What Is Known
- Elastic taping has significant effects on pain, physical functions, and range of motion in patients with knee osteoarthritis.
What Is New
- There are significant effects of elastic taping on quadriceps muscle strength. The current evidence is insufficient to draw conclusions on the effects of elastic taping combined with other physiotherapy for knee osteoarthritis. Elastic taping can be a part of the treatment programs for knee osteoarthritis.
Osteoarthritis (OA), a leading cause of disability and pain, is the most common chronic degenerative joint disorder in the worldwide. It is characterized by the articular cartilage degradation, dysregulated subchondral trabecular bone remodeling, and synovitis, which causes joint pain, stiffness, restricted movement, functional failure, and loss of daily living activities.1–3 Aging and obesity will significantly increase the occurrence of OA-related physical, psychological, and socioeconomic burden.4,5 A total of 9.6% of men and 18.0% of women 60 yrs or older have symptomatic OA.6 The World Health Organization forecasted that OA will become the fourth primary cause of disability by 2020.7 The Osteoarthritis Research Society International and American College of Rheumatology recommendations for for knee osteoarthritis (KOA) include physical therapy (exercise programs, self-management, aerobic exercises, weight loss, etc.), pharmacological, and surgical treatment.8,9 Currently, the treatments for KOA are used to alleviate pain, improve physical function (knee-related health status), and minimize or slow the progression of disease.
Kinesio taping (KT) is the most common elastic taping, which applies appropriate tension along the tape and places the target muscle in a stretched position.10 As a specific methodology of elastic taping, Kinesio Tex Tape presents unique qualities (elasticity, adherence, mechanical, texture, and recoil). This may promote an increase of the somatosensory stimulation and consequently improve mechanoreceptors and proprioceptive input. Then, Kinesio Tex Tape also responses to inhibition, activation, and muscle facilitation of muscle.11–16 Kinesio taping has been applied in clinical practice, but the treatment rationale for KOA is unclear so far.
Some previous studies reported that KT can increase lymphatic and vascular flow, reduce pain through stimulating sensory nerve endings of the skin, and improve possible articular mal-alignments, range of motion (ROM), and muscle function.17,18 Elastic taping is widely applied to reduce pain, swelling, and inflammation pain, provide mechanical support, improve ROM and gait pattern, and enhance the functional outcomes of patients.19,20 Pain was considered to be a limiting factor for physical function, ROM, and strength, and a pain–weakness–pain vicious circle would be formed in the progression of KOA.21
Elastic taping is popularly used for various musculoskeletal conditions. Previous meta-analyses indicated that significant improvements were found in self-reported pain during activity, knee-related health status, and proprioceptive sensibility in KT group compared with the placebo group (sham taping or no taping).10,22 However, none of them have compared the effects of elastic taping alone and elastic taping combined with other physiotherapy in patients with knee OA. In many studies, elastic taping was in conjunction with other physiotherapy programs for KOA. No high-quality evidence was observed to support the effects of elastic taping combined with other physiotherapy on pain, physical function, ROM, as well as quadriceps and hamstring muscle strength. To address discrepancies between baseline and posttreatment, we set out to conduct a meta-analysis to observe the elastic taping or elastic taping with other physiotherapy for KOA.
Search Methods for Identification of Studies
In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (see Supplemental Checklist, Supplemental Digital Content 1, http://links.lww.com/PHM/A926), we identified relevant studies by searching electronic the following nine databases: PubMed, the Cochrane Central Register of Controlled Trials, Web of Science, Physiotherapy Evidence Database (PEDro), Scopus, EMBASE, OVID, CNKI, and WANFANG. The key words and search strategy include the following: (Taping or Elastic Taping or Kinesio Taping) AND (osteoarthritis OR osteoarthrosis OR osteoarthroses OR osteoarthritides OR degenerative arthritis) AND knee. All analyses were performed based on previous published studies; thus, no ethical approval or patient consent was required.
Criteria For Considering Studies For This Review
Types of Studies
Randomized controlled trials (RCTs) were included to investigate elastic taping or elastic taping combined with other physiotherapy versus placebo for patients with knee OA.
