Increased circulation with sustained acoustic medicine

Abstract

Methods for increasing local blood circulation in soft tissue, treating musculoskeletal tissue, and treating soft tissue of a subject are described. Continuous, non-pulsed ultrasound energy can be applied to a target tissue region, such as with a wearable ultrasound transducer. The ultrasound energy can be delivered at an intensity suitable for sustained application for at least 60 minutes. A statistically significant increase in local blood circulation can be achieved within 10 minutes of initiating application, occurring before a statistically significant increase in tissue temperature. In some embodiments, a topical non-steroidal anti-inflammatory drug (NSAID) is applied to the target region during ultrasound application. In some embodiments, local blood circulation is monitored using laser Doppler flowmetry until a statistically significant increase in perfusion units is detected. The increase in local blood circulation can be effective to alleviate pain and accelerate recovery from a soft tissue injury.

Description

PATENT Attorney Docket No. 6381.022WO1 (AKG)INCREASED CIRCULATION WITH SUSTAINED ACOUSTIC MEDICINECROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims priority benefit of U.S. Provisional Patent Application Serial No. 63 / 739,557, filed December 28, 2024, the disclosure of which is hereby incorporated by reference herein in its entirety.GOVERNMENT RIGHTS STATEMENT

[0002] This invention was made with Government support under grant number MD015912 awarded by the National Institutes of Minority Health and Health Disparities. The Government has certain rights in the invention.FIELD

[0003] The present disclosure generally relates to, inter alia, the use of sustained acoustic medicine to improve and increase circulation in a subject, thereby alleviating pain and accelerating recovery from soft tissue injuries in subjects in need thereof.BACKGROUND

[0004] Musculoskeletal (MSK) disorders, which affect approximately 1.71 billion people globally, are a leading cause of disability and economic burden, with their prevalence steadily increasing due to the aging population. These conditions account for an estimated 0.2% of the global gross domestic product (GDP) (1, 2). In the U.S. alone, the annual cost of treating MSK disorders exceeds $125 billion (3). Beyond the economic impact, MSK disorders are linked to cardiovascular diseases, chronic depression, insomnia, and a diminished quality of life.

[0005] Blood circulation plays an essential role in treating MSK disorders. Enhanced blood flow (hyperemia) improves tissue oxygenation, metabolic activity, and the clearance of damaged tissue (4). Studies have shown that increased tissue temperature correlates with localized hyperemia (5-7) Low-intensity ultrasound (US) generates acoustic mechanical waves, inducing mechanical and thermal forces that travel through a medium. The propagation of acoustic waves through biological tissue induces tissue, cellular, molecular, and genetic responses. The biomechanical forces induce the alignment of the extracellular matrix, activatingPATENT Attorney Docket No. 6381.022WO1 (AKG)transmembrane integrin, ion channels, receptors, and downstream pathways (6, 8). US has been shown to enhance endothelial nitric oxide (eNOS) synthase activity, increasing localized production of nitric oxide, which is known to increase blood flow, smooth muscle relaxation, and vasodilation (9, 10). US increases localized muscle temperature, leading to increase blow flow Long-duration continuous ultrasound serves as an effective modality to stimulate localized mechanical and thermal effects, promoting vasodilation, cellular proliferation, inflammation resolution, tissue regeneration, and pain relief (11-16).

[0006] Sustained Acoustic Medicine (SAM) is an FDA-approved, noninvasive, wearable medical device delivering localized ultrasound therapy. SAM operates at 3 MHz and 132 mW / cm2, providing 18,700 joules of energy over a four-hour treatment duration (17, 18). The therapy induces vigorous diathermic effects (>4°C over local temperature), increasing localized tissue temperature, accelerating healing, and alleviating MSK pain (7, 19-23). SAM’s acoustic ultrasound waves generate biomechanical forces, compression and rarefaction, which form localized cavitation bubbles in the skin and enhance its permeability (24). This diametric effect loosens the extracellular matrix, further improving transdermal drug delivery (25, 26).

[0007] Diclofenac sodium, a cyclooxygenase (COXI and COX2) inhibitor, is a widely used non-steroidal anti-inflammatory drug (NS AID) for treating chronic inflammatory and degenerative MSK conditions (27-29). The inhibition of COXI suppresses the expression of prostaglandin E2, a key modulator of inflammation and pain. COX2 upregulates inflammation and tissue degradation by activating inflammatory pathways (27, 30, 31). Additionally, diclofenac modulates cytokine expression, decreasing levels of pro-inflammatory mediators such as tumor necrosis factor-alpha (TNF-a) and interleukin- 10 (IL- 1(3), further contributing to its analgesic and anti-inflammatory properties (27, 29, 32). However, oral diclofenac often results in systemic side effects, including gastrointestinal, cardiovascular, and neurological complications (29). Topical formulations of diclofenac are safer with limited efficacy due to poor skin permeability (33).

[0008] There is a need for improved ultrasound coupling gels, patches, and devices for use in ultrasound therapies that involve an increase of circulation in a subject.

[0009] The present disclosure is directed to overcoming these and other deficiencies in the art.PATENT Attorney Docket No. 6381.022WO1 (AKG)SUMMARY OF THE DISCLOSURE

[0010] The present disclosure relates to, inter alia, methods of increasing local blood circulation in soft tissue using continuous ultrasound energy, methods of treating musculoskeletal tissue using ultrasound energy in combination with topical nonsteroidal antiinflammatory drugs, and methods of treating soft tissue using ultrasound energy while monitoring local blood circulation with laser Doppler flowmetry.

[0011] The present disclosure provides improved treatment methods for soft tissue and musculoskeletal tissue in subjects in need of such treatment. For example, the present disclosure provides a sustained, low-intensity, continuous, high-frequency ultrasound treatment (SAM) that produces a statistically significant increase in local circulation before a significant increase in tissue temperature, with the circulation increase occurring within ~10 minutes and being sustained throughout treatment.

[0012] The present disclosure also provides continuous, low-intensity ultrasound delivered over extended durations that produces a rapid onset of circulation increase without requiring high power or pulsed delivery.

[0013] The present disclosure also provides methods of sustained acoustic medicine that increases circulation even when combined with vasoconstrictive NS AIDs, contrary to expected pharmacological effects.

[0014] The present disclosure also provides methods of defining effective ultrasound therapy by achieving specific, reproducible circulation thresholds within defined time intervals.

[0015] The present disclosure also provides methods for continuous ultrasound applied at one location produces measurable circulation that increases in adjacent or offset tissue regions.

[0016] The present disclosure also provides methods for increasing circulation via mechanotransduction without reliance on achieving peak tissue temperature.

[0017] The present disclosure also provides a treatment protocol in which therapeutic efficacy is achieved within a defined early time window and sustained throughout long-duration ultrasound application.

[0018] The present disclosure provides methods for enhanced drug uptake and delivery by increasing local circulation to the region of the drug depot within the drug coupling patch. By increasing local blood flow to a target area of a subject, the methods of the present disclosure are also effective to increase drug up-take and delivery into the body of the subject. Therefore, inPATENT Attorney Docket No. 6381.022WO1 (AKG)certain aspects, the present disclosure provides a multi-modal effect with continuous long duration ultrasound.

[0019] Provided below is a summary of certain aspects of the present disclosure.Group 1: Increasing local blood circulation in soft tissue using continuous, non-pulsed ultrasound

[0020] A therapeutic method includes increasing local blood circulation in soft tissue of a subject by applying continuous, non-pulsed ultrasound energy to a target tissue region using a wearable ultrasound transducer. The ultrasound energy can be delivered at an intensity suitable for sustained application for at least 60 minutes (but could be for less time), including protocols in which the ultrasound energy is applied for long durations such as up to about 12 hours, up to about 4 hours, and / or up to about 1 hour. In some implementations, the ultrasound energy is delivered according to a treatment interval between about 10 minutes and about 60 minutes, and / or according to longer intervals that include at least 60 minutes of continuous application.

[0021] The method can be configured such that a statistically significant increase in local blood circulation is achieved within 10 minutes of initiating the application of the ultrasound energy. The increase in local blood circulation can be sustained for the duration of the application of the ultrasound energy. Tissue heating can occur as a later effect, such that a statistically significant increase in tissue temperature occurs after the increase in local blood circulation. As used herein, statistically significant can be defined as p < 0.05.

[0022] In some implementations, the ultrasound energy is applied in a manner effective to cause a statistically significant increase in local blood circulation after about 10 minutes of applied ultrasound energy treatment, and the statistically significant increase in local blood circulation can occur at least about 10 minutes before a statistically significant increase in local temperature is reached in the target tissue region. In one set of implementations, the statistically significant increase in local blood circulation includes an increase of at least about 20.93 perfusion units (PU) (95% CI: 12.89-28.87; p=0.0001) compared to placebo at 50 minutes with a standard coupling gel, and / or at least about 21.56 PU (95% CI: 15.92-27.21; p=0.001) versus placebo at 50 minutes with diclofenac gel. In some implementations, the increase in local temperature is between about 2.0-2.7°C.PATENT Attorney Docket No. 6381.022WO1 (AKG)

[0023] The ultrasound energy can be delivered using an ultrasound system effective to deliver ultrasound energy to the target tissue region at a frequency of between about 2.8 MHz and 3.1 MHz. In some implementations, the ultrasound system includes a sustained acoustic medicine therapy device effective to provide continuous high-frequency, low-intensity, long-duration ultrasound, including operation at 2.8-3.1 MHz, 132 mW / cm2, and about 779.17-4675 Joules of energy delivered to the target tissue region.

[0024] The ultrasound system can include one or more ultrasound transducers placed in and / or adjacent to the target tissue region. The one or more ultrasound transducers can be removable to facilitate placement, repositioning, reuse, and / or replacement. In some implementations, the ultrasound system includes two ultrasound transducers placed on opposite ends of the target tissue region to deliver acoustic energy across the region. The ultrasound system can include a wearable ultrasound transducer portion and / or a flexible ultrasound transducer portion to improve conformance to anatomy, comfort during extended wear, and maintenance of acoustic coupling during movement.

[0025] The ultrasound system can include at least one ultrasound transducer, a power source operably connected to the at least one ultrasound transducer, and a coupling gel. The coupling gel can be effective for operably coupling to the at least one ultrasound transducer to apply ultrasound energy to the target tissue region of the subject. The coupling gel can be a nonmedicated coupling medium and / or a medicated coupling medium that includes a topical pharmaceutical agent, as described further below.

[0026] The ultrasound energy can be delivered as deep tissue ultrasound therapy. In deep tissue implementations, the therapy can deliver therapeutic acoustic energy to a depth of up to about 10 centimeters into the target tissue region, including depths between about 3 and 5 cm and / or between about 0.1-0.3 cm, depending on transducer configuration, tissue type, and treatment objective.

[0027] The increase in local blood circulation can be effective to alleviate pain and accelerate recovery from a soft tissue injury in the target tissue region. The soft tissue injury can include any damage to muscles, tendons, and / or ligaments in the target region. Example soft tissue injuries include contusions, strains, sprains, tendonitis, and / or bursitis.

[0028] The target tissue region can include any suitable anatomical portion of the subject, including the head, neck, thorax, abdomen, and / or pelvis. The target tissue region canPATENT Attorney Docket No. 6381.022WO1 (AKG)additionally or alternatively include an upper extremity region such as a shoulder, arm, elbow, forearm, wrist, and / or hand, and / or a lower extremity region such as a quadricep, hamstring, gluteus maximus, gastrocnemius, ankle, foot, and / or knee.

