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Author: DrShifreen

Member Since: 2011-03-30 21:04:09

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Subcutaneous Prolotherapy

May 26th, 2011 by DrShifreen

Copyright K. Dean Reeves, M.D., AAPM&R, Clinical Associate Professor, University of Kansas. Also called Lyftogt Technique of Subcu Prolotherapy or Simply Lyftogt Technique.
What is Subcutaneous?

A very new wrinkle on prolotherapy has been proposed and advanced by a physician in New Zealand name John Lyftogt. (Pronounced Lift-off) To the left you see a needle. (Very small in this case IE 1/2 inch 27 gauge or so) It has penetrated just under the skin into a layer which is looser, often composed of some fat. Here the dextrose is injected.

What runs right under the skin? The photo to the left is a model of the knee bones, then the bones covered with muscle and nerves, and then a picture where the nerves are mostly covered by a layer called fascia. Through the fascia you see some smaller nerves that run right under the skin which are subcutaneous nerves.

 

Hilton’s Law

There is a principle called “Hilton’s Law” that says that the nerve that supplies sensation to a joint also supplies sensation to the skin over that joint and the muscles that move that joint. This law suggests that if a nerve is irritated that supplies skin over a joint it may affect (cause pain and change function) in the joint or muscles around that joint.

What Dr. Lyftogt did?

He knew of the concept that nerves under the skin can be a source of pain. Instead of injecting anesthetic, which is a typical nerve block but has no long term benefit, he injected dextrose around the nerves just under the skin. He did this because nerves are soft tissue also and because they are composed of a lot of connective tissue. He reasoned that dextrose heals other connective tissue and may help nerves function better.

What Dr. Lyftogt found?

When he injected just under the skin along the course of the nerve in small increments rather than in one or two locations he found that local swelling improved in the area and pain reduced and function improved. The reason for abnormal nerve function is thought to be a kinking or other change in the nerve as it penetrates muscle or fascia. Then the nerve begins to develop abnormalities all along its length. There is some indication, although not yet proven, that improper nerve functioning promotes degeneration in ligaments and tendons in the region and causes blood vessels to leak, leading to swelling.

What Dr. Lyftogt Proposed

Nervi nervorum are small nerves that supply the subcutaneous nerves themselves and connect with the subcutaneous nerves at intervals. Because they connect at intervals with the nerve, they are suspected as being the primary target of subcutaneous prolotherapy. It is known that nerves that are irritated produce substances such as CGRP (calcitonin gene related peptide) and SP (substance P) that can create leakiness of blood vessels and pain but more work needs to be done on which cells in the nerve do so. Basic scientists (scientists that study how things work but don’t directly treat people) have know for years that nerves can misbehave chronically. The term neurogenic inflammation has been proposed to describe this.

How does subcutaneous prolotherapy relate to regular prolotherapy?

Prolotherapy is Injection to promote regeneration or repair in connective tissue. Subcutaneous prolotherapy is injection to promote regeneration, repair or other functional restoration in subcutaneous nerves which are composed largely of connective tissue

Why is subcutaneous prolotherapy potentially so important?

Treating subcutaneous nerves may make it unnecessary, at least in part, to treat deeper structures, as the source of persistent lack of healing in deeper structures and their pain appears to be directly connected to dysfunction in the subcutaneous nerves. Much needs to be learned and studied about this treatment and the ideal combination of deep and subcutaneous prolotherapy. It may be that healing in deeper structures will take place spontaneously if the nerves above the deeper structures are returned to normalcy. This is suggested by three recent studies. (Below)

Frequency of Treatment

The treatment has been proposed as a weekly treatment by Dr. Lyftogt. With deeper proliferant injection we find that 2 months between treatments allows time for healing and less overall treatment. Whether that is the case with subcutaneous prolotherapy is not known at this time. In our clinic hwowever, our treatment frequency has always been every 2-4 weeks, and most commonly every 2 weeks, to allow time for healing and decrease cost and number of treatments needed

How Subcutaneous Prolotherapy Is Used In Our Practice?

