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Physiotherapy 95 (2009) 251–265
Systematic review
ffectiveness of corticosteroid injections compared with physiotherapeuticinterventions for lateral epicondylitis: A systematic review
Steven Barr a,∗, Frances L. Cerisola b, Victoria Blanchard c
a School of Health and Social Care, Teesside University, Middlesbrough TS1 3BA, UKb Physiotherapy Department, South Tyneside District Hospital, South Shields, UKc Physiotherapy Department, University Hospital of North Durham, Durham, UK
bstract
bjectives To compare the effectiveness of corticosteroid injections with physiotherapeutic interventions for the treatment of lateralpicondylitis (tennis elbow).ata sources The electronic databases AMED, Cinahl, Medline and Embase were searched up to Week 12 2009. In addition, the Cochraneentral Register of Controlled Clinical Trials, the Metaregister of Controlled Clinical Trials and the Physiotherapy Evidence Database (PEDro)ere searched up to March 2009.eview methods All English-language randomised controlled trials (RCTs) that included participants with a clinical diagnosis of lateral
picondylitis, comparing corticosteroid injections with physiotherapeutic interventions, and used at least one clinically relevant outcomeeasure were included. The review authors extracted and analysed the data independently, using the PEDro scale to assess the methodological
uality of each eligible study.esults Five RCTs were identified and included in the review. Four of the studies included the measurement of pain-free grip strength.tandardised mean differences (effect sizes) were calculated for this outcome measure and assessor’s rating of severity at 3, 6, 12, 26nd 52 weeks for two of the RCTs. Large effect sizes were demonstrated in favour of corticosteroid injections at short-term follow-up. Atntermediate- and long-term follow-up, medium-to-large effect sizes were demonstrated in favour of physiotherapeutic interventions comparedith corticosteroid injections. However, at long-term follow-up, the research suggests that there is a small benefit of physiotherapeutic
nterventions compared with a ‘wait and see’ policy.
onclusion Overall, the findings indicated that corticosteroid injections are effective at short-term follow-up, and physiotherapeutic inter-entions are effective at intermediate- and long-term follow-up. However, due to the limited number of high-quality RCTs and differences inhe interventions and outcomes utilised within each of the included studies, any conclusions drawn must be interpreted with caution.2009 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
cetonid
poacap
eywords: Tennis elbow; Physical therapy; Rehabilitation; Triamcinolone a
ackground
Lateral epicondylitis (tennis elbow) is a painful muscu-oskeletal condition which is considered to be due to over-use,ver-stress or over-exertion of the wrist extensors of the fore-rm [1]. It is often associated with individuals who haveepetitive occupations and/or hobbies [2], affects the dom-
nant hand [1] and primarily occurs between the ages of 35nd 64 years [3].∗ Corresponding author. Tel.: +44 01642 384296; fax: +44 01642 384105.E-mail address: [email protected] (S. Barr).
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031-9406/$ – see front matter © 2009 Chartered Society of Physiotherapy. Publisoi:10.1016/j.physio.2009.05.002
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Clinical presentation is characterised by lateral elbowain, which may radiate into the forearm, with reproductionf pain on resisted wrist extension and localised palpationround the common extensor origin [4]. Most individuals willlassically report pain as the main feature of their condition,ssociated with marked deficits in activities involving grip-ing and wrist extension [5]. Many individuals are referred tohysiotherapy departments for optimal management of thisondition. The primary aims of treatment are pain relief and
estoration of muscle condition [5].Although there is widespread acceptance that the com-on extensor origin, particularly the origin of extensor carpi
adialis brevis [1], is the affected structure, several the-
hed by Elsevier Ltd. All rights reserved.
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ries have developed regarding the underlying aetiology.istorically, an acute inflammatory response is thought toe responsible for the associated disability [4], suggestinghat treatments should focus on the resolution of inflamma-ion. However, more recent histopathological examinationsuggest that a non-inflammatory process is present and thatreatments should be aimed at normal vascularisation and col-agen production in the affected tendon [2,6]. There is a dearthf literature identifying numerous treatment interventions,uggesting that this musculoskeletal condition is complexo manage. Such controversy regarding the rationale behind
any advocated treatment interventions [7] introduces fur-her uncertainty into optimal management.
The Cochrane Library has published several reviewsn an attempt to determine the optimal management ofennis elbow. The reviews cover a widespread range ofreatments including: acupuncture [8], oral non-steroidalnti-inflammatory drugs (NSAIDs) [9], orthotic devices [10],hock wave therapy [11] and surgery [12]. The evaluation ofcupuncture as a treatment modality is the only review of par-icular relevance to current physiotherapy practice; however,he inclusion criteria were poorly defined and not sufficientlypecific to only include individuals with a diagnosis of lateralpicondylitis.
