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Therapies

prolotherapy

What Is It?
How Does It Work?
What You Can Expect

Health Benefits

How To Choose a Practitioner

Cautions

References

Evidence Based Rating System

 

What Is It? 

Prolotherapy is a nonsurgical treatment for damaged ligaments that relieves musculoskeletal pain. An irritant solution is injected into areas where ligaments are weak, triggering the body to heal the injury and thereby naturally strengthening the joint. 

The therapy has its roots in an ancient, if barbaric-sounding, method of healing. Around 400 B.C., Hippocrates, the father of modern medicine, learned to heal javelin throwers' injured shoulders by thrusting a hot lance into the joint. The result of this primitive precursor to prolotherapy was a restored joint that was often stronger than the original. When the wound healed, the scar tissue had made it stronger, and many of the soldiers were able to throw their lances farther than they could before. (1,2) 

Modern prolotherapy evolved from an injection technique called sclerotherapy, which was first used in the 1920s to treat hernias and hemorrhoids. In the 1930s Earl Gedney, a well-known osteopathic physician at the Philadelphia College of Osteopathic Medicine, began to use sclerotherapy for back-related ailments. It was George S. Hackett, an M.D. from Canton, OH, who first coined the term "prolotherapy" in the 1950s. His book, Ligament and Tendon Relaxation Treated by Prolotherapy, continues to be used as a basic training reference. (2,3,4) 

Today the term "sclerotherapy" mainly refers to the use of injections to eliminate small spider veins for cosmetic purposes. The term "prolotherapy" refers to injections for pain management and for strengthening joints and ligaments. 

How Does It Work?

 Prolotherapy is based on the theory that pain is related to sensitive receptors in tendons or ligaments, which are activated by pressure, stretching, and injury. Because ligaments and tendons have a poor blood supply, they often do not heal completely after tearing. When they do not return to their normal length and strength after an injury, they may become stretched and lax. This causes joints (including the vertebrae) to become unstable, producing excessive rubbing, arthritic changes, and persistent, low-grade pain. The healing mechanisms stimulated by prolotherapy help to restore normal function in weakened joints, allowing the body to relieve the pain by healing itself. (5-8) 

The therapy involves injecting a simple solution of concentrated dextrose, saline, lidocaine, glycerol, or another agent into soft tissues such as ligaments or tendons. The solution is referred to as a "proliferating agent" because it produces a "proliferation of inflammation" in the injured area. Prolotherapy is effective because inflammation leads to healing. This happens when the body's anti-inflammatory chemicals, called macrophages, rush to respond to the inflammation, stimulating a natural healing response and promoting growth factors in the cells of the affected tendons and ligaments. Connective-tissue-builders called fibroblasts lay down new fibrous tissue wherever they detect damage, while other natural substances trigger the growth of new blood vessels and the flow of nutrients. (5-9) 

The difference between prolotherapy and anti-inflammatory drugs (such as aspirin, ibuprofen, or even cortisone) is that although these medications may relieve pain temporarily, they also block some of the natural chemicals that can repair the underlying damage. In many cases, therefore, an injury never heals completely, and the pain becomes chronic and persistent. Many people with musculoskeletal pain enter a vicious cycle of pain, drugs, more pain, and more drugs. By contrast, because prolotherapy involves a cycle of controlled inflammation and healing, rather than just temporarily blocking pain sensations, it actually triggers the growth of new tissue, which permanently repairs the joint. With strong, tightened ligaments and tendons, the joint is re-stabilized, and no longer causes pain. (5-8) 

What You Can Expect

 First the doctor will locate the painful body points or "hot spots" that require treatment. (10) Sometimes x-rays or thermography (infra-red mapping of the body to detect heat sources such as inflammation) will be used to aid this process. The practitioner is also able to confirm which areas to treat by physical examination, using the sense of touch to find specific injuries. Tests such as stress analysis may also be used to confirm the exact location of the injury. (10,11) 

Next, the doctor repeatedly inserts a needle containing small amounts of prolotherapy fluid around the injured area. Because the needle is very fine, these multiple injections produce only mild pain. Discomfort is also diminished by the addition of procaine, an anesthetic, into the proliferating solution. (12) 

The number of sessions required depends on the degree of injury, but in most cases you'll need 6 to 15 sessions to fully strengthen a small joint, and 12 to 30 sessions for large joints such as the hip or back. Some doctors prefer to inject the complete area in the first session and then re-evaluate progress in six weeks, repeating every six weeks as needed. Some follow up after one to two weeks, giving three sets of injections in six weeks. Others give the injections weekly for 15 to 18 weeks. (6-8,12) 

You may experience mild pain, bruising, swelling and joint stiffness after prolotherapy injections, but these problems are temporary and can be treated with ice packs or an over-the-counter pain reliever such as acetaminophen. OTC anti-inflammatory painkillers, such as aspirin or ibuprofen, are not recommended, however, because they can lessen the essential inflammatory healing process. While pain resulting from treatment generally decreases after the first two or three injections, full repair of the joint comes only after a complete course of treatment, so it's important to see it through. (7,12) 

In a recent survey of prolotherapists, the adverse events they mentioned seeing in practice when using prolotherapy for back and neck pain were similar to other widely used injection procedures. (13) 

Health Benefits

 Although clinical research on prolotherapy is limited, a few studies reported in reliable medical journals have shown good-to-excellent results in pain relief in up to 85% to 90% of those who have tried it. (14-17) Because the principle of prolotherapy can apply to a broad range of problems that cause musculoskeletal pain, it has been used successfully to treat many different conditions. 

