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J Pain Manage 2016;VOL 9, NO1.
J Pain Manage 2016;VOL 9, NO1.
Shock wave versus phonophoresis on mechanical neck
dysfunction
Mohamed Serag Eldein Mahgoub Mohamed Mostafa , PhD, Tarek Abd
Elrahman Ali Ammar, PhD .
Department of Physical Therapy for Basic Sciences, Faculty of Physical
Therapy, Cairo University, Cairo, Egypt
Abstract: Mechanical neck dysfunction (MND) affects approximately two
thirds of people in the middle age due to bad postural habits. purpose: to
compare the efficacy of extracorporeal shock waves (ESWT) versus
phonophoresis on pain intensity, cervical range of motion and disability in
patients with MND. Design: randomized controlled trial. Methods: 45 patients
with MND participated in this study. They were assigned randomly into three
groups: Control group (A) received traditional exercises, group B received
phonophoresis and the traditional exercises and group C received ESWT once a
week for four sessions and the traditional exercises. Subjects received three
sessions a week for four weeks. The authors measured pain intensity, cervical
range of motion and neck disability by the visual analogue scale, Myrin OB
goniometer and neck disability index, respectively at baseline and after four
weeks of treatment. Results: There were significant improvements in all groups
after intervention in favor of group C. Conclusion: It was concluded that the
group that received ESWT had the greatest improvement in pain intensity,
cervical range of motion and neck disability in patients with MND.
Keywords: Neck dysfunction, phonophoresis, shock waves
Correspondence: Mohamed Serag, Department of Physical Therapy for Basic
Sciences, Faculty of Physical Therapy, Cairo University, 77 Shalhoub Street,
Ahmed Essmat ain Shams, Cairo, Egypt. E-mail: drsergany_79@hotmail.com
Submitted: January 05, 2016. Revised: January 25, 2016. Accepted: January 29,
2016. Published: March 05, 2016
Introduction
Neck pain is one of the leading causes of disability worldwide. It has a prevalence
rate of 30 percent and almost half of the population experience pain or
recurrences (1,2). Mechanical neck dysfunction (MND) is characterized by
intermittent pain, restriction of end range of movement and dysfunction of the
cervical muscles. There are several structural and behavioral changes in the
cervical musculature in patients with MND (3). Several factors may lead to MND
such as postural dysfunction, trauma, bad postural habits and it may also be of
insidious onset (4). Several authors reported a correlation between MND and
dysfunction of the cervical muscles (5,6).
Several modalities have been used in treating MND such as ultrasound,
acupuncture, laser, exercise, biofeedback, and TENS (7-9). Mechanical
vibrations (phonophoresis and shock waves) have also been used in MND.
Phonophoresis has been defined as the migration of the drug particles through the
skin using ultrasound leading to increase of the transdermal absorption of
molecules of the drug (10). It also uses acoustic cavitation to help deliver
anti-inflammatory and analgesic agents to a depth of penetration of five
J Pain Manage 2016;VOL 9, NO1.
centimeters. Moreover, it has several advantages such as minimal risk of skin
burn and hepatic or renal injury (11).
Extracorporeal shock wave therapy (ESWT) is another modality utilized
in musculoskeletal disorders such as nonunion of pseu¬doarthrosis or fracture,
calcific tenosynovitis, plantar fasciitis, and myofascial pain syndrome (12). It is
non-invasive, simple, and easy to apply. Tara et al (13) postulated that it
promotes angiogenesis, perfusion in ischemic tissues, and cell differentiation.
They added that ESWT may also reduce inflammation and pain.
The purpose of this study was to compare between the effectiveness of
ESWT and phonophoresis on pain intensity, cervical range of motion (ROM) and
neck function disability in patients with MND.
Methods
This study was a randomized controlled trial with patients randomly assigned to
one of three intervention groups: Group A received traditional exercises, group B
received phonophoresis and traditional exercises, while group C received ESWT
and exercises. Subjects in the first two groups received three sessions per week
for four weeks. However, subjects in group C received ESWT one visit a week
for four weeks and traditional exercises three sessions a week for four weeks.
Measurements were taken at baseline and after four weeks. The tester who took
the measurements and the treating therapist were blinded to group allocation.
Forty five patients diagnosed with MND were referred from an
orthopedic clinic and participated in the current study. All patients were referred
from an orthopedic consultant.
