Phonophoresis

Phonophoresis also known as sonophoresis, is the use of ultrasound to enhance the delivery of topically applied drugs to underlying tissues ¹. Iontophoresis is similar to phonophoresis except it utilizes direct current to administer the medication ². Phonophoresis has been claimed to enhance the percutaneous absorption of certain pharmacological agents such as anti-inflammatory steroids and local anesthetics from intact skin into the underlying subcutaneous structures by ultrasound, therefore improving their effectiveness. This procedure is commonly used in physical therapy practices. The procedure generally utilizes an ultrasound apparatus that generates frequencies of 0.7 to 1.1 MHz. The ultrasound intensities employed usually range from 0.0 to 3.0 Watts per cm2. Both continuous-mode as well as pulse-mode applications were utilized, and most treatments lasted from 5 to 8 mins, with the exception of treatments of larger areas (greater than 36 cm²) requiring more than 8 minutes. The exact mechanism enabling drugs to be propelled into the subcutaneous structures is still unclear.

Phonophoresis has been suggested by early studies to enhance the absorption of analgesics and anti-inflammatory agents. More recent, better-controlled studies have consistently failed to demonstrate that phonophoresis increases the rate of absorption or the extent of absorption over placebo. Several reviews stated that more research is needed to ascertain optimal techniques and conditions for safe and efficacious utilization of physical modalities including phonophoresis; and there is a need for additional research to establish clinical effectiveness and determine optimal treatment parameters for the physical agents (e.g., phonophoresis) used most frequently to alleviate pain in hand therapy.

Phonophoresis has been commonly used in physical therapy practices for many years ³. The most common drug used in phonophoresis is hydrocortisone acetate in either a 1% or 10% concentration ⁴. Hydrocortisone acetate is a naturally occurring corticosteroid that has strong anti-inflammatory properties. Hydrocortisone acetate phonophoresis has been used to treat a variety of inflammatory conditions, such as tendinopathy, tenosynovitis, bursitis, adhesive capsulitis, and carpal tunnel syndrome ⁵. A 1992 review by Newman et al ⁵ concluded that phonophoresis with hydrocortisone is effective in the treatment of a variety of musculoskeletal injuries by accelerating healing, increasing flexibility, and decreasing pain. However, more recent studies have cast doubt on the efficacy of phonophoresis ⁶. In a review article in 2007, Goraj-Szczypiorowska et al ⁷ determined that the dearth of objective research methods and reliable scientific verification does not allow unambiguous determination of the efficacy of phohophoresis. Despite these findings, a recent survey revealed that a majority of physical therapists (54.1%) with advanced clinical specialization in orthopaedics continue to use hydrocortisone acetate phonophoresis for inflammatory conditions ⁸.

Phonophoresis can be described as a non-invasive technique that uses piezoelectric potential by converting electrical energy into mechanical energy ⁹. In practice, this effect is obtained from the production of high-frequency oscillation sound waves, directed by the therapeutic ultrasound apparatus. This action provides a controlled and safe way to potentiate the transdermal absorption of a wide variety of ionizable drugs without causing significant discomfort. Thus, the action of many drugs, such as anti-inflammatories and analgesics that are administered to the outer layer of the skin, is potentiated as they penetrate in the deeper underlying tissue ¹⁰.

Although still debated, the mechanism by which ultrasound facilitates absorption of drugs is thought to occur via an alteration of the stratum corneum of the skin ⁴. Previous studies have suggested that the mechanism underlying the deposition of the drug with phonophoresis is cavitation ⁹. In cavitation, the action of the ultrasound results in the formation of gaseous microbubbles in the outer layer of the skin that can rupture violently, favoring the penetration of the drug. Additionally, cavitation causes changes in the organization of the lipids in the stratum corneum, increasing its permeability, which contributes to several physiological and therapeutic effects, including activation of blood flow, improvement of tissue nutrition, oxygenation, and metabolism, as well as rearrangement and regeneration of collagen fibers in connective tissues ¹¹. Therefore, due to its promising therapeutic effects, phonophoresis has been widely employed in clinical physiotherapy for the treatment of musculoskeletal disorders, especially in the rehabilitation of patients with acute and chronic osteomioarticular lesions, bone inflammation, pain, and edema ¹⁰.

