Authors: Leman Ilter, MD Banu Dilek, MD Ibrahim Batmaz, MD Mehmet Ali Ulu, MD Mustafa A. Sariyildiz, MD Kemal Nas, MD Remzi Cevik, MD

Pain

ORIGINAL RESEARCH ARTICLE

Affiliations: From the Department of Physical Medicine and Rehabilitation, Dicle University Faculty of Medicine, Diyarbakir (LI, IB, MAS, KN, RC); Department of Physical Medicine and Rehabilitation, Dokuz Eylul University Faculty of Medicine, Izmir (BD); and Physical Medicine and Rehabilitation Clinic, Siirt Medlife Hospital, Siirt, Turkey (MAU).

Efficacy of Pulsed and Continuous Therapeutic Ultrasound in Myofascial Pain Syndrome A Randomized Controlled Study

Correspondence:

ABSTRACT

All correspondence and requests for reprints should be addressed to: Banu Dilek, MD, Dokuz Eylul University Faculty of Medicine, Department of Physical Medicine and Rehabilitaiton, 35340 Inciralti/Izmir, Turkey.

Ilter L, Dilek B, Batmaz I, Ulu MA, Sariyildiz MA, Nas K, Cevik R: Efficacy of pulsed and continuous therapeutic ultrasound in myofascial pain syndrome: a randomized controlled study. Am J Phys Med Rehabil 2015;94:547Y554.

Objectives: This study aimed to compare continuous and pulsed ultrasound therapy with sham ultrasound in terms of pain, severity of muscle spasm, function, depression, and quality of life in patients with myofascial pain syndrome.

Disclosures: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

Editor’s Note: Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.ajpmr.com).

Design: Patients were randomly divided into three groups, including the continuous ultrasound group (3 MHz, 1 W/cm2, n = 20), the pulsed ultrasound group (3 MHz, 1 W/cm2, 1:1 ratio, n = 20), and control group (sham, n = 20). The primary outcome measures were severity of pain at rest and during activity (visual analog scale, 0Y10 cm). The secondary outcome measures were function (Neck Pain and Disability Scale), depressive mood (Beck Depression Scale), and quality of life (Nottingham Health Profile). All evaluations were performed at baseline, after treatment, and at the 6th and 12th wks.

Results: All three groups had significant improvements in all of the pain scores, the severity of muscle spasms, function assessments, and certain subparameters of the quality of life scale (P G 0.05). The continuous ultrasound group had significantly greater improvements in pain at rest (P G 0.05). However, no statistically significant differences were observed in the other parameters (P 9 0.05).

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Conclusions: Continuous ultrasound therapy is more efficient in reducing pain

DOI: 10.1097/PHM.0000000000000210

at rest for myofascial pain syndrome patients than is sham or pulsed ultrasound therapy. Key Words:

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Therapeutic Ultrasound, Sham Ultrasound, Myofascial Pain Syndrome

Efficacy of Therapeutic Ultrasound for MPS Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

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M

yofascial pain syndrome (MPS) is characterized by pain, muscle spasm, oversensitivity, limitation of movement, and weakness. In addition, MPS patients can have hypersensitive points (known as Btrigger points[) that are located in one or more muscles and/or the connective tissue layer covering the muscle.1 These trigger points and tense muscle bands can be relaxed with muscle strengthening and relaxation exercises, superficial and deep heating methods (such as therapeutic ultrasound), laser therapy, and trigger point injections.2Y4 Although there are a limited number of controlled studies regarding its efficacy, therapeutic ultrasound is recommended for the treatment of MPS.5Y8 However, there are no standard protocols regarding the appropriate frequency and intensity of therapeutic ultrasound, as there have been no systematic studies of this in the literature.5Y8 Ultrasound for the treatment of MPS can be applied in a continuous or pulsed manner, although these two methods have not yet been compared. Therefore, in this study, the aim was to compare continuous and pulsed therapeutic ultrasound in MPS with sham ultrasound in terms of their effects on pain, severity of muscle spasm, neck function, quality of life, and depression.

