Prolotherapy A Narrative Review of Mechanisms, Techniques, and Protocols, and Evidence for Common te Musculoskeletal Condi ions Connie Hsu, mo", Kevin Vu, mo, Joanne Borg-Stein, Meo KEYWORDS * Prolotherapy ® Prolotherapy techniques * Dextrose prolotherapy * Orthobiologics * Tendinopathy * Treatment KEY POINTS: » Current hypotheses suggest that prolotherapy stimulates growth factors via a multimodal mechanism of action to resume or initiate connective tissue repair, potentially strength- ening attachments, and reducing or eliminating pain, © The injection technique is focused on the regional treatment of connective tissue disease with an emphasis on fundamental anatomy. The standardization of optimal injectate tech- nique Is an active area of research. « Prolotherapy is most commonly utilized for soft-tissue injuries, primarily tendinopathies and enthesopathies a3 well a3 joint osteoarthritis. INTRODUCTION In the United States, musculoskeletal disorders are the most common reason for a doctor's visit." Musculoskeletal conditions are not only distressing to patients burdened by significant pain, but they may also result in significant disability. In the United States, 55% of adults with joint pain have difficulty with basic functioning, frequently limiting thelr participation in social, occupational, and household situa- tions.* The increasing burden of musculoskeletal conditions has led to an interest in effective nonsurgical treatment strategies, including but not limited to corticosteroids, platelet-rich plasma injections, stem cell injections, and prolotherapy. In this article, we will be discussing a nonoperative, practical, and efficacious treatment for many common musculoskeletal conditions: prolotherapy. * Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 300 Ist Avenue, Charlestown, MA 02129, USA: ” Harvard Medical School, Boston, MA, USA * Corresponding author, 300 Ist Avenue, 2nd Floor, Charlestown, MA 02129. E-mail address: jborgstein@mgh.harvard.edu Phys Med Rehabil Clin N Am 34 (2023) 165-180 hetasvfeloi.org/10.1016/).pmr.2022,08.011 pmr-theelinies.com 1047-965 1/23/© 2022 Elsevier Inc, All rights reserved,Hsu et al Prolotherapy is defined as a nonsurgical regenerative injection technique that intro- duces small amounts of an irritant solution to the site of painful and degenerated tendon insertions, joints, and ligaments to promote the growth of normal cells and tis- sues." A major goal of prolotherapy is the stimulation of regenerative processes in the joint that help facilitate the restoration of joint stability through the strengthening and stabilization of ligaments, tendons, joint capsules, menisci, and labral tissue." Prolotherapy as a treatment for musculoskeletal pain has gained a significant amount of visibility and traction over the past two decades among both physicians and patients.® This is, in part, due to an increase in the amount and quality of recent clinical trials that have shown strong evidence in support of prolotherapy for the treat- ment of chronic musculoskeletal pain. In addition, prolotherapy has been proven to be a relatively safe therapy, with few adverse effects reported across the board in the reviewed studies discussed below. In this review, we will give a broad overview of the basic science behind prolother- apy as well as the currently utilized techniques and protocols for prolotherapy injec- tions. Finally, we will discuss the evidence for the use of prolotherapy in common and uncommon musculoskeletal conditions. MECHANISM OF ACTION Prolotherapy. a portmanteau of “proliferative” and “therapy,” was initially developed by surgeon George Hackett, who used these injections on soft-tissue injuries. Prolo- therapy, inaccurately described as sclerotherapy before its mechanism of action was investigated, refers to a nonbiologic Injection of the solution proposed to repair con- nective tissues.” The currant proposed mechanisms of action are focused on the generation of low- grade inflammation related to the injection of hyperosmolar solutions. One proposed pathway is the transportation of glucose via GLUT 1-4 channels that occurs in sur- rounding cells following localized injection.” This transport, as well as the osmotic effect of solutions leading to release of water and lipids from nearby cells, is related to the generation of a temporary low-grade inflammation at the site of injury.” This process is primarily mediated by the production of cytokines. At the fibro-osseus: junction of ligaments and tendons, this inflammation laads to a healing cascade of various paracrine pathways relating to cell growth and repair.'*’'' Cells that are acti- vated in this pathway include fibroblasts, chondrocytes, and nerve cells.'