Abstract
INTRODUCTION:
Kinesio tape (KT) is an emerging tool in paediatric physiotherapy. A small body of research suggests KT is efficacious with some children, but clinical guidelines are not yet available. The aim of this study was to gather physiotherapists’ practices and experiences using KT with children. The focus was on why, where, how, and how long physiotherapists use KT with children, and the outcomes they observe, to guide future experimental research.
METHOD:
Nine Australian physiotherapists, each with at least two years of experience using KT with children, were recruited. All nine physiotherapists completed a largely open-ended online survey, and three of these physiotherapists participated in a brief follow-up telephone interview. Basic content analysis was conducted.
RESULTS:
The physiotherapists’ practices and experience with KT largely related to four themes: (1) taping for muscle activation; (2) gait and posture outcomes; (3) child tolerance limiting effectiveness; and (4) inconsistent application methods and treatment durations.
CONCLUSION:
Physiotherapists in this study used KT to serve a variety of purposes, it was mainly considered beneficial for improving gait and posture. However, there was little agreement regarding how to apply it, for how long, and the exact nature of its benefits. Empirical research is also lacking on these questions. The effectiveness of KT as an adjunct therapy for improving children’s posture and gait warrants further investigation. Research comparing specific taping application methods and durations will be valuable in guiding physiotherapists’ practice.
Introduction
Physiotherapy interventions aim to maximize children’s functional abilities and participation [1]. In addition to traditional interventions, such as strength training, adjunctive therapies include serial casting, hydrotherapy, and kinesio taping [2, 3].
Kinesio Tape (KT), also known as elastic therapeutic, neuromuscular, kinaesthetic, or kinesiology tape, is a form of adhesive tape applied to the skin. The elastic properties allow it to be stretched up to 60% from its original length [4]. It is claimed that KT increases muscle activity, re-educates the neuromuscular system, and enhances performance [5]. However, the mechanisms underlying these claims are yet to be investigated. The quantity and quality of evidence concerning KT use with children remains limited.
Much of the evidence for KT in paediatric physiotherapy is limited to children with cerebral palsy (CP) [6]. Güçhan and Mutlu [6] reviewed five studies that found that KT contributed to improvements in body structure and function, and activity and participation, for children with CP. Measured outcomes included the Gross Motor Function Measure (GMFM), Timed Up and Go and The Functional Independence Measure for Children (Wee-FIM). However, four studies in the same review found no statistically significant effect of KT. Unger et al. [7] also concluded in their systematic review that there is moderate evidence for KT as an adjunct to therapy for children with CP, in particular for Gross Motor Function Classification Scale (GMFCS) levels I and II for sitting control as measured by the GMFM. There is less evidence for the effectiveness of KT when used for children with CP classified as GMFCS levels IV and V. Footer [8] studied a therapeutic tape similar to KT, with children with quadriplegic CP GMFCS levels IV and V. Over 12 weeks, Footer’s study tested for a relationship between therapeutic taping (bilaterally along paraspinal and trapezius muscles) and functional sitting control, as measured by the GMFM-88. Footer concluded that taping is ineffective in children with exaggerated extensor tone and cognitive impairments [8]. With children with CP GMFCS levels III, IV and V, Şimşek et al. [9] found improvements in sitting activity on the Sitting Assessment Scale (SAS) resulting from KT paraspinal taping, but not GMFM scores.
There is a small body of research on the use of KT in non-CP populations, including children with torticollis [10–12], idiopathic scoliosis [13], dysphagia, and brachial plexus palsy [14, 15], and with children in an acute setting [16]. Overall, existing research on the use of KT with children remains limited and equivocal, with only a small number of controlled clinical trials [2]. Moreover, the small sample sizes and heterogeneous nature of participants in KT studies, and the lack of standardization and transparency of KT application techniques and durations, limit the clinical utility of the evidence currently available [2, 17]. Rigorous experimental studies are required to analyse possible mechanisms of effectiveness and identify moderating factors [2, 6].
Notwithstanding the absence of strong empirical evidence and the lack of evidence-based clinical guidelines, physiotherapists are using KT with children, presumably based on a trial-and-error approach and some anecdotal success. These physiotherapists are accumulating clinical experience that has not yet been captured, but which may help to guide clinically useful future research in this area. Further research is needed to establish how KT is effective, with which children, and under what circumstances. There is also a need to identify factors that might moderate the effectiveness of KT, so that such factors can be appropriately accounted for in future experimental studies.
