Chronic pain is, unfortunately, a common and challenging condition for patients and physicians alike.
The generally accepted definition of chronic pain is pain that lasts greater than three months or longer than expected for the injury or trauma that started the symptoms. Regarding chronic muscle, tendon and ligament pain, this is one of the most difficult conditions to treat in modern medicine. Some would say that there is no such thing as chronic pain; it is really acute pain that has been managed poorly for months or years without healing of the root cause.
The accepted conventional treatments have been:
- The use of nonsteroidal anti-inflammatory medications, such as over-the-counter Aleve, Advil and Nuprin, etc
- Physical therapy
- Steroid injections such as corticosteroids, Depo-Medrol and Kenalog
None of these treatments effectively change or promote the healing process. When an injury lasts longer than expected our bodies cease the healing process and change to a maintenance process. In simple terms, this means the tendon, ligament or muscle no longer has inflammation, such as a tendinitis, but rather a chronic thickening called tendinosis. This stage is where our body is no longer trying to heal the injury. It is just continuing to maintain the painful condition. Nonsteroidal anti- inflammatory medications may actually inhibit the recovery process acutely by stopping our body’s natural mechanism to heal. Corticosteroids may give short-term pain relief, but may actually inhibit healing too.
More than 60 years ago, Dr. George S. Hackett, a general surgeon, began using injections with an irritant solution to repair joints and hernias. Dr. Gustav Hemwall MD learncd of this at a medical meeting and began training with Dr. Hackett in his office to learn the technique, then called “sclerotherapy.” The initial notion was that this caused scar tissue, which would tighten the tendons and ligaments. Originally, the solutions used were toxic to tissue, and may have indeed caused scarring. As this technique evolved, the preferred solution became dextrose solution (corn extract sugar). A solution between 15-25 % was used and did not cause scarring, but, rather re-initiated the healing process of the connective tissue, releasing chemicals that use our body’s own natural healing ability.
Individuals with common strains and sprains may benefit from this healing technique.
Most insurances do not pay for Prolotherapy injections, still regarding it as unproven (Dr Mahl is living proof of its benefits), however modern research is showing that there is significant improvement with Prolotherapy, particularly for conditions such as hips, backs, tennis elbow, golfers elbow, knees, ankles and more. Corticosteroids are paid for by insurance companies, as is surgery and surgeries, and that accounts for the reason why these types of treatments are recommended 98% of the time, but there has been minimal evidence that shows that they actually increase function or decrease pain long term. Dr Christopher Centeno, in his book Orthopedics 2.0, talks about the lack of level 1 evidence (randomized controlled clinical trials) for joint arthroscopy, microfracture surgery, labral repairs, all spinal surgeries (including fusion, laminectomy, and discectomy), tenotomy, realignment surgeries (high tibial osteotomy, lateral releases), rotator cuff repair, ligament repairs, arthroscopic and surgical debridement, chiropractic adjustments, acupuncture, massage, and most physical therapy. He states “these surgical procedures and nonsurgical approaches all lack the type of rigorous scientific support that would show they are effective.”
What can someone expect with Prolotherapy? First, Dr Mahl needs to make an accurate diagnosis and determine if the injury will respond to Prolotherapy. Additionally, an individual needs to refrain from any anti-inflammatory medications. aspirin or aspirin-like products, blood-thinning medications, or immunosuppressant agents such as prednisone or Imuran, which are used in conditions such as rheumatoid arthritis. Smoking appears to inhibit the effectiveness of Prolotherapy, and if possible, this should be discontinued. Additionally, nutritional support prior to any injection is very important. This includes the building blocks that help restore injured tissue, such as protein, essential fatty acids, and vitamin C to name a few.
Once Dr Mahl has made the determination that an individual is a candidate for Prolotherapy, the individual is again briefed on the procedure. The technique entails cleaning the skin around the affected area with a bactericidal solution, then, utilizing a small needle, the areas to be treated will be anesthetized with a small amount of numbing medicine, usually lidocaine or procaine. Then, Dr Mahl utilizes a different needle to inject into the specific sites of injury, injecting small amounts of dextrose solution. These sites have been identified by Doctors Hackett and Hemwall. An individual can expect improvement over the next five to seven days. The entire healing process may take as long as six weeks. Unfortunately, the injury may be such that more than one Prolotherapy session is required. On occasion, it may require up to six treatment sessions, although this is rare. Areas that respond to such Prolotherapy injections include TMJ syndrome, neck pain, shoulder pain, elbow pain, wrist pain, hip pain, knee pain, ankle pain, and back pain, sacro-iliac and the like.
The complications of Prolotherapy include local irritation, and in rare cases, infection. A sterile technique is used so the risks for Prolotherapy are no greater than that of any other injection through the skin. In the hands of a skilled practitioner like Dr Mahl, anatomical landmarks are used so the chances of injuring structures such as an artery or vein are exceedingly rare, and when necessary, injections can be performed using ultrasonic guidance or under X Ray guidance using a C Arm fluoroscope. The prolotherapy solution is absorbed by the body and does not increase blood sugar or worsen diabetes.
Prolotherapy has been accepted and utilized throughout the world. In the United States, institutions such as the Mayo Clinic and Harvard Medical School use this routinely. Dr. Joanne Borg-Stein, medical director of the Spaulding-Wellesley Rehabilitation Center in Wellesley, Massachusetts, part of the Harvard Medical School, routinely uses this technique and finds it effective in carefully selected patients. I have trained with the American Academy of Orthopedic Medicine and was fortunate enough to be a part of a medical mission trip to rural areas of Mexico, south of Cancun, at which time, we treated over 700 patients with prolotherapy.