Effects of ultrasound therapy on calcificated tendinitis of the shoulder

Systematic literature review to inform the EULAR recommendations for the use of imaging in crystal-induced arthropathies in clinical practice

OBJECTIVE

To summarise current data regarding the use of imaging in crystal-induced arthropathies (CiAs) informing a European Alliance of Associations for Rheumatology task force.

METHODS

We performed four systematic searches in Embase, Medline and Central on imaging for diagnosis, monitoring, prediction of disease severity/treatment response, guiding procedures and patient education in gout, calcium pyrophosphate dihydrate deposition (CPPD) and basic calcium phosphate deposition (BCPD). Records were screened, manuscripts reviewed and data of the included studies extracted. The risk of bias was assessed by validated instruments.

RESULTS

For gout, 88 studies were included. Diagnostic studies reported good to excellent sensitivity and specificity of dual-energy CT (DECT) and ultrasound (US), high specificity and lower sensitivity for conventional radiographs (CR) and CT. Longitudinal studies demonstrated sensitivity to change with regard to crystal deposition by US and DECT and inflammation by US and structural progression by CR and CT. For CPPD, 50 studies were included. Diagnostic studies on CR and US showed high specificity and variable sensitivity. There was a single study on monitoring, while nine assessed the prediction in CPPD. For BCPD, 56 studies were included. There were two diagnostic studies, while monitoring by CR and US was assessed in 43 studies, showing a reduction in crystal deposition. A total of 12 studies with inconsistent results assessed the prediction of treatment response. The search on patient education retrieved two studies, suggesting a potential role of DECT.

CONCLUSION

This SLR confirmed a relevant and increasing role of imaging in the field of CiAs.

Efficacy of therapeutic ultrasound in the treatment of chronic calcific shoulder tendinitis: a randomized trial

BACKGROUND

Calcific shoulder tendinitis (CST) is characterized by hydroxyapatite crystals deposition in the rotator cuff tendons. Therapeutic exercises have been the mainstay of CST treatment, and evidence for therapeutic ultrasound (T-US) utilization and efficacy is lacking.

AIM

This study aimed to determine whether 4500 J T-US combined with therapeutic exercises is superior to therapeutic exercises alone regarding calcification size reduction and symptom improvement in chronic symptomatic CST.

DESIGN

This is a double-blind, placebo-controlled study.

SETTING

This study was conducted at a University Department for Rheumatic Diseases and Rehabilitation of a University Hospital.

POPULATION

Patients with chronic CST were analyzed.

METHODS

After eligibility allocation, 46 patients with sonographically confirmed CST were divided into two groups (56 shoulders, 26 per group). Both groups performed the same therapeutic exercises for half an hour under physiotherapist supervision. In the treatment group T-US (4500 J, 10 minutes per session at a frequency of 1 MHz and an intensity of 1.5 W/cm²), and in the placebo group, sham T-US was applied for 4 weeks. Patients were assessed for: calcification size, shoulder pain, global health (GH), shoulder mobility (ROM), handgrip strength, Health Assessment Questionnaire Disability Index (HAQ-DI), Shoulder Pain and Disability Index (SPADI), and overall rehabilitation satisfaction.

RESULTS

All assessed variables improved in both groups. A significantly greater reduction in calcification size was recorded in the treatment group compared to placebo: -10.92% (IQR 4.61% to 19.38%) versus -5.04% (2.30% to 7.22%), P=0.008. There was a significantly greater decrease in HAQ-DI, reduction of VAS GH, and an increase in hand grip strength in the treatment group, while no significant differences were observed for other parameters between the groups.

CONCLUSIONS

Our results showed that adding the 4500 J T-US to therapeutic exercises in chronic symptomatic CST therapy resulted in greater calcification size reduction immediately following the treatment, as well as hand grip strength, HAQ-DI, and VAS GH improvement.

CLINICAL REHABILITATION IMPACT

4500 J T-US combined with therapeutic exercises is more effective in reducing calcification size than therapeutic exercises alone in the treatment of chronic symptomatic CST.

