Effects of kinesio taping on neck-shoulder discomfort and EMG responses during smartphone texting in healthy young adults

Abstract

BACKGROUND:

While kinesio taping (KT) is used in several clinical settings to correct posture and reduce pain, KT effects during smartphone texting are unknown.

OBJECTIVE:

To investigate the effects among healthy young adults of KT on neck-shoulder discomfort and electromyographic (EMG) responses of neck and upper trunk muscles during smartphone texting.

METHODS:

Twenty-four participants performed a 30-minute texting task on a smartphone using both hands at two separate times under one of two conditions: KT on the right shoulder and no taping. Neck-shoulder discomfort was assessed, along with the normalized root mean square (NRMS) and normalized median frequency (NMF) of the right cervical erector spinae (CES), lower trapezius (LT), and serratus anterior (SA).

RESULTS:

Compared to baseline, both groups had significantly greater neck-shoulder discomfort, and NRMS and NMF of all muscles (p < 0.001) after performing a 30-minute texting task. Comparing between groups, the KT group experienced significantly less neck-shoulder discomfort, and demonstrated delayed deterioration of NRMS and NMF of right CES and LT muscles (p < 0.05).

CONCLUSIONS:

During smartphone texting, KT on the shoulder decreased neck-shoulder discomfort and delayed reduction of activation and fatigue of neck and upper trunk muscles among healthy young adults.

Keywords

Strapping mobile device pain muscle activity fatigability

1 Introduction

One of many types of visual display terminals, smartphones are common handheld communication devices, providing numerous applications for social networking, texting, and watching video content [1]. Globally, the number of smartphone users is forecasted to reach 2.71 billion, up from 2.53 billion in 2018 [2]. In Thailand, it is estimated that 27.14 million people are mobile device users, the largest number of mobile users in the Association of Southeast Asian Nations (ASEAN) [3]. Users spend an average of 4.1 to 5.4 hours a day on their devices [4]. Interestingly, musculoskeletal problems arising from smartphone use have increased. Among mus-culoskeletal complaints of smartphone users, neck-shoulder pain has the highest prevalence at 17.3% to 67.8% [5]. The prevalence of neck-shoulder pain among young adults over the past 20 years has significantly increased [6]; in particular, text messaging is associated with neck and upper limb symptoms in this population [7].

Smartphone users interact with their devices by looking down at them and touching the display screens, which can involve sustained and non-neutral head positioning and poor neck posture [8, 9]. A previous study proposed that neck flexion angles during smartphone use are 20 degrees or greater, and showed that among smartphone activities the greatest neck flexion angle occurred during texting [8]. Maintained flexed neck posture produces prolonged loading on the cervical spine and adjacent neck tissues, and external flexion force, causing improper activities of the neck muscles to maintain such posture [10]. Previous studies reported that smartphone texting led to increased activity of the cervical erector spinae muscle, and decreased activity of the lower trapezius and serratus anterior muscles –muscles which serve as neck and upper trunk stabilizers [9 , 12]. Although low-load activation of neck and upper trunk muscles are required to maintain neck stability during texting, prolonged muscle contraction may cause neck and upper trunk muscle fatigue, eventually inducing neck pain [8, 13]. Consequently, smartphone users may experience “text neck” syndrome if they maintain prolonged awkward neck posture while using their devices [14]. Hence, preventive methods for addressing the fatigability of neck and upper trunk muscles and relieving pain possess increasing research merit.

While there are no evidence-based ergonomic or management guidelines for smartphone users experiencing neck-shoulder discomfort, numerous methods, including EMG biofeedback [15], muscle stretching [16], and non-elastic shoulder taping [14] have been employed to alleviate texting-related neck-shoulder pain. Developed by Dr. Kenzo Kase, KT utilizes an elastic tape that mimics human skin, and is being increasingly applied to correct neck-shoulder posture [17, 18]. Although therapeutic effects of KT remain inconclusive, several authors have reported benefits in terms of pain relief [19], promoting proper postural alignment [17, 18], enhancing muscle activity [20], and improving blood and lymphatic circulation under the taping area [21].

Previous studies demonstrated the beneficial effects of KT on mechanical correction of forward head posture [17] and rounded shoulders in seated workers [18]. Nevertheless, the application of KT for pain and neuromuscular responses during smartphone texting has not been investigated.

