6.1 Need for the study :
Plantar fasciitis is a overuse injury causing inflammation at the origin of the plantar fascia and is characterized by plantar heel pain that is provoked with the first few steps in the morning and by prolonged standing.1
In 1812 , wood described this condition, which has been referred to by various synonyms, including plantar fasciitis ,heel pain syndrome, subcalcaneal pain syndrome,calcaneal periostitis, neuritis, heel spur syndrome , subcalcaneal spur syndrome, stone bruise, medial arch sprain ,runner’s heel , joggers heel and policeman’s heel.1,2
It has been reported that 15% of patient who present with foot complaints of heel pain. It is commonly seen in women, obese patient, athletes and people who are required to remain weight bearing for there occupation for long time.3
It is a common disorder in both athletic and sedentary population. Approximately 7%of adult Aged 65 years or older have plantar heel pain plantar fasciitis accounts for about 10% of runner related injuries and 11-15% of all foot symptoms requiring professional care. It is thought to occur in 10% of the general population as well.4
Plantar fasciitis multifactorial in origin factors such as obesity, excessive period of weight bearing activity and decreased range of motion commonly suggested leads to plantar fasciitis.5
Plantar fasciitis is most frequently seen in overweight male runners (BMI > 25 kg/m2) older than 30years of age.6 It is also seen in the nonathletic community among the overweight population and those who spend long period standing.7
The causes of the injury are related most commonly stress and strain. General injury to the plantar fasciitis can be divided into three categories: mechanical, degenerative and systemic.8 Mechanical conditions such as pronation, forefoot varus and rear foot valgus will often lead to increased tension and strain of the plantar aponeurosis. This may be exacerbated by increased activity and lack of proper shoes and in-step support. It is now widely accepted that degenerative changes can occur with in the plantar fascia due to repetitive micro tears and perifascial edema termed plantar fasciitis. This is characterized as a degenerative process of myxoid degeneration without inflammation.9
Low dye (LD) taping is an orthopedic strapping technique of the foot involving the application of tape inferior to the malleoli, and along the plantar aspect of the foot.10
Low dye taping short term treatment such as supportive taping are used to alleviate symptoms during interim period. The low dye taping technique being one of the most frequently used. A systemic review of randomized crossover trials examined the effect of low dye taping on biomechanical variables.5 It is thought that supportive tape reduces the symptoms of plantar heel pain by reducing strain in the plantar fascia during standing and ambulation.11A reduction in strain is achieved by reducing navicular drop upon weight bearing (i.e. arch collapse).12
Low dye taping supports the longitudinal arch of the foot, studies showed that taping significantly reduces peak plantar pressure of normal feet during gait especially plantar pressure in the medial midfoot.13
The low dye taping as affect on plantar pressure of all area of the normal foot during gait. Low dye taping provides an anti pronation and reducing pressure excreted through medial side of foot.14
Obesity and pronated foot posture are associated with plantar fasciitis and may be risk factors for the development of the condition.15
Iontophoresis involves the movement of ions across biological membranes by means of an electric current for therapeutic purposes. It is also called ion transfer.16
Iontophoresis is a non invasive method of propelling high concentrations of a charged substance, normally medication or bioactive agents transdermally by repulse electromotive force using a small electrical charged to an iontophoretic chamber containing a similarly charged active agents and its vehicles.17
The positively charged chamber, termed the cathode will repel a positively charged chemical, while negatively charged chamber, termed the anode will repel a negatively charged chemical into the skin .It uses the electrical impulses from a low voltage galvanic current stimulation unit.17
Studies have shown clinical relevant improvement in plantar fasciitis symptoms using
Iontophoresis. Study suggested that 6 treatment of acetic acid iontophoresis combined with low dye tape give greater relief in term of pain symptoms of plantar fasciitis.13
Very few studies has been done, therefore my aim of the study is to find out the effect of iontophoresis and low dye taping in obese patients with plantar fasciitis.
Hypothesis :
Null hypothesis: There will not be significant difference between low dye taping and iontophoresis treatment in obese subject with plantar fasciitis.
Experimental hypothesis: There will be significant difference between low dye taping and iontophoresis treatment in obese subject with plantar fascitis.
