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Posts Tagged ‘phonophoresis’

Here are some items that I came across recently that I thought may be of interest to you:

  • The standard Pallof press (or cable press) is probably one of my favorite exercises. Well, Nick Tumminello has taken this exercise and added to it. He has taken the traditional exercise and added a frontal plane component and a sagittal plane component making this a tri-planar exercise. Check the links out for great stuff from Coach Nick.
  • Here is a blast from the past – this was my review of a phonophoresis study that has been one of my more popular posts.
  • Another blog that you may not have checked out yet is Charlie Weingroff’s blog. Charlie is a DPT, ATC, CSCS and he always has thought provoking material on his blog. Make sure the check it out.
  • Barefoot running seems to be a raging topic everywhere you turn. Here is a blog post on Mike Reinold’s blog discussing this topic. With this topic, and seemingly every other trend in the field of sports medicine, people have a tendency to go overboard. I don’t remember the exact quote from Alwyn Cosgrove but he talked about a pendulum and how people have a tendency to go to the extremes of one side or another and the answer is probably somewhere in the middle.
  • If you are a baseball fan, I am sure you have paid attention to Stephen Strasburg’s injury. What a shame. And yet, do things like this curb the way our youth train and participate in sport – even though they head down a similar path. Eric Cressey has a good write-up on his thoughts about this case.
  • Finally, here is an article that was posted in the local paper this past weekend concerning concussions. I was disappointed in the article to say the least. There were some signs and symptoms and precautionary measures sandwiched between an account of a former player who reportedly played in a game after suffering a concussion and a poll (not a study as indicated) of coaches and how they handle the situation of concussions.  The most shocking thing about the article is that the player said that if they had to do it over again, he would have done the exact same thing. Kids reading that are going to disregard the experts and even the coaches and listen to what a fellow student-athlete says. Please take a read of the article and give me your comments. Am I overreacting or is this a pretty irresponsible piece?

Thanks again, enjoy the great resources, and please share your comments on the concussion article.

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A study was published in a 2006 issue of the Journal of Athletic Training that I found interesting back then and wanted to revisit again now. The study, entitled Cortisol Concentrations in Human Skeletal Muscle Tissue After Phonophoresis with 10% Hydrocortisone Gel, was of interest to me because I have performed many a phono treatment over my career and wanted to see “if this stuff really worked”. (Kind of backwards isn’t it but continual learning, that’s the point of all this right.)

Phonophoresis is a treatment that is commonly prescribed by physicians to treat musculoskeletal injuries and the goal of this study was to help determine if the technique really was able to deliver the hydrocortisone to the skeletal muscle tissue that was being targeted with the treatment.

The samples consisted of 6 individuals in the sham group and 6 in the phonophoresis group. Each leg of each subject was utilized for this study. One leg was chosen for treatment and the other was chosen as the control for each subject.

The study involved 12 indivduals who were split into the treatment and sham group. Treatments utilized 10% hyrdrocorisone for the medication and the region being treated was the vastus lateralis. The treatment protocol utilized ultrasound delivered at 1.0 MHz x 1.0 W/cm2 and at 7 minutes utilizing a continuous treatment setting.

After some prep work was done following the single treatment, a needle biopsy was performed in which a sample was extracted from the vastus lateralis muscle. The muscle biopsy was then examined for cortisol concentrations.

Now, the authors acknowledge that phonophoresis has been effective in the driving low-molecular-weight compounds through the dermal layer.  After that however, it is uncertain if the medication is able to make it to the targeted tissues. Hence, this study.

The results as reported by the authors showed no significant difference in cortisol concentration between the control limb and the treatment limb, in either the sham or phonophoresis samples. No significant differences were noted between the sham and phonophoresis groups. So the final conclusion resulting from this study was that 10% hydrocortisone based phonophoresis treatment (delivered at the said parameters) did not raise the concentration of cortisol in human skeletal muscle tissue following treatment.

As we try to base our treatment decisions upon sound evidence, I thought that this study would help give us some additional insight into this common treatment.