[0029] In some implementations, the method further includes delivering a nonsteroidal anti-inflammatory drug (NSAID) to the subject’s target tissue region to improve treatment. The NSAID can be applied topically, including via a medicated coupling gel, and / or via a separate topical formulation applied to the skin and then coupled to the ultrasound transducer using a coupling medium. Example NSAIDs include diclofenac, diclofenac sodium, diclofenac sodium with misoprostol, diclofenac potassium, flunixin meglumine, phenylbutazone, aspirin, acetaminophen, diflunisal, dipyrone, ketorolac, etodolac, tepoxalin, fenoprofen calcium, flurbiprofen, ibuprofen, indomethacin, celecoxib, ketoprofen, vedaprofen, meclofenamate sodium, mefenamic acid, tolfenamic acid, meloxicam, carprofen, nabumetone, naproxen, naproxen sodium, etoricoxib, piroxicam, tolmetin sodium, magnesium salicylate, choline salicylate, salsalate, sodium salicylate, alkyl salicylate, and / or disalicylate.

[0030] The increased local blood circulation can be effective for treating conditions including a musculoskeletal condition, soft tissue injury, pain relief, inflammation, osteoarthritis, rhematic arthritis, contusion, ligament injury, muscle spasm, tendinopathy, and / or bone fracture healing.

[0031] In certain embodiments, a statistically significant increase in tissue temperature can occur after the increase in local blood circulation.

[0032] In certain embodiments, the ultrasound energy is applied using an ultrasound system effective to deliver ultrasound energy to the target tissue region, where the ultrasound system includes a sustained acoustic medicine therapy device having components effective for divergent beam ultrasound, continuous ultrasound, and / or long duration ultrasound.

[0033] Moreover, the methods of the present disclosure can involve the use of the sustained acoustic medicine therapy device to apply divergent beam ultrasound, continuous ultrasound, and / or long duration ultrasound, including a combination of two or all three of these.

[0034] In certain embodiments, the method can further involve delivering a therapeutic drug suitable for treating the target tissue region, where applying the continuous ultrasound energy to the target tissue region is effective to increase delivery and efficacy of the therapeutic drug by pushing the therapeutic drug into the target tissue region so as to improve treatment,PATENT Attorney Docket No. 6381.022WO1 (AKG)where the therapeutic drug can include, without limitation, a nonsteroidal anti-inflammatory drug (NSAID).

[0035] In certain embodiments, the method can further involve delivering a therapeutic drug suitable for treating the target tissue region, where by applying the ultrasound energy to increase the local blood circulation in the target tissue region, it is then effective to increase delivery and efficacy of the therapeutic drug by pulling the therapeutic drug further into the target tissue region, thereby improving treatment, where the therapeutic drug can include, without limitation, a nonsteroidal anti-inflammatory drug (NSAID).

[0036] In certain embodiments, the method can further involve a multimodal delivery of a therapeutic drug suitable for treating the target tissue region. In certain embodiments, the multimodal delivery can include both (i) a first mode of applying continuous ultrasound energy to the target tissue region so as to be effective to increase delivery and efficacy of the therapeutic drug by pushing the therapeutic drug into the target tissue region so as to improve treatment, and (ii) a second mode of applying the ultrasound energy so as to increase the local blood circulation in the target tissue region so as to be effective to increase delivery and efficacy of the therapeutic drug by pulling the therapeutic drug into the target tissue region so as to improve treatment, where combining the first mode and the second mode can achieve a synergistic effect to increase delivery and efficacy of the therapeutic drug in treating the target tissue region, and where the therapeutic drug can include, without limitation, a nonsteroidal anti-inflammatory drug (NSAID).

[0037] In certain embodiments, the method of multimodal delivery of the therapeutic drug involves applying the first mode so as to be effective to first push the therapeutic drug into the target tissue region of the subject and then applying the second mode so as to be effective to then pull the therapeutic drug further into the target tissue region due to the increase in local blood circulation.

[0038] In accordance with the present disclosure, in certain aspects, the increased local blood circulation in combination with the local delivery of drug enhances drug delivery and uptake into the body by convection from the acoustic streaming and increased blood flow.PATENT Attorney Docket No. 6381.022WO1 (AKG)Group 2: Treating musculoskeletal tissue using continuous ultrasound and a topical NSAID during application

[0039] A method of treating musculoskeletal tissue of a subject includes applying continuous ultrasound energy to a target musculoskeletal tissue region of the subject for at least 60 minutes, and applying a topical NSAID to the target musculoskeletal tissue region during application of the ultrasound energy. Statistically significant can be defined as p < 0.05.

[0040] The continuous ultrasound energy can be delivered such that it produces a statistically significant increase in local blood circulation relative to a placebo ultrasound treatment. In this context, the placebo ultrasound treatment can be implemented using a sham protocol that mimics device placement and wear time while withholding therapeutic acoustic output, thereby allowing comparison of blood circulation metrics under active versus placebo conditions.

[0041] The method can further be configured such that the increase in local blood circulation is not reduced relative to ultrasound application with a non-medicated coupling medium. For example, when the topical NSAID is delivered using a medicated coupling medium (e.g., a diclofenac gel) during ultrasound application, local blood circulation under the medicated coupling medium can be comparable to, and not reduced relative to, local blood circulation achieved using a standard non-medicated coupling gel under otherwise similar ultrasound settings.

[0042] Any suitable aspects of the ultrasound delivery and anatomical targeting described for Group 1 can also be used for this musculoskeletal-tissue treatment, including use of a wearable and / or flexible ultrasound transducer portion, removable transducers, one transducer and / or multiple transducers (including two transducers placed on opposite ends of the target region), and an ultrasound system that includes at least one ultrasound transducer coupled to a power source. The ultrasound energy can be continuous and non-pulsed, and can be delivered at frequencies between about 2.8 MHz and 3.1 MHz and / or using continuous high-frequency, low-intensity, long-duration ultrasound settings such as 132 mW / cm2and about 779.17-4675 Joules delivered to the target region. Deep tissue ultrasound therapy and corresponding treatment depths (including up to about 10 cm, between about 3 and 5 cm, and / or between about 0.1-0.3 cm) can also be used, depending on the musculoskeletal target.PATENT Attorney Docket No. 6381.022WO1 (AKG)

[0043] Likewise, any suitable topical NSAID described for Group 1 can be used here, including diclofenac and other NSAIDs listed above, delivered in a manner coordinated with ultrasound application so that the topical NSAID is present at the target musculoskeletal tissue region during at least a portion of the continuous ultrasound application interval.Group 3: Treating soft tissue with continuous ultrasound while monitoring blood circulation using laser Doppler flowmetry

[0044] A method of treating soft tissue of a subject includes applying continuous ultrasound energy to a target soft tissue region of the subject and monitoring local blood circulation using laser Doppler flowmetry. The method further includes continuing the application of the ultrasound energy until a statistically significant increase in perfusion units is detected within 10 minutes of ultrasound energy initiation. Statistically significant can be defined as p < 0.05.

[0045] Laser Doppler flowmetry can be used to generate perfusion unit values over time for the target soft tissue region. The method can include establishing a baseline perfusion unit measurement (or baseline distribution) prior to initiating ultrasound, initiating continuous ultrasound energy delivery, and determining — based on the laser Doppler flowmetry output — that perfusion units increase to a statistically significant extent within 10 minutes of initiation. The method can be configured such that the statistically significant increase in perfusion units is detected prior to a statistically significant increase in tissue temperature.

[0046] Any suitable aspects of the continuous ultrasound application described for Group 1 can also be applied in this monitoring-based treatment approach, including delivering continuous, non-pulsed ultrasound energy using a wearable ultrasound transducer, delivering ultrasound at an intensity suitable for sustained application (including at least 60 minutes and / or longer duration protocols), using coupling gel to operably couple the transducer to the target soft tissue region, and using system configurations such as removable transducers, flexible transducer portions, and / or two transducers positioned on opposite ends of a target region. Frequencies between about 2.8 MHz and 3.1 MHz, energy delivery levels such as about 779.17-4675 Joules, and deep tissue delivery depths up to about 10 cm (including between about 3 and 5 cm and / or between about 0.1-0.3 cm) can also be used.PATENT Attorney Docket No. 6381.022WO1 (AKG)

[0047] In some implementations, the method further includes concurrently or sequentially applying a topical NSAID to the target tissue region (including via a medicated coupling gel) while still using laser Doppler flowmetry to confirm that perfusion unit increases remain statistically significant and occur prior to detectable statistically significant temperature increases, thereby supporting protocols that emphasize early perfusion response as a control point for continuing therapy.

[0048] These and other objects, features, and advantages of this invention will become apparent from the following detailed description of the various aspects of the invention taken in conjunction with the accompanying drawings.BRIEF DESCRIPTION OF THE DRAWINGS

[0049] For the purpose of illustrating aspects of the present invention, there are depicted in the drawings certain embodiments of the invention. However, the invention is not limited to the precise arrangements and instrumentalities of the embodiments depicted in the drawings. Further, if provided, like reference numerals contained in the drawings are meant to identify similar or identical elements.

[0050] Figure 1 is a CONSORT flow diagram of study inclusion / exclusion test subjects, randomization, calibration, baseline, and intervention period.

[0051] Figures 2A-2B illustrate a sustained acoustic medicine (SAM) stimulation setup, Figure 2A are photographs of subjects with application to lateral forearm position for all four study groups (A-D). Figure 2B are graphic illustrations of SAM xl and probe positioning.

[0052] Figure 3 is a graph illustrating normalized circulation is below lateral forearm skin averaged at each 10 min segment for baseline and stimulation periods. (*** p < 0.005, **** p < 0.0005 between Coupling Gel + Placebo and Coupling + SAM, ### p < 0.005, #### p < 0.0005 between 2.5% Diclofenac).

[0053] Figure 4 is a graph illustrating normalized temperature change at lateral forearm skin averaged at each 10 min segment for baseline and stimulation periods. (*** p < 0.005, **** p < 0.0005 between Coupling Gel + Placebo and Coupling + SAM, ### p < 0.005, #### p < 0.0005 between 2.5% Diclofenac Gel + Placebo and Diclofenac + SAM, Error bar represent (SEM)). SEM bars are present in placebo groups however they are not visible.PATENT Attorney Docket No. 6381.022WO1 (AKG)

[0054] Figure 5 is a graph illustrating cumulative circulation changes at the lateral forearm over 60 min treatment period. (*** p < 0.005, **** p < 0.0001 between Coupling Gel + Placebo and Coupling + SAM, ### p < 0.005, #### p < 0.0001 between 2.5% Diclofenac Gel + Placebo and Diclofenac + SA, Error bar represent (SEM)).DETAILED DESCRIPTION

[0055] The present disclosure generally relates to, inter alia, the use of sustained acoustic medicine to improve and increase circulation in a subject, thereby alleviating pain and accelerating recovery from soft tissue injuries in subjects in need thereof.

[0056] The disclosed invention provides wearable sustained acoustic medicine (SAM) systems configured to deliver continuous, low-intensity, high-frequency ultrasound over extended durations to localized soft tissue, producing early and sustained increases in blood circulation while concurrently enabling enhanced transdermal drug delivery, such as with a 2.5% diclofenac or gel capture patch. Unlike conventional short-duration or pulsed ultrasound devices, the SAM embodiments achieve statistically significant circulation increases within approximately 10 minutes of treatment, with tissue temperature rises occurring later, demonstrating that hyperemia is driven by mechanotransductive effects rather than thermal effects alone. Critically, the presence of diclofenac does not diminish circulation or diathermic effects, enabling a drug-device combination therapy that improves perfusion and supports sonophoresis without compromising safety or efficacy. These embodiments are distinguished from prior art by providing long-duration, continuous stimulation that produces cumulative perfusion gains, early vasodilation, and NSAID-compatible drug delivery, representing a novel method of treating musculoskeletal pain, inflammation, and soft-tissue injury with both therapeutic ultrasound and topical pharmacological agents.

