Postoperative pain: management and innovation
Pathos 2021; 28, 4. Online 2022, Dec 18
Paolo Barbagli, Renza Bollettin
Outpatient Pain Therapy, Riva del Garda, Trento, Italy (APSS Trento)
A.I.R.A.S. (Ass. It. per la Ricerca e l’Aggiornamento Scientifico)
The authors examined, among all treated cases of benign pain (3662) from 1982 to the first half of 2006 with reflex therapy method, the cases with unsatisfactory results and with other successive successful treatments.
This group is made up of 28 cases (with 25 patients, because in 3 cases the patients had more diseases).
Between the 25 patients, 8 improved with surgery, 4 with steroid injections, 2 with chiropraxis and/or “manipulations”, 2 with laser therapy, 2 with neuraltherapy of Huneke, and 1 each with acupuncture, auriculotherapy, NSAID, phytotherapy, connectival massage, ultrasounds and TENS plus ultrasounds.
In conclusion, there is’nt an only therapy always successful, when a reflex therapy is ineffective, but the therapheutic options can be numerous.
Sometimes, the surgical option can therefore be effective; sometimes (3 in this study) it can be effective to change reflex therapy (for example from acupuncture to neural therapy and vice versa).
Gli autori hanno esaminato, tra tutti i casi di dolore benigno (3662) da loro trattati dal 1982 al primo semestre 2006 con una metodica riflessoterapica, quei casi che, considerato insoddisfacente il risultato conseguito, hanno in seguito effettuato qualche altro tipo di terapia dimostratasi in grado di migliorare, o risolvere, la sintomatologia algica. Il gruppo così esaminato è risultato composto da 28 casi (con 25 pazienti, perché in 3 casi il paziente accusava più patologie algogene benigne).
Dei 25 pazienti analizzati, 8 hanno avuto giovamento da un intervento chirurgico, 4 da infiltrazioni di cortisone, 2 da chiroprassi e/o “manipolazioni”, 2 da laserterapia, 2 da neuralterapia secondo Huneke, e i restanti 7 rispettivamente da agopuntura, auricoloterapia, FANS, fitoterapia, massaggio connettivale, ultrasuoni e ultrasuoni + TENS.
In conclusione, non esiste la terapia più indicata in caso di insuccesso di riflessoterapia, ma le opzioni terapeutiche possono essere numerose. Nei casi ove vi siano le indicazioni, l’opzione chirurgica può pertanto essere efficace, ma in qualche caso (3 in questo studio) cambiare la metodica riflessoterapeutica (per esempio da agopuntura a neuralterapia e viceversa) può essere efficace.
Riflessoterapia, dolore benigno, agopuntura, neuralterapia
Reflex therapy, benign pain, acupuncture, neuraltherapy
Carefully examining the failures, trying to understand the reason, seems to the authors a good way, although unfortunately scarcely traveled in medical literature, to increase the percentage of successes.
Reflex therapies, a group of therapies among which the best known is certainly acupuncture,1,2 but which also include other techniques including Huneke’s neuraltherapy,3-5 reflexotherapy with saline solution6 and the reflexotherapy with homeopatic remedies,7,8 have proven effective, although with often methodologically inadequate studies, in the treatment of benign pain of various etiologies.
In order to improve the therapeutic results, and also in order to investigate the mechanism of action, it appears useful to investigate the many possible factors that tend to influence, in negative or positive, the results, such as for example factors intrinsic to the patient9-11 (sex, age, psychic disorders such as anxiety and depression, etc.) and to the method used12-13 (type, length, diameter and depth of insertion of the needles; type , quantity, concentration of any substances injected; number, frequency and duration of the sessions).
An innovative way to improve the results of a therapy, unfortunately scarcely practiced even if sometimes the failures have created completely new nosographic entities such as e.g. the FBSS (Failed back surgery syndrome),14 is to study the failures15,16 to try to understand the reasons.
E.g., it appears extremely useful for the authors to investigate which possible therapies, in the event of failure of reflexotherapy, can be effective in the case of benign pain. This conduct must be based on elements of scientificity in order to investigate the reasons for the failures and to direct patients towards another type of therapeutic approach.
Materials and methods
The authors examined, in a database that collects all the cases of benign pain (3662) they treated from 1982 to the first half of 2006 using a reflexotherapy method, those cases which, considered unsatisfactory the result achieved, have subsequently some other type of therapy has been carried out which has proved capable of significantly improving, or sometimes resolving, the pain symptoms; and then referring, during one of the scheduled check-ups or during other contact occasions, to the Authors. Subsequent therapies were almost always carried out in other health facilities, but in 2 cases they were still practiced by the authors, who directly noted the result on the database.
