olume one bone on bone - dr.babette...

V O L U M E O N E | I S S U E O N E | F E B R U A R Y 2 0 0 9 w w w . j o u r n a l of p r o l o t h e r a p y . c o m

Prolotherapy Just Makes More Sense for Cartilage Injuries than Accelerating Arthritis with Arthroscopy

JOP Dedication and Award Recognizing the Accomplishments of Gustav A. Hemwall, MD

A Retrospective Study on Dextrose Prolotherapy for Unresolved Knee Pain

Standard Clinical X-ray Studies Document CartilageRegeneration in Five Degerated Knees After Prolotherapy

Prolotherapy Saved Me From Bilateral Knee Replacements!

Prolotherapy Gets College Basketball Player Back on the Court

Prolotherapy Technique on Injecting the Anterior Cruciate Ligament

Prolotherapy and Connective Tissue Damage Syndrome

An Alternative Answer to Anterior Cruciate Ligamentand Hip Dysplasia Degeneration in Animals

It’s a Wide Wide World: Literature Reviews

Prolotherapy Skill Enhancement

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ALSO IN THIS ISSUE

Cartilage Regeneration

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EVIDENCE ofCARTILAGEREPAIR

EVIDENCE ofCARTILAGEREPAIR

Prolotherapy

Articular

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PROLOTHERAPISTS...PROLOTHERAPISTS...H E L P I N G R E L I E V E P A I N O N E P A T I E N T A T A T I M E

www.g

etprolo

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www.g

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To find a Prolotherapist in your part of the world

IF YOU ARE A PROLO THERAP IS T & WOULD L IKE YOUR PRACT ICE L I S TED ON TH IS WEBS I TEPLEASE V I S I T H T TP ://GETPROLO .COM/APPL IC AT ION .HTM

www.getprolo.comvisit www.getprolo.com

J O U R N A L of P R O L O T H E R A P Y | V O L U M E 1 , I S S U E 1 | F E B R U A R Y 2 0 0 9

I N T H I S I S S U E O F T H E J O U R N A L O F P R O L O T H E R A P Y

32 ProlotherapyGetsCollegeBasketballPlayerBackontheCourt

Mark T. Wheaton, MD & John Manley

T E A C H I N G T E C H N I Q U E S

36 ProlotherapyTechniqueonInjectingtheAnteriorCruciateLigament

Rodney S. Van Pelt, MD

W O N D E R W H Y ?

39 TheRegenerationofArticular CartilagewithProlotherapy

Ross A. Hauser, MD

45 Prolotherapy&ConnectiveTissueDamageSyndrome:WhyamIhurting,

andnooneseemstoknowwhatis wrong?Mark L. Johnson, MD, FACS

F O U R - L E G G E D P R O L O T H E R A P Y

54 MyExperienceWithProlotherapy InAnimals:AnAlternativeAnswer

toAnteriorCruciateLigament andHipDysplasiaDegeneration Roger L. DeHaan, DVM, MTS, CVC

I T ’ S A W I D E W I D E W O R L D : L I T E R A T U R E R E V I E W S

59 SevenLiteratureReviewsCathy A. Skinkis, MA & Ross A. Hauser, MD

S K I L L E N H A N C E M E N T

63 Seminars,Training,&Organizations

TableofContentsG R E A T N E W S C O R N E R

6 ProlotherapyJustMakesMoreSenseforCartilageInjuriesthanAccelerating

ArthritiswithArthroscopy Ross A. Hauser, MD

D E D I C A T I O N

8 JOPDedicationandAward RecognizingtheAccomplishments

ofGustavAndersHemwall,MD

Ross A. Hauser, MD

F A N T A S T I C F I N D I N G S

11 ARetrospectiveStudyonDextrose ProlotherapyforUnresolvedKnee

PainatanOutpatientCharityClinic inRuralIllinoisRoss A. Hauser, MD & Marion A. Hauser, MS, RD

R E M A R K A B L E R E C O V E R I E S

22 StandardClinicalX-rayStudies DocumentCartilageRegeneration

inFiveDegeneratedKneesAfter ProlotherapyRoss A. Hauser, MD

& Joseph J. Cukla, LPN

29 ProlotherapySavedMeFromBilateralKneeReplacements!

Alek Jakich & Heather L. McCullough, MA


J O P T E A M & S U B S C R I B E R I N F O R M A T I O N

SubscriberInformation

E D I T O R - I N - C H I E F

RossA.Hauser,MDOak Park, IL

E D I T O R I A L B O A R D

DonnaAlderman,DOGlendale, CA

GunterBaehnisch,MDLeipzig, Germany

RobertBanner,MDLondon, Ontario, Canada

JoseEleazarCalderon,MDMonclova, Coahuila, Mexico

JOPTeam GaryB.Clark,MD,MPABoulder, CO

ShaunFauley,DVMNaperville, IL

JoernFunck,MDLuebeck, Germany

MarkL.Johnson,MD,FACSNashville, TN

GeorgeKramer,MDMinnetonka, MN

JohnNeustadt,ND.Bozeman, MT

JoanResk,DO,JDRoanoke, VA

JudithShoemaker,DVMNottingham, PA

GarrettSwetlikoff,MDKelowna, BC, Canada

RodneyVanPelt,MDUkiah, CA

MarkT.Wheaton,MDMinnetonka, MN

R E S I D E N T E D I T O R S

PeterJ.Blakemore,DOWatertown, NY

PatrickM.Hobbins,DOSouth Bend, IN

The Journal of Prolotherapy is unique in that it has a targetaudience of both physicians and patients. The purpose ofthis journal is to provide the readers with new cutting-edgeinformation on Prolotherapy, as well as provide a forum forphysiciansandpatientsaliketotelltheirstories.

Journal of Prolotherapyispublishedquarterly–inFebruary,May,August,andNovemberbyBeulahLandPress,715LakeStreet,Suite600,OakPark,Illinois,60301.©Copyright2009byBeulahLandPress.Allrightsreserved.Noportionofthecontentsmaybereproducedinanyformwithoutwrittenpermissionfromthepublisher.

All subscription inquiries, orders, back issues, claims, andrenewalsshouldbeaddressedtoBeulahLandPress,715LakeSt. Suite 600, Oak Park, IL 60301; phone: 708-848-5011; fax:708-848-8053.Email:[email protected];http://beulahlandpress.com.

P R I C I N G

Annualsubscription:$100/year.Includes4paperissuesandonlineaccesstoallwww.JournalofProlotherapy.comwebcontent.

C L A I M S

Claimsforundeliveredcopiesmustbemadenolaterthanonemonthfollowingthemonthofpublication.Thepublisherwillsupply missing copies when losses have been sustained intransitandwhenthereservestockwillpermit.

C H A N G E O F A D D R E S S

Change of address notices should be sent to JOP, 30 days inadvancetoJOP715LakeSt.Suite600,OakPark,IL60301;phone:708-848-5011;fax:708-848-8053.

C O P Y R I G H T P E R M I S S I O N

Permission requests to photocopy or otherwise reproducecopyrighted material owned by Beulah Land Press should berequestedbycontactingBeulahLandPressat708-848-5011orbyemailinginfo@benuts.com.

D I S C L A I M E R

This publication does not constitute medical or otherprofessional advice and should not be taken as such.To theextent the articles published herein may be used to assist inthe care of patients, this is the result of the sole professionaljudgment of the health professional. The health careprofessional’s judgment is the primary component of qualityhealth care. The information presented in this journal isnot a substitute for the exercise of such judgment by thehealth professional. The opinions expressed in the Journal of Prolotherapyaretheopinionsoftheauthorsoftheirrespectivearticlesandnotnecessarilythatofthepublisher.Thedecisionson what to do for a specific medical condition or symptomshouldbebasedontheanalysisbytheperson’sprivatehealthcareprofessional.

J O P S T A F F

MarionA.Hauser,MS,RDSenior Editor

NicoleM.Baird,CHFPAssociate Editor

TravisE.MitchellSenior Graphic Designer/Webmaster

DougR.SkinkisAssistant to the Editor-in-Chief/ Assistant Graphic Designer

PatriciaH.MillerLay Editor

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MediaforDoctors,Inc.Media Relations

ISSN 1944-0421 (print)ISSN 1944-043X (online)


W H Y T H E J O U R N A L O F P R O L O T H E R A P Y ?

WhytheJournalofProlotherapy?Well, you know our mission: to educate the world about thelife-changingeffectsofProlotherapy.Likeyou,wewantmorepeopletoknowthatthereishopeforchronicpainpatientsandthathopeisProlotherapy.

WhensomeonefindsoutaboutProlotherapyforthefirsttime,acommonreactionis“whyhaven’tIheardofthisbefore?”TheJournal of Prolotherapywilldo itsbest tomakesureeveryonein chronic pain has at least heard about Prolotherapy. Theskeptics of Prolotherapy often say that research is lacking.Toprovide an avenue to make more research available, we willprint a quarterly paper journal which will also be availablein electronic form on www.journalofprolotherapy.com. Thisjournal is the place to talk about Prolotherapy—not only forphysicians,butalsoforpatients.

JOPbelievesthat it is importanttogetboththedoctors’and the patients’ perspectives. We believe that the greatestevidence for the effectiveness of Prolotherapy is not goingto come from a “double-blind scientific study” but from themillionsofchangedlivesfromProlotherapy.Inessence,almosteverypatientthatgetsProlotherapyproves thatProlotherapyworks.

Most patients who receive Prolotherapy are suffering with achronic degenerative medical condition. These conditionsare traditionally supposed to worsen with time. When one

of these patients receives Prolotherapy and their chronicdegenerative condition subsequently reverses, as evidencednot only by the relief of pain, improvement in activity level,decrease inmedicationusageandusageofotherhealthcarefortheirpain,butalsobyX-rayandMRI improvement,this, inour opinion, is definitive proof that Prolotherapy does, indeed,regeneratestructures.

What do we hope to achieve in publishing the Journal of Prolotherapy? With your help, we hope to achievechanged lives. We want to get people back to sports, backto being happy, back to being the kind of people theywish to be! We see hundreds, thousands, even millions ofpeople getting out of pain because they experienced thelife-changing effects of Prolotherapy. We believe that thisis a cause worth fighting for! We hope you will join thefight by subscribing to the Journal of Prolotherapy, writingarticles, case studies, even your own experience withProlotherapy, and get others on this crusade. It is time toeducate the world that you don’t have to live with chronicpain, that there is a treatment out there that will work...andthattreatmentisProlotherapy!

Formoreinformationabouthowtosubmitanarticleortotellyour story, please see www.journalofprolotherapy.com andview the author guidelines.We look forward to hearing fromyou.


J O U R N A L O F P R O L O T H E R A P Y A U T H O R S

R O G E R L . D e H A A N , D V M , M T S , C V C

RogerL.DeHaan,DVMgraduatedfromMichiganStateUniversitywithhisdegreeinveterinarymedicinein1967.Followingthat,hewasinvolvedinagriculturalmissionsinColombia,SouthAmericafor12years.HecurrentlyownsHolisticVeterinaryServices,aclinicalpracticeinKingsMountain,NorthCarolina.Dr.DeHaanhaspublishedtwobooksonhealthwithchallenginganswerstopeopleandpets,aswellastheplanet.Thetitlesare“We don’t Die…We Kill Ourselves: Our Foods are Killing US!”and“Restoring the Creation Mandate: HEALING for People, Pets, Plants & the Planet!”

Authors

R O S S A . H A U S E R , M D

RossA.Hauser,MDreceivedhisundergraduatedegreefromUniversityofIllinois.HegraduatedfromtheUniversityofIllinoisCollegeofMedicineinChicagoanddidhisresidencyatLoyola/HinesVAinPhysicalMedicine and Rehabilitation. Dr. Hauser is the Medical Director of Caring Medical and RehabilitationServicesinOakPark,IllinoisandispassionateaboutProlotherapyandnaturalmedicine.Dr.HauserandhiswifeMarion,havewrittensevenbooksonProlotherapy,includingthenationalbestseller“Prolo Your Pain Away! Curing Chronic Pain with Prolotherapy,”nowinitsthirdedition,alongwithafour-booktopicalminiseriesofProlotherapybooks.Healsospearheadedthewritingofa900-pageepicsportsbookthatdiscussestheuseofProlotherapyforsportsinjuries,“Prolo Your Sports Injuries Away! Curing Sports Injuries and Enhancing Athletic Performance with Prolotherapy.”

M A R I O N A . H A U S E R , M S , R D

MarionA.Hauser,MS,RDreceivedherBachelorofScienceinNutritionfromUniversityofIllinoisandherMasterofScienceinNutritionanddieteticinternshipfromEasternIllinoisUniversity.MarionistheCEOofCaringMedicalandRehabilitationServices,acomprehensiveNaturalMedicineClinicinOakPark,IllinoisandownerofBeulahLandNutritionals.Asaregistereddietitian,Marionisalsoawell-knownspeakerandwriteronavarietyoftopicsrelatedtonaturalmedicineandnutritionprovidinginformationforweeklye-newslettersand radio showsonavarietyofhealth topics.Marionhas recently released “The Hauser Diet: A Fresh Look at Healthy Living.” Along with her husband, Dr. Ross Hauser, Marion co-authored thenationalbestsellerentitled“Prolo Your Pain Away! Curing Chronic Pain with Prolotherapy”alongwithafour-bookminiseriesofProlotherapybooks,aswellasacomprehensivesportsbookdiscussingtheuseofProlotherapyforsportsinjuries.

J O S E P H J . C U K L A , L P N

JosephJ.Cukla,LPNreceivedhisBachelorofArtdegreeinEnglishfromPiedmontCollegeinGeorgia.HereceivedhisPracticalNurselicenseatCityCollegesofChicago.HeisafulltimePracticalNurseatCaringMedicalandRehabilitationServices,S.C.inOakPark,Illinois.


J O U R N A L O F P R O L O T H E R A P Y A U T H O R S

M A R K L . J O H N S O N , M D , F A C S

MarkL.Johnson,MDreceivedhisundergraduatedegreefromEmoryUniversity.AfterreceivinghisM.D.from the University of Alabama in Birmingham, he completed his General Surgery internship at theUniversity of Kentucky in Lexington, and his Urology residency at the University of Illinois in Chicago.Hehadextensivepostgraduatetraininginlaparoscopicandroboticsurgery.Heisamemberofnumerousprofessional organizations including the American College of Osteopathic Sclerotheropeutic PainManagement, the American College of Surgeons, the American Urological Association, the Society ofLaparoendoscopic Surgeons, The Tennessee Medical Association, and the Davidson County MedicalSociety.Dr.JohnsonretiredfromsurgicalpracticefiveyearsagotopracticeProlotherapyfull-time.

C A T H Y A . S K I N K I S , M A

CathyA.Skinkis,MAreceivedhermedicaltraininginthemilitaryasanAirForceMedicwheresheservedour country for four years. Cathy is currently the Clinical Manager for Caring Medical & RehabilitationServices,inOakPark,Illinois,andhasbeenworkingintheAlternativeMedicinearenafor16years.Shehasapassionforpassingonherknowledgeinordertohelpotherpeopleachieveoptimalhealth,particularlywithProlotherapy.CathyalsowritesformanyoftheCaringMedicalpublications,includingastudyonbeevenominjectionsformultiplesclerosisin2000,aswellascasereports,webcontent,andnewsletters.

M A R K T . W H E A T O N , M D

MarkT.Wheaton,MDisboard-certifiedinPhysicalMedicineandRehabilitation,withfellowshiptraininginSportsMedicine,andhasperformedProlotherapysince1996inhisprivatepractice,LakesideSportsandPainClinic,inExcelsior,Minnesota.Dr.WheatonwasacontributingauthortotheHausers’Prolo Your Pain Away!andProlo Your Sports Injuries Away!booksandwasprivilegedtobeavolunteerattheirmedicalmissionary clinic for almost 10 years. He also enjoys his role as a Prolotherapy instructor and lecturer,stating,“IoweagreatdebttoDr.GustavHemwall,whograciouslytaughtthetechniqueofProlotherapytomeandmanyothercurrentProlotherapiststhroughhisbooksandseminars.”Dr.Wheatonalsousesothercomplementary methods such as Neural Therapy, Neurotransmitter Therapy, Electrotherapy, PhysicalTherapy,andManualMuscleTherapyinhispractice.

H E A T H E R L . M c C U L L O U G H , M A

HeatherL.McCullough,MAwasbornandraised inNorthDakotathroughherhighschoolyears; thenmovedaroundquiteabitfromCalifornia,Oregon,andAlaska,tofinallylandinginOakPark,Illinois.HeatheristrainedasacertifiedMidwifehaving“caught”over200babies.HeatherworksontheclinicalteamofCaringMedical&RehabilitationServicesandispassionateaboutnaturalmedicineandProlotherapy.SheactivelydoesresearchandcasereportwritingforCaringMedical’swidearrayofpublicationswhensheisnotcaringforpatients.

R O D N E Y S . V A N P E LT , M D

Rodney S.Van Pelt, MD received his medical degree from Loma Linda University Medical School andcompletedhis familypracticeresidency inFlorida.HepracticedfamilymedicineforseveralyearsuntilfallinginlovewiththespecialtyofOrthopedicMedicinewhichusesallthedifferentmodalitiesforpainwithconservativetreatments.Dr.VanPeltthenreceivedspecializedtrainingintheCyriaxtechniqueofOrthopedic Medicine, taking some of his training in Oxford, England. He is one of the few Americanphysicians who is a member of the Society of Orthopedic Medicine of London, England. Dr.Van PeltpracticesfulltimeProlotherapyinnorthernCalifornia.

J O U R N A L of P R O L O T H E R A P Y | V O L U M E 1 , I S S U E 1 | F E B R U A R Y 2 0 0 9�

G R E A T N E W S C O R N E R : P R O L O T H E R A P Y J U S T M A K E S M O R E S E N S E F O R C A R T I L A G E I N J U R I E S

W elcome to the inaugural issue of the Journal of Prolotherapy (JOP). Unlike most medical journals which are written to doctors, this one

has a target audience of both doctors and their patients; for that matter, anyone in pain who is interested in Prolotherapy! The world needs this journal. Why? Well let me tell you a story. The other day I saw a new client by the name of Cyrus. Yes, that is his real name. He told me his story.

“Doc, I went to Dr. ______. You know the guy who is the team physician for the ______ (professional football team). He was also one of the doctors for the 19__ Olympic team. He had me get an MRI on my knee. He told me I should get arthroscopy and get some of my cartilage shaved off. When I asked him about Prolotherapy he said, ‘It is going to kill your cells. Don’t do it!’ I then asked him what would happen to my knee if he shaved some of the meniscus off. He then told me I would ‘get arthritis 20 years quicker!’ He said it would definitely accelerate the onset of arthritis!”

Cyrus was nervous coming in for Prolotherapy. He faints at the site of blood. The thought of getting a bunch of painful shots into and around his knee had him very worried. My staff and I spent a lot of time with him. He insisted I look at his MRI report, but I told him, “I like to look at that last. First, I need to talk to you. You will tell me more about your case and what treatment is needed than any MRI.” Then I examined him. I thought the whole case added up to a medial meniscal injury. I then reviewed his MRI. Yes, he had evidence of a medial collateral ligament sprain and some minor cartilage degeneration, but that was about it. So the top-notch orthopedist was going to do arthroscopy for that?

Cyrus and I talked further. I told Cyrus I felt what the orthopedist told him was true in regard to arthroscopy accelerating the arthritic process. Cyrus then proceeded

to tell me that the orthopedist also offered him a cortisone shot. Cyrus declined. What Cyrus did not know was the fact that cortisone kills cartilage cells. Prolotherapy regenerates articular cartilage cells. He researched Prolotherapy and decided to try it instead of surgery because he felt it made more sense to him (as it does to me!)

Currently in the United States there are about 1 million arthroscopies done annually. About one-third of these are for joint degeneration, even though it has been proven by modern medicine’s “gold” standard double-blinded studies that arthroscopic surgery for osteoarthritis of the knee doesn’t work any better than regular medical treatment.1,2 The conclusion of the two double-blinded studies was that arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy. According to the Cochrane Reviews “there is ‘gold’ level evidence that arthroscopic debridement has no benefit for undiscriminated osteoarthritis (mechanical or inflammatory).”3 What are the results of Prolotherapy for osteoarthritis of the knee? You draw your own conclusion as you read the experiences of patients and doctors who use Prolotherapy. My experience over the course of the last fifteen years is that Prolotherapy is incredibly effective at not only controlling the pain and disability of knee osteoarthritis (and other joints) but reversing it!

This first issue of the Journal of Prolotherapy contains many thought-provoking articles. Here is what you can expect to find regularly in issues of this journal:

Doctors’ experiences with using Prolotherapy for various conditions

Illustrations and explanations on various techniques of Prolotherapy

Research that doctors and lay people have done concerning chronic pain and Prolotherapy

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Prolotherapy Just Makes More Sense for Cartilage Injuries than Accelerating Arthritis with Arthroscopy

G R E A T N E W S C O R N E R

Ross A. Hauser, MD

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G R E A T N E W S C O R N E R : P R O L O T H E R A P Y J U S T M A K E S M O R E S E N S E F O R C A R T I L A G E I N J U R I E S

Stories from patients whose lives have changed from Prolotherapy

News from around the world as it relates to Prolotherapy

Veterinarians’ experiences with Prolotherapy

and much more!

All of the writing was done by people that I personally know. I am grateful for their help. This issue contains articles from:

Mark Johnson, MD, a traditionally trained urologist, who explains from his perspective why chronic pain should be looked at as a connective tissue damage syndrome.

Roger DeHaan, DVM, who gives us an overview of his experience with treating animals with Prolotherapy. Prolotherapy owes a great debt to him, as he is one of the veterinarians that helped get Prolotherapy information and training out to his fellow animal doctors.

Rodney Van Pelt, MD, who demonstrates his technique used for treating anterior cruciate ligament (ACL) injuries using Prolotherapy.

Mark Wheaton, MD, who describes a very interesting case of an elite college basketball player’s struggle with back pain, along with the patient’s perspective on the Prolotherapy experience, all found in Remarkable Recoveries!

Outpatient Charity Clinic Data: For many years my wife and I ran a Prolotherapy charity clinic in rural Illinois with the help of a crew of volunteer friends. Most of us who were involved with the clinic are Christians, and the clinic was held in the basement of the First Baptist Church in Thebes. We did our best to help the folks that came, giving “a lot of cups of water in Jesus’ name.” In this issue, and many subsequent issues, you will see research study data from the clients that were treated in Thebes, Illinois. All of the data was compiled by independent researchers who know very little about Prolotherapy.

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The remaining content in this first issue comes from articles my staff and I put together related to the topic of articular cartilage regeneration. Yes, Prolotherapy can regenerate articular cartilage!

In the future, as more people become aware of the journal, we hope to see our readers submitting articles for publication. The Journal of Prolotherapy will become successful only when we all take an ownership interest in it. I hope you will be kind enough to send me your thoughts and suggestions to making JOP a success. Remember, the goal is to educate the world about the life-changing effects of Prolotherapy. This will only happen by you telling how your life was changed with Prolotherapy. I cannot wait to read about it!

