What is Prolotherapy?
Prolotherapy is the injection of a proliferant substance to stimulate the body's intrinsic ability to heal. It addresses the degeneration or incomplete healing of injured ligaments, tendons, and cartilage. There are two general situations for the use of prolotherapy. A traumatic injury, which incompletely resolves and a repetitive stress beyond the reparative process. Some barriers to complete healing are excessive or inappropriate use of anti-inflammatory medications, corticosteroids, poor diet/malnutrition, smoking, maladaptive behaviors (poor training technique, posture, etc.), and other existing diseases which stress the body (co-morbidities).
Prolotherapy has been known by different names, but all have essentially the same intent. Sclerotherapy is an older term which was in use when the technique was thought to create scar in reducing symptoms. Now with the increased use and efficiency of diagnostic musculoskeletal ultrasound, the effect of tissue remolding to its normal architecture has been seen, thus there has been a movement to re-name it regenerative injection treatment (RIT).
Depending on the definition, this type of treatment has been around since Hippocrates. In its current form, prolotherapy has been around since the 1930's. The "fathers" of prolotherapy were George Stuart Hackett, MD and Gustav A. Hemwall, MD who used it to heal and cure many resistant pain cases. Dr. Hackett's book was first published in 1956 and was most recently revised in 1991. More recently, there are a growing number of scientific articles being published with slowly increasing "mainstream" support. Unfortunately, this simple, safe, cost effective treatment is considered by some to be an alternative treatment when more expensive treatments (including surgery) have greater risk with the same or worse outcomes.
Injury Background and Proposed Mechanism of Treatment Action
There is a rich supply of nerves in the connective tissue about which people including physicians, often forget. They offer feedback to determine where one is in space and different types of pain. The weakest link is typically at the attachment, but can also occur in the zone where the tendon changes to muscle (musculotendinous junction). This is the region where the pathology commonly occurs either from acute stretch or chronic overuse. When an area is injured, the body reacts with "inflammation" to "clean" out the damaged tissue and bring in the elements for repair. Anti-inflammatories (Motrin, Aleve, steroids, etc.) interfere with this healing process if used incorrectly (they are also analgesics, which is why they reduce pain). Maturation for the healing response occurs after 3 weeks and can continue for 1-3 years to obtain similar strength to pre-injury. Healing is not complete when the pain resolves or we think we can do everything again. Studies have demonstrated that after 2 weeks there are no inflammatory cells so there is not continued inflammation, but if unresolved a degenerative process (tendinitis v. tendinosis). Electron micrographs and diagnostic ultrasound evaluation of tendons demonstrates this disrupted architecture. Weak areas displace environmental stresses throughout the body and cause overload to adjacent and remote regions. This is the reason why treatment takes longer the longer the problem has been present. Muscle "spasm" is not uncommon because it is trying to stabilize the injured portion of the body. Trigger point injections (injections or dry needling into tender muscle which refers pain somewhere else) are often given to "relax" muscle and decrease pain, but if they are repetitive it is usually a reaction to the underlying pathology, not the primary problem.
Since there is poor blood supply to most of these areas, they are at greater risk for impaired healing. The classical proliferant is dextrose (i.e. sugar). This substance stimulates healing in at least two ways. First, it is more concentrated where injected as opposed to the surrounding injured tissue. This causes water to shift from the inside to outside of the cell; leading to bursting and causing a minor injury. The cell substances as well as the dextrose itself stimulates the healing cascade of cells to clear the damage and use new substances to re-build the area (macrophages, growth factors, etc.). Rehabilitation is very important once the healing has begun to prevent recurrence. If the precipitating cause can be identified and altered, this should also be addressed.
