Definition and Overview
Prolotherapy (proliferative therapy) is a regenerative injection treatment that intentionally induces a local inflammatory response by precisely injecting a stimulating solution such as hypertonic dextrose around the damaged ligament, tendon, joint capsule, or tendon enthesis, thereby promoting the regeneration of connective tissue and structural strengthening.
The name "prolotherapy" is a compound word of "proliferation" and "therapy" and reflects the principle of inducing tissue regeneration and proliferation. It began to be used clinically in the 1950s and is currently being used as a non-surgical alternative in the field of chronic musculoskeletal pain.
Mechanism of Action
The main mechanism of action of prolotherapy is understood as follows.
When a hypertonic glucose solution is injected into a tissue, microscopic damage to cells occurs due to differences in osmotic pressure. In response to this damage, platelets gather and secretion of growth factors is promoted.
Major secreted growth factors include platelet-derived growth factor (PDGF), transforming growth factor beta (TGF-β), and insulin-like growth factor (IGF-1), which activate fibroblasts to induce collagen synthesis and tissue regeneration.
Neural mechanisms include increased proprioceptor density in ligaments and tendons and decreased hypersensitivity of pain-mediated nerve fibers. However, the overall mechanism has not yet been fully elucidated, and additional research is in progress.
Indications
The main indications for prolotherapy are as follows.
Chronic low back pain is an indication when accompanied by ligament relaxation or tendon-origin pain. Studies have reported significant pain reduction over 3 to 6 months.
For knee osteoarthritis, Rabago et al. (2013) in a randomized controlled trial showed that high-dose glucose injection was significantly effective in improving pain scores and function compared to saline and home exercise.
Ligament laxity is applied to chronic laxity of the anterior cruciate ligament (ACL), sacroiliac joint ligament, and ankle ligament.
It is also being clinically applied to tendinopathy, neck pain, sacroiliac joint pain, golfer's elbow (medial epicondylitis), and Achilles tendinopathy.
Treatment method
The procedure is performed under sterile conditions after accurately identifying the target area using image guidance (ultrasound or fluoroscopy) or body surface anatomy.
The injection solution is usually a mixture of 15-25% glucose + 1% lidocaine, and the concentration and dose are adjusted depending on the treatment area. It is common to inject small amounts repeatedly into several points at the attachment of ligaments and tendons in a single procedure.
The treatment interval is 2 to 4 weeks, a total of 3 to 6 times, and is adjusted depending on the patient's response. Avoid taking steroids or NSAIDs immediately after the procedure as much as possible as they may inhibit the treatment response.
Effectiveness and Evidence
For chronic low back pain, Dagenais et al. (2007)'s Cochrane systematic review confirmed that injection of a combined solution of glucose and pyrophosphate was effective in improving back pain, but the need for additional high-quality research on sole glucose prolotherapy was raised.
Yelland et al. (2004)'s RCT comparing prolotherapy, saline injection, and exercise therapy, a decrease in pain over time was observed in all groups rather than differences between groups, which limited the interpretation of the mechanism.
Reeves and Hassanein for knee osteoarthritis (2000) in a randomized, double-blind study showed that the glucose injection group showed significant improvement in pain and function compared to the saline group. Rabago et al. (2013), this result was also replicated in a follow-up RCT.
Overall, evidence on the effectiveness of prolotherapy is accumulating, but additional high-quality, large-scale RCTs are required due to the difficulty in establishing a standard control group and study heterogeneity.
Precautions and prognosis
Contraindications include injection site infection, glucose or lidocaine allergy, coagulopathy or taking anticoagulants, and immunocompromised conditions (including poor diabetic control).
Precautions after the procedure include refraining from excessive activity in the treated area for 1 to 3 days after the procedure, limiting the intake of NSAIDs (which may inhibit the treatment response), and local heat and swelling in the treated area within 1 to 2 days after the procedure are normal inflammatory reactions.
Side effects include temporary increase in pain at the treatment site, hematoma, and infection (rare), and injecting at the correct anatomical location is the key to preventing complications.
Treatment response varies greatly from person to person, and effectiveness may vary depending on the severity and duration of the disease and overall health. There are also research results showing that the effectiveness can be improved when combined with conservative treatment (exercise therapy, physical therapy).
---
This information is provided for medical educational purposes and is not a substitute for individual medical care or treatment. If you have any symptoms, be sure to seek professional advice. Inquiries: Osang Neurosurgery 1599-5453 | osns.co.kr