Recent headlines in the health media this week suggest that physiotherapy provides no benefit for tennis elbow: “Tennis elbow: Cortisone shots and physical therapy provide no long-term relief, study finds”, and “Corticosteroid injection, physiotherapy do not provide significant improvement for ‘tennis elbow'”. These articles refer to findings from a newly published clinical study examining corticosteroid injections and physiotherapy in treating chronic lateral epicondylalgia (‘tennis elbow’) (Coombes, B.K., Bisset L., et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013 Feb6;309(5):461-9). While corticosteroid injections have historically been a more contentious treatment for tennis elbow, physiotherapy has long been the most widely accepted treatment for this condition. Various studies alongside the anecdotal evidence of patients and therapists support its use. Could current clinical practice be wrong?
The objective of this clinical study was to examine the efficacy of corticosteroid injections for treating tennis elbow in conjunction with physiotherapy. Growing clinical evidence has suggested that such injections may not have long-term efficacy, and recurrence rates may be high. In a previous study by the same investigators results showed that at 1 year follow-up, recurrence occurred for 72% of patients receiving the injection alone, compared with only 8% who received physiotherapy (Bisset L, Beller E, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939). Even though injections may not provide great long-term outcomes, they may provide significant short term pain relief (although placebo effects have not be adequately ruled out). The authors therefore devised a clinical trial of 165 patients to shed further light on the utility of using corticosteroid injections, physiotherapy, or both, in clinical practice.
So what did this clinical trial show? The authors conclude first and foremost that “there was a worse clinical outcome 1 year after corticosteroid injection compared with placebo, despite its short-term benefits”. This is an interesting result that supports a growing suspicion in the medical community regarding the potential ineffectiveness of steroid injections for tennis elbow. The authors then go on to say that when compared with no physiotherapy, “physiotherapy did not result in any significant 1-year differences.” This later conclusion was startling. How could this be the case? The answer of course is in the details.
Upon closer examination of the study it becomes apparent that the authors’ conclusions can be easily misinterpreted. Not surprisingly, one needs to read more than the study summary in order to understand what the authors are telling us. The authors actually report that physiotherapy provided significant benefits across all outcome measures (pain, disability, and quality of life) at 4 weeks, earlier than patients who did not receive physiotherapy. Patients who received physiotherapy also demonstrated the lowest recurrence rates at 1 year (4.9%), and these patients also achieved ‘100% complete recovery or much improvement’ at 1 year. So even though at the 1 year mark there was no statistically significant difference in pain, disability, and quality of life measures between patients who received physiotherapy and those who did not, those that did receive physiotherapy got better faster, had the lowest recurrence rate, and achieved ideal 1 year outcomes. The story doesn’t end there.
In reality, the difference in outcomes between patients who received physiotherapy and those that did not is likely to be significantly greater than was demonstrated in this study. The authors narrowly defined physiotherapy as consisting of only “elbow manual therapy and exercise”, and provided ALL patients with education regarding which activities to avoid, use of analgesic and anti-inflammatory medication, use of heat and cold treatments, as well as the use of support braces and other health information. So BOTH the physiotherapy group AND the no-physiotherapy group received the education component of a normal physiotherapy treatment program. In other words, it would be more accurate to say that the authors were comparing physiotherapy treatment with and without the use of manual therapy and exercise!
In direct opposition to the exciting headlines imagined by the various health writers that “reviewed” this study, this clinical trial actually provides further evidence in support of the use of physiotherapy as the gold standard treatment for tennis elbow.