If KT can be applied to the shoulder of persons during prolonged texting task on the smartphone to gain muscular efficiency by potentially delayed reduction of activation and fatigue of the neck and upper trunk muscles, it could be a suitable and inexpensive approach for smartphone users and therapists that may be incorporated into the prevention of overuse or repetitive injuries of cervical spine or soft tissues around the cervical region resulting in neck pain. Hence, this study’s purpose is to evaluate the effects of KT on neck-shoulder discomfort, and EMG activity and fatigability of neck and shoulder muscles, among healthy young adults while texting.

2 Materials and methods

2.1 Study design and participants

Conducted in the laboratory at Mae Fah Luang University (MFU) Hospital, the study was designed as an assessor-blinded randomized cross-over trial with two conditions: KT usage and no taping controls. There were two measurement sessions (pre-test at 0 minutes and post-test at 30-minutes of smartphone use), with three days allotted between sessions to minimize any carry-over effect [22].

Twenty-four right-hand dominant young adults (12 men and 12 women) were recruited via online advertising in Chiang Rai Province, Thailand, from February to June 2019. Participants were healthy, able to use both hands for texting, and had a mean age of 20.05±1.62 years and mean daily smartphone use of 7.04±3.28 hours. Participants were screened for eligibility through subjective and objective examinations by a medical doctor who was unaware of the study intervention. Exclusion criteria consisted of the following: musculoskeletal problems, neurological deficits, autoimmune diseases, cancer, history of neck and shoulder surgery, open wounds around the neck and shoulders, and allergic reactions to KT. Participants provided signed informed consent and the study was approved by the Ethics Committee for Human Research at MFU (REH-61241).

2.2 Sample size estimation

A sample size was estimated using findings from our pilot study. A 90% power of hypothesis test, an alpha level of 0.05, and effect size of 0.50 of neck-shoulder discomfort measured via 11-point numerical rating scale (NRS) were used for estima-tion. Twenty-four participants were required to detect a significant difference between KT and control groups.

2.3 Blinding and intervention

For randomization, participants were presented with a sealed opaque envelope containing two cards; participants were asked to choose a card to reveal their intervention condition. Randomization was carried out by a neutral researcher unaware of the intervention procedures. To minimize bias, the assessor did not know about the intervention or EMG data.

All participants performed the texting task on the iPhone 7 smartphone (Apple Inc., California), weighing 138 grams and featuring a 4.7-inch touchscreen with QWERTY keyboard. Before starting the procedure, participants were instructed on and familiarized with a two-handed texting technique using the smartphone. Prior to the task, participants laid supine for 15 minutes. For the task, participants sat on a height-adjustable unsupported chair, with 45 degrees of neck flexion, back straight, 90 degrees of hip and knee flexion, and feet on the floor. Both arms remained close to the trunk and eyes-to-smartphone distance was 30 cm. Participants communicated with a research assistant by texting answers to 120 yes-or-no questions posed by the research assistant using Line chatting program (Line Cooperation, Tokyo, Japan). Two digital cameras (Nikon D5300, Nikon Imaging Company, Thailand) were set up, one at the front and one at the right side of each participant; both were positioned two metres from the participant and linked to Kinovea (version 0.8.15). Developed by Joan Charmant, this open source video player enabled real-time postural correction to maintain neck, trunk, hip, and knee postures and correct those postures of the participants throughout the study period [23, 24].

For the KT group, standard 2-inch-wide kinesio Tex Tape was applied to each participant’s right shoulder, using a Y-strip technique. A Y-strip was defined as a section of tape partially cut down the middle, producing two tails. The tape was applied from the acromion process with paper-off tension; the first tail terminated at the C7 spinous process and the second terminated at the T3 spinous process with approximately 30 to 35% stretch [21]. Participants bent their necks to the left as the tape was applied (Fig. 1). For the no taping group, participants performed the texting task without any KT.

Fig. 1

Attachment of the kinesio taping on the shoulder.

2.4 Outcome measures

A blinded assessor evaluated outcomes. Measurements were taken at the same time of day to mitigate the effects of diurnal variation on muscle responses. The primary outcome measure was neck-shoulder discomfort as indicated by pain in the right neck and shoulder areas during texting. An 11-point NRS (0 equalling no discomfort, 10 equalling the worst discomfort imaginable) was used to quantify neck-shoulder discomfort [14].

