Effects of Ankle Kinesio Taping on Postural Control in Stroke Patients Zahra Rojhani-Shirazi, PhD,* Shiva Amirian, MSc,† and Narges Meftahi, PhD†
Background: To investigate the effects of kinesio taping on postural control in stroke patients. Materials and methods: Forty stroke patients aged 30 to 60 years were randomly divided into an experimental and a control group. In the experimental group, kinesio tape (KT) was applied directly on the skin over the affected ankle in the direction of dorsiflexion and eversion to correct the equinovarus deformity. The tape was kept on the ankle for 1 day. The results were measured with the forward reach test, lateral reach test, Berg Balance Scale (BBS), and timed up and go test. Center of pressure (COP) displacement and velocity were also measured while the patients stood on a force plate. All variables were measured on the first day immediately after taping and 24 hours later in the KT group, and on the first day and also 24 hours later in the control group. Results: There was a statistically significant difference in BBS between the first day and 24 hours later in the KT group (P 5.01). The forward reach test and mediolateral displacement of the COP differed significantly after taping in the experimental group compared to the control group (P 5 .04). Immediately after taping, BBS improved significantly in the KT group (P 5 .02). Conclusions: The application of KT improved forward reach test results and displacement of the COP in stroke patients. Key Words: Stroke—kinesio taping—postural control—Berg Balance Scale—equinovarus deformity. Ó 2015 by National Stroke Association
From the *Center of Human Motion Science Research, Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz; and †Center of Human Motion Science Research, Student Research Committee, Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran. Received May 23, 2015; revision received July 8, 2015; accepted July 12, 2015. The authors have no conflicts of interest to declare in relation to this article. This work was based on the MSc dissertation of the second author, (Shiva Amirian, proposal number: 91-6376) at Shiraz University of Medical Sciences, faculty of rehabilitation sciences. The authors are grateful for the financial support by Shiraz University of Medical Sciences, Shiraz, Iran. Address correspondence to Zahra Rojhani-Shirazi, Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Abiverdi 1 St, Chamran Blvd, Shiraz 1733-71345, Iran. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2015 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.07.008
Postural instability is one of the important mobility problems after stroke.1 It can result in reduced mobility, increased disability, and even mortality in stroke patients. These events have a great impact on patients’ activities of daily independent living and gait ability.2 One of the most common changes in the foot and ankle complex after a stroke is talipes equinovarus foot deformity (club foot), which can cause postural instability.3 This deformity leads to problems during quiet stance and walking.3-7 Equinovarus foot causes asymmetric weight-bearing, reduces the base of support, and further reduces equilibrium reactions during quiet stance and walking.3-14 In addition, the inability to dorsiflex and evert the ankle interferes with toe clearance during walking.15 As a result, abnormal gait, postural instability, and falling are frequently seen in these patients. Recovery of the stroke patients from postural instability which is a major source of disability is essential. Kinesio taping is a prevalent method which is being used by physical therapists during rehabilitation programs.16 Kinesio tape (KT) is a thin, highly elastic material which may be used as a modality to relieve pain, correct joint
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position, decrease swelling, increase proprioception, and increase or inhibit muscle recruitment.17 It has been shown that KT can improve postural control and gait ability by not only stimulating proprioceptive sense but also identifying the right position of the joint even in a comfortable posture with no weight-bearing.18 The equinovarus deformity consists of plantar flexion and inversion components. Therefore, concentrating on correction of its both components is important in restoring normal joint function.19 Previous studies have focused only on correcting the plantar flexion component.19,20 Ability of KT to stretch 120%-140% times its original length provides the opportunity to correct the deformed joint in both directions simultaneously.21,22 Other advantages of the KT include low cost and easy application.18 Despite the current use of KT as a part of clinical practice in physical therapy, its clinical effects on postural stability have not been extensively studied.16,18 To the best of our knowledge, no studies to date have investigated the effect of KT to correct equinovarus problems in postural control in stroke patients. There is also limited evidence of the effects of KT in neurologic patients16,23 and most of the previous studies involved non-neurologic patients.16,22,2426 Therefore, the purpose of the present study was to determine the short-term effects of KT to correct the direction of ankle dorsiflexion and eversion in improving postural control during quiet standing in stroke patients.
Methods and Materials Participants Forty patients with stroke (26 men and 14 women) aged between 30 and 60 years participated in this study. The patients in the KT group and control group were matched by age, weight, height, and duration of the disease. All patients with the following criteria participated in the study: involvement of the anterior cerebral artery on computed tomography scan at least 1 year ago, score of 21-56 on the Berg Balance Scale (BBS), spasticity level of 2-3 according to the modified Ashworth scale, ability to stand for at least 30 seconds, ability to change walking direction, and ability to understand instructions. Patients were excluded if they had hemiplegia due to traumatic brain injury, any history of lower limb surgery, fracture or joint dislocation in the lower limbs, low back pain, blindness or deafness, cerebellar disorders, middle ear problems, diabetes mellitus, neuropathy, or allergy to the KT. Patients were randomly divided into 2 groups: an experimental group with KT (14 men, 6 women) and a control group (11 men, 9 women) in which no KT was used. The nature and purposes of the study were explained to all participants, and all signed an informed consent form. Ethical approval for the study was obtained from the Human Ethics Committee of Shiraz University of Medical Sciences.
Data Acquisition The patients’ characteristics such as age, gender, height, weight, and duration of disease were recorded. Level of spasticity was measured with the modified Ashworth scale. Postural control was evaluated by functional tests and force plate measurements. The order of measurements was randomized with a table of random numbers. Functional tests included the functional reach test (FRT), lateral reach test (LRT), and BBS. In the FRT and LRT, the maximum distance that patients could reach forward or laterally without losing balance or taking a step from quiet stance was recorded.27,28 These 2 tests measure a person’s margin of stability and their ability to maintain balance during a functional task.27,29 The BBS is a standard clinical assessment tool for evaluating postural control in patients with senile disease and stroke patients, with a minimum score of zero and a maximum total score of 56. Higher scores in this scale indicate better postural control. The scale consists of 14 functional items which are similar to daily motor activities in adults.30,31 Each functional test was repeated 3 times, and the average of 3 trials was calculated for analysis. Gait ability was also assessed with the timed up and go test, which is the time a person needs to rise from a chair, walk 3 m, turn, and return to the chair.32 The average of 3 trials was recorded. Force plate measurements included center of pressure (COP) displacement and velocity along the mediolateral (ML) and anteroposterior (AP) axes. The patients stood barefoot on the force plate (model 9286A, size 400 3 600, Kistler, Switzerland) for 30 seconds and were instructed to look at a spot in front of them. The distance of the spot from floor was determined according to each patient’s eye level. The sampling frequency of the force plate was set at 50 Hz.23 This measurement was repeated 3 times, and the average of 3 trials was calculated for further analysis. The patients were allowed a 2-minute rest period between trials. Raw data were exported to Visual 3D software (C-motion, Inc. Germantown, MD) and filtered using a fourth-order low-pass Butterworth filter with a cutoff frequency of 12 Hz. After these measurements, taping was done for the KT group. Before KT application, the skin was cleaned and dried to remove all moisture and oil and then shaved if necessary. Standard 2-inch KT 3NSTEX (TS CO., LTD, Seoul, South Korea) was used. The patients were in supine position during taping, with their hip, knee, and ankle joints in neutral position. The kinesio I strip was applied with maximum tension (100%). Each strip simultaneously applied force in the directions of dorsiflexion and eversion. Three I strips, each covering approximately half the previous strip, were attached from 2-3 cm superior to the medial malleolus and passed around the ankle joint from the plantar surface of foot, then fixed at the top of the lateral malleolus. The strips were applied across the ankle joint from proximal to distal33 (Fig. 1). The patients
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tests for paired samples. The level of significance for all the tests was set at .05.
