Journal Pre-proof

The effectiveness of Biomechanical Taping and KinesioTaping on Shoulder pain,

active range of motion and function of participants with Trapezius Myalgia: a
randomized controlled trial

Valentin III.C. Dones, Jocel M. Regino, Nicole Trizia S. Esplana, Ivan Rafael V.
Rivera, Melissa Kaye R. Tomas
PII: S1360-8592(20)30027-9
DOI: https://doi.org/10.1016/j.jbmt.2020.02.004
Reference: YJBMT 1923

To appear in: Journal of Bodywork & Movement Therapies

Please cite this article as: Dones ., V.I.C, Regino, J.M., Esplana, N.T.S., Rivera, I.R.V., Tomas, M.K.R.,
The effectiveness of Biomechanical Taping and KinesioTaping on Shoulder pain, active range of motion
and function of participants with Trapezius Myalgia: a randomized controlled trial, Journal of Bodywork &
Movement Therapies, https://doi.org/10.1016/j.jbmt.2020.02.004.

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 The effectiveness of Biomechanical Taping and KinesioTaping on Shoulder pain, active range of motion
and function of participants with Trapezius Myalgia: a randomized controlled trial

Authors’ Names

Dones, Valentin III C. , PhD, MSPT, PTRP1,2

Regino, Jocel M. , MSPT, PTRP1,2
Esplana, Nicole Trizia S.1
Rivera, Ivan Rafael V.1
Tomas, Melissa Kaye R.1

College of Rehabilitation Sciences, University of Santo Tomas1

Center for Health Research and Movement Science, College of Rehabilitation Sciences, University of
Santo Tomas2

Corresponding Author
Valentin C. Dones III, PhD, MSPT, PTRP, COMT
Research Supervisor
Center for Health Research and Movement Science
College of Rehabilitation Sciences
University of Santo Tomas
Manila, Philippines
Email: vcdones@ust.edu.ph
Cellphone number: +639176364967

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13 The effectiveness of Biomechanical Taping and Kinesio Taping on shoulder pain, active range

14 of motion and function of participants with Trapezius Myalgia: a randomized controlled trial

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24 List of Abbreviations

25 AROM, active range of motion

26 BMT, Biomechanical Taping Technique

27 DASH, Disability of the Arm, Shoulder and Hand

28 KT, Kinesio Taping

29 MET, Muscle Energy Technique

30 TM, Trapezius Myalgia

31 VAS, Visual Analogue Scale

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47 Abstract

48 Background: Trapezius Myalgia (TM) is characterized by shoulder pain and dysfunction.

49 Kinesio Taping is commonly used in symptom management of TM. Biomechanical Taping

50 (BMT), a novel intervention, may provide equally effective management. Objectives: This

51 paper reports on the effectiveness of Biomechanical Taping compared with Kinesio Taping in

52 improving shoulder pain, active range of motion (AROM), and function. Methods: Two groups

53 of participants with TM were recruited through simple random sampling of participants from nine

54 call centers and purposively-sampled participants from one fast-food chain and one community

55 based rehabilitation center in Manila, Philippines. Participants were randomly allocated to either

56 Kinesio Taping or biomechanical taping group in a double-blind clinical trial. Irrespective of the

57 type of taping, participants performed gentle passive stretching of upper trapezius for six times

58 each held for 30 seconds on Days 1, 3, and 5. On Days 2 and 4, participants performed gentle

59 passive stretch of upper trapezius three times a day. Pre- and post-intervention measures were

60 taken of Visual Analogue Scale for pain intensity, AROM for shoulder movement, and Disability

61 of Arm, Shoulder, and Hand for function. Results: Of 68 participants, 62 had shoulder

62 symptoms secondary to TM. Similar significant within group improvements were found for

63 Visual Analogue Scale scores, and Disability of Arm, Shoulder and Hand for biomechanical

64 taping and Kinesio Taping interventions (p<0.05). Conclusion: Biomechanical Taping is as

65 effective as Kinesio Taping in the short term in decreasing pain and improving function of

66 individuals with TM. Both taping techniques did not restrict shoulder AROM of included

67 participants.

68 Mesh Terms: Athletic Tape, Myalgia, Pain Measurements, Shoulder Pain

69 Non-Mesh Terms: Biomechanical Taping Technique

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71

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 73 INTRODUCTION

74

75 Trapezius Myalgia (TM) is a musculoskeletal condition that affects the upper trapezius and is

76 characterized by pain, tightness, presence of myofascial trigger points, and tenderness

77 associated with shoulder pain (Nunes & Moita 2015; Larsson et al. 2000). Trapezius Myalgia is

78 common in middle-aged female adults between 30 to 60 years of age who are exposed to

79 awkward working positions and repetitive and high precision movements (Nicoletti & Laubli

80 2017; Søgaard et al. 2011; Wærsted et al. 2010; Veiersted et al. 1993).

