Prolotherapy

Prolotherapy
Intervention
Gustav Hemwall circa 1990-1995
HCPCS-L2	M0076

Prolotherapy is also known as "proliferation therapy," "regenerative injection therapy," or "proliferative injection therapy". It involves injecting an otherwise non-pharmacological and non-active irritant solution into the body, generally in the region of tendons or ligaments for the purpose of strengthening weakened connective tissue and alleviating musculoskeletal pain.

It is thought to do so by re-initiating the inflammatory process that deposits new additional fibers to repair a perceived injury. Once strengthened, the weak areas no longer send pain signals. Originally published in the Journal of Orthopaedic Medicine Vol 13 1991 No 3, Allen R Banks, Ph.D., has described in detail the theory behind prolotherapy in "A Rationale for Prolotherapy".

History

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. This practice continues with little change in present vetrinary medicine - more frequently for horses where it is presently called "needling." In the 1940s George S. Hacket started performing injections of irritant solutions in an effort to repair joints and hernias. This practice is what would eventually evolve into modern day prolotherapy. He was joined in this practice by Gustav Anders Hemwall in the 1950s. In 1955, a Dr. Hemwall became acquainted with George Hacket at an American Medical Association and started practicing prolotherapy. Today, Dr. Hemwall is regarded as an expert in prolotherapy. He has treated and collected data on more than 8,000 paitents so far.

Prolotherapy in clinical practice

Prolotherapy (PROLiferation therapy) involves the injection of an irritant solution into an area where connective tissue has been weakened or damaged through injury or strain. Many solutions are used, including dextrose (a sugar), lidocaine (a commonly used local anesthetic), phenol, glycerine, or cod liver oil extract. The injection is given into joints or tendons where they connect to bone. The injected solution causes the body to heal itself through the process of inflammation and repair. The process may result in as much as 30-40% strengthening of the connective tissue. Although well designed traditional placebo controlled scientific studies are still few, increasing numbers of good studies have been seen lately. There are now medical textbooks available to teach principles and practice of prolotherapy such as that by Dr's Ravin, Cantieri and Pasquarello.

Prolotherapy treatment sessions are generally given every three to six weeks. Many patients receive treatment at less and less frequent intervals until treatments are rarely required, if at all. Prolotherapy is sometimes used as an alternative to arthroscopic surgery.

Signs used by practitioners as possible indications for prolotherapy

• Laxity of a tested joint that fails self resolution
• Distinct tender points at tendons or ligaments as they attach to the bones
• Recurrent swelling or fullness involving a joint or muscular region
• Popping, clicking, grinding, or catching sensations in joints
• Temporary benefit from chiropractic manipulation or manual mobilization that fails to persistently resolve
• Aching or burning pain that is referred into an upper or lower extremity
• Recurrent headache, face pain, jaw pain, ear pain
• Chest wall pain with tenderness along the rib attachments on the spine or along the sternum
• Spine pain that does not respond to surgery, or whose origin is not identified by extensive studies

Evidence based medicine

A Cochrane review of the medical literature as of January 2004 on the efficacy of prolotherapy injections in adults with chronic low-back pain found four controlled trials, all measuring pain and disability levels at six months. The review concluded:

"There is conflicting evidence regarding the efficacy of prolotherapy injections in reducing pain and disability in patients with chronic low-back pain. Conclusions are confounded by clinical heterogeneity amongst studies and by the presence of co-interventions. There was no evidence that prolotherapy injections alone were more effective than control injections alone. However, in the presence of co-interventions, prolotherapy injections were more effective than control injections, more so when both injections and co-interventions were controlled concurrently."

The review also noted: "[m]inor side effects from the treatment, such as increased back pain and stiffness, were common but short-lived." Stiffness is an expected short-lived side effect, as the goal is to cause irritation and the corresponding body reaction of temporary inflammation and repair.

Criticism

Most major medical insurance policies do not cover the treatment. After a 1999 review of the medical evidence, Medicare declined to cover prolotherapy for chronic low back pain citing that prolotherapy "was last examined for coverage by the Health Care Financing Administration (HCFA) in September 1992". Currently, a few medical insurance companies have started to cover prolotherapy.

In addition, there is a lack of solid evidence that prolotherapy is effective. Recent Cochrane reviews and controlled studies of the treatment did not find any proof prolotherapy was any more effective than other fringe treatments.

Ongoing studies

Knee injuries

A randomized, double-blind, placebo control study is currently recruiting patients to determine whether prolotherapy can decrease pain and disability from knee osteoarthritis. This study is sponsored by the National Center for Complementary and Alternative Medicine (NCCAM).

Tennis elbow

A randomized, double-blind, placebo control study is currently recruiting patients to determine whether prolotherapy can be an effective treatment for lateral epicondylitis (tennis elbow).

Thumb Joint Arthritis

A randomized, double-blind, placebo control study is currently recruiting patients to compare prolotherapy to injection of corticosteroids in treating carpo-metacarpal joint arthritis of the thumb.

Plantar Fasciitis

Sonographically guided dextrose injections showed a good clinical response in patients with chronic plantar fasciitis insofar as reducing pain during rest and activity. Further studies including a control group are needed to validate these outcomes.

A double blind pilot study found strong evidence that prolotherapy can be an effective treatment for epicondylosis.

Temporomandibular Joint Hyper mobility

This study concludes "[p]rolotherapy with 10% dextrose appears promising for the treatment of symptomatic TMJ hypermobility, as evidenced by the therapeutic benefits, simplicity, safety, patients' acceptance of the injection technique, and lack of significant side effects. However, continued research into prolotherapy's effectiveness in patient populations with large sample sizes and long-term follow-up is needed."

Published studies

Knee disorders

This study demonstrated functional improvement and radiological improvement after prolotherapy

See also

• Pin firing
• Gustav Hemwall
• Sclerotherapy

External links

• www.indianprolotherapy.org
• www.ACOPMS.com - The American Osteopathic Association of Prolotherapy Integrative Pain Management, affiliated with the American Osteopathic Association, is an association of licensed practitioners dedicated toward improving the practice of, and disseminating knowledge about prolotherapy.
• Prolotherapy.org is a source for extensive articles, diagrams and other resources related to prolotherapy.
• American Association of Orthopaedic Medicine is a non-profit organization that promotes prolotherapy.
• [3] 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.
• "CAM Prolotherapy Project". 2006-08-06. http://www.camresearch.com. Retrieved 2006-08-06. 
• Brody, Jane E. (2007-08-07). "Injections to Kick-Start Tissue Repair". New York Times. http://www.nytimes.com/2007/08/07/health/07brod.html. Retrieved 2008-07-24.