Abstract

Purpose: Although the impact of Lateral Elbow Tendinopathy (LET) has been studied in relation to work absence and healthcare utilization, there is a lack of studies to explore the experience of living with this condition. A questionnaire-based survey was conducted to understand the lived experiences of people with Lateral Elbow Tendinopathy (LET).

Methods: Participants in the project on the Effectiveness of INDIBA active in patients with chronic LET answered the questionnaire.

Results: Repetitive activity was the most common cause of LET. Pain, loss of function, and decrease in strength were the symptoms of LET patients affecting everyday activities and hobbies. Although patients searched for online advice, they did not follow online treatment as they did not understand the condition after online searching. Finally, participants received no treatment or ineffective treatment.

Conclusion: For the first time, the lived experience of people from a range of backgrounds suffering from LET has been explored by a survey. The present study provides a stimulus for physicians to think about the advice and treatment provided for LET patients.

Keywords: Elbow Tendinopathy; Physician; Pain; Healthcare

Introduction

Lateral Elbow Tendinopathy (LET) is the most common tendinopathy in the elbow area. The optimal treatment approach for LET is still being investigated. There is only one qualitative (interview) study in the UK that explores the experience of living with this condition, termed ‘the lived experience’ for this study [1]. By understanding the perceptions of people living with LET, practicians may be better well informed to offer education and advice to manage LET patients, as there is the possibility the LET condition will resolve naturally over time. Therefore, the present questionnaire survey aims to understand the lived experiences of people with LET.

Materials and Methods

Patients consenting to the project of the Effectiveness of INDIBA active in patients with chronic LET [This trial was approved by the Bioethics Committee of the West Attica University (15/10/2021- 86886)] were asked to complete a questionnaire about their lived experience with LET. No validated instrument (questionnaire) existed for the study. Therefore, the present survey (DS) investigator designed a questionnaire. Experts in this field were contacted, and their comments on the draft questionnaire design were sought.

The final questionnaire comprised:

i. Background information such as sex, age, dominant and problematic arm, duration of symptoms, and occupation.

ii. Cause of onset

iii. Symptoms of everyday life

iv. Self-help and understanding of the condition

v. Previous healthcare experience [treatment(s)].

A pilot study using the described questionnaire was carried out. The number of subjects required for a pilot study often depends on circumstances and resources [2-5]. Since ten subjects have been used to run pilot studies for other questionnaire surveys [6], the present questionnaire was administered to ten LET patients. The ten LET patients who were selected for the pilot study were drawn from the population for inclusion in the main study. The design of the questionnaire was subsequently discussed with the respondents and their comments were noted. The results of the pilot study were not included in the final data analysis. All respondents returned the questionnaire and all questionnaires were fully completed. No negative comments or feedback about completing the questionnaire were received during the pilot study. Respondents noted that the questionnaire included clear and concise instructions on completing it, using simple language and leaving adequate space for them to make comments. Finally, respondents mentioned that the questionnaire held their interest and was completed easily.

The questionnaire was designed to assure the confidentiality and anonymity of the responding LET patients since there was no coding to identify the questionnaires. LET patients complete the questionnaires and submit the completed questionnaires to the investigator (DS) using an envelope. When the questionnaire was returned, the returned envelope was discarded maintaining the confidentiality and anonymity of the subjects’ responses to the questionnaire. Oppenheim (1992) suggests that questionnaires should be returned for a period of two weeks from the time they are distributed to participants [7]. However, such a period is not long enough to provide a high response rate. Therefore, the investigator of the project (DS) chose to extend the deadline of the present study for two more weeks, allowing the participants to return the questionnaires within four weeks (end of treatment period) from the time they received them. This deadline was extended in the hope of increasing the response rate. No questionnaires were received after the deadline of the four weeks. No follow-up reminders were sent to assure anonymity. Data was managed using descriptive statistical analysis.

