Integrating Kinesiology Taping Into Upper Extremity Practice:
Advance Taping Techniques For The Hand Therapy Practitioner
Tracey Edblom, OTR/CHT California Education Connection
History Began experimenting with already existing tapes. Was not getting desired results, so began to develop a new type of tape. Method originally used only in clinical rehabilitation settings in Japan. In the late 1980’s, first used on Volleyball players.
History, continued Officially Introduced to USA in 1995 Used by every professional sport in Japan, and is being used by professional teams in the United States and Europe. Seen in magazines on Lance Armstrong, Brittany Bowes, professional Bull Riders… and more!
Basic Principles of Tex Taping Skin Functions Muscular Functions Lymphatic Functions Joint Functions
Four Physiological Effects of Tex Taping Relieves Pain and altered sensation in the Skin & Muscles. Supports the Muscle in Movement (Expanding Effects) Removes Congestion of Lymphatic Fluid or Hemorrhages under the Skin Makes room for fresh circulation Corrects Misalignment of the Joint
Tracey’s “Tape Functions”: Reduce edema Increase room for circulation Speed wound healing Reduce pain Muscle spasm Improve muscle function Reduce scar density Improve scar mobility Improve proprioception/sensory remapping
Endogenous Analgesic System: Pain Mgmt & Tex Tapes… Decrease edema, decrease sensory stimuli to mechanical receptors Decrease inflammation, decrease irritation of chemical receptors Possibly activates spinal inhibitory system -through stimulation of the touch receptors in the skin Gate Control Theory
Muscle Function Improves contraction of a weakened muscle Reduces muscle fatigue Reduces over-extension and overcontraction (depends on application used) Increases Range of Motion Relieves pain
Muscle Function: Facilitation/Muscle Assist Origin to Insertion Deltoid Facilitation Origin, tape anchor
Direction of tape shrinkage back to origin/anchor
Insertion
Muscle Function: Rest/Inhibition Insertion to Origin Deltoid Inhibition
Origin
Direction of tape shrinkage is back to insertion, or in an elongation direction
Insertion, tape anchor
Lymphatic Function Improves blood and lymphatic circulation Opens lymphatic drainage directly under skin Reduces excess heat and chemical substances in tissue Reduces inflammation Reduces abnormal feeling and pain in skin and muscle
Tex Taping Effects on Lymphatic Drainage Convolutions in the tissue under the tape cause microclimates of pressure change Gentle lifting of the skin reduces pressure, and tensions filament connections to blind-end lymph tubules allowing large molecule movement Closed fluid system responds to decreased pressure channels under tape allowing high pressure (edema) to flow to low pressure (under tape, back to nodes) Decreased pain b/c decreased stimulation to pain receptors (chemical and mechanical) and ascending Gate input
By Tracey Edblom, OTR/CHT
Deep Collecting Vessels (have smooth muscle walls)
Joint Function Adjusts misalignment caused by spasm and shortened muscle Normalizes muscle tone and abnormality of fascia involved Improves range of motion Relieves pain
*Benefits of Tex Taping Assists in re-education of a weakened muscle Helps reduce muscle fatigue Increases ‘quick’ end-feel to assist in limiting over-extension (proprioception) Enhances muscle relaxation to decrease overcontraction of muscle tissue Reduces occurrence of cramping Reduces Pain
Benefits of Tex, continued Reduces inflammation Reduces edema Assists in improvement of range of motion Aids in removal of hemorrhages Assists in overall joint function
Qualities of Tex Tape which Make it Unique Elasticity of up to 130-140% of resting length 100% Acrylic heat sensitive adhesive Stretches along longitudinal axis only Thickness and weight approx. same as skin, so skin is not over-stimulated No medicinal properties in tape, and NO LATEX Able to be worn for several days, able to shower with tape applied Tape is applied to substrate with a 10% stretch
Application of Tex Taping Joint is moved through a full range of motion prior to completing tape application X, Y, I & Fan tape cuts are used, with the “Y” & “I” cut being the most common 1”, 2” & 3” tape are available, with 2” being the most commonly used
Cutting of Tex Tape
Fan Cut X Cut Y Cut I Cut
Application of Tex Taping Tape is applied to stretched tissue, minimal stretch is added to the tape ( O to I, approx. 15% of the full 40% capability, I to O basically laying the tape down 5-10% stretch)
Tape is slightly stretched if applied to non-stretched skin Tape is applied with all elastic stretch taken out only when used as a corrective technique