81

82 Based on a literature review by Tough et al. (2007), Myofascial Trigger Point Syndrome (i.e.

83 TM) is clinically determined by presence of tender spot (or nodule) in a taut band, pain

84 recognition on tender spot palpation, predicted pain referral pattern, local twitch response on

85 muscle palpation, and limited range of movement. Clinically reliable examination procedures for

86 TM were found for detecting tender spot in taut band (K=0.66), reproducing pain on tender spot

87 palpation (K=0.61), and reproducing referred pain (K=0.65) (Gerwin et al. 1997). Local twitch

88 response has low reliability in determining TM (K=0.36) (Gerwin et al. 1997).

89

90 Biomechanical Taping (BMT) is a novel manual therapy technique that consists of muscle

91 energy technique (MET) and BMT tape application. MET is a gentle manipulative technique

92 directed on the target muscle where patient exerts submaximal contraction against a

93 counterforce applied by the therapist (Nagrale et al. 2010). MET allowing post-isometric muscle

94 relaxation is performed prior to BMT tape application. Nambi et al. (2013) reported that MET

95 was effective in reducing shoulder pain and improving cervical range of motion of patients with

96 TM (p=0.001).

97

98 BMT is hypothesized to reduce musculoskeletal pain in TM by creating a skin fold over the

99 upper trapezius muscle (Figure 1). BMT uses BMT fascia tape, an inelastic tape, and BMT skin

100 tape, an elastic tape. The BMT fascia tape creates a skin fold overlying the painful area. The

101 skin fold is assumed to tighten the skin and fascia, lifting them both away from the muscle.

102 Dones et al. (2018) proposed that the tightening of the skin and fascia may possibly provide

103 stability to the underlying area, thus reducing the pain. The BMT skin tape through its recoil is

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104 assumed to pull the skin and fascia towards the shortened position, lessening the skin traction

105 created by the skin fold.

106

107 <<Figure 1 about here>>

108

109 The effectiveness of BMT on clinical symptoms of participants with TM is not reported in the

110 current literature. However, Dones et al. (2018) reported the effectiveness of BMT on lateral

111 epicondylalgia in decreasing lateral elbow pain (mean=-5.50; 95% CI -6.46, -4.54; p<0.0001),

112 increasing handgrip strength (mean,=2.97; 95% CI 0.70, 5.25; p=0.01), and improving hand

113 function intensity (mean=-36.57; 95% CI -46.19, -26.94; p<0.0001) of 23 participants with

114 unilateral lateral epicondylalgia (Dones et al. 2018). Lleva et al. (2017) reported resolution of

115 lateral elbow pain with associated decreased sonographic abnormalities in common extensor

116 origin of 4 patients with lateral epicondylalgia.

117

118 Kinesio Taping (KT) is a therapeutic taping technique developed by Kase of Japan. Kinesio

119 Taping uses Kinesio Tape®, an elastic tape with convolutions to increase the space between

120 the skin and muscles, which facilitates blood and lympathic flow (Kase 2003; Kase et al. 1998).

121 Kase (2003) claimed that KT corrects muscle function by supporting weakened muscles,

122 improves joint alignment by correcting muscle spasms, and reduces pain by stimulating the

123 nervous system.

124 The I-strip, a KT method, was developed by Kase to address pain felt by patients with TM

125 (Ay et al. 2017; Azatcam et al. 2017; Ozturk et al 2016) (Figure 2). The elastic tape was applied

126 from the acromion process to the base of the neck (Ay et al. 2017; Azatcam et al. 2017; Ozturk

127 et al. 2016). The neck was variably positioned as follows:

128 • contralateral lateral flexion and contralateral rotation (Ay et al. 2017),

129 • flexion and ipsilateral rotation (Azatcam et al. 2017), and

130 • contralateral lateral flexion and ipsilateral neck rotation (Oztruk et al. 2016).

131

132 <<Figure 2 about here>>

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133 The Kinesio Tape® an elastic tape was applied on patients with TM for the following durations:

134 • once a week for 3 days (Halski et al. 2015),

135 • twice a week for 3 and 4 days sequentially (Chao et al. 2016),

136 • twice for 3 days with 1-day rest in between study (Azatcam et al. 2016), and

137 • 5 times by interval of 3 days (Ay et al. 2017).

138 In the studies of Ay et al. (2017), Azatcam et al. (2017), and Öztürk et al. (2016), a total of

139 74 participants with TM were treated using KT. KT was reported to be effective in improving the

140 following outcomes among TM patients:

141 • cervical pain (N=74) (Ay et al. 2017; Azatcam et al. 2017; Öztürk et al. 2016),

142 • cervical pressure pain threshold (N=74) (Ay et al. 2017; Azatcam et al. 2017; Öztürk et

143 al. 2016),

144 • cervical range of motion (N=54) (Ay et al. 2017; Azatcam et al. 2017),

145 • upper trapezius strength (N=20) (Öztürk et al. 2016)

146 • cervical function (N=54) (Ay et al. 2017, Azatcam et al. 2017)

147 Evidence on the effects of KT on shoulder range of movements of patients with TM is not

148 currently available. Mostafavifar et al. (2012) suggested that the effectiveness of KT was due to

149 the elevation of the dermis, which facilitates blood flow, thus reducing pressure on

150 mechanoreceptors.

