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US on patient with hx of CA??
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US on patient with hx of CA?? - January 29, 2003 9:15:00 PM
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JSSSH
Posts: 45
Joined: September 10, 2000
From: Kingston, Ontario, Canada
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This issue came up at an outpatient clinic where I have my placement now: would you use US on a patient with hx of cancer?
Some therapists think it's better to be safe than sorry.
Some think it's okay if CA is in remission, or if CA is not in close proximity (e.g. rectal CA and shoulder tendonitis).
And some wonder the extend of effects by US. e.g. for breast CA and shoulder tendonitis, is 5 min of US going to increase circulation that much? If so, isn't it unsafe to do shoulder exs as well?
What are your thoughts? If I get some good responses, I will choose this as topic for my presentation. It's next Thurs (Feb 6).
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Re: US on patient with hx of CA?? - January 30, 2003 3:37:00 AM
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Dr.Wagner
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As a Doc, and a former practicing PT...I don't think you have a thing to worry about.
First and foremost, remember we are talking about ultrasound, a modality of little true value...sure in THEORY, but it simply doesn't have a bit of evidence based data or outcome studies that show it benefits much of anything. If anything, its cost outweighs any percieved benefits it may produce (placebo).
Secondly, perhaps you should look up in a pathology book ( I suggest Robbins) carcinogenesis and the development of neoplasms. Less has to do with "blood flow" than with lack of apoptosis in the development of malignant or benign cellular dysplasia.
And assuming ultrasound DOES increase blood flow significantly (invivo), does it increase it more than exercise or simple movement? No. But if that were true, would we suggest those with breast cancer stop exercising/moving? No.
Good Luck
Dr.Wagner, DO
[This message has been edited by Dr.Wagner (edited January 30, 2003).]
[This message has been edited by Dr.Wagner (edited January 30, 2003).]
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Re: US on patient with hx of CA?? - January 30, 2003 4:52:00 AM
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Andrew M. Ball PT PhD
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I'd tend to agree with Dr. Wanger. That doesn't mean, however, that a PT who did US over a tumor couldn't be sued by the patient in the future if metastasis occured . . .
In that vein, I think it's a good idea to find out what common practice might be, despite the facts that Dr. Wagner put forth.
Screwy ain't it?
Drew
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Re: US on patient with hx of CA?? - January 30, 2003 12:06:00 PM
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OSUPT
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We did a literature review on this earlier in the year and only came up with one article (can't remember the exact reference, but I think it was from Physical Therapy around 95 or so -- about murine tumors in mice growing with continuous ultrasound). We were taught not to do US over a tumor site in PT school, but the oncologists at our hospital don't seem to think there is any reason not to (similar to what Dr. Wagner said). So, I think it really comes down to your own comfort level with the benefits vs. the risks (similar to what Drew said).
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Re: US on patient with hx of CA?? - January 31, 2003 3:31:00 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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I agree with everyone else. We still have yet to prove if ultrasound really does anything effective on targeted tissues, let alone have the enormous power to cause a metastasis from lung tissue when you are ultrasounding the knee.
However, as Drew states, it may not be worth the risk to do over the involved tissue itself. Again, it is not that powerful of a tool that skipping that treatment is going to cause a patients rehab to fail. Remember how ligitious our society is...one slick lawyer would love to find out that metastasis was confirmed around the same time some poor PT was doing some ultrasound. It is this same reason why I really don't lay my hands on pregnant patients. A miscarriage the day after a PT does some manual technique or even modality, and guess who the finger will get pointed at?
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: US on patient with hx of CA?? - January 31, 2003 8:54:00 AM
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JSSSH
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From: Kingston, Ontario, Canada
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Thanks for your responses.
Well, according to my text book (Physical agents in rehab by Michelle H. Camerson), US is good for these conditions: tendon injuries, bone fractures, surgical skin incisions, pain, soft tissue shortening etc. (There are references for each of them.) Personally, I feel I "owe" the patient if I do not give him/her US for shoulder tendonitis.
I also did a literature search and found only one article (so far) that shows US application on mice with malignant tumors resulted in significantlylarger and heavier tumors (Phys Ther 1995; 75 (1): 3-11)
And, isn't it sad that although some of you don't believe there is any effects from applying US, your decision of not doing US on CA patients is not based on evidence based practice, but because of fear of being sued??!!
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Re: US on patient with hx of CA?? - January 31, 2003 3:42:00 PM
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Dr.Wagner
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Remember, you can get sued for anything...that doesn't mean diddly.
Step back, and learn about neoplasms, open the pathology book i mentioned. Or better yet, go to [URL=http://www.pathguy.com]www.pathguy.com[/URL] and ask Dr. Ed Freidlander the same question.
Listen, US even in the BEST testing environment (clearly not the clinical setting) does virtually nil. I guess i am rather frustrated regarding the continued belief of ultrasounds mystical properties...including causing cancer metastasis.
Though you COULD get sued how could it ever hold up in court? PT is still considered a science...yes?
I hope that doesn't sound harsh.
