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Issue: 2022, December, Volume 16, No 4
issue id: 2022_12_16_4
article id: 2022_12_16_4_15

Original Research



Original Research / Orijinal Araştırma


Effect of Neural Therapy on Cervical Discopathy-Related Chronic Neck Pain

Nöral Terapinin Servikal Diskopatiye Bağlı Kronik Boyun Ağrısına Etkisi

İbrahim Başhan1, Gülşah Yaşa Öztürk2


Abstract
Introduction: To investigate how 1% procaine injection therapy, one of the neural therapeutic agents, affects neck disability and pain intensity in patients who have cervical discopathies that are causing chronic neck pain and/or functional limitations Methods: The records of 58 patients diagnosed with cervical discopathy were examined. The Range of Motion values, Neck Disability Questionnaire and Visual Analog Scale scores were compared at baseline and one month after neural therapy. The results of cervical magnetic resonance imaging were analyzed, and the mean scores were compared between the protrusion and bulging. P values of <0.05 were considered statistically significant. Results: A statistically significant increase was observed in Range of Motion values after NT in all movements of the neck and the decrease in the mean Visual Analog Scale and Neck Disability Index scores after neural therapy were found to be statistically significant in both the protrusion and bulging groups. Conclusion: This is the first study providing evidence of the effects of neural therapy on neck pain severity and neck disability in adult patients with cervical discopathies (protrusion and bulging) presenting with chronic neck pain resistant to medical treatment, who had not yet made a surgical decision.
Key words: Neural therapy, procaine, cervical discopathy, neck pain


Özet
Giriş: Bu çalışmanın amacı, servikal diskopatisiye bağlı kronik boyun ağrısı ve/veya fonksiyon kaybı olan hastalarda uygulanan, nöral terapötik ajanlardan biri olan %1’lik prokain enjeksiyon tedavisinin, ağrı ve boyun disfonksiyonu üzerine etkisini araştırmaktır. Yöntem: Servikal diskopati tanısı alan 58 hastanın kayıtları incelendi. Hareket Açıklığı değerleri, Boyun Özürlülük Anketi ve Vizüel Analog Skala skorları başlangıçta ve nöral terapiden bir ay sonra karşılaştırıldı. p<0,05 değerleri istatistiksel olarak anlamlı kabul edildi. Bulgular: Nöral Terapi sonrası Hareket Açıklığı değerlerinde boynun tüm hareketlerinde istatistiksel olarak anlamlı bir artış gözlendi ve Vizüel Analog Skala ve Boyun Özürlülük İndeksi puan ortalamalarındaki azalma hem protrüzyon hem de bulging gruplarında istatistiksel olarak anlamlı bulundu. Sonuç: Bu çalışma, cerrahi kararı alınmamış medikal tedaviye dirençli kronik boyun ağrısı olan servikal diskopatili (protrüzyon ve bulging) erişkin hastalarda nöral terapi uygulamasının sonuçlarını gösteren ilk çalışmadır.
Anahtar kelimeler: Nöral terapi, prokain, servikal diskopati, boyun ağrısı



Geliş tarihi / Received: 19.05.2022    Kabul tarihi / Accepted: 11.10.2022

1Mersin Üniversitesi Tıp Fakültesi Tıp Eğitimi Anabilim Dalı / Türkiye
2Sağlık Bilimleri Üniversitesi Adana Şehir Sağlık Uygulama ve Araştırma Merkezi / Türkiye

Address for Correspondence / Yazışma Adresi: İbrahim Başhan, Mersin Üniversitesi Tıp Fakültesi Tıp Eğitimi Anabilim Dalı, Türkiye
ibashan@yahoo.com

Bashan I, Ozturk GY. Effect of Neural Therapy on Cervical Discopathy-Related Chronic Neck Pain. TJFMPC, 2022;16(4): 779-785

