https://doi.org/10.53453/ms.2026.5.12
Multidisciplinary management of fibromyalgia and cervicalgia
incorporating targeted mesotherapy and nutritional
neuromodulation: a clinical case report of a phased approach to
overcoming the massage paradox
Aiste Luckute-Berene
1
1
Independent researcher, Klaipeda, Lithuania
Abstract
Introduction. Fibromyalgia is a chronic nociplastic pain condition driven by central sensitization, characterized
by amplified nociceptive processing and impaired descending inhibition. It is commonly associated with a
pathophysiological triad of central nervous system hyperexcitability, peripheral metabolic dysfunction, and low-
grade systemic inflammation.
Case Presentation. A 48-year-old woman presented with a six-month history of widespread spasmodic pain, non-
restorative sleep, cognitive dysfunction, and mild anxiety. Diagnosis was established using 2016 EULAR criteria
(Widespread Pain Index: 8; Symptom Severity Scale: 6). Initial management included low-dose amitriptyline,
tizanidine, and a nutritional regimen (Silexan, creatine monohydrate, vitamin D3). Systemic symptoms resolved
within one month; however, persistent cervical and shoulder pain (VAS 4–5) remained. An eight-session
mesotherapy protocol using ketoprofen, lidocaine, and saline was introduced. A key observation was the “massage
paradox,” where deep tissue manipulation triggered symptom exacerbation and occipital numbness. Full symptom
resolution was achieved after extending mesotherapy to the occipital region and avoiding mechanical stimulation
during central stabilization.
Conclusions. This case highlights the importance of prioritizing pharmacological and interventional strategies
over mechanical therapies in fibromyalgia patients with central sensitization. Avoidance of nociceptive triggers
during early treatment phases may be critical for achieving complete symptom resolution.
Keywords: central sensitization, cervicalgia, fibromyalgia, massage paradox, mesotherapy, nutritional
neuromodulation
Journal of Medical Sciences. 25 May, 2026 - Volume 14 | Issue 3. Electronic - ISSN: 2345-0592
Medical Sciences 2026 Vol. 14 (3), p. 97-101, https://doi.org/10.53453/ms.2026.5.12
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1. Introduction
Fibromyalgia is classified as a chronic nociplastic
pain syndrome characterized by central
sensitization, a state where altered neural processing
amplifies nociceptive signals while descending
endogenous pain inhibition pathways are
significantly impaired [1]. Modern diagnostic
standards have transitioned from the subjective 1990
tender-point examination to the 2016
comprehensive criteria, which utilize the
Widespread Pain Index (WPI) and Symptom
Severity Scale (SSS) to provide an objective map of
somatic and cognitive distress [1]. The underlying
pathophysiology frequently manifests through a
triad consisting of a peripheral energy crisis within
the musculature, central nervous system (CNS)
hyperexcitability, and systemic inflammation.
Exogenous creatine monohydrate acts as a critical
intracellular energy buffer to reverse peripheral
metabolic exhaustion by rapidly replenishing
adenosine triphosphate reserves, which clinical
evidence indicates can increase intramuscular
phosphocreatine by 80% over sixteen weeks [2].
CNS hyperexcitability is addressed through Silexan,
a standardized Lavandula angustifolia oil extract
that inhibits presynaptic voltage-gated calcium
channels to suppress the release of glutamate and
substance P while inducing neuroplasticity via the
CREB transcription factor [3]. Furthermore,
optimizing Vitamin D levels manages the systemic
immunomodulatory component, as serum
concentrations are inversely correlated with the
production of pro-inflammatory cytokines [4].
The European Alliance of Associations for
Rheumatology (EULAR) guidelines emphasize a
stepwise multidisciplinary model, yet severe
localized pain often acts as a clinical barrier to the
foundational recommendation of physical
rehabilitation. Interventional mesotherapy serves as
an essential bridge in these instances by creating a
superficial micro-depot of medication to interrupt
the localized pain-spasm-ischemia cycle common in
structural pathologies [5]. In centrally sensitized
states, premature mechanical manipulation can act
as a noxious stimulus rather than a therapeutic one—
a phenomenon termed the "massage paradox"—
necessitating a phased approach where
pharmacological and interventional stabilization
strictly precede physical therapies.
