INTRODUCTION:

Chronic venous insufficiency of the lower limbs is a pathological condition produced by persistent venous hypertension as a consequence of structural or functional abnormalities of lower limbs veins. The pathological condition that occur ie valvular incompetence and/or and calf muscle pump function failure.

Venous hypertension causes interruption of venous return and microcirculation hemodynamics. The clinical manifestation is mild such as telangiectasia, varicose vein or may become progressive into skin ulceration. The impact of venous ulceration is so dramatic because it result in disruption of social participation and occupational activity that affect financial stability and deterioration of quality of life^1–4.

About 90% of the venous return in the lower extremities through the deep veins is facilitated by the pumping of the legs, calves, and thighs. The calf muscle pump is the most important and has the greatest ability to produce the highest pressure (ejection fraction 65%) than the thigh muscle pump (ejection fraction 15%)^5,6. The blood is pumped into the heart as the muscle contracts and the vein is refilled as the muscles relax^7,8. This normal cycle of the venous pump system requires functional calf muscles and the competent venous valves. Dysfunction of one component or occur venous obstruction, may cause decreased venous return². Improvement of the muscle pump efficiency may compensate for some degree of reflux and obstruction⁹.

The main non-invasive treatment option for improving venous function and hemodynamics are compression and rehabilitation program of physical activities and modalities⁴. Appropriate use of compression garments assists venous function and improves venous return. Several studies have shown that providing walking exercises, standing on tiptoes, standing with heels, and adding modalities of physical therapy during exercise with electrical stimulation and elastic taping effectively stimulates muscle pumps and improves hemodynamics^10,11.

Elastic taping is one of therapy modality with applying adhesive elastic tape into the skin. The aima of its application are to assist muscle function, improve lymphatic and vascular flow, aid the correction of joint alignment problems and activation of sensory systems^12,13. Several studies using sEMG study reported that ET applications increased the muscle activities. A study reported an increase of sEMG activities in the gastrocnemius muscle, with elastic taping atached from origo to insersio, and increased of muscle strength in full ankle dorsoflexion position^14,15. However, its effect on calf muscle pump disfunction and vascular flow in venous disease have been poorly investigated.

Therefore, we evaluate the efficacy of ET application on gastrocnemius and tibialis anterior muscles activities and venous reflux in those patients with mild CVI by assessing maximal amplitude of GL, GM, and TA muscles during active contraction and ambulation and venous reflux of FV and PV.

MATERIALS AND METHODS:

Participants:

A consecutive sample of 10 women with bilateral CVI CEAP C2 and C3, aged 45-65 years old, who met inclusion and exclusion criteria were recruited during July to Nopember 2017 from outpatient clinic of Cardiovascular Department and Physical Medicine and Rehabilitation Department Dr. Soetomo General Hospital, Surabaya. Inclussion criteria were a CVI sufferers of bilateral lower extremities that meet the clinical criteria CEAP (Clinical, Etiology, Anatomic, Patophysiology) C1 (telangiectasies or reticular veins), C2 (varicose veins), or C3 (edema), by the international consensus conference of the American Venous Forum, with age 50-65 years, can understand verbal commands well (MMSE score 24-30) and willing to participate in this research and sign the informed consent. Exclusion criteria were had peripheral artery disease, deep vein obstruction on duplex ultrasonography, suffering from severe cardiorespiratory disorders (unstable angina, blood pressure >160/100 mmHg, arrhythmias, heart failure), respiratory disease (severe COPD, asthma in attack, pneumonia, lung tuberculosis), suffering from severe systemic disease (severe kidney failure, severe liver disease, uncontrolled diabetes mellitus, generalized edema caused by heart disease or disease systemic, central and/or peripheral nervous system disorders (clinically motor, sensory or autonom deficits) and the musculoskeletal system (fracture of the lower extremities), lesions or lesions in the calf area under study, intolerant or allergic to elastic taping material, and pregnancy.

This study was approved by our institutional review committee, the subjects were informed of the investigative nature of the study and a written consent was obtained before study entry.

Design:

The right and left limbs of the same subjects were randomized into 2 groups (control and intervension). The control group received a standard therapy including compression bandage and structured exercises. The intervention group received the standard therapy with addition of ET applications with facilitation technique on gastrocnemius and anterior tibial muscles. Compression bandage therapy was given with 15-20 mmHg of compression controlled by portable Picco Press. Supervised and structured exercise include aerobic, ankle joints flexibility, and lower leg muscle strengthening exercises were prescribed during 4 days. Elastic taping used Leukotape® K is produced by BSN, 5x5cm in size, brown color, non-allergic adhesive, and has 100% strain. Elastic taping for the anterior tibial used a “Y” tape and gastrocnemius muscle used 2 pieces of “Y” tape that applied on the medial head and lateral head (figure 1).