DOI: 10.21763/tjfmpc.1118848





Introduction
Neural therapy (NT) was first defined by two German physicians, Ferdinand and Walter Huneke, in the early 1900s, and while it is widely used in central Europe, especially in Germany and England, it remains unknown in most of the remaining countries across the world.1,2 NT is a simple and effective treatment method applied by injecting local anesthetics into the most common symptom trigger points or alternatively into autonomic ganglia, scars, and other tissues to alleviate the severity of chronic pain.3
The definition of a relationship between the autonomic nervous system and inflammation and pain, as well as the effect of local anesthetics used in NT stimulating the membrane potential of the nerve cell of the symptomatic region and the autonomic nervous system, has once again attracted researchers’ attention to this system.4,5 Instead of obtaining local anesthesia, the major aim of NT is to selectively eliminate other unpleasant stimuli by activating the parasympathetic nervous system in the needle-targeted areas. By influencing both the way the nervous system is organized and tissue perfusion, the aim is to break the cycle of pain.6,7 NT is used in the treatment of acute and chronic musculoskeletal diseases (MD), inflammatory diseases, and functional conditions. As in many studies on pain, successful results have been reported regarding the effectiveness of NT in treatment-resistant MD.8-11 With the use of NT in MD, treatment costs decrease and there is an increase patient satisfaction with the treatment and therapist.12 The most important reasons for the use of 0.5-1% procaine as one of the first-choice local anesthetic agents in NT are its short duration of action, not causing allergic reactions or inflammation at the application site, its role in cell regulation by regulating endothelial function with its metabolites, and not containing sympathomimetic substances.13
Neck pain is the second most common after low back pain and creates a high economic burden. One of the most important causes of neck pain is cervical intervertebral disc diseases (CD).14,15 There is no strong evidence suggesting that intervertebral discs (via degenerative or other changes) are a discogenic source of pain.16 However, cervical disc degeneration is known to cause inflammation (or vice versa), and inflammation triggers the migration of immunocyte cells and the secretion of inflammatory cytokines from disc cells.17 These cytokines increase the production of nerve growth factor, which may lead to the release of calcitonin gene-related peptide and substance P from the dorsal root ganglia, resulting in cervical discogenic pain.18,19
This study aimed to investigate the effect of neural therapy on neck pain and function limitation in patients resistant to medical treatment.

Methods

Study design and data collection
The patients who presented to the physical therapy and rehabilitation outpatient clinic of the City Hospital between March 2020 and March 2021 with complaints of neck pain were analyzed in this cross-sectional study. After a physical examination, cervical magnetic resonance imaging (c-MRI) was performed, and according to the results, 58 patients with persistent neck pain for longer than three months, who were diagnosed with CD (protrusion and/or bulging) and determined to be resistant to medical treatment (previously used local, intramuscular, or oral analgesic, anti-inflammatory and antimuscarinic agents) were included in the study.

The exclusion criteria
Patients that were scheduled for surgery due to CD, those with a history of surgery due to CD, fracture of the cervical vertebra, inflammatory diseases in the neck area, malignancy or coagulation disorders, patients under the age of 18 years, and pregnant or breastfeeding women were excluded from the study.

Treatment protocol
The patients underwent a total of three physical therapy sessions at one-week intervals. In the first session, 1% procaine was injected into the skin to form a lentil-sized papule into the painful points on the neck and trapezius area with palpation. In addition, quaddel method was applied, and approximately 0.5 cc of 1% procaine was injected into deep segmental trigger points (into fibrocystic nodules) detected by palpation. In the second session, the treatment protocol followed in the first session was repeated. In addition, 1% procaine was injected into the area of the first and seven cervical paravertebral segments to form a lentil-sized papule into the skin. In the last session, the second session protocol was repeated.20 All treatment sessions were performed by a physical therapy specialist with a certificate of neural therapy application.
The range of motion (ROM) was measured based on the guidelines of Kendall et al.; cervical flexion, extension, rotation and lateral flexion ROM measurements were made actively, each measurement was repeated three times and average values were calculated.21 The Neck Disability Index (NDI) scores were obtained for the evaluation of the effect of neck pain on daily life function, and the Visual Analog Scale (VAS) was administered to determine the patients’ pain level both at the beginning of the treatment and at one month after the third treatment session.22,23
Written informed consent was received from all the patients and approval was obtained from the Ethics Committee of the University of Health Sciences, City Training and Research Hospital (date 08.04.2021 and number 78-1365).

Statistical Analysis
The data obtained and additional c-MRI results were analyzed using SPSS v. 21 software package. The normality of continuous variables was evaluated using the Kolmogorov-Smirnov test. The paired t-test was used for the comparison of variables before and after treatment for normally distributed data, and the Wilcoxon test was conducted for those that did not conform to a normal distribution. The changes were found to be significant and effect sizes were calculated accordingly. Spearman’s Rho coefficient was calculated to determine the linear relationship of the difference between pre- and post-treatment VAS scores with age and body mass index (BMI), as well as the relationship of the difference in pre- and post-treatment NDI with these variables. According to the c-MRI results, the homogeneity analysis of the variances in the scores was performed with the Levene test. For the NDI scores Student's t-test, and for the VAS scores the Mann-Whitney U test was performed. Descriptive statistics were given as mean or median values with 95% confidence intervals. In addition, Student's t-test was also used to compare the averages by gender. Statistical significance was accepted as p < 0.05.

Results
Of the 58 patients participating in the study, 41 (70.7%) were female. The demographic characteristics of the patients and the c-MRI results of the patients are presented in Tables 1 and 2, respectively.








A statistically significant increase was observed in ROM values evaluating cervical ROM after NT in all movements (flexion, extension, rotation, and lateral flexion) compared to the baseline data (p < 0.001) (Table 3).





