OUTCOMES OF AUTOLOGOUS BLOOD INJECTION FOR TREATMENT OF TENNIS ELBOW

Total Ninety Three (59% females, 41% male) paents were treated with the diagnosed concerned disease. The mean age of the paents was 45.39 ± 10.109 years. At the end of the trial, 90% of the paents were sasﬁed fully with the treatment. The overall performance of the regression model is signiﬁcant in all scenarios. Given the sasfactory results, the blood injecon in queson can be deemed a suitable medicaon alternave to the convenonal therapy.


Introduc on
Lateral tendinosis of the elbow, some me called tennis elbow, refers to the degenera ve process in the common source of the extensor group of forearm muscles. In orthopedic clinics, it is the most prevalent cause of elbow discomfort and pain. The condi on caused by repeated muscular mo ons is a typical cause of elbow discomfort.

Objec ves
To assess the clinical and func onal outcomes of autologous blood injec on for the treatment of tennis elbow.

Methodology
This is a hospital based cross-sec onal study, conducted in Birat Medical College teaching hospital. Here, the pa ents diagnosed with a Tennis elbow in orthopedic OPD during the study dura on of September2020 to August 2021 were included in the study. Total 93 samples were studied. Two ml of the pa ent's blood has withdrawn from the right antecubital vein and has been injected around the affected common extensor tendon origin. Data was analyzed using SPSS version 23.

Result
Total Ninety Three (59% females, 41% male) pa ents were treated with the diagnosed concerned disease. The mean age of the pa ents was 45.39 ± 10.109 years. At the end of the trial, 90% of the pa ents were sa sfied fully with the treatment. The overall performance of the regression model is significant in all scenarios.

Conclusion
Given the sa sfactory results, the blood injec on in ques on can be deemed a suitable medica on alterna ve to the conven onal therapy.

INTRODUCTION
Lateral elbow tendinosis, more commonly referred to as tennis elbow, is a degenera ve condi on affec ng the common origin of the forearm extensor group of muscles. It is the most o en seen cause of elbow discomfort in individuals who seek treatment at orthopedic clinics. Lateral epicondyli s is not inflammatory tendinopathy but degenera ve, producing prolonged recalcitrant suffering in 1 the Elbow joints. Elbow pain and discomfort is frequently caused by the disease that develops due to repeated mo ons of the affected muscles. Micro-tears in the tendon resul ng in bleeding, the development of rough granula on ssue, and subsequent healing.
For the treatment of tennis elbow, Botulinum toxin (BoNT-A) injec ons were also used. It showed a good result, but the result obtained from this showed short-dura on relief; henceforth, this treatment is unfavorable for long-term consequences. Lateral epicondyli s (LE) is a highly common enthesopathy in athle c medicine. The main symptoms were las ng discomfort and pain around the lateral 2,3 epicondyle and failure to conduct daily work.
Lateral epicondyli s is a frequent disease with pain on the 4 side of the elbow and weakness. Obesity, smoking and physical loading are o en related to exercise as well as tennis. The general popula on aged between 45 and 54 5 years is frequent in 1% to 3%. The name lateral epicondyli s is misnomer since it is primarily distress rather than an inflammatory procedure, owing to degenera on of the common extending tendon. A study recognized that tendinopathy is a clinical diagnosis while tendini s or tendinosis terms should be reserved only a er the 6 histopathological examina on has been carried out. A cadaveric study by Baleset al. showed two zones of hypovascularity in the region of the lateral epicondyle, one between the lateral epicondyle and the supracondylar ridge and the other on the deep surface of common extensor 7 tendon 2-3 cm distal to lateral epicondyle. This is probably the area where the degenera ve changes set in. Tennis elbow disorder is common in occupa ons that involve repe ve forearm rota onal ac vi es. It is differen ated from other causes of elbow pain, typically by history and clinically by appearance of pain with resisted wrist extension, also known as Cozen test. It has been es mated that only 5-10% of cases occur in tennis players. Treatment 8 can be conserva ve or surgical. Non-opera ve treatment is successful in the resolu on of symptoms in 90% of the 9 pa ents. The remaining 10% who do not respond to conserva ve treatment are labeled as resistant or refractory cases. Autologous blood injec ons are thought to work by ini a ng an inflammatory response and delivering nutrients and components necessary to promote the healing 10 process.
The Rung characterized Tennis Elbow (TE) as the first 12 frequent my tendinosis in 1873. It is a diagnosis clinically 13,14 confirmed by ultrasound and MRI imagery. A range of therapeu c methods includes repeated low-energy shock [15][16][17] waves, physical therapy, and open surgical treatments. However, no technique of therapy has shown superior to others. Cor costeroid injec on is one of the common 18 treatments. The idea of inflammatory illness is founded on the reasoning underlying its usage. Recent research has shown that TE is a prolifera ve process called angiofibroblas c or hyperplas c degenera on. Even those pa ents that were not healed through other techniques submi ed their papers addressing the use of autologous blood in TE 19 therapy. Blood includes humeral and cell mediators that begin an inflammatory response and remedy the damaged ssue. While several therapeu c approaches have been explained for lateral epicondyli s, including bracing, physical therapy, cor costeroid injec ons, and platelet-rich plasma injec ons, the op mal treatment has consistently demonstrated no superiority to the natural pathway of the illness. The objec ve is to analyze the results of autologous blood injec on at the Birat Medical College Teaching Hospital for tennis elbow treatment. Only a few research have explored self-injected blood as a lateral epicondyli s treatment technique. This study was conducted to assess the effects of autologous blood injec on lateral epicondyli s treatment. Objec ves of our study are to assess the clinical and func onal outcomes of autologous blood injec on for the treatment of tennis elbow and to analyses the clinical and func onal outcomes of autologous blood injec on for the treatment of tennis elbow.

