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Autologous Blood Injection: A Promising Treatment for Lateral Epicondylitis, Article Critique Example

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Article Critique

Abstract

Autologous blood injections (ABI’s) are one treatment option available for lateral epicondylitis.    There have been a few clinical studies done that have shown promise, but there is currently insufficient evidence to recommend ABI’s for routine clinical use. More studies are needed to determine the effectiveness of ABI’s. This project in its present form is the theoretical, hypothetical and the practical implementation of analyzing the results amongst different clinical studies, to achieve the most effective and a long term treatment for the Lateral epicondylitis.

The initial idea was to determine the most promising phases for the effective usage of CIPDUSA Foundation (n.d.) states that the Autologous Blood Injection (ABI) is the process of injecting the patient’s own blood and mixing with one 1 ml of 2% lidocaine or 1 ml of 0.5% bupivacine, which is then injected just proximal to the lateral epicondyle of the elbow along the elbow along the suparcondylar ridge and then advanced into the undersurface of the extensor Carpi radialis.

Some of the treatments as mentioned below are namely, corticosteroid injection, extracorporeal shockwave therapy, NSAIDS for temporary pain relief, Bracing the Wrist and Forearm, physical therapy, Boutulinum Toxin Type A (Botox) and surgery. The Research question initiated here is “Although Autologous Blood Injection (ABI) seems promising, more research is needed and to suggest some topics for further research.” The hypothesis indicates that ABI has positive and long term effects on the patients in comparison to all the other treatments, as well as being a cost-effective phenomena. The experimenters divided certain groups of people with the lateral elbow pain and tested the individuals with each of the treatments mentioned above. The results provide some highlights onto the prolonged effectiveness and availability of the method and its components.

Background

Lateral epicondylitis (LE) is a common overuse syndrome of the extensor tendons of the forearm; this condition affects men and women equally and typically represents the fourth to fifth decade of life.  Brett D. Owens (2012) states that Lateral epicondylitis (LE) also known as tennis elbow, is a commonly encountered problem in orthopedic practice. It is the most common cause of lateral elbow pain and affects 1-3% of the population with the dominant arm being the one most affected. It may also occur as a result of a minor, unrecognized trauma and from repetitive wrist dorsiflexion with supination and pronation.  This repetitive movement causes microtears in the extensor tendon of the forearm. It is typically a self-limiting condition with most patients having symptomatic relief in one year through modification of activities; however, 5-10 % of patients with LE will require surgical intervention. While there are numerous treatment strategies available, there have been few clinical trials to support many of the options.  Autologous Blood Injection (ABI) is one treatment for LE that has had positive results so far in the few studies that have been done.  ABI is cost effective, minimally traumatic and has few side effects.  Future research is needed to provide sufficient evidence so that ABIs can become a recommended treatment for LE.

Pathophysiology

The exact cause of LE is unknown but likely occurs on a microscopic level and is thought to be the “result of cumulative microtrauma resulting from repetitive wrist extension and alternating forearm supination and pronation” (Scher, Wolf, & Owens, 2009).  This repetitive motion results in microtears in the extensor tendon.  The extensor carpi radialis brevis origin is most commonly recognized as the site of pathology.  This region of the elbow is thought to be vulnerable to injury due to the hypovascular zones (Faro & Wolf, 2007).  These zones also make healing more difficult.  LE is most likely a tendinosis rather than an inflammatory process (tendonitis) where microtears lead to a noninflammatory, degenerative avascular process (Scher, Wolf, & Owens, 2009).  Studies of tissue excised at surgery have a lack of inflammatory cells like lymphocytes and neutrophils (Faro & Wolf, 2007).

Clinical Presentation

Patients frequently report an insidious onset of pain with no history of a traumatic event.  Patients typically complain of pain in the lateral elbow that radiates down the forearm and worsens with activity.  Patients may also complain of weakened grip strength, difficulty lifting objects and pain when carrying heavy objects.  On physical examination patients typically have point tenderness medial and distal to the lateral epicondyle and pain with wrist flexion extremes.  LE is a clinical diagnosis and imaging studies are rarely needed to make the diagnosis.

Possible Treatments for Lateral Epicondylitis

Several different methods have been advocated for the treatment of LE, many of them showing mixed results when looking at effectiveness.

Wait and See

With the Wait and See approach patients are to avoid aggravating activities and are advised to take acetaminophen or a non-steroidal anti-inflammatory (NSAID) drug for pain if necessary.  According to Johnson, Cadwallader, Scheffel, & Epperly (2007), it was found in one random control trial that “a one year watchful-waiting approach was comparable with physical therapy and superior to corticosteroid injection in alleviating a patient’s main complaint.”

