KINESIOTAPING IN DISCOPATHIES AND DEGENERATIVE SPINAL DISEASES: SYSTEMATIC REVIEW

ABSTRACT Neuromuscular taping or kinesiotaping is a technique widely used in spinal disorders. However, the scientific evidence of its use in discopathies and degenerative spine pathology is unknown. This study aimed to analyze the published clinical trials on neuromuscular taping in subjects with discopathies and degenerative spinal injuries. For this purpose, a literature search was performed following PRISMA guidelines in the following databases: PubMed, Web of Science (WOS), Scopus, Medline, and Cinahl. In analyzing bias and methodological quality, we used: the PEDro scale, Van Tulder criteria, and risk of bias analysis of the Cochrane Collaboration. A total of 5 articles were included that obtained a mean score of 6.2 on the PEDro scale. There is moderate evidence that, in the short term, neuromuscular taping reduces analgesic consumption and improves the range of motion and muscle strength in the posterior musculature. In addition, there is limited evidence that it can improve quality, while the scientific evidence on the effect of neuromuscular taping on pain is contradictory. The application of neuromuscular taping on discopathies and degenerative processes of the spine should be cautiously undertaken until more conclusive results are obtained, and the long-term effects are assessed. Level of evidence I; Systematic review.


INTRODUCTION
Disc degeneration and associated syndromes severely affect the population's daily life and work environment. 1In turn, intervertebral disc disease is considered one of the leading causes of pain with a high worldwide prevalence, especially among adults, and its etiology is multifactorial. 2,3The risk factors for disc disease are age, gender, body mass index (BMI), smoking, diabetes, type of hernia, and level of involvement. 4The presentation of symptoms is variable depending on the patient and usually includes a combination of generalized pain and weakness in the spine.In addition, there may be severe neurological compression, usually manifested by paresthesias, loss of reflexes and strength. 5he spinal segments with the highest incidence of disc disease are lumbar and cervical.At the cervical level, they occur most frequently between C3-C4 and C4-C5. 6In the lumbar spine, the most frequent levels of affectation are the lower ones (L3-L4). 7Lumbar disc degeneration is the main cause of low back pain and lumbalgia (85% of cases) in industrialized countries; it is the most prevalent cause of chronic pain, second only to headache. 8he conservative option, cell therapy, and surgery are among the different treatment modalities. 9,10The recommended initial treatment is generally conservative; it usually consists of therapeutic exercise, application of different physical agents in physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), and injection of analgesics, although in specific cases, the surgical option allows for a quicker return to work. 8euromuscular Taping (NT) or kinesiotaping was developed in Japan in the 1970s. 11NT consists of an adhesive elastic bandage that addresses soft tissues and theoretically allows an increase or decrease of muscle tone and improves lymphatic and blood circulation. 12The NT does not contain drugs, its application is simple and inexpensive, the good empirical results have made it popular, and its clinical use is widespread in different medical specialties. 13though different applications have been described, there is currently little evidence to support the use of NT on muscle function 12, and there is a discrepancy about the benefits of spinal disorders.Nelson's systematic review 13 found limited evidence about its benefit, both in the short and long term, in chronic low back pain.Saavedra--Hernández et al. 14 conclude that using NT in mechanical neck pain does not improve the effects of other treatment methods, such as neck manipulation, achieving similar results.Another review indicates that NT applied to the spine does not affect hip motion and curvatures. 15However, a recent review indicates that NT may positively affect pain and disability in patients with chronic low back pain. 16n addition, several applications of NT for discopathies and spinal processes are described in the literature, [17][18][19][20] but the level of scientific evidence for this application is unknown.
Considering the above, this systematic review aims to analyze the published scientific literature to determine the effects of NT in patients with discopathies and degenerative spinal injuries.In addition, the level of existing scientific evidence on this topic will be determined.

