Prolotherapy: An Alternative Treatment for Pain

These days, medical disinformation is widespread. Since my previous post, in which I bemoaned falsehoods about COVID-19 vaccine efficacy, COVID-19 vaccine availability, COVID-19 deaths, childhood vaccines, medications for depression and anxiety, funding for rural hospitals, causes of autism, and the MMR (measles, mumps, and rubella) vaccine, the spread of medical disinformation has continued. Recently, autism, the medications Tylenol,and leucovorin, the Hepatitis B vaccine, the MMR vaccine, and childhood vaccines in general, have been the subject of false information.

Some reporting has occurred to counter this recent disinformation, including reporting aiming to correct the record about autism, Tylenol, leucovorin, and childhood vaccines in general. Other reporting has focused on providing accurate information about the MMR vaccine in particular, while still other reporting has aimed to set the record straight about the Hepatitis B vaccine. Only time will tell whether these attempts at sharing accurate medical information will outweigh people’s belief in the disinformation.

My own medical writing, like the reporting aiming to counter medical disinformation, aims to present understandable, factual information about conditions and treatments. In the past, I’ve provided information about thoracic outlet syndrome, quadrilateral space syndrome, and hydrodissection. In this post, I’ll present information about a treatment called prolotherapy, a type of injection known to help with pain relief.

What is Prolotherapy?

As reported by Healthline, “prolotherapy involves injecting a dextrose [sugar] or saline [salt] solution into an injury site to promote a healing response.” This article explained that “these injections aim to trigger the body’s inflammatory healing process in the area.” The article noted that “in theory, the solution acts as an irritant, which may stimulate the growth of new tissues.”

As described by an article published by the American Society of Regional Anesthesia and Pain Medicine, “most [prolotherapy] injections are done in an office setting, and patients may receive topical local anesthetic solutions or subcutaneous lidocaine [delivered under the skin by needle] at the site of injection. Using ultrasound as a guide, articular spaces [joints] or tendons and ligaments are identified and the proliferant [a substance causing rapid growth of cells] is injected.” This article also explained “it is important that patients who are going to receive prolotherapy do not take anti-inflammatory medications, because they would prevent the inflammation that is required for cell regeneration.”

It should be noted that a doctor I spoke to in doing research for this blog post explained that receiving prolotherapy and avoiding anti-inflammatory medications afterword can be quite painful. However, the period of intense pain caused by the prolotherapy treatment should be relatively brief, lasting about a week to ten days, after which pain relief should occur. Those considering this treatment option should be aware of the pain the treatment causes before embarking on it.

Unlike surgical treatments, which remove or replace injured body parts such as joints, disks, or tendons, prolotherapy aims to treat body parts in place. And, whereas other treatments such as steroid injections, topical ointments, or pain-relieving tablets, that treat body parts without removing them have the aim of reducing inflammation, prolotherapy aims to cause inflammation. This is because inflammation is the means through which the body heals itself.

An article published in the journal Anesthesia and Pain Medicine explained the process of healing triggered by prolotherapy in this way: “The injected proliferant causes a healing process that is similar to the body’s natural healing process….” In this healing process, “…a local inflammatory cascade is initiated, which triggers the release of growth factors and collagen….”

The biology of prolotherapy. (Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability/Danielle Steilen et al.)

In other words, prolotherapy relies on the body’s natural response to an injury. This response uses inflammation to send healing cells to the injured site. By creating a minor injury with the injection of sugar and/or salt water, prolotherapy can promote the healing of injuries.

What is the History of Prolotherapy?

Prolotherapy has been around for a long time. As explained by an article in Clinical Medicine Insights: Arthritis and Muskuloskeletal Disorders, “prolotherapy has been used in clinical practice for more than 80 years to treat various chronic musculoskeletal conditions.” The article noted that the treatment was “formalized by Dr. George Hackett in the 1950s.” Some researchers, such as the authors of the article provided by the American Society of Regional Anesthesia and Pain Medicine, date Hackett’s work to 1937. Whichever date is correct, the treatment is not new.

Over the past few decades, as noted by the Clinical Medicine Insights article, interest in prolotherapy has grown. This is because scientific research into its use and effects has blossomed. It’s also because this research has shown both the usefulness of the treatment and a lack of serious negative side effects accompanying the treatment.

Who Can Benefit From Prolotherapy?

In speaking with a doctor about prolotherapy, I learned that the area making up the quadrilateral space in the back of the shoulder can be treated with prolotherapy. Other body parts that can benefit from prolotherapy as noted by the Healthline article include tendons, muscles, or ligaments that have been strained or sprained; joints such as knees, hips, or fingers affected by arthritis; or spinal discs that are degenerating. Seemingly a wide range of body parts can be treated with prolotherapy.

Research studies back up these generalized assertions about where prolotherapy can be effective. For example, the article in Anesthesia and Pain Medicine reviewed “10 studies involving 750 participants” that participated in “randomized controlled trials which compared the effect of…prolotherapy with that of other therapies….” The conditions the patients in those studies were treated for included knee osteoarthritis, rotator cuff tendinopathy, chronic plantar fasciitis, chronic low back pain, osteoarthritis in the thumb and finger, and osteoarthritis in the first carpometacarpal [the joint at the base of the thumb].

