A WORD ABOUT PROLOTHERAPY
If you go to Wikipedia, the write-up is not flattering regarding prolotherapy. While we, as Prolotherapy physicians, have made an effort to change the content of Wikipedia to reflect the current thinking and success of prolotherapy, the controlling editor refuses to allow this, despite an abundance of level I evidence and all the successful studies now well known to all physicians. While I hesitate to use the word “biased”, his attitude reflects that of the conventional and conservative medical establishment who continually refuse to give Prolotherapy the credence it deserves. Yet, they themselves continue to do procedures or give medicines that we now know don’t work well, simply because they learned how to do that in their residency. They did not learn Prolotherapy in their residency and it is not taught in any orthopedic program, except, at the University of Wisconsin and Harvard Medical School. Most doctors don’t recommend Prolotherapy because they simply don’t know about it, having not read about it and/or are not trained in its techniques. They utilize steroid injections, now proven to be of no value in healing injury, whereas Prolotherapy starts the healing process and gets to the root cause of the injury. They also rely on surgery to fix things or cut it out and this makes them a lot of money – and after surgery, when you still have the same pain you started with or are worse, are then shuffled off to physical therapy, never to be seen again by the surgeon, as you continue to limp and are still in pain. Not good medicine, if you ask me.
Prolotherapy is alternative medicine, since it is not in the mainstream, which is nothing new for things that really work in the field of medicine, as it just takes a long time before the rest of the physicians figure out something is good-and before they do that, they will do everything possible to stop that novel or new approach from coming into being; they don’t like change. Dr Barry Marshall, who in the 1980’s discovered that a simple bacteria was causing GI cancer and peptic ulcers and that it could be cured by a simple course of antibiotics was highly ridiculed and ostracized by his colleagues for twenty years—until he was recognized by winning the Nobel Prize. That says it all.
Prolotherapy is not paid for by insurance, because as long the insurance companies have physicians fighting over what therapies and techniques to do, they get to save money by denying these Claims. Insurance companies don’t care about you at all-in fact, the less care you get, the less expense for them and the better they do financially. They will pay for steroid injections and surgeries and that’s why almost everyone out there who has an injury or problem of non-healing and pain, ends up with one of these 2 therapies or procedures. Think about that.
These are the patients that seek prolotherapy, as they have learned the hard way what is best for their bodies. With the Internet, we now have a readily abundant amount of information, both positive and negative, on prolotherapy and patients are now able to draw their own conclusions regarding the success rates of prolotherapy. Look at the Journal of Prolotherapy website, or GetProlo website, or American Association of Orthopedic Medicine website or the American Association of Prolotherapy and Regenerative Medicine website. Dr Ross Hauser’s personal website has an incredible amount of information for patients. If you check any of these websites, and I thank you for reading the information contained in my website, you will find that there are many very highly specialized and competent physicians with extraordinary qualifications that practice prolotherapy and do it well. We are true believers, because most of us have suffered firsthand, as have our patients.
The success rates of surgery and steroid injections are dismal and many people after surgery still have pain. These patients now want an alternative with quicker healing and have educated themselves with regards to the benefits of prolotherapy.
In Orthopedics, most of what is done today for patients with musculoskeletal problems is not supported by level one evidence. This includes joint arthroscopy, arthroscopic knee debridement, microfracture surgery, labral repairs, all spinal surgeries including fusion, laminectomy and discectomy, tenotomy, realignment surgeries such as high tibial osteotomy and lateral releases, rotator cuff repair ligament repairs, arthroscopic and surgical debridement, chiropractic adjustments, acupuncture, massage and most physical therapy too. These surgical and nonsurgical techniques lack rigorous scientific support or relevant evidence to show they are effective; yet, prolotherapy has this level one evidence.
As Dr. Christopher Centeno has stated, “the shift is moving from replacement to repair”. We want to heal the injury by improving the blood supply and strengthening the tissues by injecting platelets and stem cells and growth factors directly into the site of injury and then let the body do the rest to heal itself. How about stabilizing the ligaments and tendons in this fashion and having your pain and instability go away, rather than cutting something out and seriously thinking you won’t miss it ever again. Isn’t regenerative injections like prolotherapy/PRP and stem cells better than a joint replacement, which carries the risk of heart attack, stroke, more surgery, infection, and even death from general anesthesia? Read more about Miami PRP and Miami Cell Therapy.
