Platelet Rich Plasma (PRP) and Prolotherapy are solutions injected into painful joints, ligaments, or tendons to reduce pain, improve movement and restore function by stimulating the body to produce new tissue.

To obtain the Platelet Rich Plasma, 15-60 ml of blood is drawn from a vein as if you were in the lab for blood tests. The blood is then placed in a centrifuge to separate the blood, platelets, and white blood cells. Depending on the specific problem, the injection contains concentrated platelets, with or without white blood cells. Generally, 1-2 treatments with PRP are required,  spaced 4-6 weeks apart.

Cost:  $400-$600 per treatment.

Prolotherapy is a mixture containing a medical-grade solution of dextrose (the same solution that is used to fix your blood sugar if it drops too low in the hospital), a numbing solution, and normal saline. The treatment has been available since the 1930s and is widely used. Generally, 4-8 treatments with Prolotherapy are required, spaced one month apart.

Cost: $100-$400 per treatment.

This requires a referral from your GP (and the waitlist), or you can book an initial Private Consultation for $400. A detailed evaluation of your neck pain and the headaches is completed to assess for causes for these two conditions, including the role of the occipital nerves, the facet joints, muscles and ligaments. If Botox is recommended as a treatment, it is not injected in the same pattern as migraine. The injections, done with ultrasound guidance, target muscles that are referring pain and causing headache and/or are contributing to head forward posture, if that is an issue. The Botox, if recommended, is injected at the next visit when the cost of coverage for the Botox has been discussed and a prescription provided. The injection fee for the Botox at subsequent appointments is $200. This does not include the cost of the Botox, which may be covered by extended health or occasionally by Pharmacare.

If you have been getting Botox injections for migraine, Dr. Squire is an experienced injector and will continue the injections for a fee of $200 per treatment. This requires a referral from your GP.  If you have never used Botox for migraines, but would like to have a consult, you can book an initial Private Consultation for $400 or be referred by your GP.

Dr. Squire and Dr. Amayem can provide comprehensive migraine treatment with other medications and lifestyle management options but do not prescribe opioids.

This includes conditions such as piriformis syndrome, a condition that can mimic sciatica, and other muscular injections to alleviate excessive and persistent muscle spasm. This requires a referral from your GP (and the waitlist), or you can book an initial Private Consultation for $400. The Botox, if recommended, is injected at the next visit when the cost of coverage for the Botox has been discussed and a prescription provided. The injection fee for the Botox at subsequent appointments is $200. This does not include the cost of the Botox, which may be covered by extended health or occasionally by Pharmacare.

When there is evidence of inflammation around a nerve, tendon or in a joint, a steroid injection can provide rapid relief. Inflammation can occur after acute injury or with infection, and steroids are not used at that time.

Cost: Covered by MSP

Frozen shoulder is a condition of varying severity that causes stiff, painful movement with normal x-ray findings. The condition usually starts with moderate to severe shoulder pain that is worse at night; later you develop stiffness. It is more common in people with diabetes and certain other conditions and can occur after shoulder injuries. The cause of it is not fully understood.

The diagnosis is usually made based on the history and examination. The abnormality can be seen on MRI but this test is usually unnecessary.

Steroid injections into the painful shoulder joint can be useful, especially if done early.

The steroid injection is often combined with other injections done in very specific locations to dilate the capsule or treat specific areas of adhesions such as the rotator interval. These injections are done with a combination of saline and local anesthetic and are always performed under direct ultrasound visualization.

Treatment success depends on the patient doing regular range of motion exercises directly after treatment. This website has some examples of commonly recommended stretches. Physiotherapy can help and is important to assist you to transition into exercises to return your strength.

Cost: Covered by MSP

These injections contain a gel made of hyaluronic acid that is designed to mimic joint fluid to improve joint cushioning and movement. They are used in knees and occasionally hips or small joints where there is arthritis but not inflammation. The injections do not work for severe arthritis but can be helpful in mild to moderate arthritis.

What formulations are commonly used and how much do they cost? The cost of the injection depends on the formulation used. After an evaluation, the clinic will provide a prescription and the patient who brings the hyaluronic acid formulation into the clinic for injection. Some common examples include:

• Monovisc® is approved for the treatment of arthritis and is supplied as a single dose per joint. It delivers the highest total dose of hyaluronic acid available and is not manufactured from animal parts which reduces the risk for allergic reactions. The cost is approximately $250 for 4 cc.
• Durolane is approved for the treatment of arthritis in both small and large joints. It is been available since 2001. It is a naturally occurring molecule and is not based on animal protein which reduces the risk of allergic reactions. The cost is approximately $135 for 1 cc for a small joint such as the ankle, elbow, wrist, finger and toe. The larger amount costs $250 for 3 cc for hip and knee joints.
• Cingal™ is approved for the treatment of arthritis in knee joints. It contains both a steroid and hyaluronic acid. The cost is approximately $320.
• Synvisc-One is a single injection indicated for injection into the knee 6ml ($480) or for small joints, 2 ml ($165). Three 2 mL doses are available as a single package ($472). This product is made from chicken combs and if you are allergic to feathers, eggs or other products from poultry you should not use this product.

