**Author details**

to September 2015, 10 patients with shoulder pain and functional limitation, due to biceps brachii long head muscle or rotator cuff tendonitis, bursitis, intra‐articular effusion, without indication for surgical treatment were enrolled. After a preliminary physiatric evaluation, each patient underwent the US and other successive rehabilitative treatments. The US thera‐ peutic protocol is based on 10 sessions in consecutive days for an overall period of 2 weeks. US treatments were then designed and performed by selecting the specific US parameters values and the treatment modalities for each patient in consideration of their specific clini‐ cal, functional and sonographic findings. A preliminary sonographic study was performed in order to quantify edema, phlogosis or effusion. Relevant images were saved and transferred on PC for further elaboration. As far as the other US parameter values are concerned, a care‐ ful evaluation of the estimated depth of the lesion suggested the choice of the frequency of 1 MHz for deep and of 3 MHz for more superficial treatment sites. Moreover, depending on the expected therapeutic increase in temperature at the lesion, the 'continuous' modality was selected to induce more heat deposition (for a shorter time) while the 'pulsed' modal‐ ity, with a Duty Cycle (i.e. the US emitting time related to the total time length of the cycle) selected at 25% was preferred for longer time (10 min) treatments. A multimodal assessment (clinical, functional and sonographic) of the actual pathology was performed before the US treatment, recording shoulder pain, ROM, strength, functional parameters and sonographic imaging. Pain was estimated using the Numeric Rating Scale (NRS), Constant Score and DASH scale were used for shoulder's function evaluation [25, 26]. The same procedure for result assessment was followed at the end of the US treatment. The sonographic examination was performed following a standardized procedure for the shoulder imaging named musku‐ loskeletal ultrasonographic exam (MSUS) which satisfactorily detects the main findings of the phlogosis process [27]. MSUS exam was performed before the US treatment session and at the end of the last US session by a rehabilitation medical specialist, using an Edge Ultrasound System (Sonosite, USA) connected to a 7.5 MHz frequency probe. To each alteration, a semi‐ quantitative score from 0 to 3 was given (0: no alterations; 1, 2, 3: low, mid and high inflam‐ matory alterations). Single scores were added to give a total value (total score), indicating the global index of phlogosis of the shoulder in each patient [28]. All patients enrolled in the study showed a significant reduction of shoulder pain and functional limitations with NRS and DASH scores significantly improved. Sonographic imaging supports clinical data, showing a considerable reduction of bursa or tendon's area of phlogosis. The previous expe‐ rience obtained in monitoring temperatures in a realistic model (phantom) heated with US with different modalities have been useful in defining more precisely which values of the US parameters and which treatment modalities would be optimal to induce the expected thermal

Paying attention to the equipment efficiency, the '*in vitro*' and '*in vivo*' investigations of the thermal field induced by any specific US probe working at different modalities and to the specific characteristics of the joint to be treated, US physiotherapy may dramatically improve

its quality and possibly show evidences of effectiveness which are nowadays lacking.

effects for each specific patient.

**4. Conclusions**

220 Clinical Physical Therapy

Elisa Edi Anna Nadia Lioce<sup>1</sup> , Matteo Novello<sup>2</sup> and Caterina Guiot2 \*

\*Address all correspondence to: caterina.guiot@unito.it

