Effectiveness of prolotherapy in the treatment of chronic rotator cuff lesions

Efficacy of hypertonic dextrose proliferation therapy in the treatment of rotator cuff lesions: a meta-analysis

BACKGROUND

One of the most prevalent illnesses of the shoulder is rotator cuff tendinosis, which is also a major contributor to shoulder discomfort and shoulder joint dysfunction. According to statistics, rotator cuff tendinosis occurs in 0.3-5.5% of cases and affects 0.5-7.4% of people annually. It will be necessary to conduct a meta-analysis to evaluate the efficacy of hypertonic glucose proliferation therapy in the treatment of rotator cuff problems.

METHODS

The databases Cochrane PubMed, Library, Web of Science and EMbase, are retrieved by the computer. Individuals with rotator cuff lesions in the intervention group were treated with hypertonic dextrose proliferation therapy, whereas individuals in the control condition were treated with a placebo. Outcome markers for rotator cuff lesions patients; Pursuant to studies, the visual analogue scale (VAS) score, the shoulder pain & disability index (SPADI), & other metrics are used to evaluate the effects of hypertonic dextrose proliferation treatment on individuals with rotator cuff diseases. After carefully evaluating the calibre of the literature, data analysis was performed utilising the RevMan 5.3 programme.

RESULTS

Meta-analysis finally contained 6 papers. In six investigations, the test & control group's VAS scores improved, with the test team's score considerably outperforming the control team [standardized mean difference (SMD): 1.10; 95% Cl: 0.37,1.83; P < 0.01], shoulder pain and disability index (SPADI) score (SMD:8.13; 95% Cl: 5.34,10.91; P < 0.01), Flexion (SMD:5.73; 95% Cl: 0.99,10.47; P < 0.05), Abduction (SMD:6.49; 95% Cl: 0.66,12.31; P < 0.05), Internal rotation (SMD:-1.74; 95% Cl: -4.25,0.78; P = 0.176) and External rotation (SMD:2.78; 95% Cl: -0.13,5.69; P = 0.062).

CONCLUSION

The findings of this study suggest that individuals with rotator cuff injuries may benefit from hypertonic dextrose proliferation treatment based on the visual analogue scale (VAS) score, the Shoulder Pain and Disability Index (SPADI) score, Flexion, & Abduction. These results must, nevertheless, be supported by high-caliber follow-up research.

Health Care Utilization for Common Shoulder Disorders: Analysis of the 2010-2019 National Patient Sample Data from the Health Insurance Review and Assessment Service in Korea

Background and Objective: The aim of this study was to analyze trends in surgical and non-surgical service utilization for common shoulder disorders in Korea from 2010 to 2019. Methods and Materials: This retrospective, cross-sectional, descriptive study utilized National Patient Sample data from the Health Insurance and Review Assessment Service (HIRA) of Korea. These data constitute a 2% sample out of the entire Korean population and include data for a variety of parameters instrumental for health care research. Patients with at least one medical service use for rotator cuff syndrome or tear, impingement syndrome, or adhesive capsulitis between January 2010 and December 2019 were included. Trends in healthcare utilization by disorder type, patient demographics, seasonal service use, and treatment details were examined. Results: There was an upward trend in the total number of patients and costs for shoulder disorders, from 35,798 patients and USD 5,485,196 in 2010 to 42,558 and USD 11,522,543 in 2019, respectively. The number of patients aged ≥60 and hospital visits increased. March had the highest number of claims. Physical therapy was the most common non-surgical procedure, while nerve block claims more than doubled. Opioid prescription rates also tripled. Surgical treatments were dominated by shoulder rotator cuff repair and acromioplasty. Conclusions: There was a significant increase in healthcare utilization for shoulder disorders, marked by rising costs and patient numbers. The use of nerve blocks and opioids notably increased. These data are valuable for clinicians, researchers, and policymakers.

