Effectiveness of Shoulder Taping in Treating Hemiplegic Shoulder Subluxation: A Randomized Controlled Study of 35 Patients

Introduction

The incidence of hemiplegic shoulder pain is approximately 63% in patients with acute and chronic stroke [1]. Hemiplegic shoulder pain delays upper extremity rehabilitation, negatively affects patient quality of sleep and performance of daily activities, obstructs functional motor recovery of the affected limbs, and prolongs hospitalization [2–4]. The causes of shoulder subluxation can be classified into neuromuscular, traumatic, and non-traumatic causes [5]. Stroke can cause shoulder subluxation due to neuromuscular causes [6]. In the case of nerve roots, shoulder inferior subluxation occurs due to weakness of the shoulder girdle and rotator cuff muscles. Spasticity of internal rotation muscles (pectoralis major, latissimus dorsi, and subscapularis muscles) causes shoulder posterior subluxation [7]. The degree of shoulder subluxation can be quantified as the distance from the acromion to the humeral head using fingerbreadth, tape, or caliper [8]. Tests to check shoulder relaxation include the load and shift test, drawer test, sulcus test, hyperabduction test, and push-and-pull test [9,10]. In cases in which subluxation and shoulder pain are accompanied by a history of stroke, physical examination for subacromial impingement, acromioclavicular arthropathy, and rotator cuff tendinopathy are helpful in identifying the cause of shoulder pain [11]. Additionally, 50% of patients after stroke present proprioceptive deficits in the upper extremity [12]. According to previous studies, patients with stroke have a clear relationship between affected shoulder proprioception and movement, and hemiplegic shoulder pain was observed. To determine the risk of developing hemiplegic shoulder pain, attention should be paid to a patient’s shoulder proprioception and movement [13], which are related to the grade of shoulder subluxation [14]. Moreover, these proprioceptive shortages are associated with upper extremity motor recovery and functional performance [15], limiting activity and participation [16]. Therefore, treating proprioceptive impairments and managing shoulder pain are main objectives of rehabilitation exercise programs for patients with stroke [17,18].

With this in mind, some rehabilitation exercise programs, including correct positioning [19], arm sling and shoulder strapping [20,21], electric stimulation therapy [22], traditional manual acupuncture [23], and local injections [24], have been proposed to maintain normal joint alignment and motion, treat pain, and improve muscle strength in hemiplegic shoulders. Kinesiology and shoulder taping have been proposed to decrease the incidence of shoulder subluxation or pain, improve shoulder motion and function, and prevent further shoulder injury in hemiplegic shoulders [25–29].

Taping involves an assistant method that uses elastic adhesive tape over the skin to stimulate mechanical receptors by continuous skin compression and stretching during joint motion [30,31]. Based on acknowledged principles in neuroscience, it can be hypothesized that these afferent stimuli are conveyed to the contralateral zone of the somatosensory cortex, which integrates information from various motor and sensory modalities [32]. The kinesiology taping method was developed by Kenzo-Kase in the 1970s and has gradually gained popularity in clinical practice for managing musculoskeletal disorders [33]. According to Jaraczewska and Long [34], taping can inhibit or facilitate muscle function, reduce pain, support joint structure, and deliver proprioceptive feedback to attain and continue favored body alignment. Some studies have suggested that taping can decrease pain and subluxation and improve range of motion (ROM) and motor performance in patients with stroke [27,35].

Herein, we compared the effects of a 6-week program of shoulder kinesiology taping or sham taping on the shoulder subluxation distance (SSD), active ROM (AROM), visual analog scale (VAS), shoulder pain and disability index (SPADI), and modified Barthel index (MBI) in patients with stroke. The research hypothesis was that the use of the shoulder kinesiology taping would better improve hemiplegic shoulder pain and functional outcomes, compared with sham taping, in patients with stroke. Therefore, this study included 35 patients with shoulder subluxation following stroke and aimed to compare outcomes from standard physical therapy with and without shoulder kinesiology taping.

Material and Methods

RESEARCH DESIGN:

This double-blind, placebo-controlled clinical study was performed at the Design Hospital in Jeonju City between July 2019 and August 2021. Patients were randomly assigned to 2 groups: a study group (shoulder kinesiology taping and rehabilitation exercise, n=18) and a control group (sham taping and rehabilitation exercise, n=17). Blinded allocation was performed using a computer-generated random table of numbers, which was created before data collection by a physical therapist who was not involved in the evaluation or intervention of the patients. Before and after 6 weeks of intervention, evaluation was performed by an uninvolved physical therapist who was blinded to the group allocation and patient medical information. A separate form for result assessment was given to the evaluator during the assessment. Taping was performed by a certified physical therapist directly following primary measurements. Taping in the study and control groups was performed by the same physical therapist, who was not involved in the intervention or outcome evaluation. None of the patients previously underwent shoulder kinesiology taping. The patients were evaluated in a separate room, and the tape was detached before the result assessment. SSD, AROM, VAS, SPADI, and MBI were the primary outcomes. This study was conducted with the approval of the Research Ethics Committee of Sahmyook University (2-7001793-AB-N-012018140HR), and the approved date was December 17, 2018.

