|
 What
is Prolotherapy and What are the Indications
and Contraindications for it?
K.
Dean Reeves, MD
Prolotherapy is injection of any substance that acts as a ‘growth
factor,’ that is, which promotes growth of normal cells, tissues, or
organs. Injection of the hormone, erythropoietin, to produce red blood
cells is widely used, and a number of other substances have been used
for treatment of patients with various medical disorders. This
discussion focuses on prolotherapy for musculoskeletal disorders,
including
arthritis and
back pain.
Non-inflammatory growth factor production methods have been used in the
treatment of patients with arthritis. Injection of a sub-inflammatory
level of dextrose (10%) in to the joints of patients with knee or finger
Osteoarthritis (OA) has been shown to be effective in improving pain or
disease severity.1,2,3
Dextrose can create growth without
Inflammation. Research on a variety
of human cells exposed to as little as 0.3% to 0.6% dextrose (the normal
cell has 0.1% dextrose in and around itself) indicates that within
minutes to several hours the cells begin to produce growth factors such
as platelet-derived growth factor (PDGF), transforming growth
factor-beta (TGFB), epidermal growth factor (EGF), basic fibroblast
growth factor (BFGF), and
connective tissue growth factor (CTGF). Note
that both
fibroblasts and
cartilage cells respond to a variety of growth
factors, which are often named for the first cell in which they are
discovered but usually act on a variety of cells.
Studies on non-inflammatory dextrose injection show significant
findings. The knee OA study (111 knees injected with less than an ounce
of dextrose, divided among 3 injections) demonstrated a flexion
improvement of 13°, a 65% reduction in knee-buckling, and significantly
better effect than placebo (P=0.015).1 The finger OA study was smaller
in patient numbers but showed improvement in pain with finger movement
compared with placebo (42%treatment group vs. 15%placebo, P = 0.027) and
a superior improvement in range of motion (P=00.3) with 3ml of dextrose
divided among 3 injections over 6 months.2
Inflammatory prolotherapy [that is, with dextrose over 10%
concentration] is probably less expensive [to study]. However, all
double-blind studies of this form [of prolotherapy] to date had
significant limitations. Two studies used multiple treatments
concurrently and compared an inflammatory with a non-inflammatory
solution, which in itself may affect blinding.
In a third study, the results were in such opposition to all previous
results that it raised the possibility of technical flaw(s). Difficulty
in reproduction of technique was an issue in all of these studies
because they were done with multiple injection sites in patients who had
low back pain. In addition, a large-gauge needle was used to inject bony
attachments of
ligaments, and irritation of structures by a needle has
potential therapeutic effect on its own [apart from what is then
injected].
Because the primary pathology in sprain/strain injuries is in connective
tissue, with secondary
trigger points in muscle, correcting the primary
pathology requires injection of the connective tissue. In arthritis,
there is much to learn about the balance of disrepair forces vs. growth
factors, but stimulation of growth factors has much to offer meantime.
Studies of non-inflammatory prolotherapy show probable benefit in OA and
possible benefit in
Ligament
laxity. In addition, physicians performing
acupuncture or muscle triggerpoint injection generally find prolotherapy
more potent in managing chronic pain. [Stronger still can be the
clinical effect of combining prolotherapy with triggerpoint injection.]
To learn prolotherapy, a physician interested in sports medicine
essentially must learn how to locate the pain-producing lesion zones in
ligaments and tendons and how to inject them. When this skill is
mastered, the physician can keep up with advances in available
proliferant
solutions. [Currently four are in common use worldwide.]
What the physician injects will probably change as the literature
progresses and may include different growth factors or growth factor
stimulants or inflammatory agents.
Prolotherapy is controversial because only a few hundred physicians are
currently known to have identified themselves as practicing this in the
USA, and because most physicians often use an antiquated definition of
the word, such as “inflammatory injection to create growth and repair.”
In reality, many non-inflammatory substances are capable of creating a
rise in growth factors sufficient to cause proliferation of cells or
tissues. Injection of substances to cause or create growth of cells is
currently being used in all major hospitals in the United States,
whether or not they call it Prolotherapy.
1. 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
2. Reeves KD Hassanein K
Randomized, prospective, placebo-controlled
double-blind study on dextrose prolotherapy for osteoarthritic thumb and
finger (dip, pip, and trapeziometacarpal) joints: evidence of clinical
efficacy Jnl Alt Compl Med 2000 6(4): (311-320)
3. Reeves KD Prolotherapy: Basic science, clinical studies, and
technique. In Lennard TA(Ed). Pain procedures in clinical practice. (2nd
Ed.) Philadelphia; Hanley and Belfus;2000:172-190. |
