Sustained acoustic medicine: wearable, long duration ultrasonic therapy for the treatment of tendinopathy

Sustained acoustic medicine treatment of discogenic chronic low back pain: A randomized, multisite, double-blind, placebo-controlled trial

BACKGROUND

Sustained acoustic medicine (SAM) is a noninvasive long-term treatment that provides essential mechanical and thermal stimulus to accelerate soft tissue healing, alleviate pain, and improve physical activity. SAM increases localized deep tissue temperature, blood flow, cellular proliferation, migration, and nutrition exchange, resulting in reduced inflammation and an increased rate of tissue regeneration.

OBJECTIVE

To assess the efficacy of SAM treatment of discogenic back pain in the lower spinal column to reduce pain, improve quality of life, and lower pharmacotherapy use.

METHODS

Sixty-five subjects with chronic low back pain were randomly assigned to SAM (N= 33) or placebo (N= 32) groups. Subjects self-applied SAM device bilaterality on the lower lumbar region for 4 hours daily for 8 weeks and completed daily pain diaries before, during, and after treatment. Subjects recorded pain reduction using a numeric rating scale (NRS), medication use, and physical activity using the Global Rating of Change (GROC) and Oswestry Disability Index (ODI).

RESULTS

SAM treatment significantly reduced chronic lower back pain from baseline relative to placebo treatment (p< 0.0001). SAM treated subjects reported significantly lower back pain at 4 weeks, with the highest pain reduction (-2.58 points NRS, p< 0.0001) reported at 8 weeks. Similar trends were observed in improved physical activity (3.48 GROC, p< 0.0001, 69-88% ODI, p< 0.0001) and 22.5% (15.2 morphine milligram equivalent) reduction in the use of opioid medication from baseline to 8 weeks.

CONCLUSION

Daily, home-use SAM treatment significantly improves the clinical symptoms of chronic lower back pain, improves physical mobility, and reduces daily medication use. SAM treatment is well-tolerated by patients and may be considered a safe, non-invasive treatment option for chronic discogenic, lower back pain.

Recent advances in tendon tissue engineering strategy

Tendon injuries often result in significant pain and disability and impose severe clinical and financial burdens on our society. Despite considerable achievements in the field of regenerative medicine in the past several decades, effective treatments remain a challenge due to the limited natural healing capacity of tendons caused by poor cell density and vascularization. The development of tissue engineering has provided more promising results in regenerating tendon-like tissues with compositional, structural and functional characteristics comparable to those of native tendon tissues. Tissue engineering is the discipline of regenerative medicine that aims to restore the physiological functions of tissues by using a combination of cells and materials, as well as suitable biochemical and physicochemical factors. In this review, following a discussion of tendon structure, injury and healing, we aim to elucidate the current strategies (biomaterials, scaffold fabrication techniques, cells, biological adjuncts, mechanical loading and bioreactors, and the role of macrophage polarization in tendon regeneration), challenges and future directions in the field of tendon tissue engineering.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication

BACKGROUND

The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society.

METHODS

The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature.

CONCLUSIONS

The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.

A Review of Laser Therapy and Low-Intensity Ultrasound for Chronic Pain States

PURPOSE OF REVIEW

Chronic pain management therapies have expanded quickly over the past decade. In particular, the use of laser therapy and ultrasound in the management of chronic pain has risen in recent years. Understanding the uses of these types of therapies can better equip chronic pain specialists for managing complicated chronic pain syndromes. The purpose of this review was to summarize the current literature regarding laser radiation and ultrasound therapy used for managing chronic pain syndromes.

RECENT FINDINGS

In summary, there is stronger evidence supporting the usage of laser therapy for managing chronic pain states compared to low-intensity ultrasound therapies. As a monotherapy, laser therapy has proven to be beneficial in managing chronic pain in patients with a variety of pain syndromes. On the other hand, LIUS has less clear benefits as a monotherapy with an uncertain, optimal delivery method established. Both laser therapy and low-intensity ultrasound have proven beneficial in managing various pain syndromes and can be effective interventions, in particular, when utilized in combination therapy.

