Comparison Between The Effects Of Trigger Point .
Complementary Therapies in Medicine (2011) 19, 19—26available at www.sciencedirect.comjournal homepage: www.elsevierhealth.com/journals/ctimComparison between the effects of trigger pointmesotherapy versus acupuncture pointsmesotherapy in the treatment of chronic low backpain: A short term randomized controlled trialAnnalisa Di Cesare a, , Arrigo Giombini b, Mariachiara Di Cesare c,Maurizio Ripani b, Maria Chiara Vulpiani d, Vincenzo Maria Saraceni aaComplex Operative Unit of Physical Medicine and Rehabilitation, Policlinico Umberto I Hospital, University of Rome ‘‘LaSapienza’’, Piazzale Aldo Moro, 5, 00185, Rome, ItalybDepartment of Health, University of ‘‘Foro Italico’’, Rome, ItalycCentre for International Education University of Sussex, UKdOrthopedic Unit and Kirk Kilgour Sports Injury Center, Sant’Andrea Hospital, ‘‘La Sapienza’’ University, School of Medicine,Rome, ItalyAvailable online 15 December 2010KEYWORDSMesotherapy;Acupuncture;Trigger points;Low back pain SummaryObjective: The goal of this study was to compare the effects of trigger point (TRP) mesotherapyand acupuncture (ACP) mesotherapy in the treatment of patients with chronic low back pain.Design: Short term randomized controlled trial.Setting: 62 subjects with chronic low back pain were recruited at outpatients Physical Medicineand Rehabilitation Clinic at the University of Rome ‘‘La Sapienza’’ in the period between July2006 and May 2008.Intervention: Study subjects were assigned to receive 4 weeks treatments with either trigger point mesotherapy (TRP mesotherapy, n 29) or acupoints mesotherapy (ACP mesotherapy,n 33).Main outcome measures: Pain intensity with a pain visual analogic scale (VAS) and verbal ratingscale (VRS) and pain disability with McGill Pain Questionnaire Short Form (SFMPQ), Roland MorrisDisability Questionnaire (RMQ) and Oswestry Low Back Pain Disability Questionaire (ODQ).Results: ACP mesotherapy shows a more effective results in VRS and VAS measures in the followup (pVRS .001 and pVAS .001). The SF-MPQ measure shows a better results for ACP instead ofTRP with statistically significant differences between groups and time (p .035). Participantsreported a slight discomfort at the time of the inoculation, and 15% reported slight neck painin ACP mesotherapy group.Corresponding author. Tel.: 39 06 491672; fax: 39 06 49914534.E-mail address: annalisa.dicesare@gmail.com (A. Di Cesare).0965-2299/ — see front matter 2010 Elsevier Ltd. All rights reserved.doi:10.1016/j.ctim.2010.11.002
20A. Di Cesare et al.Conclusions: Our results suggest that the response to ACP mesotherapy may be greater than theresponse to TRP mesotherapy in the short term follow-up. This technique could be neverthelessa viable option as an adjunct treatment in an overall treatment planning of CLBP. 2010 Elsevier Ltd. All rights reserved.IntroductionChronic low back pain (CLBP) is one of the most prevalent condition that affect modern society with increasingfrequency. Approximately 70—80% of the population ofindustrialised countries suffers from low back pain (LBP) atleast once in life.1 It is estimated that every year 5—10% ofworking age population is off work for a duration of approximately 7 days because of their LBP.2,3 Approximately 90% ofsubjects with acute LBP demonstrate a quick recovery evenwithout therapy.4 However between 2% and 24% of cases lastover three months.5,6 Many patients with CLBP request anunconventional therapy when treatment with non-steroidalantinflammatory drugs analgesics and myorelaxant, physiotherapy and exercise therapy is unsatisfactory.7—11 In80—90% of cases the pain is of non-specific musculoskeletalorigin with diagnostic tests (Rx, MRI) negative.12,13 Furthermore, there are many therapeutic strategies but the longterm effect of single therapeutic approach remain limited.14Mesotherapy is one of the techniques that can be consideredamong the techniques proposed by the medical communityin the treatment of LBP especially in Europe.15 The methoddates back to 1952 in France with Doctor Michel Pistor andconsists of a series of either single or simultaneous multi,intradermal or superficial subcutaneous injections directlyover the structures affected by inflammatory processes.16Mesotherapy is a specialized medical treatment that delivers approved medications like NSAIDS, analgesic, anestheticunder the surface of the skin to the mesoderm layer of theskin and it is recommended in the treatment of the painfulmusculoskeletal affections.17 Another widely complementary therapy is represented by acupuncture. Acupuncturehas been frequently used in the treatment of CLBP.19,20 Several randomized controlled trials on acupuncture for CLBPhave already been published, however, its efficacy remainscontroversial due to insufficient empirical evidence and thedifficulty to isolate the specific effects of the technique fromthe non-specific ones (i.e.,the placebo effect).20—22 The lackof scientific papers on the application of mesotherapy inthe treatment of pain, especially in an high degree of public interest condition, such as the CLBP, convinced us toundertake this trial. The