9.2 min read | Technology 

ULTRASOUND: A HIT OR A FLOP THERAPY?

Written By Anamika Bheda and Jessica Gomes
Visual Media by Riddhi Gandhi 

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Proposition:

Today I am here to argue for the notion that the US is a flop therapy.The therapeutic US, an electrophysical agent, whose mechanism of action is based on simple principles of physics has been in clinical use for over 60 years now. However, there is questionable evidence regarding the effectiveness of US in patients with pain, musculoskeletal injuries and other soft tissue lesions.
The theory behind its work may be sound, but its effect on human beings is not as predicted at all. I will soon present evidence to buttress this claim.
According to common belief, the US reduces local pain and inflammation increases blood flow and reduces scar tissue growth. 

However, a study published in the American Journal of physical medicine and rehabilitation in the issue of May 2014, states that the US had no additional benefit on pain or function in knee osteoarthritis patients. Moreover, these patients did not have an accelerated recovery. The benefits they got were solely through exercise.

Another area where the US is used recklessly and abundantly is in cases involving the shoulder, particularly adhesive capsulitis. A prospective double-blind placebo-controlled randomized trial research article published in , showed that individuals with adhesive capsulitis procured no benefit from the US. The benefit that they got was through exercises only.

The US is the first reached out treatment option when it comes to plantar fasciitis. Well, we have evidence for this too!   Research published in the Journal of Orthopaedic and Sports Physical Therapy issued in October 2018, shows how the US had no positive impact on the treatment of PF and that stretching is proven to be the optimum option.

Safe to say that whenever any positive outcome has been derived from the US, it is because of the placebo effect and not the US itself.

A study was conducted to examine whether US therapy added to the effects of exercise and mobilization in frozen shoulders. This study used US vs placebo The US along with exercises and manual therapy. Both types of US showed similar effects on pain, function and ROM. No significant improvement, either way, was seen. This study has been published in the Journal of Bodywork and Movement Therapies, October 2017.

Opposition:

I strongly oppose and disagree with my opponent’s claim, and firmly believe that the US is a HIT therapy.
Firstly, refuting to what my opponent just stated, that the US works with the patient’s mind; if my patients have a strong belief that the US therapy has a fruitful outcome, this positive belief is indeed going to reflect in their physical healing process owing to the mind-body connection.
Now going beyond comparison to a placebo, I shall put forward valid research that proves the efficacy of the US.

Firstly talking about the US’s role in treating OA knee patients:

A study published in the Journal of Orthopaedic Surgery dated July 2011–  showed that US improved joint conditions in OA knee patients vs a placebo treatment done for 8 months.

Research published in the journal of Scientific Reports October 2016  where a focused low-intensity pulsed ultrasound (FLIPUS) with diclofenac sodium therapy showed similar positive results vs the sham US.

We all know that Ankylosing spondylitis is an inflammatory condition of the spine. A study has proved that the US has shown to lessen pain in  AS patients. It is published in the Journal of Alternative Therapies in Health and Medicine in August 2018.

A very recent study published in the year 2019, stated that the US has shown to reduce pain in plantar fasciitis patients. It is published in the Journal of Foot and Ankle Surgery.

So “placebo” or “not a placebo”, the result is that the US is effective either way!!All these years the US has been in use in different countries successfully.
So, yes, the US should procure the credibility it deserves.

I would like to ask my opponent a question. If a patient comes back to your clinic satisfied and happy with the first session of the US, what will you do? Discontinue the treatment despite seeing positive results?

Proposition rebuttal:

If we were to work by the concept that what works for the mind, works for the body, there would be no need for this discussion. If the mind was the target, my opponent has put into question the entire being of physiotherapy, right from critical thinking to individualized exercise prescription, all of it will be run down to a mere nothing because clearly according to my opponent’s thinking – it doesn’t matter what you do –  US or IFT, TENS or shockwave, as long as the treatment works for the mind, it works for the body.

Coming to the statement “ if the patient believes”, since when do we operate on patient belief? And about the rhetorical question of several countries using the US as a treatment option, well you will be amazed to learn that in the last fifteen years there has been a constant decline in the use of the US in some of the major countries like Canada, USA.

According to the claim of my opponent that the US enhanced joint conditions in OA however it should be noted, the subjects received therapy for 8 months as compared to other researches to show positive results. 8 months is a considerably very long duration of treatment and not something that can be practically used for the local population. A common man cannot be arriving two or three times a week at the therapist’s clinic in the middle of a working day to get to the  US.

