Sometimes it is helpful to combine different treatments to achieve a better result, either at the same visit or subsequently.
It stands to reason that when one has an injury more than one structure may be affected- muscles, fascia, ligaments, tendons etc. What is not as well known is that cutaneous nerves become sensitized and may perpetuate pain through the release of specific chemicals (such as CGRP). Different structures require different approaches.
We may have already treated myofascial pain with the pain neutralization technique (PNT) or trigger point injections but the patient may have some residual symptoms. We often combine perineural injections with prolotherapy or may combine prolotherapy with PRP. Sometimes we use acupuncture or acupressure to calm symptoms of anxiety or light-headedness if a person is apprehensive. PNT can substantially reduce the number of trigger point injections needed.
One example: A lady was referred for acupuncture for treatment of longstanding shoulder and upper back pain which was interfering with her work. She was very keen to have this fixed but was so apprehensive about the needles that she broke out in a sweat (quite unnecessarily) before she could be examined. Instead of tackling the painful area directly she was initially asked to lie down on the exam table and four thin sterile acupuncture needles were gently inserted into peripheral points in her hands and feet which are known to have pain-modifying effects and which moderate the "fight and flight" response. After resting quietly for 20 minutes she was feeling much better (people often find acupuncture and acupressure quite relaxing or soporific). Then all but one of the tender points in her shoulder, arm and upper back were released with PNT using finger pressure only (no needles needed!). Only one resistant point on the side of her upper arm was still tender (what the Chinese would call an ah shi point); this was treated with an acupuncture needle briefly. When seen in follow-up she remained pain-free and able to work without discomfort.
Another example: A lady was seen for chronic pain in her neck, shoulders, back, thigh and hip which had persisted following a motor vehicle collision. Her X-rays were normal; all her pain was "soft-tissue" but her function was limited. At the initial visit she was found to have very limited range of movement of her one shoulder with multiple tender points around the neck, shoulder and upper back. She also had limited movement of her lower back and one hip because of pain. PNT released her shoulder and neck pain the first visit and she regained full range of movement within a few minutes. On a few subsequent visits some recurrent tender points were released. PNT also released painful areas in her abdominal muscles which can cause referred pain to the back. Her back muscles and thigh needed trigger point injections and some of her hip pain responded to perineural injections. Obviously, these methods will not correct major structural abnormalities but because pain reduces function by inhibiting muscle movement, when the pain is relieved function is often restored.
This therapy for neurogenic pain is sometimes referred to as neural prolotherapy, perineural injection therapy (PIT) or the Lyftogt (pronounced "Lift-off") technique after its developer, Dr John Lyftogt of Christchurch, New Zealand. John is a family physician, runner, and sports medicine doctor who for many years used the trigger point injection methods described so well by Drs Janet Travell and David Simons. He later was trained in traditional prolotherapy. Being an athlete he suffered from chronic achilles tendinopathy and decided to treat himself with prolotherapy by injecting his achilles tendons with concentrated dextrose and local anesthetic. He found this quite painful but found that subcutaneous (just under the skin) injections around the achilles tendons were not painful but in fact eradicated the pain and caused gradual healing. As traditional prolotherapy uses concentrated dextrose (20% or more) he published a number of studies using concentrations of 20-40% dextrose. By 2010 he discovered that isotonic dextrose 5% (D5W) could achieve the same results. After studying the literature on neurogenic pain and the anatomy of skin nerves he discovered that a large number of musculoskeletal pain conditions could be successfully treated by injecting 5% dextrose under the skin next to these sensory skin nerves. These findings were reproduced using 5% mannitol (a sugar-alcohol) in the same manner. John has recently retired from clinical practice in order to devote his time to teaching this method in centres around the world.
