Physiotherapists are increasingly using therapeutic ultrasound to treat mastitis in breastfeeding women, writes Karen Keast.

In her early physiotherapy career, Melinda Cooper was treating young mums experiencing common postnatal issues, such as back pain and pelvic floor problems.

These breastfeeding women were often unable to follow through with their treatment because they were sick with fever, breast pain, redness or swelling - all symptoms of mastitis.

Ms Cooper turned to therapeutic ultrasound, used by physiotherapists since the 1940s, and manual handling techniques to treat their mastitis.

“I looked to my skills as a physiotherapist and realised there was a lot of stuff I could do to help these women get over their mastitis and to enhance their breastfeeding experience,” she says.

“Then they were able to focus their attention on their other health concerns related to having had a baby. They could do their pelvic floor exercises and complete their postnatal recovery.”

Thirty years on, Ms Cooper remains a passionate advocate for the role of physiotherapists in treating mastitis and blocked ducts in the lactating breast.

A physiotherapist at Melbourne practice, Inform Physiotherapy, Ms Cooper treats women and trains physiotherapists and other health care providers in the management of mastitis.

She also has a teaching role in women’s health physiotherapy at the University of Melbourne, is the lead investigator with a team of Monash University researchers and collaborates with researchers from Curtin University and the University of Western Australia, investigating the effect of therapeutic ultrasound in treating mastitis.

Mastitis is an inflammation of the breast with symptoms that include redness, breast pain, swelling and generalised ‘flu-like’ symptoms. While all mastitis is characterised by inflammation, not all inflammation is due to infection.

Ms Cooper says antibiotics are often empirically prescribed for mastitis even when there is no clear evidence of infection.

In addition to local and global concerns surrounding the over-use of antibiotics, antibiotics will transfer through the mum’s breast milk to babies, which can result in the baby experiencing an upset stomach, she adds.

Ms Cooper says therapeutic ultrasound is a quick and effective non-pharmacological treatment for the inflammatory symptoms of mastitis.

If an infection is present, studies have shown that ultrasound can increase cell wall permeability of the biofilms caused by infections, making the antibiotic therapy more effective.

Ms Cooper says many women are being told to firmly massage the breast and use hot baths or showers to decrease the symptoms of mastitis - actions that can make their mastitis worse.

“I recently saw a woman who was breastfeeding four-month-old twins. She had successfully breastfed her older child for nearly two years,” she says.

“But in the month before I saw her, she had had repeated bouts of mastitis and was now on her fourth course of antibiotics. The breast lumps and pain were still present.

“The first thing we got her to do was to stop the painful and vigorous massage that she was doing - she actually had bruises on her breasts. We got her to start treating her breasts as if they were the miraculous working instruments that they are and to treat them with respect - to stop hurting them.

“With that first therapeutic ultrasound, the big lump that she had softened immediately. We saw her the next day, her pain scores had significantly improved, the mastitis was gone although some of the bruising remained.

“I then taught her how to do an effective manual massage technique that uses the whole breast which it doesn’t hurt and is very soothing.

“Within just three days, she had broken this awful cycle of recurrent mastitis by stopping the treatments that weren’t actually helping her. She had been stuck in a cycle of too much heavy-handed massage which was probably making the problem worse and the antibiotics were the ineffective attempt to help it.”

Ms Cooper says physiotherapists, especially those working in women’s health, are once again embracing therapeutic ultrasound as an effective and time-efficient modality to help breastfeeding women.

“Therapeutic ultrasound’s application goes back to the Second World War and like many treatment modalities they come and go almost like fashion and it’s now resurging again,” she says.

“This resurgence is probably as much driven by women who don’t want to be taking drugs if there’s not clear evidence of an infective process, or they might have tried antibiotics repeatedly and they’ve still got mastitis.

“Seeing a physiotherapist who is skilled in this field, who may offer therapeutic ultrasound, may give these women symptomatic relief and then they can go on to understand why they are vulnerable to this condition in the first place.”

Ms Cooper says therapeutic ultrasound works when extremely high frequency sound waves pass beyond the skin barrier, creating a vibration in the soft tissues which has an anti-inflammatory effect, reducing pain in the breast.

“We think the pain settles down because the swelling is reduced but the ultrasound might also be having an effect on the sensory nerves in the area,” she says.

“We think it helps by changing the permeability in the actual tissue cells, so the cells can then reduce the volume of inflammation around them, and we think it helps by improving the local circulation through lymphatics and the blood supply which also reduces the swelling.

“It’s probably having an effect on the breast tissue cells but also by facilitating fluid drainage via the actual motion of the transducer.”

While there are few studies supporting its benefits in the treatment of mastitis, physiotherapists and other allied health practitioners who use therapeutic ultrasound find it often delivers immediate results.

Australian researchers are now embarking on examining this modality on the lactating breast.

In the first stage of the research project, Ms Cooper and her research team are validating a clinical tool, the Breast Inflammatory Symptoms Severity Index (BISSI), developed to measure inflammatory symptoms.

Once validated, the tool will be used as an outcome measure in research to determine which treatments are effective for women with mastitis.

“The beauty about this tool is that it’s really easy to use - it’s the woman who records the scale and it’s going to give us a clinical outcome measure that we can use in further studies to work out what treatments really do help women who’ve got mastitis,” she says.

“We know therapeutic ultrasound is really helpful but it hasn’t been studied extensively. We know antibiotics can be helpful but often they are over-used and they might be used when they’re not really needed, and maybe we should save those drug treatments for when there really is an infection.”

Ms Cooper developed a course on the lactating breast for health professionals, and is running the course for the Australian Physiotherapy Association (APA) in Perth, Brisbane, Adelaide and Melbourne this year.

Ms Cooper says breastfeeding women should see a physiotherapist, trained in the use of therapeutic ultrasound, as soon as they experience any of the main symptoms of mastitis.

“It’s vital more health care providers including physiotherapists are able to help women reach their breastfeeding goals, giving babies a great start to life while helping to keep women healthier for longer,” she says.

“Women who have successfully lactated are significantly less likely to have osteoporosis, breast cancer, ovarian cancer, diabetes and obesity problems. These are long-term health impacts that all health care providers including physiotherapists should be concerned about.

“It’s not just about looking after the woman now with her little baby,” Ms Cooper says.

“If she has a history of lactation, she’s going to be healthier when she’s in her menopausal years and that makes a big difference to long-term health outcomes across at least two generations.”