1. Introduction

Compression therapy is an accessible and popular modality in the treatment of injury. For treatments of injury, increasing the amount of blood flow is one of the mechanisms in the healing process. The accumulation of fluid and edema around an injury site also increases tissue damage, delays healing, and can result in some degree of chronic disability [1, 2].

The purpose of compression is to stop hemorrage and reduce swelling. Compression is applied to limit the amount of edema caused by the exudation of fluid from the damaged capillaries into the tissue [1-3].

Controlling the amount of inflammatory exudate reduces the amount of fibrin and ultimately the production of scar tissue which helps to control the osmotic pressure of the tissue fluid in the injured area [1-5].

According to Block JE [3] compression modalities must provide the patient with the maximum degree of comfort and the shortest time to functional recovery. Bandages, elastic wraps, and intermedıate pressure devıces are always used for edema [3]. Studies in which modality must be choice is definitely not due to studies not only including the using of modalities; therefore, there is no evidence concerning edema treatment [2, 4, 5]. The present study includes no treatment groups; thus, our results alone provide the only effects of the modalities.

A multilayer bandage can only be stretched a little, and is usually used to maintain the volume reduction from the manual lymphatic drainage. It provides mild pressure during resting, and creates higher pressure during muscle contraction to prevent skin extension. The lymphatics are compressed between the muscle and the bandage, causing them to be manually pumped [6].

As we know, the immediate effect is the most important in the recovery of edema. Kinesio tape (KT) may be an alternative option in the treatment of edema, especially when an immediate effect is needed [7, 8]. Dr. Kase claimed that applying KT would have physiological effects, including removing the congestion of the lymphatic fluid or hemorrhages under the skin [6, 9]. This mechanism has no effect on compression for solving edema [9]. After applying the KT, the taped area will from convolutions to increase the space between the skin and the muscles. Once the skin is lifted, the flow of blood and lymphatic fluid is promoted. This helps to give more space and take the pressure off the interstitial fluid. The popularity of the application of tape during the rehabilitation process, shows the need for empirical evidence on the effect of KT [2, 8].

At the same time, the purpose of the study is to compare the immediately effect of both the KT and bandage on edema.

The specific null hypothesis included the following:

1) No differences existed in the outcome measurements between using a bandage or no treatment in the immediate effect on the edema.

2) No differences existed in the outcome measurements between using the tape and no treatment in immediate effect on the edema.

3) No differences existed in the outcome measurement between using the tape and bandage in the immediate effect on the edema.

Our study will be helpful in the further development of evidence-based treatment recommendations and protocols.

2. Materials and Methods

All the procedures were approved by the institutional animal care and use committee. A total of 21 male New Zealand white rabbits were randomly placed into a KT group (n=7), a bandage group (n=7), and a control group (n=7).

Experimental animals weighing 2.5-3.0kg were administered the mixture of ketamine chloride (35 mg / kg) and xylazine chloride (5 mg / kg) intramuscularly using a syringe pump, and anesthesia was provided. The anesthesia was maintained during the experiment when necessary (1.6ml / kg / hr.). The sub-anesthesia level was followed with the monitoring of the respiratory pattern and finger pinch reflex. The fur of the anterior face of the right hind leg and the dorsal part of the leg was cut. Thus, the application area was free of any hair. The body temperature of the animals was controlled at 37.8-39.2°. Initially, the measurements of the circumference and the Doppler (for the blood flow and the pulse) were carried out without applications (no KT and bandage) on the rabbit (n=21). Then, the edema was allowed to form by applying a tourniquet over the popliteal lymph nodes for 20 minutes. The resulting edema circumference was evaluated with a tape measure after applying a tourniquet. The volume of the peripheral blood flow and pulse was measured again after applying the tourniquet.

Then, the KT were applied for a 20 min period to the rabbits (n=7). In this manner, the KT group was created. The short stretch bandage was applied for a 20 min period to the rabbits (n=7). The bandage group was created in this way. No application was carried out on the control group (n=7).

The kinesio taping was applied to the areas most likely to affect the blood circulation. Taping is not applied to the pathway of the lymph flow. As we know, it is necessary to first open up the areas that the lymph will be draining towards. This study did not include manual lymph drainage. KT was applied from the proximal to the distal on the limb using the grill method (Figure 1). The short stretch bandage was applied from the metatarsophalangeal joints to the poplitea (Figure 2).

Figure 1. Application of Kinesio tape

Figure 2. Application of bandaging

After the short stretch bandage and KT application, the volume was immediately measured (approx. 20 min) to see if any changes in the volume flow were occurring. The Doppler (blood flow and pulse) and the circumference measurements were repeated, and the changes in the amount of edema and pulse and blood flow were recorded.

Each measurement and application was done by the same physiotherapist, who had a KT and lymphedema certificate.

To sum up, three different measurements at three different times were done during the study. The measurements were done normally (without application), after the application of the tourniquet (after creating the edema) and after KT and short stretch bandage application. The pulse and blood flow rate were measured (via the popliteal artery behind the knee) with a hand-held Doppler (Echo Sounder ES-101EX_8 MHz) before and after the tourniquet, and after the applications. The circumference was measured three times to calculate the median value. The measurements were taken around the most swollen part of the limb using a standard tape measure with 1mm increments [10, 11].

