The Use of Prolotherapy in the Treatment of Chronic Overuse Shoulder and Neck Pain, Neurogenic Pain and Hip Degeneration in an Incomplete C4-C5 Spinal Cord Injury Patient.
Ross A. Hauser, M.D., Kimerbely A. Gruen, BA
Spinal cord injuries currently affect approximately 450,000 people in the United States with an estimated 8,000 to 12,000 new injuries per year.1,2 About half of these injuries result in quadriplegia. One of the major complications associated with all spinal cord injuries is the treatment and management of chronic pain.3-6 It has been estimated that 40-100% of spinal cord injury (SCI) patients experience chronic pain after a SCI.7-9 Chronic pain greatly impacts the physical, and psychological well-being, as well as the quality of life of the SCI patient.10,11 The severity and persistence of pain associated with SCI are, however, of greater significance than its prevalence. It is not unusual for these patients to experience pain for decades because their longevity approaches normal life expectancy owed to early interventions and rehabilitative measures. Treatment of the chronic pain associated with spinal cord injuries has been an ongoing process, and many clinicians are unsure of how to assess and care for this complication.12-15 Some commonly used treatments include occupational and physical therapy, exercise, medication, and surgical procedures.16-20 Unfortunately, most treatments have proved to be relatively ineffective. The lack of effective treatment for SCI pain causes these patients great frustration and, in addition to long-term motor disability, they must endure intractable pain. For this reason, people with SCI and chronic pain are seeking alternative treatments. One of the treatments they are finding is Prolotherapy. Prolotherapy involves injections into injured ligaments, tendons and joints to stimulate repair. Prolotherapy is becoming a widespread form of pain management in both complementary and allopathic medicine.21-24 It is being used in the treatment of spine and joint degenerative arthritis, as well as for pain management in many areas, such as meniscus tears, fibromyalgia, and a variety of sports injuries.25,26
Another common complication for many SCI patients is
osteoporosis and joint degeneration below the lesion
level.27 Immobilization secondary to SCI is
associated with marked and rapid atrophy of bone. The
elimination or decreased use of leg muscle activity
causes the loss of calcium and phosphorus which leads to
bone loss. The condition can be avoided or lessened if
the patient is able to stand using a standing frame or
other supportive device.28 The use of a
standing frame has many other beneficial effects, such
as decreased pressure sores, increased overall strength,
and an improved sense of well-being.
The following is a case report on the use of
Prolotherapy in the treatment of a quadriplegic with
an incomplete C4-C5 spinal cord injury. The goals of the
Prolotherapy in this patient were to help eliminate
shoulder, neck, and thoracic pain and to stabilize the
patient’s right hip so he could continue to stand with
the aid of a person or a standing frame.
CASE REPORT
Michael Schwass is a 49 year-old Caucasian male who
sustained an incomplete C4-C5 spinal cord injury while
playing hockey in 1975 at the age of 16. (See Figure
1.) He underwent three surgeries following the
injury, which included a cervical spinal fusion at C4-C7
using a bone graft. In 2002, Michael came to Caring
Medical and Rehabilitation Services (Caring Medical) at
the age of 43, with complaints of upper back, neck, and
shoulder pain. His primary concern was his recent
inability to stand due to a degenerated right hip as a
result of osteoarthritis. He specifically lost the
ability to make standing pivot transfers because his
left hip would give out during this movement. Though
Michael was a quadriplegic, he prided himself on being
able to stand independently without the use of leg
braces for up to one minute. He was also able to stand
independently for short periods of time with the aid of
his standing frame. In late 2001, he lost the ability to
stand independently at all and his physicians felt it
was because of a collapsing degenerated right hip. (See
Figure 2.) He also reported that it was becoming
increasingly more difficult for him to sit in his
wheelchair because he was losing range of motion of his
hip. Sitting was getting unbearable because of the pain.
His orthopedic surgeon told Michael that a total hip
replacement was his only option. Michael noted that his
orthopedist after seeing his X-rays commented “I don’t
know how you can stand the pain in there!” He and his
surgeon discussed that he was at increased risk of wound
infection and some other complications because of his
spinal cord injury, and subsequently the spasticity in
his legs that came with it. Looking for an alternative
to total hip replacement, he sought out an evaluation
for
Prolotherapy.
| Figure 1. Michael Schwass at the time this article was written. |
|
| Figure 2. Non-weight bearing AP right X-ray. This X-ray shows Michael’s collapsing right hip. |
|
Michael also wanted an opinion on his right shoulder and
thoracic pain. He reported the shoulder pain as achy in
quality and located at the front and top of his
shoulder, which increased with driving. Michael reported
that the thoracic pain was burning in quality and the
severity of pain increased with sitting for prolonged
periods. On the initial visual analogue scale (VAS) of 0
- 10, his
neck pain rated a 7, shoulder an 8, and thoracic a
6.