Application of Tex Taping Skin should be free of oils and dry, spray or wipe adhesive can be used After application, lightly rub the tape to activate the heat sensitive adhesive Tape application in moist areas, may want to use water resistant tape Tape both the pain, and cause of the pain
There are a variety of skin adhesives on the market that will help tape stick to oily, sweaty, or frequently washed palms
Limitations of Tex Taping Body hair may need to be clipped or shaved Apply approx. 30 minutes before activity Application during activity, may require the use of a tape adherent Patient understanding & willingness to wear tape for multiple days, or in public
Initial Difficulties in Application Training for use of athletic tapes teach the need to “pull tape” for support Need to treat both the pain and the cause of pain, providing for correction of symptoms Proper muscle evaluation critical in obtaining positive results, also knowledge of the Lymphatic system helpful Unlearning what “tape” can be used for
General Benefits of Using the Tex Taping Method More Economical Easy to Apply Less Types of Tape Applied For a Longer Period of Time (application generally lasts 3-4 days)
Removal of Tex Tape Remove in direction of hair growth Use fingers to pull skin away from tape while depressing skin inward Remove tape while wet such as in shower If particularly sensitive to removal, apply mineral oil (or other) to help weaken adhesive
Precautions - Contraindicatio Allergy or immune system compromise - test strip Open Wounds - tape around Fresh scars < 6 weeks Lymphedema - must know pathways Newly Irradiated skin Sensitive skin areas Skin itching Pregnancy - selective acupuncture points
Reimbursement Options Insurance: Bill your time/intention of Rx Medicare vs. WComp Patient Sales vs. self-ordering Untimed Taping/Strapping Codes: Taping Shoulder 29240 Elbow/Wrist 29260 Hand/Finger 29280
Thoracic Outlet Syndrome Compression of the Brachial Plexus &/or subclavian ar ter y and vein, may be due to muscle involvement via ner ve entrapment Pectoralis Minor Subclavius Scalenes to
A thorough evaluation is required identify the cause
Prepare a Y tape
Anchor tape with apex of Y at the coracoid process
Lay tails at an angle directed towards the sternum
Have pt retract & elevate the scapula. Lay superior tail at a more oblique angle toward R-3
Inferior tail is directed more vertical toward R-5
Finished
Cut an I strip
Anchor tape at distal 1/3 of inferior edge of clavicle
Abduct & externally rotate shoulder
Lay tape along the contour of the clavicle
Finished
Scalenes (anterior, posterior, medius, and minimus) Can be taped exactly as in SCM Remember to pre-stretch the specific muscle according to it’s anatomy Always tape both sides of the neck in a mirror fashion – it is tolerated better by pts and is less likely to cause other muscle tension or headache Stretch the skin, not the tape, for increased tolerance of tape on necks
Finished
Lateral Epicondylitis Wrist Extensors & Supinator Group 1
Anchor Y tape at extensor surface of wrist.
2 Flex wrist, extend elbow and place lateral tape leg along lateral edge of extensor muscle compartment. 3
Place medial tape leg along medial edge of muscle compartment.
4
Fully pronate forearm & place I strip anchor lateral to the insertion point of extensor muscle mass.
5 Extend tape over muscle belly continuing to the medial side of forearm.
Measure a length of tape from the styloid process to just above the supinator tendon origin
Identify the musculotendinous junction. Cut tape into a Y configuration with apex of Y at the musculotendinous junction
Place anchor above the styloid process with apex of Y at the musculo-tendinous junction
Lay tails over the extensor musculature
Flex wrist, pronate forearm, extend elbow. Lay medial tape along the edge of the muscle.
Finish tape tail over the common tendon origin above the elbow.
Measure a length of tape from above the tendon origin to medial to the insertion
Have pt pronate forearm. Anchor tape above tendon origin.
? Is this pt in acute pain phase or strengthening?
Lay tail across muscle belly. Wrist remains flexed.
Finished
What nerve is commonly involved here? What would you do if they were acute? What if it were misdiagnosed?
Medial Epicondylitis Forearm flexor muscle mass 1 Anchor Y tape at volar aspect of wrist. Extend & supinate wrist. Position lateral tail of tape along lateral aspect of medial forearm muscle compartment. 2 Position medial tail of tape along medial aspect of muscle compartment. 3
Tails may overlap above tendon origin.