Having developed this from a background in prolotherapy he named the new technique "neural prolotherapy" and continues to use that term even though it is somewhat of a misnomer ( the 'prolo' part of the term refers to 'proliferation' of cells which is part of the healing process but requires higher concentrations of dextrose than the 5% he uses now). Others have called this technique "perineural subcutaneous injections" as that is a more accurate descriptor of the process involved. It is postulated that dextrose switches off the (TRPV1) nerve receptors involved in neurogenic inflammation but not the nerve endings which transmit other sensation (i.e. one cannot use dextrose to anesthetize the skin for procedures such as stitches).
The technique involves identifying tender skin nerves and, using a very fine, short (half inch 27 guage or even 32 gauge in sensitive areas like the face) hypodermic needle to inject small amounts (1/2-1ml) of 5% dextrose or 5% mannitol next to the tender nerves. At sites where nerves exit through small holes in the fascia or traverse fibrous tunnels over bones (e.g. the cluneal nerve in the lower back) larger volumes (2-6ml) are injected.
Hundreds of physicians around the world have accumulated considerable clinical empirical experience with this technique and found it very effective.
Some examples in our experience:
1. a lady presented with intense pain in her arm after taking up pickle ball. She was tender over the outside of her elbow (the lateral epicondyle) but also over the skin nerves (branches of the radial and musculocutaneous nerves: lateral and posterior antebrachial and nerve to anconeus) . Each tender point was injected with D5W and she was pain free. She needed 3 treatments over the next two weeks to make this permanent. That is much quicker permanent recovery than with steroids or physiotherapy.
2. another presented with tennis elbow after already having physiotherapy with limited results and only required one D5W treatment.
3. an elderly lady fell on the ice and fractured her hip and several ribs. She bled into her chest cavity and required an incision between her ribs to insert a chest tube drain and also had her hip pinned surgically. With excellent orthopaedic surgical care she made a full recovery but presented several months later with intense pain in and around both scars - chest and hip. Injecting D5W into the tender areas around each scar relieved her pain instantly and avoiding the risks of narcotic pain medications. As expected, some of her pain recurred a few days later but was less intense. In all, she required 3 treatments to obtain a permanent relief for something which could have become a chronic condition. Scar neuromas (tender injured skin nerves in scar tissue) often respond well to this treatment.
4. a mountain biker with a ten-year history of low-back pain was tender over the cluneal and neighbouring cutaneous nerves over the iliac crest of his pelvis. Only two treatments were needed.
5. a patient presented with intense burning pain involving the entire lower limb which came on after an over-vigorous massage for a calf injury. This illustrates how neurogenic pain can spread from the original site of injury. She was tender at multiple sites in her thigh, around the knee and in the lower leg (corresponding to the sensory distributions of the lateral and anterior femoral cutaneous, common peroneal, sural and saphenous nerves). Meticulously each tender point was injected with D5W and much to her surprise she climbed off the examination table pain-free. It is our aim to have the patient pain-free by the end of the visit. If this can be achieved and the pain-relief lasts at least 4 hours after the first treatment the likelihood is good that incremental progressive improvement will be achieved over a few visits.
6. one had severe pain for decades in her back, chest wall, neck and shoulders after a series of accidents. After each treatment she was pain-free for a few days and progressed enough to be able to resume activities such as sports and enjoying games with her son who had never previously seen her able to do so.
Usually the pain-relief lasts 4 hours to 4 days initially, occasionally up to 2 weeks. Very occasionally it is permanent after one visit. This is not a realistic expectation. Most people need 6-8 visits to be substantially or completely better. Some need a top-up a few times per year. Some need more. In some cases one reaches a plateau of about 50% or more reduction in pain overall without permanent complete relief.
These are success stories. Some people do not tolerate needles. We have patients who do not find this method beneficial and so we look for other alternatives. One can usually tell quite quickly whether or not the method is going to be helpful. We have others who need more treatments (8 or more) or who need a combination of neural and traditional prolotherapy or deeper trigger point injections. Some people may do better with physiotherapy.
David is a fan of books and no doubt will be sharing some good reads here.