Dextrose Prolotherapy Injections
Various types of injections have been used by doctors over the years as a means of alleviating musculo-skeletal pain. The most popular is the “cortisone shot”. Whilst there is good evidence that they dramatically reduce inflammation in the short term, they do not promote healing or regeneration of damaged tissues in the longer term. Also repeating the injections frequently may lead to actual weakening of the local tissues. The new trend is to research therapies that help heal or regenerate tissue – so called “Regenerative therapies”.
Sclerosing or prolotherapy injections were first proposed by Hackett, an orthopaedic surgeon, in the 1950s. Early injections included various solutions of vegetable oils, local anaesthetic, dextrose (sugar), phenol and glycerol. The solution was designed to create an inflammatory reaction initiating the proliferation of scar tissue (sclerosis) in the tissues injected. The idea was to cause thickening, tightening and strengthening of the tissues through scarring. Studies confirmed that treatment lead to about a 40% increase in collagen fibre strength and cross sectional area of tendons and ligaments.
More recent trends have led to the use of less irritant solutions of 5% to 35% dextrose and 0.5% Xylocaine – a very tolerable and safe injection, although the effect on the tendon strength is not known.
Other theories on how the injections work include:
- dextrose may also act as an oxygen radical scavenger – soaking up molecules that are thought to cause tissue damage, possibly having some anti-inflammatory value as well.
- repeated injections into tender points seem to de-sensitize these tissues or block pain leading to some new theories about affecting the capsaicin pain receptors around nerves in the
- subcutaneous tissue
Prolotherapy may help in the treatment of the following conditions:
- Loose or stretched ligaments (such as lateral ligament ankle sprains)
- Strained tendon attachments to bone (tennis elbow, achilles tendonitis jumper’s knee, )
- Musculo-ligamentous low back strain and sacro-iliac joint pain
- Tendonitis and para-tendonitis (achilles tendonitis)
- Osteo-arthritis of the knees and thumbs
- Groin pain including adductor strains and osteitis pubis
- Rib and sternum pain
- Bursitis such as Trachanteric bursitis and shoulder impingement
Protocol:
Up to 15 points can be injected each visit using a small volume at each site. The injections are repeated at 3 to 4 week intervals for a total of 4 visits initially. As we are trying to create a healing / inflammatory response you should stop taking anti-inflammatory tablets ( like Nurofen , Voltaren , Naprosyn, etc ). It is OK to keep taking other painkillers such as paracetamol, codeine, digesics, etc. All early trials recommended taking oral supplements of zinc, manganese and vitamin C to help promote healing of connective tissue. More recent trials suggest this may not be needed. Some improvement should be felt by about the 3rd visit. After the initial course, review is suggested to decide whether to continue for another 2 to 4 injections. Top up injections may be given at 3 months and again at 6 months. Cost is usually $165 / session. (Medicare rebate between $21 and $50 depending on length of session, maybe more if the injection is over nerves or spinal joints are involved. $84 to $132 is rebated once the Medicare Safety Net threshold is reached in a calendar year).
Side Effects:
Initially after the injection, there can be a flare up of pain for 2-3 days and this can be treated by local applications of ice to reduce bruising from the needle. Other adverse effects are rare. In particular, there is no thinning of the skin that is sometimes associated with cortisone injections. Usual activities should be maintained between injections. Once the initial soreness settles one can expect some gradual relief.
Research
A randomised controlled trial on low back pain has been conducted at Queensland University showing some benefit of injections over exercise being sustained at 2 years post treatment. Two other smaller trials have shown some benefit in osteoarthritis of the knees and base of the thumbs.
RESEARCH:
Dextrose Prolotherapy for Unresolved Low Back Pain: A Retrospective Case Series Study
RA Hauser & MA Hauser. Journal of Prolotherapy. 2009;3:145-155
145 patients, who had low back pain for an average of four years and ten months, were treated quarterly ( every 3 months) with Hackett-Hemwall dextrose Prolotherapy. This included a subset of 55 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of 26 patients who were told by their doctor(s) that surgery was their only option. Patients were contacted an average of 12 months following their last Prolotherapy session.
Results: In these 145 low backs, pain levels decreased from 5.6 to 2.7 ( 0 to 10 pain scale) after Prolotherapy; 89% experienced more than 50% pain relief with Prolotherapy; more than 80% showed improvements in walking and exercise ability, anxiety, depression and overall disability; 75% percent were able to completely stop taking pain medications. The decrease in pain reached statistical significance at the p<.000001 for the 145 low backs, including the subset of patients who were told there was no other treatment options for their pain and those who were told surgery was their only treatment option.
GA Topol, KD Reeves et al. Hyperosmolar dextrose injection for recalcitrant Osgood-Schlatter disease. Pediatrics 128 (5):e1121-e1128, 2011.
Girls aged 9 to 15 and boys aged 10 to 17 were randomly assigned to either therapist-supervised usual care or double-blind injection of 1% lidocaine solution with or without 12.5% dextrose. Injections were administered monthly for 3 months. All subjects were then offered dextrose injections monthly as needed. Sixty-five knees in 54 athletes were treated.
Results: At 1 year, asymptomatic sport was more common in dextrose-treated knees than knees treated with only lidocaine (32 of 38 vs 6 of 13; P = .024) or only usual care (32 of 38 vs 2 of 14; P < .0001). CONCLUSIONS: Our results suggest superior symptom-reduction efficacy of injection therapy over usual care in the treatment of Osgood-Schlatter disease in adolescents. A significant component of the effect seems to be associated with the dextrose component of a dextrose/lidocaine solution. Dextrose injection over the apophysis and patellar tendon origin was safe and well tolerated and resulted in more rapid and frequent achievement of unaltered sport and asymptomatic sport than usual care
A. Topol and K. D. Reeves. Regenerative injection of elite athletes with career-altering chronic groin pain who fail conservative treatment: a consecutive case series. Am.J.Phys.Med.Rehabil. 87 (11):890-902, 2008.
Seventy-two athletes (39 rugby, 29 soccer, and 4 other) completed the minimum two-treatment protocol. Their data revealed a mean groin pain history of 11 (3-60) mos. Average number of treatments received was 3 (1-6). Individual paired t tests for Visual Analog Scale (VAS) of pain with sport (VAS Pain) and Nirschl pain phase scale measured at 0 and an average of 26 (6-73) mos indicated VAS Pain improvement of 82% (P < 10) and Nirschl pain phase scale improvement of 78% (P < 10). Six athletes did not improve following regenerative injection therapy treatment, and the remaining 66 returned to unrestricted sport. Return to unrestricted sport occurred in an average of 3 (1-5) mos.
W. M. Kim, H. G. Lee, C. W. Jeong, C. M. Kim, and M. H. Yoon. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J.Altern.Complement Med. 16 (12):1285-1290, 2010.
The treatment involved intra-articular dextrose water prolotherapy or triamcinolone acetonide injection using fluoroscopic guidance, with a biweekly schedule and maximum of three injections. The numbers of recruited patients were 23 and 25 for the prolotherapy and steroid groups, respectively. The pain and disability scores were significantly improved from baseline in both groups at the 2-week follow-up, with no significant difference between them. The cumulative incidence of >/=50% pain relief at 15 months was 58.7% in the prolotherapy group and 10.2% in the steroid group. CONCLUSIONS: Intra-articular prolotherapy provided significant relief of sacroiliac joint pain, and its effects lasted longer than those of steroid injections. Further studies are needed to confirm the safety of the procedure and to validate an appropriate injection protocol
For more research see: www.prolotherapy.org
