This brief review was prompted by the recent publication of guidelines for MRI scans for low back pain by the American College of Physicians and the American Pain Society.1
WHAT IS THE BASIC PRINCIPLE OF PROLOTHERAPY?
Prolotherapy is based on the understanding that the majority of musculoskeletal pain arises from damage to soft tissue especially ligaments, tendons and joint capsules. Ligaments and tendons have a large number of sensory fibers, including those related to propioception, stretching of the spindle apparatus and intraligamentous free nerve endings.2-5 Stretching beyond the normal range or injury to these receptors causes considerable pain. The pain may radiate very widely and is commonly misdiagnosed as neuropathic pain.5
HOW IS A LIGAMENT AND TENDON INJURY DIAGNOSED?
Fortunately for the Prolotherapist, most of the commonly injured structures i.e., the limbs, dorsal and lateral neck, chest and abdominal wall and the dorsum of the spine and pelvis, are easily accessible to palpation. Damaged ligaments and tendons are tender to palpation. Therefore, careful palpation of the painful areas reveals the source of pain and is the main diagnostic tool of the Prolotherapist.
Injuries to deeper ligaments and tendons, mainly the anterior and posterior longitudinal ligaments and ligamenta flava of the spine, and the anterior pelvis cannot be determined clinically. Treatment of these structures is rarely necessary.
WHAT ABOUT RADIATING PAIN?
Many physicians believe that radiating pain indicates nerve damage and that specialized imaging, especially magnetic resonance imaging of the spine is the appropriate way to identify the source of such pain. However, there are cogent arguments against this:
- It has been known for decades that pain arising from ligament and tendon damage can radiate widely, mimicking neuropathic pain.5 This can be clearly demonstrated clinically. For example, pressure on gluteal muscle attachments to the ilium frequently reproduces radiation of pain down the leg, so called “sciatica.” Since the sciatic nerve is some distance from the palpated area, the origin of the radiating pain must be the gluteal tendinous attachments to the ilium.
- Findings from MRI scans rarely correlate with the site of the pain.1
- Therapy directed at removing disk compression on the nerve, the putative cause of pain based on MRI findings, rarely resolves the radiating symptom and may exacerbate it.
- Injection of local anesthetic into the tender area immediately relieves the referred pain.
- The radiating pain disappears when the injured ligaments and tendons are restored by Prolotherapy.
A VIGNETTE FROM MY PRACTICE
A middle aged man came to see me complaining of pain radiating from his shoulder to the hand. He had previously seen physicians who had followed the traditional approach. An MRI scan of the neck revealed disk herniation at C4-5 and he underwent surgery and fusion. However, the pain down his arm persisted. A second MRI revealed disk herniation at C3-4 and he underwent a second surgical procedure and fusion, without relief. When he consulted me, he demonstrated that the pain radiated from the shoulder blade down his arm; subsequent palpation of the infraspinatus muscle precisely reproduced the pain radiation down his arm. Careful attention to the patient’s complaints and direct clinical examination of the appropriate region is critical to making the correct diagnosis. In my opinion, this patient could have avoided unnecessary spinal surgery…twice.
WHAT IS THE ROLE OF IMAGING, ESPECIALLY “ADVANCED” IMAGING IN PROLOTHERAPY?
A trend of medicine, especially in the United States, is to rely on advanced technology, which is said to provide “objective” evidence of diagnosis. This reliance is misguided and self-fulfilling, since clinical examination is frequently cursory, if performed at all, leading to the clinician’s diminishing confidence in his/her own skills. As Dr. Hackett noted in his monograph: “With the dependence on x-rays and other modern methods of diagnosis, together with the neglect in knowledge of ligament disability, the source of pain, which is essential for accurate diagnosis, has been overlooked. Consequently, the modern diagnostician with his limited powers of perception is distinctly at a disadvantage.”5
The authors of an authoritative textbook of orthopedic medicine state that: “Blood examination, radiography, echography, electromyography, computed tomography and magnetic imaging are often requested but seldom of great help to the orthopedic physician; furthermore, they too often reveal findings that are completely irrelevant to the lesion.”6 In fact, some studies have shown that clinical examination of the shoulder and knee are more accurate than MRIs.7-9 Even for tears of the meniscus, which are not accessible to palpation, a thorough review by Hauser et al. showed that MRI scans are not reliable, producing many false positives and some false negatives.10
MRIS FOR LOW BACK PAIN
Recent guidelines for diagnostic imaging for low back pain, developed jointly by the American College of Physicians (ACP) and the American Pain Society (APS), based on a thorough review of published studies, were unequivocal: “Diagnostic imaging studies should be performed only in selected, higher risk patients who have severe or progressive neurologic deficits or are suspected of having a serious or specific underlying condition.”1 Further, these authors and others point out that performance of unnecessary tests is associated with significant potential harm, mainly the performance of invasive procedures of questionable benefit.11-14
WHAT ABOUT MUSCULOSKELETAL ULTRASOUND IMAGING?
