Ankle elastic taping: stabilometric and electromyographic evaluation of postural control/Il bendaggio elastico della caviglia: valutazione stabilometrica ed elettromiografica del controllo posturale.
Stability and motor control are fundamental elements that influence outcomes of ankle traumatic sprains. Besides ankle proprioceptive rehabilitation and strengthening of stabilizer muscles of tibio-tarsic joint (in particular the muscles of the lateral sides of the leg), a lot of taping techniques have been developed in order to improve active control of movements, above all inversion and eversion.
In literature, many studies have confirmed the usefulness of nonelastic taping, because they offer a better mechanical support of the joint and increase proprioceptive reaction, stimulating skin receptors (7,12,14).
A considerable interest in elastic adhesive taping has recently grown, mainly about Kinesio Taping[R] method. Although diffusion and application of the method allowed to achieve successful outcomes, literature and scientific studies had not supported a real and complete efficacy of tape and papers are often discordant in terms of results, methods of application and judgment (3,4,5,6,9,10,15,16,17,18).
According to other authors, elastic tape could increase eccentric strength of quadriceps (17) or electrical activity of medial vastus, 24 hours after its application (15) contrasting Vercelli and Sartorio's assertions that have not noticed important Achievement (16), as well as De Almeida Lins et al (5). Some electromyoghraphic researches about ankle muscles have not pointed out neither a significant efficacy of elastic taping compared to non-elastic taping nor a better activation of Peroneus Longus during a sudden perturbation in inversion (10). On the contrary, other authors obtained only an electrical activity of Gastrocnemius Medialis increased during an execution of a vertical jump but that excluded, however, a performance improvement (9).
The main aim of this work was to examine and verify the elastic tape efficacy for neuromuscular control of the ankle in healthy, diseaseless patients. In particular we investigated Kinesio Taping[R] effects on ankle control, analyzing the centre of pressure (COP), which can be identified with ground projection of centre of mass (COM).
These effects were studied also with surface electromyography (sEMG), calculating the electrical activity of Tibialis Anterior (TA) and Peroneus Longus (PL) with Root Main Square (RMS).
A possible correlation between electromyographic and stabilometric response was also evaluated. For each variable, monopodalic standing posture was analyzed, with or without taping and with open or closed eyes.
A contextual bibliographic research was previously conducted on Pubmed search engine (NCBI), choosing the following keywords : "Tape", "Ankle", "Postural Balance", "Electromiography", "Proprioception". This test was conducted at movement analysis lab located in (University of Udine DISM Corso di Laurea Fisioterapia Udine-Italy).
44 volunteers, 13 males and 31 females.
Age: between 19 and 37 (mean [+ or -] SD of 22.7 [+ or -] 3.3 years).
Weight: between 47 and 88 kg (mean [+ or -] SD of 62.7 [+ or -] 9 kg).
Height: between 154 and 190 cm (mean [+ or -] SD of 170.2 [+ or -] 8.5 cm).
They are university students: 29 of them played sport constantly, 2 of them had never played any sport and 13 of them played sports for at least 5 years. Patients were excluded from the study if they were minor-aged, if they reported previous ankle or foot fractures or surgical interventions, recent sprains or traumas of lower limbs and also chronic functional instability of ankle due to previous 3rd-level sprain. Informed consent was signed by all subjects and their rights were protected. A single ankle of each patient was chosen (that is 23 right and 21 left).
We used a Kistler[R] force platform (type 9286BA, 400x600 mm) (11) composed of four 3-components piezoelectric transducers. Muscle electrical activity was recorded with a portable 8-channels sEMG (TeleEMG[R], BTS s.p.a. Italy), connected to the amplifier through optical fibres, set as follows: passband bandwidth 5-200 Hz, Notch filter switched on, gain 20 dB, sample frequency 500 Hz.
Kendall[R] surface electrodes made of Ag/AgCl were used. They have a diameter of 24 mm and are latex or PVC free (ARBO, Tyco Healthcare Group LP). Patients had their skin shaved and cleaned with an abrasive and conductive paste (EVERI[R], Spes Medica s.r.l.) before electrodes application, in order to reduce contact impedance.
The software used to collect and analyze data were Gait Eliclinic[R], MATLAB[R] (Matrix Laboratory, The MathWorks, Inc.) and Stata[R] 12.0 (Stata CorpLP).
Personal data and informed consent were collected when participants arrived to the laboratory. We asked them which ankle was the most stable, also making a short monopodalic pre-test (single leg balance test) in order to confirm their answer.