Elite athletes and even weekend warrior’s, those who are active in sports on the weekends already know about prolotherapy. Europeans have known about prolotherapy for some time and Latin American physicians have also used it in their armamentarium, especially considering that the barrier to entry is minimal, equipment wise and medication wise, as compared to giving steroid injections and surgery. The real skill is in the knowledge and experience of the prolotherapist. Where did he train and for how long? Patients are now becoming more knowledgeable and seeking out prolotherapy regularly for their care, especially for musculoskeletal joint pain, neck and back pain. I myself have been plagued all my life by pain and was only helped, with my life changing for the better, by having prolotherapy performed on me.Every doctor I knew, and I knew a lot, told me it wouldn’t work. None of them had ever studied prolotherapy nor performed it. So, take my advice and help your body heal itself. We all have that capacity. Do not let misguided but well-intentioned doctors and physicians operate on you or give you steroid injections. Read more about Prolotherapy in Miami.
THE NEED FOR PROLOTHERAPY
Most joint pain, including neck and back pain is caused by damaged, unhealed ligaments and tendons. Even if there are disc problems or cartilage problems or bone spurs or other abnormalities present, pain may still be arising from damaged unhealed ligaments and tendons. Conventional treatments which include anti-inflammatory and steroid medication given either orally or as injection serve only to temporarily relieve the pain and may further reduce your ability to heal and, in the long run, will cause damage to your bones. Anti-inflammatory and steroid medication only treat the symptoms not the cause of your pain. Prolotherapy is the only therapy which successfully treats the underlying cause of most joint pain rather than treat the symptoms.
WHAT IS PROLOTHERAPY?
Prolotherapy is a nonsurgical treatment which stimulates healing of the underlying cause of joint pain and instability. Prolotherapy is also known as regenerative injection therapy.
Prolotherapy is a nonsurgical treatment which stimulates healing of the underlying cause of joint pain and instability. Also known as regenerative injection therapy or nonsurgical ligament and tendon reconstruction it works by stimulating the body’s own natural healing processes and may repair injured ligaments and tendons to lay down new, strong collagen fibers and cells. The previously damaged tissue goes through the same healing cascade as when first injured and now prompts healing in the ligaments, tendons, and cartilage. It is 80% or more effective in curing pain caused by damaged, unhealed connective-tissue and returning the structure to full load bearing capacity.
Prolotherapy is used to treat chronic pain in joints due to unhealed connective-tissue/ligament and tendon damage. Prolotherapy is used to treat cartilage loss in joints, particularly in hip joints and knee joints that cause pain with movement. Prolotherapy is used in the treatment of acute injuries especially sports injuries, when you want accelerated healing. Elite athletes are knowledgeable about prolotherapy and prefer this type of treatment.
Prolotherapy is used to treat arthritis, back pain, neck pain, fibromyalgia, sports injuries, unresolved whiplash injuries, chronic tendinitis, partially torn tendons, ligaments, cartilage, degenerated or herniated disks, TMJ, and sciatica. This treatment is based on the theory that chronic pain is often caused by laxity or looseness of the ligaments that are responsible for keeping a joint stable. When ligaments and tendons are loose, the body compensates by using muscles to stabilize the joint thus resulting in muscle spasm and pain. A lack of ligament and tendon healing leads to chronic pain. Prolotherapy treatment involves a series of injections of natural solutions into the injured area around such ligaments and tendons. These solutions caused the tissue to proliferate or grow, increasing the strength and thickness of the ligaments and tendons. This tightens the joint and relieves the burden on the surrounding muscles thus stopping muscle spasms and the associated pain. Ligaments, which are the structural “bands” that hold bones to bones can become weak and lose their original strength or endurance. The blood supply to ligaments and tendons is limited and therefore healing is slow or incomplete, and the ligaments have many nerve endings that are responsible for causing the pain in the injured area. Tendons, which connect muscles to bones, become weak and painful when injured due to nonhealing also.
Prolotherapy involves the use of dextrose or sugar-water solution, which is injected into the ligament or tendon where it is attached to the bone. This causes a localized low-grade inflammatory reaction (a good thing) to allow blood vessels and growth factors to enter the injured area and increase the activity of the fibrocytes and other cells to lay down the reparative connective-tissue in the area of disrepair and allow healing to occur, resulting in relief of pain.
REASONS TO HAVE PROLOTHERAPY?
Prolotherapy for fluoroquinolone antibiotic toxicity–if you have taken Cipro, Levaquin, Avelox or Floxin and now suffer from chronic pain all over: suffering tendon damage with pain in your neck, shoulders, elbows, lower back, knees, Achilles and other areas from the side effects of antibiotics occurs infrequently but when it does, it can be incapacitating – if you want to have permanent relief and normal function back, then you need to have prolotherapy performed to each of these areas and you may get relief of the pain and healing of the tendons after a number of prolotherapy sessions. You don’t have to suffer anymore.
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, and Surgery.