4 Anchor I tape above tendon origin and direct tape across muscle belly with forearm in maximum supination.
No tension on ends
Position wrist in extension to place tissue on stretch – increases convolutions and muscle decongestion
Split tape at musculotendinous junction to surround muscle belly to decongest and relax muscle tissue
No tension at ends again for dispersal of forces
Medial Epicondylitis With Pronator relaxed
DeQuervains Syndrome 1st dorsal compartment syndrome APL and EPB Most common in women Frequently have additional slips of tendon in the same compartment Complicated by superficial radial nerve involvement (often)
DeQuervains Radial Splint
Optional long thumb spica if symptoms are very severe
Muscle Inhib. & Space Correction
Measure a length of I tape from tip of thumb to upper 1/3 of forearm.
Split tape to 1 in. width.Create a Y tail at distal end of tape approximately 1 in. long.
NOTE: You may want to keep the tape at its 2” width – this has been very successful as it seems to stay in place longer and give the relaxation message to more tissue.
Wrap tails of Y around the distal phalanges
Apply remainder of tape to the extensor pollicis brevis & abductor pollicis longus
Prepare a ‘space correction’ tape by measuring an I tape sufficient to encircle ½ the wrist.
Prepare a Space correction tape. Use 25-50% stretch to the area over the snuff box. Allow tape to recoil so ‘space’ is created. Remember not to apply tightly or you risk compressing superficial branch of radial nerve
1st CMC Osteoarthritis Primary site of OA in the hand Can be VERY painful/dysfunctional Frequently leads to surgical solution Conservative methods relieve pain, but often contribute to further shortening and wasting of thenar musculature
Joint Tapings generally… Are applied with more stretch Are applied with more downward pressure Are intended to affect deeper structures
Structures Necessary for Stability of CMCJ SAOL – sup.ant.oblique lig DAOL – Deep.ant. Oblique lig (‘beak’ lig) ** DRL – dorso-radial lig POL – Post.oblique lig UCL – ulnar collateral lig IML – interMC lig DIML – doral interMC lig
Structures Necessary for Stability of CMCJ INTRINSIC MUSCLES Originate on trapezium Abductor Pollicis Brevis Opponens Pollicis Flexor Pollicis Brevis Adductor 1st dorsal interosseus muscle
Muscular Balance: CMC PRIME MOVERS:
SECONDARY MOVERS:
Flex: FPL, FPB Ext: EPL Add: AP Abd: APL, APB Rot’n: OP
Flex: AP, OP Ext: EPB Add: EPL, FPL Abd: EPB, OP Rot’n: EPL, FPB, APB
Note: 2 muscles that act ONLY on the CMC
Differential Diagnosis CTS Ganglia deQuervains Other tendonitis Intersection syndrome Scaphoid injury or Scapho-lunate lig injury
Subluxation Patterns: Most common – dorsal subluxation (thumb pulled more strongly into flexion) Second most common pattern – radial subluxation (thumb pulled more strongly into adduction)
CMC OA Evaluation, cont’d PROVOCATIVE TESTS Palpation Distraction Grind Test Torque Test (axial rotation) Stress Test (loading)
CMC OA Traditional Rx Patient education Pain and edema management Anti- inflammatory CMCJ mobilization, AROM, AAROM Isometric strengthening Joint protection strategies Splinting Taping
CMC Stabilization, Splint Option – MP Free
Palmar Style Thumb Opposition MCP Included
With permission from D. Slonaker, OTR/CHT
CMC OA Tex Taping (rationale) Decrease swelling Relax & decongest thenar spasms Provide support for dorsal intermetacarpal and trapezio MC ligaments Support CMC joint function Proprioceptive stimulation to muscles opposing CMC joint collapse
CMC OA Taping –Ligament and Joint Support Trapezio-MC and Intermetacarpal LIgaments
With permission from D. Slonaker, OTR/CHT
CMC Supination Assist Taping Full stretch across volar CMCJ With permission from D. Slonaker, OTR/CHT
CMC Supination Assist – cont. Light stretch to dorsal forearm. With permission from D. Slonaker, OTR/CHT
CMCJ Supination Assist - cont.