MATERIALS AND METHODS Sixty patients between the ages of 18 and 60 yrs who applied to the Dicle University School of Medicine Department of Physical Medicine and Rehabilitation between April 2012 and May 2013 were enrolled in this study. The study protocol was approved by the ethics committee at the same institution. MPS was diagnosed based on the criteria of Travell and Simons.9 MPS is considered if five major criteria and at least one of three minor criteria are satisfied. Major criteria included localized spontaneous pain; spontaneous pain or altered sensations in expected referred pain area for given trigger point; taut, palpable band in accessible muscle; exquisite, localized tenderness in precise a point along taut band; and some measurable degree of reduced range of movement. Minor criteria included reproduction of spontaneously perceived pain and altered sensations by pressure on trigger point, elicitation of a local twitch response of muscular fibers by transverse snapping palpation or by needle insertion into trigger point, and pain relief obtained by muscle stretching or injection of trigger point. Only patients who complained of neck pain, had a palpable taut band on the trapezius muscle, and had an active trigger point

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were enrolled in this study. In this way, it was aimed to assess cervicoscapular myofascial pain. This study was planned in a prospective, placebo-controlled, double-blind, and randomized manner. For this randomized controlled study, before the start of the study, an independent researcher (I. Batmaz) provided a randomization scheme from a random number table by using block randomization with four patients in a block. The eligible patients who had submitted a written informed consent were then referred to another researcher (M. Ulu) who was not involved in the selection and consent process. This researcher used the randomization scheme to assign patients into three groups. This process thus ensured allocation concealment. Detailed patient histories were taken, and the patients underwent locomotor system and general physical examinations to rule out any additional pathology. Demographic characteristics of the patients, including their age and educational status, were recorded. The inclusion criteria included an active trigger point in the upper trapezius muscle (fulfilling the diagnostic criteria of Travell and Simons), pain for at least 1 mo, aged between 18 and 60 yrs, and consent to participate in the study. The exclusion criteria included fibromyalgia syndrome, systemic diseases, marked cervical herniated disc, trigger point injections or physiotherapy within the last 3 mos, neck and shoulder surgery within the last year, pregnancy, sensory disorders in the area where the treatment would be applied, infections or skin lesions, and metallic implants or cardiac pacemakers. Patients were randomly divided into three groups based on the inclusion and exclusion criteria. The first group (group A) was treated with 3 MHz, 1 W/cm2 continuous ultrasound; the second group (group B) was treated with 3 MHz, 1 W/cm2 pulsed ultrasound (1:1 ratio); and the third group (group C) was given sham ultrasound (as the device was turned off). A researcher (L. Ilter) in the Department of Physical Medicine and Rehabilitation in the University Hospital conducted all treatments 5 days per week for a period of 2 wks. The patients underwent 5-min ultrasound therapy sessions in which the treatments were applied by the researcher (L. Ilter) with circular movements on and around the painful trigger point (see Supplemental Digital Content; http://links.lww.com/PHM/A82). All of the patients were prescribed standard stretching and range of motion exercises (neck flexion, extension, lateral flexion and rotation, shoulder roll, isometric flexion, extension and side bending strength, upper trapezius and levator scapula stretching, scapular retraction) together with hot pack treatment to the painful area for 10 mins. As for analgesics, patients

Am. J. Phys. Med. Rehabil. & Vol. 94, No. 7, July 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

were permitted to take paracetamol when needed. Patients were also asked to keep exercise and medication diaries. The evaluation of all the patients enrolled in this study was performed by a blind researcher (B. Dilek) before and after the treatment and at the 6th and 12th wks after treatment as well.

Primary Outcome Measures The primary outcome measures were the severity of pain at rest and pain movement at the 12th wk after treatment.

Pain Pain was evaluated using the 0-to-10 cm visual analog scale. The scale was explained to patients so they understood that 0 indicated the absence of pain, 10 indicated the most severe pain, and 5 corresponded to a medium-level pain. The patients were asked to indicate their pain at rest and with movement within the last 48 hrs using this 0-to-10 scale.

