Spasticity is a condition in which muscles or muscle groups become contracted and can interfere with normal movement. It is caused when there is damage to a portion of the brain or spinal cord, which can cause an imbalance in signals from the brain to the muscles. The imbalance can lead to excessive activity in the muscles, causing difficulty with walking and various other tasks (American Association of Neurological Surgeons 2017). Spasticity is a symptom most often found in patients with cerebral palsy, TBI, stroke, SCI, MS, and other conditions that affect the brain and/or spinal cord.
Spasticity can occur in various different muscle groups that will ultimately impact function differently based on what group is involved. In a situation where a person has spasticity in the gastrocnemius/soleus group, one may see a patient toe walk, and they may be unable to attain heel strike at all. Treatment strategies for lower extremity spasticity can include stretching, patient and family education of HEP, braces such as AFOs, proprioceptive activities, strengthening antagonist muscle groups, serial casting, Botox, and the potential for therapeutic taping. Different types of taping exist in the literature including McConnell taping, which is commonly used for mechanical correction and positioning, and Kinesio taping, which is more often used to facilitate or inhibit a muscle along with potential for other applications.
Kinesio taping was first introduced in 1996. Kinesio taping has become a modality used for a variety of purposes including to decrease pain, facilitate or inhibit a muscle or muscles, giving proprioceptive or sensory input, and to support joint structure. Kinesio taping has begun to show value in the pediatric setting through new research. In pediatrics, it has been used to increase sensory stimulation, strengthen weak muscles, inhibit spastic muscles, increase joint stability, increase functional motor skills, and help with postural control. Taping is being used as a less invasive solution in trying to promote normal motor development (Ibrahim 2015). Kinesio tape is relatively easy to apply and remove and can be well tolerated in the pediatric and neurological settings. Parents of children report positive feedback in regards to the tape with their children who are participating in social activities, ability, and compliance and tolerance to the taping.
Kinesio taping can be worn for 3-5 days with good skin tolerance. Kinesio taping can facilitate or inhibit a muscle by stimulating mechanoreceptors in the skin. Proximal to distal taping is used to facilitate weak muscle, while distal to proximal is generally used to inhibit a muscle. When facilitating, it is recommended that the tape should be applied with 15-35% tension. With inhibition techniques, it is recommended to apply 15-25% tension. Kinesio taping is not meant to replace treatment but instead is to be used in conjunction with other therapeutic interventions.
In the event that the goal is to decrease spasticity in a muscle, one would apply an inhibitory technique with the kinesio tape. The theory behind using Kinesio taping in a spastic muscle is that it will provide sensory input into the muscle through skin and mechanoreceptors and thus inhibit the spastic muscle. The goal of taping overall is to help improve muscular balance between the agonist and antagonist muscle groups. For a child that toe walks secondary to increased spasticity, kinesio taping aims to normalize tone, correct inappropriate positioning, and stimulating effect on skin receptors.
In this case report, kinesio taping was applied with the goal of inhibiting the gastrocnemius muscle in order to improve heel strike and balance during ambulation. The taping was used in conjunction with traditional physical therapy interventions.
The Patient is a 7-year-old male referred for physical therapy for bilateral Achilles contractures and gait abnormality. Upon evaluation initially, he is noted to have clonus bilaterally as well as marked increased plantarflexor tone. He ambulates on toes and is inverted with difficulty clearing his toes. He has been seen for therapy for over two years with multiple medical interventions over that period. He has also undergone multiple different tests over that time, including genetic testing, as well as blood work, MRIs, all of which have offered no further diagnosis. Patient has been wearing bilateral hinged AFOs with plantarflexion stops for over two years. He has had two rounds of serial casting since I have been treating him. Most recently he had serial casting from November 2016-End of December 2016 for 8 weeks. There was noted improvement after casting; however, like the first time that was casting continued to regress after removal despite use of AFOs. He also has night splints, which he was initially compliant with after casting; however, become noncompliant due to discomfort.
In the past, I have trialed kinesio tape to facilitate DF along the anterior tibialis for a period of 6 weeks with little help. After this past session of serial casting, I wanted to trial a different approach where I targeted his plantar flexors to inhibit them.
