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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 34  |  Issue : 3  |  Page : 242-245

Comparative evaluation of efficacy of therapeutic ultrasound and phonophoresis in myofascial pain dysfunction syndrome


Department of Oral Medicine and Radiology, Karpaga Vinayaga Institute of Dental Sciences, Chengalpattu, Tamil Nadu, India

Date of Submission23-Mar-2022
Date of Decision12-Jul-2022
Date of Acceptance17-Jul-2022
Date of Web Publication26-Sep-2022

Correspondence Address:
Rajamohan Radhamani Mahendra Raj
Department of Oral Medicine And Radiology, Karpaga Vinayaga Institute of Dental Sciences, Chengalpattu, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_100_22

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   Abstract 


Introduction: Myofascial pain dysfunction syndrome (MPDS) is a common presenting condition in the dental office. No specific therapy has proven its superiority over the other in managing myofascial pain dysfunction syndrome. Since phonophoresis was beneficial for other musculoskeletal medical conditions, the same strategy was adopted to prove its efficacy in MPDS. Aim and Objective: The aim of the study is to compare and evaluate the effectiveness of therapeutic ultrasound (ThUS) and diclofenac and thiocolchicoside gel phonophoresis in MPDS. Materials and Methods: Thirty patients with MPDS were randomly assigned into two groups. Group 1 (n = 15), therapeutic ultrasound was applied with ultrasound gel without any therapeutic ingredient for 10 min and five sessions. Group 2 (n = 15), ultrasound was applied with ultrasound gel with diclofenac and thiocolchicoside gel for 10 minutes and five sessions. Pain and mouth opening was taken as evaluation parameters. Result: A comparison of results obtained from the two groups before and after treatment at the end of each session shows significant improvement in both the parameters. However, in Group 2 more improvement in all outcome variables can be seen compared with group 1. Conclusion: Phonophoresis with diclofenac and thiocolchicoside (analgesic and muscle relaxant) proved to be an excellent treatment in MPDS. They proved more effective than therapeutic ultrasound in controlling pain and improving mouth opening.

Keywords: Myofascial pain dysfunction syndrome; phonophoresis; therapeutic ultrasound


How to cite this article:
Mahendra Raj RR, Saravanan T, Preethi P, Ezhilarasi I. Comparative evaluation of efficacy of therapeutic ultrasound and phonophoresis in myofascial pain dysfunction syndrome. J Indian Acad Oral Med Radiol 2022;34:242-5

How to cite this URL:
Mahendra Raj RR, Saravanan T, Preethi P, Ezhilarasi I. Comparative evaluation of efficacy of therapeutic ultrasound and phonophoresis in myofascial pain dysfunction syndrome. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Dec 3];34:242-5. Available from: http://www.jiaomr.in/text.asp?2022/34/3/242/356944




   Introduction Top


Myofascial pain dysfunction syndrome (MPDS) can be defined as “a local myofascial pain condition characterized by local areas of a firm; hypersensitive bands of muscle tissue known as trigger points” also known as myofascial trigger point pain.[1] MPDS is a stress-induced psychophysiological condition originating in the masticatory muscles, not an organic disease originating in the temporomandibular joint. Thus, rather than assessing occlusion, measuring joint gaps, and making irreversible structural changes in the dentition and articulation, therapy should focus on reducing stress, relaxing tensed jaw muscles, and educating the patient about the causes of the problem.[2] There are many treatment modalities for MPDS. The treatment of MPDS focuses on pain relief and antiinflammatory management, physiotherapy, occlusal splint management, transcutaneous electric nerve stimulation (TENS), laser therapy, biofeedback, and acupuncture. No definitive management has proved its superiority over the others till now.[3] The trigger point development is considered one of the most important characteristic features of MPDS. Trigger point inactivation is considered to be one of the treatment modalities. Therapeutic ultrasound (ThUS) is one of frequently used physical agents in soft tissue conditions, which increases the blood flow in the tissues with its thermal property, membrane permeability, and tissue healing. It decreases muscle spasms and increases the ability of collagen fibers to grow.[4] Phonophoresis is a noninvasive local transdermal drug delivery system that uses ultrasound (US) to enhance the distribution of topically applied drugs. The objective of the study is to compare the effectiveness of therapeutic ultrasound and phonophoresis with analgesic and muscle relaxants in myofascial pain dysfunction syndrome.


