March 2015

Elastic therapeutic tape: The search for evidence

3tape-iStock26526780-1By Cary Groner

Athletes swear by it, but quality studies on elastic therapeutic tape are hard to come by, and the literature is littered with conflicting or inconclusive findings about the technique’s efficacy. That means practitioners in many cases have to rely on their own clinical experience.

Researchers, clinicians, and athletic trainers continue to disagree over the purported benefits of elastic therapeutic tape (ETT), sometimes known as kinesiology tape. Since its invention by Japanese chiropractor Kenzo Kase in the late 1970s, ETT has been touted, dismissed—and finally, more recently, studied.

Research results are all over the map, however, and few in the field seem to agree about what they signify. This hasn’t stopped ETT from spreading wildly through the ranks of sports professionals, who are always looking for an edge. Volleyball player Kerri Walsh wore it at the 2008 Beijing Olympics, David Beckham has worn it on the soccer field, Serena Williams sported it at Wimbledon, and the list goes on.1

Extravagant claims about ETT’s effects may partly explain athletes’ eagerness to embrace it. The tape does have unique properties, including water resistance and skin adhesion that may last for up to five days.2 But claims about physiological effects such as improved muscle function, pain control, and better circulation of the blood and lymph have proved difficult to substantiate.

Part of the problem is that it’s challenging to devise a way to conduct blinded studies of ETT, given that study participants will always know there’s something on their bodies.

“A lot of studies have not been of very good quality,” said Ed Le Cara, DC, PhD, ATC, who practices sports medicine in Dallas and is the director of transglobal education for RockTape, a maker of ETT based in Campbell, CA. “For example, if I want to see whether kinesiology tape has a clinically significant effect on pain, I have to create some kind of sham, put something else on the control group. But even if I use a different type of tape, I’m still affecting the system. You may see no difference between the kinesiology taping and the sham taping, though there was an overall reduction in pain in both groups.”

Doing research on elastic therapeutic tape is complicated by the inability to blind participants to treatment and the challenge of controlling their activities outside the lab

In fact, despite his commercial affiliation, even research Le Cara has conducted along with academic investigators has found that ETT may offer little advantage over other treatments for pain. In a meta-analysis published last year,3 he and his coauthors reported that ETT “may have limited potential to reduce pain in individuals with musculoskeletal injury; however…the reduction in pain may not be clinically meaningful.” They went on to note that ETT did not reduce specific pain measures any better than other modalities, and suggested that ETT be used either instead of or in conjunction with more traditional therapies pending further research.

Le Cara’s coauthor, Alicia Montalvo, PhD (ABD), ATC, an assistant professor in the athletic training program at Florida International University in Miami, agreed that there are methodological problems with existing research.

“It’s not an appropriate placebo model to use a different type of tape or a different taping technique,” she said. “There are too many factors influencing results, and you can’t tell fact from fiction.”

Montalvo admits that research into ETT is also complicated by the difficulty of controlling participants’ activities outside of the lab. In one protocol she’s used, people come in for baseline testing, then on day three have the tape applied and repeat the tests immediately. They then wear the tape for five days and return to the lab for final testing. The problem is that she can’t control what happens between sessions.

“In a perfect world, I’d lock these people up in the lab and not let them do any physical activity,” she joked. “But unfortunately, they go on with their lives—run marathons, lift weights, do whatever they do—and when they come back their knee pain is worse. Or on the other hand, maybe they sat on the couch watching movies all week, and they come back and they feel and perform great. It’s just completely random, and the results are all over the place.”

Elastic therapeutic taping application for distal iliotibial band syndrome. (Photos courtesy of RockTape UK.)

Elastic therapeutic taping application for distal iliotibial band syndrome. (Photos courtesy of RockTape UK.)

The research

A meta-analysis published in 2012 reported that there was little quality evidence to support the use of ETT over other forms of taping.4 Another, from 2013, concluded that it was no more effective than sham taping or usual care.5

Individual studies sometimes shed a little more light in specific areas, despite the methodological difficulties already noted. Researchers tend to examine ETT’s effects in three primary categories: pain, muscle strength and function, and proprioception. A sampling of recent studies helps explain why experts disagree about ETT’s efficacy.

