EFFECT OF ULTRASONIC THERAPY IN PATIENTS OF EARLY PHASE

REHABILITATION POST FLEXOR TENDON REPAIR SURGERY

A RESEARCH WORK
SUBMITTED TO
THE DEPARTMENT OF PHYSIOTHERAPY,
CHRISTIAN MEDICAL COLLEGE & HOSPITAL
IN PARTIAL FULFILMENT OF THE REQUIREMENT
FOR THE DEGREE OF
BACHELOR OF PHYSIOTHERAPY (BPT)
(2014-2019)
AT
CHRISTIAN MEDICAL COLLEGE & HOSPITAL, LUDHIANA

Supervised By: Submitted By:

Dr. Sandeep S. Saini Nistara Singh Chawla
Principal & Professor Intern
College of Physiotherapy College of Physiotherapy
CMC&H, Ludhiana. CMC&H, Ludhiana.
CHRISTIAN MEDICAL COLLEGE & HOSPITAL, LUDHIANA
(Affiliated to Baba Farid University Of Heath Sciences, Faridkot)
 CERTIFICATE 1

TO WHOM IT MAY CONCERN

This is to certify that the project on ‘The effect of ultrasound in early rehabilitation phase
post flexor tendon repair surgeries’ has been carried out by Nistara Singh Chawla
(Physiotherapy Intern) at Christian Medical College & Hospital, Ludhiana under our
supervision. The assistance and help during the course have been fully acknowledged.

GUIDE: CO-GUIDE:
Dr. Pinki Pargal Dr. Sandeep S. Saini
(Associate Professor) (Professor and Principal)
Department of Plastic Surgery College of Physiotherapy,
Christian Medical College Christian Medical College
& Hospital, Ludhiana & Hospital, Ludhiana.
 CERTIFICATE-2

This is to certify that the research on ‘The effect of ultrasound in early rehabilitation
phase post flexor tendon repair surgeries’ is a bona fide work of Miss Nistara Singh
Chawla (Intern) during her internship program done at College of Physiotherapy,
Christian Medical College and Hospital, Ludhiana for Department of Physiotherapy.

Her work is duly acknowledged.

Date _________ Dr. Sandeep S. Saini

MPT (Ortho)
Principal
College of Physiotherapy
CMCH, Ludhiana
 ACKNOWLEDGEMENTS

No one can ever make an achievement on his own. It is always difficult to acknowledge so
precious debt as that of learning. It is the debt that could only be paid through gratitude. I
bow with gratitude to all the teachers who guided me.
I express my deep sense of gratitude to my parent institution, especially Dr.Sandeep Singh
Saini (MPT Ortho, Professor & Principal, College of Physiotherapy, CMC&H Ludhiana) for
their guidance and great help in the completion of my research work.
My special thanks to my guide- Dr. Pinki Pargal (Assoc.Professor) whose guidance and
support kept me going through the difficulties faced during the completion of this study.
I will be failing my duties if I don’t thank and acknowledge Dr.Mullai, Dr.Supriya,
Dr.Amarjot, Dr.Rajinderpal, Dr.Simarpreet and Dr.Gurbinder for providing me clinical
guidance and high moral support throughout the working phase.
My special thanks to Ms. Jayshree, statistician, whose guidance and support kept me going
through the difficulties faced during the statistical work.
I’ll be failing in my efforts if I don’t extend my gratitude towards my family and friends who
acted as a source of inspiration and encouragement and strength.
Last but not the least, I would like to thank all the subjects who volunteered to participate in
the study
Above all, I bow in reverence to the God whose blessings have helped and guided me
throughout the research work.
Nistara Singh Chawla
BPT Intern
 TABLE OF CONTENT

Chapter Contents

1 Introduction
2 Review of Literature
3 Research design and methodology
4 Procedure
5 Data Analysis and Interpretation of results
 Discussion
 Conclusion
Bibliography
6 Appendices
Appendix I ( CRF form)
Appendix II ( Consent Form)
Appendix III (Master Chart)
 ABSTRACT

