Ultrasound in contemporary physiotherapy practice

Ultrasound Therapy With High-Pressure Pulses Is Effective to Reduce the Effects of Collagenase-Induced Tendinopathy in Rat's Achilles Tendon

OBJECTIVE

We propose an ultrasonic treatment for collagenase-induced tendinopathy in rat's Achilles tendon using pulses with a low number of cycles, high acoustic pressure and very low duty cycle.

METHODS

Twenty rats were used to perform the experiment. Four experimental groups of calcaneal tendons were studied: control (n = 6), sham (n = 4), collagenase-induced tendinopathy (n = 8) and ultrasound-treated collagenase-induced tendinopathy (n = 8). Surgical intervention was performed to expose the tendons prior to collagenase injection. A 1 MHz ultrasonic tansducer with a focusing lens was used. Ultrasonic treatments were used with an average total treatment time of 2.5 min, 20-cycle pulses, pressure amplitude p = 7 MPa, and 0.02% duty cycle. Histopathology of the samples was performed to evaluate nuclear density, acute inflammation, and signs of neovascularization. Collagen (types I and III), elastic fibers, and glycosaminoglycans were also analyzed.

RESULTS

No tendon involvement was found by the surgical process. Ultrasonic treatment is safe, as it does not affect healthy tendons. When collagenase infiltrated animals were treated with US, a clear predominance of type I collagen fibers and a similar collagen ratio profile to that observed in the control and sham groups was observed, with a higher density of elastic fibers compared to the control and sham groups and a significant increase in the density of glycosaminoglycans.

CONCLUSION

The ultrasound treatment proposed reduces the effects of the artificial collagenase lesion to reach the basal level after 45 d.

Effects of therapeutic ultrasound in patients with knee osteoarthritis: A systematic review and meta-analysis

Background

Therapeutic ultrasound (US) is a treatment for knee osteoarthritis (KOA), but its efficacy and safety are unclear. The objective of this study is to quantify the effect of US on pain relief and function recovery in KOA, and to analyze the US treatment duration and parameters on treatment outcome.

Methods

We searched PubMed, MEDLINE, EMBASE, Google Scholar, Cochrane databases and ClinicalTrials.gov databases up to April 7, 2023. RCTs that compared the efficacy of therapeutic US with the control in KOA were included in the study, and the methodological quality of the trials was assessed using the Cochrane Risk of Bias tool.

Results

Twenty-one RCTs (1315 patients) were included. US had a positive effect on visual analog scale (VAS) (SMD = -0.64, 95 % CI [-0.88, -0.40], I2 = 71 %) and Western Ontario and McMaster Universities (WOMAC) total scale (SMD = -0.45, 95 % CI [-0.69, -0.20]; I2 = 67 %). Pulsed US with an intensity ≤2.5 W/cm2 reduced visual analog scale (VAS), and differed in sessions (24 sessions (SMD = -0.80, 95 % CI [-1.07, -0.53], I2 = 0 %) vs 10 sessions (SMD = -0.71, 95 % CI [-1.09, -0.33], I2 = 68 %)). For pulsed US, a duration of treatment of 4-8 weeks (SMD = -0.69, 95 % CI [-1.13, -0.25], I2 = 73 %) appeared to be superior to ≤4 weeks (SMD = -0.77, 95 % CI [-1.04, -0.49], I2 = 0 %) for reducing visual analog scale (VAS). No US treatment-related adverse events were reported.

Conclusion

Therapeutic US may be a safe and effective treatment for patients with KOA. The mode, intensity, frequency, and duration of US may affect the effectiveness of pain relief. Pulsed US with an intensity ≤2.5 W/cm2, 24 sessions, and a treatment duration of ≤4 weeks appears to have better pain relief.

A New Approach to Postoperative Rehabilitation following Mosaicplasty and Bone Marrow Aspiration Concentrate (BMAC) Augmentation

BACKGROUND

Chondral defects in the knee present a significant challenge due to their limited self-healing capacity, often leading to joint degeneration and functional disability. Current treatments, including surgical approaches like mosaicplasty and regenerative therapies such as bone marrow aspirate concentrate (BMAC) augmentation, aim to address these defects and improve patient outcomes.

MATERIALS AND METHODS

This study conducted a single-center, randomized controlled trial to evaluate the efficacy of different treatment approaches and rehabilitation protocols for chondral defects. Thirty-seven subjects presenting with symptomatic chondral or osteochondral defects (>3 cm2) in the weight-bearing region of the femoral condyle were partitioned into three groups, and underwent mosaicplasty with or without BMAC augmentation, followed by either a 6-week or 12-week rehabilitation program. Group 1 (n = 10) received mosaicplasty combined with BMAC augmentation and engaged in a twelve-week two-phase rehabilitation protocol. Group 2 (n = 15) underwent mosaicplasty alone and participated in the same twelve-week two-phase rehabilitation regimen. Meanwhile, Group 3 (n = 12) underwent mosaicplasty and underwent a shorter six-week one-phase rehabilitation program. Clinical assessments were performed using the visual analog scale (VAS) for pain, goniometry for the knee's range of motion (ROM), manual muscle testing (MMT) for quadricep strength, and the Western Ontario and McMaster University Arthritis Index (WOMAC) for functional evaluation in three test phases.

RESULTS

Significant differences in WOMAC scale scores were observed between the three groups at the intermediate (F(2, 34) = 5.24, p < 0.010) and final (F(2, 34) = 111, p < 0.000) stages, with post hoc Tukey tests revealing variations shared among all three groups. The between-group analysis of the VAS scale demonstrated no statistically significant difference initially (F(2, 34) = 0.18, p < 0.982), but significant differences emerged following the intermediate (F(2, 34) = 11.40, p < 0.000) and final assessments (F(2, 34) = 59.87, p < 0.000), with post hoc Tukey tests revealing specific group variations, notably between Group 1 and both Group 2 and Group 3, and also between Group 3 and Group 2. The between-group analysis of quadricep muscle strength using MMT scores revealed no statistically significant differences initially (F(2, 34) = 0.376, p < 0.689) or following the intermediate assessment (F(2, 34) = 2.090, p < 0.139). The one-way ANOVA analysis showed no significant difference in the knee ROM initially (F(2, 34) = 1.037, p < 0.366), but significant differences emerged following intermediate (F(2, 34) = 9.38, p < 0.001) and final assessments (F(2, 34) = 11.60, p < 0.000). Post hoc Tukey tests revealed significant differences between Groups 1 and 2, Groups 1 and 3, and Groups 2 and 3 at intermediate and final assessments.

CONCLUSIONS

The patients who received BMAC augmentation and completed a 12-week rehabilitation protocol had significantly better outcomes in pain relief, knee function, and ROM when compared to those who did not receive BMAC augmentation or those who completed a shorter rehabilitation period. Our findings suggest that combining mosaicplasty with BMAC augmentation and a comprehensive rehabilitation program can lead to superior clinical outcomes for patients with chondral defects in the knee.

Effectiveness of low-intensity pulsed ultrasound on osteoarthritis: molecular mechanism and tissue engineering

Osteoarthritis (OA) is distinguished by pathological alterations in the synovial membrane, articular cartilage, and subchondral bone, resulting in physical symptoms such as pain, deformity, and impaired mobility. Numerous research studies have validated the effectiveness of low-intensity pulsed ultrasound (LIPUS) in OA treatment. The periodic mechanical waves generated by LIPUS can mitigate cellular ischemia and hypoxia, induce vibration and collision, produce notable thermal and non-thermal effects, alter cellular metabolism, expedite tissue repair, improve nutrient delivery, and accelerate the healing process of damaged tissues. The efficacy and specific mechanism of LIPUS is currently under investigation. This review provides an overview of LIPUS's potential role in the treatment of OA, considering various perspectives such as the synovial membrane, cartilage, subchondral bone, and tissue engineering. It aims to facilitate interdisciplinary scientific research and further exploration of LIPUS as a complementary technique to existing methods or surgery. Ongoing research is focused on determining the optimal dosage, frequency, timing, and treatment strategy of LIPUS for OA. Additional research is required to clarify the precise mechanism of action and potential impacts on cellular, animal, and human systems prior to its integration into therapeutic applications.

