Prolotherapy: Can it help your patient?

,; ,; ,; ,

Applied Evidence

Prolotherapy: Can it help your patient?

J Fam Pract. 2015 December;64(12):763-768

PDF Download

References

1. Khan KM, Cook J, Bonar F, et al. Histopathology of common tendinopathies: update and implications for clinical management. Sports Med. 1999;27:393-408.

2. Streit JJ, Shishani Y, Rodgers M, et al. Tendinopathy of the long head of the biceps tendon: histopathologic analysis of the extraarticular biceps tendon and tenosynovium. Open Access J Sports Med. 2015;10:63-70.

3. Maganaris CN, Narici MV, Almekinders LC, et al. Biomechanics and pathophysiology of overuse tendon injuries. Sports Med. 2004;34:1005-1017.

4. Jensen KT, Rabago DP, Zgierska A, et al. Response of knee ligaments to prolotherapy in a rat injury model. Am J Sports Med. 2008;36:1347-1357.

5. Kim SR, Stitik TP, Foye PM, et al. 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.

6. Rabago D, Slattengren A, Zgierska A. Prolotherapy in primary care practice. Prim Care. 2010;37:65-80.

7. Joseph MF, Denegar CR. Treating tendinopathy: perspective on anti-inflammatory intervention and therapeutic exercise. Clin Sports Med. 2015;34:363-374.

8. Eslamian F, Amouzandeh B. Therapeutic effects of prolotherapy with intra-articular dextrose injection in patients with osteoarthritis: a single-arm study with 6 months follow up. Ther Adv Musculoskelet Dis. 2015;7:35-44.

9. Rabago D, Patterson JJ, Mundt M, et al. Dextrose prolotherapy for knee osteoarthritis: a randomized controlled trial. Ann Fam Med. 2013;11:229-237.

10. Yelland MJ, Sweeting KR, Lyftogt JA, et al. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med. 2011;45:421-428.

11. Reeves KD, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Altern Ther Health Med. 2000;6:68–74.

12. Yelland MJ, Glasziou PP, Bogduk N, et al. Prolotherapy injections, saline injections, and exercises for chronic low back pain: a randomized control trial. Spine. 2004;29:9-16.

13. Dagenais S, Yelland MJ, Del Mar C, et al. Prolotherapy injections for chronic low back pain. Cochrane Database Syst Rev. 2007;18(2):CD004059.

14. Staal JB, de Bie R, de Vet HCW, et al. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev. 2011;(3):CD001824.

15. Scarpone M, Rabago DP, Zgierska A, et al. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med. 2008;18:248.

16. Topol GA, Podesta LA, Reeves KD, et al. Hyperosmolar dextrose injection for recalcitrant Osgood-Schlatter disease. Pediatrics. 2011;128:e1121-e1128.

17. Ryan MB, Wong AD, Gillies JH, et al. Sonographically guided intratendinous injections of hyperosmolar dextrose/lidocaine: a pilot study for the treatment of chronic plantar fasciitis. Br J Sports Med. 2009;43:3003-3006.

18. Kim E, Lee JH. Autologous platelet-rich plasma versus dextrose prolotherapy for the treatment of chronic recalcitrant plantar fasciitis. PMR. 2014;6:152-158.

19. Hauser RA, Sprague IS. Outcomes of prolotherapy in chondromalacia patella patients: improvements in pain level and function. Clin Med Insights Arthritis Musculoskelet Disord. 2014;17:13-20.

20. United Healthcare medical policy. Prolotherapy for musculoskeletal indications. Available at: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Prolotherapy_for_Musculoskeletal_Indications.pdf. Accessed October 26, 2015.

21. Davidson J, Javaraman S. Guided interventions in musculoskeletal ultrasound: where’s the evidence? Clin Radiol. 2011;66:140-152.

22. Maxwell NJ, Ryan MB, Taunton JE, et al. Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study. Am J Roentgenol. 2007;189:W215.

23. Reeves KD, Hassanein K. Randomized, perspective, placebo-controlled double-blind study of dextrose prolotherapy for osteoarthritic thumb and finger (DTaP, PIP and Traneziometacarpal) joints: Evidence of clinical efficacy. J Altern Complem Med. 2000;6:311-320.

24. Cusi M, Saunders J, Hungerford B, et al. The use of prolotherapy in the sacroiliac joint. Br J Sports Med. 2010;44:100-104.