There is currently no published research investigating practice-based insights about the use of KT with children. The aim of the current study was to gather physiotherapists’ experiences with KT in paediatric practice. The intention was to uncover relevant issues and promising directions to guide the focus and design of future research in this area.
The questions guiding this study were: Why, where, and how do physiotherapists apply KT in paediatric practice? For how long do physiotherapists apply the tape in paediatric practice, and why? What changes have physiotherapists noted in children they have treated with KT?
Methods
Research design
An online cross-sectional survey with largely open-ended questions was conducted. Brief follow-up telephone interviews were conducted to clarify and elaborate on survey responses. This research was conducted with the approval of Charles Sturt University’s Human Research Ethics Committee (Project # 400/2017/27).
Sampling and recruitment
Purposive sampling required the recruitment of physiotherapists who had experience in the specific field of interest [19]. To be included, participants were required to be a qualified physiotherapist with a minimum of two years of experience using KT with children. A longer minimum period of experience was considered too restrictive, given that KT is a relatively new tool in paediatric practice in Australia.
Physiotherapists were invited to participate in this study by email and/or by an information sheet distributed via the Australian Physiotherapy Association paediatric physiotherapy group. The email was also distributed to the professional networks of physiotherapy academics at Charles Sturt University and paediatric physiotherapists known to the researchers. The emails encouraged recipients to forward the information on to others who met the inclusion criteria, as a form of snowball sampling [20].
Data collection
The survey was built with SurveyMonkey® and included ten questions, including open-ended and multiple-choice questions (see Table 1).
Research and survey questions
Research and survey questions
The survey was piloted with a physiotherapist who was experienced in paediatric practice, for feedback regarding the clarity of the questions. This feedback was used to refine the survey questions to increase the specificity of participants’ answers. The survey did not require all questions to be answered as there was the potential for answers to relate to more than one question and repetition of information was not desired. It was optional for the participants to provide their contact details for a follow-up interview. The follow-up interviews were conducted by the lead researcher using a semi-structured interview guide based on the respondent’s survey responses; for example, seeking more detail about the therapist’s KT training, methods of parent education, or changes in practice with KT experience [21].
As the survey data was submitted and the telephone interview data was transcribed, it was transferred to an Excel spread sheet. Basic content analysis was then undertaken by one coder, with regular consensus discussions with the other researchers. While care was taken to respect the non-hermeneutic nature of basic content analysis [18], categories were generated inductively to fit the points (or codes) expressed by the participants. Constant comparisons between new codes and the developing categories were made; and where needed, new categories were created to accommodate the data [21, 22]. Due to the anonymous nature of the survey and the nature of basic content analysis, member checking was not undertaken.
A preliminary set of categories was generated by sorting the data into as many categories as possible and labelling these descriptively [22]. The data was read through several times to ensure all survey-item responses were allocated to at least one category. After the preliminary category list was generated, the categories were subsumed under themes and, where applicable, subthemes were created to assimilate closely related categories [23].
Results
A total of nine participants responded to the online survey, all of whom met the inclusion criteria. As shown in Table 2, seven participants reported having 2-3 years of experience using KT in paediatric practice, and two participants reported having 4-5 years of experience. Five participants agreed to be contacted for a follow-up telephone interview; however, only three participants responded to subsequent contact and consented to being interviewed. Each interview lasted between three and a half minutes and eight minutes. All participants were physiotherapists practicing within Australia, with experience only in non-acute care. In this section, the findings are organized under the three broad research questions. The findings are summarized in Table 3.
Characteristics of participants
Characteristics of participants
Summary of the content analysis findings
Why do paediatric physiotherapists apply KT?
KT was used for a variety of treatment aims. These were not mutually exclusive, with two or more aims often overlapping. A common aim was muscle activation: activation of weak or underactive muscles was reported by eight of the nine participants. Four participants reported using KT to activate the transverse abdominal muscle, three mentioned the dorsi flexor (tibialis anterior) muscle, two mentioned trunk extensors, one mentioned the trapezius muscle, and one mentioned taping the phalangeal extensors, wrist extensors, and supinator muscles. However, four participants reported using KT for muscle relaxation: to reduce hypertonia, myofascial tension, or lower back spasms.
Four participants also reported using KT to increase proprioception to reduce toe walking or improve sitting and dynamic postures in children with CP. Three participants reported using KT to increase weight shift, two participants reported taping to improve endurance for children with pain and fatigue related to hypermobility, and one reported aiming to increase stability of the jaw to assist chewing.
