Original Article
EFFECTIVENESS OF DIADYNAM IC CURRENT AND M ENS IN HEEL
PAIN: A RANDOM IZED CLINICAL TRIAL
Anand B. Heggannavar *
1, Preeti R. Ramannavar
2, Satyam S. Bhodaji
3.
* 1 Assist ant Professor, Dept . of Ort hopedic M anual Therapy, KLE Universit y, Inst it ut e of Physiot herapy, Belgaum, Karnataka, India.
2,3 Physiot herapist , Dept . of Physiot herapy, KLE Universit y, Inst it ute of Physiot herapy, Belgaum, Karnat aka, India.
Relevance: Heel pain is one of t he m ost com m on condit ions leading t o funct ional disabilit ies seen w orldw ide. There are dif ferent m et hods t o m anage heel pain, conservat ively, and/ or surgically. Physiot herapy t reat m ent , as a par t of conservat ive m anagem ent , involves reduct ion of pain and im provem ent of funct ional abilit y by var ious approaches like exercise t herapy, elect rot herapy and m anual t herapy t echniques. Various st udies have show n t hat Diadynam ic curr ent and M ENS along w it h convent ional t reat m ent s give significant benef icial eff ect s in pain reliving. Hence t he present st udy w as undert aken t o com pare and see t he ef fect of Diadynam ic cur rent and M ENS in heel pain.
Participant s: 30 subject s (m ean age 25.73 ± 6.56) diagnosed w it h heel pain w ere recr uit ed from Out -Pat ient Depart m ent of Physiot herapy of KLES Dr. Prabhakar Kore Hospit al and M edical Research Cent re, Belagavi. M ethod: Subject s w er e random ly allocat ed int o 2 groups nam ely Gr oup A (n=15) w ho received Diadynam ic current along w it h convent ional t reat ment as Therapeut ic ult rasound and st rengthening and stret ching exercises and Group B (n=15) w ho received M ENS w it h convent ional t reat m ent sam e as in group A for 7 days. The outcom e m easures w ere Visual Analog Scale (VAS) for pain, Pain disabilit y index (PDI) and foot disabilit y index (FDI) for f unct ional disabi lit y.
Analysis: Wit hin group and bet w een group analyses aft er int ervent ion w as done t o assess changes using paired t -t est and unpair ed t - t est .
Result: M ean difference of VAS scores for Group A w as 6.9 ± 1.48 and for Group B w as 4.3 ± 2.43. M ean difference of PDI scores for Group A w as 274 ± 117 and for Group B w as 171 ± 99.M ean difference of FDI scores f or Gr oup A w as 0.36 ± 0.24 and for Group B w as 0.15 ± 0.15. Int ra group com parison w as st at ist ically significant w it h p= <0.001 for bot h t he groups in t erm s of VAS, PDI and FDI respect ively. Int er group com parison w as stat ist ically significant w it h p= 0.005, 0.031, 0.007 for VAS, PDI and FDI respect ively.
Conclusion: Diadynam ic current is effect ive in r educing pain and secondarily im proving t he f unct ional abilit y in subject s w it h heel pain.
KEY W ORDS: Diadynam ic curr ent , M icr ocurr ent Elect rical Neur om uscular St im ulat or or M ENS, Pain Disabilit y Index and Foot Disabilit y Index.
ABSTRACT
INTRODUCTION
Address for correspondence: Anand B. Heggannavar, Assistant Professor, Dept . of Ort hopedic M anual Therapy, KLE Universit y, Inst it ute of Physiot herapy, Belgaum 590010, Karnataka, India.
