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Prolotherapy

Prolotherapy for Spinal Conditions

In a systematic review of dextrose prolotherapy for chronic musculoskeletal pain by Hauser et al (Clinical Med Insights Arthritis Musculoskele Disord Jul 2016), the role of prolotherapy in spinal and pelvic pain was evaluated. The authors reviewed two randomized control trials looking at the effects of dextrose prolotherapy and corticosteroid injections for low back pain. One study (Kim et al) found a greater cumulative incidence of pain reduction (greater than or equal to 50%) for those given dextrose prolotherapy. However, in the second study that focused on iliac crest pain syndrome, there was no reported differences between dextrose and triamcinolone when looking at pain (VAS) and disability scores.

In another study by Hooper et al, patients with chronic cervical, thoracic, or lumbar pain showed significant improvement in pain and disability scores with dextrose prolotherapy. Dextrose prolotherapy has also been found to be effective for coccygodynia (tailbone pain) in randomized control trials and published case series.

The systematic review concluded that there is level 1 evidence that dextrose prolotherapy results in significantly greater long-term reduction in pain than cortisone injections in patients with sacroiliac (SI) joint pain. There is level 2 evidence supporting dextrose prolotherapy for short-term pain reduction vs. cortisone injection for SI joint pain. As for chronic neck, thoracic, and low back pain, there is level 4 evidence for improvement in pain and disability with dextrose prolotherapy.

This review again demonstrates that dextrose prolotherapy is efficacious for specific musculoskeletal conditions and is a safe alternative to corticosteroids in many cases.

Prolotherapy for Rotator Cuff Disease

In follow-up to a previous blog from October 2015 regarding prolotherapy in the treatment of rotator cuff disorders, another study was recently published showing positive results.

Lee et al (Arch Phys Med Rehab 2015) performed a retrospective case-control study evaluating prolotherapy in the treatment of rotator cuff disease. In this study, 63 patients received prolotherapy, consisting of 16.5% dextrose solution and 63 patients received conservative treatment. The outcome measures of the study included the visual analog scale (VAS), average shoulder pain score for the past week, Shoulder Pain and Disability Index Score, active range of shoulder motion, isometric shoulder strength, and medication (analgesic) use per day. At one year of follow-up, patients in the prolotherapy group received an average of 4.8 ± 1.3 injections and had significant improvements in VAS, SPADI scores, isometric strength, and active range of motion when compared with the control group.

As the authors pointed out, prolotherapy appeared to be effective in the treatment of chronic rotator cuff disease (duration of at least 3 months), however, as this study was non-randomized and retrospective in nature, the results must be interpreted with caution.

This is the second recent study to conclude that dextrose prolotherapy is efficacious in the treatment of rotator cuff disease. Bertrand et al (Arch Phys Med Rehab 2016) showed that injections of hypertonic dextrose resulted in superior long term pain improvement and patient satisfaction for those with painful rotator cuff tendinopathy. As with many prolotherapy investigations, it is often difficult to compare studies as the specific diagnosis from one study to another often differs as does the treatment protocol and outcome measures. Nonetheless, prolotherapy does appear to be beneficial for a number of musculoskeletal condition with no reported adverse events.

Rotator Cuff Tendinopathies: A case for regenerative injection therapies?

 Rotator Cuff Tendinopathies: A case for regenerative injection therapies?

A painful shoulder is one of the most common complaints seen by orthopaedists.  Athletes who participate in repetitive overhand throwing sports such as baseball, basketball, and volleyball are at increased risk for shoulder injuries.  The same holds true for those who work in an occupation requiring overhead activity.  Pain and dysfunction to the shoulder(s) can also arise from normal aging.  The term rotator cuff syndrome is often used when referring to tearing within the rotator cuff tendons.

 

Anatomically, the rotator cuff is made up of four tendons: supraspinatus, infraspinatus, subscapularis and the teres minor.  These tendons originate along the scapula and attach at various points along the head of the humerus.  Within the shoulder there are several bursa which normally facilitate smooth gliding of the tendons and muscles.