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 learned 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 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 of injection 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/anesthetic solution. 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, sacroiliac 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. I have also participated in missions in other countries and directed medical missions in Ecuador performing prolotherapy on patients suffering all types of chronic pain.
POST PROLOTHERAPY INSTRUCTIONS & GUIDELINES
Post injection soreness:
Typically, post-injection stiffness and soreness can be expected and is necessary for the healing process to begin. Some patients will describe a feeling of fullness, heaviness or numbness in the area treated and adjacent structures. Occasionally, the patient will feel a complete resolution of pain after the treatment because of the numbing effect of the anesthetic used in the prolotherapy solution. This numbing generally wears off within a couple of hours. A patient is generally sore for a couple of days after Prolotherapy. This is because the injections have to go through some muscles to get to the ligaments and tendons.
How to reduce the pain and soreness following treatment:
To help the muscle soreness resolve itself sooner, massage therapy and moist heat applied to the area is recommended.
Heat usually soothes the soreness, but ice will slow the healing prolotherapy stimulates, so don’t use ice packs.
Nutritional supplements may be prescribed afterwards to help promote a healthy inflammatory response and to help with the pain.
Other acceptable modalities that improve circulation and stimulate the healing process after prolotherapy include; acupuncture, massage therapy, ultrasound and infrared heat.
Avoid the following after treatment:
No anti-inflammatory (NSAIDs) medications may not be used once treatment begins because they interfere with the healing process. They include but are not limited to, all of the following: Advil, Ibuprofen, Motrin, Robaxacet, Vioxx, Celebrex, Prednisone, Aspirin, Cortisone, Medrol, etc. An exception to this is for those who take a baby aspirin each day for their heart. That’s ok.
Regular use of narcotic drugs should be avoided if possible because they will inhibit the immune system and slow the healing. Tylenol may be used for a short period of time. If you are not sure whether a medication you are taking interferes with your prolotherapy treatment, bring it to our attention and we will help you out. Remember, it is important to treat the source of the pain through strengthening the damaged ligaments and tendons rather than just cover it up with chronic pain medications.
Frequent high-velocity chiropractic adjustments should be avoided because they do not allow the joints treated with prolotherapy to stabilize. If you are under the care of a Chiropractor, ask Dr Mahl about when you can return to their treatments and follow-up, usually, once the joint has stabilized and is stronger and pain relief has occurred.
Controlled exercise and mobilization of the treated area promotes tissue healing and results in faster recovery after the treatment. It does so by increasing blood flow and nutrients. For this reason, movement and exercise are recommended as soon as you feel ready. The general rule is if a certain activity or exercise hurts significantly, switch to a different one. A small amount of pain is expected while recovering from an injury, but not significant pain. The amount will depend on your level of fitness before and on how many areas were treated. In most cases, depending on your job, you may return to work or school the same day as your treatment. If, however, your job places a great deal of stress on the treated area or if you have significant post-injection discomfort, you should not return to work the same day. A few days is recommended before returning to strenuous athletic activity. We will give you a medical note if needed.
Even if you receive one Prolotherapy treatment and feel fine, follow-up is still recommended to allow us to assess the treated area for complete healing. If it is still significantly tender, further treatments will be needed because the area is still injured. Gradually as treatment progresses, improvement in pain as well as functional changes (joint stability) will occur.
It is also important to remember that diet and lifestyle choices also affect the overall recovery process. Nutritional deficiencies are epidemic in our modern society and this affects our overall health and, thus, the healing of ligaments and tendons. Ligaments require proper vitamins, minerals, amino acids, and collagen formation for repair, and proper diet and nutrition is imperative for healing to occur. Similarly, lack of proper hydration will hinder healing and cause ligaments to shrink. It is recommended that you drink at least 6-8 glasses of water per day.
Lack of sleep is another significant component of chronic pain and chronic pain is a strong factor in sleep disruption. Chronic pain affects cortisol levels (a response to stress the body perceives-affecting the adrenal glands). When cortisol goes up, the feeling of restlessness and insomnia occur. The secretion of cortisol stops when the pain cycle is stopped. Other benefits of deep restful sleep is that it produces growth hormone which is released from the pituitary gland and is anabolic (which means growth and repair) so here this is a good thing too.
Prolotherapy requires an experienced and skilled physician:
Patients who receive prolotherapy have a goal of obtaining pain relief from their disease or injury. Your prolotherapy physician should be experienced in the art and science of prolotherapy and the regenerative medicine technology that uses prolotherapy. Dr. Mahl spent close to 3 years in study and Mentorship/Fellowship with Dr. Alvin Stein to learn how to perform these injections. He is now a recognized expert in the field, often teaching other physicians how to perform prolotherapy treatments including regenerative treatments such as those with Cell Therapy and PRP too.