Does elastic taping on soles improve flexibility? A randomized controlled trial with equivalence test design

Abstract

BACKGROUND:

Elastic taping that applies shear force affects joint movement. However, it remains uncertain whether elastic taping or stretching is more effective in improving flexibility.

OBJECTIVE:

We investigated whether elastic taping for flexibility improvement is comparable to traditional stretching.

METHODS:

In this randomized controlled trial, 64 university students were randomly allocated to two groups: elastic taping on the sole or 30 s of static stretching. The primary outcome measures were the straight leg raising angle, tested with an equivalence margin ( $\pm$ 9.61^∘ on changes), and the fingertip-to-floor distance. Secondary outcomes were the hip flexor and knee extensor strength, two-step distance, adverse events, and pain intensity during the intervention, which were compared using conventional statistical methods.

RESULTS:

The mean differences in straight leg raising between the two groups after the interventions were not greater than the equivalence margin (mean [95% CI]: 1.4 [ $-$ 6.9, 9.5]; equivalence margin, $-$ 9.61^∘ to 9.61^∘). There were no consistent differences between groups in terms of secondary outcomes except for pain intensity during the intervention ( $p>$ 0.05). Elastic taping did not induce pain.

CONCLUSION:

Elastic taping augments the flexibility-improving effect comparable to static stretching, based on an equivalence margin. Elastic taping of the sole appears to be an alternative method of improving flexibility.

Keywords

Athletic tape Muscle stretching exercises Range of motion articula Randomized controlled trials as topic

1. Introduction

The hamstrings are biarticular muscles composed of Semitendinosus, Semimembranosus, and Biceps Femoris, and are anatomically characterized by having fusiform muscles or long tendons [1]. Decreased flexibility of the hamstring muscles increases the risk of tendon injuries. Therefore, clinicians should target treatments to the hamstring muscles. Stretching is one approach to improving muscle flexibility. There are various methods of stretching, such as dynamic, static, loaded progressive, ballistic, and proprioceptive neuromuscular facilitation stretching, that can be used to achieve this goal [2, 3]. Static stretching is a popular method because it requires less time and effort, has a lower risk of injury, and has shown positive results in improving flexibility [4, 5, 6, 7]. There is a consensus that static stretching is effective in increasing the flexibility of the hamstring muscles in healthy young adults [8]. Stretching intensity is considered an important variable for improving flexibility, and stretching exercises with an intensity of approximately 50% of the maximum pain and discomfort felt decrease the risk of injury [9]. However, static stretching not only causes acute pain due to the passive stretching of muscles but also has the disadvantage of acutely deteriorating performance, such as in sprint running and jumping height [10]. Fauris et al. reported that plantar fascial interventions most affected hamstring flexibility [11] Previous studies [12] have shown that a 4-min myofascial release to the sole improves hamstring muscle flexibility. A recent systematic review and meta-analysis reported that myofascial intervention has a remote effect on the range of motion (ROM) [13]. The application of elastic tape has been reported to reduce muscle stiffness and pain [14, 15]. Applying shear force with the application of an elastic tape also affects the movement of joints [16, 17]. Applying elastic tape to the sole for the purpose of the fascia effect may improve the ROM of the joint immediately and remotely, without causing pain in the hamstring muscles. However, no randomized controlled trial that compares the safety and efficacy of static stretching and easy-to-operate, pain-free elastic taping has been published to date. Determining whether elastic taping can immediately improve ROM is beneficial in clinical practice. In this study, straight leg raising (SLR), which is an index of hamstring muscle flexibility, was used as one of the primary outcomes, and the non-inferiority/equivalence effect of elastic taping on static stretching was evaluated.

