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Can inhibitory and facilitatory kinesiotaping techniques affect motor neuron excitability? A randomized cross-over trial
Accepted Manuscript Can inhibitory and facilitatory kinesiotaping techniques affect motor neuron excitability? A randomized cross-over trial Amin Kordi Yoosefinejad, PT, PhD, Alireza Motealleh, PT, PhD, Shekoofeh Abbasalipur, PT, Mahan Shahroei, PT, Dr. Sobhan Sobhani, PT, PhD, Assistant Professor PII:
S1360-8592(16)30103-6
DOI:
10.1016/j.jbmt.2016.06.011
Reference:
YJBMT 1376
To appear in:
Journal of Bodywork & Movement Therapies
Received Date: 15 March 2016 Revised Date:
30 May 2016
Accepted Date: 1 June 2016
Please cite this article as: Yoosefinejad, A.K., Motealleh, A., Abbasalipur, S., Shahroei, M., Sobhani, S., Can inhibitory and facilitatory kinesiotaping techniques affect motor neuron excitability? A randomized cross-over trial, Journal of Bodywork & Movement Therapies (2016), doi: 10.1016/j.jbmt.2016.06.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title page
excitability? A randomized cross-over trial
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Can inhibitory and facilitatory kinesiotaping techniques affect motor neuron
Amin Kordi Yoosefinejad, PT, PhDa, Alireza Motealleh, PT, PhDa, Shekoofeh
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Abbasalipur, PTa, Mahan Shahroei, PTa, Sobhan Sobhani, PT, PhDa*
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a. Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz
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University of Medical Sciences, Shiraz, Iran
*Corresponding author:
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Name: Dr. Sobhan Sobhani
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Assistant Professor of Physical Therapy
Address: 1st Abivardi Avenue, Chamran Blvd, School of Rehabilitation Sciences Department of Physical Therapy, Shiraz, Iran Email: [email protected]
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Abstract Objectives: The aim of this study was to investigate the immediate effects of
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facilitatory and inhibitory kinesiotaping on motor neuron excitability. Design:
Randomized cross-over trial. Method: Twenty healthy people received inhibitory and facilitatory kinesiotaping on two testing days. The H- and M-waves of the
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lateral gasterocnemius were recorded before and immediately after applying the two modes of taping. The Hmax/Mmax ratio (a measure of motor neuron
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excitability) was determined and analyzed. Results: The mean Hmax/Mmax ratios were -0.013 (95% CI: -0.033 to 0.007) for inhibitory taping and 0.007 (95% CI: 0.013 to 0.027) for facilitatory taping. The mean difference between groups was 0.020 (95% CI: -0.048 to 0.008). The statistical model revealed no significant
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differences between the two interventions (P=0.160). Furthermore, there were no within-group differences in Hmax/Mmax ratio for either group. Conclusions: Our findings did not disclose signs of immediate change in motor neuron excitability in
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the lateral gasterocnemius.
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INTRODUCTION Kinesiotaping (KT), first introduced by Kase and colleagues in 1996 (Kase et al., 2003),
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has become a popular adjunct technique to prevent or reduce musculoskeletal injuries. KT is designed to mimic natural human skin characteristics such as stretchability, elasticity
and thickness.(Kase et al., 2003) Several therapeutic benefits have been reported for the use of KT. Some studies found positive effects on pain and disability (GonzáLez-Iglesias et
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al., 2009; Paoloni et al., 2011; Thelen et al., 2008), range of motion (Thelen et al., 2008; Yoshida & Kahanov, 2007), proprioception (Lin et al., 2011), muscle strength, and
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performance.(Huang et al., 2011; Vithoulka et al., 2010) In contrast, other researchers found no beneficial effects of KT on clinical outcomes. In two studies of patients with patellofemoral pain syndrome and low back pain, the reduction in pain scores after KT was not significant (Aytar et al., 2011), or was too small to be clinically meaningful.(Castro-
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Sánchez et al., 2012) Another study found that adding KT to conventional physical therapy did not improve quality of life in patients with neck pain.(Llopis & Aranda, 2012) Based on the available evidence, a recent systematic review concluded that the use of KT offers no
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benefits over sham taping or placebo in a wide range of musculoskeletal conditions.(Parreira et al., 2014)
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It has been suggested that KT affects muscle activity.(Hsu et al., 2009; Huang et al., 2011) KT is expected to have a facilitatory effect if applied from the origin to the insertion of the muscle, while reversing the direction of application is believed to have an inhibitory effect.(Kase et al., 2003; Wong et al., 2012) Kuo et al. demonstrated that the effects of KT may be direction-dependent.(Kuo & Huang, 2013) They applied both facilitatory and inhibitory KT in a group of 19 healthy junior college students and observed significant differences between the two techniques in maximum voluntary isometric contraction of the 3
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wrist and middle finger extensors.(Kuo & Huang, 2013) Two recent biomechanical studies, however, found no difference between the two KT techniques in total work and peak
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torques of the quadriceps muscle (Poon et al., 2015), or in maximum grip strength and electromyographic activity of the wrist extensor muscles in healthy people.(Cai et al., 2015) These contradictory findings raise questions about the probable underlying
neurophysiological mechanisms of different KT techniques. In particular, it is not clear
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whether facilitatory or inhibitory techniques affect motor neuron excitability at all. To our knowledge, very few studies have investigated this effect.
