The effects of Kinesio taping on pain intensity and soft tissue mechanical properties in non-specific low back pain.

doi:10.21203/rs.3.rs-2999203/v2

Objective:To assess the effects of Kinesio Taping (KT), with or without tension, and post-isometric muscle relaxation (PIR) on pain intensity and the mechanical properties of myofascial tissues in chronic low back pain (LBP) patients.

Material and methods: Study participants (n = 64), aged 20 to 60, were randomly assigned to one of the three intervention groups. The numerical rating scale (NRS) assessed pain intensity at rest, and the MyotonPRO© measured tension, stiffness, and relaxation in the erector spinae on both sides of the lumbar spine. The examinations were undertaken before the intervention, post-interventions, and at a seven-day follow-up.

Results: Pain level was reduced for all groups (F (4, 116) = 39.2010, p < 0.01). In addition, post hoc analysis of the KT group showed significant increases in the tension and stiffness of the erector spinae and significantly decreased relaxation between the pre-intervention and follow-up measurements, but only on the non-dominant side (p < 0.01).

Conclusions: KT with or without tape tension and PIR had similar effects in decreasing the level of resting pain, though there were no intergroup differences in the numerical pain scale or selected mechanical properties. Asymmetries in myofascial tissue between sides of the spine have occurred, it can be concluded that the interventions were insufficient to restore normal function in soft tissue.

Health sciences/Diseases

Health sciences/Health care

Health sciences/Signs and symptoms

Kinesio Tape

therapy

complementary

tension

stiffness

mechanical properties

Non-specific low back pain (LBP) is the most common musculoskeletal problem and affects approximately 80% of the adult population at least once during their lifetime [1]. Chronic LBP is a back pain problem that has persisted for at least three months [2]. Such pain leads, in most cases, to limited mobility and increased lumbar spine stiffness [3, 4].

Biomechanical properties of muscle, such as tension and stiffness, are objective parameters that describe the state of tissues [5]. Muscle stiffness is the ability to resist changes in muscle shape caused by an external force, and the mechanical stress relaxation time characterizes tissue recovery time from such displacement. Meanwhile, maintaining structural stability depends on resting muscle tension, with muscle tone (frequency) characterizing muscle tension at rest. The higher the muscle tension or stiffness, the faster it recovers its shape and the lower the value obtained (https://www.myoton.com). However, hypertonicity can cause high intramuscular pressure and detrimentally affect muscle recovery [6].

Pain intensity in adults with LBP was not associated with stiffness of the lumbar erector spinae muscle [7, 8]. In contrast, the visual analog scale (VAS) score correlated positively with lumbar extensor myofascial tone and stiffness on both sides and negatively correlated with elasticity in elderly LBP patients [9]. In addition, back pain patients may need additional spinae muscular stabilization due to reduced passive spinae stiffness resulting from damage to the intervertebral disc or ligaments [10]. Moreover, lumbar multifidus muscle stiffness was significantly higher in LBP patients than in the pain-free control group [13], while individuals with sub-acute LBP had greater trunk stiffness than those without LBP [14]. Such differences justify further investigations into the mechanical properties of muscle to build an objective evidence base. As such, Kinesio taping (KT) could be combined with core stability exercises to improve pain and balance in LBP patients [11, 12].

Kinesio tape can be stretched up to 140% of its original length, similar to the stretch capability of normal skin, and is used for treating musculature-related conditions [15]. Indeed, patients with chronic non-specific LBP achieved better pain relief and higher activities of daily living (ADL) scores than controls when using KT [16]. Furthermore, a meta-analysis study found that KT was superior to other conventional therapies, such as physical therapy, combined massage, strength training, endurance training, acupuncture, and high or medium-frequency electric therapy, in relieving pain and improving ADL in non-specific LBP patients [16]. Nonetheless, it is suggested that KT is a complementary therapy that helps to reduce pain and disability while also enhancing the lumbar flexion range of motion when used in conjunction with conventional physical therapy, including transcutaneous electrical nerve stimulation and supervised exercise therapy [17].

The post-isometric relaxation (PIR) technique is based on exerting optimal resistance through the work of the patient and therapist and may induce change via reflex mechanisms. The technique reduced tension within a muscle or group of muscles and increased muscle tolerance to stretch, which was thought to be caused by isometric contraction-induced stimulation of the Golgi tendon organs [18, 19, 20]. Unfortunately, studies on the efficiency of the muscle energy technique on pain in patients with non-specific back pain provide low-quality evidence [19]. However, investigating other stretching and movement-related interventions may provide further insight into the mechanistic changes and influencing factors [21].

