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Re: Why???
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Re: Why??? - June 22, 2004 1:26:00 AM
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nari
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Ultrasound (therapeutic) is used here mostly by students and old PTs who have not 'moved on' in updating. It has been shown in numerous studies to be ineffective or no better than stright placebo in most conditions except acute mastitis and very acute sprains.
Diagnostic US is a great tool, but hardly warrants its great cost when clinically one can use other methods; but for research purposes I would think it would be most useful.
If physiotherapy schools have to drop subjects to fit in others - eg much more on the management and neurophysiology of pain -electrotherapy should go. The evidence base for neurobiological clinical practice is pretty much EBM - what is the evidence for electrotherapy?????
Nari
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Re: Why??? - June 22, 2004 4:55:00 AM
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SJBird55
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I had forgotten how money is the big factor in what determines both the tools we use within the clinic and also individually what we are willing to pay out of pocket to learn on our own.
My dream would be to use technology a bit more aggessively than Army is... a completely paperless system for documentation - the initial evaluation (with data fields for outcome data collection), connected to a daily treatment documentation with fields within it to dump appropriate CPT codes performed based on time into a billing program and a database... with the iniital evaluation connected to a progress report document (again with data fields for outcome data collection) to then be able to dump into access or something to do queries that could answer questions involving cost of episodes of care and outcomes along with procedures performed. Within that dream system, there would just have to be some sort of classification system of patients (not ICD-9 codes) to be able to really compare apples to apples in regard to outcomes and compare therapist styles to learn what styles provide the most efficient and effective outcomes.
I've always wondered why something hasn't been designed to assist us with patients with gait abnormalities or balance disturbances. I've never felt that I'm able to challenge those patients as greatly as I'd like because of liability issues and the risk of falling - but if there was a way to safely challenge these patients AND let them feel short distance drop falls, I think that would be beneficial. I picture something coming from the ceiling attached to the patient not too stiffly to allow for a 6-8" fall. I'd like my hands free so I can observe movement patterns and facilitate the challenges - all we can do is feel with the gait belt on, I can't see a darn thing (and a mirror doesn't always help because to do my job with some activities I can't see into the mirror).
The other thing to think about with technology - does one really get better effects using technology? I mean, if you listen to what patients say, the medical field is in a catch-22. What do surgeons do diagnostically? Well, they run all the expensive tests, tell the patient the results and then offer options. Sounds good, but what do patients complain about? "The surgeon didn't even touch me." Because of our lack of technology so to speak, I think we are probably a lot stronger in our history taking skill, potentially our listening capability, our palpatory skill and our ability to basically know normal tissue feel and quality. We also probably have greater observational skills - we know if something looks goofy in a movement pattern. The biggest weakness is the simple fact that we probably never really know exactly what is causing what we are feeling or observing (that's not to say we don't have a good assumption of what we think is occurring). That weakness used to bother me a lot, but I guess I've grown used to that weakness and have the attitude that I guess technically does it really matter? If my differential diagnosis doesn't have me thinking something terrible and if the patient responds as I would anticipate, then I've learned that's the best I can currently do.
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Re: Why??? - June 22, 2004 6:44:00 AM
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steve
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Interesting that there have been many posts here regarding evidence based practice and the ineffectiveness of therapeutic ultrasound. There were two excellent double blind studies comparing ultrasound and sham ultrasound for the treatment of shoulder calcific tendonitis and CTS. Both found that ultrasound was effective. I will post the references later.
Steve
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Re: Why??? - June 22, 2004 8:12:00 AM
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Dr.Wagner
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Don't post those articles unless you read them...I read the calcific tendonitis article and it is not a positive review...it uses US settings unlike those used in practical settings and uses ultrasound daily...with no long term difference, only short term.
Read the article and not the abstracts.
I think that was something lacking in PT education, dissection of articles, not the reading of abstracts. But that is another story.
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Re: Why??? - June 22, 2004 8:25:00 AM
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Bournephysio
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Critical appraisal of evidence seems to be missing in DO school.
