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Journal of Back and Musculoskeletal Rehabilitation -1 (2018) 1–6 1

DOI 10.3233/BMR-170980
IOS Press

Evaluation of neural therapy effect in patients

with piriformis syndrome
Hüseyin Nazlıkula , Fatma Gülçin Uralb , Gökhan Tuna Öztürkc,∗ and Aycel Derya Tanay Öztürkd
a
Naturel Health Center, İstanbul, Turkey
b
Department of Physical Medicine and Rehabilitation, Yıldırım Beyazıt University Medical School, Ankara, Turkey
c
Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey

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Abstract.

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BACKGROUND: The aim of this study was to explore the effect of neural therapy on pain and functionality in patients with low
back pain due to piriformis syndrome. It also aimed to find out any possible links between the clinical changes and demographic

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features.
METHOD: One hundred and two patients were randomly divided into two groups (neural therapy and control). All patients were
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given stretching exercises for the piriformis muscle. The patients in the neural therapy group additionally received 6 sessions of
neural therapy. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were noted before and after the treatment in
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both groups.
RESULTS: The VAS and ODI improved in both groups. However, improvement of the VAS and ODI scores were more obvious
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in the neural therapy group. The changes of VAS and ODI values did not show any correlations with the demographic features.
CONCLUSION: After the neural therapy, the patients with low back pain due to piriformis syndrome may have improvement
in both pain and functioning.
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Keywords: Neural therapy, piriformis syndrome, local anesthetics, low back pain
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1 1. Introduction this condition is called as “piriformis syndrome” [2,4]. 14

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The piriformis syndrome may be present as myofas- 15

2 The piriformis muscle is located in the same plane cial pain syndrome (pain arises from muscle itself), as 16

of the gluteus medius muscle in the gluteal region [1]. signs and symptoms of sciatica, or both [5]. Mostly,
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3 17

4 This muscle leaves the pelvis through the greater sci- the patients in the fourth and five decades of life are 18

5 atic foramen and extends into the greater trochanter of affected [6,7]. In this syndrome, the rotation (toward 19

6 the femur. When the piriformis muscle is contracted, to contralateral side and anterior) is observed in the 20

7 external rotation is observed in the hip joint. Also, sacrum. The sacroiliac joint dysfunction in the con- 21

8 the contraction of this muscle occurs via abduction tralateral side and the compensatory rotation to the 22

9 in the flexed hip joint [2,3]. Another significance of affected side in the lower lumbar vertebrae may oc- 23

10 this muscle lies in its close association with the sci- cur [8]. Therefore, the low back pain may be seen in 24

11 atic nerve. The repetitive trauma and overload (result this syndrome. Prevalence of the priformis syndrome 25

12 in ischemia, spasm, edema) on the piriformis muscle is reported as 5–39% in patients with chronic low back 26

13 may lead to pain and/or sciatic nerve entrapment, and pain [6,7,9], and it should be considered in the dif- 27

ferential diagnosis of the chronic low back pain. Di- 28

agnosis of the piriformis syndrome is clinical. Radio- 29

∗ Corresponding author: Gökhan Tuna Öztürk, Ankara Physical
logic and electromyographic studies may be useful for 30
Medicine and Rehabilitation Training and Research Hospital Türko-
cağı Sokak, No. 3, Sıhhıye, Ankara, Turkey. Tel.: +90 312 310 3230; differential diagnosis [6,7,9]. Resting, non-steroidal 31

E-mail: gokhantuna06@gmail.com. anti-inflammatory drugs, stretching exercises, physical 32

ISSN 1053-8127/18/$35.00
c 2018 – IOS Press and the authors. All rights reserved
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2 H. Nazlıkul et al. / Evaluation of neural therapy effect in patients with piriformis syndrome

33 therapy modalities, corticosteroid or botulinum toxin

34 injections, and acupuncture may be offered for the
35 treatment [10,11].
36 Neural therapy is the general term for applications
37 which use the local anesthetics for diagnosis and treat-
38 ment, including local intradermal injections, spinal
39 segmental intradermal injections, ganglion and inter-
40 ference field injections [12,13]. Neural therapy may be
41 used for treatment of painful, chronic musculoskele-
42 tal disorders [14,15]. However, to the best of the au-
43 thors’ knowledge, the effect of neural therapy in pa-
44 tients with low back pain due to piriformis syndrome
45 has not been studied before. Accordingly, in this study,
46 we aimed to evaluate the effect of neural therapy in pa-
47 tients with low back pain resulting from the piriformis

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48 syndrome. We hypothesised that neural therapy is an
49 effective treatment method for this disorder.