Four systematic reviews [13–16] have studied the effec-iveness of physiotherapeutic interventions and rehabilitationn the management of lateral epicondylitis, incorporating
any different interventions, e.g. ultrasound, exercise andobilisations. One review [13] attempted to perform a quan-
itative meta-analysis of various treatments. However, due tooor methodological quality and contradictory results, theuthors concluded that there was insufficient evidence toupport a single type of intervention. Another review [14]ncluded interventions which are rarely used within currenthysiotherapy practice (e.g. ionisation, Reebox). However,his review did find good-quality evidence to support pos-tive effects with regards to acupuncture, exercise therapy,
anipulations/mobilisations and ultrasound. The only inter-entions that were refuted definitively were laser therapy andulsed electromagnetic field therapy (PEMT).
Smidt et al. [15] performed a comprehensive review withell-defined selection criteria and stringent quality assess-ent. Fourteen of 23 studies were found to have an acceptable
alidity score, although the authors found that none of thencluded studies had an adequate sample size or sufficientower. The main finding was weak evidence to support theffectiveness of ultrasound compared with placebo.
Bisset et al. [16] carried out a well-designed review anddentified 28 studies that had acceptable levels of quality fornclusion. Although some evidence was found to support thehort-term benefit of ultrasound, ionisation and acupuncture,o evidence was found to suggest a benefit over placebo in
he long term.As several treatment modalities used regularly in physio-herapy practice have been shown to lack scientific rationale,
any clinicians appear to base their management of this
wesa
95 (2009) 251–265
omplex condition on subjective data and clinical experience17].
The most consistent benefit identified in the literatureppears to be short-term pain relief following corticos-eroid injections [3,18]. Two systematic reviews havetudied the effectiveness of corticosteroid injections for lat-ral epicondylitis, and both concluded that corticosteroidnjections are effective in the short term but not at longer-erm follow-up. Conclusions were drawn with referenceo an alternative treatment, e.g. NSAIDs, wrist brace andhonophoresis.
In 1995, the scope of physiotherapy was extended tonclude corticosteroid injections within the management of
usculoskeletal conditions [19], and physiotherapists canow choose to include this as a treatment option in theanagement of tennis elbow. Thus, in an attempt to pro-
ide clinically effective treatments supported by scientificvidence as well as clinical expertise [20], it was felt that
new review was justified. The particular aim of thiseview is to compare the effectiveness of corticosteroid injec-ions with physiotherapeutic interventions regularly usedn clinical practice. No previous systematic reviews that
ake this direct comparison have been identified, and allecent and updated primary research will be included in thiseview.
bjective
The aim of this review is to compare the effectivenessf corticosteroid injections with physiotherapeutic interven-ions for the treatment of lateral epicondylitis.
ethod
earch strategy
The authors searched the databases Medline (1966 toeek 12 2009), Cinahl (1982 to Week 12, 2009), Amed
1985 to Week 12, 2009) and SPORTDiscus (1985 to Week2 2009) via the EBSCOhost searching interface. The searcherms were adapted for the Embase (1980 to Week 12 2009)atabase, which was searched via OVID. Subject headingsnd keywords based around population and interventionsere used to identify potentially relevant citations. Trunca-
ion symbols were used within the headings and keywords.n example of the Embase search strategy is detailed in Box 1In addition, the Physiotherapy Evidence Database (PEDro)as searched up to Week 12 2009 using the keywords
forearm or elbow’, ‘musculoskeletal’ and ‘clinical trial’.he Cochrane Central Register of Controlled Clinical Trials
as searched up to March 2009 using the keywords ‘tennislbow’, ‘lateral epicondylitis’ and ‘elbow pain’. Additionalearching included the metaregister of controlled clinical tri-ls, subject headings and keywords were used to identify
S. Barr et al. / Physiotherapy
Box 1Example of Embase search via OVID: to Week12 2009
1 tennis elbow.mp. or Tennis Elbow/2 lateral epicondylitis.mp. or Tennis Elbow/3 elbow joint.mp. or exp Elbow/4 tendin$.mp.5 tendon$.mp. or Tendon Injury/or Tendon Lesion/6 tendonitis.mp. or Tendinitis/7 3 and 48 3 and 59 3 and 6
10 1 or 2 or 6 or 7 or 8 or 911 physical therapy.mp. or Physiotherapy/12 physio$.mp.13 physical$.mp.14 Rehabilitation/or rehab$.mp.15 Exercise/or exercise$.mp.16 (home adj3 exercise$).mp.17 mobilis$.mp.18 manip$.mp.19 friction$.mp.20 Acupuncture Analgesia/or Acupuncture/or
acupuncture$.mp.21 acupressure.mp. or Acupressure/22 trigger point therapy.mp. or Massage/23 electro$.mp.24 ultrasonic therapy.mp. or Ultrasound Therapy/25 Ultrasound/or ultrasound.mp.26 ultrasonics.mp. or Ultrasound/27 ultra$.mp.28 tens.mp.29 Transcutaneous Nerve Stimulation/or transcuta-
neous electrical nerve stimulation.mp.30 Laser/or laser$.mp.31 laser therapy.mp.32 taping$.mp.33 bracing$.mp.34 stretching$.mp.35 strengthening$.mp.36 or/11-3537 Triamcinolone/or Corticosteroid/or Steroid/or
steroid injection.mp. or Triamcinolone Acetonide/38 steroid.mp. or Steroid/39 injection therapy.mp.40 38 or 39 or 37
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otentially relevant citations, and were based around popula-ion and both physiotherapeutic and injection interventions.
