The use of therapeutic ultrasound by physical therapists in Dutch primary health care.Key Words: Appropriate are, ICIDH ICIDH International Classification of Impairments, Disability and Handicaps , Physical theraphy, Survey research, Ultrasound. Ultrasound is an intervention that is frequently used by physical therapists. In the northeastern United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , 64% of physical therapists use ultrasound at least once per day.[1] In private physical therapy practices in Brisbane, Queensland, Australia, this percentage is 93%.[2] In physical therapy clinics of National Health Service hospitals in the United Kingdom  This article has recently been split into multiple articles entitled:
tr.v. ob·li·gat·ed, ob·li·gat·ing, ob·li·gates 1. To bind, compel, or constrain by a social, legal, or moral tie. See Synonyms at force. 2. To cause to be grateful or indebted; oblige. to have a therapeutic ultrasound Therapeutic ultrasound is a technique that uses high-frequency sound waves (ultrasound) to speed healing in injured joint or muscle tissue. The frequency used is typically 1-3 Mhz. device,[5] and ultrasound is used in 17% of all episodes of care.[6] The surveys mentioned here describe general trends in the use of ultrasound in physical therapy practices, such as conditions treated with ultrasound,[3,4] availability of ultrasound devices, and adequacy of training in the use of this form of therapy.[1,2] More specific information on practice patterns (eg, addressing treatment goals that physical therapists pursue with ultrasound and timing of its application in the course of treatment), however, is lacking. This knowledge about the use of a form of therapy is important for the further development of the physical therapy profession, especially in understanding why physical therapists apply certain interventions and the particular situations in which these interventions are applied.[7] Furthermore, this information could be helpful in designing effect studies that are clinically relevant. The first aim of our study, therefore, was to describe the use of ultrasound by Dutch physical therapists working in the primary health care system. Whether the use of ultrasound by physical therapists is in line with its expected use, based on the present body of knowledge, is not known. This is essential information from the perspective of an efficient application of care. The second aim of our study, therefore, was to gain insight into the degree of correspondence between "theory" and practice regarding the use of ultrasound. With respect to the theory on the effectiveness and working mechanisms of ultrasound, a large amount of literature is available. The hypothesized effects of ultrasound are based primarily on studies on tissue repair in animals[8-10] and on clinical experiences.[11,12] There are several studies on the clinical effectiveness of ultrasound, but these randomized clinical trials randomized clinical trial, n a clinical study where volunteer participants with comparable characteristics are randomly assigned to different test groups to compare the efficacy of therapies. have equivocal EQUIVOCAL. What has a double sense. 2. In the construction of contracts, it is a general rule that when an expression may be taken in two senses, that shall be preferred which gives it effect. Vide Ambiguity; Construction; Interpretation; and Dig. results.[11-22] On the basis of these studies, definitive conclusions about the clinical effectiveness of ultrasound cannot be drawn. Thus, criteria for the expected use of ultrasound have to be derived from a broader perspective, including textbooks,[23,24] literature on the underlying mechanisms of action of ultrasound,[8-10,25] judgments of veteran therapists,[11,12] and elements of clinical effect studies. Based on these sources of literature, we formulated 4 assumptions on the expected use of ultrasound[26] with regard to (1) reasons for referral, (2) timing of application, (3) treatment goals, and (4) contribution to total treatment. Several authors[8,12,21,23-25] refer to ultrasound as having a beneficial effect on the healing of soft tissues. The heating effects of ultrasound can reach periarticular periarticular /peri·ar·tic·u·lar/ (-ahr-tik´u-lar) around a joint. per·i·ar·tic·u·lar adj. Surrounding a joint. periarticular situated around a joint. structures.[12,13,24] Based on these presumed effects, we developed a list of indications for the use of ultrasound. Our first assumption was: Assumption 1--reasons for referral. We expected that ultrasound will be applied mainly to soft tissue injuries because of its presumed effect of accelerating healing damaged tissues.[11-13,23] According to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. the literature, injuries of the elbow (especially lateral humeral epicondylitis lateral humeral epicondylitis n. See tennis elbow. )[11,13,15-17,19,20] and of the shoulder (eg, periarthritis, capsulitis, frozen shoulder, subacromial bursitis Subacromial bursitis is inflammation of the subacromial bursa, which lies between the acromion and the head of the humerus leading to extreme pain. The cause of the condition is often unclear. )[11,13,15,16,22] are most amenable to ultrasound. We based our second assumption on the findings that the accelerating effect of ultrasound on tissue repair mainly applies to the early phases of the healing process (inflammatory and proliferative phases Proliferative phase can refer to:
bone remodeling phase) may even have adverse effects on the strength of tissue.[12,13] Thus, the timing of therapy is assumed to be critical.[12,13] Assumption 2--timing of application. We expected that ultrasound will be applied especially in recent injuries and in the first phases of treatment (eg, the first 3 weeks of treatment).[9,13,16] We expected that ultrasound will be applied in a later stage only when the healing process is delayed.[12,13] By accelerating the healing process during the early phases of inflammation and repair, the use of ultrasound may assist in pain relief[12,18,23,24] or in the alleviation of other symptoms of inflammation, such as edema edema (ĭdē`mə), abnormal accumulation of fluid in the body tissues or in the body cavities causing swelling or distention of the affected parts. .[23-25] In addition, some authors[12,14,23-25] contend that ultrasound increases the extensibility of collagen collagen (kŏl`əjən), any of a group of proteins found in skin, ligaments, tendons, bone and cartilage, and other connective tissue. Cells called fibroblasts form the various fibers in connective tissue in the body. , thus facilitating the stretching of scars or adhesions. Our third assumption is: Assumption 3--treatment goals. Based on the literature, we expected that ultrasound will affect the signs of inflammation such as pain, swelling, redness, heat, and limited function (eg, range of motion).[24,25] Based on clinical experience[12] and research on tissue repair,[18,23] reduction of pain and reduction of swelling,[12,18,23] in particular, are expected to be treatment goals with the use of ultrasound. Our fourth assumption deals with the effects of ultrasound as a component of treatment. Ultrasound has been used to increase ligament ligament (lĭg`əmənt), strong band of white fibrous connective tissue that joins bones to other bones or to cartilage in the joint areas. The bundles of collagenous fibers that form ligaments tend to be pliable but not elastic. and tendon tendon, tough cord composed of closely packed white fibers of connective tissue that serves to attach muscles to internal structures such as bones or other muscles. extensibility.[14,21,24] Ultrasound is used to help a patient benefit from other types of interventions such as exercise.[14,16,21,22,24] Assumption 4--contribution to total treatment. We expected that ultrasound will be used in combination with other forms of therapy, especially with exercise. Method Survey on Physical Therapy in Primary Health Care From February 1989 to October 1992, a survey was conducted of physical therapists working in private practice in Dutch primary health care.[27-31] Within this period, 83 physical therapists from 32 private practices participated. Therapists at the practices participated for periods between 6 months and 4 years. In the Netherlands, about 60% of all physical therapists work in primary health care.[6] The physical therapists responding to our survey appear to be representative of Dutch physical therapists in primary care[32] and were very similar in terms of gender (47% of our respondents were female versus 48% of all Dutch physical therapists) and years since graduation from a physical therapist program (67% of our respondents were graduated 5 years or longer versus 66% of all Dutch physical therapists). In our survey, younger physical therapists (ie, less than 35 years of age) were overrepresented o·ver·rep·re·sent·ed adj. Represented in excessive or disproportionately large numbers: "Some groups, and most notably some races, may be overrepresented and others may be underrepresented" (60% of our respondents versus 43% of all Dutch physical therapists), whereas physical therapists with a contract with public health insurance companies were somewhat underrepresented un·der·rep·re·sent·ed adj. Insufficiently or inadequately represented: the underrepresented minority groups, ignored by the government. (57% of our respondents versus 69% of all Dutch physical therapists). Large practices of 4 or more therapists also were underrepresented (3% of our respondents versus 29% of all Dutch physical therapists). There is no reason, however, to expect that these deviations would substantially affect the generalizability of the survey results. Patients There were 17,201 patients in our study. Patients who were treated at least once with ultrasound during their episode of care were identified as the ultrasound group (n = 3,959). Using our assumptions about the use of ultrasound, we compared the group that received ultrasound with a group of patients who were not treated with ultrasound (reference group, n = 13,242). This approach is called the case-referent approach in epidemiologic research, and the reference group provides an "anchor" from which comparisons can be made.