387829

Hindawi Publishing CorporationAdvances in OrthopedicsVolume 2012, Article ID 387829, 6 pagesdoi:10.1155/2012/387829

Clinical Study

Autologous Blood Injection and Wrist Immobilisation forChronic Lateral Epicondylitis

Nicola Massy-Westropp,1 Stuart Simmonds,2 Suzanne Caragianis,2 and Andrew Potter3

1 School of Health Sciences, University of South Australia, Adelaide, SA 5000, Australia2 SA Hand Therapy, Goodwood, SA 5035, Australia3 Ashford Specialist Centre, Ashford, SA 5035, Australia

Correspondence should be addressed to Nicola Massy-Westropp, [email protected]

Received 5 June 2012; Accepted 26 October 2012

Academic Editor: Kalman Katz

Copyright © 2012 Nicola Massy-Westropp et al. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Purpose. This study explored the effect of autologous blood injection (with ultrasound guidance) to the elbows of patients whohad radiologically assessed degeneration of the origin of extensor carpi radialis brevis and failed cortisone injection/s to the lateralepicondylitis. Methods. This prospective longitudinal series involved preinjection assessment of pain, grip strength, and function,using the patient-rated tennis elbow evaluation. Patients were injected with blood from the contralateral limb and then worea customised wrist support for five days, after which they commenced a stretching, strengthening, and massage programmewith an occupational therapist. These patients were assessed after six months and then finally between 18 months and fiveyears after injection, using the patient-rated tennis elbow evaluation. Results. Thirty-eight of 40 patients completed the study,showing significant improvement in pain; the worst pain decreased by two to five points out of a 10-point visual analogue forpain. Self-perceived function improved by 11–25 points out of 100. Women showed significant increase in grip, but men did not.Conclusions. Autologous blood injection improved pain and function in a worker’s compensation cohort of patients with chroniclateral epicondylitis, who had not had relief with cortisone injection.

1. Introduction

Lateral epicondylitis or tennis elbow is a common conditionthat causes pain on the outside of the elbow, as well as painand weakness during gripping. It has been found to occurin approximately 1.3% of people in studied populations [1].Tennis elbow is commonly associated with obesity, smoking,and physical loading during activity, as well as playing tennis[1]. The site of long-term scarring has been shown (duringultrasound) to be where the extensor carpi radialis brevismuscle, which lifts the wrist, originates from the humerus[2].

There are many conservative treatments, includingsplinting, massage, injection of nonsteroidal anti-inflamma-tories, and alteration of tasks performed by the patient.There is high level, high quality evidence to suggest thatextracorporeal shock wave therapy has little or no benefit [3]and that the evidence for orthotics and splints is not clear

[4], but a high number of studies suggest that injection ofnonsteroidal anti-inflammatories provides good immediatepain relief, with variable recurrence rates of symptoms [4].Corticosteroid injection has been shown to provide short-term relief but relapse rates are high [5].

Autologous blood injection (ABI) is theorized to stim-ulate a “healing cascade” of events, in the degeneratedtendinous origin of extensor carpi radialis brevis [6]. Twoto three millilitres of the patient’s blood is removed fromtheir contralateral arm and then at the same appointmentinjected into the origin of extensor carpi radialis brevis. Theinjection is often done using ultrasound visualization, anda one millilitre of lidocaine or marcaine is added to theinjection.

Given the physiological theory behind injecting autolo-gous blood into a degenerated tendon, postinjection therapyregimes would need to support the initial healing phasethought to occur following injection [6]. Four studies

2 Advances in Orthopedics

mentioned postinjection rest in a wrist support splint orsling; then normal activity was resumed by six weeks afterinjection. In two studies patients were told to perform onlylight duties or use modified lifting for up to four weeks afterinjection. Stretching exercises were named in two studies;apart from these, postinjection therapy was not described indetail.

There are eight published studies and one conferenceabstract of level II and IV evidence, of good to poor quality[7] regarding the efficacy of ABI in reducing pain in patientswith tennis elbow. These studies (summarized in Table 1)varied in the chronicity of patients’ symptoms, number ofinjections provided, type of assessments, and duration offollowup of patients. The aim of this study is to evaluate theeffect of ABI, splinting, and occupational therapy for patientswith chronic LE, who have not been relieved by cortisoneinjection.

