Prolotherapy: How Do You Spell Relief?

Performed by Naturopathic Doctors –  Patrick Bartoshyk, ND; Mélanie Robinson, ND

Prolotherapy, also referred to as Regenerative Injection Therapy (RIT), is defined as both a “nonsurgical ligament reconstruction” therapy as well as a treatment for chronic musculoskeletal pain.

The word “Prolo” is short for proliferation as prolotherapy treatment enhances the growth and formation of new ligaments, tendons and cartilage in areas where there is weakness or excess scar tissue. Any joint in the body can be treated successfully with prolotherapy regardless of when the injury happened. The treatment is also beneficial for most types of musculoskeletal pain. Prolotherapy incorporates the use of a specialized dextrose (sugar) solution, which is injected into a ligament or tendon where it attaches to the bone. The initial reaction of the treatment is localized inflammation triggering a wound healing cascade leading to increased blood supply and flow of nutrients and growth factors. This stimulates the tissue to repair itself by deposition of new collagen, the material that ligaments and tendons are made of. The new collagen then shrinks as it matures leading to ligament/tendon tightening and increased strength.

What Are Ligaments?

Ligaments can be described as “rubber bands” that actually hold bone to bone and allow flexible movement of joints. Injury, overstretching and degeneration/weakness of ligaments can cause them to become weak and damaged to a state of disrepair. The reason that ligaments don’t heal easily is largely due to the lack of blood supply to the area. As a result, healing is slow and not always complete. In addition, the nerve endings to ligaments can become impaired or damaged, so you may feel acute intense pain. This pain can then become chronic.

What Are Tendons?

Tendons are the name given to tissue which connects muscle to bone. Tendons may also be damaged in the same manner as ligaments which can result in pain and scar tissue development if not treated appropriately.

Why Is There Pain With The Treatments?

With Prolotherapy, an important concept to understand is that chronic pain leads to tissue destruction and acute pain leads to tissue regeneration. With this treatment, patients often say “I already have inflammation and you want to give me more?”

The idea behind this is that acute inflammation leads to healing. The ligament and tendon tissue which forms as a result of Prolotherapy is thicker and stronger than normal tissue (up to 40% stronger in some cases).

The Injection Solution

The basic Prolotherapy solution is 12.5% to 20% dextrose with 1% procaine. The dextrose makes the solution more concentrated than blood, acting as a strong proliferant. Procaine is an anaesthetic that helps reinforce the diagnosis because the patient may experience immediate pain relief after the injection. The dextrose solution, in addition to being safe, will not affect a diabetic’s blood sugar level. Other injectables may be added such as hyaluronic acid or Vitamin B12 (methylcobalamin).

The hyaluronic acid would be added in cases of osteoarthritis where cartilage regeneration is the desired outcome and methylcobalamin is used in nerve regeneration. Homeopathic remedies may also be added to help speed the healing process; however, these will vary depending on the type of injury.

How Many Treatments Are Needed, And How Might You Respond?

It will often take a series of RIT treatments spaced at appropriate intervals to maximize the healing power of the body. Sometimes a patient’s body is incapable of generating an appropriate healing response because of other factors such as deficient nutritional support. These factors are addressed in conjunction with RIT treatment so that the maximum benefit can be made with each session.

The response to treatment varies with each individual and the extent of trauma to the ligament, tendon or cartilage, as well as individual rates of healing; results are not guaranteed. Some people require a few treatments (I.E. 3 to 6) while others may need 10 or more. Once you begin treatment, you will be able to assess how you are responding.

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. Prolotherapy can be combined with Ultrasound, Acupuncture, Physiotherapy, Laser therapy, Chiropractic treatments, Homeopathy, and nutritional supplements to obtain the best results. To understand if prolotherapy could be helpful in your case, speak with your naturopathic doctor.

Exercise

In order to align the new collagen correctly with the existing ligament tissues, it is very important for the structure to heal in the presence of movement. As such, gentle walking is recommended after a treatment. This will protect the ligament from forming adhesions to neighbouring structures and increase the correct formation of the new collagen.

Pain From Injections

Not every patient experiences pain with the injection. Nevertheless, the injections may be more painful, particularly in the first two to three visits. After an injection there is usually a significant change in sensation with some contraction or release of muscles and changes in blood flow. For this reason, it may be helpful to have someone drive you home after the treatment so you can rest. After the second or third treatment, these functional changes are usually not so profound.