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50 2. Methods
Fig. 1. Points of spinal segmental injections.
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51 One hundred and two patients with low back pain
ics (5:1000 mixture of 20 mg/mL Lidocaine HCl) was 80
52 due to the piriformis syndrome were included in this
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injected in each session. Th11-S2 segmental injec- 81
53 prospective, randomized, controlled study. The piri-
tions (for autonomic, somatic and dermatomal innerva- 82
54 formis syndrome diagnosis was made by using the
tion of muscle), the piriformis muscle injections (trig-
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83
55 modified FAIR (flexion, abduction, internal rotation)
ger points, origo and insertio), and the sacral canal 84
56 test. In the FAIR test, the patient lay in supine position,
injection was performed at the each session. Th11-
with the affected hip flexed at 60◦ and the knee flexed
85
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57

58 at 90◦ , and then a physician internally rotated and ad- S2 segmental injections were intradermally performed 86

59 ducted the hip by applying downward pressure onto for each spinous process, 0.5–2 cm laterally on the 87
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60 the knee. The modified FAIR test was performed by affected side (a total of 16 injection areas, approxi- 88

mately 0.25 ml local anesthetics per injection site) [17] 89

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61 applying finger pressure on the piriformis muscle dur-

62 ing the classic FAIR test maneuver [16]. Other prob- (Fig. 1). The skin, the movement system and the related 90

63 lems considered in differential diagnosis (i.e., lumbar organ are all interrelated at the same neurological level. 91
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64 disc herniation, degenerative disorders, spondylolis- In neural therapy, all of these interrelated structures are 92

65 thesis, damage of lumbosacral plexus, facet joint de- called as a “segment” [12]. Structures within the same 93
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66 generation, psychiatric) were eliminated by using elec- segment communicate via the cutanovisceral reflex. 94

67 tromyographic and radiologic examinations. The pres- The sympathetic nervous system dominates this re- 95

68 ence of low back pain due to other reasons, the his- flex pathway, and sympathetic hyperactivity may con- 96

69 tory of trauma, or previous surgery of the hip and tribute to pain. The sympathetic hyperactivity in this 97

70 spine were identified as the exclusion criteria. Addi- reflex pathway is inhibited by intradermal injections, 98

71 tionally, patients who were treated with other modal- thus pain is reduced [12,13]. 99

72 ities for the piriformis syndrome were excluded. The For the piriformis muscle injection, a 22-gauge, 4– 100

73 study procedure was approved by the ethics commit- 6 cm (varying from person to person) needle was used. 101

74 tee of Yıldırım Beyazıt University Medical School. A When the patient is in a prone position, the sensitive 102

75 written informed consent was obtained from all the pa- trigger point of this muscle is fixed between two fin- 103

76 tients before their participation in the study. gers and an injection was performed to this area. The 104

trigger points of the piriformis muscle are shown in 105

77 2.1. Interventions Fig. 2 [18]. Additionally, the origin and insertion of 106

the muscle (anterior surface of the sacrum and greater 107

78 Neural therapy was applied by the same experi- trochanter of the femur) were injected (approximately 108

79 enced physician. A total of 24 ml of local anesthet- 15 ml local anesthetics). Also, the sacral canal injec- 109
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H. Nazlıkul et al. / Evaluation of neural therapy effect in patients with piriformis syndrome 3

westry Low Back Pain Disability Questionnaire (ODI) 135

was used to assess functional status and disability. The 136

ODI consists of 10 questions evaluating daily life ac- 137

tivities. Each question is assigned a score ranging be- 138

tween 0 and 5 (0 indicates no symptoms with activ- 139

ity, 5 indicates impossibility to do the activity due to 140

pain). The total score is expressed as a percentage (to- 141

tal points/number of questions * 100) [20]. 142

2.4. Statistical analysis 143

The SPSS (SPSS Inc., Chicago, IL, USA) 21.0 for 144

windows program was used for statistical analysis and 145

the data were expressed as mean ± standard deviation. 146

To compare demographic and clinical measurements

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147

between the two groups, the independent sample-t test 148

was used. The paired sample t test was used to compare 149

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the clinical changes in each group. The correlation be- 150

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tween the clinical and demographic features was eval- 151

Fig. 2. Trigger points of piriformis muscle. uated via Pearson test. A p value 6 0.05 was accepted 152
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as significant. No power analysis was performed be- 153

110 tion was performed in the same position. For this in- fore the study. The post-hoc power was calculated as 154
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111 jection, bilateral sacral horns were palpated, and the 0.78. 155

112 needle forwarded at approximately 45 degrees to the

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113 middle of these horns. When the physician felt that

114 the needle passed through the sacrococcygeal ligament 3. Results 156
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115 and into the hiatus, he injected the local anesthetics

