Prolotherapy

Prolotherapy

Prolotherapy is sometimes referred to as “Regenerative Injection Therapy” (RIT). “Reconstructive Therapy,” “Non-Surgical Tendon, Ligament and Joint Reconstruction,” or “Growth Factor Stimulation Injection”. “Sclerotherapy” is an older, obsolete term as it was primarily injections of caustics into the veins, in vascular surgery and dermatology to remove Physician and Sportsmedicine, “Are Your Patients Asking About Prolotherapy?” states that this form of therapy treatment is becoming more mainstream in medicine and that approximately, remember back in 2000, that approximately 450,000 Americans had undergone prolotherapy and many of them were physicians themselves. With such pronounced numbers of users quoted 8 years ago, people still automatically think of IMS when I describe the process of prolotherapy by mentioning the word needles or is a form of needling therapy. Before I delve into the fascinating world of prolotherapy, I will explain the IMS and you can see the difference between it and prolotherapy.

Needling Therapy Techniques

There are two types of needling therapy techniques-intermuscular injection therapy and intramuscular stimulation (IMS) for myofascial pain syndromes of neuropathic origin.

Intermuscular injection therapy

One type of needling therapy technique is the injection of local anesthetic into active trigger points. The injection of local anesthetic is into muscles which have been localized by physical examination and found to be responsible for the patients’ pain pattern and muscle dysfunction.

Upon injection of the trigger point there is a momentary reproduction of the characteristic pain referral pattern for each individual muscle, visible and palpable muscle twitching. This is followed by a release of the muscle spasm and increased movement and function of the involved muscle.

This form of therapy has been explained and documented by Travell & Simons in their book: Myofascial Pain and Dysfunction-The Trigger Point Manual.

Intramuscular stimulation (IMS) for myofascial pain syndromes of neuropathic origin

Intramuscular stimulation (IMS) is a new way of treating certain conditions that cause chronic pain. It has been proven effective in treating some kinds of chronic neck, shoulder, and low back pain and other conditions, caused when an oversensitive nerve keeps a muscle contracted too long. The muscle becomes shortened, causing distortion and further pain in other muscles and tissues.

Because this kind of “neuropathic” pain is not caused by any obvious injury, it can be difficult to treat with current therapies. IMS directly treats the cause of the pain by relaxing the shortened muscle and allowing it to return to its normal state. A trained therapist inserts very fine needles (like those used in acupuncture) into the shortened muscle at the point where it is tight (which usually also corresponds to a myofascial trigger point). The needles change the electrical potential of the muscle cells causing the muscle fibers to “twitch” and the muscle to relax and lengthen. It also causes micro-injuries that stimulate blood circulation and healing.

The needles cause no pain when inserted into normal muscles however, they can cause painful twitching when they are inserted into a shortened muscle, but after the muscle twitches, it relaxes. With weekly treatments overall several weeks, the initial pain is followed by long term relief for many patients. (For low back pain, studies have found the average number of treatments required is about 8).

IMS uses the tools of acupuncture, but differs fundamentally in that it is based on current western research in physiology, rather than Chinese medicine. IMS is applied directly to the size of the pain rather than to remote points based on energy flow. However, it has been found that approximately seventy percent of myofascial pain trigger points occur over corresponding classical acupuncture points.

IMS Technique

The technique of inserting a needle is simple-but good results require a correct diagnosis, a strong knowledge of muscle anatomy and much practice; especially to accurately reach deep muscle points. Generally a fine solid needle (30 gauge or less) that is usually 25 to 60 mm long, in a plunger-type needle holder. The plunger allows the length of the needle to be varied according to the thickness of the muscle being treated. The pointed tip of the solid needle is less traumatic than the beveled, cutting edge of a hollow needle. Its flexible and springy quality unlike that of a rigid hollow needle transmits the nature and consistency of the tissues penetrated. When it enters normal muscle, the needle meets with little resistance and there is no pain or twitch response. When it pierces a taunt band of muscle, the needle meets with little resistance and there is no pain or twitch response. When it pierces a taunt band of muscle, there is firm resistance and the needle is ‘grasped’ by the muscle. When it encounters fibrotic tissue, there is a grating resistance (like cutting through an unripe pear); and sometimes when fibrosis is extensive, considerable effort with repeated ‘pecking or plunging’ is required. The fine solid needle therefore allows multiple, closely-spaced penetrations to be made without excessive tissue damage and its whippy nature relays useful feedback information.