The Effect of Low-Intensity Pulsed Ultrasound on Bone Regeneration and the Expression of Osterix and Cyclooxygenase-2 during Critical-Size Bone Defect Repair

Low-intensity pulsed ultrasound (LIPUS) is a form of ultrasound that utilizes low-intensity pulsed waves. Its effect on bones that heal by intramembranous ossification has not been sufficiently investigated. In this study, we examined LIPUS and the autologous bone, to determine their effect on the healing of the critical-size bone defect (CSBD) of the rat calvaria. The bone samples underwent histological, histomorphometric and immunohistochemical analyses. Both LIPUS and autologous bone promoted osteogenesis, leading to almost complete closure of the bone defect. On day 30, the bone volume was the highest in the autologous bone group (20.35%), followed by the LIPUS group (19.12%), and the lowest value was in the control group (5.11%). The autologous bone group exhibited the highest intensities of COX-2 (167.7 ± 1.1) and Osx (177.1 ± 0.9) expression on day 30. In the LIPUS group, the highest intensity of COX-2 expression was found on day 7 (169.7 ±1.6) and day 15 (92.7 ± 2.2), while the highest Osx expression was on day 7 (131.9 ± 0.9). In conclusion, this study suggests that LIPUS could represent a viable alternative to autologous bone grafts in repairing bone defects that are ossified by intramembranous ossification.

Assessment of Integrative Therapeutic Methods for Improving the Quality of Life and Functioning in Cancer Patients-A Systematic Review

Background: Cancer rehabilitation represents a series of measures adopted for the recovery of psychological, emotional, social, and financial functioning in the case of cancer patients. The purpose of this study is to identify the main elements of therapeutic management in the field of medical rehabilitation, as well as integrative, complementary medicine and holistic approaches that can be performed on the oncological patient. Methods: This systematic literature review follows the methodology outlined in the "Preferred Reporting Items for Systematic Reviews and Meta-Analysis" ("PRISMA") statement, which is an internationally recognized and widely accepted standard. Results: Active rehabilitative therapies offer therapeutic options for improving the functioning and quality of life of oncological patients; these therapies comprehensively address both the physical and psychological aspects of the disease. This review also includes the latest novelties and nanotechnologies applied in oncological rehabilitation, for example, drugs (or supplements) inspired by nature. Conclusions: Physical and rehabilitation medicine, mostly using stimulating therapeutic methods, was recently added to the list of contraindications in the management of oncological patients, both as an approach to the pathological concept itself and as an approach to the main clinical consequences and functional aspects of oncological therapies. Integrative, complementary medicine presents an important therapeutic resource in the case of oncological patients. Advanced studies are needed in the future to further ascertain the role of these therapies.

Acupuncture and dry needling for physical therapy of scar: a systematic review

BACKGROUND

There is a continuing interest in finding effective methods for scar treatment. Dry needling is gaining popularity in physiotherapy and is defined by Western medicine as a type of acupuncture. The terms acupuncture and dry needling have been used interchangeably so we have focused on the efficacy of dry needling or acupuncture in scar treatment.

OBJECTIVE

The aim of this systematic review was to determine the usefulness of dry needling or local acupuncture for scar treatment. In our search process, we used the terms 'acupuncture,' 'needling,' or 'dry needling' to identify all relevant scientific papers. We have focused on the practical aspects of local management of different scar types with dry needling or acupuncture.

SEARCH STRATEGY

The search strategy included different combinations of the following keywords: 'scar', 'keloid', 'dry needling', 'needling', 'acupuncture', 'treatment', 'physical therapy'. This systematic review was conducted in accordance with PRISMA guidelines. MEDLINE (PubMed, EBSCOHost and Ovid), EMBASE (Elsevier), and Web of Science databases were searched for relevant publications from inception through October 2023.

INCLUSION CRITERIA

The studies that investigated the effectiveness of dry needling or acupuncture for scar treatment were included.

DATA EXTRACTION AND ANALYSIS

The main extraction data items were: the needling technique; needle: diameter, length; needling locations; manual needling manipulation; number of sessions; settings; outcomes and results.

RESULTS

As a result of a comprehensive search, 11 manuscripts were included in the systematic review, of which eight were case reports, two were randomized trials and one study concerned case series. Two case reports scored 2-4 out of 8 points on the JBI checklist, five studies scored 5-7, and one study scored 8 points. The methodological quality of the two clinical trials was rated as good or fair on the PEDro scale. The case series study scored 7 of 10 points on the JBI checklist. A meta-analysis was not possible as only two randomized trials, eight case reports, and one case series were eligible for review; also, scar assessment scales and pain severity scales were highly heterogeneous.

CONCLUSIONS

The studies differed regarding the delivery of dry needling or local acupuncture for scar treatment. Differences included treatment frequency, duration, number of treatments, selection of needle insertion sites, number of needles used, angle of needle placement, and use of manual needling manipulation.

SYSTEMATIC REVIEW REGISTRATION

INPLASY no. 202310058.

A Data-Driven Approach for Estimating Temperature Variations Based on B-mode Ultrasound Images and Changes in Backscattered Energy

Thermal treatments that use ultrasound devices as a tool have as a key point the temperature control to be applied in a specific region of the patient's body. This kind of procedure requires caution because the wrong regulation can either limit the treatment or aggravate an existing injury. Therefore, determining the temperature in a region of interest in real-time is a subject of high interest. Although this is still an open problem, in the field of ultrasound analysis, the use of machine learning as a tool for both imaging and automated diagnostics are application trends. In this work, a data-driven approach is proposed to address the problem of estimating the temperature in regions of a B-mode ultrasound image as a supervised learning problem. The proposal consists in presenting a novel data modeling for the problem that includes information retrieved from conventional B-mode ultrasound images and a parametric image built based on changes in backscattered energy (CBE). Then, we compare the performance of classic models in the literature. The computational results presented that, in a simulated scenario, the proposed approach that a Gradient Boosting model would be able to estimate the temperature with a mean absolute error of around 0.5°C, which is acceptable in practical environments both in physiotherapic treatments and high intensity focused ultrasound (HIFU).

Increased intracellular diffusivity of macromolecules within a mammalian cell by low-intensity pulsed ultrasound

Whilst a number of studies have demonstrated that low-intensity pulsed ultrasound (LIPUS) is a promising therapeutic ultrasound technique that can be used for delivering mild mechanical stimuli to target tissue non-invasively, the underlying biophysical mechanisms still remain unclear. Most mechanism studies have focused explicitly on the effects of LIPUS on the cell membrane and mechanosensitive receptors. In the present study, we propose an additional mechanism by which LIPUS propagation through living cells may directly impact intracellular dynamics, particularly the diffusion transport of biomolecules. To support our hypothesis, human epithelial-like cells (SaOS-2 and HeLa) seeded on a confocal dish placed on a microscope stage were exposed to LIPUS with various exposure conditions (ultrasound frequencies of 0.5, 1 and 3 MHz, peak acoustic pressure of 200 and 400 kPa, a pulse repetition frequency of 1 kHz and a 20 % duty cycle), and the diffusivities of various sizes of biomolecules in the cytoplasm area were measured using fluorescence recovery after photobleaching (FRAP). Furthermore, giant unilamellar vesicles (GUVs) filled with macromolecules were used to examine the physical causal relationship between LIPUS and molecular diffusion changes. Nucleocytoplasmic transport coefficients were also measured by modified FRAP that bleaches the whole cell nuclear region. Extracellular signal-regulated kinases (ERK) activity (the phosphorylation dynamics) was monitored using fluorescence resonance energy transfer (FRET) microscopy. All the measurements were taken during, before and after the LIPUS exposure. Our experimental results clearly showed that the diffusion coefficients of macromolecules within the cell increased with acoustic pressure by 12.1 to 33.5 % during the sonication, and the increments were proportional to their molecular sizes regardless of the ultrasound frequency used. This observation in living cells was consistent with the GUVs exposed to the LIPUS, which indicated that the diffusivity increase was a passive physical response to the acoustic energy of LIPUS. Under the 1 MHz LIPUS exposure with 400 kPa, the passive nucleocytoplasmic transport of enhanced green fluorescent protein (EGFP) was accelerated by 21.4 %. With the same LIPUS exposure condition, both the diffusivity and phosphorylation of ERK induced by EGF treatment were significantly elevated simultaneously, which implied that LIPUS could also modify the kinase kinetics in the signal transduction process. Taken together, this study is the first attempt to uncover the physical link between LIPUS and the dynamics of intracellular macromolecules and related biological processes that LIPUS can possibly increase the diffusivity of intracellular macromolecules, leading to the changes in the basic cellular processes: passive nucleocytoplasmic transport and ERK. Our findings can provide a novel perspective that the mechanotransduction process that the intracellular region, in addition to the cell membrane, can convert the acoustic stimuli of LIPUS to biochemical signals.

