Prolotherapy: Injections to Kick-Start Tissue Repair

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Injections to Kick-Start Tissue Repair

By JANE E. BRODY

http://www.nytimes.com/2007/08/07/health/07brod.html?

_r=1 & ref=health & oref=slogin

The human body is held together by a network of connective tissues

that are highly vulnerable to injury — through exercise, accidents

and even the normal lifting, pulling and pushing of daily life.

Few of us, for example, get through life without spraining an ankle.

And as many sadly know, once an ankle is badly sprained, it may be

sprained again and again. That often happens as well with other body

parts: shoulders, wrists, neck, back, jaw, feet, even fingers and

toes, all of which are subject to arthritic changes after an injury.

The risk of reinjury rises when the ligaments that hold bone to

bone, or the tendons that connect bone to muscle, fail to heal

completely. And such failure is apparently very common. Over time,

and with multiple injuries, this incomplete healing can result in

lax connective tissues that cannot fully support a joint.

Dr. K. Dean Reeves, clinical associate professor of physical

medicine and rehabilitation at the University of Kansas Medical

Center, likens the damage to a partly shredded rope that lacks the

strength of an intact one, and to stretched putty that will not

return to its former length. Dr. Reeves is one of several hundred

physicians and osteopaths who specialize in a therapeutic technique

called prolotherapy, an alternative medicine method to promote

connective tissue repair even years after the damage occurred.

The technique received an endorsement of sorts from the Mayo Clinic.

In its April 2005 health letter, the clinic stated that when chronic

ligament or tendon pain fails to respond to more conservative

treatments like physical therapy and prescribed

exercises, " prolotherapy may be helpful. " And when surgery is the

only remaining option to relieve chronic pain, prolotherapy is a

much less invasive and expensive technique that may be worth a try —

if you can find an experienced and skilled practitioner.

What Is Prolotherapy?

Prolotherapy involves a series of injections designed to produce

inflammation in the injured tissue. To appreciate the value of such

a seemingly counterproductive measure, you need to know something

about connective tissue and how the body normally repairs it.

When tissues are injured, inflammation is a common natural response.

It stimulates substances carried in blood that produce growth

factors in the injured area to promote healing. Ligaments, tendons

and cartilage have very poor blood supplies, which can result in

incomplete healing.

The healing process can also be impeded when injuries are treated

with anti-inflammatory medications like ibuprofen or Naprosyn, or

prescribed nonsteroidal anti-inflammatory drugs (Nsaids) to relieve

pain and swelling.

Unlike injections of corticosteroids, which also suppress

inflammation and provide only temporary relief for a chronic

condition, prolotherapy injections given over the course of several

months are meant to provide a permanent benefit. In effect,

prolotherapy tricks the body into initiating a healing response.

The technique reactivates the healing process by injecting a mildly

irritating substance — commonly a somewhat concentrated sugar

solution along with the painkiller lidocaine — into the injured area

to stimulate a temporary low-grade inflammation. In some cases,

growth factors themselves may be injected.

With growth factors in place at the site of inflammation, new tissue

is said to be produced that strengthens lax or unstable ligaments

and tendons. The technique may even support damaged or degenerated

cartilage, which normally does not repair itself, by strengthening

the fibrous connective tissues that stabilize the area.

Practitioners cite experiments in laboratory animals that

demonstrated tissue growth in ligaments and tendons stimulated by

prolotherapy injections. Two animal studies also showed healing of

cartilage defects.

Prolotherapy cannot correct mechanical problems like spinal

stenosis, in which two bones pinch a nerve, nor does it reverse

arthritic changes. But it may reduce or even eliminate the

discomfort associated with arthritis by tightening the connective

tissues that support an arthritic joint.

A leader in the field, Dr. Donna Alderman, an osteopathic physician

who is medical director of the Hemwall Family Medical Centers in

California, published two long articles on prolotherapy this year in

the magazine Practical Pain Management. She wrote that " prolotherapy

has been used in the United States for musculoskeletal pain since

the 1930s, " that it has been endorsed by former Surgeon General C.

Everett Koop, and that it is increasingly being used to treat

injuries in professional athletes.

Prolotherapy is also now the subject of a controlled clinical trial

sponsored by the National Center for Complementary and Alternative

Medicine, part of the National Institutes of Health.

Since prolotherapy is a nonsurgical technique, patients who are now

facing surgery because all else has failed might consider trying it

before having an operation. Unlike many drugs and surgery,

prolotherapy has minimal side effects when performed by an

experienced practitioner who uses sterile techniques. Patients may

experience bruising and a temporary increase in pain in the injected

area because of the induced inflammation. Rare risks include

infection, headache, nerve irritation or allergic reaction.

Does It Help?

There have been dozens of studies purporting to show benefits of

prolotherapy for people with chronic pain as well as those with

sports injuries. Among scientifically designed controlled studies,

most showed a significant improvement in the patients' level of pain

and ability to move the painful joint.

According to Dr. Alderman, in a study of people with chronic low

back pain resulting from injured ligaments in the sacroiliac joint,

biopsies done three months after treatment showed a 60 percent

increase in the diameter of connective tissue. The patients reported

a decrease in pain and an increased range of motion.

In studies of knee injuries, patients with ligament laxity and

instability experienced a tightening of those ligaments, including

the often disabling anterior cruciate ligament in the center of the

knee, Dr. Reeves showed in a double-blind study. Other studies

showed a significant improvement in the symptoms of arthritis in the

knee one to three years after prolotherapy injections.

Dr. Alderman cautions that prolotherapy is appropriate only for

patients with musculoskeletal pain who do not have underlying

conditions that would interfere with healing and who are willing to

receive painful injections in an effort to recover.

A state-by-state listing of prolotherapy practitioners can be found

at www.getprolo.com. Beware of practitioners who make rash promises,

fail to take a full medical history and to tell you about the

technique and its side effects, or who work in a disorderly or

unclean facility.