a b s t r a c t

Introduction: Rib fractures, which are among the most common injuries in blunt Thoracic trauma, are usually en- countered in Emergency Departments. Kinesiotape (KT) is a drug-free elastic therapeutic tape used for treating various musculoskeletal problems such as injury, dysfunction and pain. We aimed to investigate whether kinesotaping should be used safely and effectively in rib fractures in emergency setting.

Materials and methods: This was a prospective, randomized controlled study conducted in an Emergency Depart- ment of a University Hospital. Patients diagnosed with isolated rib fractures were included in the study. Pain se- verity of patients assessed with 0-10 cm Visual analog scale , then patients assigned into 2 treatment groups. One of them received treatment with flurbiprofen 200 mg/day and the other group received kinesiotaping in addition to the same oral therapy. On the 4th day of the procedure, both groups were assessed with VAS in the followup visit.

Results: Total of 82 patients presented with rib fractures, 52 of them were excluded. Remaining 30 constituted the study group and randomly allocated to kinesiotaping (n = 16) or control group (n = 14). In both groups, pain intensity on the 4th day was significantly reduced when compared with baseline (p for bothb0.01). Additionally, considering the reducing the pain intensity on 4th day, kinesiotaping was significantly superior than the control group (p b 0.01).

Conclusion: This study investigated the use of kinesiotaping in emergency departments. When compared to NSAID therapy alone, combined kinesiotaping and NSAID therapy appears to be more effective in terms of pain reduction in rib fractures.

(C) 2019

Introduction

Rib fractures, which are among the most common injuries in blunt thoracic trauma, are commonly encountered in emergency depart- ments. The main symptom is intense flank pain, which may last for at least 1 month and impede the functions of body movements, deep breathing and coughing [1]. Discomfort in breathing may result in atel- ectasis, decreased lung compliance, hypoxemia and respiratory distress [2]. Pain management of rib fractures is a challenge for physicians. The commonly used oral analgesics, usually non-steroidal antiinflammatory drugs (NSAID), provide limited relief to patients [3,4]. Invasive

* Corresponding author at: Manisa Celal Bayar University, Faculty of Medicine, Emergency Department, Turkey.

E-mail address: [email protected] (M.I. Sasmaz).

modalities like intercostal nerve block or operative repair have also been practiced to relieve pain but still have some controversies [5,6].

Kinesiotape (KT) is a drug-free elastic therapeutic tape used for treating various musculoskeletal problems such as injury, dysfunc- tion and pain. Kinesiotaping applications were created by a Japanese chiropractor, Dr. Kenso Kase, in 1970s. KT has become in- creasingly popular among athletes and practitioners. The profile of KT was significantly raised after it was seen on athletes at 2008 Olympic Games [7]. KT is a thin, elastic tape that is claimed to stretch to 120-140% of its original length, and then subsequently recoil back to its original length following application, thus exerting a proposed pulling force to the skin [7]. Despite the absolute action mechanism of kinesiotape is unclear, investigators assert several mechanisms such as [8]; supporting injured muscle and joints, improving fascia function and position, increasing segmental stability, activation of the blood and lymph flow by lifting the skin, decreasing pain by

https://doi.org/10.1016/j.ajem.2019.11.049

0735-6757/(C) 2019

A.H. Akca et al. / American Journal of Emergency Medicine 38 (2020) 638–640 639

reducing nociceptive stimuli. Kinesiotaping has been evaluated in several studies for low back pain and other musculoskeletal injuries especially in sports medicine [9]. However, literature has no study about kinesiotaping in emergency departments.

In our study we aimed to investigate whether kinesotaping could safely and effectively treat pain from rib fractures in an emergency department.

Materials and methods

Study design

This was a prospective, quasi-randomized trial conducted in an Emergency Department of a university hospital between July 2017 and January 2018. The study protocol was approved by the university ethics board and written informed consent was obtained from all partic- ipants prior to their involvement. Flurbiprofen alone was compared to flurbiprofen and kinesiotaping for pain control in patients with isolated rib fractures.

