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The use of elastic therapeutic tape for treatment of lateral elbow tendinosis

Raewyn Lin Wegener

B Occ Thy

Grad Cert (Wound Care)

M Hlth Sci (Occupational Therapy)

A thesis submitted in fulfilment of the requirement of the:

Doctor of Philosophy

(Thesis by Publications)

Supervisors:

Dr Lisa O’Brien

A/Prof Ted Brown

Department of Occupational Therapy

Faculty of Medicine, Nursing and Health Sciences

Monash University

Victoria, Australia

2016

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Notice 1 © Raewyn Lin Wegener (2016)

Under the Copyright Act 1968, this thesis must be used only under the normal conditions

of scholarly fair dealing. In particular, no results or conclusions should be extracted from

it, nor should it be copied or closely paraphrased in whole or in part without the written

consent of the author. Proper written acknowledgement should be made for any

assistance obtained from this thesis.

Notice 2

© Raewyn Lin Wegener (2016)

I certify that I have made all reasonable efforts to secure copyright permissions for third-

party content included in this thesis and have not knowingly added copyright content to

my work without the owner’s permission.

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General Declaration

In accordance with Monash University Doctorate Regulation 17 / Doctor of Philosophy

and Master of Philosophy regulations, the following declarations are made:

I hereby declare that this thesis contains no material which has been accepted for the

award of any other degree or diploma at any university or equivalent institution and

that, to the best of my knowledge and belief, this thesis contains no material previously

published or written by another person, except where due reference is made in the text

of the thesis. All pictures throughout this thesis were taken of myself and one of my

colleagues (with consent) who assisted in the study. Permission has been obtained for

all figures that have been included from other sources or published text.

This thesis includes five original papers and one opinion piece published (or in press) in

peer-reviewed journals. The ideas, development and writing up of all papers in the thesis

were the principal responsibility of myself, working under the supervision of Dr Lisa

O’Brien and Associate Professor Ted Brown.

Signature:

Name: Raewyn Lin Wegener

Date: 17/10/2016

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Thesis Chapter

Publication Title Publication Status

Nature and % of candidate’s contribution

Co-authors

3 A scoping review of the use of elastic therapeutic tape for neck and upper extremity conditions.

Published 80% - Concept development, literature review, data collection, writing, submission and amendments to manuscript.

A/Prof Ted Brown Dr Lisa O’Brien 20% - Revision of drafts and amendments to manuscript.

4 Knowledge of and willingness to recommend kinesiotape for upper limb overuse injuries: A comparison of therapists', GPs' and surgeons' perspectives.



5 The use of elastic therapeutic tape and eccentric exercises for lateral elbow tendinosis: a case series.



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Thesis Chapter

Publication Title Publication Status

Nature and % of candidate’s contribution

Co-authors

6 A randomized controlled trial of comparative effectiveness of elastic therapeutic tape, sham tape or eccentric exercises alone for lateral elbow tendinosis.



7 A qualitative review

of patients’

experiences using

Kinesio tape for

lateral epicondylitis.

Submitted to journal – (undergoing second revision)

80% - Concept development, literature review, data collection, writing, submission and amendments to manuscript.


Signed: Date: 17/10/2016

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Table of Contents

GENERAL DECLARATION ........................................................................................... 3

LIST OF FIGURES ..................................................................................................... 10

LIST OF TABLES ....................................................................................................... 11

APPENDICES ........................................................................................................... 12

ACKNOWLEDGEMENTS ........................................................................................... 13

THESIS SUMMARY .................................................................................................. 14

ABBREVIATIONS ..................................................................................................... 16

THESIS PUBLICATIONS ............................................................................................ 17

CHAPTER 1 – GENERAL INTRODUCTION .................................................................. 18

1.1 INTRODUCTION AND OVERVIEW OF THESIS STRUCTURE ................................................ 18

1.2 LITERATURE REVIEW ................................................................................................... 22

1.2.1 Clinical presentation and diagnostic tests ..................................................... 25

1.2.2 Treatment for lateral elbow tendinosis .......................................................... 27

1.2.3 Using elastic therapeutic tape for tendinosis ................................................. 29

1.3 CONCEPTUAL FRAMEWORKS ......................................................................................... 31

1.3.1 Biomechanical Model of Health (BMH) .......................................................... 32

1.3.2 The Occupational Adaptation Model (OAM) ................................................. 34

1.3.3 The International Classification of Functioning, Disability, and Health (ICF) . 37

1.4 CHAPTER SUMMARY ................................................................................................... 39

CHAPTER 2 – METHODOLOGY ................................................................................. 40

2.1 INTRODUCTION .......................................................................................................... 40

2.2 RESEARCH QUESTIONS ................................................................................................. 40

2.3 MATERIALS AND METHODS .......................................................................................... 42

2.3.1 Research Question 1: What is the current evidence relating the use of elastic

therapeutic tape in treating neck and upper extremity conditions? ...................... 42

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2.3.2 Research Question 2: What are the current perspectives amongst Hand

Therapists, General Practitioners and Hand Surgeons on the use of elastic

therapeutic tape and how often is it used or recommended? ................................ 43

2.3.3 Research Question 3: What is the preliminary evidence into the benefit of

elastic therapeutic tape and eccentric exercises for the treatment of lateral elbow

tendinosis? ............................................................................................................... 45

2.3.4 Research Question 4: Is the application of elastic therapeutic tape according

to the ‘Clinical Therapeutic Applications of the Kinesio Taping Method’ manual

(with the tape applied on tension), in conjunction with an eccentric exercise

program and activity modification advice, more effective than: (i) sham taping

(application with no stretch); or (ii) eccentric exercises alone; for people with

lateral elbow tendinosis? ........................................................................................ 47

2.3.5 Research Question 5: What are the experiences of people using elastic

therapeutic tape for lateral elbow tendinosis? ....................................................... 50

2.6 CHAPTER SUMMARY ................................................................................................... 52

CHAPTER 3 - A SCOPING REVIEW OF THE USE OF ELASTIC THERAPEUTIC TAPE FOR

NECK AND UPPER EXTREMITY CONDITIONS ............................................................ 53

3.1 INTRODUCTION .......................................................................................................... 53

3.2 CHAPTER CONTENTS ................................................................................................... 53

3.3 IMPACT OF THE STUDY ................................................................................................. 65

3.4 CHAPTER SUMMARY ................................................................................................... 66

CHAPTER 4 - A COMPARISON OF HAND THERAPISTS’, GENERAL PRACTITIONERS’ AND

SURGEONS’ PERSPECTIVES ON THE USE OF ELASTIC THERAPEUTIC TAPE ................. 69

4.1 INTRODUCTION .......................................................................................................... 69



4.4 CHAPTER SUMMARY ................................................................................................... 78

CHAPTER 5 - THE USE OF ELASTIC THERAPEUTIC TAPE AND ECCENTRIC EXERCISES FOR

LATERAL ELBOW TENDINOSIS: A CASE SERIES. ........................................................ 81

5.1 INTRODUCTION .......................................................................................................... 81



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5.4 CHAPTER SUMMARY ................................................................................................... 92

CHAPTER 6 – A RANDOMISED CONTROLLED TRIAL OF COMPARATIVE EFFECTIVENESS

OF ELASTIC THERAPEUTIC TAPE, SHAM TAPE OR ECCENTRIC EXERCISES ALONE FOR

LATERAL ELBOW TENDINOSIS ................................................................................. 94

6.1 INTRODUCTION .......................................................................................................... 94


6.3 IMPACT OF THE STUDY ............................................................................................... 106

6.4 CHAPTER SUMMARY ................................................................................................. 107

CHAPTER 7 - A QUALITATIVE REVIEW OF PATIENTS’ EXPERIENCES USING KINESIO

TAPE FOR LATERAL EPICONDYLITIS ....................................................................... 109

7.1 INTRODUCTION ........................................................................................................ 109

7.2 CHAPTER CONTENTS ................................................................................................. 109

7.3 IMPACT OF THE STUDY ............................................................................................... 132

7.4 CHAPTER SUMMARY ................................................................................................. 134

CHAPTER 8 – DISCUSSION AND CONCLUSION ........................................................ 137

8.1 CHAPTER OVERVIEW ................................................................................................. 137

8.2 REVISITING THE RESEARCH QUESTIONS ......................................................................... 137

8.3 DISCUSSION OF STUDY FINDINGS ................................................................................. 143

8.4 IMPLICATIONS FOR CLINICAL PRACTICE.......................................................................... 147

8.5 LIMITATIONS OF THIS THESIS ....................................................................................... 152

8.6 RECOMMENDATIONS FOR FUTURE RESEARCH ................................................................. 154

8.7 CHAPTER SUMMARY ................................................................................................. 155

REFERENCES ......................................................................................................... 156

APPENDIX ............................................................................................................ 162

APPENDIX A: PUBLISHED OPINION PIECE ............................................................................. 163

APPENDIX B: ETHICS APPROVAL AND FINAL REPORT .............................................................. 166

APPENDIX C: CONFERENCE PARTICIPATION ......................................................................... 169

Current Abstract Submissions ............................................................................... 169

Conference Presentations ..................................................................................... 169

Other Presentations .............................................................................................. 170

APPENDIX D: APPLICATION OF TAPE (STUDY 4) ................................................................... 171

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APPENDIX E: ECCENTRIC EXERCISE PROGRAM (STUDY 4) ....................................................... 173

APPENDIX F: OUTCOME MEASURES (STUDY 4) .................................................................... 175

APPENDIX G: QUALITATIVE QUESTIONS (STUDY 5) ............................................................... 184

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List of Figures

Figure 1 Biomechanical Model of Health (BMH) Page 33

Figure 2 Occupational Adaptation Model Page 36

Figure 3 International Classification of Functioning Page 38

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List of Tables

Table 1 Thesis Publications Page 17

Table 2 Summary of Research Questions and Study Findings Page 139

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Appendices

Appendix A Published Opinion Piece Page 163

Appendix B Ethics Approval and Final Report Page 166

Appendix C Conference Participation Page 167

Appendix D Application of Tape (Study 4) Page 171

Appendix E Exercise Program (Study 4) Page 173

Appendix F Outcome Measures (Study 4) Page 175

Appendix G Qualitative Questions (Study 5) Page 184

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Acknowledgements

First and foremost, I would like to express my genuine gratitude to Dr Lisa

O’Brien and Associate Professor Ted Brown for their help, advice, supervision and

support during my PhD. I feel that I was blessed to have such exceptional supervisors! I

am sincerely grateful for their continual encouragement and guidance which has

enabled me to reach such significant milestones in my research. They have both played

an invaluable role in improving my knowledge, as well as creating opportunities for

future learning and development. For this experience, I will forever be thankful to them.

I would also like to thank my husband, Andrew, for his unwavering support over

the many years of Postgraduate study. You have stood by me with continual

encouragement and motivation, especially when I doubted myself. Thank you to my

wonderful family and parents, Des and Alice, who have shared this journey with me. I

have valued your support and kindness during this time. I am also very grateful to my

Uncle David for his help and technical assistance during my studies.

Importantly, I would also like to acknowledge all of my patients for their help in

furthering my knowledge in the area of Hand Therapy. Without them, this learning and

research would not have been possible and, for that, I am sincerely appreciative.

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Thesis Summary

The development of this thesis arose from my clinical experience as a hand

therapist in a private practice setting. As is shown in the literature, lateral elbow

tendinosis is a common, yet complex, upper limb condition that is associated with long

term morbidity. Due to its degenerative aetiology, research has supported a shift away

from surgery and the use of passive interventions, such as immobilisation with splinting,

ultrasound, massage and the use of thermal modalities. Despite this evidence, it was my

observation that these treatment modalities were still commonly used amongst

therapists, including myself, who were attempting to manage the complexities of this

patient population. In particular, elastic therapeutic tape was used extensively for

tendinosis within the practice I worked, despite a lack of supporting evidence into its

use. When further examining this condition, I was led to question my own clinical

practice to ensure I was implementing interventions that were in line with the literature.

