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

i The use of elastic therapeutic tape for treatment of lateral elbow tendinosis Raewyn Lin Wegener B Occ Thy Grad Cert (Wound Care) M Hlth Sci (Occupational Therapy) A thesis submitted in fulfilment of the requirement of the: Doctor of Philosophy (Thesis by Publications) Supervisors: Dr Lisa O Brien A/Prof Ted Brown Department of Occupational Therapy Faculty of Medicine, Nursing and Health Sciences Monash University Victoria, Australia 2016

Notice 1 Raewyn Lin Wegener (2016) Under the Copyright Act 1968, this thesis must be used only under the normal conditions of scholarly fair dealing. In particular, no results or conclusions should be extracted from it, nor should it be copied or closely paraphrased in whole or in part without the written consent of the author. Proper written acknowledgement should be made for any assistance obtained from this thesis. Notice 2 Raewyn Lin Wegener (2016) I certify that I have made all reasonable efforts to secure copyright permissions for thirdparty content included in this thesis and have not knowingly added copyright content to my work without the owner s permission. 2

General Declaration In accordance with Monash University Doctorate Regulation 17 / Doctor of Philosophy and Master of Philosophy regulations, the following declarations are made: I hereby declare that this thesis contains no material which has been accepted for the award of any other degree or diploma at any university or equivalent institution and that, to the best of my knowledge and belief, this thesis contains no material previously published or written by another person, except where due reference is made in the text of the thesis. All pictures throughout this thesis were taken of myself and one of my colleagues (with consent) who assisted in the study. Permission has been obtained for all figures that have been included from other sources or published text. This thesis includes five original papers and one opinion piece published (or in press) in peer-reviewed journals. The ideas, development and writing up of all papers in the thesis were the principal responsibility of myself, working under the supervision of Dr Lisa O Brien and Associate Professor Ted Brown. Signature: Name: Raewyn Lin Wegener Date: 17/10/2016 3

Thesis Chapter Publication Title Publication Status Nature and % of candidate s contribution Co-authors 3 A scoping review of the use of elastic therapeutic tape for neck and upper extremity conditions. Published 80% - Concept development, literature review, data collection, writing, submission and amendments to manuscript. A/Prof Ted Brown Dr Lisa O Brien 20% - Revision of drafts and amendments to manuscript. 4 Knowledge of and willingness to recommend kinesiotape for upper limb overuse injuries: A comparison of therapists', GPs' and surgeons' perspectives. Published 80% - Concept development, literature review, data collection, writing, submission and amendments to manuscript. A/Prof Ted Brown Dr Lisa O Brien 20% - Revision of drafts and amendments to manuscript. 5 The use of elastic therapeutic tape and eccentric exercises for lateral elbow tendinosis: a case series. Published 80% - Concept development, literature review, data collection, writing, submission and amendments to manuscript. A/Prof Ted Brown Dr Lisa O Brien 20% - Revision of drafts and amendments to manuscript. 4

Thesis Chapter Publication Title 6 A randomized controlled trial of comparative effectiveness of elastic therapeutic tape, sham tape or eccentric exercises alone for lateral elbow tendinosis. Publication Status Published Nature and % of candidate s contribution 80% - Concept development, literature review, data collection, writing, submission and amendments to manuscript. Co-authors A/Prof Ted Brown Dr Lisa O Brien 20% - Revision of drafts and amendments to manuscript. 7 A qualitative review of patients experiences using Kinesio tape for lateral epicondylitis. Submitted to journal (undergoing second revision) 80% - Concept development, literature review, data collection, writing, submission and amendments to manuscript. A/Prof Ted Brown Dr Lisa O Brien 20% - Revision of drafts and amendments to manuscript. Signed: Date: 17/10/2016 5

Table of Contents GENERAL DECLARATION... 3 LIST OF FIGURES... 10 LIST OF TABLES... 11 APPENDICES... 12 ACKNOWLEDGEMENTS... 13 THESIS SUMMARY... 14 ABBREVIATIONS... 16 THESIS PUBLICATIONS... 17 CHAPTER 1 GENERAL INTRODUCTION... 18 1.1 INTRODUCTION AND OVERVIEW OF THESIS STRUCTURE... 18 1.2 LITERATURE REVIEW... 22 1.2.1 Clinical presentation and diagnostic tests... 25 1.2.2 Treatment for lateral elbow tendinosis... 27 1.2.3 Using elastic therapeutic tape for tendinosis... 29 1.3 CONCEPTUAL FRAMEWORKS... 31 1.3.1 Biomechanical Model of Health (BMH)... 32 1.3.2 The Occupational Adaptation Model (OAM)... 34 1.3.3 The International Classification of Functioning, Disability, and Health (ICF). 37 1.4 CHAPTER SUMMARY... 39 CHAPTER 2 METHODOLOGY... 40 2.1 INTRODUCTION... 40 2.2 RESEARCH QUESTIONS... 40 2.3 MATERIALS AND METHODS... 42 2.3.1 Research Question 1: What is the current evidence relating the use of elastic therapeutic tape in treating neck and upper extremity conditions?... 42 6

2.3.2 Research Question 2: What are the current perspectives amongst Hand Therapists, General Practitioners and Hand Surgeons on the use of elastic therapeutic tape and how often is it used or recommended?... 43 2.3.3 Research Question 3: What is the preliminary evidence into the benefit of elastic therapeutic tape and eccentric exercises for the treatment of lateral elbow tendinosis?... 45 2.3.4 Research Question 4: Is the application of elastic therapeutic tape according to the Clinical Therapeutic Applications of the Kinesio Taping Method manual (with the tape applied on tension), in conjunction with an eccentric exercise program and activity modification advice, more effective than: (i) sham taping (application with no stretch); or (ii) eccentric exercises alone; for people with lateral elbow tendinosis?... 47 2.3.5 Research Question 5: What are the experiences of people using elastic therapeutic tape for lateral elbow tendinosis?... 50 2.6 CHAPTER SUMMARY... 52 CHAPTER 3 - A SCOPING REVIEW OF THE USE OF ELASTIC THERAPEUTIC TAPE FOR NECK AND UPPER EXTREMITY CONDITIONS... 53 3.1 INTRODUCTION... 53 3.2 CHAPTER CONTENTS... 53 3.3 IMPACT OF THE STUDY... 65 3.4 CHAPTER SUMMARY... 66 CHAPTER 4 - A COMPARISON OF HAND THERAPISTS, GENERAL PRACTITIONERS AND SURGEONS PERSPECTIVES ON THE USE OF ELASTIC THERAPEUTIC TAPE... 69 4.1 INTRODUCTION... 69 4.2 CHAPTER CONTENTS... 70 4.3 IMPACT OF THE STUDY... 78 4.4 CHAPTER SUMMARY... 78 CHAPTER 5 - THE USE OF ELASTIC THERAPEUTIC TAPE AND ECCENTRIC EXERCISES FOR LATERAL ELBOW TENDINOSIS: A CASE SERIES.... 81 5.1 INTRODUCTION... 81 5.2 CHAPTER CONTENTS... 82 5.3 IMPACT OF THE STUDY... 91 7

5.4 CHAPTER SUMMARY... 92 CHAPTER 6 A RANDOMISED CONTROLLED TRIAL OF COMPARATIVE EFFECTIVENESS OF ELASTIC THERAPEUTIC TAPE, SHAM TAPE OR ECCENTRIC EXERCISES ALONE FOR LATERAL ELBOW TENDINOSIS... 94 6.1 INTRODUCTION... 94 6.2 CHAPTER CONTENTS... 96 6.3 IMPACT OF THE STUDY... 106 6.4 CHAPTER SUMMARY... 107 CHAPTER 7 - A QUALITATIVE REVIEW OF PATIENTS EXPERIENCES USING KINESIO TAPE FOR LATERAL EPICONDYLITIS... 109 7.1 INTRODUCTION... 109 7.2 CHAPTER CONTENTS... 109 7.3 IMPACT OF THE STUDY... 132 7.4 CHAPTER SUMMARY... 134 CHAPTER 8 DISCUSSION AND CONCLUSION... 137 8.1 CHAPTER OVERVIEW... 137 8.2 REVISITING THE RESEARCH QUESTIONS... 137 8.3 DISCUSSION OF STUDY FINDINGS... 143 8.4 IMPLICATIONS FOR CLINICAL PRACTICE... 147 8.5 LIMITATIONS OF THIS THESIS... 152 8.6 RECOMMENDATIONS FOR FUTURE RESEARCH... 154 8.7 CHAPTER SUMMARY... 155 REFERENCES... 156 APPENDIX... 162 APPENDIX A: PUBLISHED OPINION PIECE... 163 APPENDIX B: ETHICS APPROVAL AND FINAL REPORT... 166 APPENDIX C: CONFERENCE PARTICIPATION... 169 Current Abstract Submissions... 169 Conference Presentations... 169 Other Presentations... 170 APPENDIX D: APPLICATION OF TAPE (STUDY 4)... 171 8

APPENDIX E: ECCENTRIC EXERCISE PROGRAM (STUDY 4)... 173 APPENDIX F: OUTCOME MEASURES (STUDY 4)... 175 APPENDIX G: QUALITATIVE QUESTIONS (STUDY 5)... 184 9

List of Figures Figure 1 Biomechanical Model of Health (BMH) Page 33 Figure 2 Occupational Adaptation Model Page 36 Figure 3 International Classification of Functioning Page 38 10

List of Tables Table 1 Thesis Publications Page 17 Table 2 Summary of Research Questions and Study Findings Page 139 11

Appendices Appendix A Published Opinion Piece Page 163 Appendix B Ethics Approval and Final Report Page 166 Appendix C Conference Participation Page 167 Appendix D Application of Tape (Study 4) Page 171 Appendix E Exercise Program (Study 4) Page 173 Appendix F Outcome Measures (Study 4) Page 175 Appendix G Qualitative Questions (Study 5) Page 184 12

Acknowledgements First and foremost, I would like to express my genuine gratitude to Dr Lisa O Brien and Associate Professor Ted Brown for their help, advice, supervision and support during my PhD. I feel that I was blessed to have such exceptional supervisors! I am sincerely grateful for their continual encouragement and guidance which has enabled me to reach such significant milestones in my research. They have both played an invaluable role in improving my knowledge, as well as creating opportunities for future learning and development. For this experience, I will forever be thankful to them. I would also like to thank my husband, Andrew, for his unwavering support over the many years of Postgraduate study. You have stood by me with continual encouragement and motivation, especially when I doubted myself. Thank you to my wonderful family and parents, Des and Alice, who have shared this journey with me. I have valued your support and kindness during this time. I am also very grateful to my Uncle David for his help and technical assistance during my studies. Importantly, I would also like to acknowledge all of my patients for their help in furthering my knowledge in the area of Hand Therapy. Without them, this learning and research would not have been possible and, for that, I am sincerely appreciative. 13