°-'° One notable study noted chondrogenesis on articular surfaces that had been injected with 12.5% dextrose.'* Direct needling of the tissue may also stimulate repair, with disruption of cellular membranes and local blood supply resulting in the release of healing and inflammatory blood factors such as calcitonin gene-related protein (CGAP), bradykinin, and prostaglandins.'° The direct injection of hyperosmotic solu- tions such as dextrose may also promote the activation of pain receptors, such as the capsaicin pain receptor. Upregulation of these channels results in an increase in substance P, CGRP, and nitric oxide, thought to have a downregulating effect ‘on receptors.‘ In addition, the transmission of pain via the alpha-delta nerve fiber may result in endogenous opicid-mediated pain suppression, as described in the gate-control theory.'” TECHNIQUES AND PROTOCOL When considering the use of prolotherapy to treat a soft-tissue disorder, there are basic principles of needle technique and application that must be kept in mind. There are two general approaches to prolotherapy that are largely utilized, and physiciansProlotherapy for Common Musculoskeletal Conditions commonly combine the aspects of both methods. The first method was named after the approach used by George Hackett, named the Hackett method. With the Hackett method, dextrose is the preferred proliferant, with a frequency of treatment lasting months with sessions every 6 to 12 weeks. The West Coast method predominantly uses a mixture of phenol, dextrose, and glycerin or sodium morrhuate with weekly treatments and larger bore needles than the Hackett method. This section will detail the most important techniques and protocols involved in prolotherapy as well as infor- mation for patients to ensure proper selection of their prolotherapy treatment. Solution Preparation Before the injection, the provider must have the required equipment on hand. Prolo- therapy is primarily done with dextrose injections ranging from 10% to 25%, although animal models have noted improvement with as little as 5% dextrose." Uncommonly used injectates include phenol and sodium morrhuate, with variable results.” Sy- ringes can be prepared using \, or % of 50% dextrose to create 12.5% or 25% ‘soft-tissue solutions, respectively. If using xylocaine, the percentages of xylocaine can range between 0.4% and 0.075%. Altematively, concentrations of 0.5% to 0.75% phenol may also be utilized or combined with dextrose. In addition, sodium morrhuate, which is available as a 5% solution, can be added to a 10 mL syringe to create a 0.5% to 1% concentration. Providers should ensure that normal saline for titration of injectate, syringes appropriate to the amount of prolotherapy needed, nee- dies, and disinfectant swabs are on hand for the injection. When considering prato- therapy for soft tissues surrounding the joints, consider a sterile office procedure similar to intraarticular joint injection: chiorhexicine/iodine prep, draping, and sterile gloves and instruments may be required. Anesthetic gel and anesthetic blebs are commonly applied to diminish skin sensation with lidocaine before injection. ‘Guidance Prolotherapy is generally a region-based intervention, versus comparable tender or trigger point injections, and thus requires a thorough physical examination before and immediately following an injection. Strong anatomic knowledge and fundamentals are vital to performing prolotherapy injections successfully, particularly regarding lig- ament and tendon referral patterns of pain. Like trigger point injections, twitch con- tractions may be elicited. However, unlike trigger points, reflex twitch contractions are likely a secondary phenomenon secondary to irritation of the museles overlying the tendon or ligament in question, reproducing the connective tissue pain referral pattem, Prolotherapy can be palpation- or ultrasound-guided. Palpation-guided prolother- apy injections have been successfully performed for decades and require a strong un- derstanding of anatomy. However, ultrasound-guided injections have become increasingly more popular due to improvements in accuracy and visualization of the needle during injection. The use of ultrasound injections, in general, MSK injections, has been shown to improve both efficacy and accuracy.*° However, there has been minimal investigation on the use of ultrasound concerning outcomes from prolother- apy injections, and there is no conclusive evidence in this field.