Evaluation of Sustained Acoustic Medicine for Treating Musculoskeletal Injuries in Military and Sports Medicine

Background

Musculoskeletal injuries are common in collegiate, professional, and military personnel and require expedited recovery to reduce lost work time. Sustained acoustic medicine (SAM) provides continuous long-duration ultrasound at 3MHz and 132mW/cm². The treatment is frequently prescribed to treat acute and chronic soft tissue injuries and reduce pain. The objective of this study was to evaluate the efficacy of SAM treatment for musculoskeletal injuries and accelerated recovery.

Methods

An 18-question electronic survey and panel discussion were conducted on Athletic Trainers (ATs) using SAM treatment in professional, collegiate, and military sports medicine. The survey included both qualitative and quantitative questions. In addition, a panel discussion discussed SAM effectiveness with expert ATs. Power calculation of sampling and statistical evaluation of data was utilized to generalize the results.

Results

Survey respondents (n=97) and panelists (n=142) included ATs from all National Athletic Trainers Association districts. SAM was primarily used for musculoskeletal injuries (83.9%, p<0.001) with a focus on healing tendons and ligaments (87.3%, p<0.001). SAM treatment was also used on joints (44.8%), large muscle groups (43.7%), and bone (41.4%). SAM provided clinical improvement in under 2 weeks (68.9%, p<0.001) and a 50% reduction in pain medication (63%, p<0.001). In addition, patients were highly receptive to treatment (87.3%, p<0.001), and ATs had a high level of confidence for improved function and returned to work after 30-days of SAM use (81.2%, p<0.001).

Conclusion

SAM is an effective, safe, easy-to-use, noninvasive, comfortable, and versatile therapeutic for healing musculoskeletal injuries.

Sustained acoustic medicine for the treatment of musculoskeletal injuries: a systematic review and meta-analysis

BACKGROUND

Musculoskeletal injuries account for 10 million work-limited days per year and often lead to both acute and/or chronic pain, and increased chances of re-injury or permanent disability. Conservative treatment options include various modalities, nonsteroidal anti-inflammatory drugs, and physical rehabilitation programs. Sustained Acoustic Medicine is an emerging prescription home-use mechanotransductive device to stimulate cellular proliferation, increase microstreaming and cavitation in situ, and to increase tissue profusion and permeability. This research aims to summarize the clinical evidence on Sustained Acoustic Medicine and measurable outcomes in the literature.

METHODS

A systematic literature review was conducted using PubMed, EBSCOhost, Academic Search Complete, Google Scholar and ClinicalTrials.gov to identify studies evaluating the effects of Sustained Acoustic Medicine on the musculoskeletal system of humans. Articles identified were selected based on inclusion criteria and scored on the Downs and Black checklist. Study design, clinical outcomes and primary findings were extracted from included studies for synthesis and meta-analysis statistics.

RESULTS

A total of three hundred and seventy-two participants (372) were included in the thirteen clinical research studies reviewed including five (5) level I, four (4) level II and four (4) level IV studies. Sixty-seven (67) participants with neck and back myofascial pain and injury, one hundred and fifty-six (156) participants with moderate to severe knee pain and radiographically confirmed knee osteoarthritis (Kellgren-Lawrence grade II/III), and one hundred forty-nine (149) participants with generalized soft-tissue injury of the elbow, shoulder, back and ankle with limited function. Primary outcomes included daily change in pain intensity, change in Western Ontario McMaster Osteoarthritis Questionnaire, change in Global Rate of Change, and functional outcome measures including dynamometry, grip strength, range-of-motion, and diathermic heating (temperature measurement).

CONCLUSION

Sustained Acoustic Medicine treatment provides tissue heating and tissue recovery, improved patient function and reduction of pain. When patients failed to respond to physical therapy, Sustained Acoustic Medicine proved to be a useful adjunct to facilitate healing and return to work. As a non-invasive and non-narcotic treatment option with an excellent safety profile, Sustained Acoustic Medicine may be considered a good therapeutic option for practitioners.

