Shoulder taping reduces injury and pain in

stroke patients
Randomized controlled trial

Jeyaraj D. Pandian, DM, ABSTRACT

FRACP Objectives: We aimed to study the effectiveness of shoulder taping and conventional treatment vs
Paramdeep Kaur, MSc sham taping and conventional treatment in prevention of shoulder injuries in patients with acute stroke.
Rajni Arora, MPT
Methods: This study was a multicenter, interventional, prospective, randomized, outcome-blinded
Dheeraj K.
trial (PROBE design). All first-ever stroke patients were included within 48 hours of stroke onset
Vishwambaran, MPT
(August 2009–October 2011). The treatment group included shoulder taping and conventional
Gagan Toor, BPT
treatment, and the control group received sham taping and conventional treatment. Primary out-
Santhosh Mathangi, MD
comes were changes in visual analog scale (VAS) and shoulder pain and disability index (SPADI),
Pamidimukkala Vijaya,
and secondary outcomes were changes in shoulder range of motion (flexion and abduction) at
DM
days 14 and 30. Clinical trials registration no. NCT 01062308.
Ashok Uppal, DM
Tanvinder Kaur, BPT Results: There were 80 patients in the treatment arm and 82 in the control arm. There was a
Hisatomi Arima, PhD better reduction of VAS (on day 14: mean difference 3.7 mm, p 5 0.45; on day 30: 11.9 mm,
p 5 0.03) and SPADI scores (on day 14: mean difference 3.5, p 5 0.33; on day 30: 9.3, p 5 0.04)
in the treatment arm.
Correspondence to Conclusions: Although there was a trend toward pain reduction and functional improvement asso-
Dr. Pandian:
jeyarajpandian@hotmail.com ciated with shoulder taping for 2 weeks after acute stage of stroke, this did not reach statistical
significance. The long-term effects of taping need to be studied in large trials.
Classification of evidence: This study provided Class III evidence that tri-pull shoulder taping was
ineffective in significantly reducing shoulder pain in patients with acute stoke. Neurology

2013;80:528–532

GLOSSARY
CI 5 confidence interval; ROM 5 range of motion; SPADI 5 shoulder pain and disability index; VAS 5 visual analog scale.

Pain in the affected shoulder, often referred to as hemiplegic shoulder pain, is a common com-
plication that occurs following a stroke, and this affects rehabilitation outcomes.1 The ideal
management of hemiplegic shoulder pain is to prevent it from happening in the first place. Early
passive shoulder range of motion, supporting and protecting the affected shoulder in the early
flaccid stage, transcutaneous electrical nerve stimulation, and range of motion exercises are
regarded as important steps to reduce the development of shoulder pain.2
Taping is widely used in the field of rehabilitation as both means of treatment and prevention
of sports-related injuries.3 It helps to support or inhibit muscle function, support joint structure,
reduce soft tissue inflammation, and reduce pain. It also can produce feedback to the muscle to
maintain preferred postural alignment.4
Strapping the hemiplegic shoulder has been found effective in a small randomized controlled
trial.5 Others have not found significant difference in pain, range of motion, and functional
outcomes after the intervention phase.6 All the previous studies are limited to small numbers
and outcome measures used were also different.4,5 Moreover, the effectiveness of taping in
conjunction with other therapeutic activities in restoring functional use of the upper extremity
Supplemental data at
www.neurology.org
From the Stroke Unit, Department of Neurology (J.D.P., P.K., G.T.), College of Physiotherapy (R.A., D.K.V.), and the Department of Physical
Medicine and Rehabilitation (S.M.), Christian Medical College, Ludhiana, Punjab; Heart and Brain Center (P.V.), Guntur, Andhra Pradesh; Uppal
Neuro Hospital (A.U., T.K.), Amritsar, Punjab, India; and The George Institute for Global Health (H.A.), University of Sydney, Sydney, Australia.
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

