Patients - Journal of Prolotherapy

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BEULAH LAND PRESS
J O U R N A L of P R O L O T H E R A P Y
Doctors
SHARE YOUR EXPERIENCE
Calling all Prolotherapists! Do you have a Prolotherapy article
ISSN 1944-0421 (print)
ISSN 1944-043X (online)
VOLUME TWO | ISSUE FOUR | NOVEMBER 2010
w w w . j o u r n a l of p r o l o t h e r a p y . c o m
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both physicians and patients. Help spread the word to other people like
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VOLUME TWO | ISSUE FOUR | NOVEMBER 2010 | PAGES 465-529
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of P R O L O T H E R A P Y . C O M
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IN THIS ISSUE
■
chronic pain, and first-hand experience with Prolotherapy.
Testosterone could be a Prolotherapy Doctor’s
and a Patient’s Best Friend!
■
The Use of Testosterone and Growth Hormone for Prolotherapy
■
Pet Prolotherapy: An Overview and Current Case Studies
For information on how to tell your story in the Journal of
■
Interview with Marc N. Dubick, MD
■
Teaching Techniques: Hand and Wrist Prolotherapy
Prolotherapy, please log on to the contact section of
■
Our Patient’s Autologous Stem Cells are Drugs: The FDA Moving
Down on a Dangerous Slippery Slope
■
Building a Rationale for Evidence-Based Prolotherapy
in an Orthopedic Medicine Practice
■
A Retrospective Observational Study on Hackett-Hemwall
Dextrose Prolotherapy for Unresolved Hand and Finger Pain
at an Outpatient Charity Clinic in Rural Illinois
■
ACOSPM 2010 Spring Seminar
■
Prolotherapy Training in Maui 2010
www.journalofprolotherapy.com.
BEULAH LAND PRESS
[
for Doct or s & P at i e n t s ]
■
Prolotherapy for 20 Year Old Ankle Injury
■
More Than Just Medicine: Prolotherapy Missions in Mexico
■
The Use of Hormones for Chronic Pain
■
Prolotherapy Skill Enhancement
CURING SPORTS INJURIES
and Enhancing Athletic Performance
WITH
PROLOTHERAPY
Just as the original book Prolo Your Pain
Away! affected the pain management
field, Prolo Your Sports Injuries Away! has
rattled the sports world.
Learn the twenty myths of sports
medicine including the myths of:
• anti-inﬂammatory medications
• why cortisone shots actually
weaken tissue
• how ice, rest, & immobilization
may actually hurt the athlete
• why the common practice of
taping and bracing does not
stabilize injured areas
• & why the arthroscope is one
of athletes’ worst nightmares!
AVAILABLE AT
www.amazon.com
www.beulahlandpress.com
&
IN THIS ISSUE OF THE JOURNAL OF PROLOTHERAPY
Table of Contents
G R E AT N E W S C O R N E R
470
Testosterone could be a Prolotherapy Doctor’s and a Patient’s Best Friend!
Ross A. Hauser, MD
IN THE SPOTLIGHT
473
477
Ross A. Hauser, MD & Marc N. Dubick, MD
Our Patient’s Autologous Stem Cells
are Drugs: The FDA Moving Down on a Dangerous Slippery Slope
Christopher J. Centeno, MD
FA N TA S T I C F I N D I N G S
480
A Retrospective Observational Study on Hackett-Hemwall Dextrose Prolotherapy for Unresolved Hand and Finger Pain at an Outpatient Charity Clinic in Rural Illinois Ross A. Hauser, MD;
Thomas Ravin, MD
FOUR-LEGGED PROLOTHER APY
504
Pet Prolotherapy: An Overview and Current Case Studies Melissa S. Greenberg, DVM
TEACHING TECHNIQUES
495
508
Hand and Wrist Prolotherapy Rodney S. Van Pelt, MD
IT’S A WIDE WIDE WORLD
512
Building a Rationale for Evidence-
Based Prolotherapy in an Orthopedic Medicine Practice
Part 1: A Short History of Logical Medical Decision Making Gary B. Clark, MD, MPA
520
ACOSPM 2010 Spring Seminar Mark L. Johnson, MD, FACS
Nicole M. Baird, CHFP; Joe J. Cukla, LPN
523
525
Prolotherapy Training in Maui 2010 Rick Marinelli, ND, MAcOM
REMARKABLE RECOVERIES
487
Prolotherapy for 20 Year Old Ankle
Injury Clive Sinoff, MD
More Than Just Medicine: Prolotherapy Missions in Mexico David De La Mora, MD
WONDER WHY?
SKILL ENHANCEMENT
489
528
The Use of Hormones for Chronic
Pain Forest Tennant, MD, DrPH
Seminars, Training, & Organizations
J O U R N A L of P R O L O T H E R A P Y | V O L U M E 2 , I S S U E 4 | N O V E M B E R 2 0 1 0
JOURNAL OF PROLOTHERAPY TEAM & SUBSCRIBER INFORMATION
JOP Team
EDITOR-IN-CHIEF
Ross A. Hauser, MD
Oak Park, IL
EDITORIAL BOARD
Donna Alderman, DO
Mark DeLaurentis, MD
Cherry Hill, NJ
Shaun Fauley, DVM
Naperville, IL
Joern Funck, MD
Luebeck, Germany
Babette Gladstein, VMD
Glendale, CA
New York, NY
Gunter Baehnisch, MD
Mark L. Johnson, MD, FACS
Leipzig, Germany
Nashville, TN
Robert Banner, MD
George H. Kramer, MD
José Hector Salazar, MD
J O P S TA F F
Monterrey Nuevo Leon, Mexico
Marion A. Hauser, MS, RD
Garrett Swetlikoff, ND
Kelowna, BC, Canada
Rodney S. Van Pelt, MD
Ukiah, CA
Mark T. Wheaton, MD
Minnetonka, MN
John Neustadt, ND
Patrick M. Hobbins, DO
Boulder, CO
Senior Graphic Designer/Webmaster
Doug R. Skinkis
Patricia H. Miller
José Eleazar Calderón, MD
Joan Resk, DO, JD
Travis E. Mitchell
Peter J. Blakemore, DO
London, Ontario, Canada
Gary B. Clark, MD, MPA
Associate Editor
Assistant to the Editor-in-Chief/
Assistant Graphic Designer Watertown, NY
Bozeman, MT
Nicole M. Baird, CHFP
RESIDENT EDITORS
Minnetonka, MN
Monclova, Coahuila, Mexico
Senior Editor
South Bend, IN
Assistant to Media Relations
Enid M. Forsyth
Lay Editor
Media for Doctors, Inc.
Media Relations
Roanoke, VA
Subscriber Information
The Journal of Prolotherapy® is unique in that it has a target
audience of both physicians and patients. The purpose of
this journal is to provide the readers with new cutting-edge
information on Prolotherapy, as well as provide a forum for
physicians and patients alike to tell their stories.
The Journal of Prolotherapy® is published quarterly – in February,
May, August, and November by Beulah Land Press, 715 Lake
Street, Suite 600, Oak Park, Illinois, 60301. © Copyright 2010 by
Beulah Land Press. All rights reserved. No portion of the contents
may be reproduced in any form without written permission
from the publisher.
All subscription inquiries, orders, back issues, claims, and
renewals should be addressed to Beulah Land Press, 715 Lake
St. Suite 600, Oak Park, IL 60301; phone: 708.848.5011; fax:
708.848.0978. Email: [email protected];
http://beulahlandpress.com.
PRICING
Annual subscription: $100/year.
Includes 4 paper issues and online access to all
www.journalofprolotherapy.com web content.
CLAIMS
Claims for undelivered copies must be made no later than one
month following the month of publication. The publisher will
supply missing copies when losses have been sustained in
transit and when the reserve stock will permit.
CHANGE OF ADDRESS
Change of address notices should be sent to JOP, 30 days in
advance to: JOP 715 Lake St. Suite 600, Oak Park, IL 60301;
phone: 708.848.5011; fax: 708.848.0978.
COPYRIGHT PERMISSION
Permission requests to photocopy or otherwise reproduce
copyrighted material owned by Beulah Land Press should be
requested by contacting Beulah Land Press at 708.848.5011 or
by emailing [email protected].
DISCLAIMER
This publication does not constitute medical or other
professional advice and should not be taken as such. To the
extent the articles published herein may be used to assist in
the care of patients, this is the result of the sole professional
judgment of the health professional. The health care
professional’s judgment is the primary component of quality
health care. The information presented in this journal is
not a substitute for the exercise of such judgment by the
health professional. The opinions expressed in the Journal of
Prolotherapy® are the opinions of the authors of their respective
articles and not necessarily that of the publisher. The decisions
on what to do for a specific medical condition or symptom
should be based on the analysis by the person’s private health
care professional.
JOURNAL OF PROLOTHERAPY AUTHORS
Authors
NICOLE M. BAIRD, CHFP
Nicole M. Baird is a Certified Holistic Fitness Practitioner and is the Marketing and Publications Manager for Caring Medical
& Rehabilitation Services, as well as Beulah Land Corporation, in Oak Park, Illinois. Her passion for writing, nutrition, and
food lead her down the path of co-authoring The Hauser Diet: A Fresh Look at Healthy Living! Nicole has an avid interest in
nutrition, alternative medicine, exercise, and medical research and has used her knowledge to become an instrumental
writer for many of the publications associated with Caring Medical/Beulah Land Corporation’s many printed materials,
including patient brochures, website content, case studies, books, e-newsletters, and now the Journal of Prolotherapy®.
Nicole can be reached at Caring Medical & Rehabilitation Services, 715 Lake St. Suite 600, Oak Park, IL 60301; Tel: 708.848.7789;
www.caringmedical.com and www.journalofprolotherapy.com.
CHRISTOPHER J. CENTENO, MD
Christopher J. Centeno, MD is a double board certified physician in both Physical Medicine and Rehabilitation as
well as Pain Medicine. He is the medical director of The Centeno-Schultz Clinic. Dr. Centeno earned his MD from
the University of South Florida and completed his residency at the Institute for Rehabilitation Research, Physical
Medicine and Rehabilitation at the Baylor College of Medicine. He is a founding member and medical director of
the International Cellular Medicine Society. Through ICMS, Dr. Centeno has worked with other stem cell experts to
produce International Guidelines for stem cell use as well as an International Re-implantation Registry. Dr. Centeno
published the world’s first clinical case reports on the use of mesenchymal stem cells in orthopedic patients. He has
cared for thousands of patients in chronic pain and has authored over 20 medical publications that are indexed in
the US national library of medicine. He has also treated hundreds of patients with Prolotherapy. Dr. Centeno may be
reached at 403 Summit Blvd, Suite 201, Broomfield, CO 80021; Tel: 303.429.6448; www.centenoschultzclinic.com.
G A R Y B . C L A R K , M D, M PA
Gary B. Clark, MD, MPA is currently the Medical Director of the Center for Healing Injury and Pain and Boulder
Prolotherapy in Boulder, Colorado. Dr. Clark earned a BA and MD from University of Colorado, interned in Pediatrics
at Yale-New Haven Hospital; and completed his residency and board certification in Pathology and Neuropathology
at Walter Reed Army Medical Center and Armed Forces Institute of Pathology. Dr. Clark also earned a Masters Degree
in Public Administration with Special Study in Organizational Development at George Washington University. He
retired from the US Army in 1991 after 23 years of active duty. To contact Dr. Clark: 1790 30th Street, Suite 230, Boulder,
Colorado 80301; Tel: 303.444.5131; www.doctorclark.com.
JOSEPH J. CUKLA, LPN
Joseph J. Cukla , LPN received his Bachelor of Art degree in English from Piedmont College in Georgia. He received his
Practical Nurse license at City Colleges of Chicago. He is a full time Practical Nurse at Caring Medical and Rehabilitation
Services, 715 Lake St. Suite 600, Oak Park, Illinois; Tel: 708.848.7789; www.caringmedical.com.
D AV I D D E L A M O R A , M D
David De La Mora, MD received his Bachelor degree from Universidad de Guadalajara as a Public Health technician
and graduated from the Universidad de Guadalajara College of Medicine in México. He has been a member of The
Christian Medical Society of Jalisco for 11 years, traveling to the poorest areas in his country and other Latin American
countries giving free medical consultation and medicine to people in need. He is currently part of the HackettHemwall Foundation faculty, helping in both the annual Prolotherapy conference in Madison, WI and the mission
work every March in Honduras. He loves Prolotherapy and organizes a mission each January with the Hackett-Hemwall
Foundation México Chapter. In addition to Hackett-Hemwall Prolotherapy, he learned subcutaneous Prolotherapy
from Dr. Lyftogt in New Zealand. Dr. De La Mora may be contacted at Av. Juan Palomar y Arias 646 Fracc. Prados
Providencia, Guadalajara, Jalisco, México. Tel: (33) 36.40.48.80; Email: [email protected]. J O U R N A L of P R O L O T H E R A P Y | V O L U M E 2 , I S S U E 4 | N O V E M B E R 2 0 1 0
MARC N. DUBICK, MD
Marc N. Dubick, MD is a board certified Anesthesiologist and Interventional Pain Management physician. He
specializes in the treatment of the muscular and skeletal components of chronic pain. Dr. Dubick has performed
Prolotherapy injections for 15 years. Dr. Dubick graduated in 1975 from the University of Kentucky College of Medicine
after graduating in 1970 from the University of Maryland School of Dentistry. After practicing Anesthesiology at St.
Joseph Hospital in Lexington, KY for 17 years, he gravitated to the field of chronic pain management where he was able
to develop a continuity of care with his patients. He and his family relocated to Charleston in mid-2000, having lived for 30
years in Kentucky. He is a solo practitioner in Charleston at his clinic Pain Care and Natural Medicine Center of Charleston.
Dr. Dubick may be reached at 2097 Henry Tecklenburg Drive, Suite 203 West, Charleston, SC 29414; Tel: 843.573.3444;
www.prolotherapysc.com.
BABETTE GLADSTEIN, VMD
Babette Gladstein, VMD is a graduate of the University of Pennsylvania, School of Veterinary Medicine. Her postdoctoral work has included veterinary acupuncture at the American Academy of Veterinary Medical Acupuncture
at Colorado State University, as well as pre-veterinary studies at Hunter College in New York City. She is a member of
the American Association of Equine Practitioners, the American Veterinarian Medical Association, and the American
Holistic Veterinary Medical Association. Dr. Gladstein has also been affiliated with The New York Racing Association,
Meadowlands Raceway, and US Equestrian. As a licensed veterinarian in New York, New Jersey, Connecticut,
Florida, and California, Dr. Gladstein’s treatment modality expertise includes Prolotherapy, acupuncture, ultrasound,
chiropractic, and massage therapy. Since the mid ‘80s, Dr. Gladstein observed and studied the benefits of nutrition
and nutritional supplements in animal care and treatments and followed this with investigations into therapeutic
ultrasound, massage and acupuncture, as well as physical therapy for horses. Dr. Gladstein may be reached at 45 East
89th Street, #31D, NY, NY 10128; Tel: 212.828.5663; www.animalacupuncture.net.
MELISSA S. GREENBERG, DVM
Melissa S. Greenberg, DVM graduated from University of Florida in 1993, and has dedicated her career to the well being
of both wild and domestic animals. Dr. Greenberg’s current practice includes holistic modalities such as deep tissue
massage/myofascial release, chiropractic, homeopathy, and regenerative injection therapies (RIT). Compassionately
crusading for humane population reduction and health care for those animals otherwise uncared for has also
become a main direction of her career. She does this through the Aloha Mission for Animals, a 501(C)3 non-profit
organization of which she is a founding director. AMA projects have so far reached animals in Hawaii, Micronesia,
Marshall Islands, Indonesia, India, and Nepal. When not crusading for animals, Dr. Greenberg can be found on Kauai;
swimming, paddling, hiking, or playing with her family. Dr. Greenberg may be reached at P.O. Box 20, Hanalei, HI
96714; Tel: 808.346.7387.
ROSS A. HAUSER, MD
Ross A. Hauser, MD received his undergraduate degree from University of Illinois. He graduated from the University of
Illinois College of Medicine in Chicago and did his residency at Loyola/Hines VA in Physical Medicine and Rehabilitation.
Dr. Hauser is the Medical Director of Caring Medical and Rehabilitation Services in Oak Park, Illinois and is passionate
about Prolotherapy and natural medicine. Dr. Hauser and his wife Marion, have written seven books on Prolotherapy,
including the national best seller “Prolo Your Pain Away! Curing Chronic Pain with Prolotherapy,” now in its third
edition, a four-book mini series of Prolotherapy books, and a 900-page epic sports book on the use of Prolotherapy
for sports injuries. Dr. Hauser may be reached at 715 Lake St., Suite 600, Oak Park, IL 60301; Tel: 708.848.7789;
www.caringmedical.com.
M A R K L . J O H N S O N , M D, FA C S
Mark L. Johnson, MD, FACS received his undergraduate degree from Emory University. After receiving his M.D.
from the University of Alabama in Birmingham, he completed his General Surgery internship at the University of
Kentucky in Lexington, and his Urology residency at the University of Illinois in Chicago. He had extensive postgraduate
training in laparoscopic and robotic surgery. He is a member of numerous professional organizations including the
American College of Osteopathic Sclerotheropeutic Pain Management, the American College of Surgeons, the
American Urological Association, the Society of Laparoendoscopic Surgeons, The Tennessee Medical Association, and
the Davidson County Medical Society. Dr. Johnson retired from surgical practice five years ago to practice Prolotherapy
full-time. Dr. Johnson may be reached at Prolotherapy Nashville, 278 Franklin Road, Suite 150, Brentwood, TN 37027;
Tel: 615.506.0536; www.prolotherapynashville.com.
RICK MARINELLI, ND, MAcOM
Rick Marinelli, ND, MAcOM is a graduate of the National College of Naturopathic Medicine and the Oregon College
of Oriental Medicine. Rick has extensive experience in women’s healthcare, hormone replacement therapy for men
and women, the diagnosis and treatment of pain, diagnostic ultrasonography, sports medicine, aesthetic medicine,
weight loss, and primary care. He is especially well known for the gentle regenerative injection therapies of neural
therapy, Prolotherapy, platelet rich plasma injection, and the use of sclerotherapy for the treatment of varicose veins.
He has taught many courses in pharmacology, herbal medicine, pain management, and injection therapy and is a
sought out lecturer. In addition to practice, Rick has been very active in community and professional service with a
long list of contributions including immediate past Chair of the Oregon Board of Naturopathic Medicine, immediate
Past-President of the American Academy of Pain Management, a Commissioner of the Oregon Pain Management
Commission and Prescription Drug Monitoring Program Advisory Commission, founding Vice-President of the
Naturopathic Academy of Therapeutic Injection, and many others. Dr. Marinelli may be contacted at 1600 SW Cedar
Hills Blvd., Portland, OR 97225; Tel: 503.644.4446; www.natural-healthmedicine.com.
T H O M A S R AV I N , M D
Thomas Ravin, MD attended Colorado College and spent a year abroad at the University of Glasgow in Scotland.
After graduating from the University of Colorado Medical School, Dr. Ravin completed an internship at Madigan Army
Hospital in Tacoma, Washington. He was in the Special Forces for two years, which included one year in Southeast
Asia. He completed both a radiology residency at Fitzsimmons Army Hospital in Denver and a nuclear medicine
fellowship at the University of Missouri in Columbia. In addition to promoting Prolotherapy around the world,
Dr. Ravin continues to ski race and train in the USSA Masters program. He bicycles between 2,000 and 3,000 miles
annually and is a passionate devotee of Pilates. The injuries he has sustained during these activities have spurred his
interest particularly in the aches and pains of the active adult athlete. Dr. Ravin feels that Prolotherapy is an underused
treatment tool and can keep adult athletes doing the activities they love as Dr. Ravin, in his late sixties, can attest to.
Dr. Ravin may be reached at 45 S. Dahlia, St., Denver, CO, 80246; Tel: 303.331.9339; www.tomravinmd.com.
C L I V E S I N O F F, M D
Clive Sinoff, MD was born and raised in South Africa. He was awarded his medical degree in 1973. Having completed
additional training, Dr. Sinoff became board certified in Internal Medicine and subsequently Medical Oncology in
South Africa. Medical education and training in South Africa is noted for its clinical emphasis. After moving to Canada
in 1987, he completed his Canadian board certification in Internal Medicine and Medical Oncology. Dr. Sinoff settled
in Cleveland in 1995, and since 2002, has devoted his practice to helping patients with pain. His focus recently has
been on Prolotherapy and Laser Therapy, both non-invasive treatments, which have been shown to cause healing of
damaged tissues, even after years of pain. He is known as a warm and compassionate clinician. Dr. Sinoff has published
over 15 articles and one revision book for internal medicine. Dr. Sinoff may be contacted at 22200 Halburton Rd.,
Beachwood, OH 44122; Tel: 216.514.9590; www.osmofohio.com. F O R E S T T E N N A N T, M D , D r P H
Forest Tennant, MD, DrPH is a former US Army Medical Officer and public health physician. As a public health physician
in Eastern Los Angeles County, he started a pain clinic in 1975 primarily for cancer and post-polio patients. He retired
from public health in 1998 but still operates his original pain clinic which specializes in intractable pain. He has
published over 300 scientific articles primarily on addiction, pain, and neurochemistry. His primary research interest
is hormone metabolism and treatment involving pain. He is editor emeritus of Practical Pain Management that is
circulated to 47,000 physicians who treat pain patients. Dr. Tennant may be reached at Veract Intractable Pain Clinics,
338 S. Glendora Avenue, West Covina, CA 91790-3043; Tel: 626.919.7476; www.foresttennant.com.
R O D N E Y S . V A N P E LT , M D
Rodney S. Van Pelt, MD received his medical degree from Loma Linda University Medical School and completed
his family practice residency in Florida. He practiced family medicine for several years until falling in love with the
specialty of Orthopedic Medicine which uses all the different modalities for pain with conservative treatments. Dr. Van
Pelt then received specialized training in the Cyriax technique of Orthopedic Medicine, taking some of his training in
Oxford, England. He is one of the few American physicians who is a member of the Society of Orthopedic Medicine
of London, England. Dr. Van Pelt practices full time Prolotherapy in northern California. Dr. Van Pelt may be reached at
Orthopedic Wellness Center Plaza Del Sol, 311 Luce Ave., Ukiah, CA 95482; Tel: 707.463.1782; www.sfpmg.com.
GREAT NEWS CORNER: TESTOSTERONE COULD BE A PROLOTHERAPY DOCTOR'S AND A PATIENT'S BEST FRIEND!
G R E AT
N E W S
CO R N E R
Testosterone could be a Prolotherapy
Doctor’s and a Patient’s Best Friend!
Ross A. Hauser, MD
I
t is well known to physicians who treat athletes
that female athletes have a significantly higher
prevalence of injuries to ligaments, such as the
anterior cruciate ligament, than male athletes in the same
sports. While some explanations for this discrepancy
can include gender-related differences in bony structure
or ligament size, endurance, conditioning, or training
techniques, it most likely stems from the gender-specific
hormonal differences. We now know that there are
androgen receptors in the cells of ligaments, and one of
their functions is to enhance ligament repair. For folks
suffering with chronic pain and the doctors who treat
them, maximizing a patient’s hormonal milieu could
be one of the keys to improving with Prolotherapy. To
explore this issue, Forest Tennant, MD, the former
editor-in-chief of Practical Pain Management, writes about
testosterone and other anabolic hormones, including
human chorionic gonadotropin, and their pain reducing
effects, in his clinical experience. Drs. Tom Ravin and
Mark Dubick discuss their use of testosterone and growth
hormone in the Prolotherapy solutions and basis for this.
Perhaps testosterone (and other anabolic hormones) are a
Prolotherapy doctor’s and patient’s best friend?
Also, to wrap up the second year of JOP, Clive Sinoff, MD
presents a case of severe ankle crush in Remarkable Recoveries.
In the four-legged arena, our veterinary columnist and
board member, Babette Gladstein, VMD, introduces us
to fellow Prolotherapy doctor, Mia Greenberg, DVM. Dr.
Greenberg has an exciting veterinary practice in Kauai,
Hawaii and in this issue she presents Prolotherapy and
PRP canine case studies.
Rodney Van Pelt, MD, our Teaching Techniques columnist,
provides an excellent demonstration of Prolotherapy
to the wrist and hand. Also in this issue, I present a
retrospective observational study for hand and finger
pain, along with Nicole Baird, CHFP and Joe Cukla,
LPN. Surely physicians looking into, or performing
470
stem cell Prolotherapy will be interested in reading the
commentary piece from Dr. Centeno regarding the FDA
and their oversight of stem cell therapies.
This year has seen more amazing outreach of the
Prolotherapy community in both the teaching and mission
realm. David De La Mora, MD shares his endearing story
of how he found Prolotherapy and how it lead him to
helping expand Hackett-Hemwall Prolotherapy training
and mission work in Mexico. He’s done a lot of work in a
short time and many patients are benefiting from his efforts.
Mark Johnson, MD wrote an excellent piece showcasing
the training seminar in San Diego by the American College
of Osteopathic Sclerotherapeutic Pain Management
(ACOSPM). In addition, Rick Marinelli, ND sponsored
a great training seminar on the beautiful island of Maui
earlier this year. Thank you to everyone for your work
in 2010 teaching other practitioners about Prolotherapy,
and for sharing the experience with our readers!
We hope the work continues to grow in 2011 and more
patients will experience the power of Prolotherapy! At
JOP we are certainly excited about the upcoming 2011
volume. Remember to renew your subscription, if this is
your last issue.
Letters to the Editor
Recently, JOP columnist and board member, Gary Clark,
MD from Boulder, Colorado sent me the following
email:
Dear Ross,
I have been an editor-in-chief of a peer reviewed journal and have
done peer reviewing. Just a little experience. So, as a starter, you are
doing a great job! I suggest that you, as editor-in-chief, establish
the rules in writing by which any peer reviewing is performed.
In my estimation, the first job of the peer reviewer is to confirm
that the article submitted is accurate and satisfactorily referenced.
Second, if it is a piece of original research, the report should be
complete and in an appropriate format. You can adopt any report
style such as NEJM, JAMA, MLA, APA, etc. There are scientific
style books out there. If it is a piece of original research, the basic
assumptions, premises, and conclusions have to be inherently valid.
It is not the job of the peer reviewer to force his or her personal
writing style onto the submitting author. However, normal rules of
English syntax and grammar should be followed. Final decisions
should be made between the editor-in-chief and the original author,
paying all due respect to the comments of the peer reviewers.
Thanks for your time on this,
Gary B. Clark, MD
In this issue, Dr. Clark begins a four part series on
evidence-based medicine. Doctors who use Prolotherapy
will appreciate Dr. Clark’s expertise and insight into
appropriate clinical outcome reporting that is needed in
the field of Prolotherapy. Dr. Clark will help those of us
who do Prolotherapy design a scientifically-based practice.
Thank you, Dr. Clark!
_____________________________________________
Dr. Hauser,
1. I have been reading about the dose dependent toxicity of anesthetics
on chondrocytes for awhile now and have stopped adding them to my
steroid or Synvisc injections. There are a lot of studies on post-op
intraarticular anesthetic (Marcaine) pump.
