Piriformis Syndrome, Pelvic Pain Syndromes, and Other Complex Low Back and Body Pain

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

"Sciatica" is a term that has long been used in standard medicine to describe almost any pain syndrome with symptoms that radiate, spread, shoot, or refer to the pelvic, buttock, hip and thigh, especially if nerve related symptoms, called paresthesia and dysesthesia are present. Most often, these syndromes are not a direct pathology of the sciatic nerve, although sciatic irritation is often involved secondary to another tissue problem. Common symptoms of nerve irritation include sensations of numbness and tingling, dulled sensation, heaviness, and indistinct pain, which are called paresthesia, and burning or hot sensations, pin and needle sharp sensations, sudden stabbing or gripping pain (paroxysm), or electric pain, called dysesthesia. While standard orthopedics looks for an injury to the nerve root at the lumbar spine, which may need surgical repair, as well as inflammatory tissue lesions at the facet joints of the vertebrae, many patients are frustrated to find that MRI imaging reveals no obvious tissue causes, such as a herniated, bulging or shrunken disc (stenosis), or enlarged hardened tissues around the nerve at the facet joint (hypertrophy). This leaves many patients frustrated and confused concerning the nature of their often worsening symptoms. Many men experience a low back and pelvic pain syndrome associated with acute or chronic prostatitis, often with nerve irritation and pain radiating down the leg, and standard assessment and treatment is frustrating. While we would all like to have a straightforward and simple explanation for the many variations of Pelvic Pain Syndromes, the truth is that these syndromes are often complex, puzzling and difficult to diagnose, much less treat properly.

In addition, many women have complex pathologies with chronic vulvodynia, interstitial cystitis, pelvic endometriosis, and subserosal uterine fibroids that are not addressed adequately in standard medicine, and are part of a pelvic pain syndrome. Often, common low back pain is not felt in these pelvic pain syndromes, and the diagnosis of pelvic pain syndrome or piriformis syndrome is confusing. These syndromes often produce embarrassing symptoms of urinary incontinence, pain with contact to the vulva or vestibular region, episodic sharp or burning pain to the vagina, or large growths in the lower abdomen. A 2003 survey of nearly 4000 women published in the Journal of the American Medical Women's Association (Harlow BL Stewart EG: Spring, 2003; 58) found that 15.6 percent of these women reported episodes of chronic vulvar pain or vulvodynia in their lives, with a large majority either not seeking care or frustrated by multiple physicians failing to diagnose the condition. The age of the survey was from 18-64, and while such health problems are more prevalent in perimenopause, incidence in young women is not uncommon. While the pathology is still poorly understood, a number of explanations are being explored, often part of a multifactorial etiology. Chronic fungal infections, such as Candida, may lead to hypersensitivity, viral infections of a low grade, such as HPV, low-grade bacterial infections, chronic inflammatory disorders, accumulation of oxalate crystals, and allergic disorders are all implicated, as well as central (nervous system) causes, and history of abuse (psychosomatic disorder). Vulvodynia, or painful sensitivity to touch, was most prevalent in the survey, while burning sensations and sharp pain episodes were experienced by about 15 percent of respondents in this survey. The complexity of the causative and contributing factors point to a need for a holistic assessment and treatment protocol, and often a set of potential causative factors need to be treated that are diverse in scope. By addressing these syndromes with a thorough treatment protocol, key contributors to the pathology are less likely to be overlooked, and success more assured.

Pelvic Pain Syndromes often go undiagnosed or simply called "sciatica". Often, the key symptoms are not an acute and alarming low back and pelvic pain, but instead a nagging, chronic pain syndrome with a number of associated symptoms that present a confusing scenario. For this reason, the name of these varied disorders should be changed to Chronic Pelvic Syndrome. The wide variance in presentations of pelvic pain syndromes and piriformis syndromes require a more holistic and individualized assessment and treatment protocol. The Complementary and Integrative Medicine (CIM) Physician, especially the knowledgeable Licensed Acupuncturist and herbalist with a specialization in myofascial syndromes and soft tissue pathologies, is an ideal member of an integrated team to properly assess, diagnose and treat these complex pelvic syndromes now termed Piriformis Syndrome, CPPS, Chronic Pelvic Congestive Syndrome, Chronic Prostodynia, and unfortunately, often just "sciatica".

Piriformis Syndrome is one of the complex regional pain syndromes that explain many patient's often debilitating conditions. In studies cited in Drs. Janet Travell and David Simon's text, Myofascial Pain and Dysfunction, written decades ago, a broad review of patients with these low back and lower body symptoms revealed that more patients were diagnosed with piriformis syndrome than with nerve root irritation caused by disc protrusion in clinics specializing in low back pain and trained to diagnose myofascial pain syndromes. The ratio of women to men with the diagnosis of piriformis syndrome was 6 to 1, and in some studies, this female subset with generalized "sciatica" showed that over 40 percent could be diagnosed with piriformis syndrome. The reason that this is not well known in the United States is that most clinics are not looking at a differential diagnosis that includes piriformis syndrome and other such soft tissue regional myofascial pathologies. Most clinics are looking for a diagnosis that supports a surgical approach. While the orthopedic specialists usually have little to offer for such pain syndromes, and neurologists often have difficulties with standard diagnostic clarification, and quickly resort to prescription pain medication, anti-depressants and anti-seizure medications disguised as muscle relaxants, and neural pain relievers such as gabapentin, which are usually ineffective and come with alarming side effects, there is help and cure for these syndromes from medical practice that treats the regional syndrome holistically, and uses a variety of treatment modalities to simultaneously correct the various contributors to the dysfunction.

Standard medicine has tried unsuccessfully in the past to promote an allopathic approach to soft tissue injuries, suggesting that a limited treatment protocol of surgical repair when needed, pain medication and corticosteroid therapy is enough. Recent additions to the protocol, such as platelet-rich plasma injections, are proving ineffective, and long-term benefit from corticosteroid injections has not been shown in clinical trials, while risks from overuse of synthetic steroids is now well documented. All of these allopathic approaches have their benefits, but as more and more medical doctors are now admitting, this limited approach cannot replace a thorough holistic approach to aiding soft tissue repair with an integrated multidisclipinary and comprehensive conservative treatment strategy. Limiting rehabilitative care has been partly the fault of the insurance companies as well. But by refusing to pay for adequate therapy with rehabilitation, and failing to utilize herbal and nutrient chemistry to promote better tissue healing, many soft tissue injuries have turned into painful chronic problems, and the eventual cost of chronic health care to insurers has not been healthy financially. Patients are now becoming educated to the need for a treatment protocol that insures the best long-term outcome, and are increasingly turning to Complementary and Integrative Medicine to achieve this goal.

By 2008, increased use of advanced imaging, such as free-standing MRI, had led to a broader understanding of pelvic and hip pathologies, and the inclusion of non-operative syndromes such as piriformis syndrome, sacroiliac joint sprain and strain, a 'sports hernia' of the hip flexor complex, or iliopsoas involvement in a weak posterior inguinal wall, and mild stress fractures of the head of the femoral bone related to myofascial stress imbalance, entered the consideration in the differential diagnosis of pelvic and hip pain and pathologies. To see evidence of this expanded diagnosis, click here: http://www.ncbi.nlm.nih.gov/pubmed/19038713 . Today, we need to take the time to actually achieve a sound diagnosis with chronic hip pain, and when appropriate, integrate Complementary Medicine and conservative treatment protocols such as physiotherapy, herbal and nutrient medicine, and acupuncture. A protocol of either finding a surgical solution or waiting until the joint degenerates enough to warrant a hip replacement is not a sound strategy. Many hip pathologies that are routinely corrected with arthroscopic surgery could also benefit from a more holistic conservative care approach, either first tried to avoid surgery, or to improve surgical outcomes with short courses of care before and after surgery.

Each specialty in medicine has its focus, and each provides the injured patient with a set of skills and knowledge. Medical doctors are increasingly specialized in the United States, and the surgical skills are greatly appreciated when needed. Often, though, the medical doctor offers little more than surgery, immobilization, and pain medication for pain syndromes, and their education does not extend into areas of manual physiotherapies, or herbal and nutrient medicine. The terms Integrative Medicine and Complementary Medicine are used to describe physicians such as Licensed Acupuncturists that add these skills and knowledge to the overall treatment protocol. Physical Therapists and Chiropractors, as well as Osteopaths also offer a unique set of skills and knowledge to aid tissue healing and rehabilitation, and integrate well with the TCM physician, or Licensed Acupuncturist. Too often, the advice from the primary physician is to immobilize the injured body part for too long and avoid other therapy. These other specialties generally realize that prolonged immobility and pain medication alone is not the most scientific approach to tissue healing. When looking at the physiology of tissue healing, we see many therapeutic steps that can be taken to help our injuries heal quickly and optimally. In Piriformis Syndrome the need for a thorough holistic approach is especially important.

Understanding Piriformis Syndrome or Chronic Pelvic Syndrome

The piriformis muscle is one of the prime stabilizers of the pelvis and lumbar region, and is especially important in low back and lower body pathologies because the broad sciatic nerve may go through, under or over the muscle, increasing the possibility that a sciatic nerve impingement or irritation could be related to a contracted or dysfunctional piriformis muscle. Other important regional nerves also run along or through the piriformis muscle, and could be the primary cause of symptoms, or a secondary contributor. Nerve impingement and irritation not only causes symptoms of paresthesia and dysesthesia, but also leads to decreased muscle function and weakness from poor neural firing. Weak function of prime stabilizers of the pelvis and lumbar result in increased strain on other stabilizing muscles, as well as joint tissues. The sacroiliac joint is especially impacted in piriformis syndrome, and lumbar and lumbosacral joint tissues may also be affected, leading to degeneration of joint and disc tissues over time. This is why the pathology is called a syndrome, which is a term that implies that a number of tissue problems and possibly disease mechanisms are involved. An allopathic approach tries to narrow the diagnostic and treatment focus to one particular tissue or disease mechanism. The holistic approach analyzes the problem from a broader perspective and offers treatments that deal with the whole array of contributing health problems and injuries, and is thus perfectly suited to treat a syndrome.

