PDF(Pubmed)
Abstract：
Manual therapy and prescribed exercises are often provided together or separately in contemporary clinical practice to treat people with lateral elbow pain.
To assess the benefits and harms of manual therapy, prescribed exercises or both for adults with lateral elbow pain.
We searched the databases CENTRAL, MEDLINE and Embase, and trial registries until 31 January 2024, unrestricted by language or date of publication.
We included randomised or quasi-randomised trials. Participants were adults with lateral elbow pain. Interventions were manual therapy, prescribed exercises or both. Primary comparators were placebo or minimal or no intervention. We also included comparisons of manual therapy and prescribed exercises with either intervention alone, with or without glucocorticoid injection. Exclusions were trials testing a single application of an intervention or comparison of different types of manual therapy or prescribed exercises.
Two review authors independently selected studies for inclusion, extracted trial characteristics and numerical data, and assessed study risk of bias and certainty of evidence using GRADE. The main comparisons were manual therapy, prescribed exercises or both compared with placebo treatment, and with minimal or no intervention. Major outcomes were pain, disability, heath-related quality of life, participant-reported treatment success, participant withdrawals, adverse events and serious adverse events. The primary endpoint was end of intervention for pain, disability, health-related quality of life and participant-reported treatment success and final time point for adverse events and withdrawals.
Twenty-three trials (1612 participants) met our inclusion criteria (mean age ranged from 38 to 52 years, 47% female, 70% dominant arm affected). One trial (23 participants) compared manual therapy to placebo manual therapy, 12 trials (1124 participants) compared manual therapy, prescribed exercises or both to minimal or no intervention, six trials (228 participants) compared manual therapy and exercise to exercise alone, one trial (60 participants) compared the addition of manual therapy to prescribed exercises and glucocorticoid injection, and four trials (177 participants) assessed the addition of manual therapy, prescribed exercises or both to glucocorticoid injection. Twenty-one trials without placebo control were susceptible to performance and detection bias as participants were not blinded to the intervention. Other biases included selection (nine trials, 39%, including two quasi-randomised), attrition (eight trials, 35%) and selective reporting (15 trials, 65%) biases. We report the results of the main comparisons. Manual therapy versus placebo manual therapy Low-certainty evidence, based upon a single trial (23 participants) and downgraded due to indirectness and imprecision, indicates manual therapy may reduce pain and elbow disability at the end of two to three weeks of treatment. Mean pain at the end of treatment was 4.1 points with placebo (0 to 10 scale) and 2.0 points with manual therapy, MD -2.1 points (95% CI -4.2 to -0.1). Mean disability was 40 points with placebo (0 to 100 scale) and 15 points with manual therapy, MD -25 points (95% CI -43 to -7). There was no follow-up beyond the end of treatment to show if these effects were sustained, and no other major outcomes were reported. Manual therapy, prescribed exercises or both versus minimal intervention Low-certainty evidence indicates manual therapy, prescribed exercises or both may slightly reduce pain and disability at the end of treatment, but the effects were not sustained, and there may be little to no improvement in health-related quality of life or number of participants reporting treatment success. We downgraded the evidence due to increased risk of performance bias and detection bias across all the trials, and indirectness due to the multimodal nature of the interventions included in the trials. At four weeks to three months, mean pain was 5.10 points with minimal treatment and manual therapy, prescribed exercises or both reduced pain by a MD of -0.53 points (95% CI -0.92 to -0.14, I2 = 43%; 12 trials, 1023 participants). At four weeks to three months, mean disability was 63.8 points with minimal or no treatment and manual therapy, prescribed exercises or both reduced disability by a MD of -5.00 points (95% CI -9.22 to -0.77, I2 = 63%; 10 trials, 732 participants). At four weeks to three months, mean quality of life was 73.04 points with minimal treatment on a 0 to 100 scale and prescribed exercises reduced quality of life by a MD of -5.58 points (95% CI -10.29 to -0.99; 2 trials, 113 participants). Treatment success was reported by 42% of participants with minimal or no treatment and 57.1% of participants with manual therapy, prescribed exercises or both, RR 1.36 (95% CI 0.96 to 1.93, I2 = 73%; 6 trials, 770 participants). We are uncertain if manual therapy, prescribed exercises or both results in more withdrawals or adverse events. There were 83/566 participant withdrawals (147 per 1000) from the minimal or no intervention group, and 77/581 (126 per 1000) from the manual therapy, prescribed exercises or both groups, RR 0.86 (95% CI 0.66 to 1.12, I2 = 0%; 12 trials). Adverse events were mild and transient and included pain, bruising and gastrointestinal events, and no serious adverse events were reported. Adverse events were reported by 19/224 (85 per 1000) in the minimal treatment group and 70/233 (313 per 1000) in the manual therapy, prescribed exercises or both groups, RR 3.69 (95% CI 0.98 to 13.97, I2 = 72%; 6 trials).