As a health professional, I felt strongly about working within an evidence-based practice

model.

These concepts listed above have been explored within this thesis, based on the

frameworks of the Biomechanical Model (which is prevalent in Hand Therapy), the

Occupational Adaptation Model (OAM) and the International Classification of

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Functioning, Disability and Health (ICF). A variety of methodologies have been utilised

to address the above clinical questions, including a scoping review, cross-sectional

study, case series, qualitative methodology and a randomised controlled trial. This forms

the basis of the five publications that comprise Chapters 3 to 7. All studies supported

existing research that passive interventions, including elastic therapeutic tape, have

little impact on this condition. Overall, findings also revealed that:

1. Elastic therapeutic tape for lateral elbow tendinosis is no more effective than

sham taping or eccentric exercises at six-months post randomisation. Evidence

supports activity modification and exercises as successful interventions for this

condition.

2. Lateral elbow tendinosis is complex and treatment should be carefully

considered based on a clear diagnosis, duration of symptoms, awareness of

patient experiences and use of evidence-based interventions.

3. Further examination into elastic therapeutic tape for upper limb conditions is

warranted, especially in relation to comparisons between acute and chronic

conditions.

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Abbreviations

PRTEE Patient-Rated Tennis Elbow Evaluation

OSAv2.2 Occupational Self-Assessment (version 2.2)

SF-36 Short Form-36

BMH Biomechanical Model of Health

OAM Occupational Adaptation Model

ICF International Classification of Functioning, Disability and Health

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Thesis Publications

Title Journal Impact

Factor

Page

Article 1: Taylor, R.L., O’Brien, L. & Brown, T. (2014). A scoping review of the use of elastic therapeutic tape for neck or upper extremity conditions. Journal of Hand Therapy, 27(3), 235-246.

2.0 54

Article 2: Taylor, R.L., Brown, T. & O’Brien, L. (2015). Knowledge of and willingness to recommend kinesiotape for upper limb overuse injuries: A comparison of therapists’, general practitioners’ and surgeons’ perspectives. International Journal of Therapy and Rehabilitation, 22(5), 238-245.

N/A 71

Opinion piece: Taylor, R.L., Brown, T. & O’Brien, L. (2015). Using and prescribing kinesiotape as a treatment modality for musculoskeletal disorders. International Journal of Therapy and Rehabilitation, 22(9), 408-409.

N/A 163

Article 3: Wegener, R.L., Brown, T. & O’Brien, L. (2015). The use of elastic therapeutic tape and eccentric exercises for lateral elbow tendinosis: a case series. Hand Therapy, 20(2), 56-63.

N/A 83

Article 4: Wegener, R.L., Brown, T. & O’Brien, L. (2016). A randomized controlled trial of comparative effectiveness of elastic therapeutic tape, sham tape or eccentric exercises alone for lateral elbow tendinosis. Hand Therapy, 1758998316656660.

N/A 997

Article 5: Wegener, R.L., Brown, T. & O’Brien, L. (2016). A qualitative review of patients’ experiences using Kinesio tape for lateral epicondylitis. Submitted to the British Journal of Occupational Therapy (under second revision).

0.935 111

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Chapter 1 – General Introduction

1.1 Introduction and Overview of Thesis Structure

The aim of this chapter is to:

Provide an outline of the structure of the thesis.

Describe the scope of the problem related to lateral elbow tendinosis in the hand

therapy and rehabilitation context, including current evidence-based practice.

Examine the existing evidence relating to the use of elastic therapeutic tape for

neck and upper limb conditions.

Review health frameworks and conceptual models in relation to how these form

the foundation of the thesis.

This PhD thesis has been completed as a ‘Thesis by Publications’ and, for this

reason, it is comprised as a series of five research papers. Four of these papers are

currently published, whilst one remaining paper is under its second review by the British

Journal of Occupational Therapy. Each publication is linked with the Biomechanical

Model of Health (BMH) (Brown, 1981), the Occupational Adaptation Model (OAM)

(Schkade & Schultz, 1992; Schultz & Schkade, 1992) and the International Classification

of Functioning, Disability and Health (ICF) (WHO, 2007).

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Chapter 1 details an overview of the background for the research, defines the nature

of the problem and the need to examine current and future clinical practice for

therapists treating this condition. This chapter also covers the literature, scope of

practice and describes the conceptual models and frameworks that underpin this

thesis.

Chapter 2 details the methodologies of each study, as well as the research questions

and aims that underpin the thesis.

Chapter 3 contains the first of the publications, which is a scoping review of evidence

relating to the use of elastic therapeutic tape for neck and upper extremity

conditions. Findings showed that elastic therapeutic tape may play a role in reducing

short-term neck and upper extremity pain, however, future high quality studies that

contribute to this body of knowledge are needed.

Chapter 4 identified the perspectives amongst Australian surgeons, general

practitioners (GPs) and therapists (Physiotherapists and Occupational Therapists) on

the use of elastic therapeutic tape. Findings indicated that therapists were more

likely to rate the use of elastic therapeutic tape as successful and recommend its

clinical use, indicating that they placed greater emphasis on their own clinical

experience than on available research evidence. It is inferred that GPs and surgeons

have a higher level of scepticism for interventions without supporting evidence.

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More evidence from randomised controlled trials are required to inform

practitioners about the use of elastic therapeutic tape as an intervention.

Chapter 5 explored a case series of four patients who had used elastic therapeutic

tape, in conjunction with an eccentric exercise program, in managing lateral elbow

tendinosis. Findings showed that there may be some clinical benefit in the use of

elastic therapeutic tape, in conjunction with eccentric exercises and activity

modification techniques, for the treatment of lateral elbow tendinosis. However,

more rigorous and comprehensive studies are recommended to further investigate

this intervention.

Chapter 6 describes a randomised controlled trial of 40 participants on the

effectiveness of elastic therapeutic tape for lateral elbow tendinosis, in conjunction

with eccentric exercises and activity modification techniques. This trial compared

three different interventions: (1) elastic therapeutic tape, (2) sham tape, and (3) no

tape. All groups received the same eccentric exercises and activity modification

education. Findings indicated that, at three- and six-months post randomisation,

improvements were made in all three groups as assessed with pain-free grip

strength, the Patient-Rated Tennis Elbow Evaluation (PRTEE), Short Form 36 (SF-36)

and the Occupational Self-Assessment (OSA). However, there were no statistically

significant differences between the three participant groups. We also found no

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significant side effects or symptom exacerbation with using elastic therapeutic tape

as an intervention strategy. Further studies are needed to assess the use of elastic

therapeutic tape for a range of upper extremity conditions, especially in relation to

its use for acute versus chronic conditions.

Chapter 7 involves a qualitative study that explored the experiences of 11 patients

from the intervention group of the randomised controlled trial. Thematic analysis

was used and findings showed that, regardless of treatment, the consequences of

lateral elbow tendinosis resulted in an adjustment to work and daily activities for a

significant period. Long term changes implemented by the person themselves were

identified as the main contributing factor to improvements in their function, as

opposed to specific treatment modalities. The three key themes were:

1. Frustration at the length of time needed for functional recovery and the impact

on life roles.

2. The importance of long-term self-management.

3. Elastic therapeutic tape was easy to self-apply but was an adjunct in recovery

compared to self-management strategies.

Chapter 8 presents the discussion and conclusion to the thesis. This combines all

research projects, in conjunction with current evidence, and the impact on clinical

practice for hand therapists. It summarises the original contribution this thesis and

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research has made to the area of hand therapy. Furthermore, limitations of the

studies and suggestions are made for future research.

Appendices are included and contain documents that are relevant to this research

project, such as ethics approvals, assessment proformas and conference

presentations.

1.2 Literature Review

Lateral elbow pain, or ‘tennis elbow/lateral epicondylitis’ as it is commonly

referred to in the literature, is a condition that is known to be difficult for Hand

therapists to treat (Fedorczyk, 2006a). This is due to its long term recovery, considerable

morbidity and financial costs, including those associated with time off work and

prolonged treatment (Burton, Kendall, Pearce, Birrell, & Bainbridge, 2009). It is one of

the most common work-related disorders of the elbow with over 70% of cases being

occupation related, especially amongst individuals who perform forceful and repetitive

activities, such as tradespeople, athletes, and mine workers (Fedorczyk, 2006a). Overall

prevalence in the general population is thought to range from 1% to 5% (Shiri, Viikari-

Juntura, Varonen, & Heliövaara, 2006). Both males and females are equally affected with

the most common age of onset being 40-60 years. Approximately 40% of people will

experience lateral elbow pain at some point in their life and over 50% of these report

23

not being fully recovered at 12-months post onset (Bisset & Vicenzino, 2015; Fedorczyk,

2006b; Gruchow & Pelletier, 1979). Direct costs per case are approximately US$8099,

resulting in a significant economic burdens to the individual, health care system and

society (Bisset & Vicenzino, 2015; Silverstein, Viikari‐Juntura, & Kalat, 2002).

To date, ‘lateral epicondylitis’ and ‘tennis elbow’ are common terms used by

physicians and therapists when describing the clinical diagnosis related to pain

experienced at or around the lateral epicondyle (Fedorczyk, 2006b). However, new

research reveals that these terms are misleading. The suffix ‘itis’ implies an

inflammatory pathology, but extensive histological immunehistochemical and electron

microscopy studies have shown that the condition is degenerative rather than

inflammatory (Stasinopoulos & Johnson, 2006). It has been suggested that the more

appropriate terms for this condition are either (i) lateral elbow tendinosis, or (ii) lateral

elbow tendinopathy (Ashe, McCauley, & Khan, 2004; Stasinopoulos & Johnson, 2006). It

is important to apply the correct diagnostic terminology since the previous labels for this

condition have led to misunderstanding and inappropriate treatment. For the purpose

of this PhD research, the term ‘lateral elbow tendinosis’ is used hereafter.

Understanding the pathophysiology of lateral elbow tendinosis may enable

better targeting of treatment and rehabilitation efforts (Khan, Cook, Bonar, Harcourt, &

Åstrom, 1999; Khan, Cook, Kannus, Maffulli, & Bonar, 2002). Extensive histological,

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immunehistochemical, and electron microscopy studies have shown that the condition

is degenerative rather than inflammatory. The muscles of the lateral aspect of the elbow

include the brachioradialis, extensor carpi radialis longus (ECRL), extensor carpi radialis

brevis (ECRB), extensor carpi ulnaris (ECU), and supinators (Hausman & Lang, 2014;

Ljung, Lieber, & Friden, 1999; Reichel & Morales, 2013). All of these structures blend

together at the elbow and attach to the humerus as a merged extensor origin. These

structures become distinct only in the forearm (Hausman & Lang, 2014). Anatomical

studies of the lateral aspect of the elbow demonstrate that there is often considerable

contact between the extensor carpi radicalise brevis (ECRB) and the lateral edge of the

capitellum, especially with repeated contraction of the wrist extensor muscles, leading

to ‘wear and tear’ of the tendon. Bowing and stretching of the tendon occur with the

elbow in extension regardless of wrist position. Subsequently, degeneration at the origin

of the ECRB muscle results from an increased presence of fibroblasts, vascular

hyperplasia, proteoglycans, and glycosaminoglycans together with disorganised and

immature collagen which all occur in the absence of inflammatory cells (Cook & Purdam,

2009b).

