Design aspects of metal-free nitrogen-based catalysts and their influence on the yield in the Henry reaction

Article abstract of DOI:10.1055/s-0033-1341125

Design aspects of metal-free nitrogen-based catalysts and their influence on the yield in the Henry reaction are disclosed. C ₁-Symmetric, N,N-1,2-disposed amine-imine type catalysts were found to be most efficient. C ₁-N,N-1,2-Disposed 1,2,3,4-tetrahydro-1,1′-biisoquinoline selectively and efficiently catalyzed the addition of nitromethane to α-keto esters and aldehydes giving exclusively the corresponding β-nitro alcohol adducts in excellent yields under very mild conditions. Georg Thieme Verlag Stuttgart New York.

Full text of DOI:10.1055/s-0033-1341125

Acupuncture for lateral elbow pain (Review)
Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft WJJ
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2013, Issue 2
http://www.thecochranelibrary.com
Acupuncture for lateral elbow pain (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

T A B L E O F C O N T E N T S
HEADER
ABSTRACT
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1
1
PLAIN LANGUAGE SUMMARY
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BACKGROUND
OBJECTIVES
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METHODS
RESULTS .
DISCUSSION
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AUTHORS’ CONCLUSIONS
ACKNOWLEDGEMENTS
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REFERENCES
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CHARACTERISTICS OF STUDIES
DATA AND ANALYSES .
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Analysis 1.1. Comparison 1 ACUPUNCTURE VERSUS PLACEBO, Outcome 1 Duration of pain relief (hours).
Analysis 1.2. Comparison 1 ACUPUNCTURE VERSUS PLACEBO, Outcome 2 Overall improvement (number of
patients unchanged or worse).
Analysis 1.3. Comparison 1 ACUPUNCTURE VERSUS PLACEBO, Outcome 3 Less than 50 % pain relief after 1
treatment.
Analysis 2.1. Comparison 2 LASER ACUPUNCTURE POINTS VS PLACEBO, Outcome 1 Subjective outcome of no
change or worse. .
Analysis 3.1. Comparison 3 ACUPUNCTURE PLUS VITAMIN B12 INJECTION VS INJECTION ALONE, Outcome
1 Still with symptoms after treatment.
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WHAT’S NEW .
DECLARATIONS OF INTEREST
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SOURCES OF SUPPORT
INDEX TERMS . .
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Acupuncture for lateral elbow pain (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
i

[Intervention Review]
Acupuncture for lateral elbow pain
Sally Green1, Rachelle Buchbinder2, Les Barnsley3, Stephen Hall4, Millicent White5, Nynke Smidt6, Willem JJ Assendelft7
1School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia. 2Monash Department of Clinical Epidemi-
ology at Cabrini Hospital, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine,
3
4
Monash University, Malvern, Australia. Department of Rheumatology, Concord Hospital, Concord, Australia. Cabrini Medical
5
6
Centre, Melbourne, Australia. Linacre Physiotherapy, Linacre Physiotherapy, Hampton, Australia. Department of Epidemiology,
University Medical Center Groningen, University og Groningen, Groningen, Netherlands. 7Department of Public Health and Primary
Care, Leiden University Medical Center, Leiden, Netherlands
Contact address: Sally Green, School of Public Health & Preventive Medicine, Monash University, The Alfred Centre, 99 Commercial
Road, Melbourne, Victoria, 3004, Australia. sally.green@monash.edu.
Editorial group: Cochrane Musculoskeletal Group.
Publication status and date: Edited (no change to conclusions), published in Issue 2, 2013.
Review content assessed as up-to-date: 20 November 2001.
Citation: Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft WJJ. Acupuncture for lateral elbow pain. Cochrane
Database of Systematic Reviews 2002, Issue 1. Art. No.: CD003527. DOI: 10.1002/14651858.CD003527.
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
This review is one in a series of reviews of interventions for lateral elbow pain. Lateral elbow pain, or tennis elbow, is a common
condition causing pain in the elbow and forearm and lack of strength and function of the elbow and wrist. Acupuncture has long been
used to treat lateral elbow pain in China and in Western countries practitioners and consumers are increasingly exploring acupuncture
as a first line treatment for musculoskeletal disorders. No previous systematic review of the available evidence has been conducted to
determine whether acupuncture is efficacious in the treatment lateral elbow pain.
Objectives
To determine the effectiveness of acupuncture in the treatment of adults with lateral elbow pain with respect to pain reduction,
improvement in function, grip strength and adverse effects.
Search methods
We searched MEDLINE, CINAHL, EMBASE and SCISEARCH and the Cochrane Clinical Trials Register and the Musculoskeletal
Review Group’s specialist trial database from 1966 to June 2001. Identified keywords and authors were searched in an effort to retrieve
as many trials as possible.
Selection criteria
Two independent reviewers assessed all identified trials against pre-determined inclusion criteria. Randomised and pseudo randomised
trials in all languages were included in the review provided they were testing acupuncture compared to placebo or another intervention
in adults with lateral elbow pain (tennis elbow). Outcomes of interest were pain, function, disability, quality of life, strength, participant
satisfaction with treatment and adverse effect.
Data collection and analysis
For continuous variables means and standard deviations were extracted or imputed to allow the analysis of weighted mean difference,
while for binary data numbers of events and total population were analysed and interpreted as relative risks. Trial results were combined
only in the absence of clinical and statistical heterogeneity.
