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Ultrasonics 48 (2008) 321–329


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Ultrasound in contemporary physiotherapy practice


Tim Watson *
University of Hertfordshire, School of Health and Emergency Professions, College Lane, Hatfield AL10 9AB, United Kingdom

Received 27 June 2007; received in revised form 29 February 2008; accepted 29 February 2008
Available online 17 March 2008

Abstract

The use of therapeutic ultrasound as an element of physiotherapy practice is well established, but the nature of that practice has chan-
ged significantly over the last 20 years. This paper aims to review the rationale and range of applications for which this modality is
employed in current practice. Whereas in the past, its primary use was as a thermal modality, it is argued that currently, it is the
‘non-thermal’ aspects of the intervention that are most commonly employed. The predominant use of therapeutic ultrasound is in rela-
tion to tissue repair and soft tissue lesion management, where the evidence would support its application in the inflammatory, prolifer-
ative and remodelling phases. The clinical outcomes appear to be dose dependent, and whilst this paper does not detail dose related
clinical decision making, the broad issues are considered. The future possibilities for the use of the modality are reviewed, and although
outside the immediate remit of this paper, the use of therapeutic ultrasound in fracture management is briefly considered.
Ó 2008 Elsevier B.V. All rights reserved.

Keywords: Ultrasound therapy; Soft tissue injury; Tissue repair

Contents

1. Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
2. Historical use and recent developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
3. Physics related issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
3.1. Coupling media. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
3.2. Absorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
4. Thermal vs. non-thermal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
5. Ultrasound in soft tissue repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
5.1. Ultrasound in fracture repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
6. Clinical issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
6.1. Machine calibration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
6.2. Potential infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
6.3. Dose issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
6.4. Overlap between modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
7. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328

*
Tel.: +44 (0) 1707 284970.
E-mail address: t.watson@herts.ac.uk
URL: http://www.electrotherapy.org

0041-624X/$ - see front matter Ó 2008 Elsevier B.V. All rights reserved.
doi:10.1016/j.ultras.2008.02.004
322 T. Watson / Ultrasonics 48 (2008) 321–329