Typical Conditions Treated
Tendinopathies
Tennis and Golfer's Elbow
Jumper's Knee
Achilles "tendinitis"
Hip and Shoulder "Bursitis"
Osteoarthrosis or Cartilage Damage
Any joints, but commonly the knee
Ligaments
Various location, but commonly the neck and back
Enthesopathies (where connective tissue attaches to bone)
Fascia
Plantar fasciitis
Typical Treatment Course
The treatment depends on the extent the the problem, the ability to generate a healing response (one's own body health), duration of the pain/dysfunction, and other concomitant health issues.
The typical number of sessions ranges from two to six. A session generally consists of multiple injections to an anatomical region. If the treatment is not affording relief after two to three sessions, either the solution is adjusted, there is a greater focus on the individual's health or healing response or both. After three to four sessions to a specific region without relief, either a related area is addressed or the treatment is considered a failure. As healing takes time, the injections are repeated in 4-6 week intervals.
An informed consent form is supplied for review, questions and signature.
The patient is placed in a comfortable position to treat the intended site. Fluoroscopy is usually not necessary, but musculoskeletal ultrasound my be used for assistance. The area is marked for injection and cleansed to prevent infection. If a large region is to be treated, small amounts of anesthetic are used to numb the skin. The injections are then performed and are variable in discomfort level depending on disease and solution injected. The usual solution used initially is 12.5 to 25 percent dextrose (sugar water) mixed with an anesthetic (typically Procaine).
If the head or neck is being treated, it is strongly advised to have someone else drive since it could cause temporary dizziness or mild blurred vision.
It is common to have increased discomfort for 1-3 days and pain medication will be provided if needed. Anti-inflammatory medications (ibuprofen, naprosyn, Motrin, Aleve, Celebrex, etc.) are to be avoided as they interfere with the healing of soft tissues. Stiffness is common and bruising occasional.
Post-procedure instructions will be given.
Substances
P2G (Ongley's Solution)
Autologous Blood (ones own blood)
Soduim Morruhate (cod liver oil salt)
Blood
Miscellaneous
Various Anesthetics (typically Procaine or Lidocaine)
Assistance
Possible use of musculoskeletal ultrasound and rare need for fluoroscopy (x-ray)
Procedure - outlined above, but below are some photos of the typical markings
Lumbar Spine (Low Back)
UNDER CONSTRUCTION
*Shoulder
*Elbow
Ankle (Achilles Tendon)
Post-Procedure Instructions
Increased pain can occur 70% of the time and lasts about 1-3 days.
The activity level should be no more vigorous than the preceding month.
**NO anti-inflammatory medications (ie Ibuprofen, Motrin, Advil, Naprosyn, Aleve, Celebrex, etc.) as they can interfere with soft tissue healing.
Heat can be used, but ice should be avoided for the first week.
Pain medications are commonly prescribed and can be used as directed.
One mulit-vitamin per day.
One vitamin C (500mg to 1000mg) and one zinc (50mg to 100mg) supplement per day
Sufficient protein
Fish Oil 1g per day
Avoid High Fructose Corn Syrup and Partially Hydrogenated Oils
It takes time to heal, please be patient
If there is drainage at the injection site; increased heat, redness or fever; extreme pain; shortness of breath, hives, significant itching; or any concern, the physician should be called or go to the nearest hospital's emergency department
Risks and Informed Consent Form (link to FORM)
Stiffness of Joint Injected
Bruising
Headaches with Spine Injections
No effect from the Treatment
Infection
Bleeding
Allergic Reaction
Temporary or Permanent Nerve Injury
Pneumothorax (collapsed lung) when Injecting near the Lungs
Itching at Injection Sites
Transient Nausea/Vomiting
Dizziness or Fainting
Swelling after Joint Injections
Temporary Blood Sugar Increase
Insurance Coverage
Medicare does not reimburse this procedure
Traditional Insurance Companies generally do not cover this procedure
Worker's Compensation and Automobile Insurance Coverage is typically on a case by case basis
Articles
New York Times August 7, 2007
Injections to Kick-Start Tissue Repair by D Jane BrodyProlotherapy for Musculoskeletal Pain by Donna Alderman, DO