Ultrasound efficacy.To the Editor: It was with great interest that we read the article titled "Adding Ultrasound in the Management of Soft Tissue Disorders of the Shoulder: A Randomized ran·dom·ize tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es To make random in arrangement, especially in order to control the variables in an experiment. Placebo-Controlled Trial" by Kurtais Gursel et al in the April 2004 issue of Physical Therapy. The authors have attempted to determine whether the common clinical practice of adding ultrasound (US) in conjunction with other 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. (moist heat and interferential current) and exercise is superior when compared with a similar treatment with sham US in a patient population. After 3 weeks (15 visits), improvements in both groups were noted when their measurements were compared with their baseline measurements (pain intensity, passive and active range of motion, and scores on 2 questionnaires [Health Assessment Questionnaire and Shoulder Disability Questionnaire]). No differences, however; were noted between groups. The authors concluded that "it is apparent that adding US to a well planned intervention regimen has no benefit." Although the study has several strengths, we disagree with Verb 1. disagree with - not be very easily digestible; "Spicy food disagrees with some people" hurt - give trouble or pain to; "This exercise will hurt your back" this conclusion. First, we believe the method utilized may have precluded the independent variable (true US) from reaching the source of pathology). Second, the conclusion is too broad given the scope of the study. Regarding the method, we contend that, with the exception of the beam non-uniformity ratio, which we assume was erroneously reported as 1:6 and not 6:1, the authors selected a reasonable set of variables, including frequency, intensity, duration, and effective radiating area related to the ultrasound treatment. (1,2) We do have concerns, however, regarding patient positioning and therefore the location to which treatment was administered. As 17 of the 20 subjects in the "true US" group bad diagnoses of supraspinatus tendon involvement (either tendinosis or partial rupture), it is very unlikely the US reached this soft tissue given the patient positioning described in the article. Subjects in Ibis ibis (ī`bĭs), common name for wading birds with long, slender, decurved bills, found in the warmer regions of both hemispheres. The body is usually about 2 ft (61 cm) long. Most ibises nest in colonies. study were positioned with their forearm supinated and their arm resting in their lap. In this position, the subjects' shoulder was likely placed in a small amount of flexion flexion /flex·ion/ (flek´shun) the act of bending or the condition of being bent. flex·ion n. 1. The act of bending a joint or limb in the body by the action of flexors. 2. , In this posture, the supraspinatus tendon is positioned under the acromial process acromial process n. See acromion. . (3,4) To adequately manage this soft tissue disorder with US, we argue that the shoulder would be better positioned if placed in extension. We lack data, however; to confirm whether this placement would he better than that used by the authors. With the shoulder in extension, the supraspinatus 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. tendons are, in theory, moved anteriorly from under the acromial process and into a palpable position, thereby, we contend, exposing the tendon to the application of US. This, however, is a theoretical argument and not one that is currently supported by direct evidence for either the greater penetration of US or the benefits of intervention. We agree with the authors that more evidence is necessary regarding the efficacy of US; however; based on the results of this study, we argue that the authors can conclude only that US was not beneficial to this group of subjects in the context of the designated US settings used and the patient positioning. Before concluding that US is not effective as an added in intervention in the management of soft tissue disorders of the shoulder, we contend that additional studies are warranted. Specifically, we believe that alterations in treatment variables and patient positioning in this population as well as in patients with other painful shoulder conditions should be examined. Christopher R Carria, PT, PhD, SCS Assistant Professor Department of Physical Therapy Rangos School of Health Sciences Duquesne University Pittsburgh, PA 15282 carcia@duq.edu Rob Roy Rob Roy [Scottish Gaelic,=red Rob], 1671–1734, Scottish freebooter, whose real name was Robert MacGregor. He is remembered chiefly as he figures in Sir Walter Scott's novel Rob Roy (1818). Martin. PT, PhD, CSCS CSCS Certified Strength and Conditioning Specialist CSCS Center for the Study of Complex Systems (University of Michigan) CSCS Construction Skills Certification Scheme (UK) CSCS Center for Surface Combat Systems Assistant Professor Department of Physical Therapy Rangos School of Health Sciences Duquesne University Michael Civitello, PT, MS Doctoral Student in Rehabilitation Sciences Duquesne University References (1) Draper DO, Castel JC. Caster D. Rate of temperature increase in human muscle during 1 MHz (MegaHertZ) One million cycles per second. It is used to measure the transmission speed of electronic devices, including channels, buses and the computer's internal clock. A one-megahertz clock (1 MHz) means some number of bits (16, 32, 64, etc. and 3 MHz continuous ultrasound. J Orthop Sports Phys Ther. 1995;22: 142-150. (2) Reid DC, Cummings GE. Factors in selecting the dosage of ultrasound. Physiother Can. 1973;25:5-9. (3) Clarnette RG, Miniaci A. Clinical exam of the shoulder. Med Sci Sports Exerc. 1998;30:S1-S6. (4) Hoppenfeld S. Physical Examination of the Spine and Extremities. Upper Saddle River Saddle River may refer to:
In 1913, law professor Dr. ; 1976. To the Editor: I am writing this letter to express my concerns regarding "Adding Ultrasound in the Management of Soft Tissue Disorders of the Shoulder: A Randomized Placebo-Controlled Trial." The title of this paper is exciting and encouraging. We very much need well-designed studies evaluating the effectiveness of the interventions we commonly use, and the best trial design is the randomized controlled trial A randomized controlled trial (RCT) is a scientific procedure most commonly used in testing medicines or medical procedures. RCTs are considered the most reliable form of scientific evidence because it eliminates all forms of spurious causality. . I believe, however, that this study falls short in many ways, and, on close evaluation, I believe it does a disservice rather than a service by implying that ultrasound (US) is ineffective, when in actuality the method of the study precludes evaluation of the effects of applying US to patients in an evidence-based manner. I contend that there are problems with the method, subject selection, interventions, and outcome measures, all of which I view as combining to limit the validity of the authors' conclusions. This study was not double-blinded. The treating therapist knew who received true US and who received sham US. Although this knowledge would likely bias the results in favor of, rather than against, an effect of the intervention, the impact is not predictable. In addition, there is no mention of a power analysis to determine the appropriate number of subjects to detect the expected size of effect. The subjects in this study had a wide range of diagnoses; the only commonalities were more than 4 weeks of shoulder pain and restricted range of motion (ROM). It also is likely that the underlying pathology in these patients was at various stages of healing, which, based on current evidence from animal studies, are likely to benefit from different US doses. Previously published studies have demonstrated that pulsed low-dose US is most effective for facilitating tissue healing, (1-4) whereas continuous high-dose US has been shown to be most effective for increasing tissue temperature, which will increase tissue extensibility and thus facilitate greater gains in ROM with stretching. (5,6) In addition, in the absence of tree controls who do not receive any intervention, the changes in these patients cannot be compared with the natural course of improvement of these conditions. The intervention under investigation in this study was therapeutic US. This US was applied at an intensity of 1.5 W/[cm.sup.2], with, I presume, a continuous duty cycle, although this is not stated, for 10 minutes to an area 3 times the effective radiating area (ERA) of the sound head used. This would be predicted to increase the temperature of the area by 2[degrees]C, (6) which is not sufficient to reach the recommended goal of 40[degrees] to 45[degrees]C to produce thermal effects. (5) In addition, the US was applied "over the superior and anterior 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. regions of the glenohumeral joint The glenohumeral joint, commonly known as the shoulder joint, is a synovial ball and socket joint and involves articulation between the glenoid fossa of the scapula (shoulder blade) and the head of the humerus (upper arm bone). ," not an area likely to be the source of a restriction of ROM. If this area was the source of the patients' pain, then the pain most likely was due to inflammation and would be expected to respond to a low dose of pulsed US, and even potentially to be adversely affected by the heating produced by continuous US. This approach to applying an intervention, in this case US, to a patient without consideration of findings from a thorough examination is contradictory to the approach recommended for physical therapy interventions by the Guide to Physical Therapist Practice. (7) Furthermore, the many other interventions applied to the subjects in this study, including hot packs, sensory-level interferential electrical stimulation, and various exercises, could be expected to obscure an effect of US over a 2-week period. This concern is supported by the results of this study, as shown in Table 2, demonstrating improvement in all measurements for all subjects. The outcome measures used in this study also limit the conclusions that can be drawn. A 4-point pain scale, in my view, has limited sensitivity. The ROM measurements also were not shown to be reliable or valid. Although the report does state that the assessor practiced to improve the reliability of her measurements, no information on the reliability or validity of her measurements is provided. Given the limitations of this study, I believe the only conclusion