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Firth et al. examined the H-reflex responses of the calf muscles in athletes with Achilles tendinopathy. After KT was applied, the H-reflex amplitude remained unchanged.(Firth et al., 2010) However, the KT method used in their study was a tendon correction technique. The present study aimed to shed light on the immediate effects of facilitatory and inhibitory
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KT techniques on motor neuron excitability in the lateral gastrocnemius muscle in healthy people. We hypothesized that the facilitatory KT technique would increase motor neuron excitability while inhibitory technique would decrease it.
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Participants
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MATERIALS AND METHODS
Twenty healthy individuals (11 male, 9 female) were recruited among students at Shiraz University of Medical Sciences with a convenience sampling method. The demographic characteristics of our sample (mean ± standard deviation) were age 22.9±1.2 years, height 170±9.1 cm, and weight 68.4±12.8 kg. Volunteers were excluded if they had any history of serious injury to the back or lower limb, any rheumatological or neurological disorders, neurogenic low back pain, addiction to alcohol or any drug that might affect H-reflex 4
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parameters, leg length discrepancy, or myofascial trigger points in the lateral gastrocnemius muscle. In addition, individuals who had previous experience of using KT
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for regular or sports activity were excluded. All participants provided their informed consent in writing to take part in the study. The protocol was approved by the Ethics Committee of Shiraz University of Medical Sciences (ir.sums.rec.1394.85).
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Study design
This was a cross-over trial consisting of two sessions of taping (facilitatory and inhibitory)
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one day apart to reduce the impact of possible carryover effects. The order of receiving the taping technique was counterbalanced by dividing the participants into two groups (facilitatory/inhibitory & inhibitory/facilitatory) randomly. The randomization was carried out using a Random Sequence Generator program (available at http://www.random.org). On the first day, half of the participants received facilitatory taping and the other half received
Outcome measure
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inhibitory taping. The order was reversed on the second day.
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The amplitude of H-Reflex (recorded via sub-maximal stimulation of tibial nerve) is one of the measures to evaluate motor neuron excitability. This reflex measures the efficacy of
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synaptic transmission through corresponding motor neuron pool of a muscle. Increasing the intensity of electrical stimulation produces a muscle response called M-wave due to direct stimulation of peripheral nerves. Because of the stability of the M-wave magnitude, it is recommended to normalize that H-reflex by dividing the maximum H-reflex amplitude to the maximum M-wave amplitude (Hmax/Mmax ratio).(Hoch & Krause, 2009; Palmieri et al., 2004). The Hmax/Mmax ratio has been shown to have excellent intersession reliability (ICC 2,1 = 0.979)(Hoch & Krause, 2009) and extensively used in various fields such as 5
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sports science and rehabilitation (Klykken et al., 2011; Lepley et al., 2014; Lo et al., 2012) Due to its advantages over H-reflex, we decided to choose the Hmax/Mmax ratio as the
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primary outcome of this study. A lower ratio indicates motoneuron inhibition, whereas a higher ratio indicates motoneuron facilitation.
