Tennis Elbow and Treatment Frequency

Changes in pain, dysfunction, and grip strength of patients with acute lateral epicondylitis caused by frequency of physical therapy: a randomized controlled trial. Lee S1, Ko Y1, Lee W1. J Physical Therapy Science. 2014 Jul;26(7):1037-40. [Free Full Text]

[Purpose] The purpose of this study was to investigate the changes in pain, dysfunction, and grip strength of patients with acute lateral epicondylitis and to suggest the appropriate treatment frequency and period. [Subjects] The subjects were divided into three: 2 days per week group (n=12), 3 days per week group (n=15), and 6 days per week group (n=13). [Methods] All groups received conventional physical therapy for 40 minutes and therapeutic exercises for 20 minutes per session during 6 weeks. The outcome measurements were the visual analogue scale (VAS), Patient-Rated Tennis Elbow Evaluation (PRTEE), and grip strength. [Results] The results of this study were as follows: at 3 weeks, there were no significant differences in VAS and PRTEE in the 3 groups, but at 6 weeks, 6 days per week group significantly decreased these two outcomes. Grip strength was significantly increased in 3 and 6 days per week groups at 6 weeks. [Conclusion] In conclusion, physical therapy is needed 3 days per week for 3 weeks in patients with acute lateral epicondylitis. After 3 weeks, 6 days per week is the most effective treatment frequency.

My comments:
I was hoping this paper would be better than it was, but I think it still gave some useful data. Based on the description of the treatment (which wasn’t 100% clear), I think they came to some spurious conclusions at 3 weeks, but I expect their 6 week findings are correct. Also I think these researchers should be commended as this is the first tendinitis/tendinopathy study to look at treatment/exercise frequency that I am aware of. Given that recommendations for exercise and tendinopathy often range from 3 times per week to 2 or more times per day I think it’s a pretty important variable to be testing.
They report that for the first 3 weeks of treatment it didn’t matter much what the exercise frequency was with 2, 3, and 6 days per week treatment being the same. The problem with the study however is that they split the rehabilitation into two “stages”, and didn’t say how long each stage was. Maybe it was 3 weeks per stage? The first stage was considered “pain control” and was very light exercise and modalities that I would expect to not make much difference, regardless of how often they were done. For example, I would not expect 6 days per week of ineffective treatment to work much better than 2-3 days per week of ineffective treatment. The second stage included some isotonic strengthening exercises, which is when I think real physical therapy began, and it seems when they started noticing improvements as well. In the 2nd stage both concentric and eccentric (separated out- I’m not sure why) strengthening exercises were performed 3 sets of 10-15 reps at which point the 2 day per week treatment resulted in no further improvement in pain, strength, and function, while 3 days did better and 6 days better still. In my own tennis elbow/epicondylitis treatment program (and for tendinitis/tendinopathy in general) I find 3 days per week works, but daily works better, at least until strength is fully restored and pain reduced substantially. Generally, a physical therapist will get referrals for physical therapy 2-3 days per week, so a home exercise program with daily resistance exercises will likely speed progress. Alfredson’s eccentric exercise protocol for Achilles tendinitis calls for 6 sets of 15 reps 2 times per day, which in my experience is overkill, but it would have been good to see that frequency tested in comparison to the 2, 3, and 6 day protocol.
My main disagreement is that they reported no difference resulting from treatment frequency in the first 3 weeks. I notice my patients progressing substantially and immediately when therapy begins without a “pain control” stage, and in fact, I notice the heavier resistance exercise used in my tennis/golfers elbow treatment IS WHAT reduces the pain. I think if this study would have omitted the easy pain control stage, it would have been both more effective and have yielded more usable data. Also, they should have better described the exercises and intensities used.
Last, the study had subjects perform 20 minutes of exercise after 40 minutes of physical therapy modalities which I think for tendinitis are useless or nearly so (20 minutes heat, 5 minutes ultrasound, and 100 hz TENS).
Improvements at 6 weeks for pain on 10 point (VAS), patient rated tennis elbow evaluation (PRTEE) and grip strength in kilograms between groups were as follows.

  • 2 times per week: VAS (6.6 to 5.7), PRTEE (48.6 to 46.4), Grip Strength (27.1 to 27.0)
  • 3 times per week: VAS (7.0 to 4.6), PRTEE (54.4 to 40.2), Grip Strength (29.2 to 35.4)
  • 6 times per week: VAS (6.8 to 2.6), PRTEE (50.8 to 26.5), Grip Strength (26.7 to 38.2)

So overall, those results sound reasonable to me, but I think they should have happened 3 weeks earlier with the magnitude of gains at 6 weeks being better if they had skipped the pain control stage. I expect they would have done better still if they had focused on more strengthening, skipped the heat and ultrasound entirely, and maybe substituted EMS for their TENS.
As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.
Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

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