KT & Hypotonia. Introduction: Study completed by:

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1 KT & Hypotonia Study completed by: Carol Motyka-Miller, MAPT, CKTP Susan Greenwood, PT, DPT Michael Gleeson, PT, DPT Florence Nardone, PT, DPT Kristen Faigle, SPT (University of Medicine and Dentistry, NJ) Introduction: Children with autism and pervasive developmental disorder often present with hypotonia, joint laxity, and postural impairments. Akshoomoff and colleagues (2006) found the most common motor deficits in children with pervasive developmental disorders to be hyporeflexia, stereptypies, and hypotonia. Hypotonia can be defined as, a decrease in the amount of tension or resistance to movement in a muscle (Long, 2002). Hypotonia is an impairment associated with disorders that affect motor neurons (Long, 2002). Children with hypotonia may have delays in gross motor and fine motor skills. Hypotonic infants are late in lifting their heads while lying on their stomachs, rolling over, lifting themselves into a sitting position, crawling, and walking. Fine motor delays occur in grasping a toy or finger, transferring a small object from hand to hand, pointing out objects, following movement with the eyes, and self feeding. Additionally, hypotonia can interfere with axial muscle contractions, initiation of movement, and the length of time that a posture can be maintained (Long, 2002). Severe cases of hypotonia can lead to a lack of contraction at proximal joint and limited voluntary movements (Long, 2002). Kinesio Taping was developed in Japan in 1973 by Dr. Kenzo Kase. It was later introduced to the United States in 1995 and the technique gained more popularity when it was used on athletes during the Beijing Olympics in 2008 (Kase, 2006). Kinesio Taping has been a growing intervention in the physical therapy field of practice. The intervention can be utilized with orthopedic and sports injuries, acute rehab, lymphatic therapy, neuromuscular rehab, and in pediatrics. It allows patients to receive a therapeutic intervention over a twenty four hour period of time (Kase, 2006). Kinesio Taping has four major functions: support joint function by exerting an effect on muscle function; enhance activity of the lymphatic system and improve microcirculation; alleviate pain; and support weak muscle groups (Kase, 2006). The method of Kinesio Taping involves taping over and/or around muscles to either support a muscle group or prevent overuse of a muscle group. Kinesio Tex Tape functions by lifting the skin in order to increase interstitial space and relieve pressure from neural and sensory receptors. This relieved pressure results in reducing painful symptoms and aides in lymphatic drainage. There are five different corrective applications of Kinesio Tex Tape which include the following: mechanical correction; fascia correction; space correction; ligament/tendon correction; and a functional correction (Kase, 2006). Mechanical correction uses inward pressure to provide for positional stimuli through the skin in order to assist with postural alignment. Fascia correction involves creating or gathering fascia in order to align tissue in a desired position. The space correction method involves creating more space above the target area of pain, inflammation, and edema in order to relieve these symptoms. The ligament/tendon correction creates increased stimulation over a ligament and/or tendon resulting in an increased stimulation of mechanoreceptors. The functional correction method is used to create sensory stimulation to assist or limit a motion by placing the muscle facilitated in a shortened position (Kase, 2006).

