Low-Intensity Pulsed Ultrasound for Early-

Stage Lumbar Spondylolysis in

young athelets.
Tsukada, Masahiro PT*; Takiuchi, Toshiro MD†;
Watanabe, Kota MD, PhD‡

Clinical Journal of Sport Medicine

29(4):p 262-266, July 2019. | DOI: 10.1097/J

RITIKA KAPOOR
ROLL NO 230319054
INDEX
 INTRODUCTION
 PURPOSE OF THE STUDY
 HYPOTHESIS
 METHODOLOGY
 INCLUSION CRITERIA
 EXCLUSION CRITERIA
 LIMITATION
 DISCUSSION
 CONCLUSION
 CRITICAL ANALYSIS
 REFERENCES
INTRODUCTION
 Lumbar spondylolysis is a defect of the pars interarticularis and is a common
cause of low back pain in young athletes. (Wiltse LL, Widell EH Jr, Jackson DW)
 Although multiple factors may be involved in its genesis, when lumbar
spondylolysis occurs among sports players, it is generally manifested as a stress
fracture of the pars caused by repetitive extension and/or rotation activities.
(Ciullo JV, Jackson D)
 The treatment of spondylolysis is initially conservative and aims to reduce pain
and facilitate healing. As previous studies have reported, early diagnosis and
treatment of spondylolysis are clearly important for conservatively treating
patients successfully. (Morita T, Ikata T, Katoh S, et al)
 Conservative treatment typically requires use of a thoracolumbosacral brace and
refraining from sporting activities for 3 to 6 months.(Sys J, Michielsen J, Bracke
P, et al. )
 The treatment period is very long in many athletes who require structural repair
of their defects from rapid return to previous activities .(Panteliadis P, Nagra NS,
Edwards KL)
 Low-intensity pulsed ultrasound (LIPUS) has been extensively used in
medicine as a diagnostic and therapeutic modality. (Xavier CAM, Duarte LR)
 Low-intensity pulsed ultrasound is a form of mechanical energy that can be
transmitted into biological tissue as acoustic pressure waves.(Xavier CAM,
Duarte LR. )
 The micromechanical strain produced by these acoustic waves in biological
tissue can result in biomechanical events at the cellular level.20 It has been
reported to be effective in promoting fracture healing in animal models and
clinical trials. (Albornoz PM, Khanna A, Longo UG, et al)
 Several studies have shown the benefits of LIPUS exposure for enhancing
bone healing after fresh fractures and in patients with delayed
and nonunion of various bones.(Heckman JD, Ryaby JP, McCabe J, et al. )
 AIM OF RESEARCH
The aim of the research is to find the period of treatment time and to
compare the effect of low intensity pulsed ultrasound with standard conservative
protocol on young athletes.

OBJECTIVE OF THE RESEARCH

To examine the effect of low-intensity pulsed ultrasound (LIPUS) on early-
stage spondylolysis in young athletes.
 RESEARCH HYPOTHESIS
The authors proposed that the effect of low intensity pulsed ultrasound with
standard conservative procedure on early stage spondylolysis in young athletes
will help them to regain their sports activity in short duration of time rather than
those who were treated without LIPUS.
METHODOLOGY
 STUDY DESIGN -Case–control study.
 STUDY SETTING - A single outpatient orthopaedic and sports clinic.
 SAMPLE TECHNIQUE -
 SAMPLE SIZE - 82 young athletes (80 boys and 2 girls)
 INCLUSION CRITERIA -
1. had low back pain without neurological abnormalities in the lower limbs.
2. had early-stage spondylolysis diagnosed by plain radiography (no findings of spondylolysis) and
T1- and T2-weighted MRI (T1; low signal, T2; high signal change in the pedicle adjacent to the
pars interarticularis
3. were 18 years or younger, (Range 10 to 18)
4. were actively participating in sports were enrolled.
 EXCLUSION CRITERIA -
patients with clear spondylolysis or spondylolisthesis detectable by plain radiography were
excluded from the study.
PROCEDURE
SAMPLE SIZE= 82
80 BOYS AND 2 GIRLS

