Prolotherapy

Prolotherapy ("Proliferative Injection Therapy") 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. There is conflicting evidence about its effectiveness and it is an experimental treatment. [cite news
title = Injections to Kick-Start Tissue Repair
date = 2007-08-07
quote =Prolotherapy involves a series of injections designed to produce inflammation in the injured tissue. To appreciate the value of such a seemingly counterproductive measure, you need to know something about connective tissue and how the body normally repairs it. When tissues are injured, inflammation is a common natural response. It stimulates substances carried in blood that produce growth factors in the injured area to promote healing. Ligaments, tendons and cartilage have very poor blood supplies, which can result in incomplete healing.
url = http://www.nytimes.com/2007/08/07/health/07brod.html
publisher = New York Times
accessdate = 2008-07-24 ]

Prolotherapy can be distinguished from sclerotherapy. Sclerotherapy is the use of injections of caustics into the veins, in vascular surgery and dermatology, to remove varicose veins and other vascular irregularities. Prolotherapy is the use of injections in the treatment of connective tissue weakness and musculoskeletal pain. Prolotherapy is also called "proliferation therapy" and "regenerative injection therapy."

Prolotherapy is often used as an alternative to invasive arthroscopic surgery. A double-blind placebo-controlled study on arthroscopic surgery for osteoarthritis of the knee was published in the New England Journal of Medicine in July 2002 and concluded that the group that received actual arthroscopic surgery did not report better function or pain than the placebo group." [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12110735 "A controlled trial of arthroscopic surgery for osteoarthritis of the knee" N Engl J Med 2002 Jul 11;347(2):81-8, Moseley JB; O'Malley K; Petersen NJ; Menke TJ; Brody BA; Kuykendall DH; Hollingsworth JC; Ashton CM; Wray NP] Arthroscopic surgery of the knee is, however, rarely performed for the indication of osteoarthritis, but rather for mechanical tears or disruptions of cartilaginous tissue. Prolotherapy is not intended to address this type of problem. Doctors and surgeons have given anecdotal accounts of successful treatment for knee injuries, shoulder separation, and typical injuries to golfers (epicondylitis, shoulder strain, lower back strain and injury, hip and knee injury) [cite web|url=http://www.prolotherapy-hhf.org/Prolotherapy_insert%202006.pdf
title=Second Annual Prolotherapy Research Forum|format=PDF] [Marc Darrow, Prolotherapy: Living Pain Free, Protex Press, ISBN-13: 978-0971450325] [Ross A. Hauser, Marion A. Hauser, Prolo Your Pain Away, Beulah Land Press, ISBN-13: 978-0966101096] However, the vast majority of established musculoskeletal health care professionals do not support prolotherapy as mainstream treatment pending further investigation.Fact|date=February 2008

As of April 2005, doctors at the Mayo Clinic began supporting prolotherapy. Robert D. Sheeler, MD (Medical Editor, "Mayo Clinic Health letter") first learned of prolotherapy through C. Everett Koop’s interest in the treatment. Mayo Clinic doctors list the areas that are most likely to benefit from prolotherapy treatment: ankles, knees, elbows, and sacroiliac joint in the low back. They report that "unlike corticosteroid injections — which may provide temporary relief — prolotherapy involves improving the injected tissue by stimulating tissue growth."cite journal| journal = Mayo Clinic Health Letter| volume = 23| issue = 4| year = 2005| pages = | title = Alternative treatments: Dealing with chronic pain| last = Mayo Clinic | first = | url = | format = | accessdate = ]

An evidence-based medicine review [http://www.cochrane.org/reviews/en/ab004059.html] Cochrane Collaboration] of prolotherapy for low back pain concluded: "There is conflicting evidence regarding the efficacy of prolotherapy injections for patients with chronic low-back pain. If used alone, prolotherapy injections do not have a role in the treatment of chronic low-back pain. When combined with other treatments, they may give prolonged partial relief of pain and disability."

History

Injections of irritant solutions were performed in the late 1800’s to repair hernias and in the early 1900’s for jaw pain due to temporomandibular (jaw) joint laxity. George S. Hackett developed the technique of prolotherapy in the 1940’s. Gustav Hemwall was a pioneer, beginning his studies and treatments in the 1950s and continuing until the mid 1990s. In his study of almost 10,000 prolotherapy cases, Dr. Hackett found that over 99 percent of the patients found relief from their chronic pain. cite news |first=Ross | last=Hauser |url=http://getprolo.com/the_history_of_prolotherapy.htm |title=The History of Prolotherapy. |accessdate=2007-08-26 |quote=In 1955, at an American Medical Association meeting, Dr. Gustav Hemwall was astonished to see so many doctors at one particular exhibit. The presenter was talking about a very successful treatment for chronic low back pain. Nothing was worse at the time for Dr. Hemwall than having a chronic low back pain patient come to him, because the treatments he was able to offer were not very successful. The doctor doing the presentation was George S. Hackett, M.D., and he was discussing the technique of Prolotherapy. Once the crowd diminished, Dr. Hemwall asked Dr. Hackett how he could learn the treatment described in his book, Ligament and Tendon Relaxation Treated by Prolotherapy. Dr. Hemwall went to Dr. Hackett's office in Canton, Ohio, to learn the technique. Dr. Hemwall became so proficient at administering the technique that Dr. Hackett would later refer patients to him. Prolotherapy owes a great debt to Dr. Hemwall. Between 1955 until his retirement in 1996, he was the main instructor and proponent of Prolotherapy in the United States. He was not a researcher but a clinician, and perhaps the world's greatest Prolotherapist. He treated more than 10,000 patients world wide and collected data on 8,000 of these patients. In 1974, Dr. Hemwall presented his largest survey of 2,007 Prolotherapy patients to the Prolotherapy Association. |publisher= ]