Search Strategy
The systematic review carried out in this paper was conducted according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). 21A search was conducted during February 2022 in the PubMed, Web of Science (WoS), Scopus, Medline, and Cinahl databases.
You can see the different search equations in the different databases in Table 1.The references of the included articles were stored and registered manually.Inclusion criteria were selected for studies that: (i) analyze the effects of NT on patients with disc injuries, spondylosis, or OR "Ossification of Posterior Longitudinal Ligament"[Mesh] OR "Spinal Osteophytosis"[Mesh]) AND ("kinesiotap*" OR "taping" OR "kinesio tap*" OR "kinesio-tap*" OR "kinesio-tap*" OR "musculoskeletal tape" OR "kinaesthetic tap*" OR "Athletic Tape"[Mesh] OR "KT" OR "kinesiology tap*" OR "elastic therapeutic tape" OR "neurotape" OR "neuromuscular tape")

Methodological Quality Analysis and Risk of bias assessment
The evaluation of the methodological quality of the included articles was reviewed using the PEDro (Physiotherapy Evidence Database) scale. 22,23On the other hand, the analysis of the risk of bias was performed using the tool "The Cochrane Collaboration" 24 and its corresponding graphic representation ("robvis visualization tool" available at: https://www.riskofbias.info/welcome/robvis-visualization-tool).Each of the six items in each article is evaluated and identified according to the level of risk they present as "low risk", "high risk" or "unclear risk". 25Furthermore, the level of evidence of the review will be obtained using the Van Tulder criteria. 26

RESULTS
The item selection process is summarized by the flow chart in Figure 1.
Five articles were included to meet the objective of this work.8][29][30][31] between 60 30 to 40 28,29 subjects.During the intervention, losses were registered in three selected studies. 27,28,30The ECA [27][28][29][30][31] is performed in different age groups, with most of the studies taking adult-age subjects. 27,28,30,31Although there is an article using the adolescent population. 298][29][30][31] The second most frequently analyzed variable was the level of disability, which appears in 3 of the studies. 28,30,31The methodological quality of the five selected studies was evaluated with the PEDro scale, obtaining scores of 4 29,6,27 and 7. 28,30,31.According to Cashin et al., four of the studies in the review 27,28,30,31 present good methodological quality because they have a PEDro scale score between 6 and 8.In contrast, the Atici et al. 29 study has acceptable methodological quality.
The risk of bias in the studies was analyzed using the Cochrane tool. 24All the studies provided a low risk of bias in the sections on the generation of the randomized section and concealment of the section.On the other hand, in the blinding investigator section, all the studies reflected a high risk.(Figure 2) Finally, the level of evidence of the review was determined using the Van Tulder scale. 26Interpretation of the overall scientific evidence of the included RCTs [27][28][29][30][31] is debatable for the pain variable; a priori it could be considered moderate because there are findings that it decreases in a high quality RCT 27 and in a low-quality RCT 29 according PEDro, 23 but it is more appropriate to specify that the evidence is contradictory because the other three articles of good methodological quality that are included 28,30,31 without improvement in this variable.Moderate evidence was also obtained (one RCT of high methodological quality) on the reduction of analgesic consumption, 30 improved ROM and muscle strength. 31On the other hand, when measuring the quality-of-life variable, limited evidence was obtained by finding consistent results only in one RCT of low methodological quality. 29Other variables showed no significant results in any of the included RCTs.Among them are balance and kyphosis angle, 27 in addition to disability level, 28,30,31 flexion-relaxation ratio 28 and pain related to myofascial stiffness. 28It is also noteworthy that one of the articles included in the review presents no evidence of the use of NT in any of the variables it evaluates. 28

