Prolotherapy
Prolotherapy, or proliferation therapy, is a treatment that involves injecting irritant solutions around loose ligaments to promote healing and strengthen the affected area. Developed in the 1950s, it is based on the idea that chronic pain may arise from lax ligaments that destabilize joints, leading to compensatory muscle tension and pain. Commonly proposed uses for prolotherapy include back pain, osteoarthritis, fibromyalgia, and various sports injuries. The procedure typically involves multiple injection sessions over several weeks, utilizing solutions such as concentrated dextrose or glucose, which are believed to stimulate tissue growth.
While some studies indicate potential benefits, particularly for conditions like knee osteoarthritis, the overall scientific evidence is mixed, particularly concerning back pain. Prolotherapy is not widely embraced in conventional medicine, and its effectiveness compared to other treatments remains under investigation. Generally, the treatment is well-tolerated, but minor discomfort following injections is common. Individuals with certain medical conditions should avoid prolotherapy, and it is usually administered by qualified medical professionals specializing in orthopedics or physical rehabilitation.
Prolotherapy
DEFINITION: Treatment involving injections of chemical irritant solutions into the area around a loose ligament.
PRINCIPAL PROPOSED USES: Back pain, osteoarthritis
OTHER PROPOSED USES: Fibromyalgia, plantar fasciitis, sciatica, sports injuries, temporomandibular joint disorder, tendonitis, tension headaches, arthritis, degenerative disk disease
Overview
Invented in the 1950s by George Hackett, prolotherapy (sometimes called proliferation therapy or regenerative injection therapy) is based on the theory that chronic pain is often caused by the laxness of the ligaments that are responsible for keeping a joint stable. When ligaments and associated tendons are loose, the body is said to compensate by using muscles to stabilize the joint. The net result, according to prolotherapy theory, is muscle spasms and pain.
Prolotherapy treatment involves injections of chemical irritant solutions into the area around such ligaments. These solutions are believed to cause tissue to proliferate (grow), increasing the strength and thickness of ligaments. In turn, this presumably serves to tighten up the joint and relieve the burden on associated muscles, stopping muscle spasms. In the case of arthritic joints, increased ligament strength would allow the joint to function more efficiently, thus reducing pain.
Prolotherapy has not been widely accepted in conventional medicine. The technique is used by prolotherapy practitioners to treat many conditions, including back pain, osteoarthritis, fibromyalgia, plantar fasciitis, sciatica, sports injuries, temporomandibular joint disorder, tendonitis, and tension headaches. Most studies have focused on its use in back pain and osteoarthritis, but the evidence does not clearly support its effectiveness.
How is prolotherapy performed? Prolotherapy is generally administered at intervals of four to six weeks, although studies have used a more frequent schedule. The treatment involves injection of a mixture containing an irritant and a local anesthetic. A total of four to six treatments is typical. Sometimes, an ultrasound device may be used to guide the injection. When treating back pain, prolotherapy practitioners frequently use a form of manipulation somewhat similar to chiropractic. However, the manipulation is applied after the local anesthetic has been injected, and it is somewhat intense.
There are several irritant solutions used in prolotherapy. Concentrated dextrose or glucose has become increasingly popular because it is completely nontoxic. Phenol (a potentially toxic substance) and glycerin are also sometimes used. Other nonirritant substances may be added to the solution, such as vitamin B12, corn extracts, cod liver oil extracts, zinc, and manganese; however, there is no evidence that these substances add any benefit.
Scientific Evidence
Some animal and human studies have found that prolotherapy injections increase the strength and thickness of ligaments. Six double-blind human trials of prolotherapy have been reported: four involving back pain (with mixed results) and the other two involving osteoarthritis (with positive results).
Back pain. Although two studies have suggested prolotherapy may be effective for low back pain, two more recent studies found prolotherapy to be ineffective. In a review of five studies, three found prolotherapy to be no more effective than control treatments for low back pain. The other two studies suggested that prolotherapy was more effective than control treatments when used with therapies such as spinal manipulation and exercise. Another review suggested that prolotherapy may be effective when used with other therapies but not when used alone.
