The effect of treatment with ultrasound, massage and exercises on myofascial trigger-points (MTrP) in the neck and shoulder was assessed in a randomised controlled trial. The outcome measures were pain at rest and on daily function (Visual Analogue Scale, VAS), analgesic usage, global preference and index of MTrP. Long-term effect for treatment and control groups was assessed after 6 months using a questionnaire. The patients were randomised to three groups. The first group was treated with ultrasound, massage and exercise (A), the second group with sham-ultrasound, massage and exercise (B), while the third group was a control group (C). The duration of the study was 6 weeks. Treatment was given twice a week from the second to the fifth week. The number and index of MTrPs were recorded at each treatment session in groups A and B but only at entry as well as end of study in group C. VAS and analgesic usage was recorded in all three groups throughout the study period. Six months after the last treatment session a questionnaire was send to the patients. A total of 67 patients were included. Nine patients dropped-out during the study, which left 58 patients that could be included in the final analysis. Twenty patients were randomised to group A, 18 to group B and 18 to group C. A significant reduction in index were found between treatment groups (A and B) and control group (C), but no difference between group A and B. VAS scores, analgesic usage or global preference showed no difference between group A, B or C. The patients in the group C were offered treatment (ultrasound, massage, exercise) after the 6 weeks treatment period. At the questionnaire after 6 month 44 (87%) of the 52 patients from all three groups who had treatment responded. Sixty-four percent answered that they had had good or some effects, 68 percent were still doing the exercise programme and 17 percent had received other forms of therapy after they had completed the study. No difference between groups given ultrasound or sham ultrasound were found. It is concluded that US give no pain reduction, but apparently massage and exercise reduces the number and intensity of MTrP. The impact of this reduction on neck and shoulder pain is weak.
We have reviewed 293 papers published since 1950 to assess the evidence of effect of ultrasound in the treatment of musculoskeletal disorders. Twenty-two clinical papers describing trials comparing ultrasound treatment with sham-ultrasound treated, non-ultrasound treatment and untreated groups were found. These papers were evaluated with respect to a list of criteria which should be met in this type of trial. They were generally found lacking with respect to description of drop-outs, randomisation methods, ultrasound apparatus, sham-ultrasound apparatus, control of apparatus, mode of delivery, size of sound-head, treated area and follow-up time. In 16 of these trials, ultrasound treatments were compared with sham-ultrasound and in 13 cases data were presented in a way that made pooling possible. Two standardized effect sizes (dd/r and dd/s) were applied to the results to enable evaluation of the effect of ultrasound treatment on pain. None of the methods (dd/r = 0.64%, confidence limits -6.7 to 7.5%; and dd/s = 0.24, confidence limits -0.01 to 0.49) gave evidence that pain relief could be achieved by ultrasound treatment. Hence we found no reason to analyze the other papers where ultrasound treatment was compared with another treatment or an untreated control group. We found a significant influence of degree of blinding using the d/s for the analysis (t test, P = 0.009), while when the d/r was used, only a trend was found (P = 0.10). An analysis of the effect of proper randomisation on the result was not possible because of inadequate description of the methods used. We conclude that the use of ultrasound in treatment of musculoskeletal disorders is based on empirical experience, but is lacking firm evidence from well-designed controlled studies. One question remaining is whether ultrasound treatment can augment an effect of exercise therapy with respect to musculoskeletal disorders.
A meta-analysis was undertaken of low-level laser therapy (LLLT) on musculoskeletal pain. A literature search revealed 23 LLLT trials and of these 17 were controlled trials. Ten were double blind and 7 were insufficiently blinded. Within the studies identified pain was assessed by visual analogue scale or by "some other indices of pain". Nine double-blind trials and 4 controlled trials presented results in a form which allowed pooling of data. In the double-blind trials, the mean difference in pain between LLLT and placebo was 0.3% (S.E.(d) 4.6%, confidence limits -10.3-10.9%). In the insufficiently blinded trials the mean difference in pain was 9.5% (S.E.(d) 4.5%, confidence limits -2.9-21.8%). We conclude that LLLT has no effect on pain in musculoskeletal syndromes.
In a controlled, cross-over study the effect of low level laser therapy (LLLT) was evaluated. During a five weeks period forty-seven female laboratory technicians received six laser and six placebo treatments to tender points in the neck and shoulder girdle. Subjects rated the placebo treatment significantly more beneficial than LLLT (p = .04). There was no reduction in consumption of analgesics associated with either laser or placebo treatment. The results indicate no beneficial effect of LLLT for myofascial pain.
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