Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Unloading the infrapatellar fat pad - surely not!
- Mike Cummings (20 July 2003)
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Knee taping- of therapeutic value?
- Winston Y Kim, Lin H Yeo (25 July 2003)
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Re: Knee taping- of therapeutic value?
- Rana S Hinman, Kay M. Crossley, Jenny McConnell, Kim L. Bennell (4 August 2003)
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Re: Unloading the infrapatellar fat pad - surely not!
- Frank J.J. Conijn (8 December 2003)
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Taping and afferent response
- Mike Cummings (10 December 2003)
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Re: Taping and afferent response
- Frank J.J. Conijn (11 December 2003)
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Procedure how to apply the tape?
- Sathiya Seelan.G (19 October 2007)
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Mike Cummings, Medical Director British Medical Acupuncture Society Royal London Homeopathic Hospital
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The authors are to be congratulated for their attempt to rigorously assess this physical intervention in knee osteoarthrosis. It is a simple, and almost risk-free, intervention, and this paper demonstrates a degree of specific efficacy, however, I am concerned that the paper may be used inappropriately to support the hypothetical mechanism of taping. The authors describe therapeutic tape as providing ‘glide’ and ‘tilt’ alterations to the patella, and application to ‘unload’ the infrapatellar fat pad or pes anserinus. In their discussion, whilst accepting that the mechanism is unknown, they suggest that this may alter pressures, stresses and strains on various structures in the knee. It is very hard to conceive of how tape applied to the skin, generating very small traction forces in flexible soft tissues, can have any biomechanical impact on the forces transmitted through the weight-bearing structures of the knee, which are several orders of magnitude greater. Far more plausible, and consistent with the results of this trial, is a mechanism of action via sensory modulation at the dorsal horn. High and low threshold mechanoreceptive fibres would have been stimulated during activity in the therapeutic tape group, whereas I suspect that the control tape only stimulated low threshold fibres, as it probably generated much less traction on tissues during movement. In sensory terms, the control tape group received an active intervention, and the near 50% effect reported in this group would be consistent with that idea. It is interesting that the control tape group actually did rather well at the six week follow-up, achieving better results than the therapeutic tape group in six out of the ten outcome measures. The authors did not comment of this. We are told that there were no significant baseline differences, yet the mean ‘pain on worst activity’ in the therapeutic tape group (7.3) lay outside the 95% CI of the control tape group (5.7 to 7.2). In sensory terms this trial studies two doses of sensory input, that from inflexible (‘therapeutic’) tape and that from flexible (‘control’) tape. If the authors wished to test the biomechanical hypothesis behind taping, they would have had to use inflexible tape, incorrectly applied, in the control group. If they had done this I suspect there would have been no differences at all. Competing interests: None declared |
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Winston Y Kim, Specialist registrar orthopaedics Tameside general hospital, OL6 9RW, Lin H Yeo
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Dear Editor, Hinman et al evaluated the effect of therapeutic taping of the knee in osteoarthritis of the knee. Knee osteoarthritis is extremely heterogeneous as was stated by the authors. However, the radiological severity of osteoarthritis in the study was not adequately classified. The extent of involvement of the various knee compartments (medial/lateral compartment or patellofemoral compartment), was not documented, which would introduce bias. It is not known if the severity of osteoarthritis in all 3 groups were evenly distributed using a well validated classification system eg the Kellgren Lawrence grading system. The number of patients in the various groups was small for a very common condition. Follow up was of very short duration. The effect of ‘therapeutic’ taping was minimal compared with the control tape as was demonstrated by similar confidence interval of the primary outcome measure; thus suggesting a placebo effect. Reference 1. Hinman RS, Crossley KM, McConnell J, Bennell KL. Efficacy of knee tape in the management of osteoarthritis of the knee: blinded randomised controlled trial. BMJ 2003;327135-8. Competing interests: None declared |
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Rana S Hinman, Tutor Centre for Sports Medicine Research & Education,School of Physiotherapy, The University of Melbourne, Kay M. Crossley, Jenny McConnell, Kim L. Bennell
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We thank Kim and Yeo for their comments on our paper. Kim and Yeo state that "the radiological severity of osteoarthritis in the study was not adequately classified". We wish to highlight that radiographic severity was classified in the full-length version of the paper. The print version of BMJ necessitates an abridged version to be published, however the full-length version can be found on the BMJ website. Readers will note that Table 1 in the full-length version of our paper (which was not included in the abridged version) does indeed provide details about the radiographic severity of our study participants, graded by the Kellgren & Lawrence grading system (as suggested by Kim and Yeo). Furthermore, as there is no accepted classification system for patellofemoral joint osteoarthritis, Table 1 also provides details on the prevalence of osteophytes and joint space narrowing in this particular compartment of the knee in our