Effect of pulsed ultrasound versus low level laser therapy

Original article 53

Effect of pulsed ultrasound versus low level laser therapy onSwelling of Knee Hemoarthrosis in Hemophilic childrenAlaa R. Morgan

Department of Physical Therapy for

Disturbance of Growth and Development in

Pediatrics and its Surgeries, Faculty of Physical

Therapy, Cairo University, Cairo, Egypt

Correspondence to Alaa R. Morgan, PhD,

Department of Physical Therapy for

Disturbance of Growth and Development in

Pediatrics and its Surgeries, Faculty of Physical

Therapy, Cairo University, Cairo, 11731, Egypt.

e-mail: [email protected]

Received 30 July 2017

Accepted 15 January 2018

Bulletin of Faculty of Physical Therapy2018, 23:53–59

© 2018 Bulletin of Faculty of Physical Therapy | Publishe

BackgroundPulsed ultrasound (PUS) and low-level laser therapy (LLT) have effects in treatingswelling in knee hemarthrosis of hemophilic children as they play an important rolein decreasing swelling and improving muscle function.AimThe aim was to compare the effect of PUS versus low-level laser in the modulationof swelling and range of motion in patients with knee hemarthrosis in hemophilicchildren (after 3 successive months of treatment).Settings and designA total of 40 hemophilic patients with knee hemarthrosis from both sexes wereselected from the outpatient clinic of the Faculty of Physical Therapy, CairoUniversity and ElBhose Center, with age ranging from 9 to 14 years. They weredivided randomly into two groups (group A and group B).Patients and methodsBoth groups received selected physical therapy program (stretching andstrengthening exercises) three times per week for 3 months. Group A receivedPUS whereas group B received LLT in addition to the same program given to bothgroups.ResultsResults have shown that there was a significant reduction of swelling and significantimprovement in most of the measured variables of the two groups (P<0.005), withsignificant improvement in favor of group A.ConclusionIt may be concluded that PUS is more effective than LLT in reducing joint swellingand increasing the range of motion in knee hemarthrosis of hemophilic children.

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

Bulletin of Faculty of Physical Therapy 23:53–59

© 2018 Bulletin of Faculty of Physical Therapy

1110-6611

This is an open access journal, and articles are distributed under the terms

of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0

License, which allows others to remix, tweak, and build upon the work

non-commercially, as long as appropriate credit is given and the new

creations are licensed under the identical terms.

IntroductionHemophilia is an extreme bleeding ailment resultingfrom shortage of the critical clotting aspect that hashistorically precipitated profound morbidity andmortality. Hemophilia is an x-connected heritablecoagulopathy with a normal prevalence of ∼1 in10,000 people. The two maximum commonplaceforms are component VIII deficiency or hemophiliaa, which contains ∼80% of instances and issue IXdeficiency or hemophilia b, which contains ∼20% ofinstances [1].

The most common manifestation of hemophilia ishemarthrosis or joint bleeding. The ankles, knees,and elbows are most commonly involved, althoughthe other joints (shoulders, wrists, and hips) mayalso be affected [2,3]. The affected joints are usuallywarm, tender, and swollen, with limited range ofmotion. Bleeding occurs in patients with hemophiliamainly in the musculoskeletal system [4].

Joints hemarthrosis occurs secondary to the recurrentbleeding in joint area. Hemarthrosis continues to be

d by Wolters Kluwer - Medk

one of the most disabling and highly priced headachesof hemophilia. The kids with excessive hemophilia inthe USA and different industrialized nationsexperienced an average of 30-35% hemarthroses peryear [5]. Repetitive hemarthrosis increases synovialproliferation and hypertrophy with release ofhydrolytic enzymes. Those enzymes in conjunctionwith multiplied tiers of prostaglandins assist topreserve the inflammatory reaction within thesynovium [5,6].

Joint bleeding (hemarthrosis) has been found to be themost common (82–100%) presenting feature followedby skin bleeds (77–90%). Patients with mild andmoderate disease generally bleed after significanttrauma or major surgery; those with the severe formmay bleed spontaneously or after minor trauma [7].

now DOI: 10.4103/bfpt.bfpt_10_17

mailto:[email protected]

54 Bulletin of Faculty of Physical Therapy, Vol. 23 No. 2, July-December 2018

The most common manifestation of hemophilia isarticular bleeding (hemarthrosis). Whenhemarthrosis end up common and extreme, thesynovium would not be capable of reabsorbing theblood. To make amends for such reabsorptivedeficiency, there will be synovial hypertrophy,ensuing in continual hemophilic synovitis [8].

