Have you heard of prolotherapy? While it has been around for quite some time, it has recently become popular in sports medicine and orthopedic issues. The concept is derived on stimulating the immune system to attack a certain point of your body through injecting a simple solution. While the concept is sound, the question is does it work? Before you send your hard-earned money this expensive therapy, this article from Sports Physio provides an unbiased look at this question:
“Prolotherapy… Is it as ‘sweet’ as it sounds???
Prolotherapy is a popular yet controversial injection therapy used widely in sports medicine and recently more in general practice, that involves the injection of a dextrose solution. Yes that’s right, sugar injected into the body to help treat a variety of ligament, tendon, muscle and joint pains. However despite lots passionate anecdotal evidence for its benefits, such as speeding up healing, quicker return to sport, and the ability to reduce chronic joint and ligament laxity, there is actually little robust research that supports it use, and even less on its long-term effects.
I have personally witnessed its growing popularity and widespread use in professional sport and in general practice, and I have even referred patients for these injections. But I have to question my motives for this, and in this article we will look at what are the benefits, the risks, the research and the future for prolotherapy?
When is prolotherapy used?
Prolotherapy can be traced back about a hundred years when doctors used to give irritants to help heal many things. But its modern use has really been going since the 1950’s. It was first called ‘sclerotherapy’ as it was thought to be a scar forming therapy, and has been growing in popularity, for the treatment of acute ligament injuries, where the ligament has undergone a mechanical failure leading to laxity but not rupture, these are commonly seen in sports with the ankle and the knee ligaments being the most commonly injured areas.
Ligament laxity after a injury can be present for a long time afterwards and in some cases can be permanent leading to chronic joint instability and cause long-term pain and loss of function. This often prevents a returning to activity long after the original injury has healed. So having a treatment that could speed up the healing rate, but also reduce ligament and joint laxity seems a very attractive prospect to any medical professional, especially those working in sport, where the speed of an injured player returning to play is often the main measure of your success.
So what does prolotherapy do?
Prolotherapy acts as a local irritant and so creates an increased inflammatory response, this increases protein synthesis and collagen formation and so increased cell proliferation. Prolotherapy is also thought to increase the infiltration of leukocyte (white blood cells) and macrophages (debris removers) as well as increase platelet-derived growth factor (PDGF) and interleukin-1β (IL-1β) (chemical building blocks) and so help improve a ligaments strength, mass, thickness and a trend toward an increase in cell number, glycosaminoglycan (protien), and water content. (source, source , source)
How is prolotherapy administered?
Injections of the irritant in solution are given in and around the injured ligament, joint or muscle over a course of a few weeks to a few months. The number, dosage and concentration of the solution used is not well described or explained. Many clinicians seem use their judgement and intuition dependent on the severity and size of the injury and the amount of laxity present. One of the major limitations of prolotherapy research is the lack of consensus or standardisation of dosages or protocols to administer the injections.
Three solutions are commonly used in prolotherapy D-glucose (dextrose), phenol-glucose-glycerin (P2G), and sodium morrhuate. D-glucose is thought to be the safest solution but with conflicting evidence on its effects, with studies showing increase cell proliferation (source) but others showing cell apoptosis (cell death) (source). P2G is thought to create a stronger inflammatory response, but phenol has been found to be toxic to some human cells (source) and can also block peripheral nerves in humans (source). Sodium Morrhuate is a an extract of cod liver oil and found to be toxic to red blood cells (source). All the prolotherapy injections I have seen used have been D-glucose, which seems not only to to be the safest with regards to toxicity, but also has the most conflicting effects.
How does prolotherapy feel?
Well the first thing to mention is that prolotherapy is painful, more so in some areas than others, I have seen grown sports men and women have injections in their lateral ankle ligaments, knee MCL’s and LCL’s, lumbar facet joints, SIJ’s, and even one poor soul having is symphisis pubis injected… three times… ouch! They ALL complained of increased pain and discomfort during, and after these injections.
Thats not really surprising as the irritant nature of the solution causes a local inflammation which obviously can cause pain and discomfort, in my experience this lasts anywhere from 24 hours, up to a week afterwards. Patients are advised to rest and take analgesia as required, but obviously not anti-inflammatory medications as this counter effects the work of the injections, they are also advised not to do any vigorous exercise or have any manual therapy during this reactive inflammatory stage. Once the pain and inflammation is settled the ligament or joint is reassessed for laxity and pain and either re injected or the rehab can begin
Are there any adverse effects to prolotherapy.
In the scant literature and in my clinical experience there are no significant side effects apart for a post injection flare of pain and some tenderness around the injection site. Rabago et al. 2010 did find some very rare effects such as allergic reactions and nerve damage but none classed as serious.
However I would like to add something here, about possible long-term detrimental side effect that prolotherapy may cause. It is purely anecdotal and based only on a single case, but it was observed in conjunction with a very senior and well-respected sports orthopaedic surgeon who regularly operates on many high-profile and professional sports men and women.
It was observed that during an operation on a chronic MCL injury in a professional footballer that had previously had four prolotherapy injections over two years ago, that the ligaments collagen structure was unusual and had changed. It was noted to be comprised mainly of soft stringy collagen, Type III, opposed to the normal stiffer more rigid collagen Type I. The orthopaedic surgeon doing the surgery also commented that this is not the first time he has witnessed this unusual collagen make up with other athletes who have had prolotherapy injections around ligaments, and then needed surgery.
The surgeon explained that he thought these prolotherapy injections may indeed help with protein synthesis and collagen formation, but he believes its of this softer less dense Type III collagen which is formed rapidly and quickly after the injections, which for a stabilising ligament isn’t the best type. He went on to explain that he thought this excessive Type III collagen produced by prolotherapy injections may well actually prevent the formation of normal Type I collagen from being laid down with normal natural healing mechanisms, and so could caused potential long term deficits.”
The article continues to discuss the important question of does it really work. Finish reading the article on The Sports Physio website by clicking the link below:
Image courtesy of: Fleur De Lisa