Selection of participants

Patients presenting to our Emergency Department with blunt tho- racic trauma and diagnosed with isolated rib fractures on thorax CT in- cluded to the study. Exclusion criterias were as follows; patients younger than 18 years old, with 4 or more rib fractures, with 1st or 2nd or 12th rib fractures, accompanying hemo/pneumothorax, use of any analgesic within 12 h of ED presentation, patients required surgical operation or hospitalization, patients who refuse to participate in the study.

Consecutive patients were enrolled into the study 24 h a day and 7 days a week by the senior resident in the shift. We did not randomize patients. The first and odd numbered patients were included in the kinesIO group and the odd numbered patients were included in the con- trol group. The last (thirtieth) patient was included in the kinesio group.

Interventions and methods of measurements

2.5. Statistical analysis

Fig. 1. Application of knesiotaping.

Pain severity of patients with rib fractures assessed with 0-10 cm vi- sual analog scale (VAS) by an observer who is blinded to the treatment groups, then patients assigned into 2 treatment groups. One of them re- ceived treatment with flurbiprofen 200 mg/day (Majezik(R) tablet 100 mg, Sanovel Ilac Sanayi ve Ticaret A.S. equal to 800 mg ibuprofen) and the other group received kinesiotaping in addition to the same oral therapy. Patients were numbered and odd numbers were assigned to KT and oral therapy group, and even numbers were assigned to oral therapy group except the last patient. Kinesiotaping applied to the pa- tient immediately after the other procedures in emergency department had finished. Kinesiotaping group’s pain intensity was assessed again after 15 min of kinesiotaping application. Then on the 4th day of proce- dure, both groups were assessed with VAS in the follow-up visit. Since the kinesio bands maintained their elasticity for 3-4 days, we measured the pain levels of the patients on the 4th day.

All participants in Kinesiotaping group were taped by the same phy- sician. Two I-shaped Kinesio bands (Kinesio tape, Libor, Turkey) with a width of 5 cm and thickness of 0.5 mm were used. Patient placed in a position which shoulder abducted as much as possible. First tape was applied from inferior and posterior to the site of fracture and fan strips were laid in a crisscross pattern over the fracture area. Second was ap- plied from inferior and anterior in the same pattern as shown in Fig. 1.

Descriptive statistics for the studied variables (characteristics) were presented as mean and standard deviation. Mann-Whitney U test was performed to compare groups. In addition, Wilcoxon test also used to compare periods (0-4th day). Analysis of the data collected in the study was performed using the Statistical Package for the Social Sci- ences 22 statistical software package (IBM Corporation, IL, USA). P b

0.05 with 95% confidence intervals was considered significant in all analyses.

Results

Total of 82 patients presented with rib fractures, 52 of them (32 had additional injuries, 9 had pulmonary contusion, 5 had pneumothorax, 4 were hospitalized, and 2 had a history of analgesic use) were excluded. Remaining 30 constituted the study group and randomly allocated to kinesiotaping (n = 16) or control group (n = 14). All of 30 participants completed the study.

Table 1

Baseline characteristics of participants.

2.4. Outcome measures		KT Group (SD) (n = 16)	Control Group (SD) (n = 14)	p
	Age, y	50,06 (13,11)	49,4 (12,51)	0,984
The primary outcome measure was pain reduction in VAS score in	Gender (M/F)	12/4	9/5	0,637
kinesiotaping group at 15th minute after taped. Secondary outcome	Pain intensity (baseline)	7,94 (1,73)	8,21 (1,12)	0,984

measure was pain reduction in VAS score in both group at 4th day.

KT: Kinesiotaping; SD: Standard deviation.

640 A.H. Akca et al. / American Journal of Emergency Medicine 38 (2020) 638–640

Table 2

Comparison of groups at pain intensity.

KT Group (SD) (n = 16)

Control Group (SD) (n = p1 14)

As a result, kinesiotaping can be used as an adjunct to standard anal- gesic therapy with oral NSAIDs in pain management of isolated rib fractures.