Low-certainty evidence from a single trial in people with lateral elbow pain indicates that, compared with placebo, manual therapy may provide a clinically worthwhile benefit in terms of pain and disability at the end of treatment, although the 95% confidence interval also includes both an important improvement and no improvement, and the longer-term outcomes are unknown. Low-certainty evidence from 12 trials indicates that manual therapy and exercise may slightly reduce pain and disability at the end of treatment, but this may not be clinically worthwhile and these benefits are not sustained. While pain after treatment was an adverse event from manual therapy, the number of events was too small to be certain.
To assess the benefits and harms of manual therapy, prescribed exercises or both for adults with lateral elbow pain.
We searched the databases CENTRAL, MEDLINE and Embase, and trial registries until 31 January 2024, unrestricted by language or date of publication.
We included randomised or quasi-randomised trials. Participants were adults with lateral elbow pain. Interventions were manual therapy, prescribed exercises or both. Primary comparators were placebo or minimal or no intervention. We also included comparisons of manual therapy and prescribed exercises with either intervention alone, with or without glucocorticoid injection. Exclusions were trials testing a single application of an intervention or comparison of different types of manual therapy or prescribed exercises.
Two review authors independently selected studies for inclusion, extracted trial characteristics and numerical data, and assessed study risk of bias and certainty of evidence using GRADE. The main comparisons were manual therapy, prescribed exercises or both compared with placebo treatment, and with minimal or no intervention. Major outcomes were pain, disability, heath-related quality of life, participant-reported treatment success, participant withdrawals, adverse events and serious adverse events. The primary endpoint was end of intervention for pain, disability, health-related quality of life and participant-reported treatment success and final time point for adverse events and withdrawals.
Twenty-three trials (1612 participants) met our inclusion criteria (mean age ranged from 38 to 52 years, 47% female, 70% dominant arm affected). One trial (23 participants) compared manual therapy to placebo manual therapy, 12 trials (1124 participants) compared manual therapy, prescribed exercises or both to minimal or no intervention, six trials (228 participants) compared manual therapy and exercise to exercise alone, one trial (60 participants) compared the addition of manual therapy to prescribed exercises and glucocorticoid injection, and four trials (177 participants) assessed the addition of manual therapy, prescribed exercises or both to glucocorticoid injection. Twenty-one trials without placebo control were susceptible to performance and detection bias as participants were not blinded to the intervention. Other biases included selection (nine trials, 39%, including two quasi-randomised), attrition (eight trials, 35%) and selective reporting (15 trials, 65%) biases. We report the results of the main comparisons. Manual therapy versus placebo manual therapy Low-certainty evidence, based upon a single trial (23 participants) and downgraded due to indirectness and imprecision, indicates manual therapy may reduce pain and elbow disability at the end of two to three weeks of treatment. Mean pain at the end of treatment was 4.1 points with placebo (0 to 10 scale) and 2.0 points with manual therapy, MD -2.1 points (95% CI -4.2 to -0.1). Mean disability was 40 