Who do physiotherapists use KT with?
Five participants reported using KT with children with cerebral palsy GMFCS levels I, II and III. Two reported using KT with children with hemiplegia. One participant each reported using KT with children with diplegic, ataxic, and dystonic CP. In addition, four participants reported using KT with children with hypermobility syndrome. One participant used KT with children with structural and postural scoliosis and gross motor developmental delay, and one other reported using KT with children with patella femoral joint pain syndrome.
Where and how do paediatric physiotherapists apply KT?
Four participants reported using an ‘I’ strip taping technique. Two participants used this to activate the transverse abdominals and bilateral obliques. One reported using an ‘I’ strip across the heel from medial to lateral malleoli. One reported using a ‘Y’ strip in a variety of ways including: to inhibit the plantar flexor muscles, on the temporomandibular joint, and to activate the pectoralis major muscle. One participant reported combining two ‘I’ strips to create an ‘X’ shape with the abdominals in shortened position. Three participants used a paper-off technique when applying KT. When using this technique, one participant stated that they applied KT from origin to insertion.
Two participants reported using KT through toes or fingers. Both reported using this technique for assisting dorsi-flexion. One used an ‘I’ strip with diamonds cut to separate toes. The other participant reported applying KT through the fingers for wrist extension. Two participants used a sports taping technique, one of whom stated this was for the prevention of inversion ankle sprains.
Factors limiting effectiveness
Seven out of the nine participants reported that the child or family did not always tolerate KT. Two of these participants reported that a child’s discomfort during removal of the tape caused them to fear reapplication. Three participants reported that skin sensitivity or integrity (e.g., eczema) reduced application duration and consequently the tape’s effectiveness.
Three participants reported that they experienced cases in which taping did not produce the expected results due to comorbid limitations, particularly behavioural and cognitive processing challenges. One noted that KT was also inappropriate in a child with a high degree of spasticity. For another participant, tactile defensiveness was a condition for which KT was considered inappropriate.
Involving parents in KT treatment
The three participants who participated in a phone interview reported educating parents as part of their KT treatment. One participant reported coaching parents about the expectation of KT and said some families became confident in taping application. However, another participant reported that some parents prefer to leave the responsibility of taping to the physiotherapist. Two of the three participants said that some parents video-record the KT demonstration. One of these participants also reported providing instructional handouts to parents.
Use of KT as an adjunct therapy
All of the participants reported using KT only as an adjunct to conventional therapy. One participant emphasized pairing KT with functional training to maximise results. Three participants reported instructing the parents to increase their home exercises (e.g., encouraging parents to increase intensity of gait training when taping to increase ankle dorsi-flexion).
For how long do paediatric physiotherapists apply the tape, and why?
Duration of single application of KT
There was no consensus among the participants regarding the duration of a single application. Indeed, for any single participant, there was no one standard duration. Five out of the nine participants reported using KT for ‘two to three days on’ per week. The other four participants reported using KT for ‘five days on’. Two participants also noted that they use KT as required, depending on the specific purpose (e.g., using facial tape during mealtimes only, or using KT during game time to enhance performance).
Duration of overall KT treatment
Reported treatment durations varied between the participants. In one participant’s experience, the normal duration was two to three applications. Another participant reported taping for two to five sessions. Another reported an initial trial time of three weeks, increasing to six weeks for some older children. Another participant reported using KT for no longer than six weeks because of skin tolerance concerns.
Reason for KT duration decisions
Six participants reported that decisions regarding treatment duration were largely influenced by the child’s tolerance of the tape. Four reported that they continue taping as long as required to achieve the goal. One reported using KT as long as needed until there is ‘reasonable improvement’. Another reported that they use KT as long as they see ‘follow over results’ or a ‘carry over effect’.
Consultation with the parents was reported by two participants as an important factor in determining KT treatment duration. Two considerations were the child’s or family’s tolerance of the tape and the parent’s ability to safely remove the tape.
Two participants chose timeframes because they were recommended by a paediatric taping course or a colleague. KT coming off due to sweat was noted by another two participants, either during a treatment session or during the following days. One participant reported that the duration was influenced by the availability of the next appointment, usually a week after tape application.
What changes do physiotherapists note in children they have treated with KT?
Seven participants reported an improvement in gait as an outcome of using KT. Two of these participants reported an improvement in functional joint range which resulted in gait improvements. Five reported an improvement in posture. For example, one participant reported an improved posture measured by postural photo assessment and sacral angle measurement. Three participants noted a decrease in toe walking, based on pre- and post-gait observation.