Secondary Outcome Measures The secondary outcome measures included the severity of the palpable muscle spasm, psychologic state, quality of life, function, and patient satisfaction after treatment and at the 6th and 12th wks after treatment.

Severity of the Palpable Muscle Spasm The severity of the palpable muscle spasm in the affected muscle was assessed using a five-step scale10: (0) no spasm, (1) medium-grade spasm, (2) spasm stronger than medium grade but not limiting the range of joint movement, (3) severe spasm limiting the range of joint movement, and (4) severe spasm accompanied by postural deviation and the researcher graded the severity of muscle spasm.

Psychologic State The depressive state of each patient was evaluated using the Beck Depression Inventory, which has been demonstrated to be valid and reliable in Turkish. The Beck Depression Inventory consists of 21 questions, and the patients are asked to choose the answer best fitting their condition. Each question has four possible answers, which are listed in order from a neutral condition (0 points) to the most severe condition (3 points). The highest possible score is 63. Zero to 13 points indicate no depression; 14 to 24 points, moderate depression; and scores higher than 25 points, severe depression.11 www.ajpmr.com

Quality of Life Quality of life was evaluated using the Nottingham Health Profile, which has been demonstrated to be valid and reliable in Turkish. This questionnaire evaluates the emotional, social, and physical health problems perceived by the patient. The questionnaire is divided into six subcategories, including energy, pain, physical mobility, sleep, emotional reactions, and social isolation. The 38 yes/no questions inquire about the current complaints at the time the patient is completing the questionnaire.12

Function The Neck Pain and Disability Scale was used to functionally evaluate each patient. This scale was developed for a detailed assessment of neck pain. Patients with neck pain often score higher on this scale than do those with back and leg pain, and therefore, it is thought to be more relevant to those with neck pain. The NPAD scale consists of 20 items, and for each item, the patient makes a mark on a 10-cm scale. The score for each item varies between 0 and 5. If the patient marks the bold printed lines, half points are given. The sum of these scores indicates the final score. This scale was tested for validity and reliability by Wheeler et al. in 1999.13

Patient Satisfaction The patient satisfaction form includes five choices: 0, worse; 1, no change; 2, mild improvement; 3, good; 4, excellent. Patients indicate their satisfaction with the treatment by marking the appropriate choice immediately after the treatment and at 6 and 12 wks after treatment.

Statistical Analysis Statistical analysis was performed with the IBM SPSS 21.0 for Windows statistics software. The measured variables are presented as means T SD, whereas categorical variables are indicated as numbers and percentages (%). Data were evaluated for compliance with the normal distribution. Comparisons of the groups outside the normal distribution and comparisons between more than two variables were performed using the Kruskal-Wallis H-Tests and Friedman tests. Comparisons between the groups with two variables were performed with the Mann-Whitney U test and Wilcoxon test. The comparisons of the qualitative variables between groups were performed using the chi-square test. The hypotheses are reciprocal, and statistical significance is based on a value of P G 0.05. A retrospective power analysis was also implemented. In the post hoc power Efficacy of Therapeutic Ultrasound for MPS

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analysis, performed using sample sizes, means, and SD values for the significance level (alpha) of 0.05, the power was calculated by statistical software, PASS.

RESULTS Eighty-five patients met the inclusion criteria during their routine outpatient physical examination for MPS. After reviewing the inclusion and exclusion criteria, 77 patients (52 women, 25 men) with MPS who signed the informed consent forms were enrolled in the study. These patients were randomized into the continuous ultrasound (n = 25), pulsed ultrasound (n = 27), and sham ultrasound (n = 25) groups. Seventeen patients were lost during follow-up, and therefore, 60 patients completed the study (Supplemental Digital Content). No complications were reported in the study groups during the therapy.

