RESEARCH REPORT
THE EFFECTS OF KINESIOTM TAPE ON PERONEAL MUSCLE ACTIVITY IN
PATIENTS WITH CHRONIC ANKLE INSTABILITY
An Abstract of
A Thesis
Presented to the Faculty of
The Department of Kinesiology
Western Illinois University
In Partial Fulfillment
Of the Requirement for the Degree
Master of Science
By
JASON JOHNSON
July 2014
ABSTRACT
The purpose of this study was to investigate the effect of Kinesio tape on
peroneal muscle activity during common therapeutic exercises in patients with chronic
ankle instability (CAI). Fifteen college students with CAI performed a single leg stance
(SLS)-eyes open, SLS-eyes closed, and a SLS on a BOSU ball exercise protocol.
Surface electromyography (EMG) was used to measure peroneal muscle activity. The
protocol sequence for each participant was: (a) complete the exercises without tape, (b)
repeat the exercises with tape, (c) continue to wear the tape for 24 hours, (d) repeat the
exercises with tape, and (e) repeat the exercises without tape.
The dependent variable, peroneal muscle activity amplitude (MAA), for each of
the three conditions was analyzed using a 2×2 (Tape/No Tape Condition x Day)
repeated measures ANOVA. An alpha level of p < .05 was used for all hypothesis testing. All significant ANOVA effects were further analyzed using a post-hoc analysis of simple main effects. The results indicated a significant increase in peroneal MAA when wearing Kinesio tape during the performance of a SLS-eyes closed exercise on a stable surface. No statistically significant differences in peroneal MAA for the SLS-eyes open on stable surface or when balancing on the BOSU balance trainer were found. Kinesio tape may improve peroneal activity when the visual component is removed from rehabilitation exercises. However, from these preliminary findings, Kinesio tape cannot be recommended as a means for muscle re-education and proprioception enhancement in patients with chronic ankle instability. Further research examining the rehabilitative properties of Kinesio tape on muscle activity is needed. THE EFFECTS OF KINESIOTM TAPE ON PERONEAL MUSCLE ACTIVITY IN PATIENTS WITH CHRONIC ANKLE INSTABILITY A Thesis Presented to the Faculty of The Department of Kinesiology Western Illinois University In Partial Fulfillment Of the Requirement for the Degree Master of Science By JASON JOHNSON July 2014 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Microform Edition ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, MI 48106 - 1346 UMI 1564042 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. UMI Number: 1564042 ACKNOWLEDGMENTS Thank you to all of those who helped me through some of the most trying months of my life to date. I would not have been able to go on without your encouragement and aide. I am grateful to have this experience to build upon professionally. I would like to thank my thesis chair, Dr. Jennifer Plos. Thank you for never giving up on this project, I truly couldnt have asked for a better mentor. Thank you to Dr. Miriam Satern and Dr. Janet Wigglesworth. Your assistance and constructive feedback pushed me to my full potential. A special thank you to Dr. Noelle Selkow, this project couldnt have happened without your donation. Additionally I would like to thank Dr. Timothy Piper for his enthusiasm and support that drove me to pursue a thesis in the first place. I would also like to thank all of the individuals who participated in my study. Thank you for taking time out of your busy days. A special thanks also goes to Western Illinois University for allowing me the opportunity to complete this thesis. None of this would have been possible without my parents, Sherry and Robert. Thank you for instilling me with a positive work ethic, determination, and perseverance. Your love and support allowed me to further myself as a professional. Lastly, thank you to all my friends. Thank you for helping me to decompress and remember the bigger picture. Thank you Stephanie Rendall, weve come so far. ii TABLE OF CONTENTS Page ACKNOWLEDGMENTS ...................................................................................................... ii TABLE OF CONTENTS ........................................................................................................ iii LIST OF TABLES .................................................................................................................. vii LIST OF FIGURES ................................................................................................................ viii CHAPTERS 1. Introduction ................................................................................................................ 1 Statement of the Problem .................................................................................... 5 Hypotheses ........................................................................................................... 6 Definitions ........................................................................................................... 6 Assumptions ........................................................................................................ 7 Delimitations ....................................................................................................... 