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Ultrasonics 48 (2008) 271278

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Therapeutic opportunities in biological responses of ultrasound

Sumit Paliwal, Samir Mitragotri *
Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, United States
Received 1 July 2007; received in revised form 5 February 2008; accepted 28 February 2008
Available online 7 March 2008

Abstract
The therapeutic benets of several existing ultrasound-based therapies such as facilitated drug delivery, tumor ablation and thrombolysis derive largely from physical or mechanical eects. In contrast, ultrasound can also trigger various time-dependent biochemical
responses in the exposed biological milieu. Several biological responses to ultrasound exposure have been previously described in the
literature but only a handful of these provide therapeutic opportunities. These include the use of ultrasound for healing of soft tissues
and bones, the use of ultrasound for inducing non-necrotic tumor atrophy as well as for potentiation of chemotherapeutic drugs, activation of the immune system, angiogenesis and suppression of phagocytosis. A review of these therapeutic opportunities is presented
with particular emphasis on their mechanisms. Overall, this review presents the increasing importance of ultrasounds role as a biological
sensitizer enabling novel therapeutic strategies.
Published by Elsevier B.V.
Keywords: Ultrasound; Biological response; Wound healing; Bone regeneration; Cancer therapy; Immune response; Angiogenesis; Hemostasis

Contents
1.
2.

3.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1. Tissue healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.1. Soft tissue stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.2. Bone regeneration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2. Cancer therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3. Stimulation of immune response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.4. Inducing arteriogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.5. Hemostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. Introduction
Interactions of ultrasound with biological tissues have led
to several clinical therapies including physiotherapy [1], trans*

Corresponding author. Tel.: +1 805 893 7532; fax: +1 805 893 4731.
E-mail address: samir@engineering.ucsb.edu (S. Mitragotri).

0041-624X/$ - see front matter Published by Elsevier B.V.

doi:10.1016/j.ultras.2008.02.002

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dermal drug delivery [2], thrombolysis [3] and cancer treatment [4]. Most of these therapies are based on physical
eects of ultrasound on cells and tissues such as controlled
disruption of various biological barriers including cell membranes and tissues for drug and gene delivery [5,6]. In contrast, relatively less is known about the therapeutic potential
of subtle, biological eects of ultrasound on cells and tissues.

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Most organisms exhibit innate ability to respond to various environmental insults so as to facilitate robust recovery and minimal long-term eects of the insult. In this
context, ultrasound also exerts non-lethal trauma to the
biological milieu and can incite a survival response. Biological responses of ultrasound on cells and tissues have been
previously addressed in the literature [7,8]. However, the
major focus in these studies had been to understand and
develop safety standards for countering the possible deleterious bioeects of ultrasound exposure [9]. For example,
several reports describe ultrasounds biological eects on
embryos, central-nervous system, and other major organs
at a cellular and molecular level [8,10]. Relatively little is
known about the benecial biological responses of
ultrasound. Over the last years, a few therapies based on
ultrasounds biological eects have been demonstrated
with specic applications in tissue regeneration, cancer
treatment, and immune and vasculature stimulation. This
article reviews these novel approaches especially the underlying connections between ultrasound-induced biological
responses and therapeutic ecacy.
2. Applications
2.1. Tissue healing
With a history spanning over 6 decades, stimulation of
injured tissues for accelerated repairing is the most studied
and clinically practiced biological response of ultrasound
[9]. Therapeutic eects of regular ultrasound exposure have
been described in the literature for repairing damaged
ligaments, muscle spasms, inamed tendons, sti joints,
fractured bones and cartilage [1113]. Related eects have
also been used for debridement and accelerated healing of
wounds [1417], skin rejuvenation [18,19], nerve stimulation [2022], and improving the strength and elasticity of
scar tissues [23]. Below, we discuss some of the prominent
applications of this therapy and their underlying
mechanisms.
2.1.1. Soft tissue stimulation
Ultrasound, through its thermal and non-thermal (cavitation and acoustic streaming) mechanisms, has been implicated in stimulating soft tissue healing. Tissues, particularly
those containing densely-packed large protein molecules
such as collagen, can experience elevated temperatures
resulting in several therapeutic benets. These include
increased extensibility/exibility of collagen-rich scar tissues [23], tendons [24,25] and joints [26], pain and spasm
relief due to heating of muscles [27] and nerve roots [20
22], and possible increase in blood ow [28] to help resolution of chronic inammatory processes. Role of non-thermal mechanisms of ultrasound in tissue regeneration [29]
and soft tissue repair [17,3032] has also been widely established. At a cellular-level, it has been hypothesized that
changes in diusion rates and membrane permeability to
ions [3335] due to acoustic streaming and stable cavita-