Acupuncture for lateral elbow pain (Review)
1
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Main results
Four small randomized controlled trials were included but due to flaws in study designs (particularly small populations, uncertain
allocation concealment and substantial loss to follow up) and clinical differences between trials, data from trials could not be combined
in a meta-analysis. One randomised controlled trial found that needle acupuncture results in relief of pain for significantly longer than
placebo (WMD = 18.8 hours, 95%CI 10.1 to 27.5) and is more likely to result in a 50% or greater reduction in pain after 1 treatment
(RR 0.33, 95%CI 0.16 to 0.69) (Molsberger 1994) . A second randomized controlled trial demonstrated needle acupuncture to be
more likely to result in overall participant reported improvement than placebo in the short term (RR = 0.09 95% CI 0.01 to 0.64)
(Haker 1990a) . No significant differences were found in the longer term (after 3 or 12 months). A randomized controlled trial of laser
acupuncture versus placebo demonstrated no differences between laser acupuncture and placebo with respect to overall benefit (Haker
1990b). A fourth included trial published in Chinese demonstrated no difference between Vitamin B12 injection plus acupuncture,
and Vitamin B12 injection alone (Wang 1997).
Authors’ conclusions
There is insufficient evidence to either support or refute the use of acupuncture (either needle or laser) in the treatment of lateral
elbow pain. This review has demonstrated needle acupuncture to be of short term benefit with respect to pain, but this finding is based
on the results of 2 small trials, the results of which were not able to be combined in meta-analysis. No benefit lasting more than 24
hours following treatment has been demonstrated. No trial assessed or commented on potential adverse effect. Further trials, utilising
appropriate methods and adequate sample sizes, are needed before conclusions can be drawn regarding the effect of acupuncture on
tennis elbow.
P L A I N L A N G U A G E S U M M A R Y
Acupuncture for elbow pain
Acupuncture might be able to provide short-term relief from tennis elbow, but more research is needed.
B A C K G R O U N D
Lateral elbow pain is characterised by pain over the lateral epi-
This Cochrane review is one of a series of Cochrane reviews of
condyle of the humerus and pain on resisted dorsi-flexion of the
interventions for lateral elbow pain in adults.
wrist. It is considered an overload injury typically following mi-
Lateral elbow pain is common (population prevalence 1-3%) (
Allender 1974) and causes considerable morbidity and financial
cost. Peak incidence is 40-50 years and for women between 42
and 46 years of age the incidence increases to 10% (Chard 1989,
Verhaar 1994). While lateral elbow pain is generally self-limiting,
symptoms often persist for 18 months to two years (Hudak 1996b)
. The cost is therefore high, both in terms of loss of productivity,
and health care utilisation. The incidence of lateral elbow pain in
nor and often unrecognised trauma of the extensor muscles of the
forearm (Murtagh 1988).
Three systematic reviews specifically addressing the effect of inter-
ventions for lateral elbow pain have been published (Labelle 1992,
Hudak 1996, Assendelft 1996). All report little demonstrable ev-
idence for efficacy of any of the studied interventions. No trials of
acupuncture were included in any of these reviews.
general practice is four to seven per 1000 patients per year (Verhaar Acupuncture for the treatment of musculoskeletal pain is growing
1994, Hamilton 1986, Kivi 1983).
in acceptance, by both clinicians and consumers of health care.
Approximately one million consumers utilise acupuncture annu-
ally in the United States (Paramore 1997), and a large percentage
of these suffer musculoskeletal disorders (Diehl 1997).
“Lateral elbow pain” is described by many analogous terms in the
literature, including “tennis elbow”, “lateral epicondylitis”, “row-
ing elbow”, “tendonitis of the common extensor origin”, and peri-
tendonitis of the elbow“. For the purposes of this review the term Acupuncture is thought to confer an analgesic effect and several
”lateral elbow pain“ will be used as it best describes the site of the hypotheses as to the chain of events resulting in analgesia from
pain, and will allow for greater clarity of inclusion.
acupuncture have been proposed. Some authors attribute the anal-
Acupuncture for lateral elbow pain (Review)
2
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

gesic effects to the release of b-endorphins in the lumbar spine d) Studies which included various soft tissue diseases and
and increased 5-Hydroxy tryptophan level in the cerebrum. Other tendinopathies at other sites were included provided that the lat-
explanations include the overriding of the pain stimulus by the eral elbow pain results were presented separately or > 90% of pa-
biochemical lines of acupuncture in the transmitting process of tients in the study had lateral elbow pain.
the central nervous system, and the more traditional explanation A full description of all inclusion criteria used to describe lateral
of the freeing of a blockage of ”Qi“ or energy flow by acupuncture elbow pain forms part of the table of included studies.
(Viola 1998).
Although acupuncture is often recommended for the treatment of
lateral elbow pain, few studies have investigated the efficacy of this
intervention, and to our knowledge, no systematic review has been
published specifically addressing the effectiveness of acupuncture
for relief of pain and dysfunction associated with lateral elbow
pain.
Types of interventions
All randomised, controlled comparisons of acupuncture versus
placebo or acupuncture versus another modality were included.
For the purposes of meta-analysis, comparisons were established
according to intervention.