Thesis Summary The development of this thesis arose from my clinical experience as a hand therapist in a private practice setting. As is shown in the literature, lateral elbow tendinosis is a common, yet complex, upper limb condition that is associated with long term morbidity. Due to its degenerative aetiology, research has supported a shift away from surgery and the use of passive interventions, such as immobilisation with splinting, ultrasound, massage and the use of thermal modalities. Despite this evidence, it was my observation that these treatment modalities were still commonly used amongst therapists, including myself, who were attempting to manage the complexities of this patient population. In particular, elastic therapeutic tape was used extensively for tendinosis within the practice I worked, despite a lack of supporting evidence into its use. When further examining this condition, I was led to question my own clinical practice to ensure I was implementing interventions that were in line with the literature. As a health professional, I felt strongly about working within an evidence-based practice model. These concepts listed above have been explored within this thesis, based on the frameworks of the Biomechanical Model (which is prevalent in Hand Therapy), the Occupational Adaptation Model (OAM) and the International Classification of 14

Functioning, Disability and Health (ICF). A variety of methodologies have been utilised to address the above clinical questions, including a scoping review, cross-sectional study, case series, qualitative methodology and a randomised controlled trial. This forms the basis of the five publications that comprise Chapters 3 to 7. All studies supported existing research that passive interventions, including elastic therapeutic tape, have little impact on this condition. Overall, findings also revealed that: 1. Elastic therapeutic tape for lateral elbow tendinosis is no more effective than sham taping or eccentric exercises at six-months post randomisation. Evidence supports activity modification and exercises as successful interventions for this condition. 2. Lateral elbow tendinosis is complex and treatment should be carefully considered based on a clear diagnosis, duration of symptoms, awareness of patient experiences and use of evidence-based interventions. 3. Further examination into elastic therapeutic tape for upper limb conditions is warranted, especially in relation to comparisons between acute and chronic conditions. 15

Abbreviations PRTEE Patient-Rated Tennis Elbow Evaluation OSAv2.2 Occupational Self-Assessment (version 2.2) SF-36 BMH OAM ICF Short Form-36 Biomechanical Model of Health Occupational Adaptation Model International Classification of Functioning, Disability and Health 16

Thesis Publications Title Article 1: Taylor, R.L., O Brien, L. & Brown, T. (2014). A scoping review of the use of elastic therapeutic tape for neck or upper extremity conditions. Journal of Hand Therapy, 27(3), 235-246. Article 2: Taylor, R.L., Brown, T. & O Brien, L. (2015). Knowledge of and willingness to recommend kinesiotape for upper limb overuse injuries: A comparison of therapists, general practitioners and surgeons perspectives. International Journal of Therapy and Rehabilitation, 22(5), 238-245. Opinion piece: Taylor, R.L., Brown, T. & O Brien, L. (2015). Using and prescribing kinesiotape as a treatment modality for musculoskeletal disorders. International Journal of Therapy and Rehabilitation, 22(9), 408-409. Article 3: Wegener, R.L., Brown, T. & O Brien, L. (2015). The use of elastic therapeutic tape and eccentric exercises for lateral elbow tendinosis: a case series. Hand Therapy, 20(2), 56-63. Article 4: Wegener, R.L., Brown, T. & O Brien, L. (2016). A randomized controlled trial of comparative effectiveness of elastic therapeutic tape, sham tape or eccentric exercises alone for lateral elbow tendinosis. Hand Therapy, 1758998316656660. Article 5: Wegener, R.L., Brown, T. & O Brien, L. (2016). A qualitative review of patients experiences using Kinesio tape for lateral epicondylitis. Submitted to the British Journal of Occupational Therapy (under second revision). Journal Impact Factor Page 2.0 54 N/A 71 N/A 163 N/A 83 N/A 997 0.935 111 17

Chapter 1 General Introduction 1.1 Introduction and Overview of Thesis Structure The aim of this chapter is to: Provide an outline of the structure of the thesis. Describe the scope of the problem related to lateral elbow tendinosis in the hand therapy and rehabilitation context, including current evidence-based practice. Examine the existing evidence relating to the use of elastic therapeutic tape for neck and upper limb conditions. Review health frameworks and conceptual models in relation to how these form the foundation of the thesis. This PhD thesis has been completed as a Thesis by Publications and, for this reason, it is comprised as a series of five research papers. Four of these papers are currently published, whilst one remaining paper is under its second review by the British Journal of Occupational Therapy. Each publication is linked with the Biomechanical Model of Health (BMH) (Brown, 1981), the Occupational Adaptation Model (OAM) (Schkade & Schultz, 1992; Schultz & Schkade, 1992) and the International Classification of Functioning, Disability and Health (ICF) (WHO, 2007). 18

Chapter 1 details an overview of the background for the research, defines the nature of the problem and the need to examine current and future clinical practice for therapists treating this condition. This chapter also covers the literature, scope of practice and describes the conceptual models and frameworks that underpin this thesis. Chapter 2 details the methodologies of each study, as well as the research questions and aims that underpin the thesis. Chapter 3 contains the first of the publications, which is a scoping review of evidence relating to the use of elastic therapeutic tape for neck and upper extremity conditions. Findings showed that elastic therapeutic tape may play a role in reducing short-term neck and upper extremity pain, however, future high quality studies that contribute to this body of knowledge are needed. Chapter 4 identified the perspectives amongst Australian surgeons, general practitioners (GPs) and therapists (Physiotherapists and Occupational Therapists) on the use of elastic therapeutic tape. Findings indicated that therapists were more likely to rate the use of elastic therapeutic tape as successful and recommend its clinical use, indicating that they placed greater emphasis on their own clinical experience than on available research evidence. It is inferred that GPs and surgeons have a higher level of scepticism for interventions without supporting evidence. 19

More evidence from randomised controlled trials are required to inform practitioners about the use of elastic therapeutic tape as an intervention. Chapter 5 explored a case series of four patients who had used elastic therapeutic tape, in conjunction with an eccentric exercise program, in managing lateral elbow tendinosis. Findings showed that there may be some clinical benefit in the use of elastic therapeutic tape, in conjunction with eccentric exercises and activity modification techniques, for the treatment of lateral elbow tendinosis. However, more rigorous and comprehensive studies are recommended to further investigate this intervention. Chapter 6 describes a randomised controlled trial of 40 participants on the effectiveness of elastic therapeutic tape for lateral elbow tendinosis, in conjunction with eccentric exercises and activity modification techniques. This trial compared three different interventions: (1) elastic therapeutic tape, (2) sham tape, and (3) no tape. All groups received the same eccentric exercises and activity modification education. Findings indicated that, at three- and six-months post randomisation, improvements were made in all three groups as assessed with pain-free grip strength, the Patient-Rated Tennis Elbow Evaluation (PRTEE), Short Form 36 (SF-36) and the Occupational Self-Assessment (OSA). However, there were no statistically significant differences between the three participant groups. We also found no 20

significant side effects or symptom exacerbation with using elastic therapeutic tape as an intervention strategy. Further studies are needed to assess the use of elastic therapeutic tape for a range of upper extremity conditions, especially in relation to its use for acute versus chronic conditions. Chapter 7 involves a qualitative study that explored the experiences of 11 patients from the intervention group of the randomised controlled trial. Thematic analysis was used and findings showed that, regardless of treatment, the consequences of lateral elbow tendinosis resulted in an adjustment to work and daily activities for a significant period. Long term changes implemented by the person themselves were identified as the main contributing factor to improvements in their function, as opposed to specific treatment modalities. The three key themes were: 1. Frustration at the length of time needed for functional recovery and the impact on life roles. 2. The importance of long-term self-management. 3. Elastic therapeutic tape was easy to self-apply but was an adjunct in recovery compared to self-management strategies. Chapter 8 presents the discussion and conclusion to the thesis. This combines all research projects, in conjunction with current evidence, and the impact on clinical practice for hand therapists. It summarises the original contribution this thesis and 21

research has made to the area of hand therapy. Furthermore, limitations of the studies and suggestions are made for future research. Appendices are included and contain documents that are relevant to this research project, such as ethics approvals, assessment proformas and conference presentations. 1.2 Literature Review Lateral elbow pain, or tennis elbow/lateral epicondylitis as it is commonly referred to in the literature, is a condition that is known to be difficult for Hand therapists to treat (Fedorczyk, 2006a). This is due to its long term recovery, considerable morbidity and financial costs, including those associated with time off work and prolonged treatment (Burton, Kendall, Pearce, Birrell, & Bainbridge, 2009). It is one of the most common work-related disorders of the elbow with over 70% of cases being occupation related, especially amongst individuals who perform forceful and repetitive activities, such as tradespeople, athletes, and mine workers (Fedorczyk, 2006a). Overall prevalence in the general population is thought to range from 1% to 5% (Shiri, Viikari- Juntura, Varonen, & Heliövaara, 2006). Both males and females are equally affected with the most common age of onset being 40-60 years. Approximately 40% of people will experience lateral elbow pain at some point in their life and over 50% of these report 22

not being fully recovered at 12-months post onset (Bisset & Vicenzino, 2015; Fedorczyk, 2006b; Gruchow & Pelletier, 1979). Direct costs per case are approximately US$8099, resulting in a significant economic burdens to the individual, health care system and society (Bisset & Vicenzino, 2015; Silverstein, Viikari Juntura, & Kalat, 2002). To date, lateral epicondylitis and tennis elbow are common terms used by physicians and therapists when describing the clinical diagnosis related to pain experienced at or around the lateral epicondyle (Fedorczyk, 2006b). However, new research reveals that these terms are misleading. The suffix itis implies an inflammatory pathology, but extensive histological immunehistochemical and electron microscopy studies have shown that the condition is degenerative rather than inflammatory (Stasinopoulos & Johnson, 2006). It has been suggested that the more appropriate terms for this condition are either (i) lateral elbow tendinosis, or (ii) lateral elbow tendinopathy (Ashe, McCauley, & Khan, 2004; Stasinopoulos & Johnson, 2006). It is important to apply the correct diagnostic terminology since the previous labels for this condition have led to misunderstanding and inappropriate treatment. For the purpose of this PhD research, the term lateral elbow tendinosis is used hereafter. Understanding the pathophysiology of lateral elbow tendinosis may enable better targeting of treatment and rehabilitation efforts (Khan, Cook, Bonar, Harcourt, & Åstrom, 1999; Khan, Cook, Kannus, Maffulli, & Bonar, 2002). Extensive histological, 23

immunehistochemical, and electron microscopy studies have shown that the condition is degenerative rather than inflammatory. The muscles of the lateral aspect of the elbow include the brachioradialis, extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), extensor carpi ulnaris (ECU), and supinators (Hausman & Lang, 2014; Ljung, Lieber, & Friden, 1999; Reichel & Morales, 2013). All of these structures blend together at the elbow and attach to the humerus as a merged extensor origin. These structures become distinct only in the forearm (Hausman & Lang, 2014). Anatomical studies of the lateral aspect of the elbow demonstrate that there is often considerable contact between the extensor carpi radicalise brevis (ECRB) and the lateral edge of the capitellum, especially with repeated contraction of the wrist extensor muscles, leading to wear and tear of the tendon. Bowing and stretching of the tendon occur with the elbow in extension regardless of wrist position. Subsequently, degeneration at the origin of the ECRB muscle results from an increased presence of fibroblasts, vascular hyperplasia, proteoglycans, and glycosaminoglycans together with disorganised and immature collagen which all occur in the absence of inflammatory cells (Cook & Purdam, 2009b). It is still not clear why tendinosis is painful, given the absence of inflammatory cells, nor is it known why collagen fails to mature. The true cause of pain may be mechanical discontinuity of collagen fibers or biochemical irritation that results from 24