Results Demographic data are shown in Table 1. There were no significant differences between the groups in any of the demographic variables (Table 1). On the first day, none of the differences between groups in postural control variables were significant (Table 2). Twenty-four hours after taping, there were significant differences between groups in FRT (P 5 .04) and ML COP displacement (P 5 .04). However, none of the other variables differed significantly between groups 24 hours after taping (Table 3). In the KT group, BBS score 24 hours after taping differed significantly from the score on the first day. However, in this group, there were no significant differences in any of the other variables 24 hours after taping in comparison with the first day. In the control group, there were no significant differences in any of the variables between the first day and 24 hours later (Table 4). Immediately after taping, BBS improved significantly in the KT group (P 5 .02). However, in this group, there were no significant differences in any of the other variables immediately after taping in comparison with before taping (Table 5). Figure 1.
Application of kinesio tape.
were asked to dorsiflex and evert the ankle joint while holding the ends of a strap looped around the plantar surface of the foot during the application of KT because the purpose of KT in this study was to correct talipes equinovarus (Fig. 2). All postural control measurements were repeated 24 hours later in both groups.
Statistical Analysis All statistical analyses were done with SPSS, version 18 (SPSS Inc., Chicago, IL). The Kolmogorov–Smirnov test confirmed that all data showed a normal distribution. The differences between the KT and control groups on the first day and after 24 hours were analyzed with t tests for independent samples. The differences between the measurements on the first day and 24 hours later in the KT group and the control group were analyzed with t
Figure 2. Dorsiflexion and eversion of the ankle joint with a strap during the application of kinesio tape.
Discussion Our results showed that the only immediate improvement seen after KT application was in the BBS score. However, other significant improvements were seen 24 hours later in FRT, BBS, and ML COP displacement. The effects of taping on postural control may need time to become measurable. Mechanoreceptors may accommodate to taping during the first 24 hours, and this process may then result in enhanced sensory stimulation and postural control. The improved postural control after taping in the present study may have several explanations. Firstly, the elastic tape stretches the skin continuously, which stimulates mechanoreceptors and thus increases sensory information to the central nervous system. Therefore, joint position sense will improve, and with it, the ability of the neuromuscular system to control movements.34,35 KT may affect the neuromuscular reflex to control
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Table 1. Demographic characteristics of the participants
Variable Age (y) Weight (kg) Height (cm) Duration of disease (y)
Intervention group
Control group
P value
49.3 6 9.3 66.3 6 9.6 163.9 6 7.4 1.4 6 .8
10.6 6 49.3 66.4 6 11.6 163.4 6 11.5 1.2 6 .5
.98 .97 .87 .28
posture and coordination.36 Secondly, because we applied taping to correct the talipes equinovarus deformity, taping may provide cutaneous cues that improve foot position and therefore help restore normal joint range of motion and function.23,37-40 In this connection, several studies have reported significant changes in peak and mean plantar pressure values after ankle taping.41,42 Thirdly, KT may promote postural control by changing the muscle activity around the ankle joint.43 Improvements in the BBS score may be important given that falling in stroke patients is associated with poor performance on the BBS.31 In addition, the analysis of COP components has proved useful in predicting the risk of falling and changes in postural performance in healthy persons and those with hemiparesis.14 Therefore, KT may decrease the risk of falling; however, further research is needed to confirm this. Several previous studies have measured the effects of taping on postural control.24,44 Leanderson et al45 reported that ankle taping reduced postural sway in male elite soccer players with unilateral functional instability.
Table 2. Comparison of balance variables between control and KT groups on the first day Groups KT (mean 6 SD)
Control (mean 6 SD)
P value
FRT (cm) 24.13 6 7.3 LRT (cm) 15.21 6 5.09 BBS 47.45 6 6.71 TUG (s) 31.46 6 38.77 COP displacement (mm) AP 3.26 6 1.54 ML 3.42 6 1.35 COP velocity (mm/s) AP 23.33 6 9.39 ML 25.83 6 7.89 Total 36.53 6 12.88
19.89 6 7.94 13.23 6 5.43 49.4 6 5.05 30.42 6 20.27
.08 .2 .3 .9
4.11 6 2.44 4.08 6 2.46
.1 .3
23.87 6 10.44 27.21 6 8.91 38.19 6 13.94
.8 .6 .6
Variables
Abbreviations: AP, anteroposterior; BBS, Berg Balance Scale; COP, center of pressure; FRT, functional reach test; KT, kinesio tape; LRT, lateral reach test; ML, mediolateral; SD, standard deviation; TUG, timed up and go test.
Table 3. Comparison of balance variables between control and KT groups after 24 hours Groups Control (mean 6 SD)
KT (mean 6 SD)
P value
FRT (cm) 19.12 6 6.48 LRT (cm) 14.83 6 6.05 BBS 49.5 6 4.97 TUG (s) 30.82 6 22.01 COP displacement (mm) AP 3.79 6 3.32 ML 4.42 6 3.8 COP velocity (mm/s) AP 23.43 6 9.68 ML 26.5 6 8.63 Total 37.27 6 13.7
23.69 6 8.01 17.01 6 4.49 48.2 6 7.21 27.92 6 27.63
.04* .2 .5 .7
2.9 6 2.06 2.7 6 1.06
.3 .04*
Variables
21.81 6 8.49 24.49 6 4.82 34.54 6 10.23
.5 .3 .4
Abbreviations: AP, anteroposterior; BBS, Berg Balance Scale; COP, center of pressure; FRT, functional reach test; KT, kinesio tape; LRT, lateral reach test; ML, mediolateral; SD, standard deviation; TUG, timed up and go test. *Significant at P , .05.
