Prolotherapy: The Foundation for Regenerative Injection Techniques.

Prolotherapy is the utilitarian method for treating fresh new tendon and ligament injuries. It is less powerful as a regenerative agent than the Orthobiologic methods but is a great first treatment for new, sprains, strains and small connective tissue injuries.

Prolotherapy is the nonsurgical method for permanent repair of damaged connective tissue. Prolotherapy injections involve pre-anesthetizing the area of ligament damage and then selectively injecting the appropriate prolotherapy solution to initiate renewed growth of the damaged cartilage and connective tissue.

Prolotherapy involves precise injections of a proliferant solution directly into areas where tendons and ligaments attach to bone, and in places where cartilage is worn or damaged for the purpose of repairing and strengthening tendons, ligaments and cartilage of the joint space. This results in a localized controlled inflammatory response that stimulates the repair mechanism to heal and regenerate the damaged tissue. Connective tissue is what makes up the supporting structures of bones (ligaments), the connection of muscles (tendons) and the sliding surfaces of joints (cartilage). Prolotherapy is also known as “RIT”– Regenerative Injection Technique.

Prolotherapy is effective for acute or chronic pain, arthritis and unresolved injuries that do not respond to rest or other less restorative treatments (surgical, anti-inflammatories or cortisone injections).

What causes most muscle and joint pain?

Most chronic musculoskeletal pain is due to damage and weakness of ligaments and tendons. Weakness or micro tears create laxity of the ligaments which makes the supporting structures of the vertebrae and joints unstable, resulting in wear and tear to the joints. With the instability of the joints and ligament connections, surrounding muscles tighten creating chronic spasms leading to increased pain.

Damaged ligament connection points can have their own referral of pain and can mimic pain caused by nerve compression. This can create confusion as to the diagnosis of the problem and improper treatment ensues. Inevitably, with the misdirected treatment comes poor results. Joints, such as the knee and shoulder, often develop instability as well as the weakening of the internal cartilage surfaces, and these are often improved by intra-articular (joint) injections of dextrose and other nutritive/proliferant solutions.

What are Clients saying?

How do you know if prolotherapy is the right treatment for you?

The importance to any outcome is the accuracy of the diagnosis. In the initial exam, palpation to identify the precise location of traumatized ligaments is the essence of effective treatment. MRI, ultrasound and xrays can be useful in determining the extent of the injury or condition. These will be helpful if you already have them and if not we may refer you for updated films. One must remember that most connective and joint problems can be accurately diagnosed with a good ortho exam and accurate palpation.

What happens after small and large tears occur to our connective tissue?

In a normal healthy response, the body will attempt to heal damaged connective tissue. However, tendons, ligament and cartilage have minimal blood supply by nature, which generally leads to incomplete healing. Poor circulation actually impedes optimal healing; this often leads to incompletely healed and/or chronically injured tissues that become a source of pain and instability. Because of the poor blood supply and the numerous nerve supply to the connective tissue, incomplete healing leads to chronic pain as feedback from the injury site. With time the tissue becomes less pliable and more prone to further tearing and degeneration. In most cases even old tissue tears can be helped with prolotherapy. The regeneration of cartilage occurs with accurate treatment done by an experienced practitioner. The skill resides in accurate diagnosis, treatment and proper follow up care.

When will the pain be gone?

The initial healing reaction can be expected to continue for six weeks following each treatment. As the tendons and ligaments grow stronger and more capable of stabilizing the joint, the pain is continually relieved. Relief can be rapid, noticeable even before leaving the clinic. Following a treatment relief of symptoms by 20-40% is not unusual. Many of our patients have reported a noticeable decrease in pain after only two or three treatments. Three to five treatments are usually required for complete repair, with an interval of one to four weeks between treatments. The number of treatments and interval length varies with the severity of the injury and health of the patient. Several areas of pain can be treated on each visit.

How Do I know if Prolotherapy is the right treatment for my pain?

Any chronic or acute pain that is relieved by 20% or more soon after the treatment, or a change in muscle tension of the painful area, is an indication that the pain is due to joint or ligament dysfunction. Hence the treatment is both diagnostically and therapeutically helpful.

How does Prolotherapy differ from cortisone injections?

Cortisone is a very powerful anti-inflammatory that will ultimately destroy the collagen matrix that makes up tendons, joint surfaces and ligaments. Therefore, compared to the regenerative action of prolotherapy it is viewed as a degenerative or suppressive treatment.

How do prolotherapy injections differ from surgery?

