Kinesio Study - Stroke Hemiplegia - Theratape

KTUS-DoCol-4 - 08-Sep-2010

Kinesio@Taping in Stroke:ImprovingFunctionalUseof the Upper Extremityin

HemiplegiaEwa]araczewska and Carol Long

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The purpose of this article is to present the Kinesios taping method used to improve the upper extremity function in theadult with hemiplegia. The article discusses various therapeutic methods used in the treatment of stroke patients to achieve /a functional upper extremity. The only taping technique for various upper extremity conditions that has been described inthe literature is the athletic taping technique. In this article, some interpretation is offered on proper assessment of thenonfunctional upper extremity, including the emphasis on postural alignment, trunk control, and scapula alignment. TheKinesios taping method in conjunction with other therapeutic interventions may fadlitate or inhibit muscle function,support joint .structure, reduce pain, and provide proprioceptive feedback to achieve and maintain preferred bodyalignment. Restoring trunk and scapula alignment after the stroke is critical in an effective treatment program for the upper

. extremity in hemiplegia.'Keywords: functionaluse,Kinesiostaping,stroke,therapy,upperextremity

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P" atients diagnosed with stroke often present,.. with a combinationofmuscleweaknessor

.. muscle imbalance, decreased postural; control, muscle spasticity, poor voluntary control,and body malalignment. The ability of the adult\with stroke to functionally use the affected arm:fuay be diminished due to all of the aboveproblems, As clinicians, we need to be aware of all

<the structures affecting patients' ability to reach,hold, and manipulate an object.

Regaining functional use of the upper extremityafter a stroke is one of the most challenging tasksfor the patient and for the therapist working withthe patient. Its result has a significant impact onthe individual's physical, psychological, and emo-tional well-being. There are several, equally impor-tant factors contributing to the problem with thefunctional use of the upper extremity. Thoracicand lumbar spine pathology may affect scapularplane shoulder abduction and muscle force.Poststrokeshoulder pain isa relativelyearlycompli-cation affecting the use of the upper extremitywithin an availablerange of motion. The correlationbetween shoulder subluxation and development ofthe shoulder pain has been reported.' When shoul-der subluxation occurs, it may inhibit functionalrecoveryby limiting the range of motion.

Impaired or lack of sensation in the hemiplegicupper limb, its spasticity or flaccidity, and theneglect of the hemiplegic arm contribute equally

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to a nonfunctional upper extremity in the strokevictim.

This article promotes the potential of a Kinesio@taping method, a treatment technique that may beused in restoring the functional use of the upperextremity in hemiplegia.

Review of Therapeutic Methods to AchieveFunctional Use of the Upper Extremity

In rehabilitation programs, it is a challenge tofind a way to stimulate the sensorimotor systemtoward regaining normal voluntary movement andupper extremity functional use. Various treatmenttechniques have been adapted to be used clinicallyin rehabilitation centers for patients who pre-sented with shoulder subluxation, shoulder pain,and nonfunctional upper extremity due to stroke.

Functional electrical stimulation (FES) appliedto shoulder muscles in patients with hemiplegiahas shown beneficial effects on mobility and pain

EwaJaraaewska, PT, CKTI, is Allied Health Manager,

Orthopedic Program, Rehabilitation Institute oj Chicago, Illinois.

Carol Long OTRlL, CKTP, is Occupational Therapist level ill,

Rehabilitation Institute oj Chicago, minois.

Top Stroke Rehabi/2006;13(3):31-42@ 2006 Thomas wmd Publishers. Inc.www.thomasland.com


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~~;d.~~l~'1.::.,fagl1ri.etal}suggestthat FEShelps ini1!Fcr~iD.g$ll§u.lderpainand subluxation and im-pro\-e,smotot function of the upper extremity.'Rrada.\aridTallis4reported the use of FESto reducethe effect of the hemi neglect. Skin stimulation ofthe affected forearm was used to draw a patient'sattention to his neglected arm.

The protocol for the use of phenol, alcohol, orBotox injections in the management of the focalspasticity has been developed and has been re-ported to improve the range of motion and theupper extremity function.5 In another study,Leandri et a1.6demonstrated that the high-inten-sity transcutanous electrical stimulation (TENS)was more effectivein increasing the range of mo-tion in the hemiplegic upper extremity when com-pared with the low-intensity TENS.

