Treatment Rationale
Problem: Treating a patient with trigger points in their upper trapezius using ultrasound.
Justification: Koca et al.(1) performed a study that compared the effectiveness of low, medium and high dose ultrasound on subjects diagnosed with myofascial pain syndrome. The subjects also had trigger points in their upper trapezius muscle. It was reported that the high power pain threshold ultrasound group had improvements in pain as measured by the visual analog scale (VAS), number of trigger points, pressure pain threshold, range of tragus-acrominoclavicular joint and neck pain disability scores whereas the low dose ultrasound group only had improvements in the VAS score. The high power pain threshold ultrasound group had better improvements in scores than the medium-dose ultrasound group. Majlesi et al.(2) performed a study that compared high power pain threshold static ultrasound with conventional ultrasound for the treatment of pain created by myofascial trigger points in the upper trapezius muscle. They discovered that the high power ultrasound was better than the conventional ultrasound by the decrease in the VAS score and the increase of range of motion of active lateral bending in the cervical spine. The high power ultrasound group also had a decrease in the length of therapy compared to the conventional ultrasound group. Unalan et al.(3) performed a study comparing high-power pain threshold ultrasound to local injections in the treatment of active myofascial trigger points in the upper trapezius. They discovered that both groups had improvements in pain (measured by VAS) and range of motion of lateral bending of the cervical spine (measured with a goniometer), but there was no significant difference between the two groups. The local injections group had a lower number of sessions needed to treat the trigger points.
Procedure: I will be using the procedure that was followed in the study by Unalan et al.(3) I will be using the high-power pain threshold group procedure. I will be using a continuous mode on the ultrasound with the transducer head directly over the trigger point and held motionless. The intensity will be raised until the max level the patient can tolerate and will be held at that level for 4 to 5 seconds and then dropped down to half of that level and held for 15 seconds. The intensity will be between 0.5 Watts/cm2 to 2.0 Watts/cm2, the frequency will be between 1 and 3 MHz and the transducer head size will be 5 cm2. The patient’s VAS score will be asked after the second day of treatment and when the patient gets a score of O or 1 the treatment will be stopped.
Outcome: Many outcomes were used in these studies, but many that were repeatedly used were the visual analog scale (VAS) for pain and cervical spine range of motion during side bend using a goniometer. The outcomes will be assessed pre-treatment and after each treatment in order to see if treatment is still necessary.
References:
1. Koca I, Tutoglu A, Boyaci A, et al. A comparison of the effectiveness of low-, moderate- and high-dose ultrasound therapy applied in the treatment of myofascial pain syndrome. Mod Rheumatol Jpn Rheum Assoc. 2014;24(4):662-666. doi:10.3109/14397595.2013.860001.
2. Majlesi J, Ãœnalan H. High-power pain threshold ultrasound technique in the treatment of active myofascial trigger points: a randomized, double-blind, case-control study. Arch Phys Med Rehabil. 2004;85(5):833-836. doi:10.1016/j.apmr.2003.07.023.
3. Halil Unalan JM. Comparison of High-Power Pain Threshold Ultrasound Therapy With Local Injection in the Treatment of Active Myofascial Trigger Points of the Upper Trapezius Muscle. Arch Phys Med Rehabil. 2011;92(4):657-662. doi:10.1016/j.apmr.2010.11.030.