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Prolotherapy

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Prolotherapy involves injecting an otherwise non-pharmacological and non-active irritant solution into the body, generally in the region of tendons or ligaments for the purpose of strengthening …

Prolotherapy involves injecting an otherwise non-pharmacological and non-active irritant solution into the body, generally in the region of tendons or ligaments for the purpose of strengthening weakened connective tissue and alleviating musculoskeletal pain.

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  • 1. Prolotherapy
    Tariq Hayat Khan
  • 2. Prolotherapy
    Also known as;
    “Proliferation therapy" or
    “Regenerative injection therapy" or
    "Proliferative injection therapy”
    Old terms;
    “Fibroproliferative therapy” or
    “Proloferant injection therapy”
  • 3. Prolotherapy
    Involves injecting an otherwise non-pharmacological and non-active irritant solution into the body, generally in the region of tendons or ligaments for the purpose of strengthening weakened connective tissue and alleviating musculoskeletal pain.
  • 4. History
    In Roman times hot needles were poked into the shoulders of injured gladiators
    In the 1940s George S. Hacket used it
    In the 1950s Gustav Anders Hemwall extensively used it
    Dr. Gustav Hemwall
  • 5. History
    The term ‘Prolotherapy’ was first used in the 1950’s by Dr. George Hackett
    Allen R Banks, Ph.D. described in detail the theory behind prolotherapy in "A Rationale for Prolotherapy” in Journal of Orthopaedic Medicine 1991;13(3).
  • 6. Solutions used
    Dextrose  
    Lidocaine 
    Phenol
    Glycerine 
    Cod liver oil extract
    Sodium morrhuate
    P2G solution, containing phenol, glycerin, and glucose
  • 7. Platelet Rich Plasma (PRP)
    Injection of plasma containing growth factor rich platelets obtained by centrifuging blood
    Used as a second line therapy
    Used in musculoskeletal conditions; tendonopathy, tendonosis, acute and chronic muscle strains, ligament sprains and intra-articular injuries and joint pain such as arthritis and knee meniscus damage
  • 8. Useful for
    Laxity of a tested joint that fails self resolution
    Distinct tender points at tendons or ligaments
    Recurrent swelling or fullness involving a joint or muscular region
    Popping, clicking, grinding, or catching sensations in joints
  • 9. Useful for
    Aching or burning pain that is referred into an upper or lower extremity
    Recurrent headache, face pain, jaw pain, ear pain
    Chest wall pain with tenderness along the rib attachments on the spine or along the sternum
    Spine pain that does not respond to surgery, or whose origin is not identified by extensive studies
  • 10. Specific conditions
    Arthritis, osteoarthritis
    Back pain, low back pain
    Neck pain, brachialgia
    Fibromyalgia
    Sports injuries
    Unresolved whiplash injuries
  • 11. Specific conditions
    Carpal tunnel syndrome
    Chronic tendonitis
    Partially torn tendons, ligaments and cartilages
    Degenerated or herniated discs
    TMJ and sciatica
  • 12. How it works
    Injections of irritant solutions at tendons and cartilages near bones
    An inflammatory response that "turns on" the healing process
    The ligaments and tendons produced are thicker, stronger, and contain fibers of varying thickness
    improved biomechanics and joint function, and decreased pain
     
