Ultrasound therapy and metal implant

[Kaushal Bhatt]

Hello everyone,
I am searching articles related to ultrasound therapy and metal implant. Can we give ultrasound therapy in metal implant patient? There is enough evidence in the literature to support the claim that ultrasound is safe over metal implants because the soundwaves do not vibrate the metal to cause increased heating. Although, there is evidence that ultrasound can cause increased heating of plastic implants and cemented joints.
Reference: Cameron, Michelle, (2003) Physical Agent Modalities: from Research to Practice.So will u help me to get more articles supporting this?

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[junior_physiotherapist]

HI,

Really a very intersting topic,right now i'm looking for the same thing ,for sure once i've found them i'll tell u!!

Regards

[arnosh123]

hii..

This is my personal experience with US in metal implant patients. Say IM nailing. US does cause internal heating and the patient experiences a kind of internal heating and even at times feels some kind of mild vibrations which he might define as mild shock or it may be mild electric shock as well.
Thanks

Hello everyone,
I am searching articles related to ultrasound therapy and metal implant. Can we give ultrasound therapy in metal implant patient? There is enough evidence in the literature to support the claim that ultrasound is safe over metal implants because the soundwaves do not vibrate the metal to cause increased heating. Although, there is evidence that ultrasound can cause increased heating of plastic implants and cemented joints.
Reference: Cameron, Michelle, (2003) Physical Agent Modalities: from Research to Practice.So will u help me to get more articles supporting this?

[grahamwebb2000]

So will u help me to get more articles supporting this?

Do you want to support a view or find the truth?!

[sharmaphysio]

hi,

even i have practically seen that the patients have discomfort,i was surprised when a orthopedician want me to give ultrasound on metal implant in one case and muscle stimulator in other case,i want to show him the proof why i dont give them but couldnt fint it,


if anyone has,please tell us all


thanks

[kiren alberini]

hi kaushal, well to tell you the truth i have done one mistake in my life .. and im not doing again- i had a patient who had wrist fracture- cant remember which carpal bone- they had done k- wiring and metal implantment - it was very bad thats why they got to put it in that way.she was having bad scar after few months- plus with stiffness.. although doctor had said that she will never be able to gain full flexion and extension of her wrist due to the lifetime implantment but yet she couldnt even flex 5 degrees of wrist flexion- so i thought of trying u/s to relieve the scar mark plus increase extensibility- but to my dismay it didnt work- she start screaming of pain after 15 secs of u/s with very low intensity ...she told mie that she got some sort of electrocuted shock at her wrist and it was very bad... mind you... i dunt really agree that metal will not get heat with u/s... you better change your view on this articles..

[erafPT]

Hi Kiren Alberini! Can I just ask, did you place the probe on with gel directly over the wrist or did you do an underwater technique?

[kiren alberini]

well.... eraf- i think i done a direct contact!!!! hehehehe just kidding!

[erafPT]

Sorry, I didn't intend to imply anything with the question, Kiren. It's completely fine to do a probe-gel-skin technique. I have done this using a small head probe on a 5th MCP fracture which was k-wired without any untoward event.

But to some hands that are bony and may have very uneven surfaces and in the absence of a small probe, you would want to use underwater technique. That was all i wanted to point out. Even direct contact would be fine so long as there was enough gel. US should not heat the appliance...well in theory and in most cases...

[kiren alberini]

well eraf... i was juz being cautious as the metal seems slightly palpate-able..so under water technique was the best way to be safe ( i thought)...but it turn out to be ! neway... i would like to ask- if anyone knows what is the structure involved -if pain starts on the hip -lateral aspect- radiating sometimes towards the upper part of groin? could it be gleutues medius?iliac- psoas? well i tried doing tests on g.med/ iliac-psoas/ t.f.l... but it turn out to be negative.... anyone knows? the pain is more like pulling- so i thought it must be a tight soft tissue- but the patient is very active in sports- he does his gym-foot ball player--and also does yoga..- but i did found out he has hamstring tightness with lower back muscles tightness.... so what do yu guys think?

[erafPT]

Have you ruled out Rectus Femoris strain--football player an dlikely to have strained with bad kicking mechanics...

Does he have pain on particular mvts only or constant? How is it with straining? Ruled out hernia?

