Prolotherapy, also called proliferation therapy, is an injection-based treatment used in chronic musculoskeletal conditions.^[1] It has been characterised as an alternative medicine practice.^[2]

Medical uses

A 2015 review found no evidence that prolotherapy is safe or effective for Achilles tendinopathy, plantar fasciosis, and Osgood–Schlatter disease.^[3] The quality of the studies was also poor.^[3] Another 2015 review assigned a strength of recommendation level A for Achilles tendinopathy and knee osteoarthritis and level B for lateral epicondylosis, Osgood–Schlatter disease, and plantar fasciosis.^[4] Level A recommendations are based on consistent and good-quality patient-oriented evidence while level B are based on inconsistent or limited-quality patient-oriented evidence.^[4]

Contraindications

Contraindications for patients to receive prolotherapy injections may include:^[18]

• Local abscess
• Bleeding disorders^[19]
• Patient on anticoagulant medication^[19]
• Known allergy to prolotherapy agent^[19]
• Acute infections such as cellulitis^[7]
• Septic arthritis^[7]

Relative contraindications include:

• Acute gouty arthritis
• Acute fracture

Side effects

Patients receiving prolotherapy injections have reported generally mild side effects, including mild pain and irritation at the injection site^[20][21] (often within 72 hours of the injection), numbness at the injection site, or mild bleeding. Pain from prolotherapy injections is temporary and is often treated with acetaminophen^[20] or, in rare cases, opioid medications. NSAIDs are not usually recommended due to their counter action to prolotherapy-induced inflammation, but are occasionally used in patients with pain refractory to other methods of pain control.^[18] Theoretical adverse events of prolotherapy injection include lightheadedness, allergic reactions to the agent used, bruising, infection, or nerve damage. Allergic reactions to sodium morrhuate are rare.^[18] Rare cases of back pain, neck pain, spinal cord irritation, pneumothorax, and disc injury have been reported at a rate comparable to that of other spinal injection procedures.^[7][18]

Technique

Prolotherapy involves the injection of an irritant solution into a joint space,^[22] weakened ligament, or tendon insertion to relieve pain. ^[7] Most commonly, hyperosmolar dextrose (a sugar) is the solution used;^[23] glycerine,^[20] lidocaine (a commonly used local anesthetic),^[24] phenol,^[20] and sodium morrhuate (a derivative of cod liver oil extract) are other commonly used agents.^[7][9] The injection is administered at joints, ligaments, or tendons where they connect to bone.

Prolotherapy treatment sessions are generally given every two to six weeks for several months in a series ranging from three to six or more treatments.^[18][20] Many patients receive treatment at less frequent intervals until treatments are rarely required, if at all.^[25]

Terminology and mechanism

The term originated with George S. Hackett, MD, in 1956 in a publication titled "The rehabilitation of an incompetent structure by the generation of new cellular tissue". He applied the term prolotherapy from the words "proli’" (Latin), meaning offspring, and "proliferate", meaning to produce new cells in rapid succession.^[26] Although the erroneous term "sclerotherapy" was utilized by some in the past to describe this treatment, it is now clear that prolotherapy does not cause scarring.^[27] The mechanism of prolotherapy requires further clarification.^{[19][20][22][27][28][29]} It is expected to involve a number of mechanisms.^[1][8][30]

Criticism

Some major medical insurance policies view prolotherapy as an investigational or experimental therapy with an inconclusive evidence base. Consequently, they currently do not provide coverage for prolotherapy procedures.^[31][32][33] Medicare reviewers in 1999 determined at that time that practitioners had not provided "any scientific evidence on which to base a [different] coverage decision," and so retained Medicare's current coverage policy to not cover prolotherapy injections for chronic low back pain, but expressed willingness to reconsider if presented with results of "further studies on the benefits of prolotherapy."^[34]

History

The concept of creating irritation or injury to stimulate healing has been recorded as early as Roman times when hot needles were poked into the shoulders of injured gladiators.

In 1840, French surgeon Alfred-Armand-Louis-Marie Velpeau published a paper detailing how he had injected an iodine solution into a hernia in order to create beneficial inflammation.^[35] American surgeon Joseph Pancoast later wrote that he had been performing this procedure (using either iodine or cantharides) since 1836.^[35] Another early American practitioner of this method was George Heaton.^[35]

After World War 1, sclerotherapy came to be a common treatment for malformations of blood vessels and the lymphatic system. This involved injecting a therapeutic liquid to shrink them.

By the late 1920s, this method was used to treat hernias.^[35][36] By the late 1930s, it was also used to treat ligamentous laxity.^[9] In the 1950s, George S. Hackett, a general surgeon in the United States, began performing injections of irritant solutions in an effort to repair joints and hernias.^[18]

In 1955, Gustav Anders Hemwall became acquainted with George Hackett at an American Medical Association meeting and started practicing the technique.

Hackett coined the term "prolotherapy" for the practice, a very early appearance being in his 1956 book Ligament and Tendon Relaxation (Skeletal Disability) Treated by Prolotherapy (Fibro-Osseus Proliferation).^[37]

References