Rajiv Gandhi University of Health Sciences, Karnataka
Bangalore
ANNEXURE II
1. / Name of the Candidate and address (in block letters) / SANDEEP BALASAHEB KADLAGDR.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(MPT) IN MUSCULO-SKELETAL
DISORDER AND SPORTS PHYSIOTHERAPY
4. / Date of Admission to Course / 13th JULY 2011
5. / Title of the Topic / A STUDY TO EVALUATE THE EFFECTIVENESS OF MYOFASCIAL RELEASE (MFR) & IONTOPHORESIS IN TREATMENT OF PLANTAR FASCIITIS.
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8. / BRIEF RESUME OF THE INTENDED WORK:
6.1) INTRODUCTION:
Plantar fasciitis (PF) is a repetitive strain injury of the medial arch and heel, is one of the common cause of inferior heel pain.1-2 Plantar Fasciitis is a common Occupational or sports related repetitive strain injury.1 Plantar Fasciitis has been reported in wide sample of the community, which affects about 10% of the population in at least one moment in life. In non athletic population, it is most frequently seen in weight bearing occupations. 65% of non sports demographics are overweight, in which unilateral involvement most common in 70% of cases. In case of athletic population,10% of all running athletes, Basket Ball, Tennis, Football, long distance runner and dance have all noted high frequency of plantar fasciitis.2
In Plantar fasciitis patient initially complains of typically sharp pain in the inner aspect of the heel and arch of the foot with the first few steps in the morning or after long periods of non-weight bearing. After a few steps (10-12 steps) and throughout the course of the day, the heel pain slowly diminishes. Symptoms may be seen as throbbing, dull ache, or a fatigue-like sensation in the medial arch of the foot after prolonged standing, especially on unyielding cement surface.1
Various physiotherapy treatment protocols have been used in the past such as taping, orthotic-night splints, stretching.15-17 Electrotherapy modalities in the form of laser therapy, extracorporeal shockwave therapy, ultrasound, and drug therapy in the form of systemic medication, percutaneous injection, and topical application, have been investigated and have shown variable clinical benefits.23
Myofascial release is a soft tissue release technique. The Aim of Myofascial release is to release fascia restriction and restore tissue elasticity.4 After Myofascial release there is a change in viscosity of ground substance to a more fluid state which eliminates the fascia’s excessive pressure and restores proper alignment.5
Iontophoresis is a technique in which medically useful ions are driven through the patient’s skin into the tissues. The basic principle is to place the ions under an electrode with the same charge. For Example: a negative ion is applied under the cathode, this electrode would then be known as the ‘active electrode’. A constant (direct) current is then applied and the ion is electrically propelled into the patient. Acetic acid iontophoresis gives greater relief from pain.10
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 alternative.11,12
Need of the Study:
Previous studies state that Myofascial Release (MFR), releases fascia restriction & restore its tissues elasticity and Iontophoresis provide more immediate pain relief than traditional modalities alone. But there is lack of studies to check the combined effects of Myofascial Release (MFR) & Iontophoresis in treatment of Plantar Fasciitis. Hence the need arises to evaluate the combined effectiveness of Myofascial Release (MFR) & Iontophoresis in treatment of plantar fasciitis.
Research Question:
Whether Myofascial Release & Iontophoresis will bring better improvement in patients with plantar fasciitis?
HYPOTHESIS:
Alternative hypothesis:
There will be significant effect of Myofascial Release & Iontophoresis in reducing pain and increasing function in patients with plantar fasciitis.
Null hypothesis:
There will be no significant effect of Myofascial Release & Iontophoresis in reducing pain and increasing function in patients with plantar fasciitis.
