Authors:

Leman Ilter, MD
Banu Dilek, MD Pain
Ibrahim Batmaz, MD
Mehmet Ali Ulu, MD
Mustafa A. Sariyildiz, MD
Kemal Nas, MD
Remzi Cevik, MD
ORIGINAL RESEARCH ARTICLE
Affiliations:
From the Department of Physical
Medicine and Rehabilitation, Dicle
University Faculty of Medicine, Efficacy of Pulsed and Continuous
Diyarbakir (LI, IB, MAS, KN, RC);
Department of Physical Medicine and
Rehabilitation, Dokuz Eylul University
Therapeutic Ultrasound in Myofascial
Faculty of Medicine, Izmir (BD); and
Physical Medicine and Rehabilitation
Pain Syndrome
Clinic, Siirt Medlife Hospital, Siirt, A Randomized Controlled Study
Turkey (MAU).

Correspondence: ABSTRACT
All correspondence and requests for Ilter L, Dilek B, Batmaz I, Ulu MA, Sariyildiz MA, Nas K, Cevik R: Efficacy of
reprints should be addressed to:
Banu Dilek, MD, Dokuz Eylul University pulsed and continuous therapeutic ultrasound in myofascial pain syndrome: a
Faculty of Medicine, Department of randomized controlled study. Am J Phys Med Rehabil 2015;94:547Y554.
Physical Medicine and Rehabilitaiton,
35340 Inciralti/Izmir, Turkey.
Objectives: This study aimed to compare continuous and pulsed ultrasound
therapy with sham ultrasound in terms of pain, severity of muscle spasm, function,
Disclosures: depression, and quality of life in patients with myofascial pain syndrome.
Financial disclosure statements have Design: Patients were randomly divided into three groups, including the con-
been obtained, and no conflicts of
interest have been reported by the tinuous ultrasound group (3 MHz, 1 W/cm2, n = 20), the pulsed ultrasound group
authors or by any individuals in control (3 MHz, 1 W/cm2, 1:1 ratio, n = 20), and control group (sham, n = 20). The
of the content of this article.
primary outcome measures were severity of pain at rest and during activity (visual
analog scale, 0Y10 cm). The secondary outcome measures were function (Neck
Editor’s Note: Pain and Disability Scale), depressive mood (Beck Depression Scale), and quality
Supplemental digital content is of life (Nottingham Health Profile). All evaluations were performed at baseline,
available for this article. Direct URL
citations appear in the printed text and after treatment, and at the 6th and 12th wks.
are provided in the HTML and PDF
versions of this article on the journal’s Results: All three groups had significant improvements in all of the pain scores,
Web site (www.ajpmr.com). 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
0894-9115/15/9407-0547
American Journal of Physical significantly greater improvements in pain at rest (P G 0.05). However, no sta-
Medicine & Rehabilitation tistically significant differences were observed in the other parameters (P 9 0.05).
Copyright * 2014 Wolters Kluwer
Health, Inc. All rights reserved. Conclusions: Continuous ultrasound therapy is more efficient in reducing pain
at rest for myofascial pain syndrome patients than is sham or pulsed ultrasound
DOI: 10.1097/PHM.0000000000000210 therapy.
Key Words: Therapeutic Ultrasound, Sham Ultrasound, Myofascial Pain Syndrome

