ORIGINAL RESEARCH ARTICLE
published: 30 May 2014
doi: 10.3389/fnhum.2014.00367

HUMAN NEUROSCIENCE

Somatosensory inputs by application of KinesioTaping:effects on spasticity, balance, and gait in chronic spinal
cord injury
Federica Tamburella*, Giorgio Scivoletto and Marco Molinari
Spinal Cord Unit, Clinical Movement Analysis and Research Laboratory, IRCCS Santa Lucia Foundation, Rome, Italy

Edited by:
Nadia Dominici, Swiss Federal
Institute of Technology (EPFL),
Switzerland
Reviewed by:Antonio Oliviero, Hospital Nacionalde Paraplejicos, Spain
Johanna Jonsdottir, Foundation Don
Gnocchi, Italy*Correspondence:Federica Tamburella, Spinal Cord
Unit, Clinical Movement Analysis
and Research Laboratory, IRCCS
Santa Lucia Foundation, Via
Ardeatina 306 - 00179 Rome, Italye-mail: f.tamburella@hsantalucia.it

Introduction: Leg paralysis, spasticity, reduced interlimb coordination, and impairedbalance are the chief limitations to overground ambulation in subjects with incomplete
spinal cord injury (SCI). In recent years, the application of KinesioTaping (KT) has been
proposed to enhance sensory inputs, decreasing spasticity by proprioception feedback
and relieving abnormal muscle tension. Because no studies have examined KT-based
techniques in SCI subjects, our goal was to analyze the effects of ankle joint KT on
spasticity, balance, and gait.
Materials and Methods: A randomized crossover case control design was used tocompare the effects of KT and conventional nonelastic silk tape (ST) in 11 chronic SCI
subjects, AIS level D, with soleus/gastrocnemius (S/G) muscle spasticity and balance andgait impairments. Treatment: 48 h of treatment with KT or ST was followed by 48 h withthe other technique after 1 week. A single Y-strip of Cure© tape (KT) and ST was to the
S and G muscles with 0% stretch. Before and 48 h after of application of KT and ST,
clinical data on the range of motion (ROM), spasticity, clonus, pain, balance, and gait werecollected. Stabilometric platform assessment of center of pressure (COP) movements;
bidimensional gait analysis; and recording of electromyographic (EMG) activity of the S, G,
and tibialis anterior and extensor hallucis lungus muscles were also performed.
Results: Only KT had significant effects on spasticity (p < 0.05), clonus (p < 0.001) and
COP movements (p < 0.05), kinematic gait parameters (p < 0.001), and EMG activity(p < 0.001). Comparison between ST and KT improvements pointed out significant
differences as concerns ROM (p < 0.001), spasticity (p < 0.001), clonus (p < 0.001), pain
(p < 0.001), COP parameters (p < 0.05), and most kinematic gait data (p < 0.05).
Discussion: Short-term application of KT reduces spasticity and pain and improves
balance and gait in chronic SCI subjects. Although these data are promising, they requireconfirmation in a larger cohort of patients.
Keywords: spinal cord injury, KinesioTaping, balance, gait, Electromyography

INTRODUCTION
In designing effective gait rehabilitation programs after spinal
cord injury (SCI), knowledge of the neuronal mechanisms thatmediate and, in particular, influence the afferent feedbacks inthe function of the damaged spinal cord is paramount (Hubliand Dietz, 2013). Locomotion requires continuous modulationof spinal central pattern generator (CPG) circuits to adapt to theeverchanging environment. Feedback from a variety of sources,
such as visual, vestibular, somatosensory, and proprioceptive circuits, must be interpreted and integrated into CPG activity togenerate locomotion that is effective under all conditions (Hubliand Dietz, 2013). In this complex framework, sensory feedback
and context-specific gait requirements interact in affecting muscle
synergies (Horak and Nashner, 1986).
In recent years, increasing cutaneous stimuli through neuromuscular KinesioTaping (KT) has been proposed to enhancesomatosensory inputs (Halseth, 2004). Alexander et al. reported

Frontiers in Human Neurosciencedecreased H-reflex amplitude after KT of the trapezius, suggesting that it influences muscle tone (Alexander et al., 2003).
This KT-dependent H-reflex decline indicates that it is inhibitory
and adjusts muscle activity through proprioception feedback(Lin et al., 2011). KT has been used in neurological pathologies(Kilbreath et al., 2006; Karadag-Saygi et al., 2010; Cortesi et al.,2011), including stroke and multiple sclerosis, and various orthopedic disorders (Alexander et al., 2003; Halseth, 2004; Thelen
et al., 2008; Lin et al., 2011), generally improving muscle tone,
range of motion, center of pressure balance parameters, and pain
symptoms.
No study has addressed the use of KT in subjects with SCI.
Major gait impairments in incomplete SCI are caused by ankle
spasticity (Scivoletto et al., 2008; Arazpour et al., 2013) anddecreased balance (Scivoletto et al., 2008; Tamburella et al.,2013a), both of which are positively affected by KT in neurological (Cortesi et al., 2011) and nonneurological disorders

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Tamburella et al.