*" Needling The needling technique can be summarized with the “ABCs” of prolotherapy injection: anatomy, bony endpoint, and compression (Fig. 1). A technique called peppering is commonly utilized with prolotherapy injections. Peppering is a technique where a ‘small amount of solution (around 0.5 cc) is injected into the injured structure multiple 167Prolotherapy for Common Musculoskeletal Conditions osteoarthritis, There is abundant yet inconsistent evidence for the use of prolotherapy in the treatment of chronic low back pain (LBP) alone, but good evidence to support the treatment of chronic low back pain with prolotherapy when coupled with adjunc- tive therapies." In addition, there has been promising evidence to support prolother- apy as a treatment for SI joint pain. Finally, there is growing evidence for the use of prolotherapy with more uncommon musculoskeletal diagnoses, such as joint laxity and hypermobility. A general overview of the most common musculoskeletal condi- tions that have been studied with prolotherapy will be discussed below. Tendinopathies Lateral epicondylosis Chronic lateral epicondylosis or “tennis elbow" pain, is a common, yet debilitating and often refractory condition.*° There have been multiple studies that suggest a benefit to treating lateral epicondylosis with prolotherapy. One of the earliest studies ‘on the efficacy of prolotherapy in lateral epicondylosis was a small double-blind ran- domized control trial (RCT) study: the treatment group, treated with 50% dextrose, 5% sodium morrhuate, 4% lidocaine, and 0.594 sensorcaine at 0, 1, and 4 months, showed significant improvement in pain levels compared with the contral group.” Another RCT study reported similar improvements in the reported pain levels in pa- tients treated exclusively with dextrose prolotherapy compared with the control group.”” A different study treated patients with lateral epicondylosis (confirmed by ul- trasound) with 159% dextrose prolotherapy and found that patients who received pro- lotherapy showed a significant reduction of pain from baseline as well as evidence of tendon healing on ultrasound imaging at subsequent follow-up appointments,”° A recent study aimed to compare the clinical effectiveness of prolotherapy monother- apy, physiotherapy monotherapy, and a combination of both prolotherapy and phys- iotherapy in a single-blinded clinical trial.’ At S2 weeks, there were significant improvements from baseline status for all outcome groups; however, there were no significant differences between groups.”’ Finally, a different triple-blinded RCT compared the effect of dextrose prolotherapy with saline in chronic epicondylapathy and reported that both groups demonstrated improvement in their outcome measures: of Patient-Rated Tennis Elbow Evaluation, disability, handgrip strength, pain, with the dextrose prolotherapy group showing significantly higher improvement in pain rating outcomes,” A couple of studies compared prolotherapy with other nonoperative treatments. ‘One such study compared the efficacy of prolotherapy versus corticosteroid injections in the treatment of chronic lateral epicondylosis and reported that while both treat- ments were well tolerated and provided benefit to the patients’ pain and disability scores at the 1 to 6 month follow-up, the sample size was too small to determine whether one therapy was superior to the other)!" For prolotherapy injections of the lateral epicondyle, it is important to position the patient in a way that optimizes accessibility of the attachment sites of the common extensor tendons. Injection sites are driven by ultrasound and physical examination findings (Fig. 2), Common injection sites include the common extensor tendon, the annular ligament, the supracondylar ridge over the radial collateral ligament, joint capsule, and the medial and lateral condyle (Table 1). Rotator cuff tandinapathy Rotator cuff pathology is one of the major causes of shoulder pain and disability.~ Like other tendinopathies, treatment of chronic rotator cuff pain with prolotherapy has been shown to reduce pain and disability. In one RCT, it was revealed that injections of hypertonic dextrose on painful entheses resulted in improvement in long-term pain 169170 Hsu et al Fig. 2. In plane injection into the elbaw for Lateral epicandylosis, ratings and patient satisfaction compared with saline injections.°“ Seven and cal- leagues similarly studied the efficacy of dextrose prolotherapy in reducing pain and improving function by dividing patients into a control group that was treated with ex- ercise, and a prolotherapy injection group treated with ultrasound-quided prolother- apy injections. Although both groups reported improved outcomes in all categories, there were significantly more improved scores across the board in the prolotherapy treatment group for pain, function, and shoulder range of motion.