The Naturopathic Integrated Approach to
Chronic Pain and Dysfunction:
Prolotherapy, PRP, NPT and Regenerative Injection
The symptoms of ligament laxity are multiple and the site of the patient's pain depends on which ligaments are 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 mechanical causes. The diagnosis is made first by learning from the patient about his pain and where it is, and secondly, by clinical examination. The diagnosis depends only a very little bit on special tests, such as x-rays and MRI's. These are obtained mainly in order to exclude other conditions.
An Integrated Approach to Spinal and Joint Treatment
It is obvious that if there is a structural misalignment, it should first be corrected with adjustments and/or mobilizations and then kept in place by strengthening the muscles and the ligaments. It is a simple concept.
- Spinal Manipulation to restore normal alignment of the sacrum, spine and/or the extremity joints.
- Prolotherapy / RIT, PRP injections, usually weekly, bi-weekly or of longer intervals depending on the case, for six sessions.
- Neural Prolotherapy
- Neural Therapy
- Scar Treatment
- Exercises to ensure healing in the presence of movement.
- Nutrients to support the strengthening of ligaments and joints.
Other factors to address that will affect recovery include hormonal status, quality of the diet, general fitness and healthy lifestyle.
" When combined with spinal manipulation, exercise, and other co-interventions, prolotherapy may improve chronic low-back and other joint pain and disability." The Cochrane Review of Prolotherapy
All Parts of the Body Benefit from the Integrated Model
These principles are useful in the management of pain and instability of any part of the musculo-skeletal system. It can be very effective for hip, knee, ankle, foot, hand, wrist, and elbow and shoulder problems. Chronic neck pain and headaches are usually relieved, even after many years of trouble, with Prolotherapy / RIT. It is also effective for TMJ (temporomandibular joint) problems, tendonitis, loose joints, sports injuries and fibromyalgia.
The Injection Solution
A simple dextrose solution is all that is needed to eliminate pain. Min-Young Kirn, M.D., and associates from Yonsei University Medical College in Seoul, South Korea, studied 64 patients with chronic pain. Dr. Kim compared using a five percent dextrose solution with the current standard trigger point injection solution of 0.5 percent procaine and placebo. The study found that not only did the dextrose solution prove to give statistically significant pain relief against placebo it was that much better when compared to the procaine solution. The study also found that in follow-up, the pain relief with the dextrose solution remained. The simplest Prolotherapy / RIT solution is 12.5% to 20% dextrose with 1% procaine. The dextrose makes the solution more concentrated than blood, acting as a strong proliferant. Procaine is an anesthetic that helps reinforce the diagnosis because the patient may experience immediate pain relief after the Prolotherapy / RIT injections. Many millions of injections have been given safely using this solution. The main side effect has been one to two days of pain after the procedure due to inflammation caused by the injection solution. The dextrose solution, in addition to being safe, will not affect a diabetic's blood sugar level. If necessary stronger proliferant agents can be used. Such agents include sodium morrhuate (an extract of cod liver oil), or a dextrose-glycerin-phenol solution known as PG2. PG2 has been used in several double blind studies that prove Prolotherapy / RIT causes ligaments to rebuild and grow stronger thicker tissue.
Platelet Rich Plasma (PRP)
More recently physicians using prolotherapy have incorporated Platelet Rich Plasma as an option for the injection solution. This therapy uses the patient's blood to extract platelets which provide the body's own growth factors. This method can greatly enhance the healing effect.
Neural Prolotherapy NPT
Neural Prolotherapy NPT, is a recent development in the treatment of osteoarthritis, joint, back, neck and muscle pain. In this case, inflamed nerves under the skin are identified as part of or as the cause of the pain and are treated with small glucose injections.
Mesenchymal Stem Cells
Stem cells extracted from the patient's fat are being used as the most potent form of regenerative injection theapy.
Scars can cause pain and disrupt nervous system function. Fascia drag from scars and adhesions can produce pain in remote areas. Scar tissue is an important area to consider in a comprehensive treatment plan for pain in any area of the body..
To stimulate the new growth of tissue 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. Movement and exercise ensures proper healing. As the healing process goes on for several months, it is recommended that patients continue with exercises for at least three months after the last injection.
