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Plantar fasciitis – to jab or to support? A systematic review of the current best evidence |
Uden H, Boesch E, Kumar S |
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CRD summary The authors concluded that limited evidence suggested that customised functional foot orthoses and corticosteroid injections reduced the pain of plantar fasciitis. Function could be improved with an orthosis, and the injections could be painful. The authors' tentative conclusions reflect the limited evidence presented, but omissions in the reporting make the generalisability of the findings unclear. Authors' objectives To evaluate the effectiveness and safety of customised functional foot orthoses and corticosteroid injections in the treatment of plantar fasciitis. Searching PubMed, EMBASE, AMED, SPORTDiscus, CINAHL, The Cochrane Library, and AUSPORT were searched for published studies in English, in peer-reviewed journals, between 1998 and 2010. Search terms were reported. Study selection Eligible for inclusion were high-quality randomised controlled trials (published in the 10 years before 2010) of custom-made functional foot orthoses, or an injected corticosteroid, in patients diagnosed with plantar fasciitis. The orthoses were defined as in-shoe devices moulded or milled from impressions of the feet, and made according to practitioner-prescribed specifications. Trial quality had to meet level II of the National Health and Medical Research Council's criteria, which included rigorous and adequately described randomisation. Comparators could be condition-specific stretching programmes, extracorporeal shock wave therapy, foot and ankle manipulation, prefabricated foot orthoses, night splints, true sham foot orthotic devices, or autologous blood injections. The outcomes of interest were pain and function. There were no high-quality trials that directly compared customised functional foot orthoses and corticosteroid injections. In the included trials, the interventions and comparators varied, and the demographics of the trial participants were not reported. The outcome measures were subjective or objective (reported in the paper) and were largely reported to be valid and reliable. Two reviewers selected studies for inclusion in the review. Assessment of study quality Trial quality was assessed using the PEDro assessment tool, covering randomisation, allocation concealment, baseline comparability, blinding (patient, therapist, and assessor), drop-out rate, intention to treat, and reporting of statistics and variability. The maximum score (indicating high quality) was 10. Two reviewers independently appraised the quality of the included trials. Discrepancies were resolved by discussion. Data extraction Where available, the data were extracted on the direction of the effect for pain and function. Extraction was carried out independently by two reviewers. Discrepancies were resolved by consensus. Methods of synthesis A narrative synthesis was carried out. Results of the review Six trials were included in the review. Four (361 participants) focused on customised functional foot orthoses, and two (189 participants) evaluated corticosteroid injections. Latest follow-up ranged from one month to one year. Four trials scored 8, and two scored 6 on the PEDro scale. All trials failed to report at least one aspect of blinding, and two trials had differences between groups at baseline. For customised functional foot orthoses, comparative data showed largely no significant differences in pain and function between treatment options. A statistically significant short-term improvement in function was found in favour of prefabricated and customised functional foot orthoses, over sham orthoses (one trial), but chiropractic treatment reduced pain more than customised functional foot orthoses (one trial). Safety data on customised functional foot orthoses was limited. Statistically significant short-term reductions in pain were found with corticosteroid injections, compared with extracorporeal shock wave therapy or autologous blood injection (two trials). Both trials reported pain due to the injection. Within-group changes from before to after intervention were reported, and showed a consistent reduction in pain with either intervention. Authors' conclusions Limited evidence suggested that customised functional foot orthoses and corticosteroid injections could reduce the pain of plantar fasciitis. Function could be improved with an orthosis, and the injections could be painful. CRD commentary The research question and inclusion criteria were well defined and reproducible. A range of relevant data sources was searched, but language and publication biases were not minimised, so trials may have been missed. The review process was carried out with sufficient attempts to minimise error and bias. Attempts were made to select high-quality evidence for this review; an appropriate quality assessment tool was used, and the results were clearly reported. The absence of the demographics of the trial participants means that the generalisability of the results is unclear. The chosen method of synthesis was appropriate, given substantial variation between the included trials. The full results were not reported, making it impossible to verify their statistical significance. The authors acknowledged the limited evidence for this review. With these limitations in mind, the authors' tentative conclusions reflect the evidence presented, and their recommendations for research appear to be appropriate. Implications of the review for practice and research Practice: The authors stated that the costs of customised functional foot orthoses, and the side-effects of corticosteroid injections, should be considered in choosing the best treatment, requiring collaboration between the clinician and the patient. Research: The authors stated that rigorous randomised controlled trials were needed to directly compare customised functional foot orthoses and corticosteroid injections. These trials should investigate the natural recovery from plantar fasciitis in a sham or placebo group. The cost-effectiveness and long-term effectiveness of the treatments should be evaluated. Bibliographic details Uden H, Boesch E, Kumar S. Plantar fasciitis – to jab or to support? A systematic review of the current best evidence. Journal of Multidisciplinary Healthcare 2011; 4: 155-164 Indexing Status Subject indexing assigned by CRD MeSH Adrenal Cortex Hormones; Fasciitis, Plantar; Humans; Orthotic Devices; Podiatry AccessionNumber 12012051587 Date bibliographic record published 07/01/2013 Date abstract record published 11/06/2013 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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