Our next speaker is Dr. Joanne Bordsheim coming to us from Harvard Spaulding System. She's really an authority in the field, and if you didn't get a chance to see her talk on this topic, it was last year or the year before on prolotherapy. It was the Password Legacy Award Lectureship. The slides are actually available through AAPM on our website, and phenomenal talk. It'll go into more detail, and we'll hear from her today for some updates. Really an authority in this field. She's lectured on it nationally. She's a director of the sports medicine program at Spaulding. Ran the fellowship there for a number of years, and has sent out disciples throughout the country, and I'm proud to say one of them is at Baylor. So I'd like to welcome Dr. Joanne Bordsheim. Thank you. Okay, is there any pointer? The red one? Can you guys see the pointer? Well, good morning everyone. Okay, how's that? Awesome. Good morning everyone. So glad to see everyone here and thank you to Jerry and Prathap for putting this together. And Bill, great intro talk and thank you for putting us a little ahead of schedule so that I can have a few more minutes to ramble a bit on prolotherapy. I have no disclosures. I have no vested interest in the dextrose production in this United States. Okay. So the goal of my presentation this morning is to go over a basic overview of prolotherapy, how, quote, sugar water may work in healing musculoskeletal injuries and the current state of scientific knowledge in this field and mostly how and when to apply this in practice. Just because this is an older technique doesn't mean it should be put on the shelf and forgotten about. And I'm going to try to take you over the next 45 minutes or so on a little bit of a journey as to how we use it practically, how we integrate it in addition to other orthobiologics in any one patient and what the approach is when you use prolotherapy. Okay. Do this. I'm supposed to move. Oh, I understand that. I'm just trying to get this to forward. It's not forwarding. Oh, I see. Okay. It's easier if I come out here. Okay. Let's make a deal. All right. So similarly to Dr. Macheo, I myself am trying to stay active as I mature. And there's a whole world of people out there in this country who similarly are trying to do so. And really what we're trying to do is see what we can do perhaps even to prevent this progression but certainly to manage the journey so that people can stay active. And we also know that arthroplasties don't last forever. So we like to try to push it down, kick the can down the road a little bit if we could so that if someone needs arthroplasty, hopefully it's one and done. Also, I've been a part of this wonderful journey as over the past decade or more, we've all advanced our skills. The technology in ultrasound has become so fabulous that we're seeing small tears and defects that even aren't visible on MRI. And this has allowed us to push the envelope. So even the prolotherapy I learned 15, 20 years ago was all by palpation. And valuable as that is, it's a whole new world to be able to combine that with ultrasound. And we've also borrowed our techniques from veterinary surgical medicine or other surgical fields as well. And this is super, super, there are only a couple of things I really hope you remember today even if you forget about one specific aspect of prolo. And that is we've gotten smarter. So the way prolo was initially taught, we talk about sort of the whole kinetic chain. They teach you to palpate all around using the knee as an example. Prolotherapy is generally not a simple intra-articular injection anywhere. It's a regional treatment. We palpate, we look at the biomechanics. And that has dovetailed with increased knowledge about what causes pain. I'm using knee arthritis as an example. But in any pain syndrome, there are going to be not only joint issues, there'll be sensitized retinacular structures, tendon structures, ligament structures, menisci. And all that needs to be factored in. So one thing I'm hoping you'll take home today is that whatever you put in that syringe, whether it be PRP, prolotherapy, orange juice, or all I care, that the approach to the patient is more global and comprehensive so that you get the best results from your orthobiologic treatments. I'm sorry, this isn't advancing. So this is just a schematic using the knee as an example. Of course, here's the patellofemoral and the femoral tibial joint. But just using the medial knee as an example. I don't have to teach you this, you know this. But to bring it to the forefront that these soft tissue structures around the knee need to be considered and treated when you're doing prolotherapy or any orthobiologic treatment. Prolo means to proliferate. And a variety of injectates can be used. And the way these are presumed to work is to initiate, or in other words, restart a healing or collagen deposition response. And as I alluded to, the targets for prolotherapy are multiple. They're not only the bone or joint itself, but they're the enthesis, the tendon, the tendon attachments, the ligaments, the joint and cartilage, and yes, even the nerve. Like all these orthobiologic treatments, prolotherapy has been in the news sometimes with fairly famous people. In the Wall Street Journal, in the New York Times, which is where I get a lot of my good medical information. There have been some articles which brought it to the forefront. And in Boston, there's an orthopedic surgeon who doesn't operate, who does, I guess, only prolotherapy. And he advertises so much on the radio that I've seen so many more patients coming in asking for prolotherapy. So a little advertisement goes a long way. And this was actually developed in the 1950s. There was a trauma surgeon named George Hackett, who was healing up all these injured situations and realized that there was still a lot of pain and disability related to the soft tissues that weren't being healed. And then also got some press when C. Everett Koop was treated for his chronic back pain. And started again getting out into the lay press. Over the years, if you've watched the research, I've got to give a shout out to the folks at Virginia Tech and especially University of Wisconsin. Their family medicine group has been extremely good at looking at double-blind trials and educating us on aspects of prolotherapy research. How come this doesn't forward? Point it there. Oh, okay. As with everything in life, precision is important, right? Okay. So also, we're all about the terminology. And you'll see different advertisements for different courses and you'll wonder what they're talking about. So Dr. Reeves is a colleague out in Kansas. He has a website that you might want to refer to. He has embedded in it many articles, a lot of the research articles. But I just want to make sure we're all talking the same language. So there's this generic term, biological repair therapy, which just means we're using some biologic agent to try to repair connective tissue. Doesn't tell you what. Second