The Pennsylvania State University. The Graduate School. College of Health and Human Development

Transcription

1 The Pennsylvania State University The Graduate School College of Health and Human Development THE EFFECT OF KINESIOLOGY TAPE ON PAIN AND FUNCTIONAL MEASURES ACUTELY AND OVER TIME IN PATELLOFEMORAL PAIN PATIENTS A Dissertation in Kinesiology by Alicia M. Montalvo 2015 Alicia M. Montalvo Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy December 2015

2 The dissertation of Alicia M. Montalvo was reviewed and approved* by the following: William E. Buckley Professor of Kinesiology Dissertation Advisor Chair of Committee S. John Miller Assistant Professor of Kinesiology Robert L. Sainburg Professor of Kinesiology and Neurobiology Giampietro L. Vairo Clinical Assistant Professor Wayne J. Sebastianelli Kalenak Professor in Orthopaedics Stephen J. Piazza Professor of Kinesiology Graduate Program Director *Signatures on file in the Graduate School. ii

3 ABSTRACT Patellofemoral pain (PFP) is the most commonly diagnosed pathology in sports medicine clinics. While its exact etiology remains unknown, factors contributing to its development are suggested to include, but are not limited to, dysfunction of the gluteus medius, abnormal trochlear morphology, and altered sagittal plane kinematics. These factors are generally agreed to result in the patellar maltracking that is proposed to cause the pathology s trademark symptoms. In most patients, PFP is chronic or recurrent, which has negative effects on their ability to be physically active. The lack of understanding regarding the development of PFP makes it difficult for clinicians to treat successfully. In addition to physical rehabilitation, therapeutic taping techniques are a part of the standard of care of PFP. Traditionally, McConnell taping techniques have been used to correct the position of the patella. Recently, the use of kinesiology tape (KT), a cotton/elastic therapeutic tape, has grown in popularity among athletes and clinicians alike. This therapeutic tape is believed to reduce pain and improve performance via cutaneous stimulation, though neither its efficacy nor its mechanism of action are well understood. The first chapter of this dissertation focused on reviewing existing literature that investigated the effects of KT on pain and quadriceps performance in physically active PFP patients. Due to the lack of literature specifically utilizing PFP patients, the second chapter of this dissertation focused on reviewing and quantifying the effects of KT on pain in individuals with musculoskeletal injury. Results from these reviews indicated that further research was necessary. Therefore, for the third chapter, an experiment was performed to further investigate the effects of KT on pain and functional measures in physically active PFP patients. Since KT manufacturers recommend prolonged applications, this experiment was designed to investigate the effects of both acute and prolonged applications. Results of the research indicate that, overall, KT application resulted in greater pain reduction and greater improvements in performance than placebo both acutely and over time as demonstrated by effect sizes. However, the main effect of intervention was never statistically significant indicating that changes in scores may have been due to chance. iii

4 TABLE OF CONTENTS LIST OF FIGURES... vi LIST OF TABLES... vii LIST OF ABBREVIATIONS... ix ACKNOWLEDGEMENTS... x CHAPTER 1: An Evidence Based Practice Approach to the Efficacy of Kinesio Taping for Improving Pain and Quadriceps Performance in Physically Active Patellofemoral Pain Syndrome Patients Background... 1 CHAPTER 2: Effect of kinesiology taping on pain in individuals with musculoskeletal injuries: systematic review and meta analysis Background... 2 CHAPTER 3: The Effect of Kinesiology Tape on Pain and Functional Measures Acutely and Over Time in Patients with Patellofemoral Pain... 3 INTRODUCTION... 3 METHODS AND MATERIALS... 7 Design... 7 Subjects... 8 Variables... 9 Interventions Knee kinesiology taping technique Hip kinesiology taping technique Knee and hip kinesiology taping technique Placebo laser treatment Testing Procedures Dynamic Postural Control: Star Excursion Balance Test (SEBT) Neuromuscular Assessments: Surface Electromyography (semg) Adapted Crossover Hop for Distance Strength and Endurance Measurements: Isokinetic Dynamometry Kujala Questionnaire Score Visual Analog Scale (VAS) for Pain iv

5 Statistical Analysis Missing data RESULTS Baseline measures Anterior reach of the SEBT: distance and pain Crossover hop test: distance and pain Isokinetic knee extension: strength and pain Isokinetic hip abduction: strength and pain Isokinetic knee extension: endurance and pain Isokinetic hip abduction: pain Performance effect sizes Pain effect size DISCUSSION Anterior reach of the SEBT: performance Crossover hop for distance: performance Knee extensor strength: performance Hip abductor strength: performance Knee extensor endurance: performance Pain LIMITATIONS AND FUTURE RESEARCH REFERENCES Appendix A: Copy of manuscript Appendix B: Copy of manuscript Appendix C: PFP Diagnosis Checklist Appendix D: Kujala Questionnaire Appendix E: Participant information sheet Appendix F: SEBT recording sheet Appendix G: Crossover hop test recording sheet Appendix H: Isokinetic VAS recording sheet v

6 LIST OF FIGURES Figure 1. Knee kiesiology tape application Figure 2. Hip kinesiology tape application Figure 3. Placebo laser treatment Figure 4. Anterior reach of the Star Excursion Balance Test Figure 5. Electode placement and maxium voluntary isometric contraction position for specified muscles Figure 6. Adapted crossover hop for distance vi

7 LIST OF TABLES Table 1. Numbers needed for effect size f = 0.5, power = 0.8, α = 0.05, and β = Table 2. Participant characteristics... 9 Table 3. Mean(SD) and results of one way ANOVA for the differences among participant characteristics by intervention Table 4. Mean(SD) and results of paired t tests for the differences between involved and uninvolved limbs for each task Table 5. Mean(SD) and results of paired t tests for the differences between involved and uninvolved limbs for the VAS during each task (mm) Table 6. Means (SD) and results of repeated measures ANOVA for differences among SEBT reach distances over time by intervention (% leg length) Table 7. 95% CI for the difference between each time relative to baseline for SEBT reach distances by intervention (% leg length) Table 8. Means (SD) and results of repeated measures ANOVA for differences among VAS scores following execution of the SEBT over time by intervention (mm) Table 9. 95% CI for the difference between each time relative to baseline for VAS scores following execution of the SEBT by intervention (mm) Table 10. Means (SD) and results of repeated measures ANOVA for differences among distances achieved on the crossover hop for distance over time by intervention (in) Table % CI for the difference between each time relative to baseline for distance achieved on the crossover hop for distance by intervention (in) Table 12. Means (SD) and results of repeated measures ANOVA for differences among VAS scores following the crossover hop for distance over time by intervention (mm) Table % CI for the difference between each time relative to baseline for VAS scores following the crossover hop for distance by intervention (mm) Table 14. Means (SD) and results of repeated measures ANOVA for differences among knee extension peak torque at 60 /s over time by intervention Table % CI for each time relative to baseline for knee extension peak torque at 60 /s over time by intervention Table 16. Means (SD) and results of repeated measures ANOVA for differences among VAS scores following knee extension at 60 /s over time by intervention (mm) Table % CI for each time relative to baseline for VAS scores following knee extension at 240 /s by intervention (mm) Table 18. Means (SD) and results of repeated measures ANOVA for differences among hip abduction peak torque at 60 /s over time by intervention vii

8 Table % SCI for each time relative to baseline for hip abduction peak torque at 60 /s by intervention Table 20. Means (SD) and results of repeated measures ANOVA for differences among VAS scores following hip abduction at 60 /s over time by intervention (mm) Table % CI for each time relative to baseline for VAS scores following hip abduction at 60 /s by intervention (mm) Table 22. Means (SD) and results of repeated measures ANOVA for differences among total work during knee extension at 240 /s over time by intervention by intervention Table % CI for each time relative to baseline for knee extension at 240 /s by intervention Table 24. Means (SD) and results of repeated measures ANOVA for differences among VAS scores following knee extension at 240 /s over time by intervention (mm) Table % CI for each time relative to baseline for VAS scores following knee extension at 240 /s by intervention (mm) Table 26. Means (SD) and results of repeated measures ANOVA for differences among VAS scores during completion of the hip abduction work at 240 /s task over time by intervention (mm) Table % CI for each time relative to baseline for VAS scores following hip abduction work at 240 /s by intervention (mm) Table 28. Cohen s d effect size to determine meaningfulness of changes in performance from baseline to acute application by intervention Table 29. Cohen s d effect size to determine meaningfulness of changes in performance from baseline to prolonged application by intervention Table 30. Cohen s d effect size to determine meaningfulness of changes in pain from baseline to acute application by intervention Table 31. Cohen s d effect size to determine meaningfulness of changes in pain from baseline to prolonged application by intervention viii

9 LIST OF ABBREVIATIONS PFP VAS SEBT Patellofemoral pain Visual analog scale Star Excursion Balance Test ix

10 ACKNOWLEDGEMENTS First, I d like to thank my parents, Edill and Alicia Montalvo, for always making me believe I m smarter than I actually am. I ve seen the elementary and middle school report cards. The jig is up. Without your encouragement, I would never have thought I was capable of getting into Harvard. I d like to thank the University of Pennsylvania for my bachelor s degree because that degree made Philadelphia guy William E. Buckley take a chance on me, which leads me to my next acknowledgement. Thanks to Buck, who thinks everything is a good idea. Because of you I have learned to encourage initiative and foster creativity in my students and to keep work light, but serious. Your air trumpet is second to none. Next, thanks to the faculty in 146 Rec for always being good for a laugh, a cry, and words of wisdom. Especially, thanks to John Miller for being a great professional role model and introducing me to some pretty smart people, and thanks to John Vairo for pushing me out of the nest and always being there for me in times of academic need. Your air trumpet is also, awkwardly, second to none. To Sam Monismith and Bob Sainburg: Thanks for your patience during this process and for being flexible as I finished this dissertation while working out of state. Also, I d like to thank all faculty and staff with whom I interacted in the Department of Kinesiology. You showed me how to aspire to more in my career. I look forward to a career full of accepting rejections for NIH funding. Thanks to the Department of Kinesiology, Penn State Orthopedics and Dr. Wayne Sebastianelli, and the Nicole Wertheim College of Nursing and Health Sciences and Dean Strickland: I would not have been able to complete this research without your generous support. I have to acknowledge Jenna Doherty Restrepo. I wouldn t be where I am or who I am without you. Thank you for taking TWO chances on me. You haven t just supported me to the bitter end; you ve been a mentor, a friend, and the best boss ever. Finally, I want to thank my wonderful husband, Joe Pilewski. I couldn t have gotten through two rounds of graduate school and a dissertation without your unconditional love and unwavering support for all my crazy endeavors. I just applied to medical school at Harvard. Let s go to Bali. I love you!!! x

11 Nothing in this world can take the place of persistence. Talent will not; nothing is more common than unsuccessful men with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent. Calvin Coolidge xi