On initial physical examination he was totally dependent
on transfers. He had no movement at all in his legs. He
had normal sensation in the face and neck and some in
the shoulder region. Below these areas he had about 50%
sensation in the torso and on the legs he was able to
sense light touch about 20%. In regard his motor system,
he had normal neck strength. He had some antigravity
movement bilaterally in shoulder abduction and shoulder
internal rotation. He could flex his elbows when gravity
was eliminated. There was no movement of the hand or
wrist. He had no active leg movement. He had tremendous
spasticity in both legs. The hip exam was very difficult
because of spasticity but hip flexion appeared to be 85
degrees, but internal and external rotation was
impossible to assess due to spasticity. He had notable
tenderness to palpitation in his posterior neck and
upper back specifically along the trapezius and levator
scapulae attachments. He also had tenderness at the
acromioclavicular joint and at the supraspinatus and
subscapular tendon attachments in the right shoulder.
Severe decrease of range of motion was observed in all
planes of his neck. Extension was more affected than
flexion. His thoracic exam was unremarkable, as
sensation was decreased in this area. His X-rays showed
hip dysplasia with flattening of the femoral head with
superior migration and a loss of joint space, sclerosis,
and large osteophytes bilateral with the right hip being
worse than the left.
Treatment with dextrose Prolo-therapy was recommended
with the objective to decrease or eliminate thoracic,
neck, shoulder, and hip pain and improve hip motion. An
additional goal for the hip was to increase his ability
to retain the erect position with the use of a standing
frame for extended periods of time and regain the
ability to do standing pivot transfers.
Prolotherapy was started on his hip in September 2002
using the Hackett-Hemwall technique of
Prolotherapy. A 15% dextrose, 10% Sarapin, and 0.1%
lidocaine solution was injected into and around the
following structures: right hip, greater trochanter, and
periarticular structures. (See Figure 3.) Eight
cc of solution was injected into the joint and another
30 injections with 40cc of solution were used to
complete the treatment.
| Figure 3. Injection sites for Prolotherapy to the right hip. |
|
Michael could stand independently for a few seconds by
the fifth treatment, and by the fifteenth treatment felt
much more stable with his right hip in regard to
transfers and standing. He stated at that time that he
was 60% of where he wanted to be. In 2006, after 25
treatments of dextrose
Prolotherapy, Michael was able to stand completely
on his own for almost one minute due to improvement in
hip stability. By this time his hip flexion range of
motion had improved to 100 degrees. He could now sit for
extended periods of time without pain.
In the meantime, Michael began receiving
Prolotherapy to his neck, shoulder, and thoracic
region. For his
neck pain,
Prolotherapy was given to his facet joints and
transverse processes of C2-C7, as well as the superior
and inferior nuchal ridge on the occiput. The
supraspinatous and subscapularis tendon attachments,
glenohumeral ligament attachments, acromio-clavicular
joint and coracoid process were injected in his right
shoulder. In regard to his thoracic area, the facet
joints and costotransverse joints from T4-T10 were
injected.
From 2002 until 2008, Michael received a total of eight
treatments to his neck with a 75% pain improvement
reported in November 2007, six treatments to his
shoulder where an 85% pain improvement was noted in
November 2006, and 10 treatments to his thoracic region
where a 90% pain improvement was reported in June 2007.
He no longer has shoulder pain with transfers or
driving. At his last treatment session, his
neck pain was down to a 2 (VAS), shoulder pain 1,
and thoracic pain 1.
DISCUSSION
This case study illustrates that
Prolotherapy can improve the quality of life for
quadriplegics. Michael, like many quadriplegics, suffers
from chronic pain in his shoulders and neck, most likely
from overuse, and also neurogenic pains in his upper and
middle back. What primarily brought Michael to get a
Prolotherapy evaluation, however, was his decline in
standing transfers because of a degenerating hip.
