prolotherapy
   HOME

TheInfoList



OR:

Prolotherapy, also called proliferation therapy, is an injection-based treatment used in chronic musculoskeletal conditions. It has been characterised as an
alternative medicine Alternative medicine is any practice that aims to achieve the healing effects of medicine despite lacking biological plausibility, testability, repeatability, or evidence from clinical trials. Complementary medicine (CM), complementary and alt ...
practice.


Medical uses

A 2015 review found no evidence that prolotherapy is safe or effective for
Achilles tendinopathy The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon at the back of the lower leg, and is the thickest in the human body. It serves to attach the plantaris, gastrocnemius (calf) and soleus muscles to the calcaneus (h ...
, plantar fasciosis, and
Osgood–Schlatter disease Osgood–Schlatter disease (OSD) is inflammation of the patellar ligament at the tibial tuberosity (apophysitis). It is characterized by a painful bump just below the knee that is worse with activity and better with rest. Episodes of pain typica ...
. The quality of the studies was also poor. Another 2015 review assigned a strength of recommendation level A for Achilles tendinopathy and knee
osteoarthritis Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone which affects 1 in 7 adults in the United States. It is believed to be the fourth leading cause of disability in the w ...
and level B for lateral epicondylosis, Osgood–Schlatter disease, and plantar fasciosis. Level A recommendations are based on consistent and good-quality patient-oriented evidence while level B are based on inconsistent or limited-quality patient-oriented evidence.


Low back pain

A 2007
Cochrane review Cochrane (previously known as the Cochrane Collaboration) is a British international charitable organisation formed to organise medical research findings to facilitate evidence-based choices about health interventions involving health professi ...
of prolotherapy in adults with chronic low-back pain found unclear evidence of effect. A 2009 review concluded the same for subacute low back pain. A 2015 review found consistent evidence that it does not help in low back pain. There was tentative evidence of benefit when used with other low back pain treatments. Evidence of benefit remains tentative (level B) for dextrose prolotherapy in low back or sacroiliac pain.


Tendinitis

A 2009
systematic review A systematic review is a Literature review, scholarly synthesis of the evidence on a clearly presented topic using critical methods to identify, define and assess research on the topic. A systematic review extracts and interprets data from publ ...
of the efficacy in the treatment of lateral epicondylitis concluded that these therapies may benefit people with lateral epicondylitis, but the evidence was limited. A 2010 review concluded moderate evidence exists to support the use of prolotherapy injections in the management of pain in lateral epicondylitis, and that prolotherapy was no more effective than eccentric exercise in the treatment of Achilles tendinopathy. A 2016 review found a trend towards benefit in 2016 for lateral epicondylitis. A 2017 review found tentative evidence in Achilles tendinopathy. In 2012, a systematic review studying various injection therapies found that prolotherapy and
hyaluronic acid Hyaluronic acid (; abbreviated HA; conjugate base hyaluronate), also called hyaluronan, is an anionic, nonsulfated glycosaminoglycan distributed widely throughout connective, epithelial, and neural tissues. It is unique among glycosaminoglycans ...
injection therapies were more effective than
placebo A placebo ( ) is a substance or treatment which is designed to have no therapeutic value. Common placebos include inert tablets (like sugar pills), inert injections (like Saline (medicine), saline), sham surgery, and other procedures. In general ...
when treating lateral epicondylitis. Of the studies evaluated, one of ten
glucocorticoid Glucocorticoids (or, less commonly, glucocorticosteroids) are a class of corticosteroids, which are a class of steroid hormones. Glucocorticoids are corticosteroids that bind to the glucocorticoid receptor that is present in almost every vertebr ...
trials, one of five trials for
autologous blood injection Autologous blood therapy, also known as autologous blood injection or autohemotherapy, comprises certain types of hemotherapy using a person's own blood ('' auto-'' + '' hemo-'' + ''therapy''). There are several kinds, the original belonging only ...
or
platelet-rich plasma Platelet-rich plasma (PRP), also known as autologous conditioned plasma, is a concentrate of platelet-rich plasma protein derived from whole blood, centrifuged to remove red blood cells. Though promoted to treat an array of medical problems, evide ...
, one trial of
polidocanol Polidocanol is a local anaesthetic and antipruritic component of ointments and bath additives. It relieves itching caused by eczema and dry skin. It has also been used to treat varicose veins, hemangiomas, and vascular malformations. It is formed ...
, 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.