Figure 1: A. “Y” tape for tibialis anterior, applied from origo to insertio, with a stretch of 50% B. Two pieces of “Y” tape for gastrocnemius lateral and medial head, applied from origo to insertio, with a stretch of 50%

Outcome Measures:

The subjects of each group underwent initial and 4 days after treatment measurements of maximal gastrocnemius and tibialis anterior amplitude using surface electromyography (sEMG) MESPEC 4000 SYSTEM, software Peak Motus 2000 device, measures during active contraction dorsoflexion-plantarflexion of ankle and ambulation. Active contraction performed with subject in sitting position, knee full extension, and ankle neutral position. Ambulation is performed with subjects walking as far as 3 meters, at speed according to their habit when walking. Femoral and popliteal venous reflux were evaluate using Duplex Ultrasonography device in upright position with non-weight bearing of the evaluated foot.

Statistical Analysis:

The result were expresed as mean (minimal – maximal) value. The normality data distribution test and Shaphiro-Wilk test were done before evaluating comparation between pre-post maximal amplitude and duration of venous reflux within each group, and comparation the outcomes after 4 days intervention between control and intervention group. Since abnormal data distribution, comparation analysis was done using Wilcoxon Signed Ranks and Mann-Whitney tests.

RESULT:

The study group included 10 women with bilateral CVI, and their ages ranged from 45 to 63 years (mean age, 54.8±6.61) . The mean value of the body mass index (BMI) was 27.17±3.94 (Table 1). The CEAP Classification owned by the control group (n = 10) were 6 subjects (60%) with C2 and 4 subjects (40%) C3, and in the intervention group (n = 10): 6(0.6) C2 and 4(0,4) C3. Daily activities as a risk factor for CVI, conducted as many as 4 subjects do activity in a long sitting position (4-8hours per day), 4 subjects do housework activities, and 2 other subjects do activities in the long standing position (4-8hours per day).

Table 1: Subject characteristic

Variable	Mean	Minimum	Maximum
Age (year)	54.8±6.61	45	63
Body height (m)	1.5±0.08	1.42	1.68
Body weight (m)	65±11.5	54	1.85
BMI	27.17±3.94	22.18	35.08

The result of Wilcoxon Signed Rank test showed significant increases in maximal amplitude of GL (p=0.04) and TA (p=0.00) muscles during active contraction, as well as increasing of the GM (p=0.00) during ambulation after additional treatment of ET application for 4 days in the intervention group. No increment of maximal amplitude of GL, GM, or TA muscles during active contraction nor ambulation after treatment in the control group. Differences test between group using Mann-Whitney test showed there was no difference in maximal amplitude of the GL, GM, and TA muscles during active contraction nor ambulation in the intervention group compared with control group. (Table 2 and 3)

Table 2: Wilcoxon Signed Ranks test of maximal amplitude in active contraction and ambulation

Variable	Pre (mV)	Post (mV)	P value
Control Group
Active Contraction
GL	0.31 (0.13-0.90)	0.46 (0.09-1.73)	0.13
GM	0.47 (0.03-0.91)	0.49 (0.03-1.37)	0.44
TA	1.19 (0.46-1.55)	1.51 (0.50-2.59)	0.16
Ambulation
GL	0.47 (0.15-2.43)	0.57 (0.34-1.99)	0.55
GM	0.60 (0.25-0.82)	0.73 (0.03-2.63)	0.37
TA	0.78 (0.51-1.12)	0.63 (0.43-0.94)	0.72
Intervention Group
Active Contraction
GL	0.37 (0.15-1.81)	0.39 (0.23-2.25)	0.04*
GM	0.41 (0.25-0.82)	0.42 (0.33-1.62)	0.20
TA	0.78 (0.51-1.12)	1.01 (0.72-1.56)	0.00*
Ambulation
GL	0.40 (0.17-1.59)	0.64 (0.35-2.13)	0.07
GM	0.59 (0.29-1.69)	0.80 (0.40-2.73)	0.00*
TA	0.53 (0.28-0.82)	0.58 (0.49-0.85)	0.24

*significant in intervention group (p<0.05). Abbrevations: GL, Gastrocnemius Lateral; GM: Gastrocnemius Medial; TA: Tibialis Anterior; mV: micro volt.

