ULTRASOUND FOR SOFT TISSUE HEALING

Deb RinkHaley Bryson

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.