Effects of KinesioTaping on SCI patients(Alexander et al., 2003; Halseth, 2004; Lin et al., 2011). Thus, we
examined KT treatment in controlling ankle muscle tone in subjects with incomplete SCI, determining its effects on spasticity,balance, and gait by clinical and instrument-based evaluations.

MATERIALS AND METHODSSTUDY DESIGN—POPULATION

A randomized crossover case control design was used to compare
the effects of KT and conventional nonelastic silk tape (ST) on
ankle muscles in subjects with chronic incomplete SCI. Patient
selection was based on the clinical assessment, per the American
Spinal Injury Association (ASIA) standards for neurological status, and on the degree of ankle spasticity, per the modified
Ashworth scale (MAS). The inclusion criteria were chronic SCI
lesion (i. e., at least 12 months post-injury), AIS level D, andMAS higher than 2 bilaterally in the soleus/gastrocnemius muscles. The exclusion criteria were the presence of other neurologicalor orthopedic impairments, participation in other studies, andpharmacological treatment for spasticity in the previous 4 weeks.
This study was approved by the local ethics committee.
From January 1, 2013 to April 30, 2013, 33 consecutive patients
who were admitted to the Spinal Cord Rehabilitation outpatient
service of Santa Lucia Foundation were examined by an experience neurologist (Giorgio Scivoletto), of whom 11 subjects met
the inclusion criteria. The demographics and clinical features of
the SCI subjects are reported in Table 1.
INTERVENTION: KT AND ST TREATMENT

After enrollment, SCI subjects were randomized into 2 treatmentgroups. Group A (n = 6) underwent 48 h of KT, followed by 48 hof ST 1 week later. Group B (n = 5) received 48 h of ST treatment,
followed by 48 h of KT treatment after 1 week (Figure 1). All
subjects underwent clinical and instrumental evaluations before(T0) and immediately after treatment (T48 h ). Electromyography(EMG) was performed only in Group B before, during, and after
KT treatment. A certified KT practitioner (Federica Tamburella)administered all taping procedures. Clinical and instrumental
outcomes were measured at T0 and T48 h after removal of the KT
by a different researcher (L.M.) who was blinded to the treatment.

KT and ST were applied bilaterally to the plantar-flexor ankle
muscles, soleus (S), and gastrocnemius (G), per Luque-Suarez
et al. (Luque-Suarez et al., 2014). Standard 5-cm single-strip
nonelastic silk tape and Cure© tape were used for the ST andKT, respectively. Y-strip tapes were applied to the S and G muscles with the subject in a prone position, the with knee extended
and the ankle in 90◦ passive dorsiflexion. Both tapes were applied
directly to the skin using a decompressive muscle technique, with
0% stretch, from the calcaneus to the medial and lateral femoral
condyles (Figure 2). To maximize their adhesion, the tape strips
were warmed by rubbing them in the hands several times on theapplication zone (Luque-Suarez et al., 2014).
SETUP AND EVALUATION OF OUTCOMES

All assessments were performed by the same examiner at the sametime each day before application of the tape (T0 ) and after 48 h
(T48 h ) of KT or ST treatment. Neurological status was assessedusing the American Spinal Injury Association (ASIA) and ASIA
Impairment Scale (AIS) (American Spinal Injury Association,2000). AIS levels A and B indicate complete motor lesions, andAIS levels C and D reflect incomplete motor lesions. Active andpassive range of motion (ROM) was measured using a standard
manual goniometer (Fong et al., 2011).
The Modified Ashworth Scale (MAS) (Gregson et al., 1999)
was used to evaluate ankle spasticity. Spasms, clonus, and pain
were scored using the Penn modified Spasm Frequency Scale(PSFS) (Penn, 1988), Spinal Cord Assessment Tool for Spastic
Reflexes subscale for clonus assessment (SCATS) (Benz et al.,2005), and Global Pain Scale (GPS) (Wewers and Lowe, 1990),
respectively. Balance and gait were assessed using the Berg Balance
Scale (BBS) (Lemay and Nadeau, 2010), Walking Index for Spinal
Cord Injury (WISCI) (Ditunno and Dittuno, 2001), 10-meterwalk test (10WT) (Rossier and Wade, 2001), 6-min walking test
(6MWT) (Poole-Wilson, 2000), and timed up and go test (TUG)(Podsiadlo and Richardson, 1991). Walking time tests were performed using a self-selected walking device, if needed (Patrick
et al., 2011) and scored using the WISCI, as reported in Table 1.
All subjects we subjected to instrument-based balance and gait
analyses as detailed below.