Until the next injection,

B I B L I O G R A P H Y

Moseley JB, et. al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. NEJM. 2002;347:81-88.

Kirkley A, et. al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. NEJM. 2008;349:1097-1107.

Laupattarakasem W, et al. Arthroscopic debridement for knee osteoarthritis. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD005118. DOI: 10.1002/14651858.CD005118.pub2. Available at: http://www.cochrane.org/reviews/en/ab005118. html. Accessed October 13, 2008.

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D E D I C A T I O N : J O U R N A L O F P R O L O T H E R A P Y R E C O G N I Z I N G G U S T A V A . H E M W A L L , M D

Journal of Prolotherapy Dedication and AwardRecognizing the Accomplishments of Gustav Anders Hemwall, MD

D E D I C A T I O N

T he name Gustav A. Hemwall most likely doesn’t ring a bell to the average American. Even those new to Prolotherapy might not know who he was.

You will not see his name in lights or read about him in the paper. He was a humble man who never sought out his own glory, only the glory of the one true God that he served. Perhaps the success of a man should be measured not by fame or fortune, but by whether their work on earth continues after they die.

Here are some of the accomplishments of Gustav A. Hemwall, MD, written 10 years after his death.

1 . C O m P A s s I O n I n t e R n A t I O n A L

Founded by Reverend Everett Swanson in 1952, Compassion began providing Korean War orphans with food, shelter, education, and health care, as well as Christian training. Dr. Hemwall was on the initial board that helped Reverend Swanson with the work he started. Compassion International exists as a Christian child advocacy ministry that releases children from spiritual, economic, social, and physical poverty, enabling them to become responsible, fulfilled, Christian adults. This organization exists with a budget of over 90 million dollars, helping orphaned children all over the world. For further information, please go to www.compassion.com.

2 . I n s t I t u t e I n B A s I C L I f e P R I n C I P L e s

Dr. Hemwall served as president of the board since its inception until he passed away in 1998. The Institute in Basic Life Principles (IBLP) was established by Bill Gothard in 1961 for the purpose of introducing people to the Lord Jesus Christ. It is dedicated to giving individuals,

families, churches, schools, communities, governments, and businesses clear instruction and training on how to find success by following God’s principles found in Scripture. These goals are accomplished primarily through seminars, educational programs, printed literature, and the operation of centers to facilitate training. For further information, please go to www.iblp.org.

3 . t H e C H R I s t I A n m e d I C A L & d e n t A L A s s O C I A t I O n

Dr. Hemwall was involved in the establishing of this organization, as well as serving on its board. In 1977 he received its highest honor, The Servant of Christ Award. The Christian Medical & Dental Association exists to motivate, educate, and equip Christian physicians and dentists to glorify God by living out the character of Christ in their homes, practices, communities, and around the world. For further information, please go to www.cmdshome.org.

4 . H A C k e t t f O u n d A t I O n

Dr. Hemwall learned Prolotherapy from the person who coined the term “Prolotherapy,” George S. Hackett, MD, in the 1950s. Dr. Hemwall helped form the Prolotherapy Association in the 1960s and started taking doctors to perform Prolotherapy in impoverished areas of Honduras. Some of the doctors that went on these mission trips are Jeffrey Patterson, DO, Rodney Van Pelt, MD, as well as myself, Ross A. Hauser, MD. Dr. Hemwall did this for over 30 years. He started the Hackett Foundation in 1969, which was committed to promoting Prolotherapy and training doctors in Prolotherapy. This foundation continues through the leadership Dr. Hemwall and wife Helen.

Ross A. Hauser, MD

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of Dr. Patterson. It has expanded to now serve several countries to give Prolotherapy care to those unable to afford the services, as well as train doctors in Prolotherapy, with the hope of getting Prolotherapy established in these other countries. This foundation has been appropriately renamed the Hackett-Hemwall Foundation. For further information please go to www.HackettHemwall.org.

5 . P R O L O t H e R A P Y

As surgery became more and more the norm in the 1960s through the 1980s, there was one main voice that kept Prolotherapy going. That voice was Gustav A. Hemwall, MD’s voice! It is possible that Prolotherapy might have vanished if not for the tenacity of this man. He was convinced that it worked and was committed to not only treating people with Prolotherapy, but training doctors to perform the therapy. He made enough “Prolotherapy disciples” that upon his death in 1998, at the age of 90, Prolotherapy has continued to prosper. Besides more books being written on the subject, research papers being published, and doctors being trained in it, now a medical journal, this journal, is devoted to educating the world on the life-changing effects of Prolotherapy. I am sure that Gustav A. Hemwall, MD, my mentor and whose medical practice I continue to run, would be very, very happy!

6 . f A m I L Y

Though this is the last one I will mention, family was certainly the priority in Dr. Hemwall’s life. He told me one story that occurred early in his career. “Most of the doctors at the hospital were joining the country club. I had no interest in joining the country club. It would cost me precious time with my family!” Dr. Hemwall was married to Helen for 65 years. They fulfilled “til death due us part.” They had four daughters. The family was, and is, still very close.

Dr. Hemwall lecturing.

These are just a small sampling of Gustav A. Hemwall, MD’s many accomplishments. If you have a great Dr. Hemwall story to tell, please write to me at: [email protected].

Here is one Dr. Hemwall story. On July 12th, 1993, I was running real fast around the office, doing three things at once. Dr. Hemwall, very humbly gave me this paraphrase of the 23rd Psalm. Instead of it starting out, The LORD



Dr. Hemwall doing Prolotherapy.

is my shepherd, I shall not want, it starts out The LORD is my pacesetter, I shall not rush... (See Figure 1.) Those who knew Dr. Hemwall, understood that worry and rushing were not part of his personality. He taught me in the bible it never said that Jesus was in a hurry. Yet at the end of Jesus’ life he said “It is finished.” Wow what a testimony for not rushing around!

In honor of Dr. Hemwall, The Journal of Prolotherapy will be setting up an award in his honor. If you would like to nominate someone who has been influential in the field of Prolotherapy and helping people relieve their pain, please let us know.

Sincerely with warm regards,

Ross A. Hauser, M.D. n

Figure 1. Paraphrase of the 23rd Psalm.


F A N T A S T I C F I N D I N G S : A R E T R O S P E C T I V E S T U D Y O N D E X T R O S E P R O L O T H E R A P Y F O R U N R E S O L V E D K N E E P A I N

A B s t R A C t

The optimal long-term, symptomatic therapy for unresolved knee pain has not been established. Accordingly, we investigated the outcomes of patients undergoing Hackett-Hemwall dextrose Prolotherapy treatment for unresolved knee pain at a charity clinic in rural Illinois. We studied a sample of 80 patients, representing a total of 119 knees, that were treated quarterly with Prolotherapy. On average, 15 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment. The results of this study showed that patients had a statistically significant decline in their level of pain, stiffness, crunching sensation, and improvement in their range of motion with Prolotherapy. More than 82% showed improvements in walking ability, medication usage, athletic ability, anxiety, depression, and overall disability with Prolotherapy. Ninety-six percent of patients felt Prolotherapy improved their life overall. Conclusion: In this study, patients with unresolved knee pain, treated with dextrose Prolotherapy, showed improvements in many clinically relevant parameters and overall quality of life.

Journal of Prolotherapy. 2009;1:11-21.keYWORds: anxiety, crunching, depression, knee pain, medication, Prolotherapy, range of motion, retrospective study, stiffness.

charity clinic in rural Illinois. Knee pain is a common problem facing many patients, presenting in up to 20% of the adult population.1 Currently in the U.S., osteoarthritis of the knee results in chronic knee pain in approximately 17 million people.2 According to the American Academy of Orthopaedic Surgeons, between the years 1998 and 2005, the number of knee replacements doubled, resulting in an estimated 533,808 procedures done in the year 2005.3 By the year 2030, this number is projected to be 3.48 million.4 With this one form of surgery already accruing over $17 billion in hospitalization charges in 2005, and 90% of these needing to be repeated in 10 years, we suggest that the Hackett-Hemwall dextrose Prolotherapy technique for treating the injured knee is a safe, effective, and less expensive solution to a portion of this rising trend.5,6

Prolotherapy is becoming a widespread form of pain management in both complementary and allopathic medicine.7,8,9,10 Its primary use is in pain management associated with tendinopathies and ligament sprains in peripheral joints.11,12,13 Prolotherapy is also being used in the treatment of spine and joint degenerative arthritis.14,15 In double-blinded human studies, the evidence on the effectiveness of Prolotherapy has been considered pro-mising, but mixed.16,17,18 Prolotherapy treatments are now done at some major medical centers and universities.19,20

George S. Hackett, MD, Prolotherapy pioneer, coined the term Prolotherapy in the 1930s.21 As he described it, “The treatment consists of the injection of a solution within the relaxed ligament and tendon which will stimulate the production of new fibrous tissue and bone cells that will strengthen the ‘weld’ of fibrous tissue and bone to stabilize the articulation and permanently eliminate the disability.”22 Animal studies have shown that Prolotherapy induces the production of new collagen by stimulating the normal inflammatory reaction.23,24 In addition, animal studies have shown improvements in ligament and tendon diameter and strength.25,26 Human studies have shown improvements in pain symptoms.27,28

A Retrospective Study on Dextrose Prolotherapy for Unresolved Knee Pain

at an Outpatient Charity Clinic in Rural Illinois

F A N T A S T I C F I N D I N G S

Ross A. Hauser, MD & Marion A. Hauser, MS, RD

I n t R O d u C t I O n

T he optimal long-term, symptomatic therapy for unresolved knee pain has not been established. Accordingly, we investigated the outcomes

of patients undergoing Hackett-Hemwall dextrose Prolotherapy treatment for unresolved knee pain at a



Studies on the effectiveness of Prolotherapy on knee pain have been promising.29,30 One of these studies showed the benefits of three bimonthly injections of dextrose as the proliferant into the degenerated knees.31 To evaluate the effectiveness of dextrose Prolotherapy, not just on knee pain but on quality of life measures, this observational study was undertaken.

O B j e C t I v e s

To investigate the outcomes of patients undergoing dextrose Prolotherapy treatment for unresolved knee pain at a charity clinic in rural Illinois. To develop selection criterion for who might be a good candidate for Prolotherapy in patients with unresolved knee pain.

m e t H O d s

Patients with unresolved knee pain who were treated with dextrose Prolotherapy every three months were included into an observational study. The patients were called on the phone, on average, fifteen months following their last Prolotherapy session and asked to answer detailed questions related to the level of knee pain, stiffness, range of motion, medication usage, anxiety, depression, activities of daily living, and other quality of life measures before and after receiving dextrose Prolotherapy.

R e s u L t s

A total of 80 patients representing 119 knees were treated in 2003-2005. The average starting knee pain level was 6.5 and ending knee pain level was 2.3. Using the matched sample test, statistically significant improvements in pain, stiffness, and crunching sensation were observed. Ninety-five percent of patients exhibited improvements in their pain levels after treatment with Prolotherapy. Long term improvements in stiffness occurred in 99% of patients. Ninety percent of patients were able to decrease their medication usage by 50% or more. More than 87% of patients were able to decrease their additional pain treatments by 50% or more. Anxiety and depression symptoms were present in 49% and 41% before Prolotherapy and only in 15% and 10%, respectively, after Prolotherapy. Ninety percent of patients who were told, prior to receiving Prolotherapy, that surgery was their only option, had 75% or greater relief of their chronic pain. While no patients stated they could walk normally before Prolotherapy, 65% stated they could walk normally after Prolotherapy. Ninety-six percent of patients felt Prolotherapy improved their life overall.

C O n C L u s I O n s

In this observational study, patients with unresolved knee pain reported clinically relevant improvements in their pain levels and quality of life after receiving dextrose Prolotherapy.

Methodsf R A m e W O R k A n d s e t t I n G

In October 1994 the two authors started a Christian charity medical clinic, called Beulah Land Natural Medicine Clinic, in an impoverished area in southern Illinois. Prolotherapy was the primary modality of treatment offered for pain control. Dextrose was selected as the main proliferant in the Prolotherapy solution because of its availability, relative inexpensiveness (compared to other proliferants), and its high safety profile. The clinic met every three months until July 2005, and all treatments were given free of charge.

P A t I e n t s

Patients who received Prolotherapy for their unresolved knee pain in the years 2003, 2004, and 2005 were called by telephone and interviewed by an independent data collector who had no prior knowledge of Prolotherapy. General inclusion criteria were an age of at least 18 years, presence of an unresolved knee condition that typically responds to Prolotherapy, and a willingness to undergo at least four Prolotherapy sessions, unless the pain remitted with less Prolotherapy sessions.

I n t e R v e n t I O n s

The Hackett-Hemwall technique of Prolotherapy was used and each patient received 20 to 40 injections of a 15% dextrose, 0.2% lidocaine solution with a total of 20 to 30cc of solution used per knee. Each patient was given an intraarticular injection of 5 to 10cc of solution. Around the knee, tender areas were also injected, and 0.5 to 1.0cc of solution was used per extra-articular injection. Tender areas injected included the medial and lateral collateral ligaments, patellar ligament, and pesanserine tendon attachments. (See Figure 1.) No other therapies were used. As much as the pain would allow, the patients were asked to reduce or stop non-steroidal anti-inflammatory and narcotic medications.



Totalnumberofpatientstreated 80

Totalnumberofkneestreated 119

Averageageofpatients 54

Percentofmalepatients 40%

Percentoffemalepatients 60%

Numberofpriorphysiciansseen 2.3

Averageyearsofpain 5.0

AveragetimesincelastProlotherapy 15months

Informedsurgeryonlytreatmentoption 13%

Informednoothertreatmentoptionfortheirchronickneepain

38%

Takingonepharmaceuticaldrugforpain 21%

Takingtwoormorepharmaceuticaldrugsforpain 23%

Table 1. Patient Characteristics at Baseline.

O u t C O m e s

The independent data collector was the sole person obtaining the patient information during the telephone interviews. The patients were asked a series of questions about their pain and previous treatments before starting Prolotherapy. Their response to Prolotherapy was also detailed with an emphasis on the effect Prolotherapy had on their need for subsequent treatments and their quality of life. Specifically, patients were asked questions concerning years of pain, pain intensity, overall disability, number of physicians seen and medications taken, quality of life concerns, psychological factors, and whether the response to Prolotherapy continued after the Prolotherapy sessions were stopped.

A n A L Y s I s

For the analysis, patient percentages of the various responses were calculated by another independent data collector, who also had no previous knowledge of Prolotherapy. These responses, gathered from clients before Prolotherapy, were then compared with the responses to the same questions after Prolotherapy. A matched sample test was used to determine if there were statistically significant improvements in the before and after Prolotherapy measurements for pain, stiffness, and crunching sensation. Further analyses were done comparing those clients who experienced great success with Prolotherapy (75% or greater pain relief) to those who had minimal success (24% or less of pain relief).

ResultsP A t I e n t C H A R A C t e R I s t I C s

From a total of 120 patients with unresolved knee pain whose charts were analyzed and who were interviewed via phone, 80 met the inclusion criteria. The main reasons for exclusion were inability to complete treatments due to travel/distance (45%); stopped treatments because of their medical doctor’s recommendation (i.e. needed treatments more frequently or other medical problems) or on their own (30%); inability or unwillingness to answer survey (15%); and other (10%).

A total of 119 knees from 80 patients met the inclusion criteria. Of these, 60% were female and 40% were male. The average age of the patients was 54 years-old. Patients reported an average of five years of pain, 30% had pain for greater than six years, and 19% had pain for between four and six years. Forty-seven percent of patients came because of financial concerns and 43% came upon the recommendation of a friend or family member. The average patient saw 2.3 M.D.’s before receiving Prolotherapy. Thirteen percent were told by one of their physicians that surgery was the only answer to their pain problem, and 38% of patients were told by their physicians that there were no other treatment options for their chronic knee pain. Twenty-one percent were taking one pharmaceutical drug for pain. Twenty-three percent were taking two or more drugs for pain. (See Table 1.)

Figure 1. Typical injection sites for Hackett-Hemwall dextrose Prolotherapy of the knee.



t R e A t m e n t O u t C O m e s

Patients received an average of four Prolotherapy treatments per knee. The average time of follow-up after their last Prolotherapy session was 15 months.

Patients were asked to rate their pain, stiffness, and crunching sensation on a scale of 1 to 10, with 1 being no pain/stiffness/crunching and 10 being severe/crippling pain/stiffness/crunching. The 119 knees had an average starting pain level of 6.5, starting stiffness level of 4.7, and starting crunching level of 3.8. Patients were asked to rate their mobility on a scale of 1 to 7, with 1 being no motion, 2 through 5 were percentages of normal motion with 2 being 1-24%, 3 being 25-49%, 4 being 50-74% and 5 being 75-99% of normal motion. Normal motion was 6, and 7 was excessive motion or hyper mobility. The average starting mobility level was 4.7.

The patients reported, after Prolotherapy, that their average ending pain level was 2.3. (See Figure 2.) Average ending mobility was 5.4, average ending stiffness 2.0, and average ending crunching 2.1. Of the patients who started with serious pain (level 8 or more), 93.5% ended with less than minimal pain (a level of 3 or less). The percentage of patients who had a decrease in their pain level was 95%. Of these patients, 83% had a significant reduction in pain of at least 50% or higher. (See Figure 3.) Eighty-four percent of patients finished with only minor restrictions in motion (75% or greater of normal motion). More than 83% of patients reported a minimal stiffness level (a level of 3 or less) after completion of the treatments. Eighty percent of patients reported improvements in the crunching level of their knees and 90% of patients were able to decrease their medication usage by 50% or more.

In regard to quality of life issues, prior to receiving Prolotherapy, none of the participants reported normal walking ability. Eight percent used a cane/walker or wheelchair for mobility. Twelve percent said they could walk for a block or less. Twenty-three percent could walk between one and three blocks. Fifty-seven percent stated they could walk more than three blocks, but not as much as they would like. All patients reported improvements in walking ability after Prolotherapy with 65% having normal walking ability, and 91% could walk three blocks or more. (See Figure 4.) Eighty percent reported that their progress had very much continued (75-99%) after the Prolotherapy sessions were stopped.

Concerning athletic ability prior to Prolotherapy, 36% said they could do no athletics, 13% said they could engage in less than 10 minutes, 22% reported they could engage in less than 30 minutes, but all 100% ranked athletic ability as at least somewhat compromised. All patients stated they had some improvements in athletic ability, with 38% getting back to completely normal athletic ability, and 80% stating that those improvements very much continued after the Prolotherapy sessions ended. After Prolotherapy, 78% stated they could now do at least 30 minutes of exercise. (See Figure 5.)

Before Prolotherapy, 16% noted some dependency on another person for activities of daily living; 35% worked full-time, 10% worked part-time, 9% were disabled and

1 2 3 4 5 � � � 9 10

�0

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50

40

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20

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0

LE VEL OF PAIN

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Figure 2. Starting and ending pain levels before and after receiving Hackett-Hemwall dextrose Prolotherapy in 80 patients (119 knees) with unresolved knee pain.

BEFORE PROLO AFTER PROLO

2 3 4 5 � � � 9 10

100%

90%

�0%

�0%

�0%

50%

40%

30%

20%

10%

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STAR TING LE VEL OF PAIN

PER

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Figure 3. Percent of patients who reported 50% or greater pain relief after receiving Hackett-Hemwall dextrose Prolotherapy.

REPOR TED 50% OR GREATER IMPROVEMENT IN PAIN



Figure 5. Starting and ending athletic ability before and after receiving Hackett-Hemwall dextrose Prolotherapy in 80 patients (119 knees) with unresolved knee pain.

StartingAthleticAbility

EndingAthleticAbility

Totally compromised (no athletics) 37%

Not compromised 0%

< 10 min. exercise 13%


< �0 min. exercise 10%

> �0 min./not as much as they would like 18%

Totally compromised (no athletics) 9%

Not compromised 38%



< �0 min. exercise 20%

> �0 min./not as much as they would like 20%

unable to work, and 25% were retired; all participants noted some overall disability with 52% having a greater than 50% disability. After Prolotherapy, 97% of patients were totally independent, 39% worked full-time, 11% worked part-time, 4% were disabled and unable to work, and 23% were retired; 29% had no disability whatsoever, with only 13% having a greater than 50% disability. Ninety-four percent of the patients felt that their improvements in disability have mostly continued (50% or greater) after Prolotherapy.

Seventy-four percent of patients had trouble sleeping prior to Prolotherapy with 82% saying they could sleep much better after Prolotherapy. Ninety-two percent stated that the improvement in sleep has at least mostly continued after Prolotherapy (50% or greater). Before Prolotherapy, 41% of patients were depressed and 49% were anxious. After Prolotherapy, 90% of patients were not depressed, and 85% were not anxious. (See Figures 6 & 7.)

To a simple yes or no question: Has Prolotherapy changed your life for the better? 96% of patients treated answered yes. In quantifying the response, 43% felt their life was at least radically better with Prolotherapy. Eighty-eight percent rated Prolotherapy at least very successful in treating their condition (50% or greater improvement) with 50% noting the Prolotherapy to be extremely successful (75% or greater improvement). The percentage of patients able to decrease their additional pain-related treatments including chiropractic, physical therapy, acupuncture, and massage after Prolotherapy was 86%. The percentage of patients able to decrease their medication usage by 50% or more was 90%.

Ninety-four percent of patients know of others who have benefited from Prolotherapy. Ninety-seven percent of patients have recommended Prolotherapy to someone. Eighty-seven percent noted that the results of Prolotherapy have mostly continued (at least 50% retained), and 52%

Figure 4. Starting and ending walking ability before and after receiving Hackett-Hemwall dextrose Prolotherapy in 80 patients (119 knees) with unresolved knee pain.

StartingWalkingAbility

Totally compromised (in a wheelchair) 2%

Not compromised 0%

Severely compromised (used cane/walker) 6%

1 block or less 12%

< 3 blocks 22%

> 3 blocks/not as much as they would like 58%

Totally compromised (in a wheelchair) 0%

Not compromised 65%

Severely compromised (used cane/walker) 1%

1 block or less 3%

< 3 blocks 5%

> 3 blocks/not as much as they would like 26%

EndingWalkingAbility



of patients noted that their overall results have very much continued to the present (75% to 99%). Seventy-eight percent noted there were reasons besides the Prolotherapy effect wearing off that were causing their continued pain and/or disability. Of the 78%, 42% of these believe they stopped Prolotherapy too soon (before the pain was totally gone), 20% re-injured the area that had received Prolotherapy, 13% had a new area of pain, 10% had increased life stressors, and 15% had other explanations for the pain. Of the clients whose pain recurred after Prolotherapy was stopped, 81% are planning on receiving more Prolotherapy.

s t A t I s t I C A L A n A L Y s I s

A matched sample test was used to calculate the difference in responses between the before and after measures for pain, stiffness, and crunching. Using the matched sample test on all three variables, all p values reached

statistical significance at the 1% level. The p values for pain, stiffness, and crunching were all 0. (See Table 2.) Analysis and calculation of the p-value was done by an independent third party who had no previous knowledge of Prolotherapy.

