Vous êtes sur la page 1sur 8

The Pain Clinic

A Multidisciplinary Approach to Acute 6- Chronic Pain Management

Position Paper of the Florida

Academy of Pain Medicine on
Regenerative Injection Therapy:
Effectiveness and Appropriate Usage .

Voted and accepted by the Florida Academy of Pain Medicine membership at the
Annual Conference at the Hyatt Regency Tampa, Florida, on Saturday, June 30, 2001.

Position Paper Committee Raphael Miguel, MD, Professor and Sanford Pollack, D0, private practice,
Members: Chief of Anesthesiology Service, H. Jacksonville
Felix S. Linetsky, MD, private practice, Lee Moffit Cancer Center, Director of Albert Ray, MD, private practice,
Palm Harbor, Florida, Clinical Pain Management Fellowship Program, Miami
Associate Professor, Department of Family Professor of Anesthesia, University of
Lloyd Saberski, MD, Medical Staff
Medicine, Nova Southeastern College of South Florida College of Medicine, Attending, Yale-New Haven Hospital,
Osteopathic Medicine Assistant Professor, Tampa New Haven, Connecticut
Department of Anatomy, University of Asya Mikulinsky, MD, private practice, Peter Taraschi, D0, private practice,
South Florida College of Medicine Miami Palm Bay
Kenneth Botwin, MD, private practice, Winston Parris, MD, private practice, Francisco Torres, MD, private practice,
Florida Spine Institute, Clearwater Clinical Professor of Anesthesiology, Florida Spine Institute, Clearwater
Lawrence Gorfine, MD, private University of South Florida, Tampa,
Andrea Trescot, MD, private practice,
practice, Lake Worth Adjunct Professor of Anesthesiology,
Vanderbilt University Medical Center,
Gary W. Jay, MD, private practice,
Nashville, Tennessee

The Florida Academy of Pain Medicine Treatment of chronic pain due to regarding the validity of an under-utilized
endorses regenerative injection therapy connective tissue diathesis by induc- type-specific treatment for chronic muscu-
and supports its usage for chronic pain tion of collagen chemomodulation though loskeletal pain related to connective
associated with sprained or strained inflammatory, proliferative, and tissue pathology.
ligaments or tendons, repetitive motion regenerative/reparative responses 2. Outline common indications and
disorders, postural pain, and recurrent mediated by multiple growth factors." conditions treated with RIT, as well as
somatic dysfunctions resulting from lax The purpose of this position paper is contraindications thereto.
ligaments. to: 3. Encourage the use of RIT for
Regenerative injection therapy 1. Inform the members of the the treatment of appropriate painful
(RIT), also known as prolotherapy, Florida Academy of Pain Medicine pathology of the connective tissue.
is an interventional technique for the (FAPM) and the medical community at

38 June 2002 THE PAIN CLINIC

(For further information, see http://
METHODOLOGY www.hcfa.gov/coverage/8b3.htm.) MECHANISM OF ACTION
The committee recommends consid-
To determine the validity of RIT, The RIT mechanism of action is
eration of RIT as a type-specific
a committee of interventional pain complex and multifaceted. The six
treatment for post-traumatic, degen-
physicians was formed to review currently identified components are:
erative, overuse, and painful condi- 1.
pertinent literature. The committee The mechanical transection of cells
tions of the musculoskeletal system and matrices induced by the
reviewed 78 articles, 9 complete
related to the pathology of the con- needle causes cellular damage
textbooks, and 51 relevant articles
nective tissue. and stimulates an inflammatory
and chapters from additional text-
books. For decades, a small group of cascade. 1,6-1,11,19,102-104
allopathic and osteopathic physicians 2. Compression of cells by the extra-
has been practicing RIT. Pilot, cellular volume of the injected
retrospective, open-face prospective, solution stimulates intracellular
and double-blind placebo-controlled growth factors .6-1.101-101
From 1937 through 2000, more than studies have clearly indicated the 3. Chemomodulation of collagen
40 publications reported case studies effectiveness of RIT in the treatment through inflammatory prolifer-
and retrospective, prospective, and of chronic musculoskeletal pain ative, regenerative/reparative
animal studies evaluating the results arising from post-traumatic and responses induced by the
of RIT treatment. The studies reported degenerative changes in connective chemical properties of the
the findings of RIT treatment of more tissue such as ligaments, tendons, proliferants and mediated by
than 530,000 patients. Improvement fascia, and intervertebral discs.'-101 cytokines and multiple growth
based on return to work and Clinical and experimental electron factors. 3,6,33,37-39,105-108
restoration of functional and occupa- microscopic studies have proved that 4. Chemoneuromodulation of
tional activities occurred in 48% to newly formed connective tissue has peripheral nociceptors and
82% of the patients. Resolution of biomechanical properties similar to antidromic, orthodromic, sympa-
pain ranged from 0% to 100%. Com- those of normal ligaments and thetic, and axon reflex transmis-
plications included pneumothorax tendons .61,11.16,15 Preliminary results sions. 3,6,43-50
(28), chest tube placement (2), aller- of clinical prospective trials for 5. Modulation of local hemodynam-
gic reaction (24), grand mal seizure chemonucleo-annuloplasty with ics with changes in intraosseous
(1), and aseptic meningitis (1). proliferation-causing substances pressure leading to the reduction of
The findings of the FAPM show significant promise .14,11.64,14 pain. Empirical observations
committee substantially contrast with Conclusions reached in the suggest that a dextrose/lidocaine
the position of Florida Workmen's literature and drawn from extensive combination has a much more
Compensation and the Health Care clinical experience have found RIT prolonged action than lidocaine'
Financing Administration (HCFA) an effective therapy for numerous alone. 6,43-50,109-111
Medicare guidelines, section 35-13, chronic pain conditions. This position 6. A temporary repetitive stabiliza-
which states that "Prolotherapy, joint paper reviews the clinical and patho- tion of the painful hypermobile
sclerotherapy, and ligamentous physiologic aspects of RIT. The joints, induced by the inflam-
injections with sclerosing agentsnot Florida Academy of Pain Medicine matory response to the prolif-
covered... the effectiveness of these endorses RIT when used appropriate- erants, provides a better
therapies has not been verified by ly for the treatment of specific environment for regeneration
scientifically controlled studies." chronic pain entities. and repair of affected ligaments
. 3,4,6,26,27,37-41,91,92,94-97
and tendon S

39 June 2002 THE PAIN CLINIC

owing to failure of cell matrix costovertebral and/or costoster-
adaptation to excessive load and
STRUCTURES AFFECTED 7. Osteoarthritis of axial and
BY RIT 5-32,35-69,80-104,112 128 tissue hypoxia with a strong
peripheral joints, spondylosis,
tendency toward chronic pain
spondylolysis, and spondylolis-
2. Ligaments: Intra-articular, and dysfunction .,105-107 128
periarticular, capsular 5. Pathologic ligament laxity: A post- 8. Painful cervical, thoracic, lum-
3. Tendons traumatic or congenital condition bar, lumbosacral, and sacroiliac
4. Fascia leading to painful hypermobility of instability secondary to ligament
5. Enthesis: The zone of insertion the axial and laxity
of ligament, tendon, or articular 9. Failed back surgery syndrome
peripheral joints .3,1,11,26-32,35-40
capsule to bone
10. Back pain refractory to radio-
6. Intervertebral discs: The outer INDICATIONS
frequency and intradiscal elec-
layers of the annulus represent a Chronic pain from ligaments or trothermal therapy procedures
typical enthesis. tendons secondary to sprains or 11. Tendon, ligament, and synovial
strains joint nociceptive sources. Not
Pain from overuse or occupa- responding to anti-inflammatory
tional conditions known as treatment approach
1. Sprain: Ligamentous injury at
repetitive motion disorders, ie, 12. Enhanced results of physical
the fibro-osseous junction or neck and wrist pain in typists therapy and chiropractic/osteo-
intersubstance disruption second- and computer operators, tennis pathic manipulations
ary to sudden or severe twisting of and golfers' elbow, and chronic
a joint with stretching or supraspinatus tendinosis
tearing of ligaments. 3. Chronic postural pain of the SYNDROMES AND
2. Strain: Muscle/tendon injury cervical, thoracic, lumbar, and DIAGNOSTIC ENTITIES
at the fibromuscular or fibro- lumbosacral regions SUCCESSFULLY TREATED
osseous interface. When con- 4. Painful recurrent somatic dys- WITH RIT 2-32,35-70,74-132
cerned with peripheral muscles functions secondary to ligament
and tendons, sprains and strains laxity that improves temporarily 1. Cervicocranial syndrome (cer-
are identified as separate injuries with manipulation. Painful vicogenic headaches, secondary
and in three stage gradations: hypermobility and subluxation at to ligament sprain and laxity,
first-, second- and third-degree given peripheral or spinal articu- atlanto-axial and atlanto-occipi-
sprain or strain." 28-130 lation(s) or mobile segment(s) tal joint sprains, mid-cervical

3. Enthesopathy: A painful degen- accompanied by a restricted zygapophyseal sprains)

erative pathologic process that range of motion at reciprocal 2. Temporomandibular pain and
results in deposition of poorly organized segment(s) muscle dysfunction syndrome
tissue, degeneration 5. Thoracic and lumbar vertebral 3. Barre-Lieou syndrome
and tendinosis at the fibro- compression fractures with a w e d g e 4. Torticollis
osseous interface, and d e f o r m i t y t h a t e x e r t s stress on 5. Cervical segmental dysfunctions
transition toward loss of the posterior ligamento-tendinous 6. Cervicobrachial syndrome
1.6,77,107,128,129 complex (shoulder/neck pain)
Recurrent painful subluxations 7. Hyperextension/hyperflexion
4. Tendinosis/ligamentosis: A focal 6.
of ribs at the costotransverse, injury syndromes
area of degenerative changes


8. Cervical, thoracic, and lumbar
Chronic ankle sprain
zygapophyseal syndromes Instability The most common solutions for injection
9. Cervical, thoracic, and lumbar Laxity of ligaments therapy are dextrose based. Dilutions can
sprain/strain syndrome be made with local anesthetic (eg, I mL
10. Costotransverse joint pain 50% dextrose plus 3 mL 1% lidocaine).
11. Costovertebral arthrosis/ CONTRAINDICATIONS Gradual progression to 25% dextrose
dysfunction solution can be considered .4-8,22
12. Slipping rib syndrome 1. Allergy to anesthetic or prolifer- For intra-articular in jection of
13. Sternoclavicular arthrosis and ant solutions or their ingredients the knee, a 25% dextrose s olution
repetitive sprain such as dextrose, sodium mor- .4
had been used for decades Recently, a
14. Thoracic segmental dysfunction rhuate, or phenol 10% dextrose solution has been
15. Tietze's syndrome 2. Acute non-reduced subluxations investigated and has proved
16. Costochondritis/chondrosis or dislocations effective." The 5% sodium morrhuate
17. Costosternal arthrosis 3. Acute arthritis (septic or post- contains sodium salts of saturated and
18. Xiphoidalgia syndrome traumatic with hemarthrosis) un sa tur at ed fa tt y a c ids o f cod liver
19. Acromioclavicular sprain/ 4. Acute bursitis or tendinitis oil and 2% benzyl alcohol. Note that
arthrosis 5. Capsular pattern shoulder and the benzyl alcohol is chemically
20. Shoulder hand syndrome hip designating acute arthritis similar to phenol and acts as a local
21. Recurrent shoulder dislocations accompanied by tendinitis anesthetic and preservative .4,6,11,77,94
22. Scapulothoracic crepitus 6. Acute gout or rheumatoid Dextrose phenol glycerin solution
23. Iliocostalis friction syndrome arthritis consists of 25% dextrose, 2.5%
24. Iliac crest syndrome 7. Recent onset of a progressive phenol, and 25% glycerin. In all
25. Iliolumbar syndrome neurologic deficit involving the referenced studies, it was diluted
26. Internal lumbar disc disruption segment to be injected, including, with a local anesthetic of the practi-
27. Interspinous pseudoarthrosis but not limited to (severe intractable tioner's choice before injection. Dilution
(Baastrup's disease) cephalgia, unilaterally dilated pupil, reported ratios are 1:1, 1:2, and
28. Lumbar instability bladder dysfunction, bowel The 6% phenol in
29. Lumbar ligament sprain incontinence) glycerin solution was used at donor
30. Spondylolysis 8. Requests for a large quantity of harvest sites of the iliac crests for
31. Sacroiliac joint pain sedation and/or narcotics before neurolytic and proliferative respons-
32. Sacrococcygeal joint pain and after treatment es. 72,101 Other solutions include pumice
33. Gluteal tendinosis 9. Paraspinal neoplastic lesions suspension, tetracycline, a mixture of
34. Trochanteric tendinosis involving the musculature and chondroitin sulfate, glucosamine
35. Myofascial pain syndromes osseous structures sulfate with dextrose, and Plasmo
36. Ehlers-Danlos syndrome 10. Severe exacerbation of pain or Q-U .4,15,25.30-32,64.126
37. Osgood-Schlatter disease lack of improvement after
38. Ankylosing spondylitis infiltration of the putative noci-
(Marie-Strumpell disease) ceptive structure with a local
39. Failed back syndrome anesthetic 1. Regenerative injection therapy,
40. Fibromyalgia syndrome H. Any acute medical or surgical also known as prolotherapy, is
41. Baker's cyst condition that renders the patient's valuable for the treatment of chronic
42. Foot and/or ankle status unstable painful conditions of the
Sinus tarsi syndrome 12. Infection or neoplasia overlying
Metatarsalgia the area of injection


The Pain Clinic
A Multidisciplinary Approach to Acute & Chronic Pain Management

locomotive systems. seminars or workshops, apprentice- 45:101-109.

2. Thorough familiarity of normal, ships, or visiting fellowships to safely 10. Barbor R. A treatment for chronic low
and effectively use this treatment. The back pain. Presented at: Fourth Interna-
pathologic, cross-sectional, and
tional Congress of Physical Medicine;
clinical anatomy, as well as Florida Academy of Pain Medicine
September 6-11. 1964; Paris, France.
anatomical variations and func- endorses RIT, when administered 11. Biegeleisen Hl. Varicose Veins,
tions is necessary to ensure appropriately for the treatment of specific Related Diseases and Sclerotherapy:
appropriate technique. chronic pain entities. A Guide for Practitioners. Montreal,

3. Current literature supports Canada: Eden Press; 1984.

12. Blaschke J. Conservative management
manipulation under local joint
REFERENCES of intervertebral disk injuries. J OK State
anesthesia and a series of local Med Assoc. 1961;54:144-151.
anesthetic blocks for somatic pain. 1. Cotran RS, Kumar V, Collins T. 13. Blumenthal L. Injury to the cervical
4. Use of RIT in an ambulatory setting Robbins Pathologic Basis of Disease. spine as a cause of headache. Postgrad
is an acceptable standard of care in Philadelphia, Pa: WB Saunders; 1999. Med. 1974;56:3.
the community. 2. Dorman TA, Ravin TH. Diagnosis and 14. Bourdeau Y. Five-year follow-up on
Injection Techniques in Orthopedic sclerotherapy/prolotherapy for low back
5. Current literature suggests that
Medicine. Baltimore, MD: Williams & pain. Manual Med. 1988;3:155-157.
NSAIDs and steroid preparations Wilkins; 1991. 15. Chase R. Basic sclerotherapy.
have limited use in chronic painful 3. Hackett GS, Hemwall GA, Osteopath Ann. 1978;6:12-15.
overuse conditions and in Montgomery GA. Ligament and Tendon 16. Coleman AH. Physician electing to
degenerative painful conditions of Relaxation-Treated by Prolotherapy. treat by prolotherapy alters the method
5th ed. Springfield, Ill: Charles C. at his peril. J Nail Med Assn. 1968;60:
ligaments and tendons: howe v e r ,
Thomas; 1991. 346-348.
t h e y a r e o c c a s i o n a l l y helpful
4. Hackett GS. Ligament and Tendon 17. Compere EL, Kernahan WT.
to curb a significant inflammatory Relaxation-Treated by Prolotherapy. Persistent backache. Med Clin North Am.
reaction to proliferants. 3rd ed. Springfield, Ill: Charles C. 1958;42:299-307.
Microinterventional regenerative Thomas; 1958. 18. Coplans C. The use of sclerosant
techniques and proper rehabilitation 5. Linetsky F, Saberski L, Miguel R, injections in ligamentous pain. In: Heflet
up to 6 months or I year, supported Snyder A. A history of application in pain A, Grueble L, David M, eds. Disorders of
management: Part II, 1960s-1980s. Pain the Lumbar Spine. Philadelphia, Pa:
with mild opioid analgesics, may be
Clin. 2001;3:32-36. Lippincott Co; 1972.
more appropriate. 6. Linetsky F, Miguel R, Saberski L. 19. Cyriax J. Diagnosis of soft tissue
Pain management with regenerative lesion. In: Cyriax J, ed. Textbook of
injection therapy (RIT). In: Weiner RS, ed. Orthopaedic Medicine. London, England:
SUMMARY Pain Management: A Practical Guide for Bailliere Tindall; 1982.
Clinicians. 6th ed. Washington, DC: CRC 20. Cyriax J. Textbook of Orthopaedic
RIT is a safe and effective treatment
Press; 2002. Medicine. 5th ed. Baltimore, MD:
modality that is very useful in a significant
7. Reeves KD. Prolotherapy: basic Williams & Wilkins; 1969.
number of pain syndromes arising from science clinical studies and technique. 21. Dorman T. Storage and release of
ligament and tendon diathesis, as well as In: Lennard TA, ed. Pain Procedures in elastic energy in the pelvis: dysfunction,
other clearly delineated pain problems. Clinical Practice. Philadelphia, Pa: diagnosis and treatment. In: Vleeming A,
Physicians who use RIT must be Hanley and Belfus Inc; 2000. Mooney V, Snijders C, Dorman T, eds.
knowledgeable in clinical anatomy and 8. Reeves KD. Prolotherapy: present and Low Back Pain and its Relation to the
future applications in soft-tissue pain and Sacroiliac Joint. San Diego, Calif:
function and should be properly trained in
disability. Phys Med Rehab Clin North Philips Medical Systems; 1992.
this technique via a combination of Am. 1995;6:917-926. 22. Dorman T. Prolotherapy: a survey. J
9. Bahme B. Observations on the treat- Orthop Med. 1993;15:49-50.
ment of hypermotile joints by injection. J 23. Dorman T. Prolotherapy in the
Am Osteopath Assoc. November 1945; Lumbar Spine and Pelvis. Philadelphia,


Pa: Hanley and Belfus Inc; 1995. through induced ligament sclerosis. Ohio 52. Haldeman KO, Soto-Hall R. The
24. Eck B. New directions in the treat- State Med .l. 1953;49:877-884. diagnosis and treatment of sacroiliac
ment of disc pain. Presented at: Annual 38. Hackett GS, Henderson DG. Joint conditions by the injection of procaine
Meeting of the International Spinal Stabilization: an experimental, histologic (novocain). J Bone Joint Surg. 1938;
Injection Society; August 16, 1996; study with comments on the clinical 20:675-685.
Vancouver, British Columbia. application in ligament proliferation. 53. Hirsch C. An attempt to diagnose the
25. Eek B. Intradiscal injection therapy for Am .1 Surg. 1955:89:968-973. level of a disc lesion clinically by disc
chronic discogenic pain, a prospective trial. 39. Hackett GS. Joint Ligament puncture. Acta Orthop Scand. 1948;
Presented at: Annual Meeting of the Relaxation Treated by Fibro-osseous 18:131-140.
American Association of Orthopedic Proliferation. Springfield, I]]: Charles C. 54. Hirschberg G, Naeim F, Froetscher L.
Medicine; April 2001; Memphis, Tenn. Thomas; 1956. Treatment of the chronic iliolumbar
26. Gedney E. Special technic hypermo- 40. Hackett GS. Ligament relaxation and syndrome by infiltration of the iliolumbar
bile joint: a preliminary report. Osten Prof. osteo-arthritis (loose jointed vs close ligament. Western .1 Med. 1992:136: 372-
June 1937:30-31. jointed). Rheumatism. 1958;15:28-33. 374.
27. Gedney E. The hypermobile joint. 41. Hackett GS. Low back pain. Indust 55. Hirschberg G, Williams KA. Byrd
Further reports on injection method. Read Med Surg. 1959-,28:416-419. JG. Diagnosis and treatment of iliocostal
before the Osteopathic Clinical Society of 42. Hackett GS. Prolotherapy in whiplash friction syndromes. .1 Orthop Med. 1992:
Pennsylvania, Philadelphia. Pa. February and low back pain. Postgrad Med. 1960; 14:35-39.
13, 1938. 27:214-219. 56. Kayfetz DO, Blumenthal I.S. Hackett
28. Gedney E. Disc syndrome. Osten 43. Hackett GS. Prolotherapy in low back GS, Hemwall GA, Neff FE. Whiplash
Prof. September 1951:11-15. 38-46, 50. pain from ligament relaxation and bone injury and other ligamentous headache--
29. Gedney E. Use of sclerosing solution dystrophy. Clin Med. 1960;7:2551-256 1. its management with prolotherapy.
may change therapy in vertebral disk 44. Hackett GS, Huang TC, Raftery A, Headache. 1963;3:1.
problem. Osteo Prof April 1952:11-13, 34- Dodd TJ. Back pain following trauma 57. K a y f e t z D . O c c i p i t o - c e r v i c a l
40. and disease-prolotherapy. Mil Med. (whiplash) injuries treated by prolothera-
30. Gedney E. Technic for sclerotherapy 1961;126:517-525. py. Med Trial Tech Q. June 1963;147-167.
in the management of hypermobile 45. Hackett GS, Huang TC. Prolotherapy 58. Kellgren JH. On the distribution of pain
sacroiliac. Osten Prof August 1952: 16- for sciatica from weak pelvic ligaments and arising from deep somatic structures with
19, 37-38. bone dystrophy. Clin Med. December charts of segmental pain areas. Somatic
31. Gedney E. Progress report on use of 1961;8:2301-2316. Pain. 1939;4:35-46.
sclerosing solutions in low back syn- 46. Hackett GS, Huang TC. Prolotherapy 59. Kidd R. Recent developments in the
dromes. Osteo Prof. August 1954:18-21, for headache: pain in the head and neck, understanding of Osgood- Schl atter
40-44. and neuritis. Headache. 1962;2:20-28. disease: a literature review. J Orthop
32. Gedney E. The application of scle- 47. Hackett GS. Arteriosclerosis, carcino- Med. 1993;15:59-61.
rotherapy in spondylolisthesis and genesis, neuritis and osteoporosis. 60. Kidd R. Treatment of OsgoodSchlatter
spondylolysis. Osten Prqf. September Angiology. 1966;17:109-118. disease by prolotherapy: a case report.J
1964:66-69, 102-105. 48. Hackett GS. Cause and mechanism of Orthop Med. 1993;15:62-63.
33. Williams PL, Bannister LH, Barry MM, headache, pain and neuritis. Headache. 61. Klein RG, Dorman TA, Johnson CE.
et al. Gray's v Anatomy. 38th ed. New 1966;6:88-92. Proliferation injections for low back pain:
York, NY: Churchill Livingston-, 1995. 49. Hackett GS. Uninhibited reversible histologic changes of injected ligaments &
34. Grayson ME Sterile meningitis after antidromic vasodilation in pathophysio- objective measurement-, of lumbar
lumbosacral ligament sclerosing injections. logic diseases: arteriosclerosis, carcino- spine mobility before & after treatment. J
J Orthop Med. 1994;16:98-99.
genesis, neuritis and osteoporosis. Neurol Orthop Med Surg. 1989;10: 123-
Angiology. 1966:17:109-118. 126.
35. Green S. Hypermobility of joints:
causes, treatment and technic of scle- 50. Hackett GS. Uninhibited reversible 62. Klein RG, Eek BC. Prolotherapy:
rotherapy. Osteo Prof. April 1956:26-27, antidromic vasodilatation in bronchiogenic an alternative approach to managing
42-47. pathophysiologic diseases. Lancet. low back pain. J Musculoskel Med. May
36. Green S. The study of ligamentous 1966;86:398-404. 1997:45-59.
tissue is regarded as key to sclerotherapy. 51. Hackett GS. Prevention of cancer, 63. Klein RG. Diagnosis and treatment of
Osteo Prof January 1958:26-29.
heart, lung and other diseases. Clin Med. gluteus medius syndrome. J Orthop Med.
37. Hackett GS. Joint stabilization 1967;74:19. 1991;13:73-76.


The Pain Clinic
A Multidisciplinary Approach to Acute & Chronic Pain Management

6 4 . K l e i n R G . I nt r ad i s c a l i n j ec ti o n prolotherapy of the ipsilateral sacroiliac 89. Reeves KD. Treatment of consecutive

therapy for chronic discogenic pain, a ligaments. Am J Pain Manage. 1995; severe fibromyalgia patients with pro-
prospective trial in progress. Presented at a 5:91-93. lotherapy. J Orthop Med. 1994;16:84-89.
workshop sponsored by the American 7 6 . Maynard JA, Pedrini VA, PedrineMille 9 0 . Riddle P. Injection Treatment of
Association of Orthopedic Medicine; A, Romanus B, Ohlerking F. Morphological Hernia, Hydrocele, Ganglion, Hemor-
February 2001; Daly City, California. and biochemical effects of sodium rhoids, Prostate Gland, Angioma, Vari-
6 5 . Klein RG, Eek BC, DeLong WB. morrhuate on tendons. J Orthop Res. cocele, Varicose Veins, Bursae and Joints.
Mooney V. A randomized double-blind trial 1985;3:236-248. Philadelphia, Pa: WB Saunders; 1940.
of dextrose-glycerin-phenol injections for 7 7 . Mirman M. Sclerotherapy. 4th ed. 9 1 . Schultz L. A treatment for subluxa-
chronic, low back pain. J Spinal Disord. Springfield, Pa: Mirman; 1989. tion of the temporomandibular joint.
1993;6:23-33. 7 8 . Mooney V. Sclerotherapy in back JAMA. 1937;256:1032-1035.
6 6 . Koudele CJ. Treatment of joint pain. pain? Yes, if clinician is skilled. .1 9 2 . Schultz L. Twenty years' experience in
Osteo Ann. 1978;6:42-45. Musculoskel Med. January 1993:13. treating hypermobility of the temporo-
6 7 . Leedy R, Kulik AL. Analysis of 50 low 7 9 . Mooney V. Understanding, examining mandibular joints. Am J Surg. 1956;92:
back cases 6 years after treatment by joint for, and treating sacroiliac pain. J 925-928.
ligament sclerotherapy. Osteo Med. Musculoskel Med. July 1993:37-49. 9 3 . Schwartz R, Sagedy N. Prolotherapy: a
1976;6:15-2. 8 0 . Myers A. Prolotherapy treatment of literature review and retrospective
6 8 . Leedy R. Applications of sclerothera- low back pain and sciatica. Bull Hosp study. J Neurol Orthop Med Surg. 1991;
py to specific problems. Osteo Med. Joint Dis. 1961;22:48-55. 12:220-223.
August 1977;79-81,85,86,89-91,94-96. 8 1 . Neff F. A new approach in the 9 4 . Shuman D. Low Back Pain.
6 9 . Leriche R. Effets de ]'anesthesia A la treatment of chronic back disabilities. Philadelphia, Pa: David Shuman; 1958.
novocame des ligaments et des insertions Fam Phys. 1959;9:3. 9 5 . Shuman D. Luxation recurring in
tenineuses periarticulaires daps certaines 8 2 . Neff F. Low back pain and disability. shoulder. Osteo Prof 1941;8:11-13.
maladies articulaires et daps les vices des West Med. 1960;1:12. 9 6 . Shuman D. Sclerotherapy: injections
positions fonctionnelles des articulations. 8 3 . Ombregt L, Bisschop P, ter Veer HJ, may be best way to restrengthen ligaments
Gaz Hop. 1930;103:1294. Van de Velde T. A System of Orthopaedic in case of slipped knee cartilage. Osteo
7 0 . Linetsky FS, Mikulinsky A, Gorfine Medicine. Philadelphia, Pa: WB Prof. March 1949.
L. Regenerative injection therapy: history Saunders; 1995. 9 7 . Shuman D. The place of joint scle-
of application in pain management: Part 8 4 . Ongley MJ, Dorman TA, Klein RG, rotherapy in today's practice. Bull NJ
I, 1930s-1950s. Pain Clin. 2000;2:8-13. Eek BC, Hubert LJ. A new approach to Assoc Osteo Phys Surg. October 1949.
7 1 . Liu Y, Tipton CM, Matthes RD, the treatment of chronic low back pain. 9 8 . Shuman D. Sclerotherapy: statistics
Bedford TG, Maynard JA, Walmer HC. Lancet. July 1987:143-146. on its effectiveness for unstable joint
An in situ study of the influence of a 8 5 . Ongley MJ, Dorman TA, Eek BC, conditions. Osteo Prof. 1954;21:11-15, 37-
sclerosing solution in rabbit medial Lundgren D, Klein RG. Ligament 38.
collateral ligaments and its junction instability of knees: A new approach to 9 9 . Vanderschot L. Trigger points vs
strength. Conn Tissue Res. 1983;11: 95- treatment. Manual Med. 1988;3:152-154. acupuncture points. Intl J Acupunc.
102. 8 6 . Poritt A. The injection treatment of 1976;4:233-238.
7 2 . Maher RM. Neurone selection in hydrocele, varicocele, bursae and nevi. 100. Vlemming A, Mooney V, Dorman T,
relief of pain. Further experiences with Proc Royal Soc Med. 1931;24:81. Snijders C, Stoeckart R. Movement,
intrathecal injections. Lancet. January 8 7 . Reeves KD, Hassanein K. Stability and Low Back Pain: The
1957;16-19. Randomized prospective double-blind Essential Role of the Pelvis. New York,
7 3 . Marui T, Niyibizi C, Georgescu HI, placebo-controlled study of dextrose NY: Churchill Livingstone; 1997.
et al. Effect of growth factors on matrix prolotherapy for knee osteoarthritis with 101. Wilkinson HA. The Failed Back
synthesis by ligament fibroblasts. J Orthop or without ACL laxity. Ahern Ther Syndrome Etiology and Therapy. 2nd ed.
Res. 1997;15:18-23. Health Med. 2000;6:68-74,77-80. New York, NY: Springer-Verlag; 1992.
7 4 . Massie J, Mooney V, Green DA. Is it 88. R e e v e s K D , H a s s a n e i n K . 102. Cousins MJ, Fink R, Bridenbaugh PO,
possible to stimulate fibroplasia within Randomized, prospective, placebo- et al. Neural Blockage in Clinical
the intervertebral disc? J Orthop Med. controlled double-blind study of dextrose Anesthesia and Management of Pain.
1993;15:83. prolotherapy for osteoarthritic thumb and Philadelphia, Pa: JB Lippincott Co; 1988.
7 5 . Matthews JH. A new approach to the finger joints: evidence of clinical efficacy. J 103. Roosth H. Low back and leg pain
treatment of osteoarthritis of the knee: Altern Complement Med. 2000;6:311-320. attributed to gluteal tendinosis. Orthop


