Discuss the therapeutic effects of Ultrasound in the treatment of a tennis elbow soft tissue injury
Introduction
The ultrasound is used as a treatment for soft tissue injuries using sound waves that are beyond the range of normal hearing. An ultrasound consists of inaudible high frequency mechanical vibrations (Gibbs, Cole and Sassano, 2009) which are created upon the conversion of electrical energy into acoustic energy through mechanical deformation of the piezoelectric crystal which lies within the transducer (Rheumatology, 2011). Therapeutic ultrasound uses a frequency between 0.75 and 3 MHz (Knight, Knight and Draper, 2013) for heating deeper and superficial tissues. Low frequency ultrasound at 1 Mhz is absorbed by tissues up to 3 to 5 cm deep which is ideal in the treatment of deeper soft tissue injuries. Higher frequency ultrasound at 3 Mhz is effective in heating superficial soft tissue injuries.
According to Michlovitz, Bellew and Nolar, Jr (2005), ultrasound is one among the common therapeutic modalities used in the treatment of tennis elbow injury. Also called as lateral epicondylitis, tennis elbow is a common degererative tendon disease in the elbow (Salter, 1999). The soft tissue lesion usually occurs owing to the repetitive overuse of the extensor muscles in the elbow. In soft tissue injuries as tennis elbow, the patient will experience pain during the inflammation process and physical therapists apply therapeutic ultrasound as part of its modality treatment options. The aim of this paper is to discuss the therapeutic effects of ultrasound in the treatment of soft tissue injuries like a tennis elbow. Among the important point of discussion in this paper include the biophysical effects of ultrasound therapy to soft tissue injuries as tennis elbow, the therapeutic dose and application of ultrasound in the treatment of musculoskeletal conditions as soft tissue injuries and its effects in tissue repair and healing. Research will be sourced out from literature reviews from databases like Medline including other primary book resources using keywords like ultrasound, therapeutic ultrasound, tennis elbow and lateral epicondylitis.
Body
The use of ultrasound therapy is very common in the rehabilitation centers as a common modality treatment used in the management of musculoskeletal and soft tissue injuries. The therapeutic effects of ultrasound are founded on the theory of ultrasonic treatment that is known to produce both thermal and non-thermal effects that can improve the tissue repair and healing of the injured soft tissues. The ultrasound is applied locally within the area of the soft tissue injury. The machine comes with a transducer head that is applied in small circular motion within the affected area for at least 5 minutes (Behrens and Michlovitz, 1996). For chronic tissue injuries, the ultrasound therapy is given twice a day (Dvorak, Gilliar, Schneider, Spring and Tritschler, 2008). Coupling media like water and gels are applied on the skin surface in order to prevent the reflection of the waves between the skin surface and the transducer head. The dosage application will depend upon the condition of the soft tissue injury. Continuous ultrasound produces a greater heating effect making it more appropriate in the treatment for chronic soft tissue conditions at an intensity of 1 MHz (Moros, 2013). The choice between the use of the thermal and non-thermal ultrasound therapy will depend upon the extent of the tissue injury. Both types of therapeutic ultrasound are helpful in relieving soft tissue injuries and in accelerating the healing process of the injured soft tissues.
The thermal effect increases the blood flow going to the injured soft tissues as the heat is absorbed by the tissues while the non-thermal effects helped in the soft tissue repair through the mechanical process of micro streaming, cavitation and acoustic streaming (Chen, Sharma and Mudhoo, 2012). The major physical effects of the ultrasound application include changes in the superficial and deep tissue temperature both through its thermal and non-thermal effects in a continuous ultrasound application (Cameron, 2013). The increase in the tissue temperature improves the blood flow that helps in the faster healing process and enhanced tissue repair. The changes in temperature caused by the thermal effect of ultrasound application also increases the cellular and chemical changes that help in the repair of the damaged tissues. The major cellular changes affecting the tissue repair involves the activation of cells that can help in the repair of the injured tissues like the mast cells, fibroblasts, T lymphocytes, endothelial cells, platelets and macrophages. With the increase in the blood flow, therapeutic ultrasound helps in accelerating the release and migration of these cellular factors by enhancing the cell membrane permeability of the calcium ions that serve as a messenger in the release of these cellular processes for a faster tissue repair and healing. The thermal therapeutic effects also help diminish the pain perception, increases the metabolism and the blood flow. It also produce the physiological changes of increased histamine release, calcium ion influx, enhanced protein synthesis, tissue regeneration, wound healing, increased fibroblasts and vascular regeneration (Nanda, 2008). The heat produced by the ultrasound induces the therapeutic response that causes cellular reactions in response to a gradual increase in the soft tissue temperature thereby accelerating blood flow, cellular generation and relaxation (Magee, Kachazewski and Quillen, 2007). The non-thermal effects of the ultrasound through the cavitation process on the other hand, produce a vibrating reaction that creates microscopic bubbles, taking the vibration along the cell membranes for stimulation (Johns, 2002).
