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Prolotherapy - feed back

Discussion in 'Biomechanics, Sports and Foot orthoses' started by podstudent, May 1, 2007.

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  1. podstudent

    podstudent Member


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    hey everyone

    We have been using prolotherapy in the our clinics for the last 10 months. we have found grest success in the injection.

    i was wondering if there is anyone who would share some experiences and tips on the injection.

    cheers
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. Dieter Fellner

    Dieter Fellner Well-Known Member

    Used it once only. For common garden variety heel pain. Not a great success - patient said it made the heel very sore and did not improve the pain.
     
  4. podstudent

    podstudent Member

    how many treatments and what dosage did you use?
     
  5. METaylor

    METaylor Active Member

    Hi Omar
    Im quite excited about it too as I think that pods are going to get great results with prolotherapy as they use gait analysis as well and know how to realign the leg which will make prolotherapy to the knee and foot so much more effective. Other pods who attended the same workshop last year are also very pleased with the results.
    A podiatrist in Melbourne says that 'a patient in her 50's with insertional tendonitis/osis and bone changes, had bad pain for first couple of days and is now pain free!!' I guess it's like microsurgery. My personal best result is the complete relief of pain from a stress fracture in the metatarsal in a runner training for a marathon, who hadn't been able to run for 6 weeks. One injection to the painful site of 1ml of a 50:50 mixture of 1% lignocaine and 25% glucose and he was pain free in 24 hours and running again in 3 days with no further recurrence. I've now taught 100 podiatrists the technique and will be running a workshop in Auckland on Saturday June 16 if there are any New Zealanders who are interested. Generation of growth factors to strengthen ligaments is the core idea - see www.podprol.org for more info.
     
  6. Dieter Fellner

    Dieter Fellner Well-Known Member


    I used it only the once because the patient could not be persuaded to have any more ! I used only LA. Partly because I cannot seem to get a hold of any glucose, which for some odd reason is POM, partly because there is a belief it is the action of needling and not any particular solution which works. I cannot claim any great expertise and this particular patient has been unresponsive to a whole range of other treatments so I guess it cannot be said to be representative.

    sorry for the slow response - busy !
     
  7. podstudent

    podstudent Member

    i have also had very successful outcomes, we give maybe up to 6 injections a day, we mainly use a 1:10 local to 25% glucose. i can comfortably say that only about 1 in 20 patient have no change what so ever. Patients report less or no pain, increase joint stability and function only after a few injection, sometimes only one!. but there is a catch, i believe that the injection is not always enough, the underlying causes of the problem must also be addressed or the pain may re-occur.

    We have also found that in some cases, joint space increases. one particular case of a 60 year old man with lateral joint space narrowing of both knees (alomost bone to bone). he had 4 treatments (one each week), after the four weeks, there was a visible increase in joint cartliage and the patient is over the moon with no pain.

    keep up the good work.
     
  8. METaylor

    METaylor Active Member

    With plantar fasciitis you mark the tender area (may be more than a point) and then slowly do a tunnel of 1% local anaesthetic from skin down to the tender area. Then using 20% glucose and some lignocaine gently pepper the bone with 1-1.5cc mixture. Then get them to walk on the heel and see if the pain has all gone. If not do a bit more. It will be sore for a day or two then settles and may need 2-3 more treatments. Glucose is better than lignocaine alone as it is good at generating growth factors. See excellent article at http://www.drreevesonline.com/Recent Talk.html by Dean Reeves, M.D. Associate Professor Physical Medicine and Rehabilitation Univ of Kansas. If you can't get glucose use some of the patient's blood.
     
  9. martinharvey

    martinharvey Active Member

    Hello Margaret, Omar and Dieter. I can echo Margarets and Omars ringing endorsment of prolo. Nothing works all the time but it's as good as anything else and better than many modalities, it's a whole lot cheaper than hyaluronic acid for joints and a whole lot safer that methylprednisolone. Admittedly, glucose is a problem in the UK with our limited medicines act exemptions prescribing list but if you can persuede a Doctor and Pharmacist to sign off a Patient Group Direction (PGD) then you can obtain it as you need it. Prolotherapy is only an 'off label' use of a licensed med outside it's summary of product characteristics so a PGD is entirely lawful. (I can send you a PDF of a Royal Pharmaceutical Society legal affairs directorate guide to off label PGD's if anyone wants to use it to show a prescriber) If all else fails, then just repeated needling with LA is an acceptable alternative, some research suggests that any solution which raises the concentration of extracellular fluid by >0.5% will affect the osmolality of tissue fibroblasts enough to start cytokine expression and a consequent healing cascade. For example, biopuncture just uses LA alone in acupuncture points or myogeloses (see Travell and Simons trigger point manual).

