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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 23  |  Issue : 2  |  Page : 53-59

Effect of pulsed ultrasound versus low level laser therapy on Swelling of Knee Hemoarthrosis in Hemophilic children


Department of Physical Therapy for Disturbance of Growth and Development in Pediatrics and its Surgeries, Faculty of Physical Therapy, Cairo University, Cairo, Egypt

Date of Submission30-Jul-2017
Date of Acceptance15-Jan-2018
Date of Web Publication27-Dec-2018

Correspondence Address:
Alaa R Morgan
Department of Physical Therapy for Disturbance of Growth and Development in Pediatrics and its Surgeries, Faculty of Physical Therapy, Cairo University, Cairo, 11731
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bfpt.bfpt_10_17

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  Abstract 

Background Pulsed ultrasound (PUS) and low-level laser therapy (LLT) have effects in treating swelling in knee hemarthrosis of hemophilic children as they play an important role in decreasing swelling and improving muscle function.
Aim The aim was to compare the effect of PUS versus low-level laser in the modulation of swelling and range of motion in patients with knee hemarthrosis in hemophilic children (after 3 successive months of treatment).
Settings and design A total of 40 hemophilic patients with knee hemarthrosis from both sexes were selected from the outpatient clinic of the Faculty of Physical Therapy, Cairo University and ElBhose Center, with age ranging from 9 to 14 years. They were divided randomly into two groups (group A and group B).
Patients and methods Both groups received selected physical therapy program (stretching and strengthening exercises) three times per week for 3 months. Group A received PUS whereas group B received LLT in addition to the same program given to both groups.
Results Results have shown that there was a significant reduction of swelling and significant improvement in most of the measured variables of the two groups (P<0.005), with significant improvement in favor of group A.
Conclusion It may be concluded that PUS is more effective than LLT in reducing joint swelling and increasing the range of motion in knee hemarthrosis of hemophilic children.

Keywords: hemophilia, knee hemarthrosis, low-level laser therapy, pulsed ultrasound


How to cite this article:
Morgan AR. Effect of pulsed ultrasound versus low level laser therapy on Swelling of Knee Hemoarthrosis in Hemophilic children. Bull Fac Phys Ther 2018;23:53-9

How to cite this URL:
Morgan AR. Effect of pulsed ultrasound versus low level laser therapy on Swelling of Knee Hemoarthrosis in Hemophilic children. Bull Fac Phys Ther [serial online] 2018 [cited 2019 Jul 21];23:53-9. Available from: http://www.bfpt.eg.net/text.asp?2018/23/2/53/248784


  Introduction Top


Hemophilia is an extreme bleeding ailment resulting from shortage of the critical clotting aspect that has historically precipitated profound morbidity and mortality. Hemophilia is an x-connected heritable coagulopathy with a normal prevalence of ∼1 in 10,000 people. The two maximum commonplace forms are component VIII deficiency or hemophilia a, which contains ∼80% of instances and issue IX deficiency or hemophilia b, which contains ∼20% of instances [1].

The most common manifestation of hemophilia is hemarthrosis or joint bleeding. The ankles, knees, and elbows are most commonly involved, although the other joints (shoulders, wrists, and hips) may also be affected [2],[3]. The affected joints are usually warm, tender, and swollen, with limited range of motion. Bleeding occurs in patients with hemophilia mainly in the musculoskeletal system [4].

Joints hemarthrosis occurs secondary to the recurrent bleeding in joint area. Hemarthrosis continues to be one of the most disabling and highly priced headaches of hemophilia. The kids with excessive hemophilia in the USA and different industrialized nations experienced an average of 30-35% hemarthroses per year [5]. Repetitive hemarthrosis increases synovial proliferation and hypertrophy with release of hydrolytic enzymes. Those enzymes in conjunction with multiplied tiers of prostaglandins assist to preserve the inflammatory reaction within the synovium [5],[6].

Joint bleeding (hemarthrosis) has been found to be the most common (82–100%) presenting feature followed by skin bleeds (77–90%). Patients with mild and moderate disease generally bleed after significant trauma or major surgery; those with the severe form may bleed spontaneously or after minor trauma [7].