STUDY PARTICIPANTS:

Of the 124 patients with stroke admitted to the Design Hospital Rehabilitation Center for inpatient rehabilitation exercise, 42 patients with a hemiplegic shoulder met the inclusion criteria, and 35 patients completed all procedures in the study. Study participants provided informed consent, following an explanation of the study purpose and procedures (Figure 1).

The following were the inclusion criteria: (1) unilateral infarction or hemorrhage stroke lesions identified using computed tomography or magnetic resonance imaging; (2) >6 months since the occurrence of stroke; (3) at least 9.5 mm (0.37 inch) of shoulder subluxation in the affected upper extremity; (4) pain in the subluxated shoulder; (5) spasticity for shoulder flexor and abductor level of <1+ on the modified Ashworth scale; (6) age between 50 and 70 years; (7) appropriate trunk control, defined as the ability to maintain a sitting position without support for the trunk and/or of the arms for 1 min; and (8) intact cognitive function and adequate communication skills (Mini-Mental Status Examination-Korean version score of ≥24 points). Exclusion criteria were as follows: (1) shoulder pain or history of neurological diseases or other orthopedic injuries in the affected shoulder before the onset of stroke; (2) communication or cognitive impairments; (3) infection, skin problems, or wounds in the affected shoulder; and (4) a history of skin allergy (redness and itching) to tape. A summary of the participants’ clinical information is presented in Table 1.

SSD MEASUREMENT: This study used a jig measuring instrument to evaluate shoulder subluxation in hemiplegic patients. The jig-measuring instrument was used to measure shoulder subluxation. It comprised an L-shaped rod and an adjustable mover. The acromion process was marked with a pen by drooping the affected arm and then marking the point 20 cm above the olecranon with the pen while passively flexing the elbow joint. The rod was then placed on the acromion, and the length of the end of the mover was measured against the point marked with the pen. The subluxation of the patient was then re-measured after the reduction. The degree of subluxation was determined by comparing the differences before and after the reduction. This measuring instrument has intra-rater (intraclass correlation coefficient [ICC]=0.89) and inter-rater reliability (ICC=0.74) [36].

AROM OF THE SHOULDER: AROM was assessed using smartphone clinometer application measurements for shoulder flexion and abduction. Shoulder flexion and abduction were measured with the patient in the standing position. This test tool has intra- and inter-rater reliability (ICC=0.80–0.89) and is appropriate for measuring the ROM of the shoulder [37].

SHOULDER PAIN: Pain level was assessed using the VAS as the degree of subjective pain to assess the level of shoulder joint pain in patients with hemiplegia. The VAS is an 11-point scale displayed on a 10-cm horizontal line, ranging from 0 (no pain) to 10 (worst pain imaginable) [38]. This test tool has intra- and inter-rater reliability (ICC=0.99–1.00) [39].

SPADI MEASUREMENT: SPADI, a self-administered evaluation tool, was used to measure pain and disability related to shoulder pathology. The SPADI is a 13-item form that comprises 2 subscale measures of 5 items on pain and 8 items on disability, which is scored by taking an average of the 2 lower measures. Pain and disability subscales were calculated as the mean of the matching items on a scale of 0 to 100, with the uppermost score representing the most severe pain and disability. The total result score used for statistical analysis was the sum of the pain and disability subscales. This test tool has test-retest reliability (ICC=0.99) and Cronbach’s alpha value of 0.96 [40].

MBI MEASUREMENT: The MBI measures the functional ability to perform activities of daily living and the degree of independence of patients with a disease. The 10 items comprise personal hygiene, self-bathing, feeding, toilet use, stair climbing, dressing, bladder and bowel control, ambulation, and chair or bed transfer. The maximum score is 100, indicating that the patient is fully independent in physical functioning. The lowest score is 0, indicating a completely dependent incapacitated state. This test tool has intra-rater (ICC=0.87–1.00) and inter-rater reliability (ICC=0.93–0.98) and Cronbach’s alpha value of 0.84 [41].

