PRP vs Prolotherapy for lumbar/SI - pros/cons?

[Lady_Eboshi]

[QUOTE=Simkie;8773137]
Lady E, you’ve posted this several times: http://dralisongrimaldi.com/resources/lateral-hip-pain-mechanisms-and-management/

Can you please point me to multiple, peer-reviewed studies that prove this treatment is effective? No? Oh, it must not work.

There is SO much we don’t understand about pain. SO MUCH. It is unfair, and, frankly, offensive for you to say that the only way these “alternative” therapies work is the placebo effect and insinuate that anyone who finds relief must be getting it because of that effect. I think we understand that you’re not supportive. Fine, you don’t have to go get dry needled. Or have PRP. Or go for Myofacial Release. Or try Kinesio Taping. But these things WORK for some people. Why?? Dunno. Maybe we’ll find out once we learn more about pain.[/QUOTE]

You got it–it DOESN’T work. If you read that article, the only thing anyone can agree upon is that for the condition described, there is as of now NO demonstrably effective treatment except time and rest. So why bother paying for any?

That’s my point; as Dr. Nortin M. Hadler says in Worried Sick, the only common denominator among nearly all the “modalities” peddled today for musculo-skeletal pain is their ineffectiveness. Many are sheer quackery.
Some of you asked how double-blind studies would be done. They have been, I refer you to The Cochrane Collaboration’s library. “Sham” (fake) treatment acts worked exactly as well as “real” treatments–in chiro, acupuncture, even fake surgeries for low back pain. Which is to say, anecdotal subjective relief, usually very temporary. Bottom line is still that Nature has to do any healing that is possible. Many of us, like unsound horses, will be facing it in the coming years that lifelong athleticism may not be possible for all as a result of pushing our limits so much in the past–it even has a name now, “Boomeritis.”

The devil of it all is that ANY pain in the low back/hip region, excepting from obvious osteoarthritis of the hip, is extremely difficult to Dx, imaging is seldom conclusive, and many, MANY treatments are tendered to the wrong thing in the wrong spot (and this is by MD’s!) with the net result, null or worse. Under those circumstances “What will happen if I just do nothing?” is a very valid question, I feel.

For those of us stuck with Obamacare, which is many in the horse business who had to buy individual insurance policies, money is tight. It makes the most sense to put that money into things that are actually medically proven to advantage you; not partisan belief-systems for which no known biological plausibility exists.

First, do no harm. PLENTY of these people do harm, if you’re lucky only to your checkbook and frustration factor. In horses, rest, gentle natural movement as opposed to hard training, and NSAID’s when an active inflammatory state exists is still the best bet. And you can do the equivalent yourself for free! Hey, it’s one opinion you can take or leave; lots of times here I’m also writing for the lurkers.

Wishing anyone fighting a literal PITA the best of luck!

[Simkie]

Prove to me that anything said here is different than pure quackery. You’re advocating for something with no blinded study backup. Stop talking out of both sides of your mouth.

Tendon decompression strategies aim to minimise the amount of compressive loading that may occur over a 24-hour period. this is the key to early symptom control. increasing awareness of negative postural habits and controlling them are critical. Positions to avoid include standing hanging on one hip in adduction, sitting with legs crossed, or sitting with the feet wide and knees together, which is a common female trait. due to the connection of the fascia lata into the gluteal and thoracodorsal fascia, sitting in more than 90-degree hip flexion for prolonged periods can also be a problem. sitting in low lounges and car seats, which generally slope backwards, often results in ‘start up’ pain on rising to stand. avoiding low chairs and using a wedge cushion to bring the hips higher than the knees can be very beneficial.
Night time is the other major issue, as it represents a significant portion of the 24-hour period. eight hours of either lying on the symptomatic side (direct compression against bed), or lying with the symptomatic hip in flexion/ adduction will significantly add to the cumulative compressive load. Patients may be most painful at night, particularly lying on their side, or when initiating a rolling manoeuvre, similar to the sit-to•stand ‘start up’ pain. sleeping in supine with a pillow under the knees to offload the hips and lumbar spine minimises compressive loading. Many patients, however, find it difficult to sleep in this position. to reduce compression for the side-sleeper, an appropriate recommendation would be to add an eggshell mattress overlay to the bed, and sleep with a pillow, or pillows, between the knees and ankles that preferably approximates a horizontal position of the uppermost lower limb.

