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PROLOTHERAPY
Regenerative Injection Therapy
What is Prolotherapy?
Prolotherapy is short for proliferative therapy, also commonly referred to as regenerative injection therapy. Regenerative injection therapies are used to treat chronic pain conditions and musculoskeletal injuries. This treatment consists of injecting a proliferating agent into an injured tendon or ligament attachment site (bone or joint), to stimulate the body’s natural healing process. Prolotherapy treatment enhances the growth and formation of new ligaments, tendons, and cartilage in areas where there is weakness, laxity or excess scar tissue. Prolotherapy discussed here refers to Dextrose prolotherapy and is one of three Regenerative Injection Therapies (RIT) that also includes PRP Prolotherapy, and Adipose Stem Cells (known as Biocellular Prolotherapy).
In North America, prolotherapy can only be performed by a trained naturopathic doctor, medical doctor or osteopath (in the U.S.) and only in permitted jurisdictions. Currently, Dr. Nurani uses prolotherapy as part of his naturopathic practice at Nova Naturopathic and will be introducing PRP or Platelet Rich Plasma prolotherapy in the near future. Prolotherapy treatments are restricted to non-spinal parts of the body at this time.
How Does it Work?
Prolotherapy is both natural and non-surgical. Prolotherapy works by exactly the same process that the human body naturally uses to stimulate the body’s healing system, a process called inflammation. The technique involves the injection of a proliferant (a mild irritant solution) that triggers a series of reactions that are collectively known as ‘the wound healing cascade’. As part of this process, the body recruits fibroblasts into the injured area. Fibroblasts are the body’s major cells responsible for the production of new collagen, the material that ligaments and tendons are made of. The goal of this treatment is to stimulate the growth of new, healthier and stronger connective tissue to restore structure and function to the joint.
Prolotherapy is similar to “welding” of a joint…
Most things break down at a junction site because this is the weakest part of the structure; this is especially true in weight-bearing joints. The areas surrounding the weak structure have to be reinforced so as to offer support to the weakened structure. This is true in metal work as it is in the human body. Prolotherapy “welds” the ligaments and tendons to the bone to increase the joint’s overall stability and strength. In metal work, sometimes more than one weld is required and often in a few different spots. Prolotherapy causes the proliferation of new ligament and tendon tissue exactly where the injections are given. It is just like spot welding. It strengthens the exact spot where the weld or injection takes place. The more injections, the stronger the weld!
Applications of Dextrose Prolotherapy
Prolotherapy has a wide range of applications and has been shown to be effective in treating the following conditions:
Ingredients
Dextrose Prolotherapy
There are 4 common ingredients used in standard dextrose prolotherapy solutions. Depending on the condition being treated, and the desired effect, the doctor may modify the solution.
DEXTROSE
This is the main proliferative agent used in the treatment. Concentrated dextrose (sugar solution) is used as an irritant to stimulate a mild inflammation which “tricks” the body into thinking the area is injured and to begin healing.
PROCAINE
Procaine is a short-acting anesthetic that helps control pain. Additional benefits of using procaine include stopping muscle spasms, increasing muscle strength, breaking up scar tissue & resetting malfunctioning nerves.
ADENOSINE MONOPHOSPHATE
AMP reduces inflammation and has also been shown to dissolve bone spurs & other pathological calcium deposits.
METHYLCOBALAMIN / VITAMIN B12
Is added to aid in the repair of nerve function. It also has been used for sciatica, carpal tunnel syndrome, and bone spurs.
Number of Treatments
Unlike cortisone injections, regenerative injections work cumulatively and more than one treatment is usually required to achieve full healing and function of the compromised joint. It is difficult to know the exact number of treatments since there are so many factors involved. For example, a chronic osteoarthritic hip joint will take much longer to heal than a mild partial tear of the knee ligament. Some of the variables that dictate length and number of treatments include:
- Severity of injury
- Person’s overall health status
- Patient’s age
- Patient’s gender
- Prior and ongoing use of anti-inflammatory medication
- Activity levels of the patient
- Patient’s diet and lifestyle
Wound strength studies show that it takes 6-12 months for maximum tensile strength to occur without prolotherapy and even then the resultant wound has approximately 60% of the original strength. With a treatment every 2 weeks, prolotherapy healing can occur in 1-2 months.
Commonly, patients start to see results after 3 to 6 injections. For some chronic conditions, it may take more than 10 injections and several months of treatment. There are no guarantees and sometimes a stronger proliferant such as platelet-rich-plasma may be needed to enhance the body’s healing response further.
Prolotherapy is NOT the same as Cortisone Injections…
Cortisone shots are used routinely for chronic pain due to their effectiveness in decreasing inflammation and pain for up to 8 weeks; however, patient’s should know that:
- Cortisone inhibits blood flow to the injured area, suppressing new blood vessel formation, suppressing growth of immune cells like leukocytes and macrophages, preventing protein synthesis, fibroblast proliferation and ultimately collagen formation.