The article in Clinical Medicine Insights reviewed 33 studies examining the use of prolotherapy. In addition to some of the conditions listed in the article in Anesthesia and Pain Medicine, this article listed a few others that can benefit from prolotherapy. They included Osgood-Schattler disease (a disease of the patellar tendon at the base of the knee), patellar tendinopathy, temporomandibular joint (TMJ) syndrome (a condition affecting the jaw joint), Achilles tendinopathy, lateral epicondylitis of the elbow (also known as tennis elbow), groin pain, discogenic leg pain (leg pain originating from a spinal disk in the low back), spine pain (in the neck, torso, or low back), and pain in the pelvic, coccyx (tailbone), or sacroiliac region.

Still another article, this one in the Journal of Rehabilitative Medicine, focused on osteoarthritis. It listed, in addition to the studies about knee and hand osteoarthritis I’ve already mentioned, a study focused on hip osteoarthritis involving 23 participants where prolotherapy had good results. Overall, the sampling provided by these articles offers a glimpse into the wide range of body parts that can be treated with prolotherapy.

How Many Prolotherapy Treatments are Required?

As noted by the article provided by the American Society of Regional Anesthesia and Pain Medicine, treatments generally follow “a protocol of solution injection in 2-to-8-week intervals over the course of several months.” The doctor I spoke to who uses prolotherapy as a treatment in his practice indicated that most studies indicate a total of six or seven treatments can be used, after which a long pause of six to twelve months should be allowed before more prolotherapy is administered. A review of the research studies I looked at confirms this.

For example, the article in the journal Anesthesia and Pain Medicine reviewed 10 articles that used an “injection interval [that] ranged from weeks to months.” Specifically, the studies reviewed in this article reported using a low of two injections to a high of six and spacing of the injections ranging from a low of one week apart to a high of two months apart. The same range in the number and spacing of injections was reported by the article in Clinical Medicine Insights, which reviewed 33 studies. The article in the Journal of Rehabilitative Medicine reviewed 14 studies with a low of one injection to a high of six and a low of spacing the injections one week apart to high of two months apart.

As for having more injections if full pain relief isn’t achieved by the initial protocol, two of the articles I reviewed mentioned this possibility, with the article in the journal Anesthesia and Pain Medicine noting a low of a three month wait time for additional treatments to a high of a six month wait time. Of the studies reviewed by the article in Clinical Medicine Insights, those that mentioned additional injections after the initial protocol indicated a low of a one month wait time to a high of a six month wait time. One study reviewed in this article provided additional treatments with no wait time. This seems to be an outlier.

Overall, it seems there is variability in treatment plans. Each provider likely considers each case and determines which protocol to follow and whether to allow additional treatments after the initial protocol is completed. If you are considering this treatment for pain, you will need to consult with your provider to find out what to expect about number and spacing of injections.

Who Provides Prolotherapy?

A range of providers can administer prolotherapy. As noted by the article published by the American Society of Regional Anesthesia and Pain Medicine, prolotherapy is often offered by doctors practicing at pain clinics. Authors of the other articles I’ve drawn on in writing this post were doctors working in physical medicine and rehabilitation, cerebellum medicine, regenerative medicine, and anesthesiology. The doctor I spoke to in preparing this post was a doctor of sports medicine.

This range in types of providers can be both helpful and confusing at the same time. On the helpful side, patients seeking prolotherapy as a treatment might find several specialists providing the treatment in several different specialty clinics. However, on the confusing side, patients might need to try reaching out to several doctors in different specialties to find someone local who provides the treatment.

What Makes Prolotherapy an Alternative Treatment?

It should be noted that prolotherapy is considered an alternative treatment option. This is because “this therapy is not approved for use by the Federal Drug Administration (FDA),” as explained by the article provided by the American Society of Regional Anesthesia and Pain Medicine. To be more specific, “Dextrose proliferant has been approved for injection by United States Food and Drug Administration but not for prolotherapy; thus, it is currently used in prolotherapy as an off-label substance,” as elucidated by the article in Clinical Medicine Insights.

Despite the alarming feeling patients may experience when told a treatment they are considering for pain relief is not approved by the FDA, this state of affairs does not mean such a treatment is not safe. None of the 57 studies I read about in the articles I looked at in writing this post reported any injuries caused by prolotherapy treatment. At worst, some patients did not achieve full pain relief.

For this and other reasons, many medical providers and institutions are moving away from the label “alternative” for non-FDA approved treatments. As the Cleveland Clinic put it, the term “alternative” is “becoming outdated as providers turn to an ‘integrative’ approach instead.” This type of approach incorporates “different types of evidence-based therapies to care for all of you.” Such an approach “can be especially helpful if you have a long-term (chronic) or complex condition.”

Disclaimer

As with my other pieces of medical writing, I offer this one as informational only. Before undertaking any medical treatment, you should check with a doctor or other licensed medical professional.

Hydrodissection: A Minimally Invasive Option for Nerve Pain Treatment

At the moment, disinformation about medical care is proliferating. For example, in one US Senate hearing, falsehoods were spread about COVID-19 vaccine efficacy, COVID-19 vaccine availability, COVID-19 deaths, childhood vaccines, medications for depression and anxiety, and funding for rural hospitals. Disinformation about the causes of autism has also been spread lately, with unsupported claims gaining traction that the use of acetaminophen by pregnant people and vitamin deficiencies in pregnant people cause autism. (If you’re interested in more details about the falsehoods being spread about autism, FactCheck.org, a publication of the Annenberg Public Policy Center at the University of Pennsylvania, provides a detailed analysis.) Not too long ago, a lot of disinformation was being spread about the measles, mumps, and rubella (MMR) vaccine.

