Summaries by Sarah L, Brianna, and Natalie
Ultrasound is a very common modality used in the outpatient setting for physical therapy. It is often used for soft tissue and bony lesions but it can also be used in wound care. Pulsed ultrasound is used in wounds to help accelerate the inflammatory phase of healing. It stimulates the release of histamine from mast cells which then attract neutrophils and monocytes to the injured area to help clean up and repair the site of injury. Research is still increasing for the use of ultrasound, especially towards wound care. Below are some articles that both support and oppose the use of ultrasound for wound care.
Supporting Articles:
Wollina, Heinid, Naumann, Scheibe, Schmidt, and Neugebauer studied the effects of ultrasound on wound care using three different levels of ultrasound, 34 kHz, 53.5 kHz, and 75 kHz. Twelve different patients over the age of 18 who had chronic venous leg ulcers participated. Non-contact ultrasound was applied to their leg ulcers while submerged in water, for ten minutes, once a day. They measured the microcirculation before applying ultrasound, immediately after and thirty minutes after applying ultrasound. They also used micro-light guide spectrophotometer and contact-free remission spectrophotometer to collect measurements. Overall there was not much of an effect at the levels of 53.5 kHz or 75 kHz, but at continuous-wave low-frequency ultrasound of 34 kHz there was a slight increase in microcirculation. This was most likely due to the increase of oxygenation to that area but further studies are still needed.
Low intensity pulsed ultrasound (LIPUS) and pulsed electromagnetic fields are used in healing bone after fracture. To determine how effective each is in the healing of bone, the authors conducted a systematic review of literature. Using the most common outcome measure of radiographic healing of the cortices, both methods were determined to be effective in healing fractures. LIPUS has strong evidence in supporting its use for fracture healing. In randomized, controlled clinical trials, it promotes healing in nonunion and acute fractures with the following parameters: burst width of 200 microseconds containing 1.5 MHz sine waves, repetition rate of 1 KHz and spatial average temporal intensity of 30 mV/cm2, treatment applied with 20 minutes daily. Using these parameters and evidence, PTs can apply LIPUS in the clinic to aid in bone healing after fracture.
Kavros, Liedl, Boon, Miller, Hobbs, and Andrews found that ultrasound was an effective modality for the treatment of chronic wounds in patients with an average age of 71 years. This retrospective study reviewed the charts of 210 patients with below-the-knee, lower extremity wounds of varied etiology. Forty-seven patients were placed in the control group because their wounds were treated with standard wound care alone. The remaining 163 patients were placed in the intervention group because their wounds were treated with MIST ultrasound therapy - a low-intensity, low frequency, non-contact ultrasound technique - in addition to standard wound care. Patients in the ultrasound group had been treated 3 times per week for 90 days or until the wound healed. Results showed that those in the ultrasound group saw better results in regards to wound volume, percent wound closure, and rate of healing as compared to the control group (Kavros et al., 2008).
Opposing Articles:
Watson, Kang, Soares, Chuang, Worthy, Bland, and Iglesias, studied 337 patients who had at least one venous leg ulcer for greater than 6 months or that was larger than a 5cm2 area. They aimed to see if low dose, high frequency ultrasound (1 MHz and 0.5 W/cm2) applied once a week to the ulcer for 12 weeks along with standard care would improve wound healing over just standard wound care alone. It was found that applying ultrasound between wound dressings did not improve ulcer healing time nor reduce ulcer recurrence. It also did not improve the quality of life of the patients.
Ultrasound has many physiologic effects on soft tissue and it has been hypothesized that can aid in tissue lesion repair. Thermal effects of ultrasound include increasing tissue extensibility, controlling pain, increasing blood flow, and reducing muscle spasm. Non-thermal effects of cavitation and microstreaming are thought to help with tissue healing. Cavitation causes compression and expansion of gas bubbles in the tissue increasing fluid flow. Microstreaming increases cell permeability to stimulate repair. Through article review, Speed has determined that while these events can help with wound and tissue repair in vitro, there is a lack of evidence for success in vivo. However, this lack of success may be due to flawed study designs and the presence of underlying pathologies in patients. At this time, the evidence does not support its use in the clinic, but more research need to be in order to validate or definitively dispute its effects on soft tissue lesion repair.
Ter Riet, Kessels, and Knipschild found that ultrasound was not an effective modality for treating pressure ulcers in nursing home patients. This randomized clinical trial recruited 88 patients with pressure ulcers from 11 different nursing homes and one hospital. Half of the patients were assigned to the ultrasound group and received ultrasound to the wound and the extended wound area. The other half of the subjects were assigned to the sham ultrasound group. A nurse applied and ultrasound transducer to these patient’s wounds, but the beam wasn’t actually turned on. Both groups received treatment for 12 weeks. Results showed that after 12 weeks, 40% of the ulcers in the ultrasound group had closed and 44% of the ulcers in the sham ultrasound group had closed. Closure rates and healing rates were almost equal between the two groups. These data indicate that ultrasound does not speed up the healing of pressure ulcers (ter Riet, Kessels & Knipschild, 1996).
