Plain language summary
Non-steroidal anti-inflammatory drugs (NSAIDs) for treating tennis elbow pain in adults
This summary of a Cochrane review presents what we know from research about the effects of non-steroidal anti-inflammatory drugs (NSAIDs) on lateral elbow pain, also known as tennis elbow. The review, which included 13 trials involving 664 participants, shows the following:
In people with lateral elbow pain:
- Topical NSAIDs (applied to the skin in a gel) may improve treatment success.
- We are uncertain whether topical NSAIDs improve pain because of the low quality of the evidence.
- NSAIDs applied to the skin may result in a skin rash.
- We are uncertain whether NSAIDs taken orally in tablet form improve pain or function because of the low quality of the evidence.
- NSAIDs in tablet form probably result in increased stomach pain and diarrhoea, but we are not certain of the precise estimates because of the low quality of the evidence.
Function and quality of life were not reported.
We do not have precise information about side effects and complications, particularly for rare but serious side effects. NSAIDs may cause stomach, kidney or heart problems, and NSAIDs applied to the skin may cause rash.
What is lateral elbow pain and what are NSAIDs?
Lateral elbow pain, or tennis elbow, can occur for no reason or can be caused by too much stress on the tendon at the elbow. This condition can cause the outside of the elbow (lateral epicondyle) and the upper forearm to become painful and tender to touch. Pain can last for 6 months to 2 years, and may get better on its own. Many treatments have been used to treat elbow pain, but it is not clear whether these treatments work, or if the pain simply goes away on its own.
Non-steroidal anti-inflammatory drugs (NSAIDs) (e.g. ibuprofen, diclofenac, celecoxib) can be used to manage the pain. NSAIDs can be applied directly to the skin in the form of a gel, or can be taken in tablet form.
Best estimate of what happens to people with lateral elbow pain who use NSAIDs
Pain (higher scores mean worse or more severe pain):
- People who used NSAID gel compared with a placebo gel rated their pain 1.6 points lower on a scale of 0 to 10 after 4 weeks (16% absolute improvement).
- People who applied NSAID gel rated their pain to be 2.14 on a scale of 0 to 10 after 4 weeks.
- People who applied placebo gel rated their pain to be 3.78 on a scale of 0 to 10.
- 24 more people out of 100 reported improvement in their condition with topical NSAIDs (24% absolute improvement).
- 73 out of 100 people who applied NSAID gel improved.
- 49 out of 100 people who applied placebo gel improved.
- 1 more person using NSAID gel out of 100 had minor side effects such as skin rash at the site of application (0% absolute difference, ranging from 5% fewer to 6% more).
- 2 out of 100 using NSAID gel had side effects,
- 1 out of 100 people using placebo gel had side effects.
டென்னிஸ் முழங்கை (TENNIS ELBOW) வலிக்கு ஊக்கி அல்லா அழற்சி மருந்துகளின் (NSAIDS) சிகிச்சை
இந்த காக்ரைன் திறனாய்வின் மூலம் நாங்கள் ஆராய்ச்சிகளில் இருந்து முழங்கையின் வெளிநோக்கி பகுதியில் வலி (lateral elbow pain) அல்லது (tennis elbow) டென்னிஸ் எல்போ என்று அழைக்கப்படும் வலிக்கு ஊக்கி அல்லா அழற்சி மருந்துகள் (NSAIDs) ஏற்படுத்தும் விளைவுகளை பற்றி அறிந்தவற்றை கூறுகிறோம். 664 பங்கேற்பாளர்கள் மீது நடத்தப்பட்ட 13 சோதனைகளின் விளைவுகளை இந்த திறனாய்வு பின்வருமாறு வெளிப்படுத்துகிறது:
முழங்கையின் வெளிநோக்கி பகுதி வலி உள்ள மக்கள்:
-புற மருந்துப் பூச்சு NSAIDsகளின் (தோல் மீது பூசப்படும் களிம்பு) சிகிச்சையின் பலனை அதிகரிக்க கூடும்.
