Hana Hronková, Leoš Navrátil, Jiří Škopek, Jaroslava Kymplová,

Charles University, 1st Medical Faculty, Prague, CZ
Laser Centrum THERAP-TILIA, Prague, CZ

Jiri Knizek

Medical Military Academy, JEP, Hradec Králové, CZ

 

SUMMARY

Objective

To compare the effectiveness of the two therapeutical approaches, ultrasound and low level laser used in patients suffering from calcar calcanei-plantar fasciitis.

Methods

171 patients with calcar calcanei and plantar fasciitis diagnosed with the X-ray were divided into four groups:

Group A

60 patients treated with ultrasound therapy (UST). Ultrasound with the output of 1 W per cm² was applied for 5 minutes in each of 10 applications and the head of device pointed to the place of maximum pain;

Group B

61patients were treated with low level laser therapy (LLLT) without any additional treatment including pharmacotherapy. Laser with 870 nm of wavelength, output of 200 mW, was applied on the place of maximum pain. Energy density of 9 J/cm² in the series of 10 laser applications every other day was used.

Group C

8 patients where previous UST had no or minimal effect and therefore LLLT was subsequently applied the same way as in the group B. Laser was applied not earlier than 14 days after the ultrasound.

Group D (control)

In this group of 52 patients the sham laser radiation (no laser beam) was applied whereas patient and personnel could not identify whether the laser was shamed or not. This group is used as control "placebo" group.

The effectiveness of the treatment was determined according to the evaluation of the patient using certain criteria described in the table.

Results

The complete disappearance of pain was seen in 50 % of patients, partial improvement in 16,6% and no effect in 33,3% of patients treated with US.

In the group B, where LLLT has been used, 64% of patients described disappearance of pain, 26% with improvement and in 10% of patients this therapy brought no effect.

In the group C of previous UST and subsequent use of LLLT, 75% of patients evaluated their treatment as successful. In 25 %, however, laser had no effect.

Summarily, 69 patients were treated with LLLT from which 67% described complete pain relief, 20% partial improvement and in 13% laser brought no effect.

In the group D there were 50 patients treated with sham laser and full effect was seen in 18% of them, partially reduced pain in 42% and without any effect in 40% .

Discussion and conclusion

The results show that the LLLT is a good therapeutical approach in the treatment of pain in patients suffering from calcar calcanei - plantar fasciitis. The treatment with laser was significantly more successful then the ultrasound therapy, which is currently the most common therapy used for plantar fasciitis.

 

INTRODUCTION

Man can make about 10-15.000 of steps a day. Good and painless function of legs is therefore a very important need for everyone.

The structure of the foot is made to fulfill the basic functions - static and kinetic. It is important mainly to transfer the body weight onto the floor and to maintain the stability. The skeleton of the foot is not one-plane situated but it is double arched, lengthwise and crosswise. Arch of the foot is maintained by the system of ligaments and muscles as m. tibialis anterior a posterior and inner muscles of the foot but the other factor is the osseous architecture which corresponds with the direction of the biggest pressure. The shape of the foot and the height of arch differ individually. That affects subsequent disorders.

The most common trouble is the pain in the region of heal which is usually overloaded by body overweight and by insufficient function of the plantar arch. The calcanean reaction to the overload is resulting in creation of two types of exostosis; one on the dorsal side, e.g. Haglund's exostosis, and second one on plantar side, so called calcar calcanei. The main range of age of patients suffering from this disorder was between 40 and 60 years of age. They appear mostly on both feet.

The main cause of the problems of patients suffering from calcar calcanei is the inflammation of tentacles of muscles and plantar aponeurosis in the place of calcanean tuberosity. Subsequently, calcification and ossification start in these focuses which can be detected by the X-ray. Patients then suffer from the pain when they tread fully on this foot. It affects a walking pattern of the person and leads to the overloading of the second foot that often develops similar problems and changes.

