A chapter from the revised Alternative Medicine, the Definitive Guide,
and copyrighted and compiled by The Burton Goldberg Group. It is co-written by Marc Darrow MD,JD.

Prolotherapy

Prolotherapy rejuvenates the body by injection of natural substances to stimulate the growth of collagen in order to strengthen weak or damaged joints, tendons, ligaments, or muscles. As a simple, cost-effective alternative to drugs and surgery, prolotherapy is an effective treatment for many pain syndromes, including degenerative arthritis, low back and neck pain, joint pain, carpal tunnel syndrome, migraine headaches, and torn ligaments and cartilage.

Joint, tendon, ligament, cartilage, and arthritic problems are among the most common afflictions suffered by Americans today. Many remedies are used to treat these problems, such as rest, medication, traction, exercise, cortisone injections, physical therapy, and surgery, but for many patients, these fail to provide lasting relief. In many cases, prolotherapy (also known as reconstructive therapy, sclerotherapy, or proliferative therapy), a nonsurgical method that stimulates the body's natural healing abilities to repair injured tissues and joints, can provide an answer. The word prolotherapy is derived from the root prolo, which is short for proliferation. Prolotherapy is so named because it causes new collagen to grow, or proliferate, in areas of the body where it has been weakened or injured.

"Ligaments, tendons, cartilage, and bones have poor healing abilities due to the lack of blood supply to these tissues," says William Faber, D.O., director of the Milwaukee Pain Clinic, in Wisconsin, and a leading authority in the field of prolotherapy. "This is why injuries to these areas are so long lasting. When these tissues become damaged, the joint becomes unstable and, in order to compensate, the body forms bony, arthritic spurs. This causes increased friction, increased pain and weakness, and a loss in joint mobility. Further injury often results."

Prolotherapy can facilitate the healing process for specific injuries. In the case of injured joints, a local anesthetic and a natural irritant (sodium morrhuate, a purified derivative of cod liver oil), dextrose, phenol, minerals, or other natural substances are injected into areas where ligaments, tendons, or cartilage are torn or weak. "The injection stimulates the body to produce more connective tissue, which helps to strengthen the weak or damaged areas," says Dr. Faber. "As a result, the patient will often experience less pain and greater strength and endurance." Greater mobility and range of motion are other benefits of prolotherapy treatment. The injections are completely safe and trigger the same natural healing response that normally occurs after an injury.

Collagen is a component of ligaments, tendons, cartilage, muscle, and the outer covering of muscle called fascia. All of the soft tissue of the body is composed of collagen.

Ligaments are sheets or bands of connective tissues made out of collagen that provide stability to the joints of the body by connecting two or more bones together. When ligaments become weak or damaged, healing is often slow and the injury may not fully recover, primarily because the blood supply to ligaments is limited. Ligaments also contain many nerve endings that can exacerbate the pain a person feels when ligaments are injured or loosened.

Tendons are fibrous connective tissues made out of collagen, which connect muscles to bones. Like ligaments, when tendons become damaged they can cause pain.

 

How Prolotherapy Works

"Mild, irritating reconstructive solutions cause dilation of blood vessels and a migration of fibroblasts [healing cells] to the injured areas," according to Dr. Faber. "These healing cells lay down collagen to repair the area." This re-growth has been substantiated by research studies dating back nearly 50 years.

In healthy ligaments or tendons, connective tissue, especially collagen fibers, limit themselves to a certain amount of stretch. When ligaments or tendons are injured, however, these connective fibers are also weakened, causing them to lose their ability to prevent further stretch. As a result, ligaments become "loose" and joints and other ligament-based structures become unstable and, ultimately, very painful. Prolotherapy eliminates or reduces pain by stimulating the body to rebuild ligaments and tendons, in many cases producing ligaments and tendons that are stronger and more stable than they were before injury occurred. While prolotherapy cannot reduce abnormal bone growth that has already occurred, it can eliminate the resulting pain. It is most effective when used in conjunction with proper diet, treatment for bacterial and fungal infections, and proper balancing of omega-3 fatty acids.