On the other hand, Bennell and Goldie44 showed that normal young subjects with ankle taping during single leg stance were less stable compared to a group with no taping. Gross et al showed that ankle taping might have adverse effects on postural control in healthy adults during drop landing onto a force platform, because vertical ground reaction force was increased after taping.46 The participants in these 3 studies were healthy adult or athletes with functional instability of the ankle, and the sample size was small in all studies. The only published report that measured the effects of ankle taping on postural control in stroke patients is a 2012 study by Kim et al. They found that ankle KT in conjunction with 8 weeks of routine physical therapy including exercise resulted in more improvements in postural control compared to routine physical therapy alone. They measured postural balance with Romberg’s tests, limits of stability, the forward and back test, the timed up and go test, and a 10-m gait velocity test. The patients in their study were in the acute phase whereas in our patients, stroke had occurred an average of 1.3 years earlier.47 Maximum motor recovery in stroke patients takes place in the acute phase because of brain plasticity.48 Thus, recovery in acute patients is better than in chronic patients. This may explain why Kim et al found improvements in all postural control variables.47 Of course, the cumulative effects of exercise with taping should also be noted. It is worth mentioning that we observed improvements in postural control after 24 hours with taping alone. This may be helpful for therapists in the management of patients who are not cooperative in adhering to all parts of the rehabilitation program. The exact effect of taping
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Table 4. Comparison of the balance variables on the first day of measurement and 24 hours after taping Control group
KT group
First day (mean 6 SD)
After 24 h (mean 6 SD)
P value
First day (mean 6 SD)
After 24 h (mean 6 SD)
P value
FRT (cm) 19.89 6 7.94 LRT (cm) 13.23 6 5.43 BBS 49.4 6 5.05 TUG (s) 30.42 6 20.27 COP displacement (mm) AP 4.11 6 2.44 ML 4.08 6 2.46 COP velocity (mm/s) AP 23.87 6 10.44 ML 27.21 6 8.91 Total 38.19 6 13.94
19.12 6 6.48 14.83 6 6.05 49.5 6 4.97 30.82 6 22.01
.4 .1 .1 .5
24.13 6 7.30 15.21 6 5.09 47.45 6 6.71 31.46 6 38.77
23.69 6 8.01 17.01 6 4.49 48.2 6 7.21 27.92 6 27.63
.7 .09 .01* .3
3.79 6 3.32 4.42 6 3.8
.7 .7
3.26 6 1.54 3.42 6 1.35
2.90 6 2.06 2.70 6 1.06
.4 .056
23.43 6 9.68 26.5 6 8.63 37.27 6 13.7
.7 .5 .6
23.33 6 9.39 25.83 6 7.89 36.53 6 12.88
21.81 6 8.49 24.49 6 4.82 34.54 6 10.23
Variables
.5 .4 .5
Abbreviations: AP, anteroposterior; BBS, Berg Balance Scale; COP, center of pressure; FRT, functional reach test; LRT, lateral reach test; ML, mediolateral; SD, standard deviation; TUG, timed up and go test. *Significant at P , .05.
and whether the effects are maintained are questions that will need further research. Cortesi et al conducted another study with neurologic methods. They tested the effect of ankle KT on COP displacement and velocity in multiple sclerosis patients and used KT to inhibit the calf muscles. They reported decreases in COP displacement and velocity in the AP direction. They attributed the decrease in AP COP displacement to taping over the Achilles tendon, which primarily affects flexion–extension movement. In contrast, we placed the tape in a direction medial to the Table 5. Comparison of the balance variables on the first day of measurement and immediately after taping KT group First day (mean 6 SD)
Immediately (mean 6 SD)
P value
FRT (cm) 24.13 6 7.30 LRT (cm) 15.21 6 5.09 BBS 47.45 6 6.71 TUG (s) 31.46 6 38.77 COP displacement (mm) AP 3.26 6 1.54 ML 3.42 6 1.35 COP velocity (mm/s) AP 23.33 6 9.39 ML 25.83 6 7.89 Total 36.53 6 12.88
27.77 6 27.79 24.45 6 7.82 47.9 6 6.96 15.66 6 5.38
.7 .6 .02* .2
Variables
2.13 6 3.12 3.77 6 1.57
.7 .3
11.50 6 23.51 27.27 6 9.33 20.75 6 37.73
.8 .4 .4
Abbreviations: AP, anteroposterior; BBS, Berg Balance Scale; COP, center of pressure; FRT, functional reach test; KT, kinesio tape; LRT, lateral reach test; ML, mediolateral; SD, standard deviation; TUG: timed up and go test. *Significant at P , .05.
lateral side of the ankle joint, where the tape may act primarily on inversion–eversion movement.23 Therefore, we expected to see improvements in postural control in the ML direction with respect to the direction of correction. However, our results showed that only COP displacement in the ML direction improved significantly. The results reported by Cortesi et al should be considered with caution, because they did not use a control group and their sample size was small. To our knowledge, no other studies have investigated the effects of KT on postural control in stroke patients. Future research should test the effects of taping with motion capture analysis, elecromyographic activity, proprioception, and balance in different situations. Additions studies need to determine whether correcting the talipes equinovarus deformity will improve gait ability and reduce the risk of falling in stroke patients. In addition, more research is needed to verify the effects of ankle taping on postural control in stroke patients.
Limitations of the Study The main limitation of our study is the relatively short duration of follow-up. Future studies should determine whether the effects of KT on postural control are maintained in the long term.
Conclusion In conclusion, the results of the present study demonstrated that KT improved forward reach and ML COP displacement. Kinesio taping to correct talipes equinovarus appears to improve postural control in stroke patients, but additional studies will be needed to confirm the effectiveness of this treatment.
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6 Acknowledgments: We thank Ndumiso Tshuma and K. Shashok (Author AID in the Eastern Mediterranean) for improving the use of English in the manuscript.