tion, can stimulate cells by upregulation of signaling molecules [11]. Specically, ultrasound has been shown to
increase protein synthesis [31] including that of collagen
[32,36], which is essential for repair mechanisms in cells.
During the inammation phase of the healing process,
ultrasound can activate immune cells to migrate to the site
of injury. In two separate studies, Fyfe et al. showed ultrasonic induction (0.5 W/cm2) of mast cell degranulation and
histamine release in injury models in vivo [37,38]. Similar
results were reported for dermal mast cells, demonstrating
that ultrasound can accelerate the inammatory healing
phase for skin lesions/ulcers in vivo (Wistar rats, 0.753 MHz, 0.25-3 W/cm2) [39]. In a related study, Young
et al. showed that ultrasound (3 MHz, 0.5 W/cm2) can
stimulate macrophages in vitro to release broblast mitogenic factors, resulting in enhanced broblast proliferation
[40]. Ultrasound may also help in wound contraction [41]
and scar tissue remodeling [42] by possibly altering the collagen ber pattern. These benecial eects of ultrasound
have been used in treating various skin conditions including varicose ulcers [17], skin lesions [43], pressure sores
[30,44], acceptance of skin grafts [45], and sutured incised
wounds [46]. Therapeutic eects due to ultrasound exposure have been demonstrated during regeneration of damaged muscle tissue [27], and peripheral and sciatic nerves
[2022]. In an exciting application, ultrasound has been
proposed for skin rejuvenation and wrinkle removal by
controlled ablation of dermal tissue and provoking a
wound healing type response [18,19].
2.1.2. Bone regeneration
In addition to the various tissue repair applications and
mechanisms discussed above, ultrasonic bone regeneration
forms an attractive subset due to bone tissues special physiology and the clinical success of this therapy. Stimulatory
eect of ultrasound on osteogenesis was established as
early as in 1950 [47], but its clinical popularity as a therapeutic tool for treating fractures came much later in
1990s (1994: FDA approval for ultrasonic treatment of
fresh fractures). This was facilitated by the use of lowintensity pulsed ultrasound (LIPUS; early report Ref.
[48]). Many studies have demonstrated the use of ultrasound for accelerating healing in fresh [49,50], nonunion
[5153] and delayed-union [53] type fractures, and for
enhanced ossication in distraction osteogenesis [5456].
Healing of fractures is a complex process involving inammation, proliferation (angiogenesis and callus formation
and hardening), and remodeling of the bone tissue. Plenty
of evidence supports the conclusion that ultrasound is
more eective in early-stage of fractures (inammation
and proliferation) compared to the remodeling phase [57
61]. While during the inammation phase, formation of
haematoma helps recruitment of cells to the fracture site,
the proliferation phase includes angiogenesis, dierentiation of mesenchymal stem cells and endochondral ossication [62]. In vitro ultrasonic treatment of cells that are
typically involved in fracture healing (osteoblasts, bro-

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blasts and monocytes), showed secretion of inammatory