purpose of this study is to evaluate the effects of superficial trigger points mesotherapyversus acupuncture points mesotherapy in the treatment ofpatients affected by CLBP.Materials and methods110 subjects with CLBP were examined at the outpatientPhysical Medicine and Rehabilitation Clinic of the Locomotor Apparatus Sciences Department at the University ofRome ‘‘La Sapienza’’, in the period between July 2006 andMay 2008. After having met inclusion and exclusion crite-ria for the study, a sample of 62 subjects, were selected(Fig. 1a). The inclusion criteria were low back pain for atleast 6 months, patient age above 45, no pharmacological therapy for other systemic pathologies, and no previoustreatment with mesotherapy for CLBP. The exclusion criteriawere the presence of neurological pathologies, concomitant severe rheumatic disease, systemic pathologies (e.g.diabetes), a surgical intervention within 3 months prior tothe study, psychiatric pathologies or patients undergoingpsychotherapeutic treatment or physical treatment within5 weeks prior to the study. Patients did not receive anyother medical intervention during the study. All patientswho met the inclusion criteria and agreed to participatein the study received a general explanation of the trial,and gave written informed consent, approved by the University of Rome ‘‘La Sapienza’’ Istitutional Review Boardfor Biomedical Research, were enrolled and randomly allocated to one of two groups by using 2 and 4 permutatedblock size randomization by employing a sequence of random numbers obtained from a statistics textbook. One ofthe investigators who was not involved in the clinical management of the patients prepared the results in sequentiallynumbered opaque envelopes. The sealed envelopes werethen opened for each patient and patients were includedin the study after taking a record of the allocation. Bothgroups were treated with drug injection. TRP mesotherapygroup consisting of 29 subjects, treated according to the TRPmesotherapy and ACP mesotherapy group consisting of 33patients treated according to ACP mesotherapy (Table 1).At baseline all patients underwent complete evaluationincluding a detailed medical history, report of any allergic reactions to anesthetics, routine physical examinationand a neurological investigation. The physical examinationof the lumbar spine was conducted by a doctor who wasunaware of the group allocation. All patients were askedto provide a standard radiography (anterior—posterior andlateral X-rays) of the lumbosacral tract. Primary outcomemeasures were pain intensity, quantified using a 10 cm VAS(visual analogic scale) where the patient is asked to markon a millimetric scale from 0 (absence of pain) to 10 (theworst pain imaginable) the degree of intensity of LBP23 andVRS (verbal rating scale) graded on a six points scale (nopain, very slight, mild, moderate, severe, and intolerablepain)24 ; pain disability measured with the most used validated scales for patients with LBP: SFMPQ (McGill PainQuestionnaire Short Form)25 this scale consists in 15 descriptors (11 sensory, 4 affective) which are rated on an intensityscale as 0 no pain, 1 mild, 2 moderate, 3 severe, threepain scores are derived from the sum of intensity rank values of the words chosen for sensory, affective and totaldescriptors; RMQ (Roland Morris Disability Questionnaire)26which consists of 24 questions answered yes or no responsefor each range 0—24 points, the ODQ (Oswestry Low Back
The effects of trigger point mesotherapy versus acupuncture points mesotherapyFigure 1(a) Participation flow in the study. (b) Design of the trial.Pain Disability Questionaire)27 which consists of 10 itemsassessing the level of pain and interference with severalphysical activities, with six response options per item withan overall score 0—50. The evaluation scales were carried out by a blinded assessor before the first treatment(pre), at the end of the treatment after 4 weeks (post),and at a follow-up of 12 weeks after the last treatment(Fig. 1b).Table 121Interventions2 cc of local anesthetic lidocaine cloridrate 2% was usedfor injection. 18 injection points were stimulated in bothgroups. The main investigator (3 years of acupuncture training and 8 years of clinical experience) used a point by pointinjecting technique with specific needles (Luer needles,30 G 0.4 mm 4 mm) fully inserted. In this technique a 5 ccBaseline characteristics of TRP and ACP group mean values (standard deviation) at baseline, p-values.SexAge (y)Pain duration (months)VRSVASSF-MPQRMQODQGroup A TRP mesotherapy (n 29)Group B ACP mesotherapy (n 33)p-value16 female; 13 male52.5 12.15 0.24.7 0.97.5 1.618.7 8.212.8 4.827.4 13.918 female; 15 male52.5 12.94.7 1.15 0.77.3 1.516.3 7.713.3 4.124.5 13.60.9230.544—0.2440.7840.7520.8560.629
