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A Needle in Time

MagazineJune 2013 (Vol. 24 Issue 3)A Needle in Time

The best-kept secret of many elite athletes, says Alison Levy, offers a simple alternative to surgery by stimulating the body to heal itself

The best-kept secret of many elite athletes, says Alison Levy, offers a simple alternative to surgery by stimulating the body to heal itself

Pittsburgh Steelers' wide receiver Hines Ward, the team's best player, was going to be forced to sit out the 2009 Super Bowl, sidelined by a knee injury-a sprained medial collateral ligament (MCL), the ligament running along the inner side of the knee. But two weeks before the Super Bowl, he'd received a little-known treatment and one week before the big game, Ward surprised reporters by coming out to practice, apparently no longer injured. When questioned, he said he had recovered-thanks to a shot. It was assumed that Ward had received a corticosteroid injection, but that was not the case. Ward credited both his recovery and ability to play in the Super Bowl to some mysterious injection therapy that few commentators or even his fellow players had ever heard of, and it was discussed throughout the game. Not only did Ward play, but he played superbly. The Steelers won the Super Bowl, and Ward was voted the Most Valuable Player.

Knee injuries, back pain, tennis elbow-all these musculoskeletal complaints can be debilitating, sidelining not only peak athletes but just about anyone. Following a battery of X-rays, CT (computed tomography) scans and MRI (magnetic resonance imaging), steroids, surgery and joint replacements are the conventional treatments of choice, with variable levels of success and often unacceptable side effects.

But are operations and drugs the only options? What treatment prompted Hines Ward's near-miraculous recovery?

Enter prolotherapy

Don't be surprised if you've never heard of it. Even though it's a highly effective and powerful treatment, it's one of the lesser-known alternatives to drugs and surgery.

Prolotherapy involves injecting growth-enhancing substances into specific tendons, ligaments, muscles and joints to stimulate the body's own self-healing mechanisms. Commonly used agents such as dextrose, phenol-glucose- glycerol (P2G) and hypertonic saline can strengthen and rebuild weakened, disconnected and torn musculoskeletal attachments to provide pain relief, stabilize joints and optimize function, and the track record for solving problems that medicine can't readily fix is nothing less than impressive.

One study of patients with chronic low back pain found a 60 per cent increase in the thickness of the sacroiliac ligaments in the three months following prolotherapy treatment. Patients also reported having less pain and increases in their range of motion.

In one study testing four different types of injection therapy, including prolotherapy, to treat tennis elbow ('lateral epicondylosis' in medical-speak), patients tracked for up to more than two years showed improvement, based on pain scores and functional assessments, ranging from 51 per cent to 94 per cent. Like any sort of jabs, these injections are momentarily uncomfortable because they induce inflammation, the body's first line of healing response. But most practitioners use lidocaine (a mild local anaesthetic) either mixed in with or prior to the jab, or 'gas and air' (nitrous oxide, or 'laughing gas').

Shocked into action

How can a mere injection make such a difference? Most of the active ingredients used in prolotherapy induce an 'osmotic shock' that then leads to an inflammatory response. White blood cells migrate to the site to address the inflammation, followed by platelets and fibroblasts that lay down healthy new collagen.

To avoid interfering with the healing effects of inflammation, recipients are advised to avoid any over-the-counter non-steroidal analgesics (NSAIDs) such as Advil or Alleve and any other drugs that reduce inflammation. But some consider low-dose aspirin (85-325 mg/day) or paracetamol (acetaminophen) acceptable.

While peak healing occurs in the two to four weeks following each treatment, tissue reconstruction can go on for a month or more.

Post-treatment discomfort in the injected area is a normal response and may last for several days. Aftera typical round of treatments (three to six sessionsevery one to three weeks or so), both long-term and acute pain can disappear, often permanently. Mobility and an expanded range of function is often restoredor increased, say organizations like the Osteopathic Association of Prolotherapy and Regenerative Medicine (AOAPRM), a US-based professional organization that also offers clinical training in the method (see www. acopms.com for more information), a view backed up by a growing body of research.

London-based physician Dr Brian Pattinson first discovered prolotherapy when he needed to treat his own back problems-a degenerative disc so severe it was reduced to a thickness of 1 mm-after his own orthopaedic surgeon recommended surgery. He opted for prolotherapy instead and was able to take up skiing, badminton and even martial arts, with no resulting pain. In his own experience, people sometimes return many years later for a booster. "I haven't needed it myself for 20 years," he said.

