Dr. Neil Nathan, a specialist in diagnosis and treatment of complex medical illnesses, practices with Gordan Medical Associates near Mendocino, CA. This information is excerpted with kind permission from his book On Hope and Healing for Those Who Have Fallen Through the Medical Cracks ©2010 Neil Nathan, MD, all rights reserved.
Prolotherapy, and New Platelet Rich Plasma Prolotherapy
A highly underutilized treatment for chronic pain conditions is: prolotherapy. This treatment technique has been around since the 1940s, when it was called sclerotherapy, but it has recently increased in popularity.
It consists of a series of injections into ligaments or tendon insertions, which are designed to make these tissues stronger and tighter. The name prolo is a shortened form of the word proliferate, a clear description of what is occurring on a cellular and tissue level.
In prolotherapy, a mildly irritating solution is injected into the ligaments or tendons of the body, and at the site of that injection we intentionally irritate and inflame those tissues. This in turn stimulates the natural healing forces of the body to bring new cells, called fibroblasts, into the inflamed tissues to deal with this inflammatory process.
The fibroblasts grow, or proliferate, in the ligaments we have injected.
The growth of these fibroblasts creates a thicker, stronger ligament or tendinous insertion, which, as we shall soon see, directly promotes healing. Studies have been done in rabbits showing that ligaments can potentially grow 40% stronger by using this treatment.
Humans respond beautifully to this method, and it is the only method I know of in which a ligament can truly be strengthened.
Muscles, of course, can be strengthened by a wide variety of exercises. But ligaments, as they are an entirely different type of tissue, do not respond to the kinds of treatments so useful for muscles. The good news is that we now have, through prolotherapy, a way to heal damaged ligaments.
You may not be aware of how essential ligaments are in all joint functioning.
The integrity of every joint in the body is created by and composed of ligaments. When a ligament becomes stretched or damaged, it is no longer capable of holding the joint together properly. Frictional forces start to wear away the smooth cartilage surfaces that cover the opposing bones that create the joint.
Thus the process of arthritis begins. When this erosion of cartilage becomes severe, we call it bone-on-bone, meaning that the cartilage has work away so completely that the bones are now rubbing against each other.
In a normal joint, the bones and the cartilage that covers them are held apart by the tight ligaments, allowing the lubricating fluid in the joint space to keep these tissues healthy.
Let’s take a look at the knee joint as a good description of this process….
In a normal joint, tight ligaments hold the joint spaces apart. Since we usually associate tightness with pain and strain, it’s important to appreciate that this is the normal tension in the ligament and is essential to its functioning.
If the ligaments become weak, the joint space collapses and the bones start to rub against each other, eventually creating an arthritic condition.
If we can stimulate these weakened ligaments to tighten, we can literally start to pull the bones that have collapsed into the joint space apart, thereby recreating the normal joint space and normalizing the joint function.
As long as the damage has not gone on for too long, we have the wonderful possibility of treating arthritis of any joint in a preventive manner, by using prolotherapy.
It allows us to put off, sometimes indefinitely, the need for surgery or joint replacement, and it markedly cures or reduces the joint pain we call arthritis.
Virtually any joint can be treated with prolotherapy.
Let’s take, for example, one of the most commonly injured joints: the sacroiliac joint. This joint is located in the lower back area between the sacrum (the thick triangle of bone at the base of the spine) and the two hip bones, which are medically referred to as the ilia, hence the technical term sacroiliac.
Often patients refer to this area as their hips, but technically that is not correct; the hip refers to the joint between the femur (the lower leg bone) and the acetabulum (the area in the pelvis to which it attaches).
Lower back injuries frequently involve damage to the sacroiliac ligaments, and often patients are told by those proficient in manipulative medicine that their hip is ‘out of place.’ While this term is not used in conventional medicine, it is actually often correct. The weakened ligament caused by injury allows the whole ilium, or hip, to rotate around, usually making one leg longer than the other.
This is fairly easy to diagnose. When these injured sacroiliac joints are treated repeatedly by manipulation but the hip won’t stay in place, the ligaments have most likely been damaged. The use of prolotherapy in this instance can be exceedingly helpful.
Here is a brief description of the process of providing prolotherapy:
While a variety of injection materials can be used, most often we employ a dextrose (sugar) solution of 12.5% or more, often coupled with a weak solution of phenol, and perhaps sodium morrhuate (a fish oil) in sterile form. These materials act as irritants to the ligaments and cause the body to start producing fibroblasts.
Some of you might be surprised that dextrose [aka glucose] can irritate the body, as it is a natural material. It is true that diluted doses of dextrose don’t have an inflammatory or stimulatory effect, but once the concentration gets to 12.5% or more, it can take on a new role and be effective in this capacity.
