|Year : 2020 | Volume
| Issue : 1 | Page : 17-25
Should kinesiology taping be used to manage pain in musculoskeletal disorders? An evidence synthesis from systematic reviews
Gourav Banerjee, Mark I Johnson
Centre for Pain Research, School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, United Kingdom
|Date of Submission||22-Oct-2019|
|Date of Decision||20-Feb-2020|
|Date of Acceptance||23-Mar-2020|
|Date of Web Publication||29-Jun-2020|
Dr. Gourav Banerjee
Centre for Pain Research, School of Clinical and Applied Sciences, Leeds Beckett University, Leeds
Source of Support: None, Conflict of Interest: None
Kinesiology taping has emerged as a relatively new treatment used for the management of pain in musculoskeletal disorders. The purpose of our review was to synthesise up-to-date evidence from systematic reviews on the clinical efficacy of kinesiology taping for managing musculoskeletal pain. Electronic databases (MEDLINE/PubMed, CENTRAL, AMED, CINAHL, PEDro, SPORTDiscus, OTseeker, Scopus, Web of Science, ProQuest, Open Thesis, EThOS) were searched for systematic reviews with or without meta-analysis published in English and non-English languages. Search findings were screened against eligibility criteria and systematic review data was extracted, tabulated and descriptively analysed. Our review included 43 systematic reviews (17 meta-analyses). Systematic reviewers reported a paucity of high-quality randomised controlled trials and that overall evidence was of “very low” to “moderate” quality. There were 32 systematic reviews published since 2015 and these provided tentative evidence that kinesiology taping was superior to no or minimal treatment, but not superior to conventional physical therapies for reducing pain and improving function in the short-term in myofascial pain syndrome, shoulder impingement syndrome, chronic low back pain, knee osteoarthritis and patellofemoral pain syndrome. There is insufficient high-quality evidence to determine the clinical efficacy of kinesiology taping for managing musculoskeletal pain with any certainty. We recommend that an enriched enrolment randomised withdrawal trial is needed to increase the trustworthiness of evidence to inform clinical practice. Healthcare professionals in musculoskeletal practice should view kinesiology taping as one of a variety of nonpharmacological approaches with uncertain efficacy that may be used in combination with the core treatment.
Keywords: Athletic tape, complementary therapy, Kinesio tape, pain, physical therapy modality
|How to cite this article:|
Banerjee G, Johnson MI. Should kinesiology taping be used to manage pain in musculoskeletal disorders? An evidence synthesis from systematic reviews. Physiother - J Indian Assoc Physiother 2020;14:17-25
|How to cite this URL:|
Banerjee G, Johnson MI. Should kinesiology taping be used to manage pain in musculoskeletal disorders? An evidence synthesis from systematic reviews. Physiother - J Indian Assoc Physiother [serial online] 2020 [cited 2020 Jul 6];14:17-25. Available from: http://www.pjiap.org/text.asp?2020/14/1/17/288363
| Introduction|| |
Musculoskeletal pain is a common consequence of cumulative trauma, repetitive strain, or overuse injuries of the soft-tissues, bones and joints. Chronic musculoskeletal pain that persists or recurs for longer than 3 months is one of the leading causes of suffering and disability worldwide and is associated with large direct (e.g., healthcare costs) and indirect (e.g., sickness benefit and lost productivity) financial costs to the society.,, It is estimated that the annual costs of chronic pain in the USA is greater than that for heart disease, cancer and diabetes, and that chronic pain in Europe accounts for approximately 1.5% to 3% of its gross domestic product expenditure., Management of chronic musculoskeletal primary and secondary pain is challenging and involves the use of a multidisciplinary biopsychosocial approach. In many cases pain-relief is inadequate despite optimal evidence-based treatment., The role of pharmacotherapy for managing chronic pain in the long-term is limited given the propensity of analgesic drugs to cause adverse effects. This is especially problematic in the elderly population in whom musculoskeletal pain (e.g., due to arthritis) is more prevalent putting them at risk of developing polypharmacy-related complications including organ damage and death.,,,, The World Health Organization and the International Association for the Study of Pain recommend using effective, safe, low-cost nonpharmacological therapies integrated into a self-management care plan that empowers patients to take control of their pain management leading to better outcomes in the longer term.,
Kinesiology taping is a low-cost, non-pharmacological treatment method commonly used by healthcare professionals in musculoskeletal and sports settings for the prevention and rehabilitation of musculoskeletal injuries including management of pain. Kinesiology taping involves the application of thin, elastic cotton-based water-resistant adhesive kinesiology tape to the skin using a variety of techniques. Kinesiology tape can be stretched longitudinally 60% or more of its resting length and worn continuously for 3 days or longer to support soft tissues and joints without restricting movements.,, This differs from conventional therapeutic tapes that are rigid or minimally elasticated in nature and are used to provide structural support at joints and soft-tissues.
