Introduction to Prolotherapy

What is prolotherapy?

Prolotherapy is an injectable solution usually made up of a sugar compound, a local anesthetic, distilled water and specific vitamins and minerals. The physician injects the solution directly into an area that needs more healing or stability. Often times, past injuries or surgery never fully heal or just don’t heal correctly. When the fluid solution is injected, the sugar compound, usually dextrose, irritates the area just enough to cause a small inflammatory response. The body brings a fresh blood supply through increased circulation with nutrients to the agitated area so healing can begin. The sugar is easily absorbed by the cells into the body and the new cells are already in the area ready to restart some of the healing process toward the old injury. Prolotherapy works best and is most often used in joints and joint areas.

What treatments look like

First, the doctor will examine the area that may need additional healing or strengthening. Most people complain of pain in areas that didn’t heal correctly because the tissue is still damaged or the miss-healed tissues are not allowing the joint to work properly. Keep in mind, joint areas that didn’t heal fully are not necessarily painful, they might just be loose. The physician I worked with, Dr. Amber Belt, would examine how loose the joint is and then test to find the tenderer and painful points marking them with pen. She then mixes the solution in a rather large syringe. In joints, she injects dextrose, the sugar, and lidocaine, the local anesthetic. In more fleshy areas, her solution consist of dextrose, lidocaine, distilled water, and vitamin B-12 -- which she has found helps tissues heal. With a needle long enough for the area of treatment, she injects the solution deep into the most painful and loose points of the area. The injection time only lasts a few seconds, and the patient is quickly out of pain. For ideal outcomes, treatments are suggested to take place every two to six weeks until the area is healed. Depending on the patient and their situation, treatments may last a few months, or indefinitely, as in the case of pain relieve for arthritis or other causes of chronic pain.  Treatment is as individual as the patient and his or her pain they he or she are seeking relief for.  

Side effects

The doctor should first make sure the patient isn’t allergic to anything in the injection solution. This is highly unlikely, unless the patient knows specifically that they are allergic to local anesthetics like lidocaine. The injections can be particularly painful but tend to be less painful the more the procedure is done and as the area heals. Immediately after the injection, the local anesthetic begins to numb the area. Though the area is “numb”, it will often feel achy and “squishy”. The “squishy” sensation is especially noticeable inside the joint where it is filled with fluid that would not normally be there. In the day or two following, most people find the area particularly sore. After the soreness subsides, the area seems to returns to what the condition was before. The aimed effects of the treatments are not usually noticeable for a few months of persistent treatment. Prolotherapy should not worsen the condition or cause permanent harm.

Intended outcomes

Since the treatments I witness didn’t immediately relieve pain, I wasn’t quite sure what I was looking for to tell if this was a viable way to relieve pain. At first when I heard that the solution had a local anesthetic, I thought that must be the relief causing variable in this type of treatment. Though the local anesthetic does relieve some pain, it is intended for the discomfort of the injection and the hours following. After enough treatments, the healed tissues that used to send alarm pain signals to the brain no longer have to. This type of treatment takes time and patience and won’t give most people that quick relief that some are seeking. This type of treatment, in time, will help heal and relieve pain for the long-term in some cases. Prolotherapy is not ideal for acute injuries; there is no use to remind the body of a new injury. Many patients find it successful in treating old injuries and as an alternative to surgery. As I talked to patients early on in their treatment program, they weren’t noticing the positive effects immediately; the majority of these patients, however, remained hopeful and patient, knowing their healing and relief would come in time. As I talked to the patients well into their treatment plans, I asked what they had noticed change in their body and how they could tell if the prolotherapy had been successful. Common answers included increased range of mobility without pain, delayed onset of pain, and fewer sharp pain episodes. The further the patient was along in their treatment plan, it seemed the more promising and positive the results became. Over and over again I heard stories of people not only avoiding surgeries such as total knee replacements, but also being pain-free and able to move in ways they had not moved in many years, sometimes even decades. The positive outcomes are across the board. I am currently in the process of evaluating literature and writing a systematic review to help fully conclude the effects of prolotherapy.

