Tricking the body to heal through inflammation
I’d like to present for you today, a common scenario, one which occurs on a regular basis. An individual has experienced chronic pain from some particular part of the body. Perhaps it started with an old high school sports injury, which led to this recurrent pain. Eventually, in the face of this unyielding discomfort, the sufferer seeks medical care. Our tale of the trials and tribulations of 21st-century medicine thus begins.
Let us presume, for a moment, this hypothetical individual (we’ll call him Tom), experiences pain from the back of the heel, and has done so for years. Like many (men?), he has “sucked it up” and lived with it for long enough. The pain has progressed to the point that something needs to be done. Or, more specifically, the pain is now interfering with his golf game. This clearly won’t do, and a visit to a physician is in order. His PCP knows the anatomy sufficiently to diagnose an Achilles tendon disorder, and consequently prescribes a course of anti-inflammatory medication and rest. His heel feels better for a matter of weeks, but the pain returns when he becomes more active, and his golf score suffers. A call to his doctor results in a referral to a specialist who declares that surgery is required to resolve his pain. It is at this point in our tale the real discussion begins.
Is surgery the “magic bullet”? Many people feel this way, that surgery will fix their problem, and make everything better. But surgery is trauma, make no mistake about it, and Tom is hesitant. Is this truly his best option? Have conservative measures been exhausted? Aren’t there other options? It would seem to the physician who has recommended the procedure there are not. Tom’s concerns about the long and difficult recovery period linger. What else can be done that doesn’t have the potential for such dramatic complications, including infection, scarring of the tendon, over-lengthening, and others.
It is at this juncture that his wife suggested getting another opinion, which seemed a wise idea. Tom was told about a local practitioner who utilized a great variety of techniques to resolve lower extremity pain. Following a thorough exam and history, this clinician discussed several options for care with the most intriguing being something called regenerative medicine. This is the concept of getting the body to heal itself, something that we all are hard-wired for. If a part is acutely injured in some fashion, a cut for example, it is understood this will go through the normal healing process, leading to complete repair of the damage.
Why can’t Tom’s Achilles tendon go through the chain of events which leads to repair? It can, and this is the principal behind regenerative medicine. Trigger the body, trick it, if you will, into re-instituting the normal and appropriate steps to healing. This process has been studied extensively (although this is very different from being able to control it). Anti-inflammatory medication, such as NSAID’s and cortisone-type drugs, interfere with the process of healing because the first phase of healing is inflammation. This is a natural and appropriate part of the multiple phases of healing. During inflammation, certain substances are produced which stimulate the production of growth factors. These complex chemicals in the body lead to the production of new tissue, such as new, healthy tendon.
How can we stimulate the body to resume this process, to re-invigorate it? Through the institution of regenerative medicine, we can. To take a chronically inflamed part, where the healing process has stalled, and make it acutely inflamed, causing the many phases of healing to occur in an appropriate fashion. Although regenerative medicine is a new term, treatments utilizing this concept have been performed for many years, with the oldest being that of prolotherapy. This technique involves the administration of a naturally occurring substance which acts as a mild irritant, producing inflammation of the injured tissue.
This may seem counterintuitive since inflammation has developed a very negative connotation, but, as explained, it is part of healing. This injection technique is intended to turn a chronically inflamed tissue into an acutely inflamed one. This, in turn, stimulates the body to proceed through the processes of healing via the production of those growth factors. These elicit the proliferation of new tissue (which is where the term “Prolotherapy” is derived from). Newer techniques utilize this same concept with the administration of actual growth factors themselves. With new growth factors in place, new tissue is produced, strengthening the diseased structure (in this case Tom’s Achilles tendon). Because the result is a stronger, healthier structure, the benefits of regenerative medicine techniques are lasting, and not a temporary phenomenon, as would be encountered with an anti-inflammatory medication.
Prolotherapy has been used for over 75 years to treat a variety of orthopedic problems. Numerous studies have been performed demonstrating its benefits and paucity of possible complications. Because standard prolotherapy uses dextrose, a naturally occurring sugar molecule, there are no drug-induced side effects or complications. Naturally, getting an injection is not a fun process, but there are many ways to mitigate this discomfort when performed by a concerned physician. Standard prolotherapy injections include the administration of an anesthetic, thus quickly reducing the pain of the procedure.
There have been dozens of studies over the years demonstrating its benefits and lack of harmful consequences for the treatment of chronic pain. Susceptible conditions include those resulting from trauma or sports injuries, even arthritic joints. Research has shown improvements from back and knee pain, as well as the aforementioned Achilles tendon problems. Even Mayo Clinic has discussed the potential benefits of this technique, mentioning the lack of harmful consequences, especially as an option prior to surgical intervention. Many others have endorsed its rewards, including former Surgeon General C. Everett Koop.
Newer manifestations of regenerative medicine involve the administration of platelet-rich plasma, a distillate of blood containing higher amounts of growth factors. Even greater amounts of these important and extremely beneficial substances can be harnessed for healing by administering amniotic membrane. This amazing tissue, obtained from processing placental tissue, contains extremely high amounts of stem cells (cells that can become most any kind of tissue, including ligament, cartilage, or our much-discussed Achilles tendon), and so has been a welcome addition to our treatment armamentarium.
The latest addition to regenerative medicine has been in the use human adipose tissue (aka fat!). It turns out fat cells are an abundant source of stem cells with extensive proliferative capacity, and the ability to differentiate into multiple types of tissue. I don’t think it is necessary to mention that this cell type is quite abundant. Adipose tissue is easily obtained, with few problems associated with harvesting.
Tom ended up getting a series of prolotherapy treatments, with the result being a pain-free Achilles, and an improved golf game. Also important, he suffered no complications, no disability and no recovery time during the treatment process. Although our current school of medicine tends to promote a pharmacologic treatment paradigm, many options exist, and all should be considered when treating a patient’s condition. Regenerative medicine is a technique which has shown multiple benefits and few drawbacks. Unfortunately, not enough practitioners are versed in its application. Still, if you suffer from a chronic musculoskeletal problem, this is an option that may be right for you.