Failure to obtain the distal pulses, and the faded color of the leg were evaluated as ischemia. The normalization of the leg color, and being able to obtain the distal pulses with a hand-held Doppler were considered as reperfusion [13]. The possibility of the cessation of the blood flow that might occur due to either severe ischemia, or the wound dehiscence in tissue was eliminated due to the blood flow measurement that was carried out with a hand-held Doppler immediately after the tourniquet application over the popliteal region for 20 minutes [13].

The total time spent with each rabbit varied between one hour and 20 minutes, and one hour and 30 minutes, including the preparation time of the animal for anesthesia (approximately 20 min), the tourniquet time (20 min), the application time (20 min) and the time for the animal's withdrawal from anesthesia (about 20 mins).

After all procedures were completed, the animal was delivered to the laboratory when it had woken from the anesthesia.

2.1. Statistical Analysis

Descriptive statistics were computed as mean±SE (Standart Error of Mean) for variables in each subgroups. Two factor repeated measurement analysis of variance with one factor within (time periods) and one factor between (groups) were used to compare “different times”, “groups” and “times x group interaction” with regard to pulse, circumferences, and blood flow followed by the Tukey’s multiple comparisons test. The level of p < 0.05 was considered as statistically significant. All statistical computations were done by using the SPSS (ver.18.0) program.

2.2. Results

There was no significant interaction between the groups and the measurement time (p = 0.134) as a result of the comparison performed in terms of the measurement of the circumference. Accordingly, it can be said that the difference between the groups depending on the time of the measurements did not change. Considering the difference between groups, it was determined that there was a significant difference between the bandage with the control (p = 0.0001), and between the bandage with the KT (p = 0.0001). According to the these results, it can stated that the control was significantly higher compared to the bandage, and a significantly a higher average was abtained in the KT group compared to the bandage in the normal one, both after the tourniquet and the other applications. However, the difference between the control group and the KT group was not significant, and this result did not change in the normal group after tourniquet and after the applications either.

In addition, when the differences between the measurement times were examined, it was found that these differences did not change from group to group (p=0.085). There was no significant difference between the normal group after the applications (p=0.294), but the circumference measurements after the tourniquet were determined to be significantly higher compared to the measurements after the application (p=0.002). The descriptive statistics for each the measurement times and the circumference measurements of each group are given in Table 1.

Table 1. To compare circumference (cm) of groups of bandage, KT and control at after-before tourniquet and after application

There was no significant interaction between the groups and time of the measurements in terms of the average value of the blood flow rate (p=0.242). Accordingly, it can be said that the difference between the groups did not change depending on the time of the measurements. It was found that there was no significant difference between the groups (p = 0.488) in all the measurement times. Considering the differences between the measurement times, the average blood flow rate after the edema was found to be significantly higher both before (p=0.024), and after the applications (p=0.04). However, there was no significant difference between these groups (p = 0.990) in all the measurement times. According to these results, it can be stated that there were no significant differences between the groups, which was also valid for the three measurement periods. In addition, the differences in the measurement period were in a similar direction for the three groups. The descriptive statistics for the time of each measurement and the mean value of blood flow rate in each group are given in Table 2.

Table 2. To compare blood flow velocity (cm/s) of groups of bandage, KT and control after-before the tourniquet and after application

There was no significant interaction between the groups and the measurement time in terms of the pulse measurements (p = 0.461). Thus, it can be said that the difference between the groups did not change depending on the time of the measurements. It was found that there was no significant difference between the groups (p=0.376) for the three measurement periods. Considering the differences between measurement times, the pulse measurements before the tourniquet were found to be significantly higher than those after the application (p=0.046), but there were no significant differences in the other measurement times in all groups. According to these results, it can be said that there were no significant differences between the groups, and this result was also valid for the three measurement periods. In addition, the differences in the measurement period were similar for all three groups. The descriptive statistics for the time of each measurement and the the pulse values in each group are given in Table 3.

Table 3. To compare the heart rate (BPM) of groups of bandage, KT and control after-before the tourniquet and after application

2.3. Discussion

Our study is the first experimental study comparing KT and short-stretch bandage applications. In our study, the effects of two important applications commonly used for edema were investigated experimentally. No significant differences statistically in volume change outcomes were found among the three groups. There were no changed values in the circumference, blood flow, and pulse were found.

However, this study proved that there were no statistically significant differences in the pulse values and blood flow values. According to the mathematical calculations the short-stretch bandage, showed that it is capable of putting pressure on the tissue, the KT, which has a property of adhesion to the skin, was effective on the edema without affecting the arterial blood circulation. It can be said observationally and subjectively that both applications of the KT and short-stretch bandage were effective on the edema, but the short-stretch bandage provided more impact.