that can be drawn is that the addition of US with a frequency of 1 MHz and an intensity of 1.5 W/[cm.sup.2], applied with a transducer transducer, device that accepts an input of energy in one form and produces an output of energy in some other form, with a known, fixed relationship between the input and output. head with an ERA of 5 [cm.sup.2] to a 15-[cm.sup.2] area over the superior and anterior periarticular regions of the glenohumeral joint, in patients with pain and decreased ROM of the shoulder does not provide a large additional benefit beyond those produced by exercise, hot packs, and sensory electrical stimulation combined. These findings are to be expected because the interventions are not consistent with current evidence-based recommendations and the study design was unlikely to be able to detect a treatment effect. This is very different from the authors' conclusion that "there is insufficient evidence insufficient evidence n. a finding (decision) by a trial judge or an appeals court that the prosecution in a criminal case or a plaintiff in a lawsuit has not proved the case because the attorney did not present enough convincing evidence. to support the use of 1-MHz ultrasound in combination with other interventions in the management of painful shoulder conditions." Michelle H Cameron, MD, PT, OCS OCS - Object Compatibility Standard michcameron@yahoo.com References (1) Dyson M, Suckling suckling In mammals, the drawing of milk into the mouth from the nipple of a mammary gland. In human beings, it is referred to as nursing or breast-feeding. The word also denotes an animal that has not yet been weaned—that is, whose access to milk has not yet been J. Stimulation of tissue repair by ultrasound: a survey of the mechanisms involved. Physiotherapy. 1978;63:105-108. (2) Byl NN, McKenzie AL, Wong T, et al. Incisional wound healing wound healing Physiology The repair of a wound Steps Inflammation, repair and closure, remodeling, final healing; repair of incisions may be either simple–'clean' wounds with little loss of tissue heal by 'primary intention', or 'dirty' wounds heal by : a controlled study of low dose and high dose ultrasound. J Orthop Sports Phys Ther 1993;18:619-628. (3) Binder A, Hodge G, Greenwood AM, et al. Is 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. effective in treating soft tissue lesions? Br Med J. 1985; 290:512-514. (4) Ebenbichler GR, Erdogmus CB, Resch KL, et al. Ultrasound therapy ultrasound therapy Mainstream medicine The application of ultrasound waves to soft tissue to heat and relax injured tissue and disperse edema for calcific tendonitis calcific tendonitis Orthopedics Inflammation of a tendon accompanied by focal calcium deposits, common in the supraspinatus tendon of shoulder joint Clinical Pain, ↓ ROM Management NSAIDs, needle aspiration, surgery, pulse ultrasound. See Tendinitis. of the shoulder. N Engl J Med. 1999;340:1533-1538. (5) Lehmann JF, DeLateur BJ, Warren G, et al. Bone and soft tissue heating produced by ultrasound. Arch Phys Med Rehabil. 1967;48:397-401. (6) Draper DO, Castel JC, Castel D. Rate of temperature increase in human muscle during 1 MHz and 3 MHz continuous ultrasound. J Orthop Sports Phys Ther. 1995;22:142-150. (7) Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9-746. To the Editor: Despite the poignant title of the Editor's Note Editor's Note (foaled in 1993 in Kentucky) is an American thoroughbred Stallion racehorse. He was sired by 1992 U.S. Champion 2 YO Colt Forty Niner, who in turn was a son of Champion sire Mr. Prospector and out of the mare, Beware Of The Cat. Trained by D. ("The Difference Between Knowing and Applying") in the April 2004 issue, I believe that a huge "difference between knowing and applying" was missed in this issue. I believe that, having focused on Edwards and colleagues' article titled "Clinical Reasoning Strategies in Physical Therapy" in the same issue, the Journal unfortunately overlooked an error in the article by Kurtais Gursel et al. Not all exercise is the same kind of exercise; there is tremendous variability, and complexity to stretching, strengthening, and all of the other exercise interventions we use in our profession. Conducting a general study on a nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik) 1. not due to any single known cause. 2. not directed against a particular agent, but rather having a general effect. nonspecific 1. type of exercise is unheard of Not heard of; of which there are no tidings. Unknown to fame; obscure. - Glanvill. See also: Unheard Unheard in this decade of specific and objective research. Likewise for our modalities such as ultrasound (US). Ultrasound is not a "generic" modality modality /mo·dal·i·ty/ (mo-dal´i-te) 1. a method of application of, or the employment of, any therapeutic agent, especially a physical agent. 