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Prolotherapy (sclerosant therapy) for chronic back pain
Dr Brian Pattinson, Pattinson Clinic |
This treatment which has been used for over 50 years has been described as a
neglected treatment or "secret therapy" for low back pain. It was first widely
used by an American surgeon, Dr G.S. Hackett, who published 4 editions of a
book on it in the 1950s. Hackett had worked with Sir Henry Head, a
distinguished English physiologist, at the Royal London Hospital in 1916.
It was Head who coined the term "referred pain" - such as low back pain being
"referred" down a leg as in sciatica.
It was in 1939 that G.S. Hackett concluded that some low back disability
was due to relaxation of the posterior sacro-iliac ligaments. He initiated
the method of strengthening the ligaments by the intraligamentous injection
of a proliferating solution. Many patients attained relief. In 1955 he
concluded that the tendons of muscles became relaxed at their attachment to
bone similarly to ligaments. He found that Prolotherapy was an attractive
alternative to the operation of spinal fusion, which he considered impaired
function and usually resulted in limited activity and continued discomfort.
He complained of the lack of information about the disability of ligaments
in medical schools, postgraduate training and in medical literature,
including textbooks. Ligament disability apart from strains is rarely
mentioned, unfortunately this still applies today. If the ligaments do not
regain their normal stabilising strength, the use of prolotherapy will ensure
stability in joints by tightly linking bone to bone.
Selection of patients for Sclerotherapy (Prolotherapy - U.S.A.)
- Recurrent episodes of the "low back going out" - These patients at
first respond well to manipulation but after a few years, increased
slackness of the ligaments develops in response to repeated
ligament-stretching strain and manipulation, however skilfully applied,
added to the problem by further stretching the ligaments. Relief between
manipulative treatments becomes shorter and shorter until there should
become a time when the therapist should "stabilise" not "mobilise".
The condition has become "lumbar instability" and sclerosant therapy is
the only logical therapy apart from a lumbar corset or spinal fusion
operation - neither are very satisfactory alternatives.
- "Theatre, Cocktail-Party Syndrome" - These patients, through poor
muscle tone, poor posture following trauma, of often without known cause,
find that they can no longer sit or stand for very long without feeling a
nagging low back pain. They are very often active, often sporting and
literally have to keep "on the move" to remain comfortable. They often
admit to being "never really free from pain". They have often been told
to "learn to live with it"! A daytime corset may have helped a bit. If
the condition is advanced, restlessness at night due to discomfort may be a
feature, even with a firm mattress. Forward-bending pain such as ironing,
washing the face or brushing teeth may be a feature.
- After a prolapsed lumbar intervertabral disc, discdegeneration is a
common cause of instability. Due to slight loss of intervertabral disc
thickness, the midline back ligaments become slack.
Most patients will have tried, and if not should try, spinal manipulation
first. Those who do not obtain sustained relief from manipulation should be
assessed to see if they will be suitable for Prolotherapy.
What is involved?
The proliferant solution is called P2G, a mixture of phenol, glucose and
glycerol, which is the same solution used by surgeons to inject varicose
veins. The mixture plus local anaesthetic is injected into both ends of
supporting ligaments of the low back and acts as a minor irritant. The
body responds by producing more collagen fibres. These add on to the ligaments.
As they form, they shrink slightly which tightens and strengthens the
ligaments. It also makes them less painful.
Prolotherapy is a slow process requiring 4 to 12 injections or more.
The average is 5-6. The reason for this is that the body is doing the
healing. The solutions merely stimulate the body to heal itself.
Side effects
Some specialists use 25% glucose instead of P2G. They claim the rare
occurrence of headache (about 1 in 1,500 to 2,000 injections) is less likely
with dextrose and claim the same beneficial results. If headache does occur,
it goes away on lying down after 5 minutes. After 6 days the headache goes
and does not return. There is no resulting disability. The use of Glucose
is less established.
Allergic reactions (*to local anaesthetic) are rare. The injections themselves
are mild to moderately painful and there is some local soreness for a day or
two after. All patients are offered Entonox analgesia (gas and oxygen) as
used in childbirth, I have not found intravenous sedation necessary. The
injection is given in one or more sites, which can be numbed first by a
Dermojet, which injects a small amount of local anaesthetic under air pressure
(no needle). The injection contains no steroid.
At least 60% of people treated with Prolotherapy have a good or excellent
response. One to two booster injections may be needed later at varying
intervals often after 2-4 years. Many other patients have more pain-free
years than this.
Other uses of Prolotherapy
- Commonly knee and ankle ligament sprains.
- Osteoarthritis of peripheral joints - especially knee, shoulder and
collarbone joints. These have great potential. I am one of the few
practitioners to use Prolotherapy for osteoarthritis, and began in 1991.
Joints can often be rendered pain-free or nearly so, meaning that joint
replacement operations can be delayed, and sometimes be avoided altogether.
When patients are too young or too infirm for joint replacement operations an
injection into a joint of P2G mixed with local anaesthetic is preferable to
injecting steroid with local anaesthetic in my experience. Steroid often
relieves pain and swelling but often only for 3 months and then it needs to
be repeated. Steroid injections into joints are thought by some doctors to
cause degeneration of the hyaline cartilage. Prolotherapy injections on
the other hand commonly give several years of pain relief only occasionally
needing a booster injection. There appears to be no adverse effects.
References
- George Stuart Hackett, Ligament and Tendon Relaxation Treated by
Prolotherapy, 1991, 5th edition
- Milne J. Ongley, A New Approach to the treatment of chronic low back pain:
The Lancet, 1987.
- R.G. Klein et al, A Randomised Double-Blind Trial of
Dextrose-Glycerine-Phenol Injections for Chronic, Low Back Pain, 1993.
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