Michael, because of his innate tenacity and personality,
has not given up on the idea of a quadriplegic standing
on his/her own two feet. (See Figure 4.) It is
well known in the rehabilitation field that standing is
an excellent exercise for those with spinal cord injury
to prevent pressure sores and slow down the onset of
osteoporosis.
| Figure 4. Michael can now stand erect with help from his personal assistant, as well as Prolotherapy. |
|
In the case presented, Michael received
Prolotherapy to his right shoulder. His pain level
went from an 8 to a 2 (VAS) with
Prolotherapy. Because Michael has no voluntary leg
motion, like all quadriplegics, his shoulders feel the
major force of all transfers as well as physical and
daily living activities.29 All of these
activities place a great deal of stress on the bones,
joints, and soft tissues of the shoulder complex,
placing these structures at significant risk for overuse
and injury. Overuse-type injuries are the most common
cause of shoulder pain in the chronic SCI population.30
The structures most affected are the rotator cuff
tendons. Risk factors for shoulder pain in spinal cord
injury include duration of injury, older age, higher
body mass index, the use of a manual wheelchair, poor
seated posture, decreased flexibility, and muscle
imbalances in the rotator cuff and scapular stabilizing
muscles.31,32 Michael had basically all of
these risk factors and made only a little progress with
traditional physiotherapy to help his shoulder pain.
Prolotherapy to his rotator cuff tendons gradually
helped him regain his shoulder function. The shoulder
joint, specifically the rotator cuff tendons, are
commonly treated with
Prolotherapy.33,34 Traditionally, the
main use of
Prolotherapy has been on tendinopathies and ligament
sprains in peripheral joints.35-37
In regard to his neck, Michael was seen about 30 years
after his multilevel fusion. His neck CT scan was done
before coming to Caring Medical and showed extensive
degenerative changes above and below his fusion. This
type of response is very common. After a segment of the
spine is fused, increased pressure in the vertebral
segments above and below the fusion is typically seen.
This additional stress on the adjacent segments seems to
increase the rate of degeneration at these joints.38-39
Michael responded well to the
Prolotherapy of his neck. His pain level went from a
7 to a 2 (VAS).
Prolotherapy has a long history of being used in the
treatment of spine and joint degenerative
arthritis.40,41 This is especially true
in regard to chronic low back pain arising from the
sacroilliac joints and as an alternative to surgery.42-44
Prolotherapy has been shown in low back studies to
improve pain levels and range of motion.45-48
In double-blinded human studies the evidence on the
effectiveness of
Prolotherapy has been considered promising but
mixed.49-50 In regard to
Prolotherapy studies on the neck
Prolotherapy has been shown to be effective for
facet joint arthropathy, cervicogenic pain and
headaches, and cervical instability.51-53
Michael did not get hip replacement surgery, partly
because of his fear of the hip replacement dislocating,
which is of increased risk when a person has spastic
quadriplegia.59 In Michael’s case, his major
goal was standing and transferring better. He feels that
his hip stability is much improved after the
Prolotherapy.
Also of interest is that Michael’s neurogenic thoracic
pain was also significantly reduced with
Prolotherapy. Most people with spinal cord injury
suffer from abnormal sensations and pain below the
injury site.60 These abnormal sensations are
often “burning” or “freezing” with pain ranging from
mild to severe.61 When the pain is a burning
quality the patient is often labeled as having
dysesthetic pain syndrome. About 11% of all SCI patients
have painful dysesthesias and another five percent have
non-painful but chronic and distressing dysesthesia.62
The term neurogenic pain presumes that the origin of the
pain stems from the SCI. Regardless of the nomenclature,
the condition is difficult to treat even with
conventional pain-killing drugs.63-65
Sometimes SCI patients seek neurosurgical procedures to
ablate some of the pain tracts in the spinal cord. This
usually fails to relieve chronic SCI pain and frequently
produces a higher level of neurological loss and
deafferentation.66,67
Prolotherapy could offer a non-surgical treatment
option also for this condition.
SUMMARY
This case study exhibited many of the difficult to
treat pain issues that occur in quadriplegics. Michael
presented with neurogenic thoracic pain, a dysplastic
painful hip, neck degeneration above and below the level
of his fusion, as well as an overuse injury of his right
shoulder. We were able to help Michael with all of these
conditions through treatment with
Prolotherapy. He regained some hip stability which
helped him improve his standing pivot transfers and his
ability to stand independently.
Prolotherapy treatments provided relief of Michael’s
shoulder, neck, and thoracic pain. Chronic pain is
common after spinal cord injury and is difficult to
treat effectively. Further research into
Prolotherapy with this patient population seems
warranted.
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