BMJ  2003;327:135 (19 July), doi:10.1136/bmj.327.7407.135

Primary care

Efficacy of knee tape in the management of osteoarthritis of the knee: blinded randomised controlled trial

¹ Centre for Sports Medicine Research and Education, School of Physiotherapy, University of Melbourne, Victoria, 3010, Australia

Abstract

Objectives To test the hypotheses that therapeutic taping of the knee improves pain and disability in patients with osteoarthritis of the knee and that benefits remain after stopping treatment.

Design Randomised single blind controlled trial with three intervention arms (therapeutic tape, control tape, and no tape) of three weeks' duration and three week follow up.

Setting Outcome assessment was performed in a university based laboratory. Taping interventions were applied by eight physiotherapists in metropolitan private practice.

Participants 87 patients with symptoms of knee osteoarthritis as defined by the American College of Rheumatology.

Main outcome measures Primary outcome measure was pain as measured by visual analogue scale and participant perceived rating of change. Secondary measures of pain and disability included the Western Ontario and MacMaster Universities osteoarthritis index, knee pain scale, and the SF-36.

Results The therapeutic tape group reported a greater reduction in pain on all primary outcomes than either of the other two groups. A significant association was evident between intervention and change in pain at three weeks (P=0.000), with 73% (21/29) of the therapeutic tape group reporting improvement compared with 49% (14/29) of the control tape group and 10% (3/29) of the no tape group. Significantly greater improvement in pain and disability was observed on most secondary outcomes in the therapeutic tape group compared with the no tape group. Benefits of therapeutic tape were maintained three weeks after stopping treatment.

Conclusions Therapeutic knee taping is an efficacious treatment for the management of pain and disability in patients with knee osteoarthritis.

Introduction

Osteoarthritis is a leading cause of pain and disability in elderly people worldwide and accounts for a large proportion of visits to health professionals each year.^1-4 The American College of Rheumatology recommends knee taping for patients with osteoarthritis of the knee, but there is little evidence to justify its use.^{5 6} We aimed to establish the effect of therapeutic knee taping on pain and disability in patients with symptoms of knee osteoarthritis and to determine if any benefits could be maintained after stopping treatment.

Methods

Participants and group assignment
Volunteers from the community responded to advertisements in local papers. Inclusion criteria were based on the clinical and radiological classification criteria of the American College of Rheumatology (presence of osteophytes, age over 50 years, and pain in the knee).⁷ Exclusion criteria were allergy to tape or history of joint replacement, symptoms or signs suggestive of another cause of knee pain, physiotherapy for the knee (previous six months), body mass index > 38 (owing to difficulties of taping the knee effectively), rheumatoid arthritis, steroid injection or knee surgery (previous six months), history of knee taping, and fragile skin around the knee.

All participants gave written informed consent then were randomised to receive either therapeutic tape, control tape, or no tape. Immediately after baseline assessment by a blinded assessor, the treating physiotherapist accessed the allocation schedule from a centrally located locked cabinet.

Protocol
The trial comprised a three week intervention period and a three week follow up. Participants were assessed before treatment (baseline), after three weeks of treatment (final assessment), and at six weeks (follow up). Tape was applied by 12 trained physiotherapists at the university (n=4) and in private practice (n=8) around the metropolitan region. The tape was worn for three weeks and reapplied weekly.

Therapeutic tape (rigid strapping tape and hypoallergenic undertape) provided medial glide, medial tilt, and anteroposterior tilt to the patella (fig 1). As inflamed soft tissue is aggravated by stretch, tape was also applied to unload either the infrapatellar fat pad or the pes anserinus (determined by clinical assessment to ascertain the most tender).⁸ Control tape aimed to provide sensory input only. Hypoallergenic tape alone was laid over the same areas of skin as the therapeutic tape. Participants allocated to the no tape group received no intervention. All participants continued current treatments but were instructed to refrain from starting new ones. Analgesic use was recorded in a diary.

View larger version (101K): [in this window] [in a new window]   Fig 1 Positioning of therapeutic knee tape

 

Participants were unaware of which taping technique was considered therapeutic. Assessments were performed by one assessor (RH), who remained blinded to treatment allocation until after statistical analyses.

