Ultrasound Use in the Treatment of Osteoarthritis

Submitted by: Tyler Booth, Brooklyn Foy, Josiah Myers, and Lauren Wu
Introduction

Ultrasound (US) therapy is a physical therapy modality that is based on the concept of an

induced biological response within a patients tissue resulting from the mechanical energy

produced by differing sound wave frequencies1. While US has been widely used to produce

thermal effects in tissue for the past 50 years, therapeutic applications for pulsed USwith

nonthermal effectshave still been developing over the past 20 years. US application leads to

mechanical events, including cavitation, microstreaming, and acoustic streaming, which are

thought to lead to the nonthermal effects of US. Due to the increased cellular level and vascular

responses essential to tissue healing that occur as a result of pulsed US, it is thought to lead to an

enhanced recovery in patients with a variety of pathological conditions2.

Osteoarthritis (OA) is a multifactorial disease commonly treated by physical therapists

that is a major cause of musculoskeletal pain and disability in older adults. It features joint pain,

stiffness, and immobility resulting from the failure of joint cartilage to repair itself. The

Osteoarthritis Research Society International (OARSI) has twenty-five recommendationsbased

on a systematic review of research evidencefor the treatment of OA, which include both

pharmacological and nonpharmacological therapies. Three of the aims of these treatments are to

reduce joint pain and stiffness, maintain and improve joint mobility, and reduce physical

disability. While pulsed US has been found to enhanced tissue healing and continuous US has

been linked to decreased joint stiffness, US is still not featured in the OARSIs treatment

guidelines3. Therefore, the purpose of this paper is to examine past evidence to determine the

efficacy of US in the treatment of OA.

Literature Summary

Mascarin et al. performed a study to assess the effects of kinesiotherapy (KIN), US, and

electrotherapy in the management of bilateral knee OA4. Participants40 women with bilateral

knee OAwere assigned to three different therapy groups: 16 received kinesiotherapy, 12

received TENS, and the remaining 10 participants received US. Each group underwent 12 weeks

of intervention, twice per week. These modalities were used to investigate their effect on

functional exercise capacity using the 6-minute walk test (6-MWT). Other secondary

measurements included ROM, severity of pain (VAS), and a measure of perceived health and

physical function that was evaluated by the use of the Western Ontario and McMaster

Universities (WOMAC) Osteoarthritis Index.

The KIN protocol consisted of four different isometric exercises; three exercises used a

conventional plastic ball with a diameter of 20 cm and the other used an elastic band with strong

resistance. Each participant had to perform a total of 30 reps that lasted 6 seconds with an

interval of about 3 seconds and each session lasted for 20 minutes. Participants receiving the

TENS treatment had it delivered by a transcutaneous electrical stimulator with two channels. It

was applied using a frequency of 100 Hz, pulse width of 50 microseconds, intensity set at

patients tolerance level, and at a quadratic biphasic symmetrical pulse. The percutaneous

electrodes were placed on the anterior medial and lateral portions of the knee and applied for 20

minutes. The participants receiving US had a protocol that consisted of continuous US at 1 MHz

and 0.8 W/cm2. An acoustic gel was used and was applied with a 5-cm diameter applicator to the

medial and lateral parts of the knee in circular movements. The sessions usually lasted about 3-4

minutes depending upon knee size due to edema.

 Results of statistical analysis indicated that both the KIN and US groups showed to have

significantly higher 6-MWT distances compared to electrotherapy. However, the VAS for pain

showed a statistically significant decrease in all the experimental groups for each modality. In

conclusion, Mascarin et al. demonstrated that US use on patients with knee OA is linked to

improvements in the 6-MWT, which represents an increase in functional exercise capacity.

Tascioglu et al. conducted a study to assess the short-term effectiveness of US therapy in

knee osteoarthritis5. This was a randomized, placebo-controlled, double blind study that involved

90 patients with knee OA. Patients were randomly assigned into three groups. Group 1 received

continuous US at 1 MHz and 2 W/cm2. These were applied with a 5-cm diameter applicator for 5

minutes each session. Group 2 received pulsed US at the same criteria stated above. Group 3

received placebo US for 5 minutes each session. All three groups received treatment 5 days a

week for 2 weeks. US was applied to the superomedial and lateral parts of the knee in a circular

motion.

