Typically physical therapy
modalities have had very poor evidence to support their use. Despite the historical lack of evidence 63% of chiropractors use ultrasound for therapy. Positive results account for this significant segment of the profession using ultrasound therapy (UT) but without evidence reimbursement has become a challenge. Fortunately more emphasis is now being placed on examining the efficacy of UT and there have been a significant number of research studies published in 2010 that support its use. Two different papers recommend UT for myofascial pain syndromes. It is characterized as both safe and cost-effective for trigger points. In another small (N=26) single blind trigger point study the conclusion was that “Thermal ultrasound over latent trigger points is comfortable and can decrease stiffness of a trigger point”.
Two other 2010 studies support the use of UT for osteoarthritis. One study was a well designed randomized placebo controlled clinical trial for hip osteoarthritis. The conclusion was that “addition of therapeutic ultrasound to the traditional physical therapy showed a longitudinal positive effect on pain, functional status, and physical QoL in patients with hip osteoarthritis. The use of therapeutic ultrasound in the treatment of hip osteoarthritis should be encouraged, and it seems worthy to continue with large clinical trials on ultrasound in order to standardize the treatment modality in this patient group.” Yet another osteoarthritis systematic review of UT for hip and knee was conducted as a Cochrane Database Systematic Review. Their conclusions were that “In contrast to the previous version of this review, our results suggest that therapeutic ultrasound may be beneficial for patients with osteoarthritis of the knee.”
Two other studies have been published this year supporting the use of UT for spinal stenosis and acute bacterial rhinosinusitis. The latter was an RCT that concluded that “The results of this study suggest that therapeutic ultrasound is a viable alternative to antibiotics in the management of acute bacterial rhinosinusitis.”
Obviously more research is needed but this is an unparalleled year for research supporting the use of ultrasound therapy. For more on ultrasound therapy, please visit the procedure overview at ChiroACCESS.
Note: These mini-reviews are designed as updates and direct the reader to the full text of current research. The abstracts presented here are no substitute for reading and critically reviewing the full text of the original research. Where permitted we will direct the reader to that full text.
New trends in the treatment and management of myofascial pain syndrome.
]Curr Pain Headache Rep.
Srbely JZ. Department of Human Health and Nutritional Science, University of Guelph, Guelph, ON, N1G 2W1, Canada, firstname.lastname@example.org.
Myofascial pain syndrome presents a significant physical and financial
burden to society. In view of the aging demographics, myofascial pain promises to be an even greater challenge to health care in the future. Myofascial trigger points have been identified as important anatomic and physiologic phenomena in the pathophysiology of myofascial pain. While their pathophysiologic mechanisms are still unclear, emerging research suggests that trigger points may be initiated by neurogenic mechanisms secondary to central sensitization, and not necessarily by local injury. A variety of treatments are employed in the management of trigger points, including manual therapy, electrotherapy, exercise, and needle therapy. Therapeutic ultrasound demonstrates significant potential as a safe, cost-effective, and relatively noninvasive therapeutic alternative in the treatment and management of this modern day medical enigma.
Efficacy of exercise and ultrasound in patients with lumbar spinal stenosis: a prospective randomized controlled trial.
2010 Jul;24(7):623-31. Epub 2010 Jun 8.
Goren A, Yildiz N, Topuz O, Findikoglu G, Ardic F. Bio-Fiz Rehabilitation Center, Ankara, Turkey. OBJECTIVE:
To assess the effectiveness of therapeutic exercises alone and in combination with a single physical agent - ultrasound - in patients with lumbar spinal stenosis. DESIGN:
Randomized, prospective, controlled trial. SETTING:
Department of Physical Medicine and Rehabilitation, University Hospital. SUBJECTS:
Forty-five patients presenting with symptoms of neurological claudication and magnetic resonance image-proven lumbar spinal stenosis were assigned to one of three groups: ultrasound plus exercise group (group 1, n =15), sham ultrasound plus exercise group (group 2, n= 15) and no exercise - no treatment group (control group, n = 15). INTERVENTIONS:
Stretching and strengthening exercises for lumbar, abdominal, leg muscles as well as low-intensity cycling exercises were given as therapeutic exercises. Ultrasound was applied with 1 mHz, 1.5 W/cm(2) intensity, in continuous mode on the back muscle for 10 minutes in group 1 while ultrasound on/off mode was applied in group 2. MAIN OUTCOME MEASURES:
Before and after a three-week period, all subjects were evaluated by pain, disability, functional capacity and consumption of analgesic. RESULTS:
Thirty-two of the participants were women and 13 were men, with an average age of 53.2 +/- 12.68 years (range 25-82 years). After a three-week treatment period, leg pain decreased in group 1 (-1.47 +/- 3.02) and group 2 (-2.47 +/- 3.75) compared with the control group (P<0.05). Disability score decreased in group 1 (-3.94 +/- 7.20) and group 2 (-7.80 +/- 10.26) compared with control group (P<0.05). We did not find any statistically significant difference between groups 1 and 2 (P>0.05). The amount of analgesic consumption is significantly less in the group with ultrasound application compared to that in the control group (P<0.05). CONCLUSION:
The results of our study suggest that therapeutic exercises are effective for pain and disability in patients with lumbar spinal stenosis and that addition of ultrasound to exercise therapy lowers the analgesic intake substantially.
