full article 3750 words
Ultrasound therapy (US) is the use of sound waves above the range of human hearing12 to treat injuries like muscle strains or runner’s knee. It is mostly used by physical therapists, and has been one of the Greatest Hits of musculoskeletal medicine since the 1950s.34 There are many flavours of therapeutic ultrasound, using different intensities and frequencies of sound, but all share the basic principle of “stimulating” or even provoking tissue5 with sound waves above the range of human hearing. Vibration therapy, in other words.
Almost everyone seems to assume that ultrasound is proven — good technological medicine — but that just doesn’t seem to be the case.
There is a jarring, bizarre lack of research for such a popular therapy.Unfortunately — although there are some interesting exceptions and tantalizing hopes for some conditions — ultrasound is not a promising therapy for most of the painful problems it is used for. There is a jarring, bizarre lack of quality research for such a popular, mainstream therapy. What little research is available paints a bland picture. Ultrasound therapy isn’t even on good theoretical foundations. At best, it’s more complicated and unpredictable than most therapists believe. At worst, there is no rational basis for US at all.
Although ultrasound is almost certainly useful for some patients, some of the time, it is not a reliable or evidence-based therapy, and enjoys far more credibility than it deserves.
I do not like the principle of using magic machines to treat.
“Nari,” physical therapist, in an internet forum discussion
The vast majority of patients will encounter therapeutic ultrasound in one of two forms:
Garden-variety therapeutic US is cheap and available everywhere. The machines are small, even portable: you can buy small handheld ones. Treatment is brief and painless, and applied (indiscriminately?) to almost any common musculoskeletal problem.
On the one hand, ESWT is just a “more is better” version of standard US, because it is often used with the same imprecise clinical intention to stimulate/provoke tissues. On the other hand, because it was originally developed for smashing gall stones, ESWT is strong enough to actually disrupt tissue, such as calcifications in tendons — which is a nice precise clinical goal and a whole different kettle of fish.
When I started studying for this article way back in the mid-2000s, I was quite surprised by how little there was to study. Back then, every scientific paper about US pointed out there is not enough research on this topic, or at least not enough good research … and not much has changed. A 2015 review of ultrasound for rotator cuff tendinopathy (cited below) found only six trials, all poor quality.
That’s not a lot to go on, and it’s typical. It’s a bit shocking. We’re talking about ultrasound, here: one of the staples of physical therapy! It’s not a fringe treatment. It practically defines the experience of going to a physiotherapist. Everyone has had that cold gel slapped on an injury, and felt that tingling, penetrating … placebo?
The disconnect between the popularity of US and the more or less total lack of informative research is troubling. A handful of good studies is a joke for a therapy that is worth literally billions of dollars in the marketplace. How can that much therapy be sold without a satisfactory body of evidence that it works? Bizarre! This is the ultimate example of pseudo-quackery: popular treatments that aren’t overt quackery (they are plausible, not obviously at odds with established science) but fall well short of validated, scientific medicine and are sold with excessive confidence and usually considered mainstream.
This does not mean that US never works for anyone. It does mean that it has been prescribed and sold to patients for decades with unjustified confidence. And that is not cool.
In most cases I consider ultrasound less than useless — that's 8-10 minutes wasted that could be used doing something that might actually help.
Jason Silvernail, DPT, Board-Certified in Orthopedic Physical Therapy, in an internet forum discussion
Ultrasound is an unusually easy treatment to test scientifically.10 If it works reasonably well, then the results should be pretty clear. Just compare results in patients who received real ultrasound to patients who get a fake instead! And yet there are just a few dozen such experiments in the scientific literature, and most of them are seriously flawed. Conclusions from evidence reviews like this one from van der Windt et al are typical:
As yet, there seems to be little evidence to support the use of ultrasound therapy in the treatment of musculoskeletal disorders. The large majority of 13 randomized placebo-controlled trials with adequate methods did not support the existence of clinically important or statistically significant differences in favour of ultrasound therapy.
van der Windt et al, 1999, Pain
Did not support the “existence of”? Ouch! Ultrasound’s therapeutic effect has an existential crisis.
Several reviews give a nod towards some ray of hope. For instance, van der Windt et al, despite their overwhelmingly negative conclusion, also noted that “findings for lateral epicondylitis [tennis elbow] may warrant further investigation.” But, naturally, that optimism about tennis elbow is contradicted by other studies.11 The science is mostly a discouraging, unimpressive mess — a classic case (yet another one) of a damning failure to impress.
