Prolotherapy, short for proliferation therapy is a controversial technique that involves a series of injections of an inactive irritant substance into a painful joint, or area where ligaments or tendons insert into bone. The injected substance can be dextrose, phenol, saline solution, glycerol, lidocaine, or even cod liver oil extract. Prolotherapy injections are intended to artificially initiate the natural healing process by causing an influx of fibroblasts that synthesize collagen at the injection site, leading to the formation of new ligament and tendon tissue.
Some of the signs that might benefit from prolotherapy include:
Joint laxity, such as in the shoulder, that does not resolve with standard treatment
Distinct tender points at tendons or ligaments as they attach to the bones
Unresolved, intermittent swelling or fullness involving a joint or muscle
Popping, clicking, grinding, or catching sensations in joints
Temporary benefit from chiropractic manipulation or manual mobilization
Aching or burning pain that is referred into an upper or lower extremity
Recurrent headache, face pain, jaw pain, ear pain
Chest wall pain with tenderness along the rib attachments on the spine or along the sternum
Spine pain that does not respond to surgery, or where there is no definitive diagnosis despite X-rays, MRIs and other tests.
So why is prolotherapy considered “controversial?” Because, according to the federal government (Health Care Financing Administration) there is currently no strong, compelling study that proves prolotherapy can cure cases of soft tissue pain. A “strong” study is one that has at least several hundred test subjects; has a control group (who get a placebo, or fake treatment) and is done in a “double-blind” methodology where the test subject and the administering doctor do not know if the injection is a prolotherapy agent (only a third member of the research study knows). However, there are numerous studies in the literature using smaller test populations (less than a hundred) that support prolotherapy as an effective treatment for pain.
Two RCTs (randomized controlled trials) on osteoarthritis reported decreased pain, increased range of motion, and increased patellofemoral cartilage thickness after prolotherapy
Two RCTs on low back pain reported significant improvements in pain and disability compared with control subjects, whereas 2 did not. All studies had significant methodological limitations.
So, if you have chronic musculoskeletal / joint pain, especially related to trauma, that has not resolved with cortisone injections, chiropractic, physical therapy, personal training, surgery, and time, prolotherapy may be worth investigating. The good thing about it is that it is generally safe.
The short answer to the first question is “yes” if the bulge is not severe and the body still has in place the mechanisms to keep the disc living and healthy (see below).
The other answer to the first question is “no” if the disc bulge is the result of breakdown of the nutrient-delivery mechanism to the disc. If this is the case, it is a matter of time before the disc totally degenerates. Physical therapy, chiropractic, spinal decompression and exercises can slow it down, but one cannot do these things indefinitely and often enough to stop the progression.
It’s important to know that your spinal discs are mostly avascular; meaning, don’t have a direct blood supply. Discs get their nutrients (water, oxygen, glucose, minerals, vitamins) via slow absorption from the capillaries directly underneath the vertebral end plates. At the end of the day, your discs flatten from the effects of gravity. As you sleep, they soak up fluids and expand, so that by the time you wake up in the morning you are at least 5 mm taller than when you first went to bed. This is called the diurnal cycle of fluid movement in and out of the disc and is the major means of nutrient delivery.
At the center of the disc is the nucleus, which has tiny cells that make the proteoglycan molecules responsible for attracting and holding onto water. This maintains a hydrostatic pressure that allows the disc to bear about 80% of the weight applied to its spinal level. These cells, similar to chondrocytes that make collagen in the joints, are the most active when the pressure in the disc is about 3 atmospheres. If the pressure is higher (obese individuals, those who carry heavy weight frequently at work) or lower, the cells make less of these molecules, putting the disc at greater risk of drying out. Injuries to the internal part of the disc or vertebral bodies can increase the volume of the nucleus, drastically reducing its hydrostatic pressure and slowing down proteoglycan synthesis. This is one of the pathways of degenerative disc disease, or DDD as the posterior (facet) joints, which are not designed for bearing much weight take on the responsibility of the disc and quickly wear down, forming the familiar osteophytes (bone spurs) seen on X-ray and MRI studies.
Here are the basic risk factors for developing DDD/ bulging discs:
1) History of Structural Damage to the Disc or Vertebra
Single event trauma to the spine resulting in damage to the vertebral end plates . An example would be a parachuter landing hard on the ground on his feet. This can cause a small injury, or even a significant compression fracture to the bony end plates– the surfaces to which the disc attaches. This is bad news, because nutrients to the disc (blood, oxygen, glucose) traverse through these end plates from the top and bottom of the disc. If it is damaged, the area calcifies and “shuts the gate,” depriving the disc of critical nutrients needed to stay healthy. This sets the stage for a slow procession of degeneration over the years which will have phases of back pain, stiffness, disc bulging, stenosis, and in severe cases leg pain, leg weakness and altered sensation.
