Phonophoresis versus ultrasound in the treatment of common musculoskeletal conditions

Phonophoresis through Nonsteroidal Anti-Inflammatory Drugs for Knee Osteoarthritis Treatment: Systematic Review and Meta-Analysis

Knee osteoarthritis (OA) is the most common joint disease. The administration of nonsteroidal anti-inflammatory drugs (NSAIDs) by phonophoresis is a therapeutic alternative to relieve pain in inflammatory pathologies. The main aim was to analyze the efficacy of the application of NSAIDs by phonophoresis in knee OA. A systematic review and meta-analysis of controlled clinical trials were performed between January and March 2021 in the following databases: Web of Science, Scopus, PubMed, Cinahl, SciELO, and PEDro. The PEDro scale was used to evaluate the level of evidence of the selected studies. The RevMan 5.4 statistical software was used to obtain the meta-analysis. Eight studies were included, of which five were included in the meta-analysis, involving 195 participants. The NSAIDs used through phonophoresis were ibuprofen, piroxicam, diclofenac sodium, diclofenac diethylammonium, ketoprofen, and methyl salicylate. The overall result for pain showed not-conclusive results, but a trend toward significance was found in favor of the phonophoresis group compared to the control group (standardized mean difference (SMD) = -0.92; 95% confidence interval: -1.87-0.02). Favorable results were obtained for physical function (SMD = -1.34; 95% CI: -2.00-0.68). Based on the selected studies, the application of NSAIDs by phonophoresis is effective in relieving the symptoms of knee OA. Future long-term studies are recommended.

Effect of Zingiber Cassumunar Roxb. Phonophoresis Versus Aqua Sonic Gel on Pain, Range of Motion, and Functional Disability in Patients With Osteoarthritis of Knee: A Randomized Controlled Trial

The aim of this trial was to collate, analyze, and compare the effectiveness of phonophoresis and ultrasound adjunct to Otago exercise program for pain, knee range of motion, and functional disability in patients with grades I and II of knee osteoarthritis. This is a single-blind randomized control study. A total of 52 patients with pre-diagnosed osteoarthritis on radiological investigation were included in the study. They were then randomly assigned into two groups: group A (n=26) received the experimental treatment, which included phonophoresis, and group B (n=26) subjects were treated with conventional physiotherapy. The interventions were given for six days/week for two weeks. Pain via the visual analog scale, knee range of motion via a goniometer, level of functional disability through the Western Ontario and McMaster Universities Osteoarthritis Index, and balance through the star excursion balance test were evaluated. Measurements of the outcome were taken prior to initiation of intervention and on the day of the last session, succeeding the treatment. Statistically, both the groups showed significant improvement in pain, range, dynamic balance, and functioning. Between the two groups, no clinically significant difference was present for balance, but the intergroup comparison for pain and functions was statistically and therefore clinically significant. Phonophoresis treatment was observed to be effective in treating pain in osteoarthritis. Combined Otago exercises and phonophoresis with modified gel can be used to achieve superior clinical results.

Potential Utility of Ultrasound-Enhanced Delivery of Antibiotics, Anti-Inflammatory Agents, and Nutraceuticals: A Mini Review

Ultrasound technology has therapeutic properties that can be harnessed to enhance topical drug delivery in a process known as phonophoresis. The literature on this method of drug delivery is currently sparse and scattered. In this review, we explore in vivo and in vitro controlled trials as well as studies detailing the mechanism of action in phonophoresis to gain a clearer picture of the treatment modality and explore its utility in chronic wound management. Upon review, we believe that phonophoresis has the potential to aid in chronic wound management, particularly against complicated bacterial biofilms. This would offer a minimally invasive wound management option for patients in the community.

Comparing the efficacy of continuous and pulsed ultrasound therapies in patients with lateral epicondylitis: A double-blind, randomized, placebo-controlled study

Objectives

The aim of this study was to investigate the efficacy of continuous and pulsed ultrasound therapies in lateral epicondylitis.

Patients and methods

A total of 51 patients (18 males, 33 females; mean age: 46.52±6.16 years; range, 27 to 64 years) who were diagnosed with lateral epicondylitis between February 2013 and October 2014 were included. The patients were randomized to either continuous ultrasound (n=17), pulsed ultrasound (n=17), or placebo (n=17) groups. First group received 10 sessions of continuous ultrasound therapy. The second group received 10 sessions of pulsed ultrasound therapy in a ratio of 1:4. The third group received 10 sessions of placebo treatment. The pain levels of the patients were evaluated using Visual Analog Scale (VAS). The muscle strength was evaluated using a dynamometer. For functional evaluation, Duruöz’s Hand Index (DHI) and Patient-Rated Tennis Elbow Evaluation (PRTEE) scales were used. Assessments were made at baseline, at the end of therapy, and one month after therapy. The thickness of the common extensor tendon was also measured using ultrasonic imaging at baseline and at the end of therapy.

