Effect of corticosteroid injection, physiotherapy, or
both on clinical outcomes in patients with unilateral lateral epicondylalgia
both on clinical outcomes in patients with unilateral lateral epicondylalgia
Coombes BK, Bisset L,
Brooks P, Khan A, and Vicenzino B. JAMA. 2013; 309(5):461-469.
Brooks P, Khan A, and Vicenzino B. JAMA. 2013; 309(5):461-469.
Take Home Message: Corticosteroid injections and
structured physiotherapy are not associated with improved patient-reported measures
of pain and disability following one year of treatment.
structured physiotherapy are not associated with improved patient-reported measures
of pain and disability following one year of treatment.
With epicondylalgia, or
tennis elbow, the patient experiences pain along the lateral epicondyle during
gripping and wrist extension. This condition is usually treated
with a combination of corticosteroid injection and physiotherapy. While the
short-term effects of this treatment strategy appears
favorable, there is a lack of evidence to support its long-term efficacy.
Therefore,
Coombes and colleagues completed a randomized, blinded, placebo-controlled
trial to evaluate the clinical efficacy of corticosteroid injection and physiotherapy
at a one year follow-up in patients suffering from unilateral lateral epicondylalgia.
A total of 165 patients were randomly assigned into 4 treatment groups
(corticosteroid injection = 43
patients,
placebo injection = 40 patients,
corticosteroid injection plus physiotherapy = 39 patients, and placebo injection plus physiotherapy = 41 patients). The authors included patients 18
years or older who
experienced unilateral lateral epicondylalgia for longer than 6 weeks. Additionally, the authors excluded patients
who received a corticosteroid injection in the preceding 6 months, received physiotherapy in the preceding 3 months, had concomitant neck or other arm
pain, had symptoms suggesting radicular, neurological, or systemic arthritic
conditions, were pregnant or breastfeeding, or had contradictions to injections.
The injection groups received either a placebo
of 0.5mL of 0.9% isotonic saline or 10mg/mL of triamcinolone acetonide plus 1mL
of 1% lignocaine. Physiotherapy groups
underwent 8, 30–minute
sessions during an 8–week
period. All physiotherapy was supervised by an experienced physiotherapy practitioner. At
4, 8, 12, 26, and 52 weeks post-treatment, patients recorded their global rating of change on a 6-point Likert-like scale, a 100 mm visual analog scale, and Patient-Rated Tennis Elbow Evaluation score range. Overall, physiotherapy had no effect on outcome measures, though
engaging in physiotherapy was associated with decreased use of analgesic and anti-inflammatory
medications. At one year follow-up,
patients receiving a corticosteroid injection reported less improvement than
placebo injections.
tennis elbow, the patient experiences pain along the lateral epicondyle during
gripping and wrist extension. This condition is usually treated
with a combination of corticosteroid injection and physiotherapy. While the
short-term effects of this treatment strategy appears
favorable, there is a lack of evidence to support its long-term efficacy.
Therefore,
Coombes and colleagues completed a randomized, blinded, placebo-controlled
trial to evaluate the clinical efficacy of corticosteroid injection and physiotherapy
at a one year follow-up in patients suffering from unilateral lateral epicondylalgia.
A total of 165 patients were randomly assigned into 4 treatment groups
(corticosteroid injection = 43
patients,
placebo injection = 40 patients,
corticosteroid injection plus physiotherapy = 39 patients, and placebo injection plus physiotherapy = 41 patients). The authors included patients 18
years or older who
experienced unilateral lateral epicondylalgia for longer than 6 weeks. Additionally, the authors excluded patients
who received a corticosteroid injection in the preceding 6 months, received physiotherapy in the preceding 3 months, had concomitant neck or other arm
pain, had symptoms suggesting radicular, neurological, or systemic arthritic
conditions, were pregnant or breastfeeding, or had contradictions to injections.
The injection groups received either a placebo
of 0.5mL of 0.9% isotonic saline or 10mg/mL of triamcinolone acetonide plus 1mL
of 1% lignocaine. Physiotherapy groups
underwent 8, 30–minute
sessions during an 8–week
period. All physiotherapy was supervised by an experienced physiotherapy practitioner. At
4, 8, 12, 26, and 52 weeks post-treatment, patients recorded their global rating of change on a 6-point Likert-like scale, a 100 mm visual analog scale, and Patient-Rated Tennis Elbow Evaluation score range. Overall, physiotherapy had no effect on outcome measures, though
engaging in physiotherapy was associated with decreased use of analgesic and anti-inflammatory
medications. At one year follow-up,
patients receiving a corticosteroid injection reported less improvement than
placebo injections.
Corticosteroid
injections and physiotherapy are traditional treatments for epicondylalgia; however,
these results suggest that these options have little impact at one-year
follow-up. The clinical applicability of these results is difficult to
determine as patients were allowed to use analgesic or anti-inflammatory
medication; making a true assessment of change in pain and/or disability
difficult. At one-year post-treatment, patients who completed physiotherapy reported
using less analgesic and anti-inflammatory medications. While use of these
medications is not as drastic of a treatment, as a corticosteroid injection,
their purpose is similar: decrease inflammation and thus, perceived pain level.
This may provide some evidence, although not definitive, that physiotherapy may
be beneficial in the treatment of epicondylalgia. Tell us
what you think. Even though physiotherapy showed little influence on the
subjective measures of patients with epicondylalgia, do you believe there is
still benefit from having patients undergo a physiotherapy program? Why or why
not?
injections and physiotherapy are traditional treatments for epicondylalgia; however,
these results suggest that these options have little impact at one-year
follow-up. The clinical applicability of these results is difficult to
determine as patients were allowed to use analgesic or anti-inflammatory
medication; making a true assessment of change in pain and/or disability
difficult. At one-year post-treatment, patients who completed physiotherapy reported
using less analgesic and anti-inflammatory medications. While use of these
medications is not as drastic of a treatment, as a corticosteroid injection,
their purpose is similar: decrease inflammation and thus, perceived pain level.
This may provide some evidence, although not definitive, that physiotherapy may
be beneficial in the treatment of epicondylalgia. Tell us
what you think. Even though physiotherapy showed little influence on the
subjective measures of patients with epicondylalgia, do you believe there is
still benefit from having patients undergo a physiotherapy program? Why or why
not?
Written by: Kyle
Harris
Harris
Reviewed by: Laura
McDonald
McDonald
Related Posts:
Coombes BK, Bisset L, Brooks P, Khan A, & Vicenzino B (2013). Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA, 309 (5), 461-9 PMID: 23385272
In reading the actual study from JAMA, it is still unclear what interventions were actually applied, how they were applied (were patients told to stop if they had pain). I would also say that it seems a larger issue of concurrent proximal shoulder/scap stabilizer weakness was not addressed. In my experience, a large majority of patients that have lateral epicondyilits and especially those that have recurrences, have proximal weakness that contributes to their distal symptoms. I would like to see research done on the effectiveness of this tretament long-term.
Thanks for the comment. I think you bring up a few excellent points. Firstly, yes I agree. there were some important points of the study that could be clarified. Your other point concerning the shoulder/scap stabilizers is also interesting. First we should be careful as to the objective of the study. This study was focus primarily on the treatment of the lateral epicondylalgia rather than the causation. With that being said, I agree that as clinicians it is critical that we focus on the cause of a condition, especially in cases where the patient has a recurrence of that condition. I think this is an excellent focus for future research in this area.