Renewed Treatment for Low Back Pain
Prolotherapy has been introduced for the treatment of chronic pain arising from problems with ligaments. A previous form of treatment to strengthen ligaments and form scar tissue was popular in the last century for the repair of hernias. With the advent of modern surgery, sclerotherapy, as it was called, has been reserved for varicose veins and the like. Earl Gedney, as osteopath from Philadelphia was the first to use an injection to strengthen sacroiliac ligaments. George Hackett, an industrial surgeon from Canton Ohio, active in the late fifties, correlated pain patterns from stained ligament with instability He treated thousands of patients with ligament strengthening injections which he renamed prolotherapy and reported a 90% improvement.
Though prolotherapy has not been popular in the last thirty years because of complications reported in five cases in the early sixties, a resurgence in its use is taking place.
What is Prolotherapy?
The word comes from proles – to stimulate growth (in Latin). It has been found over the last 150 years that a variety of agents can stimulate the growth and regrowth of ligament tissue. In many instances, it is thought, the stimulation for the growth is from an internal bruise, or hematoma which induces the natural healing process. Fibroblasts are the cells responsible for creating the ‘stings’ and ‘ropes’ which join the bones, crossing the joints. They are particularly important in the spine. The spine can be described as analogous to a pile of bricks bound together in a mobile column by the ligaments which tie each vertebra to its neighbor, creating from this pile a mobile strong and flexible support for the body. It is not surprising that a combination of mobility and support occasionally fails. With use, the normally perfect and smooth movements can become ‘kinky’. We speak of somatic dysfunction to describe the areas where movement is stiff or absent. Ligaments are also thought to store elastic energy, a little like a spring, this being their second function. The springiness of ligaments improves body motion and when they deteriorate the elasticity fails.
It was Dr. Hackett who introduced the term relaxation of ligaments. It is plain that in certain instances the ligaments are frayed and even torn from injuries. But it is now thought, particularly in connection with the spine, that the ligaments become relaxed in part because of the shrinkage of the vertebrae and the intervertebral discs and only in part from direct stretching and damage to the ligaments themselves. Probably both mechanisms are active in certain situations.
The spine as a column of vertebrae
When the ligaments do not hold the vertebrae in perfect alignment there is a tendency for one or more vertebra to be slightly displaced or rotated. It is thought that the sacrum is particularly prone to minor displacements between the two pelvic (iliac) bones. Chiropractors use the terminology of a displacement in the sacroiliac joint to describe this. According to official medical dogma this phenomenon does not occur, but many patients who have the experience of ‘putting my back out’ and having it corrected with a chiropractic manipulation have firsthand experience of something moving. The cause for this abnormal movement is ligament relaxation.
How to correct ligament relaxation
Since it is possible with prolotherapy to stimulate ligaments to become stronger, and probably more elastic, it is quite easy to understand that prolotherapy is the treatment of choice when chronic pain is due to ligament relaxation.
The symptoms of ligament relaxation are multiple and the site of the patient’s pain depends on which ligament is strained. It is usual for pain to move from place to place in the body due to the phenomenon of referred pain as well as to mechanical causes. It is the doctor’s job to make the diagnosis. A number of physicians who have trained in orthopedic medicine in modern times have made it their business to study these problems. The diagnosis is made first of all, by learning from the patient about his pain and where it is, and secondly, by sophisticated clinical examination. The diagnosis depends only a very little bit on special tests, such as x-rays. These are obtained mainly in order to exclude other conditions.
The modern use of prolotherapy
It is almost too simple to need stating that if something is out of place it should first be put back and then kept in place_ It is however amazing, how this simple concept has been battered by disbelief and institutionalized dogma.
Milne J. Ongley, a New Zealand physician integrated Hackett’s understanding of ligament relaxation with the existing British style of systemadc clinical evaluation in the musculoskeletal system, called by it initiator, James Cyriax, orthopedic medicine. He also developed Clinical techniques which ensure safety. Indeed in the last 30 years his methods have been used in many thousands of cases without important complications.
The routine for low back treatment
In cases of chronic low back pain, when the orthopedic physician has made the diagnosis of ligamentous insufficiency, usually in association with a displacement of the sacrum or one of the lower lumbar vertebrae, the following routine is undertaken: 1) the use of local anesthesia, 2) manipulation to restore normal alignment of the sacrum and spine, 3) prolotherapy injections, usually weekly for six week. 4) exercises to ensure healing in the presence of movement. It is sometimes advisable to reduce the inflammation at sites of strain (but not in mechanically important ligaments) with an injection of a steroid (modern cortisone) into an inflamed and painful part. The steroids are used occasionally and sparingly.
Other parts of the body
The principles discussed here are useful in the management of pain and instability of any part of the musculoskeletal system (Perhaps it would be better called the ligamentous and fascia] system?) The routine for low back treatment, which is the best known can be applied very effectively to other parts of the spine. Chronic neck pain and headaches are usually relieved, even after many years of trouble, with prolotherapy.