Table 1 | Patients’ clinical and epidemiological data.
Patients

Sex

Age

Weight(Kg)

Height (cm)

Etiology

Lesion level

Years since SCI

MAS

WISCI level

PT1

M

34

85

1.82

Traumatic

PT2

M

69

75

1.65

Traumatic

C6

4

3

13

C6

8

2

18

PT3

F

35

60

1.76

Nontraumatic (Degenerative)

T9

4

5

19

PT4

M

51

74

1.73

Nontraumatic (Vascular)

C6

3

2

18

PT5

F

41

60

1.64

Nontraumatic (Vascular)

T6

4

2

19

PT6

M

52

80

1.78

Traumatic

C6

3

2

20

PT7

F

77

67

1.66

Nontraumatic (Vascular)

T10

7

2

19

PT8

M

58

66

1.73

Nontraumatic (Tumoral)

T11

2

4

19

PT9

F

41

55

1.7

Nontraumatic (Tumoral)

T7

10

4

20

PT10

M

72

81

1.64

Nontraumatic (Degenerative)

C7

6

3

13

PT11

F

38

64

1.6

Traumatic

T8

12

3

20

Mean

52

70

170

5.72

2.9

18

SD

16

10

0.07

3.19

1.04

2.57

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Tamburella et al.

Effects of KinesioTaping on SCI patients

We considered the following quantitative COP parameters:- Length indicators: path length (L, mm), mean (V, L divided
by trial duration), anteroposterior velocity (VAP , mm/s) laterolateral velocity (VLL , mm/s), and mean position of planar
laterolateral COP.
- Surface indicators: area of the ellipse encompassing 90%
of COP samples (A, cm2 ) and length of its semiaxes (Xand Y, cm).

FIGURE 1 | Randomized crossover case control study schema. Group(A) (n = 6), SCI patients who underwent 48 h of KT, followed by 48 h of ST
1 week later. Group (B) (n = 5), SCI patients who received 48 h of ST
treatment, followed by 48 h of KT 1 week later.

FIGURE 2 | Application of KT and ST tape to soleus and gastrocnemius
ankle muscles.

EVALUATION OF GAIT

Locomotion kinematic gait data were recorded and analyzed
using the bidimensional KineView Motion System ® (Kineview,
Hafnarfjordur, Iceland) per the protocol for chronic SCI subjects in Tamburella et al. (2013a,b), based on 3 strides at aself-determined velocity. Spatial movements of the lower extremity segments were monitored, based on the position of passive
markers that were placed per the Helen Hayes biomechanical model (Kadaba et al., 1990). Kinematic data were reconstructed offline using Matlab (Mathworks, Inc., version 7.1,
Natick, Massachusetts, USA).
The following kinematic data were considered: speed (m/s),
cadence (N◦ step/min), stride length (STRIDE: mean of rightand left stride in m), stance phase (STANCE: mean of rightand left stance phase expressed as the percentage of gait cycle),and double-time support phase (DTS: mean of right and left
double-time support phase, expressed as the percentage of gait
cycle). STRIDE was defined as the event between 2 successive
instances of foot-ground contact. STANCE was defined as theevent from foot-ground contact to liftoff, and DTS was the time
during which both feet were in contact with the ground (Huxham
et al., 2006; Tamburella et al., 2013a,b). Foot-ground contact wasdetermined manually from video recordings (Tamburella et al.,2013a,b). All gait variables were averaged from the kinematic
data of the 3 trials.
EMG ASSESSMENT

The visual analog scale (VAS) was administered at T48 h toassess perception of reductions in spasticity. Patients were asked
to quantify the reduction in spasticity due to the tape, on a scalefrom 0 (no reduction in spasticity) to 10 (maximum reductionin spasticity). Electromyography (EMG) analyses were performed
only for KT-treated subjects in Group B.
EVALUATION OF BALANCE