Persistent irritation causes joint shape andcharacteristic abnormalities. Extended production ofthe synovial fluid stretches and weakens the joint pilland adjacent systems. Erosions in the articular cartilageand subchondral bone cause irregularities in the jointsurface that can bring about problems in a variety ofmovement [9]. Physiotherapy and rehabilitationtherapy can help restore or preserve variety ofmovement, mobility, and characteristics. Mild jointmobilization and correction of imbalances betweenmuscle companies assist to reap these desires [3].

Low-intensity pulsed ultrasound (PUS) may be used tostimulate cartilage restoration with the aid ofstimulating cartilage anabolism by enhancing themanufacturing of matrix molecules which includesproteoglycan and collagen [10–12]. The applicationof US to surgically-induced full-thicknessosteochondral lesions in the rabbit knee ended in astatistically good improvement in joint pathology andinside the histology of restore cartilage [13].

PUS had the unique ability of reducing joint frictionbelow normal values. However, it was not successful inreturning the articular cartilage force and stiffness tonormal state [14].Within a longitudinal wave pathway,like US, there are regions of compression andrarefactions. Thus, the nature of the ultrasound (US)wave is more compatible with initial lymphaticstructure and function to help reduce swelling. Thesynovial cells in a cleaner environment could performtheir function better and hence the synovial fluidsecreted has improved lubricating properties afterPUS insonation [15]. Low-level laser therapy (LLT)was more effective in increasing the equilibrium forceof the articular cartilage than PUS; however, neithertherapy normalized this parameter. From these data,we conclude that the PUS is more effective than LLTin reducing joint swelling and articular joint frictionafter experimental hemarthosis [14].

Results have been concluded that LLT gives significanteffect on cell functions including repair processes andneurotransmitter release. Clinically, this may beexpressed 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 andto increase joint mobility in patients suffering fromHeberden’s and Bouchard’s osteoarthritis [16].

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

Patients and methodsPatientsThe study involved 40 hemophilic children with kneehemarthrosis; their age ranged from 9 to 14 years. Thisstudy was approved by the Ethical ScientificCommittee in the Faculty of Physical Therapy,Cairo University, Egypt and was conducted inaccordance with the university bylaws for humanresearch. The patients were selected according to thefollowing criteria: all of the patients have a history ofknee joint affection such as bleeding and swelling;patients are able to walk with variable degrees oflimitation; they have no impairment of sensation orother neurological or psychological problems. They areclinically and medically stable and they are able tounderstand the requirements of the study. Patientswere excluded if they had advanced radiographicchanges (bone destruction, bony ankylosis, and kneejoint subluxation), had congenital or acquired skeletaldeformities or patients with any cardiopulmonarydysfunctions and neurological deficits such asconvulsions, involuntary movements, or receivingmuscle relaxants.

DesignThis study is a randomized controlled trial (parallelcontrolled study), pretest and post-test design study.All patients were selected from the outpatient clinic ofFaculty of Physical Therapy, Cairo University andElBhose Center. The parents of patients signedinformed consent forms giving agreement forparticipation and publications of the study results.The patients were randomly divided into twogroups. Group A included 20 children, who receivedPUS and traditional treatment program for hemophilia(stretching, and strengthening exercises) and group Bincluded 20 children, who received low-level laser inaddition to traditional treatment program forhemophilia.

ProceduresEach participant underwent the same evaluation,which was performed by the same therapist at thebeginning and end of the treatment period (3

Pulsed ultrasound versus low-level laser therapy Morgan 55

months). All participants were asked to maintain theiractivity levels during the period of the study.Evaluation procedures included the following.

For assessment:

(1)

Figu

Compoten

Tape measurement: tape measurement was used tomeasure the circumference of the knee incentimeters at two levels (mid patella and above it).