[33,34] For example, if a reason for referral is expected to be correct for treatment with ultrasound, this reason should occur more often for patients in the ultrasound group than for patients in the reference group. Assessment During treatment, records were kept for the patients using a standardized standardized pertaining to data that have been submitted to standardization procedures. standardized morbidity rate see morbidity rate. standardized mortality rate see mortality rate. two-part patient record form.[27-31,35] The general part of the form was filled in at the start of the episode of care. This part concerned patient characteristics, complaints, and reasons for referral. Referring physicians could establish a maximum of 4 reasons for referral for a patient. These reasons for referral were classified by a research assistant according to the International Classification of Primary Care The International Classification of Primary Care (ICPC) is a classification method for primary care encounter classification. It allows for the classification of the patient’s reason for encounter (RFE), the problems/diagnosis managed, primary care interventions, and (ICPC ICPC International Conference on Program Comprehension (software engineering and maintenance activity) ICPC International Classification of Primary Care ICPC International Conference of Police Chaplains .)[36] After each visit, the physical therapist completed the second part of the form regarding treatment goals and physical therapy interventions used for the patient. For each visit, the physical therapist could choose a maximum of 4 treatment goals and could specify one intervention for each goal. For example, the therapist could indicate pain reduction as a therapeutic goal, with ultrasound as the intervention. Physical therapists registered treatment goals in terms of impairments and disabilities.[37] Data Analysis Making an appropriate comparison between episodes of care is complex, because episodes of care have different numbers of visits and each visit consists of different numbers and types of treatment goals and interventions. Data on treatment goals and interventions, therefore, were aggregated into episodes of care.[29-31] For each patient, the relative occurrence of interventions during the whole episode of care was calculated; the frequency of use of an intervention was divided by the frequency of all interventions used in the episode of care. For example, if a patient had an episode of care consisting of 10 visits in which he or she was treated 8 times with ultrasound, 4 times with massage, and 4 times with exercise, the relative occurrence of ultrasound for this episode was 50% and the relative occurrence of massage and of exercise was 25%. Because no other interventions were used in this episode, the relative occurrence of other interventions was 0%. In a similar way, the relative occurrences of treatment goals regarding impairments and disabilities were calculated. To investigate the timing of ultrasound during the course of an episode of care, we divided treatment into 3 phases. These phases were chosen to correspond with the phases that are described for the healing process. The first phase (0-3 weeks) corresponded to the inflammatory and proliferative phase, the second phase (3-6 weeks) corresponded to the overlay (1) A preprinted, precut form placed over a screen, key or tablet for identification purposes. See keyboard template. (2) A program segment called into memory when required. of the proliferative pro·lif·er·a·tive or pro·lif·er·ous adj. Tending to proliferate. proliferative pertaining to or emanating from proliferation. and remodeling phases, and the third phase (more than 6 weeks) corresponded to the late remodeling phase of tissue repair.[25] The duration of patients' complaints at the start of the episode of care was categorized cat·e·go·rize tr.v. cat·e·go·rized, cat·e·go·riz·ing, cat·e·go·riz·es To put into a category or categories; classify. cat in a comparable way. Statistics Differences between the ultrasound group and the reference group were tested by means of a chi-square test chi-square test: see statistics. for independence.[38] If the strength of the relationships was significant, it was expressed by means of Cramer's coefficient V (r classes x 2 groups) or phi coefficient Noun 1. phi coefficient - an index of the relation between any two sets of scores that can both be represented on ordered binary dimensions (e.g., male-female) fourfold point correlation, phi correlation (2 classes x 2 groups) (nominal level This article is about the term used in sound and signal processing. For usage in statistics, see nominal measurement. Nominal level is the operating level at which an electronic signal processing device is designed to operate. ).[38] Regarding reasons for referral, differences were tested for each reason separately. For each intervention, we tested whether the mean relative occurrence differed between the ultrasound group and the reference group. Comparably, differences were tested for the relative occurrence of specific treatment goals with ultrasound and with other interventions. Because the relative occurrences of interventions and treatment goals were not normally distributed, nonparametric Kruskal-Wallis one-way analyses of variance were used.