Prolotherapy, also called proliferation therapy, is an injection-based unproven treatment used in chronic musculoskeletal conditions.
Medical uses
A 2015 review found no evidence that prolotherapy is safe or effective for Achilles tendinopathy, plantar fasciosis, and Osgood–Schlatter disease. Another 2015 review assigned a strength of recommendation level A for Achilles tendinopathy and knee osteoarthritis and level B for lateral epicondylosis, Osgood–Schlatter disease, and plantar fasciosis. Level A recommendations are based on consistent and good-quality patient-oriented evidence while level B are based on inconsistent or limited-quality patient-oriented evidence. A 2009 review concluded the same for subacute low back pain. A 2015 review found consistent evidence that it does not help in low back pain.
Tendinitis
A 2009 systematic review of the efficacy in the treatment of lateral epicondylitis concluded that these therapies may benefit people with lateral epicondylitis, but the evidence was limited. A 2016 review found a trend towards benefit in 2016 for lateral epicondylitis. A 2017 review found tentative evidence in Achilles tendinopathy.
In 2012, a systematic review studying various injection therapies found that prolotherapy and hyaluronic acid injection therapies were more effective than placebo when treating lateral epicondylitis. Of the studies evaluated, one of ten glucocorticoid trials, one of five trials for autologous blood injection or platelet-rich plasma, one trial of polidocanol, and one trial of prolotherapy met the criteria for low risk of bias. The authors noted that few of the reviewed trials met the criteria for low risk of bias.
Knee osteoarthritis
Tentative evidence of prolotherapy benefit was reported in a 2011 review. A 2017 review described the evidence as moderate for knee osteoarthritis. A 2016 review found benefit but there was a moderate degree of variability between trials and risk of bias. In 2019, the American College of Rheumatology recommended against prolotherapy for knee osteoarthritis.
Contraindications
Contraindications for patients to receive prolotherapy injections may include: (often within 72 hours of the injection), numbness at the injection site, or mild bleeding. Pain from prolotherapy injections is temporary and is often treated with acetaminophen glycerine, lidocaine (a commonly used local anesthetic), phenol,
Terminology and mechanism
The term originated with George S. Hackett, MD, in 1956 in a publication titled "The rehabilitation of an incompetent structure by the generation of new cellular tissue". He applied the term prolotherapy from the words "proli'" (Latin), meaning offspring, and "proliferate", meaning to produce new cells in rapid succession. Although the erroneous term "sclerotherapy" was utilized by some in the past to describe this treatment, it is now clear that prolotherapy does not cause scarring. The mechanism of prolotherapy requires further clarification. It is expected to involve a number of mechanisms.
Criticism
Some major medical insurance policies view prolotherapy as an investigational or experimental therapy with an inconclusive evidence base. Consequently, they currently do not provide coverage for prolotherapy procedures. Medicare reviewers in 1999 determined at that time that practitioners had not provided "any scientific evidence on which to base a [different] coverage decision," and so retained Medicare's current coverage policy to not cover prolotherapy injections for chronic low back pain, but expressed willingness to reconsider if presented with results of "further studies on the benefits of prolotherapy."
History
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The concept of creating irritation or injury to stimulate healing has been recorded as early as Roman times when hot needles were poked into the shoulders of injured gladiators.
In 1840, French surgeon Alfred-Armand-Louis-Marie Velpeau published a paper detailing how he had injected an iodine solution into a hernia in order to create beneficial inflammation. American surgeon Joseph Pancoast later wrote that he had been performing this procedure (using either iodine or cantharides) since 1836.
By the late 1920s, this method was used to treat hernias. By the late 1930s, it was also used to treat ligamentous laxity. In the 1950s, George S. Hackett, a general surgeon in the United States, began performing injections of irritant solutions in an effort to repair joints and hernias.
In 1955, Gustav Anders Hemwall became acquainted with George Hackett at an American Medical Association meeting and started practicing the technique.
Hackett coined the term "prolotherapy" for the practice, a very early appearance being in his 1956 book Ligament and Tendon Relaxation (Skeletal Disability) Treated by Prolotherapy (Fibro-Osseus Proliferation).