Outcome measures and statistical analysis
Primary outcome
The primary outcome was change in pain, measured on an 11 point, 10 cm horizontal visual analogue scale, numbered in 1 cm increments.⁹ Participants rated the average severity of knee pain, over the previous week, on movement and during an aggravating activity nominated by the participant, by selecting an appropriate whole number. Participant perceived rating of change in pain was recorded on a 5 point Likert scale ranging from 1 (much worse) to 5 (much better). Participants with scores of 4 or 5 were considered "improvers."

Secondary outcomes
Secondary measures of pain included the pain subscale of the Western Ontario and MacMaster Universities osteoarthritis index, the knee pain scale, and the bodily pain domain of the SF-36.^10-12 Disability was measured on a visual analogue scale (average restriction of activity), the physical function subscale of the osteoarthritis index, and the physical function and role domains of the SF-36. Analyses were performed with SPSS software on an intention to treat basis.

Results

Between July 2001 and April 2002, we screened 325 volunteers from the community. Of these, 87 met the selection criteria and were enrolled into our study. Twenty nine participants were randomised to each of the three intervention groups. All participants completed the intervention as allocated. All but one participant completed follow up. Groups did not differ significantly at baseline for personal characteristics (including age, sex, and body mass index) or outcome measures (table).

View this table: [in this window] [in a new window]   Change in outcomes from baseline over time in participants allocated no tape, control tape, or therapeutic tape for osteoarthritis of the knee

 

Primary outcome measures
After intervention the therapeutic tape group showed a significantly greater reduction in pain than the control and no tape groups (table). Effect sizes were large. A small, although non-significant, benefit of control tape was observed. On most comparisons at six weeks, a significantly greater reduction in pain from baseline was evident in the therapeutic tape group. This indicates a prolonged effect of therapeutic tape three weeks after stopping treatment. An association was evident between group and perceived improvement in pain after three weeks (² test P=0.000; fig 2), with 21 (73%) participants in the therapeutic tape group reporting improved pain compared with three (10%) in the no tape group (95% confidence interval of difference 42% to 82%), and corresponding to a number needed to treat of 2 (1.8 to 2.2). Compared with no tape group, the therapeutic tape group was seven times more likely to report improved pain (relative risk 7.00, 2.34 to 20.92), and the control tape group was four and a half times more likely (4.67, 1.50 to 14.53).

View larger version (40K): [in this window] [in a new window]   Fig 2 Participant perceived change in pain after intervention period

 

Secondary outcome measures
The therapeutic tape group experienced a significantly greater reduction in pain and disability on most secondary outcomes than the no tape group. Although control tape achieved small beneficial effects, most differences were not significantly different from no tape. Although therapeutic tape seemed more effective than control tape, differences were small for most outcomes and were not statistically significant. However, at six weeks both tape groups showed significant improvements from baseline compared with the no tape group.

Compliance, cointerventions, and adverse effects
Minor skin irritations affected eight (28%) participants in the therapeutic tape group and one (3%) participant in the control tape group, but all participants continued to wear the tape as prescribed. One participant (no tape group) underwent corticosteroid injection for the knee during the intervention period, and one participant (dropout from no tape group) sought alternative treatment after the intervention period. No differences were found in analgesic use between groups over the intervention period (28% no tape (eight participants), 14% control tape (four), and 31% therapeutic tape (nine), ² test P=0.27).

Discussion

Therapeutic knee tape reapplied weekly and worn continuously for three weeks significantly improved pain and disability in patients with osteoarthritis of the knee. This effect was greater than that observed with control tape and was of a magnitude considered clinically significant.¹³ Furthermore, benefits may be maintained three weeks after stopping treatment.

