Prolotherapy is also known regenerative injection therapy. These names mean respectively:

 

• Prolotherapy: injection of proliferant substance

• Regenerative injection therapy: injection of solutions for the purpose of regeneratingtissues

 

Cortisone injections have become the panacea treatment of almost all musculoskeletal injuries; cortisone is injected to injured tendons and ligaments, as well as to arthritic joints with the purpose of reducing the inflammation resulting from the injury. However, cortisone has well known side effects which can be categorised into local and systemic. Cortisone is ‘catabolic’, that is, it breaks down proteins, thereby weakening collagen tissue. However, this may well interfere with the body’s response to healing, and increases the risk of a rupture of the ligament or tendon. When injected into joints repeatedly, a ‘steroid arthropathy’ results, which is further degeneration of the cartilage. When absorbed into the bloodstream, cortisone causes significant appetite and weight gain, increases blood pressure, reduces the immune response, and may even lead to depression.

 

The weakening effect of injected cortisone is especially pronounced in weight-bearing structures, such as the knee joint and ligaments, and the Achilles tendon. It has been recommended by many clinicians not to inject cortisone into such structures.

 

In contrast, the proliferant solution, usually dextrose, injected in prolotherapy stimulates the synthesis of more collagen tissue in the ligament or tendon. This enables the ligament or tendon to withstand the forces applied to it and makes them more resistant to further wear and tear. In addition, it has also been proposed in research studies that the dextrose injected has an effect in reducing pain perception. This treatment is a much healthier and rehabilitative method than cortisone injections. Prolotherapy is especially recommended for the treatment of ligaments and tendons of weight bearing joints.

 

Both prolotherapy and PRP share common mechanisms of action.  PRP is considered a type of prolotherapy. Generally, PRP can be used in the treatment of any condition that dextrose prolotherapy is used for, whether the shoulder, knee, ankle, or even lower back and sacroiliac ligaments. PRP is more versatile in repairing partial tendon and ligament tears than dextrose. Full tears will not be healed by either; however, in some cases as in the shoulder, stability can be improved markedly with these injections to the surrounding structures.

 

For the prolotherapy and PRP to have maximal effect an environment conducive for tissue regeneration should be maintained (de Vos et al. 2010; De Pascale et al. 2015). The patient should be active, though not excessively, in order to encourage motion, mechanical loading, and increased blood supply to the treated tissues. Recommendations for an active life, proper exercise and good ergonomic advice go hand in hand with promoting, maintaining and maximizing the effect of these treatment methods.

 

Substances Injected

 

There are many substances that were once used in prolotherapy; these include phenol, glycerine, and dextrose. It has become more common practice in recent years to simply inject dextrose with local anaesthetic; the alternate solutions have been slowly abandoned for safety reasons. Dextrose is the exact same sugar molecule that exists within the body so that nothing foreign to the body (except for local anaesthetic) is being introduced. When indicated, our physician will inject dextrose in a final concentration of 20-25% together with local anaesthetic. This is much less painful than the other solutions used in the past, has fewer side effects, and is safer to inject. The volume injected into each point is minimal: between 0.2 and 0.5 cc, and will therefore not affect the blood sugar level, even in diabetics. In fact, intense pain causes the body to release more glucose into the bloodstream, so that diabetic patients with unresolved pain will have high levels of circulating glucose in their bloodstream anyway. If the treatment works in reducing pain, the sugar levels will fall!

 

In addition, using PRP, platelets can be concentrated from the patients’ blood and injected into the injury site.

 

The longer treatment is delayed the more treatment sessions will be required. This is because wear and tear is increased on already dysfunctional areas of the bodywhich impose stress on neighbouring areas. In addition, patients tend to compensate poorly, such as with limping, sitting lopsided or refraining from moving the involved limb which increases wear and tear on the better functioning areas.