In terms of pain, a 2013 study compared ETT and McConnell taping (a method that doesn’t use elastic tape) in 20 individuals with unilateral anterior knee pain and found both approaches effective for reducing pain during stair climbing activities, with no significant difference between them.6 In a 2014 paper, researchers were
unable to establish the clinical effectiveness of ETT for improving single-leg hop function in individuals with patellofemoral pain syndrome (PFPS).7 By contrast, another 2014 study reported that, in patients with knee osteoarthritis, ETT improved quadriceps torque and performance in a stair-climbing task, and reduced knee pain.8 More recently, a 2015 meta-analysis found that ETT was no better than more traditional treatments for pain and disability in individuals with chronic musculoskeletal pain.9

Studies of ETT’s effects on muscle strength and function have been similarly equivocal. For example, a 2012 paper found that—though it didn’t inhibit overall performance when used in basketball players with chronic inversion sprains—in certain tasks (eg, standing heel rise, vertical jump), ETT led to decreased performance, whereas in another (single-limb hurdle), performance improved.10 A 2013 randomized crossover trial reported that ETT didn’t improve jumping and balance performance in 20 healthy college athletes;11 another paper that year found no performance improvement in 18 young elite soccer players;12 yet another reported that ETT didn’t alter quadriceps neuromuscular performance in healthy individuals.13 By contrast, one study found that ETT was associated with a significant increase in gastrocnemius peak force immediately after application, and with a similar increase in hamstrings peak force two days later. (This delayed effect has been observed in other studies but isn’t clearly understood.) A 2014 study offered similar glimmers of hope, reporting that ETT shortened the time to peak torque generation during isometric knee extension, though it had no effects on other aspects of muscle performance.14 This year, though, the news got worse again: one 2015 paper reported no effect on jumping performance in healthy female athletes,15 and another found that ETT didn’t help individuals generate higher peak torque, earlier onset peak torque, or greater total muscle work.16

For proprioception, tidings have been a little better. For example, a 2014 study found that ETT had no overall effect on knee proprioception in 12 young women during a 30-minute uphill treadmill protocol, but did significantly enhance proprioception in those who demonstrated poor proprioceptive ability at baseline.17 Similarly, in 30 healthy individuals, ETT decreased the rate of knee repositioning errors associated with quadriceps fatigue.18 Finally, in a study of 28 participants, half of whom had functional ankle instability (FAI), ETT had no immediate effect but 72 hours after application those with FAI had proprioception equivalent to those with healthy ankles.19

Clinical experience

Clinicians may be forgiven for scratching their heads. The result, not surprisingly, is that they tend to trust their experience more than their reading of the literature.

“I’m skeptical that [placing] this tape on the skin could have direct mechanical effects on the subcutaneous tissues that are so free to move relative to the skin,” said Michael Gross, PT, PhD, a professor of physical therapy at the University of North Carolina at Chapel Hill. “[Although] there may be some effect on the neuromuscular system as the tape tugs on the skin and supplies afferent input into the system.”

Gross uses ETT in patients with kyphotic posture requiring correction; vertical strips on the back provide a gentle tug that reminds them to stand up straight.

According to Jonathan Chang, MD, a clinical associate professor of orthopedics at the University of Southern California in Los Angeles, the tape may offer some proprioceptive effects but few mechanical ones. That’s not to dismiss its value, he added.

“Proprioceptive effects can make a big difference to athletes in sports where the difference between ranking number one and ranking number one hundred is razor thin,” Chang said.

In regard to findings noted above, that injured or otherwise inhibited individuals seem to benefit more from ETT than healthy ones,17 Chang speculated that it may be a matter of degree.