Effective assessments to identify overuse injuries in unaffected limbs of persons with unilateral upper limb amputations

STUDY DESIGN

Cross-sectional study.

INTRODUCTION

Overuse injuries (OI) present major health problems and oftentimes, permanent disability. Persons with unilateral upper limb diagnoses, such as amputation, are at-risk for developing OI in their unaffected limbs. Measures to identify high-risk populations are needed.

PURPOSE OF THE STUDY

Scores on 6 OI-assessments were compared for persons with unilateral upper limb amputations (UULA) and healthy participants. Cutoff values were proposed.

METHODS

Sixty-two persons with UULA and 62 healthy controls completed this study. Scores for hand volume (HV), visual analogue scale (VAS), multi-site Semmes Weinstein Monofilament for median and ulnar nerves (SWM-M/SWM-U), torque range of motion for wrist/finger extension and flexion (TROM-E/TROM-F), intrinsic tightness (IT), and differential flexor tendon gliding (DFTG) were collected before and after 15 minutes of repetitive and resistive exercise. When analyzing collected data, descriptive statistics, and ANOVA were used to identify differences between groups. Receiver operating characteristic curves (ROC), area under the curve (AUC), sensitivity, and specificity were calculated to determine acceptable cutoff scores. Cutoff values with significant AUC ≥ 0.60 and sensitivity ≥ 0.80 were accepted.

RESULTS

Statistically significant differences were found between HV by gender in both pre-exercise and post-exercise conditions. Gain scores for whole sample HV, female HV, and TROM-E were statistically different although differences were small and not meaningful. Significant AUC and acceptable pre-exercise cutoff values included 375 ml. for female HV (sensitivity 89%, specificity 87%), 505 ml. for male HV (sensitivity 81%, specificity 70%), 82 degrees for TROM-E (sensitivity 92%, specificity 71%), and 73 degrees of TROM-F (sensitivity 90%, specificity 89%).

CONCLUSIONS

Potential at-risk OI-related populations, especially unaffected limbs of UULA persons, are best identified by pre-exercise cutoff values using HV by gender, TROM, and single-site SWM 2.83.

Low-Intensity Continuous Ultrasound Therapies—A Systematic Review of Current State-of-the-Art and Future Perspectives

Therapeutic ultrasound has been studied for over seven decades for different medical applications. The versatility of ultrasound applications are highly dependent on the frequency, intensity, duration, duty cycle, power, wavelength, and form. In this review article, we will focus on low-intensity continuous ultrasound (LICUS). LICUS has been well-studied for numerous clinical disorders, including tissue regeneration, pain management, neuromodulation, thrombosis, and cancer treatment. PubMed and Google Scholar databases were used to conduct a comprehensive review of all research studying the application of LICUS in pre-clinical and clinical studies. The review includes articles that specify intensity and duty cycle (continuous). Any studies that did not identify these parameters or used high-intensity and pulsed ultrasound were not included in the review. The literature review shows the vast implication of LICUS in many medical fields at the pre-clinical and clinical levels. Its applications depend on variables such as frequency, intensity, duration, and type of medical disorder. Overall, these studies show that LICUS has significant promise, but conflicting data remain regarding the parameters used, and further studies are required to fully realize the potential benefits of LICUS.

Sustained Acoustic Medicine Combined with A Diclofenac Ultrasound Coupling Patch for the Rapid Symptomatic Relief of Knee Osteoarthritis: Multi-Site Clinical Efficacy Study

BACKGROUND

Sustained Acoustic Medicine (SAM) is an emerging, non-invasive, non-narcotic, home-use ultrasound therapy for the daily treatment of joint pain. The aim of this multi-site clinical study was to examine the efficacy of long-duration continuous ultrasound combined with a 1% diclofenac ultrasound gel patch in treating pain and improving function in patients with knee osteoarthritis.