Types of Participants
The participants included in our study were diagnosed by the American College of Rheumatology criteria23: knee pain and radiographic osteophytes and at least one of the following three items including older than 50 yrs, morning stiffness of 30 mins or less in duration, and crepitus on motion or Kellgren and Lawrence criteria: no osteoarthritis (grade 0: no osteoarthritis), doubtful narrowing of joint space and possible osteophytic lipping (grade 1: doubtful); definite osteophytes and possible narrowing of joint space (grade 2: mild); multiple osteophytes, definite narrowing of joint space, and some sclerosis and possible deformity of bone ends (grade 3: moderate); and large osteophyte, marked narrowing of joint space, severe sclerosis, and definite deformity of bone ends (grade 4: severe) of knee osteoarthritis.
Types of Interventions
We included studies using elastic taping, compared with sham taping (eg, tape placed across the surface without tension) or no taping. Taping could be the only intervention or combined with other physiotherapy.
Types of Outcome Measures
The primary outcomes were pain during activities (eg, visual analog scale [VAS], the Numerical Pain Rating Scale, and the Western Ontario and McMaster (WOMAC) pain), physical function (eg, the WOMAC and Timed Up and Go Test [TUG]). The secondary outcomes were ROM (measured by goniometer) and muscle strength (measured by dynamometer). If multiple optional scales were used in a single study, the most representative scale was included in the analysis. For example, the WOMAC and TUG were concurrently measured for physical function in one study, and we will select the WOMAC.
According to the type of intervention, we undertook the following subgroup analyses: elastic taping alone versus elastic taping combined with other physiotherapy as well as elastic taping versus sham taping and elastic taping versus no taping in the primary outcomes. We excluded the poor-quality studies (PEDro score <6, see quality assessment).
Data Collection and Analysis Selection
Selection of Studies
Two reviewers identified eligible studies based on potentially relevant titles and extracted data independently. Then, titles and abstracts were screened to select relevant articles by two reviewers. To identify their eligibility, the full texts of the remaining articles were read in detail. We contacted authors for additional information if any study has incomplete data. In addition, reference lists of the included studies were manually screened.
Assessment of Risk of Bias in Included Studies
The PEDro tool was used to evaluate the methodological quality,24 which is based on the Delphi List criteria.25 It is considered valid and reliable.24,26 The PEDro tool consists of 11 items, item 1 refers to external validity and is not included in the total PEDro score, each receiving either a yes or no.27 Higher PEDro scores represent superior methodological quality (9–10 = excellent, 6–8 = good, 4–5 = fair, and <4 = poor).28 This process was carried out by two reviewers independently. The disagreements between them were resolved by discussion and by third reviewer, if needed.
Two reviewers extract data independently; the following data were included: (a) first author, (b) year of publication, (c) characteristics of participants (ie, age, sex, sample size, and duration of complaint), (d) the type of intervention, and (e) outcome measures (primary outcome and second outcome). The extracted data were input into a standardized Excel file and checked by a third reviewer. Any disagreements were resolved by discussions.
All data analyses were conducted using RevMan5.3. For continuous outcomes, the total effect size was calculated by the mean difference (MD)29 and 95% confidence intervals (CIs) derived from the mean and standard deviation (SD) after treatment. If studies used different methods or scales to measure the same outcome, we calculated standardized MD (SMD) instead. Heterogeneity was examined using I2 statistic.29 A random effects model was applied if severe heterogeneity was observed (P < 0.05 and I2 > 50%). Otherwise, a fixed-effects model was chose.30 When I2 > 50%, we analyzed the potential source of heterogeneity by sensitivity analysis, omitting one study in each turn. Statistical significance was defined as P < 0.05.
The initial search included a total of 936 articles. After screening the titles and abstracts, 526 were excluded for duplicate studies and 344 were excluded for some reasons (eg, nonrandomized studies and/or not relevant outcomes) (Fig. 1). We identified 66 potentially relevant articles, whereas 39 studies were excluded because they were not RCT. Subsequently, we excluded nine studies because they did not study the KOA. Four studies were excluded because of irrelevant outcomes; three studies were excluded because of PEDro scores of less than 6. Consequently, 11 studies were selected in our study.
Description of Studies
The descriptive data of the included studies were presented in Table 1. The 11 studies were published between 2014 and 2018 and involved 490 participants with KOA. The elastic taping compared with placebo in the included studies. The elastic taping combined with other physiotherapy was prescribed in six trials. The “Y” or “I” taping was applied in quadriceps or hamstring.
