rajiv gandhi university of health sciences,...
TRANSCRIPT
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Brief resume of the intended work:
6.1 Need for the study
The elbow complex includes the elbow joint (humeroulnar and humeroradial joints) and the
proximal and distal radioulnar joints. The elbow joint considered to be a compound joint that
functions as a modified or loose hinge joint having one degree of freedom at elbow, permitting the
motions of flexion and extension, which occur in the sagittal plane around a coronal axis.1 Elbow
stability and stabilizer structures are active and passive structures. These passive structures are
articular surfaces and attached ligaments around joints; active structures are muscles which crosses
the elbow joints i.e. flexors group of muscles from medial epicondyle and extensors group of muscles
from lateral epicondyle of humerus.2 Commonly we are seen many conditions such as Tennis Elbow
or Lateral Epicondylitis, Elbow Bursitis, Golfer’s Elbow or Medial Epicondylitis, Cubital Tunnel
Syndrome, Radial Tunnel Syndrome, distal biceps rupture, olecranon fracture, Monteggia fracture,
elbow dislocation.
Tennis elbow, or Lateral Epicondylitis, describes soreness or pain around the bony prominence
(epicondyle) on the outside (lateral) part of the elbow.3 Tennis Elbow develops due to overuse of the
muscle and tendon of the forearm and elbow, repeating some types of activities over and over again
can put too much strain on the elbow tendons. These activities are not necessarily high-level sports
competition. Hammering nails, picking up heavy buckets, or pruming shrubs can cause the pain of
tennis elbow.4Tennis elbow occurs most commonly in the tendon of the extensor carpi brevis muscle
at approximately 2cm below the outer edge of the elbow joint or lateral epicondyle of the humerus
bone.2
A50% prevalence is repeated among the tennis player older than 30years with a peak between
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age of the 35-50. Lateral pain is 5-10times more common than medial pain .5 There are different types
of conservative treatment Lateral Epicondylitis includes, non-steroidal anti-inflammatory
medications, physical therapy, and avoiding the aggravating physical activities contributing to
overuse of the tendons. In some cases, steroid injections may be used to reduce pain and
inflammation, but they are used sparingly due to potentially damaging side effect conservative
treatment may taken extended period of time to relieve the pain.2Tennis Elbow braces and supports.6
While the majority of the therapeutic efforts will be directed at rehabilitation of the wrist extensor
mechanism.7The treatment of the patient’s pain can be accomplished through a variety of therapeutic
modalities cold application7-9 ,heating modalities8-9 ,shortwave & microwave diathermy, electrical
stimulation with TENS, high-voltage galvanic stimulator8 bracing like cock-up splint.10 Conventional
surgery is the last resort for Lateral Epicondylitis that does not respond to conservative treatment.2
There are different types of normal taping in tennis elbow condition such as diamond shaped
taping11-12 placebo tape technique11 sports taping13. Kinesio taping, an organized wrapping technique
using kinesio tape proposed by Kase, is claimed to be able to reduce pain, swelling and muscle
spasms, as well as to prevent sport injury. 14 Kinesio taping (KT) method is a relatively new taping
technique which requires kinesio tex tape. Tape used for KT is different from taping using traditional
white athletic tape. First, it has elasticity in one direction and before applying to skin it can be
stretched to 140% of its original length.14 It provides a constant pulling (shear) force to the skin.
Second, kinesio tex tape is air permeable and water resistant and can be worn for several days without
removal. KT is being used following injury and during the rehabilitation. 14-15Kinesio taping is
effective in different conditions such as mechanical neck pain, acute whiplash injury17 shoulder pain15
tennis athlete19 muscle strength after ACL repair20. Chronic iliotibial band syndrome, ankle condition
21 and planter fasciitis.
The kinesio taping method involves taping over and around muscle in order to assist and give
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support or to prevent over-contraction. It gives support while maintaining full range of motion
enabling the individual to participate in physical activity with functional assistance. For the first 10
years, orthopedists, chiropractors, acupuncturists and other medical practitioners were the main users
of kinesio taping. Soon thereafter, kinesio taping was used by the Japanese Olympic volleyball
players & word quickly spread to other athletes. Today, kinesio taping is used by medical
practitioners & athletes around the world.
