Best Practice Guide to Management of Plantar Heel Pain incorporating the 3 EBP pillars

Transcription

1 Best Practice Guide to Management of Plantar Heel Pain incorporating the 3 EBP pillars Dylan Morrissey Professor of Sports and MSK physiotherapy NIHR/HEE Consultant Physiotherapist Ian Griffiths, Trevor Prior, Christian Barton, Michael Rathleff, Bill Vincenzino, Matt Cotchett Marina Chan, Halime Gulle 1

2 Why a best practice guide? Explosion of evidence. Much of it poor quality. Agree guidelines not well followed Lin I, et al. Br J Sports Med 2018;52: Clinical practice very variable and often not evidencebased Outcomes not good enough.

3 Clinical reasoning Patient values Evidence BPG British Medical Association Book Award Winner - President's Award of the Year

4 Clinical reasoning Methods - Online survey with open questions - Presented the evidence synthesis and clinical reasoning - Responses analysed with FRAMEWORK method Patient values Evidence

5 Clinical reasoning Patient values Thoughts on condition cause Thoughts on pathology Expectations Needed improvements Strengths of management Experience Key information and sources Evidence

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7 Findings Illustrative quotes Theme 7: patient values Foot arch height; age; activity Walking on the outside edge of my foot when I was having pain in my pattern; new load increase; long second toe periods weight More bearing; information; standing on Thoughts on Heel quick spurs, arthritis hard surfaces; minimally supportive condition Long shifts on my feet in facilities with hard floors. footwear; limb recovery- length asymmetry; unrealised; cause Excess loads exercise with inadequate progression rapidly changing load; altered gait; a number of contributory factors which is why is occurred now altered movement programme due to other esp. foot conditions Tissue irritation; strengthening; degeneration; Tissue pain band has become irritated through age/overuse inflammation ; tearing; It feels like it is tearing. I think I have torn a ligament Thoughts on inadequate tissue capacity; Inflamed damaged pf which needs to heal/repair. pathology elimination; access to contracture Struggling to cope with the demand and non adapted tissue orthoses; specific tendon contracture treatments; is wanting to happen all the time. More information; quick recoveryunrealised; better exercise programme explanation to break of down the scaring or thickening tissue. Wasn t offered Expected to get a steroid shot, and was hoping for deep tissue manipulation esp. foot strengthening; pain I assumed wrongly I would need insoles. I expected to be back on my feet Expectations elimination; treatment/condition access to orthoses; within a few and weeks (very optimistic). specific treatments; better as swift as recovery as possible, relief from the pain and programme of explanation causes of treatment/condition exercises to treat and causes Facilitation of earlier recognition by better understanding of symptoms and types of patients prone to PHP patients; better communication as adherence promotion; More explanation for the mechanism of the symptoms in order to motivate me to do the exercise Intervention strategy for pain; Easier Needed Get rid of the pain forever access to, and more information on, improvements Standardised treatment from NHS across the country. I've gone private specific treatments; Standardised as Dr can't refer. treatment across sectors; Clarity of treatment and expectations; reduced Strengths of waiting times From no Time strengths to course positive of Q1: recovery; Range of options considered and clearly explained management experiences; fast decisions; specific Q2: Spent time explaining in detail the condition/cause/treatment interventions; self-management clear plan; individual advice; function preferences accounted for; detailed explanation; specific interventions how pain relief works; long Restricted activity; intermittent It restricted the activities I wished to carry out severe pain; reduced exercise; It s very painful under my heel when I get up in the morning altered activity; term morning effects; pain; explanation of Experience Miserable 6 months. Had a huge impact on daily activities. Painful; emotionally affected; large Very long process and uncertain outcome impact on what ADL; long, was uncertain not done; recovery Time course unsure; of recovery; selfmanagement statistics What on can usual I do to reduce my pain and improves function advice; how pain Will pain reliever actually address the issue or just mask the pain? Expectations Key information Key information timescales for effects relief works; long term effects; explanation of what was not done; unsure; statistics on usual timescales for effects When they could make the pain go away Expected outcome at the end of rehab Expected to get a steroid shot, and was hoping for deep tissue manipulation to break down the scaring or thickening tissue. Wasn t offered I assumed wrongly I would need insoles. I expected to be back on my feet within a few weeks (very optimistic). as swift as recovery as possible, relief from the pain and programme of exercises to treat What can I do to reduce my pain and improve Will pain reliever actually address the issue or just mask the pain? When they could make the pain go away Expected outcome at the end of rehab Sources of information Range of online methods predominated; clinicians; friends; magazines I can google it all day, and there isn t much out there Patient groups on Facebook aren t even very helpful, because everyone using them hasn t found relief. online forums, confusing as everyone s cause is different therefore treatment different 8