528 © 2013 American Academy of Neurology

ª 2013 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

 during the acute phase of stroke has not been
studied. The aim of this trial was to investigate
the effectiveness of shoulder taping with con-
ventional treatment vs sham taping and con-
ventional treatment in prevention of shoulder
injuries in patients with acute stroke.
METHODS Participants. This study was a multicenter, inter-
ventional, prospective, randomized, outcome-blinded trial (PROBE
design). This trial was carried out in the Christian Medical College
and Hospital, Ludhiana, Uppal Neuro Center, Amritsar, and Heart
and Brain Center, Guntur, from August 2009 to October 2011. All
stroke patients who fulfilled the inclusion criteria were randomized
to the treatment group (group I) or the control group (group II).
Following are the inclusion and exclusion criteria for the trial.
Inclusion criteria.
1. All first-ever stroke patients (ischemic and hemorrhagic) with
upper limb weakness within 48 hours after the ictus ($18 years).
2. Brunnstrom stage of motor recovery 1 and 2 (stage 1, immediately
following a stroke there is a period of flaccidity whereby no move-
ment of the limbs on the affected side occurs; stage 2, recovery
begins with developing spasticity, increased reflexes, and synergic
movement patterns, termed obligatory synergies; stage 3, spasticity
becomes more pronounced and obligatory synergies become strong.
The patient gains voluntary control through the synergy pattern,
but may have a limited range within it; stage 4, spasticity and the
influence of synergy begins to decline and the patient is able to
move with less restrictions. The ease of these movements progresses
from difficult to easy within this stage; stage 5, spasticity continues
to decline, and there is a greater ability for the patient to move freely
from the synergy pattern; stage 6, spasticity is no longer apparent,
allowing near-normal to normal movement and coordination).7
3. Patients willing to participate in the study.
Exclusion criteria.
1. Patients with Glasgow Coma Scale score ,7.
2. Patients on ventilator.
3. Uncooperative patients.
4. Patients having previous history of shoulder injury.
5. Patients having previous history of shoulder pain.
6. Any previous history of skin allergy to tape.
Randomization. Participants were randomly assigned to the
treatment group (taping of the affected shoulder with conven-
tional treatment) or the control group (sham taping of the
affected shoulder with conventional treatment).
A random allocation sequence was created using random dig-
its generated using RALOC software and conveyed to the
Figure 1 Tri-pull method of taping
ª 2013 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
investigators by sealed numbered envelopes, one for each partic-
ipant, with instructions to use the envelopes in numerical order.
The outcome was assessed by an independent therapist who was
blinded to randomized treatment and clinical information of
patients. The assessor was not part of the therapy team and there
was a separate form for the outcome assessment which was given
to the assessor during the evaluation. In this way, we were able to
maintain the blinding in outcome assessment in all the centers.
Interventions. For patients allocated to the treatment group, the
tri-pull method of taping was used (figure 1).4 First the micropore
tape was used and then the elastic adhesive tape was applied on
top of the micropore tape. The patient was made to sit in an
upright position with the hemiparetic upper extremity supported
so that the head of the humerus is approximated into the gleno-
humeral joint as in figure 1. Taping was initiated by first applying
3 elastic adhesive tape strips that were 2 inches wide and approx-
imately 10 inches long. The first strip was applied from the mid-
humerus deltoid tuberosity across the scapula. The second strip
was applied from the deltoid tuberosity across the clavicle to the
mid-clavicle, but before the suprasternal notch. The third strip
was placed from the deltoid tuberosity over the acromion process
to the neck. The tape was applied and kept for 3 days along with
conventional treatment. The skin was examined after each
removal of the tape for any changes in skin integrity and rash
or allergy due to application of tape. Locally available tapes like
plastic micropore and elastic adhesive tape (Hospiplast) were used
for taping the shoulder. This was tested in a few stroke patients
before the beginning of the trial and was found effective and safe.
The procedure was continued for 2 weeks. The intervention was
given by 2 physiotherapists, nurses, and relatives. The caregiver
was trained under supervision of the therapist about shoulder
taping during the hospital stay and at the time of discharge.
The relatives were contacted by phone to check the compliance
of taping and reinforcement was given regarding the technique for
both the groups. Patients in the treatment group also received the
conventional treatment that was positioning, handling technique,
and passive range of motion exercises.
For patients allocated to the control group, sham taping was
done using the same tapes. Three strips of tapes were applied in
the same position without repositioning the joint (figure 2). All
other physiotherapy measures like positioning, handling technique,
and range of motion exercises were equally done for both the groups.
Outcome measures. The following outcome measures were as-
sessed at baseline and on days 14 and 30 by the physiotherapist
who was blinded to the group allocation and clinical information.
Visual analog scale (VAS) is an 11-point scale displayed on a
100-mm horizontal line, ranging from 0 (“no pain”) to 100
(“worst pain imaginable”).8 Shoulder pain and disability index
Figure 2 Sham taping
Neurology 80 February 5, 2013 529
 (SPADI) is a 13-item questionnaire that consists of 2 subscales
for pain (5 items) and disability (8 items), which is scored by
taking an average of the 2 subscales. Scores range from 0 to
100, with higher scores indicating greater pain and disability.9
Passive range of motion (ROM) of shoulder was measured
with full circle goniometer. The normal range of movement
of flexion and abduction is 180 degrees. The range of move-
ments of the shoulder was taken. All outcomes were assessed
by an independent physiotherapist who was blinded to ran-
domized treatment and clinical details. The other 2 centers’
physiotherapists were trained on-site by viewing a DVD of the
taping method and doubts were clarified over the telephone.
Primary outcomes were changes in VAS and SPADI, and sec-
ondary outcomes were changes in flexion and abduction in
shoulder ROM.
Standard protocol approvals, registrations, and patient
consents. Written informed consent was given by 162
patients. The ethical approval was obtained from the institu-
tional ethics committees at all centers. This study was regis-
tered at http://clinicaltrials.gov (NCT01062308) and at
http://ctri.nic.in and allocated (2012/05/003577).
Statistical analysis. A target sample size of 160 was chosen to pro-
vide 90% power (a 5 0.05) with 25% dropout to detect
a minimum reduction in VAS of 38 in the intervention group
based on the assumption that mean reduction in VAS score is
27 (SD 18) in the control group.10 We assumed further reduction
in VAS of .10 (from 27 to 38) deemed minimum clinically worth-
while.10 The sample size of 160 also had 90% power (a 5 0.05)
with 25% dropout to detect a minimum of 20 reduction in SPADI
score in the intervention group based on the assumption that mean
reduction in SPADI score is 12 (SD 12) in control group.11
The effects of randomized treatment on changes in VAS, SPADI,
flexion, and abduction from baseline to day 14 or those from baseline
to day 30 were assessed by an analysis of covariance. Differences in