For the patient who has tightness and overactivity of the superficial soft tissues, stretching, while a common strategy, will only aggravate the situation due to the associated compressive loading. Massage, self-trigger point releases, acupuncture, dry needling and heat will all be more appropriate. But this should never be an isolated management approach. Long-term positive outcomes will only be achieved by addressing poor postural and movement habits, and active correction of muscle dysfunction.
Therapeutic exercise should be directed towards techniques that aim to recruit the muscles of the abductor synergy in a way in which:

• there is adequate recruitment of the deep abductors, gluteus minimus and the deep fibres of gluteus medius;
• there is consistency with the natural function of these muscles; and
• compressive loading is minimised by avoidance of repetitive or loaded hip adduction.

Real-time ultrasound presents the best opportunity in a clinical situation to assess and retrain the deeper hip abductors. once appropriate recruitment strategies have been elicited, graduated strengthening should occur wherever possible in a weightbearing environment. sidelying 'clams' (abduction/ external rotation to adduction/ internal rotation) and sidelying leg lifts are often provocative due to repetitive compressive loading on return to adducted start positions. these exercises should therefore be avoided. Furthermore, open chain exercise is unlikely to replicate closely enough the natural proprioceptive stimulus and balanced abductor activation of weightbearing function. sliding platforms (e.g. Pilates reformers) that allow resisted abduction in standing provide both a low compression exercise alternative and a situation more consistent with natural functioning in these antigravity muscles. Further bias for the deeper abductors can also be achieved via targeted inner range abductor strengthening on these sliding platforms. the primary focus during other functional weightbearing tasks such as single leg stance, lunges and step work should be on minimising hip adduction, which may require hand support (stick, back of chair, wall) in the early phases. Higher level exercises should be progressed as appropriate for the patient's needs. a graduated return to activity should also be instituted to avoid rapid changes in tendon loading which may be provocative.

[Simkie]

Prove to me that anything said here is different than pure quackery. You’re advocating for something with no blinded study backup while demanding blinded study backup for other treatments. Stop talking out of both sides of your mouth.

Have you ever noticed how this article advocates for dry needling? :lol:

Tendon decompression strategies aim to minimise the amount of compressive loading that may occur over a 24-hour period. this is the key to early symptom control. increasing awareness of negative postural habits and controlling them are critical. Positions to avoid include standing hanging on one hip in adduction, sitting with legs crossed, or sitting with the feet wide and knees together, which is a common female trait. due to the connection of the fascia lata into the gluteal and thoracodorsal fascia, sitting in more than 90-degree hip flexion for prolonged periods can also be a problem. sitting in low lounges and car seats, which generally slope backwards, often results in ‘start up’ pain on rising to stand. avoiding low chairs and using a wedge cushion to bring the hips higher than the knees can be very beneficial.
Night time is the other major issue, as it represents a significant portion of the 24-hour period. eight hours of either lying on the symptomatic side (direct compression against bed), or lying with the symptomatic hip in flexion/ adduction will significantly add to the cumulative compressive load. Patients may be most painful at night, particularly lying on their side, or when initiating a rolling manoeuvre, similar to the sit-to•stand ‘start up’ pain. sleeping in supine with a pillow under the knees to offload the hips and lumbar spine minimises compressive loading. Many patients, however, find it difficult to sleep in this position. to reduce compression for the side-sleeper, an appropriate recommendation would be to add an eggshell mattress overlay to the bed, and sleep with a pillow, or pillows, between the knees and ankles that preferably approximates a horizontal position of the uppermost lower limb.

For the patient who has tightness and overactivity of the superficial soft tissues, stretching, while a common strategy, will only aggravate the situation due to the associated compressive loading. Massage, self-trigger point releases, acupuncture, dry needling and heat will all be more appropriate. But this should never be an isolated management approach. Long-term positive outcomes will only be achieved by addressing poor postural and movement habits, and active correction of muscle dysfunction.
Therapeutic exercise should be directed towards techniques that aim to recruit the muscles of the abductor synergy in a way in which:

• there is adequate recruitment of the deep abductors, gluteus minimus and the deep fibres of gluteus medius;
• there is consistency with the natural function of these muscles; and
• compressive loading is minimised by avoidance of repetitive or loaded hip adduction.