In a study conducted in the 1950s by surgeon George Hackett, M.D., 1,600 patients with severe sacroiliac sprain were treated with prolotherapy injections. When the patients were examined by independent physicians two to 12 years later, 82% had remained free of pain or recurrences.(1) Dr. Hackett's experiments were repeated in 1983 and 1985 by the University of Iowa's Department of orthopaedic Research. Both studies found that the patients' tendons became more firmly attached to the bone and increased in strength and structure by 30%-40% above normal.(2)

In 1987, at the Sansum Medical Clinic of Santa Barbara, California, rheumatologist Robert Klein, M.D., and internist Thomas Dorman, M.D., conducted a double-blind study of 81 patients who suffered from continuous low-back pain for more than ten years. They found that 88% of the patients injected with a prolotherapy solution of dextrose, glycerine, and phenol demonstrated moderate to marked improvement.(3) A similar study, reported in the Journal of Spinal Disorders, showed an 80% improvement.(4) Both studies support Dr. Hackett's findings.

Studies conducted by Harold Walmer, D.O., of Elizabeth, Pennsylvania, have also shown that prolotherapy increases mechanical strength in ligaments and joints.(5) This may explain why so many patients with advanced degeneration of bones and soft tissues, or those who suffer from a wide range of musculoskeletal problems, have improved so dramatically when given prolotherapy injections.

Two placebo-controlled, blinded clinical trials of prolotherapy conducted in 2000 also attest to the therapy's effectiveness for treating osteoarthritic conditions. In the first study, 13 patients suffering from osteoarthritis in their knees showed significant improvement in knee pain, swelling, buckling, and joint flexibility after receiving prolotherapy treatments. Additionally, eight of the patients with loose anterior cruciate ligaments found that they tightened following prolotherapy injection alone.(6) The second study investigated the effectiveness of prolotherapy for treating osteoarthritis in finger and thumb joints. Upon completion of the study, prolotherapy was shown to produce significant improvement of pain and joint flexibility.(7)

A 16-year study conducted by Harold Wilkinson, M.D., former chair of neurosurgery at Massachusetts Medical Center, also supports prolotherapy's effectiveness. While patients typically require a series of prolotherapy injections before they experience complete elimination of their pain, Dr. Wilkinson reported that "a sizeable portion of people with unresolved chronic pain had more than a year's pain relief with only one injection."(8)

According to Dr. Faber, when a patient does not improve after receiving prolotherapy, typically it is due to the fact that one or more pre-existing conditions are inhibiting the body's healing process; these include infection or the use of cortisone, which can interfere with prolotherapy's effectiveness. Ross Hauser, M.D., founding medical director of Caring Medical and Rehabilitation Services, in Oak Park, Illinois, concurs, after observing that some patients who came to him for prolotherapy needed more than the treatments alone to heal. "It is as if some patients have lost the ability to heal, a condition I call 'connective tissue deficiency'," says Dr. Hauser. He points out that the use of synthetic estrogen by women can also inhibit prolotherapy's effectiveness.

Conditions Benefited by Prolotherapy

Prolotherapy has been practiced in the United States for more than 50 years as a treatment for America's most common afflictions: tendon, ligament, and arthritic problems. To date, over one million patients have been successfully treated with prolotherapy, including the former U.S. Surgeon General, C. Everett Koop, M.D., who suffered from chronic back pain until prolotherapy cured it. Common symptoms and conditions that respond well to prolotherapy include:

Prolotherapy is also recommended for weak joints; joints requiring a brace; joints that continually pop, snap, and grind; or joints that cannot maintain alignment (particularly when chiropractic or osteopathic manipulations fail to help). It is also effective as a treatment for a wide range of musculoskeletal problems caused by failed surgery, compression fractures, degenerated disks, and muscular dystrophy.

Prolotherapy can provide a more cost-effective solution to musculoskeletal and joint problems than traditional surgery.

Examples of Prolotherapy's Effectivenes

One of Dr. Faber's cases, involving physician John Parks Trowbridge of Houston, Texas, illustrates how effective prolotherapy can be. Dr. Trowbridge had been experiencing chronic low-back pain since the age of 14. At the age of 30, he had sprained his neck, worsening his condition, and a cervical laminectomy (excision of the vertebral posterior arch) was surgically performed. However, his back problems persisted and, ten years later, he injured his back once again. Diagnosis showed a herniated lumbar disk and another operation followed, but his back pain persisted. When it became so severe that he could barely move without pain, he sought prolotherapy. The pain was relieved immediately, Dr. Faber reports, with his neck and back steadily strengthening during the days after his first treatment. Further treatments provided more relief. "He told me that prolotherapy was the most valuable of any of the treatments he had received, and it only cost a fraction of the $120,000 he had spent on surgery, medications, and other physical therapies," reports Dr. Faber.

