Therapeutic Ultrasound as a Treatment for Chronic Low Back Pain

Submitted by: Brandon Ashley, Alex Caudy, and Ashley Pasterkiewicz

PTH 645 – Foundations of Patient Care I

 At some point throughout their adult life, 60 – 85% of people will experience low back

pain (LBP).1 The severity of symptoms in the preponderance of people with LBP are mild and

short-lasting; symptoms normally subside within six weeks.1 Pain in the low back region present

for longer than three months is considered to be chronic in nature.1 Roughly 15 – 45% of the

population has chronic low back pain (CLBP).1 As future physical therapists, we will potentially

treat many patients with CLBP. Knowledge of modalities as an adjunct treatment and their

outcomes could ultimately help alleviate pain for our patients. Currently, there is a lack of

evidence regarding the effectiveness of therapeutic US in CLBP. 2 However, a lack of evidence

does not represent a lack of beneficial effect. In order for us to draw a conclusion on the efficacy

of therapeutic US as a treatment for CLBP and whether or not it reduces pain, as well as

improves other meaningful outcomes, we will analyze research relating to this topic.

To investigate the benefits of therapeutic US in individuals with CLBP, Durmus, Akyol,

Cengiz, et al., compared the outcomes of therapeutic US treatment to sham US treatment.3 In this

study, forty-two patients were randomly assigned to two groups.3 Group 1 was treated using

therapeutic US over the lumbar paravertebral region with a frequency of 1 MHz, probe effective

radiating area (ERA) of 5 cm2, and an intensity of 1.0 W/cm2 for 10 minutes, in addition to 15

minutes of superficial heat via hot pack, and an exercise program.3 The exercise program

included range of motion (ROM), stretching, and strengthening exercises.3 Group 2 was treated

identical to Group 1, except they were given a sham US treatment.3 Treatment was provided 5

times per week for 3 weeks.3 Outcomes were assessed at baseline and after three weeks using a

visual analog scale (VAS) for pain, the Oswestry Questionnaire which measured disability, and a

6 minute walk test (6MWT) for functional performance.3 Pain, disability, and functional

performance all showed significant improvement after three weeks in both groups.3 However,
these improvements may be due to the fact that both groups received superficial heat and

exercise, which can produce therapeutic effects independently. When comparing therapeutic US

to sham US, a significantly greater improvement was observed in the therapeutic US group.3

This study provides strong evidence for the use of therapeutic US in terms of decreasing pain, as

well as improving certain disability measures and functional performance.

To support the use of therapeutic US as a treatment for CLBP, Cisowska-Adamiak,

Mackiewicz-Milewska, Szymkuc-Bukowska, et al., compared the effects of different therapeutic

US intensities on CLBP in adults.4 This study consisted of 62 participants (48 female, 14 male)

with CLBP randomly assigned to two groups receiving different US treatment intensities.4 Over

two weeks, ten treatments were administered over the lumbar region at a frequency of 1MHz

with a continuous duty cycle and an intensity of 1.0 W/cm2 (Group A) or 0.5 W/cm2 (Group B).4

The Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RM), and a VAS

were used to evaluate the results of this study.4 For each intensity group, ODI scores improved

significantly, with 1.0 W/cm2 (Group A) showing slightly more benefit than 0.5 W/cm2 (Group

B).4 RM disability scores significantly improved in both groups, but Group B had a more

favorable outcome.4 Average VAS pain scores significantly decreased in both groups, with

Group A demonstrating a slightly better outcome in terms of pain reduction.4 Overall, this study

showed that Group A experienced greater benefit in terms of pain scores and similar benefit in

terms of disability measures. This provides moderate support for the use of therapeutic US at an

intensity of 1.0 W/cm2 (with all other parameters set as described above) in CLBP patients.

A study conducted by Ebadi, Ansari, Naghdi, et al., evaluated the effect of continuous

therapeutic US along with an exercise program compared to placebo US with exercise for

patients with non-specific CLBP.2 For this study, 50 subjects, most of whom were female, were
divided randomly between two groups.2 An intervention group was treated with continuous

therapeutic US and a control group received placebo US.2 Both groups were given the same

semi-supervised (partially home-based) exercise program to perform daily in conjunction with

their respective treatment programs.2 Stretching and walking for at least 15 minutes was done

prior to exercise.2 Therapeutic US treatment was provided 3 times per week, every other day, for

10 sessions.2 The parameters of US for the intervention group were as follows: continuous duty

cycle, frequency of 1 MHz, intensity of 1.5 W/cm2 , and a transducer head size of 5 cm2.2