    (Hackett GS, Hemwall GA, Montgomery GA. Ligament and Tendon Relaxation Treated by Prolotherapy. Springfield, Ill: Charles C Thomas; 1993.)
    (Linetsky FS, Rafael M, Saberski L. Pain management with regenerative injection therapy (RIT) In: Weiner RS, editor. Pain Management: A Practical Guide for Clincians. Washington, DC: CRC Press; 2002. pp. 381–402.)
  • 13. an inhibiting effect on pathologic angiogenesis (neovascularity)?
    elimination of nerve fibers associated with neovessels?
    Relationships between the destruction of pathologic neovascularity and substance P, calcitonin gene-related peptide, and vascular endothelial growth factor have been hypothesized but not clarified
    Alfredson H, Ohberg L. Chronic tendon pain: no tendinitis, but high levels of glutamate and a vasculoneuralingrowth—implications for a new treatment? Therapy. 2005;2:387–392.
    Zeisig E, Ohberg L, Alfredson H. Extensor origin vascularity related to pain in patients with tennis elbow. Knee Surg Sports TraumatolArthrosc. 2006;14:659–663. 
     Zeisig E, Ohberg L, Alfredson H. Sclerosingpolidocanol injections in chronic painful tennis elbow—promising results in a pilot study. Knee Surg Sports TraumatolArthrosc. 2006;14:1218–1224.
  • 14. Duration of treatment
    A few treatments to 10 or more
    The average number of treatments is 4-6 for an area treated
  • 15. Against prolo
  • 16. Most major medical insurance policies do not cover the treatment
    Medicare declined to cover prolotherapy for chronic low back pain citing that prolotherapy is not a scientific treatment
    There is still a lack of solid evidence that prolotherapy is effective.
    Dagenais, S.; Yelland, M.; Del Mar, C.; Schoene, M. (2007). "Prolotherapy injections for chronic low-back pain.". Cochrane Database of Systematic Reviews (2)
    HCFA Decision Memorandum. Quackwatch.
  • 17. … used to treat chronic low-back pain for over 50 years but their use remains controversial…. .
    Of the five studies reviewed, three found that prolotherapy injections alone were not an effective treatment for chronic low-back pain and two found that a combination of prolotherapy injections, spinal manipulation, exercises, and other treatments can help chronic low-back pain and disability.
    the role of prolotherapy injections for chronic low-back pain is still not clear.
    http://www2.cochrane.org/reviews/en/ab004059.html
    Cochrane review 2004
  • 18. Response of Knee Ligaments to Prolotherapy in a Rat Injury Model
    Hypotheses: Dextrose injections will enlarge cross-sectional area, decrease laxity, strengthen, and stiffen stretch-injured medial collateral ligaments (MCLs) compared with controls.
    Dextrose prolotherapy will increase collagen fibril diameter and density of stretch-injured MCLs.
    Jensen KT, Rabago DP, et al. Response of Knee Ligaments to Prolotherapy in a Rat Injury Model. Am J Sports Med. 2008 July; 36(7): 1347–1357.
  • 19. After 5 weeks of healing, dextrose and saline injections did not alter laxity (P = .28)
    Stiffness was not different after 2, 4, or 5 weeks of healing
    Few macrophages were found in injured and injected ligaments 5 weeks after injury
    Jensen KT, Rabago DP, et al. Response of Knee Ligaments to Prolotherapy in a Rat Injury Model. Am J Sports Med. 2008 July; 36(7): 1347–1357.
  • 20. Transmission electron microscopy images of the cross-section of ligaments. 5wks after injury, collagen fibril diameter and density were decreased compared with uninjured ligaments. This effect did not change with injection treatment
    A, uninjured with no injection; B, injured with no injection; C, injured with saline injection; and D, injured with dextrose injection.
  • 21. No compelling evidence that dextrose injections cause consistent biomechanical response and does not provide a clear mechanism to explain positive clinical effects of decreased pain and disability
    ..clinical improvement may result from factors not directly assessed in this study, such as an effect on peripheral nerves rather than on ligament biomechanics…
  • 22. For Prolo
  • 23. Proponents
    Robert C. Shuman, M.D
    Ravin
    Cantieri
    Pasquarello
    Ross Hauser, M.D.
    Donna Alderman, D.O.
     