points with placebo (0 to 100 scale) and 15 points with manual therapy, MD -25 points (95% CI -43 to -7). There was no follow-up beyond the end of treatment to show if these effects were sustained, and no other major outcomes were reported. Manual therapy, prescribed exercises or both versus minimal intervention Low-certainty evidence indicates manual therapy, prescribed exercises or both may slightly reduce pain and disability at the end of treatment, but the effects were not sustained, and there may be little to no improvement in health-related quality of life or number of participants reporting treatment success. We downgraded the evidence due to increased risk of performance bias and detection bias across all the trials, and indirectness due to the multimodal nature of the interventions included in the trials. At four weeks to three months, mean pain was 5.10 points with minimal treatment and manual therapy, prescribed exercises or both reduced pain by a MD of -0.53 points (95% CI -0.92 to -0.14, I2 = 43%; 12 trials, 1023 participants). At four weeks to three months, mean disability was 63.8 points with minimal or no treatment and manual therapy, prescribed exercises or both reduced disability by a MD of -5.00 points (95% CI -9.22 to -0.77, I2 = 63%; 10 trials, 732 participants). At four weeks to three months, mean quality of life was 73.04 points with minimal treatment on a 0 to 100 scale and prescribed exercises reduced quality of life by a MD of -5.58 points (95% CI -10.29 to -0.99; 2 trials, 113 participants). Treatment success was reported by 42% of participants with minimal or no treatment and 57.1% of participants with manual therapy, prescribed exercises or both, RR 1.36 (95% CI 0.96 to 1.93, I2 = 73%; 6 trials, 770 participants). We are uncertain if manual therapy, prescribed exercises or both results in more withdrawals or adverse events. There were 83/566 participant withdrawals (147 per 1000) from the minimal or no intervention group, and 77/581 (126 per 1000) from the manual therapy, prescribed exercises or both groups, RR 0.86 (95% CI 0.66 to 1.12, I2 = 0%; 12 trials). Adverse events were mild and transient and included pain, bruising and gastrointestinal events, and no serious adverse events were reported. Adverse events were reported by 19/224 (85 per 1000) in the minimal treatment group and 70/233 (313 per 1000) in the manual therapy, prescribed exercises or both groups, RR 3.69 (95% CI 0.98 to 13.97, I2 = 72%; 6 trials).
Low-certainty evidence from a single trial in people with lateral elbow pain indicates that, compared with placebo, manual therapy may provide a clinically worthwhile benefit in terms of pain and disability at the end of treatment, although the 95% confidence interval also includes both an important improvement and no improvement, and the longer-term outcomes are unknown. Low-certainty evidence from 12 trials indicates that manual therapy and exercise may slightly reduce pain and disability at the end of treatment, but this may not be clinically worthwhile and these benefits are not sustained. While pain after treatment was an adverse event from manual therapy, the number of events was too small to be certain.
摘要：
背景：在当代临床实践中，通常将手动疗法和处方锻炼一起或分开提供，以治疗肘部外侧疼痛的患者。
目的：为了评估手法治疗的益处和危害，成人肘部外侧疼痛的规定锻炼或两者兼而有之。
方法：我们搜索了CENTRAL数据库，MEDLINE和Embase,和试验登记处，直至2024年1月31日，不受语言或出版日期的限制。
方法：我们纳入了随机或准随机试验。参与者是患有肘部外侧疼痛的成年人。干预是手动治疗，规定的练习或两者兼而有之。主要比较者为安慰剂或最小或无干预。我们还包括手动治疗和处方锻炼与单独干预的比较，有或没有糖皮质激素注射。排除是测试干预措施的单一应用或比较不同类型的手动治疗或规定锻炼的试验。
方法：两位综述作者独立选择纳入研究，提取试验特征和数值数据，并使用GRADE评估研究的偏倚风险和证据的确定性。主要比较是手法治疗,与安慰剂治疗相比，规定的锻炼或两者兼而有之，很少或没有干预。主要结果是疼痛，残疾,与健康相关的生活质量，参与者报告的治疗成功，参与者退出，不良事件和严重不良事件。主要终点是疼痛干预结束，残疾,健康相关的生活质量和参与者报告的治疗成功以及不良事件和停药的最终时间点.