In contrast to these examples of medical disinformation, in my medical writing, I aim to provide easy to understand, accurate information about medical conditions and treatments. A few years ago, I wrote about a rare condition called thoracic outlet syndrome. I followed that up with a blog post about another rare condition called quadrilateral space syndrome. This time, instead of focusing on a condition, I’m focusing on a treatment: hydrodissection.

What is Hydrodissection?

As explained by the Sports Medicine Center at the University of Washington (UW) Medical Center, hydrodissection is a minimally invasive procedure that aims to decompress nerves entrapped by surrounding tissues. These entrapments can result from scarring or tight muscles caused by injuries. To eliminate the entrapments, a provider with specialized training injects liquid into the tissue surrounding the affected nerve in order to break up the entrapments and allow the nerve to glide smoothly. The procedure is performed in a medical office under ultrasound so the provider has a clear view of the affected tissue and nerve. As described in the Journal of Pain Research, the needle used ranges from 50 mm–100 mm (about two to four inches) long, and it can be repositioned while inserted during the procedure to direct the liquid effectively.

The UW Sports Medicine Center indicates that the liquid injected into the tissue is often a combination of numbing medicine, saline, and cortisone, with each provider determining the best liquids to use in each case. Other options, as reported in the Journal of Pain Research, replace the saline and cortisone with sugar water, a type of enzyme called hyaluronidase, or platelet rich plasma. This report also notes that not only scarring and tight muscles can be the culprit in causing nerve entrapments but that fascia can cause entrapments as well. As described by the Cleveland Clinic, “Fascia is a sheath of stringy connective tissue that surrounds every part of your body….When your fascia is healthy, it’s flexible and stretches with you. When your fascia tightens up, it can restrict movement and cause painful health conditions.”

Hydrodissection procedure. (A) Prone position for the ultrasound-guided ulnar nerve in-plane injection with the elbow flexed and hanging over the examination bed. (B) The same procedure as described before in detail. (C) Supine position for the ultrasound-guided ulnar nerve in-plane injection; the patient is positioned on the examination bed with the elbow flexed and hand over the head. (D) The same procedure as described before in details. (Ulnar Neuropathy at the Elbow: From Ultrasound Scanning to Treatment/Kamal Mezian et al.)

Which Nerves Are Treated With Hydrodissection?

Several studies have investigated the use of hydrodissection to treat various nerves. For example, some studies have focused on the nerves that pass through the wrist. One study published in the journal Current Sports Medicine Reports examined the use of hydrodissection in radial tunnel syndrome, which affects the radial nerve as it passes through the wrist. Another study, this one published in the Journal of Clinical Medicine, focused on the use of hydrodissection for treating carpal tunnel syndrome, which affects the median nerve as it passes through the wrist.

Other studies have focused on other areas of the body. For example, a study published in Springer Nature’s Scientific Reports investigated the use of hydrodissection on the tissues surrounding nerves in the neck. An article in the Baylor University Medical Center Proceedings presented data related to the use of hydrodissection for the peroneal nerve in the knee. And, a study published in the Journal of Women’s Health and Gynecology examined the use of hydrodissection to treat the tissues surrounding nerves in the pelvic floor. Additionally, in speaking with a provider who uses hydrodissection in his medical practice, I learned that hydrodissection can also be used to treat the tissues surrounding the axillary nerve, a nerve that passes through the back of the shoulder and upper arm. These are just a few examples of the many nerves in the body with the potential to be treated with hydrodissection.

How Many Hydrodissection Treatments are Required?

The articles I’ve cited range in the number of hydrodissection treatments used. The lowest number of treatments mentioned that resulted in a positive effect was just one treatment in the article published by the Journal of Pain Research, and the highest number was six treatments over six weeks in the article published by the Journal of Women’s Health and Gynecology. The doctor I spoke with who uses hydrodissection in his practice mentioned that the literature supports using up to six or seven treatments, after which a significant break of six months to a year should be taken before resuming. Overall, it seems a wide range of treatment practices are observed, and patients should consult with their doctor about the best course of action for their case.

Who Provides Hydrodissection?

As evidenced by the articles I’ve cited, doctors researching hydrodissection work in several areas of medicine, including musculoskeletal medicine, physical medicine, rehabilitative medicine, orthopedic medicine, pain medicine, and sports medicine. Sometimes, the authors of the articles performed the hydrodissection treatments themselves, meaning practitioners of hydrodissection can be found among this same list of medical specialties. Other times, the authors of the articles reported on case studies carried out by other doctors. In these instances, the doctors who carried out the hydrodissection treatments represented a similar list of specialties, with the addition of neurology, radiology, and anesthesiology. Overall, then, patients have a wide variety of options for seeking out a practitioner who provides this treatment.

Who Can Benefit From Hydrodissection?

