Prolotherapy

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Prolotherapy
Intervention
HCPCS-L2 M0076

Prolotherapy, also called proliferation therapy or regenerative injection therapy is a treatment of tissue with the injection of an irritant solution into a joint space, weakened ligament, or tendon insertion to relieve pain.

Medical uses[edit]

Prolotherapy may help in the following conditions: low back pain, tendinitis and osteoarthritis.[1] The evidence for these uses, however, is tentative.[2] There is also little good evidence for sports related injuries.[3]

Low back pain[edit]

A 2007 Cochrane review of prolotherapy in adults with chronic low-back pain found unclear evidence of effect.[4] A 2009 review came to the same conclusions for subacute low back pain.[5] There was tentative evidence of benefit when used with other low back pain treatments.[2][4]

Tendinitis[edit]

A 2009 systematic review of the efficacy in the treatment of lateral epicondylosis concluded that these therapies may benefit people with lateral epicondylosis, but the evidence was limited.[6] A 2010 systematic review concluded moderate evidence exists to support the use of prolotherapy injections in the management of pain in lateral epicondyalgia and that prolotherapy was no more effective than eccentric exercise in the treatment of achilles tendinopathy.[7]

In 2012, a systematic review studying various injection therapies found that prolotherapy and hyaluronic acid injection therapies were more effective than placebo when treating lateral epicondylosis. Of the studies evaluated, one of ten glucocorticoid trials, one of five trials for autologous blood injection or platelet-rich plasma, one trial of polidocanol, and one trial of prolotherapy met the criteria for low risk of bias. The authors noted that few of the reviewed trials met the criteria for low risk of bias.[8]

Osteoarthritis[edit]

There is tentative evidence that prolotherapy may be useful in osteoarthritis.[2]

Contraindications[edit]

Contraindications for patients to receive prolotherapy injections may include:[1]

Relative contraindications include:

Side effects[edit]

Patients receiving prolotherapy injections have reported generally mild side effects including: mild pain and irritation at the injection site[10] (often within 72 hours of the injection), numbness at the injection site, or mild bleeding. Pain from prolotherapy injections is temporary and is often treated with acetaminophen[10] or in rare cases opioid medications; NSAIDs are not usually recommended, but are occasionally used in patients with pain refractory to other methods of pain control.[1] Theoretical adverse events of prolotherapy injection include lightheadedness, allergic reactions to the agent used, bruising, infection, or nerve damage. However, allergic reactions to sodium morrhuate are rare.[1] Rare cases of back pain, neck pain, spinal cord irritation, pneumothorax, and disc injury have been reported at a rate comparable to that of other spinal injection procedures.[1][2]

Technique[edit]

Prolotherapy involves the injection of an irritant solution into a joint space, weakened ligament, or tendon insertion to relieve pain.[2] Most commonly, hyperosmolar dextrose (a sugar) is the solution used;[11] glycerine,[10] lidocaine (a commonly used local anesthetic),[12] phenol,[10] and sodium morrhuate (a derivative of cod liver oil extract) are other commonly used agents.[2][6] The injection is administered at joints or at tendons where they connect to bone.

Prolotherapy treatment sessions are generally given every two to six weeks for several months in a series ranging from 3 to 6 or more treatments.[10][1] Many patients receive treatment at less frequent intervals until treatments are rarely required, if at all.[13]

Terminology[edit]

The term originated with George S. Hackett, M.D. in 1956, as “The rehabilitation of an incompetent structure by the generation of new cellular tissue”. He “applied the term prolotherapy from the word “proli’” (Latin) meaning offspring; “proliferate” -to produce new cells in rapid succession.[14] Although an erroneous term (sclerotherapy) was utilized by some in the past to describe this treatment, it is now clear that prolotherapy does not cause scarring.[15] The mechanism of prolotherapy requires further clarification.[9][10][15][16][17][18]

Criticism[edit]

Major medical insurance policies view prolotherapy as an investigational or experimental therapy with an inconclusive evidence base. Consequently, they currently do not provide coverage for prolotherapy procedures.[19][20][21] Medicare reviewers in 1999 determined at that time that practitioners had not provided "any scientific evidence on which to base a [different] coverage decision," and so retained Medicare's current coverage policy to not cover prolotherapy injections for chronic low back pain, but expressed willingness to reconsider if presented with results of "further studies on the benefits of prolotherapy."[22]

History[edit]

Gustav Hemwall circa 1990-1995

The concept of creating irritation or injury to stimulate healing has been recorded as early as Roman times where hot needles were poked into the shoulders of injured gladiators. Prolotherapy use began in the 1930s and was originally used in the treatment of ligamentous laxity.[6] In the 1950s Dr. George S. Hackett, a general surgeon in the United States, began performing injections of irritant solutions in an effort to repair joints and hernias.[1] This practice is what would eventually evolve into modern day prolotherapy. In 1955, Gustav Anders Hemwall became acquainted with George Hackett at an American Medical Association meeting and started practicing prolotherapy.

