InflammatioN AND HEALING
Ross Hauser, M.D.

The body has an amazing capacity to heal itself, even in the face of severe injuries, yet at the same time, sometimes seemingly trivial injuries can become the focus of debilitating chronic pain problems. 

The same mechanism of healing is used in both of these scenarios, inflammation. Without inflammation, infections would go unchecked and wounds would never heal. However, inflammation may be potentially harmful. Inflammatory reactions underlie the genesis of rheumatoid arthritis, life-threatening allergic reactions, and some forms of fatal kidney disease. It is for this reason that our pharmacies abound with so-called "anti-inflammatory medications," which supposedly limit, control, or modify the normal inflammatory reaction. 

In healing we want to stimulate inflammation for faster repair of an injury. For example, when people are sick they often get a fever. Fever is a normal response to infection. Suppressing the fever by taking Tylenol and other such medications will only prolong the illness. Stimulating the fever, by being in bed under a mountain of blankets and sweating it out, speeds the healing process and shortens the illness. 

In Prolotherapy, we do not want to suppress this inflammation with anti-inflammatory drugs because the above named potentially dangerous side effects of inflammation do not occur in this instance. The inflammation occurs only around the patient's damaged ligaments and tendons.

The Stages of Healing
After the initial injury or Prolotherapy, there are characteristically three stages of ligament and tendon healing: inflammatory, proliferative, and remodeling. During the initial inflammatory phase, the immune system increases circulation to the injured area, which produces the classic redness and warmth, which typifies soft tissue injury. The increased circulation also helps produce edema (swelling) and the accompanying pain. Unfortunately, many athletes, athletic trainers, and team physicians see pain after an injury as bad and prescribe treatments such as RICE treatment and anti-inflammatories to stop the pain. Pain should signal to the athlete that the immune response to injury is working correctly. Stopping the above inflammatory reaction to any degree decreases the athlete's chances of complete healing. This is why some people are advocating doing Prolotherapy, initially, right after the injury to speed along the healing process as much as possible.

During this proliferative phase, type I collagen is being laid down by the fibroblasts to increase ligament and tendon strength. After about four weeks, about 60 percent of the tensile strength of the tissue may be restored. This obviously depends on the amount of tissue damage and the ability to mount an inflammatory response after injury. The healthier the immune system, the quicker the ability to heal. Because the proliferative phase lasts about four to six weeks in most individuals, Prolotherapy injections are given by most clinicians every four to six weeks. Some clinicians desire to speed up the process (especially for athletes) and Prolotherapy injections are given as frequently as once a week.

The remodeling phase of healing occurs for up to one to one and a half years after the original injury, when the body attempts to restructure the injury in an attempt to restore the body to a pre-injury state.

Inadequate Healing, Not Inflammation, is the Problem
The ligaments and other connective tissue may not heal properly after minor injuries or repetitive motion injuries. While we may refer to chronically painful areas as "chronically inflamed," this may not be the case. Indeed, this is exactly what some recent studies have shown. In studies of chronic pain patients with "tennis elbow" and "achilliodynia" (Achilles tendon pain), many of whom were athletes, ligamentous and tendon tissue biopsies of these respective areas revealed no inflammation. Instead, the tissue appeared to be inadequately healed.

Collagen fibers were altered in structure and arrangement, and blood vessels were inadequately formed. These changes revealed deficient repair ability. This condition is more aptly termed tendinosis, and is most likely the reason for chronic non-healing sports injuries. In other words, the normal healing process had simply not occurred. One wonders how many of these people took anti-inflammatory medications or received cortisone shots. Realize anti-inflammatory medications and cortisone shots do in fact stop the inflammatory-healing cascade. An athlete, to effectively heal, needs to stimulate or at least, let the inflammatory process occur. It is only by doing this that the injured ligaments, tendons, and connective tissue have an opportunity to heal.

Summary
Inflammation is the process by which the body heals soft tissue injuries, including injuries to connective tissues, ligaments, and tendons. This healing process goes through characteristic phases: inflammatory, proliferative, and remodeling. The goal of this inflammatory-reparative cascade is to regenerate the collagen and extracellular matrix (Proteoglycans) that give the connective tissues their strength and characteristic ability to handle great strain forces. Anti-inflammatory medications and corticosteroids block this process. Prolotherapy, on the other hand, provides the stimulus that is needed to bring in healing fibroblasts and allow them to proliferate (where Prolo comes from) and lay down new collagen fibers. This causes the connective tissues, ligaments, and tendons to become thicker and stronger. Thus, Prolotherapy stimulates the normal inflammatory-reparative mechanisms of the body, encouraging normal collagen and extracellular matrix growth. The athlete's chronic pain is dissipated, but so are the joint weakness, dizziness, and balance difficulties that can accompany connective tissue and ligament injury. Truly, athletic performance is enhanced by Prolotherapy because of these facts. It is for this reason that many athletes are choosing to cure their sports injuries and enhance their athletic performances with Prolotherapy.