Figure 3 Recruitment of subjects at each stage of the clinical trial

530 Neurology 80 February 5, 2013

ª 2013 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

 2 groups during an overall period of 30 days were ascertained by lin-
Table 1 Baseline demography, stroke
ear mixed models using changes in outcomes as repeat measures.
characteristics, and outcome measures
Analyses were conducted according to the modified intention-to-treat
between 2 groups
principle. Missing values on outcomes on day 30 were imputed by
using the outcome measurements on day 14. A p value of ,0.05 Treatment Control
was considered significant. Statistical analysis was performed using group group
Variables (n 5 80) (n 5 82)
SAS system for Windows release 9.2 (SAS Institute, Cary, NC) and
SPSS version 16.0 (SPSS Inc., Chicago, IL). Age, y, mean 6 SD 55.7 6 13.1 59.5 6 13.2

Classification of evidence. The research question is to study Sex, n (%)

the effectiveness of shoulder taping with conventional treatment Men 57 (71.3) 49 (59.8)
vs sham taping and conventional treatment in prevention of
Women 23 (28.7) 33 (40.2)
shoulder injuries in patients with acute stroke. This study pro-
vided Class III evidence that tri-pull shoulder taping was ineffec- Type of stroke, n (%)

tive in significantly reducing shoulder pain in patients with acute Ischemic stroke 60 (75) 54 (65.9)
stoke.
Intracerebral hemorrhage 20 (25) 28 (34.1)

