Rheumatol Int DOI 10.1007/s00296-013-2881-2
Original Article
Efficacy of EMLA cream phonophoresis comparison with ultrasound therapy on myofascial pain syndrome of the trapezius: a single‑blind, randomized clinical study Nilgun Ustun · Fatma Arslan · Ayhan Mansuroglu · Deniz Inanoglu · Abdullah Erman Yagız · Hayal Guler · Ayse Dicle Turhanoglu
Received: 8 October 2012 / Accepted: 10 October 2013 © Springer-Verlag Berlin Heidelberg 2013
Abstract The aim of this study is to investigate whether eutectic mixture of local anesthetics (EMLA) cream phonophoresis superior to conventional US over the trigger points (TPs) in terms of improvements of pain, range of motion and disability in myofascial pain syndrome (MPS). Fifty patients (42 female, 8 male) diagnosed with MPS were included in the study. Patients were randomly assigned into two treatment groups including phonophoresis (PH) group (n = 25) and ultrasound (US) group (n = 25). PH group received EMLA cream phonophoresis (2.5 % lidocaine, 2.5 % prilocaine); US group received conventional ultrasound therapy over the all active TPs on trapezius muscle for 10 min a day for 15 sessions. Outcome measures were performed before the treatment course and at the end of a 15-session course of treatment. Student T, Mann–Whitney U, chi-square and Wilcoxon tests were used for statistical analysis. At the end of the therapy, there was statistically significant decrease in both PH group and US group in terms of number of trigger point (NTP) (p = 0.001, p = 0.029), pain intensity on movement (p = 0.001 vs. 0.002) and right/left cervical lateral ROMs (p = 0.001/p = 0.001, p = 0.009/p = 0.020) relative to baseline. The NTP decrease in PH group was significantly higher than that in US group (1.84 ± 1.46 vs. 0.72 ± 1.45; p = 0.01). Pain intensity at rest (p = 0.001) and NPDI scores (p = 0.001) were statistically improvement in only PH group. EMLA cream phonophoresis is more effective than conventional ultrasound therapy in terms of pain and
N. Ustun (*) · F. Arslan · A. Mansuroglu · D. Inanoglu · A. E. Yagız · H. Guler · A. D. Turhanoglu Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Mustafa Kemal University, Hatay, Turkey e-mail: [email protected]
associated neck disability, and it seems the complementary treatment option for MPS. Keywords Myofascial pain syndrome · EMLA cream · Phonophoresis · Ultrasound
Introduction Myofascial pain syndrome (MPS) is a well-known regional pain condition of skeletal muscle fibers caused by myofascial trigger points (TPs) and taut bands, which produces muscle pain, limitations of related joints and disability [1, 2]. It is a common cause of musculoskeletal pain and disability especially in adult women [1]. TP may occur in any skeletal muscle. The muscles used to maintain body posture including the trapezius, scalene, sternocleidomastoid, levator scapulae, and quadratus lumborum are more often affected [2]. Various treatment methods have been used in MPS to inactivate the TPs, release the taut bands and relieve the pain [3]. Among these, removal of factors susceptible to “activate” TPs such as sudden overloading and repetitive motion, ergonomically corrections, TP injection with local anesthetic, dry needling, ultrasound (US), transcutaneous electrical nerve stimulation, heat application and stretching exercise have been proven effective [2]. TP injection with lidocaine is most effective method in MPS treatment [4, 5]. Although effective, the injection approach can be unpleasant for the patients [6]. US treatment is one of the most important physical treatment modality in MPS, which is used for heating the deep tissues [7]. US increases local metabolism, circulation, regeneration and extensibility of connective tissue with its assuming thermal and nonthermal effects [7].
13
Phonophoresis (PH) is the use of US to increase in skin absorption and penetration topically applied drugs. PH is a noninvasive, painless method that has fewer side effects and well tolerated [8]. A topical anesthetic cream, EMLA, is a 1:1 eutectic mixture of lidocaine (2.5 %) and prilocaine (2.5 %) has been widely used as a local anesthetic to reduce the pain and discomfort [9]. Lidocaine/prilocaine is marketed as EMLA (an abbreviation for Eutectic Mixture of Local Anesthetics). EMLA cream provides local analgesia by blocking the initiation and transmission of impulses [10]. This formulation allows the use of high concentrations of the anesthetic bases without concern about local irritation, uneven absorption or systemic toxicity [11]. This study was initiated to investigate whether EMLA cream PH superior to conventional US over the TPs in terms of improvements of pain, range of motion (ROM) and disability in MPS.