E-M ail: anandhegs@yahoo.co.in
International Journal of Physiotherapy and Research, Int J Physiother Res 2015, Vol 3(2):992-98. ISSN 2321-1822 DOI: ht t p:/ / dx.doi.org/10.16965/ ijpr.2015.121
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International Journal of Physiotherapy and Research
ISSN 2321- 1822
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DOI: 10.16965/ ijpr.2015.121
Received: 12-03-2015 Peer Review : 12-03-2015 Revised: None
Accept ed : 23-03-2015 Published (O): 11-04-2015 Published (P): 11-04-2015
The heel is t he port ion of t he human body t hat
t her apy f or a gr o up o f p at i en t s w it h pat ellofemoral pain, t hey recruit ed 40 subject s among w hich group A consist of 20 individuals and group B consist of 20 individuals. These result s show ed t hat bot h t he t herapies t hat are TENS and Diadynamic current s w ere effect ive in t erms of pain management [6]. Rat ajczak B, Haw rylak A et al. st udied t he comparison w it h t he efficiency of analgesic Diadynamic current t herapy and TENS in low back discopat hy in age group of 45 t o 60 years w ho w as diagnosed w it h low back pain syndrome due to discopathy where subjected t o t herapy. There were 80 sample size in w hich group A of 40 individuals w ere given Diadynamic current t herapy and group B of 40 individuals w ere given TENS t herapy. On t he b asi s o f r esear ch t h ey co ncl u ded t h at Diadynamic current and TENS t herapies in low back discopat hy have an analgesic impact and improve funct ional fit ness [7].
M ENS is a device used t o send w eak elect rical si gn al s in t o t he b ody. Su ch d ev ices app ly ext rem ely sm all (less t han 1 m icro am pere) elect rical cur r ent s t o ner ves. M icr ocur r ent elect r i cal n er v e st i m ul at io n uses m i cr o -amperage current as opposed t o mill -amperage current w hich is found primarily in TENS devices. M icro am p cur rent is 1/1000 of a m illiam p current and is closer t o our ow n body’s nat ural healing current . M ENS w orks more on a cellular level and aids in t he healing pr ocess w hile relieving pain. It has been found t hat M ENS can help increase levels of a chem ical called ATP (adenosine t r iph osphat e) w hich pr om ot es prot ein synt hesis and healing in t issue cells [8]. Gabriel A, et al. st udied t he effect ive post o-perat ive analgesia is a prerequisit e t o enhance t he recovery process and reduce morbidit y. The sample size was 33 in which they concluded that M ENS t herapy, w hich enhances post surgical recovery by stimulating t he body’s nature healing p r o cess [ 9] . Zu im PR, et al . st ud ied t h e applicat ion of M ENS and occlusal splint t herapy in TM D (t emporomandibular disorders) pat ient s w it h muscle pain. 30 samples w ere st udied in w hich t hey concluded t hat t here w as an equal result found bet w een bot h t he t herapies [10]. There are various lit erat ures suggest ing t he effect of Diadynamic current s on numerous musculoskeletal pains. Similarly, t here have (calcaneus) is t he lar gest . It is f ound r ight
beneat h t he ankle joint . Expert s say t hat st ress placed on a foot when walking may be 1.25 t imes of our body w eight , and 2.75 t imes w hen run-ning [1]. Heel pain is usually focused on t he underside or t he back of your heel. In t he major-it y of cases, heel pain has mechanical cause. It may also caused by art hrit is, infect ion, an au-toimmune problem, trauma, a neurological prob-lem, or some ot her syst emic condit ion [2]. Up t o 10% of t he populat ion may present w it h heel pain over t he course of t heir lives, w hich under-scores t he import ance of pract it ioner familiar-it y w familiar-it h t he diagnosis of plant ar fascifamiliar-it is and t he associat ed risk fact ors, bot h int rinsic and ext rin-sic [3].
Heel pain is a common problem t hat people face, especially w omen. M ild heel pain can be short -term and may disappear on it s ow n. How ever, it can persist for a long t ime and t urn into a chronic condit ion w hich needs immediat e at t ent ion [4]. Various measures are available for t he t reatment of heel pain such as conservat ive management including Pharmacot herapy and Physiot herapy, o r su r gi cal m an agem en t . Phy si ot h er ap y t r eat m en t ai m s at r ed u ct i o n o f pai n an d stiffness, improve joint mobility, increase muscle st rengt h and t o help the individuals affect ed with heel pain great er funct ional independence in performing act ivit ies of daily living using various app r o ach es su ch as exer ci se t her apy, elect rot herapy, m anual t herapy t echniques, t aping and by providing ergonomic advice t o t he pat ient .