Stabilometric parameters were analyzed using a 320 × 75-cm(length × width) static force platform (Platform BPM 120,
Physical Support Italia, Italy). The signals were amplified andacquired using dedicated software (Physical Gait Software Vv.
2.66, Physical Support Italia, Italy). Static stability was assessed
per Tamburella et al. for chronic SCI subjects (Tamburella et al.,2013a). Patients stood barefoot in a natural and relaxed position with their arms by their sides, without shoes and with bothheels lined up, under 2 sensory conditions: eyes open (OE) facing forward to a target 1.5 m away and eyes closed (CE). For eachcondition, the recording time was set to 51.2 s. and measurements
were recorded 3 times and averaged.
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For Group B patients, surface EMGs of tibialis anterior (TA),extensor hallucis longus (EHL), S, and G muscle activity wereanalyzed. Recordings were made before (T0 ), 5 minutes after KT
was applied (T1 ), and after the KT was removed (T48 h ). EMG
data were acquired through 4 wireless EMG sensors, 1 for eachmuscle, affixed per SENIAM recommendations (Oliveira et al.,2012) using EMG Delsys. EMG data were processed using EMG
Works Analysis (Delsys, Boston, USA) using a pass-band filter
between 10 and 450 Hz, and successively a 50-Hz notch filter.
Root mean square (RMS) values, with a window of 0.250 and an
overlap of 0.0625, were obtained from the filtered data. Data oneach muscle were then imported into Matlab (Mathworks, Inc.,
version 7.1, Natick, Massachusetts, USA) to analyze muscle coactivation by calculating the coactivation index (CI) (Kellis et al.,2003).

EMG(S + G)

CI =
· 100
EMG[(TA + EHL) + (S + G)]
CI is a relative measure of antagonist (S and G) contribution tototal activation (S and G + TA and EHL) during the dorsiflexion

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Effects of KinesioTaping on SCI patientstask (Kellis et al., 2003). Thus, an increase in CI reflects a rise inco-contraction. CI ranged from 0 to 100%, with 100% indicating
full muscle coactivation, defined as coactivation (i. e., simultaneous activity) of all ankle muscles. EMG data were recorded whilepatients were asked to perform maximal voluntary contraction(MVC) during 5 dorsiflexion active movements lying down withknees flexed and extended. Data were averaged across the 5 active
tasks.

Statistical significance was considered at p < 0.05 (∗ p < 0.05,∗∗ p < 0.005, ∗∗∗ p < 0.001). All statistical tests were performed

using the Statistical Package for the Social Sciences Software(SPSS), version 12.0 (Chicago, IL).

RESULTSNo clinical or instrument-based assessment differed significantly
between Groups A and B at T0 (Table 2) (p > 0.05).
CLINICAL ASSESSMENT

STATISTICAL ANALYSIS

No participant withdrew from the trial, and all outcome measures were obtained for all SCI subjects. Descriptive statistics weregenerated for all variables. Prior to the statistical comparisons,normal distribution of the data was confirmed by KolmogorovSmirnov test.
Treatment effects were analyzed by grouping the KT and ST
data on Group A and B subjects. Paired t-test was used to compare
the effects of treatment, evaluated as T0 vs. T48 h , for each KT or
SK treatment groups. At T0 and T48 h , KT and ST were comparedby independent t-test and Mann-Whitney U-test for ordinal andnonordinal variables, respectively.
For each clinical and instrument-based parameter, the percentage of improvement due to KT and ST was calculated asfollows:
Percentage of improvement = [(T48 h data-T0 data)/T0 ]∗ 100.
Treatment effects on percentage of improvement data were analyzed by independent t-test or Mann-Whitney U-test whenappropriate.
CI data on KT-treated Group B patients were analyzed byrepeated measures ANOVA, with time (T0 vs. T1 vs. T48 h ) as themain within-group factor, followed by Bonferroni post-hoc testwhen the ANOVA results reached significance.

The clinical assessment results are shown in Table 2. As expected,
almost no changes were observed between T0 and T48 h in the
ST group. Conversely, vs. T0 , KT treatment at T48 h significantly
improved passive (p < 0.005) and active ROM (p < 0.001),SCATS score with the knees flexed and extended (p < 0.001),
PSFS (p < 0.001), BBS (p < 0.001), and 6MWT (p < 0.001).
Compared with ST, KT had significant treatment effects T48 h on
SCATS with the knees flexed and extended (p < 0.05) and on
MAS (p < 0.05).
Based on percentage of improvement values, we noted significant treatment effects on active and passive dorsiflexion ROM(p < 0.001), pathological reflex with the knees flexed (p < 0.005)
and extended (p < 0.001), PSFS (p < 0.001), GPN (p < 0.001),
BBS, and 6MWT (p < 0.001).
With regard to perception of spasticity, VAS score was 7.9 ± 1.2
after KT and 2.5 ± 1.3 after ST (p < 0.05).
EVALUATION OF BALANCE

Between T0 and T48 h, KT significantly improved L, C, VLL , and
VAP under the OE and CE conditions (p < 0.05). Comparedwith ST, at T48 h , KT had significant treatment effects on L, V,
VLL (p < 0.05), and VAP (p < 0.001) under the OE conditionand on L and V under the CE condition (p < 0.05). Based on

Table 2 | Clinical and instrumental assessment.
Clinical data

KT Mean (SD)ST Mean (SD)P
KT vs. ST

T0

T48 h

T0

T48 h

T0

T48 h

Percentage ofimprovement

Passive ROM (◦ )88.64 (11.63)

78.64** (10.88)

85.27 (13.07)

85.27 (13.07)

n.s.

n.s.

