Introduction
ain in the anterior and posterior part of the patella, without the presence of other pathologies of the knee joint, is called Patellofemoral Pain Syndrome (PFPS) [1, 2]. One of the consequences of this syndrome is a change in balance control [4, 5, 6, 7, 8]. One of the influential anatomical factors in the patellar joint’s stability is the balance between the internal and external vas deferens muscles. After decreasing quadriceps muscle activity and disrupting the contraction sequence of these muscles in PFPS, joint stability indicators also change. Therefore, the afferents of muscle receptors alter, and knee joint proprioception, the most crucial sensory source for balance, is damaged [9, 10, 11, 12]. Although muscular inhibition does not directly impair proprioception, it can impair neuromuscular control mechanisms in people with PFPS [13]. Regulating the proprioception in people with this PFPS helps to increase the patient’s performance and accelerate the rehabilitation process [14]. The results of previous studies have indicated a change in proprioception and a decrease in dynamic balance in these patients [15، 16، 17، 18]. Hence, it is necessary to pay attention to improving proprioception and dynamic balance in rehabilitating people with PFPS.
One of the treatment techniques in physiotherapy that improves balance in people with PFPS is the use of kinesio taping. It can treat imbalance between the internal and external vas deferens muscles [19, 20]. It also improves the decreased proprioception in people with PFPS [21]. Since women’s knee joints are looser than men’s, it is expected that women’s knee joint proprioception decrease and their risk of injury increase, which can make a significant difference in balance between men and women [22, 23]. Neuromuscular control during physical movements has also been reported differently in male and female adolescents [24]. Besides, the presence of some hormonal, anatomical, and neuromuscular factors in women has made PFPS more common in women [12, 22, 25]. To our knowledge, there is no study, neither on the effect of kinesio taping on dynamic balance in men with PFPS nor on comparing its effect on dynamic balance and pain in non-athlete men and women with this syndrome. Therefore, considering the mentioned physiological and anatomical differences between men’s and women’s knees, it seems necessary to study the effect of kinesio taping on dynamic balance in men with PFPS and compare it with women. Given the importance of balance in daily activities, this study aimed to compare the effect of kinesio taping on pain and dynamic balance between non-athlete men and women with unilateral PFPS.
Materials and Methods
This study was performed with the approval of the Ethics Committee of Isfahan University of Medical Sciences and in the physiotherapy clinic of Shahid Sadoughi Hospital in Isfahan City, Iran. The participants were 30 men and 31 women aged 18-40 years with unilateral PFPS who were selected using a convenience sampling method. The inclusion criteria were the existence of pain in the back of the patella or anterior knee, exacerbated during at least two activities of walking, running, jumping, stair climbing, and prolonged kneeling and sitting [26]; unilateral PFPS [27]; a pain score more than 3 under single-leg squat-test on the involved leg up to a 45-degree angle for 10 seconds [28]; and the existence of external glide based on McConnell test [29]. The exclusion criteria were receiving any type of rehabilitation for the knee joint in the past three months [30]; participating in a particular sport; gradual onset of pain