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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 weakened connective tissue and alleviating musculoskeletal pain.

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  1. 1. Prolotherapy<br />Tariq Hayat Khan<br />
  2. 2. Prolotherapy<br />Also known as;<br />“Proliferation therapy" or <br />“Regenerative injection therapy" or<br />"Proliferative injection therapy”<br />Old terms;<br />“Fibroproliferative therapy” or <br />“Proloferant injection therapy”<br />
  3. 3. Prolotherapy<br />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.<br />
  4. 4. History<br />In Roman times hot needles were poked into the shoulders of injured gladiators<br />In the 1940s George S. Hacket used it<br />In the 1950s Gustav Anders Hemwall extensively used it<br />Dr. Gustav Hemwall<br />
  5. 5. History<br />The term ‘Prolotherapy’ was first used in the 1950’s by Dr. George Hackett<br />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).<br />
  6. 6. Solutions used<br />Dextrose  <br />Lidocaine <br />Phenol<br />Glycerine <br />Cod liver oil extract<br />Sodium morrhuate<br />P2G solution, containing phenol, glycerin, and glucose<br />
  7. 7. Platelet Rich Plasma (PRP)<br />Injection of plasma containing growth factor rich platelets obtained by centrifuging blood <br />Used as a second line therapy<br />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<br />
  8. 8. Useful for<br />Laxity of a tested joint that fails self resolution<br />Distinct tender points at tendons or ligaments<br />Recurrent swelling or fullness involving a joint or muscular region<br />Popping, clicking, grinding, or catching sensations in joints<br />
  9. 9. Useful for<br />Aching or burning pain that is referred into an upper or lower extremity<br />Recurrent headache, face pain, jaw pain, ear pain<br />Chest wall pain with tenderness along the rib attachments on the spine or along the sternum<br />Spine pain that does not respond to surgery, or whose origin is not identified by extensive studies<br />
  10. 10. Specific conditions<br />Arthritis, osteoarthritis<br />Back pain, low back pain<br />Neck pain, brachialgia<br />Fibromyalgia<br />Sports injuries<br />Unresolved whiplash injuries<br />
  11. 11. Specific conditions<br />Carpal tunnel syndrome<br />Chronic tendonitis<br />Partially torn tendons, ligaments and cartilages<br />Degenerated or herniated discs<br />TMJ and sciatica<br />
  12. 12. How it works<br />Injections of irritant solutions at tendons and cartilages near bones<br />An inflammatory response that "turns on" the healing process<br />The ligaments and tendons produced are thicker, stronger, and contain fibers of varying thickness<br />improved biomechanics and joint function, and decreased pain<br /> <br />(Hackett GS, Hemwall GA, Montgomery GA. Ligament and Tendon Relaxation Treated by Prolotherapy. Springfield, Ill: Charles C Thomas; 1993.)<br />(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.)<br />
  13. 13. an inhibiting effect on pathologic angiogenesis (neovascularity)?<br />elimination of nerve fibers associated with neovessels?<br />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<br />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.<br />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. <br /> 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.<br />
  14. 14. Duration of treatment<br />A few treatments to 10 or more<br />The average number of treatments is 4-6 for an area treated<br />
  15. 15. Against prolo<br />
  16. 16. Most major medical insurance policies do not cover the treatment<br />Medicare declined to cover prolotherapy for chronic low back pain citing that prolotherapy is not a scientific treatment<br />There is still a lack of solid evidence that prolotherapy is effective. <br />Dagenais, S.; Yelland, M.; Del Mar, C.; Schoene, M. (2007). "Prolotherapy injections for chronic low-back pain.". Cochrane Database of Systematic Reviews (2)<br />HCFA Decision Memorandum. Quackwatch.<br />
  17. 17. … used to treat chronic low-back pain for over 50 years but their use remains controversial…. . <br />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.<br />the role of prolotherapy injections for chronic low-back pain is still not clear.<br /><br />Cochrane review 2004<br />
