URJHS Volume 13

The Effects of Kinesio Taping for Pain Management

Drew Slocum

California University of Pennsylvania

Abstract

Kinesio tape is an elastic, adhesive-backed cotton tape that was created in the late 1970's by Dr. Kenzo Kase of Japan to treat athletic injuries and aid in athletic performance. Aiding in athletic performance includes pain reduction, neuromuscular system re-education, performance optimization, injury prevention, and the promotion of improved circulation and healing. The specific purpose of this review is to determine the effectiveness of kinesio taping on pain reduction. Musculoskeletal pain affects athletes in a negative manner and can lead to a decrease in athletic performance. Numerous studies were reviewed to determine the pain reducing effects of kinesio tape on musculoskeletal injuries that include subacromial impingement syndrome, rotator cuff tendonitis, patellofemoral pain syndrome, mechanical neck pain, and Achilles tendinosis. In conclusion, the studies conducted determined that kinesio tape does have an effect on pain reduction but the exact physiological cause is unknown. Although the results hypothesize that kinesio tape affects the gate control theory, more research is needed to determine the effectiveness of kinesio taping on the reduction of pain management.

Introduction

Pain is defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage" (Prentice, 2009, p.33). With an abundance of descriptors, pain is a subjective sensation composed of a variety of human discomforts. The purpose of pain is to warn us that something is wrong and provides a withdrawal response to avoid further injury. However, pain can also persist after it is no longer useful. It can enhance disability and inhibit the efforts to rehabilitate the patient (Prentice, 2009).

Pain is initially triggered by the activation of pain receptors called nociceptors (Fine, 1993). A nociceptor is a peripheral pain receptor, with its cell body located in the dorsal root ganglion near the spinal cord (Prentice, 2009). When there is injury to a cell, three chemicals, substance P, prostaglandin, and leukotrienes are released. These chemicals sensitize the nociceptors in and around the area of injury by lowering their depolarization threshold, known as primary hyperalgesia. The nerve's threshold to noxious stimuli is lowered, which enhances the pain response (Prentice, 2009).

There are several types of pain, including acute, chronic, referred, and radiating. Acute pain is experienced when tissue damage is impending after an injury has occurred, while chronic pain is classified as pain lasting for more than 6 months (Prentice, 2009). Referred pain is perceived in regions innervated by nerves other than those that innervate the site of noxious stimulation (Bogduk, 2009).  Pain evoked by ectopic discharges emanating from a dorsal root or its ganglion can cause radiating pain, with disk herniation being the most common cause (Bogduk, 2009).

Pain sensation is transmitted through two types of neurons. Slow conducting neurons with an unmyelinated axon known as the C-fibers, produce a dull, poorly localized, lingering pain while myelinated A-delta axons produce a well localized sharp pain (Fine, 1993). C-fibers are categorized as polymodal nociceptors due to their responsiveness to thermal, chemical, and mechanical stimuli. Because of their small receptive field, C-fibers maintain firing for several seconds after the given stimulus has ceased. Also, after initial activation, the receptors have a lower threshold to firing when exposed to a subsequent stimulus, known as sensitization (Fine, 1993). This property may explain the increased sensitivity to pain, called hyperalgesia, which develops after trauma to the skin (Fine, 1993).

Nociceptive information that reaches the dorsal horn region of the spinal cord is influenced by concurrent neuronal activity within the spinal cord as well as by descending pathways originating in the brain (Fine, 1993). The dorsal horn region can be thought of as a neurosensory switching station, a concept that is the essence of the gate control theory. The concept behind the gate control theory contends that the neural mechanisms in the dorsal horns of the spinal cord that are activated by non-pain-producing peripheral nerve inputs serve to increase or decrease the flow of pain-producing impulses from the site of injury to processing centers in the central nervous system (CNS) (Fine, 1993). The effect of gating can inhibit pain signals before they reach cortical areas in the brain that register pain as a specific perception. In theory, persons who stub their toe can reduce the discomfort by rubbing the area around it (Fine, 1993). The mechanical stimulation blocks or gates the nociceptive impulses. The gate can open or close depending upon the state of concurrent input from multiple pain pathways (Fine, 1993).