cytokines (IL-1b) and angiogenesis-inducing factors (IL8, b-FGF, and VEGF) inducing cell proliferation, collagen
production, bone formation, and angiogenesis [6365].
Rawool et al. demonstrated a 33% increase in vascularity
at the osteotomy site in dogs, suggesting that ultrasound
(1.5 MHz, 30 mW/cm2: daily treatment for 11 day) may
stimulate angiogenesis, which is critical for successful
osteogenesis [66]. Several studies have also indicated that
ultrasound signicantly stimulates the formation and
strengthening of calluses, which was demonstrated by fast
recovery of the mechanical properties of bone tissue (measured by bones maximal torque and torsional stiness)
[48,57,59,61]. Tsai et al., using fractured rabbit bulae
model, showed enhanced mineral apposition rates in ultrasound-treated cases (1.5 MHz, 0.5 W/cm2: treatment for
525 min/day) [67]. Further, dierentiation of cartilagespecic chondrocytes from mesenchymal stem cells [6870]
and subsequent upregulation of various biomolecules such
as procollagens [71], aggrecan [59,70,71], proteoglycan [71],
and chondroitin sulphate [72] as a response to ultrasound
have been reported. Interestingly, ultrasound has also been
demonstrated in vitro to directly stimulate bone formation,
in terms of quantitative increase in various bone markers
including osteocalcin and alkaline phosphatase [7375].
2.2. Cancer therapy
Extensive work has been done in the past showing harmful biological responses of cells and tissues to ultrasound
exposure including growth suppression, retarded protein
synthesis, cytoplasmic vacuolation and disruption of intracellular components such as mitochondria, microtubules
and endoplasmic reticulum (for a comprehensive compilation of such eects, see Ref. [10]). In clinical practice such
harmful and potentially lethal biological eects of ultrasound can be used to target tumor suppression or possibly
elimination. Specically, ultrasound-induced microtubule
disassembly [7678] is of special interest in cancer therapy.
Cancer drugs such as taxol, which are known to disrupt
intracellular microtubule dynamics, are routinely used for
chemotherapy. Hrazdira et al. reported that a low-intensity
ultrasound exposure (0.8 MHz, 50500 mW/cm2 for
510 min) made HeLa cells undergoing M- and S-phases
of the cell cycle sensitive to cytoskeleton disassembly with
prominent changes in the microtubules and microlaments
networks [78]. Later, Skorpikova et al. using similar ultrasound parameter, followed up with these results to show
that ultrasonic cytoskeletal disruption in tumor cells potentiated two cytostatic cancer drugs, cycloplatin and methotrexate [77].
Another application of ultrasound is to induce nonnecrotic and localized hyperthermia in tumor tissues for
cancer therapy [79,80]. Sustained heating of solid tumor tissues at temperatures of 42.543 C for 2030 min is known
to induce favorable therapeutic eect [81]. Several clinical
studies have successfully demonstrated tumoricidal eects

273

of ultrasonic hyperthermia employing frequencies in the

range of 13 MHz [8284]. It is understood that ultrasonic
hyperthermia may manifest its therapeutic eects through
arresting cancer cells in the S phase of the cell cycle and
may have preferential eects on hypoxic, acidic and malnourished tumor cells [79].
Several clinical studies have been actively undertaken
for the treatment of solid tumors in prostate [85,86], liver
[87], breast [88], kidney [89], sarcoma [87] and uterus [90]
using ultrasound-induced hyperthermia. While instantaneous thermal ablation remains the chief mechanism of this
treatment strategy, recent in vivo studies have indicated
that ultrasound exposure can strongly stimulate long-term
antitumor immunity in the host. In a preliminary study,
Yang et al. demonstrated that ultrasound exposure
(4 MHz, 550 W/cm2) of neuroblastoma implanted in mice
led to signicantly slower growth of the tumor when it
was re-implanted at the previously ultrasound-treated site
[91]. The authors concluded that ultrasound exposure activated the immune response against the tumor. Mechanistically, ultrasound treatment can facilitate the interactions of
tumor-specic antigens with the immune system and elicit
an antitumor response. Wu et al., in two separate studies
on 23 breast cancer patients, showed that several tumor
antigens, which are otherwise sequestered in the tumorcytoplasm, were extensively present, preserved and available for immunostimulation in the extracellular matrix of
the ultrasound-ablated (1.6 MHz, 515 kW/cm2) tumor
debris [92,93]. Further, ultrasound exposure can increase
the tumor antigenicity by release of endogenous inammatory cytokines [94,95] as well as upregulation of heat shock
proteins [93,95,96] in the surrounding viable tissues, and
thereby activating and attracting immune cells to the tumor
site. Hu et al. showed that ultrasound exposure at 1.1.
MHz to MC-38 colon adenocarcinoma tumor cells
in vitro led to the release of endogenous ATP and hsp60
in the culture medium [94]. Furthermore, exposure of this
culture medium resulted in robust activation of antigenpresenting cells (dendritic cells and macrophages) and led
to enhanced secretion of pro-inammatory cytokines
(IL-12 and TNF-a) by them [94]. In a follow up study,
Hu et al. ablated MC-38 tumors in mice and found pronounced accumulation of activated dendritic cells in the
ultrasound-treated tumors and in the local draining lymph
nodes [97]. Such inammatory reaction upon ultrasound
exposure can provide an ideal environment for the development of mature T-cells and lead to a systemic antitumor
immune response. Rosberger et al. reported for patients
with posterior choroidal melanomas that ultrasound
treatment resulted in signicant increase in CD4 T cells
[98]. In a total of 16 patients with osteosarcoma, hepatocellular carcinoma, or renal cell carcinoma, Wu et al. reported
that ultrasound-assisted tumor ablation (0.8 MHz, 5
20 kW/cm2) resulted in a signicant increase in the population of CD4+ lymphocytes and cytotoxic NK cells in the
peripheral blood [99]. Interestingly, a recent study by Zhou
et al. demonstrated that ultrasound treatment can augment