Currently, there are some studies demonstrating the effects of the association between drugs and phonophoresis at different conditions of exposure to ultrasonic waves (e.g., intensity, frequency, duration, and continuity) ¹². However, the effectiveness of phonophoresis physical therapy in improving the therapeutic effect of drugs remains to be better investigated ¹³.

Phonophoresis review

In a randomized study (n = 60) comparing the effectiveness of ibuprofen phonophoresis with conventional ultrasound therapy in patients with knee osteoarthritis, Kozanoglu et al ¹⁴ found that ibuprofen phonophoresis was not superior to conventional ultrasound.

One high-quality randomized controlled trial, by Stratford et al. ¹⁵, reported significant pain relief using therapeutic ultrasound alone compared with placebo in the short term treatment of extensor carpi radialis tendinitis. Stratford et al. ¹⁵ also examined therapeutic ultrasound in combination with friction massage, phonophoresis alone and phonophoresis with frictional massage, and found all treatments to be beneficial for pain relief; however, no one treatment was superior to another.

Ellis et al ¹⁶ stated that iliotibial band friction syndrome is a common injury of the lateral aspect of the knee particularly in runners, cyclists and endurance sports. A number of investigators suggested that iliotibial band friction syndrome responds well to conservative treatment, however, much of this notion appears anecdotal and is not supported by available evidence. These researchers performed a systematic review of the literature on the conservative treatment of iliotibial band friction syndrome. With respect to the management of iliotibial band friction syndrome, 4 randomized controlled trials were identified. The interventions examined included the use of non-steroidal anti-inflammatory drugs, deep friction massage, phonophoresis versus immobilization and corticosteroid injection. This review highlighted both the paucity in quality and quantity of research regarding the conservative treatment of iliotibial band friction syndrome. There seems limited evidence to suggest that the conservative treatments that have been studied offer any significant benefit in the management of iliotibial band friction syndrome. The authors noted that future research will need to re-examine those conservative therapies, which have already been examined, along with others, and will need to be of sufficient quality to enable accurate clinical judgements to be made regarding their use ¹⁶.

In a review on factors that influence the quality and effectiveness of ultrasound and phonophoresis treatment, Goraj-Szczypiorowska and colleagues ¹⁷ noted that although phonophoresis is commonly used among physical therapists, doubts persist as to the relevance and effectiveness of this method. Despite its popularity, the issue of conditions underlying the effectiveness of phonophoresis treatment has still not been adequately addressed. Particular areas of interest include:

1. treatment parameters to be followed in physical therapy,
2. appropriate dosage forms of drugs to ensure propagation of ultrasound waves,
3. principles of homoeostasis and other physiological processes that play a decisive role in achieving the biological and
4. therapeutic effects of ultrasound therapy, and indications and contraindications to this kind of treatment.

The dearth of objective research methods and reliable scientific verification does not allow unambiguous determination of the effectiveness of phonophoresis ¹⁷.

Jewell et al ¹⁸ examined if physical therapy interventions predicted meaningful short-term improvement in 4 measures of physical health, pain, and function for patients diagnosed with adhesive capsulitis. Data were examined from 2,370 patients (mean age of 55.3 years, SD = 12.4; 65 % females, 35 % males) classified into patients who had completed an episode of outpatient physical therapy. Principal components factor analysis was used to define intervention categories from specific treatments applied during the episode of care. A nested logistic regression model was used to identify intervention categories that predicted a 50 % or greater change in Physical Component Summary-12 (PCS-12), physical function, bodily pain, and hybrid function scores. None of the patients achieved a 50 % or greater improvement in PCS-12 scores. Improvement in bodily pain scores was more likely in patients who received joint mobility interventions (odds ratio = 1.35). Improvement in hybrid function scores was more likely in patients who received exercise interventions (odds ratio = 1.50). Use of iontophoresis, phonophoresis, ultrasound, or massage reduced the likelihood of improvement in these 3 outcome measures by 19 % to 3 2%. The authors concluded that these results are consistent with findings from randomized clinical trials that demonstrated the effectiveness of joint mobilization and exercise for patients with adhesive capsulitis ¹⁸. However, ultrasound, massage, iontophoresis, and phonophoresis reduced the likelihood of a favorable outcome, which suggests that use of these modalities should be discouraged.

