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Overview of Ultrasound (US)
Definition: inaudible, acoustic vibrations of high frequency that produce thermal and/or non-thermal physiological effects (Knight, 2008)
Primarily used for soft tissue healing and pain relief
Selectively heats deep tissues high in collagen without heating more superficial structures
Uses the vibration of the crystal to generate heat: not an electromagnetic modality http://www.youtube.com/watch?v=e9mIlejjk1I
Thermal Effects
Increases extensibility of collagen fibers Reduces fluid viscosity in the Rx area Decreases joint stiffness Reduces muscle spasm Diminishes pain perception Increases cellular metabolism Increases blood flow
Non-thermal Effects
Increases histamine release Calcium ion influx Increases phagocytosis Increases protein production Increases capillary density Promotes tissue regeneration Promotes wound healing Cell membrane alterations Attraction of immune cells Increases fibroblasts to the area Promotes vascular regeneration
Therapeutic Uses
Aid in inflammatory process Superficial wound healing Connective tissue healing Bone healing Bone growth stimulators Growth plates Assessing stress fractures Pitting edema Reducing muscle spasm Reducing pain Restoring ROM from scar tissue and/or joint contractures Stretching connective tissue Treating chronic inflammation Drug administration
Indications Acute and post-acute conditions Soft tissue healing and repair Scar tissue Joint contracture Chronic inflammation Increase extensibility of collagen Reduction of muscle spasm Pain modulation Increase blood flow Soft tissue repair Increase protein synthesis Bone healing Repair of non-union fractures Inflammation associated with myositis ossificans Plantar warts Myofascial trigger points
Contraindications
Acute and post-acute Vascular insufficiency Thrombophlebitis Eyes Reproductive organs Pelvis immediately after menstruation Pregnancy Pacemaker Malignancy infection
Summary of Studies: Animal Model
Animal studies showed physiological success
Shown to have an increase in mechanical strength of patellar tendon (Fu, 2008, Sparrow, 2004)
Increased amount of type 1 collagen in patellar tendon (Fu, 2008, Sparrow, 2004)
Summary of Studies: Human Model
Treatment groups had insignificant and/or no change versus the sham group with lateral epicondylitis and patellar tendinitis (D’Vaz, 2005, Warden, 2008, Stastinopoulos, 2004)
Only one study showed significant improvements with calcific tendons in the shoulder (Ebenbichlere, 1999)
Injuries treated in these studies may have benefited from thermal effects
Concluded that there needs to be more studies to look at the effectiveness of this modality
Gaps in Current Research
Differing opinions exist concerning the effects US has on soft tissue because of a lack of evidence (Speed, 2001)
Insufficient evidence to support that US for soft tissue healing is effective
Not a consistent body of evidence for any one situation Too much variety in Rx areas and not enough
evidence on any one area: patellar tendon, MCL, lateral elbow tendons, shoulder tendons
Inconclusive and inconsistent findings in this group of evidence based research articles
Gaps in Current Research
Long term benefits after cessation of US to various types of soft tissue have not been investigated (Sparrow, 2005)
Human studies are not all randomized as the researchers have to seek out subjects who have been injured
Majority of studies only look at low-intensity pulsed US and not continuous US
In vivo studies show vastly different results than human studies and it is difficult to impossible to extrapolate between the studies In vivo: physiological measurements and no subjective
measurements Human: subjective measurements and no physiological
measurements
Proposed Methodology
The purpose of this study is to determine the effectiveness of low-intensity pulsed ultrasound on healing patellar tendinitis, and specifically, to compare ROM and subjective reports of pain between the low intensity pulsed ultrasound group, the sham group, and control group.
