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Prolotherapy Can Effectively
Reduce Chronic Pain

By Marc Darrow, MD, JD, QME

 

The idea of introducing an irritant to an injured joint certainly isn't new.

In ancient Greece, Hippocrates used heated metal probes to treat dislocated and painful shoulders of javelin throwers. He believed this technique created tough scar tissue that tightened the shoulder capsule and kept the joint in place.

George S. Hackett, MD, continued to build on Hippocrates' theories in 1939. While working with car accident survivors, he realized that patients experienced pain when ligaments and tendons were injured. He believed that repairing connective tissues could resolve most of the pain. Dr. Hackett introduced an irritating compound to activate the body's natural mechanisms and prompt production of new collagen tissues—a proliferation process that became known as prolotherapy.

Also known as proliferation therapy, prolotherapy is a pain management technique that can treat degenerative or chronic injury to ligaments, tendons, muscle fascia and joint capsular tissue. It also can be effective for areas that are painful, but not tender to the touch, such as the inside of a joint.

Through injections, prolotherapy allows rapid production of collagen and cartilage.1 Collagen, a naturally occurring protein in the body, is a crucial element to the formation of new connective tissue. And healthy connective tissue creates a solid foundation to hold the skeletal infrastructure together.


Healing Mechanisms

Prolotherapy helps produce collagen by injecting mild chemical or natural irritants, such as dextrose—sugar. The injections stimulate the immune system's healing mechanism to create collagen naturally. This strengthens and restores joints, which provides permanent pain relief.

Consider a condition such as chronic pain, in which injured, loose or stretched out ligaments often cause ligament laxity. Laxity produces pain and discomfort, especially during movements. This occurs because the connection of ligaments and tendons to bone may be inflamed, and a joint may be moving beyond its normal range of motion.

The body, therefore, must create collagen to heal injured tendons and ligaments. But it doesn't provide ligaments and tendons with a proper blood supply, which means lower collagen production and a poor chance for complete healing.

The same holds true in cases of degenerative disease and aging. In particular, collagen may dry out and lose its stretching ability. This process is more severe in some people, and researchers don't know why. Theories behind this deficiency include poor genetic makeup, blood type with specific dietary requirements, viral or bacterial load, pathological conditions, body acidity or food allergies.

In healthy ligaments or tendons, collagen fibers are flexible and elastic. But injuries can stretch fibers beyond their designed lengths, and repetitive motion frays or tears them.

When tissues are stretched beyond their normal limits, inflammation occurs. A patient experiences inflammation, the immune system's response to injury, when the body tries to heal damage. However, a weakened immune system or severe injury also can restrict the ability of ligaments and tendons to heal correctly. Since connective tissue around joints and cartilage has such poor blood circulation, injuries to connective tissue are often irreparable.

The key to prolotherapy is stimulating collagen development and growing new ligament and tendon tissue. By growing stronger ligaments and tendons, you can repair the injury, and reverse the degenerative cycle of arthritis and wear-and-tear disorders.


Injection Ingredients
Injection ingredients for prolotherapy consist of compounds that alleviate chronic pain. To trigger the healing process, clinicians use mild chemical irritants, such as phenol, guaiacol or tannic acid.

After injection, these substances attach to cell walls to stimulate the body's reactive healing process. Some clinicians prefer to use chemotactic agents, such as sodium morrhuate, a fatty acid derived from cod liver oil.

Osmotic shock agents—the most frequently used compounds in prolotherapy—are simple compounds, such as dextrose and glycerine. They work by causing cells to lose water, which leads to cellular dehydration and then inflammation, triggering the healing response. Because these ingredients are water-soluble, they're excreted from the body after producing the desired effect.

Practitioners can add cofactors, such as the anti-oxidant mineral manganese. Or they can use a combination of glucosamine sulfate and condroitin sulfate, which may aid arthritic joint repair. Based on the combinations of compounds, these cofactors may increase efficacy.

Research by Liu observed that efficacy. In a study of prolotherapy's effectiveness, Liu injected a 5 percent sodium morrhuate solution into the medial collateral ligaments of rabbits. After five injections, the ligament mass increased 44 percent, thickness increased 27 percent, and strength of the ligament bone junction increased 28 percent.2

Liu's research confirmed the results of an earlier study; Dr. Hackett and colleagues examined the proliferant Sylnasol when it was injected into rabbit tendons.3 After 48 hours, an early inflammatory reaction surrounding the nerves and blood vessels with lymphocytic (immune system cells that remove damaged tissue) infiltration occurred in the area between two tendons and the tendons and sheath.

Two weeks after injections, fibrous tissue existed. Lymphocytic infiltration had diminished, although small levels were present, which indicated that new white fibrous tissue was still being stimulated.

One month after injection, fibrous tissue was present, and lymphocytic and fibroblastic (immune system rebuilding cells) activity had diminished. In other words, the rebuilding cells had finished their job and moved on.

Although prolotherapy compounds work differently and motivate the body to heal through various natural responses, the end result is the same: It cures pain by building new tissue and stabilizing joints.

Before administering prolotherapy, you should examine a patient by carefully and gently pressing on an area suspected of causing pain. You'll know where to apply the prolotherapy injection when your touch elicits an intense pain reaction—a trigger or tender point.

Most of the prolotherapy solutions have a "double-edged" effect and should produce anesthetic and proliferant qualities. For example, the anesthetic agent alleviates the "pain trigger" and lets you know a solution was placed in the proper area. Simultaneously, the proliferant agent begins strengthening ligaments and tendons at the trigger or tender point site.

Injections at trigger points cause irritation that stimulates the body's natural process for repairing damaged tissue. It does so by causing an influx of fibroblasts and chrondroblasts, the healing cells that create collagen and cartilage.

Joints are gradually pulled back into proper alignment as newly produced collagen reinforces muscles, tendons and ligaments. Then, as collagen shrinks, it tightens the joint capsule and prevents excessive, unnatural movement.

The number of treatments and injections required per treatment are based on the type of injury. For example, two prolotherapy treatments for patellofemoral syndrome of the knee (runner's knee) will usually eliminate the pain.

But for a more complex problem, such as bone-on-bone arthritis, it may take six to eight treatments over two months. Back and neck pain may call for a series of four to eight treatments.

Anti-inflammatory medications are contraindicated during prolotherapy. And higher doses of NSAIDS, such as aspirin, ibuprofen, Celebrex or Vioxx, may inhibit the necessary inflammation and reduce the positive effects of prolotherapy. Studies on chronic NSAID users actually show greater joint destruction, compared to patients who don't take these medications.

Remember that every patient heals differently, and recovery depends on overall health status and how frequently a patient uses an affected area. Regardless of health status, prolotherapy may be the answer to effectively reduce or eliminate chronic pain.

For a list of references, go to www.ADVANCEforDR.com and click on the references tool bar.

Marc Darrow, MD, JD, QME, is board-certified in physical medicine and rehabilitation and is the medical director of Joint Rehabilitation & Sports Medical Center in West Los Angeles. He's also an assistant clinical professor of medicine at UCLA and author of Prolotherapy, The Collagen Revolution: Living Pain Free. He can be reached at www.JointRehab.com or (310) 231-7000.

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