(2)
A digital electrogoniometer (Fig. 1)
The device consists of the following:

(1)
Two copper arms, with a length of 25 cm andwidth of 5 cm placed parallel to the longitudinalaxis of the body segment.
(2)
A potentiometer placed between the two copperarms with one arm strapped to the proximal limbsegment and the other strapped to the distal limbsegment. The potentiometer, which is placed overthe joint, provides a varying of electrical impulses,depending on the instantaneous angle between thetwo limb segments. This electrical impulseinformation is then interfaced to an analog-to-digital converter in a personal computer to plotjoint angle information.
(3)
A digital display is connected to the potentiometerthrough insulated electrical wires by sockets in thedigital display unit andmetal jacks at the end of theelectrical wires. This display converts each 1° ofangular displacement to one electrical volt.
(4)
Four straps are used for fixation and stabilization ofthe instrument around the knee joint.
(5)
The source of power supply was from directcurrent with two batteries each of 9V.
re 1

ponent of electrogoniometer. (a) Digital display; (b) volumetiometer; (C and D) copper arms; (E) straps.

Treatment proceduresGroup A: the participants of group A received PUS.The options of the appliance were adjusted with afrequency of 1MHz with pulsed mode (cycle of 1/3),and intensity of 1.5W/cm, and traditional treatmentprogram for hemophilia (stretching exercises for hipflexors, adductors, hamstrings, and cuff muscles in thelower limbs; strengthening exercises using bicycleergometer training for 3min as a warming up, thengradually increasing resistance for about 14min, andend the treatment session with unloaded cycling foranother 3min as a cooling down; treadmill training,walk on the treadmill with a speed of 1.5 km/h; and 0°of inclination for 5min as a warming up. Then, thespeed was increased gradually to reach 3 km/h and 10°inclination for 15min. And group B: participants ofthat group received low-level laser (HE–NE lasertherapy unit). The options of the appliance wereadjusted with frequency (700Hz), and for 11min inaddition to the traditional treatment program forhemophilia. The child received the sessions in afrequency of three sessions per week.

Statistical analysisDescriptive statistics (mean±SD) was used for allparticipants in the two groups to study all variables.Independent t-test was used to compare thepretreatment and post-treatment of swelling betweenthe two groups of the study. Paired t-test was used tocompare the before and after treatment results in thesame group for the swelling variable. A P value of lessthan 0.05 was considered statistically significant.

ResultsNone of the patients in either treatment groupsdropped out throughout the study period. There wasno significant difference (P>0.05) between bothgroups. The study was carried out on two groups ofequal 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-treatmentStatistical analyses for both groups were studied beforeand after treatment. The results showed significantdifferences in post-treatment results of swelling ofthe knee joint when compared with the pretreatmentresults as shown in Tables 1 and 2, and Figs 2 and 3.

Range of motion of the knee joint for both groupspretreatment and post-treatmentTables 3 and 4, and Figs 4–7 identify that thedifferences between both groups in their

Table 1 Influence of pulsed ultrasound on knee swelling at different levels and pretreatment and post-treatment results ofswelling of knee joints in group A

Affected side Level of measurement Pretreatment (mean±SD) (cm) Post-treatment (mean±SD) (cm) t-Value P value Significance

Right knee Mid patella 29.18±4.57 22.43±4.76 1.14 0.001 S

Above patella 30.28±2.87 23.13±3.20 2.41 0.002 S

Left knee Mid patella 29.85±4.11 21.88±3.14 1.11 0.001 S

Above patella 32.71±2.3 24.22±2.80 1.28 0.002 S

S, significant.

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



Above patella 30.80±2.21 27.25±2.10 9.09 0.002 S


Above patella 32.30±1.9 27.94±1.46 9.97 0.001 S

S, significant.

Figure 2

048

121620242832

mid Rt patellaabove Rt patellamid Lt patellaabove Lt patella

Cir

cum

fere

nce

(cm

)

Group A

Group B

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

Figure 3

0102030405060708090

100110120

Flex.Rt.

KneeFlex.Lt.

knee

Ran

ge o

f m

otio

n (D

egre

e)

Group A

Group B

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

Table 3 Influence of pulsed ultrasound on knee range of motion pretreatment and post-treatment results of knee joints in groupA


Right knee Flexion 102.00±8.30 128.15±5.95 −14.64 0.001 S

Extension 16.40±5.69 6.85±2.60 7.61 0.001 S

Left knee Flexion 110.25±8.39 130.75±3.01 −11.84 0.002 S

Extension 14.25±4.96 5.85±2.54 9.81 0.002 S

S, significant.


pretreatment and post-treatment values of knees rangeof motion assessment were statistically significant.