When the mean VAS and NDI scores of the patients were compared between the baseline and post-NT evaluations, statistically significant decreases were found (p < 0.001) (Table 4). In addition, there was a positive linear correlation between the VAS and NDI mean scores at baseline and after NT (r = 0.274; p = 0.037). The decrease in the VAS and NDI values after NT did not show a significant difference according to gender (Data not shown).





Table 5 shows the differences in the NDI and VAS score averages between the baseline and post-NT evaluations in the bulging and protrusion groups. In both groups, the decrease in the mean NDI and VAS scores was statistically significant (p < 0.001). When the bulging and protrusion groups were compared, although the baseline NDI values were numerically higher in the protrusion group, there was no statistically significant difference between the groups (p = 0.055). After NT, the decrease in the mean NDI scores (p = 0.999) and the decrease in the median VAS scores were similar in the bulging and protrusion groups (p = 0.999 and 0.453, respectively). No significant difference was observed in terms of the median VAS scores of the bulging and protrusion groups before and after NT (p = 0.100 and 0.261, respectively).





Discussion
In this study, neural therapy was shown to have positive effects on neck pain and functional disability in patients with CD. The aim of neural therapy practice is to increase the perfusion of unregulated tissues, organs, or systems and to remove destruction products by taking advantage of the effects of local anesthetics on anti-inflammatory, analgesic, sympatholytic, and cell membrane activation potential. This provides both analgesic efficiency and healthy functioning (regulation) of the organism.24,25 NT is known to be particularly effective on the autonomic nervous system. In addition to maintaining vital functions, the autonomic nervous system has the task of establishing a connection between the cells in the body. Abnormal electrical signals created by scar tissues are transmitted to other parts of the body via the autonomic nervous system. The term 'interference field', which refers to disturbances and pain in another part of the body with the dissemination of abnormal electrical activity, was first defined by Huneke in 1940. It is considered that these areas can develop as a result of physical trauma, and the application of local anesthetic corrects bioelectrical disorders and associated functional impairment.3,8,12 In the current literature, there are neural therapy studies on treatment-resistant chronic pain conditions (fibromyalgia, lumbar degenerative diseases, cervical myofascial pain syndrome, and degenerative diseases of the knee joint, etc.), which have reported successful results.10 Atalay et al. compared physical therapy over five sessions of neural therapy using lidocaine in the treatment of chronic low back pain and reported that both methods were effective in reducing this pain.9 In another study, 280 patients with chronic pain were evaluated, and it was reported that neural therapy was an effective method in the treatment of chronic pain, significantly increased patient satisfaction, and significantly reduced treatment costs.6 In a case report, Ugurlu et al. described a patient with persistent low back and leg pain due to lumbar disc herniation and piriformis muscle spasm, who was successfully treated with neural therapy techniques.26
Our sample consisted of patients with chronic neck pain and functional disability due to cervical discopathies, who were resistant to medical therapy and had not yet taken a surgical decision. To our knowledge, the literature contains no study investigating the efficacy of neural therapy on this patient population.
Among the cervical spinal movement segments, the thickest disc and the most mobile segment of the spine is C5-C6, and cervical discopathies are most common in this region.27 In this study, according to the C-MRI results, discopathy (bulging and protrusion) was found to be most common in the cervical C5-6 and C6-7 segments. Bulging refers to the penetration of the nucleus pulposus into the multiple annular tears and the overflow of the disc, and the protrusion is defined as localized disc bulging. A natural increase is expected in neck pain and dysfunction caused by bulging toward protrusion, extrusion, and hernia.28 In our study, the mean baseline NDI scores were found to be higher in the protrusion group compared to the bulging group, although this was not statistically significant.
ROM value is directly related to functionality and activities of daily routine, and the significant increase in cervical ROM values after NT allowed the study to be evaluated objectively.29 Since pain is a subjective concept based on the patient's complaint, it is very difficult to ensure objectivity in its evaluation. Despite the subjective evaluation of VAS, it is a frequently preferred pain scale due to its ease of application. Neck pain due to cervical discopathy negatively affects neck functions and quality of life. To evaluate the level of disability in patients with neck pain, the NDI questionnaire has been accepted and widely used.24,25 In the current study, we determined a positive linear correlation between the differences in the VAS and NDI scores between the baseline and post-NT evaluations, which can reduce the subjectivity of such assessments.

Conclusion
NT is a treatment method widely used in daily clinical practice. It has the advantages of effective treatment, cost-effectiveness, and patient satisfaction. It is considered that neural therapy decreases the cost of treatment and can contribute to the national economy in patients with diseases that do not respond to treatment for years.

Limitations
The main limitations of this study are the limited number of patients and the lack of output regarding the long-term results of neural therapy.






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