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Rheumatol Int (2011) 31:1203–1208

DOI 10.1007/s00296-010-1419-0

ORIGINAL ARTICLE

Comparison the efficacy of phonophoresis and ultrasound therapy


in myofascial pain syndrome
Saime Ay • Şebnem Koldaş Doğan •
Deniz Evcik • Özgün Çakmak Başer

Received: 24 May 2009 / Accepted: 10 March 2010 / Published online: 31 March 2010
Ó Springer-Verlag 2010

Abstract The aim of this study is to compare the effect of NPDI score, pressure pain threshold (P [ 0.05), also there
phonophoresis, ultrasound and placebo ultrasound thera- were no significant differences in all parameters between
pies in the treatment of myofascial pain syndrome (MPS). group 1 and 2 (P = 0.05). Both diclofenac phonophoresis
This is a randomized, double-blind placebo controlled and ultrasound therapy were effective in the treatment of
study. Sixty patients (48 women, 12 men, mean age patients with MPS. Phonophoresis was not found to be
37.9 ± 12.2 years) with MPS were included in this study. superior over ultrasound therapy.
Patients were allocated into three groups. Group 1(n = 20)
was received diclofenac phonophoresis, group 2(n = 20) Keywords Myofascial pain syndrome  Phonophoresis 
was received ultrasound and group 3(n = 20) was received Ultrasound
placebo ultrasound therapies over trigger points, 10 min a
day for 15 session during 3 weeks (1 MHz-1,5 watt/cm2).
Additionally, all patients were given neck exercise program Introduction
including isotonic, isometric and stretching. Patients were
assessed by means of pain, range of motion (ROM) of Myofascial Pain Syndrome (MPS) is a well-known painful
neck, number of trigger points (NTP), algometric mea- condition of musculoskeletal system, which is character-
surement and disability. Pain severity was measured by ized by myofascial trigger points and taut bands. Sensi-
visual analog scale (VAS) and Likert scale. The neck pain tivity in the muscles, local spasm, stiffness, limitations of
disability index (NPDI) was used for assessing disability. related joints are mostly associated with MPS [1, 2]. It is
Measurements were taken before and after treatment. After one of the most important reasons of disability in the
treatment, there were statistically significant improvements musculoskeletal system problems as it is seen in %37 in
in pain severity, NTP, pressure pain threshold (PPT), ROM men and %65 in women before the ages of 30–60 [1, 3].
and NPDI scores both in phonophoresis and in ultrasound The etiology of MPS is still unknown; therefore, the
therapy groups (P \ 0.05). Statistically significant increase treatment approach is much more symptomatic. The goals
in cervical lateral flexion and rotation was observed in the of the therapy are the inactivation of the trigger
placebo US group. While there was no statistically sig- points, release of the taut bands and pain relief [4].
nificant improvement in the cervical flexion–extension Patients’ education and training programs, nonsteroidal
joint movement, pain levels, number of trigger points and anti-inflammatory drugs (NSAID), local injections, phys-
iotherapy programs including heat applications, electro-
therapy and exercise are the most common treatment
S. Ay  Ş. K. Doğan  D. Evcik  Ö. Ç. Başer
Department of Physical Medicine and Rehabilitation, Ufuk methods [1, 5].
University School of Medicine, Ankara, Turkey Ultrasound (US) treatment is one of the most important
physical treatment modalities in MPS treatment which is
S. Ay (&)
used for heating the deep tissues. It is a noninvasive
Tıp Fakültesi Dr. Rıdvan Ege Hastanesi, Ufuk Üniversitesi,
06520 Balgat, Ankara, Turkey method which consists of piezoelectric crystals that convert
e-mail: saimeay@yahoo.com the electrical energy to mechanical oscillation energy using

