Understanding prognosis to improve rehabilitation: The example of lateral elbow pain

  • Pamela L. Hudak
    Reprint requests to P. Hudak, Institute for Work and Health, 250 Bloor St E, Ste 702, Toronto, Ontario, Canada M4W 1E6.
    Institute for Work and Health, Toronto, Canada

    The Toronto Hospital Hand Program, Toronto, Canada
    Search for articles by this author
  • Donald C. Cole
    Institute for Work and Health, Toronto, Canada

    Department of Clinical Epidemiology and Biostatistics, and the Occupational Health Program, McMcaster University, Hamilton, Canada
    Search for articles by this author
  • A.Ted Haines
    Department of Clinical Epidemiology and Biostatistics, and the Occupational Health Program, McMcaster University, Hamilton, Canada

    LAMP Occupational Health Program, Etobicoke Ontario, Canada
    Search for articles by this author
      This paper is only available as a PDF. To read, Please Download here.


      Objective: A systematic overview of evidence aimed at determining the clinical course of lateral elbow pain and prognostic factors that affect elbow pain duration and outcomes.
      Data Sources: Online bibliographic database searches from 1983 to 1994; information requests from selected authors and bibliography screenings.
      Study Selection: One author reviewed 424 articles; 40 met the following eligibility criteria: any study with primary data on soft tissue injuries specific to the elbow which referred to prognosis or reported use of any outcome measure.
      Data Abstraction: Strength of evidence grade based on clinical epidemiological validity assessment. Criteria included in the validity assessment included case definition, patient selection, follow-up, outcome, prognostic factors, and analysis. All eligible studies were independently assessed by two investigators.
      Data Synthesis: Four studies (10%) were judged to provide moderate strength of evidence; no studies were graded as providing strong evidence on prognosis. All four moderate-quality studies were clinical trials of short duration. One study indicated that site of lesion and prior occurrence may be predictive of poorer outcome in patients with lateral epicondylitis.
      Conclusion: The majority of studies on lateral elbow pain were limited by methodological weaknesses in selection and definition of the study population, length of follow-up, and analysis of prognostic factors. Estimates of duration were only available from weaker studies with longer follow-up times; significant subject heterogeneity in the weaker studies prevented a determination of usual clinical course. More methodologically rigorous research on prognosis could assist clinicians in patient care and evaluation of interventions.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Fletcher RH
        • Fletcher SW
        • Wagner EH
        Clinical epidemiology—the essentials.
        Williams & Wilkins, Baltimore/London1988
        • Beaton DE
        Examining the clinical course of work-related musculoskeletal disorders of the upper extremity using the Ontario workers' compensation board administrative database.
        in: 4th ed. MSc Thesis. University of Toronto, Toronto1995
        • Reid J
        • Ewan C
        • Lowy E
        Pilgrimage of pain: the illness experiences of women with repetition strain injury and the search for credibility.
        Soc Sci med. 1991; 32: 601-612
        • Tarasuk V
        • Eakin JM
        Back problems are for life: perceived vulnerability and its implications for chronic disability.
        J Occup Rehabil. 1994; 4: 55-64
        • Taylor P
        Keyboard grief: computing with computer-caused injuries.
        in: Toronto Globe and Mail. 1993 Dec 27: 1-8 (Sect A)
      1. Cole DC, Hudak PL. Understanding the prognosis of non-specific work related musculoskeletal disorders of the neck and upper extremity. Am J Ind Med. In Press.