www.ajpmr.com Efficacy of Therapeutic Ultrasound for MPS 547

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 M yofascial pain syndrome (MPS) is character-
ized by pain, muscle spasm, oversensitivity, limita-
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,
tion of movement, and weakness. In addition, MPS double-blind, and randomized manner. For this ran-
patients can have hypersensitive points (known as domized controlled study, before the start of the
Btrigger points[) that are located in one or more study, an independent researcher (I. Batmaz) pro-
muscles and/or the connective tissue layer covering vided a randomization scheme from a random
the muscle.1 These trigger points and tense muscle number table by using block randomization with
bands can be relaxed with muscle strengthening and four patients in a block. The eligible patients who
relaxation exercises, superficial and deep heating had submitted a written informed consent were then
methods (such as therapeutic ultrasound), laser ther- referred to another researcher (M. Ulu) who was not
apy, and trigger point injections.2Y4 involved in the selection and consent process. This
Although there are a limited number of con- researcher used the randomization scheme to assign
trolled studies regarding its efficacy, therapeutic patients into three groups. This process thus ensured
ultrasound is recommended for the treatment of allocation concealment. Detailed patient histories
MPS.5Y8 However, there are no standard protocols were taken, and the patients underwent locomotor
regarding the appropriate frequency and intensity of system and general physical examinations to rule
therapeutic ultrasound, as there have been no sys- out any additional pathology. Demographic charac-
tematic studies of this in the literature.5Y8 teristics of the patients, including their age and edu-
Ultrasound for the treatment of MPS can be cational status, were recorded. The inclusion criteria
applied in a continuous or pulsed manner, although included an active trigger point in the upper tra-
these two methods have not yet been compared. pezius muscle (fulfilling the diagnostic criteria of
Therefore, in this study, the aim was to compare Travell and Simons), pain for at least 1 mo, aged be-
continuous and pulsed therapeutic ultrasound in tween 18 and 60 yrs, and consent to participate in the
MPS with sham ultrasound in terms of their effects study. The exclusion criteria included fibromyalgia
on pain, severity of muscle spasm, neck function, syndrome, systemic diseases, marked cervical herni-
quality of life, and depression. ated disc, trigger point injections or physiotherapy
within the last 3 mos, neck and shoulder surgery
within the last year, pregnancy, sensory disorders
MATERIALS AND METHODS in the area where the treatment would be applied,
Sixty patients between the ages of 18 and 60 yrs infections or skin lesions, and metallic implants or
who applied to the Dicle University School of Medi- cardiac pacemakers. Patients were randomly divided
cine Department of Physical Medicine and Reha- into three groups based on the inclusion and exclu-
bilitation between April 2012 and May 2013 were sion criteria. The first group (group A) was treated
enrolled in this study. The study protocol was ap- with 3 MHz, 1 W/cm2 continuous ultrasound; the
proved by the ethics committee at the same institu- second group (group B) was treated with 3 MHz,
tion. MPS was diagnosed based on the criteria of 1 W/cm2 pulsed ultrasound (1:1 ratio); and the third
Travell and Simons.9 MPS is considered if five major group (group C) was given sham ultrasound (as the
criteria and at least one of three minor criteria are device was turned off). A researcher (L. Ilter) in the
satisfied. Major criteria included localized spontane- Department of Physical Medicine and Rehabilitation
ous pain; spontaneous pain or altered sensations in in the University Hospital conducted all treatments
expected referred pain area for given trigger point; 5 days per week for a period of 2 wks. The patients
taut, palpable band in accessible muscle; exquisite, underwent 5-min ultrasound therapy sessions in
localized tenderness in precise a point along taut which the treatments were applied by the researcher
band; and some measurable degree of reduced range (L. Ilter) with circular movements on and around
of movement. Minor criteria included reproduction the painful trigger point (see Supplemental Digital
of spontaneously perceived pain and altered sensa- Content; http://links.lww.com/PHM/A82). All of the
tions by pressure on trigger point, elicitation of a patients were prescribed standard stretching and
local twitch response of muscular fibers by transverse range of motion exercises (neck flexion, extension,
snapping palpation or by needle insertion into trigger lateral flexion and rotation, shoulder roll, isometric
point, and pain relief obtained by muscle stretching flexion, extension and side bending strength, upper
or injection of trigger point. Only patients who com- trapezius and levator scapula stretching, scapular re-
plained of neck pain, had a palpable taut band on the traction) together with hot pack treatment to the
trapezius muscle, and had an active trigger point painful area for 10 mins. As for analgesics, patients