Today. November 1991:10. in the cervical zygapophyseal joints. N Pathology. 1st ed. Champaign, 111:
104. Vanderschot L. The American Engl J Med. 1994;330:1047-1050. Human Kinetics; 1997.
version of acupuncture. Prolotherapy: 116. Bogduk N. Clinical Anatomy of the 129. Dorland's Illustrated Medical
coming to an understanding. Am J Lumbar Spine and Sacrum. 3rd ed. New Dictionary. 28th ed. Philadelphia, Pa:
Acupunct. 1976;4:309-316. York, NY: Churchill Livingstone; 1997. WB Saunders; 1994.
105. Leadbetter W. Cell-matrix response 117. Broadhurst NA, Wilk VJ. Vertebral 130. Merskey H, Bogduk N. Classifica-
in tendon injury. Clin Sports Med. 1992; mid-line pain: pain arising from the tion of Chronic Pain, Descriptions of
11:533-578. interspinous spaces. J Orthop Med. 1996; Chronic Pain Syndromes and Definitions
106. Leadbetter W. Anti-inflammatory 18:2-4. of Pain Terms. 2nd ed. Seattle, Wash:
therapy in sports injury: The role of non- 118. Cyriax J. Illustrated Manual of IASP Press; 1994.
steroidal drugs and corticosteroid injection. Orthopaedic Medicine. 2nd ed. Oxford, 131. Ranney D. Chronic Musculoskeletal
Clin Sports Med. 1995;14:353-410. England. Butterworth Heinemann; 1993. Injuries in the Workplace. Philadelphia,
107. Leadbetter W. Soft Tissue Athletic 119. DesRosiers EA, Yahia L, Rivard C. Pa: WB Saunders; 1997.
Injuries-Sports Injuries: Mechanisms, Proliferative and matrix synthesis re- 132. Kang HJ, Kang ES. Ideal concentra-
Prevention, Treatment. Philadelphia, Pa: sponse of canine anterior cruciate liga- tion of growth factors in rabbit's flexor
Williams & Wilkins; 1994:736-737. ment fibroblasts submitted to combined tendon culture. Yonsei Med J. 1999; 40:26-
108. Best T. Basic science of soft tissue. growth factors. J Orthop Res. 1996; 29.
In: Delee JC, Drez D Jr, eds. Orthopedic 14:200-208.
Sports Medicine Principles and Practice. 120. Dreyfuss P, Michaelsen M, Fletcher
Philadelphia, Pa: WB Saunders: 1994;1: 7- D. Atlanto-occipital and lateral atlanto- THE FLORIDA ACADEMY OF
35. axial joint pain patterns. Spine. 1994: PAIN MEDICINE
109. Shevelev OA, Sokov EL, Klepikov 19:1125-1131.
121. Dreyfuss P, Tibiletti C, Dreyer SJ. 3807 NW 53rd Terrace
RV. Interosseous receptor system as the
Thoracic zygapophyseal joint pain Gainesville, FL 32606
modulator of trigeminal afferent reactions.
(352) 372-9360
Pain Clin. 2000;34:715-721. patterns: a study in normal volunteers.
110. Sokov E, Mustafa A. Are herniated Spine. 1994; 19:807-811. Become a member of the Florida
disks the main cause of low back pain. 122. Dreyfuss P. Differential diagnosis of Academy of Pain Medicine today to take
thoracic pain and diagnostic/therapeutic advantage of a broad range of
Pain Clin. 2000;74:715-721.
membership benefits, including:
111. Zoppi M, Beneforti E. From intra- injection techniques. ISIS Newsletter Discounted registration at educational
osseous pain syndrome to osteoarthritis. 1997:10-29. conferences, important legal and
Worldwide Pain Conference. Pain and 123. Dreyfuss P, Michaelsen M, Home regulatory updates, advocacy on
Neuromodulation: The New Millennium. M. MUJA: manipulation under joint billing and reimbursement issues, and the
Proceedings of the 9th World Congress. anesthesia/analgesia: a treatment ap- opportunity to network with colleagues
from a wide variety of specialties. For
The Pain Clinic. July 2000; San Francisco, proach for recalcitrant low back pain of
more information, contact the FAPM
Calif. synovial joint origin. J Manipulative ve headquarters at (352) 372-9360.
112. Agur A, Lee MJ. Grants Atlas of Physiol Ther October 1995;18:537-546.
Anatomy. 9th ed. Baltimore, Md. 124. Dussault R, Kaplan PA. Facet joint
Williams & Wilkins; 1991. injection: diagnosis and therapy. Appl
113. Aprill C, Dwyer A, Bogduk N. Radiol. June 1994:35-39.
Cervical zygapophyseal joint pain patterns 125. Dwyer A, Aprill C, Bogduk N. President - Andrea M. Trescot, MD
Cervical zygapophyseal joint pain patterns President-elect - Gary W. Jay, MD
11: a clinical evaluation. Spine.
Secretary - Winston Parris, MD
1990;15:458-461. I: a study in normal volunteers. Spine. Vice President -
114. Ashton IK, Ashton BA, Gibson SJ, 1990;15:453-457. Francisco M. Torres, MD
Polak JM, Jaffray DC, Eisenstein SM. 126. Freemont A. Nerve ingrowth into Treasurer - Kenneth P. Botwin, MD
Morphological basis for back pain: the diseased intervertebral disc in chronic Legislative Committee Chair -
back pain. Lancet. 1997;350:178-181. Sanford Z. Pollack, DO
demonstration of nerve fibers and neu-
127. Hunt WE, Baird WC. Complications Membership Committee -
ropeptides in the lumbar facet joint James J. Worden, MD
capsule but not in ligamentum flavum. J following injection of sclerosing agent to Past President -
Orthop Res. 1992;10:72-77. precipitate fibro-osseous proliferation. J James B. Boorstin, MD
115. Barnsley L, Lord SM, Wallis BJ, Neurourg. 1981;18:461-465. Immediate Past President -
Bogduk N. Lack of effect of intra-articular 128. Jozsa LG, Kannus P. Human Felix S. Linetsky, MD
corticosteroids for chronic pain Tendons: Anatomy, Physiology and

TH E PAI N C LI N I C JUNE 2002 45