22A. Di Cesare et al.syringe is held at 45 angle from the skin and only a drop ofanesthetic is introduced at each of the selected site. In TRPmesotherapy group 18 local superficial trigger points of themost important accessible muscles of the lumbar tract andthe hip were examined and treated; the correct applicationof the technique requires experience in palpation and localisation of tender points in taut bands of skeletal muscles;these were identified according to Travell and Simons triggerpoint manual.28,29 In particular, for the quadratus lomborum 2 bilateral trigger points were treated: one at the anglebetween the crest of the ilium and transverse processes ofL4 and the other at the transverse processes of L1—L2; forthe iliopsoas muscle two paravertebral bilateral points weretreated: one on the D12 thoracic vertebrae and the otherone on L2 lumbar vertebrae; for the gluteus maximus threebilateral trigger points were treated all on the medial superior portion of sacrum region; for the piriformis muscle 2bilateral points were treated: one at the junction betweenthe middle and the outer third of the piriformis line and theother one at medial end of piriformis line (Fig. 2). In ACPmesotherapy group after a literature review on acupuncturefor the treatment of LBP17—19 only widely accepted acupoints according to the traditional Chinese medicine wereselected. We did not conduct a diagnostic procedure todetermine individual acupoints. In particular, the following18 fixed body acupoints were selected and treated: gall bladder 30, bladder 31 and 52 bilateral, governor vessel (Du Mai)3, dorsal (Ashi) and points at a distance: gall bladder 34 and41, bladder 60, kidney 4 bilateral, triple energizer 5 (Fig. 3).All the subjects received one treatment per week for fourweeks. The follow up evaluation was carried out 12 weeksafter the last treatment (Fig. 1b). The same experiencedFigure 3Figure 2Trigger points used for TRP mesotherapy.acupuncturist performed all treatments. To keep to a minimum the interaction with the subjects the main investigatorwas not involved in any other procedure of the study.Statistical analysisBlinding was maintained until the end of the study. Demographic and baseline values of clinical data of all subjectswere calculated as the mean values at the first visit. Comparative analysis was focused on the end of the treatment(after 4 weeks) and follow-up (12 weeks from the last treatment). An intention to treat approach in all the statisticalanalyses was adopted. However, a per-protocol analysis wasalso performed. We assigned a constant outcome based onthe last observed response to the dropout patients. Thisinvolved assigning the baseline response at 4 and 12 weeksmeasurement for the dropout at 0 weeks in TRP group,Acupuncture points used for ACP mesotherapy.
The effects of trigger point mesotherapy versus acupuncture points mesotherapyFigure 423Mean value VRS, VAS, SF-MPQ, RMQ, ODQ — pre, post and follow-up.and the end of treatment (week 4) response for the 12weeks measurement for the single dropout patient in ACPgroup.A Student unpaired t-test was performed to determinewhether the two groups were similar at baseline (for demographic and the five outcomes scores), while the analysisof covariance (ANCOVA) for each individual’s post andfollow-up treatment means with baseline measurements ascovariate was performed to determine differences at postand follow-up between the two groups. A p level of .05 wasconsidered to be statistically significant. All data analyseswere performed with SPSS 13.ResultsThe average age of the patients and the standard deviationwas calculated for all subjects (Table 1). No differences werefound between the two groups regarding the evaluated variables at the baseline including sex, age and duration of pain.At baseline there were also no statistically significant differences (p .01) between the groups regarding the outcomemeasures examined, pain intensity (VAS and VRS scales) andpain disability (SFMPQ, RMQ, ODQ scales). The appearanceof a new systemic disease (diabetes) was the reason forTable 2 Mean values, standard deviation, differences between groups, p-values of all outcomes scales (VRS, VAS, SF-MPQ,RMQ, ODQ) — means and differences adjust for baseline scores.WeekTRP groupMean (SD)ACP groupMean (SD)TRP group—ACP group (95% C.I.)pVSR4122.27 (.20)3.27 (.20)2.32 (.19)2.49 (.19).05 ( .50 to .60) .78 ( 1.34 to .22).852.008VAS4123.80 (.27)4.73 (.25)3.62 (.25)3.53 (.24) .18 ( .91 to .55) 1.21 ( 1.90 to .53).625.001SF-MPQ41210.75 (.95)12.00 (1.09)8.28 (.89)7.26 (1.02) 2.46 ( 5.07 to .15) 4.75 ( 7.76 to 1.74).064.002RMQ4127.68 (.51)7.96 (.53)7.10 (.48)6.88 (.50)ODQ41218.74 (1.09)19.42 (1.55)16.32 (1.02)14.80 (1.46) 58 ( 1.98 to .82) 1.08 ( 2.55 to .38) 2.42 ( 5.41 to .57) 4.63 ( 8.90 to .36).411.146.111.034
