THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 8 - AUGUST 2021
Are Your Patients Asking About Prolotherapy?
Prolotherapy, considered an alternative therapy, is quietly establishing itself in mainstream sports medicine practice because of its almost irresistible draw for both physicians and patients: nonsurgical treatment for musculoskeletal conditions.
One source estimates that as many as 450,000 Americans have undergone prolotherapy (1). And some of the patients reporting benefits from prolotherapy are physicians themselves.
What Is Prolotherapy?
The word "prolotherapy" (also called sclerosant therapy) stems from "proliferative injection therapy," whereby practitioners inject a substance that stimulates proliferation, such as a dextrose-phenol combination, into ligaments and tendons. Treatments are intended to cause an influx of fibroblasts that synthesize collagen, along with new ligament and tendon tissue, at the injection site.
The American Association of Orthopaedic Medicine (AAOM), based in Colorado Springs, offers physicians workshops on how to perform prolotherapy as well as other alternative methods of treating pain. According to the AAOM Web site (https://www.aaomed.org), about 400 to 500 physicians are qualified to perform prolotherapy.
Similar techniques date back to the time of Hippocrates. Though the modern form of prolotherapy has been in use since 1939, few studies demonstrate its clinical efficacy (2).
Physicians who use prolotherapy point to anecdotal evidence of its effectiveness. Patients and physicians have repeatedly asked the Health Care Financing Administration (HCFA) to provide Medicare coverage for the injections (1). In 1997, Irwin Abraham, MD, an internist and sports medicine physician from Rochester, New York, appealed HCFA's policy on behalf of a Medicare beneficiary who sought prolotherapy coverage for chronic back pain. In issuing its coverage denial in September 1999 (2), HCFA noted two main flaws in studies that found a beneficial effect (3,4): The number of participants was small, and the studies lacked objective measures that clearly connect the benefits to prolotherapy.
A recent study (5), not included in the HCFA review, of 74 patients with chronic low-back pain found that three weekly prolotherapy injections alone did not reduce pain. However, a recent randomized, prospective, double-blind, placebo-controlled study (6) of prolotherapy for knee osteoarthritis, also not included in the HCFA review, showed promise. In this study, researchers found that knees treated with prolotherapy had significantly less pain, swelling, and buckling. Blinded radiographic readings suggested improvement in osteoarthritis severity. Eight of 13 knees noted to have anterior cruciate ligament laxity were no longer lax after 1 year.
Warren Scott, MD, a sports medicine physician in private practice in Soquel, California, has performed hundreds of prolotherapy injections over the past 4 years and has also undergone treatments for back problems. He says momentum for prolotherapy treatment is building because patients read about alternative medicine on the Internet and are eager to try new therapies. "And physicians are always looking for something new to help patients," Scott says.
Physicians should be very cautious when considering administering prolotherapy treatments, Scott says, adding that permanent nerve damage is one of the biggest concerns. "You have to be a good injector, and you have to take your time" he says. Scott has permanent nerve damage in his arm from a prolotherapy injection and suffered a 6-day headache and leaky spinal fluid when a practitioner mistakenly punctured his lumbar spinal canal during a treatment for back pain.
Despite the personal suffering, Scott strongly believes in prolotherapy's benefits. He says he has a theory about why few research reports have been published on the treatments. "Prolotherapy is a nonproprietary mix of sugar and alcohol," he says. "No drug company owns it, so almost no research has been done." Mark Timmerman, MD, chair of the department of sports medicine at the Dean Clinic in Madison, Wisconsin, where he performs prolotherapy on about 3 of every 14 patients, has another view of why little research exists on treatment efficacy. "Prolotherapy represents a very practical approach," he says. "Those of us who are using 'prolo' have busy clinic practices and don't have time to apply for grants and conduct research." However, he says better and more research would enable wider acceptance of the therapy.
No guidelines exist for prolotherapy, and treatment protocols vary by physician. Some find prolotherapy useful only for certain conditions, some use it as first-line therapy, and others reserve it for chronic conditions that have not improved with traditional treatments.
