Clinical outcomes of kinesio taping applied in patients with knee osteoarthritis: A randomized controlled trial

Abstract

INTRODUCTION:

The aim of this study was to compare kinesio taping along with conventional treatment to conventional treatment alone and to report the results of both a single and repetitive kinesio taping application applied on quadriceps femoris and hamstring muscles on pain, range of motion, muscle strength, and functional status in patients with knee osteoarthritis.

METHODS:

Fifty-four patients with knee osteoarthritis were randomly allocated to two groups. A total of 28 patients were included in kinesio taping group, others were included in the control group. Before and after intervention, pain was measured with visual analog scale, range of motion was measured with universal goniometer, muscle strength was measured with dynamometer, and functional status was measured with Knee Injury Osteoarthritis Outcome Score.

RESULTS:

There were statistically significant improvements in measures of pain, range of motion, quadriceps muscle strength and functional status between pre- and post-treatment in both groups ( $p<$ 0.05). In comparison, there were no significant differences with these parameters between groups ( $p>$ 0.05).

It was also found that significant difference was observed in terms of range of motion, pain, functional status between pre-treatment and post-taping in intervention group ( $p<$ 0.017).

CONCLUSION:

In conclusion, we could report that kinesio taping has significant immediate effects after a single kinesio taping application on range of motion, pain and functional status in patients with knee osteoarthritis. We could also report that KT in addition to conventional treatment is not superior to conventional treatment alone in terms of clinical outcomes over 3 weeks later.

Keywords

Kinesio taping osteoarthritis physiotherapy

1. Introduction

Osteoarthritis (OA) is considered to be the most common rheumatologic disease which affects more than 80% of the population above 55 years [1, 2]. OA occurs most commonly in the hip and knee [3]. Knee osteoarthritis causes functional restriction in the activities of the lower extremities that results in dependence for activities such as walking, going up and down stairs, and causes significant economic loss in the society [4]. Knee OA treatment aims to increase quality of life, prevent disability, improve physical functions, and reduce pain [5]. Therapeutic exercises, manipulative treatment applications that have increased recently and treatments other than medicine and surgery are recommended for the patients with knee OA as primary care [6]. In addition, the American College of Rheumatology has suggested taping in patients with knee OA [7]. Taping method which is recommended by clinic guidelines [8] may be an alternative therapy for patients with knee OA. It has been shown that elastic tape, introduced by Kinesio Tape (KT) in 1980, could increase regional circulation, reduce edema [9], control joint stability, help fix postural array and enable the relaxation of muscles, when it is used correctly [10]. Furthermore, KT, which is widely used in the injury and protection of the musculoskeletal system, has become one of the rehabilitation modalities [11].

In the literature, there are a number of evidence-based studies about taping approach, which is recommended by the American College of Rheumatology for patients with knee OA [7]. Although there are numerous of published articles studied about KT, the effect of KT is still controversial. However, some of these studies were performed in patients with knee OA to manage OA-related pain and symptoms or in healthy people to answer the question whether outcomes could be changed or not by KT [12, 13]. In some others, KT was generally applied to not all of knee muscles, to only one muscle, especially quadriceps femoris to investigate the outcomes [12, 14]. Remaining research investigated the effects of a single or repetitive KT application in different population. Although, literature includes in hundreds of studies examined about different types of tape and their associated application methods, these studies have reported diverse results [15, 16]. However, no previous study investigating both a single and repetitive KT application was reported. Thus, a study to demonstrate the effects of KT applied in different times on knee muscles is needed for a clear characterization of the effects of this intervention.

The aim of this study was to compare KT along with classic treatment to classic treatment alone and to report the results of both a single and repetitive KT application applied on quadriceps femoris and hamstring muscles on pain, range of motion (ROM), muscle strength, and functional status in patients with knee OA. We hypothesized that patients who received KT, along with classic treatment over 3 weeks, would have better ROM, muscle strength, functional status and less pain, versus the patients who received classic treatment alone. Our second hypothesis was that these clinical outcomes would have better results after a single KT application.

