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The International Society for Electrophysical Agents in Physical Therapy (ISEAPT) is a formal subgroup of the World Congress Physical Therapy (WCPT) and is the leading International organisation concerned primarily with Electro Physical Agents
The Electro Physical Agents and Diagnostic Ultrasound (EPADU) group is a Professional Networks of the Chartered Society of Physiotherapy based in the UK.
Numerous recent papers have identified the benefits of using therapeutic ultrasound for both normally healing (fresh) fractures and those that demonstrate either a delayed union or non union (e.g. Mayr et al 2000, Busse et al 2002, Warden et al 1999). Ultrasound has been historically considered to be a contraindication is these circumstances, though the exact reason for this remains unclear. Given the volume and quality of the published evidence, it would be entirely inappropriate for fractures to remain on the contraindication list.
The ultrasound application which is evidenced for this type of application is commonly referred to as LOW INTENSITY PULSED ULTRASOUND (or LIPUS). The does delivered is both SPECIFIC to this treatment and it is much LOWER than delivered from standard therapy machines.
DOSE : Full details are included on the downloadable pdf file, but summarised thus :
0.03 W cm-2 (sometimes described as 30mW cm-2)
Pulsed at 1:4 (20%) at 1000Hz
20 minutes, daily
It can be clearly seen this this application is not routinely available on most existing machines
Two existing machines (that I am aware of) can deliver this treatment :
Exogen series of machines which was from Smith + Nephew but is NOW available from Bioventus
A recent systematic review and meta-analysis (Busse et al 2002) has carefully considered the evidence in respect to the effect of low intensity pulsed ultrasound on the time to fracture healing. They conclude that the evidence from randomised trials where the data could be pooled (3 studies, 158 fractures) that the time to fracture healing was significantly reduced in the ultrasound treated groups than in the control groups and the mean difference in healing time was 64 days.
Warden et al (1999) published a review paper concluded that from animal and human studies, the use of ultrasound could accelerate the rate of fracture repair by a factor of 1.6. The unit utilised for this work (Sonic Accelerated Fracture Healing System – SAFHS) delivers a low intensity (0.03 W cm-2) at 1.5MHz pulsed at a ratio of 1:4. Whilst this dose may be reproducible by standard therapeutic machines, the SAFHS device has a particularly low BNR and thus is considered to be safe to apply with a stationary treatment head, unlike conventional physiotherapy ultrasound machines. This could be an important factor as treatment was for 20 minutes daily, with the patient using the device rather than attending for therapy.
Heckman et al (1994) demonstrated a 38% reduction in the healing time for tibial fractures using the SAFHS device whilst Kristiansen et al (1997) demonstrated a 30% acceleration in healing for fractures of the radius. Jensen (1998) identifies the beneficial effects of ultrasound in the treatment (as opposed to the diagnosis) of stress fractures with an overall success rate of 96%. The report fails to identify all relevant data for consideration and must therefore be considered with some caution in terms of ‘quality evidence’.
Mayr et al (2000) report a series of outcomes when using low intensity pulsed ultrasound for patients with delayed unions (n=951) and non unions (n=366). The overall success rate for the delayed unions was 91% for the delayed and 86% for the non unions.
The authors undertook an interesting stratified analysis of their patients, and identified that those who were using non steroidal anti inflammatory drugs, calcium channel blockers or steroids had a less favourable outcome, a finding that could be considered to be consistent with several research publications that have tried to identify the mechanism by which the ultrasound could bring about fracture healing acceleration and other wider research concerning the adverse influence of NSAID’s on tissue repair (e.g. Tsai et al 2004, Evans & Butcher2004).
The use of such low doses has been shown to result in non significant increases in tissue temperature. Using higher ultrasound doses could have an adverse effect on the fracture healing process and the low intensity pulsed system is considered to be effective and safe for this patient group. Reher et al (1997) demonstrated a stimulative effect at low dose (0.1 W cm-2) whilst an inhibitory effect at a higher dose (1 – 2 W cm-2). Chang et al (2002) demonstrated that the effect of low intensity pulsed ultrasound in these circumstances was achieved by non thermal mechanisms rather than as a phenomenon secondary to thermal effects.
The mechanisms by which therapeutic ultrasound can be effective for fracture repair includes nitric oxide (NO) pathways and prostaglandin (PGE2) (Reher et al 2002, Warden et al 2001, Kobubu et al 1999). This too would be consistent with other proposed mechanisms of ultrasound action (ter Haar 1999) and the relationship between the use of NSAID’s and tissue repair following injury.
Both Tis et al (2002) and Sakurakichi et al (2004) have evaluated the use of ultrasound as a component of treatment (in an animal model) during distraction osteogenesis, and both have demonstrated significant benefits. Cook et al (2001) have demonstrated similar benefits following spinal fusion surgery and Tanzer et al (2001) have shown that the use of ultrasound in combination with porous intramedullary implants is also beneficial. There are many other studies concerning the use of US and bone repair, but essentially the published work shows a consistent benefit, and the use of low intensity pulsed ultrasound for patients with bone related disorders, including normally healing fractures, stress fractures, delayed and non unions and as a post surgical intervention should be considered positively.