Anand B. Heggannavar et al. EFFECTIVENESS OF DIADYNAM IC CURRENT AND M ENS IN HEEL PAIN: A RANDOM IZED CLINICAL TRIAL.
been various st udies on t he effect of M ENS on pain. As t here is paucit y of st udy sugges-t ing sugges-t he effecsugges-t iveness of sugges-t hese modalisugges-t ies on t he basis of comparison, t he aim of t his st udy is t o examine t he effect iveness of Diadynamic current and M ENS along w it h t he same convent ional t reatment in bot h the groups in t erms of heel pain reduct ion and increase in funct ional abilit y.
M ETERIALS AND M ETHODS
Participants: 30 subject s w it h heel pain w ere r ecruit ed in t he st udy as per t he follow ing i ncl usi on cr i t er ia: 1) In di v id u al s w i t h age bet w een 18 t o 45 years, 2) Part icipant w illing t o p ar t i cip at e i n t h e st u dy, 3) Un cl assi f i ed mechanical plant ar heel pain, 4) Chronic heel pain defined as at least 3 m ont hs of ongoing heel pain w it h no evidence of acut e t rauma t o t he heel,5) Degree of heel pain rat ing on t he 0-10 Visual Analog Scale (VAS) is at least 3 for heel pain experienced upon t aking t he first few steps of t he day. Subject s w ere excluded if t hey had 1) Evidence of acut e t rauma t o t he heel, 2) Loss of plant ar foot sensat ion, 3) Skin ulcerat ion (infect ion or wound) on the heel and surrounding area, 4) Benign and malignant t umors, 5) Any Neurological condit ions. Informed consent w as taken from t he part icipant before intervent ion. St udy w as carried out in KLES Dr Prabhakar Kore Hospit al and M edical Research Cent er, aft er approval of Institut ional Ethical Committ ee, KLEU Inst it ute of Physiot herapy, Belgaum.
Outcome m easures: The out com e m easures
were Visual Analog Scale (VAS)[11], for pain, Pain Disabilit y Index and Foot Disabilit y Index for funct ional disabilit y. Pain was measured using VAS by asking t he pat ient t o m ar k a point indicat ing t he severit y of his/ her pain on a 0 t o 10 cm horizont al scale, w here 0 signified no pain and 10 signified t he w orst pain. Pain Disabilit y Index [12]is t he rat ing scale w hich has been designed t o m easur e t he degr ee t o w hich aspect s of t heir life are disrupt ed by chronic pain. In ot her w ords, it is t o know how much pain is prevent ing individuals from doing w hat t hey w ould normally do or from doing it as w ell as t hey normally w ould. PDI has 7 cat egories of life act ivit y list ed; individual should circle t he number on t he scale t hat describes t he level of
disabilit y t hey t ypically experience. A score of 0 m eans no disabilit y at all, and a score of 10 signifies t hat all of t he act ivit ies in w hich t hey w ould normally be involved have been t ot ally disrupt ed or prevent ed by t heir pain. Foot disabilit y Index is t he quest ionnaire w hich has been designed t o give t he physical t herapist infor m at ion as t o have t heir f oot pain has affect ed t heir abilit y t o manage everyday life. FDI [13] has 12 sect ions in each 6 st at ement s from w hich any one should be marked w hichever most closely applies t o t he individual.
Intervention: Aft er briefing t he part icipant s informed consent w as obt ained. The subject s w ere randomly allocat ed int o 2 groups by chit m et h o d. Gr o u p A: Di ad yn am ic cur r ent s, Therapeut ic ult rasound, st ret ching, exercises. Gr ou p B: M ENS, Th er ap eut i c u l t r aso un d , st ret ching, exercises.
Diadynamic current w as used w it h increase in int ensit y gradually unt il definit e vibrat ion or prickling sensat ion occurs, durat ion w as not more t han 12 minut es; for M odulat ion 4 And frequency w as one session daily not more t han 15 minut es for 7 sessions.
Fig. 1: Applicat ion of Diadynam ic Current .