Someone could contest that we did not consider the lower limb dominance; however, according to some authors, this aspect does not condition monopodalic balance in sedentary people (1) and there are not differences of functional stability between dominant and non-dominant lower limb in healthy subjects (8). Furthermore, the most part of the tests used to identify lower limb dominance is based on subject's spontaneous choice during different functional actions (kicking a ball, hopping on one leg, defending from a fall, writing with a foot, etc.) and gave different explanations (1,2,8).
For sEMG reproducibility, SENIAM recommendations (13) were followed for electrodes application on Tibialis Anterior (TA), Peroneus Longus (PL), Rectus Femoris (RF), Biceps Femoris (BF), Gastrocnemius Medialis (GM), Soleus (SOL).
Skin area involved in taping was that relative to TA, PL and Tibialis Posterior (TP) as these are the muscles mainly recruited in concentric and eccentric ankle control. TP, because of its depth under skin surface, cannot be undergone to tape effect and cannot also be recorded by sEMG survey; for these reasons, taping was useful to support muscle action along its contraction direction, passing over GM and SOL. For each muscle on which we applied Kinesio Taping[R], we found and marked the origin and insertion point; later, the distance between these points, was measured putting the muscle in maximum elongation (plantar flexion for TA, eversion for TP, inversion for PL). The measure observed was inserted in an algorithm that adapted it in order to cut the tape guaranteeing the same tension for each subject. We used the tape application called "functional correction", which provided an elevate stimulation of receptors through a high level of tension; in this case the tape was around 75% of its maximum elongation. This choice was made with the purpose to give an elevate stimulation and a mechanical support to ankle muscles, so that they could contract with faster reactivity, stabilizing the joint during test perturbations. Each of 3 taping strips was applied fixing the anchors (without tension) with the muscles in minimum elongation, so that it stood above them as a "bridge"; later, we stuck tape on skin, doing a maximum muscle elongation. At the end, it was heated up rubbing with hands and sliced on the sEMG electrodes. Previously, a preliminary test was done in order to exclude any conduction interference between tape adhesive and electrodes surface.
At the end of every individual preparation, each subject had to have on 13 sEMG electrodes (two for every muscle and one for the grounding test) and the 3 Kinesio Taping[R] strips applied on TA, TP and PL [Fig 6].
After linking the portable sEMG to the electrodes, a randomized sequence was assigned to the participants; since experimental conditions could be with or without tape, and these, in turn, could be open-eyes (OE) or closed-eyes (CE), every sequence consisted of four different tests series:
1--without taping (OE), without taping (CE), with tape (OE), with tape (CE);
2--with tape (OE), with tape (CE), without tape (OE), without tape (CE);
3--without tape (CE), without tape (OE), with tape (CE), with tape (OE);
4--with tape (CE), with tape (OE), without tape (CE), without tape (OE).
Each tests series was set up by four repetitions in turn (16 tests to each subject in all).
Taping was applied from 10 to 15 minutes before the tests with tape, so that it could permit a sensorial adaptation. Tests consisted in maintaining monopodalic posture (standing on the tested ankle) for 22 seconds; the first and the last second were not considered in order to eliminate beginning and ending perturbations, so only 20 effective seconds were evaluated [Fig. 5].
Before starting every test, force platform was set with the subject standing on it with both legs.
Test position had to be done, as much as possible, with the foot centred on platform, upper limbs at the sides or slightly abducted, lower limb hanging with hip and knee flexed. If subjects had too many difficulties to hold this position (especially during closed-eyes tests), it was allowed to stretch slightly the arms or to lower the hanging leg, as long as they maintained the same posture during the whole tests. Tests were interrupted, cancelled and repeated when participants lost their balance or modified excessively their position; every three failed attempts a longer rest period was given. When subjects completed all the 16 tests, a short questionnaire was given to them; it had two questions with tree possible answers (improved/unchanged/worsened) to test if they felt a change in stability or fatigue sensation in the taped tests.
> Test avalaible on line at HTTP//AIFI.NET/SCIENZA-RIABILITATIVA
Data evaluated were: the statokinesigram length (total COP way during tests--declared in cm) and the RMS (Root Mean Square--declared in [micro]V) which quantifies the TA and PL electric signal because it reflects their activity during contraction. The sEMG signals of the other muscles were acquired just for monitoring and they did not influence the study.
Individual performances were obtained averaging out the 4 tests that composed each series. We selected the average value (rather than the best or last performance) because it mainly limits individual variability, training effect, fatigue and outliers incidence.
Open-eyes and closed-eyes tests were independently analyzed, because they are not comparable. Variables were summarized with mean and standard deviation or median and range.
Shapiro Wilk's test was used to test if variables were spread out in a Gaussian way or not.
In order to compare quantitative variables, we used t-test for coupled variables if data spread out in a Gaussian way; otherwise we used Wilcoxon test for coupled data. To evaluate the correlation among quantitative variables, we calculated Pearson's r coefficient, if possible; otherwise we used Spearman's coefficient of rank correlation.
