field of spinal disorders

Splinting for carpal tunnel syndrome: prognostic indicators of success

To identify (combinations of) prognostic indicators for the long term success of splinting in patients with electrophysiologically confirmed idiopathic carpal tunnel syndrome (CTS). This study was conducted within the framework of a randomised controlled trial on the efficacy of splinting and surgery for CTS. Patients randomised to splinting received a wrist splint, which they had to wear during the night for at least six weeks. To assess the long term success, patients were asked to indicate whether there was any improvement 12 months after randomisation. Potential prognostic indicators included variables from the history taking and physical examination, self administered questionnaires on severity of symptoms, and electrodiagnostic studies. Multiple logistic regression was used to identify (combinations of) prognostic indicators. Of the 89 patients randomised to splinting, 83 attended the follow up measurement at 12 months, of whom 60 reported improvement. However, 34 patients had received one or more additional types of treatment during the follow up period and were therefore considered as treatment failures for splinting, resulting in a final success rate of 31% for splinting (26 of 83 patients). Only two prognostic indicators could be identified, namely a short duration of CTS complaints (one year or less) and a score of 6 or less for severity of paraesthesia at night at baseline. For patients to whom both factors applied, the predicted probability of treatment success, according to the model, was 62%. The overall percentage of patients who were correctly classified by the model was 78% (95% CI 69% to 87%

Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial

Background: Lateral epicondylitis is generally treated with corticosteroid injections or physiotherapy. Dutch clinical guidelines recommend a wait-and-see policy. We compared the efficacy of these approaches. Methods: Patients with lateral epicondylitis of at least 6 weeks' duration were recruited by family doctors. We randomly allocated eligible patients to 6 weeks of treatment with corticosteroid injections, physiotherapy, or a wait-and-see policy. Outcome measures included general improvement, severity of the main complaint, pain, elbow disability, and patient satisfaction. Severity of elbow complaints, grip strength, and pressure pain threshold were assessed by a research physiotherapist who was unaware of treatment allocation. We assessed all outcomes at 3, 6, 12, 26, and 52 weeks. The principal analysis was done on an intention-to-treat basis. Findings: We randomly assigned 185 patients. At 6 weeks, corticosteroid injections were significantly better than all other therapy options for all outcome measures. Success rates were 92% (57) compared with 47% (30) for physiotherapy and 32% (19) for wait-and-see policy. However, recurrence rate in the injection group was high. Long-term differences between injections and physiotherapy were significantly in favour of physiotherapy. Success rates at 52 weeks were 69% (43) for injections, 91% (58) for physiotherapy, and 83% (49) for a wait-and-see policy. Physiotherapy had better results than a wait-and-see policy, but differences were not significant. Interpretation: Patients should be properly informed about the advantages and disadvantages of the treatment options for lateral epicondylitis. The decision to treat with physiotherapy or to adopt a wait-and-see policy might depend on available resources, since the relative gain of physiotherapy is small