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Meta-Analysis
. 2020 Jul 5;7(7):CD009169.
doi: 10.1002/14651858.CD009169.pub3.

Therapeutic ultrasound for chronic low back pain

Safoora Ebadi  1   2 , Nicholas Henschke  3 , Bijan Forogh  1   2 , Noureddin Nakhostin Ansari  4 , Maurits W van Tulder  5 , Arash Babaei-Ghazani  1   2 , Ehsan Fallah  6
Affiliations
Meta-Analysis

Therapeutic ultrasound for chronic low back pain

Safoora Ebadi et al. Cochrane Database Syst Rev. .

Abstract

Background: This is an update of a Cochrane Review published in 2014. Chronic non-specific low back pain (LBP) has become one of the main causes of disability in the adult population around the world. Although therapeutic ultrasound is not recommended in recent clinical guidelines, it is frequently used by physiotherapists in the treatment of chronic LBP.

Objectives: The objective of this review was to determine the effectiveness of therapeutic ultrasound in the management of chronic non-specific LBP. A secondary objective was to determine the most effective dosage and intensity of therapeutic ultrasound for chronic LBP.

Search methods: We performed electronic searches in CENTRAL, MEDLINE, Embase, CINAHL, PEDro, Index to Chiropractic Literature, and two trials registers to 7 January 2020. We checked the reference lists of eligible studies and relevant systematic reviews and performed forward citation searching.

Selection criteria: We included randomised controlled trials (RCTs) on therapeutic ultrasound for chronic non-specific LBP. We compared ultrasound (either alone or in combination with another treatment) with placebo or other interventions for chronic LBP.

Data collection and analysis: Two review authors independently assessed the risk of bias of each trial and extracted the data. We performed a meta-analysis when sufficient clinical and statistical homogeneity existed. We determined the certainty of the evidence for each comparison using the GRADE approach.

Main results: We included 10 RCTs involving a total of 1025 participants with chronic LBP. The included studies were carried out in secondary care settings in Turkey, Iran, Saudi Arabia, Croatia, the UK, and the USA, and most applied therapeutic ultrasound in addition to another treatment, for six to 18 treatment sessions. The risk of bias was unclear in most studies. Eight studies (80%) had unclear or high risk of selection bias; no studies blinded care providers to the intervention; and only five studies (50%) blinded participants. There was a risk of selective reporting in eight studies (80%), and no studies adequately assessed compliance with the intervention. There was very low-certainty evidence (downgraded for imprecision, inconsistency, and limitations in design) of little to no difference between therapeutic ultrasound and placebo for short-term pain improvement (mean difference (MD) -7.12, 95% confidence interval (CI) -17.99 to 3.75; n = 121, 3 RCTs; 0-to-100-point visual analogue scale (VAS)). There was also moderate-certainty evidence (downgraded for imprecision) of little to no difference in the number of participants achieving a 30% reduction in pain in the short term (risk ratio 1.08, 95% CI 0.81 to 1.44; n = 225, 1 RCT). There was low-certainty evidence (downgraded for imprecision and limitations in design) that therapeutic ultrasound has a small effect on back-specific function compared with placebo in the short term (standardised mean difference -0.29, 95% CI -0.51 to -0.07 (MD -1.07, 95% CI -1.89 to -0.26; Roland Morris Disability Questionnaire); n = 325; 4 RCTs), but this effect does not appear to be clinically important. There was moderate-certainty evidence (downgraded for imprecision) of little to no difference between therapeutic ultrasound and placebo on well-being (MD -2.71, 95% CI -9.85 to 4.44; n = 267, 2 RCTs; general health subscale of the 36-item Short Form Health Survey (SF-36)). Two studies (n = 486) reported on overall improvement and satisfaction between groups, and both reported little to no difference between groups (low-certainty evidence, downgraded for serious imprecision). One study (n = 225) reported on adverse events and did not identify any adverse events related to the intervention (low-certainty evidence, downgraded for serious imprecision). No study reported on disability for this comparison. We do not know whether therapeutic ultrasound in addition to exercise results in better outcomes than exercise alone because the certainty of the evidence for all outcomes was very low (downgraded for imprecision and serious limitations in design). The estimate effect for pain was in favour of the ultrasound plus exercise group (MD -21.1, 95% CI -27.6 to -14.5; n = 70, 2 RCTs; 0-to-100-point VAS) at short term. Regarding back-specific function (MD - 0.41, 95% CI -3.14 to 2.32; n = 79, 2 RCTs; Oswestry Disability Questionnaire) and well-being (MD -2.50, 95% CI -9.53 to 4.53; n = 79, 2 RCTs; general health subscale of the SF-36), there was little to no difference between groups at short term. No studies reported on the number of participants achieving a 30% reduction in pain, patient satisfaction, disability, or adverse events for this comparison.