Results

At the end of the study, there was a statistically significant improvement in the rest and activation VAS scores, and DHI and PRTEE scores in both continuous and pulsed ultrasound therapy groups, compared to placebo (p<0.05). However, no superiority was found between the continuous and pulsed ultrasound therapy groups (p>0.05). A statistically significant reduction in the common extensor tendon thickness was found only in the pulsed ultrasound therapy group (p<0.05).

Conclusion

Our study results show that both continuous and pulsed ultrasound applications are effective in the treatment of lateral epicondylitis.

Comparing the efficiency of ultrasound, ketoprofen, and mucopolysaccharide polysulfate phonophoresis in the treatment of lateral epicondylitis: A randomized-controlled clinical study

Objectives

In this study, we aimed to compare the efficiency of ultrasound, mucopolysaccharide polysulfate phonophoresis, ketoprofen phonophoresis and exercise combinations in terms of pain, functionality, disability, and strength in patients with lateral epicondylitis (LE).

Patients and methods

This prospective, parallel-group, randomized-controlled clinical study included a total of 60 patients (42 males, 18 females; mean age 38.08 years; range, 21 to 50 years) with LE between April 2016 and October 2017. The patients were equally randomized into four groups based on the time of admission to the outpatient clinic. The Visual Analog Scale (VAS), painless weight lifting, the Patient- Rated Tennis Elbow Evaluation (PRTEE), and Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) were used to measure the outcomes. The measurements were performed at baseline, at the end of 10 daily sessions, and after a six-week follow-up period.

Results

The resting VAS scores in the ketoprofen phonophoresis group and lifted weights in the MPS and ketoprofen phonophoresis groups showed a significant improvement both after 10 days of treatment and at six-week follow-up visits (p<0.001). In the QuickDASH model, there was no significant improvement in the control group after 10 days of treatment (p>0.05); however, a significant improvement was observed after six weeks (p<0.001). Except for these variables, significant improvements were found in all groups for all variables at six-week follow-up (p<0.05). However, improvements were similar in all groups (p>0.05).

Conclusion

Based on our study results, for LE patients who are unable to adhere to exercise and splint use and are given a physical treatment plan, inclusion of ketoprofen and MPS phonophoresis in the treatment program may yield additional benefits in their daily living activities, functionality, and working life.

Comparative efficacy of analgesic gel phonophoresis and ultrasound in the treatment of temporomandibular joint disorders

Aim

The aim of this study is to determine the efficacy of phonophoresis in patients with temporomandibular disorders.

Objective

To prove that phonophoresis could be an effective treatment modality in in patients with temporomandibular disorders.

Procedure

Fifty patients diagnosed clinically and radiographically as temporomandibular disorder were randomly assigned into either of the two groups, namely, (Group A) plain ultrasound and (Group B) phonophoresis. Acoustic gel containing no pharmacological agent was applied in the ultrasound group, whereas a gel containing aceclofenac was applied in the phonophoresis group. Each group was treated three times a week for 2 weeks. The assessment of pain and inflammation both before and after treatment were done using the visual analog scale (VAS) and Creactive protein (CRP).

Results

Intergroup comparison was done and analyzed statistically using independent ttest. Intragroup comparison was done using paired ttest. A significant difference in VAS scores and CRP levels before and after treatment were seen within both ultrasound phonophoresis PH groups. No significant difference was noted statistically between ultrasound and phonophoresis group.

Conclusion

The results of this study suggests that though plain ultrasound as well as phonophoresis with aceclofenac gel are effective in the management of temporomandibular disorders. Phonophoresis was found be slightly superior as evident in VAS scores and CRP levels though not statistically significant.

Evidence based treatment options for common knee injuries in runners

The purpose of this paper is to review the current literature regarding conservative treatment options for the three most common knee injuries in runners including patellofemoral pain syndrome (PFPS), iliotibial band friction syndrome (ITBFS), and patellar tendinopathy (PT). Each diagnosis is discussed using current research to describe the pathophysiology, evaluation process, and evidence based effective treatment strategies including therapeutic exercise, manual therapy, neuromuscular re-education, and modalities. The result is a comprehensive overview of each diagnosis and a research-based approach to effectively evaluate and treat each condition for best outcomes.

