ACCELERATE YOUR PATIENTS’ RECOVERY EL PHYSIOTHERAPY INFORMATION BULLETIN PHYSIOTHERAPY IN GASTROENTEROLOGICAL PATHOLOGIES Functional dyspepsia Functional dyspepsia is a symptoms complex characterised by upper abdominal discomfort or pain, nausea, vomiting, bloating, early satiety, and anorexia in the absence of organic disease. The aetiology of this disease is poorly understood (1).The main aim of the treatment of functional dyspepsia is to reduce or eliminate the symptoms and thus to improve the conditions of the patient. Standard pharmacological treatment includes prokinetics, analgesics, H2-receptor antagonists, proton pump inhibitors, antacids, serotonin receptor antagonists, and antidepressants. This treatment often has low efficacy and might cause side effects associated with the drugs (2, 3). The patients with functional dyspepsia which is refractory to the drug treatments would require other therapeutic options. Treatment of these pathological conditions using electrotherapy modalities such as transcutaneous electroacupuncture (TEA) showed successful results without any reported adverse reactions (4). It accelerates gastric emptying, inhibits gastrointestinal motility, increases plasma levels of neuropeptide Y, stimulates food intake and reduces the symptom scores. Figure 1. The effect of TEA on dyspeptic symptoms (S. Liu et al. Neurogastroenterology & Motility 2008; 20 (11): 1204-1211) The results indicated a marked statistically significant (p ≤ 0.001) improvement in the total symptom score from 16.5±1.9 to 4.2±1.5 following the 2-week TEA treatment. References 1.Timmons S, Liston R, Moriarty KJ. Functional dyspepsia: motor abnormalities, sensory dysfunction, and therapeutic options. Am J Gastroenterol 2004; 99: 739–749 2. Mönkemüller K, Malfertheiner P. Drug treatment of functional dyspepsia. World J Gastroenterol 2006; 12(17): 2694-2700 3. Myers RP, McLaughlin K, Hollomby D. Acute interstitial nephritis due to omeprazole. Am J Gastroenterol 2001; 96(12): 3428-3431 4. Liu S, Peng S, Hou X, Ke M, Chen JD.Transcutaneous electroacupuncture improves dyspeptic symptoms and increases high frequency heart rate variability in patients with functional dyspepsia. Neurogastroenterol Motil 2008; 20(11): 1204-1211 EL PHYSIOTHERAPY 765c Hawthorn Rd Brighton East 3187 Phone: (03) 9005 9282 Idiopathic fecal incontinence Fecal incontinence is a disabling pathological condition. Few therapeutic tools are available for treating idiopathic anal incontinence (1). The use of transcutaneous electrical stimulation (TENS) of posterior tibial nerve showed encouraging results for treatment of the disease.The patients were treated 20 minutes daily for 4 weeks and the results were estimated according to the Wexner’s score before and after the treatment period (1). Figure 1. Incontinence score pre- and post-4 week neurostimulation (M. Queralto et al. International Journal of Colorectal Disease 2006; 21: 670-672) Wexner’s scores were improved in eight of the ten patients in 4 weeks. Mean improvement in the score was more than 60% (statistically significant difference p = 0.0046, Wilcoxon rank test). No adverse event was observed. References 1. Queralto M, Portier G, Cabarrot PH, Bonnaud G, Chotard JP, Nadrigny M, Lazorthes F. Preliminary results of peripheral transcutaneous neuromodulation in the treatment of idiopathic fecal incontinence. Int J Colorectal Dis 2006; 21: 670-672 Some other gastrointestinal pathologies effectively treated using physiotherapy techniques Pathology Technique Source Irritable bowel syndrome TENS Body awareness therapy (BAT) Xiao WB, LiuYL. Digestive Diseases and Sciences 2004; 49 (2): 312-319 Eriksson EM et al. World Journal of Gastroenterology 2007; 13 (23): 3206-3214 Inflammatory bowel disease TENS Low intensity exercise Vitton V et al. Inflammatory Bowel Diseases 2009; 15 (3): 402-405 Loudon CP et al. American Journal of Gastroenterology 1999; 94 (3): 697-703 Biliary dyskinesia TENS Electroacupuncture Blaut U et al. European Journal of Gastroenterology & Hepatology 2003; 15 (1): 21-26 Lee SK et al. Gastrointestinal Endoscopy 2001; 53: 211-216 Haemorrhoids Direct current electrotherapy Izadpanah A, Hosseini SV. International Journal of Surgery 2005; 3 (4): 258-262 Schubach G. Diseases of the Colon & Rectum 2004; 47: 1990 For additional information or questions please contact Dr Vladimir Gurevich, Senior Clinical Advisor, on 9005 9282 or email [email protected] EL PHYSIOTHERAPY 765c Hawthorn Rd Brighton East 3187 Phone: (03) 9005 9282 ACCELERATE YOUR PATIENTS’ RECOVERY EL PHYSIOTHERAPY INFORMATION BULLETIN PHYSIOTHERAPY IN MUSCULOSKELETAL PATHOLOGIES Bone Fractures Bone fractures have a high epidemiological prevalence in various age groups around the world and are associated with substantial disability and socioeconomic costs (1, 2).There is evidence from randomised trials that the use of low-intensity pulsed ultrasound appears to promote accelerated fracture healing (3). J. Busse with co-authors (3) performed a meta-analysis of the trials investigating the effect of low-intensity pulsed ultrasound on time to fracture healing. The internal validity of the trials was estimated using a 5-point scale that evaluates the quality of trial method on the basis of description and appropriateness of randomisation and doubleblinding, and assessment of study withdrawals and likelihood of bias.The results of their studies are shown in Table 1. Table 1: Summary of the trials included in the meta-analysis Sample size, no of fractures Location of fracture Treatment group Control group Heckman et al39 Tibial shaft 33 34 Kristiansen et al 40 Distal radius 30 31 Mayr et al 42 Scaphoid 15 15 Trial Fracture Mean age (and SD), yr Male; female ratio Mean time to healing (and SD), d Open Closed Treatment group Control group Effect size Quality score✝ Treatment 36 (2) 54:13 Control 31 (2) 3 (grade 1) 64 114 (7.5) 182 (15.8) 5.41 5 Treatment 54 (3) 10:51 Control 58 (2) 0 61 61 (3) 98 (5) 8.82 5 NA NA 43 (11) 62 (19)* 1.20 4 37 (14) 25:5 Note: SD = standard deviation. NA = not applicable Healing time was defined as the time from initiation of treatment to removal of the cast. ✝Maximum score 5 (see Methods section). CMAJ. 2002 February 19; 166(4): 437–441. The data indicates that ultrasound therapy is efficient in fracture healing.The findings suggest that treatment with low-intensity pulsed ultrasound could significantly reduce healing time and yield substantial cost savings and decreases in disability associated with delayed union and nonunion of fractures (3). References 1. Hannon M, Hadjizacharia P, Chan L, Plurad D, Demetriades D. Prognostic significance of lower extremity bone fractures after automobile versus pedestrian injuries. J. Trauma 2009; 67 (6): 1384-1388 2. Rewers A, Hedegaard H, Lezotte D, Meng K, Battan FK, Emery K, Hamman RF. Childhood femur fractures, associated injuries, and sociodemographic risk factors: a population based study. Pediatrics 2005; 115 (5): 543-552 3. Busse JW, Bhandari M, Kulkarni AV, Tunks E. The effect of low-intensity pulsed ultrasound therapy on time to fracture healing: a meta-analysis. CMAJ 2002; 166 (4): 437-441. EL PHYSIOTHERAPY 765c Hawthorn Rd Brighton East 3187 Phone: (03) 9005 9282 Fibromyalgia Fibromyalgia is a common disorder of unknown aetiology characterised by chronic musculoskeletal pain and increased tenderness at standardised tender points. Additional symptoms are fatigue, sleep disturbances, deconditioning and reduced quality of life. Treatment of the disease and other painful conditions using individual physiotherapy modalities and their combinations was documented (1). The effect of treatment using combined therapy including both ultrasound and interferential current on pain and sleep parameters in fibromyalgia (1) are shown in Tables 1 and 2. Table 1. Subjective pre- and