Results

All the patients (forty) who participated in the project “The Effectiveness of INDIBA activ in patients with chronic LET” completed the questionnaire. They completed all the sections of the questionnaire. All were Greeks. There were more women than men who completed the questionnaire (five more in total). The mean age of the patients was about 48 years, and the duration of LET was about 6 months. LET was in the dominant arm in 82% of patients. 35 participants were manual workers and the rest were amateur tennis players. Repetitive activity was the most common cause of LET (80%). Sudden changes in activity (20%) were the other cause of the condition. Pain and loss of function were the most common symptoms (100%). Participants reported pain performing daily tasks such as washing (34%), dressing (28%), household chores (72%), driving the car (45%), gardening (14%), exercising in a gym (11%), gripping (81%) such carry a bag or briefcase; open a jar; and turn a key, eating (23%) and drinking (18%). The decrease of strength was reported by 30 participants (75%). All participants (100%) searched for self-help advice online. In addition, all participants (100%) searched the internet to understand the condition. 95% of participants neither understand the condition nor follow the online advice. 20 out of 40 participants did not receive any treatment (50%). 40% of participants received drugs, painkillers, and/or non-steroidal anti-inflammatory drugs (NSAIDs). 3 patients (7.5%) received acupuncture and 1 patient (2.5%) received electrophysical agents. 80% of participants were advised to completely avoid all painful activities.

Discussion

To our knowledge, this is the first questionnaire survey exploring the lived experience of people with LET. There is only one qualitative (interview) study in the UK on the same topic [1].

Four themes were identified related to the condition:

1) Cause of onset.

2) Symptoms of the condition.

3) Self-help and understanding of the condition.

4) Previous treatment approach.

The most common cause of onset was repetitive activity. A less common cause was the sudden change of activity. Our results are in line with previous evidence [1]. however, the above finding needs to be treated with caution because many times patients misattribute the causes of their pain. In addition, there are arm health conditions such as shoulder pain or carpal tunnel syndrome, which is commonly associated with LET and few patients related the cause of onset and their symptoms to these conditions [8-11].

The questionnaire findings suggest that LET patients frequently experience a substantial impact on basic functional tasks and hobbies. The participants did not answer that they stopped their activity or work due to pain. Bateman et al (2023) described a novel finding in their study, the sleep disturbance [1]. Previous research on the topic does not support the last finding [1]. This difference occurred because previous studies recruited patients who reported high levels of baseline pain and disability. Our study did not support the sleep disturbance finding from the Bateman et al study even in our trial recruiting patients who were actively seeking healthcare, as in the Bateman et al study [1].

All participants searched online to find information for LET. However, they did not understand the condition. The above occurred due to many terms that are used to describe the condition. LET seems to be the most appropriate term to use in clinical practice because all the other terms such as lateral epicondylitis, lateral epicondylalgia, lateral epicondylosis, and/or tennis elbow refer to inappropriate aetiological, anatomical, and pathophysiological terms [12]. It is time the inappropriate clinical diagnostic terminology to be removed from the clinical vocabulary to avoid confusion. Even though participants reported feeling reluctant to seek self-help advice, they did not follow online advice because probably they did not understand the condition and feared self-administered treatment that may “aggravate” their symptoms.

Half of the participants received no treatment approach. They thought probably that LET is a self-limiting condition. However, LET is not self-limiting and is associated with ongoing pain and disability in a substantial proportion of sufferers [12]. 40% of participants received drugs, painkillers, and/or NSAIDs. Oral NSAIDs carry the risk of gastrointestinal bleeding, myocardial infarction, and stroke, as well as rarer side effects [13]. There is a lack of evidence to suggest that NSAIDs are effective for LET [14]. There appears to be a risk that clinicians are offering patients false hope by providing treatments that are not clinically effective [1]. 10% of participants received acupuncture and electrophysical agents. These treatments were ineffective.

