Professional and college sport ATs and military ATs routinely use SAM. We used an email survey of these athletic trainers and a follow-up live panel discussion to determine their use and experience with SAM to treat injuries. Survey and panel participation was voluntary and did not include costs or fees.

The 18-question survey was emailed to members of the NATA using SurveyMonkey^® 7-days before the panel review. Survey participants were requested to have experience using SAM treatment for sports-medicine-related injuries and participate in live and virtual panel discussions in reviewing real-time results at the time of the meeting. The data was collected by Survey-Monkey^® cloud-based data capture.

The acquisition of data on the practical application of SAM was two-fold. First, ATs were asked to complete questionnaires with specific questions about SAM treatment, clinical utilization, use of topical therapeutics, and overall confidence in the therapeutic approach. This included questions about patient attitude, treatment response, and compliance (Table 1); data were collected and coded using Survey-Monkey ^®. A total of 97 written responses were received over seven days.

In the second phase, an open panel review of survey results and questions was conducted via live meeting and Zoom video conferencing. 142 ATs attended the 2-hour long virtual-and-in-person panel meeting. The panel was open to everyone in the panel to comment, provide best practice feedback, and review the survey results presented by the hosts. There was no external observer in the panel. Eighteen participants spoke for the direct review of questions. The discussion panel leaders with prior experience in SAM treatment included the paper's authors, Dr. Walters, ATC, EdD, and Dr. Ortiz, D.O., MPH-certified sports physicians and athletic trainers. Both interviewers are males, Dr. Walters has 27 years of experience in physician education, sports medicine, and training, and Dr. Ortiz has 25 years of experience as a researcher and a Family medicine practitioner with specialties in pain management and sports medicine. The participants were selected based on their experiences being athletic trainers and physical therapist and their years of experience with patients. The interviewers had no relationship with the participants. The participants were informed about the interviewers' credentials and background, the interview's purpose, and the survey's synthesis. The panel discussion was closed after the completion of the panel session, and no-repeat interviews or panel discussions were conducted. The data was collected using the standard USA health system requirements and recorded for analysis. Data was analyzed in its raw form without any saturation. The guided discussion focused on specific examples and used case treatment scenarios representative of the survey results. The authors' synthesis of the discussion and summary of the panel review covered relevant aspects of collegiate sports athletic training, professional sports athletic training, military training, pain management, physical medicine, and rehabilitation. The data was analyzed using content analysis based on the responses from the participants. Field notes were made during the panel discussion and recorded for data analysis. The data was not saturated, considering this was a first-time study.

According to the U.S. Bureau of Labor Statistics, approximately 32,100 ATs were employed in 2019. The NATA database further breaks down the employment of ATs, which identifies areas of ATs employed actively: 6,099 or 19% College/University, 642 or 2% Professional Sports, and 642 or 2% Emerging Settings, including the military [48]. Therefore, the survey population was estimated to be 7,383 for collegiate, professional, and military ATs in the United States. A sample size power analysis for the survey with 95% confidence and 10% margin of error provides the sample respondence size of n=95. All the statistical analyses were conducted using R (The R Project for Statistical Computing). Results from the survey data were expressed in percentages and analyzed with a standard two-sample proportion test, t-tests, and ANOVA as appropriate for response grouping or individual response selection with significance set at p<0.05. Power calculation of sampling was utilized for generalizability of respondents surveyed, and statistical evaluation of survey data was used to determine if trends in the survey data and subgroups were meaningful among the ATs in using SAM therapy.

Data from the written survey and live discussion of athletic trainers are presented here. The respondents provided information on their experience with SAM. They included their positions and levels of experience as ATs, the number of patients treated with SAM, and their age range. Members of all ten NATA districts in the United States participated in the survey (Table 2). Responses for the clinical utilization of SAM included the type of injuries treated, length and duration of treatment, and sonophoresis of topical NSAIDs for enhanced pain relief. They also gave their input on the acceptance and compliance of the athletes using SAM, including patient emotional state, expectations, and satisfaction with treatment.

3.1.3. Timing and Length of Treatment for the Healing Response

SAM was prescribed for 2-4 hours per day by a significant majority of the surveyed ATs (60.9%, p<0.001). Some replied that their injured athletes used it for more than 4 hours daily (24.2%). A minority of ATs recommended it for only 1-2 hours daily (14.9%).

Fig. (1). Patient benefits from the use of SAM combined with topical medication for pain management.

Some ATs reported that their athletes responded to SAM within one week (25.3%). However, most gave 1-2 weeks as the usual length of treatment needed to see a definitive healing boost from SAM (69%, p<0.001). Virtually all the remaining responses indicated improvement by 4-8 weeks (5.8%). Eighty-one-point four percent (81.4%) of all respondents gave an 80-100% confidence expectancy that SAM would provide a positive tissue healing response within 30 days (p<0.001).

Two (2) physicians led the panel discussion with in-person and virtual attendees. Participants identified themselves as licensed or certified ATs, physical therapists, and medical professionals involved in professional sports, college sports, and military sports medicine. The format was an open question-and-answer forum, where the panel moderators reviewed the survey results and introduced questions based on the survey. Participants responded with their own experiences in each subject area.