8 Limitations ........................................................................................................... 8 Significance of the Problem................................................................................. 9 2. Review of Literature ..................................................................................................... 10 Chronic Ankle Instability (CAI) .......................................................................... 10 Assessment of CAI ................................................................................ 11 Proprioception .................................................................................................... 12 Peroneal latency (stretch reflex) .............................................................. 13 iii Assessment of proprioception ................................................................. 15 Reproduction of joint position .................................................. 16 Electromyography (EMG) ........................................................ 16 Balance testing ........................................................................... 18 Neuromuscular Control ....................................................................................... 19 Rehabilitation for CAI ......................................................................................... 19 Balance Training ................................................................................................. 21 Balance Training on Stable and Unstable Surfaces ............................... 23 BOSU Balance Trainer for Proprioceptive Enhancement ................ 24 Kinesio Tape .................................................................................................... 26 Benefits of Kinesio Tape.................................................................... 27 Effects of Kinesio Tape on Ankle Proprioception ............................. 27 Summary .............................................................................................................. 30 3. Research Methodology .............................................................................................. 32 Participants ......................................................................................................... 32 Instrumentation ................................................................................................... 33 Pilot Study .......................................................................................................... 33 Procedures ........................................................................................................... 34 Day 1: Informed Consent and Inclusion Determination .......................... 34 Day 2: MAA for SLS-Eyes Open, No-Tape followed by Tape .............. 34 EMG protocol ............................................................................ 35 iv Rehabilitation exercise protocol ................................................ 35 Peroneal muscle activity measurements .................................... 38 Kinesio Tape Application ...................................................... 38 Day 3: MAA for SLS-Eyes Open, Tape followed by No-Tape .............. 39 Days 4-6: Rest and Recovery .................................................................. 40 Day 7: MAA for SLS-Eyes Closed, No-Tape followed by Tape ............ 40 Rehabilitation exercise protocol ................................................ 40 Day 8: MAA for SLS-Eyes Closed, Tape followed by No-Tape ............ 41 Statistical Analysis .............................................................................................. 41 4. Results & Discussion .................................................................................................. 43 Participants .......................................................................................................... 43 Results ................................................................................................................. 43 Results of MAA during SLS-Eyes Open ................................................ 43 Results of MAA during SLS-Eyes Closed ............................................. 44 Results of MAA during SLS-BOSU ...................................................... 45 Summary of Results ............................................................................................ 47 Discussion of Findings ........................................................................................ 49 Hypothesis 1 ............................................................................................ 49 Hypothesis 2 ............................................................................................ 50 Hypothesis 3 ............................................................................................ 51 v Additional Findings ............................................................................................ 52 Concepts for Consideration ................................................................................. 54 5. Summary, Conclusions, & Recommendations .......................................................... 58 Summary ............................................................................................................. 