Inclusion criteria were age between 20-45 years and a score of at least five
on the neck disability index (NDI) (14). Inclusion criteria also included subjects
with pain of less than 12 weeks. Reasons for exclusion criteria included cervical
disc problems, history of neck trauma, head injuries, ankylosing spondylitis,
osteoporosis of the cervical spine, cervical rib, post-surgical neck conditions,
open wound over the cervical region, internal fixation of the cervical vertebrae,
or cerebrovascular abnormalities. All subjects signed a consent form permitting
the use of their data for research purposes, and confidentiality was assured by the
use of an anonymous coding system. Participants were asked to refrain from
other forms of physical therapy or other medical procedures for pain during the
study. The procedures were followed according to the agreement of the
institutional ethical committee.
Instrumentation
Myrin OB Goniometer was used to measure cervical spine ROM. It is valid and
reliable tool (15). Visual analogue scale (VAS) was also used to measure pain
intensity. Its validity and test-retest reliability was between 0.95 and 0.97 (16).
The authors also used the Neck disability index (NDI). It is a self-rated disability
questionnaire with high test-retest reliability and good concurrent validity (17).
Macdermid et al (18) reported that the NDI is strongly correlated (>0.70) to a
number of similar functional disability measures and moderately related to both
physical and mental aspects of the general health.
Evotron RFL0300 (Swiss Tech Medical AG, Switzerland) was used to
deliver shock waves. It has a depth of penetration between 0 to 30 mm. Pulse
rates were 60, 120, 180, 240 impulses per minute. Phyaction Ub machine was
also utilized to produce ultrasound waves. It is produced by Gymna Uniphy
Company, New Delhi, India.
J Pain Manage 2016;VOL 9, NO1.
Procedures
Group A: Patients received the traditional (isometric and stretching) exercises.
The subjects did the isometric exercises for the neck extensors, flexors and side
benders. They were asked to hold each contraction for six seconds and then relax
for another six seconds. All patients repeated each exercise for five times. They
also received stretching exercises for the levator scapula, upper fibers of
trapezius and sternocleidomastoid muscles, if tight. Patients repeated each
exercise for three times. Each patient was instructed to hold for 30 seconds and
relax for another 30 seconds (19,20).
Group B: The therapist applied the ultrasound on the paraspinal muscles
of the neck and on the upper fiber of the trapezius muscle using the diclofenac
sodium gel as a coupling medium (21). Frequency was 1 MHz with the
transducer having a radiating area of 5.0 cm2. The intensity used was of 1 W/cm2
in continuous mode to reach the deep tissues (22). The subjects also performed
the same traditional exercises.
Group C: Patients were given total of 1,500 shock waves for each session
at the rate of 240 waves, each with low en¬ergy flux density of 0.10 mJ/mm2 per
minute. Treatment was given by focusing on the pain taut area by appropriately
adjusting the location of the localized probe. It was used once weekly four times
with a week’s interval between the treatment sessions. The therapist started at
low energy levels and gradually increased the intensity within the patient’s
tolerance, not exceeding the sixth level(total of 6000 shock waves). Patients were
instructed to refrain from physical activities for 48 hours following each shock
wave session.
Data analysis
A statistical power analysis suggested that sample sizes above 15 participants per
group were required to achieve more than 80% power. Statistical tests were
performed using SPSS version 17 (Chicago, IL, USA). Descriptive statistics
(mean and standard deviation) were computed for all data. The authors used the
ANOVA test to assess pain intensity, cervical ROM and neck disability among
the three groups.
Results
45 patients with MND were randomly assigned into three groups with 15 patients
in each group. There was no significant difference between the three groups in
their ages, weights, heights and body mass index where their P-values were
(0.55), (0.65), (0.55) and (0.4) respectively at baseline as shown in table 1.
Table 1. Means and standard deviations of age, height, weight and body Mass
index of groups A, B and C
Comparison
Group (C)
Group (B)
Group (A)
P-value
F-value
±SD
Mean
±SD
Mean
± SD
Mean
0.55
0.58
±6.1
32.84
±5.3
30.64
± 4.9
31.71
Age
0.65
0.43
±4.4
78.11
±4.5
79.70
± 5.9
79.42
Weight(Kg)
0.55
0.63
±6.5
171.86
±5.4
171.6
± 5.9
169.5
Height (cm)
0.4
0.90
±1.6
26.39
±2.3
27.02
± 2.8
27.55
BMI(Kg/m2)
J Pain Manage 2016;VOL 9, NO1.