Penetrations of a shortened muscle usually activate the muscle to fasciculate or twitch: this is usually accompanied by near-instantaneous muscle relaxation. Any muscle contraction not thus released invariably grasps the needle and this can be clearly perceived as the contraction resists the needle’s withdrawal. Subjectively, penetrating into a normal muscle is nearly painless; but when a contraction is encountered, the patient experiences peculiar, twitch parallels that of contractor: It can be excruciating painful but gradually resolves as the contraction eases. The distribution of the sensation may also be widespread; for example, a needle inserted into the erector spinae muscle at L1-2 may cause contraction in the entire length of the muscle that can be felt in the low back at the iliac crest, in the gluteal muscles and in the muscles of the abdominal wall as well as intra-abdominally. Many times this follows the pain referral patterns of myofascial pain trigger points and or classical acupuncture meridians.

Proliferative Ligament Reparative Therapy (Prolotherapy) is 2500 years old

Before I get into the intricacies of prolotherapy, its history should be mentioned as this is not a new technique. Prolotherapy was first used by Hippocrates on Olympic javelin throwers and soldiers who occasionally dislocated their shoulders. A red hot iron was thrust into the stretched lax ligaments of the shoulder causing inflammation and thus tightening of the joint. From 1835-1935, injection of sclerosing type agents were used to treat hernias before modern surgical techniques became available. The techniques that most common medical doctor’s practice today was first developed in the 1930’s by George Hackett, MD, a general surgeon. He made the general observation that “Injections (usually in error) at the junction of ligament and bone in profuse proliferation of new tissue at this union” Hackett spent many years studying and developing injection therapy in ligaments and in 1956 published his research, known as prolotherapy-“the rehabilitation of an incompetent structure [ligament or tendon] by the generation of new cellular tissue. Hackett drew upon an old phrase to re-iterate the treatment’s effectiveness by pointing out that “a joint is only as strong as its weakest ligament.” The same techniques and drugs have been used successfully for pain relief from ligament laxity for nearly sixty years. Prolotherapy is now gaining wider acceptance for painful musculoskeletal and ligamentous problems and has demonstrated long lasting results.

Treatment for Ligamentous laxity

What are Ligaments?

Ligaments are cable like structures which hold your bones together and allow you to walk and move without falling apart. Ligaments are flexible but they do not stretch very far. Injuries such as a sprained ankle, twisted knee, a bad fall, whiplash or the likes of lifting something which is too heavy, can tear or fray these cable like structures. These injuries set up a healing process call inflammation to repair the injured ligament. You know the process is happening when you feel the pain, heat, note swelling and cannot move the injured joint. If the healing process is completely successful then the ligaments will be returned to their normal strength and length and you may return to your normal activities. If this “stretched out” ligament will lead to a situation which can cause pain and discomfort with movement.

When a ligament is “strained” or injured, some of the strands of threads which make up the cable become over stretched and broken. The torn or strained ligament is really millions of tears of these strands which in fact are molecules of collagen. Loose ligaments allow the joint to move beyond its normal range of motion. The abnormal motion allowed by the strained ligament will produce painful sensations and make you aware of the problem. These sensations also include “numbness and tingling” and a phenomena known as referred pain. This referred pain is created by the ligament laxity around the joint but is felt at some distance from the injured joint. The abnormal joint movement also creates many protective actions by adjacent tissues. Muscles will contract in an attempt to pull the joint back to the correct location and stabilize it and protect it from further damage. We then feel the muscle spasms which are related to the ligamentous laxity.

There is a tendency to treat the muscle spasms as the primary cause of the problem and many medical treatments may be directed toward the muscular spasm and not to the primary cause—the ligamentous strain. If the joint is slightly out of place because of the ligamentous laxity, it may respond to manipulative care. Such manipulative techniques will often provide relief and in some cases permanent relief.

If lax ligaments can lead to muscle spasm, loss of movement and all sorts of painful sensations and feelings, what can be done?