In the UK, only MDs are licensed to provide this treatment, says Pattinson, who has offered prolotherapy for 40 of his 50 years as a clinical practitioner, treating more than 150,000 patients with this approach. Dueto high demand, his practice is now nearly exclusively prolotherapeutic, with patients flying in from France, Norway, Finland and the Netherlands, as well as from faraway places like Cambodia, India and even Australia.

In the US, either MDs or DOs (doctors of osteopathy) can give the treatment. An article in The Physician and Sports medicine reported that as of 2000 450,000 Americans had undergone prolotherapy and found benefits, including many patients who were themselves physicians.

Although not available on the National Health, prolotherapy is performed as an outpatients treatment in doctors' offices and clinical settings such as sports medicine facilities. A number of British private insurers will cover what is usually referred to as 'sclerosant therapy'.

In the US, prolotherapy has been covered by health- insurance providers since 2010, but is consideredan out-of-pocket expense and categorized as an "experimental" procedure-implying that it's a novel, unproven practice.

An ancient healing art

"Experimental? " wryly comments Walter Grote, DO, a US-based osteopathand internist who has practised prolotherapy since 2001.

"It's believed that Hippocrates was the first to experiment with it back in Ancient Greece."According to Grote, the famed physician" utilized a hot wire to induce prolotherapy to heal rotator-cuff injuries in gladiators".

That ancient method induced scarring, whereas our modern-day treatments using injections of proliferative agents do not.

In the 1930s, Iowa physician George Hackett noticed that osteopaths were using this approachto treat hernias, which arise when a weakness in the muscles of the abdominal wall (or elsewhere) permits a small portion of an internal organ (like the colon) to protrude. This led Hackett to apply the technique to treat what he called the "relaxed" ligaments and tendons that contribute to joint dysfunction. (The technique can also be used to treat varicose veins.)

Connective tissue like tendons and ligaments can only be safely stretched to a limited degree before they rupture or tear. Hyper mobile or 'double-jointed' people-like the performing contortionists in the Cirque du Soleil, and some gymnasts and dancers- are more prone to these kinds of injuries. When a ligament is stretched beyond its natural extension, some of its fibres are lengthened permanently like an overstretched elastic band. With constant lengthening and tearing, the area is then weakened permanently. According to his book Ligament and Tendon Relaxation Treated by Prolotherapy (Springfield, IL: Charles C Thomas, 1956), updated versions of which still serve as the clinician's prolotherapy manual to this day, Hackett performed the first animal study using this method. After injecting a rabbit's Achilles tendon, he documented a 100 per cent increase in tendon thickness and strength.

Although first thought to create scar or fibrous tissue, more recent animal studies have confirmed that normal tissue regrows because the body lays down new collagen when stimulated by the injected substances. Because of the "proliferative" action, the treatment was re-dubbed 'prolotherapy'.

Despite its usefulness for a wide catalogue of complaints, prolotherapy is neither well known nor well used for a variety of reasons. A side from the issue of insurance coverage, there are far fewer prolotherapists than surgeons or doctors willing to offer it, with about 30 practitioners in the UK and around 300 in the US.

What's in the jabs?

According to Los Angeles-based physician Marc Darrow (who has treated American basketball great Abdul-Karim al-Jabbar), the "specific combinations of chemicals and substances used are as varied as the 'schools' of prolotherapy using them." These agents include:

-D50W (50 per cent dextrose in water)

-Sodium morrhuate

-Hypertonic saline

-Calcium carbonate

-Pumice 'solution'

-PQU (phenol-quinine-urea)

-P2G (phenol-glucose-glycerine)

-PRP (platelet-rich plasma)

-Growth factors

-Stem cells.

Common to all of them is the ability to act as an irritant to prompt the body to initiate its own innate healing response.

Results compared to surgery

While no double-blind studies have been done to measure differences in outcomes between surgery and prolotherapy, various studies of each form of intervention on its own do provide some data for comparison.

A double-blind controlled study carried out in 2002 compared the outcomes in patients with knee arthritis who were assigned to two treatment groups: an arthroscopic knee-surgery group and a control group who underwent matching placebo or fake surgery.

Based on their findings, the authors concluded that the effectiveness of 'keyhole' surgery for knee osteoarthritis was no better than the sham surgery, prompting their comment that "the billions of dollars spent on such procedures annually might be put to better use."