[38] The strength of the relationships was assessed using Spearman spear·man n. A man, especially a soldier, armed with a spear. rank-order correlation coefficient Noun 1. rank-order correlation coefficient - the most commonly used method of computing a correlation coefficient between the ranks of scores on two variables rank-difference correlation, rank-difference correlation coefficient, rank-order correlation (r) (ordinal (mathematics) ordinal - An isomorphism class of well-ordered sets. level).[38] Differences in the relative occurrence of ultrasound use between various phases of treatment were tested by means of the nonparametric Friedman test Friedman test a modification of the aschheim-zondek test for pregnancy in the mare based on the use of a rabbit instead of mice. Little used because of the cost of the rabbit. for matched samples.[38] For all tests, the significance level was set at .01. Analyses were performed using SPSS-X.[39](*) Results General Characteristics of Patients Treated With Ultrasound About half of the patients in the ultrasound group were male (51%). In this respect, the ultrasound group differed slightly from the reference group, in which 44% of the patients were male. The age distribution of patients in each group is shown in Table 1. Ultrasound was applied somewhat less frequently in the older age categories. In the ultrasound group, 11.7% of the patients were 65 years of age or older, compared with 17.4% in the reference group. Table 1. Percentage of Patients by Age in Ultrasound Group and Reference Group
Percentage of Patients
Ultrasound Reference
Group Group
Age (y)(a) (n = 3,957)(b) (n = 13,222)(c)
0-14 1.2 3.2
15-24 12.5 11.0
25-34 19.1 18.7
35-44 22.5 19.9
45-54 19.6 16.9
55-64 13.4 12.9
65-74 8.1 10.0
75+ 3.6 7.4
(a) The age distribution (8 classes) differed between the ultrasound group and the reference group (P [is less than] .001; Cramer's V = .09). (b) For 2 patients in the ultrasound group, data on age were missing. (c) For 20 patients in the reference group, data on age were missing. Reasons for Referral and Duration of Complaints Based on our assumptions for the group receiving ultrasound, use of ultrasound was categorized with respect to location and diagnosis (ICPC codes). The 15 most commonly reported reasons for using ultrasound were selected. The percentages of patients in the ultrasound group with these reasons were compared with the respective percentages in the reference group (Tab. 2). As expected, shoulder syndromes (including periarthritis humeroscapularis, bursitis bursitis (bərsī`təs), acute or chronic inflammation of a bursa, or fluid sac, located close to a joint. In response to irritation or injury the bursa may become inflamed, causing pain, restricting motion, and producing more fluid than can , and rotator cuff rotator cuff n. A set of muscles and tendons that secures the arm to the shoulder joint and permits rotation of the arm. Also called musculotendinous cuff. tendinitis tendinitis or tendonitis Inflammation of a tendon sheath, due to irritation of this thin, filmy tissue by overuse of the tendons, which slide within them, or to bacterial infection. ) and lateral epicondylitis lateral epicondylitis Tennis elbow, see there occurred more frequently in the ultrasound group (12.4% and 9% of the patients, respectively) than in the reference group (3.1% and 1.3% of the patients, respectively). Similarly, diagnoses or complaints involving the knee occurred more frequently in the ultrasound group (3.7%-7.2% of the patients) than in the reference group (2.6%-3.2% of the patients), and diagnoses or complaints involving the ankle occurred more frequently in the ultrasound group (5.1% of the patients) than in the reference group (1.5% of the patients). Injuries and complaints involving the neck and back occurred less frequently in the ultrasound group (3.9%-6.6% of the patients) than in the reference group (7.5%-16.9% of the patients). Therefore, there were no specific reasons for ultrasound use. Patients in the ultrasound group differed slightly from patients in the reference group with respect to the duration of their complaints at the start of the episode of care (Tab. 3). Chronic complaints (ie, complaints of longer than 3 months' duration) occurred less frequently in the ultrasound group (21.9% of the patients) than in the reference group (30.1%). Occurrence of Ultrasound Use and Its Timing During the Course of Treatment In 23% of the patients who received ultrasound, physical therapists used ultrasound at least once during the episode of care. In 52% of these patients, ultrasound comprised a relatively large part of their treatment (ie, more than 30%). The Figure shows the relative occurrence of ultrasound in different phases of treatment. During episodes of care of short duration ([is less than] 3 weeks) and medium duration (3-6 weeks), ultrasound was applied relatively frequently (mean relative occurrence of 35% and 32%, respectively), compared with episodes of long duration ([is greater than] 6 weeks; mean relative occurrence of 27%). This finding corresponds to our assumption that the emphasis on ultrasound was expected in the first 3 weeks of treatment. During episodes of care of medium and long duration, however, ultrasound was applied slightly more frequently in the second treatment phase (3-6 weeks) than in the first treatment phase (0-3 weeks). This result does not correspond to our assumption regarding an early timing of ultrasound during the course of treatment. [Figure ILLUSTRATION OMITTED] Treatment Goals Table 4 shows the mean relative occurrence ([+ or -] SD) of treatment goals pursued with ultrasound as compared with the treatment goals used with other interventions in the reference group. As expected, ultrasound was used relatively frequently for reduction of pain and swelling. The mean relative occurrence of these goals was 66.4% and 15.3%, respectively, in the ultrasound group compared with 26.2% and 2%, respectively, in the reference group. Improvement of joint range of motion was an infrequently in·fre·quent adj. 1. Not occurring regularly; occasional or rare: an infrequent guest. 