A Comparison of the Efficacy of Diclofenac Phonophoresis and Ultrasound Therapy in Upper Trapezius Myofascial Pain Syndrome: A Double-Blinded Randomized Controlled Trial


  • Threenuch Amornpinyokiat medical service office


phonophoresis, ultrasound diathermy, myofascial pain syndrome, trapezius muscle, diclofenac gel


Objectives: To compare the pain numeric rating scale (NRS) and active cervical lateral flexion between diclofenac phonophoresis (DPP) and a conventional ultrasound therapy (UST) in treating myofascial pain syndrome (MPS).

Study design: A double-blinded randomized controlled trial.

Setting: Department of Physical Medicine and Rehabilitation, Taksin Hospital, Thailand.

Subjects: Fifty-two participants (41 females, 11 males, mean age 42 years, mean MPS duration 2 months) with myofascial pain syndrome at the upper trapezius muscle

Methods: Participants were allocated by block randomization into 2 groups, the UST Group (n = 26) treated with a conventional UST using a 1-MHz applicator, a standard coupling agent, stroke technique, continuous mode, intensity of 1 watt/cm2 for 10 minutes, and the DPP Group (n = 26) treated with the same UST technique but using a mixture of 4 grams of diclofenac gel and a standard coupling agent in a ratio of 1:4 instead of the standard coupling agent. Each participant was treated 3 times per week for 3 weeks for a total of 9 treatments. All participants rated their pain on a numeric rating scale (NRS). Active cervical lateral flexion was measured by an assessor prior to the initial treatment and following the final treatment. All participants and the assessor were blinded to the treatments received.

Results: Before the treatments, there was no statistically significance in NRS (p = 1.00) or active cervical lateral flexion (p = 0.75) between the two groups. After the treatments, NRS of the DPP group was significantly lower than the UST group (p = 0.03). However, active cervical lateral flexion was not significantly different between the groups (p = 0.29). Group analysis found that NRS was significantly reduced, by 2.58 in the UST group (p = 0.00) and by 3.46 in the DPP group (p = 0.00). Active cervical lateral flexion motion was significantly increased in the DPP group (p = 0.02) but not in UST group (p = 0.08) after the 3-week therapy.

Conclusions: Diclofenac phonophoresis can reduce pain in myofascial pain syndrome at upper trapezius muscle better than conventional ultrasound therapy.

Keywords: phonophoresis, ultrasound diathermy, myofascial pain syndrome, trapezius muscle, diclofenac gel


Lavelle ED, Lavelle W, Smith HS. Myofascial trigger points. Anesthesiol Clin. 2007;25:841-51, vii-iii.

Srbely JZ. New trends in the treatment and management of myofascial pain syndrome. Curr Pain Headache Rep. 2010;14:346-52.

Barbero M, Schneebeli A, Koetsier E, Maino P. Myofascial pain syndrome and trigger points: evaluation and treatment in patients with musculoskeletal pain. Curr Opin Support Palliat Care. 2019; 13:270-6.

Desai MJ, Saini V, Saini S. Myofascial pain syndrome: a treatment review. Pain Ther. 2013;2:21-36.

Hsieh LF, Hong CZ, Chern SH, Chen CC. Efficacy and side effects of diclofenac patch in treatment of patients with myofascial pain syndrome of the upper trapezius. J Pain Symptom Manage. 2010;39:116-25.

Ay S, Dogan SK, Evcik D, Baser OC. Comparison the efficacy of phonophoresis and ultrasound therapy in myofascial pain syndrome. Rheumatol Int. 2011;31:1203-8.

Derry S, Moore RA, Gaskell H, McIntyre M, Wiffen PJ. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database Syst Rev. 2015(6):CD007402.

Majlesi J, Unalan 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;85:833-6.

Srbely JZ, Dickey JP. Randomized controlled study of the antinociceptive effect of ultrasound on trigger point sensitivity: novel applications in myofascial therapy? Clin Rehabil. 2007;21:411-7.

Yildiz N, Atalay NS, Gungen GO, Sanal E, Akkaya N, Topuz O. Comparison of ultrasound and ketoprofen phonophoresis in the treatment of carpal tunnel syndrome. J Back Musculoskelet Rehabil. 2011;24:39-47.

Sarrafzadeh J, Ahmadi A, Yassin M. The effects of pressure release, phonophoresis of hydrocortisone, and ultrasound on upper trapezius latent myofascial trigger point. Arch Phys Med Rehabil. 2012;93:72-7.

Ustun N, Arslan F, Mansuroglu A, Inanoglu D, Yagiz AE, Guler H, et al. Efficacy of EMLA cream phonophoresis comparison with ultrasound therapy on myofascial pain syndrome of the trapezius: a single-blind, randomized clinical study. Rheumatol Int. 2014;34:453-7.

Luksurapan W, Boonhong J. Effects of phonophoresis of piroxicam and ultrasound on symptomatic knee osteoarthritis. Arch Phys Med Rehabil. 2013;94:250-5.

Kavadar G, Caglar N, Ozen S, Tutun S, Demircioglu D. Efficacy of conventional ultrasound therapy on myofascial pain syndrome: a placebo controlled study. Agri. 2015;27:190-6.

Ilter L, Dilek B, Batmaz I, Ulu MA, Sariyildiz MA, Nas K, et al. Efficacy of pulsed and continuous therapeutic ultrasound in myofascial pain syndrome: a randomized controlled study. Am J Phys Med Rehabil. 2015;94:547-54.

Xia P, Wang X, Lin Q, Cheng K, Li X. Effectiveness of ultrasound therapy for myofascial pain syndrome: a systematic review and meta-analysis. J Pain Res. 2017;10:545-55.

Takla MKN, Rezk-Allah SS. Immediate Effects of simultaneous application of transcutaneous electrical nerve stimulation and ultrasound phonophoresis on active myofascial trigger points: a randomized controlled trial. Am J Phys Med Rehabil. 2018;97:332-8.

Yildirim MA, Ones K, Goksenoglu G. Effectiveness of ultrasound therapy on myofascial pain syndrome of the upper trapezius: randomized, single-blind, placebo-controlled study. Arch Rheumatol. 2018;33:418-23.

Altan L, Kasapoglu Aksoy M, Kosegil Ozturk E. Efficacy of diclofenac & thiocolchioside gel phonophoresis comparison with ultrasound therapy on acute low back pain; a prospective, double-blind, rando-mized clinical study. Ultrasonics. 2019;91:201-5.

Gam AN, Warming S, Larsen LH, Jensen B, Hoydalsmo O, Allon I, et al. Treatment of myofascial trigger-points with ultrasound combined with massage and exercise--a randomised controlled trial. Pain. 1998;77:73-9.

Durmus D, Alayli G, Goktepe AS, Taskaynatan MA, Bilgici A, Kuru O. Is phonophoresis effective in the treatment of chronic low back pain? A single-blind randomized controlled trial. Rheumatol Int. 2013;33:1737-44.

Boyaci A, Tutoglu A, Boyaci N, Aridici R, Koca I. Comparison of the efficacy of ketoprofen phonophoresis, ultrasound, and short-wave diathermy in knee osteoarthritis. Rheumatol Int. 2013;33:2811-8.

Robertson VJ, Baker KG. A review of therapeutic ultrasound: effectiveness studies. Phys Ther. 2001;81:1339-50.