2. Materials and Methods

Approval for this study was obtained from the Ethics andCompliance Committee of the University of South Australia.All patients provided informed consent prior to participationin the study.

Patients had to be over the age of 18 years and able toprovide informed consent. They had to have experiencedlateral epicondylitis as diagnosed by a physician (AP) fora minimum of six months, and they had to have had atleast one steroid injection before being offered autologousblood. Patients then underwent a diagnostic ultrasound toconfirm their appropriateness for ABI; they had to show signsof tendon origin degeneration rather than inflammation, asdiagnosed by one radiologist. Consecutive patients who fitthese eligibility criteria were invited into the study.

Patients were fitted with a custom fabricated volar wristresting splint in a neutral to 10◦ extension wrist positionprior to injection. The patients then returned to theirphysician and had two millilitres of venous blood withdrawnfrom their contralateral arm, mixed with one millilitreof bupivacaine, which was then injected using ultrasoundguidance into the tendinous origin of their extensor carpiradialis brevis tendon. Patients spent five days followinginjection resting in the custom made wrist splint and thenwere taught elbow, wrist, and hand range of motion, stretch-ing dynamic concentric and later eccentric strengtheningand self-monitoring techniques. Their performance of theexercises was checked fortnightly for the first four weeks bytheir occupational therapist and then as required for up to 12weeks.

Short-term assessments, made at baseline, three andsixmonths following injection included visual analoguemea-sures of pain (at worst, at best, and on average);grip strength,using a Jamar dynamometer and protocol from the AmericanSociety of Hand Therapists Clinical AssessmentRecommen-dations [17].

Patients completed the Patient Rated Tennis ElbowEvaluation [18] (formerly the Patient Rated Forearm Ques-tionnaire) before treatment, after six months and annuallyafter that by telephone interview. This questionnaire has

three subscales of questions asking patients to rate theirpain, specific abilities, and overall function in numericalanalogues. The worst possible score is 100 and the best iszero.

Power calculation based upon significant (P < 0.05)pain reduction of more than three points on a ten-pointvisual analogue scale suggested that thirty-two patientswere needed for this study. All data were deidentified,and assessment scores of function, pain, and strength wereevaluated for normalcy of distribution, and changes in alloutcome measures were calculated.

3. Results

Forty-five consecutive patients were eligible for this studyand 40 consented to participate; one patient had two elbowsincluded in the study. There were initially 8 men and 32women aged 33 to 56 years, mean 47 years (SD 5.7). Threepatients were excluded during the study because they hadother procedures such as carpal tunnel release and shoulderinjections on the same arm, which altered their pain andfunction. Two further patients were eliminated because theyhad lateral epicondyle release after their ABI, and six declinedto return for assessment as their symptoms were resolved, sothere were 28 elbows in the final analysis. Eight patients hadshoulder pain or wrist pain on the same side as their lateralepicondylitis.

The duration of patients’ symptoms ranged from sevenmonths to six years (CI 18 months to three years). Thirty-seven were under workers’ compensation, and three wereprivate patients. All had one or more cortisone injection,plus either electric shock wave therapy, ultrasound, NSAIDS,braces to the forearm and wrist, and exercise therapy withoutsatisfactory relief from symptoms. Radiologic assessment ofall included patients described degeneration or discontinuityin the tendinous origin of extensor carpi radialis brevis, somewith calcification of the tendon.

No patients experienced severe bruising, and none hadinfection on the donor arm or on the injected arm. Signif-icant improvements occurred in self-perceived measures ofpain and upper limb function and in women’s hand gripstrength. Two of the eight men lost hand grip strength, oneby five kilograms and the other by seven. Table 2 shows 95%confidence intervals for pain and grip strength.

Patient-rated tennis elbow evaluation scores at baselinewere (95%CI) 40–52/100. At 12 weeks they were 13–26/100.Between 18 months and 5 years, four patients were lost tofollowup. Remaining patients rated 13–27100, a significantdecrease in pain and increase in function (P = 0.002).