2. . The mechanical and thermal effects of this intervention are distinct, and I believe that the outcome depends on applying the modality correctly. A study done by Ebenbichler et al (1) is an excellent example of how a specific setting of US (pulsed) can demonstrate positive clinical results for management of a specific diagnosis (calcific calcific /cal·cif·ic/ (-ik) forming lime. calcific forming lime. shoulder tendinitis) in a randomized controlled trial. In other studies, parameters of US were used that were inappropriate for the purpose of the intervention. Falconer et al (2) used continuous US at an intensity of 1.0 W/[cm.sup.2] on arthritic knees. Based on Leung et al (3) and Miller et al, (4) this is an inappropriate setting if the knees are at all inflamed and, therefore, will yield non-significant or poor results. Similarly, Lundeberg et al used continuous US in the management of lateral epicondylitis lateral epicondylitis Tennis elbow, see there when, based on Belanger, (6) pulsed US would have been the appropriate modality. Hashish hashish (hăsh`ēsh, –ĭsh), resin extracted from the flower clusters and top leaves of the hemp plant, Cannabis sativa, and C. indica. et al (7) demonstrated negative effects of US in reducing inflammation. However; the intensity of 1.5 W/[cm.sup.2] that they used, which will increase blood flow to the tissue, was inappropriate to reduce inflammation. (6) Kurtais Gursel et al managed all shoulder problems with thermal US, which is contraindicated for many of the types of patients in their study who had inflammatory problems. (6) When reading the literature about US, the parameters of the intervention must be carefully scrutinized. Carole Lewis, PT, PhD, GCS GCS Glasgow Coma Scale GCS Guilford County Schools (North Carolina) GCS Ground Control Station GCS Grand Central Station GCS Ground Control System GCS Ground Combat Systems GCS Group Communication Systems CLEWISPHD@aol.com References (1) Ebenbichler GR, Erdogmus CB, Resch KL, et al. Ultrasound therapy for calcific tendinitis Calcific Tendinitis (also calcific/calcifying/calcified/calcareous tenonitis/tendonitis/tendinopathy, and tendinosis calcarea of the shoulder: N Engl J Med. 1999;340:1533-1538. (2) Falconer J, Hayes KW, Chang RW. Effect of ultrasound on mobility in osteoarthritis osteoarthritis or osteoarthrosis or degenerative joint disease Most common joint disorder, afflicting over 80% of those who reach age 70. It does not involve excessive inflammation and may have no symptoms, especially at first. of the knee: a randomized clinical trial 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. . Arthritis Care Arthritis Care is the UK's largest charity dedicated to supporting people with arthritis. The organisation is staffed and led by people who also have arthritis. It provides information and support on a range of issues related to living with arthritis. Res. 1992;5:29-35. (3) Leung MC, Ng GY, Yip KK. Effect of ultrasound on acute inflammation acute inflammation n. Inflammation having a rapid onset and coming to a crisis relatively quickly, with a clear and distinct termination. of transected medial collateral ligaments The medial collateral ligament or MCL (or tibial collateral ligament) is one of the four major ligaments of the knee. It is on the medial or inner side of the joint. . Arch Phys Med Rehabil. 2004;85:963-966. (4) Millett PJ, Johnson B, Carlson J, et al. Rehabilitation of the arthrofibrotic knee. Am J Orthop. 2003;32:531-538. (5) Lundeberg T, Abrahamsson P, Haker E. A comparative study of continuous ultra sound, placebo ultrasound, and rest in epicondylalgia. Scand J Rehabil Med. 1988;20:99-101. (6) Belanger A. Evidence-Based Guide to Therapeutic Physical Agents. Baltimore, Md: Lippincott Williams & Wilkins; 2002. (7) Hashish I, Harvey W, Harris M. Anti-inflammatory effects of ultrasound therapy: evidence for a major placebo effect placebo effect n. A beneficial effect in a patient following a particular treatment that arises from the patient's expectations concerning the treatment rather than from the treatment itself. . Br J Rheumatol. 1986;25:77-81. Author Response: Therapeutic ultrasound (US) is one of the most commonly used physical agents for the management of musculoskeletal musculoskeletal /mus·cu·lo·skel·e·tal/ (-skel´e-t'l) pertaining to or comprising the skeleton and muscles. mus·cu·lo·skel·e·tal adj. Relating to or involving the muscles and the skeleton. injuries, but we still do not have sufficient evidence about the efficacy of US. (1-5) We agree that further well-designed studies are needed to assess the efficacy of US and other physical agents. Yet, there should be some major ethical concerns in these studies when they involve teal teal: see duck. teal Any of about 15 species (genus Anas, family Anatidae) of small dabbling ducks found on the major continents and many islands. Many are popular game birds. patients. This requirement may result in bias, but it is difficult In leave a group of patients without any intervention or to administer only placebo treatment and wait for the natural course of improvement as Cameron proposes. In our study, there were some limitations, such as the heterogenity of the patient groups regarding the duration of the symptoms and the diagnosis. The patients were probably in different stages of healing, but there were no acute cases, and the cases were mostly chronic. This explains why patients were treated with 1.5 W/[cm.sup.2], which is within the intensity range proposed by Khan. (6) The use of low intensities (less than 1.0 W/[cm.sup.2]) is recommended to achieve maximum healing rates in inflamed tissues, (7) but there are no quantitative or scientific data indicating that higher intensities are harmful. (8) Furthermore, Jackson et al (9) showed that the mechanical properties of injured tendon could be improved with US, and