Authors' conclusions: The evidence from this systematic review is uncertain regarding the effect of therapeutic ultrasound on pain in individuals with chronic non-specific LBP. Whilst there is some evidence that therapeutic ultrasound may have a small effect on improving low back function in the short term compared to placebo, the certainty of evidence is very low. The true effect is likely to be substantially different. There are few high-quality randomised trials, and the available trials were very small. The current evidence does not support the use of therapeutic ultrasound in the management of chronic LBP.

Trial registration: ClinicalTrials.gov NCT03835182.

PubMed Disclaimer

Conflict of interest statement

SE: no conflicts of interest to declare

NH: declares no conflicts of interest. NH works for Cochrane Response, an evidence consultancy initiative from Cochrane, but did not receive any payment for his contribution to this review.

BF: no conflicts of interest to declare

NNA: no conflicts of interest to declare

MvT: At the time of conducting this systematic review, MvT was a Co‐ordinating Editor of the Cochrane Back and Neck Review Group. He is currently on the Editorial Board and therefore was not part of the peer review or publication decision‐making process. Editorial Board members are required to author reviews to remain current in methods. MvT has also received grants and money to his institution from the Netherlands Organisation for Health Research and Development and The Dutch Health Insurance Council. He has also received travel, accommodation, or meeting expenses unrelated to the activities listed from EFIC (European Pain Federation) and the Danish Occupational Therapy Association. He declares no competing interest; all research funding comes from nonprofit, governmental funding agencies, and all funding including travel and stay expenses were paid to the Vrije Universiteit.

