RE: ultrasound (Full Version)

All Forums >> [RehabEdge Forum] >> Open Forum



Message


HarperPT -> RE: ultrasound (August 30, 2012 6:26:18 PM)

quote:

Have you ever seen a study proving that green men on Mars do NOT exist? If not, can we then assume they do exist?


I can't believe I'm responding to this point but......the "Curiosity" is sending images back to earth from mars as we speak. This is evidence against your green men.

No study for US showing that it doesn't break up scar tissue/stimulate healing exists (as far as I know).




SJBird55 -> RE: ultrasound (August 30, 2012 6:47:04 PM)

Can I interrupt with a serious question? Literature reviews can be a horrible basis from which to make decisions. Think of this type of literature systematic review: effectiveness of physical therapy for rotator cuff tendonitis. "Physical therapy" is too broad of a term & mixed results will be reported. Depending on the question of the review kind of determines the value.




Chocco -> RE: ultrasound (August 30, 2012 6:54:16 PM)

quote:

ORIGINAL: HarperPT

I never said that. I said it's logical to use because it's mechanism of action is based on a science.


Ha ha thats funny




HarperPT -> RE: ultrasound (August 30, 2012 6:59:30 PM)

quote:

ORIGINAL: SJBird55

Can I interrupt with a serious question? Literature reviews can be a horrible basis from which to make decisions. Think of this type of literature systematic review: effectiveness of physical therapy for rotator cuff tendonitis. "Physical therapy" is too broad of a term & mixed results will be reported. Depending on the question of the review kind of determines the value.

Great post!

This is what I have been trying to say.




Chocco -> RE: ultrasound (August 30, 2012 7:01:07 PM)

I have seen reviews with opposing viewpoints reference the same articles. They can be valuable resources but you have to be careful reading them because the author is taking a stance and using different studies to back him up. That could allow for some bias, misinterpretation and misrepresentation of the actual data so the author can back up his idea or hypothesis. That being said some of the best articles I have read have been reviews.




Chocco -> RE: ultrasound (August 30, 2012 7:03:09 PM)

quote:

ORIGINAL: honker23

Too often we as PTs, think we have something to do with healing.  Except for a few instances....(wound care) we really aren't too involved in this process.  The patient does this on their own, some better than others.  The role of exercise and manual therapy is more to re-educate the patient's system to move from alert, danger, injured status to calm, pain-free, it's really OK to move again status.

So to think of US, Estim, manual therapy in terms of healing tissues sends us all for a loop in my opinion.


I like to think that I have something to do with it. I just don't want them to think that.




proud -> RE: ultrasound (August 30, 2012 7:36:16 PM)

quote:

ORIGINAL: SJBird55

Can I interrupt with a serious question? Literature reviews can be a horrible basis from which to make decisions. Think of this type of literature systematic review: effectiveness of physical therapy for rotator cuff tendonitis. "Physical therapy" is too broad of a term & mixed results will be reported. Depending on the question of the review kind of determines the value.


Na. Not going to agree with you on this one SJ (A rarity for me...but... it happens to the best of aligned professionals from time to time)

Ultrasound is a pretty narrow scope SJ, unlike as you stated the broad term "Physical therapy" for instance. As well, isolated biopysical claims have been specifically analyzed together and seperately (protien synthesis,mast cell degranulation, growth factor production, fibroblast mobility).

I am not here to suggest that I base my practice on literature reviews as I understand the review is only as strong as the research for which it's reviewing. But I am here to say that I did some significant investigation into ultrasound specifically and I am indeed confident in what the literature trends toward in regards to it's purported effects.

Now if there was a literature review that asked a broad sweeping question like : " Is ultrasound effective for musckulopskeletal pain"....I'd agree. But that's not what we have here.




HarperPT -> RE: ultrasound (August 30, 2012 9:08:02 PM)

quote:

ORIGINAL: proud

quote:

ORIGINAL: SJBird55

Can I interrupt with a serious question? Literature reviews can be a horrible basis from which to make decisions. Think of this type of literature systematic review: effectiveness of physical therapy for rotator cuff tendonitis. "Physical therapy" is too broad of a term & mixed results will be reported. Depending on the question of the review kind of determines the value.