Bobath approach and other exercise programshave been implemented early after the onset of thestroke to prevent immobility7and soft tissue con-tractUreand to alter the muscle tone in order to gainmobility. The goal of most therapy programs is tomaintain the affected upper extremity in the bestpossible alignedposition to avoidoverstretchedsofttissue, edema, and pain. Therapists use and teachproper handling techniques, use an arm trough ortray on a wheelchair, and correcdy position theaffectedupper extremity in bed. Through the exer-ciseprogram and use of weight-bearingtechniques,the therapist attempts to maintain and improvetrunk and shoulder alignment to allow the func-tional use of the upper extremity. Passiverange ofmotion of the upper extremity is often required;however, the overhead exercise pulleys shouldnever be used.1 The use of the overhead pulleysystem has been documented to cause pain, im-pingement, and even rotator cuff ruptUre.sInstead,a range of motion program using bilateral tech-niques is strongly recommended. Taping can beused as an adjunct during the rehabilitation pro-gram.to enhance functional recovery by reducingpaiIi,'improving alignment, and stimulating or in-hibiting muscle function and improving proprio-ceptive function of the joint structure. Athletic tap-ing has been used in promoting a proximal stabilityof the scapula. It is suggested that the taping tech-nique affects the resting position of the scapulaand assists in maintaining the proximal shoulder

Igirdle stability. A specific taping technique withLeukotape@P was described in the case of im-pingement of the rotator cuff tendons.9

Kinesid~ taping is a treatment method used inconjunction with other therapeutic techniques inthe treatment of various musculoskeletal and neu-

romuscular deficits. Kinesio@taping has a longhistory of use by occupational therapists, physicaltherapists, athletic trainers, and other trainedhealth professionals to achieveimprovement in thetreatment ofjoint sprains and joint instability, softtissue inflammation, muscle weakness, and pain.

The elastic quality of the Kinesio@Tex Tape, ifused and applied properly, may help to support orinhibit muscle function, support joint structure,reduce soft tissue inflammation, and reduce pain.It can provide feedback to the muscles to maintainpreferred postUral alignment.

Kinesio@Tex Tape has an effecton sensorimotorand proprioceptive systems, as seen in its benefitin the treatment of various neurological' condi-tions, including shoulder subluxation following astroke. No information exists, however, on theeffectiveness of Kinesio@taping in conjunctionwith other therapeutic activities to facilitate im-provement in restoring functional use of the upperextremity in hemiplegia.

Yasukawa studied the results of the Kinesio@

taping application in improving upper extremitycontrol and function in the acute pediatric reha-bilitationsetting.10Basedon a clinicalevaluation,Kinesio@Tex Tape was applied to facilitatea func-tional upright position of the trunk, to assist withpositioning the shoulder in neutral alignment, andto provide palmar stability and arch support forthe involved hand. Yasukawa concludes that theuse of the Kinesio@taping method appeared tohave improved purposeful movement and pro-vided needed stability of the shoulder and hand.10Yasukawa et al. found that the application of theKinesio@Tex Tape provided the proper bodyalignment to allow performance of reach, grasp,release, and manipulation tasks.

This article attempts to review the importantfactors in restoring the upper extremity functionfollowing a stroke. Presented factors were chosenbased on the literature review and the clinical

experience of a physical therapist and an occupa-


tional therapist certified in the Kinesio@tapingmethod.

. Functional Anatomy and Kinesiology of theUpper Extremity: Thoracic and Lumbar SpinePerspective

t The thoracic spine has three roles related toupper extremity function. It supports and stabi-lizes the rib cage that provides housing and allowsmovement of the scapula. Its articulating vertebralfacets allow full range of extension and flexion ofthe thoracic spine to assist with shoulder elevationand depression. The thoracic spine provides sup-port for the lumbar spine and together they con-struct the upright column that stabilizes the upperextremity in relation to the trunk.

It is apparent that without a stable supportingcentral point the muscles of the upper limbs wouldnot be effectivein their function.

The thoracic spine flexion and extension rangeof motion is limited by the attachment of the ribcage. Axial rotation is, however, relatively wide-ranging, exceeding that of the lumbar spine. Itallows the upper extremity to perform a variety offunctional tasks.

The lumbar spine has a wide range of flexionand extension because there are no ribs attached to

it. However, there is only little motion in the indi-vidual facetjoints of the lumbar spine. Major mo-tion oflumbar spine flexion depends on the avail-able range of motion in the hip joint, and itsstability depends on a strong action of the abdomi-nal muscles.

