Med. J. Cairo Univ., Vol. 83, No. 2, December: 37-44, 2015

www.medicaljournalofcairouniversity.net

The Effect of Kinesio Taping on Seated Postural Control in

Spastic Diplegic Cerebral Palsy Children

WANEES M. BADAWY, Ph.D.*; MOHAMED B. IBRAHEM, Ph.D.** and KHALED M. SHAWKY, M.D.***

The Departments of Physical Therapy for Neuromuscular Disorder & Its Surgery* and Physical Therapy for Growth & Development Disorders in Children and Its Surgery**, Faculty of Physical Therapy, Cairo University** and

The Department of Radiology, Faculty of Medicine, Zagazig University***, Egypt

Abstract

Background: Children with spastic diplegic Cerebral Palsy (CP) often show the difficulty to achieve well-balanced sitting

posture and display the poor sitting posture such as flexed

trunk with kyphotic curvature of the spine and asymmetry of

trunk.

Aim of the Study: The present study was designed to determine the effectiveness of kinesio taping over the paraspi-nal muscles in improving sitting balance in young children with Spastic Diplegic (CP) who displayed poor trunk control.

Material and Methods: Thirty children with Spastic Diplegic (CP) of both sexes with age ranged between 10-16

months were included in this study. Children were randomly

assigned to two equal groups (Group I and Group II). The study group (Group I) was treated by kinesio taping which was applied over the paraspinal region for 12 successive weeks in addition to a designed physical therapy program.

The control group (Group II) was treated by the designed

physical therapy program only. The children were evaluated by sitting score of Gross Motor Function Measure (GMFM)

and radiographic studies (Kyphotic and Cobb's angles) were

carried out on the whole spine while the children were sitting

before and after treatment.

Results: There was a statistically significant improvement

in the measured parameters in both groups when comparing

their pre and post treatment mean values. However, significant

difference was recorded between the two groups after treatment

in favor of the study group.

Conclusion: The obtained results suggest that the appli-cation of kinesio taping over the trunk become a beneficial

therapeutic technique in improving the sitting posture and

trunk control in children with Spastic Diplegic (CP) when

adjunct to a physical therapy program.

Key Words: Cerebral palsy – Spastic diplegia – Trunk control – Kinesio taping – Dynamic splint.

Introduction

CEREBRAL Palsy (CP) describes a group of

disorders of the development of movement and

posture causing activity limitations that are attrib-

Correspondence to: Dr. Wanees M.A. Badawy, E-mail: wanees.alamir@pt.cu.edu.eg

uted to non progressive disturbances that occurred

in the developing fetus or infant brain [1] . Cerebral palsy is the major developmental disability affecting

function in children. It is characterized by the

inability to normally control motor functions and

it has the potential to have an effect on the overall

development of a child [2] .

Most children with spastic diplegia have some motor impairment in their upper extremities milder

than lower ones. The primary functional problems include difficulty with mobility and posture. Other

problems include postural deviations, inability to

sit without support, inability to stand and difficulty

in movement transitions [3] .

Sitting is an important step for child to achieve

the upright posture against gravity and also an essential activity to provide the postural background

tone required for the functional movement of upper

extremity. However, the children with CP often

show the difficulty to achieve well-balanced sitting

posture and display the poor sitting posture such as flexed trunk with kyphotic curvature of the spine and asymmetry of trunk [4] .

Therapeutic interventions for seated postural

dyscontrol typically are directed at improving the

quality of information feedback, as well as stabi-lizing the body for functional control. This can

theoretically be achieved by improving postural alignment and gravitational forces concerning the body via which best possible muscle length and

normalization of recruitment and timing patterns

of muscles might be executed. These interventions might enable control to be gained over the entire

vertically oriented column of segments [5] .

