July 2002
Prolotherapy for Shifty Joints             

One of the most significant concerns in chiropractic clinical practice is the proper position and movement of the spine and other joints throughout the body.  Chiropractic technique is heavily weighted towards mobilization in the treatment of various (neuro)musculoskeletal disorders, including subluxation.  In the case of CBP®, global spinal subluxation is detected through postural and radiological examination, and corrected mainly through Mirror Image® drop-table / manipulation / instrument adjusting, Mirror Image® exercises, and traction. 

            Although the majority of chiropractic education espouses a segmental approach to spinal analysis and adjusting, the spinal segments function in groups or units in terms of body motion.    

            The global spinal approach views segmental misalignment as coupling patterns within a larger postural distortion.   

            As one practical example, try moving your C5 vertebra. This can be accomplished by moving your head relative to your ribcage in any plane of motion, because the cervical vertebrae including C5 connect the skull to the thorax.  Now try moving just C5.  Can’t be done because functionally C5 doesn’t position and move in isolation to the other segmental cervical spinal units.  So why try correcting one spinal segment in isolation to its neighbors?

            In all probability, most joint dysfunction occurs during everyday use and abuse (such as postural strain) where groups or units of the spine are affected in the manner in which they move and function.  However, there are exceptions to every rule.  Segmental misalignments can and do occur in cases of ligamentous failure.  A knife-hand karate chop to the mid-neck could certainly move just C5 by tearing the tissues that connect that segment to its neighbors above and below.  If the injury heals poorly and becomes chronic, or is repeatedly injured over time by way of recurrent micro-traumas, the supporting soft tissues can lose their natural ability to hold the segment in place and guide physiologic motion properly.  No amount of mobilization or adjusting will correct the problem.  This injury scenario may explain one common mechanism for some of those patients that never seem to get well.  How can we help them?

            When adjusting / manipulation / mobilizations aren’t the answer, and rest / support / bracing fails to stabilize the affected joint(s), one possible solution (no pun intended) is a solution of as dextrose-glycerine-phenol, otherwise known as a sclerosing agent.  The injecting of sclerosing agents, or “sclerosants” goes back to the 1830s when chemical irritants were used for nonsurgical repair of hernias.  The term prolotherapy was first coined in the 1950s and is derived from the Latin “proles” which refers to the stimulation of growth

            In prolotherapy, solutions that provoke an inflammatory response are injected at the interface between bone and tendon, ligament, or fascia (passive or non-contractile connective tissues) that provide much of the static postural support for the spine.  These tissues are subject to micro-tearing after irreversible joint strain has occurred.  The tears usually occur at the fibro-osseous junction where two tissues with dissimilar properties unite.  The joint can become partially unstable, lax or hypermobile.  Attempting to heal these tissues with bracing or immobilization alone may cause an alteration of collagen with a decrease in glycosaminoglycans and a reduction in tensile strength.  The benefits of manipulation are not sustainable without strengthening the supporting ligaments.

            A proliferant solution such as dextrose-glycerine-phenol, injected into the intraligament or intratendinous junction induces a temporary inflammatory response that leads to fibroblastic hyperplasia and the growth of collagen.  The synthesis of new collagen in an extracellular connective tissue matrix increases tendon or ligament junction strength and, through controlled tissue stressing (exercise), induces proliferating fibroblasts to line up in parallel to existing connective tissue.  Thus, the proliferation process initiates an injury-repair sequence. 

            After the proliferant solution or sclerosant is injected, an inflammatory exudates peaks at 24 hours then subsides completely over the next 48 hours.  By 72 hours there is a proliferation of fibroblasts leading to new collagen formation by day seven, and dense fibrous tissues become evident by eight weeks.  Animal studies have shown an increase in ligament mass, thickness and junction strength following prolotherapy injections.  Side effects are limited to soreness and stiffness for several days after each treatment, of which 6 to 10 are generally required spaced apart at one or two week intervals.

            The technique involves making multiple insertions and withdrawals with a small gauge needle, fanning out from each cutaneous entry point.  Bony landmarks may be lightly touched at the periosteum with the needle tip and aspirated (slightly pulling back on the syringe) before each injection to be certain it is the fibro-osseous junction that is being contacted.  Spinal and other joints of the body that have been injured (torn) by way of acute or chronic trauma and need to be tightening up are candidates for this procedure.  Hypermobile joints in those patients who seem to have “greater than normal” flexibility and never seem to hold an adjustment often fit the profile of properly selected cases.

References

            1. M. Ongley et al.  A New Approach To The Treatment Of Chronic Low Back Pain.  The Lancet July 18, 1987:143-146.

            2. R. Klein, B. Eek.  Prolotherapy: An alternative approach to managing low back pain.  J Musculoskel Med 1997; 14(5):45-59.

            3. R. Klein et al.  A Randomized Double-Blind Trial of Dextrose-Glycerine-Phenol Injections for Chronic, Low Back Pain. J Spinal Dis 1993; 6(1):23-33.