Are there any changes in strength after the application of Kinesio taping in lateral epicondylalgia?

Abstract

BACKGROUND:

In 1973, Dr. Kenzo Kase developed Kinesio taping from the hypothesis that this external component could aid the functions of muscles and other tissues. There are different studies on this issue, but none has completely clarified the research question.

OBJECTIVE:

To study the application of Kinesio taping in the variation of isometric muscle strength of the hand extension and grip, isokinetic strength of the pronation and supination movements, and the time it takes to reach that strength in patients with lateral epicondylalgia.

METHODS:

An analytical, experimental, randomized study was carried out with 104 subjects with lateral epicondylalgia. The subjects were randomly distributed among two groups: one received Kinesio taping and the other a placebo material. A pre- and post-intervention measurement was performed. The post-measurement was carried out 24 hours later so as to completely eliminate the fatigue effect produced by the first day measurements, as well as to ensure that the intervention was effective, and not immediate. The measurements were made using a dynamometer.

RESULTS:

No significant differences were found between the application of Kinesio taping and placebo material in subjects with lateral epicondylalgia regarding the variation of muscle strength in any of the study variables ( $p>$ 0.05 for all studied variables).

CONCLUSIONS:

Kinesio taping produces no change in strength after application and exerts an effect similar to that of a placebo.

Keywords

Taping lateral epicondylalgia muscle strength dynamometer

1. Introduction

Lateral epicondylalgia (LE), or tennis elbow, is characterized by pain in the lateral epicondyle of the humerus. This musculoskeletal pain disorder is usually caused by an excessive use of wrist and forearm movements, causing muscle weakness [1]. LE affects around 1–3% of the world population, equally distributed between men and women [2]. LE occurs most frequently between the third and sixth decade of life, especially in the dominant arm [3]. In most cases, it is self-limiting, lasting from 6 to 24 months, although it may continue in some patients, causing persistent symptoms [4, 5].

The neuromuscular bandage or Kinesio taping (KT) is a type of bandage that was developed in Japan in the 1970s by Kenzo Kase. Its use has become increasingly popular in different sports and for the rehabilitation of various musculoskeletal disorders [6, 7]. It consists of an elastic band with the ability to stretch up to 140–160% of its length, thus providing a constant shear force on the skin [8]. According to Bravi et al. [9], the application of KT causes elevations or folds in the skin, lifting it above the underlying tissues, thus favoring the release of those tissues and providing space for a better lymphatic flow.

Various effects or benefits of the KT application have been proposed, depending on the stretching capacity of the bandage applied. Some of these are: normalizing muscle function or restoring its correct function, inhibiting/relaxing overstrained muscles, increasing lymphatic and vascular flows, decreasing pain, and helping in the correction of inadequate alignments at the joints level, among others [10].

The stretch applied to the bandage creates a tension in the skin that improves the communication of the mechanoreceptors and increases the number of motor units recruited during the muscle contraction, so, through these effects, the bandage could improve muscle function, which would facilitate the contraction of inactive muscles [11].

Several studies have tried to cast light on the question regarding the relationship between KT and muscle strength. The problem is that they do not follow homogeneous methodological criteria, thus reaching diverse results and conclusions. Furthermore, the studies support the idea that the conclusions concerning muscle strength and KT are not very revealing [12, 13, 14, 15].

The main objective of this study is to evaluate the influence of the application of KT, in comparison to a placebo material, in patients with LE regarding the following aspects: the maximum isometric muscle strength of the wrist extension and hand grip, the maximum isokinetic force at 60 ${}^{\circ}$ /sec of the pronation and supination movements, and the time needed to reach these strengths.

2. Material and methods

2.1 Design

A randomized clinical trial was designed for subjects with LE.

The ethical recommendations of the 1964 Declaration of Helsinki of the World Medical Assembly, as revised at the 64th General Assembly (October 2013), have been complied with.

This research was previously evaluated and approved by the Research Commission of the San Juan de Dios School of Nursing and Physiotherapy (Universidad Pontificia Comillas de Madrid) and by the Clinical Research Ethics Committee of the San Carlos Clinical Hospital of Madrid (C.P. – C.I. 14/531-P).

The patients read and signed the patient information sheet and the informed consent, in which all the characteristics of the study were explained.

All the data collected for the study were treated according to the security measures established in compliance with the “Ley Orgánica 15/1999” of December 13, 1999, regarding personal data protection.

2.2 Participants

Among a total sample of 120 subjects originally obtained, a non-probabilistic sample was selected for convenience, balanced by gender, where women and men were selected separately, so as to ensure a similar proportion of women and men [2, 16]. A sample calculation was made based on the data from the study by Donec et al. [17]. Assuming an Alpha risk of 0.10 (90% confidence level) and a Beta risk of 0.20 (statistical power of 80%) in a bilateral contrast, 51 subjects were required in each group so as to detect a difference equal to or greater than 5.4 N.