NSAID வலியை குறைக்கிறது என்பது எங்களால் நிச்சயமாக கூற இயலாது, ஏனெனில் அவை குறைந்த தரமுடைய ஆதாரங்களிலிருந்து பெறப்பட்டது.
NSAIDs தோல் மீது பூசப்படுவதால் தோலில் தடிப்பு ஏற்ப்படலாம்.
-மாத்திரை வடிவில் எடுத்துக்கொளும் NSAID வலியை குறைத்து அல்லது செயல்திறனை அதிகப்படுத்துகிறது என்பது நிச்சயமற்றது, ஏனெனில் அவை குறைந்த தரமுடைய ஆதாரங்களிலிருந்து பெறப்பட்டவை.
மாத்திரை வடிவில் எடுத்துக்கொள்ளப்படும் NSAIDsகள் வயிற்றுவலியையும், வயிற்றுபோக்கையும் ஏற்படுத்தலாம், ஆனால் இவற்றை நாங்கள் துல்லியமாக மதிப்பிட முடியவில்லை, ஏனெனில் அவை குறைந்த தரமுடைய ஆதாரங்களிலிருந்து அறியப்பட்டவை.
வாழ்க்கை தரம் மற்றும் செயல்பாடுகள் பற்றிய தகவல் இல்லை.
எங்களிடம் பக்கவிளைவுகள் மற்ற சிக்கல்கள், குறிப்பாக அரிதான ஆனால் தீவிர பக்கவிளைவுகள் பற்றிய துல்லியமான தகவல் எதுவும் இல்லை. NSAIDs சிறுநீரகம் மற்றும் இருதயத்தில் பிரச்சனைகளை ஏற்படுத்தலாம், மற்றும் தோல் மீது பூசப்படும் NSAIDsகள் தோலில்தடிப்புகளை ஏற்படுத்தலாம்.
முழங்கை வெளிநோக்கி பகுதி வலி என்றால் என்ன மற்றும் NSAIDsகள் என்றால் என்ன?
முழங்கை வெளிநோக்கி பகுதி வலி அல்லது டென்னிஸ் எல்போ எந்த ஒரு காரணமும் இல்லாமல் ஏற்படலாம் அல்லது முழங்கையின் தசைநாரில் ஏற்படும் அதிக அழுத்தத்தினாலும் ஏற்படலாம். இந்த நோய் (முழங்கையின் வெளிநோக்கி முண்டுமேவி epicondyle) மற்றும் மேல் முன்கை பகுதி வலி மற்றும் தொடுவதற்கு மென்மையாகவும் இருக்காலாம். வலி ஆறு மாதத்திலிருந்து இரண்டு வருடத்திற்கு நீடிக்கலாம் மற்றும் அது தானாக குறையலாம். பல சிகிச்சை முறைகள் முழங்கை வலியை குணப்படுத்த அளிக்கபடுகிறது ஆனால் வலி தானாகவே சரியாகிறதா அல்லது இந்த சிகிச்சையின் முலமா என்பது தெளிவாக தெரியவில்ல.
ஊக்கி அல்லா அழற்சி மருந்துகள் (NSAIDs) (உதாரணமாக ஐபுப்ரோபென், டைகுலோபிநெக், செலோகாசிப்) வலியை குறைக்க பயன்படுத்தப்படலாம். NSAIDs களிம்பாக தோல் மீது மேற்பூச்சாகவும் அல்லது வாய்வழியாக மாத்திரை வடிவிலும் எடுத்துக் கொள்ள முடியும்.