Two participants reported improvement in endurance, which increased activity participation time. Two participants reported an improvement in upper limb function. For example, one reported an improvement in functional hand use with the wrist in an extended position. Two participants reported an improvement in the quality of a functional task: stair climbing, table-top tasks, or handwriting. One participant also reported an improvement in balance strategies.
One participant reported improvement in a child’s ability to chew, based on time to complete a meal and amount of intake. One participant reported a decrease in exertional dystonia during standing and walking. One participant noted improvement in a child’s sports performance.
Seven participants reported child or parent perceived improvements. Three reported a decrease in pain as reported by the child or parent. Two reported that KT improved children’s splint- and shoe-wearing time, as reported by parents. Three participants reported a parent perceived reduction in falls at home after KT intervention.
Discussion
The aim of this study was to explore physiotherapists’ experiences with the use of KT in children: why, where, how, and how they apply KT; how long they apply it for; and what changes they have noted. A range of clinical experiences were captured that signal important considerations and worthwhile directions for future research. Muscle activation was the most commonly reported treatment aim, followed by muscle relaxation and proprioception. Cerebral palsy was the most frequently reported diagnostic group. Reported sites and techniques of KT application varied. Durations of single KT applications and overall KT treatment durations also varied. The participants considered a range of contextual factors when deciding whether and for how long to use KT. These factors included child factors (e.g., child tolerance, skin sensitivity, sweating), parent factors (e.g., the parent’s willingness and ability to apply and remove KT), and evidence of benefit. The participants noted a wide range of positive outcomes in children they have treated with KT, most commonly improvements in gait and posture. Other less frequently reported outcomes included improved chewing.
The use of KT by almost all the participants for muscle activation is consistent with KT use in existing research [9, 24]. However, given the beliefs/aims of some of the participants regarding the use of KT for muscle relaxation, research ruling out or confirming the ability of KT to induce muscle relaxation would be helpful. The current study shows that some physiotherapists are using KT for transverse abdominis activation; however, there is no published research investigating KT for muscle activation of the transverse abdominis muscle in children. Since improvements have been reported in the research literature with other postural muscles, research on the effect of KT use with this specific muscle is warranted.
The participants’ exclusive use of KT with children with CP GMFCS level I, II and III is also consistent with past research findings [7, 25]. Footer [8] found that use of KT with children with CP GMFCS level IV or V was not effective. Children with CP GMFCS level IV and V often have comorbid conditions [26] which, as suggested by participants in this study, may compromise the effectiveness of KT. In the current study, participants believed factors such as spasticity compromise KT effectiveness.
The participants’ taping techniques were inconsistent. This may partly be because the tape is applied with varying aims. For example, taping was reported for both activating and relaxing muscles. However, the fact that past research has not compared the effectiveness of different application methods for any particular aim is a limitation in the existing evidence base. Indeed, the general lack of transparency in application methods in the existing literature limits repeatability and clinical utility [2, 27]. In the absence of evidence comparing different techniques, clinicians are required to analyse the functional deficit and apply the tape using their clinical reasoning [6]. The current study highlights the potential helpfulness of future research directly comparing taping techniques for a particular purpose.
The durations of KT use also varied. Research investigating the most effective KT application durations for particular purposes is limited. In general (beyond KT use), there is a lack of published research investigating minimal timeframes for eliciting clinically significant improvements. However, one study by Christiansen and Lange [28] found that continuous conventional physiotherapy showed no additional benefit when compared to four-week interventions with six-week pauses [28]. More research focused on questions of duration in relation to specific purposes (e.g., muscle activation) is needed to guide physiotherapists.
The participants in this study reported issues concerning child and family tolerance, particularly skin sensitivity. This point has attracted surprisingly little attention in the existing research literature. Safety of KT application has been discussed in relation to cancer lymphoedema treatment [29]. However, such research is not directly transferrable to paediatric practice. In the existing paediatric KT research literature, Giray et al. [12] used a 24-hour period to test for allergic reaction. Şimşek et al. ‘followed’ (with unclear meaning) children for three days to monitor for skin irritation. Footer [8] completed an eight-day skin check to rule out any responses to the tape. The issue of skin sensitivity should be assessed more directly in future KT research. Güçhan and Mutlu [6] pointed out that allergy and sensitivity to taping needs to be monitored in KT research. However, the safest and most effective ways to test sensitivity to KT have not been identified. Research into the safest KT sensitivity-testing method is warranted.