|van der Windt 199912||musculoskeletal disorders||strongly negative review of 13 “adequate” trials did not support “the existence” of therapeutic effects|
|Robertson 200113||pain and injury||“little evidence” of therapeutic benefit in 10 “acceptable” trials out of 35 candidates; 2 positive trials, 8 negative|
|Baker 200114||biological effects||“insufficient biophysical evidence” to justify therapeutic use for pain and injury|
|Buchbinder 200615||tennis elbow||nine studies produced “platinum” level (better than gold!) evidence of “little or no benefit” (for ESWT)|
|Ho 200716||tennis elbow||conflicting, “unconvincing” evidence of efficacy from a few trials (of ESWT again)|
|Ho 200717||rotator cuff tendinopathy||limited evidence “supports … ESWT for chronic calcific rotator cuff tendonitis,” but no non non-calcific|
|Rutjes 201018||osteoarthritis of knee||a positive update to a previously negative review, which is strange because it’s based on just 5 small, poor quality trials with trivial “positive” results|
|Shanks 201019||lower limb conditions||inconclusive review of 10 of 15 candidates: “no high quality evidence available”|
|van den Bekerom 201120||ankle sprains||inconclusive but discouraging review of “five small placebo-controlled trials”; the “potential treatment effects of ultrasound appear to be generally small”|
|Page 201321||carpal tunnel syndrome||inconclusive but slightly encouraging review of “only poor quality evidence from very limited data” from 11 trials|
|Ebadi 201422||chronic low back pain||inconclusive and underwhelming review of 7 small trials, none of them good quality|
|Desmeules 201523||rotator cuff tendinopathy||negative review “does not provide any benefit…based on low to moderate level evidence” from 11 weak trials|
Standard therapeutic ultrasound probably does little or nothing for most people. A sliver of hope remains that some specific conditions will respond to ultrasound with just the right settings.
Therapeutic ultrasound … has fallen out of favor as research has shown a lack of efficacy and a lack of scientific basis for proposed biophysical effects.
Baker et al, 2001, Physical Therapy
Except it hasn’t fallen out of favour! It’s still widely used. The only professionals it’s fallen out of favour with, I imagine, are a small minority of scientists and unusually alert clinicians.
Not only that, but ultrasound has found new life in the marketplace as shockwave therapy — faster, stronger waves, with a bigger price tag! Consider this marketing language from a Canadian company, Shockwave Institute, specializing in ESWT:
Provided you are a candidate for this type of treatment, clinical studies suggest there is a 80–85% chance this technology will improve your condition.
from the Shockwave Alberta FAQ, as of Nov 30, 2009
Shockwave Alberta certainly doesn’t think ultrasound has fallen out of favour! Here we have an entire company devoted to delivery of therapeutic US, and selling it with the implication that it is not only proven to be effective, but exactly how effective — to within 5%!
Based on the available evidence, do you think it’s actually possible or meaningful to declare that ESWT is exactly “80–85% effective”? Where are the scientific review papers confirming this marvellous triumph of US? Where is the data to support such a specific promise of therapeutic success? You sure couldn’t find them in 2009!
Well, things seem to have changed… and, believe it or not, it’s good news so far. There are multiple positive reviews of ESWT, specifically for stubborn cases of plantar fasciitis, a painful irritation of th arch of the foot. A good 2016 example is Lou et al, who concluded that “ESWT seems to be particularly effective in relieving pain associated with recalcitrant plantar fasciitis.”24 Plantar fasciitis is by far the most commonly ESWT-treated condition for some reason: other conditions may be a completely different matter, but certainly the evidence for plantar fasciitis is surprisingly good, almost amazingly so (it’s a stark contrast with the vast majority of treatments for musculoskeletal conditions).
Having noticed that the wind is blowing in a new direction, I’ll expand on this update soon.
There is nothing a cold slimy prickling ultrasound wand can do that a pair of warm hands can’t do way better.
If only I had a buck for every time a patient or reader has told me that they are skeptical about “that ultrasound thing they always do to you at physiotherapy”!
Patients often express irritation with a common physical therapy business model: working with several patients at once, rotating between rooms or beds, often leaving patients with passive therapies (like a moist hot pack from a hydrocollator — nice enough, but worth a steep fee?) Many patients often go a step further and complain specifically about ultrasound and TENS, skeptical that these treatments really do anything.25 To the patient, these treatments seem unremarkable & also obvious ways for a physiotherapist to get paid while not doing much.To the patient, they seem therapeutically unremarkable and also obvious ways for a physiotherapist to get paid while not doing much. This perception really pushes people’s “I don’t want to be a sucker” button.
And so few patients are singing the virtues of standard US. It not only fails to generate testimonials, but actually generates many annoyed antimonials.
Patients do not (yet) feel the same cynicism about shockwave ultrasound. As a more expensive and painful medicine, ESWT is a hope-generating machine. Having spent their hard-earned dollars and endured the discomfort of treatment, patients are more subject to expectation effects (placebo) — and much less willing to entertain the possibility that it was all a waste. At this stage in their quest to feel better, more people will report ambiguous results if they were positive (“Yeah, I think it did some good!”), and even negative reports will often be toned down (“I didn’t seem to get that much out of it, but I guess it works really well for some people.”) This could go on for years.