High-energy dose of therapeutic ultrasound in the treatment of patellar tendinopathy: protocol of a randomized placebo-controlled clinical trial

BACKGROUND

Patellar tendinopathy is an extremely debilitating condition and its treatment usually requires a combination of clinical approaches. Therapeutic ultrasound (TUS) is one of the most available electrophysical agent in rehabilitation settings; however, there is also a lack of high-quality studies that test different dosimetric aspects of TUS. Thus, the purpose of this study is to evaluate the short-, medium-, and long-term effects of the combination of high-energy TUS with a rehabilitation program for patellar tendinopathy.

METHODS

This will be a randomized, placebo-controlled trial with blinding of patients, assessors, and therapist. The setting is an outpatient physical therapy clinic. We will recruit 66 participants (male and female) aged between 18 and 40 years and presenting with patellar tendinopathy. A treatment combining high-energy dose TUS and a rehabilitation program for patellar tendinopathy will be delivered twice a week for 8 weeks. The control group will receive the same treatment, but with a placebo TUS. The effectiveness of the intervention will be measured at the beginning (baseline), midpoint (4 weeks), and end of treatment (8 weeks), as well as at 3- and 6-months post-treatment. Primary outcomes will be pain intensity (visual analogue scale, VAS), and VISA-P questionnaire and primary time points will be baseline (T0) and the end of the program (T2). Also, IPAQ-short form questionnaire, muscle strength (manual dynamometry), 2D kinematics, pain pressure threshold (PPT) algometry, thermography, and magnetic resonance imaging (MRI) will be collected.

DISCUSSION

TUS will be applied in an attempt to enhance the results obtained with the rehabilitation program proposed in this study, as well as stimulate some repair responses in individuals undergoing treatment for patellar tendinopathy, which in turn may optimize and improve treatment programs for patellar tendinopathy as well as to establish new guidelines for the application of TUS.

TRIAL REGISTRATION

This study was prospectively registered at April-3rd-2018 and updated at September-1st-2019 in the Brazilian Registry of Clinical Trials (REBEC) under the registration number: RBR-658n6w.

Sustained Acoustic Medicine: A Novel Long Duration Approach to Biomodulation Utilizing Low Intensity Therapeutic Ultrasound

Therapeutic ultrasound is an established technique for biomodulation used by physical therapists. Typically it is used to deliver energy locally for the purpose of altering tissue plasticity and increasing local circulation. Access to ultrasound therapy has been limited by equipment and logistic requirements, which has reduced the overall efficacy of the therapy. Ultrasound miniaturization allows for development of portable, wearable, self-applied ultrasound devices that sidestep these limitations. Additionally, research has shown that the timescale of acoustic stimulation matters, and directly affects the quality of result. This paper describes a novel, long duration approach to therapeutic ultrasound and reviews the current data available for a variety of musculoskeletal conditions.

O ultrassom é efetivo no tratamento da tendinite calcárea do ombro?

Introdução: A tendinite calcária do ombro é uma calcificação caracterizada pela deposição de sais de cálcio nos tendões do manguito rotador, provocando dor no ombro e perda de amplitude de movimento (ADM). O ultrassom é sugerido como alternativa promissora para facilitar a reabsorção dos depósitos de cálcio. Os mecanismos que fundamentam esse efeito são, entretanto, ainda controversos na literatura, e a utilização clínica do ultrassom na tendinite calcária tem sido baseada mais em evidências empíricas do que científicas. Objetivos: Realizar uma revisão bibliográfica sobre os efeitos biológicos e terapêuticos do ultrassom, a fim de identificar o real papel desse recurso no tratamento da tendinite calcária do ombro. Materiais e métodos: Para sua elaboração, foi feita uma busca bibliográfica em bases de dados eletrônicas e uma pesquisa manual. Resultados: Dentre os estudos selecionados, dois demonstraram redução da dor e do tamanho da calcificação e dois não apresentaram resultados positivos. Discussão: Os benefícios promovidos pelo ultrassom são dependentes dos parâmetros utilizados. Variáveis como o tamanho da área a ser tratada, diferenças teciduais, duração da aplicação e o objetivo da conduta terapêutica também devem ser considerados. Conclusão: Com base nesta revisão, pode-se afirmar que o ultrassom terapêutico é um recurso efetivo no tratamento da tendinite calcária do ombro.

Evidence supporting the use of physical modalities in the treatment of upper extremity musculoskeletal conditions

PURPOSE OF REVIEW

To evaluate recent trials and reviews of physical modalities and conservative treatments for selected upper extremity musculoskeletal conditions for evidence supporting their use.