Na. Not going to agree with you on this one SJ (A rarity for me...but... it happens to the best of aligned professionals from time to time)

Ultrasound is a pretty narrow scope SJ, unlike as you stated the broad term "Physical therapy" for instance. As well, isolated biopysical claims have been specifically analyzed together and seperately (protien synthesis,mast cell degranulation, growth factor production, fibroblast mobility).

I am not here to suggest that I base my practice on literature reviews as I understand the review is only as strong as the research for which it's reviewing. But I am here to say that I did some significant investigation into ultrasound specifically and I am indeed confident in what the literature trends toward in regards to it's purported effects.

Now if there was a literature review that asked a broad sweeping question like : " Is ultrasound effective for musckulopskeletal pain"....I'd agree. But that's not what we have here.

Sorry, I have to disagree that your lit reviews have a narrow scope. The first one examines US and it's use for pain and soft tissue injuries. The second one simply reviews US to see if it is "effective".

Also...still waiting on that study that backs your claims.




proud -> RE: ultrasound (August 30, 2012 9:41:36 PM)

Well that solidifies my interpretation of things. Not at all accurately reflects those two (only ) literature reviews.

Thanks Harper but I'm out...




Sebastian Asselbergs -> RE: ultrasound (August 30, 2012 9:43:02 PM)

Harper you have just very clearly shown you really do not know what research and a "study" means:
quote:

I can't believe I'm responding to this point but......the "Curiosity" is sending images back to earth from mars as we speak. This is evidence against your green men.


Your post and mine were talking about a study, not "evidence" (which in the Mars issue, is still extremely "poor evidence" - it has barely moved across a small area of the planet). If you have trouble understanding the difference, I can not help you.

I am still waiting for your study showing that US can selectively treat "bad" scar tissue versus "good" scar tissue.




HarperPT -> RE: ultrasound (August 30, 2012 10:16:16 PM)

quote:

ORIGINAL: proud

Well that solidifies my interpretation of things. Not at all accurately reflects those two (only ) literature reviews.

Thanks Harper but I'm out...


No studies to back your claims?

What a SHOCKER!




HarperPT -> RE: ultrasound (August 30, 2012 10:25:13 PM)

quote:

I am still waiting for your study showing that US can selectively treat "bad" scar tissue versus "good" scar tissue.


Why don't you Google it?

LOL




SJBird55 -> RE: ultrasound (August 30, 2012 10:26:52 PM)

Sorry I basically was thinking aloud about generalizing types of studies & their value. Yes, the ultrasound topic would be narrow with the current question. I was just thinking how blanket statements could be misleading and falsely elevating the value of reviews. Sorry for creating a tangent. I think I play in twitter too much with live conversations & tangents. ;)




Niko -> RE: ultrasound (August 30, 2012 10:54:26 PM)

Thanks everyone for your input!

Sebastian:

quote:

Niko, can you point to a study that shows that specific and clinically significant scar tissue is significantly altered by the application of US?


I don't believe it exists Sebastian. And I personally care less about the scar tissue breakdown specifically. I care if US can accelerate acute cellular mechanisms for remodeling/tissue normalization after injury to the local tissue, not necessarily related to pain in the brain, even though I think it can influence brain processes beyond placebo. So to me the question is, can it speed up the cell proliferation phase or not? As clinical significance: can the patient return to function/sports,work demands let's say 24 hrs sooner without question of damaging or interfering with the tissue healing process? I don't think any study up to date was able to address that (in terms of timeframe). in terms of long term outcomes of course there will be no difference with sham ultrasound, the cell proliferation phase is complete anyway. For the heating effects/tissue extensibility you may as well use a heating pad or even better have the patients do nonspecific cardio.
quote:


With regards to input changing output: no argument from me. But to does this justify the present use of the US machines?