All searches were limited to studies published in thenglish language, and the references of all primary studiesnd publications identified were screened for further relevanttudies.
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95 (2009) 251–265 253
tudy selection
Studies were eligible for inclusion in the review if theyet the following criteria.
tudy designRandomised controlled trials (RCTs) were considered for
nclusion if they demonstrated evidence of random allocationf subjects to either an injection group or a physiotherapeu-ic intervention group. Only trials published in the Englishanguage were considered.
articipantsMale or female participants aged at least 18 years with
clinical diagnosis of lateral epicondylitis, characterisedy lateral elbow pain reproduced on resisted wrist exten-ion/dorsiflexion, were included [4].
nterventionsStudies which compared a corticosteroid injection group
ith a physiotherapeutic intervention group were included.he latter comprised any interventions regularly usedithin physiotherapy practice in the management of lat-
ral epicondylitis. These included (but were not limitedo): ultrasound, electrotherapy, frictions, taping, acupuncture,
obilisations, manipulations, exercises, home exercise pro-rammes and mills manipulation. The review authors wereequired to be familiar with the intervention and agree on itsnclusion.
Studies were excluded if there was failure to define andescribe the physiotherapeutic intervention and/or the corti-osteroid injections used within the study.
utcomesAll studies had to include at least one clinically relevant
nd validated outcome measure which has been shown to beensitive to change [21]. These could include (but were notimited to) measures of the severity of pain, grip strength (painree or maximum), elbow disability and global improvement,ith follow-up of at least 6 weeks.
tudy quality assessment
The 11-item PEDro scale was used to assess the qual-ty of the studies eligible for inclusion in the review. Thisas included as it is a scale specifically designed to assessCTs on PEDro [22]. It is based on the Delphi list describedy Verhagen et al. [23], and includes assessment of cri-eria which are thought to be central to bias minimisationnd high internal validity; namely randomisation, concealedllocation, and blinding of subjects, therapists and assessors24–26].
Eligible studies identified in the search were assessed inde-endently by the review authors. Each study was openlyssessed and documented. Any disagreements involvinguality assessment of the pilot or selected studies were
254 S. Barr et al. / Physiotherapy 95 (2009) 251–265
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ig. 1. Flow diagram of study selection.
esolved in a consensus meeting and documented to demon-trate the level of disagreement [25].
ata extraction
A comprehensive data extraction form was developedhich was independently pilot tested prior to use in the
eview. Data extracted included participant eligibility crite-ia, the type and duration of interventions, outcome measuressed within each study, follow-up periods, methods of datanalysis and research findings. Data extraction forms wereompared at consensus meetings.
ata analysis
Data from the injection, physiotherapeutic interventionnd ‘wait and see’ study groups were analysed. Where
ossible, effect sizes (standardised mean differences) werealculated at short- (3 to 6 weeks), intermediate- (between 6nd 26 weeks) and long-term (52 weeks) follow-up periods intudies which included outcome measures that were directlyctgg
omparable. The effect size was calculated as described byoe [27].
Data analysis was undertaken using MedCalc® Version0.4 (MedCalc Software: Mariarkerke, Belgium). Standard-sed mean differences and 95% confidence intervals werealculated using a random effects model. Descriptive analysisas undertaken on studies with heterogenous outcomes.As effect sizes are calculated using an experimen-
al and control group, for the purpose of the review,ata from the injection groups were substituted as thexperimental group, and data from the control/‘wait andee’ and physiotherapeutic intervention groups were sub-tituted as the control group. Analysis was made witheference to the injection group [27], i.e. positive effectizes indicated a beneficial effect in favour of the injec-ion group, and negative effect sizes indicated a beneficialffect in favour of the physiotherapeutic intervention or
ontrol/‘wait and see’ group. For comparison betweenhe physiotherapeutic intervention group and the controlroup, intervention data were substituted as the experimentalroup.
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95(2009)
251–265255
Table 1Summary of the characteristics of the included studies.