In normal taping there are some limitations like it will restrict the movement because of its non-
stretchable property, its durability is less because it is not water resistant, it affect the body’s own
natural healing process by irritating the skin and affect the activities of daily living. In contrast of this
kinesio tape has got main advantage like –It has got a stretchable property which not affect the ROM
and its durability is 4-5 days , It is water resistant, supports the body own natural healing process and
supports the functional activities without irritating the skin. The kinesio taping method involves
taping over and around muscle in order to assist and give support or to prevent over-contraction. It
gives support while maintaining full range of motion enabling the individual to participate in physical
activity with functional assistance. The kinesio taping method is applied over muscles to reduce pain
and inflammation, relax overused tired muscles, and to support muscles in movement on a 24hr/day
basis. It is non-restrictive type of taping which allows for full range of motion.
If joints or ligaments are injured. They should be stretched before application to the skin. The
damaged joint or ligaments are incapable of functioning normally are rely on stretched tape for
correction. It is also important that while depending on the injury, tape is either stretched or not
stretched, this does not mean that the actual application technique will change. The different
treatment modalities and techniques used to treat lateral epicondylitis are therapeutic ultrasound, deep
friction massage, elbow manipulation, stretching exercises, bracing, fore arm band, combining wrist
manipulation has been done but no previous study has done on combination of modalities and kinesio
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taping on elbow condition particular kinesio taping technique on tennis elbow to reduce the pain.
Hypothesis:
There will be no significant difference between combined effect of ultrasound and kinesio taping to
reduce pain in tennis elbow.
6.2 Review of Literature:
Review on management of tennis elbow:
Rajadurai Viswas, Rejeeshkumar Ramachandran and Payal Korde Anantkumar et al (2012)
did the study on comparison of effectiveness of supervised exercise program and cyriax
physiotherapy in patients with tennis elbow (Lateral Epicondylitis) and the result will be both the
supervised exercise program and cyriax physiotherapy were found to be significantly effective in
reduction of pain and in the improvement of functional status. The supervised exercise programme
resulted in greater improvement in comparison to those who received cyriax physiotherapy. They
concluded that the results of this clinical trial demonstrate that the supervised exercise program may
be the first treatment choice for therapist in managing tennis elbow.22
Phil Page (2010) gives clinical suggestions that eccentric exercise has been effectively used in the
management of tendinopathies in multiple regions of the body. Lateral epicondylosis (“tennis elbow”)
is a common tendinopathy that has shown improvement following treatment utilizing isokinetic
eccentric exercise. A novel exercise was developed for home-based eccentric exercise that has shown
promise for use with patients with lateral epicondylosis. Clinicians should be aware of this exercise
and consider it as an evidence-based intervention.23
Hiroshi Takasaki et al (2008) did research to measure the strain at the proximal origin of the
extensor carpi radialis brevis (ECRB), and to determine the influence of a forearm support band and
in the result was when no tension was applied to the ECRB, there was no statistically significant
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difference in strain values at the ECRB origin by mounting the band at any of the forearm positions.