The application of thermoplastic orthotic de-vices may allow the child to gain such control. The rigidity of this type of orthotic intervention

37

38 The Effect of Kinesio Taping on Seated Postural Control

theoretically acts through biomechanical principles

to reduce the degrees of freedom at which learning

must simultaneously take place, to control postural

alignment, to prevent deformity and to improve

function [6] . While the thermoplastic orthotic in-tervention can be used for seated postural control,

it is at the sacrifice of the child's ability to move

freely and limits the child's sensorimotor experi-ences for motor learning. Dynamic bracing offers

an alternative approach. Such braces are generally

fabricated from lycra material and have been re-ferred to as dynamic lycra pressure orthoses, lycra

garment or lycra splints. The inbuilt flexibility of

these orthoses allows movement freedom whilst

ensuring close skin contact with dynamic corrective

forces; therefore the child experiences more normal

movement patterns, these preferred movements

could be learned [7] .

Results from previous intervention studies on children with CP suggest that improvements in sitting control can be achieved through the facili-tation of sensorimotor systems, improvement of

postural alignment and dynamic splinting usage [8] . Although dynamic splinting is certainly avail-able as an intervention choice for poor postural

control, the used brace can be: (1) Meet the an

individual child needs, (2) Expensive, (3) Seemed

to be unsuitable and not used friendly, (4) Hot,

and (5) Not accommodative to the child growth

[7] .

As an alternative to lycra garments, therapeutic

taping may afford similar advantages for controlling

the seated posture in children with CP. It is antic-ipated that therapeutic taping would offer the

establishment for improved functional sitting abil-ities by: (1) Increasing proprioceptive and tactile

facilitation, (2) Controlling trunk movement in the

frontal and sagittal planes, (3) Restoring optimal

muscle length to provide a foundation for normal firing and recruitment patterns, (4) Orienting the

muscle force along more normal vectors, (5) As-sisting with static and dynamic balance and (6)

Optimizing gravitational forces about the column

of segments by improving body alignment [9] .

A very useful physiotherapeutic modality if

applied properly is the kinesio tape, which is a

valuable adjunct to therapeutic rehabilitation. It is

a specialized tape which is thin, elastic and can be stretched up to 120-140% of its original length

making it quite elastic, compared with the conven-tional taping. It allows a partial to full range of motion for the applied muscles and joints with

different pulling forces to the skin [9] . It is a tech-nique that allows a therapist to work on more

purposeful activities through improved proper

alignment but with the tape acting as an extra hand

[10] .

Therefore, this study was designed to determine

the effect of using kinesio taping over paraspinal

musculature on functional sitting control in children

with spastic CP.

Patients and Methods

Thirty CP children aged from 10-16 months were enrolled in this study as subjects. Children were selected from the outpatient clinic of the

Faculty of Physcial Therapy, Cairo University in the period from January 2015 to June 2015. Sub-jects were divided randomly into two equal groups. The first group (Group I) was treated by kinesio

taping which was applied over the paraspinal region

in addition to a designed physical therapy program.

The second group (Group II) received the same designed physical therapy program only.

The patients were diagnosed as having CP with

spastic diplegia based on careful clinical assessment by a neuropediatrican and magnetic resonance

imaging of the brain. The subjects' parents signed

a written consent forms approved by the Ethics

Committee of the Faculty of Physical Therapy,

Cairo University.

Study design: This was a randomized controlled trail.

Inclusion criteria were children who have had CP since birth. Patients displayed abnormal neuro-logic signs such as hypertonia in both lower limbs, ankle clonus, hyperactive deep tendon reflexes and

delayed motor development. The muscle tone of

the lower limbs ranged from 1+ to 2 according to Modified Asworth Scale (MAS) for muscle tone grading [11] . Patients were unable to sit alone

according to Gross motor function measure scale

[12] .

Exclusion criteria include patients who had

fixed skeletal hip deformities, structural scoliosis,

history of surgical interference, seizures or allergic

reactions to the adhesive kinesio tape or any other

materials used in this study.

Instrumentation: - Modified Ashworth Scale for assessment of mus-

cle tone.