The most common manifestation of hemophilia is articular bleeding (hemarthrosis). When hemarthrosis end up common and extreme, the synovium would not be capable of reabsorbing the blood. To make amends for such reabsorptive deficiency, there will be synovial hypertrophy, ensuing in continual hemophilic synovitis [8].

Persistent irritation causes joint shape and characteristic abnormalities. Extended production of the synovial fluid stretches and weakens the joint pill and adjacent systems. Erosions in the articular cartilage and subchondral bone cause irregularities in the joint surface that can bring about problems in a variety of movement [9]. Physiotherapy and rehabilitation therapy can help restore or preserve variety of movement, mobility, and characteristics. Mild joint mobilization and correction of imbalances between muscle companies assist to reap these desires [3].

Low-intensity pulsed ultrasound (PUS) may be used to stimulate cartilage restoration with the aid of stimulating cartilage anabolism by enhancing the manufacturing of matrix molecules which includes proteoglycan and collagen [10],[11],[12]. The application of US to surgically-induced full-thickness osteochondral lesions in the rabbit knee ended in a statistically good improvement in joint pathology and inside the histology of restore cartilage [13].

PUS had the unique ability of reducing joint friction below normal values. However, it was not successful in returning the articular cartilage force and stiffness to normal state [14]. Within a longitudinal wave pathway, like US, there are regions of compression and rarefactions. Thus, the nature of the ultrasound (US) wave is more compatible with initial lymphatic structure and function to help reduce swelling. The synovial cells in a cleaner environment could perform their function better and hence the synovial fluid secreted has improved lubricating properties after PUS insonation [15]. Low-level laser therapy (LLT) was more effective in increasing the equilibrium force of the articular cartilage than PUS; however, neither therapy normalized this parameter. From these data, we conclude that the PUS is more effective than LLT in reducing joint swelling and articular joint friction after experimental hemarthosis [14].

Results have been concluded that LLT gives significant effect on cell functions including repair processes and neurotransmitter release. Clinically, this may be expressed as an enhancement of wound healing, possessing anti-inflammatory and analgesic properties [16]. LLT is a safe, noninvasive, efficient, and efficacious means to reduce pain and swelling and to increase joint mobility in patients suffering from Heberden’s and Bouchard’s osteoarthritis [16].

Thus, this study was conducted to investigate the effect of PUS versus low-level laser in modulation of swelling in patients with knee hemarthrosis in hemophilic children (after successive 3 months of treatment).


  Patients and methods Top


Patients

The study involved 40 hemophilic children with knee hemarthrosis; their age ranged from 9 to 14 years. This study was approved by the Ethical Scientific Committee in the Faculty of Physical Therapy, Cairo University, Egypt and was conducted in accordance with the university bylaws for human research. The patients were selected according to the following criteria: all of the patients have a history of knee joint affection such as bleeding and swelling; patients are able to walk with variable degrees of limitation; they have no impairment of sensation or other neurological or psychological problems. They are clinically and medically stable and they are able to understand the requirements of the study. Patients were excluded if they had advanced radiographic changes (bone destruction, bony ankylosis, and knee joint subluxation), had congenital or acquired skeletal deformities or patients with any cardiopulmonary dysfunctions and neurological deficits such as convulsions, involuntary movements, or receiving muscle relaxants.

Design

This study is a randomized controlled trial (parallel controlled study), pretest and post-test design study. All patients were selected from the outpatient clinic of Faculty of Physical Therapy, Cairo University and ElBhose Center. The parents of patients signed informed consent forms giving agreement for participation and publications of the study results. The patients were randomly divided into two groups. Group A included 20 children, who received PUS and traditional treatment program for hemophilia (stretching, and strengthening exercises) and group B included 20 children, who received low-level laser in addition to traditional treatment program for hemophilia.

Procedures

Each participant underwent the same evaluation, which was performed by the same therapist at the beginning and end of the treatment period (3 months). All participants were asked to maintain their activity levels during the period of the study. Evaluation procedures included the following.

For assessment:
  1. Tape measurement: tape measurement was used to measure the circumference of the knee in centimeters at two levels (mid patella and above it).
  2. A digital electrogoniometer ([Figure 1])
    Figure 1 Component of electrogoniometer. (a) Digital display; (b) volume potentiometer; (C and D) copper arms; (E) straps.