INTRODUCTION:
The healing process of tendon injuries can take months, but the use of electrotherapeutic
resources may help accelerate recovery and prevent functional complications that might
otherwise delay the rehabilitation process. The use of ultrasound in tendon repair in early
phase shall help in accelerating the process.
METHODOLOGY:
A comparison was made between the means of final and initial values of ROM and MMT
scores of the patients of Group A(experimental group) and Group B(control group) using
unpaired T-Test and Chi square test respectively.The results were analysed using Ms. Excel.
RESULT:
The ROM and MMT score of Group A and Group B were recorded before the intervention
and compared to the ROM and MMT score post intervention and a comparison was made
between the mean of the observation in the final recordings of both the groups using unpaired
t-test and chi square test. The results were significant.
CONCLUSION:
After flexor tendon repair, pulsed ultrasound therapy during the early rehabilitation phase is
safe and effective. The results are comparable to conventional mobilization protocols.
CHAPTER 1
 INTRODUCTION

ANATOMY
The anatomy of hand is complex, intricate and fascinating. It’s integrity is
absolutely essential for our everyday functional living.
The hand consists of 27 bones:
 8 carpals
 5 metacarpals
 15 phalanges
INNERVATION:
 Median nerve
 Ulnar nerve
 Radial nerve

MUSCLES:
The hand activities are brought about by two muscle groups:
 Intrinsic muscles
 Extrinsic muscles
INTRINSIC MUSCLES- originate and insert within the hand. These include:
 Thenar muscles
 Adductor pollicis
 Hypothenar muscles
 Lumbricals
 Interossei
EXTRINSIC MUSCLES- originate in the forearm, proximal to the wrist and act
on the hand. The integrated functioning of both muscle groups is the
prerequisite for a variety of hand activities.
 Extensor muscles
 Flexor muscles
FLEXOR MUSCLES AND TENDONS:
  Flexor carpi radialis
 Flexor carpi ulnaris
 Flexor digitorum profundus
 Flexor digitorum superficialis
 Flexor pollicis longus

PULLEY:
The pulley system is critical to flexion of the finger. The retinacular system
for each of the fingers contains 5 annular pulleys and 4 cruciate pulleys. The
thumb has 2 annular pulleys and 1 oblique pulley. In the finger, the second
and fourth annular pulley are critical pulleys. The oblique pulley in the
critical pulley in the thumb.

Injuries to the flexor tendons of hand may not be seen as very complicated, but the
rehabilitation of a patient who has sustained an injury of the kind requires sincere
commitment and hard work of the surgeon, the physical therapist and the compliance of the
patient with the treatment.[1] The healing process of tendon injuries can take months, but the
use of electrotherapeutic resources may help accelerate recovery and prevent functional
complications that might otherwise delay the rehabilitation process.[2]

The high incidence of these injuries justifies more studies to improve tendon repair by
reducing recovery time and the time to return to functional activities. As observed through
the available literature, the treatment protocols have been designed and designated to a
particular zone of the hand where the injury is sustained.

The existing protocols of rehabilitation in patients with flexor tendon repair consist of
varying intervals of immobilization which have been shown to yielding suboptimal results
mostly due to non-compliance of the patients.[1] Some studies also highlight the importance of
therapeutic ultrasound with early mobilization in the treatment of such cases. Ultrasound
therapy is being used safely after tendon repair, during the re-modelling phase (after three
weeks) as an adjunct to mobilization to improve the tendon gliding.[1] However, we thought
of using this mode of treatment during the earlier phase of tendon healing. But there is no
ideal intensity, frequency and duration of treatment with ultrasound therapy been chalked out
for stat reference.

Also, Ultrasound therapy has also been considered as a strong placebo [3] and undue exposure
to ultrasonic radiations may predispose the patients to potential thermal injury [4]. Along with
that, the number of treatment sessions required according to the safety standards of ultrasonic
therapy has not been mentioned in the literature available.
CHAPTER 2
 REVIEW OF LITERATURE

B. S. GAN, et Al (1995) -The effects of Ultrasound Treatment on Flexor Tendon Healing in

the Chicken Limb suggested that treatment was shown to increase range of movement, to
advance scar maturation and to decrease the amount of inflammatory infiltrate around the
repair site. No adverse effects on tensile strength were noted in either group.

C.A. Speed (2001) -Therapeutic ultrasound in soft tissue lesions suggested that the basis for
the use of ultrasound to promote and accelerate tissue healing and repair.

James L. Karnes, Harold W. Burton (2002) -Continuous therapeutic ultrasound accelerates

repair of contraction-induced skeletal muscle damage in rats suggested that Continuous
therapeutic ultrasound accelerates repair of contraction-induced skeletal muscle damage in
rats.

