Odom Sports Medicine
John Odom, MD MPH
Prolotherapy is a safe, non-surgical treatment for chronic pain using injections to stimulate healing. It has been used for decades on patients in pain from aging, overuse or injury. It is defined by Webster’s
Third New International Dictionary as “the rehabilitation of an incompetent structure, such as ligaments or tendons, by the induced proliferation of new cells.” Pain from auto accidents, athletic injuries, and overuse injuries often arise from injury to the soft tissues in the body. These soft tissues which include ligaments, muscles, tendons and joint capsules are also called “connective tissues” because they connect to bones, thereby supporting the bony skeleton. Prolotherapy causes these connections to be repaired, rebuilt and strengthened. It is for this reason that prolotherapy has also been called ligament reconstructive therapy or stimulated ligament repair.
COMMON INJURIES TREATED WITH PROLOTHERAPY
? Whiplash Injury to the Neck, Upper Back, Shoulders and Low Back
; Tension and Migraine Headaches
; TMJ Syndrome
; Low Back Pain from Lifting or Work-Related Injuries
; Postural Strain of the Neck and Back
; Overuse Injuries such as Tennis Elbow, Shoulder Tendonitis, Achilles tendonitis and Carpal Tunnel
; Fibromyalgia and Myofascial Pain
; Sacroiliac Joint Disorders
; Muscle Tightness, Strain and Spasm
; Arthritis Pain-Knee, Hands, Neck and Back
; Herniated and Degenerative Discs
; Pinched Nerves and Sciatica
; Weak, Loose, and Unstable Joints (Hypermobility/Subluxations/Dislocations)
; Athletic Injuries, New and Old
These represent soft tissue injuries, which can often become chronically painful. Normally, these injured muscles, tendons, and ligaments go through a repair and healing process, which takes about four to six weeks. But, what happens when the low back pain, neck pain, and headaches from a whiplash injury just will not bet better? Or, the athletic injury that continues to cause nagging pain and is preventing you from staying active, especially keeping you from the sport you enjoy the most? What about the pain where you cannot pinpoint a specific injury, but think it may be due to some repetitive tasks at work, or from overdoing it while working around the houses. Anti-inflammatories and medications are often given to treat these injuries, but they may actually slow or stop this
When rest and pain medications fail, and usually they do
because they only mask or cover up the underlying
problem, other types of treatment is often tried. One
method of treating these kinds of injuries is a specific
flexibility and strengthening program, tailored to the
individual and the areas of weakness. A physical therapist
can administer therapeutic treatment, teach an exercise
program, and provide the education to the individual to
allow them to follow their program at home, giving them
independence in their recovery.
Another type of treatment is manual therapy, in which a therapist uses his hands to break up or release adhesions, muscle spasms and restricted fascia (connective tissue). Acupuncture may only give temporary relief. In a significant number of cases, despite a reasonable treatment plan and consistent effort from the individual, residual pain and dysfunction may persist. Chronic pain is often quite disabling and may affect job performance, recreational activities and activities of daily living. Along the way a doctor may state that “you just have to live with it…there is nothing you can do about it” or say that surgery is the
only option. That news is frustrating and discouraging.
Although you may not have heard about prolotherapy until now, it has been used to treat pain and injuries for more than sixty years and the results have been amazing. In studies conducted on pain patients ,up to 85-90% of patients receive good-to-excellent results in pain relief and improved function. We are finding similar statistics in our practice as well. Also, the use of pain medications can be greatly reduced or even eliminated after treatment. This is good news, because pain medications can be costly and have potentially serious side effects with chronic use. But, the best part of all is that prolotherapy produces long-lasting relief through stimulating the body’s natural healing response. Most other types of treatment provide only temporary relief. Prolotherapy is an alternative to surgery in many cases, thereby avoiding dysfunctional scar tissue and lengthy rehabilitation. George Hackett, M.D., a prolotherapy pioneer, proved that strengthening connective tissue relieves soft tissue pain and a research study in the respected medical journal, Lancet, demonstrated the effectiveness of prolotherapy.
Before Prolotherapy After Prolotherapy
Ligaments loose and damaged Ligaments healed and strengthened
HOW DOES PROLOTHERAPY WORK?
Prolotherapy works on a very simple principle: injecting the prolotherapy solution at the sites of pain and weakness stimulates the body’s own healing mechanism to repair and rebuild injured tissue into a stronger, more supportive, less painful tissue than it was before treatment.