The group so examined (Table 1) was composed of 28 cases with pain not of neoplastic origin, with a mean age of 60.5 ± 16.1 years (range 33-85), 21 female and 7 male.
From the point of view of temporality, the pain lasted from 23.6 ± 42.8 months (range 0.1-195), and there were 14 cases of chronic pain (> 6 months); 4 cases of intermediate pain (lasting from 1 to 6 months); 2 cases of exacerbated chronic pain; 8 cases of acute pain (up to 5 weeks).
The pathologies treated were: 5 scapulo-humeral periarthritis, 5 lumbosciatic pain, 4 gonalgia, 3 lumbago, 2 cervicobrachial pain, 2 neck pain, 2 hand finger pain, 2 carpal tunnel syndrome, 2 atypical facial neuralgia, 1 metatarsal pain.
The reflexotherapies used by the authors with unsatisfactory results were Huneke’s neuraltherapy in 17 cases, acupuncture in 10 cases, reflexotherapy with saline solution in 1 case.
The number of sessions performed was 5.25 ± 3.7 (range 1-12).
The result of the reflex therapies used was considered "unsatisfactory", beyond the subjective opinion of the patient, when at the end of the therapeutic cycle the pain was unchanged or worsened (without improvement within 1 month from the end of therapy) or, even in case positive result at the end of therapy, but with a benefit of less than 1 month.
The subsequent therapy was instead considered effective if the patient declared that he had obtained a satisfactory benefit, however superior to the reflexotherapy used by the authors.
Table 2 lists the 28 cases analyzed here, with the pathologies treated, the reflexotherapy used and the subsequent “effective” therapy.
Case 1 consists of a case of cervicobrachialgia that started 4 months earlier on a probable basis of arthrosis, subjected to a single session of neural therapy with good results (70% improvement) for 10 days. Then the pain relapsed and the patient underwent a cycle of ultrasounds, with the disappearance of the symptoms. In this case, the partial failure of neural therapy is clearly due to the interruption of the therapeutic cycle, which in the case of chronic pain generally requires 8-10 sessions.
Similarly, case 2, a mild chronic neck pain which began about 6 months ago, responded unsatisfactorily (for the patient), being almost unchanged after a single session of neural therapy, subsequently benefiting from a laser cycle.
Case 3, a meniscopathy that had arisen for about 20 days already on the waiting list for arthroscopic surgery, had an improvement of about 50% with only 2 sessions of neural therapy; the pain, however, relapsed, as it was legitimate to expect, after a week; a month later, surgery was decisive.
Case 4, an 80-year-old lady with metatarsalgia for 6 months, was unchanged after 4 sessions of reflexotherapy with saline solution; the pain has instead almost disappeared, with a follow-up of 3 years, with a cycle of 6 sessions of neural therapy with 1% lidocaine, immediately followed by the previous one and performed by the same therapist, who is one of the Authors.
Case 5, a scapulo-humeral periarthritis that began about 3 months ago and underwent only two acupuncture sessions with unchanged pain, was immediately after (3 days), by the same therapist, subjected to a course of neural therapy (4 sessions) with good immediate improvement (70%) and disappearance of pain after about a month; the pain subsequently relapsed twice in the following 2 years and was successfully treated with 2 short cycles of neural therapy.
Case 6, a left cervicobrachialgia treated with 4 sessions of neural therapy followed by a worsening, 1 month and a half later had immediate resolution and duration by surgical removal of a small ipsilateral thumb tendon cyst. Evidently it was a radiated pain, caused by the irritating spine "cyst", although apparently this did not appear painful. It should be noted that no tender or trigger point was found in the pain area.
Case 7, a chronic left knee pain that began 2 years earlier, was unchanged after 11 sessions of neural therapy. The CT scan found: "limited degenerative-traumatic structural alteration anterior horn external meniscus, with limited liquid collection in the vicinity". The pain was of very high intensity (VAS 10), and was benefited 1 month later, following arthroscopic meniscectomy.
Case 8, a scapulo-humeral periarthritis in an 81-year-old lady, unchanged after 8 sessions of neural therapy, was not helped even after a single session of cortison and local anesthetic in the painful points of the deltoid, always carried out by one of the Authors; instead, shortly afterwards, 2 intraarticular infiltrations with cortisone, carried out in a hospital setting, were found to be decisive. Therefore, probably, the pain was of an arthritic joint and not a periarticular nature.
Case 9, an 85-year-old woman with acute right knee pain (for 10 days) from arthrosis, after 4 sessions of neural therapy did not experience any benefit; she shortly after she had an improvement after 3 infiltrations, carried out by an orthopedist, which the patient does not know how to specify: in all probability it was an intra-articular cortisone preparation.
