Tennis Elbow - Work or Rest or Steroids

Motivation: Summer is the time for tennis and tennis elbow.  Anyone who has suffered a tennis elbow - known in medial lingo as lateral epicondylalgia -  can attest to the frustration and pain that keeps people away from the beautiful sport after waiting all winter.  I have often wondered what works.  Using an injured elbow hardly seems wise but then again, exercise sounds like a good idea.  If all else fails, do steroid injections work?  Recently, this idea was tested in a randomized way.

Paper: Coombes, B.K., Bisset, L., Brooks, P. et. al. "Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients with Unilateral Lateral Epicondylalgia." JAMA (2013); 309(5): 461-469.

Methods: 2x2 factorial multi-center randomized blinded placebo controlled trial.  Inclusion critera were essentially untreated unilateral lateral elbow pain of greater than six weeks duration provoked by palpation or stretching the region.  The two intervention arms were a single corticosteroid (triamcinolone) vs. placebo injection and physiotherapy for eight weeks vs. no physiotherapy.  The primary outcomes were one year rating of change score (using Likert scale from "complete recovery" to "much worse") and one year recurrence.  Secondary outcomes were rate of complete recovery to much improvement at four and 26 weeks.

Results:
 Cohort: A total of 165 patients were randomized with mean age of 49 years and male predominance of 62%.  Average duration of symptoms was 16 weeks. On visual analog scale (VAS), resting median pain level was 7.5 out of 100 with worst pain of 61.7 out of 100.  In total , 41 patients only got placebo, 41 got placebo plus physiotherapy, 43 got corticosteroids, and 40 got corticosteroids plus physiotherapy.

Primary Outcome (one year): Corticosteroids resulted in lower recovery or improvement at one year compared to placebo (83% with steroids vs. 96% without, p = 0.01).  There was increased recurrence of elbow pain at one year with corticosteroids (54% with steroids vs. 12%, p < 0.001).  There was no difference between physiotherapy or no physiotherapy in terms of recovery or rate of recurrence.  There was no interaction between corticosteroids and physiotherapy.

Four week Outcome: In absence of physiotherapy, complete recovery or much improvement was greater following steroid injection than placebo (RR: 7.32, NNT 1.6, p < 0.001).  With physiotherapy, steroids did not significantly improve recovery compared to placebo (RR: 1.73 (95% CI, 0.97 to 3.08)) though combination had some additional benefit on pain scores.  Physiotherapy alone in absence of steroids also significantly improved recovery (RR: 4,.0, NNT: 3.4, p = 0.004).  There was no major difference between steroids plus physiotherapy versus steroids alone.

Discussion: This paper points out an instance where trials with short term follow-up miss deleterious effects in the long term.  Steroids are quite efficacious in four weeks but result in greater recurrence of pain and with lower recovery in one year.  In comparison, while physiotherapy does not make a difference in the long term, it is comparable to steroids for recovery at four weeks.  Consequently, for someone with a tennis elbow, a reasonable strategy would be to use physiotherapy in the short term and expect spontaneous recovery in the long term (96% recovery naturally) - avoid the steroids.

Albuterol, levalbuterol and tachycardia

Motivation:  In the ICU and inpatient setting, tachycardia is a common vital sign abnormality that has many different root causes. One of the measures taken in attempt to decrease heart rate is to limit beta-agonists such as inhaled or nebulized albuterol, a common medication used for the shortness of breath or wheezing experienced by many patients. One solution that has been suggested to me was to use levalbuterol instead of albuterol...Physiologically it makes sense that albuterol or levalbuterol would increase heart rate, but I was not sure about any physiological/molecular reason why levalbuterol would be associated with less tachycardic side effects, and was also concerned about levalbuterol's higher cost. So does albuterol really contribute to increased tachycardia, and would levalbuterol be a better option?

Study:  Khorfan FM, Smith P, Watt S, Barber KR. Effects of nebulized bronchodilator therapy on heart rate and arrhythmias in critically ill adult patients. Chest. 2011 Dec;140(6):1466-72.

Methods: This was a 2:1 randomized, prospective, single-blind crossover study in 70 adult ICU patients who were randomized to alternating 4-6 hour courses of nebulized albuterol (2.5 mg) or levalbuterol, along with ipratropium. Group A received 0.63 mg, while Group B received 1.25 mg of levalbeterol. Cardiac monitoring was performed to measure heart rate and rhythm before, during and after treatment.

Results: The 70 patients consisted of almost equal numbers of men and women, with age ranges from 35-92, and slightly more than half on mechanical ventilation. Multisystem organ problems were common in this population. The median number of treatments per patient was 23, ranging from 1 to 45. There was no significant difference in change in heart rate after albuterol (0.89 ± 4.5 bpm) or levalbuterol (0.85 ± 5.3 bpm) treatment in Group A. In Group B, levalbuterol actually was associated with faster heart rate (increase of 1.4 ± 5.4 bpm) compared to albuterol (decrease of 0.16 ± 5.1 bpm) (p=0.03); but when analyzing for measures that were taken >= 5 hours apart, this difference was no long statistically significant. There was only one patient who had to be discontinued on treatment, after experience a 5 beat run of NSVT after 6x albuterol treatment.

Discussion: As for levalbuterol, its substitution for albuterol was not justified in this study - in fact, in Group B, in which a higher levalbuterol dose was used, post-therapy heart rate was actually faster than post-albuterol heart rate. Unexpectedly, from this study, it seemed that albuterol or levalbuterol did not significantly worsen tachycardia, even in this very sick population of patients. This is useful - and comforting - to know for patients who are tachycardic, but also have wheezes or increased airway resistance who would benefit from temporary courses of nebulized beta-agonists. One limitation of the applicability of this study is the fact that heart rate comparisons were made only after a limited number of treatments per patient, so it could be possible that over longer term and more treatments +/- higher frequency +/- higher dosing, there would be significantly increased heart rate. So in a patient receiving longer term albuterol therapy, I would still consider tapering down or decreasing albuterol therapy if tachycardia were a problem, since this would make sense physiologically.