Written by The ‘U Word’ (Therapeutic Ultrasound) has had a lot of press recently thanks to everyone’s favorite “doctor” and unfortunately this modality just cannot be put to rest. Li et al conducted a survey attempting to determine the typical treatment approaches used for patients suffering from low back pain of varying intensities (Acute, Sub-acute, and Acute with Sciatica). The results indicated that almost 80% of therapists used physical modalities for all three scenarios, with Ultrasound (US) being utilized by almost 1/3 of all therapists. Additionally, this study showed that spinal mobilization (40%) and manipulation (5%) were used sparingly, despite the evidence supporting their efficacy. Honestly, I thought it would be worse. A more recent survey by Wong et al sought out the practice patterns of Orthopaedic Certified Specialists (OCS) with regards to the use of ultrasound. This survey of certified experts in our field concluded that of the over 200 respondents, 83.6% use US to decrease soft-tissue inflammation, 70.9% to increase tissue extensibility, 68.8% to enhance scar tissue remodeling, 52.5% to increase soft-tissue healing, 49.3% to decrease pain, and 35.1% to decrease soft-tissue swelling. With such widespread use of this intervention for so many varying reasons, there has to be supporting evidence, doesn’t there?
It has been theorized that US has the ability to heat deeper anatomical structures (i.e. muscle, tendon, and bone), accelerate tissue regeneration, increase pain threshold, stimulate bone growth, and increase tendon extensibility. Sounds pretty good, right?
Problem number one: The majority of the supporting research was conducted between 1950 and 1980.
Problem number two: Results of recent efficacy studies.
Gam et al completed a meta-analysis investigating the use of ultrasound in musculoskeletal disorders. After pooling the outcomes of 29 randomized controlled trials, they concluded that US contributed a negligible amount to the subjects’ rehabilitation. Later, in 1999, van der Windt et al conducted a systematic review of US therapy for musculoskeletal disorders. Of the 18 placebo-controlled studies evaluated, only 2 yielded results that showed US to be beneficial. It was determined that the magnitude of the reported treatment effects were small, and were probably of little clinical importance. To build upon these findings, Robertson et al published a systematic review once again looking into the efficacy of therapeutic ultrasound in the treatment of common musculoskeletal disorders (as determined by randomized controlled trials). Not too surprisingly, of the ten studies that met the inclusion criteria, only 2 studies showed statistically significant benefits (carpal tunnel syndrome and calcific tendinitis of the shoulder).
But, these studies compared treatments of different pathologies… Surely there are pathologies where US is supported?
There have been a few high-quality systematic reviews conducted looking into ultrasound’s therapeutic effect on specific pathologies. Seco et al investigated its efficacy in the treatment of low back pain (remember the Li study?). 242 patients were included in the 4 studies that met the inclusion criteria and none of these studies showed statistically significant benefits. In addition, one of the studies included (Mohseni-Bandpei et al) looked into the effectiveness of US versus spinal manipulation. They evaluated the outcomes of 116 patients over 6 months and found that spinal manipulation demonstrated greater improvements in pain, disability, flexion ROM, and extension ROM (remember the Li study?). It is postulated that only tissues that are superficial can be affected, so maybe that’s why the effects on LBP are minuscule.
The lateral ankle ligaments are superficial, so surely US will be of benefit, right? A Cochrane Review was published by van den Bekerom et al investigating just that hypothesis. This review included 6 studies and over 600 patients, but once again US did not provide the benefits that many are led to believe. No statistically significant benefits were found for improvements in pain, swelling, functional disability, or range of motion in any of the 6 studies.
Clinical instructors and colleagues continue to use this poorly supported intervention, but shy away from those interventions supported by current research. The Li and Wong studies say it all. We need to educate our fellow colleagues about the ineffectiveness of what has become a mainstay in many outpatient physical therapy and chiropractic offices. Why do we continue to utilize old, outdated interventions? Is it fear of change? Is it stubbornness? Is it a lack of awareness?
Regardless of the reason, our clinical practice patterns need to change. The evidence is lopsided contrary to previous beliefs regarding ultrasound’s efficacy in treating musculoskeletal pain/dysfunction and we, as a profession, must adapt and move on. So, unless you are treating a huge proportion of calcific tendonitis of the shoulder or carpal tunnel syndrome, just keep your ultrasound machine in the storage closet.