548 Ilter et al. 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. Quality of Life
Patients were also asked to keep exercise and medi- Quality of life was evaluated using the Notting-
cation diaries. ham Health Profile, which has been demonstrated to
The evaluation of all the patients enrolled in this be valid and reliable in Turkish. This questionnaire
study was performed by a blind researcher (B. Dilek) evaluates the emotional, social, and physical health
before and after the treatment and at the 6th and problems perceived by the patient. The questionnaire
12th wks after treatment as well. is divided into six subcategories, including energy,
pain, physical mobility, sleep, emotional reactions,
Primary Outcome Measures and social isolation. The 38 yes/no questions inquire
about the current complaints at the time the patient
The primary outcome measures were the sever-
is completing the questionnaire.12
ity of pain at rest and pain movement at the 12th wk
after treatment. Function
The Neck Pain and Disability Scale was used
Pain to functionally evaluate each patient. This scale was
Pain was evaluated using the 0-to-10 cm visual developed for a detailed assessment of neck pain.
analog scale. The scale was explained to patients so Patients with neck pain often score higher on this
they understood that 0 indicated the absence of pain, scale than do those with back and leg pain, and
10 indicated the most severe pain, and 5 corresponded therefore, it is thought to be more relevant to those
to a medium-level pain. The patients were asked to with neck pain. The NPAD scale consists of 20 items,
indicate their pain at rest and with movement within and for each item, the patient makes a mark on a
the last 48 hrs using this 0-to-10 scale. 10-cm scale. The score for each item varies between
0 and 5. If the patient marks the bold printed lines,
Secondary Outcome Measures half points are given. The sum of these scores indi-
cates the final score. This scale was tested for validity
The secondary outcome measures included the
and reliability by Wheeler et al. in 1999.13
severity of the palpable muscle spasm, psychologic
state, quality of life, function, and patient satisfac- Patient Satisfaction
tion after treatment and at the 6th and 12th wks The patient satisfaction form includes five
after treatment. choices: 0, worse; 1, no change; 2, mild improve-
ment; 3, good; 4, excellent. Patients indicate their
Severity of the Palpable Muscle Spasm satisfaction with the treatment by marking the ap-
The severity of the palpable muscle spasm in propriate choice immediately after the treatment and
the affected muscle was assessed using a five-step at 6 and 12 wks after treatment.
scale10: (0) no spasm, (1) medium-grade spasm, (2)
spasm stronger than medium grade but not limit-
ing the range of joint movement, (3) severe spasm Statistical Analysis
limiting the range of joint movement, and (4) severe Statistical analysis was performed with the IBM
spasm accompanied by postural deviation and the SPSS 21.0 for Windows statistics software. The
researcher graded the severity of muscle spasm. measured variables are presented as means T SD,
whereas categorical variables are indicated as num-
Psychologic State bers and percentages (%). Data were evaluated for
The depressive state of each patient was eval- compliance with the normal distribution. Compari-
uated using the Beck Depression Inventory, which sons of the groups outside the normal distribution
has been demonstrated to be valid and reliable in and comparisons between more than two variables
Turkish. The Beck Depression Inventory consists of were performed using the Kruskal-Wallis H-Tests
21 questions, and the patients are asked to choose and Friedman tests. Comparisons between the
the answer best fitting their condition. Each ques- groups with two variables were performed with the
tion has four possible answers, which are listed in Mann-Whitney U test and Wilcoxon test. The com-
order from a neutral condition (0 points) to the parisons of the qualitative variables between groups
most severe condition (3 points). The highest pos- were performed using the chi-square test. The hy-
sible score is 63. Zero to 13 points indicate no de- potheses are reciprocal, and statistical significance
pression; 14 to 24 points, moderate depression; and is based on a value of P G 0.05. A retrospective power
scores higher than 25 points, severe depression.11 analysis was also implemented. In the post hoc power