References 1. Chen IC, Cheng PT, Hu AL, et al. Balance evaluation in hemiplegic stroke patients. Chang Gung Med J 2000; 23:339-347. 2. Sawacha Z, Carraro E, Contessa P, et al. Relationship between clinical and instrumental balance assessments in chronic post-stroke hemiparesis subjects. J Neuroeng Rehabil 2013;10:95. 3. Fish D, Kosta CS. Walking impediments and gait inefficiencies in the CVA patient. J Prosthetics Orthotics 1999; 11:33-37. 4. Dieli J, Ayyappa E, Hornbeak S. Effect of dynamic AFOs on three hemiplegic adults. J Prosthetics Orthotics 1997; 9:82-89. 5. Kuan TS, Tsou JY, Su FC. Hemiplegic gait of stroke patients: the effect of using a cane. Arch Phys Med Rehabil 1999;80:777-784. 6. Lehmann JF, Condon SM, Price R, et al. Gait abnormalities in hemiplegia: their correction by ankle-foot orthoses. Arch Phys Med Rehabil 1987;68:763-771. 7. Sobel E, Giorgini R. Problems and management of the rearfoot in neuromuscular disease. A report of ten cases. J Am Podiatr Med Assoc 1999;89:24-38. 8. Shumway-Cook A, Anson D, Haller S. Postural sway biofeedback: its effect on reestablishing stance stability in hemiplegic patients. Arch Phys Med Rehabil 1988; 69:395-400. 9. Rode G, Tiliket C, Boisson D. Predominance of postural imbalance in left hemiparetic patients. Scand J Rehabil Med 1997;29:11-16. 10. Renzenbrink GJ, Buurke JH, Nene AV, et al. Improving walking capacity by surgical correction of equinovarus foot deformity in adult patients with stroke or traumatic brain injury: a systematic review. J Rehabil Med 2012; 44:614-623. 11. Di Fabio RP. Lower extremity antagonist muscle response following standing perturbation in subjects with cerebrovascular disease. Brain Res 1987;406:43-51. 12. Mizrahi J, Solzi P, Ring H, et al. Postural stability in stroke patients: vectorial expression of asymmetry, sway activity and relative sequence of reactive forces. Med Biol Eng Comput 1989;27:181-190. 13. Laufer Y, Dickstein R, Resnik S, et al. Weight-bearing shifts of hemiparetic and healthy adults upon stepping on stairs of various heights. Clin Rehabil 2000;14:125-129. 14. Dickstein R, Abulaffio N. Postural sway of the affected and nonaffected pelvis and leg in stance of hemiparetic patients. Arch Phys Med Rehabil 2000;81:364-367. 15. Burridge J, Taylor PN, Hagan SA, et al. The effects of common peroneal stimulation on the effort and speed of walking: a randomized controlled trial with chronic hemiplegic patients. Clin Rehabil 1997;11:201-210. 16. Briem K, Eyth€ orsd€ ottir H, Magn usd ottir RG, et al. Effects of kinesio tape compared with nonelastic sports tape and the untaped ankle during a sudden inversion perturbation in male athletes. J Orthop Sports Phys Ther 2011; 41:328-335. 17. Cepeda, J., Fishweicher, A., Gleeson, M., et al., Does Kinesio Taping of the abdominal muscles improve the supineto-sit transition in children with hypotonia. Retrieved on April 2008. 12: p. 2011.
18. Kim WI, Choi YK, Lee JH, et al. The effect of muscle facilitation using kinesio taping on walking and balance of stroke patients. J Phys Ther Sci 2014;26:1831. 19. Waters RL, Perry J, Garland D. Surgical correction of gait abnormalities following stroke. Clin Orthop Relat Res 1978;131:54-63. 20. Karadag-Saygi E, Cubukcu-Aydoseli K, Kablan N, et al. The role of kinesiotaping combined with botulinum toxin to reduce plantar flexors spasticity after stroke. Top stroke Rehabil 2010;17:318-322. 21. Morris D, Jones D, Ryan H, et al. The clinical effects of KinesioÒ Tex taping: a systematic review. Physiother Theor Pract 2013;29:259-270. 22. Fu TC, Wong AM, Pei YC, et al. Effect of Kinesio taping on muscle strength in athletes—a pilot study. J Sci Med Sport 2008;11:198-201. 23. Cortesi M, Cattaneo D, Jonsdottir J. Effect of kinesio taping on standing balance in subjects with multiple sclerosis: a pilot studyy m {1}. NeuroRehabilitation 2010; 28:365-372. 24. Yi CH, Brunt D, Kim HD, et al. Effect of ankle taping and exercise on EMG and kinetics during landing. J Phys Ther Sci 2003;15:81-85. 25. Murray H, Husk LJ. Effect of kinesio taping on proprioception in the ankle. J Orthop Sports Phys Ther 2001;31. 26. Lee JH, Yoo WG. The mechanical effect of anterior pelvic tilt taping on slump sitting by seated workers. Ind Health 2011;49:403-409. 27. Brauer S, Burns Y, Galley P. Lateral reach: a clinical measure of medio-lateral postural stability. Physiother Res Int 1999;4:81-88. 28. de Oliveira CB, de Medeiros IR, Frota NA, et al. Balance control in hemiparetic stroke patients: main tools for evaluation. J Rehabil Res Dev 2008;45:1215-1226. 29. Jonsson E, Henriksson M, Hirschfeld H. Does the functional reach test reflect stability limits in elderly people? J Rehabil Med 2003;35:26-30. 30. Berg K, Wood-Dauphinee S, Williams J. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med 1995;27:27-36. 31. Thorbahn LD, Newton RA. Use of the Berg Balance Test to predict falls in elderly persons. Phys Ther 1996; 76:576-583. 32. Ng SS, Hui-Chan CW. The timed up & go test: its reliability and association with lower-limb impairments and locomotor capacities in people with chronic stroke. Arch Phys Med Rehabil 2005;86:1641-1647. 33. SM Y. Taping Techniques: Principles & Practice. 2nd ed., Vol. 96. Seoul: e-public 2007. 34. Lentell G, Baas B, Lopez D, et al. The contributions of proprioceptive deficits, muscle function, and anatomic laxity to functional instability of the ankle. J Orthop Sports Phys Ther 1995;21:206-215. 35. Lohrer H, Alt W, Gollhofer A. Neuromuscular properties and functional aspects of taped ankles. Am J Sports Med 1999;27:69-75. 36. Matsusaka N, Yokoyama S, Tsurusaki T, et al. Effect of ankle disk training combined with tactile stimulation to the leg and foot on functional instability of the ankle. Am J Sports Med 2001;29:25-30. 37. Nishikawa T, Kurosaka M, Yoshiya S, et al. Effects of prophylactic ankle supports on pronation during gait. Int Orthop 2002;26:381-385. 38. Bohannon RW. Taping for positioning and stabilizing the ankle of patients with hemiparesis. Suggestion from the field. Phys Ther 1983;63:524-525.
KINESIO TAPING AND POSTURAL CONTROL IN STROKE PATIENTS 39. Paris DL, Kokkaliaris J, Vardaxis V. Ankle ranges of motion during extended activity periods while taped and braced. J Athl Train 1995;30:223. 40. Wilkerson GB. Biomechanical and neuromuscular effects of ankle taping and bracing. J Athl Train 2002;37:436. 41. Scranton PE, Pedegana LR, Whitesel JP. Gait analysis alterations in support phase forces using supportive devices. Am J Sports Med 1982;10:6-11. 42. Lange B, Chipchase L, Evans A. The effect of low-Dye taping on plantar pressures, during gait, in subjects with navicular drop exceeding 10 mm. J Orthop Sports Phys Ther 2004;34:201-209. 43. Franettovich M, Chapman A, Blanch P, et al. A physiological and psychological basis for anti-pronation taping from a critical review of the literature. Sports Med 2008;38:617-631.
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44. Bennell KL, Goldie PA. The differential effects of external ankle support on postural control. J Orthop Sports Phys Ther 1994;20:287-295. 45. Leanderson J, Ekstam S, Salomonsson C. Taping of the ankle—the effect on postural sway during perturbation, before and after a training session. Knee Surg Sports Traumatol Arthrosc 1996;4:53-56. 46. Gross MT, Liu HY. The role of ankle bracing for prevention of ankle sprain injuries. J Orthop Sports Phys Ther 2003;33:572-577. 47. Kim YR, Kim JI, Kim YY, et al. Effects of ankle joint taping on postural balance control in stroke patients. J Int Acad Phys Ther Res 2012;3:446-452. 48. Bonita R, Beaglehole R. Recovery of motor function after stroke. Stroke 1988;19:1497-1500.