“Something like this may have more effect on someone who has a deficit because of injury or decreased ability, versus someone at the top of their game,” he said. “My patients are injured, of course, and they find that using the tape can sometimes enhance recovery, allowing them to do certain things sooner or better than the usual timetable would suggest.”

Chang noted further that proper training in how to use the tape is critical.

“If you have someone with residual weakness after surgery, the tape can help them not only in proprioception, but can aid in the efficiency of using muscles in rehabilitation. If you put the tape in the wrong place, you may inhibit that,” he said.

Ed Le Cara agreed that mechanical effects may be limited.

“We think it’s more neurological,” he said. “Your body senses something there, which causes the brain to respond with awareness. That improves proprioception.”

Le Cara believes that studies showing increased effects in tired individuals18 may offer important insights into ETT’s best uses.

“When you see effects in people who are fatigued, it’s important to consider when injuries happen,” he said. “In soccer, for example, people tend to get injured most near the end of the halves, when they’re tired. So the idea is that if we use tape in someone who is eventually going to get fatigued—say, a triathlete, a soccer player, or a marathon runner—it may not help in the beginning of the event. But if it brings more awareness and neurosensory control later on, when those athletes are tired, maybe they’ll be less likely to roll their ankles, because they’re not allowing their joints to fall into improper positions. It’s not conclusive; we need more research. But that’s what it looks like.”

This emphasis on proper positioning applies to efficiency as well as injury avoidance, Le Cara noted.

“When we use kinesiology tape with CrossFit athletes, it’s not necessarily to make the muscle contract harder or use more force,” he said. “You want to put them in a position that allows their joints and muscles to work ideally. It’s a matter of asking the right question: What are we going to do for performance? You’re not going to take a weightlifter from four hundred and fifty pounds to five hundred by using tape. But you can put him in a position so that his muscles are at increased advantage.”

Le Cara told LER that he uses ETT in nine of 10 patients he sees. A typical case would be someone with plantar fasciitis, whom Le Cara would treat with a soft-tissue technique such as myofascial release, then apply tape.

“When we treat the tissue or the joint, it creates a physiological window of improved range of motion,” he said. “Once I’ve mobilized the ankle, I want the brain to remember what it’s like to have this improved range of motion, so it will accept that range as safe; otherwise it will start tightening up again. So I use the tape as an adjunct, not as a stand-alone treatment.”

Le Cara said he’s had particular success using ETT on the bottom of the foot, with calf strains, with Achilles tendinitis, and with mediotibial stress syndrome (MTTS, or shin splints).

“If I can make the brain more aware of the area by using tape, that may also help to get more muscle fibers to contract,” he said. “Then, instead of all the force going along, say, ten fibers, maybe it’s getting disseminated across twelve or fifteen, and hopefully healing can occur without overloading the system.”

Le Cara doesn’t discount the possibility of a placebo effect, but he also emphasizes that such an effect can be helpful in itself.

“If they see the tape on their skin and it reminds them to do the things I’ve asked them to do, or to avoid certain things, then that’s beneficial,” he said.

“The placebo effect is real,” agreed Alicia Montalvo. “The patient’s expectations can mean the difference between a nonsignificant decrease in pain versus a significant decrease.”

Montalvo thinks this type of placebo effect may partly explain why ETT seems to work better in injured or lower-functioning athletes.

“You don’t expect to see pain reduction in someone who does not have pain,” she said. “But you do expect to see it in someone who does. That reduction may come from somebody caring for them, touching them, or applying an intervention that they expect to help. It’s also possible that we see benefits in people who are injured because the tape is actually doing something; we just don’t know what it is.”

Montalvo uses ETT on her husband and on her friends, and said they love it.

“It seems to provide enough feedback, enough stimulation, for them to not think about that pain,” she said.

She’s also using the tape in a way similar to that described above by Michael Gross, to cue patients when their bodies or joints are out of position.

“I’m experimenting with both verbal and tactile cuing for knee valgus, so when patients have that valgus collapse they feel the tape pulling and remember to get their knees out,” Montalvo said.

