Report on Hands from Doctors Demystify, March 2013
Contents:
DD The Whys and Hows of Hand Surgery for OTs and PTs
Comments from Jan-Feb sessions—Registrants love the Q/A sessions
Upcoming cities and dates
Journal Article Review
Does phonophoresis deliver hydrocortisone to human tendons?
Musical Fingertips
DOCTORS DEMYSTIFY THE WHYS AND HOWS OF HAND SURGERY FOR OTs and PTs
Spend a Saturday getting inside of the heads of area hand surgeons. Understand hands from the
surgical perspective. Enhance your knowledge. Enlighten your patients. details
Format: After each of 6 talks (bone, skin, tendon, cartilage and ligaments, nerves, vessels)
registrants submit questions on notecards. Hand surgeon panelists discuss answers during 30
minute session following each talk.
Comments from Jan-Feb sessions of DD Whys and Hows:
Los Angeles: Speakers were great, and all very approachable! I loved the Q&A format.
Phoenix: Excellent course with excellent surgeons presenting the information!
Winston-Salem: Great to have Q&A sessions with all the doctors available, It certainly generated
more questions from attendees.
Oklahoma City: I hope that the extended discussion time continues in future courses.
Phoenix: DD continues to deliver convenient, low cost, and well-presented information by local
hand surgeons. All presenters were absolutely awesome! Information was concise and presented
in a fashion that was understandable and interesting to the new hand therapist and experienced.
Tampa: Enjoyed the panel discussions. Great group of approachable hand surgeons.
St. Louis: All presenters were good! Informal panel discussions were great!
Upcoming cities and dates Atlanta, Miami, New Orleans, and Seattle on March 16
Ann Arbor/Detroit
May 11 recently changed
Atlanta
March 16
Baltimore
April 27 Dr. Meals will participate
Boston
May 4
Chicago
April 13
Cleveland
(TBD Fall 2013)
Dallas
April13
Denver
April 20
Detroit/Ann Arbor
May 4
Grand Rapids
April 20
Houston
May 4
Kansas City
Sept 21
Miami
March 16
Minneapolis
April 27
New Orleans
March 16
New York City
May 18
Pittsburgh
May 4
Portland
May 18
Rochester NY
Salt Lake City
San Diego
San Francisco
Seattle (Kirkland)
April 6
April 27
May 18
June 1
March 16
JOURNAL ARTICLE REVIEW Does phonophoresis deliver hydrocortisone to human
tendons?
There is no doubt that phonophoresis can drive certain chemicals through the skin. The question
relevant to hand therapy is whether phonophoresis can actually drive medicines into the target
tissue deep to the skin. A group of doctors and physical therapists at University of New Mexico
report the results of a well-controlled clinical study.
Patients about to undergo anterior cruciate ligament (ACL) reconstruction were randomly divided
into a sham group (n=9) or a phonophoresis group (n=12). Patients, surgeons, and laboratory
analysts were all blinded regarding the randomization. The treatment group received 6 minutes
of continuous ultrasound using 5 grams of 10% hydrocortisone gel. The ultrasound was applied
to a 5 square cm area over the semitendinosus tendon on the posterior medial aspect of the
distal thigh. The sham group received “treatment” to the same area, just the ultrasound machine
was disabled.
During knee surgery 2-3 hours later, the surgeon, as the first step in ACL reconstruction, divided
the semitendinosus from its insertion. He took a small sample of the tendon at its insertion to
serve as a control specimen. Eight cm more proximally and at the site of the recent real or sham
phonophoresis, the surgeon removed the accessory semitendinosus tendon. (This accessory
tendon is routinely removed for this type of ACL reconstruction, so the subjects were no worse
off for being part of the experiment.)
The investigators then assayed the control tendon samples and the treated tendon samples from
all 21 subjects for hydrocortisone. If phonophoresis worked, the accessory semitendinosus
tendons in the real group should show markedly higher levels of hydrocortisone than their own
control tendon more distally and higher than both biopsy sites in the sham group.
The hydrocortisone levels were not statistically different between the control site and the
treatment site nor were they different between the patients receiving sham and real treatments.
In other words, phonophoresis did not drive hydrocortisone into the tendon.
The authors provide an excellent discussion including previous studies regarding the benefit or
lack of benefit of phonophoresis for focal tissue treatment. They point out that results using one
medication, animal model, or tissue type may not translate to other medications, animals, or
tissues.
The authors also discuss potential weaknesses in their study, including the time between
treatment and biopsy. Theoretically, the phonophoresis may have worked and then the drug
diffused away before biopsy. For hydrocortisone to have an anti-inflammatory effect in
connective tissue, however, it would have to have detectable levels remaining for at least many
hours if not days.
The authors conclude, “Given the results of this study, we cannot recommend hydrocortisone
phonophoresis for treatment of inflammatory conditions of connective tissues.” abstract
For those of you who have attended DD Current Science, you know that I concur with this
conclusion. Think about it. As soon as a drug gets through the epidermis, it is exposed to the rich
capillary network in the dermis and subcutaneous fat. Here the circulatory system is going to pick
up the drug and carry it away rather than letting it bore on past the capillaries and into the
targeted connective tissue. If patients tell you they feel better after phonophoresis, ask yourself
was it the medication, the ultrasound, or the placebo effect, which can be powerful. (See last
month’s Report on Hands.)
USING RIDGED FINGERTIP SKIN TO MAKE MUSIC
Until next month,
Roy A. Meals, MD
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