Neuromuscular taping treatment of diabetic foot: a concept analysis 231

Review Clin Ter 2021; 172 (3):231-235 doi: 10.7417/CT.2021.2320

Neuromuscular taping treatment of diabetic foot: a concept

analysis
H. Kristianto1,2, A. Waluyo2, D. Gayatri2, E. Yunir3, D. Blow4
1
Department of Medical Surgical Nursing, School of Nursing, Faculty of Medicine, Universitas Brawijaya, Indonesia; 2Faculty of
Nursing, Universitas Indonesia; 3Faculty of Medicine, Universitas Indonesia; 4NeuroMuscular Taping Institute, Rome, Italy

Abstract Introduction

Objective. The definition of neuromuscular taping (NMT) has yet
to be clearly analysed as a possible treatment for diabetic foot. Case
studies, theoretical analysis and results of existing research may lead
to varying perceptions on the definition of NMT and its possible effects
on diabetic foot. This article aims to analyse the definition of the NMT
concept and furthermore as a basis for future research development
on diabetic foot.
Methods. The procedure for reference source search include the
principal data bases using “neuromuscular taping” and “diabetic foot”
keywords for the period of 2010-2019. The concept analysis uses an
8-step approach with the Walker and Avant’s method.
Results. Analysis of the NMT concept on diabetic foot obtained
attributes of elastic tape, skin, pain, edema, injury, sensorimotor,
circulation, drainage, relaxation, local, proprioceptive, motion func-
tion, strength, contraction, stabilisation, reflex, rehabilitation, care,
musculoskeletal, nerve, muscles, tendons, fascia, joints, lymphatic,
longitudinal, wrinkles. There were four groups of attributes, namely
inflammatory response, vascularity, neuromusculoskeletal function and
musculoskeletal system. NMT application benefits for diabetic foot can
be attributed to improving walking function, leg position, decreasing
pain response, improving body function index, improving leg muscle
strength and motor function, increasing range of movement (ROM),
maintaining stability of leg joint function, preventing injury, increas-
ing strength and improving position of ankle joints, reducing stiffness,
reducing edema and helping wound healing processes.
Conclusions. NMT is a decompression application of an elastic
tape on the skin on the diabetic foot that has the effect of reducing the
inflammatory response, improving vascularity and neuromusculoskel-
etal function. It aims to improve neuromusculoskeletal and lymphatic
system functioning due to the presence of wrinkles, indicating dila-
tion, with local effects on the sensorimotor and proprioceptive senses
in conditions of care, rehabilitation and injury. Clin Ter 2021; 172
(3):231-235. doi: 10.7417/CT.2021.2320
Key words: neuromuscular taping, diabetic foot, concept analysis,
operational definition
Diabetic foot complications require special treatment,
starting from the onset of symptoms to the occurrence of
diabetic foot ulcers as a result of changes in peripheral cir-
culation. Care management for patients with diabetic foot
focuses on efforts to cure the condition through treatment of
wounds and ulcers, management of infection and manage-
ment of PAD vascularity. Meanwhile, treatment efforts in the
pre-injury phase are still focused on therapeutic approaches
to reduce symptoms with a pharmacological approach (1, 2).
Therefore, it is necessary to develop complementary nurs-
ing interventions that can help improve the quality of life
of patients with diabetic foot based on scientifically strong
concepts giving clinical results. NeuroMuscular Taping
(NMT) is a non pharmacological intervention that can be
used in the management of diabetic foot. NMT is thought
to be able to improve peripheral circulation in diabetic
foot, creating an option in the development of alternative
modality therapy.
The NMT concept as a form of complementary inter-
vention in patient care management has developed through
various existing studies. Thus requiring a concept analysis
study for NMT on diabetic foot in the efforts to provide a
scientific foundation in the development of these treatment
interventions which distinguishes itself from other types of
taping. NMT is defined as a specific technique of applying
elastic adhesive tape to the skin using a decompression
methodology providing a local therapeutic effect directly
on the treatment site to reduce pain, facilitate lymphatic
drainage, and increase vascularity due to wrinkles created
on the skin (3). The NMT treatment hypothesis has been
defined as; applying an elastic tape without tension over
the skin stretched (over the target area) which will create
skin wrinkling, which is further accentuated by movement,
resulting in a dilation effect on the underlying body tissue.
Furthermore it is stated that reduced pressure on vascular
and lymphatic capillaries will facilitate fluid exchange and
oxygenation as the treatment and prevention objective in

