PROLOTHERAPY
Sagiv Ben-Yakir DVM, MRCVS, BSc
The Academic College at Wingate Institute, ISRAEL
Netanya, ISRAEL
Prolotherapy is defined by Webster’s Third New International Dictionary as “the rehabilitation of incompetent structure, such as ligaments or tendons, by the induced proliferation of new cells”, that is done for the purpose of strengthening weakened connective tissue and alleviating musculoskeletal pain. The term derived from the word prolo short for proliferation, as the therapy is intended to proliferate tissue growth in the damaged area.
Prolotherapy is also called "proliferation therapy" and "regenerative injection therapy” (RIT).
Prolotherapy can be distinguished from sclerotherapy, the use of injections of caustics into the veins, in vascular surgery and dermatology, to remove varicose veins and other vascular irregularities.
In prolotherapy we inject solutions into the area where connective tissue has been weakened or damaged through injury or strain. Many solutions are used, including dextrose, lidocaine, combination of both, animal own blood, added growth factors, phenol, glycerine, sodium morrhuate etc.
The injection is given into joint capsules or where tendon connects to bone. Many points may require injection. The Injected solution causes the body to heal itself through the process of inflammation and repair. In the case of weakened or torn connective tissue, induced inflammation and release of growth factor at the site of injury may result in 40% strengthening of the attachment points.
Prolotherapy treatment sessions are generally given every two to six weeks. Many patients receive treatment at less and less frequent intervals until treatments are required only every several years, if at all. Prolotherapy is often used as an alternative to an invasive and expensive surgery, and it is done at in-clinic & on out-patient status.
The Injections of irritant solutions were performed in the late 1800’s to repair hernias and in the early 1900’s for jaw pain due to temporomandibular joint laxity. Dr. George S. Hackett, MD developed the technique of prolotherapy in the 1940’s. He claimed in his book “Ligaments and tendons relaxation treated by prolotherapy” (1958) that he cured 90% of 656 patients. At the time he used as an injection solution fatty acids mixture to induce inflammatory reaction, nowadays we are using a simple dextrose solution diluted with local anesthetic as lidocaine to achieve the same results without the possible risks (e.g. shock). Dr. Hackett found that the injected tendons increased in diameter by 40% after prolotherapy, and histological exams showed no destruction of nerves or blood vessels and no scarring, which is a chaotic matrix of collagen fibers. The ligaments and tendons produced after prolotherapy appear much the same as normal tissue, except that they are thicker, stronger, and contain fibers of varying thickness with normal histological organization. There is an increase in collagen producing fibroblasts, the ligaments orientation and internal organization is linear.
Dr. Gustav A. Hemwall, M.D. is one of the most famous Hacketts’ students, beginning his studies and treatments in the 1950s and continuing until the mid 1990s. In his study of almost 10,000 cases he found from 75%-90% successful results, and some of them for longstanding problems that have been resistant to other treatments.
If one is wondering what might happen in years to come with complementary and alternative veterinary medicine – the following story has a point of is interest – Dr. Everett Koop, M.D. USA Surgeon General had a severe pain followed by almost a complete paralysis of his right hand during 1980’. Since no therapy solved his condition, he approached Dr. Hemwall. Dr. Hemwall treated Dr. Koop by prolotherapy injections into his neck, and the medical issue was solved in a short time successfully. Dr. Koop studied more about the prolotherapy methods, endorsed it, and nowadays prolotherapy is considered as sub-speciality of the American Association of Orthopedic Medicine.
There are different solutions that can be injected in prolotherapy:
Osmotic proliferants that by their higher osmotic pressure induce the process of inflammation and healing. e.g dextrose which is water-soluble and does not stored in the body but excreted out.
Irritants are substances that alter the surface of the cells and induce the process – e.g. phenol.
Particulates as pumic flour or animal own blood attract macrophages and induce the process of prolotherapy.
Chemotactics directlyt attract immune system cells to the area as sodium morrhuate.
Growth factors.
Prolotherapy mechanism of action: the mechanism of action is complex and multifaceted. Six identified components include:
1) The mechanical transection of cells and matrix induced by the needle, causes cellular damage, stimulating an inflammatory cascade.
2) Compression of cells by the extracellular volume of the injected solution stimulates intracellular growth factors.
3) Chemomodulation of collagen through inflammatory proliferative, regenerative/reparative responses induced by the chemical properties of the proliferants and mediated by cytokines and multiple growth factors. 4) Chemoneuromodulation of peripheral nociceptors and antidromic, orthodromic, sympathetic and axon reflex transmission. 5) Modulation of local hemodynamics with changes in intraosseous pressure leading to the reduction of pain. Empirical observations suggest that a dextrose/lidocaine combination has a much more prolonged action than lidocaine alone.
6) A temporary repetitive stabilization of the painful hypermobile joints, induced by the inflammatory response to the proliferants, provides a better environment for regeneration and repair of affected ligaments and tendons.