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Electromyographic measurement
The skin was prepared by abrading with fine sandpaper and cleaning with alcohol. The H-
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reflex was recorded with a Medelec Sapphire 2ME clinical electromyography unit (Medelec, Old Woking, UK). The tibial nerve was stimulated with a rectangular electrode placed in the middle of the popliteal fossa and the cathode placed proximal to the anode.(Dumitru et al., 2002) The H- and M-waves were recorded from the lateral head of the gastrocnemius with a surface electrode. An imaginary line connecting the midpopliteal
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fossa to the proximal flare of the medial malleolus was bisected to approximately locate the musculotendinous junction of the gastrocnemius muscle.(Dumitru et al., 2002) The lateral head of the gastrocnemius was determined by resisted plantar flexion. The ground
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electrode was placed over the head of the fibula.(Lee & DeLisa, 2004) The duration of each stimulus was 1 ms (0.1 pps) and the intensity was gradually increased to obtain
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Hmax and Mmax responses (Johnson & Pease, 1997) (Figure 1). Kinesio tape application A trained physical therapist applied the KT. An adhesive waterproof KT 5 cm wide and 0.5 mm thick (3NS TEX Tape, 3NS Inc, Korea) was used in this study. The participants’ legs were shaved from the knee down to increase the adhesion of the tape.(Kase et al., 2003) The length of the tape was determined and was cut by estimating the muscle length and 6
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required tension. The KT was applied to the lateral gastrocnemius with the Y-shaped technique as proposed by Kase and colleagues.(Kase et al., 2003) The proximal and distal
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ends of the tape were applied under no tension while the foot was in a neutral position. The Y-shaped technique is used to either facilitate or inhibit muscle.(Kase et al., 2003) Facilitatory KT was applied to the leg from the origin to the insertion of the lateral
gastrocnemius at 50% tension, while inhibitory KT was applied from the insertion to the
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origin at 15% tension (Figure 2).
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Procedures
The procedures were described in detail to the participants. The participants’ barefoot weight and height were recorded. Then they were asked to lay prone with their arms at their sides, head in a neutral position, and feet extended past the edge of the bed. All measurements were taken from the right leg. A pillow was placed under the ankle to allow
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for slight knee flexion. Hmax/Mmax ratio was recorded before applying KT. After applying the first assigned taping according to the randomization scheme, Hmax/Mmax ratio was again recorded from the lateral gastrocnemius as described above. The tape was, then,
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removed. The participants returned to the lab after 24 hours, and all the procedures were repeated for the second assigned taping technique. To avoid the negative effect of fatigue
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on H-reflex amplitude, we asked the participants to get sufficient rest the night before the experiment.(Garland & McComas, 1990). Room temperature was maintained at between 22 and 24 °C throughout the study. Statistical analysis
Descriptive statistics were used to summarize the participants’ demographic characteristics. The analysis was done with a linear mixed model with Hmax/Mmax ratio 7
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(average values) as the dependent factor, intervention (taping), sequence of intervention, and period as fixed factors, and participant (nested in sequence of the interventions) as a
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random factor. The sequence and period terms were included in the model to test for possible carryover effect. The effect of the intervention was determined with the mixed
model using a type III test. For within-group analysis, pre- and post-intervention scores
were compared with paired t-tests. A two-sided P value <0.05 was considered significant.
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All analyses were done with IBM SPSS version 20 (SPSS Inc., Chicago, IL). A post hoc
power analysis (crossover 2×2) was conducted to determine the power of our sample size
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with SAS software, version 9.2 (SAS Institute Inc, Cary, NC). RESULTS
There were no sequence (P=0.722) or period (P=0.619) effects on the Hmax/Mmax ratios. The mean Hmax/Mmax ratio was -0.013 (95% CI: -0.033 to 0.007) for inhibitory taping and
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0.007 (95% CI: -0.013 to 0.027) for facilitatory taping. The mean difference between groups was -0.020 (95% CI: -0.048 to 0.008). The mixed model revealed no significant differences between the two interventions (P=0.160). There were no within-group
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differences in Hmax/Mmax ratio for either group (Figure 3). Post hoc power analysis confirmed that our sample size (n=20) had 98% power to detect a 20% mean difference
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between the two KT groups.
