Pain Medicine, 21(7), 2020, 1482–1493

doi: 10.1093/pm/pny287
Advance Access Publication Date: 12 January 2019
Review Article

REHABILITATION & REGENERATIVE MEDICINE SECTION

Therapeutic Ultrasound for Pain Management in Chronic Low Back

Pain and Chronic Neck Pain: A Systematic Review

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Selaiman A. Noori, MD,* Abdullah Rasheed, MD,† Rohit Aiyer, MD,† Boyoun Jung, MD,† Nitin Bansal,
MD,† Ke-Vin Chang, MD,‡ Einar Ottestad, MD,§ and Amitabh Gulati, MD¶
*Department of Pain Management, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA; †Department of Anesthesiology, NewYork-
Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA; ‡Department of Physical Medicine and Rehabilitation, National Taiwan
University Hospital, Bei-Hu Branch, Taipei City, Taiwan; §Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of
Medicine, Palo Alto, California, USA; ¶Department of Anesthesia and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA

Correspondence to: Selaiman A. Noori, MD, Department of Pain Management, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue,
C-25, Cleveland, OH 44195, USA. Tel: 216–445–9421; Fax: 216-444-9890; E-mail: selaiman.noori@gmail.com
Funding sources: The authors report no funding sources.

Conflicts of interest: The authors report no conflicts of interest.

Abstract
Background. Low back pain (LBP) and neck pain are major causes of pain and disability that are experienced across
all ages. The primary goals of treatment are to improve patient function and facilitate a return to the patient’s desired
level of daily activity. Therapeutic ultrasound is a noninvasive modality widely utilized in the management of muscu-
loskeletal disorders, but there continues to be controversy regarding its use due to insufficient evidence of effective-
ness. The objective of this systematic review was to evaluate the effectiveness of therapeutic ultrasound in the man-
agement of patients with chronic LBP and neck pain. Methods. Using PRISMA guidelines, a search of the PubMed
and CENTRAL (The Cochrane Library) databases was performed to retrieve randomized controlled trials (RCTs) that
evaluated therapeutic ultrasound in patients with chronic LBP or neck pain. Results. The search strategy identified
10 trials that met the criteria for inclusion. Three studies in LBP reported that both therapeutic and sham (placebo) ul-
trasound provided significant improvement in pain intensity. In each of these studies, ultrasound was found to be
more effective than placebo when using only one of several validated instruments to measure pain. Three of the
four studies on neck pain demonstrated significant pain relief with ultrasound in combination with other treatment
modalities. However, only one of these studies demonstrated that the use of ultrasound was the cause of the statisti-
cally significant improvement in pain intensity. Conclusions. Therapeutic ultrasound is frequently used in the treat-
ment of LBP and neck pain and is often combined with other physiotherapeutic modalities. However, given the pau-
city of trials and conflicting results, we cannot recommend the use of monotherapeutic ultrasound for chronic LBP
or neck pain. It does seem that ultrasound may be considered as part of a physical modality treatment plan that may
be potentially helpful for short-term pain relief; however, it is undetermined which modality may be superior. In
both pain syndromes, further trials are needed to define the true effect of low-intensity ultrasound therapy for axial
back pain. No conclusive recommendations may be made for optimal settings or session duration.

Key Words: Therapeutic Ultrasound; Low Back Pain; Neck Pain; Axial Pain.

Introduction globally, with a worldwide prevalence of 540 million and

Low back pain and neck pain are major causes of pain 358 million, respectively [2]. These spinal conditions
and disability that are experienced across all ages [1]. In have a major impact on individuals and their families,
2015, low back pain (LBP) and neck pain were the fourth businesses, communities, and health care systems [3]. As
leading cause of disability-adjusted life-years (DALYs) leading causes of work absenteeism and lost productivity,