Here are some of my observations as well as some additional commentary and discussion added by the authors:

  1. First off, the subjects were better men and women than me. Offering to have some muscle extracted for the sake of science is quite admirable. As you read the study, you’ll think the same thing.
  2. The authors admit that the sample size is small and I would agree. I would have loved to see a much larger sample but going back to the first point, getting many more to commit to what these subjects did may have been a minor miracle in and of itself.
  3. Probably one of the more interesting points the authors brought up centered around treatment length and intensity. At first blush, my thought was that the intensity was probably too low and the treatment length could have been longer. (Treatment lengths for ultrasound will generally vary from 5-20 minutes). The authors did report however that studies with swine showed an increase in cortisol levels with prolonged treatment (17+ minutes) and with lower intensities. I found this very interesting. Treatments at .1 and .3 W/cm2 were more effective in the swine. I may have surmised that higher intensity coupled with longer treatment times would be more effective but previous studies indicate otherwise. How this translates to human studies remains to be seen but the authors do note that utilizing multiple treatment settings for the delivery of phonophoresis should be further investigated. I agree.
  4. Another point the authors brought up was regarding injured vs. uninjured tissue. All of the subjects in this study were of apparent good health. The authors noted that healthy tissue may be more resistant to pharmaceutical delivery. Some studies have also shown injured cells to be more amenable to pharmaceutical delivery. This is a very valid point and very well could have some merit.
  5. Another point the authors discuss revolves around thermal vs. non-thermal delivery. The authors site a reference that notes that non-thermal delivery played a significant role in transdermal drug delivery. This is a valid consideration as well. Does the thermal aspect of the treatment alter or hinder the delivery of the medication versus the mechanical delivery settings? Is a pulsed setting more appropriate in this type of treatment?
  6. The authors also discuss the delivery of the medication indirectly through the blood (once the drug is delivered subdermally, the medication is delivered to the muscle through its blood supply) as opposed to directly through delivery of the medication to the  muscle tissue itself. They discuss this possibility as unlikely but do address it for discussion purposes.

Overall, the study was very interesting and I commend the authors for venturing into this study. It is important to have research validate our methodology. There are a lot of variables that this study was unable to account for but I do think that we did discover some important findings as a result.

So what are some takeaways.
Well aside from the point regarding injured vs. non-injured tissue, the study stongly shows that trying to deliver phonophoresis using 10% hydrocortisone cream to deep muscle tissue at the settings demonstrated is largely ineffective. One would argue that using similar parameters as illustrated and expecting different results is not good practice.

Secondly, the medication is not cheap. I wouldn’t necessarily consider “wasting” this medication utilizing application settings that are ineffective as good practice either.

Does this study particular study discount the use of phonophoresis? At this point, I’d say no but it definitely helps us to start thinking more about what we are trying to accomplish with this treatment and what methods we may go about  in order to accomplish our goals. We really need to consider the area we are treating and the parameters that we are using. What are our goals for the treatment as well? This study should help us to be more specific with our treatment goals.

I think that the authors clearly point to the fact that more research needs to be done and I agree. The trick is to take what we learned through this study and apply it to our daily practice.

What are your thoughts? Do you have any additional observations? Do you know of additional studies that refute or validate these findings. Feel free to share your comments.

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Why do you do what you do when treating a patient? study-pic

Huh???

Okay, let me ask it this way: What is the rationale that you are using when implementing a treatment strategy?

In other words, are you letting experience and research and sound data/information determine your treatment approach or do you rely on what you have always done because that’s the way it has always been done?

Let me give you an example: In the articlCurrent Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature, Reinold, et al. discuss a variety of data that point to the efficacy for the use of exercise to target specific muscles in the shoulder complex.

One of the exercises they examine is the empty-can exercise to strengthen the supraspinatus. Their research validates that the exercise of choice for strengthening the supraspinatus is actually the full-can exercise and not the empty-can exercise. Can you you use the empty-can exercise to strengthen the supraspinatus?  Sure. But when you produce the same amount of EMG activity with the full-can exercise as the empty-can and provide an environment that results in less potential humeral head migration and less anterior and medial deltoid activation, why would you continue to use the empty-can exercise (unless there was an absolute specific result you were trying to create)?

Because that’s what we learned in college…that’s is what someone once taught us…I’ve used that exercise for patients for my whole career…that’s the way I’ve always done it…and you can add your rationale here.

I am of the opinion that just because that is the way something has always been done, it doesn’t mean it is right.

And that is one small example.

Another example is regarding phonophoresis. There was a study in the Journal of Athletic Training a few years back that reported that there was no increase in the level of cortisol in the skeletal tissue following phonophoresis treatment (I’ll try and review this in a later blog post). So…if my goal is to treat deep muscular tissue with phonophoresis in the hopes of driving this medication into the tissue, I quite possibly am laboring in vain since the research is contrary to the goal.

There are countless other examples.

Question yourself and your methods. Frequently review why it is that you do what you do.

It is okay to change course and go a direction that is better – this is patient care, not politics.  Flip-flopping is okay if it ultimately leads to better care for your patients.

So…keep learning and calling into question things you have always done. Review and research again and again. You’ll be a better clinician for it.

Photo Credit by xb3

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