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Muscle energy techniques provides long term benefits vs. corticosteroid injections LE
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February 2014
Muscle energy techniques provides long term benefits vs. corticosteroid injections LE
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
Muscle Energy Technique Versus Corticosteroid Injection for Management of Chronic Lateral Epicondylitis: Randomized Controlled Trial With 1-Year Follow-up
Arch Phys Med Rehabil. 2013 Nov;94(11):2068-74Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
82 patients with persisting (over 3 months) unilateral lateral epicondylitis participated in this study to compare muscle energy techniques (MET) to corticosteroid steroid injections (CSI) in the treatment of lateral epicondylitis. Patients participated in 8 sessions of muscle energy technique over the course of 4 weeks or were administered a single injection of triamcinolone acetonide and lidocaine. Patients were assessed at 6, 26 and 52 week follow-ups. Both treatments resulted in improved pain and function throughout the one year study period. CSI patients experienced accelerated results in the first 6 post-treatment weeks. However after 1 year, patients who underwent muscle energy techniques had superior outcomes concerning pain-free grip strength and pain intensity.
Publication Funding Details
+
Funding:
Not Reported
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Randomization
4/4
Outcome Measurements
4/4
Inclusion / Exclusion
4/4
Therapy Description
3/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Lateral epicondylitis (LE), more commonly known as tennis elbow, involves tenderness and pain of the lateral epicondyle of the humerus caused by repetitive wrist movements and strong gripping. The precise etiology and pathophysiology are undetermined, which subsequently makes determining the optimal treatment difficult. Various treatment methods for LE include rest, non-steroidal anti-inflammatory drugs (NSAIDs), bracing, physical therapy, corticosteroid injections, exercise, extra-corporeal shock wave therapy, platelet-rich plasma injections, prolotherapy, botulin toxin injections, and surgery. Of all these treatments, corticosteroid injections have traditionally been viewed as effective in the short term, but may actually impair recovery in the long-term and lead to an assortment of adverse events. Muscle energy techniques (MET) have been developed to treat musculoskeletal disorders, and may lead to improvements in both pain and function. Therefore, this study was brought forward to compare corticoteroid injections and muscle energy techniques in the treatment of lateral epicondylitis.
What was the principal research question?
How do muscle energy techniques compare to corticosteroid injections in the short- and long-term efficacy of lateral epicondylitis treatment, when assessed over a 1 year period?
Study Characteristics
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Population:
82 patients (18-70 years of age) with persisting (duration more than 3 months) unilateral lateral epicondylitis. Patients were instructed not to take NSAIDs over the study period. Acetominophen was allowed, with the exception of the 24h prior to measurements being taken.
Intervention:
Muscle Energy Technique (MET) Group: Patients were treated twice a week for 4 consecutive weeks with MET as described by Sucher and Glassman. The patient's humerus was stabilized while their forearm was supinated until resistance or discomfort is detected and held in that position. During this time, the patient pronated the forearm against resistance for 5 seconds. Immediately after, supination was increased slightly until resistance was met again. After 5 seconds of relaxation, this process was repeated 5 times (Mean age = 46.17 +/- 7.56 years) (n=41, 39 at follow-up; 18M/23F).
Comparison:
Corticosteroid Injection (CSI) Group: 1mL of triamcinolone acetonide (40mg/mL) plus 1mL of 1% lidocaine (10mg/mL) were injected deep into the subcutaneous tissues and muscles of the patients arm, 1 cm distal to the lateral epicondyle (Mean age = 43.78 +/- 9.16 years) (n=41, 38 at follow-up; 19M/22F).
Outcomes:
Primary Outcome: Pain-free grip strength (PFGS) of affected side as a ratio of nonaffected side. Secondary Outcomes: Pain (VAS), and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.
Methods:
RCT; Single-Center; Single-Blind
Time:
Patients were assessed at weeks 6, 26 and 52.
What were the important findings?
- At the 6 week follow-up, PSGF in the MET group was 60.95% compared to 72.48% in the CSI group. PSGF continued to improve in the MET group at 26 and 52 weeks (68.90% and 75.08%) respectively, but improvements in the CSI group decreased at 26 (61.45%) and 52 weeks (62.24%). The differences were significant in favour of the CSI group at the first follow-up (p=0.005), but results were in favour of the MET group by 52 weeks (p=0.007).
- At each follow-up, the MET measurements for PSFG improved significantly from the last (p<0.001). The CSI group showed significant improvements at week 6 compared to baseline only. The decrease in PSGF in the CSI group from week 6 to week 26 was statistically significant (p<0.001).
- VAS scores were comparable between groups at baseline (p=0.330). At 6 weeks, the CSI group had significantly lower pain scores (2.98 compared to 4.38; p=0.004). By week 26, the MET group had lower pain scores than the CSI group (4.00 compared to 5.29; p=0.016). At the final follow-up, VAS pain scores for the MET group were 3.28 compared to 4.95 in the CSI group (p=0.001).
- In the MET group, the reduction in pain from baseline to 6 weeks and from 26 to 52 weeks were both statistically significant (p<0.001). In the CSI group, noticeable improvements in VAS pain were observed from baseline to week 6. The increase in pain (ie. worsening) from 6 weeks to 26 weeks in the CSI group was also statistically significant (p<0.001).
- There was no significant difference in DASH score between groups at 6 weeks (MET 26.25; CSI 21.10; p=0.113). DASH scores at the 26 and 52 week follow-ups were lower in the MET group (23.78 and 22.56, respectively) compared to the CSI group (27.84 and 27.03, respectively), although statistical significance was not reached (p=0.079 and p=0.061).
- Within the MET group, improvement in DASH score was significant from baseline to 6 weeks and from 26 weeks to 52 weeks (both p<0.001). Within the CSI group, improvement in DASH score was significant from baseline to 6 weeks. The worsening in DASH score from 6 weeks to 26 weeks in the CSI group was also statistically significant (p<0.001).
- No adverse events were observed in the MET group. Three AEs were reported in CSI patients; 1 patient experienced pain for 5 days following the injection, 2 reported loss of skin pigment and 1 patient had subcutaneous atrophy.
What should I remember most?
Although the corticosteroid group had superior pain-free grip strength and pain intensity in the first 6 weeks following treatment for lateral epicondylitis, treatment with muscle energy techniques resulted in significantly better results 26 and 52 weeks for these outcomes. By 1 year, measures of clinical outcome (ie DASH) were trending to be favoured with MET as well. There were no adverse events reported with treatment through MET.
How will this affect the care of my patients?
The conclusions of this study suggest both corticosteroid injections and muscle energy techniques improve pain and function associated with lateral epicondylitis in the short-term, but continued improvement with muscle energy techniques combined with regressive effects corticosteroid injections in the long term may identify MET as a more efficacious treatment. Further research is required to compare muscle energy techniques to a sham treatment and treatment modalities, with outcome determined through a comprehensive set of measurements.
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