Case in Point Prolotherapy for Management of Myofascial Pain Syndrome

Quynh Pham, MD; Ann Quan, BS; and Lida Bao, NP

This case details the treatment of a patient with myofascial pain syndrome who was unresponsive to conservative treatments but showed significant pain reduction following prolotherapy.

yofascial pain syndrome used to manage various pain condi- pain with diffuse tender points.4 The (MPS) is a regional pain tions. One example is prolotherapy, classic location of tender points are syndrome characterized which involves injecting proliferative listed in Table 1. She described the by a trigger point in a taut agents, such as dextrose and hyper- pain as diffuse aches over joints of the M 1 band of skeletal muscle. The key tonic saline, near ligaments and ten- upper and lower limbs and muscle to identifying MPS in a patient is dons.3 The proliferative agents induce pain in the back, chest, and legs. The the presence of pain that radiates release of growth factors and assist in pain increased with stress and fatigue from the original trigger point in healing.3 If the ligaments and tendons and decreased with medication, rest, the muscle. are strengthened around the joints, and relaxation. Pain intensity was Traditional care modalities include there will be increased joint stability, rated between 3/10 to 8-9/10 without physical therapy, such as massage, followed by improved muscle relax- any specific trigger. ultrasound, relaxation, and stretch- ation, and diminished pain from trig- In addition to these symptoms, the ing exercises.2 Medications that have ger points.1 Prolotherapy has been patient’s feet were constantly hot and been used to alleviate pain include used to treat the following pain con- burning with pain. Twice a month, nonsteroidal antiinflammatories ditions: tendonitis, migraines, osteo- the patient reported numbness that (NSAIDs), acetaminophen, antide- arthritis, sports injuries, degenerated radiated from her feet to buttocks. pressants, muscle relaxants, and opi- joints, and ligament strains.2 She reported that the pain symptoms oids. Many patients find relief with This case describes a patient with were worse when her body tempera- dry needling, a procedure in which complications who had chronic pain ture increased to about 101 degrees. a needle is inserted into the skin and due to MFS for 15 years and was un- She was evaluated in the Women’s muscle directly at the trigger point, responsive to the abovementioned Clinic for the fever, which was of or injections of anesthetics, such as conservative treatments. Following 3 unknown etiology; results from the . The goal of treatment is to courses of prolotherapy, however, the physical workup were normal. reduce pain from the chronic strain of patient experienced a significant re- The patient’s medical history in- the affected muscle area. duction in pain and a decreased need cluded osteopenia, Addison disease, Alternative treatments may also be for opiates. The patient was able to re- degenerative arthritis of the spine, turn to work as a military instructor. sciatica, major depressive disorder, Dr. Pham is program director of the Pain Medi- cine Fellowship Training at the VA Greater Los Sheehan syndrome (on chronic oral Angeles Healthcare System (GLAHS); associate INITIAL EXAMINATION steroid management), military sexual program director of the physical medicine and A 52-year-old white female was seen trauma, and dyslipidemia. The pa- rehabilitation residency training program at UCLA/ GLAHS; and associate professor of the David in the Chronic Pain Clinic at the VA tient’s family history included a sis- Geffen School of Medicine at UCLA, all in Los An- Greater Los Angeles Hospital in Los ter who has multiple sclerosis and a geles, California. Ms. Quan is a medical student Angeles, California, for long-standing mother who has polymyalgia rheu- at David Geffen School of Medicine and Charles Drew University, both at UCLA in Los Angeles, “total body pain” of 15 years. Prior matica. California, and Ms. Bao is a physical medicine to the clinic visit, she was evaluated Furthermore, the patient reported and rehabilitation services in the Rheumatology Clinic and di- smoking 5 to 10 cigarettes per day, nurse practitioner at GLAHS and assistant clinical professor at the UCLA School of Nursing, both in agnosed with fibromyalgia, a disorder consuming 5 beers per week, and no Los Angeles, California. characterized by chronic widespread use of recreational substances. She