    I know that Margaret is doing a workshop in Aukland NZ in June, the 16th isn't it Margaret?. If you get a chance go, she is absolutely brilliant (blush, blush! Margaret but its true). Check out her website www.drmtaylor.com.au
    Cheers,
    Martin
     
  10. podstudent

    podstudent Member

    To Dr Taylor - yes i remember you now, you ran a workshop at ICB gait and posture clinic in sydney last year. my brother is Abbie Najjarine (podiatrist) do you remember him?
     
  11. Hi Martin

    You aware of any courses planned for the UK?
     
  12. martinharvey

    martinharvey Active Member

    Hi Mark,

    Margaret held some workshops at a couple of my practices last year and then I arranged a study day last Feb at Robert Peel Hospital, Tamworth, on the subject and am currently at the end of a short series of workshops on prolo at my own practice in Tamworth. There will be another study day on the subject at Robert Peel this coming october. It is a really useful modality and often works very well. The only problem we encounter in the UK is the fact that glucose is a POM. So to get it you need a PSD or PGD. Some few doctors are helpful but they are definitely in the minority, as a profession in the UK they are broadly very mistrustful of anything that 'poaches' on their territory and when you tell them the use is 'off label' they tend to panic and get awfully confused about the difference between a licensed medicine used off label and an unlicensed medicine. I cant really blame them for that because it is a confusing minefield of laws, loopholes and grey areas and it has taken me a few months of digging to find the ins and outs and im still learning. When I hold a workshop now I cover autologous blood use and stress how effective LA is by itself, if you can get glucose great, if you cant then it does not invalidate the modality - just use alternatives. Ideally, we should get glucose added to our list of medicines act exemptions but that will be a long and rocky road because no-one I have spoken to so far at the MHRA knows whether a licensed medicine can be exempted and then used 'off label' - and they are the ones who police the regulations! . You can see the outline of the workshops on www.masterpod.org If you want any further info my email is : podmart@tiscali.co.uk
    Kind Regards,
    Martin
     
  13. Thanks Martin. Will have a look at the site after the weekend.

    All the best.

    MR
     
  14. Dieter Fellner

    Dieter Fellner Well-Known Member

    Martin

    Do you have a PGD to use 'off the shelf'.

    I note Dr. Taylor's suggestion about the use of the patients' blood. When peppering the region it is highly likely there will be plenty of patient blood in the field from needle trauma. It is remarkable how much trauma is caused by the needle - even when this is controlled e.g. ankle block. The effect is transparent when operating on the foot using this modality. There can be so much haematoma to the point I have to ask my anaesthetists to steer clear of the operating field as this can sometimes obscure the anatomy in an unhelpful way. So I am kind of dubious it is necessary to add more blood to the cocktail when this peppering action is performed. Anyone have any thoughts about this?

    A workshop / study day will be a useful opportunity to consider such issues. Sadly I couldn't manage the time when Dr. Taylor was here. I will keep an eye out for further opportunities.
    Dieter
     
  15. martinharvey

    martinharvey Active Member

    Hi Dieter,

    The majority of my prolo Pts come by referral from Doctors in the group practice so at the moment it is PSD. I'm looking at starting the treatments at my central Birmingham clinic so will need a PGD for that which is in the process of being set up.

    About the amount of blood are you are mainly talking about forefoot surgery? The plantar calcaneal entheses are possibly more avascular so perhaps may benefit from a bit of additional PDGF.

    There is a fair bit of information on the use of blood, viz:

    Edwards S, Calandruccio J: Autologous blood injections for refractory lateral epicondylitis. J Hand Surg 28A (2):272-278, 2003.