12 CHAPTER 1: An Evidence Based Practice Approach to the Efficacy of Kinesio Taping for Improving Pain and Quadriceps Performance in Physically Active Patellofemoral Pain Syndrome Patients. Background Patellofemoral pain (PFP) is the most commonly diagnosed pathology in sports medicine clinics. This pathology is problematic because its etiology is multifactorial and its mechanism has not yet been established. As a result, it is difficult for clinicians to treat PFP. Traditionally, therapeutic taping techniques, especially McConnell techniques, have been used to help PFP patients decrease pain and improve performance. In recent years, the use of kinesiology tape (KT) has grown in popularity for the treatment of musculoskeletal injuries. It is unclear whether or not KT has a positive effect on pain and quadriceps performance in PFP patients. Therefore, the purpose of this systematic review was to objectively investigate the effect of KT on pain and quadriceps performance in physically active PFP patients (Appendix A). Five studies that utilized pain and quadriceps performance as outcome measures were reviewed and critically appraised. Results suggested that KT may be used in place of or with other therapeutic modalities to treat PFP. However, existing literature is not of high quality. The final conclusion was that more research needs to be done to quantify the benefits of KT application in treating patients with PFP and that different therapeutic techniques should be investigated in order to determine if the location of the application plays a role in mitigating symptoms in this population. 1

13 CHAPTER 2: Effect of kinesiology taping on pain in individuals with musculoskeletal injuries: systematic review and meta analysis. Background The previous chapter alluded to the notion that research was lacking with regard to quantifying the benefits of KT in PFP patients. Due to the lack of research on the use of KT in PFP patients, the next study investigated the effect of KT on pain in individuals with musculoskeletal injury. By utilizing individuals with musculoskeletal injury as the patient, we were able to aggregate data from 13 articles and perform a meta analysis to establish a more valid conclusion. Previous research indicated that benefits in performance following the application of KT may come as a result of a decrease in pain. As such, it was our intention to determine if KT does indeed decrease pain (Appendix B). The results of this research indicated that KT is as effective as other modalities for decreasing pain. However, studies were of varying methodological quality and most of them did not investigate prolonged application. Additionally, the studies did not focus specifically on patellofemoral pain, which dictated the need to design and perform an experiment to address the shortcomings of previous research. 2

14 CHAPTER 3: The Effect of Kinesiology Tape on Pain and Functional Measures Acutely and Over Time in Patients with Patellofemoral Pain INTRODUCTION Patellofemoral pain (PFP) is one of the most commonly diagnosed musculoskeletal conditions in physically active individuals. 1,2 Prevalence of PFP has been reported to be in the range of 12 15% in the physically active. 3 Females are over two times more likely than males to experience PFP. 3,4 Research indicates that 70 90% of PFP patients have recurrent events or chronic pain. 5 As a result, individuals with PFP may experience negative long term effects with regard to physical activity. 6 There is concern regarding the development of knee osteoarthritis from recurrent PFP, though this association has not yet been substantiated by research. 7 The etiology of PFP is multi factorial. Patellar maltracking is proposed to contribute to the development of the condition Conventionally, it was suggested that this maltracking was caused by the movement of an unstable patella over a stable femur. 11 However, recent research has demonstrated that an unstable femur may be moving under a stable patella In females, the development of PFP is associated with greater hip abduction and hip internal rotation This finding has not been established in males, indicating the risk factors for development of PFP may be sex specific. 15,16 Factors associated with PFP in both males and females include reduced contact area of the patella on the femur 17, a shallow trochlear groove 17, altered sagittal plane mechanics in the trunk and hip extensors 16,18,19, and abnormal functioning of the gluteus medius 20,21. 3

15 As a result of the lack of understanding of the mechanisms contributing to PFP, successful treatment of the condition is a challenge for clinicians. While research indicates that the standard of care may be effective at reducing pain and improving short term (<1 year) function, approximately 40% of individuals have reported that it does not result in adequate long term resolution of symptoms. 22,23 Currently, the standard of care for PFP includes therapeutic exercises and modalities, manual therapy, and taping. 7 Most clinicians are familiar with McConnell taping techniques. These techniques are used to reposition the patella prior to activity in order to improve tracking. 24 Stiff tape is used to mechanically correct the patella s glide, tilt, and rotation to be more favorable. 24 Research indicates that these techniques aid in reducing pain and improving function during activity, though the mechanism of action is not understood. 25 In recent years, the number of companies selling kinesiology tape (KT) has increased; however, there is currently no consensus as to its benefits with regard to the treatment of specific conditions, including PFP. Unlike the tape used in McConnell taping, KT is a cottonelastic tape and is not typically used to mechanically change the position of body structures. Instead, it is applied to the skin and is believed to function through the deformation of cutaneous mechanoreceptors. 26 Riemann and Lephart 27 suggest that cutaneous stimulation may result in increased gamma motorneuron activation, which would improve muscle spindle sensitivity. In turn, this may enhance afferent input to the central nervous system and improve both proprioception and neuromuscular control. Additionally, KT may deform and stimulate large fiber cutaneous mechanoreceptors that inhibit nociceptive impulses in 4

16 the spinal column and decrease pain via an ascending pathway. However, these is a lack of evidence to support these possible mechanisms as they pertain to KT. Evidence exists supporting the use of KT to reduce pain and improve function. In separate meta analyses, both Montalvo et al 28 and Lim and Tay 29 found that KT application decreased pain in individuals with musculoskeletal injury and musculoskeletal pain/disability, respectively. While both found that the improvements were minimal, they reported that KT was as effective as other treatment modalities. 28,29 Csapo and Alegre 30 performed a meta analysis investigating the effects of KT on skeletal muscle strength. Similar to Montalvo et al 28 and Lim and Tay 29, they found that KT improved strength, though only minimally. 30 In another meta analysis, Williams et al 31 found that KT was more effective than other tapes in improving strength and range of motion in injured individuals. However, again, these benefits were minimal. Conversely, a systematic review by Mostafavifar et al 32 on the effect of KT on musculoskeletal injury reported that there was insufficient evidence to make a recommendation about the use of KT. Additionally, in another systematic review, Morris et al 33 did not recommend the use of KT over other modalities for the treatment of clinical conditions. Neither Mostafavifar et al 32 nor Morris et al 33 included statistical analysis in their systematic reviews. All authors made recommendations for more rigorous, higher quality future research. Finally, it is important to note than none of the studies reported that there were detrimental effects resulting from the use of KT. With regard to PFP specifically, the effects of KT on pain and functional measures are currently inconclusive. In a systematic review, Aguilar and Merino Marban 34 suggest that KT 5

17 appears to improve pain in individuals with PFP, but the existing evidence is inconclusive. This is likely because results from individual studies vary. Additionally, in a systematic review, Montalvo et al 35 noted that the benefits of KT do not appears to differ from those of the McConnell medial glide technique and that KT is minimally effective in reducing pain and improving knee extensor performance in individuals with PFP. However, both sets of authors noted that existing literature is of varying quality and that more high quality research needs to be conducted. 34,35 In addition to claims about pain reduction and performance improvements, KT manufacturers claim that the benefits of the tape can be maintained when left in situ for up to five days. 36,37 Few studies have investigated prolonged application. 38,39 Kaya et al 38 compared a physical rehabilitation protocol to a physical rehabilitation protocol and KT application in patients with subacromial impingement. Kinesiology tape was applied every three days for two weeks. 38 Pain and disability scores were significantly lower in the KT group compared to the control group after one week of treatment, though they did not differ at the end of two weeks. 38 Similarly, Castro Sanchez et al 39 compared a therapeutic KT application to sham application on the low back in individuals with chronic low back pain. Kinesiology tape was applied every seven days for four weeks. 39 Pain and disability scores were significantly lower and trunk muscle endurance was significantly higher in the therapeutic KT group compared to the sham group at one week. 39 While there were no difference between groups with regard to disability, improvements in pain and trunk endurance were maintained in the therapeutic KT group at the end of the four weeks. 39 Conversely, neither Akbas et al 40 nor Aytar et al 41 found more rapid improvements in pain 6

18 or functional performance in individuals with PFP with prolonged KT application. These findings indicate that pain reduction and performance improvements may result more quickly with the application of KT, though evidence is conflicting. As demonstrated in this literature review, evidence on the use of KT to improve pain and functional performance in individuals with musculoskeletal injury, and specifically PFP, is inconclusive. Moreover, there is conflicting evidence regarding the prolonged use of KT to treat musculoskeletal injury and PFP. Therefore, the purpose of this dissertation was to investigate the effects of different therapeutic KT applications on pain and functional measures in physically active individuals with PFP both acutely and over time. METHODS AND MATERIALS Design A randomized repeated measures design with within and between group factors was used. Sixty four PFP patients will serve as their own controls. Results from the power analysis to determine sample size for each component of the experiment are listed in Table 1. Table 1. Numbers needed for effect size f = 0.5, power = 0.8, α = 0.05, and β = 0.8 Comparison N Within groups 12 Between groups 36 Interaction 16 7

19 Subjects Patients were recruited from the general student population at a large university by the principal investigator. Flyers were placed at student health services and in the university recreation center. Additionally, the principal investigator recruited in person in a variety of high enrollment classes on campus and sport clubs. Potential participants were referred to student health services to be assessed for PFP by a licensed athletic trainer. Athletic trainers are employed by the university to treat all musculoskeletal injuries presenting to the clinic where there are no attending sports medicine or orthopedic specialist physicians. In order to standardize a clinical impression, a PFP criteria form was created using diagnostic criteria from previous research (Appendix C) Participants were eligible for inclusion if they met the following criteria: had unilateral knee pain, were assessed for PFP by a licensed athletic trainer, were between the ages of 18 35, and were physically active (exercised a minimum of three days per week for 30 minutes for the last six months). Participants were excluded if they met the following criteria: had knee pain for greater than six months, previous history of traumatic injury or surgery to either hip, knee, or ankle, history of concussion within the preceding 6 months, history of systemic or metabolic dysfunction impairing sensorimotor capabilities, sustained concussion within the preceding six months, or were non English speaking. To date, a total of 33 participants completed this study. There were 9 males and 24 females. Fourteen of 33 participants presented with unilateral pain in the left knee and about 19/33 participants presented with unilateral pain in the right knee. Table 2 demonstrates overall participant characteristics. 8

20 Table 2. Participant demographics and antrhopometrics Characteristic Mean(SD) Age 21.2(3.1) Height (in) 65.5(4.1) Weight (lb) 147.4(32.6) Involved leg length (cm) 34.2(2.3) Uninvolved leg length (cm) 34.2(2.4) Kujala score 80.0(7.9) Tegner activity score 6.0(1.4) Variables This experiment had two independent variables: intervention and time. Intervention had four levels: knee kinesiology tape, hip kinesiology tape, combined knee and hip kinesiology tape, and placebo treatment. The placebo treatment was a simulated threeminute laser therapy session. Time had three levels: baseline, acute application, and prolonged application. Independent Variables Intervention o Knee KT o Hip KT o Knee and hip KT o Placebo laser treatment Time o Baseline (day 0) o Acute (day 3) o Prolonged (day 8) 9