Types of outcome measures
The outcomes of interest include pain (at night, at rest and on
movement), function, disability and quality of life (including sur-
rogate measures such as return to work), grip strength, participant
perception of overall effect or global preference, range of motion
(active and passive) and adverse effects.
O B J E C T I V E S
To determine the effectiveness of acupuncture in the treatment of
patients with lateral elbow pain with respect to symptom reduc-
tion including pain, improvement in function, grip strength, and
adverse effect.
Search methods for identification of studies
M E T H O D S
We searched MEDLINE, EMBASE, CINAHL (includes all ma-
jor physiotherapy and occupational therapy journals from U.S.A.,
Canada, England, Australia and New Zealand), and Science Ci-
tation Index (SCISEARCH) from 1966 to June 2001 using the
Cochrane Musculoskeletal Review Group’s ”optimally sensitive
search strategy“ to identify all possible randomised controlled tri-
als. Keywords gained from previous reviews and all relevant arti-
cles were searched. Any additional keyword identified from subse-
quent articles was searched again. As this review is one of a series
of interventions for lateral elbow pain, various interventions were
included in the search strategy.
Criteria for considering studies for this review
Types of studies
Studies were included following blinded review (author, year and
journal concealed) by two independent reviewers (SH, LB). Cri-
teria for inclusion were:
a) randomised controlled trials
1 RANDOMIZED-CONTROLLED TRIAL in PT
2 RANDOMIZED-CONTROLLED-TRIALS
3 RANDOM-ALLOCATION
b) outcome assessor blind or not blind to allocated group (a sen-
sitivity analysis was planned both including and excluding un-
blinded studies since foreknowledge of treatment allocation may
lead to biased assessment of outcome).
4 DOUBLE-BLIND-METHOD
5 SINGLE-BLIND-METHOD
c) all languages were considered, and a translator was if necessary.
A second sensitivity analysis was planned including and excluding
foreign language publications.
6 CLINICAL-TRIAL in PT
7 explode CLINICAL-TRIALS
8 (clin* near trial*) in TI
9 (clin* near trial*) in AB
10 (singl* or doubl* or trebl* or tripl*) near (blind* or mask*)
11 (#10 in TI) or (#10 in AB)
Types of participants
Inclusion in this review was restricted to trials with participants 12 PLACEBOS
meeting the following criteria:
a) Adults >16 years of age.
b) Lateral elbow pain for greater than three weeks duration.
13 placebo * in TI
14 placebo in AB
15 random * in TI
c) No history of significant trauma or systemic inflammatory con- 16 random * in AB
ditions such as rheumatoid arthritis.
17 RESEARCH DESIGN
Acupuncture for lateral elbow pain (Review)
3
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

18 #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 #15 #16 # Data collection and analysis
17
Following identification of potential trials for inclusion by the pre-
19 EXPLODE (* see note )
20 EXPLODE (* see note)
21 EXPLODE (see* note)
viously outlined search strategy (SG), the blinded methods sec-
tions of all identified trials were reviewed independently according
to predetermined criteria (see selection criteria), by two of three
investigators (LB, SH, RB). Decisions regarding the inclusion of
trials were be made independently and any disagreements resolved
by consensus where possible, or arbitration by the third reviewer.
DESCRIPTION OF VALIDITY
22 TEXT WORDS for all SYNONYMS or /
23 #19 or #20 or # 21 or #22
24 #18 AND # 23
25 TG=ANIMAL not ( TG=HUMAN and TG=ANIMAL)
26 #24 not 25
27 acupuncture*
Theblindedmethodsandresultssectionsof each includedtrialwas
assessed by the same two independent reviewers and the following
key methodological criteria were extracted.
28 analgesics*
29 anti-inflammatory drugs*
Allocation concealment
Blinded assessment of outcome
30 N.S.A.I.D.S.*
31 NSAID*
Numbers lost to follow up
Appropriate statistical analysis
32 extra corporeal shock wave therapy*
33 non steroidal anti-inflammatory drugs*
34 orthopaedic surgery*
A descriptive approach to validity assessment was chosen rather
than use of a scale due to concerns regarding the consistency and
validity of available scales. The key methodological criteria were
selected based on there being empirical evidence linking failure to
meet these criteria with the possibility of a biased trial result.
This information was then collated in the table of included studies,
and blinded outcome assessor used as the basis of a sensitivity
analysis.
35 surgery*
36 Ultrasound*
37 LLLT*
38 Laser*
39 Shortwave*
40 TENS*
41 #27 or #28 or #29 or #30 or #31 or #32 or #33 or #34 or #35
or #36 or #37 or #38 or #39 or #40
42 common extensor origin*
DATA EXTRACTION AND ANALYSIS
Data was extracted and recorded onto specially developed data
extraction forms. The following characteristics were extracted for
each trial and recorded along with the results of trial methodolog-
ical assessment in the Table of Included Studies.
43 epicondylitis*
44 lateral epicondylitis*
45 lateral elbow pain*
46 tendonitis*
1. Details of participants including demographic characteristics,
source of recruitment and criteria for diagnosis
47 tennis elbow*
48 #42 or #43 or #44 or #45 or #46 or #47
49 #26 and #41 and #48
2. Details of the experimental and control interventions including
intervention type, dosage and duration of treatment
3. Outcomes measures used in the trial (outcome, method of mea-
surement and timing)
Further electronic searches for key authors identified were made,
and a record of these searches kept. Print outs of all search strategies
were compiled and stored for future reproduction and review if
required.
