Pressure pain threshold and visual analogue scale changes in the high and low energy extracorporeal shock wave

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1 Original Article htt://dx.doi.org/ /trs Phys Ther Rehabil Sci ISSN , 3 (2), eissn Pressure ain threshold and visual analogue scale changes in the high and low energy extracororeal shock wave You-Jin Yang a, Seung-Joon Lee b, Matthew Choi c a Deartment of Rehabilitation Medicine, Wonju Medical Center, Wonju, Reublic of Korea b Medical Fitness Center, Jung Hosital, Wonju, Reublic of Korea c Deartment of Physical Theray, College of Health and Welfare, Sahmyook University, Seoul, Reublic of Korea Objective: This study aims to investigate high energy and low energy extracororeal shockwave theray (ESWT) and which one is more effective for shoulder ain. Design: Single blind randomized controlled trial. Methods: Fifty two subjects with uer traezius (UT) trigger oint (TrP) articiated in this study. They were allocated to high energy (n=26) and low energy grou (n=26). This study alies ESWT and investigates the changes of ressure ain threshold (PPT) and visual analogue scale (VAS). The high and low energy grous received focused iezo electric tye ESWT 4 Hz, 1,000 ulses and and mj/mm 2 resectively. Outcome measures of PPT and ain was measured by algometer and ain VAS. These measurements were erformed before and after treatment. Results: The PPT value was significantly increased in both grous after treatment (<0.05) and VAS scores were significantly decreased after treatment in both grous (<0.05). However, there were no significant differences between grous. Conclusions: ESWT is an effective treatment for the alication of the UT TrP. Although there were significant effects of extracororeal shock wave theray on PPT and VAS scores, there were no signficant differences between high and low energy extracororeal shock wave theray. Key Words: Extracororreal shok wave, Traezius, Trigger oint Introduction Myofascial ain syndrome (MPS) is reresented by a myofascial trigger oint (MTrP). MTrP s are hyer sensitive and when nodules come in contact with a taut band, the sensitive areas of the muscles can cause radiating ain when alated [1]. Symtoms of MPS include ain and autonomic dysfunction such as abnormal sweating, tearing, redness, and temerature changes [2]. As a result, muscle coordination and work erformance is decreased due to increased fatigue and muscle weakness [3]. MPS aears frequently in atients who comlain of musculoskeletal ain. MTrP s can be easily found in the neck and shoulder area [4]. Among the shoulder and neck muscles, the uer traezius (UT) has a high revalence of MTrP and can cause neck ain and chronic tension-tye headaches [5]. The MPS is caused due to an acute trauma, reetitive micro-trauma, or incorrect osture (esecially if the rate of static osture or reetitive work is high) [6]. Thus, the urose of treatment is to inactivate the MTrP by avoiding ostures that may cause ain and by having the taut band relax [7,8]. Methods of treatment are Non-steroidal anti-inflammatory drugs, ain relievers such as tramadol [3], dry needling, injection [9], and hysical theray treatments such as ultrasound [10], high-ower laser [11], soft tissue mobilizations Received: 12 Setember, 2014 Revised: 23 October, 2014 Acceted: 21 November, 2014 Corresonding author: Seung-Joon Lee Medical Fitness Center, Jung Hosital, 141 Wonmun-ro, Wonju , Reublic of Korea Tel: Fax: simon1984@naver.com This is an Oen-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (htt://creativecommons.org/licens es/by-nc/3.0) which ermits unrestricted non-commercial use, distribution, and reroduction in any medium, rovided the original work is roerly cited. Coyright 2014 Korean Academy of Physical Theray Rehabilitation Science