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Re: US on patient with hx of CA?? - January 31, 2003 6:29:00 PM
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flexion
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The U/S isn't going to cause any major effect on a CA.
The practicle problem I see is that this can be interpreted as a form of Tx for the CA potentially by the MD or give the patient false hope that, even though that isn't your intention, could come back and bite you in the future depending on the interpretation by the patient.
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Re: US on patient with hx of CA?? - January 31, 2003 9:33:00 PM
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Bournephysio
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What is with everyone putting down ultrasound these days? I suggest people look at Ebenbichler et al. NEJM May, 1999. If you do a bunch of studies with ineffective dosages, of course you will get negative results.
For those of you who think us does nothing, try using us at 2.0W/cm2 for 5 min holding the head perfectly still.
Remember that ultrasound is a mechanical modality not just a heating modality. If you just think in terms of heating or blood flow you are likely to miss other problems. When treating someone with cancer you need to use a different level of evidence. You have to be sure that it is not going to cause a problem. You could imagine that high frequency vibration might have a different effect on diseased cell proteins or damaged dna. Of course doing ultrasound on the knee won't affect lung cancer but what if the pain in the knee is from an undetected bone met?
Has Dr. Freidlander done a lot of work with ultrasound and cancer? I don't see how asking a doctor, who probably has no idea what ultrasound is, is going to help me determine if it is safe to use.
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Re: US on patient with hx of CA?? - February 1, 2003 3:07:00 AM
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PTupdate.com
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Sorry JSSSH, even though I don't believe a modality has a ton of healing power, I still won't use it if my backside is on the line. Avoid a certain treatment for fear of being sued? YOU BET I will!
As Bourneo mentions, there is more to ultrasound than the heat. After all, has heat ever cured anybody? I use it on focal lesions, in a pulsed mode, convinced after finding that even 2 minutes over my plantar fascia insertion side relieved pain for hours. Add on some MFR cleansing techniques, and the pain was gone for a day. Thus seeded my own protocol.
US does something, but is that something always a healing property. Just because US causes pain at 2.0 w/cm2 when held stationary doesn't mean it is a good thing. A good punch in the forearm hurts for days, but didn't do me any good!
John Duffy, PT OCS [URL=http://www.PTUpdate.com]www.PTUpdate.com[/URL]
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Re: US on patient with hx of CA?? - February 1, 2003 5:49:00 AM
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Bournephysio
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From: Calgary
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I wrote that late last night so my points probably weren't clear.
My points were:
1. There is good evidence that us works.
2. Whether or not it works it has an effect on tissues (might be good, bad or neither).
3. We don't know what it will do to cancer so we better be careful until we do.
so basically I agree with you.
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Re: US on patient with hx of CA?? - February 1, 2003 3:52:00 PM
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Dr.Wagner
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By asking Dr. Friedlander, a pathologist of CONSIDERIBLE knowledge of neoplasms...you may get one heck of an answer. I learned alot from him in medical school...and remember, therapuetic ultrasound is not that different than diagnostic ultrasound.
Anyway, this subject is a bit worn...and I am glad people are actually questioning some of the myths they learn.
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Re: US on patient with hx of CA?? - February 3, 2003 1:04:00 PM
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JSSSH
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Joined: September 10, 2000
From: Kingston, Ontario, Canada
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I hear clinical instructors and other PTs discuss about this every time this topic is brought up. And there are always a wide range of responses, just like the discussion in this forum! So I have decided to use this as my presentation topic on Thurs Feb 6.
I am going to present this topic by investigating: 1. physical properties of US 2. pathology of tumors 3. Review of lit 4. clinical application (incl crochrane review) 5. legal issue (if I find any info)
I found another journal article on this topic. It concluded that growth of tumors after application of pulsed US or low intersity US is not significantly different than control. (Phys Ther 1998; 78: 271-277)
Dr.Wagner, I will definitely look up the pathology of neoplasms. sorry I want to clarify, do you mean that you won't use US on pt with CA because you think US doesn't have good therapeutic effects, and you don't think US will cause increase growth of tumors?
BTW, I personally do find US helpful when I had plantar fascitis last summer.
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Re: US on patient with hx of CA?? - February 3, 2003 4:01:00 PM
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Andrew M. Ball PT PhD
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From: Charlotte, NC
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Jsssh,
Take a look at Sue Michlovich's work in her Thermal Agents book. She measured blood flow and heating effects resulting from continuous US, finding that no less than 2.0 W/cm squared at a duration of more than 10 minutes in an area no more than 3 times the size of the sound head was required for consistent heating effects.
Given the 1.5 W/cm squared max for 5 to 8 minutes, in the clinic, it’s no wonder that there exists a wide variation in option as to weather or not US has any clinical effect.
My own opinion is that it may have some heating effect, but almost never at the intensities and durations used in the clinic.