The primary outcome being looked at was knee pain associated with movement--assessed

using the VAS. Secondary outcomes were the WOMAC, knee ROM, and a 20-meter walking

time. Compared with the baseline scores, there were significant improvements observed in the

VAS pain scores and the WOMAC from all three groups. The overall reductions in pain and

WOMAC scores were significantly higher in those patients treated with pulsed US compared to

the placebo group. In conclusion, it is inferred that the use of pulsed US is an effective treatment

modality for patients with knee OA.

zgnenel et al. conducted a study to assess the effectiveness of therapeutic US in knee

OA6. Participants were adults (45-65 yrs) who had recently been diagnosed with knee OA. The

primary outcome measure was knee pain during movement, which was assessed by VAS. The
secondary outcome measures were WOMAC scores and 50-meter walking time. Participants

were randomly assigned to receive therapeutic US or to receive sham ultrasound. In the group

receiving therapeutic US, an aqueous gel was used as a coupling medium for a 25cm2 treatment

area on the target knee. Continuous US was used at 1 MHz and 1 W/cm2. A 4 cm diameter

applicator was used for 5 minutes of therapy in each session. The placebo group received the

same procedure for US, but a cable was disconnected from the back of the machine. Patients

came in 5 times a week for 2 weeks to receive 10 total treatments.

After the intervention, VAS measurements significantly improved in both groups,

showing reduced knee pain during movement. The placebo groups pain was reduced on average

by 20.6% compared to 42.8% in the treatment group. As for secondary outcomes, the total

WOMAC score improved significantly for the treatment group, as did 50-meter walking time.

These results indicate that therapeutic US may be an effective intervention for the reduction of

pain and increase in physical functioning in patients with knee OA.

Huang et al. conducted a study analyzing the therapeutic effects of US treatment coupled

with isokinetic exercise for patients with knee OA7. Participants were 120 patients with bilateral

moderate knee OA who were randomly assigned to 4 groups--each receiving treatments 3 times a

week for 8 weeks. Groups II and III received isokinetic exercise with continuous and pulsed US,

respectively. Group I only received isokinetic exercise and Group IV served as the control group,

not receiving exercise or US. However, every group received 20 minutes of hot packs, 5 minutes

of passive ROM exercise using a stationary bike, and muscle strengthening exercises. Outcome

measures (measured before, after, and 1-year post-treatment) included changes in knee ROM,

pain severity, disability, ambulation speed, and muscle peak torques during knee flexion and

extension.
 For the groups receiving US, the areas of application were the medial collateral ligament,

anserine bursa and tender points of the popliteal fossa. For group II, continuous US with a

frequency of 1 MHz and a spatial and temporal peak intensity of 1.5 W/cm2 was applied for 5

minutes at each treatment area. For the pulsed US in group III, the duty cycle was set at 25%

with a frequency of 1 MHz and a spatial and temporal peak intensity of 2.5 W/cm2 for 5 minutes

at the treatment areas. For both groups, the intensity of US was adjusted to the level where the

patient felt a mild sting or a warm sensation. Isokinetic exercises included concentric muscle

contractions for extensors, and both eccentric and concentric contractions for flexors.

After the treatments, patients scores in groups II and III increased significantly for ROM

after treatment and in the follow-up period. All groups showed significant decreases in pain after

treatment, but patients in groups II and III were the only groups with significantly decreased pain

at follow-up. For disability (measured by the Lequesne Index), patients in group III had the

greatest reduction in scores after treatment and at follow-up. Furthermore, patients in groups II

and III increased their average ambulation speed significantly after treatment, but all treated

groups showed significant improvements at follow-up. Patients in groups II and III also

demonstrated significantly increased average peak torque after treatment and during follow-up.

Overall, Group III seemed to show the greatest improvements: greatest increase in ROM,

the greatest reduction of pain, greatest reduction in disability, greatest increase in ambulation

speed, and the most improvement in peak torque both after treatment and at follow-up for all

outcome measures. This study suggests that isokinetic strengthening exercise can be coupled

with US (especially pulsed US) to treat soft tissue pain in patients with knee OA.