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antitumor immunity by reducing the immunosuppressive

eects of tumors a phenomenon by which cancer cells
can downregulate hosts immune system, resulting in their
enhanced growth and progression [100]. The authors
reported that serum levels of immunosuppressive cytokines
(VEGF, TGF-b1, and TGF-b2) in patients with solid
malignancies were signicantly reduced after ultrasound
treatment (0.8 MHz, 520 kW/cm2) [100].
Inducing selective cytotoxicity in tumor cells, while leaving healthy cells unaected, is a signicant challenge.
Through in vitro studies, using biological responses
towards ultrasound, Paliwal et al. showed that a brief exposure to ultrasound (20 kHz, 2 W/cm2) followed by treatment with quercetin (a weak chemotherapeutic drug)
induced selective cytotoxicity in prostate and skin cancer
cells [101]. The investigators reported that about 90% of
the skin cancer cell population was lost after ultrasound
application and subsequent 48 h incubation with 50 lM
quercetin. Further, ultrasound led to an 80-fold enhancement in skin cancer cell toxicity (measured by LC50 of
quercetin), while the treatment had minimal eects on
non-malignant skin cells. This high treatment selectivity
towards cancer cells was hypothesized to be due to the
dierential protein-expression response of heat shock
protein-hsp72 after ultrasound exposure. hsp72 is a vital
stress-protein essential for the survival of cancer cells; the
ultrasound-quercetin combined treatment induced selective
and strong inhibition of hsp72 in cancer cell as compared to
normal cells [101].
2.3. Stimulation of immune response
Transcutaneous immunization (TCI) involves application of vaccines on the skin to induce immunization
[102]. Physiologically, skin represents bodys rst line of
defense against pathogens and hence it is an ideal site for
vaccination due to the presence of various immune cells,
particularly Langerhans cells (LCs) which are highly potent
antigen-presenting cells [103]. However, simple topical
application of vaccines does not yield an adequate immune
response [102]. In order to achieve a robust immune
response through TCI, skin tissue has to be suciently
stimulated with adjuvants to develop an inammatory type
response, which includes secretion of signaling proteins
cytokines leading to the activation of immune cells
[104,105]. In parallel to pro-inammatory toxic chemical
adjuvants, ultrasound has been demonstrated as a potent
physical adjuvant for TCI. Specically, pre-exposure of
ultrasound (20 kHz, 2.4 W/cm2) followed by topical incubation of tetanus toxoid resulted in strong systemic
increase of specic IgG antibody titers in mice, which were
comparable to the titers obtained from conventionally
administered subcutaneous vaccine injections, though at
much higher doses [106]. The mechanisms behind this novel
biological response of ultrasound to stimulate skins
immune functionality have been studied. Ultrasound,
through acoustic cavitation, breaches the skins barrier

