Prolotherapy

A 2015 review found limited evidence that prolotherapy is safe and effective for Achilles tendinopathy, plantar fasciosis, and Osgood Schlatter disease.[3] The quality of the studies was also poor.[3] Another 2015 review assigned a strength of recommendation level A for Achilles tendinopathy, knee osteoarthritis and level B for lateral epicondylosis, Osgood Schlatter disease, and plantar fasciosis.[4] Level A recommendations are based on consistent and good-quality patient-oriented evidence while level B are based on inconsistent or limited-quality patient-oriented evidence.[4] Two 2016 review articles expanded level B strength of recommendations to include low back/sacroiliac pain and rotator cuff tendinopathy. As of 2016 evidence to support the use of prolotherapy in acute pain, myofascial pain or as first-line therapy, could not be determined.[5]

Contraindications for patients to receive prolotherapy injections may include:[18]

• Local abscess
• Bleeding disorders[19]
• Patient on anticoagulant medication[19]
• Known allergy to prolotherapy agent[19]
• Acute infections such as cellulitis[8]
• Septic arthritis[8]

Relative contraindications include:

• Acute gouty arthritis
• Acute fracture

Patients receiving prolotherapy injections have reported generally mild side effects, including mild pain and irritation at the injection site[20] (often within 72 hours of the injection), numbness at the injection site, or mild bleeding. Pain from prolotherapy injections is temporary and is often treated with acetaminophen[20] or, in rare cases, opioid medications. NSAIDs are not usually recommended due to their counter action to prolotherapy-induced inflammation, but are occasionally used in patients with pain refractory to other methods of pain control.[18] Theoretical adverse events of prolotherapy injection include lightheadedness, allergic reactions to the agent used, bruising, infection, or nerve damage. Allergic reactions to sodium morrhuate are rare.[18] Rare cases of back pain, neck pain, spinal cord irritation, pneumothorax, and disc injury have been reported at a rate comparable to that of other spinal injection procedures.[8][18]

Prolotherapy involves the injection of an irritant solution into a joint space,[21] weakened ligament, or tendon insertion to relieve pain. [8] Most commonly, hyperosmolar dextrose (a sugar) is the solution used;[22] glycerine,[20] lidocaine (a commonly used local anesthetic),[23] phenol,[20] and sodium morrhuate (a derivative of cod liver oil extract) are other commonly used agents.[8][10] The injection is administered at joints or at tendons where they connect to bone.

Prolotherapy treatment sessions are generally given every two to six weeks for several months in a series ranging from 3 to 6 or more treatments.[18][20] Many patients receive treatment at less frequent intervals until treatments are rarely required, if at all.[24]

The term originated with George S. Hackett, MD, in 1956 in a publication titled “The rehabilitation of an incompetent structure by the generation of new cellular tissue”. He applied the term prolotherapy from the words “proli’” (Latin), meaning offspring, and “proliferate”, meaning to produce new cells in rapid succession.[25] Although the erroneous term "sclerotherapy" was utilized by some in the past to describe this treatment, it is now clear that prolotherapy does not cause scarring.[26] The mechanism of prolotherapy requires further clarification.[19][20][21][26][27][28] It is expected to involved a number of mechanisms.[1][9]

Some major medical insurance policies view prolotherapy as an investigational or experimental therapy with an inconclusive evidence base. Consequently, they currently do not provide coverage for prolotherapy procedures.[29][30][31] Medicare reviewers in 1999 determined at that time that practitioners had not provided "any scientific evidence on which to base a [different] coverage decision," and so retained Medicare's current coverage policy to not cover prolotherapy injections for chronic low back pain, but expressed willingness to reconsider if presented with results of "further studies on the benefits of prolotherapy."[32]

The concept of creating irritation or injury to stimulate healing has been recorded as early as Roman times when hot needles were poked into the shoulders of injured gladiators. Prolotherapy use began in the 1930s and was originally used in the treatment of ligamentous laxity.[10] In the 1950s, George S. Hackett, a general surgeon in the United States, began performing injections of irritant solutions in an effort to repair joints and hernias.[18] This practice is what would eventually evolve into modern-day prolotherapy. In 1955, Gustav Anders Hemwall became acquainted with George Hackett at an American Medical Association meeting and started practicing prolotherapy.

• Rabago, David; Patterson, Jeffrey J.; Mundt, Marlon; Kijowski, Richard; Grettie, Jessica; Segal, Neil A.; Zgierska, Aleksandra (2013). "Dextrose Prolotherapy for Knee Osteoarthritis: A Randomized Controlled Trial". The Annals of Family Medicine. 11 (3): 229–37. doi:10.1370/afm.1504. PMC 3659139. PMID 23690322. Lay summary – Medscape Medical News (May 31, 2013).
• Rabago, David; Zgierska, Aleksandra; Fortney, Luke; Kijowski, Richard; Mundt, Marlon; Ryan, Michael; Grettie, Jessica; Patterson, Jeffrey J. (2012). "Hypertonic Dextrose Injections (Prolotherapy) for Knee Osteoarthritis: Results of a Single-Arm Uncontrolled Study with 1-Year Follow-Up". The Journal of Alternative and Complementary Medicine. 18 (4): 408–14. doi:10.1089/acm.2011.0030. PMC 3326267. PMID 22515800.