Inflammation-Healing the Body

Inflammation has several distinct phases, the acute inflammation phase, the granulation phase and the remodeling phase. The “Healing Cascade” is basic to all injuries regardless of the site of tissue involved. Each phase is dependent upon the previous phase for initiation of the next step in the healing process. Understanding inflammation is the key to gaining insight into how prolotherapy works.

Phase one begins at the time of injury, when the ligament and the adjacent cells are broken open and their contents in the fluid or plasma around the broken-open cells attract an influx of white blood cells called leukocytes. Their job is to clean out the bacteria and prevent infection at the injury site. Many of the chemicals released during this phase will be broken down into messengers or chemical signals that tell cells to become active or inactive during this phase of inflammation. Some of these chemicals are called prostaglandins, which cause pain at the injury site.

The leukocytes also secrete hormones which attract an important cell called the “Macrophage”. The arrival of the macrophage at the injury site signal the beginning of the next phase in the healing process called the granulation phase. As the macrophage at the injury site they begin to “clean up” the area through a combination of digesting the broken down cell parts and secreting enzymes which break down many of the damaged ligament molecules. The macrophage also releases chemicals (growth factors) which stimulate the growth of new blood vessels, intercellular matrix, and the cells that will make new ligaments. This process gives the area a second chance to heal. In most soft tissue areas have relatively poor blood supply and therefore take longer to heal. These specialized cells which make ligaments are called fibroblasts. The fibroblast will be responsible for the actual repairing of the damaged ligament. The combination of all these cells and the new blood vessels being formed causes the thickness and fullness that can be felt at the injury site. The granulation phase will be present for ten days to two weeks. Fibroblasts will find the site where the ligamentous structures attach to the bone-the fibro-osseous junction.

The fibroblasts will be stimulated or “turned on” to make new ligaments by chemicals and hormones that will have been released by the incoming clean up cells (macrophage). When the macrophages are functioning they rapidly make massive amounts of the basic building blocks of ligaments, namely, collagen.

The third phase of healing is called “wound contraction”. During this phase the new collagen deposited at the injury site will be organized into a new ligament. The fibroblasts make single long molecules which when outside of the cell will begin to entwine around each other forming what we call a collagen fiber which is a “triple helix” of these molecules. The individual molecules are held together by a strong chemical bond. As the collagen fibers wind around each other they begin to contract and the molecules become shorter and tighter. Water is squeezed out (like squeezing a sponge) causing further shrinkage. As the millions of collagen fibers lose water and shrink, the ends of the ligament will be slowly pulled together and the laxity will decrease.

We can observe this in the healing of a skin wound as the edges of the wound pull tightly together near the end of the healing process. This process is summarized in Figure 1. During the third phase of the healing process, all of the cells originally present to “clean up” the wound are recalled by the body. All that is left at the injury site are fibroblasts which have “turned on” and are secreting the collagen and other substances which will be used to increase the integrity of the injury site. The third phase of inflammation lasts for a number of weeks and the “new ligament” tissue will not reach its maximum strength for several months. With prolotherapy the cells in the ligaments become 50% thicker and are 200-400% stronger.

Ligament Injection Therapy

Now that it is understood how inflammation and collagen works, we can really understand what we need to do is to create inflammation. Ligament injection therapy simply stimulates this healing process in a more controlled and less violent way than occurs during trauma in an automobile accident, slip or fall, twist or athletic injury. The technique of creating this inflammation and the creation of collagen is done by injection of proliferants.

Proliferants are nothing more than irritants. These irritants are enough to break open the surface of the cell walls and allow the spilling of their contents into the immediate and adjacent tissue spaces near where the fibroblasts reside at the junction of the ligament and the bone. This then stimulates the healing cascade. A number of different proliferants may be used which are capable of causing this process to initiate. The most frequently used in the office I go to are osmotic shock agents. These drugs are dehydrating agents and are going to remove the fluids from the cells around the injection site. In the modern orthopedic medicine practice, this osmotic shock agent is primarily a concentrated solution of glucose, glycerin and a very small amount of phenol. It is called “P2G”. A saline, rather than dextrose is also used as a proliferant.