21 Dependent Variables Dynamic postural control o Reach distance for the anterior reach of the SEBT (% leg length) Lower extremity mean surface electromyography (semg) amplitude (% maximum voluntary isometric contraction) during execution of the anterior reach of the SEBT o Quadriceps (vastus medialis, vastus lateralis) o Hip (gluteus maximus as a proxy for the gluteus medius) Dynamic stability o Jump distance on the modified crossover hop for distance Knee flexion and hip abduction peak moment (ft lbs) at 60 /s Knee flexion and hip abduction endurance/total work (ft lbs) at 240 /s Pain during each successful trial of each task Interventions Knee kinesiology taping technique (Figure 1) Before the knee therapeutic taping technique, body hair was removed with electric clippers. For the application, participants sat in a chair with the knee in 90 of flexion. The anchor of a Y strip was placed at the tibial tuberosity. One arm of the Y strip was placed along the medial knee (out of the way of the vastus medialis oblique to allow semg pad placement) and was anchored at the mid thigh with no tension. The other arm of the Y strip was placed along the lateral knee and was anchored at the mid thigh with no tension. 10

22 Hip kinesiology taping technique (Figure 2) For the hip therapeutic taping technique, body hair was removed with electric clippers. For the application, participants were side lying on the uninvolved leg. Participants were instructed to move to the end of the table so as to allow the involved leg to hang posteriorly in a stretched position. An I strip was anchored just inferior to the iliac crest. The tape was then placed distally with no tension inferior to the greater trochanter. 11

23 Knee and hip kinesiology taping technique Both the aforementioned knee and hip kinesiology taping techniques were applied. Placebo laser treatment (Figure 3) For the placebo laser treatment, participants were instructed to lay supine on a table. Both the investigator and the participant wore protective eyewear and a towel covered the treatment area. A laser head was attached to the Chattanooga Vectra Genisys combination electrical stimulation and laser unit (DJO Global, Inc., Chatanooga, Inc., Vista, CA, USA) and, in order to simulate a typical treatment. Participants underwent three sets of one minute laser treatments. The laser head was placed at three sites surrounding the most painful area of the anterior knee for one minute each. The investigator instructed the participant to notify her if excessive heat or discomfort were felt so simulate a true treatment. The participant was unaware that no treatment was administered. While the unit was making sounds, there was no therapeutic value to the placebo treatment. This placebo was designed to control for investigator time and attention. 12

24 Testing Procedures Upon being assessed for PFP by an athletic trainer, participants were scheduled for three lab sessions over an eight day period. Upon consenting at the baseline data collection session, participants completed the Kujala Questionnaire to quantify the disability resulting from their knee pain (Appendix D). Their Tegner Activity Score was also assessed to quantify their level of physical activity over the preceding six month period. Demographics (age, gender) and biometric data (height, weight, leg length) were recorded from each participant (Appendix E). Every data collection session was preceded by a warm up of walking at 2.7 miles per hours for five minutes on a treadmill (Trackmaster Treadmills, Newton, KS, USA). At the baseline data collection session both the involved and uninvolved legs were tested. The uninvolved leg was used as a control for the involved leg. The sequence of testing legs was randomized using permutation to eliminate the effect of order. Patellofemoral patients underwent a baseline testing session in order to both gather 13

25 bilateral baseline information for comparisons. Participants were randomly assigned to complete either the Star Excursion Balance Test (SEBT) first or the modified crossover hop for distance first using permutation. These tests were followed by knee and hip isokinetic dynamometry so as to prevent the effects of fatigue from maximal strength and endurance output on SEBT execution and hop distance. Patients were randomized to complete hip or knee testing first using permutation. Strength testing preceded endurance testing to eliminate the effect of fatigue. Following a 72 hour break used to recover from the baseline protocol, PFP patients returned for a second data collection session to measure functional outcomes in the involved leg only following the application of the first randomly selected intervention (knee KT, hip KT, knee & hip KT, or placebo). They completed the same randomly assigned protocol from the first data collection session. Patients assigned to taping interventions were instructed to leave the tape in situ and continue with outside activity as normal until the third data collection session five days later. During the third data collection session, functional outcomes were measured one final time in the involved limb using the same protocol as the previous data collection sessions. Dynamic Postural Control: Star Excursion Balance Test (SEBT) The goal of the SEBT is to reach as far as possible with one leg in each of the eight prescribed directions while maintaining balance on the contralateral leg. The stance leg requires sufficient dorsiflexion, knee flexion, and hip flexion, and strength, proprioception, and neuromuscular control to execute the task appropriately. The SEBT is best described as 14

26 a functional screening protocol that assesses lower extremity stability. Reliability of the SEBT has been established previously. 49,50 For this study, only the anterior reach of the SEBT was used as research indicates it is most sensitive to patellofemoral pain. 42 The SEBT was performed with the participant standing at the center of an outlined floor grid with one line extending at a 90 angle from the center of another line. The grid was constructed in an open area using a protractor and two 1.5 in wide adhesive tape strips on a hard bare floor. A verbal and visual demonstration of the testing procedure was given to each participant by the investigator. Each participant performed four practice trials in the anterior direction before attempting successful reaches to become familiar with the task, as recommended by Robinson & Gribble 51. Practice trials were followed by two minutes of rest before successful reaches were attempted. To perform the SEBT, the participant maintained a single leg stance while reaching with the opposite leg as far forward as possible along the anterior vector (Figure 4). The participant touched the furthest point possible on the line with a toe touch using minimal pressure in order to ensure that stability was achieved through neuromuscular control of the stance leg. The participant then returned to a unilateral stance while maintaining equilibrium. The investigator manually measured the distance from the center of the grid to the touch point with a tape measure in centimeters. Measurements were taken at the end of the research by the same investigator. Reach distance was marked and measured from the crosshair at the center of the star to the mark within 1 mm of precision. Three successful reaches in the anterior direction were recorded along with pain measures (Appendix F). Participants were given 15 s of rest between reaches. For the baseline session, 15

27 participants rested for two minutes before the contralateral leg was tested and the protocol was repeated. The mean of the three reaches for each leg was calculated. The involved leg was considered the stance leg for follow up testing. The protocol for the SEBT has been described previously. 51 Trials were discarded and repeated if the participant did not touch the line with the foot while maintaining weight bearing on the stance leg, lifted the stance leg from the center grid, lost balance at any point in the trial, or did not maintain start and end positions for one full second. If a participant was judged by the investigator to have touched down with the reach foot in a manner that caused that foot to provide too much support, the trial was discarded and repeated. For example, if the reach foot was used to widen the base of support the trial was discarded. The base of support was the stance foot for the entire trial, including the time when the reach foot tapped the ground. To control for countermovement with the upper 16

28 body, participants were instructed to perform the task with their hands on hips. Neither verbal cues nor encouragement were provided to participants during execution of the SEBT. Neuromuscular Assessments: Surface Electromyography (semg) For the semg protocol, body hair was removed with electric clippers. The sites of electrode placement on the skin were scrubbed with an adhesive pad and cleaned with an alcohol prep pad. Self adhesive Ag/AgCl bipolar surface electrodes (BIOPAC Systems, Inc., Santa Barbara, CA) 10 millimeters (mm) in diameter were positioned in pairs 25 mm apart over the mid belly of appropriate musculature in line with the direction of fibers. Standard anatomic locations for placing electrodes were identified by palpation of respective midbelly musculature during isometric contraction (Figure 5). 52 A single reference electrode was placed on the anteromedial aspect of the tibial tuberosity as suggested standard procedure. 52 Surface electromyographic (semg) signal activity collected via electrodes was conveyed to a stationary tethered module (BIOPAC Systems, Inc., Santa Barbara, CA). Normalization of semg was accomplished with the collection of respective maximum voluntary isometric contractions (MVICs). To achieve the MVIC, patients were placed in the mid range of motion for each joint using the Biodex System 4 Dynamometer (Biodex Medical Inc., Shirley, NY, USA). The mid range for the knee was 45 of flexion and the midrange for the hip was 68 of abduction. Participants completed one practice MVIC at each position that lasted six seconds before MVIC was completed for data collection. On each day, before beginning the SEBT, participants were placed into the respective positions for MVIC collection for the knee and hip. For the MVIC data collections, the investigator verbally encouraged the participant to achieve maximum contraction. 17

29 For the SEBT, the semg signal was considered a muscular contraction if the neuromuscular activity exceeded a set trigger level of 10% MVIC. Integrated semg values were to be separately averaged across three successful trials in the anterior reach direction of the SEBT. Mean amplitude of signal activity of the following musculature were to be assessed: vastus medialis, vastus lateralis, and gluteus maximus as a proxy for the gluteus medius. Earl and Hertel 53 have previously established utility of SEMG in assessing lower extremity neuromuscular profiles during execution of the SEBT and its applications to various lower extremity conditions. For collection of semg data, the investigator told the participant when to begin the reach. Participants were instructed to first assume a single leg stance position. Once the position was achieved, the investigator directed the participant to begin the anterior reach of the SEBT after initiating semg data collection. A laboratory assistant marked the location of the toe touch and the investigator ended the semg data collection once the participant showed one second of control in the ending stance position. 18

30 Adapted Crossover Hop for Distance Hop tests are used to assess performance related to dynamic stability in patients with knee pathology. 54 They have been shown to have both high measurement reliability and high intra tester reliability in a healthy population. 55,56 The goal of the adapted crossover hop is for the participants to cover as much distance as possible in four hops. With each hop, the participant was instructed cross over a pre marked course that was 20 cm wide by 900 cm long. The participant was instructed to stand on their dominant leg with the lateral portion of the foot in line with the contralateral edge of the course, with the most tip of their longest toe touching the edge of the starting line (Figure 6). The participant was then instructed to try to cover the most distance possible by completing four consecutive hops, crossing over the course with each hop. If the participant touched the ground with the non stance foot during the trial, did not clear the lateral sides of the course, and/or the paused for too long in between each hop, the trial was discarded and repeated. Distance covered was measured using a measuring tape in inches and recorded along with pain measures (Appendix G). Three practice trials followed by three successful trials were completed with a minute of rest between each trial. The average of the three test trials was calculated and used as the final measurement. 19

31 Strength and Endurance Measurements: Isokinetic Dynamometry Isokinetic knee extensor and hip abductor muscular strength and endurance were tested with the Biodex System 4 Dynamometer (Biodex Medical Inc., Shirley, NY, USA) calibrated to specifications outlined by the manufacturer. Parameters assessed included bilateral concentric reciprocal knee extension/flexion peak moment in ft lbs at 60 /s and total work (endurance) in ft lbs at 240 /s. Moment values were automatically adjusted for gravity via Biodex Advantage Software (Biodex Medical Inc., Shirley, NY, USA). These velocities were chosen due to their prevalence in sports medicine literature assessing knee muscular strength and endurance. 57 Kannus 58 established validity of peak moment in strength assessments and reliability of the parameter as a significantly reproducible variable to calculate via isokinetic dynamometry. Feiring et al 59 established reliability and validity for 20