An UpToDate review on “Rotator cuff tendinopathy” ¹⁹ lists electrical stimulation, iontophoresis, laser, phonophoresis, and therapeutic ultrasound as adjunct therapies. Moreover, it states that “No clear evidence exists to support the use of the modalities listed here and we do not routinely use them in the care of our patients”.

Jain et al ²⁰ hypothesized that transdermal steroid delivery would yield short-term improvements for trapezio-metacarpal joint arthritis, although these improvements would not persist at later follow-up (3 or 6 months). A total of 84 consecutive trapezio-metacarpal joints in 62 patients presenting to an orthopedic hand surgeon were randomized to receive either steroid delivery by iontophoresis or phonophoresis or placebo delivery via iontophoresis or phonophoresis. The researchers and patients were blinded as to the treatment assignment. Patients were evaluated before treatment and at 3 follow-up appointments. Subjects were assessed via the Michigan Hand Outcomes Questionnaire, Short Form 12, analog pain score, and provocative and strength testing. The subjects’ study group, gender, and arthritic grade were statistically analyzed versus patient-reported and physician-assessed data over the different time points. Following subject recruitment, 17 joints discontinued the study due to joint discomfort, electing for other treatments. Approximately 50 % of the 67 subject joints opted for alternative treatment after the first or second follow-up; 34 subject joints completed all follow-up time points. There was no significant predictive relationship between the independent variables and their ability to predict the 9 dependent measures of pain, strength, and well-being. There were trends for the pain to decrease over time, although the trends were not uniform between the different pain metrics and groups. The strength for both iontophoresis groups tended to increase over time, whereas the phonophoresis groups tended to decline. The authors concluded that although there were some trends in the follow-up data, the overall lack of significant differences in the data suggested that transdermal steroid delivery might not be helpful in providing short- or long-term relief of arthritic symptoms ²⁰.

Donovan et al ²¹ examined the anesthetic effect of 1-MHz phonophoresis using lidocaine on the anterior forearm following 5- and 10-min interventions. This was a cross-over study in a laboratory involving 22 healthy participants (13 women, 9 men; age, 23.0 +/- 3.2 yrs; height, 169.1 +/- 7.2 cm; weight, 70.9 +/- 13.9 kg). All subjects received 4 interventions on 4 different days:

• 1.5 W/cm, 100 % duty cycle with lidocaine for 5 mins (short);
• 1.5 W/cm, 50 % duty cycle with lidocaine for 10 mins (long);
• no ultrasound for 10 mins with lidocaine gel (lidocaine sham); and
• no ultrasound for 10 mins with ultrasound gel (true sham).

Skin sensation was measured for analysis. The main outcome measures were Semmes-Weinstein Monofilament (SWM) scores, with higher scores indicating less sensitivity. There was a significant time main effect for SWM scores. Baseline SWM scores were the lowest (3.00 +/- 0.53) and post-SWM scores (0 mins) were the highest (3.63 +/- .44), indicating an anesthetic effect at this time. The authors concluded that neither the long nor the short treatment decreased skin sensation compared with sham conditions. All interventions resulted in decreased skin sensation when comparing baseline SWM scores to all post-treatment scores. Phonophoresis with lidocaine did not result in an enhanced anesthetic effect on human subjects ²¹.