The piriformis muscle is located between the sacrum and the hip, and is the prime lateral rotator of the hip, as well as one of the most important stabilizers of the pelvis and low back. This broad muscle is located deep to the main gluteal, or buttock, muscle. Its origin is across the underside of the sacrum, the greater sciatic foramen of the pelvis, and the pelvic surface of the sacrotuberous ligament, which is a broad ligament that holds the sacrum to the lower pelvic bone. This ligament is directly continuous with the biceps tendon origin on the lower pelvic bone in 50% of the population, and thus piriformis syndrome is often associated with, or confused with, tendinosis of the biceps attachment. Innervation of the piriformis comes from the fifth lumbar to second sacral nerve roots, which are part of the sciatic complex, and so problems with the piriformis may contribute to decreased neural firing of the muscle, perpetuating the problem. The piriformis may also become either swollen or widened with held contracture, and since it fills the greater sciatic notch of the pelvic girdle, this chronic contracture may compress the broad sciatic nerve complex here as well. We see that chronic problems with piriformis dysfunction could thus irritate the nerve at three locations, the lumbosacral nerve roots, the greater sciatic notch of the pelvis, and the pathway of the sciatic nerve through or around the muscle. Other nerves can also be irritated by the chronic piriformis contracture, and innervation to the gluteal and coccyx muscles may also be affected, as well as the nerves that go through the broad sacral nerve plexus, such as the pudendal nerve, which innervates the bladder and rectal sphincters, the external genitalia, and has an autonomic component. Thus, some patients may experience symptoms of increased or urgent urination, urinary escape with coughing, pain associated with bowel movements, and even pain episodes with sexual intercourse.

The piriformis muscle attaches to the greater trochanter of the femur at the hip, and chronic contracture and/or weakness can also create hip pain and dysfunction, as well as postural problems that may lead to low back strain, knee strain, or even improper postural mechanics of the feet and ankles. The most typical sign of piriformis contracture is out-toeing, or the assuming of a lateral angle to the foot when standing or walking. This occurs because the piriformis is the primary lateral rotator of the hip, and the leg is held in a lateral rotation. We can see from this description that the chronic piriformis strain may create many potential problems, and present a very confusing array of symptoms, both to the patient and to the physician. Like all myofascial pain syndromes, this one could eventually lead to increased autonomic stress, which may manifest as insomnia, anxiety, constipation, abnormal sweating patterns, increased sinus congestion, poor temperature regulation, neurogenic bladder pathology, etc. Since the piriformis can directly impact the pudendal nerve, which has a strong autonomic component, there is increased potential for these types of autonomic dysfunctions. Even acute syndromes attributed to Pudendal Neuralgia and nerve entrapment syndromes often involve the piriformis muscle. In addition, since this syndrome primarily affects women, and is most likely to occur in the perimenopausal to postmenopausal time frame, when hormonal deficiencies decrease the efficiency of normal tissue maintenance, there may be an impact on menopausal symptoms, which are themselves autonomic in origin.

The sacroiliac joint is often involved in Piriformis Syndrome. The SI joint problems can cause piriformis syndrome or be caused by piriformis syndrome. This joint is not a typical joint, and the movement is very limited. It's main joint function is to lock and unlock to provide a complex stabilization when we turn and move. Problems with the SI joint occur typically when the joint fails to lock and unlock with movement of the body. When this occurs, much strain is added to the lumbar and pelvic joints and muscle stabilizers. The SI joint is directly attached to and involved in a number of muscular tendons and ligaments. Five important ligaments attach to the SI joint, and a number of muscles, including the gluteus maximums and minimus, as well as the piriformis, are directly involved in SI movement and stability. The joint has greater movement in a woman's body, precluding the sacroiliac involvement in female piriformis syndrome. As stated, the sacroiliac joint does move very little, up to 5.8 millimeters, or about 1/4 inch, in women. This joint is important, though, because it moves in three directions, and is very integral to low back and pelvic stabilization during movements, with its locking and unlocking function. When the muscle quits unlocking, it causes quite a bit of strain on surrounding tissues, and can cause direct pain. This can also lead to hardened and hypertrophied tissue around the joint, leading to limited mobility. Another type of sacroiliac dysfunction is called upslip, or upward displacement of the innominate bone in relation to the sacrum. This type of SI dysfunction typically causes low back and groin pain, or pain located in the upper buttocks as well as the inguinal area and upper anterior thigh. Unfortunately, the diagnostic evaluation used to determine innominate upslip is not certain, and anterior torsion of the pelvic girdle, as well as other stress imbalances of the pelvis often make it difficult to determine this joint subluxation. Considering that the sacroiliac joint is held in place by some of the strongest ligaments in the body, upslip is unlikely unless a significant trauma has occurred. Regardless of the diagnosis, myofascial release, trigger point therapy and neuromuscular reeducation to the array of deep pelvic stabilizing muscles is the primary therapy.

To summarize, Piriformis Syndrome may involve sciatic irritation or impingement, local pain deep to the buttock, strain of surrounding muscles, sacroiliac dysfunction, lumbosacral degeneration, nerve irritation or compression at multiple sites, irritation of the femoris biceps tendon origin and the ligament sling, and strain injury involving the hip, knee or foot. The symptoms are typically varied and confusing, involving increased pain with prolonged pressure on the piriformis when sitting or driving, often with dysesthesias, such as burning pain, or pins and needles sensation, as well as referred pain in various myofascial patterns, and possibly pain referred to the groin. A variety of autonomic symptoms can also eventually manifest, especially increased menopausal or perimenopausal symptoms, urinary problems, and potentially discomfort in sexual intercourse. Syndromes are complex and varied in presentation, so an individual patient may experience just some, or one, of these symptoms, or many of them.

Effective Treatment Protocol in Piriformis Syndrome or Chronic Pelvic Pain Syndromes

As you can see from the complex description of this syndrome, there may be many simultaneous components to the pathology. Poor success with therapy usually can be attributed to not addressing all of the components involved. Misdiagnosis is the greatest problem, but too much focus in treatment on specific aspects of the overall tissue pathology is also common in medicine. The successful physician, and patient, will work simultaneously on all of the aspects of the pathology in order to achieve results that are not hampered by aggravating factors that are not addressed in the treatment protocol. This means that a holistic approach should be utilized, with myofascial release, joint mobilization, improved tissue healing and circulation, and correction of postural mechanics, as well as targeted stretch and exercise. The piriformis, gluteal muscles, TFL, and low back stabilizers, the quadratus lumborum and iliopsoas, should all be restored with myofascial release and soft tissue mobilization. The sacroiliac joint should be unlocked and restored with mobilization. The lumbosacral joints should be mobilized. The nerve conduction should be stimulated, and mechanical pressure on the nerves should be released. One may need to treat the biceps femoris (hamstring) tendon. Pelvic floor myofascial pathology and trigger point needling could be an effective part of the protocol, but this type of therapy is very difficult, as the pelvic flood is protected by the pelvic bone girdle, and direct therapy often involves entry via the vagina or anus, and guided needle therapy with imaging. The array of therapies that are more accessible, combined with neuromuscular reeducation and actve release techniques, often will produce good results without needing to resort to specialists that use these more invasive direct pelvic floor treatment protocols. The key is to utilize a more holistic protocol in treatment. When only one aspect of this whole treatment strategy is utilized, there will be limited success.

Tissue healing may be hampered by problems with the general health, and could also perpetuate the Piriformis Syndrome. Since piriformis syndrome is typically seen in women, and especially in women of perimenopausal to postmenopausal states, or with other hormonal and metabolic imbalances, analysis of and addressing hormonal balance may be important. Tissue repair and maintenance is an ongoing issue in the body, and hormones are integral to regulation of this process. When hormonal deficiency and imbalance occurs, there is a greater chance of calcified tissues, poor inflammatory response, and degeneration of joint tissues. Even the presence of a strong premenstrual imbalance could be a sign that progesterone deficiency in the second half of the menstrual cycle is contributing to poor tissue maintenance. Adrenal insufficiency and subclinical hypothyroid and hyperparathyroid imbalances may also play a significant role in poor tissue maintenance and play a part in the array of degenerative tissues often seen in piriformis syndrome.

A wide variety of approaches with herbal and nutrient medicine may be important in the overall treatment protocol. Herbal formulas that stimulate improved tissue healing, decrease spasm, promote improved blood and nerve circulation, and stimulate better immune and adrenal health may be very helpful in the long run. Hormonal balance may be aided with bioidentical hormones, as well as a variety of herbal and nutrient medicines. Topical herbal salves, lotions and plaster, as well as herb infused oils, may also deliver effective tissue repair aids directly to the local tissues, as well as the blood circulation. Much study has been conducted to elucidate the role of various nutrient supplements on tissue healing. While oral glucosamine and chondroitin have been proven to have only mild benefit due to the problem of digestive breakdown and poor delivery to the tight joint tissues, there are a number of nutrients that are proven to stimulate improved tissue healing, especially amino acids, and essential fatty acids. In addition, a variety of nutrient medicines may contribute to a healthier nervous function, as well as improved hormonal and metabolic health. Much of this science is complex and difficult to understand, as many nutrient medicines work indirectly on the various systems of the body to achieve goals. Utilizing a professional with knowledge of these therapies affords the patient a great chance of success.

