The most common reason why healing hasn’t occurred, is because it was interrupted with the use of anti-inflammatory medications such as ibuprofen, Aleve, Motrin, Advil, Celebrex, Naprosyn, and many other over the counter and prescription medications. Prednisone and corticosteroids in the form of creams, eye drops, inhalers, pills and injections can also interfere with normal healing.
Multiple sessions are typically needed to treat each area, with benefit accruing over time. Prolotherapy is typically repeated in 2-4 week intervals for three to six treatments. Timing varies according to individual needs and the degree of injury.
Carefully conducted research shows evidence of reduced pain in patients with knee osteoarthritis. Research for lateral epicondylitis and Achilles tendinosis is currently underway. However, prolotherapy’s clinical use over the last 80 years to treat pain, prior to MRI and surgical interventions, has established a foundation for proven healing. Now ultrasound guided prolotherapy injections have improved the accuracy of treatment.
The research on platelet-rich plasma is extensive. There are many studies evaluating the benefit on tendinopathy (tendon injuries > 6 weeks old have lost their blood supply. They heal great with 1 treatment with PRP), osteoarthritis (early arthritis has great success), muscle strains/tears (faster return to sport), and Nerve (easier to treat immediately after the injury).
Patients who are healthier heal faster. Younger patients heal incredibly fast and require less treatments. Diabetics, patients with chronic inflammation, daily alcohol use, use of anti-inflammatory medications and smokers, don’t heal fast, so more treatment sessions are needed. Patients whose diet has 8-9 servings of fruits and vegetables have a good source of vitamins that allow for healing. Consuming an adequate amount of protein is important to heal, as amino acids are needed to repair an area. Patients whose hormones are in the ideal range heal faster.
The injections are never performed without local anesthesia both superficial and deep. If you have difficulty getting numb or experience more pain or are extremely needle phobic, there are other ways to make you more comfortable. Prolotherapy is an injection that occurs at the attachments of ligaments and tendons to bone. When the bone is injected, people experience a buzzy discomfort. Some people describe it as nervey. This dissipates immediately. Usually a bruised like discomfort remains for the next 24- 72 hours. There can be a sense of tightness during the first day. On occasion, patients experience pain for 3-5 days. Anything longer should be a reason to call.
Avoid all anti-inflammatories. Move gently during the immediate 3-5 days after treatment. You may return to your normal activity after the initial pain and swelling have gone away, avoiding injury. For example, substitute running with elliptical, swimming or stationary cycling if the treatment was to a hip, ankle, knee or foot. Likewise avoiding swimming for shoulder injuries, substituting swimming with walking, stationary cycling, elliptical or the like. Weight lifting for the upper body is fine when the lower body is treated (and vice versa) if it is already part of your routine. Avoid the temptation to get a project done if the pain subsides and you start to feel better. Healing typically takes about 6 weeks. We usually repeat the prolotherapy injections as 2-4 weeks. Correcting the biomechanics of how you move can also prevent further injury. Many chiropractors, athletic trainers, physical therapists can assist with correcting posture and biomechanics. If you have a relationship with someone skilled in this, we will communicate with them as part of the treatment plan.
On the day that you receive prolotherapy treatment, going back to work is not a common practice. However, returning to work the next day should not be an issue.
Yes, any manipulation that can cause ligament strain of the joint treated with prolotherapy should be avoided. In general, this encompasses any High Velocity, Low Amplitude techniques, including using a drop table for the area that was treated. Soft tissue techniques, such as muscle energy, facilitated release, counterstain, balance ligamentous tension, fascial stretching, and massage are fine. There is a definite benefit with incorporation of these soft tissue techniques within two weeks of a treatment.
Many of the same principles apply. PRP is not comfortable and requires anesthesia. Nerve blocks and local anesthesia are done to give local relief. Because PRP is viscous and there are other pain pathways, besides nerve pain, there may be some injection discomfort that lingers. Injecting PRP slowly improves pain tolerance. In certain patients, oral medications can be used to assist with pain. Nitrous oxide is available and is extremely beneficial. In addition, we welcome having patients bring in their own music. Tapping, meditation and other techniques are also helpful. That being said, the benefit is significant. (see testimonials). The pain compared to having joint replacement is days, not weeks.