Also, according to these mathematical calculations we can interpret subjectively the immediately effects of both methods. Here are some mathematical calculations for subjectively results. When the data in Table 1 was analyzed, the average differences of the circumference measurement were given for the control, the KT and the bandage groups: the difference between the 1st and 2nd measurements (1.32cm, 1.10cm 0.06 cm); the difference between the 2nd and 3rd measurements (0.15cm, 0.27cm 0.58 cm) and the difference between the 1st and 3rd measurements (0.17cm, 0.52cm and 0.07 cm). We can suggest that tourniquets can be used to create edema without requiring surgical procedures in order to increase the rate and the number of applications, because the values of the circumference measurement increased in all three groups after the tourniquet. The results obtained also evaluated the efficacy of the tourniquet application used to create the edema in the experimental animals while at the same time exhibiting the effectiveness of the applications. This study would suggest that tourniquets can be used to create edema without requiring surgical procedures in order to increase the rate and the number of applications because the values of circumference measurement increased in all three groups after tourniquet.

However, it was calculated mathematically that the edema that formed through the tourniquet was the highest in the control group (1.32cm). However, when the mean differences in the 1st and 3rd circumference measurements of the control group were evaluated, it was observed that the edema still continued with a difference of 0.17 cm. The reduction in the edema was observed in the groups that underwent the application. The most important difference here, was that a reduction in the edema that was provided in the bandage group (0.52cm) was greater than the KT group (0.07 cm). Based on this, it can be said that both observationally and subjectively both the applications of the KT and short-stretch bandage were effective on the edema, but the short-stretch bandage provided more impact.

We analyzed how the pulse values were affected by the applications. When the differences of the average value of the pulse of the KT group (the difference in the 1st and the 2nd measurements (0.66cm / s); the difference in the 2nd and 3rd measurements (0.34cm / s) and the difference in the 1st and 3rd measurements (1.00cm / s)) were calculated mathematically for the three measurement times, it was observed that the values had a continuous downward trend. However, the pulse values of the bandage group, particularly in the period after the application [the difference in the 1st and 2nd measurements (3.29cm/s); the difference in the 2nd and 3rd measurements (2.86cm/s); the difference in the 1st and 3rd measurements (0.43cm/s)] and the control group [the difference in the 1st and 2nd measurements (2.85cm/s); the difference in the 2nd and 3rd measurements (2.28cm/s); the difference in the 1st and 3rd measurements(0.57cm/s)] appeared to be high and close to the initial value.

When the differences in the average values of the blood flow were calculated mathematically, and it was observed that the values behaved similarly in all the three groups. The blood pressure values, respectively: in the control group, the difference in the 1st and 2nd measurements (2.29bpm); the difference in the 2nd and 3rd measurements (10.14bpm) and the difference in the 1st and 3rd measurements (12.44bpm); in the KT group, the difference in the 1st and 2nd measurements (24.33bpm); the difference in the 2nd and 3rd measurements (27.50bpm), and the difference in the 1st and 3rd measurements (51.83bpm); and in the bandage group, the difference in the 1st and 2nd measurements (9.43bpm); the difference in 2nd and 3rd measurements (10.57bpm) and the difference of 1st and 3rd measurements (1.14bpm) all behaved similarly.

A well-defined randomized controlled trial using this model could provide the clear evidence needed to guide decisions regarding the clinical application of tape and compression with immediate effect [8, 13-15]. Unfortunately, the studies are not uniform in their choices of experimental and control groups, study duration, sample size, or surgical procedure, which renders the “evidence” diluted. Previous reviews have attempted to disentangle the effects of tape and static compression to elucidate the independent contributions of each. The task has been daunting [14-17]. Additionally, because of the different indications for use, types of treatment modalities, and clinical heterogeneity, it was impossible to pool the results in a meaningful way with respect to some index of improvement.

KT has become extremely popular recently; however, there remains a paucity of evidence on the use of KT for edema as well as other conditions [18].

Finally, there is a lack of research comparing these two different methods for the treatment of edema.

The purpose of this study was to compare the effectiveness of edema control in the immediate effect between the KT and the short stretch bandage on healthy tissue. The results revealed no significant difference to edema between the three conditions. Both the KT and the short stretch bandage were not effective in reducing edema when compared to the no application condition. The KT and short stretch bandage appear to be viable alternative methods for addressing the edema in case both of them had the same effect as no application. According to our results, the doppler indicated no major changes to the blood flow after the applications. Thus, we can say with some confidence that both of them have no major adverse effects.

The ideal pressure, which can be applied on the artery by compression, is currently being investigated [19-21] This study provides additional information to the literature for studies investigating the pressure to be applied to the arteries in the region by the compression applied for the treatment of venous insufficiency, lymphedema, and edema etc. However, it is KT application which is the recommended option as an alternative to the short-stretch bandage application for clinical cases where arterial blood flow is not to be affected (venous insufficiency, lymphedema, and edema etc.).

3. Conclusions

In conclusion, our study can make an important contribution to the literature as the first experimental study comparing KT and a short-stretch bandage application. However, individual and environmental factors that might influence the application were eliminated as much as possible because we completed our study as an animal experiment. The standard conditions were created for the application. In the homogeneous conditions provided, two application types, KT and short-stretch bandage applications, were compared and evaluated with the control groups. Therefore, the data with high evidence values, which can be a base for future studies, especially in the field of physiotherapy, have added to the literature.