4. Discussion

This study of chronic patients shows positive medium andlong-term results from a single injection of autologousblood. The injection under ultrasound visualization accom-panying treatments, splinting, and occupational therapywere free of adverse events such as severe bruising orinfection.

Advances in Orthopedics 3

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Advances in Orthopedics 5

Table 2: Shows the 95% CI for pain, grip, and the patient-rated tennis elbow Evaluations of the 38 patients before injection, 12 weeks afterinjection, 26 weeks and one to four years after injection.

MeasureBefore injection 12 Weeks 26 Weeks

N = 38 N = 38 N = 32

Visual analogue pain at worst 0–10 7.5–8.8 3.3 – 5 2.6–5.2∗

Visual analogue pain at best 0–10 1.4–2.8 0.3–1.5 0.2–1.1∗

Visual analogue average pain 0–10 3.6–4.9 2.2–3.7 0.9–2.1∗

Hand Grip Strength (kilograms)Men 37–53 40–56 42–59

Women 18–23 20–26 23–29∗∗

significant at P < 0.000

This study was slightly different to past studies in patientselection; all were symptomatic for at least six months andhad failed cortisone injection treatment. Radiology reportssuggested degenerative changes and “discontinuity” or tears,in the tendinous origin at the lateral epicondyle. Thissuggests that these patients had a more degenerative thaninflammatory condition, despite their diagnosis being lateralepicondylitis.

One limitation of this study was the absence of random-ization into a control group. The reason for this was thatmost patients were under worker’s compensation and thedoctor treating them felt it unethical to deny the injection tothose with chronic and resistant symptoms. A comparisongroup was initially formed but these patients were unlikethose in the study, in their duration of symptoms.

More recent studies of ABI for lateral epicondylitishave injected plasma-rich proteins (PRPs) which have beeninjected in the same manner as untreated autologous blood.Preparation of PRP involves withdrawing approximately27 millilitres of anticoagulated blood and placing it ina centrifuge, before adding anaesthetic and injecting [2].Platelet-rich plasma has positive effects, but in many studiesthese results have not been significantly different to ABIresults [10, 13].

Considerable thought was given to the issue of comor-bidity. In this study, eight patients had diagnoses of carpaltunnel syndrome, shoulder overuse, ulnar neuropathy, andosteoarthritis of the wrist. Two patients were excluded fromthe follow-up analyses because they had surgery to theirelbows, but other patients had procedures of carpal tunnelrelease, wrist fusion, and arthroscopic shoulder repair in theyears following their elbow surgery. Although the symptomsfrom these conditions may affect the results of pain andfunctional evaluation, these results are representative ofoccupational overuse syndromes of the upper limbs [19, 20].

A further limitation of this study was that some patientsdeclined to return to the clinic for their six-month assess-ment of grip function. These patients were under worker’scompensation, and it was not reasonable to request that theyreturn to occupational therapy in work hours. Intention totreat analysis was not used as this would likely show aninaccurate picture of their function.

When the patient-rated tennis elbow evaluation wascompleted with the occupational therapist, the patients’comments were recorded; numerous patients said that theyhad no functional limitations, scoring the highest marks

on this evaluation. These patients also said that they nowdid things differently, had altered their work duties, orceased certain activities. In one case, a woman changedher vacuum cleaner to a self-propelling model, and shehad no pain or difficulty with vacuuming. These strategieswere all successful but perhaps give more positive functionalresults than can be compared with the patients’ originalactivities. Despite these limitations, this study still describesdramatic improvement in the functional ability of patientswith chronic degenerative tennis elbow, who had autologousblood injection wrist immobilisation and a home exerciseprogramme, including those under worker’s compensation,and having upper limb comorbidities.

References

[1] A. Bharti, S. Avasthi, K. Solanki, S. Kumar, A. Swaroop, and G.K. Sengar, “Clinical assessment of functional outcome in lat-eral epicondylitis managed by local infiltration of autologousblood,” Internet Journal of Medical Update, vol. 5, no. 1, pp.20–24, 2010.

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