2. Materials and methods

2.1 Study design

A randomized parallel-group clinical trial was conducted to investigate whether elastic taping improves flexibility as quickly as static stretching. This trial has been designed according to the CONsolidated Standards Of Reporting Trials (CONSORT) statement [18], and is reported according to the Template for Intervention Description and Replication (TIDieR) checklist [19]. Participants were assigned to either the static stretching group or the elastic tape group. The SLR angle and fingertip-to-floor distance (FFD) were set as the primary outcomes of flexibility. In addition to these performance abilities, the degree of pain during the intervention was assessed as a secondary outcome.

2.2 Participants

Participants consisted of physically active university students, and the following exclusion criteria were applied: Those who have reported 1) lower limb injury in the past 6 weeks; 2) lumbar spinal injury or surgery in the last 6 weeks; and 3) lower limb surgery within the last 6 months and major ligament surgery within the previous year. Participants were recruited from students belonging to one university, and the volunteers were recruited using a bulletin board. This research was conducted at a private medical university in the Kanto area of Japan. Sixty-five participants were screened in June 2021 (Fig. 1). Finally, 64 students were enrolled in this study (31 men and 33 women, average age: 20.9 years).

Table 1
Demographic data of participants

	Total ( $n=$ 64)	Stretching ( $n=$ 32)	Elastic tape ( $n=$ 32)
Age, years	20.9 $\pm$ 0.6	21.0 $\pm$ 0.5	20.7 $\pm$ 0.6
Sex, m/f	31/33	17/15	14/18
Height, cm	164.6 $\pm$ 7.7	165.7 $\pm$ 8.1	163.5 $\pm$ 7.2
Mass, kg	61.5 $\pm$ 10.2	63.6 $\pm$ 10.7	59.5 $\pm$ 9.3

m, male; f, female; Values are expressed as mean $\pm$ standard deviation.

Figure 1.

Flowchart showing study participants’ enrollment. SLR, straight leg raising; FFD, fingertip-to-floor distance; HFS, hip flexor strength; KES, knee extensor strength; TSD, two-step distance; VAS, visual analog scale.

2.3 Randomization

Figure 2.

Elastic taping protocol.

Participant allocation was set so that the ratio of the static stretching group to the elastic tape group was 1:1. An online statistical computer program (Graph Pad Software, USA, https://www.graphpad.com/quickcalcs/ index.cfm) was used to randomly generate an allocation order. The allocation type was an 8-block randomization to equalize each intervention to a 1:1 ratio, with no stratification for other factors. The randomization process was performed by a researcher belonging to a trial management center who did not contribute to the outcome measurements or treatment interventions. Participants were assigned to either the static stretching group or the elastic tape group after another researcher screened and enrolled them for eligibility. Thirty-two participants each were randomly allocated to the static stretching group (17 men and 15 women; average age: 21.0 years) and the elastic tape group (14 men and 18 women, average age: 20.7 years) (Table 1).

2.4 Procedures

2.4.1 Interventions

Participants assigned to the static stretching group were prescribed static stretching of the hamstring muscles. One researcher individually instructed the participants about the stretching procedure. The stretching method was as follows: the crouching state was the starting posture, the knee was gradually extended while keeping the front of the thigh and the front of the chest in contact, and finally, the buttocks were raised as much as possible. Stretching interventions were held only once for 30 s, with the buttocks raised as much as possible.

For the participants assigned to the elastic tape group, kinesiology tape (NK-50, Nitto Denko, Osaka, Japan) cut to 50% of the foot length was applied on the sole of the dominant foot. The kinesiology tape was devised so that it was extended 1 cm from its natural length during its application and was applied from the tip of the toe to a position 3 cm behind the heel; the tape was applied by a physical therapist (Fig. 2). Elastic tape was applied individually by the same therapist. The application was performed in a long sitting position. The elastic tape was applied once after baseline assessment and removed after follow-up assessment. All participants assigned to the elastic tape group received the same intervention. No modification occurred in the intervention. Because all participants consented to a single intervention, no assessment of intervention adherence or fidelity was planned. Different sets of participants were assigned to the groups, and the allocation of participants was concealed by central computerized randomization.

