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Progress in Orthopedic Science ISSN: 2146 - 8370
Progress in Orthopedic Science. 2015; 1(1):(1-92)


Conservative treatment of lateral epicondylitis: The impact of psychosocial factors on perceived treatment efficacy

Thomas Isaac Sherman, Kayvon Reza Golshani, Kevin Emmerich, Ling Cai, Weiling Gu, Michael Kessler

Abstract
Background: The relationship of pain, function, and treatment in lateral epicondylitis is not fully understood.  Improved understanding of this interrelationship may be required to optimize treatment strategies, particularly with regard to bracing and activity modification. Methods: A cohort of 36 patients diagnosed by a fellowship-trained hand surgeon over a 25-month period that received treatment in the form of a cock-up wrist splint (CUWS) and recommendations of activity modification was identified. The patients’ function was defined by the QuickDash Outcome measure and pain by the Numeric Pain Rating.  Retrospective analysis of prospectively collected pre-treatment data were compared to those obtained following treatment using Wilcoxon signed-rank test. Changes in QuickDash Outcome measures and Numeric Pain Rating following treatment were compared between those individuals that stated the treatment helped and those that stated it did not. Result: Following treatment with a CUWS and activity modification, the median QuickDash score was 8 compared to 40 prior to treatment (95% CI: -32 ~ -20, p-value < 0.0001) indicating statistically significant functional improvement.  All 36 of 36 (100%) patients stated that they were able to return to a normal activity level at the time of follow-up. Numeric Pain Rating values improved from 6 to 1 following treatment (95% CI: -6  ~ -4, p-value < 0.0001). The Kendall’s Tau-b correlation coefficient between Numeric Pain Ratings and QuickDash Outcome measure was 0.296 (p-value = 0.018) and 0.473 (p-value = 0.001) before and after treatment, respectively, suggesting a weak to moderate correlation. Patients who stated that the treatment was effective experienced a median change in their QuickDash outcome score of -23 compared to -37 for those whom did not think it was an effective treatment; the estimated difference between the two groups was 14 (CI: 2, 30, p-value 0.019) indicating that patients who thought treatment was not effective actually experienced greater functional improvement. Conclusions: These results indicate that use of a CUWS and recommendations of activity modification is an effective strategy to help improve patient function and pain levels. However, low to moderate correlation between pain and disability both before and after treatment indicate that other factors such as coping skills and psychosocial influences may effect the disease and treatment course.  Furthermore, patients may still make gains in function while questioning the effectiveness of their treatment, which may make assessment of therapeutic response difficult.  Future research should be directed at identifying which factors other than pain may influence disability and devising strategies to address them.