Many painful conditions related to overuse that encompass the rotator cuff tendons and surrounding soft tissues, are commonly referred to as rotator cuff tendinopathy.  Rotator cuff tendinopathy is a very complex, multifactorial process involving both intrinsic (within a tendon) and extrinsic (outside of a tendon) factors.  Clinically, patients often complain of pain with specific motions such as reaching overhead, with lifting, and often at night when sleeping on the affected shoulder. Loss of normal range of motion may also be present with forward elevation of the shoulder and with abduction (moving arm away from the body).  Weakness and further loss of motion often result from disease progression. These symptomatic complaints may be caused by underlying degenerative changes within the tendons resulting in mechanical overload. Additionally, compression on the tendon(s) caused by bony structures may also accompany the forementioned intrinsic factors.

 

The combination of a good detailed patient history of complaints, a sound physical examination, and an MRI of shoulder can help the physician provide the proper clinical diagnosis and direct treatment.  Traditionally, treatment for tendinopathies has included NSAIDs, physical therapy, and corticosteroid injections.  Many can be successfully managed utilizing these non-surgical treatments.  As previously mentioned, rotator cuff tendinopathy is a complex condition and in some cases traditional treatments fail to help improve symptoms.   While there are varying surgical options depending on the specific underlying issue(s), the risks of the procedure and outcomes must be weighed.

In the last decade, the use of regenerative injection therapies for rotator cuff tendinopathies, has been developed and continues to evolve. Prolotherapy, Platelet-Rich Plasma (PRP), and even stem cell therapies have been applied.  Presently there is limited data to support regenerative injection therapies as a part of a standard medical treatment plan for rotator cuff tendinopathies.  However, its use has been reported with increasing frequency by the media among professional athletes.

A few randomized controlled trials and prospective studies utilizing Prolotherapy and/or PRP have been published in the last few years. Outcome measures have focused on pain scales, patient satisfaction, and disability indexes (Western Ontario Rotator Cuff Index, Shoulder Pain and Disability Index).  The results for the most part have been positive.  Further studies to show efficacy are needed.

 

References:

Bertran H, Reeves KD, Bennett CJ, Bicknell S, Cheng AL. Dextrose Prolotherapy versus Control Injections in Painful Rotator Cuff Tendinopathy. Arch Phys Med Rehabil. 2015 Aug 21.

Scarpone M, Rabago D, Snell E, Demeo P, Ruppert K, Pritchard P, Arbogast G, Wilson JJ, Balzano JF. Effectiveness of Platelet-rich Plasma Injection for Rotator Cuff Tendinopathy: A Prospective Open-label Study. Glob Adv Health. Med. 2013 Mar;2(2):26-31.

 

 

 

Regenerative Injection Therapies for Hip Bursitis

Regenerative Injection Therapies for Hip Bursitis

Trochanteric bursitis, or hip bursitis, as it is commonly referred to as, is a common orthopedic condition that normally is self-limiting. The condition refers to inflammation of a fluid filled sac (bursa) that sits along the outside of the hip. This area, known as the greater trochanter, is formed from the upper end of the femur bone. This is attachment point for muscles and tendons and is an area where friction may develop. The body’s response to friction is to produce bursa tissue.

What causes bursitis and what are the common symptoms?

Trochanteric bursitis typically develops gradually. Injury to the lateral (outside) part of the hip, an overuse injury such as standing for prolonged periods of time, poor posture, lower spinal related disorders, calcium deposits in the surrounding tendons, a sudden change in a workout or training routine, a leg length discrepancy, and other medical conditions such as rheumatoid disease, gout, or thyroid disease can cause hip bursitis. Bursitis also may develop following a hip replacement.

Pain usually develops along the outside of the hip and may begin to radiate downward. There may be tenderness along the bony ridge that forms the greater trochanter. There may be pain with standing from a seated position or with stair climbing. As the disease progresses, increased stiffness within the hip may lead to a limp. Sufferers of hip bursitis often complain of increased pain at night while lying on the affected side.