Figure 1.

Flow chart of the study protocol and exclusion diagram for the patients.

2. Materials and methods

2.1 Subjects

A total of 94 patients who applied to the Private Meditepe and Kardelen Medical Centers for treatment between 2012 and 2013 were screened. Twenty-four patients were not eligible for the study, other 70 patients were included in the study who were all diagnosed with unilateral knee osteoarthritis according to the American College of Rheumatology and were stage 2 and 3 based on the Kellgren-Lawrence criteria. Sixteen out of 70 patients included in the study were excluded from the evaluation since they could not complete the study due to other reasons (Fig. 1).

The participants with the following conditions were excluded from the study: participants who underwent knee joint operation, pregnancy or mental problems preventing them from doing exercise; participants with infection in the areas close to the knee joint, metal implant, or allergy to KT (Fig. 1).

2.2 Randomization

The study was planned as a randomized controlled study and the ethical approval was obtained from Marmara University Faculty of Medicine Clinic Researches Ethical Board (Protocol No: 09.2012.0029).

A simple randomization was used to allocate the patients into either control or intervention group. All patients were randomized into two groups via closed-envelop technique (sealed-envelope randomization). After the randomization, a total of 28 patients were included in intervention group and others were included in control group. All patients were previously informed about the study and a signed ‘Informed Patient Consent Form’ were obtained.

2.3 Outcome measures

After recording the patients’ demographic information, the following measurements were measured: pain level was measured with the visual analog scale [17], range of motion was measured with the universal goniometer [18], muscle strength was measured with digital muscle strength dynamometer (J-TECH Power Track II Commander) [19], and functional status was measured with Knee Injury and Osteoarthritis Outcome Score (KOOS) [20].

The assessments were performed three times in the intervention group; before the treatment, approximately 1 hour later after taping in first session, and three weeks later. On the other hand, all assessments were performed twice in the control group; before and after the treatment.

2.4 Classic treatment

A conventional treatment which includes electro-physical agents was performed. Hot-pack (HP) was applied for 20 minutes. Ultrasound (US) was applied for 5 minutes by using a 1.5 watt/cm ${}^{2}$ treatment dosage with a 1 MHz ultrasound head, and conventional TENS was applied for 20 minutes to the patients included in both control and intervention group.

Supervised exercises consisted of stretching hamstring and quadriceps muscles and isometric and isotonic exercises for quadriceps, hip adductors, gluteus medius and maximus, open chain exercises like straight leg raise and leg raise with internal and external rotation and closed chain exercises like mini squat. All exercises were repeated with 10 times and were done only one time by patients. A session was taken about one hour.

The treatment program started after the first assessment and was applied as 15 sessions for a total of three weeks, five sessions per week.

Figure 2.

The taping method and the subject’s posture when applying kinesio taping.

2.5 Taping procedure

KT on quadriceps and hamstring muscles was performed with Y-shaped technique.

All subjects were taped according to the KT guidelines by the same physiotherapist. Before KT application, the skin was cleaned with alcohol to make it adhesive. The subjects lay in the supine position with the hip flexed at 30 ${}^{\circ}$ and the knee flexed at 60 ${}^{\circ}$ . In the supine position, taping was first applied to the quadriceps femoris. The tape was applied from a point 10 cm inferior to the anterior superior iliac spine, bisected at the junction between quadriceps femoris tendon and the patella, and circled around the patella, ending at its inferior side. The first 5 cm of the tape were not stretched. The portion between the first part of tape and superior patella was stretched to 50–70%. The remaining tape around the patella remained un-stretched. After that, in the prone position, hamstring was taped secondly with the same method (Fig. 2). The subjects were instructed to take the tape off before the subsequent application. The tape was renewed daily for six weeks [21].