C 2019 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
V 1482
Therapeutic Ultrasound for Axial Spine Pain
LBP and neck pain are both an enormous socioeconomic
problem and a major public health burden [3,4].
The primary goals of treatment for LBP and neck
pain are to improve patient function and facilitate a return
to the patient’s desired level of daily activity. Although
different treatment modalities are used, many practice
guidelines recommend a biopsychosocial approach with
greater focus on self-management and psychological and
physiotherapy, and less emphasis on medication use and
surgical intervention [5,6]. Therapeutic ultrasound is a
noninvasive modality commonly used in the management
of musculoskeletal disorders. It is utilized by 65% and 94%
of physical therapists in the United States and Canada,
respectively [7].
It has been proposed that therapeutic ultrasound has
thermal and mechanical effects on deep tissue sites
through the delivery of ultrasonic energy [7]. When ex-
posed to the acoustic wave, soft tissue molecules vibrate
and generate frictional heat, referred to as the “thermal
effects” of ultrasound.
The objective of this systematic review was to evaluate the
effectiveness of therapeutic ultrasound in the management of
patients with chronic nonspecific LBP and neck pain.
Methods
This systematic review sought to evaluate whether con-
tinuous ultrasound provided significantly better pain
scores than standard therapy or no therapy in adult
patients with chronic nonspecific LBP or neck pain. The
Preferred Reporting in Systematic and Meta-Analyses
(PRISMA) guidelines (http://www.prisma-statement.org/)
were followed to conduct this systematic review. A search
of the PubMed (1966–2018), CENTRAL (The Cochrane
Library, 1970–2018), Scopus (1960–2018), and Web of
Sciences (1965–2018) databases was performed to retrieve
studies, and the search terms utilized are shown in
Appendix Table A1.
Only randomized controlled trials (RCTs) were con-
sidered for inclusion, and studies were required to be
published in English and as full reports. Other exclusion
criteria included studies assessing ultrasound as one part
of a treatment package (e.g., electrical stimula-
tion þ ultrasound compared with exercise þ hot packs)
and studies with patients in whom a specific cause of
LBP or neck pain had been determined (e.g., spinal steno-
sis, disc herniation). As our study aim was to determine
the effectiveness of ultrasound in the management of
chronic pain, we focused on extracting outcome data
reported by validated pain scales (e.g., the visual analog
scale) and instruments in which there is a scale item mea-
suring pain (e.g., the Functional Rating Index). Two
reviewers (SAN, AR) performed eligibility assessment in-
dependently in a standardized manner, and a third re-
viewer (RA) resolved any disagreements.
1483
The Pain Conditions
LBP is defined as pain in the lumbosacral region, typi-
cally between the lower margin of the 12th ribs and the
inferior gluteal folds, which may or may not have re-
ferred pain to the lower limb(s) [1]. Neck pain is typically
described as pain located in the anatomical posterior re-
gion of the neck from the superior nuchal line to the first
thoracic spinous process, which may or may not radiate
to the upper limb(s) [2]. When LBP or neck pain persists
for more than 12 weeks, it is considered chronic [1,8].
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The Intervention
Therapeutic ultrasound is a one-way energy delivery that
utilizes a crystal sound head to transmit acoustic waves
at 1 or 3 MHz and at amplitude densities between 0.1
and 3 W/cm2 [9]. In continuous delivery mode, there is
nonstop delivery of ultrasonic waves throughout the
treatment period [9]. Continuous ultrasound is used for
its thermal effects, produced by attenuation of the sound
wave as it passes through tissue [9].
Outcome Measures
Visual Analog Scale
The visual analog scale (VAS) is a valid and reliable out-
come measure used to assess global pain intensity. It is a
100-mm scale in which higher scores indicate more inten-
sive pain [10].
Numeric Pain Rating Scale
The numeric pain rating scale (NPRS) is valid and reli-
able unidimensional measure used to assess pain intensity
in adults. The assessment consists of an 11-point numeric
scale ranging from 0 to 10, with 0 representing “no pain”
and 10 representing the “worst pain imaginable” [11].
Oswestry Disability Index
The Oswestry Disability Index (ODI) is a valid measure
of functional disability related to LBP. It consists of 10
sections evaluated with 0–5 scores (0 ¼ no difficulty,
5 ¼ total disability in this function), for a maximum score
of 50, which corresponds to worst disability. The sec-
tions of the ODI are pain intensity, personal care, lifting,
walking, sitting, standing, sleeping, sex life (if applica-
ble), social life, and traveling [12].
Neck Disability Index
The Neck Disability Index (NDI) is a modification of the
ODI. It is a valid and reliable self-report measure for
neck pain. Like the ODI, it too consists of 10 sections
evaluated with 0–5 scores (0 ¼ no difficulty, 5 ¼ total dis-
ability in this function), for a maximum score of 50,
which corresponds to worst disability [13].
1484 Noori et al.