Saini NS, Roy KS, et al (2002) -A preliminary study on the effect of ultra sound therapy on
the healing of surgically severed Achilles tendon in five dogs suggested that the Achilles
tendon in group II showed comparatively fewer adhesions than in group I animals.
Histologically, in group II (treated), on day 40, the union was comparatively better without
any inflammatory reaction. Bundle formation had begun in the ultrasound-treated animals
which was not observed in the control animals. By day 90, more compact parallel bundle
formation had taken place with minimum cellularity. Bundle formation was in its advanced
stage in the treated animals. By day 120, the tendon tissue was comparatively acellular and
looking like a normal tendon. The use of the cortical screw provided good immobilization
and ultrasound therapy at 0.5 W/cm2 enhanced the Achilles tendon healing in dogs.

Merrick MA, Bernard KD, Devor ST, Williams MJ. (2003) - Identical 3-MHz ultrasound
treatments with different devices produce different intramuscular temperatures. suggested
that Because there are differences in thermal effects between ultrasound devices, our results
suggest that recently published parameters for ultrasound intensity and duration parameters
will not produce equally therapeutic effects for all ultrasound devices.

Tang JB. (2005) -Clinical outcomes associated with flexor tendon repair. suggested that
advances in the outcomes with excellent or good functional return in more than three fourths
of primary tendon repairs following a variety of postoperative passive/active mobilization
treatments.

PeterLorenz H, Michael T. Longaker (2006) -Wound healing: Repair, biology and wound and
scar treatment. suggested that a transition from healing scarlessly to healing with scar
formation characterizes skin repair in rat and sheep foetuses. New knowledge of the
regulatory processes occurring in the foetal wound at the initial stages of scar formation may
provide insights into the early mechanisms of scar formation
Maiti SK, Kumar N, Singh GR, Hoque M, Singh R. (2006) -Ultrasound therapy in tendinous
injury healing in goats. suggested that when the superficial digital flexor tendon was sutured
with catgut using two horizontal mattress sutures. No ultrasound therapy was used in the
animals of group I (control). Ultrasound therapy was given to the animals of group II
(treated) starting from the third day post-operatively at 0.5 W/cm2 for 10 min daily for 10
days. A cortical screw was used for immobilization of the tibio-tarsal joint which was
removed 4 weeks after tenorrhaphy. Post-operatively, healing of the Achilles tendon was
monitored using clinical observations, ultrasonography, gross and histo-morphological
observations at various intervals up to 120 days in both groups

Ng GY, Fung DT. (2007) -The effect of Ultrasound intensity on the ultra-structural
morphology of tendon repair. suggested that the mean collagen fibril size of all treatment
groups was higher than the control (p < 0.05). There was no significant difference in the
collagen fibril size among the treatment groups. These findings suggest that therapeutic
ultrasound can enhance the maturation of collagen fibrils of repairing tendons, and this was
not dependent on the intensity of ultrasound applied.

Khanna A, Friel M, Gougoulias N, Longo UG, Maffulli N. (2009) -Prevention of adhesions

in surgery of the flexor tendons of the hand: What is the evidence? Suggested that despite
advances in knowledge and refinements of technique, the management of flexor tendon
injuries within the digital sheath continues to present a formidable challenge. This in turn has
led to a massive expansion in search of modified surgical therapies and various adjuvant
therapies, which could prevent adhesion formation without compromising digital function.

Ahmed M. Zarraa, et al (2018) -Early Intervention of Ultrasound and Active Mobilization

Post-Surgical Repair of Hand Flexor Tendon Laceration suggested that The use of Ultrasound
(US) in tendon healing may be accompanied by increases in the tendon initial tensile
strength, increased motion, improved collagen alignment, and reduction in inflammatory
infiltrate and scar tissue in tendons
.

CHAPTER 3
 MATERIALS AND METHODOLOGY

Source of Data Collection: Data will be collected from patients with flexor tendon injury
who are referred to the Physiotherapy OPD of College of Physiotherapy, CMC&H, Ludhiana,
referred from the Department of Plastic Surgery, after taking informed consent.
Aim To study the Effect of ultrasonic therapy in patients of early phase rehabilitation post
flexor tendon repair surgery.

Objectives: For the patients sustaining such injuries that fall under the inclusion criteria of
the research, we propose to use the ultrasound therapy within the safety standards and assess
the effect it has on the healing process compared to a group which is not given the ultrasound
therapy but the rest of the rehabilitation protocol is kept the same for both the groups.

