Comparison of the Efficacy of Dextrose Prolotherapy in Lateral Elbow Tendinopathy: A Systematic Review and Meta-Analysis of Randomized Controlled trials

Chernkhuan Stonsaovapak; Natthiya Tantisiriwat

Authors

Chernkhuan Stonsaovapak Chulalongkorn hospital
Natthiya Tantisiriwat Chulalongkorn hospital

Keywords:

dextrose prolotherapy, lateral epicondylitis, regenera-tive medicine, tennis elbow, treatment

Abstract

Objectives: To compare the efficacy of dextrose prolotherapy (DPT) and alternative treatments for lateral elbow tendinopathy (LET) patients.

Study design: A systematic review and meta-analysis.

Setting: Not applicable.

Subjects: Patients in all stages of LET.

Methods: The authors searched databases of studies that compared the efficacy of DPT to alternative treatments for LET published in PubMed and Scopus from 1 January 2001 to 20 April 2021. The primary outcomes were the visual analog scale for pain (VAS) at rest and during movement. Secondary outcomes included pain-free grip strength, Quick Disabilities of the Arm, Shoulder and Hands (QuickDASH) scores, and Patient-Rated Tennis Elbow Evaluation (PRTEE) scores. The data, provided as means and standard deviations, were converted to standardized mean differences (SMD) with 95% confidence intervals (CI). The Review Manager 5.3 Software, Risk of Bias 2, and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) were used for data analysis, risk of bias assessment, and quality assessment.

Results: Six randomized controlled trials (RCTs) which met the eligibility criteria were included. In each of those trials, the DPT group had significantly reduced VAS pain scores at rest and during movement at 12 weeks post-treatment compared to the other treatment groups. In terms of function improvement, the DPT group also had significantly greater improvement in QuickDASH scores than the other treatment groups at 12 weeks. However, these positive findings were based on methodologies which had a moderate to high risk of bias and were underpowered.

Conclusions: DPT requires additional high-quality RCTs to deter-mine the benefits to patients with LET. The main reason for the inconclusive results in this study was that most of the reviewed RCTs demonstrated a moderate to high risk of bias.

Keywords: dextrose prolotherapy, lateral epicondylitis, regenera-tive medicine, tennis elbow, treatment

References

Thompson C, Visco C. Lateral epicondylosis: emerging management options. Curr Sports Med Rep. 2015;14:215-20.

Houck DA, Kraeutler MJ, Thornton LB, McCarty EC, Bravman JT. Treatment of lateral epicondylitis with autologous blood, platelet-rich plasma, or corticosteroid injections: a systematic review of overlapping meta-analyses. Orthop J Sports Med. 2019;7. doi:10.1177/2325967119831052.

Xu Q, Chen J, Cheng L. Comparison of platelet rich plasma and corticosteroids in the management of lateral epicondylitis: a meta-analysis of randomized controlled trials. Int J Surg. 2019;67:37-46.

Keijsers R, de Vos RJ, Kuijer PPF, van den Bekerom MP, van der Woude HJ, Eygendaal D. Tennis elbow. Shoulder Elbow. 2019;11:384-92.

Chen J, Wang A, Xu J, Zheng M. In chronic lateral epicondylitis, apoptosis and autophagic cell death occur in the extensor carpi radialis brevis tendon. J Shoulder Elbow Surg. 2010;19:355-62.

Alfredson H, Ljung BO, Thorsen K, Lorentzon R. In vivo investigation of ECRB tendons with microdialysis technique--no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop Scand. 2000;71:475-9.

Claessen FMAP, Heesters BA, Chan JJ, Kachooei AR, Ring D. A meta-analysis of the effect of corticosteroid injection for enthesopathy of the extensor carpi radialis brevis origin. J Hand Surg Am. 2016;41:988-98.e2.

Arirachakaran A, Sukthuayat A, Sisayanarane T, Laoratanavoraphong S, Kanchanatawan W, Kongtharvonskul J. Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis. J Orthop Traumatol. 2016;17:101-12.

Simental-Mendía M, Vilchez-Cavazos F, Álvarez-Villalobos N, Blázquez-Saldaña J, Peña-Martínez V, Villarreal-Villarreal G, et al. Clinical efficacy of platelet-rich plasma in the treatment of lateral epicondylitis: a systematic review and meta-analysis of randomized placebo-controlled clinical trials. Clin Rheumatol. 2020; 39:2255-65.

Yao G, Chen J, Duan Y, Chen X. Efficacy of extracorporeal shock wave therapy for lateral epicondylitis: a systematic review and meta-analysis. Biomed Res Int. 2020 Mar 18;2020:2064781. doi: 10.1155/2020/2064781.

Yan C, Xiong Y, Chen L, Endo Y, Hu L, Liu M, et al. A comparative study of the efficacy of ultrasonics and extracorporeal shock wave in the treatment of tennis elbow: A meta-analysis of randomized controlled trials. J Orthop Surg Res. 2019;14:248. doi:10.1186/s13018-019-1290-y.

