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Presented by:

Jason Shane, Physical Therapy Student

Ultrasound and Evidence BasedPractice

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Stages of Healing and implementation of USExplain the proposed mechanisms by whichUS provides benefitsUS contraindicationsReview of dosages and settingsSelected clinical indications based on themost recent research (2000-present)

Objectives

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Stages of Healing

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Contraindicated over open wounds dueto infection and possibility of increasedcirculation

First Stage - Bleeding

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US has a stimulating effect on the mast cells,platelets, white cells with phagocytic roles and themacrophagesinduces synthesis of prostaglandins andleukotreine which act as inflammatory mediators

It does not increase the inflammatory responsebut rather optimizes itinflammatory response is essential to theeffective repair of tissuethe more efficiently the process can complete,

the more effectively the tissue can progress to thenext phase, proliferation (Watson 2006)

Second Stage - Inflammation

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US also has a stimulative effect (cellular upregulation)The primary active targets are now thefibroblasts, endothelial cells and

myofibroblastsit does not change the normal events, butmaximizes their efficiency producing therequired scar tissue in an optimal fashion(Watson 2006)

Third Stage - Proliferation

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enhances the appropriate orientation of thenewly formed collagen fibres

enhances the collagen profile change frommainly Type III to a more dominant Type Iconstruction, thus increasing tensile strengthand enhancing scar mobility

Fourth Stage - Remodeling

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The energy transported by an ultrasonicbeamdecreases in intensity as it passes throughtissue.

Energy loss occurs and is due to scatteringout of theUS beam and to absorption

This acoustic absorption results in tissue

heating (Haar 1999)

Proposed MechanismsHeat

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3-MHz ultrasound at 1.5 W/cm2 for 7minutes ~5-6C increase at 1-2 cm (intriceps)

1-MHz ultrasound at 1.5 W/cm2

for 12minutes ~3-4C increase at 3-5 cm(Draper et. al 1995)

Heat Cont.

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Treatment with continuous ultrasound produced amean (SD) temperature increase of 2.8C 0.8Cabove baseline.Treatment with pulsed ultrasound produced amean (SD)temperature increase of 2.8C 0.7C abovebaselineStatistical analysis revealed no significantdifferences in either the extent or rate of

temperature increases between the 2 modes ofultrasound application (Gallo, Draper, et. al

Most recent research on Heat

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

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Using ultrasound to treat a lesion located in atissue that is a poor absorber of the energy is lesslikely to be effective whencompared with treating a tissue which is a betterabsorberof the energy (Watson 2008)A recent paper evaluated the effectiveness oftherapeutic ultrasound immediately followingcontusion injury in muscle (of rats) and no

significant beneficial effects were demonstrated,most likely due to the aforementioned point

Heat and Clinical Decision Making

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Production and vibration of micron-sizedbubbles within the coupling medium andfluids within the tissuesAs the bubbles collect and condense, they

are compressed before moving on to the nextareaThe movement and compression of thebubbles can cause changes in the cellularactivities of the tissues subjected toultrasound (Ennis 2005)

Cavitation

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the movement of fluids along theacoustical boundaries as a result of themechanical pressure wave associatedwith the ultrasound beam

refers to the development of microscopiccavities created by the formation of micro-bubbles.combination of cavitation and

microstreaming, provides a mechanical

Microstreaming

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PregnancyOver the eyeBrain, spinal cord or large subcutaneous peripheral nervesReproductive organsCancerous tissue

Epiphyseal plates in childrenOver acute infection of bone or tissueOver thoracic area if pacemaker presentBlood vessels in poor conditionSource: Health Canada, http://www.hc-sc.gc.ca/ewh-

semt/pubs/radiation/safety-code_23-securite/index-eng.php

Contraindications

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Frequency: most US machines have achoice of 1 or 3 MHzInverse relationship between higherfrequency and depth of penetration

As the frequency increases from 1 to 3 MHz,the depth of penetration decreaseshigher the frequency the less penetration.

Dosages and Settings

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Intensity: Measured in W/cm2

Increasing intensity increases tissueheating, mechanical effects, and depth of

penetration (Davis)

Dosages and Settings Cont.

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Osteoarthritis of the knee:

randomized double blind placebo controlled trial ofUS therapy in knee OAPain and joint function improved after 10 sessions

of therapy spanning over 2 wk with either the realUS or the sham USpatients enrolled in the sham US group showedimprovement only in some pain scores (VAS) andfunction.