However, today the most common agent used is dextrose; a concentrated form of sugar mixed with a local anesthetic usually lidocaine, procaine or xylocaine is also used to reduce the sharp, stabbing like pain when the needle penetrates the injured ligament. From my own experience one particular session the doctor ran out of the anesthetic and the difference in the pain that I felt was very noticeable. Note all of these proliferants are injected at the fibro-osseous junction.

The discomfort of prolotherapy is due to the fact that the doctor is causing an “artificial” injury which is an important signal that healing is underway. The pain, swelling, heat and redness caused by the injections are all signs that the underlying cellular and chemical processes of 200 million years of evolution are safely underway. The body’s pain signals can be listened to and as the pain decreases the joint movement can increase. In a ligament injury can cause such severe pain is because ligaments are full of nerve endings. once the pain is treated with prolotherapy, the ligaments heal, pain receptors stop firing, and this type of pain will resolve. As you have probably already deduced, having a very knowledgeable person, a doctor who is highly trained in ligament complexities and trigger point areas is very important.

Who should get Prolotherapy?

This question as in the beginning of prolotherapy remains true today of who should inquire getting this sort of treatment-based on your type of musculoskeletal injury and by the type of patient you are. In the Hackett/Henwall/Montgomery book on prolotherapy this issue is addressed right away:

“Criteria for Injection Therapy in New Patients:

1. Appropriate medical problem.

2. Desire for recovery.

3. No underlying medical conditions which would significantly interfere with healing.

4. Ability and willingness to follow instructions.

5. Willingness to report progress.

6. Willingness to receive painful injections in an effort to recover from injury.”

Furthermore, cases with individuals with illness with autoimmune or immunodeficiency disorders should not undergo this treatment. This is discussed later. It is important to know that age is not a factor as long as the individual is healthy, and it does not matter how long someone has injured themselves. With that being said and I would not recommend this treatment to my mom who I know would not be able to undergo this type of therapy for reasons stated in number 6 would be too much for her to bare.

Also, the evaluation of MRI’s might be misleading when trying to diagnose the source of the pain as nothing may show up in the MRI but obviously, the pain can still be pertinent. The reasons for this can be very long and complicated one that this article will not delve into but I will say is everyone has higher and lower pain tolerances. A pain-free person might have some results that can be interpreted into them receiving pain, when actuality none is registering for that person and the opposite can occur for people who are in pain as stated above. For this group of people shoulders, knees and back problems should be taken in account their MRI reading and prolotherapy might be their ticket to later become pain free.

For more information if prolotherapy can help you go to http://prolotherapy.com/prolohelp.htm and it has many injuries that you can click on to see if your ailment can be effectively treated by prolotherapy.

Why is Secondary Treatment Needed?

If the process is a natural one, why did it not do the job correctly the first time?

Orthopedic medical physicians do not understand all the reasons. Some of the more likely causes could be explained this way. Initially, there was continued joint displacement following the injury and the ligament healed in the “longest possible length” position. Possibly the nutrition of the patient was inadequate. The genetic tendencies to heal are not complete. The healing process was itself suppressed by such medications as aspirin.

Aspirin and other non-steroidal anti-inflammatory (NSAIDS) can knock out or suppress the healing response by interfering with the prostaglandin growth factor pathways. These drugs are frequently prescribed because they are thought to be safe and a conservative treatment modality for pain. However, research has shown that aspirin is not without significant side effects relating to inflammation. In addition to the well documented adverse effects, this medication has the stomach, it may directly inhibit healing or injured ligaments.

Typical Treatment Course

The typical treatment course really depends on how that individual heals and can vary on such discrepancies of the ones listed above. Generally, 3 to 4 weeks between treatments is a decent amount of time between treatments as the prolotherapy solution lasts up to 6 weeks in the body. The average number of treatments in a given area is between 4 and 6-however, that if is the doctor can find the exact spot that is needed, as I am told within 2 millimeters of the injured ligament. This can be a daunting task for anyone to find and depending on the severity of the injury is in more than one area, unbeknownst to the individual as that area might not be the one that is in the most pain. In severe cases such as my own, Alex Mardell where I was to compete for Team Canada in the World Powerlifting Championships in Soelden, Austria had possibly 4 treatments in 4 weeks. Under these adverse conditions I needed to still be able to train in order to compete. The injections did just that as it made the ligament in my hip more stable and relatively involved a lower pain threshold when attempting to go quite heavy in the squat. As a testimonial after each treatment I did feel noticeably better and if I was allowed the luxury to not train as heavy but more moderately I know the results would have been much more profound.