Case 10, a 69-year-old woman with chronic osteoarthritis knee pain for 2 years, after 4 acupuncture sessions had the pain disappeared, but it relapsed after 1 month. Subsequently (almost 2 years later) a positive result is reported (lasting disappearance of pain) after knee arthroplasty occurred about 8 months after acupuncture.
In case 11, a subacute lumbosciatalgia (from one month and a half) in a 65-year-old lady, after 10 acupuncture sessions the pain was unchanged. A subsequent CT scan showed an expelled hernia L5-S1, which seemed topographically correlated with pain. She was not operated on, and reported benefit after a cycle of TENS and ultrasound together.
Case 12, a chronic low back pain (for about 15 years) in an exacerbation phase, treated with 3 sessions of neural therapy, at the end of which the pain, after an initial improvement, was suddenly 3 days after the last session got worse. For this reason, the patient was hospitalized in a hospital (Physiatry), after a herniated disc was found by MRI scan. Refused surgery, 3 months later he underwent a course of chiropractic, with reportedly good results.
Cases 13 and 14 consist of two different pathologies (neck pain and rizoarthosis of the thumb) in the same person, who responded to neural therapy in an unsatisfactory way (improvement of 30% and 70% respectively for about 15 days), and instead benefited from a subsequent phytotherapy with Devil's Claw (50 drops of mother tincture/ day for 3 months).
Case 15, an acute scapulo-humeral periarthritis from trauma, after 5 sessions of neural therapy had no result. A good result was instead reported successively after infiltration (intra-articular?) with cortisone.
Case 16, acute lumbosciatica (from 2 days), worsened after 5 sessions of neural therapy. A single infiltration with cortisone in the point of maximum pain, always carried out by one of the Authors, caused the immediate disappearance of the pain, which lasted about 20 days. When the pain returned, the treatment continued with a cycle of reflexotherapy with homeopathic remedies, with a good result. The patient, a 64-year-old lady, however, attributed the therapeutic result to the only infiltration with cortisone.
Case 17, an acute sciatica (from about 10 days) was first treated with a cycle of 10 sessions of reflexotherapy with saline solution, with a slight improvement of about 30%; immediately after with 3 sessions of neural therapy, with unchanged improvement; on the other hand, he had a clear improvement with 4 acupuncture sessions, always started by one of the Authors a few days later, at the end of which the pain had almost disappeared. 2-year follow up. In summary, of the 17 reflexotherapy sessions, which lasted a total of 1 month and a half, the 10 of reflexotherapy with saline solution determined only a modest improvement, the 3 of neural therapy no additional improvement, while the 4 of acupuncture were followed by the definitive resolution of the pain.
Case 18 is probably a false failure of acupuncture and a false success of NSAIDs. The patient, suffering from chronic lumbosciatica for 2 years, at the end of a cycle of 8 acupuncture sessions, reported unchanged pain, while she later reported that she had benefited from a single (!) intramuscular injection of ketorolac. A "deferred" result of acupuncture appears more likely.
In case 19, a tendinitis of a finger with pain and trigger finger for 2 months, subjected to a course of acupuncture (10 sessions) without any improvement, only surgery solved the problem.
Case 20, an atypical facial neuralgia persisting for a very long time (about 10 years) and of unclear etiology, a cycle of 6 acupuncture sessions had an ephemeral improvement (50 % for about 15 days). The best result was a subsequent course of laser therapy with another therapist. It must be said that this case, a chronic pain of unclear origin with periodic exacerbations, sometimes seems to respond to the various therapies undertaken, sometimes not.
Cases 21 and 22 refer to a single case of chronic scapulohumeral periarthritis, which began 1 year earlier, which underwent, in succession and treated by one of the Authors, first to a single acupuncture session, after which it got worse, then at a single session of neural therapy, after which it got worse, then at 4 sessions of auricular acupuncture; cycle interrupted when the improvement was about 60%, improvement which progressed (without other therapies) until the total disappearance of the symptoms after 2 months. Therefore, the failure of somatic acupuncture and neural therapy remains doubtful, followed by the success of auricular acupuncture; probably, even by continuing the reflex therapy undertaken, perhaps by temporarily suspending it or slowing down the rhythm of the sessions, after the initial deterioration the positive result would follow.
Cases 23 and 24 refer to the same person, suffering from bilateral carpal tunnel syndrome (with paresthesias and pains especially at night), who had no improvement after an acupuncture cycle of 12 sessions. The subsequent surgery was decisive instead.
Case 25, a 33-year-old young woman suffering from chronic low back pain exacerbated for a few days, with radiographic findings of severe L5-S1 spondylolisthesis, was treated with occasional neural therapy sessions (in 2 and a half months in total 5 sessions, therefore on average one every 15 days), after which she had a transient well-being. After this therapy, whose decidedly anomalous rhythm was dictated by the patient, she decided to interrupt her to consult an orthopedist, who planned an intervention. This intervention, subsequently performed (about 3 months after the end of the reflex therapy), significantly improved the painful situation.
