What is that wand called that we rub on patients' backs???

The results of this survey are a bit sobering. The fact that 84% of orthopaedic certified clinical specialists indicate the likely use of therapeutic ultrasound indicates that although we have scratched the surface of EBP in PT practice, many years of opportunity remain. Ultrasound device carts do make a nice place to put your laptop...just throw the machine away.

John

Comments

[Jon Newman]

I was a bit surprised that one of the survey items wasn't "increase productivity."

Ah well. Missed opportunities.

[David Poultr PT]

This is got to be one scary result for the Physical Therapy profession. I suppose my favorite question of, why do cats lick their butts? Answer: Because they can, is an excellent metaphor for why therapists use ultrasound?

How long are therapists going to go on using a modality, which at best is a placebo. In fact it may be worse than placebo, at least placebo ultrasound has a beneficial effect on healing ( Hashis 1986, 1988) Hashis found that any anti-inflammatory effect of ultrasound may be attributed to the placebo effect.
“The results showed that the beneficial analgesic and anti-inflammatory effects of US therapy were placebo-mediated, with maximum effect in the placebo ('mock' US) group without circular massaging with the applicator). Self-massage by the patient produced no significant effect” (Hashis 1988)

Robertson and Baker’s review on ultrasounds effectiveness found: “There was little evidence that active therapeutic ultrasound is more effective than placebo ultrasound for treating people with pain or a range of musculoskeletal injuries or for promoting soft tissue healing.” ( Robertson and Baker 2001)

van der Windt concluded “There is no evidence to support the use of ultrasound therapy
singly or in combination with exercise therapy for musculoskeletal disorders.” (Van der Windt et al 1999)

One area of concerns about the survey results is that 86% of the respondents said they would use ultrasound to reduce inflammation and treat tendonitis. Isn’t it time we realized that the vast majority of our patients do not have an inflammatory mediated condition? Pain does not equal inflammation. A large percentage of patients with low back problems have mechanical problems. Even if they did have some inflammation ultrasound isn’t going to help it.

Kahn’s work on tendonosis has shown that 80% plus of patients presenting with tendon pain have a non inflammatory condition, yet 90% of treatment they receive is aimed at treating inflammation. (Kahn 2002)

A bigger question is why is ultrasound still taught as part of the curriculm even on the new PDT programs?

If our profession is to move forward and truly embrace evidence-based practice isn’t it time we gave up tradition and started listening to the evidence?

Hopefully we are not using the dictum absence of proof isn’t proof on absence?

Kind regards,

David

References

Hashis et al Reduction of postoperative pain and swelling by ultrasound treatment: a placebo effect. : Pain. 1988 Jun;33(3):303-11.

Hashis et al. Anti-inflammatory effects of ultrasound therapy: evidence for a major placebo effect. Br J Rheumatol. 1986 Feb;25(1):77-81.

Robertson VJ, Baker GB, A Review of Therapeutic Ultrasound: Effectiveness Studies Physical Therapy , 2001

van der Windt D, van der Heijden G, vanden Berg S, ter Riet G, de Winter A and Bouter L :Ultrasound therapy for musculoskeletal disorders: asystematic review. Pain 81: 257-271. 1999

Kahn et al Time to abandon the “tendinitis” myth
Painful, overuse tendon conditions have a non­inflammatory pathology. BMJ VOLUME 324 16 MARCH 2002

[Carina Lowry]

My favorite quote is: These findings may help researchers prioritize needs for future research on the clinical effectiveness of US.

Huh?

Who wants to give up precious resources to determine once again US is at best a placebo?

Anyone?

Carina

[Louie Puentedua]

Are we forgetting that evidence-based practice does not just equal the best of research evidence? What about the other two important ingredients in the mix - clinicians experience/skills and patients views/preferences?
I still use US in my clinical work. Want to know when I will use it? When my patient tells me that the last time they had a particular problem, they were given US and they felt that it helped them. Am I using placebo to the best advantage? Why not, if it advances the desired outcome - quicker and more fuller recovery.

[David Poulter]

Louie,

I don't think there is anything wrong with utilizing a placebo. There are some possible ethical problems if you do not inform your patients that they may receive a placebo treatment as part of their therapy. It is a general requirement of a placebo controlled trial that the participants are informed that they would stand a chance of receiving a placebo treatment.

A second consideration is what your payor may think?
Are they going to pay for ultrasound if you are knowingly using it as a placebo.