  18. 18. Response of Knee Ligaments to Prolotherapy in a Rat Injury Model<br />Hypotheses: Dextrose injections will enlarge cross-sectional area, decrease laxity, strengthen, and stiffen stretch-injured medial collateral ligaments (MCLs) compared with controls. <br />Dextrose prolotherapy will increase collagen fibril diameter and density of stretch-injured MCLs.<br />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.<br />
  19. 19. After 5 weeks of healing, dextrose and saline injections did not alter laxity (P = .28)<br />Stiffness was not different after 2, 4, or 5 weeks of healing<br />Few macrophages were found in injured and injected ligaments 5 weeks after injury<br />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.<br />
  20. 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 <br />A, uninjured with no injection; B, injured with no injection; C, injured with saline injection; and D, injured with dextrose injection.<br />
  21. 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<br />..clinical improvement may result from factors not directly assessed in this study, such as an effect on peripheral nerves rather than on ligament biomechanics…<br />
  22. 22. For Prolo<br />
  23. 23. Proponents<br />Robert C. Shuman, M.D<br />Ravin<br />Cantieri<br />Pasquarello<br />Ross Hauser, M.D.<br />Donna Alderman, D.O.<br /> <br />
  24. 24. Links<br /><br /> Website by Dr. Ross Hauser<br /><br /><br /><br /><br />
  25. 25. Proponents<br />American College of Osteopathic Sclerotherapeutic Pain Management <br />American Academy of Orthopaedic Medicine.<br />
  26. 26.
  27. 27.
  28. 28. Hacket GS. Ligament and tendon relaxation treated by prolotherapy. Springfield: CC Thomas; 1956;<br />Reeves KD. Prolotherapy: regenerative injection therapy. In:  Waldman SD editors. Pain management. Philadelphia: WB Saunders; 2007;p. 1106–1127<br />Loeser JD. Point of view. Spine. 2004;29:16 <br />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 <br />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<br />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 <br />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 <br />Reeves KD, Hassanein K. Dextrose injection prolotherapy for ACL laxity. AlternTher Health Med. 2003;9:58–62 <br />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 <br />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 <br />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 <br />Martinoli C, Derchi LE, Pastorino C, Bertolotto M, Silvestri E. Analysis of echotexture of tendons with US. Radiology. 1993;186:839–843 <br />Van Holsbeek M. Musculoskeletal ultrasound. 2nd ed.. St Louis: Mosby; 2001;<br />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 <br />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<br />And many, many more……<br />
  29. 29. Evidence<br />Injured ligaments with dextrose injection, saline injection, and no injection had 90%, 46%, and 62% larger cross-sectional area than uninjured ligaments<br />Injured ligaments with dextrose injections had a 30% larger cross-sectional area than injured ligaments with saline injections (P < .05)<br />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.<br />
  30. 30. High-Resolution Ultrasound and Magnetic Resonance Imaging to Document Tissue Repair After Prolotherapy: A Report of 3 Cases<br />Bradley D. Fullerton, MD<br />Archives of Physical Medicine and Rehabilitation<br />Volume 89, Issue 2, Pages 377-385 (February 2008)<br />DOI: 10.1016/j.apmr.2007.09.017<br />
  31. 31. Fig 1<br />Patellar Tendinopathy With a Partial Tear<br />Sagittal views<br />Axial views<br />
  32. 32. Fig 2<br />Patellar tendon ultrasound <br />
  33. 33. Fig 3<br />Anterior Talofibular Ligament Sprain<br />
  34. 34. Fig 5<br />A Degenerative, Complex Tear of the Medial Meniscus<br />
  35. 35. Fig 6<br />
  36. 36. Fig 7<br />
  37. 37. Fig 8<br />
  38. 38. Procedure<br />
  39. 39. EMLA application<br />
  40. 40.
  41. 41.
  42. 42.
  43. 43. Positioning<br />
  44. 44. Marking<br />
  45. 45. Prepping<br />
  46. 46.
  47. 47. Injecting<br />
  48. 48.
  49. 49.
  50. 50. Covering<br />
  51. 51. Completed<br />
  52. 52. My limited experience<br />
  53. 53. Conclusion<br />The exact mechanism of action for prolotherapy remains controversial<br />It is being used with a high degree of success in terms of pain relief and improved workability in thousands of patients<br />
  54. 54. Comments & Questions<br />