Orthopedic and Regenerative Medicine
Prolotherapy is a regenerative therapy that uses a concentrated dextrose (sugar) solution to enhance healing. A solution of dextrose, anesthetic and saline is injected into the injured areas and acts as an irritant to stimulate a temporary, low grade inflammation. With the mild inflammation comes increased blood flow bringing with it platelets, growth factors and other cells to restart the repair process and allow the body to heal on its own. The treatment course often requires a series of several rounds of injections for maximal effect.
The efficacy of prolotherapy has been studied or reported in the setting of:
- tendonopathies such as lateral epicondylitis and Achilles tendonitis
- general musculoskeletal conditions
- pain in and around the region of the coccyx
- osteoarthritis of the hand
- sacroiliac disorders
- various types of neck pain
- temporomandibular joint disfunction
- cervicogenic headaches, chronic headaches
- foot problems
For further reading about Prolotherapy, see:
- Prolotherapy for Musculoskeletal Pain and Disability, David Robago, MD, et al.
- Journal of the American Osteopathic Association, February 2013: Prolotherapy: An Effective Adjunctive Therapy for Knee Osteoarthritis
- Primary Care, March 2010: Prolotherapy in Primary Care Practice
- New York Times, Aug 7, 2007: Injections to Kick-Start Tissue Repair
- Reuters, Nov 6, 2007: Achilles Tendon Treatment Shows Promise
- Hackett Hemwall Patterson Foundation
- American Association of Orthopaedic Medicine
Perineural Injection Therapy
Perineural Injection Therapy uses a weak (5%) solution of dextrose (a type of sugar used in intravenous medications) as a safe and effective treatment for painful conditions due to sport and occupation or other chronic non-malignant pain related issues.
This dextrose solution often immediately calms down inflamed nerves. Nerves can be inflamed in many different types of injuries, including musculoskeletal injuries. Oftentimes treating the inflamed nerves can not only help with pain, but also assist with healing the underlying tissue. The treatment often requires a series of injections, typically done 1 week apart.
Platelet Rich Plasma
Our office is now using the Emcyte system, generally regarded as the most advanced and sophisticated platelet rich plasma system commercially available.
Platelet Rich Plasma (PRP) Prolotherapy, like Dextrose Prolotherapy, is an injection therapy that provokes the body’s own innate healing response.
“Platelet rich plasma” is defined as “autologous blood with concentrations of platelets above baseline levels.”
How Platelet Rich Plasma is created:
Blood is drawn from the patient, treated with an anticoagulant, and spun in a special kit and centrifuge. After about ten minutes, the platelet rich plasma portion (“PRP) is drawn off. It requires about 60cc of blood to create 6cc of PRP.
How PRP works:
Platelets contain molecules such as proteins and cytokines that initiate and regulate wound healing. The increased platelet concentration in PRP appears to enhance tissue healing. Activated platelets “signal” to distant repair cells, including adult stem cells, to come to the injury site.
By concentrating the patient’s own platelets and using them for injection, a “repair matrix” is created. Three important plasma proteins, (fibrin, fibronectin, and vitronection) contribute to this repair matrix. Once the PRP is injected, the platelets become “activated” and secrete growth factors into the tissue for about seven days. The platelets also stimulate repair cells, such as stem cells and macrophages to migrate into the region. The platelets die after about 7-10 days, then the macrophages take over and secrete repairs proteins and growth factors.
The difference between Dextrose Prolotherapy and Platelet Rich Plamsa Therapy:
As Donna Alderman, MD, a nationally recognized regenerative medicine physician, put it, “Prolotherapy is like planting seeds in a garden; PRP Prolotherapy is planting seeds with fertilizer.”
Common questions about Orthopedic Regenerative Medicine
Are the injections painful?
The skin at the site of each injection is anesthetized with a “bleb” or “wheal.” Most of the pain/sensory nerve fibers are superficial, and for many persons this is sufficient. Rarely, someone may require premedication with acetaminophen or other analgesic.
After platelet rich plasma injections there are sometimes a few moments of increased pain that typically pass within a few minutes, and respond very well to topical application of ice.
What can a patient expect to happen immediately after the Prolotherapy/PRP/Perineural injection? How long does it take for the condition being treated to improve?
Immediately following the injections the patient may feel a dramatic improvement and almost complete resolution of his or her pain. This is thought to be due to the lidocaine (anesthetic in the syringe), or in the case of perinueral injection therapy, due to the remarkable effect of 5% dextrose on sensory nerves.
Regenerative injections are not a band-aid or a quick fix but rather a long-lasting and potentially permanent reparative process. It is important that the region of injection is not overused and/or re-injured during or after the treatment series. A general rule of thumb for exercise is half the duration and half the intensity of prior exercise regime for at least several days following the injections. In addition, commitment to a Physical Therapy program of rehabilitative and corrective exercises is crucial to insure an optimal outcome. The healing process is gradual and progressive, and initially healing may be more subtle or intermittent during the early phases but usually significant and dramatic by the completion of treatment. More endurance, less pain, and better function are typically experienced over time.
How are the injections administered?
Prolotherapy and PRP injections are directed toward ligaments, tendons, and joint capsules of the affected body region. Perineural injections are placed at the site of nerve exit from connective tissue (sometimes known as the “chronic constriction injury”, or CCI). Generally the injections are performed by using palpation to identify discrete anatomical structures. Often pain upon palpation of a structure is thought to indicate dysfunction and the structure is marked for injection. We sometimes tongue in cheek describe using a type of MRI (My Regional Investigator- AKA my thumb!) indicating that we palpate to determine which tissues are dysfunctional. At times, Musculoskeletal Ultrasound (MSKUS) may be utlilzed to guide the injections, for example in sites such as the labrum surround the hip.
How do regenerative injections work?
“Tensegrity is an elision of ‘tension + integrity’. Buckminster Fuller, building on the highly original sculptures of Kenneth Snelson, coined the term, to indicate that the integrity of the structure derived from the balance of tension members, not the compression struts.”