Per Protocol No statistically significant differences were observed between the groups in terms of sex, age, duration of pain, education, or occupation (P 9 0.05) (Table 1). All three groups had a statistically significant improvement in all of the pain scores, degree of muscle spasm, assessment of neck function, and the pain subparameter of the quality of life parameter after the therapy and at 6 and 12 wks after treatment (P G 0.05). The Beck Depression Scale indicated that there was no significant improvement in the sham ultrasound group. In addition, no significant improvement was observed in any of the three groups in terms of social isolation subparameter of the

quality of life parameter in the Beck Depression Scale (P 9 0.05) (Tables 2Y7) and patient satisfaction (P 9 0.05). Pain at rest was significantly improved in the group that was treated with continuous ultrasound, whereas no difference was observed between the groups with regard to the other scores (P G 0.05). When the intragroup changes after the therapy were compared, the improvement in pain at rest among the group that was treated with continuous ultrasound was significantly higher compared with that in the groups that received pulsed and sham ultrasound (P G 0.05). However, there were no statistically significant differences in any of the other parameters (P 9 0.05) (Tables 2Y7).

Intention to Treat In the intention-to-treat analysis, the significance of the results did not differ from the per protocol analysis for the primary outcomes. The P values are provided in Tables 2 through 7. In the post hoc power analysis, performed using sample sizes, means, and SD values for the significance level (alpha) of 0.05, the power was found to be 96% for pain at rest and 100% for pain at movement. However, the power was below 50% for the secondary outcome measures.

DISCUSSION MPS is characterized by hypersensitive points (known as Btrigger points[) located in the muscles and/or the fasciae that may lead to pain, muscle spasm, hypersensitivity, limitation of movement, weakness, and sometimes to autonomous disorders.2Y4

TABLE 1 Comparison of the demographic characteristics of the groups Group A (n = 20) Group B (n = 20) Group C (n = 20) Female Age, mean T SD, yrs Duration of symptoms, median (minYmax), mos Occupation worker Civil servant Homemaker Other Education illiterate Literate Elementary school Middle school High school College

60 (12) 33 T 8 12 (1Y60) 7 (35) 10 (50) 1 (5) 2 (10) 0 (0) 1 (5) 1 (5) 1 (5) 3 (15) 14 (70)

80 (16) 32 T 7 11 (1Y60) 9 (45) 9 (45) 1 (5) 1 (5) 1 (5) 0 (0) 0 (0) 2 (10) 7 (35) 10 (50)

70 (14) 33 T 8 5 (1Y36) 7 (35) 9 (45) 4 (20) 0 (0) 1 (5) 0 (0) 5 (25) 1 (5) 5 (25) 8 (40)

P 0.386 0.496 0.237 0.491

0.180

Data are presented as n (%), unless otherwise indicated.

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TABLE 2 Comparison of resting pain among the groups Pain at Rest (VAS 0Y10 cm) Baseline AT 6th wk 12th wk P (Wilcoxon) P-int Change BaselineYAT BaselineY6th wk BaselineY12th wk

Group A 4 (0 to 7) 1.5 (0 to 6) 2 (0 to 7) 0 (0 to 8) 0.003a 0.001a

Group B 5.5 (2 to 10) 2.5 (0 to 10) 1 (0 to 8) 1 (0 to 7) G0.001a G0.001a

1 (j2 to 6) 1.5 (j4 to 5) 2 (j3 to 7)

P/P-int (Kruskal) P/P-int (Friedman)

Group C 5 (0 to 9) 2 (0 to 8) 1 (0 to 7) 0 (0 to 7) G0.001a G0.001a

2 (0 to 8) 2.5 (0 to 5) 3 (j4 to 10) 3 (0 to 5) 3 (j2 to 10) 3.5 (0 to 6)

0.023a/0.027a 0.338/0.502 0.804/0.803 0.769/0.925

G0.001a/G0.001a

0.371 0.035a 0.013a

Difference between baseline and 6 wks AT: AYB, 0.031; AYC, 0.021; BYC, 0.753. Difference between baseline and 12th wks AT: AYB, 0.015; AYC, 0.008; BYC, 0.775. Data are presented as median (minYmax). a P G 0.05. VAS, visual analog scale; int, intention-to-treat analysis; AT, after treatment.