   Material and Method Top


The study was conducted in the Department of Oral Medicine and Radiology in Karpaga Vinayaka institute of dental sciences in Chengalpattu, Tamil Nadu, India, Institutional Ethical committee clearance approval was obtained (Institutional Ethical Committee clearance NO.: KIDS/IEC/028/2021/IV), and Helsinki declaration (2013) was followed. The subjects were chosen from the pool of patients attending the department of oral medicine and radiology of Karpaga Vinayaka institute of dental sciences in Chengalpattu, Tamil Nadu, India. The clinical examination was done according to the Helkimo index,[5] and trigger points were identified via manual palpation by the same clinician with over 25 years of experience.

Inclusion criteria

Patients between 20 to 50 years of age, unilateral pain, pain on palpation of muscles of mastication, joint sound (clicking), restricted mouth opening, no joint tenderness palpating through external auditory meatus, and no clinical, radiographic, or biochemical evidence of organic joint disease (Laskin's criteria) were included.

Exclusion criteria

Patients excluded were pregnant and lactating women, those with pacemakers, diclofenac allergy, the pain of odontogenic origin, neuralgias, neuromuscular disorders, already treated with anti-inflammatory, muscle relaxant, and analgesic drugs, intraarticular temporomandibular joint disorders, jaw tumors, and trauma.

The sample size was calculated using G power software with an effect size of 0.5 (α = 0.05) and power of study is 0.8; the sample size derived is 24 and is rounded off to 30. 30 qualified subjects were then divided randomly into two groups. Each group consists of 15 subjects. None of the subjects have withdrawn during the study.

Informed consent was obtained from each patient.

Outcome measures

Pain intensity was recorded before and after treatment on the Visual Analog Scale (VAS), with a score from 0 to 10. The score “0” was considered as No pain. The score increases with pain intensity, and a score of 10 was considered unbearable pain. Mouth opening was measured in millimeters by measuring the interincisal distance and recorded.

Intervention

Group A

Therapeutic ultrasound (MEDGEARS) transducer head was placed over the trigger points in circular motion without any therapeutic agent (ultrasound gel alone) with the intensity of 1.5 W/cm2 for 10 min in continuous mode [Figure 1]. The procedure was carried out in the same clinical set up with the same therapeutic ultrasound device by the same clinician, a single session each day for 5 consecutive days [Figure 2]. At the end of each session, evaluation was done for all the patients using VAS method for pain and mouth opening using a ruler in mm [Figure 2].
Figure 1: Therapeutic ultrasound machine

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Figure 2: Therapeutic ultrasound transducer head over trigger point

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Group B

A patch test was done to rule out diclofenac allergy. The transducer head of therapeutic ultrasound (MEDGEARS), with the intensity of 1.5 W/cm2 for 10 minutes in continuous mode, was placed over the trigger points in a circular motion with the help of ultrasound jelly and diclofenac sodium and thiocolchicoside gel (THIOFORD PLUS) in the proportion of 1:1 as a transducer medium (evenly spread over the transducer head). Treatment was carried out for five sessions, a single session each day in the same clinical set up by the same clinician. At the end of each session, evaluation was done for all the patients using VAS method for pain and mouth opening using a ruler in mm [Figure 3].
Figure 3: Phonophoresis (1:1 thiocolchicoside gel and ultrasound gel)

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Statistical analysis

Statistical analysis was conducted using IBM SPSS statistics 16.0 (Statistical Package for the Social Science IBM Corporation, Armonk, NY, USA). Demographic data were statistically analyzed using descriptive statistics, and paired t test was done to compare pain values and mouth opening before and after treatment between and within groups (P > 0.05).


   Result Top


The mean age of the study population was 32.57 ± 8.5 (standard deviation [SD]) with a range of 20 to 50 years. Among 30 patients included in the study, 23 (77%) were female and 7 (33%) were male.

Comparing VAS scores between Group 1 and Group 2 on the 1st, 3rd, and 5th day (P > 0.05) are statistically significant [Graph 1] and [Table 1].