Secondary outcome measures consisted of muscle activity and fatigue, measured by the normalized root mean square (NRMS) and normalized median frequency (NMF) respectively, using a surface EMG system (Biopac, Goleta, CA, USA). The EMG setting followed a method proposed previously [25]. The skin over the right cervical erector spinae (CES), lower trapezius (LT), and serratus anterior (SA) were cleaned with fine sandpaper and alcohol, and hair was shaved to reduce skin impedance to <5 kΩ. For the CES muscle, two electrodes were attached parallel to the belly of the muscle at the level of the C4 spinous process [14]. For the LT muscle, electrodes were attached at an oblique vertical angle 5 cm medio-caudal from the root of spine of the scapula with the shoulder in 90 degrees of flexion [26]. For the SA muscle, electrodes were applied along the mid-axillary line at the sixth and eighth right ribs during shoulder abduction at 90 degrees [26].

The root mean square (RMS) of the CES, LT, and SA muscles at the start and end point of smartphone texting was normalized using their maximum voluntary isometric contractions (MVICs) as described previously [27, 28]. The normalized RMS (NRMS) represented muscle activity. For each muscle, the MVIC test was performed for three five-second sessions. The middle third seconds over three MVIC sessions were averaged and used for normalization. A 30-second rest period was provided to prevent muscle fatigue between MVIC sessions [14].

The normalized median frequency (NMF) represents muscle fatigability. The signal spectrum was calculated by a fast Fourier transform with one-second data epochs. The NMFs at minute 0 and 30 were normalized by the initial MF value at minute 0 for each muscle. A lower NMF during an isometric contraction represented more muscle fatigue [29].

2.5 Statistical analyses

The Shapiro-Wilk test confirmed normal distribution of NRS, NRMS, and NMF data. A group-by-time (2×2) two-way repeated measures analysis of variance (ANOVA) was employed. When a significant group×time interaction effect was observed, pairwise comparisons were performed to examine group differences for each time. For within-group comparison, a paired t-test was used to evaluate differences of each outcome. An alpha level was set at 0.05 for the level of statistical significance. The statistical analyses were calculated with SPSS version 16.0 for Windows (SPSS Inc., Chicago, IL, USA).

The intra-rater reliability of MVIC testing of CES, LT, and SA muscles was evaluated on 10 participants via three assessments with a 30-second rest provided between measurements. The intraclass correlation coefficient showed excellent reliability of the CES, LT, and SA muscles [ICC(1,1) = 0.97, ICC(1,1) = 0.91, ICC(1,1) = 0.97 for CES, LT and SA, respectively].

3 Results

Two-way repeated measures ANOVA determined a statistically significant group×time interaction effect on the NRS rating neck-shoulder discomfort (F_(1,92) = 4.92, p = 0.03). Pairwise comparisons showed the KT group had significantly lower shoulder-neck discomfort than the no taping group at the 30-minute mark of the testing period (p = 0.03). A paired t-test showed significantly greater neck-sho-ulder discomfort in both groups (p < 0.001) (Table 1).

Table 1
Differences within group and between groups after performing 30-min smartphone texting task on numerical rating score (NRS) for neck-shoulder discomfort, normalized root mean square (NRMS) and normalized median frequency (NMF) of right side of the cervical erector spinae (CES), lower trapezius (LT), and serratus anterior (SA) in the kinesio taping or the no taping group

Variables Intervention group (n = 24) p-value Control group (n = 24) p-value Group difference p-value

Pretest mean±SD Posttest mean±SD Difference mean±SD (95% CI) Pretest mean±SD Posttest mean±SD Difference mean±SD (95% CI) mean±SD (95% CI)^*

Neck-shoulder discomfort (score) 0 4.25±1.92 4.25±1.92 <0.001 0 5.37±1.58 5.37±1.58 <0.001 1.12±0.51 0.03

(3.44 to 4.06) (4.71 to 6.04) (0.10 to 2.15)

NRMS of CES (%) 4.72±1.41 13.83±2.01 9.12±2.51 <0.001 4.46±0.95 15.50±2.49 11.03±2.88 <0.001 1.67±0.65 0.01

(8.06 to 10.17) (9.82 to 12.25) (0.35 to 2.99)

NRMS of LT (%) 4.92±1.36 13.41±1.37 8.49±1.68 <0.001 4.42±0.90 14.67±2.34 10.25±2.34 <0.001 1.26±0.55 0.03

(7.78 to 9.20) (9.25 to 11.24) (0.14 to 2.37)