In summary, for the upper extremity to performits functional tasks, the trunk needs to be heldupright and needs to be able to move freely fromone stable position to another either against thepull of the gravity or despite its pull.

Two groups of muscles are responsible for trunkcontrol. There are back extensors posteriorly andabdominal muscle anteriorly. Back extensors thatsurround the vertebral column provide a flexiblesupport for the trunk. Manyof these muscles func-tion as the "guy-ropes" supporting the uprightpole. While producing a variable tension on thespine during different activitiesin sitting or stand-ing, they allow the entire trunk or its segments to

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Kinesio~Taping in Stroke 33

deviate in any direction and still provide the stabil-ity required for the function performed.

An important function of the trunk musculatureis to fixate the thorax, lumbar spine, and pelvis tostabilize the proximal attachment of the shouldermuscles when the arm is moving. Specific elec-tromyographic study of the trunk muscles demon-strates that manual resistance to shoulder exten-

sion and adduction will activate )tbdominalmuscles; with the arms placed over head andlifted, the back extensors will contract.ll

When the upper extremity performs its func-tional activity, it requires efficient function of theabdominal muscles to maintain and achieve a de-sired movement. For the abdominal muscles to act

efficiently, they need a stable thorax. With in-creased thoracic kyphosis, the insertion and originof the obliques is approximated, therefore themuscles cannot function in full capacity. It is im-portant to mention that an excessivekyphotic po-sition of the thoracic spine caused by poor posture,muscle weakness, or muscle imbalancewill cause acompression of the rib cage. Such compressionwill reduce the volume of the lungs and cause thepatient to fatigue easily.

When evaluating the upper extremity function,one has to include postural assessment. Alignmentof the cervical, thoracic, and lumbar spine influ-ences scapular position and the overall upper ex-tremity function.

During the shoulder abduction, scapulohumeralrhythm determines the range and the quality of themovement. It is further concluded that the exten-sion of the thoracic spine is necessary for a fullrange of motion of the shoulder.12

It is known that increased thoracic kyphosistends to abduct the scapula and downwardly ro-tate it, altering the scapulohumeral relationship,13

which leads to muscle weakness and decreased

range of motion. As a result, shoulder impinge-ment syndrome may be present.

Due to the aging process or illness, the thoraciccurvature tends to increase. In addition, varioussoft tissue restrictions occur. The upper trapeziusmuscle is placed in shortened position and itsability to generate tension is affected. In theslouched posture, the deltoid and the supraspina-tUs are also in the excessivelyshortened position.

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Poor posture can also precipitate translation of thehumeral head, resulting in impingement.

Decreased ability to abduct the shoulder is clini-cally significant due to the fact that the upperextremity function depends on the activities per-formed at the shoulder level. The shoulder girdlehas no direct articulation with the venebral col-

umn and is dependent on complex muscle activityto provide the necessary support for the functionalarm. The action of the serratus anterior and pecto-ralis minor in scapula stability depends uponstable thorax due to these muscle attachments on

the rib cage. Similarly the pectoralis major in-volved with arm movement requires a stable tho-rax in order to act in shoulder flexion, internalrotation, and adduction due to its attachment to

nearly all the true ribs. To allow the pectoralismajor to function efficiently, the abdominalmuscles act in holding the ribs down. All themuscles that act on the shoulder depend on thestability provided by the shoulder girdle, whichitself depends on the stability of the thorax. Be-cause the trunk is involved in every activity per-formed against gravity, without its stable center,the movements of the upper extremity are difficultor impossible. .

Thoracic and lumbar spine pathology in theneurologically impaired patient is reflected in theupper extremity function. The neuromuscular as-sessment of the thoracolumbar system provides acomprehensive understanding of the upper ex-tremity function. After onset of hemiplegia, theabdominal muscles demonstrate a significant lossof activity and tone and the patient experiencesdifficulty in moving against gravity. The effect oftrunk instability on upper extremity function is

profou9d. When one of the aforementionedgroups of muscles becomes weak, the body as-sumes a position that eliminates the necessity ofaction of this group. The venebral column willconcave toward the side of the weak muscles and

the lateral curvature of the spine will increase onthe opposite side. The muscles on the convex sideare placed in the stretched position, and they areno longer able to provide an adequate stability ofthe spine in the upright position.