Background: To investigate the effects of kinesio taping on postural control in stroke patients. Materials and methods: Forty stroke patients aged 30 to 60 years were randomly divided into an experimental and a control group. In the experimental group, kinesio tape (KT) was applied directly on the skin over the affected ankle in the direction of dorsiflexion and eversion to correct the equinovarus deformity. The tape was kept on the ankle for 1 day. The results were measured with the forward reach test, lateral reach test, Berg Balance Scale (BBS), and timed up and go test. Center of pressure (COP) displacement and velocity were also measured while the patients stood on a force plate. All variables were measured on the first day immediately after taping and 24 hours later in the KT group, and on the first day and also 24 hours later in the control group. Results: There was a statistically significant difference in BBS between the first day and 24 hours later in the KT group (P 5.01). The forward reach test and mediolateral displacement of the COP differed significantly after taping in the experimental group compared to the control group (P 5 .04). Immediately after taping, BBS improved significantly in the KT group (P 5 .02). Conclusions: The application of KT improved forward reach test results and displacement of the COP in stroke patients. Key Words: Stroke—kinesio taping—postural control—Berg Balance Scale—equinovarus deformity. Ó 2015 by National Stroke Association
From the *Center of Human Motion Science Research, Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz; and †Center of Human Motion Science Research, Student Research Committee, Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran. Received May 23, 2015; revision received July 8, 2015; accepted July 12, 2015. The authors have no conflicts of interest to declare in relation to this article. This work was based on the MSc dissertation of the second author, (Shiva Amirian, proposal number: 91-6376) at Shiraz University of Medical Sciences, faculty of rehabilitation sciences. The authors are grateful for the financial support by Shiraz University of Medical Sciences, Shiraz, Iran. Address correspondence to Zahra Rojhani-Shirazi, Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Abiverdi 1 St, Chamran Blvd, Shiraz 1733-71345, Iran. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2015 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.07.008
Postural instability is one of the important mobility problems after stroke.1 It can result in reduced mobility, increased disability, and even mortality in stroke patients. These events have a great impact on patients’ activities of daily independent living and gait ability.2 One of the most common changes in the foot and ankle complex after a stroke is talipes equinovarus foot deformity (club foot), which can cause postural instability.3 This deformity leads to problems during quiet stance and walking.3-7 Equinovarus foot causes asymmetric weight-bearing, reduces the base of support, and further reduces equilibrium reactions during quiet stance and walking.3-14 In addition, the inability to dorsiflex and evert the ankle interferes with toe clearance during walking.15 As a result, abnormal gait, postural instability, and falling are frequently seen in these patients. Recovery of the stroke patients from postural instability which is a major source of disability is essential. Kinesio taping is a prevalent method which is being used by physical therapists during rehabilitation programs.16 Kinesio tape (KT) is a thin, highly elastic material which may be used as a modality to relieve pain, correct joint
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position, decrease swelling, increase proprioception, and increase or inhibit muscle recruitment.17 It has been shown that KT can improve postural control and gait ability by not only stimulating proprioceptive sense but also identifying the right position of the joint even in a comfortable posture with no weight-bearing.18 The equinovarus deformity consists of plantar flexion and inversion components. Therefore, concentrating on correction of its both components is important in restoring normal joint function.19 Previous studies have focused only on correcting the plantar flexion component.19,20 Ability of KT to stretch 120%-140% times its original length provides the opportunity to correct the deformed joint in both directions simultaneously.21,22 Other advantages of the KT include low cost and easy application.18 Despite the current use of KT as a part of clinical practice in physical therapy, its clinical effects on postural stability have not been extensively studied.16,18 To the best of our knowledge, no studies to date have investigated the effect of KT to correct equinovarus problems in postural control in stroke patients. There is also limited evidence of the effects of KT in neurologic patients16,23 and most of the previous studies involved non-neurologic patients.16,22,2426 Therefore, the purpose of the present study was to determine the short-term effects of KT to correct the direction of ankle dorsiflexion and eversion in improving postural control during quiet standing in stroke patients.
Methods and Materials Participants Forty patients with stroke (26 men and 14 women) aged between 30 and 60 years participated in this study. The patients in the KT group and control group were matched by age, weight, height, and duration of the disease. All patients with the following criteria participated in the study: involvement of the anterior cerebral artery on computed tomography scan at least 1 year ago, score of 21-56 on the Berg Balance Scale (BBS), spasticity level of 2-3 according to the modified Ashworth scale, ability to stand for at least 30 seconds, ability to change walking direction, and ability to understand instructions. Patients were excluded if they had hemiplegia due to traumatic brain injury, any history of lower limb surgery, fracture or joint dislocation in the lower limbs, low back pain, blindness or deafness, cerebellar disorders, middle ear problems, diabetes mellitus, neuropathy, or allergy to the KT. Patients were randomly divided into 2 groups: an experimental group with KT (14 men, 6 women) and a control group (11 men, 9 women) in which no KT was used. The nature and purposes of the study were explained to all participants, and all signed an informed consent form. Ethical approval for the study was obtained from the Human Ethics Committee of Shiraz University of Medical Sciences.
Data Acquisition The patients’ characteristics such as age, gender, height, weight, and duration of disease were recorded. Level of spasticity was measured with the modified Ashworth scale. Postural control was evaluated by functional tests and force plate measurements. The order of measurements was randomized with a table of random numbers. Functional tests included the functional reach test (FRT), lateral reach test (LRT), and BBS. In the FRT and LRT, the maximum distance that patients could reach forward or laterally without losing balance or taking a step from quiet stance was recorded.27,28 These 2 tests measure a person’s margin of stability and their ability to maintain balance during a functional task.27,29 The BBS is a standard clinical assessment tool for evaluating postural control in patients with senile disease and stroke patients, with a minimum score of zero and a maximum total score of 56. Higher scores in this scale indicate better postural control. The scale consists of 14 functional items which are similar to daily motor activities in adults.30,31 Each functional test was repeated 3 times, and the average of 3 trials was calculated for analysis. Gait ability was also assessed with the timed up and go test, which is the time a person needs to rise from a chair, walk 3 m, turn, and return to the chair.32 The average of 3 trials was recorded. Force plate measurements included center of pressure (COP) displacement and velocity along the mediolateral (ML) and anteroposterior (AP) axes. The patients stood barefoot on the force plate (model 9286A, size 400 3 600, Kistler, Switzerland) for 30 seconds and were instructed to look at a spot in front of them. The distance of the spot from floor was determined according to each patient’s eye level. The sampling frequency of the force plate was set at 50 Hz.23 This measurement was repeated 3 times, and the average of 3 trials was calculated for further analysis. The patients were allowed a 2-minute rest period between trials. Raw data were exported to Visual 3D software (C-motion, Inc. Germantown, MD) and filtered using a fourth-order low-pass Butterworth filter with a cutoff frequency of 12 Hz. After these measurements, taping was done for the KT group. Before KT application, the skin was cleaned and dried to remove all moisture and oil and then shaved if necessary. Standard 2-inch KT 3NSTEX (TS CO., LTD, Seoul, South Korea) was used. The patients were in supine position during taping, with their hip, knee, and ankle joints in neutral position. The kinesio I strip was applied with maximum tension (100%). Each strip simultaneously applied force in the directions of dorsiflexion and eversion. Three I strips, each covering approximately half the previous strip, were attached from 2-3 cm superior to the medial malleolus and passed around the ankle joint from the plantar surface of foot, then fixed at the top of the lateral malleolus. The strips were applied across the ankle joint from proximal to distal33 (Fig. 1). The patients
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tests for paired samples. The level of significance for all the tests was set at .05.