METHODS

The Consolidated Standards of Reporting Trials (CONSORT) were followed. Thirty-two (32) patients (18-males, 14-females) 54 years of average age with moderate to severe knee pain and radiographically confirmed knee osteoarthritis (Kellgren-Lawrence (KL) grade II/III) were enrolled for treatment with the SAM device and diclofenac patch applied daily to the treated knee. SAM ultrasound (3 MHz, 0.132 W/cm2, 1.3 W) and 6 grams of 1% diclofenac were applied with a wearable device for 4 hours daily for 1 week, delivering 18,720 Joules of ultrasound energy per treatment. The primary outcome was the daily change in pain intensity using a numeric rating scale (NRS 0-10), which was assessed prior to intervention (baseline, day 1), before and after each daily treatment, and after 1 week of daily treatment (day 7). Rapid responders were classified as those patients exhibiting greater than a 1-point reduction in pain following the first treatment. Change in Western Ontario McMaster Osteoarthritis Questionnaire (WOMAC) score from baseline to day 7 was the secondary functional outcome measure. Additionally, a series of daily usability and user experience questions related to devising ease of use, functionality, safety, and effectiveness, were collected. Data were analyzed using t-tests and repeated measure ANOVAs.

RESULTS

The study had a 94% retention rate, and there were no adverse events or study-related complaints across 224 unique treatment sessions. Rapid responders included 75% of the study population. Patients exhibited a significant mean NRS pain reduction over the 7-day study of 2.06-points (50%) for all subjects (n=32, p<0.001) and 2.96-points (70%) for rapid responders (n=24, p<0.001). The WOMAC functional score significantly improved by 351 points for all subjects (n=32, p<0.001), and 510 points for rapid responders (n=24, p<0.001). Over 95% of patients found the device safe, effective and easy to use, and would continue treatment for their knee OA symptoms.

CONCLUSION

Sustained Acoustic Medicine combined with 1% topical diclofenac rapidly reduced pain and improved function in patients with moderate to severe osteoarthritis-related knee pain. The clinical findings suggest that this treatment approach may be used as a conservative, non-invasive treatment option for patients with knee osteoarthritis. Additional research is warranted on non-weight bearing joints of the musculoskeletal system as well as different topical drugs that could benefit from improved localized delivery.Clinical Trial Registry Number: (NCT04391842).

Sustained acoustic medicine as a non-surgical and non-opioid knee osteoarthritis treatment option: a health economic cost-effectiveness analysis for symptom management

Background

Patients diagnosed with osteoarthritis (OA) and presenting with symptoms are seeking conservative treatment options to reduce pain, improve function, and avoid surgery. Sustained acoustic medicine (SAM), a multi-hour treatment has demonstrated improved clinical outcomes for patients with knee OA. The purpose of this analysis was to compare the costs and effectiveness of multi-hour SAM treatment versus the standard of care (SOC) over a 6-month timeframe for OA symptom management.

Methods

A decision tree analysis was used to compare the costs and effectiveness of SAM treatment versus SOC in patients with OA. Probabilities of success for OA treatment and effectiveness were derived from the literature using systematic reviews and meta-analyses. Costs were derived from Medicare payment rates and manufacturer prices. Functional effectiveness was measured as the effect size of a therapy and treatment pathways compared to a SOC treatment pathway. A sensitivity analysis was performed to determine which cost variables had the greatest effect on deciding which option was the least costly. An incremental cost-effectiveness plot comparing SAM treatment vs. SOC was also generated using 1000 iterations of the model. Lastly, the incremental cost-effectiveness ratio (ICER) was calculated as the (cost of SAM minus cost of SOC) divided by (functional effectiveness of SAM minus functional effectiveness of SOC).

Results

Base case demonstrated that over 6 months, the cost and functional effectiveness of SAM was $8641 and 0.52 versus SOC at: $6281 and 0.39, respectively. Sensitivity analysis demonstrated that in order for SAM to be the less expensive option, the cost per 15-min session of PT would need to be greater than $88, or SAM would need to be priced at less than or equal to $2276. Incremental cost-effectiveness demonstrated that most of the time (84%) SAM treatment resulted in improved functional effectiveness but at a higher cost than SOC.