damaged tendon tissue that activates nociceptors (Chourasia et al., 2012; Cook & Purdam, 2009a). There may also be other potential mechanisms of tendon pain including the involvement of other tissues such as nerves, vessels and bones that are intimately related to tendon (Khan, Cook, Maffulli, & Kannus, 2000b). 1.2.1 Clinical presentation and diagnostic tests As with most conditions managed by hand therapists, it is important that clinical symptoms and assessments of lateral elbow tendinosis are correlated with relevant imaging findings and advice from the referring Specialist/Surgeon where applicable. A skilled therapist should elicit appropriate information via a person s history that will direct a specific physical examination of key structures that need to be assessed. Magnetic Resonance Imaging (MRI) is still the gold standard in diagnosing lateral elbow tendinosis (Geoffroy, Yaffe, & Rohan, 1994; Miller, Shapiro, Schultz, & Kalish, 2002; Vicenzino, Brooksbank, Minto, Offord, & Paungmali, 2003). However, in general, lateral elbow tendinosis can be a relatively straightforward condition to identify in the clinic, with the key physical examination features being (i) reproduction of pain in response to direct palpation over the lateral epicondyle (or up to 5mm anterior or distal) and (ii) pain provocation in response to tests of forearm extensor muscle function (Fedorczyk, 2006b; Valdes & LaStayo, 2013). In most cases, there is often a deficit in 25

strength in these muscles, especially with a reduced ability to tolerate load with the elbow extended. Common reported symptoms are aching in the evening and stiffness in the morning. Gripping, resisted wrist extension, radial deviation, finger extension, and forearm supination can produce pain depending on the irritability of the tissues (Wilhelm, 2009). Specifically, there are also a number of provocative tests that are typically used to diagnose lateral elbow tendinosis (Fedorczyk, 2006b; MacDermid & Michlovitz, 2006). These include: 1. Chair Test lifting the back of a chair with three digits (thumb, index and middle fingers), whilst extending the elbow, provokes pain at the lateral epicondyle. 2. Cozens Test - The elbow is extended and then a fist is made with wrist extension against resistance. This is followed by pronation and passive radial deviation to examine pain at the lateral epicondyle. 3. Mill s Test passively moving the elbow in pronation with wrist flexion then elbow extension provokes pain at the lateral epicondyle. 4. Maudsley Test resisted middle finger extension with the forearm in pronation provokes pain at the lateral epicondyle. Apart from MRI, the Mill s Test has the highest diagnostic accuracy with specificity of 100% in some studies. It must be noted that the sensitivity of these tests are not 26

discussed in detail as they have not been recently or thoroughly examined to determine their diagnostic accuracy or clinical usefulness (Valdes & LaStayo, 2013). It is important to consider that differential diagnoses for lateral elbow tendinosis can include cervical radiculopathy, neurovascular entrapment, and radial tunnel syndrome (Vicenzino & Wright, 1996). It is beyond the scope of this PhD to discuss all the tests or pathologies of the elbow. 1.2.2 Treatment for lateral elbow tendinosis To date, there has been consensus that the recommended management of tendinosis is through conservative treatment (Vicenzino, 2003). While many treatments for lateral elbow tendinosis have been researched, including friction massage, ultrasound, acupuncture, orthotics, splinting, shock wave therapy, oral non-steroidal anti-inflammatory medications and surgery, many have small short-term effects and few have shown consistent effectiveness over other treatments (Bisset & Vicenzino, 2015; Buchbinder, Green, Bell, et al., 2002; Buchbinder, Green, White, et al., 2002; Green et al., 2002; Green et al., 2001; Labelle et al., 1992; Smidt et al., 2002; Struijs et al., 2001). From the available evidence, there is emerging support for exercise as an important aspect of the management of lateral elbow tendinosis. Systematic reviews have concluded that eccentric exercises have had some positive effect on clinical 27

outcomes such as pain, function, patient satisfaction and return to work amongst this population (Cullinane, Boocock, & Trevelyan, 2014; Raman, MacDermid, & Grewal, 2012). It has been suggested that eccentric loading may assist with tendon rehabilitation by improving collagen alignment and stimulating collagen cross-linkage formation, both of which can improve tensile strength. Although most studies did not adequately address exercise dosages or include exercise descriptions that could be reproduced, Raman, MacDermid, and Grewal (2012) suggested that a protocol of eccentric exercises performed for three sets of 10-15 repetitions daily for approximately 6-12 weeks has the best current supporting evidence. Despite the reported benefits of eccentric exercises, a barrier in conservative management is often the considerable pain reported by people with elbow tendinosis which directly impacts on their ability to effectively undertake a therapeutic exercise program (Malliaras, Maffulli, & Garau, 2008). The pain also directly impacts patients abilities to engage in many daily functional activities that require elbow movement, such as keyboarding, driving a car, lifting objects off a shelf, doing up buttons, and handwriting. The hand therapists management of lateral elbow tendinosis revolves primarily around modulating tendon pain, as pain is the primary presenting and limiting factor experienced by this patient group (Carlo, 2009; Clarke, Ahmad, Curtis, & Connell, 2013). Additional goals of rehabilitative treatment are to maintain movement and 28

strength, and to develop endurance over time to increase function and maintain participation in work and meaningful activities (Cook & Purdam, 2013). One suggested modality for managing pain during elbow motion and exercise is the application of elastic therapeutic tape (Kase, Tatsuyuki, & Tomoko, 1996). The next section describes how elastic tape is thought to work, and how it may be applied in the management of tendinosis. 1.2.3 Using elastic therapeutic tape for tendinosis It is proposed that elastic therapeutic tape may play a role in biomechanically unloading the affected tendon, thereby reducing symptoms and allowing patients to undertake appropriate strengthening exercises (Bassett, 2010). Developed in the 1970 s by Dr Kenzo Kase, a chiropractor, elastic therapeutic tape is a relatively new modality used for treating a variety of injuries (Kase, Tatsuyuki, & Tomoko, 1996). Since that time, different names and brands have emerged and it has gained increased recognition especially after it was donated to 58 countries for use during the 2008 Olympic Games and was used by many high-profile athletes. Traditional taping methods for elbow tendinopathy have been examined in clinical studies (Amro et al., 2010; Vicenzino, Brooksbank, Minto, Offord, & Paungmali, 2003) with results demonstrating some shortterm improvements in pain-free grip strength; however, no studies have explored the 29

use of elastic therapeutic tape for this condition with long term follow-up (Taylor, O'Brien, & Brown, 2014). Although unsupported by evidence, the proposed mechanisms of elastic therapeutic tape include alleviating pain, correcting muscle function, restoring functional movement patterns, improving circulation, and relieving abnormal muscle tension (Bassett, 2010; Kase, Tatsuyuki, & Tomoko, 1996; Moore, 2012). In particular, it is reported that the application of elastic therapeutic tape over stretched muscle will create convolutions in the person s skin which subsequently reduce the pressure in the mechanoreceptors that are located below the dermis, thereby decreasing nociceptive stimuli (Parreira et al., 2014). Through these mechanisms, it is hypothesised that elastic therapeutic tape can assist in reducing symptoms and thus allow patients to undertake appropriate rehabilitative exercises (Bassett, 2010). Recommended tape application methods are outlined in Clinical Therapeutic Applications of the Kinesio Taping Method (Kase, 2003). Elastic therapeutic tape is designed to allow for a longitudinal stretch of up to 140% of its resting length; however, the majority of tape applications are applied between 25-50% and occasionally up to 100%. The tape has no horizontal stretch and it is designed to approximate the elastic qualities of the human skin. There are currently no available guidelines on how to achieve consistency with the tape s stretch and application; therefore, therapists must 30

rely on their own clinical judgement during tape application (Kase, 2003; Kase, Tatsuyuki, & Tomoko, 1996). In particular, this factor is an important consideration when teaching patients or family members to re-apply the tape and may affect compliance with treatment. Despite its popularity and widespread clinical use, there is relatively little evidence to support the effectiveness of elastic therapeutic tape, let alone for specific neck and upper extremity conditions. To date, evidence regarding the effectiveness of elastic therapeutic tape has relied predominantly on case reports, small pilot studies and research on healthy participant groups (Bassett, 2010). 1.3 Conceptual frameworks Evidence-based practice in the absence of a good foundation in theoretical models is problematic because it is difficult to evaluate research findings without understanding theory (Peachey-Hill & Law, 2000). For the research presented in this thesis, an understanding of theoretical conceptual models and frameworks underpinned the assessments and interventions to both measure and facilitate change in patients occupational performance. This knowledge provides the explanatory power on how interventions guide change in our patients function (Ikiugu, Smallfield, & Condit, 2009). 31

Two models and one framework have been selected to provide a theoretical foundation for this PhD program: (1) the Biomechanical Model of Health (BMH) (Brown, 1981), (2) The Occupational Adaptation Model (OAM) (Schkade & Schultz, 1992; Schultz & Schkade, 1992), and (3) the International Classification of Functioning, Disability and Health (ICF) (WHO, 2007). These models and frameworks were chosen to guide the biopsychosocial approach to this study. Whilst hand therapy has traditionally used a biomechanical approach towards treatment, it was important to include the OAM and ICF to address broader psychosocial components. 1.3.1 Biomechanical Model of Health (BMH) The BMH (Seidel, 1998) has commonly been used in the treatment of patients with musculoskeletal conditions, such as lateral elbow tendinosis, within a rehabilitation setting. It has intuitive appeal and is supported by a wealth of biological findings (Mishler, 1981). The BMH has foundations in assessing the symptoms of an injury or condition to determine what is not functioning optimally. Once the pathology is identified, treatment aims to eliminate, repair or correct the existing pathology through medical methods. This model incorporates exercise and activity to reduce deficits in occupational performance components and emphasises that the reduction of physical deficits will promote independence in daily activities (Cole & Tufano, 2008; Jackson & 32

Schkade, 2001b). The therapist considers the patient s goals; however, treatment focuses on overcoming deficits, improving range of motion, increasing mobility and prescribing strengthening exercises (Cole & Tufano, 2008). The BMH is consistent with the theories that underpin the use of elastic therapeutic tape and eccentric exercises in managing lateral elbow tendinosis. A limitation of using this model in isolation is that it may not provide the person with much opportunity to plan and participate in the process of therapy. The role of the person can become passive; therefore, the BMH does not incorporate all the strengths of occupational therapy service delivery (Cole & Tufano, 2008). For this reason, an additional occupational model and a health framework were also used as the foundation of this thesis. Joint Range of Motion Muscle Strength Physical Endurance Figure 1: Biomechanical Model of Health (Brown, 1981; Kielhofner, 2009) 33

