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Tender Point Injections

“When the patient with fibromyalgia (FM) comes in the front door, I want to leave by the back door”, stated Sir William Osler many years ago. Such is the plight of many rheumatologists who are frustrated by the current means at our disposal of treating FM.

It is true that until recently we had no specific therapy for FMS. Today, we have 3 FDA approved drugs for this disorder: Lyrica, Cymbalta and Savella. However, it has been the experience of many physicians, including myself, that there has been resistance from the patient on taking these, primarily due to 2 factors: adverse effects and cost. At present there is no generic product for any of these drugs, so the cost may be very high.

Multiple possible adverse effects may be perceived by the patient, highlighted by the package insert received from the pharmacist, as well as frequent television advertisements for the medication.

One of the treatment modalities that many rheumatologists employ to treat FM is trigger area injection. We are all familiar with the diagnostic 18 trigger point areas, which are easily accessible to local injection.

Until recently, the injected modality of choice was repository steroid mixed with xylocaine. Although effective, this may not be done too frequently due to the risk of a cumulative steroid adverse effect, especially in the elderly, thin female population who is most prone to develop bone loss from chronic steroid use. This is also true of the diabetic patient who may develop marked hyperglycemia following steroid use.

We have been utilizing a different regimen for trigger point injection, namely a combination of 2 innocuous homeopathic products - Traumeel and Spascupreel Injection Solutions, combined with .05 or 1% xylocaine. We have treated multiple patients with this combination homeopathic regimen.

Unlike steroids, there is virtually no limit to the number of trigger areas that may be treated. Once the trigger point is identified, one ampule each of Traumeel and Spascupreel and 1-2 cc of xylocaine is injected into the symptomatic region, utilizing a .5 inch 25 or 27 gauge needle, or with a 3/4 inch 25 gauge needle if the target area seems to be deeper. The procedure is without significant discomfort to the patient, and may be performed by a Physician Assistant or Nurse Practitioner.

In most cases, the patient was given a choice of corticosteroid or this natural modality.

The injection may be repeated weekly 3 times (or more), but usually 2 injections are sufficient and even 1 injection is frequently adequate, especially if onset of symptoms has been recent.

We have even seen symptomatic benefit in secondary fibromyalgia related to autoimmune connective tissue disorders; but by far, idiopathic FM has been the main indication.

Neurologists have for years used local steroid-xylocaine injections to treat migraine disorders. Recently the FDA has approved Botoxlonabotulinum toxin A (Botox) for local injection in patients with chronic migraine. This treatment has been shown to be effective but there are very significant cost and some safety issues associated with this therapeutic approach. It would be interesting to consider use of Traumeel and Spascupreel Injection Solutions for this indication.

We have used this regimen in treatment of several other connective tissue disorders in which we would otherwise have used corticosteroid, such as bursitis and tendonitis, with similar results.

Certainly, our results in use of Traumeel and Spascupreel Injection Solutions in treating trigger areas are anecdotal, however our experience in using these for the above myofascial pain syndromes has generally been favorable. Granted, randomized controlled trials need to be conducted.

Traumeel and Spascupreel Injection Solutions may be compared to saline, xylocaine or even just mechanical trigger point needling of the test area in the patient with FM. In addition, a non-inferiority trial could be conducted comparing Traumeel and Spascupreel trigger point injection to repository steroid injection.

The purpose of this communication is simply to alert the treating physician that an inexpensive, safe, and effective therapy may be utilized instead of local steroid injection and other medications in treatment of FM and other disorders. Case histories will be available upon request.

Dr. Charles Kahn, Rheumatologist, Hollywood, FL