In early stages of hemiplegia, the patient usuallymaintains unsupported sitting with hips in some

degree of extension and thoracic spine in flexion.Due to the approximation of the abdominalmuscles origin and insertion, the muscles are notable to perform a stabilizing function for the trunkand upper extremity. With the lack of selectivetrunk activity and poor stability of the ribs due toweak abdominals, the scapula is no longer held ina steady position required for effective shouldermovement.

When working on achieving a functional move-ment of the upper extremity for a patient withhemiplegia, clinicians need to focus their attention

on the position and movement of rye trunk, ribcage, and scapula. Only this stable foundation willallow the patient a functional use of the upperextremity.

Functional Anatomy and Kinesiology of theUpper Extremity: Scapular Perpective

Having fullyevaluated the trunk, cliniciansmustnext consider the role of the scapula when evaluat-ing and treating functional ability and use of thehemiplegic upper extremity. DePahna et al.Hnotesthat the scapula is central in proficient shoulderactivity, and rotator cuff muscles will not operateoptimally if the scapula is poorly positioned. Ashas already been noted, the scapula can only bestabilized dynamically if the thoracic spine and theribs can provide adequate anchorage or founda-tion for the relevant muscle groupS.15Poor posi-tion, alignment, or stability of the scapula on thechest wall will significantly impact the availablerange of motion of the shoulder, may also causepain, and will consequently impede functional useof the upper extremity.

The scapula is a flat triangular bone with threeborders: medial, lateral, and superior. The supe-rior border contains the coracoid process, de-scribed by Calais-Germainl6as looking like a bentfinger pointing forward. The scapula rests on theribcage just lateral to where the ribs curve anteri-orly. The spines of the scapulae should be at thesame level and can be easilypalpated. The depres-sions above and below these structures are known

as the supraspinous and infraspinous fossa, re-spectively. The scapula itself extends from T2spinous process to T7/8 spinous process of the


d~()racicvenebrae, and it is slighdy upwardly ro-~t~: The spines of the. scapulae on the medial

"tJptder should be equidistant and. approximately{:.~:r~e to four fingers width from the thoracic spine.]fb.einferior angle of the medial border should be'loUtto five fingers width from the spine. Lack of$X"1pIrietryof the scapulae will result in poor posi-1:~911'.alignment, or stability of the scapula. An~x~riipleof this is scapular winging, often due to~~eakserratus anterior musculature. The serratus~ferior muscle originates at ribs one through~fght and inserts along the medial border of the

,5(:;.lpulae.Its function is to laterally rotate and ab-i£l1t~tthescapula. It also maintains proximity be-;E...,,~enthescapula and the thoracic wall.H Weak-D.~or paralysis of this muscle due to a stroke may'!'~1lltin the medial border moving away from the~§racic wall (winging). This can be most clearly;Qb.~ervedwhen the patient is engaged in forward

5:fte1donof the upper extremity in a closed chain1J'fpdifiedpush-up position against a wall. It canal$o be seen during functional tasks such as

'''..~mbulationwhile weight bearing on a walker. Be-Qluse the serratus anterior is the most effective

1;Ilpsclefor producing scapular upward rotation.during arm elevation,17the individual will be un-~ple to raise the affected upper extremity greaterl~~t 120°. In lateral scapular winging, the lateralb'order of the scapula is prominent during humeral~1Jductionand the upper trapeziusis flattened.14

..$lllsindicates upper trapezius weakness. The up-p~ttrapeziu~ muscle is the only muscle respon-$iblefor el~ation of the lateral aspect of the spinehfLthe scapula, and weakness or imbalance hereJ\';jllresult in a notable depression of the lateral;ingle.I8In conjunction with the upper fibersof thetrapezius, the levator scapulae and the rhomboids~.$t in elevation of the scapula. When the upper:~fa]?eziusmusculature becomes weak or para-"'l};zed,elevation becomes the sole responsibility oftl'lelevator scapulae and the rhomboids. They re-~pdnd reflexively to the increase in stretch, thusth,eycontract to produce excessiveelevation of the'S,Hperiorangle of the scapula. Early identification~'1'ldmanagementof weak musculature can reducemalalignment of the humeral head in the glenoidfQssa, which could result in painful movementlater in the rehabilitation process due to impinge-

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Kinesio@Taping in Stroke 35

ment. Painduringmovementwillgreadyaffectthefunctional use of the upper extremity and must bea priority for the therapist.

