ChiroACCESS Article



Prolotherapy, Where Does It Stand Today?



This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.

Dwain M. Daniel, D.C.

  

ChiroACCESS



Published on

April 19, 2010

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Prolotherapy is a somewhat controversial intervention for a variety of musculoskeletal complaints.  The treatment consists of a series of injections of an irritant, usually a dextrose based compound, into painful soft tissues.  In theory the injection begins a controlled inflammatory response.  This in turn causes connective tissue growth and collagen tissue formation resulting in a more stable, less painful joint or strengthened tendons or ligaments.1  Chronic low back pain, knee and hand osteoarthritis, lateral epicondylosis, Achilles tendonitis and plantar fasciitis, to name a few, have been reported in the scientific literature as conditions for which prolotherapy has been utilized.2-6

SyringeThe evidence for the efficacy of prolotherapy is slowly becoming clearer.  Systematic reviews of prolotherapy point out two major factors which make evaluation of studies difficult.  The first is the wide variety of compounds and protocols used for the injections and the second is the presence of co-interventions in the studies which demonstrate efficacy.  A recent Cochrane review for the treatment of chronic low back pain found 5 high quality randomized controlled trials (RCT) investigating prolotherapy.  Three trials which used prolotherapy as a single treatment did not demonstrate efficacy.  In 2 trials when prolotherapy was used in conjunction with spinal manipulation, exercise and other treatments, the protocol reduced pain and disability.7  Both of these studies reported a statistically significant difference in patients reporting greater than 50%  reduction in pain and disability after 6 months compared to the control group.8;9  Two other systematic reviews came to similar conclusions.10;11  A study investigating the adverse effects of prolotherapy found a similar profile to other injection therapies of the spine which include pain, stiffness and bruising post-injection.  Some more serious side effects were noted such as pneumothorax and nerve damage but, again, no more common than other similar procedures.12 

Although the study was small, a recent systematic review evaluating four injection therapies, including prolotherapy, for lateral epicondylosis concluded that the reported effect sizes were large and justified additional study.  A small RCT compared eccentric loading exercises and prolotherapy in combination and separately for Achilles tendonosis and found combination therapy was less costly and provided more rapid improvements.6  Reeves et al has performed 2 RCT’s using prolotherapy for osteoarthritis of the wrist and knee and found in both studies that prolotherapy was more effective than the control group in pain reduction and functional improvement.13;14

Although absolute efficacy for the above mentioned conditions remains elusive, it should be pointed out that facet joint injection, intradiscal steroid injection and epidural steroid injection for low back pain may have even less evidence yet these procedures are considered mainstream treatments.  Mooney in his editorial in The Spine Journal states “this fringe treatment is no longer at the periphery and seems to be at the frontier of a justifiable, rational treatment with significant potential to avoid destructive procedures”.15

The economic and quality of life burden that chronic musculoskeletal pain places upon many people in our society is immense.  In the best interest of our patients, it may be time to consider co-management of non-responsive patients with a physician practicing prolotherapy.
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References

1.   

Dagenais S, Mayer J, Haldeman S, Borg-Stein J. Evidence-informed management of chronic low back pain with prolotherapy. Spine J 2008 Jan;8(1):203-12.

 [ Medline ID 18164468 ]

2.   

Kim SR, Stitik TP, Foye PM, Greenwald BD, Campagnolo DI. Critical review of prolotherapy for osteoarthritis, low back pain, and other musculoskeletal conditions: a physiatric perspective. Am J Phys Med Rehabil 2004 May;83(5):379-89.

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Rabago D, Best TM, Beamsley M, Patterson J. A systematic review of prolotherapy for chronic musculoskeletal pain. Clin J Sport Med 2005 Sep;15(5):376-80.

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4.   

Rabago D. Prolotherapy for treatment of lateral epicondylosis. Am Fam Physician 2009 Sep 1;80(5):441.

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5.   

Tsatsos G, Mandal R. Prolotherapy in the treatment of foot problems. J Am Podiatr Med Assoc 2002 Jun;92(6):366-8.

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6.   

Yelland MJ, Sweeting KR, Lyftogt JA, Ng SK, Scuffham PA, Evans KA. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med 2009 Sep 6.

 [ Medline ID 19549615 ]

7.   

Dagenais S, Yelland MJ, Del MC, Schoene ML. Prolotherapy injections for chronic low-back pain. Cochrane Database Syst Rev 2007 Apr 18;(2):CD004059.

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8.   

Ongley MJ, Klein RG, Dorman TA, Eek BC, Hubert LJ. A new approach to the treatment of chronic low back pain. Lancet 1987 Jul 18;2(8551):143-6.



9.   

Klein RG, Eek BC, DeLong WB, Mooney V. A randomized double-blind trial of dextrose-glycerine-phenol injections for chronic, low back pain. J Spinal Disord 1993 Feb;6(1):23-33.

 [ Medline ID 2439856 ]

10.   

Dagenais S, Haldeman S, Wooley JR. Intraligamentous injection of sclerosing solutions (prolotherapy) for spinal pain: a critical review of the literature. Spine J 2005 May;5(3):310-28.

 [ Medline ID 15863087 ]

11.   

Yelland MJ, Mar C, Pirozzo S, Schoene ML, Vercoe P. Prolotherapy injections for chronic low-back pain. Cochrane Database Syst Rev 2004;(2):CD004059.

 [ Medline ID 15106234 ]

12.   

Dagenais S, Ogunseitan O, Haldeman S, Wooley JR, Newcomb RL. Side effects and adverse events related to intraligamentous injection of sclerosing solutions (prolotherapy) for back and neck pain: A survey of practitioners. Arch Phys Med Rehabil 2006 Jul;87(7):909-13.

 [ Medline ID 16813776 ]

13.   

Reeves KD, Hassanein K. Randomized, prospective, placebo-controlled double-blind study of dextrose prolotherapy for osteoarthritic thumb and finger (DIP, PIP, and trapeziometacarpal) joints: evidence of clinical efficacy. J Altern Complement Med 2000 Aug;6(4):311-20.

 [ Medline ID 10976977 ]

14.   

Reeves KD, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Altern Ther Health Med 2000 Mar;6(2):68-80.

 [ Medline ID 10710805 ]

15.   

Mooney V. Prolotherapy at the fringe of medical care, or is it the frontier? Spine J 2003 Jul;3(4):253-4.

 [ Medline ID 14589182 ]