Similar effect of therapeutic ultrasound and antibiotics for acute bacterial rhinosinusitis: a randomised trial.
Høsøien E, Lund AB, Vasseljen O. Physiotherapy Private Practice, Roros, Norway. QUESTION:
Is there any difference between the effect of therapeutic ultrasound and antibiotics (amoxicillin) on pain and congestion for acute bacterial rhinosinusitis in the short-term? Is there any difference in patient satisfaction, preferred future intervention, side-effects and relapses in the long-term? DESIGN:
A randomised trial with concealed allocation and intention-to-treat analysis. PARTICIPANTS:
48 patients (6 dropouts) with clinically diagnosed acute bacterial rhinosinusitis in primary care. Intervention: The experimental group received 4 consecutive days of ultrasound and the control group received a 10-day course of antibiotics. OUTCOME MEASURES:
Pain and congestion around the nose and in the forehead and teeth were measured on a 0-10 numeric rating scale at baseline, Day 4, and Day 21. Satisfaction, preferred future intervention, side-effects, and relapses were measured one year later. RESULTS:
By Day 4, pain around the nose had decreased by 1.5 points out of 10 (95% CI 0.6 to 2.5) more in the experimental group than the control group. There were no other differences in decrease in pain and congestion between the groups at Day 4 or 21. At one year follow-up, the experimental group were more likely to prefer ultrasound than the control group were to prefer antibiotics to manage a future episode (RR 2.75, 95% CI 1.19 to 7.91). There were no other differences between the groups in terms of satisfaction with intervention, number of side-effects, or number of relapses. CONCLUSION:
The results of this study suggest that therapeutic ultrasound is a viable alternative to antibiotics in the management of acute bacterial rhinosinusitis.
The effect of additional therapeutic ultrasound in patients with primary hip osteoarthritis: a randomized placebo-controlled study.
2010 May 26. [Epub ahead of print]
Köybasi M, Borman P, Kocaoglu S, Ceceli E. Ankara Training and Research Hospital, Clinic of Physical Medicine and Rehabilitation, Cebeci, Ulucanlar, Ankara, Turkey.
To the best of our knowledge, there is no study in the English literature about the usefulness of ultrasound therapy in degenerative hip osteoarthritis. The aim of this study was to examine its short- and long-term efficacy in patients with primary hip osteoarthritis with regard to pain, functional status, and quality of life (QoL). Forty-five patients with primary hip osteoarthritis were enrolled into the study. Demographic and clinical characteristics including age, sex, duration of disease, and pain on activity and at rest using visual analogue scale (VAS) were recorded. Functional status was determined by a 15-m timed walking test and Western Ontario McMaster Osteoarthritis Questionnaire. QoL was determined by the Short Form-36 survey (SF-36). Each patient was randomly assigned to either group I (standard physical therapy including hot pack and exercise program), group II (sham ultrasound in addition to standard physical therapy), or group III (ultrasound and standard physical therapy). The main outcome measures of the treatment were pain intensity by VAS; functional status measurements that were evaluated at baseline, at the end of the therapies, and at the first and third month of follow-up; and QoL scores that were determined at baseline and at the end of the first and third months. Twelve male and 33 female patients (mean age, 65.3 +/- 6.7 years; mean disease duration, 2.5 +/- 1.7 years) were included in the study. There were no differences between the groups regarding demographic variables on entry to the study. There were 15 patients in each group. Pain and functional outcome measures were determined to have improved significantly in all of the groups at the end of the therapies, but these improvements continued at the end of the first and third months only in group III (p < 0.001) The physical subscores of SF-36 were improved at the end of the first month and were maintained at the end of the third month only in patients receiving additional ultrasound therapy (group III, p < 0.001), while mental subscores of SF-36 did not change significantly in any group. In conclusion, addition of therapeutic ultrasound to the traditional physical therapy showed a longitudinal positive effect on pain, functional status, and physical QoL in patients with hip osteoarthritis. The use of therapeutic ultrasound in the treatment of hip osteoarthritis should be encouraged, and it seems worthy to continue with large clinical trials on ultrasound in order to standardize the treatment modality in this patient group.
