PROLOTHERAPY
What is Prolotherapy?
Prolotherapy, also referred to as Regenerative Injection Therapy (RIT), is defined as both a “nonsurgical ligament reconstruction” therapy as well as a treatment for chronic musculoskeletal pain.
The word “Prolo” is short for proliferation as prolotherapy treatment enhances the growth and formation of new ligaments, tendons and cartilage in areas where there is weakness or excess scar tissue.
Prolotherapy incorporates the use of a specialized dextrose (sugar) solution, which is injected into a ligament or tendon where it attaches to the bone.
The initial reaction of the treatment is localized inflammation triggering a wound healing cascade leading to increased blood supply and flow of nutrients and growth factors. This stimulates the tissue to repair itself by deposition of new collagen, the material that ligaments and tendons are made of. The new collagen then shrinks as it matures leading to ligament/tendon tightening and increased strength.
Treatment Course
How many prolotherapy treatments will I need?
While highly individual, 3-6 treatments spaced 4-6 weeks apart are commonly performed to achieve sufficient pain reduction.
What can I expect DURING a treatment session?
Prolotherapy treatments usually take 30-60 minutes in the clinic, depending on the area being treated. Patients are able to walk out/drive home on their own and there is generally little to no downtime.
What can I expect AFTER a treatment session?
Some post-injection pain in the form of localized soreness and discomfort is normal and expected. Some patients may experience a flare of pain for 1 to 2 days after the injection. It is important to remember that it takes time to heal and instant results should not be expected. The regeneration of damaged ligaments, tendons, and joints may take months, but you will likely start to notice the benefits of your treatment well before this period.
How long do the healing effects from prolotherapy last?
Since we can continue to “wear out” or be re-injured, it is impossible to predict how long your healing will last. Sometimes patients come back a year or more later for a “booster” procedure in the same area, others have to come back sooner. Some patients don’t require any boosters. It really depends how well you take care of yourself and how your body will respond to the treatments.
What exercises and activities may be performed after treatment?
Be active but modest.
Gentle activity and stretching is encouraged and essential for recovery; continue core strength, swimming, walking and gentle exercises.
Avoid sport/vigorous activity, deep yoga stretches and heavy lifting for 1 week after treatment. The majority of healing after a prolotherapy session occurs in the first 2 weeks; however, the first 3-5 days post prolotherapy are the most important and you should avoid stressing the joint or you may cause the treatment to be undone.
Let pain be the measure for how much stretching or movement you can do. For example, mild pain or discomfort is acceptable if the activity you are doing does not worsen when you stop. However, if you feel no pain during the activity but experience an aggravation after then you have over exerted and in the future should only perform 50% of the activity that caused this aggravation.
Rehabilitation and physiotherapy are encouraged to assist with the return of normal range of motion, strength, and function.
Supportive Therapy
Pharmaceutical Support
If the pain is enough to interrupt your sleep or ability to function the following may be used at your discretion:
Acetaminophen (Tylenol)
Topical creams that do not contain anti-inflammatories (e.g., lidocaine containing creams, Tiger Balm)
Avoid the falling for 72 hours before and 1 week after prolotherapy treatment:
Anti-inflammatory drugs such as Aspirin, Ibuprofen (Advil), Aleve, Hydrocortisone, and Prednisone.
Nutraceutical Support
Oral Methyl sulfonyl methane (MSM), glucosamine sulphate, and chondroitin sulphate may support optimal tissue healing.
Topical pain relief creams and sprays (e.g., Traumacare, SierraSil Pain Relief Spray).
Epsom salt baths (after 48 hours) and/or the application of heat to the affected area.
Contrast hydrotherapy can improve blood flow and overall healing time. Alternate hot and cold compresses for 3 minutes and 1 minute, respectively. Repeat 1-3 times.
