6

Brief resume of the intended work:

6.1 Need for the study

The elbow complex includes the elbow joint (humeroulnar and humeroradial joints) and the

proximal and distal radioulnar joints. The elbow joint considered to be a compound joint that

functions as a modified or loose hinge joint having one degree of freedom at elbow, permitting the

motions of flexion and extension, which occur in the sagittal plane around a coronal axis.1 Elbow

stability and stabilizer structures are active and passive structures. These passive structures are

articular surfaces and attached ligaments around joints; active structures are muscles which crosses

the elbow joints i.e. flexors group of muscles from medial epicondyle and extensors group of muscles

from lateral epicondyle of humerus.2 Commonly we are seen many conditions such as Tennis Elbow

or Lateral Epicondylitis, Elbow Bursitis, Golfer’s Elbow or Medial Epicondylitis, Cubital Tunnel

Syndrome, Radial Tunnel Syndrome, distal biceps rupture, olecranon fracture, Monteggia fracture,

elbow dislocation.

Tennis elbow, or Lateral Epicondylitis, describes soreness or pain around the bony prominence

(epicondyle) on the outside (lateral) part of the elbow.3 Tennis Elbow develops due to overuse of the

muscle and tendon of the forearm and elbow, repeating some types of activities over and over again

can put too much strain on the elbow tendons. These activities are not necessarily high-level sports

competition. Hammering nails, picking up heavy buckets, or pruming shrubs can cause the pain of

tennis elbow.4Tennis elbow occurs most commonly in the tendon of the extensor carpi brevis muscle

at approximately 2cm below the outer edge of the elbow joint or lateral epicondyle of the humerus

bone.2

A50% prevalence is repeated among the tennis player older than 30years with a peak between

1

age of the 35-50. Lateral pain is 5-10times more common than medial pain .5 There are different types

of conservative treatment Lateral Epicondylitis includes, non-steroidal anti-inflammatory

medications, physical therapy, and avoiding the aggravating physical activities contributing to

overuse of the tendons. In some cases, steroid injections may be used to reduce pain and

inflammation, but they are used sparingly due to potentially damaging side effect conservative

treatment may taken extended period of time to relieve the pain.2Tennis Elbow braces and supports.6

While the majority of the therapeutic efforts will be directed at rehabilitation of the wrist extensor

mechanism.7The treatment of the patient’s pain can be accomplished through a variety of therapeutic

modalities cold application7-9 ,heating modalities8-9 ,shortwave & microwave diathermy, electrical

stimulation with TENS, high-voltage galvanic stimulator8 bracing like cock-up splint.10 Conventional

surgery is the last resort for Lateral Epicondylitis that does not respond to conservative treatment.2

There are different types of normal taping in tennis elbow condition such as diamond shaped

taping11-12 placebo tape technique11 sports taping13. Kinesio taping, an organized wrapping technique

using kinesio tape proposed by Kase, is claimed to be able to reduce pain, swelling and muscle

spasms, as well as to prevent sport injury. 14 Kinesio taping (KT) method is a relatively new taping

technique which requires kinesio tex tape. Tape used for KT is different from taping using traditional

white athletic tape. First, it has elasticity in one direction and before applying to skin it can be

stretched to 140% of its original length.14 It provides a constant pulling (shear) force to the skin.

Second, kinesio tex tape is air permeable and water resistant and can be worn for several days without

removal. KT is being used following injury and during the rehabilitation. 14-15Kinesio taping is

effective in different conditions such as mechanical neck pain, acute whiplash injury17 shoulder pain15

tennis athlete19 muscle strength after ACL repair20. Chronic iliotibial band syndrome, ankle condition

21 and planter fasciitis.

The kinesio taping method involves taping over and around muscle in order to assist and give

2

support or to prevent over-contraction. It gives support while maintaining full range of motion

enabling the individual to participate in physical activity with functional assistance. For the first 10

years, orthopedists, chiropractors, acupuncturists and other medical practitioners were the main users

of kinesio taping. Soon thereafter, kinesio taping was used by the Japanese Olympic volleyball

players & word quickly spread to other athletes. Today, kinesio taping is used by medical

practitioners & athletes around the world.