Drew
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Re: US on patient with hx of CA?? - February 3, 2003 4:22:00 PM
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jma
Posts: 2432
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From: NY
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Hello,
Saw this from a reference and it sounds intersting to those who may want more info:
1. Dalzell MA: Biophysical modalities in oncology: guidelines for the use of electrical stimulation, laser and ultrasound. Proceedings from Cnacer rehabilitation: the multidisciplinary integration of traditional and "whole person" care, Montral, L'Espirit Rehabilitation Centers, Jan 21-23-2000.
2. Pfalzer L: Physical agents/modalities for survivors of cancer, Rehabilitation Oncology 19(2): 12-24, 2001
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Re: US on patient with hx of CA?? - February 3, 2003 7:22:00 PM
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johnjfraser
Posts: 102
Joined: June 11, 2000
From: Staten Island, NY
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My problem with that high of an intensity is that cavitation occurs at 9.0W/cm2. If you are using 1.5 W/cm2 and the sound head has a BNR of 6:1 (which is a fairly good head), you have reached your 9.0. Now if you use an intensity of 1 W/cm2, and dont paint the limb and stay inside the 2X the area of the soundhead, your good to go. None of the US studies that I know have followed stringent criteria. Besides, who would use US in isolation, and not with other techniques. Has anyone gotten a patient better with heat alone? Personally I use this modality sparingly.
------------------
John J Fraser, PT, MS
johnjfraser@yahoo.com
[URL=http://www.geocities.com/johnjfraser]http://www.geocities.com/johnjfraser[/URL]
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Re: US on patient with hx of CA?? - February 4, 2003 3:04:00 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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John Fraser, I completely agree. For those who use US for the heat effect alone, I remind you that heat never is going to really cure anything. The mechanical effects of pulsed US may be more beneficial, and augement an appropriate PT program. If your treatment fails because you quit performing an ultrasound on that person, it may be time to turn in your license!
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: US on patient with hx of CA?? - February 4, 2003 3:30:00 AM
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Diane
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It's been a lo-o-o-ong time since I've stood there ultrasounding any human being, preferring to make better use of my hands and somebody's hurting body and our combined time still available in life; but having said that, back to ultrasound;
The mechanical effects were always the thing that one went for, the 100,000 jiggles per second to wake up cellular processes, make membranes more permeable etc., and the heat was always an undesireable side effect, which is why "pulsed" machines came along. The idea was to dissipate the heat without having to move off the target so much...
Ultrasound actually began (as so many medicalistic things begin) as war technology in Britain at the beginning of the last century. Experiments were done to see how much ultrasonic intensity was required to kill small animals, mice, goldfish, etc...the cavitation effects were noted. It was noted that at less high frequencies cellular function seemed to be enhanced, and lo...ultrasound as we know and love it (or hate it) came into use. (I don't have a reference for you...I read a book from a PT dept. library 35 years ago to write a student paper.)
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Re: US on patient with hx of CA?? - February 4, 2003 5:33:00 AM
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Bournephysio
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From: Calgary
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The Ebenbichler study was done on calcific tendonitis with the following settings: 2.5W/cm2 15minutes 1:4 duty cycle.
I personally hate doing ultrasound. Its pretty boring sitting there moving the ultrasound head around. But considering the positive results of this study and positive results of ECSWT in some studies, it may be worthwhile to use.
Dalzell taught us modalities in school. As far as I know she is not a researcher. So her presentation was probably based on her review of the literature. (ps its Montreal)
jsssh: let us know what you find. I would like to know if there is a trend towards significant effects with higher intensities.
Doug
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Re: US on patient with hx of CA?? - February 4, 2003 2:36:00 PM
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JSSSH
Posts: 45
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From: Kingston, Ontario, Canada
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Did anyone know of any court cases of PTs being blamed for using US on patients with CA? I didn't find any news on this.
Should US be considered in the first place? Although the textbook advocates application for many conditions, here's what I found from crochrane database of systemic reviews Issue 4, 2002:
not enough evidence to support use of US for planta heel pain, knee OA, pressure sores, PFS. Some evidence for RA and healing of venous leg ulcers.
But the reviewers always end the reviews saying more randomized, well designed studies are needed.
The only positive research finding is from the Ebenbichler study. However, US was used at 0.89MHz, 2.5W/cm2, 1:4 duty cycle, for 15 minutes. The first 15 Rx were given 5x/week and the last 9 Rx were given 3x/week. My CI would not let me use 0.89MHz for shoulder tendonitis! And definitely it's hard to see pt 5x/week!
I find these on [URL=http://www.physiomontreal.com/ultrasound.pdf]http://www.physiomontreal.com/ultrasound.pdf[/URL]
Case 1:
Pt had a hysterectomy for benign cyst growth 1 yr ago. She c/o numbness in the area and thickened scar.
Case 2:
Patient just came out of breast CA and now developed scarring in the breast tissue and limited ROM in shld. She had been too fearful to move her shld x2 mo and developed frozen shld.
Case 1:
3MHz 0.8 to 1.2W/cm2 for 5 min to break down the scar
Reason: uterus was removed, and US can only penetrate to a depth of 1.5 cm which is not far enough to affect internal organs.
Case 2:
Contraindicated
(but did not mention if CA is in remission)
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