Case 26, a periauricular pain in a 53-year-old woman, which arose about 1 year ago after plastic surgery with a retroauricular scar (painful to pressure), following the infiltration of the scar with lidocaine (probable “interference field” according to Huneke's neural therapy) had an immediate disappearance of pain, which lasted about 20 days. A subsequent new infiltration, which took place a few months later, had no effect, while, according to the patient, a cycle of "manipulations" of the spine, of an unspecified nature, carried out both at the cervical and lumbar level, was effective.
Cases 27 and 28 both refer to the same person, a 61-year-old lady suffering from multiple sclerosis and suffering for about 5 months from lumbosciatalgia, previously treated by one of the Authors with a cycle of 10 sessions of acupuncture, with slight improvement. In particular, there was a good improvement in pain in the limb, while the lumbosacral pain persisted almost unchanged. She therefore returned for a new acupuncture cycle in the hope of further improvement. After 3 acupuncture sessions (case 27), the pain was unchanged. In a subsequent session (case 28) an infiltration of 0.5% lidocaine (Huneke neural therapy) was performed on a bone protrusion in the sacral area from which, according to the patient, the pain "started". In addition, the patient reported having suffered several traumas in the sacral area in her life. No result. At a subsequent check-up (2 months later), the patient reported that she had found benefit from a cycle of “connective tissue” massage.
Table 3 summarizes the therapies that have been reported as "effective" after reflex therapy failure. In the case of effective therapy in the same patient, such therapy is counted only once (eg, in cases 27 and 28, the connective tissue massage is counted only once).
Therefore, in the 25 patients treated, in 8 the surgery was decisive (3 operations on the knee - 1 trigger finger - 2 carpal tunnel - 1 lumbar spondylolisthesis - 1 tendon cyst), 4 benefited from infiltrations of cortisone, 2 from chiropractic and / or "manipulations", 2 from laser therapy, 2 from Huneke’s neural therapy, and 1 each from acupuncture, auriculotherapy, NSAIDs, phytotherapy, connective tissue massage, ultrasound and ultrasound + TENS.
In 4 cases, better results were obtained by changing the reflexotherapy technique; in 2 cases the neural therapy was more effective, respectively, than acupuncture and reflex therapy saline solution ; in another case, a patient who did not respond to acupuncture and neural therapy had a good result with auriculotherapy;17 in another case, finally, acupuncture proved to be more effective than neural therapy.
Discussion and conclusions
From the results illustrated so far, the following considerations can be elaborated.
1) There is no “one” therapy that is the most suitable in case of failure of a reflex therapy, but a long list of therapeutic possibilities, each of which has the chance to be effective.
2) In case of failure of a therapeutic attempt with a reflexotherapy, and when there is a surgical indication, it is probably good to refer to the surgeon, without delaying with other non-invasive therapies.
3) Case number 6 seems to recommend, in the absence of tender points in the area referred to pain relief, the search for a different etiology, looking in particular in the metameric afferent areas, and reinforces the theory of the so-called "interference field", an organic alteration chronic capable of causing a chronic disease (painful or not) in the metamer or even at a distance of.18-20
4) It seems justified, when there is the possibility, to change reflexotherapy technique in case of lack of response to a technique. In this case study, one technique that is certainly superior to another has not been found; instead, for reasons that for the moment we do not understand, a patient can respond positively to one technique and not to another.
5) In some cases, cortisone has proved effective and therefore can be taken into consideration (despite recent studies have questioned its effectiveness)21-23 in localized joint or periarticular pains, in case of failure of reflexotherapy without a clear surgical indication, or even before any intervention, as a possible subsequent therapy. It should also be considered that, in a previous work by the same authors,5 it is noted that, in 20 cases treated with Huneke’s neural therapy, with the addition of cortisone to the anesthetic solution in the penultimate session no additional improvement in pain was observed.
6) Other possible subsequent therapeutic options appear to be, in the light of the results of this study, manual techniques such as chiropractic24 or connective tissue massage;25 phytotherapy with Harpagophytum (Devil's Claw), which can represent a good therapeutic alternative to NSAIDs;26 non-invasive physical stimulation techniques such as laser,27 ultrasound,28 TENS.29
Paolo Barbagli, via Storch 15, Riva del Garda (TN), tel. 0464-520511; email: firstname.lastname@example.org
The authors declare that all the cases treated have expressed an informed consent to the proposed treatment
Conflict of interest
The authors declare that the article is not sponsored and that it was written in the absence of conflicts of interest
18th December 2021
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