28 Nov Platelet-Rich Plasma Prolotherapy for Low Back Pain Caused by Sacroiliac Joint Laxity
Past medical history included previous mild scoliosis documented at the T3 level, premenstrual syndrome, and fractures of the left first and second toes. She was a non-smoker, drank alcohol occasionally and ate a mostly vegetarian diet. Her NRS pain 7/10; SFMcGill 23/45; and Oswestry 36/50. Pain was in the midline lower lumbar and parasacral region with radiation into both groins and down the left lateral thigh. Sitting and standing tolerance was limited to 5 to 15 minutes. Physical exam revealed a height of 5’1” and weight 148 lbs. BP 101/67mm Hg. Pulse 84bpm. Straight leg raising was limited to 75 degrees on the left with back pain (no sciatica). Maneuvers of the SI joints provoked pain (including Patrick’s, Faber, Gaenslen, Gillett, Yeomen and shear tests), primarily on the left side. Stability testing revealed 2+ instability in the left SI joint.
She underwent PRPP injections to the left SI joint (Hackett’s B and C points) with 15% dextrose (July 29, 2008—complicated by increased pain which was treated with traumeel-marcaine injections into the piriformis muscles) and then with sodium morrhuate (Hackett’s A,B,C and L4-5 facets, interspinous ligaments for five sessions on Aug. 19, Oct. 14, Nov. 4, Dec. 9, 2008, Feb. 10, 2009) with good results and improved stability. NRS was down to 3/10 and she felt 80% improved. Unfortunately, this was all set back when she was rear-ended in a car accident on April 25, 2009 with NRS pain back up to 7/10. Her right SI joint (foot on brake side) was 3+ unstable. Whitmore-Gordons score 41/60. She received approval from the insurer for PRPP and this was administered on July 14, 2009 (Rt. Hackett’s A, B, C points and L4-5 interspinous and facet ligaments) and repeated on the left side Sept. 18, 2009 (in which additional PRPP to the C6-7 facets also helped to resolve the post-MVA neck pain). Her low back pain measures on March 2010 (6 months post-PRPP) were NRS 1.5/10; SFMcGill 2/45; and Oswestry 4/50. She successfully got married, graduated from naturopathic college and returned back to full activity and sport (pool and weight exercises, cross country skiing).
| Please circle ONE number corresponding to the statement in EACH question that BEST describes your low back pain. | ||||||
| Never | Rarely | Sometimes | Occasional | Often | Always | |
| 1. I have pain in my buttock. | ||||||
| 0 | 1 | 2 | 3 | 4 | 5 | |
| 2. My back feels unstable. | ||||||
| 0 | 1 | 2 | 3 | 4 | 5 | |
| 3. I get pain (in the low back-buttock area) when I turn in bed. | ||||||
| 0 | 1 | 2 | 3 | 4 | 5 | |
| 4. I get pain (same area) when I get out of a low chair. | ||||||
| 0 | 1 | 2 | 3 | 4 | 5 | |
| 5. I get pains (same area) when I bend the leg up (such as to put on my sock). | ||||||
| 0 | 1 | 2 | 3 | 4 | 5 | |
| 6. I get pain (same area) when going up or down stairs. | ||||||
| 0 | 1 | 2 | 3 | 4 | 5 | |
| 7. I feel clicking/ clunking/ popping (same area) when I move. | ||||||
| 0 | 1 | 2 | 3 | 4 | 5 | |
| 8. I have had the following injuries to my low back: | ||||||
| ___ a) | motor vehicle accident with foot on brake at time of impact (score as 5) | |||||
| ___ b) | fall on the same buttock or hip (score as 5) | |||||
| ___ c) | women: pregnancy-related pelvic pain (score as 5) | |||||
| ___ c) | men: unexplained pain (normal urology studies) referred into the testicle (score as5) | |||||
| ___ d) | temporary relief with spinal manipulation or sacroiliac belt (score as 5) | |||||
| ___ e) | sports or work-related twisting-lifting injury—e.g., bowling, figure skating, etc. (score as 3) | |||||
| ___ f) | history of hypermobile “loose” joints (score as 2) | |||||
| Total Score ____/60
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| Scoring: Preliminary data on consecutive patients suggests a score over 30 has a sensitivity of 85% and specificity close to 100% (with exclusion of fibromyalgia patients) in correlating with an unstable sacroiliac joint that would respond to the PRP prolotherapy treatment.43 (This is to be further studied with multivariate logistic stepwise regression analysis on a larger number of patients.) | ||||||
Conclusion
These case studies suggest a role for PRP prolotherapy in the management of chronic low back pain—particularly in those with sacroiliac joint pain and instability. Such cases studies and the newly-described screening tool need to be validated with more research, including double-blind randomized controlled trials.
Acknowledgements
Special thanks to the multidisciplinary team at the Canadian Centre for Integrative Medicine: Scott Whitmore, BScPT, FCAMT; Gordon Lawson, MSc, DC; Mark Tsai, MScPT, FCAMT; Thomas Hein, BScPT, FCAMT; Rob McDonald, BSc, RMT DiplOsteo; Kevin Ho, RN, DC; Leigh Arseneau, BSc, ND; Melanie Eitel, RMA; and Rebecca Chau, RNA.
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