Natural anti-inflammatories such as bromelain, curcumin, proteolytic enzymes, and fish oils will help the healing response. However, avoid use 72 hours before and 1 week after injections as they could lessen the initial inflammatory effects of prolotherapy.
Success Rates
While research has reported 80-90% success rates, prolotherapy may not provide relief for everyone and success rates depend upon multiple factors such as individual health, severity of the injury, follow-up care, and precision of the injector.
Conditions or lifestyle factors that may cause some people not to respond as well include post-menopausal females with uncontrolled symptoms and/or hormone imbalance, men older than 50 years with low testosterone levels and metabolic syndrome, obesity, hypothyroidism, malnourishment (e.g., poor dietary habits; low protein), fibromyalgia, smokers, moderate to excess alcohol consumption.
Disclaimer
Naturopathic doctors and other physicians do not imply or guarantee a cure for the symptoms of complaints for which the patient requests treatment.
Treatment is unsolicited and provided only with the patient's consent and at their request with their full knowledge of the limitations and potential complications of treatment.
POTENTIAL INDICATIONS AND RESEARCH SUMMARIES
ROTATOR CUFF PAIN
Treatment:
Dextrose vs saline (control)
Frequency:
Monthly x 3
Participants:
73 participants
Mean age 51.3±14.2
Male (63%):Female (37%)
This double-blind RCT examined the efficacy of dextrose prolotherapy for painful rotator cuff tendinopathy of 7.6±9.6 years duration. The researchers hypothesized that dextrose injections would be superior in decreasing shoulder pain and reversing degenerative changes. Seventy-three study participants with previous ultrasound-confirmed supra-spinatus tear and a mean age of 51.3±14.2 were randomized to three monthly injections of either dextrose or saline. At 9 month follow up, differences in pain were measured using the Visual Analog Scale (VAS), the Ultrasound Shoulder Pathology Rating Scale (USPRS), and a numerically-scaled patient satisfaction score. In comparison to saline, dextrose prolotherapy significantly reduced shoulder pain and demonstrated patient satisfaction with the outcome. While regenerative pathological healing effects were demonstrated by ultrasound measurements, they were not significant enough to be attributed to dextrose prolotherapy.
Bertrand, H., Reeves, K. D., Bennett, C. J., Bicknell, S., & Cheng, A. (2016). Dextrose prolotherapy versus control injections in painful rotator cuff tendinopathy. Archives of Physical Medicine and Rehabilitation, 97(1), 17-25. doi:10.1016/j.apmr.2015.08.412
TENNIS ELBOW
Treatment:
Dextrose vs dextrose-morrhulate sodium vs
‘wait-and-see’
Frequency:
Single session
Participants:
26 participants
Ages 18-65
Male (65%):Female (35%)
This three-arm, single-blind, randomized controlled trial compared dextrose or dextrose-morrhuate sodium prolotherapy with watchful waiting/lifestyle counseling in patients with chronic and painful lateral epicondylosis (CLE). It was hypothesized that prolotherapy would offer improved elbow-related quality of life. Twenty-six participants between the ages of 18 and 65 were randomized to no therapy (wait-and-see) or blinded to either dextrose or dextrose-morrhulate sodium injections.Using the Patient-Rated Tennis Elbow Evaluation and a grip strength rating scale, outcome measurements for functionality and pain, respectively, were taken at 4, 8, and 16 weeks for all groups and again at 32 weeks for the two prolotherapy groups. While the results demonstrated less grip strength pain in the dextrose group than the dextrose-morrhulate sodium group, in comparison with the wait-and-see control group, both types of prolotherapy resulted in statistically significant improvement of elbow pain and functionality.