32 isokinetic concentric modes of knee joint flexion and extension peak moment at 60 /s and work at 240 /s. For the knee protocols, participants were seated and secured in an upright position on the dynamometer via torso, pelvic and thigh straps. Individuals folded their arms across their chest while seated to minimize body displacement. For knee joint measurements, the lateral femoral epicondyle was aligned with the axis of rotation of the dynamometer at the resistance adaptor axis. Testing at 60 /s consisted of three progressive warm up trials as follows: 50%, 75%, and 100% of maximum effort. 59 Following two minutes of rest, final measurement of strength was assessed using three maximal repetitions of reciprocal knee joint flexion and extension. 59 At the onset of testing, participants were instructed to beat their last rep and observe the system s computer monitor during data collection in an attempt to provide feedback about maintenance of maximal force output. For the baseline data collection session, participants completed strength testing on the contralateral leg before moving onto the hip strength protocol. Upon completion of all knee and hip strength protocols, endurance testing was performed at 240 /s. Prior to completing the endurance protocol, participants completed four sub maximal warm up repetitions with a fifth maximal repetition. 59 Following 15 seconds of rest, participants completed as many maximal reciprocal knee joint flexion and extension contractions as possible in a 45 s time period. 59 Participants were instructed to beat their last rep by observing the system s computer monitor during data collection in an attempt to provide feedback about maximal force output. 21

33 For the hip protocols, participants assumed a side lying position with their shoulders, hips, and knees stacked, square, and in line with one another. For the hip joint measurements, the resistance adaptor axis was placed slightly superior and medial to the greater trochanter. Once the distal thigh was secured in the hip arm of the dynamometer, participants were instructed to flex the knee and thigh of the contralateral limb to allow full adduction of the test limb. Testing at 60 /s consisted of three progressive warm up trials as follows: 50%, 75%, and 100% of maximum effort. 59 Following two minutes of rest, final measurement of strength was assessed using three maximal repetitions of reciprocal hip joint abduction and adduction. 59 Because participants could only observe the system s computer monitor from one position in the test position, no visual feedback regarding maintenance of maximal output was allowed. For the baseline data collection session, participants completed strength testing on the contralateral leg before moving onto the hip strength protocol. Upon completion of all knee and hip strength protocols, endurance testing was performed at 240 /s. Prior to completing the endurance protocol, participants completed four sub maximal warm up repetitions with a fifth maximal repetition. 59 Following 15 seconds of rest, participants completed as many maximal reciprocal knee joint flexion and extension contractions as possible in a 45 s time period. 59 At the end of each trial for data collection, participants were instructed to record their pain (Appendix H). Neither verbal cues nor communication of encouragement were directed to participants performing any of the aforementioned isokinetic dynamometer protocols. 22

34 Kujala Questionnaire Score The Kujala Questionnaire Score is a tool that measures the function and amount of knee joint pain a patient experiences while performing several tasks associated with activities of daily living. 60 An advantage of this questionnaire is that it is suitable for administering to any patient experiencing anterior knee pain. It also includes a variety of questions addressing knee joint pain encountered with running, jumping, squatting, sitting with the knee in flexion, and knee joint swelling. The questionnaire is self administered and consists of thirteen inquiries in one consistent format. Each question has answers that correspond with a point value and participants were instructed to choose the most appropriate selection. The final cumulative score ranges from 0 to 100 with a higher tally indicating a more favorable knee joint condition. Reliability of this subjective assessment tool has been previously established for clinical applications pertaining to patellofemoral joint dysfunction. 61 Patients with PFP completed questionnaire prior to the baseline data collection session. Participants were instructed to choose the answer that best described their knee pain symptom. Visual Analog Scale (VAS) for Pain A VAS is a measurement instrument that records a subjective characteristic, which ranges across a continuum of values. 62 For application in this research study the amount of pain that a PFP patient experienced was described as ranging across a continuum from 0 mm (no pain) to 100 mm (extreme pain). Participants marked a point on the continuum (line) they felt best described their knee pain immediately following each successful trial the aforementioned tasks. The instruction was, Please mark your pain, if you had any. The 23

35 VAS score was determined by measuring with a standard ruler in mm from the left hand end of the line to the point that the patient marked. The VAS has been previously validated in sports medicine literature and is commonly used in patients suffering from PFP. 63 No verbal cues or communication of recommended assessments will be directed to participants at any time during completion of the VAS. Statistical Analysis Descriptive statistics, including group means and standard deviations were calculated for participant characteristics and dependent variables. Paired t tests were used to identify differences in dependent variables between the involved and uninvolved limbs. One way ANOVA was used to identify differences among interventions with regard to the dependent variables at baseline, for all times, and Tukey s HSD was used to make pairwise comparisons where there were significant differences and to obtain 95% confidence intervals. A 3x4 repeated measures ANOVA was used to examine the condition x time interactions, within group differences over time, and between group differences with regard to the interventions. When indicated, Bonferroni post hoc tests were conducted to make pairwise comparisons. Effect sizes (Cohen s d) were calculated for each condition using the baseline as the comparison for each intervention and each dependent variable. Residual analyses were performed on all data to determine assumptions for ANOVa. Most data violated the assumption of homogeneity and both parametric and nonparametric statistics were used for all analyses. There were no differences in results between parametric and nonparametric statistics. Because the parametric statistics used are robust and more detailed information can be taken from them, we decided to present the results 24

36 of the parametric tests. An a priori alpha level of p < 0.05 was selected to determine statistical significance. Missing data There were invalid data collected for semg. There were only seven participants with valid data, or data that only had one measure or less that registered over 100% of MVIC. This was a repeated measures study; as such, if two out of three data collection sessions were successful, the data could not be used for analysis. As a result, semg data were not analyzed. Additionally, all uninvolved hip abductor endurance data points, 17 involved hip abductor endurance data points, ten acute hip abductor endurance data points, and ten prolonged hip abductor endurance data points were missing. Those data were also not analyzed. There may have been an error with the Biodex that resulted in lost data for this measure. RESULTS Baseline measures Table 3 demonstrates the results of a one way ANOVA to investigate differences in characteristics among the four intervention groups at baseline. There were no differences in age, height, weight, or Tegner activity score. There was a statistically significant difference in Kujala score. A post hoc analysis revealed that the placebo group had a significantly lower score than the hip KT group (p = 0.024) and the hip and knee KT group (p = 0.014), but was not different from the knee KT group (p = 0.225). The results of baseline performance comparing involved and uninvolved limbs using a paired t test are presented in Table 4. There was no difference between involved and 25

37 uninvolved limbs with regard to performance on the crossover hop test. However, the uninvolved limb performed significantly better than the involved limb for the anterior reach of the SEBT, knee extension peak torque, hip abduction peak torque, and knee extension work. The results of baseline visual analog scale for pain comparing involved and uninvolved limbs using a paired t test are presented in Table 5. There was no difference between involved and uninvolved limbs with regard to self reported pain during the hip abduction strength measure. However, participants reported significantly high pain in the involved limb during execution of the anterior reach of the SEBT, crossover hop test, knee extension strength measures, and knee extension and hip abduction work measures. Table 3. Mean(SD) and results of one way ANOVA for the differences among participant characteristics by intervention Intervention Characteristic Knee KT Hip KT Knee + Hip KT Placebo Sig. Number Age 22.7(4.6) 20.4(2.6) 20.6(2.0) 21.2(3.1) Height (in) 65.7(4.2) 63.3(5.0) 67.2(3.9) 64.9(2.2) Weight (lb) 152.2(33.7) 133.8(26.0) 157.3(35.4) 137.7(32.3) Duration of symptoms (mo) 2.9(1.1) 2.8(2.0) 3.2(1.4) 3.8(1.8) Kujala score 79(8.3) 83.4(7.9) 83.2(4.5) 71.7(7.4) Tegner activity score 6.0(0.9) 6.0(1.7) 6.0(1.7) 5.8(1.5) Table 4. Mean(SD) and results of paired t tests for the differences between involved and uninvolved limbs for each task Task Involved Uninvolved Sig. SEBT reach distance (% leg length) 81.3(9.7) 83.4(9.6) Crossover hop distance (in) 140.8(50.0) 147.0(46.3) Knee extension peak torque () 102.1(50.2) 111.2(55.0) <0.001 Hip abduction peak torque() 62.2(24.5) 66.0(27.2) <0.001 Knee extension work (942.2) (1020.5) <

38 Table 5. Mean(SD) and results of paired t tests for the differences between involved and uninvolved limbs for the VAS during each task (mm) Task Involved Uninvolved Sig. SEBT reach distance 13.0(15.3) 2.1(7.2) <0.001 Crossover hop for distance 23.2(20.6) 3.5(7.4) Knee extension peak torque 24.1(22.2) 4.9(11.5) <0.001 Hip abduction peak torque 6.8(13.7) 1.0(3.3) Knee extension work 19.6(21.6) 3.9(8.9) <0.001 Hip abduction work 8.7(12.6) 1.5(4.1) <0.001 Anterior reach of the SEBT: distance and pain Results of a one way ANOVA investigating differences in mean scores among intervention groups for both performance on and pain during execution of the SEBT revealed that there were no differences at baseline. For distance (% leg length), neither the time x intervention interaction nor the main effect of intervention were statistically significant (Table 6). However, the main effect of time was statistically significant (p = 0.031). A Bonferroni post hoc test indicated that participants performance following prolonged wear was significantly better than that at acute application. The 95% confidence intervals (CIs) for SEBT performance are presented in Table 7. For the visual analog scale for pain, neither the time x intervention interaction nor the main effect of intervention were statistically significant (Table 8). However, the main effect of time was statistically significant (p = 0.010). A Bonferroni post hoc test revealed that pain following prolonged wear was lower than pain at baseline. The 95% CIs for SEBT pain are presented in Table 9. 27

39 Table 6. Means (SD) and results of repeated measures and one way ANOVA for differences among SEBT reach distances over time by intervention (% leg length) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo Total F p Baseline 84.7(9.7) 80.4(13.2) 79.5(8.9) 80.5(7.1) 81.3(9.7) Acute 84.0(11.4) 81.4(13.2) 81.7(10.2) 79.6(7.4) 82.0(10.4) Prolonged 87.2(12.4) 83.0(11.7) 82.1(8.5) 82.2(7.0) 83.7(10.0)* F intervention x time = 0.54, p = *significantly different from baseline F time = 4.13, p = Table 7. 95% CI for the mean difference among SEBT reach distances over time by intervention (% leg length) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo 95% CI (lower, upper) Baseline Acute ( 6.8, 5.3) ( 2.5, 7.8) ( 3.3, 7.8) ( 9.0, 7.0) Prolonged ( 4.6, 9.6) ( 2.6, 7.8) ( 0.6, 5.9) ( 6.5, 9.7) Acute vs. Prolonged (0.3, 6.2) ( 1.6, 3.9) ( 3.1, 4.0) ( 1.5, 6.6) Table 8. Means (SD) and results of repeated measures and one way ANOVA for differences among VAS scores following execution of the SEBT over time by intervention (mm) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo Total F p Baseline 9.5(8.0) 8.2(7.1) 15.3(21.6) 19.5(16.9) 13.0(15.3) Acute 12.0(16.9) 2.3(2.1) 7.1(9.3) 15.6(24.9) 9.0(14.7) Prolonged 2.7(3.2) 4.7(8.7) 4.8(5.6) 5.6(8.4) 4.4(6.2)* F intervention x time = 0.84, p = *significantly different from baseline F time = 5.00, p =