Study Design Population Duration ofdisorder
Injectionintervention
Physiotherapeuticintervention
Control Outcomemeasures
Follow-up Summary of findings
Smidt et al.2002 [30]
RCT n = *185 At least 6/52(median 11/52)
10 mgtriamcinoloneacetonide and 1 mllidocaine 2%.Tender pointsidentified andinjected untilpatient pain freewith resisteddorsiflexion. Maxthree injections in6/52
Pulsed U/S, deepfriction massage,exercise programmeand home exerciseprogramme
Wait and seeadvice,paracetamolor NSAIDs
Overall severity ofcomplaints, painduring day,pain-free gripstrength, max gripstrength, modifiedpain-freequestionnaire,globalimprovement, painpressure threshold,inconvenience,patient satisfaction
3,6,12,26 and 52weeks
At 6/52, corticosteroidinjection groupshowed significantimprovement acrossall outcomescompared withphysiotherapy group.At 12, 26 and 52weeks, physiotherapygroup showedsignificantimprovement acrossall outcomescompared withcorticosteroidinjection group.Short-term significantfindings in favour ofphysiotherapy groupcompared with waitand see group. At 52weeks, no significantdifference inoutcomes betweenphysiotherapy groupand wait and seegroup
Female n = 93
37% recurrence ininjection group
Mean age 47 yearsPain at lateral sideof elbow increasedwith pressure onlateral epicondyleand resisteddorsi-flexion.Injection groupn = 62Physiotherapygroup n = 64Wait and seegroup n = 59
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Table 1 ( Continued )
Study Design Population Duration ofdisorder
Injectionintervention
Physiotherapeuticintervention
Control Outcomemeasures
Follow-up Summary of findings
Bisset et al.2006 [31]
RCT n = *198 At least 6/52(median 22/52)
1 mg lidocaine 1%with 10 mgtriamcinoloneacetonidedelivered topainful elbowpoints. 2nd
injection after2/52 if required.
Elbowmanipulation andexercise and homeexerciseprogramme.
Wait and seeadvice onactivitymodification,use ofanalgaesia,heat, cold andbrace if needed
Severity of elbowcomplaints, severityof pain in previous1/52, pain-free gripstrength, pain-freefunctionquestionnaire,global/generalimprovement
3,6,12,26 and 52weeks
At 6/52, corticosteroidinjection showedsignificantimprovement acrossall outcomescompared withphysiotherapy groupand wait and seegroup.
Female n = 70
Advice tocontinue normalactivities
Eight 30-minutetreatments over6/52
At 6/52,physiotherapy groupshowed significantimprovementcompared with waitand see group for alloutcomes.
Mean age 47.6years
At 12, 26 and 52weeks, physiotherapygroup showedsignificantimprovementcompared withcorticosteroidinjection group.
Pain over lateralelbow increasedwith palpation oflateral epicondyle,gripping, resistedwrist or 2nd, 3rd
finger extension.Injection groupn = 65
At 52 weeks, nosignificant differencein outcomes betweenphysiotherapy groupand wait and seegroup.
Physiotherapygroup n = 66
72% recurrence ininjection group
Wait and seegroup n = 67
S.Barr
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95(2009)
251–265257
Table 1 (Continued )
Study Design Population Duration ofdisorder
Injectionintervention
Physiotherapeuticintervention
Control Outcomemeasures
Follow-up Summary of findings
Verhaar et al.1996 [32]
RCT n = *106 Mean 33/52 1 ml triamcinoloneacetate suspension1%, diluted with1 ml lidocaine intoorigins of extensordigitorum andextensor carpiradialis brevis.
Deep transversefrictions and millsmanipulations.
N/A Occurrence of pain,severity of pain,mean grip strength,subjective loss ofgrip strength,resumption oflabour, resisteddorsi-flexion andresisteddorsi-flexion ofmiddle finger, localtenderness
6 and 52weeks
At 6/52, corticosteroidinjection groupshowed significantimprovement acrossall outcomes.
Female n = 47
Max threeinjections in 4/52.Advice to avoidpain provokingactivity
12 treatments over4/52 At 52 weeks, no
difference inoutcomes between thetwo groups.
Mean age 43 years
34% recurrence ratein injection group
Pain at lateral sideelbow, tendernessover extensororigin, pain onresisteddorsi-flexion.Injection groupn = 53Physiotherapygroup n = 53
Uzunca et al.2007 [33]
RCT n = *60 Mean 3.4/12 Single injection of1 cc methyl-prednisolone(40 mg)
PEMF x 5sessions per weekover 3/52.
Sham PEMF VAS: pain levelsduring rest, nighttime and resistedwrist extensionand supination.
3 and 12weeks
All pain parametersimproved after 3/52 inall groups. VAS levelsduring activity and onresisted wristextension weresignificantly lower inthe injection groupcompared with thePEMF group. Onlypain levels on resistedwrist extension andsupination weresignificantly lower inthe PEMF groupcompared with thesham group.
