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Restorative Invection Therapy.ppt
- 1. Restorative Injection Therapy (ReconstructiveTherapy) (Prolotherapy) Andrea Trescot, MD With special thanks to my mentor, Dr. Felix Linetsky
- 2. The History ofProlotherapy Started with Hernia Repairs Installation of irritating substances into a pathologic, fluid filled cavity has been known since Aurelius Cornelius Celsus (25 B.C.– 50 A.D.) described the injection of saltpeter (potassium nitrate), to cure hydroceles and hernias. Hernia
- 3. Observations on referredpain Kellgren JH. Cl Sci 1937;3:175-190 • 75 medical students – You could do anything you wanted with medical students in those days • Injected with 1cc 6% hypertonic saline into the midline spinous ligament – Asked them to map out where they felt the pain
- 4. Kellgren et alCl. Sci.1937-1938.
- 6. George S. Hackett,M.D. (1/14/1888 – 8/17/1969) Joint stabilization through induced ligament sclerosis. Ohio State Medical Journal 1953, 49, 877–884.
- 7. First edition just97 pages Fibro-osseous Proliferation Fibroproliferative Therapy Prolotherapy
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- 13. Hackett’s paradigm: • Ajoint is only as strong as its weakest ligament, majority of chronic pain is caused by connective tissue deficiency complicated by injury or repetitive strain. • Predominant clinical manifestation of this pathology is local tenderness, and diagnostic test is relief of pain after anesthesia. • Prolotherapy or injection of irritants to stimulate repair of fibrous connective tissue, is the treatment of choice.
- 14. Hackett in 1955presented at the AMA Annual Meeting • 656 patients • Aged 15 to 88 years old • Average duration of symptoms 4.5 years • Followed patients for 12 years after the injections – 82% of patients considered themselves “cured”
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- 16. Enthesopathy • A diseasepathology at the 'entheses', i.e. attachment sites of muscles, tendons, joint capsules, ligaments and fascia to the bone.
- 17. Enthesopathy • The body’sresponse is inflammation and subsequent calcification • Locations: knees, hips, shoulders, ankles, spine, etc • The diagnosis is made by palpation, Xrays, ultrasound, and diagnostic injection
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- 21. Knee Replacements Ibuprofen OTC1984 Ibuprofen introduced in US 1974
- 22. Degenerative Disc Diseaseis Progressive
- 23. DDD is aprogressive condition
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- 67. So, What isthe Evidence?
- 69. Proliferant injections forlow back pain: Histologic changes of injected ligaments and objective measurements of lumbar spine mobility before and after treatment. Klein, Dorman & Johnson 1989. J of Neuro. & Ortho. Med.& Surg.10(2), 123–126. • Posterior SIJ ligaments biopsied in 3 patients before treatment, and 3 month after last treatment. • Light microscopy – fibroblastic hyperplasia
- 70. PLAIN MICROSCOPY: a)BEFORE INJECTIONS, b) AFTER INJECTIONS a b Histologic changes of injected ligaments after treatment. Klein et al, J. Neuro. & Ortho. Med. Surg. 1989;10/ 123-25.
- 71. ELECTRON MICROSCOPY: a)BEFORE INJECTIONS, b) AFTER INJECTIONS a b Ibid Klein et al,
- 72. Efficacy of dextroseprolotherapy in elite male kicking-sport athletes with chronic groin pain Topol, et al Arch Phys Med Rehabil. 2005 Apr;86(4):697-702. • 24 professional rugby and soccer players disabled because of chronic groin pain, unresponsive to standard therapy. • Average 2.8 injections of 12.5% dextrose and lidocaine to pubic insertions of thigh adductor and suprapubic abdominal muscles. VAS improved from 6.3 to 1.0 ( P <.001) • 20 of 24 had no pain and 22 of 24 returned to full sport activities.
- 73. A new approachto the treatment of chronic low back pain. Ongley, Klein, Dorman, Eek et al. 1987, July 18. Lancet, 143–146. 81 pts with chronic LBP (av. duration 10 yr) randomized in 2 groups, series of 5 double blinded injections 0.2-0.4ml at each side, total volume 20ml + exercise Needles:19g 3.5” •Both groups improved, “therefore it must be placebo effect”. •But the treated group improved more than the control
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- 75. Large Needle Contactwith Bone • Disrupts cell membranes – Release of phospholipids and inflammatory cascade • Creates microbleeding – Platelet response • Local anesthetic or saline is not a placebo, but a less effective active agent if injected onto periosteum
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- 79. • PRP group= 15, bupivacaine = 5; single injection • 8 weeks after tx, PRP patients improved 60% – control patients improved 16% (P =.001) • 6 months, PRP patients improved 81% in VAS (P=.0001). • Final follow-up (mean, 25.6 months; range, 12-38 months), PRP patients reported 93% reduction in pain compared with before the treatment (P <.0001). • “Platelet-rich plasma should be considered before surgical intervention”. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Mishra A, Pavelko T. Am J Sports Med. 2006Dept. Orthopedic Surgery, Stanford
- 80. Regeneration of meniscuscartilage in a knee treated with percutaneously implanted autologous mesenchymal stem cells. Centano CJ, Busse D, Kisiday, et al. Med Hypothesis 2008;71:900-908 • Because of their multi-potent capabilities, mesenchymal stem cells (MSC) have been used successfully in animal models to regenerate articular cartilage and in human models to regenerate bone. • “This review highlights the developments in cellular and regenerative medicine, as well as a case of successful harvest, expansion, and transplant of autologous mesenchymal stem cells into an adult human knee that resulted in an increase in meniscal cartilage volume.”
- 81. What Does itCost? • Prolotherapy – $100 - $400/session – UW $150/session (5 sessions = $750) • UW charges an additional $250 facility fee/session • Platelet rich plasma – $500 - $1000/session • Stem cells – $8,000
- 82. What is theAlternative? • Spinal fusion – $70,000 for hospitalization • Plus meds, PT, work loss • Total knee replacement – $35,000 for hospitalization • Plus meds, PT, work loss • Inpatient Rehabilitation for MVA – $11,265 per patient per year • US Dept of Transportation 2006
- 84. Every Thing Oldis New Again Thank you [email protected] [email protected]
Editor's Notes
- #74 Looks like placebo but there is something in the NS; also needles were quite large