Hyaluronidase for Trigger Point Injection in Myofascial Pain Syndrome
Condition: Myofascial Pain Syndrome
MeSH terms: Myofascial Pain Syndromes; Fibromyalgia; Syndrome; Somatoform Disorders
Study type: Interventional

Summary: 
      Myofascial pain syndrome (MPS) is the most common cause of persistent regional pain
      characterized by myofascial trigger points. Trigger point injection (TPI) using local
      anesthetics is one of the most effective methods for treatment of MPS, and steroids or
      botulinum toxin can be added to local injections .

      Recent study suggested that the hyaluronan (HA) could be the basis of myofascial pain. HA
      within the deep fascia facilitates the free sliding of two adjacent fibrous fascial layers.
      If the HA assumes a more packed conformation, or more generally, if the loose connective
      tissue inside the fascia alters its density, the behavior of the entire deep fascia and the
      underlying muscle would be compromised.

      The investigators anticipated that hyaluronidase could decrease the viscosity of HA near the
      muscle and fascia of trigger points. Meanwhile, hyaluronidase is thought to promote the
      spread of local anesthetic solution by hydrolyzing glycosidic bonds within HA. Hyaluronidase
      was shown to be effective in retro- and peribulbar block for ophthalmologic surgery or
      reducing tissue edema in dermatology, and adhesiolysis for some interventional pain
      managements.

      However, the effect of the addition of hyaluronidase to local anesthetics during TPI has not
      been studied. The investigators aimed to compare the efficacy of TPI with the addition of
      hyaluronidase compared to local anesthetic alone on pain and quality of life in MPS patients.
    

Detailed description: 
      Study approval was obtained from Institutional Review Board (IRB) of Samsung medical center,
      and written informed consent was obtained from all participants.

      The required sample size was determined by power analysis on the basis of a previous study.
      The primary outcome was pain intensity in the posterior neck and upper back after TPI using
      verbal numerical rating scale (VNRS). The standard deviation of VNRS was assumed to be 20.
      Power calculations indicated that detecting 20 points difference in VNRS between the two
      groups (with α = 0.05 and β = 0.1) would require a sample of 29 subjects for each group. To
      account for dropouts, 33 subjects were recruited for each group.

      Group L received TPI with a 3.2 ml of a 1:1 mixture of 1% lidocaine and 0.9% normal saline.
      Group H received TPI with the same volume of solution supplemented with hyaluronidase
      (H-LASE®, 1500 iu, L&H Pharm., Seoul, Korea) 600 iu/ml. The investigators monitored vital
      sign and any signs of complications such as bleeding, hematoma, allergic reactions for 30
      minutes. Treatment efficacy was evaluated by one of the authors (J.W.C.) using VNRS. To
      reduce bias, this evaluator and the participants were not informed of the assigned group.

      Patients' characteristics such as age, height, weight, BMI and pretreatment neck disability
      index (NDI) and brief pain inventory (BPI) were analyzed by independent t-test. The sex
      distribution was analyzed by the chi-square test. P values were corrected by Bonferroni's
      method. Pretreatment VNRS and the duration of pain were evaluated by the Wilcoxon two-sample
      test. Repeated measures ANOVA was used to compare changes in the VNRS over time between the
      two groups. Pre- and post-TPI changes in NDI and BPI were compared between the two groups
      with the Wilcoxon signed rank test and the independent t-test, respectively. All analyses
      were performed with SPSS 18.0 (SPSS Inc., Chicago, IL, USA) statistical software.
      Significance was assumed for P values of less than 0.05.
    

Intervention name(s): trigger point injection
Intervention type(s): Drug
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Treatment