Prolotherapy and Relief from Joint Pain

What is prolotherapy?

Prolotherapy is a treatment used to treat joint ailments. The treatment involves injecting a natural irritant (dextrose) into the soft tissue of an injured joint to produce a mild inflammatory response. This begins a healing response. The treatment itself or in combination with other therapies, such as spinal manipulation, has been shown to improve disability in cases of arthritis, low back pain and tendon injury. 

How does prolotherapy work? 

The treatment initiates a healing cascade that duplicates the natural healing process of poorly vascularized tissue such as ligaments, tendons, and cartilage. After injection with a solution containing dextrose the body produces a mild inflammatory response. This is followed by a proliferation cascade where more collagen is deposited in ligaments, cartilage and tendons. This increases the strength of the tissue and pain resolves.

Confirmation that prolotherapy induces the repair of ligaments and other soft tissue structures has been reported in both animal and human studies. Prolotherapy injections to rabbit ligaments increased ligamentous mass (44%), thickness (27%), as well as ligament-bone junction strength (28%) over a six-week period. In human studies, biopsies revealed a 60% increase in ligament size after prolotherapy injections. Another study relying on ultrasound also showed that treatment with prolotherapy increased ligament size by 27%.

Who will benefit from prolotherapy? 

Most patients with chronic joint pain and instability will benefit from prolotherapy. Prolotherapy can provide permanent relief from joint pain. Anyone considering surgery for a chronic joint injury may want to consider prolotherapy first.

How effective is prolotherapy?

Studies show that prolotherapy helps to reduce pain and disability in arthritis and tendon overuse injury. When compared to other therapeutic injections, prolotherapy compares favorably with other commonly used injections including hyaluronic acid and corticosteroid injections. 

Corticosteroid injections tend to provide symptomatic relief quickly but usually benefits are short lasting whereas prolotherapy tends to provide improvements long term. In patients with sacroiliac joint pain, almost 60% of patients having received prolotherapy injections had improvements in pain of more than 50% after 15months vs. only 10% of patient having received steroid injections. Similar results were found when it comes to treating osteoarthritis of the hand. Prolotherapy was found to be more effective that corticosteroid injections especially in the long term. Prolotherapy was also more effective at improving function.

There is preliminary information showing that prolotherapy is likely helpful in most joint conditions including temporomandibular dysfunction.- Research shows that in rotator cuff injuries, prolotherapy improves range of motion and shoulder function. Similar results were obtained for arthritis of the knee with results demonstrating that prolotherapy reduced pain, improved function and quality of life when compared to patients receiving salt water injections.-

For knee osteoarthritis, patients receiving an average of four prolotherapy treatments had a 17.2% improvement in pain after four weeks and a 36% improvement after 52 weeks. In other studies, prolotherapy was shown to be effective at relieving pain in the short, medium and long term without significant side effects. 

Prolotherapy is particularly effective when combined with other therapies such as spinal manipulation. 

Prolotherapy for instability of the upper spine

Chronic neck pain is often a symptom of an unstable cervical spine. The presence of excessive motion between two consecutive vertebras is known as cervical instability. When ligaments in the neck are injured they become elongated. Sometimes this comes from a traumatic injury such as whiplash or concussions but it can also be the result of constant stain inflicted by poor posture. This allows for more motion between vertebras and irritates the facet joints - the joints that, together with our neck ligaments, provide stability to the spine. This instability irritates the facet joint and leads to pain, headaches and referred pain. This instability also severely increases the risk of developing arthritis and other chronic degenerative changes to the spine. Studies show that facet joint pain is responsible for the majority of neck pain. The treatment needs to be aimed at repairing the ligaments in the neck to restore some stability.  This is precisely what prolotherapy does. 

Cervical instability can also lead to the compression of the vagus nerve. The nerve is a major component of the parasympathetic nervous system. As such, it helps to control mood, immune response, digestion and heart rate. Compression of the vagus nerve affects our ability to regulate the stress response and can lead to significant disability and mood problems such as anxiety. 

What are the potential side effects?

As with any treatment, potential side effects are possible but rare. Most studies report decrease pain and disability with the use of prolotherapy.  Although serious adverse effects are exceedingly rare, benign reactions such as temporary post-injection pain, stiffness, and bruising are common. 

Dr. Ludo Brunel is a Naturopathic Doctor and is certified in administering Prolotherapy. Please contact Cadence Chiropractic, Sport & Health to learn more about Dr. Ludo and what he can do for you at 403.521.2278

References

1 Rabago D, Nourani B. Prolotherapy for Osteoarthritis and Tendinopathy: a Descriptive Review. Curr Rheumatol Rep. 2017 Jun;19(6):34.

2 Hackett G, editor. Oak Park IL. 5th ed. 1993. Ligament and tendon relaxation treated by prolotherapy ; pp. 94–6.

3 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. Open Orthop J. 2014 Oct 1;8:326-45. 

