Prolotherapy

What is ligamentous instability?

Ligaments contribute to joint stability. They prevent movement beyond a “normal” range, which can vary from one individual to another. Some people have lax ligaments that enable more movement. They are often referred to as being double-jointed and they have various forms of hypermobility, including Ehlers-Danlos syndrome. In the spine, there is a complex arrangement of ligaments between each vertebral segment, and between the spine and the pelvis. This allows flexibility in some directions but not in others.
 
Sometimes, ligaments can be overstretched or even torn (as in a sprained ankle). In this case, they may not adequately control the joints, leading to instability and potentially putting abnormal stress on motion segments in the spine. In women, the pelvic joints need to be supple for childbearing, so the ligaments soften and stretch more readily. On occasions, they do not tighten up after childbirth and allow too much movement, hence sacroiliac instability.
 

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What is prolotherapy?

Prolotherapy works by stimulating the body to make new fibres, which are formed within the substance of ligaments, thickening and strengthening them. The solution (P2G – phenol 2%, dextrose 30%, glycerol 30%) is mixed with local anaesthetic, and a small amount (0.5 ml) is injected into each end of the ligament, close to its attachment to the bone. A solution with only 12.5-25% dextrose can be used to avoid excessive inflammation. The injections initially provoke inflammation, stimulating cells that make collagen fibres. Over the ensuing four to five months, new collagen fibres are incorporated into the existing ligament.

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Each ligament has to be stimulated three or four times (sometimes up to six, at weekly intervals) for successful fibrous development to occur. Hence, the injections are given as a course of treatment. Prolotherapy for ligaments is not widely practised, so it has not yet been licensed for this particular application. However, the solution in the injections is used to treat other ailments, such as varicose veins; it is known to be safe. It is equally safe to repeat the treatment, should this be necessary, because the organic compounds in the solution are rapidly metabolised by the body. Prolotherapy does not create scar tissue. It encourages the growth of healthy collagen fibres. Injections are commonly given in the lumbar or sacroiliac region, and in the cervical or thoracic spine. They are also useful in the ankle, knee, shoulder, and temporomandibular joint (jaw).

 

Entonox analgesia (nitrous oxide and oxygen, as administered during labour) may be offered to relieve the discomfort of the injections. Intravenous sedation is also available for those who prefer it. If sedation is used, the patient will need to be accompanied home.

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What advice is there for aftercare? Are there any possible complications?

These injections may cause some aching and stiffness for two or three days. Rest is not necessary; normal activities should be continued. Paracetamol, rather than aspirin or Nurofen, can be taken for pain relief.

 

Complications are very rare when being treated by an experienced practitioner, since the injection is not placed into the spinal canal or near spinal nerves. The occasional patient may experience a severe flare-up of pain lasting several days, which can be addressed by reducing the concentration of the injections next time.

 

The benefit is not immediate, but gradual. It becomes noticeable after six to eight weeks, increasing up to eighteen weeks.

 

If you have any further queries, please ask your doctor.

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How much research has been done on prolotherapy?

Ongley, M.J., Klein, R.G., Dorman, T.A., Eek, B.C., & Hubert, L.J. (1987). A new approach to the treatment of chronic low back pain. Lancet (London, England), 2(8551), 143–146. https://doi.org/10.1016/s0140-6736(87)92340-3

 

Klein, R.G., Eek, B.C., DeLong, W.B., & Mooney, V. (1993). A randomised double-blind trial of dextrose-glycerine-phenol injections for chronic, low back pain. Journal of spinal disorders, 6(1), 23–33.

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Rabago, D., Best, T M., Beamsley, M., & Patterson, J. (2005). A systematic review of prolotherapy for chronic musculoskeletal pain. Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine, 15(5), 376–380. https://doi.org/10.1097/01.jsm.0000173268.05318.a4

 

Cusi, M., Saunders, J., Hungerford, B., Wisbey-Roth, T., Lucas, P., & Wilson, S. (2010). The use of prolotherapy in the sacroiliac joint. British journal of sports medicine, 44(2), 100–104. https://doi.org/10.1136/bjsm.2007.042044

 

Hauser, R.A., Lackner, J.B., Steilen-Matias, D., & Harris, D.K. (2016). A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain. Clinical medicine insights. Arthritis and musculoskeletal disorders, 9, 139–159. https://doi.org/10.4137/CMAMD.S39160