American College of Osteopathic Pain Management & Sclerotherapy: Reference Material

Article: Prolotherapy For Beginners

References:
The following list of reference material is not all inclusive. This list includes a small sample of articles regarding various prolotherapy/sclerotherapy techniques and applications.

Banks, PhD., Allen R., A Rationale for Prolotherapy, Journal of Orthopedic Medicine, 13:3 (1991) 55 -59.
Barret, John and Golding, Douglas N. The Practical Treatment of Backache and Sciatica Lancaster: MTP Press Limited. 1984. pp. 68-74.
Dorman, Thomas A. and Ravin, Thomas H. Diagnosis and Injection Techniques in Orthopedic Medicine. Baltimore: Williams & Wilkins. 1991
Faber, D.O., William C., Biological Reconstruction - Alternative to Hip Prosthesis , The Digest of Chiropractic Economics, (1991) 50-54.
Green, David, Mechanisms of Action of Sclerotherapy, Seminars in Dermatology, 12:2 (June1993), 98-101.
Hackett, M.D., George S., Referred Pain and Sciatica in Diagnosis of Low Back Disabilities, JAMA, 63:3 (January 19, 1957), 183-185.
Johanson, John F. and Rimm, Alfred, Optimal Nonsurgical Treatment of Hemorroids: A Comparative Analysis of Infrared Coagulation, Rubber Band Ligation, and Injection Therapy, The American Journal of Gastroenterology, 87:11 (November 1992), 1601-1606.
Klein, M.D., Robert G. and Eeek, M.D., Bjorn C.J. Prolotherapy: An Alternative Approach to Managing Low Back Pain , The Journal of Musculoskeletal Medicine, (May 1997) 45 - 59.
Koop, M.D., C. Everett, A New "Old" Therapy for Back and Joint Pain, The Health Resource Newsletter, (1997) Vol. 12, No. 3, pp.1
Leedy, D.O., Richard F., - Basic Techniques of Sclerotherapy, Osteopathic Medicine, August 1977.
Leedy, D.O., Richard F., Applications of Sclerotherapy to Specific Problems, Osteopathic Medicine, September 1977.
Lynch, M.C. and Taylor, J.F., Facet Joint Injection for Low Back Pain, The Journal of Bone and Joint Surgery, 68B:1 (January 1986), 138-141.
Williams, D.O., Michael, K., Lumbar Spine and Pelvic Erect Posture Series, Journal of the A.O.A., Volume 76, June 1977.
McFadden, K.D. and Taylor, J.R., Axial Rotation in the Lumbar Spine and Gaping of the Zygaphyseal Joints, Spine, 15:4 (1990), 295-299.
Mercer, S. and Bogduk, N., Intra-Articular Inclusions of the Cervical Synovial Joints, British Journal of Rheumatology, 32:8 (1993), 705-710.
Ongley, Michael, J, Dorman, Thomas, A., Eek, Bjorn, C., Lundgren, David, and Klein, Robert, G. Ligament Instability of Knees: A New Approach to Treatment, Manual Medicine (1988) 3:152-154.
Thibault, Paul Kenneth and Lewis, Warren Anthony, Recurrent Varicose Veins, Part 1: Evaulation Utilizing Duplex Venous Imaging, J Dermatol Surg Oncol, 18 (1992), 618-624.
Thibault, Paul Kenneth and Lewis, Warren Anthony, Recurrent Varicose Veins, Part 2: Injectin of Incompetent Perforation Veins Using Ultrasound Guidance, J Dermatol Surg Oncol, 18 (1992), 895-900.
Tucker, Miriam, E.,Sclerotherapy May Subdue Stubborn Back Pain, Family Practice News (Dec 15, 1993) pp.5.

PROLOTHERAPY FOR BEGINNERS

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Prepared for the American Osteopathic Academy of Sclerotherapy (Current name - American Osteopathic Association of Prolotherapy Integrative Pain Management) by:

Richard F. Leedy, D.O.
Herbert M. Fichman, D.O.
Andrew Kulik, D.O.

Reasons For Our Methods
We are presenting these injections techniques as we now do them. There have been many changes over the years. Techniques vary with different doctors, but basic principles are the same --- all producing satisfactory results. We use the techniques given here for the following reasons:

We have a high percentage of excellent results (90% usually) so it has a proven effectiveness.
We use the smallest needle and the smallest amount of solutions necessary to stimulate a fibrous connective tissue response at the desired sites - dictated by experience.
Our solutions are all aqueous and will flow through a small gauge needle. This minimizes the trauma of needles passing through healthy muscle tissue some-times necessary to reach ligaments. Healthy muscle tissue should always be respected and protected - it deteriotes fast enough as life progresses.
We believe weak joint ligaments should be injected in all area possible with small amounts of solution in a regular weekly sequence to insure a more even proliferation in contrast to heavy doses in fewer sites. 5. To stabilize a long standing area - such as lumbo-pelvic - many injections are involved - 10 to 20 in each sacroiliac and ileo-lumbar, 2-3 interspinous, 4-6 facet areas and a variety of associated area are sometimes involved as along the pelvic rim, tensor fascia lata and ischial tuberosity.