4 Liu Y, Tipton C, Matthes R, 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. Connect Tissue Res. 1983;11: 95–102. 

5 Klein R, Dorman T, Johnson C. Proliferant injections for low back pain histologic changes of injected ligaments and objective measurements of lumbar spine mobility before and after treatment. J Neuro Ortho Med Surg. 1989;10: 123–6.

6 Auburn A, Benjamin S, Bechtel R, Matthews S. Increase in cross sectional area of the iliolumbar ligament using prolotherapy agents an ultrasonic case study. J Prolotherapy. 1999;1: 156–62.

7 Rabago D, Nourani B. Prolotherapy for Osteoarthritis and Tendinopathy: a Descriptive Review. Curr Rheumatol Rep. 2017 Jun;19(6):34.

8 Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010 Nov 20;376(9754):1751-67. 

9 Kim WM, Lee HG, Jeong CW, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med. 2010 Dec;16(12):1285-90. 

10 Jahangiri A, Moghaddam FR, Najafi S. Hypertonic dextrose versus corticosteroid local injection for the treatment of osteoarthritis in the first carpometacarpal joint: a double-blind randomized clinical trial. J Orthop Sci. 2014 Sep;19(5):737-43.

11 Nagori SA, Jose A, Gopalakrishnan V, Roy ID, Chattopadhyay PK, Roychoudhury A. Efficacy of prolotherapy and arthrocentesis in management of temporomandibular joint hypermobility. J Oral Rehabil. 2018 Dec;45(12):998-1006. 

12 Refai H. Long-term therapeutic effects of dextrose prolotherapy in patients with hypermobility of the temporomandibular joint: a single-arm study with 1-4 years' follow up. Br J Oral Maxillofac Surg. 2017 Jun;55(5):465-470.

13 Seven MM, Ersen O, Akpancar S, Ozkan H, Turkkan S, Yıldız Y, Koca K. Effectiveness of prolotherapy in the treatment of chronic rotator cuff lesions. Orthop Traumatol Surg Res. 2017 May;103(3):427-433. 

14 Sit RW, Chung VCh, Reeves KD, Rabago D, Chan KK, Chan DC, Wu X, Ho RS, Wong SY. Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: A systematic review and meta-analysis. Sci Rep. 2016 May 5;6:25247. 

15 Sit RWS, Wu RWK, Rabago D, Reeves KD, Chan DCC, Yip BHK, Chung VCH, Wong SYS. Efficacy of Intra-Articular Hypertonic Dextrose (Prolotherapy) for Knee Osteoarthritis: A Randomized Controlled Trial. Ann Fam Med. 2020 May;18(3):235-242.

16Rabago D, Kijowski R, Woods M, Patterson JJ, Mundt M, Zgierska A, Grettie J, Lyftogt J, Fortney L. Association between disease-specific quality of life and magnetic resonance imaging outcomes in a clinical trial of prolotherapy for knee osteoarthritis. Arch Phys Med Rehabil. 2013 Nov;94(11):2075-82. 

17 Refai H. Long-term therapeutic effects of dextrose prolotherapy in patients with hypermobility of the temporomandibular joint: a single-arm study with 1-4 years' follow up. Br J Oral Maxillofac Surg. 2017.

18 Arias-Vázquez PI, Tovilla-Zárate CA, Legorreta-Ramírez BG, Burad Fonz W, Magaña-Ricardez D, González-Castro TB, Juárez-Rojop IE, López-Narváez ML. Prolotherapy for knee osteoarthritis using hypertonic dextrose vs other interventional treatments: systematic review of clinical trials. Adv Rheumatol. 2019 Aug 19;59(1):39.

19 Distel LM, Best TM. Prolotherapy: a clinical review of its role in treating chronic musculoskeletal pain. PM R. 2011 Jun;3(6 Suppl 1):S78-81.

20 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. Open Orthop J. 2014 Oct 1;8:326-45. 

21 Manchikanti  L et al. Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician. 2002 Jul;5(3):243-9.

23 Breit S et al. Vagus Nerve as Modulator of the Brain–Gut Axis in Psychiatric and Inflammatory Disorders. Front Psychiatry. 2018; 9: 44.

24 Breit S et al. Vagus Nerve as Modulator of the Brain–Gut Axis in Psychiatric and Inflammatory Disorders. Front Psychiatry. 2018; 9: 44.

25 Dagenais S, Haldeman S, Wooley JR. Intraligamentous injection of sclerosing solutions (prolotherapy) for spinal pain: a critical review of the literature. Spine J. 2005 May-Jun;5(3):310-28.

26 Dagenais S, Ogunseitan O, Haldeman S, Wooley JR, Newcomb RL. Side effects and adverse events related to intraligamentous injection of sclerosing solutions (prolotherapy) for back and neck pain: A survey of practitioners. Arch Phys Med Rehabil. 2006 Jul;87(7):909-13.

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