LIPUS GROUP CONTROL

N= 35 GROUP
N= 47

LIPUS +STANDARD ONLY STANDARD

CONSERVATIVE CONSERVATIVE
TREATMENT TREATMENT
 Patients with early-stage lumbar spondylolysis received either LIPUS combination or noncombination
treatment.
 All patients received standard conservative treatment, including thoracolumbosacral brace, sports
modification, and therapeutic exercise.
 The brace was a Damen-type soft corset, and patients were asked to use it during all active periods
of the day. In principle, sports activities were prohibited. Therapeutic exercises included stretching
of the muscles surrounding the hip and strengthening of the trunk muscles.
 the patients in the LIPUS group were treated by using an ultrasonic therapeutic device (Accellus;
Nippon Sigmax Co, Ltd, Tokyo, Japan).
 Low-intensity pulsed ultrasound exposure was performed once to the affected area more than 3
times a week during the treatment period.
 .The treatment head module was coupled with the skin over the site of bone stress injury using a
standard ultrasound transmission gel (Aquasonic 100; Parker Laboratories Inc, Fairfield, NJ) and
fixed with a Velcro strap.
 The ultrasound pressure wave signal was applied by using the following parameters:
o 1.5-MHz oscillation frequency,
o 1-kHz pulsed frequency,
o 30-mW/cm2 spatial intensity,
o duration of 20 minutes.
 Clinical follow-up after 2 months evaluations were performed by the same orthopedic surgeon. The
endpoint of this study was healed spondylolysis, as judged by T2-weighted MRI (disappearance of
high signal change in the pedicle adjacent to the pars interarticularis, and by radiography (without
separation)
 A representative case. Magnetic resonance
imaging scan (T2-weighted image) of the
lumbar spine in a 16-year-old male baseball
player. A, At the first presentation, axial slice
shows high signal intensity at the right
pedicle adjacent to the pars interarticularis
of L5 (arrow). High signal intensity area
indicates a bone stress injury. B, High signal
intensity was diminished 2 months later
(arrow). C, On the 4-month follow-up MRI,
high signal intensity was completely resolved
(arrow). Confirmation of this image was the
primary endpoint of this study.
STATISTICAL ANALYSIS

 The continuous variables were presented as the mean ± SD

for normally distributed data and as the median [95%
confidence interval (CI)] for non-normally distributed data.
The Mann–Whitney U test was used to compare the
continuous variables between groups, and the Fisher exact
test or χ2 test was used to compare the categorical data
between groups.
 In addition, log-rank life-table analysis was used to compare
the time to return to sports activities between the 2 groups.
Survival curves were determined by using Kaplan–Meier
methods, and differences in survival between groups were
compared by using the log-rank test. All statistical analyses
were performed by using EZR (Saitama Medical Center, Jichi
Medical University, Saitama, Japan), and significance was
defined as P ≤ 0.05.
RESULT
 As a result of that the analysis, the median time to the
endpoint of the study (disappearance of high signal
change in the pedicle adjacent to the pars
interarticularis judged by T2-weighted MRI) was 61 days
(95% CI, 58-69 days) for the LIPUS group
 167 days (95% CI, 135-263 days) for the control group P <
0.01).
 At 90 days after the start of treatment, 65.7% of the
patients with spondylolysis in the LIPUS group had
recovered compared with only 12.8% of the patients in
the control group; at 120 days, 82.9% of the patients with
spondylolysis in the LIPUS group had recovered compared
with only 25.5% of the patients in the control group
 Graph comparing the cumulative percentage of those
who returned to previous sports activities in the group
treated with LIPUS and the group treated without LIPUS
(control). P value from log-rank test. LIPUS, low-intensity
pulsed ultrasound.
Sports Activity of Patients
RESULTS OF BOTH THE GROUPS
DISCUSSION
 Low-intensity pulsed ultrasound is a special type of acoustic pulsed energy that provides an optimal biological and biophysical environment
promoting skeletal maintenance and repair as a safe and non invasive method