Real-time ultrasound presents the best opportunity in a clinical situation to assess and retrain the deeper hip abductors. once appropriate recruitment strategies have been elicited, graduated strengthening should occur wherever possible in a weightbearing environment. sidelying 'clams' (abduction/ external rotation to adduction/ internal rotation) and sidelying leg lifts are often provocative due to repetitive compressive loading on return to adducted start positions. these exercises should therefore be avoided. Furthermore, open chain exercise is unlikely to replicate closely enough the natural proprioceptive stimulus and balanced abductor activation of weightbearing function. sliding platforms (e.g. Pilates reformers) that allow resisted abduction in standing provide both a low compression exercise alternative and a situation more consistent with natural functioning in these antigravity muscles. Further bias for the deeper abductors can also be achieved via targeted inner range abductor strengthening on these sliding platforms. the primary focus during other functional weightbearing tasks such as single leg stance, lunges and step work should be on minimising hip adduction, which may require hand support (stick, back of chair, wall) in the early phases. Higher level exercises should be progressed as appropriate for the patient's needs. a graduated return to activity should also be instituted to avoid rapid changes in tendon loading which may be provocative.

[Where_sMyWhite]

Lady E. Then feel free to believe as you do and please do not belittle those of us who choose to pursue alternatives which are not medically proven.

FWIW, the only modality of those I personally have tried to address musculo-skeletal pain was Feldenkrais. I am more than sure that my results would not be quantifiable but I do believe, despite being skeptical going into the process, that 10 years of Feldenkrais kept me off the surgeon’s table.

The other modalities that I mentioned, dry needling and MFR, were to address other non-musculo-skeletal pain issues. Dry needling did not do anything to address what I was seeking (not pain management). MFR did and continues to help the issue I pursued it for (not pain management).

Yes, the OP was seeing to address pain, but these modalities can certainly be used for other things…

[beaujolais]

My question to Eboshi is, are you a chronic pain patient yourself? I don’t “know” you, you may be, but I get the feeling not. People who suffer terribly usually don’t present as, “I’m not going to try that, as it’s not proven.”

Slightly different but I find Ultram to be a good medication. Some here say it absolutely does not work on them at all. Goes to show, different things for different people.

[Mouse_amp_Bay]

Sometimes it just takes a good long while for science to catch up with old school remedies (in this example, acupuncture):

https://www.actcm.edu/news/new-scientific-breakthrough-proves-why-acupuncture-works/

Keep in mind that this is now considered a pretty standard treatment modality, recommended for pain relief by many physiatrists and pain specialists. Despite us not really being sure exactly how it works.

When science can make a cell from scratch (not clone, actually put the pieces together), then you’ll convince me that we’ve got it all figured out.

[Lady_Eboshi]

[QUOTE=beaujolais;8774978]
My question to Eboshi is, are you a chronic pain patient yourself? I don’t “know” you, you may be, but I get the feeling not. People who suffer terribly usually don’t present as, “I’m not going to try that, as it’s not proven.”

Slightly different but I find Ultram to be a good medication. Some here say it absolutely does not work on them at all. Goes to show, different things for different people.[/QUOTE]

Yes. Been lurchin’ around the farm with a lovely Trendelenberg gimp for 16 months now. Some recurrent/remittent soft-tissue thing, fits the description of glute-medius tendinopathy to a “t”, and getting better this time glacially. It doesn’t hurt at night or when sitting any more, huge step up. Fortunately, I can do my barn work and ride lightly, albeit a lot more slowly and carefully than I used to. Blew it this time by violently turning my ankle and taking an awkward plunge (caught myself before going down) on a day when my back was already “out” from flipping a cast horse.

Which is why I’ve been doing the extensive reading, and a bit of posting here. From what I’ve seen, if you don’t go the “alternative” route, the sequence with the equally ineffective orthos is:

(1) Heavy pain pills that work somewhat and temporarily (and are addicting).

(2) Cortisone injections that work somewhat/temporarily, and degrade joints.

(3) P.T. that will force you to use #1 above, and convince you to have surgery.

(4) Back surgery that “fixes” incidentalomas found on imaging, which most likely are not the thing causing the pain–since surgery so seldom brings relief.

