OBJECTIVE:To appraise existing evidence for prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injection therapies for lateral epicondylosis (LE).

DESIGN:Systematic review.

DATA SOURCES:Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine. Search strategy: names and descriptors of the therapies and LE.

STUDY SELECTION:All human studies assessing the four therapies for LE.

MAIN RESULTS:Results of five prospective case series and four controlled trials (three prolotherapy, two polidocanol, three autologous whole blood and one platelet-rich plasma) suggest each of the four therapies is effective for LE. In follow-up periods ranging from 9 to 108 weeks, studies reported sustained, statistically significant (p<0.05) improvement in visual analogue scale primary outcome pain score measures and disease-specific questionnaires; relative effect sizes ranged from 51% to 94%; Cohen's d ranged from 0.68 to 6.68. Secondary outcomes also improved, including biomechanical elbow function assessment (polidocanol and prolotherapy), presence of abnormalities and increased vascularity on ultrasound (autologous whole blood and polidocanol). Subjects reported satisfaction with therapies on single-item assessments. All studies were limited by small sample size.

CONCLUSIONS:There is strong pilot-level evidence supporting the use of prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injections in the treatment of LE. Rigorous studies of sufficient sample size, assessing these injection therapies using validated clinical, radiological and biomechanical measures, and tissue injury/healing-responsive biomarkers, are needed to determine long-term effectiveness and safety, and whether these techniques can play a definitive role in the management of LE and other tendinopathies.

PURPOSE:To present the results of dextrose prolotherapy undertaken for chronic non-responding coccygodynia in 37 patients.

METHODS:14 men and 23 women (mean age, 36 years) with chronic coccygodynia not responding to conservative treatment for more than 6 months were included. 27 of them had received local steroid injections. A visual analogue score (VAS) was recorded for all patients before and after injection of 8 ml of 25% dextrose and 2 ml of 2% lignocaine into the coccyx. In 8 patients with a VAS of more than 4 after the second injection, a third injection was given 4 weeks later.

RESULTS:The mean VAS before prolotherapy was 8.5. It was 3.4 after the first injection and 2.5 after the second injection. Minimal or no improvement was noted in 7 patients; the remaining 30 patients had good pain relief.

CONCLUSION:Dextrose prolotherapy is an effective treatment option in patients with chronic, recalcitrant coccygodynia and should be used before undergoing coccygectomy. Randomised studies are needed to compare prolotherapy with local steroid injections or coccygectomies.

OBJECTIVE:The objective of this study was to determine whether prolotherapy, an injection-based complementary treatment for chronic musculoskeletal conditions, improves pain, stiffness, and function in adults with symptomatic knee osteoarthritis (KOA) compared to baseline status.

DESIGN:This was a prospective, uncontrolled study with 1-year follow-up.

SETTING:The study was conducted in an outpatient setting.

PARTICIPANTS:Adults with at least 3 months of symptomatic KOA, recruited from clinical and community settings, participated in the study.

INTERVENTIONS:Participants received extra-articular injections of 15% dextrose and intra-articular prolotherapy injections of 25% dextrose at 1, 5, and 9 weeks, with as-needed treatments at weeks 13 and 17.

OUTCOME MEASURES:Primary outcome measure was the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC). Secondary outcome measure was the validated Knee Pain Scale (KPS). Tertiary outcome measure was procedure-related pain severity and participant satisfaction.

RESULTS:Thirty-six (36) participants (60± 8.7 years old, 21 female) with moderate-to-severe KOA received an average of 4.3 ± 0.7 prolotherapy injection sessions over a 17-week treatment period and reported progressively improved scores during the 52-week study on WOMAC and KPS measures. Participants reported overall WOMAC score improvement 4 weeks after the first injection session (7.6 ± 2.4 points, 17.2%), and continued to improve through the 52-week follow-up (15.9 ± 2.5 points, p<0.001, 36.1%). KPS scores improved in both injected (p<0.001) and uninjected knees (p<0.05). Prescribed low-dose opioid analgesia effectively treated procedure-related pain. Satisfaction was high and there were no adverse events. Female gender, age 46-65 years old, and body-mass index of 25 kg/m(2) or less were associated with greater improvement on the WOMAC instrument.

CONCLUSIONS:In adults with moderate to severe KOA, dextrose prolotherapy may result in safe, significant, sustained improvement of knee pain, function, and stiffness scores. Randomized multidisciplinary effectiveness trials including evaluation of potential disease modification are warranted to further assess the effects of prolotherapy for KOA.