Female n = 451 cc prilocainemost painful areaaround lateralepicondyle
Dose = 6 MT
Same audio andvisual sense butno exposure tomagnetic field
Algometric painthresholds
At 12/52, the PEMFgroup had lower painduring rest, activityand night-timecompared with theinjection group
Mean age 48.6years
Frequency = 25 Hzand 4.6 Hzconsecutively
Tenderness overextensor carpiradialis brevisorigin. Pain onresisted wristextension andsupination.Injection groupn = 20Physiotherapygroup n = 20Shamphysiotherapygroup n = 20
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Table 1 ( Continued )
Study Design Population Duration ofdisorder
Injectionintervention
Physiotherapeuticintervention
Control Outcomemeasures
Follow-up Summary of findings
Tonks et al.2007 [34]
RCT n = *48 Not stated Single injection of10 mgtriamcinolone and2% lignocainehydrochloride overtender part ofextensor origin
Exerciseprogramme:progressive slowrepetitive wriststretching andmuscleconditioningintensified overfour stages.
Notreatment
Pain-free gripstrength, PRFEQ,extensor weightstrength
7/52 Significantimprovement in alloutcomes for injectiongroup only comparedwith physiotherapyand injection group,physiotherapy alonegroup and notreatment group
Gender or meanage not stated
Duration andfrequency notstated
Pain on palpationof extensor originand resisted wristextension.Injection groupn = 12Physiotherapygroup n = 12Injection andphysiotherapygroup n = 12No treatmentgroup n = 12
RCT, randomised controlled trial; NSAIDs, non-steroidal anti-inflammatory drugs; U/S, ultrasound; PEMF, pulsed electromagnetic field therapy; VAS, visual analogue scale; PRFEQ, patient related forearmevaluation questionnaire.
* Sample size at commencement of study.
therapy
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S. Barr et al. / Physio
The effect sizes were interpreted as described by Cohen28]. An effect size of 0.2 was considered to represent a smalleneficial effect, 0.5 a medium effect and >0.8 a large effect.
esults
earch results
The review authors independently assessed the title andbstract of each article. In total, 997 studies were initiallydentified from the search. From these, 990 were excludednd seven were deemed to be eligible for closer scrutiny.ne study was excluded after retrieval of the full text [29].his study proved to be a cost-effective analysis of anotherCT [30]. One unpublished trial required additional details
o be scrutinised. Further investigation found that the trial hadecently been published and was one of the selected RCTs.he results of the search are detailed in Fig. 1.
Subsequently, five studies were deemed to be eligible fornclusion in the final review [30–34]. All five studies wereCTs that included comparison between an injection groupnd a physiotherapeutic intervention group. The studies byisset et al. [31], Smidt et al. [30] and Tonks et al. [34] also
ncluded a control/‘wait and see’ group. The study by Verhaart al. [33] only included a comparison between a physio-herapeutic intervention group and a corticosteroid injectionroup. The study by Tonks et al. [34] had an additional grouphich received physiotherapeutic interventions in combina-
ion with corticosteroid injections. The control group in thetudy by Uzunca [33] received sham PEMT.
haracteristics of included studies
opulationsThe characteristics of each study are summarised in
able 1. All studies identified clear inclusion and exclusion
riteria. The mean age and gender of participants in eachtudy were comparable, although the average duration ofennis elbow varied. Bisset et al. [31] and Smidt et al. [30]eported calculations to determine that a sample size of 60Q
d
able 2uality assessment of included studies using the Physiotherapy Evidence Database
Bisset et al.2002 [30]
Smidt et al.2006 [31]
andom allocation 1 1oncealed allocation 1 1aseline comparability 1 1lind subject 0 0lind clinician 0 0lind assessor 1 1dequate follow-up 1 1
ntention-to-treat analysis 1 1etween-group analysis 1 1oint estimates and variability 1 1otal score 8 8
95 (2009) 251–265 259
articipants per group was necessary to detect a clinicallymportant difference of 25% in success rate between groups.n both studies, at least 60 participants per group started andompleted the trial. In the study by Verhaar et al. [32], theaximum number of participants per group at any stage was
3. In comparison, the sample populations in each group inhe studies by Uzunca et al. [33] and Tonks et al. [34] wereower at 20 and 12, respectively.
nterventionsThe type, frequency and duration of the physiotherapeutic
nterventions varied significantly across the included studies.he interventions included different types of electrotherapy
ultrasound and PEMT), manual therapy and exercise pro-rammes. The interventions for each study are summarised inable 1. The injection drugs were comparable between four of
he studies, although one study [33] used methylprednisolonenstead of triamcinolone. There were differences across alltudies in the strength of the local anaesthetic, injection sitend number of injections administered.
utcome assessmentEach study included more than one outcome measure,
nd variations of pain and grip strength were reported in allve RCTs. However, a wide variety of outcome measure-ents were included, using a variety of assessment tools.our studies [30–33] incorporated pain-free grip strength asmeasure. Only the studies by Bisset et al. [31] and Smidt
t al. [30] reported comparable measures between groups ataseline, which permitted meta-analysis for both pain-freerip strength and assessor’s rating of severity.