2. used treatment goal in the ultrasound group, as compared with the reference group (relative occurrence of 1.5% versus 21.5%). Furthermore, we found that treatment goals that theoretically cannot be pursued by means of ultrasound were chosen infrequently. This finding applies to the improvement of muscle strength, respiratory disorders Noun 1. respiratory disorder - a disease affecting the respiratory system respiratory disease, respiratory illness adult respiratory distress syndrome, ARDS, wet lung, white lung - acute lung injury characterized by coughing and rales; inflammation of the , posture, and function and stabilization of the spine and other joints (relative occurrence varying from 0% to 0.9%). Table 4. Treatment Goals Pursued With Ultrasound and With Reference Interventions(a)
Relative Occurrence (%)
Ultrasound Reference
Group Group
(n=3,951)(b) (n=13,089)(c)
Treatment Goal X SD X SD
Pain reduction 66.4 45.8 26.2 30.9
Reduction of swelling 15.3 34.6 2.0 10.2
Recovery of range of motion 1.5 11.0 21.5 28.2
Regulation of muscle tone 3.3 16.8 19.3 27.9
Improvement of muscle strength 0.2 3.9 6.7 18.7
Reduction of respiratory
problems 0 0 2.6 15.4
Improvement of posture 0.1 3.5 4.8 15.3
Improvement of function in
spine and other joints 0.9 8.9 9.4 21.3
Improvement of stabilization
spine and other joints 0.1 1.9 2.2 10.7
Alleviation of other impairments 12.2 31.8 5.2 18.4
Kruskal-Wallis
One-Way Analysis of
Variance(d)
Treatment Goal P Spearman r
Pain reduction < .001 .44
Reduction of swelling < .001 .20
Recovery of range of motion < .001 -.47
Regulation of muscle tone < .001 -.35
Improvement of muscle strength < .001 -.20
Reduction of respiratory
problems < .001 -.09
Improvement of posture < .001 -.19
Improvement of function in
spine and other joints < .001 -.23
Improvement of stabilization
spine and other joints < .001 -.12
Alleviation of other impairments < .001 -.04
(a) The entries in the table are relative occurrences of treatment goals during the episodes of care. (b) For 8 parents in ultrasound group, data on treatment goals were missing. (c) For 153 patients in the reference group, data on treatment goals were missing. (d) Testing the difference between ultrasound and other interventions for each treatment goal. Interventions Table 5 shows the mean relative occurrences ([+ or -] SD) of interventions applied in the ultrasound group and in the reference group. The use of ultrasound was restricted to the ultrasound group (mean relative occurrence of 30.2% [+ or -] 15.1%). Of the other interventions, only massage was applied somewhat more frequently in the ultrasound group (mean relative occurrence of 26.7%) than in the reference group (mean relative occurrence of 23.3%). Contrary to our assumptions, the physical therapists used exercise less frequently and gave fewer instructions for home exercises in the ultrasound group (mean relative occurrence of 14.1% and 5.2%, respectively) than in the reference group (mean relative occurrence of 21.6% and 10.9% respectively). They also applied manual therapy less frequently in the ultrasound group (mean relative occurrence of 3.7%) than in the reference group (mean relative occurrence of 13.5%). For other interventions, only small differences between groups were found. Table 5. Interventions in Ultrasound Group and Reference Group(a)
Relative Occurrence (%)
Ultrasound Group Reference Group
(n=3,959) (n= 13,241)(b)
Intervention X SD X SD
Ultrasound 30.2 15.1 0.0 0.0
Massage 26.7 17.3 23.2 24.2
Exercise 14.1 15.8 21.6 24.9
Instruction (home exercise) 5.2 9.1 10.9 16.3
Manual therapy 3.7 10.1 13.5 21.8
Interferential current 4.0 9.8 6.7 14.8
Shortwave diathermy 3.0 8.7 3.0 10.3
Heat and cryotherapy 1.3 5.8 3.2 10.0
Diadynamic current(d) 0.5 3.5 0.5 4.8
Advice (living rules) 1.1 3.9 1.7 5.7
Others(e) 10.3 11.0 15.7 18.6
Kruskal-Wallis One-Way
Analysis of Variance(c)
Intervention P Spearman r
Ultrasound < .001 .99
Massage < .001 .10
Exercise < .001 -.10
Instruction (home exercise) < .001 -.12
Manual therapy < .001 -.20
Interferential current < .001 -.05
Shortwave diathermy < .001 .04
Heat and cryotherapy < .001 -.06
Diadynamic current(d) < .01 .02
Advice (living rules) < .001 -.04
Others(e) < .001 -.11
