Prolotherapy for Low Back Pain
In the January/February 2007 issue of this journal,1 a review article on Prolotherapy outlined the use of Prolotherapy for musculoskeletal pain. This is the first of a series of articles which will go into more detail regarding the use of prolotherapy for different areas. This article will discuss the use of prolotherapy for low back pain, disc disease, and sciatica, together with case reports.
Prolotherapy is a method of injection treatment designed to stimulate healing.2 Many different types of musculoskeletal injuries and pain lend themselves to prolotherapy treatment including low back and neck pain, chronic sprains and/or strains, whiplash injuries, tennis and golfer’s elbow, knee, ankle, shoulder or other joint pain, chronic tendonitis/tendonosis, and musculoskeletal pain related to osteoarthritis. Prolotherapy works by raising growth factor levels or effectiveness to promote tissue repair or growth.3 It can be used years after the initial pain or problem began, as long as the patient is healthy.
Prolotherapy works by causing a temporary, low grade inflammation at the site of ligament or tendon weakness (fibro-osseous junction), “tricking” the body into initialing a new healing cascade. Inflammation activates fibroblasts to the area, which synthesize precursors to mature collagen, and thereby reinforcing connective tissue.3 This inflammatory stimulus raises the level of growth factors to resume or initiate a new connective tissue repair sequence to complete one which had prematurely aborted or never started.3 Prolotherapy is also known as “regenerative injection therapy (RIT),” “non-surgical tendon, ligament and joint reconstruction,” or “growth factor stimulation injection therapy.”
Low Back Pain
Low back pain is a common medical complaint and, in the United States alone, more than 5 million people are disabled by low back pain, half of these permanently.4 Low back pain affects most people at some point during their lifetimes. It is the second most frequently reported illness in industrialized countries, next to the common cold.5 In fact, it has been reported that 80 percent of the general U.S. population will at some time suffer from low back pain, and 20 percent are suffering at any given time.6,7 It is the subject of numerous books, articles, and media reports. A variety of sports activities—such as gymnastics, football, weight lifting, rowing, golf, dance, tennis, baseball, basketball, and cycling—have been linked to low back pain.8 Non-athletes and athletes alike, however, can suffer from this condition
Causes of Musculoskeletal Low Back Pain
Ninety percent of low back pain is mechanical. This type of low back pain is the result of overuse or straining, spraining, lifting, or bending that results in ligament sprains, muscle pulls, or disc herniations.9 Mechanical low back pain is the most common cause of work-related disability in persons under 45 years old.10 While disc problems have gotten much of the credit for low back pain, ligament injury is a more important source of back pain.11 In fact, it has been reported that only 4 percent of low back pain is due to a herniated disc.12
To understand why the disc has been given so much credit for low back pain, one has to understand some medical history. In 1934 researchers named Mixter and Barr became popular.13 They focused attention on the disc, giving root to a popular theory and, from that time forward, “disc disease” has overshadowed the ligaments’ importance. Then, with the introduction of CAT or CT scanners (Computerized Axial Tomography) in the 1970s, and the popularity of MRIs in the 1980s and 1990s, further attention was focused on the disc as the cause of low back pain—because discs are easily seen in these types of studies. On the other hand, ligament injury often involves very small micro-tears which usually do not show up well on these investigations and so have been largely overlooked.
MRIs Are Not a Diagnosis
The Textbook of Orthopedic Medicine (Ombregt et al.) states, “The results of radiographic examinations should never be given to the patient as a diagnosis.”14 MRIs show disc herniations; however, they do not reveal how old those herniations are or whether that herniation is the cause of the person’s pain. Many studies have documented the fact that abnormal MRI findings exist in large groups of pain-free individuals.15-21 A study published in the New England Journal of Medicine showed that, out of 98 pain-free people, 64% had abnormal back scans.22 However, many surgeons base their decisions to operate primarily on the outcome of these investigations.23 It is inevitable, then, that some of the surgeries done are not necessary and will not resolve the pain for which they are intended. Because of this, if the herniation is used as the only basis for a treatment plan, the person’s pain may not improve. And, because MRI’s may also show abnormalities not related to the patient’s current pain complaint, these MRI findings should always be correlated to the individual patient.
During recent years, the idea has become accepted by the general public that a herniated disc requires surgery, especially if the pain has not resolved after a few weeks and there is a positive MRI or CT. However common, this opinion has not been supported by evidence in long-term studies which show, instead, that equally good or better results are obtained after conservative non-surgical treatment. Two studies found no difference between final results of surgical and non-surgical therapy after 7 and 20 years of observation.24,25 Another study found a 92 percent return-to-work rate in a group treated conservatively, even though 60 percent had muscle weakness and 26 percent showed disc rupture on the CT scan.26 Therefore, the presence of even large herniations and/or disc ruptures should not be taken as an absolute reason for surgery.27-29 Due to the risks involved in surgery, conservative treatments—among them Prolotherapy—should always be undertaken first.
Weak Spinal Ligaments Precede Disc Herniation
Weakening of the spinal ligaments precedes disc herniations.30 For a disc to herniate, there must first be a primary ligament weakness and a deteriorating disc.31 Disc degeneration is so common it is considered part of the normal aging process.32 In the natural course of aging, a disc loses pliability and is less able to withstand normal pressures. Thus, it is more prone to having its outside edges become cracked or torn.33 If the pressure goes high enough, the fluid in the disc’s center can leak through these cracks or fissures. This also leads to decreased disc height. In addition, the ligament that holds the disc in place becomes lax and weakened. As a result, the joint becomes even more unstable and more likely to herniate (see Figure 1). Ligaments hold the disc in place, so if the ligament weakens, the disc can more easily herniate through it. In fact, increased pressure in the disc, together with increased ligament laxity, is the perfect recipe for disc herniation.34,35