116 (about 5 ml) [19]. Neural therapy was applied two days All participants completed the study. The demo- 157

a week, for 3 weeks (6 sessions in total). No adverse graphic characteristics of the patients are given in Ta-
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117 158

118 effect was observed in the patients. ble 1. The groups were not different with regards to 159
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age, sex, BMI and disease duration (all p > 0.05). 160

119 2.2. Patients Clinical features are summarized in Table 2. Scores 161

of VAS and ODI improved significantly in both groups

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162

120 The participants were randomly divided into two (all p < 0.01). However, improvement of the neu- 163

groups: the neural therapy and control groups. Pa- ral therapy group was more prominent. In the pre-
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121 164

122 tients were numbered in order of acceptance to the treatment, the neural therapy group’s VAS and ODI 165

123 out-patient clinic. Randomization was carried out us- scores were higher than those of the control group, 166

124 ing a computer program. The rest and stretching exer- while the post-treatment values were higher for the 167

125 cises were offered to all the patients, while the neural control group (all p < 0.01). The clinical changes did 168

126 therapy group received additional neural therapy treat- not correlate with disease duration, age and BMI in 169

127 ment. both groups (all p > 0.05). 170

128 2.3. Outcome measurements

171 4. Discussion
129 The demographic features including age, gender,
130 body mass index (BMI) and disease duration of all 172 The goal of this research was to explore whether
131 patients were noted. The severity of pain and func- 173 neural therapy had any effect on pain and functional
132 tional status were evaluated before and at the end of 174 status in patients with low back pain due to piriformis
133 the treatment. The severity of pain was measured by 175 syndrome. The findings of this study showed that pain
134 the visual analog scale (VAS) (0–100 mm). The Os- 176 and functional status improved after the neural therapy
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4 H. Nazlıkul et al. / Evaluation of neural therapy effect in patients with piriformis syndrome

Table 1
Demographic features of patients
Neural therapy Control group P
group (N = 51) (N = 51)
Age (years) 50.3 ± 11.4 49.2 ± 11.7 0.63
Body mass index (kg/m2 ) 26.8 ± 5.0 27.3 ± 4.7 0.61
Gender (male/female) 25/26 25/26 1.00
Duration of disease (months) 18.3 ± 6.6 19.3 ± 11.1 0.44
Data are given as mean ± standard deviation or n.

Table 2
Clinical features of patients
206 apy are referred to as segmental therapy mentioned
207 above.
Neural therapy Control group P
group (N = 51) (N = 51)
Myofascial trigger points are described as palpa- 208

VAS ble, hypersensitive and painful spots in the skeletal 209

Before 87.4 ± 6.9 83.1 ± 8.8 < 0.01 muscles [21]. Stretching, pressing or forcing of the 210

After 6.3 ± 7.5 37.2 ± 10.4 < 0.01 skeletal muscles (including trigger point) may lead to 211

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P < 0.01 < 0.01
pain in the remote body region, and this condition is 212
ODI
Before 69.0 ± 7.6 64.9 ± 10.1 < 0.01 called as “referred pain”. Micro-traumas due to ex- 213

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After 15.2 ± 8.5 32.2 ± 11.9 < 0.01 cessive use (i.e., long distance walking, running, cy- 214
P < 0.01 < 0.01 cling) or prolonged sitting may cause the formation 215

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Data are given mean ± standard deviation. VAS; visual analog scale, of trigger points in the piriformis muscle [8]. The re- 216
ODI; Oswestry Disability Index.
ferred pain of the trigger points in the piriformis mus-
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cle can spread to the lumbar region [6–9]. It is be- 218

177 application. However, no association was identified be- lieved that the formation of trigger points results from
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219
178 tween the clinical changes and demographic features. a dysfunction of the motor-end plates (called as in- 220
179 In most cases, chronic illness is believed to result in nervation zone) where an α-motor nerve ending is at- 221
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180 autonomic nervous system changes that include shifts tached to the muscular fiber. The maintained depolar- 222
181 in membrane potentials of ganglia and nerve fibers ization of these areas may result in local hypoxic en- 223
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182 which cause changes in conductivity [12,13]. Abnor- ergy crisis (causing local ischemia and hypoxia), and 224

183 mal signals from the periphery may be inhibited by in various substance releases from nervous and vas- 225

the control mechanism (gate-control mechanism) at

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184 cular systems [22–24]. Further, sacroiliac joint dys- 226

185 the spinal cord level. When these signals increase, the function related to piriformis syndrome may be an- 227
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186 mass effect can occur in the spinal cord. The mass ef- other cause of low back pain [8]. However, the re- 228