Correspondence: Heri Kristianto, MN, Sp.MSN, RN, Lecturer at the Universitas Brawijaya; doctoral student at the Universitas, Indonesia; spe-
cialist of medical surgical nursing in wound, diabetic foot and diabetes educators, Department of Medical Surgical Nursing, School of Nursing,
Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia. E-mail: heri.kristianto@ub.ac.id

Copyright © Società Editrice Universo (SEU)

ISSN 1972-6007
232
diabetic foot. The definitions that have been formulated
are still general in nature and require specific analysis on
diabetic foot cases from theoretical and research viewpoints.
When referring to “taping”, even from a descriptive point
of view, the argument is penalised by substantial ambigu-
ity due to the terms mentioned, often used as synonyms,
actually refer to uses of taping that are completely different
both conceptually and on a practical and application level
through differing tension levels and so forth. Consequent
research methodology in many publications are penalised
due to inconsistent definitions. Taping can be similar to a
compressive bandage/tape application or an opposing de-
compressive taping application.
Research results on NMT include a variety of cases and
pathologies such as multiple sclerosis (4, 5), hemiplegia (6),
and musculoskeletal disorders (7); while specific studies on
diabetic foot management have never been done. The results
of this concept analysis are expected to provide a basis
and opportunity for the development of NMT research on
diabetic foot. This article aims to specifically analyse and
minimise ambiguous understanding in the definition of the
NMT treatment concept for diabetic foot.
Materials and methods
Reference source search was performed through Pubmed,
Clinical Key, EBSCO, Proquest, Sage Pub, Google Scholar
and Willey Online with “neuromuscular taping” and “dia-
betic foot” keywords and documented with EndNote X8 (8).
The language used was limited to English with a search time
period from 2010-2019. The Walker and Avant’s method
approach was used for concept analysis, which consists
of selecting concepts; determining the aims or purposes
of analysis; identifying all uses of the concept that can be
discovered; determining the defining attributes; identify-
ing a model case; identifying borderline cases; identifying
contrary cases; identifying antecedents and consequences;
and defining empirical referents (9).
Results and discussion
Concept Selection
In the initial stages of concept selection, identification of
phenomena is used as a reference for the writer’s thinking in
describing the concept images that will be taken. Phenomena
can be obtained from experience, observation and analysis
of the conditions that are around it so that it becomes the
focus of one’s attention and making it an issue that needs
to be discussed. People with diabetes mellitus will experi-
ence foot problems that can affect quality of life. There is a
significant relationship between the duration of diagnosis,
age and compliance in controlling diabetes mellitus with
the occurrence of diabetic neuropathy which contributes to
diabetic foot complications (2, 10). Complications of dia-
betic neuropathy are divided into sensory neuropathy, auto-
nomic neuropathy and motor neuropathy. Distal symmetrical
sensorimotor neuropathy occurs in 30% of hospitalised
diabetes mellitus patients and it is reported that 13%-26%
H. Kristianto, et al.
complain of chronic polyneuropathy pain which contributes
to disruption of comfort and affects activities daily living
(ADL) (2, 11). Autonomic neuropathy occurs in 20% of
cases, whereas the incidence of peripheral neuropathy as-
sociated with autonomic neuropathy is found in 30%-50%
of cases (2). Autonomic neuropathy causes damage to the
nociceptor C which can cause disruption in the vasomotor
reflexes and decrease the vasodilator effect of capillaries to
provide blood circulation to the peripheral tissues so that
O2 supply decreases. Motor neuropathy can be found as a
condition of muscle atrophy due to changes in the shape of
the toes, movement fatigue and decreased reflex function.
One typical symptom is decreased Achilles tendon reflexes.
Diabetic neuropathy can cause physical mobilisation and
walking disturbances.
Taping is generally known as a physical rehabilitation
method used with the aim of reducing pain, increasing
joint stability, improving bodily functions in athletes, as
well reducing recurrent injury. One of the various forms of
taping used is neuromuscular taping (NMT). The specific
NMT method is a treatment intervention using tape that is
placed on the skin surface with the aim of providing a dila-
tion effect so that peripheral circulation may improve (12).
NMT is used as a supportive therapy in impaired physical
mobility, acute and chronic pain, impaired walking, fatigue
and unstable blood pressure (4, 13-20). NMT stimulatory
effects include areas of skin anatomy, muscle and fascia
tissue, tendons, nerve tissue, lymphatic, and blood vessels
creating wrinkles on the surface of the skin to help stretch
the skin passively. Tape applied without tension, creating
an elongation force, will assist in muscle contraction and
relaxation. To date no NMT research has been published on
diabetic foot so the authors deem it necessary to conduct a
concept analysis as a first step in the research phase.
Determining the aims or purposes of analysis
The purpose of the concept analysis of NMT on diabetic
foot is to determine the attributes in the concept, determine
operational definitions, and identify instruments related to
NMT applications on diabetic foot.
Identifying all uses of the concept discovered
The stage of defining attributes is the core of the concept
analysis and determines which attributes are very closely
related to the concept analysed (9). This will help in deter-
mining the characteristics of a concept that distinguishes
it from other concepts. Table 1 explains the definition of
neuromuscular taping which consists of various attributes
based on the definitions from the reference sources.
Determining the defining attributes
Several important attributes were found based on the
identification of concepts from several reference sources,
namely elastic tape, skin, pain, edema, injury, sensorimo-
tor, circulation, drainage, relaxation, local, proprioceptive,
motion function, strength, contraction, stabilisation, reflex,
rehabilitation, care, musculoskeletal, nerve, muscle, tendon,
fascia, joint, lymphatic, longitudinal, and wrinkling. Some of
Neuromuscular taping treatment of diabetic foot: a concept analysis 233

