- Dede G, Boston, MA

Dear Dede: This question opens a can of worms in the realm of physical therapy. Essentially two camps exist in this debate, and you've already named them: those using ultrasound (US), and those who do not. Personally, I fall into the latter category, based on fairly strong evidence suggesting that the use of US fails to produce results above those of placebo US; in other words, whether you remember to turn the machine on or not makes no difference in the outcome. This holds particularly true for studies utilizing US in combination with other PT interventions (e.g., exercise, manual therapy, etc).^1-4

Does any support exist supporting the use of US in physical therapy? Yes. Good support for the use of US to promote fracture healing exists.⁵ The catch? It requires daily US application, typically for 20 minutes across many weeks (4-6+) to decrease the amount of time to fully heal a fracture by a few weeks. To treat calcific tendonitis (uncommon), one study⁶ found that 6wks of US treatment demonstrated significant benefit. Their protocol required 24 treatments across 6wks (15 minutes of US applied 5x/wk for 3 weeks, then 3x/wk for 3 weeks) utilizing the a very unusual (and typically unavailable) US frequency. However, another study⁷ tried this across just 9 sessions lasting only 5 minutes each (a typical duration applied in the clinic) and found no benefit for this same patient population. This last study should cause particular concern for those receiving US, as very few therapists use US for the lengthy durations which demonstrating any benefit.⁸

So why do therapists use US? Good question. I suspect most of those using US have historically noted improvement in their patients, and so anecdotally, ultrasound must be effective. However few therapists use a single intervention (i.e., only using US, only using manual therapy, only using cryotherapy, etc), so they must be using US in combination with other interventions. Also note that other common interventions do demonstrate significant benefit for more common athletic injuries (such as manual therapy,^9-13exercise,^14-18 and neuromuscular training^{19, 20} Physiotherapy interventions for shoulder pain.). Applying the research findings previously noted (that adding US to a combined treatment program does not improve outcome), I suspect that their patients have improved because of the other treatments they are doing alongside US (or perhaps despite the use of US).

Finally let's talk practicality. Typical PT appointments get scheduled every 30 minutes. This means that anything requiring your therapist's presence (manual therapy, instruction in new exercises, review and/or correction of existing exercises, education on modification of daily life, gait training, etc) must all happen within 30 minutes. While you may spend longer than that in the clinic practicing those exercises, icing, etc, time spent performing US takes time away from other, more effective interventions. If I had hours to spend with each patient, I might include US; why not? But for those patients lacking a fracture, evidence suggests that "if time permits and all other more effective treatments have been completed" is the only criteria promoting the inclusion of US in your treatment.

REFERENCES:

1. Gursel YK, Ulus Y, Bilgic A, Dincer G, van der Heijden GJMG. Adding Ultrasound in the Management of Soft Tissue Disorders of the Shoulder: A Randomized Placebo-Controlled Trial. PHYS THER. April 1, 2004 2004;84(4):336-343.

2. Van Der Heijden GJ, Leffers P, Wolters PJ, et al. No effect of bipolar interferential electrotherapy and pulsed ultrasound for soft tissue shoulder disorders: a randomised controlled trial. Ann Rheum Dis. Sep 1999;58(9):530-540.

3. Ainsworth R, Dziedzic K, Hiller L, Daniels J, Bruton A, Broadfield J. A prospective double blind placebo-controlled randomized trial of ultrasound in the physiotherapy treatment of shoulder pain. Rheumatology (Oxford). May 2007;46(5):815-820.

4. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003(2):CD004258.

5. Pounder NM, Harrison AJ. Low intensity pulsed ultrasound for fracture healing: a review of the clinical evidence and the associated biological mechanism of action. Ultrasonics. Aug 2008;48(4):330-338.

6. Ebenbichler GR, Erdogmus CB, Resch KL, et al. Ultrasound Therapy for Calcific Tendinitis of the Shoulder. N Engl J Med. May 20, 1999 1999;340(20):1533-1538.

7. Perron M, Malouin F. Acetic acid iontophoresis and ultrasound for the treatment of calcifying tendinitis of the shoulder: a randomized control trial. Arch Phys Med Rehabil. Apr 1997;78(4):379-384.

8. Robertson VJ. Commentary on Wong et al, (2007) Ultrasound Use in Orthopedic Physical Therapy. Physical Therapy. 2007;87(8):995-999.

9. Cleland JA, Glynn P, Whitman JM, Eberhart SL, MacDonald C, Childs JD. Short-Term Effects of Thrust Versus Nonthrust Mobilization/Manipulation Directed at the Thoracic Spine in Patients With Neck Pain: A Randomized Clinical Trial. PHYS THER. April 1, 2007 2007;87(4):431-440.

10. Browder DA, Childs JD, Cleland JA, Fritz JM. Effectiveness of an Extension-Oriented Treatment Approach in a Subgroup of Subjects With Low Back Pain: A Randomized Clinical Trial. PHYS THER. December 1, 2007 2007;87(12):1608-1618.

11. Young B, Walker MJ, Strunce J, Boyles R. A combined treatment approach emphasizing impairment-based manual physical therapy for plantar heel pain: a case series. J Orthop Sports Phys Ther. Nov 2004;34(11):725-733.

12. Bergman GJD, Winters JC, Groenier KH, et al. Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain: A Randomized, Controlled Trial. Ann Intern Med. September 21, 2004 2004;141(6):432-439.

13. Gross AR, Hoving JL, Haines TA, et al. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine. Jul 15 2004;29(14):1541-1548.

14. Young MA, Cook JL, Purdam CR, Kiss ZS, Alfredson H. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. Br J Sports Med. Feb 2005;39(2):102-105.

15. Croisier J-L, Foidart-Dessalle M, Tinant F, Crielaard J-M, Forthomme B. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br. J. Sports Med. April 1, 2007 2007;41(4):269-275.

16. Bizzini M, Childs JD, Piva SR, Delitto A. Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. J Orthop Sports Phys Ther. Jan 2003;33(1):4-20.

17. Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment. Sports Med. 2005;35(5):451-459.

18. Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2005(3):CD004250.

19. Risberg MA, Holm I, Myklebust G, Engebretsen L. Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial. Phys Ther. Jun 2007;87(6):737-750.

20. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. Jul 2005;33(7):1003-1010.

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