Chronic Pelvic Pain Syndromes (CPPS) in both Men and Women

Pelvic pain syndromes are multifactorial syndromes of chronic pain that affect both men and women and are often associated with urinary problems related both to interstitial cystitis and chronic non-bacterial prostatitis, or prostatodynia (pain around the prostate). Pain may be a symptom that is overshadowed by other symptoms in these syndromes. Pain symptoms often wax and wane, and may be experienced in the pelvis, low back, hip and groin, sometimes felt only as discomfort associated with sexual intercourse, urinary function, or wearing of a tampon. There is much overlap between Piriformis Syndrome and Pelvic Pain Syndrome, and the chronicity and complexity of Pelvic Pain Syndrome, with its variations, often produces a misdiagnosis. Patients experiencing an array of symptoms and a chronic pain lasting for more than 3 months in the pelvic area, low back and/or hip should suspect that this syndrome is affecting them. In men, pain after ejaculation is a hallmark symptom, and this complaint is both embarrassing and routinely dismissed as a psychological problem. In women, difficulty holding the urine, frequent urination, and stress incontinence are hallmark signs, but many patients without these more dramatic symptoms suffer from Pelvic Pain Syndrome. Researchers at Stanford University Medical School have produced a high selling book entitled Headache in the Pelvis, which is now in its sixth edition, and has helped many patients better understand this confusing syndrome of pain and dysfunction.

In 2006, the Feinberg School of Medicine at Northwestern University in Chicago, Illinois, a prestigious medical school, reviewed all clinical data on prostatitis in the United States and determined that 90-95% of cases of chronic prostatitis actually involve Pelvic Pain Syndrome (PMID: 16409145). This was then classified as non-bacterial prostatitis, or prostatodynia when chronic inflammation was not apparent. Symptom-based evaluations of the general population by 2013, or epidemiological evaluation, has revealed that male chronic pelvic pain syndrome affects 2.7-6.3 percent of the male population in the United States. The diagnosis and treatment with standard medicine for this condition is unclear and offers little chance of success, often treating with such problematic pharmaceuticals as alpha receptor blockers (alpha adrenergic receptor antagonists). These drugs are prescribed for a variety of conditions, including hypertension of autonomic origin, autoimmune diseases, autonomic vascular diseases such as Renaud's phenomenon, and some anxiety disorders. A number of herbs contain chemicals that are alpha receptor blockers as well. For example, the once popular herb, Yohimbine, is a selective alpha receptor blocker. Standard medical guidelines suggest that these drugs should only be used for benign prostatic hyperplasia with moderate to severe symptoms, though, and the side effects tend to create noncompliance in a large percentage of patients. In other words, standard medicine has little to offer the patient with Pelvic Pain Syndrome causing prostate problems. On the other hand, Complementary Medicine and the knowledgeable Licensed Acupuncturist has an array of therapeutic tools to treat this problem thoroughly, systematically and holistically. By 2013, standard medicine started including these treatments seen as Alternative and Complementary Medicine in the guidelines for treatment of male chronic pelvic pain syndrome, including diathermy, physiotherapy, targeted stretch and exercise, herbal medicine, diet and lifestyle modification, and yoga, as well as cognitive and behavioral therapy when chronic pain created hypersensitivity and allodynia.

The finding that Pelvic Pain Syndrome accounts for almost all of the cases of male benign prostate hyperplasia or chronic prostatitis has led to the impression for many patients that Pelvic Pain Syndrome is a male disorder and does not exist outside of the prostatitis, though. This is patently untrue, and in fact, as researchers at Stanford University Medical School have indicated, perhaps a majority of women with unclear diagnoses of stress incontinence, chronic interstitial cystitis, and chronic pain syndromes of the pelvic area and low back may attribute their condition to Pelvic Pain Syndrome, even if pain is not a significant symptom. For aging women especially, Pelvic Pain Syndrome is now considered one of the most common gynecological complaints, and points to the need to take a holistic approach in medicine. Pelvic Pain Syndrome as a gynecological pathology involves the nervous system, both central and peripheral, chronic inflammation, hormonal dysregulation, and musculoskeletal problems, and is associated with gastrointestinal disorders such as irritable bowel syndrome (IBS) and interstitial cystitis (chronic inflammation of the bladder, usually associated with low-grade bacterial infections). There is a need for a new name for this syndrome of dysfunction for many patients, or perhaps a diagnostic differential for pelvic syndromes without pain. The long avoidance of this syndrome has led to slow progress in understanding and treatment.

What exactly is Pelvic Pain Syndrome, or Chronic Pelvic Syndrome, you may ask. As with all pathologies that are called a syndrome rather than a disease or specific injury, Chronic Pelvic Pain Syndrome is defined by a wide variety of parameters, making the definition unclear. At the heart of the Pelvic Pain Syndrome, though, is a myofascial syndrome of strain and dysfunction of the deep pelvic muscles. Of course, a number of these muscles are not easily treated, as they are located on the inner side of the pelvic bones, called the Pelvic Floor. A number of techniques of neuromuscular reeducation can be utilized to directly release these problematic muscles and restore function, and should be the focus of therapy for the muscles not easily reached by the deep tissue therapist skilled in myofascial release. Chronic myofascial syndromes often create autonomic nervous system stress that leads to dysfunction, and this creates a variety of symptoms in Pelvic Pain Syndrome. Local tissue problems, such as uterine fibroids and polyps, endometriosis, interstitial cystitis, intestinal inflammation and functional disorders, such as irritable bowel syndrome, diverticulitis, and prostate hypertrophy and chronic inflammation all may contribute to the deep pelvic myositis, or myofascial inflammation.

Women with Pelvic Pain Syndromes involving localized or generalized vulvodynia (heightened pain sensitivity to touch or pressure) may be experiencing changes in either the central or peripheral nervous system. Persistent low-grade inflammatory damage to tissues, or low-grade infections, often associated with interstitial cystitis (inflammation or the bladder membrane), may lead to hypersensitivity, or even excess growth, or peripheral sensory nerves. The symptoms may occur only with sexual intercourse, with insertion of tampons, with cycling, or when wearing tight clothing or irritating synthetic fabrics. Deeper pain may be felt as well, typically referred to as vulvovestibulodynia, and may involve interstitial cystitis, uterine fibroids, pelvic endometriosis (tissues of the uterine lining expressing outside of the uterus), or irritable bowel syndrome. Even syndromes without any of these more common underlying conditions, and only a pelvic pain myofascial syndrome, may occur. A proper assessment often requires patience and persistence. Treatment may need to address a number of these underlying problems at once. Studies have shown that hypersensitivity disorders, similar to allergic reactions, may involve increased mast cell populations in the tissues, and subsequent overexpression of certain inflammatory cytokines, from CD4 T-cells, that stimulate and sensitize nerve endings. Ovarian dysfunction and imbalance or deficiency of ovarian hormones have been associated in a number of studies with vulvodynia, and the relationship between ovarian hormones and vulvar pain threshold, and the impact of oral contraceptives on vulvar sensory processing is being researched. Fibromyalgia and some autoimmune disorders are also associated with a small percentage of cases. Recent studies have shown that a history of psychological neglect or abuse may be causative of a dysfunction of the hypothalamus/pituitary adrenal axis, and mis-coordination between the hypothalamus and hippocampus, the center modulating pain and memory, leading to hypersensitivity of cortisol receptors in the vaginal tissues, as well as tissues of the bladder and colon. Studies documenting this research are found linked below in Additional Information. Such studies point to the need to address homeostatic modulation and regulation in the brain, as well as low-grade tissue inflammation in the local tissues, to achieve the desired results. Only Complementary Medicine, in the form of acupuncture, electroacupuncture, herbal and nutrient medicine, and soft tisse physiotherapies such as myofascial release and neuromuscular reeducation, provided by specialized Licensed Acupuncturists and herbalists, can provide such a holistic and complete therapeutic protocol. The key to proper evaluation and treatment is time spent by both the patient and physician, working together, to increase understanding of the pathology and potential of a multifactorial cause of Pelvic Pain Syndrome and Vulvodynia, and devising a persistent step-by-step thorough course of treatment.

Pelvic Pain Syndromes require patience, persistence and a holistic and thorough approach to treatment. Patient knowledge and understanding is critical, as the bulk of the therapeutic work needs to be accomplished by the patient. A comprehensive treatment strategy, utilizing acupuncture, physiotherapy, herbal and nutrient medicine, combined with patient instruction in therapeutic techniques, postural corrections, and ways to improve underlying health provides the proactive patient with the tools to correct this difficult health problem. The key areas of neuronal pathways at the sympathetic portions of the spinal nerves need to be addressed in therapy as well. The sympathetic innervation of the pelvic organs originates in the thoracolumbar area and the parasympathetic portions follow vagal nerve distribution at the sacral nerve roots. Sensory innervation is shared among the pelvic organ tissues, making the sensation of pain and other symptoms vague and confusing. In the brain, symptoms stimulate portions of the brain closely associated with the limbic system, and a strong interaction between emotional memory and motivational states linked to anxiety and depression has been noted, with a gate-control theory developed to explain this confusing ineraction between the emotional and psychological states of the patient and their symptoms. Treatment of the Pelvic Pain Syndromes must therefore be individualized, address the healthy function of the brain, spine, pelvic organs, and pelvic musculature. Associated problems must also be addressed, and restoration of the hormonal balance, gastrointestinal health, and optimum immune function may also be needed to fully treat Pelvic Pain Syndrome. Complementary Medicine and the skilled Licensed Acupuncturist and herbalist can deliver such a broad and holistic approach.