Table 1. Definition of Neuromuscular Taping from Reference Sources

Sources Definition
Aguilar et al. A tape application technique with longitudinal manipulation of human skin (13)
Conejo et al. A method to reduce pain, improve motion function and reduce swelling in cases of sports injury, muscle disorders,
disturbance of balance and activity functions so that sensorimotor synchronization occurs using coated tape (7)
Lima et al. Methods to help increase local circulation, reduce edema, help with muscle relaxation and improve joint position
and are proprioceptive due to sensory mechanisms with elastic tape (17)
Constantino et al. Methods for increasing muscle strength and movement function with tape (16)
Berlingeri et al. A method of applying plaster to create strength in the skin and underlying muscles that affect sensorimotor and
proprioceptive thereby reducing pain, increasing muscle strength (4)
Sinaj et al. Rehabilitation methods for musculoskeletal disorders and sports injuries using tape (15)
Russo et al. Rehabilitation therapy for joint stabilization, joint function, movement, neuromuscular reflexes and improved pro-
prioceptive control by using tape (14)
Camerota et al. The main treatment protocol in postoperative, oncological, neurological and sports medicine treatment with
eccentric stimulation of the skin, muscle tissue, tendons, nerves, lymphatic pathways and blood vessels with
passive stretching effects through the application of a tape that encourages flexibility and coordination thereby
increasing range of movement in patients experiencing impaired muscular coordination with sensorimotor modifi-
cation mechanisms and proprioceptive feedback (6, 21)
Shah et al. The method for muscle stimulation that causes an increase in local blood circulation by stimulating the structure
of the skin, muscles and fascia in the presence of wrinkles using tape (19, 22)
Blow The technique of applying elastic tape to the skin to provide a therapeutic effect locally and directly on the area
attached to reduce pain, facilitate lymphatic drainage, increase vascularity due to wrinkles on the skin (3, 12)

