Here is a leading authority in the rheumatology/clinical epidemiology world, talking about a commentary she did on tennis elbow for the Canadian Medical Journal….
Lateral epicondylitis or ‘tennis elbow’ is a prevalent and costly disorder that affects 1-3% of the general population and up to 15% of workers in at risk industries. While it is generally self-limiting with most people completely recovered by a year, in the short-term it can cause significant disability. Therefore treatment that can shorten the duration of symptoms has the potential to be of significant value. Botulinum toxin type A injection is a promising new treatment, proposed for this condition on the basis that temporary paralysis of the proximal extensor muscles of the forearm might aid recovery. Three of four randomised placebo-controlled trials that have evaluated its efficacy have reported that it significantly reduces pain in comparison to placebo, although it has not been shown to reduce pain during maximum grip or improve maximum grip strength and its effect on function, quality of life and pain-free grip strength is unknown. Temporary partial or complete paresis of the third and fourth finger extensors occurs in 20 to 96% of patients and may last up to 16 weeks. This may be unacceptable for many individuals who rely on normal hand function for their work. It is also unclear whether any therapeutic effects remain or diminish once the muscle paralysis has abated. At the present time doubt remains about the true efficacy and safety of Botulinum toxin A injection for lateral epicondylitis and further studies are required before it can be introduced into clinical practice.
About Rachelle
Rachelle Buchbinder is an NHMRC Practitioner Fellow, rheumatologist and clinical epidemiologist. She is currently Director of the Monash Department of Clinical Epidemiology at Cabrini Hospital and Professor in the School of Public Health and Preventive Medicine, Monash University in Melbourne, Australia. She combines rheumatology practice with clinical research in a wide range of multidisciplinary projects relating to arthritis and other musculoskeletal conditions. She is a principle investigator of the Australian Rheumatology Association Database (ARAD) that is evaluating the long-term outcomes of biological therapy for inflammatory arthritis and she is also one of the Coordinating Editors of the Cochrane Musculoskeletal Group. Other research interests include health literacy and improving the quality of written information for patients.
In case you haven’t worked it out, Prof Buchbinder is a what we would call a dead-set superstar. One of her early projects in back-pain stuff involved a multi-media ad campaign that remains, in my view, the most innovative and effective education strategy I have seen in this area. We are thrilled, absolutely chuffed, that Rachelle has contributed to our blog.
Buchbinder R, & Richards BL (2010). Is lateral epicondylitis a new indication for botulinum toxin? CMAJ : Canadian Medical Association journal, 182 (8), 749-50 PMID: 20421352
All blog posts should be attributed to their author, not to BodyInMind. That is, BodyInMind wants authors to say what they really think, not what they think BodyInMind thinks they should think. Think about that!
Considering botox is a neuro-toxin shouldn’t an aggressive bout of conservative treatment (i.e. physical therapy consisting of soft tissue mobilization/cross friction massage, stretching, eccentric strengthening, activity modification, etc, etc) be tried BEFORE the consideration of an injection? Eccentric extension exercises have been shown to be an efficacious option for lateral epicondyalgia, achilles tendonopathy, etc.
Further, for most patients lateral epicondylitis is the probably the wrong terminology. For most, it is chronic tendon changes more indicative of an OSIS/OPATHY not acute inflammation (of course inflammation is also involved, especially in the beginning).
Thoughts?
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Rachelle Buchbinder Reply:
July 5th, 2010 at 5:29 pm
At the moment there is not enough evidence to support the use of botulinum toxin in routine clinical care as it is unclear that any benefits outweigh the risks and known high incidence of weakness of the hand. The natural history of lateral epicondylitis is self-limiting and so it is important to tell patients of the favourable prognosis irrespective of treatment. I agree that physical therapy modalities such as the ones you describe may provide limited benefits and are safe so are a reasonable first option. Steroid injection may also be useful for people with inflammatory symptoms such as night pain and stiffness but their effect may only be short lasting (2-6 weeks) and two studies have suggested a rebound worsening of symptoms. Terminology for this condition varies but lateral epicondylitis is the term most commonly used. There is mounting evidence of an inflammatory component early in the course of the condition and the aetiology is likely multifactorial.
[Reply]
Deanne Brown Reply:
July 10th, 2010 at 6:50 am
My husband had severe tennis elbow many years ago. It bothered him constantly, including aching so much it prevented him from sleeping. Then we spent 3 weeks in the algarve. Yes, the hot white sand and warm salt water and, since that trip he has never had a concern again. Must have allowed his body a chance to heal!
Deanne
Vancouver, Canada
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>>”mobilization/cross friction massage, stretching, eccentric strengthening, activity modification”
“Aggressive” or placid, is there any clinical evidence that these are any more effective? (And as this is PT were talking about I’m not asking for it to be high level evidence.)
The use of Botulinum Toxin has been proven to be effective in neuromuscular re education – as an adjunct, rather than a ‘cure’ – and physio is still required to optimise outcomes…you also have the advantage of central plastic reorganisation that has the potential to prevent re-injury.
Check Cullen et al 2007 – http://www.ncbi.nlm.nih.gov/pubmed/18033608
[Reply]
Rachelle Buchbinder Reply:
July 5th, 2010 at 5:33 pm
There are no comparative trials comparing botulinum toxin injection to physical therapy so we have no evidence one way or the other that one or other is more effective.
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adorablesin Reply:
July 6th, 2010 at 8:53 pm
Fair comment, and thanks (I was a little over-enthusiastic.)
A question: Did you mean no comparative trials for PT versus botulinum toxin injection for lateral epicondylitis, or for all aspects of physical therapy versus botulinum toxin for other conditions?
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Adorable sin,
«And as this is PT were talking about I’m not asking for it to be high level evidence.»
This sounds a bit disrespectful to me. Maybe I understood you wrong. As for your question on the effectiveness on some PT modalities and a review on epicondylagia’s pathobiology I suggest this :
http://www.ncbi.nlm.nih.gov/pubmed/19050004
[Reply]
adorablesin Reply:
July 6th, 2010 at 8:18 pm
“This sounds a bit disrespectful to me”.
This was not my intention, so please forgive me. How I intended it to be taken was: there is evidence for many things in PT but little of it high level in the grand scheme of things. However, we are married (again no disrespect) to the medical model of the hierarchy of evidence with SRs and MAs of RCTs at the zenith and as such, there is little high-level evidence in relation to the modalities suggested for lateral epicondylitis (or as talked of a lateral epicondyle tendonopathy). As per the article you suggest:
“There is some evidence, albeit low-level, of positive initial
effects of several manipulative therapy techniques for pain relief
and restoration of function when compared with control (p. 255)”…that’s what I meant by not expecting it to be high-level in relation to manual therapy
interventions.
Many thanks for your suggestion, I’ll follow up the references contained therein. Adorablesin.
[Reply]
Frédéric Wellens, pht Reply:
July 6th, 2010 at 11:15 pm
Thanks,
no offense taken then!
It is true that many things that are done in PT lack strong evidence behinf it. It is the case in lat. epicondylagia. But, some good research is available on other topics, namely LBP.
Research wise, we are getting on the right track. I think, I hope.
[Reply]
Great post…my thoughts:
Injections – works in the short term, causes tendon degeneration.
Anti-inflammatories – pain relief for 2-3 hours, pain returns, cycle starts again.
Braces/bands/straps – promotes muscle fatigue and weakness.
Oh wait…how about preventative therapy, simple tennis elbow exercises
Good health,
Jim
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