1. Scope have a direct influence of practice and will therefore be


identified in that context.
Although therapeutic ultrasound has been used for over
50 years in physiotherapy, its use in the clinical environment 3.1. Coupling media
has changed significantly over this period, and whereas in
the past, its use was primarily for its thermal effect, it is Ultrasound will be reflected at the metal/air interface
now more widely employed for its ‘non-thermal’ effects, found at the treatment head, it is necessary to provide a
especially in relation to tissue repair and wound healing. medium through which the ultrasound can freely pass in
There is a substantial volume of published evidence order to reach the patients tissues. This medium is most
relating to the effects and use of ultrasound as a therapeutic commonly referred to as a coupling medium, and several
modality, and the overall aim of this paper is to review the different types are used in practice. Given that the job of
current use of ultrasound in the realm of physiotherapy the coupling medium is to allow transmission of the ultra-
and associated practice, providing an overview of key sound, a coupling medium that absorbs, changes or dis-
issues. Whilst considering the evidence and providing key turbs the ultrasound energy is not performing in an ideal
reference material, it does not purport to be a systematic way.
review of the literature. The coupling media used in this context include water,
various oils, creams and gels. Ideally, the coupling medium
2. Historical use and recent developments should be sufficiently fluid to fill all available spaces, rela-
tively viscous so that it stays in place, have an impedance
Ultrasound is almost certainly the most widely used of appropriate to the media it connects, and should allow
the electrophysical agents in current clinical practice. In transmission of ultrasound energy with minimal absorp-
addition to its widespread use by physiotherapists [1–3], tion, attenuation or disturbance. For extensive discussions
it is also commonly used by numerous therapists from regarding coupling media, see [6–10]. Water and gel based
other professional groups (e.g. osteopaths, chiropractors, media are clearly preferable to oil and cream based media.
sports therapists). The results of a recent national survey A recent detailed study considering the effect of different
of physiotherapists carried out in Australia [4] indicates coupling gels on ultrasound transmission did demonstrate
that therapeutic ultrasound remains the most popular that there were differences in transmission characteristics
modality in use. and absorption levels of commonly employed ultrasound
The results of a survey carried out in Britain in 1985 [2] gels [9] but that there was no clinically significant difference
showed that 20% of all physiotherapy treatments in NHS between them. Most of the commonly employed gels only
departments and 54% of all private treatments involved varied in their absorption characteristics by approximately
therapeutic ultrasound and the widely cited survey by Pope 3% compared with water, and given the inaccuracy of clin-
et al. [1] identified ultrasound as the most frequently ical machine calibration [11], this is an insignificant vari-
employed modality (94%) and 64% of respondents reported ability. The addition of drug based material to the gel
that they used the modality more than once a day. (for the purpose of phonophoresis) is not strongly sup-
In the 1985 survey, it was shown that there were large ported by the literature, and the preliminary results from
variations in the use of ultrasound including a range of ongoing work in this unit (Todd and Watson) would sug-
intensities from 0.1 to 3.0 W/cm2 giving a variation factor gest that the inclusion of pharmaceutical agents in the
of 30 from the lowest to the highest applied intensity. ultrasound gel appears to significantly reduce ultrasound
The current application of ultrasound for fracture healing transmission to the tissues, and therefore reduces the effi-
at even lower doses (typically 0.03 W/cm2) would take that cacy of the ultrasound component of the treatment.
to a factor of 100. This is a very substantial variation on Whether this is outweighed by the clinical benefits of
just one factor that affects the output of the machine, enhanced drug delivery remains to be established.
and it is not surprising therefore that some research evi- In an extension to this work, the capacity for various
dence is supportive of the modality whilst other publica- wound dressing materials to transmit ultrasound has been
tions are clearly not. Given that the effects of investigated. If it can be argued that of ultrasound energy
‘electrotherapy’ interventions have a dose dependency [5], can be effectively passed through a wound dressing without
this wide variation in applied power would be expected significant absorption, there is a potential value for not
to generate a range of effects including more and less effec- having to disturb the dressing in order to apply this modal-
tive therapeutic outcomes. Further identification of the ity which has an established role in chronic wound manage-
critical machine and dose parameters is clearly needed ment [12–15]. Furthermore, US scanning of the wound bed
and is being undertaken within this research group. and environment without having to remove the dressing
may be clinically advantageous, especially given that the
3. Physics related issues removal of wound dressings is considered to result in inhib-
ited repair for several hours on each occasion [16].
The physics of therapeutic ultrasound are outwith the A total of 48 different wound dressings were evaluated,
remit of this paper, but there are two essential issues that and there was a very wide variation in their transmission
T. Watson / Ultrasonics 48 (2008) 321–329 323

