Athletic Training and Sports Health Care

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Clinical Roundtable 

Ultrasound

Craig R. Denegar, PhD, PT, ATC, FNATA; Chad Starkey, PhD, AT, FNATA

Abstract

This Clinical Roundtable was conducted March 3, 2010.

Dr. Konin: What trends are you seeing these days related to clinical ultrasound use?

Dr. Denegar: Use of ultrasound seems to vary between facilities and providers. Most of the information I get is from physical therapy students returning from clinical practicum experiences. Some report rarely or never seeing ultrasound applied, while others work in facilities where treatment with ultrasound is fairly common. Overall, treatment with ultrasound seems to have declined quite a bit over the past 15 to 20 years.

Dr. Starkey: I agree with Dr. Denegar’s assessment that ultrasound is, rightfully, falling out of vogue. I believe that there are currently two schools of thought. One states that the historic “ultrasound can be used for every condition” and is a rite of passage through the treatment spectrum. The other represents clinicians who yield to informed decision making whereby ultrasound is the right intervention for the right pathology at the right time.

Dr. Konin: Have we learned anything new over the past decade related to ultrasound interventions?

Dr. Denegar: The past decade has seen increased attention to the practice of evidence-based health care, and with it more focus on patient-related outcomes as opposed to changes in physiological measures and clinician measured impairments. When one reviews the clinical literature related to therapeutic ultrasound, there are not a lot of data suggesting that the treatments improve outcomes.Much of the literature is devoted to the treatment of tendinopathy. We struggle to fully understand tendon pathology after decades of assuming that we were treating tissue in an inflamed state. It comes as no surprise that treatments of a poorly understood pathology are often ineffective.There may be circumstances where ultrasound can improve the outcome of care, but a lot of work is needed to identify those conditions where therapeutic ultrasound leads to better outcomes that are cost effective. In summary, I think that the biggest thing learned in the past decade is that, when we consider the use of therapeutic modalities, we need to look at patient-oriented outcomes of care to guide our clinical decisions.

Dr. Starkey: Dr. Denegar has investigated the parameters and effects of therapeutic and ultrasound for stimulation of fracture healing. Over the past decade, we have gained much insight into the proper output intensity and duration of treatment. As clinicians, we must gain better skill in determining the optimal parameters for ultrasound treatment on a case-by-case basis.

Dr. Konin: Where did some of our clinical parameters originate? For example, the size of the area to be treated, the length of time a delivery should occur within, or intensity guidelines for creating thermal effects?

Dr. Starkey: We can’t deny that some of the current treatment parameters for all therapeutic agents have been somewhat influenced by reimbursement patterns. While this primarily affects the for-profit setting, it would be naïve for us to think that its influence has not been felt in the not-for-profit sector.

Dr. Denegar: I learned about ultrasound back in a day where most, if not all, units were a 10-cm2 soundhead with a treatment frequency of 0.8 to 1.0 MHz. We were taught to treat for 5 minutes at 1.5 wcm2. The technology of the times limited the options. With the availability of higher frequency units (eg, 3 MHz), the availability of smaller soundheads, and laboratory research, much has changed.As Dr. Starkey mentioned, Dr. Dave Draper has done a lot of work to help clinicians understand the depth of heating and the time required to heat tissues with various parameter settings. We know a good bit about heating tissues but considerably less…

This Clinical Roundtable was conducted March 3, 2010.

Dr. Konin: What trends are you seeing these days related to clinical ultrasound use?

Dr. Denegar: Use of ultrasound seems to vary between facilities and providers. Most of the information I get is from physical therapy students returning from clinical practicum experiences. Some report rarely or never seeing ultrasound applied, while others work in facilities where treatment with ultrasound is fairly common. Overall, treatment with ultrasound seems to have declined quite a bit over the past 15 to 20 years.

Dr. Starkey: I agree with Dr. Denegar’s assessment that ultrasound is, rightfully, falling out of vogue. I believe that there are currently two schools of thought. One states that the historic “ultrasound can be used for every condition” and is a rite of passage through the treatment spectrum. The other represents clinicians who yield to informed decision making whereby ultrasound is the right intervention for the right pathology at the right time.

Dr. Konin: Have we learned anything new over the past decade related to ultrasound interventions?