- Cortisone inhibits the release of growth hormone, which further decreases soft tissue and bone repair.
- Cortisone weakens collagen and therefore soft tissue such as ligaments and tendons.
- Cortisone shots are not administered more than 4 times a year
Inflammation is how the body heals itself and by arresting this process, you are inhibiting tissue repair. In contrast, prolotherapy helps to direct healing factors that are part of the acute inflammatory process to help HEAL the old injury.
We do not discount the use of cortisone injections as they are sometimes necessary when inflammation turns chronic and needs to be contained. Typically this means that the underlying problem has not been addressed. However, chronic inflammation can lead to collateral damage and cortisone injections can help prevent further injury caused by this runaway pathological process. If your doctor has told you that you need cortisone shots, you should talk to a naturopathic doctor or medical doctor to see if prolotherapy can help you.
Side Effects
Prolotherapy is a very safe procedure but like all injection therapies there are some risks involved:
- Pain from needling / soft tissue trauma
- Bleeding and bruising
- Post-injection pain*
- Post-injection stiffness**
- Allergic reaction to the injectable materials such as dextrose or procaine
- Nerve injury
- Infection
- Flu-like symptoms
* Rarely, excessive post-injection pain can occur due to a “hyperinflammatory response”. This seems to be more common in young athletes and older women.
** Rare and commonly transient
Contraindications
ABSOLUTE contraindications
- Acute infection at the injection site
- Fractures or implants in the area
- Metastatic cancer
- Bleeding disorders
- Allergy to one of the ingredients
RELATIVE contraindications
Some patients may require more sessions if they have a health condition that compromises immune system function:
- Smokers
- Patients with type 1 or 2 diabetes
- Patients taking daily NSAID’s (non-steroidal anti-inflammatory drugs).
- Patients taking immune suppressant drugs (prednisone, methotrexate, etc.)
Frequently Asked Questions
- How can I prepare for my treatment?
- Will the injections hurt?
- How long will my treatment take?
- How will I feel after the treatment?
- Will the treatment affect my daily activities?
- Can I take Ibuprofen, Aspirin or Naproxen?
- What can I do to enhance the healing process?
- How will I know if prolotherapy is working?
- How much do the treatments cost?
- Does insurance cover prolotherapy treatments?
- Will the sugar injections raise my blood sugar levels?
- Will I be able to avoid surgery?
- Where can I read more about the research on prolotherapy?
How can I prepare for my treatment?
- If available, arrange for your naturopathic doctor to receive all pertinent bloodwork and imaging before your appointment date
- Please stop taking all anti-inflammatory and/or steroid medications beforehand as it will affect the results of your treatment
- If available, apply EMLA (lidocaine-prilocaine) cream to the treatment area 2 hours before injection to numb the skin, and wrap area in plastic wrap to enhance absorption
- Although, you will be able to walk out of the appointment with only minor discomfort, have someone drive you just in case
- If you choose to take pain medication, you may take Tylenol 500-1000 mg or narcotics as prescribed (please no anti-inflammatories!). If you have anxiety concerns, you may take your anxiety meds or supplements before arriving
- Arrive early to your appointment
Will the injections hurt?
- The injections are momentarily painful because the areas being treated are already injured, but if the treatment reproduces your exact pain, this is a very good sign that the correct areas are being treated and that they will heal over time
- You may feel the needle lightly touching the surface of the bone where the ligament or tendon attaches – this is completely normal and maximizes the safety of the treatment by ensuring that the needle is not in an area such as a nerve, organ or blood vessel
- You may feel brief but somewhat painful twitches or spasms in the muscle during treatment – this is completely normal and is actually an additional benefit where the needle treatment will help the surrounding tight muscles to relax. It is commonly known as a trigger point injection.
How long will my treatment take?
- The very first consultation appointment will usually take about 30 minutes and will involve a physical examination of the affected area(s) as well as a review of any imaging and bloodwork. Safety and health concerns are discussed and the doctor will come up with a treatment plan.
- Treatment appointments usually last 20 minutes. There is no recuperation period, and you may leave the office immediately.
How will I feel after the treatment?
- The anesthetic used in the treatment will typically last less than 1 hour. Previously painful areas may be relatively improved during this time but when the anesthetic wears off, your pain will return and may even be a bit worse.
- Over the next day, the pain may worsen to a moderate or in rare cases significant degree – this is a normal and expected reaction as part of your body’s healing response.
- This increased pain can last anywhere from 1 to 10 days, with the average being 3-4 days.
- You may use ice and/or heat (preferred) 10-20 minutes at a time, several times per day, as well as any pain medications prescribed or recommended by your doctor.