Prior to taping measurements were taken during a progress note performed 5/3/17. ROM at PN on 5/3/17 is as follows: AROM DF right -5, left -10. PROM right 5, left -3. PF is WNL bilaterally. AROM Inversion is 25 degrees bilaterally; PROM is 35 bilaterally. Everson is 10 degrees AROM bilaterally, passively 20 on right, 25 on left. Single leg balance was measured at this time to be 4 seconds on each leg. Patient was listed at 2 on modified ashworth scale, indicating marked increased tone throughout most of the ROM in bilateral plantarflexors. Hopping is improving with true hop only for 1 rep on each leg, emerging second hop.
Taping was initiated on 5/3/17 after progress note completed. To perform the technique, the patient was positioned in prone, and the anchor is applied to plantar surface of calcaneus in neutral. The patient was then asked to bring toes up in order to put the plantarflexors on stretch. The tape is applied using 15 % tension along muscle belly and ended with no tension at tail. Patient is told to keep on tape for 3-5 days and is compliant with use. His mother is also educated on proper removal. Therapeutic exercises were performed with tape applied for an hour session without shoes or braces on to maximize stretch including dynamic standing balance with reaching, gait training, single leg activities, as well as continued stretching of bilateral lower extremities both passively and with dynamic stretching. Kinesio taping was completed for 9 weeks, with 7 consecutive at end with two session missed at end of May due to patient being out sick followed by myself being out for a course.
Measurements were repeated after the kinesio taping trial was completed on 7/19/17 and are as follows: ROM at PN on 5/3/17 is as follows: AROM DF right 0 degrees, left -8. PROM right 5, left 0. PF is WNL bilaterally. AROM Inversion is 30 degrees bilaterally; PROM is 35 bilaterally. Eversion is 13 degrees AROM bilaterally, passively 23 on right, 25 on left. Single leg balance was measured at this time to be 5 seconds on right leg and 6 seconds on left leg. Patient continues to be at 2 on modified ashworth scale, indicating marked increased tone in bilateral plantarflexors; however, during sessions when tape was applied, noted less resistance throughout and would be listed at 1+ with catch and release. Hopping had improved with 2 repetitions able on each leg. Patient is able to ambulate without AFOs with improved rearfoot contact. He continues to lack heel strike, however, overall seems to have made improvements. He displays a 5 degree improvement in AROM of DF on right and a 3 degree improvement on left.
His family was happy with the taping application, and the patient was agreeable throughout all sessions to have taping completed. Limitations to the analysis portion is lack of gait analysis computerized program that is often used in literature, which limits ability to report improvement on percentage of heel strike attained. Benefits is that there is relatively no harm as long as no allergy is reported and it is fairly quick to apply in session.
As Kinesio taping becomes a more commonly used modality in physical therapy clinics across the world, more research is being performed to support the use. As something that was initially mostly used by athletes, the theory is beginning to be applied to neurological populations, with research bringing forward some promising results. Neuromuscular kinesio taping has been proposed to enhance somatosensory inputs, improve muscle tone, improve ROM, increase center of balance parameters, and decrease pain (Tamburella, 2014). There have been studies applying kinesio tape to various muscle groups and patient populations including stroke, cerebral palsy, MS, and spinal cord injury.
In Tamburella et al, 2014, the application of Kinesio tape was examined on patients with SCI to analyze the effects of ankle joint taping on spasticity, balance, and gait. As gait impairments are often due to ankle spasticity, the authors looked to test this with incomplete SCI patients. This was done using a randomized crossover case control design comparing kinesio tape and conventional nonelastic silk tape. The tape was applied bilaterally to the plantarflexor ankle muscles with patients in prone for both tapes at 0% stretch. The modified ashworth scale was used to evaluate ankle spasticity, balance and gait was measure using the Berg. They used a motion system and EMGS to collect data as well. Results showed that there was no change in the silk tape group. The group that received the kinesio tape demos significantly improved PROM, AROM, Berg scores, 6-minute walk test. Their results showed better functional status after KT with reduced spasticity and improved balance and gait. No adverse effects were reported. The EMG reports showed that there was a significant reduction of CI, which is an index of spasticity in stroke patients, suggesting improved motor outcome. They concluded that kinesio tape is a valid technique to use in the short time and to improve balance and gait, with need for further studies for the long-term effects.