Records identified through database Additional records identified

searching through other resources
(n=882) (n=12)

Identification

Records after duplicates removed

(n=871)

Records excluded
(n=805)

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Screening Records screened
(n=65)

Eligibility Full-text articles assessed for eligibility

(n=49)

Full-text articles excluded

(n=43)

Included Studies included in

qualitative synthesis
(n=6)

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram for chronic low back pain.

Neck Pain Disability Scale
The Neck Pain Disability Scale (NPDS) contains 20 items
related to four dimensions, including pain intensity,
neck problems, interferences with activities, and
emotion/cognition. Each item is evaluated on a scale of
0 (normal function) to 5 (worst possible situation), for a
maximum score of 100, indicating the worst pain and
disability possible [14].
Short-Form 36
The Short-Form 36 (SF-36) is a generic questionnaire for
measuring health-related quality of life. It consists of
eight subscales and a total of 36 questions, with lower
scores corresponding to poorer health (range ¼ 0–100).
The eight dimensions include physical function, role limi-
tation due to a physical problem, bodily pain, general
health perceptions, vitality, social functioning, role limi-
tation due to emotional problem, and mental health [15].
Functional Rating Index
The Functional Rating Index (FRI) is a valid instrument
for quantifying pain and function of the spinal musculo-
skeletal system, including the cervical and lumbar regions.
It consists of 10 items, including pain intensity, personal
care, lifting, sleeping, social life, traveling, walking, stand-
ing, work, and frequency of pain. Each item is ranked on a
five-point scale that is anchored by bipolar statements
(0 ¼ no pain or full ability to function, 4 ¼ worst possible
pain and/or unable to perform this function at all). The
higher the total index score (range ¼ 0–100%), the higher
the perceived dysfunction and pain [16].
Pain Pressure Threshold
The pain pressue threshold (PT) is a valid and reliable
measure in which a pressure algometer (a metal rod at-
tached to a device that applies a discrete and variable
amount of force) is applied perpendicularly to the
patient’s skin. The pressure is gradually increased until
the patient reports a sensation of pain, at which point the
value on the algometer is recorded [17].
Strength of Evidence
Guidelines from the Oxford Centre for Evidence-Based
Medicine (CEBM) Levels of Evidence (March 2009)
were utilized to determine the strength of evidence for in-
cluded RCTs [18].
Results
Low Back Pain
The search strategy identified six trials that met the crite-
ria for inclusion (Figure 1), and 43 full-text articles were
Table 1. Characteristics and results of included studies for chronic low back pain

Conclusions of RCT Level of

Study Study Duration No. Intervention Controls Follow-up Scale Results Authors Evidence
Ansari, 2006 [19] 10 sessions, 3 10 US 1 MHz, Sham US None FRI FRI before and after Mean changes of FRI IIb
(Iran) days per week, continuous treatment (0–100%), were significantly bet-
every other day mean 6 SD ter in the US group
Continuous US: 56.5 6 than in the placebo
20.35, 34.5 6 13.5 group (P ¼ 0.016 and
Sham US: 46.95 6 14.38, P ¼ 0.032,
39.9 6 16.5 respectively)
Mohseni-Bandpei, US: avg of 6 ses- 112 US 1 MHz, continu- Spinal manipulation 6 months after VAS, ODI Mean between-group dif- Both therapies were effec- Ib
2006 [20] sions (range ¼ ous (5–10 min) Exercise randomization ferences (95% CIs) tive; however, spinal
(UK) 3–11), 1–2 days Exercise Baseline and end of treat- manipulation demon-
per week ment strated a significantly
Manipulation: avg VAS (0–100 mm): 16.4 greater reduction in
Therapeutic Ultrasound for Axial Spine Pain

