MUSCULOSKELETAL MEDICINE AND PROLOTHERAPY

This is the first in a series of articles aimed at creating awareness of a variety of ‘alternative’ allied health and medical practices. As a Pilates teacher, I have constantly struggled to find more information and guidance when working with clients who have chronic pain or musculoskeletal dysfunction.  A recent study by the Royal Australian College of General Practitioners estimates that six million people in Australia suffer from musculoskeletal problems. ‘Many of these have soft tissue pain sources in their joints, muscles and ligaments’. After ruling out serious causes of pain, doctors often refer these people on to allied health therapists, with a very general diagnosis e.g. chronic lower back pain. The same people often end up in a Pilates class with a very general prescription of ‘strengthen the core’. This can make the job of a highly skilled (but not qualified to diagnose) Pilates practitioner very difficult.

It has been my experience that working collaboratively with selective medical and allied health practitioners can lead to more sustainable progress with clients suffering from chronic pain.  In these articles, I will be interviewing a variety of the practitioners I have worked with over the years and discussing their diagnostic and treatment models. I have chosen these practitioners because there specialities or approaches are not ‘mainstream’ and their knowledge and ideas have contributed greatly to my understanding of the human system and how we can live more comfortably and efficiently in it!

DR PHILIP LIM

The first of my interviews is with Dr Philip Lim, from Northside Physical Medicine in St Leonards, NSW. Dr Lim is a general medical practitioner (University of London, UK. MB.BS.) with a Graduate Diploma and Masters in Physical (Musculoskeletal) Medicine, from the University of Sydney. He holds certification in Prolotherapy as well as membership with The American Association of Orthopaedic Medicine (AAOM). He is a member of the Australian College of Physical Medicine (ACPM), the Australian Association of Musculoskeletal Medicine (AAMM) and the Hong Kong Institute of Musculoskeletal Medicine (HKIMM).

Although the format of this article is question and answer, the information presented is a synthesis of my discussions with Dr Lim and my independent research into the literature on musculoskeletal medicine and prolotherapy.

WHAT IS MUSCULOSKELETAL MEDICINE (MSKM)?

‘Soft tissue pain disorders …are diagnosable and quite often treatable by doctors appropriately trained in diagnosing musculoskeletal issues, however unless the GP has done further studies specific to musculoskeletal issues, this is often not the case’.  Ass. Professor Michael Cheswick. Australian School of Advanced Medicine, Macquarie University

MSKM is a nonsurgical approach to diagnosing and treating joint injury, instability and movement impairment. Doctors of Musculoskeletal Medicine in Australia are qualified GPs who have undertaken postgraduate studies in Musculoskeletal or Physical medicine. There are slight differences between the two in Australia, however in this article I will refer to them both as Musculoskeletal Medicine (MSKM).

THE EVOLUTION OF MUSCULOSKELETAL MEDICINE

MSKM has evolved out of general medical practice over the last 60 years.   The literature indicates that as physicians struggled to understand and treat chronic musculoskeletal pain, they sought alternatives to the traditional Cartesian Medical model (Raven et al, 2008). Modern day MSKM incorporates functional anatomy, medical aspects of orthopaedic surgery, osteopathy, chiropractory, family medicine, rehabilitative medicine, anaesthesiology and pain management.  Historically there have been many visionary influences that have shaped this modern discipline. I have summarised some of these below, however please note that this list is by no means complete.

Musculoskeletal medicine began to develop as a specialty in the 1950s, however its influences date back to the late 1800s when Head (1893) and Kellgren (1938) identified typical patterns of pain referral. Throughout the 1950s Cyriax refined these ideas, developing a series of objective clinical exams that diagnosed soft tissue musculoskeletal lesions for each joint and a treatment system for these. He called his approach Orthopaedic Medicine (Cyriax 1982).

In the early 1940s, Janet Travell (MD) began developing the concepts of somatic pain referral from myofascial trigger points. In 1942 Travell used the term ‘trigger point’ to describe a clinical finding with the following characteristics:

‘Pain related to a discrete, irritable point in skeletal muscle or fascia, not caused by acute local trauma, inflammation, degeneration, neoplasm or infection. The pain cannot be explained by findings on neurological examination’.

