Focused shockwave and ultrasound therapies in the treatment of tennis elbow

ISRCTN ISRCTN11907358
DOI https://doi.org/10.1186/ISRCTN11907358
Secondary identifying numbers 2/2019
Submission date
13/07/2020
Registration date
30/07/2020
Last edited
30/10/2024
Recruitment status
No longer recruiting
Overall study status
Completed
Condition category
Musculoskeletal Diseases
Prospectively registered
Protocol
Statistical analysis plan
Results
Individual participant data

Plain English summary of protocol

Background and study aims.
Lateral epicondylitis (tennis elbow) is a condition resulting from overuse and injury to the wrist and fingers following extension movements. Tennis elbow can have a range of symptoms, most commonly: pain in the lateral epicondyle (The bony bump on the outside of the elbow) that increases during extension of the wrist and fingers; tenderness of the lateral epicondyle when touched; and weakening of the wrist and finger muscles.

One form of therapy used to treat lateral epicondylitis involves mechanical waves such as ultrasound directed at the affected tendon. The aim of the trial is to determine the effects of focused shock wave and ultrasound therapies in the treatment of lateral epicondylitis.

Who can participate?
Patients with lateral epicondylitis.

What does the study involve?
Patients will be randomly divided into three equal groups A, B, and C. Group A will receive shock wave therapy once weekly over 3 weeks, group B will receive ultrasound therapy in 10 sessions over 2 weeks, while patients in group C will be treated with a false treatment that appears the same as group B but without the ultrasound. All patients will also be given deep friction massage.

What are the possible benefits and risks of participating?
Possible benefits of participating in the study include reduced pain, increased muscle strength, and an improvement in quality of life. Possible risks of participating in the study include local pain caused by deep friction massage and shock wave therapy.

Where is the study run from?
Academy of Physical Education in Katowice (Poland)

When is the study starting and how long is it expected to run for?
August 2020 to February 2022

Who is funding the study?
Academy of Physical Education in Katowice (Poland)

Who is the main contact?
Piotr Król
p.krol@awf.katowice.pl

Contact information

Dr Piotr Król
Scientific

ul. Mikołowska 72b
Katowice
40-065
Poland

ORCiD logoORCID ID 0000-0001-7673-4375
Phone +48 606 62 89 89
Email p.krol@awf.katowice.pl
Dr Piotr Król
Public

ul. Mikołowska 72b
Katowice
40-065
Poland

ORCiD logoORCID ID 0000-0001-7673-4375
Phone +48 606 62 89 89
Email p.krol@awf.katowice.pl

Study information

Study designSingle-centre interventional double-blinded randomized control trial
Primary study designInterventional
Secondary study designRandomised controlled trial
Study setting(s)Community
Study typeTreatment
Participant information sheet Not available in web format, please use contact details to request a participant information sheet.
Scientific titleThe objective and subjective assessment of the effects of focused shockwave and ultrasound therapies in the treatment of lateral epicondylitis
Study objectives1. Focused shockwave and ultrasound therapies have better effects than placebo ultrasound therapy
2. Focused shockwave therapy has better effects than ultrasound therapy
Ethics approval(s)Approved 17/01/2019, the Research Ethics Committee of the Academy of Physical Education in Katowice (ul. Mikołowska 72, 40-065 Katowice, Poland; +48 322075152; a.smykla@awf.katowice.pl), ref: 2/2019
Health condition(s) or problem(s) studiedTennis elbow
InterventionPatients with lateral epicondylitis will be enrolled in the trial. Patients will be randomly assigned to groups A, B and C, (1:1:1 ratio) in which participants will receive treatment with either focused shockwave therapy, ultrasound therapy, or sham ultrasound therapy, respectively.

Before the trial, the principal investigator will prepare a list with randomly arranged numbers, each denoting the group, which will be delivered to a physiotherapist in charge of treatment procedures. A physician will direct the enrolled patients to the person in charge of measurements and collecting the necessary data and then to the physiotherapist.