Active ROM (◦ )90.18 (13.47)

80.45*** (12.41)

87.27 (14.55)

87 (14.21)

n.s.

n.s.

0.001***SCATS (flexed knee)

2.18 (0.82)

1.55*** (0.82)

2.09 (0.91)

2.09 (0.91)

n.s.

0.008*

0.002**SCATS (extended knee)

2.18 (0.82)

1.09*** (0.54)

2.09 (0.91)

2.09 (0.91)

n.s.

0.008*

0.001***

MAS

3.82 (1.17)

1.82 (0.75)

3.6 (0.84)

2.45 (0.93)

n.s.

0.05*

0.001***

PSFS

2.73 (1.35)

1*** (1.26)

2.09 (1.51)

2.09 (1.51)

n.s.

n.s.

0.001***

GPS

2.45 (3.3)

1 (2.49)

2 (3.26)

2 (3.26)

n.s.

n.s.

0.04*

BBS

39.64 (7.7)

42.82*** (7.15)

40.36 (7.68)

40.55 (8)

n.s.

n.s.

0.001***WISCI

18 (2.57)

18 (2.57)

18 (2.57)

18 (2.57)

n.s.

n.s.

n.s.

6 MWT (m)231.65 (106.479)

259.63*** (116.13)

253.63 (125.16)

251.25 (125.02)

n.s.

n.s.

0.001***

10 MWT (s)24.62 (17.07)

19.94 (14.28)

22.97 (18.11)

21.94 (17.32)

n.s.

n.s.

n.s.

TUG (s)25.69 (17.50)

20.45 (13.30)

22.11 (14.34)

21.27 (13.92)

n.s.

n.s.

n.s.

0.001***The KT, T48 h column lists the statistical comparison of T0 vs. T48 h data. Comparisons between KT and SHAM data at T0 and T48 h and percentage of improvement
between KT and ST groups are reported in the last columns of the table (*p < 0.05, **p < 0.005, ***p < 0.001). Gray cells indicate significant p-values. n.s., notsignificant; for clinical scales abbreviations, see main text.

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Effects of KinesioTaping on SCI patients

percentage of improvement values, significantly treatment effects
were pointed out for L, V, and VAP (p < 0.05) under the OE andCE conditions and enhanced A, Y, and VLL under the CE condition(A and VLL : p < 0.05; Y and VAP p < 0.005) (Table 3).
EVALUATION OF GAIT

The effects of KT on STRIDE, STANCE, and DTS at T48 h vs.
T0 were significant (p < 0.001). Further STRIDE (p < 0.001),
STANCE, and DTS (p < 0.005) improved with KT at T48 hcompared with ST. Comparison of percentage improvement values demonstrated significant treatment effects for all kinematicparameters (speed, cadence, and DTS: p < 0.05; STRIDE andSTANCE: p < 0.001) (Table 4).
ASSESSMENT OF EMG CI

CI, as assessed with the knees flexed or extended,declined significantly immediately after application of KT(p < 0.001 − F[19.046]). After 48 h of treatment, this effect wasmaintained only with the knees flexed (p < 0.001 − F[0.820])(Figure 3).
To determine the most notable effects of KT, the results
were divided into primary and secondary outcome measures, asreported in Table 5. MAS, BBS, CoP V, 6MWT, STRIDE, and
STANCE were identified as the most important outcomes, and theremaining data were considered secondary outcomes and used toevaluate additional effects of the intervention.

DISCUSSION
In this study, we examined the effects of KT treatment inchronic incomplete SCI subjects compared with nonelastic ST

on functional relevant aspects of the post-SCI condition—, i. e.,ankle muscle spasticity, balance, and gait. By MAS and analysis
of functional balance and gait, 48 h of KT treatment improved
all primary outcomes: MAS, BBS, V CoP, 6MWT, STRIDE, and
STANCE (Figure 4), indicating better functional status after KT,
with reduced spasticity and improved balance and gait. In general no adverse events were observed, and subjects reported no
discomfort during KT treatment.
KT is used to enhance sensory inputs, decreasing spasticity
through proprioception feedback and relieving abnormal muscle tension, in healthy athletic subjects (Thelen et al., 2008; Linet al., 2011). Few studies have examined KT in neurologicallesions, such as multiple sclerosis (Cortesi et al., 2011) and stroke(Kilbreath et al., 2006; Karadag-Saygi et al., 2010). In multiple
sclerosis, Cortesi et al. observed positive effects of KT of the ankle
on COP balance parameters, suggesting that ankle taping helps
stabilize body posture immediately (Cortesi et al., 2011). In stroke
patients, KT of the gluteus muscles increases hip extension duringgait, suggesting that muscle activation improves through cutaneous stimuli (Kilbreath et al., 2006), whereas no positive effects
were obtained by combining ankle KT and botulinum toxin to
reduce plantar flexor spasticity (Karadag-Saygi et al., 2010). No
data are available on the effects of KT in SCI subjects.
The crossover paradigm that we used allowed us to blind subjects to the treatment allocation and limit the risk of compliancein analyzing the effects of KT vs. ST (Mills et al., 2009). To prevent
overflow effects of KT, an interval of 7 days separated applicationof the tapes (Chen et al., 2013; de Hoyo et al., 2013).
Although significant differences were observed in passive/active ROM, clonus, spasms, BBS, 6MWT, and most COP

