Prolotherapy Lumbar Spine Pain and Management. By Richard Hull D.O.

Transcription

1 Prolotherapy Lumbar Spine Pain and Management By Richard Hull D.O.

2 Lecture Points to be Covered Anatomy review Functional anatomy Muscle testing to determine a diagnoses Differential diagnosis Confirming my diagnosis Inform patient Solutions that I use Equipment Technique Post injection instructions

3 Your ability to recognize the correct Diagnosis! The Diagnosis of a Diagnostic Dilemma Lies Within! Your belief the patient has a problem! Your ability to ask the right questions! Your physical diagnostic abilities! Your ability to order the right tests!

4 The Resolution of a Diagnostic Dilemma Lies Within Your knowledge of the best option for the treatment of this patients problem. This entails knowledge all possible treatments and risk verses benefit of each treatment option. Prolotherapy should be one of the options in pain and musculoskeletal problems.

5 Anatomy of the Low Back & Pelvis To master prolotherapy of a region you must first master the anatomy of the deep structures of that region by visual skin anatomy, palpable anatomy and mentally know you can place a needle to the desired enthesis.

6 Anatomical Landmarks of Importance Lumber Spinous Processes Ilio-lumbar Ligament PSIS Posterior Superior Iliac Spines Sacral Iliac Joint Origin and Insertion of all Tendon in the Region

7 Latissimus Dorsi Ext. Abdominal Oblique Gluteus Medius Gluteus Maximus

8 Gluteus Medius Piriformis Quad Sup. Gemelius Obturator Internus Quadratus Femoris

9 Piriformis Coccygeus Lev. Ani (illiococcygeus part) Sup. Gemelius Obturator Int. Inf. Gemelius. Quadratus Femoris Lev. Ani. (puborectalis part)

10 Biceps Femoris (long Head) Vastus Lateralis Semitendinosus Adductor Magnus Gracilis

11 Serratus Posterior Inferior Longissimus Thoracis Iliocostalis Gluteus Minimus Piriformis Superior Gemelius Obturator Internus Quadratus Femoris

12 Longissimus Thoracis Quadratus Lumborum Psoas Intertransversarii Lumborum Lat. Multifidi Transversus Abdominis Psoas Obturator Internus

13 Quadratus Lumborum Multifidi Quadratus Femoris Adductor Minimis Adductor Brevis Adductor Longus

14 Intertransversarii Lumborum Lat. Intertransversarii Lumborum Med. Interspinalis Lumborum

15 Obturator Ext. Adductor Minimus Adductor Brevis

16 Intertransverse lig. Interspinous Joint Capsule Iliolumbar Interosseous Sacroiliac Sacrotuberous Sacrospinous

17 Iliolumbar Sacroiliac

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24 Pain as Second Degree Sprains and Ligament Instability Sensory Fibers and Stretch Receptors Second Degree Sprains and relation to the Surgical Scar in Healing The Purpose of Prolotherapy is to reopen the window of healing by reinitiating the current of injury in unstable ligaments and tendons. Where do we start

25 Chronic Pain Primary or Referral Pain is stimulation of sensory nerve fibers. Referral pain is from a distant site with autonomic nervous system involvement. Sensory fibers and stretch receptors Interference field as originator of referral pain through; embryologic connection, acupuncture meridian, reflexology, etc, all probably transmitted through interstitial connective tissue.

26 Chronic Pain Primary or Referral Second Degree Sprains and relation to Scar in Healing the Surgical The Purpose of Prolotherapy is to reopen the window of healing in unstable ligaments and tendons. Neraltherapy by depolarizing the interference field we obtain a reset and eliminate the referred pain Where do we start

27 Pain Level The "Anchor Point As the patient improves They forget where they started and how bad they were when they presented to you. Therefore the well documented history as to degree of pain and limitations to activities of daily living form the anchor as to where we started. This anchor will keep the patient s focus and commitment.

28 My Pain Scale Worst pain imaginable! Pain so bad you can t communicate, you lose control of emotions and body functions.(crying, screaming, loss of urine, etc.) 8 - Pain constantly! This pain makes it impossible to work or sleep. 6 - Pain that constantly disrupts sleep or physical activity. 4 - Pain that disrupts sleep or physical activity only occasionally. 2 - Pain Noticeable only when resting and not physical or mentally active. 0 - No perceivable pain.

29 Expand c/c & Hx of c/c ONSET LOCATION PRECEDING INJURIES RADIATION OF PAIN SEVERITY OF PAIN ASSOCIATED SYMPTOMS ALLEVIATING FACTORS AGGRAVATING FACTORS PSYCHOLOGICAL FACTORS EFFECTS ON FUNCTION AND ACTIVITIES RESPONSE TO PAST TREATMENTS CHANGES IN HABITS COPING SKILLS SEVERETY OF PAIN ON SCALE 0 TO 10

30 Physical Exam Starts with observation when you first encounter the patient Remember you are the PHYSICIAN Range of motion Somatic Exam Palpation and loading of enthesopathies TOUCH THE PATIENT

31 Differential diagnosis Arthritis Lumbar Radiculopathy Somatic Dysfunction Tumor Infection Fracture Referred Pain Neuropathic Pain

32 The Work Up Have we missed anything! [lab Xray, CT, MRI, Musculoskeletal Ultrasound, etc.] Constantly think and expound the possiblities, and question your MIND Believe in the Patient Ask the Right Questions Think In and Out of the Box

33 Tell the story INFORM THE PATIENT

34 Confirming my diagnosis Lidocaine block at Periostium, the Enthesis and potential Interference Fields of scars Retest the area for pain strength & ROM Determine the percentage of pain relieved and increase in function from each tx. site If correct and % pain relief. Reschedule to determine Interference Field vs. Instability of the Enthesis Or proceed with injection of Prolo solution. This is patient and your choice.