Results Demographic data are shown in Table 1. There were no significant differences between the groups in any of the demographic variables (Table 1). On the first day, none of the differences between groups in postural control variables were significant (Table 2). Twenty-four hours after taping, there were significant differences between groups in FRT (P 5 .04) and ML COP displacement (P 5 .04). However, none of the other variables differed significantly between groups 24 hours after taping (Table 3). In the KT group, BBS score 24 hours after taping differed significantly from the score on the first day. However, in this group, there were no significant differences in any of the other variables 24 hours after taping in comparison with the first day. In the control group, there were no significant differences in any of the variables between the first day and 24 hours later (Table 4). Immediately after taping, BBS improved significantly in the KT group (P 5 .02). However, in this group, there were no significant differences in any of the other variables immediately after taping in comparison with before taping (Table 5). Figure 1.
Application of kinesio tape.
were asked to dorsiflex and evert the ankle joint while holding the ends of a strap looped around the plantar surface of the foot during the application of KT because the purpose of KT in this study was to correct talipes equinovarus (Fig. 2). All postural control measurements were repeated 24 hours later in both groups.
Statistical Analysis All statistical analyses were done with SPSS, version 18 (SPSS Inc., Chicago, IL). The Kolmogorov–Smirnov test confirmed that all data showed a normal distribution. The differences between the KT and control groups on the first day and after 24 hours were analyzed with t tests for independent samples. The differences between the measurements on the first day and 24 hours later in the KT group and the control group were analyzed with t
Figure 2. Dorsiflexion and eversion of the ankle joint with a strap during the application of kinesio tape.
Discussion Our results showed that the only immediate improvement seen after KT application was in the BBS score. However, other significant improvements were seen 24 hours later in FRT, BBS, and ML COP displacement. The effects of taping on postural control may need time to become measurable. Mechanoreceptors may accommodate to taping during the first 24 hours, and this process may then result in enhanced sensory stimulation and postural control. The improved postural control after taping in the present study may have several explanations. Firstly, the elastic tape stretches the skin continuously, which stimulates mechanoreceptors and thus increases sensory information to the central nervous system. Therefore, joint position sense will improve, and with it, the ability of the neuromuscular system to control movements.34,35 KT may affect the neuromuscular reflex to control
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Table 1. Demographic characteristics of the participants
Variable Age (y) Weight (kg) Height (cm) Duration of disease (y)
Intervention group
Control group
P value
49.3 6 9.3 66.3 6 9.6 163.9 6 7.4 1.4 6 .8
10.6 6 49.3 66.4 6 11.6 163.4 6 11.5 1.2 6 .5
.98 .97 .87 .28
posture and coordination.36 Secondly, because we applied taping to correct the talipes equinovarus deformity, taping may provide cutaneous cues that improve foot position and therefore help restore normal joint range of motion and function.23,37-40 In this connection, several studies have reported significant changes in peak and mean plantar pressure values after ankle taping.41,42 Thirdly, KT may promote postural control by changing the muscle activity around the ankle joint.43 Improvements in the BBS score may be important given that falling in stroke patients is associated with poor performance on the BBS.31 In addition, the analysis of COP components has proved useful in predicting the risk of falling and changes in postural performance in healthy persons and those with hemiparesis.14 Therefore, KT may decrease the risk of falling; however, further research is needed to confirm this. Several previous studies have measured the effects of taping on postural control.24,44 Leanderson et al45 reported that ankle taping reduced postural sway in male elite soccer players with unilateral functional instability.
Table 2. Comparison of balance variables between control and KT groups on the first day Groups KT (mean 6 SD)
Control (mean 6 SD)
P value
FRT (cm) 24.13 6 7.3 LRT (cm) 15.21 6 5.09 BBS 47.45 6 6.71 TUG (s) 31.46 6 38.77 COP displacement (mm) AP 3.26 6 1.54 ML 3.42 6 1.35 COP velocity (mm/s) AP 23.33 6 9.39 ML 25.83 6 7.89 Total 36.53 6 12.88
19.89 6 7.94 13.23 6 5.43 49.4 6 5.05 30.42 6 20.27
.08 .2 .3 .9
4.11 6 2.44 4.08 6 2.46
.1 .3
23.87 6 10.44 27.21 6 8.91 38.19 6 13.94
.8 .6 .6
Variables
Abbreviations: AP, anteroposterior; BBS, Berg Balance Scale; COP, center of pressure; FRT, functional reach test; KT, kinesio tape; LRT, lateral reach test; ML, mediolateral; SD, standard deviation; TUG, timed up and go test.
Table 3. Comparison of balance variables between control and KT groups after 24 hours Groups Control (mean 6 SD)
KT (mean 6 SD)
P value
FRT (cm) 19.12 6 6.48 LRT (cm) 14.83 6 6.05 BBS 49.5 6 4.97 TUG (s) 30.82 6 22.01 COP displacement (mm) AP 3.79 6 3.32 ML 4.42 6 3.8 COP velocity (mm/s) AP 23.43 6 9.68 ML 26.5 6 8.63 Total 37.27 6 13.7
23.69 6 8.01 17.01 6 4.49 48.2 6 7.21 27.92 6 27.63
.04* .2 .5 .7
2.9 6 2.06 2.7 6 1.06
.3 .04*
Variables
21.81 6 8.49 24.49 6 4.82 34.54 6 10.23
.5 .3 .4
Abbreviations: AP, anteroposterior; BBS, Berg Balance Scale; COP, center of pressure; FRT, functional reach test; KT, kinesio tape; LRT, lateral reach test; ML, mediolateral; SD, standard deviation; TUG, timed up and go test. *Significant at P , .05.