Dr. Denegar: The past decade has seen increased attention to the practice of evidence-based health care, and with it more focus on patient-related outcomes as opposed to changes in physiological measures and clinician measured impairments. When one reviews the clinical literature related to therapeutic ultrasound, there are not a lot of data suggesting that the treatments improve outcomes.Much of the literature is devoted to the treatment of tendinopathy. We struggle to fully understand tendon pathology after decades of assuming that we were treating tissue in an inflamed state. It comes as no surprise that treatments of a poorly understood pathology are often ineffective.There may be circumstances where ultrasound can improve the outcome of care, but a lot of work is needed to identify those conditions where therapeutic ultrasound leads to better outcomes that are cost effective. In summary, I think that the biggest thing learned in the past decade is that, when we consider the use of therapeutic modalities, we need to look at patient-oriented outcomes of care to guide our clinical decisions.

Dr. Starkey: Dr. Denegar has investigated the parameters and effects of therapeutic and ultrasound for stimulation of fracture healing. Over the past decade, we have gained much insight into the proper output intensity and duration of treatment. As clinicians, we must gain better skill in determining the optimal parameters for ultrasound treatment on a case-by-case basis.

Dr. Konin: Where did some of our clinical parameters originate? For example, the size of the area to be treated, the length of time a delivery should occur within, or intensity guidelines for creating thermal effects?

Dr. Starkey: We can’t deny that some of the current treatment parameters for all therapeutic agents have been somewhat influenced by reimbursement patterns. While this primarily affects the for-profit setting, it would be naïve for us to think that its influence has not been felt in the not-for-profit sector.

Dr. Denegar: I learned about ultrasound back in a day where most, if not all, units were a 10-cm2 soundhead with a treatment frequency of 0.8 to 1.0 MHz. We were taught to treat for 5 minutes at 1.5 wcm2. The technology of the times limited the options. With the availability of higher frequency units (eg, 3 MHz), the availability of smaller soundheads, and laboratory research, much has changed.As Dr. Starkey mentioned, Dr. Dave Draper has done a lot of work to help clinicians understand the depth of heating and the time required to heat tissues with various parameter settings. We know a good bit about heating tissues but considerably less about cellular responses in vivo.The use of ultrasound to speed fracture repair is an example of the potential for ultrasound to improve treatment outcomes, but the devices for fracture management are not the same as those used in athletic training rooms and clinics. At this point, we know very little about the parameters that might yield favorable results when using these units.

Dr. Konin: Where do you think our future with ultrasound as a clinical tool lies?

Dr. Starkey: Ultrasound will always be with us in some form; I doubt that it will go the route of the infrared generator (ie, “heat lamp”). The future promise of ultrasound probably lies in its nonthermal effects, including low pulsed and low-intensity output or low-frequency ultrasound; however, the biophysical effects and efficacy of this approach must first be elucidated. The ultimate future of all therapeutic interventions will depend on the results of well-designed, controlled clinical research studies.

Dr. Denegar: The future likely lies in condition-specific applications likely with new technology. If we can facilitate repair of soft tissue with ultrasound, the devices will have to produce precisely controlled quantities of energy. Current clinical devices vary considerably in terms of beam uniformity and output.The lack of evidence of treatment efficacy may result in a halt to third-party reimbursement for treatment with ultrasound in many circumstances. This may not be a bad decision, given the need to address health care costs. The time has come to examine modality application from the perspective or effectiveness and cost, rather than safety and theory.

Dr. Konin: What one piece of advice would you provide regarding efficacy and use of ultrasound for clinicians?

Dr. Denegar: Practice evidence-based health care and differentiate clinician experience from practice habit. Ask: Is there evidence to guide my decision to use or not use a modality? If the evidence is lacking, ask: Does my experience strongly suggest that a treatment may be beneficial? Too often we fall into practice habits.For those who work with healthy athletic individuals, we see most patients recover and return to high levels of function and perhaps falsely assume that the recovery was facilitated by each aspect of our plan of care. The more closely we investigate the effects of modalities, the less impact on outcomes appear to be realized. Personally, I now hesitate to apply a treatment that I would not personally pay for.

Dr. Starkey: Although evidence-based practice is often thought of as a buzz phrase, I echo Dr. Denegar’s point. All clinicians should start to think of a review of the literature as a basic element in their treatment and rehabilitation planning. Indeed, incorporating evidence should become a major element in our overall practice pattern.

Craig R. Denegar, PhD, PT, ATC, FNATA, is from the Department of Kinesiology, University of Connecticut, Storrs, Conn.

Chad Starkey, PhD, AT, FNATA, is from the Division of Athletic Training, Ohio University, Athens, Ohio.

Moderator: Jeff G. Konin, PhD, ATC, PT, FACSM, FNATA

Authors

This Clinical Roundtable was conducted March 3, 2010.

10.3928/19425864-20100428-04

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