Gurney et al ²² noted that phonophoresis has been a mainstay in physical therapy. The most common drug used in phonophoresis is hydrocortisone acetate. A number of studies have been done examining phonophoresis in the delivery of hydrocortisone acetate through the skin to underlying tissues; however, a study has never been done examining the absorption of hydrocortisone acetate using phonophoresis on human connective tissue. In a randomized controlled study, these researchers examined if phonophoresis will facilitate the transmission of hydrocortisone acetate in human connective tissue. A total of 21 patients undergoing anterior cruciate ligament reconstruction surgery were randomly assigned to either a sham or true phonophoresis treatment group. The latter group received 6 minutes of 10 % hydrocortisone acetate ultrasound at a point consistent with the gastrocnemius slip of the semitendinosis tendon (treatment site). The sham group received 6 minutes of 10 % hydrocortisone acetate ultrasound to the same area, but the ultrasound was not turned on. The slip and a sample of the distal attachment of the tendon (control) were removed. Samples were analyzed for hydrocortisone acetate levels. Although the mean and median levels of hydrocortisone acetate found at the treatment site were greater than those of the control site (means, 34.1 versus 22.9 parts per billion; medians, 7 versus 0 parts per billion), the levels of hydrocortisone acetate found at the treatment site were not significantly greater than those at the control site (p = 0.15). There were no statistically significant differences between the true and sham phonophoresis groups in hydrocortisone acetate levels (p = 0.80) nor in age, sex, or skin thickness. The authors concluded that phonophoresis does not appear to facilitate the absorption of hydrocortisone acetate in connective tissue when compared with simple absorption (sham) ²². Thus, the, use of phonophoresis should be re-considered in inflammatory conditions.

Lake and Wofford ²³ determined the effectiveness of therapeutic modalities for the treatment of patients with patella-femoral pain syndrome. Selected studies were randomized controlled trials that used a therapeutic modality to treat patients with patella-femoral pain syndrome. The review included articles with all outcome measures relevant for the patella-femoral pain syndrome patient: knee extension and flexion strength (isokinetic and isometric), patella-femoral pain assessment during activities of daily life, functional tests (e.g., squats), Kujala patella-femoral score, and electromyographic (EMG) recording from knee flexors and extensors and quadriceps femoris cross-sectional areas. Authors conducted independent quality appraisals of studies using the PEDro Scale and a system designed for analysis of studies on interventions for patella-femoral pain. A total of 12 studies met criteria: 1 on the effects of cold and ultrasound together, ice alone, iontophoresis, and phonophoresis; 3, neuromuscular electrical stimulation; 4, EMG biofeedback; 3, electrical stimulation for control of pain; and 1, laser. Most studies were of low-to-moderate quality. Some reported that therapeutic modalities, when combined with other treatments, may be of some benefit for pain management or other symptoms. There was no consistent evidence of any beneficial effect when a therapeutic modality was used alone. Studies did not consistently provide added benefit to conventional physical therapy in the treatment of patella-femoral pain syndrome. The authors concluded that none of the therapeutic modalities reviewed has sound scientific justification for the treatment of patellofemoral pain syndrome when used alone ²³.

An UpToDate review on “Patellofemoral pain syndrome” ²⁴ states that “There is no empiric evidence to support the use of ultrasound, iontophoresis, phonophoresis, or electrical stimulation in the treatment of patellofemoral pain syndrome”.

The American College of Occupational and Environmental Medicine’s occupational medicine practice guidelines on “Elbow disorder” ²⁵ phonophoresis is not recommended for acute, subacute, or chronic lateral epicondylalgia. Furthermore, the ACOEM guidelines offer no recommendation regarding the use of phonophoresis for acute, subacute, or chronic ulnar neuropathies at the elbow.

Bakhtiary et al ²⁶ compared the effectiveness of iontophoresis and phonophoresis of dexamethasone sodium phosphate (Dex-P) treatment for mild-to-moderate carpal tunnel syndrome. A total of 52 hands in 34 consecutive patients with mild-to-moderate carpal tunnel syndrome confirmed by EMG were allocated randomly into 2 groups. One group received iontophoresis of 0.4 % Dex-P and the other group received phonophoresis of 0.4 % Dex-P. Phonophoresis (using ultrasound 1 MHz, 5-cm probe, 1.0 W/cm, pulse 1:4, 5 mins/session) and iontophoresis (using galvanic current, negative electrode, 2 mA/min, total dose 40 mA for 20 mins) was applied over the wrist chin for 10 daily treatment sessions (5 sessions/week). Measurements were performed before and after treatment and at follow-up 4 weeks later, and included pain assessment by visual analog scale, electroneurographic measurement (motor and sensory latency, motor and sensory action potential amplitude), and pinch and grip strength. Improvement was significantly more pronounced in the phonophoresis group than in the iontophoresis group for motor latency [mean difference 0.8 m/s], motor action potential amplitude (4.1 mV), finger pinch strength (31.6 N), hand grip strength (27.1 N), and pain relief (2.1 points on a 10-point scale). Effects were sustained in the follow-up period. The authors concluded that phonophoresis of Dex-P treatment was more effective than iontophoresis of Dex-P for treatment of carpal tunnel syndrome. Moreover, they stated that further investigation is needed to examine the combination therapy effects of these treatments with other conservative treatments in carpal tunnel syndrome patients ²⁶.