NSAIDகள் பயன்படுத்தும் மக்களின் முழங்கையின் வெளிநோக்கி பகுதி வலியில் என்ன நடக்கும் என்பதற்கான சிறந்த மதிப்பீடு
வலி (அதிக மதிப்பீடு என்பது மோசமான அல்லது மேலும் கடுமையான வலியாகும்).நான்கு வாரங்கள் ஊக்கி அல்லா அழற்சி மருந்துகளை களிம்பாக பயன்படுத்த்திய மக்கள் மருந்தற்ற குளிகையுடன் பயன்படுத்த்தியோர்ரை ஒப்பிடும்போது அவர்களின் வலி பற்றிய 0 முதல் 10 வரையிலான மதிப்பீட்டு அளவில் 1.6 புள்ளிகள் அளவு குறைந்து இருந்தது. (16 சதவீதம் திட்டவட்டமான முன்னேற்றம்).
NSAIDயை களிம்பாக பயன்படுத்தும் மக்களின் வலி நான்கு வாரங்களுக்கு பின் 0 முதல் 10 வரையிலான அளவு கோலில் 2.14 என்று மதிப்பிட்டனர்.
மருந்தற்ற குளிகை களிம்பை உபயோகித்த மக்கள் 0 முதல் 10 வரையிலான வலி அளவில்கோளில் 3.78 என்று மதிப்பிட்டனர்.
-மேலும் 24 பேர் NSAIDளை மேற்ப்பூச்சாக பயன்படுத்தியவர்கள் தங்கள் நிலையில் முன்னேற்றம் பெற்றனர். (24 சதவீதம் முழுமையான முன்னேற்றம்)
NSAIDளை களிம்பாக பயன்படுத்தும் மக்களில் 100 ல் 73 பேருக்கு முன்னேற்றம் தெரிந்தது.
வெற்று சிகிச்சை முறையை பயன்படுத்தியதில் 100ல் 49 பேருக்கு முன்னேற்றம் தெரிந்தது.
-NSAID, களிம்பு பயன்படுத்திய 100 பேரில், ஒருவருக்கு கூடுதலாக களிம்பு தடவிய இடத்தில் தோல் தடிப்பு போன்ற சிறிய பக்க விளைவுகள் ஏற்பட்டது.
NSAID களிம்பை பயன்படுத்திய 100ல் 2 பேர்க்கு பக்க விளைவுகள் ஏற்பட்டது,
வெற்று சிகிச்சை களிம்பு பயன்படுத்திய நூற்றில் ஒருவருக்கு பக்கவிளைவுகள் ஏற்பட்டது.
மொழி பெயர்ப்பு: அம்பிகை அருணகிரி மற்றும் சி.இ.பி.என்.அர் குழு
Nesteroidni protuupalni lijekovi (NSAID) u liječenju teniskog lakta kod odraslih
Ovaj Cochrane sustavni pregled analizirao je rezultate svih dosad provedenih kliničkih studija o učincima nesteroidnih protuupalnih lijekova (NSAID) u liječenju postranične (lateralne) boli u laktu, koja se još naziva „teniski lakat“. Ovaj pregled, koji je uključivao 13 istraživanja te 664 sudionika, pokazao je sljedeće:
Kod pacijenata s lateralnom lakatnom boli:
- Lokalni NSAID-i (primijenjeni na kožu u obliku gela) mogu poboljšati uspjeh liječenja.
- Zbog loše kvalitete podataka još uvijek se ne zna je li lokalni NSAID-i umanjuju i bol.
- NSAID-i primijenjeni na kožu mogu uzrokovati kožni osip.
- Zbog loše kvalitete podataka još uvijek se ne zna je li NSAID-i uzeti na usta u obliku tableta umanjuju bol ili poboljšavaju funkciju.
- NSAID-i u obliku tableta vjerojatno uzrokuju bolove u trbuhu i proljev, ali točne procjene navedenog se još uvijek ne znaju zbog loše kvalitete dokaza.
Funkcija i kvaliteta života nisu zabilježene.
Precizne informacije o neželjenim štetnim učincima i komplikacijama nisu prikazane u pronađenim ispitivanjima, posebno za rijetke, ali ozbiljne nuspojave. NSAID-i mogu uzrokovati bol u trbuhu, bubrežne i srčane probleme, a oni koji se stavljaju na kožu i osip.
Što je lateralna lakatna bol i što su NSAID-i?
