ultrasound therapy in joint mobilzation

[vikks1984]

hi,
i have a patient who have fracture supracondylar of left humerus and she is treated surgically by y-plate and screws and in ulna by pins and k-wire.Range of motion of left elbow is flexion-100degree and extension-140 degree and she is come to me after 3 month of fracture so i want to ask that if i use ultrasound for mobilizing purpose so what is the mode,intensity and timing used and i have only 1MHZ frequency ultrasound.

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[estherderu]

dear colleague,

for up-to-date information regarding electrotherapy I suggest you go to
Electrotherapy on the Web - Home Page

kind regards

esther

[physiobob]

hi,
i have a patient who have fracture supracondylar of left humerus and she is treated surgically by y-plate and screws and in ulna by pins and k-wire.Range of motion of left elbow is flexion-100degree and extension-140 degree and she is come to me after 3 month of fracture so i want to ask that if i use ultrasound for mobilizing purpose so what is the mode,intensity and timing used and i have only 1MHZ frequency ultrasound.

I would suggest that Ultrasound is contraindicated with that much metal work in the joint. Suggest perhaps using some contract/relax type techniques, Manual mobilisation, perhaps some muscle stim to biceps or triceps with a view to assisting some reciprocal inhibition. But U/S is probable a NO-NO!

[Ontogenese]

I would suggest that Ultrasound is contraindicated with that much metal work in the joint. Suggest perhaps using some contract/relax type techniques, Manual mobilisation, perhaps some muscle stim to biceps or triceps with a view to assisting some reciprocal inhibition. But U/S is probable a NO-NO!

I got to agree with physiobob here...

To be honest, if you ask me... U/S in general is a NO-NO.

[smshaffe]

US has been shown to be virtually useless in lots of studies. but, i do believe it is safe to use over titanium (opinions vary on this topic - see article below). if you want a joint to improve its movement then mobilize it (unless the hardware physically restricts it from moving).

From the literature (I cut a bunch out but it is worth finding and reading):
"OBJECTIVES: To determine the amount of agreement among general rehabilitation sources for both superficial heating and therapeutic ultrasound contraindications... DATA SYNTHESIS: Eighteen superficial heat and 20 ultrasound sources identified anywhere from 5 to 22 and 9 to 36 contraindications/precautions, respectively. Agreement among sources was generally high but ranged from 11% to 95%, with lower agreement noted for pregnancy, metal implants, edema, skin integrity, and cognitive/communicative concerns. Seventy-two percent of superficial heat sources and 25% of ultrasound sources failed to reference at least 1 contraindication claim."
Batavia M. Contraindications for superficial heat and therapeutic ultrasound: do sources agree? Arch Phys Med Rehabil. 2004 Jun;85(6):1006-12.

[Josephine]

US has been shown to be virtually useless in lots of studies.

Thank you for that comment. I'm not an academic but have often thought as much!

but, i do believe it is safe to use over titanium

Very interesting.

[Ontogenese]

US has been shown to be virtually useless in lots of studies.

It has to be said though, that most of the studies investigating US as a useful treatment modality, had - unfortunately - little or nothing to do with proper physiotherapeutic care.

[smshaffe]

It has to be said though, that most of the studies investigating US as a useful treatment modality, had - unfortunately - little or nothing to do with proper physiotherapeutic care.

this i respectfully disagree with. US has been studied for decades and no one can agree if it works. that is not good. furthermore, it has been studied across lots of populations for lots of diagnoses and also in more scientific/parameter based approaches. in fact, lots of studies use it as a sham treatment because there is no convincing evidence that it does much (albeit many use very low frequencies but not all). even scarier, there have been studies done that show factory fresh units vary extensively in terms of their output (two sited below that aren't even ones with the highest variability found).

