Rheumatology Advance Access originally published online on December 3, 2007
Rheumatology 2008 47(2):229-230; doi:10.1093/rheumatology/kem295
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Comment on: A prospective double-blind placebo-controlled randomized trial of ultrasound in the physiotherapy treatment of shoulder pain
Saxion Hogeschool Enschede, The Netherlands
Correspondence to: G. Koel. E-mail: g.koel{at}home.nl
SIR, Ainsworth et al. [1] included 221 patients with unilateral shoulder pain, and randomized them into two groups that received (on average) six treatments in 6 weeks. Both groups received the interventions information and manual therapy; the intervention group further was ‘applicated with’ real ultrasound (US) (that is indeed something totally different from ‘treated with’) and the control group with sham US (average 4–5 min).
Let us mention three major diagnoses for the included patient group: instability, impingement and frozen shoulder. In case of instability, US has no treatment rationale. Michener et al. [2] describe seven aetiological factors for impingement. In just one of the seven factors (tendinosis), US therapy is indicated. In fact, there is sufficient evidence for the application of US in case of tendinosis on fundamental [3, 4] as well as clinical level [5, 6]. US therapy is especially effective if tendons show calcification. In case of shoulder joint hypomobility (frozen shoulder), US therapy can be useful but only in combination with capsular stretching [7]. So in the main number of patients in the Ainsworth study, US therapy is simply not indicated. So it is a non-valid effect study.
If US therapy has effects, the effects are at the structural or impairment level. It is wrong to measure possible effects with a measurement tool [shoulder disability questionnaire (SDQ)] on disability level. It is incorrect to apply US with a frequency of 3 MHz (in at least 39% of the cases) that is not sufficient to influence tissues around the shoulder. It is not realistic to expect that US with local effects is capable of realizing clinical effects if the local condition is stimulated only six times for 4–5 min in 6 weeks.
In the discussion section, Ainsworth et al. [1] describe the difficulty to come up with specific diagnosis in case of shoulder pain. Nevertheless, they also describe (p. 819) that ‘attempts were made to ensure that any interventions used were based on sound clinical reasoning’. This is of course impossible. A physical therapist (PT) can only choose a proper therapy based on reasoning if he has an interpretation about the reason why the patient complains. Clear application of clinical tests to realize classification and differential diagnosis of shoulder pain is difficult. But appropriate treatment without an interpretation about the possible cause of shoulder pain is not possible [8]. A medical doctor can indeed apply a non-specific therapy like non-steroidal anti-inflammatory drugs (NSAIDs), positive for patients with non-specific shoulder pain, whereas a PT cannot! I am very interested in the content of the two other interventions: information and manual therapy. Are those interventions also standardized in a standardized way? Did my colleagues treat the patients with different types of shoulder pain with the same information and manual therapy? I am pretty sure they did not. They applied information and manual therapy based upon actual clinical signs and symptoms. That should also count for US therapy; US should only be used if there is a rationale to do so; for instance, the empty can test is positive and there is primary hyperalgesia on the upper facet of tuberculum majus. Let us treat the insertion of the supraspinatus with US therapy.
In the Ainsworth trial [1], US therapy is used in an inappropriate, non-valid way (because in most cases there is no indication for US therapy), using insufficient dosage (too short treatment time, too low intensity and wrong US frequency) and measured using an improper tool (on disability level instead of impairment level). Yes, US therapy should not be used at random in patients with random shoulder pain. But I presume that this lesson is already well known, also in the neighbourhood of Birmingham. PT researchers did well on the methodical part (design of the study) but strongly underestimated the physiotherapeutic reasoning.
Disclosure statement: The author has declared no conflicts of interest.
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- Ainsworth R, Dziedzic K, Hiller L, Daniels J, Bruton A, Broadfield J. A prospective double blind placebo-controlled randomized trial of ultrasound in the physiotherapy treatment of shoulder pain. Rheumatology (2007) 46:815–20.
[Abstract/Free Full Text] - Michener LA, McClure PW, Karduna AR. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Clin Biomech (2003) 18:369–79.[CrossRef][Medline]
- Ng GY, NG CO, See EK. Comparison of therapeutic ultrasound and exercises for augmentation of tendon healing in rats. Ultrasound Med Biol (2004) 30:1539–43.[CrossRef][Web of Science][Medline]
- Tsai WC, Pang JH, Hsu CG, Chu NK, Lin MS, Hu CF. Ultrasound stimulation of types I and III collagen expression of tendon cell and upregulation of transforming growth factor beta. J Orthop Res (2006) 24:1310–6.[CrossRef][Web of Science][Medline]
- Ebenbichler GR, Erdogmus CB, Resch KL. Ultrasound therapy for calcific tendinitis of the shoulder. N Eng J Med (1999) 340:1533–8.
[Abstract/Free Full Text] - Rahman MH, Khan SZ, Ramiz MS. Effect of therapeutic ultrasound on calcific supraspinatus tendonitis. Mymensingh Med J (2007) 16:33–5.[Medline]
- Johnson AJ, Godges JJ, Zimmerman GJ, Ounanian LL. The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with adhesive capsulitis. JOSPT (2007) 37:88–99.[Medline]
- Jones M, Higgs J. Will evidence-based practice take the reasoning out of the practice? In: Clinical reasoning in the health professions, ch. 36 (2000) 2nd. Oxford: Butterworth Heinemann.
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