METHODOLOGY
A hospital based cross-sec onal study was carried out in Birat Medical College teaching hospital, a ter ary level hospital of Province 1 in Nepal. The sample was selected through the pa ents diagnosed with a Tennis elbow case in orthopedic OPD during the study dura on September2020 to August2021. All the pa ents during this one year study period were included and total 93 pa ents were studied. Treatment was given and quan ta ve data were recorded. In the data collec on method, specifically designed semistructured ques onnaires were used. The follow-up study was taken from Pre-injec on score to 24-week follow-up. Treatment: two ml of the pa ent's blood has withdrawn from the right antecubital vein and has been injected around the affected common extensor tendon origin.For ini al relief of pain oral NSAID was prescribed for first three days. In that process, following inclusion and exclusion criteria were considered, i) Inclusion Criteria-All newly diagnosed pa ents were presen ng in orthopedic OPD and who gives consent. ii) Exclusion Criteriaiii) Pa ents who have received any surgical treatment earlier for same problem. iv) Steroid injec on pa ents three months before injec on of the blood. v) Pa ents suffering with any form of Diabetes mellitus and Rheumatoid arthri s. There were following variables were considered: A) Dependent variables-Clinical -pain, Grip strength, post-injec on infec on. B) Independent variables-Age, Occupa on, gender. C) Confounding variables-Cervical radiculopathy. All the collected data were checked, compiled, and entered in MS Excel and analyzed by SPSS version 23. The anonymity and confiden ality of study par cipants were maintained. The regression modeling has been used as a sta s cal analysis of this study. Detail of regression modeling is given in the below sec ons: Regression Modeling: Regression modeling were used for the data analysis in this study. Regression analysis collects sta s cal methods in sta s cal modeling to es mate links between a dependent variable and one or more independent variables. Linear regression is the most frequently used regression assessment in quan ta ve data, in which the line that best fits the data according to a 11 par cular mathema cal criterion is considered.