It is still not clear why tendinosis is painful, given the absence of inflammatory

cells, nor is it known why collagen fails to mature. The true cause of pain may be

mechanical discontinuity of collagen fibers or biochemical irritation that results from

25

damaged tendon tissue that activates nociceptors (Chourasia et al., 2012; Cook &

Purdam, 2009a). There may also be other potential mechanisms of tendon pain

including the involvement of other tissues such as nerves, vessels and bones that are

intimately related to tendon (Khan, Cook, Maffulli, & Kannus, 2000b).

1.2.1 Clinical presentation and diagnostic tests

As with most conditions managed by hand therapists, it is important that clinical

symptoms and assessments of lateral elbow tendinosis are correlated with relevant

imaging findings and advice from the referring Specialist/Surgeon where applicable. A

skilled therapist should elicit appropriate information via a person’s history that will

direct a specific physical examination of key structures that need to be assessed.

Magnetic Resonance Imaging (MRI) is still the gold standard in diagnosing lateral

elbow tendinosis (Geoffroy, Yaffe, & Rohan, 1994; Miller, Shapiro, Schultz, & Kalish,

2002; Vicenzino, Brooksbank, Minto, Offord, & Paungmali, 2003). However, in general,

lateral elbow tendinosis can be a relatively straightforward condition to identify in the

clinic, with the key physical examination features being (i) reproduction of pain in

response to direct palpation over the lateral epicondyle (or up to 5mm anterior or distal)

and (ii) pain provocation in response to tests of forearm extensor muscle function

(Fedorczyk, 2006b; Valdes & LaStayo, 2013). In most cases, there is often a deficit in

26

strength in these muscles, especially with a reduced ability to tolerate load with the

elbow extended. Common reported symptoms are aching in the evening and stiffness

in the morning. Gripping, resisted wrist extension, radial deviation, finger extension, and

forearm supination can produce pain depending on the irritability of the tissues

(Wilhelm, 2009).

Specifically, there are also a number of provocative tests that are typically used

to diagnose lateral elbow tendinosis (Fedorczyk, 2006b; MacDermid & Michlovitz, 2006).

These include:

1. Chair Test – lifting the back of a chair with three digits (thumb, index and middle

fingers), whilst extending the elbow, provokes pain at the lateral epicondyle.

2. Cozens Test - The elbow is extended and then a fist is made with wrist extension

against resistance. This is followed by pronation and passive radial deviation to

examine pain at the lateral epicondyle.

3. Mill’s Test – passively moving the elbow in pronation with wrist flexion then

elbow extension provokes pain at the lateral epicondyle.

4. Maudsley Test – resisted middle finger extension with the forearm in pronation

provokes pain at the lateral epicondyle.

Apart from MRI, the Mill’s Test has the highest diagnostic accuracy with specificity

of 100% in some studies. It must be noted that the sensitivity of these tests are not

27

discussed in detail as they have not been recently or thoroughly examined to determine

their diagnostic accuracy or clinical usefulness (Valdes & LaStayo, 2013). It is important

to consider that differential diagnoses for lateral elbow tendinosis can include cervical

radiculopathy, neurovascular entrapment, and radial tunnel syndrome (Vicenzino &

Wright, 1996). It is beyond the scope of this PhD to discuss all the tests or pathologies

of the elbow.

1.2.2 Treatment for lateral elbow tendinosis

To date, there has been consensus that the recommended management of

tendinosis is through conservative treatment (Vicenzino, 2003). While many treatments

for lateral elbow tendinosis have been researched, including friction massage,

ultrasound, acupuncture, orthotics, splinting, shock wave therapy, oral non-steroidal

anti-inflammatory medications and surgery, many have small short-term effects and few

have shown consistent effectiveness over other treatments (Bisset & Vicenzino, 2015;

Buchbinder, Green, Bell, et al., 2002; Buchbinder, Green, White, et al., 2002; Green et

al., 2002; Green et al., 2001; Labelle et al., 1992; Smidt et al., 2002; Struijs et al., 2001).

From the available evidence, there is emerging support for exercise as an

important aspect of the management of lateral elbow tendinosis. Systematic reviews

have concluded that eccentric exercises have had some positive effect on clinical

28

outcomes such as pain, function, patient satisfaction and return to work amongst this

population (Cullinane, Boocock, & Trevelyan, 2014; Raman, MacDermid, & Grewal,

2012). It has been suggested that eccentric loading may assist with tendon rehabilitation

by improving collagen alignment and stimulating collagen cross-linkage formation, both

of which can improve tensile strength. Although most studies did not adequately

address exercise dosages or include exercise descriptions that could be reproduced,

Raman, MacDermid, and Grewal (2012) suggested that a protocol of eccentric exercises

performed for three sets of 10-15 repetitions daily for approximately 6-12 weeks has

the best current supporting evidence.

Despite the reported benefits of eccentric exercises, a barrier in conservative

management is often the considerable pain reported by people with elbow tendinosis

which directly impacts on their ability to effectively undertake a therapeutic exercise

program (Malliaras, Maffulli, & Garau, 2008). The pain also directly impacts patients’

abilities to engage in many daily functional activities that require elbow movement, such

as keyboarding, driving a car, lifting objects off a shelf, doing up buttons, and

handwriting. The hand therapists’ management of lateral elbow tendinosis revolves

primarily around modulating tendon pain, as pain is the primary presenting and limiting

factor experienced by this patient group (Carlo, 2009; Clarke, Ahmad, Curtis, & Connell,

2013). Additional goals of rehabilitative treatment are to maintain movement and

29

strength, and to develop endurance over time to increase function and maintain

participation in work and meaningful activities (Cook & Purdam, 2013).

One suggested modality for managing pain during elbow motion and exercise is

the application of elastic therapeutic tape (Kase, Tatsuyuki, & Tomoko, 1996). The next

section describes how elastic tape is thought to work, and how it may be applied in the

management of tendinosis.

1.2.3 Using elastic therapeutic tape for tendinosis

It is proposed that elastic therapeutic tape may play a role in biomechanically

unloading the affected tendon, thereby reducing symptoms and allowing patients to

undertake appropriate strengthening exercises (Bassett, 2010). Developed in the 1970’s

by Dr Kenzo Kase, a chiropractor, elastic therapeutic tape is a relatively new modality

used for treating a variety of injuries (Kase, Tatsuyuki, & Tomoko, 1996). Since that time,

different names and brands have emerged and it has gained increased recognition

especially after it was donated to 58 countries for use during the 2008 Olympic Games

and was used by many high-profile athletes. Traditional taping methods for elbow

tendinopathy have been examined in clinical studies (Amro et al., 2010; Vicenzino,

Brooksbank, Minto, Offord, & Paungmali, 2003) with results demonstrating some short-

term improvements in pain-free grip strength; however, no studies have explored the

30

use of elastic therapeutic tape for this condition with long term follow-up (Taylor,

O'Brien, & Brown, 2014).

Although unsupported by evidence, the proposed mechanisms of elastic

therapeutic tape include alleviating pain, correcting muscle function, restoring

functional movement patterns, improving circulation, and relieving abnormal muscle

tension (Bassett, 2010; Kase, Tatsuyuki, & Tomoko, 1996; Moore, 2012). In particular, it

is reported that the application of elastic therapeutic tape over stretched muscle will

create convolutions in the person’s skin which subsequently reduce the pressure in the

mechanoreceptors that are located below the dermis, thereby decreasing nociceptive

stimuli (Parreira et al., 2014). Through these mechanisms, it is hypothesised that elastic

therapeutic tape can assist in reducing symptoms and thus allow patients to undertake

appropriate rehabilitative exercises (Bassett, 2010).

Recommended tape application methods are outlined in ‘Clinical Therapeutic

Applications of the Kinesio Taping Method’ (Kase, 2003). Elastic therapeutic tape is

designed to allow for a longitudinal stretch of up to 140% of its resting length; however,

the majority of tape applications are applied between 25-50% and occasionally up to

100%. The tape has no horizontal stretch and it is designed to approximate the elastic

qualities of the human skin. There are currently no available guidelines on how to

achieve consistency with the tape’s stretch and application; therefore, therapists must

31

rely on their own clinical judgement during tape application (Kase, 2003; Kase,

Tatsuyuki, & Tomoko, 1996). In particular, this factor is an important consideration when

teaching patients or family members to re-apply the tape and may affect compliance

with treatment.

Despite its popularity and widespread clinical use, there is relatively little

evidence to support the effectiveness of elastic therapeutic tape, let alone for specific

neck and upper extremity conditions. To date, evidence regarding the effectiveness of

elastic therapeutic tape has relied predominantly on case reports, small pilot studies and

research on healthy participant groups (Bassett, 2010).

1.3 Conceptual frameworks

Evidence-based practice in the absence of a good foundation in theoretical

models is problematic because it is difficult to evaluate research findings without

understanding theory (Peachey-Hill & Law, 2000). For the research presented in this

thesis, an understanding of theoretical conceptual models and frameworks underpinned

the assessments and interventions to both measure and facilitate change in patients’

occupational performance. This knowledge provides the explanatory power on how

interventions guide change in our patients’ function (Ikiugu, Smallfield, & Condit, 2009).

32

Two models and one framework have been selected to provide a theoretical

foundation for this PhD program: (1) the Biomechanical Model of Health (BMH) (Brown,

1981), (2) The Occupational Adaptation Model (OAM) (Schkade & Schultz, 1992; Schultz

& Schkade, 1992), and (3) the International Classification of Functioning, Disability and

Health (ICF) (WHO, 2007). These models and frameworks were chosen to guide the

biopsychosocial approach to this study. Whilst hand therapy has traditionally used a

biomechanical approach towards treatment, it was important to include the OAM and

ICF to address broader psychosocial components.

1.3.1 Biomechanical Model of Health (BMH)

The BMH (Seidel, 1998) has commonly been used in the treatment of patients

with musculoskeletal conditions, such as lateral elbow tendinosis, within a rehabilitation

setting. It has intuitive appeal and is supported by a wealth of biological findings

(Mishler, 1981). The BMH has foundations in assessing the symptoms of an injury or

condition to determine what is not functioning optimally. Once the pathology is

identified, treatment aims to eliminate, repair or correct the existing pathology through

medical methods. This model incorporates exercise and activity to reduce deficits in

occupational performance components and emphasises that the reduction of physical

deficits will promote independence in daily activities (Cole & Tufano, 2008; Jackson &

33

Schkade, 2001b). The therapist considers the patient’s goals; however, treatment

focuses on overcoming deficits, improving range of motion, increasing mobility and

prescribing strengthening exercises (Cole & Tufano, 2008). The BMH is consistent with

the theories that underpin the use of elastic therapeutic tape and eccentric exercises in

managing lateral elbow tendinosis.

A limitation of using this model in isolation is that it may not provide the person

with much opportunity to plan and participate in the process of therapy. The role of the

person can become passive; therefore, the BMH does not incorporate all the strengths

of occupational therapy service delivery (Cole & Tufano, 2008). For this reason, an

additional occupational model and a health framework were also used as the foundation

of this thesis.

Figure 1: Biomechanical Model of Health (Brown, 1981; Kielhofner, 2009)

Joint Range of Motion

Physical Endurance

Muscle Strength

34

1.3.2 The Occupational Adaptation Model (OAM)

The OAM developed by Schkade and Schultz (1992) differs from other models

due to its focus on one’s internal adaptation (ability to adjust oneself to different

conditions and environments) as opposed to occupational performance. In doing so, this

model has great applicability to the specialty area of Hand Therapy. Therapists often

assume that, as clients recover function (i.e. improved goniometer measures of Range

of Motion, increased grip strength and return to work), they will become more adaptive.