In order to assess efficacy, raw data (means and standard deviations
of change scores) were extracted and entered into Revman 4.1.
When trials reported standard error of the mean it was converted
to a standard deviation. When data reported in the included trial
was converted or imputed details of this were recorded in the notes
section of the included studies table. All data transformation and
entry was performed by one reviewer and checked by a second
(SG, MW).
i) The Cochrane Controlled Trials Register (CCTR)
This is an electronic database and is published on the Cochrane
Library. The search for relevant trials was conducted on Issue 1,
2001.
All articles were coded and details of source, intervention, popu-
lation and funding recorded. The investigator compiling the ref-
erences (SG) decided on potentially relevant trials (based on the
article being a trial of an intervention for tennis elbow), and col-
lated these trials for first round inclusion. The methods sections
of these trials were then blinded of all reference to journal, author
or country of origin, and sent to the blinded reviewers (LB & SH)
for inclusion assessment.
For trials where the required data was not reported or able to
be calculated, further details were requested from first authors.
When unsuccessful, the study was included in the review and fully
described, but not included in the meta-analysis. An entry to that
effect was made in the notes section of the included studies table.
DATA SYNTHESIS
Meta-analysis was facilitated by RevMan 4.1, using the following
choices of summary statistic.
CONTINUOUS OUTCOMES:
Acupuncture for lateral elbow pain (Review)
4
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Weighted mean difference using a random effects model was se- while two reported outcome only immediately following treat-
lectedasthesummarystatistic. Arandomeffectsmodel wasusedto ment (Huang 1998, Molsberger 1994).
account for the anticipated large amount of heterogeneity among Due to the clinical heterogeneity of differing interventions and
the primary trials. In the event of significant heterogeneity (p < timing of outcome assessment, no pooling of studies was possible.
0.1), trials results were not pooled.
BINARY OUTCOMES:
Relative risk using a random effects model was selected for in-
Risk of bias in included studies
terpretation of the dichotomous outcome measures in this review
Trial populations ranged from 48 to 93 participants (see table
of included studies). Concealment of allocation was unclear in
all trials. All but one trial (Huang 1998) had a blinded outcome
assessor. In the two trials following participants for longer than one
assessment immediately after treatment, up to 20% of participants
were lost to follow up (see table of included studies).
as events were not rare (Deeks 1998) . A random effects model
was selected to account for the large amount of anticipated het-
erogeneity among the primary trials. In the event of significant
heterogeneity, trial results were not pooled.
Sensitivity analyses were planned to assess the effect of blinding of
outcome assessor, and of the inclusion of foreign language trials. It
was planned to perform meta-analysis both including and exclud-
ing trials without a blinded assessment of outcome, and including
and excluding trials published in languages other than English,
and the impact on the summary result assessed. Due to a paucity
of trials sensitivity analysis was not possible but may be included
in future updates of this review.
Effects of interventions
Based on the results of two randomised controlled trials which
could not be combined, acupuncture results in relief of pain for
significantly longer than placebo (WMD = 18.8 hours, 95%CI
10.1 to 27.5) (Molsberger 1994), is more likely to result in a 50%
or greater reduction in pain after 1 treatment (RR 0.33, 95%CI
0.16 to 0.69) (Molsberger 1994) , and more likely to result in
overall improvement (RR = 0.09 95% CI 0.01 to 0.64) after 10
treatments (Haker 1990a). No significant differences were found
in the longer term (after 3 or 12 months).
R E S U L T S
No differences were demonstrated between laser acupuncture and
placebo with respect to overall benefit, and no differences were
demonstrated between Vitamin B12 injection plus acupuncture,
and Vitamin B12 injection alone.
Description of studies
See: Characteristicsofincludedstudies; Characteristicsof excluded
studies.
Eleven potential studies were identified and five references in-
cluded. Of these one was a duplicate publication, therefore four
trials were included in the review. Of the six excluded studies, four
were not randomised (Brattberg 1983, Zhiming 1990, Zhongying
1989, Wu 1997) one was a narrative review (Lee 2000) and one
was a trial in a population of general non-specific tendinopathies
where the results of those with lateral elbow pain were not re-
ported separately (Ammer 1994). One of these excluded studies
was published in Chinese and translated into English (Wu 1997).
The remaining excluded trials were all published in English. All
were from the published literature.
D I S C U S S I O N
Due to the small number of included trials and problems with
methodology of the included trials (particularly small populations,
uncertain allocation concealment and substantial
loss to follow up), the results of this review are inconclusive and
should be interpreted with caution.
Of the included studies, two trials compared needle acupunc-
ture to placebo (Molsberger 1994, Haker 1990a) but used differ-
ent outcome assessments. One trial compared laser acupuncture
to placebo (Haker 1990b), and one compared a combination of
acupuncture and vitamin B12 injection to Vitamin B12 injection
alone (Wang 1997).
Acupuncture is increasingly been used in the treatment of muscu-
loskeletal conditions in Western countries, and has been the treat-
ment of choice in China for centuries. While there is evidence for
the use of acupuncture in idiopathic headache (Linde 2001), this
review does not provide sufficient evidence to support or oppose
the use of acupuncture (needle or laser) in the treatment of lateral
elbow pain.
