Rajiv Gandhi University of Health Sciences, Karnataka
Bangalore
ANNEXURE II
1. / Name of the Candidate and Address (in block letters) / BIJU CHETRIDR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY
VIDYANAGAR
KULOOR,MANGALORE-575013
2. / Name of the Institution / DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY
3. / Course of Study and Subject / MASTER OF PHYSIOTHERAPY
MUSCULO SKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY
4. / Date of Admission to Course / 22nd May, 2010.
5. / Title of the Topic / COMPARATIVE STUDY BETWEEN EFFECTIVENESS OF TAPING WITH IONTOPHORESIS AND TAPING ALONE IN CHRONIC PLANTAR FASCITIS
6.
7.
8. / BRIEF RESUME OF THE INTENDED WORK:
6.1) INTRODUCTION AND NEED OF THE STUDY:
Plantar fasciitis is a painful condition caused by microtrauma to plantar fascia due to overuse. It is common in sports which involve running, dancing or jumping. It is a degenerative abnormality of the planar fascia that affects upto 10% of the general population1.
Plantar fasciitis causes pain and stiffness in the heel and medial arch of the plantar surface of the foot and can interfere considerably with activities of daily living. It is common in the community and prevalent among those participating in running sports2,3.
Patients with plantar fasciitis report pain and/ or stiffness localized to their heel which may extend distally to the arch of the foot. The typical patient describes symptoms during the first steps after rising in the morning. In most patients these symptoms vary in intensity and may settle or resolve after a variable period from a few steps to a few hour. In most cases symptoms then increase as the day progresses. On palpation of the heel, tenderness is focal and localized to the medial calcaneal origin of the plantar fascia4,5,6,7.
Various treatment strategies including orthosis, stretching, taping, extracorporeal shockwave therapy, laser therapy and drug therapy in the form of systemic medication, percutaneous injection and topical application have been investigated and have shown variable clinical benefit7,8,9,10,11,12,13,14,15.
Taping technique is one of the most frequently used treatment for plantar fasciitis. It is thought that supportive tape reduces the symptoms of plantar heel pain by reducing strain in the plantar fascia. It supports the longitudinal arch of the foot. It has been shown to reduce peak plantar pressure of normal feet during gait, especially the peak plantar pressure of the medial midfoot. Hence it plays an important role in the management of plantar fasciitis12,16.
Iontophoresis is a technique in which medically useful ions are driven through the patients skin into the tissues. The basic principle is to place the ion under an electrode with the same charge. Example: negatively charged ion is applied on cathode. This electrode would then be known as the active electrode. A constant current is then applied and then the ion is electrically propelled into the patient17.
Plantar fascia stretching has been proved to give beneficial effect in plantar fasciitis. It is given with the aim of suppressing pain and restoring mechanical function of the plantar fascia for gait improvement. Stretching of plantar fascia and the posterior leg muscle is one of the most commonly indicated therapeutic alternative18,19.
Need of the study:
Various studies have been done using taping as an intervention in the treatment of plantar fasciitis and have concluded taping as an effective form of intervention in the treatment of plantar fasciitis12,16.
Other studies have also been done using iontophoresis as an intervention in the treatment of plantar fasciitis and have shown significant improvement with iontophoresis17.
But there are no studies which have been done comparing the combined effect of iontophoresis with taping and taping alone in the treatment of plantar fasciitis by relieving pain and increasing function.
Research Question:
Whether the combined effect of taping with iontophoresis will bring better improvement in patients with plantar fasciitis as compared to taping alone?
Hypothesis:
Null hypotheses:
There will be no significant difference between taping with iontophoresis and taping alone in reducing pain and increasing function in patients with plantar fasciitis.
Alternative hypotheses:
There will be significant difference between taping with iontophoresis and taping alone in reducing pain and increasing the function in patients with plantar fasciitis.