Another of Dr. Faber's cases involved a college football player who had suffered repeated injuries to his left shoulder. He relied upon various medications and therapies until the pain became too great, and then underwent orthopaedic surgery; but his condition worsened. Chiropractic treatments afforded him only temporary relief, and his chiropractor suggested prolotherapy. After receiving the injections, his condition improved dramatically. In fact, in a metered punching test, it was found that he ended up with more strength in the left shoulder than in the right.

A third patient of Dr. Faber's suffered from lumbar spondylolisthesis (a forward slipping of one vertebra on the one below it) for more than two years; he experienced constant pain. After receiving prolotherapy from Dr. Faber, he was pain free. Eight years later, he reported no recurrences. Today, he does landscaping, hunts, and even goes waterskiing.

Dr. Hauser has also had many successful outcomes using prolotherapy. One of his patients was a 41-year-old woman who came to him suffering from severe hip pain. After undergoing numerous X rays and an MRI scan, her doctors had told her the pain was most likely due to a fall she had suffered some time before, as well as to hereditary arthritis. Over time, the pain became so great that she was forced to stop all physical activity and was sometimes unable to walk for weeks at a time. Finally, after 18 months of anti-inflammatory medication and pain pills, her doctors informed her that the only remaining option was hip replacement surgery. After examining her, Dr. Hauser administered a series of prolotherapy treatments and she became completely pain free. Three years later, she wrote Dr. Hauser to inform him that she was still free of pain and had traveled to Alaska, where she went mountain climbing and hiked to the top of a glacier field.

Degenerative muscle and joint complaints in particular seem to benefit from prolotherapy. James Carlson, D.O., an orthopaedic and sports medicine specialist in Knoxville, Tennessee, and past president of the American Association of orthopaedic Medicine, believes prolotherapy is the most effective treatment for Osgood-Schlatter disease, a tendon-insertion ailment that affects adolescents. "These kids have such severe pain in the knees, they can't participate in exercise, sports, or dance, and traditional medicine just dictates 'donot do anything athletic'," says Dr. Carlson. "Prolotherapy is the best thing I've ever seen." His own son, an aspiring baseball catcher, couldn't squat down or kneel. After therapy, he made the team as a catcher, and later, became a top school athlete.

Marc Darrow, M.D., co-director of the Joint Rehabilitation and Sports Medical Center, in Los Angeles, California, trains physicians in the use of prolotherapy at the University of California at Los Angeles Physical Medicine and Rehabilitation Residency Program. He became convinced its effectiveness after years of gymnastics, skiing, tennis, and golf left his left wrist "basically useless because of exquisite pain." After only one prolotherapy treatment, he reports that his wrist was 50% better and, after further injections, he was completely pain free and able to return to an active sports life.

"I have successfully used prolotherapy to treat almost every part of the musculoskeletal system, from head to toe," says Dr. Darrow, noting that his entire staff has benefited from prolotherapy treatments. "It's a shame that prolotherapy isn't taught in every medical school and residency program as a core curriculum. If it was mainstream, many of today's musculoskeletal surgeries could be avoided. " Dr. Darrow makes it a habit to carry prolotherapy supplies in his car. "The treatment is so simple, I can help people right at the tennis court," he says.

Prolotherapy and Trigger Point Therapy

While prolotherapy is little known among conventional medical practitioners, and not covered by most insurance companies, a treatment known as trigger point therapy is endorsed by many physicians and insurance companies. According to Marc Darrow, M.D., co-director of the Joint Rehabilitation and Sports Medical Center, trigger points are "hyperirritable, painful bundles of muscle fibers." When pressed, they can refer pain to other areas of the body, yet they can often be deactivated by injection of a solution such as lidocaine into the tender area, which is what trigger point therapy involves.