2 Kinesio Tex Tape may be an effective intervention for children with autism and pervasive developmental disorder who present with hypotonia. Additionally, children with autism and pervasive developmental disorder often present with decreased body awareness, decreased core stability and impairments in posture, balance, and movement skills. Kinesio Tex Tape may improve these impairments as it functions to improve body alignment, muscle balance, and functional mobility. Therefore, the goal of this study is to evaluate the effectiveness of Kinesio Tex Tape as an intervention for children with hypotonia and decreased core stability. The purpose of this study is the following: to determine if Kinesio Taping the internal and external oblique muscles would affect the performance of the task of high kneeling and reaching at a ninety degree angle with the right upper extremity to grasp a toy. Literature Search: The literature search I conducted on Kinesio Tex Tape revealed minimal amounts of research on the use of Kinesio Tex Tape in the pediatric setting. Most of the research found on Kinesio Tex Tape involved treating impairments associated with orthopedic injuries. Yoshida and Kahanov (2007) studied the effects of Kinesio Taping on the trunk flexion, extension, and lateral flexion. The study found that Kinesio Tex Tape applied on healthy subjects with no history of back pain can increase active trunk flexion range of motion. Slupik, Dwornik, Bialosezewski, and Zych (2007) studied the effects of Kinesio Taping on the bioelectrical activity of the vastus medialis muscle and on changes in the tone of the muscle during isometric contractions. The study found increased bioelectrical activity of the muscle after twenty four hours of Kinesio Tex Tape application as determined by a transdermal EMG. Fu and colleagues (2006) studied the effects of Kinesio Taping on quadriceps and hamstring muscle strength in athletes. Muscle strength was assessed by isokinetic dynamometer and the results revealed no significant difference between muscle strength in subjects with and without Kinesio Tex Tape application. Finally, one study was found on utilizing Kinesio Tex Tape to enhance the lymphatic system. Tsai and colleagues (2009) compared the treatment and retention effects between standard decongestive lymphatic therapy and a modified lymphatic therapy using Kinesio Tex Tape in subjects with unilateral breast cancer. The study found that excess circumference and excess water conposition were reduced significantly in subjects receiving the Kinesio Tex Tape intervention. Additionally, subjects in the Kinesio Tex Tape group reported increased comfort with thet tape, longer wearing time, and less difficulty with application. Two studies were found on the use of Kinesio Tex Tape in the pediatric setting. Yasaukawa, Patel, and Sisung (2006) studied the effects of Kinesio Taping the upper extremity and functional mobility in an acute pediatric rehabilitation setting. The study found improvements with upper limb control in children with neurological disorders including encephalitis, brain tumors, cerebral vascular accidents, traumatic brain injuries, and spinal cord injuries secondary to the sensory input provided by the Kinesio Tex Tape. Footer (2006) examined the effects of therapeutic taping the paraspinal muscles in children with quadriplegic cerebral palsy. However, the results showed that therapeutic taping did not significantly impact seated postural control. I found no specific research on utilizing Kinesio Tex Tape to increase core stability in children with hypotonia. However, numerous research studies have been conducted on core stability in athletes and in typically developing adults. Liemohn and colleagues (2005) studied core stability and measurement schedules to maximize internal consistency and statistical reliability. The results of their study found that administering five trials and one practice trial on a testing day is sufficient to obtain a test score with adequate reliability. Additionally, their study further revealed that a kneeling arm raise and quadruped parallel arm raise were the most reliable core stability tests.

3 Purpose: To determine if Kinesio Taping the internal and external oblique muscles would affect the performance of the task of high kneeling and reaching at a ninety degree angle with the right upper extremity to grasp a toy. Subjects: Five special needs students from a special service school in Bergen County, New Jersey were selected to participate in the study. Selection of subjects was based on the following inclusion criteria: hypotonia of the abdominal muscles, decreased core stability, impairments in high kneel and reaching tasks, and the cognitive ability to follow verbal commands and/or physical prompts. Before the start of the study, an informed consent form (Appendix 2) was sent home to the five selected subjects' parents and/or guardians. One subject was excluded from the study after guardians declined to sign the informed consent form for personal reasons. Ther informed consent form was signed by the other four subjects. After receiving the completed informed consent form, a patch test was applied to each of the subjects' upper back at approximately the C 7 region. The patch test is necessary to examine the subject's skin integrity and to assess for tape allergies. Subjects were excluded from the study if they had any of the following contraindications to Kinesio Taping: open wounds; fragile skin; poor skin integrity; abrasion; and/or tape allergies. All four subjects tested negative for tape allergies and decreased skin integrity. The subject demographics are summarized in the following table: Previously had KT as an Subject Sex Age Diagnosis Intervention 1 Male 8 Developmental delay & seizure disorder Yes, > 10 months ago 2 Male 9 Autism No 3 Male 6 Autism Yes, > 10 months ago 4 Female 5 Procedure: Developmental delay & possible cerebral palsy Yes, 1 session 7 months ago (to feet) Pre ing Measurements The pre testing procedure was conducted in a quiet room to avoid distractions and to increase attention to the task. A yardstick was placed on the wall and lined up with the subjects' glenohumeral joint. The yardstick was utilized in order to measure the distance the subjects reached for the object, such as, a functional reach test. Additionally, a line of tape was placed on the floor and the subjects knees were brought to the edge of the line of tape to ensure the same knee placement for each trial. In order to make sure the subjects were using a shoulder width base of support, two boxes of tape were also drawn to indicate proper knee placement. For the high kneel task subjects 2, 3, and 4 kneeled on the line of tape and reached with their right upper extremity for a light up toy that was held parallel to their body. Subject 1 reached for puzzle pieces with his right upper extremity in order to increase his attention and motivation to complete the task. The right upper extremity was chosen to maintain