Kinesio Taping[R] incidence was effective if statistically there was a significant decrease of COP values in the tests with tape compared to those without it. [Table I, II, IV]
Analyzing with a two-tailed test the differences produced by the tape to COP, RMS of TA and PL, there was no statistic relevance (p value > 0.05). Nevertheless some cases had benefits from tape application, improving postural control. In 59.1% of open-eyes conditions, there was an improvement of 11.51% in postural control (about 0.54 cm/sec less in COP length, in a period of 20 seconds); in closed-eyes conditions, 56.8% of cases had about 10.64% of improvement (about 0.92 cm/sec less in COP length during the recording period). [Table III and Fig. 1,2,3,4]
In order to examine the possible interactions between stabilometric and electromyographic performance, correlation coefficient and regression line were calculated among changes produced by taping to COP and RMS. These differences (?) were obtained subtracting average values of conditions with tape to those without tape. [Fig. 1,2,3,4]
Graphics show the linear regression among differences caused by tape to studied muscles in COP (x-axis) and RMS (y-axis). You can observe that a moderate correlation exists in most part of cases (0.3 < r < 0.7) among COP and RMS trend of changes; in one case you have a strong correlation (r > 0.7). Furthermore, about 70% of subjects of the 4 analyzed conditions shows a decreasing postural oscillation (COP values) coupled with a decreasing muscular electrical activity (RMS).
Questionnaires investigated participants' subjective perception to evaluate how the change they felt could be compared to the quantitative variations recorded during tests. Examined conditions concerned on one hand stability, control and safety sensation of taped ankle, on the other hand the fatigue felt to maintain test positions.
Concerning stability, 27 cases reported improvements, 9 reported worsening and 8 reported that the situation was unchanged; sense of fatigue decreased in 16 subjects, increased in 3 and remained unvaried in 25.
As far as the variable stability and control is concerned, a correspondence between the objective and the perceived result by the subject in 22 cases was observed; however rarely a correspondence for the variable fatigue was evidenced (7 cases).
Some subjects reported that the test sequences they made influenced definitely the detected results, increasing their fatigue in the last test (6 cases) or allowing them to acquire a better strategy as shown in the improvements of the final tests (5 cases). Some participants pointed out that the benefits they felt occurred only in open-eyes sequences (4 cases) or only in closed-eyes sequences (2 cases).
The main purpose of the study was to investigate the effects of Kinesio Taping [R] on ankle neuromuscular control; analyzing statistic data with a two-tailed test (t-test for coupled data), there were no significant differences in COP and RMS values for TA and PL muscles.
As we noticed in the questionnaires, an important outcome was the probable influence caused by the assigned sequences; starting the sequence with closed-eyes tests (without preliminary training test) influenced negatively some performances of the sample. In the same way, performing specific tests at the beginning, probably allowed to learn a strategy for the following exams, causing an improvement due to a training effect. Nevertheless, this result should have been cancelled because of the use of a randomized sequence which is well-balanced among the sample (4 type of sequences for 44 subjects) in order to allow the improvements of test taken first with tape and then without tape. Actually, improvements (in terms of decrease of COP values) were mostly shown in sequences started with tape applied, independently from open-eyes or closed-eyes conditions.
Some authors declared that Kinesio Taping[R] needs a longer period of application to be incisive (17), as affirmed Slupik et al. (15) in his study, where a significant increase of electrical activity was found in muscles undergone to taping action for more than 24 hours.
We investigated the possible correlation between data of postural control (COP) and electrical activity indicators of ankle muscles (TA and PL RMS). Differences in COP oscillations were calculated in each condition, that is with or without tape, so that positive values suggested a decrease of postural oscillations ([DELTA]COP > 0; [DELTA]COP = COPN--COPY; N = without tape; Y = with tape). In the same way, RMS variations were calculated, in order to describe electrical power of the muscles ([micro]V). Considering the differences of this datum between RMS tests with or without tape, a positive value indicated a reduction of electrical activity in tests with tape ([DELTA]RMS > 0; [DELTA]RMS = RMSN--RMSY; N = without tape; Y = with tape); instead, a negative result ([DELTA]RMS < 0) indicated an increase of electrical activity in muscles without tape.
As results showed, a moderate or strong linear correlation exists between decreases of COP and RMS in conditions with tape; this may suggest that Kinesio Taping[R] acts positively on ankle control, decreasing postural oscillations and electrical activity of muscles. Half of the cases showed a direct correlation (increase or decrease) in [DELTA]COP and [DELTA]RMS for both muscles, in open-eyes (21 cases) and closed-eyes (24 cases) conditions.
