Review ArticleThe efficacy, safety, effectiveness, and cost-effectiveness of ultrasound and shock wave therapies for low back pain: a systematic review
Introduction
Nonspecific or common low back pain (LBP) is defined as pain between the costal margins and the inferior gluteal folds, which may be associated with pain referred down to the leg (“leg pain”), and is usually accompanied by painful limitation of movement [1]. Diagnosing common LBP implies that the pain is not related to conditions such as fractures, spondylitis, direct trauma, or neoplastic, infectious, vascular, metabolic, or endocrine-related processes [1].
Two forms of mechanical vibration are used for treating LBP. Ultrasound is the term used when the frequency of vibration is above 20,000 Hz and generates heat. Ultrasound penetrates the tissue in a focused directional manner, transmitting heat deep into the tissue. It is believed that ultrasound can increase local metabolism and blood circulation, enhance the flexibility of connective tissue, and accelerate tissue regeneration, potentially reducing pain and stiffness, while improving mobility [2], [3]. Shock wave is a form of treatment that applies vibration at a low frequency (10, 50, 100, or 250 Hz), causing an oscillatory pressure. Several devices have been designed to provide “shock waves,” such as “FairMed,” “muscle relaxation machines,” and vibratory platforms. Shock wave is commonly referred to as “vibrotherapy,” but it will be referred to as shock wave hereafter because both shock wave and ultrasound use vibration with a therapeutic goal and, therefore, strictly speaking, both could be referred to as “vibrotherapy.”
The most recent evidence-based guidelines for the treatment of LBP do not recommend shock wave or ultrasound [4], [5], [6]. Nevertheless, ultrasound is commonly used in routine clinical practice for musculoskeletal problems, including LBP [7], [8], [9]. Approximately 50% of UK physiotherapists, 65% of US physiotherapists, and 94% of Canadian physiotherapists use it [10]. In the United States, 55% of primary care practitioners recommend ultrasound as a form of treatment [11]. Moreover, the most recent Cochrane review on ultrasound suggests that it might be useful for treating knee osteoarthritis, although firm conclusions could not be drawn because of the low quality of the trials included [12].
No systematic reviews on shock wave have been published, and the last one on ultrasound for LBP did not find any randomized clinical trials. However, it dates back to 2001 [13], and new evidence may have been published since then.
Therefore, the objective of this study was to systematically review the evidence on the efficacy, safety, effectiveness, and cost-effectiveness of “ultrasound/shock wave” versus placebo or other treatments, for treating pain and disability in LBP patients with or without radiculopathy.
Section snippets
Materials and methods
The protocol of this study was approved by and registered in the Spanish Ministry of Health's (“Fondo de Investigación Sanitaria” FIS 03/0908) and the Spanish Back Pain Research Network's databases.
Results
The electronic search provided 1,419 references, which led to the identification of 13 studies potentially eligible for inclusion in this review [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27]. Twelve focused on ultrasound [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], and one on a shock wave device [15]. Nine studies were excluded: two because they turned out to not be randomized studies [20], [21], one because it used sham ultrasound (a
Discussion
Results from this review do not support the use of ultrasound or shock wave for treating patients with LBP and leg pain. Only one study included such patients in which leg pain was attributed to disc herniation and ultrasound was compared with low-power laser and traction [17]. Neither traction nor low-power laser has shown to be effective for LBP, with or without sciatica [28], [29]. Therefore, results suggesting that ultrasound is equivalent to these procedures for patients with lumbar disc
Acknowledgments
The authors are grateful to Dr Mohammad A. Mohseni-Bandpei [16] for having provided the correct data corresponding to a table that was misprinted in the publication and to him, Ms Barker [15], Dr Jeremy Fairbank [15], and Dr Noureddin Nakhostin Ansari [18] for having provided additional data on their studies.
This study was jointly funded by the Spanish Health Ministry’s Instituto de Salud Carlos III (FIS 03/0908), and the Kovacs Foundation, an independent not for profit institution specializing
References (53)
Therapeutic ultrasound: its effects on the cellular and molecular mechanisms of inflammation and repair
Physiotherapy
(1992)- et al.
Electrophysical agents: implications of EPA availability and use in undergraduate clinical placements
Physiotherapy
(1998) - et al.
A prospective randomized controlled trial of spinal manipulation and ultrasound in the treatment of chronic low back pain
Physiotherapy
(2006) - et al.
Comparison of 3 physical therapy modalities for acute pain in lumbar disc herniation measured by clinical evaluation and magnetic resonance imaging
J Manipulative Physiol Ther
(2008) - et al.
The effectiveness of physical modalities among patients with low back pain randomized to chiropractic care: findings from the UCLA low back pain study
J Manipulative Physiol Ther
(2002) - et al.
Ultrasound therapy for musculoskeletal disorders
Pain
(1999) - et al.
Does spinal manipulative therapy help people with chronic low back pain?
Aust J Physiother
(2002) - et al.
A checklist to evaluate a report of a nonpharmacological trial (CLEAR NPT) was developed using consensus
J Clin Epidemiol
(2005) - et al.
The measurement of clinical pain intensity: a comparison of six methods
Pain
(1986) - et al.
The development of a battery of measures for assessing physical functioning of chronic pain patients
Pain
(1994)
The pain self-efficacy questionnaire: taking pain into account
Eur J Pain
The back pain revolution
Ultrasound
European guidelines for the management of chronic nonspecific low back pain
Eur Spine J
Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline
Ann Intern Med
European guidelines for the management of acute nonspecific low back pain in primary care
Eur Spine J
Ultrasound: to heat or not to heat—that is the question
Phys Ther Rev
The use of therapeutic ultrasound by physical therapists in Dutch primary health care
Phys Ther
Electrotherapy usage trends in private physiotherapy practice in Alberta
Physiother Can
A survey of primary care physician practice patterns and adherence to acute low back problem guidelines
Arch Fam Med
Therapeutic ultrasound for osteoarthritis of the knee or hip
Cochrane Database Syst Rev
Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain [with systematic review]
Phys Ther
2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group
Spine
Treatment of chronic back pain by sensory discrimination training. A Phase I RCT of a novel device (FairMed) vs. TENS
BMC Musculoskelet Disord
A randomized, single blind placebo controlled clinical trial on the effect of continuous ultrasound on low back pain
Electromyogr Clin Neurophysiol
A randomized, placebo-controlled trial of exercise therapy in patients with acute low back pain
Spine
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FDA device/drug status: Not applicable.
Author disclosures: JS: Nothing to disclose. FMK: Nothing to disclose. GU: Nothing to disclose.
Gerard Urrutia is a PhD candidate at the Public Health and Research Methodology Programme, Universitat Autonoma de Barcelona (UAB).