is prolotherapy, which is an injection to repair connective tissue. But generally, when folks are talking about this, we're not talking about other biologic agents such as PRP or bone marrow or fat. Thank you for turning that up. PSI, perineural subcutaneous injection, there was also another term called neural prolotherapy. Have you guys heard about this? Yeah. Okay. There's a guy, Dr. John Lifcott, who kind of made this famous, goes around the world teaching it. And he really looks more at the neurologic and neurogenic inflammatory cascade to manage pain as part of a prolotherapy spectrum. And then there's another term called GDI, if you will, or hydrodissection or perineural deep injection. And this is where we use ultrasound to hydrodissect around nerves in and around an area that may be painful. This is often done or can be done with a more diluted 5% dextrose concentration. But what these techniques all share is they use some form of dextrose in and around an injured or painful area to reduce pain and improve healing and function. Okay. Proposed mechanisms. We'll kind of run through this. There are plenty of articles out there, and I've referenced these in your handout. So a couple of things that have been noticed is growth factor, elevation, a stimulation of the healing cascade. And when prolotherapy is done, the needling effect and the needling technique is key. And also with the 5% dextrose techniques, we're looking at the effect of the 5% dextrose techniques. We're looking to reduce neurogenic inflammation and pain. Some of the growth factors that have been shown to be released with prolotherapy activation include all the alphabet soup you know about, platelet-derived growth factors, TGF, cartilage growth factors as well. And dextrose, the amounts that you use can vary in concentration. So people talk about sort of a low inflammatory or non-inflammatory prolotherapy, which has been shown in studies to be less than a 10% dextrose concentration. Greater than that is considered more pro-inflammatory. So greater than 10% when you inject this, there's an osmotic effect, some cell shrinkage, leakage of lipids, and some temporary inflammation and healing response. I can't emphasize enough. I'll tell you when I want you to remember something. The needling effect is critical here. So even when we're doing procedures that you've learned about, such as percutaneous tenotomy and you're needling a tendon to try to get a healing, the needling effect, the periosteal stimulation to the bone, to the enthesis, to the tendon attachment is a critical part of prolotherapy. How much it is part of the therapeutic effect versus some of these other growth factors is unclear. But we will get some cell membrane disruption. We will get a small amount of bleeding with platelet and blood effects, which in essence, of course, makes it difficult to do a controlled trial. Not impossible, but difficult because the needling effect itself, without anything injected, may be part of the therapeutic effect. So neuroprolotherapy, if you really get interested in this, there's a lot written and a lot of courses and a lot of opportunity to learn from Dr. John Liftock. He's a sports medicine physician from New Zealand. And what you really, again, the take-home message here, I'm not trying to turn you into a neural prolotherapist. The take-home message here is you're looking at the path, sort of the subcutaneous path of nerves in and around any painful area. And the idea here is that with tight fascia, connective tissue, you might call this like a carpal tunnel, just more superficially, these nerves get kind of tugged on, if you will. They develop neurogenic inflammation, and this can be part of the cause of pain. He's looked at some of the science of this and using a 5% dextrose or 5% mannitol solution seems to block the TRPV1, or capsaicin receptor, on the nerve. And if you're, how many people do this now who are in the room? Oh, good, okay. Not too many. Pay attention. We're not gonna teach you how to do it this morning, but this is an important part of everything, I think, that we do. So whether you do it with dextrose or even just some plain anesthetic or some saline, this is an important technique to remember. And I often find it interesting, now we've developed all these techniques for cool leaf and other things, and what are they really doing? They're modulating nerves around the knee. So here's some of the applied science of this in real life. This was just a study that came out a couple of years ago on topical mannitol, which I must say I do not use. I haven't had experience with it. But even topical mannitol was shown to be improving pain in the capsaicin-induced model of pain. So in terms of the perineural deep injection, again, beyond what we're gonna focus on here, but you can take dextrose, you can take anything you want to, but the idea here is that your ultrasound is gonna be guiding you. You're gonna find that nerve, and they're generally deeper. You must use ultrasound for these. And you're gonna use your needle to sort of hydrodissect or separate out these nerves from scar tissue around it. It travels in the fascial layers, and this technique is called hydrodissection. And we do it fairly frequently with the 5% dextrose solution. I just want to point out, again, this is an overview, and I want to give you information so that if you're interested, you can go on. Pay also attention to Dr. Lamb, Dr. Stanley Lamb. He's a brilliant guy, a sports medicine physiatrist. And he's the one who started really giving us, there's a book that he's written with like 115 nerves that you should know about. And he's the one who really started, in my mind, putting out there, teaching and educating us where these nerves are, what nerves to think about, how to approach them with this hydrodissection technique. So he talks about using the common perineal nerve as an example. He talks about, and we know that there's nervi nervorum, there are nerve endings. We talk about this in chronic tendinopathy. These nerve endings kind of ingrow to the epineurium. And what you're doing, just simply with a hydrodissection technique with dextrose, is again to sort of hydrodissect or separate out these nervi nervorum from their adjacent epineurium. And there are different techniques of doing this, different planes, different approaches. But the idea behind this, I think also has its roots in the prolotherapy world and is important to think about even if you're doing a bone marrow aspirate for somebody's knee arthritis. They may have a scar, they may have had an old ACL injury, they may have had meniscal surgery, all that stuff. So as an example, this is an example we know. We do it all the time, right? Here's the deep branch of the radial nerve, the posterior interosseous nerve, and the simple hydrodissection technique might be to take your dextrose or whatever you want and sort of separate out the supinator, the two heads of the supinator muscle from the posterior interosseous nerve. Again, key