Null hypothesis: there will be a significant change in the muscle power and rom of the
patients of experimental group.

Alternate hypothesis: The comparison of rom and muscle power in both groups will not be
significant.

Research design: Prospective Study.

Research setting: College of Physiotherapy, Christian Medical College, Ludhiana

Target population: Patients with flexor tendon injuries of the hand post surgical repair.

Sampling technique: Simple random sampling technique

Sample size: 50

Randomization: The randomization will be done by using lottery method divided into two
groups: Control group (n=25); assessment will be done without intervention and
experimental groups (n=25)

Research variables:

Independent variable: Ultrasonic Therapy

Dependent variable: Tendon healing

 Inclusion criteria:
1. Flexor tendon injury
2. Age 18-60 years
3. Mode of injury-mechanical, traumatic, glass cut;
4. Injury in any zone of the hand
5. 3 weeks post-op
Exclusion criteria:
1. More than 3 weeks post-op without PT
2. Degloving injury
3. Burns
4. Tendon injuries with tendon loss
5. Crush injury
6. Age less than 18 years or more than 60 years
7. Injury associated with or extending to extensor tendons

Procedure:
Sample of 50 will be selected by simple random sampling technique after meeting preset
inclusion and exclusion criteria. Before selecting the sample all the participants will be
assessed for extent and mode of injury. The subjects will be randomly divided into
experiment and control group. This is an experimental study done over a period of six
months, involving a total of patients with flexor tendon injuries of the hand. Permission to
conduct the study was obtained from the institutional ethics committee. Patients were
explained about the procedure and written consents were obtained for the same. After
randomization, we administered ultrasonic therapy with the parameters adjusted to- a pulse
ratio of 1:4, frequency of 1Mhz and intensity of 0.7wt/cm2 for a treatment period of 5 mins
per session [1] for a total of 25 patients using combo rehab ultrasound machine.

Standard protocol used:

 Electrical stimulation of the FDP/FDS muscle
 Infrared irradiation for 10 mins
 Joint mobilization
 Hand gripping exercises
CHAPTER 4
 ANALYSIS AND RESULT
A comparison was made between the means of final and initial values of ROM and MMT
scores of the patients of Group A(experimental group) and Group B(control group) using
unpaired T-Test and Chi square test respectively.

The results were analysed using Ms. Excel.

Unpaired t test results
P value and statistical significance:
The two-tailed P value equals 0.0082
By conventional criteria, this difference is considered to be very statistically significant.

Confidence interval:
The mean of Group One minus Group Two equals 6.60
95% confidence interval of this difference: From 1.79 to 11.41

Intermediate values used in calculations:

t = 2.7564
df = 48
standard error of difference = 2.394

Group Group One Group Two

Mean 22.40 15.80

SD 10.22 6.24

SEM 2.04 1.25

N 25 25
 Mean ROM Group1 & Group2
25

20

15

10

0
1 2

The bar graph plotted between the means of the change in range of motion
post intervention of the subjects in Group A versus Group B. The difference
in the height of the bars depicts that the patients of one group showed
significantly better results in terms of range of motion post intervention.

Chi-Square Test Results:

The chi-square statistic is 5.515.
The p-value is .238413.
The result is not significant at p < .05.
RESULTS
Group 1 Group2 Row Total
1 6 6 12
1+ 6 7 13
2- 10 4 14
2 1 5 6
2+ 2 3 5
 Group 1 MMT
SCORE(%)

1
8% 1+
4% 24% 2-
2
2+

40%
24%

The pie chart depicts the percentage of subjects falling into the categories according to the
grading of their muscle power post intervention.

Group 2MMT SCORE(%)

12% 1
24% 1+
2-
20% 2
2+

16% 28%

The pie chart depicts the percentage of subjects falling into the categories according to the
grading of their muscle power post intervention.