Travell’s work and groundbreaking texts (Travell, Simons’, 1983) explained that many painful muscular points could be secondary to other musculoskeletal system problems, such as ligamentous laxity and joint dysfunction. Travell and others also recognised that trigger point therapy alone, was not a complete solution to complex musculoskeletal pain. This highlighted the significance of ligament and tendon injury as the major source of musculoskeletal dysfunction and the key to its treatment.

In the early 1930s Earl Gedney (DO) began to develop a technique for healing injured ligaments by stimulating regeneration (Gedney 1937). Hackett (MD) expanded on Gedney’s work and was the first to call the technique prolotherapy after the Latin proles – meaning to stimulate growth. (Hackett, 1958). Gustav Hemwall (MD) and others continued to practice and develop the technique.

In the late 1980s, the use of prolotherapy began to accelerate and academic research into wound healing and tissue repair began to address the ‘hypothesised’ mechanisms of prolotherapy and attempted to scientifically explain how it promotes therapeutic healing (Clark 1996).

Another significant area of knowledge influencing MSKM today is the concept of tensegrity which Buckminster Fuller introduced in explaining how geodesic domes remain standing in strong winds. His physical model integrated the opposing forces of compression and tension. In the 1980s Steven Levin, MD, used Buckminster Fuller’s concept of tensegrity to explain why an injury to a single ligament could create devastating dysfunction to the entire musculoskeletal system. He used the term bio-tensegrity to describe his findings (Levin 1986).

Throughout the last 20 years MSKM has continued to evolve. Both the diagnostic models and many of the key techniques – manual manipulation, prolotherapy and trigger point therapy – have become more advanced and refined.

WHAT ARE THE DIAGNOSTIC MODELS USED IN MSKM?

Diagnosis first involves a thorough patient history, including the severity, duration and location of symptoms. This is generally followed by:

• examination of posture, gait and muscle behaviour patterns
• reproduction of symptoms through palpation and joint motion testing
• depending upon the severity of symptoms and findings, diagnostic imaging may be required to rule out more severe implications, and
• because practitioners are qualified GPs they can also exclude or identify pathology as an underlying cause of pain.

MSKM doctors use a variety of postural models to understand their findings and design a treatment plan that prevents or delays the onset of decompensatory postural changes. Decompensation occurs when the body can no longer compensate for functional overload in its parts and begins to degenerate.

Postural models show how the whole body is influenced by its individual parts and examine the body’s response to the forces that are exerted on it.  For example, the Decompensation Cascade model (Cantieri) can help a practitioner predict where and when alignment will commonly fail and demonstrates how a localised injury can alter forces of tension and compression throughout the body, to cause a predictable sequence of musculoskeletal reactions.

Elements of many of the postural models used in MSKM have also influenced the Pilates profession, as we too have sought to understand pain and dysfunction.  For example – the Muscle Tone models of the Kendall’s and Janda, Biomechanical models (Panjabi, Sahramann, Hodges, Richardson, McGill, Dorman, Vleeming and many others), Fascial twist and Common Compensatory models (Zink, Lawson) and Biotensegrity models (Levin, Ingber).

WHAT DOES A MSKM TREATMENT PLAN INVOLVE?

Treatment includes the application of a wide range of manual therapy techniques – including mobilisation, manipulation, Muscle Energy Release, positional releases etc, and various injection techniques – including prolotherapy, platelet rich plasma (PRP) and the treatment of trigger points via injection of local anesthetic. Specific exercise prescription and behavioural modification are also components of treatment. The lesser-known practices of prolotherapy, PRP and trigger point therapy will be discussed in further detail later in this article.

WHAT KIND OF ISSUES DO PATIENTS PRESENT WITH IN MSKM?

Generally people don’t present with issues – they present with PAIN.

Following on from the above discussion of postural decompensation, we know that pain is usually present after a series of biomechanical failures, stemming from ligament laxity and joint instability and dysfunction. Vertebral spinal pathology can also be a cause of pain. Treating the source of the pain is important, however detecting and treating the biomechanical or ‘system’ failures (which may be pain free) is imperative.

