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Three Part Question

In [adults with chronic tennis elbow] does [an epicondyle clasp in combination with physiotherapy] improve [pain and function]

Clinical Scenario

A 28year old female presents with a 4 month history of 'tennis elbow' (lateral epicondylitis). She receives physiotherapy in the form of manual and electrotherapy and you wonder if there is any benefit from additional use of an epicondyle clasp.

Search Strategy

MEDLINE 1966-02/07, CINAHL 1982 –02/07, AMED 1985-02/07, SPORTDiscus 1830-02/07, EMBASE 1996-02/07, via the OVID interface. In addition the Cochrane database and PEDro database were also searched
Medline, CINAHL, AMED, EMBASE, SPORTSDiscus: [{(exp ('tennis elbow' OR lateral elbow pain OR lateral epicondylitis OR epicondylitis) AND (support OR strapping OR epicondyle clasp OR elbow support OR epicondylitis clasp)] LIMIT to human AND English language.

Search Outcome

149 papers were retrieved and after reading the abstracts, a total of 4 papers were considered relevant to the question. One was a Cochrane review that was last updated in October 2001. The other 3 papers were published since that time one of which did not use a clasp as an additional treatment to physiotherapy. This was discounted as it did not answer the clinical question. The final paper was an economic evaluation of the Struijs study.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Struijs et al 2002 Holland	5 RCTs N = 109 3 of these used epicondyle clasp/bandage as addition to physiotherapy treatment	Cochrane review	Pain	Not statistically significant on short term pain relief	Low power
			Elbow function/grip strength/painfree grip/global improvement/ . lateral epicondyle pressure pain	All studies low power. Impossible to make definite conclusions
Struijs et al 2004 Holland	N = 180 Clinical diagnosis of 6 weeks lateral epicondylitis 3 Groups; i.physiotherapy ii. clasp only iii. clasp and physio combined	RCT	8 outcomes scoring pain all based on 100 point numerical scale @ 6 weeks	N=176 Contradictory results at 6 weeks; combination therapy better than brace–only in 3 outcomes (pain main complaint, inconvenience and severity of complaint) but worse in 1 (abilities of daily living). Combination better than physio alone in 1 outcome (increase in pressure pain threshold). These were significant at p<0.05, but showed wide confidence intervals.	Condition only 6 weeks old. No control group No statistical adjustment for multiple analyses. Exercise regime not supervised (?compliance)
			@ 6 months	not statistically significant
			@ 1 year	not statistically significant

Comment(s)

The Cochrane review was unable to provide definite conclusions as to the efficacy of an epicondyle clasp in conjunction with physiotherapy (see table). The most recent RCT, by the same authors, found short term benefits for a combination of brace and physiotherapy over brace only in 3 out of 8 outcome measures of 'severity of complaints', a 'pain free function questionnaire', and 'convenience of daily activities'. The same combination was also superior to physiotherapy only in 1 out of 8 outcomes for 'pressure pain threshold'. These significant differences are not seen at 6 months or 1 year follow-up. There are confounding results concerning the use of an epicondyle clasp in addition to other physiotherapy for chronic tennis elbow.

Clinical Bottom Line

There is some weak evidence that any improvement seems to occur soon after the clasp is applied, but this is not maintained after 6 months and 1 year follow up

References

1. Struijs PAPAA, Arola H, Assendelft WJJ, Buchbinder R, Smidt NN, van Dijk CN. Orthotic devices for the treatment of tennis elbow. The Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD001821. DOI: 10.1002/14651858.CD001821.
2. Struijs PA, Kerkhoffs GM, Assendelft WJ, Van Dijk CN. Conservative treatment of lateral epicondylitis: brace versus physical therapy or a combination of both-a randomized clinical trial. American Journal of Sports Medicine 2004 Mar:32(2);462-9.