As seen from the evidence above though, ultrasound has been seen to be effective and non-effective for wound care. More evidence is still needed in this area to really confirm the effectiveness and efficacy of ultrasound on wound healing. For now, using ultrasound is often based on personal opinion and experience. One thing is known for sure about ultrasound, is that it does not help in treating DOMS (delayed onset muscle soreness). However, it is seen that ultrasound can also help with managing scar tissue and joint contractures and has been seen to increase bone healing.
References
Kavros, S. J., Liedl, D. A., Boon, A. J., Miller, J. L., Hobbs, J. A., & Andrews, K. L. (2008). Expedited wound healing with noncontact, low-frequency ultrasound therapy in chronic wounds: a retrospective analysis. Advances in skin & wound care, 21(9), 416-23. doi:10.1097/01.ASW.0000323546.04734.31
Speed, C. A. (2001). Therapeutic ultrasound in soft tissue lesions. Rheumatology (Oxford, England), 40, 1331-1336.
ter Riet, G., Kessels, A. G., & Knipschild, P. (1996). A randomized clinical trial of ultrasound in the treatment of pressure ulcers. Physical therapy, 76(12), 1301-11. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8959999
Walker, N. A., Denegar, C. R., and Preische, J. (2007). Low-intensity pulsed ultrasound and pulsed electromagnetic field in the treatment of tibial fractures: A systematic review. Journal of Athletic Training, 42(4), 530-535.
Watson, J. M., Kang’ombe, A. R., Soares, M. O., Chuang, L.-H., Worthy, G., Bland, J. M., Iglesias, C., et al. (2011). Use of weekly, low dose, high frequency ultrasound for hard to heal venous leg ulcers: the VenUS III randomised controlled trial. BMJ (Clinical research ed.), 342, d1092. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3050437&tool=pmcentrez&rendertype=abstract
Wollina, U., Heinig, B., Naumann, G., Scheibe, A., Schmidt, W.-D., & Neugebauer, R. (2011). Effects of low-frequency ultrasound on microcirculation in venous leg ulcers. Indian journal of dermatology, 56(2), 174-9. doi:10.4103/0019-5154.80412
Effectiveness of ultrasound therapy in treatment of venous leg ulcers
ReplyDeleteA summary by Laura Webb
Referenced article: Escandon J, Vivas AC, Perez R, Kirsner R, Davis S. A prospective pilot study of ultrasound therapy effectiveness in refractory venous leg ulcers. Int Wound J 2012; 9:570–578
What problems did the researchers set out to study, and why?
This article studied the effect of non-contact ultrasound on wound closure, bacterial counts, expression of inflammatory cytokines, and pain reduction. Venous insufficiency is the most common cause of leg ulcers in the US, and these ulcers cost our health care system billions of dollars each year. Although the exact reason for its effect is uncertain, ultrasound has been used to treat chronic wounds and is believed to decrease wound bacterial counts. The authors wanted to test this theory clinically by analyzing changes in wound size and bacterial burden over a 4-week treatment course. Inflammatory cytokines were also evaluated, along with the relationships between gene expression for said cytokines with wound size, bacteria burden and inflammation in wounds that healed versus those that did not. Reported pain changes were also documented using the visual analog scale (VAS).
Who participated in the study?
Ten patients were enrolled; 9 of the ten completed all 4 weeks of treatment. To be eligible, patients must have had a refractory venous leg ulcer that was present for at least 6 months, was at least 5cm2 in size, and had failed to improve in previous 30 days with supervised multilayered compression bandages
Patients who were excluded from this study had used topical antibiotics or systemic anticoagulants, were diagnosed with DVT in last 6 weeks, had a malignancy in the wound bed, or had wounds of non-venous etiologies.
What new information does this study offer?
This study focused on refractory venous leg ulcers, a group of wounds that are considered difficult to heal. The results coincide with previous studies showing the benefits of using non-contact, low-frequency ultrasound to promote healing. It is believed that this is achieved by cleansing and debriding dead tissue, as well as by removing bacteria and other unwanted material. There was a statistically significant reduction in average wound size (from 38.3cm2 to 29.0cm2). A statistically significant negative correlation was found between cytokine expression from the baseline assessment to the final assessment. This indicated increased healing as these inflammatory markers decreased.
How did the researchers go about this study?
Patients were seen 3x/week for 4 weeks. Therapy duration depended on wound size, although the minimum treatment time was 3 minutes for a wound of <10cm2; treatment time increased 1 minute for every 10cm2 increase in wound size.
How might the results of this study apply to physical therapist practice?
When treating patients with wounds that are difficult to heal, ultrasound therapy may be useful in reducing wound size, decreasing the expression of inflammatory cytokines, and decreasing pain – even though bacterial counts may not be significantly affected by this modality.
What are the limitations of the study, and what further research is needed?
No sham control group was used in this study; further research might utilize a sham ultrasound treatment, although the ethics of this approach may be questionable.
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