Hi everyone,
Since this subject has been discussed over about the last month, we will
repost what we said about our use of ultrasound with our clients. We
apologise for the time lapse over our response, but life here has been
hectic lately.

Text of previous mail sent 25 July:

There was an article on the use of ultrasound for blocked ducts in lactating
breasts in Breastfeeding Review No 1 or 2, in about 1983, reprinted from the
original article in the Australian Journal of Physiotherapy. It was written
by a physio, Margaret Shellshear (?spelling). My BRs are all at home, so I
can't check them here at Anne's.

Mothers do not need to be referred to a physio by a doctor - they can just
take themselves along to one without any health care provider's referral if
they wish. (In Australia, anyway! We are considerably more free to self-
refer to hcp's here than you may be elsewhere in the world.) All
physiotherapists are trained in the use of ultrasound for therapeutic rather
than diagnostic purposes. I am not happy about doctors using ultrasound
equipment unless they have been trained to do so. The dosage level used on
breasts is fairly low, and has been reduced further on what it was in 1983.
It is important that the practitioner using ultrasound knows the usage
criteria because it is possible to damage delicate body tissues with too
high a dosage level of ultrasound treatment. There are also cautions issued
about the use of ultrasound on infected tissues because of the risk of
spreading the infection further. This is not generally regarded as a
significant risk when treating breasts because the recommended dosage levels
are low, and in fact one of the case histories in the BR article was of a
breast that was infected so badly that it was just at the early abscess
stage, and the ultrasound treatment resolved it within hours. I can report
similar outcomes with many other women in this situation in the 12 years
since. (It seems to work if the abscess has not encapsulated - if it has,
surgical drainage is more appropriate treatment.)

Ultrasound works by the effect of very fast vibration of the molecules in
the body tissues being treated. This causes local friction of those
molecules and therefore local heat production. It is very effective for
breaking up lumps of cheesy milk residues such as in blocked ducts (the
Americans call them plugged ducts). Ultrasound is a form of sound waves, but
at a frequency the human ear can't hear.

The advantages of using ultrasound on these breast conditions are that
physios are easily accessible in most local communities (here anyway!), it's
a fairly cheap, non-invasive and pain-free treatment that takes only about
10-15 minutes, that provides very fast resolution of the problem. (Within 8
hours.)

The 1993 article in BR was a study that looked at the effectiveness of
ultrasound on breast engorgement. The findings were that this was not an
effective way of resolving engorgement. This does not surprise me, and the
other methods we are more familiar with are more helpful in these cases.
(And soaking breasts in very warm solutions of Epsom's Salts (Magnesium
Sulphate) is magic for those really intractable cases! It works by simple
osmosis to unload excess fluid from body tissues - but needs to be washed
off breasts before feeding/expressing, to avoid exposing the baby to the
magnesium which is a heavy metal.)

Other than "caked breast", the extreme form of blocked ducts (where the milk
would all be "spaghetti milk" ), which I mentioned in my previous letter,
these are the only situations where ultrasound will be appropriate
treatment. We can't see any virtue at all in attempting to express a mother
who has these extreme problems until some hours after the ultrasound
(usually 4-8 hours, depending on severity) when hopefully her baby will be
interested in helping her to drain the breasts! And it becomes much more
like her normal pleasant experience of breastfeeding.

End of previous mail.

The original article we referred to was:
Marguerite Shellshear "Therapeutic Ultrasound in Post Partum Breast
Engorgement - Clinical Notes", Breastfeeding Review(NMAA)No2,March,1983,p11.

This article was reprinted from the Australian Journal of
Physiotherapy,1981.27(1)15-16.

The article reports two case histories which are far beyond simple
engorgement - the first being a breast with a solid section (which we would
have called blocked ducts) and which was resisting any attempts at
significant drainage of milk. The second case was at the early stages of
breast abscess. Both cases were treated with ultrasound.  The results in
both cases were rapid resolution of the problems so that by the next day
minimal residual signs of the problems were evident and no further treatment
of any kind was required.

The author stated that these were representative of other cases she had
treated in the previous few years.

Since then, ultrasound treatment has been quite commonly used for cases such
as these in Australia,although as we reported, the dosage levels have been
adjusted further downwards. Physiotherapists we have asked about this topic
have advised us that the dose depends on how localised the problem in the
breast is, that they may use pulse rather than continuous ultrasound, and
that doses may vary between .5 and 1.75 W/cmxcm for 3 - 10 minutes. They
also tell us that they will undertreat rather than overtreat with
ultrasound, and that these are regarded as low risk levels of ultrasound in
comparison to the other many and varied uses of ultrasound in medicine. Yes,
ultrasound can be used to shatter kidney stones, but the difference in doses
between this application and what we make use of for breasts is like the
comparison between sound at conversation level and that of sound loud enough
to shatter windows. It helps not to lose sight of the fact that ultrasound
IS sound, except that we can't hear it - some animals can! And if you wish
to define sound, light etc as radiation in the strict physical sense, you
are quite correct. So you will already know just from your everyday life
experience that there are harmless through to highly injurious forms of
radiation.

The breast problems which are treated most appropriately with ultrasound are
those where the normal simple measures are not helping - in other words,
tissue damage is ALREADY a risk because of unresolving blocked (plugged)
ducts. Manual breast expression is not a viable option in these cases - it
is too painful and is also likely to cause some degree of bruising which in
itself can take weeks to heal. We reiterate that it is known that ultrasound
can cause tissue damage, but that this is also regarded as low risk at the
dosage levels now used on breasts. At this stage of these cases, tissue
damage from another source is already the likely scenario. Mothers' response
to the fast resolution of their pain and breast problem is universally deep
relief and very often saves them from weaning their babies. This is often
real "last resort" stuff!!

 In the 1993 study ..Ultrasound Treatment for Breast Engorgement. A
Randomised Double Blind Trial. J. Lumley, B Walker, Z. McLachlan, E.J.
Milne.  Breastfeeding Review (NMAA) Vol II No 7, May, 1993 pp316-320.....



the use of ultrasound for simple engorgement (no inflammation or blocked
ducts present) showed that this was not a useful treatment. At a recent
Australian conference (Melbourne, Victoria), Anne and I heard Zoe present a
paper on what their research did AND DID NOT show. She did this because of
confusion arising from interpretations made of their work. She made it quite
clear that their study should NOT be applied to use of ultrasound for
blocked ducts and mastitis, and that she was aware of many case history
reports of the success of therapeutic ultrasound in both of these other
situations.


ROBYN NOBLE and         ANNE BOVEY