Pilot Clinical Studies of Long Duration, Low Intensity Therapeutic Ultrasound for Osteoarthritis

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.

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.

Effect of Sustained Acoustic Medicine on Bruising Following A Bicycle Crash

In late September, 2020 a man was riding his mountain bike on a trail. Half-way into his ride his bike flipped and he fell off. His hip hit a rock. On examination 1 hour later he noticed a severe bruise on his hip. He immediately applied RICES for the next 2 days, except when he was sleeping. His on-off ratio for the RICES was 90-min "on", 90 "min" off. Two days later he quit using RICES. Three days later he used sustained acoustic ultrasound (SAM) a small, portable ultrasound that can be used for up to 4hrs. Photos were taken after the 3^rd and 6^th treatment. There was lots of flesh colored tissue on the skin where the leg was treated with SAM.

Efficacy of Sustained Acoustic Medicine as an Add-on to Traditional Therapy in Treating Sport-related Injuries : Case Reports

CONTEXT

Musculoskeletal injuries are prevalent in sports, and the application of Sustain Acoustic Medicine (SAM) as a home-use add-on therapy to reduce pain and to increase the probability of athletes returning to sports was evaluated in a case series.

OBJECTIVES

To examine the improvements in pain and return to function of athletes using SAM in conjunction with traditional therapies after sustaining sports-related musculoskeletal injuries.

INTRODUCTION

Traditional treatments such as rest, physical therapy, manual therapy, a combination of rest, ice compression, and elevation (RICE) are standard of care for musculoskeletal injuries and do not provide adequate accelerated healing to return athletes to activity. SAM is an FDA-approved bio-regenerative technology, which can provide mechanotransductive and thermal stimuli to accelerate tissue healing and reduction in pain daily. Interventions: A case series of 18 athletes who showed little or no improvement with traditional therapies where prescribed SAM treatment as an add-on daily home-use intervention. The study included athletes with sports musculoskeletal injuries, including the arm/shoulder, upper leg/glutes/hips, knees, back, and foot/ankle. Clinical outcomes were recorded along with the ability of athletes' ability to go back to sports, and satisfaction and usability measures of the home treatment. Results: All athletes were satisfied with the usability and comfort of the therapy and 93%reported the therapy was sufficiently discrete. Clinical outcomes indicate all athletes showed an average pain decrease of 3.33±0.82 (p≤0.05) numerical rating scales (NRS), improvement in function, and quality of life. 87% of the athletes documented an improvement in function, and 55% were able to return to sports after conservative intervention failed. Conclusion: The results of this study indicate that SAM improves athletes' clinical outcomes. Over 50% of athletes were able to return to sports and resume normal daily function after conservative intervention had failed with addition of daily SAM treatment.

Skin Temperature Increase Mediated By Wearable, Long Duration, Low-Intensity Therapeutic Ultrasound

One of the safety concerns with the delivery of therapeutic ultrasound is overheating of the transducer-skin interface due to poor or improper coupling. The objective of this research was to define a model that could be used to calculate the heating in the skin as a result of a novel, wearable long-duration ultrasound device. This model was used to determine that the maximum heating in the skin remained below the minimum threshold necessary to cause thermal injury over multiple hours of use. In addition to this model data, a human clinical study used wire thermocouples on the skin surface to measure heating characteristics during treatment with the sustained ultrasound system. Parametric analysis of the model determined that the maximum temperature increase is at the surface of the skin ranged from 40-41.8° C when perfusion was taken into account. The clinical data agreed well with the model predictions. The average steady state temperature observed across all 44 subjects was 40°C. The maximum temperature observed was less than 44° C, which is clinically safe for over 5 hours of human skin contact. The resultant clinical temperature data paired well with the model data suggesting the model can be used for future transducer and ultrasound system design simulation. As a result, the device was validated for thermal safety for typical users and use conditions.

Energy-triggered drug release from polymer nanoparticles for orthopedic applications

Sequestra, present in many cancers and orthopedic infections, provide a safe harbor for the development of drug resistance. In the face of burgeoning drug resistance, the importance of nanoscale, microenvironment-triggered drug delivery cannot be overestimated. Such strategies may preserve pharmaceutical efficacy and significantly alter the etiology of many orthopedic diseases. Although temperature-, pH- and redox-responsive nanoparticle-based systems have been extensively studied, local drug delivery from polymeric nanoparticles can be triggered by a variety of energy forms. This review offers an overview of the state of the field as well as a perspective on the safety and efficacy of ultrasound, hyperthermia and radio frequency-triggered internal delivery systems in a variety of applications.

Human Factors Engineering and testing for a wearable, long duration ultrasound system self-applied by an end user

One of the major challenges in the design of a new class of medical device is ensuring that the device will have a safe and effective user interface for the intended users. Human Factors Engineering addresses these concerns through direct study of how a user interacts with newly designed devices with unique features. In this study, a novel long duration, low intensity therapeutic ultrasound device is tested by 20 end users representative of the intended user population. Over 90% of users were able to operate the device successfully. The therapeutic ultrasound device was found to be reasonably safe and effective for the intended users, uses, and use environments.