Applied Evidence

Prolotherapy: Can it help your patient?

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Prolotherapy appears to be effective for Achilles tendinopathy and knee osteoarthritis, but has limited efficacy for low back pain. Find out when—and whether—to consider this option.


 

References

PRACTICE RECOMMENDATIONS

› Advise patients with Achilles tendinopathy that a combination of prolotherapy and eccentric exercise is likely to provide more rapid and sustained pain relief than either option alone. A
› Offer a third round of prolotherapy to a patient whose pain and/or function has not improved or has returned after 2 treatments. C
› Consider prolotherapy administered by a physician with expertise in the technique for adolescents with recalcitrant Osgood-Schlatter disease. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Over the past several years, prolotherapy has been gaining support as an option for patients with tendinopathies and painful osteoarthritic conditions. Yet the technique lacks both a consistent definition and an abundance of evidence.

Because the prefix “prolo” is thought to refer to proliferation or regeneration, some physicians prefer the term “sclerotherapy” when injecting sclerosing agents. Others point out that “prolotherapy” refers to the proliferation of tissue that the injections provoke, which has never been proven. We believe that the material injected should dictate the term used to describe it—dextrose prolotherapy (DPT) or platelet-rich plasma therapy (PRP), for example.

In this update, we focus on DPT—the injection of a solution containing hypertonic dextrose into ligaments, tendons, and joints to promote healing. You’ll find an overview of the proposed mechanism of action and a description of the technique (see “How DPT works”1-9), as well as a look at the evidence of its effectiveness for a variety of musculoskeletal conditions in the text and TABLE9-19 that follow. Our review is limited by the dearth of large, definitive studies, and consists mainly of anecdotal evidence, case reports, and other low-quality studies.

Considering DPT—for which patients?

Even for conditions for which the evidence of its efficacy is unequivocal, DPT is only one part of a comprehensive treatment plan. Functional assessment and correction of any weaknesses, inflexibilities, and/or training errors are also essential.

Dextrose prolotherapy is rarely covered by health insurance and is often considered only after conservative treatment has failed.

There are a number of other considerations, as well. For one thing, DPT is rarely covered by health insurance20 and is often considered only after conservative treatment has failed. What’s more, it is not suited to every patient.

Absolute contraindications include acute infections at the injection site, such as cellulitis, abscess, or septic arthritis. Relative contraindications include acute gout flare and acute fracture near the site.6

When DPT is a viable alternative, keep in mind that the procedure should only be done by a physician experienced in the technique—and that ultrasound guidance should be used to ensure precise anatomical delivery (FIGURE 1).21 Consent must be obtained and documented, and universal precautions observed.

Read on to find out whether to consider DPT for particular patients.

Achilles tendinopathy: DPT decreases pain, improves function (SOR A)

Non-insertional Achilles tendinopathy can be treated with prolotherapy to decrease pain and tendon thickness (FIGURE 2). A small, single blind randomized trial compared the effectiveness of eccentric exercise (ie, contractions performed to lengthen the muscle), DPT alone, and a combination of DPT and exercise for patients with chronic Achilles tendinopathy.10

The investigators found greater improvement in the Victorian Institute of Sport Assessment-Achilles (VISA-A) score at 12 months with the combined therapy (41.1 on a 0-100 scale) vs either eccentric exercise (23.7) or DPT (27.5) alone. The increase from baseline was greater for those who received combination therapy at 6 weeks (+11.7) compared with the eccentric-only group.10 Adding DPT (injected into the tender points of the subcutaneous tissues adjacent to the Achilles tendon) to eccentric exercise resulted in a more rapid and sustained improvement in pain, function, and stiffness.

In an earlier observational study, researchers achieved improvement in pain scores using a different DPT technique.22 Here, patients with chronic Achilles tendinosis received ultrasound-guided intratendinous dextrose injections every 6 weeks until symptoms resolved. Pain scores, calculated using a visual analogue scale (VAS), showed a mean reduction at rest (88%), during normal daily activities (84%), and during physical activity (78%). The mean number of treatment sessions was 4, and the mean time to achieve results was 30 weeks.22

How DPT works: Variations complicate the picture

Studies have shown that inflammatory changes are infrequently associated with chronic painful tendon conditions.1,2 Instead, the changes are degenerative in nature, and can occur in the main body of the tendon, in its bony insertion site, and in the structures surrounding the tendon.3 While the exact mechanism of action for DPT is unknown, studies have shown that cells exposed to hypertonic dextrose undergo osmotic lysis, creating a proinflammatory environment. This leads to recruitment of several growth factors that promote the healing of tendons, ligaments, and cartilage.4-6

Neovascularity and neuronal ingrowth, also present in tendinopathies, are believed to be a source of pain, as well. The injection of hypertonic dextrose may destroy the neovasculature, thus removing a nidus, or focal point, for pain.7

Concentrations of dextrose used may range from 10% to 50% and be combined with an injectable anesthetic alone or with other proliferants/sclerosing agents.6 We prefer a 50/50 mixture of 50% dextrose and 2% xylocaine without epinephrine, resulting in a final injection concentration of 25% dextrose and 1% xylocaine.

Techniques for tendinopathies vary from bathing the tendon without tenotomy to performing multiple tenotomies (with or without injection material into the tenotomy). For knee osteoarthritis, for example, both extra- and intra-articular approaches can be used alone or in combination.8,9 The extra-articular injections are done either at tender locations around the knee joint or at ligamentous attachment sites. The number of injection sessions can vary, as well. Variations in both the concentrations and techniques contribute to the difficulty in interpreting existing evidence.

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