points. We made one or two already. The prolotherapy approach to treatment is regional, okay? We're generally not treating a point, but we're treating a region. So things like, whatever you want to call it, osteitis pubic, pubic pain, groin pain in athletes is often not just about that one isolated small partial tear of the adductor longus at the adductor tubercle. It may also be about the rectus attachment. It may be also about the pectineus attachment. It may be about the joint capsule or the connecting ligaments. So just knowing your anatomy and applying them in this fashion is very important. We also talk about the enthesis, so this zone of attachment of ligaments, tendons, muscle is really important. The clinical presentation is going to be basically local tenderness at the enthesis. And we all know how to palpate these and people will tell you, that's it. You've gotten there. And then an exacerbation of the pain with resisted activation of that muscle and pain with stretch. So tennis elbow lateral epicondylopathy is your classic example of that. In terms of treatment technique, injection technique, of course anatomy is key. Bony endpoint. Unless you're doing a special technique like around a tendon or a perineural hydrodissection, your target is the endpoint where these tendon ligaments attach to bone. So always feel bone. And you need to, of course, compress the tissues around that target so that you're going to more easily be able to get down to the bone. So the ABCs are anatomy, bony end feel, and tissue compression. In terms of how often to do this, I see different things practiced. There's, funny, there's sort of like an east-west coast divide. So folks, for some reason, I don't know how it got started. Folks who come from the west coast seem to get these done weekly. But most of us tend to treat more like every three to four weeks. Concentrations vary. I'll talk to you about this a little bit later. Generally, we use the lower concentrations for sensitized structures. We use the higher concentrations in the joint. And we kind of work our way up. And when you read these prolotherapy studies, you need to also be looking at what concentration they use, where they inject it. Should we be using dextrose anymore? If I can treat someone and it takes me three or four months to get them better, perhaps one platelet-rich plasma injection with the same technique is all we really need. And then do we need image guidance? I would say to use it as often and regularly as you can. There's nothing to lose except time in your practice. But you don't lose anything by seeing your target structure, as long as you're also palpating. Let's go really quickly through some of the scientific evidence, because you can read this on your own. We'll just look at some of the case series and a couple of double-blind trials. And at the end, I also gave you three more recent update and meta-analyses about prolotherapy. So everyone wants a bottom line. You're not going to remember the rest. You can just remember a couple of things that tell you where are we at in 2018? What do I tell patients? What do I tell colleagues? CMC, arthritis, there are at least two randomized controlled trials comparing it to steroid. And certainly in almost every trial you look at in orthobiologic, if it's a well-placed steroid injection, patients will feel better at one month. It works quickly and it works effectively. The divergence is at the three months, six month, and certainly a year mark. So in this case, CMC arthritis, and I don't know about others in the room, this is probably one of my absolute favorite joints to treat with prolotherapy. I rarely need to go beyond it in the orthobiologic choice. Plus there's not a whole lot, the surgery is good, but it's a heck of a long recovery. So this is something to remember. NEOA, there have been, again, a couple of randomized trials I will tell you about. Low back pain sort of generically lumped together. It's really not a good evidence to support its use. Sacroiliac pain, there's actually been a couple of trials. So within that low back pain paradigm, what are the ones that I like to tell you guys to think about using right off the bat? SI joint, CMC arthritis. I don't see a ton of Osgood-Schlatter's, but that has a really nice case series published in Pediatrics on this. But for the joints, I would say SI and CMC. And for SI, again, it's intraarticular and it's periarticular. It's ligamentous. In terms of the tendons, where do we sit with prolotherapy? There may be some data that suggests that using dextrose prolotherapy with eccentric exercises is better than either one alone. There have been a couple of studies looking at it in lateral epicondylosis and plantar fasciosis. There's one study I came across that was done well in terms of chronic rotator cuff tendinopathy. I will tell you honestly, even with that data, it's really not a go-to for me. I think we have better agents for that at this point in time. So in terms of highlights of some selective studies, this came out about the, just was coming out about the last time we ran this course about the chondrogenic effect of intraarticular hypertonic dextrose in severe Neo-A. Gaston, Dr. Tulpal from South America and Rabago from University of Wisconsin led this effort. And I find this absolutely incredible. They screened 20 patients. They were able to enroll six patients with severe baseline OA. They did ultrasound and diagnostic local anesthetic injections to confirm that there's an intraarticular source of pain. And then in a study that I think would be hard to replicate here in the United States, they were, just to show you, I mean, these were not, this was not easy, mild, early OA. A lot of us might offer an orthobiologic. I sure as heck might suggest this person have arthroplasty. And what they did with these patients, it was a single arm study. They had a pre-treatment and post-treatment arthroscopy with cartilage mapping. And they even took a little biopsy to look at the cartilage. And they did this before and after. They stained with methylene blue and looked on biopsy for new areas of cartilage growth. And what they did show is, A, I'll show you in a moment, there was new areas of cartilage growth. This was a mixture. This was a mixture of fibrocartilage and hyaline-like cartilage, so this was not the panacea. And whether or not this would stand up compared to other orthobiologics or even viscose supplementation if done in a randomized, controlled fashion, I don't know. But I found this absolutely fascinating and intriguing. And what that looked like, on the left side of the screen, you can see the methylene blue stains the cartilage. So it does seem, and at least the slices were given here, that there's improvement in cartilage mapping with this treatment. So their conclusion here was they saw positive clinical and chondrogenic effect, even in more advanced days, osteoarthritis. Certainly this is intriguing, but not of itself full-grown proof that there's