Laser Therapy for Plantar Fasciitis

Laser Therapy for Plantar Fasciitis
Ed Mulligan, PT, DPT, OCS, SCS, ATC
Associate Professor
UT Southwestern Medical Center School of Health Professions
Department of Physical Therapy
Dallas, TX
Disclosure Statement
Neither I, Edward P. Mulligan, nor any family member(s), have any relevant
financial relationships to be discussed, directly or indirectly, referred to or
illustrated with or without recognition within the presentation
However, …
LiteCure, Inc (Newark, DE) donated a Class IV
laser (LaserForce Pro) to the Department
of Physical Therapy at UT Southwestern
for use in this investigation
Plantar Fasciitis
Groucho Marx
What is low level laser therapy?
a.k.a. – cold laser or photobiostimulation
The use of a non-surgical, non-invasive, and drug free device
to stimulate cellular activity via specific wavelengths of light
Low Level Laser Therapy

Physiological Effects
–
–
–
–

Anti-inflammatory, analgesic, and anti-edematous
Increased microcirculation
Increased cellular activity
Increased rate of tissue regeneration and wound healing
Resulting in:
–
–
–
–
Reduced pain and inflammation
Accelerated tissue repair and cell growth
Faster healing of injury
Reduced fibrous tissue formation
What does the literature say?
Low Level Laser Therapy
Clinical Practice Guidelines for Ankle Ligament Sprains
Martin RL, et al, J Orthop Sports Phys Ther, 2013
Low Level Laser Therapy
Clinical Practice Guidelines for Achilles Pathology
Carcia CR, et al, J Orthop Sports Phys Ther, 2010
Low Level Laser Therapy
Clinical Practice Guidelines for Plantar Fasciitis


LLLT not addressed in 2008
guidelines
Only electrotherapeutic
modality evaluated was
iontophoresis which was
given a
level strength of
recommendation
Current Research Project
Ed Mulligan, DPT
Ross Querry, PT, PhD
Emily Middleton, DPT
Michael VanPelt, DPM
George Liu, DPM
Laser Type: Class 4,
Laser Wavelength: 980 nm
Laser Power: 10 W
6 joules/cm2 x 6 minutes =3600 total joules
Operating Modes: continuous
Current Best Evidence is equivocal
RCT with 32 subjects who received
sham or actual LLLT (30mW) TIW x 4
wks. (12 visits)
RCT with 25 subjects (uninvolved side
serving as control) who received placebo or
actual LLLT (240mW) x 6 weeks (18 visits)
No significant difference between
groups in regard to pain, provocative
testing, or need for medication or
orthotic usage at a one-month followup. While intervention is safe it does
not appear to be beneficial
Significant difference between groups in
regards to first step and average daily pain
levels and greater % of plantar fascia
thickness reduction in the “real” laser
cohort.
Study Design
Inclusion Criteria:
1.
2.
3.
18-70 years old
Maximal point tenderness to palpation at the medial calcaneal tuberosity
Symptom increase with weight bearing after > 30 minutes of non-weight
bearing or with positive Windlass test
Exclusion Criteria:
1.
2.
3.
4.
Injury or trauma to foot in previous 30 days
Medical conditions – rheumatoid arthritis, SLE, calcaneal fractures, PVD,
anticoagulant use, CCS injection or ESWT within past 6 months, use of
photosensitive medications
+ Tinel’s or dorsiflexion-eversion test (rule out TTS)
Onset secondary to temporary weight gain from pregnancy
Study Procedures


IRB approved study at UT Southwestern Medical Center
Double Blind design
–



principle investigator and subjects blinded to the treatment allocation group
Power Analysis
–
based on continuous response variable (FAAM score) from a matched pair of
study subjects
–
need 20 pairs of subjects to be able to reject the null hypothesis with a
power of .80 and a type I error tolerance of alpha < 0.05
Random and concealed group allocation following initial exam
We currently have 31 subjects enrolled with one month follow-up
data on 22 subjects
Demographic Data Collected







Age, Height, Weight, BMI
Symptom chronicity
Prior medical/therapeutic treatment
Imaging presence of heel spur
% of time standing during day
Standing time tolerance
Walking distance tolerance
Impairment Data Collected





TCJ dorsiflexion range
1st MTP dorsiflexion range
Longitudinal arch angle
Navicular drop distance
Arch Morphology
–

cavus-normal-planus
Windlass Test Result
Usual and Customary EvidenceBased Rehabilitation Intervention
6 physical therapy visits and 10 laser treatments over a 4-wk period


Educational Handout
Stretching Program
–

Strengthening Program
–

Toe Curls, Short foot intrinsics, Towel Sweeps, 4-way elastic band
Manual Therapy


Standing G/S stretch; Plantar fascia-specific stretch; Arch rolling
(joint or soft tissue mobilization per therapist discretion)
Low-Dye taping → OTC orthotic recommendation
Independent Variable

Therapeutic Cold Laser Treatment
 sub-clinical sham vs. optimal dose
Dependent Variables

Primary Outcomes:
–
–
–
–

1st step pain in morning: 0-10 NPRS
Average pain during day: 0-10 NPRS
Patient satisfaction: Global Rating of Change scale: (-7 to +7 scale)
Self-report outcome tool: FAAM (Foot and Ankle Abilities Measure) scale
Secondary Outcomes:
–
–
–
Result of Windlass test in standing
Ankle dorsiflexion and 1st MTP dorsiflexion ROM
Distance walked before pain onset
findings based on 10 of 20 in sham; 12 of 20 in optimal
dosage have completed 30-day follow-up
Preliminary Results
Independent
Variable
TRUE LLLT
SHAM LLLT
Significance
Baseline
30 days
Change
Baseline
30 days
Change
1st Step Pain
(NPRS)
8.1
3.0
5.1
6.0
2.8
3.2
p = 0.01
Average Pain
(NPRS)
5.7
2.6
3.1
4.5
2.6
1.9
p = 0.34
Self-Report Function
(FAAM)
65
85
20
75
87
12
p = 0.41
5.5
p = 0.82
Global Rating of
Change
5.5
findings based on 5 of 20 in sham; 7 of 20 in optimal
dosage have completed 3-month follow-up
Preliminary Results
Independent
Variable
TRUE LLLT
SHAM LLLT
3-mo. Change
3-mo. Status
3-mo. Change
3-mo. Status
Significance
Change / Status
1st Step Pain
(NPRS)
5.8
2.4
3.2
3.0
p = 0.06 / 0.20
Average Pain
(NPRS)
4.0
1.25
2.2
2.6
p = 0.12 / 0.64
Self-Report
Function (FAAM)
25
91
2
91
p = 0.20 / 0.64
6
p = 0.43
Global Rating of
Change
underpowered conclusions
5
What does this mean?

3 and 6-month follow-up data still to come
–
Based on regression to the mean – value of laser (if
present) is probably more likely in acute, early phase

Standard care and usual medical advice is sufficiently
beneficial in most cases

LLLT may decrease acute 1st step pain
but have negligible impact on function
or patient satisfaction
[email protected]