Short-term effects of low-level laser versus ultrasound therapy on children's neck posture after long-term use of electronic devices

The purpose of the study was to compare the effect of low-level laser therapy (LLLT), ultrasound therapy (US), and strengthening and stretching exercise in children diagnosed with cervical straightening caused by long-term use of electronic devices. A total of 60 patients from 12 to 18 years of both gender diagnosed with straight neck syndrome which is losing the normal C shape of cervical vertebrae. Patients were randomized into three groups. In group A, patients received LLLT plus exercise, while in group B, they received US plus exercise, and group C received exercise. In group A and B, Cobb angle and VAS showed a significant improvement (more significant in group A) with P < 0.001, while in group C P = 0.006. LLLT, US, and exercise improved the cervical straight curve, and reduced pain with maximum effect was done by LLLT.

Effects of Low-Intensity Pulsed Ultrasound in Tendon Injuries

Tendon injuries are the most common soft tissue injuries, caused by tissue overuse and age-related degeneration. However, the tendon repair process is slow and inefficient due to the lack of cellular structure and blood vessels in the tendon. Low-intensity pulsed ultrasound (LIPUS) has received increasing attention as a non-invasive, simple, and safe way to promote tendon healing. This review summarizes the effects and underlying mechanisms of LIPUS on tendon injury by comprehensively examining the published literature, including in vitro, in vivo, and clinical studies. This review reviewed 24 studies, with 87.5% showing improvement. The application of LIPUS in tendon diseases is a promising field worthy of further study.

The effectiveness of biophysical agents in the treatment of carpal tunnel syndrome- an umbrella review

BACKGROUND

Our objective was to summarize, synthesize, and integrate the evidence evaluating the effectiveness of biophysical agents compared to other conservative treatments, for the management of carpal tunnel syndrome (CTS).

METHODS

This was an overview of systematic reviews (SRs). We searched several online databases and obtained SRs relating to managing CTS using biophysical agents. Two independent researchers screened and appraised the quality of the SRs using the A MeaSurement Tool to Assess systematic Reviews-2 appraisal tool. We extracted information related to study characteristics as well as the effectiveness of biophysical agents for CTS, the effect sizes, and between-group significances. We categorized the information based on the type of biophysical agent. We also performed a citation mapping and calculated the corrected covered area index.

RESULTS

We found 17 SRs addressing 12 different biophysical agents. The quality of the SRs was mainly critically low (n = 16) or low (n = 1). The evidence was inconclusive for the effectiveness of Low-level Laser therapy and favorable for the short-term efficacy of non-thermal ultrasound in improving symptom severity, function, pain, global rating of improvement, satisfaction with treatment, and other electrophysiological measures compared to manual therapy or placebo. Evidence was inconclusive for Extracorporeal Shockwave therapy, and favorable for the short-term effectiveness of Shortwave and Microwave Diathermy on pain and hand function. The corrected covered area index was lower than 35% indicating a low overlap of the SRs.

CONCLUSIONS

The findings were based on low-quality primary studies, with an unclear or high risk of bias, small sample sizes, and short follow-ups. Therefore, no recommendations can be made for the long-term effectiveness of any biophysical agents. High-quality evidence is needed to support evidence-based recommendations on the use of biophysical agents in the management of CTS.

PROSPERO REGISTRATION NUMBER

CRD42022319002, registered on 17/04/2022.

Low-intensity pulsed ultrasound in obstetrics and gynecology: advances in clinical application and research progress

In the past decade, research on ultrasound therapy in obstetrics and gynecology has rapidly developed. Currently, high-intensity ultrasound has been widely used in clinical practice, while low-intensity ultrasound has gradually emerged as a new trend of transitioning from pre-clinical research to clinical applications. Low-intensity pulsed ultrasound (LIPUS), characterized by a non-invasive low-intensity pulse wave stimulation method, employs its non-thermal effects to achieve safe, economical, and convenient therapeutic outcomes. LIPUS converts into biochemical signals within cells through pathways such as cavitation, acoustic flow, and mechanical stimulation, regulating molecular biological mechanisms and exerting various biological effects. The molecular biology mechanisms underlying the application of LIPUS in obstetrics and gynecology mainly include signaling pathways, key gene expression, angiogenesis, inflammation inhibition, and stem cell differentiation. LIPUS plays a positive role in promoting soft tissue regeneration, bone regeneration, nerve regulation, and changes in cell membrane permeability. LIPUS can improve the treatment benefit of premature ovarian failure, pelvic floor dysfunction, nerve damage caused by intrauterine growth restriction, ovariectomized osteoporosis, and incomplete uterine involution through the above biological effects, and it also has application value in the adjuvant treatment of malignant tumors such as ovarian cancer and cervical cancer. This study outlines the biological mechanisms and applications of LIPUS in treating various obstetric and gynecologic diseases, aiming to promote its precise application and provide a theoretical basis for its use in the field.

Shockwave versus ultrasound therapy in the enhancement of Aloe vera in cutaneous wound healing

OBJECTIVE

To investigate the healing efficacy of topical Aloe vera enhanced by shockwave or ultrasound therapy on wounds in rats and compare both effects.

METHOD

A total of 75 male albino rats were randomly divided into equal groups A, B, C, D and E. Under anaesthesia, a wound (6cm2) was created on the back of each rat. Group A received topical Aloe vera under occlusive dressing followed by shockwave therapy with the following parameters: 600 shocks, four pulses/second and 0.11mJ/mm2. Group B received topical Aloe vera under occlusive dressing followed by therapeutic ultrasound with the following parameters: pulsed mode, 2:8 duty cycle, 1MHz and 0.5 W/cm2. Group C received the same treatment as group A but in a reversed sequence-the shockwave therapy followed by the Aloe vera gel. Group D received the same treatment as group B but in a reversed sequence-therapeutic ultrasound followed by the Aloe vera gel. And control group E only received topical Aloe vera under occlusive dressing. Each group received three sessions per week, for two weeks. Wound extent and shrinkage rates were measured at study initiation and at the end of each week.

RESULTS

There were significant wound reductions in groups A and B compared to C and D, respectively, and in group A compared to group B.

CONCLUSION

Shockwaves and ultrasound were found to amplify the effect of the Aloe vera on the wound, and there was improved wound healing in the shockwave group A compared to the ultrasound group B.

Immunomodulation and targeted drug delivery with high intensity focused ultrasound (HIFU): Principles and mechanisms

High intensity focused ultrasound (HIFU) is a non-invasive and non-ionizing sonic energy-based therapeutic technology for inducing thermal and non-thermal effects in tissues. Depending on the parameters, HIFU can ablate tissues by heating them to >55 °C to induce denaturation and coagulative necrosis, improve radio- and chemo-sensitizations and local drug delivery from nanoparticles at moderate hyperthermia (~41-43 °C), and mechanically fragment cells using acoustic cavitation (also known as histotripsy). HIFU has already emerged as an attractive modality for treating human prostate cancer, veterinary cancers, and neuromodulation. Herein, we comprehensively review the role of HIFU in enhancing drug delivery and immunotherapy in soft and calcified tissues. Specifically, the ability of HIFU to improve adjuvant treatments from various classes of drugs is described. These crucial insights highlight the opportunities and challenges of HIFU technology and its potential to support new clinical trials and translation to patients.

Comparison of the effectiveness of high-intensity laser and ultrasound therapies in adhesive capsulitis: A randomized controlled study

BACKGROUND

Adhesive capsulitis (AC) is a common musculoskeletal disease characterized with shoulder pain, limitation of range of motion (ROM) and disability. Although physical therapy is used in the treatment of AC, studies on its effectiveness are continuing.

OBJECTIVE

This study aimed to assess the effectiveness of ultrasound (US) and high-intensity laser therapy (HILT) in the treatment of AC.

METHODS

Sixty patients were randomized into two groups. Group I received US (15 sessions) and Group II received HILT (9 sessions) for 3 weeks. In addition, all patients received physical therapy program (hot pack, TENS and exercises). Assessments were made using VAS-pain, Shoulder Pain and Disability Index (SPADI), range of motion (ROM) at baseline and in post-treatment 3rd, 8th and 24th weeks.