40 Table 9. 95% CI for the mean difference among pain scores during the SEBT over time by intervention (mm) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo 95% CI (lower, upper) Baseline Acute ( 17.5, 22.4) ( 14.8, 3.1) ( 25.9, 9.4) ( 21.6, 13.8) Prolonged ( 14.7, 1.1) ( 12.5, 5.6) ( 28.4, 7.4) ( 33.3, 5.5) Acute vs. Prolonged ( 27.1, 8.6) ( 7.9, 12.6) ( 9.6, 5.2) ( 42.0, 22.0) Crossover hop test: distance and pain Results of a one way ANOVA investigating differences in mean scores among intervention groups for both performance on and pain during the crossover hop test revealed that there were no differences at baseline. For distance, neither the time x intervention interaction nor the main effect of intervention were statistically significant (Table 10). However, the main effect of time was statistically significant (p = 0.011). A Bonferroni post hoc test indicated that participants performed significantly better following prolonged application compared to both baseline measure and acute application. The 95% CIs for crossover hop performance are presented in Table 11. For the visual analog scale for pain, neither the time x intervention interaction nor the main effect of intervention were statistically significant (Table 12). However, the main effect of time was statistically significant (p = 0.001). A Bonferroni post hoc test indicated that participants reported significantly lower pain following both acute application and prolonged application 29

41 compared to the baseline measure. The 95% CIs for pain during the crossover hop are presented in Table 13. Table 10. Means (SD) and results of repeated measures and one way ANOVA for differences among distances achieved on the crossover hop for distance over time by intervention (in) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo Total F p Baseline 127.6(27.7) 144.8(43.9) 152.4(46.4) 134.4(86.4) 148.8(50.0) Acute 146.5(47.1) 144.4(38.4) 156.4(45.0) 133.5(84.2) 147.0(51.4) Prolonged 150.0(57.0) 151.6(38.8) 161.0(49.2) 141.3(94.9) 152.4(57.6)* F intervention x time = 1.26, p = *significantly different from baseline F time = 6.05, p = Table % CI for the mean difference between crossover hop distances over time by intervention (in) Intervention Knee + Hip Time Knee KT Hip KT KT Placebo 95% CI (lower, upper) Baseline Acute ( 4.2, 42.0) ( 23.1, 22.3) ( 8.5, 16.7) ( 18.8, 17.0) Prolonged ( 11.3, 55.8) ( 7.4, 21.1) ( 7.8, 25.0) ( 19.6, 33.3) Acute vs. Prolonged ( 10.1, 16.8) ( 4.8, 19.4) ( 4.5, 13.5) ( 10.1, 25.6) Table 12. Means (SD) and results of repeated measures and one way ANOVA for differences among VAS scores following the crossover hop for distance over time by intervention (mm) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo Total F p Baseline 25.3(25.9) 11.3(11.5) 25.1(19.2) 30.2(21.5) 23.2(20.6) Acute 7.2(7.8) 8.6(9.2) 18.5(19.9) 21.3(18.1) 13.8(15.6) Prolonged 7.0(8.5) 8.6(16.6) 12.2(11.6) 20.4(20.7) 11.5(14.2) F intervention x time = 0.92, p = F time = 7.53, p =

42 Table % CI for the mean difference among pain scores during the crossover hop over time by intervention (mm) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo 95% CI (lower, upper) Baseline Acute ( 40.0, 3.8) ( 13.0, 7.7) ( 24.6, 11.3) ( 33.4, 15.6) Prolonged ( 40.9, 4.3) ( 17.4, 12.0) ( 28.5, 2.7) ( 37.1, 17.5) Acute vs. Prolonged ( 7.9, 7.5) ( 13.6, 13.6) ( 20.7, 8.2) ( 19.4, 17.6) Isokinetic knee extension: strength and pain Results of a one way ANOVA investigating differences in mean scores among intervention groups for both performance on and pain during the knee extensor strength task revealed that there were no differences at baseline (Table 14). Additionally, neither the time x intervention interaction nor the main effects of time or intervention were statistically significant for peak torque. The 95% CIs for knee extensor strength are presented in Table 15. For the visual analog scale for pain, neither the time x intervention interaction nor the main effect of intervention were statistically significant (Table 16). However, the main effect of time was statistically significant (p = 0.006). A Bonferroni post hoc test indicated that participants reported significantly lower pain following prolonged application compared to the baseline measure. The 95% CIs for pain are presented in Table

43 Table 14. Means (SD) and results of repeated measures and one way ANOVA for differences among knee extension peak torque at 60 /s over time by intervention Intervention Time Knee KT Hip KT Knee + Hip KT Placebo Total F p Baseline 89.8(39.8) 79.8(46.4) 118.3(45.0) 116.7(71.8) 102.1(50.2) Acute 109.4(44.6) 91.5(44.9) 116.1(36.0) 121.2(79.3) 110.0(48.8) Prolonged 101.7(42.1) 88.2(36.9) 128.8(56.4) 114.2(77.8) 110.1(53.7) F intervention x time = 0.40, p = F time = 0.76, p = Table % CI for the mean difference among knee extension peak torques at 60 /s over time by intervention (ft lbs) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo 95% CI (lower, upper) Baseline Acute (6.1, 33.2) ( 13.1, 36.4) ( 20.1, 15.8) ( 13.0, 22.1) Prolonged ( 3.6, 27.3) ( 24.9, 41.7) ( 9.0, 30.1) ( 151.7, 146.7) Acute vs. Prolonged ( 18.0, 2.5) ( 20.3, 13.7) ( 12.7, 38.1) ( 169.1, 155.0) Table 16. Means (SD) and results of repeated measures and one way ANOVA for differences among VAS scores following knee extension at 60 /s over time by intervention (mm) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo Total F p Baseline 27.1(24.5) 10.6(15.2) 23.5(21.6) 36.5(22.7) 23.2(20.6) Acute 29.6(26.2) 9.0(15.0) 18.6(14.5) 31.7(20.1) 13.8(15.6) Prolonged 18.2(20.6) 8.9(17.9) 15.5(13.8) 21.3(17.1) 11.5(14.2) F intervention x time = 0.83, p = F time = 5.62, p =

44 Table % CI for the mean difference among pain scores during knee extension peak torques at 60 /s over time by intervention (mm) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo 95% CI (lower, upper) Baseline Acute ( 14.0, 18.9) ( 6.9, 3.6) ( 21.2, 11.3) ( 22.5, 12.9) Prolonged ( 30.2, 12.4) ( 8.5, 4.9) ( 20.1, 4.1) ( 26.7, 3.7) Acute vs. Prolonged ( 31.5, 8.8) ( 5.6, 5.3) ( 14.4, 8.2) ( 31.1, 10.4) Isokinetic hip abduction: strength and pain Results of a one way ANOVA investigating differences in mean scores among intervention groups for both performance on and pain during the hip abductor strength task revealed that there were no differences at baseline. For hip abductor strength, neither the time x intervention interaction nor the main effect of intervention were statistically significant (Table 18). However, the main effect of time was statistically significant (p = 0.007). A Bonferroni post hoc test indicated that participants performed significantly better following both acute application and prolonged application compared to the baseline measure. The 95% CIs for hip abductor strength are presented in Table 19. For the visual analog scale for pain, neither the time x intervention interaction nor the main effects of time or intervention were statistically significant (Table 20). The 95% CIs for pain are presented in Table

45 Table 18. Means (SD) and results of repeated measures and one way ANOVA for differences among hip abduction peak torque at 60 /s over time by intervention Intervention Time Knee KT Hip KT Knee + Hip KT Placebo Total F p Baseline 68.6(25.7) 42.8(13.4) 72.5(22.6) 56.5(25.9) 62.2(25.7) Acute 82.4(29.7) 60.2(23.6) 79.9(16.2) 75.5(35.5) 75.6(26.0) Prolonged 77.7(29.2) 68.2(27.0) 78.4(25.2) 81.8(56.3) 76.7(32.7) F intervention x time = 0.62, p = F time = 6.68, p Table % CI for the mean difference among hip abduction peak torques at 60 /s over time by intervention (ft lbs) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo 95% CI (lower, upper) Baseline Acute ( 1.2, 28.2) ( 5.1, 39.8) ( 10.5, 25.3) (2.6, 35.6) Prolonged ( 7.8, 25.9) (1.1, 49.8) ( 5.1, 16.9) ( 63.1, 113.9) Acute vs. Prolonged ( 14.3, 4.9) ( 12.4, 28.6) ( 18.8, 15.8) ( 96.6, 109.2) Table 20. Means (SD) and results of repeated measures and one way ANOVA for differences among VAS scores following hip abduction at 60 /s over time by intervention (mm) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo Total F p Baseline 7.3(13.2) 0.71(1.9) 12.1(19.6) 3.3(4.2) 6.8(13.7) Acute 7.1(12.3) 0.71(1.5) 6.4(7.4) 8.7(11.3) 5.8(9.1) Prolonged 1.6(3.4) 0.71(1.9) 3.6(5.3) 2.7(4.5) 2.3(4.1) F intervention x time = 0.62, p = F time = 1.42, p =

46 Table % CI for the mean difference among pain scores during hip abduction peak torques at 60 /s over time by intervention (mm) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo 95% CI (lower, upper) Baseline Acute ( 18.0, 17.6) ( 3.3, 3.3) ( 25.8, 14.3) ( 12.2, 22.9) Prolonged ( 19.0, 7.5) ( 3.6, 3.6) ( 26.2, 9.3) ( 2.4, 1.1) Acute vs. Prolonged ( 19.1, 8.0) ( 0.7, 0.7) ( 9.2, 3.8) ( 23.0, 11.0) Isokinetic knee extension: endurance and pain Results of a one way ANOVA investigating differences in mean scores among intervention groups for both performance on and pain during the knee extension endurance task revealed that there were no differences at baseline. For knee extensor endurance, neither the time x intervention interaction nor the main effect of intervention were statistically significant (Table 22). However, the main effect of time was statistically significant (p = 0.010). A Bonferroni post hoc test indicated that participants performed significantly better following prolonged application compared to the baseline measure. The 95% CIs for knee extensor endurance are presented in Table 23. For the visual analog scale for pain, neither the time x intervention interaction nor the main effects or time or intervention were significant (Table 24). The 95% CIs for pain are presented in Table

