PCerebral palsy (CP) describes a group of non-progressive developmental disorders of the foetal or infant brain leading to permanent motor impairment (1). According to recent studies, the prevalence of CP is 2-4 per 1000 live births (2). It has an incidence of 2.06 cases per 1000 live births in Iran (3). So far, fourteen different gait patterns have been identified in patients with CP, such as crouch gait and in-toeing (4). In-toeing is among the most common gait patterns in children with spastic diplegic CP with a prevalence of 64 % (4). Diplegic CP, also known as spastic diplegia, is one of three categories of spastic CP (5).
The most commonly encountered problem amongst children with CP is muscle stiffness. It manifests during infancy and early childhood and is typically diagnosed by the age of three (6). Spastic diplegia mostly affects the lower extremities and sometimes the arms, making them stiff and contracted (7). It causes difficulty crawling and walking (8). In-toeing is a gait pattern in which the lower limbs are deviated toward each other instead of functioning in a more ideal alignment during ambulation (9). The reason for in-toeing is often multifactorial. The commonest causes of in-toeing in spastic diplegic CP are femoral anteversion, hip internal rotation, and internal tibial torsion (10). Dynamic factors such as abnormal muscle tone (spasticity of the hip internal rotators and adductors as well as the medial hamstrings) can also play a major role in the development of in-toeing (11). Failure to immediately manage muscular imbalances leads to permanent increased femoral anteversion (12). The main complaints of this gait pattern include recurrent cramping of the leg muscles particularly during running, uncoordinated movements during physical activity and fatigue-induced pain in the lower extremity muscles (13). Patellofemoral joint impairment (14), abnormal pronation of the subtalar joint (15), hip osteoarthritis (16), and patellar instability are among the long-term consequences of in-toeing (17).
In-toeing can be modified using surgical interventions, assistive orthotic devices, and physiotherapy (13). Chang and colleagues showed that a customized external strap orthosis improved gait performance and corrected leg alignment in a group of CP children with in-toeing (18, 19). Abd El-Kafy evaluated the clinical impact of an orthotic intervention composed of a static ground reaction ankle foot orthosis combined with the Thera-Togs strapping system on the gait pattern of spastic diplegic CP children in Gross Motor Function Classification System (GMFCS) levels I and II. The orthotic intervention improved the gait more than conventional treatment with or without Thera-Togs (19). An alternative for orthotic device is Kinesio Taping (KT), which is reported to be able to modify joint alignment (20).
KT is an increasingly popular adjunct therapy because it is an accessible, non-invasive and inexpensive method for therapists (21). Over the last few years, KT has been used to improve functional mobility, balance, and posture in children with CP (22, 23).
With a general look at the articles and given the impact of this intervention and the gaps in the studies, the objective of this study was to evaluate the immediate effects of KT on gait spatio-temporal parameters. We hypothesized that re-aligning femoral and tibial internal rotations using KT might improve in-toeing in this patient group.
 

Fourteen children with spastic diplegic CP participated in the study. Demographic data of the participants is summarised in Table 1. A statistically significant difference was observed in the spatial and temporal indices before and after the intervention. Gait velocity increased by 9 cm/s and stride duration increased by 0.20 seconds, indicating an improvement in temporo-spatial parameters of the gait. Internal rotations of the hip, knee, and ankle decreased after applying KT (Table 2).
Figure 1 is a representative cycle of one of the participants. It represents the changes of internal/external rotation angles of the dominant lower extremity during the stance phase of gait before and after the application of KT.
 

 
Figure 1. Joint angles obtained from gait analysis, from the dominant side of one participant