Knee osteoarthritis

Tentative evidence of prolotherapy benefit was reported in a 2011 review. One 2017 review found evidence of benefit from low-quality studies. A 2017 review described the evidence as moderate for knee osteoarthritis. A 2016 review found benefit but there was a moderate degree of variability between trials and risk of bias. In 2019, the
American College of Rheumatology The American College of Rheumatology (ACR; until 1985 called American Rheumatism Association) is an organization of and for physicians, health professionals, and scientists that advances rheumatology through programs of education, research, advocacy ...
recommended against prolotherapy for knee osteoarthritis.


Contraindications

Contraindications In medicine, a contraindication is a condition that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a reason to use a certain tre ...
for patients to receive prolotherapy injections may include: * Local
abscess An abscess is a collection of pus that has built up within the tissue of the body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed. The area of redness often extends b ...
*
Bleeding disorders Coagulopathy (also called a bleeding disorder) is a condition in which the blood's ability to coagulate (form clots) is impaired. This condition can cause a tendency toward prolonged or excessive bleeding (bleeding diathesis), which may occur spo ...
* Patient on
anticoagulant Anticoagulants, commonly known as blood thinners, are chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time. Some of them occur naturally in blood-eating animals such as leeches and mosquitoes, where the ...
medication * Known allergy to prolotherapy agent * Acute infections such as
cellulitis Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of t ...
*
Septic arthritis Acute septic arthritis, infectious arthritis, suppurative arthritis, osteomyelitis, or joint infection is the invasion of a joint by an infectious agent resulting in joint inflammation. Generally speaking, symptoms typically include redness, hea ...
Relative contraindications include: * Acute
gouty arthritis Gout ( ) is a form of inflammatory arthritis characterized by recurrent attacks of a red, tender, hot and swollen joint, caused by deposition of monosodium urate monohydrate crystals. Pain typically comes on rapidly, reaching maximal intensit ...
* Acute
fracture Fracture is the separation of an object or material into two or more pieces under the action of stress. The fracture of a solid usually occurs due to the development of certain displacement discontinuity surfaces within the solid. If a displa ...


Side effects

Patients receiving prolotherapy injections have reported generally mild side effects, including mild pain and irritation at the injection site (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 Paracetamol, also known as acetaminophen, is a medication used to treat fever and mild to moderate pain. Common brand names include Tylenol and Panadol. At a standard dose, paracetamol only slightly decreases body temperature; it is inferior ...
or, in rare cases,
opioid Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid us ...
medications. NSAIDs are not usually recommended due to their counter action to prolotherapy-induced inflammation, but are occasionally used in patients with pain refractory to other methods of
pain control Pain management is an aspect of medicine and health care involving relief of pain (pain relief, analgesia, pain control) in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals pr ...
. Theoretical adverse events of prolotherapy injection include
lightheadedness Lightheadedness is a common and typically unpleasant sensation of dizziness or a feeling that one may faint. The sensation of lightheadedness can be short-lived, prolonged, or, rarely, recurring. In addition to dizziness, the individual may feel ...
, allergic reactions to the agent used, bruising, infection, or
nerve damage Nerve injury is an injury to nervous tissue. There is no single classification system that can describe all the many variations of nerve injuries. In 1941, Seddon introduced a classification of nerve injuries based on three main types of nerve f ...
.
Allergic reactions Allergies, also known as allergic diseases, refer a number of conditions caused by the hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include hay fever, food allergies, atopic derma ...
to sodium morrhuate are rare. Rare cases of back pain, neck pain, spinal cord irritation,
pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...
, and disc injury have been reported at a rate comparable to that of other spinal injection procedures.