cartilage regeneration, and I certainly don't promise that to patients at all in this technique. There was another well-done study that was published a couple of years before that. Same group, Dave Hrabago leading that charge, again, University of Wisconsin. And this was a really well-done study. They had three groups, double-blind, prospective, randomized, controlled trial. The three groups were dextrose prolotherapy, saline, and home exercise program. They did a standard treatment technique with injections, basically monthly for three months, and then with an option for a couple more. They did what I told you. They went in the joint with a higher concentration, 25% dextrose. They treated periarticularly as a standard with a 15% dextrose. They standardized the treatment for each patient just for the purposes of this study. And what they showed was that groups who received the dextrose prolotherapy had greater improvement at a year compared with the groups of saline and exercise. So again, when you're looking at these things, you're not looking at someone about to go on a cruise with their family who needs relief in two weeks. You're looking about a longer-term result and a longer-term and more durable effect from your treatment. This is just, again, I'm not gonna go through all the details of this because I will absolutely put you to sleep, but this is one of the two randomized controlled trials looking at hypertonic dextrose in CMC arthritis. And what they showed, they had 60 patients with CMCOA. They had a steroid group, which was one steroid injection and two saline injections. And the other group was 10% dextrose, which is just on the lower inflammatory end. And they looked at different pain intensity, hand function measures, and showed these. You will see, oh, sorry. You will see that over time, the dextrose prolotherapy was more advantageous. In the short run, both groups were better. But when they looked out at six months and beyond, dextrose prolotherapy was a more durable response. And again, we'll discuss this in the Q&A if there's questions about this. Just as a pearl, find the CMC joint doesn't do particularly well with the highest concentration, even though other joints might. This is a highly sensitized, very neurally innervated structure. So I think we're generally more successful with the lower concentrations dextrose here as well. This is a famous study that came out with a two-year follow-up study from South America, Dr. Topal and Dr. Reeves, again, looking at 12.5% dextrose in chronic adductor injuries in high-level athletes who had had their symptoms for more than two years. And this is, again, the approach to treatment. And they, honestly, I think these were all patients, all athletes who had failed every other treatment, including good physical therapy, over the course of more than a year, and all got back to play within a couple of months. And the average number of treatments was 2.1. So 75 athletes, 72 completed, average number of treatments just under three. 66 returned to unrestricted sport. And this is rugby and soccer. So again, if you take home what, now we're on the Borkstein Journal of Anecdotia, supported by evidence. Again, one of my favorite areas to treat. Certainly we use PRP here as well, but for that more global pubic region pain, I'll present you a case. This is one of my favorites. And our colleague, again, Dr. Topal, Dr. Reeves, and Brad Fullerton published this a few years ago in Pediatrics. And they just looked at lidocaine versus dextrose for Osgood-Schlatter's, and had some remarkably good results with that. I don't see a lot of Osgood-Schlatter's in my practice, but I think this is something you definitely want to keep in mind. Just lastly, I can't go through all the literature this morning, but there have been three, within the past couple of years, there have been three reviews, systematic reviews on the topic. So again, I included these. If you're interested, you can go back and review them in a bit more detail. But what I tried to do for you was just kind of summarize it, bottom line it, where are we at, and then add a little bit of clinical experience into what would you think of using, when would you use it, and then as we go through the course of this day, how that might compare to other biologics you have to choose from. So just to how to apply this in practice, you could, we take hypertonic dextrose and just dilute it out to whatever concentration we want to use. When we use 5% dextrose, we just get it generally out of one of these bags. I chose a patient who was one of the most challenging patients I ever started with, not emotionally, but in terms of anatomy. Because this is relatively recent, so I had the options of using PRP or stem cells or everything else in her case. So this is a woman with pain in the pubic bone and right hip flexor. She's 30 years old, she does marathons, ultra marathons, and certainly didn't listen to her body signals over the course of the year. She kept running and got progressive refractory pubic pain and some hip flexor pain. And just to show you, her exam certainly was consistent with that, she had no other signs or symptoms to suggest either a lumbar process or an intra-articular hip process. And this is an athletic pubalgia protocol MRI, it's pubic symphysis, and this is nasty looking. If you don't look at these a lot, there's cystic changes, this is a 30 year old woman, osteophytes, this was really a tough case. And on the axial, you could see that there's also some tears and disruption of the muscle and the pectineus and inflammation in the joint, and even thickening and slight displacement of the pubic plate. So how many in the room treat this, I mean, forgetting her severity, see athletic patients with pubalgia? So keep this in mind, this is sort of one of the worst that I had ever seen at the time. So among other things, we switched around her physical therapy, addressed her pelvic floor, but the intervention here was dextrose based prolotherapy. And the reason why I chose this, pardon me, there are a lot of areas to treat. You look at that MRI, you know you're gonna be at that for a while. So you could do that with PRP. A, it's considerably more uncomfortable, but B, you can get as much dextrose as you need relatively easily. So when there's a wide area to treat, and you really just need to narrow it down, I think again, dextrose has a good long track record in this area, and it's easy to use, easy to tolerate in this, well, let me put it, there's nothing easy to tolerate when you're at somebody's pubic area, guy or gal. It's relatively easy to tolerate compared to some of the other orthobiologics. So long story short, no one presents their failures up here. So she did well. It took me months to get her back. She did go back to running. I told her not to run past a 10K, but I ran into her about another shoulder issue about a year ago, and she stopped at half marathons, but she actually did recover. We only took her so far with the prolotherapy, and