Examples of some specific veterinary clinical conditions to be treated with prolotherapy
Cruciates laxity or partial/complete rupture
Patellar sub-luxation
Atlantoaxial subluxation
Cervical Vertebral Instability (CVI)
Osteochondrosis dissecans (OCD)
Stifle collateral lig’ injury
Carpal/tarsal laxity of ligaments
TMJ luxation
Sacro-iliac subluxation
Recurent Shoulder/elbow/carpal disluxations
Contraindications:
Neoplastic lesions involving the near-by musculature and osseous structures
Acute non-reduced subluxations or dislocations
Acute arthritis (septic or post-traumatic)
Acute bursitis or tendonitis
Allergy to anesthetic or proliferant solutions or their ingredients such as dextrose, sodium morrhuate or phenol
Adverse effects + preventative measures
Infection - do proper preparation
Pain - do Lidocaine in the injected solution, cold packs +/- NSAIDS as needed
Stiffness – physical therapy
Nerves/Blood vessels – know your anatomy
In our practice:
Evaluate the clinical case at hand
Review the anatomy
Prepare the solution to be injected – 15% final concentration of Dextrose e.g. 1 ml of Lidocaine 2% without epinephrine, 3 ml of D-50 (Dextrose 50%), 6 ml of sterile water
Shave the area to be injected, scrub it with Septal Scrub (4% Chlorhexidine), wash it with 70% alcohol, and finish up with application of P.V.P Iodine 10%
Use 27\30 g needles 1 ½’ length & inject many small drops rather than large amounts
In some active animals : light sedation or short acting anesthesia might be required
Quantity: 0.1-0.5 ml in small animal (cat) or small joint (carpus), up to 2-5 ml in large dog or large joint (knee), 5-10 ml in horse (sacro-iliac joint)
Frequency: once every two wks at least for 4 sessions, then – re-evaluate
NSAIDS: on-off for the first few wks(?), as inflammation is what we are looking for (NO steroids!)
Veterinary Low Level Laser Therapy (VLLLT) – bid for 6-8 minutes at lesion site for as long as you treat the case
Improvement: usually after a few wks (rarely after 2 wks)
Physical activities: are allowed – but no jumping; do manual therapy 2-3 times/day/first few weeks
For the severe cases – add animal own blood (3 cc instead of the water)
In some animals “a tune-up” injection is needed after 6 months or 12 months.
Indications for Veterinary Prolotherapy?
Chronic pain from ligaments or tendons secondary to sprains or strains.
Pain from overuse or occupational conditions (e.g. dog/horse racing) known as "Repetitive Motion Disorders".
Chronic postural pain of the cervical, thoracic, lumbar and lumbosacral regions.
Painful recurrent somatic dysfunctions secondary to ligament laxity that improves temporarily with manipulation.
Painful hypermobility and subluxation at given peripheral or spinal articulation(s) or mobile segment(s) accompanied by a restricted range of motion at reciprocal segment(s).
Thoracic and lumbar vertebral compression fractures with a wedge deformity that exert additional stress on the posterior ligamento-tendinous complex.
Recurrent painful subluxations of ribs at the costotransverse, costovertebral and/or costosternal articulations.
Osteoarthritis of axial and peripheral joints, spondylosis, spondylolysis and spondylolisthesis.
Painful cervical, thoracic, lumbar, lumbosacral and sacroiliac instability secondary to ligament laxity.
Intolerance to NSAIDs, steroids or opiates. Prolotherapy may be the treatment of choice if the patient fails to improve after physical therapy, chiropractic or osteopathic manipulations, steroid injections or radiofrequency denervation, or surgical interventions in the aforementioned conditions, or if such modalities are contraindicated.
Syndromes and diagnostic entities, caused by ligaments and tendon pathology that have been successfully treated with prolotherapy:
Cervicocranial Syndrome (cervicogenic pain, secondary to ligament sprain and laxity, atlanto-axial and atlanto-occipital joint sprains, mid cervical zygoapophyseal sprains).
Temporomandibular Pain and Muscle Dysfunction Syndrome
Torticollis
Cervical segmental dysfunctions
Cervicobrachial Syndrome (shoulder/neck pain)
Hyperextension/Hyperflexion injury Syndromes
Cervical, Thoracic and Lumbar Sprain/Strain Syndrome
Costochondritis/chondrosis
Recurrent shoulder dislocations
Lumbar instability
Lumbar Spondylolysis
Sacroiliac joint pain
Sacrococcygeal joint pain
Myofascial Pain Syndromes
Ankylosing Spondylitis
Shoulder, stifle, foot and ankle chronic sprain, instability, laxity of ligaments
Specific veterinary examples –
cruciates ligaments laxity or partial rupture
patellar sub-luxation/luxations
stifle collateral ligaments injury
tarsocrural luxations
other carpal and tarsal luxations
TMJ luxation
shoulder, elbow, carpal, sacro-iliac luxation
wobbler’s syndrome.
In summary – prolotherapy is a safe and effective medical method in which mildly irritating solution is injected into ligaments, tendons, or their insertions to bones or muscles, causing mild inflammatory response which stimulate healing. The result is a thicker, stronger, well-organized tendon/ligaments, a less sensitive one, that decreases local and remote structure stresses. Over 75-90% of patients treated with prolotherapy get significant improvement or cure.
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