Reducing pain is an essential part of treatment. Pain signals the patient to seek assistance and is useful in establishing a diagnosis but serves little purpose once the injury has been diagnosed (Prentice, 2009). The presence of pain can inhibit therapeutic exercise. Controlling pain is an essential aspect of caring for an injured patient (Aronson, 2002). The treatment of pain is to merely change a patients' perception (Bishop, 1980).

Modalities are often used in the rehabilitation setting to reduce a patient's pain level by stimulating large-diameter afferent fibers. This can be done through the use of transcutaneous electrical nerve stimulation (TENS), which is an electrotherapeutic procedure used for pain control (Sluka, Bjordal, Marchand, & Rakel, 2013). The TENS unit consists of an electric signal generator, a battery, and a set of electrodes. These small, programmable units deliver stimuli with variable currents strengths, pulse rates, and pulse widths (Prentice, 2009). In the rehabilitation setting, TENS treatment is referred to as a conventional, high-frequency, or sensory-level treatment. The intensity is set only high enough to elicit a tingling sensation but not high enough to cause a muscle contraction. This treatment provides maximum sensory cutaneous stimulation through use of the gate control theory (Prentice, 2009). Essentially, the maximum sensory stimulation allows these pleasant sensations to travel up the spinal cord overriding the pain stimulation, thus closing the gate.

Massage is also widely used in rehabilitation to reduce pain. The effect of massage on pain is regulated by the gate control theory by cutaneous stimulation of large-diameter afferent nerve fibers that effectively block transmission of pain information carried by small-diameter nerve fibers (Prentice, 2009). Massage is a mechanical stimulation of the tissues by means of rhythmically applied pressure and stretching (Domenico, 2007). It has been used to increase flexibility, coordination, and pain threshold through decreasing neuromuscular excitability in the muscle being massaged (Prentice, 2009).

Along with stimulating large-diameter afferent fibers, modalities are also used to decrease pain fiber transmission velocity (Prentice, 2009). Cryotherapy is the use of cold in the treatment of acute trauma and subacute injury (Johnson, 2012).  Cold is used to reduce pain and the reflex muscle spasm and spastic conditions that accompany it (Merrick, Knight, Ingersoll, & Potteiger, 1993). The analgesic effect of cold therapy decreases the velocity of nerve conduction, but does not completely eliminate it (De Jong, Hershey, & Wagman, 1966). Cold may also overwhelm central pain receptor areas with numerous cold impulses that allow pain impulses to become lost through the gate control theory (Prentice, 2009).

Thermal modalities, such as ultrasound, have been used in the rehabilitation setting as well to decrease pain. Ultrasound has been used to elevate tissue temperature at depths up to 5 cm and has the ability to penetrate deeper than other thermal agents with minimal increase in skin temperature (Hayes, Merrick, Sandrey, & Cordova, 2004). Through thermal effects, ultrasound is used to elevate the threshold for activation of free nerve endings (Prentice, 2009). By increasing nerve conduction velocity in normal nerves, a counterirritant effect may take place through the effect of thermal mechanisms, leading to a decrease in pain (Prentice, 2009). Heat produced by ultrasound in large-diameter myelinated nerve fibers may reduce pain through the gate control theory (Prentice, 2009).

In recent history, conventional methods such as therapeutic modalities and athletic taping have been the preferred methods of optimizing sports performance affected by injury or limitation. Since its creation in the late 1970's by Dr. Kenzo Kase of Japan, kinesio taping (KT) has gradually been introduced throughout the worldwide athletic community for treating athletic injuries (Williams, Whatman, Hume, & Sheerin, 2012). However, little is known about the physiological effects of KT. Unlike traditional white athletic tape, which has been one of the preferred choices, KT is an elastic, adhesive-backed cotton tape that can be stretched up to 140% of its resting length to apply a constant pulling force on the skin (Halseth, McChesney, DeBeliso, Vaughn, & Lien, 2004).