- It is normal to also have mild to significant stiffness in the areas injected for several hours to a couple days after treatment. Move the areas gently through a moderate range of motion several times per day.
- If you experience significantly worsening pain, develop a fever, and notice warmth, redness, and tenderness around the injection sites, especially if it starts a couple of days after the injection, make sure you call the doctor right away. Although very rare, this may indicate an infection from the injection, which needs to be treated quickly. In this situation, the doctor may request some blood work and imaging studies such as an MRI to look for any infections.
Will the treatment affect my daily activities?
- Typically no. You can resume daily activities like before your treatment but you want to avoid vigorous exercise which is out of your ordinary.
- It is possible to overdo it if your pain has decreased substantially, however, try to ramp up activities gradually.
- If you are in physical therapy tell the therapist to avoid MET. If you see a chiropractor, avoid forceful manipulation. Massage is OK.
Can I take Ibuprofen, Aspirin or Naproxen?
- Please do not take anti-inflammatory medications before or after the injections, they will block the effect of the treatment!! This includes Motrin, Ibuprofen, Advil, Aleve, Midol, Celebrex, Naproxen, Aspirin, etc.
- You can continue to take baby aspirin if you are taking it for heart conditions or strokes
- Tylenol is not an anti-inflammatory so it can be used for pain management if desired
What can I do to enhance the healing process?
- You can do a lot to help yourself. Above all, do not take any anti-inflammatory medications during the course of this treatment.
- Drink at least 2 liters of water following all injection therapies. Dehydration is the number one reason for post-injection discomfort.
- Staying active is better than being sedentary
- Smoking also strongly limits your healing response, so smokers usually need more of the injections and often do not get as long lasting results from this treatment. We will be glad to work with you to help you quit smoking before initiating prolotherapy treatments.
- A fitness program also helps increase healing by improving circulation and it also helps stabilize ligaments and tendons. The same exercises which strengthen muscles also build stronger ligaments and tendons.
- Ask the naturopathic doctor for proper diet recommendations that will enhance healing and will help ensure your overall treatment success.
- Finally, proper supplementation is also important to consider. Studies show that Vitamin C, Zinc, Copper, etc enhance the healing of connective tissue. Ask your naturopathic doctor for a supplementation plan including an evaluation of important vitamin and nutrient deficiencies.
How will I know if prolotherapy is working?
- Overall, most patients do very well with this treatment!
- Pain relief, improved strength, better joint stability and joint mechanics are some of the wonderful benefits of prolotherapy treatments. Most patients will notice progressive improvements in function including being able to work better, do more physical activities and more social activities.
- Not everyone is a great candidate for prolotherapy however. A careful assessment of who is a good candidate for this procedure is important to ensure that you are not wasting your valuable time and money. Please talk to the doctor to discuss whether prolotherapy can be of benefit to you or not.
How much do the treatments cost?
- The cost of treatment usually depends upon how many injections are necessary during your treatment. The number of injections typically depends on the severity of the injury as well as the structures being treated. Hands and feet require fewer injections than hips for example.
- Individual sessions typically range from $135 to $250. For best results, it is recommended that patients get a minimum of 4 treatments for each body part.
- Initial prolotherapy consults cost $65 at our clinic. These appointments involve an assessment of the concern and review of any imaging and bloodwork as well as an opportunity for patients to discuss their treatment with the doctor.
Does insurance cover prolotherapy treatments?
- There are many different extended healthcare insurance companies and it is best to check with your employer’s plan to see if the treatment is covered
- The initial evaluation appointment is often reimbursable by insurance carriers depending on your policy
Will the sugar injections raise my blood sugar levels?
- No, dextrose prolotherapy solution has no effect on blood sugar levels and is safe for diabetic patients
Will I be able to avoid surgery?
- A comprehensive prolotherapy plan can offer an excellent alternative to surgery for patients with chronic pain from tissue damage.
- For severely deteriorated conditions, stronger prolotherapy solutions such as PRP may be required. In addition, patients that are candidates for surgery will usually require multiple treatments.
- Surgery is irreversible, is more invasive than injections, can be risky and can permanently affect your form and function. In addition, scar tissue formed after surgery can lead to more problems.
- If after exhausting all of your conservative treatment options with little success, then it may be time to consult with a surgeon.
Where can I read more about the research on prolotherapy?
- There are a number of published scientific studies that support the use of prolotherapy for chronic musculoskeletal conditions and chronic pain. Many of these studies are available on the internet.
- Some reputable reference websites for prolotherapy related information include www.prolotherapy.com, www.aaomed.org and www.acospm.com
- The Canadian Agency for Drugs and Technologies in Health (CADTH) has published a review of the clinical effectiveness of Prolotherapy for the Management of Musculoskeletal Pain which can be accessed by clicking HERE.