Trigger point injections are designed to treat myofascial pain or painful knots (called trigger points) in muscles. Myofascial trigger points can be treated by physicians by injecting them with one of several different solutions (but never steroids or Botox), by needling them with an acupuncture needle (by a physiotherapist) or by using active release therapy or direct pressure (usually by massage therapists or chiropractors). When the only areas treated are the painful areas, they often provide only short-term relief. Effective treatment requires expert knowledge of body kinetics and posture to identify the underlying problems, not just where the body is experiencing pain.

Cost: Covered by MSP

Nerve blocks are injections done with a nerve-numbing substance that is injected around a nerve. The injection is done using ultrasound guidance to ensure the injection is safe and accurate.

Sometimes the nerve is blocked (frozen) as a test to help determine if your pain is due to a specific nerve that is damaged or dysfunctional. For example, sometimes, tennis elbow pain is not caused by the tendon but from irritation of a nearby nerve. To test for this, we block the nerve and look to see if your “tennis elbow” pain gets better. This can save you from spending money on expensive tendon treatments like prolotherapy and PRP that would not be effective.

Sometimes a nerve block is done to tell if a joint in your spine is the cause of your spine pain, because most of the time we cannot tell if a spine joint is painful based on how it looks on a CT or MRI scan. For low back pain, doing this kind of block is the ONLY way to tell if a particular joint(s) is the cause of your pain, because the examination cannot predict it either. If the nerve block reduces your pain by at least 50% for the first 2-4 hours after the block, then there are treatments that can reduce the spine joint pain for up to a year when done by an experienced provider. The treatment, called a radio frequency neurotomy, is not performed by this clinic but you can be referred to your local hospital-affiliated clinic. This treatment is minimally invasive and is much more effective than a steroid injection and does not cause osteoporosis.

Sometimes a nerve block is used to provide pain relief to an area that is being treated with other injections or painful manual therapy. This is the same idea as the block your dentist does before working on your teeth.

Cost: Covered by MSP

What is Fascial Manipulation?

Fascial manipulation©(FM) is a manual therapy method that was developed to treat areas of movement restriction and pain due to injuries of the deep fascia. There are many different types of treatment for fascia. There are only a few practitioners certified in this method in B.C.

What is fascia and what is its function?

 Fascia is the name of the layer of connective tissue that surrounds every individual muscle. The fascia has many functions but one is to make a slippery substance called hyaluron. If you have ever run your fingers under chicken skin you have felt the hyaluron making the chicken muscle slippery. Large amounts of hyaluron make up your joint fluid. This slippery substance helps one muscle to slide over another. Fascia surrounds nerves and blood vessel with a protective slippery sheath so they can slide between muscles and then they travel through muscles.

Fascia has many nerves that help to tell our body where it is in space (that’s one of the ways your ankle doesn’t roll over every time you step on uneven ground). The nerves in the fascia also transmit pain messages when the fascia is injured.

Other layers of fascia exist all over the body. Some of the lines run down the front of your body, others down the back or only on the sides. These fascial layers run from one muscle to another connecting them so that when they are tensioned and then released, the energy in the elasticity of the fascia is released, increasing the force of the action. One starts on the palm of your hand, runs down the arm and the chest then crosses over to run down the front of the opposite leg.  When a baseball pitcher throws, they do not just use their arm, they wind up the tension in that line of fascia by moving their right arm and left leg behind them just before they let go of the ball. Tensioning this line of fascial just before they release the ball increases the force of their throw by 30%.

It is common to injure fascia by trauma or overuse and have only temporary pain and soreness, like you would expect after a fall on your tailbone, an ankle sprain or after too many tennis shots with poor technique! You heal some of the injury and if there are any ongoing problems with poor fascial sliding the body is an expert at using other strategies to get around these but after enough injuries, the body runs out of effective compensations and pain, difficulty moving  and stiffness can result. Often this starts after a seemingly minor injury or it can start gradually without any obvious cause

Injured deep fascial layers (by trauma or overuse) causes the hyaluron to become sticky leading to areas where the fascial layer of one muscle sticks to another. This can lead to loss of joint movement, painful stiff movements or muscle weakness. Fascial pain is often better with heat and sometimes improves with movement.

If there is sticky injured fascia in the front of the left thigh it can cause pain in the thigh and difficulty with knee movements but because the fascia is connected to the shoulder it can make it hard to move the right shoulder backwards. The problem is in the front of the left thigh but if you have this problem you might only complain of pain and tightness in the front of your opposite shoulder. Because of this, finding the area of fascial restriction that is causing the pain and loss of movement can be difficult and time consuming.

Treating this condition with dry needling, trigger point injection, massage therapy, lasers or fascial stretching can sometimes reduce the pain but doesn’t always provide long-lasting relief.

How Does Fascial Manipulation Work?

 The therapist takes a detailed history of all of your previous injuries, surgeries or any pain that took a long time to recover. Then a detailed examination of the painful areas is completed. The examination is designed to evaluate for the underlying cause of the pain to determine if there are problems not just in the fascia but looks for abnormalities in muscles, ligaments, tendons, nerves, joint dysfunction or problems related to pain processing (examples abnormal pain processing include migraine and phantom limb pain).

