Monday, February 3, 2014

Reviewing Concussions: Lubomir Visnovsky returns after his post-concussive troubles. What is prolotherapy?

Lubomir Visnovsky, 37, returned January 27th in a 6-3 Islanders loss against the Boston Bruins. The veteran defenseman was absent from the lineup for three months, missing 46 games, more than half a season.

Visnovsky was injured on October 19th in the first period of a game against the Carolina Hurricanes on a seemingly innocent hit by forward Riley Nash. Contrary to original belief, many believed Visnovsky was injured on a check by Hurricanes forward Radek Dvorak, which is shown below in gif format courtesy of of Islanders Point Blank. After the Dvorak hit, Visnovsky made it to the bench on his own but left the ice hunched over during the next TV timeout (Islanders benches at Nassau Coliseum don't have direct access to the locker room) and didn't return. Visnovsky wanted to make clear that although he left after the Dvorak hit, it was the hit earlier in the game by Nash.




In an article in the New York Post, Visnovsky described to writer Brett Cygralis that he immediately knew he had a concussion because of his previous concussion history. Visnovsky's last concussion was during the last game of the regular season in 2012 when he was a member of the Anaheim Ducks. Additionally, Visnovsky suffered 4 previous concussions while a member of the Los Angeles Kings and his hometown Slovakian team, Bratislava Slovan.

However, according to Visnovsky, this concussion lingered and kept him out of commission much longer than most. Is it the cumulative effect of his previous concussion history? Does it have to do with his age? Possibly, they all can be considered factors, but the bottom line is we don't know. Additionally, a players post-concussion management and symptoms can be affected by their social situation. Does Visnovsky have a strong social structure at home on Long Island? There are several factors.

In the NY Post article, it's reported that Visnovsky visited renowned concussion specialist, Dr. Jeffrey Scott Kutcher. Kutcher is very well known in the world of neurology, an has worked with NHL players such as Mark Staal, the NHLPA, and will be traveling to Sochi as Team USA's neurologist/medical consultant. Kutcher is well respected in the industry and since he sees such high-profile patients (mostly, if not all athletes) and participates in numerous concussion research studies, he's able to provide new and unique care for patients struggling with concussions.

Visnovsky's concussion lingered and he was unable to return to play or follow a specific timeline to recovery. Visnovsky would "wake up with a migraine," and it would last all day, frustrating him. However after seeing Dr. Kutcher on New Year's eve, Visnovsky felt much better and was able to return in less than a month. So what therapy did he undergo?


PROLOTHERAPY- WHAT IS IT ACTUALLY? 

It's reported that Kutcher gave Visnovsky two injections to the back of his neck as part of a treatment known as prolotherapy. As Cygralis says in the NY Post article, prolotherapy is meant to avoid surgery and help the nerves of the neck "communicate better with the brain, lessen pain (including headaches) and increase mobility."

When a player sustains a concussion, or any form of traumatic head injury, multiple things happen during the mechanism of injury. Not only is there significant trauma to the skull which damages the brain, a significant whiplash injury can be sustained to the neck and base of the skull. The skull base is an important area, containing the brainstem, the posterior part of the brain which is structurally continuous with the spinal cord. The brainstem is extremely important, playing an important role in the regulation of cardiac and respiratory function (why you don't have to think about breathing or heart beats) and providing the passage for nerve connections of the motor and sensory systems from the spinal cord to the cerebrum (brain). Included in these systems are tracts such as the corticospinal tract or motor system (controlling things such as balance and coordination) and the spinothalamic tract (pain, temperature, itch, etc.). In addition, the brainstem also regulates the central nervous system (CNS) and is pivotal in regulating the sleep cycle (many concussion patients struggle with sleep).

Injury to the skull base and upper neck area may change the relationship between the brainstem, cerebrum, and cervical canal, causing increased pressure on nerve control. Those that use prolotherapy on their patients, believe that this increased pressure leads to many of the symptoms of post-concussion patients.

Prolotherapy is a method of injection treatment designed to stimulate healing which is designed to be used for musculoskeletal pain that has occurred for loner than 8 weeks (Hackett et al.). Essentially, prolotherapy works by raising the growth factor levels or effectiveness to promote tissue repair or growth and is considered a long-term solution (Reeves). The treatment is based on the premise that chronic musculoskeletal pain is due to inadequate repair of fibrous connective tissue, resulting in ligament and tendon weakness or relaxation, also known as connective tissue insufficiency (Hackett et al.).

Since ligament and tendon tissues have poor blood supply, they take longer to heal that other tissues. Additionally, it's been estimated that the usual best result of a completed connective tissue repair process is only 50-60% of pre-injury tensile strength (Andriacchi et al.). Over time, multiple injuries (additional trauma) and interfering factors such as stress and lack of sleep may interfere with the healing process.

Prolotherapy is designed to cause a temporary, low grade inflammation at the site of ligament or tendon weakness, which is supposed to "trick" the body into initiating a new healing process in the affected area. Inflammation activates fibroblasts to the area, which are a type of cell that synthesizes collagen, thereby reinforcing connective tissue (Reeves).

Prolotherapy has been used in the United States for musculoskeletal pain since the 1930s, but has always been considered an alternative therapy despite as many as 450,000 Americans having undergone prolotherapy.

In fact, Visnovsky isn't the first NHL player to receive prolotherapy. Simon Gagne who suffered multiple concussions late in his NHL career, underwent prolotherpy with Dr. Greenberg in New Jersey. In the video below, both Dr. Greenberg and Gagne discuss the process.



CONCLUSION/TLDR

Visnovsky was concussed and after several months of no significant improvement and a difficult return to play management, he opted for an alternative therapy known as prolotherapy. Now is prolotherapy legit? Honestly, many doctors haven't even heard of it. Concussion is a difficult injury, accompanied by symptoms associated with unknown causes. Many think somatization is a difficult issue when dealing with post-concussion syndrome. Is it possible prolotherapy helps? Yes. Is it possible it's also a placebo where the patient thinks they're receiving treatment and actually recover on their own? Possibly. 

The bottom line is Visnovsky is back, which is good for the Islanders.  


SOURCES:

Andriacchi T, Sabiston P, DeHaven K, et al. Ligament: Injury and Repair. Acta Rheum Scand. 1956. 2:109-116. 

Hackett GS, Hemwall GA, and Montgomery GA. Ligament and Tendon Relaxation Treated by Prolotherapy. (1956 First Edition; Charles C. Thomas, Publisher). Fifth Edition. Gustav A. Hemwall, Publisher. Institute in Basic Life Principles. Oak Brook, IL. 1991. 

Reeves KD. Prolotherapy: Basic Science, Clinical Studies, and Technique. Lennard TA (Ed) Pain Procedures in Clinical Practice, 2nd Ed. Hanley and Belfus. Philadelphia. 200. pp 172-190.