Question: When and how soon do you notice the benefits of SAM on patients?

Response: SAM treatment provides a strong clinical response in 1-2 weeks. There is an immediately improved joint range of motion, vasodilation and heating of tissue in a single treatment. Adding a topical NSAID in the coupling patch and SAM treatment can provide near-immediate relief from pain for patients using SAM.

Question Is there any treatment difference based on the size (BMI) of the patient as it relates to the efficacy profile for osteoarthritis [51]?

Response: SAM is an ultrasound-based therapeutic and will penetrate deep tissue. An osteoarthritis study was performed with patients with high BMIs treating relatively larger joints, which found SAM effective [42, 51, 52]. Ultrasound wave interactions allow two transducers combined to produce a higher cumulative treatment depth, allowing the ultrasound to penetrate deeper into the tissue. Therefore, for a larger patient, two transducers applied close together will have an additive effect for a therapeutic benefit. Other types of energy therapy (electromagnetic), for example, laser therapy, are not additive like mechanical/ultrasonic energy in this way and cannot effectively treat a larger joint the way SAM can.

Question: How soon can you apply SAM after an acute injury when treating chronic vs. acute injuries? How does treatment benefit an acute injury?

Response: It is more beneficial to treat an acute injury rather than resolve a lingering injury later. It is unnecessary to let the tissue initiate the healing process before applying SAM; the sooner treatment is applied, the better it is for returning the athlete to play. SAM stimulates all phases of the healing process, which has been documented in science. With an injury such as a rotator cuff tear that requires surgical intervention, SAM can be used immediately post-operatively; however, it is not a sterile device and cannot be put over fresh wounds, so the device must be applied proximal to the incision sites. In this scenario, ATs use SAM as soon as the patient can tolerate the treatment on their skin.

Question: Where do ATs use SAM on the body most often?

Response: SAM is used by most participants for tendon and ligament injuries. Treatment sites include shoulder and bicep tendonitis. Patellar tendonitis overuse injuries from basketball jumping respond well to SAM. Patients are told what to expect and use the device for 4-hour daily treatments. Patients show good compliance and recover within a couple of weeks. Football ATs like SAM for their tendon and hamstring injuries. We use the treatment regularly during our 3-hour team meeting windows.

SAM is beneficial in healing bone fractures. The panel discussed the treatment of athletes who have fractured metatarsals, clavicles, and ribs. After 3 weeks of SAM treatment, fractures are usually halfway healed, and at 6 weeks, they are healed completely, allowing the athlete to play again. The panel agreed that it takes six to eight weeks for a minor fracture to heal completely with SAM.

Question: How long does it take for your patients to respond to SAM treatment?

Response: After 1-2 weeks, the treatment benefit is very clear, with treated patients showing a better range of motion, improved function, and about 50% faster healing than patients not receiving SAM treatment.

Question: What conditions show improvement in response in less than a week?

Response: About a quarter of the respondents said their patients responded to SAM in less than a week. In less than one week, conditions improved, including acute tendonitis, muscle damage, inflammation, joint stiffness, and severe metatarsal pain.

Question: How quickly do patients respond to SAM with and without topical NSAID?

Response: Diclofenac within the SAM patch is helpful in older populations, usually alleviating pain within a day or two. A football athlete with a rib fracture showed a significant decrease in pain within 3 weeks. The patient was not x-rayed weekly to minimize radiation exposure. After 5 weeks of SAM therapy, 7 days a week, 4 hours a day, he healed without tenderness and could play.

Question: About half of survey respondents did not use topical drugs with SAM. What limits or prevents you from using it? When would you think about trying it for a patient's treatment?

Response: SAM alone works well for pain modulation by helping soft tissue injuries heal. ATs would consider using a topical drug with SAM treatment if the patient does not respond to SAM alone.

Question: What are the most common injuries you target for healing with SAM?

Response: In football, soft tissue traumas are treated, including hamstring strains, ankle sprains, and tendinopathies. Both acute and chronic injuries respond well to SAM.

Question: Is there anything in the patient demographic where you only treat pain with SAM? Is reducing pain a secondary healing effect, or is it something you're targeting?

Response: Chronic joint pain, where athletes can't pinpoint the source of their pain or an arthritic shoulder or knee that may be already past the healing stage, are targets for SAM. Good results are seen when treating just for pain.

Question: The military will be the second-largest employer of ATs in the United States. Are you treating acute trauma like athletes or more chronic conditions?

Response: It is a combination of both acute and chronic injuries. Military personnel is “tactical athletes.” The major type of injury varies with the location of deployment. There is no “off-season,” as there is for athletics, for recovery. The training cycle is constant, and they need to recover. The military works with the “aging operator” population 28-40 years old with chronic arthritic joints. It is high mileage, high wear-and-tear job. Personnel sustains a lot of acute injuries during training.

Question: Are military patients faced with cognitive dysfunctions due to medications required to ease the pain?