then there was one really resistant spot, just one adductor attachment. We treated that with PRP to sort of complete the treatment. So when you're thinking about when to use this, it's not unreasonable to think about it, sort of that whole landscape is so broadly uncomfortable. Bring it down, treat the entheses, and then if you have one tendon or one joint that's not responding, consider targeting that with a different orthobiologic. Second case, not joint area, but tendon. This was a 57-year-old golfer who owns his own construction company, one of my downtown colleagues referred him after she tried PRP, and he was miserable, made him, quote, worse, and he absolutely did not want surgical treatment. What would you, well, I know this is a talk on prolotherapy, what would you think about this guy? Options? Well, I'm gonna tell you the answer. Okay, so he got worse after PRP, and he absolutely doesn't want surgical treatment, so obviously, in a talk on prolotherapy, we use prolotherapy. Now, I wanna show you a couple of things about this treatment, again, treatment pearls. Certainly, any time you can do an ultrasound-guided nerve block prior to your orthobiologic treatments, take the time and do it, or anesthetize the track. These can be uncomfortable. The scraping techniques can be uncomfortable. The PRP itself can give a throbbing sensation. So, first of all, knowing that he didn't do particularly well tolerating PRP, we started with a seral nerve block, which was done, and then we used 10% dextro-prolotherapy, which is the least inflammatory, and did basically the same type of sort of hydro-dissection scraping technique at the border between the fat pad and the Achilles tendon, and it took us three visits, but he did absolutely great. This is, you guys know this stuff. This is just a view of the seral nerve block before the technique, and the serals work, and it'll work well as long as you come from a lateral approach. So, let's get to some summary things here. What are my, our recommendations to you for prolotherapy in 2018? Where does it fit? It's old, but it shouldn't be forgotten. So, I would say to you, the current and most promising indication for the use of prolotherapy appears to be in the treatment of refractory tendinopathies and osteoarthritis of those joints we discussed. It's relatively safe. There are few adverse effects, but treatment paradigm is important to consider. Think about whether you're gonna be peritendinous or intratendinous, and in general, if I'm going to be intratendinous, I will use a different orthobiologic agent, okay? Think about the enthesis, and think about your needling technique, and remember to treat the region, and not just a point. With that, a comprehensive regional approach with all the stuff that Dr. Macheo just spoke about, and especially think about it when you have a very broad region that you need to start with in terms of volume. If you think this patient has a sensitized region, there's neurogenic inflammation, sensitization, think strongly about adding a perineural technique, whether that be more of a subcutaneous one or a deeper perineural ultrasound-guided hydrodissection with 5% dextrose. In general, think about using the higher concentration, 25% for intraarticular applications, and the lower concentration for periarticular concentrations, and always remember in your back pocket, you have that 10%, which is sort of a non-inflammatory concentration, so insensitize patients, and these days, I start almost all prolotherapy series with 10% because you don't always know how someone's going to respond, and it's kind of hard for them to come back and get into the treatment if the first time you see them, you make them pretty darn miserable, inflamed, and uncomfortable, so I start pretty much every one with 10% and then see how they do. Talk about athletes in season. Prolotherapy traditionally has had almost no downtime. You sort of do it, let them rest for a day or two just to get over the post-injection flare and soreness, and then we let them go back to play as tolerated, so it is my go-to for athletes in season. I've had folks with chronic hamstring, tendinopathy, sacrotubous ligament, that kind of proximal issue, and they're training for marathons while we're seeing them and treating them with prolotherapy. If blood draw is a problem, there are some off-the-shelf products you can use, but this is certainly something simple and easy if you just can't get blood. Think about it also. The classic teaching years ago was dextrose, and working on these ligaments and periarticular structures strengthens the capsule around it, so I find it particularly helpful in folks with ligament dyslaxia. How many of our female athletes are hypermobile, right, or post-pregnancy? Those SI joint patients, quote, hypermobile, or sequela of chronic ligament injuries for which instability may be a part of the picture, such as a chronic ankle sprain. It's also less expensive. Dextrose is cheap, although you need more visits, so in the end, it's probably not less expensive if someone requires a full course of treatment, but up front, it's less expensive, and that expense can be spread out over six months or more. We talked about adding it in for neurogenic inflammation and using different types of prolotherapy even in the same clinical visit. Use ultrasound guidance, please, for deeper structures and deep nerve hydrodissection, and studies have shown that if you're going to do this for the low back or sacroiliac area, that it is best and most effective combined with appropriate manual therapy. In terms of patient education, even in this day, we have handouts and articles we give people, people look back at you and say, and by the way, I don't use phenol at all, really, anymore, or sodium moruate. They have toxicities associated with them, and I think pretty much everyone I know is using pure dextrose, but you're having this conversation with a patient, you're telling about this treatment, and they ask you, what are you going to inject? And you tell them, sugar water. I don't even use it. I say, oh, it's a hypertonic dextrose solution, and what is that? It's sugar, right? You get a look back like, and I'm gonna pay you to do that? So there needs to be a little bit of education around what we're doing. People, pardon me, people need to know this is gonna take months, and they have to be patient, otherwise you'll lose them within the first month or two. We talked about using this with an athlete in season. You need to pull up an anatomy, I recommend you pull up an anatomy chart and show the patient why you're doing all these injections. They've previously, before coming to you, had one injection in the knee with steroid, maybe viscose supplementation. They have to understand what you're doing, why you're poking around that knee so much. We talked about co-treating with manual therapy, review with folks, the current literature, and again, this is like preaching to the choir, because we're all physiatry folks