RECENT FINDINGS

Recent evidence suggests that many localized tendinopathies are related more to degenerative than inflammatory processes. With this realization, there is increased emphasis on finding new modalities to treat tendinopathies and other localized musculoskeletal conditions that rely on other than anti-inflammatory mechanisms. Although there is good evidence to support the short-term benefits of corticosteroid injections, convincing evidence in support of other conservative treatments and modalities is generally lacking. Extracorpal shock wave therapy may have significant clinical benefit for calcific tendinitis; however, it requires intravenous sedation in most cases and does not appear to be effective in lateral epicondylitis. The most consistent positive treatment effects for rotator cuff tendinitis were achieved by ultrasound-guided subacromial corticosteroid injection as well as manual therapy in conjunction with therapeutic exercise.

SUMMARY

Although there is evidence supporting the use of several different physical modalities and conservative treatments for upper extremity musculoskeletal conditions, there is a strong need for larger, higher quality randomized controlled trials. Although most studies are able to demonstrate short-term benefits, there is a lack of high-quality data demonstrating that these conservative treatments have long-term benefits, particularly, with regard to functional outcomes.

Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review

BACKGROUND

Although therapeutic ultrasound is commonly used to treat shoulder injuries, research to date on the ability of ultrasound to improve outcomes for shoulder pathologies is conflicting.

OBJECTIVE

This study aimed to systematically and critically review available literature to ascertain whether beneficial effects of ultrasound were associated with certain shoulder pathologies or particular ultrasound treatment protocols.

METHODS

Five electronic databases were searched, and the included studies, identified through pair consensus, were randomized controlled trials (RCTs) that utilized ultrasound for soft tissue shoulder injury or pain.

STUDY SELECTION AND DATA EXTRACTION

Eight studies included in this review (n=586 patients, median PEDro score=8.0/10) evaluated various parameters, including the duration of patients' symptoms (0-12 months), duty cycle (20% and 100%), intensity (0.1-2.0 W/cm2), treatment time per session (4.5-15.8 minutes), number of treatments (6-39), and total energy applied per treatment (181-8,152 J).

DATA SYNTHESIS

Inconsistent outcome measures among studies precluded meta-analysis; however, 3 RCTs showed statistically significant benefits of ultrasound, 2 of which examined calcific tendinitis. Studies that showed beneficial effects of ultrasound typically had 4 times longer total exposure times and applied much greater ultrasound energy per session (average of 4,228 J) compared with studies that showed no benefit of ultrasound (average of 2,019 J). No studies that delivered < or = 720 J per session showed improvement in treatment groups.

LIMITATIONS

Current research involving ultrasound treatment protocols that delivered low levels of ultrasound energy do not adequately address whether ultrasound can improve outcomes for shoulder disorders.

CONCLUSION

Determining whether therapeutic ultrasound can affect soft tissue shoulder pathologies will require further research and systematic reviews that involve appropriate ultrasound treatment protocols.

Efeito do ultra-som terapêutico contínuo em placas epifisárias de coelhos

Devido aos efeitos terapêuticos, o ultra-som tem se tornado ferramenta indispensável no tratamento fisioterapêutico de alterações causadas por lesões e em diversas doenças, porém seu uso em pacientes pediátricos é controverso por possíveis distúrbios e danos à placa epifisária. O objetivo deste estudo é verificar se o ultra-som contínuo apresenta efeitos de alteração na placa de crescimento da tíbia de coelhas. Oito coelhas da raça Nova Zelândia com dois meses de idade foram submetidas a um tratamento usando ultra-som terapêutico de forma contínua com dose de 1W/cm² na região lateral da articulação do joelho direito por 5min, durante 10 dias com dois dias de intervalo após a 5ª aplicação. A articulação do joelho esquerdo foi utilizada como controle. A análise histológica mostrou uma alteração na espessura da cartilagem epifisária, sendo que no lado tratado o tamanho foi 24,40% maior do que no controle (p < 0,0001), enquanto a análise radiológica não apresentou diferença entre os membros. Conclui-se que o ultra-som terapêutico na forma utilizada produz alterações histológicas significativas na espessura da cartilagem no lado tratado, sugerindo uma aceleração no metabolismo da placa.