Back pain responds particularly well to prolotherapy, because many types of back pain are the result of injuries to the ligaments that hold the spine together. (18-20) The results of studies are mixed. However, the Mayo Clinic suggests that when prolotherapy is combined with other treatments, such as spinal manipulation and exercise, it may improve back pain. (21) Because headache pain is often a result of similar ligament/tendon damage, it too can often be improved with a course of prolotherapy injections. (22) A variety of other joint problems have shown significant relief as well. These include pain in the shoulders, elbows, knees, ankles, and jaw (TMJ, or temporomandibular joint pain). (23-26) 

Other problems that have been reported to be relieved by prolotherapy include arthritis, fibromyalgia, sports injuries, whiplash, carpal tunnel syndrome, degenerated or herniated disks, and sciatica. (26-33) However, studies in general are small for use of prolotherapy and offer no comparison group to exclude the possibility that the perceived benefits are due to placebo. For instance, for fibromyalgia, only a case series of 31 patients has been reported and there was no control group to compare with those who did receive the experimental therapy. (31) The U.S. government is funding research on the potential benefit of prolotherapy. Its National Center for Complementary and Alternative Medicine (NCCAM) is sponsoring 2 studies, one of people with knee pain and one of people with tennis elbow, both of which are currently recruiting potential participants. (34) 

How To Choose a Practitioner

 Currently, there are only about 500 physicians across the country who administer prolotherapy, although the number is growing. The injections should be given only by a physician with an M.D. (medical doctor) or D.O. (doctor of osteopathy) license, or by state-licensed naturopaths (N.D.s), where their state's scope of practice allows such treatments. The physician should have training and experience in the technique. The injections may be given by a physician's assistant (PA) working under the doctor's supervision. There is no legal credentialing required to do prolotherapy, as the method is a procedure included in state medical licensure. 

Many doctors who offer prolotherapy have been trained by other doctors or in seminars. The Hackett Hemwall Foundation, named for George S. Hackett who popularized the technique and Dr. Gus Hemwall who established the foundation, sponsors the primary training seminar, which is offered for physicians annually. 

There are programs that teach prolotherapy methods to physicians and maintain a registry of qualified practitioners. You can call these organizations for a referral:

  • American Association of Orthopaedic Medicine, Buena Vista, CO, 888-687-1920, or visit their website at www.aaomed.org
  • The American College of Osteopathic Sclerotherapeutic Pain Management, Middletown, DE, 302-376-8080, or visit their website at www.acopms.com

Cautions

 It is best to avoid the use of caffeine, alcohol, and anti-inflammatory drugs during prolotherapy; they may reduce its effectiveness or lengthen the number of treatments required.