Plus the studlies show that ultrasound switched off is a better placebo than switched on (Hashis 1988) (see above post)

I would propose that any modality should have a measurable outcome and should also be better than natural history.

I would suggest what I call the five digit function rule for measuring the outcomes of modalities. Frequency, duration, intensity, distribution, amount of medication and change in function, can be used to monitor the effect.

If you are not measuring the effect of your modality it could lead to problems. Some years ago several Physiotherapist were sued in Victoria Austrlaia for utlilizing ultrasound on patients for several sessions without a measurable outcome. The patient did report that they flet better and said that they thought it helped. The judge ruled that there were no measurable outcomes on the effect, just feeling better was the realm of psychology not physical therapy. If Ultrasound is an anti-inflammatory then there should be a measurable change in pain, swelling and function.

Isn't it time we started educating the public, referral sources and payors?
Or is it better to maintain the status quo in the name of clinical experience and patient feel good therapies?

We can only change by challenging tradition and providing sound education based on all leels of evidence.

Kind regards,

David

[Doug Bourne]

I'm surprised with the findings, considering how much ultrasound gets bashed these days. I'm pleased that it isn't disappearing just yet. It would be a shame if physios let it go only to find out that it can be very effective in certain situations. Because of the almost infinite dosages that you could use and the variety of conditions that you could use it on, it is very difficult to do research on ultrasound. I suspect many of the poor results are do to poor dosages and innappropriate conditions. For instance, one of the studies showing some effectiveness for us used much higher doses than used in practice (ebenbichler used 2.5W/cm2).

I think that it is important to understand that statements like “ultrasound is an antiinflammatory modality and tendonopathy is not an inflammatory condition; therefore ultrasound will not work for tendonopathies” are flawed. Ultrasound is inherently a mechanical modality not an antiinflammatory modality. If it has antiinflammatory effects, they stem from the mechanical stimulation. That doesn't mean that the mechanical stimulation doesn't have other effects. (the same basic premise works for corticosteroids except they are a biological modality) The ultrasound pressure wave will most likely cause fluid flow around cells as well as producing shear stresses across cell membranes and membrane proteins. These types of stimulation are known induce signalling mechanisms in cells. If you are familiar with current research on bone growth, you will know that fluid flow is thought to be one of the main stimuli for bone growth. There is current research suggesting that ultrasound may be beneficial for healing fractures. I am beginning to see more and more basic science research into ultrasound at meetings such as the orthopaedic research society.

I think that ultrasound is a popular target to bash for a number of reasons (besides the equivocal research).
1.Its not manual. We all know that are hands are better than a machine.
2.Its not skilled so it can't be good.
3.Little understanding of how ultrasound works
4.Little understanding of mechanobiology

While the research isn't strong yet, there is the possibility for a bright future for ultrasound. Don't give up on it so soon.

Doug

[David Poulter PT]

Doug,

I agree with you that there have been some studies in small animals, which show that ultrasound, may have a beneficial effect on fracture healing. (Warden et al 2006) There are also studies, which show it has a beneficial effect on carpal tunnel type presentations. (Ebenbichler et al 1998)

The only problem with these studies is that the way the ultrasound was used is not typical of current practice. Warden et al used 20 minutes for five days a week and Ebenbichler used 15minutes for five days a week.

Dosage differences aside, why five days a week and what happens at the weekend?

Think of this why do some patients get ultrasound two times a week and others three times a week form the same therapist treating the same condition? Why once a day?

There are not only vast possibilities of dose, including pulse variations, there are also frequency, duration of use.

Maybe it is time that manufactures and sellers did some research into the best practice use of ultrasound.

I’m not sure how we justify using a modality to treat specific conditions when it has been shown to have minimal to no effect other than placebo (Robertson et al 2001), in the hope that it might be shown useful in treating conditions we currently don’t use it on i.e. fractures?

Kind regards, David

Ebenbichler, et al Ultrasound treatment for treating the carpal tunnel
syndrome: randomised “sham” controlled trial, BMJ VOLUME 316 7 MARCH 1998

Warden et al Ultrasound Produced by a Conventional Therapeutic Ultrasound
Unit Accelerates Fracture Repair. Physical Therapy . Volume 86 . Number 8 . August 2006

Robertson VJ, Baker GB, A Review of Therapeutic Ultrasound: Effectiveness Studies. Physical Therapy , 2001

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