The big idea is — this will blow your mind! — that cells and tissues respond “well” to being shaken (not stirred). In theory, ultrasound works by vibrating tissues back to health, which sounds like something you’d hear on an infomercial, or the Dr. Oz Show. What, exactly, does vibration do to tissues? Does anyone actually understand it?
In 2001, Physical Therapy published a review of the biological effects of ultrasound. More than ten years ago, the authors — Baker, Robertson, and Duck — explained that it had already been at least two decades since it was first pointed out that “physical therapists tended to overlook the tenuous nature of the scientific basis for the use of therapeutic ultrasound.”26 They also point out — it’s the point of their whole paper — that the situation had not improved in twenty years (before 2001):
The frequently described biophysical effects of ultrasound either do not occur in vivo under therapeutic conditions or have not been proven to have a clinical effect under these conditions. This review reveals that there is currently insufficient biophysical evidence to provide a scientific foundation for the clinical use of therapeutic ultrasound …
There is lots of interesting ultrasound biology to consider, and scientists may eventually nail down effects that might be the basis for new evidence-based therapies. For instance, a decade later, Tsai et al declared that “There is strong supporting evidence from animal studies about the positive effects of ultrasound on tendon healing”27 — but animal studies are notoriously misleading, and they certainly can’t justify the use of ultrasound (especially when US has already been tested on tendinopathy with underwhelming results).
The clinical bottom line is complex and unpredictable, and there is no basis for concluding that ultrasound has a basis. The entire enterprise rests on the single, oversimplified idea that “stimulation is good” and the hope that we might someday figure out exactly why. Ultrasound is literally just tissue vibration therapy.
Physical therapists often cite the “gate control” mechanism as a justification for US and ESWT (and some other popular treatments, especially TENS). This is nonsense and a great example of why patients should be cautious, especially with the expense of ESWT.
The “gate control” mechanism is an important idea in pain science, proposed in 1965 by Dr. Ronald Melzack and Dr. Patrick Wall, and still accepted today as an explanation for a familiar phenomenon: the way we rub injured body parts for a little pain relief. The idea is that pain signals pass through a “gate” in the spinal column. The state of the gate is controlled by many factors. How much pain can get through depends on competing signals and information from other sources, such as touch and pressure, as well as emotional context.
So the idea with US is that the stimulation closes the gate and thus reduces pain. This may well occur, but it’s nothing to write home about. It’s not a “treatment” — it doesn’t fix anything— and it’s simply ridiculous as a justification for an expensive therapy. It’s a minor and temporary effect, and can be achieved just as easily by rubbing the area yourself! There is no reason to think that any kind of ultrasound closes the gate better or longer than any other stimulus.
The reasons for doing ultrasound are not at all clear, and adding this one is just a way to pad the list in a way that sounds scientific — especially handy when you’re trying to sell expensive ESWT — but is actually almost meaningless. It’s disturbingly marketing-savvy, but not at all medically savvy.
File this one under “intriguing”: Canadian researchers treated trigger points (muscle knots) in 50 patients with either ultrasound or a sham, and the amount of pressure on the trigger point required to induce pain was measured before and after. Trigger points treated with ultrasound were more tolerant of pressure than those that were not treated, at 1, 3 and 5 minutes after treatment.28 The improvement was no longer significant just 10 and 15 minutes later, however — so the effect in this case was brief. The authors concluded:
…low-dose ultrasound evokes short-term segmental antinociceptive effects on trigger points which may have applications in the management of musculoskeletal pain.
They are not necessarily proposing that ultrasound is a useful treatment for myofascial pain syndrome, but producing evidence of an interesting effect that may prove to be clinically significant in time — an important distinction.
Although it may be surprising in contrast to the generally unimpressive evidence of the effectiveness about therapeutic ultrasound, it nevertheless reinforces that ultrasound does indeed do some interesting things to tissues: it’s just not clear exactly what. An important caveat is that there is significant scientific debate about what “trigger points” really are.29 Some would say it’s hard to study the effect of ultrasound on a phenomenon that may or may not even exist!
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
— Added a brief acknowledgement of the surprisingly positive evidence for shockwave therapy for plantar fasciitis, plus a bunch of miscellaneous editing.
— Big science update — Added a table of summarized recent reviews, including six new citations from the last decade (basically all still about scanty, crappy evidence). Several related editorial changes.
Ultrasound is widely used. This 2007 survey of the usage of ultrasound, the first such American survey for almost 20 years (see Robinson 1988), “examined the opinions of physical therapists with advanced competency in orthopedics about the use and perceived clinical importance of ultrasound.” They found that “ultrasound continues to be a popular adjunctive modality in orthopedic physical therapy. These findings may help researchers prioritize needs for future research on the clinical effectiveness of US.”BACK TO TEXT
This 2013 Canadian survey of the usage of ultrasound found that “despite the questionable effectiveness of therapeutic US, physical therapists still commonly use this treatment modality, largely because of a belief that US is clinically useful. However, US usage has decreased over the past 15 years.”BACK TO TEXT