All trials defined lateral elbow pain according to a similar set of
diagnostic criteria (pain over the lateral epicondyle with pain pro-
duced by grip, resisted wrist and/ or finger dorsiflexion) and ex- Only four randomised controlled trials meeting the inclusion cri-
cluded participants with cervical spine pathology. Two trials fol- teria of this review were identified and no data could be combined
lowed participants for 12 months (Haker 1990a, Haker 1990b), due to clinical heterogeneity between trials.
Acupuncture for lateral elbow pain (Review)
5
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

One trial of needle acupuncture demonstrated significantly longer Implications for research
duration of pain relief following acupuncture than placebo, how-
Further randomised controlled trials of both laser and needle
ever, while statistically significant, the acupuncture group experi-
enced a mean pain relief following treatment of less than 24 hours
which may not be considered clinically significant for a chronic
condition. Two trials demonstrated participants felt significantly
better in terms of pain and overall improvement immediately fol-
lowing treatment, but this improvement was not sustained at 3 or
12months. Inaselflimitingconditionhoweversuch improvement
may be clinically significant if it allows improvement in function
while the condition follows its natural history toward recovery.
However, such short term improvement needs to be validated by
further trials before acupuncture can be recommended for short
term and temporary symptom relief.
acupuncture are needed to assess the efficacy of this increasingly
popular intervention for treating lateral elbow pain. Trials should
be adequately powered, attempt to blind both participant and out-
come assessor, and include outcome measures of pain and func-
tion and adverse effect. Outcome measures should be valid, reli-
able and responsive. Future studies of the benefit of acupuncture
should give consideration to the most appropriate dosage, site and
method of administration of acupuncture.
A C K N O W L E D G E M E N T S
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
This review was supported by a fellowship granted to the first au-
thor by the Department of Health and Human Services, Victo-
rian State Government, Victoria, Australia, and a one week visit-
There is insufficient evidence to either support or refute the use ing fellowship to the Australasian Cochrane Centre granted by the
of acupuncture (either needle or laser) in the treatment of lateral Cochrane Collaboration. The authors extend their gratitude to
elbow pain. This review has demonstrated needle acupuncture to these two bodies in addition to acknowledging the methodolog-
be of short term benefit with respect to pain, but this finding is ical support and advice of the staff at the Australasian Cochrane
based on the results of 2 small trials, the results of which were Centre. The authors would also like to thank the Cochrane Mus-
not able to be combined in meta-analysis. No benefit lasting more culoskeletal Review Group (CMSG) Editorial Team, Arne Gam,
than 24 hours following treatment has been demonstrated. No Bill Gillespie and Vivian Robinson for their helpful comments
trial assessed or commented on potential adverse effect.
and suggestions.
R E F E R E N C E S
References to studies included in this review
References to studies excluded from this review
Haker 1990a {published data only}
Ammer 1994 {published data only}
∗
Haker E, Lundeberg, T. Acupuncture treatment in
epicodylalgia: A comparative study of two acupuncture
techniques. The Clinical Journal of Pain 1990;6:221–6.
Haker E, Lundeberg T. Acupuncture treatment in
epicondylalgia: A comparative study of two treatment
techniques. Journal of Musculoskeletal Pain 1994;2(4):
126–8.
Ammer, K, Kitzinger, E. Thermography of the auricle.
Deutsche Zeitschrift Fur Akupunktur 1994;37(6):133–8.
Brattberg 1983 {published data only}
Brattberg G. Acupuncture therapy for tennis elbow. Pain
1983:258–88.
Huang 1998 {published data only}
∗
Haker 1990b {published data only}
∗
Huang, Y, Zhonghua, F, Dongbin, X, Rangke, W.
Haker, E, Lundeberg, T. Laser treatment applied to
Introduction to floating acupuncture: Clinical study on
the treatment of lateral acupuncture. American Journal of
Acupuncture 1998;26(1):27–31.
acupuncture points in lateral humeral epicondylalgia. A
double-blind study. Pain 1990;43(2):243–7.
Molsberger 1994 {published data only}
Molsberger A, Hille E. The analgesic effect of acupuncture
in chronic tennis elbow pain. British Journal of Rheumatology
1994;33:1162–5.
Lee 2000 {published data only}
Lee, T. Acupuncture and chronic pain management. Annals
of the Academy of Medicine 2000;29:17–21.
Wang 1997 {published data only}
∗
Pan 1997 {published data only}
∗
Wang LC. 30 Cases of tennis elbow treated by
Pan N. 78 cases of tennis elbow treated by raised up
moxibustion. Shanghai Journal of acupuncture and
moxibustion 1997;16(6):20.
needling. Shanghai Journal of acupuncture and moxibustion
1997;16(5):19.
Acupuncture for lateral elbow pain (Review)
6
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Wu 1997 {published data only}
∗
Hamilton 1986
Hamilton, P. The prevalence of humeral epicondylitis: a
Wu, ZP. Tennis elbow treated by plum-blossom needle
therapy combined with ginger-partitioned moxibustion:
report of 28 cases. Jiling Journal Traditional Chinese
Medicine 1997;17:27.
survey in general practice. J Royal College G Practitioners
1986;36:p. 464-5.