RESULTS

There was no statistically significant difference between the groups in terms of all pre-treatment values. In intragroup assessment, statistically significant difference was identified in all the values of Groups 1 and 2 in all assessment periods compared with the pre-treatment values (p< 0.05). There was no significant difference between groups in all assessment periods.

CONCLUSION

According to results, US therapy and HILT were effective on the improvement of pain, ROM and functional conditions of patients in the treatment of AC.

The role of anti-tumor immunity of focused ultrasound for the malignancies: depended on the different ablation categories

Improving anti-tumor immunity has promising outcomes in eradicating malignant tumors. Tumor cells can escape from immune surveillance and killing; therefore, various strategies are continuously developing to inhibit immune escape. Focused ultrasound (FUS) has recently emerged to play an important role in immune modulation. After FUS therapy, various tumor antigens and related signals are released. The non-thermal effect of FUS strengthens the blood and lymph circulation, increases cell permeability, and helps in crossing the physical barrier like the blood-brain barrier and blood-tumor barrier. However, the different ablation of FUS is proposed to have a different anti-tumor immune effect. Therefore, we categorized the FUS ablation into thermal and non-thermal ablation and summarized possible anti-tumor immunity mechanisms.

Optimization of a random linear ultrasonic therapeutic array based on a genetic algorithm

Given their advantage of suppressing grating lobes, randomly arranged linear arrays have potential for use in ultrasonic treatment. The current work proposes a method based on genetic algorithm to optimize the random arrangement of array elements, so that the suppression effect of grating lobes can be significantly improved with reduced calculating time. The maximum and average kerfs of array elements are used as genes, and the ratio of the maximum to the secondary maximum sound pressure at the focal plane is used as the optimized target. Typically, the calculation requirements of the current method can be reduced to ∼ 25% of the traversing method. We further discuss how the kerf width, the effective ratio of element areas and the ratio of focal distance to array aperture affect the suppression of grating lobes. For a typical linear array with 32 elements (1-MHz operating frequency, 1.5-mm element width and 150-mm focal distance), the results suggest that the grating lobes are suppressed well when (1) the ratio of maximum width to average width of the element is between 5 and 8, (2) the ratio of the effective element area to the area of the whole array is between 0.5 and 0.9, and (3) the ratio of the effective emission aperture to the actual emission aperture of the array is as large as possible. Based on optimized parameters, an experimental array was fabricated and the measured results of corresponding sound field were entirely consistent with the simulated results (Given her role as an Associate Editor of this journal, Juan Tu had no involvement in the peer-review of articles for which she was an author and had no access to information regarding the peer-review. Full responsibility for the peer-review process for this article was delegated to another Editor of this journal.).

Ultrasound triggered organic mechanoluminescence materials

Ultrasound induced organic mechanoluminescence materials have become one of the focal topics in wireless light sources since they exhibit high spatiotemporal resolution, biocompatibility and excellent tissue penetration depth. These properties promote great potential in ultrahigh sensitive bioimaging with no background noise and noninvasive nanodevices. Recent advances in chemistry, nanotechnology and biomedical research are revolutionizing ultrasound induced organic mechanoluminescence. Herein, we try to summarize some recent researches in ultrasound induced mechanoluminescence that use various materials design strategies based on the molecular conformational changes and cycloreversion reaction. Practical applications, like noninvasive bioimaging and noninvasive optogenetics, are also presented and prospected.

Effectiveness of High Power Laser Therapy on Pain and Isokinetic Peak Torque in Athletes with Proximal Hamstring Tendinopathy: A Randomized Trial

Athletes such as long-distance runners, sprinters, hockey, and/or football players may have proximal hamstring tendinopathy (PHT). Laser therapy has been shown to be effective in tendinopathies. High power laser therapy (HPLT) is used for the treatment of several musculoskeletal conditions; however, its efficacy on PHT has not been investigated. This study is aimed at examining the effects of HPLT on pain and isokinetic peak torque (IPT) in athletes with PHT. The two-arm comparative pretest-posttest experimental design was used with random allocation of 36 athletes aged 18-35 years into two groups (experimental and conventional group). The experimental group included the application of HPLT for 3 weeks. The conventional group included treatment with a conventional physiotherapy program including ultrasound therapy, moist heat pack, and home exercises for a total of 3 weeks. Pain and IPT of the hamstring muscle were measured before and after the application of the intervention. Pain score decreased, and IPT increased significantly (p < 0.05) after application of HPLT, by 61.26% and 13.18%, respectively. In the conventional group, a significant difference (p < 0.05) was observed in pain scores only, which decreased by 41.14%. No significant difference (p > 0.05) was observed in IPT in the conventional group. When HPLT was compared with conventional physiotherapy, a significant difference was found in pain scores only. HPLT for 3 weeks was found to be effective in improving pain in athletes with PHT. However, no significant difference was found between HPLT and conventional physiotherapy (US, moist heat, and home exercises) in improving the IPT of the hamstring muscle.

System and method for applying physiotherapeutic focused ultrasound

Despite many years of clinical use of ultrasound, the results of different reviews of controlled trials on the efficacy of ultrasound physical therapy for different musculoskeletal injuries continue to question its efficacy. However, "in vitro" experiments with well-controlled cell cultures and experiments with animal models show positive results. The question is whether the commercial systems used by physiotherapists can deliver the required ultrasonic dose to the exact location on the body. The object of this work is the design, realization and testing of a new concept of ultrasound system for Physiotherapy capable of focusing the ultrasound beam to apply the required ultrasonic energy dose at the point targeted by the physiotherapist. The system is designed for non-thermal effects Physiotherapy. The system consists of conceptually new piezocomposite arrays with a metallic delay line, multi-pulser electronics for emission focusing, parallel robots for mechanical steering and positioning of the array transducers, and linear and angular encoders to allow the physiotherapist to direct the focus to the target. The multi-pulser and parallel robot angulation are controlled by the computer, using a graphical interface software.

Efficacy of ultrasound therapy for the treatment of lateral elbow tendinopathy (the UCICLET Trial): study protocol for a three-arm, prospective, multicentre, randomised controlled trial

INTRODUCTION

Lateral elbow tendinopathy (LET) is a highly prevalent disease among the middle-aged population, with no consensus on optimal management. Non-operative treatment is generally accepted as the first-line intervention. Ultrasound (US) therapy has been reported to be beneficial for various orthopaedic diseases, including tendinopathy. The purpose of this study is to investigate the efficacy of US for LET treatment.

METHODS AND ANALYSIS

This protocol entails a three-arm, prospective, multicentre, randomised controlled trial. Seventy-two eligible participants with clinically confirmed LET will be assigned to either (1) US, (2) corticosteroid injections or (3) control group. All participants will receive exercise-based therapy as a fundamental intervention. The primary outcome is Patient-rated Tennis Elbow Evaluation. The secondary outcomes include Visual Analogue Scale for pain, shortened version of the Disabilities of the Arm, Shoulder and Hand for upper limb disability, pain free/maximum grip strength, Work Limitations Questionnaire-25 for functional limitations at work, EuroQol-5D for general health, Hospital Anxiety and Depression Scale for mental status, Global Rating of Change for treatment success and recurrence rate, and Mahomed Scale for the participant's satisfaction. Adverse events will be recorded. Intention-to-treat analyses will be used.

ETHICS AND DISSEMINATION

Ethics committees of all clinical centres have approved this study. The leading centre is Shanghai Sixth People's Hospital, whose approval number is 2021-153. New versions with appropriate amendments will be submitted to the committee for further approval. Final results will be published in peer-reviewed journals and presented at local, national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2100050547.

Effects of Therapeutic Ultrasound on Growth Plates: A Systematic Review

PURPOSE

The aim of this systematic review was to evaluate studies reporting on the effects of therapeutic ultrasound on the physis.

SUMMARY OF KEY POINTS

Eight studies were included in the final analysis, all of which were animal studies. At higher doses, studies found skin and bone necrosis and inhibition of growth, while in lower doses some studies found that ultrasound had a transient stimulatory effect on growth, increased thickness of the hypertrophic zone, and increased thickness of the whole growth plate. Overall, experimental evidence in animal models suggests that therapeutic ultrasound, even at low doses, might induce microscopic changes to the histology of the growth plate.