[0057] In certain aspects, the present disclosure involves the use of SAM’s mechanotransducive and thermal properties that are emitted from the transducer during ultrasound treatment. More specifically, the present disclosure involves the use of SAM devices and systems in significantly increasing local circulation. The present disclosure further relates to the use of SAM devices and systems for improved recovery applications for soft tissue injuries.PATENT Attorney Docket No. 6381.022WO1 (AKG)

[0058] In certain embodiments, the present disclosure involves the use of SAM devices and systems in therapeutic methods that are effective in increasing local circulation in the subject being treated throughout the first hour of treatment duration.

[0059] Various SAM devices and systems for use in the aspects of the present disclosure can be found, without limitation, in U.S. Patent No. 9,492,687, U.S. Patent No. 11,724,130, U.S. Patent Application Publication No. US 2020 / 0061393-Al, U.S. Patent the disclosures of which are hereby incorporated by reference herein.

[0060] The methods of the present disclosure can be used with various ultrasound coupling patches, wearable ultrasound devices, and ultrasound therapeutic technology in the art. Samples of such complementary technology for use with the high density ultrasound coupling gel, devices, systems, and methods of the present disclosure include, without limitation, the following: WO2011 / 082402 (Ultrasound Coupling Device); WO2011 / 082407 (Portable Ultrasound System); WO2011 / 082408 (Low-Profile Ultrasound Transducer); WO2011 / 163570 (Hydrogel Ultrasound Coupling Device); WO2014 / 210063 (Low-Profile, Low-Frequency, and Low-Impedance Broad-Band Ultrasound Transducer and Methods Thereof); W02014 / 210065 (Wearable Ultrasound Device); W02015 / 130841 (Limited Use Ultrasonic Coupling Device); WO2018 / 102828 (Ultrasound Coupling Patch with Gel Capture Feature); and W02020 / 046847 (Flexible and Wearable Long Duration Ultrasound Device), the disclosures of which are hereby incorporated by reference in their entirety.

[0061] Suitable ultrasound devices for use with the method of the present disclosure can include any ultrasound device or ultrasound system that is configured or functional to apply therapeutic ultrasound to a mammalian subject (humans, animals, marine mammals). Suitable ultrasound devices and systems can include, without limitation, the Sustained Acoustic Medicine (SAM) ultrasound devices, ultrasound systems, and ultrasonic diathermy medical devices (ZetrOZ Systems LLC., Trumbull, CT).

[0062] In certain embodiments, the method of the present disclosure can include applying a nonsteroidal anti-inflammatory drug (NSAID) and sodium.

[0063] In certain embodiments, the NSAID includes, without limitation, diclofenac, diclofenac sodium, diclofenac sodium with misoprostol, diclofenac potassium, flunixin meglumine, phenylbutazone, aspirin, acetaminophen, diflunisal, dipyrone, ketorolac, etodolac, tepoxalin, fenoprofen calcium, flurbiprofen, ibuprofen, indomethacin, celecoxib, ketoprofen,PATENT Attorney Docket No. 6381.022WO1 (AKG)vedaprofen, meclofenamate sodium, mefenamic acid, tolfenamic acid, meloxicam, carprofen, nabumetone, naproxen, naproxen sodium, etoricoxib, piroxicam, tolmetin sodium, magnesium salicylate, choline salicylate, salsalate, sodium salicylate, alkyl salicylate, disalicylate, and the like.

[0064] In certain embodiments, the ultrasound coupling device is wearable.

[0065] In certain embodiments, the ultrasound coupling device is flexible.

[0066] In certain embodiments, the ultrasound coupling device is in the form of a gel patch and is made using measurements and techniques known to those of ordinary skill in the art. For example, the ultrasound coupling device can be manufactured by providing or producing the high density ultrasound coupling gel of the present disclosure and filling a compartment (patch) with the gel, and then sealing the compartment (patch). Various types of compartments and patch configurations are found in the art as referenced herein.

[0067] As provided herein, the ultrasound devices of the present disclosure can be manufactured and assembled using standard materials and techniques known in the art and / or taught herein, as long as the gel used to make the ultrasound system is a high density ultrasound coupling gel according to the present disclosure. To reiterate, the ultrasound device can include, without limitation, a SAM gel patch for use in a therapeutic ultrasound system such as SAM (ZetrOZ Systems, Trumbull, CT). See also WO2011 / 082402 (Ultrasound Coupling Device); WO2011 / 082407 (Portable Ultrasound System); WO2011 / 082408 (Low-Profile Ultrasound Transducer); WO2011 / 163570 (Hydrogel Ultrasound Coupling Device); W02014 / 210063 (Low-Profile, Low-Frequency, and Low-Impedance Broad-Band Ultrasound Transducer and Methods Thereof); WO2014 / 210065 (Wearable Ultrasound Device); W02015 / 130841 (Limited Use Ultrasonic Coupling Device); WO2018 / 102828 (Ultrasound Coupling Patch with Gel Capture Feature); and W02020 / 046847 (Flexible and Wearable Long Duration Ultrasound Device), the disclosures of which are hereby incorporated by reference in their entirety.

[0068] In another aspect, the present disclosure relates to the use of an ultrasound system that includes: (i) at least one ultrasound transducer; (ii) a power source operably connected to the ultrasound transducer; and (iii) a high density ultrasound coupling gel according to the present disclosure. The high density ultrasound coupling gel is effective for operably coupling to the at least one ultrasound transducer to apply therapeutic ultrasound energy to a subject.PATENT Attorney Docket No. 6381.022WO1 (AKG)

[0069] As provided herein, the ultrasound system of the present disclosure can be manufactured and assembled using standard materials and techniques known in the art and / or taught herein, as long as the gel used with the ultrasound system is a high density ultrasound coupling gel according to the present disclosure. To reiterate, the ultrasound system can include, without limitation, a SAM ultrasound system (ZetrOZ Systems, Trumbull, CT). See also WO2011 / 082402 (Ultrasound Coupling Device); WO2011 / 082407 (Portable Ultrasound System); WO2011 / 082408 (Low-Profde Ultrasound Transducer); WO2011 / 163570 (Hydrogel Ultrasound Coupling Device); WO2014 / 210063 (Low-Profile, Low-Frequency, and Low-Impedance Broad-Band Ultrasound Transducer and Methods Thereof); W02014 / 210065 (Wearable Ultrasound Device); W02015 / 130841 (Limited Use Ultrasonic Coupling Device); WO2018 / 102828 (Ultrasound Coupling Patch with Gel Capture Feature); and W02020 / 046847 (Flexible and Wearable Long Duration Ultrasound Device), the disclosures of which are hereby incorporated by reference in their entirety.

[0070] The methods of treatment of the present disclosure can be used in accordance with any long-duration ultrasound therapeutic treatment protocols, devices, and systems, including, without limitation, in low-intensity continuous ultrasound (LICUS), Sustained Acoustic Medicine (SAM), long-duration low intensity therapeutic ultrasound (LITUS) treatment protocols, devices, and systems.Section 1: Method of Increasing Local Blood Circulation in Soft Tissue

[0071] A method of increasing local blood circulation in soft tissue of a subject includes applying continuous, non-pulsed ultrasound energy to a target tissue region of a subject using a wearable ultrasound transducer. The ultrasound energy is delivered at an intensity suitable for sustained application for at least 60 minutes (but could be for less time). A statistically significant increase in local blood circulation is achieved within 10 minutes of initiating the application of the ultrasound energy, where statistically significant is defined as p < 0.05. A statistically significant increase in tissue temperature occurs after the increase in local blood circulation. The increase in local blood circulation is sustained for a duration of the application of the ultrasound energy.

[0072] The ultrasound energy can be applied using an ultrasound system effective to deliver ultrasound energy to the target tissue region for a period of between about 10 and 60PATENT Attorney Docket No. 6381.022WO1 (AKG)minutes at a frequency of between about 2.8 MHz and 3.1 MHz. The ultrasound system can include a sustained acoustic medicine therapy device effective to provide continuous high-frequency, low-intensity long-duration ultrasound of 2.8-3.1 MHz, 132 mW / cm2, and 779.17-4675 Joules of energy to the target tissue region.

[0073] The ultrasound system can include one or more ultrasound transducers placed in and / or adjacent to the target tissue region, where the one or more ultrasound transducers are removable. The ultrasound system can include two ultrasound transducers placed on opposite ends of the target tissue region. The ultrasound system can include at least one ultrasound transducer, a power source operably connected to the at least one ultrasound transducer, and a coupling gel, where the coupling gel is effective for operably coupling to the at least one ultrasound transducer to apply ultrasound energy to the target tissue region of the subject.

[0074] The ultrasound system can include a wearable ultrasound transducer portion. The ultrasound system can include a flexible ultrasound transducer portion. These features allow the ultrasound system to be worn comfortably by the subject during extended treatment periods while maintaining effective acoustic coupling to the target tissue region.

[0075] The ultrasound energy can be applied in a manner effective to cause a statistically significant increase in local blood circulation after about 10 minutes of applied ultrasound energy treatment. The statistically significant increase in local blood circulation can occur at least about 10 minutes before a statistically significant increase in local temperature is reached in the target tissue region. This temporal separation between blood flow enhancement and temperature elevation represents a novel characteristic of the treatment approach, indicating that the increase in blood circulation is not merely a thermal effect but represents a distinct biological response to the ultrasound energy.

[0076] The statistically significant increase in local blood circulation can include at least about 20.93 PU (95% CI: 12.89-28.87; p=0.0001) compared to placebo at 50 minutes with standard gel and / or at least about 21.56 PU (95% CI: 15.92-27.21; p=0.001) versus placebo at 50 minutes with diclofenac gel. The increase in local temperature can be between about 2.0-2.7°C. This modest temperature increase, combined with the substantial blood flow enhancement, demonstrates that the method achieves significant therapeutic effects without excessive heating that could damage tissue and / or cause discomfort to the subject.PATENT Attorney Docket No. 6381.022WO1 (AKG)

[0077] The increase in local blood circulation in the target tissue region of the subject can be effective to alleviate pain and accelerate recovery from a soft tissue injury in the target tissue region of the subject. The soft tissue injury can include any damage to muscles, tendons, and / or ligaments in the target region. The soft tissue injury can be selected from the group consisting of contusions, strains, sprains, tendonitis, bursitis, and the like. Enhanced blood circulation delivers increased oxygen, nutrients, and immune cells to the injured tissue while facilitating removal of metabolic waste products and inflammatory mediators, thereby promoting tissue repair and reducing pain.

[0078] The target tissue region can include any portion of the subject selected from the group consisting of the head, neck, thorax, abdomen, pelvis, an upper extremity including a shoulder, arm, elbow, forearm, wrist, and / or hand, and a lower extremity including a quadricep, hamstring, gluteus maximus, gastrocnemius, ankle, foot, and / or knee. This broad applicability across multiple anatomical locations demonstrates the versatility of the method for treating soft tissue injuries and conditions throughout the body.

[0079] The ultrasound energy can include long duration ultrasound therapy of up to about 12 hours, up to about 4 hours, and / or up to about 1 hour. The extended treatment duration is made possible by the low-intensity nature of the ultrasound energy, which can be safely applied for prolonged periods without causing tissue damage and / or excessive heating. The ultrasound energy can include deep tissue ultrasound therapy. The deep tissue ultrasound therapy can deliver therapeutic acoustic energy to a depth of up to about 10 centimeters (cm), between about 3 and 5 cm, and / or between about 0.1-0.3 cm into the target tissue region of the subject. This depth penetration allows treatment of both superficial and deep soft tissue structures.