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high-frequency alternative current [6, 7]. US increases treatment program during the last 6 months, neck or back
local metabolism, circulation, regeneration and extensibil- surgery, trauma history and pregnancy were excluded [12].
ity of connective tissue with its assuming thermal and
mechanical effects. However, results in the studies related Study design
to its efficacy in the musculoskeletal system problems are
conflicting [7–9]. This study was prospective, randomized, placebo-con-
Phonophoresis (PH) is the process of increasing skin trolled double-blind trial. Before treatment, all participants
absorption and penetration of the topical medications to the were informed of the study and signed written informed
deep tissues using US. Topically applied drugs therapeutic consent. The study was approved by the University of Ufuk
effects depend on different factors such as rate, amount, Human Research Ethics Committee.
drug penetration dept of the skin and the potential drug
toxicological hazards on the tissues. Local anesthetics, Randomization
counterirritants (substances such as menthol that cause
inflammation of the skin for purposes of relieving pain Patients were randomly assigned into three groups. Ran-
from stimulation rather than depression of cutaneous sen- domization was allocated by numbered envelopes method.
sory receptors) and anti-inflammatory drugs (steroidal and Before the therapy, a physician evaluated the patient. Post-
nonsteroidal medications) are used in PH. PH is a nonin- treatment outcomes were assessed by another physician.
vasive, painless method that has less side effects and well Both of the physicians and patients were blinded to the
tolerated and has been used in musculoskeletal and der- treatments. Only the physiotherapist who applied the
matologic disorders in several years. Despite extensive therapy was aware of the procedure.
clinical trials of PH, questions remain regarding treatment Group 1 (n = 20, 17 women and 3 men) was the pho-
validity and effectiveness [6, 10]. However, no study was nophoresis group. Ultrasound device (Chattanooga, Intelect
found in literature about its effectiveness in the MPS Advanced, USA) was used. Initially, diclofenac gel (Vol-
treatment. taren emulgel) was applied circularly with a thickness of 2–
In this double-blinded, randomized placebo controlled 3 mm. Then ultrasound with a 5-cm-diameter applicator
study, we aimed to compare the efficacy of PH with dic- was applied with 1 MHz frequency and 1.5 Wt/cm2 power
lofenac gel, conventional US and placebo US methods on over the two trigger points on trapezius muscle, for 10 min.
pain, range of motion and disability in patients with MPS. Group 2 (n = 20, 15 women and five men) was the
conventional ultrasound group. The same ultrasound
device was used using ultrasound gel, which does not have
Patients and methods any pharmacologic drug ingredient. It was applied over the
same trigger point for 10-min duration.
Sixty patients (48 women, 12 men) diagnosed as MPS were Group 3 (n = 20, 16 women and four men) accepted as
included the study. The diagnosis of MPS was based on the placebo group. The ultrasound probe was held over the two
criteria described by Travell and Simons (5 major and trigger points on the trapezius using ultrasound gel which
minimum 1 minor criteria are required for clinical diag- was the same as in group 2. Ultrasound device seemed to
nosis) [11]. Major criteria included pain, palpable taut be working for 10-min period with light-off position.
bands, reflected of pain from trigger point, hypersensitivity A total of 15 therapies were applied once a day, five
on taut bands and decrease in range of motion. Minor times a week for 3 weeks. Patients were treated by the
criteria are pain with palpation of trigger point and/or same physiotherapist. Additionally, all patients were
occurrence of sensory change, local twitch response of taut received home-based exercise program including isomet-
bands with palpation and injection and decrease in pain ric-isotonic neck exercises and back extensor stretching
with injection of trigger point or stretching of muscle. exercises.
The patients’ inclusion criteria in the study were pres- Patients were not allowed taking analgesic or NSAID
ence of at least one active trigger point located in the upper during the follow-up period.
trapezius muscle, age between 20 and 73 years, symptom
durations for 1 month. The place of the trigger point was Clinical outcomes
found by the experienced physiatrist by palpation. After
physical examination, full blood count, erythrocyte sedi- Patients were evaluated according to pain, number of
mentation rate (ESR) and biochemical markers were trigger points, pressure pain threshold, cervical joint range
evaluated. Patients having fibromyalgia, discal hernia, of motion (ROM) and disability. Assessments were done
radiculopathy, myelopathy, trigger point injection, physical before and after the therapy by different physicians.