They concluded that the strain on the ECRB origin was less when the forearm support band was
applied 80% proximal from the wrist joint.24
Miriam Faes et al (March 2006): did study on the effect of an external wrist extension force on
extensor muscle activity during hand gripping in patients with lateral epicondylalgia. The results are
at all levels of MVC gripping, the EMG signal of the ECRB and EDC were significantly lower for
gripping with than without brace. An extension force of 3% of the MVC force significantly reduced
the EMG signal of all muscles in almost all measurement conditions and concluded that the results of
this study indicate that the dynamic extensor brace as well as the external extension force
significantly reduced the EMG signal of the wrist extensor muscles during gripping in patients with
lateral epicondylalgia. Based on these results, the dynamic extensor brace could be a promising new
intervention for lateral epicondylalgia.25
Review on effect of ultra sound in soft tissue disorders:
Oken O et al (2008) conducted study on the short-term efficacy of laser, brace, and ultrasound
treatment in lateral epicondylitis and the results show that, in patients with lateral epicondylitis, a
brace has a shorter beneficial effect than US and laser therapy in reducing pain, and that laser therapy
is more effective than the brace and US treatment in improving grip strength.26
Yesim Kurtais Gürsel et al (2004) mentioned that by adding ultrasound in the management of soft
tissue disorders of the shoulder. In result they found among subjects showed within-group
improvements in pain, range of motion, shoulder disability questionnaire scores, and health
assessment questionnaire scores with the intervention, but the differences did not reach significance
when compared between the groups. They discussed and concluded that true US, compared with
sham US, brings no further benefit when applied in addition to other physical therapy interventions in
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the management of soft tissue disorders of the shoulder.27
Review on recent studies on kinesio taping:
Erkan Kaya et al (2011) The purpose of this study was to determine and compare the efficacy of
kinesio taping compared to physical therapy modalities for the treatment of shoulder impingement
syndrome. Kinesio tape has been found to be more effective than the local modalities at the first week
and was similarly effective at the second week of the treatment. Kinesio taping may be an alternative
treatment option in the treatment of shoulder impingement syndrome especially when an immediate
effect is needed.28
Kristin Briem et al (2011) they did researched in male athletes (soccer, team handball, basketball) to
examine the effect of 2 adhesive tape conditions compared to a no-tape condition on muscle activity
of the fibularis longus during a sudden inversion perturbation. The result will be significantly greater
mean muscle activity was found when ankles were taped with nonelastic tape compared to no tape,
while kinesio tape had no significant effect on mean or maximum muscle activity compared to the
no-tape condition. Neither stability level nor taping condition had a significant effect on the amount
of time from perturbation to maximum activity of the fibularis longus muscle and concluded that
nonelastic sports tape may enhance dynamic muscle support of the ankle. The efficacy of kinesio tape
in preventing ankle sprains via the same mechanism is unlikely, as it had no effect on muscle
activation of the fibularis longus.29
Javier Gonzalez-Iglesias et al (2009) they determined the short-term effects of kinesio taping,
applied to the cervical spine, on neck pain and cervical range of motion in individuals with acute
whiplash-associated disorders (WADs).In result they found that patients with acute WAD receiving
an application of kinesio taping, applied with proper tension, exhibited statistically significant
improvements immediately following application of the kinesio tape and at a 24-hour follow-up.
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However, the improvements in pain and cervical range of motion were small and may not be
clinically meaningful. Future studies should investigate if kinesio taping provides enhanced outcomes
when added to physical therapy interventions with proven efficacy or when applied over a longer
period.30
Reliability of VAS:
Scott, Huskisson et al (1976), showed in their study of graphic representation of pain that, test-retest
reliability of vas is .71 to .99 and convergent validity (Mcgill pain questionnaire, numeric pain rating
scale) is .95 with a confidence interval of 95%.31
Reliability of PRTEE:
According to Lal Altan et al the objective of this study was to test the reliability of the Turkish
version of PRTEE (PRTEE-T) as a specific scale for LE. The results of our study have shown that the
Turkish version of a specific and practical scale developed for LE can be both valid and reliable.
PRTEE-T is easy to apply in a relatively short period and may prove to be valuable for evaluation and
follow up of the patients in daily clinical practice.32
6.2 Objectives of the study:
1. To evaluate the effect of kinesio taping on pain and functional outcome.
7Materials and Methods:
7.1Source of Data:
ESIC Hospital, Rajajinagar, Bangalore.
Padmashree clinic Nagarbhavi, Bangalore.
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Ravi Kirloskar Memorial Hospital, Bangalore.
7.2 Method of collection of data:
Population :- Patient with Lateral Epicondylitis
Sample design :- Convenience Sampling
Sample size :- 30
Study design : - Two group experimental design
Duration of the study :- 6 month
Inclusion criteria:
Subjects with Tennis Elbow diagnosed by orthopaedician.
Subjects with cozen test positive.
Lateral elbow pain at least 1-2weeks.
Both genders are included.
Age between 18-40years.
Exclusion criteria:
Cervical spondylosis with radiating pain on lateral elbow.
Arthritis of the elbow joint.
Musculoskeletal conditions such as fracture, surgery, dislocation, subluxation, avulsion
fracture, sprain, strain, bursitis and any kind of boney deformities around elbow.
Neurological involvement.
