A Winning Combination

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November 2003

By David O. Draper, EdD, ATC

Two NBA superstars who have played for several years without winning a championship have recently taken pay cuts to join a team with a long history of winning championships. They are hoping that this combination will produce a winning team and the championship rings that have eluded them for years.

In physical medicine and rehabilitation, I believe there are two modalities that, when combined, produce a winning combination. When the goal is increased range of motion (ROM) in a contracted or frozen joint, that winning combination is deep heat and joint mobilizations. The purpose of this article is twofold: first, to present a case study where ultrasound and joint mobilizations were effectively used on a frozen joint; and second, to provide a rationale for why these two modalities are so effective when used together.

A Case to Learn From

A 22-year-old man presented to the Brigham Young University Therapeutic Modality Research Laboratory in April 2003. When he was 19, a surgeon accidentally severed three extensor tendons in his hand while trying to extract a ganglion cyst. The patient underwent more surgery by another physician to repair the tendons. After prolonged immobilization in a splint, he had extensive physical therapy that included ultrasound and stretching to help gain back lost ROM.

Three years after the injury, however, his wrist movement was still very limited and exhibited a firm, capsular, pathological end-feel. Wrist flexion was 49° out of a possible range of 80° to 90°, while wrist extension was 65° out of a possible 80°.

Our treatment sessions included ultrasound to heat the tissue, immediately followed by joint mobilizations and wrist traction. Ultrasound parameters were frequency (3 MHz), intensity (1.5 W/cm²), treatment size (twice the size of the soundhead faceplate, 5 cm²), and treatment time (5 minutes, anterior wrist; 5 minutes, posterior wrist). Standard topical ultrasound gel was used as the coupling medium. As soon as the ultrasound treatment was finished, I started joint mobilizations. These lasted for 6 to 8 minutes and consisted of radial-carpal glides in both the anterior and posterior direction to gain back wrist flexion and extension. A total of three treatments were given (Mon, Weds, Fri) over the course of 1 week.

The subject saw immediate improvement of 6° in flexion and 7° in extension after the first treatment session. By the end of the third treatment, the subject had gained 23° flexion (see Figures 1 and 2, page 20) and 15° of extension (see Figures 3 and 4, page 20), with near-normal bilateral ROM. Six months after the treatments, he had maintained the ROM that was gained from the ultrasound and mobilization regimen.

Figure 1. The patient was lacking 31° of wrist flexion prior to the treatments.

Thermal effects of Ultrasound

When therapeutic ultrasound is applied to tissue, both thermal and nonthermal effects occur.^1-3 Ultrasound influences both normal and damaged biologic tissues; however, damaged tissue may be more responsive to ultrasound than normal tissue.

Conventionally, ultrasound has been used for the most part to increase tissue temperature.^4,5 The primary advantage of ultrasound over other nonacoustic heating modalities is that tissues high in collagen such as tendons, muscles, ligaments, joint capsules, joint menisci, intramuscular interfaces, nerve roots, periosteum, cortical bone, and other deep tissues may be selectively heated to the therapeutic range without causing a significant increase in tissue temperature in skin or fat.^4,6 Ultrasound penetrates skin and fat with very little attenuation.⁷

The clinical effects of thermal ultrasound include but are not limited to⁸:

An increase in the extensibility of collagen fibers found in tendons and joint capsules
Reduction in viscosity of fluid elements in the tissues
Decrease in joint stiffness
Reduction of muscle spasm
Diminished pain perception
Slowing of nerve conduction velocity
Increased metabolism
Increased blood flow
Mild inflammatory reaction, which may help in the resolution of chronic inflammation

The first six of these nine properties can have a very positive impact on preparing tissue for the implementation of joint mobilizations.

Figure 2. After three treatments, the patient gained 23° of wrist flexion.

Scar Tissue, Joint Contracture

During remodeling, collagen fibers are realigned along lines of tensile stresses and strains, forming scar tissue. This process may continue for months or even years. In scar tissue, collagen never attains the same pattern and remains weaker and less elastic than normal tissue prior to injury. Scar tissue in tendons, ligaments, and capsules surrounding joints can produce joint contractures that limit range of motion. It has been theorized that increased tissue temperatures during ultrasound treatment decrease the viscosity of collagen fibers while increasing their elasticity. In this case, ultrasound is the treatment modality of choice, because the deeper tissues surrounding joints that most often restrict range are rich in collagen.⁹

A number of researchers have investigated the effects of ultrasound treatment on scar tissue and joint contracture. Ultrasound has been demonstrated to increase mobility in a mature scar.¹⁰ A greater residual increase in tissue length with less potential damage is produced through preheating with ultrasound prior to or while stretching.¹¹ Tissue extensibility increases when continuous ultrasound is applied at higher intensities, causing vigorous heating of tissues.¹² Periarticular structures and scar tissues become significantly more extensible after treatment with ultrasound involving thermal effects at intensities of 1.2 to 2.0 W/cm².¹¹ Scar tissue can be softened if treated with ultrasound at an early stage.¹³ Early treatment of Dupuytren’s contracture with ultrasound shows a beneficial effect on long-standing contracted bands of scar and a decrease in pain.¹⁴

Figure 3. The patient was lacking 15° of wrist extension prior to the treatments.