Treatment for trochanteric bursitis may include activity modification, rest, non-steroidal anti-inflammatory (NSAID) medication, and physical therapy and corticosteroid injections. As systematic review published by Lustenberger et al (2011) found that as many as 33% of patients treated required a second corticosteroid injection to alleviate symptoms of hip bursitis while some had 5 injections!

Surgical management of trochanteric bursitis may be recommended for those who have tried and failed all of the conservative treatment options and still remain symptomatic.
A 2014 study published by the American Academy of Orthopaedic Surgeons (AAOS), compared a single corticosteroid injection to a single platelet rich plasma (PRP) injection for chronic hip bursitis. Twenty patients were included in each group. Outcomes were measured based on validated outcome questionnaires that looked at pain levels, function, and stiffness. Patients treated with PRP had greater improvements in post-treatment scores and had lasting effect (at 1 year after injection) whereas those treated with a cortisone injection had scores that returned back to pretreatment levels within 3 months. The results of the small study appear promising, but further well controlled studies are needed to fully delineate the effectiveness of PRP injections for hip bursitis.
At present, the medical literature is very limited on studies looking at PRP injections and Prolotherapy for hip bursitis. There are a few case reports about patients being successfully treated with either PRP or Prolotherapy. Both PRP and Prolotherapy appear safe and may offer suffers long lasting relief.

Hip bursitis is one of the most common causes of pain in the adult population. It is normally a condition that can be treated non-surgically for most. Unfortunately, some will not improve with treatment resulting in a chronic condition that is much harder to cure. Regenerative injection therapies such as PRP and Prolotherapy should be considered if clinical improvements are not seen early in the treatment process.

References:
Lustenberger DP, Ng, YV, Best TM, Ellis TJ. Efficacy of Treatment of Trochanteric Bursitis: A Systematic Review. Clin J Sports Med. 2011 Sept: 21(5): 447-453.
Monto RR. Paper #778. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 11-15, 2014; New Orleans

PRP / Prolo for Whiplash

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 Prolotherapy for Post-Traumatic Neck Pain Caused by a Whiplash Type Injury

 

 

 

Over 2.3 million people were injured on U.S. roadways in 2013.  When looking at injuries sustained from nonfatal crashes, whiplash is among one of most commonly reported injuries.  Whiplash can also occur from other traumatic events including falls, sports injuries, physical violence and work related accidents.

 

The term “Whiplash” is actually a generic term referring to a rapid forward then backward motion of the head and head.  The true definition of whiplash debateable.  In medical terms, this is a hyperflexion – hyperextension or acceleration-deceleration type injury.  With the forces that cause this type of injury, the cervical spine is believed to go beyond its normal range of motion and has the potential to injure the surrounding soft tissue structures (ligaments) and discs. As a protective mechanism, the neurological system attempts to stabilize the area by contracting the surrounding muscles. There are several known factors (and some unknown) which may determine the extent of injury. This includes prior level of health, physical condition, posture or position of neck at the time of impact, and awareness of pending impact.

 

Commonly reported symptoms of a whiplash type injury include immediate or a delayed onset of neck pain with or without referred pain to the upper back and shoulders, tingling and numbness to the upper extremities, headaches, dizziness, and blurred vision.  Often patients will complain of referred pain to the arm(s) which may include tingling and numbness, yet clinically there may be no loss of strength, sensation, or function.

 

Treatment for whiplash injuries has also been all across the board.  Some focus on rest and immobilization of the neck while the general consensus for treatment for those with a whiplash type injury (without neurologic deficit) has been promoting an active lifestyle. Specific treatments may include non-steroidal anti-inflammatory medication and physical therapy.

 

Taken from a 2008 systematic review and meta-analysis of the literature, Kamper et al looked at 37 published articles focused on acute whiplash injuries.  The findings from this showed that a significant proportion of those injured recovered in the first three months following an accident.  The authors concluded that pain and disability tends to reduce most rapidly during the initial 3 months but after that time period, little improvement occurs. 

 

There are many inconsistencies in looking at what factors are important for determining the prognosis.  Some of the postulated factors found in the literature associated with a poor recovery include high pain levels, disability levels, depression, and neck range of motion, mechanical hyperalgesia, and the presence of post-traumatic stress symptoms.