However, function and adaptation are not the same – increased function does not

necessarily mean more adaptation, especially in the case of long-term conditions.

Therapists may incorrectly assume that as the patient acquires more functional skills,

adaptation is occurring; however, the person’s internal adaptation may actually remain

unchanged (Schultz & Schkade, 1992).

Occupational adaptation is described as a normative process that leads to

competence in occupational functioning. This model proposes that occupation involves

the means through which adaptation occurs and an end for which functional adaptation

is desirable (Schkade & Schultz, 1992; Schultz & Schkade, 1992). Illness or trauma may

disrupt this internal process and result in maladaptive responses to daily occupational

challenges. In this model, the therapist’s role is to facilitate restoration of a functional

internal adaptation process (Jackson & Schkade, 2001a).

35

In relation to this thesis, the OAM complements the BMH as it does not exclude

biomechanical and rehabilitation principles for therapeutic interventions (Jackson &

Schkade, 2001a). However, the primary focus of treatment is placed on the patient’s

meaningful occupational role, involvement in the therapy process, and the adaptation

outcome. From the literature, lateral elbow tendinosis is recognised for having a

significant period of time during which people will experience occupational dysfunction.

As discussed previously, this condition frequently takes years to improve, during which

time people are required to develop adaptations to enable resumption of meaningful

occupations.

An adaptive response results in the person achieving greater relative mastery in

their occupational activities which is measured by three properties – efficiency (the use

of time, energy and resources), effectiveness (the degree to which one achieves a

desired result) and satisfaction (the extent to which the outcome was personally

satisfying and well-regarded) (Schkade & Schultz, 1992). Schultz and Schkade (1992)

further state that the person’s response to both intrinsic (personal) and extrinsic

(environmental) factors will dictate their final outcome. A successful response will result

in ‘occupational performance with mastery and satisfaction’ or a successful return to

meaningful occupations.

36

The diagram of the OAM (presented below) contains three elements – (i) the

person, (ii) the occupational environment and (iii) the interaction of the two as they

come together in occupation (Schkade & Schultz, 1992; Schultz & Schkade, 1992). The

occupational adaptation model can be conceptualised as having two major processes:

(1) the first is the process of moving from the press for mastery to an occupational

response, and (2) the second part is the process by which individuals make adaptive

responses through relative mastery to an occupational response.

Figure 2: Occupational Adaptation Model (Schultz & Schkade, 1992)

In the hand therapy setting, the OAM has great applicability as a large majority

of patients sustain lengthy disruptions to their everyday function, requiring them to

come forth with an adaptive response to deal with their injury. The process from the

37

onset of lateral elbow tendinosis to return to activities of daily living (ADLs) is considered

to be one of ongoing adaptation. Therapists have often focused on treating the person’s

condition, neglecting to address the illness experience (Schultz & Schkade, 1992).

This is an important concept in relation to this PhD as it focuses on physical

dysfunction, but also the notion of understanding an individual’s perspective and

experience of adaptation.

1.3.3 The International Classification of Functioning, Disability, and Health

(ICF)

Another conceptual framework that underpins this thesis is the International

Classification of Functioning, Disability, and Health (ICF) (WHO, 2007). This is structured

around the following broad components: (i) body function and structure, (ii) activities,

(iii) participation, (iv) environmental factors and (v) personal factors.

Within the ICF, functioning and disability are viewed as complex interactions

between the health condition of the individual, the environmental context, as well as

personal factors (WHO, 2007). It identifies these dimensions as being interactive and

dynamic, as opposed to linear and static. The ICF is able to assist health practitioners in

assessing the degree of disability, even though it is not a measurement instrument

(Cieza et al., 2002b). All aspects of a person’s life (development, participation and

environment) are incorporated into the ICF instead of focusing solely on a ‘diagnosis’.

38

The ICF is an important framework for this research and it complements the BMH

which forms the basis for the use of elastic therapeutic tape. The ICF acknowledges the

importance of understanding disease and dysfunction in health care (similar to the

BMH); however, it further recognises the person as a whole, including their lived

context. Identifying the limitations of function through the ICF can provide important

information to plan and implement interventions. It can be applied across cultures, age

groups and genders, making it highly suitable for various populations. It also supports

the OAM in this thesis by incorporating a holistic approach to the assessment and

management of lateral elbow tendinosis.

Figure 3: International Classification of Functioning, Disability, and Health (ICF) (WHO, 2007)

39

1.4 Chapter Summary

Whilst there appears to be some anecdotal evidence that merits using elastic

therapeutic tape as an addition to existing treatment modalities, broader, systematic

examination of this treatment is needed in order to clarify its effectiveness for neck and

upper extremity conditions. The Biomechanical and Occupational Adaptation Models,

as well as the ICF, may assist us to understand how the treatment may or may not be

effective. The next chapter outlines the origins of each research question and study that

are subsequently answered in each publication (Chapters 3 to 7). The aims and

methodologies for each study will also be outlined.

40

Chapter 2 – Methodology

2.1 Introduction

This thesis proposes a research program to investigate the effectiveness of

elastic therapeutic tape in managing lateral elbow tendinosis. It is anticipated that the

results of this research study will inform the development of a clinical pathway for hand

therapists for the management of lateral elbow tendinosis with the use of elastic

therapeutic tape.

This chapter will outline the five research questions that underpin the

foundations of this thesis which are subsequently addressed in the publications that

form Chapters 3 to 7. The separate methodologies used within each publication will also

be outlined and justified, including a scoping review, cross-sectional study, case series,

randomised controlled trial and a qualitative study.

2.2 Research questions

Specific research questions of the thesis are:

1. What is the current evidence relating the use of elastic therapeutic tape in

treating neck and upper extremity conditions?

41

2. What are the current perspectives amongst hand therapists, general

practitioners and hand surgeons on the use of elastic therapeutic tape and how

often is it used or recommended?

3. What is the preliminary evidence into the benefit of elastic therapeutic tape and

eccentric exercises for the treatment of lateral elbow tendinosis?

4. Is the application of elastic therapeutic tape according to the ‘Clinical

Therapeutic Applications of the Kinesio Taping Method’ manual (Kase, 2003)

(with the tape applied on tension), in conjunction with an eccentric exercise

program and activity modification advice, more effective than (i) a sham

application ( i.e. the tape applied with no stretch), or (ii) eccentric exercises

alone, in people with lateral elbow tendinosis? Are the benefits of three months

of treatment using elastic therapeutic tape sustained six-months post

intervention?

5. What are the experiences of people using elastic therapeutic tape for lateral

elbow tendinosis?

42

2.3 Materials and Methods

2.3.1 Research Question 1: What is the current evidence relating the use of

elastic therapeutic tape in treating neck and upper extremity conditions?

Aim: To synthesise the available evidence relating to the use of elastic

therapeutic tape in treating neck and upper extremity conditions.

Methodology: Scoping review.

Level of Evidence: N/A

A scoping review was used to address this research question as it includes a

broader range of studies and articles, including both empirical and non-empirical

sources of information, especially when there is a lack of randomised controlled

trials available.

Search strategy:

Relevant English, peer-reviewed documents were identified from a search of

OVID Medline, CINAHL and ProQUEST. Grey literature in ProQUEST Dissertations

and Theses were also included. The search was conducted between July and

September 2013. As this scoping review aimed to include all studies, no

limitations were placed in terms of and publication type.

43

Data Collection:

Where possible, data was extracted regarding the recommended application and

wear-time of elastic therapeutic tape in the treatment of neck and/or upper

extremity disorders. Participant outcomes examined were pain, range of motion,

strength and patient preference.

Data Analysis:

Study quality was assessed based on the McMaster Guidelines for Critical Review

of Quantitative Studies which examines research approach, methodology,

sample size, intervention, outcome measures and results. Studies were also

classified using the Oxford Level of Evidence.

2.3.2 Research Question 2: What are the current perspectives amongst Hand

Therapists, General Practitioners and Hand Surgeons on the use of elastic

therapeutic tape and how often is it used or recommended?

Aim: To gain insight into current perspectives on the use of elastic therapeutic

tape amongst health professionals (occupational therapists and

physiotherapists), general practitioners and hand surgeons.

Methodology: Cross-sectional study.

Level of Evidence: 4

44

This cross-sectional study used a self-report survey to gather data from

respondents. Information included number of years in clinical practice, number

of patients treated each week presenting with conditions such as ‘tennis elbow’,

self-rating of knowledge regarding the use and purpose of kinesiotape, perceived

level of success with tape when used, and reasons for recommending/not

recommending the tape.

Participants:

Inclusion criteria included being a qualified physiotherapist or occupational

therapist registered with the Australian Hand Therapy Association (AHTA) or a

qualified medical practitioner with experience in the treatment of upper limb

injuries.

Data Collection:

A convenience sampling approach was used to recruit participants. All 472

members of the Australian Hand Therapy Association (AHTA), 67 general

practitioners and surgeons in South-East Queensland and 24 hand therapists and

surgeons in Victoria were given the questionnaire via email, postage or in person.

Data Analysis:

Data was analysed using SPSS statistical software, version 20. Comparisons

between therapists, GPs and surgeons on continuous outcomes were made

45

using one-way ANOVA tests. Post-hoc comparisons were made using the Tukey

HSD test. Linear regression was used to examine which variables affected the

level of recommendation of the tape. Chi-square tests examined barriers to the

use of kinesiotape and were grouped into discrete categories based on

responses to five listed categories. Participants were provided with the

opportunities to use free text in this section; however, none of the participants

did so. Power calculations were not completed for this study as cluster sampling

was used (e.g. all members of the Australian Hand Therapy Association were

provided with the survey, as well as all upper limb Surgeons from South East

Queensland).

2.3.3 Research Question 3: What is the preliminary evidence into the benefit

of elastic therapeutic tape and eccentric exercises for the treatment of lateral

elbow tendinosis?

Aim: To examine outcomes of a retrospective case series of patients who used

elastic therapeutic tape and eccentric exercises for the treatment of lateral

elbow tendinosis.

Methodology: Case series.

Level of Evidence: 4.

Participants:

46

All four patients were treated by the same hand therapist and received

application of the tape for varying durations from one to three months. The tape

was applied in the same way for each patient in conjunction with an evidence-

based standard daily exercise program including heat, stretches, progressive

eccentric exercises and the use of compression as needed.

Data Collection:

Descriptive and retrospective review involving four patients who underwent

rehabilitation with the use of elastic therapeutic tape, in conjunction with

eccentric exercises and activity modification techniques, for treatment of lateral

elbow tendinosis. Outcome measures included a 10 cm Visual Analogue Scale

(VAS) to evaluate subjective pain levels and the Jamar dynamometer to measure

objective grip strength measurements.

Data Analysis:

Descriptive statistics and analyses of the outcome measures were recorded and

compared.

47

2.3.4 Research Question 4: Is the application of elastic therapeutic tape

according to the ‘Clinical Therapeutic Applications of the Kinesio Taping

Method’ manual (with the tape applied on tension), in conjunction with an

eccentric exercise program and activity modification advice, more effective

than: (i) sham taping (application with no stretch); or (ii) eccentric exercises

alone; for people with lateral elbow tendinosis?

Additionally, are the benefits of three months of treatment using elastic

therapeutic tape sustained six-months post intervention?

Aim: To assess the effectiveness of elastic therapeutic tape (in conjunction with

an eccentric exercise program and activity modification advice) in treating lateral

elbow tendinosis in adults when compared to sham taping or no taping (i.e.

reduced pain, increased strength and improved functional outcomes).

Methodology: Randomised Controlled Trial (RCT).

Level of Evidence: 1B.