Based on these results it was concluded that USthera has been su erior over lacebo in the

Clinical Indications

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In about 410% fractures, impairment of the healingprocess may lead to delayed union or nonunion, requiringfurther surgical proceduresHeckman et al.(1994) performed a multicenter placebocontrol clinical trial on 67 closed or grade-I open tibial

fractures to evaluate the effect of ultrasound on fracturehealingUltrasound treatment led to a significant (24%) reductionin the time to clinical healing, as well as to a 38%decrease in the time tooverall (clinical and radiographic) healing, comparedwith the control group

Bone Healing

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In Heckmans study treatment went for 20weeksBurst width of 200 microsec, 1.5 MHzRepetition rate of 1 kilohertz and spatial

average-temporal average intensity of 30milliwatts per square centimeter

Bone Healing Cont.

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Study done on low-intensity pulsed ultrasoundincreases bone volume in the area of fracturehealing in patients with a delayed union of theosteotomized fibula (Rutten 2008)US significantly increased osteoid thickness by

47%, mineral apposition rate by 27%, and bonevolume by 33%EXOGEN 2000+ low-intensity pulsed ultrasounddeviceat home for a daily 20-minute treatment for 87days200 s burst of 1.5 MHz acoustic sine waves

Bone Healing Cont.

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Therapeutic ultrasound for acute anklesprains (Van der Windt 2006)

Five trials were included, involving 572participants

None of the four placebo-controlled trials(sham ultrasound) demonstrated statisticallysignificant differences between true and shamultrasound therapy for any outcome measure

at seven to 14 days of follow up

Other Clinical Indicationsdid not fare as well

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A Systematic ReviewExposure to Low Amounts of Ultrasound Energy Does Not Improve Soft TissueShoulder Pathology (Alexander 2010))Eight studies included in this review (n=586 patients)favorable patient outcomes in RCTs of therapeutic ultrasound for shoulder painand injury have been noted when ultrasound energy of at least 2,250 J per

treatment session was appliedwhen insufficient ultrasound energy (ie, 720 J per session) was provided, positiveoutcomes rarely occurredresults suggest that the effectiveness of ultrasound on soft tissue pathologieshas not yet been evaluated using optimal treatment parameters. Premature to

conclude through systematic review of existing literature that this treatment doseis not effective (Alexander 2010)

Other Clinical Indicationsdid not fare as wellCont

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Not enough time to fully cover the below 2 inmore detail but:Lower back pain = available evidence does notsupport the effectiveness of ultrasound for treatingLBP (Seco 2010)Capsulitis = results suggest that US comparedwith sham US gives no relevant benefit in thetreatment of adhesive capsulitis (Dogru 2007)

Other Clinical Indicationsdid not fare as wellCont

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Stages of Healing and implementation ofUSExplain the proposed mechanisms bywhich US provides benefitsUS contraindicationsReview of dosages and settingsSelected clinical indications based on themost recent research (2000-present)

Conclusion

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Alexander, Lisa D, David R.D. Gilman, Derek R. Brown, Janet L. Brown,Pamela E. Houghton. Exposure to Low Amounts of Ultrasound EnergyDoes 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 humanmuscle during 1 MHz and 3 MHz continuous ultrasound. J Orthop SportsPhys Ther. 1995;22:142-150.Dogru H., et al. Effectiveness of therapeutic ultrasound in adhesivecapsulitis. 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 arandomized, double-blind, controlled, multicenter trial. Ostomy WoundManage. 2005;51:2439.(unable to download a PDF of the this article)

References

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Gallo, Joseph A, David O. Draper, Gilbert W. Fellingham, Lori Thein Brody. AComparison of Human Muscle Temperature Increases During 3-MHz Continuous andPulsed Ultrasound With Equivalent Temporal Average Intensities. J Orthop Sports PhysTher. 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 SurgAm. 1994;76:26-34.ZGNENEL, LEVENT, EBRU AYTEKIN, and GULIS DURMUSOGLU. Ultrasound.A DOUBLE-BLIND TRIAL OF CLINICAL EFFECTS OF THERAPEUTIC ULTRASOUNDIN 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 JennekeKlein-Nulend, Low-intensity pulsed ultrasound increases bone volume, osteoid

thickness and mineral apposition rate in the area of fracture healing in patients with adelayed union of the osteotomized fibula. Bone. Volume 43, Issue 2, August 2008,Pa es 348-354.

References

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Seco, Jesus, MD, PhD, Francisco M. Kovacs, MD, PhDb, Gerard Urrutia, MD.The efficacy, safety, effectiveness, and cost-effectiveness of ultrasound andshock 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 TherapeuticUltrasound on Skeletal Muscle Regeneration Following Blunt Contusion. Int JSports Med2004; 25(1): 73-77

References