Ultrasound Therapy Effects In Medial Collateral Ligament Injuries Biology Essay

The median collateral ligament ( MCL ) is one of the most often injured ligaments of the articulatio genus articulation.

Fortunately, most patients who sustain MCL hurts are able to accomplish their old degree of activity without the demand for surgical intervention. However, the most terrible hurts, particularly those affecting multiple ligaments, may necessitate operative fix. This survey will research the effectivity of a conservative intervention, viz. ultrasound therapy and exercising therapy, in the intervention of MCL hurts of the articulatio genus articulation. In a reappraisal by Phisitkul, James, Wolf, and Amendola ( 2006 ) , intervention with early scope of gesture ( ROM ) exercises and progressive strengthening has been shown to bring forth really good consequences.Ultrasound therapy has been a widely used and well-accepted physical therapy mode for musculoskeletal conditions for many old ages.

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Wong, Schumann, Townsend, and Phelps ( 2007 ) performed a study about the usage of ultrasound by physical healers who are orthopedic specializers, and found that ultrasound therapy is a popular adjunct in orthopedic physical therapy and that it is perceived as of import. However, the deficiency of surveies corroborating its benefits has led many to oppugn this traditional position. Indeed, many studied which explored the effectivity of ultrasound therapy failed in set uping a definite decision. However, it can non be assumed that this deficiency of grounds implies that ultrasound therapy is uneffective, and therefore farther research is needed to set up the adequateness of its usage.This survey aims at replying the undermentioned important inquiries: In patients with MCL hurts of the articulatio genus, can ultrasound better hurting, disablement and general recovery? Is it more effectual than exercising therapy in bettering symptoms? An reply to these inquiries will assist to break direct physical therapy intervention for these patients, and therefore optimise recovery.Subsequent chapters will discourse the current literature available on the topic, followed by the methodological analysis used in this survey. The consequences are so presented and analysed.

The reading of consequences in the context of old research will be discussed in the treatment chapter, including the strengths and restriction of the survey.

Literature Review

Ultrasound therapy has become normally used in soft tissue hurts ( Speed, 2001 ) . Research carried out in the past few decennaries sing the effects of ultrasound on organic structure tissues will be discussed below. My purpose is to reexamine the research available from the past old ages in effort to happen conclusive and consistent consequences sing the effects of ultrasound, and therefore to warrant the usage of ultrasound in the clinical scene, specifically to intervention of median indirect ligament hurts.As will be discussed in this chapter, when ultrasound enters the organic structure, it is thought to exercise an consequence on it through thermic and non-thermal mechanisms ( Robertson, Ward, Low, & A ; Reed, 2006, p.266 ) . Some of these effects may excite healing ; nevertheless others may be unsafe and may do harm.

Thermal effects of ultrasound

As ultrasound moving ridges travel trough organic structure tissues, they cause oscillation of atoms, therefore change overing sonic energy into heat energy. The sum of heat produced will greatly depend upon the strength given and the rate of energy soaking up, but besides on certain tissue belongingss, such as the heat capacity, efficiency of heat transportation, and the tissue distribution and infinite ( Robertson, Ward, Low, & A ; Reed, 2006, p.266 ) . Some writers have suggested pre-heating the country of intervention to accomplish a greater addition in tissue temperature ( Draper et al 1998a ) .

Populating tissue will be affected by an addition in temperature in assorted different ways. Harmonizing to Speed ( 2001 ) , the thermic effects of ultrasound include an increased extensibility in tissues, enhanced blood flow, hurting transition, decreased joint stiffness and musculus cramp, together with a mid inflammatory response. These could explicate why a impermanent addition in scope of gesture is observed after ultrasound intervention ( Draper et al. , 1998b ; Knight et al. , 2001 ) . Hayes, Merrick, Sandrey and Cordova ( 2004 ) studied the extent of warming in tissue at 2.5cm deepness and found that 3MHz ultrasound was more effectual in heating the tissues at this deepness than 1MHz, making a temperature of 40 grades Celsius after 4 proceedingss.

Unfortunately the production of heat may put the patient at hazard of a skin burn if applied falsely ( Robertson, Ward, Low, & A ; Reed, 2006, p.290 ) .

Physical effects of ultrasound


Cavitation is “ the formation of bantam gas bubbles in the tissues as a consequence of ultrasound quiver ” ( Robertson, Ward, Low, & A ; Reed, 2006, p.