1.3.2 The Occupational Adaptation Model (OAM) The OAM developed by Schkade and Schultz (1992) differs from other models due to its focus on one s internal adaptation (ability to adjust oneself to different conditions and environments) as opposed to occupational performance. In doing so, this model has great applicability to the specialty area of Hand Therapy. Therapists often assume that, as clients recover function (i.e. improved goniometer measures of Range of Motion, increased grip strength and return to work), they will become more adaptive. However, function and adaptation are not the same increased function does not necessarily mean more adaptation, especially in the case of long-term conditions. Therapists may incorrectly assume that as the patient acquires more functional skills, adaptation is occurring; however, the person s internal adaptation may actually remain unchanged (Schultz & Schkade, 1992). Occupational adaptation is described as a normative process that leads to competence in occupational functioning. This model proposes that occupation involves the means through which adaptation occurs and an end for which functional adaptation is desirable (Schkade & Schultz, 1992; Schultz & Schkade, 1992). Illness or trauma may disrupt this internal process and result in maladaptive responses to daily occupational challenges. In this model, the therapist s role is to facilitate restoration of a functional internal adaptation process (Jackson & Schkade, 2001a). 34

In relation to this thesis, the OAM complements the BMH as it does not exclude biomechanical and rehabilitation principles for therapeutic interventions (Jackson & Schkade, 2001a). However, the primary focus of treatment is placed on the patient s meaningful occupational role, involvement in the therapy process, and the adaptation outcome. From the literature, lateral elbow tendinosis is recognised for having a significant period of time during which people will experience occupational dysfunction. As discussed previously, this condition frequently takes years to improve, during which time people are required to develop adaptations to enable resumption of meaningful occupations. An adaptive response results in the person achieving greater relative mastery in their occupational activities which is measured by three properties efficiency (the use of time, energy and resources), effectiveness (the degree to which one achieves a desired result) and satisfaction (the extent to which the outcome was personally satisfying and well-regarded) (Schkade & Schultz, 1992). Schultz and Schkade (1992) further state that the person s response to both intrinsic (personal) and extrinsic (environmental) factors will dictate their final outcome. A successful response will result in occupational performance with mastery and satisfaction or a successful return to meaningful occupations. 35

The diagram of the OAM (presented below) contains three elements (i) the person, (ii) the occupational environment and (iii) the interaction of the two as they come together in occupation (Schkade & Schultz, 1992; Schultz & Schkade, 1992). The occupational adaptation model can be conceptualised as having two major processes: (1) the first is the process of moving from the press for mastery to an occupational response, and (2) the second part is the process by which individuals make adaptive responses through relative mastery to an occupational response. Figure 2: Occupational Adaptation Model (Schultz & Schkade, 1992) In the hand therapy setting, the OAM has great applicability as a large majority of patients sustain lengthy disruptions to their everyday function, requiring them to come forth with an adaptive response to deal with their injury. The process from the 36

onset of lateral elbow tendinosis to return to activities of daily living (ADLs) is considered to be one of ongoing adaptation. Therapists have often focused on treating the person s condition, neglecting to address the illness experience (Schultz & Schkade, 1992). This is an important concept in relation to this PhD as it focuses on physical dysfunction, but also the notion of understanding an individual s perspective and experience of adaptation. 1.3.3 The International Classification of Functioning, Disability, and Health (ICF) Another conceptual framework that underpins this thesis is the International Classification of Functioning, Disability, and Health (ICF) (WHO, 2007). This is structured around the following broad components: (i) body function and structure, (ii) activities, (iii) participation, (iv) environmental factors and (v) personal factors. Within the ICF, functioning and disability are viewed as complex interactions between the health condition of the individual, the environmental context, as well as personal factors (WHO, 2007). It identifies these dimensions as being interactive and dynamic, as opposed to linear and static. The ICF is able to assist health practitioners in assessing the degree of disability, even though it is not a measurement instrument (Cieza et al., 2002b). All aspects of a person s life (development, participation and environment) are incorporated into the ICF instead of focusing solely on a diagnosis. 37

The ICF is an important framework for this research and it complements the BMH which forms the basis for the use of elastic therapeutic tape. The ICF acknowledges the importance of understanding disease and dysfunction in health care (similar to the BMH); however, it further recognises the person as a whole, including their lived context. Identifying the limitations of function through the ICF can provide important information to plan and implement interventions. It can be applied across cultures, age groups and genders, making it highly suitable for various populations. It also supports the OAM in this thesis by incorporating a holistic approach to the assessment and management of lateral elbow tendinosis. Figure 3: International Classification of Functioning, Disability, and Health (ICF) (WHO, 2007) 38

1.4 Chapter Summary Whilst there appears to be some anecdotal evidence that merits using elastic therapeutic tape as an addition to existing treatment modalities, broader, systematic examination of this treatment is needed in order to clarify its effectiveness for neck and upper extremity conditions. The Biomechanical and Occupational Adaptation Models, as well as the ICF, may assist us to understand how the treatment may or may not be effective. The next chapter outlines the origins of each research question and study that are subsequently answered in each publication (Chapters 3 to 7). The aims and methodologies for each study will also be outlined. 39

Chapter 2 Methodology 2.1 Introduction This thesis proposes a research program to investigate the effectiveness of elastic therapeutic tape in managing lateral elbow tendinosis. It is anticipated that the results of this research study will inform the development of a clinical pathway for hand therapists for the management of lateral elbow tendinosis with the use of elastic therapeutic tape. This chapter will outline the five research questions that underpin the foundations of this thesis which are subsequently addressed in the publications that form Chapters 3 to 7. The separate methodologies used within each publication will also be outlined and justified, including a scoping review, cross-sectional study, case series, randomised controlled trial and a qualitative study. 2.2 Research questions Specific research questions of the thesis are: 1. What is the current evidence relating the use of elastic therapeutic tape in treating neck and upper extremity conditions? 40

2. What are the current perspectives amongst hand therapists, general practitioners and hand surgeons on the use of elastic therapeutic tape and how often is it used or recommended? 3. What is the preliminary evidence into the benefit of elastic therapeutic tape and eccentric exercises for the treatment of lateral elbow tendinosis? 4. Is the application of elastic therapeutic tape according to the Clinical Therapeutic Applications of the Kinesio Taping Method manual (Kase, 2003) (with the tape applied on tension), in conjunction with an eccentric exercise program and activity modification advice, more effective than (i) a sham application ( i.e. the tape applied with no stretch), or (ii) eccentric exercises alone, in people with lateral elbow tendinosis? Are the benefits of three months of treatment using elastic therapeutic tape sustained six-months post intervention? 5. What are the experiences of people using elastic therapeutic tape for lateral elbow tendinosis? 41

2.3 Materials and Methods 2.3.1 Research Question 1: What is the current evidence relating the use of elastic therapeutic tape in treating neck and upper extremity conditions? Aim: To synthesise the available evidence relating to the use of elastic therapeutic tape in treating neck and upper extremity conditions. Methodology: Scoping review. Level of Evidence: N/A A scoping review was used to address this research question as it includes a broader range of studies and articles, including both empirical and non-empirical sources of information, especially when there is a lack of randomised controlled trials available. Search strategy: Relevant English, peer-reviewed documents were identified from a search of OVID Medline, CINAHL and ProQUEST. Grey literature in ProQUEST Dissertations and Theses were also included. The search was conducted between July and September 2013. As this scoping review aimed to include all studies, no limitations were placed in terms of and publication type. 42

Data Collection: Where possible, data was extracted regarding the recommended application and wear-time of elastic therapeutic tape in the treatment of neck and/or upper extremity disorders. Participant outcomes examined were pain, range of motion, strength and patient preference. Data Analysis: Study quality was assessed based on the McMaster Guidelines for Critical Review of Quantitative Studies which examines research approach, methodology, sample size, intervention, outcome measures and results. Studies were also classified using the Oxford Level of Evidence. 2.3.2 Research Question 2: What are the current perspectives amongst Hand Therapists, General Practitioners and Hand Surgeons on the use of elastic therapeutic tape and how often is it used or recommended? Aim: To gain insight into current perspectives on the use of elastic therapeutic tape amongst health professionals (occupational therapists and physiotherapists), general practitioners and hand surgeons. Methodology: Cross-sectional study. Level of Evidence: 4 43

This cross-sectional study used a self-report survey to gather data from respondents. Information included number of years in clinical practice, number of patients treated each week presenting with conditions such as tennis elbow, self-rating of knowledge regarding the use and purpose of kinesiotape, perceived level of success with tape when used, and reasons for recommending/not recommending the tape. Participants: Inclusion criteria included being a qualified physiotherapist or occupational therapist registered with the Australian Hand Therapy Association (AHTA) or a qualified medical practitioner with experience in the treatment of upper limb injuries. Data Collection: A convenience sampling approach was used to recruit participants. All 472 members of the Australian Hand Therapy Association (AHTA), 67 general practitioners and surgeons in South-East Queensland and 24 hand therapists and surgeons in Victoria were given the questionnaire via email, postage or in person. Data Analysis: Data was analysed using SPSS statistical software, version 20. Comparisons between therapists, GPs and surgeons on continuous outcomes were made 44

using one-way ANOVA tests. Post-hoc comparisons were made using the Tukey HSD test. Linear regression was used to examine which variables affected the level of recommendation of the tape. Chi-square tests examined barriers to the use of kinesiotape and were grouped into discrete categories based on responses to five listed categories. Participants were provided with the opportunities to use free text in this section; however, none of the participants did so. Power calculations were not completed for this study as cluster sampling was used (e.g. all members of the Australian Hand Therapy Association were provided with the survey, as well as all upper limb Surgeons from South East Queensland). 2.3.3 Research Question 3: What is the preliminary evidence into the benefit of elastic therapeutic tape and eccentric exercises for the treatment of lateral elbow tendinosis? Aim: To examine outcomes of a retrospective case series of patients who used elastic therapeutic tape and eccentric exercises for the treatment of lateral elbow tendinosis. Methodology: Case series. Level of Evidence: 4. Participants: 45

All four patients were treated by the same hand therapist and received application of the tape for varying durations from one to three months. The tape was applied in the same way for each patient in conjunction with an evidencebased standard daily exercise program including heat, stretches, progressive eccentric exercises and the use of compression as needed. Data Collection: Descriptive and retrospective review involving four patients who underwent rehabilitation with the use of elastic therapeutic tape, in conjunction with eccentric exercises and activity modification techniques, for treatment of lateral elbow tendinosis. Outcome measures included a 10 cm Visual Analogue Scale (VAS) to evaluate subjective pain levels and the Jamar dynamometer to measure objective grip strength measurements. Data Analysis: Descriptive statistics and analyses of the outcome measures were recorded and compared. 46

2.3.4 Research Question 4: Is the application of elastic therapeutic tape according to the Clinical Therapeutic Applications of the Kinesio Taping Method manual (with the tape applied on tension), in conjunction with an eccentric exercise program and activity modification advice, more effective than: (i) sham taping (application with no stretch); or (ii) eccentric exercises alone; for people with lateral elbow tendinosis? Additionally, are the benefits of three months of treatment using elastic therapeutic tape sustained six-months post intervention? Aim: To assess the effectiveness of elastic therapeutic tape (in conjunction with an eccentric exercise program and activity modification advice) in treating lateral elbow tendinosis in adults when compared to sham taping or no taping (i.e. reduced pain, increased strength and improved functional outcomes). Methodology: Randomised Controlled Trial (RCT). Level of Evidence: 1B. This was a randomised controlled trial of 40 participants with lateral elbow tendinosis who received (i) elastic therapeutic tape, (ii) sham tape, and (iii) no tape, over a 12-week period (four weekly and 4 fortnightly sessions) with a 6 month follow up. All participants received eccentric exercises and advice on activity modification techniques. 47