24a drop-out in TRP mesotherapy group, while inability torespond to the functional questionnaires for work-relatedproblems, was the reason for the drop-out in ACP mesotherapy group. In our study none of the patients presented sideeffects except for a slight neck pain that was experienced bythe 15% of the patients in ACP mesotherapy group betweenthe first and the second session, which had the remissionof symptoms at the end of the second week of treatment,without the use of any drugs. In Table 2 the results forthe ANCOVA analysis are shown. The difference betweenthe two groups at post-measure (4 weeks) adjusted for thebaseline scores, do not show statistically significant differences between the two groups for all measures (pVRS .852,pVAS .625, pSF-MPQ .064, pRMQ .411, pODQ .111) (Table 2).However, the group difference between the follow-up measures adjusted for the baseline indicates that exists astatistically significant difference between the two groupsfor all the measure except for the SF-MPQ test (p .05). ForVSR (p .008), VAS (p .001), SF-MPQ (p .002), and ODQ(p .034) the ACP group shows significant better outcomesat the follow-up than the ones observed in the TRP group,indicating a better efficacy of the acupoints option in thelong term run (Fig. 4).DiscussionCLBP is an important healthcare and socioeconomic problemand is associated with high medical expenses, disability andinability to work. It often shows only minor improvementwhen treated with conventional therapies and for this reason, there is an ongoing research for additional standard oralternative treatments.3Acupuncture and mesotherapy separately represent twoof the proposed treatments by the medical community toalleviate symptoms in patients with CLBP. A recent metanalysis showed that acupuncture is more effective thansham acupuncture and no additional treatment for providing short term relief of CLBP. This short term relief seemsto be sustained over the longer term.30,31 In most of thestudies stimulation site has been a traditional acupoint.However, Kazunori et al. recently demonstrated that treatment of trigger points may be more effective on LBP inelderly patients than at traditional acupuncture points.32,33Long before, mesotherapy became an acceptable treatmentmodality in cosmetic dermatology34 but it gained recognition primarily in pain management, sport medicine andrheumatology.17 Claiming that localized therapy avoids systemic adverse effects, mesotherapy originally conceived inEurope, has been used primarily for pain relief followingdental procedures and to treat a broad spectrum of injuriesand medical conditions such as tendonitis, tendon calcifications, cervicobrachialgia, arthritis, etc.15,35—39 However,information on mesotherapy in the English language medical literature is scant, the majority of scientific data on theuse of mesotherapy in sport medicine and in the treatmentof pain are currently written in French and consist of clinicalcase studies, all published in the journal of French Society ofMesotherapy, which has been published for 30 years.17,40 Themajor strength of our study lies in its scientific stringency.We were extremely careful in the randomisation process,the two groups showed no statistically difference at base-A. Di Cesare et al.line regarding their demographic variables, and in the use,as outcome measures, of different subjective pain scalesand validated disability questionnaires, designed by selecting items relevant to back pain. Our design was moreoverimportant, in fact all patients received treatment for fourweeks and the final evaluation was performed after 12 moreweeks to ascertain whether improvements lasted over time.The data for the statistical analysis were processed by astatistician who was unaware of the treatment allocation.In the present study TRP and ACP mesoteraphy show similarpatterns in the decrease of measures between pre and post,however some differences can be identified at the followup. Using ACP instead of TRP show a more effective resultsin VRS and VAS measures in the follow-up. For the formerthe change in VRS measure between the post and the followshows a slight increase compared to the TRP. For the latterat the follow-up the ACP show a slight decrease versus anincrease in the value observed for the TRP group. The SFMPQ measure shows a better results for ACP instead of TRPwith statistically significant differences between groups andtime.Our results suggest that the response to ACP mesotherapy may be greater than the response to TRP mesotherapyin the short term follow-up (12 weeks after the end of lasttreatment). Our results suggest, moreover that the stimulation site is important. We hypothesized that the longlasting effect of ACP mesotherapy could be due to thesmoothing out blocked energy (Qi) that stuck in differentareas of the body; our hypothesis is further on strengthened by the presence of neck pain as a distance side effectexperienced by the 15% of patients in the ACP mesotherapy, as a result of a general activation.41 The proposedmechanism of action of mesotherapy is that solutions thatare injected intracutaneously remain in the area longerthat
Acupuncture; Trigger points; Low back pain Summary Objective: The goal of this study was to compare the effects of trigger point (TRP) mesotherapy and acupuncture (ACP) mesotherapy in the treatment of patients with chronic low back pain. Design: Short term randomized controlled trial. Setting: 62 subjects with chronic low back pain were recruited at outpatients Physical Medicine and .
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Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. Crawford M., Marsh D. The driving force : food in human evolution and the future.
Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. 3 Crawford M., Marsh D. The driving force : food in human evolution and the future.