Disc Disease, Drugs and Surgery
Chronic back, leg and arm pain is sometimes due to disc disease. When this is so, medical doctors often recommend anti-inflammatory medication to relieve the symptoms. Although the pain may be eased in the short term the drugs do nothing to heal the spine. Studies have shown that the use of these medications actually weaken ligaments and tendons and increase the long term instability in the joints, as well as damaging the digestive system and being a potential cause of death. A New England Journal of Medicine study determined that 16,500 people in the U.S. die each year from the use of NSAIDs (non-steroidal anti-inflammatory drugs). As well, the FDA recently announced that 450 Americans die each year from the use of acetaminophen (Tylenol).
Often surgery is recommended in an attempt to relieve pressure on a nerve. Although this surgery is often successful in relieving pain, it should be reserved as a treatment of last resort. Not all surgeries are successful, and frequently even successful ones, require further surgery in the future as other discs degenerate because the underlying problems have not been addressed. Surgery requires a long recovery time as well as having much greater risks than other treatments. There is a 3-4% rate of complication for cervical spine surgery, and 4,000-10,000 deaths per million neck surgeries. If you are considering lumbar spinal surgery, realize that there is a risk of death of 7 persons per 10,000 surgeries.
A study of over 2,000 low back pain patients, published in the Journal of the American Medical Association (JAMA) was recently reported in the New York Times. The study clearly demonstrated that patients with lower back pain that had surgery, may have had a short term improvement in pain, but after 3-6 months they were no better off than those that did nothing but wait. As well the study demonstrated that waiting for surgery did not put a patient at risk for further aggravation of the condition. This study does not address the issue of what many prolo doctors observe clinically, which is the reoccurrence of lower back pain years after surgery in many patients and the long term improvement of those cases treated with prolotherapy. To view the report: "Study Questions Need to Operate on Disk Injuries".
It should be understood that the presence of disc degeneration is often seen in cases of chronic back pain but it is also often found in individuals without pain. Even though spinal or disc degeneration may be seen on x-rays or MRI it is not always the actual cause of pain.
Disc disease itself is due to ligament relaxation in the first place. It is the abnormal range of movement caused by relaxed ligaments which allows for most of the abnormal strain on the discs. Therefore, prolotherapy; ligament strengthening treatment is highly recommended for treating disc problems, even if surgery has been recommended. Orthopaedic surgeon Dr. Jean Paul Oullette, of Orleans, Ontario, has stated that after more that 20 years he stopped performing disc surgery, relying instead on prolotherapy to successfully treat these problems.
There are cases of course where surgery is essential and sometimes urgent. Many doctors do realize that in the majority of instances a trial of conservative therapy 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 and dura).
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 nerve pain and is often confused with pain due to pressure on a nerve root from an abnormal disc in the spine. Differentiating between these causes is not always easy, but it is exactly this differentiation that is necessary for the skillful and proper resolution of the patient’s complaints and dysfunction. Most cases of back pain, suitably diagnosed, improve with treatment with prolotherapy.
Hackett reported about 90% success. Contemporary research shows similar results. In a double blind trial of Ongley's method performed in Santa Barbara in 1986 on 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. 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.
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. Soreness usually lasts for 1 to 2 days then subsides as the ligaments go through their growth and repair phases.
It is not uncommon as one area of the body begins to recover, that other areas of previous injury begin to display symptoms. This is because the symptom of pain is usually the latest expression of a process of adaptation from previous injuries and degenerative changes. For example, you might have injured your knee when younger and limped around for a period of time. The limping put strain on the back, but eventually the knee pain stopped. The strain on the back at some point became aggravated with a lifting injury and a disc problem emerged. Prolotherapy would stabilize the lower back, return normal function, but the untreated knee injury may flare up as the body de-compensates.
Occasionally, for some patients the correction of old traumas will cause a release of long held emotion. This is a positive sign and indicates that healing is occurring.
Pain from Injections
Not all persons experience the injections as being particularly painful although they often may be. The injections may be more painful, particularly in the first two to three visits. For this reason relaxation methods and local anesthesia of the skin prior to injection may be used. After injection there is usually significant change of sensation with some contraction or release of muscles and changes of blood flow. For this reason it may be useful to have a driver for the trip home and plan on resting for a while after treatment. After the second or third treatment these changes in autonomic nerve function are usually not so profound.