here, but this isn't going to happen. This is not a standalone treatment without all the good stuff that we do in terms of rehabilitation and prehabilitation and nutrition counseling and sleep restoration and vitamin D levels and all that other very, very important stuff to promote a healthy environment for healing. And then of course, this is an out-of-pocket expenditure. So as I conclude, what I want to let you know is, so I consider prolotherapy kind of the grandfather or grandmother of the orthobiologic treatments. It was around for a long time before any of the others, it just wasn't particularly sexy to talk about. So as the grandmother of this clan, I'm hoping that by the time my grandkids are physiatrists up here speaking to everyone that we have this all figured out. And I thank you for your attention. Thank you. Great talk to Joanne. And we can even bring up Dr. Micheo if he's in the back. We're running a little ahead of schedule, so we'll field some questions from the morning sessions. Any specific questions on prolotherapy or specific pathologies? Yeah, you had mentioned that this is all out-of-pocket. Why couldn't you, that sure doesn't cost hardly any money. Why couldn't you just charge an office visit, ultrasound guidance, injection fee, and not charge an amount of pocket money? Did everyone hear the question? This comes up for discussion all the time in every orthobiologic injection that we do. And we went to our compliance folks on this. And if intrinsically it is a non-covered service, if PRP is quote non-covered by that insurance provider, then they considered it kind of a fraudulent billing paradigm to do that. So anything that's out-of-pocket, even if visco-supplementation isn't covered by that person's insurance, right? In our state, a lot of the insurers have stopped covering it. If we're going to be injecting visco-supplementation, everything associated with that visit needs to be out-of-pocket. And our patients are asked to sign a waiver that they understand this. So it's a really matter of billing compliance as sort of our folks have interpreted it. I don't know how it works in PRP. Anyone else have that issue and are able to do prolotherapy and not have patients pay out-of-pocket? Now, having said that, I often end up just kind of giving it away sometimes. So if I have another reason to see somebody, right, or they're doing some PRP for something, but I know they need prolo for the rest, or I'm going to be treating them, I don't know, down the line for Achilles tendinopathy, and they might do a nerve block and just put in a little dextrose, or they come in for something else, but they're all sensitized, I'll use a little 5% extras, but I don't I don't I don't bill insurance for that component of it You said in your presentation that it's original therapy in addition to the point therapy for example if you inject the knee What else do you inject around the knee in order to make it a complete treatment? Everyone hear that Question is what structures around the knee as an example, we inject I Think this all depends on your history and physical so of course you're gonna look at imaging and you're gonna see that medial compartment has reduced Right cartilage in it. So if that's Away, and they're in fault in the joint and you think there's a joint process. You're certainly gonna put some in the joint Then you start seeing where their pain is and pal painting All right, so it may be that the proximal attachment of the MCL is very tender so I would inject there It's possible and this could be a PRP talk and I tell you the same thing Maybe they have a degenerative meniscal tear or a meniscal cyst that you can see on ultrasound So we'll need all that aspirated and put a little ortho biologic in that as well Maybe the coronary ligaments, right or the patella Ligament patella tendon, so wherever you find that they're sensitive Sensitive to the touch. There's pain induced with that. I would include that in the field of treatment whether it's PRP Whether it's prolotherapy, it really doesn't matter and I think that's part of the beauty of this is is kind of It's exciting to use your ultrasound your palpation skills your x-rays and put it all together With a relatively safe treatment if you're a surgeon you generally need to go in and fix one or one or two things But as non surgeons, we have the ability to treat the region You don't most of the time what patients want is to just hurt less Right. So including all that so it's palpation imaging physical exam, etc I have two more questions question Number one is in your experience or in the literature. Have you found any best concentration? What is the best concentration that used to have the best result like 5% 10% 15 25, whatever and Yeah, just this question for now So the concentration is a little bit There's a little science behind it as I presented to you and it's it ends up being a bit more of an art in some Ways so for sure everyone would agree on that 5% and not higher is the concentration to use around nerves So if you're everything you're doing either subcutaneous or deep perineurals Structures use 5% The classic teaching is a higher concentration dextrose in the joints But even if you look at Robago study, he only used 12 and a half percent So having done this over many years and knowing sometimes that these very high Concentrations can make people very very sore and inflamed and you people don't like that They're not happy with it And you're also trying to balance do the fewest number of visits because people are paying out of pocket you don't want to do anything extra so I generally start almost every treatment Perry and Perry and Intraarticular with a 10% and sue how people do if they respond and usually you have to tell people you're not expecting much of a response till the first two or three visits have passed But if they start responding and they tolerate that treatment at the 10% I'm just going to keep with it If they tolerate Really? You're not getting any response. I'll go up Maybe go up to 12 and a half or 15% and by the third visit Same thing if they're tolerating it not responding especially for intraarticular structures I might go up to 25 for soft tissue, maybe about 20% So you can choose to do this guy I told you about in Boston who advertises all the time in the radio I happen to see one of his patients After the fact who actually did okay with his technique for that joint And I don't know if anyone else has experience with this. He uses 40 to 50 percent Dextrose like I've never heard that and he treats weekly So I don't maybe people are just like yes, I'm better. I'm not coming back, but I've never heard that Anywhere else so that's that's really one extreme. So I think what I'm telling you is kind of Middle reasonable like like politics. We always thinks we're right in the middle and reasonable So This is regarding the protherapy for CMC You presented a slide Comparing that to corticosteroids and its beneficial effect and improve function question