Scott says he has found prolotherapy useful for tennis elbow, golfer's elbow, insertional Achilles tendinitis, patellar tendinitis, spine problems (cervical, thoracic, and lumbosacral), and sacroiliac problems. He's treated patients of all activity levels, from ages 25 to 80. "I have very few patients anymore who undergo back surgery," he says.
Patients often require more than one injection. Patients who have tennis elbow, for example, typically need four to six injections 2 weeks apart.
Timmerman says he reserves prolotherapy for situations when patients' ligaments or tendons are "devitalized." He says that though he's never had a patient's condition worsen after prolotherapy, certain conditions seem to respond particularly well, such as recurrent ankle sprains, sacroiliac instability, and costochondritis.
Prolotherapy treatments require intensive patient counseling, Scott says. The injection site is usually swollen and painful for 2 or 3 days after the injection. Patients can take acetaminophen or hydrocodone bitartrate plus acetaminophen for pain, but—because inflammation is part of the healing process—not anti-inflammatory medications. He advises patients to ice the area three to five times a day for 20 minutes at a time as needed.
The pain patients experience is an intense stiffness, Scott says. "The stiffness is ameliorated by exercise, which helps to create a mechanical stimulus to build collagen at a very fast rate," he says.
Timmerman says patients who are willing to continue aggressive physical therapy have the best prognosis after prolotherapy treatment. "Doing something as radical as prolotherapy may stimulate patients' motivation to work hard," he says, adding that some physicians believe prolotherapy may have a placebo effect. "I'm open to that thought," he says.
Patients are charged for an office visit and a joint injection. Scott says workers' compensation generally covers prolotherapy treatments; however, insurance coverage varies.
Katherine L. Dec, MD, a physiatrist working in a private sports medicine practice in Richmond, Virginia, says she is skeptical about referring patients for prolotherapy. "I haven't seen the scientific research," she says. "I think patients should understand what treatment involves, outcome expected, and cost. It is not typically covered by insurance here," she says. Dec adds that, as a former student of traditional Chinese medicine and as medical director for the Mind Body Medical Institute in Richmond, she is open to alternative options for patients, as long as the treatments are not harmful. "So I'm not so skeptical that I would discourage a patient from receiving prolotherapy treatments," she says.
Jerry Ryan, MD, a family practice physician at the University of Wisconsin, Madison, says he was skeptical about the merits of prolotherapy until he volunteered to be a guinea pig at a demonstration for residents by Jeff Patterson, DO, a faculty member who has been performing prolotherapy for about 20 years. "My chronic back problem had become so severe that I figured I had nothing to lose," he says.
"I know that I'm an 'N' of one and I do not like to base any therapeutic decisions on anecdotal evidence, but I must admit that after the injections I obtained my first relief in months," Ryan says. "I think, just as [with] any other treatment for soft-tissue problems, there are successes and failures. But I do think prolotherapy is a viable alternative to consider."
Medical Coverage of Wimbledon
It's easy to see why covering Wimbledon would be a dream assignment for any sports medicine physician. The tournament's aristocratic traditions and finely manicured grass courts are as famous as its all-star competitor roster. Mark Batt, MB, BChir, an editorial board member of The Physician and Sportsmedicine, served on the Wimbledon medical team for the first time this year. "Do you have a title yet for your article?" he asked during a phone interview, punctuated by player walk-in appointments. "How about 'Sweat and Strawberries?'"
Tournament organizers advertised nationally for sports medicine physicians to cover the event, an approach that is good for sports medicine, Batt says. "It's an open competition, not based on an old boys' club or nepotism, which reflects well on the All England Lawn Tennis and Croquet Club." Other members of this year's medical team included Philip Bell, MB, Nick Webborn, MB, and medical director Peter Tudor-Miles, MB. Assisting the medical team are large staffs of physical therapists, athletic trainers, and massage therapists who work with the men's and women's tours. Athletic trainers travel with the tours and provide consistent care. Spectator care is delivered at six first aid posts staffed by the St John Ambulance Brigade. "Wimbledon is steeped in history, but very contemporary. It's a privilege to be here," says Batt, who is a consultant and senior lecturer in sports and exercise medicine at Queens Medical Center in Nottingham, United Kingdom.
