Therapeutic ultrasound

Last updated
Therapeutic ultrasound
ICD-10-PCS 6A7
ICD-9-CM 00.0

Therapeutic ultrasound refers generally to the use of ultrasound for the treatment of a medical condition or for therapeutic benefit. Physiotherapeutic ultrasound was introduced into clinical practice in the 1950s, with lithotripsy introduced in the 1980s. [1] Other uses of ultrasound for therapeutic benefit are at various stages in transitioning from research to clinical use and include: high-intensity focused ultrasound (HIFU), targeted ultrasound drug delivery, trans-dermal ultrasound drug delivery, ultrasound hemostasis, cancer therapy, and ultrasound assisted thrombolysis [2] [3] Ultrasound used for therapeutic benefit often use focused ultrasound waves, however, unfocused ultrasound waves may also be used. [4]

Contents

The top probe highlights the use of ultrasound for diagnostic purposes such as imaging tissue. The bottom probe demonstrates the use of ultrasound for therapeutic benefits, which often utilize high-energy, focused ultrasound beams. Ultrasound Imaging vs. Ultrasound Therapy.png
The top probe highlights the use of ultrasound for diagnostic purposes such as imaging tissue. The bottom probe demonstrates the use of ultrasound for therapeutic benefits, which often utilize high-energy, focused ultrasound beams.

In the above applications, the ultrasound passes through human tissue where it is the main source of the observed biological effect (the oscillation of abrasive dental tools at ultrasonic frequencies therefore do not belong to this class). The ultrasound within tissue consists of very high frequency sound waves, between 800,000 Hz and 20,000,000 Hz, which cannot be heard by humans.

Some of the advantages of ultrasound as a diagnostic and therapeutic tool include its safety profile, lack of radiation, portability, and low cost. [4] Therapeutic ultrasound in medicine ranges from extracorporeal shockwave therapy for the breaking of renal calculi to HIFU in which tumors are ablated. In the research field, use of ultrasound is being explored as a mechanism of enhancing drug delivery, sorting particles, and measuring properties of tissue. [2] [5] [6] In physical therapy, there is some evidence that ultrasound is more effective than placebo treatment for treating patients with arthritis pain, [7] a range of musculoskeletal injuries [8] and for promoting tissue healing. [9]

Medical uses

Relatively high-energy ultrasound can break up stony deposits, ablate tissue, accelerate the effect of drugs in a targeted area, assist in the measurement of the elastic properties of tissue, and sort cells or small particles for research. [4] [5]

Calcium oxalate (a type of kidney stone) fragments collected after treatment with lithotripsy. Calcium-oxalate-fragments-collected-after-ESWL.jpg
Calcium oxalate (a type of kidney stone) fragments collected after treatment with lithotripsy.

Extracorporeal Shockwave Therapy

Oncology

Ophthalmology

Enhanced drug uptake using acoustic targeted drug delivery ATDD Topical Application.jpg
Enhanced drug uptake using acoustic targeted drug delivery

Drug Delivery

Shown in this picture are varicose veins that would be targeted with ultrasound-guided sclerotherapy. Varicose veins affecting the lower leg Wellcome L0061800.jpg
Shown in this picture are varicose veins that would be targeted with ultrasound-guided sclerotherapy.

Vascular Surgery

Plastic Surgery

History

The first large scale application of ultrasound was around World War II. Sonar systems were being built and used to navigate submarines. It was realized that the high intensity ultrasound waves that they were using were heating and killing fish. [20] This led to research in tissue heating and healing effects. Since the 1940s, ultrasound has been used by physical and occupational therapists for therapeutic effects. [4]

Physical therapy

Ultrasound is applied using a transducer or applicator that is in direct contact with the patient's skin. Gel is used on all surfaces of the head to reduce friction and assist transmission of the ultrasonic waves. Therapeutic ultrasound in physical therapy is alternating compression and rarefaction of sound waves with a frequency of 0.7 to 3.3  MHz. [21] Maximum energy absorption in soft tissue occurs from 2 to 5 cm. Intensity decreases as the waves penetrate deeper. They are absorbed primarily by connective tissue: ligaments, tendons, and fascia (and also by scar tissue). [22]