结果：23项试验（1612名参与者）符合我们的纳入标准（平均年龄为38至52岁，47%是女性,70%的优势臂受到影响)。一项试验（23名参与者）将手动治疗与安慰剂手动治疗进行了比较，12项试验(1124名参与者)比较了手动治疗，规定的锻炼或两者兼而有之，以尽量减少或不干预，六项试验（228名参与者）比较了手动治疗和运动与单独运动，一项试验（60名参与者）比较了在规定的运动和糖皮质激素注射中增加手动治疗，四项试验（177名参与者）评估了手动治疗的增加，规定的运动或两者都注射糖皮质激素。没有安慰剂对照的21项试验容易受到性能和检测偏倚的影响，因为参与者没有对干预措施视而不见。其他偏见包括选择(九项试验，39%,包括两个准随机)，减员(八项试验，35%)和选择性报告(15项试验，65%)的偏见。我们报告主要比较的结果。手动治疗与安慰剂手动治疗低确定性证据，基于一项试验(23名参与者)，并由于间接性和不精确性而降级，表明手动治疗可以减少疼痛和肘部残疾在两到三周的治疗结束。安慰剂治疗结束时的平均疼痛为4.1分（0至10分），手动治疗为2.0分，MD-2.1点（95%CI-4.2至-0.1）。安慰剂的平均残疾为40分（0至100分），手动治疗为15分，MD-25点（95%CI-43至-7）。治疗结束后没有随访来显示这些效果是否持续，未报告其他主要结局.手动治疗,规定的锻炼或两者兼而有之，与最低限度的干预低确定性证据表明手动治疗，规定的锻炼或两者都可以在治疗结束时略微减轻疼痛和残疾，但是效果没有持续，与健康相关的生活质量或报告治疗成功的参与者数量可能几乎没有改善。由于所有试验的性能偏差和检测偏差的风险增加，我们降低了证据的评级，以及由于纳入试验的干预措施的多模态性质而导致的间接性。在四周到三个月的时间里，最小治疗和手动治疗的平均疼痛为5.10分，规定的运动或两者均可减少疼痛，MD为-0.53分（95％CI-0.92至-0.14，I2=43％；12项试验，1023名参与者)。在四周到三个月的时间里，平均残疾为63.8分，最少或没有治疗和手动治疗，规定的锻炼或两者都减少了-5.00点的MD（95％CI-9.22至-0.77，I2=63％；10项试验，732名参与者)。在四周到三个月的时间里，平均生活质量为73.04分，在0至100量表上进行最少的治疗，规定的运动使生活质量降低了-5.58分的MD（95％CI-10.29至-0.99；2项试验，113名参与者)。据报道，42%的参与者接受了少量治疗或不接受治疗，57.1%的参与者接受了手动治疗。规定的锻炼或两者兼而有之，RR1.36（95%CI0.96至1.93，I2=73%；6项试验，770名参与者)。我们不确定手动治疗是否，规定的锻炼或两者都会导致更多的提款或不良事件。有83/566参与者退出（147/1000）从最小或无干预组，和77/581(每1000人中有126人)来自手动治疗，规定的锻炼或两组，RR0.86（95%CI0.66至1.12，I2=0%；12项试验）。不良事件是轻度和短暂的，包括疼痛，瘀伤和胃肠道事件，未报告严重不良事件.最小治疗组的不良事件报告为19/224（85/1000），手动治疗组的不良事件报告为70/233（313/1000）。规定的锻炼或两组，RR3.69（95%CI0.98至13.97，I2=72%；6项试验）。
结论：一项针对肘部外侧疼痛患者的单一试验的低确定性证据表明，与安慰剂相比，在治疗结束时，手动治疗可以在疼痛和残疾方面提供临床上有价值的益处，虽然95%的置信区间也包括了重要的改善和没有改善，和长期的结果是未知的。来自12项试验的低确定性证据表明，手动治疗和运动可能会在治疗结束时略微减轻疼痛和残疾。但这在临床上可能不值得，并且这些益处无法持续。虽然治疗后疼痛是手动治疗的不良事件，事件的数量太少，无法确定。
目的：为了评估手法治疗的益处和危害，成人肘部外侧疼痛的规定锻炼或两者兼而有之。
方法：我们搜索了CENTRAL数据库，MEDLINE和Embase,和试验登记处，直至2024年1月31日，不受语言或出版日期的限制。
方法：我们纳入了随机或准随机试验。参与者是患有肘部外侧疼痛的成年人。干预是手动治疗，规定的练习或两者兼而有之。主要比较者为安慰剂或最小或无干预。我们还包括手动治疗和处方锻炼与单独干预的比较，有或没有糖皮质激素注射。排除是测试干预措施的单一应用或比较不同类型的手动治疗或规定锻炼的试验。
方法：两位综述作者独立选择纳入研究，提取试验特征和数值数据，并使用GRADE评估研究的偏倚风险和证据的确定性。主要比较是手法治疗,与安慰剂治疗相比，规定的锻炼或两者兼而有之，很少或没有干预。主要结果是疼痛，残疾,与健康相关的生活质量，参与者报告的治疗成功，参与者退出，不良事件和严重不良事件。主要终点是疼痛干预结束，残疾,健康相关的生活质量和参与者报告的治疗成功以及不良事件和停药的最终时间点.
