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Restorative Injection Therapy (Reconstructive Therapy) (Prolotherapy) Andrea Trescot, MD With special thanks to my mentor, Dr. Felix Linetsky

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Restorative Injection Therapy (Reconstructive Therapy)

(Prolotherapy)

Andrea Trescot, MD

With special thanks to my mentor, Dr. Felix Linetsky

The History of Prolotherapy Started with Hernia Repairs

Installation of irritating substances into a pathologic, fluid filled cavity has been known since Aurelius Cornelius Celsus (25 B.C.– 50 A.D.) described the injection of saltpeter (potassium nitrate), to cure hydroceles and hernias.

Hernia

Observations on referred painKellgren JH. Cl Sci 1937;3:175-190

• 75 medical students – You could do anything you wanted with

medical students in those days

• Injected with 1cc 6% hypertonic saline into the midline spinous ligament– Asked them to map out where they felt

the pain

Kellgren et al Cl. Sci.1937-1938.

George S. Hackett,

M.D. (1/14/1888 – 8/17/1969)

Joint stabilization

through induced

ligament sclerosis. Ohio State Medical Journal

1953, 49, 877–884.

First edition just 97 pages

Fibro-osseous Proliferation

Fibroproliferative Therapy

Prolotherapy

Third edition

Inherited Characteristics

Hackett’s paradigm:• A joint is only as strong as its weakest

ligament, majority of chronic pain is caused by connective tissue deficiency complicated by injury or repetitive strain.

• Predominant clinical manifestation of

this pathology is local tenderness, and diagnostic test is relief of pain after anesthesia.

• Prolotherapy or injection of irritants to stimulate repair of fibrous connective

tissue, is the treatment of choice.

Hackett in 1955 presented at the AMA Annual Meeting

• 656 patients

• Aged 15 to 88 years old

• Average duration of symptoms 4.5 years

• Followed patients for 12 years after the injections– 82% of patients considered themselves

“cured”

Treatment Dilemma

Enthesopathy• A disease pathology at the 'entheses',

i.e. attachment sites of muscles, tendons, joint capsules, ligaments and fascia to the bone.

Enthesopathy

• The body’s response is inflammation and subsequent calcification

• Locations: knees, hips, shoulders, ankles, spine, etc

• The diagnosis is made by palpation, Xrays, ultrasound, and diagnostic injection

Enthesopathy

InflammationTrauma

InflammationNSAIDs

Knee Replacements

Ibuprofen OTC 1984

Ibuprofen introduced in US 1974

Degenerative Disc Disease is Progressive

DDD is a progressive condition

Palpation

Cervical Injuries

Spinous

So, What is the Evidence?

Proliferant injections for low back pain: Histologic changes of injected ligaments and objective measurements of lumbar spine mobility before and after treatment.

Klein, Dorman & Johnson 1989. J of Neuro. & Ortho. Med.& Surg.10(2), 123–126.

• Posterior SIJ ligaments biopsied in 3 patients before treatment, and 3 month after last treatment.• Light microscopy – fibroblastic hyperplasia

PLAIN MICROSCOPY: a) BEFORE INJECTIONS, b) AFTER INJECTIONS

a b

Histologic changes of injected ligaments after treatment. Klein et al, J. Neuro. & Ortho. Med. Surg. 1989;10/ 123-25.

ELECTRON MICROSCOPY: a) BEFORE INJECTIONS, b) AFTER INJECTIONS

a b

Ibid Klein et al,

Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin painTopol, et al

Arch Phys Med Rehabil. 2005 Apr;86(4):697-702.

• 24 professional rugby and soccer players disabled because of chronic groin pain, unresponsive to standard therapy.

• Average 2.8 injections of 12.5% dextrose and lidocaine to pubic insertions of thigh adductor and suprapubic abdominal muscles.

VAS improved from 6.3 to 1.0 ( P <.001)• 20 of 24 had no pain and 22 of 24 returned to full

sport activities.

A new approach to the treatment of chronic low back pain. Ongley, Klein, Dorman, Eek et al. 1987, July 18. Lancet, 143–146.

81 pts with chronic LBP (av. duration 10 yr) randomized in 2 groups, series of 5 double blinded injections

0.2-0.4ml at each side, total volume 20ml + exercise

Needles:19g 3.5” •Both groups improved,

“therefore it must be placebo effect”.

•But the treated group improved more than the control

WAS IT A PLACEBO???

Large Needle Contact with Bone

• Disrupts cell membranes– Release of phospholipids and inflammatory

cascade

• Creates microbleeding– Platelet response

• Local anesthetic or saline is not a placebo, but a less effective active agent if injected onto periosteum

New Treatments

Platelet Rich PlasmaPRP

Stem Cells

• PRP group = 15, bupivacaine = 5; single injection• 8 weeks after tx, PRP patients improved 60%

– control patients improved 16% (P =.001)

• 6 months, PRP patients improved 81% in VAS (P=.0001).

• Final follow-up (mean, 25.6 months; range, 12-38 months), PRP patients reported 93% reduction in pain compared with before the treatment

(P <.0001). • “Platelet-rich plasma should be considered before

surgical intervention”.

Treatment of chronic elbow tendinosis with buffered platelet-rich plasma.

Mishra A, Pavelko T. Am J Sports Med. 2006 Dept. Orthopedic Surgery, Stanford

Regeneration of meniscus cartilage in a knee treated with percutaneously implanted autologous

mesenchymal stem cells.Centano CJ, Busse D, Kisiday, et al.

Med Hypothesis 2008;71:900-908

• Because of their multi-potent capabilities, mesenchymal stem cells (MSC) have been used successfully in animal models to regenerate articular cartilage and in human models to regenerate bone.

• “This review highlights the developments in cellular and regenerative medicine, as well as a case of successful harvest, expansion, and transplant of autologous mesenchymal stem cells into an adult human knee that resulted in an increase in meniscal cartilage volume.”

What Does it Cost?

• Prolotherapy– $100 - $400/session– UW $150/session (5 sessions = $750)

• UW charges an additional $250 facility fee/session

• Platelet rich plasma– $500 - $1000/session

• Stem cells– $8,000

What is the Alternative?

• Spinal fusion– $70,000 for hospitalization

• Plus meds, PT, work loss

• Total knee replacement– $35,000 for hospitalization

• Plus meds, PT, work loss

• Inpatient Rehabilitation for MVA– $11,265 per patient per year

• US Dept of Transportation 2006

Every Thing Old is New Again

Thank [email protected]@aol.com