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Table 1. Location of 18 tender points in patients with fibromyalgia5 Right Left Tender points on both the right and left sides of the human body X X 1. Low cervical region (front neck area): between the transverse processes of C5- C7. X X 2. Second rib (front chest area): at second costochondral junctions. X X 3. Occiput (back of the neck): at suboccipital muscle insertions. X X 4. Trapezius muscle (back shoulder area): at midpoint of the upper border. X X 5. Supraspinatus muscle (shoulder blade area): above the medial border of the scapular spine. X X 6. Lateral epicondyle (elbow area): 2 cm distal to the lateral epicondyle. X X 7. Gluteal (rear end): at upper outer quadrant of the buttocks. X X 8. Greater trochanter (rear hip): posterior to the greater trochanteric prominence. X X 9. Knee (knee area): at the medial fat pad proximal to the joint line. previously worked as a U.S. Air Force tal muscle insertions, costochondral the electromyogram of the lower ex- cadet instructor but was unable to junction, supraspinatus, distal lateral tremities were normal. continue due to worsening pain. She epicondyle, superior lateral gluteal Based on the findings of trigger was previously married and has an areas, or medial knee. She had pain points on physical examination, the estranged teenaged son. Two years be- in 8 out of 18 preestablished tender patient was given the diagnosis of fore her visit to the pain clinic, she points. This finding did not meet the MFS rather than fibromyalgia. The moved from the East Coast to Califor- criteria for fibromyalgia, which re- differences between MFS and fibro- nia to live with her fiancé; however, quires the presence of 11 out of 18 myalgia are described in Table 2. Her their engagement did not work out tender points listed in Table 1.4 pain was attributed to multiple fac- because of trust issues. Pressure over the bilateral upper tors, including psychosocial stressors, The patient, a slim, petite female, trapezius and gluteal trigger point re- deconditioning, and depression. was dressed appropriately for the gions produced sharp pain radiating physical examinations. She was often to the upper and lower extremities, TREATMENT depressed and cried during the ses- respectively. The patient’s test results During the course of treatment in the sions. Her vitals were consistently were negative for both the straight-leg Chronic Pain Clinic, the patient re- normal despite reports of low-grade raise test and the flexion, abduction, ceived a multidisciplinary treatment fevers. Her musculoskeletal exami- external rotation test. Her neurologic that included therapies, oral medi- nation showed a normal range of examinations showed symmetrical re- cations, local muscle injections, and motion in all joints of the upper and flexes in the bilateral upper and lower psychological counseling. In this lower extremities. There were no joint extremities and normal tone. Addi- time period, she was given various effusions, increased warmth, or ery- tionally, her test results were negative NSAIDs, muscle relaxants, thema in those regions. In addition, for the Hoffman and Babinski signs. (extended-release morphine with she had diffuse pain and tenderness Magnetic resonance imaging (MRI) oxycodone or hydrocodone for break- over the bilateral upper trapezius of the spine revealed mild hypertro- through pain), an anticonvulsant (ga- (midway between neck and shoul- phic degenerative facet joint disease at bapentin) for neuropathic pain, and der), gluteal (over piriformis mus- L4-L5 and annular disc bulging at L4- antidepressants (fluoxetine, nortrip- cles), lumbar paraspinal (L3 to S1), L5, without other significant disc ab- tyline, trazodone, and venlafaxine) as and sacroiliac (SI) ligament (over normality or significant central canal adjuvant therapy. The nonpharmaco- posterior superior iliac spine) areas. stenosis. Radiograph with flexion/ex- logic management included ice and However, the tender points were not tension views of the lumbar spine was heat, physical therapy (myofascial re- found over the bilateral suboccipi- normal without instability. Results of lease, posture corrections, stretches,

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Table 2. The differences between myofascial pain syndrome (MPS) and fibromyalgia—MPS is often present in the fibromyalgia patient, but not all MPS patients have fibromyalgia MPS Fibromyalgia Trigger points are painful points that radiate Tender points are painful areas over specific regions of the to distal areas in the body with pressure. Taut, body. The pain does not spread or radiate distally. ropy bands in the muscle may be palpated over trigger points throughout the body. Diagnosis requires the presence of any trigger Diagnosis requires the presence of 11 of 18 preestablished points over a muscle group. tender points listed in Table 1. Trigger points are usually localized to a specific Tender points are diffuse and usually present in all 4 quadrants muscle group, such as shoulder, back, neck, etc. of the body (bilateral upper and lower parts of the human body). Pain can be intermittent and is often associ- Pain is widespread, more or less continuous, and present for ated with increased activity. at least 3 months. Pain is often associated with muscle, liga- Pain is often associated with depression, insomnia, and other ment, or tendon sprain. It is often a result of psychological symptoms. chronic trauma due to repetitive work injury or altered posture due to poor exercise. Treatment includes myofascial release, trigger Treatment includes antidepressant medications, muscle re- point injections, stretching exercises, postural laxants, psychological counseling, and general conditioning training, and strengthening exercises. exercises.

