Accepted Manuscript

Can inhibitory and facilitatory kinesiotaping techniques affect motor neuron

excitability? A randomized cross-over trial

Amin Kordi Yoosefinejad, PT, PhD, Alireza Motealleh, PT, PhD, Shekoofeh
Abbasalipur, PT, Mahan Shahroei, PT, Dr. Sobhan Sobhani, PT, PhD, Assistant
Professor
PII: S1360-8592(16)30103-6
DOI: 10.1016/j.jbmt.2016.06.011
Reference: YJBMT 1376

To appear in: Journal of Bodywork & Movement Therapies

Received Date: 15 March 2016

Revised Date: 30 May 2016
Accepted Date: 1 June 2016

Please cite this article as: Yoosefinejad, A.K., Motealleh, A., Abbasalipur, S., Shahroei, M., Sobhani, S.,
Can inhibitory and facilitatory kinesiotaping techniques affect motor neuron excitability? A randomized
cross-over trial, Journal of Bodywork & Movement Therapies (2016), doi: 10.1016/j.jbmt.2016.06.011.

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 ACCEPTED MANUSCRIPT

Title page

Can inhibitory and facilitatory kinesiotaping techniques affect motor neuron

excitability? A randomized cross-over trial

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Amin Kordi Yoosefinejad, PT, PhDa, Alireza Motealleh, PT, PhDa, Shekoofeh

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Abbasalipur, PTa, Mahan Shahroei, PTa, Sobhan Sobhani, PT, PhDa*

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a. Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz

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University of Medical Sciences, Shiraz, Iran
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*Corresponding author:

Name: Dr. Sobhan Sobhani

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Assistant Professor of Physical Therapy

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Address: 1st Abivardi Avenue, Chamran Blvd, School of Rehabilitation Sciences

Department of Physical Therapy, Shiraz, Iran

Email: sobhan132@gamil.com

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Abstract

Objectives: The aim of this study was to investigate the immediate effects of

facilitatory and inhibitory kinesiotaping on motor neuron excitability. Design:

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Randomized cross-over trial. Method: Twenty healthy people received inhibitory

and facilitatory kinesiotaping on two testing days. The H- and M-waves of the

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lateral gasterocnemius were recorded before and immediately after applying the

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two modes of taping. The Hmax/Mmax ratio (a measure of motor neuron

excitability) was determined and analyzed. Results: The mean Hmax/Mmax ratios

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were -0.013 (95% CI: -0.033 to 0.007) for inhibitory taping and 0.007 (95% CI: -
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0.013 to 0.027) for facilitatory taping. The mean difference between groups was -

0.020 (95% CI: -0.048 to 0.008). The statistical model revealed no significant
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differences between the two interventions (P=0.160). Furthermore, there were no

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within-group differences in Hmax/Mmax ratio for either group. Conclusions: Our

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findings did not disclose signs of immediate change in motor neuron excitability in

the lateral gasterocnemius.

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INTRODUCTION

Kinesiotaping (KT), first introduced by Kase and colleagues in 1996 (Kase et al., 2003),

has become a popular adjunct technique to prevent or reduce musculoskeletal injuries. KT

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is designed to mimic natural human skin characteristics such as stretchability, elasticity

and thickness.(Kase et al., 2003) Several therapeutic benefits have been reported for the

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use of KT. Some studies found positive effects on pain and disability (GonzáLez-Iglesias et

al., 2009; Paoloni et al., 2011; Thelen et al., 2008), range of motion (Thelen et al., 2008;

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Yoshida & Kahanov, 2007), proprioception (Lin et al., 2011), muscle strength, and

performance.(Huang et al., 2011; Vithoulka et al., 2010) In contrast, other researchers

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found no beneficial effects of KT on clinical outcomes. In two studies of patients with
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patellofemoral pain syndrome and low back pain, the reduction in pain scores after KT was

not significant (Aytar et al., 2011), or was too small to be clinically meaningful.(Castro-
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Sánchez et al., 2012) Another study found that adding KT to conventional physical therapy
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did not improve quality of life in patients with neck pain.(Llopis & Aranda, 2012) Based on
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the available evidence, a recent systematic review concluded that the use of KT offers no

benefits over sham taping or placebo in a wide range of musculoskeletal

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conditions.(Parreira et al., 2014)

