Rajivgandhi University of Health Science

Rajivgandhi University of Health Science

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / Name of the candidate and address / Miss. Sharvari Shriram Shahane
Flat no. 26, Ganga Lahari Society,
Behind Pratidnya Hall,
Karve Nagar, Pune-411052,
Maharashtra.
2. / Name of the institution / Kempegowda Institute of Physiotherapy
K.R. road, V.V. Puram,
Bangalore-560004.
3. / Course of the study and subject / Master of Physiotherapy-
(Musculoskeletal disorders and Sports Physiotherapy)
4. / Date of admission to the course / 23rd March 2011
5. / Title of the topic:
THE EFFECT OF MYOFASCIAL RELEASE TECHNIQUE AND STRETCHING VERSUS MYOFASCIAL RELEASE TECHNIQUE AND TAPING IN PATIENTS WITH CHRONIC PLANTAR FASCIITIS.
- A COMPARATIVE STUDY.
6.
7
8 / Brief resume of the intended work.
6.1 Need of the study.
Plantar fasciitis is another word for the deep fascia of the footpad. Frequent load on the fascia can cause micro cracks which can eventually lead to inflammation and degeneration of the connective tissue in the fascia.[1] Plantar fasciitis affects adult population. Approximately 10% of patients with plantar fasciitis have development of persistant and often disabling symptoms.[2] Plantar fasciitis is a most common cause of inferior heel pain. The pain and discomfort associated with this condition have a dramatic impact on physical mobility. The etiology of this condition is not clearly understood and is probably multifunctional in nature. Obesity, occupation- related activity, anatomical variation, poor biomechanics, over exertion and inadequate foot wear and contributing factors.[3] The most common cause of injury is overuse such as running, jobs with prolong standing, etc which allow for repetitive micro trauma to the fascia.[4] The classic presentation of plantar fascia is pain on the sole of the foot at the inferior region of the heel. Patient reports the pain to be particularly bad with the first steps taken on rising in the morning or after extended refrain from weight bearing activity.[5] Other characteristic features of plantar fasciitis includes tenderness to the anterior medial heel, limited dorsiflexion of the ankle. Many treatment options exist, including rest, stretching, strengthening, change of shoes modification with arch supports, anti inflammatory agents and surgery.[3]
The treatment aims at reducing pain and inflammation, reducing tissue stress to a tolerable level, restoring muscle strength and flexibility of involved tissues.[6]
Plantar fascia is plantar aponeuorosis, lies superficial to the muscles of the plantar surface of the foot. The plantar fascia originates on the medial tubercle of the calcaneus and fans out to the flexor tendon sheaths to form the longitudinal arch. Plantar fascia has a thick central part which covers the central muscles of the 1st layer, flexor digitorum brevis and is immediately deep to the superficial fascia of the plantar surface. It acts as a truss, maintaining the medial longitudinal arch of the foot, and assists during the gait cycle and facilitates shock absorption during weight bearing activities.[7]
Myofascial release is a soft tissue mobilization technique. If symptoms are treated in chronic stage, they will be alleviated. Myofascial release techniques stem from the foundation that fascia, a connective tissue found throughout the body, reorganizes itself in response to physical stress and thickness along the lines of tension. [8] By myofascial release there is change in the viscosity of the ground substance to more fluid state which eliminates that fascia’s excessive pressure on the pain sensitive structure and restores proper alignment.[9] Myofascial techniques have been shown to stimulate fibroblast proliferation, leading to collagen synthesis that may promote healing of plantar fasciitis by replacing degenerative tissue with a stronger and more functional tissue. Hence this technique is proposed to act as a catalyst in the resolution of plantar fasciitis.[10]
Taping will help to protect the fascia and allow time for healing to occur. It can also enable patient with severe pain to walk again. The tape should tighten when standing, and should absorb some of the tension that would have been in the fascia. (The pain may be relieved immediately).[11] The kinesio tape acts as a form of support without compromising on the patients range of motion while biomechanically allowing the body to heal itself.[12]
Stretching is a general term used to describe any therapeutic maneuver designed to increase the extensibility of soft tissues, thereby improving flexibility by elongation of the shortened structures. Stretching exercise programs play an important role in treatment of plantar fasciitis and can correct weakness of intrinsic foot muscles. If there is pain with few steps in morning, massage and stretching the fascia itself before getting out of bed may help.[13]
Purpose of the study:
Even though both myofascial release technique and stretching and myofascial release technique and tapping give better effectiveness in treating chronic plantar fasciitis, there is no clear evidence to prove the comparative effect between the two. Thus, there is an effort taken by the researcher to analyze, the effect of myofascial release and stretching and myofascial release technique and taping in chronic plantar fasciitis.