Thermal ultrasound decreases tissue stiffness of trigger points in upper trapezius muscles.
]Physiother Theory Pract.
2010 Apr 22;26(3):167-72.
Draper DO, Mahaffey C, Kaiser D, Eggett D, Jarmin J. Department of Exercise Sciences, Brigham Young University, Provo, Utah, USA.
Many trigger point therapies, such as deep pressure massage
and injection, are painful. Thermal ultrasound might be a comfortable procedure used to soften trigger points. Our objective was to compare thermal ultrasound with sham ultrasound in the ability to soften trigger points with pretest/posttest repeated-measures design for depth of tissue in a massage therapy clinic. Twenty-six patients with latent trigger points in their upper trapezius muscles were studied. Independent variables were treatments; dependent variables were tissue depth. Subjects were randomly assigned to either the treatment or sham group. The study was single-blinded; the investigator taking the measurements was blinded to which group the subjects were in, and the clinician treating with ultrasound was blinded to the measurements. Each trigger point in the treatment group received 3 MHz ultrasound at the following parameters: 1.4 W/cm(2), 5 min, circular motion, 2x the size of the 7 cm(2) soundhead. The ultrasound was not turned on for the sham group. This procedure was repeated one week later. Trigger point depth was measured with a pressure algometer before and immediately after each treatment. A 2 x 2 x 2 repeated measures ANOVA was used to analyze depth (mm). The immediate effects were as follows: The mean depth value for the sham group was an increase of 0.64+/-0.33 mm; the treatment group's mean increase was 2.65+/-0.33 mm (F(1,24)=19.01; p=0.01). The residual effects were as follows: The two treatments over the course of the 2 weeks also showed that the trigger points of the ultrasound groups got softer with an increase in depth of 2.09+/-0.82 mm compared to -0.93+/-0.82 mm of the sham group (F(1,24)=6.81; p<0.01). Thermal ultrasound over latent trigger points is comfortable and can decrease stiffness of a trigger point.
Therapeutic ultrasound for osteoarthritis of the knee or hip.
]Cochrane Database Syst Rev.
2010 Jan 20;(1):CD003132.
Rutjes AW, Nüesch E, Sterchi R, Jüni P. Division of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, Bern, Switzerland, 3012. BACKGROUND:
Osteoarthritis is the most common form of joint disease and the leading cause of pain and physical disability in the elderly. Therapeutic ultrasound is one of several physical therapy modalities suggested for the management of pain and loss of function due to osteoarthritis (OA).
To compare therapeutic ultrasound with sham or no specific intervention in terms of effects on pain and function safety outcomes in patients with knee or hip OA.
We updated the search in CENTRAL, CINAHL, EMBASE, MEDLINE and PEDro up to 23 July 2009, checked conference proceedings, reference lists, and contacted authors.
Studies were included if they were randomised or quasi-randomised controlled trials that compared therapeutic ultrasound with a sham intervention or no intervention in patients with osteoarthritis of the knee or hip.
DATA COLLECTION AND ANALYSIS:
Two independent review authors extracted data using standardized forms. Investigators were contacted to obtain missing outcome information. Standardised mean differences (SMDs) were calculated for pain and function, relative risks for safety outcomes. Trials were combined using inverse-variance random-effects meta-analysis
Compared to the previous version of the review, four additional trials were identified resulting in the inclusion of five small sized trials in a total of 341 patients with knee OA. No trial included patients with hip OA. Two evaluated pulsed ultrasound, two continuous and one evaluated both pulsed and continuous ultrasound as the active treatment. The methodological quality and the quality of reporting was poor and a high degree of heterogeneity among the trials was revealed for function (88%). For pain, there was an effect in favour of ultrasound therapy, which corresponded to a difference in pain scores between ultrasound and control of -1.2 cm on a 10-cm VAS (95% CI -1.9 to -0.6 cm). For function, we found a trend in favour of ultrasound, which corresponded to a difference in function scores of -1.3 units on a standardised WOMAC disability scale ranging from 0 to 10 (95% CI -3.0 to 0.3). Safety was evaluated in two trials including up to 136 patients; no adverse event, serious adverse event or withdrawals due to adverse events occurred in either trial.
In contrast to the previous version of this review, our results suggest that therapeutic ultrasound may be beneficial for patients with osteoarthritis of the knee. Because of the low quality of the evidence, we are uncertain about the magnitude of the effects on pain relief and function, however. Therapeutic ultrasound is widely used for its potential benefits on both knee pain and function, which may be clinically relevant. Appropriately designed trials of adequate power are therefore warranted.