Ultrasound has been used to help physical therapists navigate transcutaneous modalities that aim to stimulate specific muscles beneath the skin; modalities such as dry needling and acupuncture. The use of ultrasound provides a way for physical therapists to better locate superficial musculature. [23] Conditions for which ultrasound may be used for treatment include the following examples: ligament sprains, muscle strains, tendonitis, joint inflammation, plantar fasciitis, metatarsalgia, facet irritation, impingement syndrome, bursitis, rheumatoid arthritis, osteoarthritis, and scar tissue adhesion. There is no evidence to support the use of ultrasound for the treatment of low back pain, [24] and current clinical guidelines recommend that ultrasound is not used for this condition. [25] In a critical review, it was demonstrated that therapeutic ultrasound was effective in improving pain, function, and cartilage repair in knee osteoarthritis.[ citation needed ] Another systematic review and meta-analysis of low-intensity pulsed ultrasound on knee osteoarthritis demonstrated a significant effect on pain reduction and knee functional recovery. [26] Ultrasound used for calcific tendonitis had a positive short term effect. For the long term, there was no significant difference with ultrasound use. This shows that for pain relief and short-term treatment ultrasound can be an effective treatment for Calcific Tendonitis [27] A review with five small placebo‐controlled trials from 2011, did not support the use of ultrasound in the treatment of acute ankle sprains and the potential treatment effects of ultrasound appear to be generally small and of probably of limited clinical importance, especially in the context of the usually short‐term recovery period for these injuries. [28] However, therapeutic ultrasound is reported to have beneficial effects in sports injuries pain relief, edema control, and range of joint motion, possibly by increasing pain thresholds, collagen extensibility, reducing edema, and therefore inflammation, muscle spasms, and joint stiffness. [26] A meta-analysis found that ultrasound therapy is effective in reducing pain, increasing ROM, and reducing WOMAC functional scores in patients with knee osteoarthritis. [7]

There are three potential therapeutic mechanisms of ultrasound in physical therapy. The first is the increase in blood flow in the treated area. [4] [21] The second is the decrease in pain from the reduction of swelling and edema. [21] The third is the gentle massage of muscle tendons and ligaments in the treated area because no strain is added and existing scar tissue may be softened with ultrasound. [21] These three benefits are achieved by two main effects of therapeutic ultrasound: thermal and non-thermal effects. [21] Thermal effects are due to the absorption of the sound waves and result in heating of biological tissue. Non-thermal effects are from cavitation, microstreaming and acoustic streaming. [15] [21]

Cavitation is the main non-thermal effect of therapeutic ultrasound. [4] [21] Cavitation results from the vibration of tissue causing microscopic bubbles to form. These microscopic bubbles may directly stimulate cell membranes and cause shockwaves within the tissue. [4] This physical stimulation appears to enhance the cell-repair effects of the inflammatory response.

Knee osteoarthritis

According to recent research, therapeutic ultrasound has not shown any significant improvement for chronic low back pain, chronic neck pain, and hip pain in combination with other physiotherapeutic techniques. [29] [30] However, the most conclusive evidence to support therapeutic ultrasound use is seen with its use in patients with knee osteoarthritis. Knee osteoarthritis affects approximately 250 million people worldwide. [31] While there is no known cure, therapeutic regimens are often used to intervene with the diseases chronic symptoms. [31] In a systematic review of 15 studies, patients who received ultrasound treatments were compared to those who received a placebo treatment. [7] The evidence demonstrated that therapeutic ultrasound significantly relieved pain, increases range of motion, and reduced WOMAC functional scores in patients with knee osteoarthritis when compared to the placebo group. [7] In a separate meta-analysis, it reinforced the use of therapeutic ultrasound by deeming it as a safe non-pharmalogical treatment option that may provide additional pain relief as well as functional improvement when used secondarily to therapy in patients with knee osteoarthritis. [31]

Use of Ultrasound in Research

Acoustic tweezers sorted ten cells into the shape of the letters "A" and "T" at a scale of micrometers. Cells patterned with selective acoustical tweezers.png
Acoustic tweezers sorted ten cells into the shape of the letters "A" and "T" at a scale of micrometers.

Research Tools

Biophysical Effects of Ultrasound

Enhancing Drug Delivery

Musculoskeletal Research

See also

Related Research Articles

<span class="mw-page-title-main">Rheumatoid arthritis</span> Type of autoimmune arthritis

Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are involved, with the same joints typically involved on both sides of the body. The disease may also affect other parts of the body, including skin, eyes, lungs, heart, nerves, and blood. This may result in a low red blood cell count, inflammation around the lungs, and inflammation around the heart. Fever and low energy may also be present. Often, symptoms come on gradually over weeks to months.