of 4 sessions (6.1 to 26.9) VAS and ODI than US

(range ¼ 2–7), ODI (0–100%): 7.8 (2.4
1–2 days per to 13.2)Baseline and
week 6-month follow-up
VAS (0–100 mm): 1.4
(0.1 to 2.7)
ODI (0–100%): 7.4 (0.1
to 13.8)
Durmus, 2010 5 days a week for 42 US 1 MHz, continu- Sham US (10 min) None VAS, ODI, SF-36 VAS reduction (0–100 Significant improvement
[21] 3 weeks ous (10 min) Exercise (15 min) mm) at rest, median
(Turkey) Exercise (15 min) Hot packs (15 min) (range)
Hot packs (15 min) Continuous US: 4 (1–7)
Sham US: 2 (0–6)
VAS reduction (0–100
mm) during activity,
median (range)
Continuous US: 2 (0–4)
Sham US: 1 (0–4)
ODI reduction
(0–100%), median
(range)
Continuous US: 8 (2–36)
Sham US: 6 (0–22)
SF-36 pain domain
(0–100), median (range)
Continuous US: 0.14
(0–0.77)
Sham US: 0.05 (0–0.45)
(P < 0.01); these differ-
ences persisted at 6-
month follow-up
IIb
in pain in both groups
after treatment; be-
tween-group analyses
showed a significantly
greater improvement in
VAS at rest in the US
group compared with
the sham US group
(P ¼ 0.001); no signifi-
cant differences in ODI
and bodily pain do-
main of SF-36 between
groups (P ¼ 0.347 and
P ¼ 0.132,
respectively)

(continued)
1485

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Table 1. continued
1486

Conclusions of RCT Level of

Study Study Duration No. Intervention Controls Follow-up Scale Results Authors Evidence
Durmus, 2010 3 days a week for 59 US 1 MHz, 1. Electrical stimula- None VAS, ODI, VAS before and after VAS reduction was signif- Ib
[22] 6 weeks continuous tion (4 electrodes SF-36 treatment (0–100 mm): icantly greater in the
(Turkey) Exercise (45 min) on L2-L4 levels no numerical scores US and ES groups com-
over erector spina reported in text pared with the exer-
muscles, 50 Hz, ODI before and after cise-only group (P <
60–130 mA, 10-s treatment (0–100%), 0.05); there was no sig-
contraction) mean 6 SD nificant difference be-
Exercise (45 min) Continuous US: 26.26 6 tween US and ES in
2. Exercise only (45 4.65, 8.68 6 3.37 VAS reduction (P >
min) ES: 28.40 6 5.30, 6.80 6 0.05); there were sig-
2.52 nificant improvements
Exercise only: 26.40 6 for ODI and SF-36
5.94, 8.40 6 3.99 pain domain scores in
SF-36 pain domain before all groups, but the
and after treatment intergroup comparison
(0–100), median did not show a signifi-
(minimum–maximum) cant difference (P ¼
Continuous US: 44.0 0.069 and P ¼ 0.285,
(44–88), 88.0 (66–99) respectively)
ES: 49.5 (11–77), 88.0
(55–100)
Exercise only: 52.0
(44–88), 77.0 (65–100)
Ebadi, 2012 [23] 10 sessions, 3 50 US 1 MHz, Sham US 1 month after VAS, FRI VAS before and after FRI and VAS improved Ib
(Iran) times a week, continuous Exercise treatment treatment (0–100 mm), after 10 sessions and
every other day Exercise completion mean 6 SD over time after 1 month
Continuous US: 46.6 6 in both groups; FRI im-
17.7, 26.6 6 13.8 provement was signifi-
Sham US: 49 6 16, 30.7 cantly greater in the
6 13.1 group receiving thera-
FRI before and after peutic US (P ¼ 0.004)
treatment (0–100%),
mean 6 SD
Continuous US: 40.8 6
14.6, 23.4 6 6.9
Sham US: 43.9 6 16.9,
31.1 6 13.4

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Noori et al.