Conclusion

In patients with osteoarthritis, SAM treatment demonstrated improved pain and functional gains compared to SOC but at an increased cost. Based on the SAM treatment ICER score being ≤ $50,000, it appears that SAM is a cost-effective treatment for knee OA.

Low-Intensity Continuous Ultrasound for the Symptomatic Treatment of Upper Shoulder and Neck Pain: A Randomized, Double-Blind Placebo-Controlled Clinical Trial

Purpose

Low-intensity continuous ultrasound (LICUS) is an emerging high-dosimetry ultrasound-based therapy for accelerated tissue healing and the treatment of myofascial pain. In this study, LICUS treatment is clinically evaluated for chronic upper neck and shoulder pain in a randomized, multi-site, double-blind, placebo-controlled study.

Patients and Methods

CONSORT guidelines were followed in conducting and reporting the clinical trial. Thirty-three participants with upper trapezius myofascial pain were randomized for treatment with active (n=25) or placebo (n=8) devices. Investigators and subjects were blinded to treatment groups. Participants self-reported pain daily, rating from 0–10 on the numeric rating scale. If pain rating was more significant than or equal to 3, the LICUS (3MHz, 0.132W/cm², 1.3W, 4 hours) was self-applied for total energy dosimetry of 18,720 Joules per treatment. During the 4-week study, daily pain rating was recorded. If LICUS treatment was delivered, pain before, during, and after treatment were recorded as well as the global rate of change (GROC). Independent t-tests were used to assess change from baseline and differences between treatment groups. ClinicalTrials.gov: NCT02135094.

Results

There was a 100% completion rate for participants enrolled in the study and no significant differences between the groups regarding demographic variables or baseline outcome measures. Participants treated with active therapy observed a significant mean pain reduction from baseline of 2.61 points for active (p<0.001), compared to 1.58 points decrease from baseline for placebo (p=0.087), resulting in a 1.03 points significant decrease in the active group over placebo (p=0.003). The total GROC was significantly higher in the active group at 2.84 points compared to the placebo group at 0.46 points (p<0.001).

Conclusion

Low-intensity continuous ultrasound treatment significantly reduced pain in patients with upper trapezius myofascial pain of the neck and shoulder. LICUS treatment showed a clinically meaningful improvement in the GROC scores for patients. The results from this clinical trial indicate that the LICUS treatment of 18,720 Joules can effectively be used to treat clinical pain related to upper trapezius myofascial pain. Further research could investigate varying dosimetry to improve efficacy and/or reduce the dose.

Alleviation Effects and Mechanisms of Low-intensity Focused Ultrasound on Pain Triggered by Soft Tissue Injury

OBJECTIVES

Pain caused by soft tissue injury (STI) is always intractable and will eventually result in physical and psychological problems. This experiment aimed to assess the efficacy and mechanisms of low-intensity focused ultrasound (LIFU) for pain-related STI.

METHODS

Rabbits (n = 30) with STI were given fixed treatment for 20 seconds and then mobile treatment for 60 seconds daily for 10 consecutive days by an LIFU device with a power output of 5 to 6 W and a frequency of 0.8 MHz. To evaluate the degree of pain, the levels of β-endorphin in serum were measured by an enzyme-linked immunosorbent assay before and 5 to 10 minutes after the 1st, 3rd, 7th, and 10th treatments. The pain threshold was measured by an electronic analgesy meter on the 1st, 3rd, 7th, 10th, 17th, and 24th days after the start of the treatment. To investigate inflammation, prostaglandin E₂ , interleukin-1β, and 5-hydroxytryptamine levels were detected by an enzyme-linked immunosorbent assay, and nuclear factor κB messenger RNA levels were determined by a real-time quantitative polymerase chain reaction at the same time as the pain threshold was tested.

RESULTS

Compared with non-LIFU groups, β-endorphin levels and pain thresholds were significantly increased (P < .05), whereas nuclear factor- κB messenger RNA, prostaglandin E₂ , interleukin- 1β, and 5-hydroxytryptamine levels were significantly reduced (P < .05) after LIFU treatment in rabbits with STI.