Figure 3.

FFD mesurement.

Figure 4.

Difference in SLR from baseline to each follow-up between elastic tape and static stretching groups. M $=$ (SLR immediately after intervention) $-$ (SLR at baseline). M_E: elastic tape, M_S: static stretching.

2.4.2 Outcome measures

The SLR angle, which is one of the primary outcomes, was measured with the participants in the supine position. The angle was measured at which the dominant leg was raised as much as possible with the fully extended knee. A digital inclinometer smartphone application (Clinometer, Tokyo, Japan, https://apps.apple. com/jp/app/%E8%A8%88%E6%B8%AC/id1383426740) was used for the measurement. The smartphone was fixed at the center of the participant’s thigh. The inclinometer was calibrated by setting it to 0^∘ before raising the lower limbs, and the maximum lifting angle was measured. In the FFD measurement, which is another primary outcome, the distance between the fingertip and the floor was measured with a digital flexibility testing device (Standing Trunk Flexion meter TKK 5403, Takei Co., Tokyo, Japan). Participants were instructed to lean forward as far as possible to reach the floor with their fingertips (Fig. 3). Outcomes were measured by researchers who were blinded to the intervention assignment.

In addition to the performance abilities of hip flexor strength (HFS), knee extensor strength (KES), and two-step distance (TSD), the degree of pain during the intervention was assessed as a secondary outcome. Muscle strength, including HFS and KES, was measured using a handheld dynamometer ( $\mu$ TasF-1, ANIMA, Tokyo, Japan). HFS and KES were measured at 9^∘ for both the hip and knee joints in the sitting position. The chair leg and the participant’s thigh or lower leg were secured using belts. For the measurement of TSD participants took two steps forward at a maximum stride while trying to maintain balance and not fall and then stopped with both feet on the ground. The distance traveled during the two steps was then measured. This test is often used in Japan as an index of overall physical function, including muscle strength, balance ability, and flexibility of the lower limbs. All outcomes were measured before and immediately after the intervention for participants assigned to either group. Participants were measured for all outcomes while wearing socks and shoes, and outcome measures were concealed; the respective intervention given to each participant was unknown. The numeric rating scale (NRS) was used to assess the degree of pain during the intervention. The numeric scale was the rating of the pain from 0 (no pain) to 10 (worst pain). We preliminarily analyzed the reliability of SLR, FFD, TSD, HFS, and KES in 16 university students (8 men and 8 women, average age: 20.8 years), and found that ICC (1,1) was 0.949, 0.992, 0.982, 0.784, and 0.962, respectively. Therefore, a single measurement was taken as the representative value in this study. There were no method changes, including the eligibility criteria, after the start of the study. The order of random allocation was concealed for all persons involved in this study, including participants until the assignment for each group was completed. Interventions and outcome measurements were performed between June and July 2021.

2.5 Data analysis

These data were analyzed using the intention-to-treat methodology developed for randomized controlled clinical trials. To verify that the effects of elastic taping and static stretching on SLR, which is one of the primary outcomes, were equivalent, we calculated 95% confidence intervals (CIs) for the difference between the two groups.

We then tested the following null (H₀) and alternative (H₁) hypotheses as M_E: mean value of SLR after applying elastic tape is attached, M_S: mean value of SLR after performing static stretching, and $\delta$ : equivalence margin Because, in a meta-analysis of static stretching of the hamstring muscles, it was reported that the lower bound of the 95% CI was 9.61^∘ [8].

$\displaystyle H_{0}:|M_{E}-M_{S}|\geqslant\delta(9.61)$ $\displaystyle H_{1}:|M_{E}-M_{S}|<\delta(9.61)$

We calculated the sample size for the primary outcome of change in SLR with a significance level of 5%, a power of 90%, and a standard deviation of 10.57, based on a previous study. Each group included 32 participants. In addition, the values of secondary outcomes were analyzed using Student’s unpaired t-tests or Mann-Whitney U tests, depending on the data’s distribution. Normality was confirmed using the Kolmogorov–Smirnov test. SPSS Statistics Ver. 26 (manufactured by IBM, Tokyo, Japan) was used for statistical analysis, and the significance level was set at 5%.