Participants: Participants with lateral elbow tendinosis, aged between 18 and 80 years, were recruited through three private hand therapy practices. Selection criteria was based on medical investigations confirming lateral elbow tendinosis (e.g. MRI), or provocative tests completed by the treating therapist. Participants were excluded if they had co-morbidities, any contraindications to the use of taping, inability to understand written material in English and inability to give informed consent. Data Collection: 40 participants were randomly allocated to receive three different approaches for the management of lateral elbow tendinosis. Participants in all three groups received the same evidence-based exercise program and advice on activity modification techniques, including ergonomic modifications and how to avoid aggravating tasks. Exercises and the application of tape (for the three participant groups) were reviewed at each session to further enhance adherence to therapy. Primary outcomes were pain and level of disability as measured by the Patient Rated Tennis Elbow Evaluation (PRTEE) and pain-free grip strength assessments using the Jamar dynamometer. Secondary outcome measures were overall health status as measured by the Short Form 36 (SF-36), the Occupational Self- 48

Assessment (OSA v 2.2). All of these are standardised outcomes measures. In particular, the PRTEE was specifically chosen for this study due to its high validity, reliability, reproducibility and sensitivity to change amongst a tennis elbow population. Other outcome measures, such as the Disability of the Arm, Shoulder and Hand (DASH) and the Upper Extremity Functional Index (UEFI), have been used in clinical practice to measure elbow conditions; however, these measures are general in nature and have been found to not accurately assess the specific symptoms and functions of an individual joint. Therefore, the PRTEE was the most appropriate choice as a primary outcome measure. Data Analysis: Data analysis was conducted by the un-blinded primary researcher and independently checked by a statistician who was blinded to group allocation. All data was coded for analysis. Differences in primary and secondary outcomes between groups were compared using intention-to-treat analysis. Baseline participant characteristics in the three groups were compared using one-way ANOVA for continuous variables (age) and chi-square tests for categorical variables (gender, work status). Outcomes were compared over the follow-up period with one-way ANOVA for all variables; however, linear mixed model analysis was also used for primary outcome variables (PRTEE and grip strength) 49

due to missing data amongst these measures. The Statistical Package for Social Sciences (SPSS version 20) was used for all analyses (SPSS, 2011). 2.3.5 Research Question 5: What are the experiences of people using elastic therapeutic tape for lateral elbow tendinosis? Aim: To investigate people s experience with using elastic therapeutic tape, adherence with treatment, and the perceived impact of using the tape on their recovery, function and return to pre-injury roles. Methodology: Qualitative Study. Thematic analysis was the methodological framework used to categorise data into patterns and develop themes in order to find meaning. Level of Evidence: N/A. Participants: Qualitative interviews were undertaken with 11 participants from the intervention group of the randomised controlled trial at six-months post randomisation. Data Collection: The qualitative interviews were semi-structured and conducted face-to-face to encourage participants to freely express their own views and experiences, 50

specifically in relation to using the tape. Guiding questions were drafted by the primary researcher and piloted amongst three other therapists to review the appropriateness of questions. Following minor grammatical changes, the interviews were implemented in person and prompts were used when required. All interviews were recorded using a digital voice recorder and transcribed for analysis by the first author. The following specific areas of interest were explored: 1. Perceptions of impact on overall function over the six months after the commencement of the taping intervention. 2. Patient experiences during everyday activities. 3. Experiences of using elastic therapeutic tape as a treatment modality. Data Analysis: Transcripts of the interviews were analysed using a three-step process. First level coding described and categorised responses; second level coding identified patterns or groups in the first level codes; third level coding involved interpreting these to find meanings behind the perceptions expressed by the participants. Contextual information from field notes was also used (e.g. body language to clarify the meaning of some texts) and a reflective diary was kept after each interview. Transcripts and codes were then checked with two of the interviewees 51

to ensure that the interpretation of the findings accurately represented participants perceptions regarding their experience. 2.6 Chapter Summary This chapter has outlined the five research questions that form the foundation of this thesis, in addition to the selection of various methodologies to address these questions. The following chapters will address the specific details of each individual study, starting with the next chapter which is a scoping review of the evidence into the use of elastic therapeutic tape for neck and upper extremity conditions. 52

Chapter 3 - A scoping review of the use of elastic therapeutic tape for neck and upper extremity conditions 3.1 Introduction Chapter Three contains both an extract from the manuscript of Study 1, as well as the full article, which is published in Journal of Hand Therapy. This is the first of five publication chapters and presents a scoping review on the current evidence for the use, implementation and effectiveness of elastic therapeutic tape for neck and upper extremity conditions in clinical practice. 3.2 Chapter Contents Taylor, R.L., O Brien, L. & Brown, T. (2014). A scoping review of the use of elastic therapeutic tape for neck or upper extremity conditions. Journal of Hand Therapy, 27, 235-246. Date submitted: 3 rd December 2013 Date of resubmission: 20 th February 2014 Date of acceptance: 10 th March 2014 Date of publication in hard copy: July 2014 53

3.3 Impact of the study Journal Metrics: Source Normalized Impact per Paper (SNIP) - 0.762 Impact per Publication (IPP) 1.331 SCImago Journal Rank (SJR) 0.547 Despite its popularity and widespread clinical use, this study revealed that there is relatively little evidence to support the effectiveness of elastic therapeutic tape for specific neck and upper extremity conditions. These findings provide useful information for therapists using this intervention, especially in relation to the use of evidence-based practices. At present, therapists who incorporate elastic taping in their clinical practice are required to construct a treatment plan using the manufacturer s information, their own experience, and previous clinical observations. This exposes them to the risks associated with prescribing a treatment modality that has uncertain clinical benefits, cost-effectiveness, and/or safety. It is important for therapists to be aware of these considerations. 65

3.4 Chapter Summary The study presented in this chapter specifically examined 14 documents relating to the use of elastic therapeutic tape for neck and upper extremity disorders from searches in OVID Medline, CINAHL, ProQUEST and ProQUEST Dissertations. The key findings of this study were: To date, evidence regarding the effectiveness of elastic therapeutic tape has relied predominantly on case reports, small pilot studies and research on healthy participant groups. There appears to be some anecdotal evidence that merits using elastic therapeutic tape as an addition to existing treatment modalities, but broader, systematic examination of this treatment is needed in order to clarify its effectiveness for neck and upper extremity conditions. It must be acknowledged that, due to the small sample size of the seven RCT s included in this scoping review, the lack of significant findings may represent a Type II error. These studies may have concluded that there was no difference between treatment groups when, in fact, there may have been a difference but the study was not adequately powered. No side effects or adverse events were documented in any of the studies. 66

Overall, this is a topic with limited high quality published research. Ideally, future studies would be multi-centred, include an adequate sample size/population, follow-up participants for at least 6 months or longer, and consider the costeffectiveness of elastic therapeutic tape compared to other existing interventions for neck and upper extremity disorders. 67

Chapter 4 - A comparison of hand therapists, general practitioners and surgeons perspectives on the use of elastic therapeutic tape 4.1 Introduction This chapter specifically explores the experiences and opinions of physiotherapists, occupational therapists, general practitioners and hand surgeons on the use of elastic therapeutic tape for upper extremity disorders in clinical practice. This cross-sectional study used a self-report survey to gather data from respondents. Information included number of years in clinical practice, number of patients treated each week presenting with conditions such as tennis elbow, self-rating of knowledge regarding the use and purpose of elastic therapeutic tape, level of success with tape when used, and reasons for recommending/not recommending the tape. The full article is included in this chapter and is published in International Journal of Therapy and Rehabilitation. 69

4.2 Chapter Contents Taylor, R.L., Brown, T. & O Brien, L. (2015). Knowledge of and willingness to recommend kinesiotape for upper limb overuse injuries: A comparison of therapists, general practitioners and surgeons perspectives. International Journal of Therapy and Rehabilitation, 22(5), 238-245. Date submitted: 13 th January 2014 Date of resubmission: 6 th February 2015 Date of acceptance: 17 th February 2015 Date of publication in hard copy: May 2015 70

4.3 Impact of the Study Journal Metrics: Source Normalized Impact per Paper (SNIP) 0.27 Impact per Publication (IPP) 0.337 SCImago Journal Rank (SJR) 0.173 Results of this study supported the findings from the scoping review in Study 1. It is clear from this survey that the use of elastic therapeutic tape is common amongst therapists in clinical practice, even though it is not supported by evidence gained from high quality randomised controlled trials. 4.4 Chapter Summary This study has shown that hand therapists, GPs and Surgeons have differing perceptions on the use of elastic therapeutic tape. Although overall perceptions of the tape s purpose, usefulness and effectiveness amongst the three groups were only low to moderate, therapists are more likely to report higher understanding levels and subsequent higher levels of recommendation and success with its use compared to GPs and surgeons. GPs and surgeons were less likely to recommend the use of elastic 78

therapeutic tape due to limited understanding of its potential use and/or doubts regarding its effectiveness in clinical practice. This survey is consistent with existing literature that states there is a need for more evidence into the use of elastic therapeutic tape and long-term follow-up into its reported benefits. 79

Chapter 5 - The use of elastic therapeutic tape and eccentric exercises for lateral elbow tendinosis: a case series. 5.1 Introduction Chapter 3 aimed to identify the current evidence on the use of elastic therapeutic tape and revealed that there was limited high quality evidence available. This was built on in Chapter 4 in which results showed that therapists were more likely to use and recommend elastic therapeutic tape (compared to GP s and Surgeons) despite limited evidence into its use. This chapter comprises of Study 3 which arose based on the author s clinical experience with using elastic therapeutic tape for lateral elbow tendinosis. The objective of this study was to retrospectively examine four patients who underwent rehabilitation with the use of elastic therapeutic tape, in conjunction with eccentric exercises and activity modification techniques, for treatment of lateral elbow tendinosis. The full article is included in this chapter and is published in Hand Therapy. 81

5.2 Chapter Contents Wegener, R.L., Brown, T. & O Brien, L. (2015). The use of elastic therapeutic tape and eccentric exercises for lateral elbow tendinosis: a case series. Hand Therapy, 20(2), 56-63. Date submitted: 1 st January 2015 Date of resubmission: 8 th March 2015 Date of acceptance: 13 th March 2015 Date of publication in hard copy: April 2015 82