CONCLUSION

While we found no reports of growth disturbance in humans, given the histological changes found in animal studies, the current limited literature seems to support the recommendation that the application of therapeutic ultrasound around the physis should be avoided.

Radiofrequency ablation and related ultrasound-guided ablation technologies for treatment of benign and malignant thyroid disease: An international multidisciplinary consensus statement of the American Head and Neck Society Endocrine Surgery Section with the Asia Pacific Society of Thyroid Surgery, Associazione Medici Endocrinologi, British Association of Endocrine and Thyroid Surgeons, European Thyroid Association, Italian Society of Endocrine Surgery Units, Korean Society of Thyroid Radiology, Latin American Thyroid Society, and Thyroid Nodules Therapies Association

BACKGROUND

The use of ultrasound-guided ablation procedures to treat both benign and malignant thyroid conditions is gaining increasing interest. This document has been developed as an international interdisciplinary evidence-based statement with a primary focus on radiofrequency ablation and is intended to serve as a manual for best practice application of ablation technologies.

METHODS

A comprehensive literature review was conducted to guide statement development and generation of best practice recommendations. Modified Delphi method was applied to assess whether statements met consensus among the entire author panel.

RESULTS

A review of the current state of ultrasound-guided ablation procedures for the treatment of benign and malignant thyroid conditions is presented. Eighteen best practice recommendations in topic areas of preprocedural evaluation, technique, postprocedural management, efficacy, potential complications, and implementation are provided.

CONCLUSIONS

As ultrasound-guided ablation procedures are increasingly utilized in benign and malignant thyroid disease, evidence-based and thoughtful application of best practices is warranted.

Therapeutic ultrasound for knee osteoarthritis: A systematic review and meta-analysis with grade quality assessment

BACKGROUND

Therapeutic ultrasound (US) is a widely used intervention in physical therapy to manage pain and to aid in the healing of soft tissue.

OBJECTIVE

This systematic review aimed to determine the effects of therapeutic US on knee osteoarthritis (KOA) symptoms.

METHODS

PubMed, MEDLINE, EMBASE, Google Scholar, and the Cochrane databases were searched from inception to April 2019. Randomized controlled trials (RCTs) involving adults with symptomatic KOA that compared therapeutic US with a sham or other control were included. The methodological quality of the trials was assessed at the study level using the Cochrane Risk of Bias tool. The quality of evidence at the outcome level- and overall- was assessed using GRADE methodology. Meta-analyses were conducted using random effects models, and heterogeneity was assessed using the I2 statistic.

RESULTS

Four studies (N = 234 participants) were eligible for inclusion in our primary analyses assessing therapeutic US versus sham. The methodological quality of the included RCTs ranged from moderate to very low. Treatment with therapeutic US resulted in small, statistically significant benefits for pain (approximate 9.6% improvement on a 0-100 visual analog scale [95% confidence interval: 2, 17.4%]) and self-reported measures of function (approximate 12.8% improvement on a 0-100 visual analog scale [0.4, 25.2%]). The overall quality of the evidence was very low. No adverse events were reported in any of the included studies.

CONCLUSIONS

The use of therapeutic US may provide additional benefits to physical therapy regimens in terms of symptom relief in individuals with KOA. However, it is not possible to make any meaningful recommendations for clinical practice due to the small number of applicable RCTs and the low methodological quality of the RCTs deemed eligible for this study.

Far field during sonication experiments in vitro - Is it really far enough?

In many in vitro experiments studying ultrasound bioeffects the sonicated samples are placed to far field with intention of exposing them to as uniform ultrasound field as possible. The main aim of this work is to assess whether the sonicated samples really experience what they are believed to. Also we would like to suggest basic rules for construction of sonication vessels. We used 3.5 MHz and 7 MHz ultrasound transducers for measurements. We measured ultrasound field inside and behind common culture plates and special 3D printed plates placed to last axial maximum in water sonication tank with use of a needle hydrophone. Our results show that even though the sonication vessels with sonicated samples are placed into far field, the sonicated samples are actually exposed to some kind of a near field pattern which develops due to the interaction between ultrasound and well of culture plate. The variability of local acoustic intensity can reach up to several hundreds of percent. Our results are also supported by theoretical calculation and software for simulation of ultrasound fields. Even though the sonicated samples may have actually been exposed to some kind of near field pattern in many past studies, the whole phenomenon of creation of near field pattern can be controlled to some extent for future studies. Thus, we suggest that the sonication vessel should always be designed for particular ultrasound transducer.

Effects of Non-thermal Ultrasound on a Fibroblast Monolayer Culture: Influence of Pulse Number and Pulse Repetition Frequency

Despite the use of therapeutic ultrasound in the treatment of soft tissue pathologies, there remains some controversy regarding its efficacy. In order to develop new treatment protocols, it is a common practice to carry out in vitro studies in cell cultures before conducting animal tests. The lack of reproducibility of the experimental results observed in the literature concerning in vitro experiments motivated us to establish a methodology for characterizing the acoustic field in culture plate wells. In this work, such acoustic fields are fully characterized in a real experimental configuration, with the transducer being placed in contact with the surface of a standard 12-well culture plate. To study the non-thermal effects of ultrasound on fibroblasts, two different treatment protocols are proposed: long pulse (200 cycles) signals, which give rise to a standing wave in the well with the presence of cavitation (I_SPTP max = 19.25 W/cm²), and a short pulse (five cycles) of high acoustic pressure, which produces a number of echoes in the cavity (I_SPTP = 33.1 W/cm², with P_max = 1.01 MPa). The influence of the acoustic intensity, the number of pulses, and the pulse repetition frequency was studied. We further analyzed the correlation of these acoustic parameters with cell viability, population, occupied surface, and cell morphology. Lytic effects when cavitation was present, as well as mechanotransduction reactions, were observed.

Acceleration of Bone-Tendon Interface Healing by Low-Intensity Pulsed Ultrasound Is Mediated by Macrophages

OBJECTIVE

Low-intensity pulsed ultrasound (LIPUS) has been proven to facilitate bone-tendon interface (BTI) healing and regulate some inflammatory cytokines. However, the role of macrophages, a key type of inflammatory cell, during treatment remains unknown. This study aimed to investigate the role of macrophages in the treatment of BTI injury with LIPUS in a rotator cuff tear animal model.

METHODS

In this experimental and comparative study, a total of 160 C57BL/6 mature male mice that underwent supraspinatus tendon detachment and repair were randomly assigned to 4 groups: daily ultrasonic treatment and liposomal clodronate (LIPUS+LC), daily ultrasonic treatment and liposomes (LIPUS), daily mock sonication and liposomal clodronate (LC), and daily mock sonication and liposomes (control [CTL]). LIPUS treatment was initiated immediately postoperatively and continued daily until the end of the experimental period.

RESULTS

The failure load and stiffness of the supraspinatus tendon-humerus junction were significantly higher in the LIPUS group than in the other groups at postoperative weeks 2 and 4, whereas those in the LIPUS+LC and LC groups were lower than those in the CTL group at postoperative week 4. The LIPUS, LIPUS+LC, and LC groups exhibited significantly more fibrocartilage than the CTL group at 2 weeks. Only the LIPUS group had more fibrocartilage than the CTL group at 4 weeks. Micro-computed tomography results indicated that LIPUS treatment could improve the bone quality of the attachment site after both 2 and 4 weeks. When macrophages were depleted by LC, the bone quality-promoting effect of LIPUS treatment was significantly reduced.

CONCLUSION

The enhancement of BTI healing by LIPUS might be mediated by macrophages.

IMPACT

In our study, LIPUS treatment appeared to accelerate BTI healing, which was associated with macrophages based on our murine rotator cuff repair model. The expressions of macrophage under LIPUS treatment may offer a potential mechanism to explain BTI healing and the effects of LIPUS on BTI healing.

Therapeutic Ultrasound for Chemotherapy-Related Pain and Sensory Disturbance in the Hands and Feet in Patients With Colorectal Cancer: A Pilot Randomized Controlled Trial

CONTEXT

This proof-of-concept trial was undertaken as a first step in exploring the clinical benefit of therapeutic ultrasound for pain and sensory disturbance in patients with colorectal cancer.

OBJECTIVES

The aim of this study was to determine the feasibility and preliminary efficacy of adding therapeutic ultrasound to a home-based therapeutic exercise program (current standard of care) for patients presenting with oxaliplatin-related pain and sensory disturbance in the hands and feet.