CONCLUSIONS

Low-intensity focused ultrasound can alleviate pain induced by STI and could have further clinical applications.

High-energy dose of therapeutic ultrasound in the treatment of patellar tendinopathy: protocol of a randomized placebo-controlled clinical trial

BACKGROUND

Patellar tendinopathy is an extremely debilitating condition and its treatment usually requires a combination of clinical approaches. Therapeutic ultrasound (TUS) is one of the most available electrophysical agent in rehabilitation settings; however, there is also a lack of high-quality studies that test different dosimetric aspects of TUS. Thus, the purpose of this study is to evaluate the short-, medium-, and long-term effects of the combination of high-energy TUS with a rehabilitation program for patellar tendinopathy.

METHODS

This will be a randomized, placebo-controlled trial with blinding of patients, assessors, and therapist. The setting is an outpatient physical therapy clinic. We will recruit 66 participants (male and female) aged between 18 and 40 years and presenting with patellar tendinopathy. A treatment combining high-energy dose TUS and a rehabilitation program for patellar tendinopathy will be delivered twice a week for 8 weeks. The control group will receive the same treatment, but with a placebo TUS. The effectiveness of the intervention will be measured at the beginning (baseline), midpoint (4 weeks), and end of treatment (8 weeks), as well as at 3- and 6-months post-treatment. Primary outcomes will be pain intensity (visual analogue scale, VAS), and VISA-P questionnaire and primary time points will be baseline (T0) and the end of the program (T2). Also, IPAQ-short form questionnaire, muscle strength (manual dynamometry), 2D kinematics, pain pressure threshold (PPT) algometry, thermography, and magnetic resonance imaging (MRI) will be collected.

DISCUSSION

TUS will be applied in an attempt to enhance the results obtained with the rehabilitation program proposed in this study, as well as stimulate some repair responses in individuals undergoing treatment for patellar tendinopathy, which in turn may optimize and improve treatment programs for patellar tendinopathy as well as to establish new guidelines for the application of TUS.

TRIAL REGISTRATION

This study was prospectively registered at April-3rd-2018 and updated at September-1st-2019 in the Brazilian Registry of Clinical Trials (REBEC) under the registration number: RBR-658n6w.

Chinese Consensus on Insertional Achilles Tendinopathy

Background:

Insertional Achilles tendinopathy (IAT) is a common finding in the clinic. However, consensus on its mechanism, pathological process, diagnosis, treatment, and rehabilitation is lacking. Thus, the Chinese Society of Sports Medicine organized and invited experts representing the fields of ankle disease and tendinopathy to jointly develop an expert consensus on IAT.

Study Design:

A consensus statement of the Chinese Society of Sports Medicine.

Methods:

A total of 34 experts in the field of sports medicine and orthopaedics were invited to participate in the compilation of a consensus statement regarding IAT. Consensus was achieved according to the Delphi method. First, 10 working groups composed of 34 experts were established to compile draft statements about clinical problems related to IAT by reviewing and analyzing the available literature. An expert consensus meeting to discuss drafts was then arranged. Each statement was individually presented and discussed, followed by a secret vote. Consensus was reached when more than 50% of the experts voted in its favor. The strength of the proposed recommendation was classified based on the proportion of favorable votes: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimity, 100%.

Results:

Of the 10 expert consensus statements on the clinical diagnosis and treatment of IAT, there was strong consensus for 8 statements and unanimity for 2 statements.

Conclusion:

This expert consensus focused on the concepts, causes, pathological process, clinical diagnosis, and treatment of IAT. Accepted recommendations in these areas which will assist clinicians in carrying out standardized management of related diseases.

The Effects of Low-Intensity Therapeutic Ultrasound on Measurable Outcomes: A Critically Appraised Topic

Clinical Scenario: Therapeutic ultrasound (US) is a popular modality among health care professionals and is used to treat a variety of musculoskeletal conditions. A new technology has been established to allow for the miniaturization of the US unit. Patients receive treatment with the device secured to them, eliminating the portability constraint of traditional US units. Early studies suggest that this portable unit can deliver low-intensity acoustic energy achieving the same temperature increase and pain relief that come from traditional US units, in a more versatile and patient-friendly manner.