As previously noted, 38% of patients were told prior to Prolotherapy that no other treatment options existed for their pain. In analyzing these patients, 53% achieved least 75% pain relief with Prolotherapy. All patients stated they had achieved at least some relief of their pain with Prolotherapy. Thirteen percent of patients, prior to Prolotherapy, were told by their physician that surgery was their only option and 90% of them received at least 75% relief from their pain.

To further analyze the data, we asked the question “Were there any characteristic differences in patients who had excellent pain relief with Prolotherapy (greater than 75%

Figure 6. Starting and ending depression level before and after receiving Hackett-Hemwall dextrose Prolotherapy in 80 patients (119 knees) with unresolved knee pain.

StartingDepressionLevel

EndingDepressionLevel

Not depressed 59%

Extremely depressed but not on medication 0%

Very depressed 8%

Somewhat depressed 29%

Extremely depressed and on medication 4%

Not depressed 90%

Extremely depressed but not on medication 0%

Very depressed 1%

Somewhat depressed 9%

Extremely depressed and on medication 0%

Figure 7. Starting and ending anxiety level before and after receiving Hackett-Hemwall dextrose Prolotherapy in 80 patients (119 knees) with unresolved knee pain.

StartingAnxietyLevel

EndingAnxietyLevel

Not anxious 51%

Extremely anxious and taking medication 3%

Very anxious 9%

Somewhat anxious 36%

Extremely anxious but not taking medication 1%

Not anxious 85%

Extremely anxious and taking medication 0%

Very anxious 0%

Somewhat anxious 15%

Extremely anxious but not taking medication 0%

J O U R N A L of P R O L O T H E R A P Y | V O L U M E 1 , I S S U E 1 | F E B R U A R Y 2 0 0 9 1�


100%90%�0%�0% �0% 50% 40% 30% 20% 10%

0%

Figure 9. The effectiveness of Hackett-Hemwall dextrose Prolotherapy versus patients’ starting range of motion.

% EXCELLENT (GREATER THAN �5% PAIN RELIEF)% MINIMAL (LESS THAN 25% PAIN RELIEF)

AlmostNone

1-24% 25-49% 50-�4% �5-99% 100% Hyper-mobility

STAR TING RANGE OF MOTION

People who had pain < 1 year

100%90%�0%�0% �0% 50% 40% 30% 20% 10%

0%

Figure 8. Percent of patients with excellent pain relief versus minimal pain relief based on length of pain. The best responders to dextrose Prolotherapy received the Prolotherapy within three years of having pain.

LENGTH OF PAIN


People who had pain 2-3 years

People who had pain 4-� years

People who had pain > � years

of their pain relieved) versus those who had minimal pain relief with Prolotherapy (less than 25% pain relief)?” Figure 8 represents the effectiveness of Prolotherapy compared to how many years the patient had been in pain. As illustrated, 85% of the patients who had pain three years or less prior to Prolotherapy reported excellent results with Prolotherapy (greater than 75% relieved). In regard to patients who had four or more years of pain prior to getting Prolotherapy, 10% experienced minimal pain relief (less than 25% relief) with Prolotherapy. Of patients who started with almost no motion in their knees, 85% had minimal pain relief with Prolotherapy. Of patients whose starting motion was at least 50% of normal, 72% reported excellent pain relief with Prolotherapy. (See Figure 9.)

Another characteristic analyzed was stiffness. In this study, stiffness was measured on a scale of 1 to 10 with 1 being little to no stiffness and 10 being extreme stiffness. As seen in Figure 10, 76% of patients who rated their starting stiffness level as a 7 or less had excellent pain relief following Prolotherapy. Those who had minimal results with Prolotherapy was only 3.4%. But when the initial stiffness level was 8 or more, 14% had minimal results. Using the same scale, patients with an initial crunching level of 6 or less only 3.5% had minimal results with Prolotherapy, while 30% of those, with a level of 7 or more, reported minimal results. (See Figure 11.)

When patients stated their starting walking level was somewhat compromised (able to walk more than three blocks) or not compromised at all, 80% had excellent results and only 1.7% had minimal results with Prolotherapy. When starting walking ability was definitely compromised or worse (at least 25% or greater compromised), 22 % of patients had minimal pain relief. (See Figure 12.)

When a patient’s starting work situation was examined, 36 of the 37 patients that worked had excellent pain relief with Prolotherapy. In regard to those who were disabled at the time of their first Prolotherapy treatment, 44% had excellent pain relief with Prolotherapy. All of the patients who started extremely depressed and on medications reported 100% excellent pain relief with Prolotherapy. Of those who were very depressed, but not on medication, 17% of them reported excellent pain relief.

Outcome Measures Starting Ending

Averagepainlevel 6.5 2.3

Percentageofpatientsw/painlevel8orgreater

41% 3%

Percentageofpatientsw/painlevel3orless

13% 78%

Averagestiffnesslevel 4.7 2.0

Averagecrunchinglevel 3.8 2.1

Patientsfeltatleastsomedepression 40% 8%

Patientsfeltatleastsomeanxiety 39% 12%

Inabilitytoexercise 33% 9%

Uncompromisedabilitytoexercise 0% 30%

Table 2. Main outcome measures at baseline and after treatment with Prolotherapy.



DiscussionP R I n C I P L e f I n d I n G s

The results of this retrospective, uncontrolled, observational study, show that Prolotherapy helps decrease pain and improve the quality of life of patients with unresolved knee pain. Decreases in pain, stiffness, and crunching levels reached statistical significance with Prolotherapy. The percentage of patients with less knee pain was 95%, and 99% reported long term improvements in stiffness after Prolotherapy. Eighty-six percent of patients decreased their need for additional pain therapies, including medication usage by 90% or more, after Prolotherapy. Eighty-two percent showed an improvement in sleep. For those with depression and anxiety, 86% were less depressed and 82% were less anxious. In regard to activities of daily living, Prolotherapy improved walking ability in 84%, athletic ability in 76%, and dependency on another person in 75% of patients treated. Of the patients treated with the Hackett-Hemwall technique of dextrose Prolotherapy, 95% felt an overall improvement in their quality of life. Ninety-four percent of patients noted their improvement in overall disability has mostly continued since their last treatment.

s t R e n G t H s A n d L I m I t A t I O n s

Our study cannot be compared to a clinical trial in which an intervention is investigated under controlled conditions. Instead, it is aimed to document the response of patients with unresolved knee pain to Prolotherapy at a charity medical clinic. Clear strengths of the study are the numerous quality of life parameters that were studied. Such quality of life issues as walking ability, stiffness, range of motion, activities of daily living, athletic ability, dependency on others, sleep, anxiety and depression, in addition to pain level, are important factors affecting the person with unresolved knee pain. The improvement in such a large number of knees treated solely by Prolotherapy, even though subjective, is likely to have resulted from the Prolotherapy.

Another strength of this study is that the study population received only Prolotherapy as a treatment for their knee pain; no other treatment modalities were used. Because of the number of patients coming to each clinic (anywhere from 250 to 500), it was impossible to perform numerous modalities on each of them. The financial constraints on

100%90%�0%�0% �0% 50% 40% 30% 20% 10%

0%

Figure 10. The effectiveness of Hackett-Hemwall dextrose Prolotherapy versus patients’ starting level of stiffness.


STAR TING LE VEL OF STIFFNESS

1 2 3 4 5 � � � 9 10

100%90%�0%�0% �0% 50% 40% 30% 20% 10%

0%

Figure 11. The effectiveness of Hackett-Hemwall dextrose Prolotherapy versus patients’ starting crunching levels.


STAR TING LE VEL OF CRUNCHING

1 2 3 4 5 � � � 9 10

100%90%�0%�0% �0% 50% 40% 30% 20% 10%

0%

Figure 12. The effectiveness of Hackett-Hemwall dextrose Prolotherapy versus patients’ starting walking ability.


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joint replacement, and education and counseling. Many times the results of such therapies leave patients with residual pain.38,39,40 Because of this; many patients with osteoarthritis are searching for alternative treatments for their pain. One of the treatments they are trying is Prolotherapy.

Prolotherapy is a treatment being performed by more physicians based on positive anecdotal evidence, yet large studies on long term outcomes are limited. From at least one source, some 450,000 Americans have undergone Prolotherapy.41 There have been numerous studies on animals’ knees showing the efficacy with Prolotherapy42-46, but only two in humans.47,48 The studies showed Prolotherapy resulted in significant improvements in knee osteoarthritis, including improvements in pain, swelling complaints, and knee buckling frequency. Radiographic improvements in the knee osteoarthritis also occurred.49 This observational study was the first to show Prolotherapy helps not only the physical components of unresolved knee complaints such as pain, stiffness, range of motion and crunching sensations, but also helps numerous quality of life functions including walking ability, sleep, athletic ability, activities of daily living, and feelings of depression and anxiety. This study also showed that 15 months after their last Prolotherapy session, the vast majority of improvements continued. In this study population, Prolotherapy reduced the patients’ subjective overall disability, medication usage, other pain therapy treatments needed, as well as depressed and anxious feelings. Prolotherapy improved the patients walking and exercise ability, sleep, activities of daily living, and work situation. For the vast majority of the patients, Prolotherapy had a long lasting effect and changed their lives for the better.

In regard to the question, who is a good Prolotherapy candidate? this study compared patients who had great pain relief (greater than 75%) to those that had minimal pain relief (less than 25%) with Prolotherapy. This observational study showed that patients at initial presentation did better with Prolotherapy if they had pain less than three years, starting range of motion of 50% or more of normal, stiffness and crunching level of 7 or less, saw three or fewer M.D.’s prior to Prolotherapy, had an overall disability of 50% or less, could walk greater than 3 blocks, had employment and they were on medications if they were extremely depressed. (See Table 3.)

the patient population also precluded them from getting other therapies. Thus, their improvement most likely stems from the Prolotherapy, not any other treatment.

A weakness of this study is that most Prolotherapists using the Hackett-Hemwall method of Prolotherapy see patients every four to six weeks, which is in tune with the normal healing time of ligaments and tendons. Because this was a charity clinic that required numerous volunteers to run it, it was only possible to provide care once every quarter (every three months). Because of this extended follow-up time, the actual cure rates of pain were below what others have found with Prolotherapy.32-34 If the Prolotherapy treatments were received more frequently, we would expect the cure rates of pain to be even greater.

Another weakness of this study is that there was not a control group. Because the average person in this study had pain for an average of five years and was an average age of 54, their unresolved knee complaints most likely stem from a chronic degenerated knee. Since these conditions are almost universally progressive and often don’t spontaneously improve, a control group, while helpful, does not negate the results of the study.

An important limitation of our study is the subjective nature of the evaluated parameters. Another limitation is the lack of X-ray and MRI correlation for diagnosis and response to treatment. There was also a lack of physical examination documentation in the patients’ charts to include in the study.

I n t e R P R e t A t I O n O f f I n d I n G s

It is estimated that 80% of people over the age of 50 suffer from some degree of progressive osteoarthritis. Generally speaking, weight-bearing joints, such as the hips, spine, knees, and hands are most commonly involved.35,36 These joints are especially prone to degeneration as a result of the greater wear and tear they experience than other tissues through the body.37

Current conventional therapy of painful osteoarthritis of the knee include: medical treatment with analgesics, non-steroidal anti-inflammatory drugs, and intraarticular corticosteroid or Hyaluronan injections, muscle strengthening exercises, weight loss, the use of assisted devices, such as canes and orthotics, surgical treatment that range from arthroscopic joint debridement to total



Lennard T. Physiatric Procedures In Clinical Practice. Philadelphia, PA: Hanley & Belfus, Inc., 1995.

Hauser R, et al. Prolo Your Pain Away! Second Edition. Oak Park, IL, Beulah Land Press, 2004.

Dorman T. Prolotherapy In The Lumbar Spine And Pelvis. Philadelphia, PA: Hanley & Belfus, Inc., 1995.

Hackett G, et al. Ligament And Tendon Relaxation Treated By Prolotherapy. Fifth Edition. Oak Park, IL Gustav A. Hemwall, 1992.

Reeves KD. Prolotherapy: Present and future applications in soft tissue pain and disability. Phys Med Rehabil Clin North Am 1995;6:917-926.

Ongley M. Ligament instability of knees: a new approach to treatment. Manual Medicine. 1988;3:152-154.

Hackett G. Prolotherapy in whiplash and low back pain. Postgrad Med 1960;27:214-219.

Kayfetz D. Occipital-cervical (whiplash) injuries treated by Prolotherapy. Medical Trial Technique Quarterly. 1963; June 9-29.

Klein R. A randomized double-blind trial of dextrose-glycerin- phenol injections for chronic, low back pain. Journal of Spinal Disorders. 1993;6:23-33.

Reeves K, et al. Randomized, prospective, placebo-controlled double-blind study of dextrose Prolotherapy for osteoarthritic thumb and finger joints: evidence of clinical efficacy. Journal of Alternative and Complementary Medicine. 2000;6:311-320.

Yelland M. Prolotherapy injections, Saline injections, and exercises for chronic low back pain: A randomized trial. Spine. 2004;29(1):9-16.

Brolinson G. Prolotherapy: Cutting edge therapy for chronic injuries? ACC Sports Sciences Main Page. 2005, June: 1-3.

Sheeler R. Alternative treatments: Dealing with chronic pain. Mayo Clinic Health Newsletter. April 2005.

Hackett G. Ligament And Tendon Relaxation Treated By Prolotherapy. Springfield, IL: Charles C. Thomas, 1958.

Hackett G. Joint stabilization: An experimental, histologic study with comments on the clinical application in ligament proliferation. American Journal of Surgery. 1955;89:968-973.

Schwartz R. Prolotherapy: A literature review and retrospective study. Journal of Neurology, Orthopedic Medicine and Surgery. 1991;12:220-223.

Schmidt H. Effect of growth factors on proliferation of fibroblasts from the medical collateral and anterior cruciate ligaments. Journal of Orthopedic Research. 1995;13:184-190.

Liu Y. An in situ study of the influence of a sclerosing solution in rabbit medical collateral ligaments and its junction strength. Connective Tissue Research. 1983;2:95-102.

Maynard J. Morphological and biomechanical effects of sodium morrhuate on tendons. Journal of Orthopedic Research. 1985; 3:236-248.

Hackett G. Prolotherapy for headache. Headache. 1962;3-11.

Hackett G. Low back pain. The British Journal of Physical Medicine. 1956;19:25-35.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

Yearsofpain <3years

Rangeofmotion 50%ormoreofnormal

Stiffnessandcrunchinglevel 7orless

NumberofphysiciansseenpriortoProlotherapy 3orless

Overalldisability 50%orless

Walkingability >3blocks

Employed Yes

Table 3. Characteristics of the best responders to dextrose Prolotherapy.

ConclusionsThe Hackett-Hemwall technique of dextrose Prolotherapy used on patients who had a duration of five years of unresolved knee pain was shown in this observational study to improve their quality of life. They reported less pain, stiffness, disability, depressed and anxious thoughts, medication and other pain therapy usage, as well as improved walking ability, range of motion, ability to work and activities of daily living. Therefore, Prolotherapy appears to be a viable treatment option for people suffering with unresolved knee pain. n


Levy D. Knee injury, soft tissue. [Medscape Website]. May 8, 2006. Available at: http://www.emedicine.com/emerg/ TOPIC288.HTM. Accessed November 8, 2007.

Medscape Medical News. Sufferers of osteoarthritis of the knee now may be pain – free 12 months after treatment. January 28, 2000. Available at: http://www.medscape.com/viewarticle/ 411438. Accessed November 11, 2007.

Common orthopaedic procedures [American Academy of Orthopaedic Surgeons Website]. Available at: http://www.aaos. org/Research/stats/Knee%20Facts.pdf. Accessed November 28, 2007.

Mann D. Joint replacement surgery on the rise [Medscape/ Web MD Health Website]. 2006. Available at: http://www. medscape.com/viewarticle/528464. Accessed November 8, 2007.

Common orthopaedic procedures [American Academy of Orthopaedic Surgeons Website]. Available at: http://www.aaos. org/Research/stats/Knee%20Facts.pdf. Accessed November 28, 2007.

Mann D. Joint replacement surgery on the rise [Medscape/ Web MD Health Website]. 2006. Available at: http://www. medscape.com/viewarticle/528464. Accessed November 8, 2007.

Lennard T. Pain Procedures In Clinical Practice. Second Edition. Philadelphia, PA: Hanley & Belfus, Inc., 2000.

1.

2.

3.

4.

5.

6.

7.



Reeves K, et al. Randomized, prospective double-blind placebo- controlled study of dextrose Prolotherapy for knee osteoarthritis with or without ACL laxity. Alternative Therapies. 2000;6:311-320.

Ongley M, et al. Ligament instability of knees: A new approach to treatment. Maunual Medicine. 1988;3:152-154.

Reeves K, et al. Randomized, prospective double-blind placebo- controlled study of dextrose Prolotherapy for knee osteoarthritis with or without ACL laxity. Alternative Therapies. 2000;6:311-320.

Hackett G. Ligament And Tendon Relaxation Treated By Prolotherapy. Third Edition. Springfield, IL: Charles C. Thomas, Publisher. 1958.

Hackett G. Referred pain and sciatica in diagnosis of low back disability. Journal of American Medical Association. 1957;163: 183-185.

Hackett G. Joint stabilization. American Journal of Surgery. 1955; 89:968-973.

Tepper S, et al. Factors associated with hip osteoarthritis: Data from the first national health and nutrition examination survey (NHANES-1). American Journal of Epidemiology. 1993; 137:1081-1088.

Schouten J, et al. A 12 year follow up study in the general population on prognostic factors of cartilage loss in osteoarthritis of the knee. Annals of the Rheumatic Diseases. 1992;51:932-937.

Cooper C, et al. Occupational activity and osteoarthritis of the knee. Annals of the Rheumatic Diseases. 1994;53:90-93.

Hauser R, et al. Prolo Your Pain Away! Second Edition. Oak Park, IL: Beulah Land Press, 2004.

Adams M. An analysis of clinical studies of the use of crosslinked hyaluronan, hylan, in the treatment of osteoarthritis. The Journal of Rheumatology. 1993;20:16-18.

Stovitz S. NSAIDs and musculoskeletal treatment. The Physician and Sports Medicine. 2003;31:35-52.

Prolotherapy: government review identifies gaps in the scientific evidence. The Back Letter. 2000;15(4):42.

Liu Y. An in situ study of the influence of a sclerosing solution in rabbit medial collateral ligaments and its junction strength. Connective Tissue Research. 1983;2:95-102.

Hauser R. Prolotherapy: An Alternative To Knee Surgery. Oak Park, IL: Beulah Land Press. 2004;pp.56-58.

Maynard J. Morphological and biochemical effects of sodium morrhuate on tendons. Journal of Orthopedic Research. 1985;3: 236-248.

Schmidt C. Effect of growth factors on the proliferation of fribroblasts from the medial collateral and anterior cruciate ligaments. Journal of Orthopedic Research. 1995;13:184-190.

Hauser R. Prolo Your Sports Injuries Away! Oak Park, IL: Beulah Land Press, 2001;pp.264-287.

Ongley M. Ligament instability of the knees: a new approach to treatment. Manual Medicine. 1988;3:152-154.

Reeves K. Randomized prospective double-blind placebo- controlled study of dextrose Prolotherapy for knee osteoarthritis with and without ACL laxity. Alternative Therapies 2000;2:68-70.

IBID.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

A C k n O W L e d G e m e n t s

Data Collection:

Doug Puller BS Chemical Engineering Spirit Lake, ID Statistical Analysis:

Anne M. Drougas, PhD Associate Professor of Finance & Economics Dominican University – Brennan School of Business 7900 West Division Street, River Forest, IL 60305 (708) 524-6938 [email protected]

Carol Tallarico, PhD Associate Professor of Finance & Economics Dominican University – Brennan School of Business 7900 West Division Street, River Forest, IL 60305 (708) 351-8961 [email protected] Dave Gruen Senior Vice President, Consulting Division BolderImage 707 N. Iowa Ave. Villa Park, IL 60181 (630) 279-4000 [email protected]


R E M A R K A B L E R E C O V E R I E S : S T A N D A R D C L I N I C A L X - R A Y S T U D I E S D O C U M E N T C A R T I L A G E R E G E N E R A T I O N

Standard Clinical X-ray Studies Document Cartilage Regeneration

in Five Degenerated Knees After Prolotherapy


A B s t R A C t

Degenerative joint disease is the most common form of arthritis. The condition is marked by progressive destruction of the articular cartilage which is easily documented by standard X-ray studies. The regeneration of this articular cartilage in clinical practice has been difficult. Five knees with articular cartilage degeneration were treated with Prolotherapy in this report. Each of the five knees showed improvement of their standard clinical X-rays after the Prolotherapy, signifying articular cartilage repair with Prolotherapy. It is suggested that before and after X-ray studies can be used to document the response of degenerated joints to Prolotherapy.

Journal of Prolotherapy. 2009;1:22-28.keYWORds: articular cartilage, cartilage, chondromalacia patella, joint space width, knee, osteoarthritis, patellar tracking, Prolotherapy.

Ross A. Hauser, MD & Joseph J. Cukla, LPN

I n t R O d u C t I O n

O steoarthritis (OA) is one of the major problems affecting our aging population. It has been estimated that two to three percent of the adult

American population suffers from regular pain from OA, and approximately one-third of adults in the US between the ages of 25-74 have radiological evidence of OA in at least one of the major joints.1 Autopsy specimens have demonstrated a 90% prevalence of articular cartilage degenerative changes in weight bearing joints in individuals older than 40 years old.2 The knee is the most symptomatic joint affecting 6.1% of all adults over the age of 30 but rising to 16% of adults over the age of 45.3,4,5 Because there is no currently accepted method to stop or reverse joint degeneration, the incidence of symptomatic OA increases by about 1% each year.6

Osteoarthritis is the most common form of knee arthritis and can involve any or all three compartments in the knee: the medial compartment (medial tibial plateau and medial femoral condyle); the lateral compartment (lateral tibial plateau and lateral femoral condyle); or the patellofemoral compartment (patella and femoral trochlear notch).

The increasing number of joint complaints and radiological OA is matched by the rising number of major joint replacements. In one state alone the total number of total knee replacements increased by 81.5% from 1990 to 2000, with a subsequent rise in costs for these procedures of over 200%.7 It is estimated that in the US, the total number of joint replacement surgeries of the hip and knee will increase from 684,000 cases in 2003 to over a million by 2013.8

The current conservative treatments for OA including medications, exercise, physical therapy, corticosteroid injections, weight control, Synvisc and Hyalgan injections, and operative treatments including arthroscopy often leave people with residual pain.9,10, 11, 12 Because of this, many people with OA are seeking alternative treatments including Prolotherapy.13,14

Prolotherapy, also known as regenerative injection therapy, involves the injection of substances into degenerated or injured areas to stimulate healing.15,16,17 While it has been traditionally used for ligament and tendon injuries, it has a long history of use in OA.18,19,20 Two placebo-controlled double-blind studies by K. Dean Reeves and associates have demonstrated beneficial effects of Prolotherapy on OA including some X-ray changes.21,22

This report documents the results in five degenerated knees treated with Prolotherapy. Before and after X-rays were available to document articular cartilage regeneration with Prolotherapy.



m e t H O d s

Three patients representing five degenerated knees underwent Prolotherapy at the private practice of the primary author at Caring Medical and Rehabilitation Services in Oak Park, Illinois. Each patient underwent standard Hackett-Hemwall Prolotherapy to the knee.23 Each patient had the following areas injected: intraarticular, pes anserine, medial collateral and lateral collateral ligament attachments, and medial side of the patella. The basic solution used was 15% dextrose and 10% Sarapin. Each joint received 2IU of Human Growth Hormone by injection. A total of 5 to 10cc of Prolotherapy solution was injected into the joint at each visit. Four hundred milligrams of glucosamine sulfate was added to one of the 10cc syringes. A total of 30 to 40cc of Prolotherapy solution was used per knee at each visit. This represented 20 to 30 injections per knee per visit.