DISCUSSION
This review aimed to evaluate the effects of neuromuscular bandaging in patients with disc disease or degenerative spine processes.In our opinion, this is the first systematic review that addresses this topic.However, the application of NT is very widespread at the clinical level, and NT applications are widespread in different manuals. 17  The main results of the RCTs included in this review [27][28][29][30][31] indicate that in the short term, a significant improvement is described when using it as an analgesic method.However, no conclusive long-term results were obtained because there are parameters such as kyphosis angle or balance 27 in which no significant differences were observed in the analyzed studies.There were also no changes at the myofascial level or in trunk extension strength. 28Regarding ROM, there are different results depending on the type of movement to be performed and the area of the spinal column involved. 28,30,31ffect of NT on the cervical spine Only the article by Copurgensli et al. 31 deals with cervical spondylosis, so it is difficult to establish comparisons between the results and the other articles included.
Firstly, significant short-term increases were obtained after applying NT and conventional rehabilitation (CR) only in the cervical ROM and deep cervical flexor muscle strength variables, compared to the exclusive use of CR. 31 In the investigations by Ay et al. 32 and Onat et al. 33 observed a short-term improvement in ROM parameters when comparing the use of NT versus placebo taping or dry puncture in patients with cervical myofascial pain syndrome and chronic neck pain, respectively.However, in other studies 34 conventional massage achieved better results in cervical ROM parameteres.Puerma-Castillo et al. 35 indicate that NT does not improve against CR.
Secondly, the article by Copurgensli et al. 31 did not obtain positive results about using NT in other variables, such as pain or disability index, compared to other treatment modalities, such as Mulligan's mobilization (MM) together with CR or the use of CR exclusively.][34][35][36] On the one hand, the Puerma-Castillo 35 does not observe significant results of the use of NT vs. CR, in the variables of pain and disability index.In the study by El-Gendy 36 positive results are recorded for both variables after one week of intervention, but after six weeks of treatment these improvements are no longer significant.The study by Toprak Celanay et al. 34 shows that the application of NT is beneficial in both variables after 4 weeks of treatment.Furthermore, in the study by Ay et al. 32 changes are observed after the application of NT in the decrease in pain, while the disability index -Pre-and post-evaluation in process time.
-Evaluation at the beginning and the end of the procedure.
-GC: stretches (3 sets of 4 repetitions of 20 s on the concave side) + NT without tension -GI: stretching (same as in GC) + NT -Pain: VAS scale -Quality of life: SRS-20 Score based on the SRS-22 questionnaire for the evaluation of spinal column deformity Keles et al. 30 (2017) -12 weeks.-NT is applied once a week for the first three weeks, then every three weeks (weeks 1, 2, 3, 6, 9, and 12).
-Evaluations before the start and after 3,6,12 weeks of trial.An additional evaluation is performed 30 min after placement of the first NT.
-GC: NT without tension on the painful point + exercise.
-GI: NT at a painful point + exercise.
- -Evaluation at the beginning (T1) and end of treatment (T2); additional evaluation one month after the end of treatment (T3).
-GC: RC, which consists of a heat pack for 15 min, Conventional TENS for 20 min, and exercises (strength, balance, and stretching).
The measurement of the intervention is divided into T1 (at the beginning), T2 at the end of the intervention) and T3 (after a month of follow-up).

Author KT application type Results
Bulut et al. 27 (2019) .Corrective Technique in X: With the patient in flexion and the shoulders protruding, the NT is applied at the level of the AAC, where the base of the I-band is taken without stretching, and then applying maximum stretch to the lower limit of the contralateral costal patella; the end of the adhesion is applied without stretching.Another NT I-band was also applied to the opposite shoulder with the same technique to obtain a cross sign.The cross point was adjusted to correspond to the lower third of the medial border of the scapula.
Pain: ↓VAS in both groups after six weeks; in the first three weeks ↓, VAS GI>GC.
Balance: EE and EF ↑ in both groups after six weeks; ↑EE at 30 min after placing the NT in GI.
AC: no significant changes between groups after six weeks; ↑AC at 30 min after placing the NT in the GI.
Grzeskowiak et al. 28 (2019) Corrective technique in X: With the patient in bipedestation, 2 NT belts were placed with an I-section from the axillary fold to the major trochanter on the opposite side in the form of a cross, with the midpoint superimposed on the lumbosacral junction.The midpoint was fixed without tension, and the tails of the strips were applied with 15-25% tension.
Disability level: ↓ in both groups.No significant differences between the two groups.
Pain: ↓ in both groups.No significant differences between the two groups.
FRR, ERR, lumbar myofascial stiffness-related pain, and spinal extension force: no significant changes.

Atici et al .29 (2017)
The I-band muscle technique was used on the paraspinal muscles between D3 and L1.The point of origin is the spinal apophyses from D11 to L3, and the insertion point is the spinal apophyses from D3 to T8. Base grip and 25-50% tension are applied on the convex side (from origin to insertion) and 15-25% on the concave side (from insertion to origin).
Quality of life: ↑ en GI>GC.
Keles et al. 30 (2017) The star technique is used.Four I-bands were applied with the patient in maximum trunk flexion.In the GK, the middle point of the belt that is stretched to the maximum is applied at the most painful point, and the ends of the belt are held without stretching.
Pain: ↓ in both groups, but analgesic consumption ↓ in GI.Level of disability: ↓ HAQ and ODI in both groups, but without significant differences between groups Lumbar flexion: no significant changes in FFD or LST.
Copurgensli et al. 31 (2017) Muscle technique is applied: NT with 5% tension to reduce pain and strengthen the movement in the upper, middle, and lower trapezius muscles and the paravertebral muscles in the sitting position, with a Y-band and an I-band.
Pain and NDI score: ↓ in all groups ROM: -In EC after ↑ at T2 in all, ↓ at T3 in GC, and ↑ at T3 in GMM and GK.-In the ID, the ↑ en T2 of the GK > GC.
-In DR and RI, after ↑ at T2 in all, only ↑ at T3 in GMM and GK.
Muscle strength: -↑ in all groups without significant differences, but in the deep cervical flexor, the ↑ of the T2 force of the GK > (GMM or GC).variable does not vary.On the contrary, in the study by Onat et al. 33 the changes are significant in the disability index while they are not significant on pain.