Also, we use anti-inflammatory injections of a local anesthesia plus steroid in spastic muscles, bursae, and tendons as indicated. Thus 12-20 visits are usually necessary for the primary build up and follow up booster injections are a must.

Structural Evaluation Condensed

The following routine is recommended as a practical for hospital, home and office use. It does not require excess size or strength. It places some emphasis on observation but mostly on palpation. We feel that every good physician must develop palpatory skill. We use this routine regularly as necessary for injection techniques.

This method is in agreement and satisfies the recommendations of the Committee on Hospital Assistance of the American Academy of Applied Osteopathy updated to April, 1979.

It is assumed that the basic workup has taken place and the patient is ready for the structural examination.

The patient (men in shorts-women in office gowns) is first observed walking, and abnormalities noted. The patient is then asked to place a hand on the spots that hurt -- this provides a starting point. The patient is placed supine on a table with the body relaxed and positioned in the center as well as possible. A pillow is placed under the head.

FOOT AND ANKLE - range of motion, edema, arches, masses, and general conditions are what is looked for.

KNEE - leg raising test, palpate for intrapatellar edema, effusions by lifting patella with fore fingers and pressing with thumbs. Medial and lateral ligaments for pain, edema, and hypersensitivity. Move knee in all positions to determine mobility and hypermobility. A knee that fully flexes and extends can be injected by sclerosants.

SACROILIAC AND HIPS - The lumbar muscles are evaluated for rigidity, splinting, atrophy, and hypertrophy. The spinous processes and interspinous areas of the lumbar vertebrae are palpated for positioning and sensitivity. Record findings - usually one sacroiliac is found to be at fault. Note: At this time it is well to quickly examine the abdomen for tender inguinal ligaments (related to sacroiliacs), masses, and liver size. It is very embarrassing to treat a weak sacroiliac and later someone finds a large uterine fibroid easily palpable.

SHOULDER AND ARM - Examine the hand-for arthritis, forearm - for tendonitis, elbow-for tendonitis, range of motion, bursitis, the shoulder for range motion, restrictions, tender spots, atrophy. Examine lower cervical and dorsal vertebrae areas by lifting arm and palpating the area, examine opposite side.

HEAD, NECK, AND UPPER DORSAL AREAS - Clasp lower neck with both hands - move head in all directions, palpate facets, spinous processes and interspinous ligaments down to D#, 4. Record abnormalities.

SIDE POSITION - The patient is now placed on one side then the other - with a pillow under the head. The entire spine is palpated for abnormal bony landmarks, abnormal muscle masses, painful areas and other abnormalities. Record all.

PRONE POSITION - Lastly, the patient is placed on his abdomen with a pillow under the pelvis to reduce the L-S kyphotic curve, the chin is balanced on the table, arm dropping on the side. From this position the sacroiliac area is reexamined - bony landmarks, pelvic rim, sensitive areas, gluteal muscle changes, sacroiliac ligament sensitivity, lumbar muscle tension (compare both sides), abnormalities in dorsal and lumbar, spinous process, positioning, interspinous and paraveretbral tenderness, and shoulder girdle painful areas.

Having completed the examination of all body articulations the specific problem needing special attention should not required more than ten (ten) minutes - with experience.

