PROLOTHERAPY

Prolotherapy (aka Regenerative Injection Therapy – RIT) is based on the premise that much of chronic musculoskeletal pain is caused by the degeneration of connective tissue secondary to both macro and micro trauma (major injuries and repetitive movement injuries). The tissues affected and targeted by treatment are ligaments, tendons and joints. The most commonly treated conditions are:

   • Arthritis
   • Tendonosis (chronic tendonitis)
   • Low Back Pain
   • Neck Pain
   • Headaches
   • Sports Injuries (rotator cuff tear, ACL tear, chronic ankle sprains, chronic shoulder dislocations, etc)

To understand how prolotherapy works, we must understand that chronic pain from tendons, ligaments, and joint surfaces is due to a degenerative process of these tissues, not an inflammatory process. We must also understand the process of normal healing from acute injuries.

Sprains (ligaments) and strains (tendons) are the stretching and potentially the partial tear of tissue. The majority of healing occurs in the first eight weeks after an injury during which time growth factors are elevated to stimulate growth. Next, the tissue is tightened and thickened. After this time, if healing is not complete, the injury and pain can become chronic, and subsequently the structure does not have sufficient tensile strength, or is too loose. In essence, these tissues turn form normal connective tissue into scar tissue. When this happens, the nerve receptors in those tendons and ligaments continue to fire pain signals. Stretched ligaments are no longer able to stabilize their corresponding joint which leads to muscle spasm and predisposition for the early-onset of arthritis later in life.

Arthritis similarly, is degeneration of joint surface tissue secondary to macro or micro trauma. The onset of arthritis is dependant on many factors, but injury definitely speeds up the process.

Conventional treatment of sprain/strain and arthritis is to mask the pain until the condition becomes bad enough to perform surgery. How can we reverse the degenerative process and heal the connective tissue? What we need to do is "trick" your body into thinking it has been re-injured without actually insulting the tissue.

Prolotherapy (also called "prolo") is the precise injection of a mild irritant solution directly on the site of the torn or stretched ligament or tendon which creates a mild, controlled inflammation that stimulates the body's natural healing mechanisms to lay down new collagen fibers on the weakened area. The previously stretched tendon or ligament goes through the same healing cascade as when first injured and is given a second chance to heal. Studies have been performed showing microscopic views of ligaments before and after prolo, and show prolo does in fact normalize tissue. Prolo is extremely safe, relatively inexpensive (compared to drugs and surgery), and compared to chronic pain is relatively painless.

PLATELET RICH PLASMA

Most everyone thinks of blood platelets as being responsible for blood clotting after injury which is true. What many people do not know is that blood platelets serve two other important functions. Blood platelets are responsible for bringing white blood cells to the injured area to clean up the remains of dead and injured cells. Most importantly to this discussion, blood platelets release growth factors that are directly responsible for tissue regeneration. These substances are called cytokins and include platelet derived growth factor, epithelial growth factor, and other important growth factors.

PRP has been used for years in surgical centers around the US and abroad to improve the success of bone grafting (especially in dental surgery) and also by cosmetic surgeons for speeding healing time and decreasing the risk of infection after surgery. Only in the last few years have doctors and surgeons been experimenting with injecting PRP for the treatment of chronic pain. Tennis elbow, plantar fasciitis, Achilles tendonitis/tendonosis, rotator cuff tears, meniscal tears, osteoarthritis and chronic low back and neck pain are all being treated with the injection of PRP with the goal of regenerating degenerated connective tissue with reports of success.

A PRP treatment looks like this: a patient’s blood is drawn and placed into a special collection kit. Using the person’s own blood eliminates the risk of transmission of any blood-borne disease. This kit is placed in a centrifuge for 15 minutes and the platelets and plasma are separated from the red and white blood cells. Two thirds of the plasma is removed and discarded and the remaining plasma is mixed with the platelets. This higher than normal concentration of platelets is what gives us platelet rich plasma. The PRP is drawn into a syringe. The area to be treated is injected with a local anesthetic and after waiting five minutes for the anesthetic to take effect, the PRP is injected.

The injection technique is identical to prolotherapy/regenerative injection therapy, only the solution injected is different. Same instrument, different sheet music.

People generally report two days of being sore and then usually pain relief occurs within the first week and continues to improve over a period of months. To date, my experience is that one PRP treatment is the therapeutic equivalent of three or four prolotherapy/regenerative injection therapy treatments using dextrose.

MUSCULOSKELETAL ULTRASOUND

Most people associate ultrasound cameras with looking at the baby to determine the gender. However an ultrasound camera is also an excellent tool for both diagnosing musculoskeletal disorders and precise needle placement for prolotherapy. Musculoskeletal ultrasound is widely used in Europe and Australia and is gaining popularity in the US.