Treatment was provided over the paravertebral low back region for 8 minutes over a surface area

of 40 cm2 (1 minute per 5 cm2 area).2 The placebo US group received sham treatment, where the

intensity was set to 0.0 W/Cm2, in an identical manner to the intervention group, with the dials of

the machine out of the subjects’ sight.2 Outcome measures were based on pain, functional status,

lumbar ROM, and endurance of paravertebral and hip muscles.2 After the final treatment session,

patients were asked to continue the exercise program for one month, after which follow-up

measures were taken.2

Results of this study indicate that both the intervention US and placebo US group had

significant improvements regarding pain after receiving 10 treatments.2 The reduction in pain

was still present in both groups at the one month follow-up, indicating true improvement of the

condition.2 This outcome suggests that the exercise program, and perhaps the motion of the

ultrasound transducer on the surface of the body, had a significant influence on the reduction of

pain because those were the only common treatment factors between the groups.2 However, the

results also showed the intervention US group benefited significantly more, with respect to pain,

functional status scores, lumbar ROM, and lumbar muscle endurance, compared to the placebo

US group.2 Overall, the study shows that exercise, stretching, and walking (and perhaps to a
small extent: light localized massage) are all beneficial in the treatment of non-specific CLBP

and also supports therapeutic US as a means of providing improvement in pain, functional status,

ROM, and endurance outcomes.

While many studies report therapeutic US as an effective modality for treating CLBP,

research does not always consider it the most effective treatment or prefer it over other

modalities. In a study conducted by Mohseni-Bandpei, Critchley, Staunton, et al., they compared

the effectiveness of therapeutic US to spinal manipulation.5 This study consisted of 120 subjects

with CLBP assigned to an US group or spinal manipulation group.5 The US group received an

average of six sessions of therapeutic US over the lumbar region with a frequency of 1MHz, a

continuous duty cycle, and depending on the size of the treatment area, an intensity between

1.5 W/cm2 and 2.5 W/cm2 for a duration of 5 – 10 minutes.5 The spinal manipulation group

received an average of four sessions of manipulations applied to the lumbar spine and sacro-iliac

joint.5 Outcome measures were recorded using a VAS, the Oswestry Questionnaire (for

functional performance), and surface electromyography (sEMG) to help quantify muscular

endurance.5 Results were gathered at the conclusion of the study and again at a six month follow-

up visit.5 Even though therapeutic US decreased pain, spinal manipulation showed to be more

effective in pain and disability measures for both short- and long-term outcomes.5 This result

supports the common clinical practice of using therapeutic US as a supplemental treatment

alongside other techniques.

A study conducted by Yurdakul, Beydoğan, and Yalçınkaya examined potential

differences in the early effects of therapy using superficial heat combined with TENS versus

therapy using superficial heat combined with TENS and therapeutic US for subjects with non-

specific CLBP.6 Subjects were separated into three groups. One group was a control group,
which did not receive any therapy for 3 weeks.6 The second group was treated 5 days a week

with superficial heat via a hot pack for 20 minutes and conventional TENS set at 100 Hz for 30

minutes to the lumbar region, for 15 total sessions.6 The third group was treated in the same

manner as the second group, but with the addition of therapeutic US.6 US treatment was given

for 5 minutes over the right and left lumbar paravertebral muscles (10 minutes total) and set to a

frequency of 1 MHz, with an intensity of 2.0 W/cm2 during each session.6 All patients were

evaluated based on a Numeric Rating Scale (NRS) for pain, Oswestry Disability Index (ODI),

and Short Form-36 (SF-36) questionnaire at baseline and at the end of the study, 3 weeks later.6

Outcomes of this study showed that patients in both of the treatment groups experienced

significant early improvement over the control group in terms of pain, physical function, and

general health perceptions.6 However, there was no significant difference in the outcomes

between the two treatment groups, as they provided similar benefits for each of their respective

subjects.6 Essentially, both treatments were shown to be more effective than the control, but the

addition of US did not prove to be more beneficial compared to using a hot pack combined with

TENS. This suggests that the beneficial outcomes of TENS therapy are potentially equal to or

even greater than those of therapeutic US in treating CLBP, although this suggestion is hindered

somewhat by the fact that this study did not contain a “superficial heat and US without TENS”

group, limiting the ability to compare the two modalities directly. Therefore, based on this study,

we would say that one could use either TENS therapy or therapeutic US when treating CLBP,

based on clinical availability and/or patient preference.