Rabago, D., Lee, K. S., Ryan, M., Chourasia, A. O., Sesto, M. E., Zgierska, A., et al. (2013). Hypertonic dextrose and morrhuate sodium injections (prolotherapy) for lateral epicondylosis (tennis elbow): Results of a single-blind, pilot-level, randomized controlled trial. American Journal of Physical Medicine & Rehabilitation, 92(7), 587-596. Doi:10.1097/PHM.0b013e31827d695f
KNEE OSTEOARTHRITIS
Treatment:
Dextrose 12.5% vs
ozone-oxygen
Frequency:
Every 7-10 days x 3 sessions
Participants:
80 participants
Ages 40-75
Male (39%):Female (61%)
This double-blind RCT compared the efficacy of dextrose prolotherapy injections with prolozone injections for mild to moderate knee osteoarthritis confirmed by clinical examination and radiography. The researchers hypothesized that both therapies would be effective in decreasing knee pain and stiffness while improving overall functionality. The study participants included 80 adults age 40 to 75 years were randomized to either dextrose or ozone-oxygen injections three times at seven to 10 day intervals. The Western Ontario McMaster University Osteoarthritis Index (WOMAC) and Visual Analog Scale (VAS) outcome scores were used to measure knee functionality and pain, respectively, at 26 and 52 weeks. Pain control and functional ability improved significantly and comparatively with both therapies.
Hashemi, M., Jalili, P., Mennati, S., Koosha, A., Rohanifar, R., Madadi, F., et al. (2015). The effects of prolotherapy with hypertonic dextrose versus prolozone (intraarticular ozone) in patients with knee osteoarthritis. Anesthesiology and Pain Medicine, 5(5), e27585
SACROILIAC JOINT PAIN
Treatment:
Dextrose (25% intra-articular) vs steroid
Frequency:
Bi-weekly x 3 sessions
Participants:
48 participants
Mean age 60.15±14.1
Male (29%):Female (71%)
This prospective two-arm RCT compared dextrose prolotherapy with corticosteroid local injection to determine if pain control could be improved in the presence of sacroiliac pain. It was hypothesized that dextrose therapy would be superior to cortisone injection. Forty-eight participants with a mean age of 60.15±14.1 years were equally randomized to three bi-weekly injections of either dextrose or triamcinolone. Outcome measurements were assessed using the Numeric Rating Scale (NRS) where a score of 0 is no pain and 10 is maximum pain. Follow up at two weeks demonstrated significant and comparable results in both the dextrose and steroid group. However, at fifteen weeks statistically significant improvement in pain occurred with the prolotherapy group in comparison to the steroid group.
Kim, W. M., Lee, H. G., Jeong, C. W., Kim, C. M., & Yoon, M. H. (2010). A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. Journal of Alternative and Complementary Medicine (New York, N.Y.), 16(12), 1285-1290. Doi:10.1089/acm.2010.0031
THUMB OSTEOARTHRITIS
Treatment:
Dextrose 20% vs corticosteroid
Frequency:
Monthly x 3 sessions
Participants:
60 participants
Mean age 63.6±9.7
Male (27%):Female (73%)
This RCT compared dextrose prolotherapy with corticosteroid local injection to determine if pain control and functional ability could be improved in the presence of radiographical confirmed carpometacarpal joint osteoarthritis. It was hypothesized that dextrose therapy would be superior to cortisone injection. Sixty participants with a mean age of 63.6±9.7 years were equally randomized to three monthly injections of dextrose or two monthly saline placebo injections followed by a single injection of methyl-prednisone acetate. Participants and assessors were blinded, and follow up was performed at 1, 2, and 6 months. Pain levels were measured using the Fisher’s pressure algometer in conjunction with the Visual Analog Scale (VAS) while hand function was assessed using the Health Assessment Questionnaire Disability Index (HAQ-DI) during three specific activities of eating, gripping, and dressing. Follow up demonstrated comparable results at 2 months and better results with dextrose therapy at 6 months.