Extra support around wrist With permission from D. Slonaker, OTR/CHT
See Appendix A & B – Back of Manual
With permission from Jan Albrecht, OTR/CHT
PIP Dislocation/Trauma
PIP Dorsal Dislocation
Initial treatment, rested in PIP extension
Coban as early edema control
DIP mobilization, blocking exercises for intrinsic restoration
Splint for PIP extension if not recovered after edema controlled
Merit screw to assist in IP flexion recovery
Blocking exercises with splint
PIP blocking exercises – no splint
Buddy taping for flexion and function recovery
Mechanical correction for PIP collateral ligament sprain
Dorsal tape for increased edema drainage, decreased pain, increased ROM. If successful, pt will have increased function, too
Note that you could preload PIP &/or DIP in ext. to protect pt from ROM that activates pain signal and progress taping as pt improves
Persistently tender collateral ligaments may require extra support/reinforcement with additional ½ inch diagonals
Mallet Finger
Custom bobsled or a Stack splint uninterrupted for 6-8 weeks
Lateral conjoined extensor tendon Common extensor tendon Lateral fibers Lateral tendons interossei
Common extensor tendon Central fibers
Common extensor tendon
Additional volar tape for relaxation/elongation of flexor structures, removal of additional edema
Dorsal tape for edema removal, pain reduction…..
….With mechanical correction to assist DIP extension. Can also be done in one long strip volar to dorsal – watch tip pressure.
DIP remains extended on tenodesis, though pt can flex, also has assist back into extension – needs daily retaping.
End a.m. Program
Current Cases Group brain-storm for tape solutions
Intro to Advanced Taping Concepts
Mechanical Correction ”Positional” in nature, to assist in the positioning of muscle, fascia or joint position to stimulate a perception that results in the body’s adaptation to the stimulus.
Fascia Correction Tape application incorporates gathering of tissue during application or pre-gathering of tissue and taping to maintain gathered dimension of tissue for improved circulation and tissue extensibility
Space Correction Tape application lifts tissue and reduces pressure by creating space above injured tissue thereby reducing fluid pressure, improving circulation and clearing inflammatory components (reducing stimulation to chemical and mechanical pain receptors)
Ligament/Tendon Correction Joint is positioned in stretch before pain occurs. With tape applied at increased stretch, mechanoreceptors (golgi tendon organs) are primed for muscle contraction earlier to prevent entering ROM where pain occurs and tissue is additionally strained (75-100% for ligaments, 25-50% for tendons)
Functional Correction Tape is applied to increase sensory stimulus in an area as well as to assist or limit a motion Perceived stimuli are interpreted as proprioceptive stimuli, which acts as a preload during end of motion positions
TFCC Components Dorsal and volar radioulnar ligaments Ulnar collateral ligament Meniscus homologue Extensor carpi ulnaris sheath Ulnolunate and ulnotriquetral ligaments TFC disc proper “TFCC maintains stable but moving relationship of radius and ulna during pronation and supination”
TFCC
Ulnolunate Lig Ulnotriquetral Lig
Volar Radioulnar Lig
Meniscus Homologue
TFC Articular Disc
Problem-Solve TFCC Corrective/Functional Tapings
Tape for acute symptoms, edema/pain Tape for support, light activity, gentle strengthening activities
Ulnar collateral support with mechanical correction. Remember it is “positional” not just space correction
Support ulnotriquetral as well as dorsal and volar stability
Additional dorso-volar support
Space correction above painful area for edema/pain reduction
Complete circumferential taping with <25% stretch for improved proprioception and stability
Additional ECU inhibition for improved resting, decreased edema in sheath. May be under or over the circumferential taping.
Scapho-Lunate Ligament Strain/Sprain
Scapho-lunate dissociation
Often not completely ruptured, needs rad/uln dev. XR and AP clenched-fist XR to confirm diagnosis SL dorsal component
SL volar component SL proximal component
Problem-Solve SL Lig Sprain Is pain/instability more volar? Is pain/instability more dorsal? Consider other treatments…tape & splint combination? How could a k-tape regimen progress?
“Scapholunate dissociation is the most common form of carpal instability” – Hunter.
S-L sprains frequently from falls with contusion of volar aspect with localized pain and edema
Star pattern tape will increase proprioceptive message to limit wrist extension or weight-bearing as well as assist in removal of edema and inflammatory by-products.