References 

1. Pomery KL. Introduction to Sclerotherapy (Prolotherapy) & Research Review. Paper given at AAOM seminar. March 23, 2004. Available at: http://www.drpomeroy.com/pages/documents/intro_scleropathy.pdf.
2. Kidd RF. Indications for low back prolotherapy. Available at: http://www.rfkidd.com/Indications_For_Low_Back_Prolotherapy.
3. Gedney EH. Hypermobile joint. Osteopath Profess.1937;4:30-31.
4. Hackett GS. Ligament and Tendon Relaxation Treated by Prolotherapy. 3rd ed. Illinois: Hemwall G Institute: 1958.
5. Prolotherapy Injection Treatment for Ligamentous Laxity. Brochure. American Association of Orthopedic Medicine. Woodland Park, CO: AAOM: 2006. Available at: http://www.aaomed.org. Accessed: November 8, 2008.
6. Prolotherapy Defined. Web page of Hemwall Family Medical. Available at: http://www.prolotherapy.com/prolodefine.htm. Accessed: November 8, 2008.
7. Alvin Stein. What is prolotherapy? Web page. Available at: http://www.getprolo.com/what_is_prolotherapy.htm. Accessed: November 9, 2008.
8. American College of Osteopathic Sclerotherapeutic Pain Management, Inc.  Web page. Available at: http://www.acopms.com/. Accessed: November 9, 2008.
9. Dagenais S, Haldeman S, Wooley JR. Intraligamentous injection of sclerosing solutions (prolotherapy) for spinal pain: a critical review of the literature. Spine J. 2005;5(3):310-328.
10. Darrow M. What is prolotherapy and how does it work? Web page. Available at: www.getprolo.com/how_does_prolo_work.htm.
11. Hooshmand H, Hashmi M, Phillips EM. Infrared thermal imaging as a tool in pain management – an 11 year study. Part II: Clinical applications. Web article. Available at: http://rsdrx.com/thermography_part-_ii.htm. Accessed: November 9, 2008.
12. Weiner RS, Ed. Pain Management: a Practical Guide for Clinicians. 6th ed. CRC Press; 2002:382-387.
13. Dagenais S, Ogunseitan O, Haldeman S, et al. Side effects and adverse events related to intraligamentous injection of sclerosing solutions (prolotherapy) for back and neck pain: A survey of practitioners. Arch Phys Med & Rehabil. 2006;87(7):909-913.
14. Hooper RA, Ding M. Retrospective case series on patients with chronic spinal pain treated with dextrose therapy. J Altern Complement Med. 2004;10(4):670-674.
15. Yelland MJ. Del Mar C, Priozzo S, Schoene ML. Prolotherapy injections for chronic low back pain: a systematic review. Spine. 2004;29(19):2126-2133.
16. Yelland MJ, Mar C, Pirozzo S, et al. Prolotherapy injections for chronic back pain. Cochrane Database Syst Rev. 2004;2:CD004059. [Abstract].
17. Yelland MJ, Glasziou PP, Bogduk N, et al. Prolotherapy injections, saline injections, and exercises for chronic low back pain: a randomized trial. Spine. 2004;29(1):9-16.
18. Wilkinson HA. Injection therapy for entheropathies causing axial spine pain and the ‘failed back syndrome’: a single-blinded randomized and cross-over study. Pain Physician. 2005;8(2):167-173.
19. Cusi M, Saunders J, Hungerford B, et al. The use of prolotherapy in the sacro-iliac joint. Br J Sports Med. 2008 Apr 8. Epub.
20. Forst SL, Wheeler MT, Fortin JD, Vilensky JA. The sacroiliac joint: anatomy, physiology and clinical significance. Pain Phys. 2006;9:61-68.
21. Prolotherapy: An effective treatment for back pain? Mayo Clinic Web page. Available at: www.mayoclinic.com/health/prolotherapy/AN01330. Accessed: November 7, 2008.
22. Current Pain & Headaches Report. AAOM page. Available at: www.aaomed.org/files/headaches_report.pdf.
23. Rabago D, Best TM, Beamsley M, Patterson J. A systematic review of prolotherapy for chronic musculoskeletal pain. Clin J Sport Med. 2005;15(5):376-380.
24. Hakala RV. Prolotherapy (proliferation therapy) in the treatment of TMJ. Cranio. 2005;23(4):283-288.
25. Reeves KD, Hassanein KM. Long-term effects of dextrose prolotherapy for anterior cruciate ligament laxity. Altern Ther Health Med. 2003;9(3):58-62.
26. Florida Academy of Pain Management Position Paper on Regenerative Injection Therapy (RIT): Effectiveness and Appropriate Usage. Whitepaper. May 24, 2001.
27. Khan SA, Kumar A, Varshney MK, et al. Dextrose prolotherapy for recalcitrant coccygodnia. J Orthop Surg (Hong Kong). 2008;16(1):27-29.
28. Kim SR, Stitik TP, Foye PM, et al. Critical review of prolotherapy for osteoarthritis, low back pain, and other musculoskeletal conditions: a physiatric perspective. Am J Phys Med Rehabil. 2004;83(5):379-389.
29. Reeves KD, Hassanein K. Randomized, prospective, placebo-controlled double-blind study of dextrose prolotherapy for osteoarthritic thumb and finger (DIP, PIP, and trapeziometacarpal) joints: evidence of clinical efficacy. J Altern Complement Med. 2000;6(4):311-320. 
30. Reeves KD, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Altern Ther Health med. 2000;6(2):68-74.
31. Reeves KD. Treatment of consecutive severe fibromyalgia patients with prolotherapy. J Orthopaedic Med. 1994;16(3). Reprint available online at: http://www.prolotherapy.com/articles/reeves.htm. Accessed: November 8, 2008.
32. Centeno CJ, Elliott J, Elkins WL, Freeman M. Fluoroscopically guided cervical prolotherapy for instability with blinded pre and post radiographic reading. Pain Physician. 2005;8(1):67-72.
33. Scarpone M, Rabago DP, Zgierska A, et al. The efficacy of prolotherapy for lateral epicondyosis. 2008;18(3):248-254.
34. ClinicalTrials.gov. NIH Web site. Available at: http://clinicaltrials.gov/search/term=(NCCAM)+%5BSPONSOR%5D+(recruiting)+%5BOVERALL-STATUS%5D+OR+(NCCAM)+%5BSPONSOR%5D+(not+yet+recruiting)+%5BOVERALL-STATUS%5D. Accessed: November 9, 2008.

Evidence Based Rating Scale 

The Evidence Based Rating Scale is a tool that helps consumers translate the findings of medical research studies with what our clinical advisors have found to be efficacious in their personal practice. This tool is meant to simplify which supplements and therapies demonstrate promise in the treatment of certain conditions. This scale does not take into account any possible interactions with any medication/ condition/ or therapy which you may be currently undertaking. It is therefore advisable to ask your doctor before starting any new treatment regimen.

Condition

Rating

Explanation

 

  

 

 

Arthritis

 

 

 

 

 

 

Practitioners use for wrist and knee therapy

 


Date Published: 04/19/2005

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