Prolotherapy can help treat pain and range of motion associated with arthritis, old injuries, trigger finger, and carpal tunnel. Almost all joint and joint areas can be treated with prolotherapy according to Dr. Belt; hips, knees, feet, shoulders, and even fingers can be treated. Prolotherapy can be more successful in some cases if it is accompanied with physical therapy for that targeted area. 

A Mind-Body Connection

If you have a basic understanding of pain or if you read my previous blog post, you will know that pain deals with signals and connections between nerves in the body and the brain. We now have scientific insight to a whole other side to “mind-body connection” and the sensation of pain. In the last decade or so, there is a new popular idea backed by research that your brain sends signals alarming your body is in pain when the body never sent nerve signals that the body was in danger. This would mean that the brain is perceiving pain that may or may not be necessarily triggered at that moment or to a greater or lesser extent! There is a big element of pain that is made up in your mind! Let me be clear about a few things; pain that is made up in the brain does not mean that the person tries to convince themselves that they are hurting and then all the sudden – poof—there is pain. This idea is legitimate, proven, and effects everyone. Your mind has control over your health and how your body feels. This “mind-body connection” could help explain why everyone has a different pain threshold, pain in nonexistent limbs, and chronic pain in many cases. If you have 15 minutes, I highly suggest watching this TED Talk Lorimer Moseley gave on why things hurt, or rather, why some things hurt when they shouldn’t necessarily hurt. In his video, he talks about his own experience with this complex phenomenon. He describes as he walked through a bush the first day, twigs and branches scratched and cut up his legs, yet he was in no extreme amount of pain. His pain changed when he was bit by a snake and almost died. The next time he walked through the bush, he perceived extreme pain. There was no way that the sensations on his skin from the bush put him in that amount of pain, so what did? His brain rewired itself to produce massive amounts of pain while in the bush because that previous experience was linked to the event of the snake bite in those bushes. From an evolutionary stand point, this rewiring mechanism could have saved us from many dangers out in the wild, but today, in our lives now, many of these rewiring scenarios may be less necessary, or even a nuisance, and cause sensations of pain triggered by these experiences. Another more common example of this phenomenon is often seen when old people bend down to pick something up and they “throw out their back.” When the person bent down and felt extreme sharp pain, they probably didn’t break a vertebrae or dislocate their spine. If there was no serious tissue damage or measurable tissue damage at all, a rewired brain would perfectly make sense. The person could have had an injury that rewired the brain to cause pain to warn the body to stay out of that position because it could be dangerous.

So if real sensation of pain can be made up in the brain, can the brain also be taught or trained to alleviate pain? In short, science says yes. We often have a number of options to treat the brain-triggered pain, though it can be very difficult. The most common has become medication like narcotics; this method will not help the underlying problem, it can only mask the pain and could cause other harmful side effects. The next method is to retrain the brain that it doesn’t have to produce the sensation of perceived pain. I will explore this method later on in my blog. The last option is another fascinating phenomenon that deals with the “mind-body connection”; I will call this the placebo effect.

https://www.youtube.com/watch?v=gwd-wLdIHjs  - Lorimer Moseley’s TED Talk on why things hurt.

Meditation for pain

What is meditation?

“Meditation is a practice where an individual trains the mind or induces a mode of consciousness, either to realize some benefit or for the mind to simply acknowledge its content without becoming identified with that content, or as an end in itself.”- (Lutz, 2008)

The way I define meditation is either focusing on one thing or nothing at all. The most essential things to focus on during meditations are your breathing, your surroundings, or one thought that is in your mind. Often, when you meditate, you are called to focus on your breathing and to try not to think about anything else that is on your mind, just the way your lungs fill up and then collapse down again. Some might call this “a grounding experience” or “enlightening”. For some people this type of diction scares them away or makes them feel like this practice is illegitimate, but in reality it is just a relaxation method.