 Yadav et al32 performed a double-blind, randomized, controlled trial of 67 military personnel with tibial stress fractures and also
demonstrated that patients in the LIPUS treatment group were able to return to duty faster than those in the placebo group. Similar positive
effects were observed by Uchiyama et al33 in delayed and non union tibial stress fractures. However, in a controlled clinical study by Rue et
al,35 daily exposure of LIPUS did not significantly reduce the healing time for tibial stress fractures. The effect of LIPUS on bone stress
injuries is still under discussion.

 Rue et al, daily exposure of LIPUS did not significantly reduce the healing time for tibial stress fractures. The effect of LIPUS on bone stress
injuries is still under discussion no study was done till now on lipus can effect on pars intrarticularis defect .

 Sairyo et al reported that a high signal change in the pedicle was useful for diagnosis of early-stage spondylolysis and its change due to bone
marrow edema. In this study, the high signal change exhibited by patients in the LIPUS group disappeared within approximately 2 months, and
the patients were able to return to sports activities. ( Sairyo K, Katoh S, Takata Y, et al.)

 Previous studies suggested that the mechanical energy transferred by LIPUS acts on various processes, such as inflammatory reaction,
angiogenesis, chondrogenesis, intramembranous ossification, endochondral ossification, and bone remodeling. (Azuma Y, Ito M, Harada Y, et
al.)
 The most common nonoperative management of spondylolysis includes cessation of
sports, thoracolumbosacral braces, and physiotherapy.These treatments are generally
recommended for 3 to 6 months. (Leone A, Cianfoni A, Cerase A, et al.)
 Panteliadis et al14analyzed the pooled outcomes of conservative management for an
athletic population with spondylolysis and reported that the weighted mean duration of
treatment was 3.7 months.
 In this study, the median time to return to achieve vigorous sports activities was 61
days in the LIPUS group, which was significantly shorter than that of the control group
(167 days), and the treatment period was shortened by 63.5%.
conclusion

 In conclusion, the study findings indicate that

LIPUS exposure may be useful not only for
fracture treatment but also for treatment of bone
stress injuries, such as early-stage lumbar
spondylolysis, in young athlete
s.
LIMITATIONS

 The study itself showed and have mentioned their own weak points or limitations . It
is a shortcoming and a critique in its own .
 Limitations mentioned
1. Selection biasness have occurred
2. Problem in study design, lack of placebo control, diagnosis not quantified which may
can affect the result.
3. Lack of strict criteria and treatment protocol
4. No determining of factors or environmental factors
5. Not mentioned the validity of exposure of frequency
6. As the study was conducted in Japanese public Health insurance system , MRI
assessment interval was set to 2 months .So there can be a possibility of 60 days
difference in the treatment protocol after the drop out from the control group.
CRITICAL ANALYSIS
 The authors did not mentioned about the mechanical factors or environmental factors
which can cause defect in pars or pars fracture. ( sundell et.al)
 No comparison of sports mentioned in the article as the biomechanics of every sport
is different so the type of injury would be different in each individual which can vary in
results (Shouchen Dun, Glenn S. Fleisig)
 The article is itself contradicted about its diagnosing procedure for MRI and plane
radiography
 The incidence level of pars is different in lumbar area so the defect can vary according
to the level of pars and treatment can still vary according to the stage of defect.
( sundell et.al) ( A. linton et.al )
 There was no significant pain assessment or scale to measure the pain of the patient
Numerical Pain Rating Scale (NPRS), Oswestry Disability Index (ODI)
 The quality of life was also needed to be observed which was not significantly revised
or mentioned in the article which could be done through Japanese Orthopedic
Association Back Pain Evaluation Questionnaire (Yao.Min et.al)
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