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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 1  |  Issue : 1  |  Page : 29-36

Effect of therapeutic ultrasound versus shortwave diathermy combined with suboccipital release and manual drainage techniques for chronic sinusitis: A randomized clinical trial


Department of Orthopaedic Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission10-Nov-2018
Date of Acceptance04-Apr-2019
Date of Web Publication3-Jul-2019

Correspondence Address:
Ms. Sharon Kalekar
Department of Orthopaedic Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijptr.ijptr_12_19

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  Abstract 


Background: The repeated occurrences of sinusitis hinders patients from carrying out their daily life activities efficiently. The successful application of therapeutic ultrasound and shortwave diathermy (SWD) with the addition of suboccipital release and manual techniques could develop a new paradigm in the treatment of chronic sinusitis.
Objectives: The aim of the study was to compare the effect of therapeutic ultrasound versus SWD combined with suboccipital release and manual drainage techniques in chronic sinusitis in terms of pain intensity, tenderness, and quality of life.
Materials and Methods: Forty-six patients with chronic sinusitis were randomly assigned to therapeutic ultrasound and SWD groups consisting of 23 patients each. Both groups received suboccipital release and manual drainage techniques and the outcome measures were assessed at baseline and after five sessions.
Results: Compared with the baseline levels, pain intensity, tenderness, and quality of life significantly reduced in both the study groups (P < 0.05) at the end of five sessions. Further, the ultrasound group showed to be better as compared to SWD group.
Conclusion: Both therapeutic ultrasound and SWD combined with suboccipital release and manual drainage techniques improve pain intensity, tenderness, and quality of life in chronic sinusitis. However, ultrasound therapy showed quicker and better effects as compared to SWD along with suboccipital release and manual drainage techniques.

Keywords: Chronic sinusitis, Manual therapy, Pain pressure threshold, Shortwave diathermy, Therapeutic ultrasound


How to cite this article:
Kalekar S, Gurudut P. Effect of therapeutic ultrasound versus shortwave diathermy combined with suboccipital release and manual drainage techniques for chronic sinusitis: A randomized clinical trial. Indian J Phys Ther Res 2019;1:29-36

How to cite this URL:
Kalekar S, Gurudut P. Effect of therapeutic ultrasound versus shortwave diathermy combined with suboccipital release and manual drainage techniques for chronic sinusitis: A randomized clinical trial. Indian J Phys Ther Res [serial online] 2019 [cited 2019 Aug 21];1:29-36. Available from: http://www.ijptr.org/text.asp?2019/1/1/29/261987




  Introduction Top


Sinusitis is the inflammation or the infection of the mucus lining of any sinuses.[1] The sinuses are a connected system of hollow air-filled cavities located in the skull.[2] Rhinosinusitis is a condition with symptomatic inflammation of the paranasal sinuses with inflammation of the connecting nasal mucosa.[3] The frontal, maxillary, ethmoid, and sphenoid sinuses are the four sinuses located.[4],[5]

In an article by Times of India, it was reported that almost 134 million people in India suffer from sinusitis. It is estimated that sinusitis affection in the adult population is translated into a huge burden of the health-care costs and increases the burden on the economy of health-care facilities. The pain and discomfort endured by these patients make them seek additional adjunct therapy.[6] The peak prevalence rate is noted in between 44 and 64 years old. It affects all socioeconomic backgrounds and races of the society. Sinusitis can affect the quality of life, requiring considerable direct medical expenditures.[7]

Sinusitis is mainly divided into four stages depending on the duration: acute stage which lasts up to 2–4 weeks, subacute stages for 4–8 weeks, chronic stage lasting up to ≥8–12 weeks, and recurrent sinusitis which occurs more than thrice per year.[8]

Acute sinusitis is caused by viral, bacterial, or fungal infections. Chronic sinusitis presents with a history of swelling and sinus inflammation. It can result from repeated and consistent episodes of acute sinusitis or other health conditions such as allergic rhinitis, asthma, or structural abnormalities (e.g., deviated septum or nasal polyps). Sinusitis presents with clinical manifestations such as nasal discharge, facial pain/pressure, severe headache, fever, decreased sense of smell, cough, ear pain, and pressure. Chronic sinusitis is an enhanced immune response to ubiquitous airborne fungi infection.[9] Pathogenesis of sinuses involves narrowing of the sinus ostia, obstruction in the free flow of the air, thereby causing the blockage. Dysfunction of mucociliary apparatus may also lead to the pathogenesis of sinusitis.[10],[11]