5.3 Impact of the Study Journal Metrics: Source Normalized Impact per Paper (SNIP) - 0.162 Impact per Publication (IPP) - 0.133 SCImago Journal Rank (SJR) - 0.114 This retrospective case series suggests preliminary benefit for the use of elastic therapeutic tape and eccentric exercises in treating patients with lateral elbow tendinosis. However, conclusions by health professionals cannot be drawn from this study on the effectiveness of elastic therapeutic tape alone, or in combination with activity modification and exercise without more rigorous examination. For this reason, it is important to proceed to a randomized controlled trial as these results cannot confidently conclude results were gained from the tape, as opposed to patients who may experience natural recovery of this condition. Additionally, as elastic therapeutic tape is reported to have benefit through the tape s elastic properties, including a control group involving sham tape will provide important findings. Although this group will receive an un-blinded placebo intervention, these participants will not know they are receiving a treatment that is not the targeted clinical intervention being examined for its clinical effectiveness. The role of a possible placebo effect from the tape warrants further investigation. 91

5.4 Chapter Summary This study provided the potential for preliminary support of elastic therapeutic tape for lateral elbow tendinosis, in combination with eccentric exercise and activity modification techniques. Participants in this study reported decreased pain levels, no adverse effects, tolerated the wearing regime well and reported ease of application. A rigorous randomised controlled trial with assessor blinding is required, with adequate follow-up to determine longer term functional outcomes of this treatment modality. 92

Chapter 6 A randomised controlled trial of comparative effectiveness of elastic therapeutic tape, sham tape or eccentric exercises alone for lateral elbow tendinosis 6.1 Introduction The previous chapters have discussed the use of elastic therapeutic tape and shown that, whilst there is a lack of evidence for its use, there is possibly some preliminary support for its use for upper limb conditions. This chapter includes Study 4, a randomised controlled trial, which arose based on the recommendation of Study 3 whereby more high quality evidence into elastic therapeutic tape was required. In particular, it was also important for the role of the tape s application (to create skin convolutions when applied to stretched muscle) to be examined as it has been hypothesised that this property can reduce pressure in the mechanoreceptors below the dermis, thereby decreasing nociceptive stimuli. As mentioned throughout this thesis, there remains conjecture in the literature regarding how and why tape may work, but concluding that a perceive benefit cannot be discounted. This is an important research question within this study because the theory that skin convolutions are the mechanism for the tape s effectiveness (especially in relation to upper limb conditions) has never been tested in a high-quality randomised controlled trial. 94

Study 4 consisted of a randomised controlled trial of 40 participants with lateral elbow tendinosis who received (i) elastic therapeutic tape, (ii) sham tape, and (iii) no tape, over a 12-week period (four weekly and 4 fortnightly sessions) with a 6 month follow up. All participants received eccentric exercises and advice on activity modification techniques. Intervention group: Participants received the application of tape based on the recommended application techniques by Dr Kenzo Kase in Clinical Therapeutic Applications of the Kinesio Taping Method (refer to Appendix D). Participants were educated on all precautions (such as how to monitor for reactions to the tape) and were shown how to remove the tape safely. Comparison group (Sham taping): Participants in this group were taped the same way as the intervention group; however, the tape was applied with no tension. Participants were not aware they were receiving sham treatment as they were instructed on how to apply the tape without tension and were not told of the alternative method (tape applied with stretch). Control group: Participants in this group received no taping. Participants in all three groups received the same structured exercise program which was established from existing literature on the benefits of eccentric exercises for 95

lateral elbow tendinosis (refer to Appendix E). Advice on activity modification techniques were also provided, including ergonomic modifications and how to avoid aggravating tasks. Exercises and the application of tape (for the intervention and control groups) were reviewed at each session to further enhance adherence to therapy. The full article is included in this chapter and is published in Hand Therapy. 6.2 Chapter Contents Wegener, R.L., Brown, T. & O Brien, L. (2016). A randomized controlled trial of comparative effectiveness of elastic therapeutic tape, sham tape or eccentric exercises alone for lateral elbow tendinosis. Hand Therapy, 1758998316656660. Date submitted: 27 th March 2016 Date of resubmission: 2 nd June 2016 Date of acceptance: 3 rd June 2015 Date of publication online: 11 th July 2016 96

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6.3 Impact of the Study Journal Metrics: Source Normalized Impact per Paper (SNIP) - 0.162 Impact per Publication (IPP) - 0.133 SCImago Journal Rank (SJR) - 0.114 The objective of this study was to provide more rigorous information for Hand therapists when using elastic therapeutic tape for lateral elbow tendinosis. Lateral elbow tendinosis is well known to cause difficult challenges due to its long-term recovery and morbidity. Elastic therapeutic tape is commonly used as a treatment modality for this condition, despite limited evidence. At three and six-months post randomisation, improvements were made in all three groups as assessed with the Patient-Rated Tennis Elbow Evaluation (PRTEE), the Short Form 36 (SF-36) pain-free grip strength, and the Occupational Self-Assessment (OSA). However, there were no statistically significant differences between groups in any of these measures. Whilst all groups improved on key outcomes, it is possible that exercise alone and/or natural recovery were responsible for improvements. For future research, a study that involves another control group who do not receive any form of direct 106

intervention may be needed so as to be able to more definitively differentiate spontaneous healing from response to specific interventions. Despite the intent of the sham application to be non-therapeutic, the findings of similar improvements in both taping groups indicates that how the tape was applied had minimal impact. Therefore, the physiological mechanisms by which elastic therapeutic tape is presumed to work on this population remains hypothetical and open to speculation. It is positive to note that the use of elastic therapeutic tape was well tolerated by participants and not associated with any significant side effects or symptom exacerbation. 6.4 Chapter Summary This study provided more clarity on the use of elastic therapeutic tape for lateral elbow tendinosis and, whilst Study 3 showed preliminary support for its use, findings from this RCT demonstrated that differences were not statistically significant from those achieved by sham taping or exercises alone. Given these findings, therapists should continue to be guided by evidence-based practice when working with this patient population. Based on the literature, eccentric exercises and activity modification techniques continue to be more appropriate, evidence-based, and cost-effective in the clinical management of lateral elbow tendinosis. 107

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Chapter 7 - A qualitative review of patients experiences using Kinesio tape for lateral epicondylitis 7.1 Introduction This chapter comprises the final study of this PhD thesis. While many other interventions for lateral elbow tendinosis are widely used and have been researched, limited research has been conducted on specific patient experiences with this often long-term condition which often leads to reduced function in daily life. This qualitative study aimed to describe the lived experiences of 11 participants from the intervention group of the RCT in Study 4 (three participants were lost to follow up). This included their perspectives on the use of a passive intervention, elastic therapeutic tape, for the treatment of lateral elbow tendinosis compared to self-management strategies alone over a six-month period. The full article of Study 5 is included in this chapter in its revised submitted version to the British Journal of Occupational Therapy. 7.2 Chapter Contents Wegener, R.L., Brown, T. & O Brien, L. (2016). A qualitative review of patients experiences using Kinesio tape for lateral epicondylitis. Submitted to British Journal of Occupational Therapy and currently under second review. 109

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7.3 Impact of the Study Journal Metrics: Source Normalized Impact per Paper (SNIP) - 0.6 Impact per Publication (IPP) - 0.667 SCImago Journal Rank (SJR) - 0.461 The findings of this study further support existing literature, as well as the results of Study 4, which identified activity modification and exercises as important components in the recovery of lateral elbow tendinosis. There is limited research into patients experiences with lateral elbow tendinosis and, for this reason, this study adds valuable information for therapists. It was found that patients recovery from lateral epicondylitis took longer than they expected and that it was a frustrating time involving multiple impacts and adjustments to their usual work and daily activities. Changes in life roles during this period led to concerns about future recovery and long-term function. The limitations of this study that must be acknowledged are: (i) all participant groups were not interviewed thus restricting the ability to gather broader data regarding participant experiences of living with and managing the condition; and (ii) the interviews could have been piloted amongst a patient population (instead of therapists alone) in order to identify areas of greater conceptual complexity. By reflecting on the research 132

relationship (reflexivity) after this qualitative study, it must be acknowledged that there was potential for pre-conceptions as the primary researcher knew all of the participants prior to the interviews. For instance, my perceptions regarding how adherent patients were with prescribed treatment may have influenced what was emphasised, explored and, therefore, reported in the findings. My preconceptions may have also influenced how questions were asked (e.g. such as tone of voice, sympathetic body language and facial expressions) and subsequently what responses were given. These two factors may have impacted on the findings of this study. If these interviews were to be conducted again, it would be beneficial to have another therapist observe the interviews as they are taking place, thereby providing another perspective on the interview findings. Discussion with this colleague after the interview may have revealed angles that I may have overlooked or dismissed without taking the time to consider them thoroughly. It would also have encouraged critical reflection on the interview and may have changed how subsequent interviews were conducted. Additionally, keeping a detailed diary of my own emotions, thoughts and impressions before and after interviews would also have been useful practice. It is possible that other issues in my own home and work life were impacting how interviews were conducted, and may have introduced unconscious bias. 133

Overall, it was identified that these long-term changes implemented by the person themselves were the most important for improvements in function. By considering the person s perception of lateral elbow tendinosis, including their function and occupational adaptations, therapists improve their understanding of the complexities of this condition and consider avoiding the trial of multiple passive interventions that may actually have little additional benefit compared to existing evidence-based interventions. 7.4 Chapter Summary The objective of this qualitative study was to gather interview data to identify people s experiences with lateral elbow tendinosis, as well as their perception on using elastic therapeutic tape as an intervention for this complex and often chronic condition. Emergent themes included: 1. Frustration at the length of time needed for functional recovery and the impact on life roles. 2. The importance of long-term self-management for lateral epicondylitis. 3. Kinesio tape was an adjunct in recovery compared to self-management strategies. 134

In particular, these themes fit within the Occupational Adaptation Model which proposes that increased function does not automatically equate to occupational adaptation. As is shown in this study, people with this condition will often make physical/functional improvements over time; however, this does not necessarily result in occupational adaptation and this should be considered by therapists. This study concluded that, although this condition has been widely researched, many focus on quantitative results as opposed to qualitative findings. Specific findings found that ongoing adjustments to work and daily activities, as well as adherence to prescribed exercises, were the largest contributor to improvements in function. The next chapter collaborates all the findings from the previous five chapters and discusses these in depth, based on existing research and within the context of the conceptual frameworks and models that underpin this thesis. 135

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Chapter 8 Discussion and Conclusion 8.1 Chapter Overview The purpose of this chapter is to present the overall findings from research projects that addressed the original thesis research questions. The use of elastic therapeutic tape as an intervention approach for lateral elbow tendinosis is discussed, including the current body of evidence, limitations of the thesis, recommendations for future research, and future implications for practice. 8.2 Revisiting the Research Questions The five studies presented in this Thesis by Publication are the first to comprehensively investigate the effectiveness as well as clinician and patient perceptions of elastic therapeutic tape as a treatment for lateral elbow tendinosis. A summary of the research questions and related study findings are outlined below in Table 2. As discussed throughout this thesis, lateral elbow tendinosis is known to result in considerable morbidity, long-term recovery and high financial costs (Gruchow & Pelletier, 1979). With a prevalence in the general population of 1-5%, it is a common 137

condition treated in Hand Therapy settings and often presents challenges for achieving successful rehabilitation (Fedorczyk, 2006b, 2012). To date, many interventions with varying levels of effectiveness for lateral elbow tendinosis have been researched. More recently, elastic therapeutic tape has been increasingly used in clinical practice despite limited evidence being reported regarding its effectiveness (Bassett, 2010; Bisset & Vicenzino, 2015; Parreira, Costa, Hespanhol Junior, Lopes, & Costa, 2014). Currently, there is still no gold standard for tape application and its recommended use varies between different manufacturing brands (Parreira, Costa, Hespanhol Junior, Lopes, & Costa, 2014). Therapists are required to use this modality based on the information and recommendations provided by manufacturers, combined with their own clinical reasoning and previous experience. This carries risks associated with prescribing an intervention without proven clinical benefit, safety or cost effectiveness. For this reason, the development of this research project and its findings aim to inform the practice of hand therapists when using this treatment modality for lateral elbow tendinosis. 138