151 Considering the lack of published studies on effectiveness of BMT on TM patients, this study

152 aims to attain the following objectives:

153 a. to determine the effectiveness of BMT on pain, shoulder active range of motion, and

154 function of patients with TM; and

155 b. to compare the effectiveness of BMT with KT on pain, shoulder active range of motion,

156 and function of patients with TM.

157

158

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159 MATERIALS AND METHODS

160 Materials

161 The BMT fascia tape is a highly adhesive, hypoallergenic, inelastic tape with skin-like properties

162 (Dones et al. 2018) (Figure 3a). It consists of zinc oxide (MacDonald 2004) and can be

163 stretched 10% to 15% beyond its resting length. It is less elastic than Kinesio Tape® and more

164 elastic than Leukoplast and Mueller tapes. The BMT fascia tape is manufactured in rolls

165 measuring 5 cm by 9 m (Painfree 2018). A single roll of tape can be applied to 10 patients with

166 TM and costs 6.00 USD. Seven short strips of BMT fascia tape that adequately covered the

167 painful spot overlying the upper trapezius muscle were used for each participant.

168

169 <<Figure 3 about here>>

170

171 The BMT skin tape, on the other hand, is a highly adhesive hypoallergenic elastic tape

172 (Figure 3b). It is as elastic as the Kinesio Tape®. A single roll measures 6 cm by 5 m (Painfree

173 2018) and costs 8.54 USD. A roll of tape can be applied on 15 patients with TM. One strip of

174 BMT skin tape was applied with only 25% stretch over the painful site for each participant.

175

176 The Kinesio Tape® is a highly adhesive, hypoallergenic, latex-free, elastic tape. It can be

177 stretched by 30% to 40% beyond its resting length (Mostafavifar et al. 2012). Its elasticity is

178 thought to pull the skin and fascia, thus altering an individual’s pain perception (Kaur et al.

179 2016). It replicates the flexibility and thickness of the skin, hence providing mechanical support

180 without restricting movement (Morris et al. 2012). A single roll of this tape measures 5 cm by

181 5 m and costs 17.07 USD. A roll of tape can be applied to 10 patients with TM.

182

183 Outcome Measures

184 The following valid and reliable outcome measures were used in this study:

185 • Visual Analogue Scale (VAS) for assessing shoulder pain intensity;

186 • Disabilities of the Arm, Shoulder, and Hand (DASH) for assessing shoulder function

187 • Standard goniometer for assessing shoulder active range of motion.

188 Each outcome measure is described in the following sections.

189 Visual Analogue Scale

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190 The VAS has a 10-cm horizontal line with ends defining the minimum and maximum extremes

191 of perceived pain. A VAS score of 0 means "no pain" while 10 means "worst pain possible."

192 The VAS is sensitive to small changes in pain and is reliable (r=0.97 to 0.99) in measuring

193 intensity of pain (Williamson & Hoggart 2005).

194

195 The Disabilities of the Arm, Shoulder, and Hand

196 The DASH is a 30-item self-administered questionnaire that examines the ability of a patient in

197 performing upper extremity activities. Using this questionnaire, patients rate the difficulty and

198 interference of pain with daily life using a 5-point Likert scale. DASH has high test-retest

199 reliability (K=0.96) and has acceptable validity (r=>0.70) (Beaton et al. 2001).

200

201 Standard goniometer

202 A standard goniometer measured shoulder range of motion, with fair to good intra-tester and

203 inter-tester reliability of r=0.53 to 0.65 and r=0.64 to 0.69, respectively (Hayes et al. 2001). It

204 has a concurrent validity with digital inclinometer of r=0.86 to 0.95 (Kolber et al. 2011).

205

206 Methods

207 Study Design

208 This study was approved by the University of ---------- Ethics Review Committee. (Ethics

209 protocol number: _________). This study is a single center, active-controlled, randomized

210 clinical trial comparing the effectiveness of BMT and KT in improving pain outcomes of patients

211 with TM.

212

213 Sample Size

214 The minimum sample size computed for this study was a total of 38 patients with TM. A-priori

215 power analysis using a two-tailed hypothesis of difference between two independent means was

216 used. The input parameters were as follows: a. effect size = 1.10 (Dones et al. 2018); b. alpha

217 of 0.05; and c. power of 0.90. An allocation ratio of 1 was used in determining sample size

218 considering that both taping techniques have comparable risks of skin injuries, costs, and

219 drop-out rate when investigated for effectiveness in treating symptoms of musculoskeletal

220 conditions. G*Power 3.1.9.2 was utilized in this sample size calculation (Psychology, DO, nd).