Kinesiology taping is indicated for the management of chronic pain associated with musculoskeletal conditions highly prevalent in the adult general population such as the lower back, shoulders and knees.,, Kinesiology taping has a low-risk of hazard probability and severity with minor skin-related irritation occurring in a small proportion of individuals. Kinesiology taping is inexpensive, available without prescription, and can be administered by patient or carer following relatively simple instructions or training. Hence, kinesiology taping aligns with the good practice recommendations and has potential as a treatment option for managing musculoskeletal pain., The purpose of our review was to synthesise up-to-date evidence from systematic reviews evaluating the clinical efficacy of kinesiology taping for managing musculoskeletal pain. Our approach was to outline research findings through commentary rather than a comprehensive objective appraisal of systematic reviews.
| Methods|| |
The following electronic databases were searched throughout June 2019 for systematic reviews published in English and non-English languages: MEDLINE/PubMed, CENTRAL, AMED, CINAHL, PEDro, SPORTDiscus, OTseeker, Scopus, Web of Science, ProQuest, Open Thesis, EThOS [Table 1]. In addition, a search of Google Scholar was performed (up to 5 pages of each keyword search). Detailed search strategies were developed separately for each database based on controlled vocabulary and free text terms with the combination of multiple keywords and the Boolean operators AND/OR ([“kinesiology tap*e/ing; kinesio tap*e/ing; elastic therapeutic tap*ing; neuromuscular tap*ing” AND “systematic review OR meta-analysis” “ALL FIELDS”]). The reference lists of systematic reviews found from the search were also screened for potentially relevant reviews.
Criteria for considering systematic reviews in this review
For this review, kinesiology tape was defined as an “elastic adhesive tape” of any colour, shape, size, texture or brand. Rigid nonelastic or minimally elastic adhesive tapes, elastic adhesive and nonadhesive bandages were excluded from the review. The eligibility criteria were decided a priori by the authors. Eligibility for inclusion were full report of systematic reviews with or without meta-analysis of kinesiology taping (in combination with or without other interventions including nonelastic taping) for pain and related outcome measures including range-of-motion, function, disability and quality-of-life (QoL). Systematic reviews evaluating the efficacy of kinesiology taping for nonpain related outcome measures such as muscle strength and proprioception in healthy human population were excluded. Systematic reviews that included primary studies evaluating both pain and nonpain outcomes were included, however, only findings related to pain and associated outcomes such as function, disability and QoL were included for descriptive analysis.
Data collection and analysis
Titles and abstracts of reports identified by the search were screened for relevance by Gourav Banerjee (GB) and cross-checked by Mark I. Johnson (MIJ). Full text reports of potentially relevant systematic reviews articles were obtained and screened independently by GB and MIJ and any disagreements about meeting eligibility criteria resolved by discussion. Information from systematic reviews was extracted and tabulated prior to undertaking a descriptive analysis.
| Results|| |
Searches of databases found 49 systematic reviews that evaluated the effects of kinesiology taping on pain and related outcome measures. Three of these 49 systematic reviews were excluded because they had been previously 'withdrawn' by the publisher or a full text report was not available or could not be obtained., Additionally, three reports were excluded despite being titled as “systematic review” because they were narrative in nature and lacked characteristics associated with systematic review methodology.,, Thus, 43 systematic reviews were included in our synthesis, and 17 of these systematic reviews included a meta-analysis [Table 2].
|Table 2: Summary of systematic reviews with or without meta-analysis included in this review|
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It was notable that 32 out of 43 systematic reviews were published between 2015 and June 2019. Systematic reviews published between 2010 and 2014 tended to be inconclusive because of a paucity of randomised controlled trials (RCTs) on which to base a judgement of clinical efficacy. Inspection of the 32 systematic reviews published after 2014 revealed an increase in the numbers of RCTs being analysed, although reviewers still reported insufficient high-quality evidence on which to judge the efficacy of kinesiology taping for managing musculoskeletal pain with certainty. In general, reviewers judged the overall quality of evidence as either “very low”, “low” or “moderate” when using GRADE, or “limited”, “conflicting” and “moderate” when using the Cochrane grading system. In general, the effect size was small with reviewers arguing that kinesiology taping may have short-term benefits as an adjunct to the conventional physical therapies such as exercise and manual therapies. There was “low” quality evidence of clinical efficacy for alleviating pain associated with myofascial pain syndrome (MPS),, and “very low” to “moderate” evidence for sub-acromial/shoulder impingement syndrome,,,,, chronic low back pain,,,, osteoarthritis of the knee,, and patellofemoral pain syndrome.,,, It was notable that some systematic reviewers reported nonelastic or minimally elastic/rigid taping was superior to kinesiology taping for reducing knee pain associated with patellofemoral pain syndrome, and osteoarthritis. Evidence from the systematic reviews for other conditions such as Achilles tendinopathy was lacking due to insufficient RCTs.