 

So what treatment options exist for those who do not improve initially and develop chronic pain? Some are told to live with the pain while surgery may be recommended for others.   Prolotherapy may be a reasonable option for this subset of patients.  While the literature is very limited in regards to studies involving prolotherapy for post-traumatic neck pain or whiplash, reports from as early as the 1960’s published in the literature, showed treatment success in the range of 90% for this specific application. An observational study published by Hauser et al (2007) showed significant improvements in pain levels, cervical range of motion, and disability levels for the study population.  Hooper et al (2007) reported on 18 patients treated with dextrose Prolotherapy. The findings from this study were similar to Hauser et al.  Significant improvements were seen in pain scores and disability measures. Limited conclusions can be drawn based on the methodology and outcomes of these types of studies, however, the results do show the potential for prolotherapy as a viable treatment for those with chronic neck pain from a whiplash type injury.

 

 

 

 

 

References:

 

U.S. Department of Transportation. NHTSA. Traffic Safety Facts. December 2014.

 

Kamper SJ., Rebbeck TJ., Maher CG., McAuley JH., Sterling M. Course and prognostic factors of whiplash: a systematic review and meta-analysis. Pain. 2008 Sept 15; 138(3): 617-629.

 

Hackett G. Prolotherapy in whiplash and low back pain. Postgraduate Medicine. 1960. pp 214-219.

 

Hauser RA, Hauser MA. Dextrose Prolotherapy for Unresolved Neck Pain. Practical Pain Management. 2007.

 

Hooper RA, Frizzell JB., Faris P. Case Series on Whiplash Related Neck Pain Treated with Zygspophysial Joint Regeneration Injection Therapy. Pain Physician. 2007 Mar; 10(2): 313-8.

 

 

 

 

 

Update on Achilles Tendiopathy

An update to the use of PRP in the treatment of Achilles Tendinopathy

In an update to our recent post regarding the use of PRP for Achilles Tendinopathy, a retrospective analysis of 26 patients was published this past month in Foot and Ankle Specialist (Oloff et al 2015). One of the authors has used PRP to treat Achilles Tendinopathy for both those patients who have needed surgery and for those treated non-operatively for the condition.  Outcomes were based on the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire and evaluation of pre and post treatment MRI images. There was a statistically significant degree of improvement seen on pre and post MRI images. Both groups (surgical and non-surgical) improved to a similar degree. 

One criticism is that this is a level IV study (evidence based medicine) and is based on a case series.  It adds to the current body of literature which has shown that PRP may be helpful for Achilles Tendinopathy.  Certainly, data from larger well controlled clinical trials is needed to determine effectiveness of PRP therapy and to define more specific treatment protocols.

References:

Oloff L., Elmi E., Nelson J., Crain J. Retrospective Analysis of the Effectiveness of Platelet-Rich Plasma in the Treatment of Achilles Tendinopathy: Pre-Treatment and Posttreatment Correlation of Magnetic Resonance Imaging and Clinical Assessment. Foot Ankle Spec. 2015 Aug 7.

 

Achilles Tendinopathy

Regenerative Injection Therapies for Achilles Tendinopathy

Achilles tendonitis is one of the most common overuse injuries seen by orthopaedists.  While there are several different known causes of Achilles tendonitis, overuse and degeneration are two of the most common reasons.  In the truest sense, Achilles tendinopathy more accurately describes the condition.  Tendinitis means inflammation within a tendon whereas, tendinosis refers to micro tears commonly as the result of overuse. Collectively tendinopathy incorporates both of these findings.

Those who suffer from Achilles tendinopathy typically complain of pain either along the midportion of the tendon or at the insertion site at the heel.  Stiffness in the morning and increasing pain with activity is common. Thickening of the tendon can result from injury or from degenerative changes seen with age.  For some, swelling and redness may also be present.

Historically, the normal treatment course for Achilles tendinopathy has focused on activity modification including rest, ice, non-steroidal ant inflammatory medication (NSAID), and stretching exercises. In rare cases, corticosteroid injections have been given for Achilles tendonitis, but there is concern for risk of tendon rupture associated with this.

