Prolotherapy and Prolozone
Prolotherapy and prolozone are used for treating:
- Chronic pain from sports, vehicle, home or work-related injuries
- Neck, including (whip-lash), upper and lower Back, sacroiliac joint pain
- Shoulder (rotator cuff injury), tennis /golfer’s elbow, wrist, hand, osteoarthritis, pain or tendinosus
- Hip, groin sprain, knee, foot or ankle pain
- Complex Regional Pain Syndrome (CRPS, RSD)
- Degenerative Disc Disease in the neck, upper and lower back
- Cervicogenic headaches( coming from the neck)
- Myofascial pain syndromes
- Pain Persistent After Spine Surgery
- Piriformis Syndrome
- Sciatica and TMJ
- Spondylosis (Spinal Arthritis)
Other treatment options include Platelet Rich Plasma Injections.
Prolotherapy / RIT
Regenerative Injection Therapy/(RIT) also known as prolotherapy or sclerotherapy is an interventional pain management technique that repetitively provides a mild neurolytic effect followed by a complex restorative process with biochemically induced collagen regeneration. It is also called Reconstructive Therapy, It is a non-surgical ligament reconstruction that accelerates the rate of cartilage growth. This therapy is effective because it addresses and eliminates the cause of chronic pain arising from connective tissue such as ligaments, tendons and cartilage. It is an injection technique that has been shown to cause growth of cells and tissue to stabilize and strengthen weakened joints, cartilage, ligaments and tendons. It rebuilds and strengthens the complete joint structure even in patients with no cartilage. This therapy may eliminate the need for joint replacement which usually takes three or more months to recover and costs thousands. Some family doctors prescribe pain killers, NSAIDs and Cortisone shots which offer only temporary relief.
The term prolotherapy is derived from the word prolo, short for proliferation, as the therapy is intended to proliferate tissue growth in the damaged area. This is also called Regenerative Injection Therapy (RIT), since it is recognized that it extends beyond the proliferative stage-now understood as only the second stage of regenerative healing process. The idea behind this therapy dates back more than 2000 years to Hippocrates, who used it to treat soldiers with injured shoulders. Instead of injections Hippocrates used a hot poker, which he speared into the shoulder joint, causing and stimulating the body to repair itself of inflammation.
The injection is placed into the damaged ligament or tendon at the point where it attaches to the bone. The injection produces an inflammation, which increases blood flow, swelling, and pain. The body then launches a course of repair and healing. The inflammation tricks the body into thinking another injury has occurred, so it sends in macrophages, which are cells that ingest and destroy the irritant solution. These cells clean up the area. The body then sends in fibroblasts, which are cells that help build fibrous tissue. The fibroblasts excrete collagen, a protein that makes the ligaments denser and stronger. The stronger ligaments provide more support for the joints and alleviates the pain.
What's it made of?
- Dextrose- utilized in intravenous solutions, when injected into the ligament, produces a temporary inflammatory response, causing specialized cells called fibroblasts to migrate to the injected site and produce new collagen (the protein found in ligaments).
- Phenol- used in many inject able medications as a preservative to prevent the growth of bacteria, also induces the growth of new collagen in connective tissue, and has some properties as a long-lasting local anesthetic. Xylocaine, Marcaine and Lidocaine are local anesthetics.
- Sodium morrhuate- (a derivative of cod liver oil) stimulates collagen formation.
This procedure uses an oxygen/ozone gas mixture which directs oxidation to the affected painful area. The affectied area is anesthetized with procaine, a local anesthetic, vitamin B12 and folic acid is added to the procaine. This combination stimulates the DNA of cells to start repairs to the damaged joint and relieves pain at once. Oxygen/ozone is the most critical nutrient for energy production and healing and is the magic ingredient in the new prolotherapy. Prolozone Therapy involves the injection of ozone in and around ligaments where they attach to the bone. The injected ozone increases the blood supply and flow of healing nutrients. More importantly, it also stimulates the deposition and activity of fibroblasts and chondroblasts. These cells synthesize the collagen and cartilage that the body uses to repair damaged ligaments and joints. This increase in cellular repair activity strengthens and tightens the injured tissues; thereby stabilizing the area, and removing the cause of the pain.
Dr. Robert Jay Rowan said the meniscus doesn’t repair itself because cartilage does not have a blood supply. It receives is oxygen and nutrients from the synovial fluid that baths the joints. Nutrition must migrate in through osmosis. Very good results have been obtained by injection ozone directly into the joint. Ozone is a very active form of oxygen and it stimulates cartilage growth and can stimulate damaged articular cartilage back to reasonable function. The meniscus is a piece of cartilage between the femur and tibia, not on the bone surface. Another approach is growth hormone which also stimulates cartilage growth. Combine Ozone, growth hormone and prolotherapy for joint problems have had wonderful results according to my colleagues.