Similarly, she said, those with patellofemoral pain frequently report that after a few days of wearing the tape they’re more aware of the position of their knees.

Mechanical effects?

A few researchers have concluded that ETT’s efficacy may lie more in its influence on mechanics, however.

According to Alan Needle, PhD, ATC, the tape can, in fact, have such effects—but surprisingly little impact on balance or proprioception. Needle is an assistant professor in the Department of Health and Exercise Science, and director of the Injury Neuromechanics Laboratory, at Appalachian State University in Boone, NC, where he and his colleagues have researched ETT’s properties.

“We’ve looked at various measures in different studies,” he said. “We’ve looked at ankle stiffness, dynamic and static balance, muscle activation, and plantar forces. When we look at proprioception and balance measures, we’re really not seeing much effect.”

For example, in a 2013 paper,20 the researchers tested 30 healthy female volunteers for passive ankle laxity and stiffness, and time to stabilization after a multidirectional hop, before and after taping. They reported that ETT appears to improve static restraint in the ankle joint without altering peak motion or dynamic postural control. Another of their studies from that year did not support the use of ETT for improving postural control deficits in individuals with ankle instability.21

Studies of muscle activity and loading told a different story, however. In the former case, the researchers studied 22 healthy adults with no history of ankle injury and found that ETT decreased muscle activity in the ankle during a drop jump, even though no changes in ground reaction forces were observed.22

“It didn’t change peak laxity, and it didn’t change how far they moved; it just changed how the ankle absorbed forces,” Needle said. “We decreased the amount of muscle activity needed to maintain the same biomechanics, and as far as I’m concerned that’s mechanical support.”

In another study, they found that the tape decreased the rate of medial loading in 200 MTTS patients.23

“We used a strip to support the tibialis posterior,” he said. “The band goes down the inside of the shin, then passes anterior and posterior to the medial malleolus and goes under the arch of the foot. This provides extra support along the medial ankle to help slow pronation speed—and pronation causes MTTS. You’ve got the same amount of motion, but it slows you down.”

Needle said runners might use the taping when increasing their mileage, for example, to prevent shin problems, particularly if they have a history of MTTS.

“I know there are studies17,18 that show there is no effect on healthy people, while there is an effect on the injured,” he added. “I think that reflects the fact that injured people have abnormal biomechanics, and we’re correcting those.”

Needle considers ETT a preventive tool at the ankle, as well.

“We can use the mechanical properties of the tape to get people in a more dorsiflexed and/or everted position so they’re making ground contact in the right position,” he said. “The idea is to position them correctly rather than stop motion.”

Needle said he wears ETT when he runs for just this reason, and has found that he’s much less likely to roll over his ankle as a result.

“It gives me that sensation, but it’s not like I’m restricted and can’t move my ankle,” he said. “It just nudges me in the right direction to not injure myself. I wouldn’t recommend this for a basketball player with a history of severe recurrent ankle sprains. But to give mild support to somebody who is generally stable, I think it’s very useful.”

When it was pointed out to Needle that what he described actually sounded more like a proprioceptive effect than a mechanical one, he paused.

“I shy away from calling it that based on the evidence, but I’ll admit that it does feel like a proprioceptive effect,” he acknowledged. “But if, by definition, proprioception is increasing the sensation from the ankle joint, the evidence isn’t there that it’s doing that. I’d argue that it’s actually putting me in a more stable position, without the restriction associated with something like white tape. A mechanical effect is only applicable if you’re crossing a joint, though. If the tape is just running along a single segment of the body such as the shin, we’re probably not changing biomechanics, so any change we see is more likely proprioceptive.”

Going forward

Further research will presumably continue to shed light on the ways in which ETT affects the body. In the meantime, as clinicians continue to refine their experience and techniques, one thing seems certain: As long as athletes perceive that the tape offers them an advantage, they’ll be wearing those brightly colored stripes like a herd of neon zebras.

Cary Groner is a freelance writer based in the San Francisco Bay Area.

REFERENCES
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