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Therapeutic Ultrasound and Pain in Degenerative Diseases of Musculoskeletal System

ACTA INFORM MED. 2013 Sep; 21(3): 170-172

Received: 05 June 2013 Accepted: 10 August 2013 CONFLICT OF INTEREST: NONE DECLARED AVICENA 2013

doi: 10.5455/aim.2013.21.170-172

Therapeutic Ultrasound and Pain in Degenerative Diseases of Musculoskeletal System


Mirsad Muftic1, Ksenija Miladinovic2 Faculty of Health Sciences, University of Sarajevo, Bosnia and Herzegovina1 Clinic for Physiotherapy and Rehabilitation, Clinical Centre of Sarajevo University Sarajevo, Bosnia i Herzegovina2
Corresponding author: Mirsad Muftic, MD, PhD. Faculty of Health Sciences, University of Sarajevo, BiH. Sarajevo. Bosnia and Herzegovina. E-mail: mhs@bih.net.ba Original paper ABSTRACT Introduction: Therapeutic ultrasound is a physical modality which is constantly expanding range of indications. Analgesic effect of ultrasound is still under discussion. Regardless the extensive application of pulsed ultrasound of low intensity, continuous ultrasound has a better analgesis effect, which is explained by its mechanism of action. Aims: The main research objective of this study was to determine the effect of continuous ultrasound to pain caused by degenerative diseases of the musculoskeletal system in the intensity and duration of ultrasound treatment. Other objectives are entailed determining the correlation between the degree of pain reduction with: location of pain, age, gender and body mass index (BMI). Material and methods: The study included 68 patients with chronic pain localized in the region of the spine or major joints of the extremities, depending on the localization of the degenerative changes. Patients are divided into two groups. The first group was treated with 10 applications of continuous ultrasound with frequency of 1 MHz, intensity 0.4 W/cm2 for 8 minutes, and the other group with 10 applications of ultrasound with frequency of 1 MHz, intensity 0.8 W/cm 2 for 4 minutes. Results and Discussion: Pain intensity was assessed before and after ultrasound therapy performed by subjective visual analogue scale (VAS) for pain, numbered from 0-10, where 0 is the rating for the state of no pain, and 10 grades for severe pain. The average VAS improvement in the first group was 3.97, and 4.74 in second one. The results of F (1.66) = 2.93, p = 0.09 analysis of variance showed no significance difference between the average improvement of two groups. Correlation between the degree of pain reduction showed significance only with BMI, or that higher BMI is associated with a lower degree of pain reduction. The results of this study showed that application of continuous ultrasound in patients with chronic pain, caused by degenerative changes in the musculoskeletal system, led to a significant reduction in pain. Different intensity and duration of ultrasound application showed no significant effect on the degree of pain reduction. Body mass index showed significant negative correlation with the degree of pain reduction, but age, gender and location of pain did not show significant correlation. Key words: therapeutic ultrasound, musculoskeletal pain.

World Association for the study of pain IASP (International Association for the Study of Pain) has decided that in the 2009/2010 year focuses on musculoskeletal pain (MP) because it is an enormous problem that affects millions of people worldwide. Compared to other types of pain, the highest number of people in the world experience exactly MP (1). Problem of musculoskeletal pain is complex and includes dierent types of pain, whether it is about an anatomical location of the pain, or about subjective sensations that occur in a patient. So MP, among others, includes neck pain, pain in the limbs, bone pain, chronic generalized pain, described as drilling , boring or tightening. It can be acute (the injury) or chronic (in rheumatoid arthritis), mild or strong, local or diffuse.

1. INTRODUCTION

Clinical types of MP can be represented as: bone (injuries, tumors, degenerative disease), muscular (injury, autoimmune disorders, circulatory disorders, infections, tumors), tendon and ligamentary (injuries, mechanical inammation due to over use), bromyalgic (includes muscles , tendons, fascia, ligaments, joint capsules), arthritic (autoimmune diseases, degenerative diseases, infections, metabolic disorders, a vascular disorders, conditions after injuries), bursatic (infections, bromyalgia) and projecting (in diseases of the internal organs). Factors contributing to the higher incidence of MP are: increase in the elderly population, sedentary lifestyle and increased incidence of obesity. Basic characteristics of MP are: a) deep tissue hyperalgesia (localized or generalized), b) abnormal muscle function, c)

projecting pain to distant somatic structures, and d) the transition from acute to chronic pain. Pathophysiologicaly, MP sensation is result of activation of polimodal muscle nocioceptors from group III (A bers) and from group IV (C bers) (2). These nocioceptors can be sensitized by release of neuropeptids from the nerve endings, which eventually leads to hyperalgesia and central sensitization of neurons of posterior horn of spinal cord, manifested as prolonged neuronal discharge, as increased response to dened noxious stimulus , as well as respond to un noxious stimulus, and as expansion of the eld of sensitivity (2). Clinical tests that are commonly used to evaluate the MP and assess patient functionality are: VAS (visual analogue scale), GFS (General functional scores), RMDS (Roland and

