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Improvement in Anxiety and Pain After Whole Body Whirlpool Hydrotherapy

Among Patients With Myofascial Pain Syndrome

Article in Annals of Rehabilitation Medicine · August 2013

DOI: 10.5535/arm.2013.37.4.534 · Source: PubMed

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Original Article
Ann Rehabil Med 2013;37(4):534-540
pISSN: 2234-0645 • eISSN: 2234-0653
http://dx.doi.org/10.5535/arm.2013.37.4.534 Annals of Rehabilitation Medicine

Improvement in Anxiety and Pain After Whole

Body Whirlpool Hydrotherapy Among Patients
With Myofascial Pain Syndrome
Sang Hee Im, MD1, Eun Young Han, MD2
1
Department of Rehabilitation Medicine, Kwandong University College of Medicine, Goyang;
2
Department of Rehabilitation Medicine, Jeju National University Hospital, Jeju, Korea

Objective To evaluate the effect of the Whirlpool hydrotherapy on pain and anxiety in chronic myofascial pain
syndrome (MPS) patients, compared to the conventional hydrocollator pack therapy.
Methods Forty-one subjects who have MPS in the upper trapezius muscles without depression were recruited.
The patients were randomly assigned into two groups: the whirlpool therapy group whose bodies were immersed
in a whirlpool bath at 34oC—36oC for 30 minutes; the hydrocollator group who took a 30-minute application of
a standard hot hydrocollator pack. Patients in both groups received therapy three days a week for 2 weeks and
underwent several evaluations at baseline and after treatment. The variables we analyzed during evaluations were
as follows: the primary outcome we considered was pain severity using a visual analogue scale. And the secondary
outcomes examined included anxiety using the Korean version of the Beck Anxiety Inventory and quality of life
(QoL) using the Korean version of the World Health Organization QoL Assessment, Brief Form. All follow-up
values were compared with the baseline values.
Results The baseline parameters did not show significant differences between two groups. And after 2-week
treatment, both groups revealed significant improvement in anxiety levels and QoL, as well as in pain. However,
the improvement on pain (p=0.002) and anxiety (p=0.010) was significantly greater in the whirlpool group,
compared to the hydrocollator group.
Conclusion The whirlpool hydrotherapy can be used as a more effective therapeutic method to reduce pain and
anxiety in chronic MPS patients without depression.

Keywords Hydrotherapy, Myofascial pain syndromes, Anxiety

Received October 8, 2012; Accepted January 22, 2013

Corresponding author: Eun Young Han INTRODUCTION
Department of Rehabilitation Medicine, Jeju National University Hospital,
15 Aran 13-gil, Jeju 690-767, Korea
Tel: +82-64-717-1672, Fax: +82-64-717-1131, E-mail: clearblue10@naver. Pain is very common component [1] among major
com public health problems [2] and a compelling reason for
This is an open-access article distributed under the terms of the Creative seeking medical attention [3]. The definition of pain is ‘an
Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/3.0) which permits unrestricted noncommercial use, unpleasant sensory and emotional experience associated
distribution, and reproduction in any medium, provided the original work is
properly cited. with actual and potential tissue damage, or described in
Copyright © 2013 by Korean Academy of Rehabilitation Medicine terms of such damage’ [4], and pain that persists more
 Improvement in Anxiety and Pain After Whole Body Hydrotherapy in MPS