DISCUSSION
Kinesiotaping has been claimed to have facilitatory or inhibitory effects on muscle activity. Our aim was to clarify whether any neurophysiological modulation occurs at the spinal cord level immediately after applying KT. We used the Hmax/Mmax ratio as an accepted measure of motor neuron pool excitability. The results of our study showed that neither the 8
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facilitatory nor the inhibitory KT technique altered the Hmax/Mmax ratio in the lateral gastrocnemius muscle. Moreover, by comparing pre- and post-treatment values, we found
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no within-group changes in the Hmax/Mmax ratio in either of the KT groups. The effects of taping on motor neuron excitability remain debatable. Taping is believed to influence motor neuron excitability by affecting cutaneous and muscle mechanoreceptors such as muscle spindles and Ia afferents.(Konishi, 2013; MacGregor et al., 2005) To date,
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few studies have investigated the effect of KT on motor neuron excitability. Alexander et al. found that tape applied along the gastrocnemius may have an inhibitory effect on motor
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neuron excitability, which contrasts with our findings. An explanation for this discrepancy may be the different types of tape used (non-elastic athletic type vs. KT).(Alexander et al., 2008) It is likely that skin and muscle mechanoreceptors are stimulated more by rigid tapes than elastic ones. Moreover, Alexander et al. measured motor neuron excitability as H-
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reflex amplitude, whereas we used the Hmax/Mmax ratio which is regarded as a better estimate of motor neuron excitability.(Hoch & Krause, 2009; Palmieri et al., 2004) Another research group investigated motor neuron excitability after applying KT over the Achilles
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tendon in both healthy people and people with Achilles tendinopathy.(Firth et al., 2010) Like us, they found no change in amplitude of the calf muscle H-reflex in either group after
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KT application. Interestingly, H-reflex amplitude was increased in the healthy group after the tape was removed.(Firth et al., 2010) The authors speculated that the observed facilitation may be related to cutaneous input.(Firth et al., 2010) Therefore, evidence regarding the effect of KT on motor neuron excitability still remains inconclusive. A few studies have investigated the inhibitory and facilitatory effects of KT on muscle strength.(Kuo & Huang, 2013; Vercelli et al., 2012) These investigations found neither inhibitory nor facilitatory effects of KT on muscle strength.(Kuo & Huang, 2013; Vercelli et 9
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al., 2012) Moreover, a number of studies have evaluated the effects of KT on sports performance, produced torque, muscle strength and function in healthy individuals
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independently of tape direction. The results of these studies did not provide evidence in support of the use of KT to improve the measured outcomes.(Cai et al., 2015; Csapo et al., 2012; de Almeida Lins et al., 2013; Huang et al., 2011) The influence of KT on
electromyographic (EMG) results is still debatable. Although some studies found a
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significant increase in EMG activity in the lower limb muscles after KT application (Csapo et al., 2012; Gómez-Soriano et al., 2014), other studies reported no change.(de Almeida
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Lins et al., 2013; Halski et al., 2015) Nevertheless, the results of our study should not be compared directly with those mentioned above, because the relationship between H-reflex and EMG activity cannot be assumed to be linear.(Schieppati & Crenna, 1984) For example, H-reflex amplitude can increase or decrease while EMG activity remains
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stable.(Thompson et al., 2009)
Some limitations to our study should be noted. Firstly, our results can be generalized only to healthy people. Future studies are warranted to evaluate the directional dependency of
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KT techniques in patients with neurogenic-based low back pain or S1 radiculopathy. Secondly, it was unfortunate that we did not include a functional task in our study. Earlier
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studies have shown that the changes in Hmax/Mmax ratio after an intervention can differ under functional and resting conditions.(Aagaard et al., 2002; Voigt et al., 1998) For example, Voigt et al. investigated the Hmax/Mmax ratio in the soleus muscle after training in hopping in a group of healthy adults. They found no difference in Hmax/Mmax ratios measured during the resting condition. However, during the functional task (hopping), they observed increased H-reflex excitability.(Voigt et al., 1998) Accordingly, we may speculate that Hmax/Mmax ratios obtained after KT application might yield different results during a 10
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functional task. A final limitation was that our EMG apparatus did not have the capability for concurrent recording of H-reflexes from the medial gastrocnemius and soleus muscles.
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Although a previous study with athletic tape found that these muscles exhibited convergent changes in H-reflex amplitude in line with the lateral gastrocnemius (Alexander et al., 2008), we are unable to discuss the implications of associated alterations in the
Hmax/Mmax ratio in the medial gastrocnemius and soleus muscles. We hope that our
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study will pave the way for further exploration of the possible effects of KT application. The main strength of our study is its randomized cross-over design, which is known to be a
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statistically efficient approach with reduced inter-individual and experimental variability.(Senn, 2002)
CONCLUSION
In conclusion, our findings did not reveal signs of immediate change in motor neuron
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excitability in the lateral gastrocnemius when measurements were taken in a static condition. Therefore, the results of previous studies may not be attributable to neurophysiological mechanisms.
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Acknowledgements
The authors wish to express their thanks to all the volunteers for their participation in our
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study. We thank K. Shashok (AuthorAID in the Eastern Mediterranean) for improving the use of English in the manuscript. This study was supported by a grant from Shiraz University of Medical Sciences.
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Captions to illustrations
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Figure 1. A representative recording of Mmax (left) and Hmax (right).