and general conditioning exercises), tinued to seek medical care from her injections with few adverse effects chiropractic therapy, and aquatic ther- psychiatrist and primary care physi- (AEs). apy. The abovementioned treatments cian for psychotherapy and medical The patient continued to do well yielded no long-term relief. The pa- treatment. After 2 years of using tradi- after 1 month, when she returned for tient also received multiple trigger tional treatments and failing to obtain her follow-up visit. After 2 additional point injections to the upper and long-lasting pain relief, the physicians injections at 1-month intervals, she lower back areas (bilateral upper tra- decided to try a course of prolother- reported that her mood improved as pezius, bilateral rhomboids, and bilat- apy to the trigger points over bilat- the pain level decreased, and she no eral lumbar paraspinal muscles—L5/ eral trapezius, gluteal, and SI ligament longer experienced crying episodes. L4). The injections were performed areas. This was performed with a 25- At that time, an examination showed using a 1.5-inch 25-gauge needle with gauge needle injecting a solution of persistent tenderness over the same a solution of 1 cc of 1% lidocaine 1 cc of 50% dextrose mixed with 1 cc trigger points; however, these areas to each trigger point along with dry of 1% lidocaine into each of the trig- were far less painful. The patient’s needling. This regimen gave her ef- ger point areas. The patient tolerated pain level decreased from 8/10 to fective but temporary relief for about the prolotherapy injection procedure 3/10, and she was able to exercise reg- 2 weeks. She also received injections well and reported improved symp- ularly. After a course of 3 prolother- with a combination of 1 cc of 1% li- toms within a few minutes after the apy injections, the patient improved docaine and 4 mg of methylpredniso- injection. The immediate resolution significantly. She was able to return lone acetate injectable suspension to of pain is most likely related to the to work, and the dosage of her each trigger point site. However, the lidocaine. Depending on the concen- medication was reduced. Morphine combination of lidocaine with a ste- tration of dextrose to lidocaine ratio sulfate sustained action 15 mg bid roid was not as effective as the injec- and the patient’s pain tolerance, some was reduced to once a day as needed. tion with lidocaine alone. patients may develop local muscle Oxycodone 5 mg tid was reduced to During her enrollment in the soreness after the lidocaine solution once a day as needed. Chronic Pain Clinic, the patient con- wears off. This patient tolerated the

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DISCUSSION in the formation of connective tis- may interfere with the healing cycle This case details prolotherapy treat- sue—tendons, ligaments, muscle fas- and, thus, the body’s attempt to heal. ment that resulted in effective pain cia, and joint capsular tissue—which Injured tendons or muscles that do relief in a patient with chronic MFS. holds the skeletal structure together.3 not heal completely are more likely Myofascial pain syndrome is among When injured, the body produces to sustain injury with daily activities, the most common disorders seen in collagen to heal the wound, but poor resulting in chronic inflammation pain clinics.3 However, many patients blood supply to connective tissues and, therefore, chronic pain. Thus, with MFS also experience psychologi- prolongs the healing process. Pro- treating the resultant inflammatory cal symptoms, which may likely in- lotherapy helps produce collagen process with antiinflammatory drugs crease the perception of pain level. In through injections of mild natural (NSAIDS and steroids) can reduce this particular patient, conservative dextrose or chemical irritants, which the pain symptoms, but treating the treatments alone were unsuccessful triggers the immune system’s process underlying cause of pain, such as in treating the injury of the affected to create collagen naturally.3 the weakened structure, is equally muscles caused by chronic strain with Some prolotherapists use mild important. In addition, this patient underlying deconditioning. Symp- chemical irritants, such as phenol, was on chronic steroid treatment for toms of depression, psychosocial guaiacol, or tannic acid, to stimu- Sheehan syndrome. Chronic steroid stressors, and other comorbidities, late the healing mechanism.3 These use is expected to weaken tendons such as Sheehan syndrome, contrib- agents adhere to the walls of the cells and ligaments, impairing the healing uted to her pain perception. Her wherever they are injected and cause process.10 While the healing effects chronic opioid treatment resulted in inflammation. In addition, other pro- of prolotherapy can be reduced by opioid tolerance and a possible opi- lotherapists use osmotic shock agents, steroid use, this alternative treatment oid hypersensitivity syndrome, a which are simply compounds, such as may have provided tissue healing and condition which causes the body to dextrose and glycerine.3 These sub- pain relief in the patient. become very sensitive to pain. Since stances are commonly used in treat- the patient’s pain was refractory to tra- ment and are soluble in water and CONCLUSION ditional treatment, an alternative ap- not toxic to the body. After having This case demonstrates the poten- proach was needed. the initial desired effects, these com- tial value of prolotherapy in treat- Prolotherapy at the trigger pounds are easily excreted from the ing chronic pain, especially when all points—hypersensitive bundles of body. They function by causing water other treatment options have been ligament, muscle fiber, or tendons to flow out of the cells, leading to cel- exhausted. This patient also had that cause referred soreness and local lular dehydration, inflammation, and complex medical and psychosocial soreness—may have strengthened the healing. factors that likely contributed to her tissue by increasing its fibrous con- Inflammation is the body’s re- overall pain concerns. Resolution tent.2,3 Past studies done by Liu and sponse to injuries and is described or improvement of any of these fac- colleagues regarding the treatment by the buildup of leukocytes, fluid, tors is expected to improve her pain of prolotherapy on rabbit tendons cytokines (inflammatory mediators), symptoms. However, despite contin- showed increased ligament mass by and blood flow to the site of damage.3 ued medical treatments and psycho- 44% as well as increased strength by Inflammation creates pain, indicating logical counseling, the patient’s pain 28%.6 This experiment provided fur- that the body’s healing mechanisms symptoms were not effectively man- ther support for Hackett’s 1955 study are occurring. Injecting the prolifer- aged. In addition, she reported no on the proliferation of rabbit tendons ant stimulates the inflammatory pro- changes in her social situation dur- using prolotherapy.7 In 1955, Dr. cess, causing an influx of cytokines ing the course of treatment. After 2 Hackett studied the effects of inject- and growth factors, which creates years, she expressed frustration with ing a proliferant into rabbit tendons. new tissues and repairs the damage.3 the lack of progress and was recep- He reported moderate infiltration of The inflammatory process is thought tive to trying alternative treatment op- lymphocytes in the tissues within 48 to alleviate pain by creating new tis- tions. The concept of treatment using hours of injection and fibroblastic or- sues in the area of the trigger points. proliferative agents was new to her, ganization and capillary proliferation Since ligaments and tendons have and the effect likely played within 2 weeks.7 limited blood supply, prevention of a role in her responses to this treat- Collagen plays a significant role the initial inflammatory response ment. Nevertheless, it is believed that