[0080] The method can further include delivering a nonsteroidal anti-inflammatory drug (NSAID) to the subject's target tissue region to improve treatment. The NSAID can be selected from the group consisting of diclofenac, diclofenac sodium, diclofenac sodium with misoprostol, diclofenac potassium, flunixin meglumine, phenylbutazone, aspirin, acetaminophen, diflunisal, dipyrone, ketorolac, etodolac, tepoxalin, fenoprofen calcium, flurbiprofen, ibuprofen, indomethacin, celecoxib, ketoprofen, vedaprofen, meclofenamate sodium, mefenamic acid, tolfenamic acid, meloxicam, carprofen, nabumetone, naproxen, naproxen sodium, etoricoxib, piroxicam, tolmetin sodium, magnesium salicylate, choline salicylate, salsalate, sodium salicylate, alkyl salicylate, and disalicylate. The combination of ultrasound therapy with NSAIDPATENT Attorney Docket No. 6381.022WO1 (AKG)delivery can provide synergistic therapeutic benefits, with the enhanced blood circulation potentially improving drug distribution within the target tissue region.

[0081] The increase in local blood circulation can be effective for treating conditions selected from the group consisting of a musculoskeletal condition, soft tissue injury, pain relief, inflammation, osteoarthritis, rheumatic arthritis, contusion, ligament injury, muscle spasm, tendinopathy, and bone fracture healing. The broad therapeutic applicability reflects the fundamental role of adequate blood perfusion in tissue health, healing, and pain management across diverse pathological conditions.

[0082] In certain embodiments, a statistically significant increase in tissue temperature can occur after the increase in local blood circulation.

[0083] In certain embodiments, the ultrasound energy is applied using an ultrasound system effective to deliver ultrasound energy to the target tissue region, where the ultrasound system includes a sustained acoustic medicine therapy device having components effective for divergent beam ultrasound, continuous ultrasound, and / or long duration ultrasound. Moreover, the methods of the present disclosure can involve the use of the sustained acoustic medicine therapy device to apply divergent beam ultrasound, continuous ultrasound, and / or long duration ultrasound, including a combination of two or all three of these.

[0084] In certain embodiments, the method can further involve delivering a therapeutic drug suitable for treating the target tissue region, where applying the continuous ultrasound energy to the target tissue region is effective to increase delivery and efficacy of the therapeutic drug by pushing the therapeutic drug into the target tissue region so as to improve treatment, where the therapeutic drug can include, without limitation, a nonsteroidal anti-inflammatory drug (NSAID).

[0085] In certain embodiments, the method can further involve delivering a therapeutic drug suitable for treating the target tissue region, where by applying the ultrasound energy to increase the local blood circulation in the target tissue region, it is then effective to increase delivery and efficacy of the therapeutic drug by pulling the therapeutic drug further into the target tissue region, thereby improving treatment, where the therapeutic drug can include, without limitation, a nonsteroidal anti-inflammatory drug (NSAID).

[0086] In certain embodiments, the method can further involve a multimodal delivery of a therapeutic drug suitable for treating the target tissue region. In certain embodiments, thePATENT Attorney Docket No. 6381.022WO1 (AKG)multimodal delivery can include both (i) a first mode of applying continuous ultrasound energy to the target tissue region so as to be effective to increase delivery and efficacy of the therapeutic drug by pushing the therapeutic drug into the target tissue region so as to improve treatment, and (ii) a second mode of applying the ultrasound energy so as to increase the local blood circulation in the target tissue region so as to be effective to increase delivery and efficacy of the therapeutic drug by pulling the therapeutic drug into the target tissue region so as to improve treatment, where combining the first mode and the second mode can achieve a synergistic effect to increase delivery and efficacy of the therapeutic drug in treating the target tissue region, and where the therapeutic drug can include, without limitation, a nonsteroidal anti-inflammatory drug (NSAID).

[0087] In certain embodiments, the method of multimodal delivery of the therapeutic drug involves applying the first mode so as to be effective to first push the therapeutic drug into the target tissue region of the subject and then applying the second mode so as to be effective to then pull the therapeutic drug further into the target tissue region due to the increase in local blood circulation.

[0088] In accordance with the present disclosure, in certain aspects, the increased local blood circulation in combination with the local delivery of drug enhances drug delivery and uptake into the body by convection from the acoustic streaming and increased blood flow.Section 2: Method of Treating Musculoskeletal Tissue with Combined Ultrasound and Topical NSAID

[0089] A method of treating musculoskeletal tissue of a subject includes applying continuous ultrasound energy to a target musculoskeletal tissue region of the subject for at least 60 minutes and applying a topical non-steroidal anti-inflammatory drug (NSAID) to the target musculoskeletal tissue region during application of the ultrasound energy. The continuous ultrasound energy produces a statistically significant increase in local blood circulation relative to a placebo ultrasound treatment, where statistically significant is defined as p < 0.05. The increase in local blood circulation is not reduced relative to ultrasound application with a nonmedicated coupling medium.

[0090] This method addresses a technical challenge in combining ultrasound therapy with topical pharmaceutical agents. The finding that local blood circulation enhancement isPATENT Attorney Docket No. 6381.022WO1 (AKG)maintained when using an NSATD-containing coupling medium, compared to a non-medicated coupling medium, demonstrates that the topical NS AID does not interfere with the hemodynamic effects of the ultrasound energy. This allows clinicians to simultaneously achieve both enhanced blood perfusion and targeted anti-inflammatory drug delivery without compromising either therapeutic modality.

[0091] The continuous ultrasound energy can be applied using any of the ultrasound systems and configurations described in Section 1, including wearable ultrasound transducers, flexible ultrasound transducer portions, and / or systems with one or more removable ultrasound transducers. The ultrasound energy can be delivered at a frequency of between about 2.8 MHz and 3.1 MHz for a period of between about 10 and 60 minutes, and / or up to about 12 hours, up to about 4 hours, and / or up to about 1 hour.

[0092] The ultrasound system can include a sustained acoustic medicine therapy device effective to provide continuous high-frequency, low-intensity long-duration ultrasound of 2.8-3.1 MHz, 132 mW / cm2, and 779.17-4675 Joules of energy to the target musculoskeletal tissue region. The ultrasound energy can be delivered at an intensity suitable for sustained application, allowing prolonged treatment periods that enhance both blood circulation and potentially facilitate deeper penetration and / or improved distribution of the topical NSAID.

[0093] The topical NSAID can be formulated as a gel, cream, ointment, patch, and / or other suitable topical formulation that provides acoustic coupling between the ultrasound transducer and the skin surface while delivering the pharmaceutical agent to the target musculoskeletal tissue region. The topical NSAID can be selected from the group consisting of diclofenac, diclofenac sodium, diclofenac sodium with misoprostol, diclofenac potassium, flunixin meglumine, phenylbutazone, aspirin, acetaminophen, diflunisal, dipyrone, ketorolac, etodolac, tepoxalin, fenoprofen calcium, flurbiprofen, ibuprofen, indomethacin, celecoxib, ketoprofen, vedaprofen, meclofenamate sodium, mefenamic acid, tolfenamic acid, meloxicam, carprofen, nabumetone, naproxen, naproxen sodium, etoricoxib, piroxicam, tolmetin sodium, magnesium salicylate, choline salicylate, salsalate, sodium salicylate, alkyl salicylate, and disalicylate.

[0094] The statistically significant increase in local blood circulation can be achieved within 10 minutes of initiating the application of the ultrasound energy, and a statistically significant increase in tissue temperature can occur after the increase in local blood circulation.PATENT Attorney Docket No. 6381.022WO1 (AKG)The statistically significant increase in local blood circulation can occur at least about 10 minutes before a statistically significant increase in local temperature is reached in the target musculoskeletal tissue region. The statistically significant increase in local blood circulation can include at least about 20.93 PU (95% CI: 12.89-28.87; p=0.0001) compared to placebo at 50 minutes with standard gel and / or at least about 21.56 PU (95% CI: 15.92-27.21; p=0.001) versus placebo at 50 minutes with diclofenac gel.

[0095] The target musculoskeletal tissue region can include any portion of the subject selected from the group consisting of the head, neck, thorax, abdomen, pelvis, an upper extremity including a shoulder, arm, elbow, forearm, wrist, and / or hand, and a lower extremity including a quadricep, hamstring, gluteus maximus, gastrocnemius, ankle, foot, and / or knee. The method can be effective for treating musculoskeletal conditions including soft tissue injury, pain relief, inflammation, osteoarthritis, rheumatic arthritis, contusion, ligament injury, muscle spasm, tendinopathy, and bone fracture healing.

[0096] The combined application of continuous ultrasound energy and topical NSAID provides synergistic therapeutic benefits. The ultrasound-induced increase in local blood circulation can enhance delivery and distribution of the NSAID within the target tissue, while the NSAID provides anti-inflammatory and analgesic effects that complement the tissue healing benefits of enhanced perfusion. The maintained blood circulation response despite the presence of the NSAID indicates that these therapeutic mechanisms operate through complementary rather than interfering pathways.Section 3: Method of Treating Soft Tissue with Real-Time Perfusion Monitoring

[0097] A method of treating soft tissue of a subject includes applying continuous ultrasound energy to a target soft tissue region of the subject, monitoring local blood circulation using laser Doppler flowmetry, and continuing the application of the ultrasound energy until a statistically significant increase in perfusion units is detected within 10 minutes of ultrasound energy initiation. The increase in perfusion units is detected prior to a statistically significant increase in tissue temperature, where statistically significant is defined as p < 0.05.

[0098] This method incorporates real-time monitoring of the physiological response to ultrasound therapy, allowing verification that the desired therapeutic effect — enhanced blood circulation — is being achieved during the treatment session. Laser Doppler flowmetry providesPATENT Attorney Docket No. 6381.022WO1 (AKG)continuous, non-invasive measurement of microvascular blood perfusion in the target soft tissue region, expressed in perfusion units. This monitoring capability allows clinicians to confirm that the ultrasound system is properly positioned and operating effectively, and to detect the characteristic temporal sequence in which blood circulation increases before tissue temperature rises significantly.

[0099] The continuous ultrasound energy can be applied using any of the ultrasound systems and configurations described in Section 1, including wearable ultrasound transducers, flexible ultrasound transducer portions, and / or systems with one or more removable ultrasound transducers. The ultrasound energy can be delivered at a frequency of between about 2.8 MHz and 3.1 MHz. The ultrasound system can include a sustained acoustic medicine therapy device effective to provide continuous high-frequency, low-intensity long-duration ultrasound of 2.8-3.1 MHz, 132 mW / cm2, and 779.17-4675 Joules of energy to the target soft tissue region.

[0100] The ultrasound energy can be delivered at an intensity suitable for sustained application for at least 60 minutes, and / or can include long duration ultrasound therapy of up to about 12 hours, up to about 4 hours, and / or up to about 1 hour. The ultrasound energy can be applied for a period of between about 10 and 60 minutes. The extended treatment duration allows for sustained enhancement of blood circulation throughout the treatment period.

[0101] The laser Doppler flowmetry monitoring provides quantitative measurement of blood perfusion changes in real time. The statistically significant increase in perfusion units can include at least about 20.93 PU (95% CI: 12.89-28.87; p=0.0001) compared to placebo at 50 minutes with standard gel and / or at least about 21.56 PU (95% CI: 15.92-27.21; p=0.001) versus placebo at 50 minutes with diclofenac gel. The detection of increased perfusion units within 10 minutes of ultrasound energy initiation, prior to significant tissue temperature increase, confirms the non-thermal mechanism by which the ultrasound energy enhances blood circulation.

[0102] The increase in local tissue temperature, when it occurs after the blood circulation increase, can be between about 2.0-2.7°C. This modest temperature elevation indicates that the method achieves therapeutic blood flow enhancement without excessive heating. The temporal separation between perfusion increase and temperature increase can be at least about 10 minutes, providing a clear window during which the hemodynamic response can be distinguished from thermal effects.PATENT Attorney Docket No. 6381.022WO1 (AKG)

[0103] The ultrasound energy can include deep tissue ultrasound therapy that delivers therapeutic acoustic energy to a depth of up to about 10 centimeters (cm), between about 3 and 5 cm, and / or between about 0.1-0.3 cm into the target soft tissue region of the subject. The laser Doppler flowmetry can be configured to monitor blood circulation at appropriate tissue depths corresponding to the ultrasound penetration depth, ensuring that perfusion measurements reflect the tissue region receiving therapeutic ultrasound energy.