[107], which can result in skins inammatory response

needed for TCI. Indeed, the connection between restoration of skin permeability barrier homeostasis and activation
of various signaling pathways leading to upregulation of
various pro- inammatory cytokines and growth factors,
is well established [108]. This hypothesis was revealed in
a study by Choi et al., who showed that 1 MHz ultrasound
exposure up-regulates epidermal pro-inammatory cytokine (IL-1a, TNFa, and TGFb) expression in skin [109].
Ultrasound exposure activated various immune cells in
the skin, particularly Langehans cells [106]. Overall, these
results suggest that ultrasound, in its capacity as a mechanical stimulant, can enable upregulation of cytokines in the
skin, activate immune cells and generate an immune
response against topically delivered vaccines.
Intravenously-injected polymer nanoparticles have
found applications in several medical therapies, particularly due to the high exibility in tuning their properties
such as size, shape, surface characteristics and degradation
rate [110]. Nanoparticles are being developed as contrast
agents for blood and tissue imaging, with specic application in cancer diagnosis [111]. Amid considerable interest,
polymer nanoparticles have also been used for drug delivery applications [112]. In their role as carriers of therapeutic agents, nanoparticles provide several distinct
advantages such as enzymatic protection of the drug,
targeted delivery and sustained release of the drug over
prolonged time periods [113115]. In spite of this great
potential, nanoparticles have found limited practical applications due to their short vascular circulation lifetimes
[116,117]. Circulating particles, however, are recognized
and captured by the phagocytic cells of the immune system
(reticuloendothelial system) within minutes of their administrating [110,116]. Ultrasound has been previously
reported to suppress the phagocytic activity of immune
cells, and thus can nd a potentially attractive therapeutic
application as an extracorporeally-administered and targeted immuno-suppressant for prolonged circulation of
polymeric particles. In a direct attempt to evaluate ultrasonic response of the reticuloendothelial system, Saad
et al. demonstrated in vivo that ultrasound exposure to
the umbilical area of rats showed decreased clearance of
intravenously-injected colloidal sulfur particles [118]. The
clearance was shown to further decrease with increasing
intensity of ultrasound and with the duration of exposure
(1.65 MHz, 60400 J/cm2) [119]. Studies by Anderson
et al. also showed impaired anti-bacterial activity of peritoneal macrophages [120], depression of phagocytic clearance
of intravascular carbon [120], and immuno-suppressive
eects on spleen [121] by ultrasound exposure (2 MHz,
8.9 mW/cm2).
2.4. Inducing arteriogenesis
Occlusive vascular disease is marked by inadequate
blood ow to organs often leading to malnutrition and
ischemic conditions, particularly involving the myocar-

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dium and skeletal muscle tissue. Various approaches for

targeted stimulation of neovascularization have been
pursued in the past, including delivery of growth factor
proteins or genes [122] and more relevantly, by inducing
inammatory response in the aected vasculature [123].
In this context, ultrasound was hypothesized to initiate
an inammatory response through implosion of microbubbles in ischemic tissues, leading to triggering of various
angiogenic pathways [124]. In this study, exposure of
1 MHz ultrasound to intravenously-injected microbubbles
resulted in increased arteriole density, arteriole diameters,
and nutrient blood ow into the treated rat skeletal muscle
[124]. With a similar procedure, microvascular remodeling
response was observed in a rat model of arterial occlusion
[125]. In a recent mechanistic study, the therapeutic
potential of this strategy was shown to originate from the
recruitment of growth factor-producing cells to the ultrasonically-inamed site [126]. Interestingly, a combined
treatment of ultrasound-triggered arteriogenesis and transplantation of bone marrow-derived mononuclear cells
facilitated blood ow restoration by stimulating both
angiogenesis and arteriogenesis in an ischemic rat model
[127,128].

