World Applied Sciences Journal 33 (12): 1793-1797, 2015

ISSN 1818-4952
© IDOSI Publications, 2015
DOI: 10.5829/idosi.wasj.2015.33.12.96262

Low Frequency Ultrasound Cavitation Versus Phosphatidylcholine

Injection on Fat Adiposity in Women with Gynoid Obesity
1
Maha Samir Younis, 2Hala M. EzzEldeen and 2Mariam E. Mohamed and 3Mohamed Aboulghate

1
Department of Physical Therapy, Institute Of Health Insurance, Cairo, Egypt
2
Department of Physical Therapy for Cardiopulmonary Disorders and Geriatrics,
Faculty of Physical Therapy, Cairo University, Egypt
3
Department of Anesthesiology, Faculty of Medicine, Cairo University, Egypt

Abstract: Overweight and obesity is a world epidemic problem, many therapeutic approaches are used to
overcome the problem of overweight and localized obesity. Low frequency ultrasound cavitation and
mesotherapy injection were recommended as non-invasive way to get rid of localized adiposity. The aim of the
current study was to compare between the effect of low frequency ultrasound cavitation versus
phosphatidylcholine injection on fat adiposity in females with gynoid obesity.Forty overweight females with
age ranged from 30-40 years and their body mass indices ranged between 25-30kg/m2were included in the study.
The subjects were divided into two equal groups: group I received low frequency ultrasound cavitation twice
weekly and group received phosphatidylcholine injection every two weeks and both groups received
treatment for 4 months. The mean values of waist/hip ratio, fat percentage and skin fold thickness were
significantly changed from 0.71± 0.03, 30.7 ± 1.88 and 35.4 ± 1.26 to 0.77 ± 0.004, 25.6 ± 1.89 and 26.1 ± 2.02
respectively, in group I and from 0.69 ± 0.004, 32 ± 3.36 and 36 ± 0.81 to 0.73 ± 0.009, 27.1 ± 1.66 and 31.1 ± 1.66
respectively, in group II.Also, there was a significant difference between the two groups after treatment on
waist/hip ratio and skin fold thickness variables. It is suggested that low frequency ultrasound cavitation is
more effective and safe to decrease fat adiposity than phosphatidylcholine injection in females with gynoid
obesity.

Key words: Low frequency ultrasound cavitation Phosphatidylcholine Gynoid obesity

INTRODUCTION A large number of physical and mental conditions

have been associated with obesity. Health consequences
Overweight and obesity are a result of energy can be categorized by the effects of increased fat mass
imbalance over a long period of time. The cause of energy (osteoarthritis, obstructive sleep apnea, social
imbalance for each individual may be due to a stigmatization) or by the increased number of fat cells
combination of several factors. Individual behaviors, (diabetes, cancer, cardiovascular disease, non-alcoholic
environmental factors and genetics, all contribute to the fatty liver disease). Increases in body fat alter the body's
complexity of the obesity epidemic. Recent studies have response to insulin, potentially leading to insulin
shown that overweight and obesity affect over half the resistance. Increased fat also creates a pro-inflammatory
adult population in many countries.In many countries, state, increasing the risk of thrombosis [4].
overweight and obesity have reached epidemic levels and Fat distribution refers to pattern of body fat located
obesity is now well recognized as a disease in its own in different regions of the body both central and truncal
right [1]. The prevalence of obesity is increasing globally locations. Persons with central (abdominal) fat are
and also in undeveloped countries as Egypt due to the commonly referred to as “apple shaped” or android (male)
westernization of lifestyles [2,3]. and those with truncal (gluteofemoral) or peripheral fat are

Corresponding Author: Mariam E. Mohamed, Department of Physical Therapy for Cardiopulmonary Disorders and Geriatrics,
Faculty of Physical Therapy, Cairo University, Giza, Egypt. E-mail: drkarimpt@hotmail.com.
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called “pear shape” or gynoid (female). Regional fat can aggregation[10]. Therefore the purpose of this study was
be estimated by skin fold measurements, by waist hip to investigate the influence of low frequency ultrasound
ratios or methods such as computed tomography [5]. cavitation versus phosphatidylcholine injection on fat
Short- and long-term weight reduction programs both adiposity in women with gynoid obesity. On comparing
resulted in a significant decrease in the waist/hip ratio the results, the most appropriate and effective method to
(WHR) among obese premenopausal women. In matched decrease fat adiposity can be determined.
groups of women with gynoid and android obesity, the
latter demonstrated a greater decrease in WHR after one MATERIALS AND METHODS
year's weight reduction and, at the same level of body
weight loss, a consistently lower decrease in the lean Study Subjects: Forty women suffering from localized fat
body mass. Gluteal fat cells were found to empty at a deposits at the buttocks area were selected from the
slower rate than those in the abdominal region, outpatient clinics of the general institute of health
particularly in gynoid obesity. After one year's insurance, nonsmokers and non-hypertensive, having
weightreduction, the decrease in WHR correlated tumor or fragile skin, taking oral weight loss medications,
significantly with decreases in body weight, blood free from respiratory, kidney, liver and metabolic disorders
pressure and metabolic variables [6]. as well as chronic cardiac problems as heart failure,
One method of managing localized obesity is low ischemic heart disease and coronary artery bypass graft.
frequency ultrasound cavitation, which is used both in Their age ranged from 30 to 40 years and not involved in
cosmetology and in aesthetic medicine and surgery. It is any physical therapy program.
an innovative technique mainly for reducing localized Subjects were randomly assigned to two groups
adiposity and cellulite in a non-surgical manner, which equal in size: Group I received low frequency ultrasound
uses low frequency ultrasound (from 30 to 70 KHz). It is cavitation twice weekly and Group II received
a safe, efficient method, which is non-invasive, causes phosphatidylcholine injection every two weeks. Both
no pain or collateral effects, consisting of diluting fat groups received treatment for 4 months.All sessions were
through movement, safely, with no anesthetic or recovery supervised and participation assessed. The purpose,
time required [7]. nature and potential risks of the study were explained to
Other method of treating localized adiposity is all participants before providing their informed consent.
mesotherapy. Mesotherapy is a form of medical treatment
based on affecting tissue derived from the embryonic General Experimental Design
mesodermal layer. The development of mesotherapy is Evaluated Parameters: The subjects of both groups
attributed to Dr. Pistor in France and is accepted as a part underwent measurement of waist/hip ratio,fat percentage
of medical studies in Europe. It is often used for various and skin fold thickness before, after 2 months, at the end
types of medical problems and recently has been of treatment program after 4 months and Follow up
advocated for the improvement of localized areas of fat measurement after 3 months of program termination.
deposition and cellulite. It is said to break down fat Waist was measured midway between the lower rib margin
beneath the skin and shrink fat cells; the fat dissolves and and iliac crest, with a horizontal tape at the end of gentle
is carried through the bloodstream before being excreted. expiration while hip was measured around the maximum
It is often paired with aminophylline (an asthma circumference of the buttocks; for women this is usually
medication) which stimulates the release of fat into the at groin level [11,12]. Skin fold thickness was measured by
bloodstream. Lidocaine (an anesthetic) is used to improve gripping the skin about 1cm above the selected site and
the absorption of the drugs. L-carnitine (an amino acid), the calipers applied below this site, the grip was removed
that metabolize the stored fats [8,9]. and the measurement noted to the nearest 0.2mm. Body
Phosphatidylcholine is a phospholipids extracted composition was measured using body fat analyzer
from soybean lecithin present in abundance in cell device, subject data entered including (age, sex, weight
membranes, actively participating in the structure and and height). Subject skin was cleaned with alcohol and
transport between the cells. This substance can alter four electrodes were used; two electrodes on wrist level
cholesterol and other triglycerides metabolism. It seems to and the other two electrodes placed on ankle level of the
be able to increase cholesterol solubility, alter the same side of the body, then running a small electrical
composition of fat deposits and inhibit plaque signal through the body [13].