characteristics, ranging from excellent to zero [17]. The other classes of dressing are much greater, with transmis-
dressing included alginates, foams, honey-impregnated sivity varying from 100% to 0%. Combination of dressings
dressings, hydrocolloids, hydrogel sheets, low-adherence in layers showed results that were as would have been pre-
dressings, vapour-permeable films and odour-absorbent dicted from the individual sample data. Detailed analysis
dressings. In practice multiple dressings may be applied and ranking of the 48 dressings tested at varying frequency
to a wound, for example an alginate held in place with a and power output are included in the original paper [17].
vapour permeable film. If ultrasound were to be applied
through these dressings, a layer of standard couplant gel 3.2. Absorption
might be applied. Therefore additional tests were carried
out on combination of 2 typical dressings plus couplant In order to have a therapeutic effect, absorption of the
gel to see if the overall transmissivity was significantly dif- applied energy is necessary [19], hence the effectiveness of
ferent from what would be expected by combining the data the modality will vary according to a tissues capacity to
gathered separately for each component. Some dressings absorb the applied energy. Tissues with a higher protein
were found to behave in an unstable fashion (demonstrat- content will absorb US to a greater extent, thus tissues with
ing visible changes in the structure of the dressing material) high water content and low protein content (e.g. blood and
when using a continuous mode of ultrasound and these fat) absorb little of the US energy whilst those with a lower
were further tested with the energy applied in a pulsed water content and a higher protein content (e.g. ligament,
mode. tendon) will absorb US far more efficiently. It has been sug-
The results demonstrate that many of the dressings gested [19,20] that tissues can therefore be ranked accord-
tested are good transmitters of ultrasound which suggests ing to their tissue absorption (Fig. 1).
that there may be scope, previously unexplored, for the Although cartilage and bone are at the upper end of this
application of therapeutic US to wounds through a variety scale, the problems associated with wave reflection at the
of dressings. However the data also demonstrate that it is tissue surface mean that a significant proportion of US
not appropriate to make generalisations about dressing energy striking the surface of either of these tissues is likely
transmissivity. Each dressing has its own transmission to be reflected. The best absorbing tissues in terms of clin-
characteristics, which may change with both US power ical practice are those with high collagen content – liga-
and frequency. Some dressings that were unstable using a ment, tendon, fascia, joint capsule, scar tissue [3,20–23].
continuous beam demonstrated stability when the duty The differential absorption of US energy has an impor-
cycle was reduced to 20%, suggesting that a thermal mech- tant influence on clinical decision making. Using ultra-
anism may be involved as US energy absorbed by the sound to treat a lesion located in a tissue that is a poor
dressing increased its temperature and may have caused absorber of the energy is less likely to be effective when
its acoustic characteristics to change. compared with treating a tissue which is a ‘better’ absorber
The dressings tested vary significantly in their capacity of the energy. For example, in a recent paper which evalu-
to transmit ultrasound, and some demonstrate excellent ated the effectiveness of therapeutic ultrasound immedi-
US transmissivity characteristics. Even dressings of the ately following contusion injury in muscle [24] no
same type had significantly different transmissivities. This significant beneficial effects were demonstrated. Although
may be of particular importance in the case of hydrogel this could be interpreted as a negative research finding, it
dressings, since these are recommended as a class of dress- would be difficult to argue why ultrasound should have
ings through which wounds may be insonated [18]. The an effect following this type of injury as the insulted tissues
results indicate that their transmissivities may vary between will absorb a relatively small proportion of the energy and
80% and 100%. This means that for a given nominal power hence it is unlikely to have a significant effect. Trials that
output by a US generator, there might be considerable dis- have evaluated the effect of the same modality on lesions
parity in the power reaching the wound according to the in dense collagenous tissue have demonstrated significant
specific hydrogel dressing used. Differences within some therapeutic effects (e.g. [25,26]).

Increasing protein content

Blood, Fat, Nerve, Muscle, Skin, Tendon, [Cartilage, Bone]

LOW US absorption HIGH

Best absorption therefore in TENDON, LIGAMENT, FASCIA,


JOINT CAPSULE and SCAR TISSUE

Fig. 1. Ultrasound tissue absorption characteristics.