M ENS w as used w it h i ncr ease in int ensit y gr adu all y u nt i l p r ickli ng sen sat ion occur s, Frequency: 1 microampere for 15 minut es for 7 sessions.
f requency 100-200 and durat ion of 1 M Hz, cont inuous, for 5 minut es for bot h t he groups as convent ional t reat ment .
Th e Lo w i n t en sit y exer cise gi v en as t h e convent ional t reat ment included 1. Ankle t oe movement s, 2. Walking on t oes, 3. Toe curling, 4. in t r i nsic m u scl e st r engt hen ing of Foo t . Follow ed by st ret ching exercises t hat included, 1. General calf st ret ch, 2. Foot sole st ret ch 3. Ball st ret ch.
RESULTS
The result s w ere analyzed in t erms of reduct ion in pain, and funct ional improvement . St at ist ical an al ysis w as do ne usin g SPSS ver si on 16. St at ist ical m easures such as m ean, st andard deviat ion and t est of significance (paired and unpaired “ t ” t est s) w ere used t o analyze t he dat a.
D em ogra p hic p ro file: Each gr o up had 15 part icipant s. M ean age of group A w as 25.8 ± 7.14 years and mean age of group B w as 25.7 ± 5.99 years (Table 1, Graph 1). Due t o t he randomizat ion process and pat ient compliance, bot h males and female part icipant s w ere not ed in bot h t he groups. 15 part icipant s in group A included 13 females 2 males t hat in group B out of 15, 13 w ere females and 2 w ere males.
Graph 1:Age dist r ibut ion.
Table 1: Age dist ribut ion am ong Group A and Group B.
M ean SD
Group A 25.8 ±7.14
Group B 25.7 ±5.99
Outcom e param eters: W it hin each group a st at ist ically significant decrease in pain and increase in funct ional abilit y w as not ed. In group A, t he mean VAS score pret reatment of 7.6 ± 1.12
mean difference of 6.9 ± 1.48. In group B, t he m ean VAS score pret reat m ent of 7.8 ± 0.77 reduced t o 3.4 ± 2.06 w it h mean difference of 4.3 ± 2.43. Int ra group comparison of pain score revealed st at ist ical significance w it h t =3.64and p =0.001for Group A and t = 2.99 and p=0.001 for Group B. In group A, t he mean PDI score pret reat ment of 326 ± 132 reduced t o 52 ± 36 post -t reat ment w it h mean difference of 274 ± 117. In group B, the mean PDI score pretreat ment of 289 ± 152 reduced t o 118 ± 88 w it h mean difference of 171 ± 99. Int ra group comparison of pain score revealed st at ist ical significance w it h t=2.43 and p= 0.001 for Group A and t= 2.51 and p=0.001 for Group B. In group A, t he mean FDI score pret reat ment of 0.59 ± 0.25 reduced t o 0.23 ± 0.6 po st -t r eat m ent w it h m ean difference of 0.36 ± 0.24. In group B, t he mean FDI score pret reat ment of 0.47 ± 0.26 reduced t o 0.32 ± 0.13 w it h mean difference of 0.15 ± 0.15In t r a gr ou p co m par ison of pain sco r e revealed st at ist ical significance w it h t =2.56 and p =0.001 for Group A and t = 2.82 and p=0.001 for Group B. (Table 2, Graph 2)
Table 2:Int ra group com parison of outcom e m easures.
M ean diff t P
Grp A 6.9± 1.48 3.65 0.001*
Grp B 4.3± 2.43 2.99 0.001*
Grp A 274± 117 2.43 0.001*
Grp B 171± 99 2.51 0.001*
Grp A 0.36± 0.24 2.56 0.001*
Grp B 0.15± 0.15 2.82 0.001*
VAS
PDI
FDI
* St at ist ically signif icant
Graph 2:M ean diff erence of Out com e M easures.
Anand B. Heggannavar et al. EFFECTIVENESS OF DIADYNAM IC CURRENT AND M ENS IN HEEL PAIN: A RANDOM IZED CLINICAL TRIAL.
