1. 2097 Henry Tecklenburg Drive
Localized Proliferant Injections of the Anabolic Hormones Growth Hormone and Testosterone
Marc N. Dubick M.D.
2097 Henry Tecklenburg Drive
Suite 203 West
Charleston, SC
Prolotherapysc.com

2. But first a necessary review of
Structural pain
The enthesis
Wound healing

3. Structural Pain
Pain left when epidurals don’t work, surgery was not indicated or did not get rid of all the pain and diskogenic pain or radicular (nerve) pain is not the problem.
Primarily involves:
Degenerative joints, ligament and tendon degeneration/injury
Muscle weakness/deconditioning
Degeneration at the enthesis
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4. The Enthesis Attachment site of tendons and ligaments (TL) to bone
This site creates a firm union by splaying out the fibers to create a larger surface area.
The enthesis has 2-3 times the cross sectional area as the mid substance TL.
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5. The Enthesis
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6. Chronic Enthesis Injuries
The consequence of chronic stress at enthesis is tissue micro trauma with altered or incomplete tissue repair.
Orderly phased wound repair is absent or aborted in these areas of micro trauma because of hypoxia.
Result of acute injuries that have not healed over time.
This is enthesopathy or tendonosis.
CHRONIC ENTHESIS INJURIES
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7. Wound Healing Three distinct phases that overlap in time.
Inflammation
Granulation
Remodeling

8. Wound Healing has distinct phases that overlap in time.

9. Remodeling Phase To complete healing of LIGAMENTS
Movement and loading of the tissue is critical
Ligaments need movement from the beginning of the granulation phase
There is period of vulnerability when the curve of wound healing is plotted against pain and ligament strength.
Period of vulnerability is proportional to original severity of injury and expected demand.

10. Remodeling Phase To complete healing of TENDONS
Movement and some loading of the tissue is critical to a good outcome
Periods of stress need to be spaced with rest periods from 4 to 72 hours
Stress needs to be incrementally increased
Progressive stress is critical
What is the balance between stress, rest and intensity?

11. Diagnosis and Treatment
First and Foremost
Make the correct diagnosis
Combination of a complete HPI and thorough structural Physical Examination
Careful listening often provides the diagnosis
Imaging studies
Local anesthetic injections
DIAGNOSIS AND TREATMENT
Sacroiliac pain
Look--patient can't sit at all or for long on affected side
Listen--Increased pain with driving, prolonged sitting or standing
Frequent presenting symptom—”My knee buckles and I fall occasionally”.
Failure of the Slip-Clutch Mechanism--due to posterior sacral ligament weakness and causes the knee to give way.
Touch--pain pinpointed at the sacroiliac joint, inferior sacral boarder, leg length discrepency
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12. Initial Conservative Treatment
Evaluation and treatment by Physical Therapy or Chiropractic
Joint manipulation
Stabilization exercises
Core strengthening exercises
Aerobic exercise
Local anesthetic/steroid injection as a therapeutic/diagnostic measure
Healthy diet/Nutritional supplements
INITIAL CONSERVATIVE TREATMENT
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13. Treatment When Conservative Measures Fail: Proliferant Injections The iatrogenic stimulation of the wound healing and tissue repair process.

14. Three Types of Proliferant Injections
Prolotherapy--Injection of a glucose based solution that stimulates new tissue formation via an intense inflammatory response
Growth Hormone/Testosterone--Localized injections that directly stimulate healing on a cellular basis
TREATMENT WHEN CONSERVATIVE MEASURES FAIL
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15. Indications for Proliferant Injections
Chronic ligament and tendon weakness/laxity
Chronic tendonosis or degenerative ligament changes/enthesopathies virtually anywhere in the body
Continued joint instability despite frequent joint manipulations
PROLOTHERAPY INDICATIONS
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16. Most Common Areas Treated
Cervical, Thoracic, Lumbar Spine
Sacroiliac Joints/Ligaments
Shoulder, Elbow, Wrist
Hip, Knee, Ankle, Foot
Essentially at any ligament or tendon enthesis or in any joint/capsule
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17. hGH and Testosterone hGH—anabolic protein hormone—NOT A STEROID
Recombinant human growth hormone (DNA origin)
Manufactured from e. coli bacteria
Testosterone—anabolic/androgenic steroid hormone
Synthetic bioidentical hormone compounded in an aqueous form

18. Hormone Molecules
aka ligands—molecules that are able to bind to other molecules and form new ones that serve biological purposes
Signal triggering molecules that bind to a particular site on a target cell known as a receptor protein
Secreted by specialized cells and carried by the circulatory system to their target organs
Have cell wall receptors

19. hGH and Testosterone Intrinsic factors
Vitally important for normal body function and wound healing
Share many common pathways and stimulate the production of common cytokines necessary for wound healing
Major impact likely in the first few minutes of wound healing
The effect of the two together most probably outweighs the effect of each one individually

20. Cytokines
A small protein released by cells that has a specific effect on the interactions between cells, on communications between cells or on the behavior of cells.