 

There are many substances that were once used in prolotherapy; these include phenol, glycerine, and dextrose. It has become more common practice in recent years to simply inject dextrose with local anaesthetic; the alternate solutions have been slowly abandoned for safety reasons. Dextrose is the exact same sugar molecule that exists within the body so that nothing foreign to the body (except for local anaesthetic) is being introduced. In my practice, our physician may l inject dextrose in a final concentration of 20-25% together with local anaesthetic. This is much less painful than the other solutions used in the past, has fewer side effects, and is safer to inject. The volume injected into each point is minimal: between 0.2 and 0.5 cc, and will therefore not affect the blood sugar level, even in diabetics. In fact, intense pain causes the body to release more glucose into the bloodstream, so that diabetic patients with unresolved pain will have high levels of circulating glucose in their bloodstream anyway. If the treatment works in reducing pain, the sugar levels will fall!

 

Using PRP, platelets can be concentrated from the patients’ blood and injected into the injury site.

 

The longer treatment is delayed the more treatment sessions will be required. This is because wear and tear is increased on already dysfunctional areas of the bodywhich impose stress on neighbouring areas. In addition, people tend to compensate poorly, such as with limping, sitting lopsided or refraining from moving the involved limb which increases wear and tear on the better functioning areas. 

 

Examples of Where Prolotherapy May Be Useful

 

Sacro-Iliac Joints (Pelvic Joints or SI ligaments) and the lower back

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The sacro-iliac ligaments are capable of referring pain locally as well as all the way down the leg (figure 1). Pain can be chronic and incapacitating. If there are positive clinical signs on the physical examination of sacro-iliac dysfunction, then prolotherapy to these ligaments can lead to lasting relief of severe pain and prevent future relapse of pain. In addition, patients usually feel that they function better, are better able to sit, walk and stand, are more stable and that their legs don’t give way as much as they used to.

 

There are a number of ligaments (see figure 2) that may be the cause of the pain, each one causing a different pain referral pattern. Since the whole SI region is pivotal to normal bio-mechanic functioning of the musculoskeletal system, it is important to treat it as a whole system even if it is not the direct cause of the pain.

 

Because these ligaments act as shock absorbers, they also suffer from tremendous stress when the lumbar spine is limited in movement due to pain, spinal stenosis and especially after a spine fusion. They also suffer when the hip has pathology such as osteoarthritis or fracture.

 

A thorough treatment to the lower back must address all of these structures.

 

Spondylolisthesis and Back Pain

 

As we age and the disc height decreases, the ligaments become slack, which can lead to vertebrae slipping one on the other- a condition called “spondylolisthesis”. The direction of slipping can be from side to side or front to back (see figure 3). Often CTs and MRIs do not pick up very mild cases as this is a functional dynamic phenomenon which is not always detected when we lie still on our backs, unless the situation is more pronounced. The extra traction caused by the slipping movement can add to the pressure or traction on nerve roots. These ligaments are targeted during prolotherapy treatments.

 

Stabilising the lumbar spine through prolotherapy often relieves pain from disc lesions and from spinal stenosis; the method by which this occurs is unclear. Cortisone injections, on the other hand, will likely mostly have a very temporary effect. Although epidural injections will relieve inflammation around an irritated nerve root that has arisen from mechanical traction described above, in the long term they are unlikely to achieve improvement in function of the structure.

 

Rotator Cuff Tears

 

Prolotherapy and platelet rich plasma can not only help repair partially torn tendons but also helps to stabilize the shoulder joint. Prolotherapy can be combined very effectively with intramuscular stimulation in order to bring the whole of the shoulder girdle to normal alignment and function. This is in contrast to cortisone injections which have been found, at best, to bring about short term relief only (Buchbinder, Green, & Youd, 2003)(Buchbinder, Green, Youd, & Johnston, 2006). A review in The Lancet has shown that if cortisone injections are repeated over and over, whether in the shoulder or other areas such as the elbow, the condition ends up worse than what it was prior to the beginning of the treatment. The shoulder girdle is comprised of 4 joints; the glenohumeral, acromio-clavicular, sterno-clavicular and the scapula-thoracic joints. The latter 3 are often neglected by most practitioners. Treatment of the shoulder must always address the shoulder girdle as a whole and not just the glenohumeral joint in order to achieve long-lasting results. Neglecting to include these three joints will leave excess stress on the rotator cuff tendons and therefore no matter what treatment the patient receives the problem is likely to recur.