DISCUSSION
The present st udy was undertaken t o determine t he effect iveness of Diadynamic current s and M ENS on heel pain, as measured using Visual analog scale. The ot her out comes paramet ers w ere funct ional limit at ion m easured by Pain disabilit y Index and Foot Disabilit y Index. Group A received Diadynamic current along w it h convent ional treatment (Therapeut ic ult rasound + exercise + St ret ching) w hile group B M ENS in addit ion t o convent ional treat ment .
Bot h groups show ed improvement in pain as evident by a decrease in t he VAS score and improvement in funct ional abilit y as evident in PDI and FDI score.
The mean difference of VAS scores for group A w as 6.9 ± 1.48 and for group B w as 4.3 ± 2.43. Int ra group comparison of pain score revealed st at ist ical significance w it h p value < 0.001+ in bot h t he groups. These may be at t ribut ed t o Diadynamic current t hat have t he effect of pain reliving t hrough 1) Pain masking i.e. increase of t he st i m u lat i on t hr esho l d b y DF cur r ent , 2) Vasodilatat ion and hyperemia due t o release of hist amine in t he t issues. The same can occur in deeper st ruct ures by reflex act ivit y, 3) M uscle f ib er s st im u l at i o n as Di ady n am i c cu r r en t st imulat es t he m uscle fibers, causing m uscle cont r act ion. CP and LP cur r en t s st im u lat e increase blood flow t o t he muscle and reduce edema, 4) St imulat ion of vibrat ion sense t hat leads t o cent ral masking of pain sensat ion [5], where M ENS treatment concentrat e on pain and/ or speeding w ound healing and recovery [14]. It also has been t heorized t hat M ENS increase the protein synthesis, stimulat e t he regeneration of injured t issue, st imulat e lymphat ic flow and relive m yofascial t rigger point s. M ENS w orks more on a cellular level and aids in t he healing process w hile relieving pain. It has been found
t hat M ENS can help increase levels of a chemical called ATP (adenosine t r iphosphat e) w hich promotes protein synt hesis and healing in t issue cells [8].
A st udy conduct ed by Rat ajczak B, Haw rylak A et al. t o com pare t he efficiency of analgesic Diadynamic current t herapy and TENS in low back discopat hy in age group of 45 t o 60 years w ho w as d iagn osed w i t h l o w b ack p ai n syndrome due t o discopathy w here subjected t o t herapy. On t he basis of research t hey concluded t hat Diadynamic current and TENS t herapies in low back discopat hy have an analgesic impact and improve functional fitness [7]. Present study agreed w it h a clinical t rial by Philipson T, et al on t he applicat ion of Diadynam ic current on chronic soft -tissue pain in t he neck and shoulder girdle. On t he basis of research t hey concluded that Diadynamic current t herapy gives equal pain relief for bot h neck and shoulder girdle soft -t issue pain [15].
M icro current t reat ment s concent rat e on pain and/ or speeding w ound healing and recovery [14] . It also has been t heor ized t hat M ENS increase t he prot ein synt hesis, st im ulat e t he r egen er at io n of i nj u r ed t issu e, st i m u lat e lym phat ic flow and relive m yofascial t rigger point s. A st udy w as done by Gabriel A et al. for ef f ect iv e po st op er at i v e an al gesi a is a prerequisit e t o enhance t he recovery process and reduce morbidit y and concluded t hat M ENS t herapy, w hich enhances post surgical recovery by st imulat ing t he body’s nat ure healing process [9]. Present st udy correlat ed w it h Zuim PR et al. st udied t he applicat ion of M ENS and occlusal splint t her apy in TM D (t em por om andibular d isor d er s) p at i en t s w i t h m u scl e pai n an d concluded t hat t here w ere equal result s found bet w een bot h t he t herapies [10].
