Types of conservative care treatments and spinal injections for low back pain, degenerative disc disease, lumbar instability
Ross Hauser, MD and Danielle Matias, PA-C
Many people that read articles on lumbar or spinal instability are clearly still searching for some answers for their or a loved one’s chronic pain issues. These people are typically someone who have had many years of treatments, and, a list of general and more specific recommendations to consider for the various forms of spinal surgery that may be available to them, and most impactful, they suffer from a reduced quality of life because of back pain and loss of function.
These people do understand that their lumbar instability describes two or more vertebrae in the lumbar spine that are wandering around, banging into each other. When they move closer together, they compress nerves and herniate discs. These people are also progressing to a point where their spine is, or will soon be, no longer be able to support the weight of their core, torso, and upper body. They may be at a point where their bodies are desperately trying to support the spine with bone spurs, a point of lumbar osteoarthritis degeneration.
The people wehave described above have likely taken their fair share of anti-inflammatory medications, painkillers, nutritional supplements, and other home remedies to help them get through their day and night of back pain. As mentioned many have also had various discussions on the possibility of new or future spinal surgery. Except in a life-threatening situation or impending neurologic injury, surgery should always be a last resort and performed only after all conservative treatments have been exhausted. Pain is not a life-threatening situation, although it can lead to back pain with anxiety and depression, loss of quality of life, and be burdensome on family members. Pain should not be an automatic indication that surgery is necessary. As you are reading this article it is very likely that you have had years of various treatments with varying degrees of short-term success. Obviously, if your treatments or surgery were successful, you would not be reading this article.
- Treating back pain and lumbar spinal instability.
- Conservative care options that would provide minimal clinically important differences (MCID).
- The use of Nonsteroidal anti-inflammatory drugs and antidepressants.
- Manipulative therapy, physiotherapy, and massage therapy studies have also shown only temporary benefits.
- Patients went to see their doctor for low back pain – what types of treatments did they get?
- More treatments are considered surprising or questionable for low back pain.
- Epidural steroid injections
- The search for the baseline cause of low back pain is often elusive.
- Identifying spinal instability in nonspecific low back pain.
- Chronic low back pain is caused by difficulty in understanding what is causing it.
- Diagnosing lumbar instability & treatment with Prolotherapy, PRP, cortisone, and nerve blocks.
- The problem of treatments for lumbar spinal instability is the subject of numerous medical research papers.
- Aren’t degenerated discs the problem of low back pain?
- The spinal ligaments are the focus of this article – not the muscles – not the discs.
- What makes the lumbar spine stable? What makes the lumbar spine unstable?
- Symptoms of worsening lumbar spinal instability.
- Mechanical and functional spinal instability.
- What then are the overriding effects of a gradual loosening of the ligaments in the lower back?
- When the cause of low back pain is misdiagnosed or not identified – inappropriate treatment follows.
- Targeting injections at the facet joints of the spine.
- The lumbar facet capsular ligament is always under tension and likely always being stretched.
- What then are the overriding effects of a gradual loosening of the ligaments in the lower back?
When the cause of low back pain is misdiagnosed or not identified – inappropriate treatment follows.
- Targeting injections at the facet joints of the spine.
- The lumbar facet capsular ligament is always under tension and likely always being stretched.
- The lumbar spine is considered unstable if abnormal strains or excessive motion develop in the functional spinal unit.
- When the ligaments of the posterior ligament complex – bend too far and that is painful.
- Injury to the sacroiliac ligaments.
- Prolotherapy and PRP for facet joint pain.
Treating back pain and lumbar spinal instability
As we noted, people with low back pain may spend years or decades of their lives in pursuit of something, or anything, that will help them with their low back pain. These people, perhaps like yourself, may find short-term relief with rest, pain medications, trigger point shots, manipulation, and massage, but these treatments are usually temporary in their benefits.
One reason that long-term relief and improvement in function are not attained is that these remedies and treatments may be addressing the wrong problem or are simply providing pain suppression, sometimes at a great cost to future quality of life.
Treating chronic back pain can be tricky. Somedays a person’s back will hurt tremendously, other days the person feels little to no pain. To the person with back pain, it is a mystery to them why their back hurts sometimes and other times does not. Was their disc not as herniated today? Was their nerves not as compressed today? How come their muscles were not sore today? For most, the answer is an unstable spine or spinal instability that causes pain with certain and prolonged movements, but limited or no pain with other activities.
In the image below we see lumbar instability seen under fluoroscopic motion imaging in flexion (patient is bending forward). When the person bends forward, the vertebrae start wandering out of position because the spine is not stable. When the person bends backward, the vertebrae line up as they should. The spinal instability is coming from the spinal ligament’s inability to hold the vertebrae in place while bending forward.
Lumbar instability is chronic in nature. People have had it come and go perhaps many times over many years. The problem for most people of course is that “it always comes back.” Why does it always come back? One reason is that the treatments for it are not the correct treatments. So, let’s get into the research of treating chronic low back pain cases.
Conservative care options that would provide minimal clinically important differences (MCID).
There is some consensus in the medical community on how to treat acute low back pain, but the treatment of chronic low back pain presents many challenges and little agreement on the standard of care.
An August 2022 paper in the journal BioMed Central musculoskeletal disorders (1) looked at conservative care options that would provide minimal clinically important differences or MCID, in quality of life for patients with degenerative spine disease. The treatments the patients were offered were:
- Physical therapy (such as back strengthening and mobilization, hydrotherapy, passive leg stretching if radicular symptoms present), or
- Passive treatment (like heat, traction, massage or bracing) if patients were not tolerating the physical therapy.
- When deemed necessary the prescription of analgesics, facet or epidural injections according to standard practices for 1 year since baseline.
- Analgesics provided included paracetamol (Tylenol) 500 mg 4 times daily as required, non-steroidal anti-inflammatory agents (naproxen 250 mg twice daily as required or diclofenac slow release 100 mg daily as required) and pregabalin 75 mg twice daily for radicular symptoms.
- In patients who showed no improvement in radicular symptoms at three months with the physiotherapy and pregabalin, the patient was offered an epidural injection. Facet injections would also be offered for patients with predominantly back-extension (bending over backwards type movements) related pain if no improvement was reported with the prior mentioned conservative treatment.
When patients went to see their doctor for low back pain – what types of treatments did they get? “Nearly two-thirds of the patients reported that their doctor had recommended prescription medications, including opioids, benzodiazepines, Gabapentin, Neurontin, or cortisone injections.”
In the above study, doctors outlined the many types of conservative care treatments that could help a patient get to a minimum standard of improvement. But there are many treatments. Can this process of finding something effective be streamlined?
In a March 2021 paper led by the Department of Orthopaedic Surgery, Duke University School of Medicine, and published in The Journal of Alternative and Complementary Medicine (2) the researchers found that patients indeed were being prescribed many treatments for their low back pain. In this study, patients went to see their doctor for low back pain. Following their visit, the study researchers contacted these patients to ask about the types of treatment recommendations they were getting. “Participants were asked about medical doctor recommendations for both drugs (acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs], opioids, benzodiazepines, Gabapentin, Neurontin, and cortisone injections) and nondrug (self-care treatments, massage, acupuncture, spinal manipulation, and physical therapy) treatments.
This is what they got:
- Ninety-six percent (96%) of patients who visited a medical doctor for low back pain received a recommendation for one or more pain treatments, with 81% reporting that their medical doctor recommended both drug and non-drug therapies.
- Seventy-six percent (76%) of respondents were recommended acetaminophen or NSAIDs,
- Seventy-nine percent (79%) were recommended self-care treatments,
- Thirty-seven percent (37%) were recommended massage, acupuncture, or spinal manipulation, and
- Sixty percent (60%) were recommended physical therapy.
Nearly two-thirds of the patients reported that their doctor had recommended prescription medications, including opioids, benzodiazepines, Gabapentin, Neurontin, or cortisone injections. Reported adherence to treatment recommendations ranged from 68% for acupuncture to 94% for NSAIDs.
- 94% of patients, told to take NSAIDs, took them.
Let’s review these treatments a little further:
Nonsteroidal anti-inflammatory drugs and antidepressants provide some short-term benefits
Nonsteroidal anti-inflammatory drugs and antidepressants provide some short-term benefits, but no published data warrant their long-term use. This was pointed out recently in the journal Systematic Reviews (3) February 2021. Here researchers described the small benefits of anti-depressant use for people with back pain.
In this study, the researchers suggested:
- On average, patients with low back pain treated with antidepressant medicines will experience a small improvement in pain and function and no improvement in symptoms of depression, compared to placebo. The benefits of anti-depressants were not seen as clinically significant.
- Patients are at increased odds of experiencing an adverse or serious adverse effect to the anti-depressants and at increased odds of stopping (anti-depressant) treatment due to an adverse effect or another reason, compared to placebo.
- Taken together, these data indicate treatment of low back pain symptoms with antidepressants has no important benefit; is less acceptable, less safe, and less tolerable; and may be harmful, compared to treatment with placebo medicine.
Numerous recently published clinical care guidelines call for nonpharmacological approaches to pain management. However, little data (research) exists regarding the extent to which these guidelines have been adopted by patients and medical doctors. In other words, are the doctors and patients compliant in trying to avoid pharmacological pain management? Remember what we said above 94% of patients, told to take NSAIDs, took them.
More treatments considered surprising or questionable for low back pain
The researchers of this study also noted that the high number of respondents (29%) who reported that their doctor recommended the use of opioids in the past 12 months, considering well established guidelines and concerns surrounding the use of opioids, surprising.
Further, the study says, more than a third of respondents (38%) reported a recommendation of cortisone injections, a treatment that may offer short-term benefits, but it is also associated with a significant risk of contamination and infection. Cortisone injections are generally not recommended in clinical care guidelines due to weak evidence for pain and function benefits.
- The researchers also reported that patient-reported use of over-the-counter medications was high in spite of questionable benefits and known risks.
- Nearly 80% of respondents reported that they received a recommendation from their doctor to take either acetaminophen or NSAIDs. NSAIDs may result in a small-to-moderate effect on pain and function, however, the risks of gastrointestinal bleeding associated with NSAIDs are well established
Patients selected their own treatments with MD guidelines:
- Patients reported self-management treatments such as heat, yoga, or other exercises, as well as therapies provided by complementary and integrative health practitioners such as spinal manipulation and massage, was relatively high in respondents who did not receive a recommendation by an MD to do so.
- Conclusions: “In the majority of patient cases, a combination of prescription medications and self-care were recommended, according to the researchers this illustrates the need for additional research on the effectiveness of multimodal treatment strategies. (In other words what will work and what does not work).”
No magic bullet exists for nonspecific chronic low back pain
A December 2022 paper from a team of international researchers and published in the Journal of orthopaedic surgery and research (4) wrote: (For patients with non-specific caused back pain) “No magic bullet exists: interventions to reduce pain and disability are available, but long-term outcomes are unpredictable. Non-pharmacological methodologies are recommended as a first-line therapy for nonspecific chronic low back pain. . . Pharmacological management should be considered as co-adjuvant to non-pharmacological therapy and should be guided by the symptoms reported by the patients. Clinicians have to choose from drugs with very modest effects and variable risk profiles. Hence, the widespread recommendations to use pharmacological options as a last resort. The benefits are just not there to justify the routine prolonged use of any given drug in nonspecific chronic low back pain: this is a major challenge, and it is often hard to accept for clinicians and patients . . . ”
An August 2022 study (5) from the University of North Texas Health Science Center and published in the Journal of osteopathic medicine tackled a subject that researchers had not previously spent a lot of time on. The subject was, what happens to people who have chronic low back pain and are on long-term opioid use? In this study, 96 long-term opioid users were followed.
In these 96 patients, the researchers found outcomes that they called largely consistent with existing literature regarding the outcomes of long-term opioid therapy.
- Long-term opioid use (more than 12 months) patients had a worse disability, physical function, fatigue, and other pain-related problems including the earlier onset of sleep disturbance.
Manipulative therapy, physiotherapy, and massage therapy studies have also shown only temporary benefits in helping low back pain patients
A March 2019 paper in the British Medical Journal (6) suggests that “In the treatment of chronic low back pain in adults, moderate-quality evidence suggests that spinal manipulative therapy results in similar outcomes to recommended therapies (exercise, physical therapy) for short, intermediate, and long term pain relief as well as improvement in function. In addition, the quality of evidence varied suggesting that spinal manipulative therapy does not result in clinically better effects for pain relief but does result in clinically better short-term improvement in function compared with non-recommended therapies, or sham, and when included as adjuvant therapy.
Covering this ground much more extensively is our article Why physical therapy and yoga did not help your low back pain. In this article we discuss:
Why physical therapy and yoga did not help your low back pain.
- We offer the research and clinical observation that physical therapy will not make gains without strengthened, repaired ligaments.
- We make the case for strengthening the ligaments to help the core muscles.
- Yoga works when there are strong ligaments, yoga will not help when ligament instability prevents muscles from getting needed resistance.
- Just walking may be better than yoga.
- Pilates works when there are strong ligaments, Pilates will not help when ligament instability prevents muscles from getting needed resistance.
Epidural steroid injections
In our article Alternatives to Epidural Steroid Injections, we present the latest research on these injections. We invite you to explore that research. In summary, in that article we present:
- The realistic outlook of Epidural steroid injections in helping people avoid spinal surgery.
- Patient pain needs and the hope of getting any pain relief regardless of side effects.
- The patient understands that “Epidurals may be bad for me, but I need options.”
- Do epidurals offer meaningful relief in lumbosacral radicular syndrome?
- Understanding side-effects – Epidural steroid injections CANNOT be repeated without concern regarding the duration of time between injections.
- Epidural Steroid Injections Risks and Concerns.
- “Unnecessary multiple epidural steroid injections delay surgery for massive lumbar disc herniation.”
- Alternatives to Epidural Steroid Injections
The search for the baseline cause of low back pain is often elusive.
What causes low back pain? There are many causes. Most common are problems with herniated discs, Facet Syndrome, Lumbar stenosis, Lumbar Spondylolisthesis, and various spinal curvature problems including lordosis, kyphosis, and scoliosis. What all of these problems have in common is lumbar instability. The vertebrae are moving out of their natural alignment. What causes lumbar instability? Spinal ligament weakness and damage.
For the most part, many people have not been told that their spinal ligaments are weak. Many patients are not even informed that the spinal ligaments are what hold the vertebrae to each other. A ligament is a band of connective tissue that holds bone to bone. Of all the ligaments the most famous one lives in the knee the ACL, the anterior cruciate ligament, which connects the thigh to the shin bone.
Since the majority of spinal ligament injuries cannot be seen on a conventional x-ray or MRIs, doctors and patients look for other problems or diagnoses, such as the previously mentioned degenerative disc disease, stenosis, and SI joint pain, among others. Yet in many cases, the common underlying cause of low back pain, degenerative arthritis in the spine, facet joint osteoarthritis towards the development of stenosis, lumbar spondylosis, loss of spinal curve, or development of excessive spinal curve, is in large part, due to facet joint capsular ligament injury and is the cause of almost every chronic spinal pain.
Identifying spinal instability in nonspecific low back pain
Spinal instability begins when the stabilizing structures of the spine, the spinal ligaments, can no longer hold adjacent bones together. When present, this is termed mechanical instability.
The term functional instability is used when mechanical instability causes symptoms with a certain function or activity.
- Many people are walking around with mechanical instability but are asymptomatic because the force required to perform current normal activities is not beyond the tissue strength.
- Problems arise when mechanical instability worsens when patients overdo an activity or start a new exercise program.
- Thus the patient may have symptoms only when performing a certain activity, such as back pain with running.
- From the patient’s perspective, pain symptoms do not exist during any other activity.
- This is called functional spinal instability with running and mechanical instability of the entire low back.
- Functional instability, or symptomatic instability with movement, occurs with mechanical failure of the spinal ligaments and the subsequent excessive motion of adjacent bones. This can be caused by trauma, disease, surgery, or any combination thereof to one or more regions of the spine.
Chronic low back pain is caused by difficulty in understanding what is causing it.
Researchers in Germany writing in the medical journal Clinical Rheumatology (7) discussed the problems of assessing the true cause of back pain. To summarize their findings, the researchers noted that:
- The most examined spinal problem is low back pain.
- Low back pain, for the most part, is caused by a nonspecific problem that is difficult to diagnose. (Note: This is not very reassuring to patients that the most chronic back pain problem is difficult to understand. This is also why the rush to lumbar surgery is so troubling.)
- Inflammation of the spine is not as widespread.
- Only a small amount of patients have axial (low back sacroiliac joint) inflammation as the major cause of their back complaints with chronic inflammatory back pain as the most prominent clinical feature of spondyloarthritis (inflammatory/rheumatoid arthritis). (Note: This is also troubling to patients as if inflammation is not the problem, as patients are being put on long-term anti-inflammatory treatment plans.)
- Numerous diseases such as:
- degenerative disc disease,
- degenerative changes in the intervertebral (facet) joints and the associated ligaments,
- spinal instability,
- herniation of the intervertebral disc,
- and spinal stenosis has to be differentiated in interpreting imaging of the spine.
- (Ross Hauser MD has written an article on this site on how the MRI is a risk factor for failed back surgery)
In our opinion, most healthcare providers rely too heavily on diagnostic tests, especially for low back problems. Consequently, many who suffer from low back pain do not find relief.
The typical scenario is as follows:
- A person complains to a physician about low back pain that radiates down the leg.
- The physician orders x-rays and an MRI.
- The scan reveals an abnormality in the disc—such as a herniated, bulging, or degenerated disc.
- Unfortunately for the patient, this finding usually has nothing to do with the pain.
Diagnosing lumbar instability & treatment with Prolotherapy, PRP, cortisone, and nerve blocks
Ross Hauser, MD, and Danielle Matias, PA-C discuss the types of cases we see at Caring Medical Florida for low back pain and spinal instability.
The problem of treatments for lumbar spinal instability is the subject of numerous medical research papers.
The problem of treatments for lumbar spinal instability is the subject of numerous medical research papers. An August 2021 study published in The Spine Journal (8) led by researchers at the Department of Orthopaedics and Physical Medicine, Medical University of South Carolina; Brigham and Women’s Hospital, Harvard Medical School; Tufts University School of Medicine selected 131 different patient scenarios and presented them to doctors for a possible recommendation of treatments. The Main diagnosis these scenarios centered on was lumbar spondylolisthesis.
Here are some of the learning points of this research:
- These scenarios addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities that may impact the success of treatment.
- For most of these scenarios, appropriateness of treatment was established for:
- physical therapy,
- and various forms of surgical intervention.
- Physical therapy was appropriate in most scenarios and most appropriate in patients with back pain and no neurological deficits.
- Epidural steroid injections were most appropriate in patients with radiculopathy.
- Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis.
- Patients with mechanical back pain and the presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision-making.
- Lumbar decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers.
Caring Medical published research
In December 2021, we published our peer review paper Lumbar instability as an etiology of low back pain and its treatment by prolotherapy: A review in the Journal of Back and Musculoskeletal Rehabilitation. (9) Here in this article we present a lay version with explanatory notes. We start with that article now. First we will start with three case histories.
These three case histories demonstrate the successful outcomes of a combined dextrose Prolotherapy – PRP ultrasound-guided injection therapy targeting the ligaments and structures of the lumbosacral region. While ultrasound has limited diagnostic value in the spine, it does aid in identifying target structures and landmarks, such as the sacroiliac joint and the iliolumbar, supraspinous, interspinous lumbosacral, sacral, and sacroiliac ligaments as well as the facet joints.
Case 1: A 78-year-old woman came to our clinic with a six-year history of low back and lateral hip pain, which interfered with her mobility. Because she had not responded to conventional treatment she sought out alternatives. She was given Prolotherapy treatment to the left gluteal tendon and spine in five injection sessions spaced 4-8 weeks apart. At baseline, patient reported pain levels of 8/10; at two months, pain was 1-2/10. At 12 months patient reported no use of pain medications, ability to ambulate without a cane, as well as six to seven days per week of adequate pain relief. She indicated being “extremely satisfied” on the post procedure pain inventory assessment.
Case 2: A 67-year-old woman who had previously undergone a L4/5 and L5/S1 laminotomy came to us suffering with left sacroiliac (SI) pain for six months. She reported the pain as being 5/10 and impeding her ability to sit. The patient received a series of ultrasound-guided Prolotherapy and PRP injection therapeutic applications to the left SI joint and overlying dorsal SI ligaments. She underwent three injection sessions approximately every four weeks. Functional outcome measures and goals included tolerable sitting. At one month, the patient reported a 50-60% decrease in pain and an increase in sitting ability and at two months, pain was 3/10. By three months (third treatment), pain was 3-4/10 with notable improvement in sitting tolerance and seven straight days of adequate pain relief.
Case 3: An at-risk 83-year-old man with a history of cardiac dysrhythmia, hypertension, and coronary artery disease came in with complaints of low back pain that had been radiating down both legs for the past five years. He reported constant pain and additional symptoms of numbness and tingling of both feet. His pain worsened when lying flat in bed, maintaining an erect posture, and walking. He noted his walking had become increasingly less frequent over the past five years. He declined recommended surgery. An ultrasound-guided caudal epidural relieved his leg pain, numbness, and tingling, but did not alleviate his low back and hip pain. As a result, he continued to require a walker, although an X-ray of the right hip was within normal limits. The patient received Prolotherapy treatments consisting of concentrated dextrose and PRP, which were given by injection to the lumbosacral region via ultrasound-guidance. He received six treatments spaced 4-5 weeks apart. At six weeks the patient reported back pain was 4/10 and hip pain, 0/10; at three months back pain was 4/10, but walker was no longer being used; at 11 months back pain was down to 2/10 and walker was still not with being used.
Aren’t degenerated discs the problem of low back pain?
Most people experience some form of back pain by the time they reach middle age. However, athletes who participate in twisting sports such as golf, tennis, and bowling, due to the forces exerted during their sports, are more at risk for developing osteoarthritis of the spine. Other athletes experience repeated strain on the back due to postures, such as backpacking and hiking. We cannot forget, however, the constant poor posture of most Americans as they sit at their desks, and slouch on their couches, all the while face down into their computers or mobile devices.
A good portion of the population suffers from daily back pain and ends up choosing back surgery in hopes of alleviating the pain. Unfortunately, many patients are left with even more pain because the surgery that was supposed to strengthen the weak area actually ended up weakening the area to the point that the non-surgeries back was actually stronger. Degeneration occurs in the back due to a weakening of the support structures. Left untreated, this leads to osteoarthritis with accompanying pain and stiffness.
Aren’t degenerated discs the problem? The intervertebral disc is a major component contributing to segmental stability as well as a major load-bearing structure. However, disc abnormalities that occur in osteoarthritis are not associated with pain. Many patients and athletes are distressed at being told that they are suffering from one or more degenerated discs. Disc degeneration occurs as age advances but often causes no pain. Thus the other structures in the back are causing the problem.
The spinal ligaments are the focus of this article – not the muscles – not the discs
In this image, we see the posterior or rear view of the spine showing the ligaments (white) and nerves (yellow). Most spinal nerve entrapments (radiculopathy) as we will see in the research below can be traced to spinal instability caused by ligament injury.
The most common cause of unresolved chronic back pain is spinal instability. People who have low back (lumbar) pain know that rest, pain medications, trigger point shots, manipulation, and massage may be helpful, but they did not alleviate their pain long-term. Common sense tells us that if chronic lumbar pain were simply and only a muscle problem, anyone could sit in a hot tub for two hours or get a long massage and they would be cured of their pain. But we know this does not occur. Those therapies only help temporarily. The underlying cause of the chronic pain is not the muscles themselves but rather muscle spasms brought on by ligament laxity. Since over 90% of the injuries to any one of the over 900 ligaments in the body cannot be seen on conventional x-ray or MRI, patients are not told that the reason for their chronic low back pain is facet joint instability from ligament laxity. Spinal instability, in large part, is due to facet joint capsular ligament injury and is the cause of almost every chronic spinal pain.
More specifically, in the instance of low back pain, injury to the sacroiliac ligaments typically occurs from bending over and twisting with the knees in a locked, extended position. This maneuver stretches the sacroiliac ligaments, placing them in a vulnerable position. The ligaments are white (poor blood supply), and they are very unlikely to heal on their own, especially in chronic back pain, yet are incredibly important for spinal stability and movement.
The supraspinatus and interspinous ligaments go from vertebra to vertebra. The iliolumbar ligaments attach along the ilium to the sacrum (sacroiliac ligaments). Cumulative injury (without repair) over years of sports or improper movement can result in small tears in these ligaments. Often healing never occurs and people report “chronic nagging back pain.” Since the ligaments do not heal, the intervertebral discs do not have the support they need. Instability and ligament laxity with resultant instability cause chronic low back pain.
Thus, spending a lot of time and money on therapies that work the surrounding muscles is only going to produce a temporary benefit. Patients with back pain frequently complain about muscle tightness, spasms, or feeling like the SI might “give out.” They focus so much on the muscles (workout harder, stretch more, get more massage, etc…), that they ignore or do not know why the muscles got that way is due to overcompensation for the lack of stability in the ligaments that hold the lumbar spine and sacroiliac joints in place.
What makes the lumbar spine stable? What makes the lumbar spine unstable?
The spine is held together and made stable by the intervertebral discs and the surrounding ligaments and muscles, with the discs and ligaments providing the spine with its natural function and stability, and the muscles, extrinsic (outer) support. In the lumbar spine, there are usually 5 vertebrae (L1–L5); rarely. The lower back is formed by the lumbar spine and the beginning of the sacral spine (S1), which is why it is important to examine the sacroiliac joints when a patient complains of persistent low back pain.
The Denis model (a means to help classify injury to the spine) divides the spine into 3 columns.
The anterior longitudinal ligament
- The first column is made up of the anterior longitudinal ligament and the front half of the vertebral body and disc. The anterior longitudinal ligament is a primary spine stabilizer. The one-inch wide ligament runs from the base of the skull all the way down the spine to the sacrum. Since this ligament runs down the front of the spine the front half of the vertebral body and discs make up the first classification column. This would be one area of suspected instability.
The posterior longitudinal ligament
- The middle column of the Denis spinal injury model consists of the back half of the vertebral body and disc, plus the posterior longitudinal ligament. As opposed to the anterior or front, the posterior longitudinal ligament is beyond the vertebrae. This is a very strong stabilizing ligament that runs from the Axis (C2) to the posterior surface to the back of the sacrum.
The ligamentum flavum, and the interconnecting ligaments of the posterior spine
- The third column of the Denis spinal injury model is the posterior column. This column comprises the facet joints, the ligamentum flavum, and the interconnecting ligaments of the posterior elements. The sacrum and its surrounding ligaments form a foundation of structural integrity for both the lumbar spine and posterior pelvic ring, allowing a seamless transition of force from the upper body to the lower extremities.
How much column injury is considered enough to cause spinal instability?
- Although the spine is still usually considered stable when only one of the columns has been disrupted, this may not remain so because any looseness of the ligaments in the posterior column can act as a springboard for the degeneration of a second column.
What are we seeing in this image? The columns of the spine and the areas where spinal instability may occur.
At the front of the spine facing forward are:
- the anterior longitudinal ligament
- the anterior of the front surface of the vertebrae or vertebral body
- the anterior aspect of the intervertebral disc (the front of the disc)
- nucleus pulposus of the disc
At the back of the spinal column, we see the components of the third column of the Denis spinal injury model with a focus on the interconnecting ligaments of the posterior elements.
Degenerative disc disease or chronic back problems typically do not begin immediately after a traumatic injury but instead begin to develop once ligaments start to creep (tendency to slowly elongate and become loose and lax) after prolonged stretching. (The ligaments are like rubber bands. Over time the rubber band through continuous hyper-stretching becomes stretched out. This creeping behavior is the result of the forward motions engrained in the human lifestyle. Our days are spent in physically demanding activities or in sedentary postures that can lead to gradual loosening of the posterior ligamentous complex (PLC) over time.
Symptoms of worsening lumbar spinal instability
- Back pain and spine “giving out” is progressively worsening.
- You develop a fear of specific movements such as bending over.
- You have to pace yourself or slowly rise from a bent position into standing straight. Sometimes telling yourself “don’t hurt yourself” when changing into the upright position.
- Sleeping in certain positions is giving you spasms and pain in your lower back when you wake up.
- You have difficulty with unsupported sitting (such as on a stool or chair without good back support) and better with a supported backrest.
- Chronic, daily, frequent bouts or episodes of symptoms (recurrence, not first episode).
- Chronic, daily, frequent episodes of muscle spasms.
- Need to frequently crack or pop the back to reduce symptoms.
- The pain increased with sudden, trivial, or mild movements. You throw your back out for no reason. You were standing there and you spasmed.
- Temporary relief with a back brace or corset.
I have been diagnosed with lumbar stenosis. I have terrible pain in my lower back, buttocks, and upper thighs. Especially when I stand. I have a stability problem in my back and with my ability to balance myself from tipping over. If I fall, I cannot get up. I have diminished leg strength and now need a cane or a walker to get myself around. I have had this going on for 20 years. Most recently the problem has accelerated. I have had physical therapy and epidural injection.
Mechanical and functional spinal instability
What are we seeing in this image? The caption reads: Almost all chronic pain in the lower back occurs in a six-by-four-inch area. Pain in the lower back occurs in the area where the lumbar vertebrae join the sacrum and the iliac crest.
Ninety-five percent of low back pain is located in a six-by-four-inch area, the weakest link in the vertebral-pelvis complex.
At the end of the spine, four structures connect in a very small space, which happens to be a six-by-four-inch area. The fifth lumbar vertebra connects with the base of the sacrum. This is held together by the lumbosacral ligaments. The sacrum is connected on its sides to the ilium and iliac crest. This is held together by the sacroiliac ligaments. The lumbar vertebrae are held to the iliac crest and ilium by the iliolumbar ligaments.
Lumbar instability begins when the stabilizing structures of the spine, especially the ligaments can no longer hold adjacent bones together. When present, this is termed mechanical instability. The term functional instability is used when mechanical instability causes symptoms with a certain function or activity (like those described above). Many people are walking around with mechanical instability but are asymptomatic because the force required to perform current normal activities is not beyond the ligaments and muscles’ ability and strength to perform these functions.
Problems develop when mechanical instability worsens when patients overdo an activity or start a new exercise program. Thus the patient may have symptoms only when performing a certain activity, such as back pain with running. From the patient’s perspective, pain symptoms do not exist during any other activities. This is called functional spinal instability with running and mechanical instability of the entire low back.
Functional instability, or symptomatic instability with movement, occurs with mechanical failure of the spinal ligaments and the subsequent excessive motion of adjacent bones. This can be caused by trauma, disease, surgery, or any combination thereof to one or more regions of the spine.
What then are the overriding effects of a gradual loosening of the ligaments in the lower back?
Our bodies are remarkably intuitive in sensing when something has gone awry, especially when it concerns a vital structure like the spine, and respond by adopting other measures to maintain the spine’s stability.
- Muscle spasms may develop along the spine generated by the ligamento-muscular reflex, whereby the stretched ligaments rapidly react by signaling the muscles over top of them to squeeze and spasm to prevent the spine from destabilizing.
- The body also responds to joint instability by causing joint swelling, paraspinal muscle tightening or osteophytes (bone spurs), all of which may help to decrease the force per unit area on the (facet) joints.
- By doing so, the body temporarily stabilizes the joints. With this said, the body’s overall reaction to the worsening of ligament laxity and instability in the lower spine is to initiate both degenerative and growth mechanisms (balance of anabolic and catabolic events) as protective measures.
When the cause of low back pain is misdiagnosed or not identified – inappropriate treatment follows
When the cause of the person’s low back pain is unknown, or a person is given an inaccurate diagnosis, unnecessary spinal surgeries or other invasive procedures are more likely to occur, (please see my articles Can you realistically avoid lumbar surgery for bulging or herniated disc?, Is your MRI or CT Scan sending you to a back surgery you do not need?) and the overuse of opioids and imaging will continue to be a widespread problem. Diagnosing a person’s low back pain can be difficult to determine since the lumbar spine, like the body itself, consists of many components capable of generating pain and does so via a set of complex pain patterns.
Although many treatments and interventions have been explored for disc degeneration, all have had drawbacks. Treatment options such as pain medications, steroid injections, discectomies, and spinal fusion surgeries only address symptoms but do little to stop the degeneration process. Regenerative medicine, including cellular therapies, focuses instead on the biological repair or regeneration of the disc and surrounding facet joints, posterior ligaments, etc. This has many advantages over current therapies and regenerative treatments that are coming of age in treating discogenic back pain. These therapies include non-cellular and cellular prolotherapy (mesenchymal stem cells or bone marrow aspirate, PRP (please see my article Platelet Rich Plasma Therapy and lower back pain) and offer the most promise, as they have the potential to provide meaningful pain relief and functional restoration to the spinal ligaments and discs.
The main theme of this article is treating low back pain with Prolotherapy. So let’s begin with an explanation of Prolotherapy.
Prolotherapy is a regenerative injection treatment that uses various injectable biological substances to initiate an inflammatory healing cascade, mimicking the body’s own response to repairing musculoskeletal injuries.
Prolotherapy treatments are broadly divided into three types of injectables
- (d-glucose/hypertonic (higher levels) dextrose – dextrose is a simple sugar – the sugar acts to irritate the injury and cause the immune system to restart a repair process.
- Platelet-rich plasma; PRP or PRP Prolotherapy. Platelet Rich Plasma is an injectable growth and healing factor solution that is derived from your own blood. To prepare this injectable a small blood draw is taken and the blood is then separated into a plasma that is rich in healing blood platelets.
- and mesenchymal signaling cells/stem cells. This is sometimes referred to as stem cell Prolotherapy or bone marrow aspirate or liposuction Prolotherapy. In the United States, the practice of regenerative medicine, including Prolotherapy, is currently limited to using autologous (from the patient) mesenchymal stem cells, which must be obtained and used during the same procedure with little manipulation. Generally, PRP or mesenchymal signaling cells/stem cells Prolotherapy is reserved for more severe cases of ligament damage/instability and spinal joint degeneration.
While these different methods of Prolotherapy can be used to treat lumbar instability and its consequent pain syndromes, the administered treatment should be tailored to each individual patient, depending upon confirmation of their diagnosis and primary pain generator. Pain sources include the lumbar facet joints and their capsular ligaments, over-pressured or deranged intervertebral discs resulting from lumbar instability, and sacroiliac and iliolumbar ligaments.
Prolotherapy strengthens the lumbar vertebral ligaments and prevents the progressive degeneration that occurs with age to the intervertebral discs. A patient with chronic low back pain is typically treated with Prolotherapy injections into the insertions of the lumbosacral, iliolumbar, and sacroiliac ligaments. The initial assessment may reveal that the chronic low back pain and referred leg pain may be caused by a referred pain from other areas such as the pubic symphysis, hip joint, ischial tuberosity, sacrospinous, and sacrotuberous ligaments. Therefore, these areas are also examined.
In a paper published in the Journal of Prolotherapy, (10) doctors offered a case study series as to how Prolotherapy injections might be advantageous in the management of discogenic low back pain through improving vertebral segmental stability. This is achieved by addressing damage to the spinal ligaments. The authors noted: “In comparison to other soft tissues, ligaments have less vascularity. Once injured or degenerated, this lack of blood supply may delay healing. Prolotherapy may offer the stimulus for ligament regeneration. However, without a program of lumbar stabilization exercises, it is likely to be less effective in directing the healing tissues to become more organized, flexible, and less prone to re-injury. Therefore, rehabilitative exercise is an essential component to achieve a maximum stabilization effect.”
A December 2021 paper in the Journal of Back and Musculoskeletal Rehabilitation (11) comes to us from the University of Health Sciences in Ankara, Turkey. These are the learning points of this research.
- Six hundred fifty-four patients were included in the study. Diagnostic injections were performed on all patients who were thought to be eligible candidates for Prolotherapy indications. A 4-or-6 week interval was allowed between treatment sessions.
- 1954 patient treatments were completed.
- The Visual Analogue Scale (0-10 0 = no pain 10 = severe, unbearable pain) scores decreased from very severe pain of 7.2 to a mild to almost no pain score of 0.9 after 52 weeks of the treatment.
- Thirty-four patients’ treatments resulted in poor clinical results (5.2%), and 620 of the patient’s pain improved (94.8%).
- Conclusion: “Prolotherapy can be regarded as a safe way of providing a meaningful improvement in pain and musculoskeletal function compared to the initial status. The diagnostic injection is an easy way to eliminate patients and may become a favorite treatment modality. 5% dextrose is a more simple and painless solution for Prolotherapy and also has a high success.”
Note: One aspect of this research was the use of numbing agents as a diagnostic tool to pre-assess if Prolotherapy would be effective. It should be noted that while Prolotherapy treatments reduced the Visual Analogue Scale from 7.2 severe pain to mild to almost no pain on average in 94.8% of patients, numbing agents injected only reduced pain in the same group from 7.2 severe pain to 5.1 or a grade of moderate to severe pain.
Another aspect was the amount of dextrose given in the injection. Prolotherapy injections can come in varying amounts of dextrose concentration. Here a more modest 5% dextrose solution was used to great effect. The concentration of dextrose in Prolotherapy injections can range from 5% to 25%, we prefer the lower ranges.
Targeting injections at the facet joints of the spine
In the illustration below we see normal capsular ligaments at the facet joint, the joint between two vertebrae. When the capsular ligaments at the facet joint are injured, stretched, or loose, the integrity of the spinal column is compromised and the vertebrae start wandering around. This results in the flattening of the disc and a diagnosis of degenerative disc disease. This is demonstrated in the bottom half of the illustration where we see the damage to the capsular ligaments resulting in hypermobility of the facet joint or gapping fact joint that is now flattening the disc.
The lumbar facet capsular ligament is always under tension and likely always being stretched.
In June 2022 (12) researchers at the Department of Biomedical Engineering, University of Minnesota offered an examination and assessment of the lumbar facet capsular ligament. They write: “(the lumbar facet capsular ligament) which surrounds and limits the motion of each facet joint in the lumbar spine, has been recognized as being mechanically significant and has been the subject of multiple mechanical characterization studies in the past. Those studies, however, were performed on isolated tissue samples and thus could not assess the mechanical state of the ligament in vivo. . . )” In other words, understanding the lumbar facet capsular ligament was based on small tissue samples studied in a laboratory. In this study, the researchers performed cadaveric studies to show increases in pressure and strain. What they found, based on testing the ligaments and on the work of previous studies was that the lumbar facet capsular ligaments are in tension and that the collagen in the ligament is likely uncrimped (stretched) even when the spine is not loaded.”
The lumbar spine is considered unstable if abnormal strains or excessive motion develop in the functional spinal unit
The facet joints are considered crucial stabilizers of the spine because they play an important role in load transmission, acting as the posterior load-bearing component for stabilizing the motion segment in flexion (bending forward) and extension (bending backward) while restricting axial rotation (turning to the side). Together with the intervertebral disc, the facet joints transfer loads and guide and constrain motions in the spine.
The lumbar spine is considered unstable if abnormal strains or excessive motion develop in the functional spinal unit, a structure that contains the bodies of the upper and lower vertebrae and the disc between them, as well as the facet joints, which join the vertebrae together. The functional spinal unit is surrounded by ligaments, including the posterior ligament complex (the ligaments demonstrated in the illustration above) which are crucial for maintaining spinal stability. This includes the posterior longitudinal ligament, supraspinous ligament, interspinous ligament, ligamentum flavum, and facet capsule ligaments. The roles of the posterior ligament complex are to limit excess motion and resist bending and compressive forces. This second function is particularly important, as demonstrated in a study that found intradiscal pressure increases greatly during sitting, lifting, or forward-leaning, alone or with twisting, the latter of which involves shear forces that the posterior ligament complex is ill-equipped to handle. All these motions were found to trigger the loading of such forces onto the posterior ligament complex [13,14].
The facet joints are where the bones of the spine meet and connect to form the spinal column. Functionally, they are the joints that allow the spine to bend and twist. They also hold the spine in place so you do not “bend over backward.” The nerves of the spinal cord pass through these joints. If the facet joint is compromised or in a state of degenerative disc disease, the familiar numbness and pain extending into the arms and legs can be seen.
For our companion article please see Facet Joint Osteoarthritis and Facet Arthropathy Treatments.
Injury to the sacroiliac ligaments
The most common cause of unresolved chronic back pain is spinal instability. In the instance of low back pain, injury to the sacroiliac ligaments typically occurs from bending over and twisting with the knees in a locked, extended position. This maneuver stretches the sacroiliac ligaments, placing them in a vulnerable position. Remember that because the ligaments are white (poor blood supply), they are very unlikely to heal on their own, especially in chronic back pain, yet are incredibly important for spinal stability and movement. Thus, spending a lot of time and money on therapies that work the surrounding muscles is only going to produce a temporary benefit. This should come as no surprise as you understand the principles of Prolotherapy or ligament repair treatments. Patients with back pain frequently complain about muscle tightness, spasms, or feeling like the SI might “give out.” They focus so much on the muscles (workout harder, stretch more, get more massage, etc…), that they forget why the muscles got that way is due to overcompensation for the lack of stability in the ligaments that hold the lumbar spine and sacroiliac joints in place.
What are we seeing in this image?
The facet joint is at the rear of the vertebrae. The small arrows pointing away from each other in the first image and the small arrows pointing toward each other in the second image are at the point of the facet joints. What is that spring in the back? The spring represents forces.
Spinal force transmission, which some people call strain on the back, is represented by the various motions of the spine. A flexion, bending forward causes the posterior or back portion of the disc to bulge outwards and the facet joint and the “tail” or protrusion of the vertebrae, the spinous process, to pull away from each other. The opposite happens with extension, bending backward. The same forces apply to banding to the side at the waist.
When the ligaments of the posterior ligament complex – bend too far and that is painful.
Should the posterior ligament complex become injured or unable to resist those forces, the lumbar disc would become a pain generator. Other important ligaments surrounding the functional spinal unit are the intertransverse ligament, the anterior longitudinal ligament, and the posterior longitudinal ligament.
Studies have evaluated the effects when various ligaments of the posterior ligament complex become dysfunctional. For instance, the removal of the facet joint capsular ligaments in the lower lumbar spine causes a large increase in pressure within an otherwise healthy lumbar disc, which we discussed above and demonstrated in the illustration, damage to the ligaments causes the disc to bulge, and cutting these ligaments in the upper lumbar spine causes an increase in a side-to-side bending motion, simply you bend too far.
What are we seeing in this image?
While the lumbar disc and the facet joints are both common pain generators, the facet joint capsular ligaments are arguably the most critical starting point in the development of lower back disorders. This is so because their injury would result in increases in shear forces (side-to-side motion), thereby increasing the likelihood that instability would occur, along with subsequent facet joints and lumbar disc degeneration. It should be noted that the facet joints and interspinous ligaments are the first to be injured under degenerative conditions.
Prolotherapy to target this problem – research is limited
Although facet joint pain can account for up to 45% of low back pain, there are few randomized controlled studies in the literature on the use of comprehensive or cellular prolotherapy for treating this type of pain. Narrative review studies (where the authors interpret previously published medical works) and systemic reviews (where the authors combine data and empirical evidence from previously published medical works), as well as meta-analysis (authors rely on data outcomes), noted overall positive results, especially with cellular (PRP and/or Mesenchymal stem cells prolotherapy but mixed with dextrose prolotherapy for chronic low back pain [15, 16]. Currently, standard medical care remains focused on masking facet joint pain instead of diagnosing and treating the real cause, which is joint instability. Historically, treatment options have included oral NSAIDs and physical therapy, as well as more invasive interventions such as facet joint corticosteroid injections, diagnostic nerve blocks to the facet joints, and radiofrequency ablation of the sensory nerves supplying the joints if the diagnostic block is positive.
Summary and Learning Points of Prolotherapy to the low back
- Prolotherapy is multiple injections of simple dextrose into the damaged spinal area.
- Each injection goes down to the bone, where the ligaments meet the bone at the fibro-osseous junction. It is at this junction we want to stimulate the repair of the ligament attachment to the bone.
- We treat the whole low back area including the sacroiliac or SI joint. In the photo above, the patient’s sacroiliac area is being treated to make sure that we get the ligament insertions and attachments of the SI joint in the low back.
- Why the black crayon lines? This patient has a curvature of her spine, scoliosis, so it is important to understand where the midpoint (center) of her spine is. In this patient, we are going to go up to the horizontal line into the thoracic area which is usually not typical of all treatments.
- After treatment we want the patient to take it easy for about 4 days.
- Depending on the severity of the low back pain condition, we may need to offer 3 to 10 treatments every 4 to 6 weeks.
What are we seeing in this image?
Normal enthesis vs. enthesopathy from joint instability and aging. The entheses organ (the whole soft tissue) is the place where ligaments attach to bone. Increased forces (abnormal stress as in conditions of instability and spine or joint) on the entheses cause them to thicken and with continued joint forces, entheses inflammation, causing a lot of pain.
What we see in this image is:
- Normal attachments of sot-tissue to the bone, normal enthesis.
- Age-related thickened enthesis. The thickening or scarring of the enthesis occurs because of chronic inflammation in the area.
- This progresses to long-standing joint instability with inflamed enthesis and diffuse bone edema.
- This progresses to enthesopathy, the diagnosis of inflammation and degenerative disease in the spine.
- Eventually, degenerative spine or disc disease develops into arthritis, the development of bone spurs along the spine, and a flattening of the disc as outlined above.
Prolotherapy and PRP for facet joint pain
A single-blind, randomized, crossover study evaluated the effectiveness of injection therapy in 35 patients diagnosed as having painful enthesopathy (these are painful conditions caused by the ligament or tendon attachment to the bone). (17)
In this study, 86% of patients had prior spinal surgery and continued pain.
- Thirty-five patients diagnosed as having painful enthesopathy as a major pain generator were studied.
- Among the study’s participants, 86% had undergone prior spinal surgery, and all had been referred to a neurosurgeon to see if more surgery was needed.
- Patients were injected with either anesthetic alone or with anesthetics combined with a phenol-glycerol proliferant (Prolotherapy).
Outcomes following Prolotherapy treatment
- Outcomes were done clinically at regular follow-ups, and subjectively (how do you feel? type surveys) by a series of questionnaires.
- Clinical assessment revealed that 80% of patients had excellent to good relief of pain and tenderness when prolotherapy injections were given, but only 47% of patients given anesthetics alone had the same amount of pain relief.
- Of the questionnaire responses, 66% reported excellent to good pain relief after Prolotherapy vs. 34% after anesthetics alone.
- Patients in both groups reported improvements in work capacity and social functioning, but patients who received prolotherapy injections had a greater reduction in focal pain intensity than those with anesthetics alone.
- In the crossover portion of the study, patients who had been in the anesthetics-alone group reported they had much better pain relief after getting prolotherapy injections. Those who had been in the initial Prolotherapy group said the anesthetic-only injections failed to provide as much pain relief. The study concluded that prolotherapy injections to painful enthesopathy provide substantial relief from axial pain and tenderness along with functional improvement, even in cases of “failed back [surgery] syndrome”
Degenerated discs produce a pain that is typically resistant to steroids, intra-discal electrothermoplasty, (or IDET used to treat lumbar discogenic pain, and direct surgical intervention, while also being difficult to resolve. However, exposure of irritated nerves to hypertonic dextrose prolotherapy is thought to have chemoneuromodulatory (in simplest terms works as an anti-inflammatory in nerve-related pain) potential.
Sustained pain reduction has been demonstrated in a prospective consecutive patient series in which the effects of disc space injections of hypertonic dextrose were assessed in patients with chronic advanced degenerative discogenic leg pain, with or without low back pain, including those with moderate to severe disc degeneration and concordant pain reproduction with CT discography. In this 2006 study published in the journal Pain Medicine (18) patients underwent bi-weekly disc space injections of a solution consisting of 50% dextrose and 0.25% bupivacaine in the affected disc(s). Each patient has been injected an average of 3.5 times. Overall, 43.4% of patients achieved sustained improvement as shown by average changes in numeric pain scores of 71% between pretreatment and 18-month measurements. The authors concluded that intradiscal injection of hypertonic dextrose has promise as a treatment for managing the pain of advanced lumbar disc degeneration.
Returning to the research we cited above, in a retrospective case series of 21 patients with MRI-confirmed lumbar disc degeneration and refractory low back pain/non-radicular low back pain, 18 (86%) of patients experienced 70% or greater improvements in pain and function at 1-year follow up. Patients underwent 3 Prolotherapy treatment sessions at 1–3 weeks apart, which included injections at the ligament-periosteal junctions at the origin and insertion of the posterior sacroiliac ligaments, iliolumbar ligaments, facet joint capsules, and supraspinous and interspinous ligaments (all bilaterally). Injections were done under fluoroscopic guidance.
A small case series of 4 patients (19) with low back pain also proved successful in treating those with disc herniations with Prolotherapy. Patients underwent 3–9 Prolotherapy sessions to the ligaments of the low back (almost all 1 month apart) with all patients experiencing 95–100% pain relief and an increase in function, including the ability to return to work.
Patients improvements solely attributed to Prolotherapy or in combination with supportive conservative care treatments, including physical therapy?
A September 2023 paper in the journal Medicine, (20) looked at patients with low back pain. They were trying to determine in after one prolotherapy treatment, the patients improvements could be solely attributed to prolotherapy or the supportive conservative care treatments, including physical therapy. Of note in that the patient enrolled in this study, did not have beneficial results from physical therapy for their back pain after one month of PT sessions.
The researcher here wrote: “(Single treatment) benefits of prolotherapy (for many) are temporary and generally not permanent unless the ligaments are strengthened. (In other words, unless the single treatment of Prolotherapy was sufficient to repair damaged ligaments, the results would not be permanent). Strengthening the musculoskeletal system has been shown to lead to better long-term results because prolotherapy induces an inflammatory response that can lead to fibroblastic hyperplasia (soft tissue response, which is inflammation, to an irritant, i.e, dextrose or glucose that stimulates the healing response), and exercise stimulates the synthesis of the extracellular connective tissue matrix. (In simplest terms the extracellular connective tissue matrix is a subsatnces that is discharged from cells that act as a scaffold to build new regenerative tissue). This increases the strength of the ligamentous connection and induces the proliferation of fibroblasts (cells that are building blocks of connective tissue) to connect to the connective tissue, resulting in more effective clinical improvement. Therefore, prolotherapy alone cannot guarantee overall results unless accompanied by comprehensive multidisciplinary follow-up.” In other words, the best Prolotherapy results can be seen in follow up, and in our opinion, multiple treatments. Prolotherapy is a not a single one-shot wonder.
Physical therapy can help highly obese patients
A January 2021 study (20) in the journal Medicine comes from the Department of Physical Therapy, Daejeon University in Korea. In this research, the therapists wrote that intensive neuromuscular stabilization exercise on highly obese patients with low back pain results in positive effects of body fat decline (weight loss) and prevention of complications. Further a more progressive neuromuscular stabilization exercise (exercises that concentrate on muscle strength) on unstable surfaces (areas of instability) on pain, motor function, psychosocial factors, balance, and abdominal contraction with highly obese patients with lumbar instability.
Please see our article Weight loss can reduce back pain for a more detailed discussion on the benefits and motivation for weight loss in the treatment of lumbar instability and back pain.
Sacroiliac joint-mediated pain
Published in the British Journal of Sports Medicine, doctors found positive clinical outcomes for 76% of patients with sacroiliac joint problems. (21) This study was conducted to determine whether Prolotherapy is effective in the treatment of deficient load transfer of the sacroiliac joint in 25 patients. In this study, 3 injections at 6-week intervals of a hypertonic dextrose solution were given into the dorsal interosseous ligament of the affected sacroiliac joint of each patient. Outcome measures standard test scoring to determine pain and function as well as an independent clinical examination by the paper’s two authors. The authors concluded that their descriptive study of Prolotherapy in private practice showed positive clinical outcomes for the 76% of patients who attended the 3-month follow-up visit (76% at 12 months and 32% at 24 months).
A 2010 paper published in the Journal of Alternative and Complementary Medicine (22) compared the pain relief effects of Prolotherapy to corticosteroid injection. At 15 months, 58% of the patients treated with Prolotherapy reported that more than half of their pain was relieved, which was statistically significant compared with only 10% in the corticosteroid group who reported that same level of pain relief. The researchers here concluded: “Intra-articular Prolotherapy provided significant relief of sacroiliac joint pain, and its effects lasted longer than those of steroid injections. Further studies are needed to confirm the safety of the procedure and to validate an appropriate injection protocol.”
An earlier study in the Journal of Spine Disorders (23) demonstrated that for patients with chronic low back pain who had failed to respond to previous conservative care Prolotherapy could be an effective treatment. Patients were randomly assigned to receive a double-blind series of 6 injections at weekly intervals of either a xylocaine/proliferant or a xylocaine/saline solution into the posterior sacroiliac and interspinous ligaments, fascia, and joint capsules of the lower back from L4 to the sacrum. Of the 39 patients assigned to the proliferant group, 30 achieved a 50% or greater reduction in both pain and disability scores at 6 months compared with 21 of 40 in the group receiving the saline solution. The proliferant group also achieved greater improvements on the visual analog, pain, and disability scales.
In a 2004 (24) audit of conservative treatments for low back pain, patients who were diagnosed with sacroiliac pain via diagnostic block were treated either by corticosteroid injection to the sacroiliac joint or by Prolotherapy to the sacroiliac ligaments. Long-term improvement was assessed at 6 months, after which 63% of the Prolotherapy group reported a substantial drop in pain severity compared with only 33% in the corticosteroid group.
A study (25) into the use of PRP for facet joint pain examined the results of guided injections of PRP into the lumbar facet joints of 19 patients. The study found that PRP had beneficial effects which improved over time, with 15 of the 19 patients experiencing significant pain reduction by 3 months.
In a subsequent randomized prospective study with a larger cohort of 46 subjects, the same lead author (26) compared the results of facet joint injections using either PRP or anesthetic and corticosteroid. At the 1-month mark, 80% of subjects in the corticosteroid group were satisfied with the results of the procedure, but this declined to between 20% and 50% after 6 months. Conversely, the subjects in the PRP group had increased satisfaction over time, leading the authors to conclude that PRP was the superior treatment. As the facet joint capsular ligaments loosen, the spinal segments begin to flex (bend forward) more, though imperceptibly to us, when a person leans forward, sits, or lifts. Over time, this results in several possible adaptations, the first of which is disc degeneration.
The use of PRP for treating musculoskeletal conditions is growing, and studies specific to sacroiliac-mediated pain have found that PRP provides favorable outcomes. In one randomized, controlled trial of PRP versus corticosteroid injection, 90% of subjects treated with PRP to the sacroiliac joint were satisfied at the 3-month follow-up compared with only 25% of those who were treated with the steroid. The researchers concluded “Despite the widespread use of steroids to treat sacroiliac joint pain, their duration of pain reduction is short. Platelet-Rich Plasma (PRP) can potentially enhance tissue healing and may have a longer-lasting effect on pain.”(27).
“Platelet-Rich Plasma” epidural injection
The results of an April 2023 study in the journal BioMed Central musculoskeletal disorders (30) suggested a “Platelet-Rich Plasma” epidural injection is superior to that of a steroid epidural injection and should be considered an emerging strategy and alternative to epidural in treating lumbar disc herniation.
In this comparison to triamcinolone, a widely used steroid seen as effective in bringing about low back pain reduction for up to three months, PRP transforaminal epidural injections yielded superior results. The researchers noted that alternatives to steroid injections are sought because of the severe adverse events attributed to corticosteroid use. The researchers concluded: “Due to its efficacy and safety, the procedure is recommended in treating single level lumbar herniated.
What are we seeing in this image?
The progression of degeneration in the lower back starts with an initial injury to one or more spinal ligaments. Over time, the process progresses to involve more spinal segments. Eventually, unresolved spinal instability can cause multi-level degeneration of the lumbar spine.
In an editorial, a board-certified physician in family medicine whose specialty is pain management made several points about the treatment of low back pain with Prolotherapy (28).
- When patients have weakness of the sacroiliac ligament, it generates pain similar to that of spinal stenosis – that is, pain during ambulation and standing.
- Such patients will respond to ligament Prolotherapy.
- Patients with clearly unilateral symptoms often respond to ligament Prolotherapy on the painful side of the body.
- Patients who have listhesis and/or disc disease contributing to the stenosis often respond to Prolotherapy at that level in the spine.
- Decompressive surgery can worsen the instability of the spine. The sciatic pain often improves, but the lower back pain often worsens.
The longer you wait to treat your back pain, the worse your situation becomes
Recent research from doctors at the University of Sydney published in the Journal of the Canadian Medical Association says the faster you get treatment for your back pain, the sooner you will get pain relief. That seems obvious.
Now they do not specify a specific treatment, only that in their examination of the medical literature, patients who got treatment sooner had a better chance for pain relief and that any treatment would be preferable to none. These treatments could include chiropractic, yoga, therapy, epidurals, etc.
Here is what the Australian team suggested:
“Patients who presented with acute or persistent low-back pain improved markedly in the first six weeks (of treatment). After that time, improvement slowed. Low to moderate levels of pain and disability were still present at one year.”(29)
Again, this is based on any treatment, improvement is seen in the first six weeks then the level of improvement declines based on what type of treatments you get.
The point of this research again was to suggest that people get treatment because it will help them short term.
An October 2023 study in the European spine journal (32) comes from American researchers lead by Bellin College. In this study, the researchers suggest that the failure of conservative care treatment is under reported or not fully understood in papers regarding the move of patients to lumbar fusion surgery.
Simply, surgery is typically performed when all conservative care options have been explored and found to be non-helpful. To these researchers, it would have been helpful to better understand how, why, what and when these conservative therapies failed. Let’s have them explain:
- “Of 166 studies (the data of patient outcomes the researchers assessed), 62.0% reported a failure in conservative care prior to lumbar fusion, but only 15.1% detailed the type of specific conservative care received. None of the studies provided sufficient details to understand the nature of the pre-surgical conservative treatment, such as frequency, (how recent they were to surgery or not)/timing, or dosage of conservative interventions.”
They concluded: “This lack of information creates ambiguity in the surgical decision-making process, setting the assumption that all patients received adequate conservative care prior to surgery. Details about pre-surgical conservative care should be disclosed to allow for appropriate clinical application, decision-making, and interpretation of treatment effects.”
So are patients being offered “adequate conservative care prior to surgery?”
Above we cited our own 2021 research: Lumbar instability as an etiology of low back pain and its treatment by prolotherapy. This was not the only time we presented research on the subject of low back pain. In 2009 our researchers at Caring Medical investigated the outcomes of patients undergoing dextrose Prolotherapy treatment for chronic low back pain. You can read the entire paper here: Dextrose Prolotherapy for Unresolved Low Back Pain: A Retrospective Case Series Study.
We looked at 145 patients, who had been in pain for an average of four years and ten months, and were treated quarterly with Prolotherapy.
- This included a subset of 55 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of 26 patients who were told by their doctor(s) that surgery was their only option.
Patients were contacted an average of 12 months following their last Prolotherapy session and asked questions regarding their levels of pain, physical and psychological symptoms, and activities of daily living, before and after their last Prolotherapy treatment.
- In these 145 low backs, pain levels decreased from 5.6 to 2.7 after Prolotherapy;
- 89% experienced more than 50% pain relief with Prolotherapy;
- more than 80% showed improvements in walking and exercise ability, anxiety, depression, and overall disability;
- 75% percent were able to completely stop taking pain medications.
In summary, Prolotherapy can be an effective treatment for chronic back pain due to spinal instability. Some telltale signs that you have spinal instability include chronic muscle spasms, pain that shoots down the legs intermittently, your spine cracks and pops, and you feel the need to manipulate your spine or receive frequent adjustments and massages.
The true source of pain is due to ligament weakness. The causes can be many, such as traumatic or over time due to poor posture or overuse. Either way, it is a ligament problem. Prolotherapy strengthens ligaments and eliminates chronic back pain in conditions such as degenerated discs, herniated discs, spondylolisthesis, post-surgery pain syndromes, arachnoiditis, and scoliosis. The most common cause of chronic low back pain and “sciatica” is the laxity of the sacroiliac ligaments. For many people, Prolotherapy should be considered before any surgical procedure is performed for chronic back pain.
Given the widespread prevalence of spinal disorders, clinicians should understand ligaments as a causative factor for lumbar spinal instability resulting in chronic and worsening low back pain. Degenerative spine conditions are initiated by the development of instability within the posterior ligament complex, most notably the facet joint capsular ligaments. In response, the body makes adaptations trying to stabilize the spine, which is initially protective but eventually becomes harmful (e.g., bone spurs). Without addressing the instability, the progression of degenerative spinal conditions with low back pain will continue.