the intensity used in their study was 1.5 W/[cm.sup.2]. The thermal properties of US have been shown to increase elasticity and decrease the viscosity of collagen fibers and soft tissue, thus allowing for greater residual length gains while reducing the risk of damage through the applied stretching force. The change in viscoelastic Adj. 1. viscoelastic - having viscous as well as elastic properties natural philosophy, physics - the science of matter and energy and their interactions; "his favorite subject was physics" properties is transient, and, in order to achieve optimal effects, the stretching should be applied during or immediately following heating. (10,11) Concerning these data, exercise was added to the treatment in this study. We would like to address some of the specific criticisms of our study. Carcia is absolutely right about the beam nonuniformity ratio, which was erroneously reported as 1:6 and not 6:1. Regarding Carcia's comment that we did not define the patients' position during treatment precisely, the patients were silting on a table with their hands supinated in their lap and placed far from each other so that the shoulder was in extension. We assume that is the position in which the components of the rotator cuff can be exposed to US. This position also allowed the bicipital bicipital /bi·cip·i·tal/ (bi-sip´i-t'l) having two heads; pertaining to a biceps muscle. bicipital having two heads; pertaining to a biceps muscle. tendon to be treated by US for the patients who had bicipital tendinitis bicipital tendinitis Rheumatology Tendinitis of the biceps brachii Etiology ↑ Activity of biceps or shoulder, especially if repetitious Clinical Shoulder pain aggravated by shoulder movement or resisted flexion of biceps muscle Management Rest, NSAIDs, RICE . Both the patients and the assessor were masked throughout the study. The treating physical therapist was not masked. It would have been difficult for us to mask the treating therapist because an experienced therapist can discern whether true or sham US is applied from the rate of disappearance of the transmission gel. In addition, the role of the treating therapist was to administer the planned treatment without intervening, and she had no role in assessing or informing the patient in any of the steps of our study design. The outcome measures used in our study also were questioned regarding limited sensitivity. The Shoulder Disability Questionnaire, however, was shown to yield valid data and to be sensitive to change. (12) The Likert-type pain scale was preferred in this study because, in our daily practice, we feel that Turkish patients respond better to this scale. Personal feeling, however, is not sufficient to decide which outcome measures to use, and the evidence comes from the studies in which Likert-type scales correlated well with visual analog scales. (13-15) We believe that the comparison made in our study is valid: after randomization randomization (ranˈ·d  ·m , the relatively small groups were comparable with respect to prognosis, and groups were comparable regarding extraneous factors, such as exercise treatment. Moreover, to date, evidence is lacking that, for a given shoulder complaint, one type of exercise is more effective than another. In contrast to confidence intervals, an a priori a priori In epistemology, knowledge that is independent of all particular experiences, as opposed to a posteriori (or empirical) knowledge, which derives from experience. sample size calculation does not contain valuable information regarding the precision or statistical power of the study. To date, regardless of the results of our study, evidence is lacking that, for a given shoulder complaint, one US dosage is more effective than another. Thus, within the context of our study--although there are some pitfalls--we conclude there is still insufficient evidence to merit use of 1-MHz, continuous, 1.5 W/[cm.sup.2] US in the treatment of patients with soft tissue disorders who are in the subacute-chronic phase when added to other physical agents such as hot packs or electrical stimulation. Yesim Kurtais Gursel, MD Professor Department Physical Medicine and Rehabilitation physical medicine and rehabilitation or physiatry or physical therapy or rehabilitation medicine Medical specialty treating chronic disabilities through physical means to help patients return to a comfortable, productive life despite a medical School of Medicine University of Ankara 06100 Ankara, Turkey ykurtais@ttnet.net.tr Yasemin Ulus, MD Specialist in Physical Medicine and Rehabilitation Department of Physical Medicine and Rehabilitation Bayindir Hospital Ankara, Turkey Ayse Bilgic, MD Assistant Professor Department of Physical Medicine and Rehabilitation School of Medicine University of Ankara Gulay Dincer, MD Professor Department of Physical Medicine and Rehabilitation School of Medicine University of Ankara Geert JMG JMG Journal of Medical Genetics JMG Junior Master Gardener JMG Journal of Metamorphic Geology JMG Junior Maine Guide JMG Joint Meteorological Group JMG Jam Master Geordie van der Heijde, PT, PhD Clinical Epidemiologist and Physiotherapist Julius Center for Health Sciences and Primary Care University Medical Center Utrecht, the Netherlands References (1) van der Heijden GJ, van der Windt DA, de Winter AE Physiotherapy for patients with soft tissue shoulder disorders: a systematic review of randomised Adj. 1. randomised - set up or distributed in a deliberately random way randomized irregular - contrary to rule or accepted order or general practice; "irregular hiring practices" clinical trials. BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift . 1997;315:25-30. (2) Gam AN, Johannsen F. Ultrasound therapy in musculoskeletal disorders Musculoskeletal disorders (MSDs) can affect the body's muscles, joints, tendons, ligaments and nerves. Most-work related MSDs develop over time and are caused either by the work itself or by the employees' working environment. : a meta-analysis. Pain. 1995;63:85-91. (3) Ogilvie-Harris DJ, Gilbert M. Treatment modalities for soft tissue injuries of the ankle: a critical review. Clin J Sport Med. 1995;5:175-186. (4) Falconer J, Hayes KW, Chang RW. Therapeutic ultrasound in the treatment of musculoskeletal conditions. Arthritis Care Res. 1990;3:85-91. (5) Beckerman H, Bouter LM, van der Heijden GJ, et al. Efficacy of physiotherapy for musculoskeletal disorders: what can we learn from research? Br J Gen Pract. 1993;43:73-77. (6) Khan J. Ultrasound. In: Khan J, ed. Principals and Practice 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. . New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of . NY: Churchill Livingstone Imprint of a medical publishing company owned by Elsevier Ltd, but previously owned by Harcourt and Pearsons. Originally formed from Livingstone, Edinburgh, Scotland, and J & A Churchill, London, UK, and subsequently with an office in New York, but now integrated with the rest of Inc; 1991:51-70. (7) Byl NN, McKenzie AL, Wong T, et al. Incisional wound healing: a controlled study of low- and high-dose ultrasound. J Orthop Sprees Phys Ther. 1993;18:619-628. (8) Young S. Ultrasound therapy. In: Kitchen S, ed. Electrotherapy: Evidence-Based Practice. New York, NY: Churchill Livingstone Inc; 2002:211-230. (9) Jackson BA, Schwane JA, Starcher BC. Effect of ultrasound therapy on the repair of achilles tendon Achilles tendon n. The large tendon connecting the heel bone to the calf muscle of the leg. Also called calcanean tendon, heel tendon. injuries in rats. Med Sci Sports Exerc. 1991;23:171-176. (10) Prentice WE. Therapeutic Modalities for Allied Health Professionals. New York, NY: McGraw-Hill Health Professions Division; 1998:271, 279, 280, 289. (11) Hecox B, Mehreteab TA, Weisberg J. Physical Agents: A Comprehensive Text for Physical Therapists. Norwalk, Conn: Appleton & Lange; 1994:116. (12) van der Windt DA, van der Heijden GJ, de Winter AF, et al. The responsiveness of the Shoulder Disability Questionnaire. Ann Rheum rheum (rldbomacm) any watery or catarrhal discharge. rheum n. A watery or thin mucous discharge from the eyes or nose. rheum any watery or catarrhal discharge. Dis. 1998;57:82-87. (13) Downie WW, Leatham PA, Rhind VM, et al. Studies with pain rating scales. Ann Rheum Dis. 1978;37:378-381. (14) Jensen MP, Karoly P, Sandford B. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1986;27:117-126. (15) Ferraz MB, Quaresma MR, Aquino LRL LRL Lugradio Live (Open Source technologies conference) LRL Lunar Receiving Laboratory LRL Lawrence Radiation Laboratory LRL Least Recently Loaded LRL Line-Reflect-Line LRL Logical Record Length LRL Lower Range Limit , et al. Reliability of pain scales in the assessment of literate and illiterate patients with rheumatoid arthritis rheumatoid arthritis Chronic, progressive autoimmune disease causing connective-tissue inflammation, mostly in synovial joints. It can occur at any age, is more common in women, and has an unpredictable course. . J Rheumatol. 1990;17:1022-1024. Editorial Board Member Response: The paper by Kurtais Gursel et al has generated some heated responses (pun intended). Many of the concerns relate to the specifics of how the ultrasound (US) was delivered. Was it delivered to the correct location? Was it delivered at the proper intensity considering the conditions being treated? Was the proper duty cycle used? Was the US delivery tailored to each patient's need? The letter writers essentially are contending that the US was not delivered as it should have been, thus accounting for the conclusion that US does not add any further benefit to those benefits obtained by the other forms of treatment. Both Cameron and Lewis declare that the US parameters used were inappropriate for these patients. For example, Cameron states, "It also is likely that the underlying pathology, in these patients was at various stages of healing, which, based on current evidence from animal studies, are likely to benefit from different US doses. Previously published studies have demonstrated that pulsed low-dose US is most effective for facilitating tissue healing...." In a similar vein, Lewis references studies, including the study by Kurtais Gursel et al, that were negative for an added benefit of US and suggests that the parameters were wrong for the conditions being treated. In contrast, Carcia et al state that Kurtais Gursel et al "selected a reasonable set of variables, including frequency, intensity, duration, and effective radiating area related to the ultrasound treatment." It is obvious that, with respect to the US parameters used in the study by Kurtais Gursel et al, we are confronted with "dueling opinions." Cameron