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Table 1. continued
Conclusions of RCT Level of
Study Study Duration No. Intervention Controls Follow-up Scale Results Authors Evidence
Durmus, 2013 3 days a week for 60 US 1 MHz, continu- 1. Phonophoresis None VAS, ODI, SF-36 VAS before and after All groups showed signifi- Ib
[24] 6 weeks ous (10 min) with capsaicin gel treatment (0–10 cm), cant improvements in
(Turkey) Exercise (60 min) (2–3 mm, 10 min) mean 6 SD VAS, ODI, and SF-36
Exercise (60 min) Continuous US: 5.55 6 pain domain scores; the
2. Exercise only 1.27, 1.35 6 1.30 US and PP groups had
(60 min) PP: 6.80 6 1.82, 1.25 6 significant improvement
1.20 in VAS compared with
Exercise only: 6.10 6 the exercise-only group
1.99, 3.05 6 1.50 (P ¼ 0.001); there was
ODI before and after no significant difference
treatment (0–100%), between the US and PP
mean 6 SD groups (P > 0.05)
Therapeutic Ultrasound for Axial Spine Pain

Continuous US: 12.75 6 The PP group had a sig-

4.56, 4.95 6 3.31 nificantly greater im-
PP: 16.55 6 3.99, 3.65 6 provement on the pain
2.30 domain of the SF-36
Exercise only: 13.75 6 compared with the US
6.71, 5.55 6 3.76 and exercise-only
SF-36 pain domain (0– groups (P ¼ 0.046)
100), mean 6 SD
Continuous US: 58.65 6
16.23, 77.20 6 11.44
PP: 62.10 6 20.86, 86.55
6 7.89
Exercise only: 65.50 6
17.69, 77.45 6 12.48

CI ¼ confidence interval; ES ¼ electrical stimulation; FRI ¼ Functional Rating Index; ODI ¼ Oswestry Disability Index; PP ¼ phonophoresis; SF-36 ¼ Short-Form 36; US ¼ ultrasound; VAS ¼ visual analog scale.
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1488
Records identified through database
searching
(n=520)
Identification
Screening
Eligibility
Included
Figure 2. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram for chronic neck pain.
excluded (Supplementary Data). The characteristics and
results of these six studies are shown in Table 1. The in-
cluded studies had sample sizes ranging from 10 to 112
participants and treatment durations of three to six
weeks. Most studies included blinded patients and/or
outcome assessors blinded to treatment allocation; how-
ever, no study blinded the care providers. Across all stud-
ies, therapeutic ultrasound consisted of a 1-MHz
frequency in continuous mode, ranging in intensity from
1 W/cm2 to 2.5 W/cm2 and in effective radiating area
(ERA) from 4 cm2 to 5 cm2.
Three studies blinded patients to group allocation by
utilizing sham ultrasound [19,21,23]. Three studies
(N ¼ 102) reported that both therapeutic and sham (pla-
cebo) ultrasound provided significant improvement in
pain intensity [19,21,23]. In each of these studies, thera-
peutic ultrasound was found to be more effective than
placebo in only one of several validated instruments (e.g.,
VAS, FRI) used to measure pain. No study reported ad-
verse events or assessed cost-effectiveness.
Neck Pain
The search strategy identified five trials that met the cri-
teria for inclusion (Figure 2), and five full-text articles
were excluded (Supplementary Data). The characteristics
and results of these five studies are shown in Table 2.
Noori et al.
Additional records identified
through other resources
(n=0)
Records after duplicates removed
(n=511)
Records excluded
(n=487)
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Records screened
(n=24)
Full-text articles assessed for eligibility
(n=10)
Full-text articles excluded
(n=5)
Studies included in
qualitative synthesis
(n=5)
The study samples ranged from 26 to 102 participants
and had treatment durations of three to six weeks.
Discussion
Although therapeutic ultrasound is not regarded as
firstline treatment for nonspecific LBP and neck pain, it
is often used—especially combined with physiotherapy
or exercise [7,25]. The aim of our study was to determine
the effectiveness of therapeutic ultrasound in pain reduc-
tion for patients with nonspecific chronic LBP or neck
pain.
Low Back Pain
Six small randomized controlled trials (333 participants)
evaluating ultrasound therapy for chronic LBP were in-
cluded in this systematic review. The majority of RCTs
that did not meet inclusion criteria utilized ultrasound as
part of a treatment package; therefore, it was not possible
to isolate the effectiveness of ultrasound alone. Three
studies (N ¼ 102) reported that therapeutic ultrasound
was more effective than placebo in only one of several
scales used to measure pain.
The included studies indicate that there is a lack of
strong evidence that therapeutic ultrasound significantly
improves pain scores in patients with nonspecific chronic
Table 2. Characteristics and results of included studies for chronic neck pain.