Secondary Effects

Soreness and bruising at the injection site and temporary muscle stiffness are normal and may last for 1-2 days. That said, the use of over the counter anti-inflammatories is discouraged as these will defeat the purpose of prolotherapy which is to temporarily increase inflammation.

You can apply alternating hot and cold compresses over the affected area. Traumeel cream or a “deep heat” like Tiger Balm can be used if some additional relief is needed.

Using MSM and glucosamine sulphate may also lessen the secondary pain reaction. Natural anti-inflammatories, such as bromelain, curcumin, proteolytic enzymes, fish oils etc., will help the healing response. If you are taking any of these, please stop taking them the day before, day of, and day after a prolotherapy treatment to allow the natural inflammatory response to occur.

Conditions Treated with Prolotherapy

Prolotherapy (RIT) has been found to be an effective treatment for:

  • Joint pain (all locations)
  • Torn ligaments, tendons and cartilage
  • Herniated / Degenerated discs
  • Post injury / Trauma pain
  • Low Back Pain /Rib Pain
  • Neck Pain /Headaches / TMJ
  • Unstable shoulder joints (dislocations)
  • Surgical scar reduction
  • Yoga overstretch injuries
  • Post fractures
  • Pain conditions: Sciatica, Arthritis, etc.
  • Frozen shoulder
  • Whiplash injuries /Sports Injuries
  • Fibromyalgia
  • Tendonitis

Prolotherapy FAQs

You may be new to the world of Prolotherapy for chronic pain relief and have many questions. Here are general answers to some questions we are frequently asked:

Prolotherapy is a little known but highly effective method of treating osteoarthritic joint pain, and chronic ligament and tendon weakness. The term “Prolotherapy” is short for “proliferation therapy” with proliferation meaning “rapid production”. In Prolotherapy, the weakened areas are injected with a “proliferant solution” that directly stimulates the growth of healthy, strong tissue.

Prolotherapy treatments consist of injecting a proliferant solution into the painful area or joint. This creates a short duration of inflammation and stimulates the immune system’s own healing mechanism to produce collagen and cartilage. The new collagen and cartilage strengthens and restores joints and supporting soft tissue, reducing or eliminating many different types of pain.

The injection consists of: 1% Procaine, Dextrose (pharmaceutical grade sugar water), Methylcobalamin (which is the active form of Vitamin B12) and Hyaluronic acid. On occasion individualized homeopathic remedies are added to the solution.

Patients report varying degrees of discomfort from mild to moderate. You can be assured that any discomfort you may experience will be brief and manageable. Occasionally a nerve may be touched with the needle, this leads to an electric jolt going down the leg or arm, the jolt goes away as soon as the needle is moved off of the nerve.

No, cortisone is not used in any treatments. Long-term medical research studies show that cortisone injections weaken tissue and interfere with the healing process. Prolotherapy solutions are called proliferants and cause the ligaments and tendons to be strengthened or lead to cartilage regeneration by stimulating the body’s natural healing response.

  • Gowns are provided however some patients prefer their own loose clothing or shorts as we will be examining the lower back &/or lower extremities
  • Any reports of MRI’s, CT scans, x-rays, & ultrasounds, etc.
  • Copies of all recent blood work (less than 6 months old)

It usually takes less than 20 minutes to administer the Prolotherapy. There is no recuperation period, and you may leave the office immediately. Often you will be in the office for 1.5 hours on the first visit to review your medical history, conduct a complaint oriented physical, go over your medical lab reports and have time to ask questions and have the answers fully explained.

Immediately after the treatment many patients describe a feeling of fullness in the joint. Quite often for the first hour the joint feels better because the Procaine has numbed the joint. Once the Procaine wears off you may feel sore at the injection site for a day or two. For the first two weeks you may feel the same, better or worse as the healing process proceeds. The fourth week after the injection is the time when you can best assess the results of treatment. Any noticeable increase in strength, decrease in pain, improvement in sleep or change in other symptoms is evidence that the healing process has been triggered.