Tumors.
Materials used :
Examination table
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Pillow
Scissors
Therapeutic Ultrasound machine
Kinesio tape
Visual Analogue Scale
Patient Rated Tennis Elbow Evaluation
Methodology:
Ethical clearance will be taken from concern hospitals and institutions for the aged. Informed and
written consent from each subject will be taken which will state that the individual has agreed to
participate in the study and that the data collected will be analyzed using evaluation tools. Subject
will be screened for inclusion and exclusion criteria. Subjects enrolled in the study were assigned to
1st group with ultrasound while 2nd group recommended 5-6min of 3Hz, 0.5 intensity of ultrasound
is given once in a day for 3 days along with kinesio taping by making a fist, pronate the forearm (turn
over your hand so your palm is facing down), extend the elbow (straighten the arm), and flex the
wrist (down towards the ground) then ‘Y’ strip of kinesio taping is apply from the wrist to a spot 1
inch below the elbow.
Outcome measures:
There are 3 assessment is taken i.e. pre assessment, post assessment after 3 days and after 2 weeks of
follow-up by using visual analogue scale (VAS) and PRTEE (Patient Rated Tennis Elbow
Evaluation).
Statistics:
Data analysis will be performed by SPSS (version 17) for windows.
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Mean standard deviation range will be used to assess the pain and PRTEE.
Wilcoxson’s test will be used to compare the pre and post pain and PRTEE.
Mann- Whitney U test will be used to compare the post test level of pain and PRTEE.
7.3 Does the study require any investigation or interventions to be conducted on patients or
other humans or animals? If so please describe briefly.
Yes ,the will be carried out on human subject of both the gender with the age group of 18-40 years
having Lateral Epicondylitis to evaluate the effect of kinesio taping on pain and functional outcome.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes, the ethical clearance been obtained from the institution.
8List of References:
1. Cynthia C. Norkin, PT, EdD - Joint structure & function. 4thedition.India. Jaypee Brothers-
Medical Publishers (P) LTD; 2006.
2. Fornalski S, Gupta R, Lee T. Anatomy and Biomechanics of the Elbow Joint. Techniques in Hand
and Upper Extremity Surgery 2003; 7(4):168–178.
3. Neil Motyer- managing tennis elbow (lateral epicondylitis). Journals of the Australian association
of massage therapists.2008; 10.
4. Administrator patient education.elbow lateral epicondylitis (tennis elbow).2006, 20 july.
5. Bruce Reider. Sports medicine. 2nd edition. W.B. Saunders company, Pennsylvnania.1996
6. Pamela K. Levangie, Cynthia C. Norkin. Joint structure and function. 3rd edition. India. Jaypee
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Brother, 2003.
7. Lee DG. Tennis elbow: A manual therapist’s perspective. J ortho sports phy. Ther. 1986; 8:134-
141,
8. Gieck JH, Saliba E: Application of modalities in overuse syndromes.clin sports med.1987; 6:427-
466.
9. La Freniere J. Tennis elbow evaluation, treatment & prevention. Phys ther.1979; 59:742-746.
10. Coonrad RW, Hooper WR. Tennis elbow: Its course, natural history, conservative and surgical
management J Bone joint surg (Am) 1973; 55:1177-1182.
11. Bill Vicenzino. Jane Brooksbank, Joanne Minto, Sonia Offord, Aatit Paungmali, Initial Effects of
Elbow Taping on Pain-Free Grip Strength and Pressure Pain Threshold. J Orthop Sports Phys
Ther.2003.july; 33(7).
12. Alireza Shamsoddini, Mohammad Taghi Hollisaz, Rahmatollah Hafezi Initial effect of taping
technique on wrist extension and grip strength and pain of Individuals with lateral epicondylitis.
Iranian Rehabilitation Journal.2010; 8(11).
13. B. Vicenzino: Lateral epicondylalgia: a musculoskeletal physiotherapy perspective, Manual
Therapy. 2003; 8(2), 66–79.