The ligaments and tendons produced after RIT/Prolotherapy appear much the same as normal tissue, except that they are thicker, stronger, and contain fibers of varying thickness, testifying to the new and on going creation of tissue which stimulates the natural healing process. The injections stimulate blood vessel growth into tissues. This increases oxygen, nutrients and growth factor delivery to the areas in the joint structure which facilitates healing. Ozone is a naturally-occurring highly reactive molecule consisting of three atoms of oxygen. Because ozone is so reactive, it is able to stimulate fibroblastic and chondroblastic activity to an almost unbelievable extent. This high level of reactivity, combined with the innate safety of oxygen, makes ozone the ideal therapeutic molecule.
What's it made of?
- Oxygen/ozone gas mixture instead of the prolo solution. The affected joint is anesthetized with procaine which is a local anesthetic.
- B12 and folic acid is added to the procaine and this combination will stimulate the DNA of cells to jump into repair action faster and longer than other treatments.
- Oxygen called ozone is the most critical nutrient for energy production and healing. It stimulates the cells to excrete waste material and promotes their ability to repair themselves and the tissues around them. This makes PROLOZONE® a miracle healer as ozone is a powerful stimulant of cellular growth factors such as Transforming Growth Factor Beta (TGF-B).
The Stages of Healing
The Initial stage - inflammatory stage which lasts about a week.
Second Stage - Proliferative phase (where the word “Prolo” comes from, meaning to proliferate) which lasts for six weeks.
Final Stage - remodeling phase, which can take up to 18 months.
In regard to RIT/Prolotherapy, it is important to get treatment at about six weeks to maximize the effect of the inflammatory and proliferative phases of healing. When a person gets treated more frequently as for the athlete in the middle of his/her season, there is no choice other than to use really strong proliferans (cause more inflammation) so the inflammatory phase and proliferative phase are accelerated.
Without deep sleep, you lose your ability to repair damage to your joints because it is during deep sleep that our bodies secrete human growth hormone, which helps connective tissues regenerate and repair. During deep sleep your body is at its peak repair cycle, and the human growth hormone promotes the absorption of nutrients into your cells and aids healing. The result is immune cells are produced which are required for healing process.
RIT/PROLOTHERAPY WORKS BY INFLAMMATION - DON’T STOP IT!
This means you should not be taking any anti-inflammatory or narcotic medications, which inhibit the immune system and inflammation. Tylenol, acetaminophen, muscle relaxers, and Ultram are okay. These help decrease pain, but do not inhibit the inflammatory response. Herbs, enzymes and vitamins are also very helpful, but avoid ginger as this inhibits prostaglandin synthesis which is needed for proper inflammation.
Do not engage in too much stretching or Yoga as to stretch the ligaments inappropriately. If you are stretching and a joint (such as the knee or hip) is hurting, then you are probably stretching the ligament and thus, potentially undoing the Prolotherapy strengthening to the ligaments. Light stretching is fine. Certain exercises (those that avoid creating high impact or stress on recently treated ligaments) and massage are great after Prolotherapy. These loosen muscles without stretching ligaments.
For the person wanting to maximize the healing after RIT/Prolotherapy, it is essential to eat a healthy diet, which includes up toeight glasses of water per day. The person getting a sugar load several times a day is walking around in an immunosuppressed state. The immune system is what proliferates the tissue after RIT/Prolotherapy. So stop eating sugar and junk food and start eating healthy. It’s all part of the program. You need the building blocks to build new tissue.
Evidence for Prolotherapy
1800 patients followed for 2 years; 80% showed marked improvement in upper and lower body pain; Hackett GS: Prolotherapy in whiplash and low back pain. Postgrad Med 27:214-219, 1960 Two RCTs (160 participants) found that prolotherapy injections, given with spinal manipulation, exercise, and other therapies, are more effective than control injections for chronic low-back pain and disability. http://www.cochrane.org/reviews/en/ab004059.html
60% increase in collagen fibril diameter measured at 3 months after 6 weekly injections in patients with low back pain; Klein RG, Dorman TA, Johnson CE: Proliferant Injections for Low Back Pain: Histological Changes of Injected Ligagments and Objective Measurements of Lumbar Spine Mobility Before and After Treatment J Neurol Orthop Med Surg 10: 141-144, 1989 Osmolarity studies: Elevation osmolarity by as little as 50 mOsm has been found to activate multiple growth factors including PDGF
Response of Knee Ligaments to Prolotherapy in a Rat Injury Model; Am J Sports Med July 2008 vol. 36 no. 7 1347-1357 Conclusion: Dextrose injections increased the cross-sectional area of MCLs compared with saline-injected and uninjured controls. Dextrose injections did not alter other measured properties in this model.