8 Clinical reasoning Patient values Evidence ALL interventions RCTs to 7/18 Quality 8/10 on the PEDro risk of bias <= 2/6 adequate sample size, calculated to be 38 To be considered efficacious (i) (ii) primary proof of superiority compared to a no treatment control, sham or placebo secondary proof of efficacy when compared to another treatment of proven efficacy. N = 42, 3627 patients, focus on efficacy 9

9 Short term = 0-3m Medium term = 3<6m Long = >6m Small ES = Medium = Large > 1.0. Evidence Intervention Custom orthoses Prefabricated orthoses Magnetised insoles Radial ESWT Focused ESWT Dry needling Outcome measure Pain First step pain Function Pain First step pain Function Pain Pain First step pain Function Pain First step pain Function Pain First step pain Function Short term Medium term Long Term Primary Primary Primary Positive Moderate Positive limited Negative moderate [-1.49, -1.00] [-2.18, -1.12] [-0.45, 0.37] Negative Limited [-0.91, 0.26] Negative Moderate [-0.48, 0.06] Negative Moderate [-0.59, 0.09] None Negative limited [-0.85, 0.07] What do you Negative Moderate Negative Moderate see and what [-0.40, 0.28] 0.00 [-0.39, 0.39] Positive Moderate [-6.17, -1.38] Positive Moderate Positive limited [-8.05, -3.57] [-1.63, -0.76] do you NOT Positive Moderate [-4.37, -2.57] Positive strong [-1.72, -0.94] Positive strong [-3.48, -0.75] Positive moderate [-1.53, -0.99] Positive moderate [-1.71, -0.76] Positive moderate [-2.86, -1.74] Positive moderate [-1.80, -0.84] Wheatgrass Pain Negative moderate Plantar fascia stretching Function First step pain Negative moderate Positive moderate [-3.35, -2.27] Positive Limited [-5.65, -3.48] Negative Moderate 0.18 [-0.24, 0.60] see Positive Limited [-3.73, -1.94] Positive moderate [-3.83, -2.67] Negative moderate [-0.53, 0.29] Negative moderate [-0.50, 0.33] Negative moderate [-0.50, 0.33] Positive moderate [-7.83, -4.99] Positive moderate [-3.51, -2.34] Positive Limited [-3.61, -2.02] Positive limited [-3.87, -2.78] Negative moderate [-1.06, 0.86] 10