NRMS of SA (%) 4.15±1.05 12.62±1.45 8.47±1.42 <0.001 4.32±0.89 13.47±2.40 9.14±2.60 <0.001 0.85±0.57 0.15

(7.85 to 9.09) (8.09 to 10.19) (–0.31 to 1.99)

NMF of CES (%) 100 77.17±8.03 22.83±8.03 <0.001 100 73.04±4.34 26.96±4.34 <0.001 4.13±1.86 0.03

(19.44 to 26.22) (25.13 to 28.79) (0.37 to 7.87)

NMF of LT (%) 100 78.94±4.68 21.06±4.68 <0.001 100 73.96±4.36 26.04±4.36 <0.001 4.98±1.31 <0.001

(19.09 to 23.04) (24.20 to 27.88) (2.35 to 7.60)

NMF of SA (%) 100 80.29±4.89 19.71±4.89 <0.001 100 78.66±4.66 21.34±4.46 <0.001 1.63±1.35 0.23

(17.65 to 21.77) (19.45 to 23.22) (–1.09 to 4.35)

Variables	Intervention group (n = 24)	p-value	Control group (n = 24)	p-value	Group difference	p-value
Neck-shoulder discomfort (score)	0	4.25±1.92	4.25±1.92	<0.001	0	5.37±1.58	5.37±1.58	<0.001	1.12±0.51	0.03
			(3.44 to 4.06)				(4.71 to 6.04)		(0.10 to 2.15)
NRMS of CES (%)	4.72±1.41	13.83±2.01	9.12±2.51	<0.001	4.46±0.95	15.50±2.49	11.03±2.88	<0.001	1.67±0.65	0.01
			(8.06 to 10.17)				(9.82 to 12.25)		(0.35 to 2.99)
NRMS of LT (%)	4.92±1.36	13.41±1.37	8.49±1.68	<0.001	4.42±0.90	14.67±2.34	10.25±2.34	<0.001	1.26±0.55	0.03
			(7.78 to 9.20)				(9.25 to 11.24)		(0.14 to 2.37)
NRMS of SA (%)	4.15±1.05	12.62±1.45	8.47±1.42	<0.001	4.32±0.89	13.47±2.40	9.14±2.60	<0.001	0.85±0.57	0.15
			(7.85 to 9.09)				(8.09 to 10.19)		(–0.31 to 1.99)
NMF of CES (%)	100	77.17±8.03	22.83±8.03	<0.001	100	73.04±4.34	26.96±4.34	<0.001	4.13±1.86	0.03
			(19.44 to 26.22)				(25.13 to 28.79)		(0.37 to 7.87)
NMF of LT (%)	100	78.94±4.68	21.06±4.68	<0.001	100	73.96±4.36	26.04±4.36	<0.001	4.98±1.31	<0.001
			(19.09 to 23.04)				(24.20 to 27.88)		(2.35 to 7.60)
NMF of SA (%)	100	80.29±4.89	19.71±4.89	<0.001	100	78.66±4.66	21.34±4.46	<0.001	1.63±1.35	0.23
			(17.65 to 21.77)				(19.45 to 23.22)		(–1.09 to 4.35)

Note: ^*Group difference at 30 min.

Effects of the significant interaction on the NRMS representing muscle activity were observed (F_(1,92) =6.75, p = 0.01; F_(1,92) = 7.38, p = 0.008; F_(1,92) = 1.12, p = 0.29 for CES, LT, and SA muscles, respectively). Pairwise comparison showed the KT group having significantly less the activity of CES and LT muscles than the no taping group at 30 minutes of testing (p < 0.05). When comparing within-group, all muscles showed significant decreases in activity in both groups (p < 0.001) (Table 1).

Significant interaction effects on the NMF representing muscle fatigue were observed (F_(1,92) = 4.87, p = 0.03; F_(1,92) = 14.55, p < 0.001; F_(1,92) = 1.45, p =0.23 for CES, LT, and SA muscles, respectively). Similar to the findings of muscle activity, the KT group had significantly less fatigability of CES and LT muscles than the no taping group at 30 minutes of testing (p < 0.05). When comparing within-group, all muscles showed a significant increase in their fatigability in both groups (p < 0.001) (Table 1).

4 Discussion

This study examined responses of neck-shoulder discomfort and EMG activation and fatigue of the CES, LT, and SA muscles during a 30-minute smartphone texting task. The study revealed that while the KT group had greater neck-shoulder discomfort, greater activation of the CES, LT, and SA muscles, and greater fatigability of those muscles compared to baseline, the KT group had greater neck-shoulder comfort, and reduced muscle activation and fatigability of the CES and LT than the no taping controls.