When used alone, prolotherapy is probably no more effective than a placebo injection for the treatment of low back pain. However, there is some evidence that the technique may be beneficial when combined with other therapies.
Osteoarthritis. A double-blind, placebo-controlled study evaluated the effects of three prolotherapy injections (using a 10 percent dextrose solution) at two-month intervals in sixty-eight people with osteoarthritis of the knee. At the six-month follow-up, participants who had received prolotherapy showed significant improvements in pain at rest and while walking. These participants also showed reduced swelling and fewer episodes of “buckling” than those who had received placebo treatment.
The same research group performed a similar double-blind trial of twenty-seven people with osteoarthritis in the hands. The results at the six-month follow-up showed that range of motion and pain with movement improved significantly in the treated group compared with the placebo group.
Further research found mixed results. While prolotherapy shows very positive results for some patients with conditions like plantar fascitis or osteoarthritis of the knee, other studies have found very weak and temporary improvements in symptoms in individuals with back pain. In one meta-analysis, hyperosmolar dextrose prolotherapy was as effective as steroid injections. However, further research is needed to compare the standardized use of saline therapy injections, platelet-rich plasma injections, steroid injections, and hyperosmolar dextrose prolotherapy to properly assess and compare the utility of each therapy method. Additionally, studies are needed that expand beyond back and knee pain treatment.
Safety Issues
In studies, prolotherapy has not caused any serious, irreversible injury. After each injection, there is usually discomfort that lasts for a few minutes to several days, but this discomfort is seldom severe. Of more concern is that severe headaches have been reported in the treatment of low back pain in a minority of patients. Also, because phenol is a potentially toxic substance, treatment with a dextrose solution alone is preferable. Some individuals should avoid this treatment, such as those with gouty arthritis, abscesses, septic arthritis, cellulitis, or any fractures.
Choosing a Practitioner
Prolotherapy is practiced by a medical doctor or a doctor of osteopathy. Generally, physicians specializing in orthopedics or physical medicine and rehabilitation are most likely to practice prolotherapy.
Bibliography
Coombes, B. K., L., et al. “Efficacy and Safety of Corticosteroid Injections and Other Injections for Management of Tendinopathy.” The Lancet 376 (2010): 1751-67.
Dagenais, S., J. Mayer, et al. “Evidence-Informed Management of Chronic Low Back Pain with Prolotherapy.” Spine Journal 8 (2008): 203-12.
Dagenais, S., M. Yelland, et al. “Prolotherapy Injections for Chronic Low-Back Pain.” Cochrane Database of Systematic Reviews (2007): CD004059. Available through EBSCO DynaMed Systematic Literature Surveillance www.ebscohost.com/dynamed.
Geonhyeong, Bae, et al. “Prolotherapy for the Patients with Chronic Musculoskeletal Pain: Systematic Review and Meta-Analysis.” Anesthesia and Pain Medicine, vol. 16, no. 1, 2021, pp. 81–95, doi.org/10.17085/apm.20078.
Hauser, R. A. “Punishing the Pain: Treating Chronic Pain with Prolotherapy.” Rehab Management 12 (1999): 26-30.
"Prolotherapy." Cleveland Clinic, 14 Feb. 2022, my.clevelandclinic.org/health/treatments/22426-prolotherapy. Accessed 20 Sept. 2024.
Wee, Tze Chao, Edmund Jin Rui Neo, and Yeow Leng Tan. "Dextrose Prolotherapy in Knee Osteoarthritis: A Systematic Review and Meta-Analysis." Journal of Clinical Orthopaedics and Trauma, vol. 19, Aug. 2021, pp. 108-17, doi: 10.1016/j.jcot.2021.05.015.
Yelland, M. J., et al. “Prolotherapy Injections, Saline Injections, and Exercises for Chronic Low-Back Pain.” Spine 29 (2004): 9-16.
Zelman, David. "What to Know About Prolotherapy." WebMD, 13 Sept. 2023, www.webmd.com/osteoarthritis/what-to-know-about-prolotherapy. Accessed 20 Sept. 2024.