6.2) REVIEW OF LITERATURE:
Joel A Radford et al– 2006 performed a study to check out the effectiveness of low dye taping for the short term treatment in heel pain using 92 participants randomly allotting into two groups. Group A received low dye taping and sham ultrasound and Group B received sham ultrasound for a period of 1 week and results concluded that group receiving low dye taping and sham ultrasound produced beneficial effect by relieving pain and improving function than the other group20.
Russo S J, Chipchase S – 2001 conducted a study on the effectiveness of low dye taping on peak plantar pressure of normal feet during gait and found out low dye taping is an effective form of intervention in decreasing peak plantar pressure of normal feet during gait especially peak plantar pressure in the medial midfoot21.
T. M. Van de Water et al-2010 carried out a systemic review to check the efficacy of taping in the treatment of plantar fasciitis and concluded that taping is effective form of treatment which produces superior effect in the treatment of plantar fasciitis22.
Lynch B M et al-1998 conducted a study on various conservative treatment approaches for plantar fasciitis and found out taping produced a significantly greater effect than compared to other treatment approaches23.
H R Osborn and G T Allison-2006 performed a comparative study on the effectiveness of acetic acid and dexamethasone in iontophoresis and concluded acetic acid in iontophoresis produced significantly better effect in reducing pain than dexamethasone in iontophoresis24.
Gudeman S D et al-1997 conducted a randomized double blinded placebo controlled study to check effectiveness of iontophoresis in plantar fasciitis using 0.4% dexamethasone and concluded iontophoresis to be an effective form of treatment in plantar fasciitis25.
Benedict F Digiovanni-2003 performed a prospective clinical study using two different stretching approaches such as plantar fascia stretching such as tendoachillis stretching protocol in the treatment of chronic plantar fascitis and outcome measure revealed that the plantar fascia stretching programme produces beneficial effect in reducing pain, improving function and high rate of satisfaction than in patients with plantar fasciitis26.
Barry L D-2002 performed a retrospective study between two protocols such as Gastrocnemius-Soleus stretching versus night splinting in the treatment of plantar fasciitis and found out that Gastrocneimeus-Soleus stretching produced greater beneficits than the application of night splint alone in the treatment of plantar fasciitis27.
Shih- Heuy Wu, Huey-Wen Liang et al-2008 performed a study to evaluate the reliability and validity of foot function index among patients with plantar fasciitis and the results concluded the foot function index to be a very reliable and valid outcome measure to assess pain and disability among patients with plantar fasciitis28.
Boonstra AM et al-2008 carried out a study to determine the Reliability and Validity of the Visual Analogue Scale for disability in patients with chronic musculoskeletal pain and they conducted that reliability of the VAS for disability is moderated to good and a strong correlation with the VAS for pain29.
6.3) OBJECTIVES OF STUDY:
1. To find out whether the application of taping combined with iontophoresis can reduce pain and improve function in patients with plantar fasciitis.
2. To find out whether the application of tapping alone can reduce pain and improve function in patients with plantar fasciitis.
3. To compare the efficacy of taping combined with iontophoresis versus taping alone to reduce pain and improve function in patients with plantar fasciitis.
MATERIALS AND METHODS :
7.1) Study Design:
Experimental Design (Comparative Study).
7.2) Source of data:
Patients suffering from plantar fasciitis referred to physiotherapy by a physician/othropaedic surgeon in and around Mangalore.
7.2(I) Definition of Study Subjects:
A sample size of 50 patients in the age group of 30-60 years with 25 in each of the two groups will be there for the study.
7.2(II) Inclusion and Exclusion Criteria:
Inclusion Criteria:
1. Unilateral symptomatic plantar fasciitis
2. Both males and females
3. Age group 30-60 years.
4. Chronic plantar fasciitis (3 months of more)
Exclusion Criteria:
1. Allergic to acetic acid and tape.
2. Contraindicated for iontophresis.
3. Specific pathology from trauma or other co existing symptomatic foot pathology requiring treatment.
4. Calcaneal stress fracture, gout bone tumor, osteomyelitis, diabetes.
5. Surgery for Plantar Fasciitis within previous 6 months.
6. New orthotics or corticosteroid treatment in the previous month .
7.2(III) Study Sampling Design, Method and Size:
Sample design:
Purposive sampling technique which is randomly assigned into two groups, Group A and Group B.