Musculoskeletal pain is a common condition that affects athletes in a negative manner and is aggravated during activity. Pain is often interpreted differently by individuals and can lead to a pain-related fear of physical activity, which can result in avoidance of pain-inducing situations (Damsgård, Thrane, Anke, Fors, & Røe, 2010). As a result, psychological and physiological factors can influence pain disability. It is believed that the external use of a therapeutic technique such as KT may influence an athlete's psychological and physiological perception of pain in a positive manner (Damsgård et al., 2010).

According to the Kinesio Taping Association (KTA), kinesio taping aids in athletic performance, which includes: pain reduction, neuromuscular system re-education, performance optimization, injury prevention, and the promotion of improved circulation and healing. The purpose of this research is to determine the effect KT has on the reduction of pain in subjects with musculoskeletal limitations or injuries. Pain can limit an athlete's ability to perform at an optimal level from practice to the championship game. Kinesio taping is said to reduce injury recovery time by decreasing pain and inflammation (Mostafavifar, Wertz, & Borchers, 2012). The use of KT may provide a more viable and less time-consuming approach to reduce injury recovery time as opposed to conventional therapeutic modalities or athletic tape. The specific aim of the literature review is to determine if the application of KT to musculoskeletal injuries can decrease pain after application to the affected area.

Discussion

Kinesio Taping (KT) was introduced to the United States in the 1990s and has widely been used as an alternative to standard athletic taping to assist in edema reduction, pain management, and facilitation of motor activity (Osterhues, 2004). Physical Therapists, Physical Therapists Assistants, Occupational Therapists, Certified Occupational Therapy Assistants, Chiropractors, Massage Therapists, and Athletic Trainers are amongst the many whom use KT. With global marketing and its appearance in the US, KT has quickly become more visible with health care professionals demanding its availability and use. Most notably, KT has been seen on the Olympic stage. Many can recall the use of KT on the United States women's beach volleyball team comprised of Misty May-Treanor and Kerri Walsh. Kinesio tape was applied to help support Kerri Walsh's left shoulder after she received rotator cuff surgery (Dusen, 2008).

The tape exhibits its effects through the activation of neurological and circulatory systems with movement (Osterhues, 2004). It is used to support the fascia, muscles, and joints while offering unrestricted range of motion (ROM). Kinesio taping is also suggested to reduce injury recovery time by decreasing pain and inflammation (Mostafavifar et al., 2012). Depending on the amount of stretch applied, Thelen, Dauber, and Stoneman, (2008) proposed several benefits including: to provide a positional stimulus through the skin, align fascial tissues, to create more space by lifting fascia and soft tissue above area of pain/inflammation, to provide sensory stimulation to assist or limit motion, and to assist in the removal of edema by directing exudates toward a lymph duct.

The concept behind KT is to closely mimic the properties of the epidermis of human skin in terms of thickness and weight. The tape has an elasticity of up to 30%-140% over its resting length and is latex-free. The material, 100% cotton, assists in water evaporation so the tape can be worn in the shower or pool and can last for several days continuously with the help of 100% heat-activated acrylic adhesive (Mostafavifar et al., 2012). Kinesio taping allows a partial to full ROM to applied muscles and joints while administering different pulling forces on the skin. The tape is said to lift the skin to increase space for reducing localized pressure while promoting circulation and lymphatic drainage (Williams et al, 2012). As a result, KT reduces pain, swelling, and muscle spasm (Chen, Hong, Lin, & Chen, 2008). The following sections will address how KT has been used to alleviate anterior knee pain compared to the McConnell Taping Technique and its ability to decrease calf pain and increase ankle range of motion in duathletes. Also included is the effect KT has with specific orthopedic injuries such as Subacromial Impingement Syndrome, Rotator Cuff Tendinitis, Patellofemoral Pain Syndrome, Mechanical Neck Pain, and Achilles Tendinosis.