<span class="mw-page-title-main">Tendinopathy</span> Inflammation of the tendon

Tendinopathy is a type of tendon disorder that results in pain, swelling, and impaired function. The pain is typically worse with movement. It most commonly occurs around the shoulder, elbow, wrist, hip, knee, or ankle.

<span class="mw-page-title-main">Pain management</span> Interdisciplinary approach for easing pain

Pain management is an aspect of medicine and health care involving relief of pain in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals provide some pain control in the normal course of their practice, and for the more complex instances of pain, they also call on additional help from a specific medical specialty devoted to pain, which is called pain medicine.

<span class="mw-page-title-main">Osteoarthritis</span> Form of arthritis caused by degeneration of joints

Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone. It is believed to be the fourth leading cause of disability in the world, affecting 1 in 7 adults in the United States alone. The most common symptoms are joint pain and stiffness. Usually the symptoms progress slowly over years. Other symptoms may include joint swelling, decreased range of motion, and, when the back is affected, weakness or numbness of the arms and legs. The most commonly involved joints are the two near the ends of the fingers and the joint at the base of the thumbs, the knee and hip joints, and the joints of the neck and lower back. The symptoms can interfere with work and normal daily activities. Unlike some other types of arthritis, only the joints, not internal organs, are affected.

<span class="mw-page-title-main">Transcutaneous electrical nerve stimulation</span> Therapeutic technique

A transcutaneous electrical nerve stimulation is a device that produces mild electric current to stimulate the nerves for therapeutic purposes. TENS, by definition, covers the complete range of transcutaneously applied currents used for nerve excitation, but the term is often used with a more restrictive intent, namely, to describe the kind of pulses produced by portable stimulators used to reduce pain. The unit is usually connected to the skin using two or more electrodes which are typically conductive gel pads. A typical battery-operated TENS unit is able to modulate pulse width, frequency, and intensity. Generally, TENS is applied at high frequency (>50 Hz) with an intensity below motor contraction or low frequency (<10 Hz) with an intensity that produces motor contraction. More recently, many TENS units use a mixed frequency mode which alleviates tolerance to repeated use. Intensity of stimulation should be strong but comfortable with greater intensities, regardless of frequency, producing the greatest analgesia. While the use of TENS has proved effective in clinical studies, there is controversy over which conditions the device should be used to treat.

<span class="mw-page-title-main">Joint injection</span> Method of delivering drugs into a joint

In medicine, a joint injection is a procedure used in the treatment of inflammatory joint conditions, such as rheumatoid arthritis, psoriatic arthritis, gout, tendinitis, bursitis, Carpal Tunnel Syndrome, and occasionally osteoarthritis. A hypodermic needle is injected into the affected joint where it delivers a dose of any one of many anti-inflammatory agents, the most common of which are corticosteroids. Hyaluronic acid, because of its high viscosity, is sometimes used to replace bursa fluids. The technique may be used to also withdraw excess fluid from the joint.

Prolotherapy, also called proliferation therapy, is an injection-based treatment used in chronic musculoskeletal conditions. It has been characterised as an alternative medicine practice.

<span class="mw-page-title-main">Traction (orthopedics)</span> Process for straightening broken bones

Traction is a set of mechanisms for straightening broken bones or relieving pressure on the spine and skeletal system. There are two types of traction: skin traction and skeletal traction. They are used in orthopedic medicine.

<span class="mw-page-title-main">Focused ultrasound</span> Non-invasive therapeutic technique

High-intensity focused ultrasound (HIFU), or MR-guided focused ultrasound surgery, is an incisionless therapeutic technique that uses non-ionizing ultrasonic waves to heat or ablate tissue. HIFU can be used to increase the flow of blood or lymph or to destroy tissue, such as tumors, via thermal and mechanical mechanisms. Given the prevalence and relatively low cost of ultrasound generation mechanisms, the premise of HIFU is that it is expected to be a non-invasive and low-cost therapy that can at least outperform care in the operating room.

Therapeutic effect refers to the response(s) after a treatment of any kind, the results of which are judged to be useful or favorable. This is true whether the result was expected, unexpected, or even an unintended consequence. An adverse effect is the converse and refers to harmful or undesired response(s). What constitutes a therapeutic effect versus a side effect is a matter of both the nature of the situation and the goals of treatment. No inherent difference separates therapeutic and undesired side effects; both responses are behavioral/physiologic changes that occur as a response to the treatment strategy or agent.