Table 3 | Balance assessment.
CoP parameters

KT Mean (SD)ST Mean (SD)P
KT vs. ST

T0

T48 h

T0

T48 h

T0

T48 h

Percentage ofimprovement

Open eyes

Closed eyes

A (cm2 )2.53 (3.10)

2.72 (5.81)

2.33 (3.16)

2.67 (3.14)

n.s.

n.s.

n.s.

X (cm)

1.32 (0.98)

1.26 (1.15)

1.37 (0.97)

1.26 (0.97)

n.s.

n.s.

n.s.

Y (cm)

1.33 (0.89)

1.22 (0.79)

1.27 (0.71)

1.4 (0.85)

n.s.

n.s.

n.s.

L (mm)

193.68 (104.44)

157.07* (76.78)

183.47 (95.57)

183.19 (107.36)

n.s.

0.01*

0.01*

V (mm/s)

3.78 (2.04)

3.08* (1.49)(3.64) (1.92)

3.66 (2.1)

n.s.

0.01*

0.02*

VLL (mm/s)

2.79 (1.48)

2.26* (1.1)

2.68 (1.39)

2.59 (1.45)

n.s.

0.02*

n.s.

VAP (mm/s)

2.05 (1.19)

1.65* (0.79)

2 (1.15)

2.08 (1.29)

n.s.

0.001***

0.01*

A (cm2 )5.00 (6.12)

4.19 (5.74)

3.28 (4.36)

4.53 (6)

n.s.

n.s.

0.04*

X (cm)

1.69 (1.60)

1.52 (1.23)

1.60 (1.1)

1.52 (1.3)

n.s.

n.s.

n.s.

Y (cm)

1.94 (1.30)

1.63 (1.18)

1.46 (0.97)

1.83 (1.36)

n.s.

n.s.

0.002**L (mm)

283.37 (188.56)

246.69* (165.09)

244.33 (143.46)

268.13 (199.79)

n.s.

0.03*

0.02*

V (mm/s)

5.53 (3.68)

4.82* (3.22)

4.77 (2.80)

5.21 (3.92)

n.s.

0.03*

0.02*

VLL (mm/s)

3.84 (2.47)

3.29* (2.18)

3.36 (1.88)

3.51 (2.48)

n.s.

n.s.

0.05*

VAP (mm/s)

3.30 (2.42)

2.89* (2.05)

2.79 (1.84)

3.21 (2.6)

n.s.

n.s.

0.007*The KT, T48 h column lists the statistical comparison of T0 vs. T48 h data. Comparisons between KT and SHAM data at T0 and T48 h and percentage of improvement
between KT and ST groups are reported in the last columns of the table (*p < 0.05, **p < 0.005, ***p < 0.001). Gray cells indicate significant p-values. n.s., notsignificant; for abbreviation of COP parameters, see main text.

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Table 4 | Gait assessment.
Kinematic gait data

KT Mean (SD)ST Mean (SD)P
KT vs. ST

T0

T48 h

T0

T48 h

T0

T48 h

Percentage ofimprovement

Speed (m/s)

0.54 (0.2)

0.56 (0.24)

0.51 (0.18)

0.50 (0.19)

n.s.

n.s.

0.02*

Cadence (steps/min)

69.67 (22.61)

71.09 (24.80)

66.47 (20.52)

65.79 (20.55)

n.s.

n.s.

0.04*

STRIDE (m)1.04 (0.15)

1.15*** (0.19)

1 (0.13)0.97 (0.13)

n.s.

0.001***

0.001***STANCE (%)

72.42 (24.39)

64.99*** (21.63)

69.94 (23.81)

65.49 (23.66)

n.s.

0.005**

0.001***DTS (%)

27.44 (11.05)

24.46*** (9.20)

26.66 (10.93)

24.64 (10.52)

n.s.

0.005**

0.05*

The KT, T48 h column lists the statistical comparison of T0 vs. T48 h data. Comparisons between KT and SHAM data at T0 and T48 h and percentage of improvement
between KT and ST groups are reported in the last columns of the table (*p < 0.05, **p < 0.005, ***p < 0.001). Gray cells indicate significant p-values. n.s., notsignificant; DTS, double-time support phase.