Baseline VAS 7,94 (1,73) 8,21 (1,12) 0,984

-VAS after procedure	3,31 (1,25)	–
-Difference	4,63 (1,71)	–
Fourth Day VAS	2,00 (0,89)	4,71 (1,27)	b0,01
Difference	5,94 (1,69)	3,50 (0,76)	b0,01
p2	b0,01	b0,01

KT: Kinesiotaping; SD: Standard Deviation; VAS: Visual Analog Scale.

p1: Comparison of two groups; p2: Difference in each group at baseline and fourth day.

There was no significant differences between two groups in terms of age, gender and baseline intensity of pain (p = 0.984, 0.637 and 0.984 consecutively) (Table 1).

In both groups, pain intensity on the 4th day was significantly re- duced when compared with baseline (p for bothb0.01). Additionally, considering the reducing the pain intensity on 4th day, kinesiotaping was significantly superior than the control group (Table 2).

On the other hand, pain intensity on 15th minute after kinesiotaping procedure was significantly reduced from the baseline (p b 0.01) (Table 2).

Discussion

Blunt thoracic trauma and rib fractures usually encountered in emergency departments. Once additional injuries are excluded, pain control is one of the mainstays of therapy for rib fractures. Guidelines recommend analgesia as first line therapy for the management of rib fracture in order to decrease pulmonary complication rates [3]. Discom- fort in breathing due to pain may result in atelectasis, decreased lung compliance, hypoxemia and respiratory distress [2].

The pain associated with rib fractures usually reaches its peak level in first 2 weeks and it starts to improve after 2-4 weeks [10]. While Acute pain control during hospitalization has been well studied in the literature, there still exists room for improvement and better therapeu- tic strategies other than conventional analgesics and nerve blocker in- jection are need to be explored [1]. Various techniques for the management of rib fracture pain especially for hospitalized patients have been published in both the thoracic surgical and anesthesiology lit- erature like intercostal nerve blocks, paravertebral nerve blocks, epidu- ral analgesia and interpleural catheters. Each of these modalities has their limitations and risks [11-14].

In this study, we investigated whether kinesiotaping technique should be used as a complementary therapy in patients with rib frac- tures without any known adverse effect. In this mean, this study is the first which is taking into consideration a totally new and effective treat- ment in emergency departments. An important result of our study was the significant decrease of the pain severity of the patients within 15 min after kinesiotaping. The other is, kinesiotaping in addition to oral NSAID was significantly effective than NSAID therapy alone in terms of pain reduction on 4th day. Additionally, kinesiotaping for 4 days was excellently well-tolerated by patients with no adverse effect. Intercalarily, kinesiotaping is a rapid-acting method, which succeeds to reduce pain score of patients significantly in 15 min.

Consequently, kinesiotaping is widely used in sports medicine and musculoskeletal problems in a safe and effective way for years. Hence pain intensities of patients significantly reduced with this Treatment modality in a painful condition like rib fracture without any adverse ef- fect, we could deliberate to use this effective technique in emergency departments.

Limitations

This study was not randomized and the last patients was mis- allocated. The lack of banding with plaster in the oral therapy group may have affected the results, considering that kinesiotaping may also have a placebo effect. Another limitation was the low number of pa- tients in our study.

Conclusion

This study investigated the use of kinesiotaping for the treatment of rib fracture pain in the emergency department. When compared to NSAID therapy alone, combined kinesiotaping and NSAID therapy ap- pears to be more effective in terms of pain reduction in rib fractures. As a conclusion, kinesiotaping should be used as a complementary treatment method to provide analgesia for rib fractures in emergency setting. On the other hand, our study should be investigated by addi- tional researches.

Author contribution statement

Ali Haydar Akca: Conceptualization, Methodology, Investigation, Formal analysis.

Muhammed Ikbal Sasmaz: Methodology, Writing- Reviewing and Editing.

Seyhmus Kaplan: Visualization, Investigation.

Declaration of competing interest

Authors declare that they have no conflict of interest.

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