The PEDro scores were presented in Table 2. The scores of the included studies ranged from 6 to 8 and can be accepted. A total of 11 studies found did not blind the therapists. Six studies found did not blind the subjects. Three studies found did not blind the assessors. Three studies found have unclear risk of concealment of allocation. Seven studies found did not perform an intention-to-treat analysis. The methodological quality of the included studies was good.
Quantitative Analysis of Effects
The self-reported pain was measured by VAS and numeric pain rating scale in the 10 studies (451 patients).18,20,31–33,35–39 We found that four studies reported elastic taping alone compared with placebo.20,32,37,38 The elastic taping improved self-reported pain relief (SMD = −0.76, 95% CI = −1.39 to −0.13, P = 0.02, P for heterogeneity = 0.0004, I2 = 78%, Fig. 2). Six studies reported that elastic taping combined with other physiotherapy compared with other physiotherapy.18,31,33,35,36,39 Improvements in self-reported pain relief were observed in patients (SMD = −0.78, 95% CI = −1.07 to −0.50, P < 0.00001, P for heterogeneity = 0.31, I2 = 16%, Fig. 2). However, high heterogeneity was observed in the subgroup analysis of elastic taping alone for pain. Sensitivity analysis was conducted that the aggregated result was the same except the Anandkumar et al.38 with low heterogeneity (SMD = −0.43, 95% CI = −0.74 to −0.13, P = 0.006). The random effects model was chosen. The elastic taping group combined with other physiotherapy was found to be superior to elastic taping alone on pain.
The physical function was measured by the WOMAC and TUG in the nine studies (399 patients).18,20,31,32,34–37,39 Four studies reported elastic taping alone compared with placebo.20,32,34,37 Improvements in physical function were observed in patients (SMD = −0.39, 95% CI = −0.67 to −0.12, P = 0.005, P for heterogeneity = 0.36, I2 = 7%, Fig. 3). Five studies reported that elastic taping combined with other physiotherapy compared with other physiotherapy.18,31,35,36,39 The elastic taping combined with other physiotherapy improved physical function (SMD = −0.73, 95% CI = −1.03 to −0.43, P < 0.0000, P for heterogeneity = 0.18, I2 = 37%, Fig. 3). The fixed effects model was chosen. The elastic taping group combined with other physiotherapy was found to be superior to elastic taping alone on physical function.
Range of Motion
The ROM was measured by goniometer in the three studies (180 patients).20,32,33 The assessment was pain free. Improvement in ROM with low heterogeneity (MD = 2.04, 95% CI = 0.14 to 3.94, P = 0.04, P for heterogeneity = 0.20, I2 = 39%, Fig. 4) was observed. The fixed effects model was chosen. The elastic taping can increase ROM in patients with KOA.
The quadriceps and hamstring muscle strength were measured by dynamometer in the five studies (249 patients).20,32–34,36 Significant difference between elastic taping and placebo was observed in quadriceps muscle strength with low heterogeneity (MD = 2.42, 95% CI = 1.09 to 3.74, P = 0.0004, P for heterogeneity = 0.70, I2 = 0%, Fig. 4). However, no significant difference was observed in hamstring muscle strength (MD = 0.12, 95% CI = −1.30 to 1.54, P = 0.87, P for heterogeneity = 0.58, I2 = 0%, Fig. 4). The fixed effects model was chosen. The elastic taping was beneficial for increasing quadriceps muscle strength, but not for the hamstring.
The subgroup analysis of elastic taping versus sham taping and elastic taping versus no taping showed that elastic taping improved pain (SMD = −0.72, 95% CI = −1.22 to −0.23, P = 0.004) and physical function (SMD = −0.82, 95% CI = −1.16 to −0.47, P < 0.00001) comparing sham taping. Compared with no taping, elastic taping improved pain (SMD = −0.43, 95% CI = −0.69 to −0.18, P = 0.0009) and physical function (SMD = −0.63, 95% CI = −0.97 to −0.30, P = 0.0002). Furthermore, no significant discovery was identified in subgroup analyses (Supplementary Files 1 and 2, Supplemental Digital Content 2 and 3, http://links.lww.com/PHM/A927, http://links.lww.com/PHM/A928).