C A s e d e s C R I P t I O n s

Case One: CW is a 72 year-old woman who presented in July 2004, complaining of a five-year history of severe right knee pain. She rated her knee pain on the visual analogue scale (VAS) at a level of 6 on a scale of 0 to 10. She experienced daily pain throughout the whole knee and noted that the severity of the pain was also increasing. Her other symptoms were increased pain upon sitting for long periods of time, difficulty with stairs, and increased pain with walking. She was not exercising. She had no previous history of trauma or knee surgery. Three previous hyaluronic acid treatments provided diminishing relief. She used the oral pain relievers, tramadol hydrochloride and acetaminophen, as needed. X-rays done in 2002 showed osteoarthritis, marked loss of joint space medially, subchondral sclerosis and osteophyte formation. CW was told by an orthopedist that she needed a total knee replacement. She read about Prolotherapy in an alternative medicine newsletter and wanted to try it instead of surgery.

Physical examination showed normal knee alignment. Lachman, anterior drawer, valgus and varus stress tests were all negative. She exhibited joint line tenderness both medially and laterally, but worse medially, as well as quite a bit of crepitus in the knee throughout the range of motion. There was no swelling present in the knee. Her range of motion was 3 to 95 degrees.

Prolotherapy treatments began in July 2004. CW received nine treatments on her right knee through May 2005. She reported an incremental decrease in pain and increased mobility as she was interviewed every four to six weeks during the course of treatment. Her range of motion had improved to full extension and flexion to 110 degrees. Her crepitus was nearly nonexistent. She reported at this time, “I am 97% better. I have no pain (VAS score 0), just mild stiffness that subsides with walking.” She was treated one more time and told to return to the clinic if the pain returned. She no longer needed medications or a total knee replacement.

CW returned to the clinic in May 2006 because she twisted her knee and some of her pain returned. Her physical exam at that time was unchanged from when she was seen in May 2005, except she showed more medial joint line tenderness and tenderness at the pes anserine area. She received four more treatments over the next four months, making incremental improvements in her pain. At this time, the patient was doing great, yet desired to see “how my cartilage was doing.” The X-rays showed a large increase of medial joint space. (See Figure 1.) By this time, the patient had received 14 Prolotherapy treatments to her knee.

Seventeen months after her last Prolotherapy treatment, the patient continues to have full function of the knee with almost no pain (0 to 1 on VAS). She has returned to full activities without pain and is on no pain medications.

Case Two: JP is a 60 year-old female who was first seen in October 2005 complaining of a three year history of bilateral knee pain. She rated her right knee pain as 6 and her left knee as a 5 on the VAS. The pain in both knees occurred primarily in the medial area. Rising from a chair, taking the stairs, and simply walking caused pain. The patient tried using heat, ice, aspirin and ibuprofen to alleviate the pain. She tried to avoid allowing the pain to limit her activities, but she was now down to walking once or twice a week instead of daily. She could only stand for short periods of time now. She also noted that getting up from a low couch or stool was now “very difficult.” She felt the strength in her legs was rapidly diminishing. X-rays done in April 2005 by her primary care physician showed moderately severe osteoarthritic degenerative changes bilaterally, greatest in the medial compartments. She told her massage therapist about the X-ray and she recommended a Prolotherapy evaluation.



Physical examination revealed full extension, but only 90 degrees of flexion. Tenderness with palpation at the medial joint line bilaterally was also noted. The patient was unsteady with a one-legged stand on either leg. Moderate clicking was noted in both knees. There was no evidence of swelling or joint instability.

JP steadily improved with Prolotherapy treatments. When seen in September 2006, after eight Prolotherapy treatments on her right knee and six on her left, she reported an 85% reduction in pain in the right knee and 70% in the left. She now had some pain free days. She noticed the clicking in both knees was markedly less and was now able to climb stairs without any complaints. Her walking was uninhibited as long as it was slow without much pain. She felt she had poor balance if she walked fast. JP did great, but felt some stiffness with long periods of sitting, thus she came in for one more visit in May 2007. This was her eleventh Prolotherapy on her right knee and ninth on her left knee. Her walking was now completely pain free. Physical examination at that time showed that her bilateral knee flexion had increased to 100 degrees and the clicking had completely resolved. She requested repeat X-rays after that visit and they showed a significant improvement of the joint space width in both knees

Figure 1. Standard weight bearing knee X-rays of C.W. before and after Prolotherapy. The widening of the medial joint space width indicates that cartilage regeneration has taken place.

BEFORE PROLOTHERAPY AFTER PROLOTHERAPY

2002 2006

BONE ON BONEPHENOMENON CARTILAGE

REGENERATION

both medially and laterally. (See Figure 2.) Specifically the X-rays on both knees showed a joint space now present medially.

When phoned six months after her last visit in 2007, she noted that both knee joints were gliding smoothly and were “not making any noises” according to the patient. She had no pain with walking or stairs. She was on no pain medications and felt she had absolutely no limitations in regard to her knees.

Case Three: JL is a 42 year-old female who came in with a ten year history of bilateral knee subluxations and diffuse knee pains. Her goal was to decrease pain with the hope of being able to play competitive tennis again. She complained of her knees “giving out,” along with having bilateral medial knee weakness, joint stiffness, and recurring edema with most leg exercises. The patient reported that the pain was making tennis playing impossible. She was being followed by an orthopedic physician because of her severe bilateral chondromalacia. He prescribed piroxicam 20mg daily and ordered her to discontinue tennis and lower extremity weight training for a minimum of eight weeks. He also ordered 10 weeks of physical therapy, which was of no help to the patient in



reducing her pain. She rated her pain as a seven on the left knee and six on the right knee (VAS) 0 to 10. Physical exam revealed significant crepitation in knees bilaterally. The patellas were tracking laterally with excessive movement. Lachman, anterior drawer, valgus and varus stress tests were all negative. She had full knee extension, but flexion was limited to 90 degrees bilaterally. She found out about Prolotherapy through an internet search.

The knees were treated with Prolotherapy on her first visit in October, 2006 and she returned for treatment every four to six weeks. As she felt better, she began to increase her tennis and exercise levels with slight discomfort coming only after competitive tennis, especially playing consecutive days. She reported after the seventh visit that she was having no recurrences of her knees “giving out” and her knee pain was improved 80%. She rated it a 3 bilaterally on VAS. After the ninth visit, she reported a 90% improvement in knee strength, and a 75% improvement in crepitus. She noted some pain-free days. On physical examination she had almost no clicking in the knee. JL received a total of 11 Prolotherapy treatments when seen in September 2007. Her patellar gliding was normal with normal patellar tracking. Her range of motion was now full. At this time her chiropractor ordered X-rays of her knees. Comparison X-rays of September 2006 versus September 2007 showed a significant increase in joint space in the lateral compartments, with improvement of patellar alignment. (See Figure 3.)

Figure 2. Standard weight bearing bilateral knee X-rays of J.P. before and after Prolotherapy. The widening of the medial joint space width in both knees indicates that cartilage regeneration has taken place.

BEFORE PROLOTHERAPY AFTER PROLOTHERAPY

2005 2007

DECREASED JOINT SPACE

WIDTHINCREASED

JOINT SPACE WIDTH

While JL made tremendous strides with Prolotherapy, unfortunately in the spring of 2008, because of her tremendous training schedule, to make an elite traveling tennis team, she developed new injuries and had to give up her spot on the team.

d I s C u s s I O n

A series of Prolotherapy treatments improved the X-ray findings in these five degenerated knees. Specifically, the joint space width (JSW) in these X-rays increased with Prolotherapy, signifying the regeneration of articular cartilage. The three patients also reported improvements in their pain and function with the Prolotherapy treatments.

Articular cartilage degeneration is the hallmark of the osteoarthritis that affects 46 million Americans. It has a major impact on functioning and independence and is the leading cause of disability in the general population of the United States according to the Center for Disease Control (CDC).24 As the U.S. population ages, these numbers are likely to increase sharply. Among adults of working age (18 to 64 years), work limitations attributable to arthritis affects about one in 20 adults in the general population and one-third of those with arthritis.25 For example, the annual cost of OA per person living with OA is approximately $5,700, but the economic burden of



Absolute values for what is normal JSW is impossible because cartilage thickness varies so much from person to person.35 Its use though is invaluable when monitoring the normal progression of OA and would be following the regression of OA with Prolotherapy.36

According to the American Association of Orthopedic Surgeons from a clinical perspective, the most compelling definition of knee OA is one that combines the pathology of osteoarthritis through confirming radiographs with patient reported symptoms of pain that occurs with joint use.37 When evaluating patients with osteoarthritis of the knee, anterior/posterior, and lateral radiographs allow an adequate evaluation of the medial and lateral joint spaces.38 To adequately assess the joint space, the anterior/posterior view should be obtained

with the patient in a standing position.39 The lateral view also allows evaluation of the patellofemoral joint; however, an additional view, known as the sunrise view, can offer, even more information about this joint space (this is also called the merchant or sunrise view).40 To ensure that the pre and post-Prolotherapy X-rays could be compared in regard to angle of the X-ray, a board certified radiologist reviewed all the films.41

X-rays were obtained in these five knees upon the request of the patients. It is not routine to order X-rays on patients with positive or curative results. These five knees suggest that standard clinical radiographs of the knee may prove beneficial in confirming the reason for the patients’ improvement with Prolotherapy.

Cases one and two represent the most common form of knee OA, degeneration of the medial femorotibial joint. The improvement of the JSW in case one was 0.5mm. In case two, the right knee JSW increased by 0.4mm and the left by 0.3mm. Case three involved the regeneration of the patellofemoral joint. This person had chondromalacia patellae. Not only was there evidence of increase in the JSW laterally of 0.6mm bilaterally, but the tracking of

disabling knee and hip osteoarthritis has an annual cost per person of almost $10,000.26,27 Needless to say efforts or treatments that could potentially reverse or stop the progression of OA would have a huge quality of life, as well as economic impact not only on individual patients but on health care costs overall.

Radiography is currently the most widely used method to assess damage in osteoarthritis, and regulatory requirements for the development of disease-modifying drugs in osteoarthritis still consider the measurement of joint space narrowing on plain X-rays to be the appropriate primary endpoint for demonstration of efficacy.28,29,30 The radiographic grade of osteoarthritis has been shown to correlate with the amount of actual articular cartilage degeneration in the knee with chronic pain.31 Standardized techniques for measuring joint space width (JSW) in the tibiofemoral compartments, taken from carefully acquired radiographs, have become accepted for quantifying changes in tibiofemoral hyaline articular cartilage thickness in knee osteoarthritis.32,33 JSW measurement is used in the diagnosis of OA.34 (See Figure 4.)

Figure 3. Standard bilateral sunrise view knee X-rays of J.L. before and after Prolotherapy. These X-rays demonstrate J.L.’s chondromalacia patella and lateral patellar tracking are much improved with Prolotherapy.

BEFORE PROLOTHERAPY

AFTER PROLOTHERAPY

2002

2006

ABNORMAL PATELLAR TRACKING

IMPROVED PATELLAR TRACKING



the patella improved. All of this improvement came while the patients’ functions improved. All met their pre-treatment goals except case three, JL, who did not get back to unlimited competitive tennis. One item not in her favor is her 5’4”, 200+ pound muscular frame.

Previous attempts at cartilage regeneration have been numerous and mostly futile.42,43,44,45 While a number of very complex surgical techniques exist, they require extensive rehabilitation periods and tremendous expense. Prolotherapy, on the other hand, is a simple, cost effective, time-efficient alternative. Prolotherapy injections are an outpatient procedure, taking the clinician just minutes to perform. Patient activities are virtually unlimited during the course of Prolotherapy treatments with a gradual return to pre-injury exercise levels. While the potential is there for Prolotherapy to improve the quality of life of patients with degenerative knee arthritis and be a cost savings, future long-term controlled studies will be needed to assess this.

To the age old question “Can adult articular cartilage cells be regenerated?” these five knees suggest the answer is “yes.” Each of the five post-Prolotherapy radiographs revealed an increase in joint space width which coincided with symptom relief and return of most function. This suggests in these five degenerated knees that Prolotherapy has the potential to reverse degenerative knee arthritis. Further research with a larger patient population and under a more controlled setting is needed to provide further evidence of cartilage regeneration and Prolotherapy.

C O n C L u s I O n

Prolotherapy improved the pain and function in five knees with osteoarthritis. All five degenerated knees showed evidence of articular cartilage regeneration in their standard weight-bearing X-rays after Prolotherapy. It is suggested that before and after X-ray studies can be used to document the response of degenerated joints to Prolotherapy. Future research is needed with a larger patient population and under a more controlled setting to further

evidence of clinical responses and cartilage regeneration with Prolotherapy. n


Callahan J. Arthritis overview. In Lippincott Williams and Wilkins, pub. The Adult Knee. Philadelphia, PA; 2003:465-468.

Marwin S. Medial compartment arthritis. eMedicine Specialties. 2008:3-15. Available at: http://www.emedicine.com/orthoped/TOPICS518.HTM. Accessed August, 2009.

Dillon CF, et al. Prevalence of knee osteoarthritis in the United States: arthritis data from the Third National Health and Nutrition Examination Survey 1991-1994. J Rheum. 2006;33(11):2271-9.

Felson DT, et al. The prevalence of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis Rheum. 1987;30(3):914-918.

Jordan JM, et al. Prevalence of knee symptoms and radiographic and symptomatic knee osteoarthritis in African Americans and Caucasians: The Johnston County Osteoarthritis Project. J Rheum. 2007;34(1):172-180.

Felson DT, et al. The incidence and natural history of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis Rheum.1995;38(10):1500-1505.

Mehrotra C, et al. Trends in total knee replacement surgeries and implications for public health, 1990-2000. Public Health Rep. 2005;120(3):278-282.

Koppenheffer M, et al. Joints still volume mainstay, but margin pressures increasing. Executive summary: Future of Orthopedics: strategic forecast for a service line under siege. Health Care Advisory Board, Washington DC. 2003:26-29.

Manek NJ, et al. Osteoarthritis: current concepts in diagnosis and management. Am Fam Physician. 2000;61:1795-1804.

1.

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4.

5.

6.

7.

8.

9.

Figure 4. Measurement of joint space width in weight-bearing knee X-ray. A decreased Joint Space Width (JSW) indicates articular cartilage degeneration medially.

JOINTSPACEWIDTH

DECREASEDJOINT SPACEWIDTH



Kirkley A, et al. A randomized trial of arthroscopy for osteoarthritis of the knee. NEJM. 2008;359:1097-1107.

Adams M. An analysis of clinical studies of the use of crosslinked hyaluronan, hylan, in the treatment of osteoarthritis. J Rheum. 1993;20:16-18.

Stovitz S, et al. NSAIDs and musculoskeletal treatment. The Physician and Sports Medicine. 2003;31:35-52.

Brolinson G, et al. Prolotherapy: Cutting edge therapy for chronic injuries? ACC Sports Sciences Web Site. 2005. Available at: http://www.theacc.com/sports/c-track/spec-rel/061005aac. html. Accessed August 2008.

Sheeler R. Alternative treatments: Dealing with chronic pain. Mayo Clinic Health Newsletter. April 2005.

Hackett G. Joint stabilization: An experimental, histologic study with comments on the clinical application in ligament proliferation. American Journal of Surgery. 1955;89:968-973.

Schwartz R, et al. Prolotherapy: A literature review and retrospective study. Journal of Neurology, Orthopedic Medicine and Surgery. 1991;12:220-223.

Hooper R, et al. Case series on chronic whiplash related neck pain treated with intraarticular zygapophysial joint regeneration injection therapy. Pain Physician. 2007;10(2):313-318.

Ongley M, et al. A new approach to the treatment of chronic low back pain. Lancet. 1987;2(8551):143-147.

Klein R. Proliferant injections for low back pain: histologic changes of injected ligaments and objective measures of lumbar spine mobility before and after treatment. Journal of Neurology, Orthopedic Medicine and Surgery. 1989;10:141-144.

Hackett G, et al. Ligament And Tendon Relaxation Treated By Prolotherapy, 5th ed. Oak Park, IL, Gustav A. Hemwall; 1992.

Reeves KD, et al. Randomized, prospective double-blind placebo-controlled study of dextrose Prolotherapy for knee osteoarthritis with or without ACL laxity. Alternative Therapies. 2000;6:311-320.

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Hauser R. Prolotherapy: An Alternative To Knee Surgery. Beulah Land Press, Oak Park, IL, 2004.

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R E M A R K A B L E R E C O V E R I E S : P R O L O T H E R A P Y S A V E D M E F R O M B I L A T E R A L K N E E R E P L A C E M E N T S !

Prolotherapy Saved Me From Bilateral Knee Replacements!


I started bodybuilding in the spring of 1962 in an attempt to get bigger and stronger to fend off neighborhood bullies. I brought my first 160 pound

barbell set home on the bus with the help of a friend. Bodybuilding quickly became a lifestyle for me that has lasted to this day. In short, I enjoy it. However, the combination of years of abuse from heavy exercise, construction work, and just plain time, began to take its toll on my knees.

During the nineties my knee pain became absolutely unbearable. Like most people, I did the normal treatments. I took a lot of anti-inflammatories and went to my fair share of orthopedists. I had arthroscopic surgeries on my right knee and one on my left to remove torn medial and lateral menisci. Having endured three knee surgeries, I was in worse shape than when I went in and I was in absolute agony.

The knee pain was unforgiving and unrelenting. I definitely was having depression due to the constant pain, which also woke me up frequently at night, making uninterrupted sleep a rarity. I couldn’t sit, stand, walk, or lie down without being in unbelievable pain. I was never in my life so miserable. It changed my personality, outlook

Alek Jakich & Heather L. McCullough, MA

on life, and worse yet, my judgment. I would virtually do anything to gain the smallest modicum of relief from pain. I was crabby to those around me. My friends and family began to avoid any contact with me because of behavior and attitude. Basically I struggled with knee pain for six years by the time I “hobbled” into Caring Medical in Oak Park, in November of 2005 at the age of 56, hoping for some help.

The orthopedists (three of them) at Northwestern Memorial Hospital informed me that they had taken me as far as they could. They were referring me to another surgeon at Rush Presbyterian St. Luke’s Hospital. The surgeon at Rush announced that both my knees needed replacement. “Not to worry,” the doctor declared. After all, he was the master of the “minimally invasive knee replacement surgery.” “We’ll have you up and around in no time,” he declared. I didn’t find that very comforting. I felt that knee replacement should be held off as long as possible, and began researching my options. I was informed that knee replacements, given my activity level, would last about ten years, and to expect that each subsequent replacement would become less successful than the previous. I definitely wanted to continue to weight lift. I definitely didn’t want knee replacements!

A B s t R A C t

This case study discusses the case of 56 year-old Alek Jakich, an avid body builder, who suffered from chronic, severe, debilitating bilateral knee pain who was told he needed bilateral knee replacements in order to have any chance at a semi-normal life again, but was told he would likely never lift weights again post surgery. Alek chose Prolotherapy, along with proper exercise and nutritional supplementation over surgery to regain the active life style to which he was accustomed.

Journal of Prolotherapy. 2009;1:29-31.keYWORds: bilateral knee replacements, chondromalacia patella, mCL tear, osteoarthritis, Prolotherapy, weight lifting.



The prognosis on my knee when I walked in to my first Prolotherapy visit was not good. I had many MRIs prior to getting Prolotherapy. For instance, the MRIs of February 2004 documented Grad IV chondromalacia of both the right and left knees. (See Figure 1.) The MRI in 2005 also showed that the medial meniscus was a mess. These were some of the reasons that the orthopedists wanted me to get bilateral knee replacements. A popliteal cyst was found in the right knee. The surgeons were telling me surgery was my only option, other than living with the pain.

At the time of my first appointment in November 2005 with Dr. Hauser, I was in pain 100% of the time, making daily activities almost impossible. I was using a cane to assist with all walking. The pain level I experienced normally was 9 out of 10 for my right knee, and 4 out of 10 with my left knee. If I did too much, or the weather changed, the pain in both knees could easily be 10 out 10. I was miserable! Walking one city block what my knees could tolerate. Believe it or not, my maximum weight with leg extensions was five pounds at this time.

On my initial visit, Dr. Hauser made it clear that to get my knees to a high functioning level, I would most likely need one to two years worth of care. I would also have to do exercise, including cycling. I was diligent getting Prolotherapy every four to six weeks, and taking the supplements Dr. Hauser recommended, which assisted in soft tissue and cartilage growth and healing. By June of 2006, I was able to walk down stairs, which I had not been able to do for years. The best part was that I was no longer in constant pain. In August of 2006, I was about 75% improved overall, and able to do 105 pound leg lifts!

I continued to get treated every four to six weeks. It seemed with each visit I had less pain, more motion, and increased strength as evidenced by my being able to lift more weight on the machines. By April of 2007, the range of motion for both of my knees was almost normal. I had minimal pain but maximum function! I was doing everything I wanted to do. I could walk for miles without any noticeable “real” pain. I had an X-ray of both knees, post-Prolotherapy series, performed in December of 2007, which showed an increase in cartilage growth. (See Figures 2 & 3.)

Figure 1. Alek’s MRI report in February 2004.



Prolotherapy had gotten me to complete extension in both of my knees and the flexion was also full as far as I could tell. I was pain free almost all the time, only experiencing pain with long periods of standing or kneeling. Following the completion of my treatment, I went back to the physician that had recommended the double knee replacement initially. My intention was to show the huge physical improvement, specifically the cartilage re-growth in my knees the Prolotherapy had provided. I clearly thought he would be excited because it was documented

in the X-rays. Unfortunately, the physician was not receptive, and I left his office disappointed, knowing that future patients would not be referred for Prolotherapy prior to surgery.

It has been about a year since my last Prolotherapy session. I can now for the first time in ten years walk up and down stairs, walk around the block with the dogs, go to the movies, sit in a restaurant, and exercise my legs in the gym all without pain. I am able do 400 pounds on the leg press machine, and

200 pounds on leg extensions. I would like to take this opportunity to thank Dr. Hauser and his incredible staff for their talent, patience, and positive reinforcement. Thank you for giving me my life back. n

Figure 3. Right and left X-rays, AP views. This X-ray shows preservation of the joint spaces indicative of cartilage, though it is still compromised slightly in the medial compartment.