 

The smaller the tear, the greater the success. However even when there is a complete tear, stability can be improved provided that the joint cartilage has not been damaged severely.

 

Chronic Ankle and Foot Pain

 

One of the most common causes of chronic ankle pain results from ankle sprain and sprains secondary to fractures. A sprain in the general case is a partial tear of the ligament, muscle or tendon. In an ankle sprain the stabilizing ligaments are partially torn; in addition to just causing pain, this also contributes to further instability. The proliferant solution injected in prolotherapy can stimulate repair of the torn ligament and leads to increased stability of the ankle joint.

 

An injury strong enough to cause a fracture will invariably be strong enough to cause damage to the surrounding ligaments as well. Bone, under healthy and normal circumstances, heals well, however ligaments often remain stretched and therefore cannot stabilise the joint as well they did prior to the injury. These must be addressed in a methodical manner that considers total function of the ankle and surrounding joints.

 

Knee Injuries and Osteoarthritis (OA)

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Knee Injuries often result from car accidents and sports injuries. Common findings are torn collateral ligaments and meniscal tears. The menisci are attached to a ligament called the “coronary ligaments”. The injection of prolotherapy solutions into the knee is not intended to heal the tear within the meniscus. However, in the case of a mild tear, when prolotherapy solutions are injected into the coronary ligaments, it is thought that the coronary ligaments tighten up, preventing the loose section of the meniscus being thrown around within the knee joint during movement. Prolotherapy can also be used to treat patella tendonitis.

 

Surprisingly enough, according to several studies, injection of dextrose into a mildly to moderately arthritic joint has been found to be of benefit. This is in contrast to injection of cortisone which leads eventually to a steroid arthropathy in which case the cartilage is more degenerated than to begin with. Most studies on prolotherapy for osteoarthritis have been targeted to the knee (Rabago, Slattengren, and Zgierska 2010; Rabago et al. 2012), however, dextrose can be injected intra-articularly to most joints such as the hip, shoulder, hand joints and even the temporo-mandibular (jaw) joint. Much more literature is available on the treatment of OA with PRP, however prolotherapy can definitely help in mild to moderate cases of osteoarthritis. The mechanism by which this works is unclear, however it is clear that the induction of growth factors plays a factor in the response, theoretically much more so with PRP.

 

Whiplash Injury

 

Whiplash injury can cause chronic neck pain in which muscles and ligaments in the neck are sprained leading to muscle spasm which limits movement. The IMS technique discussed in a separate section addresses the muscle spasm and asymmetries. Prolotherapy is targeted to ligaments which may have been damaged and sprained, bringing lasting relief. Both of these techniques work wonderfully together to achieve good results. However, in order to achieve lasting relief, it is imperative to adopt healthy sitting, working and sleeping postures and avoid the “head forward position” so rampantly adopted in our modern society.

 

Elbow Pain and Other Tendinoses

 

Prolotherapy and PRP has been compared to cortisone in several research studies and has been found to be superior to cortisone injections for the treatment of golfers and tennis elbow. The IMS technique combines well with prolotherapy in the treatment of these conditions. However, in order for these treatments to be effective, the ergonomic issues leading to the problem must also be addressed and treated.

 

A very methodical review of 41 research studies on injections for treating tendinoses was published in The Lancet in 2010 (Coombes, Bisset, and Vicenzino 2010b). Corticosteroids were found on the whole to be beneficial in the short term only; repeated injections not only had no beneficial effect but actually worsened the patient’s condition relative to pre-treatment state. This finding must be internalized by practitioners, considering that until today, steroids are still the mainstay treatment of tendinoses. In contrast, the studies cited using prolotherapy solutions and PRP showed positive long term results. Both prolotherapy and PRP have been found to improve long term function and structure of the tendons (quote). PRP is perceived by many orthopedists as having more healing power than prolotherapy but it has never been compared head to head with prolotherapy.

 

Temporo-mandibular Joint (TMJ) Dysfunction

 

Pain arising from the TMJ can be due to various factors; trigger points, loose ligaments, a disrupted disc, or a combination of these. A previous whiplash injury can precipitate TMJ pain. Treatment involves a combination of dry needling and prolotherapy injections as well as addressing posture and ergonomics.​