RESULTS A total of 581 patients were approached Risk factors, n (%)

and 162 patients participated in the study (figure 3). Atrial fibrillation 7 (8.8) 11 (13.4)
At day 14, 15 patients (7 refused, 8 died) in the treat- Current tobacco use 10 (12.5) 6 (7.5)
ment group and 10 patients (4 refused, 6 died) in the Diabetes mellitus 32 (40) 33 (41.3)
control group were excluded from the study. At
Hypercholesterolemia 27 (33.8) 28 (35)
30 days follow-up, one patient in the treatment group
Hypertension 74 (92.5) 72 (88.9)
discontinued intervention because of subluxation and
was excluded from the analysis. In the control group, 2 Carotid stenosis 10 (12.5) 6 (7.5)

patients (1 refused, 1 died) were lost to follow-up, but Previous TIA 11 (13.8) 2 (2.5)

we included these 2 patients in the final analysis by Alcohol (current) 22 (27.5) 18 (22.5)
using last observation carried forward. A total of 136 NIHSS, mean 6 SD 12.6 6 4.7 12.5 6 5.6
patients were included in the final analysis (figure 3).
Taping applied by:
Baseline demography, stroke characteristics, and outcome Family, n (%) 35 (43.8) 43 (52.4)
measures. The mean age in the treatment group was 55.7
Physiotherapist, n (%) 45 (56.3) 39 (47.6)
6 13.1 years (range 18–85 years) and 57 (71.3%) were
Onset of stroke to initial
men. In the sham group the mean age was 59.5 6 13.2 entry, n (%)
years (range 29–86 years) and 49 (59.8%) were men Within 24 h 68 (85) 69 (84.1)
(table 1). We did a sensitivity analysis regarding adjust-
within 24–48 h 12 (15) 13 (15.9)
ment of baseline imbalance in age and gender and there
was no real difference (table e-1 on the Neurology® Web Abbreviation: NIHSS 5 NIH Stroke Scale.

site at www.neurology.org). There was some baseline dif-

ference in VAS scores between the groups; hence we did
not use follow-up value but used change from baseline.
Further adjustment of baseline VAS using sensitivity anal-
ysis demonstrated similar results (table e-2).
Mean change in outcome measures at day 14 and 30 from
the baseline in the 2 groups. The mean changes in outcome
scores (VAS, SPADI, and ROM) are shown in table e-3.
Compared with the control group, the treatment group
showed differences of 3.7 mm (95% confidence interval
[CI] 26.0 to 13.4 mm) and 11.9 mm (95% CI 1.1 to
22.6 mm) better reduction in VAS on day 14 and day 30
(p 5 0.45 and 0.03, respectively). The overall differences
during the follow-up period did not reach statistical sig-
nificance (7.8 mm [95% CI 21.4 to 17.0 mm], p 5
0.10). Likewise, there was trend toward better reduction
in SPADI in the treatment group (difference 3.5 [95%
CI 23.6 to 10.6], p 5 0. 33 on day 14 and 9.3 [0.2 to
18.5] on day 30), but the difference during the overall
period did not reach statistical significance (6.4 [95%
CI 21.1 to 13.9], p 5 0.10). There were no significant
differences seen in ROM changes on days 14 and 30
between randomized groups (table e-3).
There were 5 patients who had side effects (rashes,
redness) from taping. Of these, 2 were from the treat-
ment group and 3 were from the control group.
DISCUSSION We studied the effectiveness of taping
technique in prevention of shoulder injuries in patients
with acute stroke. There was a reduction in VAS and
SPADI scores at day 30 in the treatment group but it
did not reach statistical significance. There were no sig-
nificant differences seen in ROM at the baseline or
days 14 and 30 between the 2 groups.
Studies have used different techniques to reduce
shoulder pain. In a study using a hemi sling in decreas-
ing pain, the control group without hemi sling had sig-
nificant reduction in pain as compared to the treatment
group.12 In another trial examining the effect of strap-
ping in decreasing pain, pain was reported as the num-
ber of pain-free days after admission to the study.5
Shoulder strapping significantly delayed the onset of