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Re: Why??? - June 22, 2004 9:51:00 AM
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steve
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Dr. Wagner,
I have read them, although it was about a year ago. Don't quote me but treatment protocol was:
US@3.0/20%/15 minutes 5 times per week for 3 weeks followed by 3 times a week for 3 weeks. Sham group was given ultrasound with a sham machine. Clinician and patient blind. Outcomes included nerve conduction and functional scales for CTS, Radiological studies and functional scales for calcific tendonitis. Evaluators also blinded. Minimal drop outs. Findings for both studies were significant both immediately post intervention and I believe at the 9 month or year follow-up. I believe that the clinical (Functional scales) measures had a tendancy towards significance but that this did not reach significance.
Yes, I do know how to critically appraise the literature and would not post unless they were quality articles. I believ that the fact that these studies were double blind, had minimal drop outs, used proper outcomes and had long term follow-up makes them appropriate to base treatment on. Although the settings for ultrasound are lengthy, if it is effective why shouldn't it be done this way?
I will find the exact references and post them later.
Times are changing and critical appraisal was a huge component of my education.
Steve
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Re: Why??? - June 22, 2004 11:49:00 AM
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Diane
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Here's a "new gadget" that may find a place in our lifetimes:
http://www.newswise.com/articles/view/505678/?sc=wire
I think it might be cool to have one of these
1. In the clinic as a virtual distractor for people in acute pain/distress
2. On my head, in my deathbed, if I am in acute pain/distress, and the meds don't work anymore
:) ,
Diane
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Re: Why??? - June 22, 2004 3:03:00 PM
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nrl
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Technology advance, big companies and EBP came up
Look at biofeedback systems : biofeedback , as we use it (concurrent, high frequency, small bandwidth), has been shown to be INEFFECTIVE AND EVEN DETRIMENTAL TO LEARNING A SKILL. A lot of the research that proved this was done by physios and published in our leading journals. Using simple programming we could change the way we give feedback in a way that has been shown to be effective (post-response, low frequency, large bandwidth). Yet we don’t.
As was mentioned, companies do a good job at selling us nicer looking and user friendly systems. Though the evidence is there, we don’t ask for better software based on that evidence. I’m sure if we, as consumers, were to say “this does not work. make certain changes and only then we’ll reach for our wallets ” then new or maybe updated technology will show up.
I think it is the same with U.S. Why change a product that sells so well ? U.S. has some effect on body tissues. Maybe different frequencies will be more effective ? but why spend money looking for changes if it sells well anyway.
We , probably, have to rely on the big companies to develop new and improve existing technologies. They will do that only if we will create a demand. We need to create that demand based on our growing knowledge base and EBP. So it is basically up to us and our attitude.
Dianne’s link is a good example. Someone saw the clinical potential in VR . Some research was done with entertainment equipment. Seemed to have potential and a demand was created, so new systems were developed and voila we have a new technology.
Nirit
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Re: Why??? - June 22, 2004 3:23:00 PM
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steve
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NRL,
Interestingly, I had the exact same idea for Biofeedback - after doing some research I figured that adding a seven second delay or giving summary feedback after multiple trials could significantly increase effectiveness. I actually spoke to some profs at the university I was affiliated and the feedback I was given was that biofeedback was no longer a hot research topic and that funding would be difficult to get. This was a few years back and I wonder if any company has actually thought about changing their machines?
Steve
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Re: Why??? - June 22, 2004 4:08:00 PM
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nari
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I think that high dose of US for 15 minutes over 3 weeks is bizarre and probably risky- nothing at all to do with how US is actually used in clinical practice! As no-one would use that high intensity for so long, the study is ineffective in that sense.
One of the strict restrictions we learned in the Dark Ages was that because it is not known how US actually works, but it is known to cause cavitation if used erroneously, we had to be very careful what wattage and for how long.
here the radiographers/radiologists used to joke about physios and their 'killer' doses, the effect of which nobody knew.
nari
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Re: Why??? - June 22, 2004 6:10:00 PM
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Dr.Wagner
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exactly...