 

 

NSAIDS

Topical or oral NSAIDs can be used for short term pain relief.

 

Corticosteroid Injection

Corticosteroid injection is a popular treatment for LE and was once considered to be the golden standard for treatment; however, today the effectiveness of the treatment is controversial (Peerbooms, Sluimer, Bruijn, & Gosens, 2010). Local corticosteroid injection has been found to have short term benefits, lasting from two to six weeks, in pain reduction and grip strength.  Patients should have no more than three injections in a year and if the patient has little response to the first injection then subsequent injections should not be given.  Johnson et al. found that “Although corticosteroid injections are effective in the short-term, their long-term effectiveness and advantages over conservative treatments are uncertain” (2007).  Another randomized control trial found that the short-term benefits of corticosteroid injection are reversed after six weeks, with high recurrence rates possibly up to 60 % (Kazemi, Azma, Tavana, Moghaddam & Panahi, 2010).

Extracorporeal Shock Wave Therapy

The usage of Extracorporeal Shock Wave Therapy was started in the last decade due to its success in the treatment of other soft tissue injuries.  Extracorporeal Shock Wave Therapy

was once thought to be a beneficial treatment for LE and is still sometimes used, even though a randomized control trial in 2005 and several other studies have found strong evidence against using it as a treatment for LE (Johnson et al., 2007).

 

 

Bracing the Wrist and Forearm

Inelastic, nonarticular proximal forearm straps have been found to decrease pain and increase grip strength.  It is recommended that these straps be used for up to six weeks.  However, multiple studies have been done and have been unable to provide conclusions about the benefits of the forearm strap and bracing for LE (Johnson et al., 2007).  Wrist splints that limit extension and cause a decrease in the amount of stress placed on the extensor origin are another treatment option.

Physical Therapy

Physical therapy including strength training, stretching and deep friction massage may be used.  Physical therapy may reduce pain but it is unclear whether or not physical therapy helps to increase grip strength (Johnson et al., 2007).

Boutulinum Toxin Type A (Botox)

Botox is thought to facilitate healing by temporarily paralyzing the common extensor origin.  There have only been a couple of small randomized control trials done regarding the effectiveness of Botox with only one trial showing promise for this therapy (Johnson et al., 2007).

Surgery

Surgery is typically recommended when more conservative treatments have failed to relieve LE symptoms after six to twelve months.  There are several surgical techniques including open, percutaneous and arthroscopic.  The optimal surgical technique is debatable, but most options are associated with successful outcomes (Faro & Wolf, 2007).

Autologous Blood Injection

ABI involves taking a sample of the patients own blood and then injecting it into the area of tendon damage.  This treatment option will be discussed in more detail in the next section.

Combination of Treatments

Many times a combination of the above mentioned therapies is used to treatment.  For example physical therapy and bracing or adding NSAIDs to the wait and see approach. 

Autologous Blood Injection

ABI is a treatment for LE that has been introduced over the past ten years to aide in the recovery of tendon injuries.  ABI involves taking a small sample of the patients own blood, mixing it with lidocaine and then injecting it into the region of tendon damage.  The exact mechanism of action of ABI is unknown, but it is thought to trigger the inflammatory response of the body and initiate healing in the tendon.  It is hypothesized that ABI works because the injected cells release mediators of inflammation and healing, specifically Platelet Derived Growth Factor and Insulin like Growth Factor.  These growth factors are anabolic hormones that promote a positive healing environment (Hanna, 2009).  There tends to be a cumulative effect with ABIs requiring some patients to need more than one injection (Ozturan, Istemi, Husamettin & Guven, 2010).

ABI injections are minimally traumatic and cheaper than many of the other treatments for LE.  There is also no requirement for any additional equipment.  Patients receiving ABIs tend to have fewer short and long term effects rather than with any other LE treatment choice.  ABIs have a low complication rate with no reported infections or tendon ruptures (Faro & Wolf, 2007).  ABIs have also been found to cause no structural damage or changes to the tendon.  Some patients do report pain at the injection site lasting 24 to 48 hours after the injection.