Knee swelling for both groups post-treatmentTable 5 and Fig. 8 identify significant improvements ingroup A more than in group B in their post-treatmentvalues of knee swelling assessment.

Range of motion of the knee joint for both groupspost-treatmentStatistical analyses for both groups were studied aftertreatment. The post-treatment results showedsignificant improvement in the range of motion ofthe knee joint in group A more than in group B, asshown in Table 6, and Figs 9 and 10.

DiscussionHemophilia is an inherited bleeding disorder caused bya deficiency in one of the blood coagulation factors. Forpeople affected by severe hemophilia, the deficiencycan cause spontaneous internal bleeding [17].

The significant improvement in decreasing swelling atthe end of the treatment program for hemophilicchildren in group A may be due to the effect of usingUS which has an effect on the inflammatory process.Thismay be caused by an ultrasonically induced increasein the release of platelets and macrophages. It also can

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


Right knee Flexion 100.40±10.71 113.60±8.65 −9.10 0.003 S

Extension 15.00±5.42 10.10±3.97 10.08 0.003 S

Left knee Flexion 109.30±8.60 120.20±7.40 −9.89 0.002 S

Extension 15.00±5.75 9.95±3.47 8.60 0.002 S

S, significant.

Figure 4

02468

10121416

Ext. Rt.knee Ext. Lt.

knee

Ran

ge o

f m

otio

n (D

egre

e)

Group A

Group B

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

Figure 5

0

5

10

15

20

25

30

35


Cir

cum

fere

nce

(cm

)

Pre treatment

Post treatment

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

Table 5 Comparison between pulsed ultrasound versus low-level laser on knee swelling at different levels and post-treatmentresults of knee joints in both groups

Affected side Level of measurement Group A (mean±SD) (cm) Group B (mean±SD) (cm) t-Value P value Significance


Above patella 23.13±3.20 27.25±2.10 2.01 0.001 S


Above patella 24.22±2.80 27.94±1.46 3.17 0.003 S

S, significant.

Table 6 Comparison between pulsed ultrasound versus low-level laser on knee range of motion post-treatment results of kneejoints in both groups

Affected side Level of measurement Group A (mean±SD) (cm) Group B (mean±SD) (cm) t-Value P value Significance

Right knee Flexion 128.15±5.95 113.60±8.65 6.26 0.001 S

Extension 6.85±2.60 10.10±3.97 −3.47 0.003 S

Left knee Flexion 130.75±3.01 120.20±7.40 6.13 0.002 S

Extension 5.85±2.54 9.95±3.47 −5.60 0.002 S

S, significant.

Figure 6

0

5

10

15

20

25

30

35


Cir

cum

fere

nce

(cm

) Pre treatment

Post treatment

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


reduce pain and encourages the reabsorption ofhemarthrosis [18].

This observation comes in agreement with Watsonwho reported that US as an optimizer in the repairprocess of inflammation. For tissues in aninflammatory phase, the benefit of US is to promoteresolution of the inflammation [19]. David et al. [21]reported that US help to soften and breakdown thehematoma. He used a therapeutic dose of 1.5W/cm2

for 10min through a coupling agent or under water[20].

There is significant improvement in the range ofmotion at the end of the treatment program for

hemophilic children in group B. This may beattributed to the effect of low-level laser on

Figure 7

0

50

100

150

Rt.knee flexion Lt.knee flexionRan

ge o

f m

otio

n (D

egre

e)

Pre treatment

Post treatment

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

Figure 8

0

5

10

15

20

Rt.knee extension Lt.knee extension

Ran

ge o

f m

otio

n (D

egre

e)

Pre treatment

Post treatment

The mean value of post-treatment of swelling of knee joints in bothgroups.

Figure 10

0

2

4

6

8

10

12

14

16

Rt.knee extension Lt.knee extension

Ran

ge o

f m

otio

n (D

egre

e)

Pre treatment

Post treatment

The mean value of post-treatment of range of motion of knee jointsextension in both groups.