In a case report, Ansari et al ²⁷ described the results of a novel treatment, erythromycin phonophoresis, in a woman with chronic rhino-sinusitis. A 31-year old woman with a 7-month history of chronic rhino-sinusitis refractory to conventional medical management was treated with erythromycin phonophoresis to both maxillary sinuses. Individual sinus symptom severity was assessed and sinus CT scans were obtained both pre-treatment and post-treatment. After treatment, the total sinusitis symptom score improved from 12 to 0 and the CT scan showed almost complete disease resolution. At 5-month follow-up, the patient reported sustained improvement. The authors concluded that erythromycin phonophoresis has potential as an effective treatment for chronic rhino-sinusitis ²⁷.

Packer et al ²⁸ stated that the dental anesthesia sonophoresis device is a novel device that is intended to reduce the discomfort associated with intra-oral mucosa needle puncture. The dental anesthesia sonophoresis device produces ultrasonic energy that provides a sonophoretic effect on the oral mucosa, generating micro-channels through the lipids between the keratinized cells that make up the stratum corneum. Once the topical anesthetic has permeated the stratum corneum, it quickly diffuses through the soft tissue, desensitizing the nerve endings and reducing the perception of pain caused by needle penetration. In a pilot study, these researchers evaluated whether topical anesthesia applied using the dental anesthesia sonophoresis device will reduce the discomfort of the needle puncture when compared to the control device. A split-mouth model, using 50 healthy subjects with puncture site at the maxillary canine vestibule, was used for this study. Subjects received a needle puncture on both sides of the mouth. Prior to the needle puncture, there was randomized application of 5 % lidocaine with the dental anesthesia sonophoresis device and a control device. Subjects rated their discomfort after needle punctures utilizing the visual analog scale pain scoring system. There was no statistically significant difference in the pain perception using the dental anesthesia sonophoresis device versus the control device.

Winters et al ²⁹ stated that medial tibial stress syndrome is a common exercise-induced leg injury among athletes and military personnel. Several treatment options have been described in the literature, but it remains unclear which treatment is most effective. The objective of this systematic review was to evaluate the effectiveness of any intervention in the treatment of medial tibial stress syndrome. Published or non-published studies, reporting randomized controlled trials or non-randomized controlled trials of any treatment in subjects with medial tibial stress syndrome were eligible for inclusion. Treatments were assessed for effects on pain, time to recovery or global perceived effect. Computerized bibliographic databases (MEDLINE, CENTRAL, EMBASE, CINAHL, PEDro and SPORTDiscus) and trial registries were searched for relevant reports, from their inception to June 1, 2012. Grey literature was searched for additional relevant reports. The Cochrane Risk of Bias Tool was used to appraise study quality of randomized controlled trials whereas the Newcastle Ottawa Scale was used to appraise non-randomized controlled trials. The “levels of evidence”, according to the Oxford Centre for Evidence-Based Medicine, addressed the impact of the assessed trials. Two reviewers independently performed the search for articles, study selection, data extraction and appraised methodological quality. A total of 11 trials were included in this systematic review. All randomized controlled trials revealed a high-risk of bias (Level 3 of evidence). Both non-randomized controlled trials were found to be of poor quality (Level 4 of evidence). Randomized clinical trials, studying the effect of a lower leg brace versus no lower leg brace, and iontophoresis versus phonophoresis, were pooled using a fixed-effects model. No significant differences were found for lower leg braces (standardized mean difference -0.06), or iontophoresis (standardized mean difference 0.09). Iontophoresis, phonophoresis, ice massage, ultrasound therapy, periosteal pecking and extracorporeal shockwave therapy (ESWT) could be effective in treating medial tibial stress syndrome when compared with control (Level 3 to 4 of evidence). Low-energy laser treatment, stretching and strengthening exercises, sports compression stockings, lower leg braces and pulsed electromagnetic fields have not been proven to be effective in treating medial tibial stress syndrome (level 3 of evidence). The authors concluded that none of the studies was sufficiently free from methodological bias to recommend any of the treatments investigated. Of those examined, extracorporeal shockwave therapy appeared to have the most promise.