The above treatments are not used as a stand-alone treatment. The most effective physiotherapy treatment for LET is an exercise program, in the clinic or supervised [15]. Electrotherapy agents and acupuncture are used as a supplement to an exercise program and not as a substitute for exercise [16]. The strength point of this trial is that this is the first questionnaire study exploring the impact of LET on patients’ everyday lives. We acknowledge though that survey studies draw on the opinions of those questioned and may not be truly representative of the wider population. The answers presented are from people accessing clinicians for LET and so may not reflect the aspects of those who do not access practicians for LET, due to lower symptom severity, stoicism, or inaccessibility. This may exclude some underserved groups [1].

Conclusions

A questionnaire-based survey was conducted to understand the lived experiences of people with LET. Repetitive activity was the most common cause of LET. Pain, loss of function, and decrease in strength were the symptoms of LET patients affecting everyday activities and hobbies. Although patients searched for online advice, they did not follow online treatment as they did not understand the condition after online searching. Finally, participants received no treatment or ineffective treatment. The present study provides a stimulus for physicians to think about the advice and treatment provided for LET patients.

dropdown Start here

References

1. Bateman M, Hill JC, Cooper K, Littlewood C, Saunders B (2023) Lived experience of people with lateral elbow tendinopathy: a qualitative study from the OPTimisE pilot and feasibility trial. BMJ 13(8): e072070.
2. Thomas J, Nelson J (1996) Research Methods in Physical Activity, 3^rd 174 ed. Human Kinetics, Champaign, Canada.
3. Hicks CM (1999) Research Methods for Clinical Therapists: Applied project design and analysis, 3^rd 177 ed. Churchill Livingstone, Edinburgh, Scotland.
4. Domholdt E (2000) Physical therapy research: principles and applications. 2^nd 178 ed. Saunders Company, Philadelphia.
5. Berg K, Latin R (2004) Essentials of research methods in health, physical education exercise science and recreation 2^nd 181 ed. Lippincott Williams and Wilkins, Baltimore, USA.
6. Dimitrios SA (2020) Questionnaire Survey to Establish Current Clinical Practice of Radial Extracorporeal Shock Wave Therapy (rESWT) for the Management of Pain and Functional Impairment on Chronic Lateral Elbow Tendinopathy in Nicosia. J Nov Physiother 10(7): 443.
7. Oppenheim A (1992) Questionnaire Design, Interviewing and Attitude Measurement, 2^nd 186 ed. Pinter Publications, London; New York.
8. Titchener AG, Fakis A, Tambe AA, C Smith, R B Hubbard, et al. (2013) Risk factors in lateral epicondylitis (tennis elbow): a case-control study. J Hand Surg Eur 38(2): 159-164.
9. Lemmers M, Versluijs Y, Kortlever JTP, Amanda I Gonzalez, David Ring (2020) Misperception of disease onset in people with gradual-onset disease of the upper extremity. Journal of Bone and Joint Surgery 102(24): 2174-2180.
10. Van Hoorn BT, Wilkens SC, Ring D (2017) Gradual onset diseases: misperception of disease onset. J Hand Surg Am 42(12): 971-977.
11. Walker-Bone K, Palmer KT, Reading I, David Coggon, Cyrus Cooper (2004) Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Rheum 51(4): 642-651.
12. Stasinopoulos D, Johnson MI (2006) “Lateral elbow tendinopathy” is the most appropriate diagnostic term for the condition commonly referred-to as lateral epicondylitis. Med Hypotheses 67: 1400-1402.
13. Davis A, Robson J (2016) The dangers of NSAIDs: look both ways. Br J Gen Pract 66(645): 172-173.
14. Pattanittum P, Turner T, Green S, Rachelle Buchbinder (2013) Non-Steroidal antiinflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Cochrane Database Syst Rev 2013(5): CD003686.
15. Stasinopoulos D (2022) Is a Heavy-Slow Resistance Exercise Program an Appropriate Treatment Approach for All Patients with Lateral Elbow Tendinopathy? Editorial. J. Clin. Med 11: 1556.
16. Kinney WR, Anderson BR (2023) Nonoperative Management of Lateral Epicondyle Tendinopathy: An Umbrella Review. J Chiropr Med 22: 204-211.