Smartphone texting with both hands is performed in many daily situations, such as while sitting on a train or bus. People often use their arms to hold smartphones in unsupported positions. The smartphone position is relatively low, leading to a tendency to flex the neck toward the device and pull the shoulders downward [30]. In this study, neck flexion during the texting task was maintained at 45 degrees, which may result in overloading neck and shoulder muscles compared with the neutral position of the neck and upper trunk [8 –10]. During smartphone use, the typical reasoning for the increased EMG activity of the CSE, LT, and SA muscles –which are the neck and upper trunk stabilizers [9 , 12] –is the generation of extensor moments against flexor moments relative to a flexed neck position [30]. Previous studies stated that prolonged low-load activation of the neck and upper trunk muscles may cause muscle fatigue and induce compression force on the adjacent tissues of the cervical spine, and eventual pain around the neck-shoulder area [8, 13].

To the best of our knowledge this study is the first to show that compared to the no taping group, the KT group had greater reductions in EMG activation and less fatigue of CES and LT muscles over the 30-minute texting task. This may be due to the beneficial effects of KT on muscle responses, although the mechanism for this phenomenon remains unclear. Prolonged muscle contraction could reduce muscle activation and increases muscle fatigue rate [32]. Muscle fatigability could be a result of several factors; particularly, an increase of intracellular metabolites such as protons (H+) and lactate associated with impaired cross-bridge activity [32]. This study used KT applied with tension, potentially increasing blood flow and lymphatic fluids; KT may provide greater spacing between the muscle, interstitial compartment, and skin, known as a skin-lifting effect [21, 31]. With taping, intracellular metabolites may be subsidized from the muscle to the blood circulation. Furthermore, the pulling force of KT may trigger cutaneous mechanoreceptors in fascia and subdermal soft tissues. As a result, the central nervous system integrates the sensory input and modulates gamma-motor firing, possibly improving muscle activation and fatigue [33] during prolonged texting.

The KT group reported less neck-shoulder discomfort compared to no taping controls. We acknowledge that the actual mechanisms by which KT relieves neck-shoulder discomfort are unclear, but KT effects influencing improving muscle fatigue may be a possible mechanism. This speculation may be supported by the previous findings reporting the correlation between muscle fatigue and perceived discomfort during manual task [34 –36]. In addition, KT tension may play a role for decreased neck-shoulder discomfort. KT may apply pressure to the skin or stretch the skin, possibly stimulating cutaneous mechanoreceptors causing pain or discomfort modulation (gate control theory) around the taped area [37]. In addition, participants who used KT reported that they felt stable and moderate skin tension, and less pain compared to the no taping group. However, psychological effects of taping may have affected participants’ feelings of discomfort; future studies should investigate this issue.

Limitations of this study include: 1) this study did not compare effects of KT with other taping techniques or sham controls, therefore further studies should be conducted; 2) as this study solely employed a smartphone in gauging subjective and muscle responses during texting, findings may not be generalized to other tasks, such as watching videos or reading e-magazines on smartphones; 3) as healthy young adults were studied, their results may not represent other populations such as older and/or unhealthy adults, notably those with existing neck or shoulder pain; and 4) findings of this study may not be generalized to other people who have different anthropometrics and characteristics when compared to those participants of this study.

5 Implication and conclusion

Neck-shoulder discomfort is a common symptom among smartphone users [8, 13]. Several interventions for relieving discomfort during smartphone texting have been proposed, but KT intervention on the shoulder is a potential alternative choice for smartphone users and therapists in order to delay reduction of activation and fatigue of neck and upper trunk muscles, and eliminate perceived discomfort on the neck and shoulder. As KT is thin cotton porous fabric with acrylic adhesive and latex-free, it could be comfortably worn for 3-4 consecutive days without compromising adhesive quality and it also limit skin irritation [21]. Thus, it could be a suitable and inexpensive approach which may be incorporated into the prevention of overuse or repetitive injuries of cervical spine or soft tissues around the cervical region resulting from prolonged smartphone texting.

In conclusion, study findings suggest that the utilization of KT on the shoulder during 30-minutes of smartphone texting can improve neck-shoulder discomfort, and decrease neck and upper trunk muscle fatigue and activations in healthy young adults.

Conflict of interest

The authors declare that there is no conflict of interest.

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