| Discussion|| |
This review summarises the up-to-date evidence synthesised from systematic reviews on the effectiveness of kinesiology taping for managing pain in musculoskeletal disorders. We noted inconsistency in grading of methodological quality of RCTs in similar systematic reviews. For example, Morris et al. used multiple tools including the Cochrane criteria checklist to assess methodological quality of RCTs, and then categorised RCT quality using a method adapted from Clarke et al. to exclude low quality studies from the analysis. Morris et al., then, graded the overall quality of evidence using the Cochrane level of evidence grading system. In contrast, Luz Júnior et al. assessed the methodological quality of RCTs using the PEDro scale and graded the overall quality of evidence using the GRADE classification system. Nevertheless, our review found a large number of systematic reviews yet few high-quality RCTs from which to judge efficacy with any degree of certainty. In some instances, the quality of evidence from RCTs with higher methodological quality scores on PEDro scale when meta-analysed was downgraded to “low” or “very low” because of inadequate sample sizes, substantial statistical heterogeneity, imprecision of treatment effects, inconsistency of results between studies and the presence of publication bias.
Overall, we judge there to be tentative evidence from systematic reviews that kinesiology taping is superior to no treatment at short-term alleviation of musculoskeletal pain associated with chronic low back pain, osteoarthritis of the knee, sub-acromial/shoulder impingement syndrome and patellofemoral pain syndrome. At present, it is difficult to judge with certainty whether kinesiology taping is superior to conventional physical therapies. To date, the strongest evidence comes from a recent systematic review of 20 RCTs that included a meta-analysis of 959 patients with MPS and found that kinesiology taping was superior to noninvasive therapies (including manual therapies) for reducing pain and increasing range of motion.
The mechanism (s) of action of kinesiology taping remains largely speculative to date due to the lack of scientific evidence. Conventional taping and bandaging techniques use rigid or minimally elasticated tapes or bandages to provide compression, immobilisation and stabilisation to the injured soft tissues and joints for alleviating pain and promoting recovery. Manufacturers claim that kinesiology taping reduces pain by different mechanisms depending on the location and stretch of kinesiology tape. It is claimed that kinesiology taping techniques for pain relief create traction on the skin to produce convolutions of the skin, i.e., lifting of the epidermis away from the underlying tissues thereby causing decompression in the regions underneath. This is believed to reduce pressure on the subcutaneous nociceptors during inflammation and facilitate increase of the flow of blood and lymph in the microcirculation resulting in the drainage of inflammatory exudates thereby reducing swelling and pain., While there is evidence that kinesiology taping of the skin produces mechanical deformation of tissues underneath and an increase in epidermal-dermal distance,,,, laboratory studies have found that kinesiology taping does not increase cutaneous or skeletal muscle blood flow when measured using laser Doppler imaging technologies under a variety of experimental conditions such as at rest and during exercise.,,,
Perhaps the most plausible mechanism by which kinesiology taping may reduce pain is the notion that kinesiology taping during movement causes stretching and recoil of the skin, which activates low-threshold mechanoreceptor peripheral afferents causing central inhibition of nociceptive transmission and hence modulation of pain in line with the gate control theory of pain. Findings from laboratory studies that evaluated the effect of kinesiology taping to transient nociceptive-stimuli interacting with a normally functioning nociceptive system in the presence or absence of sensitisation found conflicting results.,,,,,,, Thus, it seems plausible that pain-relief effects associated with kinesiology taping techniques result from a combination of (a) neurophysiological, i.e., stimulation of low threshold mechanoreceptors, (b) biomechanical, i.e., correction of articular malalignments and elasticated support to the soft-tissues and joints to unload incumbent forces acting on painful structures,, as well as (c) psychological mechanisms, i.e., expectation of benefit from being administered a treatment by a clinician, “laying on of hands”.,, Notwithstanding, it seems likely that kinesiology tape will have lesser stabilising influence on correcting joint and soft-tissues malalignment in conditions such as patellofemoral pain syndrome than conventional rigid or minimally elasticated tapes.