Falconer et al. conducted a study to investigate the effectiveness of US therapy in

combination with exercise compared to US without exercise in patients with knee OA8.
Participants were 69 patients with an OA diagnosis and knee contracture. Patients with total knee

replacements and connective tissue tightness were allowed to participate if at least 6 months had

passed since the surgery, but were analyzed separately from other participants. Participants were

randomly assigned to either US or sham US treatments. Outcome measures included active

ROM, knee pain, and gait velocity.

The parameters for the US group (n = 34) were set at 1 MHz, using a 10 cm2 sound head.

US was applied using an aqueous gel in areas approximately 100 cm2 anterior, posterior, medial

and lateral to the knee. Treatment times were 3 minutes in each area at an intensity that

progressively increased from 0.0 to 2.5 W/cm2. Following US, all participants followed a 30-

minute exercise regimen including passive stretching, tibiofemoral grade-3 or grade-4 glides,

active ROM, and exercises for isometric strengthening. Participants underwent 12 treatments

scheduled at 2-3 times per week during a period of 4-6 weeks and were given home exercise

programs identical to the clinical exercise program. The sham US group (n = 35) experienced an

identical protocol, except for receiving a sham-US procedure.

Results concluded that the average active ROM for the US group was slightly higher at

post-treatment and follow-up evaluation than sham US. Pain scores were found to be slightly

lower for US group than for sham US at baseline, post-treatment, and follow-up. As a whole,

77% of patients experienced active ROM improvements, 71% experienced decreased knee pain,

and 72% experienced increases in gait velocity. Falconer et al. concluded that US is not an

effective method for increasing active ROM and alleviating pain because the experimental group

receiving US was not shown to be significantly different from the control group receiving the

placebo treatment.
 A study conducted by Loyola-Sanchez et al. examined the effect of pulsed US on

cartilage thickness, physical function, and overall level of pain in patients with knee OA1.

Researchers performed a double-blind, randomized placebo-controlled pilot on 27 adults (>45

yrs) with medial joint space narrowing secondary to knee OA. Any participants with recent (<6

months) surgical interventions or intraarticular injections were excluded from the study. Fourteen

participants received active US therapy at 1 MHz and average temporal intensity of 0.2 W/cm2

with a sound head area of 5 cm2. US was applied for 9.5 minutes at a 20% duty cycle for 24

sessions over 3 weeks. The sound head was held medial to the patellar tendon over the

tibiofemoral joint. In contrast, the remaining 13 participants received sham US therapy with an

identical US device that lacked a sound-head crystal.

Statistical analysis found that age was a confounding variable--due to positive correlation

between age and cartilage deterioration--and therefore age was used as a covariate in analysis of

the data. A one-way multivariate analysis used the presence of US as the independent variable.

Dependent variables included cartilage volume and cartilage thickness (measured using magnetic

resonance imaging), joint pain, physical function, and joint stiffness (measured using the

WOMAC). Results from statistical analysis concluded that only one dependent variable--medial

tibia cartilage thickness--displayed only small statistically significant differences between active

and sham US groups (90 m; P=.05). All of the other dependent variables exhibited statistically

insignificant changes. Therefore, Loyola-Sanchez et al. found no beneficial effect of US on pain

and physical function in knee OA patients and only a minimal effect on increased cartilage

thickness.
Conclusion

After researching the literature, the consensus is that US therapy is generally effective in

treating patients with osteoarthritis. US was demonstrated to significantly increase functional

exercise capacity as well as decrease pain without the use of other physical therapy interventions,

indicating strong support for the use of this modality4,5. While other studies showed insignificant

results, it was commonly speculated that the benefits of using US could be attributed to the

implementation of other interventions, such as incorporating regular exercise into treatment

programs6,7,8. Only one study concluded that US had no significant impact on treating pain,

functionality, or the pathology of OA itself1. Other varying factors, such as using continuous or

pulsed US, the frequency and duration of treatment sessions, and intensity of US received may

have an impact on the results, but there were no exact parameters established for optimal

treatment of OA.

In conclusion, using US as a physical therapy intervention is an effective method for

treating OA. US has benefits in tissue healing, increasing ROM and functional exercise capacity,

and decreasing joint stiffness and joint pain. For these outcomes, both continuous and pulsed US

appear to be effective techniques for OA. To further optimize the effects of US, it may be

beneficial to incorporate other interventions, such as regular exercise or a structured activity

program, into the care and rehabilitation for this population.

References

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hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines.

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