3. Results

One of the screened 65 students had a history of knee ligament surgery within the past year and was, thus, excluded. None of the participants in this study dropped out at the end of the post-intervention outcome measurement. No participant changed their originally assigned groups; 32 participants in each group received the intended treatment and the same number was used to analyze the outcomes. There were no changes in the outcomes after the start of the trial.

Table 2
Physical performance at baseline in the two groups

	Total ( $n=$ 64)	Stretching ( $n=$ 32)	Elastic tape ( $n=$ 32)	Difference between groups Stretching minus elastic tape (95% CI)	$p$ -value
SLR, deg	76.6 $\pm$ 17.0	77.3 $\pm$ 14.9	75.8 $\pm$ 19.0	1.4 ( $-$ 7.0 to 10.0)	0.369
FFD, cm	2.7 $\pm$ 10.0	2.4 $\pm$ 9.9	2.9 $\pm$ 10.3	$-$ 0.5 ( $-$ 5.6 to 4.5)	0.421
HFS, Nm/kg	1.17 $\pm$ 0.37	1.20 $\pm$ 0.43	1.15 $\pm$ 0.31	0.05 ( $-$ 0.13 to 0.24)	0.284
KES, Nm/kg	1.68 $\pm$ 0.85	1.79 $\pm$ 0.95	1.57 $\pm$ 0.74	0.22 ( $-$ 0.21 to 0.64)	0.156
TSD, m/m	1.58 $\pm$ 0.12	1.58 $\pm$ 0.13	1.58 $\pm$ 0.12	0.01 ( $-$ 0.05 to 0.07)	0.402

CI, confidence internal; SLR, straight leg raising; FFD, fingertip-to-floor distance; HFS, hip flexor strength; KES, knee extensor strength; TSD, two-step distance; Values are presented as mean $\pm$ standard deviation. Statistical analyses were conducted using Student’s $t$ -test.

Table 3

Comparison of clinical outcomes after intervention between the two groups

	Post intervention		$p$ -value	Mean change from baseline				Difference between
	Stretching ( $n=$ 32)	Elastic tape ( $n=$ 32)		Stretching ( $n=$ 32) (95% CI)	$p$ -value	Elastic tape ( $n=$ 32) (95% CI)	$p$ -value	groupsStretching minus elastic tape (95% CI)
SLR, deg	83.5 $\pm$ 15.0	82.2 $\pm$ 17.7	0.750	6.2 (2.9 to 9.5)	0.001	6.3 (3.6 to 9.1)	$p<$ 0.001	$-$ 0.1 ( $-$ 4.3 to 4.1)
FFD, cm	5.2 $\pm$ 9.0	5.1 $\pm$ 9.9	0.964	2.7 (1.3 to 4.1)	$p<$ 0.001	2.1 (0.8 to 3.5)	0.003	0.6 ( $-$ 1.3 to 2.5)
HFS, Nm/kg	1.15 $\pm$ 0.47	1.12 $\pm$ 0.29	0.750	$-$ 0.05 ( $-$ 0.11 to 0.02)	0.189	$-$ 0.02 ( $-$ 0.08 to 0.03)	0.426	$-$ 0.02 ( $-$ 0.11 to 0.07)
KES, Nm/kg	1.82 $\pm$ 1.01	1.62 $\pm$ 0.69	0.359	0.03 ( $-$ 0.08 to 0.14)	0.564	0.05 ( $-$ 0.05 to 0.15)	0.335	$-$ 0.02 ( $-$ 0.16 to 0.13)
TSD, m/m	1.62 $\pm$ 0.12	1.57 $\pm$ 0.13	0.147	0.04 (0.01 to 0.06)	0.004	0.00 ( $-$ 0.03 to 0.02)	0.818	0.04 ( $-$ 0.01 to 0.07)

CI, confidence interval; SLR, straight leg raising; FFD, fingertip-to-floor distance; HFS, hip flexor strength; KES, knee extensor strength; TSD, two-step distance; Values are presented as mean $\pm$ standard deviation. Statistical analyses were conducted using Student’s $t$ -test.