The above study was terrible and has zero clinical applications.
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Dr. Wagner DO
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Re: Why??? - June 22, 2004 7:01:00 PM
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Jon Newman
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The following is an excerpt from the APTA "Hooked on Evidence" site.
1. Ultrasound therapy for calcific tendinitis of the shoulder.
Ebenbichler GR, Erdogmus CB, Resch KL, Funovics MA, Kainberger F, Barisani G, Aringer M, Nicolakis P, Wiesinger GF, Baghestanian M, Preisinger E, Fialka-Moser V.
N Engl J Med 1999; 340(20): 1533-1538
Design Type: Clinical Trial, Random
Study Population: Adults (18-64 years)
Population Location: Outpatient / ambulatory care
Number of subjects: 63
Clinical characteristics of study participants: Left and right shoulders affected equally. Location of calcification primarily in supraspinatus tendon, but also in infraspinatus and subscapularis. Mean diameter of calcification ~14 mm. More type I calcifications than type II. Majority of participants with moderate pain; pain of a median of 8 weeks duration.
Authors Stated Purpose: To assess the efficacy of pulsed ultrasound as a treatment for idiopathic calcific tendinitis in a controlled trial.
Treatment 1 and Control/Referent Group
Odds Ratio: 7.65 95% Confidence Interval: 1.92 to 30.4
Risk Ratio: 4.53 95% Confidence Interval: 1.46 to 14.0
NNT: 2.74
Authors Conclusions: In patients with symptomatic calcific tendinitis of the shoulder, ultrasound treatment helps resolve calcifications and is associated with short-term clinical improvement.
Reviewer: David Scalzitti Date last modified: 08/13/2003
My two cents: I hate those short term clincial improvements too.
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Why??? - June 22, 2004 10:34:00 PM
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nrl
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From: israel
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Steve,
It is interesting. A few years ago I worked in a medical engineering start-up company. We developed such a program for our device. I talked to the programmer and showed him some of the existing systems (EMG, balance). He said writing new programs is a few days work. As far as I know no one has yet changed those systems.
There is a good chance feedback as a research topic is about to make a small comeback. A new hypothesis (other then the guidance hypothesis) that explains the research findings is being put to the test. I think some interesting results are expected. So it is a renewed research topic. Maybe this time around it will change the way things are done.
Winstein’s “Knowledge of results and motor learning--implications for physical therapy.” was published in Physical Therapy
13 (!!!!) YEARS AGO.
It is about time to start applying.
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Re: Why??? - June 23, 2004 6:48:00 AM
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steve
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Let me get this straight - nobody would use those ultrasound settings even if they did have long term effectiveness (Which they did in the CTS study both functionally and with nerve conduction studies and radiographically with calcific tendonitis)?
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Re: Why??? - June 23, 2004 6:58:00 AM
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Dr.Wagner
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I don't have the access, but someone needs to post the methods...NOT the conclusions. As this is a clinical treatment discussion, methodology is of utmost importance so as to reproduce results.
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Dr. Wagner DO
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Re: Why??? - June 23, 2004 9:38:00 AM
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Shill
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Dr Wagner,
Here are the methods, sans results or conclusions
Methods
Patients
Between October 1994 and April 1997, patients with radiographically verified calcific tendinitis who were seen at various departments and outpatient clinics in participating hospitals and by specialists in private practice in Vienna, Austria, were invited to take part in a randomized, double-blind comparison of ultrasound therapy and sham insonation. Those interested were referred to the outpatient clinic of the Department of Physical Medicine and Rehabilitation of the University Hospital of Vienna.