Complete with CMC taping to support light thumb function
Optional repeat to CMC taping
Soft Tissue Tapings generally… Are more variable depending on the degree of sensory/proprioceptive input desired, and the tolerance of the tissue being taped Involve more combined tapings such as a scar taping (more tension) with a fascial release taping (less tension) to improve ROM, or an edema taping combined with a mechanical correction taping to limit or assist a specific soft tissue motion
NERVES: Carpal Tunnel Cubital Tunnel Radial Tunnel
Nerve Entrapment A thorough evaluation is necessary to determine the cause and location of the entrapment. Muscle spasm, fascial restriction or poor patient posture can individually or in combination cause a nerve entrapment. Two methods of dealing with this problem utilizing Tex Tape are: Space correction - The tape is applied to create a space in an area of inflammation/pain, OR, To improve circulation, stretch tape lightly and apply it over elongated tissue. This will result in the creation of convolutions in the tissue as the tape recoils. This creates a lifting effect on the skin, decreasing pressure in the underlying tissues improving lymph and vascular flow length of nerve.
Nerve Entrapment cont’d Fascial correction - achieved by either of the following techniques: 1 The tape anchor is applied with a vibration created by a rapid pulling of the opposite end of the tape while maintaining a constant tension on the tape. This will relax the tissue and allow a release of the fascia. When this is achieved, apply the remainder of the tape to the skin. 2 Anchor the tape and achieve a myofascial release of the tissue by moving the fascia in the opposite direction. Then apply the tape across the structure to use the elasticity of the tape to facilitate the desired movement
Carpal Tunnel Volar Splint
Carpal Tunnel Volar Splint
Carpal Tunnel: X Strip Taping
Carpal Tunnel X Strip
Carpal Tunnel X Strip & Space Correction
Edema Management: “Tab and Tails”
Carpal Tunnel “Glove” Taping
“Glove” Tape Application
“Glove” Taping continued
“Glove” Taping Completed
Measure a length of I tape sufficient to encircle ¾ of the circumference of the wrist
Apply anchor with 100% stretch applied to tape
“Glove” with Dorsal Wrist Space Correction for drainage
CARPAL TUNNEL RELEASE Post-op; Open approach in an elderly woman with long-standing symptoms 3 weeks post-op
Split tape in center
Place tissue on stretch, tape at 90% stretch, and apply, no tension on tails
Finished. This taping helps with scar modeling, decreases local tissue edema, and helps with mild post-op dysesthesia and hypersensitivity. Pt’s can manage this one easily on their own
Radial Nerve Pain and/or numbness with stretch and/or manual compression of radial nerve. May need decompression from above elbow, spiral groove, under ECRL, to arcade of Frohse, supinator, and possibly EDC. Check distally as nerve becomes more superficial Treat conservatively with nerve mobilization home exercise program, iontophoresis & ergonomic education Tex taping will enhance circulation and reinforce ergonomic training
Apply 1” width tape distal to proximal following radial nerve path. Make sure wrist is flexed, elbow is straight, and forearm is pronated as tolerated to mobilize tissue over nerve. Consider fascial gathering especially over areas of greatest irritation.
Quiet supinator with inhibition tape, or use space correction, or use fascial correction directly over most irritated area as identified by pt.
Horizontally adduct arm as you apply proximal portion of tape over spiral groove, extending to posterior shoulder CAN be helpful
Ulnar Nerve As with radial nerve, frequently there is more than one irritated area. Identify most irritated area and check length of nerve with upper limb tension test Tape length of nerve if necessary making positional adjustments that coincide with ulnar nerve tension test
Begin over guyons canal, with wrist in extension
With wrist extended, continue to elbow with elbow in approx. 90 degrees flexion
Continue along nerve pathway with a triceps stretch position till tape reaches posterior axilla
Then horizontally adduct arm and continue tape application toward spine Finished ulnar nerve taping
Post Traumatic / Surgical Hand Edema 1 Requires I strip with buttonhole cut. Tear paper backing at tape’s crease. 2 3
Peal back paper & place digits 3 & 4 into cut openings. With wrist flexed, apply tape proximally on extensor surface of forearm to extensor tendon origin.
4 Repeat with flexor surface tape with wrist extended apply tape proximally to flexor compartment tendon. You may use a wrist pain tape for decompression of the carpal tunnel.