Figure 2. Right and left X-rays, patellar views. Notice significant cartilage in both knees after Prolotherapy.


R E M A R K A B L E R E C O V E R I E S : P R O L O T H E R A P Y G E T S C O L L E G E B A S K E T B A L L P L A Y E R B A C K O N T H E C O U R T

ThePhysician’sPerspective

H I s t O R Y

W hen a highly trained, elite athlete returns to his sport after having back surgery and being told he will never play basketball again, it is a

true testament to the Prolotherapy treatment method and the body’s ability to heal itself.

John Manley was exactly this type of patient. Having received a full scholarship for Division I Basketball at Cal Poly University in California, John had high hopes for an exciting career, only to be dashed halfway through his freshman season by a career-threatening back and hip injury. He was undercut as he was attempting a slam dunk and landed flat on his lower back, resulting in excruciating pain.

Prior to his initial visit, John had an extensive orthopedic workup both in California and Minnesota. MRIs from November and December of 2004 revealed a bulging disc at L4-L5 with some degeneration and mild stenosis of the subarticular recess. Further review of the MRIs indicated juvenile discogenic disease and degenerative disc changes at L4-L5 and L5-S1, along with retrolisthesis of L4 with respect to L5 and slight exaggeration of the retrolisthesis in extension. He saw his trainers daily, diligently performed the exercises recommended by his physical therapist, and eventually underwent a successful laminectomy and decompression surgery. However, he continued to suffer from unresolved pain and was told by his surgeon that he would have to quit basketball and never play again.

Prolotherapy Gets College

Basketball Player Back on the Court


Mark T. Wheaton, MD

A B s t R A C t

Prolotherapy is the definitive treatment choice when it comes to connective tissue injuries (ligaments, muscles, tendons, joints) from any cause, such as a sports injury, as is illustrated in the following case report. Usual conservative care options (rest, medications, ice, heat, epidural steroid injections, physical therapy, strengthening and stretching exercises, and massage) were tried without success and lumbar spine surgery (laminectomy, diskectomy) was performed after multiple imaging studies without notable benefit.

After a thorough history, physical examination, and record review were completed, it was determined that this Division I college basketball player had unrecognized and untreated connective tissue injuries. Because the Prolotherapy treatment method is the only medical intervention that is known to stimulate natural healing, produce collagen, strengthen damaged and weakened ligaments and tendons, stabilize joints, and subsequently eliminate pain and increase function, the patient/athlete and I decided on pursuing this course of treatment. Despite the length of time since the injury (over two years), the lack of improvement with both conservative and surgical care, and the extreme demands of an elite college athlete, there was a great deal of optimism about the outcome, provided a consistent, complete, and aggressive plan using Prolotherapy was followed.

The final results exceeded expectations. The patient/athlete followed the recommended course of treatment and after six Prolotherapy treatments using either a 12.5% dextrose solution or a 0.5% sodium morrhuate solution, he has returned to full-time, unrestricted participation with his college basketball team and reports none of the pain which he previously experienced. This case highlights the need for greater access and early utilization of this effective treatment approach for athletes, workers, and others with injuries and chronic pain. Further study and education would also facilitate the acceptance of Prolotherapy as a cost-effective solution.

Journal of Prolotherapy. 2009;1:32-35.keYWORds: back pain, bulging discs, college basketball, connective tissue injury, degenerative disc disease, musculoligamentous sprain, Prolotherapy, sacroiliac instability, sciatica, spinal stenosis, sports injury.



e x A m I n A t I O n

My initial exam revealed connective tissue and soft tissue injuries that had previously not been diagnosed, judging from his medical record. The surgeon had no further post-operative recommendations, as the surgery was intact and successfully completed. However, I felt there were clearly other factors contributing to John’s pain that were being missed, namely the ligaments and other connective tissues. His range of motion was moderately decreased and painful in flexion, though normal in other planes. Paravertebral tenderness was present bilaterally. Trigger points were noted in the bilateral quadratus lumborum and ilium, gluteus medius and minimus, tensor fascia lata, adductor muscles and hamstrings. Strength, sensation, and deep tendon reflexes of the bilateral lower extremities were normal. A three-inch surgical scar and step-off was present from the spinous process just above the scar below. Hamstring muscles were extremely tight and restricted.

In my medical opinion, when the mechanism of injury puts such tremendous sheer force on the lumbar spine, sacroiliac joints, and hip structures, tearing and stretching of muscle, tendon, and ligament tissues can occur.

d I A G n O s I s

• Musculoligamentous sprain/strain of the lumbosacral spine• Sciatica, referred pain to the left leg• Chronic sacroiliac instability• Degenerative disc disease L4-L5-S1• Spinal stenosis

d I s C u s s I O n

When I discussed my findings with John and his parents I told them that Prolotherapy would likely hold the answers to his pain, and though not guaranteed, he could then return to playing basketball at his previously competitive level. While we also discussed other possible treatment options including additional diagnostic testing, diagnostic blocks, or other treatment routes, my experience told me that Prolotherapy would be the one and only treatment method that would give him the best shot at returning to basketball.

P L A n

The plan I laid out was to treat John’s lumbar spine and sacroiliac joints with a dextrose-based Prolotherapy solution of 12.5% with diluted 1% lidocaine. If necessary, depending on his results after a few treatments, I would also treat the left hip and pelvic structures. John was so excited about the possibility of an effective approach for his chronic pain condition that he decided on his first visit to begin treatment without any further deliberation. I performed his first two Prolotherapy sessions two weeks apart and then followed-up with monthly treatments.

The Prolotherapy injections were performed at the lumbar facets, the interspinous ligaments, the iliolumbar ligaments, and the sacroiliac joint ligaments. In addition, I performed Neural Therapy on his post-surgical scar. Because he had left-sided sciatic leading up to this time, I performed an EMG test to help allay his worries about ongoing nerve injury from his injuries. The EMG revealed borderline abnormalities at best, and a mild chronic left L5 nerve root change. A follow-up MRI with dye to enhance the surgical site, ordered by his surgeon, only revealed post-operative fibrosis and scar but no new changes or new herniations at the disc level.

John’s MRI of the lower back. The arrows point to the two lower lumbar discs that are degenerated.



basketball. He is once again excited, as he anticipates the 2008/2009 basketball season for Cal Poly, and looks forward to the contributions he hopes to make towards their team winning a championship.

ThePatient’sPerspective

After receiving a full scholarship to play Division I Basketball at Cal Poly University, I was excited to begin what I thought would be a great four years of college basketball. The excitement increased after I played significant minutes and hit some big late game shots in an upset win over 25th ranked Cal in my first collegiate game ever. After playing well the first half of my freshman year, I was excited to play in our rival game against Santa Barbara. With a sold-out crowd in attendance I came into the game. Toward the end of the first half, I stole the ball and went in for what I thought was an uncontested dunk. Instead I jumped up in the air and felt my shoulders being pulled down from behind. I fell back in mid-air and landed flat on my lower back without bracing myself. I was on the floor in excruciating pain while the arena was silent. My greatly anticipated four years of college basketball were now in jeopardy.

I continued to play through the pain the rest of the season while my team trainers and doctors tried to figure out what was wrong. As the pain continued, I grew more frustrated, and by the following fall I was no longer able to play basketball. The pain had increased so much, not

For his third Prolotherapy treatment, I not only expanded the treatment area to his left hip and pelvis, I also changed the proliferating agent to sodium morrhuate (a derivative of cod liver oil) to cause a more powerful inflammatory response with the potential for greater proliferative affects. I felt the hip and pelvic ligaments, as well as tendon attachments, were important structures in his case as a significant amount of his pain centered in that region. He was tender over the sacrospinous and sacral tendinous ligaments, posterior gluteal attachments, the greater trochanter, and ligament and tendinous attachment sites at the ischial tuberosity.

John continued to travel back and forth between California, where he was in school, and Minnesota to receive his Prolotherapy treatments. Over a span of two months he had received six Prolotherapy treatments into the lumbar and sacroiliac regions and four treatments into the left hip and pelvic regions. He reported 50% improvement in his symptoms, which included a decrease in pain and soreness. I advised him to continue with his physical therapist to keep his muscles conditioned, and to stay away from impact activities as a whole and rather focus on non-impact workouts such as the elliptical machine, the StairMaster®, and specific weight exercises.

While he was making great progress with the Prolotherapy treatments, he was a long way from returning to competitive basketball. Aside from one more Prolotherapy treatment into his hip joint and capsular ligaments, for the next six months, we focused more on conditioning. The plan was that when he returned for treatments I would give him trigger point and Neural Therapy injections to help reduce spasms in some stubborn gluteal muscles. He also received manual muscle therapy during this time to assist in this process as well.

His final Prolotherapy and Neural Therapy treatment came at the end of July 2006, only eight months after he had begun treatment.

Follow-up phone calls with John from school, and discussions with his parents, indicated that he was making great strides and was able to return to the basketball court. The last time that I saw him in person was less than a month ago on a visit home for the summer and he reported to me that he was completely pain-free, was playing and practicing with the team without restrictions. He was able to run, jump, shoot, and yes, slam dunk a

John Manley, college basketball player, returns to playing with the help of Prolotherapy after being sidelined with a back injury.

By John Manley



only could I not make it through practice, I had a hard time sleeping, sitting in class, and escaping the daily pain. I needed to figure out, once and for all, the true source of the problem. I saw many trainers, therapists, and doctors in the San Luis Obispo area and did not receive any convincing answers as to what was causing the pain.

My family then decided to fly me back home to Minneapolis to see local doctors and I was referred to a spine specialist in the Twin Cities area. After an MRI revealed two herniated discs and some concern with nerve and spinal cord irritation, I underwent a successful spinal surgery (laminectomy and decompression). After the surgery I finally had hope that I was on the road to recovery and a pain-free life. I started post-surgical physical therapy and returned to classes at Cal Poly. I was excited and worked hard every day, doing exactly what the physical therapists suggested. However, after months of rehab I was not getting better. During a follow-up visit with my spine surgeon, he told my parents and I that, among other things, as a result of the pain not subsiding, he felt I would never play college basketball again. The frustration started to mount as weeks turned into months with no improvement. Almost six months had passed with no significant improvement and no change in my pain level.

It was now time to search for answers and new doctors. During this search, a family friend highly recommended Dr. Mark Wheaton. Our family friend described the great success she had with him and a treatment method called Prolotherapy, so we decided to schedule a consultation. We met with Dr. Wheaton, and after the initial visit, my parents and I were more optimistic than we had ever been. I knew it would not be easy since I would have to travel from San Luis Obispo, California to Minnetonka, Minnesota for each Prolotherapy treatment. Yet I was so hopeful, I was willing to do what it took to

get treatment. I felt improvement soon after my first few treatments from Dr. Wheaton, so I continued making trips from California to Minnesota during the spring of 2006 and into the summer. Dr. Wheaton slowly increased my activity level. By the middle of the summer he had increased it to the point where I was able to run, lift weights, and shoot basketballs pain-free. My hopes of returning to play college basketball were slowly becoming a reality. I continued with the Prolotherapy treatments and other muscle treatments recommended by Dr. Wheaton and kept increasing my workouts. By the end of the summer, I played in a summer Pro-Am game, which was my first organized basketball game in nearly two years. At that time, I knew my comeback was almost complete, thanks to the guidance, support, and work of Dr. Wheaton. The natural and effective Prolotherapy treatment method made the difference for me.

In the end, I received a medical red-shirt year and was granted a sixth year by the NCAA so I didn’t lose the two years I had to sit out with my injury. I have now played two seasons since returning and graduated after my fourth year. I am currently entering my senior year of basketball and my second, and final, year of graduate school. I am pain-free and get to play four years of Division I College Basketball just as I had always dreamed. The last five years have not been quite how I planned, but have turned out better than I ever expected! n


T E A C H I N G T E C H N I Q U E S : P R O L O T H E R A P Y T E C H N I Q U E O N I N J E C T I N G T H E A N T E R I O R C R U C I A T E L I G A M E N T

A B s t R A C t

Anterior Cruciate Ligament (ACL) injuries are very common in any sports medicine practice. Incomplete tears and sprains are the most common injury to the ACL. In the author’s experience, if an ACL sprain or incomplete tear does not heal on its own, it will most likely remain chronic, unless Prolotherapy is done. The technique of Prolotherapy for stimulating ACL healing is shown.

Journal of Prolotherapy. 2009;1:36-38.keYWORds: anterior cruciate ligament, injection technique, Prolotherapy.

Prolotherapy Technique on Injecting the Anterior Cruciate Ligament

T E A C H I N G T E C H N I Q U E S

Since the cruciate ligaments are not in the synovial fluid, simple Prolotherapy intra-articular injections will not lead to strengthening of the cruciates. We must therefore identify the anterior and posterior insertion sites, and carefully inject the proliferant there.

Let’s review the ACL anatomy. The proximal end (posterior portion) of the ligament is located posteriorly on the medial superior aspect of the lateral condyle of the femur. From there the ligament runs distally, slightly medially and anterior to its attachment (anterior portion) on the tibia. It attaches on the tibial plateau between the tibial eminences just anterior to the coronal midline and slightly medial to the sagittal midline. The origin is about 20mm by 10mm. The insertion is about 10mm by 30mm, with the long axis running anterior/posterior. (See Figure 1.)

Rodney S. Van Pelt, MD

H ere he is. O.T. has just walked into your office. He is a 69 year-old paving company owner, complaining that his right knee hurts and has

been gradually getting worse over the last two years. He complains of pain with descending a slope and prolonged walking. He has a history of twisting of his knee with an unexpected step into a hole at the work site. On exam he has a mild effusion of the right knee and positive anterior drawer test. The rest of the exam is negative. He has a partially torn Anterior Cruciate Ligament (ACL).

This orthopedic condition brings the skilled Prolotherapist special challenges. The cruciate ligaments are almost two inches long. They are located in the center of the knee, rather than on the outside. Also they are intra-capsular but extra-synovial.

We all know that we see more ACL than Posterior Cruciate Ligament (PCL) injuries. This is for two main reasons. First, the ACL stabilizes the knee in multiple places. This means it is vulnerable to injury from traumatic forces from several directions. Secondly, the blood supply to the PCL is more generous than the supply to the ACL. This leaves the ACL more vulnerable to injury and less able to heal after injury.

Figure 1. Anterior view of a right knee.The arrows show the attachments of the ACL.



To inject the ACL, cleanse the skin with some type of antibiotic solution. Use a 22G 3-inch needle and a 10cc syringe of 15% dextrose. I do not recommend using strong proliferants for treating the cruciates due to the possibility of causing an intense capsulitis. It is possible to reach the insertion of the ACL using a smaller needle but the ligament is too dense to inject into it with a smaller gauge.

With patient seated, legs hanging over the edge of the table bent at 90 degrees, or with the patient lying supine with the knee bent at 90 degrees, insert the needle slightly lateral to midline near the inferior edge of the patella. (See Figure 2.) Angle the needle inferior, posterior, and slightly medially to touch the tibial plateau between the tibial eminences. You will feel the needle enter the dense ligament and feel substantial resistance when injecting. Inject 0.5cc, withdraw the needle partially, insert again and inject another 0.5cc. Repeat this “peppering” technique over the extent of the insertion, using 5cc of proliferant.

Before inserting the needle you will use your non-needle hand to push the neuro-vascular bundle laterally. Do not push it down. Our goal is to clear the needle path so that our needle passes safely, first beside, then beneath, the femoral nerve, artery, and vein. (See Figure 3.)

Figure 2. Injection technique of the anterior portion of the left knee ACL.

Figure 3. Prolotherapy injection technique of the posterior portion of the left knee ACL.

After cleansing the skin, insert the needle at the level of the joint line at the lateral aspect of the medial condyle. Exercising proper caution, you will advance the needle. Angle the needle toward the inner side of the lateral condyle, near the roof of the intercondylar notch. This is about 45 degrees anterior, 45 degrees cephalad, and 45 degrees lateral. You will feel the needle touch the femur. As you begin to inject, you should feel the resistance of the substance of the ligament. (See Figure 4.) When the needle tip is not at the origin site, the proliferant will flow with very little resistance into the joint space. This will not harm, but it is not our target. After proper insertion, use the “peppering” technique previously described to pepper the origin site with proliferant at the fibro-osseous junction.

In my opinion, Prolotherapy is extremely safe. It has a tiny fraction of the risk of surgery and a small fraction of the risk of cortisone injection. Treatment of the cruciates

We generally do not give Prolotherapy in the back of the knee, in part because of the blood vessels and nerve running there. In this case we cannot access the origin (posterior portion) of the ACL or the insertion of the PCL from the front of the knee.

When it is decided to inject the origin of the ACL, you do so by positioning the patient face down with a roll under the ankle to leave the knee slightly bent. This relieves tension on the posterior structures of the knee, making it easier to push them aside to safely give the injection.



Figure 5. Injection of the posterior portion of the right knee ACL via the anterior approach.

We have just reviewed treating partially torn cruciate ligaments with Prolotherapy. It takes special skill and precaution. With proper training, it is safe and very effective. Next time you are presented with cruciate ligament injury, consider using Prolotherapy to save your patient from the risk, debilitation, and expense of surgery.

e d I t O R ’ s C O m m e n t

I have seen Dr. Van Pelt successfully treat many patients with ACL injuries using the described technique. I would just add that it is possible to inject portions of the posterior part of the ACL from the anterior approach. (See Figure 5.) If this anterior approach does not induce enough ACL repair then I would also do Prolotherapy posteriorly as Dr. Van Pelt has described. In the next issue, Dr. Van Pelt will discuss and illustrate his Prolotherapy technique for injecting the posterior cruciate ligament. n

introduces a special risk due to the approach from the back of the knee with its proximity to the femoral nerve, artery, and vein. There is a possibility of nicking or puncturing the femoral artery, and touching the femoral nerve with the needle. This technique requires careful training and knowledge of the anatomy of the knee. In more than 700 treatments, I have never had a complication with the posterior approach using the precautions previously described. Do not attempt this posterior approach without sufficient training.

Due to the cruciate ligaments being nearly two inches long, the desired shortening of the ligaments is often substantial. In some cases this can reach a couple of millimeters. Patients experience just mild to moderate soreness of their knees following the treatment, and are routinely able to drive themselves home or back to their employment. The success rate is about 85 to 90 percent. You can expect results in all but complete tears of the cruciates in about six to eight treatments.

Figure 4. Posterior view of a right knee model. To inject the ACL from the posterior approach the needle is positioned directly posterior to the joint line at the lateral edge of the medial condyle, aiming the needle cephalad, medial and anterior.


W O N D E R W H Y ? : T H E R E G E N E R A T I O N O F A R T I C U L A R C A R T I L A G E W I T H P R O L O T H E R A P Y

The Regeneration of Articular Cartilage with Prolotherapy

W O N D E R W H Y ?

A B s t R A C t

What most people may not realize is that chondrocytes, the cells that make articular cartilage, are metabolically active. Chondrocytes proliferate and actively make articular cartilage. Osteoarthritis is an example of this, in that both the degradation and synthesis of articular cartilage are enhanced. It is well known that in osteoarthritis, chondrocytes retain their proliferative activity. Osteophytes or bone spurs are an example of this activity. Another example of adult articular cartilage cells’ replication is acromegaly. In this condition the body produces an excessive amount of human growth hormone and with it, articular cartilage. Acromegalics often suffer from joint abnormalities caused by proliferation of chondroytes in articular cartilage. In other words, they produce too much cartilage. When a healthy articular cartilage cell is injured, it demonstrates an enhanced reparative response and can replicate its DNA to form new cells. The rate of formation of articular cartilage can be enhanced by such stimuli as altered hydrostatic pressure, varied oxygen tension, growth factors, as well as nutrient and substrate manipulation.

If by traditional orthopedic surgery or medical standards, articular cartilage injury or degeneration causes such symptoms as knee pain, stiffness, clicking, crunching, and inability to walk, then the reversal of such symptoms with Prolotherapy must mean that articular cartilage regeneration has taken place. In this scientific editorial, the author makes the case for using Prolotherapy as the treatment of choice for degenerated joints.

Journal of Prolotherapy. 2009;1:39-44.keYWORds: acromegaly, articular cartilage, osteoarthritis, Prolotherapy, regeneration.

S imply put, I believe that articular cartilage is regenerated with Prolotherapy. In my opinion, Prolotherapy should be the treatment of choice

for most cases of pain involving the degeneration of a joint. It is common knowledge that even the most effective current treatments for osteoarthritis do not restore the joint. Conservative treatments such as exercise, medications, physical therapy, and lifestyle modification can decrease symptoms and improve mobility, but they do not reverse the disease. I believe if Prolotherapy were utilized to its fullest in the treatment of knee, shoulder, and other peripheral joint degenerative conditions, it would be shown to be the one treatment that does restore some, or most, of the degenerated structures, as well as the functions of the joint.

What most people may not realize is that chondrocytes, the cells that make articular cartilage, are metabolically active.1 Yes, chondrocytes do proliferate and actively make articular cartilage. In normal cartilage, there is a strict regulation of cartilage turnover, a delicate balance between synthesis and degradation. The problem is, for those suffering from osteoarthritis, the system is imbalanced. There is more cartilage degeneration than rebuilding.

In osteoarthritis, both degradation and synthesis of articular cartilage are enhanced. The problem is that the “messenger” molecules that allow cells to communicate and alter one another’s functions, called cytokines, cause more breakdown of articular cartilage than repair. The catabolic (break down) cytokines IL-1, TNF-a, IL-17, and IL-18 act to decrease extracellular matrix synthesis (cartilage synthesis). The anabolic cytokines (substances that build up) IGF-1, TGF-B1, 2, and 3, fibroblast growth factors (FGFs) 2, 4, and 8, and the bone morphogenetic proteins act to stimulate extracellular matrix synthesis.2,3 In osteoarthritis, unfortunately, the catabolic cytokines are winning.

Ross A. Hauser, MD

A S C I E N T I F I C E D I T O R I A L



It is well known that in osteoarthritis, chondrocytes retain their proliferative activity.4,5,6 As a matter of fact, a number of biochemical studies have demonstrated enhanced synthesis of the extracellular matrix of cartilage.7,8 Chondrocytes attempt to repair the damaged matrix in osteoarthritis by increasing their anabolic activity.9,10 One of the reasons for this is that on a molecular level, a significant proportion of adult articular chondrocytes start to re-express a chonodroprogenitor phenotype in osteoarthritic cartilage degeneration, which is comparable to the chondroprogenitor phenotype observed in fetal skeletal development.11,12 In other words, with injury/degeneration, the adult chondrocyte cells change to more “primitive” cells, which have more proliferative ability. In the natural history of the disease, despite this increased activity, a net loss of proteoglycan content (extracellular cartilage matrix) is one of the common features of all stages of osteoarthritic cartilage degeneration.13

One of the main hallmarks of osteoarthritis in a joint is the development of prominent osteochondral nodules known as osteophytes. These are also called osteochondrophytes or chondro-osteophytes. Most of us know them as bone spurs. Indeed, the presence of osteophytes in a joint, more than any other pathological feature, distinguishes osteoarthritis from other arthritides.14 Osteophytes are an example of new cartilage and bone development in osteoarthritc joints, and arise from tissue associated with the chondro-synovial junction or from progenitor cells residing in the perichondrium.15,16 This basically means there is a population of joint cells (pluri-potential cells) that can respond to injury and differentiate into cells that make cartilage and bone. The purpose of osteophytes is presumed to be the stabilization of joints affected by osteoarthritis.17

When larger osteophytes are examined from human patients, areas of hyaline cartilage can be seen to extend to the surface of the osteophyte. These cartilaginous tissues resemble genuine articular cartilage in chondrocyte morphology and in extracellular matrix. Interestingly, the anabolic factors TGF-B and TGF-B2 have been found in osteophytes from human femoral heads.18 Again this signifies that adult articular cartilage retains repair (anabolic) activity.