(5) Now you have “failed back syndrome,” you’re on your own with OTC’s and woo-woo, and if Nature can heal it, in a couple years or so Nature will.

That’s pretty much been the experience of boarders, friends, etc. who’ve been through this. Lots of pills and procedures, much frustration, and it heals when it’s damned good and ready. Also, like a 20-year old event horse, we’re not going to be the athletes in our 50’s that we were at 35. At the end of the day, doing “everything” or “nothing” gets you about the same, and my principal concern is I don’t want it made WORSE. Right now I’m functional; if somebody mucks around there, I may NOT be! Granted that my pain is more annoying and restricting than desperate and life-altering like some of yours may be, but so far I’m at least keeping my money in my pocket.

I throw this admittedly seldom heard perspective out there because (1) it’s actually the KNOWN state of the science concerning back/hip pain and (2) many COTH’ers seem, much more than people I know IRL, to have a near-religious level of belief in all things “therapeutic” for both horse and rider and spend a tremendous amount of money, time, and pain on unnecessary or unhelpful “treatments” that have long since been debunked. Insurance companies don’t pay for things like “prolotherapy” for a REASON. And that is a painful, invasive procedure! Consider carefully.

The argument for evidence-based medicine is certainly a valid one, and happens to be my personal choice. Just one more opinion like any other posted here, take it or leave it as you will.

[Laurierace]

You are entitled to your opinion and are entitled to express your opinion over and over and over and over. You are not entitled to belittle people who don’t agree with your opinion. That is saved for the Current Events forum.

[Lady_Eboshi]

Haven’t “belittled” anyone.

I just happen to have a different opinion from yours.

[JoannaHCR]

I have had myofasical releases done on me 1-2 times, and have used it many times on the horses, it has worked wonders for them.

I broke my back when 13 years ago and had a fusion from L4-S1. At one point about 3 years post injury I was in such bad pain from my sacrum sliding in and out of place that I couldn’t make it through a day of high school with out Hydrocodone, and one wasn’t cutting it anymore. My osteopath suggested prolo.

I started the initial “loading” phase at 18 and have gotten the booster every year/every other year depending on my back. I seriously don’t know where I would be without it. Yes, the injections hurt like heck, but when you go from popping 4 ibprophen several times a day, to not even needing to take any on a daily basis, it’s worth it.

I don’t know the details of your injury, but Prolo definitely makes it so I can actually live my life. I know several others who have seen fantastic results from it. I’d be happy to discuss how it has worked for me, or any other details you have from someone who has been using it for 10 years if you’d like. I hope you are able to find something that helps!

[Bearskin]

[QUOTE=JoannaHCR;8776129]
I have had myofasical releases done on me 1-2 times, and have used it many times on the horses, it has worked wonders for them.

I broke my back when 13 years ago and had a fusion from L4-S1. At one point about 3 years post injury I was in such bad pain from my sacrum sliding in and out of place that I couldn’t make it through a day of high school with out Hydrocodone, and one wasn’t cutting it anymore. My osteopath suggested prolo.

I started the initial “loading” phase at 18 and have gotten the booster every year/every other year depending on my back. I seriously don’t know where I would be without it. Yes, the injections hurt like heck, but when you go from popping 4 ibprophen several times a day, to not even needing to take any on a daily basis, it’s worth it.

I don’t know the details of your injury, but Prolo definitely makes it so I can actually live my life. I know several others who have seen fantastic results from it. I’d be happy to discuss how it has worked for me, or any other details you have from someone who has been using it for 10 years if you’d like. I hope you are able to find something that helps![/QUOTE]

Thank you for your insightful response. The consensus of those who have experienced one or the other (PRP or Prolo) is that there is a lot of initial pain from the inflammatory response. This wasn’t even touched on by either the ortho, the neuro or the DO. Would you mind sharing how long the pain from the actual injections lasted and what you did to manage it in the interim? How much “down time” is there (kind of wondering if I will need extra help on the farm)?

[JoannaHCR]

[QUOTE=Bearskin;8778836]
Would you mind sharing how long the pain from the actual injections lasted and what you did to manage it in the interim? How much “down time” is there (kind of wondering if I will need extra help on the farm)?[/QUOTE]

The first batch–I had to have 6 treatments 2 weeks apart, about 6 injections/ treatment, that is the “loading” time frame I guess, and I won’t lie, it was pretty rough and I would plan on having help for at least the day of, and the day after. Because of how close they were together, it seemed like you’d be recovering for a week, then normal for a week, then injected again.