Trescot A. Everything old is new again: new developments in prolotherapy. Tech Reg Anesth Pain Manag. 2015;19:14-8.

Chung MW, Hsu CY, Chung WK, Lin YN. Effects of dextrose prolotherapy on tendinopathy, fasciopathy, and ligament injuries, fact or myth? a systematic review and meta-analysis. Medicine (Baltimore). 2020;99(46).e23201. doi: 10.1097/MD.0000000000023201.

Sit RW, Chung VCh, Reeves KD, Rabago D, Chan KK, Chan DC, et al. Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: a systematic review and meta-analysis. Sci Rep. 2016;6:25247. doi:10.1038/srep25247.

Bae G, Kim S, Lee S, Lee WY, Lim Y. Prolotherapy for the patients with chronic musculoskeletal pain: systematic review and meta-analysis. Anesth Pain Med (Seoul). 2021;16:81-95.

Rabago D, Lee KS, Ryan M, Chourasia AO, Sesto ME, Zgierska A, et al. Hypertonic dextrose and morrhuate sodium injections (prolotherapy) for lateral epicondylosis (tennis elbow): results of a single-blind, pilot-level, randomized controlled trial. Am J Phys Med Rehabil. 2013;92:587-96.

Yelland M, Rabago D, Ryan M, Ng SK, Vithanachchi D, Manickaraj N, et al. Prolotherapy injections and physiotherapy used singly and in combination for lateral epicondylalgia: a single-blinded randomised clinical trial. BMC Musculoskelet Disord. 2019;20:509. doi:10.1186/s12891-019-2905-5.

Ahadi T, Esmaeili Jamkarani M, Raissi GR, Mansoori K, Emami Razavi SZ, Sajadi S. Prolotherapy vs radial extracorporeal shock wave therapy in the short-term treatment of lateral epicondylosis: a randomized clinical trial. Pain Med. 2019;20:1745-1749.

Bayat M, Raeissadat SA, Mortazavian Babaki M, Rahimi-Dehgolan S. Is dextrose prolotherapy superior to corticosteroid injection in patients with chronic lateral epicondylitis? a randomized clinical trial. Orthop Res Rev. 2019;11:167-75.

Akcay S, Gurel Kandemir N, Kaya T, Dogan N, Eren M. Dextrose prolotherapy versus normal saline injection for the treatment of lateral epicondylopathy: a randomized controlled trial. J Altern Complement Med. 2020;26:1159-68.

Apaydin H, Bazancir Z, Altay Z. Injection therapy in patients with lateral epicondylalgia: hyaluronic acid or dextrose prolotherapy? a single-blind, randomized clinical trial. J Altern Complement Med. 2020;26:1169-75.

Covidence systematic review software [Internet]. Australia: Veritas Health Innovation; 2014. Covidence systematic review; 2014 [cited 2021 Aug 17]; Available from: www.covidence.org

Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005 Apr 20;5:13. doi: 10.1186/1471-2288-5-13.

Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014 Dec 19;14:135. doi:10.1186/1471-2288-14-135.

Higgins JPT, Li T, Deeks JJ. Chapter 6: Choosing effect measures and computing estimates of effect. Cochrane Handbook for Systematic Reviews of Interventions version 6.2 [Internet]. [place unknown]: Cochrane; 2021 [updated 2021 February; cited 2021 August 19]. Available from: www.training.cochrane.org/handbook

Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019 Aug 28;366:l4898. doi:10.1136/bmj.l4898.

McGuinness, LA, Higgins, JPT. Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments. Res Syn Meth. 2021;12:55-61.

Cochrane Consumers And Communication La Trobe University, Ryan R, Hill S. How to GRADE. La Trobe [Internet]. 2018 [cited 2021 Aug 17]; Available from: https://opal.latrobe.edu.au/articles/How_to_GRADE/6818894

Scarpone M, Rabago DP, Zgierska A, Arbogast G, Snell E. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med. 2008;18:248-54. doi:10.1097/JSM.0b013e 318170fc87.

Carayannopoulos A, Borg-Stein J, Sokolof J, Meleger A, Rosenberg D. Prolotherapy versus corticosteroid injections for the treatment of lateral epicondylosis: a randomized controlled trial. PM R. 2011;3:706-15.

Kachooei AR, Talaei-Khoei M, Faghfouri A, Ring D. Factors associated with operative treatment of enthesopathy of the extensor carpi radialis brevis origin. J Shoulder Elbow Surg. 2016;25:666-70.

Wang CT, Lin J, Chang CJ, Lin YT, Hou SM. Therapeutic effects of hyaluronic acid on osteoarthritis of the knee. a meta-analysis of randomized controlled trials. J Bone Joint Surg Am. 2004;86:538-45.

Fogli M, Giordan N, Mazzoni G. Efficacy and safety of hyaluronic acid (500-730kDa) ultrasound-guided injections on painful tendinopathies: a prospective, open label, clinical study. Muscles Ligaments Tendons J. 2017;7:388-95.