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Low intensity pulsed ultrasound for bone healing: systematic review of randomized controlled trials.

Abstract Objective To determine the efficacy of low intensity pulsed ultrasound (LIPUS) for healing of fracture or osteotomy.Design Systematic review and meta-analysis.Data sources Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and trial registries up to November 2016.Study selection Randomized controlled trials of LIPUS compared with sham device or no device in patients with any kind of fracture or osteotomy.Review methods Two independent reviewers identified studies, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including selection of outcomes important to patients. The GRADE system was used to assess the quality of evidence.Results 26 randomized controlled trials with a median sample size of 30 (range 8-501) were included. The most trustworthy evidence came from four trials at low risk of bias that included patients with tibia or clavicle fractures. Compared with control, LIPUS did not reduce time to return to work (percentage difference: 2.7% later with LIPUS, 95% confidence interval 7.7% earlier to 14.3% later; moderate certainty) or the number of subsequent operations (risk ratio 0.80, 95% confidence interval 0.55 to 1.16; moderate certainty). For pain, days to weight bearing, and radiographic healing, effects varied substantially among studies. For all three outcomes, trials at low risk of bias failed to show a benefit with LIPUS, while trials at high risk of bias suggested a benefit (interaction P<0.001). When only trials at low risk of bias trials were considered, LIPUS did not reduce days to weight bearing (4.8% later, 4.0% earlier to 14.4% later; high certainty), pain at four to six weeks (mean difference on 0-100 visual analogue scale: 0.93 lower, 2.51 lower to 0.64 higher; high certainty), and days to radiographic healing (1.7% earlier, 11.2% earlier to 8.8% later; moderate certainty).Conclusions Based on moderate to high quality evidence from studies in patients with fresh fracture, LIPUS does not improve outcomes important to patients and probably has no effect on radiographic bone healing. The applicability to other types of fracture or osteotomy is open to debate.Systematic review registration PROSPERO CRD42016050965.
PMID
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Authors