- The sitting section of the Gross Motor Function

Measure (GMFM-88) was used to evaluate the functional sitting abilities of the subjects. The

GMFM-88 is an observational measurement tool

Wanees M. Badawy, et al. 39

that incorporates 88 items that address five gross

motor function domains: (A) Lying and rolling, (B) Sitting, (C) Crawling and kneeling, (D) Stand-ing, (E) Walking, running and jumping [12] .

- Plain anterior-posterior and lateral radiographs

of the whole spine. Radiographs were taken while the child was sitting on chair without arm rest

with 90º of knee flexion and neutral ankle posi-tion. The upper extremities of the child were

positioned at their sides.

In this study, the kyphotic angle might represent

the magnitude of round back and the Cobb's angle

might represent the magnitude of functional trunk

asymmetry of the spine. The kyphotic angle was

measured as usual method; first both ends of ver-tebrae of kyphotic curve were identified on the

lateral whole spine film and then a line along the upper end plate of upper end vertebrae and the other line along the lower end plate of the lower

vertebrae were drawn. At last the angle formed by these two lines was measured. The Cobb's angle

was measured by finding the upper and lower limits

of the primary curve by drawing tangents to the

vertebral bodies then draw erect perpendiculars

from the vertebrae which form the limits of the

curve. The angle formed between the erect inter-secting perpendicular lines and facing the parallel

lines (tangents) is the Cobb's angle [13] .

- Kinesio® Tex Classic tape.

- 2 inches width.

- Physical therapy tools of different shapes in the

form of: Mats, wedge, rolls and medical balls.

A- Evaluation session: Assessment of spinal curvatures (kyphotic and

Cobb's angles) using the Radiographs and were conducted at the Radiology Department, Faculty

of Medicine, Cairo University. Also, assessment

of the functional sitting abilities was done using

the sitting section of the Gross Motor Function

Measure (GMFM-88). These tests were done pre-and post treatment.

B- Training Session: In the study group (GI) before using kinesio

taping a skin sensitivity test was done by applying a square piece of kinesio tape (5 X 2.5cm) over

the back and kept for 48 hours then removed and

the skin was observed for a reaction to the tape.

Since no reaction was detected, the tape was applied

for 3 days as the elastic qualities of the kinesio

tape are effective for 3-5 days before the elastic

polymer diminishes. The kinesio taping was applied

as the protocol followed by Footer [5] :

1- The subjects were positioned in a supported

upright sitting position.

2- Prior to kinesio tape application, the therapist

used medical cotton damped with alcohol to

clean the skin over the paraspinal musculature

from the first thoracic vertebra (T 1) to the level

between the third and fourth lumbar vertebrae

(L3-4) as well as over the lower trapezius muscle

from the twelfth thoracic vertebra (T12) ob-liquely to the acromion process.

3- The kinesio tape was applied bilaterally in the following manner: Two strips were placed im-mediately lateral to the vertebral spinous pro-cesses in a caudal-cephalo direction from L3- 4 to T1 Fig. (1A) and two other strips were

placed along the course of the lower portion of

the trapezius muscle in a lateral to medial di-rection from the acromion process obliquely to

T12 Fig. (1B).

Fig. (1): Kinesio tape placements: (A) Vertical paraspinal

strips and (B) Oblique strips.

4- The tape was applied for 3 days then removed

for 24 hours to allow skin perspiration and then a new one was reapplied again [5] and the pro-cedure was repeated throughout the whole study

(12 successive weeks).

All patients in both groups (GI and GII) received

the designed physical therapy program for one and half hour, 3 times per week, day after day for 12

successive weeks. The program was based on Neurodevelopmental Technique (NDT) which di-rected towards inhibiting abnormal muscle tone

and abnormal reflexes and facilitation of normal

Kyp

hotic

ang

le 0

40

20

50

30

10

0

44.64 44.38

18.09

35.26

40 The Effect of Kinesio Taping on Seated Postural Control

movement patterns of postural control through reflex inhibiting positions using proximal and distal key points of control [14] .