and Lewis believe that continuous wave US is inappropriate for the conditions described in the article (because of the "inflammatory" nature of the condition), whereas Garcia et al consider continuous wave the proper treatment. However, and perhaps even more important, can we be certain that "inflammation" is a component of the pathology that was treated in these patients? Certainly not 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. Khan et al, (1) who contend that "since painful overuse overuse Health care The common use of a particular intervention even when the benefits of the intervention don't justify the potential harm or cost–eg, prescribing antibiotics for a probable viral URI. Cf Misuse, Underuse. tendon conditions have a non-inflammatory pathology," the term "tendinitis" is incorrect, based on histopathological studies. Indeed, Khan et al favor the terms "tendinosis" or "tendonopathy," rather than "tendinitis," because "within two to three weeks of tendon insult tendinosis is present and inflammatory cells are absent." (1) Therefore, the arguments of Cameron and Lewis may be based on incorrect assumptions about the pathology being treated. But this brings us to an interesting question. Why are there such strong but opposing opinions among the letter writers? Possibly inn part because these clinicians have observed patients benefiting although each uses different US parameters. But if different US parameters are associated with good clinical outcomes in their hands, this leaves us with 2 possibilities: (1) benefits accrue regardless of the form of US chosen, or (2) neither form of US affords any added benefit, meaning the benefits observed by both groups of letter writers are due to the other treatments given in addition to the US (which brings us back to the results of the paper that started all this). There is obviously no unanimity UNANIMITY. The agreement of all the persons concerned in a thing in design and opinion. 2. Generally a simple majority (q.v.) of any number of persons is sufficient to do such acts as the whole number can do; for example, a majority of the legislature can pass of opinion among clinicians concerning many aspects of therapeutic US. Some questions raised by the letter writers might have been answered by greater detail in the method section. Kurtais Gursel et al describe how the modalities of US, moist heat, and electhrotherapy were delivered and then comment on the passive and active exercises--but not the sequence with which these procedures were applied--and, perhaps most important for the US, how much time (if any) elapsed e·lapse intr.v. e·lapsed, e·laps·ing, e·laps·es To slip by; pass: Weeks elapsed before we could start renovating. n. between giving the US and the institution of the exercises (eg, stretching, ROM). For example, did the stretching commence before the tissues cooled down? A method section that contains sufficient information for a reader to reproduce the work would include detailed descriptions of just how the treatments flowed in order to convince readers that the US was given its maximum opportunity to show a benefit, if a benefit is added. Kurtais Gursel et al may indeed have applied the various components properly, but the review team, of which I was a member, did not ask them to supply the necessary information. Neil I Spielholz, PT, PhD References (1) Khan KM, Cook JL, Kannus P, Maffulli N. Time to abandon the "tendinitis" myth: painful, overuse tendon conditions have a non-inflammatory pathology. BMJ. 2002;324:626-627. Although Carcia et al, Cameron, and Lewis intend in dispute the conclusion regarding the addition of ultrasound (US), we should not lose sight of the fact that the patients in both groups (continuous US and sham US) showed marked improvements in terms of impairments, functional limitations, and disability. As a reader, I found this quite remarkable given the chronicity of the pathology. All subjects had a history of shoulder pain for at least 1 month, with the mean duration of symptoms being more than 8 months. The fact that statistically and clinically significant improvements were seen in both groups would seem to weaken several of the criticisms made in the letters. For instance, the across-the-board improvements seen in only 3 weeks make concerns about the reliability of the range of motion (ROM) measurements and the lack of statistical power seem somewhat less convincing. The measurements were certainly reliable enough--and the study powerful enough--to demonstrate a significant main effect of one of the independent variables (time), suggesting that either there was no effect of the other independent variable (US) or that any such effect must have been very small. As detailed in the authors' response, the chronicity of the problems being treated also seems to provide a reasonable rationale for the authors' choice of continuous US. As discussed above by Dr Spielholz, the numerous and conflicting suggestions found in the letters regarding the mode, dosage, and treatment area for the US treatment underscores the contention of Kurtais Gursel et al that there is no consensus regarding optimal treatment parameters. Furthermore, despite the contention that use of incorrect US parameters would actually be harmful, no such results are apparent. Some of the letters suggested that the treatment approach should have been "optimized" for each patient, but the investigators' choice to use a standard treatment protocol for the US is a classic case of strengthening the internal validity Internal validity is a form of experimental validity [1]. An experiment is said to possess internal validity if it properly demonstrates a causal relation between two variables [2] [3]. of the study (by limiting extraneous variables) while somewhat weakening the external validity External validity is a form of experimental validity.