324 T. Watson / Ultrasonics 48 (2008) 321–329

An important rider to this phenomenon is that once ited to some 3 min immediately after treatment. Although
damaged, musculocutaneous tissues will repair which there are certainly ultrasound generated thermal changes
involves the formation of scar tissue, and hence, therapeu- in the tissues, it is important to differentiate between those
tic ultrasound may be of significant clinical value in that produced in the skin and superficial tissues – where they are
the scar tissue becomes the target of the therapy. In a dam- easily detected by the patient – and those generated at
aged muscle, ultrasound could therefore be expected to be ‘depth’ which are of more clinical importance, and are
effective once the scar tissue has become established. not readily identifiable by the recipient of the therapy.
An example of the skin surface thermal changes are seen
4. Thermal vs. non-thermal in Fig. 2. Ultrasound was applied for 5 min at 1.5 W/cm2
in continuous mode using a 3 MHz application over an
When ultrasound travels through tissue a percentage of area of twice the treatment head. The change in peak tem-
it is absorbed, and this leads to the generation of heat perature in the central hand zone was from 34.3 to 37.3 °C
within that tissue. The amount of absorption depends upon by the end of the application. Clearly, this is more than suf-
the nature of the tissue, its degree of vascularisation, and ficient for the patient to report a feeling of warmth or heat-
the frequency of the applied ultrasound. Tissues with a ing, but that does not necessarily equate to a therapeutic
high protein content absorb ultrasound more readily than heating at any tissue depth.
those with a higher fat content, and also the higher the Ultrasound has historically been used primarily for its
US frequency, the greater is the absorption rate. A biolog- perceived thermal effects, and although this is a less fre-
ically significant thermal effect can be achieved if the tem- quently employed rationale in current clinical practice,
perature of the tissue is raised to between 40 and 45 °C
for at least 5 min. Controlled heating can produce desirable
effects [27], which include pain relief, decrease in joint stiff-
ness and increased local blood flow. Whilst the therapeutic
benefits of tissue heating are well established, ultrasound is
relatively inefficient at generating sufficient thermal change
in the tissues to achieve this therapeutic effect when applied
at commonly applied clinical doses.
Historically, US has been widely employed for its ther-
mal effects, but it has been argued more recently that the
‘non-thermal’ effects of this energy form are more effective
[3,19] and currently, the majority of clinical applications
focus on these. Gallo et al. [28] demonstrated that both
continuous and pulsed ultrasound interventions generated
measurable thermal changes in the tissues (muscle), but
considering the temperature changes achieved, they would
be expected to be of minimal therapeutic value. Garrett
et al. [29] compared the heating effect of a pulsed shortwave
treatment with an ultrasound treatment, and the pulsed
shortwave intervention was clearly more effective at achiev-
ing the required thermal change for therapeutic benefit. A
patient treated with ultrasound in continuous mode at rel-
atively high power density will feel a temperature change
(mainly in the skin which is where thermal receptors are
predominantly located), but this is not the same as achiev-
ing a clinically significant thermal change in deeper tissues.
A recent comparative study from this research unit eval-
uated the efficacy of a locally applied thermal modality
with (kHz) ultrasound with regards their effect on soft tis-
sue extensibility [30]. Although both modalities were found
to be effective in this regard, the ultrasound demonstrated
no significant benefit over the heat treatment, and in fact,
there was a trend for the thermal intervention producing
greater benefit. In another ultrasound, heating and stretch-
ing study, Draper and Ricard [31] demonstrated that there
was a clinically useful temperature rise in the tissues but Fig. 2. Thermographic images of the hand before and after ultrasound: (a)
that the return to baseline was swift, and the therapeutic baseline thermograph and (b) thermograph at the end of the 5 min
window for stretching following US application was lim- treatment period.
T. Watson / Ultrasonics 48 (2008) 321–329 325