Ligaments are like elastic bands that hold bone to bone in a joint. When they are lax or injured, the joint becomes dysfunctional and susceptible to wear and tear and then degeneration. Ligaments also have many nerves that may cause pain in the damaged or loose areas. Tendons connect muscle to bones and can also become injured or worn and cause pain. Overloading of a joint also leads to muscle dysfunction and the formation of active myofascial pain trigger points, causing muscle shortening and pain.

The following description of causes of ligament laxity and joint instability is fairly accurate. Most people in pain are a combination of the last two, but I know from personal experience that some of us can be all three!

1. ‘Born loose’- individuals may have a congenital hypermobility of joints that can lead to instability and chronic pain.
2. ‘Worn loose’ – individuals ligamentous system and joints deteriorate and develop instability over time.
3. ‘Torn loose’ – individuals have traumatic injuries that can lead to ligamentous damage and instability.

(Dr. M Brown 2012).

Common problems that may be treated with MSKM include:

• Acute and chronic lower back pain
• Peripheral joint dysfunction
• Disturbance of gait or posture
• Musculoskeletal pelvic pain and dysfunction
• Migraine headaches, cervicogenic headaches
• Neck stiffness or pain, including acute and chronic whiplash
• Shoulder stiffness or pain and shoulder dysfunction
• Chest pain (musculoskeletal), mid-scapular pain
• Peripheral limb pain or paraesthesiae
• Elbow tendonitis
• Foot pain, heel pain, and ankle dysfunction
• TMJ dysfunction
• Hypermobility syndrome and Ehlers Danos Syndrome

(Taken from the Australian College of Physical Medicine website.)

AN EXAMPLE OF A MSKM APPROACH TO LOWER BACK PAIN

Most medical and surgical approaches to lower back pain focus on the intervertebral disc and the associated neurological pain. MSKM looks at the soft tissue. Dr Lim gave an example of a patient presenting with lower back pain. The pain is identified as coming from a nerve irritated by a joint dysfunction over the right L4/5 lumbar vertebral facet joint.

The MSKM doctor can manipulate or mobilise the joint, which will improve the pain, however he will also question why the joint became dysfunctional. Further assessment shows right sacroiliac joint dysfunction, due to previous trauma and resultant ligament laxity. There is also compensatory shortening of his lumbar spine muscles, with palpable trigger points. Unless these elements are also treated his pain will almost certainly come back.

A MSKM treatment protocol for this patient could include:

• treatment of ligament laxity using prolotherapy techniques with dextrose or Platelet Rich Plasma
• treatment of trigger points using lignocaine injections and stretch to normalise muscle function
• treatment of joint dysfunction using Osteopathic releases and Muscle Energy Release, and
• prescription of specific core stability exercises and/or referral to an appropriate exercise practitioner.

It is important to note the systemic approach in the example given by Dr Lim above. Each of the treatment protocols he uses serves a different purpose and none of them work as effectively in isolation as they do in the correct combination. It is also important to note that in cases of musculoskeletal dysfunction, neither stability nor strength exercises may be useful until the underlying imbalances are diagnosed and treated.

HOW AND WHY ARE TRIGGER POINTS TREATED?

As discussed earlier, a myofascial trigger point was defined by Travell as a hyperirritable spot within taut bands of skeletal muscle or associated fascia. Myofascial pain is referred from trigger points in specific patterns characteristic of each muscle. Trigger points are activated directly by acute overload, overwork fatigue, direct trauma and indirectly by other trigger points, visceral disease, and arthritic joints and emotional distress.

Both latent and active trigger points cause dysfunction, but only active trigger points cause pain. A latent trigger point may persist for years after recovery from injury, but minor overstretching or overuse of the muscle can easily reactivate it.  This predisposes the area to acute attacks of pain.

Treatment involves injecting local anaesthetic into the taut bands of muscle. Once anaesthetised, trigger points can be dry needled to break up the abnormal muscle bands and the muscle can be stretched to release the trigger point. Sometimes home stretching exercises are given to maximise the treatment.

WHAT IS PROLOTHERAPY?

Prolotherapy is a non-surgical treatment that involves injecting substances into ligaments and tendon attachments, for the purpose of proliferating the collagen in these connective tissues. Prolotherapy provides stimulation of the body’s capacity to repair injured tissue. It is also known as Regenerative Injection Therapy.