47 Table 22. Means (SD) and results of repeated measures and one way ANOVA for differences among total work during knee extension at 240 /s over time by intervention by intervention (ft lbs) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo Total F p Baseline (982.9) (615.2) (1079.1) (1115.0) (942.2) Acute (909.5) (482.3) (889.2) (1352.9) (941.6) Prolonged (958.5) (653.1) (873.9) (1654.9) (1018.3) F intervention x time = 1.5, p = F time = 5.58, p = Table % CI for the mean difference among knee extension total work at 240 /s over time by intervention (ft lbs) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo 95% CI (lower, upper) Baseline Acute ( 196.7, 578.5) ( 276.4, 345.3) (33.7, 930.9) ( 637.4, 627.0) Prolonged ( 317.9, 582.1) ( 106.5, 537.6) ( 129.9, 971.6) ( 998.1, ) Acute vs. Prolonged ( 281.8, 164.2) ( 94.0, 456.3) ( 397.5, 274.6) ( , ) Table 24. Means (SD) and results of repeated measures and one way ANOVA for differences among VAS scores following knee extension at 240 /s over time by intervention (mm) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo Total F p Baseline 22.6(25.5) 5.9(7.4) 22.3(23.5) 26.2(20.8) 19.6(21.6) Acute 14.9(16.4) 8.7(12.6) 20.3(21.1) 22.0(22.3) 16.7(18.4) Prolonged 14.4(20.9) 3.4(5.1) 18.1(22.2) 20.3(13.5) 14.4(18.3) F intervention x time = 0.25, p = F time = 1.33, p =

48 Table % CI for the mean difference among pain scores during knee extension work at 60 /s over time by intervention (mm) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo 95% CI (lower, upper) Baseline Acute ( 22.2, 6.8) ( 13.1, 18.7) ( 16.7, 12.7) ( 34.3, 25.9) Prolonged ( 41.2, 25.0) ( 12.2, 7.5) ( 12.4, 4.0) ( 25.8, 14.1) Acute vs. Prolonged ( 25.7, 24.8) ( 14.7, 4.4) ( 12.5, 8.2) ( 26.1, 22.7) Isokinetic hip abduction: pain Results of a one way ANOVA investigating differences in mean scores among intervention groups for pain during the hip abduction endurance task revealed that there were no differences at baseline. For the visual analog scale for pain, neither the time x intervention interaction nor the main effect of intervention were statistically significant (Table 26). However, the main effect of time was statistically significant (p = 0.014). A Bonferroni post hoc test revealed that participants reported significantly lower pain following prolonged application compared to the baseline measure. The 95% CIs for pain are presented in Table 27. Table 26. Means (SD) and results of repeated measures and one way ANOVA for differences among VAS scores during completion of the hip abduction work at 240 /s task over time by intervention (mm) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo Total F p Baseline 5.3(11.5) 2.5(4.9) 15.6(16.0) 8.3(8.8) 8.7(12.6) Acute 4.8(6.5) 3.9(6.6) 7.6(11.2) 7.2(8.6) 6.0(8.5) Prolonged 2.4(3.8) 0.9(2.3) 3.8(5.2) 3.3(5.3) 2.7(4.3) F intervention x time = 1.28, p = F time = 4.78, p =

49 Table % CI for the mean difference among pain scores during knee extension work at 60 /s over time by intervention (mm) Intervention Time Knee KT Hip KT Knee + Hip KT Placebo 95% CI (lower, upper) Baseline Acute ( 22.2, 6.8) ( 13.1, 18.7) ( 16.7, 12.7) ( 34.3, 25.9) Prolonged ( 41.2, 25.0) ( 12.2, 7.5) ( 12.4, 4.0) ( 25.8, 14.1) Acute vs. Prolonged ( 7.2, 2.5) ( 9.5, 3.5) ( 12.7, 5.1) ( 19.0, 11.4) Performance effect sizes For the acute condition of pain, outcomes worsened for some interventions and improved for others. Effect sizes for conditions that showed improvement ranged from low to high (Table 28). Knee KT resulted in the greatest effect sizes for the crossover hop (d = 0.489) and knee extension strength (d = 0.464). Hip KT resulted in the greatest effect size for hip abduction strength (d = 0.907). Combination knee and hip KT resulted in the greatest effect sizes for the SEBT (d = 0.230) and knee extension endurance (d = 0.488). For the prolonged condition of performance, the effect sizes ranged from low to high for nearly all interventions, including placebo (Table 29). Knee KT resulted in the greatest effect sizes on the crossover hop test (d = 0.500) and on knee extension strength (d = 0.290). Hip KT resulted in the greatest effect size for hip abduction endurance (d = 1.192). Combination knee and hip KT resulted in the greatest effect sizes for reach distance on the SEBT (d = 0.299) and knee extension work (d = 0.429). 38

50 Table 28. Cohen s d effect size to determine magnitude of changes in performance from baseline to acute application by intervention Task Knee KT Hip KT Knee + hip KT Placebo SEBT reach distance NA NA Crossover hop for distance NA NA Knee extension peak torque NA Hip abduction peak torque Knee extension work NA Table 29. Cohen s d effect size to determine magnitude of changes in performance from baseline to prolonged application by intervention Task Knee KT Hip KT Knee + hip KT Placebo SEBT reach distance Crossover hop for distance Knee extension peak torque NA Hip abduction peak torque Knee extension work Pain effect size For the acute condition of pain, outcomes worsened for some interventions and improved for others. Effect size for conditions that showed improvement ranged from zero to high (Table 30). Knee KT resulted in the greatest effect sizes for the crossover hop (d = 0.946) and knee extension work (d = 0.359). Hip KT resulted in the greatest effect size for the SEBT (d = 1.127). Combination knee and hip KT resulted in the greatest effect sizes for knee extension strength (d = 0.266), hip abduction strength (d = 0.385), and hip abduction work (d = 0.579). For the prolonged condition of pain, the effect sizes ranged from low to high for nearly all interventions, including placebo (Table 31). Knee KT resulted in the greatest effect sizes for the SEBT (d = 1.116), the crossover hop test (d = 0.949), and knee extension work (d = 0.351). Combination knee and hip KT resulted in the greatest effect sizes for hip 39

51 abduction strength (d = 0.592) and hip abduction work (d = 0.992). Finally, placebo resulted in the greatest effect size for knee extension strength (d = 0.756). Table 30. Cohen s d effect size to determine magnitude of changes in pain from baseline to acute application by intervention Task Knee KT Hip KT Knee + hip KT Placebo SEBT reach distance NA Crossover hop for distance Knee extension peak torque NA Hip abduction peak torque NA Knee extension work NA Hip abduction work NA Table 31. Cohen s d effect size to determine magnitude of changes in pain from baseline to prolonged application by intervention Task Knee KT Hip KT Knee + hip KT Placebo SEBT reach distance Crossover hop for distance Knee extension peak torque Hip abduction peak torque Knee extension work Hip abduction work DISCUSSION The purpose of this research was to investigate the effect KT on pain and functional performance in physically active individuals with PFP. Overall, the results of this research demonstrated that the use of different therapeutic KT techniques did not differ from placebo for reducing pain and improving functional performance in PFP patients. The main effect of intervention was not statistically significant for any of the pain or performance measures; however, there was a significant main effect of time for nearly all measures. The effect sizes for both the therapeutic interventions and the placebo ranged from low to high. 40

52 This finding suggests that improvements may have been due to either placebo effect or to the effect of learning. Anterior reach of the SEBT: performance With regard to performance on the anterior reach of the SEBT, there were no differences between interventions. The main effect of time was significant, indicating that all PFP patients improved reach distance from the baseline condition to the prolonged condition. These results are similar to those of Bicici et al 64 who compared no tape, placebo, athletic tape, and KT applications with regard to performance on four reaches of the SEBT in basketball players with chronic inversion ankle sprains. They found that there were no differences between groups in reach distance for any direction of the SEBT. 64 Shields et al 65 compared healthy controls, copers, and individuals with unstable ankles with regard to postural control before and after the application of KT and found that KT did not significantly improve postural control in either healthy individuals or individuals with ankle pathology. Conversely, Aytar et al 41 compared therapeutic KT to placebo KT with regard to both static and dynamic balance in PFP patients. They found that therapeutic KT significantly improved dynamic balance and that placebo KT significantly improved static balance. 41 The authors suggest that KT may not cause enough cutaneous stimulation to result in consistent changes. 41 While improvements in performance were not statistically significant, the effect sizes indicate that there were minimal improvements in reach distance. The combination knee and hip KT application resulted in the greatest effect sizes for the acute (d = 0.385) and prolonged (d = 0.581) conditions. Slight improvements in the placebo intervention indicate 41

53 that participants may have improved as a result of either placebo effect or the effect of learning. For each testing session, the three recorded trials were preceded by four familiarization tasks. Herrington 49 found that reach distance stabilized after four trials. Changes in reach from baseline to acute conditions and baseline to prolonged conditions did not achieve the 6 8% minimum to be considered real changes in SEBT performance. 49 Therefore, while the effect sizes for the knee and hip KT condition were moderate, improvements in performance were likely random. This finding is supported by the slight improvements also observed in the placebo for the prolonged condition. Crossover hop for distance: performance There were no differences between interventions with regard to performance on the crossover hop test for distance. The main effect of time was significant, indicating that participants improved hop distance from baseline to prolonged conditions. These results were similar to those of previous research. Firth et al 66 investigated single leg hop distance before and after the application of KT in individuals with Achilles tendinopathy. The found that KT had no effect of hop distance. 66 Conversely, Freedman et al 67 used single leg hop distance to compare KT, and sham KT in PFP patients and found that KT significantly improved hop distance. However, they did not have a tapeless control and it is difficult to draw a conclusion about the true effects of hop improvement. 67 As previously mentioned, the observed changes in hop distance were not statistically significant. The effect sizes for two interventions in the acute condition and all interventions in the prolonged condition were low to moderate, indicating that there were slight improvements. In this case, the placebo intervention for the acute condition showed 42

54 decrements in performance and the placebo intervention effect size for the prolonged condition was close to zero. The highest effect size, which was moderate, was observed in the knee KT group both for the acute (d = 0.489) and prolonged (d = 0.500) conditions. The knee KT intervention resulted in a 14 18% change for both time conditions whereas the placebo resulted in a 5% change. While no information exists regarding minimal changes in the modified crossover hop in PFP patients, Reid et al 68 noted that the minimal change of crossover hop distance in anterior cruciate ligament reconstruction patients was 7 13%. The 18% change in the knee KT group exceeds this estimate. Therefore, while not statistically significant, knee KT may have had a real effect on hop distance. This notion is further supported by the lack of improvement in the placebo group. Additionally, no other interventions achieved more than 6% improvement. Knee extensor strength: performance There were no differences between interventions with regard to knee extensor strength. The main effect of time was significant, indicating that participants improved from baseline to prolonged conditions. Aytar et al 41 compared therapeutic KT and placebo KT in PFP patients with regard to knee extensor strength. They found that both therapeutic and placebo KT significantly improved peak torque at 60 /s. 41 However, the improvements were no more than 7% for either group. While statistically significant, the improvements may not have been clinically meaningful. Based on the reported means, the calculated effect size (d = 0.245) was smaller than our effect sizes for the acute (d = 0.464) and prolonged (d = 0.290) conditions. 43