4 consistency between all subjects and consistency between the pre and post testing measures. A functional reach test was scored based on the distance the subject's reached to obtain the toy. The distance on the yardstick was measured from where the toy lined up on the yardstick when the grasp was achieved. The high kneel task was administered for five trials with one practice trial and the number of times balance was lost during the five trials. Pre test measurements were videotaped in both sagittal and anterior views in order to analyze the subjects' movement strategies to accurately collect pre test data. (pictures of high kneeling and reaching task) Analysis of Pre ing Video Subject 1 was able to reach for a puzzle for a piece 31 cm away with compensations. The subject compensated on all five trials by bringing his right hip into flexion above the red line to further reach for the object. The subject required verbal cueing to reach for the puzzle piece, and physical cueing with minimal assistance from two therapists at times to maintain the high kneel position for a significant portion of the test. He reached for the objects with trunk flexion on some trials and would posture into an increased lordosis with some trials as well. The subject lost his balance twice during the five trials and utilized a protective extension reflex pattern of his left upper extremity to regain his balance. Subject 2 was able to reach for a toy a distance of 25.5 cm with out compensations and 27 cm with compensations. The subject would compensate and move his hips into flexion above the red line (right hip more significantly forward than the left hip) on three of the five trials. The subject was able to maintain the high kneel position indepentently, but required verbal cueing to reach for the toy. The subject postured his left upper extremity into shoulder extension and elbow flexion with each trial. Subject 3 was able to reach for a toy a distance of 30 cm away with out compensations. The subject was able to maintain the high kneel position independently, but required verbal cueing to reach for the toy. The subject would compensate and move his left hip info flexion then his right hip into flexion above the red line on three of the five trails. Additionally, the subject postured his left upper extremity into extension with each trial. Finally, the sagittal view of the videotape showed an increased lordotic posture. Subject 4 was able to reach for a toy a distance of 24 cm aawy with out compensations. The subject required tactile cueing on the hand to reach for the objects, and physical cueing with minimal assistance from one therapist at times to maintain the high kneeling position. The subject was very slow to initiate reaching for the toy and grasping the toy. Balance was lost backwards into hip flexion on one trial. Finally, the sagittal view of the videotape showed an increased lordotic posture. Kinesio Taping Intervention One week after the pre test was administered, the subjects all received Kinesio Taping once a week for four consecutive weeks. The taping procedure was performed the same day each week and was administered in a quiet room. Subjects were prepared for the first taping procedure by having them observe the Kinesio Taping procedure on a doll. This was done to eliminate any fear some of the subjects may have had with the taping procedure. A certified