Confirmatory diagnosis of sinusitis comprises of patient symptoms, physical examination, nasal endoscopy, questionnaires, laboratory investigations, and imaging techniques such as radiographs and computed tomography scans.[11],[12],[13],[14],[15]

The first line of treatment for sinusitis is mostly medical drugs including antimicrobial drugs, decongestants, nasal sprays, corticosteroids, and antihistamine drugs which can effectively dry the mucus. In extreme troublesome cases of recurrent sinusitis, operative procedures such as functional endoscopic sinus surgery, balloon sinuplasty, insertion of drainage tube, and invasive conventional surgery may be required.[15],[16] Physical therapy also offers a variety of treatment approaches in sinusitis. It includes various electrotherapy modalities, manual drainage techniques, suboccipital release for sinus headache, Kinesio taping, nebulization, stretching the muscles of the neck, dry needling, and rhinoflow therapy.[17] Ultrasound is the most widely used physiotherapeutic agent in the treatment of sinusitis. Shortwave diathermy (SWD) is a deep heating modality used for the treatment of sinusitis. It works on the basic principle of heat production of the body tissues.[18] A study which was done to measure the quality of life and nonattendance in patients with chronic rhinosinusitis concluded that almost 20% of the patients had probable anxiety and depression disorders and remaining reported lack of presence at work due to sinus problems.[6]

In spite of many studies and treatment approaches done on sinusitis, there are limitations faced in evidence where comparisons between two electrotherapy modalities have been done. In addition, there is a paucity in the literature on the evidence of use of manual draining techniques as adjunct to electrotherapy modalities. The basic idea of the study was to control the infection and pathological cycle leading to sinusitis. The objective of the study was to study and compare the effect of therapeutic ultrasound versus SWD combined with suboccipital release and manual drainage techniques in chronic sinusitis in terms of pain intensity, tenderness, and quality of life.


  Materials and Methods Top


The present study was an experimental randomized clinical trial conducted on patients who were referred the outpatient department of physiotherapy from a tertiary care hospital, Belagavi city, between March 2017 and February 2018. The study protocol was approved by the Institutional Ethical Committee (KIPT/SI No. 130/29.05.2017), and written informed consent was obtained from all the patients before their recruitment. In addition, the study was registered under the Clinical Trial Registry - India with registration number CTRI/2018/04/013030. The inclusion criteria were: patients who were clinically diagnosed by ENT surgeon with chronic sinusitis with a history of 3 months or longer, age group from 18 to 50 years, presence of either two or more major symptoms, or one major plus two minor symptoms of sinusitis according to the task force diagnosis [Table 1].[19]
Table 1: Task force diagnosis for sinusitis*

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Patients were excluded from the study presenting with any metal implants (pacemakers, dental implants, or any other implants), individuals with involvement of ≥1 sinus area (frontal or maxillary), and history of any space-occupying lesions or malignancy. Patients with history of low blood pressure and dizziness and suffering from any systemic illness, any history of neurological or cognitive deficits, and pregnancy. Prior consent was taken to include the photographs of the patients [Figure 1].
Figure 1: CONSORT chart

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Visual analog scale

A visual analog scale is an instrument used for measuring the pain intensity or frequency of various symptoms. The patient was asked to mark his/her pain levels according to the severity.[20] This was recorded pre- and post-intervention.

Pressure algometer

It is a clinical tool which is used to identify the pressure and/or force eliciting a pain pressure threshold. The digital pressure algometer was placed perpendicularly on the site to be tested and pressed against the area while increasing the force. The unit at which the patient gets pain was noted. The unit of measurement was in kg/cm 2 [Figure 2] and [Figure 3].[21]
Figure 2: Pressure algometer – frontal sinus

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Figure 3: Pressure algometer – maxillary sinus

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Sino-nasal Outcome Test-22[22]

This is a Quality Of Life Questionnaire specifically designed for sinusitis patient. It consists of 22-item sinus specific question which has to be administered to the patient and the total sum of all the items will be recorded based on the severity of the patient's condition and the scores were calculated.

