Rheumatol Int (2011) 31:1203–1208
DOI 10.1007/s00296-010-1419-0
ORIGINAL ARTICLE
Comparison the efficacy of phonophoresis and ultrasound therapy
in myofascial pain syndrome
Saime Ay • Şebnem Koldaş Doğan •
Deniz Evcik • Özgün Çakmak Başer
Received: 24 May 2009 / Accepted: 10 March 2010 / Published online: 31 March 2010
Ó Springer-Verlag 2010
Abstract The aim of this study is to compare the effect of
phonophoresis, ultrasound and placebo ultrasound thera-
pies in the treatment of myofascial pain syndrome (MPS).
This is a randomized, double-blind placebo controlled
study. Sixty patients (48 women, 12 men, mean age
37.9 ± 12.2 years) with MPS were included in this study.
Patients were allocated into three groups. Group 1(n = 20)
was received diclofenac phonophoresis, group 2(n = 20)
was received ultrasound and group 3(n = 20) was received
placebo ultrasound therapies over trigger points, 10 min a
day for 15 session during 3 weeks (1 MHz-1,5 watt/cm2).
Additionally, all patients were given neck exercise program
including isotonic, isometric and stretching. Patients were
assessed by means of pain, range of motion (ROM) of
neck, number of trigger points (NTP), algometric mea-
surement and disability. Pain severity was measured by
visual analog scale (VAS) and Likert scale. The neck pain
disability index (NPDI) was used for assessing disability.
Measurements were taken before and after treatment. After
treatment, there were statistically significant improvements
in pain severity, NTP, pressure pain threshold (PPT), ROM
and NPDI scores both in phonophoresis and in ultrasound
therapy groups (P \ 0.05). Statistically significant increase
in cervical lateral flexion and rotation was observed in the
placebo US group. While there was no statistically sig-
nificant improvement in the cervical flexion–extension
joint movement, pain levels, number of trigger points and
S. Ay
Ş. K. Doğan
D. Evcik
Ö. Ç. Başer
Department of Physical Medicine and Rehabilitation, Ufuk
University School of Medicine, Ankara, Turkey
S. Ay (&)
Tıp Fakültesi Dr. Rıdvan Ege Hastanesi, Ufuk Üniversitesi,
06520 Balgat, Ankara, Turkey
e-mail: saimeay@yahoo.com
NPDI score, pressure pain threshold (P [ 0.05), also there
were no significant differences in all parameters between
group 1 and 2 (P = 0.05). Both diclofenac phonophoresis
and ultrasound therapy were effective in the treatment of
patients with MPS. Phonophoresis was not found to be
superior over ultrasound therapy.
Keywords Myofascial pain syndrome
Phonophoresis