An UpToDate review on “Shoulder impingement syndrome” ³⁰ lists acupuncture, electrical stimulation, iontophoresis, laser, phonophoresis, and therapeutic ultrasound as adjunct therapies. Moreover, it states that “No clear evidence exists to support the use of the modalities listed here in the treatment of shoulder impingement syndrome, and we do not routinely use them in the care of our patients”.

An UpToDate review on “Overview of geriatric rehabilitation: Program components and settings for rehabilitation” ³¹ states that “Iontophoresis/Phonophoresis — These modalities utilize electric current (iontophoresis) or ultrasound energy (phonophoresis) to force a therapeutic medication (e.g., glucocorticoid) into tissues. Both are used to treat soft tissue musculoskeletal injuries. Although evidence is limited, the few randomized controlled trials indicate that these modalities are generally no more effective than placebo”.

Myositis ossificans

Bagnulo et al ³² noted that myositis ossificans is a potential complication of muscle contusion. In a case-series study, these researchers presented the findings of patients who developed traumatic myositis ossificans (confirmed on diagnostic ultrasound) who participated in a treatment regimen consisting of phonophoresis of acetic acid with ultrasound. In all cases, a trial of phonophoresis therapy significantly decreased patient signs, symptoms and the size of the calcification on diagnostic ultrasound in most at a 4-week post-diagnosis mark. The authors concluded that due to the potential damage to the muscle and its function that surgical excision carries, safe and effective conservative treatments for myositis ossificans are crucial ³². They also stated that “Research on conservative care is necessary for chiropractors and other manual therapists to appropriately manage patients with myositis ossificans. Proving to be effective in this case and the paucity of literature on conservative treatment, this area needs to be investigated … Acetic acid phonophoresis deserves more attention in the literature. For conclusive information about conservative care, studies must investigate long-term effects of conservative care in a randomized trial with a clinically significant number of participants” ³². These findings need to be validated by well-designed studies.

An UpToDate review on “Quadriceps muscle and tendon injuries” ³³ does not mention phonophoresis as a management tool for myositis ossificans.

Tuberculous lymphadenitis

Chen et al ³⁴ stated that electro-phonophoresis has been used in various clinical fields. These researchers evaluated the skin permeability of isoniazid (INH) and rifampicin (RIF) in patients with tuberculous lymphadenitis with the aid of electro-phonophoresis to validate the clinical applications of this transdermal delivery system for the treatment of superficial extra-pulmonary tuberculosis. Isoniazid and rifampicin solutions were delivered transdermally, with or without electro-phonophoresis, in the surrounding tissue of the lesion for 30 minutes. Local pyogenic fluids or necrotic tissue samples from the infection sites in patients were collected at 1 hour after dosing. Drug concentrations in samples were evaluated by high performance liquid chromatography. The median INH and rifampicin intra-lesional concentrations were 0.365 (interquartile range 0.185 to 1.775) μg/ml and 1.231 (interquartile range 0.304 to 1.836) μg/ml in oral group; 2.964 (IQR 0.193 to 7.325) μg/ml and 2.646 (IQR 1.211 to 3.753) μg/ml in INH- and rifampicin-transdermal plus electro-phonophoresis group. Drug concentrations in the local sites of patients receiving INH or rifampicin through electro-phonophoresis transdermal delivery were statistically higher than those observed in patients only taking INH and rifampicin orally. However, this enhancement was not observed in the transdermal delivery of INH or rifampicin without electro-phonophoresis in contrast to the oral administrations of drugs. The authors concluded that electro-phonophoresis can effectively enhance the skin permeability of INH and rifampicin in patients with tuberculous lymphadenitis. The increase in drug concentrations in the lesions could help eradication of the germs; shorten the treatment course and increase the cure rate of patients with tuberculous lymphadenitis. These finding need to be validated by well-designed studies to show that electro-phonophoresis would improve health outcomes in patients with tuberculous lymphadenitis.