After learning of this technique and its research (below) we have included an examination of subcutaneous nerves in our initial evaluation and at followup. Since doing this we have been very impressed with the importance of these nerves in almost all patients we see. The technique does not add risk to prolotherapy but actually is less invasive. Because it adds benefit without additional risk, we will be utilizing it while we also prepare to get involved in research about it.

Research

Three studies have now been published, all consecutive patient type.

Lyftogt J. Prolotherapy for recalcitrant lumbago. Australas Musculoskeletal Med 2008;13(5):18-20.

46 consecutive patients with low back pain (without leg pain) were seen. 2 were diagnosed with hip pain and sent for surgery. 2 dropped out before treatment. 1 was treated twice and dropped out in favor of a non injection treatment..Of the remaining 41 patients 24 (58%) were male and 17 (42%) female. Mean age was 48.3 (range 23-73) years. Mean duration of symptoms was 5.5 years (range 1- 264 months). The swollen and tender nerves were clinically identified and treated with “percutaneous near nerve injections” approximately 1 ml every 2 cm. The objective of the treatment was to achieve a complete local anesthetic response for all low back pain at the time of the treatment. The solution used in the earlier part of the audit was hypertonic dextrose 20-40%, mixed with 0.1% lignocaine and/or ropivacaine 0.1% in normal saline. Towards the end of the treatment the solution consisted of dextrose 20%, lignocaine 0.1% and cholecalciferol (Vit D) 1000 IU/ml in normal saline. In the earlier phase of the audit period “tender points” were targeted mainly along the latissimus dorsi tendons, the gluteus maximus origin and the supraspinous ligament. In the latter phase the focus became the “inflamed” superior and intermediate cluneal nerves and thoracic spinal nerves where clinically indicated. Mean initial VAS was 7.6 (range 5-10). Mean VAS at last treatment was 1.4 (range 0-6). Mean duration of treatment was 8.3 weeks (range 1-17). The mean number of treatments was 6.2 (range 2-16). Ninety percent of patients improved more than 50%, and 10% less than 50%. Twenty-nine percent of patients reported no pain at the last consultation. Long term followup results were not stated.

Lyftogt J. Subcutaneous prolotherapy for Achilles tendinopathy Australas Musculoskeletal Med Nov 2007;12(11):107-109.

Different dextrose concentrations were clinically trialed over a four-year period with long-term follow up of 132 Achilles tendons. Results are broken down by year and cannot be looked at in total with information given. A representative year was 2006 in which 30% glucose was use in 0.1% ropivacaine and 0.1% lidocoane. In that year 34 tendons in 31 subjecdts were treated with mean age 47 (28-69) years, and mean symptom duration of 14 months (1-60). The mean length of treatment was 7.6 weeks (3-15 weeks) 84% were available for long term followup at mean of 12 months with mean VAS change from 6.7 to 1.1 and 88% of those that were contactable at 12 months satisfied with treatment.

Lyftogt J. Subcutaneous prolotherapy treatment of refractory knee, shoulder and lateral elbow pain. Australas Musculoskeletal Med 2007;12(2):110-112.

In 2005, 127 painful knees (74), shoulders (33) and lateral elbows (20) were treated with subcutaneous prolotherapy. . The treatment was well tolerated and safe. The treatment protocol consisted of weekly treatments where possible. All active TPs were identified by palpation and injected subcutaneously with 0.5-1 ml of a Glucose 20%/Lignocaine 0.1% solution. The objective at the time of each treatment was to achieve complete local anesthetic pain relief. Treatments were continued until VAS 0-1 and/or after consultation with the patient. The combined outcome statistics for the treatment of the 2005 knee, shoulder and lateral elbow pain showed a mean length of symptoms of 23.9 months and a mean treatment length of 7 weeks. The mean initial VAS 6.7 reduced at follow up of mean 21.4 months to VAS 0.76. The combined satisfaction rate at follow up was 91.7%. However, the follow-up success was an average of about 75% so approximately 25% were lost to long term followup.