Effect of NT on the dorsal root
The ECAs on the dorsal spine 27,29 observe positive short-term changes in pain 27,29 and quality of life 29 after applying NT with exercise 27 or stretching. 29All this agrees with the data obtained in the research by Mohamed et al., 37 in which NT achieves positive results in variables such as pain and Cobb angle in women with scoliosis.On the other hand, in the measurement of other parameters such as the kyphosis angle or balance, no differential results are reflected when compared to the use of conventional exercise alone; only with NT is there a one-time improvement compared to the use of exercise alone, and that is in the kyphosis angle at 30 minutes after NT placement.Still, this effect is not maintained over time. 27uangkeaw et al. 38 indicate that the combination of exercise and NT improve children with scoliosis, but the differences with exercise alone are insignificant.Also, Karabay et al. 39 suggest short-term improvements in the kyphosis index after applying NT to children with cerebral palsy.Still, they conclude that NT remains less effective than other treatment modalities.
Another study 40 also concludes that the application of NT and exercise in patients with thoracic hyperkyphosis does not achieve results when compared to using exercise alone on pain and quality of life variables.

Effect of NT on the lumbar spine
Finally, the rest of the included articles focus their studies on lumbar discopathies. 28,30Both studies compare the application of NT with a placebo, 28 or as a complement to exercise versus conventional exercise. 30Significant improvements were obtained in pain reduction 28,30 and reducing the number of painkillers ingested. 30elenay and Kaya 41 analyze the immediate effect of NT in patients with chronic lumbar pain, using a band and observing positive short-term changes in pain intensity or postural stability, along with others such as load distribution, can also be observed in studies such as that of Bernardelli et al., 42 in which elastic bands can maintain their effects up to 10 days.
Other research, such as that of Kelle et al. 43, states that NT achieves changes in pain intensity and disability index.However, after one month of application, this improvement is only perceived in analgesia as a complement in treating acute nonspecific low back pain.
Also, the study by Köroğlu et al. 44 applies NT as an additional technique in chronic low back pain, together with ultrasound, heat packs, electrotherapy, and exercise.After finishing the intervention at ten days, improvements in the evaluated parameters were obtained, thus increasing the effectiveness of treating chronic low back pain in the short term.
The studies by Kachanathu et al. 45 and Added et al. 46 concur that, in the long term, conventional rehabilitation based on manual therapy or manual therapy plus exercise, respectively, achieves the same benefits in the parameters of pain, muscle strength, elasticity, and range of motion with or without the application of NT.

NT application techniques
If the area of the rachis involved is related to the type of NT application, for the cervical area, the muscle technique with I-and Y-bands was chosen, as shown in the research by Copurgensli et al. 31 To verify this use, the previously mentioned articles by Celenay et al. 34 and El-Gendy et al. 36 have also obtained satisfactory results using the muscle technique in patients with chronic neck pain.
For the dorsal raphe, two studies 27,29 in which different NT application techniques are used are included in the review.The first is the study by Bulut et al. 27 that applies the cross-correction technique to women presenting with thoracic hyperkyphosis without obtaining significant long-term results compared to other treatment modalities.Similar results can be seen in the study by Karabay et al., 39 in which cross NT does not improve the data obtained by muscle neurostimulation in thoracic hyperkyphosis.Nor have other types of NT applications generated significant changes by combining NT with other treatment models for thoracic hyperkyphosis. 40n the second of the articles included in the review, which covers the dorsal spine, NT is applied through muscle technique and combined with stretching in adolescents with scoliosis, obtaining improvements in variables such as pain and quality of life. 29Contrasting the results with other articles that treat scoliosis with this application, contradictory results were obtained.On the one hand, studies such as Mohamed et al. 37 support the improvement after applying NT, while other studies, such as Duangkeaw et al., 38 states that these improvements are not significant.Therefore, when approaching this rachis region, there is no predominance of any technique for applying NT.
Finally, between the two studies included in the review that covers the lumbar region, 28,30 there are also differences in the type of application of NT on disc herniations.The study by Grzeskowiak et al. 28 uses the cross-correction technique, while the article by Keles et al. 30 uses the star technique with I-bands.
In contrast to the literature, the corrective cross technique is applied in the study by Celenay and Kaya 41 , obtaining significant short-term results in postural stability and pain.On the other hand, the study by Kelle et al. 43 obtained significant results on pain and disability when applying NT using the star technique.In addition, studies such as those by Bernardelli 42 and Koroglu 44 use other NT application techniques and also obtain positive results.[43][44]