It has been suggested that KT affects muscle activity.(Hsu et al., 2009; Huang et al., 2011)
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KT is expected to have a facilitatory effect if applied from the origin to the insertion of the
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muscle, while reversing the direction of application is believed to have an inhibitory

effect.(Kase et al., 2003; Wong et al., 2012) Kuo et al. demonstrated that the effects of KT

may be direction-dependent.(Kuo & Huang, 2013) They applied both facilitatory and

inhibitory KT in a group of 19 healthy junior college students and observed significant

differences between the two techniques in maximum voluntary isometric contraction of the
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wrist and middle finger extensors.(Kuo & Huang, 2013) Two recent biomechanical studies,

however, found no difference between the two KT techniques in total work and peak

torques of the quadriceps muscle (Poon et al., 2015), or in maximum grip strength and

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electromyographic activity of the wrist extensor muscles in healthy people.(Cai et al., 2015)

These contradictory findings raise questions about the probable underlying

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neurophysiological mechanisms of different KT techniques. In particular, it is not clear

whether facilitatory or inhibitory techniques affect motor neuron excitability at all. To our

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knowledge, very few studies have investigated this effect.

Firth et al. examined the H-reflex responses of the calf muscles in athletes with Achilles

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tendinopathy. After KT was applied, the H-reflex amplitude remained unchanged.(Firth et
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al., 2010) However, the KT method used in their study was a tendon correction technique.

The present study aimed to shed light on the immediate effects of facilitatory and inhibitory
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KT techniques on motor neuron excitability in the lateral gastrocnemius muscle in healthy

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people. We hypothesized that the facilitatory KT technique would increase motor neuron
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excitability while inhibitory technique would decrease it.

MATERIALS AND METHODS

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Participants
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Twenty healthy individuals (11 male, 9 female) were recruited among students at Shiraz
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University of Medical Sciences with a convenience sampling method. The demographic

characteristics of our sample (mean ± standard deviation) were age 22.9±1.2 years, height

170±9.1 cm, and weight 68.4±12.8 kg. Volunteers were excluded if they had any history of

serious injury to the back or lower limb, any rheumatological or neurological disorders,

neurogenic low back pain, addiction to alcohol or any drug that might affect H-reflex

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parameters, leg length discrepancy, or myofascial trigger points in the lateral

gastrocnemius muscle. In addition, individuals who had previous experience of using KT

for regular or sports activity were excluded. All participants provided their informed consent

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in writing to take part in the study. The protocol was approved by the Ethics Committee of

Shiraz University of Medical Sciences (ir.sums.rec.1394.85).

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Study design

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This was a cross-over trial consisting of two sessions of taping (facilitatory and inhibitory)

one day apart to reduce the impact of possible carryover effects. The order of receiving the

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taping technique was counterbalanced by dividing the participants into two groups
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(facilitatory/inhibitory & inhibitory/facilitatory) randomly. The randomization was carried out

using a Random Sequence Generator program (available at http://www.random.org). On

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the first day, half of the participants received facilitatory taping and the other half received

inhibitory taping. The order was reversed on the second day.

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Outcome measure
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The amplitude of H-Reflex (recorded via sub-maximal stimulation of tibial nerve) is one of
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the measures to evaluate motor neuron excitability. This reflex measures the efficacy of

synaptic transmission through corresponding motor neuron pool of a muscle. Increasing

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the intensity of electrical stimulation produces a muscle response called M-wave due to
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direct stimulation of peripheral nerves. Because of the stability of the M-wave magnitude, it

is recommended to normalize that H-reflex by dividing the maximum H-reflex amplitude to

the maximum M-wave amplitude (Hmax/Mmax ratio).(Hoch & Krause, 2009; Palmieri et

al., 2004). The Hmax/Mmax ratio has been shown to have excellent intersession reliability

(ICC 2,1 = 0.979)(Hoch & Krause, 2009) and extensively used in various fields such as

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sports science and rehabilitation (Klykken et al., 2011; Lepley et al., 2014; Lo et al., 2012)

Due to its advantages over H-reflex, we decided to choose the Hmax/Mmax ratio as the

primary outcome of this study.

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A lower ratio indicates motoneuron inhibition, whereas a higher ratio indicates motoneuron

facilitation.

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Electromyographic measurement

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The skin was prepared by abrading with fine sandpaper and cleaning with alcohol. The H-

reflex was recorded with a Medelec Sapphire 2ME clinical electromyography unit

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(Medelec, Old Woking, UK). The tibial nerve was stimulated with a rectangular electrode
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placed in the middle of the popliteal fossa and the cathode placed proximal to the

anode.(Dumitru et al., 2002) The H- and M-waves were recorded from the lateral head of
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the gastrocnemius with a surface electrode. An imaginary line connecting the midpopliteal

fossa to the proximal flare of the medial malleolus was bisected to approximately locate
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the musculotendinous junction of the gastrocnemius muscle.(Dumitru et al., 2002) The