Ravin (2008) defines Prolotherapy as ‘…the iatrogenic stimulation of the wound repair process…’ The word iatrogenic is used as the procedure actually creates inflammation. The concept of irritating tissue to promote healing dates back to ancient Greece when Hippocrates treated shoulder instability in Olympic javelin throwers by touching a ‘slender hot iron’ to the ligaments holding the shoulder joints together. The heat irritated the ligament capsules, causing them to tighten up.

The prolotherapy techniques used today were developed in the 1930s by American surgeon G.S. Hackett, along with other MDs and osteopaths. These techniques have since been used successfully to treat pain resulting from ligament laxity.[1][2]

HOW DOES PROLOTHERAPY WORK?

The hypothesis underlying prolotherapy is that the proliferants cause local irritation with subsequent inflammation, collagen proliferation and tissue healing. The result is the enlargement and strengthening of damaged ligaments, tendon and other intra-articular structures.

To appreciate this hypothesis, the process of collagen production needs to be understood.  Collagen is a specialised protein that supports structures in living cells and tissues. It is made in the body by cells called tissue fibroblasts. Their job is to repair tissue damage. Fibroblasts usually lie dormant in tissues and are activated with injury, by cell-to-cell communication and chemical signals. The chemical signals are released by injured cells.

When the body sustains an injury e.g. a sprained ankle, the cells in the damaged tissue release chemical messengers called growth factors into the surrounding tissues. These substances stimulate the dormant fibroblast to become active. Fibroblasts then move through tissue, creating a matrix of collagen that knits in with the existing collagen. The early prolotherapists sought to make use of this process. They began injecting dextrose sugar as a means to stimulate the release of tissue growth factors and activate fibroblasts to lay down collagen.  This stimulus, when directly targeted, activated the bodies natural wound healing. The technique became the foundation of prolotherapy.

WHAT DOES A PROLOTHERAPY TREATMENT INVOLVE?

Prolotherapy treatment usually involves several injection sessions conducted every 2 to 6 weeks, over the course of several months. During a prolotherapy session, proliferants are injected at painful ligament and tendon insertions and in adjacent joint spaces. Ultra-sound guidance is often used to improve accuracy.

There are many proliferants or stimulating agents used. When he first began practicing prolotherapy, Dr Lim used the classic dextrose solution.  This solution has been proven to be safe and effective and acts as an osmotic shock agent by dehydrating the cells at the injection site – thus triggering cell to cell signalling and subsequent collagen formation and tissue healing.

Platelet Rich Plasma (PRP), is now the preferred proliferant of Lim and many others, due to the substantial growth factors identified in the activated blood plasma.

WHAT IS PLATELET RICH PLASMA (PRP)?

PRP is prepared by obtaining the patient’s own blood via an IV. The blood is then put through a series of centrifugal processes that allow the separation of red blood cells and white blood cells from plasma and platelets. The plasma and platelets are then centrifuged again to concentrate platelets. PRP therefore has a higher concentration of platelets compared to whole blood.

In MSKM, PRP is used to accelerate healing of tendon tears, ligament laxity and joint osteoarthritis. PRP is also used outside MSKM to accelerate and aid healing in dental implants, surgery and the treatment of severe burns.

ARE THERE CASES WHERE PROLOTHERAPY IS NOT SUCCESSFUL?

When a patient is taking anti-inflammatory medication there is inhibition of tissue inflammation, which is vital for the stimulation of healing and a full response. A low-dose Aspirin is allowed when needed to prevent cardiac or neurological (stroke) problems. PRP cannot be used with cancer patients due to the high level of growth factors, however these patients can be treated safely using dextrose solution.

When the patient has an underlying healing deficiency, prolotherapy has less success but can still be used e.g. an immune system dysfunction, rheumatoid illness, chronic infection, nutritional deficit, or hormonal deficiency.

Certain ligaments and tendons and certain types of damage respond better to prolotherapy then others, so it is always best to discuss the appropriateness of prolotherapy with A MSKM doctor on a case-by-case basis.

Success is also influenced by the stage at which the intervention occurs. If the condition has progressed to osteoarthritis, prolotherapy may still be used, but with a lesser expectation of resolving the dysfunction. At the very least it can create ligamentous support, which combined with specific stability and strength exercises can aid in the management of pain and dysfunction.

