Prolotherapy

Prolotherapy ("Proliferative Injection Therapy") involves injecting an irritant solution into the body, generally in the region of tendons or ligaments, for the purpose of strengthening weakened connective tissue and alleviating musculoskeletal pain. Prolotherapy, in combination with chiropractic manipulation and physical therapy, has been reported to alleviate chronic pain.

Prolotherapy can be distinguished from sclerotherapy. Sclerotherapy is the use of injections of caustics into the veins, in vascular surgery and dermatology, to remove varicose veins and other vascular irregularities. Prolotherapy is the use of injections in the treatment of connective tissue weakness and musculoskeletal pain. Prolotherapy is also called "proliferation therapy" and "regenerative injection therapy."

An evidence-based medicine review of prolotherapy for low back pain concluded: ''If used alone, prolotherapy injections do not have a role in the treatment of chronic low-back pain. When combined with other treatments, they may give prolonged partial relief of pain and disability.''

Prolotherapy in clinical practice
Prolotherapy involves the injection of an irritant solution into the area where connective tissue has been weakened or damaged through injury or strain. Many solutions are used, including Dextrose, Lidocaine (a commonly used local anesthetic), Phenol (an alcohol), Glycerine, or Cod Liver Oil extract. The injection is given into joint capsules or where tendon connects to bone. Many points may require injection. Th Injected solution causes the body to heal itself through the process of inflammation and repair. In the case of weakened or torn connective tissue, induced inflammation and release of growth factor at the site of injury may result in a 30-40% strengthening of the attachment points, although strong scientific evidence supporting this is lacking.

Prolotherapy treatment sessions are generally given every two to six weeks. Many patients receive treatment at less and less frequent intervals until treatments are required only every several years, if at all.

History of Prolotherapy
Injections of irritant solutions were performed in the late 1800’s to repair hernias and in the early 1900’s for jaw pain due to temporomandibular (jaw) joint laxity. Dr. George Hackett, MD developed the technique of prolotherapy in the 1940’s.

Guidelines used by practitioners as indicators for prolotherapy

 * Recurrent swelling or fullness involving a joint or muscular region
 * Popping, clicking, grinding, or catching sensations with movement
 * A sensation of the “leg giving way” with associated back pain
 * Temporary benefit from chiropractic manipulation or manual mobilization that fails to ultimately resolve the pain
 * Distinct tender points and “jump signs” along the bone at tendon or ligament attachments
 * Numbness, tingling, aching, or burning, referred into an upper or lower extremity
 * Recurrent headache, face pain, jaw pain, ear pain
 * Chest pain with tenderness along the rib attachments on the spine or along the front of the chest
 * Spine pain that does not respond to surgery, or whose origin is not clear or consistent based on extensive studies

Evidence based medicine
A Cochrane review of the medical literature as of January 2004 on the efficacy of prolotherapy injections in adults with chronic low-back pain found four controlled trials, all measuring pain and disability levels at six months. The review concluded:


 * "There is conflicting evidence regarding the efficacy of prolotherapy injections in reducing pain and disability in patients with chronic low-back pain. Conclusions are confounded by clinical heterogeneity amongst studies and by the presence of co-interventions. There was no evidence that prolotherapy injections alone were more effective than control injections alone. However, in the presence of co-interventions, prolotherapy injections were more effective than control injections, more so when both injections and co-interventions were controlled concurrently."

The review also noted: "[m]inor side effects from the treatment, such as increased back pain and stiffness, were common but short-lived."

More recently, Rabago et al. [A systematic review of prolotherapy for chronic musculoskeletal pain. Clin J Sport Med. 2005 Sep;15(5):376-80] noted: "Two [randomized controlled trials] on osteoarthritis reported decreased pain, increased range of motion, and increased patellofemoral cartilage thickness after prolotherapy."

Criticism
The medical community does not generally recognize the efficacy of prolotherapy, in part because of a lack of extensive controlled studies of the treatment, and because the controlled studies that exist show little or no benefit. Most major medical insurance policies do not cover the treatment. After a review of the medical evidence, Medicare declined to cover prolotherapy