Because the etiology of MPS is yet to be elucidated, most of the treatment protocols target the symptoms. Various physical therapy modalities aim to inactivate the trigger points, relax the rigid bands, and control the predisposing factors. Physical therapy modalities including injections, spraying and stretching techniques, hot packs, ice packs, therapeutic massages, electrotherapy, and ultrasound are also effective in reducing pain.3,14 Ultrasound is a noninvasive technique that is frequently used in the treatment of MPS because of its thermal and biophysical effects. Thermal and nonthermal effect occurs in tissue during the ultrasound treatment by using high-frequency acoustic energy. During the absorption of ultrasonic waves in tissues and their reflection among the surfaces, heat energy is produced and provides deep heating. At the same time, ultrasound therapy has analgesic effects, increases nutrition, and also speeds blood circulation. In addition, the micromassage effects of high-frequency sound waves have been demonstrated.5 KNsaog˘lu et al.6 reported that ultrasound reduces myofascial pain, improves tissue

compliance, significantly reduces pain scores, and significantly improves tissue compliance and pressure pain threshold values. In a study by Esenyel et al.,7 neck stretching exercises combined with ultrasound and injection treatment led to significant improvements in comparison with the control group, although they were not found to be superior to each other. However, another study reported no significant difference between the ultrasound group and a placebo ultrasound group, although a nonsignificant improvement in the placebo group was associated with the effects of the massage and exercise.8 In this study, it was observed that all pain was significantly reduced in all three groups after therapy. However, only the group receiving continuous ultrasound had a significant improvement in resting pain scores at 6 and 12 wks after treatment. It has been reported that the location of the trigger point has the most important diagnostic value in MPS. Previous studies have reported that the most reliable physical examination results of the trigger point are focal sensitivity and pain.15,16 Determining the sensitivity of this area is of utmost importance

TABLE 3 Comparison of motion-induced pain among the groups Motion VAS

Group A

Group B

Group C

P/P-int (Kruskal)

P/P-int (Friedman)

Baseline AT 6 wks AT 12 wks AT P (Wilcoxon) P-int

5 (3Y10) 2.5 (0Y6) 3 (0Y6) 2.5 (0Y7) G0.001a 0.001a

5.5 (1Y10) 3 (0Y10) 2 (0Y6) 2 (0Y6) G0.001a G0.001a

6 (3Y9) 3 (0Y8) 2 (0Y8) 1 (0Y6) G0.001a G0.001a

0.564/0.413 0.752/0.623 0.881/0.945 0.471/0.740

G0.001a/G0.001a

Data are presented as median (minYmax). a P G 0.05. VAS, visual analog scale; int, intention-to-treat analysis; AT, after treatment.

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TABLE 4 Comparison of palpable muscle spasm among the groups Degree of the Palpable Muscle Spasm

Group A

Group B

Group C

P/P-int (Kruskal)

P/P-int (Friedman)

Baseline AT 6 wks AT 12 wks AT P (Wilcoxon) P-int

2 (1Y3) 1 (0Y3) 1 (0Y3) 1 (0Y3) G0.001a 0.009a

2.5 (1Y3) 2 (0Y3) 1 (0Y3) 1 (0Y3) G0.001a G0.001a

2 (1Y3) 1 (0Y3) 1 (0Y3) 1 (0Y3) G0.001a G0.001a

0.526/0.119 0.555/0.336 0.819/0.850 0.939/0.938

G0.001a/G0.001a

Data are presented as median (minYmax). a P G 0.05. Int, intention-to-treat analysis; AT, after treatment.