FIGURE 3 | CI index at T0 , T1 , and T48 h for EXP group. ∗∗∗ p < 0.001.

parameters and kinematic gait data after 48 h of KT, almost nochanges were observed after 48 h of ST treatment, as expected,
due to the chronic condition. Treatment effects were analyzed bycomparing improvements after 48 h of KT and ST treatments.
KT reduced MAS and improved active and passive ankle ROM,
which was paralleled by a decrease in spasticity-associated symptoms, clonus, and pain. Control of ankle spasticity is paramountin improving balance and gait in SCI subjects (Arazpour et al.,2013). KT had significant therapeutic effects on balance and gait,

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both of which improved with regard to the clinical scales andstabilometric and kinematic data. After KT treatment, there wasbetter control of balance, as confirmed by the decline in V and L
COP parameters (Cortesi et al., 2011; Tamburella et al., 2013a), as
well as an improvement in kinematic gait parameters. Decreases
in STANCE and DTS reflect improved dynamic postural stability(Tamburella et al., 2013b), which has been suggested to specifically improve gait in subjects with chronic motor incomplete SCI(Tamburella et al., 2013a).
To determine the possible mechanism of these improvements,
EMG data were collected in Group B patients before, during, andafter KT treatment. CI has been proposed as an index of spasticity
in stroke subjects (Hu et al., 2007) and is indicative of fatigueinduced decreases in muscular co-contraction in healthy athletic
subjects (Missenard et al., 2008). In this study, we used the CI
to evaluate EMG activity of agonist vs. antagonist ankle muscles.
A high degree of CI reflects excessive antagonistic muscle contractions during dynamic activities compared with agonist muscle
activity, impairing function and increasing the metabolic cost of
performing the task (Knarr et al., 2012). Our EMG data demonstrated a significant reduction in CI with KT, suggesting improved
motor outcome (Hu et al., 2009) and confirming our clinical dataon spasticity.
Notably, CI improved immediately after application of KT—
an effect that was maintained, although slightly reduced, after
48 h. The lack of significance of the CI data at 48 h with the knee
extended confirm the high variability of spasticity measurementsin this posture compared with the knee flexed (Figure 3). The
significant reduction in CI due to KT might be explained by 2 reasons: the increase in EMG activation of the TA and EHL and thedecreased co-contraction phase of the antagonist S and G muscles. Considering the findings of Alexander et al. (2003), in which
amplitude of the H-reflex decreased after KT of the trapezius
in healthy subjects, it is conceivable that KT also adjusts muscle
activity by inhibiting proprioception feedback (Lin et al., 2011)
also in SCI subjects.
To improve outcomes and methods of applying the tape, itis necessary to understand the mechanism that leads to better upright balance and gait. The effects of KT were clinicallysignificant immediately after its application, implying that the

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Table 5 | Primary and secondary outcome measures.
KT Mean (SD)T0
Primary Outcomes

T48 h

P: KT vs. ST

T0

T48 h

T0

T48 h

% of improvement
0.001***

MAS

3.82 (1.17)

1.82 (0.75)

3.6 (0.84)

2.45 (0.93)

n.s.

0.05*

BBS

39.64 (7.7)

42.82*** (7.15)

40.36 (7.68)

40.55 (8)

n.s.

n.s.

OE

3.78 (2.04)

3.08* (1.49)(3.64) (1.92)

3.66 (2.1)

n.s. 0.01*

0.02*

CE

5.53 (3.68)

4.82* (3.22)

4.77 (2.80)

5.21 (3.92)

n.s. 0.03*

0.02*

V (mm/s)

6 MWT (m)Secondary Outcomes

ST Mean (SD)

231.65 (106.479) 259.63*** (116.13) 253.63 (125.16) 251.25 (125.02) n.s.

n.s.

0.001***

0.001***

Stride (m)1.04 (0.15)

1.15*** (0.19)

1 (0.13)0.97 (0.13)

n.s. 0.001***

0.001***

Stance (%)

72.42 (24.39)

64.99*** (21.63)

69.94 (23.81)

65.49 (23.66)

n.s. 0.005**

0.001***

Clinical Data

Passive/Active ROM, SCATS, PSFS, GPS, WISCI, 10MWT, TUG (for details, see Table 2)

Instrumental Data BALANCE: A, X, Y, L, VLL , VAP for both visual conditions: OE and CE (for details, see Table 3)
GAIT: Speed, Cadence, DTS (for details see Table 4)
Clinical and instrumental data on spasticity, balance, and gait have been divided into primary and secondary outcome measures. The KT, T48 h column lists thestatistical comparison of T0 vs. T48 h data. Comparisons between KT and SHAM data at T0 and T48 h and percentage of improvement between KT and ST groups
are reported in the last columns of the table (*p < 0.05, **p < 0.005, ***p < 0.001). Gray cells indicate significant p-values. n.s., not significant; for abbreviations,see main text.

