Microsoft word - prolotherapy for podiatrists v3 part 2c
Prolotherapy for Podiatrists - part 2 Basic Premise, History, Agents and Techniques Martin Harvey BSc(Hons) MInstChP Introduction
In the first part of this article we examined the mechanisms of injury and
normal physiological repair in Dense Connective Tissue (DCT). The
common misconception of treating what may often be a virtually non-
inflammatory condition with anti-inflammatories and further compromising injected with agents such as the chance of a physiological healing cascade developing in a reasonable
Basic premise of prolotherapy
The simple basic premise of prolotherapy is that a sustained and
closes the vein(27).
physiologically structured healing cascade is required in order to repair
damaged DCT. In instances where a healing cascade has not commenced,
Glucose is currently the hyperosmolar agent of choice of many
prolotherapy seeks to initiate and maintain one.
prolotherapy practitioners and research supports its efficacy as a cytokine
expressant due to its interference with cellular osmolality (28) (29). A solution
of 20% W/V glucose for injection combined with 1% W/V Lidocaine
The term prolotherapy was suggested in 1956 by the American Physician
Hydrochloride (formerly Lignocaine) is advocated by many acknowledged
Dr George S Hackett, in his book; Ligament and tendon relaxation treated
experts including the Australian prolotherapy tutor, Dr Margaret Taylor
by prolotherapy(19). There are much earlier references to the use of
(Margaret’s website, Prolotherapy for Doctors, : www.drmtaylor.com.au
‘sclerosing injections’ and ‘sclerotherapy’ to treat a variety of DCT
contains much interesting information). In New Zealand the researcher and
pathologies, and Rice and Aratson in their 1936 work(20) anecdotally refer
clinician Dr John Lyftogt advocates a stronger glucose component but in
to a Dr Jaynes of Louisiana in the early part of the 19th Century introducing
contrast Dr Giresh Kanji a pain specialist from NZ advocates simple
undisclosed irritants into hernias in order to stimulate healing.
normal saline for injection plus an anaesthetic without glucose (Giresh’s
website is: www.southerncrosspain.co.nz ).
The concept of irritating tissue to stimulate healing by causing
inflammation is much older, and can certainly be traced back to the writings It is interesting to speculate whether 1% lidocaine hydrochloride, which of Hippocrates in the 4th Century BC(21). In this instance the inflammation
also contains 0.7% of sodium chloride in its standard formulation may have
was caused by using slim heated irons; Kauterion, which, in the case of lax
a prolotherapeutic effect in its own right when used alone. This is perhaps
ligaments in the shoulder, were thrust red hot into the tissue in order to
an area that requires more research and properly constituted studies.
cause scarring. The scarring (as we note in keloid scars today) promoted
thickening and contraction of the tissue(22).
Other substances that may be used to good effect are the injectable
homeopathic solutions such as Zeel or Traumeel (popular for sports injuries
By the early to mid 20th Century, sclerotherapy was being used to treat
due to a lack of doping / drug test conflicts) which are manufactured in
sprained spinal and other ligaments, hernias and varicose veins(23). The
Europe by Heel GmBh of Baden Baden. Homeopathy is a contentious
importance of using a local anaesthetic, as an aid to patient comfort, was
subject in medicine with strong opinions being held by both its supporters
highlighted by Leriche in 1937, who identified the rich supply of sensory
and its detractors. The Author frequently uses homeopathic agents and
nerve endings in ligaments and articular tissues(24). Steindler and Luck, in
must report that they do appear to have a significantly beneficial effect with
their research into lumbrosacral pain, built on Leriche’s principles and in
virtually no possibility of side effects.
1938 advocated infiltration of local anaesthetic into lumbrosacral ligaments
in order to abolish pain in both the ligament and the dermatome served by
Direct application of growth factors
its adjacent nerve root(25). They also established the principle of using local
An additional way that is currently being explored by many researchers is
anaesthetic as a diagnostic tool to precisely identify the area of damaged
to directly introduce growth factors or the cells carrying them, by injection
into the area of damage. Cytokine research is one of the fastest growing
areas of biological study and new information is being gleaned in this area
Current methods of Prolotherapy that seek to induce healing:
almost daily. An insight into the vast amount of information already
discovered can be assessed by visiting the famous website of Professor
Horst Ibelgaufts ‘Cytokines and Cells online pathfinder encyclopaedia’
The ‘traditional’ prolotherapy method of Hackett and his followers is to
(http://www.copewithcytokines.de/). This monumental source of
induce an inflammatory response in the area of damaged tissue by
information is now in its 19.4th version and has tens of thousands of entries
introducing irritants that will ‘stress’ the cell population and initiate
on these fascinating proteins and similar chemical messengers.