METHODS

Thirty-one colorectal cancer patients with presenting symptoms of peripheral sensory neuropathy, based on a physician-rated grade 1, 2, or 3 on the National Cancer Institute Common Terminology Criteria for Adverse Events for sensory and motor neuropathy, were enrolled in the trial. Patients were randomized to either 10 sessions of ultrasound therapy intervention over two-week period (continuous ultrasound at an intensity of 0.7 to 0.8 w/cm², and frequency of 3 MHz for 5 minutes) plus standard care (n = 16) or to standard care alone (n = 15). The feasibility of therapeutic ultrasound was determined by the recruitment rate, participants' adherence to the intervention, and the study completion rates. Assessments of pain, sensory disturbance, sensation, and balance were conducted at baseline, two and six weeks.

RESULTS

We achieved a recruitment rate of 84%, an adherence rate of 100% to the intervention, and a completion rate of 100%. Adding therapeutic ultrasound to standard care resulted in a statistically and clinically significant improvement in symptoms of pain and sensory disturbance (P = 0.003) at two weeks; however, no significance difference between the groups was found at the six-week follow-up.

CONCLUSIONS

The findings of this proof-of-concept study support the feasibility of the therapeutic ultrasound in addition to standard care as an intervention for colorectal cancer patients with oxaliplatin-related pain and sensory disturbance in the hands and feet. The findings warrant a large-scale placebo-controlled trial.

Ultrasound-responsive polymer-based drug delivery systems

Ultrasound-responsive polymeric materials have received a tremendous amount of attention from scientists for several decades. Compared to other stimuli-responsive materials (such as UV-, thermal-, and pH-responsive materials), these smart materials are more applicable since they allow more efficient drug delivery and targeted treatment by fairly non-invasive means. This review describes the recent advances of such ultrasound-responsive polymer-based drug delivery systems and illustrates various applications. More specifically, the mechanism of ultrasound-induced drug delivery, typical formulations, and biomedical applications (tumor therapy, disruption of blood-brain barrier, fighting infectious diseases, transdermal drug delivery, and enhanced thrombolysis) are summarized. Finally, a perspective on the future research directions for the development of ultrasound-responsive polymeric materials to facilitate a clinical translation is given.

Comparison of the clinical and sonographic effects of ultrasound therapy, extracorporeal shock wave therapy, and Kinesio taping in lateral epicondylitis

Background/aim

The aim of this study was to compare the clinical and sonographic effects of the ultrasound (US) therapy, extracorporeal shock wave therapy (ESWT), and Kinesio taping (KT) in the lateral epicondylitis (LE).

Materials and methods

A total of 40 patients with LE were included in the present study. The patients were randomly assigned to 3 treatment groups: US (n = 13), ESWT (n = 14), and KT (n = 13) groups.

Results

The visual analog scale (VAS) scores significantly decreased in all groups (P < 0.05). Grip strength significantly increased after 8 weeks in only the KT group (P < 0.05). The Patient-Rated Tennis Elbow Evaluation Scale (PRTEE) scores significantly decreased after 2 weeks and after 8 weeks in the US group and ESWT groups, and after 8 weeks in the KT group (P < 0.05). Common extensor tendon (CET) thicknesses significantly decreased after 8 weeks in only the ESWT group (P < 0.05).

Conclusion

The US therapy, KT, and ESWT are effective in reducing pain and improving functionality. However, none of these treatment methods were found to be superior to others in reducing the pain and improving functionality.

Ultrasonic therapy modulates the expression of genes related to neovascularization and inflammation in fibroblasts

Abstract Introduction: In the rehabilitation of musculoskeletal injuries, ultrasound is widely used in clinical practice. Objective: To evaluate the effects of pulsed ultrasonic therapy on the viability and modulation of genes involved in inflammation (IL-6) and neovascularization (VEGF) processes of L929 fibroblast cells. Methods: For irradiation with ultrasound the cells were subdivided into groups: G1 (without irradiation), G2 (0.3 W/cm2-20%) and G3 (0.6 W/cm2-20%), with periods of treatment at 24, 48 and 72 hours. The cell viability assay was analyzed by the MTT method and gene modulation was analyzed by RT-qPCR method. Results: After the comparative analysis between groups, only G2 and G3 (48-hour) presented statistically significant differences in relation to the control. In relation to the gene expression, the selection of the groups analyzed was delimited according to the comparative analysis of the values obtained by the MTT test. After the achievement of RT-qPCR, it could be observed that in G2 the amount of VEGF gene transcripts increased by 1.125-fold compared to endogenous controls, and increased 1.388-fold in G3. The IL-6 gene, on the other hand, had its transcripts reduced in both G2 (5.64x10-9) and G3 (1.91x10-6). Conclusion: Pulsed ultrasound in L929 fibroblasts showed a significant biostimulatory effect in the 48-hour period, with increased cell viability, and the same effect in the modulation of gene expression related the neovascularization and inflammation, mediating the acceleration of the tissue repair cascade.

Review on experimental study and clinical application of low-intensity pulsed ultrasound in inflammation

Low-intensity pulsed ultrasound (LIPUS), as physical therapy, is widely used in both research and clinical settings. It induces multiple bioeffects, such as alleviating pain, promoting tissue repair, and shortening disease duration. LIPUS can also mediate inflammation. This paper reviews the application of LIPUS in inflammation and discusses the underlying mechanism. In basic experiments, LIPUS can regulate inflammatory responses at the cellular level by affecting some signaling pathways. In a clinical trial, LIPUS has been shown to alleviate inflammatory responses efficiently. As a cheap, safe, and convenient physical method, LIPUS is promising as anti-inflammatory therapy.

The additive efficacy of therapeutic low-intensity pulsed ultrasound in the treatment of vitiligo: A randomized, left-right comparison clinical trial

Repigmentation of vitiligo relies on the proliferation and migration of melanoblasts from hair follicles to the epidermis to replenish epidermal melanin. Our previous study has demonstrated low-intensity pulsed ultrasound (LIPUS) can stimulate melanoblast migration in vitro. We sought to evaluate the potential additive efficacy and safety of LIPUS for repigmentation of vitiligo. Twenty-seven adult patients with stable generalized vitiligo on the face or trunk were recruited in this randomized, open, left-right comparison study. In each patient, two symmetric lesional sites were randomly selected; one was assigned as the target lesion, which was treated with add-on LIPUS twice weekly for 24 weeks, and the other as the control lesion, which was administrated with sham sonification. The primary outcome was the difference of repigmentation degree between the target and control lesions at week 24, based on the 7-point physician global assessment score. At the end of study, 23 patients with vitiligo on the face (n = 10) or trunk (n = 13) completed the 24-week treatment course. Enhanced repigmentation for vitiligo receiving LIPUS as compared to sham sonification was observed in 38.5% (5/13) of the patients with truncal vitiligo, but none of those with facial vitiligo. Truncal vitiligo (P = .046) and higher intensity of LIPUS administered (P = .01) were statistically significantly associated with the effectiveness of additive LIPUS treatment. The LIPUS treatment was well-tolerated without remarkable adverse effects. This pilot study showed that LIPUS could provide therapeutic benefits and could be considered as a treatment adjunct for truncal vitiligo.

Therapeutic ultrasound for chronic low back pain

BACKGROUND

This is an update of a Cochrane Review published in 2014. Chronic non-specific low back pain (LBP) has become one of the main causes of disability in the adult population around the world. Although therapeutic ultrasound is not recommended in recent clinical guidelines, it is frequently used by physiotherapists in the treatment of chronic LBP.

OBJECTIVES

The objective of this review was to determine the effectiveness of therapeutic ultrasound in the management of chronic non-specific LBP. A secondary objective was to determine the most effective dosage and intensity of therapeutic ultrasound for chronic LBP.