Anyone with a nerve injury caused by entrapment in a location that can be reached by a needle can benefit from hydrodissection. As reported in the Journal of Pain Research, one type of person who might experience this phenomenon is someone who has suffered a sprain or strain that has stretched a nerve in the injured area. The report additionally notes that nerve stretch injuries can occur during surgeries. Someone who has had a surgery with pain lingering beyond the expected time for healing could be a good candidate for hydrodissection..

As also reported in the Journal of Pain Research, someone with bone spurs, tendinosis (an injury to a tendon), or ligamentosis (an injury to a ligament) could also benefit from hydrodissection. The report also notes that fractures can cause injuries to nerves and that these injuries can be candidates for treatment with hydrodissection. Someone who has suffered a fracture and is experiencing lingering pain could therefore benefit from the treatment.

Some syndromes can also cause injuries to nerves, such as radial tunnel syndrome as reported on in Current Sports Medicine Reports, carpal tunnel syndrome as reported on in the Journal of Clinical Medicine, and quadrilateral space syndrome as mentioned by the doctor I spoke with in researching this article who has used hydrodissection to treat the axillary nerve that is a factor in this condition. Anyone with one of these conditions might want to consider hydrodissection as a treatment option. Neck pain, knee pain, and pelvic floor pain have all been treated with hydrodissection, as reported in Scientific Reports, Baylor University Medical Center Proceedings, and the Journal of Women’s Health and Gynecology. Someone with one of these types of pains could benefit from hydrodissection.

These are just a few examples of the types of conditions that could be treated with hydrodissection. If you have chronic pain that hasn’t responded to other treatments, you might consider hydrodissection as a treatment option. Of course, you should consult with a doctor before embarking on any treatment, ideally getting several opinions. When looking for doctors to interview about this procedure, it took me six tries before I found someone who provides hydrodissection in his practice. Although doctors with many medical specialties can offer hydrodissection, not all are trained in the procedure, so if you aren’t able to find a provider on your first attempt, keep trying. You might find someone with your next attempt.

An Emergency Preparedness Checklist for Trying Times

If you’ve been following my blog for a while, you know I’ve shared different forms, or genres, of writing. Some examples of these are the following:

• Interview
• Medical writing
• Call for proposals
• Fitness writing
• Listicle
• Travel writing
• Public service announcement
• Poetry
• Review

With this blog entry, I’m adding to that catalog by posting a checklist.

About Checklists

Checklists are used for a wide variety of topics. Some types of checklists you might be most familiar with from your personal life include a shopping list, a to-do list, or a packing list. In the work world, many industries use checklists, such as safety checklists in transportation industries, performance checklists in the human resources field, or procedural checklists in the medical field. Innumerable types of checklists are commonly used in daily life. If you’re interested in learning more about the history and current use of checklists, I suggest checking out articles published by TechBullion, Canva, and the Hawaii International Conference on System Science. The type of checklist I’m offering is an emergency preparedness checklist.

Types of Emergencies: Natural Disasters, Armed Conflicts, Health Crises, Theft

Lately I’ve been sensitive to emergencies of many kinds. For example, natural disasters seem increasingly common. Last year, Hurricane Helene wreaked havoc not far from where I live in western North Carolina. This brought back memories of when I lived in Rhode Island and the eyes of Hurricane Gloria and Hurricane Bob passed over my family’s house. Just a few months ago, raging wildfires devastated the Los Angeles area. And these are just a few examples. The Global Disaster Alert and Coordination System shares information about natural disaster alerts that have been issued around the world for earthquakes, tropical cyclones, floods, volcano eruptions, droughts, and forest fires. At any one time, this website lists close to 100 events that have occurred over the past several months. That’s a lot of natural disasters! When might the next one strike where you live?

Another type of emergency that’s drawing my attention is war. In the US, the war between Russia and Ukraine is in the news practically on a daily basis. Similarly, the latest flare up in the long conflict between Israel and the Palestinians gets a lot of news coverage. The United States recently attacked Yemen in retaliation for its attacks on ships passing by its borders. But these are not the only armed conflicts occurring right now. According to the Academy of International Humanitarian Law and Human Rights based in Geneva, Switzerland, there are over 100 armed conflicts happening in the world today. While it may seem far-fetched to imagine war breaking out in the United States, it’s not unprecedented. As listed by ThoughtCo., wars that have taken place on American land include King Philip’s War, the Cherokee War, the Revolutionary War, the War of 1812, and the Civil War. We’ve also seen plenty of violent civil unrest on our soil that, while not resulting in full-fledged war, has been catastrophic for those involved. While Wikipedia isn’t always the most reliable source, it contains the most comprehensive accounting of American civil unrest I could find, listing close to 400 events in the 240 years between 1783 and 2023. Could such types of violence lead to war in the United States? According to Science, as of 2022, almost half of all Americans expected a civil war to erupt in the next few years. Given such an environment, taking steps to be prepared seems wise.

Then there are health emergencies, such as epidemics, pandemics, or personal health crises, that can strike at any time. The COVID-19 pandemic was declared a health emergency five years ago, and we are still feeling its effects. According to ABC News, there were 2,100 COVID-19 deaths in the United States in January 2025, with another 761 worldwide. The COVID-19 pandemic has been so deadly that Live Science lists it among the worst 21 pandemics in global history. With rising numbers of measles deaths reported in the US, Europe, Africa, and Asia and cases of bird flu being found in humans, health concerns are making the news. And such widespread health concerns don’t account for personal health emergencies. Are you ready for the aftermath if you have to be rushed to the hospital due to a life-threatening situation?