cohort. Statistical testing confirmed no significant differences across groups with regard to radiographic evaluations. Whilst Kim and Yeo comment that our sample was "small for a very common condition", a priori power calculations revealed that only 81 participants in total were required to demonstrate a significant and clinically relevant reduction in pain (1.75 cm) [1] on our primary outcome measure, the visual analogue scale. Thus our study was adequately powered to detect a difference in pain levels between interventions that is of relevance to the patient. It is not ethical to involve more subjects than is necessary to answer the research hypothesis, regardless of the prevalence of the condition. While our follow-up was of a short duration, we do not feel this diminishes the relevance of the findings. Tape is generally worn to provide pain relief while in situ so we were not necessarily expecting to see benefits in the absence of tape. Certainly it would be interesting to track how long such benefits can be maintained. Whilst Kim and Yeo comment that the effect of therapeutic tape was "minimal" compared to control tape, one-way ANOVA revealed a significantly greater reduction in pain with therapeutic tape compared to control tape (on our primary outcomes). Similarly, the confidence intervals of the mean difference in pain when comparing therapeutic tape to control tape (at final assessment) demonstrate a significant, superior effect of therapeutic tape. We do acknowledge a small placebo component to the effects of therapeutic tape. A final question for all health practitioners to consider- placebo or otherwise, does it matter to the patient how their pain is relieved, as long as it reduced? 1. Bellamy N, Carette S, Ford PM et al. Osteoarthritis antirheumatic drug trials. III. Setting the delta for clinical trials: results of a consensus development (Delphi) exercise. J Rheumatol 1992; 19: 451-7. Competing interests: Jenny Mcconell receives a royalty from sales of Endura tape, however Endura tape was not used in this study. |
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Frank J.J. Conijn, Editor, Physical Therapist's Literature Update 10 68 CE Amsterdam, The Netherlands
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Editor, Dr. Cummings makes some possibly valid remarks about the mechanism behind the found results. However, he ends his letter with: "If the authors wished to test the biomechanical hypothesis behind taping, they would have had to use inflexible tape, incorrectly applied, in the control group. If they had done this I suspect there would have been no differences at all." Actually, Cushnaghan et al (1) seem to have done a randomised study with just that design. But found: "Medial taping of the patella was significantly better than the neutral or lateral taping for pain scores, symptom change, and patient preference. The medial tape resulted in a 25% reduction in knee pain." Reference:
Competing interests: The author thinks physiotherapy is undervalued in the treatment of osteoarthritis |
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Mike Cummings, Medical Director British Medical Acupuncture Society Royal London Homeopathic Hospital
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I appreciate Frank Conijn drawing attention to the paper comparing medial, lateral and neutral taping published in the BMJ in 1994. I note that the number of subjects in the trial was small (n=14), but that there was a significant difference between medial and lateral taping. I still contend, however, that the effect could be due to sensory stimulation rather than biomechanical factors. It is not clear from the methods that sensory factors were controlled for in any way, and a biomechanical mechanism still seems implausible from the view point of applied physics. I will submit though, that if asked by my physical therapist during discussion of treatment for OA knee, that I will opt for medial taping. Competing interests: None declared |
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Frank J.J. Conijn, Editor, Physical Therapist's Literature Update 1068 CE Amsterdam, The Netherlands
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Editor, In turn, I (truely) appreciate Dr. Cummings admitting that the would opt for biomechanically determined taping (although I would advise to check what would be best: neutral, lateral or medial, by means of trying out the three different types, for two consecutive days each, or maybe by means of the valgus/neutral/varus angle of the lower leg.) In addition, and this also applies to the (also possibly valid) comment made by Drs. Kim and Yeo, I would like to introduce the following hypothesis: the control tape was not a placebo tape, but the same kind of intervention as the real tape, only with a lesser effect. After all, the difference between the real and the placebo tape was only a matter of material. Who is to say to two similarly applied tapes, with only the tape materials being different, do not have -- more or less -- the same effect? Until the time that answers have been found to the above questions, I would suggest that studies on medially -- better: according to three two-day tests? -- taping the osteoarthritic knee should be funded generously. The costs of secondary-care interventions justify it more than sufficiently. Lastly, I hope Dr. Cummings does not suffer from knee osteoarthritis himself, since he speaks of "my physical therapist." Competing interests: The author thinks physiotherapy is still undervalued for osteoarthritis, especially since (a) recent Cochrane review(s) found a very worthwhile effect size of a physiotherapeutical exercise program. |
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Sathiya Seelan.G, physiotherapy student Coimbatore,India-641014
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Hi editor, In this article there is no procedure how to apply the tape.But only the picture shown how it was.It is not enough to apply the tape to the patient. Competing interests: None declared |
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