This study measured biomechanical properties of soft tissue in response to specific physiotherapeutic interventions: KT and PIR in the LBP population to determine effects subjectively and objectively. The study hypothesis states that applying KT or PIR reduces pain intensity at rest, and increases muscle tone and stiffness, but decreases relaxation time in tissue viscoelasticity of lumbar spine extensor in LBP patients.

Study participants were recruited through word of mouth, posters, and social media and included 64 patients with non-specific LBP (females, n=34; males, n=30). The inclusion criteria were patients with chronic LBP syndrome, pain intensity on the numerical rating scale (NRS) between one and six on the day of examination, and aged 20-60 years. Exclusion criteria included neurological and rheumatoid diseases, radiating pain below the buttock fold, and recent post-traumatic orthopedic diseases.

Each participant gave signed consent to participate in the study. The study used simple random assignment, by giving every participant in the sample a unique number and manually, random assigning each participant to one of the research groups undergoing a selected therapeutic intervention: PIR group, KT group, or placebo (KT-PEBO) (Table 1).

The Wroclaw University of Health and Sport Sciences Research Ethics Committee approved the project (14.02.2020). All participants had to be tested three times for the study to be fully conducted: before intervention (PRE), seven days after therapy (POST), and after a further seven therapy-free days, to evaluate the effect of the interventions (FOL) [22]. Pain intensity was assessed using the Numeric Rating Scale (NRS).

The non-invasive MyotonPRO© diagnostic tool (Myoton AS, Tallinn, Estonia) was used to measure biomechanical properties in the lumbar region after causing mechanical deformation of the soft tissue by applying 15 ms mechanical pulses and a mechanical force of 0.40 N. All measurements were taken in the supine position with hands positioned to the side of the body. The assessments were blinded to participants. The erector muscles of the spine were examined at the L2 vertebrae level at the same points on both sides. The probe of the device (diameter 3 mm) was placed perpendicular to the surface of the skin, and the device program distributed five mechanical impulses to the muscles and recorded frequency (Hz), dynamic stiffness (N/m), relaxation time (ms) state of tension and tissue viscoelasticity [23]. The analysis was based on the mean value of three consecutive measurements, on dominant (D), and contralateral side (OP). The myotonometer between-day and intra-rater reliability was acceptable when used to measure muscle tone and stiffness in young adults with chronic LBP in an outpatient setting [24].

Interventions

The group (PIR) underwent therapy of the erector spinae muscle, for which they performed three series of self-PIR exercises for seven days. For each treatment series, the participants performed five repetitions of muscle tension and relaxation phases, with a single tension lasting five to seven seconds and the relaxation phase with stretching of the erector spinae muscle lasting three to four seconds.

The group (KT) underwent a seven-day intervention that included an H-shaped KT of the lumbar spine. The first base was applied at the level of the twelfth rib, and the patch was applied with the participants in a bent forward position with a tension of 15 to 20%. After participants returned to the starting position, the final base was glued at the level of the sacroiliac joints (about 2-3 cm) without tension. The same application was made on the other side of the spine. Finally, the third patch was applied transversely to the first two with a tension correction of 70-80% using the musculoskeletal method, then the bases of the patch were glued on both sides without generating tension [25, 26].

The group (KT-PEBO) received a placebo KT, with the patches applied in an H-shape similar to the KT group (3NS-TEX). The same type of plaster was applied from the level of the twelfth rib to the sacroiliac joints on both sides of the spine and laterally without tension and movement of the participant. Applications had to be maintained for seven days, if possible. In addition, subjects from all groups received instructions on how to perform everyday activities according to the principles of alignment of the spine. Ergonomic adjustments can prevent sick leave due to LBP but the quality of evidence is very low [1].

Statistics

The Statistica software package (StatSoft Poland, Krakow, Poland) was used for analysis. Power analysis and sample size selection assumed a clinically significant effect size of 20% change in pain intensity [27], and a sample size of 20 participants was sufficient to provide a study design with acceptable power (0.8) at P < 0.05. The Shapiro-Wilk test determined the normality of the data distribution. The one factor parametric/nonparametric ANOVA analyzed the differences between demographics. The three-factor ANOVA was compared between-group means using the main effects of the intervention group (PIR, KT, and KT-PEBO), treatment time (PRE, POST, and FOL), dominant side (D), and contralateral side (OP). The analysis of variance was performed by controlling the observed power and effect size measurements (Eta squared), with an Eta square of 0.01 representing a small effect, 0.06 an average effect, and 0.14 indicating a large effect [28]. The Bonferroni correction method was used for post hoc analysis. The results are graphed as means and 95% confidence intervals. A value of p < 0.05 was assumed to be significant.