If the wave transmission part can accelerate cellular processes responsible for local tissue normalization I think it does justify its use. It may be that this acceleration is not consistently significant and also does not reach a perceived change in the brain. After all you don't feel much during ultrasound, one can argue that this makes the placebo much less powerful than when using stronger inputs from manual therapy or exercise. If that makes sense then the positive outcomes when using ultrasound are most likely from reducing local tissue recovery time and the nervous system in turn may be more comfortable with reducing protective behavior sooner.
Of course this will not show on studies with emphasis on clinical outcomes based on statistical significance. Is 50% success rate a reason to stop using ultrasound or a reason to further examine those 50% cases that works, further than just concluding its just the placebo.
quote:


Does it justify the "scar tissue" explanation (never shown to have any clinical relevance)?

Does that not leave the patient with more confounding information regarding their painful condition? (Not saying YOU do, but apparently US is still used by "thousands of PTs" to treat scar tissue).


not if you explain that it MAY speed up the local tissue healing time by a few hours/days, and which is not necessarily related to pain but it will insure that tissue healing phase is complete as soon as possible, and we are confident that there is no damage to be done with return to regular function. Then our attention can shift solely to neurodesensitization and movement without fear avoidance.
quote:


So what is it supposed to do exactly?


as many studies suggest " upregulation of cell proliferation and proteoglycan (PG) synthesis." "ultrasound stimulates cell division during periods of rapid cell proliferation."

quote:


At least manual therapy has the advantage that we know we are social human beings, that we have extremely well-innervated hands (PT) and very strong cutaneous input (patient) directly to the somato-sensory cortex, and that there is continous feedback from hands and skin. Why would one use US for a "it's input to change output" effect?


I would never cut my hands off and replace them with ultrasound machines. I'm not saying that. Again, the ultrasound has nothing to do with direct output in the brain, it only ensures local tissue recovery as fast as it gets so the patient can move on and stop being fixated at the local tissue. Has nothing to do with pain relief. I always clarify that to patients. Now when it does offer pain relief (for me 50% of the time I use it) then I'll take it (placebo or not)

Now some food for thought regarding the input and output model, neurophysiology, and local tissue medical procedures: with the same reasoning, why would somebody do surgery to change pain output? isnt pain the no 1 reason for msuculoskeletal surgery?maybe we should worry more about that vs the noninvasive innocent ultrasound that takes 5-10 minutes of our time and has no averse reactions/side effects.


Proud,
quote:

The basis for the effects of ultrasound as stated are largely based on in vitro studies performed in the early 60's and into the early 80's. Recently however, those purported effects have been investigated on live tissue and what we thought happened...seems to not happen unless dealing with a dead rat tendon or something.


I agree that most studies that prove my main point are done in vitro. not only in the 60s and 80s though. This is a 2005 study:
http://www.ncbi.nlm.nih.gov/pubmed/16023014
and a 2006 study
http://www.ncbi.nlm.nih.gov/pubmed/16705693

Also not only on dead rat tendon. Full text of a 2009 study done in human nucleus pulposus cells
http://d7c.ecmjournal.org/journal/papers/vol017/pdf/v017a02.pdf

In terms of vitro vs "live" tissue the main difference is that the nervous system is out of the equation. Now if we take the neural tissue out of the equation isn't this eliminating the placebo( as neural tissue is the main source of placebo). Therefore, findings can only be due to ultrasound and no confouding variables. And tissue is tissue, same composition in rats and humans, not? can you provide us with the study investigating live tissue and suggesting otherwise?
In terms of clinical significance I think more research needs to be done further investigating timeframe specific measures of tissue proliferation phase with US vs no US and when tested in humans possible synergistic effects with other PT procedures(I mean who does ultrasound only treatments?)




proud -> RE: ultrasound (August 31, 2012 7:34:11 AM)

quote:

ORIGINAL: SJBird55

Sorry I basically was thinking aloud about generalizing types of studies & their value. Yes, the ultrasound topic would be narrow with the current question. I was just thinking how blanket statements could be misleading and falsely elevating the value of reviews. Sorry for creating a tangent. I think I play in twitter too much with live conversations & tangents. ;)


HA. No problems SJ. Not to drag you into this rather bizzare back and forth but I can certainly see in the case of Harper here how things can be mis-leading. It appears I've been attempting a professional debate with someone who clearly get's confused easily with basic research concepts.