"In reality, when trigger or tender points are injected near tendons, ligaments, bones, or muscle fascia, prolotherapy is also being done at the same time," says Dr. Darrow. "Even without a proliferant solution being injected, there is trauma to tissue and a small amount of bleeding, and blood is one of the most effective proliferants of collagen. What is often found is that pain may be reduced or eliminated by one or two injections. Therefore, prolotherapy and trigger point therapy are often performed at the same time without the specific intention of the doctor." For this reason, Dr. Darrow feels that prolotherapy deserves the same degree of acceptance that trigger point therapy currently enjoys.

What to Expect from Prolotherapy

Prolotherapy is estimated to be significantly more cost-effective than surgery or joint replacement. Dr. Carlson notes that any pain or discomfort associated with receiving multiple injections is compensated for by the benefits received from prolotherapy. "Dramatic results should be noted by the patient within the first week of treatment," according to Kent Pomeroy, M.D., an Arizona physical medicine and rehabilitation specialist, and co-founder and past President of the American Association of orthopaedic Medicine. "But if swelling occurs, improvement may not be noticed until the swelling subsides. If marked improvement is not obtained after the first six treatments, then further examination is recommended to find out why the patient's body is failing to reconstruct tissue."

Prolotherapy is significantly more cost-effective than surgery or joint replacement.

Generally, a patient improves dramatically after the first four to six injections. According to Dr. Darrow, often two to four treatments are all that is necessary to bring joints back to full strength and function. However, the response time of the therapy varies from patient to patient, depending on each person's healing ability, and some patients may require as many as 12-30 treatments. Prior to beginning treatment, it is best to be evaluated by a physician trained in prolotherapy. Once treatment begins, the physician can then gauge your response and give you an accurate estimate of how many treatment sessions will be needed.

The benefits of prolotherapy over other methods of treatment include:

Eliminating the need for drugs or surgery
Stimulating the body's natural healing mechanism, causing natural re-growth of structural tissue
A low risk of side effects, when performed correctly
Permanent results when full treatment course is completed
Research into the effectiveness of prolotherapy is needed. This type of therapy could provide a revolution in orthopaedic medicine by offering rejuvenation rather than surgery, which actually damages and removes tissue.

The Future of Prolotherapy

Although prolotherapy has been used to treat a wide range of musculoskeletal conditions for over 50 years, its practice has not become widespread in the United States. In recent years, however, according to Dr. Faber, the number of practitioners has been growing and currently approximately 400 physicians practice prolotherapy. "One major reason for the slow growth of prolotherapy may be the fact that the substances used in prolotherapy are not patented and therefore would not provide the huge profits that pharmaceutical therapies receive," suggests Dr. Faber. "Prolotherapy also requires specialized training, and a serious commitment on the part of the physician to master the procedure."

Prolotherapy can play an important role in the medicine of the future. It may well be the first nondrug, nonsurgical approach to long-lasting musculoskeletal problems, resulting in a much-needed change from the current medical treatment, which involves orthopaedics, surgery, physical medicine, and physical therapy. Besides being less expensive and less risky than surgery, prolotherapy is more effective in the treatment of pain, aids in the prevention of future injuries, and has a lasting effect on energy and endurance.

"The initial turning point will be the discovery of prolotherapy by professional athletes," Dr. Faber believes. "Although prolotherapy is well-documented in science and through the case histories of thousands of successful patients, the recovery of a single famous athlete by prolotherapy is what's needed to bring the therapy into the spotlight it so richly deserves."

Such a discovery is already happening, according to Dr. Darrow, who has healed many notable athletes and entertainers using prolotherapy. Among them is Johnny Morton, Jr., a wide receiver on the Detroit Lions football team. "Johnny suffered from both a painful sprain where the gluteus muscle attaches to the pelvis and a badly sprained thumb joint from getting clipped during games," Dr. Darrow says. "After only two prolotherapy sessions on each site, he played his first pain-free season in ten years, and is now referring other athletes to me for care."

 

Where to Find Help

Physicians can vary greatly in knowledge, skills, and experience in the performance of the art and science of prolotherapy. Further information, contact the following organizations.

Milwaukee Pain Clinic
6529 West Fond du Lac Avenue
Milwaukee, Wisconsin 53218
(414) 464-7246
www.milwaukeepainclinic.com

Directed by Dr. Faber, the clinic provides prolotherapy and other musculoskeletal therapies; training courses in prolotherapy are also available. For additional information, send a legal size, self-addressed, stamped envelope.