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All participants were free to withdraw from the study Patient was instructed to use analgesics especially in the
at anytime. If any adverse effects had occurred, the first 2 days [10]. In the post-application care, all subjects
experiment would have been stopped. However, no of both groups received massage and lymphatic drainage
adverse effects occurred and so the data of all the by an experienced professional following the session for
patients were available for analysis. duration of 15 minutes to help fat absorption and reduce
edema [14].
Detailed Training Regimen:
Group (I) Low Frequency Ultrasound Cavitation: Subjects Statistical Analysis: The mean values of WHR, fat
were instructed not to eat at least for 3 hours before the percentage and skin fold thickness obtained before and
session and to drink plenty of water before the treatment after four months in both groups were compared using the
session. Patient lied on abdomen with buttocks area paired "t" test. Unpaired "t" test was used for the
exposed.A 63 Applicator to treat large and wide areas with comparison between the two groups (P < 0.05).
Voltage (100-240V), frequency (50-60 HZ) and output
level: 100%; Treatment applied for 30 min using Auto RESULTS
mode.
Forty women had localized fat deposits at the
Group (II) Phosphatidylcholine Injection: Subjects buttocks area participated in this study. Table
received subcutaneous injection of phosphatidylcholine 1representsnon significance difference between both
in buttocks area, received one treatment session every groups of low frequency ultrasound cavitation and
two weeks; for a complete 4 successive months. The phosphatidylcholine injection before treatment. The mean
medication administered (250mg/ml phosphatidylcholine), values of WHR, fat percentage and skin fold thickness
have been injected pure into the area to be treated [8]. were significantly changed from 0.71 ± 0.03, 30.7 ± 1.88
Injections were applied in the subcutaneous tissue using and 35.4 ± 1.26 to 0.77 ± 0.004, 25.6 ± 1.89 and 26.1 ± 2.02
Point By Point technique with 0.1 to 0.3ml for each point; respectively, in group I and from 0.69 ± 0.004, 32 ± 3.36
a separation distance of 0.5- 2cm between the points and and 36 ± 0.81 to 0.73 ± 0.009, 27.1 ± 1.66 and 31.1 ± 1.66
application depth from 2 to 12mm below the cutaneous respectively, in group II (Table 2,3). Also, there was a
surface. The total volume of phosphatidylcholine injected significant difference between the groups after treatment
was not more than two vials (10ml) applied per session. (Table 4).

Table 1: Clinical characteristics of study subjects of both groups at baseline

Group 1 Group B p-value Sig.
Age (years) 36.3 ± 2.75 37.2 ± 2.09 0.42 NS
Weight (kg) 80.9 ± 4.77 79.3 ± 2.31 0.35 NS
Height (cm) 167.5 ± 2.79 166.2 ± 2.04 0.25 NS
BMI (kg/m²) 28.8 ± 0.78 28.71 ± 0.75 0.78 NS
WHR 0.71± 0.03 0.69± 0.004 0.11 NS
Fat percentage 30.7± 1.88 32± 3.36 0.3 NS
Skin fold thickness 35.4± 1.26 36± 0.81 0.22 NS
BMI: Body mass index p value: Probability value NS: Non significant
WHR: waist hip ratio

Table 2: Mean values and significance of low frequency ultrasound cavitation in first group before and after treatment
Pre treatment Post I Post II Post III p- value Sig.
WHR 0.71 ± 0.03 0.71 ± 0.01 0.77 ± 0.01 0.77 ± 0.004 0.0001 S
Fat percentage 30.7 ± 1.88 27.3 ± 2.21 25.8 ± 1.81 25.6 ± 1.89 0.0001 S
Skin fold thickness 35.4 ± 1.26 30.4 ± 2.06 26.9 ± 2.33 26.1 ± 2.02 0.0001 S
WHR: waist hip ratio; Sig.: significant; P-value: probability value

Table 3. Mean values and significance of phosphatidylcholine injection in the second group before and after treatment
Pre treatment Post I Post II Post III p- value Sig
WHR 0.69± 0.004 0.72 ± 0.008 0.73 ± 0.008 0.73 ± 0.009 0.0001 S
Fat percentage 32± 3.36 29.9 ± 1.19 27.5 ± 1.58 27.1 ± 1.66 0.0001 S
Skin fold thickness 36± 0.81 34.1 ± 1.19 31.5 ± 1.95 31.1 ± 1.66 0.0001 S
WHR: waist hip ratio; SD: standard deviation; S: significant; P-value: probability value