cytokine expression. It is important to differentiate here between the non
tissue destructive stressing or shocking of a cell in prolotherapy and tissue
Commercially prepared growth factors are probably outside the remit of
destruction and subsequent formation of scar tissue which occurs in
this article as costs are somewhat high, e.g. : the cost of frozen PDGF for
1mg is; $3,400 + tax & shipping. Enquiries to: GenWay Biotech, Inc. 6777 performing prolotherapy need to have an excellent knowledge of the Nancy Ridge Drive, San Diego, CA 92121
structure that they are working upon. Also, all procedures should be carried
out with due care and an aseptic injection technique.
Examples of pathologies suitable for prolotherapy Autologous whole Blood
Conditions to which prolotherapy could possibly be applied by Podiatrists
There is recent research that suggests that a few ml’s of a patients own
familiar with its mechanism of use include; hammer toes, hallux abducto
blood, freshly harvested from a suitable vein (the inner brachial point is
valgus, neuromas, sprained ligaments in the tarsus, and ankle inversion
usual) can be infiltrated into sites of damaged DCT and used to initiate a
sprains affecting the talofibular and deltoid ligaments. In the Achilles
healing cascade. Studies in both the UK and the USA have taken place on
region it may help both acute tendinopathies and chronic tendinoses if
its use in lateral epicondylitis (tennis elbow) with encouraging results(30).
administered outwith the tendon in the lateral and medial areas to bathe the
Naturally, the limiting factor in this case is the speed with which fresh
paratenon. Currently (2007) the use of prolotherapy in tendinopathies is
blood coagulates. To overcome this it is possible to mix an anticoagulant
being further investigated by Kent Sweeting, research fellow in Podiatry at
with the blood as it is withdrawn, in the same ratio as used in transfusion
Griffith University School of Medicine, Brisbane. Kent’s research has been
funded by the Australian Podiatric Education and Research Foundation.
Refined preparations from Autologous blood
In the area of the Knee, the lateral and medial collateral ligaments and the
There is an increasing amount of published research appearing on the use of coronary ligaments at the anterior lip of the tibial plateau are frequent sites Platelet Rich Plasma (PRP), including its use in surgery , wound healing,
of palpable pain and easily infiltrated with a prolotherapy solution.
osteoarthritis and dentistry(31) plus its application in DCT pathologies such
as plantar fasciitis(38).
In most cases the patient will suffer, at worst, a mild soreness at the site of
prolotherapy as the healing cascade takes effect(39) A skilful technique can
minimise this. The intelligent use of concurrent modalities that Podiatrists
follows, a sample of the patients own blood
should be familiar with such as orthoses to minimise inappropriate joint
is collected and by a process which includes
movements, and advising on nutritional supplements such as Zinc and
centrifugation, a platelet rich supernatant
Manganese which are increasingly reported to benefit DCT healing(40)
(the liquid above a sediment or precipitate)
can also be considered. Additionally, advice on footwear and exercise
is prepared. The PRP fraction is withdrawn
should be considered as part of an overall treatment strategy(41)
and injected using the prolotherapy method,
In examining the safety of such procedures, Dr Tom Dorman conducted a
There are already commercial kits for this process but some involve ‘open
retrospective analysis of 494,845 patients(42) and reported no fatalities. It is
processing’ which may give rise to the possibility of contamination of the
worth pointing out that the majority of the few problems recorded were
products. However, Cascade Medical Inc market a CE marked PRP
overwhelmingly in areas of the body far outside the remit of the Podiatrist,
preparation kit, that shows particular promise and a study of its use in
ie: pneumothoraces due to cannulation of the chest wall and spinal cord
podiatric prolotherapy is currently in hand. The kit features a sterile
damage. Also, the study records that many of the procedures had used overt
evacuated blood collection tube that can be used with a suitable centrifuge
sclerosants rather than simple local anaesthetic and glucose or other agents
to prepare platelet rich plasma for injection. Apparatus supplied with the kit with a low toxicity potential. also allows the plasma to be easily transferred to another sterile tube
containing additives that permit either an autologous platelet gel or a semi
Although not advocated here, even the use of sclerosants such as P2G and
solid platelet rich fibrin scaffold to be manufactured by further
polidoconol has been identified by a 2006 report by the UK National
centrifugation. The gel has particular relevance in the treatment of lower
Institute of Clinical Excellence (NICE) to be safe and entirely free from
limb wounds such as ulcers. (see: http://www.cascademedical.com )
fatalities(43) and again, the use of these far more potentially toxic agents is
primarily in area’s of the body capable of much greater complications than
The method of prolotherapy solution application
the easily identified joints , peri articular ligaments, tendons and entheses
Once the needle has been inserted into the area to be treated it is repeatedly
partially withdrawn and then repositioned in a slightly different part of the
area of treatment with a tiny amount of the prolotherapy solution being
It is also perhaps worth considering that UK Chartered Physiotherapists
deposited at each point. This is essentially the ‘peppering’ technique
have been injecting joints, ligaments and tendons all over the body with
advocated for steroid injection by the British physician Dr James Cyriax(26)
local anaesthetics and steroids since around 1995. Whilst there was
When the needle contacts bone it should be withdrawn very slightly before
substantial opposition initially from entrenched medical opinion, and
a deposition takes place. Bone contact should be done very gently because
indeed the older more conservative elements in their own profession, this
the periosteum surrounding a bone is rich in nerve endings and it is
has gradually faded before the impressive safety record of the many
exceptionally painful if forcefully traumatised without adequate analgesia .