This was a randomised controlled trial of 40 participants with lateral elbow

tendinosis who received (i) elastic therapeutic tape, (ii) sham tape, and (iii) no

tape, over a 12-week period (four weekly and 4 fortnightly sessions) with a 6

month follow up. All participants received eccentric exercises and advice on

activity modification techniques.

48

Participants:

Participants with lateral elbow tendinosis, aged between 18 and 80 years, were

recruited through three private hand therapy practices. Selection criteria was

based on medical investigations confirming lateral elbow tendinosis (e.g. MRI),

or provocative tests completed by the treating therapist. Participants were

excluded if they had co-morbidities, any contraindications to the use of taping,

inability to understand written material in English and inability to give informed

consent.

Data Collection:

40 participants were randomly allocated to receive three different approaches

for the management of lateral elbow tendinosis. Participants in all three groups

received the same evidence-based exercise program and advice on activity

modification techniques, including ergonomic modifications and how to avoid

aggravating tasks. Exercises and the application of tape (for the three participant

groups) were reviewed at each session to further enhance adherence to therapy.

Primary outcomes were pain and level of disability as measured by the Patient

Rated Tennis Elbow Evaluation (PRTEE) and pain-free grip strength assessments

using the Jamar dynamometer. Secondary outcome measures were overall

health status as measured by the Short Form 36 (SF-36), the Occupational Self-

49

Assessment (OSA v 2.2). All of these are standardised outcomes measures. In

particular, the PRTEE was specifically chosen for this study due to its high validity,

reliability, reproducibility and sensitivity to change amongst a ‘tennis elbow’

population. Other outcome measures, such as the Disability of the Arm, Shoulder

and Hand (DASH) and the Upper Extremity Functional Index (UEFI), have been

used in clinical practice to measure elbow conditions; however, these measures

are general in nature and have been found to not accurately assess the specific

symptoms and functions of an individual joint. Therefore, the PRTEE was the

most appropriate choice as a primary outcome measure.

Data Analysis:

Data analysis was conducted by the un-blinded primary researcher and

independently checked by a statistician who was blinded to group allocation. All

data was coded for analysis. Differences in primary and secondary outcomes

between groups were compared using intention-to-treat analysis. Baseline

participant characteristics in the three groups were compared using one-way

ANOVA for continuous variables (age) and chi-square tests for categorical

variables (gender, work status). Outcomes were compared over the follow-up

period with one-way ANOVA for all variables; however, linear mixed model

analysis was also used for primary outcome variables (PRTEE and grip strength)

50

due to missing data amongst these measures. The Statistical Package for Social

Sciences (SPSS version 20) was used for all analyses (SPSS, 2011).

2.3.5 Research Question 5: What are the experiences of people using elastic

therapeutic tape for lateral elbow tendinosis?

Aim: To investigate people’s experience with using elastic therapeutic tape,

adherence with treatment, and the perceived impact of using the tape on their

recovery, function and return to pre-injury roles.

Methodology: Qualitative Study.

Thematic analysis was the methodological framework used to categorise data

into patterns and develop themes in order to find meaning.

Level of Evidence: N/A.

Participants:

Qualitative interviews were undertaken with 11 participants from the

intervention group of the randomised controlled trial at six-months post

randomisation.

Data Collection:

The qualitative interviews were semi-structured and conducted face-to-face to

encourage participants to freely express their own views and experiences,

51

specifically in relation to using the tape. Guiding questions were drafted by the

primary researcher and piloted amongst three other therapists to review the

appropriateness of questions. Following minor grammatical changes, the

interviews were implemented in person and prompts were used when required.

All interviews were recorded using a digital voice recorder and transcribed for

analysis by the first author. The following specific areas of interest were

explored:

1. Perceptions of impact on overall function over the six months after the

commencement of the taping intervention.

2. Patient experiences during everyday activities.

3. Experiences of using elastic therapeutic tape as a treatment modality.

Data Analysis:

Transcripts of the interviews were analysed using a three-step process. First level

coding described and categorised responses; second level coding identified

patterns or groups in the first level codes; third level coding involved interpreting

these to find meanings behind the perceptions expressed by the participants.

Contextual information from field notes was also used (e.g. body language to

clarify the meaning of some texts) and a reflective diary was kept after each

interview. Transcripts and codes were then checked with two of the interviewees

52

to ensure that the interpretation of the findings accurately represented

participants’ perceptions regarding their experience.

2.6 Chapter Summary

This chapter has outlined the five research questions that form the foundation of this

thesis, in addition to the selection of various methodologies to address these questions.

The following chapters will address the specific details of each individual study, starting

with the next chapter which is a scoping review of the evidence into the use of elastic

therapeutic tape for neck and upper extremity conditions.

53

Chapter 3 - A scoping review of the use of elastic

therapeutic tape for neck and upper extremity conditions

3.1 Introduction

Chapter Three contains both an extract from the manuscript of Study 1, as well

as the full article, which is published in ‘Journal of Hand Therapy’. This is the first of five

publication chapters and presents a scoping review on the current evidence for the use,

implementation and effectiveness of elastic therapeutic tape for neck and upper

extremity conditions in clinical practice.

3.2 Chapter Contents

Taylor, R.L., O’Brien, L. & Brown, T. (2014). A scoping review of the use of elastic

therapeutic tape for neck or upper extremity conditions. Journal of Hand Therapy, 27,

235-246.

Date submitted: 3rd December 2013

Date of resubmission: 20th February 2014

Date of acceptance: 10th March 2014

Date of publication in hard copy: July 2014

65

3.3 Impact of the study

Journal Metrics:

Source Normalized Impact per Paper (SNIP) - 0.762

Impact per Publication (IPP) – 1.331

SCImago Journal Rank (SJR) – 0.547

Despite its popularity and widespread clinical use, this study revealed that there

is relatively little evidence to support the effectiveness of elastic therapeutic tape for

specific neck and upper extremity conditions. These findings provide useful information

for therapists using this intervention, especially in relation to the use of evidence-based

practices. At present, therapists who incorporate elastic taping in their clinical practice

are required to construct a treatment plan using the manufacturer’s information, their

own experience, and previous clinical observations. This exposes them to the risks

associated with prescribing a treatment modality that has uncertain clinical benefits,

cost-effectiveness, and/or safety. It is important for therapists to be aware of these

considerations.

66

3.4 Chapter Summary

The study presented in this chapter specifically examined 14 documents relating

to the use of elastic therapeutic tape for neck and upper extremity disorders from

searches in OVID Medline, CINAHL, ProQUEST and ProQUEST Dissertations. The key

findings of this study were:

To date, evidence regarding the effectiveness of elastic therapeutic tape has

relied predominantly on case reports, small pilot studies and research on healthy

participant groups.

There appears to be some anecdotal evidence that merits using elastic

therapeutic tape as an addition to existing treatment modalities, but broader,

systematic examination of this treatment is needed in order to clarify its

effectiveness for neck and upper extremity conditions.

It must be acknowledged that, due to the small sample size of the seven RCT’s

included in this scoping review, the lack of significant findings may represent a

Type II error. These studies may have concluded that there was no difference

between treatment groups when, in fact, there may have been a difference but

the study was not adequately powered.

No side effects or adverse events were documented in any of the studies.

67

Overall, this is a topic with limited high quality published research. Ideally, future

studies would be multi-centred, include an adequate sample size/population,

follow-up participants for at least 6 months or longer, and consider the cost-

effectiveness of elastic therapeutic tape compared to other existing

interventions for neck and upper extremity disorders.

69

Chapter 4 - A comparison of hand therapists’, general

practitioners’ and surgeons’ perspectives on the use of

elastic therapeutic tape

4.1 Introduction

This chapter specifically explores the experiences and opinions of

physiotherapists, occupational therapists, general practitioners and hand surgeons on

the use of elastic therapeutic tape for upper extremity disorders in clinical practice.

This cross-sectional study used a self-report survey to gather data from

respondents. Information included number of years in clinical practice, number of

patients treated each week presenting with conditions such as ‘tennis elbow’, self-rating

of knowledge regarding the use and purpose of elastic therapeutic tape, level of success

with tape when used, and reasons for recommending/not recommending the tape. The

full article is included in this chapter and is published in ‘International Journal of Therapy

and Rehabilitation’.

70


Taylor, R.L., Brown, T. & O’Brien, L. (2015). Knowledge of and willingness to recommend

kinesiotape for upper limb overuse injuries: A comparison of therapists’, general

practitioners’ and surgeons’ perspectives. International Journal of Therapy and

Rehabilitation, 22(5), 238-245.

Date submitted: 13th January 2014

Date of resubmission: 6th February 2015

Date of acceptance: 17th February 2015

Date of publication in hard copy: May 2015

78

4.3 Impact of the Study

Journal Metrics:

Source Normalized Impact per Paper (SNIP) – 0.27

Impact per Publication (IPP) – 0.337

SCImago Journal Rank (SJR) – 0.173

Results of this study supported the findings from the scoping review in Study 1. It is clear

from this survey that the use of elastic therapeutic tape is common amongst therapists

in clinical practice, even though it is not supported by evidence gained from high quality

randomised controlled trials.

4.4 Chapter Summary

This study has shown that hand therapists, GPs and Surgeons have differing

perceptions on the use of elastic therapeutic tape. Although overall perceptions of the

tape’s purpose, usefulness and effectiveness amongst the three groups were only low

to moderate, therapists are more likely to report higher understanding levels and

subsequent higher levels of recommendation and success with its use compared to GPs

and surgeons. GPs and surgeons were less likely to recommend the use of elastic

79

therapeutic tape due to limited understanding of its potential use and/or doubts

regarding its effectiveness in clinical practice.

This survey is consistent with existing literature that states there is a need for

more evidence into the use of elastic therapeutic tape and long-term follow-up into its

reported benefits.

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Chapter 5 - The use of elastic therapeutic tape and

eccentric exercises for lateral elbow tendinosis: a case

series.

5.1 Introduction

Chapter 3 aimed to identify the current evidence on the use of elastic therapeutic

tape and revealed that there was limited high quality evidence available. This was built

on in Chapter 4 in which results showed that therapists were more likely to use and

recommend elastic therapeutic tape (compared to GP’s and Surgeons) despite limited

evidence into its use.

This chapter comprises of Study 3 which arose based on the author’s clinical

experience with using elastic therapeutic tape for lateral elbow tendinosis. The objective

of this study was to retrospectively examine four patients who underwent rehabilitation

with the use of elastic therapeutic tape, in conjunction with eccentric exercises and

activity modification techniques, for treatment of lateral elbow tendinosis. The full

article is included in this chapter and is published in ‘Hand Therapy’.

82


Wegener, R.L., Brown, T. & O’Brien, L. (2015). The use of elastic therapeutic tape and

eccentric exercises for lateral elbow tendinosis: a case series. Hand Therapy, 20(2), 56-

63.

Date submitted: 1st January 2015

Date of resubmission: 8th March 2015

Date of acceptance: 13th March 2015

Date of publication in hard copy: April 2015

91


Journal Metrics:


Impact per Publication (IPP) - 0.133

SCImago Journal Rank (SJR) - 0.114

This retrospective case series suggests preliminary benefit for the use of elastic

therapeutic tape and eccentric exercises in treating patients with lateral elbow

tendinosis. However, conclusions by health professionals cannot be drawn from this

study on the effectiveness of elastic therapeutic tape alone, or in combination with

activity modification and exercise without more rigorous examination.

For this reason, it is important to proceed to a randomized controlled trial as

these results cannot confidently conclude results were gained from the tape, as

opposed to patients who may experience ‘natural recovery’ of this condition.