An UpToDate review on “Tuberculous lymphadenitis” ³⁵ does not mention phonophoresis as a management tool.

Knee pain

In a double blinded, randomized clinical trial, Nakhostin-Roohi et al ³⁶ evaluated the effects of virgin olive oil phonophoresis on female athletes’ anterior knee pain. A total of 93 female athletes suffering from anterior knee pain voluntarily participated in this study. Patients were randomly assigned into olive oil (n = 31), piroxicam (n = 31) or base gel phonophoresis (n = 31) groups. At the baseline visit, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire was filled by subjects who were then treated with olive oil, piroxicam or pure phonophoresis for 12 sessions. After 6 and 12 sessions of physiotherapy, subjects filled the questionnaire again. Main outcomes were significant improvement in pain, stiffness, physical function, and total WOMAC scores. Although, there was a significant reduction in symptoms of anterior knee pain at the end of the therapy in all groups (p < 0.05), but in olive oil group, this improvement was seen after 6 sessions of treatment. A significant difference between olive oil group and piroxicam and/or phonophoresis group was observed after 6 sessions of therapy. The authors concluded that it could be proposed that phonophoresis with virgin olive oil is as effective as piroxicam gel on lowering WOMAC scores of anterior knee pain in female athletes and also has several beneficial properties including faster effect and shorter duration of therapy ³⁶. The exact mechanism of beneficial action of virgin olive oil on anterior knee pain is unclear and requires further studies.

Chronic non-bacterial prostatitis

Tantawy and colleagues ³⁷ noted that a significant number of men who are younger than 50 years visit urologists for interminable prostatitis. These investigators examined the effect of pumpkin seed oil phonophoresis on chronic non-bacterial prostatitis. A total of 60 patients with chronic non-bacterial prostatitis were randomly assigned to 3 groups: Group A patients were treated with pumpkin seed oil using phonophoresis; Group B patients underwent trans-perineal continuous low-intensity ultrasound (LIUS); and Group C patients underwent placebo low-intensity ultrasound (LIUS). All 3 groups received their corresponding treatments daily for up to 3 weeks. The NIH-Chronic Prostatitis Symptom Index (NIH-CPSI), residual urine determined by urodynamic measurements, and flow rate were used to analyze study outcomes. The white blood cell (WBC) count in the prostatic secretion was determined. Comparisons of the intra-group mean values of all measurements in Groups A and B before and after the end of the treatment showed a significant improvement in residual urine, flow rate, WBC count, and NIH-CPSI, whereas no significant change was found in Group C. Between-group comparisons of all variables showed a significant difference was found after intervention. Post-intervention comparisons between Groups A and B showed a significant difference in all measurements, except for WBC, in favor of Group A. Comparing the changes between Groups A and C, a significant difference was found in all measurements (p < 0.05). Furthermore, all parameters differed significantly when comparing Groups B and C. The authors concluded that the findings of this study demonstrated that pumpkin seed oil phonophoresis could produce a significant effect in the management of chronic non-bacterial prostatitis and thus could be considered a safe, non-invasive method for the treatment of chronic non-bacterial prostatitis ³⁷. Moreover, these researchers stated that future investigations should examine the use of other different herbal sources that can be presented to the body by using different modes of low-intensity ultrasound (LIUS) by phonophoresis. The outcome measures of the present study were limited to the use of some urodynamic parameters, such as urinary flow rate and residual urine, WBCs, and NIH-CPSI, which were insufficient measures to strongly support the use of the treatment protocol; thus, further studies should be conducted along with the measurement of prostate weight, inflammatory markers in prostatic secretions (tumor necrotic factor [TNF] and interleukin-6 [IL-6] or interleukin-1 beta (IL-1B), nuclear factor-kappaB [NF-kB]), and dihydrotestosterone levels.