Finally, there are emergencies due to theft, including identity theft, to be prepared for. If your wallet were stolen, for example, would you know your driver’s license number and how to contact your state’s department of motor vehicles? What about how to contact the customer service departments of your credit card companies? Or your bank, assuming you have a debit/ATM card in your wallet? And this is just a few impacts having your wallet stolen could have. What other cards do you keep in your wallet? And what about other kinds of theft? For example, fears of identity theft have risen recently, with both National Public Radio (NPR) and the Washington Post covering the risk to personal data due to actions the Department of Government Efficiency (DOGE) has taken lately. Do you know what to do either to protect yourself from nefarious uses of your data before it happens or to recover from malicious use of your personal data after identity theft occurs?

Why and How I Created This Checklist

Perhaps this foregoing litany of possible emergencies stresses you out. Me too! But note: taking action in the face of a stressful situation can be soothing. In an article published in Psychology Today, Dr. Esther Sternberg, an expert in the mind-body connection, recommended the three-step process of “parse, prioritize, and act.” Step one is “break the situation down into its smallest controllable parts.” Step two is “decide which of the parts is easier to control….” And step three is “take action.” Hopefully the checklist I’ve come up with will help you follow her steps!

 

“Let’s DO this” checklist (Pixabay/Gerd Altmann “geralt”)

One note about this checklist: I developed it using my own ideas and a few checklists I found online, namely ones published by the American Red Cross, AARP, Lifehacker, Consumer Reports, PCMag, and the Federal Emergency Management Agency (FEMA), although it’s worth noting that the FEMA checklist may disappear from the web, as reports by Government Executive, CNN, and CBS News, among others, indicate the agency is set for elimination or a major reorganization. If it does disappear from the web, you can look for it on the internet archive at https://archive.org/. I’m sure there are other checklists available, too. Hopefully the checklist I’ve come up with is comprehensive, but if you find anything I’ve missed, let me know!

Emergency Preparedness Checklist

This checklist is broken down into categories: packaging, food and water, clothing, toiletries, medicines and medical paperwork, identification and ownership paperwork, finances and financial paperwork, insurance paperwork, electronics, vehicles and appliances, and comfort items. When it comes to paperwork, aim to keep three copies of all documents: a local hard copy, a local digital copy protected by password, and a remote digital copy protected by password (some remote copies might be stored by providers, such as medical providers, banks, credit card companies, etc.).

Depending on the type of emergency you want to prepare for, you may decide to collect only some of the recommended materials at any one time. This is because while it might be helpful to be prepared for all types of emergencies, some of the materials required to prepare for an imminent natural disaster, for example, might not make sense to stockpile too far in advance, such as food and water, both of which can spoil over time. Therefore, I suggest keeping the checklist handy and preparing as much as possible in advance, saving only a small number of items to organize should a last minute emergency situation arise.

You should review this checklist annually or any time you make a major life change, such as moving, getting a new job, finding a new doctor, or the like, and appraise the items you have prepared, updating or refreshing as needed (such as paperwork, stale batteries, expired foods, etc.).

Packaging

o For food and water in an evacuation emergency, one or more medium-sized, durable, portable containers such as reusable shopping totes, crates with handles, or wheeled carts

o For clothing, toiletries, and medicines in an evacuation emergency, a medium-sized, durable, portable, zip-up container such as a backpack, duffle bag, or roller bag

o For electronics in an evacuation emergency, a durable, portable, zip-up container such as an electronics organizer, tech pouch, messenger bag, or backpack (you may choose to keep several smaller electronics and accompanying cords in their own organizers or pouches within a larger bag or backpack)

o For documents in either an evacuation or shelter-in-place emergency, a water resistant, fire resistant, durable, portable, sealable container, such as a zippered document bag, zippered briefcase, or lidded box with handles (note that while resealable plastic food bags are fine for providing water resistance, they won’t help with fire resistance)

Food and water

o For an evacuation emergency, at least three days of food and water

o For a shelter-in-place emergency, at least two weeks of food and water

o One gallon of water per person per day (for shelter-in-place, fill bathtubs or washing machine for flushing toilets in addition to stockpiling bottled water for drinking)

o Easy to prepare nonperishable foods (such as cereals, instant oatmeal, crackers, breads, protein bars, protein powders, nuts, nut butters, dried fruits, dried meats, canned goods, freeze dried meals, and shelf-stable or powdered milks—for shelter-in-place with a generator or outdoor grill, perishable foods can be an option)

o Pet foods

o Manual can opener

o Pair of scissors and/or sharp knife

o Eating utensils

o Dishware (for evacuation emergencies, non-breakable, lightweight is best)

o Cookware (for evacuation emergencies, a small, multi-use pot or pan is best)