Some literature:
"Although many laboratory-based research studies have demonstrated a number of physiological effects of ultrasound upon living tissue, there is remarkably little evidence for benefit in the treatment of soft tissue injuries. This may be related to several confounding factors, including technical variables, the complexity and variety of underlying pathologies in soft tissue lesions, methodological limitations of clinical studies, or true lack of effect."
Therapeutic ultrasound in soft tissue lesions. Speed CA. Rheumatology (Oxford). 2001 Dec;40(12):1331-6.

even low intensity pulsed US which recently looked promising to heal fractures is somewhat in doubt. "CONCLUSION: Evidence for the effect of low intensity pulsed ultrasonography on healing of fractures is moderate to very low in quality and provides conflicting results. Although overall results are promising, establishing the role of low intensity pulsed ultrasonography in the management of fractures requires large, blinded trials, directly addressing patient important outcomes such as return to function."
Low intensity pulsed ultrasonography for fractures: systematic review of randomised controlled trials. Busse JW et al. BMJ. 2009 Feb 27;338:b351.

US variability:
"All manufacturers with the exception of Omnisound (P = .534) showed a difference between the reported and measured effective radiating area values (P < .001). All transducers were within FDA guidelines for power (+/-20%). Chattanooga (0.85 +/- 0.05 W/cm(2)) had a lower nSAI (P < .05) than all other manufacturers functioning at 3 MHz. Intramanufacturer variability in SAI ranged from 16% to 35%, and intermanufacturer variability ranged from 22% to 61%"
Variability in effective radiating area and output power of new ultrasound transducers at 3 MHz. Johns LD et al. J Athl Train. 2007 Jan-Mar;42(1):22-8.

Another:
"Differences between measured and displayed power output (limit, +/-20%) ranged between -32% and 28%. CONCLUSIONS: The effectiveness of treatment is lowered if the value of emitted power is not known reliably. In the worst case, damage or irritation of the skin is possible, particularly in patients with sensory compromised skin."
Variations in the output power and surface heating effects of transducers in therapeutic ultrasound. Kollmann C et al. Arch Phys Med Rehabil. 2005 Jul;86(7):1318-24.

[Ontogenese]

Dear SMSHAFFE,

first off, thank you for the interesting articles. I miss, however, the method and result section; personally I prefer those above the conclusion.
Second, I completely agree with you that US is most likely a doubtful treatment modality, at best. However, alot of studies that investigated US had little or nothing to do with the daily practice of the physiotherapist; a very prevalent problem in physiotherapy research. Considering the latter, one should ask him-/herself whether a randomized clinical trials is the optimal design for physiotherapy research. I don't think so, therefore I am very pleased to see more and more naturalistic trials embark in our field.
But I am wondering of... what were we talking about...

Regards,

Thomas

[smshaffe]

the topic at hand is using mobilization and US together. we both apparently agree that there is little added benefit from using US. mobilization and stretching is the key here if ROM is to be gained. additionally, I point out that we have to keep up on research. i doubt a physical therapist or any medical professional can practice at their best potential without keeping up on research. as for the articles i posted, this is no forum to cut and paste entire publications. if you would like to read anything i posted let me know and i can email it to you if you do not have access otherwise.

what form of research do you propose replaces RCTs? PT is hard to research because it is hard to have (if not impossible in most scenarios) a double blind scenario unlike pharmacology etc. it is also difficulty to quantify “impairment based” treatment which is really what we do (or should be doing instead of using US). for now the research we have is the best option to keep us informed and it is not likely to change any time soon despite the fact that a lot of it is crap.

[Ontogenese]

In my opinion, physiotherapy research will shift from RCT's to more advanced observational trials. If you look at the latest cochrane handbook (Cochrane Handbook for Systematic Reviews of Interventions) you will see the implementation of the GRADE approach to evaluate the body of evidence.
According to this approach a properly executed randomized trial is rated qualitatively as high as a double-upgraded observational study. Moreover, the upcoming use of computers by physiotherapists will result in the increase use of outcome measures and finally faclitate research projects in the actual physiotherapist's environment.

[Josephine]

hi,
i have a patient who have fracture supracondylar of left humerus and she is treated surgically by y-plate and screws and in ulna by pins and k-wire.

Not to be nit-picky! but her humerus is fixed with a tension band wire, not just K wires. It's a lot more stable a fixation than just Kirshner wires alone.

And for what it's worth, it looks like a superb bit of surgery! I'm impressed!

[davismathews]

hi you are not suppose u/s in supracondyle # b cos it is a contraindicated with the metal implantation ithink you can do with the other sort of manipulation like stretch stimulus &traction ,approximation technique ,pushpull method