When injuries to the connective tissues (ligaments, tendons, and muscles) occur, the area may not heal completely, due to poor blood supply to these tissues and from lack of proper treatment. For this reason, ligaments heal very slowly. If left untreated, damaged ligaments become loose, allowing bones in the joint to swing out of alignment causing pain, muscle spasms, and eventually arthritis. The attachment sites or anchor points of ligament to bone are the weak links. Connective tissue cells called fibroblasts are deficient, as seen under microscope. This deficiency of fibroblasts leads to loose ligaments and weakened tissues. As a result, the normal supportive function of the ligaments, which was present prior to injury, is lost. Therefore, joint stability is reduced.
Small pain fibers in these damaged ligaments transmit pain
impulses to the brain when stretched. Through a subconscious
reflex, the surrounding muscles go into a tight and painful
spasm in an attempt to stabilize the joint. This causes the
region to feel tight, stiff, achy, burning, tingling, numb, fatigued,
and painful. The individual will often notice painful knots in the
affected muscles. These muscles become tight and painful as
they try to compensate for the weak and damaged underlying
tissue structures. The muscle spasms reduce blood flow,
causing even more pain. Not only are these symptoms local,
but they are often referred (transmitted) through nerve
pathways into the legs and feet, arms and hands, and head
(headaches). In other words, pain felt in the head, arms, or legs
may be due to instability in the neck or back.
For example, weakness or injury to the ligaments in the neck
may interfere with the sympathetic (automatic) nervous system,
causing a group of symptoms called Barre-Lieou Syndrome. This syndrome consists of one or more of the following: dizziness, visual blurring, loss of balance, ringing in the ears, runny nose, salivation, trouble
swallowing, hoarse voice, nausea, vomiting, nervousness and headaches. These symptoms are caused by instability in the neck and can be eliminated by prolotherapy.
Medications and other forms of passive treatment such as ultrasound, ice, heat, massage, acupuncture and manipulation may give minimal lasting benefits because the primary problem, the loose and injured ligaments, is not being addressed. Stretching and strengthening exercises usually can provide some relief from chronic pain, but this is often only temporary. When these exercises have failed to increase the support sufficiently to diminish pain and improve function, the chronic pain cycle ensues. Prolotherapy should be initiated as soon as possible, before the problem progresses and becomes widespread.
The most basic prolotherapy solution contains a naturally occurring sugar (dextrose) derived from corn combined with an anesthetic (lidocaine). Other common, natural substances can also be used effectively. This solution does not contain cortisone, which is known to decrease
inflammation, but will also slow or stop the healing process. Acute pain may be
relieved with cortisone, but repeated use causes a weakening of the tissues and chronic pain develops.
PROLOTHERAPY AND THE THREE STAGES OF HEALING
INFLAMMATORY FIBROBLASTIC MATURATION
Increased blood flow, Swelling and pain begin to New blood vessels mature,
swelling and pain. Immune subside and new blood tissue is stronger and pain
cells remove damaged vessels form. Tissue repair subsides. Collagen density
tissue. cells (fibroblasts) form new and diameter is increased.
stOccurs during 1 week
Starts at day 2 or 3 and Continues from week 6 to
continues for 6 weeks. 18 months after injection.
When the injured tissues are injected with small amounts of the prolotherapy solution, a reaction begins, starting a three-stage healing process (see table above). Prolotherapy initiates the first stage (Inflammation). Stages two (Fibroblastic) and three (Maturation) will then follow automatically. In stage one, the body sends in special cells, which help to clean up the debris and damaged areas. These cells respond as if another injury has occurred resulting in a controlled inflammation and increased blood flow.
This process takes a week. In stage two, the body begins the process of repair and healing. This is accomplished by the addition of tissue repair cells called fibroblasts, which are deficient in the injured
tissue. Fibroblasts increase in number at the sites of injection, and over the course of four to six weeks, secretes a substance called collagen, which is a very strong and relatively inelastic substance and the most abundant protein in the body. The new collagen makes the ligaments thicker, denser and stronger, providing more support to the joints primarily where the ligaments anchor or attach to bone. The strength of the injected ligaments can increase up to 40% above normal. Stability is increased as pain and muscle spasm decrease. In stage three, the newly formed tissue continues to mature for one to three years. Improvement, therefore, may continue for up to three years after the last treatment. If, during the three stages of the healing process, anti-inflammatory drugs, ice, compression and/or immobilization are used to reduce pain and inflammation, complete and normal healing will be inhibited. Most people are taught that inflammation is bad and don’t realize that, without inflammation, no healing will occur.
