Table.
GRADE evaluation of interventions for tennis elbow
| Important outcomes | Pain relief, global improvement, functional improvement, quality of life, adverse effects. | ||||||||
| Number of studies (participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of treatments for tennis elbow? | |||||||||
| 2 (at least 49) | Pain relief | Corticosteroid injection v placebo or no treatment | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for narrowness of population in one study |
| 3 (at least 98) | Global improvement | Corticosteroid injection v placebo or no treatment | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data, poor methodologies, and incomplete reporting of results. Directness point deducted for outcome not fully defined |
| 3 (at least 108) | Functional improvement | Corticosteroid injection v placebo or no treatment | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for different results for different outcomes |
| 1 (not stated) | Pain relief | Corticosteroid injection plus local anaesthetic injection v oral NSAID v placebo | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for short follow-up, use of vitamin C as placebo, and incomplete reporting of results |
| 2 (at least 53) | Global improvement | Corticosteroid injection v local anaesthetic injection | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, uncertain follow-up, and incomplete reporting of results |
| 1 (56) | Global improvement | Corticosteroid injection v orthoses | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and for pooling results from two arms in control group |
| 1 (at least 53) | Pain relief | Corticosteroid injection v exercise plus mobilisation | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, unclear definition of outcome, and incomplete reporting of results |
| 2 (at least 112) | Global improvement | Corticosteroid injection v exercise plus mobilisation | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and poor methodologies. Directness point deducted for outcome not fully defined |
| 1 (at least 59) | Functional improvement | Corticosteroid injection v exercise plus mobilisation | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (93) | Pain relief | Corticosteroid injection plus local anaesthetic injection v ESWT | 4 | –2 | 0 | 0 | 0 | Low | Quality point deducted for sparse data, and no intention-to-treat analysis |
| 1 (246) | Pain relief | Different types of corticosteroid injections v each other | 4 | –1 | 0 | –1 | 0 | Low | Quality points deducted for incomplete reporting of results. Directness point deducted for few comparators |
| 1 (52) | Pain relief | Single v multiple injections | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for unclear outcome measurement |
| 3 (175) | Pain relief | Acupuncture v sham acupuncture | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (161) | Global improvement | Acupuncture v sham acupuncture | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for unclear measurement of outcomes |
| 1 (45) | Functional improvement | Acupuncture v sham acupuncture | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for short follow-up |
| 1 (20) | Pain relief | Manual v electroacupuncture | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for short follow-up |
| 1 (62) | Pain relief | Exercise v control | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for sparse data. Directness points deducted for unclear measurement of outcomes and inclusion of co-intervention |
| 1 (62) | Functional improvement | Exercise v control | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for sparse data. Directness points deducted for unclear measurement of outcomes and inclusion of co-intervention |
| 1 (36) | Pain relief | Exercise v ultrasound plus friction massage | 4 | –2 | 0 | –1 | 0 | Very low | Quality point deducted for sparse data and incomplete reporting of results. Directness point deducted for multiple interventions in comparison |
| 1 (183) | Pain relief | Exercise plus massage plus ultrasound v no treatment | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for multiple interventions in comparison |
| 1 (183) | Global improvement | Exercise plus massage plus ultrasound v no treatment | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for multiple interventions in comparison |
| 1 (94) | Pain relief | Eccentric strengthening plus stretching v concentric strengthening plus stretching v stretching | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (94) | Functional improvement | Eccentric strengthening plus stretching v concentric strengthening plus stretching v stretching | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 3 (76) | Pain relief | Different manipulation techniques for mobilisation | 4 | –2 | –1 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for conflicting results. Directness point deducted for inclusion of different comparators |
| 2 (293) | Pain relief | Oral NSAIDs v placebo | 4 | –3 | –1 | 0 | 0 | Very low | Quality point deducted for incomplete reporting of results, short follow-up, and use of vitamin C as placebo. Consistency point deducted for conflicting results |
| 1 (164) | Functional improvement | Oral NSAIDs v placebo | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and use of vitamin C as placebo |
| 2 (at least 53) | Pain relief | Oral NSAIDs v corticosteroid injection | 4 | –3 | –1 | 0 | 0 | Very low | Quality points deducted for sparse data, unclear definition of outcome, and incomplete reporting of results. Consistency point deducted for conflicting results |
| 2 (not stated) | Global improvement | Oral NSAIDs v corticosteroid injection | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and subjective assessment of outcome |
| 1 (180) | Pain relief | Orthoses v physiotherapy | 4 | –1 | 0 | –2 | 0 | Very low | Quality points deducted for sparse data. Directness points deducted for inclusion of different comparators and sub-group analysis |
| 1 (180) | Global improvement | Orthoses v physiotherapy | 4 | –1 | 0 | –1 | 0 | Low | Quality points deducted for sparse data. Directness point deducted for inclusion of different comparators |
| 1 (180) | Functional improvement | Orthoses v physiotherapy | 4 | –1 | 0 | –1 | 0 | Low | Quality points deducted for sparse data. Directness point deducted for inclusion of different comparators |
| 1 (47) | Functional improvement | Open v percutaneous release surgery | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, not blinded, and uncertainty about clinical relevance of improvement |
| 3 (130) | Pain relief | Topical NSAIDs v placebo | 4 | –1 | 0 | 0 | 0 | Moderate | Quality points deducted for sparse data |
| 2 (119) | Global improvement | Topical NSAIDs v placebo | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data, and subjective assessment of outcomes |
| 2 (at least 40) | Functional improvement | Topical NSAIDs v placebo | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 6 (618) | Pain relief | ESWT v placebo | 4 | 0 | 0 | –1 | 0 | Moderate | Directness point deducted for inclusion of other intervention |
| 7 (at least 252) | Global improvement | ESWT v placebo | 4 | –2 | –1 | –1 | 0 | Very low | Quality point deducted for incomplete reporting of results and poor methodologies. Consistency point deducted for conflicting results. Directness point deducted for inclusion of other interventions |
Type of evidence: 4 = RCT; 2 = Observational; 1 = Non-analytical/expert opinion. ESWT, extracorporeal shock wave therapyConsistency: similarity of results across studies Directness: generalisability of population or outcomes Effect size: based on relative risk or odds ratio