Figure 9

0102030405060708090

100110120130

Rt.kneeflexion

Lt.kneeflexion

Ran

ge o

f m

otio

n (D

egre

e)

Pre treatment

Post treatment

The mean value of post-treatment of range of motion of knee jointsflexion in both groups.


inhibition of the formation of edema and inflammatorycells migration into muscles tissue and adjacentconjunctive tissue [21].

This also may be explained by Conlan who reportedthat low-level laser was effective in reducing edemaformation. The total number of leukocytes andpolymorphonuclear cells is significantly reduced byusing low-level laser [22]. LLT can modulateimmune response, and to accelerate the regenerationof damaged tissue [23].

Laser irradiation may have a beneficial effect on woundhealing of the bone through acceleration of boneregeneration stimulating the formation of the

trabecular osteoid tissue increasing vascularizationand promoting faster metabolism [6].

Comparison between the improvement in swelling andrange of motion at the end of treatment program forhemophilic children in both groups show that there issignificant improvement in group A more than ingroup B; this may be attributed to the strong anti-inflammatory effect of the US.

This observation comes in agreement with LedermanandKnight, who reported that fluid that is drained fromthe interstitial space through the microlymphaticsconsists of two segments including initial andcollecting lymphatics. The initial lymphatics are sac-like structures lined by the endotheliumwith incompleteattachment between the neighboring cells forming aspecialized valve mechanism that allows theendothelial cells to swing with alternate opening andclosing of the gap between the cells. The compressioncloses the gap between the endothelial cells and propelsfluid into microlymphatic vessels and expansion makestheendothelial cells swing toopen thegap, allowing fluidflow into the lumen. Within a longitudinal wavepathway, like US, there are regions of compressionand rarefactions. Thus, the nature of the US wave ismore compatible with initial lymphatic structure andfunction to help reduce swelling. The synovial cells in acleaner environment could better perform their functionbetter andhence the synovial fluid secretedhas improvedlubricating properties after PUS insonation [24,25].

PUS and low-level laser intervention has beenrecommended for the treatment of knee hemarthrosisin hemophilic children. Early intervention shouldattempt to increase physical activity. The emphasisshould be laid on to decrease pain and increase therange of motion. It is very encouraging that PUS ismore effective than low-level laser in reducing swellingand improving inflammation with the traditionaltreatment program for hemophilia [26,27].


ConclusionIn summary, our results suggest that PUS and low-levellaser intervention in children with knee hemarthrosiscan lead to a significant improvement of swelling andrange of motion, but pulsed ultrasonic has significantimprovement of swelling and range of motion morethan low-level laser.

Financial support and sponsorshipNil.

Conflicts of interestThere are no conflicts of interest.

References1 Payal V, Sharma P, Goyal V, ora R, Parakh M, Payal D. Clinical profile of

hemophilia patients, 3rd ed. Asian J Transfus Sci; 2016. 323–335.

2 Nieuwenhuizen L, Schutqens RE, Van Asbeck BS, Wenting MJ, VanVeghel K, Roosendaal G, et al. Identification and expression of ironregulators in human synovium: evidence for upregulation in haemophilicarthropathy .compared to rheumatoid arthritis, osteoarthritis, and healthycontrols. Hemophilia 2013; 19:e218–e227.

3 Brown D. Congenital bleeding disorders. Curr Probl Pediatr Adolesc HealthCare 2005; 35:L38–L62.

4 Michel A, Adeline D. Rheumatogical management of patient withhemophilia. Part I: joint manifestation. Joint Bone Spine 2002; 69:992–999.

5 Heyworth BE, Sutyg EP, Figgie MP, Acharya SS, Sculco TP. Orthopedicmanagement of hemophilia. Am J Orthop 2005; 34:479–486.

6 Nuss R, Kilcoyne R, Geraghty S, Shroyer A, Rosky J, Mawhinney S, et al.MRI findings in hemophilic joints treated with radiotherapy withdevelopment of an MRI scale of joint damage. Hemophilia 2000;6:162–169.

7 Aljasser MI, Sladden C, Crawford RI, Au S. Bullous pemphigoid associatedwith acquired hemophilia a: a rare association of autoimmune disease. JCutan Med Surg 2014; 18:123–126. doi: 10.2310/7750.2013.13060.

8 Conlan MJ, Raplay JW, Cobb CM. Biostimulation of wound healing by low-energy laser irradiation. J Clin Periodontol 2007; 23:492–496.

