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Taping The Deficit, Not The Diagnosis

Many clinicians suffer from taping fatigue (not to be confused with tape fatigue where rigid tapes
in particular lose their effect after relatively short periods of loading). The meteoric rise of Kinesio
Tape following the Beijing Olympics followed by a plethora of generic copies and seemingly
endless taping courses combined with a lack of support in the research has lead to a justified
apathy and even dismissal of taping altogether.

I get that. Dynamic Tape and the Biomechanical Taping ™ approach that underpins it pre-dates
the 2008 Olympics by several years, with our work to address load and movement through foam
or fabric based products commencing in earnest in 2004, the idea ruminating for a decade prior
to this. Our original foam PosturePals appeared on the New Inventors on ABC TV in Australia in
2008 winning the episode with both the judges and the people’s choice, and with support of
leading clinicians and mentors gave us the encouragement we needed to launch Dynamic Tape in
its roll form.

Despite, the aims, applications, properties and effects of Dynamic Tape being completely different
to a kinesiology tape, timing and taping fatigue sees it tarred with the same brush so I feel the
effects more keenly and in fact personally. Clearly, the mechanisms and kinesiotaping philosophy
are somewhat dubious and have been brought into question in the research – lifting skin, taping
from one end or the other and so on all shown to make no difference and this should set our open
minded scepticism alarm bells jingling. But why does it seem that all taping has been thrown in
the same basket? I think that the taping education has a large part to play.

In many cases the education that has accompanied kinesiology taping products has sought
primarily to advance sales rather than advance clinical practice. In fact, it has gone a long way to
doing the opposite. Done well, clinical practice is not easy. It is an exercise in problem solving,
often complex and involves thorough history taking, clear identification of what to assess, how to
do it, how to interpret it, how to integrate the findings across a range of systems from
pathophysiology to pain physiology to biomechanics, function, performance and patient goals,
and then come up with an approach to address the various influencers.

Telling people that it is hard is not conducive to tape sales. Dumbing things down so that anyone
can tape themselves is a far easier marketing sell. And this is what we have seen. Taping
education has been based on a diagnosis and generally ones familiar to the general public. For
plantar fasciitis, put a strip this way and a strip that way. All fixed. For tennis elbow, run a piece up
this way, but make sure that you go from this end to that end otherwise it won’t work – enough
science and rules to sound like it must be doing something but in reality an elastic sock might be
just as effective on your plantar fascia.

Effective taping should be based on identified deficits and not a diagnosis. Our educational
pathway does not simply teach people to tape. It guides people through a comprehensive clinical
reasoning process helping them to identify or exclude various factors giving due consideration to
structural integrity, the influence of load and movement control on structure, function, pain and
performance, pain mechanisms and peripheral, central and psychosocial influencers. Dynamic
Tape when applied correctly can introduce 15kg or more equivalent of force into the kinetic chain.
When clinicians have a clear aim of what they are trying to achieve with tape, the technique
follows.

Importantly, we must identify a deficit and its cause. We must understand its relationship with the
movement we are observing, how this influences load and structural integrity, and how this in turn
might have an impact on pain, movement and function. We must understand how applying a force
(tape) externally can address the observed deficit and we must know how to apply a tape
correctly to get a genuine force into the system. It is not possible for everything. We must then
understand the mechanism or mechanisms by which the tape can have its effect. How do we
then re-evaluate, firstly to determine that we did in fact create a genuine force but secondly to
determine if this force addressed the deficit and how that impacted the underlying condition, it’s
signs and symptoms. We may have been wrong. We might have created a large force, modified
movement and load but it has not affected the functional outcomes or pain because it was not
relevant in the first place or the magnitude of change may need to be greater. How do we
determine the difference?

We do not simply tape a label or even tape a movement based on the movement alone without a
deeper understanding of why that is occurring. To illustrate the point I refer you to the case study
using DorsaVi that can be found on our research page.