There have been only a few clinical studies done on ABIs and all have shown success, but because of the limited number of studies, the size of the studies and inadequate length of follow up there is currently insufficient evidence to recommend ABI’s for routine clinical use.   Few studies have been done in which ABI’s have proven to be a better short term and long term treatment than other treatment modalities that it was tested against.  Significant difference was found in the studies in the areas of grip strength, limb function and the severity of the patient’s pain.  ABIs were found to greatly increase patient’s function and to have low recurrence rates.  In one study done by Kazemi, et al., 2010, ABIs were compared with corticosteroid injections in a randomized control trial of 60 patients looking at the outcomes of grip strength, severity of pain and limb function at 4 and 8 week intervals following their injections.  They found that ABI was more effective in all situations and concluded that ABI is more effective in short term treatment as compared to corticosteroid injections (Kazemi et al., 2010).  Ozturan, et al., 2010, performed a randomized control trial looking at the short, medium and long-term effects of ABIs, corticosteroid injections and extracorpeal shock therapy.  The study included 60 patients, divided into three groups and the patients were followed for 1 year.  Ozturan, et al., 2010, found that corticosteroid injections provided a high success rate in the short- term but had high recurrence rates, and ABIs gave better long-term results.  “We suggest that the treatment of choice for lateral epicondylitis be autologous blood injection” (Ozturan, et al., 2010).

Implications for Nurse Practitioners

Lateral epicondylitis is one of the most common overuse syndromes seen in primary care.  It is important for Nurse Practitioners to have knowledge of the most effective treatments available and be up to date on the current research.  More studies need to be done to determine the effectiveness of ABIs and both the short and long term effects.  Researchers recommend future studies looking at the long-term effectiveness and possible complications of ABIs.  Researchers also stress the need for high quality, well conducted studies.  Another suggestion is for more studies comparing ABIs to the golden standard, corticosteroid injections.

References

  1. CIPDUSA Foundation. “Autologous Blood Injection in the Treatment of Plantar Fasciitis.” Accessed January 16th, 2012. http://emedicine.medscape.com/article/1231903-overview
  2. Faro, F., & Wolf, J. M.  (2007). Lateral epicondylitis: Review and current concepts.  Journal of Hand Surgery, 32A (8), 1271-1279.  doi:10.1016/j.jhsa.2007.07.019.
  3. Hanna, C.  (2009). Autologous blood injections.  New Zealand Journal of Physiotherapy, 37(3), 147.
  4. Johnson, G. W., Cadwallader, K., Scheffel, S.B., & Epperly, G. W.  (2007). Treatment of lateral    epicondylitis.  American Family Physician, 76(6,) 849-853.
  5. Kazemi, M., Azma, K., Tavana, B., Moghaddam, F. R., & Panahi, A.  (2010). Autologous blood       verses local injection in the short-term treatment of lateral elbow tendinopathy.    American Journal of Physical Medicine & Rehabilitation/Association of Academic        Physiatrists, 89(8), 660-667.  doi:10.1097/PMH.0b013e3181ddcb31.
  6. Owens, D. Brett.” Web Med Professional: Drug, Disease and Procedures” Background:  Lateral epicondylitis surgery, July 11th , 2011, accessed January 16th, 2012, http://emedicine.medscape.com/article/1231903-overview
  7. Ozturan, K. E., Istemi, Y., Husamettin, C., Guven. M., & Sungur, I.  (2010). Autologous blood       and corticosteroid injection and extracorporeal shock wave therapy in the treatment of        lateral epicondylitis.  Orthopedics, 33(2), 84-91doi: 10.3928/01477447-20100104-9.
  8. Peerbooms, J. C., Sluimer, J., Bruijn, D. J., & Gosens, T.  (2010). Positive effect of autologous    platelet concentrate in lateral epicondylitis in a double-blind randomized control trial.  The   American Journal of Sports Medicine, 38(2), 255-262.  doi:10.1177/0363546509355445.
  9. Scher, D. L., Moriatis, J., & Owens, B. D.  (2009).  Lateral epicondylitis.  Orthopedics, 32(4),     276-282.

 

Journal Requirements-

The Nurse Practitioner Journal; The American Journal of Primary Healthcare

All articles must be submitted electronically in the Chicago Manual of Style.  Articles can have a maximum of 4,000 words including references and tables.  The article must include an abstract that is less than 50 words.  The submission must be double spaced, with 12 point type and one inch margins.

Notes:

I have made some changes to the grammatical version of the article journal, as there were some grammatical errors in phrases and some punctuation mistakes, as well as I am including the abstract and the following summary with it. I hope you get the entire idea about the main concept of the paper. I have numbered the references and have cited couple references to present the work in a cohesive manner.

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