Prolotherapy in clinical practice

Prolotherapy involves the injection of an irritant solution into the area where connective tissue has been weakened or damaged through injury or strain. Many solutions are used, including Dextrose, Lidocaine (a commonly used local anesthetic), Phenol (an alcohol), Glycerine, or Cod Liver Oil extract. The injection is given into joint capsules or where tendon connects to bone. Many points may require injection. The Injected solution causes the body to heal itself through the process of inflammation and repair. In the case of weakened or torn connective tissue, induced inflammation and release of growth factor at the site of injury may result in a 30-40% strengthening of the attachment points, although strong scientific evidence supporting this is lacking.

Prolotherapy treatment sessions are generally given every two to six weeks. Many patients receive treatment at less and less frequent intervals until treatments are required only every several years, if at all.cite news| first=Alan | last=Banks | url= http://www.prolotherapy.com/articles/banks.htm |title=A Rationale for Prolotherapy |quote=Prolotherapy, the technology for strengthening lax ligaments, has found increased acceptance in recent years. However, despite its greater use, the mechanism of action of prolotherapy is not well understood. In the past few years a number of advances have been made in the understanding of wound repair. This author believes the increased knowledge which has been made available in the field of wound healing has application to a more complete understanding of prolotherapy. There follows a general discussion of wound healing and a hypothesis which provides a basis for understanding prolotherapy. ]

Allen R Banks, Ph.D., has described in detail the theory behind prolotherapy in "A Rationale for Prolotherapy".

Guidelines used by practitioners as indicators for prolotherapy

* Recurrent swelling or fullness involving a joint or muscular region
* Popping, clicking, grinding, or catching sensations with movement
* A sensation of the “leg giving way” with associated back pain
* Temporary benefit from chiropractic manipulation or manual mobilization that fails to ultimately resolve the pain
* Distinct tender points and “jump signs” along the bone at tendon or ligament attachments
* Numbness, tingling, aching, or burning, referred into an upper or lower extremity
* Recurrent headache, face pain, jaw pain, ear pain
* Chest pain with tenderness along the rib attachments on the spine or along the front of the chest
* Spine pain that does not respond to surgery, or whose origin is not clear or consistent based on 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 [http://www.cochrane.org/reviews/en/ab004059.html] Cochrane collaboration] 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.)

More recently, Rabago et al. [A systematic review of prolotherapy for chronic musculoskeletal pain. Clin J Sport Med. 2005 Sep;15(5):376-80] noted: "Two [randomized controlled trials] on osteoarthritis reported decreased pain, increased range of motion, and increased patellofemoral cartilage thickness after prolotherapy."

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". [cite web |url=http://www.quackwatch.org/01QuackeryRelatedTopics/prolo.html |title=HCFA Decision Memorandum |accessdate=2008-07-24 |quote= |publisher=Quackwatch ]

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). [ [http://clinicaltrials.gov/show/NCT00085722] Clinicaltrials.Gov, Joint Injections for Osteoarthritic Knee Pain, web page last updated October 16, 2006]

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). [http://clinicaltrials.gov/ct2/show?cond=%22Tennis+Elbow%22&rank=3 Clinicaltrials.Gov, Efficacy Study of Prolotherapy vs Corticosteroid for Tennis Elbow]

ee also

*Pin firing
*Gustav Hemwall

References

External links

* [http://www.prolotherapy.org Prolotherapy.org] is a source for extensive articles, diagrams and other resources related to prolotherapy.
* [http://prolotherapy.com/ Prolotherapy.com] - a source for information on nonsurgical ligament reconstruction
* [http://www.aaomed.org American Association of Orthopaedic Medicine] is a non-profit organization that promotes prolotherapy.
*cite web
title = CAM Prolotherapy Project
date = 2006-08-06
url = http://www.camresearch.com
accessdate = 2006-08-06
*cite news
title = Injections to Kick-Start Tissue Repair
date = 2007-08-07
url = http://www.nytimes.com/2007/08/07/health/07brod.html
publisher = New York Times
accessdate = 2008-07-24