This participant performed a hopping and landing task and showed an increase in the velocity and
magnitude of frontal plane movement at the hip. Many patients will show an inability to prevent or
efficiently decelerate motion often collapsing into hip adduction and internal rotation giving rise to
dynamic valgus at the knee. These movements have been associated with for example increased
loading on the ACL and increased compression over gluteal tendons at the greater trochanteric
region, compression adding to increased tensile load and poorer force generation capacity being
key factors in the development of tendinopathy.

Many people at this stage would suggest that we tape the hip to resist and decelerate into hip
adduction and internal rotation and the papers by Robinson et al and Bittencourt et al
have both shown that this can be effective in different patient populations. However,
identifying the deficit and addressing it is likely to yield better results.

The person in the aforementioned case study had long standing L3/4 nerve root compression with
quads weakness. His inability to dissipate load and control inner range of knee extension in the
sagittal plane (power plane) resulted in a compensatory load absorption movement at the hip
resulting in increased speed and magnitude of frontal plane motion. Taping the hip provided a
large deceleration of hip movement however as it had not addressed the ability to control the
knee, the magnitude was largely unaltered. The extra movement was still required to attenuate the
loads. Taping the knee to resist the collapse into flexion under the weight of the body (addressing
the deficit) resulted in reduction in both magnitude and velocity of the frontal plane movement at
the hip. Taping a movement is a step forward from taping based on a name alone, but taping the
deficit is likely to provide better outcomes particularly as the problems become more complex.

Dynamic Taping – Mechanically or Neurophysiologically Driven?

You only have to have had Dynamic Tape correctly applied to you to recognise that we can get a genuine mechanical force into the system. The resistance and recoil is felt immediately. It can be demonstrated and measured in applications like this one for creating a plantar flexion moment. This force is sufficient to overcome gravity in those with nerve injuries and is specific to the joints and movements targeted like in this person with a radial nerve injury from a knife wound (part 1 and part 2).

But are the effects due to the mechanical forces applied rather than neurophysiological effects created via stimulation of the skin and soft tissues when the nervous system is seemingly intact? It is likely that multiple mechanisms are at play but mounting research lends increasing support for a strong mechanical effect.

Robinson et al. 2019 investigated women with Greater Trochanteric Pain Syndrome (GTPS) and compared sham taping in a more lengthened position (still some external rotation and potential for a mechanical effect) with active taping in a shortened position (more abduction and external rotation so more potential for a mechanical effect). The second technique created significant reductions in hip adduction moment and movement displacement, pelvic obliquity and internal rotation during walking gait. It also provided a statistically significant reduction in pain. The sham taping did produce some lesser effects on movement and pain. It is not possible to discern whether these were due to a reduced mechanical effect or due to somatosensory mechanisms from this study. Nevertheless, the tape was identical in location, skin contact, pattern and appearance in both conditions accounting significantly for somatosensory and placebo effects, yet the active technique produced significantly greater changes in movement and pain.

Alahmari et al. 2020 lend further support with their investigation into chronic low back pain where taping in a shortened position with Dynamic Tape resulted in improved back extensor endurance when compared to kinesiology taping (in the lengthened position). Again, the location, skin contact and appearance of the tape was identical in both conditions, the major difference being the potential for mechanical assistance. Luke Welch conducted a pilot study into the effect of Dynamic Taping on Delayed Onset Muscle Soreness (DOMS) of the hamstrings which showed that Dynamic Taping prevented the usual changes associated with DOMS in the taped limb but not the untaped limb. Further studies comparing to a passive tape (lengthened position with no stretch) and increasing layers of tape would provide further insight into the mechanical nature of this effect.