The lateral border of the scapula contains. theshallow glenoid cavity that, when properlyaligned, articulates with the head of the humerusto form the glenohumeral joint. The glenoid. la-brum is a fibrocanilaginous ring that helps to sealthe joint and somewhat increase the depJfl of theglenoid cavity. DaviesI9notes that this makes.theshoulder joint unstable to allow for the enormousrange of movement required for skilled manipula-tions of the hand and fingers.

To elevate the upper extremity, the humeralhead must be placed within the glenoid fossa. Thedeltoid and rotator cuff muscles act together as aforce couple to achieve this. Weakness or paralysisof the normally strong musculature can result insubluxation of the shoulder. A patient who hasexperienced a stroke may not experience any paindue to subluxation; however the different musclegroups may be vulnerable to overstretching, in-creased contraction, and premature fatigue. Thiscan most cenainly decrease the coordination ofmuscular activity, alter muscle patterns, and ulti-mately impede the functional use of the upperextremity. The posterior fibers of the deltoid, thesupraspinatus, and the infraspinatus are the mostimponant muscles in preventing subluxation ofthe glenohumeral joint. 19The deltoid muscle origi-nates from the spine and acromion of the scapulaand lateral third of the clavicleand inserts on thedeltoid tuberosity on the lateral aspect of the hu-meral shaft. The deltoid primarily acts to abductthe humerus. When the deltoid is combined withthe rotator cuff muscles (adduction of the hu-merus) as a force couple, the humerus is preventedfrom jamming into the bony structures (i.e., theacromion) and causing pain. A force couple isdefined as two equal forces acting in oppositedirections to rotate a pan about its axis ofmo-tion.2oWeakness or paralysis of these muscles willresult in a downward sloping glenoid fossa.Daviesl9notes that with the scapula rotating down-ward and retracted, the humerus is in a position ofabduction. The capsule is no longertant, arid thehead of the humerus slides around in the glenoidfossa. The weak or paralyzed posterior portion of

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the deltoid, supraspinatus, and infraspinatus can-not maintain the head of the humerus in the gle-noid fossa and subluxation occurs. During clinicalobservation, a droop in the shoulder girdle can benoted, a flattening of the normal round deltoidmuscle area can be seen, and a sulcus sign can beobserved. Early detection and prevention of sub-luxation through correct positioning and align-ment will reduce the likelihood of overstretched

soft tissue, edema, and pain.According to Bobath,1there is also evidence of

spasticity in a predominately flaccid arm, particu-larly around the lateral flexors of the neck andthose around the scapula. The shoulder girdle isretracted and the inferior angle of the scapula isfixed, restricting movement laterally and upwardwhen the arm is elevated. The acromion therefore

does not turn upward to maintain the head of thehumerus in the glenoid fossa. Bobath7concludesthat it is not only gravity that pulls the humeralhead out of the glenoid cavity,but also the spastic-ity of the depressors of the humerus, that is, thesubscapularis, infraspinatus, and teres minor.

The lateral end of the spine is enlarged andflattened to form the acromion process. The acro-mion and the lateral end of the claviclearticulate to

form the acromioclavicular joint. If a flaccidhemiplegic patient with subluxation experiencespain with shoulder elevation above 90°, it is likelyindicative of supraspinatus impingement againstthe acromion. The supraspinatus muscle origi-nates at the supraspinous fossa of the scapula andinserts at the greater tubercle of the humerus (su-perior aspect). Its primary function is abduction ofthe humerus. The supraspinatus is sometimes vis-ible as it produces a slight outward bulging of thetrapeziu~ immediately above the scapular spine.ISIt is d:i1ficultto palpate, because the overlyingupper trapezius muscle also contracts during ab-duction. A weakened or impinged supraspinatusmuscle may cause the individual to hike the shoul-der to achieve abduction. Rotation (upward) andabduction of the scapula may be prevented if thereis spasticity of the rhomboids, latissimus, and tra-pezius muscles. The glenoid fossais then unable torotate upward and remains downward facing, re-sulting in pain as the humerus is pushed againstthe acromion, impinging the supraspinatus ten-

don. The position of the scapula must be correctedand the cause of the impingement identified toachieve decreased pain and improved functionalability of the upper extremity.