Meditation for pain relief

Recently I went to a Buddhist themed meditation group that meets at the Federated Community Church here in Flagstaff. The group does guided meditations, breathing meditations, self-meditations, and even walking meditations. When I decided to go to this meditation group for the purpose of the project, I did not know what to expect. As we sat down, we started with some deep breathing. After we were calmed down from our day, we started a discussion about our inner peace. For this particular section, it is helpful to know a little bit about Buddhism to understand the nature of this meditation group.  Buddhism cannot only be classified as a religion, but also a philosophy. Some sects of Buddhism don’t even believe in a god. A main idea throughout Buddhism is to be at peace with the present. In our culture today, our lives are plagued with regrets of the past and worries for our future. Our minds are hardy in the present moment. And even when they are in the present moment, we often have a discontentment and feel the need to change something, or we are unhappy. When one is in pain and in the moment, they often wish they could change the fact that they are in pain. This person is not at peace.

When I was with this group, they explained something to me. First of all, it is hard to always be at peace. No one is going to sit there and say to themselves, “I am fine with being in pain. It doesn’t bother me; I am at peace.” You might be uncomfortable; that does not mean you cannot strive for peace. If your hand is in pain, our society might be quick to focus on it and yell, “Where’s the icepack? Where are the pills? Where’s the pain relief?” At this group, they sought to focus on something else. If your hand is in pain, focus on your feet, or wherever, wherever’s not in pain. Keep your mind locked on the fact that your toes, your foot, your leg have no sensation op pain at all; be at peace with that while trying to ignore your hand. This is not easy and takes self-mastery over your mind and thoughts. Because it was my first real time “meditating”, I was not very proficient. I can definitely see how this can be used as a tool for pain relief, especially for those who are good at meditating. I don’t think that this alone could relieve pain, but it would definitely help manage low pain if we can control our minds enough. Who knows? You might be able to conquer your mind enough to eradicate your pain and maybe even unlock the secrets to the placebo effect (which I will talk about in a later post).

Lutz et. al; Slagter, HA; Dunne, JD; Davidson, RJ (2008). "Attention regulation and monitoring in meditation". Trends in Cognitive Sciences 12 (4): 163–9.

NSAIDs and Possible Alternatives

What should I be using NSAIDs for?

NSAIDs are often used for low grade acute pain like headaches, small injuries, or lower back pain (LBP). NSAID medications are well researched and proven; they are most effective for short-term use once in a while. Some doctors feel that drugs like NSAIDs are never necessary or advised because they feel there are better ways to treat the pain with no possibilities of harmful side effects. Most doctors have no problem with suggesting NSAIDs, but almost all doctors are against long-term use of NSAIDs. So, in short, you might want to consider NSAIDs if you have a day-long headache, or a week long injury. You should never consider NSAIDs as a pain management option for chronic conditions like back pain that you need to find a relief from every day for the next ten years. NSAIDs could have harmful side effects for you, but the chances of having severe harmful side effects is drastically increased after taking the drug 30 days or longer.

Harmful side effects of NSAIDs

Common side effects include high blood pressure, fluid retention, and kidney problems, but maybe the most notable side effects are upset stomachs, ulcers, or stomach bleeding. As the COX enzymes are blocked, stomach lining is often striped and causes these stomach issues. If you get any of these side effects, stop taking NSAIDs, the side effects are harmful and might cause long-term damage. Over the last few weeks I have met many people who took NSAIDs long-term for chronic conditions like arthritis. Now, many of them are living with the consequences and can never take NSAIDs again. Most described to me that toward the end of their time chronically taking the drug that they no longer felt relief because their body became so used to and resistant toward the drug. They had to decide to either take more pills, poison their bodies more and feel pain relief, or, stop taking NSAIDs altogether and find an alternative. When they stopped taking NSAIDs regularly, but attempted to take it on occasion, they were usually doubled over in pain with ulcers throwing up blood from their stomach. Their stomachs were stripped from any protective layer by the years of taking the drug, and they became over-sensitized to NSAIDs. These people were forced to look for alternatives to NSAIDs and have done so with success. One of my main goals of this project is to highlight some of the alternatives so that it is never necessary to take NSAIDs.

