11/06/2025
TESTIMONIAL: Post-Traumatic Stress Disorder
On October 7, 2025, a 63- year- old male presented to the clinic having been referred by his wife with chief complaints of constant occipital headaches on the right side, constant orbital and periorbital pain on the right side, chronic neck and lower back pain, mood disorders including anxiety and depression, post-Traumatic stress disorder ( PTSD), inability to remain asleep, non-restorative sleep, cognitive deficit, excessive daytime sleepiness, and intermittent radiculopathy of the left arm extending to his fingertips ( numbness- or stinging sensation).
Two and a half years earlier this patient was violently assaulted, being beaten about the head and neck during a riot at a youth detention facility. He suffered a minor stroke during the attack and a second minor stroke at the hospital. He initially had A metal plate inserted beneath his right eye to replace the fractured suborbital plate. Since the attack he has experienced a constant, dull throbbing pain extending from the occipital region to the frontal and orbital regions on the right side of his head. Neck pain is also constant primarily on the right side. He experiences night terrors and on average sleeps only five hours each night.
Upon examination, the patient could only open 30mm which is well below normal. His neck range of motion was only 20 degrees to the right and 30 degrees to the left. Due to the significant trauma to his head and neck he had a significant number of active and referring trigger points in the auxiliary muscles. The muscles which control the lower jaw were extremely hypertrophic and tender which greatly reduced opening and chewing function. His right joint, upon listening with the stethoscope exhibited grinding and crunching noises and the left joint also had grinding and crunching noises along with a pop with reciprocal pop.
As you might imagine, this patient has seen numerous health care providers over the past 2 ½ years with very little reduction in symptoms.
My diagnosis included temporomandibular disorders (TMD), myofascial pain syndrome (MPS), PTSD, maintenance insomnia, radiculopathy of the upper left extremity, possible neuralgia of the right lesser occipital nerve, and probable obstructive sleep apnea (OSA).
The treatment plan included 3-4 sessions of Prolotherapy which involves treating trigger points in the head and neck region by painlessly administering local anesthetic into” knots” in muscles then mechanically disrupting those knots with a slightly larger needle. As I am mechanically disrupting the trigger point, I will dispense a holistic plant and mineral extract which is to help expedite connective tissue healing. I planned a mandibular repositioning splint to address the TMD problems. I also planned 2-3 sessions of transnasal sphenopalatine ganglion blocks to help reduce anxiety and depression as well as diminished facial pain. We discussed scheduling a consultation with the TJ Sampson Sleep Clinic as soon as he felt up to having the consultation and probable sleep study. I discussed with the patient that due to the severity of injuries, we might plateau at 70% improvement and I expected at least 50% improvement after three weeks of treatment.
As you would expect, this patient has been on multiple medications since the trauma occurred. With the 10/24/2025 Progress notes delivered to the P*P, I requested he increase the dosage amitriptyline to improve maintenance insomnia and help with chronic pain. I also suggested adding an SNRI which is an antidepressant that is a first line of pharmacological therapy in treating chronic pain. These medications, anecdotally, have been greatly successful.
At the October 24 visit the patient reported neck pain being improved 50% and headache was improved 75%. His range of motion was 75 degrees left and 60 degrees to the right. I performed the third session of Prolotherapy at this visit.
At the October 28 visit, when asked about the percentage of improvement thus far the patient replied that he was 75% better overall. During this visit I inserted the mandibular repositioning splint to help with muscles of mastication and joints. I also performed manual manipulation of his neck including suboccipital decompression.
The patient will return November 11 for follow-up. I am now anticipating greater than 80% improvement