Response: Military patients are not significantly challenged with pain drugs that change their mental acuity or ability to perform during training. There is mostly no pharmacological intervention because patients don't want to become compromised and unable to fight. Ex-Military pain patients are good patients for SAM. They are compliant with their treatment regimen. Providers are encouraged to focus on SAM in aging populations with chronic injuries, not just younger athletes.

Question: About 60% of respondents dosed their patients with SAM for 2-4 hours a day. When would you recommend more than 4 hours?

Response: It is time-dependent and depends on our time with the athlete. Most patients take SAM home for a 4-hour dose. If that is not feasible, then a one to two-hour dose during meetings. Some athletes are nervous that they will have an adverse reaction to SAM, so we set the first dose for two hours. We have to tell patients to wear it a little longer than 4 hours to sustain healing and to bump it up to 20,000 joules for patients who can only wear it 2-3 times per week. It's tough sometimes to get the SAM treatment time in. Travel, hotel time, and downtime are good for getting in multi-hour treatments on athletes.

Question: How receptive are your patients to treatment and following instructions? How are you coaching patients to ensure they are using SAM appropriately?

Response: First, pick patients who will not lose the device and use it. It is also essential to educate the patient on how the device operates. For example, sometimes it vibrates and turns red. Tell them, “Do not take it off!” Some patients take it off too early because they misinterpret its signals, especially on their feet, so make sure they understand what will happen when used.

Question: How do you coach patients to ensure they use it appropriately?

Response: Do not throw it away! Do not take it off if it vibrates and the light turns red and blue. We tell the athletes to stay with treatment and remove the device if it hurts.

Question: How has treatment reduced the need for oral pain medicine?

Response: More than 80% of respondents say at least 50% of their athletes take less oral pain medication, and 20% report a substantial reduction in medication with SAM treatment. Patients can use a local analgesic patch with SAM to load the area with NSAID without systemic medication. It is a great approach to reducing total NSAID use on the body.

Question: What are the early indications for treatment success?

Response: I think the biggest indication is that athletes ask for it because it works for them.

Question: Rate your satisfaction with drug delivery and sonophoresis with SAM.

Response: 55% found that SAM with a topical agent is helpful, but 35% don't use a topical agent at all. If an athlete is nonresponsive to pain reduction with SAM or has an inflammatory healing response, the addition of a topical agent is recommended.

Question: About 73% of respondents stated that injured athletes showed noticeable major mood changes after an injury. Are there certain stigmas out there that, once damaged, a player can no longer play?

Response: Depression directly correlates to the amount of time the athlete is expected to miss across most sports settings. They will be more depressed if they are out longer. An athlete with a sprained ankle could be out for 6 weeks. There's a negative stigma around being pulled out of the sport with an injury or illness. If a college player is hurt in their draft-eligible year, it is important to understand what is at stake situationally.

Question: The survey shows a 50% increase in confidence levels in athletes returning to play after SAM treatment. Is this confidence important?

Response: SAM is an important and advanced treatment option for musculoskeletal injuries. For athletes, SAM noticeably augments their rehabilitation and return to sport. We ensure the athletes are reacclimatized to 100% effort during the return to play and utilize SAM during reintroduction. A multi-modal approach is recommended and helps rebuild the athletes' confidence before returning.

Question: Where would you like to see more research and evidence on sustained acoustic medicine as healthcare providers? Do you want to see more basic mechanisms of action on biological response? More clinical trials to help understand its effect on athletes? What area of research is most influential to you?

Response: Human clinical outcomes, with possible effects on ligament tears that don't involve surgery, would be better so that athletes are not out for as long.

Question: What would you like to see as a control group in clinical studies?

Response: Standard of care compared to standard of care plus SAM would compare with what is usually done and look at the factors involved. Another interesting study would be using mechanical stimulation with SAM to stimulate full-body recovery instead of just the area of injury. Does wearing the SAM unit help recovery even after the athlete returns to active play?

ATs are interested in seeing if SAM could help with nerve injury, pain in the lower back, or arthritis.

The panel of ATs agreed that SAM is a beneficial therapy for athletic injuries, including trauma to joints, muscles, bones, tendons, and ligaments. SAM is also part of their treatment protocol for pain management, general recovery, and post-operative healing. Most ATs prescribed SAM treatment for 2-4 hours per day. In addition, participants felt that SAM should be utilized as soon as possible after an injury, the exception being that it should not be applied over an open wound.

Sonophoresis of topical pain medications with SAM was used by less than half of the ATs; nevertheless, 83% indicated that SAM alleviated pain in their patients.

An important observation is that SAM therapy gave ATs and athletes high confidence in their recovery. In addition, enhanced speed and strength of the recovery and a reduction in the use of oral pain medications led to positive physical and psychological responses. The participants were asked to provide their feedback about the panel session toward the end of the panel. Participants were excited about the panel session and encouraged to hold such sessions in the future.

In the future, panel participants would like to see data on the non-surgical healing of ligament tears and general use to stimulate full-body recovery.