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The device consists of the following:
  1. Two copper arms, with a length of 25 cm and width of 5 cm placed parallel to the longitudinal axis of the body segment.
  2. A potentiometer placed between the two copper arms with one arm strapped to the proximal limb segment and the other strapped to the distal limb segment. The potentiometer, which is placed over the joint, provides a varying of electrical impulses, depending on the instantaneous angle between the two limb segments. This electrical impulse information is then interfaced to an analog-to-digital converter in a personal computer to plot joint angle information.
  3. A digital display is connected to the potentiometer through insulated electrical wires by sockets in the digital display unit and metal jacks at the end of the electrical wires. This display converts each 1° of angular displacement to one electrical volt.
  4. Four straps are used for fixation and stabilization of the instrument around the knee joint.
  5. The source of power supply was from direct current with two batteries each of 9 V.


Treatment procedures

Group A: the participants of group A received PUS. The options of the appliance were adjusted with a frequency of 1 MHz with pulsed mode (cycle of 1/3), and intensity of 1.5 W/cm, and traditional treatment program for hemophilia (stretching exercises for hip flexors, adductors, hamstrings, and cuff muscles in the lower limbs; strengthening exercises using bicycle ergometer training for 3 min as a warming up, then gradually increasing resistance for about 14 min, and end the treatment session with unloaded cycling for another 3 min as a cooling down; treadmill training, walk on the treadmill with a speed of 1.5 km/h; and 0° of inclination for 5 min as a warming up. Then, the speed was increased gradually to reach 3 km/h and 10° inclination for 15 min. And group B: participants of that group received low-level laser (HE–NE laser therapy unit). The options of the appliance were adjusted with frequency (700 Hz), and for 11 min in addition to the traditional treatment program for hemophilia. The child received the sessions in a frequency of three sessions per week.

Statistical analysis

Descriptive statistics (mean±SD) was used for all participants in the two groups to study all variables. Independent t-test was used to compare the pretreatment and post-treatment of swelling between the two groups of the study. Paired t-test was used to compare the before and after treatment results in the same group for the swelling variable. A P value of less than 0.05 was considered statistically significant.


  Results Top


None of the patients in either treatment groups dropped out throughout the study period. There was no significant difference (P>0.05) between both groups. The study was carried out on two groups of equal number: group A and group B, 20 patients each. The mean ages of group A and group B were 11.0±2.616 and 10.0±2.368, respectively.

Knee swelling for both groups pretreatment and post-treatment

Statistical analyses for both groups were studied before and after treatment. The results showed significant differences in post-treatment results of swelling of the knee joint when compared with the pretreatment results as shown in [Table 1] and [Table 2], and [Figure 2] and [Figure 3].
Table 1 Influence of pulsed ultrasound on knee swelling at different levels and pretreatment and post-treatment results of swelling of knee joints in group A

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Table 2 Influence of low-level laser on knee swelling at different levels pretreatment and post-treatment results of swelling of knee joints in group B

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Figure 2 The mean values of pretreatment and post-treatment of swelling of knee joints using pulsed ultrasonic in group A.

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Figure 3 The mean value of pretreatment and post-treatment of swelling of knee joints using low-level laser in group B.

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Range of motion of the knee joint for both groups pretreatment and post-treatment

[Table 3] and [Table 4], and [Figure 4],[Figure 5],[Figure 6],[Figure 7] identify that the differences between both groups in their pretreatment and post-treatment values of knees range of motion assessment were statistically significant.
Table 3 Influence of pulsed ultrasound on knee range of motion pretreatment and post-treatment results of knee joints in group A

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Table 4 Influence of low-level laser on knee range of motion and pretreatment and post-treatment results of knee joints in group B

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Figure 4 The mean value of pretreatment and post-treatment of range of motion of knee joints flexion using pulsed ultrasonic in group A.

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Figure 5 The mean value of pretreatment and post-treatment of range of motion of knee joints extension using pulsed ultrasonic in group A.

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Figure 6 The mean value of pretreatment and post-treatment of range of motion of knee joints flexion using low-level laser in group B.

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Figure 7 The mean value of pretreatment and post-treatment of range of motion of knee joints extension using low-level laser in group B.