post-sleep pain parameters modified by treatment (T. Almeida et al., Pain, 2003) Pain parameters Sleep Sham treatment Before Body map (number) Pain Intensity (VAS) Pre Post Pre Post CIPI treatment After 21.1 +- 4.5 19.6 +- 7.4 7.3 +- 1.5 7.4 +- 1.45 2 Way ANOVA F (1.15) Before 18.8 +- 11.8 18.1 +- 10.7 7.2 +- 2.1 7.3 +- 2.0 After 17.8 +- 8.0 15.6 +- 4.7 6.8 +- 1.4 7.4 +- 1.5 A 1.2 +- 1.1a.b 1.4 +- 1.2a.b 3.0 +- 2.1a.b 2.8 +- 2.6a.b B 41.2* 24.1* 6.7* 5.8* C 49.8* 47.4* 14.0* 15.6* 31.2* 38.2* 12.6* 13.3* Mean±SD. Two-way ANOVA: A, factor group; B, factor time; C, Interaction factor. *P<0.001; #P<0.005. Table 2. Subjective sleep parameters modified by treatment (T. Almeida et al., Pain, 2003) Sleep parameters Sham treatment Before Refreshing sleep (VAS Morning fatigue (VAS 2.8 +- 0.6 8.0 +- 0.5 CIPI treatment After 2 Way ANOVA F (1.15) Before 2.9 +- 0.6 8.3 +- 0.5 After 2.1 +- 0.7 7.0 +- 1.2 7.5 +- 0.7a.b 2.6 +- 1.0a.b A B C 45.3* 229.0* 229.0* 84.4* 71.7* 101.5* Mean±SD. Two-way ANOVA: A, factor group; B, factor time; C, Interaction factor. *P<0.001. The results show that pain manifestations and sleep disturbances were significantly improved after the treatment (1). References 1.Almeida T, Roizenblatt S, Benedito-Silva A,Tufik S.The effect of combined therapy (ultrasound and interferential current) on pain and sleep in fibromyalgia. Pain 2003; 104 (3): 665-672 Some other musculoskeletal pathologies effectively treated using physiotherapy techniques Pathology Technique Source Knee osteoarthritis Ibuprofen phonophoresis Kozanoglu E et al. Swiss Medical Weekly 2003; 133: 333-338 Carpal tunnel syndrome Ultrasound Bakhtiary AH, Rashidy-Pour A. The Australian Journal of Physiotherapy 2004; 50: 147-151 Lateral epicondylitis Naproxen phonophoresis and iontophoresis Baskurt F et al. Clinical Rehabilitation 2003; 17 (1): 96-100 For additional information or questions please contact Dr Vladimir Gurevich, Senior Clinical Advisor, on 9005 9282 or email [email protected] EL PHYSIOTHERAPY 765c Hawthorn Rd Brighton East 3187 Phone: (03) 9005 9282 ACCELERATE YOUR PATIENTS’ RECOVERY EL PHYSIOTHERAPY INFORMATION BULLETIN PHYSIOTHERAPY IN UROLOGICAL AND GYNAECOLOGICAL PATHOLOGIES Chronic pelvic pain syndrome The incidence of chronic pelvic pain syndrome (CPPS) is increasing and the vast majority of male patients suffer from its abacterial forms. Pharmacotherapy of the disease utilises analgesics, antibiotics, α-receptor blockers, 5α-reductase inhibitors and some other agents which have limited effectiveness (1). Use of physiotherapy techniques showed beneficial results for treatment of lower urinary tract dysfunctions (2, 3). Treatment of these conditions with low-energy extracorporeal shock wave therapy (ESWT) as illustrated below represents an efficient therapeutic option resulting in significant improvements of the CPPS-related parameters. Table 1. Changes in parameters for the sham and verum treatment groups (R. Zimmermann et al., European Urology, 2009) Parameter Placebo Rel. change % (median values) Significant changes Verum Rel. change % (median values) Significant changes IPSS (1 wk)–IPSS (pre) 0 No (p = 0.947) -15.6 Yes (p = 0.001) IPSS (4wk)–IPSS (pre) 0 No (p = 0.631) -18.8 Yes (p = 0.001) IPSS (12wk)–IPSS (pre) 0 No (p = 0.280) -25 Yes (p = 0.001) IIEF (1 wk)–IIEF (pre) 0 No (p = 0.959) 10.5 Yes (p = 0.029) IIEF (4wk)–IIEF(pre) 0 No (p = 0.894) 5.3 Yes (p = 0.034) IIEF (12wk)–IIEF(pre) 0 No (p = 0.569) 5.3 Yes (p = 0.036) CPSI (1 wk)–CPSI (pre) 0 No (p = 0.935) -16.7 Yes (p = 0.001) CPSI (4wk)–CPSI (pre) 2.1 No (p = 0.865) -16.7 Yes (p = 0.001) CPSI (12wk)–CPSI (pre) 4.2 No (p = 0.935) -16.7 Yes (p = 0.001) VAS (1 wk)–VAS (pre) -16.7 No (p = 0.151) -33.3 Yes (p = 0.001) VAS (4 wk)–VAS (pre) 0 No (p = 0.865) -50 Yes (p = 0.001) VAS (12 wk)–VAS (pre) 0 No (p = 0.227) -50 Yes (p = 0.001) CPSI = Chronic Prostatitis Symptom Index; IIEF = International Index of Erectile