Prolotherapy (Regenerative Injection Therapy) in Chronic Pain – A review of the Literature and Clinical Experience

Robert Banner MD, CCFP, FRCP , Beverley Padfield PT, FCAMT, Cathy Rohfritsch RN

Department of Anesthesiology and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada

Background

The use of prolotherapy or regenerative injection therapy to treat chronic musculoskeletal pain related to connective tissue pathology is largely unknown in conventional medicine but is used by a small group of allopathic and osteopathic physicians. It is important for those who look to treat pain to be aware of alternative or complementary therapies. Such treatments require scrutiny and scientific evaluation before being accepted and or recommended for patients with chronic musculoskeletal pain

Modern prolotherapy evolved from an injection technique called sclerotherapy, first used in the 1920’s to treat hernias and hemorrhoids. In the 1940’s Earl Gedney, a well-known osteopath at the Philadelphia College of Osteopathic Medicine began to use sclerotherapy for back-related ailments. It was George Hackett a physician from Canton, Ohio who first coined the term “prolotherapy” in the 1950’s. His book “Ligament and Tendon Relaxation Treated by Prolotherapy” continues to be used as a training reference. A new textbook will soon be published by Tom Ravin MD, Mark Cantieri DO and George Pasquarello DO.

Proponents of regenerative injection therapy propose that when ligaments and tendons are stretched, torn or fragmented, joints become painful. Prolotherapy has the ability to address the cause of instability and repair the weakened sites, resulting in permanent stabilization of the joint. When precisely injected into the site of pain or injury, prolotherapy creates a controlled inflammation that stimulates the body to lay down new tendon or ligament fibers resulting in a strengthening of the weakened structure. When the joint becomes stronger, nerves are no longer “stretched” and pain may be relieved.Prolotherapy has been observed to increase the size of tendons and ligaments by up to 40% and increase their tensile strength by 200%. The tissue formed is healthy, strong flexible ligament or tendon.

History of Prolotherapy

Wound Healing has distinct phases thatoverlap in time.

RIT Solutions

Irritants – phenol, tannic acid, pumice

Chemo - tactics – Sodium Morrhuate

Osmotic – dextrose, glycerine

Combination – P2G

Optimal solution and concentration to yet be found

Contraindications to RIT

1. Allergy to local anesthetic or proliferantsolutions or their ingredients

2. Acute non-reduced subluxations ordislocations

3. Acute arthritis, bursitis or tendinitis, goutor rheumatoid arthritis

Schedule of Treatments

Fibroblastic activity subsides within 6 –8 weeks following an injection

Partial or complete relief is about 60-70% following 3 – 6 injections (Klein 1989)

It seems wise to try an initial course of 6 injections

Follow up 2 months after the last of the initial course

Schedule of Treatments

Debatable with large variation in practice

Currently I advise a treatment every 3 to 6 weeks

Concurrent physical / manual / orthopedic / osteopathic treatment for better result

No need for “maintenance” or “booster” treatments

RemodelingComplications

Dorman (1992) survey of 95 experienced practitioners on a patient pool of 494,845

Total of 66 ‘minor’ and 14 ‘major’ complications

‘Major’ was defined as either requiring hospitalization or having transient or permanent nerve damage

Risk-to-benefit = low complication rate

Results

In appropriately selected patients 70 – 80% receive complete or significant relief of pain

Patient should notice a significant reduction in pain by the 5th treatment

50% of patients notice some improvement after just one treatment

Procedure

Physician must be properly trained in this technique via a combination of seminars/workshops, apprenticeships or visiting fellowships in order to safely and effectively utilize this treatment.

Aseptic technique