the attributes that are found to have similarities in accordance
with existing concepts such as pain and edema attributes are
classified as inflammatory response attributes; circulation,
drainage and relaxation attributes are grouped as vascular-
ity attributes; attributes of motion, strength, contraction,
stabilisation and reflexes are grouped as neuromusculosk-
eletal function attributes; musculoskeletal, nerve, muscle,
tendon, fascia, joint attributes are classified as attributes of
the musculoskeletal system. The purpose of this grouping
is to simplify quite complex attributes found from several
references. Operational definitions obtained based on the
characteristic attributes conclude that neuromuscular taping
is an application of elastic tape on the skin which has the
effect of decreasing the inflammatory response, improving
vascularity and neuromusculoskeletal function targeting the
neuromusculoskeletal and lymphatic systems through the
formation of wrinkles with local effects on sensorimotor
and proprioceptive senses in conditions of care, rehabilita-
tion or injury.
Identifying a model case
In making the case model, what needs to be considered
is that all the selected attributes in the operational definition
must be listed in the case made. Attributes come from real
cases, literature studies and analysis results from the authors
(9). The case model reflects the author’s consistency in
conducting concept analysis to help overcome the internal
structure of the concept and clarify its meaning and context.
The following is a case model created according to existing
attributes.
Male, aged 56 years with a history of type 2 diabetes
mellitus since 10 years ago complaining of tingling and pain
in the right leg and came to the internal medicine clinic to
receive rehabilitation treatment. The patient complains of
pain and tingling in the right leg due to injury. Physical
examination results obtained a right leg muscle strength
score of 3, decreased muscle contraction, and the leg ap-
pears swollen. The patient routinely visits the doctor but
there has been no improvement in the function of motion in
his right leg joint. Then the nurses at the hospital polyclinic
provided education by administering modality therapy by
applying elastic tape on the skin of the right foot. The goal
of this therapy is to provide a local effect through the cre-
ation of wrinkles on the skin by improving vascularity and
lymphatic drainage due to impaired lower limb function.
Nurses conducted an evaluation 3 days after application
and were informed that complaints of pain began to de-
crease, the feet felt lighter than before taping, and edema
began to decrease.
Based on the development of the case, it appears that all
component attributes can be developed in a type 2 diabetes
mellitus case model with complaints on the feet that are
indicated by the relationship between other body parts.
Identifying borderline and contrary cases
Borderline cases are additional development cases that
contain some of the attributes that have been determined (9).
The following is the development of borderline cases in type
2 diabetes mellitus with stroke complications.
Male, 60 years old with a medical diagnosis of type 2
diabetes mellitus with a history of stroke 3 years ago and
experiencing movement disorders in the right limb joint.
Currently being treated in a nursing ward with complaints
of swelling, tingling and weakness of the muscles in the
right hand. The nurse is conducting a mobilisation exercise
intervention.
The case above illustrates that some of the attributes
found can be developed in the case of type 2 diabetes mel-
litus which is more complex in the case of stroke that shows
the relationship with different complications.
234
Contrary cases are examples of case models that do not
contain the attributes contained in the concept (9). Here fol-
lows the development of contrary cases in type 2 diabetes
mellitus.
Male, 60 years old with type 2 diabetes and a history
of stroke 3 years ago. Patient has routinely undergone a
post-stroke rehabilitation program for 2 months with the
application of elastic tape on the surface of the skin on the
limbs with reduced function. Now the patient is able to fulfil
their ADL needs independently. The patients are able to pick
up things, sit and stand independently.
The above case can help the writer to understand dif-
ferent contexts where existing attributes are not needed in
this case. This will increase understanding of the concepts
to be formed.
Identifying antecedents and consequences
An antecedent is an entire incident or event that occurred
before the concept exists, while the consequence is the
entire event that occurs due to the concept (9). Antecedent
and consequence identification can be obtained from the
results of research, literature studies and clinical evidence-
based experience that support the development of existing
concepts.
Definition of empirical referents
Empirical referents are the categorisation of real phe-
nomena that show their existence towards the concept (9).
By categorising the phenomena in Figure 1, an instrument
was obtained to measure the effects of NMT on diabetic
foot: namely the Foot And Ankle Ability Measure (FAAM)
instrument (26) and the Leeds Assessment of Neuropathic
Symptoms and Signs (LANSS) (27). FAAM consists of 21
ADL items and 8 sport assessment items. The ADL assess-
H. Kristianto, et al.
ment assesses basic functional activities, while the sports as-
sessment evaluates the more challenging activities that occur
during exercise. The LANSS score is a suitable instrument
for assessing neuropathic pain in DM patients associated
with changes in ADL and changes in quality of life.
Conclusions
The results of the analysis concept are operational defi-
nitions of NMT on diabetic foot, which is an application
of elastic tape on the skin of diabetic foot that provides an
effect of reducing the inflammatory response, improving vas-
cularity and neuromusculoskeletal function with the aim of
targeting the neuromusculoskeletal and lymphatic systems.
The presence of wrinkles, created by the tape application,
effects sensorimotor and proprioceptive functions deemed
effective in conditions of care, rehabilitation or injury. NMT
application on diabetic foot can provide benefits to improve
walking function, leg position, decrease pain response,
improve body function index, improve leg muscle strength
and motor function, increase ROM, maintain stability of leg
joint function, prevent injury, increase strength and improve
position ankle joints, reduce stiffness, reduce edema and
accelerate the wound healing process.
Acknowledgments
We would also like to acknowledge Professor Yeni Rus-
tina and Professor Junaiti Sahar (Senior Lecturer in Faculty
of Nursing, Universitas Indonesia) in the learning process
of developing nursing theory.
Declaration of interest statement
There is no conflict of interest.
Fig. 1 Identification
Scheme of Ante-
cedents, Concepts
and Consequences
of NMT on Diabetic
Foot
Neuromuscular taping treatment of diabetic foot: a concept analysis
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