than 3 months and beyond the expected period of heal- Leading Industry” project.
ing is defined as chronic [5].
Several studies have reported about associations be- MATERIALS AND METHODS
tween physical and mental problems and comorbidity
between mental and somatic disorders in the general Study subjects
population [6-8]. Among mental disorders, depression, Forty-one subjects who were diagnosed as having MPS
and anxiety are commonly associated with pain in pri- in the upper trapezius muscles without depression were
mary care [9]. Depression refers to an array of abnormal recruited from December 1, 2009 to May 31, 2010.
variations in the mood of a person and is more than just Inclusion criteria were: 1) palpable taut band formed in
a feeling of being sad or blue and anxiety is described as painful local sites [10] of upper trapezius, 2) pain when
a feeling of nervousness or uneasiness, which creates a the involved muscles were pressed with trigger points
critical disturbance in the mental state. causing referred pain [10] at relatively accurate spots
Myofascial pain is traditionally defined as the localized around the skeletal muscles, 3) limited joint motion
and referred pain that arises from trigger points in the because of such pain, 4) duration of pain for at least 3
muscle [10]. Many patients with chronic pain have prob- months, and 5) moderate or greater intensity of pain (≥4
lems related to muscular conditions and more than one on the visual analogue scale [VAS]).
third of those meet the diagnostic criteria for myofascial Patients with depression (Beck Depression Inven-
pain syndrome (MPS) [11]. Chronic MPS patients often tory [BDI] >10), psychiatric disease, impaired cognition
complain of considerable physical and psychosocial (Mini-Mental Status Examination <24) and severe radi-
impairment and distress as well as comorbid conditions ating pain in the upper extremities, or with peripheral
such as depression or anxiety [3,8,12-14], which also may neuropathy were excluded from the study. Other exclu-
perpetuate or aggravate the severity of muscle tension in sion criteria were as follows: abnormal neurologic signs,
MPS [15]. Most patients suffering chronic musculoskel- previous spinal or musculoskeletal fracture or surgery,
etal pain have lower quality of life (QoL), compared with pregnant women or serious medical illness.
a normal population.
However, the majority of studies placed the emphasis Evaluation
only on the relationship between pain and depression All patients were assessed the degree of independence
[16]. Little attention has focused on the comorbidity during daily activities using the Korean-version of the
with anxiety and pain and especially research on cor- Modified Barthel Index (K-MBI) [18] for evaluation of the
relation with anxiety has not been performed in patients impact of pain on daily life independence at baseline.
with chronic myofascial pain. Furthermore, although And their emotional states were also evaluated using
hydrotherapy is frequently applied to patients with mus- the Korean version of the Beck Depression Inventory
culoskeletal pain and enhances muscle relaxation [17], (K-BDI) [19]. BDI [19,20] is a 21-item scale that gathers
the effects of hydrotherapy have not been recognized for information on different symptoms of depression. Each
reducing pain and anxiety in patients with MPS. item on the scale is scored from 0 to 3. It provides infor-
Therefore, the current study addressed several ob- mation on both the presence and severity of depression
jectives. First, we evaluated the prevalence of anxiety and higher scores indicate the presence of more severe
in chronic MPS patients without depression. Second, depression. Patients who have scores above 10 out of 63
we compared MPS patients’ pain severity with levels were excluded in this study.
of anxiety. Third, we evaluated the therapeutic effects The variables evaluated were as follows: the primary
of hydrotherapy on pain, anxiety, and QoL in chronic outcome we considered was pain severity using a VAS
MPS patients, and compared the effectiveness of the [21]. The VAS for pain consists of three 100-mm lines,
whirlpool hydrotherapy on pain and anxiety with that of each labeled at the left end as ‘no pain’ (0 mm) and at
conventional hydrocollator pack therapy. And finally we the right end as ‘very severe pain’ (100 mm) [21]. Patients
proposed the results to apply to invigorating the “Hu- were asked to draw a vertical mark on each line, one on
man Resource Development Center for Economic Region the upper line for their current pain, one on the middle

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Sang Hee Im, et al.