The Risks of Ligament Injection Therapy

Treatment with Prolotherapy is not without risk. Since the intent of the technique is to create inflammation, pain, swelling and redness, the result can sometimes be more than anticipated. The injections may also be painful because the placement of the needle in the fibro-osseous junction is also a tender site. Bruising around the injected area is a common occurrence and the risk of being in more pain than before the treatment for one to two days after, which is caused by the intended inflammation. Some other risks which have been rarely reported are: infection-since the skin is broken with a needle, “headache, nerve irritation, allergy, puncture of an organ (such as the lungs) if injecting around that region.” The most serious complication with prolotherapy, which is extremely rare, includes death-however has been reported from prolotherapy in the last 25 years. Also, one last risk that must be mentioned in regards to RIT and that is the risk that this procedure might not necessarily work for some people. Some known causes for this contradiction include active infection or cancer or some other condition that interferes with healing. Immunodeficiency conditions, complete rupture of a tendon or ligament, allergies to any of the ingredients of the prolotherapy formula and even the patient’s unwillingness to experience the associated discomfort after the treatment. The use of Non Steroidal Anti-inflammatory Drugs (NSAID’s) (See TSC glossary for examples of NSAID’s) also can hinder the healing process as these drugs work against and block the treatment as the body needs to try to repair itself with carrying leukocytes to the stimulated infected area with reparative growth hormone.

Overall, prolotherapy has proven to be a safe therapeutic technique in well trained hands. The procedure is not easily learned. The Prolotherapists must have training in the form of workshops, apprenticeships and be a true student of functional anatomy. Prolotherapy performed in trained hands is an effective treatment method for the pain and dysfunction of ligamentous laxity.

Summary

In Summary, accidents which cause ligament strains are normally healed by a process called inflammation. Inflammation is a multi-phased process, but the end product is the production of collagen which will form the threads of a new ligament. As the collagen looses water, it shrinks, becomes shorter and tends to pull the two ends of the ligament together. If the process is incomplete, the joint may remain in an abnormal position and this causes pain, numbness and muscle spasms as well as muscle dysfunction.

Prolotherapy is an injection technique whereby drugs are injected at the fibro-osseneous junction causing inflammation and the resultant stimulation of fibroblasts to make new collagen fibers. The technique may be painful, but safe and effective in decreasing the pain of abnormal joint movement or ligament laxity.

Patient Instructions for Prolotherapy

After your prolotherapy treatment, please note the following items which may be helpful:

1) After all your treatment do not take aspirin (or anything containing A.S.A.) or anti-inflammatories (Tylenol is okay). Aspirin interferes with the body’s natural healing process for the ligaments. Try ROBAXACET (generic product is available at most pharmacies-just ask for it as it’s much cheaper) For your first dosage take 3 tablets.

2) Try applying heat first to painful areas for 20 to 30 minutes or better yet go into a hot tub to loosen up. This may be necessary for one or two days.

3) The area of where the Prolotherapy was injected will be stiff for one or two days. Often your pain will migrate as a response to therapy. Please fill in the body chart so you can remember what happened after prolotherapy.

4) Ensure you take: Vitamin C-2000 mg/day

Glucosamine Sulfate-2000 mg/day

MSM-1000 to 2000 mg/day

B50 or B100 daily

These should help the healing process well.

5) You should not be stiff and painful for more than two-three days at the most. If you are please contact your doctor and inform them of your situation. They will do their best to accommodate your visit back to the office as quickly as possible. In some cases, the treatment may initially increase the pain. An increase in pain can be done to the treatment’s effect on the body’s compensation for the previous injury, i.e. opposite muscles spasm because of weakness or tightness in those muscles.

6) Each subsequent treatment is less painful than the first.

7) Please eat at least half to one hour before your prolotherapy treatments. Ensure that you eat something high in protein and low in carbohydrates.

Anyone, living in the Edmonton area and wants to try this treatment, please email me alex@thestrengthcenter.com and I will reply with the name, address and phone number of the doctor that I have seen. However, he is extremely busy and you might need consulting documentation from your doctor to get in.