What is Prolotherapy?
Prolotherapy or proliferative therapy is a regenerative injection technique which involves multiple small injections of an irritant solution at the site of ligament attachments, painful and degenerated tendon insertions and into the joint space depending on the site of pathology, in order to promote the growth of normal and healthy cells. In selected cases, autologous cellular solutions such as platelet-rich plasma (PRP), bone marrow, or adipose tissue are also used to administer prolotherapy.
History of Prolotherapy
Dr George Hackett believed that at the root of a lot of of musculoskeletal pain is tendon and ligament relaxation. He treated thousand of patients of lower back pain with prolotherapy to great success. He believed that the degenerative conditions in the back such as degenerative disc disease, sacroiliac joint disease and facet joint disease are all initiated by the relaxation of the adjoining ligaments. Hence prolotherapy which is a proliferative treatment addresses the lax ligament by helping in strengthening it and regaining it’s tautness. the junction of ligament and bone resulted in profuse proliferation of new tissue at this union.”This further strengthens the back and prevents further degeneration. Dr Hackett’s worry was followed by Dr Gustaav Hemwall, who took forward Dr Hackett’s work in extensively treating other musculoskeletal conditions like knee, wrist and ankle pain arising due to joint arthritis, tendonitis and other ligament pathologies.
Mechanism of Action
Prolotherapy is believed to simulate the natural healing process of the body by initiating a local inflammatory cascade which stimulates the release of growth factors and collagen deposition. This is mediated by cytokines which act via chemomodulation leading to proliferation and strengthening of new connective tissue, strengthening of the joint and bringing about a reduction in pain and dysfunction.
The biology of prolotherapy. Prolotherapy induces the three stages of healing and restoration: inflammation, proliferation, and tissue remodeling. Reused from: Steilen D, Hauser R, Woldin B, Sawyer S. Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability. The Open Orthopaedics Journal. 2014;8:326–345, under the terms of a CC-BY 2.5 license.
Studies have shown, exposure to extracellular dextrose concentrations in vitro has resulted in the proliferation and production of a number of growth factors, many of which are essential to repair, structural integrity, functions and optimal growth of connective tissue structures like tendons, ligaments and other tissues.
These include platelet- derived growth factor, epidermal growth factor, basic fibroblast growth factor, insulin like growth factor and connective tissue growth factor.
Prolotherapy thus has been seen to bring about an inflammatory response which brings about strengthening of ligaments, hypertrophy of tendons, extracellular matrix and fibroblastic proliferation.
Technique of Prolotherapy
Prolotherapy treatment generally consists of multiple injections of the proliferative solution , carried out at painful Tendon and ligament insertions and in adjoining joint spaces. These are repeated every 2-6 weeks depending on the condition and the practitioner’s preference. The inflammation produced is expected to cause tissue healing, resulting in enlargement and strengthening of damaged ligamentous, tendon and intra-articular structures. Thus the aim is to use prolotherapy to improve joint stability, biomechanics, function and ultimately, to decrease pain.
Indications for Prolotherapy
- Tendinopathies like Achilles Tendonitis, Plantar Fasciitis and Lateral Epicondylitis/ Tennis Elbow.
- Partial ligament injuries like Partial Anterior cruciate ligaments and Partial Meniscus injuries knee and Chronic Ankle sprains
- Osteoarthritis of the knee, shoulder and hip.
- Chondromalacia Patella knee
- Ligamentous laxity and hyper mobility syndromes like Ehler Danlos syndrome
- Conditions affecting the lower back- Sacroiliac joint dysfunction, Facet joint disease and degenerative disc disease.
- Cervical Instability or Whiplash injury to the neck causing symptoms.
Literature Evidence
32 doctor reviewed studies have helped us reach the following conclusions
- Prolotherapy is supported in the treatment of tendinopathies in patients who fail conservative therapies
- Treatment of knee osteoarthritis
- Treatment of finger joint osteoarthritis in patients who do not respond to conservative therapies
- Treatment of back pain and,
- Treatment of pelvic pain in patients who fail to respond to conservative therapies.
We would like to conclude by saying that Prolotherapy is a wonderful cost effective, regeneration injection technique which can be utilised in a number of musculoskeletal conditions as a first line treatment option. It is excellent at addressing pain and dysfunction arising from these chronic conditions by improving stability and increasing the inherent strength of the structures treated.