In Yazici, et al, 2015, they looked to evaluate the effectiveness of Kinesio tape on balance in stroke patients. They used the computerized Balance master to measure balance scores, as well as the sensory organization tests. The patients that were included had a modified ashworth of 0-2 in their plantarflexors. Taping was applied by a certified kinesio tape provider. They applied the tape in inhibit the gastrocnemius, facilitation dorsiflexors, and to correct subtalar position as well as fibular head position. Results showed that the group that received the KT had statistically significant improvement of scores in conditions 3,4, 6 with the Balance Master which showed that they showed better adaptation to visual illusions and ground movement compared with no tape. Both groups improved after 8 weeks, but noted that there were significantly greater (Yazici & al., 2015) improvements in the tape group.
In Iosa, et al, 2009, they discussed the benefit of a pilot study, which tests the effects of lower extremity taping on the function of children with spastic unilateral CP. Patients were already treated by PT but therapy was becoming no longer effective. 8 children were included, all of which were ambulatory. Ankle taping was applied weekly and kept on for 6 days for a period over 6 months. Motor ability was assessed using ankle PROM, ashworth scale, GMFM, and instrumental gait analysis. Assessment was performed without taping before treatment, and 6 months later. Results show increased GMFM scores, improved symmetry in gait patterns, but no change in equinus foot. The gait improvements carried over after 6 month follow-up. Parents also reported positive feedback about the children participation in activity and compliance and tolerance to the treatment.
In Da Costa et al, 2013, four children with CP received kinesiotaping to their lower extremities in conjunction with physical therapy. The article used sit to stand movement as a measure as well as the pediatric balance scale and the TUG. There was a statistically significant improvement in sit to stand, which was reflected by decrease in time of execution. The children also decreased their TUG scores, showing decreased risk of falls. They concluded that kinesiotaping significantly improved dynamic activities.
Kinesio taping is becoming a useful adjunct in treatment for pediatric clients throughout physical therapy. As new research is applied to neurological conditions, it can continue to be extrapolated into the pediatric setting. Many parents are agreeable to a trial of kinesio tape, and can be easily explained to a pediatric client with good education. Although taping is not curative for spasticity, it can assist in inhibiting a muscle group to better maintain muscular balance and ROM for ambulation and dynamic activities. Although there are limited studies at this time in regards to specific spasticity in gastrocnemius muscle group in pediatrics, it is an emerging topic across the realm of physical therapy and can be a useful adjunct to treatment for patients with spasticity.
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Da Costa, C. S., Rodrigues, F., Leal, F., & Rocha, N. A. (2013). Pilot Study:Investigating the effects of Kinesio Taping on functional activies in children with cerebral palsy. Developmental Neurorehabiliation , 16 (2), 121-128.
Ibrahim, M. M. (2015). Investigating the Effect of Therapeutic Taping on Trunk Posture and Control in Cerebral Palsy Children with spastic Diplegia. . Journal of Medical Science and Clinical Research. , 3 (9), 7452-7459.
Iosa, M. e. (2009). Functional Taping: a promising technique for children with cerebral palsy. Developmental Medicine and Child Neurology , 587-589.
Surgeons, A. A. (2017). Spasticity. Retrieved July 18, 2017, from Neurosurgical Conditions and Treatments : http://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Spasticity
Tamburella, F., Scivoletto, G., & Molinari, M. (2014). Somatosensory inputs by application if Kinesio Taping: effects on spasticity, alance, and gait in chronic spinal cord injury. Fronteirs in Human Neuroscience , 8, 1- 9.
Yazici, G., & al., e. (2015). Does correcting position and increasing sensorial input of the foot and ankle with Kinesio Taping improve balance in stroke patients. . Neuro Rehabilitation (36), 345-353.