CLINICAL QUESTION

What effects does low-intensity therapeutic ultrasound (LITUS) have on measurable outcomes? Summary of Key Findings: The literature was searched for level 4 evidence or higher that investigated the effectiveness of LITUS. The literature search produced 3 possible studies related to the clinical question: 2 randomized controlled trials and 1 case series met the inclusion and exclusion criteria. Of the included studies, 1 study investigated the effects of LITUS on tissue temperature, 2 studies investigated the effects of LITUS on pain, and 1 study investigated LITUS effects on function. Clinical Bottom Line: The evidence supports the use of the LITUS unit to increase tissue temperature, decrease pain, and increase function. Therefore, practitioners may consider the use of the LITUS unit in patient populations over the use of the traditional high-intensity US treatment. Strength of Recommendation: In accordance with the 2009 Centre for Evidence-Based Medicine levels of evidence, there is grade I (insufficient) evidence to support the positive effects of the LITUS device for improving the following clinical outcomes: tissue temperature, decreasing pain, and increasing function. The inconsistency in the measured outcomes across the 3 studies only allows for minimal support of the LITUS device, warranting further research. Although clinical outcomes were different in each study, consistent evidence ranging from 4 to 1B levels were found in the 3 included studies.

New Chronic Pain Treatments in the Outpatient Setting: Review Article

Chronic pain is an issue encountered by many health care providers in their routine clinical practice. In addition to generalized patient suffering, this condition has significant clinical, psychological, and socioeconomic impact due to its widespread occurrence. The landscape of chronic pain management has been changing rapidly with an array of treatment innovations, better understanding of established therapies, and care coordination across specialties. In this article, we have reviewed emerging new modalities as well as transformation of established therapies by interventional, pharmacologic, rehabilitative, psychological, complimentary, and interdisciplinary approaches.

Low Intensity Ultrasound for Promoting Soft Tissue Healing: A Systematic Review of the Literature and Medical Technology

Therapeutic ultrasound has been studied and used for the past seven decades to treat musculoskeletal injuries. Recently, a significant body of animal and human research has focused on the biomechanical effects of daily-applied, low intensity therapeutic ultrasound (LITUS) on soft tissue recovery. We performed a systematic review of the last two decades of LITUS literature to examine the effects on tendon, skeletal muscle, ligament, and tendon-bone junction injuries. LITUS facilitated tendon healing, with increased tensile strength and improved collagen alignment. For skeletal muscle and ligament injuries, LITUS increased cell proliferation during myoregeneration and improved tissue biomechanics (ultimate load, stiffness, energy absorption). LITUS aided tendon-bone junction healing through improved tissue function. Scientific evidence supports the use of LITUS to treat soft tissue injuries, and improve outcomes for musculoskeletal injuries and post-operative recovery. Lastly, we discuss the use of LITUS devices facilitating daily applied therapy in the home setting.

Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments

Achilles tendinopathy is one of the most frequently ankle and foot overuse injuries, which is a clinical syndrome characterized by the combination of pain, swelling, and impaired performance. The two main categories of Achilles tendinopathy are classified according to anatomical location and broadly include insertional and noninsertional tendinopathy. The etiology of Achilles tendinopathy is multifactorial including both intrinsic and extrinsic factors. Failed healing response and degenerative changes were found in the tendon. The failed healing response includes three different and continuous stages (reactive tendinopathy, tendon disrepair, and degenerative tendinopathy). The histological studies have demonstrated an increased number of tenocytes and concentration of glycosaminoglycans in the ground substance, disorganization and fragmentation of the collagen, and neovascularization. There are variable conservative and surgical treatment options for Achilles tendinopathy. However, there has not been a gold standard of these treatments because of the controversial clinical results between various studies. In the future, new level I researches will be needed to prove the effect of these treatment options.