In 2013, experts at Temple University Hospital, in Philadelphia, Pennsylvania, U.S.A. published a meta-review of current findings in diagnosis and treatment of Chronic Pelvic Pain Syndrome and Chronic Prostatitis, noting that these syndromes often are complex, associated with chronic comorbid conditions such as Irritable Bowel Syndrome, Fibromyalgia, Chronic Fatigue Syndrome, Autoimmune disorder, and chronic inflammatory disease of either the peripheral or central nervous system, obviously requiring a more comprehensive and holistic approach in therapy. These experts stated that acupuncture and related physiotherapies, such as pelvic myofascial release and neuromuscular reeducation, have recently received much attention in the treatment protocol and appear to be good treatment options (Current Opinions in Urology Nov 2013; 23(6): 565-569). When there are few effective treatments in standard medicine, the diagnoses are often discouraged, but in recent years the acknowledgement that Complementary Medicine, in the form of the medical specialty of Traditional Chinese Medicine (TCM), is sensible, scientifically proven, and offers an array of treatment options that addresses a number of concerns at once, integrating well with standard medicine, has opened up these difficult to treat diseases and syndromes to more honest diagnosis and treatment recommendation. The benefits for many patients are finally being realized.

Understanding Injury to Better Understand Healing needs

The precipitating cause of piriformis and pelvic pain syndromes is often a chronic or acute tissue injury. When these injuries are not treated properly, and become a chronic nagging health problem, syndromes such as piriformis and pelvic pain syndromes may be created, especially when other contributing health factors, such as intestinal inflammation and dysfunction, uterine fibroids and endometrial lesions, chronic bladder inflammation or dysfunction, or prostate problems exist. Understanding myofascial injury and treating it properly, whether it is an acute injury or a chronic strain, is very important to the resolution of piriformis and pelvic pain syndromes. Understanding the underlying causes of perpetuation of poor tissue healing and maintenance is also very important, though, as the best physiotherapies and therapeutic activities may not be enough if there are perpetuating factors that prevent tissue healing or continue to aggravate tissues, especially if many of those tissues are located in the pelvic floor, unable to be treated directly with manual therapies.

Each patient that suffers injury to muscle, tendon and joint tissues experiences a unique injury that must be rehabilitated according to the individual needs of the patient. That person's body will do the work of repair, which is an amazing physiological process, and even patients with severe injury will experience a regrowth of tissue that is often stronger than the original tissue, although in many cases, poor rehabilitation will result in strong adhesive tissues that continue to cause dysfunction. This is especially true of tissue injuries within the pelvic girdle. Patients with chronic health problems that could impede tissue healing, or perpetuate chronic inflammation, such as hormonal imbalances and chronic inflammatory disease, need to understand the special needs that must be addressed as well. Often, a holistic and thorough approach must be taken to fix these problems. By taking the time to better understand tissue repair, you can feel more confident in the process, and avoid the disability of chronic pain and dysfunction. How your body heals is not out of your control, but you must understand that your own body does the work, not some outside force.

Soft tissue injuries basically are comprised of what we call strain and sprain in most cases. In acute injury, strain refers to injury of a muscle or tendon in which the fibers of these tissues tear as a result of overstretch, or overload. In repetitive and postural stress injuries, or subacute injuries, strain is defined as pathological tissue reaction to prolonged stress, usually sustained overload from repetitive use, or maintaining postural positions that strain. In overuse injury that does not happen suddenly, with a strong trauma, which is called subacute, excessive cumulative loading leads to microtrauma, and often a chronic inflammatory response, as collagen is deformed under consistent low level overloading. The deformed collagen and inflammatory response leads to unwanted scar tissue and adhesion, which must be broken up and rehealed. The least elastic part of the muscle is the tendon, and the most frequent site of injury in muscle strain is the myotendonal junction. This part of the strain injury is called an enthesopathy, and must be treated by decreasing contractile tension with myofascial release, gently breaking up tissue lesions with active release technique, and increasing nutrient delivery to the tendon tissue with mobilization.

In most acute injuries with a chronic underlying tissue injury, we rarely see tendon inflammation, which accompanies acute rupture or tear, but instead see a degenerative tendon condition that is exacerbated by the acute injury. This is called a tendinosis. Chronic inflammatory problems with the joint capsule itself are common, and this is called arthritis, often affecting the lumbosacral and sacroiliac joints. The patient must understand that arthritis is a symptom, not a disease, although over 50 types of arthritic disease are classified, usually utilizing the term arthritis in the name, such as Rheumatoid arthritis. As we approach the subject of sensible treatment protocol for acute injury with underlying tissue problems, we must usually treat degenerated tendons and chronically inflamed joints. Although the term partial tendon tear is often used to describe tendon injuries viewed with MRI, many experts feel that this term has been routinely used to justify arthroscopic surgeries, and the the partial tendon tear is in actuality more rarely seen than degenerative tedoninosis. To correct underlying tendinosis and chronic arthritis, mechanical tension on these tissues must be reduced, tissue perfusion restored, stabilization of the joint must be accomplished, and proper joint mechanics must be taught to the patient. This involves myofascial release, neuromuscular reeduction, active release technique, and stimulation of the circulation and neural firing.

Sprain refers to injury to the ligament and joint capsule that is caused by stretch beyond their normal capacity, also involving tissue tears and other pathological reactions, such as the pulling of the tissues off of the bone attachment, and eventual degeneration of the cartilage and spinal discs. Often, chronic tissue injury underlies the acute strain and sprain injury, with calcified and degenerative arthritic tissues more susceptible to injury. If the past injuries were not treated with a thorough protocol, the possiblity of future reinjury is greatly increased. By taking a holistic and individualized approach to therapy, both the acute and chronic underlying tissue problems can be addressed to maximize successful outcomes. If the tissue tears are partial, or composed of many small tears in the tissues, surgical repair is usually unnecessary. This does not mean that the patient should do nothing to promote healing of these partial tissue tears and microtears, as well as other degenerative tissue problems that can lead to prolonged pain and dysfunction. Proper conservative care is needed. Decreased range of motion, weakness, and positional pain may all result from incomplete repair of strain and sprain injuries.

By first defining your injury as acute, subacute, chronic, or acute with chronic underlying conditions, you can better understand the individualized needs of your body in tissue healing, and choose the right therapeutic routine to promote quick and healthy healing. Often, repetitive and postural strain injuries occur insidiously, without an acute trauma. If you promote the best healing process in each individual case, you might be surprised to find that in many ways your body heals with new tissue that in some ways is stronger and healthier than what you had before. If you fail to promote the healing process intelligently, you may find yourself with chronic tissue adhesions and inflammation. If you approach your healing process intelligently, you might also develop new skills in maintaining tissue health that will stick with you and benefit you in the future. Time and money spent in proper healing from injury is an investment in your future health, and Complementary Medicine often provides the patient with a variety of protocols to promote healthy tissue regrowth, while standard medicine often is limited to diagnosis and prescription of palliative medication.

Of course, with strain and sprain injuries inside the pelvic girdle, direct tissue therapy is almost impossible, due to the fact that the pelvic floor muscles and tendons, along with the connective fascia, and chronic tissue adhesions and scar tissue, are covered by the bone of the pelvic girdle. Peripheral tissues, such as the gluteal and piriformis muscles, and the joint tissues of the lumbosacral spine and hips, can be directly worked on, but tissues within the pelvic girdle need to be addressed with neuromuscular reeducation and active release techniques. Some therapists do work on the tissues able to be reached from inside the vagina or rectum, but this is of limited benefit, and is of course problematic. A treatment utilizing acupuncture stimulation, soft tissue mobilization, myofascial release of the muscles outside the pelvic girdle, joint mobilization, and active release techniques with neuromuscular reeducation to the pelvic floor musculature, provides a thorough treatment of the pelvic pain syndromes.

The array of therapies available from the experienced Licensed Acupuncturist

The physiotherapies of Traditional Chinese Medicine, called TuiNa, address many of the needs of the tissues during the healing phases. Soft tissue mobilization stimulates new growth, gently breaks up adhesions, and increases circulation. One problem often encountered as injuries heal are contractures or shortening of the various tissues, especially the tendons. If the shortened tendon and muscle is left in an immobilized and shortened position, the outcome may be poor for regaining full range of motion. In the joint, ligament and capsule may regrow in a position that also restricts movement and range of motion. Gentle soft tissue mobilization will prevent this undesirable outcome. Active release techniques will gently break up the adhesions and tissue lesions near the joint. Myofascial release will reduce spasms and contracture, taking the pressure off of tendons, myotendinous junctions, and joint tissues that are difficult to heal. Neuromuscular reeducation will help the patient focus on the restoration of proper joint mechanics and postural stress, as well as targeted stretch and excercise that can be continued at home. Often, the continued use of improper body mechanics, with overuse of the crutch or cane, will cause more long-term problems than the injury itself, as improper body mechanics put unnatural stress on the healing tissues, itself a cause of strain and sprain.