Continued Reading…
John Snyder, DPT 
I apologize for my brevity. I am a PP owner and one of the “Old” PTs w/o a Masters or Doctorate, but I had over 260 credit hours of College work, 7 years total, graduated with Honors and scored in the 90% of the State PT Lic exam. I’ve worked hard to develop my practice skills and my practice and business. I attend over 30-40 hrs of Cont educ each year to stay abreast with up to date science and clinical “best tx” approaches only to have to compete with many POPTs that are staffed by “DPTs” that often times don’t give the quality care and time the patient deserves in order to keep the “revenue up” for the Dr’s “deep pockets” and that only hurts the chance of themselves to ever have/own their own clinic. I’ve followed your blog but recently noticed what I perceive as a bit of a “Confidence” level as though we all need to be DPTs. I don’t agree. It has not achieved what it was supposed to; help us become more independent and free us from having to be dependent on the Dr’s for our referral base etc.. I see more and more DPTs working for POPTS and it is killing our independence. I see both sides, kids graduating with Huge Student loan debt and needing a job vs understanding that working for the Dr’s is just killing and competing directly with PT owned PT PP clinics. I don’t mind a good for “fight”/competition, but I don’t get to “control” the patient flow, what they know, that they can “choose their own PT and not have to go to the POPTs, so the Dr offices “Kindly” refer them around the corner, or is some instances, “the very next door office” (how convenient) to be seen by “their PT” that just happens to be a DPT. Isn’t that convenient also. And in order for the DPT to keep their job “Value” the tell the patient “their clinic is the best” and don’t go down to the other place (the one that just happens to be owned and run by the PP PT) and the patients listen because how could they know any better?? Now, until we somehow get some laws that prevent Dr’s from referring to themselves us “OLD Non DPTs” have to compete against that??? We have and we do because we are the ones that paved the way for the DPTs and now they are “shooting our” profession in the foot and deeply hurting their chances of ever owning their own clinics………… Wasn’t that one of the reasons for all the extra “education”? I could write more, but I have to get back to work, my days are long and hard,…….and I love it, just give me a level playing field and I like my chances. I suggest you go and shadow and “OLD PT” someday and see just how much they know, then ask yourself if you would rather have their experience and savvy or you knew DPT. I for one am tired of hearing how much better the new PTs are vs the OLD. Its not very accurate to say the least and won’t matter much longer if the majority of the neW DPT grads just go work for the POPTs. Enough said. Good luck to you. JVD PT Date: Thu, 7 Feb 2013 12:17:43 +0000 To: jvandyke1@hotmail.com
LikeLike
Jim,
I’m assuming you meant to post this under the “What’s in a Title?” (http://orthopedicmanualpt.com/2013/02/04/whats-in-a-title/) article? I have reposted this comment there for you. Thanks!
LikeLike
What about the idea that using Ultrasound as a placebo effect for the patient. The patient can think “oh i’m getting some advanced technology used on me, I feel better already”. Is this a negative modality if the patient feels relief and becomes pain free?
LikeLike
Jeff,
I agree that there is likely a profound placebo effect. However, with that said, is it ethical to be offering a patient a modality that you know to be ineffective just to gain the placebo effect? Can we get this same placebo effect with an intervention that is actually effective? I believe this is where pain science education comes into play and reducing the fears of our patients. I welcome your thoughts and comments.
LikeLike
Unfortunately, I think there may also be a nocebo effect in that case too. As PTs, especially as “Doctors” (aka Teachers), we need to teach and empower our patients so that next time they get a little ankle twinge, they don’t come running back for more US.
LikeLike
Before casting ultrasound completely aside as an intervention it might be worth considering the effect dosing might have in the outcomes of some of these studies. The different trials included in the literature reviews used ultrasound treatments delivered with a wide range of different variables (frequency, intensity, time) yet the treatments are compared as if they are identical. An analogy to this might be looking at a group of findings from studies that include manual therapy as an intervention, but without specifying or controlling for the techniques used, amount of force applied, duration of each treatment etc., but still making a determination on the effectiveness of manual therapy as if these variables were not relevant. Another example might be doing a systemic review on the effectiveness of a particular medication, but then including a majority of studies that are delivering a sub-therapeutic dose for the desired effect.
The discussion in Robertson study had this to say regarding dose: “No underlying patterns were evident except possibly that the studies with significant outcomes were among those using a higher total energy output.” I’d like to see a study designed that had the amount of energy being delivered as a variable. If ultrasound is supposed to have a specific physiologic effect, wouldn’t it make sense to establish if there is a minimal dose required to achieve that effect?
Based on the bulk of evidence it would seem there are better treatments at our disposal than ultrasound, but to flatly dismiss it based on the available research would mean overlooking this potentially important factor. It’s still possible that regardless of the dose, ultrasound would still fail to deliver clinically meaningful improvements, so it may not even be worth researching at this point. To be fair though, if we are going to say it is ineffective we should also note that standardized experimental and treatment protocols have not been established.
LikeLike
I could not agree more. Clinic owners need to throw away thier ultrasound units. I have a hard time believing that there are many therapists that do not realize that what they are doing in strictly placebo when they use ultrasound. It is a lazy and ineffective way to make patients feel like they are being “treated”
LikeLike
There is some evidence for the short term benefits of US in superficial tendinitis. Also lateral epicondylitis and wound healing. As a means to provide local temperature increase for athletes and performing artists before events or performances, there is evidence, however it is not strong.