On the other hand, Bennell and Goldie44 showed that normal young subjects with ankle taping during single leg stance were less stable compared to a group with no taping. Gross et al showed that ankle taping might have adverse effects on postural control in healthy adults during drop landing onto a force platform, because vertical ground reaction force was increased after taping.46 The participants in these 3 studies were healthy adult or athletes with functional instability of the ankle, and the sample size was small in all studies. The only published report that measured the effects of ankle taping on postural control in stroke patients is a 2012 study by Kim et al. They found that ankle KT in conjunction with 8 weeks of routine physical therapy including exercise resulted in more improvements in postural control compared to routine physical therapy alone. They measured postural balance with Romberg’s tests, limits of stability, the forward and back test, the timed up and go test, and a 10-m gait velocity test. The patients in their study were in the acute phase whereas in our patients, stroke had occurred an average of 1.3 years earlier.47 Maximum motor recovery in stroke patients takes place in the acute phase because of brain plasticity.48 Thus, recovery in acute patients is better than in chronic patients. This may explain why Kim et al found improvements in all postural control variables.47 Of course, the cumulative effects of exercise with taping should also be noted. It is worth mentioning that we observed improvements in postural control after 24 hours with taping alone. This may be helpful for therapists in the management of patients who are not cooperative in adhering to all parts of the rehabilitation program. The exact effect of taping
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Table 4. Comparison of the balance variables on the first day of measurement and 24 hours after taping Control group
KT group
First day (mean 6 SD)
After 24 h (mean 6 SD)
P value
First day (mean 6 SD)
After 24 h (mean 6 SD)
P value
FRT (cm) 19.89 6 7.94 LRT (cm) 13.23 6 5.43 BBS 49.4 6 5.05 TUG (s) 30.42 6 20.27 COP displacement (mm) AP 4.11 6 2.44 ML 4.08 6 2.46 COP velocity (mm/s) AP 23.87 6 10.44 ML 27.21 6 8.91 Total 38.19 6 13.94
19.12 6 6.48 14.83 6 6.05 49.5 6 4.97 30.82 6 22.01
.4 .1 .1 .5
24.13 6 7.30 15.21 6 5.09 47.45 6 6.71 31.46 6 38.77
23.69 6 8.01 17.01 6 4.49 48.2 6 7.21 27.92 6 27.63
.7 .09 .01* .3
3.79 6 3.32 4.42 6 3.8
.7 .7
3.26 6 1.54 3.42 6 1.35
2.90 6 2.06 2.70 6 1.06
.4 .056
23.43 6 9.68 26.5 6 8.63 37.27 6 13.7
.7 .5 .6
23.33 6 9.39 25.83 6 7.89 36.53 6 12.88
21.81 6 8.49 24.49 6 4.82 34.54 6 10.23
Variables
.5 .4 .5
Abbreviations: AP, anteroposterior; BBS, Berg Balance Scale; COP, center of pressure; FRT, functional reach test; LRT, lateral reach test; ML, mediolateral; SD, standard deviation; TUG, timed up and go test. *Significant at P , .05.
and whether the effects are maintained are questions that will need further research. Cortesi et al conducted another study with neurologic methods. They tested the effect of ankle KT on COP displacement and velocity in multiple sclerosis patients and used KT to inhibit the calf muscles. They reported decreases in COP displacement and velocity in the AP direction. They attributed the decrease in AP COP displacement to taping over the Achilles tendon, which primarily affects flexion–extension movement. In contrast, we placed the tape in a direction medial to the Table 5. Comparison of the balance variables on the first day of measurement and immediately after taping KT group First day (mean 6 SD)
Immediately (mean 6 SD)
P value
FRT (cm) 24.13 6 7.30 LRT (cm) 15.21 6 5.09 BBS 47.45 6 6.71 TUG (s) 31.46 6 38.77 COP displacement (mm) AP 3.26 6 1.54 ML 3.42 6 1.35 COP velocity (mm/s) AP 23.33 6 9.39 ML 25.83 6 7.89 Total 36.53 6 12.88
27.77 6 27.79 24.45 6 7.82 47.9 6 6.96 15.66 6 5.38
.7 .6 .02* .2
Variables
2.13 6 3.12 3.77 6 1.57
.7 .3
11.50 6 23.51 27.27 6 9.33 20.75 6 37.73
.8 .4 .4
Abbreviations: AP, anteroposterior; BBS, Berg Balance Scale; COP, center of pressure; FRT, functional reach test; KT, kinesio tape; LRT, lateral reach test; ML, mediolateral; SD, standard deviation; TUG: timed up and go test. *Significant at P , .05.
lateral side of the ankle joint, where the tape may act primarily on inversion–eversion movement.23 Therefore, we expected to see improvements in postural control in the ML direction with respect to the direction of correction. However, our results showed that only COP displacement in the ML direction improved significantly. The results reported by Cortesi et al should be considered with caution, because they did not use a control group and their sample size was small. To our knowledge, no other studies have investigated the effects of KT on postural control in stroke patients. Future research should test the effects of taping with motion capture analysis, elecromyographic activity, proprioception, and balance in different situations. Additions studies need to determine whether correcting the talipes equinovarus deformity will improve gait ability and reduce the risk of falling in stroke patients. In addition, more research is needed to verify the effects of ankle taping on postural control in stroke patients.
Limitations of the Study The main limitation of our study is the relatively short duration of follow-up. Future studies should determine whether the effects of KT on postural control are maintained in the long term.
Conclusion In conclusion, the results of the present study demonstrated that KT improved forward reach and ML COP displacement. Kinesio taping to correct talipes equinovarus appears to improve postural control in stroke patients, but additional studies will be needed to confirm the effectiveness of this treatment.
Z. ROJHANI-SHIRAZI ET AL.
6 Acknowledgments: We thank Ndumiso Tshuma and K. Shashok (Author AID in the Eastern Mediterranean) for improving the use of English in the manuscript.
References 1. Chen IC, Cheng PT, Hu AL, et al. Balance evaluation in hemiplegic stroke patients. Chang Gung Med J 2000; 23:339-347. 2. Sawacha Z, Carraro E, Contessa P, et al. Relationship between clinical and instrumental balance assessments in chronic post-stroke hemiparesis subjects. J Neuroeng Rehabil 2013;10:95. 3. Fish D, Kosta CS. Walking impediments and gait inefficiencies in the CVA patient. J Prosthetics Orthotics 1999; 11:33-37. 4. Dieli J, Ayyappa E, Hornbeak S. Effect of dynamic AFOs on three hemiplegic adults. J Prosthetics Orthotics 1997; 9:82-89. 5. Kuan TS, Tsou JY, Su FC. Hemiplegic gait of stroke patients: the effect of using a cane. Arch Phys Med Rehabil 1999;80:777-784. 6. Lehmann JF, Condon SM, Price R, et al. Gait abnormalities in hemiplegia: their correction by ankle-foot orthoses. Arch Phys Med Rehabil 1987;68:763-771. 7. Sobel E, Giorgini R. Problems and management of the rearfoot in neuromuscular disease. A report of ten cases. J Am Podiatr Med Assoc 1999;89:24-38. 8. Shumway-Cook A, Anson D, Haller S. Postural sway biofeedback: its effect on reestablishing stance stability in hemiplegic patients. Arch Phys Med Rehabil 1988; 69:395-400. 9. Rode G, Tiliket C, Boisson D. Predominance of postural imbalance in left hemiparetic patients. Scand J Rehabil Med 1997;29:11-16. 10. Renzenbrink GJ, Buurke JH, Nene AV, et al. Improving walking capacity by surgical correction of equinovarus foot deformity in adult patients with stroke or traumatic brain injury: a systematic review. J Rehabil Med 2012; 44:614-623. 11. Di Fabio RP. Lower extremity antagonist muscle response following standing perturbation in subjects with cerebrovascular disease. Brain Res 1987;406:43-51. 12. Mizrahi J, Solzi P, Ring H, et al. Postural stability in stroke patients: vectorial expression of asymmetry, sway activity and relative sequence of reactive forces. Med Biol Eng Comput 1989;27:181-190. 13. Laufer Y, Dickstein R, Resnik S, et al. Weight-bearing shifts of hemiparetic and healthy adults upon stepping on stairs of various heights. Clin Rehabil 2000;14:125-129. 14. Dickstein R, Abulaffio N. Postural sway of the affected and nonaffected pelvis and leg in stance of hemiparetic patients. Arch Phys Med Rehabil 2000;81:364-367. 15. Burridge J, Taylor PN, Hagan SA, et al. The effects of common peroneal stimulation on the effort and speed of walking: a randomized controlled trial with chronic hemiplegic patients. Clin Rehabil 1997;11:201-210. 16. Briem K, Eyth€ orsd€ ottir H, Magn usd ottir RG, et al. Effects of kinesio tape compared with nonelastic sports tape and the untaped ankle during a sudden inversion perturbation in male athletes. J Orthop Sports Phys Ther 2011; 41:328-335. 17. Cepeda, J., Fishweicher, A., Gleeson, M., et al., Does Kinesio Taping of the abdominal muscles improve the supineto-sit transition in children with hypotonia. Retrieved on April 2008. 12: p. 2011.