As for managing it, my back hurt so bad before I got it done, that I’d take some Tylenol, or maybe a Hydrocodone the day of, but within a day or 2, the other pain stops for me, and yeah, the injection site may still twinge a bit, but that deep dull ache and pain being gone is more than enough to make up for the discomfort of the injections themselves. It does feel kind of weird when my sacrum isn’t sliding around anymore, kind of like I can feel the tightness of the ligaments or something.

I would encourage you to speak with your Dr. about pain management during the procedure, I always just got numbing spray, but I’m having to go to a new Dr. b/c mine retired, so I’ll be asking if maybe there is something a little more substantial I can have and how many injection sites on each side, it always helped me deal with the pain of the actual injection to know how many were left.

I have to have 3 or 4 (can’t remember) on each side, and one of the ones on my right side, right about where the waist band of my jeans sit, makes it tingle and hurt all the way down in the bottom of my butt, and back of my knee, so be prepared for some weird sensations.

I hope if you go that route, that it will work for you as well as it has worked for me!

[Bearskin]

JoannaHCR, thanks for sharing your story. What’s the longest the relief has lasted for you? My understanding is that the PRP or Prolo basically causes an inflammation that then induces a “healing response.” I have been repeatedly told that soft tissue remodeling stops after about a year post-incident. My injury site is old, old, old and done healing (we are just managing minimizing breakdown due to age, etc. at this point). So, I guess my question is whether there is anything to “heal,” or if this is used as a pain management strategy. Make sense? I feel like I have not really gotten a straightforward answer from any of the docs. I almost feel like “well, we don’t really know what else we can do for you at this point, but lets try this.” (maybe that’s more in line with what LadyE was saying).

[JoannaHCR]

Mine is used to contract the ligaments around my sacrum–b/c of the way they did my fusion. So, it’s not even really to treat an injury, more a maintenance thing to keep my body from continuing to mess itself up. At this point, I get booster anywhere from every year, to 2 years depending on what I’m doing. I had to have them at a year when I was showing Hunter Eq in college, and less now that I’m doing eventing again.

It was kind of a last option for me also, other than just being adjusted on a super regular basis b/c my sacrum would slip out so frequently. I can tell when I’m close to needing it again b/c it will slip out, and when it gets really bad, I can pop it back in on my own–hurts like heck when it’s out though.

I don’t know the specifics of your injury, but I would guess success depends on if your are dealing with ligaments or not. If my DO wasn’t retired, I’d offer you his number, he is wonderful about answering questions about it, as he not only performs it, but gets it himself. Has your DO gotten Prolo or just given? Also, you are welcome to pm me, I’d be happy to give you my phone # if you have more specific questions.

This link has some good info: http://sckcmo.com/hl/?/21357/Prolotherapy

[2miniB]

I fractured my L5 vertebra in 2 places after forcible ejection for a high velocity equine (aka getting bucked off a cantering horse ). Massage, structural integration/rolfing, myofascial release, chiro and narcotics did nothing. I don’t respond well to narcotic meds and just wind up extremely disoriented and dizzy…but still in pain.

I found a good physiatrist (doctor specialized in physical medicine and rehabilitation), and she sent me to PT which helped for a while. I eventually figured out that I need to keep up my core strength with some yoga positions (plank, side plank and the one where you’re on your hands and knees and extend opposing arm/leg, and the one where you try to balance on your butt with your upper body at an angle and move your legs in the air like you’re pedaling a bicycle). There’s a youtube ab workout I was doing, but I can’t find it. Its really more isometric type stuff since crunches/situps kill my back.

I used to have killer sciatica, and homeopathic hypericum 1M taken once during a flare helped. So much so that the sciatica is about 1/8-1/4 as severe as it was. I was only taking it as a quick fix after heavy work. Never expected it’d do so much for me. I also like curcumin and fish oil as anti-inflammatories (vs NSAIDs), since it works so much better for me.

If you have or had Lyme, its possible that might be keeping you in pain. Lyme treatment has probably helped the most with my back pain out of everything (about 10 years after the injury). After successful treatment, I can move hay and trim hooves on my 3 horse…and not be crippled by pain for 3 days-a week after.