Lateralna lakatna bol, ili teniski lakat, je stanje koje se može pojaviti spontano - bez jasnog razloga ili može biti uzrokovano prevelikom količinom stresa koji djeluje na području tetive lakta. To stanje može dovesti do pojave bolnosti i osjetljivosti na dodir u području izvan lakta (lateralni epikondil nadlaktične kosti) te u gornjem dijelu podlaktice. Bol može trajati od 6 mjeseci do 2 godine pa nije sasvim jasno je li liječenje uistinu djeluje ili bol sama prolazi.
Nesteroidni protuupalni lijekovi (NSAID-i) (lijekovi kao što su ibuprofen, diklofenak, celekoksib) mogu se koristiti u liječenju boli. Mogu se primijeniti izravno na kožu u obliku gela ili uzeti na usta u obliku tableta.
Najbolja procjena onoga što se događa ljudima s lateralnom lakatnom boli koji su uzimali NSAID-e
Bol (viši rezultat predstavlja veću ili ozbiljniju bol):
- Ljudi koji su uzimali NSAID u obliku gela u usporedbi s onim koji su primijenili placebo (određena tvar bez pravog učinka) također u obliku gela ocijenili su svoju bol za 1,6 bodova niže na ljestvici od 0 do 10 nakon 4 tjedna (16%-tno apsolutno poboljšanje).
- Ljudi koji su primijenili NSAID gel ocijenili su svoju bol s 2,14 na ljestvici od 0 do 10 nakon 4 tjedna.
- Ljudi koji su primijenili placebo gel su ocijenili svoju bol s 3,78 na ljestvici od 0 do 10.
- 24 od 100 ljudi su prijavili poboljšanje njihovog stanja s primjenom lokalnih NSAID-a (24%-tno apsolutno poboljšanje).
- 73 od 100 ljudi koji su primijenili NSAID-e bilježe određeni napredak.
- 49 od 100 ljudi koji su primijenili placebo u obliku gela bilježe određeni napredak.
- 1 osoba od njih 100 koji su uzimali NSAID gel je imala blaži neželjeni učinak kao što je kožni osip na mjestu primjene lijeka (0% apsolutne razlike, u rasponu od 5% manje do 6% više osoba s takvom nuspojavom).
- 2 od 100 osoba koji su uzimali NSAID-e je prijavilo neželjene učinke.
- 1 od 100 onih koji su uzimali placebo je prijavilo neželjene učinke.
Prevele: Matea Dragun i Antea Grubišić
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: email@example.com
This Cochrane review is one of a series of Cochrane reviews of interventions for lateral elbow pain in adults and is an update of a Cochrane review first published in 2002 (Green 2002).
Description of the condition
Lateral elbow pain is described by many analogous terms in the literature, including tennis elbow, lateral epicondylitis, lateral epicondylalgia, rowing elbow, tendonitis of the common extensor origin, and peritendonitis of the elbow. For the purposes of this review, the term lateral elbow pain will be used as it best describes the site of the pain, and will allow for greater clarity of inclusion.
Lateral elbow pain is a common disorder with a prevalence of 1% to 3% in adults of working age (Allander 1974; Roquelaure 2006; Shiri 2006; Walker-Bone 2004). It affects up to 15% of workers in at-risk industries and is a common sports injury ( Hume 2006; Ranney 1995; Walker-Bone 2004). It has a reported incidence of between 4.8% and 5.3% in Dutch general practice, with an incidence of 11 per 1000 person-years in the 40 to 60-year age group－the age group most affected (Bot 2005). Shiri 2006 reported no gender difference in the prevalence of lateral elbow pain, although a slight excess of men (Walker-Bone 2004) or women (Roquelaure 2006) has been reported.