        • Cyriax JH
        The pathology and treatment of tennis elbow.
        J Bone Joint Surg. 1936; 18: 921-940
        • Murtagh JE
        Tennis elbow.
        Aust Fam Physician. 1988; 17: 90-95
        • Wood M
        • Knight NC
        Tennis elbow: its clinical course, etiology and treatment.
        J Ark Med Soc. 1959; 85: 499-500
        • Leach RE
        Lateral and medial epicondylitis of the elbow.
        Clin Sports Med. 1987; 6: 259-272
        • Wortman PM
        Judging research quality.
        in: 4th ed. The handbook of research synthesis. Russell Sage Foundation, New York1994: 97-108
        • Stratford PW
        • Levy DR
        • Gauldie S
        • Miseferi D
        • Levy K
        The evaluation of phonophoresis and friction massage as treatments for extensor carpi radialis tendinitis: a randomized controlled trial.
        Physiother Canada. 1989; 41: 93-99
        • Haker E
        • Lundeberg T
        Acupuncture treatment in epicondylalgia: a comparative study of two acupuncture techniques.
        Clin J Pain. 1990; 6: 221-226
        • Vasseljen Jr, O
        • Hoeg N
        • Kjeldstad B
        • Johnsson A
        • Larsen S
        Low level laser versus placebo in the treatment of tennis elbow.
        Scand J Rehabil Med. 1992; 24: 37-42
        • Lundeberg T
        • Abrahamsson P
        • Haker E
        A comparative study of continuous ultrasound, placebo ultrasound and rest in epicondylalgia.
        Scand J Rehabil Med. 1988; 20: 99-101
        • Sackett DL
        • Haynes RB
        • Tugwell P
        Clinical epidemiology: a basic science for clinical medicine.
        Little, Brown, Boston/Toronto1985
        • Kernan WN
        • Feinstein AR
        • Brass LM
        A methodological appraisal of research on prognosis after transient ischemic attacks.
        Stroke. 1991; 22: 1108-1116
        • Landis JR
        • Koch GG
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Pulcins IR
        • Goel V
        • Cohen JE
        • Frank JW
        A structured critical review of acute back pain prognosis studies.
        in: 4th ed. Working Paper no. 21. Institute for Work and Health, Toronto1994
        • Sackett DL
        • Whelan G
        Cancer risk in ulcerative colitis: scientific requirements for the study of prognosis.
        Gastoenterology. 1980; 78: 1632-1634
        • Haker E
        • Lundeberg T
        Elbow-bond, splintage and steroids in lateral epicondylalgia (tennis elbow).
        The Pain Clinic. 1993; 6: 103-112
        • Haker E
        Lateral epicondylalgia: diagnosis, treatment and evaluation.
        Crit Rev Phys Rehabil Med. 1993; 5: 129-154
        • Croft P
        Soft tissue rheumatism.
        in: Silman AJ Hochberg MC Epidemiology of the rhematic diseases. Oxford University Press, Oxford/New York/Tokyo1993: 375-421
        • Buchbinder R
        The classification of soft tissue disorders of the neck and upper limb for epidemiological research.
        in: 4th ed. MSc Thesis. University of Toronto, Toronto1993
        • Eisen A
        • Danon J
        The mild cubital tunnel syndrome its natural history and indications for surgical intervention.
        Neurology. 1974; 24: 608-613
        • Kaplan PE
        Posterior interosseous neuropathies: natural history.
        Arch Phys Med Rehabil. 1984; 65: 399-400
        • Smith DL
        • McAfee JH
        • Lucas LM
        • Kumar KL
        • Romney DM
        Treatment of nonseptic olecranon bursitis: a controlled, blinded prospective trial.
        Arch Intern Med. 1989; 149: 2527-2530
        • Maya-Segrelles C
        • Lopez-Casquero C
        • Vidal-Fuentes J
        Effectiveness of treatment with orgotein infiltration on epicondylitis: an open study.
        Curr Ther Res. 1989; 45: 593-603
        • Nevelos AB
        The treatment of tennis elbow with triamcinolone acetonide.
        Curr Med Res Opin. 1990; 6: 507-509
        • Holdsworth LK
        • Anderson DM
        Effectiveness of ultrasound used with a hydrocortisone coupling medium or epicondylitis clasp to treat lateral epicondylitis: pilot study.
        Physiotherapy. 1993; 79: 19-25
        • Burton AK
        A comparative trial of forearm strap and topical anti-inflammatory as adjuncts to manipulative therapy in tennis elbow.
        Manual Med. 1988; 3: 141-143
        • Schapira D
        • Linn S
        • Scharf Y
        A placebo-controlled evaluation of diclofenac diethylamine salt in the treatment of lateral epicondylitis of the elbow.
        Curr Ther Res. 1991; 49: 162-168
        • Gatchel RJ
        • Mayer TG
        • Hard RG
        • Rainville J
        • Mooney V
        Functional restoration.
        in: Pitfalls in evaluating efficacy. 4th ed. Spine. 17. 1992: 988-995 ([Editorial])
        • Kaegi E
        New approaches to worker compensation.
        Occup Health Ontario. 1990; 11: 60-70
        • Mitchell RI
        • Carmen GM
        Results of a multicenter trial using an intensive active exercise program for the treatment of acute soft tissue and back injuries.
        Spine. 1990; 15: 514-521
        • Gerberich S
        • Priest JD
        Treatment for lateral epicondylitis: variables related to recovery.
        Br J Sports Med. 1985; 19: 224-227
        • Kamien M
        A rational management of tennis elbow.
        Sports Med. 1990; 9: 173-191
        • Chalmers TC
        • Smith Jr, H
        • Blackburn B
        • Silverman B
        • Schroeder B
        • Reitman D
        • et al.
        A method for assessing the quality of a randomized control trial.
        Control Clin Trial. 1981; 2: 31-49
        • Hogg-Johnson S
        • Frank JW
        • Rael E
        Prognostic risk factor models for low back pain: why they have failed and a new hypothesis.
        in: 4th ed. Working Paper no. 19. Institute for Work and Health, Toronto1994