Clothing

o This section is mostly applicable to evacuation emergencies, as you will have access to all your clothing in a shelter-in-place emergency; however, if you keep off-season items in storage, make sure you can access those items at will

o Cold weather—hat, gloves/mittens, snow boots, parka or other warm jacket

o Warm weather—sun hat, sunglasses, rain boots, rain coat

o Layerable shirts and tops of easy-care, durable fabrics

o Pants/shorts (depending on weather) of easy-care, durable fabrics

o Pajamas

o Blanket (fleece is a good lightweight yet warm option useful year-round)

o Socks (woolen or synthetic wool for cold weather)

o Undergarments

o Pet blanket/sweater/coat/booties/leash/carrier

Toiletries

o For evacuation emergencies, travel size products to last at least three days

o For shelter-in-place emergencies, enough supplies on hand to last two weeks

o Body soap/cleanser

o Shampoo and conditioner

o Deodorant

o Toothbrush, toothpaste, and mouthwash

o Hair styling products (including comb or brush and hair ties for long hair)

o Body and facial moisturizer

o Sunscreen

o Shaving products

o Feminine products

o Facial tissue

o Toilet paper/diapers/adult incontinence supplies

o Washcloth, hand towel, and bath towel (made of quick-dry material if possible)

Medicines and medical paperwork

o For evacuation emergencies, travel size products are recommended

o First aid kit (adhesive bandages of various sizes, gauze pads of various sizes, adhesive cloth tape, antiseptic ointment, antiseptic wipes, hand sanitizer, non-latex gloves, hydrocortisone ointment, tweezers, thermometer, instant cold pack, N95 or KN95 face masks, COVID/flu tests)

o Prescription and daily over-the-counter medications to last two weeks (including for pets)

o Over the counter pain relievers to last two weeks

o Bug repellant (including flea collar/treatment for pets)

o Contact lenses and supplies/extra glasses

o Medical equipment (such as CPAP machine, oxygen tank, syringes, diabetic testing supplies) to last two weeks—portable versions for evacuation emergencies

o List of all doctors with contact information (including veterinarian for pets)

o Pharmacy contact information

o List of all prescription medications including date of prescription, prescription number, prescriber name, and dose (including for pets)

o Vision prescription information, including prescriber name and date

o Medical history including immunizations, screenings, allergies, surgeries, chronic conditions (including for pets)

o Disability documentation

o List of medical equipment suppliers and contact information

o Advance directive and medical/healthcare power of attorney

Identification and ownership paperwork

o Driver’s license (original and digital copy of front and back)

o Social Security card (original and digital copy of front and back)

o Passport (original and digital copy of first two pages)

o Naturalization documents

o Green card (original and digital copy of front and back)

o Birth certificate

o Adoption certificate

o Child custody documents

o School registration forms

o School ID (original and digital copy of front and back)

o Pet adoption certificate/ID tags/microchip information

o Service animal/emotional support animal certification

o Marriage license

o Divorce decree

o Military/veteran identification and records (including DD214, duty stations and assignments, medals and decorations, qualifications, licenses, certificates)

o Federal employment records (including SF50 and other items in your Official Personnel Folder, or OPF)

o Car title

o Home/property deed, rental lease, or elder care housing agreement

o Photographs of interior and exterior of home

o Photographs of household belongings

o Appraisals of personal property

o Will/estate plan and contact information for lawyer

o Church/house of worship membership documentation and contact information

o List of contact information of loved ones and essential business colleagues (don’t rely only on the contact list in your cell phone or in your email in case your phone or computer is lost, damaged, or loses power—include phone number, email address, physical address)

Finances and financial paperwork

o For evacuation emergencies, enough cash in a variety of bill sizes to last at least three days

o For shelter-in-place emergencies, enough cash in a variety of bill sizes to last at least two weeks

o Credit card numbers and contact information

o Debit card numbers and contact information

o Bank account numbers and contact information

o Retirement account numbers and contact information

o Investment account numbers and contact information

o Government benefits information (most recent Social Security statement of earnings, enrollment paperwork for TANF, SNAP, VA, etc.)

o Loan agreements and payment receipts (home, vehicle, student, etc.)

o Alimony payment agreement and receipts

o Child support payment agreement and receipts

o Property tax statement and receipt

o Vehicle tax statement and receipt

o Income tax statement and receipt (to apply for an emergency loan, you may need up to the most recent three years, but in general, you should keep the most recent seven years—you might keep the most recent three years in your evacuation emergency kit and the next older four years in your shelter-in-place kit)

o Employment contract, most recent paystub, and employer contact information

o Utility account numbers and contact information (water, gas, electric, cable, internet, cell phone, etc.)

o List of accounts paid with automatic debit from your bank account, such as memberships, utilities, rent, mortgage, credit cards, etc.—if you’re unable to work during an emergency and stop receiving income, you’ll likely need to turn off automatic debit to avoid overdrafts of your bank account and make other arrangements with creditors to pay your bills

o FICO Score and copy of most recent credit report (these can be obtained weekly from https://www.annualcreditreport.com/—find out more about the program at https://consumer.ftc.gov/consumer-alerts/2023/10/you-now-have-permanent-access-free-weekly-credit-reports—if this page has been removed due to government restructuring, you can check for it on the internet archive at https://archive.org/)

o For an identity theft emergency, place a fraud alert and/or freeze on your credit (find out how at https://consumer.ftc.gov/articles/credit-freeze-or-fraud-alert-whats-right-your-credit-report— if this page has been removed due to government restructuring, you can check for it on the internet archive at https://archive.org/—note that if you already have a freeze on your credit and need to apply for a loan due to natural disaster or other type of emergency, you’ll have to lift the freeze before any loan requests can be processed)

o Rewards account numbers and contact information (frequent flyer, hotel rewards, grocery rewards, etc.)