58 Conclusions ........................................................................................................ 59 Recommendations .............................................................................................. 60 REFERENCES ............................................................................................................... 63 APPENDICES A. INFORMED CONSENT ............................................................................... 73 B. HEALTH HISTORY QUESTIONNAIRE .................................................... 77 C. FOOT & ANKLE DISABILITY INDEX (FADI).......................................... 80 D. INDIVIDUAL TRIAL MAA SCORES ......................................................... 82 vi LIST OF TABLES Page Table 1: Means and Standard Deviations for MAA (mV) during Single Leg Stance
Eyes Open ………………………………………………………………………………………………… 44
Table 2: ANOVA Summary Table of MAA Single Leg Stance Eyes Open
(Tape/No Tape) x (Day)………………………………………………………………………………. 44
Table 3: Means and Standard Deviations for MAA (mV) during Single Leg Stance
Eyes Closed ……………………………………………………………………………………………….. 45
Table 4: ANOVA Summary Table of MAA Single Leg Stance Eyes Closed
(Condition) x (Day)…………………………………………………………………………………….. 45
Table 5: Summary of Results from the Post-Hoc Analysis of the Day x Condition
Interaction for Single Leg Stance Eyes Closed ……………………………………………. 45
Table 6: Means and Standard Deviations for MAA (mV) during Single Leg Stance on
BOSU Balance Trainer ……………………………………………………………………………. 46
Table 7: ANOVA Summary Table of MAA Single Leg Stance on (BOSU)
(Tape/No Tape) x (Day)………………………………………………………………………………. 46
Table 8: Summary of Kinesio Tape Studies for the Ankle …………………………………………….. 55
vii
LIST OF FIGURES
Page
Figure 1: Mechanism of an inversion ankle sprain and involved ligaments ……………………… 1
Figure 2: Peroneus brevis and longus complex on lateral side of ankle …………………………… 2
Figure 3: Mechanical and functional insufficiencies that contribute to chronic ankle
instability …………………………………………………………………………………………………… 3
Figure 4: Overview of procedures by day…………………………………………………………………… 35
Figure 5: Markings for electrode placement ……………………………………………………………….. 36
Figure 6: BOSU balance trainer with inflatable bladder side up ……………………………………. 37
Figure 7: Summary of the mean peroneal MAA during SLS-eyes closed trials ………………. 46
Figure 8: Means and standard deviations for peroneal muscle activity measured by
EMG ……………………………………………………………………………………………………….. 48
Figure 9: Sample research protocol to investigate fatigue factors ………………………………….. 62
viii
1
CHAPTER 1
INTRODUCTION
Over 23,000 inversion ankle sprains occur in the athletic population each year
(Hertel, 2002) and account for 10-28% of all athletic injuries (Barrett et al., 1993).
Inversion ankle sprains occur when an athlete lands on the lateral aspect of the foot and
rolls the sole of the foot up and in (Hertel, 2002). Stress from the excessive inversion
mechanism on the lateral, or outer, aspect of the foot/ankle causes a stretch or tear of the
lateral ligamentous complex, commonly called a sprain. The ligaments that are damaged
during a lateral ankle sprain include the anterior talofibular, calcaneofibular, and
posterior talofibular ligaments (see Figure 1).
Figure 1. Mechanism of an inversion ankle sprain and involved ligaments.
Adapted from: http://www.consultant360.com/articles/weekend-athlete-common-foot-and-ankle-injuries
2
In addition to ligamentous damage, inversion ankle sprains also cause
neuromuscular deficits in the peroneal brevis and longus complex (see Figure 2),
potentially leading to functional ankle instability and a decrease in the ability to prevent
further ankle sprains (Hertel, 2002). Inversion ankle sprains are painful, debilitating, and
often lead to chronic ankle instability for the athlete (Yeung, Chan, So, & Yuan, 1994).
Chronic Ankle Instability (CAI) is defined as the occurrence of repetitive bouts
of lateral ankle instability, resulting in numerous ankle sprains (Hertel, 2002, p. 364).
While the mechanism of the initial lateral ankle sprain is well documented, the direct
causes of CAI are still unknown. However, Herman, Magrum, and Hertel (2013)
describe two potential contributors to CAI: mechanical and functional instability (see
Figure 3).
Figure 2. Peroneus brevis and longus complex on lateral side of ankle.
Adapted from: http://www.cps.ca/documents/position/ankle-sprains-athlete
3
Figure 3. Mechanical and functional insufficiencies that contribute to chronic ankle instability.
Adapted from Functional anatomy, pathomechanics, and pathophysiology of lateral ankle
instability, by J. Hertel, 2002, Journal of Athletic Training, 37(4), p. 369.
Mechanical instability following an ankle injury is the result of multiple
deficiencies predisposing the injured part to future injury. These deficiencies include
increased pathological laxity, synovial disruption, degenerative changes, and impaired
biomechanics (Hertel, 2002). Treatment for these insufficiencies requires a patient to be
referred to an orthopedic surgeon for surgical intervention.
Functional instability is the result of deficiencies in the neuromuscular
system caused by injury to the muscle complex following a lateral ankle sprain.