One of many publications: http://www.aaos.org/News/aaosnow/
jun08/clinical4.asp I’m checking into the effects of prolotherapy
that has a ton of anesthetics (1:1:1 ratio of D5W:Xylocaine:
Marcaine).
2. What about steroid use to allow a pinched nerve to heal itself
(CTS, radiculopathy,...). What is your opinion about epidurals
or CT injections. I personally like steroids primarily for nerve
entrapment.
Behzad Emad, MD
Dear Dr. Emad,
Thank you for your email. Our readers should know
that in your practice you perform Prolotherapy, along
with other procedures, for pain management. You bring
up two issues of importance to the Prolotherapy doctor
which are as follows:
1. Which Prolotherapy solutions to use and in what
amount.
2. When to use steroids.
In regard to your first question, this research was by
Constance R. Chu, MD, Associate Professor, Albert
Ferguson Endowed Chair Joint Replacement and Sports
Medicine, in the Department of Orthopaedic Surgery at
the University of Pittsburgh.1 This research was basically
done because it is becoming increasing clear that the large
amount of anesthetics pumped into joints during and after
arthroscopy can have damaging effects on the cartilage.
Prior to the last decade, it was common to use anesthetics
like bupivacaine during the arthroscopies. But when it
was found that pain relief after the arthroscopies could be
improved with anesthetics being pumped into the joint,
this became common practice. Hence, in the last decade,
joints such as the shoulder and knee were being subjected
to large amounts of anesthetics like bupivacaine, via pain
pumps, for up to two days after the surgery! So one can
only imagine the amount of exposure to the anesthetic
drugs the joints experienced!
It isn’t surprising that subjecting the joint to such large
amounts of medications over a period of 48 hours was
damaging. Many reports have come out that chondrolysis
(articular cartilage damage) can occur with anesthetics,
especially those in the bupivacaine or lidocaine class,
when cartilage cells are exposed over many, many hours.2, 3
So, what is done with Prolotherapy and what was and
is done during and after arthroscopic surgery is clearly
different. One involves a very short term, low dose
exposure and the other involves a much higher exposure.
But your question related to the research lead by Dr. Chu
which showed a dose- and time-dependent toxic effect
of lidocaine, bupivacaine, and the combined effects of
lidocaine and Depo-medrol on articular chondrocytes
is a good one. The study showed for instance that 0.5%
bupivacaine was highly toxic to human chondrocytes and
human articular cartilage in vitro, while the chondrotoxicity
of 0.25% bupivacaine increased proportionally to both
the duration of bupivacaine exposure and time after
bupivacaine exposure. Of special interest was that the
study found no chondrotoxicity following exposure to
0.125% bupivacaine.
As you are aware, lidocaine and bupivacaine are B-amide
type anesthetics, whereas procaine and tetracaine are
A-esters. Some physicians use other anesthetics, such as
471
procaine, instead of lidocaine or bupivicaine and most
doctors use a very low dose of anesthetic in the solution.
For instance, most solutions used in my office have 0.1%
amount of anesthetic, which is far below the amount
used in Dr. Chu’s study to cause harm. I welcome other
doctors’ input into this issue!
As a related question, there are times when a steroid
injection to reduce harmful inflammation is necessary.
Most Prolotherapists would agree that if a nerve is
getting pinched or irritated, a joint is swollen and hot, a
person is suffering from a true bursitis (as evidenced by
heat and redness), or if a person has a trigger finger or
tenosynovitis, then a steroid shot often does have a role.
These conditions are different than a patient suffering
from tendinosis, ligament injury, degenerative arthritis, or
joint instability. In such instances, steroids play basically
no role in the resolution of the underlying problem and
have the potential to make it much worse. Again, JOP
welcomes our readers’ thoughts and opinions on this
issue.
As you know, I am a strong advocate of a pain doctor
limiting his or her use of steroids and anti-inflammatory
medications because of their potential harmful effects on
articular cartilage.4, 5 The clients I typically see, which I
am sure are similar to most Prolotherapy doctors, have
not been helped by steroid injections or anti-inflammatory
medications. The argument could be made that they (like
the chondrolysis case) have been hurt by these injections
and medications. It is not uncommon for Prolotherapy
doctors to get a history like the one in Table 1 revealing the
myriad of steroid shots their patient has received. This
particular patient gave me a complete typed out steroid
history. Here I have only included the years 2004-2008. I
hope you get my point. n
Until the next injection,
Ross A. Hauser, MD
Table 1. A patient’s steriod history.
Date
Treatment
Doctor
2004 - One Injection
1/5/04
injection right elbow
Dr. L
2005 - Six Injections
2/3/05
Dr. L
2/3/05
injection right hip
Dr. L
2/17/05
injection right hip
Dr. J
5/19/05
Dr. J
9/20/05
Dr. J
11/4/05
injection due to spider bite
Dr. L
2006 - Five Injections / Two Medrol Dosepaks
1/10/06
Dr. J
3/31/06
injection left knee
Dr. K
4/15/06
medrol dosepak, sinuses
Dr. P
6/1/06
Dr. J
8/30/06
Dr. L
11/16/06
Dr. J
11/16/06
injection left elbow
Dr. J
2007 - One Injections / Two Epidurals / Two Medrol Dosepaks
3/?/07
medrol dosepak, herniated disc
Dr. J
4/?/07
Dr. L
5/23/07
Dr. J
8/3/07
lumbar epidural injection
Dr. L
11/?/07
Dr. L
2008 - One Injection / One Epidural / One Medrol Pak
1/8/08
Dr. J
3/7/08
Dr. L
11/25/08
Dr. P
B i bl i o g r a p h y
1. Chu CR, et al. The in vitro effects of bupivacaine on articular
chondrocytes. Journal of Bone and Joint Surgery (Br). 2008;90(6):814-820.
2. Larsen MW, et al. Severe glenohumeral chondrolysis following
shoulder arthroscopy resulting in arthroplasty. Program and
abstracts of the American Academy of Orthopedic Surgeons 2006
Annual Meeting; March 22-26, 2006; Chicago Illinois. Paper 284.
3. Anderson SL, et al. Chondrolysis of the glenohumeral joint after
infusion of bupivacaine through an intra-articular pain pump
catheter: A report of 18 cases. European Journal of Cardiovascular
Prevention. 2010;26:451-461.
4. Hauser R. The deterioration of articular cartilage in
osteoarthritis by corticosteroid injections. JOP. 2009;1(2):107-123.
5. Hauser R. The acceleration of articular cartilage degeneration
in osteoarthritis by nonsteroidal anti-inflammatory drugs. JOP.
2010;2(1):305-322.
472
IN THE SPOTLIGHT: INTERVIEW WITH MARC N. DUBICK, MD
I N T H E
S P OT L I G H T
Interview with
Marc N. Dubick, MD
Ross A. Hauser, MD & Marc N. Dubick, MD
Hauser: Dr. Dubick, can you please tell us a little bit
about your background?
Dubick: I’m a board certified anesthesiologist, and I’ve
been performing interventional pain management full
time since 1993. I’m board certified in pain management
through the American Board of Anesthesiology, which is
the only pain management subspecialty recognized by the
American Board of Medical Specialties.
I have been practicing structural medicine since 1995
and performing Prolotherapy injections since that time,
after being introduced to Dr. Tom Ravin at the AAOM
(American Academy of Osteopathic Medicine) annual
meeting in 1994. I had been treating my patients with
steroid injections for my first couple of years in pain
management, but was concerned that most patients
received only temporary benefits. Finding the AAOM
opened my eyes to the field of musculoskeletal and
structural medicine, an area that I found to be so vital in
helping my patients achieve improved outcomes.
Hauser: Dr. Dubick, you stated that you were traditionally
trained as an anesthesiologist. You mentioned the notion
of steroids and that they may not be the best treatment.
Obviously the light bulb went on at some point. Can
you describe that? Thinking outside the box is one thing.
But from going from anti-inflammation to basically
inflammation and structural medicine is completely the
opposite. Have you gotten any flack for it from other
colleagues?
Dubick: Ross, it’s funny how some things happen.
My introduction to Prolotherapy came from a very
traditional, but innovative, neurosurgeon friend of mine
who heard about Prolotherapy from a nurse who had
moved back home to Kentucky. She had been living in
Texas where she was involved in a serious MVA. She had
been bedridden for a year with back dysfunction until
she heard about Drs. Kline and Eck in Santa Barbara,
CA. She flew to Santa Barbara for a year where she was
treated successfully with Prolotherapy. It was just luck
of the draw that this woman moved back to Kentucky,
and I heard her story from my friend. In answer to your
second question, yes, I believe that a number of my peers
used to look at my way of thinking as being unusual, both
in Lexington and in Charleston. However, results speak
for themselves and many of those physicians now send
me referrals. Prolotherapy was a credentialed procedure
at St. Joseph Hospital while I was on the staff and is
currently a credentialed procedure at St. Francis Hospital
in Charleston, SC.
Hauser: Marc, if you were teaching a course to your
fellow anesthesiologists and you were going to say to them,
“For these certain conditions, the steroid shots make sense
and are a good treatment. However, these other cases are
where you should consider Prolotherapy,” where would
you make the distinction?
Dubick: When I first started practicing in Charleston,
almost every patient sent to every pain management
physician with back pain had an epidural steroid injection
ordered if there was any abnormal finding on imaging
studies. A large percentage of those injections provided
only temporary relief because the vast majority of back
pain is not caused by radicular or discogenic issues.
Epidural steroid injections can often be very useful for
radicular pain and occasionally discogenic pain. Most
of the chronic pain issues that are not radicular and are
not discogenic are usually caused by a structural issue.
These structural dysfunctions can often be treated with
a combination of good joint mobilization, rehabilitative
Marc Dubick, MD performing Prolotherapy on the lower
back.
473
therapy, and proliferant therapy to strengthen the
weakened elements. Many people just go by the wayside
and are never assigned the correct diagnosis. Many
physicians don’t look at structural issues. It’s not taught in
medical school, and essentially, it’s not there as far as most
people are concerned. Most MRIs and radiographs don’t
reveal the cause and complete hands-on physical exams are
often not performed. In all probability, a large percentage
of patients with chronic, undiagnosed problems can have
their structural issues treated successfully with a good
diagnostic exam and appropriate treatment directed at
the indicated problems.
Hauser: That’s a great explanation. You mentioned in
your journey you eventually connected with Dr. Ravin.
Can you expand on how you got involved in Prolotherapy
and also using human growth hormone and testosterone
as a proliferant, and a little about your IRB?
Dubick: As I mentioned previously, I met Tom Ravin
at my first AAOM meeting in 1994, and we became
friends. I spent a week observing at his office, and I began
my understanding of the interrelationship of structural
issues and their treatment as an important aspect of
pain management. Tom has been at the forefront of
Prolotherapy for 25 years, is a free thinker, and a real
innovator. I began performing Prolotherapy injections in
1995 and have continually expanded my knowledge base
and technical proficiency over the last 15 years. I perform
all of my injections under fluoroscopic guidance as a carryover from my anesthesia pain management techniques.
I treat appropriate patients with Prolotherapy as well as
continuing to see other pain management patients who
are candidates for other treatments and modalities.
Tom had been considering the use of testosterone as a
proliferant for a number of years. We started discussing
its use in an injection protocol and we added HGH
(human growth hormone) in the theoretical solution along
with procaine. Based on many reports in the literature
describing the positive benefits of systemically injected
HGH in helping speed the healing of serious burns, skin
grafts, and fractures, we hypothesized that a localized
injection of HGH would also be beneficial. I could find
only one study in the literature using localized injection of
HGH. The study involved brachial artery injections using
a tourniquet and compared muscle mass in the treated
arm with the untreated arm used as the control. Muscle
mass increased significantly in the treated arm and the
serum IGF-1 levels did not rise. HGH is a strong stimulant
of protein synthesis, with the effect being significantly
enhanced with the addition of aqueous testosterone.
Because HGH used in this capacity is an off-labeled
use by the FDA, we felt that obtaining Investigational
Review Board approval was an important first step before
beginning the injections. After a 6 month process, I was
awarded an IRB approval from the Roper/St. Francis
Healthcare System IRB committee in Charleston, SC for
a two year study with 100 subjects. The study started in
June 2009, and I am currently treating or have treated
40 patients. The preliminary results have been quite
gratifying. I’ve found anecdotally that the areas treated
are healing faster, stabilizing more quickly, and patients
are reporting less pain than was observed with the
Prolotherapy procedures that I perform. I am averaging 3
sets of injections per body area, with minimal discomfort
during and after the procedure. A number of patients
report improvements very early on during treatment.
Each subject will be re-evaluated 12 months following the
completion of the injections, and I have not yet reached
that timeline.
The HGH injections are being performed in every area
of the body that I would perform standard Prolotherapy
injections. I plan to report the final results of this study, in
hopes that others will repeat the process, with the ultimate
goal of convincing the FDA to make localized injections
of HGH for healing purposes to be a labeled use.
Marc Dubick, MD consulting with a patient in his Charleston,
South Carolina office.
474
Hauser: You would probably say the same thing about
using testosterone in the Prolotherapy solution.
Dubick: Yes, testosterone is intricately involved with
HGH and exerts a synergistic effect, increasing its
effectiveness. Testosterone also has a direct stimulant
effect on protein synthesis and most probably would exert
beneficial effects if used with a glucose based proliferant.
However, I have not tried this combination myself.
Hauser: Some of the subscribers to the Journal of
Prolotherapy are the lay public. Can you please explain a
little about what an IRB is and what it stands for?
Dubick: IRB stands for Investigational Review Board.
An Investigation Review Board Committee is a hospital
committee made up of medical, nursing, pharmacy,
administration professionals and lay people. It is a
committee that has been formally designated to approve,
monitor, and review biomedical and behavioral research
involving humans with the aim to protect the rights and
welfare of the research subjects. An IRB performs critical
oversight functions for research conducted on human
subjects that are scientific, ethical, and regulatory. In my
case, I obtained an IRB approval because of the “off label”
use of HGH and because I feel it is important to publish
the results of the injection study, as I believe it will show a
significant benefit to the study subjects. My IRB allows me
a two year study with 100 patients to do these injections.
They’re performed under specific criteria and follow up
that was agreed upon during the approval process.
Hauser: Prolotherapy doctors traditionally treat a
wide variety of conditions, including degenerative joint
disease. Do you have a feel for human growth hormone/
testosterone combination across the board? Is it more
beneficial compared to the traditional Prolotherapy? Do
you feel it will have a specific place for certain conditions?
Or maybe it is just too soon to tell at this point?
Dubick: I’ve used it successfully with patients who have
sports type related injuries, degenerative joint disease,
overuse syndromes, motor vehicle and work related
injuries, and with osteoarthritis. I’m seeing benefit with
injections into small joints in the hands and feet. I am
adding the HGH/testosterone combination into the
knee and hip joints, but only when I am also treating the
hip capsule and knee ligaments. I’m using the HGH/
testosterone combination in all areas where I have used
traditional Prolotherapy. Thus far, I have seen benefits
in all areas that I have treated with the exception of
moderate to severe osteoarthritis of the hip.
Marc Dubick, MD examining a patient prior to treatment.
Hauser: I understand. Is there anything else you would
like to share?
Dubick: One thing I’d like to touch on is that I am
disturbed by the negative publicity surrounding human
growth hormone. I am finding the HGH/testosterone
combination to be a potent initiator of healing that can
have wide-ranging benefits for those suffering from chronic
and possibly acute structural injuries. I have patients that
range in age from 18 to 91 years old who are benefiting
from these injections. The rapidity with which the healing
phase appears to begin and the minimal discomfort noted
during and after the procedures are two advantages
that differentiate the HGH/testosterone from the P2G
Prolotherapy that I perform. Adjunctive therapy is also
very important, including joint mobilization to maintain
normal skeletal alignment and a strong rehab program.
Hauser: Those traditional doctors who are not
Prolotherapy doctors may say, “What about the side effects
of growth hormone?” What would you say to them, as a
doctor who does structural medicine?
Dubick: From a structural medicine standpoint, I’ve seen
no side effects since I’ve been performing these injections.
The growth hormone is most probably denatured very
quickly after injection. It appears to work on target cells,
very possibly the macrophage, but this has not been
elucidated at this point. I have not seen any side effects of
this localized injection, and do not expect to see a rise in
IGF-1 levels following the procedures.
The testosterone is an aqueous based solution that is
present in the body for several days. The levels rise
475
Marc Dubick, MD performing Prolotherapy under
fluoroscopy.
transiently, but I’ve seen no significant side effects on
either men or women.
Hauser: If you looked at the package insert of
testosterone or human growth hormone, some side effects
that might be listed are swelling, carpal tunnel syndrome,
and things like that. Would you say there is a maximum
dose you would use at one time?
Dubick: I use a set maximum dose of growth hormone,
and the injections are localized at tendon and ligament
entheses. As I mentioned, HGH is probably denatured
very quickly, and it is doubtful that any increase in IGF-1
levels occur systemically. The brachial artery study that
I mentioned earlier did not show a systemic increase
in IGF-1 and I would not expect it to rise with these
localized injections. Therefore, I would not expect to see
any systemic side effects. To be on the safe side, however,
any patients with carcinoma, present or in the recent past,
are not considered for these injections.
Hauser: Marc, that was a great explanation. Out of
curiosity, have you also done some work as far as using
growth hormone and testosterone? Not necessarily in
the Prolotherapy solution but, creams or shots, to help a
person become more anabolic.
Dubick: My patients who have low levels of testosterone
on lab testing are referred for replacement therapy,
primarily with creams, sublingual tablets, or oral drops.
Low levels of testosterone are very common in men and
women with long standing severe chronic pain. I definitely
feel that normal levels of testosterone are important for
476
Dr. Dubick explaining treatment, using a skeleton model.
overall systemic function. I don’t suggest replacing HGH
unless the levels are below the lower normal limits, and
I don’t really know the significance of lower levels of
HGH.
Both testosterone and HGH are vital for the initiation of
the healing response in the body, and we hypothesized
that creating an iatrogenic wound with needling and
the flooding of the area with testosterone and HGH
would stimulate the healing response even in patients
with low levels of these two vital hormones. Thus far in
the study, even very elderly patients with low hormone
levels, particularly testosterone, appear to be healing very
quickly with the HGH and testosterone injections, even
faster than with traditional Prolotherapy.
Hauser: Do you use certain guidelines for recommending
a man or woman start hormone replacement therapy?
Dubick: Yes, I do. As I mentioned previously, my
recommendations for replacement depend on how low
the levels are in serum testing. I recommend testosterone
replacement routinely for both men and women,
although a greater percentage of women seem to have
very low testosterone compared to men. I recommend
HGH replacement therapy rarely. Replacement is only
by injections daily, and is very expensive. Also, there is
significant controversy regarding HGH replacement
unless the levels are well below low normal values.
Hauser: Dr. Dubick, thanks so much for your time.
Dubick: Thank you. n
IN THE SPOTLIGHT: THE FDA MOVING DOWN A DANGEROUS SLIPPERY SLOPE
I N TH E
S P OT L I G H T
Our Patient’s Autologous Stem Cells
are Drugs: The FDA Moving Down a
Dangerous Slippery Slope
Christopher J. Centeno, MD
A
dult autologous stem cells (A-ASC’s) show great
promise in research and early pre-clinical/clinical
use. These cells have the potential to revolutionize
medicine by repairing tissues directly or assisting in tissue
healing.1 What you may not realize is that a herculean
power struggle going on behind the scenes where the Food
and Drug Administration (FDA) is now claiming, through
the “canary in the coal mine” of the new field of cell
therapy, to have authority over the stem cells in your body.
If left unchecked, the next logical step in this regulatory
pathway appears to be dividing certain common medical
procedures into those that require federal regulation and
those that do not.
Cellular therapy is the next logical step in regenerative
medicine. The world’s first regenerative medicine
procedure in widespread use was Prolotherapy. This
procedure simply spurred the body to repair itself through
creating small injuries in need of healing. The next step
beyond Prolotherapy is using the patient’s own cells to act
as stimulants for healing or the building blocks for new
tissue. Platelet rich plasma (PRP) is a new technique that
uses blood platelets (which contain healing growth factors)
to help heal tissue. The next logical step in regenerative
medicine beyond PRP is stem cell therapy. This procedure
uses the patient’s own stem cells to act as building blocks
for new tissue. However, the FDA’s new regulatory posture
would seem to place both PRP and stem cell therapy at
risk of being regulated into oblivion.
The problem began in 2005, when the FDA dramatically,
and quietly, changed its regulatory approach with
potential to upset the “great wall” between medical
practice and mass drug production. Historically, the
FDA has never had the power to control any aspect
of the relationship between a doctor and a patient. In
2005, the agency made changes to the 361 Public Health
Service (PHS) act to classify certain A-ASC’s as biologic
drugs requiring pre-market, federal approval before sale
in interstate commerce.2 Before 2005, the FDA only had
authority over tissue transplants, for example, where one
patient’s organ was transplanted to another person. This
made sense, as nobody wants to get a diseased organ
from someone else. Prior to 2005, the agency also had the
power to declare certain transplanted cells as drugs, for
example someone else’s cells that were mass produced in
vials for mass distribution. However, after 2005, this same
rule was applied to all human tissue. For the first time,
this gave the agency authority over the tissues in your body
used to treat your disease as part of a surgical procedure.
The agency now purports that it gave itself the ability to
declare certain types of your tissues, processed in certain
ways, to be drugs. For example, if PRP is activated in a
certain way by your doctor, it’s a drug. Again, stem cells
processed in certain ways are also drugs.
The agency has traditionally gone to great lengths to
differentiate one on one medical care risks (over which
it has no authority) from one on many drug and device
production risks (it’s congressional mandate). One on one
risks are the things you get exposed to everyday when you
have a surgery. One patient, one doctor, one risk of the
surgery. One on many risks are different, as their impacts
are magnified. Imagine if one bad batch of drugs was
contaminated and those drugs were shipped all over the
country—one bad drug batch gets distributed to many
patients or one on many. However, after this subtle change
in its regulations, the agency drew a regulatory, public
health risk line through a one on one medical procedure
risk for the first time. For example, instead of only claiming
authority over mass produced donor cells in a vial, the
agency asserted authority over the re-implantation of the
patient’s own tissue. This change, may sound esoteric at
first, yet by this regulatory sleight of hand, the agency
gave itself the authority to regulate medical practice.
477
This wall between the agency and the practice of medicine
has been defined by many court cases, but the case the
agency brought against an Alabama physician (United
States v. Evers) is illustrative. In this case, Dr. Evers was
prosecuted by the government for using prescription drugs
off label. The judge sided with Dr. Evers and explained
why the FDA should not interfere with the practice of
medicine. For example, the Court noted that a drug’s
package insert is not the most up-to-date information on
the drug’s uses. New uses are often discovered, reported
through medical journals or seminars, and may become
widely used in the medical profession; however, the
drug manufacturer may not have sufficient financial
or other interests to pursue FDA approval for the new
uses. Further, if a doctor must prescribe and treat only
within “federally sanctioned” methods, this would result
in medical stagnation at the best, as physicians await
drug manufacturers’ initiative and FDA approval.3 The
court reasoned, “A free, progressive society has an
enormous stake in recognizing and protecting
this right of the physician.”
The best everyday example of the line FDA has drawn
between one on one medical care risks and one on many public
health risks, is how it currently handles compounded
pharmaceuticals.4 Compounding is a practice whereby a
doctor writes a prescription for a non-FDA approved drug
or formulation to treat one patient. After initially trying
to assert regulatory control over pharmacy compounding
and place it in the same category as drug mass production
(something it is not), the FDA had to back off after it lost
several key lawsuits brought by pharmacists. To clarify
the issue and fill the regulatory gap left by these suits, the
FDA issued a “Compliance Policy Guideline” (CPG) for
compounding pharmacies. In this document, the agency
states that since it doesn’t regulate the practice of medicine
or pharmacy, that it will only attempt to interfere in this
relationship if a pharmacy is compounding drugs in
advance of receiving a prescription, manufacturing on a
commercial scale, or compounding drugs for resellers or
for wholesale use. In essence, the FDA will only intervene
if the pharmacy crosses the line and departs from filing a
single patient’s prescription and starts mass manufacturing
of lots of drugs. However, the agency has not shown the
same digression in its regulatory framework for autologous
cell therapy and this marks a stark change in agency
policy toward physicians and patients. Since A-ASC’s can
only represent a one on one medical care risk because they
are derived from the same patient in which they will be
478
re-implanted, the FDA has now arbitrarily drawn the risk
line through this one on one medical care risk and assigned
it a mass production, public health risk status.
Are body parts drugs? In the same way that the agency
in Evers (above) declared it had authority over how drugs
should be prescribed, it has now declared authority over
what constitutes a drug in the first place. This problem
with this stance is further illustrated by a recent U.S. district
court decision which stated that genes (and by extension
stem cells) are laws of nature and therefore cannot be
patented.5 This patent case creates clear precedence
that the cells or genes in our bodies are not property of
the biotech industry (devices or drugs) to be registered
in the federal patent office, but body parts no different
than a knee or an elbow. Nobody invented autologous
stem cells, nor genes, nor knees or elbows, hence they are
not biotechnology property to be regulated as drugs, but
merely parts to be used in surgery.
A recent publication on stem cell treatment used to help
patients avoid the need for a knee replacement shows this
procedure was safer than the bigger orthopedic surgeries
it helped many patients avoid.6 Even if for other types of
therapies the risk of the stem cells is more than reported
in this study, how does any aspect of an autologous one
on one medical care risk transform that risk into a one on
many batch drug production risk? Stated another way,
can a medical procedure, no matter how unfamiliar,
ever have the same widespread public health impact as
drug production? As an example, we would all agree that
a bad batch of mass produced drugs or devices would
have serious and far reaching public health implications.
A single bad batch of drugs may make many patients ill
in all 50 states (a one on many risk, hence the reason we
have an FDA in the first place). However, no aspect of a
single medical care procedure, can be morphed into this
kind of magnified public health impact. The surgery a
patient chooses to undergo, the IVF fertility treatment,
the testosterone use from a compounded prescription, or
the Prolotherapy are all one on one medical care risks, which
the doctor and patient discuss, and the patient either
chooses to accept or avoid. They are not, by their one on one
nature, national public health epidemics to be regulated
at a federal level. Some one on one medical care risks are
quite serious and some are miniscule; for example certain
types of cardiac surgery have high morbidity or mortality
rates while other types of cardiac procedures such as an
EKG, have negligible risks. The medical care system goes
to great lengths everyday to mitigate these risks. However,
drawing an arbitrary risk line through these procedures
(or others in the future), allows the FDA to divide medical
care into a type that requires federal regulation and a
type that does not. If this is allowed, since all one on one
procedures by their definition are medical practice, the
FDA is by default regulating the practice of medicine.
To illustrate the problems with drawing the risk
line through a medical procedure, consider a recent
publication showing that a routine MRI magnetic field
changes the biologic characteristics of stem cells.7 Before
the publication of this MRI paper, the agency defined a
biologic drug by cell processing that changed the biologic
characteristics of the cells, however, this research confirms
that a routine MRI changes the biologic characteristics
of the cells. Do the stem cells injected into the patient
as body parts become federally regulated drugs after a
routine MRI?