[chovik]

I haven't seen any valid research that actually says US is of any use at all. Causing pain due to applying over metal does not validate that US is, or would have been, of any use in the first place

[RTP]

I agree, there's insufficient evidence to say that ultrasound is of use. That doesn't necessarily mean that it's useless, but rather just that no-one has (as yet) been able to prove that it's beneficial. Having said that, I never use ultrasound in my clinic.

However, ultrasound over implants is ALWAYS going to be a bad idea, not because it heats the implant itself, but because too much heat is deposited into too small a volume of soft tissue. Normally when we use ultrasound, the "energy" of the vibration is slowly absorbed over a 3-4cm depth of soft tissue, meaning that the heat is distributed and the resulting heat effect isn't going to be too intense in any 1 spot. If there's an implant, the sudden change in density at the soft tissue/implant border means that the vibration can't carry across from one into the other, which means that all the remaining "energy" of the original vibration will be dumped into the tissues just before the implant. In other words, the tissues immediately superficial to the implant get too hot, and this can cause a burn. Unfortunately, since the burn is inside the body, you may not be able to see any sign of it on the skin at all. Best thing to do is explain the risks to your client (patient) and make sure they understand the importance of telling you immediately if they feel any heat concentrating in any 1 spot. Or better yet, use another modality, like scar massage?

[AussiePhysio]

I thoroughly agree with RTP's reply

WHY do we use u/s so much? - we have so many better options.

basic u/s physics will tell you that a soft tisue/metal interface = reflection of sound energy from the sound head (instead of absorption or transmission of the enery. This means the soft tissue surrounding the metal gets an extra (reflected) dose of sound energy, heating adjacent tissues much more quickly and possibly burning them. Thats one possible mechanism for pain from U/S around highly reflective areas.

The metal is not what gets hot as far as i have been taught- it's the tissue immediately adjacent.

At any rate, there is little evidence to support the use of ultrasound for most conditions it has been studied in - so does the risk outway the benefit?

we have far better tools to use than U/S

[blinko]

from my phsyics at A level, the sound will bounce back off the metal objkect, in fact it will be exactly how submaries and whales use sonar, so it will show up on the picture

but also it will absorb the sound waves and in turn generate heat and begin to vibate, now I doubt it wil be anything significant and Im talking on a grand scale here

I also doubt they will find the resonance frequncy (optimal) of the metal object with ultrasound

so long as you tell them, they will know exactly what to do

[zisuer]

To Kiren, from my personal experience, I don't think the electrical shock like sensation is caused by metal. When I was a student, my classmate put the US on my elbow, I don't have metal inside, but I felt this kind of electrical like pain, very sharp. The intensity is very low, we even put it very low, but I still feel it. I can't explain why this happened. I just know that I don't have metal implant.

[gcoe]

HI zisuer

I understand the sharp pain is due to a build up of standing waves that are created at at the interface between bone and soft tissue. Because the elbow is so boney this is easy to do. the incident waves coming from the US head interact with the waves reflected off the bone to create standing waves - the two superimposed waves interact so that two peaks come together to create abnormally high intensities and pressures. Standing waves are more or less statiunary because of the waves combining from two opposing directions - and hence they build up very quickly. It is because of standing waves that you are supposed to keep the US head moving at all times. The periosteum is in the firing line of the standing waves and as it is a very pain sensitive tissue you get this very sharp pain. beacuse of the pain sensitive nature of periosteum you don't need the US up very high to get the effect

Standing waves not only cause pain but do terrible things to blood vessels and other other cells, destroying erythrocytes and generating free radicals - so use lots of gel , lowest possible dosage to achieve the effect, and keep the head moving.

At the end of the day I wonder if it is worth it. Most of the studies show it is useless for most purposes.

[zisuer]

Thanks for the explaination, but we did use a lot of gel, and kept moving, and very low dose. it still occured.

Anyway, my understanding is that, there is no evidence for the effectiveness of US, but there is no enough evidence to say that US does't work for sure.

[gcoe]

I don't know about that, zisuer. It seems to have no real benefit for OA, patello-femoral pain, tendon problems, ankle sprains etc etc. Most systematic review report no benefit. Yes we could always have more trials but given the number of trials already conducted of adequate quality demonstrating no benefit, how much evidence do we need before we'll wake up to it and give it away? It isn't as if we don't have good evidence for other techniques for such patients

The real exception seems to be various types of open wound/ulcer healing where it may have modest benefits.