Figure 1. Application of facilitatory (top) and inhibitory (bottom) kinesiotaping.
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Figure 2. Means and standard deviations of Hmax/Mmax ratio for facilitatory and inhibitory kinesiotaping.
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S1360-8592(16)30103-6
DOI:
10.1016/j.jbmt.2016.06.011
Reference:
YJBMT 1376
To appear in:
Journal of Bodywork & Movement Therapies
Received Date: 15 March 2016 Revised Date:
30 May 2016
Accepted Date: 1 June 2016
Please cite this article as: Yoosefinejad, A.K., Motealleh, A., Abbasalipur, S., Shahroei, M., Sobhani, S., Can inhibitory and facilitatory kinesiotaping techniques affect motor neuron excitability? A randomized cross-over trial, Journal of Bodywork & Movement Therapies (2016), doi: 10.1016/j.jbmt.2016.06.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title page
excitability? A randomized cross-over trial
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Can inhibitory and facilitatory kinesiotaping techniques affect motor neuron
Amin Kordi Yoosefinejad, PT, PhDa, Alireza Motealleh, PT, PhDa, Shekoofeh
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Abbasalipur, PTa, Mahan Shahroei, PTa, Sobhan Sobhani, PT, PhDa*
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a. Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz
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University of Medical Sciences, Shiraz, Iran
*Corresponding author:
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Name: Dr. Sobhan Sobhani
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Assistant Professor of Physical Therapy
Address: 1st Abivardi Avenue, Chamran Blvd, School of Rehabilitation Sciences Department of Physical Therapy, Shiraz, Iran Email: [email protected]
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Abstract Objectives: The aim of this study was to investigate the immediate effects of
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facilitatory and inhibitory kinesiotaping on motor neuron excitability. Design:
Randomized cross-over trial. Method: Twenty healthy people received inhibitory and facilitatory kinesiotaping on two testing days. The H- and M-waves of the
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lateral gasterocnemius were recorded before and immediately after applying the two modes of taping. The Hmax/Mmax ratio (a measure of motor neuron
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excitability) was determined and analyzed. Results: The mean Hmax/Mmax ratios were -0.013 (95% CI: -0.033 to 0.007) for inhibitory taping and 0.007 (95% CI: 0.013 to 0.027) for facilitatory taping. The mean difference between groups was 0.020 (95% CI: -0.048 to 0.008). The statistical model revealed no significant
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differences between the two interventions (P=0.160). Furthermore, there were no within-group differences in Hmax/Mmax ratio for either group. Conclusions: Our findings did not disclose signs of immediate change in motor neuron excitability in
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the lateral gasterocnemius.
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INTRODUCTION Kinesiotaping (KT), first introduced by Kase and colleagues in 1996 (Kase et al., 2003),
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has become a popular adjunct technique to prevent or reduce musculoskeletal injuries. KT is designed to mimic natural human skin characteristics such as stretchability, elasticity
and thickness.(Kase et al., 2003) Several therapeutic benefits have been reported for the use of KT. Some studies found positive effects on pain and disability (GonzáLez-Iglesias et
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al., 2009; Paoloni et al., 2011; Thelen et al., 2008), range of motion (Thelen et al., 2008; Yoshida & Kahanov, 2007), proprioception (Lin et al., 2011), muscle strength, and
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performance.(Huang et al., 2011; Vithoulka et al., 2010) In contrast, other researchers found no beneficial effects of KT on clinical outcomes. In two studies of patients with patellofemoral pain syndrome and low back pain, the reduction in pain scores after KT was not significant (Aytar et al., 2011), or was too small to be clinically meaningful.(Castro-
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Sánchez et al., 2012) Another study found that adding KT to conventional physical therapy did not improve quality of life in patients with neck pain.(Llopis & Aranda, 2012) Based on the available evidence, a recent systematic review concluded that the use of KT offers no
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benefits over sham taping or placebo in a wide range of musculoskeletal conditions.(Parreira et al., 2014)
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It has been suggested that KT affects muscle activity.(Hsu et al., 2009; Huang et al., 2011) KT is expected to have a facilitatory effect if applied from the origin to the insertion of the muscle, while reversing the direction of application is believed to have an inhibitory effect.(Kase et al., 2003; Wong et al., 2012) Kuo et al. demonstrated that the effects of KT may be direction-dependent.(Kuo & Huang, 2013) They applied both facilitatory and inhibitory KT in a group of 19 healthy junior college students and observed significant differences between the two techniques in maximum voluntary isometric contraction of the 3
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wrist and middle finger extensors.(Kuo & Huang, 2013) Two recent biomechanical studies, however, found no difference between the two KT techniques in total work and peak
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torques of the quadriceps muscle (Poon et al., 2015), or in maximum grip strength and electromyographic activity of the wrist extensor muscles in healthy people.(Cai et al., 2015) These contradictory findings raise questions about the probable underlying
neurophysiological mechanisms of different KT techniques. In particular, it is not clear
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whether facilitatory or inhibitory techniques affect motor neuron excitability at all. To our knowledge, very few studies have investigated this effect.