The subjects were recruited within the Community of Madrid and had to meet the following inclusion criteria: confirmed pathology under study with more than three months of evolution, age between 30 and 60 years, no previous knowledge of the KT technique [17, 18, 19], and not receiving treatment at the time of recruitment. For the diagnosis of LE, at least two of these characteristics were required: pain and/or sensitivity in the lateral epicondyle at palpation compared to the contralateral side, pain in the lateral epicondyle at resisted extension of the wrist, pain in the lateral epicondyle at stretching of the wrist extensor musculature, Thompson test, chair test and positive Cozen test [2, 20, 21].

With regard to the exclusion criteria, the subjects could not participate in the study if they showed any of the following: radial tunnel syndrome (posterior interosseous entrapment), fracture and intra-articular pathology of the elbow, pain in the homolateral upper limbs originated in the cervical spine, fibromyalgia, previous elbow surgery on the homolateral side, mobility limitations due to previous fractures in the ulna, radius or carpal bones, osteoporosis, cervical pathology with acute symptoms at the time of recruitment, neurological deficit of the upper limb on the homolateral side, cognitive dysfunction, allergy to any component of the KT or the placebo material, or dermatological alterations in the area involved in the intervention.

Figure 1.

Consolidated Standards of Reporting Trials flowchart of the study.

2.3 Procedures

The final sample size for this study was 104 subjects, distributed among two groups by means of a simple randomization system of computer-generated random numbers: one group received the intervention with KT ( $n=$ 52) while the other group received a placebo material (KT Placebo) ( $n=$ 52). Finally, 52 subjects were analyzed in the KT group and 51 in the KT placebo, due to an error in the measuring device. Participants were blinded to the treatment received, as one of the inclusion criteria was having no previous knowledge of the KT technique. The Consolidated Standards of Reporting Trials (CONSORT) flowchart [22] are described in Fig. 1.

A pre- and post-intervention measurement was performed. The post-intervention measurement was carried out one week later in order to completely eliminate the fatigue effect produced by the first day measurements [7]. The intervention was carried out 24 hours before the post-intervention measurement to ensure that the KT had an effective effect, and not an immediate one [23].

The dynamometric measurements were performed with a BTE-PRIMUS system, one of the highest quality instruments for carrying out these tests [24, 25, 26]. The methodology in this study was based on other studies that have already used the same system and methodology for assessing muscle strength in patients with LE [27, 28].

A warm-up was performed on the same dynamometer before the corresponding measurements were made. The warm-up procedure was conducted by means of a concentric-concentric isokinetic test at 120 ${}^{\circ}$ /s of the wrist flexo-extension movement, 10 repetitions.

The tests performed were: an in line isometric test of 6 seconds for the wrist extension and hand grip movement, and an isokinetic test at 60 ${}^{\circ}$ /sec of the pronation and supination movements. For the isometric tests, an average of three repetitions were performed with a 30-second rest interval between them. For the isokinetic tests, there were five repetitions for each of the movements, and the average was calculated.

In all the measurements, the data regarding the maximum strength and the time of occurrence in reaching it were collected, with a 2-minute break between measurements.

The dynamometer head was placed in position 5 for all the measurements. For the 6-second online isometric test for wrist extension, tool 701 and the stabilization support (Arm rest) were used. The patient’s position was standing lateral to the dynamometer, with their feet together and their shoulders relaxed, arm attached to the body, elbow flexed to 90 ${}^{\circ}$ and forearm attached to the latter tool, as in the warm-up (Fig. 2A). This positioning was maintained in the 6-second online isometric test for wrist extension, but tool 162 was used without the stabilization support (Fig. 2B). Finally, for the 60 ${}^{\circ}$ /sec isokinetic test of the pronation and supination movements, tool 601 and the stabilization support were required, with the same positioning as the previous ones, but now with the patient looking at the axis of the dynamometer and not lateral to it (Fig. 2C). Regarding the KT intervention, an “I” muscle toning technique was proposed from the epicondyle to the wrist, i.e. from origin to insertion (Temtex ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}\textregistered}$ , South Korea). More details about the composition, mechanical and comfort properties of the KT used in this study can be verified in the study of Tunakova et al. [29]. The base was applied on the lateral epicondyle without stretching, the active part was stuck with the elbow in extension, forearm in prone position, wrist in palmar flexion and ulnar deviation with a tension between 15% and 25%, and the stretching position was then relaxed to finish the anchorage (Fig. 3A). For the KT Placebo group, a 5 cm wide inelastic white athletic bandage (like the KT) was used (Fig. 3B). The steps of the KT intervention were followed in a similar way, but without tension or muscle stretching since this bandage has no tension. This bandage is the one used for functional bandaging to limit movement, but it does not have any effect like those of KT. Therefore, the subjects were blinded and not aware of the technique, a requirement included in the inclusion criteria. The time to perform these interventions was approximately 2–3 minutes and the subjects used the bandages (KT placebo and KT) for 24 hours as mentioned above.