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lateral head of the gastrocnemius was determined by resisted plantar flexion. The ground

electrode was placed over the head of the fibula.(Lee & DeLisa, 2004) The duration of
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each stimulus was 1 ms (0.1 pps) and the intensity was gradually increased to obtain

Hmax and Mmax responses (Johnson & Pease, 1997) (Figure 1).
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Kinesio tape application

A trained physical therapist applied the KT. An adhesive waterproof KT 5 cm wide and 0.5

mm thick (3NS TEX Tape, 3NS Inc, Korea) was used in this study. The participants’ legs

were shaved from the knee down to increase the adhesion of the tape.(Kase et al., 2003)

The length of the tape was determined and was cut by estimating the muscle length and
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required tension. The KT was applied to the lateral gastrocnemius with the Y-shaped

technique as proposed by Kase and colleagues.(Kase et al., 2003) The proximal and distal

ends of the tape were applied under no tension while the foot was in a neutral position.

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The Y-shaped technique is used to either facilitate or inhibit muscle.(Kase et al., 2003)

Facilitatory KT was applied to the leg from the origin to the insertion of the lateral

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gastrocnemius at 50% tension, while inhibitory KT was applied from the insertion to the

origin at 15% tension (Figure 2).

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Procedures

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The procedures were described in detail to the participants. The participants’ barefoot
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weight and height were recorded. Then they were asked to lay prone with their arms at

their sides, head in a neutral position, and feet extended past the edge of the bed. All
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measurements were taken from the right leg. A pillow was placed under the ankle to allow

for slight knee flexion. Hmax/Mmax ratio was recorded before applying KT. After applying
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the first assigned taping according to the randomization scheme, Hmax/Mmax ratio was
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again recorded from the lateral gastrocnemius as described above. The tape was, then,

removed. The participants returned to the lab after 24 hours, and all the procedures were
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repeated for the second assigned taping technique. To avoid the negative effect of fatigue

on H-reflex amplitude, we asked the participants to get sufficient rest the night before the
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experiment.(Garland & McComas, 1990). Room temperature was maintained at between

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22 and 24 °C throughout the study.

Statistical analysis

Descriptive statistics were used to summarize the participants’ demographic

characteristics. The analysis was done with a linear mixed model with Hmax/Mmax ratio

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(average values) as the dependent factor, intervention (taping), sequence of intervention,

and period as fixed factors, and participant (nested in sequence of the interventions) as a

random factor. The sequence and period terms were included in the model to test for

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possible carryover effect. The effect of the intervention was determined with the mixed

model using a type III test. For within-group analysis, pre- and post-intervention scores

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were compared with paired t-tests. A two-sided P value <0.05 was considered significant.

All analyses were done with IBM SPSS version 20 (SPSS Inc., Chicago, IL). A post hoc

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power analysis (crossover 2×2) was conducted to determine the power of our sample size

with SAS software, version 9.2 (SAS Institute Inc, Cary, NC).

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RESULTS
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There were no sequence (P=0.722) or period (P=0.619) effects on the Hmax/Mmax ratios.
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The mean Hmax/Mmax ratio was -0.013 (95% CI: -0.033 to 0.007) for inhibitory taping and

0.007 (95% CI: -0.013 to 0.027) for facilitatory taping. The mean difference between
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groups was -0.020 (95% CI: -0.048 to 0.008). The mixed model revealed no significant
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differences between the two interventions (P=0.160). There were no within-group

differences in Hmax/Mmax ratio for either group (Figure 3). Post hoc power analysis
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confirmed that our sample size (n=20) had 98% power to detect a 20% mean difference

between the two KT groups.

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DISCUSSION
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Kinesiotaping has been claimed to have facilitatory or inhibitory effects on muscle activity.

Our aim was to clarify whether any neurophysiological modulation occurs at the spinal cord

level immediately after applying KT. We used the Hmax/Mmax ratio as an accepted

measure of motor neuron pool excitability. The results of our study showed that neither the

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facilitatory nor the inhibitory KT technique altered the Hmax/Mmax ratio in the lateral

gastrocnemius muscle. Moreover, by comparing pre- and post-treatment values, we found

no within-group changes in the Hmax/Mmax ratio in either of the KT groups.

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The effects of taping on motor neuron excitability remain debatable. Taping is believed to

influence motor neuron excitability by affecting cutaneous and muscle mechanoreceptors

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such as muscle spindles and Ia afferents.(Konishi, 2013; MacGregor et al., 2005) To date,

few studies have investigated the effect of KT on motor neuron excitability. Alexander et al.