Repetitive, axial loads to the spine. An axial force is one that travels straight down the spine, while standing. If you are in a job that requires frequent heavy lifting, especially above the shoulders; or requires you to carry 50 or more pounds of gear most of the day, you are placing axial loads on your spine. Similar to #1, it can slowly damage the vertebral end plates and damage the nutrient delivery system to the disc.
2) Hereditary Factors – there are respected studies that strongly suggest a genetic component to DDD. One study showed that there is a 50% greater chance of developing severe disc degeneration in the relatives of past disc surgery patients. Another study found mutations in the genes responsible for the synthesis of proteoglycan molecules, which are responsible for water retention in the disc. If the disc cannot attract and hold onto water, it cannot maintain its hydrostatic pressure. As a result, it loses its ability to distribute weight and slowly dessicates (dries out).
3) Occupation. This is pretty obvious. Those who work with heavy machinery or require heavy lifting are more prone to developing bulging discs.
4) Smoking. Smoking damages the fine blood vessels that the disc depends on to deliver nutrients. It also generates a lot of free radicals, which can damage the disc further. Some surgeons require patients to be “smoke-free” for at least three months prior to surgery.
So, here are the lessons to take here. First, if you have a parent who suffers from bulging discs and degeneration, realize that you have a 50% greater chance of developing them on your own. You may have a mutant gene that is making defective collagen in your disc, making it a ticking time bomb ready to go off in the near future. Your best bet is to minimize the expression of this gene, and a good way to do it is to eat as healthy as you can; ditch the toxins (smoking, excessive alcohol and sugar); avoid getting overweight, and maintain positive thoughts (may affect gene expression to your benefit).
Secondly, avoid unnecessary axial forces to your spine. Stay away from things that involve hard landings on your feet, and don’t lift weights in a way that places pressure to your lower back.
If your job, hobby, or recreational activities involve repetitive movement patterns you may develop a repetitive strain injury, or RSI. Also known as overuse injuries, cumulative trauma disorders, and musculoskeletal disorders these types of conditions are characterized by pain, inflammation, swelling, and reduced joint movement.
Some of the more well-know causes of RSIs include:
RSIs mostly affect tendons, ligaments, bursae, and neural sheaths but they can affect muscle fibers as well. What happens is the offending activity places unusually high demand on these structures resulting in microscopic tears to the tissues. A very gradual inflammatory response follows, which then takes a life of its own. At this point the patient notices that the pain is more frequent and doesn’t go away with rest, and he/she may reach for an over the counter non-steroidal anti-inflammatory like Motrin.
What makes repetitive strain injuries so persistent is that they are caused by an activity the individual needs ( job) or loves (favorite sport) to do, and essentially he/ she “re-injures” the condition with the activity until it gets to an advanced stage.
Most of the time a repetitive strain injury is transient; i.e. it appears for several weeks then disappears. The patient resorts to icing, rest, temporary discontinuation of the offending activity, over the counter meds, massage therapy, bracing, and in some cases, cortisone shots.
In some people, the pain turns chronic; i.e. doesn’t entirely go away even after weeks and months since the onset. If you are experiencing this, it can be due to improperly healed microtears causing abnormal muscle and tendon performance; and perhaps trigger points which are believed to be concentrations of nerve endings at an old injury site.
When the condition is chronic, you can attempt to do the therapy in the video above. You use a flat edged massage instrument to “strip” the muscle close to where it attaches to the joint. This can help loosen any fibrous adhesions (“stickiness”) that may be interfering with muscle and tendon movement. It also mildly agitates the area (be careful not to overdo it) and increases blood flow, which can stimulate repair by fibroblasts, special cells that synthesize collagen.
This therapy is not to be done when the condition is acute (recent onset, hot, red, swelling). Doing so will make it worse. Try it only when it has reached a chronic stage and inflammation is absent. If it causes an unusual increase in pain, discontinue and apply ice.
If you notice a gradually developing pain in your forefoot (just past your instep) between the tarsal bones of the 3rd and 4th toes that is worse when you press it between your thumb and index finger, you most likely have what’s called a Morton’s Neuroma.
Despite it’s name, it is not a true tumor. It is a buildup of fibrous tissue that surrounds the sheath of one of the nerves that innervate the foot. The nerve lies between the muscles that connect the tarsal bones and due to the fibrous buildup gets compressed within this narrow confine. It is worse when standing and walking.
Morton’s neuromas are usually treated with orthotics (custom shoe inserts to help counter flat arches, over pronation, or other abnormalities of the foot) and cortisone injections to the painful nerve. Sometimes surgical removal of the excess fibrous tissue is done if the condition does not resolve.
A simple remedy that can provide welcome relief, and perhaps allow the nerve to heal faster is inserting rolled up gauze or cotton between the 3rd and 4th toes. This spreads apart the tarsal bones and creates more room for the nerve. Sometimes simple things make for effective remedies, and this is one of them.
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I’ve been fielding a lot of questions about bulging discs lately. Here are some of the questions I get:
