Prolotherapy: Cutting Edge Therapy for Chronic Injuries?
June 10, 2005
Gunnar Brolinson, D.O.
Many active people suffer from chronic or episodic musculoskeletal pain as a result of joint laxity or tendon/ligament pain resulting from recurrent tensile overload (stretching the tendon or ligament beyond its' capacity). Typically, this can result from overuse syndromes as well as acute traumatic injuries. Common examples are "high hamstring" strains that don't seem to get better, "tennis elbow" and recurrent ankle sprains from "loose ligaments". Prolotherapy is a technique utilizing injections of an irritant solution which can bring about new tissue healing and strength to these problem areas. It is typically used when patients have run out of options utilizing standard medical treatments. "Prolo" is short for "proliferative", referring to the goal of treatment - proliferation of new blood flow the affected area resulting in strengthening and healing of the damaged tissue. The solution consists of a combination of local anesthetic and dextrose (sugar water). Sometimes small amounts of other chemicals called phenol and glycerin are used depending on the type of injury being treated.
Traditionally when patients think about "getting a shot" they are referring to an injection of corticosteroid (cortisone) and local anesthetic. The theory behind these injections is that delivering a concentrated amount of anti-inflammatory medicine (the corticosteroid) to an inflamed, painful area decreases the inflammatory cascade and thus, the pain. However, there are drawbacks to corticosteroids including elevated blood sugars, immune system compromise and breakdown of body tissues such as joint capsules, cartilage, ligaments and tendons. New thinking about inflammation and healing of soft tissue (muscle, tendon or ligament) injuries raises questions as to whether we should be altering this natural physiologic inflammatory process at all. In this light, prolotherapy offers a favorable alternative because of the comparatively benign nature of the solution injected. The goal of prolotherapy is to actually "stir up" or cause inflammation. This sets about the cascade of: 1) inflammation, 2) granulation (healing) tissue formation and 3) new tissue growth (not scar tissue) which results, in theory, of relief of pain.
A large number of medical conditions can be potentially treated with prolotherapy. Most often these are acute or chronic musculoskeletal issues such as low back pain, overuse syndromes or sprains and strains. Some physicians are describing success treating chronic pain syndromes and neurologic disorders such as multiple sclerosis. Experience with these more esoteric or difficult to treat conditions is limited but patients may opt for prolotherapy because there are no other relatively safe or effective procedures.
A typical prolotherapy appointment involves a brief meeting with the physician where the procedure is explained, the risk and side effect profile is discussed and the treatment plan mapped out. When the patient comes in for treatment the affected area is usually iced down for 10 to 15 minutes to provide some topical anesthesia (cold spray can also be used) which make the injections more comfortable. The skin is then cleansed with alcohol and/or betadine to reduce the risk of infection. The proliferative solution is then mixed half and half with the local anesthetic. After this, a series of prolotherapy injections are carried out using a needle and syringe. The solution is usually injected at the attachment of the tendon or ligament to the bone (the "enthesis"). Sometimes the injections are "intra-articular" or inside the joint (such as the knee or shoulder). After the injections are completed the area is again cleaned. Typically the patient goes back to their normal day. As with any injection, there can be some discomfort from the injections themselves. Sometimes patients get a "post-injection flare" (mild redness and discomfort) which occurs in about 10% of patients. Most prolotherapy treatments involve four to six office visits for repeat injections which are usually spaced one or two weeks apart. One of the nice things about prolotherapy is that because of the inert nature of the solution, many treatments can be applied safely and it is usually well tolerated.
The jury is still out on prolotherapy in terms of both clinical and basic science studies. Many studies do show benefit and there are currently ongoing clinical trials across the country. One of the difficulties in designing and controlling such studies is that prolotherapy is very dependent on the skill of the administering physician and a "placebo" treatment group is difficult to include.
Injections of any kind carry the risk of bleeding and infection but these can be avoided in most cases with careful preparation and a skilled physician. As with any procedure, some things will interfere with the treatment. First, if a patient is taking anti-inflammatory medication such as ibuprofen, celebrex, aleve, etc., the prolotherapy will not work. This is because prolotherapy causes inflammation and anti-inflammatory medicines are counter-productive in this case. Smokers are also not good candidates. Compromised immune status or diseases such as hypothyroidism and uncontrolled diabetes can also interfere with the treatment. A known infection or malignancy is a reason not to perform it. Persons with bleeding disorders are also not good candidates. Lastly, returning to activity too soon can work against the injections and maintain the injury patterns. The bottom line is that it is important to listen to the guidance of your physician and trainer as to the best conditioning and exercise regimen during the prolotherapy treatments.
If you have a condition which you may believe could benefit from prolotherapy, talk to your doctor, athletic trainer or other health care provider.