Familiarity with grass courts is crucial for Wimbledon medical staff because the surface creates a unique injury profile compared with other tennis surfaces. Batt had previously covered the Nottingham Open, a precursor to Wimbledon, which is also played on grass courts. Though he says playing on grass is kinder to the joints, it is typically damper than other tennis surfaces and can contribute to slips and falls. "The ball bounces faster and lower," Batt says. "Players react with different techniques. They have to get down lower, and that can be hard on the back, gluteal, and hamstring muscles."
Most injuries encountered by the medical team are typical of those to elite tennis players, such as overuse injuries of the shoulder, elbow, and wrist. Patellar tendinosis is common, Batt says, as are foot and ankle complaints. Players usually arrive at the sports medicine office—located within the Centre Court complex and just a short underground tunnel walk from the nearby number 1 court—with a specific complaint and escorted by a trainer from their respective tours. A factor that can complicate injury management is timing treatments based on a player's next match, he says. Match duration varies depending on match length and player success.
Are there some practice pearls that will help Batt in his regular sports medicine practice? "It's too soon to tell," he says, then pauses. "But if there's a concern we all share, it's the number of hours the junior players put in. We can all see the attrition on them." (See "AAP Advises Against Early Sports Specialization," below.)
AAP Advises Against Early Sports Specialization
Though many anecdotal reports describe adverse consequences from intense training and competition, the AAP statement notes that more research is needed to determine the cardiac effects of elite training on children and the long-term effects of repetitive microtrauma on the epiphyses. However, they state that research supports their stance against early sports specialization. "Those who participate in a variety of sports and specialize only after reaching the age of puberty tend to be more consistent performers, have fewer injuries, and adhere to sports play longer than those who specialize early," the report states.
The AAP acknowledges that the increasing competitiveness of sports demands that athletes train longer, harder, smarter, and younger. The group recommends that physicians be a safety net for active children who seek to meet these demands. Besides advising against early specialization, the AAP recommends that physicians:
AAP Offers Heat Stress Recommendations
In the statement, the AAP outlines why children do not adapt to high temperatures as effectively as adults. Children's greater surface-area-to-body-mass ratio contributes to greater heat gains on hot days; children produce more metabolic heat during walking or running; and sweating capacity is lower.
The AAP's recommendations address four major areas.
Outdoor temperature. The intensity of activities that last 15 minutes or more should be reduced whenever wet bulb globe temperature (WBGT) reaches critical levels: less than 75°F WBGT, activity allowed, but be alert for heat illness prodromes during prolonged events; 75°F to 78.6°F, longer rest periods in the shade, and enforce drinking every 15 minutes; 79°F to 84°F, stop activity of unacclimatized and other high-risk persons and limit activities of all others; above 85°F, cancel all athletic activities.
Acclimatization. At the start of a strenuous activity program or upon travel to a warmer climate, allow 10 to 14 days of acclimatization. If this is not practical, curtail the lengths of practice and competition.
Hydration. Ensure adequate hydration before activity and enforce regular drinking breaks (eg, cold tap water or flavored, salted beverage every 20 minutes).
Clothing. One layer of light-colored and lightweight fabric should be worn. Sweat-saturated clothes should be replaced by dry clothing. Rubberized suits should never be worn.
Musculoskeletal Conditions by the Numbers
Other notable findings are that musculoskeletal conditions are responsible for:
The AAOS released its report during the launch of its Bone and Joint Decade activities. Proclaimed by the United Nations, the World Health Organization, and 22 countries, the Bone and Joint Decade—2021 through 2010—is designed to raise awareness and stimulate research in musculoskeletal health.