2 Yang, et al: Effect of different energy density shock waves on the ain 143 [12]. In the 1990s, extracororeal shock wave theray (ESWT) began to be alied to the enthesioathies, such as seudoarthrosis, fractures, ainful heel, tennis elbow, and tendinitis of the shoulder [13-17]. Alication of ESWT treatment for muscle began in the late 1990s [18]. Recently ESWT has been used for the urose of treating MTrPs and there are a number of studies that have been conducted. Ji et al. [19] reorted visual analog scale (VAS) was significantly decreased and ressure ain threshold (PPT) was significantly increased in alying ESWT (energy density of mj/mm 2 ) to the UT TrP grou than the lacebo grou, so that they are suggest ESWT is effective in TrP ain control. In Jeon s study [20], atients with MPS in the traezius muscle were divide into two grous. The exerimental grou received ESWT (4 Hz, 0.10 mj/mm 2, 1,500 ulses) and the control grou received a trigger oint injection and transcutaneous electrical nerve stimulation. Both treatments were effective for ain relief and increased range of motion of the neck. Moghtaderi et al. [21] reorted atients in the exerimental grou with lantar fasciitis received ESWT (0.2 mj/mm 2 ) for the heel region and for the gastroc-soleus trigger oints, while the control grou received ESWT just for the heel region. They found there were significantly better results in treatment with the exerimental grou. Gleitz [22] roosed the technique of ESWT for the UT. Energy level of the focused ESWT was mj/mm 2. ESWT has been reorted in many studies to be effective in the treatment of MTrP s ain. However, there are divided oinions on the effectiveness because ESWT does not have a clear rocedure of the intensity of energy level, frequency, and treatment interval [23,24]. Although several studies have been conducted as above, alied energy density is different. Several articles were comared to the effects of high and low energy ESWT alication [25,26]. Subjects were atients of enthesioathy such as rotator cuff tendinitis Table 1. General characteristics of the subjects Characteristic Age (y) Sex (male:female) Weight (kg) Height (cm) Low energy grou (n=26) (5.65) 17: (10.13) (7.42) Values are resented as mean (SD). High energy grou (n=26) (3.56) 16: (11.67) (21.281) (N=52) and calcific tendinitis. However, there are no study was aimed at MTrP. Therefore, at which energy density is the best treatment intensity for MTrP remains unknown. Thus, we wanted to investigate the effects of high-energy and low-energy ESWT when the TrP treatment is alied to the UT. Methods Subjects This study was aroved by the institutional clinical study review board. For this study we recruited 52 subjects in Jung Hosital, who had ain in their UT. Subject s characteristics are described in Table 1. Inclusion criteria were determined by the following five criteria: (1) Localization of a alable taut band within skeletal muscle. (2) Hyersensitive tender sot within taut bands. (3) Local twitch resonse elicited by a snaing alation of the taut band. (4) Reroduction of a tyical referred ain attern of the MTrP in resonse to comression. (5) Recognition of familiar ain atterns. Exclusion criteria were medication or other theraies for MPS, neurological deficits, history of cervical sinal injury and surgery. The study was aroved by the institutional ethics committee, and articiants signed a written informed consent rior to articiation. Procedures For this study we recruited 52 subjects in Jung Hosital, who had ain in their UT. Subjects were allocated by a matched air randomization design for equivalent distribution according to gender. Thirty-three male subjects and 19 female subjects are divided high energy grou (male:female, 17:9) and low energy grou (male:female, 16:10). To measure the degree of ain was quantified by the PPT and VAS. This study was conducted in three sequences. First, we located a taut band and MTrP. We then marked the location and the PPT and VAS were tested. Second, ESWT was alied on the marked area. The instrument that was used for the ESWT was the Piezowave, hand-held F10G4 (Richard Wolf, Knittlingen, Germany). In order to revent lung injury we alied shock wave from theanterior and osterior ortion of the marked area and lungs are located in vertically under 2-3 cm from UT surfaceused 10 mm deth alication (Figure 1) [22]. The high energy grou received 4 Hz and intensity level 10 (0.351 mj/mm 2 ). Low energy grou received 4 Hz and an intensity level 1 (0.092 mj/mm 2 ). The

3 144 Phys Ther Rehabil Sci 3(2) Figure 2. Comarison of ain ressure threshold. PPT: ain ressure threshold, LE: low energy grou, HE: high energy grou. * <0.05. Figure 1. Extracororeal shock wave theray alication. number of shock wave was alied to anterior and osterior 500 ulses resectively, total 1,000 ulses received (Figure 1). Lastly, the PPT and VAS was measured again after treatment. Outcome measures Pressure ain threshold PPT was measured by Commander Algometer (JTECH Medical, Salt Lake City, UT, USA).The subjects in sitting osition and examiner found taut band and MTrP to alation UT. How to find MTrP was carried out by Simons method [1]. And then mark with aqueous en. Before the test educated to subjects say Sto or Ah when they feel ain or any uncomfortable feeling from the ressure. Located in algometer to reviously marked area and gave ressure constantly 3 N er second. When subject say Sto or Ah remove the ressure and note measured values [27]. Test was measured 3times before and after the treatment, and for 10 seconds intervals between the test. Visual analogue scale Visual analogue scale (VAS) was measured 10 cm scale. VAS is valid tool for ain intensity level [28]. Examiner exlain to subjects, when you feel no ain is 0 and you feel unbearable ain is 10. Asked to subjects check the ain rate in arallel line when using Algometer ressed at a ressure of 50 N. Data analysis Data analysis was using IBM SPSS Statistic version 21.0 for Windows (IBM Co., Armonk, NY, USA). Comarison of PPT before and after each grou using the aired t-test and comarison between grous, using the indeendent t-tests were analyzed. Comarison of the VAS before and after using the aired t-test, comarison between grous, using the indeendent t-tests. The -value was set at 0.05 for all analyses. Results This study is alying the different energy (high or low) of ESWT to the MTrP for the UT muscle and we confirmed the changes in ain level. Pre-PPT was (11.99) for low energy grou, (10.41) for high energy grou. There are no significantly difference between the grous at re-ppt. Post-PPT was (11.90) for low energy grou, (14.58) for high energy grou in which we found a significant difference in each grou (Figure 2), but not a significantly difference between the grous (Table 2).