When prolotherapy and exercise therapy, on the other hand, were given to patients with the same type of osteoarthritis in the knee, function improved and pain was reduced by nearly 50 per cent.

Although back pain is the most common pain complaint, surgery can be risky, possibly causing bleeding, nerve injury, damage to vertebrae and a host of other side-effects. That's why many orthopaedists prefer to prescribe pain medications like NSAIDs (non- steroidal anti-inflammatory drugs) or opioids like oxycodone (sold as OxyContin and OxyNorm in both the UK and US). But this form of management can lead to drug dependency or addiction and of course doesn't cure the underlying problem. In Pattinson's experience, the correct use of prolotherapy can reduce or eliminate the need for surgical treatments or corticosteroid drugs, which may work at best for only a short time before they have to be discontinued.

In one study of 81 patients with an average of 10 years of back pain of those given spinal manipulation and prolotherapy and the other half were giventhe same kind of manipulation, but a sham injection of salt water. After six months, more than a third of patients treated by prolotherapy were entirely freefrom pain, compared to just three in the control group, and 35 of the 40 patients were more than 50 per cent improved, compared with 16 of the controls.6 A more recent review of high-quality studies concluded that, when combined with spinal manipulation or exercise, prolotherapy can reduce pain and improve movement.

On Father's Day 2012, John Gill, a guidance counsellor and wrestling coach at Kittatinny Regional High School in New Jersey, was volunteering at his church. While dragging some brush to a wood chipper, he twisted in an unaccustomed way and suddenly experienced "the worst back pain of my life.

I went home in agony, "here called. Within a few weeks ,Gill reported he was" taking pain pills 24 hours a day, like they were candy". He tried chiropractic and was advised that he needed surgery, but "I didn't want anyone cutting my back," Gill said.

By his second prolotherapy session, Coach Gill experienced a lessening of pain. Today, after a courseof seven treatments, he is totally pain-free. "Before if I stood on my left leg, it would collapse beneath me. I was in my early 50s, and no way was I ready to give up and get in a wheel chair," here calls. "Now I coach, I lift weights. Prolotherapy changed my life."

Gill's story isn't unique. Lars (not his real name), a spindly 22-year-old Dutch martial-arts devotee, could barely stand or sit for long periods and was no longer able to exercise when he first flew over to the UK to consult with Pattinson.

After diagnosing the problem as stretched ligaments all along his back, Pattinson gave Lars a series of intensive prolotherapy sessions-each time injecting 55placesoneithersideofhisspine.Afteranumberof visits, Lars returned to his martial arts and when he came in for his final visit, he was barely recognizable, said Pattinson."He was so built up after doing so much hard exercise.

"The most common thing I hear is 'I've had numerous consults and undergone chiropractic, acupuncture and drugs. I've tried everything else. Can you help?' "reports Pattinson.

The answer, he says, is almost certainly yes. "Some have suffered for more than half their life. Even the most sceptical often end up admitting 'I wish I had done this earlier.'"

Besides being less invasive, prolotherapy and its related (and more costly) treatment, platelet-rich plasma (PRP), which includes the patient's own blood plasma as part of the injection, are both still far less expensive than surgery.

For instance, in the US a hip replacement operation can cost around $60,000, whereas treating the hip with PRP can cost under $5,000.

Katherine Kero, a retired homemaker from Hardwick, New Jersey, underwent PRP treatment for her hip when she was 80 years old. "I didn't want to go through an operation with a long period of convalescence at this stage of life, "she explained. "My orthopaedist put me on pain medication, but I didn't like being groggy."

Kero consulted Grote and ultimately opted for PRP treatment. Her own plasma-rich platelets were withdrawn, run through a centrifuge and injected. In Kero's case, she received injections to the hip joint to spur healing.

A good rule of thumb, says Grote, is that "PRP works about three times faster as standard prolotherapy and costs about three times as much."Kero is now pain-free and satisfied with the results.

It was also PRP that prompted Pittsburgh Steeler Hines Ward's amazing recovery-and Super Bowl win.

The secret source of pain

Like many alternative approaches, prolotherapy goes beyond temporary relief to address the actual causes of a health complaint, which is not always intuitively obvious to either patients or doctors. One surprising result is that the source of the discomfort or dysfunction may be located far from where the pain is felt due to the phenomenon of referred pain.

"One man who came to me 'knew' he had a hernia which six other doctors (including two surgeons and a urologist) had failed to locate, "Grote recounts.