A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma; British Journal of Sports Medicine 2009;43:471-481 Conclusions: There is strong pilot-level evidence supporting the use of prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injections in the treatment of LE.
Positive outcomes have been reported in prospective studies assessing prolotherapy for refractory coccygodynia, sacroiliac joint dysfunction, and leg pain caused by moderate to severe degenerative disk disease.
Ultrasonography in Regenerative Injection (Prolotherapy) Using Dextrose, Platelet-rich Plasma, and Other Injectants Physical Medicine and Rehabilitation Clinics of North America - Volume 21, Issue 3 (August 2010)
Conclusion: The cases documented here show clear tissue repair on ultrasound in individual cases of prolotherapy treatment.
Hypertonic dextrose injections (prolotherapy) for knee osteoarthritis: results of a single-arm uncontrolled study with 1-year follow-up. - Rabago D - J Altern Complement Med - 01-APR-2012; 18(4): 408-14
CONCLUSIONS: In adults with moderate to severe KOA, dextrose prolotherapy may result in safe, significant, sustained improvement of knee pain, function, and stiffness scores.
Frequently Asked Questions about Prolotherapy--Answers from Dr. Hughes
1) Will prolotherapy "lock up" my back muscles?
A common reason your back muscles get chronically tight and may not function properly ("lock up") is likely because of the damaged ligaments, which have become more like rubber bands or frayed ropes, than the cables that they should be. Without rest, your ligaments may get worse. Think of it like this. Your back is like a suspension bridge (eg Golden Gate Bridge). The hardware of the bridge are the bones along with some of the cushioning of the discs. The software of the bridge are the muscles, tendons, and ligaments. The muscles are backup support and for extreme activities (like skiing, or running, etc). Otherwise, the ligaments and with some tendons do most all the work. If they fail, the bridge (your hardware and software) starts to swing and more pressure gets put on the discs and the muscles fire more frequently. Then your discs may herniate or first bulge and then herniate. Physical therapy is great to help you recover but over-strengthening and stretching the muscles before you've healed the ligaments usually is just a band-aid or at worse, more damaging than good. Trying to make these overworked muscles fire more than they want to is just asking for more injury.
Prolotherapy works by stimulating your body's natural ability to heal the ligaments and tendons which ultimately will allow your muscles to relax. Your bridge is no longer swinging the wind and the muscles will only need to tighten down on those moments when you are catching big air on your mountain bike or snowboard or maybe just running up and down your favorite trail. JH
2) Will Prolotherapy increase my inflammation?
Regarding inflammation, your body is already chronically inflamed. It needs to finish the healing process by resting and potentially utilizing controlled proliferative shots to bring the attention of the growth factors, cytokines, oxygen, and overall blood flow to the precise points of injury in the ligaments and tendons. This healing process may shift the chronic inflammation to an acute state as the body heals. That's why some patients feel more pain for a few days (or longer) after the initial prolotherapy shots.
You will likely want to rest for 2 days after each series of shots, doing light activities with minimal lifting or any kind of extreme sports. Then you need to go easy over the course of the next 2-4 months as your back heals. The level of activity varies for each person. It is you that heals your back ultimately...the same way you heal any other injury.
3) Do I need to take a pain medication before prolotherapy? In other words, how painful is prolotherapy?
Very likely. Depending on your age and level of activity, you may require more than just standard prolotherapy if your injury has existed for a long time. Dr. Hughes often must break up some of the scar tissue, bone spurs, or fibrotic tendons or ligaments before protherapy can work best. Most tendons and ligaments do not fully heal to 100% tensile strength unless that fibrotic tissue has been removed. Nerve fibers, however, get imbedded in the scarred up ligaments and tendons and thus patients will often feel a shooting pain that may be nerve like for a second or two as the needle breaks up this scar tissue. Even when a full or partial regional nerve block is done (which Dr. Hughes may do), this pain can feel almost as bad as the pain elicited by a dentist. While Dr. Hughes always uses a generous amount of local anesthetic for every procedure, this does not always reduce the nerve pain because the nerve has often been trapped in the scar tissue, preventing the local anesthetic from getting to it for a second before it breaks down. When the scar tissue is removed, the nerve "wakes up," often with little shock. This shock is quickly tempered by the local anesthetic as it bathes the nerve so that the pain discontinues rapidly. The best analogy for this type of nerve tissue that is covered by scar tissue is snow laying over a power line in a way that prevents the flow of electricity. When the "snow" is removed by the needle of Dr. Hughes (see the skier in the photo), the electrical signal begins to work again, often with a tiny little jolt. That little jolt is the life of your nervous system sending power and sensation again to the area of injury along with surround tissues.
Dr. Hughes recommends that any patients with all patients with the such fibrotic scar tissue take a little sedative and pain medication before he performs any procedure on the ligament, tendon, or joint.