Indeed systemmatic reviews can often provide blanket information based on a cluster of poorly designed studies. I don't think this is the case when it comes to the clinical relevancy of ultrasound.

But...I'm always willing and happy to be proven wrong of course.




proud -> RE: ultrasound (August 31, 2012 7:47:46 AM)

Niko you asked:

quote:

I care if US can accelerate acute cellular mechanisms for remodeling/tissue normalization after injury to the local tissue,


One of the key variable for alteration of membrane permeability is the concept of cavitation and microstreaming. It is interesting to note that this effect was originally demonstrated "in vitro" and then postulated that the same would occur "in vivo" (and voila, we have ourselves a treatment modality!). Meanwhile subsequent, more recent investigations have demonstrated that cavitation does not occur in live tissue at the frequencies and intensity typically utilized in clinical practice. The only experimental evidence for altered membrane permeability (mast cell degranulation, protein synthesis etc) comes from studies of cell cultures for which cavitation occurred.

quote:

If the wave transmission part can accelerate cellular processes responsible for local tissue normalization I think it does justify its use. It may be that this acceleration is not consistently significant and also does not reach a perceived change in the brain. After all you don't feel much during ultrasound, one can argue that this makes the placebo much less powerful than when using stronger inputs from manual therapy or exercise. If that makes sense then the positive outcomes when using ultrasound are most likely from reducing local tissue recovery time and the nervous system in turn may be more comfortable with reducing protective behavior sooner.


All that makes perfect sense to me...if ultrasound in fact "accelerated cellular processes" in live tissue. I think based on what a significant proportion of the literature is informing us drawing that conclusion is akin to magical thinking. In fact, it seems dead wrong. 

quote:

as many studies suggest " upregulation of cell proliferation and proteoglycan (PG) synthesis." "ultrasound stimulates cell division during periods of rapid cell proliferation."


Again..."in vitro". Subsequently shown to be of no clinical relevance in live tissue (when one weighs the bulk of the literature...systemmatically). 

quote:

I agree that most studies that prove my main point are done in vitro. not only in the 60s and 80s though. This is a 2005 study:
http://www.ncbi.nlm.nih.gov/pubmed/16023014
and a 2006 study
http://www.ncbi.nlm.nih.gov/pubmed/16705693

Also not only on dead rat tendon. Full text of a 2009 study done in human nucleus pulposus cells
http://d7c.ecmjournal.org/journal/papers/vol017/pdf/v017a02.pdf


As stated, when it comes to a modality, we have to weigh the literature. At this point, the significant trend is no clinical relevance for therapeutic ultrasound at the dosing levels prescibed.
 
I have those studies in my list. Again, in vitro.

 
quote:

can you provide us with the study investigating live tissue and suggesting otherwise?


As discussed above, it seems cavitation is the key to all the cellular effects once purported (discovered in vitro). This doesn't appear to happen in live tissue at the dosing levels we use clinically.









honker23 -> RE: ultrasound (August 31, 2012 1:22:08 PM)

Another thing to consider in regards to increasing cellular activity in a nucleus pulposus (in vitro) is how do we reliably know that a specific NP is the reason for pain, needs more cell proliferation...but not too much, and once this perfect amount of proliferation occurs will the pain be gone. 

Until we have reliable data showing there is consistent pain producing threshhold for decreased PG levels in a disc and that once this level has been restored pain is abolished, and PG level consistently can be restored by US on live people, I won't be sounding patients with LBP.




ovpt -> RE: ultrasound (August 31, 2012 2:21:58 PM)

anything to do with the nucleus pulposus is a moot point with US since you cant not get the sound waves at physical therapy levels to the disc anyway.




Sebastian Asselbergs -> RE: ultrasound (August 31, 2012 11:35:36 PM)

proud, sorry to have prolonged the exchange with Harper. Usually trolls go away if you ignore them. I must remember that more often.