In normal taping there are some limitations like it will restrict the movement because of its non-

stretchable property, its durability is less because it is not water resistant, it affect the body’s own

natural healing process by irritating the skin and affect the activities of daily living. In contrast of this

kinesio tape has got main advantage like –It has got a stretchable property which not affect the ROM

and its durability is 4-5 days , It is water resistant, supports the body own natural healing process and

supports the functional activities without irritating the skin. The kinesio taping method involves

taping over and around muscle in order to assist and give support or to prevent over-contraction. It

gives support while maintaining full range of motion enabling the individual to participate in physical

activity with functional assistance. The kinesio taping method is applied over muscles to reduce pain

and inflammation, relax overused tired muscles, and to support muscles in movement on a 24hr/day

basis. It is non-restrictive type of taping which allows for full range of motion.

If joints or ligaments are injured. They should be stretched before application to the skin. The

damaged joint or ligaments are incapable of functioning normally are rely on stretched tape for

correction. It is also important that while depending on the injury, tape is either stretched or not

stretched, this does not mean that the actual application technique will change. The different

treatment modalities and techniques used to treat lateral epicondylitis are therapeutic ultrasound, deep

friction massage, elbow manipulation, stretching exercises, bracing, fore arm band, combining wrist

manipulation has been done but no previous study has done on combination of modalities and kinesio

3

taping on elbow condition particular kinesio taping technique on tennis elbow to reduce the pain.

Hypothesis:

There will be no significant difference between combined effect of ultrasound and kinesio taping to

reduce pain in tennis elbow.

6.2 Review of Literature:

Review on management of tennis elbow:

Rajadurai Viswas, Rejeeshkumar Ramachandran and Payal Korde Anantkumar et al (2012)

did the study on comparison of effectiveness of supervised exercise program and cyriax

physiotherapy in patients with tennis elbow (Lateral Epicondylitis) and the result will be both the

supervised exercise program and cyriax physiotherapy were found to be significantly effective in

reduction of pain and in the improvement of functional status. The supervised exercise programme

resulted in greater improvement in comparison to those who received cyriax physiotherapy. They

concluded that the results of this clinical trial demonstrate that the supervised exercise program may

be the first treatment choice for therapist in managing tennis elbow.22

Phil Page (2010) gives clinical suggestions that eccentric exercise has been effectively used in the

management of tendinopathies in multiple regions of the body. Lateral epicondylosis (“tennis elbow”)

is a common tendinopathy that has shown improvement following treatment utilizing isokinetic

eccentric exercise. A novel exercise was developed for home-based eccentric exercise that has shown

promise for use with patients with lateral epicondylosis. Clinicians should be aware of this exercise

and consider it as an evidence-based intervention.23

Hiroshi Takasaki et al (2008) did research to measure the strain at the proximal origin of the

extensor carpi radialis brevis (ECRB), and to determine the influence of a forearm support band and

in the result was when no tension was applied to the ECRB, there was no statistically significant

4

difference in strain values at the ECRB origin by mounting the band at any of the forearm positions.

They concluded that the strain on the ECRB origin was less when the forearm support band was

applied 80% proximal from the wrist joint.24

Miriam Faes et al (March 2006): did study on the effect of an external wrist extension force on

extensor muscle activity during hand gripping in patients with lateral epicondylalgia. The results are

at all levels of MVC gripping, the EMG signal of the ECRB and EDC were significantly lower for

gripping with than without brace. An extension force of 3% of the MVC force significantly reduced

the EMG signal of all muscles in almost all measurement conditions and concluded that the results of

this study indicate that the dynamic extensor brace as well as the external extension force

significantly reduced the EMG signal of the wrist extensor muscles during gripping in patients with

lateral epicondylalgia. Based on these results, the dynamic extensor brace could be a promising new

intervention for lateral epicondylalgia.25

Review on effect of ultra sound in soft tissue disorders:

Oken O et al (2008) conducted study on the short-term efficacy of laser, brace, and ultrasound

treatment in lateral epicondylitis and the results show that, in patients with lateral epicondylitis, a

brace has a shorter beneficial effect than US and laser therapy in reducing pain, and that laser therapy

is more effective than the brace and US treatment in improving grip strength.26

Yesim Kurtais Gürsel et al (2004) mentioned that by adding ultrasound in the management of soft

tissue disorders of the shoulder. In result they found among subjects showed within-group

improvements in pain, range of motion, shoulder disability questionnaire scores, and health

assessment questionnaire scores with the intervention, but the differences did not reach significance

when compared between the groups. They discussed and concluded that true US, compared with

sham US, brings no further benefit when applied in addition to other physical therapy interventions in

5

the management of soft tissue disorders of the shoulder.27

Review on recent studies on kinesio taping:

Erkan Kaya et al (2011) The purpose of this study was to determine and compare the efficacy of

kinesio taping compared to physical therapy modalities for the treatment of shoulder impingement

syndrome. Kinesio tape has been found to be more effective than the local modalities at the first week

and was similarly effective at the second week of the treatment. Kinesio taping may be an alternative

treatment option in the treatment of shoulder impingement syndrome especially when an immediate

effect is needed.28

Kristin Briem et al (2011) they did researched in male athletes (soccer, team handball, basketball) to

examine the effect of 2 adhesive tape conditions compared to a no-tape condition on muscle activity

of the fibularis longus during a sudden inversion perturbation. The result will be significantly greater

mean muscle activity was found when ankles were taped with nonelastic tape compared to no tape,

while kinesio tape had no significant effect on mean or maximum muscle activity compared to the

no-tape condition. Neither stability level nor taping condition had a significant effect on the amount

of time from perturbation to maximum activity of the fibularis longus muscle and concluded that

nonelastic sports tape may enhance dynamic muscle support of the ankle. The efficacy of kinesio tape

in preventing ankle sprains via the same mechanism is unlikely, as it had no effect on muscle

activation of the fibularis longus.29

Javier Gonzalez-Iglesias et al (2009) they determined the short-term effects of kinesio taping,

applied to the cervical spine, on neck pain and cervical range of motion in individuals with acute

whiplash-associated disorders (WADs).In result they found that patients with acute WAD receiving

an application of kinesio taping, applied with proper tension, exhibited statistically significant

improvements immediately following application of the kinesio tape and at a 24-hour follow-up.

6

However, the improvements in pain and cervical range of motion were small and may not be

clinically meaningful. Future studies should investigate if kinesio taping provides enhanced outcomes

when added to physical therapy interventions with proven efficacy or when applied over a longer

period.30

Reliability of VAS:

Scott, Huskisson et al (1976), showed in their study of graphic representation of pain that, test-retest

reliability of vas is .71 to .99 and convergent validity (Mcgill pain questionnaire, numeric pain rating

scale) is .95 with a confidence interval of 95%.31

Reliability of PRTEE:

According to Lal Altan et al the objective of this study was to test the reliability of the Turkish

version of PRTEE (PRTEE-T) as a specific scale for LE. The results of our study have shown that the

Turkish version of a specific and practical scale developed for LE can be both valid and reliable.

PRTEE-T is easy to apply in a relatively short period and may prove to be valuable for evaluation and

follow up of the patients in daily clinical practice.32

6.2 Objectives of the study:

1. To evaluate the effect of kinesio taping on pain and functional outcome.

7Materials and Methods:

7.1Source of Data:

ESIC Hospital, Rajajinagar, Bangalore.

Padmashree clinic Nagarbhavi, Bangalore.

7

Ravi Kirloskar Memorial Hospital, Bangalore.

7.2 Method of collection of data:

Population :- Patient with Lateral Epicondylitis

Sample design :- Convenience Sampling

Sample size :- 30

Study design : - Two group experimental design

Duration of the study :- 6 month

Inclusion criteria:

Subjects with Tennis Elbow diagnosed by orthopaedician.

Subjects with cozen test positive.

Lateral elbow pain at least 1-2weeks.

Both genders are included.

Age between 18-40years.

Exclusion criteria:

Cervical spondylosis with radiating pain on lateral elbow.

Arthritis of the elbow joint.

Musculoskeletal conditions such as fracture, surgery, dislocation, subluxation, avulsion

fracture, sprain, strain, bursitis and any kind of boney deformities around elbow.

Neurological involvement.

Tumors.