Methods Study design This is a randomized single-blind clinical study. Patients A total of fifty patients (42 female, 8 male) having at least one active TP located on the trapezius muscle diagnosed with MPS according to Simons’ clinical criteria [12] from the outpatient clinic of the department of physical medicine and rehabilitation between the January 2011 and January 2012 were included in the study. Patients having fibromyalgia, cervical disk herniation, cervical radiculopathy, cervical myelopathy, treatment including TP injection, physical therapy for MPS during the last 6 months, neck surgery, trauma history, rheumatic diseases, diabetes and pregnancy were excluded from the study. The local ethical committee of our institute approved the study. Each subject signed the informed consent.
Rheumatol Int
per patient in each session. The patients were not blinded to treatment, because the cream was obtained from the patients by prescription. The same physiotherapist treated the patients. In both groups, the physiotherapist applied passive stretching exercises to patients just after the therapy session. Patients were not allowed taking analgesic or NSAID during the whole research period. Outcome measures Outcome measures with the number of TPs (NTP), pain intensity at rest, pain intensity on movement, cervical lateral ROMs and Neck Pain Disability Scale (NPDS) were performed before the treatment course and at the end of a 15-session course of treatment. Primary endpoint of the study was statistically significant improvement in outcome parameters. The same physician who was blind to the group assignment of the patients assessed pre-treatment and post-treatment evaluations. Active NTPs on trapezius muscle was evaluated by an experienced physician on the basis of pain with palpation of TPs. Pain intensity at rest and on movement of the trapezius muscle was assessed by visual analog scale (VAS, 0–10; 0 means no pain). The active right–left cervical lateral flexion ROMs were measured using a goniometer while the patients were sitting. NPDS was used to measure the disability. The NPDS is a multidimensional and self-administered scale, which contains 20 items related with 4 dimensions: neck problems, pain intensity, emotioncognition and interference with life activities. Each item is ranging from 0 (normal function) to 5 (the worst possible situation your pain problem has taken you) by using a 10-cm VAS. The total score ranges from 0 to 100 and higher values represent greater pain and disability [13]. Statistical analysis Statistical analysis was performed using SPSS software version 13.0 for windows. For statistical analysis Student t, Mann–Whitney U, chi-square and Wilcoxon tests were used. P value
Original Article
Efficacy of EMLA cream phonophoresis comparison with ultrasound therapy on myofascial pain syndrome of the trapezius: a single‑blind, randomized clinical study Nilgun Ustun · Fatma Arslan · Ayhan Mansuroglu · Deniz Inanoglu · Abdullah Erman Yagız · Hayal Guler · Ayse Dicle Turhanoglu
Received: 8 October 2012 / Accepted: 10 October 2013 © Springer-Verlag Berlin Heidelberg 2013
Abstract The aim of this study is to investigate whether eutectic mixture of local anesthetics (EMLA) cream phonophoresis superior to conventional US over the trigger points (TPs) in terms of improvements of pain, range of motion and disability in myofascial pain syndrome (MPS). Fifty patients (42 female, 8 male) diagnosed with MPS were included in the study. Patients were randomly assigned into two treatment groups including phonophoresis (PH) group (n = 25) and ultrasound (US) group (n = 25). PH group received EMLA cream phonophoresis (2.5 % lidocaine, 2.5 % prilocaine); US group received conventional ultrasound therapy over the all active TPs on trapezius muscle for 10 min a day for 15 sessions. Outcome measures were performed before the treatment course and at the end of a 15-session course of treatment. Student T, Mann–Whitney U, chi-square and Wilcoxon tests were used for statistical analysis. At the end of the therapy, there was statistically significant decrease in both PH group and US group in terms of number of trigger point (NTP) (p = 0.001, p = 0.029), pain intensity on movement (p = 0.001 vs. 0.002) and right/left cervical lateral ROMs (p = 0.001/p = 0.001, p = 0.009/p = 0.020) relative to baseline. The NTP decrease in PH group was significantly higher than that in US group (1.84 ± 1.46 vs. 0.72 ± 1.45; p = 0.01). Pain intensity at rest (p = 0.001) and NPDI scores (p = 0.001) were statistically improvement in only PH group. EMLA cream phonophoresis is more effective than conventional ultrasound therapy in terms of pain and
N. Ustun (*) · F. Arslan · A. Mansuroglu · D. Inanoglu · A. E. Yagız · H. Guler · A. D. Turhanoglu Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Mustafa Kemal University, Hatay, Turkey e-mail: [email protected]
associated neck disability, and it seems the complementary treatment option for MPS. Keywords Myofascial pain syndrome · EMLA cream · Phonophoresis · Ultrasound
