DESCRIBE IN DETAIL ABOUT PROLOTHERAPY ? 10 MARKS
A 2 DEFINITION
1 Prolotherapy (Proliferative Therapy), also know as Non-Surgical Ligament and Tendon Reconstruction and Regenerative Joint Injection, is a recognized orthopedic procedure that stimulates the body’s healing processes to strengthen and repair injured and painful joints and connective tissue.
2 It is based on the fact that when ligaments or tendons (connective tissue) are stretched or torn, the joint they are holding destabilizes and can become painful.
3 Prolotherapy, with its unique ability to directly address the cause of the instability, can repair the weakened sites and produce new collagen tissue, resulting in permanent stabilization of the joint.
4 Once the joint is stabilized, pain usually resolves.
5 Traditional approaches with surgery have more risk and may fail to stabilize the joint and relieve pain, and anti-inflammatory or other pain relievers only act temporarily.
6 The original term used for this therapy was “sclerotherapy”, coined in the 1930’s when this treatment was discovered, and included both joint and vein injections.
7 Today the term “prolotherapy” is used for joint, ligament and tendon injections, while “sclerotherapy” is used for the treatment of varicose veins, spider veins, hemorrhoids and other vascular abnormalities.
INTRODUCTION
1 Prolotherapy is injection of any substance that promotes growth of normal cells, tissues, or organs.
2 An example is injection of red blood cell growth stimulator (erythropoietin) in patients with anemia.
HISTORY
1 sclerotherapy has been used successfully as early as 500 B.C. when Roman soldiers with shoulder joint dislocations were treated with hot branding irons to help fuse the torn ligaments in the shoulder joint.
2 Advances in medicines greatly improved on this process, and led to the modern techniques of strengthening the fibrous tissue and creating new, normal collagen, rather than producing scarring to fuse tissues.
3 Hippocrates described vein sclerotherapy around 400 B.C. using “slender instruments of iron” to treat varicose veins.
4 Injection sclerotherapy of veins was first reported in 1623, and modern forms of injection sclerotherapy for varicose veins, hernias and hermorroids has been performed since the early 1900’s.
5 Earl Gedney, D.O., a well-known Orthopedist, decreased his surgical practice and began to inject joints in the 1940s and 1950s, and spent the rest of his life researching and publishing on the subject.
6 Also, George Hackett, M.D., wrote a book on this injection therapy, with Gustav Hemwall. MD adding to that publication in the 1950’s. Both Gedney and Hackett’s work is still used today in training physicians.
7 In the years since this early work, techniques and medications have advanced to move from a scarring or fusing effect to a strengthening, regenerative effect, which restores the weakened joint to its original level of stability, without loss of flexibility and function.
8 Advances in Regenerative Medicine have made the use of more advanced formulas possible, such as Platelet Rich Plasma (PRP) which contains growth factors, and autologous Adult Stem Cell sources, for even more enhanced healing.
TYPES
There are three types of prolotherapy :
- Growth factor injection prolotherapy
A ) Injection of a growth factor (a complex protein) that specifically begins growth of a certain cell line (erythropoietin example).
B ) This type of prolotherapy is in early stages of study for arthritis (growing cartilage cells) and sprain and strain (growing fibroblasts) and will advance substantially in years ahead.
C ) It will be a more expensive option however than the latter two types.
- Growth factor stimulation prolotherapy
A ) Injection of something that causes the body to produce growth factors.
B ) Non inflammatory (10% or less) dextrose is an example of this.
C ) Humans cells exposed to as little as 0.3% dextrose produce growth factors such as platelet-derived growth factor (PDGF), transforming growth factor-beta (TGFB), epidermal growth factor (EGF), basic fibroblast growth factor (bFGF), and connective tissue growth factor (CTGF).
- Inflammatory prolotherapy
A ) Injection of something that causes activation of the inflammatory cascade to produce growth factors.
B ) These solutions often include dextrose for a growth factor stimulation effect, but the inflammatory signals that result causes a more vigorous growth response.
C ) Examples of solutions in current use are 12.5%-25% dextrose, phenol-containing-solutions, and sodium-morrhuate-containing solutions
D ) Inflammatory prolotherapy will likely be the most cost effective form of prolotherapy in the future as it is an inexpensive medical technique for stimulation of the natural wound healing cascade.
MECHANISM OF ACTION
1 works by stimulating the body’s natural healing mechanisms to lay down new tissue in the weakened area.
2 This is done by a very directed injection to the injury site, “tricking” the body to repair again.
3 The mild inflammatory response which is created by the injection encourages growth of new, normal ligament or tendon fibers, resulting in a tightening of the weakened structure.
4 Additional treatments repeat this process, allowing a gradual buildup of tissue to restore the original strength to the area.
DOSAGES
1 Prolotherapy treatment sessions are generally given every two to six weeks for several months in a series ranging from 3 to 6 or more treatments.
2 Many patients receive treatment at less frequent intervals until treatments are rarely required, if at all.
USES
1 Low back or mid-back pain including degenerative disc disease and sacro-iliac joint instability/dysfunction
2 neck pain
3 knee pain
4 knee meniscal tears
5 wrist or hand pain
6 osteoarthritis
7 shoulder pain including rotator cuff tears
8 elbow pain including golfers or tennis elbow
9 foot pain including plantar fasciitis
10 ankle pain or instability, hypermobility
11 osteitis pubis
12 IT band syndrome
13 piriformis syndrome
14 temporal mandibular joint syndrome (TMJ), or other musculoskeletal pain or injury.
Contraindications
Contraindications for patients to receive prolotherapy injections may include:
1 Local abscess Bleeding disorders
2 Patient on anticoagulant medication
3 Known allergy to prolotherapy agent
4 Acute infections such as cellulitis and Septic arthritis
5 Relative contraindications include:
A Acute gouty arthritis
B Acute fracture
SIDE EFFECTS
1 mild pain and irritation at the injection site (often within 72 hours of the injection)
2 numbness at the injection site
3 mild bleeding
4 Pain from prolotherapy injections is temporary and is often treated with acetaminophenor in rare cases opioid medications
5 NSAIDs are not usually recommended due to their counter action to prolotherapy induced inflammation, but are occasionally used in patients with pain refractory to other methods of pain control ( v imp )
6 Theoretical adverse events of prolotherapy injection include
A ) lightheadedness
B ) allergic reactions to the agent used, bruising, infection, or nerve damage.
C ) However, allergic reactions to sodium morrhuate are rare
D ) Rare cases of back pain, neck pain, spinal cord irritation, pneumothorax, and disc injury have been reported at a rate comparable to that of other spinal injection procedures
PROGNOSIS
recovery in 85 to 90 %