[0104] The target soft tissue region can include any portion of the subject selected from the group consisting of the head, neck, thorax, abdomen, pelvis, an upper extremity including a shoulder, arm, elbow, forearm, wrist, and / or hand, and a lower extremity including a quadricep, hamstring, gluteus maximus, gastrocnemius, ankle, foot, and / or knee. The method can be effective for treating soft tissue injuries including any damage to muscles, tendons, and / or ligaments in the target region, such as contusions, strains, sprains, tendonitis, bursitis, and the like.

[0105] The increase in local blood circulation monitored by laser Doppler flowmetry can be effective to alleviate pain and accelerate recovery from a soft tissue injury in the target soft tissue region of the subject. The increase in local blood circulation can be effective for treating conditions selected from the group consisting of a musculoskeletal condition, soft tissue injury, pain relief, inflammation, osteoarthritis, rheumatic arthritis, contusion, ligament injury, muscle spasm, tendinopathy, and bone fracture healing.

[0106] The method can further include delivering a nonsteroidal anti-inflammatory drug (NSAID) to the subject's target soft tissue region to improve treatment, as described in Sections 1 and 2. The NSAID can be applied topically during application of the ultrasound energy, and the laser Doppler flowmetry can be used to verify that the increase in local blood circulation is not reduced relative to ultrasound application with a non-medicated coupling medium. The NSAID can be selected from the group consisting of diclofenac, diclofenac sodium, diclofenac sodium with misoprostol, diclofenac potassium, flunixin meglumine, phenylbutazone, aspirin, acetaminophen, diflunisal, dipyrone, ketorolac, etodolac, tepoxalin, fenoprofen calcium, flurbiprofen, ibuprofen, indomethacin, celecoxib, ketoprofen, vedaprofen, meclofenamate sodium, mefenamic acid, tolfenamic acid, meloxicam, carprofen, nabumetone, naproxen, naproxen sodium, etoricoxib, piroxicam, tolmetin sodium, magnesium salicylate, choline salicylate, salsalate, sodium salicylate, alkyl salicylate, and disalicylate.PATENT Attorney Docket No. 6381.022WO1 (AKG)

[0107] The real-time monitoring capability provided by laser Doppler flowmetry allows the method to be adapted and optimized during treatment. If the expected increase in perfusion units is not detected within the anticipated timeframe, adjustments can be made to ultrasound transducer positioning, coupling medium application, ultrasound intensity, and / or other treatment parameters to ensure effective therapy delivery. This feedback mechanism improves treatment reliability and allows verification of therapeutic efficacy during the treatment session rather than relying solely on delayed clinical outcomes.EXAMPLE

[0108] The following example is intended to illustrate particular embodiments of the present disclosure, but are by no means intended to limit the scope of the present disclosure.Example 1:Sustained Acoustic Medicine Increases Local Circulation with a Diclofenac Delivery Patch:A Randomized Placebo Controlled StudyAbstract[00109J Background: Sustained Acoustic Medicine (SAM) is a non-invasive long-term wearable device that delivers localized long duration high-frequency continuous ultrasound. SAM’s biomechanical and diathermic stimuli enhance local circulation and oxygenation, accelerate tissue healing, and alleviate pain. The sonophoresis effects of SAM further improve transdermal drug delivery. Diclofenac is a topical Nonsteroidal anti-inflammatory drug for treating localized musculoskeletal (MSK) pain. Its efficacy is significantly dependent on skin porosity. This study aims to determine the diathermic effects of SAM and diclofenac on localized blood circulation. Moreover, this single-blind, placebo-controlled study aims to evaluate the impact of SAM-induced hyperemia and diathermic effects on the transdermal delivery of 2.5% diclofenac ultrasound gel compared to standard ultrasound gel.

[0110] Methods: Sixty -four healthy participants were randomly assigned to four groups (Active SAM group: H = 32, Placebo SAM group: H = 32): (A) Coupling gel + placebo SAM), (B) Coupling gel + active SAM, (C) 2.5% Diclofenac gel + placebo SAM, and (D) 2.5% Diclofenac gel + active SAM. Both forearms were treated with a placebo and active SAMPATENT Attorney Docket No. 6381.022WO1 (AKG)devices for 1 h. The blood flux (perfusion units, PU) and temperature (degrees centigrade) change were recorded at 10 min intervals for 60 min using high-laser-power Doppler flowmetry. Blood circulation and temperature were recorded and reported (Clinical trial Identifier: NCT06510062).

[0111] Results: SAM increased blood flow significantly over 60 min by 19.2 PU ( / ?<0.0001) with coupling patch and 18.6PU with 2.5% diclofenac patch (p< 0.0001) vs. placebo. Surface level tissue temperature increased by A2.4°C (p < 0.0001) with gel coupling patch and A2.2°C (p < 0.0001) with 2.5% diclofenac patch vs. placebo ultrasound treatment (p < 0.0001). There was no significant difference between standard coupling ultrasound gel and 2.5% diclofenac gel in blood flow and temperature. SAM provided a significant temperature increase at 20 min and a circulation increase at 10 min, which remained for the duration of the 60 min. All participants completed the study with no adverse events.

[0112] Conclusion: SAM treatment significantly increases local blood circulation after 10 min, increases temperature after 20 min, and sustains the effects of SAM’s stimulation. The 2.5% diclofenac gel does not affect SAM’s biological effects to increase local circulation. The study concludes that the application of diclofenac does not affect the diathermic properties of SAM exposure while enhancing the efficacy of diclofenac delivery through sonophoresis.Materials and MethodsParticipants:

[0113] Sixty-seven (n = 67) healthy adults (male and female) between the ages of 18 to 50 were screened by a board-certified medical officer. Individuals were excluded if they did not meet age criteria, were pregnant or nursing, had a history of hypertension or cardiovascular disorders, had recently had coronary artery bypass graft surgery (within the past six months), had known allergic reactions to diclofenac or other NSAIDs, or had prior treatment for MSK disorders. Following this screening process, 64 participants were enrolled in the study.

[0114] Participants were recruited through flyers, social media, word of mouth, and collaborations with local physician practices. All volunteers underwent physical examinations, reviewed the Case Report Form (CRF), and informed consent with the research assistant and medical director for eligibility confirmation before enrollment.PATENT Attorney Docket No. 6381.022WO1 (AKG)Study Design:

[0115] A voluntary, randomized, single-site, placebo-controlled study was conducted at ZetrOZ Systems (Trumbull, CT). Participants were randomized with a random number generator. The study was registered on ClinicalTrials.gov (Identifier: NCT06510062) and received approval from the Advarra Institutional Review Board (IRB) (Protocol ID:Pro00080714). All the participants signed a written informed consent form, and the study adhered to Good Clinical Practice (GCP) guidelines. Sixty-four (n = 64) healthy participants, male and female, (Table 1) were randomly assigned to four groups (n = 32): A) Coupling gel + placebo SAM), B) Coupling gel + active SAM, C) 2.5% Diclofenac gel + placebo SAM, and D) 2.5% Diclofenac gel + active SAM (Figure 1). All the female participants were not postmenopausal. For groups A and C, placebo treatments were administered to the left forearm, while active SAM treatments were applied to the right forearm in a contralateral design. For groups B and D, placebo treatments were administered to the right forearm, while active SAM treatments were applied to the left forearm (Figure 2). The treatment side was selected by flipping a coin.TABLE 1: Patient demographic information for all enrolled test subjects.

[0116] Participants were instructed to refrain from strenuous exercise and only indulge in day-to-day activities. The study was conducted during daily working hours (9 am — 5 pm EST) in a well-controlled environment at 20°C. Participants were seated comfortably in an upright position for 15 min before and throughout the 60 min stimulation period (Figure 2). A high-power Laser Doppler Flowmetry (LDF) probe was positioned 2.5 cm distal to the elbow, between the two SAM xl transducers, to monitor changes in blood circulation and skin temperature during stimulation. Patches were placed over the cables 5 cm equidistant from the probe’s laser location to minimize any excess movement from the LDF device. Participants were checked every 15 min to ensure comfort and were permitted to watch pre-selected televisionPATENT Attorney Docket No. 6381.022WO1 (AKG)shows or listen to music during the procedure. Each participant received $100 compensation at the completion of the study.

[0117] Continuous data acquisition was performed using the LDF software provided by the manufacturer during a 5 min calibration period, a 10 min baseline period, and a subsequent 60 min stimulation period. Measurements were recorded at 10 min intervals throughout the entire baseline and stimulation periods for analysis. No data was analyzed during the 5 min calibration period.Instrumentation:

[0118] The study utilized the dual SAM xl device and four ultrasound coupling patches (two per forearm) to deliver active or placebo ultrasound treatment for one hour per subject. All the devices were new and calibrated prior to application. The patches were prefilled with 3 ml of coupling gel containing either standard coupling ultrasound gel or 2.5% diclofenac gel (Compounded Solutions, Monroe, CT).

[0119] A high-power Laser Doppler Flowmetry (LDF) system (VMS-LDF2-HP, Moor Instruments, UK), connected to non-invasive skin probes (VP2-V2-HP), was employed to measure real-time circulation and skin temperature. The system operated with a 785 nm, 20 mW laser, and probes were calibrated with polystyrene latex particle suspensions before each session, following manufacturer instructions. The LDF system continuously recorded data during the 1 h, 15 min protocol.

[0120] Circulation was quantified as flux perfusion units (PU), representing the red blood cell movement rate at 1-3 mm below the skin’s surface, alongside temperature in degrees Celsius. Data was analyzed using moorVMS-PC research software and exported into Excel for biostatistical analysis.

[0121] This study, supported by Minority Health and Health Disparities (Project ID: MD015912), assessed the mechanotransduction performance of the wireless SAM xl device (model SA551) with diclofenac and aqueous coupling gels.Statistical Analysis:

[0122] A statistical analysis was conducted to evaluate differences in blood flow and temperature between placebo and active treatment arms using coupling and 2.5% diclofenac gel.PATENT Attorney Docket No. 6381.022WO1 (AKG)The primary factor analyzed was the SAM stimulation (active or placebo), with gel type (waterbased or diclofenac gel) considered as an interaction factor. Raw data was aggregated, normalized in Microsoft Excel, and analyzed by an independent biostatistician using R programming.

[0123] Data analysis included baseline and treatment intervals measured every 10 min. A two-way ANOVA was employed to compare group means and assess the independent and interaction effects of SAM active or placebo treatment and aqueous or 2.5% diclofenac gel type. A post hoc test was used to determine p-values for the two-way ANOVA data. Descriptive statistics for demographic data were calculated using chi-square tests for categorical variables and t-tests for the means between the active and placebo groups at the 10 min intervals.

[0124] Statistical significance was defined as p < 0.05, with results presented as mean ± standard deviation (SD) unless stated otherwise. Confidence intervals (95%) and p-values were reported to provide additional statistical context. Graphical representations, including error bars denoting standard error of the mean (SEM), and data tables were generated using R and Excel.ResultsSubject Enrollment Demographics:

[0125] Sixty-four participants were selected for the study after physical examination and randomly assigned to four groups (n = 32), applying for a contralateral study design. The demographic data shows no significant differences between sex, age, BMI, and pulse rate before the start of the stimulation (Table 1).Circulation Results:

[0126] SAM stimulation significantly enhanced circulation and tissue perfusion during 60 min with standard coupling gel or 2.5% Diclofenac gel. With standard coupling gel, circulation increased to a maximum mean difference of 20.93 PU (95% CT: 12.89 to 28.87; p = 0.0001) compared to placebo at 50 min. Similarly, SAM with 2.5% Diclofenac gel achieved a maximum mean difference of 21.56 PU (95% CI: 15.92 to 27.21; p = 0.001) vs. placebo at 50 min (Table 2).PATENT Attorney Docket No. 6381.022WO1 (AKG)TABLE 2: Average change in circulation from baseline to treatment data.