6.2 Review of Literature :
Kieran o'sullivan, Norelee kennedy, Emer o'Neill 1and Una Ni Mhainin (2008) Conducted study to find the effect of low dye taping on rear foot motion and plantar pressure during stance phase of gait they included 20 healthy subjects with a navicular drop test exceeding 10mm participated in the study .They concluded that low dye taping is associated with alteration in peak plantar pressure in the midfoot and forefoot that indicates reduced pronation with low dye taping .Low dye taping appears to reduce both pronation and supination ,when assessed using 3D motion analysis .Therefore it would appear that low dye taping does indeed does reduce pronation by restricting rear foot motion in general rather than pronation specifically .Though degree of change observed with low dye taping was very small.18Ivano A Costa, Anita Dyson, (2007) A 15-year-old female soccer player presented with chronic plantar fasciitis. She was treated with acetic acid iontophoresis and a combination of rehabilitation protocols, ultrasound, athletic taping, custom orthotics and soft tissue therapies with symptom resolution and return to full activities within a period of 6 weeks. She reported no significant return of symptoms post follow-up at 2 months. Acetic acid iontophoresis has shown promising results and further studies should be considered to determine clinical effectiveness. The combination of acetic acid iontophoresis with conservative treatments may promote recovery within a shorter duration compared to the use of one-method treatment approaches.6
Damien B Irving, Damien B Irving, Jill L Cook, Mark A Young and Hylton B Menz (2007) Eighty participants with CPHP (33=m, 47= f) and 80 control. The two groups were then compared on body mass index (BMI), foot posture as measured by the Foot Posture Index (FPI), ankle dorsiflexion range of motion (ROM) as measured by the Dorsiflexion Lunge Test, occupational lower limb stress using the Occupational Rating Scale and calf endurance using the Standing Heel Rise Test. Obesity and pronated foot posture are associated with CPHP and may be risk factors for the development of the condition. Decreased ankle dorsiflexion, calf endurance and occupational lower limb stress may not play a role in CPHP.15
Matthew R. Hyland, Alisa Webber-Gaffney, Lior Cohen, Steven W. Lichtman, EdD,(2006) conducted study on examine the effects of a calcaneal and Achilles tendon taping technique ,utilizing only 4 pieces of tape and not involving the medial arch, on the symptoms of plantar pain.41 subjects were randomly assigned into 4 group: (1) stretching of the plantar fascia,(2)calcaneal taping,(3)control (no treatment), and (4)sham taping. A vas for pain and a patient specific functional scale (PSFS) for functional activities were measured pretreatment and after 1week of treatment (post treatment). They concluded calcaneal taping was shown to be a more effective tool for the relief of plantar heel pain than other treatment and may act as a precursor to long term management through the use of orthotics. It is easy and quick for the therapist to apply, and creates immediate symptoms relief.19
H R Osborne T Allison (2006) conducted study to determine the short term, acetic acid and dexamethasone iontophoresis combined with Low dye taping are effective in treating the symptoms of plantar fasciitis. They involved 31 patients with medial calcaneal origin plantar fasciitis. All subjects received six treatment of iontophoresis (0.4% dexamethasone ,placebo(0.9% Nacl),or 5% acetic acid to the site of maximum tenderness on the plantar aspect of the foot on alternate days over two weeks ,with continous low dye tapings during this time, and instructions on stretching exercise for the gastrocnemius /soleus. Stiffness and pain were recorded at the initial session, the end of six treatments, .And they concluded that six treatment of acetic acid iontophoresis combined with taping gave greater relief from stiffness symptoms than dexamethasone taping .13
Louise potter, chirstopher Mc carthy, Jacqueline Oldham (2006) conducted a study to know algometry reliability in measuring pain pressure threshold (PPT) over normal spinal muscles to allow quantification of anti-nociceptive treatment effects and concluded that PPT assessment by algometry is a reliable, both within session and between session, measure of a subjects pain . This study provides further validity to the use of this measure as a suitable, convenient method of monitoring treatment effects.24
Karl B. Landorf, DipAppSc(Pod), GradDipEd,Joel A. Radford, Anne-Maree Keenan, and Anthony C. Redmond, (2005) conducted a comparative study on 105 participants to find the effectiveness of low dye taping for the short term management of plantar fasciitis. Participants were divided in 2 group, in experimental group 65 participants with plantar fasciitis received taping for 3 and 5 day and in control group with 40 participants did not