In group A, focused shockwave therapy will be delivered using the Richard Wolf Piezowave without local or general anaesthesia. A special cone-like cap focusing shock waves 5 mm from its top will be deployed. The site to be treated will be prepared by applying a special conductive gel before a procedure. Patients will be treated in a sitting position, with the affected arm abducted, the elbow joint flexed at approximately 60 degrees, and the forearm pronated and rested on the therapeutic table. Density energy will be set to 0.2 mJ/mm² and shock wave frequency to 4 Hz. During each procedure, 2,000 pulses will be applied to the most painful point of the lateral epicondylus. Patients will receive a total of three procedures separated by one week-interval, each lasting 8 min 20 sec.

Patients in group B will be treated with ultrasound generated by the Cosmogamma US13 EVO provided with a 5 cm² ultrasound applicator. The site to be treated will be prepared by applying a special conductive gel before a procedure. Patients will be treated in sitting position, with the affected the arm abducted, the elbow joint flexed at approximately 60 degrees, and the forearm pronated and rested on the therapeutic table. Ultrasound frequency will be set to 3 MHz and spatial average temporal peak (SATP) to 0.5 W/cm². The duty cycle will be 20%. During each procedure, the most painful point of the lateral epicondylus will be treated with ultrasound for 5 mins in a semi-stationary manner (the applicator’s movements will be very limited). Patients will receive a total of 10 procedures on weekdays over two consecutive weeks.

The parameters of treatment in Groups A and B will be derived from clinical experience, reasoning, a literature review, and the general principles underlying the application of physical modalities.

Patients in group C will also be treated using the Cosmogamma US13 EVO unit. Their position during treatment and the unit’s settings will also be the same apart. The only difference will be that the applicator will not generate ultrasound. Patients will receive a total of 10 procedures on weekdays over two consecutive weeks.

In all three groups, shockwave and ultrasound therapies will be combined with a deep friction massage. Patients will be massaged while sitting with the arm slightly flexed, the elbow joint bent at approximately 70 degrees, and the forearm in a mid-position between supination and pronation. The massage procedures will last 12 min and will be held every second day during the treatment period (excluding the weekend), so each patient will receive a total of 7 procedures. Each procedure will be carried out 30 mins before shock wave or ultrasound therapies. In performing the massage, the therapist will use the index finger with the middle finger placed on it to increase pressure, making sure that it is strong but tolerable. The frequency of movements will be 2-3 Hz. A transverse friction technique will be used (pressure will be applied when the fingers are moving forward and released on return).
All procedures will be carried out by a long-experienced physiotherapist.
Intervention typeDevice
Pharmaceutical study type(s)
PhaseNot Applicable
Drug / device / biological / vaccine name(s)1. Richard Wolf Piezowave 2. Cosmogamma US13 EVO
Primary outcome measure1. Grip strength in the affected and unaffected upper limbs measured by a SH5001 dynamometer (SAEHAN Corporation) at baseline, 1, 6 and 12 weeks
2. Strength of the wrist extensors in the affected and unaffected upper limbs measured by a SH5001 dynamometer (SAEHAN Corporation) at baseline, 1, 6 and 12 weeks
3. Strength of the wrist flexors in the affected and unaffected upper limbs measured by a SH5001 dynamometer (SAEHAN Corporation) at baseline, 1, 6 and 12 weeks
4. Pain intensity during physical activity measured on the Visual Analog Scale 0-10 (VAS) at baseline, 1, 6 and 12 weeks
5. Pain intensity at rest measured on the Visual Analog Scale 0-10 (VAS) at baseline, 1, 6 and 12 weeks
6. Pain intensity at night measured on the Visual Analog Scale 0-10 (VAS) at baseline, 1, 6 and 12 weeks
Secondary outcome measures1. Quantitative pain assessment performed with the modified Laitinen’s questionnaire at baseline, 1, 6 and 12 weeks
Quantitative pain assessment will be performed pre-treatment and at weeks 1, 6, and 12 post-treatment.
2. Pain intensity and difficulty in performing daily activities measured using the Patient-Rated Tennis Elbow Evaluation (PRTEE) at baseline, 1, 6 and 12 weeks
3. The extent of disability of the affected upper limb measured using the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) at baseline, 1, 6 and 12 weeks
4. Treatment outcomes assessed based on the Roles and Maudsley score (RMS) at 1, 6, and 12 weeks
Overall study start date15/10/2018
Completion date04/02/2022