in the quantitative evaluation of MPS and in planning the treatment. Algometers are used to determine the trigger point sensitivity.10,17Y19 However, an algometric assessment was not made in this study. It has been previously reported that the degree of the palpable muscle spasm in MPS is positively correlated with the limitation in joint movement.10 In this study, the degree of the palpable muscle spasm improved significantly with therapy in all three groups. Studies evaluating quality of life in MPS patients are limited.20,21 In a study where the quality of life of patients with fibromyalgia and with/without MPS was studied, quality of life was lower in the patients with MPS as compared with the control group.20 The study by AltNndag˘ and Gu¨r21 compared the efficacy of dry needling with local anesthetic

injection for the treatment of MPS and found that both treatment methods are effective in reducing pain and improving quality of life, although they have no effect on depression. In this study, quality of life improved in all three groups after the therapy. Also, the patients’ functional condition, assessed through the neck pain questionnaire, improved after therapy. The pain caused by MPS negatively influences the individual’s functional condition, has an impact on the mental condition, and affects quality of life. The reduction of this pain through therapy increases the person’s functionality, which increases his/her quality of life. S$ ahin et al.22 reported that depression accompanies MPS, and patients with MPS have a higher ratio of depression and somatization than do those without widespread pain. Another study reported

TABLE 5 Comparison of the groups’ NHP scores NHP Group A

Pain Physical activity Fatigue Sleep Social isolation Emotional reaction Group B Pain Physical activity Fatigue Sleep Social isolation Emotional reaction Group C Pain Physical activity Fatigue Sleep Social isolation Emotional reaction

Baseline

AT

6 wks AT

49.2 (0Y100) 17.06 (0Y6.01) 39.2 (0Y100) 20.6 (0Y100) 0 (0Y61.50) 13.3 (0Y83.47) 61.7 (0Y100) 16.03 (0Y65.47) 63.2 (0Y100) 26.9 (0Y77.63) 0 (0Y57.34) 0 (0Y57.83) 53.4 (9.99-100) 20.72 (0Y89.43) 39.20 (0Y100) 39.83 (0Y87.63) 0 (0Y100) 22.74 (0Y100)

26.42 (0Y100) 11.87 (0Y42.86) 38 (0Y100) 12.57 (0Y65.06) 0 (0Y61.50) 4.88 (0Y90.7) 15.11 (0Y100) 10.57 (0Y35.65) 37.80 (0Y100) 12.57 (0Y77.63) 0 (0Y57.34) 0 (0Y57.83) 31.01 (0Y100) 5.28 (0Y100) 39.20 (0Y100) 12.57 (0Y87.63) 0 (0Y100) 15.39 (0Y100)

11.7 (0Y94.17) 10.57 (0Y58.86) 18.4 (0Y100) 12.57 (0Y56.64) 0 (0Y39.49) 0 (0Y50.61) 9.87 (0Y100) 0 (0Y46.22) 30.40 (0Y100) 12.57 (0Y77.63) 0 (0Y42.14) 0 (0Y78.79) 18.40 (0Y100) 10.42 (0Y66.95) 51.20 (0Y100) 12.57 (0Y87.63) 0 (0Y77.47) 5.23 (0Y89.53)

12 wks AT

P/P-int

14.37 (0Y100) 0.009a/0.010a 11.54 (0Y74.70) 0.751/0.078 38 (0Y100) 0.026a/0.021a 6.28 (0Y39.83) 0.004a/0.001a 0 (0Y39.49) 0.053/0.157 0 (0Y62.58) 0.018a/0.022a 6.45 (0Y100) 0.000a/0.000a 4.65 (0Y55.39) 0.013a/0.011a 0 (0Y100) 0.000a/0.002a 12.57 (0Y77.63) 0.147/0.145 0 (0Y42.14) 0.634/1.000 0 (0Y78.79) 0.850/0.596 20.52 (0Y100) G0.001a/0.002a 11.16 (0Y100) 0.506/0.609 39.20 (0Y100) 0.872/0.472 12.57 (0Y87.63) 0.014a/0.021a 0 (0Y22.53) 0.886/0.207 0 (0Y83.47) 0.050a/0.011a

Data are presented as median (minYmax). a P G 0.05. NHP, Nottingham Health Profile; AT, after treatment, int, intention-to-treat analysis.