Understanding the Mechanism

Study of the bony structure in the lumbo-pelvic area from the side with the subject erect reveals the acetabulum and femoral head to be located well anteriorly to the sacroiliac joint. Also, the sacral base carrying the 5th lumbar body plus the weight of the torso is anterior to the canted sacroiliac joint. Thus the sacroiliac joint is a vulnerable fulcrum subject to a scissor like motion by forces from above and below.
Traumatic force from below such as stepping down from a bus or stool is transmitted directly to the first movable joint - the sacroiliac. With counter force exerted from above by body weight, and the sacroiliac between, a sprain subluxation situation inevitably results.
Attached to the 12th rib above the pelvic crest and facets of L4-5 below are the broad flat quadratus lumorum muscles. Any force that drives the pelvis posteriorly, and moves the sacroiliac joint is bound to stretch and/or jerk the quadratus lumborum. Recalling the response of skeletal muscle to trauma in physiology experiments, a jerk would be followed by contraction, rigidity, and a drawing up. As a result then the pelvic rim would be drawn up and tilted anteriorly. Pain and spasm of this muscle then would account for (a) cough pain (b) lumbago pain, (c) why the pelvis subluxations are usually anterior in the acute low back problem.
Pelvic movement on the sacrum is not A-P but in a twist - bend or tortion pattern as described by Pratt. This twist-bend pattern must drag or involve the lower lumbar vertebrae by means of the strong ileo-lumbar producing powerful twist-bend or tortion force on the posterolateral aspect of L4-5 (where most disc extrusions are found). It seems logical to assume then that disc pathology occur after the sacroiliac is involved.
While muscles move joints they account for only a small percentage of the joint's stability. Ligaments maintain joint stability and limit their motion. Thus exercise usually is not the answer to back conditions where ligament integrity is lost. Ligaments become weaker, not stronger, by exercise.
Ligaments have been proven experimentally and clinically to have a profuse nerve supply and when traumatized become not only stretched but swollen and painful - affecting associated nerve pathways.
All movable body articulations move easily with little force it not restricted in any way.
Every muscle has an optimum or normal length from origin to insertion at which it functions at its best. Any change in this factor causes dysfunction and can contribute to structural problems.

To Understand Prolotherapy It Is Necessary To Understand Some Basic Anatomical And Physiological Concepts We Believe To Be Factual

They Follow:

Basic prolotherapy Concepts In Low Back Problems

The articulation of the lumbar spine and pelvis (as well as every joint in the body) are held in position and limited in motion by a heavy continuous mass of ligaments that surround the joints.
In the low back, failure or insufficiency of this ligamentous structure permitting excess movement of the joints often results in a tortion mechanism, and, in a traumatic degree, is the principle underlying cause of the low back problems including sacroiliac sprain-subluxation, acute and chronic myofasceitis, sciatic neuralgia, arthrosis and disc extrusion.
Recurrent episodes of traumatic sacroiliac sprain-subluxation are leading causes of degenerative changes in the area such as arthrosis and disc degeneration leading to extrusion.
Pain, incapacity, body lists, and sciatic neuralgias encountered in the acute low back syndrome are caused primarily by pressure of edema or effusion (inflammatory changes) resultant to the sprain-subluxation mechanism coupled with bony malpositioning.
Correction of the bony malpositioning, balancing of muscle tensions followed by adequate sclerosing injections into the involved ligaments corrects these abnormalities in a high percentage of patients in our experience as shown in an evaluation of fifty (50) case histories.

In a relatively small percentage of cases pressure of disc extrusion is the major factor in the sciatic syndrome and if persistent after the primary cause is removed or treated (prolotherapy), probably need for hospitalization and consultation is indicated.

Basic Prolotherapy Conclusions

Ligament rebuilding and joint stabilizing of prolotherapy blends with and definitely complements the structural evaluation - manipulations techniques and structural correction (lifts) in osteopathic medicine.
In the unstable recurrently sprain-subluxating articulation following osteopathic evaluation and correction methods the injection of sclerosing solutions employing the techniques given here will effectively relieve pain, decongest, strengthen and shorten the ligaments and usually provide the support necessary for normal function of the joint.
With proper follow-up and booster injections, a permanent result can usually be obtained in a high percentage of cases.
There are no contradictions to the injection of sclerosing solutions as indicated except the rare instances of sensitivity to the anesthesia. In our experience there has not been more than three instances of mild allergic reaction and then only to the local anesia - with no serious effects.
In our experience in the past seven years in which eight known patients required surgery for a low back syndrome following adequate ligament sclerosing, all eight had a highly successful surgical result leading to the opinion that preliminary ligament strengthing was the deciding factor. The surgeons did not report any interference to the surgical procedure to the prolotherapy injections.
Recurrent sprain-subluxating of articulations in the cervical and dorsal spine, (the basic pathology of the osteopathic lesion) cannot usually be permanently corrected without correcting pelvic imbalance, and providing adequate ligament support (prolotherapy) to that area.
When post laminectomy pain persists after surgery it is likely to be fascia or ligamentous origin. prolotherapy usually is effective in this solution.
Pain often encountered in post surgical scar tissue- following low back surgical procedure responds well to needle techniques.
The role of ligaments in body mechanism and dysfunction has been and still is greatly overlooked and under evaluated.
Based on the above noted experience we believe that failure to recognize the importance of and to treat by well established injection techniques (prolotherapy) ligament weakness and insufficiency prior to surgery in low back symptom complex is a prime factor in poor surgical results.
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