(a) The entries in the table are relative occurrences of interventions during the episodes of care. (b) For one patient in the reference group, data on interventions were missing. (c) Testing the difference between both treatment groups for each intervention. (d) Diadynamic current is a form of electrical stimulation. (e) The category "others" comprises, for example, other forms of electrotherapy electrotherapy /elec·tro·ther·a·py/ (-ther´ah-pe) treatment of disease by means of electricity. e·lec·tro·ther·a·py n. Medical therapy using electric currents. , and taping or bandaging. Discussion and Conclusions The goals of our study were to describe the use of therapeutic ultrasound by physical therapists in Dutch primary health care and to determine to what extent this use of ultrasound is what we would consider correct usage. Percentages of therapeutic ultrasound use may differ between regions or countries. Because the education of physical therapists and the dispersion dispersion, in chemistry dispersion, in chemistry, mixture in which fine particles of one substance are scattered throughout another substance. A dispersion is classed as a suspension, colloid, or solution. of recent developments in this field should be based on international literature, we contend that practice patterns could be expected to converge regarding indications for use of ultrasound, treatment goals, and timing during the course of treatment. We have no evidence, however, to support this assumption, and, in many parts of the world, there are large differences in the manner in which therapists are educated. Because separate analyses of our data showed no differences in the professional behavior of physical therapists for publicly or privately insured patients or for different systems of reimbursement Reimbursement Payment made to someone for out-of-pocket expenses has incurred. ,[40] it is not likely that the established relationships were influenced by the Dutch system of reimbursement. We do not know whether this applies equally to other countries, particularly those where there is little or no reimbursement for ultrasound or where clinical guidelines may affect the use of ultrasound. We showed that the use of ultrasound corresponds rather well with our assumptions on expected care regarding both the reason for referral and the specific treatment goals. With regard to the phase of treatment in which ultrasound is used, a mixture of correspondence and noncorrespondence was found. The same applies to the occurrence of cointerventions with ultrasound. The strength of the relationships found, however, is weak. Nevertheless, our analyses revealed treatment patterns in the ultrasound group that were different from treatment patterns in the reference group. Reasons for Referral Our data show that ultrasound is applied relatively often on patients with injuries at the shoulder and elbow joint elbow joint n. A compound hinge joint between the humerus and the bones of the forearm. Also called cubital joint. , which corresponds to our expectations. In addition, applications of ultrasound for injuries in other anatomical anatomical /ana·tom·i·cal/ (an?ah-tom´i-kal) pertaining to anatomy, or to the structure of an organism. an·a·tom·i·cal or an·a·tom·ic adj. 1. Concerned with anatomy. 2. locations have been found (eg, in the knee and ankle region). In these regions, in contrast to the deeper located hip, application of ultrasound seems appropriate, as the tissue concerned is situated rather superficially and may be reached by ultrasound. Timing of Application Several authors contend that ultrasound accelerates the first phase of the healing process for damaged tissues. In our study, the duration of complaints at the start of treatment for those patients treated with ultrasound was only slightly shorter than for the reference group. Similarly, the assumed emphasis on ultrasound in the first phase of treatment for episodes of care of long or medium duration could not be demonstrated. We found a relatively high occurrence of ultrasound use, however, in episodes of care of short duration. Thus, there is mixed support for our assumption regarding an appropriate timing of ultrasound. Possibly, for certain patients, the use of ultrasound in later phases of treatment may be due to a delayed healing process. Treatment Goals Pain reduction is often cited as a treatment goal pursued by means of ultrasound. Similarly, reduction of swelling is also used as a reason for the use of ultrasound. Our findings correspond very well with the expected use of ultrasound. We found, however, that increasing the range of motion is a scarcely used treatment goal with ultrasound. Apparently, ultrasound is not aimed directly at this goal but is used for pain relief and to increase tissue extensibility as prerequisites for this goal. Ultrasound in Combination With Other Interventions We expected that ultrasound would frequently be combined with other interventions, especially with exercise. Exercise, however, was applied less frequently in the ultrasound group than in the reference group. This finding suggests that ultrasound was not used to prepare patients for the benefits of another intervention. We were surprised to find that massage was used more frequently in the ultrasound group than in the reference group, although the difference was very small. This finding may be understood from a different perspective than the one described above. It is possible that ultrasound might induce a form of micromassage,[8,23] the effects of which are supposed to be comparable to those of other types of massage (eg, deep transverse To cross from side to side. frictions). Therapists probably assume that both interventions may enhance each other. Implications In the absence of consensus on the effectiveness of ultrasound, a description of the actual use of ultrasound and--for the present--a judgment on appropriate use might prove to be very useful. Both the reasons for ultrasound use (eg, soft tissue injuries Soft tissue injury is damage of the soft tissue of the body. These types of injuries are a major source of pain and disability. The four fundamental tissues that are affected are the epithelial, muscular, nervous and connective tissues. ) and the treatment goals (eg, reduction of pain and swelling) are in line with what we interpret as the recommended applications of ultrasound. In this respect, there seems to exist a certain degree of consensus among Dutch therapists. With regard to both the phase of treatment and suitable cointerventions, we found low correspondence (consistency) between the actual use of ultrasound and expected use of ultrasound. We hope that our results will stimulate physical therapists to reconsider their use of ultrasound. Perhaps the actual use of ultrasound should be brought in line with our assumptions on how to use ultrasound. A possible method for minimizing such discrepancies between theory and practice and for guiding physical therapists in the appropriate use of an intervention is the development and implementation of practice guidelines practice guidelines Medical practice A set of recommendations for Pt management that identifies a specific or range of range of management strategies. See Peer review organization, Practice standards. Cf 'Cookbook' medicine. for physical therapists.[41] In the Netherlands, the Netherlands, The officially Kingdom of The Netherlands byname Holland Country, northwestern Europe. Area: 16,034 sq mi (41,528 sq km). Population (2005 est.): 16,300,000. Capital: Amsterdam. Seat of government: The Hague. Most of the people are Dutch. development of central guidelines is an important part of the quality-of-care policy of the Royal Dutch Physical Therapy Association.[42,43] It might be argued with equal strength, however, that the practice patterns need not be modified but rather the assumptions and theories on ultrasound use should be revised. A research agenda can be defined, focusing on the application of therapeutic ultrasound in different phases of treatment and on the combination of ultrasound with other interventions. These aspects should be incorporated in studies on the clinical effectiveness of ultrasound. Acknowledgments We thank the physical therapists for participating in this study and Marie Boschman for her contribution to data analysis. We thank Geert Aufdemkampe and Willem Bosveld for their valuable comments on the text of this article. Table 2. Fifteen Most Reported Reasons for Referral for Physical Therapy in Ultrasound Group Compared With Reference Group
Percentage of Patients(b)
Ultrasound Group Reference Group
Reason for Referral(a) (n=3,777)(c) (n=12,614)(d)
Other diseases of
musculoskeletal system/
connective tissue (L99) 14.0 9.6
Shoulder syndrome (L92) 12.4 3.1
Elbow: epicondylitis (L93) 9.0 1.3
Other injury of musculoskeletal
system (L81) 8.8 2.7
Shoulder symptoms/
complaints (L08) 7.9 6.9
Knee symptoms/complaints (L15) 7.2 3.2
Knee: chronic internal
derangement (L97) 6.8 2.6
Low back complaints without
radiating symptoms (L03) 6.6 16.9
Neck symptoms/complaints (L01) 5.6 15.5
Ankle sprains and strains (L77) 5.1 1.5
Back pain (lumbar/thoracic)
with radiating symptoms (L86) 4.7 10.8
Back symptoms/complaints (L02) 4.2 9.6
Syndromes related to cervical
spine (L83) 3.9 7.5
Knee: acute damage to meniscus
or ligament (L96) 3.7 2.6
Leg/thigh symptoms/
complaints (L14) 2.8 2.2
[chi square](e)
Reason for Referral(a) P phi
Other diseases of
musculoskeletal system/
connective tissue (L99) < .001 .06
Shoulder syndrome (L92) < .001 .18
Elbow: epicondylitis (L93) < .001 .19
Other injury of musculoskeletal
system (L81) < .001 .13
Shoulder symptoms/
complaints (L08) NS(f)
Knee symptoms/complaints (L15) < .001 .09
Knee: chronic internal
derangement (L97) < .001 .09
Low back complaints without
radiating symptoms (L03) < .001 .12
Neck symptoms/complaints (L01) < .001 .12
Ankle sprains and strains (L77) < .001 .10
Back pain (lumbar/thoracic)
with radiating symptoms (L86) < .001 .09
Back symptoms/complaints (L02) < .001 .08
Syndromes related to cervical
spine (L83) < .001 .06
Knee: acute damage to meniscus
or ligament (L96) < .001 .03
Leg/thigh symptoms/
complaints (L14) NS
(a) International Classification of Primary Care codes shown in parentheses See parenthesis. parentheses - See left parenthesis, right parenthesis. . (b) Percentage of patients with a particular indication. As more reasons for referral could be mentioned for a patient, percentages in a column do not add to 100%. (c) For 182 patients in the ultrasound group, data on referral indication were missing. (d) For 628 patients in the reference group, data on referral indication were missing. (e) Testing the difference between both treatment groups for each reason for referral. (f) NS = not significant. Table 3. Percentages of Patients by the Duration of Their Complaints in Ultrasound Group and Reference Group