Figure 2.

Equipment used during the experiments and positioning and tool for the warm-up procedure and online isometric test for wrist extension (A); positioning for the isometric online test for hand grip (B); and positioning of the isokinetic test at 60 ${}^{\circ}$ /sec of pronation and supination movements (C).

Figure 3.

Application of KT (A) and KT placebo (B).

The measurements and interventions were conducted by one single expert researcher [15].

2.4 Statistical analysis

Firstly, a descriptive analysis of the study variables was carried out. The independent variables were described using mean and standard deviation (SD) for age and percentages for gender. As for the dependent variables, a descriptive analysis of the data was carried out for our dependent variables, including mean and SD.

The Kolmogorov-Smirnov test was performed to check the normality of the sample.

An inferential analysis to compare inter-group differences was conducted by using the independent sample t-student test to compare data between the two groups in the case of normality, while the Mann-Whitney U-test was used in non-normal distribution. In order to assess intragroup differences between pre- and post-treatment measurements, the t-student test of related samples was performed in the case of normality, while the Wilcoxon test was used in non-normal distribution.

A significance level of 0.05 and a 95% confidence level were established. The IBM ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}\textregistered}$ SPSS Statistics ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}\textregistered}$ package version 24.0 was used to perform the statistical analysis of the data.

Table 1
Mean, standard deviation and $p$ -values of the strength variables in the KT group ( $n=$ 52) and the KT placebo group ( $n=$ 51)

Variables ${}^{*}$	KT				KT placebo				$p$ -values
	Mean $\pm$ SD				Mean $\pm$ SD
	Pre		Post		Pre		Post
ISWE	86.29	$\pm$ 36.51	84.40	$\pm$ 35.51	78.77	$\pm$ 38.66	77.94	$\pm$ 35.92	0.958 ${}^{\text{a}}$
ISP 60 ${}^{\circ}$ /sec	7.10	$\pm$ 4.06	7.14	$\pm$ 4.00	6.46	$\pm$ 3.42	6.86	$\pm$ 3.58	0.293 ${}^{\text{b}}$
ISS 60 ${}^{\circ}$ /sec	6.31	$\pm$ 3.58	6.59	$\pm$ 3.82	5.57	$\pm$ 2.64	5.97	$\pm$ 3.02	0.764 ${}^{\text{b}}$
ISHG	322.95	$\pm$ 131.31	333.95	$\pm$ 136.22	308.80	$\pm$ 124.08	306.10	$\pm$ 35.92	0.058 ${}^{\text{a}}$

Note: No significant differences were found between the means of the pre-post treatments between the groups using Student’s $t$ -test ${}^{\text{a}}$ or Mann-Whitney’s U test ${}^{\text{b}}$ . N: Newton. ${}^{*}$ ISWE (N) – Isometric strength of the wrist extension; ISP 60 ${}^{\circ}$ /sec (N) – Isokinetic strength at 60 ${}^{\circ}$ /sec pronation; ISS 60 ${}^{\circ}$ /sec (N) – Isokinetic strength at 60 ${}^{\circ}$ /sec supination; ISHG (N) – Isometric strength of the hand grip.

Table 2

Mean, standard deviation and p-values of the variables of time to reach strength in the KT group ( $n=$ 52) and the KT placebo group ( $n=$ 51)

Variables ${}^{*}$	KT		KT placebo		$p$ -values
	Mean $\pm$ SD		Mean $\pm$ SD
	Pre	Post	Pre	Post
TISWE	1.76 $\pm$ 1.18	1.74 $\pm$ 1.08	1.92 $\pm$ 1.30	1.84 $\pm$ 1.24	0.311
TISP 60 ${}^{\circ}$ /sec	0.76 $\pm$ 0.30	0.81 $\pm$ 0.27	0.93 $\pm$ 0.41	0.87 $\pm$ 0.31	0.268
TISS 60 ${}^{\circ}$ /sec	2.05 $\pm$ 0.44	2.08 $\pm$ 0.41	1.98 $\pm$ 0.48	2.03 $\pm$ 0.46	0.361
TISHG	2.10 $\pm$ 1.07	1.86 $\pm$ 1.04	2.18 $\pm$ 1.11	2.20 $\pm$ 1.21	0.184

Note: No significant differences were found between the means of the pre-post treatments between the groups using Student’s $t$ -test. sec – seconds. ${}^{*}$ TISWE (sec) – time to reach the isometric strength of the wrist extension; TISP 60 ${}^{\circ}$ /sec (sec) – time to reach the isokinetic strength at 60 ${}^{\circ}$ /sec pronation; TISS 60 ${}^{\circ}$ /sec (sec) – time to reach the isokinetic strength at 60 ${}^{\circ}$ /sec supination; TISHG (sec) – time to reach the isometric strength of the hand grip.