*° A retrospective study measured the outcomes of shoulder pain and disability score in patients who received prolotherapy injections and found significant improvement in pain and disability scales 1 week to 3 months atter treatment. A systematic review conducted by Catapano and colleagues” that included 5 RCTs concluded that dextrose prolo- therapy is a potentially effective adjuvant intervention to physical therapy for patients ‘with rotator cuff tendinopathy. Several potential injection sites target the shoulder and its supporting rotator cuff muscles, Posterior injection sites include the posterior lateral aspect of the acromion, the infraspinatus and teres minor, and into and around the AC joint, Anteriorly, the sub- scapularis, pectoralis major, coracoid process, anterior lateral clavicle, and lateral hu- merus may be injected. Positioning is important in shoulder injections, and small amounts should be peppered into each injection site with time in-between injections to range the shoulder as needed to distribute the solution along the joint (see Table 1), Plantar fasciopathy Plantar fasciopathy is defined as pain and structural changes at the tendon insertion site of the plantar fascia in the os calcis located at the bottom of the foot.°” Several studies have studied prolotherapy as a treatment for chronic plantar fasciopathy, many comparing prolotherapy to various other nonsurgical treatments, such as extra- corporeal shockwave therapy and platelet-rich plasma (PRP) injections. One RCT conducted by Ersen and colleagues divided patients into either a contro! group, who were given instructions for stretching exercises, or treatment group, treated with ultrasound-guided prolotherapy injections. This study discovered that while pain and foot and ankle outcome scores were significantly improved in both treatment groups, projotherapy injections showed significantly greater improvement after 42 days of treatment.°° Another study evaluated similar outcome measures with the addition of plantar fascia thickness and found improvements in pain and foot function across all subgroups, and significantly higher plantar fascia thickness in the prolother- apy group compared with the control group.*” Multiple studies comparing prolother- apy and shockwave therapy found comparable and noninterior efficacy in reducing pain and function in patients with plantar fasciopathy with no serious adverse effects from either treatment.“°“" Finally, Kim and Lee conducted a single-blinded RCT174 Hsu et al Low Back and Sacroiliac Joint Pain Low back pain The use of prolotherapy for low back pain is controversial. Several early studies demonstrated little-to-no improvements to pain and function in patients with chronic low back pain treated with prolotherapy. One ACT investigated the efficacy of pralo- therapy on chronic low back pain by dividing patients into groups of prolotherapy with or without cointerventions, and control groups with or without interventions. At 2 to 12 months, there were no significant differences in pain intensity or disability between the groups.“* Another study had similar findings. After 1 to 6 months, there was.no dif- ference between range of motion (ROM) or pain in the prolotherapy experimental group compared with the control group that received saline. However, this study had a significant limitation given that the injector was not able to examine the patient before injection, which is an important technique required for prolotherapy administra- tion.** Furthermore, other studies discovered that even in the case where prolotherapy shows a significant benefit in the improvement of pain and function, the presence of many cointerventions confound the aforementioned conclusions.°’ However, more recent prospective case series studies have demonstrated significant improvements in pain from baseline in patients treated with prolotherapy at 12 month follow-ups.“°"" in general, there has been conflicting evidence regarding the efficacy of prolother- apy on chronic low back pain, and this is likely the case due to a large number of different mechanisms and pathologies involved in chronic back pain. However, the literature agrees that while there is little evidence that prolotherapy injections alone were more effective than control, there does seem to be a benefit to prolotherapy in conjunction with other cointerventions, namely physical therapy, compared with con- trol groups who are not treated with prolotherapy.°” ‘SI joint pain One subset of low back pain is caused by sacroiliac (Sl) jaint dysfunction or insta- bility. Several studies have investigated the treatment of prolotherapy for chronic SI or SI joint pain with promising results. One such study found a remarkable decrease in pain levels for dextrose prolotherapy patients compared with patients who received steroid injections. In addition, the effect of prolotherapy lasted longer than steroid in- jections."