275

et al. reported on post-operative wound healing type recovery response after ultrasonic hemostasis of surgical liver
injury in rabbit model [133]. They observed dense collagen
deposition and signicant tissue regeneration (indicated by
growth of new hepatocytes) at the treated site within 60
days of therapy. It was hypothesized that as early as 2
weeks after ultrasound exposure, the treatment can activate
leukocytes and broblasts from neighboring areas to
migrate and produce collagen, elastin and proteoglycans
to enhance healing [133]. Additional studies have indicated
that hemostasis may also be boosted by tissue thromboplastins released from ultrasonically heated endothelium
[138]. It is understood that tissue recovery responses in
hemostasis can be mediated by the non-thermal mechanisms of ultrasound, particularly acoustic cavitation. Poliachik et al. used ultrasound contrast agents to demonstrate
that cavitation can induce platelet activation, aggregation
and adhesion to collagen coated surfaces a phenomenon
necessary for platelet plug formation in hemostasis [139].
Further, ultrasound exposure was shown to disrupt platelets to release b-thromboglobulin, adenosine diphosphate
and other chemical factors at the site of bleeding, which
can induce clotting as well as recruitment of undamaged
platelets for accelerated clot formation [140,141].

2.5. Hemostasis
3. Conclusions
High-intensity focused ultrasound (HIFU), at typical
exposure settings of 1 5 MHz and 110 kW/cm2, has been
successfully demonstrated to achieve hemostasis in active
bleeding from blood vessels [129131] and organs such as
liver [132,133] spleen [134] and lung [135]. In a pig model,
using 2 MHz and 3.5 MHz HIFU transducers operating
at 0.53.1 kW/cm2, Vaezy et al. reported cessation of
bleeding from several types of punctured blood vessels
including abdominal aorta, femoral artery and vein, axillary artery, carotid artery and the jugular vein [130]. Treated vessels showed localized hardening of the soft tissue
surrounding the vasculature and coagulation through
extensive brin network around the vessels, providing a
seal for the punctured hole [130]. Zderic et al. examined
the long-term eects of HIFU-assisted hemostasis in punctured femoral arteries of rabbits [131]. Prolonged hemostasis over a period of 60 days was observed with no dierence
in blood ow velocities and hematocrit levels at the end of
the study [131]. Long-term safety of ultrasound to provide
hemostasis in acute organ injuries to the spleen and liver
has been also established in animal models [132,134].
Ultrasonic hemostasis strategy employs a high-intensity
beam of ultrasound, which is focused on the ruptured vasculature to achieve rapid heating (tissue temperature
exceeding 70 C), leading to coagulative necrosis of the
tissue and hemostasis [136,137]. Although this apparent
cauterization of the tissue should be classied as a direct
thermal bioeect of ultrasound, several post-exposure
observations reveal active recovery of the injured site a
biological response of ultrasound exposure resulting in
healing and prolonged hemostasis. For example, Vaezy

Ultrasound nds much of its therapeutic applications

from thermal, physical and mechanical eects on cells
and tissues. Such direct eects of ultrasound can induce
stresses in cells and tissues leading to several long-term
recovery responses. Increasingly, such ultrasound-induced
biological responses are being innovatively engineered to
therapies including tissue healing and rejuvenation, cancer
treatment, immune adjuvancy, arteriogenesis and hemostasis. At a tissue level, most of the observed ultrasonic therapeutic benets are mediated by an inammatory response
resulting in a coordinated recruitment of cells as seen in
accelerated tissue regeneration, activation of immune cells
in vaccination, or in stimulated growth of vasculature. Several cellular responses to ultrasound have been reported,
but only a handful of these eects such as upregulation
of key proteins have been therapeutically implicated.
Mechanistically, the exact biochemical pathways behind
ultrasonic therapies are not completely clear and often
many studies in the literature report conicting results.
For example, ultrasound has been reported to activate epidermal immune cells, while direct ultrasound exposure to
immune cells has been also demonstrated to suppress their
activity. Inconsistencies in the literature might arise due to
usage of dierent ultrasound parameters resulting in activation of dierent biochemical pathways (such as apoptosis
vs. necrosis). Another source of discrepancies is the
diculty in transforming ex vivo (cellular-level) results to
animal-level studies due to signicant dierences in ultrasonic bioeects at a tissue level and actuation of homeostatic mechanisms in vivo. Although, ultrasonic therapy

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S. Paliwal, S. Mitragotri / Ultrasonics 48 (2008) 271278

has yielded signicant clinical therapies since its initial

investigations, more than 5 decades ago; an improved
understanding of mechanisms instigating the ultrasonic
biological responses will allow us a better handle over engineering these responses to the clinic.
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