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My name's Jo Gibson. I'm an upper limb rehabilitation specialist working at Rehab for Performance. I've been lucky enough to specialise in helping people with shoulder pain and instability since 1995.

Now, I found myself in a situation where I had a couple of patients where for the first time in a long time, I actually thought about using tape. Now, let me tell you about these two patients first of all.

Patient 1 - Taping for volleyball post shoulder stabilisation surgery

The first patient came in, they'd had stabilisation surgery. It was revision surgery. They were going back to playing volleyball. Still said they didn't feel entirely confident going back. Despite the fact they returned all their return to play criteria. And it was very specific positions.

So in the clinic we could test everything. Essentially, we could put them in prone and test their cuff, we could test them on the isokinetic. We could do through range stuff. Whatever we threw at the rotator cuff, they tested well and tested confidently. When we looked at measures of reactive stabilisation, drop in catch times, we looked at them on force plates.

We did all sorts of stuff. We looked at the ash test with a handheld dynamometer. We looked at lots of different things to look at, all the different aspects that we know are important to make sure the stability system of that shoulder's doing its job, whether it's the muscles, whether it's feedback to the brain, whether it's that reactive stabilisation.

And yet this patient still said that when they're in certain positions playing their volleyball, they still didn't feel safe. Now clearly they've had a revision surgery. So they've already had failure of surgery once before, so it's not a hugely difficult to understand why they might still be having some problems, but clearly we can't ignore this.

We know from Margie Olds' lovely work and also that by Ian Hurley’s group, is that essentially fear of re-injury or kinesiophobia, worried about that thing happening again, actually makes it even more likely for the patient to fail. So it's clearly something I can't ignore. Now, we have talked before about the complexity of proprioception and how perhaps trying to reduce it to measurable things is a little bit difficult when you look at how many factors affect it.

However, we've talked about things like vibration and compression, closed chain exercises, how we can regulate the sensory input to make it make more sense for the patients. Now, of course, with this patient, I've got to ask about why they feel scared. And they say they feel fine doing everything, but they just can't seem to override this need to protect in certain positions.

Now, of course, I need to explore their belief system. We can do a graded exposure approach to those different positions, but I have to confess with this patient, I reached for the tape and I just put on some Kinesio tape across the scapular and essentially reinforcing almost the action of the rotator cuff. But was I thinking that I was having any biomechanical effect? No. My real purpose was thinking I was just having a sensory input, which would almost distract the patient. The tape's very colorful. They played in a sport where lots of people were wearing colorful tape. They had a positive association and it was something they'd mentioned before.

So stick with me if you are already thinking, Jo, why did you do that? And so actually I thought this would be a good thing to talk about and use as an opportunity to review the evidence that's out there.

Patient 2 - Neck driven shoulder pain

Now, interestingly, on the same day, I had another patient that came in with a really irritable cervical nerve root, neck driven shoulder pain, couldn't sleep, couldn't even lie in prone on the couch because the pain was so severe, very concentrated in the posterior shoulder with some shooting pain where they moved. Really reluctant to move. If they did a rotation, it reproduced all their right shoulder pain.

Now, again, I've got a good treatment effect getting them moving, doing some through range recruitment, doing some just gentle manual therapy in sitting. But they were really struggling to sleep. And again, I found myself reaching for the tape, having not done so for a long time.

What's the evidence for and against tape?

So what's the evidence that's out there for tape? We know that it's absolutely clear. There's very little evidence to support any biomechanical effects. So if we're using tape to try and reposition things, we haven't got real any evidence whatsoever to support that.

However, there was a recent systematic review from Araya, 2022. So a recent systematic review and meta-analysis where they basically concluded that kinesio tape was not superior to other interventions in subacromial impingement syndrome. So, obviously rotator cuff related shoulder pain, non-specific shoulder pain, whatever you want to call it. Essentially it didn't have any additional value or didn't have any superior effect when compared to things like electrotherapy, manual therapy and exercise.

So what was interesting is when you compared it to sham tape, both had an effect in reducing pain and also in terms of having an impact on how somebody was moving. Now, the effect sizes are so small in these studies. I think we have to be really honest that we are not entirely sure that actually that's got any clinical significance.