So, in essence, prolotherapy strengthens ligaments and decreases pain by stimulating the body’s own repair and healing mechanism to go into action at the areas stimulated. There is no masking of pain as tissues heal naturally and become stronger, without forming scar tissue. It is for this reason that prolotherapy gives long-lasting relief lasting months to years. Several treatments spaced apart by about three to four weeks are usually required to get the full benefit from prolotherapy.
Because there are very few doctors who perform prolotherapy, patients typically just accept the pain or have surgery. While surgery has its place, many patients and doctors are not aware that prolotherapy may relieve their pain and postpone or prevent the surgery they thought they needed.
Although research and studies are proving its efficacy, is at this time
considered by most insurance companies to be “alternative”, and is not
usually covered. It is usually covered by Auto and Work-Comp Insurance.
WHAT ABOUT THE PROCEDURE ITSELF?
Prolotherapy is a very safe procedure when performed by a trained and
highly skilled physician who has an in-depth knowledge of anatomy and
experience using this injection technique. The use of needles involves
risks, but complications from prolotherapy are rare. The solutions used
have been shown to be safe and, as stated previously, do not contain
cortisone. The most common side effect is discomfort due to the
injections, as well as temporary soreness, stiffness, and occasional
bruising. Although injection discomfort cannot be eliminated, it is well tolerated in most cases. Local anesthetic is used prior to the injections to decrease discomfort. If necessary, pain can also be reduced by the use of prescription oral medications for pain control and sedation taken prior to the treatment. Most patients prefer not to be sedated because it makes them feel groggy and because a driver is required to and from the appointment. Topical freeze sprays or anesthetic cream can also reduce needle discomfort.
Depending on the area treated and the number of injections, which is usually just a few for small areas or many for larger areas, one may return to usual activities during the next day or two. The actual treatment may last anywhere from a few minutes if there is only one site of tenderness such as the elbow, to thirty minutes, if a large region such as the back and neck are being treated together. The soreness and bruising that may occur following the injections is normal and gradually lessens over several days. Approved prescribed drugs or plain Tylenol may be taken for this discomfort. However, no anti-
inflammatory drugs may be taken during the treatment period because these will interfere with the
healing process that prolotherapy initiates. A goal of prolotherapy is to get the patient off all pain medications. Specific natural supplements may be recommended to enhance healing and alleviate pain.
CAN PROLOTHERAPY CURE EVERYTHING?
Prolotherapy is not an overnight cure. It cannot “cure” every painful condition, nor always eliminate 100% of one’s pain. There are some areas that the prolotherapist cannot safely reach with a needle. The vast majority of patients completely treated by prolotherapy (usually two to ten sessions) will receive at least 50% relief of their pain. Many even report complete resolution. These results are excellent, considering that chronic pain is exceedingly difficult to treat by any means. It is also important to know that prolotherapy only strengthens tissues. No structures are weakened and no scars are formed. Therefore, no bridges are burned in the process.
A good history and a thorough examination are necessary to select the best candidates for prolotherapy prior to treatment. The motivation to want to get better and complete the necessary treatments is vital. Patience and time are important to obtain the benefits from prolotherapy. Chronic pain problems do not occur overnight and they do not heal that way either. If the pain is enough to affect one’s life, then
prolotherapy may be indicated.
Do the injections hurt?
The use of a needle is always accompanied by some degree of discomfort. It varies from patient to patient, but is usually well tolerated. It helps to stay very relaxed by not tensing the muscles and focusing on deep breathing. Local anesthetic is used to decrease discomfort.
Are there any risks?
Anytime a needle is used to penetrate the skin into the deeper tissues, there is always the chance that inadvertent puncture of arteries, nerves, spinal fluid or lung tissue may occur. Complications are rare and are greatly minimized by the skill of the well-trained prolotherapist. The solutions used in prolotherapy are very safe and the amounts used are well within manufacturer’s guidelines. However, since prolotherapy is a procedure with some risk to the patient, all patients are asked to read and sign a consent and waiver form prior to the procedure.