I n C R e A s e d A R t I C u L A R C A R t I L A G e t H I C k n e s s I n A C R O m e G A L Y

One of the major problems in osteoarthritis care today is traditional medicine’s inability to promote effective cartilage regeneration in the presence of adult chondromalacia (cartilage degeneration). Yet such regeneration is consistently present in acromegalics. Acromegaly is a condition whereby the pituitary gland secretes too much human growth hormone (HGH). It is a disease characterized by the gradual enlargement of the bones of the hands, feet, head and chest, and thickening of the skin, lips and vocal cords. What is also characteristic of this condition is that there is an excessive amount of articular cartilage in both weight-bearing (knees) and non-weight-bearing joints.19 Acromegalics often suffer from joint abnormalities caused by the proliferation of chondrocytes in articular cartilage. Since this condition typically occurs after puberty, the increased human growth hormone secretion in acromegaly somehow,

either directly or indirectly, stimulates adult chondrocytes (cartilage cells) to make cartilage. People with acromegaly have tremendously thick articular cartilage, which can be diminished by decreasing their HGH secretion.20

HGH is known to cause the liver to increase production of Insulin-like

growth factor-1 (IGF-1). Circulating and locally produced IGF-1 is known to stimulate DNA synthesis, cell replication, and proteoglycan and glycosaminoglycan synthesis in articular chondrocytes.21 IGF-1 and HGH have both been shown to stimulate the growth and repair of adult articular cartilage.22,23,24 One reason for this cartilage growth can be that some cartilage cells have HGH receptors.25

Adults with Acromegaly have

the problem of too much cartilage.

CATABOLIC CYTOKINES ANABOLIC CYTOKINES

IL-1 IGF-1

TNF-α TGF-β1,2,3

IL-17 FGF-2,4,6

IL-18

Physiology of osteoarthritis. While articular cartilage is stimulated in osteoarthritis, the net result is degeneration in part because of the increase in catabolic cytokines. One of Prolotherapy’s effects on the physiology of osteoarthritis is thought to be an enhancement of anabolic cytokines which stimulate cartilage regeneration.



m O R e e v I d e n C e O f A R t I C u L A R C A R t I L A G e R e G e n e R A t I O n

What happens to articular cartilage when it is subjected to mechanical trauma? It is important to consider the main issue. Can adult articular cartilage respond to appropriate stimuli by an increase in its synthetic activities for DNA and matrix components? In other words, can chondrocytes replicate and make cartilage? Central to this discussion is the consideration of the ability of any tissue to increase its rate of DNA and protein synthesis. Regardless of the tissue involved, the process of repair is a cellular one in the sense that fibroblasts, or specific cells (osteoblasts, chondrocytes for example), must synthesize the repair material. For the most part, these are “new” cells that evolve by cell replication and modulation of existing cells, or from cells that have migrated either from the margins of the wound or from blood vessels entering the tissue. It is therefore important to recognize that DNA replication and cell division are essential characteristics of any repair process.

The confusion in regard to articular cartilage repair stems from the fact that chondrocytes from immature cartilage are capable of dramatic repair and synthesis, whereas aging chondrocytes show much lower rates of cell replication.26,27 This is where the notion of “cartilage cells don’t replicate” stems from. The problem with this logic is that a normal adult chondrocyte is pheno-typically different from an injured chondrocyte. Analysis of cartilage from joints with osteoarthritis has demonstrated, over and over again, an increased number of cells in clones and evidence for DNA synthesis by a number of means including 3H-thymidine metabolic studies, autoradiography, and even histological demonstration of mitotic figures.28,29,30 These data suggest that under circumstances of chronic injury, such as is seen in osteoarthritis or trauma, chondrocytes are capable of mounting a significant reparative response and can replicate their DNA to form new cells.31 This is fact. Chondrocytes can divide, and do so in the adult animal/human with osteoarthritis and from other stimuli. Ample evidence now exists that articular chondrocytes from immature and adult animals can vary the rate at which

they make cartilage matrix necessary for repair. This rate of proteoglycan synthesis can change in response to such diverse physical and pathological states as osteoarthritis (as discussed), altered hydrostatic pressure, varied oxygen tension, alternations in pH, calcium concentration, substrate concentration, and the presence of growth hormone (as discussed), growth factors, ascorbate, vitamin E, and so on.32,33,34,35,36 I could easily elaborate on each of these, but the reader is encouraged to check the references for further information. Therefore, it is reasonable to conclude from the above that injured adult articular cartilage chondrocytes have the capacity to substantially increase their rate of matrix synthesis, and that the possibility exists of chondrocyte participation in the repair of articular cartilage. All that is really needed is a method to stimulate that repair maximally. This is where Prolotherapy fits in.

P R O L O t H e R A P Y : t H e t R e A t m e n t O f C H O I C e f O R d e G e n e R A t e d j O I n t s

George S. Hackett, MD coined the term Prolotherapy. As he describes it, “To the treatment of proliferating new cells, I have applied the name Prolotherapy from the word prolix (Latin), meaning offspring; proliferate-to produce new cells in rapid succession. My definition of Prolotherapy as applied medically in the treatment of skeletal disability is ‘the rehabilitation of an incompetent structure by the generation of new cellular tissue.’”37 While traditionally

used for ligament and tendon repair, Prolotherapy has a long history of being used for degenerative joint disease.38,39,40,41 Like the chronic knee pain study published in February 2009 issue of the Journal of Prolotherapy,42 Prolotherapy has remarkable pain-relieving effects. But when a person with degen-erative knee arthritis reports less stiffness and crunching in the knee, as well as improved motion, are we to assume that there has been

cartilage repair? I would answer the question with an emphatic “yes” in most cases. But some would remain skeptical. This is why the February 2009 issue of the Journal of Prolotherapy also presented five before and after X-rays of knees showing cartilage regeneration.43 Does this prove that all Prolotherapy treatments on degenerated knees stimulate cartilage regeneration? Absolutely not! But it

Cartilage repair can be stimulated by a number of means: pressure changes,

trauma, varied oxygen, tension, pH alterations,

calcium, growth hormone factors, vitamins, nutrients.



surely shows that Prolotherapy treatments to human knees do have the potential to regenerate articular cartilage. For those who have had numerous treatments and have seen the function, signs, and symptoms of their degenerated joints reverse with Prolotherapy, is it reasonable to assume that the articular cartilage is being stimulated to repair? How else would you explain a decline in stiffness, clicking, and crunching in the person’s knee treated with Prolotherapy? How do you explain the inability to walk or do any athletics, but yet with a number of Prolotherapy injections into and around the knee, the person regains his walking ability and is now able to perform athletics? How about improvement with Prolotherapy in those patients who have been told they need knee replacements, or those whose doctors say there is no other treatment available for them? What about in these cases? If the person receives Prolotherapy to their end-stage osteoarthritic joint and not only do they not need a knee replacement, they are back to dancing, how do you explain it? Placebo? I think not. Something has changed. Their joint architecture has changed. There has been some rebuilding inside their joints. In essence, they have a regenerated joint. The chondrocytes have been activated to start making cartilage and that cartilage has been laid down.

I believe in changed lives. I believe a changed life is enough. In other words, if a person cannot walk much because of a degenerated knee and has been told by an orthopedist that he needs a knee replacement, but he refuses and decides instead to get Prolotherapy, and if after Prolotherapy treatments he can walk well with virtually no symptoms, I am satisfied. Their life was changed with Prolotherapy. I believe the patients when they tell me that it was the Prolotherapy that turned their lives around. I believe that the Prolotherapy regenerated the injured tissues. I believe that the person can now have a full life. That full life is because of Prolotherapy. Prolotherapy worked for them. I do not need an MRI or X-rays or a biopsy of cartilage cells to know that Prolotherapy worked!

The bottom line is you can’t have it both ways. If the orthopedist is saying to a patient that your knee pain, grinding, crunching, pain upon bending your knee, and your inability to walk without a limp is from your

cartilage degeneration and you need a knee replacement, then the opposite must also be true. If that same patient, after receiving Prolotherapy to the knee, has no more, or very little, pain, grinding, etc., can walk unlimited and does hiking and climbing, then it must mean that their degenerated cartilage has been regenerated! To put it bluntly, Prolotherapy regenerated their cartilage! This is my main point!

I know there are a lot of skeptics out there. They want “evidence” that Prolotherapy works. They need to see before and after X-rays and MRIs. Well, that is part

of the purpose of the Journal of Prolotherapy. The goal is to educate the world on the life-changing effects of Prolotherapy. Some of the people in the world who need educating are the traditional doctors who treat pain patients. They need to know of the life-changing effects of Prolotherapy on degenerated joints. One of the effects of Prolotherapy is to change a degenerated joint without much cartilage to a joint that has more

cartilage. How will that appear to the physician examining the joint? The doctor would notice a smooth-gliding joint instead of a joint that makes grinding, clicking, and popping sounds while the physician puts the joint through its range of motion. It is definitely noticeable and demonstrable. To the patient, the joint after Prolotherapy will produce much less crunching or clicking sounds when

Prolotherapy of the knee. The knee is the most common joint treated with Prolotherapy for articular cartilage regeneration.

Evidence of cartilage repair after Prolotherapy: Positive changes on X-ray, less clicking in the joint, less grinding, less pain,

smooth gliding joint.



the knee or joint is moved, as well as when going up and down stairs. As a given, he will experience less pain and stiffness.

C A L L t O A C t I O n

Here are some suggestions to those with degenerated joints that were regenerated with Prolotherapy, and for those who use Prolotherapy in their practices. Let’s start obtaining before and after Prolotherapy X-rays, and if possible even MRIs. Make sure the X-rays and MRIs taken after Prolotherapy are compared to the ones taken before Prolotherapy, and are evaluated by an independent radiologist who understands that the patient had Prolotherapy. I believe that you will most likely see structures be regenerated! The average radiologist has never seen menisci or cartilage tissue regeneration. Tell him you performed (or received if you are the patient) Prolotherapy on the joint. Ask him specifically if he sees regeneration of articular cartilage, menisci, ligaments and any other structures? Do not be surprised when the radiologist says, “yes.” Send us the films to be published in the Journal of Prolotherapy. Perhaps then we can eliminate some of the skepticism about Prolotherapy and people can receive the treatments they really need, such as Prolotherapy. At least one of the myths that prevails in the world of orthopedics, that articular cartilage does not regenerate, will be dismissed once and for all. We can then rejoice because people with pain will get the treatments they need. Perhaps people everywhere will finally understand that cartilage can be stimulated to repair, and that it is Prolotherapy that is needed to regenerate articular cartilage. n


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Goldring MB. Osteoarthritis and cartilage: The role of cytokines in this disorder. Curr Rheumatol Rep. 2000;2:459-465.

Meachim G, et al. Cell counts of normal and osteoarthritic articular cartilage in relation to the uptake of sulphate in vitro. Ann Rheum Dis. 1962;21:45-50.

Mankin HJ, et al. Biochemical and metabolic abnormalities in articular cartilage from osteoarthritic human hips. II. Correlation of morphology with biochemical and metabolic data. J Bone Joint Surg Am. 1971;53A:523-537.

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W O N D E R W H Y ? : P R O L O T H E R A P Y & C O N N E C T I V E T I S S U E D A M A G E S Y N D R O M E

A B s t R A C t

Many joint and connective tissue pains defy clear and precise diagnosis. Often patients with various diagnoses for joint, back and neck pain are not cured by traditional treatment regimes appropriate for their “diagnosis”. Based on observations gleaned from treatment responses to Prolotherapy, the author describes and characterizes the Connective Tissue Damage Syndrome. When properly understood, the CTDS explains not only many body pains, undiagnosed conditions, and treatment failures, but also many muscular malfunctions (spasms, weakness, trigger points, etc.), and referred symptoms such as pain, numbness, tingling, and headaches. The results of Prolotherapy treatment in patients with these disorders suggest that pathological change in ligaments (CTDS) is the underlying cause of these disorders. Prolotherapy is the most rational and effective treatment for both the underlying cause (ligament damage), and secondary degenerative effects.

The body is capable of healing damaged connective tissue structures, but certain hormone deficiencies and medical treatments such as anti-inflammatories prevent this. Once connective tissue damage syndrome is correctly diagnosed, then treatment is rightly focused on initiating and optimizing connective tissue healing. Since incomplete connective tissue healing can be principally due to either a trauma mechanism, or due to impairment of the body’s connective tissue healing system, the integrity of the healing system must be evaluated, and factors that impair connective tissue healing must be identified and addressed. These factors explain why many people with CTDS see their disease worsen over time, while under medical care. Patients who present with significant impairment of the connective tissue healing system are described, varying from “multisite connective tissue pain without trauma history” to full-blown fibromyalgia. Principles for successful treatment for the CTDS are described.

Journal of Prolotherapy. 2009;1:45-53.keYWORds: connective tissue damage syndrome, ligament injury, Prolotherapy.

Prolotherapy & Connective Tissue Damage Syndrome

Why am I hurting, and no one seems to know what is wrong?

Mark L. Johnson, MD, FACS

W O N D E R W H Y ?

P rolotherapy is certainly an important clinical tool to treat damaged connective tissue—ligaments, tendons, cartilage, meniscus, labrum, fascia, etc.

But perhaps a greater contribution made by Prolotherapy is that it sheds light on an important medical mystery. That is, when someone has pain in a joint, or in the neck, or back, or when someone has symptoms going down an arm or leg, or various other distressing symptoms, what disease process is actually causing their symptoms? I see patients on a daily basis who have had the origin of their symptoms misdiagnosed. I hear patients on a daily basis give accounts of lengthy odysseys through the health care system, often involving multiple attempted treatments, including operations, who are not better, and perhaps worse, after all the medical attention they have received. Or I see patients with significant symptoms who have been told that “nothing” is wrong—because all their tests are “negative.” One can read the medical literature and see many purported mechanisms for back, neck, and joint pain. Then read the results of patient treatment based on these proposed mechanisms, and see failure rates that are remarkably high. One can also see in the literature a large group of patients who, at the outset, do not fit into any known “diagnostic category.” Practitioners cannot be exposed to diagnosing and treating patients with musculoskeletal pain for long before a question becomes glaringly obvious. “Are we missing something here—is there a disease process that is right under our noses every day that is poorly understood, or totally misunderstood, by the medical community at large?”

I believe that the answer is “Yes.” Thanks to observations gleaned from successfully treating thousands of painful joints with Prolotherapy, I think I have developed a fairly clear understanding of this disease process. Many of these observations have been made by others in the Prolotherapy community for decades. What has been lacking thus far is assembling these observations into a description of a



disease process. That process can then be named and understood by the medical community, and the general community, in a way which explains the mystery of many misdiagnosed and undiagnosed body pains. To that end, here is an introduction to the Connective Tissue Damage Syndrome.

To restate the problem, you have neck pain with some numbness and tingling in your thumb and first two fingers, or you have lower back pain with some aching pain down the lateral thigh and lateral calf and recurring back muscle spasms, or you are limping with hip pain. You go to the doctor and get an X-ray, and the film is completely normal or shows significant cartilage loss. Then, you walk into a room filled with practitioners—Orthopedic surgeons, Neurosurgeons, Neurologists, Rheu-matologists, Physical Medicine/Re-habilitation doctors, Chiropractors, Physical Therapists, Massage Ther-apists, Family Doctors, Pain Clinic physicians, Acupuncturists, etc. You go around the room and ask a simple question. “What structure are these symptoms actually coming from?” You will get about forty different answers but the correct answer will be only one of these, or none of these. It is obvious that this is the most important question that can be answered if the patient is to be successfully treated.

I would tell each of these people previously mentioned that every symptom they described is consistent with the Connective Tissue Damage Syndrome (CTDS) affecting various ligaments and tendons. And I would probably be correct. These scenarios represent real people who have been evaluated and treated successfully by this author. In order to understand this syndrome, which is not recognized or understood by most practitioners in this country, let us first touch on some medical history. Then we will look at the mechanism by which pain and other symptoms might arise from connective tissue damage, then catalog the symptoms and findings produced by this disease process. We will consider how these patients might be best evaluated and treated. Lastly, we will consider the origins of the confusion regarding this diagnosis.

Until the 1950s, ligaments were believed to be a significant source of somatic pain—back pain, neck pain, and joint pain in general. There were at least two reasons upon which this belief was based. First, the nerve density in ligaments (and tendons) is very high. Damage in these structures would be expected to cause significant symptoms. Secondly, diagnostics were based on physical examination. The old dictum in Orthopedics used to be, “Get your history, do an examination, make a diagnosis, then confirm your diagnosis with imaging.” If you carefully palpate painful joints, necks, and backs, you will find that virtually all of the tenderness is noted over

ligaments and tendons. And if you find these tender structures around a joint, it is no great leap of logic to conclude that these are the structures from which the pain is arising. However, this type of careful palpation is rarely a part of current evaluation.

The belief that ligaments are a significant source of joint pain was abandoned abruptly in the 1950s. From that time until the current day, vast improvements in imaging clarity

have allowed us to visualize an increasing number of “abnormalities” to which patients’ symptoms are now ascribed. The current assumption is that any significant pathology will be seen on an MRI or CT. In fact, it seems that the vast majority of “diagnoses” in joint pain are based almost solely on imaging studies. Most back and neck pain is attributed to disc disease, or to pinched nerves, based on these imaging studies. Hip pain is attributed to cartilage loss. In the absence of cartilage loss, a nerve pinch at the level of the spine is often “diagnosed.” Shoulder pain is usually ascribed to damage to rotator cuff tendons seen on MRI, or to bone spurs. Knee pain is usually attributed to “loss of cartilage.”

Also in the 1950s, injectable cortisone became available. It was found that injecting this medication caused improvement in many joint pains, leading to the theory of an inflammatory cause for these complaints, and ushering in the era of anti-inflammation. Current “conservative therapy” for joint, neck, and back pain is over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), followed by prescription strength NSAIDs, followed by corticosteroid injection. For any joint pain, regardless of X-ray findings, corticosteroid injections

Until the 1950s, ligaments were believed to be a

significant source of somatic pain—back pain, neck pain, and joint pain in general.



are often prescribed based on the idea that joint pain is commonly due to “inflammation.” If “nothing” is seen on imaging studies to “account for” pain, then the pain is assumed to be coming from local inflammation (bursitis or arthritis) or from an inflamed nerve.

However we have arrived at this point, patients who arrive in my office with neck, back, or other joint pain virtually never say, “My ligaments are hurting.” What they usually say is that they have pain due to something seen on X-rays, or if “nothing” was seen on X-ray, they have been told that their pain is due to some form of inflammation or nerve pinch. But here is the problem. People have been treated appropriately for these “diagnoses” and they are not better. Often they are worse, after months or years of treatment. I see many, many patients with this story. This leads me to the inescapable conclusion that these people have been misinformed about the origin of their pain. If that is so, then where is their pain arising from?

t H e m e C H A n I s m f O R P A I n I n t H e C O n n e C t I v e t I s s u e d A m A G e s Y n d R O m e

By what mechanism could ligaments, tendons, or other connective tissue cause pain? Ligaments are cables between two bones, allowing the bones to move relative to each other, with motion limited by the ligament. Tendons are cables between a bone and a muscle that allow the muscle to move the bone. These structures are virtually indistinguishable under a microscope and are made almost entirely of collagen. Ligaments and tendons are heavily innervated.

Envision a steel cable made of many small wires, rated to hold 10,000 pounds. Break half the wires, then put 10,000 pounds of weight on the cable. Can you envision this cable stretching under the weight? In a similar way, collagen molecules confer strength like the steel wires of a cable. If you break a certain number of collagen molecules and do not replace them, can you envision these structures also beginning to stretch abnormally? (See Figure 1.)

One problem with this new “stretchiness” is the nerve supply in the ligaments and tendons. These nerves do not stretch well, so one can also envision small fiber nerve damage beginning to occur in this new stretchable matrix. Of particular interest are C-fibers. These are among the smallest nerve fibers and they principally carry pain sensation. These fibers would be particularly susceptible

to such stretching and shearing forces. Therefore, bearing weight on one of these abnormally stretchable structures would be expected to initiate a small neural firestorm of impulses. As use continues, nerve damage continues and accumulates. I refer to this status in a ligament, tendon, or sheet-like connective tissue (e.g. fascia) as “non-load bearing.”

Let us now apply this model for pain production to a common malady—tennis elbow. This condition is characterized by pain around the lateral epicondyle of the elbow when the extensor muscles of the forearm are used. Also characterized by pain when pressure is applied to the area (hurts when you use it, hurts when you press on it). This condition often gets better with anti-inflammatory medication and was deemed to be an inflammatory condition for many years. Hence, it was called “tendonitis” (or “tendon inflammation.”) This belief continued until a couple of decades ago, when biopsy studies showed conclusively that no inflammation was present in chronic cases of “tendonitis.” Instead, there was architectural disruption of the collagen fibers. In other words, there was unhealed damage (a non-load bearing connective tissue structure) that was producing pain. Based on this study, this disease was actually renamed. “Tendonitis” became “tendinosis.” Tendinosis is the term for degenerated tendon. Obviously signifying that regeneration is what is needed for the condition.

Ligaments and tendons are very similar in structure and function. Is it reasonable to assume that a ligament might be subject to the same kind of painful damage that in a tendon is called “tendinosis?” Of course this is reasonable. What is the name of this condition in a ligament? I often

Figure 1. Ligaments function like steel cables.When some of the collagen fibers are broken in ligaments it puts pressure on the rest of the ligament, stretching it and the nerves within the fibers. This causes localized and referred pain.



ask my patients this question and it is amusing to watch them struggle with it. Eventually everyone stops trying to recall an answer. I then tell them that they are correct. This disease entity does not have a name, yet I treat it every day. Perhaps it would suffice to say the person simply has degenerated ligaments or ligament damage?

The fact that anti-inflammatory medications “work” in reducing pain in these conditions is important and will be discussed later. Also worth emphasizing at this point is the fact that the medical community thought that this manifestation of the Connective Tissue Damage Syndrome was an inflammation but it is not. This mistaken assumption shows up time and time again in other body tissues (e.g. a “bursitis” diagnosis when there is CTDS in the ligaments of the hip or shoulder).

s Y m P t O m s O f t H e C O n n e C t I v e t I s s u e d A m A G e s Y n d R O m e

What symptoms are possible due to small-fiber nerve damage in connective tissue structures? The following list encompasses many common symptoms.