2.6 Sample size determination analysis

Sample size was calculated using Epi Info 7 software. The power and levels were set to 0.80 and 0.05, respectively, and effect size was set to 0.8. A priori analysis for the required sample size indicated that at least 25 subjects would be needed in each group. Thus, 26 and 28 subjects were participated in groups.

2.7 Statistical analysis

For the data analysis, SPSS version 11.5 (SPSS Inc., Chicago, IL, USA) statistics program was used. For all analyses, statistical significance was determined as $p<$ 0.05. Non-parametric tests were used due to the heterogeneity in the distribution of the data.

For pre-treatment and post-treatment comparison of patients in the control group, the “Wilcoxon signed rank” test was used. For repetitive measurements of the intervention group, The “Friedman test” was used. After the Friedman test, for the dual comparison of parameters evaluated as significant, the “Wilcoxon signed rank” test was used for making comparisons and the “Bonferonni correction” was used ( $p<$ 0.017). The difference of patients in both groups in terms of post-treatment values between groups was compared with the “Mann-whitney u” test.

Table 1
Comparison of demographic features of the groups

	Control group	Intervention group	${p}$
	(Mean $\pm$ SD)	(Mean $\pm$ SD)
Age (year)	51.19 $\pm$ 8.94	52.53 $\pm$ 9.68	0.600
Body weight (kg)	80.53 $\pm$ 14.16	80.78 $\pm$ 13.11	0.611
Height (cm)	160.07 $\pm$ 7.86	161.10 $\pm$ 6.92	0.613
Body mass index	31.52 $\pm$ 5.70	31.18 $\pm$ 5.14	0.815
(kg/m ${}^{2}$ )

SD: Standard deviation.

Table 2

Comparison of pre-treatment, taping and post-treatment measurement values of the groups

	Control group				Intervention group
	Pre-treatment	Post-treatment	$p_{1}$	Pre-treatment	Post-taping	Post-treatment	$p_{1}$	$p_{2}$
	(Mean $\pm$ SD)	(Mean $\pm$ SD)		(Mean $\pm$ SD)	(Mean $\pm$ SD)	(Mean $\pm$ SD)
Flexion ROM	107.11 $\pm$ 13.72	117.11 $\pm$ 16.07	0.001*	99.46 $\pm$ 16.74	102.85 $\pm$ 16.74	112.5 $\pm$ 14.04	0.001*	0.162
Quadriceps M.S.	59.50 $\pm$ 9.37	62.21 $\pm$ 9.31	0.004*	53.42 $\pm$ 7.85	54.1 $\pm$ 7.56	56.18 $\pm$ 7.21	0.001*	–
Hamstring M.S.	55.34 $\pm$ 9.56	57.88 $\pm$ 9.99	0.019*	50.84 $\pm$ 8.65	50.81 $\pm$ 8.67	52.51 $\pm$ 8.8	0.097	0.065
Pain	4.87 $\pm$ 1.49	2.76 $\pm$ 1.76	0.001*	4.38 $\pm$ 1.48	3.85 $\pm$ 1.57	3.37 $\pm$ 1.59	0.002*	0.070
KOOS symptom	71.61 $\pm$ 11.18	82.23 $\pm$ 11.92	0.001*	70.10 $\pm$ 13.52	71.14 $\pm$ 12.9	79.32 $\pm$ 14.18	0.026*	0.486
KOOS pain	63.53 $\pm$ 8.50	74.57 $\pm$ 10.89	0.001*	64.67 $\pm$ 11.08	67.17 $\pm$ 11.14	73.21 $\pm$ 10.43	0.001*	0.486
KOOS ADL	71.65 $\pm$ 6.77	78.38 $\pm$ 8.36	0.001*	72.92 $\pm$ 7.22	75.32 $\pm$ 7.07	78.78 $\pm$ 7.5	0.001*	0.748
KOOS sports & recreation	35 $\pm$ 10	44.03 $\pm$ 15.03	0.007*	31.96 $\pm$ 11.24	36.96 $\pm$ 9.55	40.89 $\pm$ 12.09	0.001*	0.276
KOOS QoL	47.96 $\pm$ 15.66	61.30 $\pm$ 13.80	0.002*	47.96 $\pm$ 13.90	53.46 $\pm$ 11.46	59.53 $\pm$ 13.81	0.001*	0.531