References[edit]

  1. ^ a b c d e f g Rabago, D; Slattengren, A; Zgierska, A (2010). "Prolotherapy in Primary Care Practice". Primary Care: Clinics in Office Practice 37 (1): 65–80. doi:10.1016/j.pop.2009.09.013. PMC 2831229. PMID 20188998. 
  2. ^ a b c d e f g h Distel, LM; Best, TM (June 2011). "Prolotherapy: a clinical review of its role in treating chronic musculoskeletal pain". PM&R 3 (6 supplement 1): S78–S81. doi:10.1016/j.pmrj.2011.04.003. PMID 21703585. 
  3. ^ Rabago, D; Best, TM; Beamsley, M; Patterson, J (September 2005). "A systematic review of prolotherapy for chronic musculoskeletal pain.". Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 15 (5): 376–80. PMID 16162983. 
  4. ^ a b Dagenais, S; Yelland, MJ; Del Mar, C; Schoene, ML (April 2007). "Prolotherapy injections for chronic low-back pain". Cochrane Database of Systematic Reviews. CD004059 (2): CD004059. doi:10.1002/14651858.CD004059.pub3. PMID 17443537. 
  5. ^ Staal, JB; de Bie, RA; de Vet, HC; Hildebrandt, J; Nelemans, P (1 January 2009). "Injection therapy for subacute and chronic low back pain: an updated Cochrane review.". Spine 34 (1): 49–59. PMID 19127161. 
  6. ^ a b c Rabago, D; Best, TM; Zgierska, AE; Zelsig, E; Ryan, M; Crane, D (2009). "A systematic review of four injections therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood, and platelet-rich plasma". British Journal of Sports Medicine 43 (7): 471–481. doi:10.1136/bjsm.2008.052761. PMC 2755040. PMID 19028733. 
  7. ^ Coombes, BK; Bisset, L; Vicenzino, B (November 2010). "Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials". Lancet 376 (9754): 1751–1767. doi:10.1016/S0140-6736(10)61160-9. PMID 20970844. 
  8. ^ Krogh, TP; Bartels, EM; Ellingsen, T; Stengaard-Pedersen, K; Buchbinder, R; Fredberg, U; Bliddal, H; Christensen, R (September 2012). "Comparative Effectiveness of Injection Therapies in Lateral Epicondylitis: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials". American Journal of Sports Medicine (7). doi:10.1177/0363546512458237. PMID 22972856. 
  9. ^ a b c d "Prolotherapy". University of Pittsburgh Medical Center. 2012. Retrieved 16 December 2012. 
  10. ^ a b c d e f Judson, CH; Wolf, JM (October 2013). "Lateral Epicondylitis: Review of Injection Therapies". The Orthopedic Clinics of North America 44 (4): 615–623. doi:10.1016/j.ocl.2013.06.013. PMID 24095076. 
  11. ^ Davidson, J; Jayaraman, S (February 2011). "Guided interventions in musculoskeletal ultrasound: what's the evidence?". Clinical radiology 66 (2): 140–152. doi:10.1016/j.crad.2010.09.006. PMID 21216330. 
  12. ^ Laura Johannes (2010). "A Pinch of Sugar for Pain". Wall Street Journal. Retrieved 16 December 2012. 
  13. ^ Banks, AR (1991). "A Rationale for Prolotherapy". Journal of Orthopaedic Medicine 13 (3). 
  14. ^ Hackett, GS (1956). Ligament and tendon relaxation treated by prolotherapy,. Springfield, IL: Charles C. Thomas. 
  15. ^ a b Seidenberg, P (2008). The Sports Medicine Resource Manual. Philadelphia: Elsevier. pp. 611–619. ISBN 978-1-4160-3197-0. 
  16. ^ Waldman, S (2010). Pain Management. Philadelphia: Saunders (Elsevier). pp. 1027–1044. ISBN 978-1-4377-0721-2. 
  17. ^ Brody, Jane E. (7 August 2007). "Injections to Kick-Start Tissue Repair". New York Times. Retrieved 24 July 2008. Prolotherapy involves a series of injections designed to produce inflammation in the injured tissue. 
  18. ^ Brent A. Bauer (2012). "Prolotherapy: Solution to low back pain?". Mayo Clinic. Retrieved 16 December 2012. 
  19. ^ "Clinical Policy Bulletin: Prolotherapy". Aetna, Inc. 2013. Retrieved 12 October 2013. 
  20. ^ "Prolotherapy for Musculoskeletal Indications". Medical Policy. UnitedHealthCare. 2013. Retrieved 12 October 2013. 
  21. ^ "Corporate Medical Policy". Prolotherapy. BlueCross BlueShield of North Carolina. 2013. Retrieved 12 October 2013. 
  22. ^ "Decision Memo for Prolotherapy for Chronic Low Back Pain)". Centers for Medicare and Medicaid Services. Retrieved 12 October 2013. 

External links[edit]

  • www.ACOPMS.com - The American Osteopathic Association of Prolotherapy Integrative Pain Management, affiliated with the American Osteopathic Association, is an association of osteopathic physicians dedicated toward improving the practice of, and disseminating knowledge about prolotherapy.
  • American Association of Orthopaedic Medicine is a non-profit organization that promotes prolotherapy.
  • [1] is a source of a dozen videos about prolotherapy for athletes and a wide variety of injuries. Dr. Albert Franche produced the videos for his patients.