6.2) REVIEW OF LITERATURE:
Suman Kuhar et al Performed a randomized control trial study to check out effectiveness of Myofascial Release in Treatment of Plantar Fasciitis using 30 subjects randomly allotting into two groups. Group A received therapeutic ultrasound , contrast bath, foot intrinsic muscles strengthening exercise , plantar fascia stretching exercise and Group B received conventional treatment as group A added with myofascial release for 15 minutes for 10 consecutive days and results concluded that myofascial release is an effective therapeutic option in the treatment of plantar fasciitis.6
Renan-Ordine R, Alburque-Sendin F et al Conducted a randomized control trial study to check out effectiveness of Myofascial release therapy for treating heel pain (plantar fasciitis). 4 treatment sessions given each week for total 4 weeks and result concluded that incorporation of Myofascial release technique before static Stretching is superior to isolated stretching for improving function and decreasing pain in patients with plantar fasciitis.7
H R Osborne and G T Allison Conducted a comparative study on the effectiveness of dexamethasone and acetic acid and concluded acetic acid in iontophoresis produced significantly better effect in reducing pain than dexamethasone in iontophoresis.9
Ivano A Costa et al Performed a case study on The integration of acetic acid iontophoresis, orthotic therapy and physical rehabilitation for chronic plantar fasciitis and concluded that 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.14
Gudeman SD,Eisele SA Performed a randomized, double-blind, placebo-controlled study for treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone and concluded that iontophoresis provides more immediate pain relief in plantar fasciitis.13
Benedict F Digiovanni Performed a prospective clinical study using two different stretching approaches such as plantar fascia stretching , tendoachillis stretching protocol in the treatment of Plantar Fasciitis 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 fasciitis.16
Barry L D 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 Gastrocneumius-Soleus stretching produced greater benefits than the application of night splint alone in the treatment of plantar fasciitis.17
Porter D et al Conducted a randomized, blinded control study to check effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome and data suggest that both sustained and intermittent Achilles tendon stretching exercises were effective nonsurgical treatments for painful heel syndrome.15
Boonstra AM et al Performed a study to determine the reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain and they concluded that the reliability of the VAS for disability is moderate to good and a strong correlation with the VAS for pain.19
Wu SH, Liang HW, Hou WH. 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 fasciitis.21
Agel J, Beskin JL, et al Performed a study on Reliability of the Foot Function Index: A report of the AOFAS Outcomes Committee and the results concluded that The FFI appears to be a reasonable tool for low functioning individuals with foot disorders.22
6.3) OBJECTIVE OF STUDY:
To find out whether the application of Myofascial Release & Iontophoresis can reduce pain and improve function in patients with plantar fasciitis.
MATERIALS AND METHOD:
7.1) Study Design:
Pre and Post with control, Experimental study
7.2) Source of Data:
Patients suffering from plantar fasciitis referred to physiotherapy by a Physician /Orthopedic Surgeon in and around Mangalore.
7.2(I) Definition of Study Subjects:
A Sample size of 50 patients in the age group of 18-40 years with 25 in each of the two
groups will be there for the study.
7.2(II) Inclusion and Exclusion Criteria:
Inclusion criteria:
· Age 18-40 years
· Male & Female
· Heel pain more than one month consistent history of plantar
fasciitis
· Clinical diagnosis of Plantar fasciitis
· Pain in heel on first step in Morning
Exclusion criteria:
· Contraindication for Iontophoresis/Acetic Acid
· New orthotics or corticosteroid treatment in previous month.
· Calcaneal stress fracture
· Osteomyelitis
· Subject with referred pain due to sciatica.
7.2(III) Study Sampling Design, Method and Size:
Sample Design:
Purposive Sampling Technique which is randomly assigned into two groups, Group A
Sample Size:
A total of 50 subjects fulfilling the inclusion and exclusion criteria’s.
7.2 (IV) Follow Up:
Pre Treatment Assessment will be taken for pain and Function Followed by intervention of frequency four times a week for four weeks. Post intervention Assessment will be taken for the same parameter.
7.2(V) Parameters used for comparison and Statistical analysis used:
Standard Deviation, Paired and Un-Paired ‘t’ test.
7.2(VI) Duration of Study:
The study will be conducted over duration of 12 months.
7.2(VII) METHODOLOGY:
50 Subjects with Plantar fasciitis fulfilling the inclusion criteria will be recruited and randomly divided into two groups, i.e. Group A (Experimental Group) and Group B (Control Group), each group containing 25 subjects. Informed consent will be obtained from subjects.
Pre Test will be conducted on Group A and Group B by Visual Analogue Scale for assessing pain and Foot Function Index for assessing Function.
GROUP A: (EXPERIMENTAL GROUP)
MYOFASCIIAL RELEASE AND IONTOPHORESIS WITH STRETCHING:
MYOFASCIIAL RELEASE:
PROCEDURE: Technique- Supine Direct Myofasciial Release.