Additionally, as elastic therapeutic tape is reported to have benefit through the

tape’s elastic properties, including a control group involving sham tape will provide

important findings. Although this group will receive an un-blinded ‘placebo

intervention’, these participants will not know they are receiving a treatment that is

not the targeted clinical intervention being examined for its clinical effectiveness.

The role of a possible placebo effect from the tape warrants further investigation.

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5.4 Chapter Summary

This study provided the potential for preliminary support of elastic therapeutic

tape for lateral elbow tendinosis, in combination with eccentric exercise and activity

modification techniques. Participants in this study reported decreased pain levels, no

adverse effects, tolerated the wearing regime well and reported ease of application. A

rigorous randomised controlled trial with assessor blinding is required, with adequate

follow-up to determine longer term functional outcomes of this treatment modality.

94

Chapter 6 – A randomised controlled trial of comparative

effectiveness of elastic therapeutic tape, sham tape or

eccentric exercises alone for lateral elbow tendinosis

6.1 Introduction

The previous chapters have discussed the use of elastic therapeutic tape and

shown that, whilst there is a lack of evidence for its use, there is possibly some

preliminary support for its use for upper limb conditions. This chapter includes Study 4,

a randomised controlled trial, which arose based on the recommendation of Study 3

whereby more high quality evidence into elastic therapeutic tape was required. In

particular, it was also important for the role of the tape’s application (to create skin

convolutions when applied to stretched muscle) to be examined as it has been

hypothesised that this property can reduce pressure in the mechanoreceptors below

the dermis, thereby decreasing nociceptive stimuli. As mentioned throughout this

thesis, there remains conjecture in the literature regarding how and why tape may work,

but concluding that a “perceive benefit” cannot be discounted. This is an important

research question within this study because the theory that skin convolutions are the

mechanism for the tape’s effectiveness (especially in relation to upper limb conditions)

has never been tested in a high-quality randomised controlled trial.

95

Study 4 consisted of a randomised controlled trial of 40 participants with lateral

elbow tendinosis who received (i) elastic therapeutic tape, (ii) sham tape, and (iii) no

tape, over a 12-week period (four weekly and 4 fortnightly sessions) with a 6 month

follow up. All participants received eccentric exercises and advice on activity

modification techniques.

Intervention group: Participants received the application of tape based on the

recommended application techniques by Dr Kenzo Kase in ‘Clinical Therapeutic

Applications of the Kinesio Taping Method’ (refer to Appendix D). Participants were

educated on all precautions (such as how to monitor for reactions to the tape) and were

shown how to remove the tape safely.

Comparison group (Sham taping): Participants in this group were taped the same way

as the intervention group; however, the tape was applied with no tension. Participants

were not aware they were receiving sham treatment as they were instructed on how to

apply the tape without tension and were not told of the alternative method (tape

applied with stretch).

Control group: Participants in this group received no taping.

Participants in all three groups received the same structured exercise program

which was established from existing literature on the benefits of eccentric exercises for

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lateral elbow tendinosis (refer to Appendix E). Advice on activity modification

techniques were also provided, including ergonomic modifications and how to avoid

aggravating tasks. Exercises and the application of tape (for the intervention and control

groups) were reviewed at each session to further enhance adherence to therapy. The

full article is included in this chapter and is published in ‘Hand Therapy’.


Wegener, R.L., Brown, T. & O’Brien, L. (2016). A randomized controlled trial of

comparative effectiveness of elastic therapeutic tape, sham tape or eccentric exercises

alone for lateral elbow tendinosis. Hand Therapy, 1758998316656660.

Date submitted: 27th March 2016

Date of resubmission: 2nd June 2016

Date of acceptance: 3rd June 2015

Date of publication online: 11th July 2016

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Journal Metrics:




The objective of this study was to provide more rigorous information for Hand

therapists when using elastic therapeutic tape for lateral elbow tendinosis. Lateral

elbow tendinosis is well known to cause difficult challenges due to its long-term recovery

and morbidity. Elastic therapeutic tape is commonly used as a treatment modality for

this condition, despite limited evidence.

At three and six-months post randomisation, improvements were made in all

three groups as assessed with the Patient-Rated Tennis Elbow Evaluation (PRTEE), the

Short Form 36 (SF-36) pain-free grip strength, and the Occupational Self-Assessment

(OSA). However, there were no statistically significant differences between groups in

any of these measures.

Whilst all groups improved on key outcomes, it is possible that exercise alone

and/or natural recovery were responsible for improvements. For future research, a

study that involves another control group who do not receive any form of direct

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intervention may be needed so as to be able to more definitively differentiate

spontaneous healing from response to specific interventions. Despite the intent of the

sham application to be non-therapeutic, the findings of similar improvements in both

taping groups indicates that how the tape was applied had minimal impact. Therefore,

the physiological mechanisms by which elastic therapeutic tape is presumed to work on

this population remains hypothetical and open to speculation. It is positive to note that

the use of elastic therapeutic tape was well tolerated by participants and not associated

with any significant side effects or symptom exacerbation.

6.4 Chapter Summary

This study provided more clarity on the use of elastic therapeutic tape for lateral

elbow tendinosis and, whilst Study 3 showed preliminary support for its use, findings

from this RCT demonstrated that differences were not statistically significant from those

achieved by sham taping or exercises alone.

Given these findings, therapists should continue to be guided by evidence-based

practice when working with this patient population. Based on the literature, eccentric

exercises and activity modification techniques continue to be more appropriate,

evidence-based, and cost-effective in the clinical management of lateral elbow

tendinosis.

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Chapter 7 - A qualitative review of patients’ experiences

using Kinesio tape for lateral epicondylitis

7.1 Introduction

This chapter comprises the final study of this PhD thesis. While many other

interventions for lateral elbow tendinosis are widely used and have been researched,

limited research has been conducted on specific patient experiences with this often

long-term condition which often leads to reduced function in daily life. This qualitative

study aimed to describe the lived experiences of 11 participants from the intervention

group of the RCT in Study 4 (three participants were lost to follow up). This included

their perspectives on the use of a passive intervention, elastic therapeutic tape, for the

treatment of lateral elbow tendinosis compared to self-management strategies alone

over a six-month period. The full article of Study 5 is included in this chapter in its revised

submitted version to the ‘British Journal of Occupational Therapy’.


Wegener, R.L., Brown, T. & O’Brien, L. (2016). A qualitative review of patients’

experiences using Kinesio tape for lateral epicondylitis. Submitted to British Journal of

Occupational Therapy and currently under second review.

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Date submitted: 12th July 2016

Date of re-submission with revisions: 17th September 2016

Date of acceptance: To be confirmed.

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Journal Metrics:




The findings of this study further support existing literature, as well as the results of

Study 4, which identified activity modification and exercises as important components

in the recovery of lateral elbow tendinosis. There is limited research into patients’

experiences with lateral elbow tendinosis and, for this reason, this study adds valuable

information for therapists. It was found that patients’ recovery from lateral epicondylitis

took longer than they expected and that it was a frustrating time involving multiple

impacts and adjustments to their usual work and daily activities. Changes in life roles

during this period led to concerns about future recovery and long-term function.

The limitations of this study that must be acknowledged are: (i) all participant groups

were not interviewed thus restricting the ability to gather broader data regarding

participant experiences of living with and managing the condition; and (ii) the interviews

could have been piloted amongst a patient population (instead of therapists alone) in

order to identify areas of greater conceptual complexity. By reflecting on the research

133

relationship (reflexivity) after this qualitative study, it must be acknowledged that there

was potential for pre-conceptions as the primary researcher knew all of the participants

prior to the interviews. For instance, my perceptions regarding how adherent patients

were with prescribed treatment may have influenced what was emphasised,

explored and, therefore, reported in the findings. My preconceptions may have also

influenced how questions were asked (e.g. such as tone of voice, sympathetic body

language and facial expressions) and subsequently what responses were given. These

two factors may have impacted on the findings of this study. If these interviews were to

be conducted again, it would be beneficial to have another therapist observe the

interviews as they are taking place, thereby providing another perspective on the

interview findings. Discussion with this colleague after the interview may have

revealed angles that I may have overlooked or dismissed without taking the time to

consider them thoroughly. It would also have encouraged critical reflection on the

interview and may have changed how subsequent interviews were

conducted. Additionally, keeping a detailed diary of my own emotions, thoughts and

impressions before and after interviews would also have been useful practice. It is

possible that other issues in my own home and work life were impacting how

interviews were conducted, and may have introduced unconscious bias.

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Overall, it was identified that these long-term changes implemented by the person

themselves were the most important for improvements in function. By considering the

person’s perception of lateral elbow tendinosis, including their function and

occupational adaptations, therapists improve their understanding of the complexities of

this condition and consider avoiding the trial of multiple passive interventions that may

actually have little additional benefit compared to existing evidence-based

interventions.

7.4 Chapter Summary

The objective of this qualitative study was to gather interview data to identify

people’s experiences with lateral elbow tendinosis, as well as their perception on using

elastic therapeutic tape as an intervention for this complex and often chronic condition.

Emergent themes included:

1. Frustration at the length of time needed for functional recovery and the impact

on life roles.

2. The importance of long-term self-management for lateral epicondylitis.

3. Kinesio tape was an adjunct in recovery compared to self-management

strategies.

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In particular, these themes fit within the Occupational Adaptation Model which

proposes that increased function does not automatically equate to occupational

adaptation. As is shown in this study, people with this condition will often make

physical/functional improvements over time; however, this does not necessarily result

in occupational adaptation and this should be considered by therapists.

This study concluded that, although this condition has been widely researched, many

focus on quantitative results as opposed to qualitative findings. Specific findings found

that ongoing adjustments to work and daily activities, as well as adherence to prescribed

exercises, were the largest contributor to improvements in function.

The next chapter collaborates all the findings from the previous five chapters and

discusses these in depth, based on existing research and within the context of the

conceptual frameworks and models that underpin this thesis.

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Chapter 8 – Discussion and Conclusion

8.1 Chapter Overview

The purpose of this chapter is to present the overall findings from research

projects that addressed the original thesis research questions. The use of elastic

therapeutic tape as an intervention approach for lateral elbow tendinosis is discussed,

including the current body of evidence, limitations of the thesis, recommendations for

future research, and future implications for practice.

8.2 Revisiting the Research Questions

The five studies presented in this ‘Thesis by Publication’ are the first to

comprehensively investigate the effectiveness as well as clinician and patient

perceptions of elastic therapeutic tape as a treatment for lateral elbow tendinosis. A

summary of the research questions and related study findings are outlined below in

Table 2.

As discussed throughout this thesis, lateral elbow tendinosis is known to result

in considerable morbidity, long-term recovery and high financial costs (Gruchow &

Pelletier, 1979). With a prevalence in the general population of 1-5%, it is a common

138

condition treated in Hand Therapy settings and often presents challenges for achieving

successful rehabilitation (Fedorczyk, 2006b, 2012).

To date, many interventions with varying levels of effectiveness for lateral elbow

tendinosis have been researched. More recently, elastic therapeutic tape has been

increasingly used in clinical practice despite limited evidence being reported regarding

its effectiveness (Bassett, 2010; Bisset & Vicenzino, 2015; Parreira, Costa, Hespanhol

Junior, Lopes, & Costa, 2014). Currently, there is still no gold standard for tape

application and its recommended use varies between different manufacturing brands

(Parreira, Costa, Hespanhol Junior, Lopes, & Costa, 2014). Therapists are required to use

this modality based on the information and recommendations provided by

manufacturers, combined with their own clinical reasoning and previous experience.

This carries risks associated with prescribing an intervention without proven clinical

benefit, safety or cost effectiveness. For this reason, the development of this research

project and its findings aim to inform the practice of hand therapists when using this

treatment modality for lateral elbow tendinosis.