Shoulder specific exercise therapy is effective in reducing chronic shoulder pain: A network meta-analysis

BACKGROUND

Exercise therapy (ET) is frequently an early treatment of choice when managing shoulder pain, yet evidence on its efficacy to expedite recovery is inconsistent. Moreover, the value of adding adjunct therapies (i.e. injections, manual therapy, electrotherapy) to ET is currently unclear. This study combined both direct and indirect evidence across studies on the effectiveness of ET with/without adjunct therapies compared to usual medical care for adults with chronic shoulder pain.

METHODS AND FINDINGS

Using a network meta-analysis, randomized control trials comparing ET along with adjunct therapies were identified in MEDLINE, Embase, CINAHL, Sportdiscus, CENTRAL, Conference Proceedings Citation Index-Science, clinicaltrials.gov, and association websites. Outcomes included pain, range of motion (ROM), and health-related quality of life (HRQL) measures in adult patients with chronic shoulder pain. Data analysis used a Frequentist hierarchical model. CINeMA tool assessed the confidence in the results and Cochrane Risk of Bias tool assessed quality of studies. 54 studies primarily from Europe (40.38%) included 3,893 participants who were followed up to 52 weeks. Shoulder-specific ET (Mean difference (MD) = -2.1; 95% confidence interval (CI) = -3.5 to -0.7) or in combination with electro-physical agents (MD = -2.5; 95% CI = -4.2 to -0.7), injections (MD = -2.4; 95% CI = -3.9 to-1.04) or manual therapy (MD = -2.3; 95% CI = -3.7 to -0.8) decreased pain compared to usual medical care. Trends with ROM and HRQL scores were seen; however, only Manual Therapy (MD = -12.7 and 95% CI = -24.4 to -1.0) achieved meaningfully important changes. Sensitivity analysis excluding studies with high risk of bias showed similar results, with exception of injections that did not reach significance (MD = -1.3; 95% CI = -4.3 to 1.7).

CONCLUSION(S)

Shoulder-specific ET provided pain relief up to 52 weeks. Adjunct therapies to shoulder-specific ET added little value in reducing pain. The quality of evidence varied between moderate and very low.

A scoping review and best evidence synthesis for treatment of partial-thickness rotator cuff tears

BACKGROUND

Rotator cuff disorders include a broad spectrum of pathological conditions including partial-thickness and full-thickness tears. Studies have shown partial-thickness rotator cuff tear (PTRCT) prevalence to be twice that of full-thickness tears. In the working population, PTRCTs are one of the most common causes of shoulder pain and often result in occupational disability due to pain, stiffness, and loss of shoulder function. Treatment of PTRCTs remains controversial. The purpose of this study was to consolidate the existing high-quality evidence on best management approaches in treating PTRCTs using both nonoperative and operative approaches.

METHODS

A scoping review with best evidence synthesis was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. MEDLINE (OVID), EMBASE (OVID), Cochrane Library (Wiley), SCOPUS, Web of Science Core Collection, CINAHL Plus with Full Text (EBSCOhost), PubMed Central, and Science Direct were searched from 2000 to March 3, 2023. Level 1 studies, and systematic reviews and meta-analyses that included level 1 and 2 studies, were included.

RESULTS

The search yielded 8276 articles. A total of 3930 articles were screened after removing 4346 duplicates. Application of inclusion criteria resulted in 662 articles that were selected for full-text review. Twenty-eight level 1 studies, 1 systematic review, 4 meta-analyses, and 1 network meta-analyses were included in the best evidence synthesis. Nonoperative strategies included injections (ie, platelet-rich plasma, corticosteroid, prolotherapy, sodium hyaluronate, anesthetic, and atelocollagen), exercise therapy, and physical agents. Operative interventions consisted of débridement, shaving of the tendon and footprint, transtendon repair, and traditional suture anchor repair techniques with and without tear completion. Both nonoperative and operative strategies demonstrated effectiveness at managing pain and functional outcome for PTRCTs. The evidence supports the effectiveness of surgical intervention in treating PTRCTs regardless of arthroscopic technique.