www.ajpmr.com Efficacy of Therapeutic Ultrasound for MPS 549

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 analysis, performed using sample sizes, means, and quality of life parameter in the Beck Depression
SD values for the significance level (alpha) of 0.05, Scale (P 9 0.05) (Tables 2Y7) and patient satis-
the power was calculated by statistical software, PASS. faction (P 9 0.05).
Pain at rest was significantly improved in the
group that was treated with continuous ultrasound,
RESULTS whereas no difference was observed between the
groups with regard to the other scores (P G 0.05).
Eighty-five patients met the inclusion criteria
When the intragroup changes after the therapy were
during their routine outpatient physical examina-
compared, the improvement in pain at rest among
tion for MPS. After reviewing the inclusion and
the group that was treated with continuous ultra-
exclusion criteria, 77 patients (52 women, 25 men)
sound was significantly higher compared with that
with MPS who signed the informed consent forms
in the groups that received pulsed and sham ultra-
were enrolled in the study. These patients were ran-
sound (P G 0.05). However, there were no statistically
domized into the continuous ultrasound (n = 25),
significant differences in any of the other parameters
pulsed ultrasound (n = 27), and sham ultrasound
(P 9 0.05) (Tables 2Y7).
(n = 25) groups. Seventeen patients were lost during
follow-up, and therefore, 60 patients completed the
study (Supplemental Digital Content). No compli- Intention to Treat
cations were reported in the study groups during In the intention-to-treat analysis, the signifi-
the therapy. cance of the results did not differ from the per
protocol analysis for the primary outcomes. The
Per Protocol P values are provided in Tables 2 through 7.
In the post hoc power analysis, performed using
No statistically significant differences were ob-
sample sizes, means, and SD values for the signifi-
served between the groups in terms of sex, age,
cance level (alpha) of 0.05, the power was found to be
duration of pain, education, or occupation (P 9 0.05)
96% for pain at rest and 100% for pain at movement.
(Table 1).
However, the power was below 50% for the secondary
All three groups had a statistically significant
outcome measures.
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 DISCUSSION
(P G 0.05). The Beck Depression Scale indicated that MPS is characterized by hypersensitive points
there was no significant improvement in the sham (known as Btrigger points[) located in the muscles
ultrasound group. In addition, no significant im- and/or the fasciae that may lead to pain, muscle spasm,
provement was observed in any of the three groups hypersensitivity, limitation of movement, weakness,
in terms of social isolation subparameter of the 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) P
Female 60 (12) 80 (16) 70 (14) 0.386
Age, mean T SD, yrs 33 T 8 32 T 7 33 T 8 0.496
Duration of symptoms, median (minYmax), mos 12 (1Y60) 11 (1Y60) 5 (1Y36) 0.237
Occupation worker 7 (35) 9 (45) 7 (35) 0.491
Civil servant 10 (50) 9 (45) 9 (45)
Homemaker 1 (5) 1 (5) 4 (20)
Other 2 (10) 1 (5) 0 (0)
Education illiterate 0 (0) 1 (5) 1 (5) 0.180
Literate 1 (5) 0 (0) 0 (0)
Elementary school 1 (5) 0 (0) 5 (25)
Middle school 1 (5) 2 (10) 1 (5)
High school 3 (15) 7 (35) 5 (25)
College 14 (70) 10 (50) 8 (40)
Data are presented as n (%), unless otherwise indicated.

550 Ilter et al. Am. J. Phys. Med. Rehabil. & Vol. 94, No. 7, July 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 TABLE 2 Comparison of resting pain among the groups