"I may be the seventh, "Grote told him," but will you take a leap of faith? If I find some tenderness in your back, may I inject it to see if the pain goes away?"

The man agreed and Grote proceeded to inject the ilio lumbar ligament, which runs from the hip to the lowest spinal vertebra in the lower back.

Following the initial treatment, the pain noticeably diminished. Over the course of several follow-up treatments, the pain disappeared permanently, Grote reports.

A similar situation occurs with spinal disc problems. According to the American Association of Neurological Surgeons, the spokes organization for neurosurgery, every year in the US around 200,000 disc surgeries are performed to treat 'degenerative' (bulging) discs. In the UK surgery for this condition is less common, with around 155 cases each year.

In many cases ,says Grote, the disc isn't the problem. "If you gave MRIs to a random group of 30-year-olds, nearly half of them would be found to have a bulging disc, many without experiencing any noticeable symptoms or pain, "he says.

A disc bulges, says Grote, because the surrounding ligaments have been injured or weakened so that they don't provide the proper anatomical support.

In the view of prolotherapists like Pattinson and Grote, strengthening the ligaments is a better option for permanently restoring function.

Ligaments and tendons: the flash points

The human skeleton requires both stability and flexibility. Fibrous connective tissues-ligaments and tendons-provide the stability and capacity for movement. You can bend your leg backwards at the knee because of tendons and ligaments, and you can't bend it forward at the knee-also because of tendons and ligaments.

Ligaments attach one bone to another, stabilizing structures by limiting a joint's range of movement.

Tendons attach muscles to bones and help to facilitate movement.Although the body has hundreds of tendons, only a few are especially prone to tissue damage and becoming overstretched or 'floppy'. These 'watershed zones' all have a sparser blood supply and so lesser amounts of oxygen and restorative nutrients that blood delivers. When tendons and ligaments become lax, they are less effective at self-repair, and the bones and joints they support fall out of alignment.

Watershed zones include

-The Achilles tendon (which connects the back of the heel to the calf muscles).

-The rotator cuff tendons (which connect the shoulder's rotator muscles to the arm).

-The posterior tibial tendon (which connects the front shin bone to the metatarsal bones in the ball of the foot).

-The tendons of the outer elbow (which connect the upper arm bones to the Muscles of the lower arm) that are involved in tennis elbow.

-The ligaments of the knee.

ACL rupture

According to the NHS, "Every year in the UK, thereare about 30 anterior cruciate ligament (ACL)injuries for every 100,000 people, "making it the most common knee injury in Great Britain. And because of anatomical differences in the lower limbs, ligaments, and joint strength and flexibility between men and women, women are at greater risk for this type of injury.

Located within the knee joint itself, the ACL attaches to the upper and lower leg bones and allows the knee to twist. Damage to, particularly full rupture of, this ligament is considered the kiss of death for any athlete, but this injury is more common during sports like skiing, football, netball, hockey, basketball, rugby, martial arts, gymnastics, and any activity where the body is moving at a high speed and the knee forced to respond immediately to an abrupt stop or change in direction.

The orthodox surgical approach is usually immediate surgery for a torn ACL. Due to the poor response with ACL surgical repair, reconstruction (using tissue from another of the patient's tendons, such as the hamstring) has become standard for ACL tears.

Received medical wisdom has it that ACL tears do not heal themselves. However, a recent study of skiers found that, after two years, some people had recovered equally well-or even better-without undergoing the knife, suggesting a self-repair mechanism.

The authors concluded that rather than rushing into surgery ,it may be better for practitionersto evaluate patients six to 12 weeks later, using functional tests and measures that may reveal those who are good candidates for so-called 'non- operative' recovery through the body 's own innate healing mechanisms.

And as with other operations on the knee, reconstructive surgery does not prevent problems such as arthritis from developing later on.

As prolotherapy activates the same 'non-operative' mechanisms, it also further enhances the body's innate recovery and repair processes.

Opting for a natural repair process is also better for preserving the body's own natural physiology and function rather than changing them as reconstructive surgery inevitably does, says Martha M. Murray, MD, of Children's Hospital Boston and Harvard Medical School.

"I think the future is in regeneration and repair for a lot of things, not just the ACL. Hopefully, as the science for repair and regeneration advances in a variety of wound-healing areas, we as orthopaedists will be able to take advantage of that new knowledge and apply it to some of our toughest problems- rotator-cuff repair and cartilage repair, "says Murray.