Procedure

An ethical approval for the study was obtained from the Institutional Ethical Committee. Patients were taken in the study based on the inclusion and exclusion criteria before their enrollment. The outcome measures were obtained from the patient before and after the treatment on day 1 and 5, respectively. Both the groups received the treatment for 5 consecutive days. Patients were assigned to two groups.

Common intervention (suboccipital release and manual drainage techniques)

Both the experimental groups in the study received a common intervention which consisted of suboccipital release and manual drainage techniques for chronic sinusitis. The patients were advised not to take any antibiotic medication till the complete treatment sessions were done unless they found no relief with the treatment or the sinus attack aggravated.

Suboccipital release: The patient was in a supine position with the therapist sitting at the head of the table. The finger pads were placed over the suboccipital muscles bilaterally by the therapist, just inferior to the superior nuchal line down approximately to the level of C2. The patient's head was then lifted by the therapist so as the weight of it is supported upon the pads of the fingers. Traction was then applied with fingers curled into the suboccipital muscles down until your fingers sink into muscle. The amount of traction that is used results in a force to the tissues without producing significant movement of the structures. This position was then held by the therapist until the tissues relax for 1 min.[23]

  1. Manual drainage for the sinuses:


    1. Drainage for frontal sinus [Figure 4]


    2. Hand positioning: The therapist placed his/her thumb over the frontal sinuses so as to apply direct pressure and then drained the sinuses by moving his/her thumbs inferiorly while staying in front of the ears. This was performed seven times.[24]

    3. Drainage for maxillary sinus [Figure 5]


    4. Hand positioning: The therapist places her thumbs over the maxillary sinuses of the patient so as to apply direct pressure and then drained the sinuses by moving her thumbs inferiorly until you are just below the ears. This was performed seven times.[24]
Figure 4: Manual drainage for the frontal sinus

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Figure 5: Manual drainage for the maxillary sinus

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Dosimetry

Total duration of the treatment delivered was of 30 min each session for 5 consecutive days.

Experimental Group A (therapeutic ultrasound therapy)

This group received ultrasound therapy combined with suboccipital release and manual drainage techniques for the sinuses. The patients were instructed to be in supine lying position on the wooden plinth. The therapist was in a standing position at the head end of the patient [Figure 6]. The patients received ultrasound therapy with continuous mode with an intensity of 1 and 0.5 W/cm 2 for maxillary and frontal sinus, respectively, with a frequency of 1MHz. The area of US application was the skin over the cheeks for maxillary sinus and forehead for the frontal sinus. The handheld US applicator was moved in circular motion, using a slow continuous technique for the duration of 5 min over the maxillary sinuses and 4 min over the frontal sinuses on each pair of sinuses.[21] Ultrasound transmission gel was used between the applicator and the skin.
Figure 6: Ultrasound therapy

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Experimental Group B (shortwave diathermy)

The patients in this group received SWD with small disc electrodes on continuous mode with an intensity according to the tolerance of the patient and also to produce only minimal heating of the sinuses. A standard cross-fire method was used to treat the maxillary and frontal sinuses. The patient was instructed to be in supine lying position. For the treatment of all the sinuses, one electrode was placed on the lateral part of the forehead and the other on the opposite side of the face, below the angle of jaw [Figure 7]. After 10 min of treatment, the placement of the electrodes was changed to the opposite sides so as to cause the heating of the sinuses equally.[25] Total duration of the treatment was 30 min/session for 5 consecutive days. Postcompletion of the treatment of five sessions, patients of both groups were reassessed for visual analog scale, sinus questionnaire, and pressure algometer.
Figure 7: Shortwave diathermy