$p_{1}$ : Comparison of intragroup post-treatment values with pre-treatment values; $p_{2}$ : Comparison of post-treatment values between the groups; M.S.: Muscle strength; ROM: Range of motion; ADL: Activities of Daily Life; QoL: Quality of Life; SD: Standard deviation.

Table 3

In-group comparison of the patients in the intervention group

	Flexion	Quadriceps	Pain	KOOS	KOOS	KOOS	KOOS sports	KOOS
	ROM	M.S.		symptom	pain	ADL	& recreation	QoL
Pre-Treatment – Post-Taping	0.002*	0.021	0.001*	0.039	0.003*	0.005*	0.003*	0.008*
Pre-Treatment – Post-Treatment	0.001*	0.001*	0.001*	0.001*	0.001*	0.001*	0.001*	0.001*

Wilcoxon signed test, * $p<$ 0.017; M.S.: Muscle strength; ROM: Range of motion; ADL: Activities of Daily Life; QoL: Quality of Life.

3. Results

A total of 54 patients with knee osteoarthritis, 46 of whom were female (85%) and 8 were male (15%) were included in the study. The patients were randomly separated into two groups. Twenty-six of them were included in the control group (age: 51.19 $\pm$ 8.94 years) and 28 of them were included in the intervention group (age: 52.53 $\pm$ 9.68 years) (Table 1).

It was also found that a statistically significant difference was observed in terms of ROM, pain, functional status between pre-treatment and post-taping in intervention group ( $p<$ 0.017) (Table 3). No difference was observed in quadriceps muscle strength after KT compared to pre-treatment in intervention group ( $p>$ 0.017) (Table 3).

4. Discussion

The aim of this study was to compare KT along with classic treatment to classic treatment alone and to report the results of both a single and repetitive KT application which applied on quadriceps femoris and hamstring muscles on pain, ROM, muscle strength, and functional status in patients with knee OA.

In patients with knee OA, the joint loses ROM [22]. A limited knee joint angle, which is one of the basic symptoms for patients with knee OA, is critical for daily life activities [23].

In our study it was observed that the classic treatment applied in both groups was effective for knee flexion. We could report that there was a significant improvement in terms of knee flexion degree after treatment in both groups. In comparison, no significant difference was observed between groups.

Kuru et al. studied about KT in patients with patellofemoral pain syndrome [24]. They indicated that there was a significant increase in knee ROM after treatment. Our results were similar to the results of studies in literature. It is thought that an increase in knee flexion that occurred because of the decrease in pain accordingly with the classic treatment applied in both groups. Two groups have similar effects after 15 session-treatment program in terms of ROM. This is an expected result. Furthermore, knee ROM improved just after one KT application in the intervention group in our study. Similarly, Cho et al. investigated the immediate effects of KT in patients with knee OA. They revealed ROM increased significantly by approximately 21% after KT [12]. In addition, they reported that KT increased recruitment of the muscle motor units and maximal voluntary contraction. Thus, ROM increased as a result of increased muscle activation by KT. Based on the aforementioned facts; KT has immediate effect on ROM after both a single and repetitive KT applications.

Quadriceps weakness, one of the fundamental symptoms observed in knee OA, is an important risk factor for knee OA. The weakness and atrophy that occurs in the quadriceps femoris muscle restricts muscle’s function. Accordingly, cartilage degeneration increases. Therefore, it is recommended to strengthen quadriceps in the studies [25, 26].