Three studies [30–32] reported measurements at baseline,weeks and 1 year. Uzunca et al. [33] had follow-up periodsf 3 and 12 weeks, and Tonks et al. [34] had a single follow-p at 7 weeks. Two studies [30,31] included more frequentollow-up measurements throughout the assessment period.
uality assessment
The quality assessment for each individual study isetailed in Table 2. There were variations in the method-
scale.
Verhaar et al.1996 [32]
Uzunca et al.2007 [33]
Tonks et al.2007 [34]
1 1 11 1 11 1 00 0 00 0 00 1 01 1 01 0 01 1 11 1 17 7 4
260 S. Barr et al. / Physiotherapy 95 (2009) 251–265
Table 3Effect sizes: corticosteroid injections compared with physiotherapeutic interventions for pain-free grip strength and assessor’s rating of severity.
Study Follow-up (weeks) Sample size injection Sample size physiotherapeuticinterventions
Pain-free grip strength Rating of severity
Bisset et al. 2002 [30] 3 63 64 1.25 1.266 65 63 0.55 0.65
12 65 58 −0.67 −0.726 64 59 −1.06 −1.3852 65 63 −0.61 −0.89
Smidt et al. 2006 [31] 3 62 64 1.29 1.136 62 64 1.08 1.05
12 61 64 −0.37 −0.3244
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ositive effect sizes favour corticosteroid injections. Negative effect sizes fa
logical assessment scores of each of the included studies.ll of the included studies allocated participants at random
o the corticosteroid injection group or the physiotherapeu-ic intervention group. With the exception of the study byonks et al. [34], the groups were comparable at baseline.nsurprisingly due to the nature of the interventions, none of
he participants or clinicians were blind to the interventions.hree studies [30–32] included intention-to-treat analyses.ollow-up was adequate in all studies with the exceptionf Tonks et al. [34], who only compared the short-termenefit of physiotherapeutic interventions and corticosteroidnjections.
esults of data analysis
Table 1 shows the summary of results for each of theCTs. The results of meta-analysis comparing corticos-
eroid injections and physiotherapeutic interventions on the
utcomes of pain-free grip strength and assessor’s ratingf severity in the studies by Bisset et al. [30] and Smidtt al. [31] are outlined in Table 3. Forest plots (Figs. 2–5)emonstrate the effect sizes comparing the corticosteroidwcai
ig. 2. Comparison: corticosteroid injections compared with physiotherapeutic inte
−0.57 −0.5−0.72 −0.48
ysiotherapeutic interventions.
njection, physiotherapeutic intervention and control/‘waitnd see’ groups at various follow-up points for the outcomef pain-free grip strength. The main conclusion from bothtudies [30,31] for both outcome measures is that corticos-eroid injections are effective at short-term follow-up, andhysiotherapeutic interventions are effective at intermediate-nd long-term follow-up. Physiotherapeutic interventionsemonstrated a large effect compared with the ‘wait and see’roup at short-term follow-up, but only a small benefit at long-erm follow-up. Both studies also reported sufficient sampleizes for the detection of a clinically important difference.
All of the included studies found that corticosteroidnjections were significantly more effective than physiothera-eutic interventions for outcome measurements at short-termollow-up, i.e. between 3 weeks [30,31,33] and 7 weeks32,34]. Tonks et al. [34] found that, at short-term follow-up,here was no significant difference between the group receiv-ng physiotherapeutic interventions and injections compared
ith injections alone. However, this study did have signifi-antly smaller study groups and had large loss to follow-upt 7 weeks. Where measurements were undertaken in thentermediate term, three of the studies found that physiother-
rventions at 6 week follow-up. Outcome: pain-free grip strength.
S. Barr et al. / Physiotherapy 95 (2009) 251–265 261
Fig. 3. Comparison: corticosteroid injections compared with physiotherapeutic interventions at 26 week follow-up. Outcome: pain-free grip strength.
F
F
ig. 4. Comparison: corticosteroid injections compared with physiotherapeutic inte
ig. 5. Comparison: physiotherapeutic interventions compared with ‘wait and see’
rventions at 52 week follow-up. Outcome: pain-free grip strength.
approach at 52 weeks follow-up. Outcome: pain-free grip strength.
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62 S. Barr et al. / Physio
peutic interventions were significantly more effective thanorticosteroid injections [30,31,33].