Jahangiri, A., Moghaddam, F. R., & Najafi, S. (2014). Hypertonic dextrose versus corticosteroid local injection for the treatment of osteoarthritis in the first carpometacarpal joint: A double-blind randomized clinical trial. Journal of Orthopaedic Science, 19(5), 737-743. Doi:10.1007/s00776-014-0587-2
KNEE OSTEOARTHRITIS
Treatment:
Dextrose (15% extra-articular, 25% intra-articular) vs physiotherapy
Frequency:
Monthly x 3-5 sessions
Participants:
104 participants
Mean age 50.98±10.5 years
Male (25%):Female (75%)
This two-arm RCT compared the efficacy of dextrose prolotherapy (Group 1) with physiotherapy (Group 2) for symptomatic radiographically-proven knee osteoarthritis of greater than six months duration. The researchers hypothesized that dextrose therapy would provide superior results in improving pain, functionality, and radiological grading. The study participants were age, gender, disease duration, and BMI matched, and included 104 adults between the ages of 38 and 73 years randomized 4:1 in favour of dextrose prolotherapy. Group 1 (dextrose therapy) participants received extra-articular and intra-articular dextrose injections monthly for 3 to 5 sessions while Group II (physiotherapy) were enrolled in at-home exercise intervention. Outcome measures were performed at baseline and 12 months using radiography, musculoskeletal ultrasound, and the Western Ontario McMaster University Osteoarthritis Index (WOMAC) by Visual Analog Scale (VAS). At 2 and 5 months, WOMAC/VAS scores were measured. Dextrose prolotherapy was significantly better than physiotherapy in respect to pain control, function, and regeneration.
Soliman, D. M. I., Sherif, N. M., Omar, O. H., & El Zohiery, A., K. (2016). Healing effects of prolotherapy in treatment of knee osteoarthritis healing effects of prolotherapy in treatment of knee osteoarthritis. Egyptian Rheumatology and Rehabilitation, 43(2), 47-52. doi:10.4103/1110-161X.181858
KNEE OSTEOARTHRITSIS
Treatment:
Dextrose 25% intra-articular vs erythropoieten 4000 IU intra-articular vs pulse radiofrequency articular
Frequency:
Single injection
Participants:
70 participants
Mean age 59.9±8.08
Male (43%):Female (57%)
In this double-blinded, three-arm RCT, erythropoietin, dextrose, and pulsed radiofrequency were compared to determine their effects on pain control and knee functionality in the presence of knee osteoarthritis. It was hypothesized that intra-articular injection of erythropoietin or dextrose would be more effective than pulsed radiofrequency. Seventy participants, age 40 to 70, were randomized to receive a single intra-articular injection of either erythropoietin or dextrose, or pulsed radiofrequency in the articular area of the knee. Pain levels were measured in weeks 2, 4, and 12 using the Visual Analog Scale (VAS) for pain and knee range of motion was assessed using a geometric method to assess. The results demonstrated that erythropoietin prolotherapy, when compared with dextrose injections and pulsed radiofrequency was more effective in both pain control and functional improvement.
Rahimzadeh, P., Imani, F., Faiz, S. H. R., Entezary, S. R., Nasiri, A. A., & Ziaeefard, M. (2014). Investigation the efficacy of intra-articular prolotherapy with erythropoietin and dextrose and intra-articular pulsed radiofrequency on pain level reduction and range of motion improvement in primary osteoarthritis of knee. Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences, 19(8), 696-702.
KNEE OSTEOARTHRITIS
Treatment:
Dextrose 15% extra-articular, 25% intra-articular vs saline vs exercise
Frequency:
Every 4 weeks x 3-5 sessions
Participants:
90 participants
Ages 40-60
Male (33%):Female (67%)
This 3-arm blinded RCT examined the efficacy of dextrose prolotherapy injections for moderate to severe knee osteoarthritis of greater than three months duration. The researchers hypothesized that dextrose injections would be superior in decreasing knee pain and stiffness while improving overall functionality. The study participants included 90 adults with a mean age of 56.7 years, randomized to either at-home exercise or blinded-to-participant injection of dextrose or saline every 4 weeks for 3 to 5 sessions. The Western Ontario McMaster University Osteoarthritis Index (WOMAC) and Knee Pain Scale (KPS) outcome scores were used to measure knee functionality and pain, respectively, at 26 and 52 weeks. When adjusted for gender, age, and BMI, Dextrose prolotherapy produced a significantly better knee-related quality of life than either saline or exercise.