Should I eat before I come?
A light meal and plenty of water are recommended about 1-2 hours before the procedure. Water
improves cell hydration and lessens the discomfort of the injections, while food diminishes the likelihood of dizziness. Patients report even less discomfort when they drink water right up to the time of the injections.
How many treatments are needed?
Three to six treatments for a given area is about the average needed. A few
patients respond quickly to just a treatment or two, but most patients require
more to stimulate the healing properly. Some patients who respond slowly may
need 10 or more treatments and stronger solutions may be used to improve
the response. The longer the duration of the pain and disability and the more
severe and widespread it is, the more treatments will be needed to stabilize
the joints. After the first session, successive treatments follow at intervals of two to six weeks. Re-assessment of structural healing usually occurs at the fourth session to determine if more treatments are necessary or desired. Staying on a consistent schedule of treatments will decrease the chance that early benefits are lost.
When will benefit from the injections occur?
Prolotherapy does not result in immediate relief of pain. Some patients report improvement in as little as two weeks following injections, but it is not expected that any significant relief will be obtained until four to six weeks after the first treatment. Some patients report significant improvement in their symptoms after just the first two treatments. Others may not receive much benefit at all until they have had further treatments. As ligament strength and joint stability improve, results become more noticeable with decreased pain and improved function. Improvement may continue for up to three years after the last prolotherapy treatment.
What can I take for the pain during recovery?
Typically, post-injection stiffness and soreness can be expected and is necessary for the healing process to begin. This will last for the first few days. Heat usually soothes the soreness, but ice will slow the healing prolotherapy stimulates. No anti-inflammatory (NSAIDs) medications may be used once
treatment begins because they interfere with the healing process that the prolotherapy injections started. An exception to this is for those who take a baby aspirin each day for their heart. Regular use of narcotic drugs should be avoided because they will inhibit the immune system and slow the healing. Tylenol may be used for a short period of time. If you are not sure whether a medication you are taking interferes with your prolotherapy treatment, bring it to our attention and we will help you out. Remember, it is important to treat the source of the pain through strengthening the damaged areas rather then just cover it up with chronic pain medications. Specific supplements to assist the healing process may be recommended.
Should I exercise following Prolotherapy? What should I avoid doing?
Controlled exercise and mobilization of the treated area promotes tissue
healing and results in faster recovery after the treatment. For this reason,
movement and exercise are recommended as soon as possible. The amount
will depend on your level of fitness before and on how many areas were
treated. Frequent high-velocity chiropractic adjustments should be avoided
because they do not allow the joints treatment with prolotherapy to stabilize.
Massage and other similar therapies are compatible with prolotherapy.
When should I return to work?
In most cases, depending on your job, you may return to work or school the same day as your treatment. If, however, your job places a great deal of stress on the treated area or if you have significant post-injection discomfort, you should not return to work the same day. A few days is recommended before returning to strenuous athletic activity
What is the chance I will get better? Get worse? How long will it last?
Statistics show that 85-90% of all patients treated with prolotherapy receive at least a 50% benefit when treated between two and ten times. There is no evidence of a condition becoming permanently worse from receiving prolotherapy treatments. Also, because actual healing occurs with prolotherapy, it is anticipated that long-lasting or even permanent relief of one’s pain can take place. If an area is re-injured,
prolotherapy treatments may be necessary in the future.
Will my insurance cover prolotherapy?
In most cases it will not be covered, as it still is considered by insurance companies to be an “investigational” or “alternative” type of treatment. We will discuss your particular situation regarding insurance coverage of prolotherapy and the fees involved before you proceed with treatment. Auto insurance usually will cover the procedure if the injury is related to an auto accident.
INSTRUCTIONS PRIOR TO TREATMENT
; Stop taking all anti-inflammatory medications, except for baby aspirin taken for the heart, including
Naprosyn, Ibuprofen, Aleve, Cortisone-like drugs, Relafen, Motrin, Advil, Aspirin products, Vioxx,
Please tell us in advance if you are taking blood thinners (e.g. Coumadin) or if you have
allergies to fish, corn, sugar, anesthetics, latex or painkillers.
; Eat a light meal one to two hours prior to your treatment, and drink water up to the time of your
? Try to decrease or quit smoking as it will impair the healing process.
? Bring any old x-rays or radiology studies to your appointment if available.