- Facilitation of rolling from lower limbs.

- Exercises to facilitate static sitting and dynamic sitting.

- Facilitation of different sitting positions (e.g. side

sitting, ring sitting, half-ring sitting, crossed

sitting).

- Positioning to improve sitting posture (e.g. sitting

in adaptive seating chair, sitting in corner).

- Exercises to facilitate active trunk extension to

improve trunk control and sitting balance (e.g.

prone on wedge, sitting on edge of roll, perform-ing stooping and recovery).

- Facilitation of righting and equilibrium reactions to improve postural mechanism via variety of

exercises applied on ball from different positions in forward, backward and sideways.

- Approximation as a proprioceptive training ap-plied in a slow and rhythmic manner for upper limbs, lower limbs and trunk to control spasticity and stimulate the joint mechanoreceptors from

semi reclined and quadruped positions.

- Hand weight bearing exercises from different

sitting positions and from quadruped position.

- Facilitation of hand functions from sitting posi-tions (e.g. reaching, grasping, release, transferring objects) according to the child abilities.

Statistical analysis: GraphPad Prism 5 (Graph Pad Software Inc.,

La Jolla, CA, USA) was used for data analysis.

Data were presented as mean ± standard deviation of the mean (SD). In comparing the improvement

after the intervention in each group, paired t-test was used and for the difference between the two

groups; independent t-test was used. A (p) value of less than 0.05 was considered to represent a

statistically significant difference.

Results

Demographic and clinical characteristics of

the patients in both groups: There was no statistically significant difference

between both groups regarding mean age, kyphotic angle, Cobb's angle and GMFM-Sitting domain

pre treatment (p>0.05) (Table 1). GI included 9 boys and 6 girls while GII included 10 boys and 5 girls.

I- Comparison of kyphotic angle, Cobb's angle and GMFM-Sitting scores within groups:

Group (I):

There was a statistically significant decrease in kyphotic angle and Cobb's angle values post treatment in GI (p<0.05). The mean value of ky-photic angle was 44.64 ° pre treatment and 18.09 ° post treatment. While the mean value of Cobb's

angle was 14.33 ° pre treatment and 5 ° post treat-ment. Also, there was a statistically significant

increase in GMFM-Sitting values post treatment

in GI (p<0.05). The mean value of GMFM-Sitting score was 29.76% pre treatment and 69.87% post

treatment [(Table 2), Figs. (2-4)].

Group (II):

There was a statistically significant decrease in kyphotic angle and Cobb's angle values post treatment in GII (p<0.05). The mean value of kyphotic angle was 44.38 ° pre treatment and 35.26 ° post treatment. While the mean value of Cobb's

angle was 14.75 ° pre treatment and 9.28 ° post treatment. Also, there was a statistically significant

increase in GMFM-Sitting values post treatment

in GII (p<0.05). The mean value of GMFM-Sitting

score was 29.85% pre treatment and 45.37% post

treatment [(Table 2), Figs. (2-4)].

II- Comparison between both groups as regards

kyphotic angle, Cobb's angle and GMFM-Sitting

scores post treatment:

Data presented in (Table 3) showed that there

were statistically significant difference between

both groups in their post treatment mean values of

kyphotic angle, Cobb's angle and GMFM-Sitting scores in favor of the study group (GI) (p<0.05).

GI GII

Pre treatment

Post treatment

Fig. (2): Comparison between pre and post treatment mean

values of kyphotic angle in degrees in both groups.

Cob

b's

angl

e (°

)

16

14

12

10

8

6

4

2

0

14.33 14.75

5.00

9.28

GM

FM-s

ittin

g (%

)

70

60

50

40

30

20

10

0

29.76

69.87

29.85

45.37

Wanees M. Badawy, et al. 41

GI GII

Pre treatment

Post treatment

Fig. (3): Comparison between pre and post treatment mean

values of Cobb's angle in degrees in both groups.

