Elsevier

The Spine Journal

Volume 11, Issue 10, October 2011, Pages 966-977
The Spine Journal

Review Article
The efficacy, safety, effectiveness, and cost-effectiveness of ultrasound and shock wave therapies for low back pain: a systematic review

https://doi.org/10.1016/j.spinee.2011.02.002Get rights and content

Abstract

Background context

Shock wave and especially ultrasound are commonly used to treat low back pain (LBP) in routine practice.

Purpose

To assess the evidence on the efficacy, effectiveness, cost-effectiveness, and safety of ultrasound and shock wave to treat LBP.

Study design

Systematic review.

Methods

An electronic search was performed in MEDLINE, EMBASE, and the Cochrane Library databases up to July 2009 to identify randomized controlled trials (RCTs) comparing vibrotherapy with placebo or with other treatments for LBP. No language restrictions were applied. Additional data were requested from the authors of the original studies. The risk of bias of each study was assessed following the criteria recommended by the Cochrane Back Review Group.

Results

Thirteen studies were identified. The four RCTs complying with the inclusion criteria included 252 patients. Two of the three RCTs on ultrasound had a high risk of bias. For acute patients with LBP and leg pain attributed to disc herniation, ultrasound, traction, and low-power laser obtained similar results. For chronic LBP patients without leg pain, ultrasound was less effective than spinal manipulation, whereas a shock wave device and transcutaneous electrical nerve stimulation led to similar results. Results from the only study comparing ultrasound versus a sham procedure are unreliable because of the inappropriateness of the sham procedure, low sample size, and lack of adjustment for potential confounders. No study assessed cost-effectiveness. No adverse events were reported.

Conclusion

The available evidence does not support the effectiveness of ultrasound or shock wave for treating LBP. High-quality RCTs are needed to assess their efficacy versus appropriate sham procedures, and their effectiveness and cost-effectiveness versus other procedures shown to be effective for LBP. In the absence of such evidence, the clinical use of these forms of treatment is not justified and should be discouraged.

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

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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).

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