Pain with use of structure Pain randomly or continuously with progression of damageTenderness to palpitation Reflex muscle function aberration—tension, spasm, weakness, trigger pointsReferred pain, aching, numbness and tingling, burning, “pins and needles”Referred autonomic nervous system malfunction—Barré-Lieou Syndrome from cervical CTDS, and more rarely, lower extremity autonomic findingsBarosensitive (weather changes) and stress-sensitive symptoms

Upon what evidence do I base the assertion that small fiber nerve damage in ligaments and tendons produces the above clinical manifestations? The entire discussion is beyond the scope of this publication, but in brief, Prolotherapy only modifies one variable, for the most part, which is the amount of collagen in structures. Also, in administering Prolotherapy, I inject a proliferant solution which contains lidocaine. Therefore, I sequentially subtract out symptoms from connective tissue structures during a treatment. Suppose one of the patients previously described, who comes to me with low back pain and

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aching pain down the lateral thigh and lateral calf, has been told that his back pain and referred symptoms are due to “a bulging lumbar disc and pressure on nerves in the back.” Yet on physical examination I find a group of tender lumbar ligaments, and I find significant tenderness in the upper sacroiliac ligament on the same side as his lower extremity referred symptoms. I could theorize that his pain and referred symptoms may be due to CTDS in his ligaments.

My theory at that point should be accorded no more weight than any of the myriad other possible theories for the origin of his symptoms. If however, I treat him with Prolotherapy, subtracting symptoms from each ligament structure for the duration of the action of the lidocaine, and all of his symptoms, including his referred symptoms, resolve immediately, then the argument is considerably stronger that the correct pain-causing structures have been identified. Further, although symptoms return after the local anesthetic wears off, if those symptoms are permanently relieved after three or four Prolotherapy treatments, then one can reasonably conclude that it was a lack of collagen in these structures that lead to this patient’s symptoms in the first place. And, if my success rate for treating patients with back pain with an array of previous diagnoses, who have tender ligament and tendon structures in the back, is upwards of 85%, then it could be plausibly argued that this is the correct diagnosis in everyone who completely responds to Prolotherapy.

Certain symptoms and findings of CTDS noted above merit further discussion. First, structures with CTDS are always tender to palpation (Item 3) whether pain or other symptoms are present or not at the time of examination. This is how you locate this tissue damage. Conversely, probably 90% of the symptomatic connective tissue damage that I treat does not show up on any imaging study. Thus, will practitioners who base their diagnosis on imaging studies ever correctly identify this type of damage?

Secondly, muscle aberrations (Item 4) frequently drive people to seek manipulative therapies. If muscle function problems are recurrent or chronic, there is almost always tendon damage involved, or damage in a ligament near a tendon insertion. Once this damage is rectified, the secondary muscle manifestations completely resolve with no further treatment. This is true with decreased range of motion in the cervical spine, shoulder, back, and hip,



as well as painful knots of muscle between the shoulder blades, back spasm, “chronic hamstring pulls,” etc.

Ligament referral symptoms (Item 5) were described and mapped very exactingly by Dr. George Hackett, and published in the 1950s. These maps are quite accurate and very helpful in localizing the symptom generating structure. It is not uncommon to find no complaint of pain in the symptom generating structure. However, these structures will always be tender, so confirming their presence is easy if one knows where to palpate. These referred symptoms are almost always misattributed to nerve compression or inflammation. (See Figures 2 & 3.)

The Barre-Lieou Syndrome (Item 6) consists of several possible autonomic nervous system malfunctions in the head and neck, including headache, fullness or ringing in the ears, sinus fullness or drainage, blurred vision and

abnormal tearing, abnormal salivation, hoarseness, and skin changes (flushing or edema). A single patient rarely has more than a few of these findings. A variant of this syndrome is connective tissue-triggered migraines, which are characterized by feeling a point of pain in the head or neck, just prior to onset of a severe headache. All of the Barre-Lieou symptoms may be very successfully treated with Prolotherapy of the neck ligaments. Connective tissue-triggered migraines may be successfully treated by treating the specific connective tissue trigger point or points.

Figure 2. Ligamentous structures of the lower back and hip that refer pain down the lower leg. The illustration shows the trigger points of pain and the needles in position for confirmation of the diagnosis and for treatment of ligament relaxation of the lumbosacral and pelvic joints. Used with permission from Prolo Your Pain Away! Curing Chronic Pain with Prolotherapy, Third Edition; Ross A. Hauser, et al. Beulah Land Press, 200�, Oak Park, IL.

H A C k e t t R e f e R R A L P A t t e R n s

Lower Back and Hip Ligaments t R I G G e R P O I n t s O f L I G A m e n t s

IL: Iliolumbar ST: sacrotuberus LS: Lumbosacral—supra and Interspinus SC: sacrococcygeal A, B, C, D: Posterior sacroiliac H: Hip—Articular SS: sacrospinus SN: sciatic nerve

Figure 3. Ligament referral pain patterns from structures in Figure 2. Used with permission from Prolo Your Pain Away! Curing Chronic Pain with Prolotherapy, Third Edition; Ross A. Hauser, et al. Beulah Land Press, 200�, Oak Park, IL.

H A C k e t t R e f e R R A L P A t t e R n s

Pain Referral Patterns f R O m L u m B O s A C R A L A n d P e L v I C j O I n t L I G A m e n t s

Abbreviation Ligament Referral Pattern IL: Iliolumbar Groin, testicles, vagina, Inner thigh AB: Posterior sacroiliac Buttock, thigh, Leg (upper two-thirds) (outer surface) D: Posterior sacroiliac thigh, Leg (Outer Calf) (lower outer fibers) foot (Lateral toes)— Accompanied by sciatica HP: Hip—Pelvic Attachment thigh—Posterior & medial HF: Hip—femoral Attachment thigh—Posterior & Lateral Lower Leg—Anterior & into the Big toe & second toe SS: sacrospinus & sacrotuberus thigh—Posterior Lower Leg—Posterior to the Heel SN: sciatic nerve Can Radiate Pain down the Leg



Symptoms of CTDS tend to fluctuate (Item 7). They may be intermittent. Precipitating factors for an exacerbation of symptoms include load-bearing on the structure (Item 1), stress, including lack of sleep, and falling barometric pressure.

s e C O n d A R Y m A n I f e s t A t I O n s O f L I G A m e n t d A m A G e A n d L A x I t Y

As ligaments become non-load bearing, yet continue to bear weight, they will stretch and become longer. This causes the bones connected to the ligament to develop abnormal mobility. This abnormal motion has several consequences.

Cartilage damageNew bone formation around joints (bone spurs, osteophytes, etc.)Meniscus and labrum damageDegenerative disc disease and disc damage

The relationship between ligament damage (laxity and elongation) and these secondary manifestations is often missed. This is particularly true with arthritic joint changes and degenerative disc disease. Abnormal impact on a bony surface is a stimulus for new bone formation. Joints with “play” in them, which allows such impact, would be expected to display evidence of osteogenesis (new bone formation). If an X-ray of a joint is obtained, and loss of cartilage and osteophyte formation are noted, a diagnosis will be assigned—“arthritis” or “joint inflammation.” Most practitioners assume that the pathology and the pain of arthritis reside in the joint surface, and that the cause of this pathology is inflammation (hence the suffix “itis”). However, careful palpation around virtually any osteoarthritic joint will reveal tenderness in the ligaments. Further, injection of these ligaments with local anesthetic will generally dramatically reduce, or eliminate, the joint pain in the moment. While inflammation is seen on damaged cartilage surfaces, this inflammation is likely not the cause but a result of cartilage damage due to abnormal joint motion, due to abnormally long ligaments. While osteoarthritis is a multi-factoral disease, it is safe to say

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that the role of ligaments in the genesis of this condition, and as the origin of symptoms, is underestimated.

In a similar manner, damage to the meniscus is generally preceded by laxity of the ACL, evidenced by a positive anterior drawer sign. Tearing of the labrum is accompanied by laxity of the glenohumeral ligament, which is evidenced by significant tenderness in this ligament and abnormal humeral head mobility. Bulging and degeneration of the intervertebral disc is preceded by non-load bearing status in the facet and supraspinous ligaments, evidenced by significant tenderness in these ligaments. If you do not believe this, assess laxity and tenderness in these structures the next time these injuries present, then judge for yourself.

YourBody’sDefenseAgainsttheConnectiveTissueDamageSyndromeY O u R C O n n e C t I v e t I s s u e H e A L I n G s Y s t e m s

What is the body’s defense against the Connective Tissue Damage Syndrome? Collagen repair, which is handled by two distinct healing systems. In actuality, these represent ends of a continuum but they appear on observation to be

two distinct systems. First you are in a continual tug-of-war between damage and healing. Every day you do molecular level damage to structures when you get out of bed. If you work hard, or work out, you will do more damage. Your body is supposed to repair this damage on an ongoing basis and make structures stronger as necessary. The repair system responsible for this daily, ongoing repair will be referred to as the

“Wear and Tear Healing System,” or W/T HS.

The second line of defense is the Acute Injury Healing System (AIHS) which can be observed in operation following major surgery. This system is not “turned on” continuously. It must be triggered by specific factors, and collagen production lasts for about six weeks. It is capable

While inflammation is seen on damaged cartilage surfaces,

this inflammation is likely NOT the CAUSE but a RESULT of cartilage damage due to

abnormal joint motion, due to abnormally long ligaments.



of huge feats of healing. The trigger for this system is a group of chemicals which reside in white blood cells and platelets, collectively called “growth factors.” If these growth factors are released in adequate amount from white blood cells and/or platelets, this six week healing sequence turns on and runs to completion. Prolotherapy is the art of prompting white blood cells and/or platelets to release growth factors and to trigger the AIHS, thereby making possible, huge feats of healing in damaged ligaments, tendons, and other connective tissue structures. It should be noted that Prolotherapy is the only medical specialty devoted to employing this healing system to treat connective tissue damage.

What controls the Wear and Tear Healing System, or W/T HS? A surveillance system is needed which is capable of identifying degrees of local “wear and tear” damage, then responding by triggering the repair process. The white blood cell is the logical mediator for this process since it contains the growth factors, and since its function is to scan the local environment to communicate with other cells in response to various changes in this environment. My theory is that the white blood cells are capable of “reading” the amount of cellular breakdown products in their vicinity. Then they measure out growth factors commensurate with the quantity of these breakdown products. The main event in both systems, from the standpoint of connective tissue healing, is the summoning and activating of fibroblasts, cells which make new collagen.

Most joint pain resolves because the W/T HS takes non-load bearing, painful connective tissue and heals the damage. But this system only has so much healing potential. What happens if a structure accumulates more damage than this system can repair? You develop recurring, or chronic symptoms, which may worsen over time as you continue to use a weakened, vulnerable structure.

The Connective Tissue Damage Syndrome model—pain and other symptoms due to weakened connective tissue, resolution of symptoms due to repair of connective tissue, repair of connective tissue accomplished by the body’s own healing system—easily explains a number of phenomena that baffle patients and practitioners.

What factors might lead to lack of connective tissue healing? As mentioned, connective tissue healing is a white

blood cell function. Though a full discussion of these next two factors is beyond the scope of this publication, they are testosterone and human growth hormone. In order to have proper connective tissue healing, all three factors must be in place. In my experience, lack of testosterone drive for connective tissue healing is rare, but possible, in males. It is quite common in females, and may not be at all coincident with menopause. A deficit in connective tissue healing due to lack of Human Growth Hormone is occasionally seen with a severe sleep disorder.

What would impair output of growth factors by white blood cells? Curiously, the very treatments most com-monly employed for connective tissue injury will accomplish this—ice and NSAIDs. Corticosteroids will accomplish this more powerfully and the effect lasts far longer. Also, anything that diverts significant “immune attention,” such as a severe, unrecognized food allergy, or a chronic infection, can impair connective tissue healing.

Therefore, if someone has a factor which impairs connective tissue healing (e.g. lack of testosterone, chronic NSAID use or corticosteroid use) this disease model predicts that such a person could easily develop recurring or chronic symptoms in spite of (or because of) the treatments commonly offered for these kinds of symptoms. If you want to stop these symptoms, you must activate and optimize the person’s connective tissue healing system(s).

d I A G n O s I n G A n d t R e A t I n G t H e C O n n e C t I v e t I s s u e d A m A G e s Y n d R O m e

How do patients present with the CTDS, and how will you know it when you see it? It is relatively easy, given the above discussion, to understand why a person might undergo shoulder arthroscopy for a bone spur, yet still have pain a year later. The person probably had CTDS in shoulder tendons and ligaments. To find the structures with CTDS, you simply note every tender ligament and tendon in the shoulder on physical examination. Treating the tender structures with Prolotherapy has a very high likelihood of curing this person’s shoulder pain.

More interesting are patients who present with back pain, numbness and tingling going down the outer thigh and calf, back spasms, and MRI findings of disc bulging, degenerative disc disease, and arthritis of the spine. These patients have usually been told that their referred symptoms are due to “sciatica” (or pressure on the sciatic



nerve), and that their back pain is arising from their discs or from pinched nerves. In the vast majority of these patients, all their symptoms are due to CTDS. Treating the tender ligaments in the spine and sacroiliac complex will totally cure symptoms in the vast majority of cases.

Even more interesting are people, usually women, who present with “multi-site connective tissue pain without trauma.” That is they have pain in several sites without an injury to account for the connective tissue damage. These people have often been told that they have “Fibromyalgia.” What they have is a W/T HS that is not working correctly, so that they accumulate damage in ligaments, tendons, and other structures, and develop pain in these various structures. Treatment of these people requires more than triggering healing in damaged structures. In addition, the factors that are keeping their connective tissue healing system from working must be identified and, if possible, rectified. This may be as simple as stopping regular use of NSAIDs, or it may require hormone testing and Bio-Identical Hormone Replacement, or it may involve more extensive testing and treatment. In most cases though, these factors can be rectified and healing can be accomplished.

Evaluating patients for the Connective Tissue Damage Syndrome requires the following steps. First, a practitioner must realize that this disease exists and understand its possible symptoms and findings. Secondly, one must compare the patient’s complaints with those that could be produced by the CTDS. If there is the possibility of CTDS, the structures which might be potentially damaged are determined. A thorough history is obtained—the mechanism of injury, if any, the location of the pain and other symptoms, and the location of any malfunctioning muscles. Thirdly, using knowledge of anatomy and symptom referral patterns, the likely candidate structures are examined in turn. Tender structures are mapped for treatment planning and for future reference to assess treatment results. Fourth, the competence of the healing system is assessed. Factors that may impact the healing system are noted—medications, injury-treatment strategies, possible medical or hormonal problems, etc.—and appropriate testing and treatment are offered. If connective tissue damage is due to undue stress on structures (e.g. bad weight lifting technique, poor posture at the computer), or from abnormal structure (e.g. scoliosis), these factors are identified and patients are counseled regarding strategies to minimize future

connective tissue damage. Prolotherapy is the treatment of choice for CTDS.

Following this simple pattern, patients with CTDS can be treated with great success. This includes patients with severely injured structures, long-term symptoms, one or more “failed” operations, and broad areas of CTDS due to failure of the healing system.

Since the medical community as a whole does not recognize or understand this disease process, a very fair question is “Why not?” There are several reasons. Among them,

It takes much more time to take a good history and to do a good physical exam than it does to make a “diagnosis” by looking at an X-ray. I spend about an hour with each new patient. Although I often look at

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Mark Johnson, MD, examining a patient’s neck for ligament damage.Ligament and tendon injury often does not appear on MRI or X-ray studies, but is noted by tenderness on physical examination.



imaging studies, I have not changed a single treatment plan because of something seen on an imaging study. Physicians misinterpret tenderness on physical examination as inflammation.The various theories about causes of pains (that are actually due to CTDS) are simply that—untested theories. These theories were not embraced based on evidence, but unfortunately they took firm hold in medical thinking. In contrast, the medical literature as a whole presents a very strong case that all of these theories of the sources of joint, neck, and back pain are deficient. Yet doctors, being human, know only what they have been taught and they will try to fit your complaint into one of the diagnostic categories that they “know about.” “If your only tool is a hammer, all the world is a nail.” Put more gently, doctors will not look for something that they are not aware exists, and they will not recognize it when they see it. Fundamentally, this is a paradigm, or mind set, issue. The Dean of Students at my medical school (University of Alabama) said it best. “During your medical school education, you must keep one thing in mind. Forty percent of what you are going to learn is wrong. At this point, we do not know which forty percent. You must never stop learning.” I suppose I have taken his advice by changing careers from Surgeon to Prolotherapist.

In summary, if one wants to assess the presence or absence of the Connective Tissue Damage Syndrome, the most important principle is to understand the symptoms and findings of this disease.

PainTenderness over the affected structureThe possibility of referred pain, numbness, tingling, aching, burningThe possibility of muscle malfunction—weakness or spasmCartilage lossOsteogenesis (bone spurs, arthritic lipping, osteophytes, etc.)Secondary structure damage such as meniscus, labrum, intervertebral discPalpable joint instability

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The second principle is to understand the significance of tenderness during palpation of ligaments, tendons, and other connective tissue structures. This means that connective tissue structural damage is present. It must again be emphasized that this finding does not represent inflammation. I treat every tender connective tissue structure in any area where treatment is requested.

The third principle is to understand that the cure for this disorder resides in the patient’s own healing system. Impediments to connective tissue healing must be removed (e.g. NSAIDs, corticosteroids, ice, etc.) and healing system function may need to be maximized using Prolotherapy. Occasionally medical issues which impair the connective tissue healing system may need to be rectified (e.g. testosterone deficiency).

If these simple principles are kept in mind, the millions of people in this country who are suffering activity altering pain due to the CTDS can be accurately diagnosed and effectively treated in an extremely cost-effective way. Imaging studies are largely unnecessary for diagnosis. Many operative procedures can be replaced by a more effective, and more safe, non-operative treatment, Prolotherapy. And many medications, particularly anti-inflammatory medications which often worsen the very condition they purport to treat, can be replaced by therapeutic strategies which offer cure of the actual disease process. n

The Main Points of an Evaluation for Connective Tissue Damage Syndrome:

• symptoms match up with damaged connective tissues• damaged connective tissues are mapped out for treatment with Prolotherapy• Reasons for damaged connective tissues are assessed• Postural causes of damaged connective tissues are identified and eliminated• Wear/tear healing system is evaluated• Ways to maximize W/t Hs are utilized


F O U R - L E G G E D P R O L O T H E R A P Y : M Y E X P E R I E N C E W I T H P R O L O T H E R A P Y I N A N I M A L S

A B s t R A C t

Prolotherapy has an 80 to 90% success rate of animals returning to normal function, in cases of pain and limping due to ligament injury or joint degeneration. Some of the conditions treated successfully with Prolotherapy by this veterinarian include canine hip dysplasia and anterior cruciate ligament injuries. The author believes that much of the primary causes of animal joint degeneration and ligament injury is multi-factorial including nutritional and genetic factors. The author believes that animals should be fed a diet that is more natural, with less grains, and one that keeps them at a healthy normal weight.

Journal of Prolotherapy. 2009;1:54-58.keYWORds: animals, anterior cruciate ligament, degeneration, diet, hip dysplasia, Prolotherapy.

My Experience With Prolotherapy In AnimalsAn Alternative Answer to Anterior Cruciate Ligament and Hip Dysplasia Degeneration

Roger L. DeHaan, DVM, MTS, CVC

F O U R - L E G G E D P R O L O T H E R A P Y

A s a Holistic Veterinarian, I consider Prolotherapy to be one of the “Silver Bullet” treatments in modern medicine. In the last 18 years I have

treated hundreds of pets, mainly dogs, some cats, and a few horses. It continues to amaze me that when the cause of pain and limping is ligament injury or degeneration, 80 to 90% of the patients return to normal with Prolotherapy. The younger they are, the better the results.

I remember a 6 month-old bulldog with hip dysplasia. This dog was from a long line of purebred winners in the show ring. Problem was, this pup had trouble walking up stairs, much less competing in the show ring. This was one of my first hip dysplasia cases. After six treatments, about two weeks apart, the next thing I heard was this dog was the youngest of his breed to complete his Grand Championship! Since that time I have treated household pets and competition breeds with various types of limping problems. Invariably, the competition breeds return to competition, and many improve their records. All this without surgery, drugs, and without long recuperation periods.

A n t e R I O R C R u C I A t e I n j u R Y ( A C L )

ACL injury and rupture is the number one cause of lameness in dogs. The estimated cost to owners for surgical repair and follow-up was $1.32 billion in 2003.1 That means we have an epidemic on our hands!

“Unfortunately even with surgical management, osteoarthritis develops in most patients, (so that) many patients require treatment for osteoarthritis and this treatment may be required for the duration of the patient’s life.”2 Follow up usually means NSAIDs in combination with weight management. As holistic practitioners, can we do better than that? Can we even think of prevention? Is there a non-surgical answer?

Roger DeHaan , DVM, examining Ginger, a 3 year-old French Bulldog. The hips are both severely subluxated and click on palpation.



I have been using Prolotherapy (proliferative therapy, regenerative therapy) injections for ACL injury for at least 18 years. My success rate is in the vicinity of 90% using this non-surgical therapy. Prolotherapy is as close to a “silver bullet” as anything I have ever tried in 38 years of practice. As a therapy, this technique stimulates the animal’s own natural healing mechanism. The goal is to rebuild and repair injured connective tissue into a stronger and more supportive tissue than it was previously. The end results can be tissue and ligament strength that is 30 to 40% stronger than before the initial injury.

Following my presentation on “Prolotherapy Injections—A Silver Bullet in Connective Tissue and Ligament Reconstruction & Regeneration” at the 2003 AHVMA Conference, 22 veterinarians signed up to take a two day course in Chicago, co-taught by three professionals. The reports from that conference have been encouraging, pleasantly surprising to practitioners as well as their clients. Prolotherapy truly is a technique that veterinarians can easily learn because we already have training in anatomy, injection techniques, and physiology. The questions is, can this go mainstream?

A few months after the seminar I was contacted by Dr. Narda Robinson, who oversees Complementary Veterinary Education at Colorado State University. I shared my information, experience, and a photo with her. The result was a great article in Veterinary Practice News titled “Prolotherapy for Pain Entering Mainstream” (August 2005). Apparently somebody must be catching the vision! Those who catch it first have the opportunity to be on the forefront of an emerging technique that can truly be a blessing.

W H A t I s t H e C A u s e B e H I n d t H e C A u s e ?

Every problem has a cause. Most problems are multi-factorial. I believe ACL rupture falls into this group. Obviously one cause is athletic trauma, or accident induced. However, I believe by far, the majority of these injuries result from chronically weakened ligament structures. Like disc disease in a Doxon, ACL injury can be described as an accident waiting to happen! But why? And why was this problem not as prevalent 40 or 50 years ago? What has changed from then till now?

I would like to introduce a global approach as to the cause and cure of ACL injury. I am proposing that there is a

cascade of events behind chronic ligament degeneration and final rupture. As a starter, one might ask these questions.

