Therapeutic ultrasound for acute ankle sprains

BACKGROUND

Ultrasound is used in the treatment of a wide variety of musculoskeletal disorders, which include acute ankle sprains. This is an update of a Cochrane review first published in 1999, and previously updated in 2004.

OBJECTIVES

To evaluate the effects of ultrasound therapy in the treatment of acute ankle sprains.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 3), MEDLINE (1966 to September 2010), EMBASE (1983 to September 2010), CINAHL (1982 to 2004), and PEDro - the Physiotherapy Evidence Database (accessed 01/06/09). We also searched the Cochrane Rehabilitation and Related Therapies Field database, reference lists of articles, and contacted colleagues.The WHO International Clinical Trials Registry Platform was searched for ongoing trials.

SELECTION CRITERIA

Randomised or quasi-randomised trials were included if the following conditions were met: at least one study group was treated with therapeutic ultrasound; participants had acute lateral ankle sprains; and outcome measures included general improvement, pain, swelling, functional disability, or range of motion.

DATA COLLECTION AND ANALYSIS

Two authors independently performed study selection, and assessed the risk of bias and extracted data. Risk ratios and risk differences together with 95% confidence intervals were calculated for dichotomous outcomes and mean differences together with 95% confidence intervals for continuous outcome measures. Limited pooling of data was undertaken where there was clinical homogeneity in terms of participants, treatments, outcomes, and follow-up time points.

MAIN RESULTS

Six trials were included, involving 606 participants. Five trials included comparisons of ultrasound therapy with sham ultrasound; and three trials included single comparisons of ultrasound with three other treatments. The assessment of risk of bias was hampered by poor reporting of trial methods and results. None of the five placebo-controlled trials (sham ultrasound) demonstrated statistically significant differences between true and sham ultrasound therapy for any outcome measure at one to four weeks of follow-up. The pooled risk ratio for general improvement at one week was 1.04 (random-effects model, 95% confidence interval 0.92 to 1.17) for active versus sham ultrasound. The differences between intervention groups were generally small, between zero and six per cent, for most dichotomous outcomes.

AUTHORS' CONCLUSIONS

The evidence from the five small placebo-controlled trials included in this review does not support the use of ultrasound in the treatment of acute ankle sprains. The potential treatment effects of ultrasound appear to be generally small and of probably of limited clinical importance, especially in the context of the usually short-term recovery period for these injuries. However, the available evidence is insufficient to rule out the possibility that there is an optimal dosage schedule for ultrasound therapy that may be of benefit.

Ultrasound therapy in musculoskeletal disorders: a meta-analysis

We have reviewed 293 papers published since 1950 to assess the evidence of effect of ultrasound in the treatment of musculoskeletal disorders. Twenty-two clinical papers describing trials comparing ultrasound treatment with sham-ultrasound treated, non-ultrasound treatment and untreated groups were found. These papers were evaluated with respect to a list of criteria which should be met in this type of trial. They were generally found lacking with respect to description of drop-outs, randomisation methods, ultrasound apparatus, sham-ultrasound apparatus, control of apparatus, mode of delivery, size of sound-head, treated area and follow-up time. In 16 of these trials, ultrasound treatments were compared with sham-ultrasound and in 13 cases data were presented in a way that made pooling possible. Two standardized effect sizes (dd/r and dd/s) were applied to the results to enable evaluation of the effect of ultrasound treatment on pain. None of the methods (dd/r = 0.64%, confidence limits -6.7 to 7.5%; and dd/s = 0.24, confidence limits -0.01 to 0.49) gave evidence that pain relief could be achieved by ultrasound treatment. Hence we found no reason to analyze the other papers where ultrasound treatment was compared with another treatment or an untreated control group. We found a significant influence of degree of blinding using the d/s for the analysis (t test, P = 0.009), while when the d/r was used, only a trend was found (P = 0.10). An analysis of the effect of proper randomisation on the result was not possible because of inadequate description of the methods used. We conclude that the use of ultrasound in treatment of musculoskeletal disorders is based on empirical experience, but is lacking firm evidence from well-designed controlled studies. One question remaining is whether ultrasound treatment can augment an effect of exercise therapy with respect to musculoskeletal disorders.