Unfortunately for some, Achilles tendinopathy can become a chronic condition in which adhesions can may form between the tendon and tendon sheath.  This is a much harder condition to treat. There are several different surgical approaches to address this problem however, recovery can be prolonged and return to certain activities may be limited on a long term basis.

Beyond the standard treatments mentioned above, regenerative injection therapies including Prolotherapy and PRP also may also have a place in the management of Achilles tendinopathy.   On the Prolotherapy side, a randomized clinical trial that was conducted in Australia (Yelland et al 2011) showed that Prolotherapy when combined with specific exercises was very effective early at reducing stiffness and allowing for increased activity.   Several studies have evaluated the use of PRP for Achilles tendinopathy.  A European study that is due to publish this month in Foot and Ankle Surgery, reported on 83 Achilles tendons that were followed for an average of 50 months after a single PRP injection. Statistically significant score improvements were seen on the Victoria Institute of Sports Assessment – Achilles (VISA-A) questionnaire. 91.6% of the patients were satisfied with the treatment at final follow-up. No tendon ruptures were seen.

A similar study by Filardo et al (2014) showed a positive outcomes for 27 cases of chronic Achilles tendinopathy treated with leucocyte positive PRP with an average of 54 months of follow-up.

The published data on the use of regenerative injections for Achilles tendinopathy is very limited at the present time. This is an area that is presently being investigated. The results do appear to be promising so far.

 

Prolotherapy for Sacroiliac (SI Joint) Pain

Sacroiliac joint (SI Joint) dysfunction or sacroiliac syndrome as it is sometimes referred to as, can be a potential cause of low back pain. It is a condition that is not well understood as there is no gold standard for diagnosing and treating this problem. The SI Joint is considered a diarthrodial joint and connects the sacrum to the pelvis. Limited motion does occur and the SI joints are supported by surrounding muscles and strong ligaments. While not completely clear, it is believed that SI joint pain can be caused by either too much joint movement or too little movement. Pain can also come from surrounding structures including the discs and facet joints.

Diagnosis of SI joint dysfunction is often made based on tests conducted during a physical examination. Many practitioners also utilize a SI joint injection under fluoroscopic guidance (“live x-ray”) or CT guidance to confirm the diagnosis. If the patient receives relief of pain, even if temporary, then treatment can be focused on the SI joint. Non-surgical treatment options often include corticosteroid injections, manipulative physical therapy, and the use of non-steroidal anti-inflammatory medications. More advanced options include radiofrequency neurotomy and SI joint fusion. Results of a systematic review of the literature (Rupert el al 2009) found evidence for radiofrequency neurotomy use is very limited based on only a few quality studies. The number of SI joint fusions has increased significantly in the last few years including the use of minimally invasive approaches. The indications for a fusion is limited and there are concerns that by removing motion within the joint, more forces will be transmitted across the hips and lower spine leading to further problems.

So what other options exist for those who suffer from pain emanating from the SI joints? Prolotherapy has been suggested and has been used successfully in a number of documented cases. The medical literature is very limited in regards to using prolotherapy for this condition, but the results of some smaller studies have shown that Prolotherapy may be an option to consider. Cusi et al (2010) followed 25 patients with SI joint dysfunction following a hypertonic dextrose solution injection under CT guidance. A positive clinical result was present for 76% at 12 months after injection and 32% at 24 months. In a randomized controlled study, Kim et al (2010) compared Prolotherapy injections to corticosteroid injections. At 15 months post-injection 58.7% of those treated with a Prolotherapy injection had pain relief equal to or greater than 50% versus 10.2% for the corticosteroid group.

Going back to the underlying reason for SI joint pain, the common thinking is pain and dysfunction result from changes in ligamentous laxity. Prolotherapy is aimed at injecting an irritant into the joint and/or weakened ligamentous structures to promote a response by the body to heal the affected area. While limited data to support Prolotherapy for SI joint dysfunction exists, no significant adverse events have been reported in the literature and mostly observational studies have shown the treatment to be effective at alleviating pain for the subset of patients treated.