    Barrett, S.L. , Erredge, S.E. Growth Factors for Chronic Plantar Fasciitis? Podiatry Today Vol.17-Issue 11- pages: 36-42 , November 2004

    Scioli, M. Treatment of recalcitrant enthesopathy of the hip with Platelet rich Plasma- A report of Three Cases COSNEWS, An Official Publication of The Clinical Orthopaedic Society, Spring 2006.

    Mishra, A, Pavelko, T Treatment of Chronic Elbow Tendinosis with Buffered Platelet-Rich Plasma. The Am J of Sports Med 34:1774-1778, 2006.

    Kiter, et al Comparison of Injection Modalities in the Treatment of Plantar Heel Pain A Randomized Controlled Trial JAPMA. 96, No.4, 2983-296, 2006

    Taylor M, Norman T, Clovis N, et. al.: The response of rabbit patellar tendons after autologous blood injection. Med Sci Sports Exerc 34(1):70-73, 2002.

    Best Regards,

    Martin
     
  16. Dieter Fellner

    Dieter Fellner Well-Known Member

    Hi Martin - why do you feel this is the case?

    Blood seems pretty abundant throughout the foot and I have noticed this effect with needling wherever the needle is pushed.

    Cannot say for certain if this is true throughout the tissue layers (though when observed in vivo it sure seems that way) or if it is confined to the more superfiscial structures. Though cut bone oozes red liquid like crazy and the heel is a very vascular structure also.

    Are there studies to suggest the plantar calcaneal enthesis is 'relativey' avascular?

    How much post-procedure discomfort is there for your patients when using this on heels?

    Dieter
     
  17. martinharvey

    martinharvey Active Member

    Hi Dieter,

    Morel et al : Surg Radiol Anat. 2005 Aug;27(3):176-83. Epub 2005 May 26. suggested low vascularisation at the cortical bone insertion when assessed using contrast enhanced ultrasound. Doschak and Zernicke in: Structure, function and adaptation of bone-tendon and bone-ligament complexes. J Musculoskelet Neuronal Interact 2005; 5(1):35-40, also suggested:

    "The role of the blood supply in the pathogenesis and resolution
    of enthesopathy is significant. Many of the fibrous
    connective tissues (e.g., ligaments and tendons) are sparsely
    vascularized, mostly in the outer epiligamentous layers of
    loose connective tissue. Microtrauma and disruption of collagen
    fibrils result in an inflammatory stimulus in regions of
    densely packed, mineralized tissues with cartilaginous elements.
    Cartilage-derived inhibitors of vascularization are
    known to inhibit angiogenesis, and potentially need to be
    overridden for angiogenesis to proceed. Thus, enthesopathies
    have been treated with surgical debridement, adjacent
    incision, and possibly, aggressive bone (e.g., patellar)
    forage, to stimulate sufficient angiogenic stimuli capable of
    overriding the avascular environment of entheses."

    A medial approach for initial anesthesia with scandonest, waiting for full effect and then subsequently using marcaine with the blood seems to cause minimum discomfort and fairly long lasting residual analgesia which possibly helps the Pts to tolerate the after effects of the needling.

    Perhaps the residual analgesia overcomes the possible hyperalgesia from long standing pain causing an exaggerated pain response (the famous 'wind up' syndrome).

    As you know, this exaggerated response causes the release of neurotransmitters that lead to a depolarisation in the neurons. This is so severe and prolonged that the NMDA (N-methyl-d-asparatate) receptors ion canals are activated. This leads to the influx of calcium in the neurons and a cascade of intracellular events that lead to the production of NO and prostaglandins.

    The NO and the prostaglandins increase the excitability of the original neurone together with the nearby neurons and the presynaptic terminals of the nocioceptors that synapse in the region.
    This leads to "central sensitization" that:

    makes the neurons more sensitive to other inputs
    expands the receptive field of the individual neuron
    increases the magnitude and duration of a response to a stimuli
    lowers the threshold for stimuli.

    The clinical correlate to this is hyperalgesia due to changes in the dorsal horn junctions. Perhaps by making the analgesia as long duration as possible we are interfering with this and allowing de-sensitisation.