267 ) . Johns ( 2002 ) explains how as sound moving ridges travel through the tissues, the characteristic compaction and rarefaction causes microscopic gas bubbles present in the tissue fluid to contract and expand. Injury to the cell may happen when these gas bubbles expand and collapse quickly. Nevertheless, cavitation has been found to happen merely when utilizing high strengths, and therefore it is improbable to happen in vivo with curative degrees ( Nyborg, 2001 ) . However harmonizing to a reappraisal by Baker, Robertson, and Duck ( 2001 ) , there are a few surveies which suggest the being of in vivo cavitation. Baker and his co-workers argue that these surveies were non replicated and that consequences obtained may hold been due to trouble with the analysis of B-scan imagination, which were used to mensurate cavitation. A recent survey investigated the method by which cavitation is detected.

The ripple attack was identified as a new tool for analyzing bubble cavitation ( Zhou, 2008 ) . Cavitation becomes clinically relevant during ultrasound applications in H2O, as bubbles that form between the tegument and the intervention caput may barricade transmittal of supersonic moving ridges ( Ward & A ; Robertson, 1996 ) .

Acoustic cyclosis

Acoustic cyclosis may be described as a flow of liquid caused by a coevals of force per unit area along the axis of the beam of energy and on any other constructions which reflect it ( Robertson, Ward, Low, & A ; Reed, 2006, p.268 ) .

There are two types of acoustic cyclosis: microstreaming and majority cyclosis ( Duck, as cited in Baker, Robertson & A ; Duck, 2001 ) . Bulk streaming occurs in any fluid and develops as the ultrasound beam is propagated, while microstreaming occurs at a microscopic degree and is formed as Eddies of flow flanking to an hovering surface ( Robertson, Ward, Low, & A ; Reed, 2006, p.268 ) .Unfortunately bulk cyclosis is much less automatically powerful, with microstreaming being the lone type of acoustic cyclosis which is able to excite cell activity and alteration membrane permeableness ( Duck, as cited by Baker, Robertson, & A ; Duck, 2001 ) . Microstreaming can bring forth emphasis on the cell membrane and rinse off any molecules and ions which accumulate outside the cell membrane ( Robertson, Ward, Low, & A ; Reed, 2006, p.268 ) . Harmonizing to Duck ( as cited by Baker, Robertson, & A ; Duck, 2001 ) , merely majority streaming occurs in vivo, because microstreaming merely occurs secondary to cavitation.

In vitro surveies show increased growing factor production by macrophages ( Young and Dyson, 1990a ) , increased Ca consumption ( Mortimer and Dyson, 1988 ) , increased secernment and degranulation of mast cell ( Fyfe and Chahl, 1984 ) and increase cell membrane permeableness ( McCance and Huether, as cited by Baker, Robertson, & A ; Duck, 2001 ) by microstreaming. This nevertheless will hold minimum relevancy in the clinical scene if one assumes that cavitation will non happen. Nevertheless, Manasseh, Tho, Ooi, Petkovic-Duran, and Zhu, ( 2010 ) , suggest that microstreaming which occurs secondary to cavitation will play a function in the action of microbubbles in curative ultrasound.

Standing moving ridges

Standing moving ridges are formed when reflected sound moving ridges are superimposed with incident moving ridges, and are characterized by high force per unit area extremums, the antinodes and zones of low force per unit area known as nodes ( Robertson, Ward, Low, & A ; Reed, 2006, p.

267-8 ) . Ter Haar and Wyard ( 1978 ) put frontward that blood cell stasis may happen with ultrasound, with cells organizing at half wavelength intervals in the blood vass at antinodes. These consequences match those by Dyson, Pond, Woodward, and Broadbent ( 1974 ) . The latter studied the consequence of a stationary moving ridge on blood cell stasis and endothelial harm in blood vass of biddy embryos. The cells form bands half a wavelength apart inside blood vass. They suggest that under optimal conditions, the minimal strength of less than 0.5 Wcm-2 at 3 MHz with uninterrupted irradiation is required for stasis to happen. Damage to some endothelial cells of vass in which stasis has occurred was revealed by an negatron microscope.

Therefore, it is suggested that the intervention caput is continuously moved during the intervention to minimise the formation of standing moving ridges ( Robertson, Ward, Low, & A ; Reed, 2006, p.268 ) .

The consequence of ultrasound on fix of organic structure tissues

Harmonizing the undermentioned research, ultrasound therapy may hold an consequence on cells involved in fix of organic structure tissues, including:

Degrees of prostaglandins and leukotrienes

Leung, Ng, and Yip ( 2004 ) performed a randomized, case-control survey to analyze the consequence of ultrasound during the acute redness of soft-tissue hurts. They measured the degrees of leukotriene B4 and prostaglandin E2 in the median indirect ligament of rats and found that pulsed ultrasound ( 1:4 ) applied for five proceedingss at different continuances and strengths may excite acute redness by increasing the degrees of the above mentioned leukotriene and prostaglandin.

Release of fibroblast from macrophages

Young and Dyson ( 1990a ) studied if ultrasound therapy can increase the release of fibroblast mitogenic factors from macrophages in vitro, and assessed fibroblast proliferation over five yearss. This survey showed an increased secernment of already formed fibroblasts in macrophages at 0.75 MHz ultrasound, which may be caused by permeableness alterations.

On the other manus, at 3 MHz frequence, ultrasound appeared to promote both the synthesis and secernment of fibroblast mitogenic factors. The ground why these two frequences cause different effects may be explained by the different physical mechanisms involved. Williams ( as cited in Young, 2002, p. 217 ) , argues that cavitation is more apt to happen at lower frequences, while at a higher frequence warming is more likely.

Platelets and I?-thromboglobulin

Williams, Chater, Allen, Sherwood, and Sanderson ( 1978 ) investigated the consequence of ultrasound on thrombocytes and established that more I?-thromboglobulin, a thrombocyte specific protein, was released by ultrasound therapy. They suggest that this protein is released both by the break of thrombocytes by cavitation and by other aggregating agents liberated in analogue with it which cause a release reaction in the next thrombocytes.

This nevertheless, has non been proved to go on in vivo.

Histamine release from mast cells

Fyfe and Chahl ( 1984 ) suggest that ultrasound applied in the curative scope causes a important addition in degranulated mast cells and therefore an addition in histamine release, in rats. They suggest the possibility that ultrasound increases the permeableness of mast cells to calcium doing them to degranulate, ensuing in an addition in local blood flow. On the other manus, when Hogan, Burke, and Franklin ( 1982 ) investigated the alteration in blood flow in rat musculus on insonation, they found that arteriolas vasoconstrict transiently in response to insonation, but better perfusion after long-run intervention.

Increase membrane permeableness to calcium

Change in the permeableness of membranes to Ca has been demonstrated when utilizing curative ultrasound.

Harmonizing to Al-Karmi, Dinno, Stoltz, Crum, and Matthews ( 1994 ) , using ultrasound for two proceedingss will do a important encouragement in ionic conductance in the presence of Ca ions, therefore corroborating that Ca ions influence the biological effects of ultrasound. Dinno et Al. ( 1989 ) besides used a frog tegument theoretical account to analyze the consequence of ultrasound on membranes. They argue that the addition in the concentration of Ca ions inside cells which occurs after the application of ultrasound, may diminish the permeableness of spread junctions and uncouple cells in the manner by which cells differentiate. Therefore, they concluded that ultrasound can impact cell distinction and accordingly histogenesis, and therefore its usage should be avoided over embryologic tissue.

Growth factor secernment

Ito, Azuma, Ohta, and Komoriva ( 2000 ) applied ultrasound to a co-culture system of human osteoblastic and endothelial cells and studied their consequence on growing factor secernment.

Their survey showed that ultrasound increases the degrees of platelet-derived growing factor. This may be the ground for improved break mending rate with ultrasound intervention, as discussed subsequently.

Fibroblasts and Collagen synthesis

Ramirez, Schwane, McFarland, and Starcher ( 1997 ) , conducted an probe to find the consequence of ultrasound on the rate of cell proliferation and collagen synthesis by utilizing civilized fibroblasts form the Achilles sinews of neonatal rats. They found an addition in collagen synthesis and rate of thymidine incorporation and DNA content after ultrasound intervention, proposing that ultrasound stimulates the synthesis of collagen in tendon fibroblasts and cell division after hurt. In a more recent survey Chiu, Chen, Huang, and Wang ( 2009 ) , studied the consequence of ultrasound on the proliferation of human tegument fibroblasts at different frequences. They applied ultrasound for three proceedingss daily for three yearss and found an addition in fibroblast proliferation by both 1 and 3 MHz frequences, with less stimulation when utilizing 0.5 MHz frequence. Chiu et al.