The acute pain of lateral elbow pain usually lasts 6 to 12 weeks and often results in work absence (Mallen 2009). For most it is a self-limiting condition, but for some episodes may persist for up to 2 years. One study found that 80% of participants with elbow pain already greater than 4 weeks' duration recovered after one year without any specific treatment (Bisset 2005). Prognostic factors at least moderately associated with a poorer outcome at one year include previous occurrence, high physical strain at work, manual jobs, high baseline levels of pain and/or distress, and inadequate social support. Depression and ineffective coping skills have also been found to strongly predict disability from lateral elbow pain (Alizadehkhaiyat 2007). A recent ultrasound study determined that a lateral collateral ligament tear or large (≥ 6 mm) intrasubstance tears were associated with a poorer outcome, but no relationship between tendon thickness or neovascularity and outcome was seen (Clarke 2010). Fewer than 10% of patients with lateral elbow pain need to undergo surgery (Nirschl 1979).
Description of the intervention
Non-steroidal anti-inflammatory drugs (NSAIDs) have long been the first line of treatment, along with simple analgesics, for all sites of tendonitis, including that of the lateral elbow. Several types of oral and topical NSAIDs are available over-the-counter or on prescription. These drugs are among the most frequently prescribed in the developed world. They are also well known to be associated with significant morbidity, particularly in terms of gastrointestinal and cardiovascular adverse effects (Biskupiak 2006; Garcia 2001; Kearney 2006).
How the intervention might work
NSAIDs work by preventing an enzyme called cyclooxygenase (COX) from making prostaglandins. Prostaglandins are hormone-like chemicals in the body that contribute to inflammation, pain and fever. By reducing production of prostaglandins, NSAIDs help relieve symptoms related to fever, inflammation and mild to moderate pain.
Two COX enzymes－COX-1 and COX-2－produce prostaglandins. However, only COX-1 produces prostaglandins that support platelets and protect the stomach lining. It also helps to maintain kidney function. COX-2 is produced when joints are injured or inflamed.
Most NSAIDs are nonselective inhibitors. This means that they inhibit both COX-1 and COX-2. Because nonselective NSAIDs also act on COX-1, they may decrease protective stomach prostaglandin levels, leading to stomach ulcers. A newer class of NSAIDs－the coxibs－selectively inhibit COX-2 and therefore have less adverse effect on the stomach.
Why it is important to do this review
NSAIDs are often used to treat lateral elbow pain. In our previous review, we concluded that there was some support for the use of topical NSAIDs to relieve lateral elbow pain in the short term but insufficient evidence to recommend or discourage the use of oral NSAIDs (Green 2002). No data have directly compared topical with oral NSAIDs, and some data suggest that glucocorticoid injection may be more effective than oral NSAIDs in the short term. It is important to perform an update of this review to determine whether new data are available that may alter our conclusions.
Summary of main results
Based upon data from fifteen trials, involving 759 trial participants, limited evidence was obtained from which firm conclusions could be drawn about the benefits or harms of topical or oral NSAIDs, and the following summary of results needs to be interpreted cautiously. Only two studies included in this review followed participants for longer than one month; consequently conclusions refer to short-term outcomes only. In addition none of the included studies reported the primary efficacy outcome of this review－patient-reported pain relief ≥ 30%－and the secondary efficacy outcomes were variably reported.
Eight of the included trials studied the effects of topical NSAIDs (301 participants). We found very low-quality evidence (from three trials with 153 participants) that topical NSAIDs may provide a small but significant benefit with respect to pain in the short term. In a pooled analysis of data from three of five placebo-controlled trials, topical NSAIDs provided an additional 1½ points out of 10 improvement in pain at the end of the trial period (10 days to 4 weeks) compared with placebo, with an NNTB of 7 (95% CI 3 to 21), although this finding was not robust to the potential impact introduced by the inclusion of skewed data from two of the three trials. Nevertheless one of these trials also found that topical NSAIDs were 1½ times more likely to result in treatment success in comparison with placebo (NNTB 4, 95% CI 2 to 25) (Summary of findings for the main comparison), and both trials that could not be included in the meta-analysis also reported positive results.