Conditions treated by prolotherapy

-Neck pain

-Shoulder rotator-cuff tears or irritations

-Partial dislocation of the shoulder blade and collarbone

-Shoulder joint cartilage (labral) tears

-Chronic or recurrent shoulder dislocation

-Sciatica

-Herniated discs

-Pinched nerves

-Lower back pain

-Hip ligament and tendon sprains/strains

-Carpal tunnel syndrome

-Patellofemoral syndrome

-Knee ligament and tendon

-sprains/strains

-Tennis elbow

-Golf elbow

-Ankle sprains

Which is safer: prolotherapy or surgery?

Although extremely rare, side-effects of prolotherapy can occur. Most of the problems are like those seen with any injections, including pain, infection, nerve injuries, blood clots, scarring, allergic reaction and even loss of feeling or numbness in the injected area. When injected near the spine, lumbar puncture headaches can develop for a few days, but resolve spontaneously.

To determine the side-effects of the more risky prolotherapy procedures for back and neck pain, one recent study surveyed 171 seasoned practitioners-almost all medical doctors-who'd treated a median of 500 patients and given a median of 2,000 treatments over a median of 10 years. Among the approximately 342,000 treatments in total, there were 472 reports of adverse events, including 69 requiring hospitalization and five resulting in permanent damage due to nerve injury.

In most cases, the side-effects resulted in:

-pain(70percent)

-stiffness (25 per cent)

-bruising (5 per cent)-The vast majority (80 per cent) were related to needle injuries, including: -spinal headache (164 cases)

-pneumothorax (123)

-temporary systemic reactions (73)

-nerve damage (54)

-haemorrhage (27)

-spinal cord trauma such as meningitis, paralysis or spinal cord injury (9)

-disc injury (2).

This survey suggests that side-effects, which are mostly mild, occur in one in a thousand injections, and your risk of any permanent nerve damage is one in 68,400.

Compare this track record to that of back surgery, where nearly 1 in 10 patients are left with chronic pain and one in seven, with bones that haven't knitted back together. Furthermore, one- fifth of all back-surgery patients fall into the category of 'failed back' with chronic, considerable back pain that medicine can't fix.

The worse case he'd ever seen

Ever since her Christmas 2005 skiing accident, Molly (not her real name), an 18-year-old high-school senior, had been unable to walk. Several MRI studies and two surgeons had confirmed that her injury was a virtually totally severed ACL.

Several physicians consulted by Molly had recommended surgery, but she kept putting it off. As her cousin had received effective prolotherapy treatment for tennis elbow from Grote, she finally scheduled an appointment with him-nearly six months after her accident, still untreated and on crutches. In addition to the MRIs, Grote carried out two standard tests for ACL injuries on Molly. Hers were the most pronounced injury results he'd ever seen.

Currently, with more extreme injuries like Molly's, many prolotherapists join their conventional colleagues in advising surgery. Grote himself was uncertain whether prolotherapy could address such a massive tear.

But when he communicated his misgivings to Molly and her parents, they pressed him to proceed.

Molly returned two weeks after the initial treatment. When she reported that she felt slightly better, Grote attributed her feelings to the placebo effect. Four weeks later when Molly returned for her third treatment, Grote noticed that she was able to put weight on the injured leg. The standard tests for torn ACLs showed a 50 per cent improvement.

By the fourth treatment, she was able to walk up stairs and, by the fifth session, she was able to walk up and down stairs without crutches. Grote treated her seven times over 15 weeks, reporting the results in a medical journal.

"Seven years later, she jogs five miles per day and has graduated from Johns Hopkins University," Grote reports.

A similar situation was reported with a female 26-year-old European national soccer player who had sustained a complete rupture of her Achilles tendon. As with Molly, the soccer player received eight treatments, one every fortnight. An MRI scan showed a newly formed, completely intact, Achilles tendon by the sixth treatment.

James Cyriax, an English physician who Pattinson calls the "father of modern orthopaedic medicine", was the first to introduce prolotherapy in the UK. He once said that about 15 per cent of all health complaints were musculoskeletal, and the remaining 85 per cent could be treated by prolotherapy.

In opting for prolotherapy, people may be doing morethan managing their complaints; they may be giving their bodies the boost they need to repair what even the most high- tech of modern medicine cannot.

For a list of prolotherapy specialists in the UK, seethe British Institute of Musculoskeletal Medicine's listing at www.bimm.org.uk/ prolotherapy_practitioners; for practitioners in the US, visit www.getprolo.com.


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