for at least 8 weeks [27]; surgery on the knee, lower back, hip, or lower limbs [31, 32, 33], traumatic, inflammatory, infectious disorders, fracture or deformation in the knee and lower limbs [27, 28]; patellar dislocation and subluxation and any symptoms related to the presence of knee osteoarthritis in X-rays [27]; motion restriction of the affected knee in the sagittal plane; history of neurological, rheumatic and other musculoskeletal diseases in the lower limbs and pain in the lower back, hip, and sacroiliac region [32]; history of vertigo, uncorrected vision problems and inner ear disorders [18]; injection of corticosteroids in the past three months; and taking painkillers in the last 72 hours [34].
To evaluate the participants’ dynamic balance, we employed the Y-balance test before and after the intervention (ICC=0.84-0.92). In this test, the subject stands barefoot on one leg in the center and tries to reach three directions of anterior, posterolateral, and posteromedial (Figure 1).  The test was repeated three times in each direction, and the maximum obtained numerical value in each direction was recorded [36]. The rest time between each repetition in each direction was 10 seconds, and between each movement was 20 seconds [37]. The following formula was used to eliminate the effect of individual differences such as height on the maximum reach distance:
Score= Reach distance/Limb length ×100
After 5 minutes of rest and initial tests, the intervention was started. At this stage, TEMTEX kinesio tape with a tension equal to 50%-75% of its initial length was applied on the patella of the involved limb to cause medial glide [38]. The subject was asked to lie on the bed with a straight knee. The tape was measured on the subject’s patella and cut into a Y shape. When the subject’s knee was straight or bent 20-30 degrees, the first 2 cm of the tape was attached without stretching to the outside of the patella. The therapist then held the tape-applied site tightly with one hand and, while simultaneously performing medial gliding over the patella, guided the base of the tape with 50%-75% tension towards the knee. During the procedure, the person’s knee was bent completely, and the tape base was ended up to the mid-part of the patella. By maintaining the base of the tape, the first tail of the tape was attached to the upper part of the patella with a tension equal to 15%-25% of the initial length, and the second tail was attached to the lower part of the patella with the same amount of tension. Finally, the tail ends were attached to the patella without additional tension (Figure 2) [38].   The effectiveness of kinesio taping was measured by performing a single-leg squat-test. For this purpose, before taping, the person was squatted on the involved leg for 10 seconds with the knee bent 45 degrees, and the pain intensity was recorded by the visual analog scale (ICC=0.6). This assessment was repeated after taping, and pain intensity before and after taping was finally compared. If the pain were reduced by approximately 50%, the subjects would enter the final stage of the test. Otherwise, the taping would be repeated to achieve the desired pain relief [16]. In the final step, the subjects performed the Y-balance test again. The paired t-test was used for within-group comparison of the changes, and the independent t-test was used to compare the changes between the male and female subjects. The homogeneity of the two groups was examined by Levene’s test. The significance level was set at 0.05.
Results
The age and anthropometric characteristics of the participants are shown in Table 1. 