187 fect is an electrical chaos which fails the control mech- flex response in the autonomic nervous system may 229

anism at the spinal cord level. Then these signals are

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188 accompany these conditions. The sympathetic nervous 230

189 transmitted to the brain [12,13]. The central nervous system is largely responsible for this reflex response 231

system changes enable the continuation of the origi- which includes decreased blood flow, increased skin
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190 232

191 nal disturbance in the periphery. Thus, a vicious cy- turgor, hyperalgesia in localized areas, and increased 233

192 cle is created. Neural therapy can break this vicious muscle tonus [25,26]. These changes contribute to the 234

193 cycle. The aim of neural therapy is to find the pri- vicious circle of pain [26]. Additionally, the sympa- 235

194 mary lesion that causes an abnormal electrical signal, thetic nervous system induces the neurogenic inflam- 236

195 starting abnormal events. In neural therapy, this lesion mation, and in this way it leads to peripheral sensi- 237

196 is called as an “interference field” [12,13]. The inter- tization [14,27]. Further, in an animal model it was 238

197 ference field can lead to disorder in any part of the demonstrated that the sympathetic nervous system has 239

198 body. Scar tissues, burns, tooth abscess, dysfunctions a memory for pathological stimulus [28]. All patho- 240

199 of joints/organs may all indicate interference fields. An logical mechanisms can be inhibited with neural ther- 241

200 abnormal electrical signal originating from an interfer- apy applications including local, segmental, supra- 242

201 ence field can be inhibited by using local anesthetic in- segmental injections [14,26,29]. The local anesthetic 243

202 jections which restore the membrane potential in nerve may break the vicious circle of nociceptor activity 244

203 fibers [12,13]. In this study, patients with interference (sympathetic excitation), decreased blood flow (neuro- 245

204 fields were not included to ensure the standardization genic inflammation), and increased muscle tonus [14]. 246

205 of the treatment. Other techniques used in neural ther- The peripheral sensitization and sympathetic activity 247
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H. Nazlıkul et al. / Evaluation of neural therapy effect in patients with piriformis syndrome 5

in wide dynamic range neurons is reduced by an in- 293

248 [2] Eibel P. Pyriformis syndrome. Lancet 1987; 2: 1220.
jection of local anesthetics [14,26,29]. Moreover, this 294
249 [3] Smoll RN. Variations of the piriformis and sciatic nerve with
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ory in the sympathetic nervous system [14,26]. Neu- 251
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Williams & Wilkins, Baltimore, 1992.
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low back pain [30]. However, the effects of neural ther- 256
303 [7] Pace JB, Nagle D. Piriformis syndrome. West J Med 1976;
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have been shown for the first time in this study. 258
[8] TePoorten BA. The Piriformis Muscle. JAOA 1969; 69: 150- 305
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266 anti-inflammatory effects of the lidocaine may be re- G, Garbuio P, Parratte B. Piriformis muscle syndrome: diag- 315

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267 sponsible for the effect of neural therapy. nostic criteria and treatment of a monocentric series of 250 316
patients. Ann Phys Rehabil Med 2013; 56: 371-83. 317
268 The pain, bleeding, and allergic reactions may re- [12] Nazlikul H. Nöralterapi Ders Kitabı. Nobel Kitapevi, Istanbul,
fv 318
269 sult from inappropriate injection techniques. However, 2010. 319
270 no adverse effect was observed in our patients. Neural [13] Weinschenk S. Neural therapy – A review of the therapeutic 320
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271 therapy is a safe treatment method when performed by use of local anesthetics. Acupuncture and Related Therapies 321
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This study has two major limitations. Firstly, no
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273 Fischer L. Long-term results of therapeutic local anesthesia 324

274 long-term follow up of the patients was conducted. (neural therapy) in 280 referred refractory chronic pain pa- 325

275 Secondly, the placebo effect of the neural therapy was tients. BMC Complement Altern Med 2015; 15: 200. 326
ed

[15] Weinschenk S, Hollmann MW, Göllner R, Picardi S, Strow- 327

276 not evaluated. Nonetheless, our findings are significant
itzki T, Diehl L, Hotz L, Meuser T. Heidelberg Univer- 328
277 and noteworthy. sity Neural Therapy Education and Research Group (The 329
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HUNTER Group). Injections of Local Anesthetics into the 330

Pharyngeal Region Reduce Trapezius Muscle Tenderness. 331
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278 5. Conclusion Forsch Komplementmed 2016; 23: 111-6. 332

[16] Kean Chen C, Nizar AJ. Prevalence of piriformis syndrome 333
in chronic low back pain patients. A clinical diagnosis with 334
In light of our findings, neural therapy improves pain
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286 Conflict of interest
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