Hudak 1996
Hudak P, Cole D, Haines A. Understanding Prognosis to
Improve Rehabilitation: The Example of Lateral Elbow
Pain. Arch Phys Med Rehabil 1996;77:586–92.
Yang 1997 {published data only}
∗ Yang JR, Bai JM, Wu LL. 100 cases of tennis elbow treated
by acupuncture. Shanghai Journal of Acupuncture 1997;16
(5):18.
Hudak 1996b
Hudak P, Cole D, Haines T. Understanding prognosis to
improve rehabilitation: the example of lateral elbow pain.
Arch Phys Rehabil 1996;77:568–93.
Zhiming 1990 {published data only}
∗
Zhiming, W. Successful treatment of epicondylitis with
chize-through-tender point puncturing method. Journal of
traditional chinese medicine 1990;10(2):122–3.
Jadad 1996
Jadad A, Moore A, Carroll D, Jenkinson C, Reynolds J,
Gavaghan D, McQuay H. Assessing the quality of reports of
randomised clinical trials: is blinding necessary?. Controlled
Clinical Trials 1996;17:1–12.
Zhongying 1989 {published data only}
∗
Zhongying, M. 52 cases of external humeral epicondylitis
treated by acupuncture and moxibustion. Journal of
traditional Chinese Medicine 1989;9(1):3–4.
Kivi 1983
Kivi P. The etiology and conservative treatment of lateral
Additional references
epicondylitis. Scand J Rehabil Med 1983;15:37–41.
Labelle 1992
Allender 1974
Labelle H, et al.Lack of scientific evidence for the treatment
of lateral epicondylitis of the elbow. The Journal of Bone and
Joint Surgery 1992;74:646–51.
Allander E. Prevalence, incidence and remission rates
of some common rheumatic diseases and syndromes.
Scandinavian Journal of Rheumatology 1974;3:145–53.
Linde 2001
Assendelft 1996
Linde, K, et al.Acupuncture for idiopathic
headache (Cochrane Review). Cochrane Database of
Systematic Reviews 2001, Issue 2. [DOI: 10.1002/
14651858.CD001218.pub2.]
Assendelft W. Corticosteroid injections for lateral
epicondylitis: a systematic overview. British Journal of
General Practice 1996;46:209–16.
Chard 1989
Murtagh 1988
Chard MD, Hazlemanand BL. Tennis elbow - a reappraisal.
British Journal of Rheumatology 1989;28(3):186–90.
Murtagh J. Tennis Elbow. Aust Family Physician 1988;17:
90, 91, 94-5.
Paramore 1997
Cyriax 1936
Paramore LC. The use of alternative therapies: Estimates
from the 1994 Robert Wood Johnson Foundation National
Access to Health Care Survey. J Pain Sympt Manage 1997;
13(2):83–9.
Cyriax JH. The pathology and treatment of tennis elbow.
J Bone Joint Surg (A), 1936. 4: p. J Bone Joint Surg (A)
1936;4:p. 921-40.
Deeks 1998
Verhaar 1994
Deeks, J. Odds ratios should be used only in case-control
studies and logistic regression analysis (letter). BMJ 1998;
317:1115.
Verhaar, J. Tennis elbow: Anatomical, epidemiological and
therapeutic aspects. Int Ortopaedics 1994;18:263–7.
Viola 1998
Diehl 1997
Viola Leonardo. A critical review of the current conservative
therapies for tennis elbow (lateral epicondylitis). ACO
1998;7(2):53–67.
Diehl DL, Kaplan G, Coulter I, Glik D, Huirwitz EL. Use
of acupuncture by American Physicians. J Alt Comp Med
1997;3(2):119–26.
∗
Indicates the major publication for the study
Acupuncture for lateral elbow pain (Review)
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Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Haker 1990a
Methods
Randomised controlled trial
Blinding: double-blinded,
outcome assessor was blind to intervention and placebo used
Loss to follow up:
86 enrolled, 6 drop outs in first 2 weeks (time, illness not related to elbow,
and one giving no reason). These patients were not followed up. 4 withdrawals (3 in
superficial group) withdrew after 3 months due to lack of effect.
Appropriate Statistical Analysis:
Did not use intention to treat analysis
Participants
82 participants
Inclusion criteria:
lateral elbow/ epicondyle pain produced by 2 or more of 4 diagnostic tests; palpation,
resisted wrist extension, passive stretching, resisted finger extension
Exclusion criteria:
shoulder/neck/
thoracic dysfunction
local arthritis/
general polyarthritis
neurological abnormalities
radial nerve entrapment
Interventions
Outcomes
Experimental group : 5 acupuncture points (L1 10, 11,12, Lu 5 & SJ 5) treated 10 times
(2-3 times weekly for 20 weeks
control group: placebo: superficial needle insertion only in identical areas & dosage as
experimental group
Assessment at baseline, at treatment conclusion, 3 & 12 month followups:
4 diagnostic inclusion criteria (see participants)
4 additional tests; pain reproduction on isometric pronation/
supination, vigorimeter test & lifting test
additional subjective question at completion using 5 point scale
Notes
Risk of bias
Bias
Authors’ judgement
Support for judgement
Allocation concealment (selection bias) Unclear risk
B - Unclear
Acupuncture for lateral elbow pain (Review)
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Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Haker 1990b
Methods
Randomised controlled trial
Blinding:
double blinded, placebo used but unclear who else was blinded
Loss to follow up:
all 49 completed treatment, afterwards 1 in each group withdrew, 7 withdrew after 3 month
follow up (4 in laser group and 3 in placebo) due to ongoing elbow pain and desire to try
other treatment options
Appropriate Statistical Analysis:
The analysis was appropriate for the 40 subjects that completed the assessment, however
of note there were 9 subjects lost to follow up
Participants
49 participants
Inclusion criteria:
pain over lateral epicondyle for at least 1 month and pain during 2 or more tests as follows
1) palpation lateral epicondyle 2) resisted wrist extension with elbow pronation 3) passive
stretching of extensors with elbow extension forearm pronated 4) resisted finger extension
with eblow extended, forearm pronated
Exclusion criteria:
local arthritis, generalised polyarthritis, neurological abnormalities, radial nerve entrapment
Interventions
Experimental group:
Mid 1500 IRRADIA laser, Ga-As laser, wavelength 904 nm, measured mean power outlet
12 mW, peak value 8.3 W, frequency 70 Hz (pulsed) .