McConnell Taping Technique vs. Kinesio Taping

The McConnell Taping Technique (MT) uses a rigid, highly adhesive tape that can be worn for up to 18 hours. For treatment of anterior knee pain, MT has been reported to regulate the mediolateral pulling force of the patella to reduce knee pain and improve joint alignment (Campolo, Babu, Dmochowska, Scariah, & Varughese, 2013). The MT has also been reported to stimulate cutaneous mechanoreceptors, allowing more sensory signals to be carried to the central nervous system (Campolo et al., 2013).

In a study performed by Campolo et al., (2013) 20 subjects (15 female, 5 male) ages 13-30 with unilateral anterior knee pain were recruited to participate. The subjects were asked to perform two functional activities, including a squat lift while lifting a weighted box and ascending and descending three flights of stairs under three conditions: 1) no tape, 2) MT and 3) KT. The purpose of the study was to compare the effectiveness of pain control during functional activities by the KT vs. the MT on subjects with anterior knee pain.

The results of the study revealed no significant difference in pain levels between the three conditions during the squat lift. However, during the stair climb, both KT and MT were effective in reducing pain levels compared to no tape. Although further studies are needed, both KT and MT can be used as viable alternatives to reduce anterior knee pain during stair climbing (Campolo et al., 2013). One would expect both the MT and KT methods to work as the properties of tape, relying on sensory stimulation, would override the pain stimulus thus blocking the gate in the spinal cord.

Decrease Calf Pain and Increase Ankle Range of Motion

In a study performed by Merino-Marban, Fernandez-Rodriguez, & Mayorga-Vega (2014), 34 duathletes were recruited to determine the effect of KT immediately after application and after a duathlon competition on calf pain and ankle range of motion. Duathlon is a popular sport that combines running, cycling, and running in one event. Due to overuse, it is common for duathletes to experience soreness and cramping in the calf muscles (Merino-Marban et al., 2014). The fascia, a connective tissue that surrounds and covers muscles can increase its tension due to the mechanical load applied during exercise. A theory of KT suggests that KT can improve sports performance by unloading the fascia, thus relieving pain (Merino-Marban et al., 2014).

Ankle dorsiflexion range of motion and a numeric pain rating scale were obtained at baseline, immediately after taping and 10-15 minutes after the duathlon competition. The KT was applied to one calf (experimental leg) of the duathletes 20-90 minutes before competition while the other calf acted as the control. According to the results, no differences were found immediately after application of KT and after completion of the competition in ankle range of motion and calf pain. However, there was a significant difference in ankle range of motion from baseline to immediately applying the KT to the experimental leg. Applying KT to the calf seems to immediately increase ankle dorsiflexion range of motion but does not reduce muscle pain immediately or after duathlon competition (Merino-Marban et al., 2014). This study is in contrast to the Campola et al., (2013) findings suggesting that KT can reduce pain.  

Subacromial Impingement Syndrome

A common shoulder complaint is subacromial impingement syndrome, which is the most frequent cause of shoulder pain in overhead athletes (Yin-Hsin, et al., 2009).  Subacromial impingement syndrome, or commonly known as shoulder impingement, is a compression and mechanical abrasion of the rotator cuff structures as they pass beneath the coracoacromial arch during elevation of the arm (Kaya, Zinnuroglu & Tugcu, 2011). Anatomic morphology, overuse, and instability are all contributing factors toward subacromial impingement (Yin-Hsin et al., 2009).

Overhead athletes suffering from subacromial impingement syndrome most often present with increased scapular winging during arm elevation, decreased scapular upward rotation and posterior tilt, and increased scapular superior translation (Yin-Hsin et al., 2009). In a study performed by Yin-Hsin et al., (2009), baseball players with shoulder impingement syndrome were recruited from three amateur baseball teams in Taipei. Subjects received KT and placebo taping. Measurements were taken of muscle strength, electromyography (EMG), and scapular motion. Sensors and electrodes were placed on the subject's dominant arm along with 10 bony landmarks being palpated and digitized through the use of a stylus. The testing movement performed was scaption.

