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Physiotherapy alone or in combination with corticosteroid injection for acute lateral epicondylitis in general practice: A protocol for a randomised, placebo-controlled study

Morten Olaussen*, Øystein Holmedal, Morten Lindbæk and Søren Brage

BMC Musculoskeletal Disorders 2009, 10:152  doi:10.1186/1471-2474-10-152

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Not all physiotherapy is the same

Bill Vicenzino   (2010-07-06 12:15)  University of Queensland email

long-term delay in healing after corticosteroid injections [2]. Olausson and his colleagues are commended for undertaking such a trial.

On reading the physiotherapy intervention in this protocol I was concerned to read that our previous randomised clinical trial [3] was used as the basis of their physiotherapy treatment. My concern is that in our clinical trial the physiotherapy program consisted of mobilisation with movement treatment plus exercise [3-5], whereas their program consists of friction massage, Mill’s manipulation and soft tissue treatment with stretching of radial wrist extensors plus instructions for home exercises of eccentric exercise and stretching [1]. So my intention in posting this comment is to inform readers that it is not readily apparent how the physiotherapy treatment in the protocol of Olaussen et al is based on our previous study. Nor does their physiotherapy program appear much like our current randomised clinical trial that investigates the addition of physiotherapy to corticosteroid injection [2]. I would suspect that this is most likely unintentional, though still in need of clarification.

It is difficult to know or to determine if the differences in physiotherapy programs are meaningful in terms of outcome because to my knowledge these two different physiotherapy approaches have not been tested head to head. However, there has been a study that has compared a supervised exercise program to the Cyriax protocol [6], which consists of friction massage and Mill’s manipulation [7, 8]. Exercise was shown to be superior to the Cyriax protocol [5, 8]. As this evidence is more recent than the Cochrane review of friction massage [9] cited by Olaussen et al, it raises an issue about the basis of the proposed physiotherapy program, which appears strongly biased towards the Cyriax protocol [1].

There are also other differences between the two protocols, such as the duration of condition being constrained to 2-12 weeks by Olaussen et al, whereas our protocol [2] and previous trials of Bisset [3] and Smidt [10] recruit patients with >6 week symptom duration. Those previous studies have on average studied patients with greater than 18 weeks symptom duration [11]. It is interesting to speculate that differences in symptom duration may dictate that different physiotherapy treatment approaches be used and that perhaps this forms part of the basis on which the physiotherapy treatment was selected in this protocol and agreed to by the two cooperating clinical physiotherapists, who were described to be engaged in normal practice. Once these studies [1, 2] are completed we may have some insight into this speculation, which will no doubt be useful to the practitioner consulting a patient with tennis elbow.



[1] Olaussen M, Holmedal O, Lindbaek M, Brage S. Physiotherapy alone or in combination with corticosteroid injection for acute lateral epicondylitis in general practice: A protocol for a randomised, placebo-controlled study. BMC Musculoskeletal Disorders. 2009;10(1):152.
[2] Coombes B, Bisset L, Connelly L, Brooks P, Vicenzino B. Optimising corticosteroid injection for lateral epicondylalgia with the addition of physiotherapy: A protocol for a randomised control trial with placebo comparison. BMC musculoskeletal disorders. 2009 Jun 24;10(1):76.
[3] Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006 September 29, 2006:bmj.38961.584653.AE.
[4] Vicenzino B. Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. Manual Therapy. 2003 May;8(2):66-79.
[5] Vicenzino B, Cleland J, Bisset L. Joint Manipulation in the Management of Lateral Epicondylalgia: A Clinical Commentary. Journal of Manual and Manipulative Therapy. 2007 Mar 24;15 (1):50 - 6.
[6] Cyriax J. Cyriax's illustrated manual of orthopaedic medicine. 2nd ed. Oxford: Butterworth/Heinemann 1993.
[7] Stasinopoulos D, Johnson MI. Cyriax physiotherapy for tennis elbow/lateral epicondylitis. Br J Sports Med. 2004 December 1, 2004;38(6):675-7.
[8] Stasinopoulos D, Stasinopoulos I. Comparison of effects of Cyriax physiotherapy, a supervised exercise programme and polarized polychromatic non-coherent light (Bioptron light) for the treatment of lateral epicondylitis. Clinical Rehabilitation. 2006 Jan;20(1):12-23.
[9] Brosseau L, Casimiro L, Milne S, Welch V, Shea B, Tugwell P, et al. Deep transverse friction massage for treating tendinitis. Cochrane Database of Systematic Reviews. 2002(4):DOI: 10.1002/14651858.CD003528.
[10] Smidt N, van der Windt D, Assendelft WJJ, Deville W, Korthals-de Bos IBC, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002 Feb 23;359(9307):657-62.
[11] Bisset L, Smidt N, Van der Windt DA, Bouter LM, Jull G, Brooks P, et al. Conservative treatments for tennis elbow do subgroups of patients respond differently? Rheumatology. 2007 October 1, 2007;46(10):1601-5.


Competing interests

None declared

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