* A prospective study found significant improvements at 3, 12, and 24 month follow-ups in patients treated with 3 sessions of hypertonic dextrose solution into the dorsal interosseous ligament of the affected SI! joint.“" A similar study found that a large proportion of patients with symptomatic SI joint instability as an etiology of low back pain treated with 3 prolotherapy sessions at approximately 1 month interval showed significant functional gains at follow-up." For low back and posterior hip injections, before injection. the patient's bony land- marks should be palpated. This includes the iliac crest (L4 lumbar level) and posterior superior iliac spine (PSIS) (S2 sacral level). Common injection sites include the inter- transverse and facet ligaments located at L5 just below the iliac crest, and the iliolum- bar and SI ligaments superior to the iliac crest. Several injection sites target the posterior hip, including gluteal muscle insertions, sacrospinous ligaments, and deep articular ligaments. These injections are typically completed with a 25 gauge 2 to 3 inch needle or 22 gauge spinal needle (see Table 1). Joint Laxity Owing to the proposed mechanism of prolotherapy, based on strengthening lax ten- dons and ligaments through the release of local growth factors, it is hypothesized that prolotherapy may achieve beneficial results in patients with pain secondary to jointProlotherapy for Common Musculoskeletal Conditions laxity. Prolotherapy as a treatment for TMJ has been extensively studied with impres- sive results. One study treated patients with recurrent TMJ laxity with a modified tech- nique of prolotherapy containing lignocaine and 50% dextrose for 1 to 4 treatment sessions, and discovered that after 6 months, 91% of the patients had no further dislo- cation or subluxation of their jaw."’ A recent study investigated the efficacy of dextrose prolotherapy as monotherapy for TMJ hypermobility compared with treat- ment with dextrose prolotherapy along with arthrocentesis. Although both treatment groups showed significantly improved pain scores and significantly decreased locking of the jaw, treatment with dextrose prolotherapy with arthrocentesis displayed greater improvement in the outcome measures.” One other RCT compared the efficacy of dextrose prolotherapy in treating TMJ with that of occlusal splints, another commonly utilized conservative treatment of TMJ, This study discovered that patients receiving profetherapy showed significantly greater improvements in pain, mouth opening, and clicking compared to treatment with occlusal splints.* In addition to treatment for TMJ, there have been a few studies investigating the effect of prolotherapy on other laxity in other joints. One study examined the effects of prolotherapy on 18 patients with 6 months or more of knee pain plus ACL laxity and found that at the 3 year mark, up to 10 patients no longer had ACL laxity defined by KT1000 anterior displacement. In addition, patients reported improved pain at rest, with walking, and stair use as well as improved range of motion and subjective welling at the 3 year follow-up.°° Lumbar spine instability due to ligamentous laxity has also been studied, with data to suggest that prolotherapy may be beneficial in restoring spinal stability and resolving chronic low back pain, compared with other mechanisms of chronic back pain.®°° In summary, apart from TMJ laxity, which has been well studied and documented, there are only a few studies to investigate the treatment of prolotherapy on ligamentous laxity in other joints, More data will be required to determine the benefits of prolotherapy for treating joint laxity in joints other than the TMJ. TMJ prolotherapy injection is directed at the joint capsule and its surrounding sup- portive ligaments and tendon. With the patient's mouth closed and teeth unclenched, the physician should palpate the zygomatic arch and insert a 1 inch 30 gauge needle ‘or 1", inch 27 gauge needle '/, inch inferior to the palpated zygomatic arch. The nee- dle should be advanced 1 inch and 0.75 mL of the proliferant solution should be injected. It is the authors’ opinion that this specialized injection should only be per- formed by experienced clinicians and ultrasound guidance is recommended. SUMMARY The use of prolotherapy continues to be an ongoing research interest for the use of soft tissue and MSK conditions in the body, The mechanism of prolotherapy is thought to be multifactorial in nature and broadly focuses on generating a localized inflamma- tory response to promote endogenous healing and growth factors. Applications for projotherapy injection include the above tendinopathy and osteoarthritis, with each of the above areas showing RCTs with significant positive effects. 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