Some possible alternatives

The effectiveness of herbal medicines that relieve pain have been debated for decades. Some say they can be equivalent pain relievers to NSAIDs. Homeopathic treatments such as Arnica Montana, Devil’s Claw, and Willow Bark are all said to reduce swelling and relieve pain but are not as significantly proven as NSAIDs. It is very possible that Devil’s claw (Harpagophytum procumbens) and willow bark (Salix alba) could help reduce pain. The Devil’s Claw roots contain harpagoside, a substance that is believed to be an anti-inflammatory compound. Devil’s Claw’s effectiveness is much debated. Willow Bark contains the chemical salicin. Scientists believe that the chemical salicin is an anti-inflammatory ingredient, but it is not well proven. There is less evidence that either could help reduce inflammation. Both homeopathic remedies need to have further research done to have sufficient evidence to fully suggest that they are effective pain remedies. After there is sufficient evidence that they relieve pain, there would need to be studies on the ideal dosages, ideal forms of the plant for consumption, and adverse effects.

In Chrubasik et al., (1996), the lack of research toward herbal medicine was explained in a way that made sense. “Some herbal remedies that predated the need for randomized clinical trial have become established pillars of contemporary therapeutics, while others of more recent popularity are regarded with condescension by the medical establishment because they have not yet been put to the conventionally approved test.” Some believe in the herbal remedies because they have been used since ancient times, while others need to see recent and approved evidence that supports the claims. Presently, there needs to be more research to definitively show that devil’s claw and willow bark relive pain, but there is a good start in that direction.

There might be huge advantages to homeopathic pain relievers. Standard drugs like NSAIDs can have harmful side effects, especially on the gut, but other more natural options might have fewer. “The plant extract does, however seem to be free of side effects,” (Chrubasik et al., 1996). This is great news. But, again, this too needs to be researched more thoroughly. Some articles addressed above suggested that there could be adverse effects to the gut as well. “It is recommended that the use of Salix (salicin medication) preparations be avoided in patients who are sensitive to salicylates,” (Chrubasik et al., 2000). Some patients in that study were reported with gut problems. But in the same study, willow bark was suggested to those who can’t handle NSAIDs. “These drugs [PAIDs (Phyto-anti-inflammatory drugs)] produce potent analgesia with a significantly lower risk of gastrointestinal toxicity,” (Chrubasik et al., 2001). Through the studies I’ve read and analyzed, both plant-based relievers, Devil’s Claw and willow bark, showed positive tendencies. Clearly more research is necessary to have more concrete evidence and answers, but overall, I would suggest Devil’s Claw and willow bark as alternatives to NSAIDs for pain relief.

As a side note: if you are interested in reading my literature review on Devil’s Claw and willow bark, feel free to contact me via email.

Chrubasik, S., et al. "Effectiveness of Harpagophytum procumbens in treatment of acute low back pain." Phytomedicine 3.1 (1996): 1-10.

Chrubasik, Sigrun, et al. "Treatment of low back pain exacerbations with willow bark extract: a randomized double-blind study." The American journal of medicine 109.1 (2000): 9-14.

Chrubasik, S., et al. "Treatment of low back pain with a herbal or synthetic anti‐rheumatic: a randomized controlled study. Willow bark extract for low back pain." Rheumatology 40.12 (2001): 1388-1393.

What is pain?