  • 24. Links
    www.prolotherapynashville.com
    www.prolotherapy.org: Website by Dr. Ross Hauser
    www.prolotherapy.com
    www.getprolo.com
    http://prolotherapyheals.com
    http://www.prolotherapynashville.com/history_of_prolotherapy.php
  • 25. Proponents
    American College of Osteopathic Sclerotherapeutic Pain Management
    American Academy of Orthopaedic Medicine.
  • 26.
  • 27.
  • 28. Hacket GS. Ligament and tendon relaxation treated by prolotherapy. Springfield: CC Thomas; 1956;
    Reeves KD. Prolotherapy: regenerative injection therapy. In:  Waldman SD editors. Pain management. Philadelphia: WB Saunders; 2007;p. 1106–1127
    Loeser JD. Point of view. Spine. 2004;29:16
    Kim SR, Stitik TP, Foye PM, Greenwald BD, Campagnolo DI. Critical review of prolotherapy for osteoarthritis, low back pain, and other musculoskeletal conditions: a physiatric perspective. Am J Phys Med Rehabil. 2004;83:379–389
    Reeves KD, Klein RG, DeLong WB. Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized study. Spine. 2003;29:9–16[letter]Spine. 2004;29:1839–1840author reply 1842-3
    Yelland MJ, Glasziou PP, Bogduk N, Schluter PJ, McKernon M. Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial. Spine. 2004;29:9–16
    Reeves KD, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. AlternTher Health Med. 2000;6:68–7477-80
    Reeves KD, Hassanein K. Dextrose injection prolotherapy for ACL laxity. AlternTher Health Med. 2003;9:58–62
    Topol GA, Reeves KD, Hassanein K. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil. 2005;86:697–702
    Dagenais S, Ogunseitan O, Haldeman S, Wooley JR, Newcomb RL. Side effects and adverse events related to interligamentous injection of sclerosing solutions (prolotherapy) for back and neck pain: a survey of practitioners. Arch Phys Med Rehabil.2006;87:909–913
    Reeves KD. Prolotherapy: basic science, clinical studies and technique. In:  Lennard TA editors. Pain procedures in clinical practice. 2nd ed.. Philadelphia: Hanley & Belfus; 2000;p. 172–190
    Martinoli C, Derchi LE, Pastorino C, Bertolotto M, Silvestri E. Analysis of echotexture of tendons with US. Radiology. 1993;186:839–843
    Van Holsbeek M. Musculoskeletal ultrasound. 2nd ed.. St Louis: Mosby; 2001;
    Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decrease thickness at follow-up. Br J Sports Med. 2004;38:8–11
    Nielsen PK, Jensen BR, Darvann T, Jorgensen K, Bakke M. Quantitative ultrasound tissue characterization in shoulder and thigh muscles—a new approach. BMC Musculoskeletal Disord. 2006;7:2
    And many, many more……
  • 29. Evidence
    Injured ligaments with dextrose injection, saline injection, and no injection had 90%, 46%, and 62% larger cross-sectional area than uninjured ligaments
    Injured ligaments with dextrose injections had a 30% larger cross-sectional area than injured ligaments with saline injections (P < .05)
    Jensen KT, Rabago DP, et al. Response of Knee Ligaments to Prolotherapy in a Rat Injury Model. Am J Sports Med. 2008 July; 36(7): 1347–1357.
  • 30. High-Resolution Ultrasound and Magnetic Resonance Imaging to Document Tissue Repair After Prolotherapy: A Report of 3 Cases
    Bradley D. Fullerton, MD
    Archives of Physical Medicine and Rehabilitation
    Volume 89, Issue 2, Pages 377-385 (February 2008)
    DOI: 10.1016/j.apmr.2007.09.017
  • 31. Fig 1
    Patellar Tendinopathy With a Partial Tear
    Sagittal views
    Axial views
  • 32. Fig 2
    Patellar tendon ultrasound
  • 33. Fig 3
    Anterior Talofibular Ligament Sprain
  • 34. Fig 5
    A Degenerative, Complex Tear of the Medial Meniscus
  • 35. Fig 6
  • 36. Fig 7
  • 37. Fig 8
  • 38. Procedure
  • 39. EMLA application
  • 40.
  • 41.
  • 42.
  • 43. Positioning
  • 44. Marking
  • 45. Prepping
  • 46.
  • 47. Injecting
  • 48.
  • 49.
  • 50. Covering
  • 51. Completed
  • 52. My limited experience
  • 53. Conclusion
    The exact mechanism of action for prolotherapy remains controversial
    It is being used with a high degree of success in terms of pain relief and improved workability in thousands of patients
  • 54. Comments & Questions

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