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Table 2: Summary of research questions and study findings

Research Questions Content Findings

1. Scoping Review What is the current evidence relating the use of elastic therapeutic tape in treating neck and upper extremity conditions? Taylor, R.L., O’Brien, L. & Brown, T. (2014). A scoping review of the use of elastic therapeutic tape for neck or upper extremity conditions. Journal of Hand Therapy, 27(3), 235-246.

A scoping review was completed to review the current evidence of elastic therapeutic tape for the treatment of neck and upper extremity conditions.

Whilst elastic therapeutic tape is reported to be widely used in clinical practice, there is limited evidence into its use for neck or upper extremity disorders and future studies are warranted. Elastic therapeutic tape may play a role in reducing short-term neck and upper extremity pain and it may be a more convenient and comfortable alternative to existing conservative treatments.

2. Cross-sectional Study

What are the current perspectives amongst

hand therapists, general practitioners and hand

surgeons on the use of elastic therapeutic tape

and how often is it used or recommended?

This cross-sectional study used a self-report

survey to gather data from 157 respondents

on the use of elastic therapeutic tape in

clinical practice (Occupational Therapists and

Physiotherapists who practice as hand

therapists, general practitioners and hand

surgeons).

Therapists, general practitioners and surgeons have differing

perceptions on elastic therapeutic tape. Therapists were

more likely to recommend its use based on clinical

experience, whereas GP’s and surgeons were more sceptical

regarding its use and effectiveness due to limited evidence.

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Taylor, R.L., Brown, T. & O’Brien, L. (2015).

Knowledge of and willingness to recommend

kinesiotape for upper limb overuse injuries: A

comparison of therapists’, general

practitioners’ and surgeons’ perspectives.

International Journal of Therapy and


3. Case Series What is the preliminary evidence into the benefit of elastic therapeutic tape and eccentric exercises for the treatment of lateral elbow tendinosis? Wegener, R.L., Brown, T. & O’Brien, L. (2015). The use of elastic therapeutic tape and eccentric exercises for lateral elbow tendinosis: a case series. Hand Therapy, 20(2), 56-63.

This study was developed based on the author’s clinical observations and involved a retrospective case series of four patients with lateral elbow tendinosis who were treated with elastic therapeutic tape.

This case series demonstrated some preliminary support for the use of elastic therapeutic tape and eccentric exercises in the management of lateral elbow tendinosis. This study identified the need for a randomised control trial and qualitative study in order to rigorously examine this concept.

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4. Randomised Controlled Trial Is the application of elastic therapeutic tape according to the ‘Clinical Therapeutic Applications of the Kinesio Taping Method’ manual (with the tape applied on tension), in conjunction with an eccentric exercise program and activity modification advice, more effective than (i) sham taping, or (ii) eccentric exercises alone in patients with lateral elbow tendinosis? Are the benefits of three months of treatment using elastic therapeutic tape sustained six-months post intervention? Wegener, R.L., Brown, T. & O’Brien, L. (2016). A randomized controlled trial of comparative effectiveness of elastic therapeutic tape, sham tape or eccentric exercises alone for lateral elbow tendinosis. Hand Therapy 1758998316656660, first published on July 11, 2016 doi:10.1177/1758998316656660.

This was a randomised controlled trial of 40 participants with lateral elbow tendinosis who received (i) elastic therapeutic tape, (ii) sham tape, and (iii) no tape, over a 12-week period with a 6 month follow up. All participants received eccentric exercises and advice on activity modification techniques.

Whilst 95% of participants improved over six months, there were no statistically significant differences between the intervention, sham, and control groups in measures of pain and function. It is important to note that there were also no significant adverse effects with this treatment modality.

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5. Qualitative Study What are the experiences of people using elastic therapeutic tape as a treatment for lateral elbow tendinosis? Wegener, R.L., Brown, T. & O’Brien, L. (2016). A qualitative review of patients’ experiences using Kinesio tape for lateral epicondylitis. (Submitted to British Journal of Occupational Therapy)

Thematic analysis was used to describe the experiences of participants who used elastic therapeutic tape, their adherence with treatment, and their perceptions of the impact of using the tape on their recovery, function and return to pre-injury roles.

Findings from this study showed that, regardless of treatment, people with lateral elbow tendinosis experienced frustrations associated with long-term recovery. The key finding was that continual long-term adjustments to work and daily activities, as well as adherence to prescribed exercises, were the largest contributor to improvements in function as opposed to using elastic therapeutic tape. These findings highlight the importance of exploring people’s health experiences, encouraging a self-management approach to chronic musculoskeletal conditions, and avoiding the trial of multiple passive interventions that may have no additional benefit.

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8.3 Discussion of Study Findings

The findings of this thesis contribute to the body of evidence about the clinical use

and effectiveness of elastic therapeutic tape. New trials on the use of elastic therapeutic

tape for a variety of conditions are frequently being published (Parreira, Costa,

Hespanhol Junior, Lopes, & Costa, 2014). However, the quality of these studies

continues to vary. In particular, there are still minimal high quality studies about the use

of elastic therapeutic tape for upper limb conditions (Taylor, O'Brien, & Brown, 2014).

To date, there are six published systematic reviews that evaluate the effectiveness

of elastic therapeutic tape for different conditions. Williams et al. (2012) assessed

Kinesio Taping in the prevention and treatment of sports injuries. Bassett et al. (2010)

and Mostafavifar et al. (2012) considered Kinesio Taping in people with musculoskeletal

conditions. Morris et al. and Kalron and Bar-Sela (2013) examined musculoskeletal

conditions but extended their review to include other clinical areas, such as neurological

and lymphatic conditions. Most recently, a systematic review was completed by Parreira

et al. (2014) that assessed musculoskeletal conditions, but included more recent trials

(12 RCT’s in total).

The conclusions from these published systematic reviews are very similar. Overall,

the use of elastic therapeutic tape for musculoskeletal conditions has shown no

significant benefit, or the effects have been too small to be considered clinically

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significant. All systematic reviews included trials comparing taping with a large range of

other modalities (including no treatment, sham taping, exercises, physiotherapy,

electrotherapy) and included outcome measures of pain, disability and quality of life.

Studies that have reported significant benefits from elastic therapeutic tape are mainly

trials conducted on healthy population groups or of low quality (and therefore high risk

of bias), and those with study designs of low methodological quality, such as case reports

(Taylor, O'Brien, & Brown, 2014).

The results from the five studies within this thesis are consistent with the current

evidence obtained from the existing systematic reviews described above. The scoping

review confirmed the lack of evidence into elastic therapeutic tape for neck and upper

limb conditions. The cross-sectional study found differing levels of knowledge of the

tape’s use amongst Surgeons, General Practitioners and Therapists; however, Therapists

were more likely to use a treatment modality without proven clinical effectiveness. The

case series demonstrated some preliminary support for elastic therapeutic tape for

lateral elbow tendinosis; however, this study had limitations and provided only weak

anecdotal level evidence, consistent with other small non-controlled studies that have

been published on elastic therapeutic tape (Mostafavifar, Wertz, & Borchers, 2012;

Parreira, Costa, Hespanhol Junior, Lopes, & Costa, 2014).

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The subsequent randomised controlled trial of 40 participants with lateral elbow

tendinosis who received either (i) elastic therapeutic tape, (ii) sham taping, or (iii) no

taping, provided stronger findings. Whilst 95% of participants improved over six months,

there were no statistically significant differences between the three sample groups in

measures of pain and function. However, it is important to note that there were no

significant adverse effects to participants with this treatment modality either. This

particular finding supports studies in other populations that found most patients were

satisfied with the comfort and convenience of this treatment and experienced no ill

effects, despite minimal evidence of other benefits (Ristow et al., 2013; Tsai, Hung, Yang,

Huang, & Tsauo, 2009).

The fifth and final study of this thesis involved a qualitative analysis of the

experiences of 11 participants from the intervention group of the RCT (three participants

lost to follow up). Although lateral elbow tendinosis has been widely studied with a focus

on managing physical symptoms (Bassett, 2010), limited research has been conducted

on specific patient experiences with this often long-term condition. Importantly, the

findings from this study indicated that, regardless of the treatment provided, having

lateral elbow tendinosis resulted in frustrations associated with long-term recovery.

Continual long-term adjustments to work and daily activities, as well as adherence

to prescribed exercises, were reported as the largest contributor to improvements in

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function as opposed to using elastic therapeutic tape. This is an important finding and

possibly the most relevant for therapists in clinical practice when working with this

patient population. From the available evidence, it would seem apparent that both

exercise and ergonomic adjustments are the key aspects of successful management of

lateral elbow tendinosis and a vital component of long-term self-management (Buckle

& Devereux, 2002).

This is consistent with the evidence for other conditions associated with chronic

musculoskeletal pain leading to reduced function in daily life (Lillefjell, Krokstad, &

Espnes, 2007). Individual and psychosocial factors (such as self-efficacy, adaptation,

perceived emotional and physical functioning, pain intensity and pain cognition) are

considered to be among the most important variables that influence the total health

picture (Henderson, Kidd, Pearson, & White, 2005). As therapists, it is important to

recognise that the impacts on a person’s everyday life are dependant not only on the

underlying pathophysiology, but to a larger extent on that person’s perception of the

condition in their present life situation (Henderson, Kidd, Pearson, & White, 2005;

Lillefjell, Krokstad, & Espnes, 2006).

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8.4 Implications for Clinical Practice

A reasoned argument has been presented throughout this thesis regarding the

need for a number of adjustments in the clinical practice of health professionals who

use elastic therapeutic tape and work with people experiencing lateral elbow tendinosis.

This research enquiry has culminated in three key findings.

For lateral elbow tendinosis, there is currently limited support for long-term

effectiveness of elastic therapeutic tape as a treatment modality.

The results of the Randomised Controlled Trial (RCT) showed limited support for

using elastic therapeutic tape for lateral elbow tendinosis. This is an interesting

finding and potentially adds to existing literature showing minimal evidence for

passive interventions amongst this population. While there were no significant side

effects with the use of the tape, the costs of purchasing the tape and training staff

in its correct application need to be considered. Given these findings, it is likely that

eccentric exercises and activity modification techniques are more appropriate,

evidence-based, and cost-effective interventions in the clinical management of

lateral elbow tendinosis.

These results are further supported by recent studies that continue to

recommend that conservative management for lateral elbow tendinosis remains the

148

best practice and passive interventions should be considered carefully (Bisset &

Vicenzino, 2015).

Furthermore, this study highlights the complexity of managing this condition and

the role of other factors in the aetiology of pain for lateral elbow tendinosis, such as

changes in central pain processing (Heales, Lim, Hodges, & Vicenzino, 2014; Khan,

Cook, Kannus, Maffulli, & Bonar, 2002; Khan, Cook, Maffulli, & Kannus, 2000a).

Although this delves into issues beyond the scope of this PhD, it is important to

consider these other dimensions when managing this condition.

Overall, based on the study findings of this thesis, in combination with the

current body of evidence in the literature, it can be inferred that the ongoing

widespread clinical use of elastic therapeutic tape is due to its high-profile popularity

and associated marketing (such as its use during the Olympics), as opposed to

clinicians relying on high quality scientific evidence with clinically relevant outcomes.

This was supported by findings in Study 2 which demonstrated that therapists were

likely to continue using a treatment modality, such as elastic therapeutic tape, based

on clinical experiences despite a lack of supporting evidence. Therefore, a future

recommendation is that health professionals should carefully evaluate evidence

regarding the tape’s effectiveness when using this intervention. This disparity

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between emerging evidence and therapists changing their clinical practice is an

important area in need of further examination.