Ultrasound
Introduction
Myofascial Pain Syndrome (MPS) is a well-known painful
condition of musculoskeletal system, which is character-
ized by myofascial trigger points and taut bands. Sensi-
tivity in the muscles, local spasm, stiffness, limitations of
related joints are mostly associated with MPS [1, 2]. It is
one of the most important reasons of disability in the
musculoskeletal system problems as it is seen in %37 in
men and %65 in women before the ages of 30–60 [1, 3].
The etiology of MPS is still unknown; therefore, the
treatment approach is much more symptomatic. The goals
of the therapy are the inactivation of the trigger
points, release of the taut bands and pain relief [4].
Patients’ education and training programs, nonsteroidal
anti-inflammatory drugs (NSAID), local injections, phys-
iotherapy programs including heat applications, electro-
therapy and exercise are the most common treatment
methods [1, 5].
Ultrasound (US) treatment is one of the most important
physical treatment modalities in MPS treatment which is
used for heating the deep tissues. It is a noninvasive
method which consists of piezoelectric crystals that convert
the electrical energy to mechanical oscillation energy using
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high-frequency alternative current [6, 7]. US increases
local metabolism, circulation, regeneration and extensibil-
ity of connective tissue with its assuming thermal and
mechanical effects. However, results in the studies related
to its efficacy in the musculoskeletal system problems are
conflicting [7–9].
Phonophoresis (PH) is the process of increasing skin
absorption and penetration of the topical medications to the
deep tissues using US. Topically applied drugs therapeutic
effects depend on different factors such as rate, amount,
drug penetration dept of the skin and the potential drug
toxicological hazards on the tissues. Local anesthetics,
counterirritants (substances such as menthol that cause
inflammation of the skin for purposes of relieving pain
from stimulation rather than depression of cutaneous sen-
sory receptors) and anti-inflammatory drugs (steroidal and
nonsteroidal medications) are used in PH. PH is a nonin-
vasive, painless method that has less side effects and well
tolerated and has been used in musculoskeletal and der-
matologic disorders in several years. Despite extensive
clinical trials of PH, questions remain regarding treatment
validity and effectiveness [6, 10]. However, no study was
found in literature about its effectiveness in the MPS
treatment.
In this double-blinded, randomized placebo controlled
study, we aimed to compare the efficacy of PH with dic-
lofenac gel, conventional US and placebo US methods on
pain, range of motion and disability in patients with MPS.
Patients and methods
Sixty patients (48 women, 12 men) diagnosed as MPS were
included the study. The diagnosis of MPS was based on the
criteria described by Travell and Simons (5 major and
minimum 1 minor criteria are required for clinical diag-
nosis) [11]. Major criteria included pain, palpable taut
bands, reflected of pain from trigger point, hypersensitivity
on taut bands and decrease in range of motion. Minor
criteria are pain with palpation of trigger point and/or
occurrence of sensory change, local twitch response of taut
bands with palpation and injection and decrease in pain
with injection of trigger point or stretching of muscle.
The patients’ inclusion criteria in the study were pres-
ence of at least one active trigger point located in the upper
trapezius muscle, age between 20 and 73 years, symptom
durations for 1 month. The place of the trigger point was
found by the experienced physiatrist by palpation. After
physical examination, full blood count, erythrocyte sedi-
mentation rate (ESR) and biochemical markers were
evaluated. Patients having fibromyalgia, discal hernia,
radiculopathy, myelopathy, trigger point injection, physical
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Rheumatol Int (2011) 31:1203–1208
treatment program during the last 6 months, neck or back
surgery, trauma history and pregnancy were excluded [12].
Study design
This study was prospective, randomized, placebo-con-
trolled double-blind trial. Before treatment, all participants
were informed of the study and signed written informed
consent. The study was approved by the University of Ufuk
Human Research Ethics Committee.
Randomization
Patients were randomly assigned into three groups. Ran-
domization was allocated by numbered envelopes method.
Before the therapy, a physician evaluated the patient. Post-
treatment outcomes were assessed by another physician.
Both of the physicians and patients were blinded to the
treatments. Only the physiotherapist who applied the
therapy was aware of the procedure.
Group 1 (n = 20, 17 women and 3 men) was the pho-
nophoresis group. Ultrasound device (Chattanooga, Intelect
Advanced, USA) was used. Initially, diclofenac gel (Vol-
taren emulgel) was applied circularly with a thickness of 2–