5 Kinesio Taping physical therapist was in charge of the first taping to ensure reliability and correct technique of the procedure. The certified Kinesio Taping physical therapist instructed the student physical therapist on the procedure, so that she could tape the subjects in later weeks. The internal and external abdominal oblique Kinesio Taping application procedure was taken from Kase (2006). For the first week of taping, two 2" Kinesio Tex Tapes were utilized for the taping procedure. The subjects were placed in supine with their hips flexed to approximately 45 degrees in order to place the pelvis in a more neutral position. The subjects' shoulders were flexed over their head to elongate the trunk musculature. The length of the tape was measured from the subject's anterior superior iliac spine to their opposite lateral 10 th rib. The tape was anchored at the anterior superior iliac spine and applied toward the subjects' umbilicus with paper off tension. The same procedure was repeated to the opposite side of the body and the completed application of Kinesio Tex Tape formed an X shape. The length of Kinesio Tex Tape utilized for each subject was measured to the nearest inch to ensure the same length of tape for each week of taping. A note was sent home to the subjects' parents/guardians after each Kinesio Taping intervention with instructions to leave the tape on for 3-5 days and instructions on removal of the tape if skin irritation occurred (Appendix 3). It is important to note that all subjects still received their regular weekly physical therapy sessions, however therapists avoided practicing any high kneeling and reaching tasks to avoid the practice effect. Additionally, it should be noted that the Kinesio Tex Tape and physical therapy was only one intervention that was being used with all the subjects. All subjects also received their regular weekly occupational therapy and speech language interventions. Two of the subjects had some slight skin irritation after the first week of taping. Therefore, their Kinesio Taping application procedure was modified during the second week of taping. Once of the two 2" Kinesio Tex Tapes were cut into a "Y" shape to avoid re-covering the area with skin irritation. The other two subjects without skin irritation received the same Kinesio Taping procedure that was conducted on week one. In weeks three and four, all subjects received the original Kinesio Taping application procedure. However, skin prep was applied to the subjects' who has previous skin irritation to decrease skin sensitivity. (pictures of Kinesio Taping application procedure) Questionnaire to Teachers and Other Therapy Disciplines A questionnaire (Appendix 1) was created for the study in order to gain information from teachers, occupational therapists, and speech therapists regarding the effectiveness of this treatment in other environments aside from physical therapy. The questionnaire asked for feedback in the following areas: sitting posture; body awareness; respiration/speech; fine motor skills; and attention to task. The questionnaire was handed out to teachers and related disciplines during the first week of Kinesio Taping and was collected on the fifth week of the study. Post ing Measurements On the sixth week, the high kneel and reaching task was completed as a post test

6 measurement. The high kneel task was administered for five trials with one practice trial and the best score out of the five trials was recorded as the functional reach score. Similarly to the pre test, the number of times balance was displaced and the amount of assistance to complete the task was also recorded. Once again, the post test measurements were videotaped in order to analyze the subjects' results and movement strategies. Analysis of Post ing Video Subject 1 reached the same distance as the pre test, 31 cm away with compensations. Identical to the pre test, the subject compensated on all five trials by bringing his left hip forward into flexion followed by this right hip forward into flexion above the red line to further reach for the object. However, the subjects' amount of assistance decreased from pre and post tests. The subject still required verbal cueing to reach for the puzzle piece, physical cueing, and minimal assistance from one therapist, instead of two therapists as in the pre test. Furthermore, the subject only required a therapist to manually support his heels for a small duration of the post test. Additionally, the subject was able to maintain the high kneel position independently for a continuous 20 seconds during the post test. The subject only lost his balance once during the five trials, improving from his pre testing score. Subject 2 was able to reach for a toy a distance of 26 cm with out compensations and 28 cm with compensations. The distance he reached with out compensations was.5 cm greater than his functional reach on the pre test. The subject's amount of task assistance remained the same, he was able to maintain the high kneel position independently, but required verbal cueing to reach for the toy. However, the subject's compensatory patterns improved. The subject did not move his hips into flexion above the red line on any of the five trials, he contacted his left upper extremity onto the wall briefly for support. Additionally, on two trials, he postured his left upper extremity into shoulder extension. Subject 3 was able to reach the same distance as the pre test, 30 cm with out compensations. The subject required the same amount of assistance, he was able to maintain the high kneel position independently, but required verbal cueing to reach for the toy. The subject's balance improved as he only lost his balance twice during the five trials. Additionally, the subject's compensatory patterns improved. The subject did not move his bilateral hip forward into flexion above the red line on any of the five trials. Additionally, he only postured his left upper extremity into extension to increase his stability on one trial, instead of all five trials. Subject 4 was able to reach for a toy a distance of 20 cm away with compensations. Unlike the pre test, the subject compensated on all five trials by flexing her hips above the red line to further reach for the object. The distance she reached is 4 cm less than her functional reach in the pre test. Additionally, the subject's balance did not improve during the task. She lost her balance twice during the five trials. As with the pre test, the subject required tactile cueing on the hand to reach for the objects, and physical cueing with minimal assistance at times to maintain the high kneeling position. The subject was very slow to initiate reaching for the toy and grasping the toy. The subject initiated more movement from her core instead of posturing her back into extension while reaching. Results: Questionnaire to Teachers and Other Therapy Disiplines The questionnaire provided additional information on the subjects' presentation and progress outside the physical therapy setting. All subjects demonstrated improvements on some of the areas listed on the questionnaire. Subject 1's occupational therapist reported improvements in sitting posture and task attention. The occupational therapist reported, "the student will sit for short periods of time on a regular school chair." Additionally, subject 1's teacher noticed improvements in sitting posture and speech. She reported the following, "the