Neurology 80 February 5, 2013 531

ª 2013 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

 shoulder pain by 14 days in this study. In another trial
there was no difference between the strapping groups vs
the no strapping group in reducing shoulder pain.6
In our study, pain and disability scores improved in
the treatment arm. Pain modulation via the gate con-
trol theory is one possible explanation for such a
change, because it has been proposed that tape stimu-
lates neuromuscular pathways via increased afferent
feedback.13 Under the gate control theory, an increase
in afferent stimulus to large-diameter nerve fibers can
serve to mitigate the input received from the small-
diameter nerve fibers conducting nociception.
We included patients in Brunnstrom stages 1 and 2
of motor recovery for the following reasons: taping of
the shoulder in stage 1 has the advantage of supporting
the shoulder completely. When spasticity starts develop-
ing in stage 2, this is the time when there is a high risk of
subluxation of shoulder due to muscle imbalance. In
Brunnstrom stages more than 2, protecting the joint
from spasticity and pain is not possible, since both
would have already developed. In addition, we used
ROM and SPADI as the outcome measures. Patients
are more likely to gain upper extremity function with
taping and other routine physiotherapy measures only
when they are in initial Brunnstrom stages 1 and 2.
Although our results suggest that taping may be
better at preventing shoulder pain and improving
functional activities of the patient than sham taping,
we were unable to detect a statistically significant dif-
ference between the 2 groups. However, taping treat-
ment is cheaper (USD $9) compared with other
treatment modalities (approximately USD $40), such
as electrical stimulation, long-term medication use, or
traditional therapy (e.g., hot pack, massage, or neuro-
developmental treatments). Hence it could be widely
implemented during the acute phase.
This study has limitations. First, the follow-up
period was short and hence we could not explore the
long-term benefits of this treatment. Second, X rays
of the shoulder were not done to document other
shoulder injuries. Third, we excluded some patients
since outcome assessment was not possible during fol-
low-up. Despite the limitations, this is the largest study
done so far particularly during the acute phase of stroke.
Future clinical trials should look at the long-term effects
of taping in the prevention of shoulder injuries.
Although there was a trend toward pain reduction
and functional improvement associated with shoulder
taping for 2 weeks after the acute period, this did not
reach statistical significance. The long-term effects of
taping need to be studied in future trials of larger
populations.
AUTHOR CONTRIBUTIONS
Jeyaraj Durai Pandian: literature search, study design, data collection,
data interpretation and writing. Paramdeep Kaur: data analysis, data
532 Neurology 80 February 5, 2013
ª 2013 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
interpretation and writing. Rajni Arora: literature search, study design,
data collection, data interpretation and writing. Dheeraj Karyamparambil
Vishwambaran: literature search, study design, data collection, data inter-
pretation and writing. Gagan Toor: literature search, study design, data
collection, data interpretation and writing. Santhosh Mathangi: literature
search, study design, data collection, data interpretation and writing.
Pamidimukkala Vijaya: study design, data collection and data interpreta-
tion. Ashok Uppal: study design, data collection and data interpretation.
Tanvinder Kaur: study design, data collection and data interpretation.
Hisatomi Arima: data analysis and writing.
ACKNOWLEDGMENT
The authors thank Mrs. Madhu Bala for data entry.
STUDY FUNDING
Department of Neurology intramural research fund.
DISCLOSURE
The authors report no disclosures relevant to the manuscript. Go to
Neurology.org for full disclosures.
Received July 3, 2012. Accepted in final form October 5, 2012.
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 Shoulder taping reduces injury and pain in stroke patients: Randomized controlled
trial
Jeyaraj D. Pandian, Paramdeep Kaur, Rajni Arora, et al.
Neurology 2013;80;528-532 Published Online before print January 23, 2013
DOI 10.1212/WNL.0b013e318281550e

This information is current as of January 23, 2013

Updated Information & including high resolution figures, can be found at:
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Supplementary Material Supplementary material can be found at:

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References This article cites 11 articles, 1 of which you can access for free at:
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