Table 3: Mann-Whitney test of duration of maximal amplitude during active contraction and ambulation after treatment.

Variable	Control Group (mV)	Intervention Group (mV)	P value
Active Contraction
GL	0.46 (0.09-1.73)	0.39 (0.23-2.25)	0.79
GM	0.50 (0.03-1.37)	0.42 (0.33-1.62)	1.00
TA	1.51 (0.50-2.59)	1.01 (0.72-1.56)	0.13
Ambulation
GL	0.57 (0.34-1.99)	0.64 (0.35-2.13)	0.40
GM	0.73 (0.03-2.63)	0.80 (0.40-2.73)	0.44
TA	0.63 (0.43-0.94)	0.58 (0.49-0.85)	0.59

*significant in intervention group (p<0.05). Abbrevations: GL, Gastrocnemius Lateral; GM: Gastrocnemius Medial; TA: Tibialis Anterior; mV: micro volt.

The duration of venous reflux showed no improvement of FV reflux, but significant decrement in the duration of PV reflux (p=0.02) after additional treatment of ET application for 4 days in the intervention group. There was a significant difference in the duration of PV reflux when the intervention compared to the control group (p=0.00). (Table 4 and 5)

Table 4: Wilcoxon Signed Ranks test of duration of venous reflux

Variable	Pre (second)	Post (second)	P value
Control Group
FV	1.85 (1.58-2.66)	1.81 (1.18-3.303)	0.83
PV	2.18 (1.33-2.80)	1.67 (1.40-3.25)	0.33
Intervention Group
FV	1.89 (1.18-3.25)	1.48 (1.04-3.25)	0.15
PV	1.96 (1.26-2.88)	1.26 (1.04-2.43)	0.02*

*significant in intervention group (p<0.05). Abbrevations: FV, Femoral Vein; PV: Popliteal Vein

Table 5: Mann-Whitney test of duration of venous reflux after treatment

Variable

Control Group

(second)

Intervention Group (second)

P value

1,81 (1,18 - 3,03)

1,480 (1,04 - 3,25)

0,30

1,67 (1,40 - 3,25)

1,260 (1,04 - 2,43)

0,00*

*significant in intervention group (p<0.05). Abbrevations: FV, Femoral Vein; PV: Popliteal Vein

DISCUSSION:

Sex homogenization on the characteristics of research subjects due to CVI is more prevalent in adult females ie CEAP C2 of 13.9-46.3% and C3 of 4.5 – 13.6% occur more in women 25% to 33% and based on the Framingham study, the incidence of occurrence of venous varicose per year is 2.6% in women, the risk increases with the number of pregnancies and postmenopausal conditions^16,17.

The result of maximal amplitude of GL, GM, and AT in control group compared between pre- and post-treatment did not differ significantly because of short period of exercise. Specific and structured exercises increased the activity of calf muscle pump contractions in patients with CVI.(4) Razaeimanech and Farsani (2011) reported that isotonic strengthening exercises of the biceps femoris and gracilis muscles within 6 weeks increased muscle activity in the EMG study and muscle strength in the volley ball athletes^18,19. Increased muscle strength in the early period of exercise can be achieved in the first until second week of exercise through neural mechanisms include better synchronization and more effective recruitment of motor units, resulting in highr muscle contractile activity^20,21. Short period of exercise in this study cause recruitment of motor unit during active contraction nor ambulation were not better than pre-treatment.

The result of present study showed significant increases in maximal amplitude of the GL and TA muscles during active contraction, as well as increasing of the GM during ambulation after additional treatment of ET application for 4 days in the intervention group.

The elastic taping working hypothesis is based on the tape relationship with the fascia that alters the superficial fascial strain underneath it in a specific direction, transmits the stretching force, and spindle sensitization resulting in increased muscle tone^22,23. During contraction GL and GM muscles may have different activation patterns²⁴. Reiman et al. (2011) compares GL and GM activation when performing a plantar flexion (heel rise) motion with foot in neutral foot position was no differencess. Heel rise in external rotation (out toeing) foot position makes activation of the GM larger than GL, and in internal rotation (in toeing) foot position makes activation of GL is bigger than GM^25,26. The tendency of the subjects to the direction of internal rotation (in toeing) when doing active contraction of plantar flexion movement can lead to greater GL muscle activation. The addition of elastic taping and the tendency of the subjects positioning the legs in the internal rotation direction may cause significant differences in GL maximal amplitude. Addition treatment of elastic taping application to the TA muscle and the measurement position resist gravitation when the subject performs active contraction of ankle dorsoflexion can cause maximal amplitude of TA muscle was significantly different from pre-treatment.