o Durable financial power of attorney and contact information for lawyer and financial planner

Insurance paperwork

o Health plan account number and contact information

o Medicare plan account number and contact information

o Medicaid plan account number and contact information

o Dental plan account number and contact information

o Vision plan account number and contact information

o Pharmacy plan account number and contact information

o Disability plan account number and contact information

o Long-term care plan account number and contact information

o Life insurance plan account number and contact information

o Funeral insurance plan account number and contact information

o Homeowners/rental/condo/co-op insurance plan account number and contact information

o Flood insurance plan account number and contact information

o Fire insurance plan account number and contact information

o Earthquake insurance plan account number and contact information

o Vehicle insurance plan account number and contact information (including car, truck, boat, motorcycle, RV, etc.)

o Business insurance plan account number and contact information

o Commercial property insurance plan account number and contact information

o Pet insurance plan account number and contact information

Electronics

o Flashlight, headlamp, or lantern and batteries (using your cell phone flashlight briefly is ok, but long use can drain its battery)

o Radio with weather band and batteries

o Cell phone and chargers (both car charger and wall charger)

o Laptop/tablet and charger

o Flash drive or external hard drive

o Power strip with surge protector

o Portable charger or power bank

Vehicles and Appliances

o Vehicle in good working order

o Vehicle fuel

o Paper or offline maps

o Cooking appliances in good working order (for shelter-in-place emergencies)

o Portable stove (for evacuation emergencies)

o Cooking fuel (for home or portable appliances)

o Generator/portable generator

o Generator fuel

Comfort items

o Note: while these items might not seem essential, they can help with mental health—if preparing for a shelter-in-place emergency, entertainment items can keep boredom at bay, and if preparing for an evacuation emergency, grabbing a few key sentimental items on the way out the door can help soothe your emotions)

o Entertainment (such as hardcopy or downloaded books or magazines with e-reader, downloaded or hardcopy videos with player, downloaded or hard copy card games, downloaded or hard copy word games, downloaded or hard copy jigsaw puzzles, children’s toys, pet toys)

o Keepsakes (such as family photos or other mementos)

o Child’s favorite stuffed animal/blanket

o Pet’s favorite toy/blanket

Quadrilateral Space Syndrome: A Rare Condition

Nine months ago, I shared a blog post that was an example of medical writing focused on thoracic outlet syndrome (TOS). As is my regular habit whenever I upload a blog post, I announced on my Facebook and LinkedIn accounts that it was live. Generally speaking, the reactions I get to these announcements are from people I know. However, about seven months after I announced my post about TOS on LinkedIn, someone I wasn’t connected to at the time commented that she has TOS and has been suffering terribly from it.

This interaction let me realize that my blog writing has the capacity to reach people who need to see what I write. As such, I’ve decided to share another piece of medical writing in this blog post, this time focused on another rare condition, quadrilateral space syndrome, which can be a complication of some TOS surgeries. Perhaps what I write here can help someone who is suffering from this condition.

What is Quadrilateral Space Syndrome?

Quadrilateral space syndrome (QSS), also known as quadrangular space syndrome, is the painful compression of the axillary nerve as it passes through the shoulder. An artery called the posterior humeral circumflex artery can also be compressed in some cases, as described in an article by Dr. Patrick T. Hangge and several of his colleagues in the Journal of Clinical Medicine. The condition gets its name because the nerve and/or artery compression occurs when the space between four structures—the teres minor muscle, the teres major muscle, the long head of the triceps muscle, and the humerus bone in the arm—becomes too small for the nerve and/or artery to pass through comfortably.

Quadrilateral Space (Radiopaedia/Craig Hacking)

What Symptoms are Caused by QSS?

Patients with QSS often report numbness, weakness, and pain in the shoulder or upper arm due to nerve compression, according to Dr. Hangge and his colleagues. They also explained that if the artery is also compressed, patients might experience paleness or coldness in the arm or shoulder. Both types of patients experience tenderness when the area of the quadrilateral space is touched.

Many patients with QSS also experience difficulty with particular arm movements, as noted by Dr. Elliott B. Tapper in an article published by WikiDoc. These movements include external rotation, adduction, and extension of the upper arm. In other words, people with QSS have trouble with rotating the arm outwardly as well as with raising and lowering the arm to the front and side.

How is QSS Diagnosed?

Arriving at a QSS diagnosis can be challenging. In fact, Dr. Tapper pointed out that frequently the condition is misdiagnosed. He even noted that sometimes the symptoms of QSS are wrongly attributed to a mental or emotional cause, rather than to a physical one.

Frequently, a QSS diagnosis is arrived at by excluding other possible causes of the symptoms, as Dr. Hangge and his colleagues detailed. Some of the other conditions they indicated should be ruled out are a rotator cuff injury, a labral injury, a problem with the cervical spine, arthritis of the glenohumeral joint, a brachial plexus injury, an injury to the suprascapular nerve, and thoracic outlet syndrome. All of these conditions can have symptoms similar to those experienced by someone with QSS.