We inject this solution into the ligaments we wish to stimulate, a procedure that will obviously be different for each joint of the body. The number of treatments, which can be given every two to four weeks, differs depending on the size and area of the ligaments or tendon areas that need to be stimulated. For example:
• An elbow problem, which most often would reflect what is commonly called tennis elbow, might respond to just two or three treatments.
• A shoulder or ankle problem usually responds to three treatments.
• Lower back and knee areas, which have a much larger ligamentous component, usually require six treatments or more to provide healing.
Once the materials have been injected, I urge my patients not to use any anti-inflammatory medications including aspirin, Aleve, ibuprofen in its many forms (including Advil and Motrin) or Celebrex, for the entire duration of the treatment program.
If pain medication is needed, Tylenol or specific stronger pain medication can be prescribed. We recommend that patients avoid ice or heat for the first few days after injections are provided, as:
• Ice may diminish the inflammatory process we are trying to create,
• And heat may exacerbate it to the point that the patient may suffer needlessly.
It is very important that the physician providing these injections is also trained in manipulative medicine.(1,2) It is vital that when these tissues tighten up, they tighten up correctly, anatomically. We encourage patients to use the area that we have injected as much as possible after the injections, as that helps the tissues to heal in the position of function.
Over the past two years, a new form of prolotherapy has entered the therapeutic scene, which is called PRP (Platelet Rich Plasma) prolotherapy.
The areas that are injected are identical to those used previously, but what is injected here is a solution made from the patient's own blood. Prior to the injection, 20 to 60 cc of an individual's blood is drawn and spun down in a special centrifuge that allows us to separate out a fraction of the blood which is, as the name implies, especially rich in platelets, as well as protein growth factors with complicated names such as platelet-derived growth factors, transforming growth factors, vascular endothelial growth factors and epithelial growth factors.
Since the materials we are injecting here are made from the patient's own blood, we know that what we are using is compatible with that individual's chemistry. We then inject this material as we had our previous prolotherapy ingredients.
PRP appears to be much more effective in speeding up the strengthening process of these ligaments and tendons, so that fewer injections can be used with equivalent or better results. PRP has also been found to be effective in improving the speed of wound healing.
Prolotherapy is specifically designed to treat pain that is caused by weakened or damaged ligaments and tendons... when used properly it can be of enormous healing benefit.
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In summary, according to GordonMedical.com:
It is common knowledge that an injured ligament, such as a sprained ankle, will predispose a person to repeated injuries at the involved joint. This is because ligaments, while highly sensitive, have less blood flow than other tissues. Thus, they tend to heal less completely than other tissues. Prolotherapy is a method for strengthening lax, injured, or painful ligaments by injecting them with a solution that stimulates the immune system to grow a stronger, thicker, more organized, and less inflamed ligament. This stabilizes the joint and relieves the nearby muscles from contracting into a painful spasm....
1. To find a physician with prolotherapy training, the American Association of Orthopaedic Medicine is an excellent resource, says Dr. Nathan. The AAOM website has a find-a-doctor feature at www.AAOMed.org/Find-Doctor.php. There is also a website called GetProlo.com which offers a listing of physicians who pay for membership/listing in the program. This list is organized by state and city.
2. With regard to treatment of hypermobile or 'loose' joints, which is a problem for many fibromyalgia patients, Dr. Nathan says, "They can be helped by prolotherapy, but rheumatologists rarely do it, know about it, or recommend it. Rare physiatrists (physical medicine & rehab specialists) are familiar with it too. Part of the problem here is that to do it well, one must become knowledgeable not only about the exact places to inject the ligaments or tendon insertions correctly, but also be well-versed in body structure and manual medicine, so that you are tightening those ligaments into the proper position. Without the manipulative medicine component, you can tighten those ligaments into the wrong position, which adds yet another layer of pain to the problem."
* Dr. Neil Nathan, MD, is perhaps best known to ProHealth readers for his recent trial of "A Simplified Methylation Protocol for Treatment of ME/CFS and Fibromyalgia," conducted in collaboration with Drs. Amy Yasko, Rich Van Konynenburg, and Jacob Teitelbaum.
Disclaimer: This information has not been evaluated by the FDA. It is general information, based on the research, experience, and opinions of Dr. Nathan; is not meant to prevent, diagnose, treat or cure any condition, illness, or disease; and is not intended to be, and cannot be taken as, professional advice to any individual. It is very important that you make no change in your healthcare plan or health support regimen without researching and discussing it in collaboration with your professional healthcare team; nor should you embark on any testing or treatment without the assistance of a medical professional experienced in its application.