Table 1: VAS score of group 1 and group 2

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Comparing mouth opening scores between Group 1 and Group 2 on the 1st, 3rd, and 5th days (P = 0.000) are statistically significant [Graph 2] and [Table 2].

Table 2: Mouth opening of group 1 and group 2

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   Discussion Top


MPDS is defined as pain that derives from myofascial trigger points, which are small, highly sensitive region in muscle that are characterized by hypersensitive, palpable, and taut band of muscle that exhibit tenderness on palpation, produce the patient'' symptoms, and cause referred pain.[6] Treatment of MPDS involves nonpharmacological and pharmacological interventions. Education and exercise are the mainstay treatments for most of the patients with this condition. Medications, physical modalities, dry needling, and trigger point injection are adjuvant therapies appropriate in some patient subjected to treat myofascial pain and associated symptoms. MPDS is one of the most challenging yet rewarding musculoskeletal pain conditions to treat.[7]

MPDS is commonly prevalent in the population aged from 27 to 50 years.[8] The patient's age in this study ranged from 20 to 50 years, as this was the most common age for this disorder by many authors.

Several studies substantiate that it is more common in females. MPDS is most frequently seen in unmarried females (married: unmarried ratio 1:2) and the female to male ratio is 3:1.[9] 23 females were included in the study. This is in accordance with Khairy.[10]

Unfocused ultrasound beam for physical therapy was the first clinical application of ultrasound dating to the 1950s, which has been often referred to as “therapeutic ultrasound.”[11]

The objective is to warm muscles, tendons, and other tissue to improve blood flow and fasten healing. The coupling medium is also included for enhancing the treatment. Ultrasound application assist the transport of the therapeutic compound through the skin, and this procedure is called as sonophoresis or phonophoresis.[12]

In myofascial pain, therapeutic ultrasound acts by converting electrical energy to sound waves and transmits heat energy to muscles. This improves persistent muscle spasm and relaxes the muscle.

Esposito et al.[13] in his study concluded that ultrasound is most successful in alleviating muscle pain.

Byatnal et al.[14] ultrasound is a step higher than TENS in pain alleviation and hence can be relied on by dentists for soothing and targeting a pain-free ambiance for the patients.

Ilter et al.[15] carried out a study and concluded that ultrasound therapy in continuous mode is more efficient in reducing pain for myofascial pain syndrome patients than pulsed ultrasound therapy.

Reji et al.[9] concluded diclofenac phonophoresis could reduce pain in myofascial pain syndrome in upper trapezius muscle better than conventional ultrasound therapy.

Thiocolchicoside is a muscle relaxant with anti-inflammatory and analgesic effects. It acts as a competitive GABA-A receptor antagonist and inhibits glycine receptors. Thiocolchicoside does not alter voluntary motility and does not interfere with the action respiratory muscles. According to Ketenci, Ayşegül et al.,[16] topical thiocolchicoside significantly improved cervical myofascial pain. In a study, Altan et al.[17] showed that phonophoresis with diclofenac and thiocolchicoside gel treatment is superior to conventional US therapy in the short term in acute back pain patients.


   Conclusion Top


Phonophoresis with diclofenac & thiocolchicoside (analgesic and muscle relaxant) proved to be an excellent treatment in MPDS. They proved more effective than therapeutic ultrasound in controlling pain and improving mouth opening.

Clinical message

Ten min of phonophoresis with the intensity of 1.5 W/cm2 reduces pain and improves mouth opening.

Ultrasound and phonophoresis are noninvasive treatment modalities. It is beneficial and well accepted by those patients who are scared of painful injections.

Drugs used in phonophoresis target the trigger point; avoiding adverse drug effects is the main benefit of the study.

Limitations

Phonophoresis is not recommended for long-term or alternative treatment of conditions like arthritis.

It may carry the minor risk of burns if the procedure is not done correctly.