Pain at Rest (VAS 0Y10 cm) Group A Group B Group C P/P-int (Kruskal) P/P-int (Friedman)
Baseline 4 (0 to 7) 5.5 (2 to 10) 5 (0 to 9) 0.023a/0.027a G0.001a/G0.001a
AT 1.5 (0 to 6) 2.5 (0 to 10) 2 (0 to 8) 0.338/0.502
6th wk 2 (0 to 7) 1 (0 to 8) 1 (0 to 7) 0.804/0.803
12th wk 0 (0 to 8) 1 (0 to 7) 0 (0 to 7) 0.769/0.925
P (Wilcoxon) 0.003a G0.001a G0.001a
P-int 0.001a G0.001a G0.001a
Change
BaselineYAT 1 (j2 to 6) 2 (0 to 8) 2.5 (0 to 5) 0.371
BaselineY6th wk 1.5 (j4 to 5) 3 (j4 to 10) 3 (0 to 5) 0.035a
BaselineY12th wk 2 (j3 to 7) 3 (j2 to 10) 3.5 (0 to 6) 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 elu- compliance, significantly reduces pain scores, and sig-
cidated, most of the treatment protocols target nificantly improves tissue compliance and pressure
the symptoms. Various physical therapy modalities pain threshold values. In a study by Esenyel et al.,7
aim to inactivate the trigger points, relax the rigid neck stretching exercises combined with ultrasound
bands, and control the predisposing factors. Physi- and injection treatment led to significant improve-
cal therapy modalities including injections, spraying ments in comparison with the control group, al-
and stretching techniques, hot packs, ice packs, ther- though they were not found to be superior to each
apeutic massages, electrotherapy, and ultrasound other. However, another study reported no signifi-
are also effective in reducing pain.3,14 cant difference between the ultrasound group and a
Ultrasound is a noninvasive technique that is placebo ultrasound group, although a nonsignificant
frequently used in the treatment of MPS because improvement in the placebo group was associated
of its thermal and biophysical effects. Thermal and with the effects of the massage and exercise.8
nonthermal effect occurs in tissue during the ul- In this study, it was observed that all pain was
trasound treatment by using high-frequency significantly reduced in all three groups after therapy.
acoustic energy. During the absorption of ultrasonic However, only the group receiving continuous ul-
waves in tissues and their reflection among the sur- trasound had a significant improvement in resting
faces, heat energy is produced and provides deep pain scores at 6 and 12 wks after treatment.
heating. At the same time, ultrasound therapy has It has been reported that the location of the
analgesic effects, increases nutrition, and also speeds trigger point has the most important diagnostic value
blood circulation. In addition, the micromassage in MPS. Previous studies have reported that the most
effects of high-frequency sound waves have been reliable physical examination results of the trigger
demonstrated.5 KNsaoğlu et al.6 reported that ul- point are focal sensitivity and pain.15,16 Determining
trasound reduces myofascial pain, improves tissue 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 5 (3Y10) 5.5 (1Y10) 6 (3Y9) 0.564/0.413 G0.001a/G0.001a
AT 2.5 (0Y6) 3 (0Y10) 3 (0Y8) 0.752/0.623
6 wks AT 3 (0Y6) 2 (0Y6) 2 (0Y8) 0.881/0.945
12 wks AT 2.5 (0Y7) 2 (0Y6) 1 (0Y6) 0.471/0.740
P (Wilcoxon) G0.001a G0.001a G0.001a
P-int 0.001a 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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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 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 2 (1Y3) 2.5 (1Y3) 2 (1Y3) 0.526/0.119 G0.001a/G0.001a
AT 1 (0Y3) 2 (0Y3) 1 (0Y3) 0.555/0.336
6 wks AT 1 (0Y3) 1 (0Y3) 1 (0Y3) 0.819/0.850
12 wks AT 1 (0Y3) 1 (0Y3) 1 (0Y3) 0.939/0.938
P (Wilcoxon) G0.001a G0.001a G0.001a
P-int 0.009a 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 injection for the treatment of MPS and found that
the treatment. Algometers are used to determine both treatment methods are effective in reducing
the trigger point sensitivity.10,17Y19 However, an pain and improving quality of life, although they
algometric assessment was not made in this study. have no effect on depression. In this study, quality of
It has been previously reported that the degree life improved in all three groups after the therapy.
of the palpable muscle spasm in MPS is positively Also, the patients’ functional condition, assessed
correlated with the limitation in joint movement.10 through the neck pain questionnaire, improved after
In this study, the degree of the palpable muscle therapy. The pain caused by MPS negatively in-
spasm improved significantly with therapy in all fluences the individual’s functional condition, has an
three groups. impact on the mental condition, and affects quality
Studies evaluating quality of life in MPS pa- of life. The reduction of this pain through therapy
tients are limited.20,21 In a study where the quality of increases the person’s functionality, which increases
life of patients with fibromyalgia and with/without his/her quality of life.
MPS was studied, quality of life was lower in the S$ ahin et al.22 reported that depression accom-
patients with MPS as compared with the control panies MPS, and patients with MPS have a higher
group.20 The study by AltNndağ and Gür21 compared ratio of depression and somatization than do those
the efficacy of dry needling with local anesthetic without widespread pain. Another study reported