Percentage of Patients
Ultrasound Reference
Duration of Group Group
Complaints(a) (n=3,936)(b) (n=12,944)(c)
< 3 wk 37.3 33.3
3-6 wk 19.5 17.8
6 wk-3 mo 21.3 18.8
[is greater than] 3 mo 21.9 30.1
(a) The distribution of duration of complaints (4 classes) differed between ultrasound group and reference group (P [is greater than] .001; Cramer's V = .08). (b) For 23 patients in the ultrasound group, data on duration of complaints were missing. (c) For 298 patients in the reference group, data on duration of complaints were missing. (*) SPSS A statistical package from SPSS, Inc., Chicago (www.spss.com) that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance. Inc, 444 N Michigan Ave, Chicago, IL 60611. References [1] Robinson AJ, Snyder-Mackler L. Clinical application of electrotherapeutic modalities Modalities The factors and circumstances that cause a patient's symptoms to improve or worsen, including weather, time of day, effects of food, and similar factors. . Phys Ther. 1988;68:1235-1238. 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[35] van Triet EF, Dekker J, Kerssens JJ, Curfs EC. Reliability of the assessment of impairments and disabilities in survey research in the field of physical therapy. International Disability Studies. 1990;12:61-65. [36] Lamberts H, Wood M. International Classification of Primary Care. Oxford, England: Oxford University Press Ltd; 1987. [37] International Classification of Impairments, Disabilities, and Handicaps. Geneva Geneva, canton and city, Switzerland Geneva (jənē`və), Fr. Genève, canton (1990 pop. 373,019), 109 sq mi (282 sq km), SW Switzerland, surrounding the southwest tip of the Lake of Geneva. , Switzerland: World Health Organization; 1980. [38] Siegel S Siegel, a surname, is associated with two ethnic groups. As a Jewish surname Siegel (סג"ל) it could be an acronym of Segan Levi (סגן לוי), meaning "Assistant Levite". , Castellan cas·tel·lan n. The keeper or governor of a castle. [Middle English castelain, from Norman French, from Medieval Latin castell NJ. Nonparametric Statistics Noun 1. nonparametric statistics - the branch of statistics dealing with variables without making assumptions about the form or the parameters of their distribution for the Behavioral Sciences behavioral sciences, n.pl those sciences devoted to the study of human and animal behavior. . London, England: McGraw-Hill; 1988. [39] SPSS-X, Release 4.1. Chicago, Ill: SPSS Inc; 1991. [40] van Baar ME, Abrahamse HPhH, Dekker J. Geen effect van invoering van een nieuw honoreringsstelsel op het handelen van fysiotherapeuten. Tijdschr Soc Gezondheidsz. 1995;73:141-148. [41] Lazaro P, Fitch K. From universalism Universalism Belief in the salvation of all souls. Arising as early as the time of Origen and at various points in Christian history, the concept became an organized movement in North America in the mid-18th century. to selectivity selectivity /se·lec·tiv·i·ty/ (se-lek-tiv´i-te) in pharmacology, the degree to which a dose of a drug produces the desired effect in relation to adverse effects. selectivity 1. : Is "appropriateness" the answer? Health Policy. 1996;36:261-272. [42] Hendriks HJM HJM Heath-Jarrow-Morton (model) , Ettekoven H, Reitsma E. Improving the quality of physical therapy by central guidelines. In: Proceedings of the 12th International Congress of the World Confederation A union of states in which each member state retains some independent control over internal and external affairs. Thus, for international purposes, there are separate states, not just one state. for Physical Therapy; June 25-30, 1995; Washington, DC. Alexandria, Va: American Physical Therapy Association The American Physical Therapy Association (APTA) is a national professional organization representing more than 66,000 members. Its goal is to foster advancements in physical therapy practice, research, and education. ; 1995:1156. [43] Hendriks HJM, Reitsma E, van Ettekoven H. Centrale richtlijnen in de fysiotherapie: introductie van het Centrale Richtlijnen (CR) project. Ned Tijdschrift Fysiotherapie. 1996;106:2-11. ME Roebroeck, PhD, is Research Associate, Netherlands Institute of Primary Health Care, PO Box 1568, 3500 BN Utrecht, the Netherlands (m.roebroeck@nivel.nl). Address all correspondence to Dr Roebroeck. J Dekker, PhD, is Head of Research Department, Netherlands Institute of Primary Health Care, and Professor of Allied Health Care, Vrije Universiteit, Amsterdam (education, body) Vrije Universiteit, Amsterdam - The "Free University of Amsterdam", founded in 1880 by Abraham Kuyper (who later became Prime Minister of The Netherlands). Originally only open to Reformed Christians, it is now open to all. , the Netherlands. RAB Oostendorp, PhD, PT, is Scientific Director, National Institute for Allied Health Professions, Amersfoort, the Netherlands, and Professor of Manual Therapy, Free University of Brussels The Free University of Brussels may refer to one of two Belgian universities, both located in Brussels, Belgium:
This article was submitted December 12, 1996, and was accepted October 8, 1997. |
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