Generally surgery is done to remove damaged areas in the joint space. The ligament laxity responsible for the joint damage is generally not addressed. Therefore following arthroscopic surgery the degenerative changes continue and arthritis will occur in the majority of cases years following surgery. Prolotherapy injections are done to the damaged areas of collagen to promote new repair and regrowth. Prolotherapy solutions and PRP are aimed at regeneration of the damaged tissues. Ligament and joint laxity is treated and joint health improves with the correct supportive measures.

Why haven’t I heard of Prolotherapy?

Prolotherapy was pioneered by an American physician, George Hackett MD in the 1940’s. due to the vested interests of the pharmaceutical and surgical industries, prolotherapy has taken a low profile in current conventional medical circles. Numbers of studies have been published in peer review journals since the 1960’s (see below). As prolotherapy and PRP do not involve patented pharmaceuticals or procedures, its mainstream progress and utilization have been minimized.

Some common conditions treated are:

Most forms of arthritis
Musculoskeletal pain, overuse injuries, sports injuries
Headaches, whiplash, neck pain
Back pain, knee pain and instability, foot/ankle pain, plantar fasciitis
Shoulder pain and instability, tendonitis, golfer/tennis elbow
Wrist pain, carpal tunnel
Partially torn tendons and ligaments

References

Merriman Prolotherapy versus intra-operative fusion in the treatment of joint instability of the spine and pelvis. Journal of the International College of Surgeons, 1964 42:150-159. Results: The success rate of the fusion was variable. The success rate of the prolotherapy was a 80-90% cure rate.
Liu, Y. An in situ study of the influence of sclerosing solution in a rabbit medial collateral ligaments and its junction strength, Connective Tissue Research ,1983 2:95-102. He found that after five injections the ligament mass increased in by 44 percent, the thickness by 27 percent, and the strength of the ligament bone junction increased by 28 percent. This study showed that prolotherapy actually causes tissue growth and strengthening.
Koop, MD., C. Everett. Former Surgeon General Treated successfully with Prolotherapy. Website: www.doctormaxwell.com/DrKoopProlo.htm

Additional Prolotherapy References:

In 1974 Dr. Hemwall presented the results of 2007 prolotherapy patients. The results were: 1871 patients were treated with prolotherapy. 1399 (75.5 percent) patients reported complete recovery or cure. 413 (24.3 percent) reported general improvement. 25 (0.2 percent) patients showed no improvement.
Hackett M.D. Low back pain British Journal of Physical Medicine 1956 19.25-33. 656 patients received a total of 18,000 injections. 12 years after the prolotherapy was completed 82% of the patients considered themselves cured.
George Hackett presented data in front of the AMA on June 1958 on prolotherapy and cervical whiplash. 1656 patients. 82% of patients considered themselves cured.
George Hackett, M.D. presented data in front of the AMA on June 1955 on prolotherapy and back pain. 563 patients. 82% of the patients considered themselves cured.
Schwartz R. Prolotherapy: A literature review and retrospective study Journal of Neurology, Orthopedic Medicine and Surgery 1991;12:220-223 He performed a retrospective study of 43 patients with chronic low back pain who had been unresponsive to other treatments, including surgery. He gave prolotherapy treatment to the sacroiliac joint area over six weeks. 93 percent of the participants reported significant improvement. Only three of the patients reported no improvement.

Prospective studies showing the effectiveness of prolotherapy:

Reeves KD Hassanein K Long term effects of dextrose prolotherapy for anterior cruciate ligament laxity: A prospective and consecutive patient study. Alt Ther Hlth Med 2003; 9(2): Using simple dextrose injection into 16 knees with a loose ACL ligament, 10/16 knees were no longer loose by machine measurement at time of follow-up, and symptoms were improved. Symptoms of osteoarthritits improved even in those who still tested loose.

Double blind studies showing the effectiveness of prolotherapy:

Ongley, M. A new approach to the treatment of chronic low back pain. Lancet July 18, 1987. 2:143- 146. this is a double-blind study in the most difficult cases of continuous low back pain patients who suffered for ten years or longer. They divided 81 patients who had surgery, medications, manipulations adjustments, exercise, physical therapy and other treatments, which failed to provide adequate relief for 10 or more years. One group was given manipulation and a reconstructive solution of dextrose, glycerine and phenol. The other group was given sham manipulations and normal saline injections. Great care was taken to insure that neither the patient nor the physicians knew which solution was injected. Both groups were given a total of six treatments. It was found that 88% of the group injected with the reconstructive solution had moderate to marked improvement. Treatment was far superior to the placebo group.
Klein A randomized double-blind trial of dextrose-glycerine-phenol injections for chronic low back Journal of Spinal Disorders 1993 6:23-33. Prolotherapy was shown to be effective versus placebo for treating low back pain.
Reeves KD Hassanein K Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Alt Ther Hlth Med 2000;6(2):37-46 Results: Less than one ounce of simple 10% dextrose over 6 months in each joint resulted in 35% reduction of pain, 45% improvement in swelling and 67% improvement in knee buckling as well as a 13 degree improvement in knee range of motion. Treatment solution was superior to placebo solution. (P = .015)
Reeves KD Hassanein K Randomized prospective placebo controlled double blind study of dextrose prolotherapy for osteoarthritic thumbs and finger (DIP, PIP and Trapeziometacarpal) joints: Evidence of clinical efficacy. Jnl Alt Compl Med 2000;6(4):311-320 Results: Less than 1 teaspoonful of simple 10% dextrose solution over 6 months in each joint resulted in a 42% improvement in pain and an 8 degree improvement in flexibility. Treatment solution was superior to placebo solution in pain improvement (p = .027) and in flexibility (p = .003)

Studies on the incidence of complications of Prolotherapy:

In 1993 Dr. Dorman published a survey of Prolotherapy injections performed by 95 respondents. These physicians reported on a total of 494,845 patients. Of these, 343,897 patients were treated for low back, 98,430 for other areas of the spine, and 26.85 percent also reported non-spine peripheral joint injections. The cumulative years in practice of all the practitioners in the survey were 1092. Only 66 minor complications were reported. These included 24 reports of allergic reactions and 29 cases of pneumothorax (a condition caused by a needle placed into the lung cavity). All of these resolved without serious problems. There were also 14 reports of major complications, defined as the patient needing hospitalization or having transient or permanent nerve damage.

Histology studies in both humans and animals have proven that Prolotherapy strengthens ligaments:

*Maynard J. Morphological and biomechanical effects of sodium morrhuate on tendons Journal of Orthopedic Research 1985 3: 236-248. treated rabbit tendons with sodium morrhuate. He found that after six weeks the diameter of the tendons increased by 20 to 25 percent.
Dorman T. Treatment for spinal pain arising in ligaments using prolotherapy: A retrospective study Journal of Orthopedic Medicine 1991 13(1):13-19 Drs. Dorman and Klein performed biopsies of posterior sacroiliac ligaments in three patients with chronic low back pain both before and after prolotherapy injections. They found that that after six weekly injections combined with mobilization and stretching exercises, that there was an increase in the average ligament diameter measured by electron microscopy from 0.055 micrometers to 0.087 micrometers. Light microscopy showed an increase in the collagen producing fibroblasts. In addition, the range of motion of the patients was significantly increased and their pain was significantly decreased as well.
The technique was first reported in a 1937 issue of The Journal of the American Medical Association by Louis W. Schultz, M.D., an oral surgeon who found he could provide full relief for patients with temporomandibular joint (TMJ) pain with injections of fatty acids.
Over the next twenty years, George S. Hackett, M.D., an Ohio physician, applied the technique to patients with a variety of pain problems. He monitored many patients for years to determine the effect of the treatment and reported his findings in leading publications such as Journal of the American Medical Association, American Journal of Surgery, and the British Journal of Physical Medicine.
One of his studies involved 665 patients, ages 15 to 88, who suffered with pain from 3 months to 65 years (average: 4 ½ years). Twelve years after treatment 82 percent of the patients considered themselves long “cured.”
Hackett’s foremost disciple was Gustav A. Hemwall, M.D., an Illinois physician. Between 1955 and 1996, when he retired, he was the leading Prolotherapy instructor and clinician in the United States. He treated more 10,000 patients. In 1974, he reported the results of a clinical survey of 2,007 patients and revealed that 75.5% of the patient considered themselves recovered and cured of chronic pain, 24.3% as generally improved, and only 0.2% as not improved.
Prolotherapy is indicated for most of the various musculoskeletal conditions listed above. Dr. Donaldson went through rigorous post-doctoral training for Prolotherapy at the University of Wisconsin Medical School & studied under the MD, DO & ND disciples of Drs. Hackett & Hemwall. It is one of Dr. Donaldson’s primary means of treatment when symptoms, history and orthopedic tests indicate positive results for associated ligament or tendon damage and accompanying weakness and pain.vbv