Low-intensity pulsed ultrasound (LIPUS) is a technology that can be used for therapeutic purposes. It exploits low intensity and pulsed mechanical waves in order to induce regenerative and anti-inflammatory effects on biological tissues, such as bone, cartilage, and tendon. Even if the real mechanism underlying its effectiveness has not been understood yet, it is plausible that the treatment relies on non-thermal phenomena, such as microbubbles and microjets induced by cavitation, acoustic streaming, and mechanical stimulation.

<span class="mw-page-title-main">Extracorporeal shockwave therapy</span> Ultrasonic, non-invasive, outpatient treatment

Extracorporeal shockwave therapy (ESWT) is a treatment using powerful acoustic pulses which is mostly used to treat kidney stones and in physical therapy and orthopedics.

<span class="mw-page-title-main">Low-level laser therapy</span> Treatment using irradiation with light of low power intensity

Low-level laser therapy (LLLT), cold laser therapy, photobiomodulation (PBM) or red light therapy is a form of medicine that applies low-level (low-power) lasers or light-emitting diodes (LEDs) to the surface of the body. Whereas high-power lasers are used in laser medicine to cut or destroy tissue, it is claimed that application of low-power lasers relieves pain or stimulates and enhances cell function. Described sometimes as Low-level Red-light Therapy (LLRL), has effects that appear to be limited to a specified set of wavelengths and new research has demonstrated effectiveness at myopia control. Several such devices are cleared by the United States Food and Drug Administration (FDA), and research shows potential for treating a range of medical problems including rheumatoid arthritis and oral mucositis.

<span class="mw-page-title-main">Sodium hyaluronate</span> Chemical compound

Sodium hyaluronate is the sodium salt of hyaluronic acid, a glycosaminoglycan found in various connective tissue of humans.

<span class="mw-page-title-main">Platelet-rich plasma</span> Blood product used in transfusion medicine

Platelet-rich plasma (PRP), also known as autologous conditioned plasma, is a concentrate of plasma protein derived from whole blood, centrifuged to remove red blood cells but retaining platelets. Though promoted for treating various medical conditions, evidence of its benefits was mixed as of 2020, showing effectiveness in certain conditions and ineffectiveness in others.

Microbubbles are bubbles smaller than one hundredth of a millimetre in diameter, but larger than one micrometre. They have widespread application in industry, medicine, life science, and food technology. The composition of the bubble shell and filling material determine important design features such as buoyancy, crush strength, thermal conductivity, and acoustic properties.

Gene therapy for osteoarthritis is the application of gene therapy to treat osteoarthritis (OA). Unlike pharmacological treatments which are administered locally or systemically as a series of interventions, gene therapy aims to establish sustained therapeutic effect after a single, local injection.

A significant amount of research has been performed on glycosaminoglycans, especially glucosamine and chondroitin, for the treatment of arthritis. These compounds are commonly marketed as nutritional supplements and numerous 'soft therapeutic claims' are made about their health benefits - especially in aging populations. Since glucosamine is a precursor for glycosaminoglycans, and glycosaminoglycans are major components of cartilage, ingesting glucosamine might nourish joints, and thereby alleviate arthritis symptoms. Authoritative opinions on the actual therapeutic value of these compounds have been very mixed.

<span class="mw-page-title-main">Ultrasound-guided hip joint injection</span>

Ultrasound-guided hip joint injection is a joint injection in the hip, assisted by medical ultrasound. Hip and groin pain often presents a diagnostic and therapeutic challenge. The differential diagnosis is extensive, comprising intra-articular and extra-articular pathology and referred pain from lumbar spine, knee and elsewhere in the pelvis. Various ultrasound-guided techniques have been described in the hip and groin region for diagnostic and therapeutic purposes. Ultrasound has many advantages over other imaging modalities, including portability, lack of ionizing radiation and real-time visualization of soft tissues and neurovascular structures. Many studies have demonstrated the safety, accuracy and efficacy of ultrasound-guided techniques, although there is lack of standardization regarding the injectates used and long-term benefit remains uncertain.

Ultrasound-triggered drug delivery using stimuli-responsive hydrogels refers to the process of using ultrasound energy for inducing drug release from hydrogels that are sensitive to acoustic stimuli. This method of approach is one of many stimuli-responsive drug delivery-based systems that has gained traction in recent years due to its demonstration of localization and specificity of disease treatment. Although recent developments in this field highlight its potential in treating certain diseases such as COVID-19, there remain many major challenges that need to be addressed and overcome before more related biomedical applications are clinically translated into standard of care.

References

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