221
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222 Eligibility Criteria

223 All patients who met the following inclusion criteria were included in this study:

224 • Age of 20 to 60 years

225 • With Tender spot in a taut band

226 • With pain upon tender spot palpation

227 • Predicted pain referral pattern upon tender spot palpation

228 • Local twitch response

229 • Limited shoulder range of movement

230 Meanwhile, patients who met the following exclusion criteria were excluded in this study:

231 • Diagnosis of fibromyalgia syndrome, cervical radiculopathy, or myelopathy

232 • History of whiplash injury

233 • Taking medicines that might change the pain intensity or pain threshold (i.e., analgesics,

234 sedatives, substance abuse including alcohol or narcotics)

235 • Currently receiving myofascial therapy or having received any in the past 6 months

236 • Current or previous fractures in the upper quarter

237 • Osteoarthritis in the upper quarter

238 • Recent blunt trauma in the upper quarter

239 • Previous surgery in the upper quarter

240 • Peripheral Neuropathy

241 • Stroke

242 • Cognitive impairment preventing them from understanding the processes involved in this

243 research

244 Note that upper quarter refers to the cervical joint, shoulder complex, upper arm, elbow, lower

245 arm, wrist, and hand.

246

247 Investigators

248 Senior Investigators VCD and JMR, who were certified manual physiotherapists, screened

249 potential participants. They had more than 15 years of clinical experience in the evaluation and

250 treatment of musculoskeletal conditions.

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251 The 6 blinded Junior Investigators who measured shoulder AROM and the other 4 blinded

252 Junior Investigators who administered VAS and DASH questionnaires to TM patients had 1 year

253 of clinical internship in musculoskeletal physiotherapy.

254

255 BMT and KT Practitioners

256 Six Junior Investigators who had 1 year of clinical internship in musculoskeletal physiotherapy

257 were trained on BMT use for two 2-hour sessions by Senior Investigator VCD. Senior

258 Investigator VCD was the founder of BMT. Six Junior Investigators who had 1 year of clinical

259 internship in musculoskeletal physiotherapy were trained on KT use for two 2-hour sessions

260 by RVE. RVE was certified Kinesio tape® practitioner and had 7 years of experience as sports

261 scientist.

262

263 Recruitment and Random Allocation of Participants

264 Participants were recruited from January 2016 to February 2017 by disseminating information

265 through social network media, leaflets, and flyers. A total of 9 call centers were included in the

266 study with each center representing a city in Metropolitan Manila. In cities with more than one

267 call center, a lottery was made by the lead researcher to determine which call center was

268 included in the study. The lead researcher sought consent from medical heads of clinics of

269 each call center to access updated medical records on musculoskeletal complaints of employed

270 call center agents. Potential participants were purposively sampled from one (1) fast food chain

271 restaurant and one (1) community based rehabilitation center.

272

273 Two Junior Investigators oriented potential participants to the nature and purpose of the study.

274 Using the common diagnostic examination for TM by Tough et al. (2017), the Senior

275 Investigators screened participants for eligibility (Appendix 1).

276

277 Eligible participants were asked for informed consent to participate in the study; consenting

278 patients signed an informed consent form. One blinded Junior Investigator used the random

279 sequence generator in assigning numbers to eligible participants. Another (1) blinded Junior

280 Investigator handed participants the concealed envelope containing odd or even number,

281 indicating BMT and KT group allocation, respectively.

282
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283 Study protocol

284

285 Participants were evaluated and treated at their workplace in a confined room with plinth and

286 seat. On Day 1, participants were asked to answer the DASH questionnaire (Figure 4). On

287 Days 1 and 3, pre- and post-intervention measurements of VAS and shoulder AROM were

288 performed on each participant by the blinded Junior Investigator. BMT or KT was applied on the

289 painful shoulder by the trained BMT and KT Practitioners. With the tape on the shoulder, the

290 participants performed gentle passive stretch of upper trapezius done for 6 times held for 30

291 seconds each. With seated participant wearing sleeved non-fit shirt that sufficiently covered the

292 taped shoulder, the Junior Investigator sequentially measured the following shoulder AROM:

293 flexion, abduction, internal rotation, and external rotation. The series of measurements was

294 repeated for 3 times. The participants wore BMT and Kinesio Tape® for 3 hours and 48 hours,

295 respectively. On Days 2 and 4, the participants performed gentle passive stretch of upper

296 trapezius for three sessions a day. Each session was performed 6 times held for 30 seconds

297 each. Participants were reminded through text or phone calls to do the gentle passive

298 stretching of upper trapezius. On Day 5, DASH, VAS, and shoulder AROM were re-evaluated by

299 the Junior Investigator. The Junior Investigator was blinded to the outcomes of the previous

300 evaluations.

301

302 <<Figure 4 about here>>

303

304 Biomechanical Taping

305 With participant lying prone on bed (Figure 5), a strip of BMT fascia tape without skin fold

306 overlying the painful area was applied. Muscle Energy Technique was performed by the BMT

307 Practitioner with counterforce of 20% applied over the affected upper trapezius muscle (Nagrale

308 et al. 2010). Upper trapezius isometric contractions were sequentially performed as follows:

309 a. Head rotated to the opposite side and neck side bent towards an elevated painful

310 shoulder,

311 b. Head and shoulders in neutral positon, and

312 c. Head rotated to same side and neck side bent to opposite side of depressed

313 painful shoulder.

314
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315 <<Figure 5 about here>>

316

317 After each isometric contraction, two strips of BMT fascia tape were applied on participant’s skin

318 creating a visible skin fold (Figure 1). As cover-up strip, the BMT skin tape was applied with

319 head rotated to same side and neck side bent to opposite side of depressed painful shoulder.

