Efficacy of Kinesio Taping in reducing low back pain : A comprehensive review

Introduction: Kinesio Taping is rehabilitative technique used to facilitate the body’s natural healing process while providing support and stability to muscles and joints, without restricting their range of motion. We conducted a thorough literature search and evaluation to clarify whether Kinesio Taping is effective in reducing lower back pain. Methods: Cochrane Library, CINAHL, COBIB.SI, PubMed and Science Direct were searched using Boolean operators search strings of different keywords such as adult, low back pain, Kinesio tape, Kinesio Taping, KinesioTaping, effects. The search was limited to full-text articles published from 2011 to 2016. Results: A total of 137 records were identified, 123 abstracts screened, and 14 full-text articles assessed for eligibility. Finally, nine publications were selected using Critical Appraisal Skills Program tool: Eight randomized clinical studies and one literature review. The key variables from collected data were the subject characteristics, taping technique, control interventions, instrument, and outcome. Conclusions: The effect of Kinesio Taping in reducing low back pain is positive but was not statistically significant in analyzed studies. Taping therapy may therefore be used as a supplementary method to conventional physical therapy procedures and may be important for patients because of its easy accessibility


INTRODUCTION
Kinesio Taping is rehabilitative technique used to facilitate the body's natural healing process while providing support and stability to muscles and joints, without restricting their range of motion.It is used in a variety of muscle-skeletal and neuromuscular problems.It is developed by Kenzo Kase, combining kinesiology with chiropractic methods, based on the use of special elastic strips, which mimic the density and elasticity of human skin.The elasticity of the strips is longitudinal while the waved adhesive allows normal mechanical functioning of the skin.Kinesio tape does not contain latex, drugs or chemical substances.It consists of 100% cotton fibers and is sensitive to temperature, water resistant.It also facilitates lymphatic drainage (1).Enhanced rehabilitation is thought to be the effect of stimulated reactivation, proprioceptive training, reduced pain, stimulation of correct movement patterns, and reduction of muscle imbalance (2,3).When the muscle is inflamed, the space between the skin and muscle is constricted, and the out flow of lymphatic fluid is compromised.Application of the Kinesio Taping results in expansion of skin interstitial space (1,3), which facilitates the drainage of lymphatic fluid, improves blood and lymph circulation, normalizes the pressure on nociceptors, and supports muscles, consequently reducing pain, swelling and inflammation (4).Kinesio tape can be applied for 3-5 days.In rare cases, it can cause skin irritation and is contraindicated in septic arthritis, deep vein thrombosis, malignancies, unhealed wounds, dermatological diseases, and bacterial infections (1).
The diseases of the locomotor system are a widespread problem and a significant socioeconomic problem (5).Pivec and Todorović (6) state that more than 40% of the Slovenian population suffers from back pain, defining it as pain between the lower edge of ribs and top of buttocks.It may include sciatica pain that radiates from the sacrum and then downward to the knee (2).Musculoskeletal conditions are a major cause of productivity loss and within European countries, the highest proportion of people reporting that ever had low back pain (including not diagnosed by a doctor) is in Slovenia (40.7%) (7).Slovenian indicators show that sick leave due to musculoskeletal diseases has a mean duration of 13.9 days (8).Besides the prevalence and gravity of locomotor system disorders, the research database about Kinesio Taping is modest (9) and just two of 25 Slovenian Hospitals provide Kinesio Taping for orthopedic patients (10).
Health-care professionals may provide patients with information about the therapeutic options and techniques for low back pain relief; therefore, we wanted to analyze the published literature with the aim to clarify whether the Kinesio Taping is effective in reducing the low back pain in adults.

METHODS
We systematically reviewed the literature to obtain the evidence pertaining practical use, techniques, and benefits of Kinesio Taping.The search was conducted in Cochrane Library, CINAHL, COBIB.SI, PubMed and Science Direct databases and was limited to full-text articles in English language, published between 2011 and 2016.Search strings consisted of different combinations of Boolean operators and search terms such as adult, low back pain, kinesiology, Kinesio tape, Kinesio Taping, KinesioTaping, and effect.
The search identified 137 publications, of which 14 complied with the research aims and matched the inclusion criteria.Results were verified for quality using the four point scale Critical Appraisal Skills Program (CASP) (CASP Systematic Reviews Checklist and CASP Randomized Controlled Trials [RCTs] Checklist) (11), and the hierarchy of evidence quality (effectiveness, appropriateness, and feasibility) (12).The compliance with the research aims was ranked from the lowest (poor = 1) to the highest (excellent = 4) (12).The key variables from collected data were the subject characteristics, the taping technique, control interventions, instrument, and outcomes.

RESULTS
In total, 137 records were identified, 123 abstracts screened and 14 full-text articles assessed for eligibility.Nine (n = 9) studies were included in qualitative synthesis: Eight randomized clinical studies and one literature review (Table 1).The studies were evaluated for subject characteristics, the taping technique, control interventions, instrument and outcomes identified from 82 codes (Table 2).Although the study participants, the taping techniques, and the evaluation instruments varied between the studies, satisfactory level of evidence has been achieved: Evidence from a review of all relevant RCT's or evidence-based clinical practice guidelines based on systematic reviews of RCT's (13).According to the studies, there is no evidence of efficacy of Kinesio Taping in reducing low-back pain.