This case report demonstrates the successful
integration of these modalities to manage treatment-
resistant fibromyalgia and highlights the adverse
effects of premature mechanical manipulation.
2. Case Presentation
A 48-year-old female (all identifiable data have been
anonymized) patient presented with a six-month
history of widespread, exhausting pain. She
described a pressing and squeezing pain localized to
the neck, shoulder girdles, interscapular region, and
lower back. She also reported spasmodic pain under
the right costal arch which when started, spread
through the whole body, and migrating tingling
sensations in the thighs, frequent headache. Her pain
intensity fluctuated from a morning VAS of four to
a peak of seven in the evenings after computer-based
work. Stress and physical activity were primary
triggers, and she noted that therapeutic massages,
which she previously enjoyed, now exacerbated her
condition. Systemic symptoms included severe
sleep fragmentation, profound daytime fatigue, and
cognitive dysfunction known as "fibro-fog" that
impacted her professional and personal relationships
because of which she felt mild anxiety. Her medical
history was notable for a cholecystectomy done
around three years ago.
Diagnostic imaging revealed some structural
changes. An abdominal ultrasound showed
hepatosteatosis, while the gallbladder was absent
and the pancreas and kidneys appeared normal. A
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lumbar magnetic resonance imaging (MRI) scan
from six months ago identified flattened lordosis,
L4/L5 left foraminal extrusion causing narrowing,
and L5/S1 bulging alongside facet joint with
osteochondrosis. A cervical radiograph from a year
ago confirmed stage II-III intervertebral
osteochondrosis and stage II spondylarthrosis.
Laboratory panels, including a complete blood
count, C-reactive protein, erythrocyte sedimentation
rate, thyroid-stimulating hormone, rheumatoid
factor, and uric acid, were all within normal limits.
Physical examination revealed diffuse paravertebral
tenderness, muscle indurations in the shoulder girdle
without active trigger points. Spinal range of motion
was moderately restricted, and the patient exhibited
rapid fatigue and a notable lack of muscular
endurance. Almost all joints were sensitive to
palpation. Diagnosis followed the 2016 EULAR
criteria: WPI was calculated at eight and SSS was
six (fatigue: one; non-restorative sleep: two;
cognitive dysfunction: two; extra somatic
symptoms: one). The clinical diagnosis was
established as fibromyalgia with central
sensitization and secondary cervicalgia.
Due to the severity of the pain, the patient initially
refused physical rehabilitation. A systemic
neuromodulation protocol was initiated: 5 mg of
amitriptyline nightly for sleep; tizanidine (2 mg
morning, 4 mg evening) for muscle tension; Silexan
80 mg twice daily for anxiety; creatine monohydrate
5 g daily for peripheral energy support; and Vitamin
D (50 mcg) as prophylaxis because current serum
vitamin D levels were unknown. At the one-month
follow-up, systemic symptoms such as sleep
architecture, anxiety, and widespread pain had
resolved. However, localized neck and shoulder
stiffness persisted at a VAS of four to five.
Tizanidine was discontinued as ineffective, and
weekly sessions of mesotherapy course was initiated
using a 10 ml mixture of 2 ml of ketoprofen 100 mg,
2 ml of lidocaine 40 mg, and 6 ml of 0.9% NaCl and
administered with a 30G 4 mm needle.
During the first two sessions, the patient achieved an
80-100% reduction in stiffness. However, after the
second session, she independently sought a deep
tissue massage, which triggered a severe pain
relapse and acute neck stiffness. This phenomenon,
termed the "massage paradox," recurred after the
third session when a second massage caused pain to
radiate into the occipital region and induced
nocturnal occipital numbness. The mesotherapy
protocol was expanded to include the occipital
region during the fourth and fifth sessions, which
successfully neutralized the radiating tension. By the
sixth session, cervical pain was permanently
eliminated, allowing the patient to finally initiate
active kinesiotherapy. The final two sessions served
as a maintenance course, all clinical
symptomatology had fully resolved with an
excellent treatment response.