As for the technique on the elbow - I guess that just shows how easy it is to set up standing waves at a bony interface.

[zisuer]

I am not the fan who like use modalities. We don't need too many trials to make the decision. We only need one trial which is good enough and big enough.

[gcoe]

Yes I agree. if it is a really well designed large trial that shows no benefit – then that will often convince me – unless there happens to be an equally well designed large trial that does show benefit.

However if there is a really well designed large trial that does show clinically significant benefit then I would be encouraged but I would still want to see the study replicated by an independent team, before being convinced. I would remain sceptical until I saw the replicated evidence because we just seem so good at fooling ourselves that our treatments are effective when they turn out not to be the case.

So why do we keep trundling the US unit out despite the evidence of no effect. I think the reason why people won’t give up on US is that it is such a good placebo:

• It is an impressive looking metal box with leads, buttons knobs and readouts that light up and flash.
• There is the ritual of putting on the gel on the head and also on the painful part
• Then gently rubbing the painful part while the machine knowingly keeps flashing lights at the patient and giving out readouts
• And all the time the therapist is by the patient concentrating on the act of healing.

I am sure if it made a nice whooshing sound and they added some more flashing lights it would work even better.

[zisuer]

Hehe. It is fun to read your tread. Anyway, you have bias, hehe. I agree with your opinion, but either way, I would like see another trial to confirm the first trial. Before we have any evidence, don't think we fool ourself. As to placebo, I remember one guy who told us that he likes placebo effect and if he can he want to enhance the placebo effect, because it can benefit patient anyway. Different attitude , eh?

Seriously, there are quite a few systemic review showed that US is no effect, but the trials included in these review either small or different dose, insuficcient treatment time. Therefore, using these evidence to prove the effective of US is not convincing. Even I only use US when I don't know what I should do. hehe.

May I ask you one extra question, what do you thinK PT can do for ganglion ( painful)? The effectiveness?

[gcoe]

Hi zisuer

Yes I am getting to be a really mean old skeptic - put it down to grumpy old man syndrome.

As for Wrist ganglion - I couldn't find anything on PEDro for treating wrist ganglion and I don't know of any such studies - I suspect there is nothing much out there but I'll check on some other databases when I am back at work next week.

I don't think the pathology is that well understood all though it is agreed that it is a cyst - probably synovial from the carpal joints. some are reduceable by pressing on them but return releasee of the pressure - in this case they are a bit like a herniation from the carpal joint.

Aspirating them with an injection has a bad relapse rate.

When I trained the treatment recommended was to get a huge hardback book (usually the families holy bible), then get the patient to put their hand palm down on the bench and give their wrist a huge whack with the bible! The idea is that this shatters the cyst and therefore the synovium in the cyst is dissipated and less likely to return. - I suspect you may think this has worked because the patient would never return (out of pure fear). Please note I am not recommending this!

The best tried and true method is surgical removal - can often be done under a local anaesthesia.

Still Zisuer, you could always give the ganglion a treatment with ultrasound - but make sure you have the machine that gives the nice whooshing sound and the extra flashing lights! (sorry couldn't help myself)

[aprillove20]

Well, It is an impressive looking metal box with leads, buttons knobs and readouts that light up and flash..

[alophysio]

Hmmm,

i am very sensitive to U/S - i once had a physio want to use it on me when i was a student and had back pain (turned out to be kidney stones). Anyway, i told him don't go above 0.5W/cm2 or you will burn me - he seemed dubious and asked if that were true - i don't think he trusted me.

Anyway, he did it and it was going ok and i checked during the treatment because i could feel it heating up a but (which it shouldn't). I think he was trying to prove me wrong to be honest...anyway i got a burnt feeling and jumped up off the table (it hurt!). He quickly turned it off and turned the knobs down and was a bit sheepish - i didn't report him or anything but he really should have listened to me!!!

The moral of the story is (apart from LISTEN to your patients) is that no one so far has talked about the mechanical stimulation of the nerves which might be happening.

I know people who feel 0.5W/cm2 as being very warm (like me) and those who don't feel a thing on 2W/cm2.

I also get a very wierd nervy kind of sensation when i U/S my ankle as a new grad...ATFL is close to branches of the peroneal nerve and posteriorly there is also the sural nerve.

just my thoughts...