结果：23项试验（1612名参与者）符合我们的纳入标准（平均年龄为38至52岁，47%是女性,70%的优势臂受到影响)。一项试验（23名参与者）将手动治疗与安慰剂手动治疗进行了比较，12项试验(1124名参与者)比较了手动治疗，规定的锻炼或两者兼而有之，以尽量减少或不干预，六项试验（228名参与者）比较了手动治疗和运动与单独运动，一项试验（60名参与者）比较了在规定的运动和糖皮质激素注射中增加手动治疗，四项试验（177名参与者）评估了手动治疗的增加，规定的运动或两者都注射糖皮质激素。没有安慰剂对照的21项试验容易受到性能和检测偏倚的影响，因为参与者没有对干预措施视而不见。其他偏见包括选择(九项试验，39%,包括两个准随机)，减员(八项试验，35%)和选择性报告(15项试验，65%)的偏见。我们报告主要比较的结果。手动治疗与安慰剂手动治疗低确定性证据，基于一项试验(23名参与者)，并由于间接性和不精确性而降级，表明手动治疗可以减少疼痛和肘部残疾在两到三周的治疗结束。安慰剂治疗结束时的平均疼痛为4.1分（0至10分），手动治疗为2.0分，MD-2.1点（95%CI-4.2至-0.1）。安慰剂的平均残疾为40分（0至100分），手动治疗为15分，MD-25点（95%CI-43至-7）。治疗结束后没有随访来显示这些效果是否持续，未报告其他主要结局.手动治疗,规定的锻炼或两者兼而有之，与最低限度的干预低确定性证据表明手动治疗，规定的锻炼或两者都可以在治疗结束时略微减轻疼痛和残疾，但是效果没有持续，与健康相关的生活质量或报告治疗成功的参与者数量可能几乎没有改善。由于所有试验的性能偏差和检测偏差的风险增加，我们降低了证据的评级，以及由于纳入试验的干预措施的多模态性质而导致的间接性。在四周到三个月的时间里，最小治疗和手动治疗的平均疼痛为5.10分，规定的运动或两者均可减少疼痛，MD为-0.53分（95％CI-0.92至-0.14，I2=43％；12项试验，1023名参与者)。在四周到三个月的时间里，平均残疾为63.8分，最少或没有治疗和手动治疗，规定的锻炼或两者都减少了-5.00点的MD（95％CI-9.22至-0.77，I2=63％；10项试验，732名参与者)。在四周到三个月的时间里，平均生活质量为73.04分，在0至100量表上进行最少的治疗，规定的运动使生活质量降低了-5.58分的MD（95％CI-10.29至-0.99；2项试验，113名参与者)。据报道，42%的参与者接受了少量治疗或不接受治疗，57.1%的参与者接受了手动治疗。规定的锻炼或两者兼而有之，RR1.36（95%CI0.96至1.93，I2=73%；6项试验，770名参与者)。我们不确定手动治疗是否，规定的锻炼或两者都会导致更多的提款或不良事件。有83/566参与者退出（147/1000）从最小或无干预组，和77/581(每1000人中有126人)来自手动治疗，规定的锻炼或两组，RR0.86（95%CI0.66至1.12，I2=0%；12项试验）。不良事件是轻度和短暂的，包括疼痛，瘀伤和胃肠道事件，未报告严重不良事件.最小治疗组的不良事件报告为19/224（85/1000），手动治疗组的不良事件报告为70/233（313/1000）。规定的锻炼或两组，RR3.69（95%CI0.98至13.97，I2=72%；6项试验）。
结论：一项针对肘部外侧疼痛患者的单一试验的低确定性证据表明，与安慰剂相比，在治疗结束时，手动治疗可以在疼痛和残疾方面提供临床上有价值的益处，虽然95%的置信区间也包括了重要的改善和没有改善，和长期的结果是未知的。来自12项试验的低确定性证据表明，手动治疗和运动可能会在治疗结束时略微减轻疼痛和残疾。但这在临床上可能不值得，并且这些益处无法持续。虽然治疗后疼痛是手动治疗的不良事件，事件的数量太少，无法确定。