SEARCH METHODS

We performed electronic searches in CENTRAL, MEDLINE, Embase, CINAHL, PEDro, Index to Chiropractic Literature, and two trials registers to 7 January 2020. We checked the reference lists of eligible studies and relevant systematic reviews and performed forward citation searching.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) on therapeutic ultrasound for chronic non-specific LBP. We compared ultrasound (either alone or in combination with another treatment) with placebo or other interventions for chronic LBP.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias of each trial and extracted the data. We performed a meta-analysis when sufficient clinical and statistical homogeneity existed. We determined the certainty of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

We included 10 RCTs involving a total of 1025 participants with chronic LBP. The included studies were carried out in secondary care settings in Turkey, Iran, Saudi Arabia, Croatia, the UK, and the USA, and most applied therapeutic ultrasound in addition to another treatment, for six to 18 treatment sessions. The risk of bias was unclear in most studies. Eight studies (80%) had unclear or high risk of selection bias; no studies blinded care providers to the intervention; and only five studies (50%) blinded participants. There was a risk of selective reporting in eight studies (80%), and no studies adequately assessed compliance with the intervention. There was very low-certainty evidence (downgraded for imprecision, inconsistency, and limitations in design) of little to no difference between therapeutic ultrasound and placebo for short-term pain improvement (mean difference (MD) -7.12, 95% confidence interval (CI) -17.99 to 3.75; n = 121, 3 RCTs; 0-to-100-point visual analogue scale (VAS)). There was also moderate-certainty evidence (downgraded for imprecision) of little to no difference in the number of participants achieving a 30% reduction in pain in the short term (risk ratio 1.08, 95% CI 0.81 to 1.44; n = 225, 1 RCT). There was low-certainty evidence (downgraded for imprecision and limitations in design) that therapeutic ultrasound has a small effect on back-specific function compared with placebo in the short term (standardised mean difference -0.29, 95% CI -0.51 to -0.07 (MD -1.07, 95% CI -1.89 to -0.26; Roland Morris Disability Questionnaire); n = 325; 4 RCTs), but this effect does not appear to be clinically important. There was moderate-certainty evidence (downgraded for imprecision) of little to no difference between therapeutic ultrasound and placebo on well-being (MD -2.71, 95% CI -9.85 to 4.44; n = 267, 2 RCTs; general health subscale of the 36-item Short Form Health Survey (SF-36)). Two studies (n = 486) reported on overall improvement and satisfaction between groups, and both reported little to no difference between groups (low-certainty evidence, downgraded for serious imprecision). One study (n = 225) reported on adverse events and did not identify any adverse events related to the intervention (low-certainty evidence, downgraded for serious imprecision). No study reported on disability for this comparison. We do not know whether therapeutic ultrasound in addition to exercise results in better outcomes than exercise alone because the certainty of the evidence for all outcomes was very low (downgraded for imprecision and serious limitations in design). The estimate effect for pain was in favour of the ultrasound plus exercise group (MD -21.1, 95% CI -27.6 to -14.5; n = 70, 2 RCTs; 0-to-100-point VAS) at short term. Regarding back-specific function (MD - 0.41, 95% CI -3.14 to 2.32; n = 79, 2 RCTs; Oswestry Disability Questionnaire) and well-being (MD -2.50, 95% CI -9.53 to 4.53; n = 79, 2 RCTs; general health subscale of the SF-36), there was little to no difference between groups at short term. No studies reported on the number of participants achieving a 30% reduction in pain, patient satisfaction, disability, or adverse events for this comparison.

AUTHORS' CONCLUSIONS

The evidence from this systematic review is uncertain regarding the effect of therapeutic ultrasound on pain in individuals with chronic non-specific LBP. Whilst there is some evidence that therapeutic ultrasound may have a small effect on improving low back function in the short term compared to placebo, the certainty of evidence is very low. The true effect is likely to be substantially different. There are few high-quality randomised trials, and the available trials were very small. The current evidence does not support the use of therapeutic ultrasound in the management of chronic LBP.

Study of Medical Ultrasound for Rhizarthrosis (SUR): study protocol for a randomized controlled single-center pilot-trial

BACKGROUND

Rhizarthrosis (trapeziometacarpal osteoarthritis) is the second most common site of osteoarthritis in the hand affecting 10-30% of adults over the age of 50. Up to four times as many women as men have rhizarthrosis. Clinical symptoms include functional disability of the thumb, pain, joint swelling, and reduced strength. The first carpometacarpal joint is pivotal in the opposition of the thumb and allows a high degree in flexibility to humans. Current therapies focus mainly on surgical strategies, which should be considered in advanced, therapy-resistant stages to relieve pain and improve function. However, conservative treatment methods are urgently required in presurgical stages. The efficacy of conservative treatment options for rhizarthrosis, which are intended to preserve function, joint integrity and to relieve pain, has not been adequately studied. In the clinical study protocol presented here, we investigate the efficacy of multimodal hand therapy versus therapeutic ultrasound versus combination therapy with both hand therapy and therapeutic ultrasound.

METHODS

This study is a single-center, randomized, controlled, parallel-group pilot trial. One hundred fifty patients with rhizarthrosis and current disease activity will be randomized to one of three conservative interventions over 6 months. Interventions are (1) multimodal hand therapy (2) therapeutic ultrasound, and (3) combination therapy with both hand therapy and ultrasound therapy. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score after 6 months. Secondary endpoints are changes in pain, quality of life, disability progression, and changes of hand function. Safety will also be assessed.

DISCUSSION

Clinical data suggest that multimodal hand therapy may improve functionality and reduce pain in rhizarthrosis. Clinical data regarding therapeutic ultrasound are not available. Clinical evidence is lacking. This study is the first clinical study investigating the effects of multimodal hand therapy in direct comparison to therapeutic ultrasound and to a combination therapy with both hand therapy and ultrasound therapy for rhizarthrosis.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT04115085; Registered on September 30, 2019.

Effect of acoustic standing waves on cellular viability and metabolic activity

Acoustic standing wave devices offer excellent potential applications in biological sciences for drug delivery, cell manipulation and tissue engineering. However, concerns have been raised about possible destructive effects on cells due to the applied acoustic field, in addition to other produced secondary factors. Here, we report a systematic study employing a 1D resonant acoustic trapping device to evaluate the cell viability and cell metabolism for a healthy cell line (Human Dermal Fibroblasts, HDF) and a cervical cancer cell line (HeLa), as a function of time and voltages applied (4-10 V_pp) under temperature-controlled conditions. We demonstrate that high cell viability can be achieved reliably when the device is operated at its minimum trapping voltage and tuned carefully to maximise the acoustic standing wave field at the cavity resonance. We found that cell viability and reductive metabolism for both cell lines are kept close to control levels at room temperature and at 34 °C after 15 minutes of acoustic exposure, while shorter acoustic exposures and small changes on temperature and voltages, had detrimental effects on cells. Our study highlights the importance of developing robust acoustic protocols where the operating mode of the acoustic device is well defined, characterized and its temperature carefully controlled, for the application of acoustic standing waves when using live cells and for potential clinical applications.

Phonophoresis of Phyllanthus amarus nanoparticle gel improves functional capacity in individuals with knee osteoarthritis: A randomized controlled trial

OBJECTIVE

This study examined the effects of treatment with Phyllanthus amarus nanoparticle gel applied by phonophoresis (PP) and ultrasound therapy (UT) in patients with symptomatic knee osteoarthritis (OA) using a randomized, double-blind, controlled trial.

METHODS

Patients with knee OA (n = 40; mean age ± SD, 64.30 ± 9.71 years), who had visual analogue scale (VAS) scores for knee pain intensity of 68.00 ± 9.58 (UT group) and 71.00 ± 8.74 (PP group, respectively) before treatment, were randomly allocated into two groups. Both groups were treated with an ultrasound program in continuous mode, 1.0 W/cm², 10 min per session, for 10 sessions. Nanoparticles of P. amarus were used in the PP group, whereas a nondrug coupling gel was used in the UT group. The 6-min walk test (6-MWT) was performed to evaluate functional capacity. The VAS and the 6-MWT were evaluated before and after 10 treatment sessions in both groups using a double-blind procedure.

RESULTS

VAS and 6-MWT showed significant improvement after treatment in both groups (p < 0.05). The PP group showed more significant effects than the UT group, in terms of both reducing the VAS pain score (p < 0.05) and improving 6-MWT (p < 0.05).

CONCLUSIONS

PP is suggested as an effective method for the treatment of symptomatic knee OA for reducing pain and improving functional capacity.

Comparison of radial extracorporeal shockwave therapy with ultrasound therapy in patients with lateral epicondylitis

PURPOSE

Patients suffering from lateral epicondylitis exhibit diminished mobility due to pain. The aim of the study was to compare the efficacy of both shockwave and ultrasound therapies in patients with lateral epicondylitis.

