Prolotherapy injections, saline injections, and exercises for chronic low-back pain: A randomized trial

Objectives. To assess the efficacy of a prolotherapy injection and exercise protocol in the treatment of chronic nonspecific low back pain. Design. Randomized controlled trial with two- by- two factorial design, triple- blinded for injection status, and single- blinded for exercise status. Setting. General practice. Participants. One hundred ten participants with nonspecific low- back pain of average 14 years duration were randomized to have repeated prolotherapy ( 20% glucose/ 0.2% lignocaine) or normal saline injections into tender lumbo- pelvic ligaments and randomized to perform either flexion/ extension exercises or normal activity over 6 months. Main outcome measures: Pain intensity ( VAS) and disability scores ( Roland- Morris) at 2.5, 4, 6, 12, and 24 months. Results. Follow- up was achieved in 96% at 12 months and 80% at 2 years. Ligament injections, with exercises and with normal activity, resulted in significant and sustained reductions in pain and disability throughout the trial, but no attributable effect was found for prolotherapy injections over saline injections or for exercises over normal activity. At 12 months, the proportions achieving more than 50% reduction in pain from baseline by injection group were glucose- lignocaine: 0.46 versus saline: 0.36. By activity group these proportions were exercise: 0.41 versus normal activity: 0.39. Corresponding proportions for > 50% reduction in disability were glucose- lignocaine: 0.42 versus saline 0.36 and exercise: 0.36 versus normal activity: 0.38. There were no between group differences in any of the above measures. Conclusions. In chronic nonspecific low- back pain, significant and sustained reductions in pain and disability occur with ligament injections, irrespective of the solution injected or the concurrent use of exercises.

The nature of anterior knee pain following injection of hypertonic saline into the infrapatellar fat pad

The infrapatellar fat pad has been implicated as a possible source of anterior knee pain. This study examined the nature, distribution and time-course of experimentally induced pain in the infrapatellar fat pad. Hypertonic saline (5%) was injected into the medial fat pad of 11 healthy individuals with no history of knee pain. Severity of pain was assessed at rest and during activity using an 11 point numerical rating scale (NRS) at regular intervals over 15-30 min following injection. Participants described the size of the pain region from a series of different sized circles while the area and type of pain was established from a body chart and the McGill pain questionnaire. The effect of pain on temperature-pain threshold and sensory thresholds of the anterior knee was assessed. Participants generally reported a deep aching pain that peaked in severity around 3 min and gradually declined over 15 min. Pain levels were not altered by clinical manoeuvres designed to impinge the fat pad. The size of the pain region was related to pain intensity. Pain was most commonly felt in the region of the fat pad medial to the patella, although some individuals reported proximal referred pain as far as the groin region. Thermal and sensory thresholds were not altered at a region close to the injection site during the experimental pain. These results suggest that nociceptive stimulation of the infrapatellar fat pad may cause anterior knee pain that is not necessarily confined locally particularly if pain is severe. This has implications for the investigation of pathological structures in patients presenting clinically with anterior knee pain and provides an experimental model of anterior knee pain. (C) 2003 Orthopaedic Research Society. Published by Elsevier Ltd. All rights reserved.

The use of hypertonic saline for treating intracranial hypertension after traumatic brain injury

The past decade has witnessed a resurgence of interest in the use of hypertonic saline for low-volume resuscitation after trauma. Preliminary studies suggested that benefits are limited to a subgroup of trauma patients with brain injury, but a recent study of prehospital administration of hypertonic saline to patients with traumatic brain injury failed to confirm a benefit. Animal and human studies have demonstrated that hypertonic saline has clinically desirable physiological effects on cerebral blood flow, intracranial pressure, and inflammatory responses in models of neurotrauma. There are few clinical studies in traumatic brain injury with patient survival as an end point. In this review, we examined the experimental and clinical knowledge of hypertonic saline as an osmotherapeutic agent in neurotrauma.

Characterisation of sea-water intrusion in the Pioneer Valley, Australia using hydrochemistry and three-dimensional numerical modelling

Sea-water intrusion is actively contaminating fresh groundwater reserves in the coastal aquifers of the Pioneer Valley,north-eastern Australia. A three-dimensional sea-water intrusion model has been developed using the MODHMS code to explore regional-scale processes and to aid assessment of management strategies for the system. A sea-water intrusion potential map, produced through analyses of the hydrochemistry, hydrology and hydrogeology, offsets model limitations by providing an alternative appraisal of susceptibility. Sea-water intrusion in the Pioneer Valley is not in equilibrium, and a potential exists for further landward shifts in the extent of saline groundwater. The model required consideration of tidal over-height (the additional hydraulic head at the coast produced by the action of tides), with over-height values in the range 0.5-0.9 m giving improved water-table predictions. The effect of the initial water-table condition dominated the sensitivity of the model to changes in the coastal hydraulic boundary condition. Several salination processes are probably occurring in the Pioneer Valley, rather than just simple landward sea-water advancement from modern sources of marine salts. The method of vertical discretisation (i.e. model-layer subdivision) was shown to introduce some errors in the prediction of watertable behaviour.