With the patient is in Supine lying position and Physiotherapist Seated at the foot of the table. By Placing thumbs are crossed and the pads are pressed into the plantar fascia at the level of the tarsal-metatarsal junctions with fingers interlaced across the dorsum of the foot. The pads of the thumbs press in the direction the thumbs are pointed, that is, toward either side of the foot and slightly toward the toes, and are taken to a point of balanced tension. Once a release occurs, thumb tips seem to slip across the fascia. Repeat the same procedure with the toes in plantar flexion. Once that release occurs, repeat the procedure with the toes in dorsiflexion. The treatment of the plantar fascia is complete once you have accomplished all three releases.
A total of 16 treatment sessions will be given on four sessions per week over a period of four 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 up to 4mA and a total dosage of 40mA for a period determined by patient’s sensitivity.
A total of 16 treatment sessions will be given on four sessions per week over a period of four weeks.
STRETCHING:
Patients will be given sustained Achilles tendon stretching for duration of three minutes, three times in a day.
GROUP B: (CONTROL GROUP)
STRETCHING:
The treatment will be given same as given for Group A.
7.3) Does the study require any investigations to be conducted on subjects or other human or animal if so please describe briefly?
YES.
Visual-Analogue Scale18-19- Pain Assessment.
Foot Function Index21-22- 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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Literature. March 2007.
2. Simon J. Bartold. Plantar heel pain syndrome: overview and management. Journal of Bodywork Movement therapies.2004; 214-226.
3. Mario Roxas, ND. Plantar fasciitis;Diagnosis and Therapeutic Considerations. Alternative Medicine Review 2005. Vol 10(2) 83-93.
4. Barnes, J F. Mind and Body of Healing, PT and OT today, Nov1996.
5. Travell,J. Simons. Myofascial pain and dysfunction. The trigger point manual. Vol 1. Willkins & Willkins. Baltimore.
6. Suman Kuhar, Khatri Subhash,et al. Effectiveness of Myofascial Release in Treatment of Plantar Fasciitis: A RCT. Indian Journal of Physiotherapy and Occupational Therapy. Vol.1, No.3 (2007-07-2007-09)
7. Renan-Ordine R, Alburquerque-Sendin F, de Souza DP, Cleland JA, Fernandez-de-Las-Penas C.Effectiveness of Myofascial trigger point manual therapy combined with a self –stretching protocol for the management of plantar heel pain: a randomized control trial. J Orthop Sports Phys Ther.2011.
8. Zanon R G, Kundrat A, Imamura M. Ultra-som continuo no tratamento da fasciite plantar cronica. Acta Ortop Bras 2006; 14:137-40.
9. H R Osborne and G T Allison. Treatment of plantar fasciits by LowDye taping and iontophoresis: short term results of a double blinded, randomized, placebo controlled clinical trial of dexamethasone and acetic acid. British Journal of Sports Medicine, Jun 2006, vol./is. 40/6(545-9), 0306-3674 (2006 Jun)
10. Forster and Palastanga. Clauton’s Electrotherapy Theory and Practise.Cha.3 Electrical Stimulation of Nerve and Muscle.Ninth Edition. 85-85.
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13. Gudeman SD,Eisele SA,Heidt RS Jr,Colosimo AJ,Stroupe AL Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone. A randomized, double-blind, placebo-controlled study. Specialty Centers for Orthopaedic & Rehabilitative Excellence, Indianapolis, Indiana, USA. Am J Sports Med.1997 May-Jun;25(3):312-6
14. Ivano A Costa,and Anita Dyson.The integration of acetic acid iontophoresis,orthotic therapy and physical rehabilitation for chronic plantar fasciitis: a case study. J Can Chiropr Assoc. 2007 Jul-Sep; 51(3): 166–174.
15. Porter D,Barri E,Oneacre K,May BD. The effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomized, blinded, control study. Foot Ankle Int.2002. Jul; 23(7):619-24.
16. DiGiovanni BF,Nawoczenski DA, 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 Jul;85-A(7):1270-7
17. Barry L D, Barry A N, Chen Y. A a retrospective study between two protocols such as Gastrocnemius-Soleus stretching versus night splinting in the treatment of plantar fasciitis. J Foot Ankle Surg 2002.41221-227.
18. Buck Willis,Angel Lopez,et al Pain Scale for PlantarFasciitis. The Foot and Ankle Online Journal 2 (5): 3
19. 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.
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21. 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.
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