25. Kim WM, Lee HG, Jeong CW, et al. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med. 2010;16:1285-1290.

26. Khan SA, Kumar A, Varshney MK, et al. Dextrose prolotherapy for recalcitrant coccygodynia. J Orthop Surg. (Hong Kong) 2008;16:27–29.

27. Miller MR, Mathews RS, Reeves KD. Treatment of painful advanced internal lumbar disc derangement with intradiscal injection of hypertonic dextrose. Pain Physician. 2006;9:115–121.

When considering or recommending DPT for an adolescent with Osgood-Schlatter disease, however, it is particularly important that he or she be referred to a physician with expertise in prolotherapy.

Plantar fasciosis: A possibility when conservative treatment fails (SOR B)

An early case series showed that DPT effectively improved pain at rest and during activity in patients with chronic plantar fasciosis refractory to conservative care.¹⁷ A small RCT recently compared PRP with DPT in such patients.¹⁸

Pain, disability, and activity limitation were measured by the Foot Functional Index. The PRP group improved by 29.7%, 26.6%, and 28% in pain, disability, and activity limitation, respectively, vs improvements of 17%, 14.5%, and 12.4% in the DPT group. Although there was a trend for PRP to be superior, the results were not statistically significant.¹⁸ This suggests that DPT may be an additional treatment option for patients with plantar fasciosis when conservative treatment fails.

Chondromalacia patella: Not enough is known (SOR C)

One study showed that DPT improved self-reported pain and function scores in patients with chronic knee pain secondary to chondromalacia patella. However, the study had no control group and no standardized injected solution; rather, the solution was tailored for each individual.¹⁹Thus, there is insufficient data to make recommendations regarding the effectiveness of DPT in treating chondromalacia patella or other causes of patellofemoral pain syndrome.

What to tell patients about recovery and adverse effects

Injection of dextrose into ligaments, tendons, and joints carries the theoretical risks of light-headedness, allergic reaction, infection, and structural damage. However, there have been no reports of serious or significant adverse events associated with DPT when used for peripheral joint indications.

To avoid inhibiting the desired inflammatory response to prolotherapy, nonsteroidal anti-inflammatory drugs should not be used to treat post-injection pain.

The most common risks of DPT are needle trauma-induced pain, mild bleeding, and bruising. A sense of fullness, stiffness, and occasional numbness at the site at the time of injection are common, benign, and typically self-limiting.⁶ If post-procedure numbness continues, the patient should follow up in 48 to 72 hours to rule out nerve damage.

Post-injection pain flare during the first 72 hours may occur. In a study of prolotherapy for knee OA pain, 10% to 20% of patients experienced such flares.¹⁵ Most patients respond well to acetaminophen and experience resolution of pain within a week. Non-steroidal anti-inflammatory drugs should not be used to treat post-procedure pain because they may interfere with the local inflammatory response needed for healing. Regular activities can be resumed immediately after an injection into a large joint, such as the knee, or after full sensation and proprioception returns if an anesthetic was used in combination with the hypertonic dextrose.

There is a theoretical risk of tendon weakening and rupture with tenotomy/intra-substance injections into weight-bearing tendons, but there are no known published reports of this complication with DPT. Nonetheless, we recommend that patients limit ballistic weight bearing or full strength activity for 48 hours after an injection into a non-weight bearing tendon and for 5 to7 days for injection into a weight-bearing tendon.

Physical/occupational therapy is important in chronic tendinopathy, and we encourage rapid return (24-48 hours) to low-intensity rehabilitation with gradual return (5-7 days) to full rehabilitation exercises.

Ballistic weight bearing and full strength activity should be limited for 48 hours after an injection into a non-weight bearing tendon and for 5 to 7 days for a weight-bearing tendon.

The number of DPT injection sessions is variable. We recommend follow-up between 3 and 6 weeks for reevaluation. If the patient’s pain and/or function has not improved after 2 sets of injections—or DPT is initially successful but pain or dysfunction returns—another round of treatment should be offered in 3 to 6 weeks.

CORRESPONDENCE
Carlton J. Covey, MD, FAAFP, Fort Belvoir Community Hospital, Sports Medicine, Eagle Pavilion, 9300 Dewitt Loop, Fort Belvoir, VA 22060; carlton.covey@usuhs.edu.