    As a Pod' Surgeon do you use adrenaline enhanced LA's at all ?


    Regards,

    Martin
     
    Last edited: May 12, 2007
  18. Dieter Fellner

    Dieter Fellner Well-Known Member

    Hello Martin

    I did not find any great advantage in using LA/adrenaline although some of my colleagues do use this.

    I agree with the injection technique and agents used. It is my preferred method also. My (one)patient nonetheless had a sustained pain response.

    What technique did you employ for the peppering?

    Thanks for taking the time to quote the study. This seems like a generic statement about entheses. Was the plantar calcaneal entheses specifically studied? (Note: I have no knowledge of any study suggesting there should be any differences) If so, what is the origin of the cartilage derived angiogenesis inhibitors?

    With much debate concerning the cause of the pain (inflammatory / degenerative) and the structures involved (fascia / muscles / ligaments) how does this fit in with the philosophy of prolotherapy ? Is there agreement it is this specific structure which is causing the pain.

    I note positive feedback from several practitioners. Is there any audit data on outcomes ?

    Dieter
     
  19. martinharvey

    martinharvey Active Member

    Hi Dieter,
    The plantar CE was not specifically studied, as you rightly say it appears generic.The inhibitory action is frequently quoted but I have not identified the specific mechanisms, perhaps the references quoted in the following article may be a starting point for further research.

    From: Inhibition of tumor angiogenesis mediated by cartilage
    H Brem and J Folkman Journal of Experimental Medicine, Vol 141, 427-439,

    "Capillary proliferation induced by tumor is shown to be inhibited by neonatal scapular cartilage. Using the rabbit cornea as an assay, the cartilage implant decreased the rate of capillary growth, induced by tumor, by an average of 75%. Vascularization was prevented completely in 28% of tumors. The inhibitory effect of small cartilage implants operates over distances of up to 2.0 mm and displays a gradient from the cartilage source. The experiments suggest that the cartilage inhibitor does not antagonize tumor angiogenesis factor, but appears to inhibit capillary proliferation directly. The inhibitory material does not elicit an inflammatory response in either the rabbit cornea or in the chick chorioallantoic membrane. Thus with further purification, it may prove useful as a means of maintaining tumor dormancy by antiangiogenesis."

    Perhaps Banks A., A Rationale for Prolotherapy. J. Orthop. Med 13;54-59,1991 is a good introduction to the subject and Dorman, T., Prolotherapy: A survey. Journal of Orthopaedic Medicine. 1993; 15. discusses outcomes but not specifically from a podiatric viewpoint.

    Regards,

    Martin
     
  20. Dieter Fellner

    Dieter Fellner Well-Known Member

    Martin,

    Do you have electronic versions of the references?

    Since in the case of PF/ CE there has been no implantation of any cartilage and there is no donour tissue in the immediate vicinity can we then state this mechanism is purely hypothetical, ( i.e. a means to show how such a process could be involved) in the case of plantar fasciitis?

    Or is this too brutal ? :eek:

    Can I assume there is (yet) no audit data you know of? Perhaps anyone else has knowledge of this? Dr. Taylor ? :confused:

    Dieter
     
  21. METaylor

    METaylor Active Member

    I don't know of any studies on plantar fascia, but if you want to look at some other randomised double blind studies (OA knee, fingers) and a 3 year followup of ACL laxity treated with intra-articular glucose and lignocaine, see http://drreeves.com/Research Articles.html
    Banks A., A Rationale for Prolotherapy. J. Orthop. Med 13;54-59,1991 is available at http://www.kalindra.com/prolo.banks_pdf but it's pretty old now. Reeves has some good discussions of growth factors in his new chapter in a Pain Management textbook http://drreeves.com/Pain Management 2007.doc and there is some mention of treatment of various foot conditions. You can email him for the pdf version which would have all the pictures. My suggestion is to try it on an old lateral ankle sprain, which will be so effective that you'll want to try it on other ligamentous lesions and do N = 1 clinical trials using the patient as their own control.
     
  22. NewsBot

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    Articles:
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    Re: Prolotherapy

    Response of Knee Ligaments to Prolotherapy in a Rat Injury Model
    American Journal of Sports Medicine First published on February 29, 2008
     
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