Proposed Methodology
Subjects 78 individuals with grade 2 or 3 patellar
tendinitis 18-30 years old Active with at least moderate exercise 3-5
times per week
Proposed Methodology
Subjects Inclusion criteria:
Pain on palpation of tenoosseous junction of the infrapatellar tendon
Unilateral pain Pain on resisted knee extension Onset of symptoms >6 weeks
Exclusion criteria: Grades 1 and 4 patellar tendinitis Any surgically repaired tendons No previous injury to the knee Non-smokers, no steroid or NSAID use within the
past 6 weeks
Proposed Methodology
Experimental Design 4 weeksof 12 treatments every Monday,
Wednesday, and Friday Subject recruitment is from physical therapy
and orthopedic clinics Outcome measures will be measured on
initiation day and after every treatment Pain using a 0-10 likert scale ROM of knee flexion and extension using
goniometry Outcome measures taken at 2 weeks and 4
weeks after the last treatment for long tern effects
Proposed Methodology
Treatment groups: Group (26 subjects)1: low intensity pulsed
ultrasound treatment group Group 2 (26 subjects): sham treatment group Group 3 (26 subjects): control group
Double blind: All treatments applied by one clinician, and all measurements taken by a different clinician. Neither clinician know which treatment is being applied. The patient does not know which treatment they are receiving.
Proposed Methodology
US treatment parameters Selected based on current evidence based
practice of US on connective tissue healing 20%, 0.5 w/cm2, 5 minutes for 12 days
Proposed Methodology
Statistics 2-tailed t-tests compared pain levels and ROM
measurements independently from each other Significance was determined at p<0.05
Conclusions
Most clinics and sites don’t use calculated US parameters or evidence based parameters
Low-intensity pulsed US on connective tissue healing is inconclusive on if it works If you use this modality in this fashion, use the
evidenced based parameters suggested in our class 20%, 0.5 W/cm2, 5 minutes, 12 days
Article Discussion
The use of US for soft tissue healing is not effectively supported by the evidenced based research available to date Most articles didn’t prove US effectiveness using
low intensity pulsed US In this article with US on calcific tendinitis of the
shoulder, positive results were found. This is the only article with calcified deposits in the
tendon and the only human study resulting in improvements in the Rx group vs. the control group.
Parameters: 20%, 0.89 MHz, 2.5 W/cm2, 5 cm2 soundhead, aquasonic gel, 15 min
References D'Vaz, A., Ostor, A., Speed, C., Jenner, J., Bradley, M., Prevost, A., & Hazelman, B. (2005). Pulsed low-intensity
ultrasound for chronic lateral epicondylitis: a randomized control trial. British Society for Rheumatology, 45(22), 566-70.
Ebenbichler, G., Erdogmus, C., Resch, K., Funovics, M., Kainberger, F., Barisani, G., Aringer, M., Nicolakis, P….. &
Fialka- Moser, V. (1999). Ultrasonic therapy for calcific tendinitis of the shoulder. The New England Journal of Medicine, 340(20), 1533-38.
Fu, S., Shum, W., & Hung , L. (2008). Low intensity pulsed ultrasound on tendon healing. The American Journal of
Sports Medicine, 36(9), 1742-49.
Knight, K., & Draper, D. (2008). Therapeutic modalities the art and science. (1 ed., pp. 255-77). Philadelphia, PA: Lippincott Williams and Wilkins.
Sparrow, K., Finucane, S., Owen, J., & Wayne, J. (2005). The effects of low intensity pulsed ultrasound on medial collateral ligament healing in the rabbit model. The American Journal of Sports Medicine, 33(7), 1048-56.
Speed, C. (2001). Therapeutic ultrasound in soft tissue lesions. British Society for Rheumatology, 40, 1331-36.
Stasinopoulus, D., & Stasinopoulos, I. (2004). Comparison of effects of an exercise programme, pulsed ultrasound, and transverse friction massage in the treatment of chronic patellar tendinopathy. Clinical Rehabilitaion, 18, 347-52.
Tsai, W., Tang, S., & Liang, F. (2011). Effect of therapeutic ultrasound on tendons. American Journal of Physical Medicine and Rehabilitation, 90, 1068-73.
Warden, S., Metcalf, B., Kiss, Z., Cook , J., Purdam , C., Bennell, K., & Crossley, K. (2008). Low intensity pulsed ultrasound for chronic patellar tendinopathy: a randomized, double-blind, placebo controlled trial. British Society for Rheumatology, 47, 467-71.