PROLOTHERAPY

 

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. 

Prolotherapy should be rendered by someone with expertise in the body's anatomy, kinetics, kinematics, and detailed understanding of the injection solutions and techniques.  Many individuals mentor with an experienced provider while others go to courses or travel outside the United States on charity missions.  Currently, it is not taught in any United States medical school or residency, but now in 2008 it has become part of medical training in Mexico.  Despite the treatment being fairly simple, it is not as basic as finding a "tender point" and injecting dextrose (sugar).  Like all things in medicine, the most vital part is identifying the correct diagnosis, understanding the pathology, and choosing the appropriate treatment for that problem.  The rendering of the treatment is the "easy" part. 

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

 
PROLOTHERAPY TREATMENT

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

  •     Dextrose  ("sugar")                               
  •     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)

 
Post-Procedure Instructions

    Reduce activities duration the initial painful post-treatment period.
    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)

    Immediate Injection Site Pain
    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 may cover on a case by case basis

 Articles

   Injections to Kick-Start Tissue Repair by D Jane Brody New York Times 2007
   Prolotherapy for Musculoskeletal Pain by Donna Alderman, DO

 

Prolotherapy

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The YANN TRUST

IN LOVING MEMORY OF YASMIN ALGARIN

Yasmin was, and always will be, a shining example of a how a person can achieve anything with hard work and a life-affirming attitude. She gave more than she took, she loved more than she feared, and she nurtured her family and friends at every opportunity. We will always remember Yasmin as a woman of strength, courage and compassion. 

Due to her untimely passing from brain cancer, we have set up a trust fund for her two children, Niles and Nylah. Please make your checks payable to: The YANN Trust (Yasmin Algarin Niles Nylah), 197 Ridgedale Ave., Suite 210, Cedar Knolls, NJ 07927.

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DISCLAIMER

The pages on this website contain general guidelines and information based on acceptable standards and should not be construed as medical advice. 

Please consult your own physician for appropriate management about your medical condition.