hundreds of Physiotherapists performing tens of thousands of effective soft
tissue injections for more than a decade (44)
It is believed that the effects of ‘needling’ alone, apart from the solution
used may be beneficial due to micro-haemorrhage and physical damage to
Availability of suitable prolotherapy substances
cells causing growth factor release. This may be an explanation for the
The Local Anaesthetics currently permitted to Podiatrists trained and
reported efficacy of the deep acupuncture technique known as ‘pecking the
licensed in their use are entirely suitable for prolotherapy. The literature on
bone’. In certain instances ‘Dry Needling’ alone may be sufficient to
the subject(45) often suggests the use of a plain 1% solution of lignocaine
provoke inflammation and subsequent healing. It is obviously more
(Lidocaine). The author usually uses this, often diluted to as little as 0.2%
comfortable if done under local anaesthesia. Naturally, Podiatrists
in the prolotherapy solution. Firm palpation with the thumb is the usual
‘tool’ used in identifying the exact location of damaged tissue in ligament
Rice CO., Aratson., Histologic changes in the tissue of man and animals following
damage and conditions such as plantar fasciitis. To subsequently find the
the injection of irritating solutions intended for the cure of hernia’s. Ill Med. J. 70:
exact point that is giving pain 3% Mepivicaine hydrochloride can be a
useful ‘diagnostic analgesic’, due to its speed of action. When the patient
“It deserves to be known how a shoulder which is subject to frequent dislocations
reports that the pain has been ‘turned off’ the clinician knows the exact spot
should be treated……. The cautery should be applied thus: taking hold with the hands of the skin at the armpit, it is to be drawn into the line, in which the head of
to concentrate their prolotherapy application in. The pre-existing analgesia
the humerus is dislocated; and then the skin thus drawn aside is to be burnt to the
will also make the multiple needling of the treatment itself much more
opposite side. The burnings should be performed with irons, which are not thick nor
tolerable. In situations where longer duration of action is required then
much rounded, but of an oblong form (for thus they pass the more readily through),
Ropivicaine or Bupivicaine Hydrochloride 0.5% plain (Marcaine) may be
and they are to be pushed forward with the hand; the cauteries should be red-hot, that they may pass through as quickly as possible; for such as are thick pass through
used additionally, possibly post - treatment. The long duration of Marcaine
slowly, and occasion eschars of a greater breadth than convenient, and there is
(up to 6hrs anaesthesia and 24hrs analgesia) may be useful to provoke de-
danger that the cicatrices may break into one another; which, although nothing very
sensitisation where ‘pain wind up syndrome’ (dorsal horn hyperalgesia) is
bad, is most unseemly, or awkward” from: Hippocrates. Works – on the articulations; section XI. Francis Adams (trans) London 1849.
suspected. A local or Hospital pharmacy is a good source of some of the
less commonly used analgesics that podiatrists can use, such as Ropivicaine 22.
Hippocrates. Works – on the articulations; section VIII. Francis Adams (trans)
or Marcaine, which is not stocked by many podiatry suppliers.
Hackett GE., Joint stabilisation through induced ligaments sclerosis. Ohio State
Glucose needs to be suitably diluted to around 20% W/V with water for
Medical Journal, 1953, vol 49: pp. 874 – 884.
injection or with the LA itself. At the time of writing (2007), glucose
solution is a Prescription Only Medicine (POM) that is not on the list of
La Chirurgie de la Douleur. Paris: Masson, 1937. English translation by Archibald
Young (1873-1939), Regius professor of surgery at the University of Glasgow: The
POM’s available directly to podiatrists. However, its use can be supported
by either a Patient Specific Direction (PSD) or a Patient Group Direction
(PGD) from an independent prescriber. A discussion with the patients GP is 25.
