Ultrasound and Evidence Based Practice

Presented by: Jason Shane, Physical Therapy Student

Objectives
Stages of Healing and implementation of US

Explain the proposed mechanisms by which

US provides benefits US contraindications Review of dosages and settings Selected clinical indications based on the most recent research (2000-present)

Stages of Healing

First Stage - Bleeding

Contraindicated over open wounds due

to infection and possibility of increased circulation

Second Stage - Inflammation

US has a stimulating effect on the mast cells,

platelets, white cells with phagocytic roles and the macrophages induces synthesis of prostaglandins and leukotreine which act as inflammatory mediators It does not increase the inflammatory response but rather optimizes it inflammatory response is essential to the effective repair of tissue the more efficiently the process can complete, the more effectively the tissue can progress to the next phase, proliferation (Watson 2006)

Third Stage - Proliferation

US also has a stimulative effect (cellular up

regulation) The primary active targets are now the fibroblasts, endothelial cells and myofibroblasts it does not change the normal events, but maximizes their efficiency producing the required scar tissue in an optimal fashion (Watson 2006)

Fourth Stage - Remodeling

enhances the appropriate orientation of the

newly formed collagen fibres enhances the collagen profile change from mainly Type III to a more dominant Type I construction, thus increasing tensile strength and enhancing scar mobility

Proposed Mechanisms Heat

The energy transported by an ultrasonic

beam decreases in intensity as it passes through tissue. Energy loss occurs and is due to scattering out of the US beam and to absorption This acoustic absorption results in tissue heating (Haar 1999)

Heat Cont.
3-MHz ultrasound at 1.5 W/cm2 for 7 minutes ~5-6C increase at 1-2 cm (in triceps) 1-MHz ultrasound at 1.5 W/cm2 for 12 minutes ~3-4C increase at 3-5 cm (Draper et. al 1995)

Most recent research on Heat

Treatment with continuous ultrasound produced a

mean (SD) temperature increase of 2.8C 0.8C above baseline. Treatment with pulsed ultrasound produced a mean (SD) temperature increase of 2.8C 0.7C above baseline Statistical analysis revealed no significant differences in either the extent or rate of temperature increases between the 2 modes of ultrasound application (Gallo, Draper, et. al

Heat Absorption
Tissues with a higher protein content will absorb US to a

greater extent (e.g. ligament, tendon) Tissues with high water content and low protein content (e.g. blood and fat) absorb little of the US energy (Watson 2008)

Heat and Clinical Decision Making

Using ultrasound to treat a lesion located in a

tissue that is a poor absorber of the energy is less likely to be effective when compared with treating a tissue which is a better absorber of the energy (Watson 2008) A recent paper evaluated the effectiveness of therapeutic ultrasound immediately following contusion injury in muscle (of rats) and no significant beneficial effects were demonstrated, most likely due to the aforementioned point

Cavitation
Production and vibration of micron-sized

bubbles within the coupling medium and fluids within the tissues As the bubbles collect and condense, they are compressed before moving on to the next area The movement and compression of the bubbles can cause changes in the cellular activities of the tissues subjected to ultrasound (Ennis 2005)

Microstreaming
the movement of fluids along the

acoustical boundaries as a result of the mechanical pressure wave associated with the ultrasound beam refers to the development of microscopic cavities created by the formation of microbubbles. combination of cavitation and microstreaming, provides a mechanical

Contraindications
Pregnancy Over the eye Brain, spinal cord or large subcutaneous peripheral nerves Reproductive organs Cancerous tissue Epiphyseal plates in children Over acute infection of bone or tissue Over thoracic area if pacemaker present Blood vessels in poor condition

Source: Health Canada, http://www.hc-sc.gc.ca/ewhsemt/pubs/radiation/safety-code_23-securite/index-eng.php

Dosages and Settings

Frequency: most US machines have a

choice of 1 or 3 MHz Inverse relationship between higher frequency and depth of penetration As the frequency increases from 1 to 3 MHz, the depth of penetration decreases higher the frequency the less penetration.

Dosages and Settings Cont.

Intensity: Measured in W/cm2 Increasing intensity increases tissue

heating, mechanical effects, and depth of penetration (Davis)

Clinical Indications
Osteoarthritis of the knee: randomized double blind placebo controlled trial of US therapy in knee OA Pain and joint function improved after 10 sessions of therapy spanning over 2 wk with either the real US or the sham US patients enrolled in the sham US group showed improvement only in some pain scores (VAS) and function. Based on these results it was concluded that US therapy has been superior over placebo in the

Bone Healing
In about 410% fractures, impairment of the healing

process may lead to delayed union or nonunion, requiring further surgical procedures Heckman et al.(1994) performed a multicenter placebo control clinical trial on 67 closed or grade-I open tibial fractures to evaluate the effect of ultrasound on fracture healing Ultrasound treatment led to a significant (24%) reduction in the time to clinical healing, as well as to a 38% decrease in the time to overall (clinical and radiographic) healing, compared with the control group

Bone Healing Cont.

In Heckmans study treatment went for 20

weeks Burst width of 200 microsec, 1.5 MHz Repetition rate of 1 kilohertz and spatial average-temporal average intensity of 30 milliwatts per square centimeter

Bone Healing Cont.