The most common tests ordered in attempting to diagnose QSS are MRI, ultrasound, and EMG, according to Dr. Tyler D. Kemp and his associates writing in the Journal of Chiropractic Medicine. They pointed out, though, that these tests can result in false negatives, which means none of them are considered ideal in definitively establishing that a patient has QSS. However, the tests can be useful in ruling out other causes of shoulder pain.

Another tool for diagnosing QSS is to give an injection of a numbing agent and/or a steroid into the quadrilateral/quadrangular space. If pain relief results, QSS is likely the cause. Dr. Shi-Hao Feng and colleagues writing in the journal Pain Medicine explained that this procedure is often performed under ultrasound guidance. Furthermore, Dr. Hamilton Chen and his colleague Dr. Vincent Reginald Narvaez proposed in their article in the journal Case Reports in Orthopedics that this procedure can be particularly helpful when other diagnostic tests are inconclusive.

Who Gets QSS?

QSS is most commonly seen in young athletes who participate in sports involving overhead motions of the arms, such as volleyball, baseball, swimming, and football, according to Kemp and his colleagues as well as Hangge and his colleagues. Others who experience QSS might have suffered a shoulder dislocation, as discussed by Kemp and his associates. An article in Radiopaedia edited by musculoskeletal radiologist Dr. Henry Knipe also mentioned cysts, tumors, or aneurysms as possible causes of the condition.

Another possible cause of QSS is a complication resulting from surgery. The Radiopaedia article mentioned that crush or traction injuries can cause CSS. These injuries might occur during some surgeries. In fact, Dr. Motohiro Nishimura and his colleagues wrote about this situation in the journal The Annals of Thoracic Surgery, where they outlined a case of QSS caused by a thoracic surgery that required positioning the arm in such a way as to stretch the axillary nerve and/or the quadrilateral/quadrangular space area.

How Common is QSS?

QSS is considered a rare condition. Notably, every article I read in researching this condition referred to it as rare. In fact, in his article, Dr. Tapper indicated that QSS accounts for only 0.8% of all cases of shoulder pain.

One anecdote that illustrates the rarity of QSS is my experience trying to find doctors who have treated this condition in order to learn more about it from them. In all, I spoke with five doctors who might be expected to have experience treating QSS. One doctor, a pain specialist, said she had never heard of QSS. Another, a physical medicine and rehabilitation specialist, said he had encountered only one case in 15 years of practice.

The other three doctors I spoke to were all orthopedists. One said he had never encountered a case and had only learned about the condition through textbooks. Another said he had seen several cases but had only operated on someone with the condition four times in his 10-year-long career.

The fifth doctor I spoke to had more experience with the condition. He claimed to perform 10-20 surgeries on patients with QSS annually. Additionally, a perusal of this doctor’s website indicated he had contributed to two scientific articles focused on the axillary nerve.

Admittedly, my survey of doctors was completely unscientific, but it indicates how challenging it can be for patients with rare conditions to find a high-volume practitioner for treatment. As Dr. Jonathan Cluett, a board certified orthopedic surgeon writing for Verywell Health, explained, being treated by a high-volume practitioner has many benefits, including fewer complications, shorter hospital stays, and less need for corrective surgeries.

How many surgeries qualify a doctor as a high-volume practitioner? Dr. Cluett indicated that for common surgical procedures, including for carpal tunnel syndrome, rotator cuff injury, and the like, a doctor should have been performing these surgeries for at least five years at a rate of 30 per year to qualify. He also indicated that for less common conditions, such as shoulder replacement, a doctor should have performed at least 30 surgeries of that type to be considered high-volume.

Using these criteria, only one doctor I spoke to would qualify as a high-volume practitioner for QSS. This situation helps illustrate the rarity of the condition. Perhaps if the condition were not so rare, more doctors would have more experience treating it.

How is QSS Treated?

Although surgery is an option for treating QSS, it is generally considered a last resort. As Dr. Kemp and his associates outlined in their article and Dr. Hangge and his associates also described, first-line treatments often begin with physical therapy. This therapy should focus on range of motion and strengthening, particularly by mobilizing the shoulder joint, manipulating the muscles surrounding the quadrilateral space, and strengthening the rotator cuff muscles.

If physical therapy is not successful in resolving QSS symptoms, the same type of injection used for diagnosis can also be helpful as a treatment, as Dr. Kemp and colleagues, Dr. Hangge and colleagues, and Dr. Feng and colleagues all explained. It should be noted that in order for pain relief to be long lasting, a steroid must be injected along with the numbing agent used in the diagnostic injection procedure. This is because the numbing agent used is a short-term medication, while the effects of steroids are known to linger for a longer time.

When all other treatments have failed, surgery is an option. The procedure used is decompression of the quadrilateral/quadrangular space. This procedure has been described in detail by Dr. Lucy E. Meyer and her colleagues in the Video Journal of Sports Medicine. (It should be noted that along with a written description of the surgery, a video is available at the link—readers should be aware before viewing the video that parts of it are graphic.) Basically, during this procedure the quadrilateral/quadrangular space is enlarged by removing scarring, fascia, or other tissues impinging on the space. Dr. Hangge and his colleagues noted that this surgery is often quite successful at resolving symptoms.

Disclaimer

Please note that the information in this blog post is general in nature and is not meant to replace advice received from a medical professional. Those experiencing symptoms suspected of being related to QSS are encouraged to seek medical care.