Introduction Myofascial pain syndrome (MPS) is a well-known regional pain condition of skeletal muscle fibers caused by myofascial trigger points (TPs) and taut bands, which produces muscle pain, limitations of related joints and disability [1, 2]. It is a common cause of musculoskeletal pain and disability especially in adult women [1]. TP may occur in any skeletal muscle. The muscles used to maintain body posture including the trapezius, scalene, sternocleidomastoid, levator scapulae, and quadratus lumborum are more often affected [2]. Various treatment methods have been used in MPS to inactivate the TPs, release the taut bands and relieve the pain [3]. Among these, removal of factors susceptible to “activate” TPs such as sudden overloading and repetitive motion, ergonomically corrections, TP injection with local anesthetic, dry needling, ultrasound (US), transcutaneous electrical nerve stimulation, heat application and stretching exercise have been proven effective [2]. TP injection with lidocaine is most effective method in MPS treatment [4, 5]. Although effective, the injection approach can be unpleasant for the patients [6]. US treatment is one of the most important physical treatment modality in MPS, which is used for heating the deep tissues [7]. US increases local metabolism, circulation, regeneration and extensibility of connective tissue with its assuming thermal and nonthermal effects [7].
13
Phonophoresis (PH) is the use of US to increase in skin absorption and penetration topically applied drugs. PH is a noninvasive, painless method that has fewer side effects and well tolerated [8]. A topical anesthetic cream, EMLA, is a 1:1 eutectic mixture of lidocaine (2.5 %) and prilocaine (2.5 %) has been widely used as a local anesthetic to reduce the pain and discomfort [9]. Lidocaine/prilocaine is marketed as EMLA (an abbreviation for Eutectic Mixture of Local Anesthetics). EMLA cream provides local analgesia by blocking the initiation and transmission of impulses [10]. This formulation allows the use of high concentrations of the anesthetic bases without concern about local irritation, uneven absorption or systemic toxicity [11]. This study was initiated to investigate whether EMLA cream PH superior to conventional US over the TPs in terms of improvements of pain, range of motion (ROM) and disability in MPS.
Methods Study design This is a randomized single-blind clinical study. Patients A total of fifty patients (42 female, 8 male) having at least one active TP located on the trapezius muscle diagnosed with MPS according to Simons’ clinical criteria [12] from the outpatient clinic of the department of physical medicine and rehabilitation between the January 2011 and January 2012 were included in the study. Patients having fibromyalgia, cervical disk herniation, cervical radiculopathy, cervical myelopathy, treatment including TP injection, physical therapy for MPS during the last 6 months, neck surgery, trauma history, rheumatic diseases, diabetes and pregnancy were excluded from the study. The local ethical committee of our institute approved the study. Each subject signed the informed consent.
Rheumatol Int
per patient in each session. The patients were not blinded to treatment, because the cream was obtained from the patients by prescription. The same physiotherapist treated the patients. In both groups, the physiotherapist applied passive stretching exercises to patients just after the therapy session. Patients were not allowed taking analgesic or NSAID during the whole research period. Outcome measures Outcome measures with the number of TPs (NTP), pain intensity at rest, pain intensity on movement, cervical lateral ROMs and Neck Pain Disability Scale (NPDS) were performed before the treatment course and at the end of a 15-session course of treatment. Primary endpoint of the study was statistically significant improvement in outcome parameters. The same physician who was blind to the group assignment of the patients assessed pre-treatment and post-treatment evaluations. Active NTPs on trapezius muscle was evaluated by an experienced physician on the basis of pain with palpation of TPs. Pain intensity at rest and on movement of the trapezius muscle was assessed by visual analog scale (VAS, 0–10; 0 means no pain). The active right–left cervical lateral flexion ROMs were measured using a goniometer while the patients were sitting. NPDS was used to measure the disability. The NPDS is a multidimensional and self-administered scale, which contains 20 items related with 4 dimensions: neck problems, pain intensity, emotioncognition and interference with life activities. Each item is ranging from 0 (normal function) to 5 (the worst possible situation your pain problem has taken you) by using a 10-cm VAS. The total score ranges from 0 to 100 and higher values represent greater pain and disability [13]. Statistical analysis Statistical analysis was performed using SPSS software version 13.0 for windows. For statistical analysis Student t, Mann–Whitney U, chi-square and Wilcoxon tests were used. P value