55 Osorio et al 43 compared no tape, McConnell medial glide tape, and KT with regard to knee extensor strength in PFP patients. They found that knee extensor strength increased significantly from no tape to McConnell tape and from no tape to KT, but that McConnell tape did not differ from KT. 43 Again, the reported effect size for KT (d = 0.287) was smaller than the effect sizes we observed both in the acute and prolonged conditions for knee KT. The percent change observed by Osorio et al 43 almost reached 17% for both McConnell tape and KT, which was below the percent change of 21% that we observed. Our findings may not have been significant because we did not achieve the statistical power with regard to sample size. Therefore, knee KT may have resulted in real increases in knee extensor strength. This finding is supported by the lack of changes in knee extensor strength observed in the placebo group for both acute and prolonged conditions. Hip abductor strength: performance There were no differences between interventions with regard to hip abductor strength. The main effect of time was significant, indicating that participants improved from baseline to prolonged conditions. To our knowledge, there have been no other studies that either utilized hip KT or investigated hip abductor strength. The results of our research indicate that hip KT may be effective for improving hip abduction performance. While not significant, changes in hip abduction strength were high for both the acute (d = 0.907) and prolonged (d = 1.192) conditions. The increase in performance from the baseline to prolonged conditions for hip KT was almost 60%. However, the increase in performance for the placebo intervention for the same time was about 45%. While apparently real, these improvements may have come as a result of familiarization with the movement. 44

56 Familiarization was built into the protocol, but because isolated side lying hip abduction is an atypical movement it is more likely that improvements in performance resulted from increased comfort with the movement than from real changes in gluteus medius strength. However, these magnitude increases were not seen in all interventions, so it is difficult to draw any conclusions. Knee extensor endurance: performance There were no differences between interventions with regard to knee extensor endurance. The main effect of time was significant, indicating that participants improved from baseline to prolonged conditions. Though they test endurance differently, Aytar et al 41 compared the effects of no tape, therapeutic KT and placebo KT with regard to knee extensor strength at 180 /s. They found that strength improved significantly in the therapeutic KT group compared to no tape, but that therapeutic KT was not different from placebo KT. 41 The therapeutic KT resulted in an 11% change in performance and had a low effect size (d = 0.263). The placebo KT resulted in very similar changes (10%) and had a similar effect size (d = 0.238). Aytar et al s 41 calculated effect sizes were slightly lower than our effect sizes in the combined knee and hip KT intervention both for the acute (d = 0.488) and prolonged (d = 0.429) conditions. Additionally, the observed changes from the baseline to prolonged conditions for the combined hip and knee KT intervention neared 20%. However, Aytar et al 41 measured peak torque over five seconds at 180 /s whereas we measured total work over 45 seconds at 240 /s. These differences in the methods could account for differences in results. 45

57 Osorio et al 43 compared no tape, McConnell medial glide tape, and KT with regard to knee extensor endurance in PFP patients. They found significant improvements between no tape compared to McConnell tape no tape compared to KT, but there were no differences between McConnell tape and KT with regard to knee extensor endurance. 43 The effect size for KT was moderate (d = 0.548), which was similar to our effect sizes for the combined knee and hip KT intervention for both the acute and prolonged conditions. However, their effect size was much higher than our effect size for the knee KT. Interestingly, changes reported by Osorio et al 43 also neared 20%, which was similar to the changes we observed in the combined knee and hip KT intervention from baseline to prolonged conditions. These findings indicate that knee KT or combined knee and hip KT may result in real improvements in knee extensor endurance. Pain With regard to pain, changes did not appear to match those seen in performance. As suggested by Osorio et al 43, we should have expected to observe decreases in pain that matched improvements in performance. However, the effect size tables indicate that high effect sizes in pain did not necessarily mean high effect sizes in performance. Changes in pain appear to be more related to time than to intervention type. Oddly, the combined knee and hip KT did not consistently result in the greatest effect sizes. Even stranger, the combined knee and hip KT intervention did not result in effect sizes similar to its individual components. These findings contradict that theory that KT acts through cutaneous stimulation as more KT did not result in less pain. 46

58 For the acute condition, some interventions did not demonstrate improvements in pain. Effect sizes ranged from zero to high. For the SEBT hip KT resulted in the greatest decrease in pain. It is possible that KT over the gluteus medius improved activation of the muscle, thereby improving stability/decreasing pain during execution of the SEBT. This is supported by the fact that the combined knee and hip KT intervention also resulted in decreases in pain. For the crossover hop test, knee KT resulted in the greatest decrease in pain. While the effect size was high (d = 0.946), the effect size for the placebo intervention was the second highest (d = 0.448). This finding indicates that knee KT may be effective at reducing pain slightly, but that other interventions were not effective at reducing pain. For knee extensor and hip abductor strength and endurance, decreases in pain were all relatively low. In this research KT did not appear to be effective at reducing pain acutely during strength or endurance measurement. For the prolonged condition, almost all interventions demonstrated improvements in pain relative to baseline. Effect sizes ranged from low to high. Interestingly, there were more improvements seen from the baseline to prolonged conditions compared to the baseline to acute conditions. Additionally, improvements observed from the baseline to acute conditions were typically maintained into the prolonged conditions. However, the same is true for the placebo condition, indicating that the improvements were due to an external factor, such as time. Our findings generally match those of previous meta analyses and systematic reviews. 28,29 Kinesiology tape application does appear to reduce pain in some circumstances, though not significantly. However, these improvements were not different 47

59 from those observed in a placebo intervention. Similary, Lim and Tay 29 and Montalvo et al 28 noted that there are no differences between KT and other interventions. It is possible that improvements are real, though minimal. Future research should randomize the no tape or baseline condition to control for the effect of time. By doing this, it may be revealed that improvements in outcome measures are due to either time or learning. It is important to note that none of the pain scores decreased in a clinically meaningful way. Lee et al 69 noted that the minimum clinically important difference (MCID) for the visual analog scale is 30mm. Our participants would not have been able to reduce their pain by 30 mm because their pain was too low. Future research on MCID in chronic conditions should focus on determining a percentage rather than a raw number in order to make findings more generalizable to conditions where initial pain is lower. Lee et al 69 developed the MCID to measure clinically meaningful reductions in pain in emergency room patients presenting with acute pain. It is clear that their population differs from patients with PFP and the application of this MCID may not be valid. It may also be useful to perform a separate analysis to specifically investigate the MCID of the VAS as it relates to PFP. LIMITATIONS AND FUTURE RESEARCH The main limitation in this research concerns the number of participants. It is possible that differences in mean scores for dependent variables were not statistically significant because statistical power was not achieved. Sixty six participants were needed for this experiment and only 33 have completed the research protocol to date. Once the remaining data are collected the results may be more conclusive. 48

60 The semg data collected for this research could not be used because too many values were over 100% of MVIC. Callaghan et al 70 found that semg had poor between days reliability and extremely high measurement error when used to assess quadriceps fatigue during multi joint tasks in both individuals with healthy and painful knees. Future research on the effects of KT on muscle activity should only use semg for intra session data collection and should be performed by well trained individuals. Another limitation was the missing data from hip abductor endurance, which likely resulted from problems with instrumentation. While the hip abduction strength data were collected, the hip abduction endurance data came up missing in the system or were obviously incorrect. It is unclear why all other data were collected without incident except for the hip abductor endurance data. While isokinetic dynamometry is useful for isolating joints and precisely quantifying strength and endurance (when functioning properly), results from dynamometry are not necessarily indicative of either functional or sports performance. This is especially true for the side lying hip abduction task. Future research should focus on functional, sport specific measures in order to be applicable to real life scenarios. As previously mentioned, this research did not control for the effect of time. While not controlling for the effect of time and applying the interventions as they would be applied in a clinic setting was highly translatable, we lost the ability to detect what was truly resulting in decreases in pain and improvements in performance. Future research should be less applied and more controlled by randomly assigning participants to control and comparison conditions in order to eliminate elapsed time as a variable. By doing so, it will 49

61 become clearer whether elapsed time or prolonged KT application result in the noted improvements. Finally, in their review, Montalvo et al 28 suggest that patient expectation may be an external factor influencing performance. Throughout the course of data collection participants asked questions about KT, including what it does, how it functions, and what my thoughts were regarding its efficacy. In order not to influence the outcome of the experiment I took great care in being neutral. However, from reading over countless methods sections involving the application of KT it is apparent that patient expectation supplied by clinicians or researchers is a variable that is thoroughly unaccounted for. Future research should explain in detail how questions from participants about KT were handled. Additionally, experiments comparing supplied expectation (no expectation of outcome versus positive expectation of outcome) should be performed. It is possible that experiments like these may elucidate the mechanism of action of KT. CONCLUSIONS Results of this research are, as of yet, inconclusive. Pain decreased and performance increased over time with the application of KT. However, similar patterns were observed in the placebo group. Effect sizes indicated that KT interventions resulted in greater changes than the placebo interventions. None of the participants reported any negative side effects resulting from the tape and compliance was 100%. It is possible that pain and performance improved from baseline to prolonged conditions in all groups due to the passage of time and the effect of learning. 50

62 REFERENCES 1. Baquie P, Brukner P. Injuries presenting to an australian sports medicine centre: A 12 month study. Clin J Sport Med. 1997;7(1): Taunton JE, Ryan MB, Clement DB, Mckenzie DC, Lloyd Smith D, Zumbo BD. A retrospective case control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2): Boling M, Padua D, Marshall S, Guskiewicz K, Pyne S, Beutler A. Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scand J Med Sci Sports. 2010;20(5): DeHaven KE, Lintner DM. Athletic injuries: Comparison by age, sport, and gender. / traumatismes sportifs: Comparaison selon l' age, le sport et le sexe. Am J Sports Med. 1986;14(3): Stathopulu E, Baildam E. Anterior knee pain: A long term follow up. Rheumatology (Oxford). 2003;42(2): Blond L, Hansen L. Patellofemoral pain syndrome in athletes: A 5.7 year retrospective follow up study of 250 athletes. Acta Orthop Belg. 1998;64(4): Witvrouw E, Callaghan MJ, Stefanik JJ, et al. Patellofemoral pain: Consensus statement from the 3rd international patellofemoral pain research retreat held in vancouver, september Br J Sports Med. 2014;48(6): Sanchis Alfonso V, Rosello Sastre E, Martinez Sanjuan V. Pathogenesis of anterior knee pain syndrome and functional patellofemoral instability in the active young. Am J Knee Surg. 1999;12(1): Goodfellow J. Patellofemoral joint mechanics and pathology: Functional anatomy of the patellofemoral joint. J Bone Joint Surg Brit. 1976;58(3): Grana WA, Kriegshauser LA. Scientific basis of extensor mechanism disorders. Clin Sports Med. 1985;4(2): Powers CM, Bolgla LA, Callaghan MJ, Collins N, Sheehan FT. Patellofemoral pain: Proximal, distal, and local factors, 2nd international research retreat. J Orthop Sports Phys Ther. 2012;42(6):A McKenzie K, Galea V, Wessel J, Pierrynowski M. Lower extremity kinematics of females with patellofemoral pain syndrome while stair stepping. J Orthop Sports Phys Ther. 2010;40(10):