Although the tolerability of topical NSAIDs was generally excellent, with no withdrawals due to adverse effects and no differences in numbers of adverse events compared with placebo, mild transient skin rash occurred in 3/204 (1.5%) participants who received topical NSAIDs and in one participant (0.5%) who received topical placebo.
One trial that compared topical NSAIDs and manipulative therapy with manipulative therapy alone failed to demonstrate any between-group differences in benefit, and an additional trial that compared iontophoresis of topical sodium diclofenac or salicylate reported that the diclofenac preparation provided better reduction of pain on pressure but no other between-group differences in outcome. One trial that compared topical NSAIDs with application of leeches reported better overall pain scores at 7 days but not at 45 days in the leech group and better function at 45 days but not at 7 days. Local skin reactions occurred less frequently with topical NSAIDs (5% of cases vs 50% in the leech group).
Six of the included trials studied the effects of oral NSAIDs (382 participants). Very low- to low-quality evidence from two trials was conflicting with respect to the benefit of oral NSAIDs (Summary of findings 2). Only one of the two trials demonstrated that oral NSAIDs provided a small but statistically significantly greater improvement in pain compared with placebo, and the other trial reported no between-group differences in terms of pain, treatment success or time off paid employment. Neither trial demonstrated benefit in terms of function or maximum pain-free grip strength.
Very low-quality evidence from three trials that compared oral NSAIDs with glucocorticoid injection revealed conflicting results (Summary of findings 3). Based upon two trials (126 participants) for which data could be pooled, no difference between treatments was noted with respect to treatment success in the short term (2 to 4 weeks). However one of these trials－the only one that blinded participants to treatment allocation but was underpowered－reported no between-group differences across a range of outcomes at 2 weeks, and the other trial, which did not blind participants and therefore could have overestimated any treatment benefit, reported significant differences favouring glucocorticoid injection over a range of outcomes at 4 weeks, favouring oral NSAIDs at 6 months and showing generally similar results by 12 months. A third trial that incompletely reported results described mixed results, with between-group differences favouring glucocorticoid injection for pain with resisted wrist extension and grip strength, but no mean improvement in pain at rest at 3 weeks; however, it is unclear whether these findings were significant because no variance measures were reported.
Use of oral NSAIDs was associated with increased risk of gastrointestinal side effects compared with placebo in one trial in the review. Another trial reported discontinuation of treatment in four participants taking NSAIDs due to gastrointestinal side effects and in another participant who developed an allergic reaction in response to oral NSAIDs.
Two trials that compared two different NSAIDs (naproxen and diflunisal) (62 participants) demonstrated no significant between-group differences with respect to benefit or numbers of adverse effects. Adverse effects in those who received diflunisal included nausea (n = 2), vomiting (n = 1), nausea and stomach cramps (n = 1) and burning during urination (n = 1); one participant who received naproxen developed drowsiness.
Overall completeness and applicability of evidence
Lateral elbow pain is a self-limiting but painful condition, and adequate pain relief is a high priority for people with the condition. Topical and oral NSAIDs continue to be commonly used to treat this condition, but the overall balance of benefits and harms associated with topical and oral NSAIDs remains a key issue.
Although most of the studies included in this review were performed between 1979 and 1999, and additional trials were published in 2005 and 2011, it is likely that results remain applicable to people with lateral elbow pain in the current era. Trial participants appeared typical of patients seen in routine care. Of note, we were unable to identify any published trials directly comparing topical with oral NSAIDs.
Outcomes reported in the trials varied widely, as did their method of measurement, and many trials inadequately reported important outcomes. For example, although seven trials have compared topical NSAIDs with placebo, we were able to draw conclusions about reduced pain and increased risk of adverse events based upon only three trials and treatment success based upon only one trial. In addition, none of the trials included a dichotomous measure of pain, as recommended by IMMPACT (Dworkin 2008). It is therefore likely that further trials will change these treatment effect estimates. None of the trials included a measure of quality of life, and less than half included a measure of function; therefore we were unable to draw any conclusions regarding these outcomes.