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found that tape applied along the gastrocnemius may have an inhibitory effect on motor

neuron excitability, which contrasts with our findings. An explanation for this discrepancy

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may be the different types of tape used (non-elastic athletic type vs. KT).(Alexander et al.,
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2008) It is likely that skin and muscle mechanoreceptors are stimulated more by rigid tapes

than elastic ones. Moreover, Alexander et al. measured motor neuron excitability as H-
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reflex amplitude, whereas we used the Hmax/Mmax ratio which is regarded as a better
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estimate of motor neuron excitability.(Hoch & Krause, 2009; Palmieri et al., 2004) Another
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research group investigated motor neuron excitability after applying KT over the Achilles

tendon in both healthy people and people with Achilles tendinopathy.(Firth et al., 2010)
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Like us, they found no change in amplitude of the calf muscle H-reflex in either group after

KT application. Interestingly, H-reflex amplitude was increased in the healthy group after
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the tape was removed.(Firth et al., 2010) The authors speculated that the observed
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facilitation may be related to cutaneous input.(Firth et al., 2010) Therefore, evidence

regarding the effect of KT on motor neuron excitability still remains inconclusive.

A few studies have investigated the inhibitory and facilitatory effects of KT on muscle

strength.(Kuo & Huang, 2013; Vercelli et al., 2012) These investigations found neither

inhibitory nor facilitatory effects of KT on muscle strength.(Kuo & Huang, 2013; Vercelli et
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al., 2012) Moreover, a number of studies have evaluated the effects of KT on sports

performance, produced torque, muscle strength and function in healthy individuals

independently of tape direction. The results of these studies did not provide evidence in

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support of the use of KT to improve the measured outcomes.(Cai et al., 2015; Csapo et al.,

2012; de Almeida Lins et al., 2013; Huang et al., 2011) The influence of KT on

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electromyographic (EMG) results is still debatable. Although some studies found a

significant increase in EMG activity in the lower limb muscles after KT application (Csapo

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et al., 2012; Gómez-Soriano et al., 2014), other studies reported no change.(de Almeida

Lins et al., 2013; Halski et al., 2015) Nevertheless, the results of our study should not be

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compared directly with those mentioned above, because the relationship between H-reflex
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and EMG activity cannot be assumed to be linear.(Schieppati & Crenna, 1984) For

example, H-reflex amplitude can increase or decrease while EMG activity remains
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stable.(Thompson et al., 2009)

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Some limitations to our study should be noted. Firstly, our results can be generalized only
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to healthy people. Future studies are warranted to evaluate the directional dependency of

KT techniques in patients with neurogenic-based low back pain or S1 radiculopathy.

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Secondly, it was unfortunate that we did not include a functional task in our study. Earlier

studies have shown that the changes in Hmax/Mmax ratio after an intervention can differ
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under functional and resting conditions.(Aagaard et al., 2002; Voigt et al., 1998) For
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example, Voigt et al. investigated the Hmax/Mmax ratio in the soleus muscle after training

in hopping in a group of healthy adults. They found no difference in Hmax/Mmax ratios

measured during the resting condition. However, during the functional task (hopping), they

observed increased H-reflex excitability.(Voigt et al., 1998) Accordingly, we may speculate

that Hmax/Mmax ratios obtained after KT application might yield different results during a

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functional task. A final limitation was that our EMG apparatus did not have the capability

for concurrent recording of H-reflexes from the medial gastrocnemius and soleus muscles.

Although a previous study with athletic tape found that these muscles exhibited convergent

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changes in H-reflex amplitude in line with the lateral gastrocnemius (Alexander et al.,

2008), we are unable to discuss the implications of associated alterations in the

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Hmax/Mmax ratio in the medial gastrocnemius and soleus muscles. We hope that our

study will pave the way for further exploration of the possible effects of KT application. The

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main strength of our study is its randomized cross-over design, which is known to be a

statistically efficient approach with reduced inter-individual and experimental

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variability.(Senn, 2002)
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CONCLUSION
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In conclusion, our findings did not reveal signs of immediate change in motor neuron

excitability in the lateral gastrocnemius when measurements were taken in a static

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condition. Therefore, the results of previous studies may not be attributable to

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neurophysiological mechanisms.

Acknowledgements
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The authors wish to express their thanks to all the volunteers for their participation in our

study. We thank K. Shashok (AuthorAID in the Eastern Mediterranean) for improving the
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use of English in the manuscript. This study was supported by a grant from Shiraz
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University of Medical Sciences.

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Captions to illustrations

Figure 1. A representative recording of Mmax (left) and Hmax (right).

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Figure 1. Application of facilitatory (top) and inhibitory (bottom) kinesiotaping.

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Figure 2. Means and standard deviations of Hmax/Mmax ratio for facilitatory and inhibitory

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kinesiotaping.

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