Table 2: Summary of research questions and study findings 1. Scoping Review Research Questions Content Findings What is the current evidence relating the use of elastic therapeutic tape in treating neck and upper extremity conditions? Taylor, R.L., O Brien, L. & Brown, T. (2014). A scoping review of the use of elastic therapeutic tape for neck or upper extremity conditions. Journal of Hand Therapy, 27(3), 235-246. A scoping review was completed to review the current evidence of elastic therapeutic tape for the treatment of neck and upper extremity conditions. Whilst elastic therapeutic tape is reported to be widely used in clinical practice, there is limited evidence into its use for neck or upper extremity disorders and future studies are warranted. Elastic therapeutic tape may play a role in reducing short-term neck and upper extremity pain and it may be a more convenient and comfortable alternative to existing conservative treatments. 2. Cross-sectional Study What are the current perspectives amongst hand therapists, general practitioners and hand surgeons on the use of elastic therapeutic tape and how often is it used or recommended? This cross-sectional study used a self-report survey to gather data from 157 respondents on the use of elastic therapeutic tape in clinical practice (Occupational Therapists and Physiotherapists who practice as hand therapists, general practitioners and hand surgeons). Therapists, general practitioners and surgeons have differing perceptions on elastic therapeutic tape. Therapists were more likely to recommend its use based on clinical experience, whereas GP s and surgeons were more sceptical regarding its use and effectiveness due to limited evidence. 139

Taylor, R.L., Brown, T. & O Brien, L. (2015). Knowledge of and willingness to recommend kinesiotape for upper limb overuse injuries: A comparison of therapists, general practitioners and surgeons perspectives. International Journal of Therapy and Rehabilitation, 22(5), 238-245. 3. Case Series What is the preliminary evidence into the benefit of elastic therapeutic tape and eccentric exercises for the treatment of lateral elbow tendinosis? Wegener, R.L., Brown, T. & O Brien, L. (2015). The use of elastic therapeutic tape and eccentric exercises for lateral elbow tendinosis: a case series. Hand Therapy, 20(2), 56-63. This study was developed based on the author s clinical observations and involved a retrospective case series of four patients with lateral elbow tendinosis who were treated with elastic therapeutic tape. This case series demonstrated some preliminary support for the use of elastic therapeutic tape and eccentric exercises in the management of lateral elbow tendinosis. This study identified the need for a randomised control trial and qualitative study in order to rigorously examine this concept. 140

4. Randomised Controlled Trial Is the application of elastic therapeutic tape according to the Clinical Therapeutic Applications of the Kinesio Taping Method manual (with the tape applied on tension), in conjunction with an eccentric exercise program and activity modification advice, more effective than (i) sham taping, or (ii) eccentric exercises alone in patients with lateral elbow tendinosis? Are the benefits of three months of treatment using elastic therapeutic tape sustained sixmonths post intervention? Wegener, R.L., Brown, T. & O Brien, L. (2016). A randomized controlled trial of comparative effectiveness of elastic therapeutic tape, sham tape or eccentric exercises alone for lateral elbow tendinosis. Hand Therapy 1758998316656660, first published on July 11, 2016 doi:10.1177/1758998316656660. This was a randomised controlled trial of 40 participants with lateral elbow tendinosis who received (i) elastic therapeutic tape, (ii) sham tape, and (iii) no tape, over a 12-week period with a 6 month follow up. All participants received eccentric exercises and advice on activity modification techniques. Whilst 95% of participants improved over six months, there were no statistically significant differences between the intervention, sham, and control groups in measures of pain and function. It is important to note that there were also no significant adverse effects with this treatment modality. 141

5. Qualitative Study What are the experiences of people using elastic therapeutic tape as a treatment for lateral elbow tendinosis? Wegener, R.L., Brown, T. & O Brien, L. (2016). A qualitative review of patients experiences using Kinesio tape for lateral epicondylitis. (Submitted to British Journal of Occupational Therapy) Thematic analysis was used to describe the experiences of participants who used elastic therapeutic tape, their adherence with treatment, and their perceptions of the impact of using the tape on their recovery, function and return to pre-injury roles. Findings from this study showed that, regardless of treatment, people with lateral elbow tendinosis experienced frustrations associated with long-term recovery. The key finding was that continual long-term adjustments to work and daily activities, as well as adherence to prescribed exercises, were the largest contributor to improvements in function as opposed to using elastic therapeutic tape. These findings highlight the importance of exploring people s health experiences, encouraging a self-management approach to chronic musculoskeletal conditions, and avoiding the trial of multiple passive interventions that may have no additional benefit. 142

8.3 Discussion of Study Findings The findings of this thesis contribute to the body of evidence about the clinical use and effectiveness of elastic therapeutic tape. New trials on the use of elastic therapeutic tape for a variety of conditions are frequently being published (Parreira, Costa, Hespanhol Junior, Lopes, & Costa, 2014). However, the quality of these studies continues to vary. In particular, there are still minimal high quality studies about the use of elastic therapeutic tape for upper limb conditions (Taylor, O'Brien, & Brown, 2014). To date, there are six published systematic reviews that evaluate the effectiveness of elastic therapeutic tape for different conditions. Williams et al. (2012) assessed Kinesio Taping in the prevention and treatment of sports injuries. Bassett et al. (2010) and Mostafavifar et al. (2012) considered Kinesio Taping in people with musculoskeletal conditions. Morris et al. and Kalron and Bar-Sela (2013) examined musculoskeletal conditions but extended their review to include other clinical areas, such as neurological and lymphatic conditions. Most recently, a systematic review was completed by Parreira et al. (2014) that assessed musculoskeletal conditions, but included more recent trials (12 RCT s in total). The conclusions from these published systematic reviews are very similar. Overall, the use of elastic therapeutic tape for musculoskeletal conditions has shown no significant benefit, or the effects have been too small to be considered clinically 143

significant. All systematic reviews included trials comparing taping with a large range of other modalities (including no treatment, sham taping, exercises, physiotherapy, electrotherapy) and included outcome measures of pain, disability and quality of life. Studies that have reported significant benefits from elastic therapeutic tape are mainly trials conducted on healthy population groups or of low quality (and therefore high risk of bias), and those with study designs of low methodological quality, such as case reports (Taylor, O'Brien, & Brown, 2014). The results from the five studies within this thesis are consistent with the current evidence obtained from the existing systematic reviews described above. The scoping review confirmed the lack of evidence into elastic therapeutic tape for neck and upper limb conditions. The cross-sectional study found differing levels of knowledge of the tape s use amongst Surgeons, General Practitioners and Therapists; however, Therapists were more likely to use a treatment modality without proven clinical effectiveness. The case series demonstrated some preliminary support for elastic therapeutic tape for lateral elbow tendinosis; however, this study had limitations and provided only weak anecdotal level evidence, consistent with other small non-controlled studies that have been published on elastic therapeutic tape (Mostafavifar, Wertz, & Borchers, 2012; Parreira, Costa, Hespanhol Junior, Lopes, & Costa, 2014). 144

The subsequent randomised controlled trial of 40 participants with lateral elbow tendinosis who received either (i) elastic therapeutic tape, (ii) sham taping, or (iii) no taping, provided stronger findings. Whilst 95% of participants improved over six months, there were no statistically significant differences between the three sample groups in measures of pain and function. However, it is important to note that there were no significant adverse effects to participants with this treatment modality either. This particular finding supports studies in other populations that found most patients were satisfied with the comfort and convenience of this treatment and experienced no ill effects, despite minimal evidence of other benefits (Ristow et al., 2013; Tsai, Hung, Yang, Huang, & Tsauo, 2009). The fifth and final study of this thesis involved a qualitative analysis of the experiences of 11 participants from the intervention group of the RCT (three participants lost to follow up). Although lateral elbow tendinosis has been widely studied with a focus on managing physical symptoms (Bassett, 2010), limited research has been conducted on specific patient experiences with this often long-term condition. Importantly, the findings from this study indicated that, regardless of the treatment provided, having lateral elbow tendinosis resulted in frustrations associated with long-term recovery. Continual long-term adjustments to work and daily activities, as well as adherence to prescribed exercises, were reported as the largest contributor to improvements in 145

function as opposed to using elastic therapeutic tape. This is an important finding and possibly the most relevant for therapists in clinical practice when working with this patient population. From the available evidence, it would seem apparent that both exercise and ergonomic adjustments are the key aspects of successful management of lateral elbow tendinosis and a vital component of long-term self-management (Buckle & Devereux, 2002). This is consistent with the evidence for other conditions associated with chronic musculoskeletal pain leading to reduced function in daily life (Lillefjell, Krokstad, & Espnes, 2007). Individual and psychosocial factors (such as self-efficacy, adaptation, perceived emotional and physical functioning, pain intensity and pain cognition) are considered to be among the most important variables that influence the total health picture (Henderson, Kidd, Pearson, & White, 2005). As therapists, it is important to recognise that the impacts on a person s everyday life are dependant not only on the underlying pathophysiology, but to a larger extent on that person s perception of the condition in their present life situation (Henderson, Kidd, Pearson, & White, 2005; Lillefjell, Krokstad, & Espnes, 2006). 146