Sample size:
A total of 50 subjects fulfilling the inclusion and exclusion criterias.
7.2(IV) Follow Up:
Pre treatment assessment will be taken for pain and function followed by intervention of frequency thrice a week for two weeks. Post intervention assessment will be taken for the same parameters.
7.2(V) Parameters used for comparison and statistical analysis used:
Wilcoxon Signed Rank Test and Manwitney U Test.
7.2(VI) Duration of study:
The study will be conducted over a duration of 12 months.
7.2(VII) METHODOLOGY:
50 symptomatic individuals fulfilling the inclusion and exclusion criterias will be selected and randomly divided into two groups i.e. Group A and Group B, each group consisting 25 members. Informed consent will be obtained from them.
Pre test will be conducted on Group A and Group B by Visual-Analogue Scale for pain and foot function index for function.
GROUP A: Taping and Iontophoresis with Plantar Fascia Stretching.
TAPING:
Procedure:
With the ankle slightly plantar flexed, adhesive felt strip will be applied at the posterior aspect of the heel and firmly pulled towards to metatarsal head. To eliminate binding, a ‘V’ shape will be cut on both the edges of the adhesive felt where the felt crosses the heel area. Once, adequate tension is applied, adhesive felt will be pressed against the plantar aspect of the foot.
A 7.5 cm adhesive anchor strip will be applied from the medial aspect of first metatarsal around the heel to the lateral aspect of the fifth metatarsal head.
A 5 cm elastic tape around the midfoot area will be applied. This circular strip will begin on the dorsal aspect, go lateral and will continue across the plantar aspect of the foot’s medial position, crossing the tape’s end.
A strip of tape will be used to reinforce the tape30.
A total of 6 treatment sessions will be given on alternating days over a period of two weeks.
IONTOPHORESIS:
The patient will be positioned in sitting with leg supported on the floor. One electrode will be placed on the site of maximum tenderness on the plantar aspect of the foot. Other electrode will be placed on the forefoot. The following parameters will be used such as 5% acetic acid will be delivered using iontophoresis drug delivery system (Technomed Electronics, Chennai). Dosage applied will be upto 4 mA and a total dosage of 40 mA for a period determined by patient’s sensitivity17.
A total of 6 treatment sessions will be delivered on alternating days over a period of two weeks.
PLANTAR FASCIA STRETCHING:
Patients will be given plantar fascia stretching for a duration of one minute repeated 10 times with a rest period of 30 seconds in between each stretch26.
GROUP B: Taping and Plantar Fascia Stretching
TAPING:
The treatment will be same as given for Group A.
PLANTAR FASCIA STRETCHING:
The treatment will be same as given for Group A.
7.3) Does the study require any investigations to be conducted on patients or other human or animal? If so, please describe briefly.
YES.
Visual-Analogue Scale29- Pain Assessment.
Foot Function Index28- Functional Assessment.
7.4) Has ethical clearance been obtained from your institution in case of 7.3.
YES
LIST OF REFERENCES:
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3. Kibler WB, Goldberg C, Chandler T J. Functional biomechanical deficits in running athelets with plantar fasciitis. Am J Sports Med 1991. 1966-71.
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9. Gross M T, Byers J M, Krafft J L et al. The impact of custom semirigid foot orthotics on pain and disability for individuals with plantar fasciitis. J Orthop Sports Phys Ther 2002. 32149-157.
10. DiGiovanni B F, Nawoczenski D A, Lintal M E. et al. Tissue specific plantar fascia stretching exercise enhances outcomes in patients with chronic heel pain. A prospective randomized study. J Bone Joint Surg [Am] 2003. 851270-1277.