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Statistical analysis

Statistical analysis for the present study was done manually as well as using SPSS version 22.0 IBM (SPSS Sttistics for windows, Armonk, NY: IBM Corp., USA) so as to verify the results obtained. Normality of all quantitative parameterswas checked using Shapiro–Wilk's test, visual inspection of their histograms, normal Q-Q plots, and box plots. Homogeneity of variances was tested by Levene's test for equality of variances. Various statistical measures such as mean, standard deviation, and interquartile range (IQR) were used. Within the current data set, visual analog scale (VAS) and pressure algometer were not normally distributed, hence were compared between the two groups using Mann–Whitney U-test (median IQR). Sino-nasal Outcome Test-22 (SNOT-22) outcome questionnaire followed the normal data distribution within each intervention groups and hence was compared using two-way mixed-ANOVA. Categorical variables were compared between the two groups using Chi-square test or Fisher's exact test. Probability values <0.05 were considered statistically significant.


  Results Top


Forty-six patients were divided into therapeutic ultrasound and SWD groups. [Table 2] presents with data of demographic distribution in two study groups. There was a significant reduction in pain intensity on VAS postintervention (P = 0.001) in both the study groups as compared to pretreatment scores. The between-group difference on median IQR showed ultrasound group to be more effective than SWD group with P < 0.001 [Table 3] and [Table 4]. For the pain pressure threshold, both groups showed significant improvement postintervention (P = 0.001). The between-group comparison of postintervention score for therapeutic ultrasound group was 4 (IQR: 3.50–4) and SWD group was 3 (IQR: 3–3.20) and difference scores resulted in statistically significant values (P < 0.001) indicating a therapeutic ultrasound group showing significant improvement in pain pressure threshold than SWD group [Table 5] and [Table 6].
Table 2: Demographic distribution of parameters in two study groups (n=46)

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Table 3: Comparison of pre- and post-visual analog scale scores within each intervention groups (n=46)#

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Table 4: Comparison of visual analog scale scores between the two intervention groups (n=46)#

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Table 5: Comparison of pre- and post-pressure algometer within each intervention group (n=46)#

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Table 6: Comparison of pressure algometer between the two intervention groups (n=46)#

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The quality of life as assessed by SNOT-22 demonstrated significant difference between pre- and post-interventional scores for both the study groups. The between-group comparison for post-intervention score for both the study groups showed statistically significant difference (P = <0.001). The SNOT-22 noticed a sharper decline from pre to post in the therapeutic ultrasound group as compared SWD group [Table 7], [Table 8], [Table 9].
Table 7: Comparison of change in Sino-nasal Outcome Test-22 questionnaire score within each intervention groups (n=46)#

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Table 8: Comparison of Sino-nasal Outcome Test-22 Questionnaire between the two intervention groups (n=46)#

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Table 9: Summary of two-way mixed-methods ANOVA to assess the interaction between group and time (n=46)

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  Discussion Top


The present randomized clinical trial was done to compare the effect of therapeutic ultrasound therapy versus SWD combined with suboccipital release and manual drainage techniques in patients with chronic sinusitis. The results from the statistical analysis of the present study support that both the experimental groups were beneficial and showed statistically significant improvement in reduction of symptoms and showed to be effective in treating patients with chronic sinusitis. However, the ultrasound therapy group showed a sharper and faster improvement as compared to that in SWD group.

In the present study, the age of the patient ranged from 18 to 50 years with the mean age for the ultrasound therapy group of 23.09 ± 1.88 and for SWD group of 22.65 ± 1.85 years indicating occurrence of chronic sinusitis is predominantly seen during the second decade of life.[26]

In the present study, ultrasound group has a significant reduction in pain posttreatment. Possible reasons for this could be explained as below. It is suggested that the latent amount of heat that is accumulated within the tissues with continuous US may attribute to increase the blood flow in the surrounding regional regions mucosa [27],[28] which have reduced circulation [29] as in cases of chronic sinusitis. Since clearing of the infection is dependent on the blood flow, the authors suggest that healing in the treatment groups may have been facilitated by this increased blood circulation. Thus, ultrasound therapy proved to be more effective for chronic rhinosinusitis. Furthermore, another possible reason for this improvement may be the psychological effect reported for US application.[27] Blockage of sinus ostium occurs due to the mucosal inflammation and then causes retention of secretions that are blocked in the sinus cavities.