Study Level of
Study Duration No. Intervention Controls Follow-up Scale Results Outcome and Results Evidence
Esenyel, 2000 [25] 10 sessions 102 US, continuous 1. TP injections 2 weeks after and VAS, PT VAS before, 2 weeks after, and Compared with the con- Ib
(Turkey) Exercise Exercise 3 months after 3 months after treatment, trol group, the thera-
2. Exercise only treatment (0–10 cm), mean 6 SD peutic US and TP
completion US: 7.24 6 1.62, 3.04 6 1.78, injection groups exhib-
3.08 6 2.42 ited a statistically sig-
TP: 7.16 6 1.66, 3.05 6 1.72, nificant improvement
3.19 6 2.51 in VAS pain score and
Stretching: 6.50 6 0.93, 6.46 PT (P < 0.001)
6 0.93, 5.78 6 0.87 (P <
0.379)
PT before, 2 weeks after, and
3 months after treatment,
Therapeutic Ultrasound for Axial Spine Pain

mean 6 SD, kg
US: 3.12 6 0.52, 4.24 6 0.62,
4.19 6 0.61
TP: 3.06 6 0.48, 4.28 6 0.57,
4.15 6 0.53
Stretching: 3.31 6 0.33, 3.33
6 0.32, 3.92 6 0.29
(P<0.517)
Lee, 1997 [26] Unspecified 26 US 1 MHz, 1. Sham US None VAS, PT Percent change in VAS, mean US alone and combined IIb
(USA) continuous 2. TENS 6 SD with TENS did not sig-
3. US þ TENS US: –0.31 6 0.37 nificantly improve pain
Sham US: –0.17 6 0.39 or pain threshold
TENS: –0.52 6 0.38, P < 0.05
US þ TENS: –0.32 6 0.35
Percent change in PT, mean 6
SD
US: 0.10 6 0.49
Sham US: 0.00 6 0.25
TENS: –0.02 6 0.24
US þ TENS: –0.02 6 0.18
Matijevic-Mikelic, 5 sessions a 100 US, continuous Sham US 1 month after VAS at rest, VAS Differences in VAS (in mm) at Both groups demon- Ib
2012 [27] week for 3 Exercise Exercise treatment during rest between the study and strated significantly less
(Croatia) weeks TENS TENS completion movement control groups, Mann- pain with treatment,
Whitney U test, Z score, but there was no statis-
P value tically significant dif-
Before treatment: 1,113, –0.97, ference in VAS scores
P > 0.01 between the study and
After 15 sessions: 1,215, –0.25, control groups at the
P > 0.01 end of treatment and 1
1 month post-treatment: 1,176, month post-treatment
–0.55, P > 0.01
1489