Technique

Prolotherapy involves the injection of an irritant solution into a joint space, weakened ligament, or tendon insertion to relieve pain. Most commonly, hyperosmolar
dextrose Glucose is a simple sugar with the molecular formula . Glucose is overall the most abundant monosaccharide, a subcategory of carbohydrates. Glucose is mainly made by plants and most algae during photosynthesis from water and carbon dioxide, using ...
(a sugar) is the solution used;
glycerine Glycerol (), also called glycerine in British English and glycerin in American English, is a simple triol compound. It is a colorless, odorless, viscous liquid that is sweet-tasting and non-toxic. The glycerol backbone is found in lipids known ...
,
lidocaine Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia. When used for local anaesthesia or in nerve blocks, lidoca ...
(a commonly used
local anesthetic A local anesthetic (LA) is a medication that causes absence of pain sensation. In the context of surgery, a local anesthetic creates an absence of pain in a specific location of the body without a loss of consciousness, as opposed to a general an ...
),
phenol Phenol (also called carbolic acid) is an aromatic organic compound with the molecular formula . It is a white crystalline solid that is volatile. The molecule consists of a phenyl group () bonded to a hydroxy group (). Mildly acidic, it req ...
, and sodium morrhuate (a derivative of
cod liver oil Cod liver oil is a dietary supplement derived from liver of cod fish (Gadidae). As with most fish oils, it contains the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), and also vitamin A and vitamin D. Historic ...
extract) are other commonly used agents. The injection is administered at joints, ligaments, or 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 three to six or more treatments. Many patients receive treatment at less frequent intervals until treatments are rarely required, if at all.


Terminology

The term originated with George S. Hackett, MD, in 1956 in a publication titled "The rehabilitation of an incompetent structure by the generation of new cellular tissue". He applied the term prolotherapy from the words "proli’" (Latin), meaning offspring, and "proliferate", meaning to produce new cells in rapid succession. Although the erroneous term "
sclerotherapy Sclerotherapy (the word reflects the Greek ''skleros'', meaning ''hard'') is a procedure used to treat blood vessel malformations (vascular malformations) and also malformations of the lymphatic system. A medicine is injected into the vessels, wh ...
" was utilized by some in the past to describe this treatment, it is now clear that prolotherapy does not cause scarring. The mechanism of prolotherapy requires further clarification. It is expected to involve a number of mechanisms.


Criticism

Some major
medical insurance Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among ma ...
policies view prolotherapy as an investigational or experimental therapy with an inconclusive evidence base. Consequently, they currently do not provide coverage for prolotherapy procedures. Medicare reviewers in 1999 determined at that time that practitioners had not provided "any scientific evidence on which to base a ifferentcoverage 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."


History

The concept of creating irritation or injury to stimulate healing has been recorded as early as Roman times when 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. In the 1950s, George S. Hackett, a general surgeon in the United States, began performing injections of irritant solutions in an effort to repair
joints A joint or articulation (or articular surface) is the connection made between bones, ossicles, or other hard structures in the body which link an animal's skeletal system into a functional whole.Saladin, Ken. Anatomy & Physiology. 7th ed. McGraw- ...
and hernias. This practice is what would eventually evolve into modern-day prolotherapy. In 1955,
Gustav Anders Hemwall Gustav Anders Hemwall (October 24, 1908 – November 22, 1998) was a physician at West Suburban Hospital in Oak Park, Illinois, and pioneer in prolotherapy. Biography He was born on October 24, 1908, in Chicago, Illinois, to the Swedish Amer ...
became acquainted with George Hackett at an
American Medical Association The American Medical Association (AMA) is a professional association and lobbying group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois. Membership was approximately 240,000 in 2016. The AMA's state ...
meeting and started practicing prolotherapy.


References

{{Reflist, 30em Musculoskeletal system Orthopedic surgical procedures Regenerative biomedicine Alternative medical treatments