Rabago, D., Patterson, J. J., Mundt, M., Kijowski, R., Grettie, J., Segal, N. A., & Zgierska, A. (2013). Dextrose prolotherapy for knee osteoarthritis: A randomized controlled trial. Annals of Family Medicine, 11(3), 229.
ROTATOR CUFF LESION
Treatment:
Dextrose
- 25% subacromial bursa
- 15% infraspinatus
- 15% supraspinatus
- 15% subscapularis
- 15% coracoid process
vs Exercise
Frequency:
2-6 injection sessions
Participants:
120 participants
Ages 30-60
Male (40%):Female (60%)
This double-blind RCT examined the efficacy of dextrose prolotherapy in comparison to physical therapy for painful rotator cuff MRI-confirmed lesions of greater than six months duration. The researchers hypothesized that dextrose injections would be superior in decreasing shoulder pain while increasing functionality and patient satisfaction with treatment. One hundred twenty participants, age 30 to 60, were randomized equally to ultrasound-guided multiple injection site sessions (2 to 6) of dextrose or three weekly supervised sessions of physical therapy (control) for 12 weeks. At-home exercises were provided to both groups. At baseline and follow up at 3, 6, and 12 weeks, pain, function, and patient satisfaction were measured using the Visual Analog Scale (VAS), the Shoulder Pain and Disability Index (SPADI), and the Western Ontario Rotary Cuff (WORC) Index. In comparison to exercise, pain, disability, and functional scores were significantly improved with dextrose prolotherapy.
Seven, M. M., Ersen, O., Akpancar, S., Ozkan, H., Turkkan, S., Yıldız, Y., & Koca, K. (2017). Effectiveness of prolotherapy in the treatment of chronic rotator cuff lesions. Orthopaedics & Traumatology: Surgery & Research, 1-20. doi:10.1016/j.otsr.2017.01.003
MORE RESEARCH
Alderman, D. (2007). Prolotherapy for golfing injuries and pain: An effective non-surgical treatment option for golf-related injuries, including low back pain, lateral and medial epicondylitis, wrist ligament injuries, shoulder injuries, and other musculoskeletal joint pain. Journal of Practical Pain Management, 8(5).
Alderman, D. (2007). Prolotherapy for knee pain: A reasonable and conservative approach to knee tendonitis/tendonosis, sprain-strains, instability, diagnosis of meniscal tear, patellofemoral pain syndrome including chrondromalacia patellae, degenerative joint disease, and osteoarthritis pain. Journal of Practical Pain Management, 7(6), 70-79.
Alderman, D. (2007). Prolotherapy for low back pain: A reasonable and conservative approach to musculoskeletal low back pain, disc disease, and sciatica. Journal of Practical Pain Management, 7(4), 58-63.
Alderman, D. (2007). Prolotherapy for musculoskeletal pain. Journal of Practical Pain Management, 7(1), 58-63.
Dumais, R., Benoit, C., Dumais, A., Babin, L., Bordage, R., de Arcos, C., et al. (2012). Effect of regenerative injection therapy on function and pain in patients with knee osteoarthritis: A randomized crossover study. Pain Medicine (Malden, Mass.), 13(8), 990-999. doi:10.1111/j.1526-4637.2012.01422.x
Hauser, R., Hauser, M. (2006). Dextrose prolotherapy for unresolved neck pain: An observational study of patients with unresolved neck pain who were treated with dextrose prolotherapy at an outpatient charity clinic in rural Illinois. Journal of Practical Pain Management Practical Pain Management, 10.