Ultrasound therapy causes mechanical vibration of the molecules which might help in the faster drainage and facilitation of the secretions and thus reducing pain.[21],[30],[31] Another study was done by Nakhostin Ansari et al. to study the effect of continuous ultrasound on chronic rhinosinusitis. The results of the trial concluded that continuous ultrasound to be an effective tool in the treatment of chronic rhinosinusitis. The significant effect of ultrasound therapy could also be because of the heating effects of ultrasound. Therapeutic ultrasound when applied to tissues converts into heat, thereby causing molecular vibration which increases the blood supply and helps in reduction of the symptoms experienced in sinusitis.[21]

The findings also suggest that the SWD group showed significant improvement in the present study. A similar study was done to find the effect of SWD by Shinde and Jayawant on efficacy of SWD in patients with sinusitis. The study groups were only SWD, SWD combined with medicinal treatment and only medical treatment. It was derived from the study that the effect of SWD or medicines alone almost had the same effects of symptomatic relief, but when used in combination, it was better.[32] The heat production and phagocytosis could have possibly helped in the reduction of the symptoms in SWD group.

A sharper and a faster decline in the symptoms were noted better in the therapeutic ultrasound group as compared to the shortwave therapy group. A possible reason for this could be the continuous contact of the ultrasound probe with the sinuses as compared to the positioning of the SWD disc electrodes which were maintained at a fix distance. This continuous friction caused by the ultrasound head must have resulted in significant friction, thereby aiding to increased heat production leading to thermal effects and thus causing a reduction in the symptoms at a quicker and faster rate. The superiority of ultrasound therapy is advisable and is a better treatment approach since SWD is now an obsolete modality and is rarely used.

The suboccipital release as mentioned in the studies reduces the overactivity of the neck muscles which is caused in chronic sinusitis, thus reducing the pain and also affects the functional outcome. When healthy, fascia is a flexible, pliable, and strong tissue, it helps in reducing the overactivity of the neck muscles. Studies suggest that overactivity of the neck muscles also can be a cause in aggravating headache in the patients. A literature review study was done to find the effectiveness of physical therapy techniques in patients with tension-type headache. The findings from these studies provide evidence that physiotherapy manual therapy techniques such as cervical muscle stretching, massage, and suboccipital release are effective in the treatment of tension-type headaches.[33]

The addition of the manual drainage techniques helped in easy removal and aiding the drainage of these sinuses into the lymphatic system postthermal production as it would have loosed the sinuses which were filled blocked pus-filled cavities. This removal of waste metabolites helped in reducing the pain intensity, facial pressure, and the tenderness over the sinuses, thereby additionally improving the symptoms and quality of life in patients suffering from chronic duration sinusitis. The limitation of the study was that long-term effects were not assessed and it was a single-center trial. Treatment of maxillary and frontal sinuses was done together and was not assessed separately. The future scope could be that a study can be done with a larger sample size and control group. Newer physiotherapy treatment approaches such as dry needling, taping, and rhinoflow therapy can be used to compare in the treatment of chronic sinusitis. Further studies can be carried out using these techniques in combination with placebo ultrasound and low-intensity laser therapy.


  Conclusion Top


The study concluded that only five sessions of both therapeutic ultrasound and SWD when combined with suboccipital release and manual drainage techniques interventions resulted in significant improvement in patients with chronic sinusitis. However, therapeutic ultrasound therapy group showed faster and quick reductions of symptoms as compared to the SWD group. Thus, the study suggests that ultrasound therapy should be implemented as treatment protocols for the treatment of individuals with chronic sinusitis patients. The clinical implication of the study states that successful application of therapeutic ultrasound and SWD with the addition of manual techniques has developed a new paradigm in the treatment of chronic sinusitis, thus helping in the reduction of antibiotic resistance and improving the medical management with a subsequent reduction in requirement of surgical intervention.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We are grateful to all the participants for providing time for the study. A heartfelt gratitude to the Management of the Institute of Physiotherapy, Belagavi, for providing infrastructure and facilities to carry out the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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