In summary, the assertion by FDA that certain processing
steps for autologous stem cells turns those cells into a
drug production is not supported by any common sense
argument. Furthermore, the agency’s decision to insert
itself into the practice of medicine by drawing a line
through one procedure, sets a dangerous precedent.
Where does this line get moved to in the future? Do certain
compounded drugs get assigned a drug manufacture risk?
Certain fertility procedures? Certain high risk surgeries?
Certain high risk surgeries involving cells? Prolotherapy?
Congress has prohibited the agency from having any
authority over the practice of medicine and as discussed,
there is great societal benefit in keeping it that
way.
If you have an interest in supporting safe A-ASC use, sign
up at http://www.cellmedicinesociety.org/. n
RE F ERE N C ES
1.
Alhadlaq A, et al. Mesenchymal stem cells: isolation and
therapeutics. Stem Cells Dev. 2004;13(4):436–48.
2. Halme DG, et al. FDA regulation of stem-cell-based therapies.
N Engl J Med. 2006;355(16):1730–5.
3. People v. Privitera. California Reporter. 1977;141:64–774.
4. USFDA, Pharmacy Compounding-Compliance Policy Guideline
460.200. Federal Register, Jun 7 2002. 67.
5. Association for Molecular Pathology, et al. vs. United States
Patent and Trademark Office. 2010, United States District Court;
Southern District of New York.
6. Centeno CJ, et al. Safety and complications reporting on the reimplantation of culture-expanded mesenchymal stem cells using
autologous platelet lysate technique. Curr Stem Cell Res Ther. 2010;
5(1):81–93.
7. Schafer R, et al. Functional investigations on human
mesenchymal stem cells exposed to magnetic fields and labeled
with clinically approved iron nanoparticles. BMC Cell Biol. 2010;
11(1):22.
479
FANTASTIC FINDINGS: A RETROSPECTIVE STUDY ON PROLOTHERAPY FOR UNRESOLVED HAND & FINGER PAIN
FA N TA S T I C
F I N D I N G S
A Retrospective Observational Study on
Hackett-Hemwall Dextrose Prolotherapy
for Unresolved Hand and Finger Pain at an
Outpatient Charity Clinic in Rural Illinois
Ross A. Hauser, MD; Nicole M. Baird, CHFP; Joe J. Cukla, LPN
In t r o d u c t i o n
A B STRA C T
Hand and finger pain and stiffness are common problems that can
affect the productivity of those afflicted, especially in regard to their
activities of daily living. Prolotherapy is an injection treatment used
to initiate a healing response in injured connective tissues such as
tendons and ligaments, tissues commonly involved with hand and
finger injuries. A retrospective observational study on Prolotherapy for
hand and finger pain was done at an outpatient charity clinic.
Objective: To investigate the outcomes of patients undergoing
Hackett-Hemwall dextrose Prolotherapy treatment for unresolved
hand and finger pain.
Design: Forty patients, who had been in pain an average of 55
months (4.6 years), were treated quarterly with Hackett-Hemwall
dextrose Prolotherapy. Patients were contacted an average of 18
months following their last Prolotherapy session and asked questions
regarding their levels of pain and stiffness before and after their last
Prolotherapy treatment.
Results: In these 40 patients, 98% had improvements in their pain.
Eighty-two percent had 50% or more pain relief. Dextrose Prolotherapy
caused a statistically significant decline in patients’ pain and stiffness.
Prolotherapy helped all but one patient on pain medications reduce
the amount of medications taken. All 40 patients have recommended
Prolotherapy to someone.
Conclusion: In this retrospective observational study, HackettHemwall dextrose Prolotherapy treatments helped reduce the pain
and stiffness in patients with unresolved hand and finger pain.
Journal of Prolotherapy. 2010;2(4):480-486.
KEYWORDS: carpometacarpal joint, degenerative arthritis, finger pain, hand pain
interphalangeal joint, Prolotherapy.
480
T
he optimal long-term, symptomatic therapy
for chronic hand and finger pain has not been
established. Symptomatic hand pain and stiffness
due to osteoarthritis (OA) effect approximately 6-8%
of the US adult population.1, 2 The prevalence of hand
OA tends to be higher in women and elderly persons.3-5
It may be diagnosed via radiological tests (eg. X-ray),
reported joint symptoms, or a combination, with the most
commonly affected sites being the distal interphalangeal
(DIP) and first carpometacarpal (CMC) joints, followed
by the proximal interphalangeal (PIP) and other CMC
joints.6
While hand osteoarthritis is a common cause of hand
and finger pain and stiffness in older populations, athletic
injuries, overuse, and excessive forces are the causes
typically associated with younger populations.7-9 Hand and
finger pain may effect a person’s activities of daily living
and quality of life enough that they seek medical attention.
The traditional and conservative treatments for
unresolved hand and finger pain can include topical
and oral analgesics, non-steroidal anti-inflammatory
(NSAID) medications, rest, exercise, splints and taping,
corticosteroid injections, and surgery, though each has its
own risks or lack of efficacy.10-15 Two of the more widely
used pain treatments include corticosteroid injection
and NSAID medications, however, these can accelerate
osteoarthritis and further damage the joint.16, 17 In
addition, anti-inflammatories may not provide much
long term pain relief, as seen in a randomized controlled
trial which showed that corticosteroid injections in the
carpometacarpal joint of the thumb for osteoarthritis
were no better than a placebo in reducing pain when
compared at 24 weeks.18 Because of the limited response
of chronic joint pain to traditional therapies, many
people are turning to alternative therapies, including
Prolotherapy, for pain control.19, 20
Dextrose Prolotherapy is becoming more widely used
for symptoms related to pain and joint dysfunction in
both integrative and allopathic medicine. Its primary
application is in pain abatement associated with
tendinopathies and ligament sprains in peripheral
joints.21, 22 It is also being used in the treatment of spine
and joint degenerative arthritis.23, 24 The effectiveness of
Prolotherapy is still being debated, with promising but
mixed results being reported.25-27
George S. Hackett, MD, coined the term Prolotherapy.28
As he described it, “The treatment consists of the
injection of a solution within the relaxed ligament and
tendon which will stimulate the production of new fibrous
tissue and bone cells that will strengthen the “weld” of
fibrous tissue and bone to stabilize the articulation and
permanently eliminate the disability.”29 Dr. Hackett
introduced Prolotherapy to Gustav Hemwall, MD, in
the mid-1950s. Dr. Hemwall continued Dr. Hackett’s
work after his death in 1969 and trained the majority
of the physicians who practiced the technique over the
next 30 years.30 Hence the designation Hackett-Hemwall
dextrose Prolotherapy.
Animal studies have shown that Prolotherapy induces
the production of new collagen by stimulating the
normal inflammatory reaction.31, 32 In addition, animal
experiments using dextrose Prolotherapy injections at the
fibro-osseous junctions have shown measurable increases
in ligament and tendon diameter and strength, as
evidenced upon post-mortem exam.33 K. Dean Reeves,
MD, has conducted two human studies that showed
Prolotherapy has the potential to reverse degenerative
arthritis. One of his studies involving 150 finger joints on
27 patients, indicated that after six series of Prolotherapy
injections a statistically significant improvement in joint
narrowing scores as revealed by X-rays, compared to a
placebo, was seen in the dextrose Prolotherapy group
one year after treatment.34, 35 Prolotherapy is commonly
taught and used for unresolved hand and finger pain.36
However, other than Dr. Reeves’ aforementioned study,
no other analysis regarding Prolotherapy and hand and
finger pain has been done. This observational study was
undertaken to evaluate the effectiveness of HackettHemwall dextrose Prolotherapy in regards to reducing
the subjects’ previously unresolved hand and finger pain
and stiffness and also its effectiveness in reducing or
eliminating their need for pain medications.
Patients and Methods
Framework and setting
In October 1994, the primary author (R.H.) started
a Christian charity medical clinic called Beulah Land
Natural Medicine Clinic in an impoverished area in
southern Illinois. The primary modality of treated
offered was Hackett-Hemwall dextrose Prolotherapy for
pain control. Dextrose was selected as the main ingredient
in the Prolotherapy solution because it is the most
commonly used proliferant in Prolotherapy, is readily
available, inexpensive (compared to other proliferants),
and has a high safety profile.37 The clinic met every three
months until July 2005. All treatments were given free of
charge.
Pat i e n ts
Patients who received Prolotherapy for their unresolved
hand pain in the years 2002 to 2005 were called by
telephone and interviewed by a data collector (D.P.)
who had no prior knowledge of Prolotherapy. General
inclusion criteria were an age of at least 18 years, having
an unresolved hand pain condition that typically responds
to Prolotherapy, and a willingness to undergo at least four
Prolotherapy sessions, unless the pain remitted with less
number of Prolotherapy sessions. Typical hand conditions
that respond to Prolotherapy include hand and/or finger
osteoarthritis, ligament sprains and tendinopathies.
In t e r v e n t i o n s
The Hackett-Hemwall technique of Prolotherapy was
used. Each patient received 10 to 30 injections of a 15%
dextrose, 0.2% lidocaine solution with a total of 15 to
30cc of solution used per hand/finger. Injections were
given into and around the areas on the hand/fingers that
were painful and/or tender with palpation. The typical
spots each injected with 0.5 to 1cc of solution can be
seen in Figures 1a & 1b. Tender areas injected included
the carpometacarpal and metacarpophalangeal joints,
proximal and distal interphalangeal joints, as well as
481
number of physicians seen and medications taken and
whether the response to Prolotherapy continued after the
Prolotherapy sessions stopped.
An a l y s i s
For the analysis, patient percentages of the various
responses were calculated. These responses gathered from
clients before Prolotherapy were then compared with the
responses to the same questions after Prolotherapy.
Pat i e n t c h a r ac t e r i s t i c s
Figure 1a. Typical injection sites for Hackett-Hemwall
Prolotherapy of the hand.
Complete data was obtained on a total of 40 hands
who met the inclusion criteria. Of these, 75% (30) were
female and 25% (10) were male. The average age of the
patients was 60 years-old. Patients reported an average
of four years seven months of pain and saw 2.8 MD’s
before receiving Prolotherapy. The average patient was
taking 1.0 pain medications. The demographics of the
patients can be seen in Table 1.
Figure 1b. Prolotherapy of the thumb, carpometacarpal
joint.
ligament and tendon attachments around the hands and
fingers. (See Figure 2.) As much as the pain would allow,
the patients were asked to cut down or stop other pain
medications they were taking.
Outcomes
D.P. was the sole person obtaining the patient information
during the telephone interviews. The patients were
asked a series of questions about their pain and various
symptoms before starting Prolotherapy. Their response
to Prolotherapy was also detailed with an emphasis on
the effect Prolotherapy had on their hand pain, stiffness
and medication use. Specifically, patients were asked
questions concerning years of pain, pain intensity, stiffness,
482
Figure 2. Ligaments of the hand, thumb and fingers.
Used with permission of Ross A. Hauser, MD and Marion A. Hauser, MS, RD, Beulah
Land Press © 2001, Prolo Your Sports Injuries Away! Curing Sports Injuries and
Enhancing Athletic Performance with Prolotherapy!
Hand patients
n=40
Percentage of female patients
75%
Percentage of male patients
25%
Average age
60
Average years of pain
4.6
Average number of MD’s seen
2.8
1
Average pain medications
No other treatment options available
38%
Surgery only other option
7%
Pain Levels Before & After Prolotherapy
NUMBER OF PATIENTS
Table 1. Patient Characteristics Prior to Prolotherapy.
20
18
16
14
12
10
8
6
4
2
0
1
2
3
4
5
6
7
8
9
10
PAIN LEVEL
BEFORE PR OLO
AFTER PR OLO
T r e at m e n t O u tco m e s
Ninety-eight percent of patients stated their hand
pain was less after Prolotherapy. Over 71% said the
improvements in their pain and stiffness since their last
Prolotherapy session have continued 100%. Eighty-two
percent of patients stated Prolotherapy relieved them of
at least 50% of their pain. (See Figure 4.) In regard to pain
medication usage, before Prolotherapy the average patient
was taking 1.0 pain medications but this decreased to
0.5 medications after Prolotherapy. Before Prolotherapy,
11 patients were taking two or more medications but
this decreased to three people after Prolotherapy. Of
patients not taking pain medications upon completion
of their Prolotherapy series, none reported subsequently
restarting pain medication due to hand or finger pain.
To a simple yes or no question: “Has Prolotherapy changed
your life for the better?” 95% percent of patients treated
answered “Yes.” Seventy-five percent came to receive
their first Prolotherapy session on the recommendation
of a friend. One hundred percent of these patients have
recommended Prolotherapy to someone else.
NUMBER OF PATIENTS
Patients were asked to rate their pain and stiffness levels
on a scale of 1 to 10 with 1 being no pain/stiffness and 10
being severe crippling pain/stiffness. The 40 hands had
an average starting pain and stiffness level of 5.9 and 5.6
respectively. Their ending pain and stiffness levels were
2.6 and 2.7 respectively. Thirty-five percent had a starting
pain level of 8 or greater, while only 10% had a starting
pain level of two or less, whereas after Prolotherapy none
had a pain level of 8 or greater while 65% had a pain
level of two or less. (See Figure 3.)
Stiffness Levels Before & After Prolotherapy
20
18
16
14
12
10
8
6
4
2
0
1
2
3
4
5
6
7
8
9
10
STIFFNESS LEVEL
BEFORE PR OLO
AFTER PR OLO
Figure 3. Pain levels and stiffness levels before and after
receiving Hackett-Hemwall Prolotherapy in 40 patients with
unresolved hand pain.
PERCENTAGE OF PATIENTS
Patients received an average of 4.5 Prolotherapy treatments
per hand/finger. The average time of follow-up after their
last Prolotherapy session was eighteen months.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
2
3
4
5
6
7
8
9
10
STARTING LEVEL OF PAIN
No patients reported a starting pain level of 4
REPOR TED 50% OR GREATER IMPR OVEMENT IN PA I N
Figure 4. Percentage of people who reported 50% or greater
pain relief.
S t a t i s t i c a l An a l y s i s
A matched sample paired t-test was used to calculate
the difference in responses between the before and after
measures for pain and stiffness for the 40 patients. Using
483
the paired t-test, all p values for pain and stiffness for
the two groups reached statistical significance at the
p < 0.000001 level or less. (See Table 2.)
Table 2. Summary of results of Hackett-Hemwall dextrose
Prolotherapy hand study.
Total number of patients
40
Average months of pain
55
Average pain level before Prolotherapy
5.9
Average pain level after Prolotherapy
2.6
15.534
Paired t ratio
P value
p < .000001
Average stiffness level before Prolotherapy
5.6
Average stiffness level after Prolotherapy
2.7
13.477
Paired t ratio
P value
p < .000001
Greater than 50% pain relief
82%
Discussion
P r i nc i p l e F i n d i n g s
The results of this retrospective, uncontrolled observational
study show that Prolotherapy helps decrease pain and
stiffness in patients with previously unresolved hand/
finger pain. The Hackett-Hemwall dextrose Prolotherapy
gave 82% of them 50% or more pain relief. Medication
use was also lessened after Prolotherapy.
S t r e n g t h s a n d L i m i tat i o n s
Our study cannot be compared to a clinical trial in
which an intervention is investigated under controlled
conditions. Instead, it is intended to document the
response of patients with unresolved hand and finger
pain and stiffness to Prolotherapy at a charity medical
clinic.
The quality of the cases is a strength in this study. The
average reported length of pain was four years, seven
months. The average patient had seen 2.8 MD’s prior to
receiving Prolotherapy. Plainly, these represented chronic
unresponsive hand and finger pain cases. The only therapy
provided for the patients at the clinic was Prolotherapy,
which was administered every three months. In private
practice, Hackett-Hemwall dextrose Prolotherapy is
typically given every four to six weeks. The treating
484
physician may also assess and recommend additional
measures to improve a patient’s overall health, such as
diet/nutritional intervention, exercise, work/ergonomic
changes, changes in medications, and other medical
care. Patients are often weaned off anti-inflammatory
and opiod medications prior to, or at the start of the
treatment series. Since this was a free medical clinic
where no additional services were able to be rendered,
the results of this study are likely an indication of the
lowest level of success with Hackett-Hemwall dextrose
Prolotherapy. This makes the results more remarkable.
Decrease in pain medication was also documented.
A shortcoming of the study is the subjective nature of the
evaluated parameters, including pain and stiffness levels.
However, the decrease in medication was documented
and objective. An additional limitation of our study is
the lack of radiologic (X-ray or MRI) correlation for
diagnosis and response to treatment. Further, there was
a lack of physical examination documentation to group
the patients into various diagnostic categories.
In t e r p r e t a t i o n o f F i n d i n g s
Hackett-Hemwall dextrose Prolotherapy was shown to
be very effective in reducing pain and stiffness in this
group of patients with unresolved hand and finger pain.
Prolotherapy is the injection of a solution for the purpose
of tightening and strengthening weak tendons, ligaments
or joint capsules. Prolotherapy works by stimulating the
body to repair these soft tissue structures. It starts and
accelerates the inflammatory healing cascade by which
fibroblasts proliferate.38 Fibroblasts are the cells through
which collagen is made and by which ligaments, cartilage,
and tendons repair.39 Prolotherapy has been shown in
one double-blinded animal study in a six-week period to
increase ligament mass by 44%, ligament thickness by
27% and the ligament-bone junction strength by 28%.40
In other studies on Prolotherapy, biopsies performed
after the completion of Prolotherapy showed statistically
significant increases in tendon and ligament collagen
fiber and diameter of 60%.41, 42 This is significant since
ligament injury has been implicated as the cause of
degenerative osteoarthritis in joints.43 When a ligament is
damaged, stretched, or torn, it can cause joint instability.
The joint instability due to the ligament injury/laxity
causes uneven stress distribution, which leads to joint
degeneration and resulting pain and can help identify
those who are predisposed to the development of OA.44, 45
Although the joints in the hands and fingers are non-
weight bearing, they are very mobile and subject to
cartilage breakdown from overuse or excessive force.46
As Fleming et al. explain in their article on ligament
injuries and osteoarthritis, “The ligament-injured joint
is at high risk for osteoarthritis. Current conservative
(e.g. rehabilitation) and surgical (e.g. reconstruction)
treatment options appear not to reduce osteoarthritis
following ligament injury. Mechanical instability is the
likely initiator of osteoarthritis in the ligament-injured
patient.”47 The stability of the carpometacarpal joints
of the fingers and thumbs depends on the integrity of
the articular surfaces of the bones and on the health of
the ligaments and muscles attached to them.48 Without
addressing the ligament laxity, sequelae from ligament
injury can include chronic pain, chronically unstable or
deformed joints.49
Current conservative and traditional chronic pain
treatments, such as for hand pain, do not work to repair
ligament laxity, but generally do temporarily block the
pain.50 Because Prolotherapy corrects underlying ligament
physiology and biomechanics, it has the potential not
only stop the pain but also the degenerative process.51
In his study on finger pain, Dr. K. Dean Reeves and
associates showed that six series of injections of dextrose
Prolotherapy not only caused improvements in pain
and range of motion of the fingers, but also statistically
significant improvement in joint narrowing score on Xrays compared to placebo.52 This current study adds to
the scientific literature that Prolotherapy helps decrease
pain, stiffness, and medication usage for patients suffering
with chronic hand and finger pain. More research is
needed to see if indeed Prolotherapy can actually reverse
the arthritic process.
C o ncl u s i o n s
The Hackett-Hemwall technique of dextrose Prolotherapy
used on patients who had an average duration of four
years, seven months of unresolved hand and finger pain
and who were 18 months out from their last Prolotherapy
session was shown to cause a statistically significant decline
in their pain and stiffness. Since this small retrospective
study showed promising results, further studies under
more controlled circumstances and with larger patient
populations should be done. n
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486
REMARKABLE RECOVERIES: PROLOTHERAPY FOR 20 YEAR OLD ANKLE INJURY
R E MA R K A B L E
R E CO V E R I E S
Prolotherapy for 20
Year Old Ankle Injury
Clive Sinoff, MD
Mr. AS was a 58 year-old man when he consulted me
in July 2005 for a work-related injury of his ankles. The
injury occurred some 22 years earlier when he fell off a
roof, landing on his feet and causing substantial damage
to his ankles and feet. He had physical therapy for seven
years following the accident, and eventually underwent
arthodesis of both ankles and right foot. This helped
his stability, but he continued to have significant pain.
Therapeutic ultrasound, a TENS unit, and hot foot soaks
only provided transient, mild relief.
Figure 1. Medial view of the right ankle and dorsum of the
foot with tender points marked at his first visit in July 2005.
At the time of his initial consultation AS reported pain
between 5 and 7 out of 10 (with 10 being extreme). Using
a cane, he was able to walk with difficulty, but was no
longer able to participate in physical leisure activities or
go shopping. In addition, he had developed some shoulder
discomfort which he attributed to the use of a cane.
Examination showed a stilted gait with a moderate limp
on the right. Ankle movement was 0 to 40 degrees on the
left, and 5 to 30 degrees on the right. There was minimal
inversion or eversion on each side and minimal movement
of the toes. There was rigidity of the hind and mid-foot
bilaterally. He had moderate tenderness around the
malleoli, anteriorly and on the dorsum and arches of each
foot. (See Figures 1 & 2.) X-rays of the right foot showed
irregular sclerosis and lysis of the tarsal bones with various
areas of joint fusion with irregularity and some narrowing
of multiple joints. X-rays of the left foot revealed fusion
of most of the hind foot and mid-foot joints, including the
tarso-metatarsal joints. (See Figures 3 & 4.)
T r e at m e n t
To control pain, the patient initially required significant
doses of narcotics. Prolotherapy was started in May
2006. On the right ankle he had two treatments, and then
refused more treatment, because of pain, until June 2007.
At that time, he had another three treatments at monthly
intervals. Later, in April 2008, he received an injection,
and a final focal injection in August 2008 (a total of seven
Figure 2. Lateral view of the right ankle and dorsum of the
foot with tender points marked in July 2005.
sessions over two years). He had only two injections in the
left ankle, one in November 2007 and the final in May
2008. The solution consisted of 3.5ml P25G (phenol
2.5%, glucose 25% and glycerin 25%), 3.5ml of Sarapin
(an extract from Sarracenia purpurea (pitcher plant) in
alkaline solution – High Chemical Company, Levittown,
PA), and 3 ml of 2% lidocaine with epinephrine per 10ml.
Injections were given into all tender ligaments and, on
two or three occasions, into the right tibio-talar joint from
an anterior approach. The early sessions used between 6
and 10ml of solution per foot. But at the end, when the
tender areas were much more focal, only 1-4ml was used
per foot.
487
REMARKABLE RECOVERIES: PROLOTHERAPY FOR 20 YEAR OLD ANKLE INJURY
Figure 3. X-ray of tarsal bones of the right foot. Extensive
lytic and sclerotic changes are noted in the tarsal bones with
extensive joint narrowing.
AS also received 10 low level laser treatments to the
right ankle, some during the time he had suspended
Prolotherapy, and some a day or two after injection to
reduce pain.
Outcome
Although there was significant injection and post injection
pain for several days after each injection, AS began to
notice a progressive reduction in pain. The narcotics were
steadily reduced and by July 2009, he reported minimal
pain and no longer needed analgesics. He had a fairly
normal gait without a cane, and no tenderness. AS
described his ankles and feet as the “best ever.”
Discussion
Prolotherapy of the ankles and feet resulted in substantial
improvement in pain and function after more than 20
years of severe pain and disability. Arthrodesis had
reduced mobility but had failed to improve his pain or
function. In retrospect, I would not use the same intensive
solution, since P25G, especially in the concentration
administered, was significantly painful, especially in the
early sessions. I would recommend using alternative,
less painful solutions such as dextrose, Sarapin (a plant
alkaloid) and/or sodium morrhuate, but without P25G,
unless healing was unsatisfactory. This case illustrates the
power of Prolotherapy. One can only imagine how much
suffering could have been avoided and how much function
488
Figure 4. X-ray of tarsal bones of the left foot. Extensive
arthritis and arthrodesis is demonstrated.
could have been preserved if AS had sought Prolotherapy
soon after his injury.
This case also illustrates the power of clinical examination,
since no further X-ray or MRI scan was performed. The
total cost of all these injections is about the same as a
single MRI scan.
Low level or “cold” laser therapy is also a useful modality
with pain reducing and healing properties. I have seen
no studies comparing laser therapy and Prolotherapy, nor
the combined use. Although some authors have claimed
laser therapy to be anti-inflammatory, the described
effects (increased blood flow, increased ATP, release of
cytokines and infiltration of inflammatory cells) suggest
that the mechanism of action is by low level inflammation
and, consequently, this may prove a useful modality to
combine with Prolotherapy.1-3 n
RE F ERE N C ES
1. Marovino T. Cold lasers in pain management. Practical Pain Mgt.
Sep/Oct 2004.
2. Bjordal JM, et al. Low-level laser therapy in acute pain: A
systematic review of possible mechanisms of action and clinical
effects in randomized placebo-controlled trials. Photomed Laser
Surg. 2006;24:158–168.
3. Fulop AM, et al. A meta-analysis of the efficacy of phototherapy
in tissue repair. Photomed Laser Surg. 2009;27:695–702.
WONDER WHY? THE USE OF HORMONES FOR CHRONIC PAIN
W O N D E R W H Y ?
The Use of Hormones
for Chronic Pain
Forest Tennant, MD, DrPH
A B STRA C T
Anabolic hormone therapies and Prolotherapy are innovative
approaches to treating chronic pain. They are complimentary and
can be simultaneously administered.
KEYWORDS: adrenal, corticoid hormones, DHEA, gonadal, HCG, HGH, human chorionic
gonadotropin, human growth hormone, iontophoresis, pituitary, pregnenolone,
testosterone.
I N TRODU C TIO N
H
ormone administration is progressively
becoming more and more important in
treatment of chronic pain.1, 2 Some specific
hormonal therapies offer the patient real opportunities to
greatly reduce and even eliminate pain and suffering.2, 3
They can be simultaneously administered to patients
who participate in Prolotherapy or take opioids which is
the standard symptomatic medication now
used by about 10 million Americans. In some
cases hormone treatments are necessary
to save a life or prevent incapacitation and
suffering.1 This report reviews the hormone
treatment and replacement needs that may
exist in chronic pain patients. Many of these
treatments can be simply and inexpensively
incorporated as adjunctive measures to a
practitioner’s current regimens.
system receptors.2, 3 The claims and
Hyperalgesia - an
concerns about “hyperalgesia”
increased sensitivity
are probably related to hormonal
to pain.
deficiencies that could be easily
corrected. The androgenic compounds testosterone,
androstenedione, and dehydroepiandrosterone (DHEA)
promote tissue growth and help regulate opioid receptors.5-7
Pregnenolone, the precursor of all adrenal and gonadal
steroids, is critical for pain control mechanisms, but poorly
recognized as essential to pain control. (See Figure 1.) It is
ubiquitous in brain and nervous tissue and interacts with
gamma-amino-butyric acid and N-methl-D-aspartate
(NMDA) receptors to help regulate neurogenic processes.8-12
The tissue building hormones, human growth hormone
(HGH) and human chorionic gonadotropin (HCG) are
emerging as true breakthroughs in some pain patients.13-15
In particular, HCG is a relatively inexpensive compound
that appears to permanently lower pain intensity in
some pain patients.1 Besides hormone administration,
the understanding of pain’s affects on the endocrine
system, particularly the pituitary-adrenal-gonadal axis,
is critical to help guide pain management. Excess pain
causes catecholamine release resulting in tachycardia and
hypertension. Pituitary, adrenal, or gonadal hypofunction
may occur with unabated, uncontrolled, and undertreated
pain, requiring a need for hormone replacement.16
The Steroidogenic Pathway
W HY HORMO N ES ?