, besides took into history temperature alterations and found a alteration of merely one grade Celsius after insonation, thereby connoting that the consequences observed where due to non-thermal effects.This can be explained by the addition in protein synthesis found to happen in fibroblasts after ultrasound intervention. Harvey, Dyson, Pond and Grahame ( 1975 ) suggest that curative ultrasound at 3 MHz frequence and at an strength of 0.5 – 2.0 Wcm-2, can straight excite protein synthesis in fibroblasts, without any other cells moving as go-betweens. In fact they attributed this to membrane-associated alterations.

However, the addition in fibroblast proliferation may happen as a consequence of the effects of ultrasound on macrophages, which release fibroblasts mitogenic factors ( Young & A ; Dyson, 1990a ) , as antecedently discussed.Ultrasound non merely stimulates fibroblasts to bring forth more collagen ( Ramirez et al. 1997 ) , but the collagen produced besides has a higher tensile strength and is better organized and aggregated. Okita et Al.

( 2009 ) studied joint mobility and collagen filament agreement in the endomysium of immobilized rat soleus musculus, and showed that curative ultrasound may forestall alterations in joint mobility and collagen filament motion which occur with stationariness. In contrast, when Larsen, Kristensen, Thorlacius-Ussing and Oxlund ( 2005 ) studied the influence of pulsed ultrasound at 3 MHz frequence and different strengths, on the mechanical belongingss of mending sinews in coneies, they found greater extensibility after insonation with higher strengths, nevertheless there was no important alteration of the point of rupture when the sinews were loaded, proposing that pulsed ultrasound did non better the mechanical belongingss of the healing sinews.


Curative ultrasound may besides impact the rate of angiogenesis.

Young and Dyson ( 1990b ) considered the formation of new blood vass in full-thickness lesions of flank tegument in grownup rats and found that by twenty-four hours 5 post-injury, ultrasound treated lesions had developed a greater figure of blood vass, and were therefore at a more advanced phase in the fix procedure. However by the 7th twenty-four hours, there was no important difference between the groups.

Curative mechanism

On the footing of these conflicting consequences, two schools of idea were developed. The ‘evidence-based ‘ or ‘factual ‘ school considers heat as the lone consequence of ultrasound therapy and therefore underscore the usage of high doses and give small value to low strength and pulsed intervention. This position is found in most American composing about this topic.

On the other manus, the other school of idea is mostly European, and is more involved in the biological and mechanical effects of pulsed low-intensity interventions ( Robertson, Ward, Low, & A ; Reed, 2006, p. 269 ) .Robertson, Ward, Low, & A ; Reed, ( 2006, p. 269 ) suggest that clinical surveies may be used to look into which doses produce better results. In vitro surveies can supply a dose-response relationship which may supply information about the most effectual dosage. Nevertheless, effects demonstrated in vitro, such as cavitation and acoustic cyclosis have non yet been shown to happen in vivo, since it is hard to bring forth doses in vivo which are comparable to dose in vitro.

They argue that in vitro, ultrasound is applied to merely a thin bed of cells, and therefore the celebrated alterations do non needfully happen when applied to a much larger volume of tissue in vivo. Furthermore, in vitro the energy is confined to a really little volume and therefore the power denseness will be much higher than in vivo.

Curative effects of Ultrasound

Ultrasound therapy has been claimed effectual in a broad scope of clinical conditions, nevertheless there are still troubles in set uping the effectivity of ultrasound with certainty and in placing a dose-response relationship, if there is any. Some of the alleged effects of ultrasound include publicity of break healing, soft tissue healing, articular gristle fix, hurting alleviation, increase local blood flow, change the extensibility of cicatrix tissue and for the diagnosing of a emphasis break, and will be discussed below.

Fracture mending

Ultrasound has been proposed to advance the procedures involved in break healing and therefore increase its rate. Sun et al.