14. Tieh-Cheng Fu, Alice M.K. Wong, Yu-Cheng Pei, Katie P. Wu, Shih-Wei Chou, Yin-Chou Lin.
Effect of Kinesio taping on muscle strength in athletes-A pilot study. Journal of Science and
Medicine in Sport (2008) 11, 198—201
15. Mark D. Thelen,James A. Dauber, Paul D.Stoneman. The Clinical Efficacy of Kinesio Tape
for Shoulder Pain: A Randomized, Double-Blinded, Clinical Trial. journal of orthopaedic & sports
physical therapy ,2008; volume 38 , number 7 , 389-395.
16. Manuel Saavedra-Hernandez, Adelaida M. Castro-Sánchez, Manuel Arroyo, Joshua A.
Inmaculada C. ,Lara-Palomo,César Fernández-D .Journal of orthopaedic & sports physical
therapy2012.August; 42(8), 725.
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17. Javier Gonzalez-iglesias. Short-Term Effects of Cervical KinesioTaping on Pain and Cervical
Range of Motion in Patients With Acute Whiplash Injury. JOSPT.2009.July 39 (7), 517.
18. Mark D. Thelen,James A. Dauber, Paul D.Stoneman. The Clinical Efficacy of Kinesio Tape
for Shoulder Pain: A Randomized, Double-Blinded, Clinical Trial. journal of orthopaedic & sports
physical therapy ,2008; volume 38 , number 7 , 389-395
19. Melissa Schneider, Matthew Rhea, Curtus Bay The Effect of Kinesio Tex Tape on Muscular
Strength of the Forearm Extensors on Collegiate Tennis Athletes.
20. Murray, H. Kinesio Taping, Muscle Strength and ROM after ACL Repair. Journal of Orthopedic
and Sports Physical Therapy.2000: 30,1
21. Travis Halseth, John W. , Mark DeBeliso, Ross Vaughn and Jeff Lien .The effects of kinesio
taping on proprioception at the ankle. Journal of Sports Science and Medicine.2004: 3, 1-7
22. Rajadurai Viswas, Rejeeshkumar Ramachandran and Payal Korde Anantkumar. Comparison of
Effectiveness of Supervised Exercise Program and Cyriax Physiotherapy in Patients with Tennis
Elbow (Lateral Epicondylitis): A Randomized Clinical Trial. The ScientificWorld Journal. 2012: 8
23. Phil Page. A new exercise for tennis elbow that works. North American Journal of Sports
Physical Therapy.September 2010:5(3),190
24. Hiroshi Takasaki et al. Strain Reduction of the extensor carpi radialis brevis tendon proximal
origin following the application of a forearm support band. Journal of orthopaedic & sports physical
therapy. May 2008: 38(5)
25. Miriam Faes et al. A dynamic extensor brace reduces electromyographic activity of wrist extensor
muscles in patients with lateral epicondylalgia. Journal of Orthopaedic & Sports Physical Therapy.
March 2006:36(3)
26. Oken O et al. The short-term efficacy of laser, brace, and ultrasound treatment in lateral
epicondylitis: a prospective, randomized, controlled trial.J Hand Ther. Jul-Sep 2008:21(3);303
27. Yesim Kurtais Gursel et al. Adding ultrasound in the management of soft tissue disorders of the
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shoulder: A randomized placebo-controlled trial. Phys Ther.2004; 84:336-343
28. Erkan Kaya & Murat Zinnuroglu & Ilknur Tugcu. Kinesio taping compared to physical therapy
modalities for the treatment of shoulder impingement syndrome. Clin Rheumatol. 2011:30;201–207
29. Kristin Briem et al. Effects of kinesio tape compared with nonelastic sports tape and the untaped
ankle during a sudden inversion perturbation in male athletes. Journal of orthopaedic & sports
physical therapy. may 2011:41(5);328-621
30. Javier González-Iglesias et al. Short-term effects of cervical kinesio taping on pain and cervical
range of motion in patients with acute whiplash injury: A randomized clinical trial. journal of
orthopaedic & sports physical therapy.july 2009:39(7)
31. Scott J, Huskisson EC. Vertical or horizontal visual analogue scales. Ann Rheum Dis
1979;38:560
32. Lale Altan, İlker Ercan, & Saniye Konur. Reliability and validity of Turkish version of the patient
rated tennis elbow evaluation. Rheumatology International.June 2010:30 (8); 1049-1054
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