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1. Neural Prolotherapy
Technique for Chronic
Pain Management
Prof. Dr. dr. Dessy Rakhmawati Emril, Sp. S (K)

2. Low back pain is the most frequent type of musculoskeletal pain
Conventional therapies can be ineffective, and some patients
may experience severe unexpected adverse effects
Neural prolotherapy treatment is a very effective treatment for
chronic painful conditions
Neural prolotherapy is probably one of the safest injection
therapies and easiest to administer with the least amount of
discomfort to the patient
INTRODUCTION

3. Neural Prolotherapy is a new, exciting breakthrough in the treatment of pain
developed by a New Zealand physician, Dr. John Lyftogt, MD
Neural Prolotherapy involves multiple small injections along the path of
tender superficial nerves in the area of the patients pain with a small
amount of 5% Dextrose
The dextrose solution works by immediately blocking the nerve endings
(TRPV-1 or Capsacin receptors) that are responsible for the nerve pain and
inflammation with the associated superficial nerves
This leads to healing beneath the nerve to deeper structures like the
associated muscles, tendons, ligaments and cartilage of involved joints
INTRODUCTION

4. Perineural
Subcutaneous
Injection (PSI)
Perineural Injection
Therapy (PIT)
Subcutaneous
Prolotherapy
Treatment
Neural
Prolotherapy
(NPT)
Injection close to subcutaneous nerves to restore their normal function
The American Academy of
Orthopaedic Medicine
To be favored in
Australia and
New Zealand
Introduced by
John Lyftogt

5. Transient receptor
potential vanilloid
type 1 (TRPV-1)
Located on the nervi-nervorum of the peripheral nervous
system
Na+
influx : formation and increased action potential causing the
neuropathic pain
Ca2+
influx : release of the neuropeptides  Substance P “SP” and
Calcitonin Gene Related Peptide “CGRP”  neurogenic
inflammation

6. Premkumar, LS. Current Neuropharmacology, 2008, 6, 151-163

7. Transient receptor potential vanilloid type 1
(TRPV-1)
TRPV-1
Down-regulated
The nerve cell will be very “good”
Non-pain producing proteins, e.g. somatostatin
and galanin
Up-regulated
The nerve cell will be very “evil/bad”
Produce damaging and pain-producing proteins,
e.g P-substance and CGRP

8. Injured or irritated nerve
Up-regulated TRPV-1 receptor/ TRPV-1 nerve
P Substance
CGRP or calcitonin-gene-related peptide
Neurogenic (nerve-caused) Inflammation
NEUROGENIC
INFLAMATION

9. CHRONIC CONSTRICTION INJURY (CCI)
Alyan II. Med. J. Cairo Univ., Vol. 86, No. 5, September: 2727-2731, 2018
Neuronal
friction
Chronic
Constriction
Injury (CCI)

10. CHRONIC CONSTRICTION INJURY (CCI)

11. Hilton’s law
“The nerve
supplying a joint
also supplies the
ligaments,
tendon and
muscles that
move the joint
and the skin
covering the
joint”
TRPV1 nerves
connect to all
other
structures.
Treating the
nerves
supplying the
muscles moving
the joint
=
Treating the
nerves
supplying the
joint
=
Treating the
cutaneous
inflamed nerves
supplying the
skin over the
joint
Soliman, DMI. Journal of Sports Science 5 (2017) 113-118. doi: 10.17265/2332-7839/2017.02.006

12. Neurogenic
Inflammation
Healthy Nerve
Dextrose 5%
HOW DOES NEURAL
PROLOTHERAPY
WORKS?

13.  Down regulate TRPV1 through an modulation effect reducing SP and
CGRP levels (Binds to presynaptic calcium channels  inhibiting the
release of neurodegenerative peptides)  decreasing neurogenic
inflammation  pain reduction, regression of soft tissue swelling,
and relief of CCI constrictions, restoring normal nerve growth factor
flow, facilitating nerve repair, and providing almost instantaneous
analgesic effect lasting from hours to days.
 Decreasing neurogenic infammation + analgesia effect 
decreasing muscle spasm  increases the function
HOW DOES NEURAL
PROLOTHERAPY
WORKS?
Dextrose 5 %

14. CONCEPT: TIME FRAME OF PAIN AND FUNCTIONAL BENEFIT
EFFECTS RESEARCH
DEXTROSE
Nerve Calming : 5-20 seconds – 2 days
Effect on Growth Factors : 20 min – 10 days
(Pain relief reason unclear)
Hyperosmolar/irritative or Needling Effect : 20
min -10 days (Pain relief reason unclear)
Tissue Maturation Over time (repair) : 10 days
– 3 months

15. Others musculoskeletal pain
Neck pain
Low back pain
Fibromyalgia
Headaches
INDICATIONS

16. Local abscess
Cellulitis
Critical thrombocytopenia
Platelet dysfunction syndrome
Hemodynamic instability
Cellulitis
Critical thrombocytopenia
Platelet dysfunction syndrome
Hemodynamic instability
Local abscess
CONTRA
INDICATIONS

17. Evaluates each patient thoroughly with a personal history and
physical examination, including observation of the gait
Careful examination with palpation of involved area is made as
it corresponds to the superficial nerves in that area when the
patient is experiencing their pain.
On an individual basis, further evaluation may include
ultrasound evaluation, X-rays and/or MRI before receiving
neural prolotherapy
In chronic pain cases, use expertise to provide a
comprehensive treatment approach that includes
rehabilitative exercises, nutrition, and specific supplements to
maximize your health and ability to heal.
EVALUATION

18.  Identify the area of pain/anatomic fields
 Using dermatomal anatomic distribution, identify the
nerves affected
 Asses range of motion of the point affected to
determine peripheral nerves affected
 Inject painful CCIs (Chronic constriction injuries)
 Reassess same sites of pain after the procedure until
areas are pain free
EVALUATION

19.  Inject tender points in the subcutaneous tissue along
the path of the affected nerve in each case.
 3 mL syringes with a 0.5 inch needle were prepared with
a solution of 5% dextrose.
 The tender points were each injected with 0.5 mL of
solution, at a 45 degree angle, 0.5- 1cm deep and
approximately 1-2 cm apart.
 The solution was injected while withdrawing the needle
so as to create a skin bleb.
TECHNIQUE

20. SOLUTIONS
5% to 20% dextrose water
5% dextrose water with 8,4% sodium
bicarbonate
10% mannitol with dextrose water
pH maintained between 7-8

21. FREQUENCY OF TREATMENT
 It is not possible to always
predict the exact number
of sessions required, since
each patient’s condition is
unique in terms of his or
her ability to repair and
heal an involved area.
 Treatment is given weekly
on the average, for
maximum of 6 sessions
 For short term treatment,
it’s given daily for 3 days,
then one week after the
third session

22. WHAT TO EXPECT
The relief from the initial treatment lasts
between 4 hours to a few days and will not
be permanent.
Typically, injections are done once weekly or
every other week.
Repetitive treatments will be required for
long term relief.
Generally patients return each week with
fewer regions to inject and 10-15% gradual
improvement weekly.

23. THANK YOU