there remain many therapists for whom the heating effects too greater intensity at this stage, it is a possible outcome
are considered to be the most important. Tissue heating is [39], but rather to act as an ‘inflammatory optimiser’.
clearly of value in numerous clinical conditions, but the evi- The inflammatory response is essential to the effective
dence does not fully support the use of ultrasound as an repair of tissue and inhibition of these events serves to inhi-
efficient thermal intervention. There are tissue heating bit the repair phases that follow [34,40–42], and the more
methods available in clinical practice that are better at efficiently the process can complete, the more effectively
achieving the desired thermal changes and based on the the tissue can progress to the next phase (proliferation).
available evidence, should be used in preference to Studies which have tried to demonstrate the anti inflamma-
ultrasound. tory effect of ultrasound have largely failed to do so (e.g.
There are many situations where ultrasound produces [43,44]), and have suggested that US is ineffective. It is
bioeffects and yet significant temperature change is not effective at promoting the normality of the inflammatory
involved (e.g. low spatial-average temporal-average events, and as such has a therapeutic value in promoting
(SATA) intensity). It is not strictly true to talk about the overall repair events [19,22].
‘non-thermal’ mechanisms, in that the delivery and absorp- Employed at an appropriate treatment dose, with opti-
tion of energy in the tissues will result in a temperature rise. mal treatment parameters (intensity, pulsing and time),
The term ‘non-thermal’ in this context relates to the fact the benefit of US is to make the earliest repair phase as effi-
that there is no apparent thermal accumulation in the tis- cient as possible, and thus have a promotional effect on the
sues, and is sometimes now referred to as a ‘microthermal’ whole healing cascade. For tissues in which there is an
effect [19,32]. The physical mechanisms thought to be inflammatory reaction, but in which there is no ‘repair’
involved in producing these non-thermal effects include to be achieved, the benefit of ultrasound is to promote
cavitation and acoustic streaming [10,22,33]. the normal resolution of the inflammatory events, and
There is evidence indicating that ‘non-thermal’ mecha- hence resolve the ‘problem’. This will of course be most
nisms play a primary role in producing a therapeutically effectively achieved in the tissues that preferentially absorb
significant effect and the focus of this section will relate the energy.
to these effects in relation to soft tissue injury as it is the During the proliferative phase (scar production) US also
most commonly employed in physiotherapy clinical has a stimulative effect (cellular up-regulation), though the
practice. primary active targets are now the fibroblasts, endothelial
cells and myofibroblasts [21,36–38,45–48]. These are all
5. Ultrasound in soft tissue repair cells that are normally active during scar production and
US is therefore pro-proliferative in the same way that it
The process of tissue repair is a complex series of cas- is pro-inflammatory – it does not change the normal prolif-
caded, chemically mediated events that lead to the produc- erative phase, but maximises its efficiency – producing the
tion of scar tissue that constitutes an effective material to required scar tissue in an optimal fashion. Harvey et al.
restore the continuity of the damaged tissue. The process [49] demonstrated that low dose pulsed ultrasound
is more complex than be described in this paper, but have increases protein synthesis and several research groups
been extensively reviewed elsewhere, including Watson have demonstrated enhanced fibroplasia and collagen syn-
[34]. thesis [46,50–54]. There is currently a growing interest in
The effect of US during the repair process varies accord- the potential role for ultrasound therapy in relation to
ing to the primary events that are occurring in the tissues. the angiogenic response which is an essential component
Immediately following injury, during the tissue bleeding of the proliferative phase, and future research may serve
phase, it is generally considered to be inadvisable to use to identify additional therapeutic benefits which at the
ultrasound in that if it has the capacity to enhance local moment remain largely speculative, or based solely on lab-
blood flow, there would be a clinical disadvantage to doing oratory based research (e.g. [55]). Transfer to the clinical
so whilst tissue bleeding was occurring. Once active bleed- environment has yet to be established.
ing has stopped, it is appropriate to start using ultrasound Scar tissue is an essential component of the repair, and
as soon as is feasible. During the inflammatory phase, US for most musculoskeletal tissues, it is the best outcome that
has a stimulating effect on the mast cells, platelets, white can be achieved. In many ways, tissue regeneration would
cells with phagocytic roles and the macrophages [22,35– be ideal, but is not available in most musculoskeletal tis-
37]. For example, the application of ultrasound induces sues. Functional scar tissue may be considered to be second
the degranulation of mast cells, causing the release of ara- best – but the aim of therapy should be to promote the con-
chidonic acid which itself is a precursor for the synthesis of struction of the most efficient scar possible.
prostaglandins and leukotreine – which act as inflamma- During the remodelling phase of repair, the somewhat
tory mediators [25,37,38]. By increasing the activity of generic scar that is produced in the initial stages is refined
these cells, the overall influence of therapeutic US is cer- such that it adopts functional characteristics of the tissue
tainly pro-inflammatory rather than anti-inflammatory. that it is repairing [34]. A scar in ligament will not ‘become’
The benefit of this mode of action is not to ‘increase’ the ligament, but will behave more like a ligamentous tissue.
inflammatory response as such (though if applied with This is achieved by a number of processes, but mainly
326 T. Watson / Ultrasonics 48 (2008) 321–329