Improved Pain and Function in Knee Osteoarthritis with Dexamethasone Phonophoresis: A Randomized Controlled Trial

BACKGROUND

Intraarticular corticosteroid injection is an adjunct to core treatments for relief of moderate-to-severe pain in osteoarthritis (OA) patients. This randomized controlled trial was conducted to determine the effect of dexamethasone phonophoresis (DxPh) on knee OA.

PATIENTS AND METHODS

Forty six female patients with knee OA were randomized into two equal groups. The study group received DxPh over the medial side of the knee, transcutaneous electrical nerve stimulation (TENS), and quadriceps strengthening exercises. Control group received ultrasound therapy and the same TENS and exercise program. Pain was assessed using the visual analog scale (VAS) and the pain subscale of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pre- and posttreatment. Functional mobility was assessed by the Timed Up and Go (TUG) test, total WOMAC, and the joint stiffness and physical function subscales of WOMAC. The minimal clinically identifiable difference was used to calculate treatment effect sizes of both modalities, which was compared to intraarticular steroid injections.

RESULTS

The VAS, TUG, and WOMAC scores improved with both modalities. Pain intensity improved by 50.6%-58.0% in the study group (VAS and pain subscale of WOMAC, respectively) compared to 17.8%-28.6% for the control group. Functional mobility showed a higher rate of improvement in the DxPh group compared to control (37.7 vs. 17.5% for TUG and 53.2 vs. 23.0 and 56.1 vs. 26.4% for the joint stiffness and physical function subscales of WOMAC, respectively). Posttreatment results revealed statistically and clinically significant improvement in pain intensity and functional mobility in the DxPh group.

CONCLUSION

DxPh resulted in a greater improvement in pain and function in patients with knee OA than therapeutic ultrasound combined with exercise and TENS. The effect size of phonophoresis was clinically significant and higher than that reported for intraarticular steroid injection from pooled data in the literature.

Effects of placebo-controlled continuous and pulsed ultrasound treatments on carpal tunnel syndrome: a randomized trial

OBJECTIVE

The aim of this placebo-controlled study was to evaluate the effects of pulsed and continuous ultrasound treatments combined with splint therapy on patients with mild and moderate idiopathic carpal tunnel syndrome.

METHODS

The study included 46 carpal tunnel syndrome patients who were randomly divided into 3 groups. The first group (n = 15) received a 0 W/cm2 ultrasound treatment (placebo); the second group (n = 16) received a 1.0 W/cm2 continuous ultrasound treatment and the third group (n = 15) received a 1.0 W/cm2 1:4 pulsed ultrasound treatment 5 days a week for a total of 15 sessions. All patients also wore night splints during treatment period. Pre-treatment and post-treatment Visual Analogue Scale, Symptom Severity Scale and Functional Status Scale scores, median nerve motor conduction velocity and distal latency and sensory conduction velocities of the median nerve in the 2nd finger and palm were compared. Clinicaltrials.gov: NCT02054247.

RESULTS

There were significant improvements in all groups in terms of the post-treatment Functional Status Scale score (p<0.05 for all groups), Symptom Severity Scale score (first group: p<0.05, second group: p<0.01, third group: p<0.001) and Visual Analogue Scale score (first and third groups: p<0.01, second group: p<0.001). Sensory conduction velocities improved in the second and third groups (p<0.01). Distal latency in the 2nd finger showed improvement only in the third group (p<0.01) and action potential latency in the palm improved only in the second group (p<0.05).

CONCLUSION

The results of this study suggest that splinting therapy combined with placebo and pulsed or continuous ultrasound have similar effects on clinical improvement. Patients treated with continuous and pulsed ultrasound showed electrophysiological improvement; however, the results were not superior to those of the placebo.

Comparison of the efficacy of ketoprofen phonophoresis, ultrasound, and short-wave diathermy in knee osteoarthritis

The present study aimed to compare the efficacy of three different deep heating modalities: phonophoresis (PH), short-wave diathermy (SWD), and ultrasound (US), in knee osteoarthritis. Patients who consented to participate in the study were randomly divided into the following three groups. Group 1 (n = 33) received PH, Group 2 (n = 33) received US, and Group 3 (n = 35) received SWD. These deep heating therapies were applied by the same therapist. Each therapy began with 20-min hot pack application. Each of the three physical therapy modalities was applied 5 days a week for 2 weeks (a total of 10 sessions). The patients were evaluated using visual analogue scale (VAS) at rest, 15-m walking time, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) both before and after the treatment. Moreover, at the end of the treatment, both the physician and the patient made an overall evaluation, by rating the treatment efficacy. The results of the study showed that VAS, 15-m walking time, and WOMAC parameters were improved with all three deep heating modalities, and all the three modalities were effective. However, there was no significant difference between the three modalities in terms of efficacy. There was also no significant difference between the three groups in terms of post-treatment general evaluation of the physician and the patient. The present study is the first to suggest that choosing one of PH/US/SWD therapy options would provide effective results and none of them are superior to the others, and we believe that these findings will be a basis for further studies.