These deficiencies can reduce the dynamic support at the ankle (Freeman, Dean,
& Hanham, 1965). Functional instability is identified by impairments of
proprioception and neuromuscular control, thus resulting in inadequacies of the
dynamic defense mechanism protecting against recurrent ankle sprains (Lephart,
Pincivero, & Rozzi, 1998). It also includes strength deficits and impaired
4
postural control of the ankle. Treatment for these insufficiencies can be
addressed through rehabilitative measures implemented under the direction and
supervision of an athletic trainer or physical therapist.
According to Hertel (2002), comprehensive rehabilitation programs for treating
CAI must emphasize proprioception, neuromuscular control, and balance training. To
assist in improving proprioception and neuromuscular control during rehabilitation,
Kinesio tape has been proposed to offer potential proprioceptive benefits (Murray &
Husk, 2001), essential to proper rehabilitation following an ankle sprain. Kinesio tape
relies on several therapeutic mechanisms of treatment. According to Kase, Tatsuyuki, and
Tomoko (1996), Kinesio tape assists in: (a) correcting muscle function by
strengthening weakened muscles, (b) improving circulation of blood and lymph by
eliminating tissue fluid or bleeding beneath the skin by moving the muscle, (c) decreasing
pain through neurological suppression, (d) repositioning subluxed joints by relieving
abnormal muscle tension, and (e) helping to return the function of fascia and muscle. In
addition, Kinesio tape has been proposed to enhance proprioception through increased
stimulation to cutaneous mechanoreceptors (Murray & Husk, 2001).
In ankle rehabilitation, there are multiple goals that must be achieved for a safe
and stable recovery. These goals include: (a) strengthening, (b) re-education of the
muscles that are considered dynamic stabilizers of the ankle (i.e. peroneal muscles as the
primary everters), and (c) re-establishing proprioception and kinesthesia.
Proprioception is the ability to determine the position of a joint in space, while
kinesthesia refers to the ability to detect movement (Grigg, 1994). Restoration of
proprioception and kinesthesia is traditionally attained through rehabilitation exercises
5
that focus on balance and coordination training of the ankle following a sprain
(Konradsen, 2002). Numerous studies have found success using balance boards to
improve strength and balance measures in subjects with acute ankle injury and CAI
(Osborne, Shan-Chou, Laskowski, Smith & Kaufman 2001; Soderman, Werner, Pietila,
Engstrom, & Alfredson, 2000; Wester, Jespersen, Nielsen, & Neumann, 1996). However,
minimal studies have promoted the addition of Kinesio tape to further enhance the
proprioception outcomes of traditional rehabilitation exercises.
Although it has been proposed that Kinesio tape is capable of correcting muscle
function by strengthening weakened muscles (Kase et al., 1996) and is also capable of
enhancing proprioception through increased stimulation to cutaneous mechanoreceptors
(Murray & Husk, 2001), little research exists on its proprioceptive effects and ability to
facilitate muscle re-education. Research specifically related to the effect of Kinesio
tape on peroneal re-education in the CAI patient is minimal. These limited studies have
postulated that Kinesio tapes ability to stretch to 140% of its original length allows
the tape to move as the body does; thus potentially enhancing the stimulation of
mechanoreceptors within the skin (Kase, 2013). Stimulation of these cutaneous
mechanoreceptors may play a role in proprioception and kinesthesia (Riemann &
Lephart, 2002).
Statement of the Problem
The purpose of this study was to investigate the effects of Kinesio tape on
peroneal muscle activity during common therapeutic exercises in patients with chronic
ankle instability (CAI).
6
Hypotheses
The hypotheses investigated in this study were as follows:
1) Kinesio tape will increase EMG activity of the peroneal muscle group during a
single leg stance (eyes open) exercise on a stable surface.
2) Kinesio tape will increase EMG activity of the peroneal muscle group during a
single leg stance (eyes closed) exercise on a stable surface.
3) Kinesio tape will increase EMG activity of the peroneal muscle group during a
single leg stance (eyes open), on the bladder portion of a BOSU balance
trainer.
Definition of Terms
The following terms have been defined to provide clarity:
Acute pain refers to pain at the time of assessment (Prentice & Arnheim, 2006).
Arthokinematics refers to the movement, which occurs in the joint surface
(Narayana, 2005).