related to the orientation of the collagen fibres in the devel- raise some concern, though it has been proposed that it
oping scar and also to the change in collagen type, from might be a realistic proposition (e.g. [62,63]).
predominantly type III collagen to a more dominant type
I collagen [56]. The remodelling process is certainly not a 6. Clinical issues
short duration phase – research has shown that it can last
for a year or more – yet it is an essential component of 6.1. Machine calibration
quality repair and the application of ultrasound appears
to enhance the events normally associated with this phase. Concern has been raised with regards the accuracy of
Ultrasound can influence the remodelling of the scar tis- clinical ultrasound machines. When used in research pro-
sue in that it appears to be capable of enhancing the appro- grammes, operating machine calibration is (normally)
priate orientation of the newly formed collagen fibres and checked to ensure accuracy, this is less likely to be the case
also to the collagen profile change from mainly type III in practice. Even if a machine undergoes an annual check,
to a more dominant type I construction, thus increasing this may not include a calibration check and Pye and Mil-
tensile strength and enhancing scar mobility (e.g. [21]). ford [11] in an evaluation of machines used in NHS prac-
Ultrasound applied to tissues enhances the functional tice in Scotland identified almost 70% of machine outputs
capacity of the scar tissues [21,53]. The role of ultrasound that differed from the expected value by more than 30%.
in this phase may also have the capacity to influence colla- More accurate test and calibration procedures have been
gen fibre orientation as demonstrated in an elegant study proposed, but at the current time, it is likely that a signif-
by Byl et al. [57], though their conclusions were quite rea- icant proportion of machines in use are not delivering what
sonably some tentative. Other studies have demonstrated the therapists assumes (based on the output set or shown
effects of ultrasound therapy on collagen behaviour in this on the device). Weekly checks using simple balance meters
latter repair stage (e.g. [26,58–60]). may help to identify gross inaccuracies, but a more com-
The application of ultrasound during the inflammatory, prehensive and rigorous quality assurance system is almost
proliferative and repair phases is not of value because it certainly required. Further papers [11,64] have identified
changes the normal sequence of events, but because it has and tried to quantify the risks associated with this problem
the capacity to stimulate or enhance these normal events and more recently [65] have reported a cost effective
and thus increase the efficiency of the repair phases method for measuring machine output accurately.
[19,22]. It would appear that if a tissue is repairing in a
compromised or inhibited fashion, the application of ther- 6.2. Potential infection
apeutic ultrasound at an appropriate dose will enhance this
activity. If the tissue is healing ‘normally’, the application Infection risk is a topical issue in current practice, and
will, it would appear, speed the process and thus enable the possibility of passing on infective micro-organisms as
the tissue to reach its endpoint faster than would otherwise a result of healthcare events is a growing area of concern.
be the case. The effective application of ultrasound to Clearly, there is a clinical risk associated with any interven-
achieve these aims is dose dependent [5,59] though some tion, but these need to be minimised as far as possible.
authors have challenged the reality of dose dependency in When using ultrasound as part of a wound management
this regard (e.g. [61]). programme, practitioners are usually mindful of infection
risk and take careful and adequate precautions. In ‘normal’
5.1. Ultrasound in fracture repair clinical practice, it is less common to find cleaning of the
ultrasound treatment applicator between every treatment,
Low intensity pulsed ultrasound (LIPUS) has emerged though many departments do have comprehensive infec-
as an effective therapeutic approach in fracture repair, for tion control policies and routinely clean the machines
both fresh fractures and those experiencing inhibited and applicators.
repair. Whereas previously, a fracture has been considered A recent study [66] investigated whether clinical ultra-
to be a local contraindication to therapeutic US, the cur- sound units were a potential vector of infection. The study
rent evidence demonstrates that this is clearly not the case. aimed to determine the degree of contamination on thera-
The review of this material is covered in a separate paper peutic ultrasound transducer heads and ultrasound gel
and will not therefore be considered in detail here. It is after routine clinical use, and to evaluate the efficacy of rec-
likely that the further development of this therapy will ommended infection control procedures. The study was
influence clinical practice, though in many instances it is conducted in Australia and microbiological cultures were
not necessary for the therapist to ‘do’ the treatment, and obtained from 44 transducer heads and 43 gels (machines
patient self management appears to be the most effective were in use in hospitals, private practices and other health-
way forward in this area. Whether a standard therapy care facilities). Swabs taken from the treatment heads and
ultrasound machine is capable of effectively delivering the the gel bottles were cultured and colony growth assessed.
required dose is still not resolved. Issues relating to accu- Twenty-seven per cent of transducer heads and 28% of gels
rate dose (intensity) delivery and the relatively high beam were contaminated. Transducer heads showed fairly low
non-uniformity ratios (BNR) of current clinical devices levels of contamination across the sample, with the major-
T. Watson / Ultrasonics 48 (2008) 321–329 327