Musculoskeletal ultrasound imaging has advanced substantially in recent years. The images produced are of higher quality and the machines are smaller and portable. They can reveal injury to ligaments and tendons, especially partial tears and damage at the enthesium, far more sensitively, and possibly more specifically than an MRI. However, my own experience has been disappointing to date. Firstly, I have encountered very little enthusiasm for musculoskeletal ultrasound imaging among radiologists in this major medical city. Secondly, I have had patients with significant ligamentous tenderness which was not identified on the ultrasound. Lastly, I am not aware of any studies that correlate ultrasound imaging with autopsy or surgical findings.
Careful clinical examination can reveal the source of pain in the majority of patients. Plain radiography is useful where distortion of anatomy is suspected, such as after surgery or in patients with trauma or severe scoliosis. Imaging may be helpful if there is strong clinical suspicion of an underlying disease; MRI scans of the spine would be critical in the presence of progressive or severe neurological signs, where surgery would likely be necessary. Although musculoskeletal ultrasound holds promise, there is not yet enough information to recommend this. It may help to guide Prolotherapy injections and would, therefore, best be done by the Prolotherapist at the bedside.
1 Chou R, et al. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011; 154:181-189.
2 Ravin TH, et al. Principles of Prolotherapy. 2008. American Academy of Musculoskeletal Medicine.
3 Hauser RA, et al. Prolo Your Sports Injuries Away. Chapter 16 pp 206-221: My reproducibility instrument: the only MRI the athlete should ever need. Beulah Land Press, 2001.
4 Alderman D. Free Yourself From Chronic Pain and Sports Injuries. Chapter 8, pp 67-72: MRIs can be misleading in diagnosing musculoskeletal pain. Family Doctor Press, 2008.
5 Hackett G. Ligament and Tendon Relaxation Treated by Prolotherapy. 3rd Edition. Springfield, IL: Charles C. Thomas, Publisher, 1958.
6 Ombregt L, et al. A System of Orthopaedic Medicine. 2nd edition 2003. Churchill Livingstone, Philadelphia, PA, USA.
7 Esmali Jah AA, et al. Accuracy of MRI in comparison with clinical and arthroscopic findings in ligamentous and meniscal injuries of the knee. Acta Orthop Belg. 2005;71:189-196.
8 Liu SH, et al. Diagnosis of glenoid labral tears. A comparison between magnetic resonance imaging and clinical examinations. Am J Sports Med. 1997; 25-141-4.
9 Goldstein WM. MRI may be overused in diagnosing knee osteoarthritis. Presentation to American Association of Orthopedic Surgeons 75th Annual Meeting. Reported by Bouck L. 2008; www.mescape.com/viewarticles/571156.
10 Hauser RA, et al. The case for utilizing Prolotherapy as first-line treatment for meniscal pathology: A retrospective study shows that prolotherapy is effective in the treatment of MRI-documented meniscal tears and degeneration. J Prolotherapy. 2010;2:416-437.
11 Hadler NM. MRI for regional back pain. Need for less imaging, better understanding. JAMA. 2003;289:2863-4.
12 Jarvik JG, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain. A randomized controlled trial. JAMA. 2003;289:2810-18.
13 Deyo RA. Magnetic resonance imaging of the lumbar spine-terrific test or tar baby? N Eng J Med. 1994;331:115-116.
14 Jensen MC, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Eng J Med. 1994;331:69-73.