Only one previous study evaluated the effects of knee tape in a population with osteoarthritis.¹⁴ Despite the limitations of that trial (small sample, lack of untaped control group, short intervention period, and limited outcome measures), a 25% reduction in pain was observed in patients with patellofemoral joint disease after taping of the patella medially for four days.¹⁴ We achieved a greater reduction in pain (38-40%) with therapeutic tape, probably because of our different protocol. Our study expands on previous findings by showing improvements in both pain and physical function using a battery of outcome measures. More importantly, we observed beneficial effects of knee taping in people with generalised, non-specific degeneration of the knee joint. Our cohort comprised patients with both varied severity of disease, as shown by radiography, and varied involvement of the patellofemoral joint. Contrary to the previous trial, some of our participants had only tibiofemoral joint disease, highlighting the generalisability of this intervention to the wider population with osteoarthritis.¹⁴ Our study provides the first evidence of the prolonged effects of knee taping in the short term, once treatment has stopped.

Strengths and limitations of study
A strength of our study is the general applicability of the therapeutic taping technique. Numerous physiotherapists, of varying ages and skill level, representative of those working in private practice, applied the intervention. The results suggest that specialist physiotherapists are not required for this intervention to be effective. The effect sizes were generally medium to large for most outcome measures, comparable with those reported for exercise programmes, physiotherapy regimens, and drug therapies.^{6 15-17}

The main limitation of our study was its short duration, although in clinical practice taping is viewed as a short term and intermittent treatment strategy, generally used as an adjunct to exercise and drug therapies in knee osteoarthritis.

Our cohort comprised volunteers from the community, which explains the large number excluded. Participants had moderately severe osteoarthritis, as assessed by radiography, and reported moderate levels of pain and disability. More women than men were enrolled. We believe that our cohort reflects patients with knee osteoarthritis presenting to health practitioners. Although patients who volunteer for research may be more motivated than those recruited from waiting lists, and thus more likely to report positive outcomes, the lack of significant change in the control tape group suggests that benefits with therapeutic tape were owing to the intervention.

It is not known how taping relieves pain. Subtle changes in patellar position may alter the magnitude or distribution of patellofemoral joint pressures or stress on joint structures.⁸ Unloading the fat pad may reduce strain on this often inflamed soft tissue.¹⁸ Changes in proprioceptive acuity, quadriceps strength, and neuromotor control of the knee with taping have been described in other populations.^19-23

What is already known on this topic Osteoarthritis of the knee is a common condition Knee taping is recommended by the American College of Rheumatology to manage the disease No randomised, controlled trial has evaluated the effects of knee tape in patients with osteoarthritis What this study adds Therapeutic knee taping reduces pain and self reported disability in patients with symptoms of knee osteoarthritis Benefits can be maintained in the short term once treatment has stopped Knee taping is a simple, inexpensive self management strategy

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This is an abridged version; the full version is on bmj.com

We thank Mike Smith for evaluating the radiographs and the physiotherapists for applying the tape. KMC is a postdoctoral research fellow of the National Health and Medical Research Council Australia.

Contributors: See bmj.com

Funding: National Health and Medical Research Council (grant No 114277) and the Australia New Zealand Charitable Trusts.

Competing interests: JMcC receives a royalty from sales of Endura-Tape (Sydney, Australia). Endura tape was not used in this study.

Ethical approval: The university human research ethics committee approved the study.

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(Accepted April 16, 2003)

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Rapid Responses:

Read all Rapid Responses

Unloading the infrapatellar fat pad - surely not!

Mike Cummings
bmj.com, 20 Jul 2003 [Full text]

Knee taping- of therapeutic value?

Winston Y Kim, et al.
bmj.com, 25 Jul 2003 [Full text]

Re: Knee taping- of therapeutic value?

Rana S Hinman, et al.
bmj.com, 4 Aug 2003 [Full text]

Re: Unloading the infrapatellar fat pad - surely not!

Frank J.J. Conijn
bmj.com, 8 Dec 2003 [Full text]

Taping and afferent response

Mike Cummings
bmj.com, 10 Dec 2003 [Full text]

Re: Taping and afferent response

Frank J.J. Conijn
bmj.com, 11 Dec 2003 [Full text]

Procedure how to apply the tape?

Sathiya Seelan.G
bmj.com, 19 Oct 2007 [Full text]