Gastrocnemius and tibialis anterior muscles contraction play a role to maintain balance when single limb support and double limb support^27,28. During ambulation occurs a combination of eccentric and concentric muscle movements of the calf muscles. It is normal to start a movement begins with activation of the previous movement in the opposite direction. The presence of this pre-activation can improve muscle performance during contractions. The combination of muscle action is called the stretch-shortening cycle (SSC). In an SSC, the potential of previous eccentric contractions is used when the action is concentric. Increased contractions during the concentric phase of SSC depend on increased neuromuscular activity as well as elastic properties of muscles and tendons. Greater speed and shorter coupling time can increase muscular concentric activity²⁹. The ability to maintain a standing upright posture is necessary to be able to ambulate by walking. Standing upright posture influenced by the gravity, so it needs the antigravity muscles to maintain it. Soames and Atha (1981) assessed the activity of muscles while standing casually barefoot over a 40-second period evaluated by sEMG. The result was the presence of moderate electrical activity in the gastrocnemius muscle and L3 spine erector level, whereas anterior tibialis muscle, bicep femoris, semitendinosus, tensor fascia lata, and spinal erector on T6 activity play a minimal role in postural control³⁰. Heroux et al (2013) conducted a study to assess the behavior of motor units on triceps surae. The study states that the lower threshold of GL motor unit is 20-35 times larger GM and soleus motor unit, and GL motor unit needs greater torque to activate recruitment^31,32.

In the intervention group of this study, the addition 4 days of elastic taping for GL muscle facilitation may only give increased muscle activity not reaching the same level of treshold as GM to improve recruitment of motor units so as not to be recorded any significant increase, in sEMG expressed as the maximum amplitude of AGL after treatment when compared to before treatment.

The standing position activates the antigravity muscle dominated by the gastrocnemius muscle³⁰. The ambulation activates the gastrocnemius muscle which duration of activation is longer than anterior tibialis muscle during the walking cycle³³. This may be the cause of elastic taping addition for TA muscle facilitation does not give significant difference between before and after treatment. The double action occurring in the gastrocnemius muscle during standing and ambulation accompanied by SSC mechanisms causes the recruitment of the motor unit to increase so that the maximum amplitude recorded on the sEMG after treatment is increased and significantly different than before the treatment in the intervention group.

Provision of conservative therapy in the form of compression therapy with elastic bandage. The compression therapy system is applied to the limb externally, by increasing pressure on the skin and underlying structures to counteract the force of gravity and facilitating the normal flow to the heart. The goal of compression therapy is to improve venous hemodynamics by increasing velous return venous flow rate, improving lymphatic flow and cutaneous microcirculation, decreasing venous hypertension by assisting calf muscle pumps and preventing leakage of transcapillary fluid into the interstitial space, and assisting venous ulcer healing^34-37.

In this study the measurement of the duration of venous reflux evaluation was performed before elastic bandage administration and the evaluation measurement was performed by removing elastic bandage first. When compression therapy is released, there is no external pressure which increases pressure on the skin and underlying structures to counteract the force of gravity and facilitates the normal flow to the heart, and the addition of 4-day exercise therapy has not reached its optimal effect of increased muscle contraction, then visible reflux and reflux duration are not different from before treatment in the control group.

Improvement of venous symptoms may be due to increased gastrocnemius myoelectric activation induced by elastic taping applications. The EMG findings in this study are similar to those of Paoloni (2011) which suggest an increase in muscle activity in subjects with musculoskeletal disorders³⁸. Gusella (2013) studied the effects of elastic taping with facial technique on the major pectoralis muscles at rest on 24 healthy subjects and the results of studies showed an increase in muscle tone²². The addition of ET application to the gastrocnemius and anterior tibial muscle may affect muscle activity, through mechanical taping mechanisms that may affect the length of muscle fibers, the proprioception mechanism that alters muscle tone due to increase of afferent impulses at central level, and neuromuscular mechanisms resulting in increased activation in calf pump muscles. This may be related to an improvement in the duration of venous reflux additional treatment of ET application for 4 days in the intervention group. The duration of PV reflux was significant decrease in intervention group after ET aplication for 4 days, but no improvement of FV reflux. A significant difference in the duration of popliteal venous reflux when compared to the control group.