SHOULDER KINESIOLOGY AND SHAM TAPING: The taping method in this study was a modification of the California tri-pull taping introduced by Hayner [26]. Taping was applied using non-elastic tape (Battlewin C tape, Nichiban, Japan) and elastic tape (Benefact tape, Nippon Sigmax, Japan). This method is known as shoulder kinesiology taping. Before the first day of intervention, the patients with hair on their shoulders were asked to shave the area. For better adherence, the skin was scrubbed with a skin preparation (a defensive skin barrier smear) before applying the tape, and if needed, a tape remover was used before the skin preparation to remove the remaining tape from a previous taping. For tape application, the patient was seated in the neutral position with the affected upper extremity side sideways, and the elbow joint was comfortably placed on the table, resulting in a reduced subluxation condition. The first elastic tape was attached from the middle part of the deltoid insertion (deltoid tuberosity) to the acromion process. The second elastic tape was attached from the posterior part of the deltoid insertion to the spine of the scapula. The third elastic tape was attached from the anterior part of the deltoid insertion to the humeral head and over the coracoid process. Next, the non-elastic tape was attached with firm pressure. Three tapes were attached to the deltoid insertion (deltoid tuberosity), middle part of the deltoid, and acromion process in the direction of internal rotation (Figure 2).

For patients allocated to the control group, sham taping was performed using elastic tape. Three pieces of tape were attached to the same position without repositioning the joint (Figure 3).

Every Monday, Wednesday, and Friday, the tape was removed, and new tape was attached. This was repeated for 6 successive weeks. Attachment of elastic and non-elastic tape was performed by a physical therapist who had completed 5 years of related training.

REHABILITATION EXERCISE PROGRAM:

The study and control groups underwent the same conventional rehabilitation exercise program, including physical and occupational therapy sessions. All other physical therapy measures, such as positioning, ROM exercises, and handling techniques, were performed in the study and control groups. Rehabilitation exercise was performed for 6 weeks, 5 days a week for 60 min. The therapists were trained to refrain from commenting on the taping when performing the daily rehabilitation exercises.

STATISTICAL ANALYSIS:

Statistical analysis was performed using SPSS/PC Statistics software (version 18.0; IBM Corp, Armonk, NY, USA) for Windows. The Shapiro-Wilk test was used to check the normal distribution of the data. A paired t test was performed to compare the differences between the groups before and after the intervention. An independent t test was performed to compare the differences between the shoulder and sham taping groups. Statistical significance was set at P<0.05.

Results

COMPARISON OF SSD CHANGES:

Within-group changes in SSD were significant in the shoulder (t=24.952, P<0.05) and sham (t=7.230, P<0.05) taping groups. The SSD was reduced to a greater extent in the shoulder kinesiology taping group than in the sham taping group, and the difference was significant (after intervention: t=−9.480; P<0.05; 95% confidence interval [CI], −4.38 to −2.83; difference: t=15.386; P<0.05; 95% CI, 3.37 to 4.40).

COMPARISON OF AROM CHANGES:

Within-group changes in AROM of shoulder flexion were significant in the shoulder (t=−12.550, P<0.05) and sham (t=−9.753, P<0.05) taping groups. There was greater improvement in AROM of shoulder flexion in the shoulder kinesiology taping group than in the sham taping group, and the difference was significant (difference: t=−7.879; P<0.05; 95% CI, −10.80 to −6.37). Within-group changes in AROM of shoulder abduction were significant in the shoulder (t=−14.830, P<0.05) and sham (t=−10.475, P<0.05) taping groups. There was greater improvement in AROM of shoulder abduction in the shoulder kinesiology taping group than in the sham taping group, and the difference was significant (difference: t=−9.377; P<0.05; 95% CI, −7.93 to −5.10).

COMPARISON OF VAS CHANGES:

Within-group changes in the VAS scores were significant in the shoulder (t=11.854, P<0.05) and sham (t=5.345, P<0.05) taping groups. VAS scores were reduced to a greater extent in the shoulder kinesiology taping group than in the sham taping group, and the difference was significant (after intervention: t=−3.584; P<0.05; 95% CI, −1.85 to −0.51; difference: t=7.151; P<0.05; 95% CI, 0.79 to 1.42).

COMPARISON OF SPADI CHANGES:

Within-group changes in the SPADI scores were significant in the shoulder (t=16.007, P<0.05) and sham (t=7.688, P<0.05) taping groups. The SPADI scores were reduced to a greater extent in the shoulder kinesiology taping group than in the sham taping group, and the difference was significant (after intervention: t=−3.274; P<0.05; 95% CI, −13.02 to −3.04; difference: t=12.014; P<0.05; 95% CI, 7.87 to 11.07).

COMPARISON OF MBI CHANGES:

Within-group changes in the MBI scores were significant in the shoulder (t=−10.564, P<0.05) and sham (t=−3.853, P<0.05) taping groups. There was greater improvement in MBI scores in the shoulder kinesiology taping group than in the sham taping group, and the difference was significant (after intervention: t=2.707; P<0.05; 95% CI, 0.76 to 5.35) (difference: t=−5.216; P<0.05; 95% CI, −4.96 to −2.18).