Both acupuncture and herbal medicine offer great advantage to the overall protocol. Acupuncture may stimulate both local circulation and healing, as well as address better systemic health, and also treat underlying health problems that may impede the healing from injury. Studies have proven that electroacupuncture treatment speeds cellular growth and accelerates repair in tendon, ligament, and joint capsule tissues. Acupuncture also stimulates healthy pain relieving neurotransmitters, endorphins, dynorphins, and enkephalins, providing sustained pain relief to allow greater ease with therapeutic protocols. Both topical herbs and oral consumption have proven benefits in tissue repair. Herbal formulas address many aspects of tissue healing, and may be combined with various food nutrients, such as antioxidants, proteolytic enzymes, amino acids etc. Professional herbal companies continue to utilize the latest research to provide better formulas and higher quality products. Since this industry is not properly regulated, it is best to depend upon professional products from a Licensed Herbalist and Acupuncturist to achieve the most assured results.

Currently, there are no standard effective therapies for Pelvic Pain Syndromes and associated disorders, such as vulvodynia and chronic prostatitis, and acupuncture is being seriously explored and clinical trials are currently underway to treat these problems. For instance, the National Vulvodynia Association provided a research grant to Lee Hullender Rubin DAOM L.Ac., of the Oregon College of Oriental Medicine, in 2013, to conduct a controlled randomized human clinical trial of acupuncture and electroacupuncture to evaluate proof of efficacy to treat vulvodynia. In 2008, U.S. National Institutes of Health grants were awarded to Dr. John N. Krieger MD, of the University of Washington School of Medicine, Department of Urological Surgery, Seattle, Washington, U.S.A. and medical doctors at the University of Science in Malaysia, Hospital Pantai Mutiara, Metro Hospital, and Island Hospital in Penang and Kedah, Malaysia, to conduct randomized controlled human clinical trials of acupuncture to treat chronic prostatitis. The results, published in the American Journal of Medicine (2008; 121, 79.el-79.e8), concluded that "after 10 weeks of treatment, acupuncture proved almost twice as likely as sham treatment to improve Chronic Prostatitis / Chronic Pelvic Pain Syndrome symptoms. Participants receiving acupuncture were 2.4-fold more likely to experience long-term benefit than were participants receiving sham acupuncture."

The so-called sham acupuncture used in these RCTs consisted of just superficial needling located 15 mm to the left of the actual 4 acupuncture points used, with the real acupuncture inserted to proper depth and stimulated via classic needle manipulation to obtain de qi. As we see acupuncture treatment today, such so-called sham acupuncture should also provide significant benefits if indeed, as this study clearly showed, acupuncture stimulation does work for Chronic Pelvic Syndromes. Overall, 18 participants (of a total 89) experienced complete resolution of symptoms after 10 weeks, and 32 percent of acupuncture participants (of a total 44) reported long-term relief of symptoms 20 weeks after completing the therapy. In the classic acupuncture group, 73 percent of patients reported significant improvement. This clinical trial shows that a real course of real treatment with proper needle stimulation in a setting where patients are receptive, namely hospitals in Malaysia, produced significant treatment benefits, and while the so called sham acupuncture was indeed acupuncture treatment itself, and also provided benefit, the actual treatment with actual needle stimulation and obtaining of de qi, conducted for a usual course, i.e. 10 weeks of treatment, provided significantly more benefit than the so-called sham, or placebo. Such trials also demonstrate that the practice of acupuncture often seen in the United States, with superficial needling and little needle stimulation, is not as helpful in treatment as classic needling techniques. The fact that a significant number of patients experienced sustained symptom relief with just 10 treatments suggests that the remaining patients may benefit from further courses of acupuncture stimulation. In addition, integration of this acupuncture stimulation within a more thorough treatment protocol would certainly produce even better results. A knowledgeable Licensed Acupuncturist and herbalist, trained in soft tissue mobilization, or Tui na, may provide an array of therapeutic protocols combined in the same session. Since there are no workable therapies in standard medicine, this presents an encouraging treatment protocol, yet Medical Doctors are still loathe to recommend it. Other recommended therapies, such as Cognitive and Behavioral Psychotherapy, various stress reduction therapies, and even the promising transcutaneous electrical stimulation for chronic pain management could be integrated in the future to insure greater success.

Joint degeneration of the Lumbar vertebrae

A similar profile of degenerative joint conditions and unnecessary surgeries has been shown in large studies of lumbar spine pathologies. The New York Times article quotes Dr. Michael Modic, chairman of the Neurological Institute at the Cleveland Clinic, who scanned hundreds of study participants with MRI and concluded that as many as 60 percent of healthy adults with no back pain have degenerative conditions in their spines, and that between 20 and 25 percent that receive MRI studies of the lumbar have herniated or bulging discs. Dr. Modic states that one-third of these herniated or bulging discs disappear in six weeks when repeat MRI studies were performed, and about two-thirds disappear in six months. His study found no definitive correlation between worsening disc bulging, resolving disc bulging, and symptoms. He recommended that a person with low back and leg pain should be treated conservatively for at least eight weeks before considering surgery, and that MRI scans should be used as a presurgical tool, and not as a definitive diagnosis suggesting surgical correction.

Unfortunately, we live in a culture that wants a quick fix, and patients usually look at their situation as a choice between one type of therapeutic agent or regimen versus another. This will result in failure in the majority of cases. The successful approach utilizes a variety of agents and therapies to accomplish all 3 of the above goals, namely pain relief, elimination of the causes and contributors to tissue degeneration, and restoration of healthy tissues. By trying to choose a simplistic treatment approach, rather than a comprehensive treatment protocol, the patient is usually prolonging their suffering and at best will only slow the degenerative process. Surgery may be necessary, and may clean up some of the problems with unhealthy tissues, but without a comprehensive treatment plan, degenerative conditions will recur and continue to cause pain down the road. Even with less invasive lumbar surgery, there is no alternative to a comprehensive protocol of restoration of the whole low back and pelvic region when these degenerative diseases occur. A comprehensive holistic approach that integrates Complementary Medicine and Licensed Acupuncturists and herbalists, or TCM physicians, that combine needle stimulation, herbal and nutrient medicines, and various direct physiotherapies, or Tui na, in the same therapeutic session, is sensible for all cases of lumbar and lumbosacral degenerative joint diseases.

In many patients, the same vascular pathology that worries them about risk of future cardiovascular problems also contributes to the spinal degenerative condition. In the medical text, Myelopathy, Radiculopathy, and Peripheral Entrapment Syndromes by David Durrant, and Jerome True, the authors state: "Many of the patients that develop degenerative stenosis fall into the same age group at risk for acquiring cardiac and peripheral vascular disease. Some of these individuals may also have a coagulation disorder from disease or from therapeutic intervention (blood thinners). Clinicians who identify cardiac, vertebral, and/or aortic diesase should pay attention to the possibility of a history suggestive of an undiagnosed intermittent myelopathic (spinal cord) presentation." The arteries run alongside the nerve roots, spinal cord, and supply the needed nutrients to maintain the vertebral discs and lamina. Attention to vascular health should be part of the therapeutic protocol for degenerative lumbar conditions.

Much scientific research is devoted to understanding the underlying health problems leading to secondary osteoarthritis, or degenerative joint disease. The National Institutes of Health estimates that 18.2% of the U.S. population will have some form of arthritis or rheumatic condition by 2020. Osteoarthritis is the most common form of arthritis, affecting 12.1% of U.S. adults in 1998, and was the second most common diagnosis in the population. It is estimated that 80% of the aging population will experience secondary osteoarthritis. Research reveals that this slowly developing degenerative condition is likely related to a syndrome of anabolic dominance leading to an eventual catabolic excess. Anabolism is the metabolic construction of complex molecules in our tissue which is balanced with catabolism, the breaking down of complex molecules in the tissues to resupply energy and the building blocks of larger molecules. This process is stimulated and regulated mainly by hormones and the endocrine feedback system. In TCM terminology, this would be referred to as a balance of Yin and Yang, with anabolism being a yang process balanced by the bioavailability of catabolic yin nutrients and energy. When this balance is dysfunctional, a gradual disease process occurs leading eventually to Osteoarthritis.

The anabolic hormones include insulin and insulin-like growth factors, testosterone, estradiol, and growth hormone. When we have problems with hormonal balance and insulin resistance, or relative excess of estrogen from progesterone deficiency, we may develop anabolic dominance. Excess adrenal stress that is chronic may not only stimulate high blood pressure, but excess androgens and testosterone. Testosterone may aromatize to estradiol in our tissues, or to dehydroepiandosterone, and stimulate breast tumors, prostate hypertrophy, and other tissue abnormalities. In a similar way, these hormones play a significant role in tissue repair and maintenance, and imbalances may lead to degenerative arthritic conditions. Insulin resistance and anabolic dominance may lead to metabolic syndrome and inability to lose weight from the midsection, high cholesterol and poor cardiovascular maintenance. Such syndromes of imbalance lead to poor inflammatory regulation and tissue remodeling, and eventually degenerative joint disease is discovered, often too late to fully correct. The smart patient will seek help to prevent these problems be utilizing preventative medicine and TCM. The knowledgeable TCM physician can test for your hormonal profile, look at the circadian rhythms of cortisol imbalance, and gradually correct the Yin and Yang of hormonal imbalances that lead to degenerative disease. TCM may thus be a valuable Complementary Medicine in prevention of osteoarthritis as well as a comprehensive treatment strategy.

Achieving pain relief with medication does not mean that the degenerative condition is resolved, and when the patient focuses only on pain relief as a measure of success, this success is usually temporary. Dependence on pain relieving medication can be very harmful to the health and create other serious problems, such as stomach and gastrointestinal problems, and cardiovascular inflammation. A whole treatment protocol, directed by a competent physician, utilizing physiotherapy, patient instruction, acupuncture, herbal prescription, dietary supplements and changes, and correction of postural mechanics is effective, especially when the physician, who is a Licensed Acupuncturist, identifies contributing health problems and addresses these as well. The ultimate benefits of this comprehensive approach are many, and the patient will emerge with not only pain relief, but lasting tissue health, a healthier daily routine, and decreased risk of serious health problems related to aging.