Thanks Niko for that post.
Other than the points proud has already addressed (and I agree with his points) there is this:
quote:

After all you don't feel much during ultrasound, one can argue that this makes the placebo much less powerful than when using stronger inputs from manual therapy or exercise
.
quote:

Again, the ultrasound has nothing to do with direct output in the brain,


I think you may be underestimating the power of the image of the therapist using a fancy machine for the healing of the tissues. It is not so much the fact that they should feel anything, it is the fact that YOU, a very nice and professional person pays close attention to them, and even does the US himself to help their healing! You must admit that this is as much a potential placebo-elicitor as buzz of IFC.

About:
quote:

that it MAY speed up the local tissue healing time

First of all, how do you know there is even tissue damage? Are you not mainly treating a chronic pain population? Isn't tissue damage a non-issue in that population and thus US rather useless?

I may have misinterpreted previous posts. If so, my apologies.




Niko -> RE: ultrasound (September 2, 2012 10:02:42 PM)

Any conclusion drawn on the effectiveness of ultrasound that is black or white based on current evidence and scientific principles is not mature enough in my opinion. There is a lot of gray area and most researchers are honest enough to admit that. I know that the black or white is very appealing and that we do not like or tolerate ambiguity in clinical practice, but we shouldn't be disappointed with the gray. I think that most of us are not comfortable with the gray and therefore stop using modalities like utlrasound or specific forms of manual therapy etc. More data is needed to help us make appropriate choices. So considering the studies that Proud provided I agree with Harper (and I think Sebastian agreed as well), any study looking for something specific there is a good dose of confirmation bias.

Having said that, Proud, reading the articles that you provided I could not find strong evidence-based conclusions from studies done in vivo suggesting that we should not use the ultrasound to accelerate tissue healing (and again I'm not talking about pain output in the brain). Moreover, I could not find any strong evidence suggesting that cavitation does not occur in live tissue during the timeframe of tissue healing at the specific location of trauma. I think this statement is relevant: "The absence of proof is not the proof of absence". Even if cavitation happens only in cell cultures and not live tissue, cavitation may not be the complete answer to the bioeffects of US ( I have found a relevant article below).

Going back to the researchers' bias, the review study that you provided in the other thread has a purpose (http://ptjournal.apta.org/content/81/7/1351.full):
"The purpose of this review is to examine the literature regarding the biophysical effects of therapeutic ultrasound to determine whether these effects may be considered sufficient to provide a reason (biological rationale) for the use of insonation for the treatment of people with pain and soft tissue injury"

First of all, the word pain is thrown in there as a reason to use US, again, US has nothing to do with pain output in the brain. Then it is clear that the authors are looking for a yes US or no US answer there. The study would have been more appealing to me if the purpose was finding what conditions/parameters may be more beneficial than others: frequency, timeframe, dosage, pt population etc. If the conclusion was that there is no difference in relevant outcomes based on different conditions/parameters, then I 'll take that and move on.

The second review study that you provided : http://ptjournalonline.org/content/81/7/1339.full also focuses on pain as an outcome /reason for US use, and also points out that the parameters of each of the studies were highly variable. The great variability of the individual studies makes the meta analysis study less valuable. (Again I agree with Harper)

Now to talk specifics: the non thermal effects of US may not be limited to cavitation and microstreaming as this article suggests:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC164359/#B18

It discusses "The concept of the absorption of ultrasonic energy by enzymatic proteins leading to changes in the enzymes' activity"
The following discussion regarding the frequency resonance hypothesis is relevant:

-----------------------------------
"The frequency resonance hypothesis differs from acoustic streaming and cavitation at the basic levels. First, acoustic streaming relates to the movement of objects from one place to another as a function of the force of the wave. In terms of ultrasound therapy, phonophoresis is commonly used to move medication transdermally. Second, cavitation relates to the oscillation of microscopic gas bubbles that may, in turn, affect the cell or cellular process. However, the frequency resonance hypothesis relates to the absorption of ultrasound by proteins and protein complexes that may directly result in alterations to signaling mechanisms within the cell, either by inducing a conformational shift or by disrupting a multimolecular complex.