35 Prolotherapy Technique Palpate the enthesis with stereoscopic perception as to depth and angle of projection of the needle. Mentally place a depth stop on the needle as a maximum penetration of the needle. Think of the layers and feel you should perceive as the needle advances through them.

36 Prolotherapy Technique Palpate the enthesis with stereoscopic perception as to depth and angle of projection of the needle. Mentally place a depth stop on the needle as a maximum penetration of the needle. Think of the layers and feel you should perceive as the needle advances through them.

37 Prolotherapy Technique Choice of needle and syringe size Choice of solution and amount at each site. (Varies by Physician) 1. My solution Presently is! 5cc. 50% Dextrose to 5cc. 2% Lidocaine with 2 cc s 23.4% NaCl. 2. If not effective I add Sodium Morruate (1/2 cc per 10 cc s) Rarely use anymore! 3. Others advocate stronger solution 4. Size of enthesis determines amount injected between 0.2cc and 4-5 cc

38 Prolotherapy Technique My experience if Morruate is ineffective the problem is Nutritional, Toxicity or Incorrect Diagnosis. (Now 4% NaCl) Insert the needle over the nail of your finger or thumb while palpating the enthsis. With rare exception inject at the periostium needle tip at bone. The NaCl with Dextrose solution see previous slide appears to work Stonger than 17% dextrose alone.

39 Post Injection Instructions Limit activity to what your pain limit was before treatment and for 2-3 weeks. Ice to injection sites min. for hours. Post injection pain Tylenol, Ultram, or Vicodin. no NSAID S Report any questions or problem Return appointment in approximately 2 weeks.

40 Complication Avoidance Starts when you address the patient. Is possible when you and the patient have confidence! That you know what you are doing. You have developed adequate skills for the area you are treating.

41 Skill Needed to Avoid Complications 1. Palpatory skill to find and distinguish enthesopathy and anatomical sites. 2. Knowledge of anatomy and areas to avoid. 3. Knowledge of appropriate solutions strengths and volumes for the area treated.

42 Skill Needed to Avoid Complications 4.. Ability to place a Needle tip where you want it through tissue to the desired site. 5.. Ability to place needle tip with small gauge needles.

43 Skill Needed to Avoid Complications 6. Ability to march or manipulate a needle tip through fascia or tissue to a point not reachable by direct route. 7. Ability to project a needle to a structure, from visual and palpatory anatomy. 8. Knowledge of possible complications and their treatment with a concern to avoid them.

44 Next Appointment Revaluate the patients pain and how they did with the treatment. How long did the lidocaine block last. Two to three hours or greater than 22 hours. Ligamentous instablity verses Interference Field

45 Supplies Betadyne solution 25 Gauge 1 or 2 22 Gauge 3 1/2 18 Guage 1 6cc or 10cc Syringe 1% Lidocaine 25% Dextrose Na Morruate 23.4% NaCl solution Ice or Ice pack Bandaids Cotton balls or Gause Tennant biomodulator or Alpha Stim unit

46 Emergency Supplies for Prolotherapy All Regions Standard Medical Emergency Kit IV Fluids, Lines, and IV Catheters. IV Steroids DMSO Cream Nitroglycerin Ointment Ability and plan to deal with a Pneumothorax. Ability and plan to deal with acute Emergency and Shock.

47 Anesthetic needle contacts bone or desired depth

48 Needle point approache s supraspino us ligament

49 Needle point traverses interspinous space/ligament

50 Injection Point

51 iliac crest

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53 Iliac crest, upper S/I

54 Mid S/I

55 Needle point on ilium

56 Sacral enthesis

57 SS-ST injections

58 Sacrum Coccyx Foramina NEVER inject into foramina nerve sleeve. Keep a safe distance from the

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60 BEWARE!

61 The following are Hacketts Study these and use them to help to make sense of referral pain From ligaments and tendons

62 Study!

63 Study! Study!

64 Study! Study! Study!

65 Ask the patient where the pain is

66 Sclerotomes vs. Dermatomes

67 Take a good history

68 And ASK

69 And TOUCH the patient!!

70 More study! =

71 More Success

72 KNOW THY ANATOMY

73 Special Points

74 Separates the novice from the pro All these sites (x) are important some can be approached by a novice others only with great experience BE SMART

75 Know This By Heart

76 Review Review

77 Thanks See you in the Lab

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