21. Questions to be answered
How can hGH and testosterone help when epidurals don’t work, surgery was not indicated or did not get rid of all the pain and diskogenic pain or radicular (nerve) pain is not the problem ?
Where and how do hGH and testosterone work in stimulating or aiding wound healing and tissue repair ?
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22. hGH and testosterone play key roles in regulating cell functions
Stimulation of protein synthesis
Releasing signaling molecules
Altering cell wall flexibility
Modify pain perception
Adjustment of blood flow at wound site
Occur in time periods ranging from a few seconds to 24 hours
hGH and testosterone play key roles in regulating cell functions

23. hGH
Regulates key metabolic processes and specifically those related to protein synthesis
Action achieved through the stimulation of the Growth Hormone Receptor and the IGF-1 pathway
Many effects on growth and metabolism mediated indirectly by control of the synthesis of other growth factors
A gene, activated by hGH has been discovered that is critical for the body’s tissues to heal and regenerate
Not as much research on cellular specifics as with testosterone—all cells appear to be involved, but particularly the macrophages

24. Testosterone Changes cell wall flexibility
Influences cellular adhesions
Influences cell-cell interactions
Increases local blood supply by changing the voltage dependent ion channels !
Stimulates production of cytokines and other peptides to help direct acute inflammation
Decreases the pain of injections by stimulation of the GABA receptors
Potent effect on the remodeling phase of wound healing, where it stimulates collagen deposition

25. HGH Studies
Reduction in wound healing times, morbidity, mortality in severe burn patients--systemic
Improvement in healing of donor skin grafts—applied topically
Healing of iatrogenic bone defects in animal studies--systemic
Stimulation of forearm muscle mass—locally injected
Enhanced reparative collagen deposition during wound healing in healthy older men--systemic
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26. PROLIFERANT INJECTIONS: THE IATROGENIC STIMULATION OF THE WOUND HEALING AND TISSUE REPAIR PROCESS

27. INJECTION CONCEPT
Needling a dysfunctional area to iatrogenically create a wound, with resultant bleeding and the initiation of the wound healing cascade.
Injection of anabolic hormones, hGH and testosterone in supra-physiologic doses that will jump start the healing process on a cellular basis and markedly enhance the arriving intrinsic hormones, platelets, growth factors, etc.
Will negate the possible negative effect of low intrinsic testosterone, which could slow healing

28. Patient Selection
Patients need good healing capacity and motivation to improve
Avoid individuals with:
Primary discogenic pain
Chronic illness, true fibromyalgia, immunocompromised
Bedridden with chronic pain
Alcohol, drug, or tobacco abusers
Malnourished
Secondary gain issues
Need other proliferants for active professional athletes
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29. Case History
25 y.o. healthy female with 1 month hx of right sided low back pain which occurred acutely while playing tennis.
Hx of previous back injury 6 yrs. Past after falling down 3 steps. Chiropractic treatment for 3 weeks resolved the problem
Top flight HS athlete who holds the SCISA record for hurdles

30. Initial Treatment for First Month
Chiropractic care since injury
Physical Therapy evaluation performed—diagnosis of right sacroiliac joint dysfunction—treatment followed
Imaging studies—normal
No improvement after one month of Chiropractic and Physical Therapy

31. H & P Right Sacroiliac joint and L5-S1 facet dysfunction
Moderate to severe right hip capsule laxity
Pubic symphysis asymmetry
Right hip adductor tendinitis/tendinosis at attachments on anterior ischium and inferior pubic ramus

32. Initial InjectionTreatment
Local anesthetic/ Anti-inflammatory injection right sacroiliac joint, L4-5, L5-S1 facet joint capsules
Results—short term significant pain relief
Injection procedure performed under fluoroscopic guidance as are all of my injections

33. Treatment Plan
Series of hGH/testosterone/procaine injections to sacroiliac joints/ligaments, L4-5, L5-S1 facet joint capsules, right hip capsule, right hip adductors, pubic ligaments.
Three injections planned per body area (not all at same sitting)

34. Results
During 1st injection, excellent tissue density found at pubic ligaments, left sacroiliac joint and ligaments, L4-5 facet capsule and these areas were no longer treated.
After a series of injections, with each area being treated 3 times, patient reported no pain and minimal ligament/joint weakness was found by treating chiropractor.
Two months following procedures, patient began running and has not slowed down since.
Now 2 years post treatment and is 100% improved, exercising and receiving maintenance joint mobilization

35. Rational for this unusual unilateral injury—High Hurdles

36. hGH/Testosterone study
IRB approval
Prospective Outcome Study: The Treatment of Chronic Enthesopathies of Ligaments and Tendons with Localized Growth Hormone and Testosterone Injections
2 year study
100 participants

37. Hypothesized Benefits of hGH/testosterone
Average three injections per body area
Minimal pain
Rapid onset of healing and joint stability
Ability to use large volumes of injectate
Safe solution