Joint Rehabilitation and Sports Medical Center
11645 Wilshire Blvd., Suite 120
Los Angeles 90025
(310) 277-4800
www.jointrehab.com
Contact us.

Overseen by medical director Marc Darrow, M.D., the center specializes in state-of-the-art treatment for joint and muscle pain, back and neck pain, and sports injuries, and provides prolotherapy, chiropractic, exercise physiology, and sophisticated computerized exercise equipment, among other treatment protocols.

American College of Osteopathic Pain Management and Sclerotherapy
5002 East Woodmill Drive
Wilmington, DE 19808
(800) 476-6114

A leading organization for the training and promotion of prolotherapy in the United States.

American Association of Orthopaedic Medicine
30897 C.R. 356-3
P.O. Box 4997
Buena Vista, Colorado 81211
(800) 992-2063
Fax: (719) 395-5615
www.aaomed.org
Email

The American Association of orthopaedic Medicine is a nonprofit organization that provides information and educational programs on various methods of diagnosing and treating musculoskeletal injuries, including manipulation, prolotherapy, neural therapy, acupuncture, nutrition, and hormonal therapies.

Recommended Reading

Pain, Pain Go Away. William J. Faber and Morton Walker. San Jose, CA: Ishi Press International, 1990.

Prolo Your Arthritis Pain Away! Curing Disabling and Disfiguring Arthritis Pain with Prolotherapy. Ross A. Hauser, M.D., and Marion A. Hauser, M.S., R.D. Oak Park, IL: Beulah Land Press, 2000.

Prolo Your Headaches and Neck Pain Away! Curing Migraines and Chronic Neck Pain with Prolotherapy. Ross A. Hauser, M.D., and Marion A. Hauser, M.S., R.D. Oak Park, IL: Beulah Land Press, 2000.

Prolo Your Pain Away! Curing Chronic Pain with Prolotherapy. Ross A. Hauser, M.D., with Marion A. Hauser, M.S., R.D., and Kurt Pottinger. Oak Park, IL: Beulah Land Press, 1998.

Prolo Your Sports Injuries Away: Curing Sports Injuries and Enhancing Athletic Performance with Prolotherapy. Ross Hauser, M.D., and Marion A. Hauser, R.D. Oak Park, IL: Beulah Land Press, 2000.

(1) Hackett, G. Ligament and Tendon Relaxation (skeletal disability) Treated by Prolotherapy (fibro-osseus proliferation). 3d ed. Springfield, IL: Charles C. Thomas, 1958.

(2) Maynard, J.; et al. "Morphological and Biochemical Effects of Sodium Morrhuate on Tendons." Journal of Orthopaedic Research 3 no. 2 (1985): 236-248.

(3) Ongley, M. J.; et al. "A New Approach to the Treatment of Chronic Low Back Pain." Lancet 2 no. 8551 (Jul 18, 1987): 143-146.

(4) Klein, R. G.; et al. "A Randomized Double-Blind Trial of Dextrose-Glycerine-Phenol Injections for Chronic, Low Back Pain." Journal of Spinal Disorders 6 no. 1 (Feb, 1993): 23-33.

(5) Liu, Y. K.; et al. "An In Situ Study of the Influence of a Sclerosing Solution in Rabbit Medial Collateral Ligaments and Its Junction Strength." Connective Tissue Research, 11 nos. 2 and 3 (1983): 95-102.

(6) Reeves, K. D.; Hassanein, K. "Randomized prospective double-blind placebo-controlled study of dextrose Prolotherapy for knee osteoarthritis with or without ACL laxity." Alternative Therapy Health Medicine 6, no 2 (2000): 37-46.

(7) Reeves, K.D.; Hassanein, K. "Randomized prospective placebo controlled double blind study of dextrose Prolotherapy for osteoarthritic thumbs and finger (DIP, PIP and Trapeziometacarpal) joints: Evidence of clinical Efficacy." Journal of Alternative and Complementary Medicine 6, no. 4 (2000): 311-320.

(8) Fletcher, D.F. "Regaining the Ability to Heal," Alternative Medicine 35 (May, 2000): 67.