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Firth et al. examined the H-reflex responses of the calf muscles in athletes with Achilles tendinopathy. After KT was applied, the H-reflex amplitude remained unchanged.(Firth et al., 2010) However, the KT method used in their study was a tendon correction technique. The present study aimed to shed light on the immediate effects of facilitatory and inhibitory
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KT techniques on motor neuron excitability in the lateral gastrocnemius muscle in healthy people. We hypothesized that the facilitatory KT technique would increase motor neuron excitability while inhibitory technique would decrease it.
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Participants
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MATERIALS AND METHODS
Twenty healthy individuals (11 male, 9 female) were recruited among students at Shiraz University of Medical Sciences with a convenience sampling method. The demographic characteristics of our sample (mean ± standard deviation) were age 22.9±1.2 years, height 170±9.1 cm, and weight 68.4±12.8 kg. Volunteers were excluded if they had any history of serious injury to the back or lower limb, any rheumatological or neurological disorders, neurogenic low back pain, addiction to alcohol or any drug that might affect H-reflex 4
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parameters, leg length discrepancy, or myofascial trigger points in the lateral gastrocnemius muscle. In addition, individuals who had previous experience of using KT
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for regular or sports activity were excluded. All participants provided their informed consent in writing to take part in the study. The protocol was approved by the Ethics Committee of Shiraz University of Medical Sciences (ir.sums.rec.1394.85).
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Study design
This was a cross-over trial consisting of two sessions of taping (facilitatory and inhibitory)
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one day apart to reduce the impact of possible carryover effects. The order of receiving the taping technique was counterbalanced by dividing the participants into two groups (facilitatory/inhibitory & inhibitory/facilitatory) randomly. The randomization was carried out using a Random Sequence Generator program (available at http://www.random.org). On the first day, half of the participants received facilitatory taping and the other half received
Outcome measure
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inhibitory taping. The order was reversed on the second day.
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The amplitude of H-Reflex (recorded via sub-maximal stimulation of tibial nerve) is one of the measures to evaluate motor neuron excitability. This reflex measures the efficacy of
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synaptic transmission through corresponding motor neuron pool of a muscle. Increasing the intensity of electrical stimulation produces a muscle response called M-wave due to direct stimulation of peripheral nerves. Because of the stability of the M-wave magnitude, it is recommended to normalize that H-reflex by dividing the maximum H-reflex amplitude to the maximum M-wave amplitude (Hmax/Mmax ratio).(Hoch & Krause, 2009; Palmieri et al., 2004). The Hmax/Mmax ratio has been shown to have excellent intersession reliability (ICC 2,1 = 0.979)(Hoch & Krause, 2009) and extensively used in various fields such as 5
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sports science and rehabilitation (Klykken et al., 2011; Lepley et al., 2014; Lo et al., 2012) Due to its advantages over H-reflex, we decided to choose the Hmax/Mmax ratio as the
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primary outcome of this study. A lower ratio indicates motoneuron inhibition, whereas a higher ratio indicates motoneuron facilitation.