DISCUSSION
The therapeutic effects of ultrasound are many folds. Various studies have proved that
ultrasound enhances healing.[7] administration of ultrasound resulted in increased range of
movement, advancement of scar maturation and reduction of the amount of inflammatory
infiltrate. There was no adverse effect on tensile strength and that early administration
was more beneficial than late. low intensities may enhance the healing process of the
surgically repaired tendons. Its effects on decreasing peritendinous adhesions ,[6] and
enhancement of collagen fibrils maturation independent of the intensity applied [15] can
explain the improved results obtained in this study.
The factors that determine the ultrasound energy delivered at the tissue level are the
frequency, the pulse ratio, the intensity of the ultrasound and the duration of therapy. The
parameters used in the study have been mentioned in the Materials and Methodology.
The ROM and MMT score of Group A and Group B were recorded before the
intervention and compared to the ROM and MMT score post intervention and a
comparison was made between the mean of the observation in the final recordings of both
the groups using unpaired t-test and chi square test. The data and comparison have been
represented in the forms of bar graphs and pie charts and analysed using Ms. Excel
software.
After comparing both the readings, it was seen that the experimental group vs control
group difference in the mean of final ROM values was highly significant. This implies
that the group which was administered with the ultrasonic therapy in adjunct with the
conventional therapy showed significantly better results in terms of increase in the joint
range of motion.
However, a significant relation could not be established between the MMT score of both
the groups. This is can be said that the administration of ultrasonic therapy can not be
significantly linked to the improvement of muscle power.

CONCLUSION

After flexor tendon repair, pulsed ultrasound therapy during the early rehabilitation phase
is safe and effective. The results are comparable to conventional protocols.
Pulsed ultrasound therapy in the early phase of tendon healing is safe. Our study shows,
starting ultrasound therapy with 1-MHz frequency on the seventh post-operative day with
intensity of 0.7 w/cm2 give high percentage of excellent-good results with no ruptures and
PIP joint flexion contractures.

REFERENCES
1. Early ultrasound therapy for rehabilitation after zone II flexor tendon repair-DOI:
10.4103/0970-0358.129629 [Pubmed]
2. Treatment time of ultrasound therapy interferes with the organization of collagen
fibers in rat tendons [scielo.br]
3. Lundeberg T, Abrahamsson P, Haker E.- A comparative study of continuous
ultrasound, placebo ultrasound and rest in epicondylalgia. [Pubmed]
4. http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1934478
5. Anesthesiology 11 2011, Vol.115, 1109-1124. doi:10.1097/ALN.0b013e31822fd1f1
6. https://doi.org/10.1016/S0266-7681(95)80054-9
7. Rheumatology, Volume 40, Issue 12, 1 December 2001, Pages 1331–1336
8. https://doi.org/10.1053/apmr.2002.26254
9. J Vet Med A Physiol Pathol Clin Med. 2002;49:321–8.
10. J Orthop Sports Phys Ther. 2003;33:379–85
11. Mathes SJ, editor. Plastic surgery. 2nd ed. Vol. 1. Philadelphia, Saunders: Elsevier; 2006. p.
215.
12. J Vet Med A Physiol Pathol Clin Med. 2006;53:249–58.
13. Ultrasound Med Biol. 2007;33:1750–4.
14. Br Med Bull. 2009;90:85–109.
15. Med. J. Cairo Univ., Vol. 86, No. 3, June: 1119-1128, 2018
 APPENDIX 1

CASE REPORT FORM

Name:

Age:

Gender:

Address:

Contact number:

Occupation:

Site of injury:

Date of injury:

Mode of injury:

Date of surgery:

Goniometry Score:

 Initial score

 Final score

MMT Score:

 Initial score

 Final score
 APPENDIX 2
CONSENT FORM
TITLE OF THE STUDY: ‘The effect of ultrasound in early rehabilitation
phase post flexor tendon repair surgeries’. I have been informed by
___________ about the study being conducted at College of Physiotherapy,
CMC&H Ludhiana, which involves the comparison of ROM and Muscle power
before and after the physiotherapeutic intervention. I understand that I will be
one of the subjects in the study. I have no objection and will be a part of the
study. I also understand that the study does not contain any object/intervention
that has negative implications on my health.
I understand that the medical information obtained through this study shall be
used for institutional records and will be treated confidentially according to the
regulations of the institution. I have been informed that if the data is used for
medical literature or teaching purposes, personal identifiers shall not be
disclosed at any cost.
I understand that I may ask any number of questions that I may have regarding
the procedure of intervention or relating to it from ______________. I
understand that my asset to this study is voluntary and I reserve the right to
withdraw from the study and discontinue my participation from the study at any
point of time during the study, if need be.

Signed:
 APPENDIX 4
MRC SCALE FOR MUSCLE POWER GRADING