Generally speaking, you could think that muscle activities should increase to improve a joint active control. Supposing that posture is kept with a minimal expenditure of energy in healthy young subjects without ankle instability, data collected in this study suggest a different hypothesis: Kinesio Taping[R] could have a direct effect on ankle proprioceptors, improving monopodalic standing control through a reduction of muscular electrical activity.
Basing on these study results, we cannot affirm that Kinesio Taping[R] causes significant modifications to values of COP and RMS (of TA and PL) in healthy subjects who belong to sampled population.
However, we found a correlation [Table III and Fig. 1,2,3,4] between the changes of COP and RMS in muscles with tape, so we can say that between 68.2% and 72.7% of cases, to a reduction of COP values corresponds a reduction of RMS for both muscles and vice versa.
Some doubts that emerged from the study concerned electromyographical (RMS values of TA and PL) interpretation of proprioceptive function of tape; the RMS and COP correlation obtained allowed us to suppose that Kinesio Taping[R] would improve monopodalic postural control (i.e. reduction of COP values) through a reduction of muscles electrical activity, acting directly on ankle proprioceptors. The influence of the different sequences on subjects' performance must be taken into consideration, according to what they reported in questionnaires.
Regardless of statistical effectiveness, 59.1% and 56.8% of subjects had benefits from tape application, both during open-eyes and during closed-eyes conditions, decreasing their COP oscillations of over than 10.64-11.51% (statokinesigram length reduced between 0.54-0.92 cm/sec during test periods).
It is important to note that this study was conducted on healthy, athletic (or ex athletic) and young people; we can suppose that they could not have had any benefit from taping application and could even have had some troubles in their performances because of their good ankle control. Maybe, as supposed by other authors16, afferents stimulated by Kinesio Taping[R] could lead to better results on pathological subjects with ankle instability or postural instability of different etiologies.
CONFLICT OF INTEREST
None of the authors report a conlict of interest.
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Vidi Daniele , Peresson Andrea , Moratti Ugo 
 PT MSc in Rehabilitation Sciences--Teacher in Orthopedic Rehabilitation University of Udine
 PT private pratictioner
 Neurophysiophatology Technician, S. Maria della Misericordia Hospital of Udine Acknowledgement: Prof. Isola Miriam for statistical support
Table I--Summarizing table of improved cases with tape. Open eyes Closed eyes Improved cases 26/44 (59.1%) 25/44 (56.8%) Worsened cases 18/44 (40.9%) 19/44 (43.2%) % means improved 11.51% 10.64% % means worsening 10.91% 11.61% Table II--Statistical analysis (mean [+ or -] standard deviation) of tests with open and closed eyes, with (Y) and without (N) tape, related to postural control (COP = Centre of Pressure) and myoelectrical activity of Tibialis Anterior muscle (RMS TA) and of Peroneus Longus muscle (RMS PL). * the value of p was calculated with t test for coupled data. Open eyes Without Tape With Tape (Y) P * (N) m [+ or -] sd m [+ or -] sd COP (cm) 87.8 [+ or -] 21.0 84.8 [+ or -] 19.1 0.091 RMS TA (MV) 131.4 [+ or -] 56.0 123.8 [+ or -] 49.7 0.096 RMS PL (MV) 138.1 [+ or -] 37.5 140.7 [+ or -] 40.5 0.313 Closed eyes Without tape (N) With tape (Y) P * m [+ or -] sd m [+ or -] sd COP (cm) 157.9 [+ or -] 38.3 154.7 [+ or -] 34.1 0.354 RMS TA (MV) 208.0 [+ or -] 45.1 206.2 [+ or -] 46.6 0.687 RMS PL (MV) 193.1 [+ or -] 47.0 194.9 [+ or -] 49.7 0.571 Table III--Pearsons r coefficient among variation ([DELTA]) of centre of pressure ([DELTA] COP) and myoelectrical activity of Tibialis Anterior and Peroneus Longus. We considered the differences between condition with (Y) or without (N) tape. Open eyes Closed eyes [DELTA] = Y - N r [p.sup.*] R [p.sup.*] ACOP/ARMS TA 0.511 0.0004 0.623 0.0000 ACOP/ARMS PL 0.535 0.0002 0.722 0.0000 Table IV--COP (Centre of Pressure) improvements in different sequences. Start sequence Open eyes Closed eyes Without Tape 18 (40.1%) 18 (40.1%) With Tape 8 (18.2%) 7 (15.9%)
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|Title Annotation:||ARTICOLO ORIGINALE|
|Author:||Daniele, Vidi; Andrea, Peresson; Ugo, Moratti|
|Date:||Apr 1, 2015|
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