HYPOTHESIS:
Null Hypothesis:
There will not be a significant difference between myofascial release technique and stretching, myofascial release technique and taping in chronic plantar fasciitis patients.
Alternate Hypothesis:
There will be significant difference between myofasical release technique and stretching, myofascial release technique and taping in chronic plantar fasciitis patients.
6.2 Review of Literatures:
Joshua Dubin [2007] studied the evidence based treatment for plantar fasciitis. He concluded that in many cases, conservative care has been found to be successful in alleviating or controlling symptoms related to plantar fasciitis. If conservative care is not effective a cortisone injection may be useful in decreasing pain symptoms. In recalcitrant cases of plantar fasciitis endoscopic conservative surgery is a viable option.[14]
DiGiovanni BF, Nawoczenski DA, et al. [2003] studied tissue specific plantar fascia stretching exercises outcomes in patients with chronic heel pain. They concluded that a program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing achilles tendon stretching exercise for the treatment of symptoms of proximal plantar fasciitis.[15]
Cheung IT, ANKN, Zhang M, et al. [2006] concluded that finite element model suggested that plantar fascia release may provide relief of focal stress and therefore could relieve associated heel pain. The operative procedure may pose a risk to arch stability and clinically may produce dorsolateral mid foot pain. The initial strategy for treating plantar fasciitis should be non operative.[16]
Suman Kuhar [2006] concluded that conservative management approach like physiotherapy in the treatment of plantar fasciitis, is beneficial. The subjects treated with myofascial release techniques showed an additional benefit in terms of reduction of pain on VAS and functional ability in terms of FFI. Hence, it can be concluded that myofascial release technique is an effective therapeutic option in the treatment of plantar fasciitis.[17]
Hyland MR, Webber - Gaffney A, et al. [2006] Examine the effects of calcaneal and Achilles, tendon-tapping technique. A measurement tool VAS is used as assessing for pain and Patient specific functional scale (PSFS)for functional activities and they concluded the calcaneal taping was shown to be more effective tool for the relief of plantar heel pain than stretching, or no treatment (control group).[18]
Osborne HR, Allison GT, et al. [2006] evaluated the treatment of plantar fasciitis by LowDye taping and iontophorosis: short term results of a double blinded, RCT of dexamethasone and acetic acid. They concluded that six treatments of acetic acid iontophorosis combined with taping gave greater relief from stiffness symptoms than, and equivalent relief from pain symptoms to, treatment with dexamethasone/taping. For the best clinical results at four weeks, taping combined with acetic acid is the preferred treatment option compared with taping combined with dexamethasone or saline iontophorosis.[19]
Chien-Tsung Tsai, Wen-Dien Chang, et al. [2010] studied the effects of short term treatment with kinesiotaping for plantar fasciitis. They concluded that the additional treatment with continuous kinesiotaping for one week might alleviate the pain of plantar fasciitis better than a traditional physical therapy program only.[20]
Landor F KB, Radgort JA, et al. [2005] Evaluated the short term effectiveness of low-dye taping in relieving pain associated with plantar fasciitis. By using visual analog scale scores, the results showed the short term, low-dye taping significantly reduces the pain associated with plantar fasciitis. These finding are the first quantitative results to demonstrate the significant therapeutic effect of this treatment modality in relieving the symptoms associated with plantar fasciitis.[21]
Pfeffer G, Bacchetti P, et al. [1999] studied the comparison of custom and prefabricated orthosis in the initial treatment of proximal plantar fasciitis. They concluded that when used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symptoms as part of the initial treatment of proximal plantar fasciitis than a custom polypropylene orthotic device.[3]