Materials used :

Examination table

8

Pillow

Scissors

Therapeutic Ultrasound machine

Kinesio tape

Visual Analogue Scale

Patient Rated Tennis Elbow Evaluation

Methodology:

Ethical clearance will be taken from concern hospitals and institutions for the aged. Informed and

written consent from each subject will be taken which will state that the individual has agreed to

participate in the study and that the data collected will be analyzed using evaluation tools. Subject

will be screened for inclusion and exclusion criteria. Subjects enrolled in the study were assigned to

1st group with ultrasound while 2nd group recommended 5-6min of 3Hz, 0.5 intensity of ultrasound

is given once in a day for 3 days along with kinesio taping by making a fist, pronate the forearm (turn

over your hand so your palm is facing down), extend the elbow (straighten the arm), and flex the

wrist (down towards the ground) then ‘Y’ strip of kinesio taping is apply from the wrist to a spot 1

inch below the elbow.

Outcome measures:

There are 3 assessment is taken i.e. pre assessment, post assessment after 3 days and after 2 weeks of

follow-up by using visual analogue scale (VAS) and PRTEE (Patient Rated Tennis Elbow

Evaluation).

Statistics:

Data analysis will be performed by SPSS (version 17) for windows.

9

Mean standard deviation range will be used to assess the pain and PRTEE.

Wilcoxson’s test will be used to compare the pre and post pain and PRTEE.

Mann- Whitney U test will be used to compare the post test level of pain and PRTEE.

7.3 Does the study require any investigation or interventions to be conducted on patients or

other humans or animals? If so please describe briefly.

Yes ,the will be carried out on human subject of both the gender with the age group of 18-40 years

having Lateral Epicondylitis to evaluate the effect of kinesio taping on pain and functional outcome.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes, the ethical clearance been obtained from the institution.

8List of References:

1. Cynthia C. Norkin, PT, EdD - Joint structure & function. 4thedition.India. Jaypee Brothers-

Medical Publishers (P) LTD; 2006.

2. Fornalski S, Gupta R, Lee T. Anatomy and Biomechanics of the Elbow Joint. Techniques in Hand

and Upper Extremity Surgery 2003; 7(4):168–178.

3. Neil Motyer- managing tennis elbow (lateral epicondylitis). Journals of the Australian association

of massage therapists.2008; 10.

4. Administrator patient education.elbow lateral epicondylitis (tennis elbow).2006, 20 july.

5. Bruce Reider. Sports medicine. 2nd edition. W.B. Saunders company, Pennsylvnania.1996

6. Pamela K. Levangie, Cynthia C. Norkin. Joint structure and function. 3rd edition. India. Jaypee

10

Brother, 2003.

7. Lee DG. Tennis elbow: A manual therapist’s perspective. J ortho sports phy. Ther. 1986; 8:134-

141,

8. Gieck JH, Saliba E: Application of modalities in overuse syndromes.clin sports med.1987; 6:427-

466.

9. La Freniere J. Tennis elbow evaluation, treatment & prevention. Phys ther.1979; 59:742-746.

10. Coonrad RW, Hooper WR. Tennis elbow: Its course, natural history, conservative and surgical

management J Bone joint surg (Am) 1973; 55:1177-1182.

11. Bill Vicenzino. Jane Brooksbank, Joanne Minto, Sonia Offord, Aatit Paungmali, Initial Effects of

Elbow Taping on Pain-Free Grip Strength and Pressure Pain Threshold. J Orthop Sports Phys

Ther.2003.july; 33(7).

12. Alireza Shamsoddini, Mohammad Taghi Hollisaz, Rahmatollah Hafezi Initial effect of taping

technique on wrist extension and grip strength and pain of Individuals with lateral epicondylitis.

Iranian Rehabilitation Journal.2010; 8(11).

13. B. Vicenzino: Lateral epicondylalgia: a musculoskeletal physiotherapy perspective, Manual

Therapy. 2003; 8(2), 66–79.