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Table 2. continued
1490

Study Level of
Study Duration No. Intervention Controls Follow-up Scale Results Outcome and Results Evidence
Differences in VAS (0–100
mm) during movement be-
tween the study and control
groups, Mann-Whitney U
test, Z score, P value
Before treatment: 893, –2.52,
P < 0.05
After 15 sessions: 979, –1.88,
P > 0.01
1 month post-treatment: 1,224,
–0.19, P > 0.01
Ustun, 2014 [14] 15 sessions, 50 US, continuous Phonophoresis None VAS at rest, VAS Difference between groups PH group had statistically Ib
(Turkey) duration of with 1 tube of during move- after treatment completion, significantly greater de-
study EMLA cream ment, NPDS mean 6 SD crease in pain intensity
unspecified (750 mg lido- VAS (0–100 mm) at rest: 1.66 at rest and NPDI
caine þ 750 mg 6 3.09, P ¼ 0.010 scores; no significant
prilocaine) VAS (0–100 mm) on move- difference in pain in-
ment: 0.36 6 2.89, tensity on movement;
P ¼ 0.476 no side effects observed
NPDS: 3.44 6 22.55, in either group
P ¼ 0.428
Dibai-Filho, 2017 10 sessions, 60 US 1 MHz, 1. Manual 1 month after NRS, NDI, PRSS NRS at rest before, after Analyzing the outcomes Ib
[28] twice a continuous therapy treatment 1 session, after 10 sessions, of all 3 groups over
(Brazil) week for 5 Manual therapy 2. Manual completion 1 month after last session time demonstrates sim-
weeks therapy þ (0–10), mean 6 SD ilar results: signifi-
diadynamic US þ manual therapy: 3.40 6 cantly reduced pain
currents 2.21, 3.35 6 2.23, 1.30 6 intensity and disability;
1.83, 1.75 6 1.68 all groups also demon-
Manual therapy: 3.50 6 1.47, strated similar
3.30 6 1.62, 1.90 6 1.77, increases in pressure
2.20 6 2.28 pain threshold
Manual therapy þ diadynamic:
3.00 6 2.02, 2.55 6 1.73,
1.55 6 0.99, 1.00 6 0.85
NDI before, after 1 session, af-
ter 10 sessions, 1 month after
last session (0–50), mean 6
SD
US þ manual therapy: 11.90 6
4.11, 9.55 6 5.27, 7.15 6
5.26, 7.80 6 5.40
Manual therapy: 12.20 6 4.14,
10.70 6 3.43, 7.45 6 3.80,
8.85 6 4.98
Noori et al.

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 Therapeutic Ultrasound for Axial Spine Pain 1491

LBP. Only three studies found significant improvement

Evidence

CLBP ¼ chronic low back pain; CNP ¼ chronic neck pain; ERA ¼ effective radiating area; ES ¼ electrical stimulation; FRI ¼ Functional Rating Index; NDI ¼ Neck Disability Index; NPDS ¼ Neck Pain Disability Scale;
NRS ¼ numeric rating scale; ODI ¼ Oswestry Disability Index; PP ¼ phonophoresis; PRSS ¼ Pain-Related Self-Statement Scale; PT ¼ pain threshold; SF-36 ¼ Short-Form 36; TENS ¼ transcutaneous electrical nerve stimulation;
Level of at the end of treatment in one of several pain scales when
therapeutic ultrasound was compared with placebo or
exercise only. All trials included in the present study were
single-blinded and had small sample sizes, and most stud-
Outcome and Results

ies lacked follow-up of participants. As ultrasound is not

the first-choice treatment for chronic LBP, in only one
study did patients receive no additional treatment beyond
therapeutic and sham ultrasound [19]. This review
reveals that ultrasound is usually evaluated as part of a
treatment package or in comparison with physiothera-
peutic modalities. Our review is in line a Cochrane re-
last session (0–5), mean 6 SD
PRSS before, after 1 session, af-
Manual therapy þ diadynamic:

Manual therapy þ diadynamic:

ter 10 sessions, 1 month after

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Manual therapy: 1.09 6 0.92,
US þ manual therapy: 1.61 6

view from 2014 concluding that there is no high-quality

10.85 6 4.49, 9.80 6 3.23,

0.75 6 0.57, 0.31 6 0.35,

1.43 6 0.97, 1.05 6 0.72,

1.12, 1.12 6 1.12, 0.73 6
6.60 6 3.48, 6.50 6 3.25

0.61 6 0.55, 0.49 6 0.58

evidence that therapeutic ultrasound improves pain or
quality of life in patients with nonspecific chronic LBP
0.94, 7.80 6 5.40