Pain level
There was no significant difference among the three groups for the pre-treatment
values (F=0.09, P=0.91). However, there was a significant difference for the post
treatment value (F=16.14, P=0.001) as shown in figure 1.
Figure 1. Means and standard deviations of the pain level for the three groups before and after
treatment
Neck flexion ROM
There was no significant differences among the three groups for the pre- treatment
value(F=0.009 and P=0.99).However, there was a significant difference for the
post treatment value (F=11.53 and P=0.001) as shown in table 2.
Table 2. Results of ANOVA among the three groups for neck flexion ROM
Neck flexion ROM
SS
MS
F
P value
S
Pre treatment
Between Groups
Within Groups
Total
0.46
886.8
895.2
0.2
21.37
0.009
0.99
NS
Post Treatment
Between Groups
Within Groups
Total
478.91
880.26
1369.2
234.46
21.17
11.53
0.001
S
S: significant NS: non significant
Neck extension ROM
There was no significant differences among the three groups for the pre-treatment
value (F=0.05, P value=0.94). However, there was a significant difference for the
post treatment value (F=16.31, P=0.001) as shown in table 3.
J Pain Manage 2016;VOL 9, NO1.
Table 3. Results of ANOVA among the three groups for neck extension ROM
Neck extension ROM
SS
MS
F
P value
S
Pre Treatment
Between Groups
Within Groups
Total
1.71
685.46
690.2
0.86
16.41
0.05
0.94
NS
Post Treatment
Between Groups
Within Groups
Total
791.93
1015.26
1809.2
395.46
24.24
16.31
0.001
S
S: significant NS: non significant
Neck side bending ROM to the Right: There was no significant differences
among the three groups for the pre-treatment value (F=0.05, P=0.94). However,
there was a significant difference for the post treatment value (F=14.4, P=0.001)
as shown in table 4.
Table 4. Results of ANOVA among the three groups for right neck side bending
ROM
Neck side bending ROM
SS
MS
F
P
S
Pre Treatment Groups
BetweenGroups
Within Groups
Total
1.24
471.5
472.7
0.62
11.2
0.05
0.94
NS
Post Treatment
Between Groups
Within Groups
Total
315.5
463.16
778.58
157.77
11.02
14.4
0.001
S
S: significant NS: non significant
ROM of neck rotation to the right
There were no significant differences among the three groups for the
pre-treatment value (F=0.34, P=0.72). However, there was a significant
difference for the post-treatment value (F=20.23, P= 0.001) as shown in table 5.
Table 5. Results of ANOVA among the three groups for right neck rotation ROM
Neck rotation ROM
SS
MS
F
P value
S
Pre Treatment
Between Groups
Within Groups
Total
6.93
444.26
451.2
3.46
10.57
0.34
0.72
NS
Post Treatment
Between Groups
Within Groups
Total
435.37
452.26
887.64
217.68
10.76
20.23
0.001
S
S: significant NS: non significant
J Pain Manage 2016;VOL 9, NO1.
Functional disability
There was no significant difference among the three groups for the pre-treatment
value (F=0.18, P=0.87). On the other hand, there were significant differences for
the post-treatment value (F=28.12, P=0.001) as shown in table 6 and figure 2.
Table 6. Results of ANOVA among the three groups for functional disability
Functional disability
SS
MS
F
P
S
Pre Treatment
Between Groups
Within Groups
Total
1.64
230.26
231.91
0.82
5.48
0.18
0.87
NS
Post Treatment
Between Groups
Within Groups
Total
277.37
207.86
485.24
138.68
4.94
28.12
0.001
S
S: significant NS: non significant
Figure 2. Mean and SD of functional disability for the three groups pre and post treatment
Discussion
The purpose of this study was to compare between the ESWT and phonophoresis
in patients with MND. The results of this randomized trial showed that there were
significant differences between all groups after the end of the intervention, in
favor of the group that received the ESWT and exercises. The Least significant
difference test showed a statistical significant difference in the mean value of all
parameters of the group C (ESWT and exercises) when compared to groups A
(exercises, p=0.02) and group B (phonophoresis and exercises p=0.04).The
observed improvements in each group were most likely the result of the
intervention. It is unlikely that the results are due to the passage of time or tester
bias due to utilization of an appropriate study design. The design included
random assignment of subjects into the groups and blinded tester to the group
allocation. There have been a few studies comparing between the ESWT and
phonophoresis in patients with MND. This study showed that exercises improved
the dependent variables in patients with MND.