320 The step-by-step procedure in BMT application is found in Appendix 2.

321

322 The participant was instructed to remove the tape after 3 hours using copious amount of skin oil.

323 The participant was also advised to remove the tape immediately with oil upon appearance of

324 skin irritation and itchiness. A total of 3 BMT applications each applied for 3 hours were

325 received by each participant in the 5-day study.

326

327 Kinesio Taping

328 I-strip Kinesio Tape® was used on the upper trapezius of each participant (Figure 2). The

329 length of Kinesio Tape® was determined by the distance between participant’s hairline to the

330 lateral edge of the acromion process. The ends of Kinesio Tape® were cut round. The Kinesio

331 Tape® was rubbed on participant’s skin for 30 seconds to activate its adhesive properties.

332

333 The seated participant was asked to bend the neck away from the painful shoulder. With neck

334 in this position, the Kinesio Tape® was applied from insertion of upper trapezius to its origin

335 (Figure 2). The Kinesio Tape® with paper off tension (0% tension) was applied on the acromion

336 process. The Kinesio Tape® was then stretched with 25% tension on the upper trapezius up to

337 the lateral side of the neck. The Kinesio Tape® with paper off tension was placed at back of

338 head near hairline. The participant was advised to remove the tape after a maximum of 48

339 hours. The participant was also advised to remove the tape immediately upon appearance of

340 skin irritation and itchiness. A total of 3 Kinesio Tape® applications each applied for 48 hours

341 (Azatcam et al. 2016; Chao et al. 2016) were received by each participant in the 5-day study.

342

343 Statistical Analyses Used

344 Using MedCalc version 15.2.2 as statistical software (Team DE, nd), the following statistics

345 were used:

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346 • Descriptive statistics (mean, standard deviation) described the participants’

347 characteristics;

348 • Paired-sample t-test determined changes in DASH, and shoulder ROM within BMT and

349 within KT groups; and

350 • Independent samples t-test with p<0.05 determined presence of significant differences

351 of outcome measures used between KT and BMT.

352

353 Intention-to-treat analysis was done. Missing data due to non-compliance were imputed using

354 the last-observation-carried-forward method. The last VAS and shoulder AROM scores were

355 carried forward and used in the analyses.

356

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357 RESULTS

358 Reliability of Junior Investigators in measuring shoulder AROM

359 The 6 Junior Investigators had strong to perfect agreement in measuring shoulder AROM

360 (Intra-rater ICC=0.71-1.0, Inter-rater ICC=0.75-0.98) of 10 healthy participants (5 males: 5

361 females).

362 Baseline Characteristics of Participants

363 Out of 68 potential participants, 62 participants (27 male: 35 female) were included in the study

364 (Figure 4). Sixty participants from call centers and 1 participant each from fast food chain and

365 community-based center were recruited for the study. All participants were not taking analgesic

366 or anti-inflammatory medications. Twenty-eight and 34 participants were randomly allocated to

367 BMT and KT groups, respectively. Figure 4 shows a total of 8 non-compliant participants from

368 BMT group and 7 non-compliant participants from KT group. On Day 1, there were

369 4 non-compliant participants in the BMT group and 2 non-compliant participants in the KT

370 group. On Day 3, there were 4 non-compliant participants in the BMT group and 5 non-

371 compliant participants in the KT group. Non-compliance of participants was due to scheduling

372 difficulties between work and participation to the research. The laterality and chronicity of TM

373 were not reported as authors did not study the relationship between these variables with the

374 outcome measures used in this study.

375 Table 1 reports no differences in age, VAS, shoulder AROM and DASH scores of TM

376 participants (independent samples t-test, p>0.05).

377 <<Table 1 about here>>

378 Table 2 presents the change in the outcome measures of TM participants during BMT and KT

379 applications from baseline. Reduced VAS scores were observed on Day 1(paired samples t-

380 test, P<0.0001) and Day 3(paired samples t-test, P<0.01). On Day 1, BMT was better than KT

381 in reducing pain intensity (independent samples t-test, t=-0.88, P=0.02). All shoulder AROM

382 increased during KT and BMT applications (paired samples t-test, P<0.05). On Day 3, an

383 increase in shoulder external rotation was found during BMT application (paired samples t-test,

384 t=3.86, 19 d.f., P=0.0035) and KT application (paired samples t-test, t=5.28, 26 d.f., P=0.0207).

385 <<Table 2 about here>>

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386 Table 3 reports findings on outcome measure scores of participants on Day 5 compared to

387 Day 1. For BMT and KT groups, reduced VAS score (paired samples t-test, P<0.0001), and

388 decreased DASH score(paired samples t-test, P<0.05) were reported. In the BMT group,

389 increased in shoulder flexion and internal rotation were noted (paired samples t-test, P<0.01).

390 In the KT group, all shoulder AROM increased, except for shoulder internal rotation (paired

391 samples t-test, P<0.05).