Control Group: placebo. Laser machine turned off but wand applied to acupuncture points
as per control group
Outcomes
Assessment at baseline, 3 months, 1 year
1. measured grip strength but no variance reported so unable to use
2. subjective report of pain on 5 point scale ( 1 = excellent, 2 = good, 3 = better, 4 = slightly
improved 5= unchanged or worse
Notes
Risk of bias
Bias
Authors’ judgement
Support for judgement
Allocation concealment (selection bias) Unclear risk
B - Unclear
Acupuncture for lateral elbow pain (Review)
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Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Molsberger 1994
Methods
Randomised placebo controlled trial.
Blinding:
stated as single blind however subject and outcome assessor were blind to group allocation
Loss to follow up: no subjects were reported as lost to follow up or withdrawn
Appropriate Statistical Analysis:
The study was subjected to an interim analysis and stopped as reported significance had
been reached.
No subjects were reported to have crossed over treatment groups
Participants
48 participants
Inclusion criteria:
subjects with chronic unilateral tennis elbow pain (> 2 months, average 15.4 months)
Exclusion criteria:
current analgesic therapy
systemic joint/bone disorders
previous acupuncture treatment
overt psychiatric illness
inability to speak/read/write German
Interventions
Outcomes
Experimental group: a single non-segmental acupuncture stimulation treatment on distal
points for elbow pain (homolateral leg)
control group: a single placebo acupuncture (no insertional needles)
Assessed before and after treatment:
pain measurement - 11 point box scale questionnaire (0 = no pain at all, 10 = pain as severe
as it could possibly be)
duration of pain reduction assessed by following patients for 72 hours
Notes
Risk of bias
Bias
Authors’ judgement
Support for judgement
Allocation concealment (selection bias) Unclear risk
B - Unclear
Wang 1997
Methods
Randomised controlled trial
No blinding
No participants lost to follow up
Intention to treat analysis: Yes
Participants
60 participants
Inclusion criteria: lateral elbow pain from 10 days to 1.5 years
Interventions
Acupuncture plus vitamin B12 injection versus vitamin B12 injection alone
Acupuncture for lateral elbow pain (Review)
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Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Wang 1997 (Continued)
Outcomes
Notes
Number cured the only outcome reported. Measured immediately following treatment
Translated from Chinese. Included in meta-analysis as a seperate comparison
Risk of bias
Bias
Authors’ judgement
Support for judgement
Allocation concealment (selection bias) Unclear risk
D - Not used
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
Ammer 1994
Population not specific to lateral epicondylitis. Included patients with various musculoskeletal conditions and
results not reported seperately
Brattberg 1983
Huang 1998
Not a randomised controlled trial.
Randomised controlled trial of 2 different methods of acupunture (floating and classic), demonstrated floating
to be significant different to classic with respect to pain at end of treatment. Not included in the review as not
comparing acupunture to placebo or another intervention
Lee 2000
Pan 1997
Review
Randomised controlled trial of 2 different methods of acupuncture. Not blinded
Wu 1997
Controlled clinical trial, participants selected to treatment or reference group non randomly by trialist
Randomised controlled trial of 2 slightly different methods of acupuncture. Not blinded
Not a randomised controlled trial
Yang 1997
Zhiming 1990
Zhongying 1989 Not a randomised controlled trial
Acupuncture for lateral elbow pain (Review)
11
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

D A T A A N D A N A L Y S E S
Comparison 1. ACUPUNCTURE VERSUS PLACEBO
No. of No. of
studies participants
Outcome or subgroup title
Statistical method
Effect size
1 Duration of pain relief (hours)
2 Overall improvement (number
of patients unchanged or
worse)
1
1
Mean Difference (IV, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected
Totals not selected
2.1 After 10 treatments
2.2 After 3 months
2.3 After 12 months
1
1
1
1
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
Totals not selected
3 Less than 50 % pain relief after 1
treatment
Comparison 2. LASER ACUPUNCTURE POINTS VS PLACEBO
No. of No. of
studies participants
Outcome or subgroup title
Statistical method
Effect size
1 Subjective outcome of no change
or worse
1
Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected
1.1 After 10 sessions
1.2 After 3 months
1.3 After 12 months
1
1
1
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
Risk Ratio (M-H, Fixed, 95% CI)
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
Comparison 3. ACUPUNCTURE PLUS VITAMIN B12 INJECTION VS INJECTION ALONE
No. of No. of
studies participants
Outcome or subgroup title
Statistical method
Effect size
1 Still with symptoms after
treatment
1
Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected
Acupuncture for lateral elbow pain (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
12

Analysis 1.1. Comparison 1 ACUPUNCTURE VERSUS PLACEBO, Outcome 1 Duration of pain relief
(hours).