This was answered somewhat by a small pilot study in Colombia by Marin et al. They investigated vertical jump height, flight time and power, comparing one or two layers for knee extension bilaterally, and then two layers for knee extension combined with one or two layers for plantarflexion (similar to the video above). The results generally showed a progressive increase in all outcome measures as additional tape (mechanical resistance and recoil) was applied reaching a maximum of 10.8% in flight time, 22.6% in jump height and 8.9% in power for the squat jump. Further larger studies are required to validate these findings but when combined with the above and several others which show changes in navicular height and drop, plantar pressures, dynamic balance tasks and two more confirming similar changes at the hip when taped in a shortened position, evidence is mounting.

Effects are often immediate which again suggest changes in load either directly by generating the force externally or indirectly as the observed changes in movements can result in changes in the efficiency of force generation (changes in length-tension and lever arms) or changes in compression (e.g. in tendinopathies) as proposed by Robinson et al as one of the mechanisms of GTPS. Further changes may result in time as a result of neuromotor training and other mechanisms may combine to produce the results observed when addressing maladaptive movement patterns and challenging flawed beliefs on movement, pain and tissue damage in some persistent pain cases but arguably we are having a significant effect on load and movement mechanically which can then have an effect on pain and pathology when this is load dependent.

RCTs – GPS or Compass?

A heavy emphasis on Evidenced Based Practice combined with an increase in online journals and an emphasis on publication for many teaching posts has seen an explosion in RCTs of varying quality making their way into the hands of ever increasing numbers of clinicians thanks to the world wide web.

 

This must be a good thing, surely?

If properly critiqued and integrated appropriately into clinical practice then absolutely. Is this occurring with the level of scrutiny required? In many cases possibly not.

During my teaching duties in many countries, I am often confronted with discussions on evidence. The presumption is that there must be an RCT before something can be indicated but even more worrying is the notion that RCTs are required to guide and negotiate every twist and turn in a client’s rehab, just like a GPS, delivering our clients and clinicians safely to destination cured. The use of the intervention from the RCT seemingly based more on the diagnosis and less on a thorough assessment and sound clinical reasoning process, the assessment and reasoning process when it does exist resembling inclusion and exclusion criteria for the RCT rather than a thorough exploration of the patient themselves.

In my clinical practice, I consider the literature to be more like a compass than a GPS for a number of reasons:

 

Reason 1: Not everyone in the cohort responded in the way that the RCT may conclude is statistically significant.

In other words, some people will have improved, some will have stayed much the same while others may have in fact gotten worse with the intervention. Which category does the patient in front of you slot into? A thorough and ongoing assessment and reassessment is required to determine the response to the intervention but determining the various influences at the outset might avoid inappropriate use of the intervention in the first place.

 

Reason 2:The patient in front of you might not have been appropriate for the study.

How much does the study actually relate to this person? My caseload has largely consisted of those with persistent pain who have had any number of procedures, surgeries and treatments by a variety of clinicians or they are elite athletes. They would either have been excluded from the majority of studies due to the complexity of their presentation or there is no study that reflects my athlete’s situation as it is simply not possible to replicate all the biopsychosocial variables in a controlled environment.
For example, one of my athletes won the bronze medal in beach volleyball at the Commonwealth Games in 2018 nursing an infant. I am yet to see a study on female beach volleyball players in a final at a major multisport event, nursing infants, let alone with the same clinical condition and contributing factors.

An element of interpretation, extrapolation, integration and evaluation drawing on research across a range of subject matter from pathology, pathophysiology, pathomechanics, pain physiology, aetiology and endocrinology is likely warranted to develop and test appropriate hypotheses in the individual.

 

Reason 3:The outcome measures of the study are not consistent or commensurate with the client’s goals.

At the Commonwealth Games, my volleyballer’s goal was to get through the next match and take home the bronze medal. It was not to have a moderate reduction in pain in four weeks or to be in the 90% of people whose problem has resolved in 12 months. Similarly, I once had a gentleman ask me how he could use Dynamic Tape for his footdrop as his daughter was getting married on the weekend and he preferred not to walk her down the aisle using an AFO. He was not looking for a cure. He was not concerned with changes in EMG or nerve conduction tests. I was able to provide some direction and he could quickly determine whether it achieved his goal or not. No RCT required. N = 1 when working clinically.