Steindler A. Luck JV, Differential diagnosis of pain low in the back . J.A.M.A. 110:
recommended to obtain a suitable prescription.
Cyriax J.H., Cyriax P.J., Illustrated Manual of Orthopaedic Medicine.
As the glucose is manufactured for intravenous use and not for infiltration,
prolotherapy is an ‘off label’ use. Again, it should be stressed that the fact
Parsons ME.: Sclerotherapy basics. Dermatol Clin 2004 Oct; 22(4): 501-8.
of any substance being used ‘off label’ under a PSD or PGD by registered
Podiatrists is perfectly permissible, and in pain medicine it is estimated that
Banks A., A Rationale for Prolotherapy. J. Orthop. Med 13;54-59,1991
over 25% of all substances used are actually used ‘off label’(46)
Di Paolo S., et al: High Glucose concentration induces the over expression of TGF – beta through the activation of a platelet derived growth factor loop in Human
The injectable homeopathic agents referred to here are available to
mesangial cells. Am J Pathol 149; 2095 – 2106, 1996.
registered Podiatrists from BioPathica Ltd : (http://www.biopathica.co.uk/ . BioPathica Ltd PO Box 21, Ashford, Kent TN23 6ZU Tel: +44 01233
Sri Priya S Suresh , Kaline E Ali , Hugh Jones and David Connell. Br J Sports Med. Published Online First: 21 September 2006. doi:10.1136/bjsm.2006.029983
Marx R, Carlson E, Eichstaedt R, et. al: Platelet-rich plasma: growth factor
Prolotherapy is a simple technique once the practical skills of
enhancement for bone and grafts. Oral Surgery, Oral Medicine, Oral Pathology 85(6):643-646, 1998.) and surgery (Cohen I, Diegelman R, Yager D, et, al: Wound
administration have been acquired. It’s documented success rates and
Care and WoundHealing, “in Principals of Surgery, ed by I Seymore, S Schwartz, T
safety record suggests that it deserves consideration as a modality that may
Shires, F Spencer, A Galloway, pp.263-196, New York, 1999.)
be suitable for trained Podiatrists to perform in a standard surgery situation.
(Barret S L, Erredge S E,. Growth factors for plantar fasciitis. Podiatry today.
A knowledge of the substances used, their methods of action and contra-
indications, familiarity with the structures being treated and the mechanical
Linetsky FS, Miguel R, Saberski L. Pain Management with Regenerative
techniques of administration can be acquired in suitable workshops by
Injection Therapy. In: Weiner RS, American Academy of Pain Management. Pain Management: A Practical Guide for Clinicians. 6th Ed. CRC Press. 2002.
Podiatrists already trained in the safe injection of local analgesics which is
US National Institutes of Health, Office of Dietary supplements, Zinc, Manganese.
Author, personal observation on the use of concurrent modalities.
Further information, including details of prolotherapy workshops for LA
qualified podiatrists is available from the author if required:
Dorman, T., Prolotherapy: A survey. Journal of Orthopaedic Medicine. 1993; 15.
Xueli J., et al: Systematic review of the safety and efficacy of foam sclerotherapy for venous disease of the lower limbs : Interventional procedures program. National
Institute for Clinical Excellence. Health Services Research Unit, University of
Aberdeen: PP 26 – 31. Table 10 P32. Published Nov 2006.
Saunders S., Longworth S., Injection Techniques in Orthopaedic and Sports Medicine - A practical Manual for Doctors and Physiotherapists.
B77 1PQ, United Kingdom. email: [email protected]Ligament and Tendon Relaxation Treatedby Prolotherapy, 5th ed. Oak Park, IL, Gustav A. Hemwall, 1992.
References and Bibliography The use of Drugs beyond licence in palliative care and pain management. A
Hackett GS., Ligament and tendon relaxation treated by prolotherapy. Charles C
position statement prepared on behalf of the UK Association for Palliative Medicine
and The Pain Society via the Royal College of Anaesthetists 2005.
Comprehensive Land Use Planning DRAFTING THE ZONING ORDINANCE Zoning is the division of a community into zones or districts (e.g. commercial, residential,industrial, institutional, etc.) according to the present potential uses of land to maximize,regulate and direct their use and development according with the CLUP. It takes theform of a locally enacted ordinance which embodies among othe