Despite corticosteroid injections being found to be moreffective in the short term compared with physiotherapeuticnterventions, reported recurrence rates varied from 34% to4% in three of the included studies [30–32].
iscussion
Although the research does indicate that corticosteroidnjections are more effective than physiotherapeutic inter-entions in the short term, and that physiotherapeuticnterventions are more effective than corticosteroid injec-ions in the intermediate to longer term, the findings muste interpreted with some caution. The results of this reviewan only suggest that corticosteroid injections or physiother-peutic interventions are more effective at different stagesf intervention. Conclusions cannot be drawn on the basis ofhis review about the effectiveness of physiotherapeutic inter-entions alone in the short term, or corticosteroid injectionslone in the intermediate to longer term. However, phys-otherapeutic interventions did have a significant effect inhe short term compared with the ‘wait and see’ approach.he smaller benefit demonstrated in the longer term per-aps adds further weight to the self-limiting nature of thisondition.
No previous systematic reviews have been undertakenhich have directly compared the effectiveness of corti-
osteroid injections with physiotherapeutic interventions.owever, the findings from this review, that corticosteroid
njections demonstrate beneficial treatment effects for short-erm outcomes, are consistent with previous findings [3,17].he outcome measures used in this review are comparableith those included in the review by Smidt et al. [17]. Neitherf these reviews have refuted the effectiveness of corticos-eroid injections at intermediate- and long-term follow-up,ut suggested that firm conclusions could not be drawnue to a lack of high-quality evidence and methodologicalaws in studies. Similarly, conclusions from reviews thatave evaluated the effectiveness of physiotherapeutic inter-entions have suggested that poor-quality primary studiesave included limited intermediate- and long-term follow-up14–16].
There were differences across all five of the includedtudies, particularly in relation to the type, frequency anduration of the physiotherapeutic interventions and corticos-eroid injections, the outcome measures used to determineffectiveness and methodological quality; these also need toe taken into consideration when interpreting the findings ofhis review.
The duration of lateral epicondylitis varied from 11 weeks
30] to 33 weeks [32]. The study by Bisset et al. [31]ad a median duration that was twice that of the compa-able study by Smidt et al. [30]. Although chronic cases arehought to be more difficult to treat [35], this did not appearo
lt
95 (2009) 251–265
o influence the outcome of either intervention in eithertudy.
Although four of the studies [30–32,34] included triamci-olone acetonide as the corticosteroid of choice, there wereifferences in the dose, frequency and sites of injection. Smidtt al. [30] included a stronger local anaesthetic mixed withhe corticosteroid, and participants were allowed three injec-ions. Only 12% of participants received a second injectionn the study by Bisset et al. [31], compared with 27% inhe comparable study [30], where 15% also received a thirdnjection.
Such differences in the injection intervention may accountor the larger effect size reported in favour of injections at 6eek follow-up for both outcome measures [30]. However,o literature has been identified which advocates an idealumber of injections, and one previous study found little evi-ence to justify the selection and dosage of corticosteroid andocal anaesthetic [36].
The purpose of this review was to compare the effec-iveness of physiotherapeutic interventions compared withorticosteroid injections. However, it does need to be clearlyeiterated that there were substantial differences with regardo the types, duration and frequency of physiotherapeuticnterventions. Smidt et al. [30] included a combination ofulsed ultrasound alongside deep friction massage and anxercise programme as the physiotherapeutic interventions.
previous systematic review [15] concluded that treatmentffects of two studies showed statistically significant andlinically relevant differences in favour of ultrasound whenompared with placebo. However, insufficient evidence wasound which demonstrated benefit or lack of effect to sup-ort the addition of deep friction massage or exercise. Andditional review [37] aimed to evaluate the effectivenessf deep transverse friction massage in the treatment of ten-onitis, and concluded that deep transverse friction massageid not demonstrate a consistent clinically important bene-t when compared with a control or combined with otherhysiotherapeutic modalities.
Bisset et al. [31] included elbow manipulation (mobili-ation with movement) and therapeutic exercise within theirhysiotherapeutic interventions. A recent systematic review16] identified preliminary evidence in support of suchreatment modalities; however, no longer-term effects wereeported.
The study by Uzunca et al. [33] investigated the effec-iveness of PEMT in comparison with sham PEMT andorticosteroid injections. They found significant improve-ents in all pain outcomes at 3 weeks for all three groups,
lthough these were significantly lower for the injectionroup. Only pain on resisted wrist extension and supina-ion were significantly different between the PEMT and shamEMT groups. This would seem to confirm the limited benefit
f PEMT reported in a previous review [14].A major methodological flaw in three of the studies withong-term follow-up [30–32] was the inclusion of addi-ional treatment following the 6-week intervention period.
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uch inclusion potentially contaminates the data collected atntermediate- and long-term follow-up, and thus influenceshe validity of the conclusions drawn from the analysis of thisata.
Co-interventions administered to injection participantsre fairly comparable between studies (49% compared with3%). However, 21% of physiotherapy participants in onetudy [31] received additional treatment compared with 81%n the comparable study [30]. The differences in the numberf participants who required additional treatment introducesurther error when attempting to compare the intermediate-nd long-term effectiveness of each intervention between thetudies.