The use of KT as compared to rigid tape causes minimal movement restriction while offering a degree of support. Subjects with shoulder impingement syndrome have shown to have a decreased posterior tilt at 45° and 90° of humeral elevation. Application of KT over the lower trapezius in subjects with shoulder impingement was shown to increase scapular posterior tilt when humeral elevation was <90°. This has shown that KT may assist in correcting the affected scapular movements while providing a balanced and stabilized base for arm function (Yin-Hsin, et al., 2009). With proper arm function and stabilization, a reduction of pain may be considered. However, pain was not measured in this study.

Rotator Cuff Tendinitis

A study by Thelen et al., (2008) compared the short-term efficacy of KT application on reducing pain and disability in subjects with shoulder pain due to rotator cuff tendinitis as compared to sham KT application. During the study, 42 subjects clinically diagnosed with rotator cuff tendonitis/impingement were randomly assigned to a group, one being a therapeutic KT group and the other a sham KT group. The groups wore their prospective tapes for two three-day intervals. Outcome measurements consisted of the Shoulder Pain and Disability Index (SPANDI), pain free active range of motion (ROM) and the 100-millimeter visual analog scale (VAS). A visual analog scale consists of a 100-millimeter line with the words "no pain" on one end and "most severe pain" on the opposite end (Aytar et al., 2011).  

By day 3 of the study, there was no significant difference between the groups. These results may indicate KT partially improving pain-free ROM of shoulder abduction immediately after application but having no long-term benefits in terms of pain reduction. One explanation may be based on the gate control theory. The application of the tape on the superficial surface of the skin may stimulate neuromuscular pathways through afferent (sensory) pathways. According to the gate control theory an increase in afferent stimulus to large-diameter nerve fibers can serve to override or lessen the input received from the small-diameter nerve fibers conducting nociception, or pain. (Thelen et al., 2008). Another theory of decreased pain may be contributed to the tape guiding the glenohumeral joint through an improved ROM allowing for less mechanical irritation.

Patellofemoral Pain Syndrome

Patellofemoral pain syndrome (PFPS) is one of the most common diagnoses amongst runners in athletics (Aytar et al., 2011). Patellofemoral Pain Syndrome can range from active adolescents to adults. Inadequate control of the vastus medialis oblique (VMO) such as a reduction in tension producing capacity or insufficient timing is considered a possible cause of PFPS (Chen et al., 2008). The VMO acts as a medial stabilizer for the patella and is a large contributor to patellar alignment. The anterior portion of the knee is often aggravated by activities such as squatting or stair climbing. The force applied to the patella can range from one half of a person's body weight while climbing stairs to seven times a person's body weight while squatting (Chen et al., 2008).

To determine the physiological effects of KT on pain reduction in subjects with PFPS a visual analog scale (VAS) was used to measure pain intensity in the study conducted by Aytar et al., (2011). Subjects were instructed to mark their pain discomfort level on the scale while walking, ascending and descending stairs. The study conducted by Chen et al., (2008) monitored VMO and vastus lateralis (VL) EMG activity through the use of force plates and surface electrodes located on the muscle bellies. Ground reaction forces (GRFs) and EMG activity were calculated.

Although KT may have a positive effect on muscular strength and balance, findings resulted in no significant difference between KT and a placebo KT regarding a decrease in pain (Aytar et al., 2011). In contrast, the study provided by Chen et al., (2008) concluded the possibility of KT providing mechanical support to the medial ligaments of the patellofemoral joint to align the patella within the trochlea to reduce pain. Both studies claim PFPS pain might also be decreased as a result of the gate control theory. Application of KT may stimulate cutaneous receptors to initially reduce pain levels. Pain may also be decreased as a result of improved patellar alignment (Aytar et al., 2011).