One study (Schortinghuis et al 2004) that employed the SAFHS ultrasound system yet failed to demonstrate a significant effect (following deliberate bone injury – rat model) is probably related to the additional inclusion of a PTFE membrane – a GoreTex® like material). This would almost certainly not enable adequate ultrasound energy transmission due to the porous nature of the material, and the consequent air trapping, leading to ultrasound energy reflection.
The SAFHS system is not the only ultrasound device employed for the clinical management of fractures, and a recent paper (Lerner et al 2004) describes the use of an alternative (Exogen) system with 17 ‘case studies’. The expgen device is additionally described in several other review papers.
The Warden et al (1999) paper provides a useful review for therapists wishing to update their knowledge in the area and who want to go beyond the material on these pages.
Busse, J. W., M. Bhandari, et al. (2002). "The effect of low-intensity pulsed ultrasound therapy on time to fracture healing: a meta-analysis." CMAJ 166(4): 437-41.
Chang, W. H., J. S. Sun, et al. (2002). "Study of thermal effects of ultrasound stimulation on fracture healing." Bioelectromagnetics 23(4): 256-63.
Cook, S. D., S. L. Salkeld, et al. (2001). "Low-intensity pulsed ultrasound improves spinal fusion." The Spine Journal 1: 246-254.
Evans, C. E. and C. Butcher (2004). Journal of Bone and Joint Surgery 86-B(3): 444-449.
Heckman, J. D., J. P. Ryaby, et al. (1994). "Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound." J Bone Joint Surg Am 76(1): 26-34.
Jensen, J. E. (1998). "Stress fracture in the world class athlete: a case study." Med Sci Sports Exerc 30(6): 783-7.
Kristiansen, T. K., J. P. Ryaby, et al. (1997). "Accelerated healing of distal radial fractures with the use of specific, low-intensity ultrasound. A multicenter, prospective, randomized, double-blind, placebo-controlled study." J Bone Joint Surg Am 79(7): 961-73.
Lerner, A., H. Stein, et al. (2004). "Compound high-energy limb fractures with delayed union: our experience with adjuvant ultrasound stimulation (exogen)." Ultrasonics 42: 915-917.
Mayr, E., V. Frankel, et al. (2000). "Ultrasound--an alternative healing method for nonunions?" Arch Orthop Trauma Surg 120(1-2): 1-8.
Reher, P., N. I. Elbeshir el, et al. (1997). "The stimulation of bone formation in vitro by therapeutic ultrasound." Ultrasound Med Biol 23(8): 1251-8.
Reher, P., M. Harris, et al. (2002). "Ultrasound stimulates nitric oxide and prostaglandin E2 production by human osteoblasts." Bone 31(1): 236-41.
Sakurakichi, K., H. Tsuchiya, et al. (2004). "Effects of timing of low-intensity pulsed ultrasound on distraction osteogenesis." J Orthop Res 22: 395-403.
Schortinghuis, J., J. L. Rubenb, et al. (2004). "Therapeutic ultrasound to stimulate osteoconduction A placebo controlled single blind study using e-PTFE membranes in rats." Archives of Oral Biology 49: 413-420.
Tanzer, M., S. Kantor, et al. (2001). "Enhancement of bone growth into porous intramedullary implant using non-invasive low intensity ultrasound." J Orthop Res 19: 195-199.
ter Haar, G. (1999). "Therapeutic Ultrsound." Eur J Ultrasound 9: 3-9.
Tis, J. E., R. H. Meffert, et al. (2002). "The effect of low intensity pulsed ultrasound applied to rabbit tibiae during the consolidation phase of distraction osteogenesis." J Orthop Res 20: 793-800.
Tsai, W.-C., F.-T. Tang, et al. (2004). "Ibuprofen inhibition of tendon cell proliferation and upregulation of the cyclin kinase inhibitor p21CIP1." Journal of Orthopaedic Research 22(3): 586-591.
Warden, S., K. Bennell, et al. (1999). "Can conventional therapeutic ultrasound units be used to accelerate fracture repair?" Phys Ther Rev 4: 117-126.
Warden, S. J., J. M. Favaloro, et al. (2001). "Low-intensity pulsed ultrasound stimulates a bone-forming response in UMR-106 cells." Biochem Biophys Res Commun 286(3): 443-50.
A wide range of Electrotherapy Courses are delivered throughout the UK, Europe and Worldwide with varying content, aims and duration.
Current books on Electrotherapy with brief descriptions and links to Amazon pages for purchase.
Some common answers to the most frequently asked questions on Electrotherapy, particularly in the area of Contraindications.