Proper pain treatment may require specific
hormone administration. Adrenal corticoid
hormones are long known to resolve
inflammation and allow healing of injured
and inflamed tissue sites. Proper blood levels
of adrenal corticoids are also necessary to
effectively treat patients with opioids and other
pharmacologic agents that must cross the
blood brain barrier and affect central nervous
Figure 1. The steriodogenic pathway is the major metabolic pathway in the
adrenals and gonads. It is incorrect to state some hormones are “male or female.”
489
C ORTI C OID HORMO N ES
Intralesional and oral adrenal corticoids have been a
mainstay in pain treatment for about six decades. Over the
years there has been steady improvement in formulation
and potency of corticoids. There is no effective substitute
for oral corticoids in such painful, inflammatory conditions
as acute flares of rheumatoid arthritis. Injections of
a corticoid into a “trigger point,” painful joint, or
epidural space are routine measures in pain treatment.
The new development in corticoid hormone treatment
is the administration of high potency adrenal corticoids
under an electromagnetic instrument. This technique
is generically termed iontophoresis which means to
“transport an ion through tissue.” While iontophoresis
is an old technique, it has never been widely accepted.
Old methods tried to administer metals, salicylates, or
weak corticoids by ineffective electric current instruments
that were cumbersome, utilized low electric intensity
and frequency, and applied medication under small skin
contact pads.
HIGH POTE N C Y C ORTI C OID HORMO N ES U N DER
E L E C TROMAG N ETI C I N STRUME N TS
There are many electromagnetic instruments that can
effectively drive high potency adrenal corticoid hormones
into a pain site. Known generally as “iontophoresis”, any
of the electric current devices on the market can be used
if it has skin contact pads capable of putting hormone
cream on the skin under them. Infrared, laser, ultrasound,
and radiofrequency instruments deliver electromagnetic
energy in waves of various lengths, and these waves,
like an electric current, will cause hormones to diffuse
through tissue from the skin surface into a pain site. There
are inexpensive, ultrasound and infrared devices that
are very suitable for at-home use by patients. Some inoffice instruments are extremely effective iontophoretic
devices in that they deliver a pulsed electric current or
electromagnetic energy, and have skin contact pads or
plates that are 2 to 8 inches on a side. If an electromagnetic
device is not available, high potency corticoid hormones
can usually reach and enter a pain site from the skin
surface if heat, massage, or a vibrator is used to promote
tissue diffusion.
The author has systematically attempted to administer
through the skin a number of androgenic and
corticoid hormones at various dosages by a variety of
electromagnetic instruments. These trials have led to the
490
Pulsed radiofrequency used as iontophoretic instrument to
drive hormones into pain site.
identification of these two adrenal corticoid analogues:
Prednisone and Medroxyprogesterone, 40mg in one
ounce of a base cream. (See Table 1.)
Iontophoretic delivery of high potency
hormones
Recommended Hormones
• Prednisone
• Medroxyprogesterone
Dosage
• 40mg in one ounce of soluble
base cream
Delivery Instruments
• Electric Current Devices
• Ultrasound
• Infrared
• Radiofrequency
• Laser
Table 1. Iontophoretic delivery of high potency hormones.
The requirements for a cream base are simply that the
cream must dissolve crushed hormone tablets and then
dissolve the cream mixture through the skin over a pain
site. Treatment sessions with a high potency corticoid
under a electromagnetic device range from 10 to 30
minutes. Not enough corticoid enters the blood by this
technique to produce hyperadrenalism symptoms, but
caution is given to avoid this theoretical complication by
avoiding daily use.
THE C RITI C A L K N O W L EDGE A B OUT
HORMO N ES A N D PAI N
Every pain practitioner must have a basic understanding
of how uncontrolled pain affects the pituitary-adrenal-
gonadal axis. (See Figure 2.) If pain is severe and goes
uncontrolled for even a few days or weeks, profound
and deleterious hormonal changes occur.4, 16, 17 It is the
disturbance of this axis that fundamentally incapacitates
a pain patient, thrusts them into a vegetative, nonfunctional, bed or house bound state, and produces
immense suffering, and shortened life.
How pain affects the pituitary-adrenal-gonadal axis
UNCONTROLLED PAIN
PITUITARY & ADRENAL
HYPOFUNCTION
LOW SERUM CORTISOL
PREGNENOLONE
TESTOSTERONE
EXCESS ELECTRICITY
OVERSTIMULATION OF PITUITARY
EXCESS RELEASE OF ACTH
CONTINUOUS UNCONTROLLED PAIN
TACHYCARDIA
HYPERTENSION
HIGH SERUM CORTISOL
ADRENAL
ADRENAL
RELEASE OF EXCESS ADRENALINE &
CORTISOL
Figure 2. How pain affects the pituitary-adrenal-gonadal axis.
Chronic, severe, uncontrolled pain will initially overstimulate the axis to cause high serum levels of corticoids
(e.g. cortisol, pregnenolone), and catecholamines (e.g.
adrenaline, noradrenaline). If over-stimulation continues,
pituitary, adrenal and gonadal exhaustion and hypofunction will occur resulting in low serum corticoids,
catecholamines, testosterone, and other compounds in
the steroidogenic pathway.4, 16, 17
B L OOD S C REE N I N G F OR
PITUITARY - ADRE N A L - GO N ADA L F U N C TIO N
Not every pain patient needs to be tested for serum
levels of pituitary-adrenal-gonadal hormones. Only
those patients that claim constant, chronic, persistent,
or intractable pain for a few weeks or more and require
regular opioid medication are candidates for hormone
screening. (See Table 2.) I recommend a simple, short
screening panel: cortisol, pregnenolone, and testosterone.
This screening panel can be done by any licensed clinical
laboratory on an 8:00am, fasting, whole blood specimen.
Recommended screening panel for
pituitary-adrenal-gonadal function
• Pregnenolone • Cortisol • Testosterone
Table 2. Recommended screening panel for pituitaryadrenal-gonadal function.
These three serum hormone levels give a pain practitioner
enough information to know if pituitary-adrenal-gonadal
overstimulation or hypofunction is present.
I recommend a total serum testosterone rather than any
free or sub-total test. Testosterone is critical for pain
control, libido, energy, motivation, and mental function.
(See Table 3.) Although some of testosterone’s functions
(e.g. libido) may rely on the non-protein bound, serum
fraction, testosterone has other functions critical to
pain management that may require the protein-bound
component.5-7
Recommended screening panel for
pituitary-adrenal-gonadal function
1. Lack of energy
2. Loss of libido
3. Depression
4. Poor healing
5. Diminished opioid affects
6. Loss of motivation
7. Apathy
Table 3. Symptoms of testosterone deficiency in males and
females.
MA N AGEME N T O F L O W SERUM C ORTISO L L EVE L S
Some severe chronic pain patients may demonstrate
serum cortisol levels that range 2 to 3 times above the
upper normal level of about 20-25ug/dl.18 A high
cortisol level simply means that pain is uncontrolled and
aggressive opioid administration will need to be instituted.
If the patient has pituitary or adrenal hypofunction,
serum cortisol levels will be under 5ug/dl. The key to
normalizing high or low serum cortisol levels is opioid
management which stabilizes the pituitary-adrenalgonadal axis. Opioid dosage should be raised from any
current daily dosage or initiated if the patient is not taking
opioids. Normalization of serum cortisol will almost
always take place within 4 to 6 weeks.17
491
Cortisol replacement is seldom necessary. I recommend
plain hydrocortisone or prednisone administration for 2
to 4 weeks if the serum cortisol is below 2ug/dl. This is
a precautionary measure done as a potential, life-saving
procedure as serum cortisol levels this low pose grave
danger to the patient. Levels this low do not provide
immunologic protection against infections or maintain
adequate blood pressure or glucose levels.
MA N AGEME N T O F L O W SERUM PREG N E N O L O N E L EVE L S
Few physicians are even aware of pregnenolone and its
numerous biologic roles.8-12 Pregnenolone is the primary
precursor of all hormones produced in the steroidogenic
pathway. A low serum pregnenolone represents a
potential, problematic situation in that there may not be
enough substrate for the steriodogenic pathway.
Pregnenolone is, itself, a critical hormone. It is probably
the most plentiful hormone in human brain. Normal levels
are necessary for gamma amino butyric acid (GABA)
neurotransmission.8-10 It also helps stabilize the NMDA
receptor.11, 12 If serum concentrations are below 20ng/dl,
I recommend a daily, oral dosage of 100 to 200mg. At
this time, pregnenolone, due to its high safety and nonabuse profile, is available over-the-counter without
prescription.
MA N AGEME N T O F L O W SERUM TESTOSTERO N E
Commercial laboratories now report normal levels for males
and females making it easy for the practitioner to make a
diagnosis of hypotestosteronemia. Patients with low serum
testosterone usually voice a number of symptoms which
are outlined in Table Three. Low testosterone in females
produces significant symptomatology just as in males.18, 19
If the serum testosterone is low, several testosterone
products are available including injectable, patch, buccal
tablet, and gel formulations. I recommend a female
starting dose of about 20 to 25% of the male dose.18 In
addition to plain testosterone, the use of progesterone,
androstenedione or DHEA may assist or enhance
testosterone activity.20-22
THE PRO B L EM O F OPIOID SUPRESSIO N O F HORMO N ES
When pain is severe enough to require regular, treatment
with opioids, the practitioner must be aware that opioids
may suppress one or more hormones of the pituitaryadrenal-gonadal axis. It is clear that hormone suppression
492
is a major opioid complication.23-26 Opioids are probably
more likely to suppress hormone production if an opioid
is constantly in the blood rather than present on an
intermittent basis.
The hormone most commonly suppressed by opioids
appears to be testosterone in males and females.18, 24 The
suppression is primarily due to suppression of follicle
stimulation hormone (FSH) and luteinizing hormone
(LH) in the pituitary. Intrathecal opioids do not enter
the general blood circulation to reach the adrenals or
gonads, but they suppress testosterone production in the
pituitary.26
It is known that opioids may, in a few patients, suppress
ACTH or directly impact adrenal metabolism.23, 25 In
these cases it may be necessary to replace pregnenolone,
cortisol, and possibly other compounds. One common
suppression may be aldosterone which is a diuresis and
fluid retention hormone. This is apparently the cause of
opioid edema.23 It can usually be relieved by a corticoid
injection since cortisone converts to aldosterone.
The author highly recommends that pain patients who
require opioids take pregnenolone and DHEA as dietary
supplements. Although no published data is available,
pregnenolone and DHEA are very active hormones,
as well as the metabolic precursors of all corticoids,
androgens, and estrogens. Dosage rages from 50 to 100mg
a day. These compounds are non-prescription and can be
inexpensively obtained over-the-counter. It is the author’s
observation that supplementation with these hormones
prevents hyperalgesia, helps retain opioid potency, and
aids adrenal and gonadal functions.20-22
THE I N TRIGUE O F
HUMA N C HORIO N I C GO N ADOTROPI N ( H C G )
A most intriguing discovery relative to pain treatment and
hormones in recent times is that HCG, in some patients,
provides short-term and/or long-term pain reduction.27 Its
cousin, human growth hormone (HGH) may also reduce
pain when given over several weeks. This is understandable
since HGH is well known to produce bone, cartilage, and
muscle growth.13-15 Just how effective HGH may be in pain
treatment is unclear, since the hormone is so expensive
that there is very limited clinical experience with it. To
date, its use in the author’s hands has been inconsistent.
On the other hand HCG elicits a positive pain reduction
response in about 75% of pain patients.27
Human chorionic gonadotropin (HCG) derives its name
from the fact that it was originally believed to be only
produced in the placenta during pregnancy. Indeed, the
common at-home pregnancy test is based on the finding
of elevated HCG levels in female urine. It is now known,
however, that it is also produced in the pituitary of males
and females of all ages.28, 29 Chemically, it is made up
of two amino acid sub-units. One of the units contains
amino acid sequences that are essentially identical to
FSH (follicle stimulating hormone), LH (luterinizing
hormone), and TSH (thyroid stimulating hormone).28, 29
Consequently, HCG, when given, stimulates the testes,
ovary, thyroid, and adrenal to elevate serum levels of
testosterone, thyroid, estradiol, progesterone and related
compounds.28, 29 It is this pro-hormone stimulation that
undoubtedly gives HCG a role in pain treatment. Severe
chronic pain patients who must take opioids develop
multiple hormonal deficiencies that may be ameliorated
by HCG’s hormone-stimulating properties.
The other sub-unit of HCG has some biologic activities
that may also assist pain patients. It increases cyclic
adenosine monophosphate (cAMP) and nitric oxide
(NO). cAMP is known to be a critical element in tissue
production and growth while NO has important
intracellular and intercellular regulatory functions. NO is
known to increase blood flow. HCG receptors are found
throughout the body, so this finding validates that HCG
has a much greater biologic role than simply maintaining
a placenta in pregnancy.
Clinicians have observed that pain patients during
pregnancy require fewer opioids. Apparently, the rise of
HCG in pregnancy is responsible. Indeed, after a single
injection of HCG, some pain patients report pain relief
within hours. Others report significant and progressive
pain reduction during a course of HCG treatment which
is 2 to 3 injections a week for 6 to 8 weeks. Each dosage is
.5 to 1.0ml of injectable HCG (10,000 units in 10ml).
Case Reports: The Use of
Hormones in Chronic Pain
Case #1
A 44 year-old male suffered three lumbar, herniated discs
which required fusion and placement of metal rods. He
was started on multiple opioids but did poorly and was
referred for medical evaluation and management. His
serum testosterone was 154mg/dl (Normal 241-827mg/
dl). Within days of starting a testosterone gel of 50mg
a day, his pain dramatically decreased and his energy,
motivation, and libido increased. An addition of oral
medroxyprogesterone 10mg, twice a day considerably
improved his libido and physical abilities. With testosterone
and a precursor, progesterone, he has gone from a bed/
house-bound state to one in which he is active each day
and can work part-time.
Case #2
A 68 year-old female has multiple cervical and lumbar
fusions. She was treated with multiple spinal corticosteroid
interventions including epidural and facet injections. She
was referred in a bed-bound state despite taking a daily,
extended release oxycodone dosage of 160mg. Admission
serum cortisol was 27.2mcg/dl (Normal 4.0-22.0mcg/dl)
indicating overstimulation of the pituitary-adrenal axis.
Her oxycodone extended release dosage was increased to
700 to 800mg a day, and she was given a trial of HCG,
0.5ml twice a week. These injections were associated with
a decrease in pain and oxycodone dosage. This dosage
was later increased to 1.0ml three times a week, and she
believes she is incapacitated if she misses HCG injections,
and she credits it for control of her pain and ability to
function. The patient now has serum cortisol levels under
20mcg/dl and is no longer bed-bound. She attends to all
her activities of daily living and is able to drive and visit
grand children.
Case #3
A 58 year-old female registered nurse was diagnosed with
degenerative cervical spine disease with bulging discs.
She subsequently developed fibromyalgia with temporal
mandibular joint (TMJ) disease, migraine headaches,
and radiating pain into the legs causing her physician
to refer her for evaluation and management. Her opioid
medication consisted of hydrocodone, 40mg a day. To
better control her pain, her opioid dosage was increased
by adding hydromorphone, 16mg a day. She was started
on HCG, 1.0ml twice weekly. Within 4 hours after
starting HCG she felt pain relief and increased energy,
motivation, and libido. After 4 weeks of HCG, all TMJ
and migraine headaches stopped. She has continued on
HCG for over 6 months, and she reports that her pain
has progressively and permanently decreased and that
her physical activities are increasing.
493
SUMMARY
Corticoid hormones for interlesional use and oral
administration have been and remain a mainstay in
pain treatment. High potency adrenal corticoids such as
topical prednisone and medroxyprogesterone in a dosage
of 40mg per ounce of base cream can be administered
iontophoretically under a number of electromagnetic
devices. Patients can use inexpensive infrared, ultrasound, or
vibrators to self-treat at home with high potency corticoids.
Severe, uncontrolled pain may overstimulate the pituitaryadrenal-gonadal axis to release excess corticoids and
catecholamines which increase heart rate and blood pressure.
If severe pain continues unabated, the pituitary and adrenal
may exhaust, deplete hormonal reserves, and demonstrate
low serum levels of cortisol, testosterone, or pregnenolone.
Hormone replacement may be necessary. Opioid treatment
may suppress some hormones, particularly testosterone, in
females as well as males. Testosterone is required for libido,
energy and opioid activity, and it has to be replaced should
serum testing show low levels. HCG is a most intriguing
hormone that apparently reduces pain by multiple,
physiologic mechanisms. It is quite void of side-effects and is
worthy of therapeutic trials to treat pain. Pregnenolone and
DHEA are themselves active as well as precursor compounds
in the steroidogenic pathway. They are safe, inexpensive and
classified as dietary supplements, and sold over-the-counter.
They are recommended as preventive measures in chronic
pain patients who take opioids. n
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intrathecal morphine. Clin J Pain. 2000; 16:251-254.
27. Tennant F. Human chorionic gonadotropin in pain treatment.
Prac Pain Manag. 2009; 9:25–27.
28. Odell WD, et al. Pulsatile secretion of human chorionic
gonadotropin in normal adults. N Engl J Med. 1987;817;1688–92.
29. Matura S, et al. Physiochemical and immunological
characterization of an HCG-like substance from human pituitary
glands. Nature. 1980;286:740–41.
WONDER WHY? THE USE OF TESTOSTERONE & GROWTH HORMONE FOR PROLOTHERAPY
W O N D E R W H Y ?
The Use of Testosterone
and Growth Hormone
for Prolotherapy
Thomas Ravin, MD
A B STRA C T
Most physicians practicing musculoskeletal medicine appreciate
the importance of testosterone and growth hormone in health and
wellness. The significance of these hormones in the earliest phases
of wound healing and tissue repair recently has been elucidated.
Testosterone and growth hormone play key roles in regulating cell
functions, from stimulating protein production (a slow process called
genomic effects) to altering cell functions in time periods ranging from
a second or two to a couple of minutes (called non-genomic effects).
The non-genomic effects play a role in Prolotherapy treatments by
releasing signaling molecules, altering cell wall flexibility, modifying
pain perception, adjusting blood flow at the wound site and even
suppressing wound healing. The non-genomic effects of testosterone
can be used clinically to benefit the patient and the Prolotherapist.
This article includes several anecdotes illustrating how testosterone
and growth hormone injections have worked in a clinical setting.
They demonstrate the advantages of using testosterone and growth
hormone to enhance Prolotherapy treatments.
KEYWORDS: HGH, human growth hormone, Prolotherapy, testosterone.
C l i n i c a l B a ck g r o u n d
T
he importance of testosterone in wound healing
and tissue repair was first brought to my
attention by Allan Banks, PhD. Our discussions
of Prolotherapy and how it works led to our considering
the possibility that testosterone might be beneficial in
the process of wound healing. The significance of this
hormone to Prolotherapy never left my mind but when
and where to use it eluded me for many years. Finally,
after personally receiving many painful injections in my
wrists, shoulders, feet and hips, I began to look for a less
painful alternative.
In the late 2000s, while trying to decide how to treat some
senior patients in their late 80’s and early 90’s, I decided to
try small doses of testosterone and growth hormone, first
on my shoulders and later on their shoulders. The pain
was considerably less and the results were clinically as
good as those achieved when using 50% glucose, glycerin
phenol (P2G). By late 2007, I was using testosterone and
growth hormone on almost all shoulders and hips with
great results and with less pain. Dr. Marc Dubick also
began using the combination of testosterone and hGH in
2009 with equally good results. He currently is doing the
injections under an institutional review board (IRB). See
Dr. Marc Dubick’s article in this issue.
The way Prolotherapy works is probably best explained
by the theories of wound healing and tissue repair
(inflammation). The book that gathered together the
operative ideas in this theory was edited by RAF Clark in
the late 1980s.1 One chapter in that book was written by
Allan Banks. This book is still considered to be important
reading in the wound healing research world and is still
referred to on a regular basis. The last thirty-five years
have seen increasingly detailed explanations of this
process but no alterations in its basic outline or features.
If this is true then the question is: Where and how do
testosterone and growth hormone work in stimulating or
aiding wound healing and tissue repair?
S o m e B a s i c H o r m o n e C o nc e p t s :
Signaling Molecules and their Receptors
There are many different kinds of molecules that transmit
information between the cells of complex multicellular
organisms. For now, this discussion is limited to hormones
and their effects. Hormone molecules are also known
as ligands, which means that they are able to bind to
other molecules and form new ones that serve biological
purposes. In a narrower sense they are signal triggering
molecules that bind to a particular site on a target cell
known as a receptor protein. Hormones are secreted by
specialized cells and are then carried by the circulatory
system to their target organs. They can be produced at the
cellular level to affect adjacent cells (panacrine secretion)
or by a cell that acts on that cell (autocrine secretion).
To better appreciate how testosterone works it is helpful
to understand that there are two types of hormones:
steroid and protein. Testosterone is a steroid hormone and
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hGH is a protein hormone. They both share many features
such as cell wall receptors. The Androgen Receptor (AR)
binds testosterone and testosterone-like molecules called
androgens; the Growth Hormone Receptor (GHR)
binds growth hormone. These hormones, by way of
their receptors, stimulate the transcription of genes into
proteins using similar pathways in the cell called “second
messenger pathways.” The newly produced proteins
control cell function, affect organ systems and affect body
functions. These are called genomic effects because they
require the decoding of the gene and then the making of
the protein. It can take from half an hour to as long as a
day for the proteins they stimulate to change the way the
target cells react. (See Figure 1.)
Testosterone
The particular focus of this article is on the non-genomic
effects of testosterone injected into a new sterile wound
site and how testosterone might impact wound healing
in the first few minutes of the inflammatory process.
These are all non-genomic effects since they occur within
the first few minutes.2 Some of the pathways involved
are mentioned in this article to illustrate the degree of
understanding of the processes at the cellular level. To
learn more about these pathways please see the review
articles by Guido Michels and Uta Hoppe and Wikipedia
by specific subject.3 The non-genomic effects have the
most relevance to practicing Prolotherapists and are
discussed in this article.
Second messenger transduction
Acute wounds create many cytokines and small signaling
peptides and most of the immediate changes that we see
are using second messenger pathways, which are either
the Ca2+ ion channels or G-protein coupled pathways. We
may never need to know the details of these pathways
but we will surely be relying on them to understand our
treatments. Following, is a brief summary of the two most
important second messengers: G-protein and Ca2+ ion
channel.
Figure 1. The nongenomic effects of testosterone are
illustrated here. Notice the relationship of the G-proteins, Gprotein receptor (GPCR) to the ion channel and the MAP kinase
pathway. These pathways play an important role in fast cellular
responses known as non-genomic signaling. The sex hormone
binding globulin receptor (SHBGR) also uses the G-protein to
stimulate the cyclic-AMP pathways which supply energy to
many other fast acting pathways.
Steroid and protein hormones can also cause what are
called non-genomic effects because they cause changes
within the cell and its functions in seconds or minutes.
These changes are too fast to be the result of gene
transcription. It is my opinion that the non-genomic
effects of testosterone and hGH are the ones that result
following a Prolotherapy treatment, and they are the ones
that will be discussed in more detail to follow.
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Second messenger transductions result when androgens
outside the cell set off changes within the cell, activating
a G-protein. These second messenger G-proteins regulate
metabolic enzymes, ion channels, transporters and other
parts of the cell machinery, controlling transcription,
motility, contractility and secretion.4 (www.youtube.com
video: “G-protein receptors”) These second messenger
reactions can be initiated by all the steroid hormones
(estrogen, progesterone, testosterone, thyroid and vitamin
D), the protein hormones (insulin, prolactin, glucagon,
growth hGH), follicle-stimulating hormones (FSH),
cytokines (fibroblast, nerve, epidermal, platelet-derived
growth factors, etc.), and by many other peptides using
their own receptors or sharing the androgen receptor.
These are almost all G-protein coupled receptors that
lead to the creation of cyclic-AMP, the Mitogin-Activated
Protein Kinase (MAPK), tyrosine kinase c-Src and the
phosphatidylinosito 3-kinase (Pl-3K) pathways.5 The PI3K pathway results in lipid products that are known to
control cell proliferation, cell survival, many metabolic
changes and responses to cytokines.6
Modulation of ion channels was one of the earliest
observed rapid non-genomic actions of sex steroids. The
ion channels are present in the membranes of all biological
cells and help control the small voltage gradient across
these plasma membranes. Ion channels are classified by
gating or what opens or closes the channel. Voltage gated
channels open or close depending on the voltage gradient
across the plasma membrane. Ligand-gated ion channels
open or close depending on the binding of ligands to the
channel. Testosterone is able to modulate the intracellular
Ca2+ level within seconds to minutes in different cell
systems using both the androgen receptor and nonAR membrane changes.7 The non-voltage calcium ion
channel pathway is a common “second messenger”
regulating a wide range of cellular pathways that control
the cell response to injury.
C e ll w a ll fl e x i b i l i t y
The earliest observations that testosterone could alter
cellular membranes in the laboratory were made
twenty-five years ago. Testosterone in high doses caused
the lipophilic or fat loving steroids to interact with cell
membrane fats known as phospholipids, changing the
lipid-lipid interactions and thereby the cell membrane
flexibility.8 They have been shown to influence cellular
adhesion, cell-cell interactions, function of the Ca2+ ion
channels and the effects of cytokines.9 These cell wall
changes have not been researched in greater detail because
they only have been observed at supra-physiological
doses.
The testosterone doses injected by Dr. Dubick and myself,
although only a couple of milligrams and in a small
volume, would likely create supra-physiological doses at
the injection site at least for a few seconds or a minute.
This would explain the powerful effects of testosterone in
the first few minutes of wound healing and tissue repair.
Ac u t e N e u r o n a l Eff e c t s The use of testosterone appears clinically to decrease the
pain of the injections and most patients are able to leave
the office without the need for narcotic pain medicine.
Many are able to return to work or play even after an
aggressive treatment. There is now a scientific explanation
for this clinical observation.