The injection of PRP is done under direct visualization, such as ultrasound or fluoroscopy, to guide the needle into the specific area that was injured. The injured tissue is determined in advance through MRI, X-ray, and ultrasound evaluation.
Chronic injury to the supporting ligaments of a joint can lead to arthritis. Chronic injury to a tendon leads to tendinopathy. In both situations, the tissue quality is compromised; as is blood supply, further detracting from healing.
PRP is used to treat injured ligaments, tendons, and capsules around a joint to improve joint stability and improve healing in, for example, knee and hip arthritis, as well as back pain and most other joint pain. Injuries to ligaments, tendons and capsules cause about 60% of the pain people experience around their knees. It is important to understand that prior to pursuing surgical treatment, as not all pain will be resolved by surgery and sometimes treatment of these areas prior to surgery can improved the success of the surgery.
PRP can also be injected into joints to assist with repair of the articular cartilage and meniscus. The addition of bone marrow concentrate may be important in these situations to augment healing, depending on the degree of damage.
The inflammatory response is greater with PRP, so 3-5 days of increased swelling with or without pain is normal. Some people have little to no swelling or pain after 24 hours and others have more. The use of crutches for 1-3 days to avoid weight bearing is suggested for treatment of the lower body. A sling for the upper body is helpful. Compression of the joint is helpful. Avoidance of heat during the first 24 hours helps reduce the inflammation that would be increased as blood vessels dilate. Ice slows down the inflammation, which is used at times with people who experience a lot of discomfort.
The first is an inflammatory phase, which begins when platelets are drawn to a site and become activated, releasing the growth factors necessary for healing. This phase lasts 3-5 days, and is an important time to avoid anti-inflammatories (such as Ibuprofen, Naprosyn, Diclofenac, Aleve), as inflammation promotes healing.
The second phase, the proliferative phase, occurs over a period of weeks. During this time, cellular material forms in a layered approach, and new blood vessels form. The layers of differentiated cells form a matrix that strengthens the injured tissue. This is the phase of healing when tissues are most prone to re-injury. It is important to moderate activity to avoid re-injury during this time.
The third phase of healing is called the remodeling phase. This lasts up to a year. During this period, collagen continues to develop and gets deposited in layers, adding strength to the tissue.
Each of the 3 stages is necessary for full healing. Interruption of any part of healing by a second injury, or by the use of anti-inflammatories, can cause incomplete healing, leading to chronic injuries (defined by an injury that lasts 6 or more weeks).
Typically, PT is started at the earliest 2 weeks after the last PRP session. Care is taken to prevent injury from being “pushed” too fast or too early… before healing has occurred fully. For this reason, some doctors who treat patients with regenerative injections will not send their patients to PT until after the treatment is done.
Aerobic exercise in the form of elliptical machine or stationary bike or swimming can be continued depending on the injured area.
Stabilization exercise, such as pilates, gyrotonics and some forms of yoga work well. We want to keep the tissue pliable, but not overstretched, which can happen if you aren’t careful while doing yoga.
Avoid strength training until you have painless full range of motion and have built up some of the stabilizer or core muscles of the joint. (Usually 6 weeks after treatment). Resistive bands are a good way to build up stabilization of a joint, start with yellow bands and progress thru the rainbow. Exercises using your body weight as the resistance are a further progression of stabilization into strength exercises. Typically the earliest strength training would occur at 6 wks to 2 months.
Dr Stebbing is contracted with a few insurances and looking to contract with more. This will assist you with your initial consultation and with treatment with Osteopathic Manipulation. Most of the other services that she offers to treat injuries are not covered by health insurances. She is not contracted with Medicare because of the many limitations that it imposes and the risks associated with offering treatment that is considered investigation (ie: platelet rich plasma), which has hundreds of studies that have documented its safely and its efficacy. In fact, most people have better outcomes with platelet-rich plasma than steroids, which have shown to encourage degeneration of a joint, which is harmful. Steroids continue to be a covered service despite these studies in all insurances. The paradigm shift in thinking that you need to understand is that healing or repair of damaged tissue with platelet-rich plasma is different than using a bandaid, like a steroid injection.