[0127] Both groups exhibited statistically significant increases in circulation compared to placebo at 10 min (Coupling Gel: 95% CI: 0.80 to 3.36; p = 0.0032; Diclofenac Gel: 95% CI: 0.78 to 3.68; p = 0.0037), with effects sustained throughout the duration of stimulation (Figure 3). No significant differences were observed between the two active SAM-stimulated groups, while placebo groups without SAM stimulation showed no significant changes in circulation (Figure 3). These findings show that SAM stimulation effectively enhances circulation, irrespective of the coupling medium.Temperature Results:

[0128] SAM treatment significantly increased tissue temperature over 60 min of stimulation compared to the placebo group. When paired with coupling gel, temperature increased by 2.67°C (95% CI: 2.35 to 2.99, p = 0.0001), while using 2.5% diclofenac gel resulted in a 2.40°C increase (95% CI: 2.04 to 2.75, p = 0.0001) (Table 3). Both SAM-treated groups exhibited a gradual rise in tissue temperature, with significant differences observed after 20 min of stimulation and sustained gradual increases through 60 min. No significant differences were noted between the coupling gel and diclofenac gel groups. The placebo groups did not show temperature change during the 60 min period (Figure 4).PATENT Attorney Docket No. 6381.022WO1 (AKG)TABLE 3: Average change in temperature from baseline to treatment data.TABLE 4: Cumulative circulation flux from baseline to end of treatment.Total Cumulative Circulation Results:

[0129] Temporal cumulative circulation showed a significant increase in both the Coupling Gel and 2.5% Diclofenac Gel groups during 60 min of SAM stimulation. Significant changes were observed as early as 10 min (Coupling Gel: 95% CI, 778.95 to 2926.14, p = 0.0014; 2.5% Diclofenac Gel: 95% CI, 929.72 to 2872.99, p = 0.0004) (Table 4). Over the stimulation period, both treatment groups demonstrated a rapid, sustained increase in blood flow, with mean differences of 116,000 PU (SAM + Coupling Gel) and 136,000 PU (SAM + 2.5% Diclofenac Gel) compared to the respective placebo treatments ( p = 0.0001). Importantly, both active treatments showed similar sustained blood flow increases with SAM stimulation, whereas placebo groups exhibited no significant cumulative flux change over 60 min (Figure 5).PATENT Attorney Docket No. 6381.022WO1 (AKG)Discussion

[0130] Sustained Acoustic Medicine (SAM) stimulation significantly improves blood circulation and induces diathermic effects in soft tissue when applied with standard ultrasound coupling gel or 2.5% diclofenac gel during a 60 min session. Importantly, adding diclofenac sodium does not alter SAM’s hyperemia or diathermic effects. Placebo groups exhibited no localized blood flow or temperature changes, confirming that these effects are directly attributable to SAM stimulation.

[0131] Managing musculoskeletal (MSK) disorders necessitate precise modulation of mechanical stress, angiogenesis, tissue perfusion, and inflammatory responses. These processes involve macrophages, neutrophils, mast cells, and cytokines such as interleukins and tumor necrosis factor-alpha (TNF-a) (34). Adequate blood flow is essential to regulate the treatment by ensuring the delivery of oxygen, nutrients, immune cells, and growth factors. Conversely, impaired blood flow or reduced angiogenesis can disrupt the balance between pro- and antiinflammatory cytokines and reduce the expression of key angiogenic and vasodilatory mediators such as vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), and endothelial nitric oxide synthase (eNOS) (35, 36), Biomechanical stimulation, localized shear and axial stress promotes the angiogenesis and blood flow by activating VEGF-2, FGF and eNOS (37-39). Mechanotransduction also regulates inflammatory mediators, including TNF-a, IL-ip, and macrophages (38, 40-43).

[0132] SAM provides targeted biomechanical forces (compression and rarefaction), providing the essential mechanical stimulus to upregulate the expression of VEGF, FDF, and eNOS over a long period of time, enhancing the angiogenesis, blood flow and regulating inflammatory responses (6, 20, 44). The diathermic effects of SAM include thermal stimuli that induce vasodilation, improve blood flow, and stimulate cellular metabolism, proliferation, and tissue regeneration (7, 17, 19). Hendren et al. demonstrated significant temperature increases at 1 cm, 2 cm, and 5 cm depths with SAM stimulation, retaining the high temperature above the therapeutic threshold deep into the tissue with little or no adverse effects (45). The biomechanical and thermal modulation of SAM treatment provides the essential stimuli to induce localized angiogenesis and enhanced blood flow to increase oxygen and nutrients and regulate the inflammatory factors to expedite tissue healing.PATENT Attorney Docket No. 6381.022WO1 (AKG)

[0133] The regulation of the COX1 / COX2 pathway has a crucial role in regulating inflammatory factors and MSK pain. COXI is essential to retain tissue mucosal integrity and platelet aggregation, and Cox2 expression upregulates the inflammation such as IL- 10, TNF-a contributing to pain and tissue degradation (46). Diclofenac sodium, an anti-inflammatory agent, inhibits PGE2 and cytokines like IL- 10, TNF-a, and VEGF. Diclofenac sodium, a non-selective COX inhibitor, effectively reduces these inflammatory mediators. However, prolonged systemic administration is associated with gastrointestinal and renal side effects (47). Topical diclofenac application improves its safety profile, and its efficacy is limited by the low permeability of the stratum comeum (29, 31, 48). Biomechanical and thermal effects disrupt the skin’s lipid bilayers, and losses in the skin’s extracellular matrix increase skin porosity (49). Furthermore, US induced cavitation, formation and oscillation of microbubbles, allow the skin to enhance transdermal drug delivery (49-51). SAM long-duration acoustic stimulation enhances skin permeability, facilitating sustained transdermal drug delivery over a long duration. Masterson et al. observed an increase in vitro diclofenac delivery after 4 h of SAM stimulation (52). Madzia et al. reported significant reductions in knee osteoarthritis pain and improved mobility with SAM plus 1% diclofenac sodium (53). Jarit et al. demonstrated that a 4-week intervention using SAM with 2.5% diclofenac gel resulted in 99.3% of patients experiencing pain reduction and 97.8% showing improved function (54).

[0134] The study shows little or no significant change in the first 10 min of treatment, there is little change in tissue temperature as body adjust to the SAM stimulation, a significant rise was recorded between after 10 min of stimulation and continued over next 40 min (50 min after the start of treatment) as body start accumulate with the biomechanical and thermal stimulation. The change in blood flux followed the same pattern observed in the increase in the local temperature, exhibiting the relation between the temperature increase and blood circulation. The cumulative flux analysis shows that the quantity of blood flow over time significantly increases in the treated site relative to placebo sites. Placebo-treated sites did not show little or no temperature and flux change, indicating that change in blood circulation was due to the SAM treatment and not systemic physiological changes. The presence of 2.5% diclofenac sodium did not alter SAM’s biomechanical or diathermic effects, demonstrating that diclofenac integration does not interfere with the therapeutic ultrasound mechanisms. Both US coupling gel and 2.5% diclofenac gel followed a similar pattern for active and placebo devices, demonstrating that thePATENT Attorney Docket No. 6381.022WO1 (AKG)addition of diclofenac would not affect the SAM thermal and biomechanical effects and making an effective device to be applied for transdermal drug delivery.

[0135] Collectively, SAM combined with diclofenac sodium provides a dual-modality approach that leverages mechanical and thermal stimulation alongside pharmacological antiinflammatory effects, offering a potent and non-invasive strategy for treating MSK disorders. Future research should evaluate the combined efficacy of SAM and topical diclofenac in broader clinical populations, including patients with knee osteoarthritis, low back pain, and other chronic MSK conditions. Furthermore, SAM efficacy with other NSAIDs would be evaluated, and data compared with diclofenac to determine the most effective combination to treat MSK disorders.Conclusion

[0136] Continuous, long-duration ultrasound treatment using the SAMxl device significantly enhances circulation to localized soft tissues. This study demonstrates that SAM effectively increases tissue perfusion with standard ultrasound coupling gel and 2.5% diclofenac gel. Adding diclofenac did not alter the hyperemic and diathermic effects observed throughout the stimulation period. Future studies will explore SAM’s hyperemic and diathermic effects at additional anatomical locations and in populations with specific conditions and MSK disorders.REFERENCES

