Perineural Injection Therapy

What are perineural injections?
These are very superficial injections using Dextrose in a dilute solution (5%) or Mannitol 5%. We inject around skin nerves and this results in almost immediate pain relief.

What conditions will these injections help?
Most painful conditions respond to these injections to some extent but they are exceptionally effective for treating pain due to nerve irritation. This might be known as neuralgia, neuropathy, neurogenic pain or just “nerve pain” which is usually burning or sensitive. It is also very effective for painful scars. 

How do they work? See Excerpt from Dr Lyftogt below.*
Perineural injections supply the painful skin nerves with a dilute sugar solution and this almost immediately shuts off production of the painful substances and helps the nerve swelling to go down. We don't know the exact mechanism at the cellular level, but it has been postulated that the dextrose works at the cellular level on the TRVP1 receptors to decrease Substance P and other chemicals that produce pain. Dextrose is also thought to work on ion channels in the affected nerve, once again aiding healing at the cell level. The nerve can once again slide easily through the fascial openings and voila, the pain is gone!

How long does pain relief last?
The first time the pain can go away from 4 hours to 2 weeks. This is important to remember as almost certainly your pain will recur to some extent at first, and each time you come for this treatment, the pain should go away for longer and longer periods. We like to do 3 treatments not too far apart initially to see if this is an effective method for you; if you are responding we then usually lengthen the time between appointments until you are pain-free, or much improved.

Does it hurt?
The needles are very thin and once the process has started, the solution makes the next injection less painful. Most people tolerate the procedure very well and are quite surprised by how quickly they become free of pain. The injections are also very superficial so they do not hurt in the same way as a “flu needle” into the muscle might hurt.

Are there any risks associated with perineural injections?
Side effects are very uncommon but may include the following:

·       Light-headedness (not serious) or nausea (rare).
·       Bruising (not serious).
·       Brief “treatment stiffness” from the process of having an injection.
·       Infections (very rare). Let us know if any of the sites become increasingly red or painful over the skin.
·       A temporary increase in pain. This is uncommon but can occur, and should be treated with any pain medication, or ice. 

What can I expect after treatment?
Your pain should be less and your range of movement improved. You don't need to restrict your activities after treatment. You may experience a little "treatment stiffness" from the needles, but this does not usually last long. Rarely you may have a flare up of pain for a few days and feel worse. This is quite unusual and after it goes away, then you will notice an improvement. ​

What is the cost?
Perineural injections are not an insured service of the Medical Services Plan of BC. The cost depends on the time required for the examination and the injections, so please ask us about this.

Practical Advice
·       Bring a hair tie if you have long hair.
·       Wear stretchy, easy to remove or loose-fitting clothes/sports clothes. A tank top and loose shorts are preferred.
·       Wear dark clothes – they might get a little blood-stained.

For more about Neural Prolotherapy/Perineural Injections See the blog entry. 


Other treatment forms you may wish to consider
We also offer trigger point treatment (useful for tight painful areas in muscles), prolotherapy injections (excellent for ligament and tendon pain) and medical acupuncture. All of these involve the use of needles but there is a manipulation technique we can use for releasing trigger points should you not wish to be injected. We offer advice for stretching, exercising and can recommend good reading material for dealing with pain.

What else can I do to aid my recovery?
·       Be aware of your body posture and your daily activities. Are there any prolonged activities in one position, for example computer use? Are there any habits which may cause aggravation to a muscle? Do you sit in a chair without good back support, or tend to slouch?
·       Keep yourself physically fit and at your correct weight. Exercise helps to release endorphins which help your general well-being, but take care not to over-work an area of your body which is just recovering from injury.
·       Myofascial stretching is another great technique for sustained recovery. Again, you should make sure you do these stretches correctly.
·       Diet is important: avoiding inflammatory and processed foods or too many carbohydrates is advisable. If your pain is persistent or recurrent, consider making healthy dietary changes.
·       Sleep is crucial: if your pain is persistent or recurrent, make sure you are getting enough.
·       Supplements may be of benefit and can be given through the skin (eg. Mannitol cream) or by mouth (eg. Curcumin, SAMe, Magnesium, and others)
·       Prescribed medications can harm or help. Unfortunately medications given for pain relief can worsen trigger points and cause skin sensitivity. These include narcotic medications like morphine, statin medication for high cholesterol, and sometimes calcium. Anti-inflammatory medications (like Advil) or simple analgesics (like Tylenol) or muscle relaxants (like Robaxacet) are advised by most doctors for immediate relief of pain, but after successful trigger point injections these should not be necessary. If you are having prolotherapy as well, you should NOT take anti-inflammatory medications. ​

Dr. Lyftogt explains
​
Because Neural Prolotherapy does not target tendons, ligaments or joints the question had to be asked what causes the sometimes dramatic decline in pain levels after even a few treatments.

A working hypothesis was developed that glucose targets glucose-sensitive pain nerves called nociceptors located in nerve trunks immediately under the skin. These nerve trunks may contain up to 30,000 small nerve fibers per mm2.  Half of these small nerve fibers are a variety of ‘pain nerves fibers’, technically known as sensocrine nociceptors. When injured these sensocrine nociceptors are thought to be responsible for painful conditions described as ‘neuralgias’ or ‘neuropathic pain’ or more commonly known as ‘chronic pain’.

The protective sheath of the nerve trunk is structurally very similar to tendons and ligaments. It protects small nerve fibers inside the nerve trunks from injury, friction and pressure. Nerve trunks have their own nervous innervation, called ‘Nervi Nervorum’.

The very small nerve fibers, innervating the nerve trunk, identified as unmyelated C-fibers or ‘Nervi Nervorum’ are responsible for pain and swelling of the protective sheath of the nerve trunk. This was already demonstrated 125 years ago by Professor John Marshall from London and called neuralgia. It is now called ‘neurogenic inflammation’.                                                                                                       

It is also known that this ‘neurogenic inflammation’ differs from other forms of inflammation in that it does not respond to anti-inflammatory drugs or cortisone injections and this is the reason why these commonly used drugs are proving to be ineffective in many painful conditions. In addition, there is a growing awareness that cortisone and anti-inflammatory drugs are associated with a variety of harmful side effects.

It is clear from clinical observations on more than five thousand patients and large case series that Neural Prolotheapy effectively reverses ‘neurogenic inflammation’ and resolves ‘neuralgia’ and ‘neuropathic’ or chronic pain.

After the success of Neural Prolotherapy with Achilles tendonitis other persistent painful conditions of the neck, back, shoulders, elbows, wrists, knees, ankles and feet have been effectively treated by targeting the local inflamed and painful superficial nerves with micro- injections with low dose Glucose.

More recently Dr Lyftogt has developed effective Neural Prolotherapy  treatment protocols for Migraine, ‘Fibromyalgia’, CRPS (Complex Regional Pain Syndrome), compartment syndrome and other difficult to treat persistent painful conditions.

Neural Prolotherapy is an effective novel and evolving treatment for non-malignant persistent pain, based on sound neuroscientific principles.

For a practitioner to be effective in treating persistent pain the first requirement is the ability to make an accurate neuro-anatomical diagnosis and secondly combining this diagnosis with training in specialised clinical skills. This knowledge and skill can only be obtained by attending specific workshops in Neural Prolotherapy. Most Doctors who have attended these workshops will develop confidence and experience over time. It will allow them to approach most chronic painful conditions with understanding and competence.

The veil surrounding the mystery of persistent pain is lifting in the 21st century.