number one How long does that function improve and last number two is any data regarding the osteoarthritis? progression in radiographic Imaging So the question was oh a CMCO a how long do these treatments last and does it really prevent progression? Do we have data about that? And I would say in general we do not have long-term data that ten years from now That joint to look better than if they didn't have prolo therapy So I can't answer that question There's only that one suggestion on cartilage in that one pre and post Arthroscopy study that I presented to so I don't think we have the information to answer that So I can't tell you that I've seen ten-year follow-up studies either I can tell you now from my own clinical experience You treat and discharge So this even in the most severe is I can't say there's a magic because there's no magic in medicine But this is as close to magic as I've I generally see my experience will tell you that it takes the false Once a month or about six months you have to dig in with the patient and let them know this I do both Perry and intraarticular but oftentimes Intraarticular is enough and I always do it with ultrasound guidance Even though you probably could could do this very easily with palpation and I've taken also to even putting a little anesthetic Subcutaneously before the injection because you know, the the thumb is very richly innervated and this can be very painful Generally at about six months as people feeling pretty darn good. We start to wean them off We have them go two or three months make sure they're holding their own They are then I'll go one more visit at six months and then we generally stop and I invite people back As need and occasionally you'll have someone, you know They spent the weekend with their grandchild or something and it flared up but most of the time even in more severe Types of away people are done. This is a durable Treatment now, there's always a possibility that I've lost people that they went on to surgery that they didn't like me They didn't come back, but in general People who I've seen for other things over the years their thumbs are good But they have to be in it for at least six six to eight eight months before it's really gonna be a durable response And the other thing in years past Also, you learn as you do this You as a practitioner can't give up too soon Right, you need to keep playing with the concentrations and really give it three or four months Some people are just a little slower to respond Because if you give up too soon, you may lose people that you're actually likely to help So that three visit mark two three four visits. They really should be Better if for some reason you can't get them better that think about other options surgical or other orthobiologics I Just want to ask Joanne about the use of Protherapy acutely for muscle tendon acute injuries I've seen two or three cases of recurrence tears hamstrings and quads following protherapy after clearance quickly to go back to play I Have to be honest. I don't use it for acute injuries, you know folks who come or You know, they've had these things for forever and they want treatment. I usually just let them get better and then I Think disappoint some of these issues for acute in season acute injuries You got to be very careful and particularly if you give clearance without rehabilitation for some of these procedures Why does it work do you know what happens locally from physiological and pathophysiology standpoint? Why does it help? It's a really powerful placebo You know, we had a lecture at our graduation from this wonderful Dr. Hall Catherine holds on a lot of research on the placebo effect and how it can be used to help Because there are definitely Physiologic neurobiologic effects that occur with the placebo response and there are various neurotransmitters and genetic profiles that will predict honestly if we if we Bio if we looked at a biobank on everyone out there about who might respond so there may be some placebo aspect Be nice be encouraging people want this sort of thing People want this to work and I don't deny that in terms of the lower concentrations It seems to work in a neuromodulatory fashion through the the trip v1 Receptor at least that's what the science is that I I've read about this for the higher concentrations again I mean if you think about micro fracture, it's kind of like prolotherapy on steroids pardon the pun Because you actually are stimulating at the periosteum So there certainly may be an effect from that as well And then as I mentioned there are certain growth factors that have been shown to be released both Mostly in animal models that are associated potentially with healing response associated with this as well So so short-term with our patients there should be some local factors neuropathic changes neurotransmitters and long-term May be some healing induced and Why some people get better with that radiographic changes or tendon changes in ultrasound? We don't know so I'm assuming there's a combination of placebo injection effects local Neurosusceptive neuropathic changes and then some Tom either partial healing or long-term mechanical changes The other issue is combination of therapies with exercise and other things that we do Strengthening the muscle around the joint and doing other things that you should do Anyway, that may also help the patient get better. So a muscle absorption of energy Mechanics changes in gate other things that also should be done So it allows you to short-term get better to train and long-term a allow healing Although we may not see complete healing by x-rays or ultrasound There's still something going there that we tell them that mechanically there's something that's happening to the structure that allows Transmission of forces in the long term But I Hold out these orthobiologics as a carrot Okay, and if someone comes in dramatically overweight sedentary not sleeping and sleep apnea They're not gonna get I'm not gonna treat them till I see some effort on their part to manage some of their Nutritional and sleep and exercise aspects Because you just people can't rehab if they're not motivated I think that that's a great point just because the patient wants it You should not be tempted to give it particularly in those cases. You will not do well so we make the issue clear to the patients that they may need rehab prior to the procedure or During the procedure or a commitment to the procedure because it's not rare to get these patients get multiple injectors around Waiting for the magic treatment, right? So those those are not going to do well other things you should make sure you're not inducing damage to this Patient by making them think they're gonna get better and do something that they should not be doing So we're gonna run the New York Marathon in two weeks And I think we should get prolo to my plan or fascia so you may get a terrible stress fracture So these things are clear you just because they want it you shouldn't give it to