OriGinal PaPer / ACTA INFORM MED. 2013 SeP; 21(3): 170-172

In an analysis of patients' gender structure, Chi-square test showed that there was no statistically significant difference in gender representation between the two groups of patients (2 = 2.4, df = 1, p = 0.62). The first group was 38.2% men and 61.8% of women in the second group 44.1% of men and 55.9% women. (Diagram 1) Therapeutic Ultrasound and Pain in Degenerative Diseases of Musculoskeletal System 171 Diagram 1. Gender structure of the patients

Morris Disability Scale), OPDI (Oswestry Pain Disability Index), MPQ (McGill Pain questionnaire). MP therapy involves pharmacological and non-pharmacological treatment. In non-pharmacological treatment, especially for chronic MB, physical modalities are of great significance, and they are in combination with patient education, cognitive therapy and psychosocial training. TENS (Transcutaneous electronerve stimulation), acupuncture, ultrasound, thermal modalities (hot and cold compresses), manual therapy (manipulation, massage) and the exercises are physical modalities that are commonly used in this indication eld. Therapeutic ultrasound (UZ) is a physical modality that has the broadest application and is commonly used in clinical practice. In the last decade its use has changed. Earlier, it was primarily used for its thermal eect, and is now it increasingly used for nonthermal eects, especially in the reconstruction of soft tissue, wound healing and the healing of bone fractures. Thermal eects are attributed to the continuous UZ and nonthermal eects to the pulsed UZ of small intensity (LIPUS Low-Intensity Pulsed Ultrasound). In addition to these biophysical eects of therapeutic UZ, his secondary physiological eects must not be forgotten, among which is the rst analgesic eect, followed by a spasmolytic, anti-inammatory, simpaticolitic , tissue regulation and trophic eects, improving microcirculation, increasing permeability of the cell membrane, increasing the biosynthesis of proteins , the regulation of muscle tone and improving the cell metabolism. The greatest analgesic eect is attributed to the thermal eect of ultrasound because it leads to increased metabolic activity in the tissue, improving circulation and relaxation of rigid structure of the soft tissues, especially in degenerative musculoskeletal system. As previously mentioned, the continuous therapeutic ultrasound has a pronounced thermal eect. Systematic reviewed study that is included in the Cochrane database