Therefore, the objective of the therapy is to reduce or cure the pain using usually physical therapy complemented with the application of suitable socks and soft heels (4,6). In the following therapy we explain to the patient the causes of overloading of calcaneum, how important is to reduce the body weight and to strengthen muscles of plantar arch which regenerate its right function. The great number of recurrence is seen when these steps are not considered.

The application of ultrasound is in the Czech republic the method of choice. If this method is not successful, patients are treated with laser therapy. Nevertheless, some doctors still prefer the roentgen therapy and the syringe application of corticoids and analgesics into the focus.

 

METHODS

171 patients ranging between 25 - 70 years of age suffering from plantar fasciitis were treated in our department during the year 1999. Patients were sent to our site from other departments and private doctors where the application of corticoids or analgesics or UST has been usually already provided. Then, in case of prolonged troubles or recurrence of problems, patients were advised to go to our department.

Patients with long term chronic pain and impairment of normal walking were taken into the study. Persons with mild problems were not included.

181 patients with calcar calcanei and plantar fasciitis diagnosed with the X-ray were divided into four groups:

Group A - 60 patients treated with ultrasound therapy (UST). Ultrasound with the output of 1 W per cm² was applied for 5 minutes in each of 10 applications and the head of device pointed to the place of maximum pain;

Group B - 61patients were treated with low level laser therapy (LLLT) without any additional treatment including pharmacotherapy. Laser with 870 nm of wavelength, output of 200 mW was applied on the place of maximum pain. Energy density of 9 J/cm² in the series of 10 laser applications every other day was used.

Group C - 8 patients where previous UST had no or minimal effect and therefore LLLT was subsequently applied the same way as in the group B. Laser was applied not earlier than 14 days after the ultrasound.

Group D (control) - In this group of 52 patients the sham laser radiation (no laser beam) was applied whereas patient and personnel could not identify whether the laser was shamed or not. This group is used as control "placebo" group.

 

EVALUATION AND RESULTS

Patients were asked for the subjective evaluation of the effectiveness from 10 to 14 days after the completion of the therapy. For this purpose certain criteria described in the table 1 were used.

Table 1 - Criteria for evaluation of the intensity of troubles described by patients

 

Coefficient	Severity of troubles after the treatment
0	Same, no improvement
1	Slightly better, pain or disorder is still present
2	No pain, completely without disablement

 

Table 2 - Results of the treatment in the study groups. (N) number of patients, (UST) ultrasound therapy, (LLLT) low level laser therapy.

 

Group	Therapy design used methods	N	Coefficient ( efficiency of the treatment)
			0	1	2
A	UST	60	20	10	30
B	LLLT	61	6	16	39
C	UST + LLLT	8	2	0	6
D	Control	52	21	22	9

 

Statistics

Statistic evaluation of the results was done with Fisher's (factorial) test, comparison of the parameters π₁  and π₂  of binomic division with the alternative of their difference π₁ ≠  π₂. Groups were evaluated mutually and against the control A, B, C and D.

Table 3 - Fisher's tests (extended for the data from binomic division) of the mutual difference

of relative numbers of kinds of therapy and control (x₁/n₁) a (x₂/n₂); borderline significance

p < 0.1), significant difference (p < 0.05), very significant difference (p < 0.01).

	x1	n1	x2	n2	p
AB	10+2*30 = 70	2*60 = 120	16+2*39 = 94	2*61 = 122	0.003 ***
AC	10+2*30 = 70	2*60 = 120	0+2*6 = 12	2*8 = 16	0.314
AD	10+2*30 = 70	2*60 = 120	22+2*9 = 40	2*52 = 104	0.004 ***
BC	16+2*39 = 94	2*61 = 122	0+2*6 = 12	2*8 = 16	1.000
BD	16+2*39 = 94	2*61 = 122	22+2*9 = 40	2*52 = 104	<0.001 ***
CD	0+2*6 = 12	2*8 = 16	22+2*9 = 40	2*52 = 104	0.013 **

 

Discussion

Non-invasive laser therapy (LLLT) is modern and trendy method in many medical branches (9,10). New findings contribute to the everlasting discussions about the effectiveness of lasers. Today is almost impossible to impeach the great benefit of laser therapy for the treatment of skin disorders. Direct analgesic (9), antiinflammatory and biostimulating effect (2,9,10) is originating in the tissue after the irradiation of it by the laser beam.