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Electromyographic measurement
The skin was prepared by abrading with fine sandpaper and cleaning with alcohol. The H-
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reflex was recorded with a Medelec Sapphire 2ME clinical electromyography unit (Medelec, Old Woking, UK). The tibial nerve was stimulated with a rectangular electrode placed in the middle of the popliteal fossa and the cathode placed proximal to the anode.(Dumitru et al., 2002) The H- and M-waves were recorded from the lateral head of the gastrocnemius with a surface electrode. An imaginary line connecting the midpopliteal
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fossa to the proximal flare of the medial malleolus was bisected to approximately locate the musculotendinous junction of the gastrocnemius muscle.(Dumitru et al., 2002) The lateral head of the gastrocnemius was determined by resisted plantar flexion. The ground
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electrode was placed over the head of the fibula.(Lee & DeLisa, 2004) The duration of each stimulus was 1 ms (0.1 pps) and the intensity was gradually increased to obtain
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Hmax and Mmax responses (Johnson & Pease, 1997) (Figure 1). Kinesio tape application A trained physical therapist applied the KT. An adhesive waterproof KT 5 cm wide and 0.5 mm thick (3NS TEX Tape, 3NS Inc, Korea) was used in this study. The participants’ legs were shaved from the knee down to increase the adhesion of the tape.(Kase et al., 2003) The length of the tape was determined and was cut by estimating the muscle length and 6
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required tension. The KT was applied to the lateral gastrocnemius with the Y-shaped technique as proposed by Kase and colleagues.(Kase et al., 2003) The proximal and distal
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ends of the tape were applied under no tension while the foot was in a neutral position. The Y-shaped technique is used to either facilitate or inhibit muscle.(Kase et al., 2003) Facilitatory KT was applied to the leg from the origin to the insertion of the lateral
gastrocnemius at 50% tension, while inhibitory KT was applied from the insertion to the
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origin at 15% tension (Figure 2).
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Procedures
The procedures were described in detail to the participants. The participants’ barefoot weight and height were recorded. Then they were asked to lay prone with their arms at their sides, head in a neutral position, and feet extended past the edge of the bed. All measurements were taken from the right leg. A pillow was placed under the ankle to allow
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for slight knee flexion. Hmax/Mmax ratio was recorded before applying KT. After applying the first assigned taping according to the randomization scheme, Hmax/Mmax ratio was again recorded from the lateral gastrocnemius as described above. The tape was, then,
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removed. The participants returned to the lab after 24 hours, and all the procedures were repeated for the second assigned taping technique. To avoid the negative effect of fatigue
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on H-reflex amplitude, we asked the participants to get sufficient rest the night before the experiment.(Garland & McComas, 1990). Room temperature was maintained at between 22 and 24 °C throughout the study. Statistical analysis
Descriptive statistics were used to summarize the participants’ demographic characteristics. The analysis was done with a linear mixed model with Hmax/Mmax ratio 7
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(average values) as the dependent factor, intervention (taping), sequence of intervention, and period as fixed factors, and participant (nested in sequence of the interventions) as a
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random factor. The sequence and period terms were included in the model to test for possible carryover effect. The effect of the intervention was determined with the mixed
model using a type III test. For within-group analysis, pre- and post-intervention scores
were compared with paired t-tests. A two-sided P value <0.05 was considered significant.
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All analyses were done with IBM SPSS version 20 (SPSS Inc., Chicago, IL). A post hoc
power analysis (crossover 2×2) was conducted to determine the power of our sample size
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with SAS software, version 9.2 (SAS Institute Inc, Cary, NC). RESULTS
There were no sequence (P=0.722) or period (P=0.619) effects on the Hmax/Mmax ratios. The mean Hmax/Mmax ratio was -0.013 (95% CI: -0.033 to 0.007) for inhibitory taping and
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0.007 (95% CI: -0.013 to 0.027) for facilitatory taping. The mean difference between groups was -0.020 (95% CI: -0.048 to 0.008). The mixed model revealed no significant differences between the two interventions (P=0.160). There were no within-group
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differences in Hmax/Mmax ratio for either group (Figure 3). Post hoc power analysis confirmed that our sample size (n=20) had 98% power to detect a 20% mean difference
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between the two KT groups.