FIGURE 4 | Percentage of improvement due to 48-h application of KT
or ST. ∗ p < 0.05, ∗∗∗ p < 0.001.

changes were not due to long-term learning, as reported in
multiple sclerosis (Cortesi et al., 2011). In addition to the secondary effects of spasticity changes, the alterations in the balance
control system might be explained by changes in skin receptor inputs due to application of KT (Morasso and Schieppati,1999). The mechanical effects of applying tape to the skinmight increase skin receptor output, stimulating supraspinal
centers and thus enhancing kinesthetic and joint position
sense (Simoneau et al., 1997; Halseth, 2004) and improving
balance.
In analyzing the effects of KT on gait, sensory components
cannot be dismissed. Applying pressure to and stretching theskin with KT can stimulate cutaneous mechanoreceptors andenhance signal information of joint movement or joint position(Hsu et al., 2009) (Riemann and Lephart, 2002). The importanceof sensory inputs in influencing the activity of gait central pattern generators (CPGs) is highlighted (Grillner, 2006). In SCI
patients, changes in CPG circuits are well documented (Grillner,
2006; Roy et al., 2012) and are learning-dependent, primarily through rhythmic peripheral influences that imposed by the
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exercise—for instance, during robotic gait training (Curt et al.,2008; van Hedel and Dietz, 2010). The importance and effectiveness of sensory input in modulating stepping in SCI has
been demonstrated in a wide range of experiments (Edgerton
and Roy, 2009); for example, modulation of sensory information influences spinal circuit reorganization to be effective frommilliseconds to months (Roy et al., 2012). Thus, sensory modulation through KT might not only influence spasticity but alsointervene in longlasting reorganization of spinal gait circuits. In
this theoretical framework, the influences of KT on gait meritstudies not only in subjects with SCI but in all neurological gait
pathologies.
Subjectively, the VAS results indicate a significant reductionin perception of spasticity after KT treatment and that spasticity
is negatively associated with quality of life after SCI (Westerkam
et al., 2011).
The significance of the sensory effects of KT must also be considered in analyzing its effects on pain. In our study, despite theshort-term treatment, GPS declined significantly after KT and
but not with ST. Treatment significance was present when comparing KT and ST GPS improvements. Although this study did
not aim to evaluate the effects of KT on pain, our results are
consistent with data in chronic low back pain patients (Paoloni
et al., 2011) and merit dedicated studies, possibly with longer
application times of KT.
In conclusion, KT is a valid technique to reduce spasticity andrelated symptoms in the short term and improve balance and gaitin chronic incomplete SCI subjects. Further studies are needed todetermine its long-lasting effects.
LIMITATIONSThe sample size of SCI subjects (n = 11) was small, which might
have limited the statistical relevance of the study. Nevertheless,the statistical differences were large, rendering the statistical errorthat was caused by sample size negligible. Further, as suggested by
Friston (2012), significant results that are based on a small sample

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Effects of KinesioTaping on SCI patients

indicate a greater treatment effect than equivalent results in a large
sample.
A follow-up study with a longer KT application is necessary
to confirm these preliminary data, and a theory on the neurophysiological effects of taping would facilitate the generation ofexperimental hypotheses.

AUTHOR CONTRIBUTIONS
Federica Tamburella: Substantial contributions to the conception
and design of the work; the acquisition, analysis, and interpretation of data; drafting of the manuscript and revising it with regard
to intellectual content. Giorgio Scivoletto: Substantial contributions to the conception and design of the work, the interpretationof data, and revision of the work with regard to intellectual content. Marco Molinari: Substantial contributions to revision of thework with regard to intellectual content and final approval of theversion to be published.

ACKNOWLEDGMENTS
This work was supported by the Italian Ministry of Health(RC08G) and the European Commission in the Seventh
Framework Program ICT-2013- 611626 SYMBITRON. Thanks to
Luca Muzzioli for data acquisition. The manuscript was reviewed
for English language by “Blue Pencil” Science.

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Conflict of Interest Statement: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could beconstrued as a potential conflict of interest.
Received: 09 January 2014; accepted: 13 May 2014; published online: 30 May 2014.
Citation: Tamburella F, Scivoletto G and Molinari M (2014) Somatosensory inputs byapplication of KinesioTaping: effects on spasticity, balance, and gait in chronic spinal
cord injury. Front. Hum. Neurosci. 8:367. doi: 10.3389/fnhum.2014.00367
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