The effect of organic mulch amendments on the physical and chemical properties and revegetation success of a saline-sodic minespoil from central Queensland, Australia

Saline-sodic clay minespoil materials excavated during open-cut coal mining in central Queensland, Australia, pose significant challenges for revegetation, particularly where suitable topsoil capping is not available. We examined the ability of sawdust or straw mulch amendments to ameliorate the adverse properties of these minespoils and improve the success of revegetation efforts. In laboratory studies, mulch application improved infiltration, increased soil moisture retention and reduced surface crust strength. In the field, mulches incorporated to a depth of 0.15 m at application rates of at least 20 t/ha straw or 80 t/ha sawdust were needed to mitigate against capillary rise of salts during drying cycles and support satisfactory vegetation cover. Further research is needed to determine whether improvements are maintained beyond the 4-year trial period reported here.

Measurement of exchangeable cations in saline soils

The measurement of exchangeable cations in saline soils is limited by the difficulty in accurately separating soluble cations from exchangeable cations. A method is examined for saline soils in which exchangeable cations are calculated as the total extractable cations minus the concentration of soil solution (soluble) cations. In addition, a further two standard methods were investigated, one which assumes the total soil extractable cations are exchangeable, the other utilises a pretreatment to remove soluble salts prior to measurement of the remaining (exchangeable) cations. After equilibration with a range of sodium adsorption ratio (SAR) solutions at various ionic strengths, the exchangeable cation concentrations of two soils (Dermosol and Vertosol) were determined by these methods and compared to known values. The assumption that exchangeable cations can be estimated as the total soil extractable cations, although valid at low ionic strength, resulted in an overestimation of exchangeable Na and Ca concentrations at higher ionic strengths due to the presence of soluble salts. Pretreatment with ethanol and glycerol was found to effectively remove soluble salts thus allowing the accurate measurement of the effective cation exchange capacity (ECEC), however, dilution associated with the pretreatment process decreased concentrations of exchangeable Ca while simultaneously increasing exchangeable Na. Using the proposed method, good correlations were found between known and measured concentrations of exchangeable Na (Dermosol: y=0.873x and Vertosol: y=0.960x) and Ca (Dermosol: y=0.906x, and Vertosol: y=1.05x). Therefore, for soils with an ionic strength of approximately 50 mM (ECse 4 dS m-1) or greater (in which exchangeable cation concentrations are overestimated by assuming the total soil cations are exchangeable), concentrations can be calculated as difference between total extractable cations and soluble cations.

Nitrogen balance for an agroforestry system irrigated with saline, high nitrogen effluent

Land disposal is commonly used for urban and industrial wastewater, largely due to the high costs involved in alternative treatments or disposal systems. However, the viability of such systems depends on many factors, including the composition of the effluent water, soil type, the plant species grown, growth rate, and planting density. The objective of this study is to establish whether land disposal of nitrogen (N) rich effluent using an agroforestry system is sustainable, and determine the effect of irrigation rate and tree planting density on the N cycle and subsequent N removal. We examined systems for the sustainable disposal of a high strength industrial effluent. The challenge was to leach the salt, by using a sufficiently high rate of irrigation, while simultaneously ensuring that N did not leach from the soil profile. We describe the N balance for two plant systems irrigated with effluent, one comprising Eucalyptus tereticornis and Eucalyptus moluccana and a Rhodes grass (Chloris gayana) pasture, and the other, Rhodes grass pasture alone. Nitrogen balance was assessed from N inputs in effluent and rainfall, accumulation of N in the plant biomass, changes in soil N storage, N loss in run-off water, denitrification and N loss to the groundwater by deep-drainage. Biomass production was estimated from allometric relationships derived from yearly destructive harvesting of selected trees. The N content of that biomass was then calculated from measured N content of the various plant parts, and their mass. Approximately 300 kg N/ha/yr was assimilated into tree biomass at a planting density of 2500 tree/ha of E. moluccana. In addition to tree assimilation, pasture growth between the tree rows, which was regularly harvested, contributed substantially to N uptake. If the trees were harvested after two years of growth and grass harvested regularly, biomass removal of N by the mixed system would be about 700 kg N/ha/yr. The results of this study show that the current system of effluent disposal is not sustainable as the nitrate leaching from the soil profile far exceeds standards set out by the ANZECC guidelines. Hence additional means of N removal will need to be implemented. Biological N removal is an area that warrants further studies as it is aimed at reducing N levels in the effluent before irrigation. This will complement the current agroforestry system.