 
Table 2. Comparison of the outcome measures pre- and post-intervention

Discussion

The aim of this study was to evaluate the immediate effects of spiral KT on in-toeing gait parameters in children with diplegic spastic CP. The results revealed significant improvements in the kinematic measures of the hip, knee, and ankle joints in the transverse plane. The spatio-temporal parameters, like velocity and stride time, showed significant improvement after spiral application of KT.
Children with CP present deficits in sensory pathways such as decreased perception of tactile and proprioceptive stimuli (25). The beneficial effects of KT may be attributed to mechanisms such as tactile-proprioceptive stimulation, realignment of muscular fascia, and the provision of a foundation for normal firing and recruitment patterns (26, 27). KT may influence the cutaneous receptors of the sensory motor system, leading to improvements in coordination and voluntary control (28). By providing somatosensory stimulation, KT is likely to activate the gamma motor neurons, in turn regulating the modulation of type Ia afferent fibres (25). We applied spiral KT with full tension over the lower extremities of children with diplegic CP. This could be considered as functional correction, according to Kase (20), and is believed to act by assisting desired motions or limiting non-desired motions. Increased stimulation of mechanoreceptors acts as a preload during the end of motion positions (20).
The study participants were classified as GMFCS level II. KT has been claimed to be mostly beneficial for CP patients at GMFCS levels I and II and also to dynamic activities (29). A review of the literature demonstrated that the impact of KT on gross and fine motor function and dynamic activities was greater than that on postural and static activities (29). There is insufficient evidence on the effects of KT on the outcomes pertaining to motor functions such as gait pattern (30). Some studies investigated the effects of KT on gait parameters in children with CP. They used KT locally either over specific muscles or joints. Kemer and colleagues evaluated the effects of KT Over gluteal muscles on activity and participation in Children with Unilateral CP (31). They found that KT combined with conventional physiotherapy could improve several parameters including cadence, functional mobility, gait and pelvic symmetry, functional mobility, gross motor function, balance, and participation in the medium term in children with unilateral CP. The dorsiflexion range at the heel strike phase of gait increased after three months of taping. Jung and colleagues evaluated the effects of KT on gait parameters in four children with diplegic spastic CP at GMFCS levels I and II (32). KT was applied to the tibialis anterior, rectus femoris, and gluteus maximus muscles using I- and Y-shaped patterns with 50-70% of the available tension. They concluded that KT provided beneficial effects on gait parameters such as gait velocity, step length, stride length, and single support time. Ozmen and colleagues evaluated the effects of KT on gait performance and balance in children with hemiplegic CP. They applied KT over the gasterocnemius and tibialis anterior muscles with 25% of the available tension using Y-shape and I-shape cuts, respectively. They concluded that facilitating dorsiflexion may contribute to the correction of equinus gait and improvement of gait pattern (33). Tsimerakis et al. reported positive results for the application of KT in children with CP in terms of increasing the function of the trunk and lower limbs (34).
Few previous studies have investigated the effects of orthotic devices on correcting rotational deformities of the lower limbs in children with CP. Abd El-Kafy found improvements in cadence, stride length, and gait speed of spastic diplegic children when using spiral strapping in combination with a solid ground reaction ankle foot orthosis (19). Chang and colleagues assessed the immediate effects of a customised external strap orthosis on gait parameters in a group of children with mild CP (18). Induction of external rotation at the lower limbs following the application of customised external strap orthosis improved the gait velocity, cadence, and stride length of the participants. Twister wraps have been shown to be effective in improving spatio-temporal parameters of the gait (stride length, cadence, and velocity) and correcting in-toeing gait pattern in children with diplegic CP (35).
In agreement with the findings from studies using corrective orthoses, our study showed that spiral KT with 100% of available tension was sufficient to improve the spatio-temporal gait parameters and correct the lower limb alignment. To the best of our knowledge, this is the first study on evaluation of the immediate effects of KT using a spiral application pattern over the lower extremities in spastic diplegic children with CP. Our method, however, has some advantages over corrective orthoses. First, parents or caregivers could easily learn how to apply KT. Donning and doffing of orthoses is usually time-consuming, while KT can be applied quickly. Orthoses are often expensive, while KT is relatively low-cost. KT could easily be reapplied several times if the child feels uncomfortable, whereas any reported discomfort derived from wearing orthoses requires referral to an orthotist for revaluation. Another advantage of KT is its invisibility, as it can be applied under clothes, and is very light in comparison to many prefabricated and custom-made orthoses. Our study had some limitations. First, we only investigated the immediate effects of KT. As such, future studies are warranted to evaluate the short term and long-term effects of this pattern of KT application. Second, these results can only be generalized to patients with diplegic spastic CP in GMFCS level II. The effects of this pattern of KT application are yet to be assessed in other types of spastic CP, or among patients with CP with different GFSCS levels. We did not simultaneously evaluate electromyography (EMG) activity in the muscles alongside the kinetics of the lower extremities. Such data may provide a clearer picture of the possible mechanisms involved in the effects of KT application. Moreover, the lack of a control group was another limitation of this study.

 

Conclusion

Applying KT in a spiral pattern over the lower extremities with 100% of the available tension immediately improved the spatio-temporal parameters of the gait including gait velocity and stride time, while decreasing the internal rotation of the hip, knee, and ankle joints in the transverse plane in children with spastic diplegic CP. Given the advantages of KT, clinicians may consider its use to improve gait with similar effects to those of corrective orthoses. Achieving more normal gait patterns using KT provides children with CP with more opportunities and self-confidence when taking part in social activities such as playing with other children and cultivating social skills.

 

Acknowledgements

None.

 

Conflicts of Interest

All authors will disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) the work.

 

Funding

The study was financially supported by the Vice Chancellor of Research, Shiraz University of Medical Sciences, Shiraz, Iran (Grant number: 95-01-06-11846).