Based on the studies concerning the determination of the efficacy of LLLT published up to the present day (9,10) it is possible to assume that probable mechanisms of the effectiveness of therapy used in our study are : reducing the muscle tension, reducing the swelling in soft tissue and stimulation in the nerve ending causing the analgesic effect (9). The improved microcirculation in the irradiated region allows faster washing off of the inflammatory mediators (8). Also, the activation of immunologic cells causes the faster amelioration of inflammatory signs and positive effect of the therapy.

There is a number of laser devices used in the clinic. The modern low level lasers use a semiconductor diode as a source of radiation. Devices with replaceable probes of different wavelengths are being advantageous in various disorders. When applied in skin affections the probe of 670nm of wavelength with smaller output is the best to use. Radiation is this way captured superficially in the skin and subdermally. If the muscle, ligament or joint is needed to be reached by the laser beam, it is better to use the probe of 700-900nm. These wavelengths allow deeper penetration of radiation (10).

We have got a laser scanner with the semiconductor diode in our out patient clinic. We are using other physical methods of therapies as well and therefore we can compare the efficacy of all of them in various diseases or disorders.

In the case of plantar fasciitis - calcar calcanei is recently recommended LLLT as a treatment of choice (9,10) or supplementary method (5). The only study designed as a double blind controlled study on plantar fasciitis is till now the work of Basford at al. (1) which was done in Mayo Clinic, Rochester, USA. The use of laser therapy is evaluated as safe but not as efficient. There was no significant difference between the effect of treatment within the laser-group and sham laser-group (placebo).

Application of therapeutical ultrasound (UST) is used widely. Crawford and Snaith (3) published the study in 1996 comparing the UST with control (placebo) group. The efficacy of 30% and it was not significantly different from control. The problem of the study is small number of patients.

In this study we compared the two methods used in rehabilitation departments in the Czech Republic as the methods of choice. As it is seen from the results, LLLT shows significant efficacy compared to control (p>0,001). Furthermore, significantly better effect of LLLT was seen in comparison with UST(p>0,003) and therefore laser therapy should be preferred if it is in the clinics and departments available. In this connection it is needed to mention that number of policlinics and doctors offices equipped with lasers in the Czech Republic is still very low. This is why the UST is being preferred. Situation in other countries is difficult to discuss. The problem is that after the failure of the treatment is the patient sent to undergo either radiological irradiation or the invasive method of treatment e.g. the syringe application of antiinflammatory remedies into the focus irrespective of the side effects (damage of the soft tissue, weakening of ligaments). However, in these cases patient should be sent in the first place sent to the center well equipped with suitable laser probe (minimum output of 200mW and 760 - 904nm of wavelength) because the relevant number of patients unsuccessfully treated with US is possible to treat wit therapeutic laser. In our study 75% of patients were improved after the LLLT. The results are very promising although the number of patients in the groups was as large.

 

Conclusion

It is necessary to remind that any of the physical methods (e.g. UST, LLLT) used in treatment of this disorder, is always only an additional method which does not solve the pathologic mechanisms. Patient needs to strengthen the plantar arch by exercising or by using the right shoes and orthopedic materials. If these actions are not followed the risk of failure of treatment - risk of recurrence is 40-50%.

We conclude that laser therapy is compared to the ultrasound therapy a modern effective method used in patients suffering from calcar calcanei (plantar fasciitis) with minimum side effects which does not harm the soft tissue and growth area of bones. This problem arise when UST is used. Laser therapy is the advantageous method also when the traditional approach is not possible to apply (e.g. in children).

 

References

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