Mechanical Neck Pain

Mechanical neck pain, or pain in the anatomical region of the spine, has long been deemed a problem amongst society with symptoms in the neck and upper extremity (Saavedra-Hernandez, Castro-Sánchez, Arroyo-Morales, Cleland, Lara-Palomo, & Fernández-de-Las-Peñas, 2012). Manual therapy methods such as cervical thrust manipulations are currently the most effective treatment methods for neck pain. The use of KT has recently been used in rehabilitation clinics for pain management and increased cervical mobility. A study performed by Saavedra-Hernandez et al., (2012) examined the short-term effects of KT versus spinal manipulation on neck pain intensity. Eighty patients were randomly assigned to one of two groups: the spinal manipulation group or the KT group. Neck pain was based on an 11-point numerical scale while disability was based on the neck disability index (NDI). Cervical ROM was collected at baseline and one week after the beginning of the study.

Recent studies have shown that cervical thrust manipulation has been effective in reducing neck pain in individuals with mechanical neck pain (Saavedra-Hernandez, et al., 2012). It was not until recently that KT has shown to provide similar results by reducing neck pain after being applied for a one-week period. Studies have shown that both cervical thrust manipulation and KT significantly reduce mechanical neck pain statistically (Saavedra-Hernandez, et al., 2012). It can be concluded that KT may have created tension in soft tissue structures that provide afferent stimuli, thus contributing to the gate control theory (Saavedra-Hernandez, et al., 2012).

Achilles Tendinosis

Acute and chronic Achilles injuries are often associated with athletes who participate in running, tennis, volleyball, soccer, basketball, and can even occur in the general population. Acute tendonitis can be characterized by swelling, local pain, and occasionally crepitus (Jung-hoon & Won-gyu, 2011). Most often treatment methods include rest, non-steroidal anti-inflammatory medication, heel lifts, and rehabilitation (Jung-hoon & Won-gyu, 2011). Tendinosis on the other hand is a chronic condition that often presents with minimal inflammation and can be painful to the touch. Tendon degeneration can be a result of tendinosis (Jung-hoon & Won-gyu, 2011). Repeated trauma and the inability to properly heal during the acute phase of an injury results in tendinosis. The healing process is usually halted by painful phases of chronic Achilles tendon injuries. During activities such as running and jumping, the Achilles tendon can be subjected to loads as high as 6-12 times a person's body weight (Jung-hoon & Won-gyu, 2011).

According to Jung-hoon & Won-gyu, (2011) the effect of KT is unknown, but it is hypothesized that the application of KT to the Achilles tendon and gastrocnemius and soleus muscles is to provide protection and support during functional activity. The elasticity of KT is considered to have an effect on pain by improving blood flow and lymphatic circulation while reducing pressure by lifting the skin (Jung-hoon & Won-gyu, 2011).  The excess pressure of the skin alerts the pain receptors beneath the skin and sends a discomfort signal to the brain through afferent pathways (Jung-hoon & Won-gyu, 2011). The tension of the KT may have also contributed to the gate control theory, as seen in the application of KT to the glenohumeral joint (Kaya et al., 2010) and patellofemoral joint (Chen et al., 2008).

Summary

Although KT has been used in the athletic arena for years, it has not been until recent years that the health science and rehabilitation professionals have begun to use this as a treatment modality to reduce pain based on the gate control theory. Throughout the review, studies have been presented in support of the KT application to reduce pain (Campolo et al., 2013; Jung-hoon & Won-gyu, 2011; Saavedra-Hernandez et al., 2012; Thelen et al., 2008), while other studies have not found significant pain relief with the use of KT application (Aytar et al., 2011; Merino-Marban et al., 2014). Other studies have found that KT application may have helped with postural or proper body positioning (Chen et al., 2008; Yin-Hsin et al., 2009), which may allow one to allude to the ability to decrease pain over time.  However, it appears to be evident that more research is needed in order to conclude that KT tape is an effective modality to reduce pain.

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