Also, the research that my opponent stated, which included treating OA patients with the US, did not use the US solely. Diclofenac sodium was used along with the US. It is not the US but the diclofenac which should be given the due credit to help US work.

Moving on to ankylosing spondylitis  – The back is a big area. How many minutes per session are you going to spend moving the transducer head? Are the effects worth spending that much time and effort?

Just because it has been in use all these years, it does not mean we have to continue using it! It’s like saying we have been following age-old costumes for decades and there is no scope for change. This is the entire purpose of evidence-based practice right?

Answer to my opponent’s questions – I don’t believe in fooling my patients. It isn’t an ethical thing to do.

Opposition rebuttal:

  • My opponent complained that the US takes a longer duration to treat the patients. Well, isn’t it great to have a “long-lasting” effect of improvement in function, healing and pain reduction by the application of US than a “faster produced” but “mere interim” result? 
  • Moreover, patients do not complain and are perfectly happy with the treatment time, which counts the most.
  • Secondly, exercise as an alternative therapy as suggested by my opponent,  the subjective factor in the patient exercise cannot be overlooked at all!

Moving on to my further arguments,  I would be highlighting the thermal effects of the US.

The application of the US to tissues causes a local rise in temperature. This in turn increases the extensibility of collagen and therefore stretching of scar tissue and adhesions are made more pliable. If the scar is bound down on underlying structures, the US helps to gain its release.

Well, the US is indeed effective on the tissues!

It has a crucial role in all three stages of repair namely the inflammatory, the proliferative stage and the remodelling stage. It has been shown to accelerate protein synthesis and stimulate the rate of repair of damaged tissues.

Moreover, no research has ever claimed that the US is harmful in any way. It is considered safe and extremely patient friendly equipment.

Proposition argue and defend:

In 18 months of practice, I have never come across patients who don’t complain about treatment time, especially as long as 18 months. Is there any piece of article that supports my opponents claim?

Besides being time-consuming, it is also heavy on the pocket. The cost includes loss in business as you take time off during a workday, travel costs and therapy costs. Using the US just for placebo will only engage the patient in more therapy sessions and also be time-consuming and expensive for a few people. It’s just about getting a patient addicted to it and keep seeing him in the clinic/hospital every time they have pain. This kind of plan of care makes no sense.

Why is my opponent in favour of a treatment option that is not the time or cost-effective for the patient? Imagine someone were to do that to you!

The US  has the potential to produce harm if the heat is left in the same place for too long. The reflection of an ultrasonic wave from bone may produce a localised concentration of heating effect leading to periosteal pain.

Cavitation which is stated to be a non-thermal effect may be unstable which is potentially dangerous and may damage cellular activity.

Opposition argue and defend: 

As my opponent has asked me to produce a survey of patients not complaining of treatment time, the proposition team should also produce a survey showing the patients that complain of treatment time of the US.
 
Refuting the claim of my opponent regarding harm due to localised heating, the simple solution to it is to keep the head of the US constantly moving over skin. This will potentially reduce any harmful effects 

We have already seen the thermal effects of the US. There are abundant non-thermal effects that are adding to the list.

1. Micro massage is one of them. This can help reduce oedema.

2. The US is often of use after soft tissue injuries, as the mechanical effect helps to remove traumatic exudate and reduces the danger of adhesion formation.

3. Analgesia produced by the ultrasound allows cautious early use of the part and makes the condition more tolerable.

4. Higher intensity ultrasound over a fracture can initiate a strong pain response – which is useful when it comes to using the modality to locate potential stress fractures.

Proposition conclusion:

Firstly I have stated my claim that the US is a sham therapy and I stand firm by it. 
Secondly, I have put forth my arguments questioning the liability of the US in treating patients with musculoskeletal injuries and provided valid evidence for the same.
I have cited the evidence below. Please refer to them.

When we know that the US is lacking in its efficacy in providing and guaranteeing better health, how can we let people spend their time and money on a therapy that does not work? Is this justifiable given the fact that we are an integral part of the Healthcare system?

Opposition conclusion: 

To conclude my argument, I would say, I am adamant about the fact that US therapy has always been promising to the patients and will continue to do so in the future, curing and caring for the better health of the patients.
I have provided enough evidence to solidify my argument.

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