LikeLike
I think that this is the key point. We sometimes embrace things that show some “evidence” of efficacy despite the treatment effect being practically negligible to the patients progress. This becomes a problem when these interventions are chosen and the basics of good rehab are ignored.
Adam D. Brown. BSc PT, MClSc PT, Cert. MDT, FCAMPT. Advanced Practice Clinician (Spine) Director – Cornerstone Physiotherapy T: 416.595.5353 F: 416.595.5354 E: adam@cornerstonephysio.com W: Cornerstonephysio.com
LikeLike
Placebo can be a powerful and very beneficial aspect of any modality, manual technique, or exercise intervention. This placebo can very well improve your patient outcomes, but is this the best we can do? Placebo is not isolated to passive modalities, it is present during any significant one-on-one time that you have with your patient. Utilize this aspect of treatment by using evidence-based or, at the very least, biologically plausible interventions. Read “Don’t Be a Sugar Pill” by Harrison Vaughn, DPT (http://intouchpt.wordpress.com/2012/08/16/dont-be-a-sugar-pill/).
There are always imperfections in any study design. Could the dosage have been more uniform across studies? Of course. However, I truly doubt it would have rendered US any more effective. As was stated within the blog post, there is moderate evidence to support US use for calcific tendinitis of the shoulder… So, if you see this on a regular basis, have at it. Wound care is a different animal and, in general, US is supported by the literature… So, if you see this on a regular basis, have at it. Otherwise, it might behoove you to leave your ultrasound gel at the OB/GYN.
LikeLike
In Gam et al “One question remaining is whether ultrasound treatment can augment an effect of exercise therapy with respect to musculoskeletal disorders.” In the other studies and review of the literature, was the benefit of US followed by hands on therapeutic techniques (MFR,AST, S-CS, Jt. mob, PROM, etc) measured in compared to those same techniques for the same diagnosis provided by the same provider without US?
I do not know of many providers — esp those with OCS that would perform US independent of utilizing hands on techniques.
LikeLike
Thank you for pointing out what should be obvious–ONLY a tool in the box per se. I have found, in over 17 years of practice, that it can reduce sensitivity to allow improved tolerance of manual techniques, etc.–not scientific, just good old fashioned patient reporting and personal experienced based evidence.
LikeLike
Is anyone out there using US imaging for tx in practice? I have seen one clinic that uses US imaging as a biofeedback mechanism in order for patients to achieve contraction of the deep abdominals.
LikeLike
I personally can’t imagine why insurance companies still pay for it…I think PT should use it as a bargaining chip. “We’ll stop using therapeutic ultrasound if you actually review evidence for PT interventions, and reward those who use it!” I would however like to use a diagnostic US…would probably be fun for a while
LikeLike
I agree – diagnostic ultrasound could be a great future tool for PT’s. I have seen it used by sport med docs to confirm tendinopathies etc. I have also seen it used as biofeedback for TrA contraction although I would be less inclined to do that simply because I think there is entirely too much focus on the isolation of transverse abs in the physio world. But that is another discussion entirely ;).
LikeLike
While I can understand your feelings about ultrasound, and personally don’t use it, take a look at the “Guide to Physical Therapist Practice” published by the APTA. Ultrasound is still listed as an accepted intervention. It will be hard to gain much momentum in eliminating or limiting ultrasound from PT practice when the APTA still endorses it.
LikeLike
I stopped using US a long time ago. One of the last uses for US for me was simply for severe bruising following surgeries like THR.. But Kinesio tape fans were far supperior so I haven’t used US in years.
Very disappointing to hear so many OCS’s use it. Takes away from that title.
I will say that Jim did have a point regarding parameters. There was a time many years ago when .5 pulsed was showing interesting success.
For me, US just never panned out. For heat, I will use a HP which I rarely use. I prefer manual for soft tissue and scar.
To use it as a placebo when you can do treatments that are more beneficial also yielding results makes no sense to me at all
Clinical experience and research removed US from my practice a long time ago
LikeLike
David, I enjoyed reading your response, and please don’t take this personally. While we all seem to be unanimous in our distaste for ultrasound due to lack of evidence, I am curious as to your endorsement of kInesio tape. From my reading, it seems to be no better than sham taping. Am I missing something?
LikeLike
Thank you for starting this discussion. I do not use US, in favor of mobilization, XFM, exercise, and most importantly, patient education. Still, I frequently get requests for it from referring MD’s and patients. I appreciate your summary of the research, as it will help me explain to patients why other interventions will be more helpful and a better use of time and money.
LikeLike