14. Tieh-Cheng Fu, Alice M.K. Wong, Yu-Cheng Pei, Katie P. Wu, Shih-Wei Chou, Yin-Chou Lin.

Effect of Kinesio taping on muscle strength in athletes-A pilot study. Journal of Science and

Medicine in Sport (2008) 11, 198—201

15. Mark D. Thelen,James A. Dauber, Paul D.Stoneman. The Clinical Efficacy of Kinesio Tape

for Shoulder Pain: A Randomized, Double-Blinded, Clinical Trial. journal of orthopaedic & sports

physical therapy ,2008; volume 38 , number 7 , 389-395.

16. Manuel Saavedra-Hernandez, Adelaida M. Castro-Sánchez, Manuel Arroyo, Joshua A.

Inmaculada C. ,Lara-Palomo,César Fernández-D .Journal of orthopaedic & sports physical

therapy2012.August; 42(8), 725.

11

17. Javier Gonzalez-iglesias. Short-Term Effects of Cervical KinesioTaping on Pain and Cervical

Range of Motion in Patients With Acute Whiplash Injury. JOSPT.2009.July 39 (7), 517.

18. Mark D. Thelen,James A. Dauber, Paul D.Stoneman. The Clinical Efficacy of Kinesio Tape

for Shoulder Pain: A Randomized, Double-Blinded, Clinical Trial. journal of orthopaedic & sports

physical therapy ,2008; volume 38 , number 7 , 389-395

19. Melissa Schneider, Matthew Rhea, Curtus Bay The Effect of Kinesio Tex Tape on Muscular

Strength of the Forearm Extensors on Collegiate Tennis Athletes.

20. Murray, H. Kinesio Taping, Muscle Strength and ROM after ACL Repair. Journal of Orthopedic

and Sports Physical Therapy.2000: 30,1

21. Travis Halseth, John W. , Mark DeBeliso, Ross Vaughn and Jeff Lien .The effects of kinesio

taping on proprioception at the ankle. Journal of Sports Science and Medicine.2004: 3, 1-7

22. Rajadurai Viswas, Rejeeshkumar Ramachandran and Payal Korde Anantkumar. Comparison of

Effectiveness of Supervised Exercise Program and Cyriax Physiotherapy in Patients with Tennis

Elbow (Lateral Epicondylitis): A Randomized Clinical Trial. The ScientificWorld Journal. 2012: 8

23. Phil Page. A new exercise for tennis elbow that works. North American Journal of Sports

Physical Therapy.September 2010:5(3),190

24. Hiroshi Takasaki et al. Strain Reduction of the extensor carpi radialis brevis tendon proximal

origin following the application of a forearm support band. Journal of orthopaedic & sports physical

therapy. May 2008: 38(5)

25. Miriam Faes et al. A dynamic extensor brace reduces electromyographic activity of wrist extensor

muscles in patients with lateral epicondylalgia. Journal of Orthopaedic & Sports Physical Therapy.

March 2006:36(3)

26. Oken O et al. The short-term efficacy of laser, brace, and ultrasound treatment in lateral

epicondylitis: a prospective, randomized, controlled trial.J Hand Ther. Jul-Sep 2008:21(3);303

27. Yesim Kurtais Gursel et al. Adding ultrasound in the management of soft tissue disorders of the

12

shoulder: A randomized placebo-controlled trial. Phys Ther.2004; 84:336-343

28. Erkan Kaya & Murat Zinnuroglu & Ilknur Tugcu. Kinesio taping compared to physical therapy

modalities for the treatment of shoulder impingement syndrome. Clin Rheumatol. 2011:30;201–207

29. Kristin Briem et al. Effects of kinesio tape compared with nonelastic sports tape and the untaped

ankle during a sudden inversion perturbation in male athletes. Journal of orthopaedic & sports

physical therapy. may 2011:41(5);328-621

30. Javier González-Iglesias et al. Short-term effects of cervical kinesio taping on pain and cervical

range of motion in patients with acute whiplash injury: A randomized clinical trial. journal of

orthopaedic & sports physical therapy.july 2009:39(7)

31. Scott J, Huskisson EC. Vertical or horizontal visual analogue scales. Ann Rheum Dis

1979;38:560

32. Lale Altan, İlker Ercan, & Saniye Konur. Reliability and validity of Turkish version of the patient

rated tennis elbow evaluation. Rheumatology International.June 2010:30 (8); 1049-1054

13

14