Prolotherapy is an injection-based complementary and alternative medical therapy for chronic musculoskeletal pain. Prolotherapy techniques and injected solutions vary by condition, clinical severity, and practitioner preferences; over several treatment sessions, a fairly small volume of an irritant or sclerosing solution is injected at sites on painful ligament and tendon insertions and in adjacent joint space during several treatment sessions. Prolotherapy is becoming increasingly popular in the United States and internationally and is actively used in clinical practice. Prolotherapy has been assessed as a treatment for various painful chronic musculoskeletal conditions that are refractory to"standard of care"therapies. Although anecdotal clinical success guides the use of prolotherapy for many conditions, clinical trial literature supporting evidence-based decision-making for the use of prolotherapy exists for low back pain, several tendinopathies, and osteoarthritis.

OBJECTIVE:To compare the effectiveness and cost-effectiveness of eccentric loading exercises (ELE) with prolotherapy injections used singly and in combination for painful Achilles tendinosis.

DESIGN:A single-blinded randomised clinical trial. The primary outcome measure was the VISA-A questionnaire with a minimum clinically important change (MCIC) of 20 points.

SETTING:Five Australian primary care centres.

PARTICIPANTS:43 patients with painful mid-portion Achilles tendinosis commenced and 40 completed treatment protocols.

INTERVENTIONS:Participants were randomised to a 12-week program of ELE (n=15), or prolotherapy injections of hypertonic glucose with lignocaine alongside the affected tendon (n=14) or combined treatment (n=14).

MAIN OUTCOME MEASUREMENTS:VISA-A, pain, stiffness and limitation of activity scores; treatment costs.

RESULTS:At 12 months, proportions achieving the MCIC for VISA-A were 73% for ELE, 79% for prolotherapy and 86% for combined treatment. Mean (95% CI) increases in VISA-A scores at 12 months were 23.7 (15.6 to 31.9) for ELE, 27.5 (12.8 to 42.2) for prolotherapy and 41.1 (29.3 to 52.9) for combined treatment. At 6 weeks and 12 months, these increases were significantly less for ELE than for combined treatment. Compared with ELE, reductions in stiffness and limitation of activity occurred earlier with prolotherapy and reductions in pain, stiffness and limitation of activity occurred earlier with combined treatment. Combined treatment had the lowest incremental cost per additional responder ($A1539) compared with ELE.

CONCLUSIONS:For Achilles tendinosis, prolotherapy and particularly ELE combined with prolotherapy give more rapid improvements in symptoms than ELE alone but long-term VISA-A scores are similar.

TRIAL REGISTRATION NUMBER:ACTRN: 12606000179538.

Prolotherapy is a technique that involves the injection of an irritant, usually a hyperosmolar dextrose solution, typically in the treatment of chronic painful musculoskeletal conditions. Despite its long history and widespread use as a form of complementary therapy, there still are disparities over its optimal indications and injection preparations. There are, however, numerous studies available regarding the use and efficacy of prolotherapy for various musculoskeletal conditions. The most frequently published indication is in the treatment of chronic low back pain, but there are recent studies that examined its use in the management of refractory tendinopathies as well as osteoarthritis. There is growing evidence to suggest that prolotherapy may be helpful in treating chronic low back pain when coupled with adjunctive therapies, such as spinal manipulation or corticosteroid injections. There is also evidence to suggest that prolotherapy is effective in treating refractory tendinopathies, particularly for lateral epicondylosis and Achilles tendinopathy. Additional larger, randomized controlled trials are needed to make specific recommendations regarding ideal protocols and indications. There is emerging evidence for the use of prolotherapy as a treatment option for osteoarthritis; however, further studies are needed to conclusively demonstrate its efficacy. Overall, prolotherapy remains a promising option for the treatment of painful musculoskeletal conditions, particularly when other standard treatments have proved ineffective.

OBJECTIVE AND IMPORTANCE: Surgical reconstruction is considered definitive treatment for anterior cruciate ligament (ACL) tears but precise surgical indications are debated. Some patients are reluctant or inappropriate surgical candidates. Prolotherapy is a non-surgical injection therapy for chronic musculoskeletal pain and instability. This case report documents the non-surgical repair of a torn ACL using prolotherapy and at-home exercise. CLINICAL PRESENTATION AND INTERVENTION: The 18 year old female patient sustained a right knee injury during a downhill skiing accident. Magnetic Resonance Imaging (MRI) revealed a high-grade partial versus complete rupture; Lachman exam findings suggested a complete rupture. She deferred surgical treatment. At 21 weeks post-injury, with unstable gait, inability to climb stairs and more than 1 cm anterior drawer test, she consented to undergo prolotherapy injections. She received 7 prolotherapy sessions over a 15 week period. At-home exercises were initiated at the 3(rd) prolotherapy session. RESULTS: The patient improved. Walking on flat ground improved 4 weeks after initiation of prolotherapy; she could ride a stationary bicycle for 30 minutes by 12 weeks. By 15 weeks, the patient had no instability climbing and descending stairs, the anterior drawer test was negative and MRI showed an intact ACL with fibrosis. Subsequently, she returned to full sport activity. CONCLUSIONS: We document the non-surgical repair of a high-grade partial or complete ACL tear using prolotherapy and at-home exercise. Prolotherapy may be an alternative to surgery in carefully selected patients. This report is consistent with findings of recent pilot-level studies and suggests the need for rigorous clinical trials assessing prolotherapy as treatment for ligament and tendon injury in selected patients.

