Lateral epicondylalgia A new structured treatment program with an inter-disciplinary approach

Abstract

Abstract Background: Lateral epicondylalgia is a common musculoskeletal diagnosis, thus there exist no structured effective treatment program and no evaluative questionnaire specific for lateral epicondylalgia. Overall aim: This thesis evaluates a structured treatment program with an interdisciplinary approach, and cross-culture adapts and translates a questionnaire for lateral epicondylalgia. Study I: Aim: To evaluate a new multidisciplinary structured home training program for patients with lateral epicondylalgia compared to conventional attendance. Method: The study had a prospective design. A total of 78 patients with lateral epicondylalgia were recruited and were divided into two groups, 51 entered the intervention group and 27 entered the control group. The intervention group was treated with a specific home training program, ergonomic advice and when necessary wrist and/or night bandages. The control group was treated with conventional treatment. Pain and function were evaluated by the Patient Rated Forearm Questionnaire, PRFEQ and strength and stamina with an electronic hand power gauge. Sick-leave absence was collected via the Regional Social Insurance Office. Results: After four weeks the intervention group experienced less sickleave, less pain, better function and returned to work earlier than the control group. After 16 weeks the intervention group still had significantly better function and had less sickleave. Their pain decreased but not significantly. No difference in grip strength between the two groups. Conclusion: A structured home training programme can improve function and reduce sick-leave in patients with lateral epicondylitis. Study II: Aim: To translate and cross-culturally adapt the questionnaire “Patient-rated Tennis Elbow Evaluation” into Swedish PRTEE-S; (Patientskattad Utvärdering av Tennisarmbåge), and to evaluate the reliability and validity of the questionnaire. Methods: The Canadian questionnaire, “Patient-rated Tennis Elbow Evaluation” (PRTEE), was cross-culturally adapted for the Swedish language according to well-established guidelines. Fifty-four patients with unilateral epicondylalgia were assessed using the PRTEE-S (Patientskattad Utvärdering av Tennisarmbåge), the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), and the Roles & Maudsley score to establish the validity and reliability of the PRTEE-S. Reliability was determined via calculation of the intra-class correlation coefficient (ICC) the internal consistency was assessed by Cronbach's alpha, and validity was calculated using Spearman's correlation coefficient. Results: The test-retest reliability, using the ICC, was 0.95 and the internal consistency was 0.94. The PRTEE-S correlated well with the DASH (r = 0.88) and the Roles & Maudsley score (r = 0.78). Conclusion: The PRTEE-S represents a reliable and valid instrument to evaluate the subjective outcome in Swedish speaking patients with lateral epicondylalgia, and can be used in both clinical settings and research. 5 Study III: Aim: To describe health care professionals´ treatment choices, their cooperation with other professionals and their perceptions regarding the treatment of acute lateral epicondylalgia. Method: The study had a quantitative descriptive study design with a summative approach to qualitative analysis using content analysis. All Orthopaedic Surgeons, General Practitioners, Physiotherapists and Occupational Therapists in a county were asked to answer a questionnaire with 18 dichotomous, multiple response, multiplechoice questions and three open-ended questions. Results: Participants n=321. The findings of the qualitative analysis dealt with perceptions of interdisciplinary cooperation and treatment which resulted in five categories; Right level of care, Increased quality of care, Decreased quality of care, Side effects and Inadequate treatment. Almost half of the General Practitioners and Orthopedic Surgeons felt potential risks associated with their treatment methods. Advantages from interdisciplinary cooperation were higher rated than disadvantages. Conclusion: Interdisciplinary cooperation in the treatment of patients with acute lateral epicondylalgia benefits the patients by shortening the rehabilitation period and provides health care professionals the opportunity for an improved learning and exchanging experiences. There was a strong will to cooperate and the risks of side effects with corticosteroid injections and NSAID are well-known although they are the most common treatments. Treating the patient at the right level of care could minimize side effects. These basic conditions must be met in order to improve health care quality. Study IV: Aim: To evaluate whether patients with lateral epicondylalgia, two years after they were treated by a structured program, had less pain or function loss and if recurrent episodes and sick-leave days differed compared to a control group. Method: This study had a prospective design with a two year follow-up. The intervention group (n=103) were referred to a physiotherapist and an occupational therapist working together with a structured treatment program. The control group, chosen from the same diagnose code (n=194) were treated with various treatments. The outcome measures were pain, function, rates of recurrences and sick-leave using a questionnaire two years after their visit at the health care center. Result: More than half of the patients experienced some pain and function loss from their elbow. The intervention group had less sick-leave absence at the time for the first visit, less pain and function loss and fewer periods of recurrences and needed less additional therapy if a recurrence occurred. Conclusion: This disease is not always a self-limiting condition and needs treatment. A structured treatment and to teach the patients how to treat themselves if the symptoms re-occur, seems to be an effective way. The patient will not need additional treatment and do not need to be on the sick list. The main findings: With a structured program and by using interdisciplinary cooperation in the treatment of lateral epicondylalgia, the absence from work could decrease, the pain and the function loss was less for the patient, side-effects were minimized and the program could be an outlined and effective way for the health care professionals to treat the patient and to evaluate lateral epicondylalgia both clinical and in science.