TABLE 5 Comparison of the groups’ NHP scores

NHP Baseline AT 6 wks AT 12 wks AT P/P-int
Group A Pain 49.2 (0Y100) 26.42 (0Y100) 11.7 (0Y94.17) 14.37 (0Y100) 0.009a/0.010a
Physical activity 17.06 (0Y6.01) 11.87 (0Y42.86) 10.57 (0Y58.86) 11.54 (0Y74.70) 0.751/0.078
Fatigue 39.2 (0Y100) 38 (0Y100) 18.4 (0Y100) 38 (0Y100) 0.026a/0.021a
Sleep 20.6 (0Y100) 12.57 (0Y65.06) 12.57 (0Y56.64) 6.28 (0Y39.83) 0.004a/0.001a
Social isolation 0 (0Y61.50) 0 (0Y61.50) 0 (0Y39.49) 0 (0Y39.49) 0.053/0.157
Emotional reaction 13.3 (0Y83.47) 4.88 (0Y90.7) 0 (0Y50.61) 0 (0Y62.58) 0.018a/0.022a
Group B Pain 61.7 (0Y100) 15.11 (0Y100) 9.87 (0Y100) 6.45 (0Y100) 0.000a/0.000a
Physical activity 16.03 (0Y65.47) 10.57 (0Y35.65) 0 (0Y46.22) 4.65 (0Y55.39) 0.013a/0.011a
Fatigue 63.2 (0Y100) 37.80 (0Y100) 30.40 (0Y100) 0 (0Y100) 0.000a/0.002a
Sleep 26.9 (0Y77.63) 12.57 (0Y77.63) 12.57 (0Y77.63) 12.57 (0Y77.63) 0.147/0.145
Social isolation 0 (0Y57.34) 0 (0Y57.34) 0 (0Y42.14) 0 (0Y42.14) 0.634/1.000
Emotional reaction 0 (0Y57.83) 0 (0Y57.83) 0 (0Y78.79) 0 (0Y78.79) 0.850/0.596
Group C Pain 53.4 (9.99-100) 31.01 (0Y100) 18.40 (0Y100) 20.52 (0Y100) G0.001a/0.002a
Physical activity 20.72 (0Y89.43) 5.28 (0Y100) 10.42 (0Y66.95) 11.16 (0Y100) 0.506/0.609
Fatigue 39.20 (0Y100) 39.20 (0Y100) 51.20 (0Y100) 39.20 (0Y100) 0.872/0.472
Sleep 39.83 (0Y87.63) 12.57 (0Y87.63) 12.57 (0Y87.63) 12.57 (0Y87.63) 0.014a/0.021a
Social isolation 0 (0Y100) 0 (0Y100) 0 (0Y77.47) 0 (0Y22.53) 0.886/0.207
Emotional reaction 22.74 (0Y100) 15.39 (0Y100) 5.23 (0Y89.53) 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.