received taping . Pain before and after treatment was measured using a vas scale. The vas scale score was improved by a mean of 20mm in the taping group and worsened by a mean of 6mm in the control group. They concluded that in the short term, low dye taping significantly reduces the pain associated with plantar fasciitis.20
Sonia J Russo and Lucy S Chip chase (2001) conducted a study on 40 subjects to Investigate whether low dye tape anti pronation taping altered peak plantar pressure of normal feet during gait. Each subject performed two sets of six walks ,one set with bared foot other set with taped foot with 5minute rest between two sets . Their results showed significant alteration between the barefoot and taped foot for plantar pressure during walking .They concluded that Low Dye anti pronation taping significantly altered peak plantar pressure of normal feet during gait. There was also significant reduction in men plantar pressure observed in the medial midfoot, while significant increase occurred in the lateral midfoot.14
Gulick dt, Bouton k,Racioppi e, Shafferman m (2000) this study was done to examine the effect of acetic acid iontophoresis on heel spur reabsorption in patients diagnosed with plantar fasciitis. In this volunteers of 7 women and 3 men patents were given 5%acetic acid for 2 times a week for 6 week it also consist of dynamic and static stretching ,ROM exercise 2 times a day .Conclusion the density of the calcaneal bones was reduced by acetic acid iontophoresis and symptoms associated with plantar fasciitis can be addressed with therapeutic exercise.21
CJ Japour, R vohra, PK Vohra L Garfunkel and N Chine (1999) it was undertaken to determine the effectiveness of acetic acid iontophoresis in treatment of heel pain. Thirty five patients treated with acetic acid iontophoresis over a 4 year period. Heel pain was rated from 0 to 10. At an average follow up time of 27 months, heel pain levels averaged 0.64, indicating continued reduction in heel pain.22
6.3 Objective of the study :
Ø To compare the effect of Iontophoresis and low dye taping in obese individuals with plantar fasciitis.
7 / Materials and Methods:
7.1 Source of data :
· K.C.G Hospital, Malleshwaram ,Bangalore.
· E.S.I Hospital, Rajajinagar, Bangalore.
· Padmashree clinic of physiotherapy, Bangalore.
7.2 Method of collection of data :
· Population :- subjects with planter fasciitis.
· Sample design :-simple random sampling .
· Study design :- Experimental design.
· Sample size :- 30.
· Duration :- 6 days treatment (every alternative day).
· Duration of treatment time 2weeks.
INCLUSION CRITERIA:
· Age : 30 to 75 years.
· Both genders.
· BMI (> 25kg/m2).
· Subjects having localized pain at the plantar heel, that worsens on first standing or walking after rest.
EXCLUSION CRITERIA:
· Congenital deformities of foot.
· Fracture of foot bone.
· Bursitis.
· Surgery for plantar fascitis in previous 6months.
· Subjects who had received Corticosteroid injection with in past 3month.
Materials required :
· Stimulator ( galvanic current).
· Examination table.
· Two electrodes and leads.
· Two lint pads to cover the electrodes.
· Cotton.
· Water.
· Pressure algometry.
· Tape.
· Spirit.
· Scissors.
· Drug :- 2% diclofenac sodium (NSAIDs).
7.3 Methodology :
Subjects fulfilling the inclusion criteria will be included for the study.
A written consent will be taken from each of the subjects prior to participation.
Instructions are given to the subjects about techniques performed.
30 subjects of plantar fasciitis will be taken and will be dividing into 2 groups (Group A and Group B) and group A as (n = 15) and group B as (n=15). Group A will be treated with iontophoresis and conventional therapy (calf muscle stretching and plantar fascia stretching) Group B will be treated with low dye taping and conventional therapy for 6days every alternative day for 2weeks and out come measures were recorded using visual analog scale and pressure algometry before first treatment session and after six treatment session.
Intervention to be conducted on participants :
Position of patient for iontophoresis : prone position
Active electrode negative electrode placed on tender area and indifferent at the calf region.
2% diclofenac sodium will be used
Intensity = 4mA(dependence on individual tolerance)
Duration = 20Min on every alternative day for 6 days .13
Position of patient taping : sitting with leg extended
The first taping will be applied down from fifth metatarsal head outer and inner border of the foot, repeat 3-4 times. Apply enough tension to avoid the tape wrinkling; it needs to be no tighter.
The second taping is applied across the underside of the foot-starting level with the ankle; apply the tape across the foot from the outside to the inside. Over lap the each strap slightly and keep going until just before reaching the ball of the foot.