Hauser, R., Hauser, M., Cukla, J. (2006). Dextrose prolotherapy for unresolved ankle pain: In this retrospective observational study of chronic unresolved ankle ankle pain, Hackett-Hemwall dextrose prolotherapy helped promote a measurable decrease in the pain and stiffness of the treated joints and improvement in clinically-relevant parameters. Journal of Practical Pain Management Practical Pain Management, 10(1).
Hauser, R., Hauser, M., Holian, P. (2006). Dextrose prolotherapy for unresolved wrist pain: An observational study of patients with unresolved wrist pain who were treated with dextrose prolotherapy at an outpatient charity clinic in rural Illinois. Journal of Practical Pain Management, 9(9).
Hooper, R.A., Ding, M. (2004). Retrospective case series on patients with chronic spinal pain treated with dextrose prolotherapy. The Journal of Alternative and Complementary Medicine. 10(4), 670-4. doi: 10.1089/acm.2004.10.670.
Kim, H., Jeong, T.S., Kim, W.S., & Park, Y.S. (2003). Comparison of histological changes in accordance with the level of dextrose-concentration in experimental prolotherapy model. Annals of Rehabilitation Medicine, 27, 935-940.
McCrory, P. (2006). Efficacy of dextrose prolotherapy in Elite Male Kicking-sport athletes with chronic groin pain. Yearbook of Sports Medicine, 52. https://doi.org/10.1016/s0162-0908(08)70290-3
Rabago, D., MD, Patterson, J. J., DO, Mundt, M., PhD, Kijowski, R., MD, Grettie, J., BS, Segal, Neil A., MD, MS, & Zgierska, Aleksandra, MD, PhD. (2013). Dextrose prolotherapy for knee osteoarthritis: A randomized controlled trial. Annals of Family Medicine, 11(3), 229-237. doi:10.1370/afm.1504
Rabago, D., Zgierska, A., Fortney, L., Kijowski, R., Mundt, M., Ryan, M., Grettie, J., & Patterson, J. J. (2012). Hypertonic dextrose injections (prolotherapy) for knee osteoarthritis: Results of a single-arm uncontrolled study with 1-year follow-up. Journal of Alternative and Complementary Medicine (New York, N.Y.), 18(4), 408–414. https://doi.org/10.1089/acm.2011.0030
Rashiq, S. (2005). Chronic pain: What colour are the emperor’s clothes? Canadian Journal of Anesthesia. 52(S1). https://doi.org/10.1007/bf03023079
Reeves, K. D. (2004). Sweet relief: Injecting tendons with a dextrose solution to trigger an inflammatory reaction is just one way in which practitioners are using prolotherapy to target sprains and strains. Biomechanics, 9, 24-35.
Reeves, K. D., & Hassanein, K. (2000). Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Alternative Therapies in Health and Medicine, 6(2), 68-80.
Topol, G. A., Podesta, L. A., Reeves, K. D., Giraldo, M. M., Johnson, L. L., Grasso, R., et al. (2016). Chondrogenic effect of intra-articular hypertonic-dextrose (prolotherapy) in severe knee osteoarthritis. PM & R: The Journal of Injury, Function, and Rehabilitation, 8(11), 1072–1082. https://doi.org/10.1016/j.pmrj.2016.03.008
Wheaton, M. J., Jenson, N, (2011). The Ligament Injury-Osteoarthritis Connection: The Role of Prolotherapy in Ligament Repair and the Prevention of Osteoarthritis. Journal of Prolotherapy, 3(4), 790-812.
Yelland, M.J., Glasziou, P. P., Bogduk, N., Schluter, P.J., & KcKernon, M. (2004). Prolotherapy injections, saline injections, and exercises for chronic low-back pain: A randomized trial. Spine (Philadelphia, Pa. 1976, 29(1), 9-16. doi:10.1097/01.brs.0000105529.07222.5b