, ( 2001 ) investigated the effects of low-intensity pulsed ultrasound on bone cells in vitro, and found a important addition in osteoblast cell counts and a important lessening in osteoclast cell count after stimulation, proposing a positive consequence on the bone-healing procedure. Nolte et al. , ( 2001 ) besides studied the in vitro effects of low strength ultrasound. The latter used fetal mouse metatarsal basicss and found an addition in length of the calcified shaft, which was significantly greater in the ultrasound treated groups compared to the untreated groups, after 7 yearss. Therefore they concluded that low-intensity ultrasound straight affects bone-forming cells and ossifying gristle, with eventful more active ossification.Cyclooxygenase-2 regulates the production of Prostaglandin E2 by bone-forming cells, both of which are thought to be an indispensable portion of break healing ( Zhang et al.

, 2002 ) . Ultrasound stimulation has been found to increase cyclooxygenase-2 look and to advance bone formation in osteoblast via assorted signalling tracts ( Tang et al. , 2006 ) . Together with prostaglandins, azotic oxide is a important go-between in early automatically induced bone formation.

Reher et al. , ( 2002 ) , investigated the consequence of ‘traditional ‘ ( 1MHz, pulsed 1:4 ) and a ‘long-wave ‘ ( 45 kilohertz, uninterrupted ) ultrasound on azotic oxide initiation and prostaglandin E2 production in vitro, on human inframaxillary bone-forming cells. A control group was set which was treated with fake ultrasound. They found a important addition in both induced nitrate and prostaglandin E2 production. Long wave ultrasound was found to be more effectual than the traditional ultrasound.Other surveies suggest that ultrasound may hold an consequence on the ordinance of cistrons necessary for osteogenesis. Suzuki and his co-workers ( 2009 ) studied the typical osteoblastic cell line in the presence or absence of day-to-day low strength pulsed ultrasound stimulation at 1.5 MHz frequence, and 30 mW/cm2 strength, for 20 proceedingss, for 2 hebdomads.

They concluded that stimulation with these parametric quantities straight affected osteogenic cells, taking to mineralized nodule formation, therefore low strength pulsed ultrasound therapy is likely to hold an influence on the activities of bone-forming cells in alveolar bone.Clinical surveies gave controversial decisions in this country. In a reappraisal, Busse et al. , ( 2002 ) concluded that grounds signifier randomised controlled tests suggest that low strength pulsed ultrasound therapy may significantly cut down the clip of break mending for non-operatively treated breaks. Five old ages subsequently, Walker, Denegar, and Preische, ( 2007 ) confirmed this determination through another reappraisal.

Furthermore, Della Rocca ( 2009 ) reviewed surveies about the effects of low-intensity pulsed ultrasound intervention in break healing and found a big organic structure of animate being and cellular research which shows this to be good in imitating faster normal break healing. However, from a reappraisal to of randomised controlled tests to find the effectivity of low strength pulsed ultrasound in break healing, Busse et al. , ( 2009 ) , concluded that the grounds available has a moderate to really low quality and provides conflicting consequences.

Pain alleviation

There are a really little figure of surveies which investigate the effectivity of ultrasound in hurting alleviation. Nevertheless, presuming that ultrasound promotes mending and resolutenesss redness, hurting should accordingly diminish. Levent, Ebru, and Gulis ( 2009 ) , used a randomized controlled test to analyze the consequence of ultrasound therapy in articulatio genus degenerative arthritis. They applied 10 Sessionss of five proceedingss of uninterrupted ultrasound at 1 MHz to the experimental group and fake ultrasound to the control group to move as a placebo.

They assessed hurting by a ocular parallel graduated table ( VAS ) and found that the lessening in hurting in the experimental group is statistically significantly more than the control group. Therefore they concluded that curative ultrasound can be used efficaciously as a hurting alleviation mode in patient agony from articulatio genus degenerative arthritis.An earlier reappraisal by Brosseau et al. , ( 2001 ) , did non demo ultrasound as clinically of import for hurting alleviation in people with patellofemoral hurting syndrome. However, they were unable to pull a decision sing its usage due to methodological defects and restrictions in the surveies included in this reappraisal.

Soft tissue hurts

Wilkin, Merrick, Kirby and Devor ( 2004 ) studied the consequence of pulsed ultrasound applied one time day-to-day for a hebdomad, on the healing of skeletal musculus in 80 rats.