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Pain Statistical analysis

Pain was assessed by the visual analog scale (VAS, 0– The results of statistical analysis were expressed as
10 cm; o means no pain, 10 means severe pain) and Likert mean ± SD (Standard deviations). The Friedman test was
pain scale (5 points; 0: no pain, 1: light pain, 2: medium, 3: used to calculate the differences between the pretreatment
severe, 4: intolerable pain). and post-treatment values. To compare the differences
between the groups, Kruskal–Wallis test was used. A level
Number of trigger points of significance of P \ 0.05 was accepted for this study. All
analysis was performed using the SPSS 16.0 for Windows.
Trigger points were evaluated with palpation by an expe-
rienced physician. The diagnostic criteria for trigger point
were palpable taut band located on the trapezius muscles, Results
tenderness within taut bands, jump sign and switch
response. A diffuse achy localized discomfort with pro- All patients were completed the study, and no side effects
longed pressure was accepted as a diagnostic criteria also had been observed. No statistical difference was observed
[11]. regarding the demographic data of the patients (Table 1).
Routine biochemical analyses, complete blood count, ESR
Pressure pain threshold and CRP levels of the groups were within normal limits.
There was no significant difference between three
It is evaluated using Algometer (Algometer Commander, groups according to pain, NTP, PPT and cervical ROM
JTECH Medical, Utah). Algometer was placed over the before treatment (P [ 0.05).
trigger point. The measurement was taken three times with
30-s pauses, and the mean average value was recorded in Pain
Newton (N).
At the end of the therapy, statistically significant
Cervical joint range of motion improvements in group 1 and group 2 regarding VAS and
Likert pain severity (P = 0.000) were observed (Tables 2,
The active range of motion of cervical joint (flexion, 3). However, there was no improvement in group 3
extension, right–left flexion and right–left rotation) was (P = 0.180, P = 0.564) (Table 4). After the therapy, no
measured using a goniometer while the patients were difference was observed between group 1 and 2
sitting. (P = 0.989, P = 0.084) (Table 5).

Disability Number of trigger points

Neck pain disability scale (NPDS) was used to measure the There was statistically significant decrease in NTP both in
disability. The NPDS is a self-administered questionnaire group 1 and 2 (P = 0.000); but no improvement was found
consisting of 20 items. The items measure the intensity of in group 3 (P = 1.000) (Tables 2, 3, and 4). After the
pain; its interference with vocational, recreational, social treatment, no difference was observed in group 1 and 2
and functional aspects of living; and the presence and (P = 0.142) (Table 5).
extent of associated emotional factors. The answers of the
items are responded using a 10-cm VAS. It is divided into Pressure pain threshold
six divisions in equal intervals by vertical lines and signed
with the numbers 0–5. Each item score ranges from 0 to 5, PPT was increased significantly in group 1 and 2
the total score ranges from 0 to 100, and higher values (P = 0.000, P = 0.007) but worsened in group 3
represent greater pain and disability [13]. (P = 0.000) (Table 2, 3 and 4). After the therapy, no

Table 1 Demographic features of patients (Mean ± standard deviation)


Group 1 (n = 20) Group 2 (n = 20) Group 3 (n = 20)

Age (years) 37.90 ± 12.29 48.80 ± 10.94 49.45 ± 13.61


Gender (female/male) 17/3 15/5 16/4
Duration of pain (month) 33.07 ± 40.58 28.20 ± 34.48 38.50 ± 41.21

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Table 2 Evaluation parameters


Pretreatment (mean ± SD) Post-treatment (mean ± SD) P
before and after the treatment in
Group 1 VAS 6.5 ± 1.96 4.25 ± 1.48 0.000
Likert 2.45 ± 0.68 1.40 ± 0.59 0.000
Trigger points 2.10 ± 0.55 1.25 ± 0.63 0.000
Pressure pain threshold 7.19 ± 2.31 7.59 ± 2.24 0.000
Flexion–Extension 61.50 ± 4.89 65.75 ± 4.12 0.000
Right lateral flexion 33.50 ± 4.32 40.75 ± 2.44 0.000
Left lateral flexion 34 ± 5.02 40 ± 3.24 0.000
Right rotation 75.50 ± 6.86 83.55 ± 5.87 0.000
SD standard deviation, VAS Left rotation 76.50 ± 6.90 84 ± 5.02 0.000
visual analog scale, NPDS neck Total NPDS 59.05 ± 18.41 84 ± 40.50 0.000
pain disability scale