Which nutrients are involved?Which supporting glands or organs are involved?Are there emotional stresses involved?Which meridians are involved?

m u L t I - f A C t O R I A L C A u s e s O f A C L d e G e n e R A t I O n A n d I n j u R Y

First Cause: To answer those questions fully will require a shift of paradigms. I believe we have overlooked some key factors. For instance, has there been a change in diet in the last 40 to 50 years that could be part of the explanation? Indeed there has! This change has included a shift from a high percentage of raw and natural food, to some raw and some cooked meat, raw cartilaginous bones and vegetables, finally to a diet based primarily on grains, soy and cheap by-products. The supplementary minerals and vitamins added to this “processed food” have primarily been derived from the soil, inorganic, and synthetic vitamin sources. Could this blend be part of the problem?

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Roger DeHaan, DVM, pointing at the canine spine demonstrating the needle placement and angle.



Second Cause: The bones and ligaments are the primary reserves for vital minerals and buffers. Due to chemical, psychological and physical stresses, the liver and adrenals have been overworked. Both the liver and adrenals require large amounts of sulfur in the methylation process. Due to imbalances in the modern diet, reserve sulfur is drawn from the storehouse of collagen and bone. For survival of the species, and in order to maintain homeostasis, the liver and adrenal get the first choice of vital nutrients, at the expense of the bone and collagen. When the sulfur reserves are depleted, the diagnosis becomes osteoarthritis, hip dysplasia, cruciate ligament injury, etc. But unfortunately that is an end problem, and it does not recognize the underlying root cause. The root cause revolves around a group of inter-related biochemical imbalances having to do with sulfur, vitamin C, selenium, calcium, and other balancing nutrients, which are the cause behind the cause.

Third Cause: There is also a genetic predisposition. I believe that is only 20% of the problem. But indiscriminate breeding and ineffective culling are part of that problem. Add to that a “high-pro” puppy growth formula, often loaded with soy and other cheap proteins that stimulate the “bigger is better” syndrome, and we have created the basis for joint laxity. In essence, we have created a body that is larger than its true genetic potential allows. Thus, breakdown is inevitable. And this is only part of the story.

Fourth Cause: Inflammation predates ligament breakdown and that has various causes. I am convinced the modern canine diet predisposes to a chronic inflammatory condition. Dr. John Symes correctly teaches that the current commercial diets are a primary cause of inflammation. This diet is, for lack of a better word, pro-

inflammatory. Read his presentation on page 241 of the “Proceedings” from the 2005 Annual Conference. Do we then solve this problem by providing daily NSAIDs in order to shut down the inflammatory condition? It shouldn’t take a rocket scientist to figure out that answer. Absolutely not—because inflammation is required for true healing! However, both NSAIDs and steroids have an adverse effect on bone and soft tissue healing by inactivating vitamin D, limiting mineral absorption, and inhibiting collagen synthesis. Thus, inadvertently we have blindly created the wrong type of inflammation by feeding the “Big Four” pro-inflammatory foods (gluten, casein, soy and corn), then we try to shut it down with drugs. That is anti-scientific! We need to get a better handle on this problem. Part of the answer includes Omega 3 essential oils and a total change in dietary philosophy for the carnivore.

A Q u e s t I O n t H A t B e G s t O B e A n s W e R e d

Now that we have been advised by our orthodox friends that ACL injury is the most common cause of lameness in dogs and has become a gigantic billion dollar problem, we as holistic veterinarians have a golden opportunity to stand in the gap and solve the problem! May I also suggest that if we only fix it, we are less than half way to the solution? The true healer looks for causes, corrects the causes, and by that, proves his theory is valid.

The orthodox community is looking for funding in order to understand the causes and solutions. In most cases, funding will go into research that emphasizes surgical and pharmaceutical solutions. May I forward the belief that the true solution has already been discovered? As we

Multifactorial Causes of ACL Degeneration and Injury

• High grain, processed diet• sulfur depletion with biochemical imbalances from diet change• Genetics• systemic inflammation from diet

Roger DeHaan, DVM, administering a Prolotherapy hip injection on Ginger, the French Bulldog.



rediscover the solution, it will require a clear focus in the right direction. I am proposing that the right direction is honoring and duplicating Creation Law as the ultimate foundation of the solution. That means:

Asking and discovering what the canine diet was in the wild. Using their instinct and innate ability to roam and seek to balance their own diet in nature.Implementing and offering an approach that we can sensibly and convincingly duplicate, and teach our clients that solution in a way that is practical and manageable in today’s society.It also means we must control weight, with 40 to 60% of our pets being overweight, opt for optimum size, discontinue the high protein—fast growth puppy formulas, and finally focus on achieving a balanced exercise program. We want them lean, agile, and with good muscle and ligament tone.

This article is offered to provoke thought and reflection. A good article adds to its breath by quoting others. I contacted Dr. John Symes on the subject and here is what he wrote me. Because his comments were so relevant, I am including them here with his permission.

“Interesting. You know how I feel about the “cruciate epidemic.” I certainly believe that it is resulting from the malnutrition stemming from the malabsorption syndrome being induced by the “big 4”...gluten, casein, soy, and corn. The ligaments are not being formed properly, in the same fashion as the rest of the skeleton, heart valves, intervertebral discs, and any other cartilaginous bone, or connection tissue. It is painfully obvious that the dogs with the worst allergies and immune-related disorders have the worst skeletal abnormalities.

Once again, as you know, the formation of the food-related antibodies occur at the time the damage is being done by the “big 4” and serve as the warning sign that this damage is occurring. This damage results in the malabsorption of calcium, vitamin C, B complex, iron, iodine, and trace minerals such as boron, zinc, copper, etc. Therefore we should not be surprised at all that the Shi Tzu and Cocker, two of the most food allergic dogs, hold the record for rupturing discs in their back at one year of age, should we? Similarly, I have repaired cruciates in one year old English bulldogs, perhaps the poster child for food allergies/intolerance if there were more of them. Thankfully there aren’t. Of course, the plight of the large breeds, Labs, Rotties, German Shepherds, is also painfully obvious.

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The interesting thing to me is the timing of the average cruciate rupture. We were taught in school that they occur mostly in 5-7 year old overweight female dogs, right? This is also the same at risk group to what? Immune-mediated diseases. And once again, the breeds at risk are eaten up with “autoimmune” diseases. A term I now no longer use due to the implication that the immune system is attacking the body for no good reason. This of course is totally false. The question is whether the ACL ruptures are due to poor initial formation and subsequent wear and tear, or whether it suffers an immune-mediated attack and fails.

So, are the cruciate problems at an average of 6-7 years a result of wear-and-tear (literally), an immune response to an entity present in those structures, or due to chronic inflammation and degradation by lectins, as in the case of other joint disorders? Ahhh! That would mean that glucosamine and other good lectins would help to protect these ligaments. Sounds like a plan to me!

But the key, once again, is to get these animals, and people, onto diets that are free of the inducers of villous atrophy of the duodenum, in order that their bodies have the adequate nutrients to develop properly. That should be elementary, right? The bonus is that they will also have a more competent immune system to deal with the potential

Roger DeHaan, DVM, using a class II laser treatment as a follow-up to Prolotherapy injections. He uses laser treatments to facilitate healing, decrease pain and inflammation, as a routine part of Prolotherapy in his clinic.



“living challenges” (I put that in quotes due to the controversy over whether viruses are “alive” or not) that we all face, the importance of which we have only begun to understand.

A P R A C t I C A L I n s I G H t

I remember a German Shepherd pair that had a litter of pups, and the entire litter developed significant hip dysplasia within two years. The high grain diet was totally revamped, including supplements to both the breeding pair and their litter. Amazingly the next litter of pups did not develop hip dysplasia. Same dam, same sire, but a different diet! That was a wake-up call to me! This was over 25 years ago, and I don’t have that one documented except in my mind!

We all know of several recent scientific feeding trials where litters of Labs and Goldens were divided into two groups. One based on “free-choice” feeding verses the other given 25% less food than the first group, plus twice daily scheduled feeding. The latter group had significantly less arthritis, better health, and the bonus was a two year longer life span. Those were impressive results.

The implications of our subject are profound, affecting the way we look at nutrition, connective tissue diseases, and autoimmune diseases in general!

m Y P R O L O C O C k t A I L

Each case must be individualized. However, here is a prolo injection cocktail that has worked for me. 25% of each of the following:

50% dextrose2% lidocaine or procaine (without epinephrine)Vitamin B 12 (1000 mcg/ml)Homeopathic combinations such as Biosode Support by HVS Labs, or Tramell, Zeel, or Discus Comp by HEEL.

Of course, as a holistic vet, I often find that chiropractic, acupuncture, and laser therapy compliment Prolotherapy. I also hit hard on the subjects of diet changes and quality joint support supplements. But if I was on a desert island and had just one therapy available, I would I would say I am addicted to Prolotherapy! n


Wilke VL, et al. Estimate of the annual economic impact of treatment of cranial cruciate ligament injury in dogs in the United States. J American Vet Association 2005;227:1604-1607.

IBID. page 1604.

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The high grain diet was totally revamped, including supplements to

both the breeding pair and their litter. Amazingly the next litter of pups did

not develop hip dysplasia.



Cathy A. Skinkis, MA & Ross A. Hauser, MD

Literature ReviewsI T ’ S A W I D E W I D E W O R L D

B esides our authors and readers commenting on their experiences with Prolotherapy, we hope to notify our readership about some of the

more interesting articles published around the globe on Prolotherapy and painful conditions. Ultimately, we all benefit by continuing to educate ourselves on the latest research and publications regarding chronic pain.

Besides letting readers know where to find the noteworthy article on the internet, we hope to publish the article summary and/or abstracts. We will also comment on why

these articles should be of interest to everyone. Please let us know if you have read a good article and it applies to those interested in helping people get out of chronic pain! We may use it in this section of JOP. We know it is a wide, wide world out there and we cannot know of all the articles! JOP ’s mission is to educate the world on the life-changing effects of Prolotherapy. If other therapies or knowledge that will help us in our quest to rid the planet of musculoskeletal pain (as much as we can) is available, then we need to get the word out!

conditions, which is weakened or stretched ligaments or tendons; nor do these treatments provide long term pain relief. We do know that ligaments and tendons have poor blood supply which inhibits much of the body’s own ability to heal injuries to these structures. Exercise alone will help keep the joints moving and may help the overall blood flow to the ligaments and tendons, but in reality, exercise only helps keep the muscles strong and the joints moving, while the degenerative process of the joints still occurs. Sclerotherapy, also known as Prolotherapy, directly addresses not only the lack of blood flow to the ligaments and tendons, but also causes a localized inflammatory response to attract the immune system to repair the weak, stretched, or torn ligaments and tendons through increased fibroblast activity. We have seen many patients through the years who have failed the previously mentioned therapies, yet succeed after a few treatments of Prolotherapy.

As for their preliminary work on growth factors and stem cells, many Prolotherapy physicians, including our office, have been utilizing growth factors retrieved from a patients’ blood samples (PRP) and have seen great results in the repair of not only tendinopathy, but also of labral tears in both the shoulder and hip. n

Treatment of tendinopathy: What works, what does not, and what is on the horizon.

Andres B, et al. treatment of tendinopathy: What works, what does not, and what is on the horizon. Clinical Orthopaedic Related Research. 2008. 466(7):1539-54. e pub: April 30, 2008. http://www.ncbi.nlm.nih.gov/pubmed/18446422?dopt=Abstract

A B s t R A C t s u m m A R Y

The authors performed a review of literature to determine the best treatment options for tendinopathy, evaluating a wide array of treatments, including surgery, growth factors, and stem cell treatment. The outcome was that the results were promising but inconsistent and that more research needed to be done to determine the ideal treatment for tendinopathies.

j O P C O m m e n t A R Y

Treat the underlying cause of tendinopathy, ligament and tendon weakness, with Prolotherapy.

This is a great article about the many traditional and alternative treatments available for the treatment of tendinopathy. As Prolotherapy physicians have known for many years, corticosteroids, NSAIDs, ultrasound, and shock wave therapy do not provide repair or strengthening of the underlying cause of many painful

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five subjects were included. Nonoperated subjects performed significantly better on two of the four tests compared with the ACL-reconstructed subjects at the one-year follow-up. ACL-injured subjects should be informed of the possibility of success after non-operative treatment, but future studies are needed to determine significant predictive factors for success for non-operative and surgically treated individuals.

j O P s u m m A R Y

Could conservative treatment with Prolotherapy be a better option than surgery for ACL-injured patients?

As this article points out, the traditional treatment for the ACL deficient knee is surgery. This study refutes that. The study showed nonoperated subjects performed significantly better on two of the four single-legged hop tests compared with the ACL-reconstructed subjects at the one-year follow-up. The bottom line was that patients treated conservatively (exercise and no surgery) did just as well as those who underwent surgery. Our question is what would results would we see with doing Prolotherapy in the knee including the ACL (assuming incomplete tear), as well as the other supporting structures, plus proper rehabilitation? We suspect this approach would show a significant improvement over surgery based on our clinical experiences in treating ACL-injured knees. n

What is the clinical course of acute ankle sprains?A systematic literature review.

van Rijn R. What is the clinical course of acute ankle sprains? A systemic literature review. American journal of medicine. 2008;121(4):324-331. http://www.ncbi.nlm.nih.gov/sites/entrez


A database search was conducted by reviewing literature related to subjects who suffered from an acute lateral ankle sprain conventionally treated with one of the following outcomes: pain, re-sprains, instability, or recovery. Thirty-one studies were included. After one year of follow-up, a high percentage of patients still experienced pain and subjective instability, while within a period of three years, as much as 34% of the patients reported at least one re-sprain, and from 36% to 85% of the patients reported full recovery within a period of three years.

j O P s u m m A R Y

Another option for ankle sprain healing? Prolotherapy?

The most common ligament injury is the ankle sprain. How well do ankle sprains heal? According to this study, they do not heal very well. Clearly three years after the injury, many people remain in pain with a high re-sprain rate. While no Prolotherapy study to date has shown whether ankle sprains remain healed with Prolotherapy, the clinical experience of Prolotherapists is that ankle sprains that are treated with Prolotherapy remain healed. n

Performance-based functional evaluation of nonoperative and operative treatment after anterior cruciate ligament injury.

moksnes H, et al. Performance-based functional evaluation of nonoperative and operative treatment after anteriorcruciate ligament injury. scandinavian journal of medicine & science in sports. Online publication may, 2008.http://www3.interscience.wiley.com/journal/120122913/abstract


The objective of this study was to compare the functional outcome after nonoperative treatment to individuals versus those with surgical treatment at a one-year follow-up. One hundred and twenty-

The roles of growth factors in tendon and ligament healing.

molloy t, et al. the roles of growth factors in tendon and ligament healing. sports medicine. 2003; 33(5):381-94. http://www.ncbi.nlm.nih.gov/pubmed/12696985


This review covers some of the recent investigations into the roles of five growth factors whose activities have been best characterized during tendon healing: insulin-like growth factor-1 (IGF-1), transforming growth factor beta (TGF-beta), vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), and basic fibroblast growth factor (bFGF). This review also covers some of the most recent studies into the use of these molecules as therapeutic agents to increase the efficacy and efficiency of tendon and ligament healing. The abstract reviews how these

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growth factors affect healing, particularly related to cellular proliferation and collagen synthesis.

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How does Prolotherapy work? This article will enlighten you.

We are often asked the question, “How does Prolotherapy work?” This article will provide some answers. Growth factors clearly enhance tendon and ligament healing, as does Prolotherapy. One of the proposed mechanisms by which Prolotherapy “proliferates” tissue is by enhancing growth factors in the area treated. With human growth hormone and platelet rich plasma now available to use as proliferants in our Prolotherapy solutions, some of these growth factors can actually be injected directly into the injured areas to even further enhance healing. This is a good article to read to glean more of the proposed “biology” of Prolotherapy. n

with knee joint laxity and osteoarthritis possessed lower muscle strength and were more disabled. This goes along with the philosophy of most Prolotherapists that the ligaments must typically be treated in people with osteoarthritis. One of the reasons for this is due to the fact that it is the joint laxity that causes the muscle spasm and leads to the osteoarthritis. Both the muscle spasm and overgrowth of bone (osteoarthritis) are the body’s attempt to stabilize a loose joint. Eventually enough bone overgrows that the joint loses motion.

Many reading this article might conclude that what is needed for patients with osteoarthritis and knee pain is muscle strengthening in the legs. This is a given. However, what most will miss is the fact that the joint laxity must also be treated. In our opinion the best option for this is Prolotherapy. n

The use of Prolotherapy in the sacroiliac joint.

Cusi m. the use of Prolotherapy in the sacro-iliac joint. British journal of sports medicine. April 9, 2008. e-published ahead of print.http://bjsm.bmj.com/cgi/content/abstract/bjsm.2007.042044v1


An author’s private practice examined whether Prolotherapy was effective in the treatment of deficient load transfer of the SIJ. The treatment given was three injections of hypertonic dextrose solution into the dorsal interosseous ligament of the affected SIJ, under CT control, six weeks apart. This descriptive study of Prolotherapy in private practice has shown positive clinical outcomes for the 76% of patients who attended the three months and 12 months’ follow up visits and for the 32% of patients who attended follow up visits at 24 months. The findings of this study warrant further research.

j O P s u m m A R Y

Prolotherapy shows remarkable improvement in patients with SIJ pain!

This study reported improvement among 76% of their treated patients with only three injections into the dorsal interosseous ligament. This is remarkable! It could also be argued that if the entire sacroiliac

Joint laxity and the relationship between muscle strength and functional ability in patients with osteoarthritis of the knee.

van der esch m, et al. joint laxity and the relationship between muscle strength and functional ability in patients with osteoarthritis of the knee. Arthritis Rheum. 2006;55(6):953-9. http://www.ncbi.nlm.nih.gov/sites/entrez


This study was done to establish the impact of knee joint laxity on the relationship between muscle strength and functional ability in osteoarthritis (OA) of the knee. Tests were performed to determine varus-valgus laxity, muscle strength, and functional ability. Patients with knee OA and high knee joint laxity show a stronger relationship between muscle strength and functional ability than patients with OA and low knee joint laxity. Patients with OA, high knee joint laxity, and low muscle strength are most at risk of being disabled.

j O P s u m m A R Y

Weak ligaments need to be treated in osteoarthritis patients.

The bottom line here is this study showed that people

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concluded that arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy.

This is another landmark study which will hopefully put a nail in the coffin for “clean-up” arthroscopies. It is the Journal of Prolotherapy’s opinion that degenerative knee arthritis causing symptoms is better treated with Prolotherapy than arthroscopy, lavage, cortisone shots, and physical therapy. While arthroscopy for specific reasons, like complete ACL tears, has its place, its role in degenerative arthritis is extremely limited. After this study, one could even argue that there is no role.

This study shows us that arthroscopic surgery for OA of the knee is not the best treatment option. As we have seen, surgery for OA should be saved as a last resort therapy once Prolotherapy, physical therapy, and other regenerative therapies have been exhausted. What an OA patient really needs is Prolotherapy with HGH which not only addresses cartilage growth, but also the overall strengthening of ligaments and tendons around the entire joint. Physical therapy can also be helpful to regain muscle strength which many OA patients have lost while looking for a solution to their pain. n

joint with all of the connecting ligaments were injected that an even more positive outcome would result. We commend these private practice clinicians for using their own time and funds to show the world that Prolotherapy should indeed be the treatment of choice for patients suffering with SIJ problems. n

A randomized trial of arthroscopic surgery for osteoarthritis of the knee.

kirkley A. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. The New England Journal of Medicine, 2008;359:1097-1107.Abstract: http://content.nejm.org/cgi/content/short/359/11/1097


The efficacy of arthroscopic surgery for the treatment of osteoarthritis of the knee is unknown. A single-center, randomized, controlled trial of arthroscopic surgery in patients with moderate to severe osteoarthritis of the knee was conducted. Patients were randomly assigned to surgical lavage and arthroscopic debridement together with optimized physical and medical therapy or to treatment with physical and medical therapy alone. Of the 92 patients assigned to surgery, six did not undergo surgery. Of the 86 patients assigned to control treatment, all received only physical and medical therapy. After two years, outcomes failed to show superiority of surgery. Arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy.

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Arthroscopic surgery does not work for osteoarthritis of the knee.

Of the 1 million arthroscopic surgeries in the United States every year, about one third of them are performed for degenerative arthritis. In this study, patients with moderate to severe osteoarthritis were randomly assigned to receive surgical lavage and arthroscopic debridement together with optimized physical and medical therapy or to treatment with physical and medical therapy alone. A total of 86 patients in each group were assessed after two years by various standardized questionnaires. The authors

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S K I L L E N H A N C E M E N T : S E M I N A R S , T R A I N I N G , & O R G A N I Z A T I O N S

Seminars, Training, & OrganizationsS K I L L E N H A N C E M E N T

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La Ceiba and Tela, HondurasThe Hackett Hemwall Foundation organizes a groupof physicians, nurses and assistants for a working,educationaltriptoHonduraswhereamixofexperiencedand novice Prolotherapists see a large number ofpatients.Datetobedetermined. Email Mary for more information:[email protected]

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Thessalonki, GreeceThe Medical Acupuncture Society of Northern Greece isholding the International Congress in Medical Acu-puncturewhichwillfeatureasectiononNeuralTherapyandProlotherapy.HeldattheGrandHotelPalace.

For more information:www.icmart2009.org

Notice to meeting organizers: If you are sponsoring a Prolotherapy meeting or training session, please email: [email protected] for a free listing of your meeting.

O R G A n I z A t I O n s

American Association of Orthopedic Medicine (AAOM)600PembrookDrive,WoodlandPark,CO80863Phone:888-687-1920Fax:719-687-5184www.aaomed.org

The Hackett Hemwall Foundation2532BaldenStreet,Madison,WI53705USAwww.HackettHemwall.org

GetProlo.comBeulahLandCorporation715LakeSt.Suite400OakPark,IL60301Phone:708-848-5011Fax:708-848-8053www.getprolo.com

The American Academy of Osteopathy3500DePauwBlvd,Suite1080Indianapolis,IN46268Phone:317-879-1881Fax:317-879-0563

Do you offerProlotherapy

Physician Trainingin your office?

Contact the Journal of Prolotherapyfor a free listing today!

[email protected]

Doctors

PatientsT E L L U S Y O U R S T O R I E S

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[ for Doctors & Patients]

[ J O U R N A L of P R O L O T H E R A P Y . C O M ] [ 7 0 8 - 8 4 8 - 5 0 1 1 ]

Calling all Prolotherapists! Do you have a Prolotherapy article

you would like published in the Journal of Prolotherapy?

We would love to review it and help you share it with

the world! For information, including submission

guidelines, please log on to the authors’ section

of www.journalofprolotherapy.com.

The Journal of Prolotherapy is unique in that it has a target audience of

both physicians and patients. Help spread the word to other people like

yourself who may benefit from learning about your struggle with

chronic pain, and first-hand experience with Prolotherapy.

For information on how to tell your story in the Journal of

Prolotherapy, please log on to the contact section of

www.journalofprolotherapy.com.

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