Due to the complexity and chronic nature of lateral elbow tendinosis, it is important

to recognise clients’ health experiences and the need for long-term occupational

adjustments.

Qualitative findings from this thesis demonstrated that the nature of lateral

elbow tendinosis’ slow recovery results in considerable patient frustration. This is an

area that has not been comprehensively examined amongst this patient population

given that research to date has focused on managing physical symptoms within a

biomechanical model (e.g. using interventions, such as elastic therapeutic tape)

(Marcum, 2004). Whilst these factors are still important, it is vital for all health

professionals to work towards optimising health, well-being and participation, as

opposed to only focusing on physical dysfunction. For this reason, the use of the

International Classification of Functioning, Disability and Health (ICF) framework in

this study complements the Biomechanical Model and acknowledges the multiple

components required for successful rehabilitation (WHO, 2001).

Functioning is central to the patient experience in musculoskeletal conditions.

The WHO identifies four health outcomes within this framework, including

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impairments (body structure and function), activity limitations, restrictions in social

participation and environmental factors (Steiner et al., 2002; WHO, 2001). Being able

to assess the effectiveness of an intervention within each of these domains provides

a means to more accurately assess its benefit and impact. For example, in the case

of lateral elbow tendinosis, an MRI may show improvements in tendon recovery

(impairment); however, the patient may not have regained full function at work

(activity limitation) and remain unable to engage with family and friends (social

participation and environment). Measurements of “outcome” for this patient would

be falsely positive if only the impairment was considered. Due to the often long-term

nature of lateral elbow tendinosis, this is a common situation for this patient

population.

The use of the Short-Form 36 (SF-36) and the Occupational Self-Assessment

(OSA) were chosen as outcome measures within this thesis as they were able to

closely evaluate aspects of these domains within the ICF. Whilst there has been

literature on linking health-status measures to the ICF (including the SF-36) (Brockow

et al., 2004), this is an area that will continue to be developed in the future (Cieza et

al., 2002a; Velstra, Ballert, & Cieza, 2011).

Through the perspective of the Occupational Adaptation Model, Schkade and

Schultz (1992) outlined that increased function does not automatically equate to

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occupational adaptation. This is a common mistake when working with patients with

conditions such as lateral elbow tendinosis. As previously mentioned, people with

this condition will often make functional improvements over time (e.g. less pain,

improved movement/strength and increased use in everyday activities) however,

this does not necessarily result in adaptation (Lillefjell, Krokstad, & Espnes, 2006,

2007). Therapists should consider these factors early in treatment and recognise

their role in facilitating the internal adaptation process to maintain or re-engage in

meaningful occupations. By incorporating evidence-based practice, there are actions

that can be undertaken in the clinical setting, such as provision of earlier and more

specific education on long-term occupational adjustments and the implementation

of strategies/treatment plans that are occupation-focused (Cullinane, Boocock, &

Trevelyan, 2014; Rothmore et al., 2016).

Changes in terminology from ‘lateral epicondylitis’ to ‘lateral elbow tendinosis’ or

‘lateral elbow tendinopathy’ should be implemented in clinical practice to better

guide treatment.

Extensive current research reveals that commonly used terms such as ‘lateral

epicondylitis’ and ‘tennis elbow’ are misleading as they imply an inflammatory

pathology as opposed to degeneration of the common extensor origin (Bunata,

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Brown, & Capelo, 2007; Nirschl & Pettrone, 1979). It is important for health

professionals to apply the correct diagnostic terminology to avoid misunderstanding

and inappropriate treatment. More appropriate terms for this condition are either

(i) lateral elbow tendinosis, or (ii) lateral elbow tendinopathy, and there should be a

shift towards using these terms in clinical practice (Ali & Lehman, 2009).

8.5 Limitations of this thesis

There are several limitations that have been identified throughout this thesis and

have been documented in more detail in the five individual studies within Chapters 3 to

7.

Overall, a summary of the main limitations includes –

Due to the limited number of randomised controlled trials into the use of

elastic therapeutic tape for neck and upper extremity disorders, a

systematic review was unable to be completed for this thesis. In order to

synthesise all available evidence into this modality, a scoping review was

completed instead.

The cross-sectional study included a small sample size that was unevenly

distributed by profession and location. Therefore, the findings may not

153

accurately represent the views of all health professionals across

Australia.

In the case series study, the lack of control group, un-blinding of patients

and therapist, as well as a lack of pre-therapy measurements, may have

led to bias in the results observed.

The cost-effectiveness of elastic therapeutic tape compared to other

existing interventions for lateral elbow tendinosis was not

comprehensively examined.

Large participant numbers were unable to be recruited in the RCT and it

was ethically not possible to include a group receiving no treatment.

There was no formal funding provided for this study thus limiting the

recruitment strategies used. We did, however, reach our a-priori

recruitment targets for 80% power to detect a clinically meaningful

difference between groups.

A geographical bias and gender imbalance must also be considered

limitations for this trial, as the majority of patients were females located

within one state; therefore, results may not be generalisable to the

broader population.

154

As it was difficult to have blinding of the assessor and therapists, this may

have increased the possibility of bias.

Another limitation of the RCT may be that the outcome measures used

(PRTEE, SF-36, OSA and grip strength) may not have been sensitive

enough to detect clinical change at three and six month follow up.

More rigorous supervision of each participant’s home exercise program

may have also been beneficial. Non-adherence to the specified treatment

regimen, incorrect exercise techniques or inconsistencies with

application of the tape may have not been reported and would most

likely have impacted on results.

8.6 Recommendations for future research

There is potential for future research into the role of elastic therapeutic tape for

a variety of other musculoskeletal conditions. Further rigorous trials into the use of

elastic therapeutic tape as an intervention strategy are needed, especially in relation to

its role for acute upper limb conditions. It is possible that the proposed mechanisms of

elastic therapeutic tape (such as reducing pressure on mechanoreceptors below the

dermis, improving circulation, decreasing oedema and correcting muscle function) may

be more aligned to the treatment of acute conditions, as opposed to chronic conditions

155

(such as lateral elbow tendinosis) that are not inflammatory in nature. This would

provide research opportunities that build on the findings of the five studies reported in

this thesis.

8.7 Chapter Summary

Elastic therapeutic tape is widely used for upper limb and neck conditions in

clinical practice despite poor evidence of its effectiveness. In particular, this thesis found

that there was limited support for its use for lateral elbow tendinosis; however, it may

be an acceptable adjunct treatment to eccentric exercise and activity modification and

is associated with minimal side effects. It must be noted that the author acknowledges

limitations with this RCT (as mentioned above) and that conclusions are based on

findings in combination with previous underpowered or low-quality published studies.

Overall, this chapter has summarised the results and limitations of the

publications that form this thesis. Implications for clinical practice and future research

have been discussed, with the findings of the five research studies indicating that certain

changes in health practice amongst this patient population are warranted and should be

considered.

156

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Appendix

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Appendix A: Published opinion piece

R.L., Brown, T. & O’Brien, L. (2015). Using and prescribing kinesiotape as a treatment

modality for musculoskeletal disorders. International Journal of Therapy and


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Appendix B: Ethics approval and Final Report

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Appendix C: Conference Participation

Current Abstract Submissions

Wegener, R.L., Brown, T. & O’Brien, L. (2017). The use of Kinesio tape for tennis elbow:

results of quantitative and qualitative studies”. Submitted for oral and poster

presentations at the Occupational Therapy Australia Association Conference, July 2017;

Perth, Australia.

Conference Presentations

Wegener, R.L., Brown, T. & O’Brien, L. (2016). Comparative effectiveness of Kinesio tape,

sham taping or eccentric exercises for tennis elbow. Oral and poster presentations at

the ACT Australian Physiotherapy Association Research Symposium, September 2016;

Canberra, Australia.

Wegener, R.L. (2016). Comparative effectiveness of Kinesio tape, sham taping or

eccentric exercises for tennis elbow. Poster presentation at CHARM (Canberra Hospital

Annual Research Meeting), August 2016; Canberra, Australia.

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Wegener, R.L., Brown, T. & O’Brien, L. (2016). Comparative effectiveness of Kinesio tape,

sham taping or eccentric exercises for tennis elbow. Oral presentation at the Australian

Hand Therapy Association Conference, August 2016; Sydney, Australia.

Wegener, R.L., Brown, T. & O’Brien, L. (2014). Kinesiotape for lateral elbow tendinosis.

Oral presentation at the Australian Hand Therapy Association Conference, August 2014;

Gold Coast, Australia. Awarded Best Poster Award.

Other Presentations

Wegener, R.L. (2016). Kinesiotape for the upper limb. Oral presentation at the ACT Hand

Therapy Special Interest Group, November 2015; Canberra, Australia.

Wegener, R.L. (2016). The use of elastic therapeutic tape for lateral elbow tendinosis.

Oral presentation at the Victorian Hand Therapy Special Interest Group, June 2015;

Melbourne, Australia.

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Appendix D: Application of Tape (Study 4)

Within the Randomised Controlled Trial (RCT) of Study 4, elastic therapeutic tape was

applied to each participant of the intervention group with the elbow extended. The first

strip of tape was applied with 25% tension (the distal 1-2 inches of tape is ‘tapered off’

and applied with no tension). The second and third strips of tape are applied as a ‘space

correction’ for the area of pain over or around the lateral epicondyle. With the elbow

slightly flexed, ‘I’ strips are used with 25-50% tension with the end of the strip tapered

off at no tension. Moderate to full tension was applied to the middle part of the tape to

further reduce tissue movement if required. Participants were shown on how to apply

the tape at the initial session and educated on how to monitor for side effects, such as

skin irritation.

Figure 4: Application of Tape Using ‘I’ Technique

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Participants in the ‘sham application’ group were taped the same way as the

intervention group; however, the tape was applied with no tension. As per the

intervention group, participants were shown how to apply the tape, monitor for side

effects, and wearing regime was identical.

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Appendix E: Eccentric Exercise Program (Study 4)

Figure 5: Eccentric Exercise Program

Eccentric strengthening exercises were completed once a day as follows:

With the elbow flexed and the wrist supported, participants undertook exercises with a

500g-1kg weight placed in the hand with the palm facing down (pronation). By

supporting the forearm on the edge of a table, the wrist is raised with the unaffected

hand (concentric contraction) and lowered slowly for 5 seconds (eccentric contraction).

Initial regimen consisted of 1-3 sets of 10-15 repetitions per day. Weights were

increased when 3 sets of 15 repetitions were completed without difficulty.

With the elbow flexed, participants held a broom in their hand at its balance point. The

broom was then rotated in a slow and controlled motion (eccentric contraction). Initial

regimen consisted of 4 sets of 8 repetitions per day. Once this exercise was completed

174

with minimal pain, the participant could move their hand 1cm along the handle (away

from the broom head) progressively each day.

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Appendix F: Outcome Measures (Study 4)

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Appendix G: Qualitative Questions (Study 5)

1. Looking back over the past 6 months, what do you think about your arm function

now?

2. For you, what did you like or not like about your experience with using the tape?

a. Were you able to apply it yourself?

b. Were there any side-effects/complications?

3. What did you think of the tape compared to other treatments you may have used in

the past?

4. Looking back over the past 6 months, how did you manage with your work duties?

a. What did you think about using the tape for work?

b. Did the tape affect the way you performed your work?

c. Did the tape change your pain/symptoms? How?

5. Looking back over the past 6 months, how did you manage with your everyday

activities?

a. Such as self-care, domestic tasks, community access, leisure/recreation

and relationships with friends/family?

b. Do you think the tape changed your pain/symptoms? How?

the use of elastic therapeutic tape for treatment of ... use of elastic therapeutic tape for...

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