GI GII

Pre treatment

Post treatment

Fig. (4): Comparison between pre and post treatment mean

values of GMFM-Sitting scores in percentage in

both groups.

Table (1): Demographic and clinical characteristics of the patients in both groups (GI & GII).

Demographic and clinical characteristics

GI GII Comparison S

Mean SD Mean SD t-value p-value

Age (months) Kyphotic angle (º) Cobb’s angle (º) GMFM-sitting (%)

12.7 44.64 14.33 29.76

1.46 1.88 1.3 3.4

12.6 44.38 14.75 29.85

1.3 1.24 1.7 3.5

0.084 0.327 0.355 0.076

<0.05 <0.05 <0.05 <0.05

NS NS NS NS

GMFM

: Gross Motor Function Measure. S

: Significance. SD : Standard deviation. NS

: Non-significant. p : Probability.

Table (2): Comparison between pre and post treatment mean values of kyphotic angle, Cobb's angle

and GMFM-Sitting scores in both groups.

Variables Pre-treatment Mean ± SD

Post-treatment Mean ± SD

Mean difference

t- value

p - value

Significance

Kyphotic angle (º): GI 44.64± 1.88 18.09±0.87 26.55 33.47 <0.05 S GII 44.38± 1.24 35.26± 1.54 9.12 11.49 <0.05 S

Cobb’s angle (º): GI 14.33± 1.3 5.00±0.66 9.33 11.76 <0.05 S GII 14.75± 1.7 9.28±0.98 5.47 6.89 <0.05 S

GMFM-sitting (%): GI 29.76±3.4 69.87±4.1 40.11 50.57 <0.05 S GII 29.85±3.5 45.37±3.2 15.52 19.56 <0.05 S

GMFM

: Gross Motor Function Measure. p : Significance. SD : Standard deviation. S : Probability.

Table (3): Comparison of the mean values of kyphotic angle, Cobb's angle and GMFM-Sitting

scores between both groups post treatment.

Independent t-test

Kyphotic angle (º) Cobb’s angle (º) GMFM-sitting (%)

GI GII GI GII GI GII

Mean 18.09 35.26 5.00 9.28 69.87 45.37 SD 0.87 1.54 0.66 0.98 4.1 3.2 Mean difference 17.17 4.28 24.5 t-value 21.64 5.39 30.89 p-value <0.05 <0.05 <0.05 Significance S S S

GMFM

: Gross Motor Function Measure. p : Significance. SD : Standard deviation. S : Probability.

42 The Effect of Kinesio Taping on Seated Postural Control

Discussion

To verify the effect of kinesio taping on the trunk control, sitting posture and sitting balance were evaluated. Our concern was how to evaluate those quantitatively in very young children. The

cerebral palsied children with poor trunk control

show rounded back and trunk asymmetry while

they are sitting. From the perspective of this point,

we postulated that the kyphotic and Cobb's angles

in sitting posture be able to represent the functional

kyphosis and trunk asymmetry respectively.

The present study included spastic diplegic

type of CP, which constitutes a major classification

among spastic types. This finding was reported by Damiano [15] who reported that spastic diplegic

patients basically had better trunk control and more

potential of functional reorganization than spastic quadriplegic patients. It was suggested that the

children with spastic diplegic CP show better response to treatment than the children with spastic

quadriplegic CP. The functional skill of sitting is

required for many activities that children encounter

in their daily lives. In typical development, the

maturation of a child's postural control system

generally ensures task-specific stability and orien-tation to support the primary movements required for functional activities [16] .

The pre treatment results of the two groups

indicated that those children often show the diffi-culty to achieve well-balanced sitting posture and

display poor trunk control. This agrees with Shum-way-Cook and Woolacott [16] who revealed that children with CP often rely upon inappropriate

control strategies and faulty feedback mechanisms

when learning to maintain both static and dynamic sitting postures, which predictably leads to postural

dyscontrol and functional dependency. In other

words, the postural control system cannot effec-tively control the body's position and motion in

space because it lacks the ability to generate ap-propriate muscular force and to coordinate and

integrate the sensory information received from

various receptors throughout the body.