 

Reason 4: Subjects are often not classified sufficiently creating significant washout in the results.

This may in part be responsible for the outcomes observed in point 1. A study may consist of 149 low back pain patients who have all had pain for greater than three months and it does not extend beyond their buttock.  That does not make this group homogenous. Why do we think a single intervention will work for all of them? That is a search for a panacea rather than evaluating a clinically reasoned and indicated intervention. We observe this time and again with research into manual therapy.

Certainly, some in the group may respond well and if identified and evaluated show a strong effect. I relate this to measuring the effect of firefighters on putting out fires by measuring the temperature of all the houses in the city pre and post being doused with water. If only ten homes out of 50,000 are on fire we are not likely to see much statistical difference in temperature across the group due to the washout (pardon the pun) effect. If however we correctly identify those on fire and in need of the intervention and study them in isolation, the effect would be wildly significant.

 

Reason 5: Conclusions are often very broad beyond what can deduced from the small amount of information gleaned from the study.

For example, a study on Dynamic Taping may show no change in 3D kinematics and therefore conclude that the tape is ineffective (this has not been shown by the way). Examining kinematics only provides part of the picture. It does not provide any information on kinetics. Position or movement does not equate to load. Consider a person’s foot and ankle when standing flat on a step in plantargrade and then imagine the person moving backwards so that they are fully supported on the balls of their feet with their heels suspended off the back of the step but still in the plantargrade position. A measure of 3D kinematics would show no difference – roughly 90º. A force platform would show a big difference as would EMG of the calf for example. If the foot is then taped into full plantar flexion using a Dynamic Tape Powerband application, the tape will provide considerable resistance to the foot moving into the plantargrade position on the back of the step thereby reducing the work that the calf must do to maintain that position. You can see some videos of the difference that Dynamic Tape can make here – https://www.youtube.com/watch?v=D_zkHEDmadI&t=27s

Reason 6: One paper is preliminary evidence only

We generally see that research can take several years to be incorporated into clinical practice but we also see the opposite where one paper has completely changed the way that people treat and dismiss anything that has gone before this. Often papers can be misrepresented through media, social media, blogs etc. and be rapidly adopted. Isometric exercises suddenly being used as a magic fix for all tendinopathies based on one paper on the patellar tendon. We have seen phases or trends from eccentrics to isometrics to heavy slow resistance, time under load and so on. Again, this often dismisses the patient’s goal. Do any of these get a tennis player through a four hour final at Wimbledon? Can managing some load via an external application like in the above video? Pain in tendinopathy is generally load dependent. Can reducing the workload requirements of the calf-achilles complex reduce stimulation of load dependent peripherally sensitized nociceptors – almost certainly.

In this age of information, clinicians often only scan the abstract and do not identify methodological flaws or overreaching conclusions as described above. Case studies which can in fact be high quality evidence and serve to guide larger studies are often dismissed despite being incredibly valuable. The patient gives way to the paper.

The literature is important but must be scrutinized and then interpreted against a backdrop of patient goals and situation specific factors. Assessment must examine biomedical and psychosocial aspects, their inter-relationship and how this impacts our aims. The most sensitive and specific evaluation procedure is of little value if applied incorrectly or used inappropriately. Clinical expertise is essential.

To me, the literature acts more like a map and compass. Road blocks often pop up on the most direct route and our original heading, the one that the RCT suggests is no longer useful. Using our map and compass (broad knowledge of related literature and fundamental sciences), we may be able to take on other landmarks and information to work our way around the block and find our way to the destination on a new heading. Our destination may change mid way through the journey based on the client (e.g. they may decide to play a different tournament giving more or less time) or the vehicle we have been using to get there might not be suitable for the journey or might simply not be working the way it should so we need to abandon it and its GPS and go on foot.

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