11. Lynch D M, Goforth W P, Martin J E. et al. Conservative treatment of plantar fasciitis. A prospective study. J Am podiatry Med Assoc 1998. 88375-380.
12. Scranton P E, Jr, Pedegana LR, Whitesel J P. Gait analysis. Alteration in support phase forces using supportive devices. Am J Sports Med 1982. 106-11.
13. Basford J R, Malanga G A, Krause D A. et al. A randomized controlled evaluation of low intensity laser therapy: plantar fasciitis. Arch Phys Med Rehabil 1998. 79249-254.
14. Cunnane G, Brophy D P, Gibney R G. et al. Diagnosis and treatment of heel pain in chronic inflammatory arthritis using ultrasound. Semin Arthritis Rheum 1996. 25383-389.
15. Japour C J, Vohra R, Vohra P K. et al. Management of heel pain syndrome with acetic acid iontophoresis. J Am Podiatr Med Assoc 1999. 89251-257.
16. Hlavach. The foot book. Mountain view, CA: World Publication, 1977.
17. John Low and Ann Reed. Electrotherapy Explained Principles and Practice. Third Edition. 41-49.
18. Carvalho A E, Imamura M, Moraes Filho D C. Talalgias. In: Hebert S, Xavier R, Pardini A G, Barros Filho, editors. TEP Ortopedia e traumatologia: principles e practica. 3a ed. Porto Alegre: Artmed; 2003. Pp. 550-6.
19. Imamura M, Carvalho A E, Fernandes T D, Leivas TP, Salomao O. Fasciite plantar: estudo Comparativo. Rev Bras Ortop. 1996; 31: 561-6.
20. Joel A Radford, Karl B Landorf, Rachelle Buchbinder and Catherine Cook. Effectiveness of low dye taping for the short-term treatment of plantar heel pain: A randomized trial. J BMC Musculoskelet Disord 2006; 7:64.
21. Russo S J, Chipchase L S. The effect of low dye taping on peak plantar pressure of normal feet during gait. Aust J Physiother 2001. 47239-244.
22. T M Van de Water and C M Speksnijder. Efficacy of taping for the treatment of plantar fasciosis: A systemic review of controlled trials. J Am Podiatr Med Assoc, January 1st 2010;100 (1):41-51.
23. Lynch B M, Goforth W B, Martin J E. et al. Conservative treatment of plantar fasciitis: A prospective study. J Am Podiatr Med Assoc 1998. 88375-380.
24. H R Osborn and G T Allison. Treatment of plantar fasciitis by low dye taping and iontophoresis: short term results of double blinded, randomized, placebo controlled clinical trial of dexamethasone and acetic acid. Br J Sports Med 2006; 40:545-549.
25. Gudeman S D, Eisele S A, Heidt R S., Jr et al Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone. A randomized, double blinded, placebo-controlled study. Am J Sports Med 1997. 25312-316.
26. Benedict F Digiovanni, Deborah A Nawoczenski, Daniel P. Malay, Petra A Graci, Taryn T Williams, Gregory E Wilding and Judith F Baumhauer. Plantar fasciitis- Specific stretching exercise improves outcomes in patients with chronic plantar fasciitis.
27. Barry L D, Barry A N, Chen Y. A retrospective study of standing Gastrocnemius-Soleus stretching versus night splinting in the treatment of plantar fasciitis. J Foot Ankle Surg 2002. 41221-227.
28. Shih-Huey Wu, Huey-Wen Liang and Wen-Hsuan Hou. Reliability and Validity of the Foot Function Index. J of the Formosan Medical Association. Vol 107, Issue 2. 2008. 111-122.
29. Boonstra AM, Schiphorst Preuper HR, Reneman MF. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. Int J Rehabil Res. 2008;31 (2):165-9.
30. Rose Macdonald. Taping Techniques Principles and Practice. Second Edition. 74-75