CONCLUSION:

ET applications in the calf muscle pump system in patient with CVI CEAP C1, C2, and C3 have an effect of increased muscle activity during active contractions and ambulation expressed as maximum amplitude in sEMG, and also decrease the duration of popliteal venous reflux.

CONFLICT OF INTEREST:

None declared.

ACKNOWLEDGMENTS:

The authors would like to thank the Department of Physical Medicine and Rehabilitation, Dr Soetomo Regional General Hospital, Airlangga University Surabaya, East Java, Indonesia and all those who have helped in this study.

REFERENCES:

1. Nicolaides AN. Investigation of chronic venous insufficiency: A consensus statement (France, March 5-9, 1997). Circulation. 2000; 102(20).

2. Kestler B. Chronic Venous Insufficiency. Physician Assist Clin. 2021; 6(2): 319–30.

3. Araujo DN, Ribeiro CTD, Maciel ACC, Bruno SS, Fregonezi GAF, Dias FAL. Physical exercise for the treatment of non-ulcerated chronic venous insufficiency. Cochrane Database Syst Rev. 2023; (6).

4. Aguilar-Ferrándiz ME, Castro-Sánchez AM, Matarán-Peñarrocha GA, García-Muro F, Serge T, Moreno-Lorenzo C. Effects of kinesio taping on venous symptoms, bioelectrical activity of the gastrocnemius muscle, range of ankle motion, and quality of life in postmenopausal women with chronic venous insufficiency: A randomized controlled trial. Arch Phys Med Rehabil. 2013; 2315–28.

5. Meissner MH. Lower extremity venous anatomy. In: Seminars in Interventional Radiology. Thieme Medical Publishers, Inc., 333 Seventh Avenue, New; 2005; 147–56.

6. Thennarasu, A. Quercetin in Health and Disease. Research J. Pharm. and Tech. 2013; 6(12): 1397-1399.

7. Stranden E. Edema in venous insufficiency. Phlebolymphology. 2011; 18(1): 2.

8. Parvathi, P., & Geetha, R. V . Spices and Oral Health. Research J. Pharm. and Tech. 2014; 7(2): 235-237.

9. Meissner MH, Moneta G, Burnand K, Gloviczki P, Lohr JM, Lurie F, et al. The hemodynamics and diagnosis of venous disease. J Vasc Surg. 2007; 46(6 SUPPL.): S4–24.

10. Faghri PD, Votto JJ, Hovorka CF. Venous hemodynamics of the lower extremities in response to electrical stimulation. Arch Phys Med Rehabil. 1998; 79(7): 842–8.

11. Padberg FT, Johnston M V., Sisto SA, Burnand KG, Wakefield TW, Perkowski P. Structured exercise improves calf muscle pump function in chronic venous insufficiency: A randomized trial. J Vasc Surg. 2004; 39(1): 79–87.

12. Kase K WJKT, Clinical therapeutic applications of the Kinesio Tapìng method. 2nd ed. New Mexi-co: Kinesio Taping Association. Albuquerque, 2013.

13. Kumbrink B. K Taping: An Illustrated Guide-Basics-Techniques-Indications. Springer Science & Business Media; 2011.

14. Csapo R, Herceg M, Alegre LM, Crevenna R, Pieber K. Do kinaesthetic tapes affect plantarflexor muscle performance? J Sports Sci. 2012; 30(14): 1513–9.

15. Kohila, K. R. V., Kodi, V. T., & Hemavathy, V. Occupational Health versus Occupational Hazards. Research J. Pharm. and Tech. 2015; 8(4): 486-489

16. Wittens C, Davies AH, Bækgaard N, Broholm R, Cavezzi A, Chastanet S, et al. Editor’s choice–management of chronic venous disease: clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2015; 678–737.

17. Maheshwari, P., Divya, M., Shanmugarajan, T. S., & Ravichandiran, V. A Prospective Study on Health Related Quality of Life among Hypertensive Patients. Research J. Pharm. and Tech. 2015; 8(9): 1221-1224.

18. Rezaimanesh D, Amiri-Farsani P, Saidian S. The effect of a 4 week plyometric training period on lower body muscle EMG changes in futsal players. Procedia - Soc Behav Sci. 2011; 38–42.