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Knee swelling for both groups post-treatment

[Table 5] and [Figure 8] identify significant improvements in group A more than in group B in their post-treatment values of knee swelling assessment.
Table 5 Comparison between pulsed ultrasound versus low-level laser on knee swelling at different levels and post-treatment results of knee joints in both groups

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Figure 8 The mean value of post-treatment of swelling of knee joints in both groups.

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Range of motion of the knee joint for both groups post-treatment

Statistical analyses for both groups were studied after treatment. The post-treatment results showed significant improvement in the range of motion of the knee joint in group A more than in group B, as shown in [Table 6], and [Figure 9] and [Figure 10].
Table 6 Comparison between pulsed ultrasound versus low-level laser on knee range of motion post-treatment results of knee joints in both groups

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Figure 9 The mean value of post-treatment of range of motion of knee joints flexion in both groups.

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Figure 10 The mean value of post-treatment of range of motion of knee joints extension in both groups.

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  Discussion Top


Hemophilia is an inherited bleeding disorder caused by a deficiency in one of the blood coagulation factors. For people affected by severe hemophilia, the deficiency can cause spontaneous internal bleeding [17].

The significant improvement in decreasing swelling at the end of the treatment program for hemophilic children in group A may be due to the effect of using US which has an effect on the inflammatory process. This may be caused by an ultrasonically induced increase in the release of platelets and macrophages. It also can reduce pain and encourages the reabsorption of hemarthrosis [18].

This observation comes in agreement with Watson who reported that US as an optimizer in the repair process of inflammation. For tissues in an inflammatory phase, the benefit of US is to promote resolution of the inflammation [19]. David et al. [21] reported that US help to soften and breakdown the hematoma. He used a therapeutic dose of 1.5 W/cm2 for 10 min through a coupling agent or under water [20].

There is significant improvement in the range of motion at the end of the treatment program for hemophilic children in group B. This may be attributed to the effect of low-level laser on inhibition of the formation of edema and inflammatory cells migration into muscles tissue and adjacent conjunctive tissue [21].

This also may be explained by Conlan who reported that low-level laser was effective in reducing edema formation. The total number of leukocytes and polymorphonuclear cells is significantly reduced by using low-level laser [22]. LLT can modulate immune response, and to accelerate the regeneration of damaged tissue [23].

Laser irradiation may have a beneficial effect on wound healing of the bone through acceleration of bone regeneration stimulating the formation of the trabecular osteoid tissue increasing vascularization and promoting faster metabolism [6].

Comparison between the improvement in swelling and range of motion at the end of treatment program for hemophilic children in both groups show that there is significant improvement in group A more than in group B; this may be attributed to the strong anti-inflammatory effect of the US.

This observation comes in agreement with Lederman and Knight, who reported that fluid that is drained from the interstitial space through the microlymphatics consists of two segments including initial and collecting lymphatics. The initial lymphatics are sac-like structures lined by the endothelium with incomplete attachment between the neighboring cells forming a specialized valve mechanism that allows the endothelial cells to swing with alternate opening and closing of the gap between the cells. The compression closes the gap between the endothelial cells and propels fluid into microlymphatic vessels and expansion makes the endothelial cells swing to open the gap, allowing fluid flow into the lumen. Within a longitudinal wave pathway, like US, there are regions of compression and rarefactions. Thus, the nature of the US wave is more compatible with initial lymphatic structure and function to help reduce swelling. The synovial cells in a cleaner environment could better perform their function better and hence the synovial fluid secreted has improved lubricating properties after PUS insonation [24],[25].

PUS and low-level laser intervention has been recommended for the treatment of knee hemarthrosis in hemophilic children. Early intervention should attempt to increase physical activity. The emphasis should be laid on to decrease pain and increase the range of motion. It is very encouraging that PUS is more effective than low-level laser in reducing swelling and improving inflammation with the traditional treatment program for hemophilia [26],[27].


  Conclusion Top


In summary, our results suggest that PUS and low-level laser intervention in children with knee hemarthrosis can lead to a significant improvement of swelling and range of motion, but pulsed ultrasonic has significant improvement of swelling and range of motion more than low-level laser.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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