When examining the functional use of the upperextremity, the clinician must also observe thescapulohumeral rhythm. Scapulohumeral rhythmrefers to the smooth and integrated motion of theshoulder girdle joints and muscles as they movethrough full elevation (shoulder flexion/abduc-tion) of the upper extremity and the consequentrelationship between the humerus and thescapula. The initial 30° to 60° of shoulder flexionor abduction is known as the setting{>hasewherethe scapula positions itself on the thoracic walLBeyond 60°, the humerus maintains a 2:1 move-ment ratio with the scapula. That is, for every 30°of scapular rotation, there is 60° of humeral eleva-tion. Impaired functional use of the upper extrem-ity occurs when any of the many components ofthe scapula and the shoulder (including all fourarticulations) malfunctions. An individual withpoor posture and weakened shoulder muscles dueto stroke will experience disruption of the normalrhythm. Attempting elevation of the upper extrem-ity in the presence of pain, capsular adhesions, orweak musculature, according to Kelley,21will leadto excessivescapular elevation, lateral rotation, orshoulder shrugging. Lumbar hyperextension andcontralateral lateral trunk flexion may also occur.Improving biomechanical deficits related to pos-ture and alignment of the trunk and scapula mustbe the initial goal of rehabilitation, according tothe authors, to begin facilitating normalscapulohumeral rhythm.

Looking at the scapula from a neurological per-spective may attribute any malalignment to, forexample, increased tone or abnormal movementpatterns. Landel and Fisherll also highlight that anorthopedic perspective can be extremely effectivein determining the relative alignment of variousbody segments. They note the importance of theposition of the head on the neck, neck on thorax,and shoulder girdle on thorax and conclude thatother possible reasons for malalignment could belack of range, weakness, habit, and resting muscletension. They state that therapists need to recog-nize that faulty alignment may predispose the pa-

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Kinesia'"Taping in Stroke 37

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Figure 1. Kinesio~taping technique for trunk extensors. This is a mechanical correction technique toassistwith proper trunk alignment.

tient to move abnonnally. Only after scapular sta-bilization is achieved should treatment focus ondistal upper extremity dysfunction.

Promoting Functional Use of the UpperExtremity: Kinesio@Taping Perspective

Kinesio@tape can be used in a variety of ways topromote postural alignment and stability of thethoracic spine and scapula. This section illustratesa numbefof taping methods that can be used aloneor in combination to support weak muscle, relaxoverstretched muscle, and reduce pain to promotefunctional use of the upper extremity.

_Ilis_.~1ft>.a.renu:b.~uhe_E;fluilibriumbetween the~~~\.W..~ 'O..~~ ~'O..\."i:.~\.~ ~~\.~ '::>'\:o.~~\:z..\.'C\.'b'-\\.~

thoracic and lumbar spine is necessary for thefunctional use of the upper extremity. After onsetof hemiplegia, the abdominal and trunk musclesdemonstrate a significant loss of activity. Lumbarhyperextension and contralateral lateral trunkflexion may occur. The thoracic c1;lrvaturetends toincrease, affecting the function of the shouldergirdle muscles. Kinesio@tape can assist withachievingproper trunk alignment, and several tap-ing techniques have been described. The purpose

of this application is to facilitate a functional, up-right position of the trunk and to reduce spineconvexity on the nonaffected site. Kinesio@tapemechanical correction technique is applied fromdistal to proximal attachments of the erectorspinae on the nonhemiplegic site (Figure 1). Thepatient is instructed to maintain upright positionduring unsupported sitting, but manual assistanceis often necessary to maintain proper alignment.Two-inch tape is stretched over the length of themuscle with downward pressure, and the elasticityis taken out of the tape as it is applied. The tape issecured in place without any tension on its end.

Due to poor trunk alignment and with the tho-racic curvature increased, various soft tissue re-

. 11.1,::>,-"'Ii~,-\.~~<;)~~'\) '1:~~ ~~~~'>: \''>:'O.¥'Z.;''\JS,~\3..Us;.me.scapula upward and inward. The middle fibers oftrapezius stabilize the scapula and the lower fiberspull the medial border of the scapula down. Inconjunction, the middle and lower fibers of thetrapezius assist with elevation of the glenoid fossa,thus contributing to the scapulohumeral rhythm.Following stroke, the upper trapezius muscle isoften placed in shortened position and its ability togenerate tension is affected. Early identificationand management of the tight upper trapezius can


Figure2. BasicKinesio@taping methodfor upper trapezius using insertion to ori-gin application to "relax" tight muscle.

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?~~_.Figure 3. Kinesio~taping technique for middle andlower trapezius using origin to insertion application toassist weak muscle.