To begin my project on pain management, we first have to understand what pain is. The most basic understanding of pain is that there is some kind of injury or harm to the body that triggers a feedback loop from the inflicted area, to the brain, and then back to the inflicted area. For example, if you pinch your shoulder, nerve signals starting from your shoulder will travel up to your brain, where the nerve signals are analyzed as pain. The brain then sends a new set of signals to the shoulder to react, maybe to jerk away out of harm.  This is a basic and simplistic way to think of one type of pain, but it is not always this strait forward or simple. Pain is quite a monster to try to understand. Someone who’s had chronic back pain for the last thirty years probably has a much deeper problem than a temporary pinch. That being said, we can see that there are different kinds of pain. The pain is either chronic or acute.

Acute Pain

The example of the shoulder being pinched is a perfect example of acute pain. Acute pain is often classified as temporary pain. If the pain lasts less than six months, it is acute pain. Also acute pain usually has a known explanation to its cause, most likely an injury that will heal. Acute pain is generally easier to treat. NSAIDs will often suffice for a while. Chronic pain on the other hand, is very different.

Chronic Pain

To begin, chronic pain lasts longer than six months. Chronic pain often stems from deeper rooted problems in which pain is only a symptom to the underlying problem. A good example of chronic pain stemming from a bigger problem is Rheumatoid arthritis, when the immune system attacks the joins causing inflammation, swelling, and pain. Other causes of chronic pain include nerve damage, injuries that did not heal right, or sometimes pain for no clear reason. Chronic pain is generally much harder to treat. NSAIDs are potentially damaging to the body if you are using them for very long. These definitions between chronic and acute pain are not hard and fast, but rather basic ideas.

Recently I sat with Jay McCallum over coffee, and learned a little about pain. Jay McCallum is the co-owner of a physical therapy practice, Corebalance Therapy, here in Flagstaff. His practice is largely based around back pain, though he treats many other ailments. I found one idea he thought regarding chronic pain particularly interesting. He explained that what once could have been an acute injury could have turned into full blown chronic pain, even if the injury had healed. When the tissue was injured, the pain signals through the nerves were constant. For whatever reason, even as the ailment was healing, the brain continued pain signals just as prominently as before. This can turn into a serious problem. The nerves that are used to the pain signals become over sensitized, and the brain could learn that sending an overwhelming amount of pain signals is the normal thing to do. Meanwhile, the patient suffers. So now, in these types of cases, the goal is to retrain the brain that it does not have to send pain signals because the body is not being harmed.  Later on in my project I will explore a little more of Jay McCallum’s work and also how there is a mind-body connection with pain. 

What is HIPAA and the history behind the law?

Before my project began, I had to learn about a law enforced throughout the medical field (via the U.S. Department of Health and Human Services) and be certified to show that I understand and would follow the law. HIPAA is a law that was put into place in 1996 to protect patients and their information. This privacy law stands for Health Insurance Portability Accountability Act; although the name of the law specifically addresses health insurance providers, this law holds everyone in healthcare accountable to keep the privacy of the patient.

How was patient privacy dealt with before HIPAA?

Before 1996, privacy laws were loose and largely based on vague unwritten medical and business ethic morals of the healthcare workers and third party administrators. In the third century BC, the Hippocratic Oath was initially developed, mainly stating that the first goal to any medical practice is to do no harm to the patient. In 1948, the Declaration of Geneva became a standard among most countries after WWII in response to the inhumane testing done on humans by Nazi Germany. The main basis to the Declaration was the Hippocratic Oath, but also the agreement expanded on ethics regarding privacy, suggesting that doctors should not use patients’ information to gain publicity, or personal gain. The Declaration states, "I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. Above all, I must not play at God.”

Until 1996, patient privacy in our healthcare system was vastly self-regulated, with the exception of healthcare within the U.S. Armed Forces. Many hospitals and practices had rules centered on ethics that they set and followed, but there was no law that could hold the United States’ healthcare system, as a whole, accountable. In 1996, HIPPA finally set privacy rules and guidelines for the entire United States healthcare system, which largely resembled the Department of Defense’s The Privacy Act of 1974.