Demographics.

There were no statistically significant differences between the three intervention groups (p>0.05). The participants’ demographic data are summarized in Table 1.

Intensity of rest pain.

The treatment time reduced pain intensity on the NRS significantly (F (4, 116) = 39.2010 (p = 0.0043, Eta = 0.40), with the post hoc analysis showing a significant decrease in the NRS between the PRE and FOL studies in the PIR group (p = 0.0047), and between PRE and POST and PRE and FOL in the KT and KT-PEBO groups (p < 0.001 ). However, there was no effect of intervention between groups for the NRS variable (p > 0.05) and no interaction between the intervention group and treatment time (F (4, 116) = 1.9056, p = 0.1141) (see Figure 1).

Lumbar spine extensor muscle tone, stiffness, and relaxation.

There was no main effect of intervention groups (p>0.05) on variable frequency (maximum) natural oscillation and no significant interactions between intervention, time, or side (F(4, 116) = 1.0379, p = 0.3908) across all intervention groups. However, a significant time effect was observed within all study groups (F (2, 116) = 6.563, p = 0.0020, Eta = 0.05). In the post hoc tests, the frequency increased significantly between the PRE and FOL examination in the KT group when comparing the OP and D sides (p < 0.01) (see Figure 2).

Analysis of variance for the stiffness variable indicated a main effect of increasing soft tissue stiffness over time (PRE, POST, FOL) (F = 6.87, p = 0.001, Eta = 0.10), time and site interactions (F = 4.27, p = 0.01, Eta = 0.06) and time, site, and group interactions (F = 2.60, p = 0.03, Eta = 0.08). In addition, post hoc tests showed a difference between PRE and FOL, on the OP side in the KT group (p < 0.001) (see Figure 3).

A main effect was demonstrated in all intervention groups for the erector spinae muscle relaxation time (F = 5.69, p = 0.004, Eta = 0.08), although there was no main effect of the intervention groups for the relaxation variable (p > 0.05). Also, there was no significant interaction of intervention, time, and site between all study groups (F = 1.3894, p = 0.24195), though a significant interaction of time and side was indicated (F = 4.37, p = 0.01, Eta = 0.07). In post hoc tests, there was a difference between PRE and FOL in the KT group, on the OP side (p < 0.05) (see Figure 4).

The most crucial finding was that all three groups had pain reduction. However, there were no intergroup differences in the NRS or selected mechanical properties of the paravertebral tissues. Nonetheless, higher variable stiffness and frequency and lower relaxation times were observed in the KT group between PRE and FOL, only in the OP side, demonstrating effects of the intervention. Asymmetries in myofascial tissue between sides of the spine have occurred in the KT group.

The participants in both KT intervention groups experienced a clinically significant 20% reduction in pain intensity [27]. A meta-analysis of studies comparing KT with sham taping therapy found no significant reduction in resting pain, as in our research [29]. In another review, the authors did not show any benefits of KT compared to sham taping and other forms of therapy, or the effects were too small to be clinically significant [30]. Moreover, the KT inhibitory muscle technique and tape conditions did not evoke significant effects on muscle activity or arm function in apparently healthy muscles [31]. In contrast, substantial pain reduction was observed using KT compared to placebo taping after three days of therapy [32].

A study on a young and healthy population provided insight into the mechanisms underlying KT therapy, demonstrating an impact on skin thickness and surface stretching. Such effects could increase proprioception and allow subjects undergoing KT to avoid postures and movements associated with injury or pain. Moreover, the changes in skin thickness could alleviate swelling associated with many lumbar pain pathologies [33, 15].

The effects of PIR and KT in myofascial pain therapy were similar, with increased frequency and stiffness observed in all groups over time, regardless of the intervention used [34]. In this study, the greatest increases in frequency and stiffness were found between the PRE and FOL tests in the KT group but only in the OP. Such asymmetry of the spine may result from the pathology of the lumbar spine in LBP patients that affects mechanical properties, contractile elements, and elastic connective tissues that determine flexibility and muscle tension. It is worth noting that the collagen content of muscles can differ, with slow-twitch (ST) fibers containing more collagen fibers than fast-twitch (FT) fibers, meaning that the former has increased stiffness. In addition to the composition of muscle fibers, their abundance also significantly impacts flexibility due to the fascia surrounding each fiber [35, 36]. Muscle cellular, morphological, and functional characteristics are associated with LBP and degenerative spine disorders [37]. Therefore, the multifactorial nature of LBP demands a spectrum of interventions for restoring function to the paraspinal muscles [38, 39].