line for the pain at their best (least painful) period during trapezius. Hydrocollator pack (25×30 cm) consisted of
the previous week, and one on the lower line for the pain hydrophilic silicate gel encased in a canvas outer cover
at their worst (most painful) period during the previous Alkamo (Samwoo Inc., Seoul, Korea). The hydrocolla-
week. tor pack was thermostatically controlled at 74.5oC in the
VAS raw change (VAS follow-up—VAS baseline) and percent- hot pack unit model WS302 (Woosin Inc., Seoul, Korea).
age change scores [(raw change/VASbaseline)×100] change A commercial terry cloth cover and four or five layers of
scores were calculated [22]. toweling were used to avoid excessive heat or burn [28].
And the secondary outcomes examined included anxi- All patients in both groups took therapy three days a
ety status that was measured using the Korean version week for 2 weeks and maintained all of their other nor-
of the Beck Anxiety Inventory (K-BAI) [23] and QoL that mal daily habits and medications.
was scored using the Korean version of the World Health
Organization QoL Assessment, Brief Form (K-WHOQOL Statistical analysis
BREF) [24,25]. BAI [23,26] consists of 21 anxiety symp- We analyzed the data using the SPSS ver. 12.0 (SPSS
toms, with respondents being asked to indicate the ex- Inc., Chicago, IL, USA). Descriptive statistics, such as
tent to which they were bothered by each item “during mean±standard deviation or range, were calculated from
the past week, including today”. Responses are scored on the data collected. Statistical analyses of parameters
a 0—3 scale ranging from “not at all” to “severely”, giving including VAS, BAI, and WHOQOL BREF across time-
a score range of 0—63. As a recommended scoring and points were performed using repeated measures analy-
interpretation system [23,26] for the BAI, 10—18 points sis of variances. Mann-Whitney test were employed for
are classified as mild-moderate anxiety, 19—29 points as determination of any significant difference in VAS raw
moderate-severe, and 30—63 points as severe anxiety. change and VAS percentage change scores. χ2 tests were
The WHOQOL BREF [24,25,27] contains 26 items performed to compare the prevalence of mild to moder-
grouped into five domains of overall QoL including gen- ate anxiety between two groups. In cases where the antic-
eral health, physical health, psychological health, social ipated frequency was lower than 5, a Fisher exact test was
relationships, and environment. It is based on a Likert- applied. We calculated Spearman correlation coefficients
type scale of 1 to 5. The highest score possible is 130. to examine the relationship between independent and
Lower scores indicate a lower QoL and higher scores in- dependent variables. To exclude type 1 error, a p-value
dicate a higher QoL. <0.017 was considered statistically significant.
All patients were evaluated at the baseline and immedi-
ately after 2-week hydrotherapy. RESULTS

Hydrotherapy (whirlpool vs. hydrocollator pack) Baseline characteristics of the patients between two
The patients were randomly assigned into two groups, groups
the whirlpool therapy group or the hydrocollator pack All patients reported perfect scores in K-MBI and re-
group. The patients in the whirlpool therapy group im- vealed no difficulty in performing daily activity.
mersed their whole body, up to the neck, in a whirlpool The baseline characteristics of the patients are sum-
bath at 32oC—36oC for 30 minutes. The whirlpool bath marized in Table 1. Statistical analysis did not show sig-
Jetsetter (Hot Spring Spas NZ Ltd., Auckland, New Zea- nificant differences in terms of age, gender distribution,
land) are composed of 14 jets (2 sets of 1 Motor-Massage the number of patients, baseline severity of pain and
DX jet, 1 Jetstream jet, 2 rotary hydromassage jets, 1 di- anxiety status, and QoL. Twenty-five patients (61.0%)
rectional hydromassage jets, 4 Hydro Stream jets, and 4 showed mild to moderate anxiety and there were no sig-
directional Precision jets). The bathroom temperature nificant differences in the number of the patients with
was maintained at around 28oC—30oC to prevent heat loss mild to moderate anxiety between two groups (whirlpool
from their bodies. group, 13; hydrocollator group, 12; p>0.05). Also, anxiety
The control group took a 30-minute application of a level correlated with pain severity at baseline (r=0.525,
standard hot hydrocollator pack on the affected upper p<0.001).

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 Improvement in Anxiety and Pain After Whole Body Hydrotherapy in MPS

Table 1. The baseline characteristics of whirlpool and control groups

Characteristic Whirlpool Control p-value
Number 21 20 0.33
Male:female 16:5 12:8 0.41
Visual analogue scale 6.81±2.21 6.05±1.91 0.25
Beck Anxiety Inventory 10.57±4.83 11.25±4.05 0.63
No. of patients with mild to moderate anxiety 13 12 0.58
Quality of life 72.29±10.45 71.35±11.07 0.78
Values are presented as mean±standard deviation.
p<0.017.