A hypothesis about the cause(s) of pain is developed and any additional investigations are ordered.

If fascial abnormalities are thought to be one of the causes of your pain then a treatment plan is discussed and specific densified areas are then treated using a deep often painful massage therapy for 2-5 minutes until there is an improvement in the muscle sliding and it begins to soften.

In some situations the adhesions are treated by injecting 5% dextrose (not prolotherapy but a kind of IV fluid also used to rehydrate the body) between the sticky layers. The injections are done using ultrasound guidance. This is particularly helpful when there is a nerve stuck in the tissue that makes manual therapy very painful or to release deeply adherent layers of a scar that are affecting fascial sliding.

Dr. Squire uses both techniques.

An improvement in the ability of the fascia to glide and slide allows for normal movement patterns to be restored and pain is reduced. Clinical experience has shown that multiple points in several muscles throughout the body can be affected and need to be treated. The number of sessions required varies with the individual but ranges between 5 and 30 depending on the length of the appointment.

The areas treated are sore and tender for 24 to 48 hours, probably due to a local inflammatory response. Palpation of the treated areas during subsequent treatment sessions often reveals that the treated area is less tender and feels softer to touch. Movement patterns and strength are gradually improved as pain and dysfunction subsides.

Clinical studies have shown that freeing fascial alterations in these key areas decreases pain, restores movement and muscle strength in patellar tendinopathy (Pedrelli et al. 2009), after whiplash injuries (Picelli et al. 2011), chronic ankle sprains (Stecco et al. 2011) and chronic neck pain (Stecco et al. 2014) with long lasting benefits. Ultrasound imaging has shown a decrease in the thickness of loose connective tissue of the deep fascia following Fascial Manipulation persisting 6 months after treatment (Stecco 2014).

Fascial Manipulation can be an effective treatment for:

• Low back pain
• Neck pain
• Hip pain
• Knee pain
• Shoulder pain
• Foot and ankle pain
• TMJ pain
• Tension headaches

What are the side effects and costs?

 At the beginning of treatment there is often quite a bit of post treatment pain, swelling and bruising. This is expected and usually resolves after 2-5 days. At times you might experience pain in a body part that was not painful before. This almost always goes away within a few days. If it does not, please contact the office and we will fit you in ASAP.

The treatment is designed to create friction between two muscles. The friction is thought to warm up the hyaluron and much like heating honey, makes it slippery. The deep and often painful massage also creates inflammation which is thought to be instrumental in restoring the slippery hyaluron. Applying heat, taking Tylenol or muscle relaxants is a good way to reduce the pain after treatment.

Generally speaking, it is better to avoid anti-inflammatory medication like Advil or Naproxen for 3 days after treatment If you are experiencing more pain than you feel you can try taking an anti-inflammatory if you are not allergic to them, do not have side effects to them or do not:

Take blood thinners;

Have kidney disease;

Have high blood pressure that is not well controlled;

Have a sensitive stomach or bowel or a history of bleeding from your bowel or bladder.

 This treatment is not covered by MSP as there are no fee codes for manual therapy by physicians. This office charges $90.00 for 20 minutes or $400.00 for an hour.

My private fees are never covered by Blue Cross or similar extended health care plans. ICBC will sometimes cover my fees.

If you have coverage for physiotherapy or massage therapy you can look here for a list of local therapists that are trained to use fascial manipulation. http://www.fascialmanipulation.com/en/

Low back pain is a common and challenging condition. Dr. Squire will perform a detailed evaluation for many causes of low back pain and try to determine when something that is seen on a CT or MRI is or isn’t the cause of your pain. Many patients are told that their CT scan does not show any abnormality and the assumption is that this means that the joints in your spine are not the cause of your pain. In fact, research has demonstrated that (almost all of the time) you cannot tell if a spine joint is painful by the way it looks, good or bad, on a CT or MRI. Research also tells us that physical examination cannot tell if the spine joints in your low back are causing your pain. The only way to tell is to do a test by freezing the joint (this takes an ultrasound or Xray guided injection called a medial branch block) and see what happens to your pain in the next 3-6 hours. 

Muscles, ligaments, and fascia can all cause low back pain. 

For example coccydynia, or tailbone pain, can occur after a fall onto the tailbone. Most pain resolves after 4-6 weeks.

In some cases, months to years later, the forgotten injury can affect the sliding ability of the local tissues (fascia) and may cause low back pain that is often felt when bending, standing and walking. This is often mistaken for other causes of low back pain.

Your brain can make you feel low back pain by several different ways. Some are related to past physical or emotional trauma and some have nothing to do with your emotions but is simply the result of a brain “software glitch”. This is not “imagined”. Think about it. If your brain can cause pain in a body part that is not even there (like phantom limb pain) it can cause pain in a body part that is still there. There are ways to find out if this is your pain problem and there are treatments for this kind of pain that work. Many people are cured. 

Treatment only works when the diagnosis is accurate.

Cost: Some treatments for this condition are covered by MSP and some are not. The best treatment can only be determined after an evaluation.