Outcomes from the interventions in the KT and KT-PEBO groups differed, with objective assessment indicating that the KT-PEBO intervention did not significantly affect the mechanical changes of soft tissues, unlike the KT intervention. Indeed, the tension, stiffness, and relaxation values in the KT group approached the average normative values for a given age [9], but only on the OP. The stiffness of the erector spinae muscle at the L3-L4 level in healthy people aged 38.0 ± 12.0 was shown to be 290.12 ± 72.15 and 301.89 ± 85.04 N/m, on the left and right sides [40], with no side-to-side differences identified when applying Student’s t-tests to measurements in LBP and Control groups [41], indicating the symmetry of stiffness as the normative value. Another study found no significant association between pain intensity and muscle stiffness and tone in chronic LBP. However, an association was observed between the mechanical properties of muscle and disability level. Therefore, muscle tone and stiffness measured by a myotonometer may be reliable outcome measures for assessing intervention-induced changes [40].

An important limitation of this study is the fairly significant age range of the participants, as other studies report changes in the mechanical properties of soft tissues in young adults and older adults [41], and males and females [42]. Evidence-based definitions for orthopedic follow-up intervals offer a citable standard for the planning and design of clinical studies: a minimum mean follow-up of a short-term study should be 30 months [43]. There is no data for muscle activity interpretation, but the mechanical properties of muscles, or the properties of subcutaneous tissues and skin elasticity. Nonetheless, the limitations of the technology should not impact the reliability of the analysis since all measurements were consistent across groups.

KT with or without tape tension and PIR had similar effects in decreasing the level of resting pain, though there were no intergroup differences in the numerical pain scale or selected mechanical properties of the paravertebral tissues. Asymmetries in myofascial tissue between sides of the spine have occurred, it can be concluded that the interventions were insufficient to restore normal function in soft tissue.

Author Contributions: Conceptualization, T.S., and B.B-P.; methodology, T.S., and B.B-P.; software, T.S., and B.B-P; validation, T.S.; formal analysis, T.S.; investigation B.B-P.; resources, T.S. and B.B-P; data curation, T.S. and B.B-P.; writing of original draft, T.S., and B.B-P; writing, review and editing, T.S. and B.B-P; visualization, T.S. and B.B-P; supervision, T.S.; project administration, T.S. and B.B-P.

All authors have read and agreed to the published version of the manuscript.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (the Ethics Committee of the Wroclaw University of Health and Sport Sciences, protocol code and data 14.02.2020).

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Conflicts of Interest: The authors declare no conflict of interest.

Data availability: The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Table 1: Demographics before the intervention.

	PIR (n=20) (females=10;males=10)		KT (n=21) (females=11;males=10)		KT-PEBO (n=23) (females=13;males=10)		ANOVA
	M ± SD	Me	M ± SD	Me	M ± SD	Me	F/H; p-value
Age (years)	41.7 ± 9.26	41.5	39.62 ± 7.80	39	44.48 ± 5.70	46	F(2, 61)=2.24 p=0.11
Weight (kg)	77.85 ± 18.06	78	77.71 ± 12.02	80	82.91 ± 13.06	82	F(2, 61)=0.92 p=0.40
Height (m)	1.75 ± 0.11	1.74	1.70 ± 0.091	1.68	1.73 ± 0.084	1.71	F(2, 61)=1.02 p=0.36
BMI (kg/cm²)	25.32 ± 5.08	24.7	26.60 ± 3.61	26.8	27.68 ± 4.06	27.4	F(2, 61)=1.63 p=0.20
NRS (0-10)	3.00 ± 1.78	2	3.95 ± 1.28	4	4.09 ± 1.81	4	H (2, 64)=5.41 p=0.06

Abbreviations: BMI - Body Mass Index, PIR - post-isometric muscle relaxation group, KT - Kinesio taping group, KT-PEBO - Placebo, M ± SD - mean ± standard deviation, Me - median, N - number, NRS - Numerical Rating Scale, H -Kruskal-Wallis test.

No competing interests reported.

The effects of Kinesio taping on pain intensity and soft tissue mechanical properties in non-specific low back pain.

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Version 2

Abstract

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Introduction

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Status:

Version 2