Quality of the evidence
Most of the thirteen trials included in this review were small (ten trials included 40 or fewer participants) and risk of bias was generally high, with only two trials adequately blinding trial participants. Methodological and reporting issues limited our ability to combine data.
At best, very low-quality evidence indicates benefit (in terms of pain relief and treatment success) of topical NSAIDs, and some patients may expect a transient mild rash with therapy. Evidence of the benefits of oral NSAIDs compared with both placebo and glucocorticoid injection was conflicting, and some patients may expect gastrointestinal and other side effects with oral NSAIDs.
Because of concerns about the potential risk of bias of all included trials and the risk of Type II error in many trials, further high-quality randomised controlled trials are needed to establish the true effects of both topical and oral NSAIDs for lateral elbow pain and their comparative effectiveness.
Potential biases in the review process
Upon completion of a thorough search of all major databases with no language restrictions, we believe that all relevant studies were identified. Two review authors assessed the trials for inclusion in the review and the risk of bias, and a third review author adjudicated whether there was any discrepancy. The biggest limitation of the review process was that many trials did not provide enough published data, or did not provide data in a form that could be extracted for meta-analysis.
Agreements and disagreements with other studies or reviews
Results of this updated review are in general agreement with those of our original review (Green 2002), although we excluded three trials erroneously included in the previous review and included an additional two trials. Our results are also in keeping with those of Boisaubert 2004－a review that found no additional trials on this topic.
This update was partially supported by a fellowship granted to the first author by the SEA-ORCHID Project (www.seaorchid.org), funded by the Wellcome Trust (UK) and the Australian National Health and Medical Research Council (NHMRC). RB is partially supported by an Australian NHMRC Practitioner Fellowship.
Drs Les Barnsley, Stephen Hall, Nynke Smidt, and Willem Assendelft as well as Millicent White, were authors of the original review.
Appendix 1. MEDLINE search strategy
1. exp Tendinopathy/
2. exp Tendon Injuries/
3. (Tendinitis or Tendinosis or Tendonitis).tw.
5. Elbow Joint/
7. 5 or 6
8. exp Pain/
10. 8 or 9
11. 7 and (4 or 10)
12. Tennis Elbow/
13. tennis elbow.tw.
14. common extensor origin.tw.
15. (epicondylalgia or epicondylitis).tw.
17. randomized controlled trial.pt.
18. controlled clinical trial.pt.
21. drug therapy.fs.
26. (animals not (humans and animals)).sh.
27. 25 not 26
28. 16 and 27
Appendix 2. EMBASE search strategy
1. exp Tendinitis/
2. exp Tendon Injury/
3. (Tendinitis or Tendinosis or Tendonitis).tw.
7. 5 or 6
8. exp pain/
10. 8 or 9
11. 7 and (4 or 10)
12. tennis elbow/
13. tennis elbow.tw.
14. common extensor origin.tw.
15. (epicondylalgia or epicondylitis).tw.
17. (random$ or placebo$).ti,ab.
18. ((single$ or double$ or triple$ or treble$) and (blind$ or mask$)).ti,ab.
19. controlled clinical trial$.ti,ab.
20. RETRACTED ARTICLE/
22. (animal$ not human$).sh,hw.
