Ultrasound Plus Manual Therapy Helps in Healing Digital Ulcers

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by Steve Bryson, PhD |

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A combination of ultrasound and therapy that includes joint manipulation and massage improved hand function and ulcer wound healing in a small group of systemic sclerosis (SSc) patients with skin involvement, a study reported.

“Therapeutic [ultrasound ] combined with manual therapy should be used as additional intervention to manage [digital ulcers] in SSc patients,” the researchers wrote.

The study, “Rehabilitative interventions for ischaemic digital ulcers, pain, and hand functioning in systemic sclerosis: a prospective before-after study,” was published in the journal BMC Musculoskeletal Disorders.

Thick and hardened skin caused by excessive collagen production, the main protein component of scar tissue, is the hallmark of systemic sclerosis (SSc), also known as scleroderma. Scar tissue can also accumulate in organs, including the heart, blood vessels, kidneys, and lungs, and cause damage.

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Excessive scar tissue is known to narrow blood vessels and restrict blood flow, resulting in ischaemic digital ulcers (IDUs). These chronic and painful lesions are found equally on patients’ hands and feet, and can lead to tissue death and bone degeneration.

Although several medicinal treatments for IDUs have been investigated, few studies focus on rehabilitation approaches such as exercise, manual therapy, and other physical applications.

This study, conducted by scientists in Italy, aimed to evaluate the effectiveness of a standardized rehabilitation regimen using a combination of ultrasound and exercise therapy for ulcers, pain, and hand function in people with IDUs associated with SSc.

“Although few studies support rehabilitative interventions for patients with SSc, these approaches are widely used in clinical practice,” the researchers noted.

It enrolled 20 SSc patients (14 women and six men), with a mean age of 61 and a mean of two digital ulcers. Four have taken immunosuppressants or immunomodulators due to disease-related lung complications. The others had no SSc manifestations except for skin involvement.

Patients were treated with ultrasound using an I-Tech medical device that involved immersing their hands in a container of body-temperature water for 15 minutes.

Manual therapy included 40 minutes of McMennel joint manipulation, a stretching technique used to ease joint stiffness, 15 minutes of pompage — applying rhythmic and regular movements involving traction and release to the fascia, or fibrous bands, of the hands — and 30 minutes of connective tissue massage, which aimed to preserve the smoothness of skin by promoting blood circulation.

This 100-minute rehabilitation regimen consisted of 10 daily weekday sessions for two consecutive weeks.

After those weeks, patients reported a significant reduction in pain, as assessed by a numerical rating scale (NRS) ranking pain from 0 (no pain) to 10 (extreme pain). Before treatment, half of these people reported an NRS value between 5.5 and 7 (median of 5.5, indicative of moderate pain), while after treatment, half reported an NRS of between 3 and 5 (median of 3, indicating mild pain).

Better NRS scores were reported by all but two people, with most patients reporting a two-point decrease and three a five-point drop. All but one had better hand function.

Scores on the Duruoz Hand Index (DHI), a self-reported questionnaire of hand impairment, and the Pressure Sore Status Tool (PSST) scores, a wound assessment, also significantly declined after treatment, indicating clinical improvements. The median DHI score dropped from 25 to 19, while the median PSST score fell from 23 to 16.

Each of five PSST items — wound depth, size, edges, wound repair, and skin color — showed significant benefits in some participants.

Wound size either reduced or was maintained in all patients, while a lessening in wound depth was evident for 11 patients. Further improvements were seen in wound edges, with better measures of wound healing found in nine people. Skin color surrounding wounds also improved after treatment for 15 patients.

“The strength of the study is the originality of the proposed treatment, as the combination of therapeutic US [ultrasound] and of manual therapy has never been studied in patients with SSc-related IDUs [ischaemic digital ulcers],” the researchers wrote.

“Based on our data, we demonstrated the effectiveness of therapeutic [ultrasound] combined with manual therapy in reducing ulcer depth and margins, improving perilesional skin colour and fullness, and in improving hand function in SSc patients with IDUs,” they concluded.

“In the future, we would improve the study design to carry out a more reliable investigation including the comparison of treatment effects with a control group.”