Mayor MeshTerms

Fracture Healing

Ultrasonic Therapy

Keywords
Journal Title bmj (clinical research ed.)
Publication Year Start




PMID- 28348110
OWN - NLM
STAT- MEDLINE
DA  - 20170328
DCOM- 20170331
LR  - 20170331
IS  - 1756-1833 (Electronic)
IS  - 0959-535X (Linking)
VI  - 356
DP  - 2017 Feb 22
TI  - Low intensity pulsed ultrasound for bone healing: systematic review of randomized
      controlled trials.
PG  - j656
LID - 10.1136/bmj.j656 [doi]
AB  - Objective To determine the efficacy of low intensity pulsed ultrasound (LIPUS)
      for healing of fracture or osteotomy.Design Systematic review and
      meta-analysis.Data sources Medline, Embase, CINAHL, Cochrane Central Register of 
      Controlled Trials, and trial registries up to November 2016.Study selection
      Randomized controlled trials of LIPUS compared with sham device or no device in
      patients with any kind of fracture or osteotomy.Review methods Two independent
      reviewers identified studies, extracted data, and assessed risk of bias. A
      parallel guideline committee (BMJ Rapid Recommendation) provided input on the
      design and interpretation of the systematic review, including selection of
      outcomes important to patients. The GRADE system was used to assess the quality
      of evidence.Results 26 randomized controlled trials with a median sample size of 
      30 (range 8-501) were included. The most trustworthy evidence came from four
      trials at low risk of bias that included patients with tibia or clavicle
      fractures. Compared with control, LIPUS did not reduce time to return to work
      (percentage difference: 2.7% later with LIPUS, 95% confidence interval 7.7%
      earlier to 14.3% later; moderate certainty) or the number of subsequent
      operations (risk ratio 0.80, 95% confidence interval 0.55 to 1.16; moderate
      certainty). For pain, days to weight bearing, and radiographic healing, effects
      varied substantially among studies. For all three outcomes, trials at low risk of
      bias failed to show a benefit with LIPUS, while trials at high risk of bias
      suggested a benefit (interaction P&lt;0.001). When only trials at low risk of bias
      trials were considered, LIPUS did not reduce days to weight bearing (4.8% later, 
      4.0% earlier to 14.4% later; high certainty), pain at four to six weeks (mean
      difference on 0-100 visual analogue scale: 0.93 lower, 2.51 lower to 0.64 higher;
      high certainty), and days to radiographic healing (1.7% earlier, 11.2% earlier to
      8.8% later; moderate certainty).Conclusions Based on moderate to high quality
      evidence from studies in patients with fresh fracture, LIPUS does not improve
      outcomes important to patients and probably has no effect on radiographic bone
      healing. The applicability to other types of fracture or osteotomy is open to
      debate.Systematic review registration PROSPERO CRD42016050965.
CI  - Published by the BMJ Publishing Group Limited. For permission to use (where not
      already granted under a licence) please go to
      http://group.bmj.com/group/rights-licensing/permissions.
FAU - Schandelmaier, Stefan
AU  - Schandelmaier S
AD  - Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 
      Main St West, Hamilton, ON L8S 4L8, Canada [email protected]
AD  - Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel,
      Spitalstrasse 12, CH-4031 Basel, Switzerland.
FAU - Kaushal, Alka
AU  - Kaushal A
AD  - Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 
      Main St West, Hamilton, ON L8S 4L8, Canada.
AD  - Michael G. DeGroote Institute for Pain Research and Care, McMaster University,
      Hamilton, ON L8S 4K1, Canada.
FAU - Lytvyn, Lyubov
AU  - Lytvyn L
AD  - Oslo University Hospital, Forskningsveien 2b, Postboks 1089, Blindern 0317 Oslo, 
      Norway.
FAU - Heels-Ansdell, Diane
AU  - Heels-Ansdell D
AD  - Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 
      Main St West, Hamilton, ON L8S 4L8, Canada.
FAU - Siemieniuk, Reed A C
AU  - Siemieniuk RA
AD  - Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 
      Main St West, Hamilton, ON L8S 4L8, Canada.
AD  - Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON,
      M5G 2C4, Canada.
FAU - Agoritsas, Thomas
AU  - Agoritsas T
AD  - Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 
      Main St West, Hamilton, ON L8S 4L8, Canada.
AD  - Division General Internal Medicine and Division of Clinical Epidemiology,
      University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211, Geneva,
      Switzerland.
FAU - Guyatt, Gordon H
AU  - Guyatt GH
AD  - Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 
      Main St West, Hamilton, ON L8S 4L8, Canada.
AD  - Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON L8S 
      4L8, Canada.
FAU - Vandvik, Per O
AU  - Vandvik PO
AD  - Institute of Health and Society, Faculty of Medicine, University of Oslo, 0318
      Oslo, Norway.
AD  - Department of Medicine, Innlandet Hospital Trust-division, Gjovik, Norway.
FAU - Couban, Rachel
AU  - Couban R
AD  - Michael G. DeGroote Institute for Pain Research and Care, McMaster University,
      Hamilton, ON L8S 4K1, Canada.
FAU - Mollon, Brent
AU  - Mollon B
AD  - Orillia Soldiers' Memorial Hospital, 41 Frederick Street, Orillia, ON L3V 5W6,
      Canada.
FAU - Busse, Jason W
AU  - Busse JW
AD  - Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 
      Main St West, Hamilton, ON L8S 4L8, Canada.
AD  - Michael G. DeGroote Institute for Pain Research and Care, McMaster University,
      Hamilton, ON L8S 4K1, Canada.
AD  - Department of Anesthesia, McMaster University, Hamilton, ON L8S 4K1, Canada.
LA  - eng
PT  - Journal Article
PT  - Review
DEP - 20170222
PL  - England
TA  - BMJ
JT  - BMJ (Clinical research ed.)
JID - 8900488
SB  - AIM
SB  - IM
MH  - *Fracture Healing
MH  - Fractures, Bone/*therapy
MH  - Humans
MH  - Randomized Controlled Trials as Topic
MH  - *Ultrasonic Therapy
EDAT- 2017/03/30 06:00
MHDA- 2017/04/01 06:00
CRDT- 2017/03/29 06:00
PHST- 2017/02/01 [accepted]
PST - epublish
SO  - BMJ. 2017 Feb 22;356:j656. doi: 10.1136/bmj.j656.

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