392 <<Table 3 about here>>

393 No difference on Day 5 mean scores of VAS, shoulder AROM and DASH were found between

394 BMT and KT (independent samples t-test, P>0.05). No adverse reactions such as skin blisters

395 were reported by all participants involved in this study.

396

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397 DISCUSSION

398 This is the first randomized controlled trial that compared the effectiveness of BMT with KT, both

399 in combination with gentle passive stretching of upper trapezius muscle, on symptomatic

400 shoulders of participants with TM. BMT technique provided a higher reduction of pain when

401 initially applied compared to KT (independent samples t-test, t=-0.88, P=0.02). We hypothesized

402 that the skin fold overlying the painful site in the BMT group has tightened the skin and fascia,

403 promoting localized stability in the taped shoulder area, thus decreasing shoulder pain at rest

404 and during movement. The skin fold in BMT created a shallow groove on taped painful area, not

405 present in KT. The skin fold felt as pinch-like by some participants could have activated large

406 diameter Beta-afferent nerve fibers at a faster rate compared to the skin recoil made by the

407 Kinesio Tape®. The sensation created by the skin fold effectively closed the Substantia

408 Gelatinosa from painful stimuli that are carried by the slow-conducting small-diameter

409 Delta-afferent nerve fibers (Moavedi & Davis 2012; Nathan 1976).

410 Albeit non-significant, a greater shoulder pain reduction in KT group compared to BMT group

411 was found on Day 5 (independent samples t-test, P>0.05). The 48-hour Kinesio Tape®

412 application compared to the 3-hour BMT tape application provided a longer mechanical stimulus

413 on skin of TM participants in the KT group. The skin recoil created by the Kinesio Tape® was

414 the mechanical stimulus that activated the Beta-afferent nerve fibers shutting off the painful

415 stimuli carried by the Delta-afferent nerve fibers (Moavedi & Davis 2012; Nathan 1976).

416 On Days 1, 3, and 5, BMT and KT did not restrict shoulder AROM of all TM participants.

417 Compared to non-stretch rigid tapes (i.e., Leukoplast and Muller tapes), the elasticity of BMT

418 fascia tape, BMT skin tape, and Kinesio Tape® measured from 10% to 40% beyond its resting

419 length conforms to the upper trapezius preventing significant limitation in shoulder AROM. In

420 contrast to the tapes used in this study, non-stretch rigid tapes purposively regulates pain by

421 restricting joint movement (Campolo et al. 2013).

422 An increase in shoulder AROM in all planes were reported on Day 1 of BMT and KT

423 applications (paired samples t-test, P<0.05). Increases in specific shoulder AROM, however

424 variable, were found on Day 3 of BMT and KT applications (paired samples t-test, P<0.05). The

425 skin fold by BMT and skin recoil by KT possibly had inhibitory effects on upper trapezius

426 muscle, causing it to relax. The upper trapezius relaxation was hypothesized to be associated

16
427 with mechanical realignment of the painful shoulder. This possible humeral head movement

428 could have optimally placed it on the glenoid fossa, thus promoting increased shoulder AROM.

429 The improved functional scores of the participants measured through Disability of Arm, Shoulder

430 and Hand (DASH) may be secondary to reduction in reported shoulder pain and non-limited

431 shoulder AROM. The participants of this study had experienced significant reduction in pain

432 possibly decreasing the upper trapezius over-contraction evidenced by increased in all shoulder

433 AROM on Day 1 (paired samples t-test, P<0.05). Less painful movements allow active

434 engagement of participants with daily tasks, as reflected by improved DASH scores.

435 Skin adverse reactions such as itchiness, redness or irritation were reported to be secondary to

436 repetitive taping applications (Kerkhoffs et al. 2002; Jongen et al. 1992). Dones et al. (2018)

437 reported that 1 of 23 participants developed skin blisters after a 24-hour BMT application,

438 secondary to skin fold that caused dermal peeling. Instead of 24-hour BMT application, a

439 maximum of 3-hour BMT application was used in this study. This dosage had prevented

440 formation of skin blisters in all participants who received BMT. The recommended 48-hour KT

441 application by Azatcam et al. (2016) and Chao et al. (2016) did not result in any skin damage of

442 participants included in our study.

443 The BMT tapes had less cost. Two BMT tapes (BMT fascia tape and BMT skin tape) were

444 cheaper by 2.53 USD compared to one (1) Kinesio Tape®. The BMT skin tape can be applied

445 to 15 individuals with TM compared to 10 individuals with TM for Kinesio Tape®. The BMT skin

446 tape (6 m by 5 m) was wider than the Kinesio Tape® (5 m by 5 m), thus applying a wider area of

447 skin potentially exposed to mechanically stimulation possibly affecting shoulder pain.