3 mm. Then ultrasound with a 5-cm-diameter applicator
was applied with 1 MHz frequency and 1.5 Wt/cm2 power
over the two trigger points on trapezius muscle, for 10 min.
Group 2 (n = 20, 15 women and five men) was the
conventional ultrasound group. The same ultrasound
device was used using ultrasound gel, which does not have
any pharmacologic drug ingredient. It was applied over the
same trigger point for 10-min duration.
Group 3 (n = 20, 16 women and four men) accepted as
placebo group. The ultrasound probe was held over the two
trigger points on the trapezius using ultrasound gel which
was the same as in group 2. Ultrasound device seemed to
be working for 10-min period with light-off position.
A total of 15 therapies were applied once a day, five
times a week for 3 weeks. Patients were treated by the
same physiotherapist. Additionally, all patients were
received home-based exercise program including isomet-
ric-isotonic neck exercises and back extensor stretching
exercises.
Patients were not allowed taking analgesic or NSAID
during the follow-up period.
Clinical outcomes
Patients were evaluated according to pain, number of
trigger points, pressure pain threshold, cervical joint range
of motion (ROM) and disability. Assessments were done
before and after the therapy by different physicians.
Rheumatol Int (2011) 31:1203–1208
Pain
Pain was assessed by the visual analog scale (VAS, 0–
10 cm; o means no pain, 10 means severe pain) and Likert
pain scale (5 points; 0: no pain, 1: light pain, 2: medium, 3:
severe, 4: intolerable pain).
Number of trigger points
Trigger points were evaluated with palpation by an expe-
rienced physician. The diagnostic criteria for trigger point
were palpable taut band located on the trapezius muscles,
tenderness within taut bands, jump sign and switch
response. A diffuse achy localized discomfort with pro-
longed pressure was accepted as a diagnostic criteria also
[11].
Pressure pain threshold
It is evaluated using Algometer (Algometer Commander,
JTECH Medical, Utah). Algometer was placed over the
trigger point. The measurement was taken three times with
30-s pauses, and the mean average value was recorded in
Newton (N).
Cervical joint range of motion
The active range of motion of cervical joint (flexion,
extension, right–left flexion and right–left rotation) was
measured using a goniometer while the patients were
sitting.
Disability
Neck pain disability scale (NPDS) was used to measure the
disability. The NPDS is a self-administered questionnaire
consisting of 20 items. The items measure the intensity of
pain; its interference with vocational, recreational, social
and functional aspects of living; and the presence and
extent of associated emotional factors. The answers of the
items are responded using a 10-cm VAS. It is divided into
six divisions in equal intervals by vertical lines and signed
with the numbers 0–5. Each item score ranges from 0 to 5,
the total score ranges from 0 to 100, and higher values
represent greater pain and disability [13].
Table 1 Demographic features of patients (Mean ± standard deviation)
Group 1 (n = 20)
Age (years) 37.90 ± 12.29
Gender (female/male) 17/3
Duration of pain (month) 33.07 ± 40.58
1205
Statistical analysis
The results of statistical analysis were expressed as
mean ± SD (Standard deviations). The Friedman test was
used to calculate the differences between the pretreatment
and post-treatment values. To compare the differences
between the groups, Kruskal–Wallis test was used. A level
of significance of P \ 0.05 was accepted for this study. All
analysis was performed using the SPSS 16.0 for Windows.
Results
All patients were completed the study, and no side effects
had been observed. No statistical difference was observed
regarding the demographic data of the patients (Table 1).
Routine biochemical analyses, complete blood count, ESR
and CRP levels of the groups were within normal limits.
There was no significant difference between three
groups according to pain, NTP, PPT and cervical ROM
before treatment (P [ 0.05).
Pain
At the end of the therapy, statistically significant
improvements in group 1 and group 2 regarding VAS and
Likert pain severity (P = 0.000) were observed (Tables 2,
3). However, there was no improvement in group 3
(P = 0.180, P = 0.564) (Table 4). After the therapy, no
difference was observed between group 1 and 2
(P = 0.989, P = 0.084) (Table 5).
Number of trigger points
There was statistically significant decrease in NTP both in
group 1 and 2 (P = 0.000); but no improvement was found
in group 3 (P = 1.000) (Tables 2, 3, and 4). After the
treatment, no difference was observed in group 1 and 2
(P = 0.142) (Table 5).
Pressure pain threshold
PPT was increased significantly in group 1 and 2
(P = 0.000, P = 0.007) but worsened in group 3
(P = 0.000) (Table 2, 3 and 4). After the therapy, no
Group 2 (n = 20) Group 3 (n = 20)
48.80 ± 10.94 49.45 ± 13.61
15/5 16/4
28.20 ± 34.48 38.50 ± 41.21
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Table 2 Evaluation parameters