Popular supplements and herbs are frequently advertised with exaggerated claims and give the patients false hope. Prescription of herbal formulas and nutriceuticals by a Complementary Physician with a Medical License and education in herbal medicine, and utilizing professional products, will be much more effective. Along with the proper herbal formulas, acupuncture and physiotherapy, there are a variety of specific herbs and supplements of use. These products are usually helpful but are not a cure by themselves, and quality varies considerably between products due to the lack of regulation by the FDA. Professional products insure quality control, and these are available only to the Licensed herbalist. Here are the facts on some of the popular therapeutic aids available to the public:

Oral Glucosamine supplement: studies show that oral glucosamine had no effect of increasing glycosaminoglycan content when the cartilage was normal, but had some mild beneficial effect if the cartilage was in a rebuilding phase. Rebuilding cartilage has a much increased demand for glucosamine. Studies show that rates of collagen repair in the cartilage & meniscus were not affected by the amounts of oral glucosamine or injected glucosamine. These studies point to the fact that the patient must improve the body's response to tissue repair in order to utilize the glucosamine supplement, and then this supplement will be effective. Thus, oral glucosamine, or glucosamine delivered locally to the tissue, in the form of topical agents or injections, will benefit only as part of a program that improves the overall tissue repair response. In patients that have no rebuilding of cartilage or meniscus, the glucosamine supplement is a waste of money. When the patient utilizes a complete conservative care treatment plan with passive soft tissue mobilization, gentle breaking up of tissue adhesions, and various stimulation techniques, the cartilage goes into a rebuilding phase, and the glucosamine is utilized fully (refer to PubMed PMID: 12355498)

Cartilage extracts with Matrix Proteins: sharks cartilage and bovine cartilage extracts have been available for some years. In many cases of degenerative joint problems, these have been ineffective. Studies that looked at patients with autoimmune cartilage diseases such as Rheumatoid Arthritis and Polymyalgia Rheumatica showed that these supplements could be useful to modify the course of the disease. The studies showed little effect in cases where the degeneration or joint inflammation was induced by medication side effect. The effectiveness of the cartilage protein extracts was linked to the immune stimulation of proteoglycan synthesis, and thus, concurrent use of immune stimulants or modifiers that enhanced interleukin or other cytotoxic immune response could greatly improve the effect. Once again, alone, these supplements may not benefit, but integrated logically into a treatment plan, they may have dramatic results for the right patients.

Collagen extracts and antioxidants: when the joint is receiving physiotherapy, with gentle breaking of chronic adhesions and improved circulation, there is a great need for large amounts of collagen in joint tissue repair. Studies show that the tissues may need up to 80 times the normal supply of collagen. Along with this nutrient material, antioxidants are required to help with clearing of dead tissues and debris. I use Health Concerns Collagenex to supply usable collagen type 2 (glucosamine, chondroitin etc.) derived from compatible tissue extracts from the chicken. Perhaps the most beneficial joint tissue antioxidant is derived from the whole pomegranate fruit, rind and seed, which is proven to be a potent tissue antioxidant, and is available from Health Concerns as well as Pomagranex. I also utilize a topical herbal cream that delivers glucosamine and chrondroitin with the carriers MSM and emu oil, so that these nutrients can get to the tissues directly. When used within the course of physiotherapy, this combination can benefit greatly. A study at Harvard University School of Medicine by Dr. David Trentham found significant improvement in rheumatoid arthritis patients with the use of low dose collagen type 2 extract derived from chicken tissue for 3 months, with the effects attributed to both increased collagen supply and an inflammatory modulating effect on cytokines. Further research at Harvard found that a patented coating on the supplement helped to deliver more bioidentical collagen type 2 to the affected joints. Further studies proved that this healthy collagen also benefited degenerated joints in cases of osteoarthritis. Since a purified type II collagen extract is needed, many collagen supplements on the market are insoluble and insufficient, and may be broken down by the body before reaching the affected joint. A professional and proven product such as Health Concerns Collagenex 2 is recommended, and concurrent phyiotherapy and acupuncture stimulation while taking these supplements insures that the circulation to the affected joint tissues is optimum for the delivery of this important nutrient supplement and antioxidant.

Maca and Cat's Claw: studies have shown significant benefit for cartilage repair with the use of these herbs. Of course, cartilage cells, or chondrocytes, will not regrow until manually stimulated. Studies have also shown that chondrocytes will regrow when the tissue is stimulated with gentle cross-fiber massage, or if this is not possible, with passive joint mobilization techniques and electrical stimulation. Studies showed enhanced mRNA (insulin like growth factor or IGF) expression and production in human chondrocytes when joint mobilization was utilized, and certain herbal chemicals have shown efficacy in promoting insulin like growth factor as well. For example, the Chinese herb Scutellaria barbata (Ban zhi lian) has been shown to beneficially modulate IGF expression via a number of herbal chemical constituents, including baicalin, berberine, resveratrol, luteolin, and apigenin. Such beneficial chemicals have now become well known and promoted as individual nutrient medicines, but are what makes up the balanced array of chemistry in this herb. Various Chinese herbs that are commonly used provide regulation and promotion of healthy growth and maintenance of joint tissues.

Gotu Kola: this herb has also demonstrated significant benefit in regrowth of joint tissues and cartilage. Chemicals act on collagen formation, anti-inflammatory activity, and antioxidant clearing. Amino acids and triterpenoids in Gotu Kola are considered to be essential to tissue healing. If there is a problem with varicosities or veinous insufficiency, combine this with Butcher's broom and Stone Root (Formula V).

Amino acids: certain amino acids are essential for repair of soft tissue such as ligament and tendons. L-Arginine, L-Lysine, L-Leusine and L-isoleucine are all effective, and should be combined with Vitamin B6 (P5P) to increase utilization. The olympic swimmer Dara Torres claimed that an amino acid formula was extremely helpful in healing her tissues and helping her get to another Olympic tournament at age 41.

Manganese or Manganese SOD: manganese deficiency has been shown to be a significant factor in many cases of degenerative cartilage. Manganese deficiency results in the poor utilization of chondroitin, glucosamine and other mucopolysaccharides in the normal repair and maintenance of cartilage. Manganese SOD (super oxide dismutase) is a combination of a potent antioxidant with manganese, and thus may aid cartilage repair even more. This supplement is hard to find, but essential mineral supplements contain manganese and will help the body to create this potent antioxidant chemical.

Proteolytic enzymes: Serratiopeptidase and Seaprose-S are two researched enzymes that help clear the rebuilding tissues and are proven to aid in both cartilage repair and decrease in chronic joint pain with a long course of use. Nattokinase is also a potent proteolytic enzyme proven potentially useful to clear fibrins and promote healthy tissue regeneration.

Pomegranate extract with seed oil and polyphenol antioxidants enhanced by fermentation: a study by the Case Western Reserve University School of Medicine, published in the September 2005 issue of the Journal of Nutrition, demonstates that a properly prepared concentrated extract of pomegranate exherts significant antioxidant and anti-inflammatory properties, such as the inhibition of interleukin 1b, which plays a key role in cartilage degeneration in osteoarthritis. Utilizing a professional extract is important to insure quality and effectiveness.

Boron and Vitamin D3: boron along with activated vitamin D3 hormone may increase cartilage formation. Boron helps regulate calcium metabolism and helps activate estrogen and vitamin D3, as well, preventing tissue calcification and aiding tissue repair. Food sources of boron include dates, raisins, prunes, almonds, hazelnuts and honey. Like many individuals, you may be deficient in activated vitamin D3, which is a hormone activated by exposure to sunlight on circulating D3. A simple blood stick test is available to determine D3 deficiency. Daily exposure to sunlight on the face and arms for 10 minutes insures activation, and so a midday walk in the sun is helpful. Exposure through glass in the car or office is not effective. You might take a cholecalciferol D3 supplement as well as chelated boron supplement combined with amino acids to aid utilization. Current study on boron supplementation is insufficient to definitively confirm that boron supplementation will treat arthritic conditons. Vitamin D3 is not really a vitamin, but rather a prohormone. D3 cholecalciferol is created daily in your body by exposure to sunlight, health cholesterol metabolism, and minimally from food sources. This cholecalciferol goes to the kidney to produce hormone D3. Two types of D3 hormone are known to science, and recent research has found that one isomer is integral to cartilage remodeling, regulating the basement membrane of the cartilage near the bone, and may be responsible for successful cartilage remodeling and repair. Since D3 hormone is tightly regulated in your body, not only supplementation with cholecalciferol and increased midday sun exposure is recommended, but also treatment to correct hormonal imbalances and improve the functions of the kidney and liver metabolism. Studies show that a high percentage of the population is deficient in D3. Utilize a holistic medical regimen to best advantage when taking these supplements.