Methodological Quality and Risk of Loss
Concerning the methodological quality of the review, an average score of 6.2 out of 10 possible points was obtained.Therefore, the overall methodological quality of the review is set to moderate--adequate.Other reviews evaluating the effects of NT, such as the one by Alonso Martín et al. 12 and Nelson, 13 obtain similar scores (6.4 and 6.6).
When evaluating the biases exposed by the Cochrane tool, 24 a high risk of performance bias was observed in most studies due to the difficulty in shielding participants and therapists in applying NT.The review by Alonso Martín et al. 12 states that in the studies that analyze the effect of NT, there is difficulty in demonstrating causality regarding its effects in clinical practice.This may be due to heterogeneity in the parameters when applying the NT.
On the other hand, one of the limitations of the review is the small number of articles included, which makes it difficult to make direct or indirect comparisons between them.Furthermore, conducting studies with more participants is necessary to obtain conclusive results and sufficient scientific evidence.An example of this was that the study with the largest sample size involved a total of 60 participants, of which only 30 subjects received NT. 30 Another limitation that can be observed is the losses in the sample during the investigation.In the review, three articles present losses in the sample. 27,28,30On the one hand, during the study by Bulut et al., 27 there were five losses due to a lack of follow-up or to pathologies that prevented the participants from continuing to participate.In this case, to justify the losses, the authors performed an intention-to-treat analysis; according to Elkins and Moseley, 47 intent--to-treat analysis includes all data from each participant regardless of whether or not he or she receives the assigned intervention and will serve to evaluate the effectiveness of an intervention when applied in daily clinical practice, where factors such as poor adherence may reduce its effect.On the other hand, the studies by Grzeskowiak et al. 28 and Keles et al. 30 did not perform the analysis by intent to treat or did not consider losses in the statistics, which means that the outcome data may be incomplete and that there may thus be a risk of attrition. 25Another of the limitations that can be highlighted in the studies analyzed is the use of NT only in the short term; for this reason, of all the trials included, the one with the longest duration does not exceed 12 weeks, 30 so it is not known how long the effects achieved may last.It is also necessary to mention about the present work that no systematic review protocol was prepared beforehand, which could be due to the scarce number of studies and reviews related to the subject.
For future research, it will be necessary to define standardized application parameters to demonstrate through scientific evidence the different effects of NT.Furthermore, studies with a longer duration of intervention and without other treatment modalities are needed to determine the specific effect of NT on patients with degenerative spinal cord processes, thus avoiding confounding variables.Also, in the future, we should study the effects of NT on histological 48 or degenerative 3 changes described in discopathies and associated disorders.

CONCLUSION
In subjects with discopathies and degenerative processes of the spine, there is moderate evidence that, in the short term, NT reduces the consumption of analgesics and improves ROM and muscle strength in the posterior musculature.Furthermore, there is limited evidence that it can improve quality, while the scientific evidence on the effect of NT on pain is contradictory.
According to the included studies, using NT as an adjunct to conventional rehabilitation does not report long-term improvements.
The NT techniques that are applied in subjects with discopathies and degenerative processes are muscle technique (Y and I cut), corrective technique (X placement), and space release technique (star application).However, considering the studies with better methodological quality, no one technique can be preferred.
The application of NT to disorders and degenerative processes of the spinal cord should be carried out with caution while waiting for more conclusive results to be obtained and the long-term effects to be evaluated.

Table 2 .
Characteristics of the participants.Anomalies or tumors of the spinal cord Any spinal pathology, such as spondylolysis, spondylolisthesis, or transitional lumbosacral anomalies, could be related to back pain.Not receiving medical and physiotherapeutic treatment in the last year and not using a brace.: Adolescent Idiopathic Scoliosis/ VAS: Visual Analog Scale/GC: Group Control/ GI: Intervention Group/ GIA: Intervention Group 1/ GIB: Intervention Group 2/ IMC: Body Mass Index/ RM: Magnetic Resonance Imaging/ NT: Neuromuscular Taping. AIS