The brain and nervous system synthesize steroids that
have been given the name neurosteroids. Neurosteroids
have been shown to have a wide variety of functions.10 The
major groups of neuroactive steroids are progesterone,
deoxycorticosterone and testosterone. Major targets of
these neurosteroids include the ligand-gated ion-channels
called GABAa, and these steroids also stimulate some
intracellular signaling molecules such as the MAPK.11
The neurosteroids act specifically at sites that are distinct
from the benzodiazepine and barbiturate modulatory
sites.12 There appear to be at least two discrete binding sites
in the transmembrane domains of the GABAa receptor
that mediate the potentiating and direct activation
effects of the neurosteroids.13 Activation of the GABAa
receptor complex by such neurosteroids resembles, but
is not identical to, activation by benzodiazepines and
barbiturates, and therefore is capable of alteration of pain
thresholds both locally and centrally.14 Testosterone and
the other endogenous steroids are between 10 and 200
times more potent than pentobarbital or benzodiazepines
in affecting the GABA-mediated changes in the brain.
The understanding of testosterone’s ability to alter pain
and create these changes is less than five years old. Notice
the publication dates of all of these references, except
one. The developing evidence that testosterone is a key
neurosteroid is truly exciting. In the next few years this
aspect of testosterone’s non-genomic effects may be
clinically of vital importance to Prolotherapists.
Ac u t e V a s c u l a r C h a n g e s
Sex hormones in general, and testosterone in particular,
have emerged as important modulators of cardiovascular
physiology and pathophysiology. For example, cardiomyocytes have been shown to be testosterone targets.15
Testosterone replacement therapy improves myocardial
ischemia in patients with coronary artery disease, an
effect presumably due to testosterone induced coronary
vasodilatation. In experimental models, androgens have
been shown to exert a specific vascular effect at physiologic
levels, and this is direct, non-genomic endothelium
independent relaxation.16 Testosterone increases the local
blood supply by changing the voltage-dependent ionchannels. When the coronary arteries are infused with
testosterone there is a rapid improvement in myocardial
ischemia.17 These effects are evidenced by the fact that the
acute administration of bucal testosterone immediately
increases cardiac output, apparently via reduction of left
ventricular after load.18 These studies confirm a rapid nongenomic—mainly vasodilatory—effect of testosterone.
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There is now convincing evidence that, at doses used
during Prolotherapy treatment, testosterone would alter
blood flow at the injection site.
Testosterone suppression of wound healing
A clinical observation of a gender difference in the pace
of wound healing suggests that testosterone may be the
culprit. Clinicians fifteen years ago noticed that elderly
males healed wounds more slowly than females.19, 20 The
initial studies showed that estrogens accelerated wound
repair by dampening local inflammation.21 More recent
evidence has suggested that testosterone is actually a
negative or down-regulator of the healing process and
leads to a slowed rate of healing of wounds in elderly
patients.22
It is unclear exactly how testosterone suppresses wound
healing and, in particular, how different cell types utilize
the cell wall testosterone receptor to regulate wound
healing.23 It seems that all of these cellular responses to
wounds use the testosterone receptor and that most use
non-genomic pathways.24 The most important of these
down regulatory pathways is increased production of the
cytokine TNF-α. because in slow-healing wounds there is
a considerable increase in TNF-α at the wound site.25
Testosterone seems to be able to either stimulate or
suppress wound healing depending on the age of the
patient, the part of the wound healing cascade occurring
(early or late), the depth of the wound, and the type of
testosterone dose – hypo, normal or supra-physiologic.
There is little or no evidence at this time that testosterone
would suppress the changes at a wound site in the first
three to three hundred seconds.
Growth Hormone
The addition of hGH to the proliferant solution makes
some sense because it is now recognized that growth
hormone, and its longer acting sister molecule InsulinLike Growth Factor-1 (IGF-1), are two important anabolic
hormones. They regulate some key metabolic processes
and specifically those related to protein synthesis in almost
all tissues throughout the lifespan of mammals.25 Growth
hormone is required for normal postnatal growth, having a
critical role in bone growth as well as important regulatory
effects on protein, carbohydrate, and lipid metabolism. It
is an important hormone to supplement in chronic burn
patients to help them maintain and gain lean body mass.26
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The action of hGH is achieved through the stimulation
of the Growth Hormone Receptor (GHR) and the
stimulation of the IGF-1 pathway and it can happen
in many cell types and tissues. The secreted IGF-1
then works in hormonal, panacrine or autocrine ways
to modulate many different growth factor and cytokine
pathways.27 Many of the effects of GH on growth and
metabolism are actually mediated indirectly via control
of the synthesis of other growth factors.30
Another key role for growth hormone is the regulation of
IGF-1 activity by increasing the production of binding
proteins, specifically the Insulin-like Growth Factor
Binding Protein-3 (IGFBP-3) that increases the half-life
of IGF-1 from minutes to hours. Circulating proteases
then act to break up the IGFBP complex, which releases
the IGF-1 over time.28 It seems that hGH and IGF-1 act
on different tissue types and operate independently.29
The addition of hGH to the proliferate injected clinically
improves the outcome of Prolotherapy and, when injected
with testosterone, enhances the results. The combination
of testosterone and growth hormone clinically creates
some of the best outcomes, in my experience.
C l i n i c a l E x p e r i e nc e
In the last twenty-five years of practicing Prolotherapy
I have had several goals. One goal has been to get the
best results with the fewest and safest treatment sessions,
another has been to find the least painful way to treat
ligament laxity, and a third has been to find the cheapest
path, due to the fact that all of my patients pay cash. It
is a given state of affairs in Prolotherapy that it is painful
to the patient to receive and it is also uncomfortable for a
doctor to have to create pain, but successful Prolotherapy
requires the creation of an inflammatory response—rubor,
color, tumor and dolor, and particularly dolor—are a part of
the treatment.
I have achieved good results with Prolotherapy using many
different kinds of proliferants. I have used just dextrose
30% to 50%, pumice, the combination of glucose,
glycerin and phenol (P2G) diluted from 30% to 50%,
P2G 50% with 5% sodium morrhuate, needling alone,
70% venous blood and 30% procaine and platelet rich
plasma (PRP). All of these injectants have worked and I
have gotten from basic, satisfactory results to unbelievable
responses with all of them. All Prolotherapists should be
getting great results because 60 million years of wound
healing and tissue repair are on our side. I have gotten
some of my very best results in treating acute injury by
simply refraining from using NSAIDs, encouraging timely
and appropriate exercise, and just letting this wonderful
process proceed on its own. I have almost always added
manipulation, physical therapy, and Pilates, and also have
encouraged participation in the activities of daily living to
enhance the results.
Getting great results is not the problem; the challenge is
how to do it causing less pain and with lower cost. Do
I need conscious sedation with its risks and cost? Do I
need fluoroscopy or ultrasound to palpate for me with
their risks and costs? Do I need PRP when just venous
blood might do the job considering the cost difference? As
I mentioned previously, striving to cause less pain is about
patient comfort.
Some Case Anecdotes
from my Practice
C a s e # 1 : C a s e R e p o r t o n m y s e lf r e g a r d i n g
r i g h t s h o u l d e r pa i n a n d t e s to s t e r o n e
Twenty-five years ago, when I was 44 years old, I
fell on my right shoulder while ski race training. I
momentarily subluxed the shoulder and got a third degree
acromioclavicular joint (ACJ) separation diagnosed in
the first aid station. For about three weeks, sleeping was
hard and it took 40mg of morphine to even make me
comfortable enough to move my arm more than a few
degrees, much less use it for basic activities like eating. On
day four after the injury, an orthopedic surgical consult was
obtained. The physical examination revealed no ability to
abduct the arm, minimal internal and external rotation
at 25 degrees abduction, a large bruise over the anterior
shoulder and a third degree ACJ separation. The situation
was discussed with the surgeon and no immediate surgery
for either condition was contemplated. (See Figure 2.)
The right shoulder remained painful for many months.
Throughout the latter 1980s and the 1990s I received
some Prolotherapy from various colleagues, most of
whom used 50% procaine and 50% P2G. Many of these
treatments were so painful that I could not use my arm
for 36 to 48 hours and they required a moderate amount
of pain medication for one and a half to two days. My
shoulder improved considerably with each Prolotherapy
Figure 2. Tom Ravin at the Vail Super G, Feb 2010. Just passed
the radar gun doing 56.4mph, without any pain.
session and the pain slipped into the background but the
weakness in abduction and numbness and tingling when
sleeping remained a problem. I continued to ski train and
race during the winters and cycled two to three thousand
miles per summer. The background pain was an ongoing
problem but it was not severe enough to prevent me from
participating.
Three years ago I began to explore alternatives to help
some older ladies with their shoulder pain. A doctor and
upper extremity surgeon from Houston was seeing me for
his bilateral shoulder pain, and we began to share stories
and ideas about finding and treating sources of our minor
but persistent weaknesses and pain. We both agreed
that P2G was a painful option and that its tendency to
create a lot of swelling limited the amount that could be
injected. At the end of one of his treatment sessions in the
fall of 2007, I asked him to evaluate my right shoulder.
The anterior compression test was 2+/4 weak both the
anterior and posterior capsules were 2+/4 TtP (tender to
palpation). We decided to do the usual injection sequence;
however, we used 10mg aqueous testosterone and 0.5%
procaine instead of the usual P2G and sodium morrhuate.
(As described in the book Principles of Prolotherapy.) Since
I had a long experience with the latter combination and
the injection sequence, I felt I could accurately evaluate
the treatment.
This first treatment was totally different. I noticed several
things initially. The pain was a lot less during the injection
499
and he was able to treat more of each ligament than I
had experienced during other treatment sessions. Later
that afternoon I noticed the biggest difference. I felt no
need for pain medication and, in fact, my shoulder felt
stronger. So I continued to treat the two remaining patients
as I normally would have. That night I had a couple of
glasses of wine with dinner and went to sleep with only
10mg of hydrocodone. Since then I have used only this
combination on my shoulders and each treatment has
helped me increase the range of motion and the strength.
I have had five more treatments by my doctor friend and
have worked hard at Pilates. Right now my shoulder is as
strong as it was before I fell.
Case # 2
The patient related six months later during a phone call
that she had no patellar or medial knee pain.
Case # 3
First visit: A 62-year-old female came in complaining of
right knee pain. She had fallen twice in a 24-hour period
one year prior. Her X-ray was negative for fracture.
Initially the pain was minimal and isolated to the anterior
medial knee. There was no history of the knee locking.
Physical examination initially revealed a 1+/4 lax medial
collateral ligament (MCL) that was tender to palpation
(TtP) and a very tender area to palpation just above the
anterior medial tibial plateau that reproduced some of
the knee pain. The initial diagnosis was a mild medial
collateral ligament tear and a bruised knee.
Second visit: Over the next six months the pain became
progressively worse and began to extend across the knee
involving the peripatellar soft tissues. The pain was then
causing disruption to sleep and the patient required one
to two hydrocodone tabs to get through the night. The
patient returned to the clinic for reevaluation. Physical
examination of the medial knee revealed that the MCL
had tightened up. The anterior medial joint line still was
3+/4 tender to palpation. The patellar tendon was 2+/4
tender to palpation and the posterior lateral corner was
2+/4 TtP. The diagnosis was a medial meniscus anterior
horn horizontal tear and mild patellar tendinosis. The
medial meniscus tear was treated with a solution of 1mg
of testosterone in 3cc’s of procaine using a 27G 1.5-inch
needle. The patellar tendon was treated with 4mg of
testosterone in 10cc’s of 1% procaine using a 22G, 2-inch
needle for a total of 3cc’s. The patient left the office with a
small limp but the medial knee was pain free. The patient
later stated she used 5mg of hydrocodone that evening
and then did not need any other pain medication.
500
Third office visit: The patient returned six weeks later
stating that there had been some improvement in the
patellar pain but essentially no change in the anterior
medial knee pain. Physical examination showed the
anterior medial knee pain was smaller in size but still
3+/4 TtP. The meniscus was treated again using the same
combination as before and, because the patellar tendon
was continuing to improve, it was decided to just watch
it. The patient did not use any pain meds during or after
the treatment.
First visit: A 50-year-old female came in complaining of
neck pain and headaches. These symptoms had been
getting worse over the years but were now interfering
with her activities and sleep. She related that the problem
may have started about twenty years earlier when she was
involved in a whiplash type car accident. She stated that
her neck felt unstable and “weak.” Physical examination
revealed 3+/4 TtP along the nucal ridge and the base of the
skull. There was bilateral posterior capsular ligamentous
laxity with associated mechanical joint dysfunctions at
C3-C6. The posterior capsules were 3+/4 TtP and the
pain increased with pressure and stress. The stress of
the joints also reproduced some of the pain complaints.
The patient was treated with manipulation only. The
manipulation resolved most of the pain complaints.
Second visit: The patient returned one week later and
stated that the manipulation helped but it only lasted
about three days. The physical examination revealed little
or no changes in the findings from the first visit. The lack
of progress suggested that the problem was tendinosis of
the semispinalus and rectus capitus tendons along nuchal
ridge and posterior capsular ligaments laxity at C3-C6.
The tendon attachments were injected with 1% procaine
and 1mg testosterone in a 10cc syringe. The right and left
C3 through C6 posterior capsular ligaments were treated
with 4mg of aqueous testosterone in a 10cc syringe of
1% procaine. The patient took 5mg of hydrocodone after
the treatment, and subsequently, needed no additional
narcotic pain relievers. (See Figure 3.)
Third visit 12 weeks later: The patient returned stating
that her headaches were much less frequent for 8 weeks
following the treatment, but had now returned to the
the anterior, lateral and posterior hip capsule using 5mg
of aqueous testosterone in 10cc of procaine in each of
the three areas of the capsule. The patient took 5mg of
hydrocodone, watched some television and went to bed
two hours later without taking more pain medication.
Second visit: The patient returned to the clinic four
months later stating that the first treatment had decreased
his left hip pain by 50%. His pain complaints had now
returned and he thought he needed another treatment.
He still was sleeping better but the pain was bothering
him after his bike rides. Physical examination revealed a
1+/4 anterior hip drawer sign and a 1+/4 posterior hip
drawer sign. The capsule was only tender to palpation
both anteriorly and posteriorly. The treatment was a
repeat of the first one.
Figure 3. Dr. Tom Ravin treating a patient’s lower thoracic
spine with procaine and testosterone.
point that they were bothering her so she wanted another
treatment. Physical examination revealed that the
semispinalus tendon and the rectus capitus tendons were
1+/4 tender and the tender areas were much smaller. The
lower cervical spine was less unstable and the posterior
capsules were only 1+/4 TtP. The treatment was a repeat
of the first injection. This time the patient needed no pain
medication after the treatment.
At this time she has some residual neck pain complaints
but feels that her neck pain is about 80% improved.
Case # 4
First visit: A 42-year-old male came in complaining of
left hip pain. The patient is an avid bike rider and over
the previous six months the left hip pain had been getting
progressively worse, particularly after riding. The left hip
pain was tolerable when he was riding but later made
it impossible for him to sleep on his left side. Physical
examination revealed normal lumbar and sacroiliac joint
function. The anterior hip drawer sign was 2+/4 positive
and the posterior hip drawer was 2+/4. The capsule
was 2+/4 TtP. The examination was discussed with the
patient and the posterior ligament laxity demonstrated
to the patient. The need for Prolotherapy to the hip was
discussed with the patient. The treatment was done on
Third visit: The patient returned to the clinic eight
weeks after the first treatment and the left hip pain had
decreased by 75%. He noticed how much more stable
it felt and he had no pain or discomfort sleeping on his
left side. Because the biking season was coming and he
was still having some pain at the end of his rides, he felt
one more treatment was indicated. Physical examination
revealed a 1+/4 anterior drawer sign and a 1+/4 posterior
drawer. The capsule was only slightly tender to palpation
posteriorly. The treatment was a repeat of the first one.
In a follow-up conversation with the patient at twelve
weeks he reported that his pain complaints are 90-95%
better. He is planning on riding the 120-mile Triple Bypass
bicycle ride, which has 9,000 vertical feet of climbing.
Case # 5
First visit: A 41-year-old female came to the office for
evaluation of persistent pain near the spine just below
the bra line, as well as a chronic headache. The pain
started several months earlier when she tried to pick
up her five-year-old son. Massage helped some but the
relief was short-lived. Physical examination of the spine
revealed a T11 vertebra that was rotated to the left and
was in extension. Deep palpation over the facet joints,
the interspinous and the left costotransverse ligaments
reproduced some of the patient’s pain complaints. The
left 11th rib was posterior to the ribs above and below.
Treatment consisted of manipulation of the rib and 11th
vertebra. The patient experienced relief of the headache
and pain.
501
Second visit: The patient returned to the office one week
later. The headaches and back pain had returned. She
related that she had felt good and did not have a headache or
backache for two days following her treatment, but then
the pain returned. On physical examination the findings
were the same as at the first visit. The treatment was
manipulation, as she was reluctant to have injections.
Third visit: The patient returned to the office three weeks
later. The headaches and back pain were back once
again. She had experienced about five days of relief
until she picked up a big bag of groceries. The physical
exam was the same as on the previous visits. The cause
of the recurrent joint dysfunctions (they were the result
of ligament laxity) was discussed with the patient. The
idea that Prolotherapy could tighten the ligaments was
broached with the patient and she thought it was a good
idea. Treatment consisted of treating the facet joints at
T10 and T11 and the left T11 costotransverse joint with
3mg of aqueous testosterone and procaine. The four
facets were each treated with 4cc’s of the solution and the
costotransverse was treated with 3cc’s.
Fourth visit: The patient returned to the office after
three weeks. In the last week the patient had experienced
only one headache and the mid-back pain was 40%
better. Physical examination revealed no vertebral or rib
dysfunction. The facets and the costotransverse ligament
were only slightly tender to palpation. It was decided that
one more treatment would stabilize the situation. The
treatment was the same as at the third visit.
Six weeks later I talked to the patient in the grocery store.
She had not had a headache since the last treatment and
the back pain was gone and she said, “Thank you very
much for all you did.”
C o ncl u s i o n
Testosterone and growth hormone are essential for the
growth and development of all mammals. Testosterone
and its metabolic derivatives play key roles in regulating
cell functions, from stimulating protein production (a slow
process called genomic effects) to altering pain in a second
or two (called non-genomic effects).
The non-genomic effects all take place within a minute or
two of exposure to testosterone and all of these changes
probably use some common cellular mechanisms.
Second messenger transduction using the G-protein and
502
Ca2+ ion channels allows testosterone to respond by
producing cytokines and other peptides that help direct
acute inflammatory process. Testosterone influences the
GABAa like receptors in nerves that alter the response
to pain signals and their pathways. Testosterone changes
vascular tone and blood flow using the voltage-dependent
ion-channels. This altered blood flow at the wound site
could influence the distribution of cytokines locally and
globally.
The use of growth hormone with testosterone enhances
the effects of both hormones on the response to wound
healing and in fact they may be essential ingredients for
good wound healing. They share many common pathways
and stimulate the production of common cytokines
necessary for wound healing. There is strong scientific
evidence that testosterone and growth hormones’ major
impact is in the first few minutes of wound healing, despite
the fact that, so far, the evidence of such mechanisms does
not derive from studies directly addressing this particular
issue.
Testosterone in the clinic gives almost as good results
as 50% dextrose and glycerin or PRP, and with less
pain. Because there is less swelling with testosterone or
testosterone with growth hormone, it is easier to extend
and expand each treatment and find more of the injured
ligament with each treatment session. As I mentioned at
the start of this discussion, there are many substances that
can be injected into ligaments and provide good to great
results, but aqueous testosterone provides a wonderful
balance of effectiveness, cost, and pain management. n
r e f e r e nc e s
1. Clark RAF, ed. 1996. The Molecular and Cellular Biology of Wound
Repair. 2nd ed. New York: Plenum Press.
2. Boonyaratanskornkit V, et al. Receptor mechanisms mediating
non-genomic actions of sex steroids. Semin Reprod Med.
2007;25:139–153.
3. Michels G, et al. Rapid actions of androgens. Frontiers
Neuroendocrinology. 2000;29:182–198.
4. Berridge MJ, et al. Calcium—a life and death signal. Nature.
1998;395:645–648.
5. Culig Z, et al. Androgen receptors in prostate cancer. J Uro.
2003;170(4):1363–1369.
6. Liu X, et al. The v-Src SH3 domain binds phosphatidylinositol
30-kinase. Mol. Cell. Biol. 13:5225–5232.
7. Sun YH, et al. Androgens induce increases in intracellular
calcium via a G protein-coupled receptor in LNCaP prostate
cancer cells. J. Androl. 2006;27:671–678.
8. Van Bommel T, et al. Effects of high-dose medroxyprogesterone
acetate and various other steroid hormones on plasma membrane
lipid mobility in CAMA-1 mammary cancer cells. Anticancer Res.
1987;7:1217–1223.
9. Duval D, et al. Non-genomic effects of steroids. interactions
of steroid molecules with membrane structures and functions.
Biochim. Biophys. Acta. 1983;737:409–442.
27. Fryburg DA. Insulin-like growth factor IGF-I exerts growth
hormone- and insulin like actions on human muscle protein
metabolism. Am J Physiol Endocrinol Metab. 1994;267:E331–E36.
28. Bergad PL, et al. Inhibition of growth hormone action in models
of inflammation. Am J Physiol Cell Physiol. 2000;Dec;279(6):
C1906–17.
10. Hosie AM, et al. endogenous neurosteroids regulate GABAA
receptors through two discrete transmembrane sites. Nature.
2006;444:486–489.
29. Goodyer CG, et al. Characterization of the growth hormone
receptor in human dermal fibroblasts and liver during
development. Am J Physiol Endocrinol Metab. 2001;281(6):E1213–
20.
11. Compagnone NA, et al. Neurosteroids: biosynthesis and
function of these novel neuromodulators. Front. Neuroendocrinol.
2000;20:211–56.
30. Butler AA, et al. Control of growth by the somatropic axis:
growth hormone and the insulin-like growth factors have related
and independent roles. Annu Rev Physiol. 2001;63:141–64. Review.
12. Michels G, et al. GABAA receptors: properties and trafficking,
Crit. Rev. Biochem. Mol. Biol. 2007;42:3–14.
13. Wilkins ME, et al. Endogenous neurosteroids regulate GABAA
receptors through two discrete transmembrane sites. Nature.
2006;444:486–489.
14. Fernandez-Guasti A, et al. Anxiolytic-like actions of testosterone
in the burying behavior test: role of androgen and GABAbenzodiazepine receptors. Psychoneuroendocrinology. 2005;30:762–
770.
15. Golden KL, et al. Testosterone regulates mRNA levels of calcium
regulatory proteins in cardiac myocytes. Horm. Metab. Res.
2004;36:197–202.
16. Yue P, et al. Testosterone relaxes rabbit coronary arteries and
aorta. Circulation. 1995;91:1154–1160.
17. Jones RD, et al. The influence of testosterone upon vascular
reactivity. Eur. J. Endocrinol. 2004;51:29–37.
18. Pugh PJ, et al. Acute hemodynamic effects of testosterone in men
with chronic heart failure. Eur. Heart J. 2003;24:909–915.
19. Ashcroft GS, et al. Estrogen accelerates cutaneous wound
healing associated with an increase in TGF-β levels. Nat. Med.
1997;3:1209–1215.
20. Ashcroft GS, et al. Androgen receptor-mediated inhibition of
cutaneous wound healing. J. Clin. Invest. 2002;110:615–624.
21. Ashcroft GS, et al. Topical estrogen accelerates cutaneous wound
healing in aged humans associated with an altered inflammatory
response. Am. J. Pathol. 1999;155:1137–1146.
22. Fimmel S, et al. Influence of physiological androgen levels
on wound healing and immune status in men. Aging Male.
2005;8:166–174.
23. Gilliver SC, et al. Androgens modulate the inflammatory
response during acute wound healing. J. Cell Sci. 2006;119:722–
732.
24. Rahman F, et al. Non-classical actions of testosterone: an update.
Trends Endocrinol. Metab. 2007;18:371–378.
25. Kuo-Pao Lai, et al. Monocyte/macrophage androgen receptor
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local TNF-α expression. J Clin Invest. 2009;119:3739–3751.
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26. Demling RH, et al. The stress response to injury and infection:
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503
FOUR-LEGGED PROLOTHERAPY: PET PROLOTHERAPY: AN OVERVIEW & CURRENT CASE STUDIES
F O U R - L E GG E D
P R O LOT H E R A P Y
Pet Prolotherapy:
An Overview and Current Case Studies
Melissa S. Greenberg, DVM
Babette Gladstein, VMD
Melissa Greenberg, DVM, has taken the time to write
up for us her numerous cases. What makes these cases
interesting is that she is combining the use of PRP (Platelet
Rich Plasma) in her therapies. She has given us insight
into the popular and up and coming technique that
aids in the healing process combined with Prolotherapy
techniques. She refers to her therapy as “Regenerative
Injection Therapies” that enhances the longevity of the
animals she is treating.
She has gone through training with the human side—in
properly administering and handling PRP. Her treatments
are done in highly controlled office environments. She is
finding the time in a busy Veterinary practice to share this
information with us all and we thank her for doing so.
Her results are conclusively positive.
R
ecently, with the increased awareness of human
regenerative injection therapies (RIT) aka
“Prolotherapy,” including platelet rich plasma
(PRP) therapy, there has been a surge of interest in the use
of these therapies in treating pets for various debilitating
conditions. Numerous musculoskeletal pathologies
commonly occurring in pets may be successfully treated
using these regenerative modalities. This may obviate
the need for surgical intervention in addition to the more
fundamental benefits of pain reduction and improved
quality of life. In veterinary medicine, pets are all too often
euthanatized as a direct sequella of challenges regarding pain
management and joint related morbidity. With appropriate
training, veterinarians could incorporate this fairly simple
and highly efficacious modality into their practices and
dynamically improve the quality of care provided in the
504
veterinary clinic or home call setting, theoretically adding
years to the lives of their cherished pets.
Pet Prolotherapy does present challenges not usually
encountered in human medicine. For instance, restraint
is required, as is thorough shaving, cleaning, and
prepping of injection sites. All pets treated by the author
are prepped by clipping of hair around injection sites,
thorough washing, and pretreatment with an antiseptic
solution such as a quaternary ammonium or alcohol. All
use of anti-inflammatory drugs is discontinued a week
prior to treatment, or more, depending on the half-life
of the particular substance in-vivo. Post procedure, this
restriction is continued and pain management is achieved
using narcotic analgesics or other non anti-inflammatory
class analgesics. It is noteworthy that while this may appear
unethical, the inflammatory cascade is crucial in collagen
formation. Consequently, anti-inflammatory medications
inhibit the regenerative response, thereby decreasing the
effectiveness of the procedure.
Due, in part, to the inflammatory ability of the solutions
used in RIT, they are considered irritants. RIT is therefore
a generally painful process. This necessitates the use of
sedation or a light plane of anesthesia in order to achieve
the needed level of restraint in almost all animal patients.
The author prefers short acting, reversible sedation to
minimize the associated risks.
Two basic Prolotherapy solutions were used in the
following studies. The intra-articular (IA) injections used
a 25% dextrose solution. The peri-articular (PA), tendon
and ligament injections used a 12-15% dextrose solution.