63 13. Wirtz AD, Willson JD, Kernozek TW, Hong DA. Patellofemoral joint stress during running in females with and without patellofemoral pain. Knee. 2012;19(5): Noehren B, Sanchez Z, Cunningham T, McKeon PO. The effect of pain on hip and knee kinematics during running in females with chronic patellofemoral pain. Gait Posture. 2012;36(3): Nakagawa TH, Moriya ET, Maciel CD, Serrao AF. Frontal plane biomechanics in males and females with and without patellofemoral pain. Med Sci Sports Exerc. 2012;44(9): Nakagawa TH, Moriya ET, Maciel CD, Serrao FV. Trunk, pelvis, hip, and knee kinematics, hip strength, and gluteal muscle activation during a single leg squat in males and females with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2012;42(6): Stefanik JJ, Zhu Y, Zumwalt AC, et al. Association between patella alta and the prevalence and worsening of structural features of patellofemoral joint osteoarthritis: The multicenter osteoarthritis study. Arthritis Care Res (Hoboken). 2010;62(9): Bazett Jones D, Cobb SC, Huddleston WE, O'Connor KM, Armstrong BSR, Earl Boehm J. Effect of patellofemoral pain on strength and mechanics after an exhaustive run. Med Sci Sport Exer. 2013;45(7): Noehren B, Pohl MB, Sanchez Z, Cunningham T, Lattermann C. Proximal and distal kinematics in female runners with patellofemoral pain. Clin Biomech. 2012;27(4): Aminaka N, Pietrosimone BG, Armstrong CW, Meszaros A, Gribble PA. Patellofemoral pain syndrome alters neuromuscular control and kinetics during stair ambulation. J Electromyogr& Kinesiol. 2011;21(4): Barton CJ, Lack S, Malliaras P, Morrissey D. Gluteal muscle activity and patellofemoral pain syndrome: A systematic review. Br J Sports Med. 2013;47(4): Natalie Collins. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: Randomised clinical trial. Br J Sports Med. 2009;43(3): van Linschoten R, van Middelkoop M, Berger MY, et al. Supervised exercise therapy versus usual care for patellofemoral pain syndrome: An open label randomised controlled trial. Brit Med J. 2009;339:b

64 24. McConnell J. The management of chondromalacia patellae: A long term solution. Aust J Physiother. 1986;332: Aminaka N, Gribble PA. A systematic review of the effects of therapeutic taping on patellofemoral pain syndrome. J Ath Train. 2005;40(4): Murray H. Effects of kinesio taping on muscle strength after ACL repair. J Orthop Sports Phys Ther. 2000;30(1). 27. Riemann BL, Lephart SM. The sensorimotor system, part II: The role of proprioception in motor control and functional joint stability. J Athl Train. 2002;37(1): Montalvo AM, Cara EL, Myer GD. Effect of kinesiology taping on pain in individuals with musculoskeletal injuries: Systematic review and meta analysis. Phys Sportsmed. 2014;42(2): Lim EC, Tay MG. Kinesio taping in musculoskeletal pain and disability that lasts for more than 4 weeks: Is it time to peel off the tape and throw it out with the sweat? A systematic review with meta analysis focused on pain and also methods of tape application. Br J Sports Med Csapo R, Alegre LM. Effects of kinesio taping on skeletal muscle strength A metaanalysis of current evidence. J Sci Med Sport. 2015;18(4): Williams I, Whatman C, Hume PA, Sheerin K. Kinesio taping in treatment and prevention of sports injuries. Sports Medicine. 2012;42(2): Mostafavifar M, Wertz J, Borchers J. A systematic review of the effectiveness of kinesio taping for musculoskeletal injury. Phys Sportsmed. 2012;40(4): Morris D, Jones D, Ryan H, Ryan CG. The clinical effects of kinesio(r) tex taping: A systematic review. Physiother Theory Pract. 2013;29(4): Aguilar BL, Merino Marban R. Kinesio taping and patellofemoral pain syndrome: A systematic review. Cent Eur J Sport Sci Med. 2015;9(1): Montalvo AM, Buckley WE, Sebastianelli W, Vairo GL. An evidence based practice approach to the efficacy of kinesio taping for improving pain and quadriceps performance in physically active patellofemoral pain syndrome patients. J Nov Physiother. 2013;3(151): KT Tape. Faq's. tape.ee/eng/faq.aspx. Updated Accessed 6/24,

65 37. RockTape. Frequently asked questions. asked questions/. Updated Accessed 6/24, Kaya E, Zinnuroglu M, Tugcu I. Kinesio taping compared to physical therapy modalities for the treatment of shoulder impingement syndrome. Clin Rheumatol. 2011;30(2): Castro Sánchez AM, Lara Palomo I, Matarán Peñarrocha GA, Fernández Sánchez M, Sánchez Labraca N, Arroyo Morales M. Kinesio taping reduces disability and pain slightly in chronic non specific low back pain: A randomised trial. J Physiother. 2012;58(2): Akbas E, Atay AO, Yuksel I. The effects of additional kinesio taping over exercise in the treatment of patellofemoral pain syndrome. Acta Orthop Traumatol Turc. 2011;45(5): Aytar A, Ozunlu N, Surenkok O, Baltaci G, Oztop P, Karatas M. Initial effects of kinesio taping in patients with patellofemoral pain syndrome: A randomized, double blind study. Isokinet Execr Sci. 2011;19(2): Aminaka N, Gribble PA. Patellar taping, patellofemoral pain syndrome, lower extremity kinematics, and dynamic postural control. J Ath Train. 2008;43(1): Osorio JA, Vairo GL, Rozea GD, et al. The effects of two therapeutic patellofemoral taping techniques on strength, endurance, and pain responses. Phys Ther Sport. 2013;14(4): Cowan SM, Crossley KM, Bennell KL. Altered hip and trunk muscle function in individuals with patellofemoral pain. Br J Sports Med. 2009;43(8): Anderson G, Herrington L. A comparison of eccentric isokinetic torque production and velocity of knee flexion angle during step down in patellofemoral pain syndrome patients and unaffected subjects. Clin Biomech. 2003;18(6): Baker V, Bennell K, Stillman B, Cowan S, Crossley K. Abnormal knee joint position sense in individuals with patellofemoral pain syndrome. J Orthop Res. 2002;20(2): Christou EA. Patellar taping increases vastus medialis oblique activity in the presence of patellofemoral pain. J Electromyogr & Kinesio. 2004;14(4): Loudon JK, Wiesner D, Goist Foley HL, Asjes C, Loudon KL. Intrarater reliability of functional performance tests for subjects with patellofemoral pain syndrome. J Ath Train. 2002;37(3):

66 49. Munro AG, Herrington LC. Between session reliability of the star excursion balance test. Phys Ther Sport. 2010;11(4): Kinzey SJ, Armstrong CW. The reliability of the star excursion test in assessing dynamic balance. J Orthop Sports Phys Ther. 1998;27(5): Robinson RH, Gribble PA. Support for a reduction in the number of trials needed for the star excursion balance test. Arch Phys Med Rehabil. 2008;89(2): Delagi EF, Iazzetti J, Perotto A, Morrison D. Anatomic guide for the electromyographer: The limbs. 2nd ed Earl JE, Hertel J. Lower extremity muscle activation during the star excursion balance tests. J Sport Rehab. 2001;10(2): Fitzgerald GK, Lephart SM, Hwang JH, Wainner MRS. Hop tests as predictors of dynamic knee stability. J Orthop Sports Phys Ther. 2001;31(10): Ross MD, Langford B, Whelan PJ. Test retest reliability of 4 single leg horizontal hop tests. J Strength Cond Res. 2002;16(4): Clark NC, Gumbrell CJ, Rana S, Traole CM, Morrissey MC. Intratester reliability and measurement error of the adapted crossover hop for distance. Phys Ther Sport. 2002;3(3): Montgomery LC, Douglass LW, Deuster PA. Reliability of an isokinetic test of muscle strength and endurance. J Orthop Sports Phys Ther. 1989;10(8): Kannus P. Isokinetic evaluation of muscular performance: Implications for muscle testing and rehabilitation. Int J Sports Med. 1994;15:S11 s Feiring DC, Ellenbecker TS, Derscheid GL. Test retest reliability of the biodex isokinetic dynamometer. J Orthop Sports Phys Ther. 1990;11(7): Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy. 1993;9(2): Bennell K, Bartam S, Crossley K, Green S. Outcome measures in patellofemoral pain syndrome: Test retest reliability and inter relationships. Phys Ther Sport. 2000;1(2): Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health. 1990;13(4):

67 63. Chesworth BM, Culham EG, Tata GE, Peat M. Validation of outcome measures in patients patellofemoral syndrome. J Orthop Sports Phys Ther. 1989;10(8): Bicici S, Karatas N, Baltaci G. Effect of athletic taping and kinesiotaping on measurements of functional performance in basketball players with chronic inversion ankle sprains. Int J Sports Phys Ther. 2012;7(2): Shields CA, Needle AR, Rose WC, Swanik CB, Kaminski TW. Effect of elastic taping on postural control deficits in subjects with healthy ankles, copers, and individuals with functional ankle instability. Foot Ankle Int. 2013;34(10): Firth BL, Dingley P, Davies ER, Lewis JS, Alexander CM. The effect of kinesiotape on function, pain, and motoneuronal excitability in healthy people and people with achilles tendinopathy. Clin J Sport Med. 2010;20(6): Freedman SR, Brody LT, Rosenthal M, Wise JC. Short term effects of patellar kinesio taping on pain and hop function in patients with patellofemoral pain syndrome. Sports Health. 2014;6(4): Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Phys Ther. 2007;87(3): Lee JS, Hobden E, Stiell IG, Wells GA. Clinically important change in the visual analog scale after adequate pain control. Acad Emerg Med. 2003;10(10): Callaghan MJ, McCarthy CJ, Oldham JA. The reliability of surface electromyography to assess quadriceps fatigue during multi joint tasks in healthy and painful knees. J Electromyogr Kinesio. 2009;19(1):

68 Appendix A: Copy of manuscript 57

69 ISSN: Journal of Novel Physiotherapies The International Open Access Journal of Novel Physiotherapies Executive Editors Raymond Chong Georgia Health Sciences University, USA Yasser Salem University of North Texas Health Science Center, USA Antonios G. Angoules Technological Educational Institute of Athens, Greece Steven L Wolf Emory University, USA Alexandre Evangelista University of Matanzas, Cuba Available online at: OMICS Publishing Group ( This article was originally published in a journal by OMICS Publishing Group, and the attached copy is provided by OMICS Publishing Group for the author s benefit and for the benefit of the author s institution, for commercial/research/educational use including without limitation use in instruction at your institution, sending it to specific colleagues that you know, and providing a copy to your institution s administrator. All other uses, reproduction and distribution, including without limitation commercial reprints, selling or licensing copies or access, or posting on open internet sites, your personal or institution s website or repository, are requested to cite properly. Digital Object Identifier: 58