DISCUSSION
Kinesiotaping has been claimed to have facilitatory or inhibitory effects on muscle activity. Our aim was to clarify whether any neurophysiological modulation occurs at the spinal cord level immediately after applying KT. We used the Hmax/Mmax ratio as an accepted measure of motor neuron pool excitability. The results of our study showed that neither the 8
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facilitatory nor the inhibitory KT technique altered the Hmax/Mmax ratio in the lateral gastrocnemius muscle. Moreover, by comparing pre- and post-treatment values, we found
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no within-group changes in the Hmax/Mmax ratio in either of the KT groups. The effects of taping on motor neuron excitability remain debatable. Taping is believed to influence motor neuron excitability by affecting cutaneous and muscle mechanoreceptors such as muscle spindles and Ia afferents.(Konishi, 2013; MacGregor et al., 2005) To date,
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few studies have investigated the effect of KT on motor neuron excitability. Alexander et al. found that tape applied along the gastrocnemius may have an inhibitory effect on motor
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neuron excitability, which contrasts with our findings. An explanation for this discrepancy may be the different types of tape used (non-elastic athletic type vs. KT).(Alexander et al., 2008) It is likely that skin and muscle mechanoreceptors are stimulated more by rigid tapes than elastic ones. Moreover, Alexander et al. measured motor neuron excitability as H-
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reflex amplitude, whereas we used the Hmax/Mmax ratio which is regarded as a better estimate of motor neuron excitability.(Hoch & Krause, 2009; Palmieri et al., 2004) Another research group investigated motor neuron excitability after applying KT over the Achilles
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tendon in both healthy people and people with Achilles tendinopathy.(Firth et al., 2010) Like us, they found no change in amplitude of the calf muscle H-reflex in either group after
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KT application. Interestingly, H-reflex amplitude was increased in the healthy group after the tape was removed.(Firth et al., 2010) The authors speculated that the observed facilitation may be related to cutaneous input.(Firth et al., 2010) Therefore, evidence regarding the effect of KT on motor neuron excitability still remains inconclusive. A few studies have investigated the inhibitory and facilitatory effects of KT on muscle strength.(Kuo & Huang, 2013; Vercelli et al., 2012) These investigations found neither inhibitory nor facilitatory effects of KT on muscle strength.(Kuo & Huang, 2013; Vercelli et 9
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al., 2012) Moreover, a number of studies have evaluated the effects of KT on sports performance, produced torque, muscle strength and function in healthy individuals
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independently of tape direction. The results of these studies did not provide evidence in support of the use of KT to improve the measured outcomes.(Cai et al., 2015; Csapo et al., 2012; de Almeida Lins et al., 2013; Huang et al., 2011) The influence of KT on
electromyographic (EMG) results is still debatable. Although some studies found a
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significant increase in EMG activity in the lower limb muscles after KT application (Csapo et al., 2012; Gómez-Soriano et al., 2014), other studies reported no change.(de Almeida
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Lins et al., 2013; Halski et al., 2015) Nevertheless, the results of our study should not be compared directly with those mentioned above, because the relationship between H-reflex and EMG activity cannot be assumed to be linear.(Schieppati & Crenna, 1984) For example, H-reflex amplitude can increase or decrease while EMG activity remains
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stable.(Thompson et al., 2009)
Some limitations to our study should be noted. Firstly, our results can be generalized only to healthy people. Future studies are warranted to evaluate the directional dependency of
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KT techniques in patients with neurogenic-based low back pain or S1 radiculopathy. Secondly, it was unfortunate that we did not include a functional task in our study. Earlier
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studies have shown that the changes in Hmax/Mmax ratio after an intervention can differ under functional and resting conditions.(Aagaard et al., 2002; Voigt et al., 1998) For example, Voigt et al. investigated the Hmax/Mmax ratio in the soleus muscle after training in hopping in a group of healthy adults. They found no difference in Hmax/Mmax ratios measured during the resting condition. However, during the functional task (hopping), they observed increased H-reflex excitability.(Voigt et al., 1998) Accordingly, we may speculate that Hmax/Mmax ratios obtained after KT application might yield different results during a 10
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functional task. A final limitation was that our EMG apparatus did not have the capability for concurrent recording of H-reflexes from the medial gastrocnemius and soleus muscles.
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Although a previous study with athletic tape found that these muscles exhibited convergent changes in H-reflex amplitude in line with the lateral gastrocnemius (Alexander et al., 2008), we are unable to discuss the implications of associated alterations in the
Hmax/Mmax ratio in the medial gastrocnemius and soleus muscles. We hope that our
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study will pave the way for further exploration of the possible effects of KT application. The main strength of our study is its randomized cross-over design, which is known to be a
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statistically efficient approach with reduced inter-individual and experimental variability.(Senn, 2002)
CONCLUSION
In conclusion, our findings did not reveal signs of immediate change in motor neuron
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excitability in the lateral gastrocnemius when measurements were taken in a static condition. Therefore, the results of previous studies may not be attributable to neurophysiological mechanisms.
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Acknowledgements
The authors wish to express their thanks to all the volunteers for their participation in our
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study. We thank K. Shashok (AuthorAID in the Eastern Mediterranean) for improving the use of English in the manuscript. This study was supported by a grant from Shiraz University of Medical Sciences.
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Captions to illustrations
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Figure 1. A representative recording of Mmax (left) and Hmax (right).
Figure 1. Application of facilitatory (top) and inhibitory (bottom) kinesiotaping.
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Figure 2. Means and standard deviations of Hmax/Mmax ratio for facilitatory and inhibitory kinesiotaping.
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