Hogan KA, Webb D, et al. [2004] Concluded the patients who had no previous foot trauma and had unilateral symptoms obtained the best results. From this endoscopic release procedure, even patients who had some residual pain in their foot were satisfied with the procedure and with the level of pain relieved that had been achieved. Endoscopic plantar fascia release does appear to benefit selected patients who fail to respond to conservative therapy.[22]
Digioranni BF, Nawoczenssic DA, et al. [2003] Concluded a program of non – weight bearing stretching exercise specific to the plantar fascia is superior to the standard program of weight bearing Achilles tendon - stretching exercise for the treatment of symptoms of proximal plantar fasciitis. These finding provide a alternative option to the present standard of care in the non – operative treatment of patients with chronic disabling plantar heel pain.[23]
Porter D, Barrill E, et al. [2002] Determined that both sustained and intermittent Achilles tendon stretching exercise increase Achilles tendon flexibility. The data suggest that both sustained and intermittent Achilles tendon stretching exercise were effective for non surgical treatments of painful heel syndrome.[24]
Richard MD, Sherwood SM, et al. [2000] Concluded that there was no difference in the amount of inversion restriction when taping with prewrap was compared with taping to the skin, Tape and tape with prewrap significantly reduced the average inversion velocity, maximum inversion, maximum inversion velocity and the time to maximum inversion, Both taping conditions offered residual restriction after exercise.[25]
Cole C, Seto C, et al. [2005] Studied plantar fasciitis: evidence-based review of diagnosis and therapy. A diagnosis of plantar fasciitis based on the patients history and physical findings. Most interventions used to manage plantar fasciitis have not been studied adequately; however, shoe inserts, stretching exercises, steroid injections, and custom made night splints may be beneficial. Extracorporeal shock wave therapy may be effectively treat runners with chronic heel pain but is ineffective in other patients. Limited evidence suggests that casting or surgery may be beneficial when conservative measures fail.[26]
Budiman Mak E, Conrad KJ, et al. [1991] Develop to measure the impact of foot pathology on function in terms of pain, disability and activity restriction. The self administered index consisting of 23 items divided into 3 sub- scales, were both total and Sub – scales scores are produced and was examined for test – retest reliability internal consistency, and construct and criterion validity. Strong correlation between the FFI total and sub- scale scores and clinical measures of foot pathology supported the criterion validity of the index.[28]
6.3 Objectives of the study:
The objectives of the study are:
  1. To find out the effect of myofascial release technique along with stretching in patients with chronic plantar fasciitis.
  2. To find out the effect of myofascial release technique along with taping in patients with chronic plantar fasciitis.
  3. To compare the effectiveness of myofascial release technique and stretching over myofascial release technique and taping in patients with chronic plantar fasciitis.
Materials and Methods:
7.1 Source of Data: Study will be conducted at:
  1. Out Patient Department of Orthopaedics in Kempegowda Institute of Medical Science Hospital and Research Center, Bangalore.
  2. In Patient Department of Orthopaedics in Kempegowda Institute of Medical Science Hospital and Research Center, Bangalore.
  3. Out Patient Department in Kempegowda Institute of Physiotherapy, Bangalore.
7.2 Methods of collection of Data:
(a) Study designs: Randomized study design.
Sample size: 60
Sample design: Randomized study technique.
Materials used :
  1. Assessment form
  2. Consent form
  3. Visual analog scale chart
  4. Foot function Index chart
  5. Adhesive tape
  6. Scissors
  7. Pen, Pencil, Paper
  8. Cotton
  9. Treatment table and pillow
(b) Inclusion criteria :
  1. Females and Males
  2. Age group between 40-60 years.
  3. Clinically diagnosed chronic plantar fasciitis
(c) Exclusion Criteria :
  1. Subjects with clinical disorders such as infective conditions of foot, tumor, calcaneal fracture, metal implant where myofascial release is contraindicated.
