The use of Elastic Therapeutic Tape (ETT) for pain relief of closed fractures of the clavicle and costae (floating ribs). The effects of Cure Tapeon pain in one paediatric & two adult cases.Revised:05-11- 2013.
Esther de Ru PT, OMT, PPT.
Abstract:
Both clavicle and rib fractured have in common that they cannot be immobilized. Pain and a feeling of anxiety are very often experienced by patients suffering from these fractures. Complications, bone healing and normal physiotherapy treatment options are discussed. Studies on the use of ETT on fracturesare scarce.
These tape applications have the potential to be a useful adjunct in pain relief.This is demonstrated in the following three case examples. Pain was scored using the VAS score.Elastic therapeutic taping(ETT) resulted in decreasing pain levels substantially in the three cases. Patients also reported that the fracture site felt supported and more comfortable during tape application. It seems that ETT is a safe and cost effective extra treatment possibility in the overall treatment of patients sufferening from these fractures.
Introduction:
As physiotherapists, we are normally not involved in the first aid treatment of rib or clavicle fractures. However we are often asked to assist during the rehab phase with postural advice, respiratory exercises and pain management. It is important to be aware of the possible complications and red-flags in all cases.
The use ofETT has been promoted in the management of both rib- and collarbone fractures. In various manuals the correct application for tape of bothstructures are mentioned. Patient testimonials, blogs and youtube videos on this subject are numerous. The website of en.allexperts[1] promotesthe Rib Taping Technique. The RTT usestape with a transparent underwrap inthe treatment offractured ribs or costochondral injuries.
Method:
To date not many articles or studies on this subject have been found. In 2010 a RCT was initiated. The hypothesis of this RCT measuring pain and Quality of Life after clavicular fracture was that patients who receive treatment with tape and sling would experience less pain and have better shoulder function compared to patients treated with only a sling. Patients with a mid-clavicular fracture and aged from 12 to 60 years participated. The results of the RTC conducted were not published due to a number of missing failures.
An initial report[2] into the effect of tape on rib fractures N = 14 was published in the Polish Rehabilitation Journal in 2012. Because the article is in Polish, the English abstract is the only information available. In this study a different manner of applying tape was used. Tape was applied in vertical broad tape strips with fan shaped spiders in horizontal direction in between. The results presented were: ‘There were differences between pain levels before and after K-Active Tape application in three different situations. There were also differences in value of average VAS points in changing body position from supine to seating (p=0,015), provoked coughing (p=0,022) and deep breathing (p=0,023). It means that pain was significantly decreased. Analysis of the average value breathing parameters indicate upward trend FVC, FEV1 and PEF after Kinesiology taping application, but it wasn’t statistically significant’. Conclusions are that: ‘Kinesiology Taping is safe, supplementary method for heeling posttraumatic rib conditions. Apply lymphatic and ligament technique using K-active tape could be effective method of reducing pain after broken ribs. It’s necessary to continue research on effectiveness Kinesiology Taping after broken ribs with extend methodology.’
Nowak M[3] publised a powerpoint presentation online: Clinical management of rib stress fractures in rowers. The patient group is healthy athletes and he advocates using 50%-75% stretch on these fractures. He also uses rigid tape to restrict rib mobility and for pain relief during competition. 02-11-13 accessed online.
A fracture [4]occurs when too much force is applied to the bone. The force can vary and may come from a direct trauma, an accident, a twisting force or repeated impact(running,marching:stress fracture). Fractures can also occur as a result ofbone disorders (e.g. osteopenia, osteoporosis, bone tumours).Fractures can be eitheropen (compound fracture)or closed (simple fracture)and the bones can be displaced. Bone fractures can be very painful because of oedema in nearby tissue, multiple nociceptors in the periosteum and muscle spasm holding bone fragments in place. The fracture can be complete, incomplete, linear, transverse, oblique, spiral, comminute (bone is broken into a number of pieces) and compact (bone fragments are driven into each other). An open fracture (bone protrudes through the skin) requires surgical intervention.
General complicationscan be:
embolism
damage to underlying structures
mal –union or non –union
coexisting trauma
restriction of adjacent joints or alignment problems after union
complex regional pain syndrome (reflex sympathetic dystrophy)
infection in either bone (osteomyelitis), joint or adjacent soft tissues (open fracture)
Bone healing:
There are three main healing phases; the reactive phase, the reparative phase and the remodelling phase. The whole bone healing and remodelling process can take up to 18 months. First a hematoma is formed, within days blood vessels appear bringing phagocytes and fibroblasts producing collagen fibres. These fibroblasts begin to lay down bone matrix. The healing bone callus is sufficiently mineralized to show up on X-ray within 6 weeks in adults and less in children. The initial “woven bone” does not have strong mechanical properties.
Medical treatment:
In general the treatment of closed fractures of collarbone and ribs differs toregular fracture treatment. These fracturescannot be immobilized in plaster, fibreglass cast or splintsas is normal practice in most fractures.
