GuidelinesJapanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication
Introduction
The first edition of the lateral epicondylitis clinical practice guidelines was published in 2006; the second edition was revised based on the concept of evidence-based medicine (EBM) issued by the Japan Council for Quality Health Care and was implemented as per the “Handbook for Clinical Practice Guideline Development 2014 (MINDS 2014)” [1]. During the creation of clinical practice guidelines, evidence, such as that from research treatises, is collected in a systematic manner using an established method called systematic review, and all the evidence adopted is evaluated and integrated as a whole. Further, the guidelines emphasize the importance of “balance between benefit and harm”. The clinical practice guidelines compare multiple intervention methods (diagnosis, treatment, prevention, etc.) that may be selected in a clinical situation and recommend the method that is considered to be the most effective. However, the intervention is equivalent to the effectiveness of the intervention. Attention should also be paid to the harmful aspects. MINDS 2014 proposed preferred methods of guideline preparation in Japan based on The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, Cochrane Collaboration, Agency for Healthcare Research and Quality (AHRQ), and the Oxford EBM center. In the MINDS 2014, the preparation procedures of the guidelines have been defined precisely; in particular, the importance of a viable body of evidence was emphasized. For clinical questions (CQ), study reports were collected using a systematic method and were evaluated as per the outcome data and study design. The results were evaluated in light of a viable body of evidence and were required to emphasize the balance between risk and benefit. Clinical and epidemiological characteristics, natural history, pathology, and diagnosis were not incorporated into the CQ; therefore, a commentary on these characteristics was added as background question (BQ). With respect to the treatment methods that are not covered by Japanese National Health Insurance (insurance), we do not present any recommendations at present and have listed them as future research questions, trusting that in the future, more extensive research will be conducted on this subject. The guidelines are designed to assist the clinician in easily identifying areas of concern and allow him/her to quickly select appropriate treatments for lateral epicondylitis.
The diagnostic criteria for lateral epicondylitis of the humerus followed the diagnostic criteria in the first edition of the guidelines.
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Most tenderness is experienced at the origin of the extensor muscles of the lateral epicondyle.
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Resisted wrist dorsiflexion causes pain on the outside of the elbow.
- 3
Exclude cases wherein the condition is attributable to disorders at sites other than the origin of the extensor muscles, such as disorders of the humero-radial joint.
This disorder is regarded as a disorder of the origin of the extensor muscle group among the disease groups presenting lateral elbow pain and is regarded as an enthesopathy among the disorders of the origin of the extensor muscle group. It is not possible to completely exclude lesions of the humero-radial joint that continuously affect enthesis, such as the annular ligament; however, at least radial tunnel syndrome that is considered entrapment neuropathy of the posterior interosseous nerve is excluded. Since the publication of the first edition, there have been remarkable advances in the treatment of refractory patients who do not respond to conservative therapy, and research is ongoing on the pathophysiology. This edition of the guidelines is applicable to cases of lateral epicondylitis refractory to conservative therapy, synovitis in the elbow joint, synovitis of the humero-radial joint, synovitis fold disorder, degeneration of the humero-radial joint, etc. We also examined lateral humero-radial joint degeneration in a lecture that included periarticular disorders.
Section snippets
Results of the literature search
In preparation for the second edition revision, the authors performed a MEDLINE search of the literature to identify papers published from January 2008 to May 2016. In this search, we used the search formula presented in Table 1 and extracted 414 papers. In addition, a Japanese Igaku-Chuo Zasshi search was performed to identify articles published from 2008 to 2016. This search was performed using the search formula presented in Table 2 and yielded 370 articles. In the initial screening,
Preparation of structured abstract and evaluation of the articles
The authors selected 102 clinicians who are experts in the treatment of elbow joints from the Japan Elbow Society Board of Trustees. These individuals constituted a systematic review (SR) team. The SR team performed a secondary screening for the full text of 402 articles and prepared structured abstracts from the articles selected in the secondary screening. Moreover, the SR team performed evaluations for the individual reports. The structured abstracts were based on the MINDS 2014
Strength of evidence and recommendations
The selected articles were evaluated as per the outcome data. Factors, such as risk, lack of direction, inconsistencies, inadequacies, and publication bias, were evaluated to formulate a viable body of evidence. The evaluation and definition of the strength of the body of evidence were determined as described in Table 3. The recommended text was created for each CQ, and the strength of the recommendation was determined by the committee members using a GRADE grid as described in Table 4. The
Caution
For the second edition, each selected article was evaluated as per the CQ, outcome data, and final body of evidence. Unlike in the previous edition, we did not evaluate the evidence level of each article. When formulating the body of evidence, the strength of the outcome data of studies, such as randomized controlled trials (RCT), was considered from the initial evaluation (A). The strength of the outcome data from observational studies was evaluated from the initial evaluation (C). Appropriate
BQ-1 What is the natural history (epidemiology) of lateral epicondylitis?
Lateral epicondylitis is common among individuals in their late 30s and 50s, with no sex-based differences. The onset is not associated with labor or the dominant hand side; however, it is associated with the performance of sports activities wherein rackets are used, such as tennis and badminton.
Lateral epicondylitis is less common in young people in their 20s, with most of the affected subjects being in their late 30s–50s [2]. To the best of our knowledge, no studies have described in detail
Declaration of competing interest
Conflicts of interest (2015–2017) were confirmed via self-reporting by all the members of the Lateral Epicondylitis Guideline Committee. No company was directly involved in the guideline recommendations and the systematic review team. The Executive Director and members declared that no company was directly involved in the recommended text for the clinical questions. To minimize bias and conflict of interest in the text, all the members voted on the recommended decisions, excluding the persons
Acknowledgement
We appreciate Masahiro Yoshida, MD, PhD for a great advice of this guidelines. We would like to express our deep gratitude to Fuminori Kanaya, MD, PhD for his contribution as an advisor to the committee. We would like to thank systematic review team for preparation of structured abstract, and NAI Inc. (www.nai.co.jp) for English language editing. We also thanks to Ms. Misako Kaji, and Ms. Mariko Henmi, International Medical Information Center, for their clerical support. Funds required to
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