Information Resources / Additional Information and Links to Scientific Studies

  1. The Cleveland Clinic, one of the most respected hospitals in the United States, gives a good standard description of "sciatica", which most often involves no direct sciatic nerve pathology, but a secondary irritation of the sciatic nerve, sometimes episodically, as in piriformis syndrome: http://my.clevelandclinic.org/disorders/sciatica/hic_what_is_sciatica.aspx
  2. A comprehensive report on scientific research of Piriformis Syndrome, and its many causes and complications, is presented here by the University of Split School of Medicine, V. Grgic of the Laboratory for Pain Research, in Croatia. This 2013 overview of the complex nature of Piriformis Syndrome shows that this is not a new disorder, first clarified in 1947, and outlines the many potential aspects and health problems that may be found in these syndromes, causing or perpetuating Piriformis Syndrome. The array of nerves that are potentially affected by piriformis impingement and irritation are also explained, showing succinctly how the confusing array of symptoms are caused by Piriformis pathology. This doctor also notes that treatment for Piriformis Syndrome must be comprehensive, and that acupuncture and physiotherapy is included in such evidence-based therapy : http://www.ncbi.nlm.nih.gov/pubmed/23607175
  3. An August 1, 2011 article in the New York Times Personal Health section describes how a prominent medical doctor in New York, Dr. Loren Fishman, a physiatrist at New York Presbyterian and Columbia hospital, utilizes trigger point needling and adapted yoga stretches and exercises to effectively cure patients in his practice. The article describes how the standard medical community frowns on this practice of treating without drugs, surgery or standard physical therapy when possible, but how effective this has been for his patients: http://www.nytimes.com/2011/08/02/health/02brody.html
  4. A report by the Justus-Leibig University Polyclinic for Urology in Giessen, Germany, pointed out that the diagnosis of Benign Prostate Hyperplasia is a mulitfactorial pathology with a number of classifications, including non-bacterial prostatitis (commonly now called Chronic Pelvic Pain Syndrome, or CPPS), and that the patient population should be aware that standard medicine has little to offer therapeutically: http://www.ncbi.nlm.nih.gov/pubmed/?term=19568373
  5. The Feinberg School of Medicine at Northwestern University in Chicago, Illinois, in 2006, did a thorough review of the clinical data on benign prostatic hypertrophy in the United States, and found that 90-95% of cases appeared to fit the description of non-bacterial chronic prostatitis, now referred to by many as Chronic Pelvic Pain Syndrome: http://www.ncbi.nlm.nih.gov/pubmed/16409145
  6. A 2015 randomized controlled study at the Dankook University College of Medicine, in Cheonan, South Korea, showed that the presence of chlamydia infection in men with pelvic pain syndrome significantly increased the level of chronic pain, as well as white blood cell counts, and impacted quality of life. Chlamydia trachomatis is a common bacterial infection passed via sexual contact, often untreated when the symptoms are mild, and is now accurately diagnosed with PCR and nucleic acid amplification tests (NAAT): http://www.ncbi.nlm.nih.gov/pubmed/25733268
  7. A 2010 study at Wuhan First Hospital, in Wuhan, China, found that a chemical in the Chinese herb Scutellaria baicalensis (Huang qin), called baicalin, effectively inhibits Chlamydia infection and growth in human tissues. Baicalin has also been shown to enhance the effectiveness of standard antibiotics: http://www.ncbi.nlm.nih.gov/pubmed/19637113
  8. A 2015 review of standard treatment for one type of Chronic Pelvic Syndrome, termed Pelvic Congestion Syndrome, by surgeons at the University of Washington, Seattle, Washington, U.S.A. notes that common treatment recommendations, such as pharmacological drugs to suppress ovarian function (contraceptive hormones in IUDs, newer oral contraceptives, or such drugs as Lupron), hysterectomy, and ovarian vein resection, are not sensible, especially as ovarian vein resection with transcatheter embolization, a much less invasive procedure, has proven effective when this specific vascular congestive syndrome is diagnosed with MRI, and should be tried, although up to 32 percent of these patients in various studies do not obtain substantial relief from the procedure. Clearly, the standard treatment of such Chronic Pelvic Pain Syndromes has been wrong in standard care, and integration of less harsh treatments, integrated with a more comprehensive Complementary and Integrative Medicine protocol, is needed: http://www.ncbi.nlm.nih.gov/pubmed/25729071
  9. A review of diagnosis and treatment of Male Chronic Pelvic Pain Syndromes by Temple University, in Philadelphia, Pennsylvania, U.S.A in 2013 found that frequently we see such comorbid conditions associated as Irritable Bowel Syndrome, Fibromyalgia, and Chronic Fatigue Syndrome, as well as evidence of autoimmune disorder and chronic inflammatory disorders of the central nervous system. These experts found that while the treatment options are few in standard medicine, that acupuncture and pelvic floor myofascial release and neuromuscular reeducation appear to be good therapeutic options, as well as a more holistic treatment protocol to address the individual comorbid conditions : http://www.ncbi.nlm.nih.gov/pubmed/24080807
  10. A 2007 meta-analysis of chronic male groin pain syndromes, by Per Holmich of the Amager University School of Medicine, in Copenhagen, shows that many studies confirm that a high percentage of patients present with multiple tissue pathologies and more than one disease, and need a more multedisciplinary approach to treatment. In 50 percent of patients presenting with chronic groin pain syndromes related to athletic activity, chronic prostatitis or hernia were found to be causing or complicating the pain syndrome. Too often, a quick assessment results in catch-all diagnoses, such as osteitis pubis, to explain these pelvic pain syndromes, this author states: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658954/
  11. A 2016 meta-analysis of all published scientific studies of acupuncture integrated into the treatment of chronic prostatitis, by experts at the National Yang-Ming University School of Medicine, in Taipei, Taiwan, concluded that acupuncture is proven to work and has better efficacy than standard treatment with antibiotics, anti-inflammatory drugs or alpha-adrenergic blockers. Incorporating acupuncture into the holistic treatment protocol for pelvic pain syndrome in male patients offers yet another benefit, and can be easily combined with myofascial physiotherapy, trigger point needling, herbs and nutrient medicines to achieve a variety of treatment goals: http://www.ncbi.nlm.nih.gov/pubmed/26741647
  12. A 2011 study by experts at the University Ray Juan Carlos School of Medicine, in Madrid, Spain, found that syndromes of fibromyalgia, often occurring with chronic pelvic pain syndromes, involved a widespread set of active myofascial trigger points that induced a hypersensitivity, and a denervation supersensitivity seen in chronic myofascial pathology. The persistence with treatment that involves myofascial release techniques and trigger point needle stimulation, as well as neuromuscular reeducation techniques, may be an important part of the integrated treatment protocol for these difficult syndromes of pain and dysfunction: http://www.ncbi.nlm.nih.gov/pubmed/21368661http://www.ncbi.nlm.nih.gov/pubmed/21368661
  13. The prestigious Johns Hopkins University School of Medicine wrote in 2002 that Chronic Pelvic Pain Syndromes were not being addressed diagnostically or in treatment for a majority of patients due to the lack of objective tests and lack of knowledge of the clinical characteristics by health providers. The treatment recommendations, though, are limited to symptomatic pain management in standard medicine. : http://www.ncbi.nlm.nih.gov/pubmed/12474033
  14. A 2015 randomized, controlled human clinical trial of 100 patients diagnosed with chronic prostatitis and chronic pelvic pain syndrome (CP/CPPS), at the Trakya University School of Medicine, in Edime, and the Bakirkoy Dr. Dadi Konuk Training and Research Hospital, in Istanbul, Turkey, found that acupuncture significantly improved pain scores, which were sustained 8 weeks after the short course of acupuncture. 92 percent of the patients that received real acupuncture stimulation noted a decrease in pain of greater than 50 percent, while only 48 percent of those receiving "sham" acupuncture noted this relief from points needled adjacent to the "real" points. This study definitively shows that acupuncture works in almost all patients: http://www.ncbi.nlm.nih.gov/pubmed/25939517
  15. A 2015 randomized, controlled human clinical trial of 54 patients diagnosed with chronic prostatitis and chronic pelvic pain syndrome (CP/CPPS), at the Umraniye Teaching Hospital, in Istanbul, Turkey, showed that a short course of acupuncture outperformed standard therapy with antibiotics and NSAIDs, with sustained benefits at an average of 28 weeks after the acupuncture treatment. The measures of pain, urinary symptoms, quality of life measures, and NIH Chronic Prostatitis Symptom Index score were all improved much more than this standard therapy: http://www.ncbi.nlm.nih.gov/pubmed/25582816
  16. A 2016 meta-analysis of all high-quality randomized controlled human clinical trials of acupuncture integrated into treatment for pelvic pain syndrome and chronic prostatitis, by experts at the National Yang-Ming University in Taipei, Taiwan, concluded that significant evidence exists for integration of short courses of acupuncture in this treatment protocol: http://www.ncbi.nlm.nih.gov/pubmed/26741647
  17. A 2014 randomized, controlled human clinical study of the effects of acupuncture in the treatment of chronic prostatitis and chronic pelvic pain syndrome (CP/CPPS), at the University of Washington School of Medicine, in response to a number of clinical studies that demonstrated significant benefits from a short course of acupuncture, found that 67 percent significantly benefited from the treatment with a high degree of pain relief, and that the "real" acupuncture group measured a 5 percent increase in NK cells and a significant reduction in white blood cell parameters, supporting the theory that the acupuncture stimulation resulted in improved immune responses: http://www.ncbi.nlm.nih.gov/pubmed/25453515
  18. Underlying health problems should be addressed to facilitate better tissue healing and pain reduction. This National Institute of Health study outlines how deficient estrogen syndromes increases pain perception and decreases tissue healing in women: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1808228/