[0137] Citation of a reference herein shall not be construed as an admission that such reference is prior art to the present invention. All references cited herein are hereby incorporated by reference in their entirety. Below is a listing of various references cited with respect to this example:1. Chen N, Fong DYT, Wong J YH. Health and economic outcomes associated with musculoskeletal disorders attributable to high body mass index in 192 countries and territories in 2019. JAMA Netw Open. (2023) 6(l):e2250674. doi: 10.1001 / jamanetworkopen.2022.50674.2. Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the global burden of disease study 2019: a systematicPATENT Attorney Docket No. 6381.022WO1 (AKG)analysis for the global burden of disease study 2019. Lancet. (2021) 396(10267):2006- 17. doi: 10.1016 / 80140-6736(20)32340-0.3. Gallagher S, Heberger JR. Examining the interaction of force and repetition on musculoskeletal disorder risk: a systematic literature review. Hum Factors. (2013) 55(1): 108-24. doi: 10.1177 / 0018720812449648.4. Gamass KK, Morkved S, Tonne T, Furan L, Vasseljen O, Johannessen HH. Mental health among patients with chronic musculoskeletal pain and its relation to number of pain sites and pain intensity, a cross-sectional study among primary health care patients. BMC Musculoskelet Disord. (2022) 23(1): 1115. doi: 10.1186 / sl2891-022-06051-9.5. Juopperi S, Sund R, Rikkonen T, Kroger H, Sirola J. Cardiovascular and musculoskeletal health disorders associate with greater decreases in physical capability in older women. BMC Musculoskelet Disord. (2021) 22(1): 192. doi: 10.1186 / sl2891-021-04056-4.6. Uddin S, Komatsu D, Motyka T, Petterson S. Low-intensity continuous ultrasound Therapies-A systematic review of current state-of-the-art and future perspectives. J Clin Med. (2021) 10(12):2698. doi: 10.3390 / jcml0122698.7. Petterson S, Plancher K, Klyve D, Draper D, Ortiz R. Low-intensity continuous ultrasound for the symptomatic treatment of upper shoulder and neck pain: a randomized, double-blind placebo-controlled clinical trial. J Pain Res. (2020) 13:1277-87. doi:10.2147 / JPR.S247463.8. Zhou J, Ning E, Lu L, Zhang H, Yang X, Hao Y. Effectiveness of low-intensity pulsed ultrasound on osteoarthritis: molecular mechanism and tissue engineering. Front Med. (2024) 11:1292473. doi: 10.3389 / fmed.2O24.1292473.9. Altland OD, Dalecki D, Suchkova VN, Francis CW. Low-intensity ultrasound increases endothelial cell nitric oxide synthase activity and nitric oxide synthesis. J Thromb Haemostasis. (2004) 2(4):637-43. doi: 10.1111 / j.l538-7836.2004.00655.x.PATENT Attorney Docket No. 6381.022WO1 (AKG)10. Grange rW, Isotani E, Lau KS, Kamm KE, Huang PL, Stull JT. Nitric oxide contributes to vascular smooth muscle relaxation in contracting fast-twitch muscles. Physiol Genomics. (2001) 5(l):35-44. doi: 10.1152 / physiolgenomics.2001.5.1.35.11. Rubira APFDA, Rubira MC, Rubira LDA, Comachio J, Magalhaes MO, Marques AP.Comparison of the effects of low-level laser and pulsed and continuous ultrasound on pain and physical disability in chronic non-specific low back pain: a randomized controlled clinical trial. Adv Rheumatol. (2019) 59(1):57. doi: 10.1186 / s42358-019- 0099-z.12. Chung JI, Min BH, Baik EJ. Effect of continuous-wave low-intensity ultrasound in inflammatory resolution of arthritis-associated synovitis. Phys Ther. (2016) 96(6): 808- 17. doi: 10.2522 / ptj .20140559.13. Gallo JA, Draper DO, Brody LT, Fellingham GW. A comparison of human muscle temperature increases during 3-MHz continuous and pulsed ultrasound with equivalent temporal average intensities. J Orthop Sports Phys Ther. (2004) 34(7):395-401. doi: 10.2519 / jospt.2004.34.7.395.14. Kames JL, Burton HW. Continuous therapeutic ultrasound accelerates repair of contraction-induced skeletal muscle damage in rats. Arch Phys Med Rehabil. (2002) 83(1): 1-4. doi: 10.1053 / apmr.2002.26254.15. Ebadi S, Ansari NN, Henschke N, Naghdi S, van Tulder MW. The effect of continuous ultrasound on chronic low back pain: protocol of a randomized controlled trial. BMC Musculoskelet Disord. (2011) 12:59. doi: 10.1186 / 1471-2474-12-59.16. Morishita K, Karasuno H, Yokoi Y, MorozumI K, Ogihara H, Ito T, et al. Effects of therapeutic ultrasound on intramuscular blood circulation and oxygen dynamics. J Jpn Phys Ther Assoc. (2014) 17(l):l-7. doi: 10.1298 / jjpta.Voll7_001.17. Langer MD, Lewis GK Jr. Sustained acoustic medicine: a novel long duration approach to biomodulation utilizing low intensity therapeutic ultrasound. Proc SPIE Int Soc Opt Eng. (2015):9467.PATENT Attorney Docket No. 6381.022WO1 (AKG)Draper DO. A comparison of traditional ultrasound with, sustained acoustic, medicine (SAM). Am J Biomed Sci & Res. (2019) 51(l):AJBSR.MS.ID.000880. doi:10.34297 / AJBSR.2019.05.000880.Rigby JH, Taggart RM, Stratton KL, Lewis GK, Draper DO. Intramuscular heating characteristics of multihour low-intensity therapeutic ultrasound. J Athl Train. (2015) 50(11): 1158-64. doi: 10.4085 / 1062-6050-50.11.03.Draper DO. The benefits of long duration ultrasound. Biomed J Sci Tech Res. (2019) 18(4): 13728-30. doi: 10.26717 / BJSTR.2019.18.003177.Draper DO, Castel JC, Castel D. Rate of temperature increase in human muscle during 1 MHz and 3 MHz continuous ultrasound. J Orthop Sports Phys Ther. (1995) 22(4): 142-50. doi: 10.2519 / jospt.l995.22.4.142.Draper DO, Edvalson CG, Knight KL, Eggett D, Shurtz J. Temperature increases in the human achilles tendon during ultrasound treatments with commercial ultrasound gel and full-thickness and half-thickness gel pads. J Athl Train. (2010) 45(4):333-7. doi:10.4085 / 1062-6050-45.4.333.Lewis GK Jr., Langer MD, Henderson CR, Ortiz R. Design and evaluation of a wearable self-applied therapeutic ultrasound device for chronic myofascial pain. Ultrasound Med Biol. (2013) 39(8): 1429-39. doi: 10.1016 / j.ultrasmedbio.2013.03.007.Hendrickse P, Degens H. The role of the microcirculation in muscle function and plasticity. J Muscle Res Cell Motil. (2019) 40(2):127-40. doi: 10.1007 / sl0974-019-09520-2.Park D, Park H, Seo J, Lee S. Sonophoresis in transdermal drug deliverys. Ultrasonics. (2014) 54(l):56-65. doi: 10.1016 / j.ultras.2013.07.007.Park J-H, Lee J-W, Kim Y-C, Prausnitz MR. The effect of heat on skin permeability. Int JPharm. (2008) 359(l-2):94-103. doi: 10.1016 / j.ijpharm.2008.03.032.PATENT Attorney Docket No. 6381.022WO1 (AKG)27. Nair B, Taylor-Gjevre R. A review of topical diclofenac use in musculoskeletal disease.Pharmaceuticals. (2010) 3(6): 1892-908. doi: 10.3390 / ph3061892.28. Ogle C. Diclofenac. Conn Med. (1989) 53(10):603-4.29. Small RE. Diclofenac sodium. Clin Pharm. (1989) 8(8):545-58.30. Ku EC, Lee W, Kothari HV, Scholer DW. Effect of diclofenac sodium on the arachidonic acid cascade. Am J Med. (1986) 80(4B): 18-23. doi: 10.1016 / 0002-9343(86) 90074-4.31. Roth SH, Fuller P. Diclofenac topical solution compared with oral diclofenac: a pooled safety analysis. J Pain Res. (2011) 4:159-67. doi: 10.2147 / JPR.S20965.32. Atzeni F, Masala IF, Sarzi-Puttini P. A review of chronic musculoskeletal pain: central and peripheral effects of diclofenac. Pain Ther. (2018) 7(2): 163-77. doi: 10.1007 / s40122-018-0100-2.33. Hagen M, Baker M. Skin penetration and tissue permeation after topical administration of diclofenac. Curr Med Res Opin. (2017) 33(9): 1623-34. doi: 10.1080 / 03007995.2017.1352497.34. Gallo J, Raska M, Kriegova E, Goodman SB. Inflammation and its resolution and the musculoskeletal system. J Orthop Translat. (2017) 10:52-67. doi: 10.1016 / j .jot.2017.05.007.35. Gerwins P, Skoldenberg E, Claesson-Welsh L. Function of fibroblast growth factors and vascular endothelial growth factors and their receptors in angiogenesis. Crit Rev Oncol Hematol. (2000) 34(3): 185-94. doi: 10.1016 / S 1040-8428(00)00062-7.36. Gladwin MT, Crawford JH, Patel RP. The biochemistry of nitric oxide, nitrite, and hemoglobin: role in blood flow regulation. Free Radic Biol Med. (2004) 36(6):707-17. doi : 10.1016 / j .freeradbiomed.2003.11.032.PATENT Attorney Docket No. 6381.022WO1 (AKG)Johnson BM, Johnson AM, Heim M, Buckley M, Mortimer B, Berry JL, et al.Biomechanical stimulation promotes blood vessel growth despite VEGFR-2 inhibition. BMC Biol. (2023) 21(l):290. doi: 10.1186 / sl2915-023-01792-y.Hoefer IE, den Adel B, Daemen MJ. Biomechanical factors as triggers of vascular growth. Cardiovasc Res. (2013) 99(2):276-83. doi: 10.1093 / cvr / cvt089.Gimbrone MA Jr., Anderson KR, Topper JN. Special communi cationthe critical role of mechanical forces in blood vessel development, physiology and pathology. J Vase Surg. (1999) 29(6): 1104-51. doi: 10.1016 / S0741-5214(99)70252-l.Du H, Bartleson JM, Butenko S, Alonso V, Liu WF, Winer DA, et al. Tuning immunity through tissue mechanotransduction. Nat Rev Immunol. (2023) 23(3): 174-88. doi:10.1038 / s41577-022-00761 -w.Diaz MF, Vaidya AB, Evans SM, Lee HJ, Aertker BM, Alexander AJ, et al.Biomechanical forces promote immune regulatory function of bone marrow mesenchymal stromal cells. Stem Cells. (2017) 35(5): 1259-72. doi: 10.1002 / stem.2587.Uddin SMZ, Richbourgh B, Ding Y, Hettinghouse A, Komatsu DE, Qin Y-X, et al.Chondro-protective effects of low intensity pulsed ultrasound. Osteoarthr Cartil. (2016) 24(11): 1989-98. doi: 10.1016 / j.joca.2016.06.014.Huang RB, Eniola-Adefeso O. Shear stress modulation of IL- 1 beta-induced E-selectin expression in human endothelial cells. PLoS One. (2012) 7(2):e31874. doi:10.1371 / journal. pone.0031874.Walters R, Kasik J, Ettel C, Ortiz R. Evaluation of sustained acoustic medicine for treating musculoskeletal injuries in military and sports medicine. Open Orthop J. (2022) 16:1-11. doi: 10.2174 / 18743250-vl6-e221130-2022-8.Hendren TF, Yeretzian NR, Bavanasi K. Clinical diathermy performance evaluation of multi-hour sustained acoustic medicine treatment with 2.5% diclofenac ultrasound coupling patch. Int J Phys Med Rehabil. (2023) 11(6):678.PATENT Attorney Docket No. 6381.022WO1 (AKG)46. Smith WL, DeWitt DL, Garavito RM. Cyclooxygenases: structural, cellular, and molecular biology. Annu Rev Biochem. (2000) 69:145-82. doi: 10.1146 / annurev. biochem.69.1.145.47. Cooper C, Chapurlat R, Al-Daghri N, Herrero-Beaumont G, Bruyere O, Rannou F, et al.Safety of oral non-selective non-steroidal anti-inflammatory drugs in osteoarthritis: what does the literature say? Drugs Aging. (2019) 36(1): 15— 24. doi: 10.1007 / s40266-019- 00660-1.48. Altman R, Barkin RL. Topical therapy for osteoarthritis: clinical and pharmacologic perspectives. Postgrad Med. (2009) 121(2): 139-47. doi: 10.3810 / pgm.2009.03.1986.49. Polat BE, Hart D, Langer R, Blankschtein D. Ultrasound-mediated transdermal drug delivery: mechanisms, scope, and emerging trends. J Control Release. (2011) 152(3)330-48. doi: 10.1016 / j.jconrel.2011.01.006.50. Tang H, Wang CCJ, Blankschtein D, Langer R. An investigation of the role of cavitation in low-frequency ultrasound-mediated transdermal drug transport. Pharm Res. (2002) 19(8): 1160-9. doi: 10.1023 / A: 1019898109793.51. Li Y, Chen Z, Ge S. Sonoporation: underlying mechanisms and applications in cellular regulation. BIO Integr. (2021) 2:29-36. doi: 10.15212 / bioi-2020-0028.52. Masterson J, Kluge B, Burdette A, Sr GL. Sustained acoustic medicine; sonophoresis for nonsteroidal anti-inflammatory drug delivery in arthritis. Ther Deliv. (2020) 11(6)363— 72. doi: 10.4155 / tde-2020-0009.53. Madzia A, Agrawal C, Jarit P, Petterson S, Plancher K, Ortiz R. Sustained acoustic medicine combined with A diclofenac ultrasound coupling patch for the rapid symptomatic relief of knee osteoarthritis: multi-site clinical efficacy study. Open Orthop J. (2020) 14:176-85. doi: 10.2174 / 1874325002014010176.54. Jarit P, Klyve D, Walters R. Long duration sonophoresis of diclofenac to augment rehabilitation of common musculoskeletal injuries. Glob J Orthop Res. (2023) 4(2):584.PATENT Attorney Docket No. 6381.022WO1 (AKG)

[0138] The terms “a,” “an,” “the” and similar referents used in the context of describing the invention (especially in the context of the following claims) are to be construed to cover both the singular and the plural, unless otherwise indicated herein or clearly contradicted by context. Recitation of ranges of values herein is merely intended to serve as a shorthand method of referring individually to each separate value falling within the range. Unless otherwise indicated herein, each individual value is incorporated into the specification as if it were individually recited herein. All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples, or exemplary language (e.g., “such as”) provided herein is intended merely to better illuminate the invention and does not pose a limitation on the scope of the invention otherwise claimed. No language in the specification should be construed as indicating any non-claimed element essential to the practice of the invention.