ity of organisms isolated found in normal skin and environ- result in more rapid delivery of the desired energy, but
mental flora. Gels were heavily contaminated with oppor- there is a strong, and growing body of evidence that sup-
tunistic and potentially pathogenic organisms, including port the contention that pulsed mode ultrasound is more
Stenotrophomonas maltophilia, Staphylococcus aureus, Aci- effective than continuous mode, especially in relation to tis-
netobacter baumannii and Rhodotorula mucilaginosa. No sue repair, and most critically, in the early (inflammatory
multi-resistant organisms were identified. and proliferative) stages.
A second element of the study was to evaluate the effec- An additional issue relates to current clinical practice
tiveness of cleaning the treatment head with 70% alcohol and treatment frequency. Much of the research that has
which significantly reduced the level of contamination on demonstrated significant clinical benefit has employed
transducer heads. The authors conclude that routine clean- treatments at regular and relatively frequent intervals.
ing of the treatment head with 70% alcohol between treat- Due to real world restrictions in current healthcare practice,
ments should be the clinical ‘norm’, and although this does many patients are seen regularly but infrequently (for exam-
not deal with the micro-organism colonies in the gel bottles ple once every 2 or 4 weeks). If ultrasound is used when the
sampled, it is at least a significant move in the right direc- patient attends on this basis, there is no evidence that there
tion, and is currently being advocated as best practice. is a clinically significant gain – there may be, but this is a
Re-usable gel containers are likely to be a bigger prob- case of a lack of evidence as opposed to evidence of a lack
lem in this regard, and if large volume gel containers are of effect – an area needing some urgent consideration.
purchased (for gains in cost saving), it is unlikely to be Further evaluation of effective doses is being undertaken
good practice to keep refilling the same small bottles for in this research unit, and it is anticipated that a more com-
use in the department. At the very least, either new or ster- prehensive dose model will emerge as a result.
ilised clean bottles should be used to reduce the risk until
further research and management strategies have been 6.4. Overlap between modalities
identified.
At face value, the therapeutic effects of ultrasound are
6.3. Dose issues remarkably similar to those of laser therapy and some
pulsed EM fields. Given that all three are means of deliver-
The widely used term ‘treatment dose’ of an ultrasound ing energy such that cellular up-regulation results, this is
application is used in the clinical environment as a combi- actually not surprising. The fundamental difference relates
nation of the selectable machine parameters – frequency, back not to a difference in their basic effect, but more
power density, duty cycle and treatment time, thus has a strongly to the fact that these three energies are preferen-
more casual meaning than in the classic physics sense. tially absorbed in different tissues [19]. There do appear
Whilst it is beyond the scope of this review to consider to be some variations between the physiological effects of
dosing issues in detail, there are several general points that these interventions, but for the most part, they appear to
merit brief consideration. Firstly, there does appear to be a overlap. Ultrasound is most effective at achieving these
dose dependency in relation to therapeutic effects [5], effects in the tissues that absorb then mechanical energy,
though as identified previously, this has been challenged and as described above, these are essentially the dense col-
in the literature [61]. There are a myriad of possible combi- lagenous tissues. The modality is less effective when it
nations of frequency, power, power density, duty cycle and comes to dealing with therapeutic gains in tissues like mus-
treatment times and from the published evidence it appears cle, nerve and where there is significant oedema. The other
that there are some combinations that are more effective modalities appear to offer advantages in these other tissues,
than others. There is not an exhaustive range of clinical lit- and hence, the use of laser, pulsed EM fields (mainly short-
erature from which to make absolutely definitive sugges- wave) and ultrasound are regarded as being complemen-
tions, but the trends that have emerged are sufficiently tary rather than competitive in clinical practice.
strong to justify a dose decision making model that is effec-
tive and amenable to adjustment as new research comes to 7. Summary
light [67].
Given the growing evidence for therapeutic windows in Therapeutic ultrasound has a long history of use in
most, if not all areas of practice, the main concern is to try physiotherapy practice, though the emphasis has changed
and identify which of the dose parameters that can be over the last 15–20 years. Several other professional groups
manipulated are in fact the most critical and which are less are also using the modality including osteopaths, chiro-
important. Leaving to one side the general decision with practors, podiatrists and sports therapists. The current
regards ultrasound frequency, the power density (W/ emphasis of use relates to enhancement of repair of soft
cm2), duty cycle and total treatment time appear to be fun- (musculoskeletal) tissues following injury, insult or irrita-
damental. Although there is a trend for outcomes to be tion, and the evidence for its value in these areas is consid-
related to the actually duty cycle (20%, 25%, 33%, etc.), erable, though there are, of course, gaps that remain and
the more basic decision is whether to apply the energy in need to be filled with quality research especially in the clin-
a continuous or pulsed mode. The continuous mode will ical arena as opposed to the laboratory.
328 T. Watson / Ultrasonics 48 (2008) 321–329

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