Current interventions in the management of knee osteoarthritis

Osteoarthritis (OA) is progressive joint disease characterized by joint inflammation and a reparative bone response and is one of the top five most disabling conditions that affects more than one-third of persons > 65 years of age, with an average estimation of about 30 million Americans currently affected by this disease. Global estimates reveal more than 100 million people are affected by OA. The financial expenditures for the care of persons with OA are estimated at a total annual national cost estimate of $15.5-$28.6 billion per year. As the number of people >65 years increases, so does the prevalence of OA and the need for cost-effective treatment and care. Developing a treatment strategy which encompasses the underlying physiology of degenerative joint disease is crucial, but it should be considerate to the different age ranges and different population needs. This paper focuses on different exercise and treatment protocols (pharmacological and non-pharmacological), the outcomes of a rehabilitation center, clinician-directed program versus an at home directed individual program to view what parameters are best at reducing pain, increasing functional independence, and reducing cost for persons diagnosed with knee OA.

Ultrasound-mediated transdermal drug delivery: mechanisms, scope, and emerging trends

The use of ultrasound for the delivery of drugs to, or through, the skin is commonly known as sonophoresis or phonophoresis. The use of therapeutic and high frequencies of ultrasound (≥0.7MHz) for sonophoresis (HFS) dates back to as early as the 1950s, while low-frequency sonophoresis (LFS, 20-100kHz) has only been investigated significantly during the past two decades. Although HFS and LFS are similar because they both utilize ultrasound to increase the skin penetration of permeants, the mechanisms associated with each physical enhancer are different. Specifically, the location of cavitation and the extent to which each process can increase skin permeability are quite dissimilar. Although the applications of both technologies are different, they each have strengths that could allow them to improve current methods of local, regional, and systemic drug delivery. In this review, we will discuss the mechanisms associated with both HFS and LFS, specifically concentrating on the key mechanistic differences between these two skin treatment methods. Background on the relevant physics associated with ultrasound transmitted through aqueous media will also be discussed, along with implications of these phenomena on sonophoresis. Finally, a thorough review of the literature is included, dating back to the first published reports of sonophoresis, including a discussion of emerging trends in the field.

Treatment of tendinopathy: what works, what does not, and what is on the horizon

Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear.

LEVEL OF EVIDENCE

Level II, systematic review.

A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia

A systematic review of the literature on the effectiveness of physical interventions for lateral epicondylalgia (tennis elbow) was carried out. Seventy six randomised controlled trials were identified, 28 of which satisfied the minimum criteria for meta-analysis. The evidence suggests that extracorporeal shock wave therapy is not beneficial in the treatment of tennis elbow. There is a lack of evidence for the long term benefit of physical interventions in general. However, further research with long term follow up into manipulation and exercise as treatments is indicated.

Patellar tendinopathy in athletes: current diagnostic and therapeutic recommendations

Formerly known as 'jumper's knee', patellar tendinopathy gives rise to considerable functional deficit and disability in recreational as well as professional athletes. It can interfere with their performance, often perseveres throughout the sporting career and may be the primary cause to end it. The diagnosis of patellar tendinopathy is primarily a clinical one but new imaging techniques, such as Doppler ultrasonography, may provide additional diagnostic value. Current therapeutic protocols are characterised by wide variability ensuing from anecdotal experience rather than evidence. Moreover, numerous reports in recent years have shattered previous doctrines and dogmatic belief on tendon overuse. Histopathological and biochemical evidence has indicated that the underlying pathology of tendinopathy is not an inflammatory tendinitis but a degenerative tendinosis. Consequently, pain in chronic patellar tendinopathy is not inflammatory in nature, but its exact origin remains unexplained. In pursuit of pathology- and evidence-based management, conservative therapy should be shifted from anti-inflammatory strategies towards a complete rehabilitation with eccentric tendon strengthening as a key element. If conservative management fails, surgery is opted for. However, considering the heterogeneity of surgical procedures and the absence of randomised studies, no conclusive evidence can be drawn from the literature regarding the effectiveness of surgical treatment for patellar tendinopathy. Parallel with the improved knowledge on the pathophysiology and pain mechanisms in patellar tendinopathy, new treatment strategies are expected to emerge in the near future.