Study done on low-intensity pulsed ultrasound

increases bone volume in the area of fracture healing in patients with a delayed union of the osteotomized fibula (Rutten 2008) US significantly increased osteoid thickness by 47%, mineral apposition rate by 27%, and bone volume by 33% EXOGEN 2000+ low-intensity pulsed ultrasound device at home for a daily 20-minute treatment for 87 days 200 s burst of 1.5 MHz acoustic sine waves

Other Clinical Indications did not fare as well

Therapeutic ultrasound for acute ankle

sprains (Van der Windt 2006) Five trials were included, involving 572 participants None of the four placebo-controlled trials (sham ultrasound) demonstrated statistically significant differences between true and sham ultrasound therapy for any outcome measure at seven to 14 days of follow up

Other Clinical Indications did not fare as wellCont

A Systematic Review
Exposure to Low Amounts of Ultrasound Energy Does Not Improve Soft Tissue

Shoulder Pathology (Alexander 2010)) Eight studies included in this review (n=586 patients) favorable patient outcomes in RCTs of therapeutic ultrasound for shoulder pain and injury have been noted when ultrasound energy of at least 2,250 J per treatment session was applied when insufficient ultrasound energy (ie, 720 J per session) was provided, positive outcomes rarely occurred results suggest that the effectiveness of ultrasound on soft tissue pathologies has not yet been evaluated using optimal treatment parameters. Premature to conclude through systematic review of existing literature that this treatment dose is not effective (Alexander 2010)

Other Clinical Indications did not fare as wellCont

Not enough time to fully cover the below 2 in

more detail but: Lower back pain = available evidence does not support the effectiveness of ultrasound for treating LBP (Seco 2010) Capsulitis = results suggest that US compared with sham US gives no relevant benefit in the treatment of adhesive capsulitis (Dogru 2007)

Conclusion
Stages of Healing and implementation of

US Explain the proposed mechanisms by which US provides benefits US contraindications Review of dosages and settings Selected clinical indications based on the most recent research (2000-present)

References
Alexander, Lisa D, David R.D. Gilman, Derek R. Brown, Janet L. Brown,

Pamela E. Houghton. Exposure to Low Amounts of Ultrasound Energy Does Not Improve Soft Tissue Shoulder Pathology: A Systematic Review. Physical Therapy. Volume 90 Number 1 January 2010. Draper, DO, Castel JC, Castel D. Rate of temperature increase in human muscle during 1 MHz and 3 MHz continuous ultrasound. J Orthop Sports Phys Ther. 1995;22:142-150. Dogru H., et al. Effectiveness of therapeutic ultrasound in adhesive capsulitis. Joint Bone Spine. 75 (2008) 445-450. Ennis, WJ, ForemannP, Mozen N, Massey J, Conner-Kerr T, Meneses P. Ultrasound therapy for recalcitrant diabetic foot ulcers: Results of a randomized, double-blind, controlled, multicenter trial. Ostomy Wound Manage. 2005;51:2439.(unable to download a PDF of the this article)

References
Gallo, Joseph A, David O. Draper, Gilbert W. Fellingham, Lori Thein Brody. A

Comparison of Human Muscle Temperature Increases During 3-MHz Continuous and Pulsed Ultrasound With Equivalent Temporal Average Intensities. J Orthop Sports Phys Ther. 2004;34(7):395-401. Haar, G. ter. Review Therapeutic ultrasound. European Journal of Ultrasound, 9 (1999) 39. Heckman, JD, JP Ryaby, J McCabe, JJ Frey and RF Kilcoyne. Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound. J Bone Joint Surg Am. 1994;76:26-34. ZGNENEL, LEVENT, EBRU AYTEKIN, and GULIS DURMUSOGLU. Ultrasound. A DOUBLE-BLIND TRIAL OF CLINICAL EFFECTS OF THERAPEUTIC ULTRASOUND IN KNEE OSTEOARTHRITIS in Med. & Biol., Vol. 35, No. 1, pp. 4449, 2009. Rutten, Sjoerd, Peter A. Nolte, Clara M. Korstjens, Marion A. van Duin and Jenneke Klein-Nulend, Low-intensity pulsed ultrasound increases bone volume, osteoid thickness and mineral apposition rate in the area of fracture healing in patients with a delayed union of the osteotomized fibula. Bone. Volume 43, Issue 2, August 2008, Pages 348-354.

References
Seco, Jesus, MD, PhD, Francisco M. Kovacs, MD, PhDb, Gerard Urrutia, MD.

The efficacy, safety, effectiveness, and cost-effectiveness of ultrasound and shock wave therapies for low back pain: a systematic review. The Spine Journal. 2011. Van der Windt DAWM, Van der Heijden GJMG, Van den Berg SGM, Ter Riet G, De Winter AF, Bouter LM. Therapeutic ultrasound for acute ankle sprains (Cochrane Review). In: The Cochrane Library, Issue 1, 2006. Watson, Electrotherapy and Tissue Repair, Sport Ex., 2006. Watson, T. Ultrasound in contemporary physiotherapy practice. Ultrasonics. 48 (2008) 321329. Wilkin, L.D., M. A. Merrick, T. E. Kirby, S. T. Devor. Influence of Therapeutic Ultrasound on Skeletal Muscle Regeneration Following Blunt Contusion. Int J Sports Med 2004; 25(1): 73-77