Stenhouse 2013.

Study characteristics
Methods	Design: single‐centre unblinded parallel 2‐arm randomised controlled trial Setting: Rheumatology or Orthopaedic Outpatient Clinic, West Middlesex University Hospital, Middlesex, United Kingdom Timing: June 2010 to August 2012 Interventions: autologous conditioned plasma injection and dry needling vs dry needling Sample size: not reported Analysis: data for participants who completed the study were analysed
Participants	Number of participants Number of participants screened for eligibility: not reported Number excluded: not reported Number randomised: 28 (15 in autologous blood group, 13 in dry needling group) Number included in analysis: 25 (13 in autologous blood group, 12 in dry needling group) Inclusion criteria Tenderness over lateral epicondyle and pain on wrist extension Diagnosis confirmed as heterogeneity, and neovascularity of common extensor tendon origin assessed via ultrasound by 1 of 2 musculoskeletal radiology consultants with over 5 years' experience Minimum symptom duration 6 months Failure of conservative treatment including physiotherapy and glucocorticoid injection Exclusion criteria Previous elbow trauma or surgery Local injection or recent steroid in the past 3 months History of inflammatory arthropathy Tendon tear Baseline characteristics Autologous conditioned plasma and dry needling group Mean (SD) age (years): 53.2 (9.87) No. male:female: 8:7 Mean (SD) duration of pain (months): 18.9 (17.8) Dominant arm affected: 13 (86.6%) Mean (SD) VAS pain score (0 to 10; 0 is no pain): 8.07 (1.18) Mean (SD) Nirschl stage (80 to 0; 80 is no pain): 11.1 (14.3) Dry needling group Mean (SD) age (years): 47.6 (6.12) No. male:female: 5:8 Mean (SD) duration of pain (months): 22.2 (14.5) Dominant arm affected: 11 (84.6) Mean (SD) VAS pain score (0 to 10; 0 is no pain): 6.87 (2.15) Mean (SD) Nirschl stage (0 to 80; 80 is no pain): 22.9 (19.1) Pretreatment group differences: Nirschl scores were higher in the dry needling group compared with the ACP and dry needling group
Interventions	The abnormal common extensor origin tendon was identified with a 15 L 8‐W transducer on a GE Logiq E9 ultrasound machine (Milwaukee, WI). Before treatment, the skin was cleaned with antiseptic solution and 1 to 2 mL of 1 % lignocaine was injected immediately deep into the deep fascia with a 23‐G needle. Care was taken to avoid local anaesthetic injection into the tendon. Following a short interval (to allow the anaesthetic to act), the patient was treated with either dry needling alone or dry needling followed by ACP injection. The procedure was repeated at 1 month Autologous conditioned plasma and dry needling group Participants had 10 mL of blood taken from their contralateral antecubital vein. The ACP double syringe (manufactured by Arthrex Double Syringe System, Inc., Naples, FL) containing whole blood was then centrifuged at 1500 rpm for 5 minutes. This separated red blood cells from platelet‐containing plasma. The plasma was drawn into the smaller syringe. Dry needling was performed initially for 2 minutes followed by a 2‐mL injection of ACP Dry needling group Dry needling consisted of passing a fine needle (23G) in and out through the long axis of the tendon without exiting the skin approximately 40 to 50 times to pepper the tendon. This lasted a total of 2 minutes Follow‐up care Participants were advised to undertake normal activities but to avoid anything that may aggravate symptoms
Outcomes	Outcomes were reported at baseline and at 2 months and 6 months Outcomes Mean pain measured on a visual analogue scale. Score scale from 0 (no pain) to 10 (maximum pain) Mean elbow function measured by the Nirschl staging system. Score scale from 0 (constant pain at rest, poor function) to 80 (no pain, improved function) Treatment success as defined by 25% reduction in pain on a visual analogue scale Adverse events Withdrawals due to adverse events Outcomes included in this review Mean pain measured on a visual analogue scale Mean elbow function measured by the Nirschl staging system Treatment success as defined by 25% reduction in pain on a visual analogue scale Adverse events Withdrawals due to adverse events Time points included in this review 2 months and 6 months
Notes	Funding: not reported Trial registration: not done Withdrawals: 2/15 in the autologous blood group and 1/13 in the dry needling group were lost to follow‐up due to increasing elbow pain after the first treatment Adverse events Autologous conditioned plasma and dry needling group Total adverse events: 2/15 No. of events: 2 Nature of event: increased elbow pain after first treatment Serious adverse events: none reported Dry needling group Total adverse events: 1/13 No. of events: 1 Nature of event: increased elbow pain after first treatment Serious adverse events: none reported Although study authors reported no adverse events in either group, 3 participants were lost from the study ‐ 2 from the autologous blood group and 1 from the dry needling group ‐ due to increasing elbow pain after first injection. We regarded these data as withdrawal due to adverse events and documented increased elbow pain following treatment as an adverse event
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"Randomization was performed using an Internet platform called 'research randomised form v4.0'”
Allocation concealment (selection bias)	Unclear risk	Allocation concealment was not adequately reported in the article
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants were not blinded to group allocation; study authors report "a separate investigator was enrolled to evaluate the outcome measures"
Blinding of outcome assessment (detection bias) for self reported subjective outcomes (pain, function, treatment success, quality of life)	High risk	As participants were not blinded to treatment allocation, there is risk of bias in the measurement of pain and function
Blinding of outcome assessment (detection bias) objective outcomes	Low risk	There were no truly objective outcomes
Incomplete outcome data (attrition bias) All outcomes	Low risk	2/15 (13%) in the autologous blood group and 1/13 (7.7%) in the dry needling group were discontinued after first intervention due to increased elbow pain after the first injection
Selective reporting (reporting bias)	Unclear risk	No protocol was found and the trial was not registered
Other bias	Low risk	No other bias was found