The diagnosis of calcific tendinitis was established by analysis of standard radiographs and ultrasonograms of the shoulder. To be eligible for the study, patients had to have idiopathic calcific tendinitis type 1 (i.e., clearly circumscribed and dense appearance on radiography) or type 2 (i.e., dense or clearly circumscribed appearance) according to the classification of Gärtner and Heyer.17 Patients with idiopathic calcific tendinitis type 3 (i.e., translucent or cloudy appearance without clear circumscription) were excluded, because this type has a strong tendency to resolve spontaneously.2,17 The diameter of calcification had to exceed 5.0 mm. To be eligible, patients had to have either mild-to-moderate pain that had been present for more than four weeks or a restricted range of motion of the affected shoulder or shoulders.
Patients were excluded if they had systemic diseases associated with an increased risk of calcification (such as gout, hypercalcemia of any cause, and various rheumatic diseases) as indicated by predefined pathological findings; had previously undergone surgery for calcifications or percutaneous needle aspiration, ultrasonography, or shock-wave therapy for calcific tendinitis; had received injections of glucocorticoids in the shoulder within the three months preceding the study; or regularly took analgesic or antiinflammatory drugs for relief of tendinitis.
All participants provided written, informed consent. The study protocol was approved by the ethics committee of the University of Vienna.
Ultrasound Therapy
Ultrasound therapy was administered for 15 minutes per session to the area over the calcification at a frequency of 0.89 MHz and an intensity of 2.5 W per square centimeter. The pulsed mode was 1:4, the transducer was 5 cm2 (Sonodyn, Siemens), and an aquasonic gel was used as the couplant. To optimize treatment of the affected areas in the supraspinatus and infraspinatus muscles and tendons, the transducer was moved slowly in circles distal to the lateral acromion and the acromial part of the clavicle while the patient flexed his or her upper arm and internally rotated the forearm. Treatment of calcium deposits in the subscapularis muscle was performed with the patient's upper arm in an abducted and externally rotated position. The sham therapy was administered in the same way except that the ultrasonic generator was not turned on.
The device was standardized initially, and output was monitored regularly by means of a simple underwater radiation balance. An on–off key introduced into the transducer circuit allowed normal ultrasonic output as well as mock insonation (sham treatment). The first 15 of the 24 treatments were given daily (five times per week) for three weeks, and the remaining 9 were given three times a week for three weeks.
For occasional pain relief, patients could take an analgesic drug (usually tramadol). Nonsteroidal or steroidal antiinflammatory drugs were not allowed.
Randomization
A spreadsheet program (Lotus Symphony, Lotus) was used to generate a list of random numbers. Since patients could have calcific tendinitis in one or both shoulders, randomization was conducted according to shoulders rather than patients. Thus, a patient could receive sham treatment for one shoulder and ultrasound treatment for the other. A therapist who was not involved in treatment handed out the treatment assignments, which were in sealed, opaque envelopes. Thus, the patients, the therapists applying the therapy, and the evaluator were all unaware of the treatment assignments.
The therapist who made the treatment assignments also switched the ultrasonic generator to either active or sham mode. Since the intensity of ultrasound therapy was usually below the threshold of sensitivity, patients were theoretically unable to distinguish between genuine and sham ultrasonography.
Outcome Measures
The primary outcome measure was changes from base line in the calcium deposits on radiography at the end of treatment and at the nine-month follow-up visit. Radiography was performed at each follow-up visit, and the results were assessed independently by two radiologists who were unaware of the patients' treatment assignments. The three-point scale of Gärtner and Heyer17 was used, in which a score of 1 indicates no change or a worsening of the condition, a score of 2 a decrease of at least 50 percent in the area and density of the calcification, and a score of 3 complete resolution of the calcification.
Radiographs were obtained under standardized conditions: a predefined posteroanterior position was used, and the same machine was used at each site, with the same exposure settings and radiographic settings. With the patient sitting and the arm placed parallel to the trunk in a standardized position, one exposure was obtained during external rotation, one while in a neutral position, and one during internal rotation. At base line, ultrasonography was used to pinpoint the location of the calcium deposits and to see whether there was a tear in the rotator cuff or inflammatory reactions within the bursae.