Statistical analysis of the post treatment results

of the two groups revealed significant improvement

in postural stability and functional ability which

is represented by keeping the body segments prop-erly aligned in upright sitting posture. Improvement

fulfilled in the control group might be attributed

to the effect of the therapeutic exercise program

which emphasized on a group of exercises for

facilitation of normal erect posture, this comes in agreement with Kern et al., [17] who established

that methods of physical therapy treatment for

children with CP focus on the attainment of se-quential developmental milestones and facilitation

of normal movement patterns.

The significant improvement in the post treat-ment results in the control group also comes in

agreement with Sterba et al., [18] who recommended strengthening of the trunk and core muscles, pro-motion of postural and equilibrium reactions and focus on postural alignment in sitting, standing and walking considered as components of physical

therapy treatment plans for pediatric therapists

who rehabilitate children with neurological condi-tions.

In respect to the study group who received kinesio taping which applied over the paraspinal

region in addition to the designed therapeutic exercise program, there was significant improve-ment in the sitting posture and trunk control in young children with spastic diplegic CP. This comes

in consistent with Hsu et al., [19] who reported that kinesio tape as an adjunct to the therapeutic pro-cedures can improve strength, functional activities, proprioception, control and positioning.

In addition this comes in agreement with Miller et al., [20] who conducted a study to examine the effect of kinesio taping on hypotonia. Four special

needs children were selected to participate in the

study. Kinesio taping was applied to the internal

and external oblique muscles once a week for four

consecutive weeks. They concluded that kinesio taping may be an effective tool for children with

hypotonia to improve core stability, attention to

task, sitting posture and fine motor skills.

Another study was performed by Yasukawa et

al., [21] to investigate the effects of kinesio taping

in an acute pediatric rehabilitation setting, they

used the kinesio taping for the upper extremity in enhancing functional motor skills of children. They

concluded that kinesio taping may be associated

with improvement in upper extremity control and

function in the acute pediatric rehabilitation setting.

In the current study, kinesio taping was applied

on the paraspinal muscles from origin to insertion.

In the context, Vithoulk et al., [22] stated that application of the tape from muscle origin to in-sertion is supportive, improves contraction and increases muscle strength. The wrinkles of the skin

formed after the application of kinesio taping in combination with the direction of the tape pulls the insertion of the muscle towards the direction

of the contraction and increases the muscle tone.

Wanees M. Badawy, et al. 43

Kinesio tape improves proprioception by pro-viding constant cutaneous afferent stimulation of

the skin. This activity improves joint function,

stimulates sensory mechanisms, decreases pain as

a result of a reduction in neurological activation, enhances blood and lymph circulation to the local

area by lifting fascia and soft tissue, realigns fascia

tissue function through normalizing muscle tension,

and improves muscle function. Conducted studies

which examined the effects of kinesio taping on

cutaneous mechanoreceptors have reported that,

kinesio taping application on selected muscles and

joints may improve muscle excitability [23-26] . On the other hand, Slupik et al., [27] proved that kinesio taping showed a significant increase in the bioelec-trical activity of the vastus medialis muscle after

24 hours of kinesio taping application and that

effect was maintained for another 48 hours after

removal of the tape.

The improvement observed in the study group comes in agreement with Simsek et al., [28] and Kaya Kara et al., [29] who concluded that kinesio taping was valuable when adjunct to an exercise

or manual therapy programs to achieve the required

goals and maximize functional independence and

there are no absolute contraindications to the use

of kinesio taping as a part of comprehensive phys-iotherapeutic management.

Conclusion: The children with spastic diplegic CP showed

better response to given treatment. Therefore,

kinesio taping applied over back muscles might

be a useful therapeutic tool and can be added with

the physical therapy as an additional modality to

improve sitting control in diplegic children.

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