9 Saito S, Shimizu N. Stimulatory effects of low power laser irradiation onbone regeneration in midpalatal suture during expansion in the rat. Am JOrthod Dentofacial Orthop 2008; 111:525–532.

10 Lai CH, Chen SC, Chiu LH, Yang CB, Tsai YH, Zuo CS, et al. Effects of low-intensity pulsed ultrasound, dexamethasone/TGF-beta1 and/or BMP-2 onthe transcriptional expression of genes in human mesenchymal stem cells:

chondrogenic vs. osteogenic differentiation. Ultrasound Med Biol 2010;36:1022–1033.

11 Korstjens CM, van der Rijt RH, Albers GH, Semeins CM, Klein-Nulend J.Low-intensity pulsed ultrasound affects human articular chondrocytes invitro. Med Biol Eng Comput 2008; 46:1263–1270.

12 Khanna A, Nelmes RT, Gougoulias N, Maffulli N, Gray J. The effects ofLIPUS on soft-tissue healing: a review of literature. Br Med Bull 2009;89:169–182.

13 Naito K, Watari T, Muta T, Furuhata A, Iwase H, Igarashi M, et al. Low-intensity pulsed ultrasound (LIPUS) increases the articular cartilage type IIcollagen in a rat osteoarthritis model. J Orthop Res 2010; 28:361–369.

14 Cook SD, Salkeld SL, Popich-Patron LS, Ryaby JP, Jones DG, Barrack RL.Improved cartilage repair after treatment with low-intensity pulsedultrasound. Clin Orthop 2001; 391:S231–S243.

15 Baxter GD, Bell AJ, Allen JM. Low level laser therapy current clinicalpractice in Northern Ireland. Physiotherapy 1991; 77:171–178.

16 Baltzer AW, Ostapczuk MS, Stosch D. Positive effects of low level lasertherapy (LLLT) on Bouchard’s and Heberden’s osteoarthritis. Lasers SurgMed 2016; 48:498–504.

17 Sandra B, VanOS, Nick A, Troop Keith R, et al.Adherence to prophylaxis inadolescents and young adults with severe haemophilia: a quantitative studywith patients. PLoS One 2017; 12:1.

18 DysonM. Ultrasound for woundmanagement: clinical woundmanagement.USA: Stack Incorporated; 2008. 197–204.

19 Watson T. Ultrasound in contemporary physiotherapy practice. Ultrasonics2008; 48:321–329.

20 David D, Nguyen M, Katrin T. Evaluation and management of hereditaryhemophilia in the emergency department. J EmergNurs 2008; 19:225–230.

21 Vladmirov YA, Osip AN, Klebanov GL. Photobiological principles oftherapeutic applications of laser radiation. Biochemistry (Mosc) 2004;69:81–90, Principles.

22 Korstjens CM, van der Rijt RH, Albers GH, Semeins CM, Klein-Nulend J.Low-intensity pulsed ultrasound affects human articular chondrocytes invitro. Med Biol Eng Comput 2008; 46:1263–1270.

23 Bjordal JM, Couppe C, Ljunggren AE. Low level laser therapy fortendinopathy. Evidence of A Dose–Response Pattern. 2013; 6:91–99.

24 Lederman E, Cramer GD, Donatelli R,Willard FH. The science and practiceof manual therapy. 2nd ed. Edinburgh: Elsevier, Churchill Livingstone;2005.

25 Knight KL, Draper DO. Therapeutic modalities, the art and science.Baltimore, MD: Lippincott Williams & Wilkins; 2008.

26 Kawano T, Miura H, Mawatari T, Moro-Oka T, Nakanishi Y, Higaki H,Iwamoto Y. Mechanical effects of the intraarticular administration of highmolecular weight hyaluronic acid plus phospholipid on synovial jointlubrication and prevention of articular cartilage degeneration inexperimental osteoarthritis. Arthritis Rheum 2003; 48:1923–1929.

27 Caligaris M, Canal CE, Ahmad CS, Gardner TR, Ateshian GA. Investigationof the frictional response of osteoarthritic human tibiofemoral joints and thepotential beneficial tribological effect of healthy synovial fluid. OsteoarthritisCartilage 2009; 17:1327–1332.

Documents

Effect of pulsed ultrasound versus low level laser therapy