Secondary outcomes included subjective and objective measures. The 100-point Constant score18 was used to provide an overall clinical assessment of the shoulder with respect to the degree of pain, the patient's ability to perform normal tasks of daily living (maximal score, 35), and the active range of motion and power of the shoulder, or torque (maximal score, 65). On this scale, the worst possible score is 0, indicating that a patient has the most severe pain and is unable to perform any activities of daily living involving the impaired shoulder. The best possible score is 100, indicating that a patient is free from pain and able to perform all activities of daily living. We also used the pain score of Binder et al.,19 which focuses exclusively on subjective symptoms including pain, pain on resisted movement, and pain on active abduction, to assess the level of pain. On this scale, the best possible score is 0 and the worst possible score is 52. The severity of pain at night and during the day, both on movement and at rest, is assessed by means of a visual-analogue scale that ranges from 0 (no pain) to 10 (severe pain). The pain induced by resisted abduction in the neutral position and external and internal rotation of the shoulder is assessed on a four-point scale in which a score of 0 indicates the absence of pain; a score of 1 slight pain, but full power; a score of 2 moderate pain and reduced power; and a score of 3 severe pain with no power against even minimal resistance. The presence of pain on active abduction is also assessed on a four-point scale in which a score of 0 indicates the absence of pain, a score of 1 pain at only one point in the arc, a score of 2 pain throughout the arc, and a score of 3 pain so severe as to prohibit completion of the arc. The patients also assessed their quality of life on a 10-cm visual-analogue scale on which 0 cm indicated an excellent quality of life and 10 cm indicated the worst imaginable.
Radiography and clinical examinations were performed immediately before the first treatment session and after the last session (an interval of about six weeks). Patients were asked to return for a follow-up visit nine months after the base-line evaluation, at which time the code was broken and patients were either no longer followed or offered individualized further treatment.
Statistical Analysis
A two-tailed Fisher's exact test was used to assess the primary outcome measure (changes in radiographic findings),20 and the Cochran–Mantel–Haenszel test was used to control for the two types of calcifications.21 For secondary outcome measures, we used two-tailed t-tests22 for independent samples to compare mean changes between the groups at the end of treatment and at the nine-month follow-up visit.
_____________________________
Steve Hill PT
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Re: Why??? - June 23, 2004 11:50:00 AM
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Bournephysio
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“However, the thread is about technology integrated into practice.”
Not any more
"Isn't it a little depressing that we are having debates about things that were developed over 30 years ago??????"
Yes, most definitely. I believe that there are many reasons for this. First, many of these technologies have not been (and can not be) thoroughly tested. It would be impossible to test ultrasound with all the possible dosage parameters and conditions. The same goes for every other treatment. Second many clinicians (PTs, DOs, MDs, Chiros, etc) still have problems evaluating literature. I think that evaluating literature can only be partly trained. Some people have a knack for it while others don’t. I know people who have gone through rigorous masters degrees who have been seduced by craniosacral therapy. I also have known clinicians with out formal scientific training (PhD) that have made exceptional contributions to research.
Physiotherapy is very bandwagony and these biases show up in how the literature is interpreted. Currently, manual therapy is the hot treatment and modalities are frowned upon. How can a machine be nearly as skilled as our hands? Evidence of short term benefit of manual therapy is taken as positive evidence while short term benefit of modalities is taken as negative evidence. When there is a positive study for manual therapy, it is still viewed as positive even if it doesn’t match with clinical practice. On the other hand positive studies on modalities are ignored if they don’t exactly match up with clinical practice. If a modality is not a panacea it isn’t useful while a manual technique with minimal application is well worth the effort. Before anyway claims that I am anti-manual therapy, remember that I am one of the few contributors to this forum that has completed an internationally recognized manual therapy program and I have presented at IFOMT.
Even taking these biases into account, two people skilled at evaluating research can come up with vastly different conclusions (mine and mcaps differing views on manual therapy). This is partly due to the vast amounts of missing information (studies that haven’t been done).