7 student sits with a more erect posture and has been attempting to verbalize more during class." Subject 2's occupational therapist reported improvements in sitting posture, fine motor skills, and attention to task. She reported, "the students sitting posture in more erect on T-stools and he will participate in fine motor tasks for longer periods of time with out losing balance on the T-stool." Additionally, the subject 2's father reported that he noticed improvements at home since the tape had been applied. Subject 3's occupational therapist reported improvements in fine motor skills. She stated, "the student has been improving with fine motor skills and is able to maintain attention to task for longer periods of time." Additionally, the student physical therapist observed that subject was able to ascend a step 12 inches high for the first time since the tape has been applied. Subject 4's occupational therapist reported improvements in sitting posture, body awareness, speech, fine motor skills, and attention to tasks. The occupational therapist stated, "the student's sitting posture is more erect and the student is able to sustain sitting with out external supports for longer periods of time." Additionally, the occupational therapist reported, "the student is moving quicker, has made balance improvements especially during postural changes, and has achieved a more mature fine motor grasp pattern." Core Stability : high kneel and reaching with one upper extremity to grasp toy (Highlighted data in red indicate changes from the pre test measurements) Outcome Measurements Number of Balance Displacements Fathest Distance Reached Amount of Assistance Needed to Complete Task Outcome Measurments Subject 1: Pre Subject 1: Post Subject 2: Pre Two One None None 31 cm w/ compensations reach for puzzle pieces, physical cueing and min A x 2 at times to maintain high kneel position & to manually decease his base of support. Subject also required manual support at his heels to help maintain the high kneel position. Subject 3: Pre 31 cm w/ compensations reach for puzzle pieces, physical cueing and min A x 1 at times to maintain high kneel position & to manually decease his base of support. Subject did not require manual support at his heels at all times to help maintain the high kneel position. Subject 3: Post 25.5 cm, subject achieved 27 cm, but w/ compensations reach for toy Subject 4: Pre Number of Three Two One One Subject 2: Post 26 cm, subject achieved 28 cm w/ compensations reach for toy Subject 4: Post

8 Balance Displacements Farthest Distance Reached Amount of Assistance Needed to Complete Task 30cm 30cm 24cm reach for toy reach for toy reach for toy, physical cueing, and min A at times to maintain high kneel position & to manually decease his base of support 20 cm w/ compensations reach for toy, physical cueing, and min A at times to maintain high kneel position & to manually decease his base of support Graphs: Statistical Analysis of Results: (Bold indicates positive statistical changes & italics indicates negative statistical changes) Outcome Measurements Farthest Distance Reached Number of Balance Displacements Mean: Pre Median: Pre Range: Pre Mean: Post Median: Post Range: Post