There was no statistically significant difference between male and female patients in age and body mass index based on the independent t-test results (P>0.05), and the homogeneity of the two groups was proved by Levene’s test (P>0.05). To control the possible effects of anthropometric characteristics, we matched the anthropometric characteristics of men and women. The result of within-group comparison of Y-balance test parameters before and after the kinesio taping in patients using paired t-test showed the highest numerical value of the distance reach in three directions, indicating the significant effect of kinesio taping over patellar on improving balance (P<0.05) (Table 2). 


According to the independent t-test, no significant difference was observed in the balance parameters between males and females at baseline (P>0.05) (Table 2). Moreover, in both male and female groups, the amount of pain was significantly reduced after kinesio taping based on the paired t-test results (P<0.05), but the between-group comparison of pain intensity showed no significant difference (P>0.05). MANCOVA was used to compare better the two gender groups and eliminate the effect of pre-intervention scores. To eliminate the effect of the height factor on the reach distance, we normalized the values and reported them in Table 2.
Discussion and Conclusion
The present study results showed a significant improvement in dynamic balance and reduced the pain of the patients with PFPS before and after kinesio taping, but there was no significant difference between the men and women after kinesio taping. To control the balance system, afferents of proprioceptive, visual, and vestibular receptors must work adequately [39, 40, 41]. The impairment of these systems can impair balance [40]. Proprioceptive information obtained from mechanical receptors in muscles, joints, and ligaments is the most important component of somatosensory afferents and has a vital role in maintaining joint function and balance control [59]. In many studies, proprioception disorder in individuals with PFPS has been reported [9, 21]. It has been reported that knee joint proprioception, which is essential in creating balance, is weaker in people with PFPS than in healthy people. Therefore, it seems that impairment in proprioception affects the body’s motor control and decreases balance [42]. Given the crucial role of proprioception and muscle activity for balance and their impairment in individuals with PFPS, balance disorders in these patients are expected [15]. 
Of course, the role of pain should not be ignored in the outcome. Patellofemoral joint reaction force in people with PFPS is more common, which can cause pain during functional activities [43]. Pain may inhibit the muscles around the knee [44]. Since these muscles are responsible for timely and effective motor responses in controlling the condition of the body, the impact of kinesio taping on improving the balance of individuals with PFPS may be related to its effect on the systems that affect the balance and reduce pain [44, 45]. The effect of kinesio taping on cutaneous mechanoreceptors and improvement of knee joint proprioception has already been reported [19, 46, 47]. Since sensory inputs can increase central nervous system feedback and reduce pain, the effect of kinesio taping seems to be justified based on the gate theory of pain. Considering the significant reduction of pain in all subjects in our study after the intervention and considering the direct relationship between pain and postural fluctuations, the improvement of balance can be justified [4]. Reduced pain increases the activity of the vastus medialis oblique muscle and helps stabilize the knee joint during testing [27]. As a result, it allows people to balance more effectively as they try to reach a greater distance. Because the muscles around the knee need to function adequately and without delay to maintain balance, delayed muscle activity in people with PFPS leads to dysfunction of the sensorimotor system for controlling postural stability and increased risk of losing balance [17]. Patellar taping improves patellar proprioception and stability, leading to improved knee function [19]. Because of the close relationship between the sensory and motor control systems, studies have shown an improvement in neuromuscular activity following the use of tapes [19, 29, 48, 59]. It seems that the improvement in proprioception after kinesio taping is due to the feedback increase transmitted from the skin, soft tissue, ligaments, and muscles to the upper nerve centers [50]. Patellar taping alters afferents and affects the ability to maintain dynamic postural control in people with PFPS [27]. According to the present study results and the relationship between pain reduction and balance improvement [51], the increased reach distance in the specified directions during the Y-balance test (improved dynamic balance) seems reasonable. 
In the present study, despite the anthropometric differences between men and women with PFPS, there was no significant difference between them in terms of maximum reach distance and dynamic balance after kinesio taping. The non-significant difference in pain between men and women (despite its decreasing trend after the intervention) is probably related to the negligible effect of kinesio taping on women and men’s balance with PFPS. Hence, kinesio taping may affect the dynamic balance of men and women with PFPS. Therefore, gender does not affect kinesio taping. Although proprioception was not examined in this study, the increase in reach distance may be due to stimulation of mechanoreceptors and the effect of proprioception. Besides, there are the effects of reduction in pain and improvement in vastus medialis oblique muscle activity [19, 27].
Kinesio taping has the same effect on the dynamic balance of women and men with PFPS. Patellar kinesio taping is recommended as a suitable treatment method for reducing pain and improving dynamic balance in patients with PFPS.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Isfahan University of Medical Sciences (code: RESEARCH.REC.1397.040) and registered in the Iranian Registry of Clinical Trials (code: IRCT20181001041197N1). Before the study, the research objectives and method were explained to the participants, and written informed consent was obtained. They were free to leave the study at any time and were assured of the confidentiality of their information.

Funding
This study was extracted from the Master’s thesis of the last author, Department of Epidemiology and Statistics, School of Health, Isfahan University of Medical Science, Isfahan. The study received financial support from the Deputy for Research and Technology of Isfahan University of Medical Sciences.

Authors' contributions
Study design and ideation: Javid Mostamand, Zohreh Shafiezadegan, Zeinab Sadat Hosseini; Data collection: Zeinab Sadat Hosseini; Data analysis and interpretation: Mohammad Javad Tarahi, Zeinab Sadat Hosseini, Zohreh Shafiezadegan and Javid Mostamand; Manuscript edited by: Zeinab Sadat Hosseini; Expert evaluation of the manuscript in terms of scientific concepts and approval of the final manuscript: Javid Mostamand and Zohreh Shafiezadegan. Maintaining the integrity of the study process from the beginning to the publication and responding to the opinions of the judges: Javid Mostamand.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank Dr. Khadem, Physiotherapy Clinic of Ayatollah Sadoughi Hospital in Isfahan City, and all participants for their valuable cooperation.


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