[29].
0.58 6 0.75

Neck Pain
Results

In regards to chronic neck pain, this systematic review

demonstrates that therapeutic ultrasound is often ineffec-
tive in reducing pain intensity even right after treatment.
Two RCTs demonstrated that therapeutic ultrasound pro-
vided no benefit over sham ultrasound [26,27]. One study
demonstrating that ultrasound was effective in the reduc-
Scale

tion of pain intensity did not, however, find the superior-

ity of ultrasound over an established treatment modality,
trigger point injections [25]. Three of the four included
studies analyzed the efficacy of ultrasound in conjunction
with other treatment modalities, such as manual therapy,
Follow-up

exercise, and electrical stimulation. It is of course possible

that there are differences in effectiveness between high-,
medium-, and low-powered ultrasound, which may be an
important variable to be considered by the treating pro-
vider [30]. Therefore, the frequency or power of the ultra-
sound therapy may be an important variable to be
Controls

considered by the treating clinician.

There is insufficient evidence to recommend the rou-
tine use of ultrasound therapy in the treatment of chronic
neck pain. Furthermore, there is no evidence to recom-
mend replacing an existing evidence-based treatment mo-
Intervention

dality. Further studies on a larger scale could change our

TP ¼ trigger point; US ¼ ultrasound; VAS ¼ visual analog scale.

results on the short-term effectiveness of ultrasound, es-

pecially because high-powered ultrasound appears to be
the least-studied modality.
No.

Recommendations
Given the paucity of trials and conflicting results, we can-
Duration

not recommend the use of low-intensity ultrasound for

Study

chronic neck pain (grade B). It does seem that low-inten-

Table 2. continued

sity therapy may be considered only as part of a physical

modality treatment plan when other treatment modalities
are not adequate.
There is reasonable evidence that low-intensity ultra-
Study

sound therapy in conjunction with exercise treatments

may improve pain scores immediately after treatment for
1492
chronic LBP, but so far, there is no evidence of long-term
benefits (grade B). In both pain syndromes, blinded trials
with adequate follow-up are needed to define the true ef-
fect of low-intensity ultrasound therapy. No conclusive
recommendations may be made for optimal settings or
session duration.
Limitations
As only English-language studies were included, some
relevant data could be left out. Due to the heterogeneity
in data reporting and outcome measures, the pooling of
study results was difficult. So far, only qualitative analy-
sis of studies was possible, whereas quantitative analysis
with effect sizes would have been more informative. The
majority of studies did not evaluate ultrasound as mono-
therapy, making it difficult to measure the efficacy of
therapeutic ultrasound. All studies were at risk for bias
as only three studies blinded participants through the use
of sham ultrasound and no study blinded the care pro-
vider to group allocation.
Supplementary Data
Supplementary data are available at Pain Medicine
online.
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Appendix

Table A1. Search phrases utilized

Lower Back Pain Neck Pain Axial Pain

Ultrasound therapy and back pain
Ultrasound therapy and lumbar back spine
Ultrasound therapy and lumbar back spine pain
Therapeutic ultrasound and back
Therapeutic ultrasound and back pain
Therapeutic ultrasound and lumbar back spine
Therapeutic ultrasound and lumbar back spine pain
Low intensity ultrasound and back
Low intensity ultrasound and back pain
Low intensity ultrasound and lumbar back spine
Low intensity ultrasound and lumbar back spine pain
Ultrasound therapy and neck
Ultrasound therapy and neck pain
Ultrasound therapy and lumbar cervical spine
Ultrasound therapy and lumbar cervical spine pain
Therapeutic ultrasound and neck
Therapeutic ultrasound and neck pain
Therapeutic ultrasound and lumbar cervical spine
Therapeutic ultrasound and lumbar cervical spine
pain
Low intensity ultrasound and neck
Low intensity ultrasound and neck pain
Ultrasound therapy and axial spine
Ultrasound therapy and axial spine
pain
Therapeutic therapy and axial spine
Therapeutic therapy and axial spine
pain
Low intensity ultrasound and axial
spine
Low intensity ultrasound and axial
spine pain