One percent (1%) procaine, methylcobalamin (B12), and
sterile water were routinely included in both formulations.
On occasion, MSM, glucosamine and/or Adequan®
(polysulfated glycosaminoglycan – IA solution only) were
also added to the author’s injection solutions.
Case Studies
C ASE # 1 : “ TOMMY ” TERRE L L
Tommy is an 80 pound, 12 year-old, male, neutered,
Australian Shepherd dog. Tommy presented with a three
year history of hind limb weakness, ataxia, and lameness.
The author was contacted on referral from the owner’s
own naturopathic physician and as a “last resort.” Tommy
had been scheduled for full hip replacement surgery prior
to his owner contacting the author.
Tommy presented with multiple severe subluxation
complexes and muscle spasms from T10-L2. He also had
a dramatically exaggerated panniculus response in that
region. In addition, there was evidence of degenerative
myelopathy of the right hind limb. The pre-treatment
exam led to a diagnosis of arthritis (spine and right hip),
moderate, as well as hip dysplasia of the right hip, mild
to moderate.
Markings for spinal segments treated with RIT.
Therapy was initiated using adjustments to rehabilitate
the innervation to the hip and hind limb. After a series
of four to five adjustments with limited lasting progress/
relief, the owner elected RIT. Tommy was then treated
four times with Prolotherapy.
The initial treatment focused on his hip and right T-L
spine segments. IA injections of hip were achieved using
a 25g X 2-inch needle. Approximately 8cc of the 25%
solution were delivered into the hip joint. PA injections
around the hip joint as well as injections on tendonous
insertions at the greater trochanter (of the femur), were
achieved using 27g X 1-inch needles and the 12.5%
solution. Approximately 1-1.5cc was delivered at each site.
Injections along the spine included the spinous processes
(27g X 5/8-inch), laminae (27g X 1-inch), and transverse
processes (27g X 1.5-inch). An excellent outcome was
achieved from this first treatment with the pet returning
to soundness and increased strength of the right hind
limb.
A second treatment was performed two weeks later in
order to repeat the spinal segments but on the contralateral side. The author used the same exact procedure
with the exception of needle placement which, in this
second treatment, was on the left side. The author requires
spinal segment RIT to be performed unilaterally in order
to avoid the risk of bilateral pneumothorax. Despite the
Dr. Greenberg performing RIT to Tommy’s hip.
obvious inconvenience of return visits, once educated
regarding these risks, clients are happy to comply with
this policy.
Approximately four days after the second treatment
Tommy was allowed to run off-leash at the beach and
swim in water with significant swell. His “over-use” and
wave related traumas set him back. Once the initial
swelling resolved he was scheduled for a second round
of treatments (treatments three and four) approximately
a week later, and a week apart. He received treatments
three and four, which were repeats of treatments one and
two, respectively. A month later Tommy demonstrated
improved hind limb coordination, hind limb strength,
and increased muscle mass. Notably, he was sound at a
walk and run.
505
C ASE # 2 : “ PA K A ” C O N DO N
Paka is a 57 pound, 4 year-old, female, spayed, Pit Bull mix
dog. Paka presented with a two year history of lameness
in the hindquarters. On presentation she was noted to be
“tripodding” and severely lame on left hind, even when
standing still.
Paka presented with multiple severe subluxation
complexes from spinal segment T8 through L3. In
addition, pre-treatment exam revealed severely decreased
range of motion (ROM) in the left hip. Radiographic
examination of the affected region confirmed the
diagnosis of moderate hip dysplasia at the left hip along
with decreased intervertebral disk spaces in the affected
area of the spine.
Paka’s owner had been referred for
the author was able to convince her
concomitant RIT. Prolotherapy was
few weeks of adjustments which alone
limited progress.
adjustments but
of the utility of
initiated after a
had yielded only
To date, only three Prolotherapy treatments have been
administered. The first treatment was performed only
at the left hip. An IA injection as described in case #1
was performed. A total volume of approximately 8cc of
25% dextrose solution was delivered. PA sites were also
injected and a 12.5% solution was used to “pepper” the
attachment sites around the left hip joint. The insertions
at the greater trochanter were treated in a similar fashion.
Paka did very well and began using her left hind limb
again, albeit cautiously.
The second treatment was performed four weeks later
and involved repeating the procedures of the first
treatment in addition to addressing the chronicity of the
spinal subluxation complexes and compression. Spinal
segments T8-L4 were treated in a similar fashion to the
treatment described in case #1. Two weeks later Paka’s
owner reported Paka was “acting like a puppy again” and
using her left hind limb regularly and fully!
However, after an episode of over-use, Paka suffered
trauma to the joint and a moderate inflammatory response
ensued along with a significant setback. Treatment three
was performed approximately three weeks after treatment
two. The RIT was performed in an identical fashion to
that performed in treatment two. Paka’s owner was also
506
re-educated at that time on the importance of limiting
Paka’s exercise, post treatment. An excellent outcome was
achieved.
Due to the severity of Paka’s initial presentation in
combination with her demeanor (and active lifestyle),
it was recommended that PRP be employed for future
treatments due to its more aggressive and efficacious
action. Her owner has elected to comply with this
recommendation. Paka received her first PRP treatment
recently and is already demonstrating signs of a successful
outcome. Hydrotherapy has also been recommended to
augment her recovery.
C ASE # 3 : “ AR C HER ” E L SO N
Archer, a 95 pound, 11 month-old, intact, male,
Great Dane dog presented for lameness of two month
duration. On exam the lameness was localized to the left
shoulder. Left forelimb lameness was further evaluated
using radiographs which revealed the diagnosis of
osteochondritis dissecans, or “OCD.” No joint mouse was
detected.
Physical exam revealed tenderness at left shoulder with
multiple, regional trigger-points. The author initiated
therapy of twice weekly intra-muscular (IM) injections
of Adequan®. After three weeks, initial Prolotherapy was
performed.
The first treatment consisted of an IA injection of the left
glenohumeral joint. The standard 25% dextrose solution
was used and approximately 5cc was delivered using
a 25g X 2.5-inch needle. Two cc of Adequan® were
also delivered directly into the glenohumeral joint. PA
injections were then performed using the 12.5% solution.
Ligaments and tendonous attachments were injected
using a 27g X 1-inch needle. A return to soundness was
achieved and owner reported an 80% improvement.
A second treatment was performed approximately six
weeks later as Archer’s owner was on vacation at four
weeks post initiation of therapy. The second treatment was
performed similarly to the first with attention being given
to remaining tender regions. Approximately one month
later, Archer’s owner reported a complete resolution of
signs and symptoms. Archer subsequently returned to full
soundness and has remained so for the last 22 months.
Due to the genetic link noted with OCD, all affected
individuals should be neutered. On Archer’s second
appointment he was neutered before receiving his RIT.
C ASE # 4 : “ B A B Y ” TREVOR
Baby is a 65 pound, 5 year-old, female, spayed, Pit Bull
mix. Baby presented for hind limb lameness of two year
duration. At the time of her initial exam, her owner was
questioned thoroughly regarding the possible inciting
cause of her lameness. Baby’s owner then reported that
“Baby loves to play Frisbee.” She then continued: “One
day about two years ago, Baby leapt approximately five
feet into the air after a Frisbee. When she came down, the
concrete decking was wet and slippery and as she landed,
something went terribly wrong. She lost her footing and
yelped loudly. She has been limping like this ever since.”
On presentation, Baby demonstrated mild right hind
limb lameness. The gait of her right hind limb appeared
aberrant and as if she was “walking on egg shells.” Physical
exam of the right knee revealed no anterior drawer sign
but some anterior laxity was present. The knee was tender
on palpation and on movement through the ROM.
Palpation revealed a laterally thickened fibrotic joint
capsule with probable calcific tendonosis of insertions
around the knee. The evidence, while not pathognomonic,
was suggestive of a partial thickness, anterior cruciate
ligament (ACL) tear with secondary degenerative
chondritis and other associated sequellae of the admittedly
mild yet chronic instability.
was dramatically improved, she had not returned to
full soundness. A second treatment was then performed
using a larger dose (7cc) of a more concentrated dextrose
solution (25%). Baby had a difficult time for three
days post treatment #2 but had recovered by day four.
Approximately one month after the second treatment,
Baby was fully sound with no evidence of residual
lameness.
Baby’s 84 year-old owner’s only concern now, is that with
Baby feeling so much better, it will be hard for her to keep
up!
C ASE # 5 : “ PU ’ I L I ” DEH N E
Pu’ili is a 105 pound, 12 year-old, female, spayed,
Rottweiler dog. Pu’ili presented with a five year history of
severe arthritis in the hind quarters.
This case is available at www.journalofprolotherapy.com.
C O N C L USIO N
This combination of therapies (traditional Prolotherapy
and the emergent, more aggressive, and efficacious PRP),
clearly has a valuable role in veterinary medicine. Not
only do they lessen the need for more invasive surgical
interventions, they also reliably enhance the quality of life
and longevity of the animals treated. It is this author’s
hope that this data will encourage other practitioners to
incorporate these relatively simple yet highly beneficial
modalities into their practice of veterinary medicine. n
Treatment number one involved an antero-medial
approach to the IA space. Prolotherapy injection was
performed using a 25g X 1.5-inch needle and a 20%
dextrose IA solution. Approximately 4cc were delivered
IA at the knee. A 12.5% PA solution was then used with a
27g X 5/8-inch needle and included needle fenestration
of the lateral collateral ligament, the tendon of insertion
of the quadriceps femoris, and surrounding “tender”
structures. All were “peppered” at multiple sites with .51.5cc of PA solution.
Three days post procedure, Baby’s owner reported that
“Baby (was) walking normally.” In fact, she quickly
resumed her active lifestyle and began to swim and run
avidly, once again. Upon follow up examination one
month post treatment, the author noted that while she
507
TEACHING TECHNIQUES: HAND AND WRIST PROLOTHERAPY
T E AC HI N G T E C H N I Q U E S
Hand and Wrist
Prolotherapy
Rodney S. Van Pelt, MD
introduction
L
isa is a 23 year-old ranch foreman. She has a rough,
physical job. Three months before she came to see
me she was thrown from a horse and landed on
her right hand. She had severe pain and swelling at her
wrist. But being tough as she is, she continued her work,
roping cattle, and caring for horses and livestock. All this
put ongoing stress on the injuries in the wrist. This led to
continued pain and very restricted range of motion.
“instrument” that can type 150 wpm, serve a tennis
ball at 138 mph, and yet, feel the gentle touch of your
romantic partner’s hand. With all this complexity it is not
surprising that chronic injuries can and do occur. I will
review how to avoid unnecessary cortisone shots, surgery
and disability by treating injuries of the wrist and hand
with Prolotherapy!
W RI S T
The carpal bones of the wrist consist of eight bones in two
rows with 27 articular surfaces. These are held together
with a “sea” of ligaments bridging the articulations giving
stability to the wrist. (See Figure 1.) We can have a variety
of injuries at the wrist and I will look at them separately.
Finally Lisa had so much pain and restriction that she
sought medical attention with an orthopedic surgeon.
He did imaging studies and told her that in addition to a
navicular fracture, she had “disrupted the major ligaments
of her wrist and needed surgery right away.” She was
further told that the surgery would decrease the range of
motion further (which was less than 10 degrees at that
time). Lastly, the surgeon told her that if she didn’t have
the surgery right away that eventually “the wrist would
collapse and the arm bones would protrude through the
wrist” and she would be unable to fix it then.
She sought my attention in an attempt to avoid the surgery
and in the hopes of regaining her range of motion.
After examination, I identified her injured ligaments and
scaphoid bone fracture as the source of her pain. She
was treated aggressively with Prolotherapy using strong
solutions targeting the injured ligaments. She received
three treatments by me, one week apart. These were
followed by three more treatments, six to eight weeks
apart, in her home state, by another practitioner.
I saw Lisa recently (two to three months after her last
treatment), and she reported no pain and full range of
motion of her wrist! She had no tenderness over the
scaphoid. She is back at full duty on the ranch and is a
very happy cowgirl!
Hands and wrists are amazing feats of engineering
and design. Twenty-seven bones, a sea of ligaments,
tendons, joints and muscles work together to make an
508
Figure 1. The wrist is comprised of 15 bones, 27 articular
surfaces, and a host of ligaments to hold it all together.
Used with permission of Beulah Land Press © 2001 Oak Park, IL. Prolo Your Sports
Injuries Away!, fig. 22-10.
Navicular Injury
This often presents as “snuff box” tenderness and radial
wrist pain. Navicular fracture comprises about 70% of
all carpal fractures and roughly one in 10 of these results
in avascular necrosis. As physicians, we all know the
challenge of diagnosing navicular fracture, especially
early. When a person has pain over the navicular bone,
while one must consider fracture, a more common
cause of navicular pain is injury to the ligaments that
surround it. While immobilization should be considered
if a fracture is present, as the previous case study shows,
aggressive Prolotherapy treatment all around the
navicular with strong solution stimulates blood supply,
local immune activity, and of course, regeneration of
stabilizing ligaments and tendons. If the pain is from the
surrounding ligaments and tendons, then a successful
outcome is highly likely.
The patient is positioned comfortably allowing the
hand to be alternately pronated and supinated. The
skin is cleansed, and the local anesthesia is administered
over the areas to be treated. A 5cc luer lock syringe is
filled with standard prolo solution. The solution may be
supplemented with zinc sulfate or sodium morrhuate
as needed (0.5 to 1cc). Injections are given onto and
immediately around the scaphoid. (See Figure 2.) Care is
taken around the volar aspect of the radial wrist to avoid
the radial artery and nerve. Four to six treatments, each
about four weeks apart, gives excellent results.
in true carpal tunnel syndrome because it increases the
space through which the median nerve traverses.** With
pseudo-carpal tunnel pain, often the annular ligament in
the elbow and/or the fourth and fifth cervical vertebrae
will need to be treated, as these areas can refer pain to
the hand.)
The skin is cleansed and local anesthesia is administered.
A 10cc luer lock syringe is filled with standard prolo
solution and a 25G 1 to 2-inch needle is attached. (The
length is not critical, we will only be using the distal 0.25
inch). Injections are given in two or three rows along the
dorsal wrist, peppering the injured areas from the radial
side to the ulnar side. (See Figure 3).
Figure 3. Dorsal wrist injection.
Figure 2. Navicular injection.
Attachments at the hook of the hamate can be
injured by repetitive pressure as in chiropractic
compression with the heel of the hand. The injury can
be palpated just distal to the volar ulna. Three careful
0.5cc injections to the hook of the hamate from various
angles resolves this well in four to six treatments.
True carpal tunnel syndrome is a debilitating
condition. It is commonly seen in patients who do a lot
of repetitive work including, typing and computer work.
Physicians will more commonly see “pseudo-carpal tunnel
syndrome” caused from ligament laxity, especially about
the elbow, not entrapment of the median nerve which
constitutes true carpal tunnel syndrome. In either case,
surgery has questionable results. In pseudo-carpal tunnel
syndrome, a series of Prolotherapy treatments along
the dorsal wrist may provide pain relief. (Editor’s note:
A CTRAC device can often be used to avoid surgery
Ganglion cysts respond well to Prolotherapy. The cyst is a
dorsal protrusion of the joint capsule containing synovial
fluid. If the cyst is merely aspirated or surgically resected
it will routinely recur. If, on the other hand, we follow up
the aspiration of the cyst with Prolotherapy to the painful
wrist dorsally, the underlying cause is stimulated to heal.
After a completed series of Prolotherapy treatments the
problem does not return.
W r i s t Co l l at e r a l l i g a m e n ts
The ulnar collateral ligament of the wrist runs from
the distal ulna to the proximal carpal bone and beyond to
the proximal fifth metacarpal. When injured, there is pain
with radial deviation of the wrist and with pressure on the
ulnar wrist. Similarly, the radial collateral ligament
runs from the radial styloid distally to the proximal carpal
bone and to the proximal first metacarpal. When injured,
**
CTRAC is available at www.ctracforcts.com.
509
the pain is elicited by ulnar deviation and direct pressure
over the radial wrist.
Treatment consists of cleansing the skin and placing local
anesthesia. A 3cc luer lock syringe is filled with standard
prolo solution and fitted with a 25G 1 to 2-inch needle.
Injection is given of 2cc “peppered” (See Sidebar A.) along
the ligament including the attachment at both ends.
(See Figure 4.)
A. Peppering is a technique where an area is peppered with injections
of 0.5cc of solution. The technique is begun with an injection of 0.5cc
into the injured structure then the needle is partially withdrawn
and redirected slightly and reinserted around the injured area and
another 0.5cc are injected there. This is repeated multiple times thus
“peppering” the fibro-osseous insertion of the tendon or ligament.
Figure 4. Radial collateral ligament injection.
H AND
In my experience, arthritis at the base of the thumb, the
metacarpo-trapezio joint, is very common. Injury to
this saddle joint is debilitating, eventually limiting almost
all opposition of the thumb. There is marked tenderness
over the joint line all the way around the joint in advanced
cases. And when the joint is isolated manually, there is
often pain with even slight movement of the joint.
Treatment begins with cleansing the skin and local
anesthesia. A 5cc luer lock syringe is filled with standard
prolo solution and fitted with a 25G 1 to 2-inch needle.
0.5cc injections are “peppered” along the joint line
beginning at the dorsal hand and finishing along the
palmar side. (See Figure 5.) The injections on the palmar
side are especially painful. Therefore, I save them for last.
510
Figure 5. Metacarpo-trapezio joint injection.
Metacarpo-phalangeal (MP) and inter-phalangeal
(IP) joints are injured in sports and accidents. Prolotherapy
effectively stimulates healing in sprains, arthritis, and
tendinosis of these joints. The affected joints are
identified and cleansed and local anesthesia is applied. A
5cc luer lock syringe is filled with standard Prolotherapy
solution and fitted with a 25G 1 to 2-inch needle. The
Prolotherapy is administered carefully, injecting 0.5 to 1cc
to the radial and ulnar side collateral ligaments and joint
capsule of each injured MP and IP joint. (See Figure 6.)
The needle does not need to slip into the joint space. The
fingers bleed readily after needle puncture and may need
light pressure.
De Quervain’s tenosynovitis is a painful inflammatory
condition of the wrist and thumb that often requires a
traditional steroid injection treatment, if the area shows
classic signs of swelling and calor. If there is clearly no heat
or inflammation, then the condition can be presumed to
be tendinosis or tendopathy, which typically responds well
to Prolotherapy. The thumb abductor (abductor pollicus
longus) is identified by having the patient abduct the
Figure 6. MP and IP injection.
thumb against light resistance. The tendon tenses and lifts
slightly. It can be seen and palpated easily at the radial
side of the wrist (it is tender).
The skin is cleansed and local anesthesia applied. A 3cc luer
lock syringe is filled with 1.5cc of standard Prolotherapy
solution and fitted with 25G 1 to 2-inch needle. With a
finger palpating the slightly elevated abductor tendon
sheath, the needle is passed through the skin and then
enters the tendon sheath to inject around the tendon. (See
Figure 7.) When the needle is positioned within the sheath,
as the injection is administered, it leads to a “sausage-like”
swelling of the tendon sheath. This is seen and palpated.
One to 1.5cc is injected into the tendon sheath.
Figure 8. Prolotherapy injection to flexor digitorum tendon.
Figure 9. Mallet finger. A severe “jammed” finger can actually
cause the distal extensor tendon to tear. Splinting is needed, but
Prolotherapy can assist healing and decrease healing time for
this condition.
Figure 7. Wrist abductor pollicis longus tendon Prolotherapy
injection.
Flexor tendon nodules or “trigger finger,” as it is
sometimes called, is caused by a tendon nodule being
hung up on, then “popping” past the tendon sheath
transverse support sling palmar to the joint line. The
tendon nodule can be felt moving under the skin of
the palm as the involved finger is passively moved. For
some cases of trigger finger, a steroid injection must be
used as the first course of action to shrink the nodule. If
there is no palpable nodule, but it is clear that the flexor
tendon attachment is the problem (either flexor digitorum
profundus or superficialis), then these tendon attachments
can be treated. (See Figure 8.)
Mallet finger and boutonniere deformity are both
effectively treated with Prolotherapy. When the distal
extensor tendon is torn the distal inter-phalangeal joint
is flexed at 90 degrees and lacks ability to actively extend
the distal phalanx. In some cases, a piece of the bony
attachment is torn off with the tendon. (See Figure 9.)
If we have a similar tear of the extensor tendon at the
proximal inter-phalangeal joint we have Boutonniere’s
Used with permission of Beulah Land Press © 2001 Oak Park, IL. Prolo Your Sports
Injuries Away!, fig. 22-16.
deformity. These injuries are effectively treated with a full
extension splint and Prolotherapy to the torn tendon in
the fully extended position. Full extension is maintained
continuously for six weeks while Prolotherapy is repeated
weekly for the first three weeks.
The skin is cleansed and anesthetized. A 3cc luer lock
syringe is filled with 1cc of standard Prolotherapy solution
and fitted with a 25G 1-inch needle. The injection is
administered at the extensor tendon tear over or just
distal to the dorsal inter-phalangeal joint line.
Each of these conditions call for an average of four to six
treatments spaced about four to six weeks apart to yield
full healing and restoration of function.
The hand and wrist are full of many small joints each
of which can be injured and cause pain. Thankfully,
Prolotherapy can safely and effectively treat each of them.
That is why we smile as we Prolo our patient’s hand and
wrist pains away! n
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IT’S A WIDE WIDE WORLD: BUILDING A RATIONALE FOR EVIDENCE-BASED PROLOTHERAPY
I T ’ S
A W I D E W I D E W O R L D
Building a Rationale for Evidence-Based
Prolotherapy in an Orthopedic Medicine Practice
Part 1: A Short History of Logical Medical Decision Making
Gary B. Clark, MD, MPA
To make the most appropriate medical decisions,
Ask the right questions.
To validate the appropriateness
of those general decisions,
Collect specific confirmatory outcome data.
I
n this first of a four-part series, I outline the
logical reasoning behind medical decision making,
including Prolotherapy. Part II will explain how to
apply such reasoning along with its logical extension, the
scientific method, to the daily practice of any Orthopedic
(Musculoskeletal) Medicine clinic by establishing
expectations for patient care outcome and setting up a
database to facilitate outcome assessment. Part III will
present an actual case series report based on a scientificallydesigned, evidence-based Prolotherapy practice. Part IV
will address the practice of evidence-based Prolotherapy
in a peer reviewed, government regulated environment.
Since the dawn of the medical profession, there has been
need for confirming reliability and safety of healthcare
practices. Medical decision-making to achieve acceptable
levels of public and professional confidence is traceable
to ancient cultures. Over the millennia, it has eventually
become one of the finest humanistic intentions to harness
the best quality data to support the most rational clinical
decision-making. In the modern day, scientific decisionmaking has become the accepted rationale behind:
• Performing a clinical history and physical examination
• Determining an integrated and differential diagnosis
• Designing and providing the most appropriate and
necessary treatment, and
• Reassessing the efficacy and risks of those diagnoses
and treatments by analyzing patient outcome.
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Development of the Scientific Method as a logical,
systematic approach to rational decision-making has
depended on several cultural innovations, including
language, philosophy of science, astronomy, mathematics,
and healthcare technology—all springing from the
growth of an inquiring human mind. The earliest efforts
at Empirical Reasoning have led to the principles of
Deductive, Inductive, and Abductive Reasoning—all
essential components of logical medical decision-making
leading to evidence-based Prolotherapy.
E m e r g e nc e o f R a t i o n a l D e c i s i o n - M a k i n g
Approximately 200,000 years ago, the earliest Homo
sapiens (“wise, or rational, man”)1 was evolving in a world
of wondrous, inexplicable—and very lethal—cause-andeffect. It was a time when our ancestors were closest to
nature—they were a part of nature—and it could be
absolutely overpowering. Then, mankind began a very
slow journey—developing culturally, adapting physically,
creating technology, and learning how to control that
hostile environment.
Empirical Reasoning
In the midst of that primeval, 24/7, reality survival
course, early humans could probably not help but
observe and recognize obviously apparent correlations
of coincident phenomena that they easily construed—or
misconstrued—as “incontrovertible” evidence of directly
related cause and effect. To the early hominid mind, it was
likely a key matter of survival to make correct experiential
correlations using all five senses—or perish. You had to
be a quick study. Thus, the earliest form of Empirical
Reasoning was born in the primitive human mind. The
only body of evidence of the evolution of any such early
thought process is mute anthropological remains. Who
knows to whom the founding of the earliest tenets of
Empiricism can be attributed—perhaps his name was
“Hunter.” We are left to pure conjecture regarding those
opening pages of our decision-making history.
that the sun is revolving around the Earth (Coincidental
Consequence B).
Relatively early on, however, it is probable that certain
H. sapiens were more successful than others at accurately
recognizing healing, even lifesaving, correlations between
natural phenomena. Such talent may have been considered
as very mysterious, happening through some inexplicable,
intuitive “sixth sense.” These more successful hominids
founded the societal lineage of the shaman, the medicine
man, the healer—all mostly bent on beneficial service.
Others may have become politicians or priests. The power
of empirical decision-making continued to prevail under
the guise of shamanism, superstition, mythology—or
theocracy—through thousands of tumultuous unrecorded
and, then, recorded centuries.
Example 2: In the Vietnamese Central Highlands,
a Rhade Montagnard shaman and his tribal patients
recognize the appearance of a tender swelling in the
arm pit. They call it “rhua.” And they all know that the
swelling is almost always coincident with the afflicted
patient’s dying. The shaman’s history taking and physical
examination assessments are limited. Neither the shaman
nor the patient know the relationships of “rat flea,”
“axillary lymph node,” “bubo,” “plague,” “Yersinia pestes,”
or Streptomycin. But, they definitely know by tribal oral
tradition and frequent occurrences of this disease—
especially around the time of the monsoon rains—that
a warm, nodular swelling (Coincidental Precondition A)
almost inevitably promises the patient a feverish death
(Coincidental Consequence B). In their view, the result of
the axillary swelling is apocryphal. So, the shaman will
place the terrified patient in a ritual smoke house, praying
to his animist gods—being as closely integrated with the
natural world as they are. And, yes, the patient will most
likely die, just as the shaman will have foretold, based on
the shaman’s experience and collective tribal wisdom.
And the fellow villagers will accept their friend’s fate,
empirically.8
Thus, early Empiricism (from the ancient Greek word
empeiria, “experience”)2 promoted supernatural, religious,
and mythological explanations to account for natural
physical phenomena, including illness and injury. The
ancient Egyptian and Babylonian cultures left early
documented evidence of pure, unbridled empirical
science. An Egyptian medical textbook (the Edwin Smith
papyrus), circa 1600 BC, prescribed the following basic
steps for treating various specific diseases: examination,
diagnosis, medical and surgical treatment, and prognosis.