them and the issue of Identifying who is the appropriate patient for which technique? including type of Technique and timing of the injury because if somebody needs to go back to something quickly some of these techniques may not be appropriate Thank you A Good question, what about diabetic patient if some if somebody is actually a brittle diabetic I probably won't do any ortho biologics till that till that's better control But these are generally pretty small concentrations and we have steroids There's always a problem with diabetes control, but I haven't really seen it with these lower concentration local Prolotherapy treatments good question Any others Okay question prolo therapy versus PRP what are some of the factors to consider I Think everyone in this in this fields opinion changes with time As our techniques get better our PRP is better understood So I think the answer today might be different than what comes down a year or two from now So a couple of caveats big region to treat I start with prolo generally if it's if it's a region that's amenable to it Central sensitization and lots of it and I'm not sure how they're going to respond or tolerate Treatment in general. I'll generally start with prolo and work the nervous system in addition You know the neurogenic stuff in addition Something intra tendinous or partial tear. I know there's studies, you know, we treat anthesis But if I can see a tear and a tendon and we'll talk about fat and other techniques that people are using I'm not likely to use prolo therapy. I'm likely to try to use some ortho biologic to get that to heal Even though in years past well, that's all we had Maybe we would but I don't I don't do it If somebody travels a distance to see you pro therapy is a drag I need to travel to see you once a month So I'm likely to use platelet-rich plasma because it's often one visit maybe a second for some tougher to treat area so depending on what they're Able to do the other nebulous and I think hard to define a question. I struggle with is what to do if someone had a history of cancer And they're treated but it's relatively recent technically that might be a slight contraindication to using PRP I might still talk to the tree oncologist But I'll probably use prolo therapy if another thing like a steroid of viscous supplementation Wouldn't be helpful. So I think it really depends on the target and the number of treatments they can get to you for Anything intra tenderness I would tend to use it and then also over the years as as the newer techniques for arthritis Management have changed. I really other than these examples. I gave you in the CMC and inside if someone comes in You know newly to see me with knee arthritis kind of moderate mild to moderate I'm generally not going to do six months of prolo therapy with them Or I might be able to do one PRP or one bone marrow aspirate, so I've gotten away from doing it as well for For inter articular treatment, especially in the larger joints does that help A question what about its use in carpal tunnel or recurring carpal tunnel? if you speak to people who are a bit more zealous about prolo therapy than I am they would say that if you treat the Sort of the carpal bones that support the carpal canal and make those stronger that maybe you can treat Carpal tunnel with prolo therapy. I don't have experience doing that I've seen some reports of using platelet-rich plasma peritendinous I'm sorry perineural in Carpal tunnel, I don't know if Jerry has more experience with that. I don't really have experience using PRP and carpal tunnel And I think for a carpal tunnel that is truly anatomically recurred That's a different story for carpal tunnel where folks may have had some other neural process that went on maybe there was a branch of the The palmar branch of the nerve or whatever I would consider a neurogenic technique because some of these are not necessarily the anatomy of the carpal canal as they are an imperfect outcome and Neurogenic sensitization, so that's where I'm very well might consider some 5% dextrose for sort of a perineural approach I'm sorry Great Question about volumes it depends on the joint so generally You're using maybe a couple of tenths of a cc per Sort of per touchdown point So if you're working the area of the MCL you might use maybe approximately maybe one cc But you're peppering it along the attachment for small joints like the CMC You're lucky if you can get in a half to one cc at the most For larger joints like let's say the ankle you might be able to get in three cc's although again for those larger joints I still tend to use different Neurobiologics other than the prologue, but the classic teaching is maybe a couple of tenths of a cc per per touchdown For the sural nerve I honestly I just I try to get it proximal to where it Branches so for most people if you just go where we learn to use nerve conduction studies So just proximal maybe a 14 centimeters or so you're you'll follow the the Achilles Tendon up it gets smaller and smaller, and you'll start to see a little Main pulsating and the nerve will lie right next to it Again That's a great question the post knee arthroplasty the quote components look good But they still have pain patient. I don't think that exists. I've never seen anyone have pain after arthroplasty Yeah And I might pass this punt this back to Joanne in a second, but post meniscal repair The orthopedic surgeon will say there's a saphenous nerve entrapment or their saphenous nerve issues We'll say that some of the athletes they have responded I'm not sure what the right dosage might be I don't know if you both could comment or if you even entertain that in your practice I Entertain anything I'm like an atheist in a foxhole I'll believe in anything that works But generally I will start with just a plain a little bit of local anesthetic and make sure I actually Have the pain generator I can find the nerve I can block it And it's actually going to relieve their pain, and I'll use some local anesthetic I would I would actually put in a little drop of steroid once or twice I don't think that's unreasonable either and if all of that works But it's not durable Then I will do some periarticular Either PRP or the 5% dextrose prolotherapy or send them to Yeah, I think we do local anesthetic and steroids first, and then if it works PRP probably Was The question is the RFA for the geniculate nerves That's done some people find the dysesthetic sensation afterwards in your experience worse Than the pain they had beforehand I haven't had that experience with prolotherapy and certainly in a neurogenically sensitized area I'm only going to be using 5% Great we're gonna pause with questions for now. We'll break and we'll be back in about 15 Minutes to resume the second part of the session. Thank you. Dr.. Joy. Thank you

prolotherapy

sugar water injections

musculoskeletal injuries

dextrose

healing response

tendinopathies

osteoarthritis

platelet-rich plasma

scientific evidence

treatment options