The resulting physiological effect is the enhancement of the cellular repair that is taking place during the inflammatory response of the tissue injury. These biophysical effects of the thermal and non-thermal ultrasound therapy are believed to arise from the cell membranes (Barnes and Greenbaum, 2007). The extent of the cellular responses in enhancing tissue repair and healing will depend upon the amount of heat the tissue receives. Hoskins, Martin and Thrush (2010) explained that as the ultrasound pulse travels through the damaged tissue in tennis elbow, the energy released from the pulse is absorbed by the affected tissue and is converted into heat thereby increasing the tissue temperature on the affected area.
A tennis elbow injury is a painful condition with pain manifesting more on the lateral side of the elbow while radiating down the forearm. Local tenderness is usually felt on the outer side of the elbow called the lateral epicondyle (Hammer, 2007). According to Maffuli, Renstrom and Leadbetter (2005), the condition usually occurs due to playing golf and tennis but overuse of the elbow may result in the occurrence of the condition with resulting injuries to the soft tissues like the tendons which are bands of tissues connecting the muscles to the bones (Medline Plus, 2014). A tennis elbow injury may be due to the mechanical stress on the soft tissues such as the tendons and ligaments around the elbow due to the wear and tear on these structures. The pathophysiological stress results in the degenerative consequences that may occur alongside the inflammatory process (Peterson, 2011) caused by the injury. The treatment for tennis elbow is usually non-surgical with 95% recovery among those suffering from the condition through conservative treatment (Gotlin, 2008). According to Barlow and Willoughby (1992), inflammation is essential in the healing process of soft tissue injury because the process activates the leukocytes and connective tissue cells to migrate on the site of the injured tissue and induces the release of cytokines to initiate the healing process. In the absence of the inflammatory response of the body, tissue repair is delayed. The application of ultrasound at its therapeutic range enhances the repair process that is taking place during the inflammation. Cormond (n.d.), citing the first study of Greg, et al., noted that the thermal effects of ultrasound on an injured tissue as lateral epicondylitis result in an increase in the extensibility of the tissue, increased metabolic process, improved blood flow and promotes tissue regeneration and is most effective when it is applied three times a week for a duration of four to six weeks. In a clinical study testing the efficacy of ultrasound and brace when treating lateral epicondylitis, Oken, Kahraman, Ayhan, Canpolat, and Yorqancioglu (2008) noted that the thermal effects of ultrasound tend to produce longer beneficial effects than a brace in terms of reducing pain and aiding in the healing process of the injured tissues.
The non-thermal ultrasound application on the hand can result in the biophysical responses on the injured soft tissues by increasing the cellular permeability and diffusion in order to facilitate the soft tissue repair. A clinical study cited by Radomski and Latham (2008)on the application of the non-thermal effects of ultrasound in soft tissue injuries provides its efficiency in producing these biophysical responses when the ultrasound is applied for a shorter duration and at a lower intensity applied every 24 to 48 hours to maximize its effects. The effectiveness of the application of the thermal and non-thermal therapeutic effects of ultrasound has some limitations. Research literatures provide that there is a lack of evidentiary support to prove the benefits of therapeutic ultrasound in soft tissue repair and healing. The cell affected by the temperature rise during the application of the ultrasound for instance is not specified making the cellular response heat purely one of speculation (Baker, Robertson and Duck, 2001). It is also difficult to support the therapeutic effects of ultrasound in tissue repair and healing because clinical studies lack the control groups. Some researchers also pointed out that unless the effectiveness of therapeutic ultrasound application is consistent not only in healing but also in its ability to alter the outcomes of the patient with soft tissue injury, the clinical use of the modality remains dubious (Ensminger and Bond, 2012). Many physicians confirmed the safety of using ultrasound application on the affected areas with reported low incidence of adverse effects (Karantanas, 2011). Common literature reviews have the same findings that there is a lack of methodologically accepted studies pointing out the problems on lack of calibration, poor outcome data and inappropriate dosage (NJD Sports Injury Clinic, n.d.).
Conclusion
The use of therapeutic ultrasound in soft tissue injuries like tennis elbow is highly prevalent in the rehabilitation settings. Ultrasound is a common therapeutic modality used by physical therapists in the treatment of musculoskeletal disorders and soft tissue injuries. The ability of the ultrasound to heal and repair injured soft tissue is attributed to the application of heat on the affected area. Ultrasound is known to produce thermal effects that are responsible for the biological and physical effects that are believed to accelerate the cellular activities. This in turn contribute to the enhancement of the healing process of soft tissue injuries. As the heat increases the blood flow on the injured soft tissue area, cellular permeability occurs which enhances the cellular activities that help in the repair of the damaged tissue fibers. There are increasing claims that therapeutic ultrasound is effective in providing relief and in accelerating tissue repair and healing in tennis elbow. Ultrasound therapy is, in fact, a popular conservative treatment for tennis elbow injury and other musculoskeletal problems. However, the lack of literature reviews supporting the accurate and reliable clinical research methodology that will support this claim makes the application of therapeutic ultrasound in clinical practice and its effectiveness remains to be doubtful within the scientific and clinical research point of views.
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