In the case of the simple clavicle fracture, most patients will either be treated with figure-8 harness or with a sling for 4-6 week and analgesics. In the case of fractured ribs careful clinical examination is needed and extra care must be taken to look for related injuries such as pulmonary, abdominal injuries and pneumothorax. The various guidelines for fracture treatment all include: pain, vital signs, age dependant therapy, check for red-flags diseases in older patients.
Costae fractures: these can be very painful because the ribs have to move to allow for breathing. They are the most common injury to the rib cage. They can occur without direct trauma and they have been reported after sustained coughing . They also occur as a consequence of diseases (cancer, bone fragility or infections). The most frequently affect the middle ribs (7th and 10th). A lower rib fracture has the complication of potentially injuring the diaphragm. The presence of rib fractures in children may indicate severe thoracic injury, their chest wall is more flexible and their ribs are more likely to bend than to break.
Clavicle fracture: twice as many clavicle fractures occur in men as in women. Clavicle fractures are the most common paediatric fracture[5].At the mean age of 21 years most clavicle fractures are caused by sports-related injuries. At the mean age of 46 years falls on the shoulder are the primary mechanism of injury[6].
Physiotherapy:
Physical therapy can assist patients to return to normal activity. Pain can be managed by using various treatment modalities. Treatment may consist of: cryrotherapy (icing), education, rest, protective padding and exercise to improve posture, flexibility, strength and pulmonary function. Soft tissue massage, activity modification during healing and graded return to activity may be needed.
The following tape applications have the potential to bea useful adjunct in pain relief.
These applications are demonstrated in the following case examples. In all cases the pain was noted using the VAS score.
Case 1: young girl 13 year old with a fractured left clavicleafter falling off her bike. After diagnosis was verified by X-ray she was sent home without a sling. Her parents were told that they could give her analgesics if necessary. She was seen one week after her fall.A sling and figure- 8 harness were fitted but both seemed to aggravated the pain. An I-tape over the length of her clavicle was applied using the ligament technique with 10-15% stretch (= paper off tension). The pain relief was immediate. Her VAS score decreased rapidly. Tape was left on for 3 days, and reapplied after one day’s rest. She needed to use the tape for 4 weeks.
Case 2: 60 year old woman suffered from a spontaneous clavicle fracture. She was known with recurrent malignant lungcancer. The fracture was caused by metastases. She was given a sling. Pain was intense (VAS 9) and analgesics were prescribed. After applying I-tape in the length of the whole bone using 15% off paper tension, the pain decreased (VAS 9-VAS 5) during the next 24 hours. In the following weeks the tape was applied twice a week and her pain decreased even more. She still suffers from pain and uses the tape when necessary. Photo 1: example of the clavicle tape application used in both cases.
Case 3: 53 year old woman fractured both floating ribs after falling sideways. She was sent home with analgesics and exercises for her ribcage. The pain was excruciating (VAS 10) and patient asked if tape could help. Tape was applied on top of the ribs with 25% stretchthree days after her fall.At this point pain was hardly bearable, she was on medication and the broken ends were crunching against each other. The tape not only gave pain relief but also ‘supported’ the ribs and the crunching resolved. During the second weekthe pain decreased (VAS 7 with medication)and the tape was applied with 10% stretch.The third week pain decreased (VAS 5 and medication was no longer necessary on a daily basis). The forth week the pain was nearly gone and patient only needed pain medication every now and again. In the fifth week the pain had decreased (VAS 2 with no medication needed). Photo 2: picture of patient’s tape application.
Conclusion:
Both clavicle and rib fractured have in common that they cannot be immobilized. Pain and a feeling of anxiety are very often experienced by patients suffering from these fractures. ETT resulted in decreasing pain levels substantially in the three cases.
Patients also reported that the fracture site felt supported and more comfortable during tape application.
More high level studiesare emerging on the effects of taping.[7] Akbas, Aytar, Callaghan, Campolo, Castro-Sanchez, Gonzales-Iglesias, Halseth, Thelen andYin-Hsinhave documented the effects of tape on pain, ROM, muscle performance and kinematics and proprioception. Only onearticle[8]on fractures and the result of using this tape during the healing process and for pain management has been found.
It seems that elastic therapeutic taping is a safe and cost effective extra treatment possibility in the overall treatment of patients sufferening from these fractures.More research into this modality and into the various applications of ETTis recommended.
Photo 1photo 2
Permission:all patients were informed and gave consent for the use of their data and pictures.
[1]
[2]Czzewski P et al (2013) Effect of Kinesiology Taping method on pain reduction after rib broken – initial report
[3]
[4] accessed on 16/08/2010
[5]Brilliant, Lawrence. "Fracture, Clavicle." eMedicine. Eds. Francis Counselman, et al. 13 Aug. 2007. Medscape. 8 Apr. 2009 < source mdguidelines.com accessed 16-08-2010
[6]Cheung, Alanet al. "Surgical versus conservative interventions for treating fractures of the middle third of the clavicle (Protocol)." Cochrane Database of Systematic Reviews 3 (2008): source mdguidelines.com accessed 16-08-2010
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