Chronic ankle instability (CAI) refers to repetitive bouts of lateral ankle instability
resulting in numerous ankle sprains (Hertel, 2002).
Electromyography (EMG) is a diagnostic test that records the electrical activity of
muscles (Horowitz, 2014).
Eversion refers to a movement of the calcaneus such that the sole of the foot turns
outward or laterally (Prentice & Arnheim, 2006).
Functional instability implies an inability to control either arthrokinematic or
osteokinematic movement in the available range of motion, either consciously or
unconsciously, during functional movement (Magee, 2008).
7
Inversion refers to a movement of the calcaneus such that the sole of the foot
turns inward or medially (Prentice & Arnheim, 2006).
Kinesio Tape refers to therapeutic tape that is an elastic cotton strip with an
acrylic adhesive used for treating athletic injuries and a variety of physical disorders
(Kase, 1996).
Kinesthesia refers to the ability to detect movement (Grigg, 1994).
Osteokinematic refers to small amplitude motions of bones at a joint surface
(Thompson, 2000).
Neuromuscular control describes the brains attempt to teach the body conscious
control of a specific movement (Swanik, 2004). In this study, neuromuscular control
refers to the peroneal brevis and longus muscles ability to contract in order to maintain
stability.
Prophylactic refers to guarding against injury or disease (Prentice, 2006). The
peroneal muscles serve as a protective guard against excessive inversion of the ankle.
Proprioception refers to the ability to determine the position of a joint in space
(Grigg, 1994).
Sprain refers to stretch or tear of a ligament that limits movements of a joint in the
body (Prentice, 2006).
Assumptions
The assumptions regarding this study were as follows:
1) The participants understood and followed all of the instructions given.
2) The participants performed all exercises to the best of their abilities.
3) The participants did not shower for a 24 hr time period to protect the EMG electrode.
8
4) The participants refrained from watching the EMG recordings while
participating in the exercises.
Delimitations
The delimitations regarding this study were as follows:
1) The study was limited to college student volunteers from one Midwestern
University.
2) The participants were limited to 18-30 year old males and females.
3) The participants were required to have a score of 90% or less on the Foot and
Ankle Disability Index (FADI) sport survey.
4) The participants could not have a history of lower extremity fracture, surgery, or
conditions which altered sensory perception or balance.
Limitations
The limitations of this study included:
1) No universally accepted definition for CAI exists, thus limiting generalization
to the population.
2) Cross talk interference resulting from the use of electromyography possibly
influenced the results.
3) Participants (collegiate athletes and general students) overall peroneal muscle
activity may have differed, depending on whether or not they underwent
rehabilitation to strengthen the muscles following their initial ankle injuries.
4) Electrode placement and taping techniques used in this study only addressed
the peroneal longus and brevis muscles.
9
5) Mechanical properties of the tape may have been altered when a cut out space
was made in the center of the tape to accommodate the EMG electrode nodes.
Significance of the Problem
Ankle sprains are the most common orthopedic injury in sports (Fong, Hong,
Chan, Yung, & Chan, 2007). While the initial symptoms resolve fairly quickly, many
individuals report recurrent symptoms months to even years after the initial injury
(Vanrijn et al., 2008). Chronic Ankle Instability (CAI) is the most common of these
residual problems (Vanrijn et al., 2008). The competitive nature of sports requires all
medical practitioners to seek out the most up to date modalities for the treatment of their
patients. Kinesio tape is a current modality that may assist in the recovery of the
peroneal muscle group following a lateral ankle sprain by assisting in proprioception
and neuromuscular control to help reduce the incidence of CAI.
Athletic tape has been used in the athletic training profession for decades, while the
use of Kinesio tape has yet to gain such prevalence. The use of athletic tape at the ankle
has been associated most often with prophylactic benefits during competition and practice.
While some studies have investigated the potential preventative benefits of Kinesio tape,
the results have yielded no conclusive data (Briem, Eythorsdottir, Magnusdottir,
Palmarsson, & Runarsdotter, 2011). While Kinesio tape may not replace athletic tape,
athletic trainers should continue to explore the potential therapeutic benefits of Kinesio
tape post injury. If effectiveness is found with the use of Kinesio tape, it may serve as a
means to speed the neural re-education process, ultimately helping an athletes recovery
from CAI. Proper muscle re-education may also help to provide greater functional stability,
allowing athletes to become less dependent on external ankle support following injury.
