887
post-template-default,single,single-post,postid-887,single-format-standard,elision-core-1.0.11,ajax_fade,page_not_loaded,qode-child-theme-ver-1.0.0,qode-theme-ver-4.5,wpb-js-composer js-comp-ver-6.6.0,vc_responsive
Title Image

Blog

Tennis Elbow Treatment: Physiotherapy, cortisone, or wait and see?

  |   Research   |   3 Comments

Study Appraised:  . Bisset, L., Beller, E., Jull, G., Brooks, P., Darnell, R., & Vicenzino, B. (2006). Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ333(7575), 939.

Level of Evidence: 2

What question did the study ask?

Purpose:    Is physical therapy more effective than no treatment or corticosteroid injections in tennis elbow over a 52 week period?

Patients – 190 individuals age 18-65

Inclusion criteria: Volunteers were eligible for participation if they met the inclusion criteria of pain over the lateral elbow that increased on palpation of the lateral epicondyle, gripping, resisted wrist, or second or third finger extension13 and age 18-65 years with pain of at least six weeks’ duration. 

Intervention Patients were randomized to physical therapy, corticosteroid injections, or a wait and see group.

  1. Participants in the wait and see group were informed that the condition would eventually settle and encouraged them to wait. They were also given instructions on modifying their activities of daily living to avoid aggravating their pain while being as active as possible and to use analgesic drugs, heat, cold, or braces as needed.
  2. The corticosteroid group received one full amount of a local injection delivered to the painful elbow points. Participants were advised to return gradually to normal activities. A second injection was allowed after two weeks if deemed necessary by the medical practitioners.
  • The physical therapy group received 8, 30 min treatments over 6 weeks consisting of elbow manipulation and therapeutic exercise. Participants were taught home exercises and self-manipulation. They also received resistance exercise bands and an exercise instruction booklet.

All participants received an information booklet that outlined the disease process and provided practical advice on self management and ergonomics on entering the study.

Outcomes

Corticosteroid injection showed significantly better effects at 6 weeks but with high recurrence rates thereafter (47/65 of successes subsequently regressed) and significantly poorer outcomes in the long term compared with physical therapy.

Physical therapy proved better than the wait and see in the short term; no difference was seen at 52 weeks, when most participants in both groups reported a successful outcome.

 ARE THE RESULTS OF THE TRIAL VALID?

     1a.   R- Was the assignment of patients to treatments randomized?

Yes. Participants were drawn up by a computerized random number generator

      1b.  R- Were the groups similar at the start of the trial?

All three groups had similar characteristics; although, there were significantly more patients with reported overuse injury in the physiotherapy group compared to the wait and see group

     2a.  A- Aside from the allocated treatment, were groups treated equally?

Yes. Although some received a second steroid injection.

      2b.  A- Were all patients who entered the trial accounted for? – and were they analysed in the groups to which they were randomized?

10% of those in the physiotherapy group didn’t receive the treatment required.

  1. M – Were measures objective or were the patients and clinicians kept “blind” to which treatment was being received?

At 52 weeks the assessors correctly guessed group allocation in greater than 50% of subjects. A post hoc subgroup analysis to assess the impact of the loss of blinding on outcome measures detected no significant difference in outcomes between the participants whose treatment allocation the assessor guessed correctly and those for whom the assessor remained blinded.

WHAT WERE THE RESULTS?

Corticosteroid injection showed significantly better effects at 6 weeks but with high recurrence rates thereafter (47/65 of successes subsequently regressed) and significantly poorer outcomes in the long term compared with physical therapy.

Physical therapy proved better than the wait and see in the short term; no difference was seen at 52 weeks, when most participants in both groups reported a successful outcome.

 Will the results help me in caring for my patient? (External Validity/Applicability)

Physical therapy with manual therapy and exercise is better than no treatment and shows benefits when compared to injections at >6 weeks.

You can use this information in educating your patients on a more long term solution to their elbow pain. If a patient desires or needs short term pain relief then a corticosteroid injection may be of benefit, but make sure to educate the patient that there is a high likelihood that their pain will return after only having the injection.

Limitations of the study:

  • duration of follow-up (one year after intervention)
  • subjective assessor rating for a primary outcome measure
  • some patients were allowed a secondary injection (if deemed necessary)

 References

Bisset, L., Beller, E., Jull, G., Brooks, P., Darnell, R., & Vicenzino, B. (2006). Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. Bmj, 333(7575), 939.

3 Comments
  • Rashmi | Nov 19, 2018 at 11:41 am

    Though we may see some short-term benefit, the negative intermediate-term effect along with an uncertain long-term effect of a steroid injection makes this treatment difficult to recommend. I do not not normally recommend a cortisone shot.

    • Janice | Nov 19, 2018 at 3:23 pm

      Thanks for the comments Rashmi. Research, since this was done, affirms that fewer patients that receive physiotherapy consume analgesics or anti-iflammatory medications and that cortisone is associated with higher rates of recurrence. Perhaps people with mild symptoms should take a wait and see approach; people with moderate symptoms should get physiotherapy.

      Coombes, B. K., 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), 461-469.

  • PaulinaBig | Apr 17, 2019 at 5:37 pm

    Great post

Post A Comment

%d bloggers like this: