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Shoulder Subluxation

As a student Occupational Therapist, I had a patient with a subluxation of the shoulder. This is a relatively common side effect for people who have had a stroke, as this person had, because essentially the weight of the arm is hanging without muscular support. When the shoulder muscles lack tone, the arm is held by flaccid tissue that has the ability to stretch out, allowing the shoulder to displace downward from the socket.

In my treatment of this patient, I did some research on shoulder subluxation, as you do when you are an evidence-based practitioner. A Google search of “treatment shoulder subluxation” found me this as the first entry.

Prolotherapy

Wikipedia describes “prolotherapy“ as having “conflicting evidence about its effectiveness”. I agree with that analysis (in fact, I would go even further and say the evidence is poor). So given the state of the evidence, the website should probably not be saying things like: “Prolotherapy offers the most curative results in treating chronic pain” or “Nearly all pain conditions can be successfully treated with Prolotherapy” [emphasis added] following misrepresentations about other treatments for pain.

Let’s examine the claims:

Traditional modern medical treatment for shoulder subluxation or instability involves rotator cuff strengthening exercises, specifically of the supraspinatus muscle, which is the primary muscle responsible for the external rotation of the shoulder. Although rotator cuff strengthening exercises help strengthen shoulder muscles, they usually do not cure the underlying problem, ligament laxity, and, thus, do not alleviate the chronic pain that people with this condition may experience.

I find the use of the term “traditional medicine” interesting when used in contrast with the word “natural” to describe their therapy elsewhere on the page. This is marketing language. Rather than objectively discussing the therapy on its merits, if any, slick and subtle language convinces the reader that this natural treatment is innovative, cutting-edge, and effective where other cold, sciency treatments fail.

However slick the marketing, they lose themselves in the anatomy. First, while supraspinatus is involved in rotator cuff stability, it is actually an abductor of the shoulder. Primary external rotators are deltoid, infraspinatus, and teres minor. …unless they are referring to abduction as external rotation, which is just bizarre. Also, if the intent is to improve shoulder stabilization, infraspinatus should have been mentioned.

Second, the pain they are describing is usually associated with bursitis, with the gleno-humeral joint being compressed, stretched, or twisted oddly due to improper movements with the humeral head out of position (a result of subluxation). So their description of “ligament laxity” as an “underlying cause” is a little misleading.

All that aside, I would not recommend an invasive treatment for shoulder subluxation unless a patient is not responding to non-invasive treatments and precautions, especially if they are apparently targeting the wrong tissues and failing to present the context of exercise in therapeutic treatments: preventing frozen shoulder and maintaining adequate circulation to the tissues through movement.

Another standard practice of modern medicine is to inject steroids or to prescribe anti-inflammatory medications. However, in the long run, these treatments do more damage than good. Although cortisone shots and anti-inflammatory drugs have been shown to produce short-term pain benefit, both result in long-term loss of function and even more chronic pain by actually inhibiting the healing process of soft tissues and accelerating cartilage degeneration. Plus, long-term use of these drugs can lead to other sources of chronic pain, allergies and leaky gut syndrome.

Though they are correct in their assessment that cortisone shots offer merely temporary pain relief, there is no evidence (that I am currently aware of — correct me if I’m wrong, please) that the treatments do more damage than good or that they directly result in long-term loss of function and chronic pain. This seems like causes have been mixed with effects. If a patient is in sufficient persistent pain to seek cortisone shots, they were likely a patient at risk for chronic pain in the first place. And, again, context is missed. Sometimes shots are recommended because patients are in too much pain to participate in therapeutic exercise and they help the patient tolerate exercise at key stages of healing.

I also agree with them that external management of pain (meds, etc) is not a desirable outcome, but not because they are not effective and cause dubious ailments (see leaky gut syndrome), but because it is not a sustainable solution for the patient. Current chronic pain management techniques incorporate self-management of pain through increasing self-efficacy, decreasing pain focus, and providing education about how pain occurs (spoiler: in the chronic pain stage, the tissue is a red herring distracting from the real problem — the brain). However, medication is an appropriate treatment for acute pain and there is no need to scare patients away from effective treatments that have appropriate applications in particular situations.

It is somewhat irresponsible to overstate the risks of acute pain management while at the same time failing to mention the risks of injection: infection, temporary discomfort at the injection site, damage caused by improper injection, and allergic reaction.

When all else fails, patients who experience chronic pain as a result of shoulder subluxation may be referred to a surgeon. Unfortunately, surgery often makes the problem worse. Surgeons will use x-ray technology as a diagnostic tool, which does not always properly diagnose the pain source.

More irresponsibility. “Dear patients, you could go to a surgeon, but good luck because your shoulder will just end up looking like a pulled pork sandwich.”

Where do I even start…

Surgery is invasive (i.e., risky) and expensive. It must be decided upon consultation with a qualified surgeon on a case by case basis after the patient has obtained the appropriate and relevant diagnostic tests. While true that X-rays are limited, soft tissue damage is imaged through other methods such as MRI and ultrasound. So their statements regarding surgery are not only misleading, but seem to suggest that surgeons are not aware of basic diagnostic technology, which is absurd.

A better approach is to strengthen the ligamentous and shoulder capsular structures with Prolotherapy. In fact, shoulder subluxation or instability is one of the easiest conditions to treat with Prolotherapy.

“Better” is one of those words that needs to be appropriately backed up with evidence. Not only must prolotherapy be demonstrably effective, it must be more effective than standard treatment for that statement to be accurate.

Prolotherapy supposedly involves deliberately irritating a part of the body to increase the body’s defenses in that area to accelerate the rate of tissue repair. So essentially they are trying to heighten the body’s normal healing response. But how effective is the treatment? A Cochrane review of 5 available studies  showed conflicting results, as did a review of several low-quality RCTs (an abysmal publishing rate considering the salesmanship).

The mere possibility of effectiveness as determined by potentially flawed anecdotal observation (what I like to call the “this rock keeps tigers away” effect) does not justify an invasive treatment nor does it justify misleading claims about competing therapies that have much better supporting evidence. Furthermore, the research seems quite limited to the application of prolotherapy to low back pain, not complex joint pain (let alone the other two dozen other claimed applications). This is like using research about apple seeds to say something about the color of oranges.

Chronic pain is most commonly due to either to cartilage deterioration, tendon weakness or ligament weakness, as is the case with shoulder subluxation.

Again they are not describing chronic pain accurately, focusing on tissues rather than the brain. If the joint is still experiencing inflammation (acute) or the joint integrity is changing (subacute) then the pain condition is not yet chronic. Chronic pain is pain in the absence of acute/subacute factors — in other words, pain that should be gone by now. Any given person can have fairly significant joint degeneration and have no symptoms at all (this is why an MRI must be interpreted with extreme caution). The body is quite good at adapting to changes when they are slow and progress naturally with aging. A quick change, however, will make the brain go “whoa now, what’s up there?” and start to send you warnings about it — i.e., pain — and may continue to do so even after the tissue-level symptoms have subsided.

The safest and most effective natural medicine treatment for repairing tendon, ligament and cartilage damage is Prolotherapy. In simple terms, Prolotherapy stimulates the body to repair painful areas. It does so by inducing a mild inflammatory reaction in the weakened ligaments and cartilage. Since the body heals by inflammation, Prolotherapy stimulates healing.

In theory. This statement is indefensible at the current level of evidence. Safest? Most effective? From what I have seen, these claims are not supported.

Prolotherapy offers the most curative results in treating chronic pain. It effectively eliminates pain because it attacks the source: the fibro-osseous junction, an area rich in sensory nerves. What’s more, the tissue strengthening and pain relief stimulated by Prolotherapy is permanent!

Most curative and permanent… again, this is indefensible. Given that prolotherapy is a relatively new therapy, I have no idea how they can have access to long-term data that proves their statement that the relief is permanent. I also have no idea how they have separated the effects of prolotherapy with natural pain resolution and healing.

Cure Alls

One other issue to point out. In their list of the many, many joints for which prolotherapy can be used, I noticed a few that didn’t seem to fit. To focus on two obvious ones, I’ll mention Carpal Tunnel Syndrome (CTS) and TMJ syndrome. If the effect is to tighten tendons and ligaments, prolotherapy treatment would worsen CTS by further compressing the median nerve and worsen TMJ by further tightening the joint. Again, there seems to be a fundamental lack of understanding anatomy, resulting in a few common ailments being inappropriately included in the treatment list.

Furthermore, rather than highlighting the evidence they do have (which isn’t much), they don’t even bother to cherry pick and go right to the testimonials.

These are not signs of a solid, evidence-based therapy.

Conclusion

If prolotherapy has weight to it, fine. But websites like this are misleading. That is not to say they are intentionally misleading. Sometimes excitement and the desire to help people gets in the way of objectivity. So its entirely possible to be accidentally misleading based on good intentions.

But my main problem with this website is that they don’t say “this a new treatment that is currently gathering evidence that might work for you and here are our sources so far”, they say/imply “traditional treatments will hurt you, so you should do this instead”. Negative aspects of traditional care are highlighted and at times exaggerated, while not mentioned for prolotherapy. Similarly, positive aspects of traditional care are played down or not mentioned at all, while exaggerated beyond the evidence for prolotherapy.

That is wrong. And it comes up second only to Wikipedia on a Google search for the problem. I originally found this website 3 years ago, and nothing significant has changed. In science, with a new supposedly up-and-coming therapy, this fact alone is very strange.

  1. July 7, 2014 at 7:45 PM

    Unfortunately, I am not able to provide direct advice over the internet, as it would violate my professional ethics. It would be more appropriate to see your family doctor and ask whether a referral to a qualified post-stroke physiotherapist would be worthwhile. Your doctor should be able to point you in the right direction.

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