from 2010. highlights the thera- 70,00% peutic ecacy in 60,00% 50,00% the treatment of 40,00% the pain in osteoar- 30,00% 20,00% men thritis of the knee 10,00% women and improving the 0,00% First group Second group Diagram 2.Avarage age of the patients in years functionality of the Diagram 1. Gender structure of the patients patients. analysis of the age structure of the patients showed that the average age of Results of the Statistical patients in the first group was 54.85 years, while in another it was 54.67 years. (Diagram 54,90% 2) .T-test for independent survey conducted in Australia 2007th samples 54,85% found no statistically significant difference (t = 0.05; p = 0.96.), and chi-square test 54,80% showed that there was no statistically significant difference years have shown that therapeutic ul- 40 by age groups (20-40 years, 54,75% - 60 years, 60-80 years and over 80 years old) within the two groups of patients with different ultrasound therapy. (2 = 03.02, df = 3, p = 0:39). trasound remains the most popular 54,70% physical agent that is used in physio- 54,65% therapy practice. (4).The survey that 54,60% 54,55% First group Second group was conducted in the U.S. showed that the use of therapeutic UZ due to Diagram 2.Avarage age of the patients in years the reduction of pain is in fth place. Diagram 3. Anatomical distribution of musculoskeletal pain In 83.6% of cases, UZ is being ap- tinuous ultrasound intensity of 0.8 plied to reduce inammation of the W/cm2 for 4 minutes, and the second vertebral pain 4 with soft tissues, in 70.9% of cases due to group of 34 patients was treated limb pain 81,00% increased tissue elasticity, in 68.8% 10 applications of continuous ultra61,00% intensity of 0.4 W/cm2 for 8 of cases due to the remodeling of sound 41,00% The intensity of pain was asscar tissue, in 52.5% of cases due to minutes. 21,00% 1,00% by subjective numerical scale wound healing , in 49.3% of cases due sessed First group Second group Scale - VAS) to the reduction of pain ,in 35.1% of of pain (Visual Analogue cases due to the reduction of the oe- that contains numeration of 0-10, where 0 is no pain condition, and dema (5). 10 is the score for the strongest pain. In the first group, 76.5% of patients had vertebral pain, and 23.5% of patients had li VAS was a parameter by the eect 2. OBJECTIVES pain. In the second group, 52.9% of set patients had vertebral pain, and 47.1% of patien had pain. (Diagramtherapy. 3) In the firstThe group ,statistical Chi-square test showed a statistically oflimb ultrasound The main objective of this study significance (2 = 9:53, p = .002) :more patients had vertebral pain (76.5%) compa analysis used statistical was to examine the ecacy of contin- limb pain (23.5%). In thedescriptive second group, Chi-square test showed a statistically insignificance (2 = .12, p = .73). methods, analysis of variance and 8 minutes) the pain uous ultrasound in the treatment of After treatment with ultrasound in the first group (0.4 W/cm2, decreased in all patients chi-square test.(100%), while the second group (0.8 W/cm2, 4 minutes) pa chronic musculoskeletal pain. was reduced in 97% of patients. (Diagram 4) Other objectives were: - To examine the inuence of var- 4. RESULTS ious parameters of ultrasound appliIn an analysis of patients gender cation to reduce pain structure, Chi-square test showed Diagram 2.Avarage age of the patients in years - To examine the correlation be- that there was no statistically signitween age, sex, BMI (Body Mass cant dierence in gender representaIndex) and location of pain (vertebral tion between the two groups of pa54,90% and limb ) with the eect of contin- tients (2 = 2.4, df = 1, p = 0.62). The 54,85% uous ultrasound on pain. rst group was 38.2% men and 61.8% 54,80% of women in the second group 44.1% 54,75% 3. PATIENTS AND METHODS of men and 55.9% women. (Diagram 54,70% 54,65% included 1) This prospective study 54,60% 68 patients with chronic musculoStatistical analysis of the age struc54,55% First group Second group showed that the skeletal pain. The pain caused by deture of the patients generative changes in the area of the average age of patients in the rst spinal column is marked was verte- group was 54.85 years, while in anDiagram 3. Anatomical distribution musculoskeletal pain (Diagram 2). bral, and pain caused by degeneraother it of was 54.67 years. tive changes in the joints of the extremvertebral pain limb pain ities was marked as 81,00% limb pain. Patients 61,00% were divided into 41,00% two groups. The rst 21,00% group of 34 patients 1,00% was treated with 10 First group Second group applications of conDiagram 3. Anatomical distribution of musculoskeletal pain ACTA INFORM MED. 2013 SeP; 21(3): 170-172 / OriGinal PaPer

In the first group, 76.5% of patients had vertebral pain, and 23.5% of patients had limb pain. In the second group, 52.9% of patients had vertebral pain, and 47.1% of patients had limb pain. (Diagram 3) In the first group , Chi-square test showed a statistically

Diagram 4. Average reduce of pain

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Therapeutic Ultrasound and Pain in Degenerative 100,00% Diseases of Musculoskeletal System

Diagram 4. Average reduce of pain 99,50% 99,00% 98,50% T-test for indepen- 100,00% 98,00% First group dent samples found 97,50% 99,50% Second group 99,00% no statistically sig- 97,00% 98,50% 96,50% nicant dierence 96,00% 98,00% First group 97,50% (t=0.05; p=0.96), 95,50% Second group and chi-square test 97,00% 96,50% 0,8W(4min) 0,4W(8min) showed that there 96,00% 95,50% Avarage improvement of pain score according to VAS in the first group of patients was was no statistically 4.74 (M = 4.74, SD = 1.69), and the other group 3.97 (M = 3.97, SD = 1.98). (Chart 5) signicant dierAnalysis of variance showed that the difference between the average value of VAS 0,8W(4min) 0,4W(8min) improvement between the two groups was not statistically significant. ence by age groups