10 Study or Subgroup Bishop 2018 Landorf 2006 Oliveira 2015a Wrobel 2015 Custom foot orthoses Sham foot orthoses Std. Mean Difference Std. Mean Difference Mean SD Total Mean SD Total Weight 17.9% 31.5% 28.4% 22.2% IV, Random, 95% CI [-1.73, -0.39] [-0.81, 0.02] [-0.69, 0.22] [-0.69, 0.45] IV, Random, 95% CI Total (95% CI) % [-0.74, -0.07] Heterogeneity: Tau² = 0.05; Chi² = 5.19, df = 3 (P = 0.16); I² = 42% Test for overall effect: Z = 2.37 (P = 0.02) Favours custom Favours sham Custom orthoses versus sham orthoses for pain in the short term Study or Subgroup Gerdesmeyer 2008 Ibrahim 2016 Radial ESWT Sham Std. Mean Difference Std. Mean Difference Mean SD Total Mean SD Total Weight 83.3% 16.7% IV, Random, 95% CI [-0.60, -0.09] [-1.24, -0.09] IV, Random, 95% CI Total (95% CI) % [-0.63, -0.16] Heterogeneity: Tau² = 0.00; Chi² = 1.01, df = 1 (P = 0.32); I² = 1% Test for overall effect: Z = 3.34 (P = ) Radial ESWT Sham Radial ESWT versus sham for pain in the long term 11

11 Clinical reasoning 13 world experts, 4 continents, 5 disciplines, mean 51 papers (12-115), mostly clinicalacademic Framework analysis Data saturation reached, respondent validation ongoing Patient values Evidence 12

12 Clinical reasoning 6 themes: 47 sub-themes 1. Diagnosis 2. Principles guiding management 3. Rehabilitation 4. Specific interventions 5. Education 6. Evidence considerations Patient values Evidence 13

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15 Themes Diagnosis Principles guiding management Rehabilitation Specific interventions Education Evidence considerations Clinical reasoning 6 themes: 48 sub-themes 1. Straightforward 2. Compliance a problem 3. tensions abound 4. Matched evidence / combinations 5. Mismatch with patients 6. stratification + combinations Patient values Evidence 16

16 Clinical reasoning BPG Patient values Evidence

17 START OF TREATMENT TIME IN WEEKS Severity determined by repeated PROMs OPTIMAL BEST PRACTISE GUIDE PLANTAR HEEL PAIN MANAGEMENT acceptable patient outcome SCENARIO 1: PROGRESSIVE RECOVERY OF VARYING SPEED FINDINGS FROM SYSTEMATIC REVIEW Education and self management is the core approach

18 DO COMBINED SR/SSI/SURVEY FINDINGS CORE APPROACH BEST PRACTISE GUIDE PLANTAR HEEL PAIN MANAGEMENT stretching education footwear taping Individual aetiological analysis STATIC DYNAMIC CHALLENGE BELIEFS REASSURE PAIN MONITORING LTCs BMI SOCIALLY ACCEPTABLE SOFT + SHOCK RF/FF DROP COMFORT load pain related aspects footwear

19 FINDINGS FROM SYSTEMATIC REVIEW EVIDENCE LEVEL: STRONG INTERVENTION BEST PRACTISE GUIDE CORE APPROACH ESWT PLANTAR HEEL PAIN MANAGEMENT MODERATE CUSTOM ORTHOSES DRY NEEDLING EXPERIMENTAL INJECTION SURGERY NO BENEFIT WHEATGRASS MAGNETIZED INSOLES PREFAB ORTHOSES

20 START OF TREATMENT TIME IN WEEKS Severity determined by repeated PROMs OPTIMAL BEST PRACTISE GUIDE PLANTAR HEEL PAIN MANAGEMENT CORE APPROACH ESWT CUSTOM ORTHOSES DRY NEEDLING INJECTION SURGERY SCENARIO 2: FAILURE TO PROGRESSIVELY RECOVER FINDINGS FROM SYSTEMATIC REVIEW Education and self management is the core approach

21 Thank you 22

22 Thank you 23

23 Applying the Best Practice Guide to Management of Plantar Heel Pain Dylan Morrissey Professor of Sports and MSK physiotherapy NIHR/HEE Consultant 25

24 Case scenarios Meet Sally 42 year old CEO logistics firm BMI 29 and dropping Started running 6/52 ago using an app Now pain every am, unable to run Meet John 54 year old father of three BMI 31 and rising Works in a shop concerned he will lose his job 24 months of pain, two episodes of rehab and four injections, 6 pairs of insoles 26