Chronic rhinosinusitis

Griffin and colleagues ³⁸ noted that the use of alternative medicine in chronic rhinosinusitis continues to increase in popularity, for the most part without meeting the burden of being based on sound clinical evidence. New and emerging treatments, both natural and developed, are numerous, and it remains a challenge for otolaryngologists as well as general practitioners to keep up-to-date with these therapies and their efficacy. In a systematic review, these investigators discussed a number of alternative therapies for chronic rhinosinusitis, their proposed physiologic mechanisms, and evidence supporting their use ³⁸. This analysis was based on their review of the English-language literature on alternative therapies for chronic rhinosinusitis (they did not include any therapies that are already recommended by accepted professional bodies). Data collection was performed using the PubMed database, the Cochrane databases, and bibliography searches. These researchers found that while many of the alternative therapies they reviewed might have a firm basis in science, they lack any clinical evidence to support their use specifically for chronic rhinosinusitis ³⁸. Some emerging therapies, such as therapeutic ultrasonography and phonophoresis, showed some promise, based on a growing body of positive evidence. In addition, the use of baby shampoo, thyme honey, and bromelain additives to saline lavage in chronic rhinosinusitis are all supported by clinical evidence, as is Sinupret, an oral preparation that contains echinacea. The authors concluded that higher levels of evidence gleaned from large, well-designed, prospective, randomized controlled trials are needed before any of these therapies can be recommended ³⁸.

Low Back Pain

In a prospective, double-blind, randomized clinical study, Altan and colleagues ³⁹ examined the effect of phonophoresis with the combination of non-steroidal anti-inflammatory drugs (NSAID’s) and myorelaxant versus routine ultrasound treatment with non-therapeutic gel on the patients with acute low back pain. A total of 60 patients with acute low back pain were randomly assigned into 2 groups. In Group 1 (n = 30) ultrasound was applied using diclofenac plus thiocolchicoside gel for 10 mins and for a total of 10 sessions. In Group 2 (n = 30) the same ultrasound protocol was applied with the same setting and timing with Group 1 using ultrasound gel that did not contain any pharmaceutical ingredient. Evaluation parameters were visual numeric scale, Oswestry Disability Index (ODI), and Shober test. Comparison of the results obtained from the 2 groups before treatment and at 2nd (W2) and 6th weeks (W6) post-treatment showed significant improvement in all parameters in both groups. Comparison of the groups showed significantly superior improvement in Group 1 for ODI while there was no difference in other parameters at 2nd week. At 6th weeks, there was significantly superior improvement in all parameters except for Shober test in Group 1. The authors concluded that these findings showed that phonophoresis was superior than conventional ultrasound therapy at short-term in the treatment of patients with acute low back pain. The relatively small sample sizes (n = 30 in each group) and the short-term follow-up (6 weeks) were the main drawbacks of this trial. These researchers suggested that further studies with larger patient groups are needed for better understanding of the effects of phonophoresis in acute and chronic low back pain ³⁹.

Upper trapezius latent myofascial trigger point

Tabatabaiee and associates ⁴⁰ stated that latent myofascial trigger point is a small hypersensitive area in skeletal muscles that becomes painful under compression or stimulation; and latent myofascial trigger points are relevant for various musculoskeletal disorders. Although several treatments have been introduced to treat latent myofascial trigger point, the most efficient one is yet to be found. These researchers compared the effectiveness of pressure release, phonophoresis of betamethasone and dry needling in treating upper trapezius latent myofascial trigger point. A total of 60 subjects (mean ± SD age of 23.6 ± 2.1 years), with at least 1 latent myofascial trigger point in the upper trapezius muscle, participated in this study. Subjects were randomly divided into 3 groups (pressure release, phonophoresis with betamethasone and dry needling groups) for 2 weeks. Pain intensity, pain pressure threshold and active cervical range of motion (ROM) were assessed. Significant pain decrease, active cervical ROM and pain pressure threshold increase were observed in the 3 groups. The dry needling and phonophoresis groups reported more significant improvement compared to the pressure release group. There was no difference between the dry needling and phonophoresis groups. The authors concluded that considering the significant, positive effects of all 3 methods, dry needling and phonophoresis appeared to be more effective than pressure release in treating upper trapezius latent myofascial trigger point ⁴⁰. This was a relatively small study (a total of 60 subjects), and no follow-up data were provided. These preliminary findings need to be validated by well-designed studies.

References

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