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Title: Regulation in vascularity after extracorporeal shock wave therapy in individuals with proximal plantar fasciitis
Authors: Chen, Hongying
Degree: Ph.D.
Issue Date: 2012
Abstract: Plantar fasciitis is one of the most common causes of heel pain, but its etiology and pathogenesis are unclear. Vascular disturbance with consequent metabolic impairment is thought to play an important role. Vascular changes have been observed in patients with plantar fasciitis and modulation in vascularity is detected in individuals with tendinopathy after extracorporeal shock wave therapy (ESWT). ESWT has been approved by the Food and Drug Administration (FDA) of the Unites States in 2000 for treating patients with plantar fasciitis and gives evident pain reduction when the treatment was delivered at low to medium intensity at weekly basis for multi-sessions. If treatment should be prescribed based on the stage of the disease, vascularization could be one of the determining factors in delineating a treatment protocol. In order to have a better understanding of the treatment's efficacy, biological effects studies need to be assessed in the short and long term after treatment. Such information would enhance our understanding of the ESWT-induced biological changes in vascularization and form a scientific basis for ESWT's clinical application. This project consisted of 5 inter-related studies. The first study (Chapter 2) aimed to establish a reliable measure to quantify the vascularity of the plantar fascia as well as delineate the minimum detectable changes and cut-off point for identifying individuals with and without unusual vascularization. Study 2 (Chapter 3) explored vascularization and fascia thickness in patients diagnosed with plantar fasciitis and able-bodied controls. The study also explored relationships between the duration of the disorder with vascularity and fascia thickness. In study 3 (Chapter 4), regulation in vascularity was assessed in patients with plantar fasciitis after 3 or 6 sessions of ESWT and compared with patients with no intervention. The influence of pre-intervention vascularization on treatment planning was explored in study 4 (Chapter 5). Patients with duration of symptoms less than 12 months were followed up 3 and 6 months after the application of ESWT. Factors affecting treatment success were investigated and reported in study 5(Chapter 6). Aside from vascularization and fascia thickness, the outcome measures included self-perceived pain and foot function.
Based on Power Doppler Ultrasonography, a quantitative vascularity index (VI) was defined which correlated well with Newman's grading scale. It provided a minimum detectable difference of 0.68% in vascularity. In addition, vascular index of 2.60% was shown to differentiate patients with and without morderate to severe vascularization. Vascularization and thickened plantar fascia were evident in the patient group. In patients with symptoms lasting less than 12 months, vascularity index was shown to be positively correlated with pain and foot function. Minimal vascularity was observed in subjects with symptoms lasting beyond 12 months. The plantar fascia in these patients had similar thickness as those with symptoms less than 12 months. Immediate after ESWT, regulation in vascularity was observed in 60% of the patients studied. The direction of change was shown to depend on the treatment dosage and baseline vascularization. Down-regulation in vascularity was observed in vascularized patients (with VI >2.6%) after 6 sessions of ESWT. Vascularity was up-regulated in non-vascularized patients after receiving either 3 or 6 sessions of ESWT. A VI score >1.55% at baseline was a strong predictor of unsuccessful recovery with only 3 sessions of ESWT, but 62.50% of patients with a baseline VI score <3.25% recovered successfully after 6 sessions of ESWT. No patients could be treated successfully if their pre-intervention VIs were beyond 3.25%. Regression of vascularity was continued to 6 months post intervention, and 91.67% patients with excellent treatment results had normal vascularity. Fascia thinning was evident after 3 months, and about 50% of the patients had regained normal fascia thickness by 6 months post intervention. Our findings thus indicate that 6 sessions of treatment were more effective for patients with greater vascularization. The above findings lead to 3 main conclusions. 1) Patients with plantar fasciitis for more than 3 months (9.21+ 6.44 months) show increased vascularity in the affected fascia. ESWT can modify the vascularity in 60% of patients, but the direction of regulation depends on the baseline vascularization and the number of treatment sessions. 2) Individuals with increased vascularization could not reach a satisfactory result after only 3 sessions of ESWT; 6 sessions of ESWT could improve about 60% of vascularized patients at 1 month follow-up. 3) The regression of vascularity after ESWT continues to 6 months post-intervention. This could be related to natural history as well as treatment effects from the shock wave. Regression analysis indicated that patients' baseline vascularization together with treatment protocol are two factors that affect treatment effectiveness in terms of pain reduction.
Subjects: Hong Kong Polytechnic University -- Dissertations
Heel bone -- Wounds and injuries -- Treatment.
Extracorporeal shock wave therapy.
Pain -- Treatment.
Pages: xxiv, 226 leaves : ill. (some col.) ; 30 cm.
Appears in Collections:Thesis

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