Muscle Energy Technique Versus Corticosteroid Injection for Management of Chronic Lateral Epicondylitis: Randomized Controlled Trial With 1-Year Follow-up – Duke Center of Excellence in Manual and Manipulative Therapy

Author Names

Küçükşen, S., Yilmaz, H., Salli, A., Uğurlu, H.

Reviewer Name

Jake Isaac, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective To determine the short- and long-term effectiveness of the muscle energy technique (MET) compared with corticosteroid injections (CSIs) for chronic lateral epicondylitis (LE). Design Randomized controlled trial with 1 year of follow-up. Setting Outpatient clinic of a university’s department of physical medicine and rehabilitation. Participants Patients with chronic LE (N=82; 45 women, 37 men). Interventions Eight sessions of MET, or a single CSI was applied. Main Outcome Measures Grip strength, pain intensity, and functional status were assessed using the pain-free grip strength (PFGS), a visual analog scale (VAS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, respectively. Measurements were performed before beginning treatment and at 6, 26, and 52 weeks afterward. Results When the baseline PFGS, VAS, and DASH scores were compared with the scores at the 52-week follow-up, statistically significant improvements were observed in both groups over time. The patients who received a CSI showed significantly better effects at 6 weeks according to the PFGS and VAS scores, but declined thereafter. At the 26- and 52-week follow-ups, the patients who received the MET were statistically significantly better in terms of grip strength and pain scores. At 52 weeks, the mean PFGS score in the MET group was significantly higher (75.08±26.19 vs 62.24±21.83; P=.007) and the mean VAS score was significantly lower (3.28±2.86 vs 4.95±2.36; P=.001) than those of the CSI group. Although improvements in the DASH scores were more pronounced in the MET group, the differences in DASH scores between the groups were not statistically significant. Conclusions This study showed that while both MET and CSI improved measures of strength, pain, and function compared with baseline, subjects receiving MET had better scores at 52 weeks for PFGS and the VAS for pain. We conclude that MET appears to be an effective intervention in the treatment of LE.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Cannot Determine, Not Reported, or Not Applicable

Were study participants and providers blinded to treatment group assignment?

Cannot Determine, Not Reported, or Not Applicable

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Compared with subjects receiving corticosteroid injections, those receiving the muscle energy technique had better scores at 52 weeks for pain free grip strength (PFGS) and pain measured by the VAS.

Key Finding #2

No significant differences were found between the two groups in DASH scores at 52 weeks, however, significant differences in DASH scores were found over time in both groups.

Please provide your summary of the paper

This randomized controlled trial examined the long- and short-term effectiveness of a muscle energy technique (MET) compared with corticosteroid injections (CSIs) for the treatment of lateral epicondylitis (LE). 82 patients with chronic LE (duration>3 months) were eligible for the study and were randomly selected into the MET or CSI group. The main outcomes assessed in the study were pain free grip strength (PFGS), pain intensity via the visual analog scale (VAS), and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Outcomes were assessed at baseline, 6, 26, and 52 weeks after treatment. The CSI group received a singular injection given 1 cm distal to the lateral epicondyle aimed towards the area of maximal tenderness. The MET was applied 2 sessions per week for 4 weeks. For the MET, the distal humerus was stabilized by the operator and then the forearm was supinated until pain or resistance was detected. After holding the position, the patient was asked to pronate the forearm against resistance for 5 seconds followed by a relaxation period and supination was increased until resistance was met again. This process was repeated 5 times in each treatment session. Compared to baseline measures, both groups improved significantly in all outcome measures. Patients in the CSI group demonstrated significantly better PFGS and VAS scores at week 6, but declined in these measures at 26 and 52 weeks. At 26 and 52 weeks, patients in the MET group showed significantly better improvements in grip strength and pain intensity compared to the CSI group. Both groups showed statistically significant improvements in DASH scores at 52 weeks compared to baseline, however, no significant difference In DASH scores was found between the two groups.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study indicates that both MET and CSIs can be effective at improving grip strength, decreasing pain, and increasing function for those with chronic lateral epicondylitis. The results demonstrate that CSIs may be effective as a short-term intervention, however, their effectiveness may dissipate after 6 weeks. Although the MET group scored lower at the 6 week period, their PFGS and VAS scores were significantly better in the long-term compared to the CSI group indicating that this may be a more beneficial intervention to generate long-term effects. The aforementioned results demonstrate that CSIs could be a short-term solution resulting in pain reduction but should not be the sole approach to treating chronic LE. Similarly, MET can be an effective approach to improve grip strength and decrease pain, however, it may require more time compared to CSIs for the benefits to be seen. These two interventions used in conjunction with one another would likely result in greater improvements in grip strength, pain, and function in those with chronic LE compared with the results seen by using the interventions independently.