8.4 Implications for Clinical Practice A reasoned argument has been presented throughout this thesis regarding the need for a number of adjustments in the clinical practice of health professionals who use elastic therapeutic tape and work with people experiencing lateral elbow tendinosis. This research enquiry has culminated in three key findings. For lateral elbow tendinosis, there is currently limited support for long-term effectiveness of elastic therapeutic tape as a treatment modality. The results of the Randomised Controlled Trial (RCT) showed limited support for using elastic therapeutic tape for lateral elbow tendinosis. This is an interesting finding and potentially adds to existing literature showing minimal evidence for passive interventions amongst this population. While there were no significant side effects with the use of the tape, the costs of purchasing the tape and training staff in its correct application need to be considered. Given these findings, it is likely that eccentric exercises and activity modification techniques are more appropriate, evidence-based, and cost-effective interventions in the clinical management of lateral elbow tendinosis. These results are further supported by recent studies that continue to recommend that conservative management for lateral elbow tendinosis remains the 147

best practice and passive interventions should be considered carefully (Bisset & Vicenzino, 2015). Furthermore, this study highlights the complexity of managing this condition and the role of other factors in the aetiology of pain for lateral elbow tendinosis, such as changes in central pain processing (Heales, Lim, Hodges, & Vicenzino, 2014; Khan, Cook, Kannus, Maffulli, & Bonar, 2002; Khan, Cook, Maffulli, & Kannus, 2000a). Although this delves into issues beyond the scope of this PhD, it is important to consider these other dimensions when managing this condition. Overall, based on the study findings of this thesis, in combination with the current body of evidence in the literature, it can be inferred that the ongoing widespread clinical use of elastic therapeutic tape is due to its high-profile popularity and associated marketing (such as its use during the Olympics), as opposed to clinicians relying on high quality scientific evidence with clinically relevant outcomes. This was supported by findings in Study 2 which demonstrated that therapists were likely to continue using a treatment modality, such as elastic therapeutic tape, based on clinical experiences despite a lack of supporting evidence. Therefore, a future recommendation is that health professionals should carefully evaluate evidence regarding the tape s effectiveness when using this intervention. This disparity 148

between emerging evidence and therapists changing their clinical practice is an important area in need of further examination. Due to the complexity and chronic nature of lateral elbow tendinosis, it is important to recognise clients health experiences and the need for long-term occupational adjustments. Qualitative findings from this thesis demonstrated that the nature of lateral elbow tendinosis slow recovery results in considerable patient frustration. This is an area that has not been comprehensively examined amongst this patient population given that research to date has focused on managing physical symptoms within a biomechanical model (e.g. using interventions, such as elastic therapeutic tape) (Marcum, 2004). Whilst these factors are still important, it is vital for all health professionals to work towards optimising health, well-being and participation, as opposed to only focusing on physical dysfunction. For this reason, the use of the International Classification of Functioning, Disability and Health (ICF) framework in this study complements the Biomechanical Model and acknowledges the multiple components required for successful rehabilitation (WHO, 2001). Functioning is central to the patient experience in musculoskeletal conditions. The WHO identifies four health outcomes within this framework, including 149

impairments (body structure and function), activity limitations, restrictions in social participation and environmental factors (Steiner et al., 2002; WHO, 2001). Being able to assess the effectiveness of an intervention within each of these domains provides a means to more accurately assess its benefit and impact. For example, in the case of lateral elbow tendinosis, an MRI may show improvements in tendon recovery (impairment); however, the patient may not have regained full function at work (activity limitation) and remain unable to engage with family and friends (social participation and environment). Measurements of outcome for this patient would be falsely positive if only the impairment was considered. Due to the often long-term nature of lateral elbow tendinosis, this is a common situation for this patient population. The use of the Short-Form 36 (SF-36) and the Occupational Self-Assessment (OSA) were chosen as outcome measures within this thesis as they were able to closely evaluate aspects of these domains within the ICF. Whilst there has been literature on linking health-status measures to the ICF (including the SF-36) (Brockow et al., 2004), this is an area that will continue to be developed in the future (Cieza et al., 2002a; Velstra, Ballert, & Cieza, 2011). Through the perspective of the Occupational Adaptation Model, Schkade and Schultz (1992) outlined that increased function does not automatically equate to 150

occupational adaptation. This is a common mistake when working with patients with conditions such as lateral elbow tendinosis. As previously mentioned, people with this condition will often make functional improvements over time (e.g. less pain, improved movement/strength and increased use in everyday activities) however, this does not necessarily result in adaptation (Lillefjell, Krokstad, & Espnes, 2006, 2007). Therapists should consider these factors early in treatment and recognise their role in facilitating the internal adaptation process to maintain or re-engage in meaningful occupations. By incorporating evidence-based practice, there are actions that can be undertaken in the clinical setting, such as provision of earlier and more specific education on long-term occupational adjustments and the implementation of strategies/treatment plans that are occupation-focused (Cullinane, Boocock, & Trevelyan, 2014; Rothmore et al., 2016). Changes in terminology from lateral epicondylitis to lateral elbow tendinosis or lateral elbow tendinopathy should be implemented in clinical practice to better guide treatment. Extensive current research reveals that commonly used terms such as lateral epicondylitis and tennis elbow are misleading as they imply an inflammatory pathology as opposed to degeneration of the common extensor origin (Bunata, 151

Brown, & Capelo, 2007; Nirschl & Pettrone, 1979). It is important for health professionals to apply the correct diagnostic terminology to avoid misunderstanding and inappropriate treatment. More appropriate terms for this condition are either (i) lateral elbow tendinosis, or (ii) lateral elbow tendinopathy, and there should be a shift towards using these terms in clinical practice (Ali & Lehman, 2009). 8.5 Limitations of this thesis There are several limitations that have been identified throughout this thesis and have been documented in more detail in the five individual studies within Chapters 3 to 7. Overall, a summary of the main limitations includes Due to the limited number of randomised controlled trials into the use of elastic therapeutic tape for neck and upper extremity disorders, a systematic review was unable to be completed for this thesis. In order to synthesise all available evidence into this modality, a scoping review was completed instead. The cross-sectional study included a small sample size that was unevenly distributed by profession and location. Therefore, the findings may not 152

accurately represent the views of all health professionals across Australia. In the case series study, the lack of control group, un-blinding of patients and therapist, as well as a lack of pre-therapy measurements, may have led to bias in the results observed. The cost-effectiveness of elastic therapeutic tape compared to other existing interventions for lateral elbow tendinosis was not comprehensively examined. Large participant numbers were unable to be recruited in the RCT and it was ethically not possible to include a group receiving no treatment. There was no formal funding provided for this study thus limiting the recruitment strategies used. We did, however, reach our a-priori recruitment targets for 80% power to detect a clinically meaningful difference between groups. A geographical bias and gender imbalance must also be considered limitations for this trial, as the majority of patients were females located within one state; therefore, results may not be generalisable to the broader population. 153

As it was difficult to have blinding of the assessor and therapists, this may have increased the possibility of bias. Another limitation of the RCT may be that the outcome measures used (PRTEE, SF-36, OSA and grip strength) may not have been sensitive enough to detect clinical change at three and six month follow up. More rigorous supervision of each participant s home exercise program may have also been beneficial. Non-adherence to the specified treatment regimen, incorrect exercise techniques or inconsistencies with application of the tape may have not been reported and would most likely have impacted on results. 8.6 Recommendations for future research There is potential for future research into the role of elastic therapeutic tape for a variety of other musculoskeletal conditions. Further rigorous trials into the use of elastic therapeutic tape as an intervention strategy are needed, especially in relation to its role for acute upper limb conditions. It is possible that the proposed mechanisms of elastic therapeutic tape (such as reducing pressure on mechanoreceptors below the dermis, improving circulation, decreasing oedema and correcting muscle function) may be more aligned to the treatment of acute conditions, as opposed to chronic conditions 154

(such as lateral elbow tendinosis) that are not inflammatory in nature. This would provide research opportunities that build on the findings of the five studies reported in this thesis. 8.7 Chapter Summary Elastic therapeutic tape is widely used for upper limb and neck conditions in clinical practice despite poor evidence of its effectiveness. In particular, this thesis found that there was limited support for its use for lateral elbow tendinosis; however, it may be an acceptable adjunct treatment to eccentric exercise and activity modification and is associated with minimal side effects. It must be noted that the author acknowledges limitations with this RCT (as mentioned above) and that conclusions are based on findings in combination with previous underpowered or low-quality published studies. Overall, this chapter has summarised the results and limitations of the publications that form this thesis. Implications for clinical practice and future research have been discussed, with the findings of the five research studies indicating that certain changes in health practice amongst this patient population are warranted and should be considered. 155

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Appendix 162

Appendix A: Published opinion piece R.L., Brown, T. & O Brien, L. (2015). Using and prescribing kinesiotape as a treatment modality for musculoskeletal disorders. International Journal of Therapy and Rehabilitation, 22(9), 408-409. 163

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Appendix B: Ethics approval and Final Report 166

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Appendix C: Conference Participation Current Abstract Submissions Wegener, R.L., Brown, T. & O Brien, L. (2017). The use of Kinesio tape for tennis elbow: results of quantitative and qualitative studies. Submitted for oral and poster presentations at the Occupational Therapy Australia Association Conference, July 2017; Perth, Australia. Conference Presentations Wegener, R.L., Brown, T. & O Brien, L. (2016). Comparative effectiveness of Kinesio tape, sham taping or eccentric exercises for tennis elbow. Oral and poster presentations at the ACT Australian Physiotherapy Association Research Symposium, September 2016; Canberra, Australia. Wegener, R.L. (2016). Comparative effectiveness of Kinesio tape, sham taping or eccentric exercises for tennis elbow. Poster presentation at CHARM (Canberra Hospital Annual Research Meeting), August 2016; Canberra, Australia. 169

Wegener, R.L., Brown, T. & O Brien, L. (2016). Comparative effectiveness of Kinesio tape, sham taping or eccentric exercises for tennis elbow. Oral presentation at the Australian Hand Therapy Association Conference, August 2016; Sydney, Australia. Wegener, R.L., Brown, T. & O Brien, L. (2014). Kinesiotape for lateral elbow tendinosis. Oral presentation at the Australian Hand Therapy Association Conference, August 2014; Gold Coast, Australia. Awarded Best Poster Award. Other Presentations Wegener, R.L. (2016). Kinesiotape for the upper limb. Oral presentation at the ACT Hand Therapy Special Interest Group, November 2015; Canberra, Australia. Wegener, R.L. (2016). The use of elastic therapeutic tape for lateral elbow tendinosis. Oral presentation at the Victorian Hand Therapy Special Interest Group, June 2015; Melbourne, Australia. 170

Appendix D: Application of Tape (Study 4) Within the Randomised Controlled Trial (RCT) of Study 4, elastic therapeutic tape was applied to each participant of the intervention group with the elbow extended. The first strip of tape was applied with 25% tension (the distal 1-2 inches of tape is tapered off and applied with no tension). The second and third strips of tape are applied as a space correction for the area of pain over or around the lateral epicondyle. With the elbow slightly flexed, I strips are used with 25-50% tension with the end of the strip tapered off at no tension. Moderate to full tension was applied to the middle part of the tape to further reduce tissue movement if required. Participants were shown on how to apply the tape at the initial session and educated on how to monitor for side effects, such as skin irritation. Figure 4: Application of Tape Using I Technique 171

Participants in the sham application group were taped the same way as the intervention group; however, the tape was applied with no tension. As per the intervention group, participants were shown how to apply the tape, monitor for side effects, and wearing regime was identical. 172

Appendix E: Eccentric Exercise Program (Study 4) Figure 5: Eccentric Exercise Program Eccentric strengthening exercises were completed once a day as follows: With the elbow flexed and the wrist supported, participants undertook exercises with a 500g-1kg weight placed in the hand with the palm facing down (pronation). By supporting the forearm on the edge of a table, the wrist is raised with the unaffected hand (concentric contraction) and lowered slowly for 5 seconds (eccentric contraction). Initial regimen consisted of 1-3 sets of 10-15 repetitions per day. Weights were increased when 3 sets of 15 repetitions were completed without difficulty. With the elbow flexed, participants held a broom in their hand at its balance point. The broom was then rotated in a slow and controlled motion (eccentric contraction). Initial regimen consisted of 4 sets of 8 repetitions per day. Once this exercise was completed 173

with minimal pain, the participant could move their hand 1cm along the handle (away from the broom head) progressively each day. 174

Appendix F: Outcome Measures (Study 4) 175

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