Table 2. Comparison of pain, anxiety, and QoL by repeated measures analysis of variance
Whirlpool group Hydrocollator group p-value
According According to time
Before After Before After
to time & type of therapy
VAS (mm) 68.1±22.1 32.9±28.3 60.5±19.1 49.0±14.5 <0.001a) 0.002a)
BAI (point) 10.57±4.83 6.14±3.85 11.25±4.05 10.20±4.24 <0.001a) 0.010a)
a)
QoL (point) 72.29±10.45 78.10±6.96 71.35±11.07 74.25±8.76 0.001 0.334
Values are presented as mean±standard deviation.
VAS, visual analogue scale; BAI, Beck Anxiety Inventory; QoL, quality of life.
a)
p<0.017.

Table 3. Mean change and standard deviation of visual improvement in the BAI (according to time, p<0.001)
analogue scale (VAS) raw scores and VAS percentage and WHOQOL BREF scores (according to time, p=0.010),
change scores in both groups compared with baseline (Table 2). BAI scores had been
Whirlpool Hydrocollator p-value more significantly reduced in whirlpool group, compared
ΔVAS raw -35.2±30.3 -11.5±12.7 0.012a) with those in the hydrocollator group (according to time
ΔVAS % -52.9±42.3 -19.3±20.2 0.011a) & type of therapy, p=0.010) (Table 2). However, WHOQOL
a)
p<0.017. BREF scores did not show any significant difference be-
tween two groups (according to time & type of therapy,
Changes in parameters after 2-week hydrotherapy p=0.334) (Table 2).
The primary outcome: pain After 2-week treatment, the number of patients with
Both groups showed significant improvement in the mild to moderate anxiety had a smaller tendency in the
VAS after 2-week treatment (according to time, p<0.001) whirlpool group (3 patients, 14.3%), compared in the hy-
(Table 2). And, VAS scores had been more significantly drocollator pack group (10 patients, 50.0%) (p=0.020).
reduced in the Whirlpool group, compared with those in
the hydrocollator pack group (according to time & type of DISCUSSION
therapy, p=0.002) (Table 2). In addition, there were sig-
nificant differences of the changes in the raw VAS value We confirmed that majority of patients with chronic
(ΔVAS raw, p=0.012) and percentage (ΔVAS %, p=0.011) MPS had mild to moderate anxiety [23,26] irrespective
in the whirlpool group, compared to the hydrocollator of depression. Also, we confirmed the effect of hydro-
group (Table 3). therapy on pain relief and on the improvement of anxiety
and that the amount of pain reduction correlated with
Secondary outcome: anxiety and quality of life improvements in BAI.
After 2-week treatment, both groups showed significant Chronic pain has been found to be associated with

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Sang Hee Im, et al.