Future prospects

Increasing the sample size in the future will lead to more results. It will enable a more confirmatory result about the benefit of phonophoresis with diclofenac and thiocolchicoside.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Key message

Since therapeutic ultrasound and phonophoresis are noninvasive treatment modalities. Ten minutes of phonophoresis with an intensity of 1.5 W/cm2 reduces pain and improves mouth opening in myofascial pain dysfunction syndrome subjects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Baig M, Ashok Y. Myofascial pain dysfunction syndrome. Oral Maxillofac Surg Clin 2021;1343-60.  Back to cited text no. 1
    
2.
Laskin DM, Block S. Diagnosis and treatment of myofascial pain-dysfunction (MPD) syndrome. J Prosthe Dent 1986;56:75-84.  Back to cited text no. 2
    
3.
Nagwan AE, El-Wegoud MA, Abdel Aziz OM, Nabhan AF, Helmy ES. Trigger point deactivation in muscles of mastication in myofascial pain dysfunction (MPD) patients: A qualitative systematic review. Int Arch Oral Maxillofac Surg 2018;2:1-10.  Back to cited text no. 3
    
4.
Yildirim MA, Öneş K, Gökşenoğlu G. Effectiveness of ultrasound therapy on myofascial pain syndrome of the upper trapezius: Randomized, single-blind, placebo-controlled study. Arch Rheumatol 2018;33:418-23.  Back to cited text no. 4
    
5.
Nokar S, Sadighpour L, Shirzad H, Shahrokhi Rad A, Keshvad A. Evaluation of signs, symptoms, and occlusal factors among patients with temporomandibular disorders according to Helkimo index. Cranio 2019;37:383-8.  Back to cited text no. 5
    
6.
Borg-Stein J, Simons DG. Myofascial pain. Arch Phys Med Rehabil 2002;83:S40-7.  Back to cited text no. 6
    
7.
Borg-Stein J, Iaccarino MA. Myofascial pain syndrome treatments. Phys Med Rehabil Clin N Am 2014;25:357-74.  Back to cited text no. 7
    
8.
Vazquez-Delgado E, Cascos-Romero J, Gay-Escoda C. Myofascial pain syndrome associated with trigger points: A literature review. (I): Epidemiology, clinical treatment and etiopathogeny. Med Oral 2009;14:e494-8.  Back to cited text no. 8
    
9.
Reji R, Krishnamurthy V, Garud M. Myofascial pain dysfunction syndrome: A revisit. IOSR J Dent Med Sci 2017;16:13-21.  Back to cited text no. 9
    
10.
Khairy N. Phonophoresis versus ultrasound therapy in myofascial pain dysfunction syndrome. Egypt Dent J 2018;64:1039-45.  Back to cited text no. 10
    
11.
Robertson VJ, Baker KG. A review of therapeutic ultrasound: Effectiveness studies. Phys Ther 2001;81:1339-50.  Back to cited text no. 11
    
12.
Machet L, Boucaud A. Phonophoresis: Efficiency, mechanisms and skin tolerance. Int J Pharm 2002;243:1-15.  Back to cited text no. 12
    
13.
Esposito CJ, Veal SJ, Farman AG. Alleviation of myofascial pain with ultrasonic therapy. J Prosthet Dent 1984;51:106-8.  Back to cited text no. 13
    
14.
Byatnal A, Ramesh DNSV, Nair D, Kempwade P, Thriveni R, Rukhsar I. Comparative evaluation of the effect of therapeutic ultrasound and transcutaneous electric nerve stimulation in temporalis and masseter myofascial pain. J Nat Sc Biol Med 2020;11:7.  Back to cited text no. 14
  [Full text]  
15.
Ilter L, Dilek B, Batmaz I, Ulu MA, Sariyildiz MA, Nas K, et al. Efficacy of pulsed and continuous therapeutic ultrasound in myofascial pain syndrome. Am J Phys Med Rehabil 2015;94:547-54.  Back to cited text no. 15
    
16.
Ketenci A, Basat H, Esmaeilzadeh S. The efficacy of topical thiocholchioside (Muscoril) in the treatment of acute cervical myofascial pain syndrome: A single-blind, randomized, prospective, phase IV clinical study. Agri 2009;21:95-103.  Back to cited text no. 16
    
17.
Altan L, Kasapoğlu Aksoy M, Kösegil Öztürk E. Efficacy of diclofenac & thiocolchioside gel phonophoresis comparison with ultrasound therapy on acute low back pain; a prospective, double-blind, randomized clinical study. Ultrasonics 2019;91:201-5.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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