METHODS

The shockwave group consisted of 117 patients, 63 patients constituted the ultrasound group, and 18 patients made up the control group. The "University of Peloponnese Pain, Functionality and Quality of Life Questionnaire" was used for the evaluation of pain, functionality, and quality of life on a five-point Likert scale, pre-treatment, post-treatment, and at 4-week follow-up.

RESULTS

The pain was reduced and the functionality and quality of life were improved in both the shockwave and ultrasound groups post-treatment (p < 0.001) and at 4-week follow-up (p < 0.001), but the results in the ultrasound group were not as pronounced as in the shockwave group (p < 0.001).

CONCLUSION

Both radial shockwave and ultrasound therapies were significantly effective in patients with lateral epicondylitis. However, ultrasound therapy was less effective than shockwave therapy.

Comparison of the effects of low-level laser and pulsed and continuous ultrasound on pain and physical disability in chronic non-specific low back pain: a randomized controlled clinical trial

OBJECTIVE

To compare the short-term effects of pulsed laser and pulsed and continuous ultrasound on pain and functional disability in women with chronic non-specific low back pain.

METHODS

The sample was composed of 100 volunteers randomly allocated into four groups: The Pulsed Laser Group (n = 26) was treated with 3 J/cm²; the Pulsed Ultrasound Group (n = 24; 3 MHz) was treated with 1 W/cm²; the Continuous Ultrasound Group (n = 26; 1 MHz) was treated with 1 W/cm²; and a Control Group (n = 24), where the patients were still waiting for treatment. Before and after 10 sessions of treatment, the intensity of pain was assessed using the visual analogue scale (VAS), the quality of pain was evaluated using the McGill pain questionnaire and functional disability was investigated using the Roland-Morris questionnaire.

RESULTS

The three treated groups exhibited a decrease in pain (p < 0.001); the Pulsed Laser Group showed the greater relative gain (91.2%), Meanwhile, the Control Group exhibited a worsening of - 5.8%. The three treated groups demonstrated improvement in the quality of pain (McGill) in the total, sensory and affective dimensions (p < 0.005; p < 0.002; p < 0.013, respectively). All treated groups showed a decrease in functional disability (p < 0.001), but the Pulsed Ultrasound Group showed the highest relative gain (83.3%).

CONCLUSIONS

The three modalities have significant effects to decreasing low back pain and improving functional disability in women with non-specific chronic low back pain, but the pulsed low-level laser had the best results on pain while the pulsed ultrasound had the best results on improve the functional disability.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02150096.

Intensity-dependent effect of pulsed and continuous therapeutic ultrasound on endothelial function: a randomised crossover clinical trial

Background/Aims

The aim of this study was to evaluate the effects of different intensities and waveforms of therapeutic ultrasound on endothelial function in typically healthy participants.

Methods

A total of 15 participants were evaluated over 2 consecutive days. Different intensities of continuous and pulsed (20% duty cycle) 1-MHz ultrasound were applied to the brachial artery for 5 minutes each. Endothelial function was measured using flow-mediated dilation technique before and immediately after ultrasound was applied.

Results

Compared to baseline values, endothelium-dependent vasodilation increased with both continuous (2.8%) and pulsed (1.6%) ultrasound at an intensity of 0.4 W/cm2SPTA. At 1.2 W/cm2SPTA, endothelium-dependent vasodilation was 4.1% above baseline for pulsed and 5.3% above baseline for continuous waveforms. There was no additional increase in vasodilation at intensities above 1.2 W/cm2SPTA. The percentage of endothelium-dependent vasodilation was similar for the all of the different waveforms studied.

Conclusions

Both continuous and pulsed ultrasound waveforms promote endothelium-dependent vasodilation. There was a dose-dependent increase in vasodilation at intensities from 0.4 W/cm2SPTA to 1.2 W/cm2SPTA. Pulsed is more efficient than continuous ultrasound because it produces the same effect on endothelium-dependent vasodilation while employing 20% of the energy applied with continuous ultrasound.

Therapeutic Systems and Technologies: State-of-the-Art Applications, Opportunities, and Challenges

In this review, we present current state-of-the-art developments and challenges in the areas of thermal therapy, ultrasound tomography, image-guided therapies, ocular drug delivery, and robotic devices in neurorehabilitation. Additionally, intellectual property and regulatory aspects pertaining to therapeutic systems and technologies are addressed.

Adjuvant Biophysical Therapies in Osteosarcoma

Osteosarcoma (OS) is a primary bone sarcoma, manifesting as osteogenesis by malignant cells. Nowadays, patients’ quality of life has been improved, however continuing high rates of limb amputation, pulmonary metastasis and drug toxicity, remain unresolved issues. Thus, effective osteosarcoma therapies are still required. Recently, the potentialities of biophysical treatments in osteosarcoma have been evaluated and seem to offer a promising future, thanks in this field as they are less invasive. Several approaches have been investigated such as hyperthermia (HT), high intensity focused ultrasound (HIFU), low intensity pulsed ultrasound (LIPUS) and sono- and photodynamic therapies (SDT, PDT). This review aims to summarize in vitro and in vivo studies and clinical trials employing biophysical stimuli in osteosarcoma treatment. The findings underscore how the technological development of biophysical therapies might represent an adjuvant role and, in some cases, alternative role to the surgery, radio and chemotherapy treatment of OS. Among them, the most promising are HIFU and HT, which are already employed in OS patient treatment, while LIPUS/SDT and PDT seem to be particularly interesting for their low toxicity.

Immediate Effects of Simultaneous Application of Transcutaneous Electrical Nerve Stimulation and Ultrasound Phonophoresis on Active Myofascial Trigger Points: A Randomized Controlled Trial

OBJECTIVE

The aim of the study was to investigate the efficacy of phonophoresis with combined therapy on active myofascial trigger points.

PARTICIPANTS

One hundred participants with acute mechanical neck pain and at least one active myofascial trigger point in the upper trapezius were randomly assigned into four equal groups.

INTERVENTION

Groups consisted of diclofenac phonophoresis with combined therapy, diclofenac phonophoresis, ultrasound (US) with coupling gel, and sham US and applied for 10 mins over myofascial trigger points.

MEASUREMENTS

Measurements included pressure pain threshold and active cervical lateral flexion.

RESULTS

There were statistically significant improvements in postintervention pressure pain threshold and range of motion values in treatment groups (P < 0.0001). As for the sham US, no significant difference was found between the preintervention and postintervention values (P > 0.05). Bonferroni correction test revealed that there was a significant difference between all the four groups in pressure pain threshold values (P < 0.0001); however, it was nonsignificant (P > 0.05) for range of motion.

CONCLUSIONS

Diclofenac phonophoresis with combined therapy, phonophoresis, and US were all effective in increasing pressure pain threshold values and range of motion. In addition, phonophoresis with combined therapy was shown to be superior over phonophoresis, and phonophoresis was superior over US in terms of reducing pain sensitivity. However, none of the treatment groups were found to be superior over the other in increasing range of motion.

Self-Assembly of Unconventional Low-Molecular-Mass Amphiphiles Containing a PEG Chain

The design and synthesis of biocompatible surfactants are important for a wide range of applications in cosmetics, personal care products, and nanomedicine. This feature article summarizes our studies over the past 8 years on the design, synthesis, surface activity, and self-assembly of a series of unconventional low-molecular-mass amphiphiles containing a poly(ethylene glycol) (PEG) tail or spacer and different ionic or zwitterionic headgroups, including carboxylate, sulfonate, and quaternary ammonium salts. Despite having a so-called polar PEG chain as a tail or spacer, these ionic amphiphiles are found to have a tendency to adsorb at the air/water interface and self-assemble in pH 7.0 buffers at 298 K in the same way that conventional hydrocarbon tail surfactants do. However, they are observed to be relatively less surface-active compared to hydrocarbon tail surfactants. Although these amphiphilic molecules have less surface activity, they do self-assemble in aqueous buffer at 298 K, producing a range of microstructures, including spherical micelles, disclike micelles, and vesicles. In fact, our group is the first to report the self-assembly of PEG-tailed ionic amphiphiles in water at room temperature. Some of these molecules are also found to gel various organic liquids on heat-cool treatment or by ultrasound irradiation. We think that the present article will arouse general interest among researchers working toward the development of new biocompatible amphiphiles and soft materials.