Ultrasound in contemporary physiotherapy practice

Use of weekly, low dose, high frequency ultrasound for hard to heal venous leg ulcers: the VenUS III randomised controlled trial

OBJECTIVE

To assess the clinical effectiveness of weekly delivery of low dose, high frequency therapeutic ultrasound in conjunction with standard care for hard to heal venous leg ulcers.

DESIGN

Multicentre, pragmatic, two arm randomised controlled trial.

SETTING

Community and district nurse led services, community leg ulcer clinics, and hospital outpatient leg ulcer clinics in 12 urban and rural settings (11 in the United Kingdom and one in the Republic of Ireland).

PARTICIPANTS

337 patients with at least one venous leg ulcer of >6 months' duration or >5 cm(2) area and an ankle brachial pressure index of ≥ 0.8.

INTERVENTIONS

Weekly administration of low dose, high frequency ultrasound therapy (0.5 W/cm(2), 1 MHz, pulsed pattern of 1:4) for up to 12 weeks plus standard care compared with standard care alone.

MAIN OUTCOME MEASURES

Primary outcome was time to healing of the largest eligible leg ulcer. Secondary outcomes were proportion of patients healed by 12 months, percentage and absolute change in ulcer size, proportion of time participants were ulcer-free, health related quality of life, and adverse events.

RESULTS

The two groups showed no significant difference in the time to healing of the reference leg ulcer (log rank test, P=0.61). After adjustment for baseline ulcer area, baseline ulcer duration, use of compression bandaging, and study centre, there was still no evidence of a difference in time to healing (hazard ratio 0.99 (95% confidence interval 0.70 to 1.40), P=0.97). The median time to healing of the reference leg ulcer was inestimable. There was no significant difference between groups in the proportion of participants with all ulcers healed by 12 months (72/168 in ultrasound group v 78/169 in standard care group, P=0.39 for Fisher's exact test) nor in the change in ulcer size at four weeks by treatment group (model estimate 0.05 (95% CI -0.09 to 0.19)). There was no difference in time to complete healing of all ulcers (log rank test, P=0.61), with median time to healing of 328 days (95% CI 235 to inestimable) with standard care and 365 days (224 days to inestimable) with ultrasound. There was no evidence of a difference in rates of recurrence of healed ulcers (17/31 with ultrasound v 14/31 with standard care, P=0.68 for Fisher's exact test). There was no difference between the two groups in health related quality of life, both for the physical component score (model estimate 0.69 (-1.79 to 3.08)) and the mental component score (model estimate -0.93 (-3.30 to 1.44)), but there were significantly more adverse events in the ultrasound group (model estimate 0.30 (0.01 to 0.60)). There was a significant relation between time to ulcer healing and baseline ulcer area (hazard ratio 0.64 (0.55 to 0.75)) and baseline ulcer duration (hazard ratio 0.59 (0.50 to 0.71)), with larger and older ulcers taking longer to heal. In addition, those centres with high recruitment rates had the highest healing rates.

CONCLUSIONS

Low dose, high frequency ultrasound administered weekly for 12 weeks during dressing changes in addition to standard care did not increase ulcer healing rates, affect quality of life, or reduce ulcer recurrence. Trial registration ISRCTN21175670 and National Research Register N0484162339.

Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments--a systematic review

OBJECTIVE

To review literature systematically concerning effectiveness of nonsurgical interventions for treating carpal tunnel syndrome (CTS).

DATA SOURCES

The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs).

STUDY SELECTION

Two reviewers independently applied the inclusion criteria to select potential studies.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality.

DATA SYNTHESIS

A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 20 RCTs were included. Strong and moderate evidence was found for the effectiveness of oral steroids, steroid injections, ultrasound, electromagnetic field therapy, nocturnal splinting, and the use of ergonomic keyboards compared with a standard keyboard, and traditional cupping versus heat pads in the short term. Also, moderate evidence was found for ultrasound in the midterm. With the exception of oral and steroid injections, no long-term results were reported for any of these treatments. No evidence was found for the effectiveness of oral steroids in long term. Moreover, although higher doses of steroid injections seem to be more effective in the midterm, the benefits of steroids injections were not maintained in the long term. For all other nonsurgical interventions studied, only limited or no evidence was found.

CONCLUSIONS

The reviewed evidence supports that a number of nonsurgical interventions benefit CTS in the short term, but there is sparse evidence on the midterm and long-term effectiveness of these interventions. Therefore, future studies should concentrate not only on short-term but also on midterm and long-term results.

Effects of therapeutic pulsed ultrasound and dimethylsulfoxide (DMSO) phonophoresis on parameters of oxidative stress in traumatized muscle

Many studies have demonstrated an increase in reactive oxygen species (ROS) and oxidative damage markers after muscle damage. Phonophoresis aims to achieve therapeutically relevant concentrations of the transdermally introduced drug in the tissues subjected to the procedure by the use ultrasound waves. The aim of the study was to evaluate the effects on the therapeutic pulsed ultrasound (TPU) together with gel-dimethylsulfoxide (DMSO) in the parameters of muscular damage and oxidative stress. Male Wistar rats were divided randomly into six groups (n=6): sham (uninjured muscle); muscle injury without treatment; muscle injury and treatment with gel-saline (0.9%); muscle injury and treatment with gel-DMSO (15mg/kg); muscle injury and TPU plus gel-saline; and muscle injury and TPU plus gel-DMSO. Gastrocnemius injury was induced by a single impact blunt trauma. TPU (6min duration, frequency of 1.0MHz, intensity of 0.8W/cm(2)) was used 2, 12, 24, 48, 72, 96 and 120h after muscle trauma. The CK and acid phosphatase activity in serum was used as an indicator of skeletal muscle injury. Superoxide anion, TBARS, protein carbonyls, superoxide dismutase (SOD) and catalase (CAT) activity was used as indicators of stress oxidative. Results showed that TPU and gel-DMSO improved muscle healing. Moreover, superoxide anion production, TBARS level and protein carbonyls levels, superoxide dismutase (SOD) and catalase (CAT) activity were all decreased in the group TPU plus gel-DMSO. Our results show that DMSO is effective in the reduction of the muscular lesion and in the oxidative stress after mechanical trauma only when used with TPU. (E-mail: silveira_paulo2004@yahoo.com.br).