448 The results of this study were based on sound methodology. As an effect of random allocation

449 and allocation concealment, participants’ characteristics in the BMT and KT control groups were

450 homogenous at baseline. The random allocation of participants to treatment groups minimized

451 participants with poor prognosis preferentially allocated to a group. Opaque and numbered

452 envelopes were used for allocation concealment, preventing reports of inflated large estimates

453 of treatment effects of BMT and KT. The participants were blinded to the superiority of KT from

454 BMT (as reflected in the current literature) and the underpinning mechanisms of action of the

455 taping techniques. This minimized biased assessments of participants on the effectiveness of

456 administered taping technique. The Junior Investigators were blinded to taping technique

17
457 ensuring unbiased ascertainment of measured outcomes. Intention-to-treat analysis through

458 imputation method was used in analyzing data of non-compliant participants ensuring

459 conservative measure of BMT and KT effects. Despite the 24% non-compliance rate in this

460 study, the total number of 47 assessed participants who completed the 5-day study was enough

461 to detect differences on treatment effects of BMT and KT with 0.05 alpha-value and 90% power.

462 Limitations of the Study

463 This study did not have MET alone as comparator group. Considering that MET was not part of

464 the recommended KT application by Ay et al. (2017), Azatcam et al. (2017), Ozturk et al. (2016),

465 MET prior to KT was not performed in this study. The effect size of MET alone on the

466 improvement in pain and function of TM participants during BMT application cannot be

467 determined in our study. Albeit MET was found to improve shoulder adduction and internal

468 rotation in 41 healthy baseball players (Moore et al. 2011) and shoulder abduction and

469 extension in 30 patients with adhesive capsulitis (Ravichandran & Balamurugan 2015), the

470 effectiveness of MET in deactivating triggers is not reported in the current literature (Simons

471 2002).

472

473 This study did not have a stretch alone group. Like MET, the degree of improvement brought by

474 stretching cannot be determined in our study. Muscle stretching decreases trigger point

475 sensitivity decreasing pain response to exercise (Hanten et al. 2000, Jaeger & Reeves 1986).

476 To regulate the effects of stretching on clinical symptoms of participants, both BMT and KT

477 participants performed stretches of upper trapezius muscles.

478

479

480 CONCLUSION

481 Combined with gentle passive stretching of upper trapezius muscle, BMT is as effective as KT

482 in improving VAS scores for pain and DASH scores for function of individuals with TM. BMT

483 was better than KT in reducing pain intensity on Day 1 (P=0.02). Both taping techniques did not

484 restrict shoulder active range of motion of participants. BMT is more cost-effective and

485 economical than Kinesio Taping.

486

487
18
488 DECLARATION OF CONFLICT OF INTEREST

489 The primary author of this study is the founder of BMT. His involvement in the study was on

490 research design, training of junior investigators on BMT application, and writing of the

491 manuscript. Other authors of study collected outcome measure results and analyzed data. The

492 other authors declare no conflict of interest.

19
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Table 1. Baseline characteristics of Trapezius Myalgia participants Legend: Abd, Abduction; BMT,
Biomechanical Taping; CI, confidence interval; DASH, Disability of Arm, Shoulder and Hand; ER, external
rotation; flex, flexion; IR, internal rotation; KT, Kinesiotaping; lat, lateral; N, number; VAS, Visual
Analogue Scale

BMT KT
Mean (95% CI) Mean (95% CI) p-value

35.44 (31.51-39.37)
Age 32.18 (28.39-35.96) 0.23
VAS 4.93 (4.23-5.63) 5.18 (4.54-5.82) 0.60
Flex 158.75 (151.17-166.33) 159.33 (154.10-164.57) 0.89
Abd 154.75 (143.88-165.62) 160.76 (153.49-168.02) 0.34
IR 34.71 (29.09-40.34) 41.16 (35.42-46.90) 0.11
ER 84.82 (77.63-91.78) 82.09 (77.15-87.03) 0.51
DASH 24.98 (16.29-33.67) 27.55 (20.37-34.73) 0.64
Table 2. Comparison of effectiveness of Biomechanical Taping and Kinesiotaping on Day 1 and Day 3. Legend: Abd, abduction; BMT, Biomechanical Tape; CI, confidence interval; diff, difference;
ext, extension; ER, external rotation; flex, flexion; IR, internal rotation; KT, Kinesiotaping; VAS, visual analogue scale