552 Ilter et al. Am. J. Phys. Med. Rehabil. & Vol. 94, No. 7, July 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 TABLE 6 Comparison of neck pain and disability among the groups
NPDI Group A Group B Group C P/P-int (Kruskal) P/P-int (Friedman)
Baseline 48 (2Y75) 48.25 (15Y77) 52 (16Y89) 0.914/0.867 G0.001a/G0.001a
AT 35.75 (2Y76) 20.50 (0Y65) 36.50 (3Y75) 0.274/0.316
>6 wks AT 28.75 (0Y78) 22 (0Y94) 29.50 (0Y66) 0.857/0.815
12 wks AT 26.50 (0Y81) 24 (0Y100) 34 (0Y75) 0.910/0.864
P (Wilcoxon) 0.007a 0.001a G0.001a
P-int 0.008a 0.004a 0.003a
Data are presented as median (minYmax).
a
P G 0.05.
NPDI, Neck Pain Disability Index; int, intention-to-treat analysis; AT, after treatment.

that MPS was accompanied by major depression in massage therapy, the improvement in the placebo
most of the cases and that the severity of the de- group may be a result of the compression and
pression was related to the perceived pain.5 In this massage effects of the ultrasound probe. Also, the
study, the depression scores of the groups that re- exercise and hot pack treatments applied to the pla-
ceived continuous and pulsed ultrasound were sig- cebo group may have also contributed to their posi-
nificantly improved immediately after treatment tive results. Another possible explanation of this
and at 6 and 12 wks after treatment in comparison study’s results may be the nonspecific treatment
with the pretreatment period. There was no signifi- effects, which are generally known as the placebo
cant difference in the depression scores of the pa- effect. These placebo effects may be associated with
tients receiving sham ultrasound during this same the care given by the researcher to the patient, the
time period. The reduction in pain due to therapy patient’s expectations from the treatment, the im-
in the MPS patients suggests that treatment may pressiveness of the treatment, characteristics of the
also contribute to the emotional improvement of therapy environment, or the close observation of the
these patients. patient within the framework of the study.
In conclusion, this prospective, randomized, Limitations of this study include the limited
placebo-controlled, double-blind study has shown number of patients and the irregular exercise and
that continuous ultrasound therapy in MPS is supe- drug diaries kept by the patients. Therefore, other
rior to pulsed and sham ultrasound in reducing pain prospective and comparative studies are needed
at rest and that continuous and pulsed ultrasound to describe the optimal and most efficient ultra-
therapies are both superior to sham ultrasound in sound therapy, whether it be continuous or pulsed
improving psychologic condition. However, contin- ultrasound.
uous ultrasound and pulsed ultrasound are no dif-
ferent than sham ultrasound in terms of their effect
on the quality of life, pain with movement, and the ACKNOWLEDGMENTS
degree of muscle spasm. Because of the compression The authors thank all participants who joined
applied on the trigger points and the efficacy of the the study.

TABLE 7 Comparison of depression among groups

Beck Depression Scale Group A Group B Group C P/P-int (Kruskal) P/P-int (Friedman)
Baseline 13 (0Y23) 8 (0Y25) 8.5 (0Y32) 0.585/0.584 G0.001a/G0.001a
AT 8.5 (0Y25) 5 (0Y25) 7 (0Y32) 0.776/0.722
6 wks AT 8 (0Y24) 4 (0Y28) 7.5 (0Y32) 0.798/0.630
12 wks AT 8.5 (0Y29) 4 (0Y28) 7.5 (0Y40) 0.432/0.352
P (Wilcoxon) 0.018a 0.047a 0.428
P-int 0.014a 0.036a 0.560
Data are presented as median (minYmax).
a
P G 0.05.
Int, intention-to-treat analysis; AT, after treatment.

www.ajpmr.com Efficacy of Therapeutic Ultrasound for MPS 553

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 REFERENCES 12. Kucukdeveci AA, Mc Kenna SP, Kutlay S, et al: The
1. Simons DG, Travell JG, Simons LS, (eds): Myofascial development and psychometric assessment of the
Pain and Dysfunction: The Trigger Point Manual, ed 2. Turkish version of the Nottingham Health Profile. Int
Baltimore, MD, Lippincott Williams & Wilkins, 1998 J Rehabil Res 2000;23:31Y8