What is HIPAA?

The Health Insurance Portability Accountability Act of 1996 is the privacy law that everyone that comes in contact with the patient’s personal identifiable information must follow. People and entities like the doctors, health insurance providers, and people like me, who sometimes shadow the doctor in the patient’s appointment, are held accountable to follow the HIPAA law. We must keep all Private Personal Information secure between the patient and healthcare team. Information we must keep secure include the patient’s name, address, and social security number. Later in my blog posts, when I write about their story, treatments, and experiences, I must make sure that no one can figure out who I am talking about by the information I present so that I follow HIPAA.

The HIPAA law does not just outline what I can and cannot disclose about the patient. The law also set guidelines about how Protected Health Information is handled and kept in the system.

HIPAA policies must be upheld by anyone or any entity that maintains, uses, or transfers patient information.  HIPAA insures that patients are told every time their information is requested and requires they give permission every time information is shared.  HIPAA also allows patients access to their own health information, and prohibits anyone or any entity from misusing the information or using it against them. Although I am required to know all parts of the law, the main piece that pertains to me and this project is what information is shared and how I present their cases so that the patients’ identity and privacy is preserved.  

Introduction 

Welcome to my blog! In these next couple of months, I will be researching and learning about pain and pain remedies. It has become so common to take a pill or two at the slightest headache. We have numbed ourselves to the pain we could otherwise suffer through. Although Advil and other light pain relievers work well and within the hour, the side effects can be great on the kidneys, stomach, and liver. I will explore lesser known and less common pain methods that are comparable to well-known and proven westernized pain relievers, particularly NSIADs (non-steroidal anti-inflammatory Drugs). I want to find lesser known alternatives to NSAIDs and show that they are viable options worth considering. My goal of this project is to, first, differentiate the types of pain, identify different ways of treating the pains, then to analyze how they work and their effectiveness. I hope to find the alternative treatments that are viable and comparable to the traditional methods with fewer side effects.

There are three main NSAIDs (non-steroidal anti-inflammatory drugs) that are widely available in stores without a prescription. Each drug works similarly; each inhibits the Cox-1 and Cox-2 enzymes from producing the substrate, prostaglandin. Prostaglandins help induce swelling which, to an extent, protects the injury. The reduction of prostaglandins helps reduce swelling and, therefore reduces pain. Often herbal homeopathic remedies are said to relieve pain. I have tried alternative medicines like Arnica but found little relief from this particular treatment. This was upsetting because I truly wanted to turn to a more natural treatment. I was especially frustrated to read the back of the bottle. They seemed to swear by the product and stand by its effectiveness, but as I started to research through past studies, I found contradicting evidence.  As I started my literature review, I researched other herbal medicines that were said to relive pain as well, much like Arnica. Devil’s Claw and willow bark could work as well as NSAIDs if proven more thoroughly (see my literature review). Other methods like physical therapy are intended to solve the underlying problem, and in turn, relieve pain.

BRAND NAME NSAID	GENERIC NAME
Advil, Motrin	Ibuprofen
Aleve	naproxen sodium
Ascriptin, Bayer, Ecotrin	Aspirin

During the course of this project, I will work with several professionals that treat pain. Some of the professionals that I will be working with do not necessarily treat pain in the clinical sense, but I can build on to my project regarding pain while working with each of the advisers. The pain I intend to focus on are all types of pain that NSAIDs can help or relieve. There are so many different kinds of pain that NSAIDs can treat from mild arthritis, and tendinitis, to head aches, non-specific low back pain, and slight injuries. NSAIDs may treat pains, but there are other options that might treat the pain like physical therapy, acupuncture, or herbs. I plan to dabble in several different methods with several different people, learning a variety of techniques. I fully intend to investigate alternative methods that do help pain and the truths behind each. I hope that my work will raise awareness about alternative pain treatments.