Day Outcome p-
Taping Pre Mean (95% CI for the mean) Post Mean (95% CI for the mean) Mean difference (95% CI) p-value Diff (95% CI of diff)
Measures value
BMT 4.93 (4.23 to 5.63) 2.46 (1.80 to 3.13) -2.46 (-3.08 to -1.84) <0.0001* -0.88 (-1.63 to -
VAS 0.02*
KT 5.18 (4.54 to 5.82) 3.59 (3.02 to 4.16) -1.59 (-2.06 to -1.12) <0.0001* 0.13)
BMT 158.75 (151.17 to 166.33) 164.25 (156.64 to 171.86) 5.50 (2.71 to 8.29) 0.0004* -1.72 (-5.50 to
Flex 0.37
KT 158.69 (153.45 to 163.92) 165.91 (161.15 to 170.66) 7.22 (4.55 to 9.89) <0.0001 2.06)
BMT 154.75 (143.88 to 165.62) 166.14 (156.62 to 175.66) 11.39 (4.78 to 18.01) 0.0015* 5.27 (-2.12 to
1 Abd 0.16
KT 160.25 (152.84 to 167.66) 166.38 (158.69 to 174.06) 6.12 (2.59 to 9.66) 0.0013* 12.66)
BMT 34.71 (29.09 to 40.34) 40.75 (34.74 to 46.76) 6.04 (1.09 to 10.98) 0.02*
IR 0.19 (-5.90 to 6.29) 0.95
KT 41.09 (35.38 to 46.80) 46.94 (41.22 to 52.65) 5.84 (1.94 to 9.75) 0.0046*
BMT 84.82 (77.86 to 91.78) 90.04 (83.77 to 96.30) 5.21 (2.52 to 7.91) 0.0005*
ER 0.37 (-4.01 to 4.75) 0.87
KT 81.84 (76.77 to 86.92) 86.69 (82.49 to 90.88) 4.84 (1.39 to 8.30) 0.0076*
BMT 2.54 (1.83 to 3.24) 1.79 (1.15 to 2.42) -0.75 (-1.25 to -0.25) 0.0049* -0.10 (-0.79 to
VAS 0.76
KT 2.71 (2.10 to 3.32) 2.06 (1.41 to 2.71) -0.65 (-1.12 to -0.17) 0.0094* 0.58)
BMT 164.04 (157.40 to 170.67) 167.79 (161.86 to 173.72) 3.75 (-0.17 to 7.67) 0.06
Flex 0.16 (-4.12 to 4.43) 0.94
KT 168.87 (164.93 to 172.82) 172.47 (168.39 to 176.55) 3.59 (1.76 to 5.43) 0.0004*
BMT 159.61 (148.05 to 171.16) 163.82 (152.71 to 174.93) 4.21 (-3.80 to 12.23) 0.29 1.96 (-6.64 to
3 Abd 0.65
KT 169.94 (164.50 to 175.38) 172.19 (165.05 to 179.32) 2.25 (-1.12 to 5.62) 0.18 10.56)
BMT 39.00 (32.44 to 45.56) 42.54 (35.90 to 49.18) 3.54 (-0.75 to 7.83) 0.1
IR 3.10 (-3.02 to 9.21) 0.31
KT 47.81 (41.07 to 54.56) 48.25 (41.56 to 54.94) 0.44 (-4.04 to 4.91) 0.84
BMT 83.00 (77.17 to 88.83) 86.86 (81.67 to 91.84) 3.86 (1.39 to 6.33) 0.0035*
ER 0.04 (-3.86 to 3.94) 0.99
KT 82.09 (75.26 to 88.93) 87.38 (80.40 to 94.35) 5.28 (0.86 to 9.70) 0.0207*
Table 3. Comparison of scores on effectiveness of Biomechanical Taping and Kinesiotaping between Day 1 and Day 5. Legend: Abd, abduction;
BMT, Biomechanical Tape; CI, confidence interval; diff, difference; ext, extension; ER, external rotation; flex, flexion; IR, internal rotation; KT,
Kinesiotaping; VAS, visual analogue scale

BMT KT
Day 1 Baseline Mean (95% CI for the mean) Day 5 Mean (95% CI for the mean) p-value Day 1 Baseline Mean (95% CI for the mean) Day 5 Final Mean (9
VAS 4.93 (4.23 to 5.63) 1.96 (1.30 to 2.64) <0.0001* 5.18 (4.54 to 5.82) 1.88 (1.1
Flex 158.75 (151.17 to 166.33) 166.07 (159.09 to 173.05) 0.0082* 158.69 (153.45 to 163.92) 170.28 (166
Abd 154.75 (143.88 to 165.62) 160.14 (148.8 to 172.20) 0.11 160.25 (152.84 to 167.66) 168.16 (160
IR 34.71 (29.09 to 40.34) 42.14 (36.50 to 47.78) 0.0066* 41.09 (35.38 to 46.80) 44.69 (38.7
ER 84.82 (77.86 to 91.78) 85.57 (85.31 to 91.83) 0.16 81.84 (76.77 to 86.92) 87.22 (81.2
DASH 24.98 (16.29 to 33.67) 19.62 (12.43 to 26.81) 0.0179 27.55 (20.37 to 34.73) 18.94 (12.9
 Recruited participants (n=68)

Excluded
Not meeting inclusion criteria (n=6)
(-) trigger points (n=3)
(+) fibromyalgia (n=1)
(+) surgery (n=2)

Randomization (n=62)

BMT Group (n=28) KT Group (n=34)

DAY 1

DASH, VAS, AROM  BMT  VAS, AROM DASH, VAS, AROM  KT  VAS, AROM

Non-compliant (n=4) DAY 3 Non-compliant (n=2)

VAS, AROM  BMT  VAS, AROM VAS, AROM  KT  VAS, AROM

Non-compliant (n=4) DAY 5 Non-compliant (n=5)

DASH, VAS, AROM DASH, VAS, AROM

Analyzed (n=28) Analyzed (n=34)

Figure 4. Study Protocol.

Legends: AROM active range of motion; BMT, Biomechanical Taping; DASH, Disability of the Arm, Shoulder and Hand; KT, Kinesio Taping; VAS, Visual Analogue Scale