The observed improvements in gait reported by almost all the participants in this study is consistent with past research. In a case report, Fergus [30] found that foot and ankle taping can improve alignment of the foot for a child with CP. Iosa et al. [31] also found similar results with a child with CP. However, research investigating gait improvements in paediatric population groups other than CP is lacking. Since some physiotherapists are finding gait improvements from KT use with a range of paediatric groups, further research in this area would seem promising.
The participants’ observations of postural improvements are also consistent with past studies that have employed varying taping methods to improve posture [9, 33]. For example, Unger et al. [7] found KT to be an effective intervention when applied to the trunk and recommended further research into methods of truncal taping. Research directly comparing taping methods for postural improvement would be useful for determining whether there is one most effective method.
The absence of empirical evidence to support clinical practice is not uncommon. Sniderman, LaChapelle, Rachon, and Furberg [34] argue that clinical reasoning, driven by experience, is the key to bridging this gap. This pragmatic approach acknowledges the importance of flexibility and trial and error in building clinical experience. Ross [35] defined five sources of knowledge that guide decision making: traditional, authority, trial and error, personal experience, and research. Naturally, when one area is lacking, there is increased reliance on another. Smith, Higgs, and Ellis [36] also espoused the importance of integrating multiple decision-making factors in evidence-based practice. The findings of the current study reinforce the importance of clinical experience and strong clinical reasoning in evidence-based practice, particularly when there is a lack of available research evidence. This study also highlights the importance of conducting research on questions of real-world relevance to clinicians.
Directions for future research
This study has several implications for future research in this area. A number of child, parent, and KT-knowledge factors were identified as factors affecting the clinical decision-making of the participants in this study. This suggests that clinician decisions in past studies may have been affected by similar factors, but variations in treatment implementation and the importance of context-based flexibility are rarely acknowledged in the existing literature. Future research should aim for greater transparency regarding child tolerance, parental involvement, and choice of technique to help maximize clinical applicability. Research should also focus on the practices engaged in by participants in this study. For example, RCTs with children with cerebral palsy, focusing on specific GMFCS level I-III, comparing the effects of different KT application methods and durations for specific gait and posture issues are needed. Researchers in this area should also report the main treatment to which the taping is an adjunct, the training provided to clinicians, the treatment durations and precise taping methods, the skin sensitivity assessments used, and the reasons behind any deviations from the initial protocol. Researchers should also use and report on outcome measures which are able to be employed by practitioners in their practice to help improve their clinical practice. Ideally, both short-term and longer-term effects of KT on children’s functioning should also be assessed. The outcomes of such research would provide valuable guidance to clinicians.
Limitations
The scope of this study was limited to identifying the experiences of physiotherapists using KT with children. No conclusions about the frequency of use or the effectiveness of KT in paediatric practice can be drawn. This study did not investigate the views of the patients or their parents; nor the veracity of the physiotherapists’ accounts. This study also did not focus on other types of therapeutic tape.
This study was limited only to physiotherapists practicing within Australia. It should be acknowledged that other health professionals may also use KT. The small sample size (nine respondents) also meant that data saturation was probably not achieved. However, data saturation might be an unrealistic goal, due to the evidently varied nature of paediatric physiotherapists’ experiences with KT. The sample size was of course restricted by the requirement of two years’ experience, as KT is only an emerging treatment tool. Moreover, only three of the survey respondents consented to being interviewed, limiting the extent to which the survey themes could be probed. However, while a larger sample size and more follow-up interviews may have uncovered more unresolved questions and directions for further research, the nature of the conclusions that could be drawn would not likely have changed.
Notwithstanding its limitations, this study has found that some physiotherapists are using KT in the absence of evidence-based guidelines, in ways that have not yet been empirically tested. The strength of these findings is not detracted by the limitations acknowledged here.
Conclusion
The aim of this study was to investigate physiotherapists’ real-world experiences with KT in paediatric practice. It was found that physiotherapists are using KT for a variety of purposes, believing it to be beneficial for facilitating muscle activation, particularly for improving gait and posture. However, there was little agreement amongst participants regarding how the tape is best applied and for how long. There is a corresponding lack of empirical evidence on these questions. A promising direction for future research would be RCTs focused on the effectiveness of KT as an adjunct therapy in improving children’s posture and gait, directly comparing specific application methods and durations. It is hoped that the current study prompts further research to help maximise the effective use of KT, to enhance the lives of children who might benefit.
Conflict of interest
The authors have no conflict of interest to report.