[1] An experiment is said to possess external validity if the experiment’s results hold across different experimental settings, procedures and participants. (by making it difficult to generalize to other modes of US treatment). On the other hand, the authors also were criticized for including multiple diagnoses and multiple treatments, both factors that enhance the external validity of the study. We would all like to see studies that are tightly controlled but still can be generalized to real-world situations; however, in most cases, there is a trade-off between internal and external validity, (1) and researchers often are forced to make decisions favoring one or the other. One issue that I believe has greater merit is the concern expressed by Carcia and colleagues that the shoulder position might not have allowed for adequate exposure of the supraspinatus tendon during the US treatment. The authors have clarified in their response that although the patients' hands were on their laps, the "[hands were] placed far from each other so that the shoulder was in extension." There is evidence, however, that maximal exposure of the supraspinatus tendon is obtained in a position of shoulder adduction adduction /ad·duc·tion/ (ah-duk´shun) the act of adducting; the state of being adducted. adduction ( , medial rotation (80-90 degrees), and hyperextension hy·per·ex·ten·sion n. Extension of a joint beyond its normal range of motion. hy  per·ex·tend of 30 to 40 degrees. (2) Thus, the arm position during the US treatment may have been less than optimal for the supraspinatus tendon, though it would still seem appropriate for treatment of the biceps tendon. A more exact description of the arm position would have been helpful and may have led to the issue of shoulder positioning being addressed during the review process rather than retrospectively. Another criticism raised in the letters is that the conclusion of the paper was overstated o·ver·state tr.v. o·ver·stat·ed, o·ver·stat·ing, o·ver·states To state in exaggerated terms. See Synonyms at exaggerate. o . The conclusion section begins with the following statement: "Based on the literature and the results of our study, we conclude that there is insufficient evidence to merit wide use of 1-MHz US in combination with other interventions in the management of painful shoulder conditions." In their response, the authors have modified their conclusion statement slightly to clarify the mode and dosage of the US treatment, whereas some of the letters suggested even more caveats were necessary to avoid overstating the conclusion. Although the conclusion section may not have included all of the possible caveats, careful reading of the paper as a whole reveals that the authors did acknowledge many of the limitations. For example, the discussion section mentions the limitations related to multiple treatments, the lack of a true control group, and the lack of statistical power, whereas the methods section, in my opinion, clearly delineates the mode and dosage of the US treatments used in this study. Open debate in the form of Commentaries or Letters to the Editor and the subsequent responses by authors is healthy and informative, and the authors of the letters published here should be commended for raising some pertinent issues. I believe that publication of the paper by Kurtais Gursel et al and publication of these letters and responses may result in two positive outcomes. First, I believe that the study results strongly support the efficacy of short-term, conservative treatment of shoulder soft tissue disorders, even when the symptoms have been present for many months or even years. Second, the debate regarding the investigative approach taken by Kurtais Gursel et al may motivate more clinicians, including those involved in this debate, to produce more and better clinical trials addressing the issues raised here. Gregory M Karst Karst (kärst), Ital. Carso, Slovenian Kras, limestone plateau, W Slovenia, N of Istria and extending c.50 mi (80 km) SE from the lower Isonzo (Soča) valley between the Bay of Trieste and the Julian Alps. , PT, PhD References (1) Portney LG, Watkins MP. Foundations of Clinical Research. Applications to Practice, 2nd edition. Norwalk, Conn: Appleton & Lange; 2000:173. (2) Mattingly GE, Mackarey PJ. Optimal methods for shoulder tendon palpation palpation /pal·pa·tion/ (pal-pa´shun) the act of feeling with the hand; the application of the fingers with light pressure to the surface of the body for the purpose of determining the condition of the parts beneath in physical diagnosis. : a cadaver cadaver /ca·dav·er/ (kah-dav´er) a dead body; generally applied to a human body preserved for anatomical study.cadav´ericcadav´erous ca·dav·er n. study. Phys Ther. 1996;76:166-174. |
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