[Simkie]

[QUOTE=Bearskin;8778836]
Thank you for your insightful response. The consensus of those who have experienced one or the other (PRP or Prolo) is that there is a lot of initial pain from the inflammatory response. This wasn’t even touched on by either the ortho, the neuro or the DO. Would you mind sharing how long the pain from the actual injections lasted and what you did to manage it in the interim? How much “down time” is there (kind of wondering if I will need extra help on the farm)?[/QUOTE]

Not sure if you’re looking for feedback for PRP, too, but I think I left my horses out in their fields so no stall cleaning for about 4 days, and my husband threw hay to them for at least the first couple so I could avoid the barn entirely.

Walking the day after the injections was happening only very, very slowly. I did go to work (desk job) but didn’t move from my chair until it was time to go home, and probably should have just stayed home. The next day was better, but still pretty dang uncomfortable.

That was IA PRP vs what you’re looking to do, but I’d say you’re going to need help for … at least 48 hours? following injections, if my experience was any indication.

[Bearskin]

Thanks Simkie! That’s so helpful. Did you find relief? how long?

[Simkie]

I had PRP in both hip joints in January or so, I guess it was. It was effective at eliminating the pain the the right, and it’s still going there, I suppose. The right hip hasn’t been particularly troublesome lately. The left hip–which is my worse–improved for about 8 weeks, and then the pain returned. Sad for me.

[airineek]

I’ve had multiple sessions of prolotherapy on a hypermobile SI joint originally caused by a running injury. The first sessions were after a couple years of nothing else working including lots of PT, massage and myofacial release, The prolo worked. For me, it was a life saver (as far as my active life anyway and being able to run and ride). The second time I had it done was after my things loosened up during my first pregnancy. I only did two sessions that time and it got me back to normal again.

There aren’t a ton of comprehensive studies and empirical evidence on prolotherapy, so it’s still considered alternative. It also depends a lot on the technique of the practitioner and an immune response from the patient’s body, since what you are doing is creating a controlled injury to give the body a second chance to heal itself. For SI ligaments, I personally think it makes tremendous sense to try if you have a non-healed old injury. It’s one of the only things I’m aware of that works to tighten a loose SI ligament and while there is a chance it won’t work, it’s relatively safe and effective, though yes, with one doctor it did hurt like a mofo. I could still drive myself home after and with the result I got, I would certainly try it again, but so far I don’t have to. It probably addressed the underlying cause for me. I can’t speak to doing it closer to the spine. I’ve never had PRP so no experience with that.

[Darkwave]

I’ve done both PRP and Prolo on several areas, including hypermobility in the lumbar and SI areas, as well as my hamstring, groin, and ankle. I credit it with my painfree existence today. Perhaps it’s the placebo effect - if so, I don’t care. I’m just happy that I don’t hurt.

I did 3 rounds of PRP over the course of about 9 months to get myself fixed, and then I go in for a “touch-up” job of prolo annually. It ain’t cheap, and I’ve tried to skip the prolo, only to realize that I do need it.

PRP is your blood, spun down and reinjected. It is more expensive, hurts more to be injected, and takes longer to kick in (about 2.5 weeks, in my experience). You also need to take some couch time (about 48 hours) after each injection.

Prolo is sugar water. It’s cheaper, hurts less, seems to kick in within a day or two, and no real rest required after. But it’s not quite as effective. My doctor told me that he uses prolo for non-athletes who just want to be functional in their daily lives, and PRP for athletes who put a lot more stress on the body part in question. Many times, with athletes, he does 2-3 sessions of PRP first (to “start the fire”), and then swaps to prolo to “keep adding logs to the fire.”

If you’re getting either, I recommend going to a doctor who specializes in these injections. It seems like everyone is offering some sort of PRP or prolo now, but not all formulations are the same. And there is a real skill to injecting the substance in just the right location (needs to be guided by ultrasound) - you’re not going to be as good if you only do the procedure a few times a month.

FWIW, I blogged about my experience with PRP here (this was my first set, in my hamstring and foot). If you click on the “PRP” tag, you’ll see some other entries as well. http://wellimtryingtorun.blogspot.com/2013/11/pincushion-me.html