To further research the benefits of therapeutic US as a treatment for CLBP, Durmus,

Alayli, Goktepe, et al. evaluated the effectiveness of therapeutic US and exercise, as well as

phonophoresis (PP) with capsaicin gel and exercise relating to pain, disability, trunk muscle
strength, walking performance, spinal mobility, quality of life (QOL), and depression in subjects

with CLBP.7 This study consisted of 60 female subjects with definite CLBP who were randomly

assigned to one of three groups; a control group, which only received exercise, an US in addition

to exercise group, or a PP with capsaicin gel in addition to exercise group.7 Each group had a

total of 20 subjects; all groups completed sixty minutes of exercise, and each group participated

in their treatment program 3 days a week for a total of 6 weeks. 7 The parameters used for the US

and exercise group included a continuous duty cycle, a frequency of 1 MHz, and an intensity of

1.5 W/cm2.7 A transducer head, with an area of 5 cm2 was applied over the paravertebral low

back region for a duration of 10 minutes. 7 The PP and exercise group followed the same

parameters as the US and exercise group, along with a capsaicin-containing gel (10% capsicum

oleoresin in 0.22% solution).7 Subjects’ pain, disability, walking performance, abdominal muscle

and extensor muscle endurance, isometric trunk flexor and extensor muscle strength (EMS),

QOL, and depression were assessed at baseline and at the conclusion of the study.7 Pain was

assessed using the visual analog scale (VAS) and in order to assess pain and disability, the

researchers used the Oswestry Disability Questionnaire (ODQ) and Pain Disability Index (PDI). 7

The results of this study show that each group demonstrated statistically significant

improvements in pain, disability, muscle strength, endurance, walking performance, mobility,

certain sub-scores of SF – 36, and depression when comparing their initial measurements to their

outcomes at six weeks.7 When comparing SF – 36 scores regarding pain, physical function, and

energy, results show a significant improvement in PP and exercise compared to both exercise

only, as well as therapeutic US and exercise.7 There was a significant improvement in VAS pain,

walking performance, and EMS in the US and exercise group, as well as the PP and exercise

group when compared to the control group.7 However, there was no significant difference in
VAS pain, walking performance, and EMS when comparing US and exercise to PP and

exercise,7 indicating both of these treatments were equally effective. Therefore, with no

significant difference determining the efficacy of US and exercise or PP and exercise in VAS

pain, walking performance, and EMS, we cannot fully conclude whether one treatment is better

than the other. However, we can say that both therapeutic US in addition to exercise and PP in

addition to exercise can improve pain, walking performance, and extensor muscle strength.

In a study completed by Tantawy, Abdelbasset, Kamel et al., they compared the effects of

an exercise program combined with either laser photobiomodulation therapy (lPBMt) or

therapeutic US in participants with non-specific CLBP.8 Participants (32 males, 13 females) were

30-40 years old and placed into three groups.8 Outcomes were measured on the basis of pain,

disability, functional performance, and lumbar ROM; utilizing the VAS, Modified Oswestry

Low Back Pain Disability Questionnaire (m-OSW), PDI, 6MWT, and lumbar ROM test

(modified Schober test).8 Participants were assessed at baseline and after 8 weeks of therapy. 8 An

exercise program was performed three days per week at an intensity of 60-80% of 1-repetition

maximum to build strength.8 Static stretching was performed for 10 minutes prior to

strengthening exercises.8 Laser therapy was performed two times per week with the following

parameters: wavelength of 808 nm, power density of 113.6 mW/cm2, continuous wave, and spot

size of 0.22 cm2, energy density of 17.05 J/cm2 for 20 minutes over the lumbar paravertebral

region (L2-S3).8 Therapeutic US was performed two times per week using the following

parameters: continuous duty cycle, a frequency of 1 MHz, and an intensity of 1 W/cm 2, for 10

minutes, using a sound head with an ERA of 5 cm2 over the paravertebral lumbar region. 8 A

control group performed exercise alone, without any additional modalities. 8

 Results indicated significant improvement in both treatment groups over the control

group. The control group showed no significant improvement in any measures. Laser therapy

showed an additional benefit over therapeutic US, with significant improvements in terms of

pain, disability, functional performance and lumbar ROM. Therapeutic US only showed

significant improvement in pain and disability scores. Both treatments showed improvement over

the control; however, laser therapy showed greater improvement than therapeutic US. These

results suggest that laser therapy may be more beneficial than therapeutic US when using the

parameters outlined in this study.

Based on the evidence provided above, we conclude that while therapeutic US is a useful

deep-heating modality for the treatment of chronic low back pain, there are other treatment

options, such as manual manipulation, laser therapy, TENS, phonophoresis, therapeutic exercise,

and superficial heat, that can be equally or more beneficial. Our review of the literature shows

that US is a valid treatment for CLBP by improving pain, as well as several other clinically

significant, patient-centered outcomes. We acknowledge that some research suggests other

modalities can be as effective as ultrasound in providing improved outcomes. Therefore, we

support using therapeutic ultrasound in the treatment of chronic low back pain, but we cannot

definitively support its use over the other modalities listed above. A wise clinician should always

consider a variety of treatment options based on what is best for the patient and we support the

consideration of therapeutic ultrasound for these purposes.

 References

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