ABG: no conflicts of interest to declare

EF: no conflicts of interest to declare

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 Ultrasound versus placebo ultrasound, outcome: 1.1 Pain (VAS) short term [mm].
5
5
Forest plot of comparison: 1 Ultrasound versus placebo ultrasound, outcome: 1.3 Back‐specific functional status (various scales) short term.
6
6
Forest plot of comparison: 2 Ultrasound plus exercise versus exercise alone, outcome: 2.1 Pain (VAS) short term.
1.1
1.1. Analysis
Comparison 1: Ultrasound versus placebo ultrasound, Outcome 1: Pain (VAS) short‐term
1.2
1.2. Analysis
Comparison 1: Ultrasound versus placebo ultrasound, Outcome 2: Pain (VAS responder analysis 30% reduction) short‐term
1.3
1.3. Analysis
Comparison 1: Ultrasound versus placebo ultrasound, Outcome 3: Back‐specific functional status (various scales) short‐term
1.4
1.4. Analysis
Comparison 1: Ultrasound versus placebo ultrasound, Outcome 4: Well‐being (general health subscale of SF‐36) short‐term
1.5
1.5. Analysis
Comparison 1: Ultrasound versus placebo ultrasound, Outcome 5: Flexion ROM (various scales) short‐term
1.6
1.6. Analysis
Comparison 1: Ultrasound versus placebo ultrasound, Outcome 6: Extension ROM (various scales) short‐term
1.7
1.7. Analysis
Comparison 1: Ultrasound versus placebo ultrasound, Outcome 7: Trunk extensor muscle endurance (Biering‐Sorensen test) short‐term
2.1
2.1. Analysis
Comparison 2: Ultrasound plus exercise versus exercise alone, Outcome 1: Pain (VAS) short‐term
2.2
2.2. Analysis
Comparison 2: Ultrasound plus exercise versus exercise alone, Outcome 2: Back‐specific functional status (Oswestry) short‐term
2.3
2.3. Analysis
Comparison 2: Ultrasound plus exercise versus exercise alone, Outcome 3: Well‐being (general health subscale of SF‐36) short‐term
2.4
2.4. Analysis
Comparison 2: Ultrasound plus exercise versus exercise alone, Outcome 4: Flexion ROM (Schober test) short‐term
2.5
2.5. Analysis
Comparison 2: Ultrasound plus exercise versus exercise alone, Outcome 5: Trunk flexor strength short‐term
2.6
2.6. Analysis
Comparison 2: Ultrasound plus exercise versus exercise alone, Outcome 6: Trunk flexor endurance short‐term
2.7
2.7. Analysis
Comparison 2: Ultrasound plus exercise versus exercise alone, Outcome 7: Trunk extensor endurance short‐term
3.1
3.1. Analysis
Comparison 3: Ultrasound versus electrical stimulation, Outcome 1: Pain (SF‐36) short‐term
3.2
3.2. Analysis
Comparison 3: Ultrasound versus electrical stimulation, Outcome 2: Back‐specific functional status (Oswestry) short‐term
3.3
3.3. Analysis
Comparison 3: Ultrasound versus electrical stimulation, Outcome 3: Flexion ROM (Schober test) short‐term
4.1
4.1. Analysis
Comparison 4: Ultrasound versus laser, Outcome 1: Pain (VAS) short‐term
4.2
4.2. Analysis
Comparison 4: Ultrasound versus laser, Outcome 2: Flexion ROM (Schober test) short‐term
5.1
5.1. Analysis
Comparison 5: Ultrasound versus phonophoresis, Outcome 1: Pain (VAS) short‐term
5.2
5.2. Analysis
Comparison 5: Ultrasound versus phonophoresis, Outcome 2: Back‐specific functional status (Oswestry) short‐term
5.3
5.3. Analysis
Comparison 5: Ultrasound versus phonophoresis, Outcome 3: Well‐being (general health subscale of SF‐36) short‐term
5.4
5.4. Analysis
Comparison 5: Ultrasound versus phonophoresis, Outcome 4: Flexion ROM (Schober test) short‐term
5.5
5.5. Analysis
Comparison 5: Ultrasound versus phonophoresis, Outcome 5: Trunk flexor strength short‐term
5.6
5.6. Analysis
Comparison 5: Ultrasound versus phonophoresis, Outcome 6: Trunk flexor endurance short‐term
5.7
5.7. Analysis
Comparison 5: Ultrasound versus phonophoresis, Outcome 7: Trunk extensor endurance short‐term
6.1
6.1. Analysis
Comparison 6: Ultrasound versus spinal manipulative therapy, Outcome 1: Pain (VAS) short‐term
6.2
6.2. Analysis
Comparison 6: Ultrasound versus spinal manipulative therapy, Outcome 2: Back‐specific functional status (Oswestry) short‐term
6.3
6.3. Analysis
Comparison 6: Ultrasound versus spinal manipulative therapy, Outcome 3: Flexion ROM short‐term
6.4
6.4. Analysis
Comparison 6: Ultrasound versus spinal manipulative therapy, Outcome 4: Extension ROM short‐term
6.5
6.5. Analysis
Comparison 6: Ultrasound versus spinal manipulative therapy, Outcome 5: Pain (VAS) at 6 months follow‐up
6.6
6.6. Analysis
Comparison 6: Ultrasound versus spinal manipulative therapy, Outcome 6: Back‐specific functional status (Oswestry) at 6 months follow‐up
7.1
7.1. Analysis
Comparison 7: Ultrasound versus osteopathic manual treatment, Outcome 1: Low back pain reduction (threshold >= 30%)
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References to studies awaiting assessment

Ojoawo 2019 {published data only}
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Rubira 2019 {published data only}
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NCT03835182 {published data only}
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