Discussion

In this study, we aimed to investigate the effect of the shoulder kinesiology taping method on the SSD, AROM, pain, function of the upper extremity, and activities of daily living in stroke patients with a subluxated shoulder.

Brunnstrom [42] described fixation movement by combining the movement pattern and spasticity of the limbs seen in patients with stroke in the synergy pattern. Conversely, the pattern of muscle weakness that occurs after a stroke has been reported by several researchers. Muscles weakened mainly in the upper extremity are the extensors of the fingers, wrist, and elbow and muscles involved in shoulder internal rotation, abduction, and extension. The weakness of these muscles is closely related to various functions [43]. Calliet [44] reported the role of the supraspinatus, deltoid, and other muscles, which prevent the head of the humerus from moving inferiorly due to the initial flaccid paralysis after stroke. The scapula is also rotated, and the glenoid fossa of the scapula is directed inferiorly, making subluxation easier. Therefore, as reported by de Kroon et al [43], the external rotator of the shoulder and weakness of the abductor and extensor muscles are related to subluxation. Shoulder kinesiology taping, used as an interventional method in the present study, attaches tape to the middle, posterior, and anterior fibers of the deltoid, which cannot perform abduction and extension of the shoulder, using elastic and non-elastic tape. The tape was attached in the direction of external rotation, which is the role of the supraspinatus. These tape attachments consistently generate sensory impulses in the skin and muscles to increase muscle activity and improve the proprioceptive sense, thereby stabilizing the shoulder joint [45–47]. Therefore, the shoulder kinesiology taping group showed improvement in SSD, increased ROM during active flexion and abduction, decrease in shoulder pain, improved function of the upper extremity, and improvement in activities of daily living, compared with the sham taping group. Hayner [26] showed improved results in AROM, pain, and SSD by applying deltoid and external rotator taping to a subluxated shoulder after stroke, and Pandian et al [48] reported improvement in pain and function of the upper extremity by applying deltoid and external rotator taping to the shoulder in patients with stroke. Chatterjee et al [35] reported improvement in ROM, pain, SSD, and function of the upper extremity by applying deltoid and external rotator taping to a subluxated shoulder after stroke. In addition, Chatterjee et al [25] reported improvement in AROM, pain, and function of the upper extremity by applying deltoid and external rotator taping to a subluxated shoulder after stroke. Yang et al [49] reported that kinesiology taping is effective in reducing pain and SSD and increasing muscle activity and AROM for patients with hemiplegic shoulder pain. Huang et al [27] found that patients with hemiplegic shoulder pain can experience greater reductions in SPADI, pain, and improvement in shoulder ROM after 3 weeks of kinesiology taping, compared with sham taping. Kinesiology taping can be an alternative intervention for patients with hemiplegic shoulder pain. According to a meta-analysis by Wang et al [50], kinesiology taping can be recommended to improve pain, SSD, disability, upper extremity function, and ROM. Thus, previous studies support the shoulder kinesiology taping method that was used to perform the role of the deltoid and external rotator in the present study.

The body function of shoulder kinesiology taping showed a decrease in SSD, an increase in AROM, and pain reduction in stroke patients with subluxation. In addition, the improvement in body function and activity by shoulder kinesiology taping improved upper extremity function and activities of daily living, which are the goals of patient treatment. The background for improving body function and activity in the present study was as follows: first, the elasticity of the tape stimulated the skin and muscle so that the muscle that was taped returned to its original state; thus, the function of the muscle appeared to be normalized. In 1 case, the muscle was torn, and the joint was shifted. Attaching the tape seemed to prevent the joint from shifting, because the tone of the muscle returned to the normal state. Second, it seemed that the tape lifted the skin to form wrinkles so that the tissue fluid, which had accumulated locally, was discharged quickly, and the smooth flow of blood or lymph improved various problems. Third, it seemed to have had the effect of neurologically eliminating pain, by the attaching of tape to the area of concern.

In the present study, shoulder kinesiology taping was effective in improving SSD, shoulder joint AROM, pain, upper extremity function, and activities of daily living in stroke patients with subluxation. Although, with subluxations limited to a single hospital, this study is not generalizable to all stroke patients, the results of this study are expected to be more meaningful if we increase the number of patients and compare them with other methods in future studies. Neurodevelopmental treatment applied to patients with stroke is also good; however, if taping is performed, more effective results will be obtained.

Conclusions

The shoulder kinesiology taping method reduced subluxation and pain and improved active shoulder flexion, upper extremity functional ability, and activities of daily living. This appears to be a potential early adjunctive intervention for patients who have experienced a stroke and demonstrate pain in a subluxated shoulder, to increase shoulder flexion and extension and upper extremity functional ability. Moreover, this taping method allows patients to participate in all active upper extremity exercises as well as all activities of daily living.