This rather impressive early “medical practice guideline”
was based on empirical interpretation of natural cause and
effect, all of which was facilitated by a complex pantheon
of deities.3, 4
Empiricism allows one to derive a Consequence B as
being caused by a coincident or sequentially associated
with Antecedent or Precondition A, whereby the only
proof or confirmation is that the correlation has been
sensed in some way. As such, Empiricism is built upon a
logical fallacy that correlation implies causation when, in
fact, it does not. This very fundamental fallacy is known
as “Cum hoc, ergo propter hoc”—”With this, therefore because
of this”—or “false cause.” Fundamental Empiricists assert
that truth must be established by reference to sensory
experience alone.5, 6, 7
Example 1: The sun is consistently observed to rise daily
from the eastern direction, move across the heavens, and
set in the western direction—and the sun appears to be
the only fiery object that is moving in the daytime sky
(Coincidental Precondition A). Ergo, it might be concluded
Example 3 (First Hypothetical): A 45-year-old female
villager, mother of five offspring presents the same Rhade
shaman with a history of chronic left lower back pain that
has become slowly but increasingly uncomfortable with
pain increasingly radiating down the left leg to her foot,
causing significant physical disability in a world where
manual labor is mandatory for survival. There has been
no antecedent traumatic event. The shaman recognizes
this malady from his mentor’s teachings and many similar
personal encounters. He performs a limited examination,
perfunctorily palpating the painful area. First, he ascertains
that this woman is aging (Coincidental Precondition A),
worn by time and a hard life. In his primitive culture,
which does not even know the use of a wheel, it seems
inevitable that a sore back (Coincidental Consequence B)
will eventually happen in most older women and men. He
considers aging as the cause of low back pain. He suggests
that the woman use a crutch to support the painful side
and sit often in the nearby cool stream to relieve the pain
because those pragmatic interventions seem to have always
helped, at least somewhat, in their past. She is to pray daily
to the jungle ocelot to re-attain agile movement.
513
Thus, a clinician can make a diagnosis by empirical
rationalization based on a mentor’s instruction or the
clinician’s personally observing multiple occurrences of
various, seemingly obvious, coincidental or sequential
precedents (i.e., so-called “Preconditions”)—such
as aging—appearing coincidentally or sequentially
with a given injury or disease process (i.e., so-called
“Consequences”)—such as low back pain—without
further testing the validity of his belief.
Deduction (from the Latin word de + ducere or deducere,
“to lead down or away”)11 allows one to derive a specific
Consequence B as being caused by a known general
Precondition A. Deduction is a logical process that
proceeds from a known general understanding (General
Precondition A) to a derived specific conclusion (Specific
Consequence B). Deduction is a logical process that
requires a validated general premise as the Precondition.
The initial general Precondition needs to have been
deemed true by measurable definition—independent of
sensory, empirical bias.9 Such a General Precondition
is often classically expressed in arithmetic or geometric
terms, such as the measurement of area, angle, arc—or
the range of physiological joint motion.
Example 1: It has been ascertained to be true by
measurement that the sum of the angles of all triangles is
always 180 degrees (General Precondition A). Ergo, if the
sizes of two angles of one triangle are known, the size of
the specific third (unknown) angle can be deduced as 180
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AN
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In the more philosophically enlightened environment of
the 5th and 4th centuries BC, the ancient Greeks began
delving into the earliest forms of more rational theories
of causality. Initially proposed by Plato, Aristotle (384-332
BC), helped to further formulate and describe the basic
principles of Deductive Reasoning.9, 10
SPEC
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Deductive Reasoning
HY POTH ES
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BA SE D O N
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Through the ensuing prehistoric years, certain thoughtful
men most likely began to realize that Empirical Reasoning
needed to be supplanted by a more rational approach to
decision-making. This could be extremely dangerous,
however, and not without risk of a questioning individual’s
being held in contempt by the established empirical
traditionalists. Such heresy could exact a deadly toll of
hemlock-laced Kool-Aid or even a more ignoble and
painful demise.
GENERAL KNOWN
RULE (TRUTH)
G. B. C.
Figure 1. Deductive reasoning.
degrees minus the sum of the two known angles (Specific
Consequence B).
Or… it is recognized by repeated measurement that the
normal range (arc) of sacroiliac joint (SIJ) movement
on physical testing is within 5 to 10 degrees (General
Precondition A). Therefore, if the movement of an
SIJ is less than five degrees, especially when compared
to the other side, it can be deduced that the joint is
abnormally hypomobile or restricted in motion (Specific
Consequence B).
Example 2 (Second Hypothetical): In about 350
BC, a Greek physician of the Hippocratic School meets
a 45-year-old Grecian mother of five, who presents with
the same history of chronic left lower back and leg pain
as exemplified in the first hypothetical. There has been
no antecedent traumatic event. The physician recognizes
this malady from his mentor’s lessons and many similar
encounters. On examination, he finds the patient’s left
leg is physically shortened when she is lying supine. Over
the course of his career, he has carefully noted that the
vast majority of all such low back pain patients have a
shortened leg (General Precondition A) on the same side
as the back and radiating leg pain. From that general,
measured and recorded observation, he deduces that the
back pain problem (Specific Consequence B) is caused by
the leg length difference—which he considers anatomical
in nature. Therefore, he improvises a sandal heel lift, a
technique that has previously helped many of his low
back patients. He suggests that the woman use a crutch
to support the shortened, painful side—also confirmed
by trial experience—and that she sit often in the nearby
cool stream to relieve the pain—which he had also often
confirmed. She is to pray daily to Asclepios, the Greek god
of healing, for Olympian intervention and pain relief.
A clinician can deduce a presumptive diagnosis based on
previously recorded clinical historical facts and measured
physical findings, which seemingly indicate a general truth.
However, in deductive reasoning, the general premise or
Precondition A (e.g., most low back pain is caused by a
leg length discrepancy) might be factually invalid while
the specific conclusion or Consequence B (e.g., low back
pain may be helped by equalizing leg length) might be,
essentially, valid.
In d u c t i v e R e a s o n i n g
Aristotle also helped formulate and, most importantly,
chronicle the precepts of Inductive Reasoning. Induction
(from the Latin word in + ducere or inducere, “to lead or
bring in”)12 is carried out by drawing conclusions about
the general physical world based upon establishing
experimentally proven specific “first principles.”10
Induction allows one to infer that a specific Precondition
A results in a general Consequence B. This logical process
is based on making specific observations, perceiving a
meaningful pattern in those observations, reaching a
tentative hypothesis, and devising a specific test for that
general hypothesis to establish a general theory. The
established tests (proofs) become useful as stepping stones
to establishing further proofs of new hypothetical theory.
An inductive statement requires experimentally “proven”
experiential evidence for it to be valid.
TEN
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A NE W TRU TH
SPECIFIC EMPIRICAL
OBSERVATIONS
G. B. C.
Figure 2. Inductive reasoning.
Example 1: It’s observed to be raining outside the building
with the rain hitting the street. On multiple occasions, the
observer ventures onto the street to test the hypothesis
that the street becomes wet during a rain, the observer
repeatedly looking at and feeling the street for moisture
during a rain (Specific Precondition A). Ergo, without
going outside to check anymore, just by seeing the specific
evidence of rain from inside the building, the observer can
induce, generally, that the street must be becoming wet
again (General Consequence B).
Example 2 (Third Hypothetical): In 160 AD, a
Roman physician of the school of Galen meets a 45-yearold mother of five, who presents with the same history
of chronic left lower back pain as exemplified in the
first hypothetical. The physician recognizes this malady
from his mentor’s lessons and many similar encounters.
On examination he finds the painful left leg is physically
shortened and abduction of that leg is weakened, a trend
that he has observed in many patients with or without low
back pain. On palpation, he tests and finds that the sacrum
(the “sacred” bone) is rotated and dropped inferiorly on
the painful side, also a trend that he has found consistently
associated with low back pain, shortened legs, and
weakened leg abduction. Also, the left SIJ is restricted in
movement. As an additional physical test, he manipulates
the sacrum back into normal alignment. He re-examines
to find there is no longer any leg length or leg abduction
discrepancy. From his detailed examination, treating,
and re-examination (all specific tests), he induces that the
patient’s specific injury is a hypermobile, displaced sacrum
(Specific Precondition A) and that the misaligned sacrum
is the specific cause of the patient’s general low back pain
(General Consequence B) and associated problems. He
retests the patient’s musculoskeletal system by asking the
patient to rise from the treatment pallet and walk a short
distance to exert some weight-bearing on the sacroiliac
joint. She returns to the table and, upon re-examination,
he finds that she has remained aligned while claiming
significant reduction of her low back pain. The physician
suggests that the woman wear a tight belt, which he has
also found by experimental clinical trial may reduce her
sacral hypermobility and need for physical realignment.
She is to pray daily to Apollo, the Roman god of healing.
Thus, a clinician can reach a confirmed diagnosis based
upon testing a hypothetical general diagnosis by submitting
the patient to certain reliable, specific physical, laboratory,
or radiological examinations for “experimental” proof.
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DIF
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AB
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A NEW TRU TH
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G
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Pierce commented that seeing the image of an azalea in
bloom is concrete, whereas the statement describing all
the biological processes inherent in that plant is abstract.
This existential paradox requires Abductive Reasoning to
explain how or why the azalea is in bloom where there
are multiple explanations. He further expounded that,
“The truth is that the whole fabric of our knowledge is
one matted felt of pure Abductive hypothesis confirmed
and refined by Induction. Not the smallest advance can
HU
NC
Abduction (from the Latin word abducere or ab + ducere,
“to lead away”) allows one to infer that a Precondition
A explains Consequence B—where there can be multiple
explanations for Consequence B. As such, Abduction is
built on the logical fallacy of “Post hoc, ergo propter hoc”—
”After this, therefore because of this.” As in all modes of
decision-making, Abduction begins empirically with an
intuitive hunch or “educated guess.” Precondition A is
chosen because it is taken to be the most likely hypothesis
based on a hunch. Conclusions by Abduction must be
validated by separately assessing each by careful Deduction
and/or Induction. Abduction can be helpful as a problemsolver when multiple causes of B are known or expected.
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Ab d u c t i v e R e a s o n i n g
By the late 1870s, Charles Sanders Pierce, a chemist, had
proposed an expanded approach to hypothesis testing,
involving an interplay of Deductive, Inductive, and
abstract reasoning—Pierce formulating the precepts of
Abductive Reasoning. Also recognized as a prominent
statistician, Pierce introduced randomization as a basis for
sound statistical inference and invented blinded, controlled
randomized experimentation.13, 14
IF IC
SPEC
Whereas Deductive Reasoning, is more narrowly
concerned in testing a general hypothesis—Inductive
Reasoning is more open-ended and exploratory,
developing broader generalizations and theories from
specific measurable observations. Following the Classical
Grecian Age, Inductive Reasoning became the bedrock of
philosophical logic and mathematical testing for certainty
through the next millennium.
HY POTH ES
IS
BA SE D O N
RU LE
GENERAL KNOWN
RULE ( TRUTH)
In inductive reasoning, the specific testing premise or
Precondition (e.g., an unlevel sacral base can cause low
back pain) can be true—while the general conclusion or
Consequence (e.g., the low back pain patient is suffering
from an unlevel sacral base) can be false—because there
might be more than one cause for low back pain.
S
G. B. C.
Figure 3. Abductive reasoning.
be made in knowledge beyond the stage of vacant staring,
without making an Abduction at every step.”13
Example 1 (Fourth Hypothetical): In 1920, an
American osteopathic physician and student of Andrew
Taylor Still, MD, DO, founder of osteopathy, meets a
45-year-old mother of five, who presents with the same
history of chronic left lower back pain as exemplified
in the first hypothetical. The physician recognizes this
malady from his mentors’ lessons and many similar
encounters. He notes the importance of her history of
multiple pregnancies and their prenatal hormonal effect
on general ligament laxity. This is verified by her shoe
size having increased by a full size since her second child’s
birth and her displaying profound Pes planus on physical
examination. On questioning, she also remembers having
intermittent right interscapular pain. On examination of
her gait, she walks with a hesitation limp and pronationexternal rotation of her foot and ankle on the right. As she
is walking, she complains of right medial knee pain. Her
posture is marked by a significantly dropped right shoulder.
Lying supine, her left leg is functionally short by about 8
mm and her left leg abduction is significantly weakened.
Her left hamstring muscle is much tighter than the right.
Her left ASIS is anterior and the left sacroiliac joint is
restricted in mobility. Lying prone, her left inferior sacral
angle is dropped inferiorly and anteriorly. When sitting,
her vertebral column is mildly scoliotic with the lumbar
convexity to the left and a high thoracic costovertebral
hump on the right (perhaps the source of her interscapular
pain). The physician determines a complex diagnosis for
the patient’s low back pain (Consequence B1), including
general ligament laxity and sprain injury (Precondition
A1) accompanied by a left sacroiliac joint ligament sprain
and misalignment (Precondition A2) resulting in an
unlevel sacral base (Precondition A3), a compensatory
scoliosis (Precondition A4), and a functionally short left leg
(Precondition A5). The Pes planus (Precondition A6) may
also be contributory to the low back pain. Compensatory
pronation of the foot of the right functionally long leg
could be contributory to the right medial knee pain.
He also considers a differential diagnosis of the left leg
radiating pain (Consequence B2) as being secondary
to the sacroiliac/iliolumbar ligament sprain injury
(Precondition A2) versus left L5-S1 nerve impingement/
sciatica (Precondition A7) possibly being aggravated by
the scoliosis (Precondition A4). His diagnostic summary
takes into consideration all the major aspects of what
we now know as tensegrity, including the significance of
the patient’s dropped right shoulder. His treatment plan
includes osteopathic manual therapy (OMT) of the lumbar
spine, sacrum, and pelvis. If the patient’s sacroiliac joint
does not remain stabilized after the OMT, he will suggest
the use of a sacroiliac belt to minimize the frequency of
return office visits for repeat OMT for lumbar, sacral, and
pelvic realignment. He will recommend intensive physical
therapy to lengthen shortened scoliotic and left leg muscle
groups (including the painful thoracic costovertebral
muscular restrictions) and to regain core postural strength
through time. He will recommend orthotics to minimize
the further deterioration of the patient’s feet and knees.
And he wishes there were a way to permanently stabilize
that “sacred” bone.
The Nobel laureate novelist, Hermann Hesse, wrote
“Magister Ludi.”15 In that novel, he described a game of
mental and spiritual gymnastics known as “The Glass Bead
Game” (Das Glasperlenspiel) in which academicians could
synthesize new knowledge or understanding based on
a combination of Deductive, Inductive, and Abductive
Reasoning—with a little added Zen. Using an analogous
logical process, a musculoskeletal clinician can reach a
complex, integrated diagnosis with differential diagnostic
options and a matched treatment plan staged through
time. In addressing low back pain, he understands by
Abduction that there can be more than one cause of a
given complaint—and those antecedent events may be
coincidental or sequential through the course of time.
And a little Zen can always be helpful.
The Logical Development of Prolotherapy
Through unrecorded and recorded history, the diagnosis
and treatment of musculoskeletal injuries has been of
common medical interest. Just as pinworm infestation,
ligament and tendon sprain injuries have plagued even
the seats of the mighty—especially their low backs. In
all the hypothetical examples provided, there has been a
glaring need for some way to more permanently stabilize
the major offending problem or Precondition of joint
hypermobility—in these case examples, the sacroiliac
joint. Prolotherapy has emerged as one answer.
The tide of logical contemplation over such postural,
strain, and sprain injuries reached its high-water mark in
the 1930s when George S. Hackett, MD, and his colleagues
began to ask how they might facilitate the healing of
chronic sprain injury. After much empirical observation
and thought along with clinical trial and error, Hackett, et
al., may have considered the following logic, as based on
Hackett’s writings.16
First, they might have asked, “If the body naturally
heals some sprain injuries, why not others?” The nonhealing sprains become persistent or recurring injuries,
characterized by chronic pain, hypermobility, and
dysfunction—the ankle joint being a good example. Often
the injury—especially that of a weight-bearing joint—
inevitably becomes worse without definitive treatment.
How does the body naturally heal such an injury? Hackett
and his colleagues probably had learned in second year
medical school pathology that the body’s natural healing
process is inflammation. They probably also recognized
that ligaments and tendons have a problem naturally
healing because they are very dense collagenous tissues
with relatively less vasculature through which inflammatory
cells might enter a sprain injury site.
Then, Hackett, et al., probably experienced, first hand,
in the third and fourth medical school years in the
clinics and wards, that one of inflammation’s four major
characteristics is pain. And, they learned that since we
physicians do not like to hear our patients complaining of
517
pain, then we do whatever is necessary to alleviate patients’
pain by prescribing rest, ice (which is anti-inflammatory),
compression, and elevation, along with non-steroidal
anti-inflammatory medication. The primary autoinflammatory diseases also give the normal healing process
a bad name—guilt by association. And then, ubiquitous
pharmaceutical advertisements incessantly campaign
against any possibility that inflammation does any good
at all and that all inflammation must be eliminated by
physicians prescribing their anti-inflammatory products.
So, Hackett, et al., deduced that if it is a general truth that
inflammation is truly the body’s way of healing (General
Precondition A), than, re-initiating an inflammatory
process at the specific site of a ligament or tendon sprain
injury might heal that specific chronic, nonhealed injury
and cause the accompanying symptoms and signs to
diminish or disappear (Specific Consequence B).
They asked, “How does one provoke an inflammatory
reaction?” Well, how about re-creating the old injury?
“How does one cause a mild injury that is just serious
enough to create an inflammatory response?” How about
producing the mildest of osmotic tissue stress by injecting
a small amount of relatively low concentration (but still
hyperosmolar) glucose solution? The rest, as they say, is
history.
Thus, Prolotherapy was born from early empirical
questioning leading to scientific reasoning followed by early
clinical trial and learning. Finally, orthopedic medicine
had a method of nonsurgically stabilizing that “sacred”
sacrum, as well as all the other joints of the body.
An E m e r g i n g B o d y o f E v i d e nc e L e a d i n g
t o E v i d e nc e - B a s e d P r o l o t h e r a p y
Over the ensuing years, a body of evidence showing the
efficacy of Prolotherapy has slowly begun to take shape.
The ultimate goal is to present Prolotherapy as an evidencebased medical approach to treating sprain injuries.
Of major importance, there is always need for a textual
explanation of theory and technique. Hackett published
the first edition of Ligament and Tendon Relaxation Treated by
Prolotherapy in 1956.16 Decades later, that text still provides
invaluable reading for any Prolotherapist. Amongst many
early revelations and didactic “pearls,” Hackett led the
way in illustrating the referral patterns of ligament pain.
Dorman and Ravin’s Diagnosis and Injection Techniques in
518
Orthopedic Medicine (1991) brought radiologic imaging
analysis to the forefront.17 Principles of Prolotherapy by Ravin,
Cantieri, and Pasquarello (2008) is most recent, very up-todate, complete, and professionally illustrated.18 The Journal
of Prolotherapy is another step toward the reporting of peerreviewed studies within the Prolotherapy community.
It is all of this basic literature on which evidence-based
education and board certification study and testing can
be based.
Dean Reeves, MD, and other dedicated Prolotherapy
investigators have followed through with the next step,
which has been to apply inductive reasoning and the
scientific method to testing the efficacy of Prolotherapy as
a treatment for various forms of chronic musculoskeletal
injury and disease. Overall, their induction-based
experimental methods have included study of retrospective
case series; prospective and consecutive case series; and
randomized, double-blind, placebo-controlled cases. These
studies have addressed several modes of Prolotherapy for
several types of musculoskeletal injuries.
In more recent years, equally dedicated and expert
investigators, such as David Rabago, MD, have brought
Prolotherapy into the arena of Evidence-Based Medicine
through the use of systematic review and meta-analysis
to identify compelling levels of evidence of the efficacy
of Prolotherapy that exists in the current literature. As
will be explained in Part IV of this series, more needs
to be accomplished at all levels of clinical practice and
research in order for Prolotherapy to achieve the levels of
confidence required to satisfy peer review and government
regulations.
In the next of this four-part series, I will explain the basics
of a well-designed scientific model for clinical Prolotherapy
practice and a database that every clinician can use in
daily practice to record and assess outcome. n
R e f e r e nc e s :
1. American Heritage Dictionary of the English Language, 4th ed.,
Philadelphia: Houghton Mifflin Co, 2000.
2. “Empiricism.” Encyclopedia Britannica Online. 09 July 2010:
http://www.britannica.com/bps/search?query=empiricism.
3. “Edwin Smith papyrus.” Encyclopedia Britannica Online. 09 Jul.
2010: http://www.britannica.com/EBchecked/topic/179901/
Edwin-Smith-papyrus.
4. “Edwin-Smith papyrus.” Wikepedia. 09 July 2010: http://
en.wikipedia.org/wiki/Edwin_Smith_papyrus.
5. “Empiricism.” Wikipedia. 09 July 2010: http://en.wikipedia.
org/wiki/Empiricism.
15. Hesse H. Magister Ludi (Das Glasperlenspiel) Vintage Classics. ISBN
9780099283621.
6. “Correlation does not imply causation.” Wikipedia. 09 July 2010:
http://en.wikipedia.org/wiki/Correlation_does_not_imply_
causation.
16. Hackett GS, Hemwall GA, Montgomery GA. Ligament and Tendon
Relaxation Treated by Prolotherapy. 5th ed. Oak Park, IL: Gustaf A.
Hemwall, MD;1993.
7. “Causality.” Wikipedia. 09 July 2010: http://en.wikipedia.org/
wiki/Causality.
17. Dorman TA, Ravin TH. Diagnosis and Injection Techniques in
Orthopedic Medicine, Baltimore, MD: Lippincott, Williams and
Williams; 1991.
8. Author’s personal observation in Vietnam as US Army Special
Forces physician in 1969-1970.
9. “Deductive Reasoning.” Wikipedia. 09 July 2010: http://
en.wikipedia.org/wiki/Deductive_Reasoning.
10. “Inductive Reasoning.” Wikipedia. 09 July 2010: http://
en.wikipedia.org/wiki/Inductive_Reasoning.
11. “Deduce.” Dictionary.com. 09 July 2010: http://dictionary.
reference.com/browse/deduce.
12. “Induce.” Dictionary.com. 09 July 2010: http://dictionary.
reference.com/browse/induce.
13. “Abductive Reasoning.” Wikipedia. 09 July 2010: http://
en.wikipedia.org/wiki/Abductive_Reasoning.
14. “Charles Sanders Pierce” Wikipedia. 09 July 2010: http://
en.wikipedia.org/wiki/Charles_Sanders_Pierce.
18. Ravin T, Cantieri M, Pasquarello G. Principles of Prolotherapy.
Denver, CO: American Academy of Musculoskeletal Medicine;
2008.
Ackn o wl e d g m e n t s
The author is grateful to the peer reviewers and Carol
Schneider, PhD, and Allen Parker, EdD, for their expert
and wise shepherding of this publication. Special thanks
to Dr. Waldo E. Nelson in his textbook, Pediatrics (circa
1965), for his description of pinworm.
PUR C HASE THE PRO L OTHERAPY I N STRU C TIO N A L DVD :
Prolotherapy: Anatomy
& Injection Techniques
By Jeffrey J. Patterson, DO with Mark G. Timmerman, MD
DVD Set: $300 + $7.50 US Shipping = $307.50
Buy online at: www.hacketthemwall.org
or
Mail a check in US funds to: Hackett Hemwall Foundation,
2532 Balden Street, Madison, WI 53713. Include your shipping address.
THE HA C K ETT HEM W A L L F OU N DATIO N
519
IT’S A WIDE WIDE WORLD: ACOSPM 2010 SPRING SEMINAR
I T ’ S
ACOSPM 2010
Spring Seminar
Mark L. Johnson, MD, FACS
The annual teaching conference of the American College
of Osteopathic Sclerotheraputic Pain Management
(ACOSPM) was held April 8-11 at the beautiful Rancho
Bernardo Inn facility in San Diego. As always, this was
a very valuable training and education experience.
Entitled “Prolotherapy, a Comprehensive Approach,”
the conference focused on teaching basic and advanced
Prolotherapy techniques, and in addition featured
introductory lectures on Mesotherapy, Neural Therapy,
Therapeutic Nutrition, Manual Medicine (musculoskeletal
manipulation), Hormone-Healing interactions, and
other topics which augment and enhance the effects of
Prolotherapy treatment. Program Chairwoman Aline
Fournier, DO assembled a stellar cast of teachers and
mentors.
picks up where the body’s natural biochemical processes
leave off.” This technique has wide application in treating
various types of joint damage and a wide array of other
connective tissue problems. Some of the attendees have
practiced this technique for over 30 years, with great
success.
Approximately one third of the 150 attendees had never
employed this treatment and were seeking basic training.
In his opening lecture, ACOSPM President Walter
Grote, DO posed the question, “Where, and how, do
you start using this treatment?” For this portion of the
audience, the essentials were conveyed over the next
three days. Ways to identify and evaluate candidates for
Prolotherapy were taught. Different proliferant solutions
and their utility were discussed. Techniques for treating
each major joint and region were taught in lecture, and
then illustrated in lab courses. New this year was video
feed of treatments to large screens in the lab areas, so
that everyone had an unobstructed view of even the
best-attended demonstrations. Attendees who desired
treatment for various problems provided a large and
varied array of treatment demonstrations for the rest.
Prolotherapy is a remarkably safe treatment modality.
The principles which result in such a low complication
rate were stressed, as well as identifying and managing
those complications which are occasionally seen. One
area of particular interest was a discussion of the
The conference room at the San Bernardo facility.
Prolotherapy is a medical technique developed in the
1930s using various “proliferant solutions” to trigger the
body’s strongest connective tissue healing response. One
of the fathers of this field was Earl Gedney, DO. This
organization carries forward his legacy, while disseminating
current research and clinical information in this rapidlygrowing field. As aptly stated by Dr. Damon Whitfield,
“All connective tissue healing is incomplete. Prolotherapy
520
Damon Whitfield, DO, lectured on treatment of non-enthesis
soft tissue damage, including muscle and fascial injuries,
then demonstrated techniques in the lab session.
Fournier, DO. Both lecturers highlighted the potential
of these modalities to treat dysfunction of the autonomic
nervous system, which is often an unrecognized component
of post-injury pain, and both illustrated in lecture and
clinical demonstration how to identify and treat these
disorders. Several lecturers detailed the interaction
between nutrition and healing, and advocated various
clinical approaches to promote connective tissue healing
and overall health.
Chris Davis, DO, next year’s Program Chairman, mixing
proliferant.
interaction of chondrocytes and various local anesthetics.
High dose administration of bupivicaine has produced
cartilage damage in some settings. There has been
concern voiced in some quarters that intra-articular
Prolotherapy using bupivicaine, and possibly other local
anesthetics, might cause a similar complication. Evidence
was presented that cartilage damage is both agent and
concentration dependent. Lidocaine above 0.25%, and
bupivicaine above 0.125% should be avoided, but below
these concentrations no chondrocyte toxicity is noted.
Ropivicaine demonstrates no such toxicity.
More experienced practitioners were greeted with a wealth
of opportunities to sharpen and enhance their skills.
All of the “basics” lectures were laced with pearls and
comments on advanced techniques. There were lectures
on use of ultrasound for diagnosis and for targeting of
treatment by John Kripsak, DO, on the use of Platelet
Rich Plasma and Mesenchymal Stem Cells by Donna
Alderman, DO, and on Prolotherapy of non-enthesis
connective tissue injuries (e.g. herniae and other fascial
injuries, muscle injuries, etc.) by Damon Whitfield, DO.