There were no significant differences in the outcome measures, including the SLR, FFD, muscle strength, and TSD, at baseline between the two groups ( $p>$ 0.05; Table 2). At post-intervention, there were no significant differences in SLR, FFD, muscle strength, and TSD between the two groups ( $p>$ 0.05; Table 3).

The results of a non-inferiority/equivalence test for the SLR showed that the 95% CIs of the difference in the SLR between the two groups after the intervention did not exceed the non-inferiority/equivalence margin, indicating elastic taping equivalence (mean difference, $-$ 1.4^∘; 95% CIs, $-$ 6.9^∘ to 9.5^∘; equivalence margin, $-$ 9.61^∘ to 9.61^∘).

The NRS, which indicates the degree of pain during the intervention, was 2.6 $\pm$ 2.5 for the static stretching group and 0.0 $\pm$ 0.0 for the elastic tape group, which was significantly higher in the static stretching group than in the elastic tape group ( $p<$ 0.001; mean diff, 2.6; 95% CIs, 1.75 to 3.50). No serious side effects, including muscle or ligament injuries, were observed in either group.

4. Discussion

This randomized controlled trial investigated whether elastic taping was as effective as static stretching for immediate effects of increased flexibility within a certain equivalence margin in Japanese university students. We found that the mean difference in SLR, an indicator of flexibility, between the two groups was within the equivalence margin and was not statistically different, suggesting that elastic taping has the same effect on flexibility improvement as static stretching.

Our findings showed that static stretching for 30 s increased the SLR by 6.2^∘ (95% CI, 2.9^∘ to 9.5^∘), and elastic taping increased the SLR by 6.3^∘ (95% CI, 3.6^∘ to 9.1^∘). The positive lower bound of the 95% CI for both interventions indicates that both interventions improved SLR. In a previous study of university students, an improvement in SLR of approximately 7^∘ was reported as an acute effect of stretching on the hamstring muscles [20]. The effects of static stretching in our study were similar to those reported previously. It has been shown that there is no difference in the improvement of flexibility between stretching for 30 s and longer intervention times [21]. The stretching intervention time in this study was sufficient to improve flexibility. Therefore, considering the intervention time and effect, it can be inferred that the stretching intervention in this study was an appropriate treatment for comparing the flexibility-improving effect with other interventions.

Previous studies investigating the efficacy of elastic taping have shown pain relief and ROM improvement [22, 23, 24]. Improvements in the ROM may be associated with pain relief, as these reports used tapes for participants who felt pain. The effects of elastic taping on healthy people without pain include the promotion of muscle activity [25] and improvement of endurance [26]. A systematic review showed that there is a lack of compelling evidence to enhance performance abilities including muscle strength, balance, and agility [27]. The results of this study revealed that elastic taping remotely increases ROM to distant body parts, similar to that of myofascial intervention [12, 13]. However, it is still difficult to elaborate on our results based on the knowledge of the specific mechanism of elastic tape, which has not been fully elucidated. Richard et al. [28] quantified the movement of the skin during joint movement and found a relationship between joint movement and skin flexibility. We believe that promoting skin movement using elastic tape as well as a myofascial intervention may remotely increase ROM to distant body parts. In a previous study by Ito et al., the application of elastic tape to the sole of the foot improved ankle dorsiflexion, but hamstring flexibility was not assessed [29]. The effects of taping on the sole on hamstring flexibility may be due to the continuity, overlapping and compartmentalization of the muscular tissue by the fascia. A possible reason for the good results of the elastic tape on the sole is the the significant fascial continuity, via the Achilles tendon, between the plantar fascia and the posterior part of the sural fascia [30, 31].