Measure an I tape to the elbow joint as above
Crease the tape in half
Cut a diamond from the creased end large enough for pts finger to fit thru.
Cut a second diamond
Break paper at crease
Fold back the ends of the backing paper
Insert pts 3rd & 4th digits thru the diamond cuts
Have pt flex wrist & apply the tape to the dorsum of the hand.
Apply tape to the forearm extensors to the tendon origin.
Extend pt’s wrist & elbow. Apply tape to the palm of the hand.
Apply tape to the forearm pronator muscle group.
Extend tape over the pronator tendon & lymph nodes
Apply a space correction tape to the dorsum of the wrist. This lifts the tissue, creates low pressure channel for lymph to drain
Direction of lymphatic flow, palmar
Direction of lymphatic flow, dorsal
Surgical Hand Edema
Add a dorsal tape to crisscross tails of tape. This creates even greater variations in pressure. Remember To combine with pt’s regular home exercise program.
Begin at cubital nodes, with skin stretched
Lay tails down over stretched skin with approximately 5-10% stretch, or paper-off tension.
Lay tails of second layer directing edema to dorsal upper arm, with skin stretched (in this case, with wrist flexed, elbow extended)
Change position of joints as needed to maintain stretch on skin, to pt’s tolerance.
High pressure
Low pressure
SCAR Management Dupuytrens Burn scars
Dupuytren’s Disease
Genetic predisposition to fascial shortening/thickening in palms with gradual loss of extension of MCP &/or PIP joints Usually affects 1-2 digits in both hands, worse in one hand More common in ulnar half of hand, radial disease usually indicates more severe disease Associated with epilepsy, alcoholism, and diabetes bu also idiopathic with no other disease presentation Resolved surgically or Xiaflex collagenase inject
SCAR MANAGEMENT: Dupuytrens Release 4 weeks Post-op
Carefully assess your pt’s phase of healing and decide how best to cover and maintain coverage of scar tissue
Apply individual scar tapes can be applied with fascial gathering. Increase tension and durability (stimulate lymphatic drainage) with buttonholed cover tape.
Finished palmar view
Have pt make a fist for completion of tape over stretched skin. Finished dorsal view
Remember this hand, 4 weeks post dupuytrens release…
2 Weeks later…and it looks even better now!
Dupuytrens Alternatives Extension assist Lymphatic drainage Nerve pain, hypersensitivity
Burn Scars There is no data/studies re: use of kinesiology tape on burn scars MDs and pt were skeptical until visual results after just 2 tapings Pt was able to DC use of Jobst glove and utilize Tex Tape independently
Burn Scars from a scald after 14 months. Utilized Tex Tape in order to discontinue use of Jobst glove. Scar changed dramatically in color and in texture. Continually improved with weekly applications for almost 1 year. Pt did make generous use of lotion applications between tapings.
1” dorsal strips applied with 25% stretch to fully flexed digits
Web space tapes have 25-50% stretch over stretched skin
Continue to apply ends with minimal stretch to maximally stretched skin on palm….
….and dorsum of hand
Stabilizing straps to palm and digits
Apply dorsal portions with skin stretched so as not to limit pt’s motion
Small ¼” anchor tapes added to fingers helps with durability of tape between sessions
Surgical Scar Management Scars respond to Tex taping with decreased turgidity, increased smoothness/softness Photograph scars when possible as color changes may be harder to document and can be very dramatic! Try fascial gathering or utilizing tape rebound over a tight ganglion cyst excision scar. This works very well to increase mobility at the same time! Consider changing direction of application with repeated applications to decrease restriction in another area as first area improves
CMC Interposition Arthroplasty And Carpal Tunnel Release 6 Weeks Post-op
Dorsal scar will not glide distally to allow full thumb flexion
Scar most adherent here
Volar wrist scar will not glide proximally
Carpal Tunnel scar also tight and ‘full’
Post-op scar management taping as previous
Scar management with fascial release, distally
Apply tape distal to proximal so recoil of tape is distal
Wrist scar taped proximal to distal to increase wrist extension and decrease ‘tight’ sensation on flexion
Remember to encourage pt to utilize tissue actively while wearing tape, will further encourage adaptation
Current Cases Group problem-solving for tape solutions
HAPPY TAPING!!!! Q&A More cases? Adjourn Thank you for having me