References
- Ashraf A, Hosseini SS. The Efficacy of Ozone Prolotherapy Compared to Intra-Articular Hypertonic Saline Injection in Reducing Pain and Improving the Function of Patients with Knee Osteoarthritis: A Randomized Clinical Trial. Evidence-Based Complementary and Alternative Medicine. 2021 Aug 3;2021. [Google Scholar]
- Johnston E, Kou Y, Junge J, Chen L, Kochan A, Johnston M, Rabago D. Hypertonic Dextrose Stimulates Chondrogenic Cells to Deposit Collagen and Proliferate. Cartilage. 2021 Jun 10:19476035211014572. [Google Scholar]
- WALUYO M, BUDU M, BUDU M, BUKHARI M, ADNAN M, HARYADI D, IDRIS M, HAMID M, USMAN M, JOHAN P, ZAINUDDIN A. Changes in levels of cartilage oligomeric proteinase and urinary C-terminal telopeptide of type II collagen in subjects with knee osteoarthritis after dextrose prolotherapy: A randomized controlled trial. J Rehabil Med. 2021. [Google Scholar]
- Rahimzadeh P, Imani F, Faiz SH, Entezary SR, Zamanabadi MN, Alebouyeh MR. The effects of injecting intra-articular platelet-rich plasma or prolotherapy on pain score and function in knee osteoarthritis. Clinical interventions in aging. 2018;13:73. [Google Scholar]
- Sert AT, Sen EI, Esmaeilzadeh S, Ozcan E. The effects of dextrose prolotherapy in symptomatic knee osteoarthritis: a randomized controlled study. The Journal of Alternative and Complementary Medicine. 2020 May 1;26(5):409-17. [Google Scholar]
- Arias-Vázquez, P.I., Tovilla-Zárate, C.A., Legorreta-Ramírez, B.G., Fonz, W.B., Magaña-Ricardez, D., González-Castro, T.B., Juárez-Rojop, I.E. and López-Narváez, M.L., 2019. Prolotherapy for knee osteoarthritis using hypertonic dextrose vs other interventional treatments: systematic review of clinical trials. Advances in Rheumatology, 59. [Google Scholar]
- Hauser RA, Matias D, Woznica D, Rawlings B, Woldin BA. Lumbar instability as an etiology of low back pain and its treatment by prolotherapy: A review. Journal of Back and Musculoskeletal Rehabilitation. 2021 Dec 14(Preprint):1-2. [Google Scholar]
- Wilkinson HA. Injection therapy for enthesopathies causing axial spine pain and the “failed back syndrome”: a single blinded, randomized and cross-over study. Pain physician. 2005 Apr;8(2):167-73. [Google Scholar]
- Inklebarger J, Petrides S, Prolotherapy for Lumbar Segmental Instability Associated with Degenerative Disc Disease. Journal of Prolotherapy. 2016;8:e971-e977. [Google Scholar]
- Alderman D. Prolotherapy for low back pain. Practical Pain Management. 2007;7(4):58-63. [Google Scholar]
- Robinson DM, Eng C, Makovitch S, Rothenberg JB, DeLuca S, Douglas S, Civitarese D, Borg-Stein J. Non-operative orthobiologic use for rotator cuff disorders and glenohumeral osteoarthritis: A systematic review. Journal of Back and Musculoskeletal Rehabilitation. 2021 Jan 1;34(1):17-32. [Google Scholar]
- Liu YK, Tipton CM, Matthes RD, Bedford TG, Maynard JA, Walmer HC. An in-situ study of the influence of a sclerosing solution in rabbit medial collateral ligaments and its junction strength. Connective Tissue Research. 1983;11:95–102. [Pub
Med] [Google Scholar] - Maynard JA, Pedrini VA, Pedrini-Mille A, Romanus B, Ohlerking F. Morphological and biochemical effects of sodium morrhuate on tendons. Journal of Orthopaedic Research. 1985;3:236–248. [Pub
Med] [Google Scholar] - Hackett GS, Hemwall GA, Montgomery GA. Ligament and tendon relaxation treated by prolotherapy. 5. Oak Park: Gustav A. Hemwall; 1993. [Google Scholar]
- Linetsky FS, FRafael M, Saberski L. Pain management with regenerative injection therapy (RIT) In: Weiner RS, editor. Pain Management. Boca Raton: CRC Press; 2002. pp. 381–402. [Google Scholar]