Table 3 Evaluation parameters


Pretreatment (mean ± SD) Post-treatment (mean ± SD) P
before and after the treatment in
Group 2 VAS 7.40 ± 1.81 4.45 ± 1.09 0.000
Likert 2.75 ± 0.63 1.75 ± 0.44 0.000
Trigger points 1.95 ± 0.60 0.95 ± 0.82 0.000
Pressure pain threshold 7.46 ± 2.72 8.01 ± 1.59 0.007
Flexion–extension 60.50 ± 15.38 66.50 ± 4.89 0.014
Right lateral flexion 34 ± 5.26 40 ± 3.24 0.003
Left lateral flexion 36 ± 5.75 40.50 ± 4.26 0.001
Right rotation 80.50 ± 7.41 85.50 ± 6.66 0.000
SD standard deviation, VAS
Left rotation 80.50 ± 7.41 85.50 ± 6.66 0.001
visual analog scale, NPDS neck
pain disability scale Total NPDS 59.80 ± 17.59 38.90 ± 14.83 0.000

Table 4 Evaluation parameters


Pretreatment (mean ± SD) Post-treatment (mean ± SD) P
before and after the treatment in
Group 3 VAS 6.09 ± 1.48 7 ± 1.41 0.180
Likert 2.45 ± 0.68 2.30 ± 0.65 0.564
Trigger points 1.90 ± 0.71 1.90 ± 0.71 1.000
Pressure pain threshold 7.26 ± 2.25 5.93 ± 2.13 0.000
Flexion–extension 63.50 ± 4.89 64.75 ± 4.99 0.083
Right lateral flexion 33.50 ± 4.89 40 ± 4.29 0.000
Left lateral flexion 35.75 ± 6.12 39 ± 5.28 0.005
Right rotation 74 ± 9.94 76 ± 9.40 0.046
SD standard deviation, VAS Left rotation 73 ± 9.23 75.75 ± 9.07 0.025
visual analog scale, NPDS neck Total NPDS 25.15 ± 9.81 25.10 ± 9.72 0.317
pain disability scale

difference was found between group 1 and 2 (P = 0.655) Disability


(Table 5).
After therapy, there was a decrease in the NPDI scores in
group 1 and group 2 (P = 0.000); however, no improve-
Cervical range of motion ment was observed in group 3 (P = 0.317) (Table 2, 3 and
4). Although no difference was detected in group 1 and 2
Cervical ROM was increased significantly in group 1 and 2 after therapy (P = 0.946) (Table 5).
(P \ 0.05). In group 3, there were detected significant
increases in cervical lateral flexion and rotation (P \ 0.05)
but no improvements in cervical flexion–extension Discussion
(P = 0.083) (Tables 2, 3 and 4). There was no difference
between group 1 and 2 in cervical ROM after therapy MPS is a significant disability reason for the patient with
(P [ 0.05) (Table 5). chronic pain [5]. The main issue in the MPS treatment is to

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Table 5 Evaluation among the groups after the treatment