Eligibility

Participant type(s)Patient
Age groupAdult
Lower age limit18 Years
SexBoth
Target number of participants60 (20 in each group)
Total final enrolment60
Key inclusion criteria1. Pain in the lateral epicondyle persisting for ≥3 months
2. Pain on palpation in the lateral epicondyle
3. A positive Thompson’s test (the patient reports pain when performing resisted extension of a slightly extended wrist, with the fingers clenched into a fist, the elbow extended, and the forearm in a pronated position)
4. A positive Mill’s test (the patient reports pain when performing resisted supination of the forearm with the elbow joint slightly flexed, the forearm in a pronated position, the wrist slightly extended, and the fingers clenched into a fist)
5. Pain during resisted extension of the middle finger
6. Aged 18 to 65 years
Key exclusion criteria1. Local infection
2. Pregnancy
3. Malignancy
4. Bilateral tennis elbow
5. Carpal tunnel syndrome
6. Medial epicondylitis
7. Elbow arthritis or instability
8. Generalized polyarthritis
9. Ipsilateral shoulder dysfunction
10. Neurological abnormalities
11. Radial-nerve entrapment
12. Cardiac arrhythmia or a pacemaker
13. Diabetes
14. Physical therapy and/or a corticosteroid injection administered within the previous six weeks
Date of first enrolment03/08/2020
Date of final enrolment22/10/2021

Locations

Countries of recruitment

  • Poland

Study participating centre

OSTEOMED - Centrum Osteopatii i Fizjoterapii (Osteopathy and Physiotherapy Centre)
ul. Południowa 18
Żywiec
34-300
Poland

Sponsor information

Academy of Physical Education in Katowice
University/education

ul. Mikołowska 72A
Katowice
40-065
Poland

Phone +48 32 207 51 10
Email rektorat@awf.katowice.pl
Website https://www.awf.katowice.pl/

Funders

Funder type

University/education

Academy of Physical Education in Katowice

No information available

Results and Publications

Intention to publish date01/10/2022
Individual participant data (IPD) Intention to shareNo
IPD sharing plan summaryNot expected to be made available
Publication and dissemination planPhD dissertation
IPD sharing planThe datasets generated during and/or analysed during the current study are not expected to be made available due to ethics restriction on sharing data.

Study outputs

Output type Details Date created Date added Peer reviewed? Patient-facing?
Protocol (other) protocol (not peer reviewed) 17/08/2021 No No
Basic results 03/11/2023 No No
Results article 30/10/2024 30/10/2024 Yes No

Additional files

ISRCTN11907358 BasicResults.pdf

Editorial Notes

30/10/2024: Publication reference and total final enrolment added.
03/11/2023: The basic results have been uploaded as an additional file.
17/08/2021: The protocol (not peer reviewed) has been added.
17/08/2021: The following changes have been made:
1. The recruitment end date has been changed from 27/08/2021 to 22/10/2021.
2. The overall trial end date has been changed from 10/12/2021 to 04/02/2022 and the plain English summary has been updated to reflect this change.
10/06/2021: The following changes have been made:
1. The recruitment end date has been changed from 18/06/2021 to 27/08/2021.
2. The overall trial end date has been changed from 01/10/2021 to 10/12/2021 and the plain English summary has been updated to reflect this change.
17/07/2020: Trial’s existence confirmed by the Research Ethics Committee of the Academy of Physical Education in Katowice.