DISCUSSION
There is a lack of evidence of efficacy of Kinesio Taping in reducing low-back pain.The studies should be standardized at least in the characteristics of study participants, the taping techniques,  and the evaluation instruments, so the systematic meta-analysis can be performed, to further confirm the results of this review.

Subject characteristics
The studies included in analysis demonstrate an evident lack of homogeneity concerning subjects' characteristics in the area of pain.Pain, which can be fully evaluated and described only by patient, is assessed as nonspecific low back pain (9,14), endurance (9), reduced extent of affected area muscles (9,15,16), related to its intensity (17,18), and duration (17,14,18).Criteria for subject selection varied more obviously in pain definition.The diagnosis of low back pain ranged from "patient seeking treatment" (9,19), "pain score at least 4" (17,18), or had to be diagnosed by an orthopedist (14).Two studies (15,20) researched just healthy subjects.It seems, that the only criteria, agreed by most analyzed studies are the statement about the chronic pain, describing it as the pain that lasts at least 3 months (14,(17)(18)(19).
Considering that knowledge and skills are both needed for quality done interventions, therapists' professionalism is probably a factor that should be taken into account in measuring taping effectiveness.

Taping methods
There are different taping methods described in low back Kinesio Taping, such as waves technique (3), Kinesio without tension (20), Kinesio Fascia Correction Technique (20), Kinesio Tex taping technique (9,19), taping over paraspinal muscles either side over lumbar spine (14,17,22), or overlapping in a star shape and asterix taping (17,18).For the stimulation of correct movements, extensibility, and fatigue delay in healthy subjects could be the optimal technique to tape either side over lumbar spine (15) or the fascial correction technique (20).Patients with chronic low back pain could benefit from overlapping technique, where the tape is in a star shape, and in that way reduce the pain, positively affect anticipatory postural control and movement-related cortical potential (18).
Another important question is the Kinesio Taping tension.Researchers approached different tape tensions, ranging from 0% to 25% of tape stretch over pain area.The tape stretch degree could relief the pain (3,20), increase muscle endurance (17) and promote mobility (20).According to the creators of the Kinesio Taping method, convolutions increase blood and lymphatic flow, and aid in reducing pain.Therefore, applying proper tension of Kinesio tape is one of the key factors for effective treatment (15,21).

Outcomes
The studies evaluated different outcomes, which hampers comparability.Measuring "pain" as criteria, several subjective instruments were used: Global impression of recovery and quality of life (19,21), Rolland-Morris low back pain and disability questionnaire (14,17,21), the visual analog pain rating scale (14,19,21), and Oswestry disability index (18).Just in one study (18), where the pain was measured with visual analog scale, the effectiveness of Kinesio Taping was significant.All other effects of Kinesio  Taping in reducing low back pain were not significant (9,14,17,16,(19)(20)(21).
The positive effects of Kinesio Taping were observed on some objective outcomes, such as paravertebral muscle fatigue measured with Biering-Sorensen test (15), on anticipatory postural control and movement-related cortical potential measured with Oswestry Disability Index (18), mobility and flexibility measured with Schober and fingertip-to-floor test (20).
Studies empirically promoting Kinesio Taping examining young healthy subjects (15,18,20), or a small sample (18) could not be used as evidence for clinical practice.In most analyzed studies (9,14,15,17,18,20) the effect of Kinesio Taping is positive, but not statistically significant.On the other side, there is evidence that chronic low back pain can be effectively managed with kinesiotherapy, depending on type and frequency of exercises (22).

CONCLUSION
The effect of Kinesio Taping in reducing low back pain is positive but was not statistically significant in analyzed studies.Taping therapy may therefore be used as a supplementary method to conventional physical therapy procedures and may be important for patients because of its easy accessibility and safety.Further studies are recommended to elucidate the effect of Kinesio Taping on low back pain.

TABLE 2 .
Codes sorted by categories BMI, certified Kinesio Taping practitioners, chronic low back pain, difficulties falling asleep, examiner, fatigue in legs, fatigue in lumbar spine, height, mass, Kinesio Taping method practitioners, mild acute complaints, musculoskeletal conditions, nonspecific low back pain, pain disturbs sleep, pain in lumbar spine, phyisiotherapist, reduced hamstring extensibility, seeking treatment, young healthy subjects Biering-Sorensen test, chronometer, electroencephalography, electromyography, fleximeter, global perceived effect scale, inclinometer, McGill Melzack Pain Questionnaire, McQuade test of trunk muscle endurance, Oswestry disability index, Pain numerical rating scale, Pain visual analogue scale, Rolland-Morris Disability questionnaire, Schober test, SF-36 Questionnaire, Tampa kinesophobia scale, Vicon motion capture system