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her ability to return to her usual work those of the authors and do not neces- 3. Darrow M. Prolotherapy: Living Pain-Free. Los An- geles, CA: Protex Press; 2004. duties contributed positively to her sarily reflect those of Federal Practi- 4. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The Ameri- overall sense of well-being, and thus tioner, Quadrant HealthCom Inc., the can College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symp- improved her coping abilities. U.S. Government, or any of its agen- tom severity. Arthritis Care Res. 2010;62(5):600-610. The authors believe that prolo- cies. This article may discuss unla- 5. Diagnosing Fibromyalgia. Fibromyalgia Information Foundation website. http://www.myalgia.com/Diag therapy has relatively low risks and beled or investigational use of certain nosis/Diagnosis.htm. Accessed October 29, 2012. minimal AEs. Thus, it is important drugs. Please review complete prescrib- 6. Liu Y, Tipton C, Matthes R, Bedford TG, Maynard JA, Walmar HC. An in situ study of the influence of for clinicians to be aware of this alter- ing information for specific drugs or a sclerosing solution in rabbit medial collateral liga- native treatment option. Additional drug combinations—including indica- ments and its junction strength. Connect Tissue Res. 1983;11(2-3):95-102. studies will be needed to determine tions, contraindications, warnings, and 7. Hackett GS, Henderson DG. Joint stabilization; an the value of prolotherapy for manage- adverse effects—before administering experimental, histologic study with comments on the clinical application in ligament proliferation. Am ment of MFS. pharmacologic therapy to patients. J Surg. 1955;89(5):968-973. 8. What are Fibromyalgia Trigger Points? Fibromyalgia Advisor website. http://www.fibromyalgia-advisor Author disclosures REFERENCES .com/fibromyalgia-trigger-points.html. Accessed The authors report no actual or poten- 1. Hou CR, Tsai LC, Cheng KF, Chung KC, Hong November 5, 2012. CZ. Immediate effects of various physical thera- 9. Hauser RA, Hauser MA. Prolo Your Pain Away! Cur- tial conflicts of interest with regard to peutic modalities on cervical myofascial pain and ing Chronic Pain With Prolotherapy. 2nd ed. Oak this article. trigger-point sensitivity. Arch Phys Med Rehabil. Park, IL: Beulah Land Press; 2004. 2002;83(10):1406-1414. 10. An Alternative to Cortisone Shots. Prolotherapy In- 2. Treatment of Myofascial Pain Syndrome. Caring Med- formation by Ross Hauser, MD, website. http://www Disclaimer ical & Rehabilitation Services website. http://www .prolonews.com/prolotherapy_e-newsletters_corti .caringmedical.com/condition_details/Myofascial sone_shots.htm. Accessed October 30, 2012. The opinions expressed herein are _Pain_Syndrome.htm. Accessed October 29, 2012.

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