3. Results

In terms of gener there are no inter-group differences since the allocation was controlled for this variable, with 50% men and women in each of the groups.

The mean age of the whole sample was 40.54 $\pm$ 8.02 years and there were no differences in this variable between the groups: 40.00 $\pm$ 8.22 years for the KT group and 41.08 $\pm$ 7.87 years for the KT placebo group.

When performing the descriptive analysis of the dependent variables of this study (Tables 1 and 2), the results showed that the standard deviations of the variables of both groups are high as far as the mean values are concerned.

An intra-group analysis was performed between pre- and post-treatment measurements, where no significant differences were observed in any of the variables of the two groups.

No statistically significant inter-group differences were found with respect to the maximum strength variables, nor in the time for reaching the maximum strength in any of the movements studied as shown in Tables 1 and 2, with $p>$ 0.05 in all the variables under study.

4. Discussion

Recently and due to its popularity, some studies have been conducted regarding changes in strength with the application of KT, although with contradictory results. Kalron and Bar-Sela [30] concluded that all health professionals should perform their duties based on evidence and not only on the popularity of the treatments, and that further studies are needed on the effect of KT. Morris et al. [31] did not find sufficient evidence to support the use of KT. In another review regarding muscle strength and KT application [13], the authors stated that the evidence found is not conclusive, since sometimes there is no control group when KT is applied on healthy people, and the interventions are different. Finally, Mostafavifar et al. [32] stated that the number of high-quality studies is limited and so, further studies should be conducted with higher levels of evidence, larger samples and unified criteria.

Similar conclusions have been drawn from the two meta-analyses conducted on this subject. In one, Williams et al. [33] proposed that subjects should be adequately blinded, compared to a placebo group, and always guaranteed good methodological quality. Finally, Csapo and Alegre [34] noted that in general, studies concerning KT and muscle strength are of moderate quality, but tend to be of lower quality when positive results are found.

After conducting their study, Slupik et al. [23] proved that the electromyographic activity increases after 24 hours of the KT application, so the post measurements concerning this topic should be done in that period of time, which was taken into account in our study. Also, based on Vercelli et al. [7], the time between measurements was taken into account, leaving a 1-week difference between pre- and post-treatment measurements in order to avoid the fatigue effect, since according to the authors, this can be a major limitation in most studies.

There are few studies conducting their analysis on LE; González-Iglesias et al. [35] studied the effect of KT in patients with LE, but as part of a complete physiotherapy program, and found improvements in function and pain. In studies carried out on medial epicondylalgia, the authors found no differences regarding muscle function [12, 14, 23, 30, 32, 33, 35]. On the other hand, it is true that there is no standardized criterion as to which placebo material should be used to compare KT. Some opt for a material very similar to KT, but with a different pattern [35, 36], while others prefer to use tension-free KT [7, 8, 11, 37, 38] or the material used in this study, that is, inelastic bandage [17, 18, 19, 38, 39]. Only Lemos et al. [11] stated that the use of KT without tension cannot be considered a placebo, but a different degree of stimulus.

In light of all this, the present study, whose results were described in the previous section, could be taken into account in an attempt to mitigate the limitations that can be deduced from previous works.

4.1 Limitations of the study

There are variables that have not been assessed, such as physical activity, occupational activity, or body mass indexes that could be related to the activity, and this could have influenced the variability of the sample.

5. Conclusions

Based on the results obtained, the authors conclude that there are no differences between the application of Kinesio tape and KT placebo in patients with lateral epicondylalgia in the maximum isometric muscle strength variation. Kinesio tape of the wrist extension and hand grip, in the maximum isokinetic strength at 60 ${}^{\circ}$ /sec of the pronation and supination movements, nor in the time to reach these strength values. KT may have a placebo effect on muscle strength variation. Therefore, Kinesio taping does not produce changes in strength after application. It exerts a similar effect to that observed in a placebo, so KT should not be used for this purpose.

Footnotes

Acknowledgments

The authors thank the San Juan de Dios School of Nursing and Physiotherapy (Comillas Pontifical University, Madrid) for the loan of its laboratory resources for this work.

Conflict of interest

The authors report no conflict of interest.

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Are there any changes in strength after the application of Kinesio taping in lateral epicondylalgia?

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Material and methods

2.1 Design

2.2 Participants

Table 1 Mean, standard deviation and p -values of the strength variables in the KT group ( n = 52) and the KT placebo group ( n = 51)

4. Discussion

4.1 Limitations of the study

5. Conclusions

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Mean, standard deviation and $p$ -values of the strength variables in the KT group ( $n=$ 52) and the KT placebo group ( $n=$ 51)