23. 21 not 22
24. 16 and 23
Appendix 3. CENTRAL search strategy
#1 MeSH descriptor Tendinopathy explode all trees
#2 MeSH descriptor Tendon Injuries explode all trees
#3 (Tendinitis or Tendinosis or Tendonitis):ti,ab
#4 (#1 OR #2 OR #3)
#5 MeSH descriptor Elbow Joint, this term only
#7 (#5 OR #6)
#8 MeSH descriptor Pain explode all trees
#10 (#8 OR #9)
#11 (#7 AND ( #4 OR #10 ))
#12 MeSH descriptor Tennis Elbow, this term only
#13 "tennis elbow":ti,ab
#15 "common extensor origin":ti,ab
#17 (#11 OR #12 OR #13 OR #14 OR #15 OR #16)
Appendix 4. CINAHL search strategy
S1 (MH "Tendinopathy+")
S2 (MH "Tendon Injuries+")
S3 TI Tendinitis OR AB Tendinitis
S4 TI Tendinosis OR AB Tendinosis
S5 TI Tendonitis OR AB Tendonitis
S6 S1 or S2 or S3 or S4 or S5
S7 (MH "Elbow Joint")
S8 TI elbow* OR AB elbow*
S9 S7 or S8
S10 (MH "Pain+")
S11 TI Pain* OR AB Pain*
S12 S10 or S11
S13 S9 and (S6 OR S12)
S14 (MH "Tennis Elbow")
S15 TI tennis elbow OR AB tennis elbow
S16 TI epicondylitis OR AB epicondylitis
S17 TI common extensor origin OR AB common extensor origin
S18 TI epicondylalgia OR AB epicondylalgia
S19 S13 or S14 or S15 or S16 or S17 or S18
S20 (MH "Clinical Trials+")
S21 PT clinical trial
S22 TI clinical* trial* or AB clinical* trial* Search modes - Boolean/Phrase
S23 TI singl* blind* or TI singl* mask* or TI doub* blind* or TI doubl* mask* or TI trebl* blind* or TI trebl* mask* or TI tripl* blind* or TI tripl* mask* Search modes - Boolean/Phrase S24 AB singl* blind* or AB singl* mask* or AB doub* blind* or AB doubl* mask* or AB trebl* blind* or AB trebl* mask* or AB tripl* blind* or AB tripl* mask*
S25 TI Randomi?ed control* trial* or AB Randomi?ed control* trial*
S26 (MH "Random Assignment")
S27 TI Placebo* or AB Placebo*
S28 (MH "Placebos")
S29 (MH "Quantitative Studies")
S30 TI Allocat* random* or AB Allocat* random*
S31 S20 or S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29 or S30
S32 S19 and S31
Appendix 5. ISI Web of Science search strategy
#1 TS=(tennis elbow or tendinitis or tendonitis tendinosis or (elbow* and pain*) or epicondylitis or common extensor origin or epicondylalgia)
#2 TS=(trial* or random* or placebo* or control* or double or treble or triple or blind* or mask* or allocat* or prospective* or volunteer*or comparative or evaluation or follow-up or followup)
#3 #1 AND #2
Contributions of authors
All authors were responsible for all components of the review, including selection of trials for the update of the review, appraisal of the risk of bias of included trials, extraction and analysis of data, interpretation of the results and writing of the manuscript.
Differences between protocol and review
In the original review we limited inclusion of trials to those with study participants who had lateral elbow pain of greater than 3 weeks' duration but removed this criterion in the updated review, as NSAIDs are most commonly used for acute symptoms.
We updated the outcomes that were considered in this review according to the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), which has published consensus recommendations for determining clinically important changes in outcome measures in clinical trials of interventions for chronic pain (Dworkin 2008).
We excluded three trials that were included in the original review (Förster 1997; Percy 1981; Primbs 1983). Förster 1997 was excluded because the published paper was a subgroup analysis of an unpublished RCT. Only data for 48/116 participants who had acute epicondylitis (< 48 hours) due to squash, tennis, golf or other sporting activities were presented, and data were not presented separately for lateral elbow pain. Percy 1981 was excluded because it was not clear what proportion of participants labelled as having tennis elbow had lateral versus medial epicondylitis. Primbs 1983 was excluded because it clearly was not an RCT, as described in the translated report.
Changes to the risk of bias table and sensitivity analysis sections in this updated review reflect advances in systematic review methodology.
In the original review we performed a sensitivity analysis excluding trials published in languages other than English. We did not perform this sensitivity analysis in this update because of reduced concerns about publication and outcome assessment bias in non-English studies.
We corrected some errors in the previous analyses. For example, in the original review, Burton 1988 was listed under topical NSAIDs versus placebo, but review of the article clearly revealed that the trial compared topical NSAIDs with no topical treatment, although both groups also received manipulative therapy.