Dr. John Sessions taught and demonstrated techniques
of venous Sclerotherapy. As always, some of the most
valuable educational experiences were the informal
discussions that took place during the delightful breakfasts
and lunches provided for attendees.
Techniques that can be used alongside Prolotherapy for
treatment of more complex pain syndromes were also
covered in detail. These included Neural Therapy, taught
by Gerald Harris, DO and Mesotherapy, taught by Aline
This conference is designed to introduce physicians
to Prolotherapy, to equip them to begin offering this
treatment, and to enhance the skills of Prolotherapists
at every level. How well does it meet these objectives?
Robert Vance, DO of Las Vegas, Nevada obtained his
first Prolotherapy training at the ACOSPM seminar a year
ago. Since this initial exposure, he has performed about
fifty treatments. His success rate for treatment is around
75%, and he cited several patients who had experienced
life-altering results. He was particularly excited about a 79
year-old patient with low back pain who was on high dose
narcotics and using a walker last year. This year she is off
narcotics and her mobility is dramatically improved. The
patient is understandably delighted. Dr. Vance is back for
more training. He highly recommends this experience for
anyone wanting to learn this technique.
Another fascinating perspective was voiced by Charles
Nowacek, MD, an Orthopedic Surgeon from Hastings,
Nebraska, who commented on the “integrity” of the
group and the conference. When asked to elaborate, he
said that this group of physicians, more than any he has
Dr. Richard Hull, past President and new Vice President of
the ACOSPM, demonstrating evaluation and treatment.
521
been around, go back to what is important in patient
care. That is, they promote doing what is RIGHT for a
particular patient, with treatment choices based on what
works to get the best result for the individual, versus the
“modern” medical algorithms that are based on financial
and insurance-driven concerns, cook-book approaches,
and cursory, if any, attention to the individual patient.
He said that the ASCOPM is a “true professional
organization of highly accomplished physicians sharing
their considerable experience with their peers, in a way
that is reminiscent of the best of our medical heritage in
this country.”
As one of the few, and as the oldest (originated in the 1930s
as at the American Osteopathic Society of Herniologists,
and reorganized in 1956 as the American Osteopathic
College of Sclerotherapy, the current organization name
was adopted in 1996.) organization for practitioners of
Prolotherapy and related disciplines, the ACOSPM is
dedicated to preserving and promulgating the considerable
experience and wisdom of its members, many of whom
have offered Prolotherapy treatment for decades, and
many of whom were close friends and associates of the
“fathers” of this discipline. Although under the aegis
of the American Osteopathic Association, there are a
number of MD’s among the membership—including this
author.
Three administrative issues of note were covered during
this meeting. First, a new slate of officers was installed.
Dr. Walter Grote, of Columbia, New Jersey passed the
President’s gavel to Dr. Aline Fournier, of Escondido,
California. The new Vice President is Richard Hull,
DO, recently retired to Cabo San Lucas, Mexico, and
Donna Alderman, DO, ACOSPM Board Member and on the
Editorial Board of the JOP, delivering a lecture on Platelet
Rich Plasma and Mesenchymal Stem Cells.
522
Walter Grote, DO, presided over this meeting, then passed
the President’s gavel to Aline Fournier, D.O.
the Program Chair for next year is Dr. Chris Davis of
Springfield, Pennsylvania. Secondly, application was
made to the American Osteopathic Association to change
the name of the organization to reflect its emphasis on
Prolotherapy. The proposed name is the American
Osteopathic Association of Prolotherapy Integrative Pain
Management (AOAPIPM). Thirdly, Dr. Grote and others,
notably Gerald Harris, DO, are continuing their efforts to
develop a Residency/Fellowship program for Prolotherapy.
Dr. Grote issued a challenge to the AOA governing body
to become more helpful in this effort, which seems to have
become stalled in the bureaucratic processes of the AOA.
Appropriate credentialing, including residency and/or
fellowship training, and board certification, seems to be
a next essential step in moving this important treatment
modality into “mainstream” medicine.
Next year this conference will be held in April 2011 in
San Marco Island, Florida. For reservations for next year’s
meeting, or to find out more about this organization,
please contact Ms. Linda Pavina, the Executive Secretary
of the ACOSPM at (800) 471-6114, or visit the website
ACOSPM.com. n
IT’S A WIDE WIDE WORLD: PROLOTHERAPY TRAINING IN MAUI 2010
I T ’ S
Prolotherapy Training
in Maui 2010
Rick Marinelli, ND, MAcOM
O
n the idyllic island of Maui, the main attractions
are the beautiful surroundings. Majestic Haleakala
and the west Maui mountains reaching for the
sky, the incredible white and sunny beaches of the south
side, the dramatic wind and waves of the north shore,
and the distant, mysterious beauty of Hana. People come
from all over the world to sight see, dive, windsurf, fish,
whale watch, and recreate in an exotic, tropical paradise.
So for those interested in learning Prolotherapy and the
newest uses of platelet-rich plasma injection, doing so on
Maui proved to be irresistible.
The course was located on the north shore of Maui in a
beautiful waterfront location where turtles could be seen
from the expansive lawn while integrative, regenerative
Qigong was practiced as part of the course. Participants
from as far as Saipan and Vancouver, BC came together
for the five-day training course in April 2010, sponsored
by the Natural Medicine Clinic. The course format was
lecture for a few hours followed by hands on practicum
doing Prolotherapy. A host of conditions were treated
including chronic low back pain, tendinosis of the
shoulder, elbow, knee, ankle, and spine, instability of all
the major joints, and advanced degenerative arthrosis of
Classic Hackett-Hemwall Prolotherapy.
hips, knees, shoulders, ankles, wrists, and spine. The course
participants, who ranged from medical students to senior
doctors, treated many chronic musculoskeletal conditions
under supervision with classic Hackett-Hemwall dextrose
Prolotherapy and platelet-rich plasma (PRP) injection.
Instruction and demonstration of diagnostic ultrasound,
ultrasound guided injection, and an introduction to
venous sclerotherapy was also part of the training. The
inclusion of sclerotherapy for varicose veins in the training
was especially gratifying for this author as many of the
traditional practitioners of Prolotherapy also treated
varicose veins with this technique and, like Prolotherapy,
there are insufficient numbers of experienced doctors
competent in this.
A particular challenge of this course was effective
instruction to all the participants. With such a wide gap of
experience, some doctors in practice for more than thirty
years and some not even in practice yet, how could they all
be taught at their level of expertise in a group setting? This
challenge was greatly aided by the obvious enthusiasm
of the group, the pairing with practicum faculty, and
the overall group dynamics. One participant, a local
Emergency Department physician, promptly returned
to his ED and, a bit to his astonishment, had immediate
success treating acute back pain with Prolotherapy. Prior
to this, he was most likely to follow conventional standard
protocol and prescribe pain meds and muscle relaxers
with a likely referral for physical therapy or acupuncture.
After discussing his new skills with his ED colleagues, he
is now empowered to help many more patients with acute
and chronic pain and wants to expand his options. The
community benefit will be more timely, cost-effective care
at the point of entry into the healthcare system.
The practicum sessions were the highlight of the course.
Participants were in groups of four and either practiced
on each other or on the many community volunteers we
had from local doctors bringing their patients. Each day
15-20 people were treated with dextrose Prolotherapy
or platelet-rich plasma for many different problems.
Chronic spinal pain, shoulder arthrosis and instability,
many elbow, knee, and ankle problems, degenerative hip
pain, Achilles tendinosis, and even varicose veins were
treated. Some patients were evaluated with state of the
art musculoskeletal ultrasonography using the Biosound
Esaote MyLab 25 Gold, which offers resolution higher
than MRI. Ultrasound guided injection was also utilized
523
IT’S A WIDE WIDE WORLD: PROLOTHERAPY TRAINING IN MAUI 2010
but the primary reliance was on good old-fashioned
palpatory injection technique that is known to yield
excellent results. Overall, participants experienced many
of the common clinical presentations of those seeking
Prolotherapy and learned classic, as well as more modern,
injection approaches and techniques.
In addition to learning Prolotherapy, there was daily
integrative Qigong taught by Kevin Davison, ND. This
system utilizes variable passive and active range of motion
to enhance and maintain joint, ligament, and tendon
function. This portion of the course was a highlight
for many. Harry Adelson, ND lectured on some of the
newest regenerative techniques utilizing PRP and adipose
tissue to enhance tissue scaffolding, provide mesenchymal
stem cells, and growth factors in orthopedic and aesthetic
techniques. Dhai Barr, ND also demonstrated aesthetic
use of PRP in the face and neck regions with Dr. Adelson.
There were great clinical discussions around the use of
these techniques in regard to sports, orthopedic, and
emergency medicine.
Orthopedic evaluation.
Rick Marinelli, ND.
With the format of the course leaving most of the afternoon
available to explore Maui’s diverse offerings, participants
and faculty engaged in recreational activities including
surfing, kitesurfing, stand up paddling, hiking Haleakala
and Hana, mountain biking, playing music, sightseeing,
beachcombing, swimming, and canoeing. The addition
of the daily recreational time was a wonderful aspect of
the training as participants and faculty returned early the
next day rested and truly enthusiastic to learn as much
as possible during the course. As one who has instructed
many in learning the art and science of Prolotherapy, I
would have to say that this group was one of the most
adept, and the venue was the most pleasant I have had
the privilege of teaching. There was discussion of making
this an annual training in a collegial, fun, and informal
setting. If you are interested please contact the author to
be placed on the mailing list for future courses. n
Careful PRP in the thoracic spine.
524
IT’S A WIDE WIDE WORLD: MORE THAN JUST MEDICINE: PROLOTHERAPY MISSIONS IN MEXICO
I T ’ S
More Than Just
Medicine: Prolotherapy
Missions in Mexico
David De La Mora, MD
E
verything started about five years ago, when a
patient came to my office in Guadalajara, Mexico
with a severe knee pain. She was overweight,
which made the problem even worse. Her pain would not
let her stand for a long period of time, in her hard work
of selling orange juice and peanuts in the street, to be able
to feed her family.
I treated her with anti-inflammatory medicine and
analgesics, hoping her pain would diminish. I knew very
well though, her relief would be temporary, since her real
problem was a bilateral degenerative osteoarthrosis. A few
days later she came back without feeling any better, I told
her that her situation could be solved only with surgery.
That advice was all I could do for her, since it was not
of my field of expertise. But I could feel her pain and
frustration for not having the means to see a specialist,
so I tried to find an alternative for her. I promised her I
would do something about it.
Searching the internet for “knee pain,” among other
phrases, I found a word that was totally unknown to me:
Prolotherapy. It sounded amazing, but too good to be
true. Nevertheless, it seemed this could very well help my
patient. During the following three months I downloaded
hundreds of articles, and the more I read, the more
my eagerness would grow. There was the name of a
doctor mentioned continuously: Dr. Ross Hauser. Upon
contacting Dr. Hauser, he forwarded me to the HackettHemwall Foundation (HHF) to learn Prolotherapy. This is
where the best adventure of my professional life started.
I decided to pull all my efforts and risk all the financial
resources I had (even a friend of mine lent me some
money) to attend the training course, but it was still
not enough to cover my expenses. Nevertheless, I met
Jeff Patterson, MD and Mary Doherty’s kindness and
generosity, that even without knowing me, they allowed
me to attend to my first Prolotherapy conference at the
University of Wisconsin in Madison, covering only one
part of the fee.
I still treasure the e-mail of my first encounter with Dr.
Patterson, from September 22, 2004:
Dear Dr. Patterson:
My name is David De La Mora, I’m a Doctor (MD) from
Guadalajara Jalisco, México. Since long time, I’ve been interested in
Prolotherapy as the best way to relieve patient’s joints pain. I wrote to
Dr. Hauser to ask for information of how and where to learn about
this method. That’s how I learned of you and the Hackett Hemwall
Foundation’s annual seminar you organize. I would like to share with
you my emotions when I found out about this technique which helps
to avoid more damage with major invasive treatments to the patients.
I’ve been working actively with the Sociedad Médica Cristiana de
Guadalajara (Christian Medical Society of Guadalajara) for seven
years along with some other doctors and missionary people reaching
the communities in our country that are in need. We bring them
food, clothing, medicine and give medical attention, all for free. I
seriously believe that this awesome technique of Prolotherapy will
bring a great benefit for them and also for my patients in my private
practice.
I would very much like to attend the next seminar and learn the
basic Prolotherapy techniques, but I have a special personal request.
If it would be possible for me to pay the Residents Fee so I can pay
the hotel and the round trip by bus from Guadalajara to Chicago,
and then to Madison, Wisconsin (some thousand miles). Sorry for
asking you this, but the economic situation is not the best. If this is
not possible, I’ll understand and somehow I will manage to be there.
I’ll be looking forward to hearing from you in not too distant future
to fill my registration form.
Thank you for your attention.
Sincerely,
Dr. David De La Mora Lara
His answer would change the course of my life, and it
arrived less than three hours later:
David,
Although I cannot imagine riding by bus from Guadalajara to
Madison, we will be delighted to have you at our conference. I will
525
work on finding you free housing so don’t worry about that part. The
resident’s fee will be fine if you are able to pay it. If not let me know
and we’ll work out a more generous discount for you. I am copying
this to Dr. Janes, who is my Spanish speaking Mexican Prolotherapy
Ambassador. We are interested in considering Prolotherapy training
in Mexico as well.
Jeff
This is how I was able to attend to my first conference,
in which I was able to realize that Prolotherapy was not
fiction, to find the project of my life that I had been
looking for, and to find the solution that my people in
Mexico needed so urgently.
I had hoped to further my learning and emailed
Dr. Ross Hauser who let me participate in his very
last Prolotherapy mission in a Church in Thebes, Illinois.
The humanitarian project was called “Beulah Land”
and ran for 11 years. I learned from Ross, among other
things, to pray for each patient in loud voice (which I still
continue doing it in my private practice today).
The next year, I was able to go to Honduras with HHF...
and WOW! These experiences were so thrilling, and
made me wish that this could also happen in Mexico. I
talked about it with Dr. Jeff Patterson, and he expressed
his excitement about it too. He later talked to the board
of directors and their affirmative answer came soon
afterward.
Trying to find the best place to carry out this brigade, I
talked to my church leaders to ask permission to use their
facilities. They accepted, without skepticism. I was able to
gather a group of friends that embraced my vision, and
thanks to them and to the support of the members of
the church, we had our first HHF Prolotherapy mission
in Mexico. The church turned into a hospital, with 17
doctor’s offices installed in the Sunday school classrooms,
where about a thousand patients were able to be seen
during five days.
“This has been one of the most gratifying experiences
of my life. It didn’t stop me thinking how exhausting it
could have been, or having to cancel some of my personal
activities. That joy that comes from helping my neighbor
in his pain, and to be able to see how that kind of help can
change somebody else’s life is something that cannot be
found anywhere else” That is how Sergio Gonzalez was
526
able to brief his experience in his first brigade, where he
was the one responsible for the “circulantes” (helpers), a
group of enthusiastic youngsters that would carry out all
kinds of jobs, from answering questions to carrying sick
people that were not able to walk by themselves. The day
the brigade was over, Sergio himself, became a patient to
ease an old pain that came up again caused by the extra
effort of the week. As a helper and a patient, Sergio was
able to receive a two sided blessing from this brigade and
of course, he repeated the “dosage” the following year.
The total success of this first brigade placed solid
foundation to continue year after year with this noble effort
to help those in great need. Last January, we carried out
our third Prolotherapy and vein mission in Guadalajara,
Mexico, and we are getting ready for 2011.
We have taken care of more than 2,500 patients during
these three missions. The team of foreign doctors,
including helpers and nurses, is close to 35 people, and the
local team for helpers, translators and people in charge
of organizing the whole event is about 80 people. This
adds up to 120 people (including my wife Martha and my
children David and Haniel), which allowed us to be able
to treat patients with excellence. From the beginning of
the project, we have also counted on the cooperation of
a very well known group of doctors specializing in veins,
directed by Dr. Rick Owens, who has strongly enriched
our humanitarian service. They bring along their own
ultrasound devices, with which they are able to have a
very precise diagnosis, and work exactly where the vein
is damaged.
In the year before mission, Dr. Black performed
obliterations of veins with laser to 33 patients, he took
care of ulcers of significant size and terrible varicose
veins were able to be healed with his treatments. He
is only an example of all the doctors with a highly
human quality that come to our country to pour
their talents in an unselfish way, leaving behind their
personal work for a week and not only that but paying
their own travel and lodging expenses, just for the sake
of helping others. Mexico is really blessed by them.
With the same spirit of doctors George Hackett and
Gus Hemwall, Dr. Jeff Patterson has continued with the
humanitarian labor of the Hackett-Hemwall Foundation
since 1968 without pursuing any benefit other than just
help others.
Dr. Patterson is also professor for the family practice
department of Medical School and Public Health for the
University of Wisconsin. His priority, as well as the one of
his mentors, continues to be to “teach anyone anywhere”
the Prolotherapy technique. And of course, I can’t miss
mentioning his partner Mary Doherty; her important
work for the organization and administration within the
foundation has been crucial for the missions to take place
in Honduras, Mexico and the rest of the world.
In Mexico, the first meeting with the Board of
Directors was at the Medical School for Universidad de
Guadalajara, where Dr. Patterson gave a lecture about
this procedure. University of Guadalajara and University
of Wisconsin signed a “memorandum of understating”
and there is hope to continue working toward having
Prolotherapy taught in the University centers of this
country.
The results of the Prolotherapy and vein missions have
been so beneficial that they are now eagerly anticipated
every year by patients, doctors and all the whole team
that make them possible. The benefits of Prolotherapy
have extended from the people in Guadalajara to other
states of our country. Many people have benefited from
only one treatment, putting an end to long periods of
suffering pain. Such is the case of Fernando Fernandez
who, after suffering a knee injury which caused him to
limp, was treated during the first brigade and now reports
being able to play soccer again. He is now an advocate
for Prolotherapy. Most of the patients treated with
Prolotherapy in the first two brigades have come back for
medical attention… Only this time, it is for a different
joint, because the one treated previously is totally healed!
Another important benefit of the mission is the teaching
for foreign and local doctors, who during that week receive
an important spring of experience working shoulder to
shoulder with the best experts in this technique. During
this last brigade the seed was planted in more Mexican
doctors (every year the number increases) and they will
take to their own towns the fruit of Prolotherapy.
All doctors that come to the brigade have something in
common—the spirit to help others in need. There are
Italians, Americans, Canadians, Romanians, Pakistanis,
etc. Despite coming from different cultures, they have the
same altruist spirit and share it with great enthusiasm.
They have even said at the end of the mission week that
it is more what they have received than what they have
given. Here are some of the commentaries that some
participant doctors have expressed:
Dear Dr. David:
I enjoyed making a contribution to your people, and I enjoyed meeting
the men, women and children of your church. Overall, I had a good
time meeting your staff, the patients and the other doctors and helpers
who also came to volunteer their time and skills. They were wonderful
people. I was impressed with the quality of your congregation,
especially the young adults because of their friendliness and their
happy attitude to life. I suspect this is because of their involvement
in your church. In addition, they were excellent translators and they
were fun to have around us. I look forward to returning again next
year to support your charitable work.
With warmest regards,
Brian McDonagh, MD
Founder, Vein Clinics of America
David and Marta,
Thank you so much for all of your help and work. Most of all for
your friendship. Mary and I feel so lucky to be working with you.
What a wonderful thing you are doing. I believe it will continue to
grow and produce great things.
Jeff Patterson
Guadalajara has very nice and warm weather, even
during winter. So doctors who come from cold countries,
find it a very nice work environment. Prolotherapy in
Mexico is growing. Seeds were planted. Five years ago,
this technique was practically unknown in the country,
and now the interest in it is growing within the medical
community, and through the testimonials expressed from
one satisfied patient to another. These things make it
possible that a bigger number of people will look for this
option to relieve their pain.
So, what happened to the woman with knee pain from the
beginning of the story? I treated her with Prolotherapy
and…voila! She was totally healed and able to continue
her life and work without any pain. This is the reason why
I have come to conclude that Prolotherapy is… more than
a medicine…It is hope. n
Please see this article on www.journalofprolotherapy.com for added
photos of the medical mission in Mexico.
527
SKILL ENHANCEMENT: SEMINARS, TRAINING, & ORGANIZATIONS
S K I L L
E N H A N C E M E N T
The British Institute of Musculoskeletal Medicine offers
educational courses in musculoskeletal medicine
targeted at GPs who wish to develop a special interest
in musculoskeletal problems, SpR’s in rheumatology,
orthopaedics and pain medicine, occupational physicians
and sports medicine practitioners. For more information:
http://www.bimm.org.uk
APRI L 7 – 1 0 , 2 0 1 1 | N AP L ES , F L ORIDA
The American Osteopathic Association of Prolotherapy
Integrative Pain Management (formerly College of
Sclerotheraputic Pain Management) will be holding its
Spring 2011 Training Seminar “Prolotherapy; A
Comprehensive Approach”, April 7-10th at the Naples
Golf and Beach Resort in Naples, Florida (anticipated
Cat 1A CME: 27). A one day optional pre-conference on
n o v e m b e r 6 – 1 3 , 2 0 1 0 | GUADA L AJARA , MEXI C O
Ultrasound Guided Prololtherapy (anticipated CAT 1A
The American Association of Orthopaedic Medicine is CME: 10) will be offered on April 6th.
offering a Hands-on Prolotherapy Course in Ciudad
For more information: contact Linda Pavina at
Guzman, Guadalajara in Mexico. This course will
302.530.2489 or [email protected]. include daily lectures, instruction in patient evaluation
http://www.prolotherapycollege.org.
and diagnosis, solutions, needle placement, injection
technique and hands-on patient treatment.
For more information: http://www.aaomed.org
Notice to meeting organizers: If you are sponsoring a
Prolotherapy meeting or training session, please email:
[email protected] for a free listing of your
meeting.
Do you offer Prolotherapy
Physician Training in your office?
Contact the Journal of Prolotherapy for a free listing today!
[email protected]
o r g a n i z at i o n s
American Association of
Orthopedic Medicine (AAOM)
600 Pembrook Drive,
Woodland Park, CO 80863
Phone: 888.687.1920
Fax: 719.687.5184
www.aaomed.org
The Hackett Hemwall Foundation
2532 Balden Street,
Madison, WI 53705 USA
www.HackettHemwall.org
GetProlo.com
Beulah Land Corporation
715 Lake St. Suite 600
Oak Park, IL 60301
Phone: 708.848.5011
Fax: 708.848.8053
www.getprolo.com
(formerly College of Sclerotheraputic Pain Management)
The American Academy
of Osteopathy
3500 DePauw Blvd, Suite 1080
Indianapolis, IN 46268
Phone: 317.879.1881
Fax: 317.879.0563
www.academyofosteopathy.org
528
The American Osteopathic
Association of Prolotherapy
Integrative Pain Management
American Holistic Veterinary
Medical Association
2218 Old Emmorton Road
Bel Air, MD 21015
Phone: 410.569.0795
Fax: 410.569.2346
www.ahvma.org
303 S. Ingram Ct.
Middletown, DE 19709
Phone: 302.376.8080
Toll Free: 800.471.6114
Fax: 302.376.8081
www.acopms.com
The International Veterinary
Acupuncture Society
2625 Redwing Rd. Suite 160
Fort Collins, CO 80526
Phone: 970.266.0666
Fax: 970.266.0777
www.ivas.org
American Osteopathic Academy
of Sports Medicine (AOASM)
2810 Crossroads Drive, Suite 3800
Madison, WI 53718
Phone: 608.443.2477
Fax: 608.443.2474
www.aoasm.org
British Institute of
Musculoskeletal Medicine
PO Box 1116
Bushey, WD23 9BY
Phone: 0208.421.9910
Fax: 0208.386.4183
www.bimm.org.uk
CURING SPORTS INJURIES
and Enhancing Athletic Performance
WITH
PROLOTHERAPY
Just as the original book Prolo Your Pain
Away! affected the pain management
field, Prolo Your Sports Injuries Away! has
rattled the sports world.
Learn the twenty myths of sports
medicine including the myths of:
• anti-inﬂammatory medications
• why cortisone shots actually
weaken tissue
• how ice, rest, & immobilization
may actually hurt the athlete
• why the common practice of
taping and bracing does not
stabilize injured areas
• & why the arthroscope is one
of athletes’ worst nightmares!
AVAILABLE AT
www.amazon.com
www.beulahlandpress.com
&
BEULAH LAND PRESS
J O U R N A L of P R O L O T H E R A P Y
Doctors
SHARE YOUR EXPERIENCE
Calling all Prolotherapists! Do you have a Prolotherapy article
VOLUME TWO | ISSUE FOUR | NOVEMBER 2010
w w w . j o u r n a l of p r o l o t h e r a p y . c o m
you would like published in the Journal of Prolotherapy?
OH
We would love to review it and help you share it with
the world! For information, including submission
3
H
C
guidelines, please log on to the authors’ section
Patients
TELL US YOUR STORIES
The Journal of Prolotherapy is unique in that it has a target audience of
both physicians and patients. Help spread the word to other people like
yourself who may benefit from learning about your struggle with
GA
N
LI
H
O
VOLUME TWO | ISSUE FOUR | NOVEMBER 2010 | PAGES 465-529
]
[ 708-848-5011]
of P R O L O T H E R A P Y . C O M
LASTIC
FIBROB
ON
ER ATI
PROLIF
MENT
of www.journalofprolotherapy.com.
[ JOURNAL
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AN
DROG
C
EN RE
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TO
R
S
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N
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R
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T
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ECTION
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T OLOTHER AP
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L ATES
STIMU
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LIGAM
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TENSIL
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CED
ENHAN
IN THIS ISSUE
■
chronic pain, and first-hand experience with Prolotherapy.
Testosterone could be a Prolotherapy Doctor’s
and a Patient’s Best Friend!
■
■
Pet Prolotherapy: An Overview and Current Case Studies
For information on how to tell your story in the Journal of
■
■
Teaching Techniques: Hand and Wrist Prolotherapy
Prolotherapy, please log on to the contact section of
■
Our Patient’s Autologous Stem Cells are Drugs: The FDA Moving
Down on a Dangerous Slippery Slope
■
Building a Rationale for Evidence-Based Prolotherapy
in an Orthopedic Medicine Practice
■
A Retrospective Observational Study on Hackett-Hemwall
Dextrose Prolotherapy for Unresolved Hand and Finger Pain
at an Outpatient Charity Clinic in Rural Illinois
■
ACOSPM 2010 Spring Seminar
■
Prolotherapy Training in Maui 2010
www.journalofprolotherapy.com.
BEULAH LAND PRESS
[
for Doct or s & P at i e n t s ]
■
Prolotherapy for 20 Year Old Ankle Injury
■
More Than Just Medicine: Prolotherapy Missions in Mexico
■
The Use of Hormones for Chronic Pain
■
Prolotherapy Skill Enhancement

Patients - Journal of Prolotherapy

Transcription

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