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Figure 4. Kinesio~taping techniques for postural alignment and scapula alignment using mechanicalcorrection technique for trunk extension and basic application technique for middle and lower trapezius.

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Kinesio@Taping in Stroke 39

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FigureS. Basic Kinesio@taping technique for supraspinatus using insertion to origin application. Thistechnique is used to "relax" overstretched muscle and provide proprioceptive feedback to rotator cuffmuscles.

reduce the malalignment of the scapula. A basicKinesio@taping method for upper trapezius isused. Kinesio<!>Tex Tape is applied from insertionto origin to relax tight muscle. The base of the 2-inch I strip Kinesio@tape is attached to the lateralthird of the clavicle.The patient rotates his or herhead toward the opposite shoulder, and the tape isadhered to the stretched skin just below the hairline (Figure 2).

The middle and lower trapezius muscles arevulnerable to overstretching, increased contrac-tion, and premature fatigue. The Kinesio@tape canhelp to support weak muscle and improve scapulaalignmeny;'thus improving the functional use ofthe upper extremity. Origin to insertion applica-tion is used for the middle and lower trapezius.Both applications require 2-inch I strip Kinesio@

.J{joP_{jpDroximar£jJ\Laffized... an. ?D.inQ.l)~ DrQC~.s$~S.of

C6-T3 for middle trapezius and on spinous pro-cessesofT4-Tl2 for lowertrapezius (Figure 3). Thetape is laid down along the muscle fiberswith paperoff tension, and it is affixedto the acromion and thespine of the scapula, respectively(Figure 4).

The supraspinatus is the rotatOrcuff muscle thatcan be affected by the slouched posture. Withincreased thoracic kyphosis and poor posture re-sulting from muscle weakness and imbalance, thesupraspinatus is in the excessivelyshortened posi-tion. The weak or paralyzed muscle, along with

other rotator cuff muscles and deltoid, cannotmaintain the head of the humerus in the glenoidfossa, affecting anterior-posterior stability of theshoulder. As a result, pain and impingement mayoccur. Kinesio@tape may assist with achievingproper shoulder and scapula alignment to reducesoft tissue overstretch, edema, and pain. For thisapplication, Kinesio@Y strip was applied from themuscle insertion at the greater tuberosity of thehumerus to its origin at the supraspinatus fossa ofscapula. For this application, basic Kinesio@tapingtechnique using 2-inch tape is demonstrated torelax overstretched muscle and to provide prop-rioceptive feedback to rotator cuff muscles.Kinesio@Tex Tape is laid down on the skinstretched over the muscle with no tension on the

tape (Figure 5).Duri~ subluxation of the humerus. the deltoid

muscle is noted to be weakened or paralyzed.Kinesio@tape is applied from origin to insertion tosupport the weak muscle. Prior to application, thepatient is positioned with the head, trunk, andscapula in the best possible alignment. The tape iscut in a Y shape with the anchor applied to theacromion using paper off tension with no stretchapplied to the tape. The shoulder is abducted to900 during application. The shoulder is nextmoved into extension, and the first tail is appliedto the anterior portion of the deltoid in a stretched


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Figure6. BasicKinesid!)taping method for del-toid using origin to insertion application to sup-port weak muscle.

Figure7. BasicKinesio~taping for deltoid; appli-cation completed.

position (Figure 6). The second tail is applied tothe posterior portion of the deltoid with the shoul-der in horizontal abduction. No tension is appliedto the tails. Patients have subjectively reported afeeling of "support" to the joint (Figure 7).

Aswas noted previously, the humeral head must

be positioned in correct alignment prior to appli-cation. Kinesio@tape does not have the tensilestrength to stop the humeral head from dislocatingor subluxing, however it can provide propriocep-tive feedback to the tissues and assist in the posi-tioning of the muscle, fasciatissue, or joint.23A

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Figure8. Basic Kinesio@taping method for deltoid; this is the final application using two Y strips foradditional support.


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Kinesio<»Taping in Stroke 41

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Figure 9. BasicKinesio~taping application for serratus anterior using origin to insertion application tosupport weak muscle. .

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Figure 10. BasicKinesioll9taping for serratus anterior. Application completed."

large shoulder may require the application of morethan one strip (Figure 8).