The proliferant in use at present consists of three common substances:
1) Dextrose, which is a type of sugar. It is used in a concentrated form. It produces an inflammatory response and is perfectly safe, even in patients with diabetes, because the total amount used is small.
2) Glycerine, is found naturally in the body as a component of some of the fats. It causes the tissues injected to swell temporarily (you will notice how puffy your back feels after the shots) and helps coagulate any blood which may form in the tissues and provides a framework or matrix on which new fibroblast cells can grow. It has recently been used for certain kinds of nerve ram (trigeminal neuralgia) where it abolishes the pain without upsetting the function o F the nerves.
3) Phenol, is used in most injectable medications as a preservative since it prevents the growth of bacteria. It also induces the growth of new collagen in connective tissue. It has been used for many years in face peels by plastic surgeons since it is known to induce healthy collagen and elastic tissue which removes wrinkles. It also has sortie properties of a long lasting anesthetic.
These three ingredients have been used together since 1948 in Britain, where they were first introduced in the treatment of varicose veins and overall it is estimated more than one million injections have been administered, all over the body, though mostly for low back pain without any permanent or serious reactions.
The United States Food and Drug Administration (FDA) has not officially approved (or disapproved) this mixture for use, but all of its constituents are in common use since before the advent of the FDA and are regarded, therefore, as standard preparations.
Safety of the solution
In the sixties there were five serious complications from intraspinal injections of proliferants. The solution used then was of different materials. The present solution is thought to be safe. Four times the concentration of phenol and glycerine has been placed intentionally into the spinal canal to relieve pain in cancer patients without dangerous effect. The needle placement used when following Ongley’s teaching is such that a high degree of safety is assured. In difficult cases x-ray control with fluoroscopy is used.
In order to stimulate the new growth of collagen the proliferant is injected, but in order to align the new collagen correctly with the existing ligament tissues it is very important for the structures to heal in the presence of movement. This will protect the ligament from forming adhesions to neighboring structures and increase longitudinal alignment of the new collagen. You will receive written and. verbal instructions for the correct exercises. These movements, which we have named exercises, are essential. Repetition of the movements ensures proper healing. As the healing process goes on for several months, it is recommended that patients continue with the exercises for at least three months after the last injection.
Chronic back, leg and arm pain is sometimes due to disc disease. When this is so, an operation can relieve pressure on nerve. Only a physician can make a determination if an. operation is necessary. Disc disease itself is due to ligament relaxation in the first place. It is the abnormal range of movement caused by the relaxed ligaments which allows for most of the abnormal strain o: the discs. Therefore, ligament strengthening is usually recommended before or after surgery, when it is necessary.
There are instances when the patient feels pain at a site. remote From the injured ligament. This is called referred pain Referred pain From ligaments can mimic sciatica and neuritis. It is often confused with pain due to pressure on a nerve root from an abnormal disc in the spine. Differentiating between these is not always easy, but it is exactly this that the orthopedic physician prides himself on doing best.
Each branch of medicine and chiropractic, etc., promotes its own methods. Patients are often stranded without a ‘shoppers guide’. It is the recognition of this problem which is bringing the orthopedic physician back into popularity. He combines the use of medicine, exercises, injections, manipulation and the select recommendation for surgery to the patients’ best advantage. It should be understood that the presence of disc degeneration is the rule in cases of chronic back pain and is often found is similar individuals without pain. Disc problems are, however, not always, or even very often, the cause of pain. In any case disc displacement can often be managed with manipulation. Most cases of back pain, suitably ‘diagnosed, improve with treatment with prolotherapy.
Surgery for discs
There are cases where surgery is essential and sometimes urgent. Most surgeons will agree, however, that in the majority of instances a trial of conservative means is best first. Surgeons should, however, recognize that if an operation is needed after prolotherapy Has been used, there is an increase in the thickness of the ligaments, so the dissection can take longer to reach the deeper structures (the nerves arid dura).
Hackett reported about 90% success. Contemporary research shows similar results. In a double blind trial of Ongley’s method performed in Santa Barbara an 1986 in 81 patients 88% reported more than 50% improvement in their back pain over the six months the trial was ‘blinded’, and at a year the improvement was the same. A similar rate of success is reported from several doctors’ offices where circumstances allow the treatment to be offered to a larger variety of patients. Several additional scientific papers have been published on a number of aspects of prolotherapy, many by Dr. Dorman_ Recurrent pain can develop, but is usually less severe, and more easily treated, often with a single visit to the doctor and perhaps one injection_ Patients who are treated are, however, not immune to injury, there are no bionic backs in this business.
Soreness and bruising at the injection site and temporary stiffness are normal. Patients often report a numbness over the injection site and tingling or itching. It always passes. Triamcinalone (the steroid) sometimes causes a flushing in the face for a few days. Palpitations, insomnia, irritability and increased urination are reported rarely. There are no long term bad effects from it. Women who have a uterus may experience unusual menstruation or uterine bleeding, like a period; for up to three months after the steroid injection, which is usually used on the first day of treatment. There is no permanent. harm from this.
Pain from the injections
The injections themselves are painful, particularly in the First two to three visits. For that reason we advise mild opioids to be taken prior to injections.