9 Discussion: The results of the study indicate that Kinesio Taping the internal and external oblique muscles can increase core stability in children with hypotonia. Improvements were seen across all subjects from pre and post testing data on the performance of high kneeling and reaching parallel with one upper extremity to grasp a toy. Although improvements were not seen for every subject across all outcome measurements, three of the four subjects improved on at least one of the three outcome measurements. Subject 1's balance improved and the amount of assistance needed to complete the task decreased. Subject 2's functional reach score increased. Subject 3's balance improved. Although subject 4 did not directly improve across the outcome measurements, analysis of the pre and post testing video tapes indicate that subject 4 initiated more movement from her core instead of posturing her back into extension while reaching. Analysis of the video tapes also indicate that subject 2 and subject 3 did not compensate on any trials by moving their hips into flexion above the red line during the post test. Additionally, other health care professionals, parents, and teachers noticed positive changes in the subjects' performance during the course of the Kinesio Taping intervention. These additional disciplines reported improvements in sitting posture, task attention, and fine motor skills. However, improvements in respiration/communication, and body awareness were not observed. Therefore, the results of the study also indicate that Kinesio Taping the internal and external oblique muscles improves sitting posture, task attention, and fine motor skills. As with any study, there are several limitations to our study. One, the study did not take into account the hip extensor muscle weakness. Hip extensor muscle weakness may have effected the quality of performance during the high kneel and reaching task. Two, instead of therapist observation, an inclinometer would have been more reliable measurement method to evaluate changes in lordotic postures. Three, the study lacked intrarater and interrater reliability measurements. Five, the study was only conducted for six weeks, a relatively short study duration. Finally, the high kneel task may not have been the best task for the selected subject population secondary to the subjects' decreased cognition level including distractibility and impairments with comprehending tasks. Furthermore, there was some technical difficulty with the video equipment and there were alterations in the Kinesio Taping pattern used for two of the subjects. Subject 1 and subject 2's pre testing sagittal view and subject 3's anterior view were unable to be analyzed, which may have affected the study's results. Additionally, two of the subjects had skin irritation after the first week of taping and their Kinesio Taping pattern had to be modified during the second week of taping.

10 Conclusion: Kinesio Taping the internal and external oblique muscles in children with hypotonia may be an effective intervention to improve core stability, attention to task, sitting posture, and fine motor skills. However, further research should be conducted on this topic to confirm the above results. References: Akshoomoff, N., Farid, N., Courchesne, E., & Hass, R. (2006). Abnormalities on the neurological examination and EEG in young children with pervasive development disorders. Journal of Autism and Developmental Disorder, 35(5), Cowley, P & Swenson, T. (2008). Development and reliability of two core stability field tests. Journal of Strength and Conditioning Research, 22(2), Footer, C. B. (2006). The effects of therapeutic taping in gross motor function in children with cerebral palsy. Pediatric Physical Therapy, 18, Fu, T., Wong, A., Pei, Y., Wu, K., & Lin, Y. (2006). Effect of Kinesio Tape on muscle strength in athletes. Journal of Science and Medicine in Sports, 11(2), Leimohn, W., Baumgartner, T., & Gagon, L. (2005). Measuring core stability, Journal of Strength and Conditioning Research, 19(3), Long, T. & Toscano, K. (2002). Handbook of pediatric physical therapy. New York: Kase, K., Martin, P., & Yasukawa, A. (2006). Kinesio Taping in Pediatrics. Tokyo: Kinesio USA, LLC Slupik, A., Dwornik, M., Bialoszewski, D., & Zych, E. (2007). Effect of Kinesio Tape on bioelectical activity of the vastus medialis muscle. Ortopedia Traumatologia Rehabilitacja, 9(6), Tsai, H., Hung, H., Yang, J., Huang, C., & Tsauo, J. (2009). Could Kinesio Tape replace the bandage in decongestive lymphatic therapy for breast cancer related lymphedema? Supportive Care in Cancer. Yasukawa, A., Patel, P., & Sinsung, C. (2006). Pilot study: Investingating the effect of Kinesio Taping in an acute pediatric rehabilitation setting. American Journal of Occupational Therapy, 60,

11 Yoshida, A., & Kahanov, L. (2007). The effects of Kinesio Taping in lower trunk range of motions. Research in Sports Medicine, 15, Volkman, G. K. et al. (2009). Factors affecting functional reach scores in youth with typical development. Journal of Pediatric Physical Therapy, 21(1),