VAS : r=.59, p<.001. BMI and degree of improvement of pain score VAS were negatively correlated, respectively higher BMU is associated with a lower degree of improvement of pain score by VAS (Diagram 6). Results of the study indicate a signicant reduction of pain in degenerative musculoskeletal system after continuous treatment with ultrasound. On VAS with numeration 0-10 , average score for reduction of pain in the rst group was M=4.74, in the second group was M=3.97. Varying intensity and duration of ultrasound application showed no signicant effect on the degree of pain reduction. Body mass index showed signicant negative correlation with the degree of pain reduction in the group of patients who have been treated with intensity 04W/cm2 for 8 minutes, and the patient age, gender and location of pain showed no signicant correlation in either group of patients.

5. CONCLUSION

Avarage 5. improvement of painthe score according to to VAS in the first scale group(VAS) of patients was (20-40 years, 4060 Diagram Average reducing pain according Visual analog 4.74 (M = 4.74, SD = 1.69), and the other group 3.97 (M = 3.97, SD = 1.98). (Chart 5) years, 60-80 years Analysis of variance showed that the difference between the average value of VAS improvement between the two groups was not statistically significant. and over 80 years 4,8 Diagram 5. 4,6 Average reducing the pain according to Visual analog scale (VAS) old) within the two 4,4 groups of patients 4,2 with dierent ul- VAS(M) 4,8 4 First group 3,8 correlation between age and VAS diff (p = .25), sex and VAS diff (p = .93), BMI and 4,6 trasound therapy. Second group 3,6 VAS diff (p = .84), and the location of pain and VAS diff (p = .98). 4,4 The second group showed statistically significant correlation between BMI and change 3,4 (2=03.02, df=3, 4,2 VAS(M) in pain score by VAS : r = - .59, p <.001. BMI and degree of improvement of pain score 4 were negatively correlated, respectively higher BMU is associated with a lower p=0:39). VAS First group 3,8 degree of improvement of pain score by VAS (Chart 6) In the rst group, Second group 3,6 3,4 Diagram 6. Correlation between BMI and pain score according to VAS 76.5% of patients Diagram 5. Average reducing the pain according to Visual analog scale (VAS) had vertebral pain, Group 2 :UZ therapy 0.4 W In the had first group of patients, it has not been established no statistically significant and 23.5% of patients correlation with the degree of improvement of pain score by VAS , respectively the limb pain. In the second group, 52.9% of patients In the first group of patients, it has not been established no statistically significant had vertebral pain, andwith the degree of improvement of pain score by VAS , respectively the 6 correlation 47.1% of patients had limb pain. (Diagram 3) In the rst group , Chi6 square test showed a statistically signicance (2 =9:53, p= .002) :more patients had vertebral pain (76.5%) compared to limb pain (23.5%). In the second group, Chi-square test 6. Correlation between BMI and pain score according to VAS showed a statistically insig- Diagram Group 2 :UZ therapy 0.4 W nicance (2= .12, p= .73). 5. Conclusion After treatment with Results of the study indicate a significant reduction of pain in degenerative musculoskeletal system after continuous treatment with ultrasound. ultrasound in the rst group (0.4 W/ groups was not statistically signiOn VAS with numeration 0-10 , average score for reduction of pain in the first group was M = 4.74, in the cant. second group was M = 3.97. Varying intensity and duration of cm2, 8 minutes) the pain decreased in all patients (100%), while the In the rst group of patients, no 7 second group (0.8 W/cm2, 4 minutes) statistically signicant correlation pain was reduced in 97% of patients. has been established with the degree (Diagram 4). of improvement of pain score by VAS Avarage improvement of pain , respectively the correlation between score according to VAS in the rst age and VAS di (p = .25), sex and group of patients was 4.74 (M=4.74, VAS di (p = .93), BMI and VAS di SD=1.69), and the other group 3.97 (p = .84), and the location of pain and (M=3.97, SD=1.98) (Diagram 5). Anal- VAS di (p = .98). ysis of variance showed that the difThe second group showed statistiference between the average value of cally signicant correlation between VAS improvement between the two BMI and change in pain score by
8W 0, 4W 0, in m (4 in m (8 ) ) 8W 0, 4W 0, in m (4 in m (8 ) )

Diagram 4. Average reduce of pain

REFERENCE
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OriGinal PaPer / ACTA INFORM MED. 2013 SeP; 21(3): 170-172