  2. History of systemic disease
  3. Skin Disease
  4. History of any major trauma or surgery in and around Ankle joint and Foot.
  5. Subjects with impaired circulation to lower extremities.
  6. Subjects with referred pain due to sciatica and other neurological disorders.
  7. Foot deformities.
  8. Arthritis.
  9. Corticosteroid injections in heel preceding 3 months.
  10. Subjects using inappropriate foot wear.
Parameters of the study:
Intensity of pain and foot function will be the parameters for this study. The intensity of pain will be assessed using visual analog scale (VAS) and Foot Function will assessed using foot Function Index (FFI).
7.3 Intervention to be conducted on Participants (Methodology):
Does the study require any Investigations or Interventions to be conducted on Patients or Humans or Animals? If so, Please describe briefly:
  • Yes, an intervention on patients is required.
Baseline pre treatment measurement of pain intensity (VAS) and foot function (FFI) will be assessed. Again pre treatment measurement of VAS and FFI will be done on day 5 and day 10. The patients will be requested to come back after 1 week and will be assessed for their pain intensity and foot function.
Assessment of pain:
The visual analog scale (VAS) is used to measure pain. A patient is asked to indicate his/her perceived pain intensity along a 100mm horizontal line, and this rating is then measured. Zero is marked on the left end depicting ‘no pain’ and ten is marked on the right end depicting ‘maximum pain’.[27]
Assessment of foot function:
The foot function index (FFI) is used to measure the foot function. The patient is asked to indicate how the foot pain has affected his/her ability to manage in everyday life. There are about 17 questions divided into 3 sections, the subjects have to score their pain and activities according to a scale from 0 to 10. Zero indicates no pain, no difficulty and none of the time. Ten indicates worst pain imaginable, so difficult unable to do and all the time.[28]
- Generate 60 random numbers from computer or random number table.
- Allocate the 2 methods alternatively to the random numbers.
- Print on each slip/paper, random numbers and methods allocated.
- Enclose the paper inside an envelope and seal it. On the envelope, print only random numbers.
- After inclusion and exclusion criteria is verified, explain about the pros and cons of the study to the subjects.
- Take written informed consent.
- Select any one envelope and proceed as per the method selected.
MFR is a soft tissue mobilization technique.[17] The patient is asked to lie prone on a couch with his feet out of the couch. He is given a pillow under his feet for support and patient comfort. The area of treatment is cleaned and dried properly. The therapist evaluates the area of pain. Sustained gentle pressure in the line with the fibers of plantar fascia from calcaneum towards the toes, using the thumb, is given. This pressure is held for 90 seconds.
Frequency: 15 minutes per session[17]
1 minute of rest interval
5 days per week
2 weeks treatment.
Stretching is given specific to plantar fascia. The patient is asked to lie supine and made comfortable. The therapist supports the patient’s ankle with his one hand. With the other hand he gives stretch to the plantar fascia. The foot is kept in neutral position. The therapist places his fingers on the patient’s toes and extends them till the patient feels the stretch on the plantar fascia. The stretch is checked by palpating tension over plantar fascia.[2]
Frequency: 30 seconds hold time
6 repititions
15 seconds rest time between each stretch
5 sessions per week
2 weeks
Calcaneum Taping is done.[18] The patient is asked to lie prone with his feet resting slightly outside the couch. The patient is made comfortable with giving pillows under the feet. The foot is kept in neutral position. One end of the tape is fixed to the patient’s calcaneum from posteriorly and pulled towards the toes from the plantar surface, with slight tension on the tape. Again a second tape is put in figure of eight around the patient’s ankle with slight tension on the tape. Patient is asked for discomfort or elevation of symptoms. If so, then the tape is removed and redone.
Frequency: one session everyday
5 sessions per week
2 weeks.
Group I: 30 Subjects in this group will be given myofascial release technique by using thumb for 15 minutes. After myofascial release technique, stretching will be given for plantar fascia. Sustained stretching will be given for the duration of 30 seconds with 6 repetitions and 15 seconds rest period will be given between each repetition. Treatment will be given for one session per day and the total treatment period will be for 2 weeks.
Group II: 30 subjects in this group will be given myofascial release technique by using thumb for 15 minutes. After myofascial release technique, calcaneal taping will be done daily. Treatment will be given for one session per day and the total treatment period will be for 2 weeks.