KT has become one of the rehabilitation modalities commonly used in injuries and protection of musculoskeletal system [11]. One of the hypotheses in our study is that KT may affect the muscle strength. One of the therapeutic effects of KT in patients with OA is on muscle strength. Although there are numerous studies about the effects of KT on muscle strength, it is still controversial [13]. Karahan et al. reported that no significant changes in immediate or delayed muscle strength [27]. Another study evaluating the muscle strength by Almeida et al. investigated quadriceps femoris muscle strength and found that there was no difference compared to pre-taping [28]. Vercelli et al. indicated no significant effect in the maximal quadriceps strength immediately after the application of inhibition, facilitation, or sham KT [29]. In another study, Fu et al. found that KT performed on quadriceps muscle with the Y technique had no immediate effect or 12-hour effect on quadriceps and hamstring muscles [13]. Our results are in line with previous studies that did not find any significant change in muscle strength after KT application. On the other hand, there are many published articles reporting that KT is effective on muscle strength in the literature. One of them determining which application, knee brace, KT or both, is more effective regarding muscular strength reported that KT was more effective in terms of muscular strength than brace and KT plus brace. Despite of these positive results for KT, KT was not compared to untapped knee in this study [30]. But, Anadkumar et al. found that KT had an immediate effect on improving the peak concentric and eccentric quadriceps torque production in subjects with OA [14]. Subjects were assessed for their peak quadriceps torque using an isokinetic dynamometer. On the other hand in our study muscle strength was measured with a digital muscle strength dynamometer which was not an objective method as isokinetic dynamometer. When the studies conducted in the literature were reviewed, it was seen that the effects of KT varied on muscle strength. This difference is thought to result from the difference in the state of the target mass in the studies (healthy ones and patients), age interval, gender, the region where the application was realized, taping technique, taping time and the treatment applied. More studies that include more cases are needed in order to understand the effects of taping on muscle strength in patients with knee OA.

One of the most common symptoms of knee OA is pain [31]. Taping is widely used in rehabilitation with the purpose of treatment and prevention of sports-related injuries. It helps to support or inhibit muscle function, support joint structure and reduce pain [32].

Kuru et al. [24] investigated the effects of KT on pain in patients with patellofemoral pain syndrome, and indicated that there was a significant decrease in post-treatment pain values compared to pre-treatment. In another study, Cho et al. reported that KT may be a suitable intervention to improve pain [12]. Similarly, in our study, pain was decreased significantly after a single KT application, and this benefit was maintained three weeks later.

Another parameter evaluated in our study was functional status. According to the results of our study, while significant improvements were detected in all sub-scales of post-treatment KOOS compared to pre-treatment, in the comparison of post-treatment values between the groups, no statistically significant difference was found in any sub-scale. Similarly, there are many studies investigating the effects of KT on functional status in patients with knee OA. Wageck et al. [33] and Kaya-Mutlu et al. [34] found similar results to our study. In both of these studies, functional status was not significantly improved after the KT, although measurement scales used for functional status were different. They thought that the lack of positive results in functional status is only a consequence of the lack of positive results in pain intensity, muscle strength and swelling [33].

This study had several limitations. First, the final evaluations of the patients were performed as soon as the treatment was over. Thus, we reported only immediate effects of taping. Second, we did not investigate effects of placebo-sham or alternative taping technique. Also, there was no healthy control group to compare the outcomes.

In conclusion, we could report that KT has significant immediate effects after a single KT application on ROM, pain and functional status in patients with knee OA. We could also report that KT in addition to classical treatment is not superior to classical treatment alone in terms of clinical outcomes over 3 weeks later.

Ethical approval

This study received ethical approval from Marmara University Faculty of Medicine Clinic Researches Ethical Board (Protocol No: 09.2012.0029).

Funding

This study was supported by Marmara University, Scientific Research Research Projects Committee (Project Number: SAG-C-YLP-090512-0144).

Conflict of interest

None declared.

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