The scapula cannot rotate unless it lies flaton thethoracic wall, thus impairing functional use of theupper extremity. Abduction of the scapula (wing-ing) can be addressed by Kinesio~tape in the fol-lowing way. For medial scapular winging with ser-ratus anterior involvement, the Kinesio\!)tape canbeapplied using a Kinesio\!)I strip from origin to inser-tion with paper off tension only. The Kinesio\!)TexTape is anchored between ribs one through eight(Figure 9). With the upper extremity in full eleva-

--

tion, the patient is instructed to take a deep breathto elevate the ribcage. The Kinesio@I strip is an-chored up, and the end of the tape is attached to themedial border of the scapula (Figure 10).

Conclusion

The use of taping method in conjunction withan established rehabilitation program ~Y. play animportant role in the reduction. of pbststrokeshoulder pain, soft tissue inflammation, muscleweakness, and postural malalignment. We believe


I

,

t that the Kinesio@Tex Tape may improve the posi-tion of the glenohumeral joint and may provide theproprioceptive feedback to achieve proper bodyalignment These factorsare fundamental when ex-ercises to restore the upper extremity functions areperformed. The use and the position of the upperextremity following a stroke affect not only thepatients' ability to reach, hold, and manipulate anobject, but also their ability to stand up and walk.

The taping method using Kinesio@Tex Tapedescribed in this article was developed solelybased on our clinical experience and in-depthknowledge of the anatomy and kinesiology of theshoulder complex. We understand that a limita-tion of this presentation includes the lack of direct

evidence for the correlation between the Kinesio@

taping method and improvement in the upper ex-tremity function after the stroke. As clinicians, weare obligated to provide evidence-based therapy,and an initiative has begun to examine the effectsof the Kinesio@tape in the clinical trial.10Furtherresearch is needed to determine the exact mecha-

nism underlying the effectof Kinesio@Tex Tape onthe sensory, musculoskeletal, and neuromuscularsystems. Most important, further research isneeded to demonstrate the safety and long-termeffectivenessof the various application techniques.In our view, however, clinicians are obligated touse every available treatment option' to assist thepatient with achieving a goal of independence.

REFERENCES

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3. Faghri PD, Rodgers MM, GlaserRM,Bors JG,Akuthota P.The effect of functional electricalstimu-lation on shoulder subluxation,,arm function recov-erY,and shoulder pain in hemiplegic strokepatients.Arch PhysMed Rehabil.1994;75:3-79.

4. Prada G, TallisR. Treatment of the neglected syn-drome in stroke patients using a contingency elec-trical stimulator. ClinRehabil.J 995;9:304-313.

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6. Leandri M, Parodi CI, Corrieri N, Rigardo S. Com-parison of TENS treatments in hemiplegic shoulderpain. Scand JRehabil Med. 1990;22:69-72.

7. Bobath B. Adult Hemiplegia: Evaluation and Treat-ment. 3rd ed. Oxford, England: Butterworth-Heil)mann Ltd.; 1991.

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10. Yasukawa A, Patel P, Sisung C. The functional effectsof Kinesio@Taping in an acute pediatric rehabilita-tion setting as measured by the MelboumeTM As-sessment. Paper presented at the Kinesio~ TapingAssociation Symposium; 2004; Japan.

11. BasmajianJV.Musclesalive. TheirFunctionRevealedby Electromyography.4th ed. Baltimore, MD: WiII-

. iams ~Williams; 1979.'12. Colham EG, Peat M. Functional anatomy of the

shoulder complex. JOrthop SportsPhysTher. 1993;18:342-350.

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18. Jenkins DB. Hollinshead'sFunctionalAnatomy of theLimbsand Back.7th ed. Philadelphia:W.B.Saunders;1998.

19. DaviesPM. Stepsto Follow.TheComprehensiveTreat-ment of Patients with Hemiplegia.2nd ed. Berlin:Springer; 2001.

20. Schenkman M, De Cartaya R. Kinesiology of theshoulder complex. J OrthopSports Phys Ther. 1987;8,9:438-450.

21. Kelley MJ.Clinical evaluation of the shoulder. In:Mackin E, Callahan AD, Skirven TM, Schneider LH,Osterman. AL,eds. ~ehabilitationof the Hand andUpperExtremity.5thed. St. Louis,MO: Mosby Inc;2002:1311-1350;

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23. Kase K, WallisJ,KaseT. Clinical TherapeuticApplica-tions of the Kinesio@Taping Method. Albuquerque,NM: Kinesi00 Taping Association; 2003.

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Documents

Kinesio Study - Stroke Hemiplegia - Theratape