19. Tamizhkodi, V., Shiba, T. M., and Hemavathy, V. A New Hope in Health-Complementary Therapies. Research J. Pharm. and Tech. 2015; 8(6): 752-754

20. Gonzalez EG, Myers SJ, Downey JA. Downey and Darling’s, Physiological basis of rehabilitation medicine 2001; 890.

21. Maheshwari, P., & Somasundaram, I. Health Related Quality of Life Measurement in Asthma and Chronic Obstructive Pulmonary Disease. Research J. Pharm. and Tech. 2016; 9(5): 518-520.

22. Gusella A, Bettuolo M, Contiero F, Volpe G. Kinesiologic taping and muscular activity: A myofascial hypothesis and a randomised, blinded trial on healthy individuals. J Bodyw Mov Ther. 2014;18(3):405–11.

23. Venkateswarlu, B., & Murty, A. V. S. N. Applications of Queuing Theory in Hospitals Using Single and Multiple Servers. Research J. Pharm. and Tech 2016; 9(12): 2211-2216

24. Cibulka M, Wenthe A, Boyle Z, Callier D, Schwerdt A, Jarman D, et al. Variation in Medial and Lateral Gastrocnemius Muscle Activity With Foot Position. Int J Sports Phys Ther, 2017; 12(2): 233–41:

25. Riemann BL, Limbaugh GK, Eitner JD, Lefavi RG. Medial and lateral gastrocnemius activation differences during heel-raise exercise with three different foot positions. J Strength Cond Res. 2011; 25(3): 634–9.

26. Rashaan, M., & Abbas, W. A. K.. Health care Personnel Practices regarding Personal Protective Equipment in the Delivery Room at the Middle Euphrates Teaching Hospitals. Research J. Pharm. and Tech. 2017; 10(6): 1969-1975.

27. Kim MK, Yoo KT. Effect of isotonic and isokinetic exercise on muscle activity and balance of the ankle joint. J Phys Ther Sci. 2015;27(2):415–20.

28. Vimal, K. S., & Mathivanan, V. Adjusting Healthcare Innovation and Software Necessities through design thinking. Research J. Pharm. and Tech. 2017; 3537-3538.

29. Carlsson U, Lind K, Möller M, Karlsson J, Svantesson U. Plantar flexor muscle function in open and closed chain. Clin Physiol. 2001; 21(1): 1–8.

30. Soames RW, Atha J. The role of the antigravity musculature during quiet standing in man. Eur J Appl Physiol Occup Physiol. 1981; 47(2): 159–67.

31. Héroux ME, Dakin CJ, Luu BL, Inglis JT, Blouin JS. Absence of lateral gastrocnemius activity and differential motor unit behavior in soleus and medial gastrocnemius during standing balance. J Appl Physiol. 2014; 116(2): 140–8.

32. Mahadeva Rao, U. S., San San, O. O., Sabrin, N. L., Razali, N. S. M., Khalid, K., Nadzari, N. F. M., & Zin, T. Accessibility and Availability, Sociodemographic characteristics, Health Centre Facilities and Knowledge, Attitude and Practice towards Modifiable Lifestyle Diseases among Adult Population in East coast Malaysia – A Cross-Sectional Study. Research J. Pharm. and Tech. 2017; 10(1): 317-324.

33. Grazia M, Agostini V, Knaflitz M, Bonato P. Muscle Activation Patterns During Level Walking and Stair Ambulation. Appl EMG Clin Sport Med. 2012; 8(2): 117–30.

34. Thomas S, Fram P. An evaluation of a new type of compression bandaging system. World Wide Wounds. 2003; 1–14.

35. Braddom RL. Physical medicine and rehabilitation e-book. Elsevier Health Sciences; 2010.

36. Armstrong DG, Meyr AJ. Compression therapy for the treatment of chronic venous insufficienc,. 2015; 1–12.

37. Kelechi TJ, Johnson JJ, Yates S. Chronic venous disease and venous leg ulcers: An evidence-based update. J Vasc Nurs. 2015; 33(2): 36–46.

38. Paoloni M, Bernetti A, Fratocchi G, Mangone M, Parrinello L, Cooper MDP, et al. Kinesio Taping applied to lumbar muscles influences clinical and electromyographic characteristics in chronic low back pain patients. Eur J Phys Rehabil Med. 2011; 47(2): 237–44.

Received on 23.09.2023 Modified on 09.11.2023

Research J. Pharm. and Tech 2024; 17(6):2901-2906.

DOI: 10.52711/0974-360X.2024.00455