A wide variety of outcome measures with varying degreesf validity and reliability were included within the five stud-es. Although four of the studies measured grip strength asn outcome, it was only possible to compare the data frommidt et al. [30] and Bisset et al. [31]. The study by Verhaart al. [32] did not specify whether pain-free or maximum griptrength was measured, or follow the standardised proceduredvocated to obtain a valid and reliable measurement. Thetudy by Tonks et al. [34] only had one follow-up period, andhe method of calculation of pain-free grip strength was notomparable with Smidt et al. [30] and Bisset et al. [31].
Two studies [30,31] also included an assessor’s ratingf severity, but used different scales to express this score.lthough Smidt et al. [30] provided a little detail about how
his score was established, no reference was given to the valid-ty of the 11-point scale used as a measure. As validatedcales are important to ensure that they measure what theylaim to measure [38], data collected from these scales mayot have been as valid a measure as intended. However, as andditional study by Smidt et al. [38] found that an identicalcale was reliable between trained assessors, it was deemedufficiently consistent to determine an effect size and baseomparisons. The authors had already transformed data into00-point scales which standardised data for comparison andnalysis. Bisset et al. [30] expressed their score on a 100-mmisual analogue scale, which has been shown to be valid,eliable and sensitive to change [21].
Although Verhaar et al. [32] measured a rating of severity,his was expressed on an ordinal four-point scale. Data wereichotomised to make comparisons, and thus it was not pos-ible to calculate an effect size. Additionally, the severity wasrating of pain rather than a multi-dimensional rating, and
o reference was made about who scored this rating. As withain-free grip strength, it was decided that this measure wasot sufficiently consistent to make a comparative analysis.
mplications of findings for practice
A number of implications for practice can be drawn
rom this review. The populations included in each of thetudies are comparable with the characteristics of patientseferred to physiotherapy departments. The corticosteroidosage and strength used in the studies is also comparable,iab
95 (2009) 251–265 263
lthough hospital guidelines govern the type of corticosteroiddministered. Professional guidelines for physiotherapists39] advocate the use of 2% lidocaine, consistent with thatsed in the study by Smidt et al. [26].
The injection technique used in the two studies where dataere synthesised [30,31] delivers the injection into painful
nd tender elbow points. Although this technique appearedo be effective in the short term, direct comparison cannote made with that used in physiotherapy practice whichispenses the injection into the teno-osseous origin of theommon extensor tendon [40]. This is more consistent withhe injection technique used in the studies by Verhaar et al.32] and Tonks et al. [34].
The physiotherapeutic treatment modalities includedithin both primary studies are comparable with those usedithin clinical practice. The exact choice of interventionften depends on the clinical experience of each individ-al physiotherapist. However, the frequency and number ofreatments included in the intervention period for each ofhe studies may be slightly higher compared with clinicalractice.
With the inclusion of corticosteroid injections in phys-otherapy practice, physiotherapists are ideally placed toombine the short-term benefits of early symptomatic reliefained from corticosteroid injections and the longer-termenefits of physiotherapeutic interventions such as the pre-ention of recurrence and addressing the cause of theroblem. Within clinical practice, professional guidelinesdvocate the inclusion of rehabilitation following injectiono maximise the potential benefits, and view injections as andjunct rather than an alternative to rehabilitation [38,40,41].ew studies have investigated the benefits of combining injec-
ions with physiotherapeutic interventions.One of the studies included in this review [34] had a com-
ination group; however, the sample size was small and theollow-up was limited to 7 weeks. In addition, the method-logical quality of this study was low. A further study [42]lso evaluated the effectiveness of corticosteroid injections,lthough there was little difference between the two groups atweek and 6 month follow-up. Further good-quality clinical
rials are needed to evaluate the effectiveness of injectionslongside physiotherapeutic interventions.
This review has highlighted several limitations in theethodological quality of the studies included within the
eview. More methodologically sound RCTs are still neededo improve the level of evidence supporting, in particular, theffectiveness of physiotherapeutic interventions in the short,ntermediate and longer term.
onclusions
The findings of this review suggest that corticosteroidnjections are favourable to physiotherapeutic interventionst short-term follow-up; however, the recurrence rates haveeen shown to vary from 34% to 72% [30–32]. Physiothera-
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eutic interventions have been shown to be favourable in thentermediate to longer term. With the inclusion of the admin-stration of corticosteroid injections within clinical practice,hysiotherapists are well placed to maximise the benefits ofoth corticosteroid injections and physiotherapeutic inter-entions. The results must be interpreted with caution dueo differences in the study interventions, outcome measures,ollow-up and methodological quality. Further high-qualityesearch is required, with greater emphasis on the efficacyf corticosteroid injections in combination with physiother-peutic interventions.
Ethical approval: Not applicable.
Conflict of interest: None declared.
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