PURPOSE:The aim of this study was to assess the efficacy of dextrose prolotherapy for the treatment of temporomandibular joint (TMJ) hypermobility.

PATIENTS AND METHODS:A prospective, randomized, double-blind clinical study using a placebo control was carried out. Twelve patients with painful subluxation or dislocation of the TMJ were randomly assigned to 1 of 2 equal-sized groups. Patients in the active group received 4 injections of dextrose solution (2 mL of 10% dextrose and 1 mL of 2% mepivacaine) for each TMJ, each 6 weeks apart, whereas patients in the placebo group received injections of placebo solution (2 mL of saline solution and 1 mL of 2% mepivacaine) on the same schedule. A verbal scale expressing TMJ pain on palpation, maximal mouth opening (MMO), clicking sound, and frequency of luxations (number of locking episodes per month) were assessed at each injection appointment just before the injection procedure and 3 months after the last injection. The collected data were then statistically analyzed.

RESULTS:By the end of the study, each group showed significant improvement in TMJ pain on palpation and number of locking episodes and insignificant improvement in clicking sound. With the exception of the MMO, there were no statistically significant differences throughout the study intervals between the active and placebo groups. The active group showed a significant reduction in MMO at the 12th week postoperatively. Differences compared with mean baseline value remained significant at the end of the follow-up period. On the other hand, the placebo group showed an insignificant difference in MMO throughout the study periods. For the last 2 intervals, the placebo group showed statistically significantly higher mean MMO values than the active group. By the end of the 12th postoperative week, the percentages of decrease in MMO were significantly greater in the active group.

CONCLUSION:Prolotherapy with 10% dextrose appears promising for the treatment of symptomatic TMJ hypermobility, as evidenced by the therapeutic benefits, simplicity, safety, patients' acceptance of the injection technique, and lack of significant side effects. However, continued research into prolotherapy's effectiveness in patient populations with large sample sizes and long-term follow-up is needed.

OBJECTIVES:To assess whether prolotherapy, an injection-based therapy, improves elbow pain, grip strength, and extension strength in patients with lateral epicondylosis.

SETTING:Outpatient Sport Medicine clinic.

STUDY DESIGN:Double-blind randomized controlled trial.

PARTICIPANTS:Twenty-four adults with at least 6 months of refractory lateral epicondylosis.

INTERVENTION:Prolotherapy participants received injections of a solution made from 1 part 5% sodium morrhuate, 1.5 parts 50% dextrose, 0.5 parts 4% lidocaine, 0.5 parts 0.5% sensorcaine and 3.5 parts normal saline. Controls received injections of 0.9% saline. Three 0.5-mL injections were made at the supracondylar ridge, lateral epicondyle, and annular ligament at baseline and at 4 and 8 weeks.

OUTCOME MEASURES:The primary outcome was resting elbow pain (0 to 10 Likert scale). Secondary outcomes were extension and grip strength. Each was performed at baseline and at 8 and 16 weeks. One-year follow-up included pain assessment and effect of pain on activities of daily living.

RESULTS:: The groups were similar at baseline. Compared to Controls, Prolotherapy subjects reported improved pain scores (4.5 +/- 1.7, 3.6 +/- 1.2, and 3.5 +/- 1.5 versus 5.1 +/- 0.8, 3.3 +/- 0.9, and 0.5 +/- 0.4 at baseline and at 8 and 16 weeks, respectively). At 16 weeks, these differences were significant compared to baseline scores within and among groups (P<0.001). Prolotherapy subjects also reported improved extension strength compared to Controls (P<0.01) and improved grip strength compared to baseline (P<0.05). Clinical improvement in Prolotherapy group subjects was maintained at 52 weeks. There were no adverse events.

CONCLUSIONS:Prolotherapy with dextrose and sodium morrhuate was well tolerated, effectively decreased elbow pain, and improved strength testing in subjects with refractory lateral epicondylosis compared to Control group injections.