18. Kim WI, Choi YK, Lee JH, et al. The effect of muscle facilitation using kinesio taping on walking and balance of stroke patients. J Phys Ther Sci 2014;26:1831. 19. Waters RL, Perry J, Garland D. Surgical correction of gait abnormalities following stroke. Clin Orthop Relat Res 1978;131:54-63. 20. Karadag-Saygi E, Cubukcu-Aydoseli K, Kablan N, et al. The role of kinesiotaping combined with botulinum toxin to reduce plantar flexors spasticity after stroke. Top stroke Rehabil 2010;17:318-322. 21. Morris D, Jones D, Ryan H, et al. The clinical effects of KinesioÒ Tex taping: a systematic review. Physiother Theor Pract 2013;29:259-270. 22. Fu TC, Wong AM, Pei YC, et al. Effect of Kinesio taping on muscle strength in athletes—a pilot study. J Sci Med Sport 2008;11:198-201. 23. Cortesi M, Cattaneo D, Jonsdottir J. Effect of kinesio taping on standing balance in subjects with multiple sclerosis: a pilot studyy m {1}. NeuroRehabilitation 2010; 28:365-372. 24. Yi CH, Brunt D, Kim HD, et al. Effect of ankle taping and exercise on EMG and kinetics during landing. J Phys Ther Sci 2003;15:81-85. 25. Murray H, Husk LJ. Effect of kinesio taping on proprioception in the ankle. J Orthop Sports Phys Ther 2001;31. 26. Lee JH, Yoo WG. The mechanical effect of anterior pelvic tilt taping on slump sitting by seated workers. Ind Health 2011;49:403-409. 27. Brauer S, Burns Y, Galley P. Lateral reach: a clinical measure of medio-lateral postural stability. Physiother Res Int 1999;4:81-88. 28. de Oliveira CB, de Medeiros IR, Frota NA, et al. Balance control in hemiparetic stroke patients: main tools for evaluation. J Rehabil Res Dev 2008;45:1215-1226. 29. Jonsson E, Henriksson M, Hirschfeld H. Does the functional reach test reflect stability limits in elderly people? J Rehabil Med 2003;35:26-30. 30. Berg K, Wood-Dauphinee S, Williams J. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med 1995;27:27-36. 31. Thorbahn LD, Newton RA. Use of the Berg Balance Test to predict falls in elderly persons. Phys Ther 1996; 76:576-583. 32. Ng SS, Hui-Chan CW. The timed up & go test: its reliability and association with lower-limb impairments and locomotor capacities in people with chronic stroke. Arch Phys Med Rehabil 2005;86:1641-1647. 33. SM Y. Taping Techniques: Principles & Practice. 2nd ed., Vol. 96. Seoul: e-public 2007. 34. Lentell G, Baas B, Lopez D, et al. The contributions of proprioceptive deficits, muscle function, and anatomic laxity to functional instability of the ankle. J Orthop Sports Phys Ther 1995;21:206-215. 35. Lohrer H, Alt W, Gollhofer A. Neuromuscular properties and functional aspects of taped ankles. Am J Sports Med 1999;27:69-75. 36. Matsusaka N, Yokoyama S, Tsurusaki T, et al. Effect of ankle disk training combined with tactile stimulation to the leg and foot on functional instability of the ankle. Am J Sports Med 2001;29:25-30. 37. Nishikawa T, Kurosaka M, Yoshiya S, et al. Effects of prophylactic ankle supports on pronation during gait. Int Orthop 2002;26:381-385. 38. Bohannon RW. Taping for positioning and stabilizing the ankle of patients with hemiparesis. Suggestion from the field. Phys Ther 1983;63:524-525.
KINESIO TAPING AND POSTURAL CONTROL IN STROKE PATIENTS 39. Paris DL, Kokkaliaris J, Vardaxis V. Ankle ranges of motion during extended activity periods while taped and braced. J Athl Train 1995;30:223. 40. Wilkerson GB. Biomechanical and neuromuscular effects of ankle taping and bracing. J Athl Train 2002;37:436. 41. Scranton PE, Pedegana LR, Whitesel JP. Gait analysis alterations in support phase forces using supportive devices. Am J Sports Med 1982;10:6-11. 42. Lange B, Chipchase L, Evans A. The effect of low-Dye taping on plantar pressures, during gait, in subjects with navicular drop exceeding 10 mm. J Orthop Sports Phys Ther 2004;34:201-209. 43. Franettovich M, Chapman A, Blanch P, et al. A physiological and psychological basis for anti-pronation taping from a critical review of the literature. Sports Med 2008;38:617-631.
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44. Bennell KL, Goldie PA. The differential effects of external ankle support on postural control. J Orthop Sports Phys Ther 1994;20:287-295. 45. Leanderson J, Ekstam S, Salomonsson C. Taping of the ankle—the effect on postural sway during perturbation, before and after a training session. Knee Surg Sports Traumatol Arthrosc 1996;4:53-56. 46. Gross MT, Liu HY. The role of ankle bracing for prevention of ankle sprain injuries. J Orthop Sports Phys Ther 2003;33:572-577. 47. Kim YR, Kim JI, Kim YY, et al. Effects of ankle joint taping on postural balance control in stroke patients. J Int Acad Phys Ther Res 2012;3:446-452. 48. Bonita R, Beaglehole R. Recovery of motor function after stroke. Stroke 1988;19:1497-1500.