Eleven trials, including 490 patients with KOA, were included. We observed that both elastic taping alone and elastic taping combined with other physiotherapy could improve pain and physical function in people with KOA. There are observed evidence that elastic taping may ameliorate ROM and quadriceps muscle strength. In addition, there are no observed associations between elastic taping and the hamstring muscle strength. The methodological quality of the included studies was good. The heterogeneity was low in our included studies.
In this study, subgroup analyses suggested that elastic taping with other physiotherapy was found to be superior to elastic taping alone. The previous studies reported that elastic taping increased the action of fast afferent fibers when applied to a painful area and then in turn inhibited the transmission of pain perception to the brain. Consequently, elastic taping increased the pressure pain threshold and reduced pain.40 Because of the presence of tension, elastic taping may provide the proper sensory feedback and mechanical receptors stimulated the skin engagement to control pain in patients with KOA.20,41 Thus, elastic taping methods reduced stress in the knee joints and alleviated symptoms due to pathological changes to be effective in improving pain and dysfunction.35
Delayed motor unit recruitment and firing rates of the quadriceps have been reported in patients with KOA, resulting in the reduction muscle force-generating capacity.42 This may have a negative influence on muscle strength. According to the cutaneous fusimotor reflex theory, the muscles contracted through gamma motor reflexes when the skin is subjected to various stimulation.38 A previous RCT study reported that tension of elastic taping enhanced muscle performance of quadriceps and aided joint movement by adding neural feedback in KOA patients.43 However, our results regarding to quadriceps muscle strength were different from previous meta-analyses.10,22 In our study, compared with placebo, elastic taping improved quadriceps muscle strength but did not affect hamstring muscle strength. The main reason may be that elastic taping has been applied to the quadriceps more than hamstring in some studies. It suggests that further large and high-quality studies are needed for observing the effectiveness of elastic taping on muscle strength.
The patients with KOA may experience joint stiffness, which could result in declining ROM. Our study showed that elastic taping can improve ROM in patients with KOA. Because of effects of convolution and lifting, elastic taping broadened the space between the muscle and the skin and then increased the blood volume, blood, and lymph flow in this area. These circulatory changes may enhance muscle function and active ROM.44,45 Physical function may be affected by pain, ROM, and muscle strength. Elastic taping regulated the homeostasis of muscles, reduced pain and stiffness, and enhanced ROM when attached to the muscles around the knee joint. Thereby, elastic taping prevented aggravation of the muscle tonus state and improved knee joint function. Our study had confirmed that elastic taping may be an effective intervention for improving the physical function in patients with KOA.
In this meta-analysis, we reviewed the evidence from RCT and observed the effects of elastic taping and elastic taping combined with other physiotherapy on knee OA. There are various brands of elastic taping reported in previous studies. Many of them demonstrated that elastic taping for KOA used KT rather than other brands.
There are several limitations in our study. First, our included studies did not perform rigidly blinding for therapists because of the characteristics of elastic taping. Furthermore, the quality of included studies was good, although the methodological defects in some studies may reduce the power of the evidence in this study. Second, the details of elastic taping (eg, detailed time and methods) were absent in some included studies. This limited the ability to study the true value of elastic taping and may underestimate its benefits. Third, some included studies aimed at studying the short-term effects of elastic taping. Considering that the treatment duration may affect the effects of elastic taping, the long-term effects of elastic taping need to be studied in the future.
Elastic taping has significant effects on pain, physical function, ROM, and quadriceps muscle strength in patients with knee osteoarthritis. The current evidence is insufficient to draw conclusions on the effects of elastic taping combined with other physiotherapy for KOA. Despite some new findings, long-term effects are unstudied and unknown. Further studies are needed to involve large, well-designed, and multicenter randomized controlled trials that investigate the long-term effects of elastic taping with another physiotherapy compared with elastic taping alone for KOA.
- Elastic taping has significant immediate effects on pain, physical functions, ROM, and quadriceps muscle strength, but not on hamstring in patients with KOA.
- The currently available evidence is insufficient to draw conclusions on the effects of elastic taping combined with other physiotherapy for KOA. Elastic taping can be a part of the treatment programs for KOA.
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