Function; IPSS = International Prostate Symptom Score; VAS = Visual Analog Scale. The median values of IPSS, IIEF, CPSI, and VAS parameters demonstrated statistically significant improvement in the verum but not in the placebo group indicating the efficacy of the ESWT treatment. No side-effects were observed in any patients during the treatment and follow-up periods (1). References 1. Zimmermann R, Cumpanas A, Miclea F, Janetshek G. Extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome in males: a randomised, double-bind, placebo-controlled study. Eur Urol 2009; 56: 418-424 2. Anderson RU, Sawyer T,Wise D, Morey A, Nathanson BH. Painful myofascial trigger points and pain sites in men with chronic prostatitis/chronic pelvic pain syndrome. J Urol 2009; 182 (6): 2753-2758 3. van Balken MR, Vergunst H, Bemelmans B. The use of electrical devices for the treatment of bladder dysfunction: a review of methods. J Urol 2004; 172 (3): 846-851 EL PHYSIOTHERAPY 765c Hawthorn Rd Brighton East 3187 Phone: (03) 9005 9282 Dysmenorrhoea Dysmenorrhoea is a female problem which has a high epidemiological prevalence (1). It causes reduced quality of life, a need for treatment, and absence from school or work. Pharmacological treatment mainly includes nonsteroidal anti-inflammatory drugs and oral contraceptives. However pharmacotherapy might be undesirable for personal reasons or contraindicated, give insufficient results, and cause adverse reactions limiting its use (2).Transcutaneous electrical nerve stimulation (TENS) and other electrotherapy treatments effectively reduce pain through stimulating Aβ proprioceptic fibres, release of endogenous endorphins and other pathways (2-4). Table 1. Pain scores and use of analgesic tablets with and without the TENS treatment (H. Schiotz et al., Journal of Obstetrics and Gynaecology, 2007) Pain scores Control cycles Active cycles p value Analgesic tablets (n/day) Mean Range SD Mean Range SD 6.73 5.18 2.5 - 10 0 - 8.6 0.0009* 2.3 2.2 2.89 1.36 0 - 12 0 - 5.5 0.003* 2.30 1.42 Number of women using analgesic tablets 20/21 13/21 0.024✝ * Two-sided paired t-test; ✝%2 test. The data showed that the TENS treatment resulted in a highly significant reduction of pain scores and number of analgesic tablets used. The treatment was not associated with any adverse events (2). The results indicated that TENS is an effective therapeutic option for dysmenorrhoea treatment and not requiring the use of medications. References 1. Polat A, Celik H, Gurates B, Kaya D, Nalbant M, Kavak E, Hanay F. Prevalence of primary dysmenorrhoea in young adult females university students. Arch Gynecol Obstet 2009; 279 (4): 527-532 2. Schiotz H, Jettestad M, Al-Heeti D. Treatment of dysmenorrhoea with a new TENS device (OVA). J Obstet Gynaecol 2007; 27 (7): 726-728 3. Tugay N, Akbayrak T, Demirturk F, Karakaya IC, Kocaacar O, Tugay U, Karakaya MG, Demirturk F. Effectiveness of transcutaneous electrical nerve stimulation and interferential currentin primary dysmenorrhoea. Pain Med 2007; 8 (4): 295-300 4. Proctor M, Farquhar C, Stones W, He L, Zhu X, Brown J.Transcutaneous electrical nerve stimulation for primary dysmenorrhoea. Cochrane Database Syst Rev 2002; 1: CD002123 Some other urological and gynaecological pathologies effectively treated using physiotherapy techniques Pathology Technique Source Chronic prostatitis TENS Sikiru L et al. International Braz J Urol 2008; 34 (6): 708-714 Interstitial cystitis Percutaneous posterior tibial nerve stimulation (PTNS) Zhao J et al. Urology 2008; 71 (6): 1080-1084 Overactive bladder Electric stimulation (ES) Wang AC et al. Urology 2006; 68 (5): 999-1004 Labour pain TENS Chao AS et al. Pain 2007; 127 (3): 214-220 For additional information or questions please contact Dr Vladimir Gurevich, Senior Clinical Advisor, on 9005 9282 or email [email protected] EL PHYSIOTHERAPY 765c Hawthorn Rd Brighton East 3187 Phone: (03) 9005 9282