  19. Research published in 2014, from experts at the Oregon Health and Science University, in Portland, Oregon, U.S.A. found that in premenopausal women with a diagnosis of Primary Provoked Localized Vulvodynia (vaginal pain), tissue biopsies show that recruitment of CD4-positive T cells are highly associated with this disease symptom, indicating that low grade infections, allergic reactions, and/or autoimmune triggers are involved in most of these pathologies: http://www.ncbi.nlm.nih.gov/pubmed/24633162
  20. A 2015 multicenter study at Ohio State University, the University of Wisconsin School of Medicine, and the Case Western Reserve University School of Medicine showed that there is a definitive autonomic nervous system involvement in pelvic pain syndromes with interstitial cystitis (chronic urinary bladder low-grade infection) in women, but not in women diagnosed with just a pelvic floor myofascial pain syndrome. This diagnosis was achieved by studying the ECG readings of the heart rate variance while the patient was lying down for 10 minutes. Such diagnostic tests may help differentiate pelvic pain syndromes and guide holistic therapy better in the future: http://www.ncbi.nlm.nih.gov/pubmed/25963185
  21. A multicenter study in China and Norway, at the University of Bergen School of Medicine, in Bergen Norway, and Southern Medical University, in Guangzhou, China, found that acupuncture stimulation at just one point, HT7, did modulate the autonomic neural regulation of the heart rate, showing that indeed acupuncture stimulation does affect the autonomic nervous system:http://www.ncbi.nlm.nih.gov/pubmed/25476448
  22. A 2005 controlled study of vulvar vestibulitis syndrome (vulvovestibulodynia), or syndromes of painful sexual intercourse (dyspareunia), at Queen's University, in Ontario, Canada, matched 14 women with this diagnosis with 14 controls of the same age and use of contraceptive method, finding that sensory sensitivity to mild or moderate pressure, with pain or unpleasant sensation, to the posterior aspect of the vulvar vestibule (inner vaginal labia where the urethra and vaginal opening occur together), occurred in all patients with this condition, and none of the control patients. These researchers found increased pain signals elicited in the insular and frontal cortices in these women, showing that sensory processing was similar to that observed in the study of hypersensitivity syndromes such as fibromyalgia, IBS, and neuropathic pain syndromes: http://diabetes.niddk.nih.gov/dm/pubs/diagnosis/
  23. A multicenter study of the effects of a single acupuncture point, ST36, on the insula and somatosensory cortex in the brain, compared to non-acupuncture points on 2 different dermatomes, by research centers at the Universities of Berlin and Humbolt in Germany, the Max Planck Institute, the Massachusetts General Hospital (associated with Harvard Medical College), the Chengdu University of TCM in China, and Logan University in Missouri, USA, found that this stimulation both increased activity in these areas of the brain profoundly over so-called placebo acupuncture, but also exerted significant modulating effects to restore homeostasis in pain sensory processing: http://www.ncbi.nlm.nih.gov/pubmed/25741269
  24. Research published in 2014, from experts at the University of Kansas Medical Center, Kansas City, Kansas, U.S.A. noted the prevalence of reports of a history of childhood neglect or abuse in patients later experiencing Vulvodynia and Vulvovestibulodynia, and conducted an objective experiment to find a central association. This study found that in study animals subjected to neonatal maternal separation, that anxiety disorders, Irritable Bowel Syndromes with colorectal hypersensitivity, and increased vaginal hypersensitivity were evident in these subjects. Measurable changes occurred centrally and peripherally with vaginal distention, with negative regulation of the hypothalamus pituitary adrenal axis, mainly in the hypothalamus and hippocampus, affecting mechanical and thermal sensitivity at peripheral nociceptors, and locally, corticotropin-releasing factor (adrenal) receptors were affected both in the vaginal tissues and tissues of the bladder and colon. This study shows that both central and peripheral changes, affected by psychological history, may drive the changes in vaginal sensitivity that create Vulvodynia and Vestibulovulvodynia. Numerous studies with fMRI now show that specific electroacupuncture and classical needle manipulations affect these regions of the brain with beneficial modulation, and also affect the degree of pain sensitivity with thermal and mechanical stimulation of peripheral nociceptors (pain receptors in peripheral nerves): http://www.ncbi.nlm.nih.gov/pubmed/24462609
  25. A 2011 meta-review of scientific studies of acupuncture to treat Chronic Pelvic Pain Syndrome and Chronic Prostatitis, at the Kyung Hee University Medical School, in Seoul, South Korea, concluded that increasing evidence shows that acupuncture is a safe and effective treatment for Chronic Pelvic Pain Syndrome, but that it is still ranked as a low-priority treatment, mainly due to the fact that valid studies had not employed standard study design and outcome measures, and were thus not published in Western or standard medical journals: http://www.ncbi.nlm.nih.gov/pubmed/21472420
  26. A 2015 randomized controlled study of acupuncture to treat Pelvic Pain Syndrome and Chronic Prostatitis, at the Umraniya Teaching Hospital, in Instanbul, Turkey, found that a simple course of 14 treatments, over 7 weeks, at just 2 points, UB32 and UB33, with electroacupuncture, significantly reduced pain, urinary symptoms, and improved quality of life measurements, with an average follow-up of sustained effects at 28 weeks: http://www.ncbi.nlm.nih.gov/pubmed/25582816
  27. A 2013 study at Wannan Medical College in Wuhu, China, found that electroacupuncture stimulation at just 2 points, ST36 and DU20, down-regulated the effects of neural nitric oxide synthase nNOS in the hippocampus of study animals subjected to post-traumatic stress disorder (PTSD), offering one objective explanation for the positive benefits obtained by electroacupuncture in treating PTSD, now widely used by the U.S. military: http://www.ncbi.nlm.nih.gov/pubmed/24032201
  28. A 2013 study at Shanghai Medical College of Fudan University, Shanghai, China, showed that electroacupuncture stimulation at just 2 points, ST36 and SP6, was able to modulate the hypothalamus and hippocampus, as well as the corticotropin-releasing factor protein messengers, to shorten recovery time in animals post-surgically and reduce this stress: http://www.ncbi.nlm.nih.gov/pubmed/24308183
  29. A 2014 study at the University of British Columbia, Vancouver, BC, Canada, found that, due to the chronicity of Provoked Vulvar Pain syndromes, or Vulvodynia, that 73 percent of male partners in the relationship reported a negative impact on the psychological and sexual aspects of the relationship, reporting poorer sexual communication and erectile function, and less sexual satisfaction in their relationship compared to controls. This study suggests that inclusion of the male partner into the therapeutic protocol may be important and helpful, and this often embarrassing and stressful condition needs a broader understanding within the relationship to reduce stress and anxiety and facilitate a recovery. http://www.ncbi.nlm.nih.gov/pubmed/24612656
  30. A 2014 study at the University of Montreal, Quebec, Canada, suggests that for couples in which the woman suffers from Provoked Vestibulodynia, often creating pain with sexual intercourse, and part of a Pelvic Pain Syndrome, that working on less ambivalence in the emotional regulation and expression of both partners in the relationship may be important to the modulation of the symptoms, occurrence of depression and anxiety, and sexual satisfaction and function. The level of pain intensity was not affected by the level of emotional ambiguity in the relationship, but these other outcome measures were: http://www.ncbi.nlm.nih.gov/pubmed/24548305
  31. A NY Times Health article on recent evidence supporting conservative care with meniscus tears points to the growing realization that Complementary Medicine should be integrated into rehabilitation injured and degenerating tissue disorders. http://www.nytimes.com/2008/12/09/health/09scan.html?partner=rss
  32. In 2006, pharmaceutical research in Japan found that a common Chinese herb used to treat tissue injury, Boswellia, or frankincense, contained 17 chemicals with marked anti-inflammatory activity: http://www.ncbi.nlm.nih.gov/pubmed/16621377
  33. In 2009, research at the National University of Singapore measured the in vitro and in vivo collagen-induced anti-platelet and anticoagulant effects of Panax notoginseng in animal studies, and found that the effects were greater than aspirin. These are just two of the many beneficial effects of the various chemicals in this herb: http://www.sciencedirect.com/science
  34. Harvard Medical University conducted a double-blind placebo human trial of collagen type 2 extract derived from chicken tissues and found a significant benefit in tissue healing in patients with rheumatoid arthritis: http://www.chickencartilage.com/harvardstudy/
  35. Environmental Health Perspectives gives a peer-reviewed in depth analysis of the benefits of boron supplement at http://www.ehponline.org/members/1994/Suppl-7/newnham-full.html
  36. Serratiopeptidase is clearly explained at http://www.purebodysolutions.com/Merchant2/graphics/00000001/PDF/serratiopeptidase.pdf
  37. Hyaluronic acid injections are not the same as prolotherapy; a large randomized trial in France was completed in 2008 and showed no benefits: http://www3.interscience.wiley.com/journal/122220639/abstract?CRETRY=1&SRETRY=0
  38. A 2009 article in the New York Times outlines current research that shows that platelet-rich plasma injections found in rigorous study to provide no better healing than saline injections, and that steroid injections provide temporary benefit, but do not change long-term outcomes of pain and disability. : http://www.nytimes.com/2010/01/13/health/13tendon.html?ref=health
  39. A 2001 study by the Univerisidad Nacional in Lima, Peru, demonstrate that Cat's Claw, or other species of Uncaria, had proven beneficial effects on human study participants with osteoarthritis of the knee, both reducing pain and with antioxidant and anti-inflammatory mechanisms, especially the inhibition of TNFalpha: http://www.ncbi.nlm.nih.gov/pubmed/11603848
  40. A 2009 NY Times article reveals manipulation of FDA approval of new biologic surgical devices: http://www.nytimes.com/2009/09/25/health/policy/25knee.html
  41. Medicare guidelines for treatment of bone fracture are described, and the evidence for use of pulsed electrical stimulation is presented: http://lobby.la.psu.edu/