RESULTS
Among total 93 samples were studies the females (59%) were propor onately higher than males (41%). The mean age of study par cipants was 45.23 years with SD 10.2 years. Graphical Presenta on: In Figure 1, we observe that data for the current study were obtained from males and females. Here we also observe that females were higher than males (Figure 1). In Figure 2, we see that histogram of age is showing a skewed pa ern. Most respondents were from the age group 55 to 60 years. (Figure 2).  Table 1, the summary sta s cs of VAS Score and Nirschl Scale is given. Here, in the first column follow up period is stated, in second and third column mean and standard devia on of VAS score is given respec vely, and in fourth and fi h column mean and standard devia on of Nirschl Scale are given respec vely. From this table it is seen that mean and standard devia on of VAS score for pre-injec on is 7.71 and 0.63, the mean and standard devia on of VAS score for two week follow up is 5.96 and 0.65, the mean and standard devia on of VAS score for six week follow up is 3.35 and 0.48 respec vely. Similarly, the mean and standard devia on of VAS score for twelve week follow up is 0.67 and 0.47 and the mean and standard devia on of VAS score for twenty four week follow up is 0.26 and 0.57 respec vely.
The data trend showed the VAS score has decreased gradually in each successive follow-up. Similarly, the mean and standard devia on of Nirschl Scale for pre-injec on is 5.96 and 0.65, the mean and standard devia on of Nirschl Scale for two week follow up is 4.58 and 0.66, the mean and standard devia on of Nirschl Scale for six week follow up is 2.57 and 0.56 respec vely. Moreover, the mean and standard devia on of Nirschl Scale for twelve week follow up is 0.53 and 0.50and the mean and standard devia on of Nirschl Scale for twenty four week follow up is 0.19 and 0.39 respec vely. The Nirschl scale had also decreased along with the successive follow-ups. Hence, it is observed that along with increasing me dura on of follow-up the mean value of VAS and Nirschl Scale also have decreased.  In this study, one way ANOVA has been used to show the mean differences in VAS and Nirschl score according to follow-up dura on. Follow-up is done in 2 weeks, 6 weeks, 12 weeks and 24 weeks. Table 2 and 3 presents the significant test (One way ANOVA) of Visual Analog Scale in different follow-up period. Researcher would like to see whether the mean differences in VAS was significant in each follow up. The analysis result showed, there was significant decrease in VAS in aggregate with P-value <0.001. Furthermore, post-hoc test also done using LSD method to see the decrease in each follow-ups. Result showed the significant decrease in VAS in all follow-up dura on including 2 weeks, 6 weeks, 12 weeks and 24 weeks.  Similarly, one way ANOVA also conducted to show the mean differences in NirschlScale according to same follow-up dura on. Table 4 and 5 presents the one way ANOVA result of Nirschl Scale according to follow-up period. The result showed, there was significant decrease in Nirschl Scale in aggregate and also in post-hoc test with P-value <0.001. Post-hoc result also showed the significant decrease in Nirschl Scale in all follow-up dura on (2 weeks, 6 weeks, 12 weeks and 24 weeks).   25 regrowth, and degrada on. As a result, the effec veness of NSAIDs in lateral epicondyli s has faced difficul es in recent years.Kachooei et.al found that, while the injec on of cor costeroids delayed surgery for lateral epicondyli s, it was linked with high surgical performance vs. non-injected pa ents. The biotherapy approach has recently developed in tendinopathy, incorpora ng autologous full-blood 27 injec ons and plasma-rich injec ons and stem cell therapy. Autologous blood injec ons may have good outcomes. This study also got very good result with over 90% success. Autologous blood injec ons are considered to occur through inflammatory reac ons and the provision of the required nutrients and components for the healing procedure. Only several research has inves gated autologous blood injec on as a lateral epicondyli s treatment op on.

CONCLUSION
Based on given acceptable outcomes, it is concluded that the concerned blood injec on can be considered a good treatment op on for the Tennis-elbow.It is a simple, cheap and effec ve method.

RECOMMENDATIONS
This study recommends the effec ve, safe, and successful method for the long-term therapy of the illness concerned for autologous blood injectors with no extra brace or exercise.

LIMITATIONS OF THE STUDY
This study has limita ons on the lack of a randomized control group.