3. Discussion
The defining clinical insight of this case is the
observation of the "massage paradox" within the
context of central sensitization. While mechanical
manipulation is a conventional therapeutic approach
for musculoskeletal tension, this patient's adverse
reactions demonstrate that in a nociplastic pain state,
such stimuli can paradoxically act as noxious
triggers. This phenomenon is driven by the hyper-
excitability of ascending pain pathways and the
failure of descending inhibitory mechanisms
characteristic of fibromyalgia. The severe
nociceptive relapses and new-onset occipital
numbness experienced by the patient after her
independent massage sessions confirm that
premature mechanical irritation can exacerbate
central hyperexcitability rather than alleviate
localized muscle ischemia.
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The successful resolution of symptoms in this case
validates the necessity of a phased, multidisciplinary
protocol. By prioritizing systemic stabilization in the
first phase, the treatment addressed the underlying
somatic anxiety and sleep fragmentation that
frequently impede recovery. The clinical efficacy of
the nutritional triad - creatine monohydrate, Silexan,
and Vitamin D - provided the systemic foundation
required to transition the patient from a state of total
rehabilitation refusal to one where localized
intervention was possible.
Mesotherapy served as a critical interventional
bridge between pharmacological stabilization and
active physical therapy. While systemic medications
successfully eliminated widespread pain, the
persistent localized cervicalgia required a targeted
approach to break the "pain-spasm-ischemia" cycle.
The use of a micro-injection technique provided a
sustained analgesic effect while bypassing the risks
of systemic toxicity associated with prolonged oral
non-steroidal anti-inflammatory drug use [6-7]. The
expansion of the protocol to the occipital region was
particularly effective in neutralizing the migrating
symptoms provoked by the "massage paradox,"
providing the seven-day window of relief necessary
for the patient to eventually engage in active
kinesiotherapy.
The outcomes of this case suggest that clinicians
should adopt a sequential strategy when managing
centrally sensitized patients. The transition to active
rehabilitation, which holds the strongest
recommendation in the EULAR guidelines, is often
only achievable once the patient's "therapeutic
window" has been opened through a combination of
systemic neuromodulation and localized
stabilization. This case underscores that for
treatment-resistant fibromyalgia, the timing of
physical interventions is as critical as the choice of
therapy itself.
4. Conclusions
Effective management of fibromyalgia and
concurrent cervicalgia requires a multimodal
strategy targeting underlying nociplastic
mechanisms rather than isolated symptoms. This
case highlights the "massage paradox," where
mechanical stimulation acts as a noxious trigger due
to central sensitization. A sequential approach
prioritizing systemic neuro-immunomodulation and
localized interventional stabilization is essential
before introducing active physical rehabilitation. By
stabilizing the central nervous system first,
clinicians can create a therapeutic window that
prevents symptom exacerbation and facilitates a
successful transition to kinesiotherapy.
Conflict of Interest
The authors declare no conflict of interest.
Additional Information Ethics Statement
All patient data presented in this case report have
been fully anonymized, and no identifiable personal
information is included. Dates, demographic details,
and clinical context have been generalized to ensure
patient confidentiality. According to local
institutional policies and applicable regulations,
ethical review and approval were not required for a
single case report with fully anonymized data.
Informed consent was not obtained as no identifiable
information is disclosed, and all reasonable
measures have been taken to protect patient privacy
in accordance with established publication ethics
guidelines.
Acknowledgments
Part of this clinical case was previously presented as
an oral presentation at the National Scientific-
Practical Medical Conference "Clinical Puzzles of
Musculoskeletal Pain" (Raumenu ir griauciu
skausmo klinikiniai galvosukiai), organized by the
Lithuanian Pain Society on March 6, 2026, in
Kaunas, Lithuania.
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