Now, we do also have studies where when we were obsessed with the size of the subacromial space, we had studies showing that doing a tape from anterior to posterior, or a tape that went diagonally across the scapula, it seemed to have a fairly consistent effect in increasing the acromiohumeral distance. And this was actually shown on radiographs, so before and after a tape application. We've also got studies showing us that if you stick a bit of tape on somebody's shoulder, it also seems to reduce muscle stiffness and also has an impact on improving muscle strength output. Now that kind of makes sense if we just giving a sensory input, but these things are really temporary. They don't last for more than 24 hours in the best case scenario. So it really is only a temporary change. Now, we've also had studies looking at applying tape diagonally across the scapula and look at is its effect on upward rotation. Again, a transient improvement, a transient change, but again, it's that just because we put a bit of tape on and made a patient more aware if you like, and just had some effect on their postural set. There's lots of authors that have tried to look at the effects of EMG. And again, as a result of putting on tape, we have some studies claiming that it has an effect on the timing of trapezius and serratus anterior and certainly Lynn Watson, an Australian Physio did a study years and years ago published in the Singapore Journal showing that again, just a simple scapula tape, starting in the axilla going over the scapula onto the opposite shoulder actually had a consistent effect on promoting upper fives of trapezius recruitment at the onset of movement. Obviously important in terms of posterior tilt, but again, we've talked a lot about the nuances of the scapula that spending ages worrying about specific muscle activation probably isn't well supported.

Now Caroline Alexander also did a study where she looked at taping along the fibers of lower trapezius and showed that had impact on feedforward and on recruitment. But again, when we look at studies that look at EMG in the effect of taping, if we're honest, the numbers are really small and the heterogeneity or like your spectrum of effect is huge. So actually trying to conclude anything meaningful is really open to criticism and potential flaws. Now, when we look at some other potential effects of tape, interestingly there have been some things looking at the potential effects on things like joint position sense error. Now looking at there was a study by Wera, Cody and Allen that essentially looked at joint position sense errors in cricket bowlers, so no symptoms of shoulder pain at all. But essentially looked at the impact of joint position sense after a fatiguing drill and found it was worse. But what was interesting is when they put the tape on, they found that the impact on their joint position sense was less.

So again, that sensory impact seemed to have some effect. When we look at the lower quadrant, there's no doubt there's evidence showing that if you stick a bit of tape on, whether it's a posh tape with lots of drama around it, or whether you just put sham tape on, it can have some effect in terms of somebody's gait, the way they're moving, it can impact strength and it can impact accuracy of a task. So the problem is we can also find as many papers that show no convincing effects on any of those domains. So it can be really difficult as a clinician to find if there's anything that really justifies its use in our clinical practice.

The other thing that's really interesting, as I say, there are several systematic reviews. There was one by Sarah Colu in 2018, which basically showed that tape, in addition to other interventions, may have some role in helping with pain at rest and suggested it had its biggest effect may be in the early stages of rehab, but only ever as an adjunct, never as a standalone solution. We have another study by Selleck in 2020 looking in comparison to sham showing both had an effect on pain at rest, but neither was superior. So again, what does that tell us? If we put something sensory on somebody's skin, for some patients, it can have an effect.

And again, a systematic review, a meta-analysis by Goze et al. in 2020, very similar conclusions that it should only ever be considered in conjunction with exercise and only had a small effect, so it couldn't be recommended in every patient. Now, as I said, it was really unusual for me. I hadn't used tape for a long period of time, but on this day, I just seemed to have these two patients where I was thinking it might make life easier for them, certainly the person with the nerve roots and the other patient, because I just needed something to override their need to protect.

We get this big kind of claim with a lot of these studies and conclusions of these systematic reviews, that actually tape is no better than placebo, but you might be aware of a paper and I can never pronounce this name, Haffier Dotte but I apologise, 2021, looking at contextual effects and placebo. And actually showing that when we look at our treatment effects of any intervention up to 70% of that effect is down to placebo and contextual effects.

Now, of course, within that, we've got natural history and regression to the mean, but the bottom line is the contextual effect is something that actually we can manipulate if you like, to increase an effectiveness. Applying the evidence around taping Now, of course, I'm not saying, oh, let's stick tape on everybody, and have a fabulous placebo effect. What I'm saying is it can have some positive effects on some of those descending influences, probably because of contextual effects. Now that's really interesting because I guess my rationale was that it would give a sensory input, it would give a cue to that patient and perhaps override that need to protect. It would almost distract the brain as well as giving them a different sensory input.