Limitations and future directions
A limitation of our review was the omission of assessment of the methodological quality of RCTs or systematic reviews. Not formally appraising the methodological quality of the systematic reviews using tools such as AMSTAR makes our review vulnerable to selection and evaluation biases and hence reduces confidence in our interpretations of evidence. In addition, we performed a simple descriptive analysis and made no attempt to extract and pool RCT data. Our original intention was to overview evidence to generate a 'one-stop' reference source of systematic review information rather than conduct a formal overview of systematic reviews that would include a meta-analysis of all available RCTs. Thus, we view our review as a precursor to a structured overview of systematic reviews.
Our finding that systematic reviews tended to be inconclusive due to insufficient high-quality RCT data raises questions about the appropriateness of continuing to undertake systematic reviews in this field. One of the recurring themes is inadequacy of sample sizes in RCTs and meta-analysis. Inadequate sample sizes are associated with larger treatment effects, and overestimation of clinical efficacy. To create a more trustworthy evidence base, the Cochrane collaboration advise that RCTs assessing pain should have at least 200 participants per treatment arm, and meta-analyses have >400 pooled data points per treatment arm.
Our review found that most of previous systematic reviews focus on specific medical conditions reducing sample sizes available for data pooling and the statistical power of the meta-analysis. In future, a review that evaluated the efficacy of kinesiology taping on musculoskeletal pain irrespective of condition would have the potential of increasing statistical power and confidence in findings. Concern about clinical heterogeneity associated with variability in the context and pathology associated with different types of pain can be offset by conducting sub-group analyses of specific medical conditions (e.g., according to ICD-11 categories). In addition, systematic reviewers express concern about statistical heterogeneity (“noisy data”) resulting from a plethora of factors including variance of baseline characteristics of participants, variance of kinesiology taping technique and/or dosage, and the appropriateness of control interventions to name but a few. There is certainly a need to develop consensus of what constitutes an adequate dose of kinesiology taping, and a systematic review that extracts, maps and analyses the variability of characteristics kinesiology taping technique used in previous RCTs would be a useful addition to the literature.
Our review demonstrates the high volume of RCT research that has persistently failed to determine with any degree of certainty the clinical efficacy of kinesiology taping for the management of musculoskeletal pain. There is a significant financial cost associated with generating such large volumes of inconclusive evidence, based on inadequate sample sizes. Conducting RCTs with adequate sample sizes is likely to remain an issue because of funding constraints for large scale studies on kinesiology taping. Thus, we propose that there needs to be refinement of the design of RCTs on kinesiology taping.
We believe that the sensitivity of RCTs on kinesiology taping could be improved by adopting an enriched enrolment randomised withdrawal trial design whereby the sample of participants enrolling into the randomised controlled phase of the trial is enriched so that it includes only those participants that are likely to benefit. This increases the trustworthiness of primary evidence by reducing variance in data and the need for large sample sizes. Enriched enrolment randomised withdrawal trials consist of two phases: firstly, an observational open-label phase where participants receive only the active treatment (kinesiology taping) and treatment and dosage is titrated and optimised; and secondly a RCT phase that includes participants who obtained befit without adverse events in phase one and who wished to continue with treatment (i.e., an enriched sample). These participants are then randomised to receive either experimental (kinesiology taping) or control interventions. The control intervention could be nonelastic tape, or no treatment, or standard of care or another treatment. To our knowledge, there have not been any enriched enrolment randomised withdrawal-controlled trials of kinesiology taping for musculoskeletal pain, although the approach has been used to determine the efficacy of drugs for chronic pain conditions.
| Conclusion|| |
Our review demonstrates that there is insufficient high-quality evidence to determine the clinical efficacy of kinesiology taping for managing musculoskeletal pain with any certainty. In view of the available evidence, healthcare professionals in musculoskeletal practice should continue to view kinesiology taping as one of a variety of nonpharmacological approaches with uncertain efficacy. The decision whether to select kinesiology taping from a raft of available treatment options (e.g., manual therapies, massage, electrophysical agents, and acupuncture) remains at the discretion of the individual practitioner and clinic policy.
Financial support and sponsorship
This project was funded by a PhD student bursary from the Jane Tomlinson Appeal, United Kingdom.
Conflicts of interest
MIJ's institution has received research and consultancy funding for work that he has undertaken for GlaxoSmithKline. GB declares that he has no conflict of interests.
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[Table 1], [Table 2]