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Innovative multimodale Therapie der chronischen lateralen Epikondylitis

Innovative multimodal therapy of chronic lateral epicondylitis

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Zusammenfassung

Hintergrund

Randomisiert-kontrollierte Studien gemäß Level-Ib-Evidenz belegen, dass die Sklerosierung der pathologischen Neovaskularisation mit Power-Doppler-kontrollierten Polidocanol-Injektionen, die extrakorporale Stoßwellentherapie (ESWT), die topische Nitroglycerinanwendung (NO) und exzentrisches Krafttraining den Schmerz bei chronischer laterale Epikondylitis reduzieren. In dieser Praktikabilitätsstudie wurden die zuvor genannten Behandlungsmöglichkeiten parallel kombiniert, um potentiell eine noch schnellere Schmerzreduktion zu erzielen.

Hypothese

Es ist möglich, fokussierte extrakorporale Stoßwellentherapie in derselben Sitzung mit Polidocanol-Sklerosierung, exzentrischem Krafttraining, fokussierter ESWT und topischer NO-Sprayapplikation bei der Behandlung der lateralen Epikondylitis zu kombinieren.

Methoden

Fünfzehn Patienten (49 ± 4 Jahre, BMI 24,0 ± 3,0, 89 % Männer, Schmerzdauer 20 ± 25 Monate) mit einer chronischen (> 6 Monate) therapierefraktären lateralen Epikondylitis wurden eingeschlossen, die eine Neovaskularisation in der Power-Doppler-Sonographie am Ort des Schmerzes aufwiesen (49 ± 4 Jahre, BMI 24,0 ± 3,0, 89 % Männer, Schmerzdauer 20 ± 25 Monate). Unter Power-Doppler-Kontrolle erfolgte die Sklerosierungstherapie mit 0,5 % Polidocanol-Injektionen alle 6 Wochen, fokussierter extrakorporaler Stoßwellentherapie (Storz Duolith, 1000 Impulse, 0,25 mJ/mm2, 4 Hz, alle 6 Wochen), tägliches exzentrisches Krafttraining (Flex-Bar 6 × 15 Wiederholungen) und tägliche lokale Nitrolingualspray (2 × 2 Hübe entsprechend 1,6 mg/Tag) durchgeführt. Registrierung der klinischen Studie (ClinicalTrials.gov): NCT01185951.

Ergebnisse

Die durchschnittliche Anzahl der Behandlungssitzungen betrug 2 ± 2, die Compliance betrug 86 %. Die Schmerzen unter Belastung lagen bei 5,8 ± 2,8 [95 %-Konfidenzintervall (-KI) 4,4–7,2) vor Behandlungsbeginn und bei 1,7 ± 2,0 (95 %-KI 0,7–2,7; p = 0,001) nach 15 Monaten. Der Schmerz in Ruhe lag bei 2,7 ± 2,5 (95 %-KI 1,4–4,0) vor Behandlungsbeginn und bei 0,4 ± 1,1 (95 %-KI −0,1–1,0; p = 0,090) nach der Behandlung. Der DASH-Score verbesserte sich von 13 ± 13 (95 %-KI 7–20) auf 6 ± 8 Punkte (95 %-KI 2–9, p = 0,443). Es wurden keine negativen Nebenwirkungen beobachtet. 80 % der Probanden befanden sich auf einem höheren sportlichen und beruflichen Aktivitätsniveau mehr als ein Jahr später, 20 % der Probanden befanden sich auf demselben sportlichen und beruflichen Aktivitätsniveau wie zuvor.

Schlussfolgerung

Die multimodale Therapie als eine Kombination von Polidocanolsklerosierungen der Neogefäße, fokussierter ESWT, exzentrischem Krafttraining und lokaler Trinitroglyceridapplikation reduziert die chronischen Schmerzen in Ruhe und unter Belastung bei lateraler Epikondylitis bei hohen Complianceraten und ohne Nebenwirkungen innerhalb von zwei Behandlungssitzungen.

Abstract

Background

There is increasing evidence from randomized controlled trials that sclerosing of pathological neovascularization with power-Doppler controlled polidocanol injections, extracorporeal shock wave therapy, topical trinitroglyercine (NO) and eccentric training may be beneficial in long standing chronic lateral elbow tendinopathy (epicondylitis). We sought to combine the aforementioned options simultaneously in a pilot feasibility trial.

Hypothesis

Is it feasible to combine shock wave therapy followed immediately in the same session with sclerosing polidocanol injections, eccentric training, topical NO spray and concomitant sport up to VAS 5/10 in lateral elbow tendinopathy?

Methods

A total of 16 patients seeking medical care for chronic tendon pain in the lateral aspect of the elbow were screened and 15 were included with lateral elbow tendinopathy associated with neovascularization found in power-Doppler ultrasound at baseline examination (average age 49 ± 4 years, BMI 24.0 ± 3.0, 89 % men, pain duration 20 ± 25 months). Power-Doppler ultrasound was performed by one expert examiner (KK) with sclerosing therapy using 0.5 % polidocanol injections every 6 weeks, focused extracorporeal shock wave therapy (Storz Duolith, 1,000 impulses, 0.25 mJ/mm2 every 6 weeks), daily eccentric training and topical trinitroglycerin (1.6 mg/day) and follow-up 15 after months. Clinical trial registration (ClinicalTrials.gov): NCT01185951.

Results

Mean number of treatment sessions was 2 ± 2 and compliance was 86 %. Pain during exercise at baseline was 5.8 ± 2.8 (95 % confidence interval CI 4.4 − 7.2) at baseline and 1.7 ± 2.0 (95 % CI 0.7 − 2.7, p = 0.001) after 15 months. Pain at rest was 2.7±2.5 (95 % CI 1.4 − 4.0) at baseline and 0.4±1.1 (95 % CI − 0.1 − 1.0, p = 0.090) afterwards. The mean DASH score changed from 13 ± 13 (95 % CI 7 − 20) to 6 ± 8 (95 % CI 2 − 9, p = 0.443) and no adverse effects were encountered whereby 80 % were on a better and 20 % on the same sports and work activity level more than 1 year afterwards.

Conclusions

The combination of sclerosing polidocanol injections, focused extracorporeal shock wave therapy, eccentric training, topical trinitroglycerin and pain-guided physical activity appears to improve pain during exercise in chronic lateral elbow tendinopathy with high compliance rates and no adverse effects within 2 treatment sessions.

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Authors and Affiliations

  1. Sportpraxis Prof. Dr. med. Karsten Knobloch, Heiligerstr. 3, 30159, Hannover, Deutschland

    Karsten Knobloch FACS

  2. Plastische, Hand- und Wiederherstellungschirurgie, Med. Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland

    Stadermann Sophia &  Peter M. Vogt

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  1. Karsten Knobloch FACS
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  2. Stadermann Sophia
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  3. Peter M. Vogt
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Correspondence to Karsten Knobloch FACS.

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Knobloch, K., Sophia, S. & Vogt, P. Innovative multimodale Therapie der chronischen lateralen Epikondylitis. Obere Extremität 7, 158–165 (2012). https://doi.org/10.1007/s11678-012-0179-8

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