4 Yang, et al: Effect of different energy density shock waves on the ain 145 Table 2. Comarison of PPT and VAS in the high and low energy extracororeal shock wave PPT Pre Post Change t b VAS Pre Post Change t b High energy grou (n=26) Mean (SD) (10.41) (14.58) 7.09 (11.66) (1.66) 4.35 (1.57) 1.32 (1.01) Value are resented as mean (SD) or mean (SD) [rank]. PPT: ain ressure threshold, VAS: visual analogue scale. a Indeendent t-test. b Paired t-test Low energy grou (n=26) Mean (SD) (11.99) (11.90) 2.78 (6.19) (1.65) 3.98 (1.47) 1.27 (0.99) t a (N=52) Figure 3. Comarison of visual analogue scale. VAS: visual analogue scale. LE: low energy grou, HE: high energy grou. * <0.05. Pre-VAS score was 5.26 (1.65) for low energy grou, 5.67 (1.66) for high energy grou. There was no significant difference between the grous at re-vas test. Post-VAS score was 3.98 (1.47) for low energy grou, 4.35 (1.57) for the high energy grou, in which there was significant difference in each grou (<0.05), but no significant difference between the grous (Figure 3). Discussion In this study, we comared the VAS and PPT before and after theray, finding no significant difference between ost treatment of low energy grou and high energy grou. Pre-ost comarisons show that there was an increase in the PPT and VAS was decreased in the low energy grou and high energy grou. The results indicate that these two grous PPT and VAS were imroved. The statistical results did not show a significant difference between the high and low energy grou. However, the difference between the averages of the PPT, the high energy grou was higher. Therefore, we calculated the mean difference divided by the standard deviation (Cohen s d) to determine the effect size. The effect size is define as small, medium and large effect and the d-value is 0.2, 0.5 and 0.8 resectively [29]. These results are similar to Rome et al. s study [26]. They reorted effect of extracororal shock waves of lowversus high energy density in atients with chronic shoulder ain and calcific tendinitis. There are no significant differences between grou at first treatment and 6 weeks follow u evaluation. However, there was a significant difference after 24 weeks. In our study, immediately evaluate outcome measure after treatment, it seems to that there was no significant difference between the two grous. The low energy and high energy grou s PPT effect size were 0.45 and This insinuates that the low energy grou has a small effect size and the high energy grou has medium effect size, and we can conclude that the high energy grou is more effective. This study is imortant as it is the first designed to randomized controlled, single blinded exeriment, which ESWT was alied to different energy densities on MTrP. In addition, PPT s are objectively evaluated by using an

5 146 Phys Ther Rehabil Sci 3(2) algometer. ESWT imroves blood circulation in caillary blood vessels and reduces the tension and stiffness of muscles along with the reduction in ain by inducing interference of flow of excessive stimulation of nocicetors and stimulation of nerves. In addition, the study carried out by Hausdorf et al. [30,31], states that ESWT reduces ain in the tissues of the musculoskeletal system through selective destruction of non-myelinated fibers and is effective in reducing the level of substance P in the dorsal root ganglia. According to Wang et al. [32], ESWT is known to be effective in the acceleration of erfusion in the ischemic tissues (myocardium and skin fla) and stimulates the generation of new blood vessels. According to Davis et al. [33], it is effective in recovering the areas of ischemic skin fla and increasing the erfusion of tissues through a reduction effect on inflammation. According to De Sanctis et al. 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