J Pain Manage 2016;VOL 9, NO1.
Exercise therapy aimed to alleviate pain and improve disability and
function in patients with MND (23). This was in agreement with Lars et al (24)
who stated that strength training led to significant relief in neck pain. Also, the
results of the study were collaborated with the findings of Ylinen et al (25) who
evaluated the effects of isometric exercises on subjects with chronic neck pain.
The subjects received exercises for three sessions per week for six weeks. They
found that there were significant differences in muscle strength and neck pain
between the patients with neck pain and healthy subjects before and after
treatment. In addition, the results of this study agreed with Berg et al (26) who
found that strengthening exercises have great effect on improving pain and
disability in workers with a high rate of neck disorders. This study demonstrated
that ESWT was effective in improving the outcomes in subjects with MND. It has
been reported that ESWT improves blood circulation in capillary blood vessels
and reduces the ten-sion of muscles along with the reduction in pain by inducing
interference of flow of excessive stimu¬lation of nociceptors and stimulation of
nerves (27). In ad¬dition Hausdorf et al 28,29) postulated that ESWT reduces
pain in the muscular tissues through selective destruction of non-myelinated
fibers and reducing the level of substance P in the target tissues as well as in the
dorsal root ganglia. Also Wang et al (30) reported that ESWT may increase
perfusion in the ischemic tissues and stimulate generation of new blood vessels.
This was supported by the findings of Ji et al (31) who concluded that
ESWT was effective in reducing pain and increasing pressure thresholds in 22
patients with myofascial pain syndrome of the upper trapezius. Results of this
study also agreed with those of Jeon et al (32) who concluded that ESWT and
transcutaneous electrical nerve stimulations were equally effective in improving
pain and pressure threshold in 30 patients with myofascial pain syndromes of the
upper trapezius.
The study also showed that subjects who received phonophoresis
experienced improvements in the dependent variables. This may be explained by
the fact that phonophoresis induces mechanical stress and/or creates temporary or
permanent cavities through corneocytes and kaeratinocytes. Thus, it increases
skin permeability. Also, it inherits thermal effects that promotes pain reduction
and joint mobility (33).
The authors used diclofenac sodium gel that enhances analgesia, reduces
inflammation and inhibits prostaglandins production (34). Subjects also had
improvement in joint mobility as the gel has non-steroidal anti-inflammatory
properties that inhibits pain. Therefore, pain reduction makes it easy for the
stretching and strengthening exercises to exert their effect in improving joint
mobility. This enables subjects to be more active and had more ability to maintain
their daily training (35). The authors used continuous ultrasound in this study.
This was supported by O’Leary et al (5) who used compared different modes of
ultrasound in myofascial pain syndrome. They showed that the continuous
ultrasound group (3 MHz, 1 W/cm2) had the greatest significant improvement in
pain at rest (P>0.05) than the pulsed or sham groups.Results of this study came in
agreement with those of Durmus et al (36) who reported significant differences in
pain and disability in 61 patients with chronic neck pain following
phonophoresis. This study also agreed with those of Ustun et al (37) who
compared between phonophoresis and ultrasound in 50 patients with myofascial
pain syndrome. They showed statistically significant decrease in number of
trigger points (p = 0.001, p = 0.029), and pain intensity on movement (p = 0.001
J Pain Manage 2016;VOL 9, NO1.
vs. 0.002) and right/left cervical lateral ROMs (p = 0.001/p = 0.001, p = 0.009/p =
0.020) relative to baseline.
There are some limitations in this study. First, the sample size was small.
Second, the daily living activities of the patients could not be completely
controlled. Last but not least, objective laboratory tests of lactic acid,
prostaglandin E, substance P and akinin were not taken. In this study, the
researchers concluded that ESWT and exercises is more effective than
phonophoresis and exercises in reducing pain, disability and increasing neck
ROM in patients with MND.
Conclusion
It was concluded that group C that had received ESWT had the greatest
improvement in pain intensity, cervical range of motion and neck disability in
patients with MND than the other groups .
Acknowledgements
We disclose that we did not received any financial support from any institution
or company it is our project and we insured all expenses. References
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