Stretching Connective Tissue

Collagenous tissue is fairly rigid when stressed; however, it yields somewhat when heated.^11,12 The blend of heat and stretch results in a residual lengthening of connective tissue, which increases according to the force applied.

The period (or window of opportunity) of vigorous heating when tissues will undergo the greatest extensibility and elongation I like to refer to as the “stretching window.”^15,16 If tissue is heated vigorously, it becomes more pliable and less resistant to stretch; yet as the tissue cools, it withstands stretching and can actually be damaged if too great a force is applied. My colleagues and I have studied the rate of tissue cooling following continuous ultrasound at both 1-MHz and 3-MHz frequencies.^15,16 For all intents and purposes here, we suggest that stretching, traction, or joint mobilization be performed immediately after ultrasound, since this stretching window of opportunity stays open for only 5 to 10 minutes following an ultrasound treatment. This window varies according to the type and depth of the tissue heated. Since tendon is much less vascular than muscle, tendon heated with ultrasound cools at a slower rate than that for muscle. Also, deeper muscle cools at a slower rate than that for superficial muscle since the added tissue serves as a barrier to escaping heat.

Figure 4. The patient’s wrist was restored to full extension after three treatments.

Why joint mobilization?

You might be asking yourself, “Why didn’t the ultrasound and stretching treatments the case study patient received 3 years ago result in regaining his ROM?” Possibly the ultrasound treatments were administered with the wrong parameters (too-low intensity or too-short treatment time to result in any significant heating, etc). Another possibility, however, is that passive stretch is inferior to joint mobilizations when dealing with contracted scar tissue. The patient in the above case was immobilized in an extension splint while his wrist extensor tendons healed. When the splint was removed, the patient had lost the majority of his wrist flexion, thus passive wrist flexion was applied in an effort to gain back this lost motion. Passive wrist flexion, however, causes the scaphoid, lunate, and triquetrum to roll and then jam against the radius. Conversely, the action of mobilizing this joint begins with pulling traction on the joint, stabilizing the radius, and then gliding these three carpal bones in a volar (anterior) direction. There is no jamming of the bones together, and what is tight (the capsule embedded with scar tissue) is lengthened.

Conclusion

Ultrasound and joint mobilizations by themselves are great modalities. However, when the opponent is a pathological frozen joint, these two modalities combined make a winning team. With larger joints than the hands or feet, ultrasound can be replaced by shortwave diathermy, a deep-heating treatment for a much larger area.¹⁷

David O. Draper, EdD, ATC, is a professor and director of the graduate athletic training program at Brigham Young University in Provo, Utah.

References

Dyson M. Mechanisms involved in therapeutic ultrasound. Physiotherapy. 1987;73(3):116-120.
Partridge CJ. Evaluation of the efficacy of ultrasound. Physiotherapy. 1987;73(4): 166-168.
ter Haar G. Basic physics of therapeutic ultrasound. Physiotherapy. 1987;73(3):
110-113.
Lehmann JF, Guy AW. Ultrasound therapy. In: Reid J, Sikov MR, eds. Interaction of Ultrasound and Biological Tissues. DHEW Publication (FDA) 73-8008. 1971; session 3(8):141.
MacDonald BL, Shipster SB. Temperature changes induced by continuous ultrasound. South African J Phys. 1981;37(1):13-15.
ter Haar G, Hopewell JW. Ultrasonic heating of mammalian tissue in vivo. Brit J Cancer. 1982;45(suppl V):65-67.
Draper DO, Sunderland S. Examination of the law of Grotthus-Draper: does ultrasound penetrate subcutaneous fat in humans? J Ath Train. 1993;28:246-250.
Draper DO, Prentice WE. Therapeutic ultrasound. In: Prentice WE, ed. Therapeutic Modalities in Sports Medicine. 5th ed. Madison, Wis: WCB McGraw-Hill; 2003;95-128.
Lehmann JF. Clinical evaluation of a new approach in the treatment of contracture associated with hip fracture after internal fixation. Arch Phys Med Rehabil. 1961;42:95.
Bierman W. Ultrasound in the treatment of scars. Arch Phys Med Rehabil. 1954;35:209.
Lehmann JF. Effect of therapeutic temperatures on tendon extensibility. Arch Phys Med Rehabil. 1970;51:481.
Gersten JW. Effect of ultrasound on tendon extensibility. Am J Phys Med. 1955; 34:662.
Patrick MK. Applications of pulsed therapeutic ultrasound. Physiotherapy. 1978;64(4):103-104.
Markham DE, Wood MR. Ultrasound for Dupuytren’s contracture. Physiother-apy. 1980;66(2):55-58.
Draper DO, Ricard MD. Rate of temperature decay in human muscle following 3 MHz ultrasound: the stretching window revealed. J Ath Train. 1995;30: 304-307.
Rose S, Draper DO, Schulthies SS, Durrant E. The stretching window part two: rate of thermal decay in deep muscle following 1 MHz ultrasound. J Ath Train. 1996;31:139-143.
Garrett C, Draper DO, Knight KL, Durrant E. Heat distribution in the lower leg from pulsed short-wave diathermy and ultrasound treatments. J Ath Train. 2000;35(1):50-55.

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November 2003