IS PROLOTHERAPY SUCCESSFUL WITH HYPERMOBILITY SYNDROME?

Joint Hypermobility Syndrome (JHS) and Ehlers-Danlos Syndrome (EDS) are genetic connective tissue disorders that cause systemic hypermobility. Prolotherapy is an ideal treatment for these conditions as they are an extreme version of the ligament laxity it is designed to treat. Further rationale for using prolotherapy for JHS and EDS include its high safety record, joint stabilisation, cost effectiveness in comparison to surgery and relatively quick and sustainable pain relief.

The most comprehensive documentation of the use of prolotherapy in the treatment of JHS and EDS appears in a paper titled Treatment of Joint Hypermobility Syndrome with Hackett- Hemwall Prolotherapy [3]. The authors discuss 20 years of experience in treating JHS and EDS with prolotherapy. They claim that prolotherapy can and has lead to the following outcomes for people with JHS and EDS:

• joint stabilisation, which is often permanent, however some patients may require follow up procedures
• elimination of chronic pain, and
• prevention of precocious arthritis.

The paper gives a promising outlook for sufferers of JHS and EDS, however it raised some issues for me. In the treatment methodology used, ‘all or most joints’ were injected in each treatment and some of the case studies mentioned that new issues can often ‘pop up’ in different areas after several treatments.  I started to wonder how these injections impacted on the whole body and the delicate relationship between various ligaments, muscles, joints etc.

When I discussed hypermobility with Dr Lim, he seemed to have a much more conservative approach. He starts by treating the area of greatest influence on overall instability first and gradually progresses to the next area, after re-assessing both function and pain. Along the way he also uses many of the techniques discussed, to support and integrate the regenerated tissue e.g. trigger point therapy, manual mobilisations and stability exercises.  When I broached my issues about the more aggressive approach outlined in the paper above, he referred me back to Buckminster Fullers model of tensegrity. Put simply, a change in tension on one ligament/tendon will change the relative degree of tension and compression equally on all other ligaments and tendons within the body.  It is therefore important to consider that structural reorganisation is taking place, as opposed to just the tightening up of joints to make them more stable. Food for thought!

SCIENTIFIC EVIDENCE AND REGULATION

The paper Prolotherapy in Primary Care Practice[4], gives a good review of the clinical evidence to date. It points out that prolotherapy has been primarily utilized outside of academic centres. This has lead to a very practical orientation of existing prolotherapy studies and a lack of major clinical trials. Various studies have been published in the Journal of Prolotherapy as well as other medical journals and since 1987 several double bind and retrospective studies have scientifically supported the use of Prolotherapy[5][6].

To date, prolotherapy has been best assessed as a treatment for lower back pain, osteoarthritis, non-specific, non-surgical lower back pain, osteoarthritis of the knee and hand and for several tendinopathies; including lateral epicondylosis, Achilles, adductor and plantar fasciitis.[7]

Scepticism and unregulated use of the prolotherapy procedure will be a constant until more detailed clinical trials and evidence-based research emerge.  Currently there seems to be no regulating body or agenda for prolotherapy in Australia and no standardised accredited training, although many MSKM doctors, Sports Medicine doctors and physiotherapists practice it.  Dr Lim completed his prolotherapy certification with the American Association of Orthopaedic Medicine (AAOM), which offers accredited certificate training. Both the Australian College of Physical Medicine (ACPM) and the Australian Association of Musculoskeletal Medicine (AAMM), have online directories where you can search for a doctor and review their modalities. When choosing a practitioner, it is useful to remember that prolotherapy works best when administered in combination with other musculoskeletal therapies.

CONCLUSION

It has taken me a long time to realise that I cannot fix complex soft tissue injuries by strengthening musculature (core or otherwise) and that intervention to address ligament laxity and muscle dysfunction can drastically reduce chronic pain and the use of anti-inflammatories and opiates. When my clients’ progress is constantly impeded by pain or injury, progress is slow or insignificant.  My work with Dr Lim has allowed me to do what I am trained to do better and provided a more holistic framework for me to understand the complexity of musculoskeletal pain. I look forward to sharing more of the insights I have garnered from my collaborations with other allied health practitioners, in the next article.