Very much alongside what I was saying about that work of Margie Olds looking at the fear of re-injury and kinesiophobia and trying to make the patient a little bit more confident and almost as a way in to then challenge those negative beliefs. Now, interestingly, if you look particularly at a sports population, so remember, this is a girl who plays volleyball. She's very used to people having tape all over their shoulders and their knees and everything else. And certainly if you watch volleyball, you'll have seen it yourself. And there's no doubt that context or those contextual factors that I've talked about are massively influenced, not only by expectations, but also by culture. Now, there was a lovely paper by Helio in 2015 at the World Congress of physiotherapy. And essentially what they did is a qualitative analysis of why athletes use tape. Now what they found was basically they were generally having tape because they'd either had an injury or had a bit of pain, and essentially those were the most common reasons.

But what was interesting in their decisions to tape or brace were massively influenced by healthcare professionals or their coaches or sports science around them. There was huge inconsistency about their beliefs. Some of them had a strong belief that actually the tape was holding things into position and making things stronger. Where on the counter side, some of the athletes thought that actually they used it too much. It would actually make them worse and make them weaker. Now, the other thing that was really interesting is this study clearly illustrated there was a huge culture of taping and bracing in some sports and certainly in some healthcare providers. So within certain coaches in certain sports, it was more prevalent because the culture was, there was a belief that it was something that would prevent injury or get an athlete through a competition if they were struggling. Now, of course, these things can potentially make people more likely to tape if there's an expectation. And there were definitely potential pressures. However, there's also no doubt that if you look at other research that sports people are very influenced by sports celebrities. So there's some fantastic work in the psychological literature showing that essentially, particularly if you look at something like at the time of the Olympics, when you've got somebody like Usain Bolt, I know that's a while ago now, but wearing all sorts of colorful K tape. The fact is, if you have a patient and then you do K tape too, and they're keen on athletics and they think Usain's the best thing ever, that tape is more likely to have more positive contextual effects. So again, we see these health related beliefs and practices.

Actually, we have a massive responsibility not to perpetuate those or drive those. And I guess what's positive is when you look at qualitative analysis of healthcare professionals beliefs in tape, actually, it's quite a rosy picture and reflects what's in a lot of those systematic reviews, in that they're generally very honest, that essentially those physiological effects are not really well supported in any of the literature, but psychological effects potentially are.

Now, that brings me nicely to some work by Simon et al. Now, this was in ankle instability, and you'll remember when I talked recently about patients who thought about things being out of position or feeling that something was clicking and worrying what was causing it, that we talk about these new concepts of embodied pain.

Now, I'm not using that as a reason to use all these kind of weird adjuncts that cause all sorts of arguments, but this lovely study by Simon et al actually showed that ankle taping gave a significant increase in perceived stability, perceived confidence, and reassured patients when they were returning from injury. Now, of course, not everybody's going to need it, but sensory input is giving some change in their perception that allows them to perform a task more confidently. Of course this isn't going to be for every patient. But if we know and we are honest about those psychological effects, then as part of a graded exposure approach back to activity, then I'm not really too worried about it because it's something that potentially changes a movement strategy. It makes a patient confident, and those are probably the mechanisms by which it works.

Now, if you've joined us for the Facebook Lives and talked about sensory input, the other thing I find fascinating is if I have a patient that maybe is struggling to reach, they're really reluctant to move their arm away from their body, my go-to is always active exercise, so trying to get them to move the body around the arm and perhaps leave the hand behind. But sometimes, again, if I'm struggling, I'm all about the can-do. So I don't want to concentrate if they're struggling to do something, I want to move on to something else and see if I can find a way in. And what I've found with some of my patients with massive cuff tears, or perhaps after surgery is putting a piece of colored tape on the back of their hand and getting them to watch their hand, so a really visual target and remember vision synapses directly into our somatosensory cortex. That actually, that can be a game changer in terms of getting somebody to move with more confidence.

Back to the case studies

So when I go back to my two patients that we started with, so my patient that was lacking in confidence, we went out into the gym. I got her to show me the things that she was struggling with and there was absolutely no doubt this kind of almost anticipation and tendency to try and protect. We put the tape on, we videoed her before and after, and there was a significant change in her strategy.

Now, If I'm honest, I'd probably use some other cues as well in that I was giving a very visual based cue. So it was basically taking away from thinking about her shoulder and thinking about the task. So again, really tapping into that visual system, but just giving her that sensory input, that peripheral up regulation, if you like.

It was a thing that allowed her to see that actually she could do it and she could translate all those tests she'd passed into the clinic. So we just used it as a training aid. She only needed to use it for two or three sessions, and then she was confident, got rid of it, and then never used it again.

But it, to me, it just said that, we know tape is not an option for everybody with shoulder pain. It's not an option for everybody within instability, but to have it in our toolbox in somebody who's struggling and in somebody like that, with that fear and kinesiophobia, then it's a potential useful tool. As long as I've clinically reasoned why I'm using it, and as I say, I've no doubt it's psychological, almost like a virtual hug for the joints and giving that peripheral input we know has the power to change how somebody's moving. Only temporarily, but it allows me to have a conversation to explore those beliefs.

Now, as I say, it was the first time I'd used it in ages, but then I had that other patient with the cervical nerve root. Now again, I put the tape on I did a tape very similar actually, to the one that I gave to the patient who was the volleyball player. Again, over the scapula, the Lynn Watson tape with the concept of unloading the shoulder.

Now I know it's not physically unloading, but I've just repeated the tape a couple of times and asked the patient how they felt, and they just said, I just feel more confident. I feel I can relax more. Now, of course, again, it's only a temporary solution. He came back the next time loads better. We didn't tape ever again. He just had it on for a couple of nights, helped him sleep. Perhaps, just made him more confident to relax and stop protecting his shoulder, lots of potential mechanisms. So guys, I haven't come on here to say, whoa, we should be taping everybody. What I have done is when you think of some of the other things that we've talked about around proprioception and its complexity around how we can manipulate how somebody moves with lots of sensory input and that visual system, a bright colored, stretchy tape, no doubt, has some potential role, a very small part to play, but something that, as I say in these two patients, actually gave me really good value. The important thing was it wasn't a solution. It was a way in to help then challenge negative beliefs with my volleyball player, but importantly, just to help debate the pain cycle in my patient with a cervical nerve root.

So I think two nice examples. Now, a cautionary tale and back to those contextual factors, I never forget a small study that actually looked at rugby players and comparing, changing nice, bright, colorful tape to flesh colored tape. Exactly the same tape, exactly the same effect, but the rugby players qualitative feedback was it wasn't as effective because it wasn't as bright. Now again, that's where we have to be really honest. Now, as long as we are honest that maybe this is just a temporary way of giving confidence, giving sensory input, changing somebody's strategy by all those potential mechanisms, then I'm not going to argue with having it as one very small part of my approach to some of my patients that are struggling.

So guys, I hope that was interesting.

Question - Can tape stimulate mechanoreceptors to give somatosensory feedback to the brain?

Tim: can tape stimulate the mechanoreceptors to give positive somatosensory feedback to the brain?

Tim, I think we have to be really honest. The evidence we have is essentially tactile stimulus of any kind, has the potential to give feedback to the brain and how the person or the patient perceives that feedback is integral to whether it has a positive or negative effect. And that's why again, as healthcare professionals, it's so important how we explain it to patients. So I'm very honest. I'm not saying I'm holding you in place. I'm not trying to make anything better. I'm just trying to give you a virtual hug that just makes it a bit easier for you to move. My volleyball player, which is giving you a bit more sensory input to try and get you out of those habits and looks at some other ways of getting you to move.

So I think we have to be honest, there is some evidence in the lower quadrant actually looking at fMRI and looking at put tape on somebody, and this is Sherman’s special tape. And just showing that you get more cortical light up when you're doing a movement than without the tape. But again, that's only a temporary effect.

So I think if we are honest, it's probably lots of different potential effects. But in answer your question, I would say that the effect is more through the mechanoreceptors in the skin, more through the muscle system than perhaps the ligaments and things in the joint, because those things will be more influenced by position and tension than perhaps just having that sensory stimulus from the actual contact. So I hope that answers that question.

I have to say the conclusions are fairly consistent. The studies that give a positive effect are relatively small numbers. And as I say, let's not claim any magic effects. Let's just be honest in the rare times where it may have some role to play.

So guys, I hope that's been interesting. Thanks as ever for joining. Bye for now and enjoy the rest of your week.