Prolotherapy is a somewhat controversial option for the treatment of chronic pain. Prolotherapy involves injections that are designed to create scar tissue (hence the name- prolotherapy is short for proliferative therapy). Wait a minute. Isn’t scar tissue supposed to be “bad”. Don’t we take all kinds of precautions related to injury and surgery to minimize scar tissue formation? Why would someone want MORE scar tissue?
Enter hypermobility. This is when the amount of movement possible across one or more joints exceeds what is safe. Everyone has that friend or relative who has knees and/or elbows that bend too much, or “the other way”. Such a person has been born with a large amount of elastin in his/her connective tissues. A moderate amount of elastin would probably be common in yoga practitioners and ballet dancers. A high amount of elastin would be more likely to be seen in circus performers who can fold themselves into a box. Such extreme examples of mobility aren’t necessarily dangerous to the joints if you have the muscle strength and coordination necessary to control all that movement. In a person with a more typical collagen/elastin ratio in their connective tissues, the ligaments and other connective tissues hold the bones together and limit “extra” mobility the body was not designed to withstand. However, some people have neither the muscular control nor the ligamentous/connective tissue integrity to prevent “extra”, potentially injurious joint movement. In such instances, some scar tissue growth in strategically important locations might be extremely helpful.
I was first exposed to prolotherapy almost 30 years ago and have watched its popularity grow steadily. It is now very widely available and is used by many leading physicians and therapists. I regularly hear testimonials from patients, describing that their prolotherapy “worked”. This is empirical evidence that in some instances the use of prolotherapy appears to result in decreased “weakness”, increased stability and sometimes even a decrease in pain symptoms. It does in fact appear that strategically increasing scar tissue in specific soft tissues surrounding hypermobile (floppy) joints can be a useful and effective strategy.
Let’s talk about the history of prolotherapy and how it became a mainstream chronic pain treatment. The basic concept behind prolotherapy may have been introduced by Hippocrates over 2100 years ago. Hippocrates proposed that heated needles be inserted into the shoulders of javelin throwers to create scar tissue and improve joint laxity. It is believed that in Roman times this technique was also used to aid the recovery of injured gladiators. However, it wasn’t until Dr. George S. Hackett began studying the injection of irritants to stabilize joints in the 1930’s that it was introduced in modern times. Dr. Hackett is considered to be the father of prolotherapy. It was largely due to Dr. Hackett’s work that the knowledge and practice of prolotherapy reached other practitioners, most notably Dr. Gustav A. Hemwall in the 1950s who soon became the leading practitioner of this unique therapy. Over the years more research began to refine the technique of prolotherapy and it is now used by doctors and therapists around the world.
Many of the patients I see have had some experience with prolotherapy. It concerns me how little most people know about this procedure. Typically, it is described to them as a way to stabilize their “weak” neck, shoulder, back or ankle. Every alarm bell in my head goes off when I hear this kind of talk. Correcting “weakness” and instability with a needle may sound like a quick and efficient path to take, but let’s take a closer look to make sure we are informed healthcare consumers not unwitting victims.
Before we delve into the intricacies of prolotherapy let’s look at the ‘irritants’ used in this treatment. The word irritant may conjure up images of harsh chemicals, but those used in prolotherapy are FDA approved for use in humans, usually dextrose, lidocaine and phenol. The injected material is carefully measured and precisely applied. Traditionally these ingredients are injected into damaged ligaments or tendons. These solutions are very effective in proliferating healing tissue and creating a scar.
Now to the “dark side”. Unsurprisingly, some patients have had bad experiences with prolotherapy. What treatment approach hasn’t yielded disappointing results on occasion? As a result, there are patients, therapists and doctors who say that prolotherapy is an ineffective, even bogus modality with more side effects than benefits. Now the question arises, how true are these claims? It is easy to jump to conclusions and condemn a practice because your cousin had a bad experience, but that is no more accurate or sophisticated than to fall in love with a technique because of one apparent “miracle cure”. As a practitioner or a patient, you shouldn’t build a belief system around one case study.
One particular way this technique can yield less than ideal results is if the joint(s) being treated are not well aligned before the prolotherapy is applied. In such cases any pre-existing malalignment is further solidified, making the underlying cause of the current complaint all that more difficult to correct. Was the apparent “weakness” in the ankle due to tissue damage in the ankle, or was it because of twisting in the hip that prevented healthy weightbearing in that foot? Is the instability in the shoulder arising from the shoulder itself, or is it due to a dysfunction in the neck? When you misunderstand the true nature of the problem, no amount of prolotherapy or any other treatment technique will get you closer to a solution.
Another potential problem with prolotherapy, even worse than the formerly mentioned, is the application of these injections into muscle. It has been confirmed that ligament laxity can be improved with prolotherapy, however, to the best of my knowledge there has been no such confirmation that muscle pain can be in any way improved with these injections. Misuse of any good thing will result in bad outcomes and prolotherapy is no different. We would do well to remember that just as consultations with orthopedic surgeons often lead to surgeries and consultations with massage therapists often lead to massages, the odds are quite high that a consultation with a person who earns his/her living with a needle will result in injections. Be informed and make sure you are “on the same page” with your friendly neighborhood injection specialist.
Considering all the information above, it is clear that prolotherapy is not a “cure-all” option for chronic pain but when used for the right reasons and with the right techniques and safeguards it can be a very useful treatment option for those suffering from chronic pain due to joint laxity/hypermobility. Be your own healthcare advocate. Be informed. Finding the right information about health problems and appropriate procedures is extremely important for us all to be equipped to make informed decisions. And hopefully you have an expert team at your disposal to shepherd you along on your healthcare journey. No one person is capable of knowing everything. Dr. Google has access to virtually limitless information but without expert guidance it can be hard to separate the good from the bad and the ugly.
Yours in health,
Geoff Dakin BPE RMT
Calgary Registered Massage Therapist