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Table 4: Comparing mean values and significance of both groups after treatment
Group IMean±SD Group IIMean±SD P-Value Level of Significance
WHR 0.77±0.004 0.73±0.009 0.0001 S
Fat Percentage 25.6±1.89 27.1± 1.66 0.07 NS
Skin Fold Thickness 26.1±2.02 31.1±1.66 0.0001 S
WHR: waist hip ratio SD: Standard Deviation
p value: Probability value NS: Non significant S: Significant

DISCUSSION nerve terminals which release catecholamines, particularly

nor-adrenaline which shows a remarkable lipolysis effect
The aim of this study was to find out the efficacy of [19].
low frequency ultrasound cavitation versus The result of the present study showed a significant
phosphatidylcholine injection in fat adiposity in women reduction in subcutaneous fat thickness, this reduction
with gynoid obesity after 4 months of treatment. The comes in agreement with the study of Enrico who reported
mean values of WHR, fat percentage and skin fold a reduction of subcutaneous fat after low frequency
thickness were significantly improved in both group I and ultrasound application and considered the low frequency
group II. Also, there was a significant difference between ultrasound treatment as a valuable tool in the treatment of
the groups after treatment. This means low frequency localized fat in the esthetic field
ultrasound cavitation is more effective and safe in The present study agrees with Baker and his
reducing fat adiposity in buttocks area than associates [20] who reported that low frequency
phosphatidylcholine injection. ultrasound can be used for reducing adipose cell volume
Phosphatidylcholine (PPC) is an antioxidant that in a human body by non-invasive, non-destructive and a
is derived from natural soy lecithin. PPC alter the non-traumatic method through increasing lipolysis rate at
metabolism of fatty substances like cholesterol and the adipose tissue of the treated area as the low frequency
triglyceride in the body. PPC is reported to penetrate ultrasound raise the temperature of the adipose tissue
the adipocyte (fat cell) through the double lipid layer between 40.0° to 41.5°C; leading to increase in the
(cell wall) where it acts as a detergent (emulsifying and lipolysis rate and cause release of FFAs, thereby reducing
tensoactive agent). The triglyceride breaks down to the volume of adipose cells.
monoglycrides by certain enzymes released from the The present study agreed with Karl [21] who reported
mitochondria of adipocytes nucleus, this means that fat that injection of PPC seems to offer a non-surgical
affected by PPC becomes water soluble. The fat is alternative to liposuction in patients objecting to surgery.
dissolved and carried to liver over high density It appears to be safe and effective in the correction of fat
lipoproteins (HDL) and metabolized via citric acid cycle deposits.
through beta oxidation. The end-product is CO and H2O Also the results of the present study come in
and a small amount less than 1% exerted via the renal agreement with the study of Palmer and his associates
system in the form of very short chained fatty acids [22] as they reported that PPC injection was efficacious in
[15,16]. reducing the fatty pads in the treated areas, with few side
Low frequency ultrasound cavitation causes heating effects including swelling, redness and bruising at sites of
of adipose tissue to a temperature range of 40-41.5°C, injection which lasts for few days.
which is non-destructively thermally encourage the
release of natural lipolysis hormones thus accelerate the CONCLUSIONS
body's own lipolysis processes and disrupting the
adipocytes own phospholipids layer [17]. In summary, both low frequency ultrasound
Application of ultrasound stimulates lipolysis in cavitation and phosphatidylcholine injection are effective
adipose tissue by increasing secretion of nor-epinephrine modalities in reducing fat adiposity in females with gynoid
and the irradiation of ultrasound frequency may cause obesity yet, this study confirmed and added strong
lipolysis and consequently inch was lost in treated area evidence that low frequency ultrasound is considered a
[18]. Ultrasound technology acting indirectly on the more effective modality in fat reduction in buttocks area
adipocytes and enabling the stimulation of sympathetic as well as, it's simple and non -invasive modality.

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