> As for acetaminophen, be VERY careful. Is is NOT a safe drug actually.

And don't go around handing out NSAIDs to other people either. Read the fine print on the packet for a basic Aspirin: it is contra-indicated for some people.
Translation: two tablets can kill some people by inducing an allergic reaction which can shut down the air channels to the point of asphyxiation and death.

It happens.

Cheers

Prolotherapy paper about NSAID risk
http://www.journalofprolotherapy.com/pdfs/issue_05/issue_05_10_nsaids.pdf

American College of Rheumatology guidelines
http://www.rheumatology.org/practice/clinical/guidelines/ACR_2012_OA_Guidelines.pdf

Jennifer, what does the PT world think of prolotherapy?

Edited by jshann on 12/13/2012 04:56:51 MST.

A little pain can be a good thing. All of these OTC and Rx meds have their different side effects. I had never heard of Cox-2 inhibitors before this thread and when I read up on some of the side effects and possible complications I decided to stick with what has worked for me in the past. I have also decided to try and let my body's natural endorphins handle any discomfort as much as possible. I'll save the "meds" for when I really hurt!

Click the link below and then scroll down to the area describing the side effects and complications.

http://www.aws-law.com/cox-2.asp

I expect nothing short of a few good natured jokes about the source of this link.

And now here for your entertainment is a short video clip to illustrate the first line of this post.

http://www.youtube.com/watch?v=g1Bd5DhItKQ

Don't you just love the white socks and the shorty shorts? L O L

Party On,

Newton

What does the PT world think of prolotherapy??

Well, that's a bit of a loaded question with many answers ;)

First of all, there are no good, peer-reviewed (in high-impact journals) randomized controlled trials that show that it is effective. This is why insurance companies won't cover it.

Many people and clinicians swear by it...but so far I have yet to be convinced. Treating tendon pathologies is very difficult, again because of a lack of good blood supply and a rather significant lack of understanding as to what is actually wrong with the tendon itself. We used to like to inject cortisone into them (and unfortunately some clinicians still do that...) thinking that it was "inflamed," which it is not. Numerous biopsies and histological studies have found NO inflammatory cells...the tendons seem to degenerate for some reason.

The idea behind prolotherapy is to actually induce a bit of inflammation into the tendon to kick start a healing process...which in theory is still somewhat iffy because we don't know why the tendon degenerates in the first place. PTs used to use aggressive, painful massage to try to increase blood flow for the same reason, with no demonstrable effects (except for my favorite: I KNOW it works...)

I think there is a lot of work going on to figure out how to deal with tendinopathies and if you can easily afford to pay for prolotherapy, and none of the other treatments (particularly eccentric loading exercises) have helped, then by all means give it a try. Its certainly better than having sie orthopod hack away at your tendons. I'm a little skeptical that the big prolotherapy groups haven't submitted their work to high-impact journals for good peer-review though.

And I have to point out, as a strong evidence-based practitioner, that the placebo effect can be as much as 75%, which only increases if you paid a lot of money for a treatment (just as people think higher priced wines taste better, they think the more they paid for a treatment the better it must be...)

There is a reason randomized controlled trials are the basis for evidence-based medicine. It is very easy to see "your" patients getting better with a treatment, or you had a good result, or your friends did...but until you compare it to good controls you really can't know if it really is more effective than that wonderful placebo.

That is what I thought, possible snake oil injections ; ). That paper by the prolotherapy "journal" looks all official (and the content may have some truth) but sorta comes across as a commercial since it is not in a mainstream journal. The placebo effect is an amazing thing.

A cortisone injection did greatly improve my carpal tunnel. It is now just a weak hand and not throbbing stabs up and down my arm. Although it's my understanding that the cortisone actually decreases inflammation OF the carpal tunnel and doesn't affect the tendons and nerves running through it. That may be completely not how it works. But at least I won't need surgery for a couple more years (hopefully more).

Cortisone certainly has a role to play in terms of fighting inflammation; it is a very powerful drug with good uses. The issue is directly injecting cortisone into tendons themselves to fight "tendinitis." I actually went to a talk last year titled "can we please stop injecting tendons?"

There is a ton of documented evidence that injecting cortisone into a tendon will rapidly accelerate the tissue degeneration and tissue breakdown. The problem arises in the timeline: the injections generally feel great! The patient thinks they are better, the physician feels like he or she helped the patient, and everyone is happy. Then 6 months later the pain returns, probably worse than before, and the patient is none the wiser. There are several good studies of tennis elbow (lateral epicondylalgia)...one in particular had people get cortisone injections, another group got PT (exercise and manual therapy, NOT crap interventions like ultrasound or electrical stimulation), and a third group did nothing. The cortisone group improved immediately, the other two groups slowly improved. By 6 months the cortisone group was worse than before, and the PT group was only slightly better than the watch and wait group (both of which were quite a bit better). The point being that you are better off in the long run sitting around watching Oprah than getting your tennis elbow injected. The rate of recurrence or even tendon rupture in folks who have tendon cortisone injections is frighteningly high. But it doesn't happen right away...right away you feel like the injection was a miracle!

Anyway, another reason why randomized controlled trials with good follow ups are so important. That's where this type of information comes out.....

"What does the PT world think of prolotherapy??"

While we've got your attention, what do you think of platelet rich plasma therapy?

Honestly, my opinion is probably quite similar to the prolotherapy, with the only caveat that at least theoretically there is a bit more oomph behind this one than simply injecting hypertonic saline into a degenerated tendon.

The proposed mechanism here is that you take the body's platelets and inject them into the degenerated tendon, then use the healing properties of the proteins in the blood to spur healing.

There are no good randomized controlled trials, only small cohort studies of patients who self-select (meaning they'd already decided to have the therapy...which means they approach the treatment with a bias).

My personal thought, as both a biomechanist and a pain scientist (my post doctoral work has been in the neurophysiology of pain), is that it isn't going to pan out with further scrutiny...and neither will prolotherapy. My reasoning is that histologically we see the tendon actually becoming disorganized as it degrades: instead of nice, neat parallel fibers that should pull in relatively uniform ways, we have a disorganized glob of tangled collagen that cannot pull effectively, and without triggering an overwhelming pain response. Think of tarp lines and how awful of a pitch you'd get if your guy lines were all tangled up and you tried to pitch anyway.

Simply inducing an inflammatory response, or in the case of platelet- rich plasma therapy actually trying to induce a "healing" response directly, is not going to reorganize those collagen fibers. There is a well-known maxim called Wolff's Law that the body responds to stress by strengthening and reoranizing along the lines of stress. A medical intervention for a mechanical problem doesn't strike me as imminently successful. Surgically you can cut out the degenerated part; mechanically you can induce a noxious eccentric loading to force a reorganization of the collagen (actually rather successful for many people, good RCTs for the knee, Achilles, and lateral epicondylalgia); and from a neurophysiological perspective we are finding some amazing changes in the central nervous system that may affect muscle behavior...which might be why the tendinopathies are happening in the first place. But that's a whole different and way more complicated conversation. But one I love to talk about, by the way. I am a nerd in more ways than my gear closet!

My long, beleaguered point here is that tendinopathies are terribly complicated, we have no really reliable ways to treat it, don't ever allow a clinician to inject cortisone into any TENDON of your body (it can be injected elsewhere...at least for now), caveat emptor in medicine (oh how much ripping off goes on in the doctors - and PT - office!!!!), and there are tons of great research projects going on that will give us more tools in the near future.

I'm guessing several of you have some tendon issues...if you PM me I can send along some descriptions of the eccentric loading protocols for you to try (if you haven't already...) for your particular body part. I'm happy to help...and it costs you nothing but your continued advice on how to lighten my pack ;)

Lots of great stuff in this thread. One thing about cartilage regeneration - while there's no evidence that the hyaline cartilage that's at many joint surfaces can regenerate, there is evidence that small meniscal tears do seem to heal with appreciable frequency. That leaves open the possibility that drugs could potentially interfere with that healing process.

>> exercise and manual therapy, NOT crap interventions like ultrasound or electrical stimulation <<

Oh, I really smiled at that one :)!

I've long been a believer that if you injure yourself there is no magic to recovery... just hard work. I think the modern age magic in PT (electronic gadgets) have been an easy sell because we are very much a lazy society that doesn't want to exert ourselves to get better (backpackers excluded of course :).

That said, I may take (Ibuprofen, Aleve, Acetaminophen etc.) if I think it will help relieve the pain of my injury while I work out with strengthening and stretching exercises. I like to get back to activity as fast as possible after an injury. If these drugs allow me work out harder and more efficiently while recovering, then I use them but I never take anything for my usual aches and pains (my normal aches and pains remind me I'm alive... and have had some fun times in the past).

I will however mention that much to my surprise, I have recently tried Intramuscular Stimulation (IMS) and have had unbelievable results treating what I call "Fly Fisherman's elbow" (serious fly fisherman will no what I'm talking about, but for others it is a nasty combination of tennis elbow and golfers elbow...repetitive stress injuries). After suffering terribly for 20 years my PT suggested I try IMS. I refused the treatment (don't believe in magic, just hard work), so I continued stretching and strengthening with minor success.

My PT finally convinced me to try IMS and in only a few treatments, I had lost about 80% of the pain! This pain reprieve allowed me to work hard at the gym (strengthening and stretching) and I'm still doing well considering I've just finished another rather intense season of fly fishing. I'll probably go back in the spring for a "tune-up" (IMS) before the next fishing season begins but I'm still in pretty good shape considering how much I abused my arm in the past six months (and no drugs needed for pain and inflammation). I now believe in MAGIC!

"First of all, no NSAID will "interfere" with cartilage healing or worsen osteoarthritis, because cartilage doesn't heal...it has no blood supply and once it is damaged that damage is permanent. We don't even have good ways to surgically repair it yet."

Maybe my wording was poorly chosen. Ibuprofen causes thinning of joint cartilage, even in people who have no initial cartilage problems but are taking it for other problems. Adding this drug on a chronic basis to joints that are already compromised is even worse. And rather than using the words 'cartilage healing', it is more correct to say cartilage maintenance and turnover. Cartilage CAN heal, though when it does happen, it is a very slow process, but cartilage is normally actively maintained, and Ibuprofen interferes with this maintenance. The COX-2 inhibitors don't seem to have this side effect, so are probably better if you absolutely need an anti-inflammatory for muscle/tendon/joint/bone pain. Agreed, they can all have nasty gastrointestinal side effects, but I assumed everyone knew that by now...? The NSAIDS are also pretty hard on your kidneys. Also agreed that acetominophen is a poor choice, as it is hard on your liver and has no anti-inflammatory properties. It is a pain killer and lowers fever, not a lot more. However, as pointed out all drugs (in fact anything you put in your body, even food) can have side effects. Caveat Emptor...

I started carrying Ibuprofen last year to deal with altitude headaches I sometimes get. I try to stay away from all medication and deal with pain, but for this scenario I though taking Ibuprofen is safer than AMS. I only took one pill so far - in the evening at camp, it helped with the headache, and I got a great nights sleep as a side effect (no more back pain).
I'm trying to change my breathing habbit (more breathing) and it's working. I realized on some of the trips with headaches, I was actually breathing less - it felt like I was expending less energy (just strolling with a lighter pack while waiting for my wife to catch up).
What would be a safer alternative for fighting the brain swell? - beside acclimatization of course.
I ask this more out of curiosity than need, as the Ibuprofen container will most likely expire with 90% of it's content intact.

First of all, you might consider ordinary aspirin rather than the other drugs.

Secondly, I've seen lots and lots of people at altitude with symptoms. In my opinion, 80% of the problem comes from dehydration. So, you might consider attacking that as a root cause.

Then, think about what you are doing with the pills. Are you merely trying to block the headache pain, or are you trying to alleviate the root cause of the pain? That's why I mentioned aspirin.

You mentioned your breathing. For the average person, when they reach a high elevation, the first two things that adjust are the respiration rate and the heart rate. In some people, perhaps you, the body does not react to the thin air very quickly or very fully, so the respiration and heart do not adjust much. This is what may be creating the problem for you.

If you can't work this out by ordinary means, then you ought to see a physician who knows something about altitude sickness, and they can prescribe Diamox (acetazolamide). Yes, I know that you don't like pills. Diamox works pretty good, assuming that you are not allergic to sulfa drugs. You take it for a day or two before you get to the mountain, and it sort of forces your body to start the adaptation more fully and quicker than it would on its own.

I know a guy who consistently got sick above 11,000 feet, and he had huge headaches and all that. Then he started taking Diamox starting one day before he started up into the mountains, and he has had no symptoms since then.

--B.G.--

Edited by --B.G.-- on 01/21/2013 16:18:37 MST.

"What would be a safer alternative for fighting the brain swell? - beside acclimatization of course."

Diamox

Bob's recommendation is worth a try. But I think that the few times you will likely need to use an NSAID, if it works for you then fine. Occasional use is not going to do you any harm. It is not yet clear that aspirin (also an NSAID) is any less detrimental to cartilage than the likes of Ibuprofen. The jury is still out on aspirin, but it is a very good anti-inflammatory as long as your stomach tolerates it.

I wouldn't put it as the Diamox fights swelling in the brain. Diamox is carbonic anhydrase inhibitor. Say that fast three times. What that means is that it makes some subtle changes in your blood chemistry, and it causes the body to start the altitude adaptation earlier, or more fully. So, it isn't really doing much that your body couldn't do on its own... assuming that your body had a normal response to altitude. But, some percentage of people have this "blunted response," so they take Diamox to speed things up.

1. Assuming that you are not allergic to sulfa drugs, it can't hurt much to take Diamox. Although the standard dosage is standard for moderate elevation travel, some people I know take a half dose and find that it works for them. I also know a guy who takes several times more than the standard dose, and he claims that it works even better for him. The problem is that the bigger the dosage, the more likely that you will have more side effects.
2. What are the side effects? For most people, you get a bit of tingling in the fingers and toes, and that can be mistaken for frostbite if you aren't paying attention. Also, it ruins the taste of carbonated beverages, since the carbonation comes from carbonic acid, and this is a carbonic anhydrase inhibitor. So, you have to hold off that beer celebration for a couple of days after your trip so that the drug washes out of your bloodstream first.

--B.G.--

"I wouldn't put it as the Diamox fights swelling in the brain."

It is a diuretic, and has everything to do with preventing swelling in the brain, which is caused by a build up of fluid.


http://www.medicinenet.com/acetazolamide-oral/article.htm

This always seems like a contradiction to some users. They hear one person claim that dehydration causes 80% of the high altitude symptoms. Then they hear another claim that a diuretic flushes excess fluid out of your system. Those seem contradictory on the surface.

Somebody might claim that they will intentionally dehydrate themselves in order to minimize the chance of any edema anywhere. Well, it just is not that simple and I can almost guarantee that'll get poor results.

Diamox changes your body's "set point" for where the water balance should be. Then, you can continue to drink lots (as you should for a dry environment), but your body has a different balance on when to discard the excess fluid.

--B.G.--

The reason your brain swells (cerebral edema), or your lungs fill with fluid (pulmonary edema), and you get dehydrated at altitude is that the water in your system is maintained by pressure gradients: as the air pressure at altitude decreases, the pressure inside your blood and organs is now out of balance with the environment and the fluid begins to seep into other spaces...your brain, your lungs, your face, your hands...any tissues that are lower on the pressure gradient (which is basically everything outside your blood vessels).

The reason you are dehydrated is that the fluid is seeping into spaces that cannot use it, thus you do not have enough available water to maintain blood volume.

Now, you take a diuretic in order to flush all that extra fluid from your body...because once it seeps into the interstitial spaces it does no good, or just can harm you if it seeps into your lungs or brain. But, even though you are taking a diuretic you still need to continue to drink lots of water in order to maintain as much fluid in the blood as possible. Sort of like pouring water into a leaking bucket...but you've got to just keep pouring....

Interestingly, since ibuprofen was mentioned again, a great study just came out last year that showed regular prophylactic doses of ibuprofen taken just prior to ascending, then continuously while at altitude, had the same effect on reducing altitude sickness as the group that took Diamox. The regimen studied is 600mg every 6 hours starting one day prior to ascending, then continuously while at altitude.

Interesting, eh?