Group 1 Group 2 P* Group 3 P**

VAS 4.25 ± 1.48 4.45 ± 1.09 0.989 7 ± 1.41 0.000


Likert 1.40 ± 0.59 1.75 ± 0.44 0.084 2.30 ± 0.65 0.000
Trigger points 1.25 ± 0.63 0.95 ± 0.82 0.142 1.90 ± 0.71 0.001
Pressure-pain threshold 7.59 ± 2.24 8.01 ± 1.59 0.655 5.93 ± 2.13 0.043
Flexion–extension 65.75 ± 4.12 66.50 ± 4.89 0.426 64.75 ± 4.99 0.137
Right lateral flexion 40.75 ± 2.44 40 ± 3.24 0.532 40 ± 4.29 0.461
Left lateral flexion 40 ± 3.24 40.50 ± 4.26 0.394 39 ± 5.28 0.713
Right rotation 83.55 ± 5.87 85.50 ± 6.66 0.497 76 ± 9.40 0.001
Left rotation 84 ± 5.02 85.50 ± 6.66 0.209 75.75 ± 9.07 0.002
Total NPDS 84 ± 40.50 38.90 ± 14.83 0.946 25.10 ± 9.72 0.003
VAS visual analog scale, NPDS neck pain disability scale
* Differences between two groups, ** Differences between three groups

provide pain relief on trigger points. The major treatment fluocinonide, PH had no superiority over US treatment
methods are patient training, elimination of trigger factors, [18]. In our study, although significant improvements were
medical treatment, superficial, deep heat applications, observed in pain, ROM, disability compared to the placebo
electrotherapy, stretching and spray technique, acupunc- group, no significant difference was observed between the
ture, local injections, massage and exercise [5, 10, 14]. PH and US groups.
US is one of the physical treatment agents which is a Fellinger and Schmid used steroid PH and found to have
deep heating agent used for heating the musculoskeletal beneficial effects on hand osteoarthritis by showing the
system tissues with high protein content like tendon, transition of hydrocortisone through the avascular mem-
muscle and joint. It has thermal and nonthermal effects like branes [10]. In the randomized double-blind study in 20
increasing blood flow, tissue metabolism, elasticity of the patients with temporomandibular joint pain, the efficiency of
connective tissue, acceleration of the damaged tissue PH using %1 indometacin was compared with placebo and
healing. PH is the penetration of the topical medicines significant decrease in pain was observed [19]. A double-
transdermale to the subcutaneous tissues via US. The blind study reported 68% decrease in pain and 25%
mechanism of PH is increasing the cell permeability via improvement in ROM in patients with knee osteoarthritis
thermal effects of the US and inducing transdermal and periarticular arthritis with hydrocortisone PH [10].
migration by doing local vasodilatation [10, 15–17]. In the The effects of US and PH treatment on pain are gener-
evaluation, PH is used in physiotherapy in proportion of ally explained with peripheral mechanisms. In an in vivo
%30 and %75 of the studies reviewed reported some of experiment on rat, Hseih et al. [20] demonstrated an
effectiveness of US on local subcutaneous drug diffusion in increase in inducible nitric oxide synthase expression in the
some areas of the musculoskeletal system [3, 10] spinal cord following the stimulus of peripheral inflam-
This study was planned as a randomized double-blind mation in PH and US groups compared to placebo group.
placebo controlled study in which efficacy of PH on the This study emphasizes the positive effects of US pain relief
trigger point by diclofenac gel, US and placebo US due to its efficiency on central neuronal pathways.
methods in pain, NTP, PPT, ROM of cervical joint and Studies mentioned that heating, moisturizing and shav-
disability in MPS treatment. There are limited number of ing the skin enhance transdermal drug delivery [10]. Some
randomized controlled studies in literature in which the authors suggested that improved results of the PH were due
efficacy of US and PH was compared. However, there is no to hot-pack application before PH therapy [14]. In our
study in which the effectiveness of two methods was study, no hot-pack was applied before treatment, and no
compared on the basis of MPS treatment. Kozanoğlu et al. difference was observed between the efficiency of PH and
compared the effectiveness of %5 ibuprofen PH and US US groups.
treatment in a randomized controlled study with 60 patients Studies mostly focused on US treatment and combined
with knee OA; they observed significant improvement in with stretching exercises, it was reported to be effective
pain severity, ROM, WOMAC scores and 20-m walking similar to trigger point injection of %1 lidocaine [21]. Also
test in both groups but they reported that both methods US found to be more effective on pain relief related to
doesn’t have an advantage than other [14]. In the treatment musculoskeletal system compared to placebo US [9].
of tendinit, epicondilit and tenosynovitis using % 0.05 Additionally, it was found to have beneficial effects in PPT

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