Pretreatment (mean ± SD) Post-treatment (mean ± SD) P
before and after the treatment in
Group 1 VAS 6.5 ± 1.96 4.25 ± 1.48 0.000
Likert 2.45 ± 0.68 1.40 ± 0.59 0.000
Trigger points 2.10 ± 0.55 1.25 ± 0.63 0.000
Pressure pain threshold 7.19 ± 2.31 7.59 ± 2.24 0.000
Flexion–Extension 61.50 ± 4.89 65.75 ± 4.12 0.000
Right lateral flexion 33.50 ± 4.32 40.75 ± 2.44 0.000
Left lateral flexion 34 ± 5.02 40 ± 3.24 0.000
Right rotation 75.50 ± 6.86 83.55 ± 5.87 0.000
SD standard deviation, VAS Left rotation 76.50 ± 6.90 84 ± 5.02 0.000
visual analog scale, NPDS neck Total NPDS 59.05 ± 18.41 84 ± 40.50 0.000
pain disability scale

Table 3 Evaluation parameters

Pretreatment (mean ± SD) Post-treatment (mean ± SD) P
before and after the treatment in
Group 2 VAS 7.40 ± 1.81 4.45 ± 1.09 0.000
Likert 2.75 ± 0.63 1.75 ± 0.44 0.000
Trigger points 1.95 ± 0.60 0.95 ± 0.82 0.000
Pressure pain threshold 7.46 ± 2.72 8.01 ± 1.59 0.007
Flexion–extension 60.50 ± 15.38 66.50 ± 4.89 0.014
Right lateral flexion 34 ± 5.26 40 ± 3.24 0.003
Left lateral flexion 36 ± 5.75 40.50 ± 4.26 0.001
Right rotation 80.50 ± 7.41 85.50 ± 6.66 0.000
SD standard deviation, VAS
Left rotation 80.50 ± 7.41 85.50 ± 6.66 0.001
visual analog scale, NPDS neck
pain disability scale Total NPDS 59.80 ± 17.59 38.90 ± 14.83 0.000

Table 4 Evaluation parameters

Pretreatment (mean ± SD) Post-treatment (mean ± SD) P
before and after the treatment in
Group 3 VAS 6.09 ± 1.48 7 ± 1.41 0.180
Likert 2.45 ± 0.68 2.30 ± 0.65 0.564
Trigger points 1.90 ± 0.71 1.90 ± 0.71 1.000
Pressure pain threshold 7.26 ± 2.25 5.93 ± 2.13 0.000
Flexion–extension 63.50 ± 4.89 64.75 ± 4.99 0.083
Right lateral flexion 33.50 ± 4.89 40 ± 4.29 0.000
Left lateral flexion 35.75 ± 6.12 39 ± 5.28 0.005
Right rotation 74 ± 9.94 76 ± 9.40 0.046
SD standard deviation, VAS Left rotation 73 ± 9.23 75.75 ± 9.07 0.025
visual analog scale, NPDS neck Total NPDS 25.15 ± 9.81 25.10 ± 9.72 0.317
pain disability scale

difference was found between group 1 and 2 (P = 0.655) Disability

(Table 5).
Cervical range of motion
Cervical ROM was increased significantly in group 1 and 2
(P \ 0.05). In group 3, there were detected significant
increases in cervical lateral flexion and rotation (P \ 0.05)
but no improvements in cervical flexion–extension
(P = 0.083) (Tables 2, 3 and 4). There was no difference
between group 1 and 2 in cervical ROM after therapy
(P [ 0.05) (Table 5).
After therapy, there was a decrease in the NPDI scores in
group 1 and group 2 (P = 0.000); however, no improve-
ment was observed in group 3 (P = 0.317) (Table 2, 3 and
4). Although no difference was detected in group 1 and 2
after therapy (P = 0.946) (Table 5).
Discussion
MPS is a significant disability reason for the patient with
chronic pain [5]. The main issue in the MPS treatment is to

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Table 5 Evaluation among the groups after the treatment

Group 1 Group 2 P* Group 3 P**

VAS 4.25 ± 1.48 4.45 ± 1.09 0.989 7 ± 1.41 0.000

Likert 1.40 ± 0.59 1.75 ± 0.44 0.084 2.30 ± 0.65 0.000
Trigger points 1.25 ± 0.63 0.95 ± 0.82 0.142 1.90 ± 0.71 0.001
Pressure-pain threshold 7.59 ± 2.24 8.01 ± 1.59 0.655 5.93 ± 2.13 0.043
Flexion–extension 65.75 ± 4.12 66.50 ± 4.89 0.426 64.75 ± 4.99 0.137
Right lateral flexion 40.75 ± 2.44 40 ± 3.24 0.532 40 ± 4.29 0.461
Left lateral flexion 40 ± 3.24 40.50 ± 4.26 0.394 39 ± 5.28 0.713
Right rotation 83.55 ± 5.87 85.50 ± 6.66 0.497 76 ± 9.40 0.001
Left rotation 84 ± 5.02 85.50 ± 6.66 0.209 75.75 ± 9.07 0.002
Total NPDS 84 ± 40.50 38.90 ± 14.83 0.946 25.10 ± 9.72 0.003
VAS visual analog scale, NPDS neck pain disability scale
* Differences between two groups, ** Differences between three groups