In any case, the mechanical effects of ultrasound may result in either the activation or inactivation of an enzymatic protein or a dissociation of a protein complex, leading to alterations in signal transduction. The frequency resonance hypothesis may describe the molecular mechanism or mechanisms responsible for alterations in cellular membrane properties,34,39,41,46,49 increases in protein production,* and modulation of enzyme activity.7–16,54–56
Frequency resonance and shearing forces on multimolecular complexes may combine to produce the nonthermal effects of therapeutic ultrasound. Collectively, the experiments reviewed here support the frequency resonance hypothesis and demonstrate that therapeutic ultrasound may modulate signal-transduction pathways and gene products associated with the inflammatory response and cells directly involved in the healing response (see Table).

The logical argument is that in vitro effects cannot be directly applied to clinical treatment protocols. However, from a cellular biology point of view, a strong argument can be made that if a stimulus reaches a critical threshold (eg, consider depolarization thresholds) the cell will respond, regardless of whether the cell is in vitro or in vivo (eg, insulin, histamine, aspirin, or any of the proteins listed in the Table). "
--------------------------------------


These are some older post op tendon healing studies in vivo not focusing on pain as an outcome:
http://www.ncbi.nlm.nih.gov/pubmed/2686717
http://www.ncbi.nlm.nih.gov/pubmed/8770748

This is a 2012 study in vivo for nerve injuries
http://ibj.pasteur.ac.ir/browse.php?a_id=686&slc_lang=en&sid=1&ftxt=1


other than that,

quote:


"anything to do with the nucleus pulposus is a moot point with US since you cant not get the sound waves at physical therapy levels to the disc anyway


ovpt, my argument at that point was that tissue is tissue so it doesn;t matter if it is a rat or a human. It is not about treating the nucleus pulposus specifically.

quote:


Another thing to consider in regards to increasing cellular activity in a nucleus pulposus (in vitro) is how do we reliably know that a specific NP is the reason for pain, needs more cell proliferation...but not too much, and once this perfect amount of proliferation occurs will the pain be gone. 

Until we have reliable data showing there is consistent pain producing threshhold for decreased PG levels in a disc and that once this level has been restored pain is abolished, and PG level consistently can be restored by US on live people, I won't be sounding patients with LBP.


Honker, again it is not about sounding patients discs, is about human or other animal cells responding the same. I think it is not recommended to sound the low back or anywhere close to air filled cavities (intenstines, lungs etc). Also, US effects have no direct effect on pain in the brain. I care if the tissue healing process can be accelerated so I can tell the patient that the tissue is now healed, lets move on to help dessensitizatize the nervous system. If that happens, then I want to know under which excact conditions /parameters (timeframe, dosage, pt population, location of injury etc)

quote:


I think you may be underestimating the power of the image of the therapist using a fancy machine for the healing of the tissues. It is not so much the fact that they should feel anything, it is the fact that YOU, a very nice and professional person pays close attention to them, and even does the US himself to help their healing! You must admit that this is as much a potential placebo-elicitor as buzz of IFC.


Sebastian,
How can I underestimate this? I was arguing in favor of this with you last month, remember? therapeutic equipment vs therapeutic hands. I totally understand the placebo is part of it, I said one can argue is less powerfull because you don't feel much with US. Since we can't quantify placebo I think this won't lead us anywhere.

quote:


First of all, how do you know there is even tissue damage? Are you not mainly treating a chronic pain population? Isn't tissue damage a non-issue in that population and thus US rather useless?


How do I know tissue damage? local tissue signs (morphology, color, temp etc), timeframe of injury, mechanism of injury so on(not pain sensitivity btw as that can be misleading). I do not treat only chronic pain population. I work with a multidisciplinary team not chronic pain clinic. I often see same day traumatic injuries. Regardless, Im interested in many areas of PT including pediatrics, stroke and spinal cord injury rehab and many more, outpatient ortho is just where I focus on today.




Page: <<   < prev  1 [2] 3   next >   >>



Forum Software © ASPPlayground.NET Advanced Edition 2.5.5 Unicode

0.172