Prolotherapy: All you need to know

“A joint is only as strong as its weakest ligament” – Dr. Hackett, father of prolotherapy

History:

  • Used in the USA since the 1930s.
  • Endorsed by former U.S Surgeon General, C. Everett Koop.
  • ‘Sclerotherapy’ was an older, inaccurate term based on the now disproven theory that the treatment worked by creating scar tissue.

The natural healing process:

  • Tendons and ligaments have poor blood supply and so healing is slow and often incomplete.
  • Factors that impede the healing process post-injury include smoking, stress, lack of sleep, poor nutrition and anti-inflammatory medications.

Purposed mechanism:

  • In the short term, the injected solution interacts with nearby damaged connective tissue, which initiates the injury response, which then actives the body’s inflammatory cascade.1
  • Once the injected fluid is diluted by the body, the inflammation ceases but growth factors (generated by the inflammatory cascade) continue to exert their effect on the damage tissue, lasting for several weeks.
  • Fibroblasts are activated and in the presence of growth factors, cell growth and collagen deposition is promoted. The treatment-induced inflammation continues the body’s healing reaction that occurred at the time of injury, but was insufficient to heal the connective tissue.2
  • Post injury, connective tissue lacks sufficient tensile strength. “It has been estimated that the usual best result of a completed connective tissue repair process is a return to normal connective tissue length, but only 50% to 60% of pre-injury tensile strength.”3  Over time, the reduced tensile strength leads to ligament laxity.
  • Weakness or laxity of ligaments triggers muscle spasms in attempt to stabilize the joint. As long as connective tissue is not fully healed, receptors continue to fire, which produces pain.4
  • Animal biopsy shows ligament thickening, enlarged tendon-bone connection and strengthening of tendon or ligament post-treatment.5

Scientific support:

  • In chronic low back pain, biopsy found 60% increase in collagen thickness 3 months post-treatment.6
  • In professional athletes with chronic groin pain, 83% reported no pain and 91.% reported no restriction with sport. An average of 2.8 treatments were required.
  • A knee osteoarthritis trial found decreased severity of symptoms and improved ACL laxity at the 1-year and 3-year follow up.7
  • The Florida Academy of Pain Medicine reviewed the medical literature for prolotherapy back to 1937 and a total of over 500,000 subjects were included.  They concluded that prolotherapy was effective as a “type-specific treatment for post-traumatic degenerative, overuse and pain conditions of the musculoskeletal system related to pathology of the connective tissue.”8

What is injected?

  • Commonly a combination of dextrose (the irritant and inflammation-inducer) and procaine (an anesthetic for immediate pain control) are used.
  • Other agents such as Sarapin, vitaminB12 or sodium morrhuate may be added.
  • With platelet-rich plasma (PRP), a different but similar treatment, blood is collected from the vein. From the blood, the platelets and growth factors are extracted and then injected directly into the site of injury.

Indicated conditions:

  • Sprains or strains causing chronic pain
  • “Overuse” injury, including tennis/golfer’s elbow and shoulder tendonitis
  • Postural pain of neck, mid-back, low back or the sacro-lumbar region
  • Painful joint hyper-mobility (often linked with restricted range of motion in a nearby joint)
  • Foot and ankle pain, plantar fasciitis
  • TMJ dysfunction or pain
  • Osteoarthritis involving any joint including fingers and toes
  • Instability of the spine due ligament laxity or degenerated disc disease
  • Failure to improve after massage, physiotherapy, chiropractic/osteopathic treatment or corticosteroid injections

Who should consider prolotherapy?

  • Must be willing to commit to a series of treatments, ranging from once ever 2 weeks to once over 6 weeks. PRP treatments are only required every month to every 3 months.
  • Must be willing to receive injections, which may be painful in the short term and may produce worsening joint pain over the days following treatment.
  • Age is not a concern, so long as there is a general state of health.
  • Must not be taking corticosteroid or immune-suppressant medications and must not take any anti-inflammatory medications (ie. Advil) during the course of treatment.

Contraindications:

  • Local, active injection in the joint to be treated
  • Active cancer (not in remission)
  • Acute gout attack in the joint to be treated
  • Rheumatoid arthritis
  • Immunodeficiency condition
  • Complete tear of ligament or tendon (surgery is your best option here)
  • Unstable spondylolithesis
  • Not willing to experience post-treatment discomfort

Risks:

  • Soreness of treatment region is common, lasting a day up to a week.
  • Bruising
  • Temporary increased pain
  • Infection (rare)
  • Allergy (rare)
  • Organ or epidural puncture (rare)
  • Possibility that minimal or no improvement in pain or stability of joint occurs

Treatment Schedule:

  • Initial visit involved history taking, assessment of co-morbid conditions that may impede healing, physical/orthopedic assessment and treatment.
  • Subsequent visit may involve continued orthopedic assessment and treatment.
  • Treatments are spaced every 2 weeks to every 4 weeks, depending on severity.
  • Multiple joints can be treated during a visit.

Complimentary Therapies:

  • Fundamental naturopathic treatments including supplements, herbs or dietary modifications may be recommended.
  • Ozone therapy is an excellent adjunct, either injected with the prolotherapy or give IV at a different time.
  • IV nutrient therapy may aid in accelerating the healing response
  • Referral to massage, physiotherapy or chiropractic is often recommended in between prolotherapy treatments.

References:

  1. Alderman, Donna. Prolotherapy for Musculoskeletal Pain: A primer for pain management physicians on the mechanism of action and indicatins for use. Practical Pain Management Jan/Feb 2007
  2. Reeves KD. Prolotherapy: Basic Science, Clinical Studies and Technique. In Lennard TA Pain Prodecures in Clinical Practice, 2nd Edition. Hanley and Belfus. Philadelphia 2000 pp 172-190
  3. Andriacchi T, Sabiston P, DeHaven K, et al. Ligament: Injury and Repair. Acta Rheum Scand. 1956.2:109-116.
  4. Biedert RM, Stauffer E, and Friederich NF. Occurrence of free nerve endings in the soft tissue of the knee joint. A histologic investigation. American Journal of Sports Medicine. 1992. 20(4):430-433.
  5. Liu Y. An in situ study of the influence of a sclerosing solution in rabbit medical collateral ligaments and its junction strength. Connective Tissue Research. 1983. 11(2):95-102.
  6. Klein RG, Dorman TA, and Johnson CE. Proliferant injection for low back pain: Histologic changes of injected ligaments and objective measurements of lumbar spine mobility before and after treatment. The Journal of Neurological and Orthopedic Medicine & Surgery. July 1989. 10(2).
  7. Topol GA, Reeves KD, and Hassanein K. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Archives of Physical Medicine and Rehabilitation. 2005. 86:697-702.
  8. Linetsky FS, Botwin K, Gorfine L, et al. Position Paper: Regenerative injection therapy (RIT) effectiveness and appropriate usage. The Florida Academy of Pain Medicine. May 24, 2001. http://www.aaomed.org/library/documents/RIT_Position_Paper_052301.pdf>