provide pain relief on trigger points. The major treatment
methods are patient training, elimination of trigger factors,
medical treatment, superficial, deep heat applications,
electrotherapy, stretching and spray technique, acupunc-
ture, local injections, massage and exercise [5, 10, 14].
US is one of the physical treatment agents which is a
deep heating agent used for heating the musculoskeletal
system tissues with high protein content like tendon,
muscle and joint. It has thermal and nonthermal effects like
increasing blood flow, tissue metabolism, elasticity of the
connective tissue, acceleration of the damaged tissue
healing. PH is the penetration of the topical medicines
transdermale to the subcutaneous tissues via US. The
mechanism of PH is increasing the cell permeability via
thermal effects of the US and inducing transdermal
migration by doing local vasodilatation [10, 15–17]. In the
evaluation, PH is used in physiotherapy in proportion of
%30 and %75 of the studies reviewed reported some of
effectiveness of US on local subcutaneous drug diffusion in
some areas of the musculoskeletal system [3, 10]
This study was planned as a randomized double-blind
placebo controlled study in which efficacy of PH on the
trigger point by diclofenac gel, US and placebo US
methods in pain, NTP, PPT, ROM of cervical joint and
disability in MPS treatment. There are limited number of
randomized controlled studies in literature in which the
efficacy of US and PH was compared. However, there is no
study in which the effectiveness of two methods was
compared on the basis of MPS treatment. Kozanoğlu et al.
compared the effectiveness of %5 ibuprofen PH and US
treatment in a randomized controlled study with 60 patients
with knee OA; they observed significant improvement in
pain severity, ROM, WOMAC scores and 20-m walking
test in both groups but they reported that both methods
doesn’t have an advantage than other [14]. In the treatment
of tendinit, epicondilit and tenosynovitis using % 0.05
fluocinonide, PH had no superiority over US treatment
[18]. In our study, although significant improvements were
observed in pain, ROM, disability compared to the placebo
group, no significant difference was observed between the
PH and US groups.
Fellinger and Schmid used steroid PH and found to have
beneficial effects on hand osteoarthritis by showing the
transition of hydrocortisone through the avascular mem-
branes [10]. In the randomized double-blind study in 20
patients with temporomandibular joint pain, the efficiency of
PH using %1 indometacin was compared with placebo and
significant decrease in pain was observed [19]. A double-
blind study reported 68% decrease in pain and 25%
improvement in ROM in patients with knee osteoarthritis
and periarticular arthritis with hydrocortisone PH [10].
The effects of US and PH treatment on pain are gener-
ally explained with peripheral mechanisms. In an in vivo
experiment on rat, Hseih et al. [20] demonstrated an
increase in inducible nitric oxide synthase expression in the
spinal cord following the stimulus of peripheral inflam-
mation in PH and US groups compared to placebo group.
This study emphasizes the positive effects of US pain relief
due to its efficiency on central neuronal pathways.
Studies mentioned that heating, moisturizing and shav-
ing the skin enhance transdermal drug delivery [10]. Some
authors suggested that improved results of the PH were due
to hot-pack application before PH therapy [14]. In our
study, no hot-pack was applied before treatment, and no
difference was observed between the efficiency of PH and
US groups.
Studies mostly focused on US treatment and combined
with stretching exercises, it was reported to be effective
similar to trigger point injection of %1 lidocaine [21]. Also
US found to be more effective on pain relief related to
musculoskeletal system compared to placebo US [9].
Additionally, it was found to have beneficial effects in PPT

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in patients with MPS [3]. Similarly in our study, significant
decrease in pain, increase in PPT and decrease in NTP in
both US and PH groups combined with exercise program.
This improvement may be explained the positive effects of
US in increasing collagen elasticity and blood flow via
vasodilatation of blood vessels with thermal effects which
cause decrease pain and muscle spasm.
In studies, the effectiveness of US in pain was evaluated
but effect of pain improvement on disability was not
investigated. In our study, both of them evaluated and
significant improvement was observed in pain and dis-
ability in PH and US groups.
Limitation of joints can be seen due to muscle spasm in
MPS. Therefore, exercise is important in the treatment of
MPS. Stretching and rezistif exercises after inactivation of
trigger points lengthen the inactivation duration of trigger
points and prevent the formation of new trigger points [1,
8, 22]. In our study, home exercise program was applied in
all three groups, and decrease in the NTP and improvement
of cervical ROM were observed in PH and US groups.
Improvement only in cervical ROM in placebo US group
shows us that exercise is effective.
The frequency and intensity of US device, content,
volume, molecular structure of material that applied, age,
thickness, hydration, lipid structure of the skin of the
patients, vascular network of dermis affect the efficacy of
PH [6, 10]. The conflicting results in studies could be
influenced by these reasons. Therefore, standard treatment
protocol should be composed for PH applications.
In conclusion, PH and US therapies are effective in the
treatment of patients with MPS but methods doesn’t have
an advantage than other. PH can be used as an alternative
therapy method in the treatment of patients with MPS.
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