10
CHAPTER 2
REVIEW OF LITERATURE
The purpose of this study was to investigate the effects of Kinesio tape on
peroneal muscle activity during common therapeutic exercises in patients with chronic ankle
instability (CAI). In order to provide background information pertinent to this study, the
following topics will be discussed: (a) Chronic Ankle Instability (CAI), (b) Proprioception,
(c) Neuromuscular Control, (d) Rehabilitation for CAI, (e) Balance Training, and
(f) Kinesio tape.
Chronic Ankle Instability (CAI)
The sensation of giving way that is often described by patients with CAI
results from damage to mechanoreceptors that compromise the prophylactic benefits of
the central nervous system by inhibiting proprioception and neuromuscular control
(Freeman et al., 1965). Gross (1987) studied the effects of recurrent lateral ankle sprains
on active and passive judgments of joint position. Participants were blindfolded while
performing active and passive attempts at replicating pre-determined ankle joint
positions in the inversion-eversion range of motion. The researcher used an isokinetic
dynamometer to measure joint position. The results showed that passive judgments were
significantly better than active judgments of joint position in the non-sprained group.
Based on these results, Gross concluded that joint receptors play a dominant role in joint
angle detection and that muscle receptors are more valuable in the perception of joint
movement.
11
In support of Gross conclusions, Lentell, Bass, Lopez, Sarrels, and Snyder
(1995) found that 58% of participants (n=42) with CAI demonstrated clinical
impairments in at least one of three categories (proprioceptive deficits, muscle function,
and anatomic laxity). Deficits in passive movement sense (proprioception) and anatomic
laxity were found to be statistically significant in the CAI ankles, while muscle function
deficits were not significantly different when compared to non-CAI ankles. Lentell et al.
concluded that the joint receptors responsible for passive movement sense
(proprioception) and anatomic stability need to be addressed more than strength deficits
when managing an ankle with functional instability.
Assessment of CAI
The Foot and Ankle Disability Index (FADI) is a survey used to determine if an
individual has CAI. The primary FADI assessment tool contains 26 items related to
activities of daily living. The extended version FADI Sport contains an additional eight
items that evaluate perceived disability due to foot or ankle injury in activities
associated with physical activity and sport participation (Hale & Hertel, 2005).
Hale and Hertel (2005) examined the FADI and FADI Sport intersession
reliability during 1- and 6-wk intervals, sensitivity to differences between healthy
subjects and subjects with chronic ankle instability (CAI), and sensitivity to changes in
function in those with CAI after rehabilitation. Subjects were classified as having CAI
if they reported having the following: (a) a history of ankle sprain with pain and/or
limping for more than one day, (b) chronic weakness, pain, or instability that they
attributed to the initial injury, and (c) giving way in the last six mos. The researchers
concluded that their results indicated that the FADI and FADI Sport are: (a) reliable in
12
detecting functional limitations in subjects with CAI, (b) sensitive to differences
between healthy subjects and subjects with CAI, and (c) responsive to improvements in
function after rehabilitation in subjects with CAI.
Proprioception
Proprioception is the ability to determine the position of a joint in space;
kinesthesia refers to ability to detect movement (Grigg, 1994). As previously mentioned,
muscle mechanoreceptors are vital to the interpretation of joint position. Every muscle
in the body is innervated by a number of these receptors that trigger reflexes throughout
the body. The simplest of these reflex arcs entails the response to muscle stretch, which
provides direct excitatory feedback to the motor neurons innervating the muscle that has
been stretched (Purves, Augustine & Fitzpatrick, 2001).
Proper proprioception from mechanoreceptors to detect joint position and
movement is essential to the bodys ability to prevent inversion ankles sprains and
reduce functional instability within the ankle (Delahunt, Monaghan & Caulfield, 2006).
While many studies focus on the afferent component of proprioc