Review: Acupuncture for lateral elbow pain
Comparison: 1 ACUPUNCTURE VERSUS PLACEBO
Outcome: 1 Duration of pain relief (hours)
Mean
Difference
Mean
Difference
Study or subgroup
Molsberger 1994
ACUPUNCTURE
N
PLACEBO
N
Mean(SD)
Mean(SD)
1.4 (3.5)
IV,Fixed,95% CI
IV,Fixed,95% CI
24
20.2 (21.54)
24
18.80 [ 10.07, 27.53 ]
-100
-50
0
50
100
Favours placebo
Favours acupuncture
Analysis 1.2. Comparison 1 ACUPUNCTURE VERSUS PLACEBO, Outcome 2 Overall improvement
(number of patients unchanged or worse).
Review: Acupuncture for lateral elbow pain
Comparison: 1 ACUPUNCTURE VERSUS PLACEBO
Outcome: 2 Overall improvement (number of patients unchanged or worse)
Placebo
Acupunc-
ture
Study or subgroup
Acupuncture
n/N
Risk Ratio
Risk Ratio
n/N
M-H,Fixed,95% CI
M-H,Fixed,95% CI
1 After 10 treatments
Haker 1990a
1/44
4/43
3/40
10/38
3/35
3/33
0.09 [ 0.01, 0.64 ]
1.09 [ 0.26, 4.53 ]
0.83 [ 0.18, 3.82 ]
2 After 3 months
Haker 1990a
3 After 12 months
Haker 1990a
0.01
0.1
1
10
100
Favours acupuncture
Favours placebo
Acupuncture for lateral elbow pain (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
13

Analysis 1.3. Comparison 1 ACUPUNCTURE VERSUS PLACEBO, Outcome 3 Less than 50 % pain relief
after 1 treatment.
Review: Acupuncture for lateral elbow pain
Comparison: 1 ACUPUNCTURE VERSUS PLACEBO
Outcome: 3 Less than 50 % pain relief after 1 treatment
Study or subgroup
Molsberger 1994
ACUPUNCTURE
n/N
PLACEBO
n/N
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
6/24
18/24
0.33 [ 0.16, 0.69 ]
0.1 0.2 0.5
1
2
5
10
Favours acupuncture
Favours placebo
Analysis 2.1. Comparison 2 LASER ACUPUNCTURE POINTS VS PLACEBO, Outcome 1 Subjective
outcome of no change or worse.
Review: Acupuncture for lateral elbow pain
Comparison: 2 LASER ACUPUNCTURE POINTS VS PLACEBO
Outcome: 1 Subjective outcome of no change or worse
Study or subgroup
Laser Treatment
n/N
Placebo
n/N
Risk Ratio
Risk Ratio
M-H,Fixed,95% CI
M-H,Fixed,95% CI
1 After 10 sessions
Haker 1990b
6/23
2/22
1/18
5/26
6/25
0/21
1.36 [ 0.48, 3.86 ]
0.38 [ 0.09, 1.69 ]
3.47 [ 0.15, 80.35 ]
2 After 3 months
Haker 1990b
3 After 12 months
Haker 1990b
0.1 0.2 0.5
Favours laser
1
2
5
10
Favours placebo
Acupuncture for lateral elbow pain (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
14

Analysis 3.1. Comparison 3 ACUPUNCTURE PLUS VITAMIN B12 INJECTION VS INJECTION ALONE,
Outcome 1 Still with symptoms after treatment.
Review: Acupuncture for lateral elbow pain
Comparison: 3 ACUPUNCTURE PLUS VITAMIN B12 INJECTION VS INJECTION ALONE
Outcome: 1 Still with symptoms after treatment
Acupuncture
plus B12
Study or subgroup
Wang 1997
B12 injection alone
n/N
Risk Ratio
Risk Ratio
n/N
M-H,Fixed,95% CI
M-H,Fixed,95% CI
4/30
9/30
0.44 [ 0.15, 1.29 ]
0.1 0.2 0.5
1
2
5
10
Favours acupuncture
Favours control
W H A T ’ S N E W
Last assessed as up-to-date: 20 November 2001.
Date
Event
Description
16 June 2008 Amended Converted to new review format. A001-R
D E C L A R A T I O N S O F I N T E R E S T
None known
S O U R C E S O F S U P P O R T
Internal sources
• Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
• Australasian Cochrane Centre, Australia.
Acupuncture for lateral elbow pain (Review)
15
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

External sources
• No sources of support supplied
I N D E X T E R M S
Medical Subject Headings (MeSH)
Acupuncture Therapy [∗methods]; Randomized Controlled Trials as Topic; Tennis Elbow [∗therapy]
MeSH check words
Adult; Humans
Acupuncture for lateral elbow pain (Review)
16
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.