MRI and CAT scans are conventionally thought of as the gold standard for diagnosing such conditions as torn rotator cuff, nerve entrapment, carpal tunnel syndrome, torn ligaments, and other such musculoskeletal conditions. The major disadvantages of these techniques are that they are very expensive, they are unappealing to those people who tend toward claustrophobia, and they do not show degeneration or laxity of soft tissues. Ultrasound, on the other hand, is done in the office within minutes and is relatively inexpensive. The exact location of degeneration of tissues (such as in tennis elbow and Achilles tendonitis) can be pinpointed. This allows for precise treatment. Because it is a motion camera, structures are viewed in real time. This gives the huge advantage of being able to view structures in real time. This is particularly valuable when evaluating impingement syndromes, snapping syndromes, laxity of ligaments causing instability of joints, and muscle and tendon tears that only show up with certain movements.

Another huge advantage of ultrasound is its use for guidance of prolotherapy injections. You can see the structure you want to treat, and you can see the needle tip touch that exact point, and then you can see the fluid infiltrate that structure. This is of particular value when injecting platelet rich plasma seeing as how PRP is expensive compared to a traditional dextrose based prolotherapy solution so one uses a 'rifle' approach rather than a 'shotgun' approach.

Studies have shown that when performing intra-articular injections of the shoulder and hip 'blind' (without any type of imaging), orthopedic doctors have a miss rate of around 70%. When injecting under ultrasound, the miss rate is exactly 0% because the doctor can see the joint, see the needle entering the joint, and see the fluid entering the joint. The conventional needle-guidance imaging for intra-articular injections is fluoroscopy (3 dimensional xray). The disadvantages of 'fluro' are that it's expensive, it's more of an ordeal (lots of people standing around in blue and machines that go 'beep'), and it involves exposure to radiation.

DRACULA THERAPY

After years of performing regenerative injection therapy (RIT) with the use of platelet rich plasma (PRP) for the treatment of chronic musculoskeletal pain and acute injury, I learned of a new use for RIT with PRP; rejuvenation of the skin. This treatment is now referred to as ‘Dracula Therapy’ by the media.

RIT with PRP has been in the news as of late as many professional football and baseball players have undergone this treatment with excellent results. This is how it works: when a tissue is injured, platelets rush to the area to form a blood clot (everyone knows this) but additionally platelets release proteins that are directly responsible for the creation of new collagen. If an injured tissue does not fully heal, we are left with a structure that does not fully function and is painful. In order to restore function and reduce pain, we can inject PRP directly into the damaged tissue such as torn muscles, chronic tendonitis, whiplashed neck, arthritic joints, etc. This ‘tricks’ the body into thinking that it has undergone a new injury (but it has not) and this launches the body’s natural healing cascade to grow new collagen. Essentially, we get a second chance at healing. The result is regeneration of new connective tissue, restoration of function, and decrease in pain.

Dracula Therapy’s mechanism of action is identical to RIT using PRP for musculoskeletal disorders. As the skin ages, there is a loss of collagen. This leads to thinning, sagging, and loss of elasticity. Injecting PRP into the skin triggers the growth of new collagen and the hands of time are turned back.

WHAT TO EXPECT
Dracula therapy has two main applications:

1. Filling in folds and creases much like a cosmetic filler (but a single treatment is much longer lasting – perhaps years). These injections are deep and leave very little bruising.

2. Rejuvenating thinning, sagging, less elastic skin anywhere on the body. I have found that while anywhere on the body can be treated (including the hands), the greatest improvement is found in the eyelids. These injections are more superficial and cause bruising that lasts a couple of days.

Once a patient has been deemed a good candidate for Dracula Therapy, his or her blood is drawn and placed into a centrifuge for 15 minutes. During this time, a numbing cream is applied to the face. When the blood is spun, the cream is removed, the skin is cleaned, and the PRP is injected into the desired area. Between the cream and my special preparation of the PRP with a very fast-acting and strong local anesthetic, the treatment is minimally painful. The area treated determines the amount of post-treatment bruising (deeper injections = less bruising, superficial injections = more bruising). Patients can then return to normal activities. Patients are advised, just as with PRP for musculoskeletal treatments, to avoid the use of non-steroidal anti-inflammatory medications such as ibuprofen as these agents block the platelet cascade.

After any bruising and swelling goes down after a few days, the patients face returns to normal. Minor if any improvement is seen. Then at about two weeks, minor improvement is noted. At one month to six weeks moderate improvement is present. At two to three months there is generally major improvement. Even at six months, improvement continues. If a second treatment is desired, I recommend a wait of at least three months because it takes that long to see the majority of the treatment. A treatment sooner may not be necessary. No one has been performing Dracula Therapy long enough to determine how long the effect lasts, but I have found that one year out from the treatment, the results do not diminish. Time will tell.