[0139] As used herein, numerical ranges (e.g., 90-99 weight percent, wt%) include all numbers and fractions thereof included within the range, as well as the numbers defining the lower and upper limits of the range. For example, the range of 90-99 would include the 90 (lower limit), 99 (upper limit), and all numbers and fractions of the numbers contained within 90 (lower limit) and 99 (upper limit). As used herein, the term “between” when defining a given range of numbers includes in that range the number at the lower and upper limits. As used herein, the term “up to” when used to define the upper limit is meant to include all, without limitation, that the functionality or feature being described is achieve at least to the number used with the term “up to”. For example, if a given function is described as being effective “up to about 12 hours,” it is meant to be effective at least up to 10 hours, but it could also be effective beyond 10 hours and / or less than 10 hours, depending on the context.

[0140] Groupings of alternative elements or embodiments of the invention disclosed herein are not to be construed as limitations. Each group member may be referred to and claimed individually or in any combination with other members of the group or other elements found herein. It is anticipated that one or more members of a group may be included in, or deleted from, a group for reasons of convenience and / or patentability. When any such inclusion or deletion occurs, the specification is deemed to contain the group as modified thus fulfilling the written description of all Markush groups used in the appended claims.PATENT Attorney Docket No. 6381.022WO1 (AKG)

[0141] Certain embodiments of this invention are described herein, including the best mode known to the inventors for carrying out the invention. Of course, variations on these described embodiments will become apparent to those of ordinary skill in the art upon reading the foregoing description. The inventor expects skilled artisans to employ such variations as appropriate, and the inventors intend for the invention to be practiced otherwise than specifically described herein. Accordingly, this invention includes all modifications and equivalents of the subject matter recited in the claims appended hereto as permitted by applicable law. Moreover, any combination of the above-described elements in all possible variations thereof is encompassed by the invention unless otherwise indicated herein or otherwise clearly contradicted by context.

[0142] Furthermore, numerous references have been made to patents and printed publications throughout this specification. Citation of a reference herein shall not be construed as an admission that such reference is prior art to the present invention. All references cited herein are hereby incorporated by reference in their entirety.

[0143] In closing, it is to be understood that the embodiments of the invention disclosed herein are illustrative of the principles of the present invention. Other modifications that may be employed are within the scope of the invention. Thus, by way of example, but not of limitation, alternative configurations of the present invention may be utilized in accordance with the teachings herein. Accordingly, the present invention is not limited to that precisely as shown and described.

[0144] Illustrative embodiments of the processes, methods, and products of the present disclosure are described herein. It should be understood, however, that the description herein of the specific embodiments is not intended to limit the present disclosure to the particular forms disclosed but, on the contrary, the intention is to cover all modifications, equivalents, and alternatives falling within the spirit and scope of the invention by the appended claims. Thus, although the present invention has been described for the purpose of illustration, it is understood that such detail is solely for that purpose and variations can be made by those skilled in the art without departing from the spirit and scope of the invention which is defined by the following claims.

Claims

PATENT Attorney Docket No. 6381.022WO1 (AKG) WHAT IS CLAIMED IS:

1. A method of increasing local blood circulation in soft tissue of a subject, said method comprising:applying continuous, non-pulsed ultrasound energy to a target tissue region of a subject using a wearable ultrasound transducer,wherein the ultrasound energy is delivered at an intensity suitable for sustained application for at least 60 minutes,wherein a statistically significant increase in local blood circulation is achieved within 10 minutes of initiating the application of the ultrasound energy,wherein the increase in local blood circulation is sustained for a duration of the application of the ultrasound energy, andwherein statistically significant is defined as p < 0.05.

2. The method according to claim 1, wherein the ultrasound energy is applied using an ultrasound system effective to deliver ultrasound energy to the target tissue region for a period of between about 10 and 60 minutes at a frequency of between about 2.8 MHz and 3.1 MHz.

3. The method according to claim 2, wherein the ultrasound system comprises a sustained acoustic medicine therapy device effective to provide continuous high-frequency, low-intensity long-duration ultrasound of 2.8-3.1 MHz, 132 mW / cm2, and 779.17-4675 Joules of energy to the target tissue region.

4. The method according to claim 3, wherein the ultrasound system comprises one or more ultrasound transducers placed in or adjacent to the target tissue region, wherein the one or more ultrasound transducers are removable.

5. The method according to claim 4, wherein the ultrasound system comprises two ultrasound transducers placed on opposite ends of the target tissue region.

6. The method according to claim 2, wherein the ultrasound system comprises at least one ultrasound transducer, a power source operably connected to the at least one ultrasoundPATENT Attorney Docket No. 6381.022WO1 (AKG)transducer, and a coupling gel, wherein the coupling gel is effective for operably coupling to the at least one ultrasound transducer to apply ultrasound energy to the target tissue region of the subject.

7. The method according to claim 2, wherein the ultrasound system comprises a wearable ultrasound transducer portion.

8. The method according to claim 2, wherein the ultrasound system comprises a flexible ultrasound transducer portion.

9. The method according to claim 1, wherein the ultrasound energy is applied in a manner effective to cause a statistically significant increase in local blood circulation after about 10 minutes of applied ultrasound energy treatment.

10. The method according to claim 9, wherein the statistically significant increase in local blood circulation occurs at least about 10 minutes before a statistically significant increase in local temperature is reached in the target tissue region.

11. The method according to claim 10, wherein the statistically significant increase in local blood circulation comprises at least about 20.93 PU (95% CI: 12.89-28.87; p=0.0001) compared to placebo at 50 minutes with standard gel and at least about 21.56 PU (95% CI: 15.92-27.21; p=0.001) versus placebo at 50 minutes with diclofenac gel.

12. The method according to claim 10, wherein the increase in local temperature is between about 2.0-2.7°C.

13. The method according to claim 1, wherein the increase in local blood circulation in the target tissue region of the subject is effective to alleviate pain and accelerate recovery from a soft tissue injury in the target tissue region of the subject.PATENT Attorney Docket No. 6381.022WO1 (AKG)14. The method according to claim 13, wherein the soft tissue injury comprises any damage to muscles, tendons, and / or ligaments in the target region.

15. The method according to claim 13, wherein the soft tissue injury is selected from the group consisting of contusions, strains, sprains, tendonitis, bursitis, and the like.

16. The method according to claim 1, wherein the target tissue region comprises any portion of the subject selected from the group consisting of the head, neck, thorax, abdomen, pelvis, an upper extremity including a shoulder, arm, elbow, forearm, wrist, and / or hand, and a lower extremity including a quadricep, hamstring, gluteus maximus, gastrocnemius, ankle, foot, and / or knee.

17. The method according to claim 1, wherein the ultrasound energy comprises long duration ultrasound therapy of up to about 12 hours, up to about 4 hours, or up to about 1 hour.

18. The method according to claim 1, wherein the ultrasound energy comprises deep tissue ultrasound therapy.

19. The method according to claim 18, wherein the deep tissue ultrasound therapy delivers therapeutic acoustic energy to a depth of up to about 10 centimeters (cm), between about 3 and 5 cm, or between about 0.1 -0.3 cm into the target tissue region of the subject.

20. The method according to claim 1, further comprising delivering a nonsteroidal antiinflammatory drug (NSAID) to the subject’s target tissue region to improve treatment.

21. The method according to claim 20, wherein the NSAID is selected from the group consisting of diclofenac, diclofenac sodium, diclofenac sodium with misoprostol, diclofenac potassium, flunixin meglumine, phenylbutazone, aspirin, acetaminophen, diflunisal, dipyrone, ketorolac, etodolac, tepoxalin, fenoprofen calcium, flurbiprofen, ibuprofen, indomethacin, celecoxib, ketoprofen, vedaprofen, meclofenamate sodium, mefenamic acid, tolfenamic acid, meloxicam, carprofen, nabumetone, naproxen, naproxen sodium, etoricoxib, piroxicam, tolmetinPATENT Attorney Docket No. 6381.022WO1 (AKG)sodium, magnesium salicylate, choline salicylate, salsalate, sodium salicylate, alkyl salicylate, and disalicylate.

22. The method according to claim 1, wherein the increase in local blood circulation is effective for treating conditions selected from the group consisting of a musculoskeletal condition, soft tissue injury, pain relief, inflammation, osteoarthritis, rhematic arthritis, contusion, ligament injury, muscle spasm, tendinopathy, and bone fracture healing.

23. The method according to claim 1, wherein a statistically significant increase in tissue temperature occurs after the increase in local blood circulation.

24. The method according to claim 1, wherein the ultrasound energy is applied using an ultrasound system effective to deliver ultrasound energy to the target tissue region, wherein the ultrasound system comprises a sustained acoustic medicine therapy device comprising components effective for divergent beam ultrasound, continuous ultrasound, and / or long duration ultrasound.

25. The method according to claim 1, further comprising delivering a therapeutic drug suitable for treating the target tissue region, wherein applying the continuous ultrasound energy to the target tissue region is effective to increase delivery and efficacy of the therapeutic drug by pushing the therapeutic drug into the target tissue region so as to improve treatment, wherein the therapeutic drug can comprise a nonsteroidal anti-inflammatory drug (NSAID).

26. The method according to claim 1, further comprising delivering a therapeutic drug suitable for treating the target tissue region, wherein by applying the ultrasound energy so as to increase the local blood circulation in the target tissue region so as to be effective to increase delivery and efficacy of the therapeutic drug by pulling the therapeutic drug into the target tissue region so as to improve treatment, wherein the therapeutic drug can comprise a nonsteroidal antiinflammatory drug (NSAID).PATENT Attorney Docket No. 6381.022WO1 (AKG)27. The method according to claim 1, further comprising a multimodal delivery of a therapeutic drug suitable for treating the target tissue region, wherein the multimodal delivery comprises both (i) a first mode of applying continuous ultrasound energy to the target tissue region so as to be effective to increase delivery and efficacy of the therapeutic drug by pushing the therapeutic drug into the target tissue region so as to improve treatment, and (ii) a second mode of applying the ultrasound energy so as to increase the local blood circulation in the target tissue region so as to be effective to increase delivery and efficacy of the therapeutic drug by pulling the therapeutic drug into the target tissue region so as to improve treatment, wherein combining the first mode and the second mode achieves a synergistic effect to increase delivery and efficacy of the therapeutic drug in treating the target tissue region, and wherein the therapeutic drug can comprise a nonsteroidal anti-inflammatory drug (NSAID).

28. The method according to claim 27, wherein the first mode is effective to first push the therapeutic drug into the target tissue region of the subject and the second mode is then effective to pull the therapeutic drug further into the target tissue region by the increase in local blood circulation.

29. A method of treating musculoskeletal tissue of a subject, said method comprising:applying continuous ultrasound energy to a target musculoskeletal tissue region of the subject for at least 60 minutes, andapplying a topical non-steroidal anti-inflammatory drug (NSAID) to the target musculoskeletal tissue region during application of the ultrasound energy,wherein the continuous ultrasound energy produces a statistically significant increase in local blood circulation relative to a placebo ultrasound treatment,wherein the increase in local blood circulation is not reduced relative to ultrasound application with a non-medicated coupling medium, andwherein statistically significant is defined as p < 0.05.

30. A method of treating soft tissue of a subject, said method comprising:applying continuous ultrasound energy to a target soft tissue region of the subject, monitoring local blood circulation using laser Doppler flowmetry, andPATENT Attorney Docket No. 6381.022WO1 (AKG)continuing the application of the ultrasound energy until a statistically significant increase in perfusion units is detected within 10 minutes of ultrasound energy initiation, wherein the increase in perfusion units is detected prior to a statistically significant increase in tissue temperature, andwherein statistically significant is defined as p < 0.05.

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