various psychiatric disorders including mood, anxiety, event, compared with paroxetine. Therefore, it might be
somatoform, and personality disorders [29] and the as- possible that anxiety reduction preceded pain relief in
sociation between chronic pain and depression has re- the whirlpool hydrotherapy.
ceived the most research and theoretical attention. Given The WHO defines QoL as an “individual’s perception
the prevalence of depression was higher in the chronic of their position in life in the context of the culture and
pain group compared to the prevalence of anxiety disor- value systems in which they live and in relation to their
ders [29] this emphasis is understandable. goals, expectations, standards and concerns” [38]. Most
On the other hand, there was not shown to be a con- patients suffering chronic musculoskeletal pain have
sistent pattern of association between anxiety disorders lower QoL compared with a normal population.
and chronic pain [29]. However, McWilliams et al. [16] Several studies using various therapeutic approaches
reported that the association between chronic pain and for neck and upper-back pain of myofascial origin dem-
anxiety disorders, such as panic disorder or post-trau- onstrated improvements in QoL measures. Lew et al. [39]
matic stress disorder, was stronger than the association concluded that an injection of botulinum led to a signifi-
between chronic pain and depression. Therefore, chronic cant improvement in the bodily pain and mental health
pain should be paid further attention in anxiety. scales of the SF-36, compared with control patients. Gur
As already described, we confirmed 61.0% of patients et al. [40] applied low-level laser therapy to 60 patients
with chronic MPS revealed mild to moderate anxiety in with MPS and reported significant improvements in pa-
MPS irrelevant to depression. Also, anxiety level correlat- tients’ QoL. Their conclusions were consistent with our
ed with pain severity at baseline (r=0.525, p<0.01). These results that both hydrotherapy using the hydrocollator
results suggested the association of pain with anxiety in pack and whirlpool led to improve QoL in patients with
MPS. MPS. However, there was no significant difference be-
Although Emshoff et al. [22] recommended that mean tween the hydrocollator pack and the whirlpool therapy
optimal cutoff points were -19.5 mm of VAS raw change in our study. Further research should be needed for eval-
and -35.1% of VAS percentage change, most clinicians uating the impact on QoL in patients with MPS according
might prefer mean cutoff points at -30 mm and -50% to to the type of hydrotherapy.
best discriminate between patients who experienced This study had several limitations. First of all, study
treatment success (recovery or important improvement) had a small sample size which limited interpretation of
or not. As this recommendation, our whirlpool group the findings and the precise psychophysiological mecha-
showed important improvement (-35.2 mm and -52.9%) nisms of hydrotherapy remained unknown. Second, our
in pain. And it might lead to reduce anxiety. study did not compare the baseline level of anxiety and
According to the gate theory, pain is relieved due to QoL with control patients without MPS. Third, we did not
the pressure and thermal temperature of hydrotherapy measure the relaxation of muscle tension and its correla-
on the skin [30]. Also thermal waters with temperatures tion with pain and anxiety. Forth, the thermal extent of
above 34oC are commonly considered to relax muscles, the whirlpool therapy exceeded that of the hydrocollator
increase tendon extensibility, dilate blood vessels, and pack therapy. This might have more beneficial effects on
facilitate blood circulation resulting in a wash out of pain pain reduction in the whirlpool therapy. Finally, we did
mediators and elevation of pain threshold [31]. not verify how long the effects of hydrotherapy would be
Although few studies have used hydrotherapy for treat- lasted.
ing MPS, the effects of hydrotherapy have been widely Further well-designed randomized clinical trials should
recognized for reducing labor pain and anxiety [32,33] be warranted in the effectiveness of hydrotherapy in vari-
and reducing symptoms of fibromyalgia or arthritis [34- ous chronic musculoskeletal diseases and other condi-
36]. Our study revealed that the whirlpool hydrotherapy tions.
had beneficial effects on pain and anxiety in patients with In our study, hydrotherapy using Jeju water demon-
MPS. strated the beneficial effects on pain, anxiety, and QoL
On the other hand, as Dubois et al. [37] reported, balne­ management in subjects with MPS and more significant
otherapy had shown the improvement of anxiety symp- improvement in the severity of pain and anxiety were ob-
toms in generalized anxiety disorders and low adverse served in patients receiving the whirlpool hydrotherapy,

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 Improvement in Anxiety and Pain After Whole Body Hydrotherapy in MPS

compared with the hydrocollator pack therapy. We pro- 7. Jacobi F, Wittchen HU, Holting C, Sommer S, Lieb R,
pose the whirlpool hydrotherapy as a scientifically based Hofler M, et al. Estimating the prevalence of mental
pain and anxiety management technique in MPS and ex- and somatic disorders in the community: aims and
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8. Lowe B, Spitzer RL, Williams JB, Mussell M, Schell-
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tion in primary care: syndrome overlap and functional
No potential conflict of interest relevant to this article impairment. Gen Hosp Psychiatry 2008;30:191-9.
was reported. 9. Toft T, Fink P, Oernboel E, Christensen K, Frostholm
L, Olesen F. Mental disorders in primary care: preva-
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