The consequences suggest that pulsed ultrasound as administered did non speed up or better regeneration of skeletal musculus tissue after bruise. Similarly, Markert, Merrick, Kirby and Devor ( 2005 ) , utilizing a randomized controlled test with rats, found no grounds that specific uninterrupted ultrasound and exercises protocols enhance skeletal musculus tissue regeneration following bruise hurt.Takakura et Al. ( 2002 ) investigated the consequence of low-intensity pulsed ultrasound on the rate of healing of injured median collateral ligaments of rat articulatio genuss and found a important betterment in the mechanical belongingss on the 12th twenty-four hours, which nevertheless was lost by the 21st twenty-four hours. Nevertheless they besides observed a larger average filament diameter in the ligaments treated with ultrasound, reasoning that low strength pulsed ultrasound enhances the early healing of median indirect ligament hurts.Ebenbichler et al. , ( 1999 ) investigated the consequence of ultrasound in the intervention of calcific tendonitis. This survey suggests better results with ultrasound intervention.

Since lone patients with calcific tendonitis diagnosed by diagnostic imagination were included in the survey, consequences are more valid than if legion shoulder pathologies with different cellular procedure were included. This survey was included in the reappraisal by Alexander et al. , ( 2010 ) . The latter carried out a reappraisal from assorted electronic databases and identified eight randomised controlled tests out of a sum of seven hundred and twenty seven, which met their inclusion standards. All the surveies reviewed focused on shoulder musculoskeletal upsets. They concluded that statistically important betterments were observed by and large in surveies which used higher degrees of entire energy and those who used longer exposure times. They noted favorable results when at least 2,250J per intervention session was applied.

This is farther suggested by the frequence resonance hypothesis, which suggests that the mechanical energy produced by the ultrasound moving ridge may be absorbed by proteins, changing the construction of single proteins or altering the map of a multi-molecular composite. Thus it may impact enzymatic proteins, bring oning impermanent conformational displacements, and therefore change the enzyme activity and cell map. This hypothesis implies that different frequences will do alone resonant or shearing forces which will hence hold specific effects at cellular and molecular degrees ( Johns, 2002 ) . Therefore farther reappraisals should turn to different parametric quantities used in different surveies, in effort to set up effectual doses.

Blood flow

Baronial, Lee, and Griffith-Noble ( 2007 ) applied ultrasound at 3 MHz frequence and 1 Wcm-2 for 6 proceedingss to measure its consequence upon cutaneal blood flow by laser Doppler flowmetry. They besides measured skin temperature. They concluded that cutaneal blood flow increased significantly with ultrasound even though no important alterations in temperature had occurred. Nevertheless, blood flow alterations in skeletal musculuss have non yet been established.

Robinson and Buono ( 1995 ) , investigated the consequence of uninterrupted ultrasound on blood flow utilizing 1.5 Wcm2 strength for 5 proceedingss and found no important alteration in skeletal musculus blood flow.

Wound mending

Other writers have studied the healing rates varicose ulcers by ultrasound and found more pronounced healing of insonated ulcers ( Dyson, Franks, & A ; Suckling, 1976 ) . However more recent surveies suggest that ultrasound does non hold an influence on the acceleration of mending or concluding phase of the lesion healing ( Dolibog, Franeki, Taradai, Blaszczak, & A ; Cierpka, 2008 ) . Different findings may be attributed to the different nature of the hurts studied and the different manner by which the effectivity of ultrasound is assessed.

Diagnosis of emphasis breaks

Romani and his co-workers ( 2001 ) , were some of the few people who investigated the effectivity of ultrasound therapy in the diagnosing of emphasis breaks.

They used 1 MHz of uninterrupted ultrasound therapy in 26 topics with hurting in the shinbone since less than 2 hebdomads. Each topic completes a ocular parallel graduated table after each different strength was applies to measure the hurting response to ultrasound. An MRI was taken to determine the diagnosing. However none of those who were found to hold a stress break by MRI were right diagnosed by ultrasound.Following this reappraisal of literature, it is suggested that there may be a specific curative window for ultrasound therapy. Conflicting consequences were obtained, perchance due to the different doses and frequences used in assorted surveies, bespeaking the demand for farther hereafter research to place the most effectual parametric quantities. Fortunately, none of the surveies reviewed mentioned any negative effects on patients, doing ultrasound a comparatively safe mode when safeguards are taken, and therefore would do an of import physical therapy mode if its usage is justified.


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