As for technology, it is defined as: “the science of the application of knowledge to practical purposes : applied science” Mirriam-Webster medical dictionary
Going by this definition, we are definitely incorporating new technology into our practice. Some (muscle re-education) faster than others (cognitive behavioural therapy or outcome measures). The challenge is how to fit this new technology into our current practice. As a profession we tend to be a little phobic about computer based technology. The medical profession is over reliant on imaging based technology. It is a challenge to maximize outcomes with technology while minimizing cost. The cost of many technologies including the training of medical professionals is getting out of hand. We only have so many health care dollars. Many technologies that sound good on paper only get in the way in the clinic. Our clinic has a fancy device to test the acl. I asked one of the therapists if it was any benefit clinically. He said no but it sometimes makes the patient feel better.
The ultrasound part of this thread should probably be in a different thread. Steve, you mentioned two studies. I only have read the Ebenbichler study. Do you have the other reference?
“I think that high dose of US for 15 minutes over 3 weeks is bizarre and probably risky- nothing at all to do with how US is actually used in clinical practice! As no-one would use that high intensity for so long, the study is ineffective in that sense.”
If it was risky, they would have had to have reported any incidences. The good results they achieved are highly suggestive that it is not risky. It is bizarre since no-one was doing it. Eccentric exercise for “tendinitis” was thought to be dangerous. This actually led to its discovery since the guy wanted to rip his achilles so he could have surgery. Upper body exercise was thought to be dangerous for patients with previous breast cancer, now there are dragon boat teams in many (most?) cities. It looks like you are valuing old opinion over new blinded rct evidence. This is what evidence based practice is all about: reading the literature and modifying your practice based upon it. Yes 15 minutes is awfully long, yes everyday is very frequent. (It would still be cheaper than ECSWT). It does SUGGEST that higher doses are more effective. I know several therapists (including myself) who have switched to high dose continuous ultrasound and are reporting excellent results. This is just clinical experience and needs to be evaluated further. Continuous us lets you cut the 15 minutes to under 5. I very rarely used ultrasound before this study (I currently only use it for tendinopathies).
“The above study was terrible and has zero clinical applications.” The New England Journal of Medicine has a bad rep for that. Considering its poor impact value it’s a wonder anyone even publishes there. Get real.
By the way: Short term clinical improvement is when the treatment group initially gets better than the control then regresses back to the control. It is not short term improvement if the treatment group initially gets better than the control and then the control catches up to the treatment group. In that instance the treatment speeded up the course of recovery.
Doug Bourne B.Sc.(Kin) B.Sc.(PT) M.Sc. CAFCI FCAMT
PhD student
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Re: Why??? - June 23, 2004 1:13:00 PM
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steve
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From: Canada
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Ebenbichler GR, Resch KL, Nicolakis P, WiesingerGF, Uhl F, Ghanem AH, et al. Ultrasound treatmentfor treating the carpal tunnel syndrome: ran-domised “sham” controlled trial. BMJ 1998;316
I believe this is the reference.
Steve
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Re: Why??? - June 23, 2004 6:49:00 PM
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nari
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From: Australia
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Doug
ECSWT has been shown to be no better than sham as well, but maybe that study was defective as well.
The point is: "doing US" for calcification or spur or whatever else shows up on imaging is fairly old hat. That is treating a diagnosis, rather than asess for alternative reasons for pain.
I am quite surprised at the number of people whose XRs show spurs, calcifications and prolapsed discs and have no pain. Also those who have had pain in the shoulder from a theoretically calcified deposit whose pain resolved completely with NON EPA mehtods.
I think EPA has had its day, the bandwagon for it is starting to need scrapping....?
Nari
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Re: Why??? - June 23, 2004 10:08:00 PM
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goodlooks58
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My original question was about Laser. In the whole thread I did not get any answers about anyone using it or have read any positive research articles about it.
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