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TABLE 6 Comparison of neck pain and disability among the groups NPDI Baseline AT >6 wks AT 12 wks AT P (Wilcoxon) P-int

Group A

Group B

Group C

P/P-int (Kruskal)

P/P-int (Friedman)

48 (2Y75) 35.75 (2Y76) 28.75 (0Y78) 26.50 (0Y81) 0.007a 0.008a

48.25 (15Y77) 20.50 (0Y65) 22 (0Y94) 24 (0Y100) 0.001a 0.004a

52 (16Y89) 36.50 (3Y75) 29.50 (0Y66) 34 (0Y75) G0.001a 0.003a

0.914/0.867 0.274/0.316 0.857/0.815 0.910/0.864

G0.001a/G0.001a

Data are presented as median (minYmax). a P G 0.05. NPDI, Neck Pain Disability Index; int, intention-to-treat analysis; AT, after treatment.

massage therapy, the improvement in the placebo group may be a result of the compression and massage effects of the ultrasound probe. Also, the exercise and hot pack treatments applied to the placebo group may have also contributed to their positive results. Another possible explanation of this study’s results may be the nonspecific treatment effects, which are generally known as the placebo effect. These placebo effects may be associated with the care given by the researcher to the patient, the patient’s expectations from the treatment, the impressiveness of the treatment, characteristics of the therapy environment, or the close observation of the patient within the framework of the study. Limitations of this study include the limited number of patients and the irregular exercise and drug diaries kept by the patients. Therefore, other prospective and comparative studies are needed to describe the optimal and most efficient ultrasound therapy, whether it be continuous or pulsed ultrasound.

that MPS was accompanied by major depression in most of the cases and that the severity of the depression was related to the perceived pain.5 In this study, the depression scores of the groups that received continuous and pulsed ultrasound were significantly improved immediately after treatment and at 6 and 12 wks after treatment in comparison with the pretreatment period. There was no significant difference in the depression scores of the patients receiving sham ultrasound during this same time period. The reduction in pain due to therapy in the MPS patients suggests that treatment may also contribute to the emotional improvement of these patients. In conclusion, this prospective, randomized, placebo-controlled, double-blind study has shown that continuous ultrasound therapy in MPS is superior to pulsed and sham ultrasound in reducing pain at rest and that continuous and pulsed ultrasound therapies are both superior to sham ultrasound in improving psychologic condition. However, continuous ultrasound and pulsed ultrasound are no different than sham ultrasound in terms of their effect on the quality of life, pain with movement, and the degree of muscle spasm. Because of the compression applied on the trigger points and the efficacy of the

ACKNOWLEDGMENTS

The authors thank all participants who joined the study.

TABLE 7 Comparison of depression among groups Beck Depression Scale Baseline AT 6 wks AT 12 wks AT P (Wilcoxon) P-int

Group A

Group B

Group C

P/P-int (Kruskal)

P/P-int (Friedman)

13 (0Y23) 8.5 (0Y25) 8 (0Y24) 8.5 (0Y29) 0.018a 0.014a

8 (0Y25) 5 (0Y25) 4 (0Y28) 4 (0Y28) 0.047a 0.036a

8.5 (0Y32) 7 (0Y32) 7.5 (0Y32) 7.5 (0Y40) 0.428 0.560

0.585/0.584 0.776/0.722 0.798/0.630 0.432/0.352

G0.001a/G0.001a

Data are presented as median (minYmax). a P G 0.05. Int, intention-to-treat analysis; AT, after treatment.

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Am. J. Phys. Med. Rehabil. & Vol. 94, No. 7, July 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Efficacy of Pulsed and Continuous Therapeutic Ultrasound in Myofascial Pain Syndrome: A Randomized Controlled Study.

This study aimed to compare continuous and pulsed ultrasound therapy with sham ultrasound in terms of pain, severity of muscle spasm, function, depres...
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