Furthermore, the degree of pain during static stretching was significantly higher than that during elastic taping. The result that applying elastic tape did not induce pain in any of the participants is very useful information. It has been reported that static stretching induces pain during an intervention and that the intensity of static stretching changes the acquisition of flexibility [9]. Excessive stretching to gain flexibility causes discomfort, and pain [32]. With regard to performing the stretches in this study, subjects were instructed to perform at half the intensity of unbearable pain. Nevertheless, the fact that there was a significant difference in the degree of pain between the two groups suggested that stretching was a considerable pain-causing intervention for gaining flexibility. Based on the results of this study, it was clarified that elastic taping can be used as an alternative therapeutic modality that is pain-free and easily feasible to increase hamstring muscle flexibility or improve the ROM.

In this study, elastic taping did not reduce performance abilities. Elastic taping reduces pain and inflammation and promotes muscle function in patients experiencing pain [33]. However, there are some reports that elastic tapes for healthy populations do not affect postural balance, muscle circulation, and muscle strength [34, 35, 36]. Therefore, it is inferred that muscle function is not promoted in healthy people without pain. In this study, static stretching did not affect performance abilities, such as HFS, KES, and TSD. Static stretching has been reported to reduce performance abilities, such as jump height [37] and muscle strength [38]. However, we speculate that 30 s of stretching a single muscle group does not reduce performance. This is because Cornwell et al. [37] set an intervention time of 5 min and Yamaguchi et al. [38] set an intervention time of 20 min. Although passive torque and activity level decreased during 30 s of static stretching, it was shown that both recovered to the same level immediately after stretching [39, 40]. We speculate that mechanical and neurophysiological changes do not occur until after the intervention with 30 s of static stretching alone, resulting in poor performance. Given the equivalence of elastic taping with short-time static stretching and the reduced pain, elastic taping is an excellent treatment.

This study has some limitations. First, the primary endpoint of this study was immediately after the intervention. The interpretation of the results is limited because the lasting effects have not been followed up. Second, because we only studied healthy university students, the effects on athletes and the elderly are also unclear. Further verification is needed to increase external validity and applicability. Finally, the clinically important difference in flexibility improvement by static stretching in healthy individuals is not clear. The lower bound of the 95% CI for the effect of the SLR associated with elastic taping was 3.6^∘. The magnitude of the effect on this number is unknown, and reference to the magnitude of the effect requires careful judgment. This study provides evidence for the efficacy of elastic taping to improve flexibility.

5. Conclusions

Elastic taping on the sole of the foot was found to be a useful intervention that immediately improves the flexibility of the hamstring muscles and hip joint ROM without causing pain. This suggests that it could be used as an alternative therapeutic modality for static stretching.

Author contributions

All authors contributed to the conception and design of the study. Material preparation, data collection, and analysis were performed by Tatsuya Igawa and Riyaka Ito. The first draft of the manuscript was written by Tatsuya Igawa, and all authors commented on the previous versions of the manuscript. All authors read and approved the final manuscript.

Data availability statement

The data that support the findings of this study are available from the corresponding author (Tatsuya Igawa) upon reasonable request.

Ethics statement

This study was approved by the ethics committee of the International University of Health and Welfare (IRB: 21-Io-6) and all research procedures were carried out in accordance with the Declaration of Helsinki. The study was registered with UMIN-CTR (UMIN000044525).

Funding

The authors report no funding.

Informed consent

Written informed consent was obtained from all participants before participation in the study.

Footnotes

Acknowledgments

The authors have no acknowledgments.

Conflict of interest

The authors declare that they have no conflict of interest.

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