Diadynam ic current s and M ENS t herapy are ef f ect iv e in r ed u cin g p ai n . In t er gr o u p comparison show ed significant difference w it h t =2.802 and p= 0.005 confirming Diadynamic current more effect ive t han M ENS Therapy. The mean difference of PDI scores for group A w as 274 ± 117 and for group B w as 171 ± 99. The mean difference of FDI scores for group A w as 0.36 ± 0.24 and for group B w as 0.15 ± 0.15. Int ra group comparison of bot h funct ional out
-Table N o. 3:Int er group com parison of outcom e m easures.
t P
Group A VAS 2.802 0.005*
Vs PDI 2.159 0.031*
Group B FDI 2.72 0.007*
-com e m easur es w er e p ain st at i st i cal l y significant w it h p value < 0.001+ in bot h t he groups. Pain and m uscle w eakness ar e t he cont ribut ing fact ors for t he disabilit y seen in t hese pat ient s w it h heel pain .Reduct ion in pain w ill lead t o an improvement in t he funct ion of t hese pat ient s, w hich w as also seen in t he present st udy. Inter group comparison show ed significant difference w it h t =2.159 and p= 0.031 and t =2.72 and p= 0.007 for PDI and FDI scores confirm ing group A funct ional abilit ies w ere more t han group B w hich could be at t ribut ed t o t he therapy t hat w as given t o t he participant s in bot h t he groups.
Participant s in bot h groups received Therapeutic ultrasound prior to t he exercises, w hich is a non-pharmacological preferent ial heat ing t reat ment . It helps cause a t em porary increase in t heir ext ensibilit y, and hence a decrease in j oint st iffness. The advant ages of using ult rasound t o achieve t his heat ing is due t o t he preferent ial heat ing of collagen t issue and t o t he effect ive penet rat ion of t his energy t o deeply placed st ruct ures. This accelerat ion may increase t he rat e of phagocyt osis, movement of part icles and t he cells. Hana Hronkova et al performed a study o n po ssi bi l it ies o f t h e anal gesi c ef f ect o f ultrasound therapy and non invasive t herapy, and concluded t hat there w as complet e reduct ion of pain in 50% of part icipants, part ial improvement in 16.6% and no effect in 33.3% of part icipant s t reat ed w it h ult rasound t herapy [16].
The increase in funct ional abilit y may be due t o increase mobility of soft t issue and subsequently improves range of mot ion (ROM ) by elongat ing (lengt hening) st ruct ures t hat have adapt ively short ened and have become hypomobile over t ime. A randomized, prospect ive st udy w it h 2-year f ol lo w up com par ed Achi ll es t en do n st ret ching w it h plant ar fascia t issue specific exercises [17] . The aut hor s f ound plant ar fascia–specific st retching exercises was better. A st udy w as conduct ed t o see t he effect iveness of st ret ching on pain and funct ion in people wit h plant ar heel pain. In t his 6 st udies w ere done t o compare st ret ching w it h a cont rol, st ret ching t o an alt ernat ive int ervent ion, st ret ching t o bot h alt er nat ive and cont r ol int er vent io ns, and different st ret ching t echniques and durat ions. St udy comparing different stretching t echniques,
show ed a st at ist ically significant reduct ion in some aspect s of pain in favour of plant ar fascia st ret ching over calf st ret ches in t he short t erm [18].
The present st udy results reflect t hat Diadynamic current along w it h t he convent ional t reat ment i.e. ult rasound, st ret ching and exercises had bet t er improvement t han t hat of M ENS along w it h the convent ional t reat ment i.e. ult rasound, st ret ching and exercises w hich w as measured in terms of pain relief, improvement in funct ional abilit y.
Limitations: St udy w as confined t o heel pain of non specific and non t raumat ic condit ions.
Re co m m e nd at ion s f or Fut u re St ud y: Th e present st udy can be conduct ed w it h specific condit ion of heel pain. St udies w it h longer durat ion are recommended w it h longer follow -up period t o assess long t erm benefit s.
CONCLUSION
Diadynamic current is effect ive in reduct ion of pain and t hereby improving t he functional abilit y in subject s w it h heel pain. It can be added as an adjunct to t he exist ing protocol for management of heel pain.
Conflicts of interest: None
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How to cite this article
:
Anand B. Heggannavar, Preet i R. Ram annavar, Sat yam S. Bhodaj i. EFFECTIVENESS OF DIADYNAM IC CURRENT AND M ENS IN HEEL PAIN: A RANDOM IZED CLINICAL TRIAL. Int J Physiot her Res 2015;3(2):992-998.