While Prolotherapy has been available in Europe for over 60 years, Prolotherapy is new to Canada and most health care professionals are not aware of it. Also, since it is not taught in medical school many practitioners don’t know that they could recommend Prolotherapy. Prolotherapy also requires special training, which most practitioners have not taken and it is performed by only a handful of physicians in Canada and the U.S. The technique of Prolotherapy requires an in-depth knowledge of anatomy and the skills to place the injections accurately. It takes a great deal of study and training for a physician to become adept at the technique.

Since we can continue to “wear out” or be re-injured, it is impossible to predict how long your healing will last. Sometimes patients come back a year or more later for a “booster” procedure in the same area, others have to come back sooner. Some patients don’t require any boosters. It really depends how well you take care of yourself and how your body will respond to the treatments.

Tissue heals better when it is being stressed – to a point. Do not do any exercise that causes significant pain. Pain is your body telling you that you are overstressing healing tissue. You may do any exercise that does not increase your pain level. For athletic injuries, do 60% of your maximum weight or intensity, but more reps. Movement is good, pain is bad. If you do not exercise regularly, start NOW!

The number of treatments varies with each patient. Many of our patients have reported partial or complete relief of pain after a few sessions. Patients with a healthy immune system generally require fewer treatments. The average person requires 4 to 8 treatment sessions given at 2 to 6 week intervals

Remember, Prolotherapy relies on a patient’s own body “healing” itself and this can be a slow process. The connective tissue strengthens 4 to 6 weeks after each treatment session, which is why it is important to continue treatment. It is normal to experience waxing and waning of functionality and pain relief during the course of treatment.

Almost invariably patients will have some return of pain after a couple of treatments. Assuming a patient’s immune system is healthy, repeated treatments should provide longer and increased pain relief until a sustained improvement in pain is realized.

Every medical procedure has risks, however Prolotherapy is an extremely safe procedure. The risks are far less than taking aspirin or ibuprofen over a lifetime to relieve chronic pain. In Prolotherapy, the risks and side effects will vary depending on the area being treated, and our Naturopathic Doctors will discuss these possibilities fully with you during the initial consultation.

There are many different extended healthcare insurance companies and it is best to check with your employers plan to see if the treatment is covered. Many have coverage for the naturopathic visit portion, but not the injection. Please check with your insurance plan.

Many doctors and patients are looking for a “quick fix”, and with Prolotherapy results do not occur overnight. Therefore the Prolotherapy patient must be committed to the treatment because multiple sessions are often required.

Because there are very few doctors who perform Prolotherapy, patients 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 delay or prevent the surgery they thought they needed.

ABSOLUTE contraindications:

  • Cancer, Pregnancy, and same day Airline travel
  • Allergy to one of the ingredients, such as: Dextrose (derived from corn) or Procaine (a short acting anesthetic).

RELATIVE contraindications:

Some patients may require more sessions if they have a health condition that compromises immune system function – please discuss these in detail with our Naturopathic doctors.

  • Smokers
  • Patients with type 1 or 2 diabetes
  • Patients taking daily NSAID’s (non-steroidal anti-inflammatory drugs).
  • Patients taking immune suppressant drugs (prednisone, Imuran, methotrexate, etc.)
  • Patients with hormone deficiencies.
  • Patients who over-exercise the healing joint or body part
  • Taking anti-inflammatory medications and/or supplements
  • Giving up and stopping Prolotherapy treatments prior to complete healing
  • Eating a diet that causes inflammation.
  • Drink at least 2 liters of water following all injection therapies. Dehydration is the number one reason for post-injection discomfort.
  • Have soft tissue therapy (ART, physical therapy, chiropractic, etc.) as soon as possible following the injection treatment. The gains made from soft tissue treatment immediately after injections seem to be really accelerated.

Research

Modern medical research demands that therapies be proven by double-blind placebo controlled trials. For medications, the pills can easily be made to look alike and a sugar pill used as a placebo that is presumed to have no therapeutic value. For procedures like Prolotherapy and most surgeries, there is no adequate placebo. Cortisone cannot be used as a placebo because cortisone can only be injected 3 times a year; typically, Prolotherapy requires 4-6 treatments.

Health Canada wants more data to show the effectiveness of Prolotherapy. Drug companies pay for research when it is profitable. They are unlikely to pay for research on Prolotherapy because this would not be a profitable venture. In fact, drug companies and surgeons would profit less if Prolotherapy would be more widely used, since fewer people would need pain medication and they could avoid expensive surgeries or complications from surgeries.

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