2. Rickards LD: The effectiveness of non-invasive treat- 13. Wheeler AH, Goolkasian P, Baird AC, et al: Item analysis,
ments for active myofascial trigger point pain: A face and criterion related validity. Spine 1999;24;1290Y4
systematic review of the literature. Int J Osteopath 14. Friction JR: Management of myofascial pain syn-
Med 2006;9:120Y36 dromes, in Friction JR, Awad E, (eds): Advances in Pain
3. Han SC, Harrison P: Myofascial pain syndrome and Research and Therapy. New York, Raven Press Ltd.,
trigger point management. Reg Anest 1997;22:89Y1 1990;325Y39

4. Aguilera FJ, Martin DP, Masanet RA, et al: Immediate 15. Nice DA, Riddle DL, Lamb RI, et al: Intertester reli-
effect of ultrasound and ischemic compression tech- ability of judgments of the presence of trigger points
niques for the treatment of trapezius latent myofascial in patients with low back pain. Arch Phys Med
trigger points in healthy subjects: A randomized con- Rehabil 1992;73:893Y8
trolled study. J Manipulative Physiol Ther 2009;32: 16. Njoo KH, Van der Does E: The occurrence and inter-
515Y20 rater reliability of myofascial trigger points in the
5. Srbely JZ, Dickey JP: Randomized controlled study of quadratus lumborum and gluteus medius: A pro-
the antinociceptive effect of ultrasound on trigger spective study in nonspecific low back pain patients
point sensitivity: Novel applications in myofascial and control in general practice. Pain 1994;58:317Y23
therapy? Clin Rehabil 2007;21:411Y7 17. Hong CZ: Lidocaine injection versus dry needling to
6. KNsaoğlu S, Erdem HR, Göncü G: Miyofasiyal ağrN myofascial trigger point: The importance of the local
sendromunda ultrasonun etkinliği. Romatizma 2000; twitch response. Am J Phys Med Rehabil 1994;73:
15:123Y7 256Y63
7. Esenyel M, Cağlar N, Aldemir T: Treatment of myo- 18. Fischer AA: Documentation of myofascial trigger
fascial pain. Am J Phys Med Rehabil 2000;79:48Y52 points. Arch Phys Med Rehabil 1988;69:268Y91
8. Gam AN, Warming S, Larsen LH, et al: Treatment of 19. Jaeger B, Reeves JL: Quantification of changes in
myofascial trigger points with ultrasound combined myofascial trigger point sensitivity with the pressure
with massage and exercise: A randomized controlled algometer following passive stretch. Pain 1986;27:
trial. Pain 1998;77:73Y9 203Y10
9. Travell JG, Simons DG (eds): Myofascial pain and dys- 20. Tüzün EH, Albayrak G, Eker L, et al: A comparison
function, in The Trigger Point Manual. Vol 1, Upper Half study of quality of life in women with fibromyalgia
of Body, ed 2. Baltimore, MD, Lippincott Williams & and myofascial pain syndrome. Disabil Rehabil 2004;
Wilkins, 1992, pp. 5Y201 26:198Y202
10. Cheshire WP, Abashian SW, Mann D: Botulinum 21. AltNndağ Ö, Gür A: Miyofasiyal ağrN sendromunda kuru
toxin in the treatment of myofascial pain syndrome. iğneleme ve lokal anestezik enjeksiyonun etkinliği.
Pain 1994;59:65Y9 Harran Üniversitesi Tııp Fakültesi Dergisi 2006;3:84Y8
11. Hisli N: Beck depresyon envanterinin üniversite 22. S$ ahin N, Karatas$ Ö, Özkaya M: Servikal miyofasyal
öğrencileri için geçerliliği ve güvenirligi. Psikoloji ağrN sendromlu hastalarda demografik özellikler, klinik
Dergisi 1989;7:3Y13 bulgular ve fonksiyonel durum. Ağrıı 2008;20:14Y9

554 Ilter et al. Am. J. Phys. Med. Rehabil. & Vol. 94, No. 7, July 2015

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