Clinically speaking, spinal stability is the ability of the spine to maintain its alignment during loading and to protect the neural structures it encloses without causing pain. It is the collective job of the bones, muscles, discs, and ligaments to maintain their alignment of the spinal column, so the spinal cord and nerves remain protected. If the spine no longer has properly functioning biomechanical properties, however, clinical stability is lost, giving rise to spinal instability and pain. Prolotherapy is a regenerative treatment option for those suffering from low back pain and associated conditions related to joint and spinal instability. Regenerative treatment of injured ligaments has the potential and ability to strengthen the posterior ligament complex, and thus relieve both chronic and acute low back pain.
Questions about our treatments?
If you have questions about your pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.
1 Cheung JP, Wong HL, Cheung PW. Predictive factors for successful non-operative treatment and achieving MCID improvement in health-related quality of life in adult spinal deformity. BMC Musculoskeletal Disorders. 2022 Dec;23(1):1-9. [Google Scholar]
2 Goertz CM, Long CR, English C, Meeker WC, Marchiori DM. Patient-reported physician treatment recommendations and compliance among us adults with low back pain. The Journal of Alternative and Complementary Medicine. 2021 Mar 1;27(S1):S-99. [Google Scholar]
3 Ferraro MC, Bagg MK, Wewege MA, Cashin AG, Leake HB, Rizzo RR, Jones MD, Gustin SM, Day R, Loo CK, McAuley JH. Efficacy, acceptability, and safety of antidepressants for low back pain: a systematic review and meta-analysis. Systematic reviews. 2021 Dec;10(1):1-3. [Google Scholar]
4 Migliorini F, Maffulli N. Choosing the appropriate pharmacotherapy for nonspecific chronic low back pain. Journal of Orthopaedic Surgery and Research. 2022 Dec;17(1):1-3. [Google Scholar]
5 Schultz MJ, Licciardone JC. The effect of long-term opioid use on back-specific disability and health-related quality of life in patients with chronic low back pain. Journal of Osteopathic Medicine. 2022 Aug 11. [Google Scholar]
6 Rubinstein SM, De Zoete A, Van Middelkoop M, Assendelft WJ, De Boer MR, Van Tulder MW. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomized controlled trials. bmj. 2019 Mar 13;364. [Google Scholar]
7 Braun J, Baraliakos X, Regel A, Kiltz U. Assessment of spinal pain. Best Pract Res Clin Rheumatol. 2014 Dec;28(6):875-87. doi: 10.1016/j.berh.2015.04.031. [Google Scholar]
8 Reitman CA, Cho CH, Bono CM, Ghogawala Z, Glaser J, Kauffman C, Mazanec D, O’Brien Jr D, O’Toole J, Prather H, Resnick D. Management of degenerative spondylolisthesis: development of appropriate use criteria. The Spine Journal. 2021 Mar 6. [Google Scholar]
9 Hauser RA, Matias D, Woznica D, Rawlings B, Woldin BA. Lumbar instability as an etiology of low back pain and its treatment by prolotherapy: A review. Journal of Back and Musculoskeletal Rehabilitation. 2021(Preprint):1-2. [Google Scholar]
10 Inklebarger J, Petrides S, Prolotherapy for Lumbar Segmental Instability Associated with Degenerative Disc Disease. Journal of Prolotherapy. 2016;8:e971-e977. [Google Scholar]
11 Solmaz I, Orscelik A, Koroglu O. Modified prolotherapy by 5% dextrose: Two years experiences of a traditional and complementary medicine practice center in Turkey. Journal of Back and Musculoskeletal Rehabilitation. 2021(Preprint):1-8. [Google Scholar]
12 Gacek E, Ellingson AM, Barocas VH. In Situ Lumbar Facet Capsular Ligament Strains Due to Joint Pressure and Residual Strain. Journal of biomechanical engineering. 2022 Jun 1;144(6):061007. [Google Scholar]
13 Li Y, Shen Z, Huang M, Wang X. Stepwise resection of the posterior ligamentous complex for stability of a thoracolumbar compression fracture: An in vitro biomechanical investigation. Medicine (Baltimore). 2017; 96(35): e7873. [Google Scholar]
14 Pizones J, Zúñiga L, Sánchez-Mariscal F, Álvarez P, Gómez-Rice A, Izquierdo E. MRI study of post-traumatic incompetence of posterior ligamentous complex: importance of the supraspinous ligament. Prospective study of 74 traumatic fractures. European Spine Journal. 2012 Nov;21(11):2222-31. [Google Scholar]
15 Dagenais S, Yelland MJ, Del Mar C, Schoene M. Prolotherapy injections for chronic low back pain. Cochrane Database Systematic Review. 2007(2): CD004059. [Google Scholar]
16 Xuan Z, Yu W, Dou Y, Wang T. Efficacy of platelet-rich plasma for low back pain: a systematic review and meta-analysis. Journal of Neurological Surgery Part A: Central European Neurosurgery. 2020 May 21. [Google Scholar]
17 Wilkinson HA. Injection therapy for enthesopathies causing axial spine pain and the “failed back syndrome”: a single blinded, randomized, and cross-over study. Pain Physician. 2005; 8(2): 167-73. [Google Scholar]
18 Miller MR, Mathews RS, Reeves KD. Treatment of painful advanced internal lumbar disc derangement with intradiscal injection of hypertonic dextrose. Pain Physician. 2006 Apr 1;9(2):115-21. [Google Scholar]
19 Alderman D. Prolotherapy for low back pain. Practical Pain Management. 2007;7(4):58-63. [Google Scholar].
20 Pires JA, Moura EC, de Oliveira CM, Dibai-Filho AV, Nascimento MD, da Cunha Leal P. Hypertonic glucose in the treatment of low back pain: A randomized clinical trial. Medicine. 2023 Sep 22;102(38):e35163. [Google Scholar]
21 Park SH, Lee MM. Effects of progressive neuromuscular stabilization exercise on the support surface on patients with high obesity with lumbar instability: A double-blinded randomized controlled trial. Medicine. 2021 Jan 29;100(4). [Google Scholar]
22 Cusi M, Saunders J, Hungerford B, Wisbey-Roth T, Lucas P, Wilson S. The use of prolotherapy in the sacroiliac joint. British journal of sports medicine. 2010 Feb 1;44(2):100-4. [Google Scholar]
23 Kim WM, Lee HG, Won Jeong C, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. The journal of alternative and complementary medicine. 2010 Dec 1;16(12):1285-90.
24 Klein RG, Eek BC, DeLong WB, Mooney V. A randomized double-blind trial of dextrose-glycerine-phenol injections for chronic, low back pain. Journal of Spinal Disorders. 1993 Feb 1;6(1):23-33. [Google Scholar]
25Chakraverty R, Dias R. Audit of conservative management of chronic low back pain in a secondary care setting–part I: facet joint and sacroiliac joint interventions. Acupuncture in Medicine. 2004 Dec;22(4):207-13. [Google Scholar]
26 Wu J, Du Z, Lv Y, Zhang J, Xiong W, Wang R. A new technique for the treatment of lumbar facet joint syndrome using intra-articular injection with autologous platelet rich plasma. Pain Physician. 2016; 19: 617-25. [Google Scholar]
27 Wu J, Zhou J, Liu C, Zhang J, Xiong W, Lv Y. A prospective study comparing platelet-rich plasma and local anesthetic (LA)/ corticosteroid in intra-articular injection for the treatment of lumbar facet joint syndrome. Pain Pract. 2017; 17: 914-24. [Google Scholar]
28 Singla V, Batra YK, Bharti N, Goni VG, Marwaha N. Steroid versus Platelet-Rich Plasma in Ultrasound-Guided Sacroiliac Joint Injection for Chronic Low Back Pain. Pain Pract. 2016 Sep 27. [Google Scholar]
29 Matthews JH. Nonsurgical treatment of pain in lumbar spine stenosis. American family physician. 1999 Jan 15;59(2):280. [Google Scholar]
30 Menezes C, Costa LA, Maher CG, Hancock MJ, et al. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ. 2012 May. doi: 10.1503/cmaj.111271 [Google Scholar]
31 Wongjarupong A, Pairuchvej S, Laohapornsvan P, Kotheeranurak V, Jitpakdee K, Yeekian C, Chanplakorn P. “Platelet-Rich Plasma” epidural injection an emerging strategy in lumbar disc herniation: a Randomized Controlled Trial. BMC Musculoskeletal Disorders. 2023 Dec;24(1):1-7. [Google Scholar]
32 Nielsen LM, Getz EN, Young JL, Rhon DI. Preoperative conservative treatment is insufficiently described in clinical trials of lumbar fusion: a scoping review. European Spine Journal. 2023 Oct 6:1-0. [Google Scholar]
This article was updated January 12, 2023