CONCLUSION

The results of this scoping review do not support superiority of operative over nonoperative management and suggest that both strategies can be effective at managing pain and functional outcome for PTRCTs. Surgery, however, is the most invasive and costly approach, with the highest risk of complications such as infection. Other variables such as patient expectation, treating practitioner bias, or preference may change which modalities are offered and in what sequence.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Comparison Clinical Effects of Hypertonic Dextrose and Steroid Injections on Chronic Subacromial Bursitis: A Double-Blind Randomized Controlled Trial

OBJECTIVE

The aim of the study is to determine and compare the treatment efficacy of subacromial steroid injections and dextrose prolotherapy for chronic subacromial bursitis patients.

DESIGN

Fifty-four patients with chronic subacromial bursitis were enrolled in this double-blind randomized controlled trial. Shoulder Pain and Disability Index and visual analog scale were the primary outcomes.

RESULTS

The steroid group ( n = 26) exhibited significant visual analog scale score improvements comparing with baseline at weeks 2, 6, and 12; the dextrose prolotherapy group ( n = 28) exhibited visual analog scale score improvements at weeks 6 and 12. The steroid group displayed significant Shoulder Pain and Disability Index score improvements compared with baseline at weeks 2, 6, and 12; the dextrose prolotherapy group exhibited significant score decreases at weeks 2 and 6. Compared with the dextrose prolotherapy group, the steroid group demonstrated significantly greater decreases in visual analog scale scores at weeks 2 and 6; the steroid group showed significantly greater decreases in Shoulder Pain and Disability Index scores at weeks 2, 6, and 12.

CONCLUSIONS

Both hypertonic dextrose prolotherapy and steroid injections can provide short-term improvements of pain and disability among chronic subacromial bursitis patients. Moreover, steroid injections showed better effectiveness than hypertonic dextrose prolotherapy in ameliorating pain and improving function.

Tendon injections - upper extremity

Imaging-guided tendon procedures aim to reduce pain and increase function by controlling inflammation and stimulating healing. Ultrasound is the preferable guiding modality due to its high resolution and real-time demonstration of the tendinous anatomy and needle positioning. The technique includes appropriate patient positioning, which varies depending on the targeted tendon, as well as sterile and proper draping. For most procedures, we prefer the "in-plane" approach, which demonstrates the entire needle as it advances through different tissue layers. Upper limb injections commonly use corticosteroids and anesthetics with different reported short- and long-term results depending on the tendon treated; better results are obtained in the treatment of tenosynovitis (sliding tendons such as trigger finger and De Quervain's tenosynovitis). Shoulder and elbow tendinopathies (anchor tendons) may also benefit from injections containing irritants or healing stimulants such as dextrose (prolotherapy) and platelet-rich plasma or by the stimulation of healing via tendon perforations (fenestration). The hyaluronic acid injection has also been used in the treatment of both tenosynovitis and tendinopathies. For tendons passing through osteofibrous tunnels, an additional release may be performed, and the techniques are discussed in this review. Therefore, this article provides practicing musculoskeletal radiologists and trainees with a comprehensive review of tendon injection musculoskeletal image-guided procedures.

Comparison of Dextrose Prolotherapy and Triamcinolone Intraarticular Injection on Pain and Function in Patients with Knee Osteoarthritis - A Randomized Clinical Trial

Background

The present study was performed to assess the therapeutic effects of combined intra and extraarticular dextrose prolotherapy on knee osteoarthritis and its comparison with intra- articular triamcinolone injection.

Methods

In this study, 50 patients suffering from knee osteoarthritis were allocated into two groups as a double-blind randomized clinical trial. The first group received one session of dextrose prolotherapy as one intra-articular injection of 10cc dextrose 16% and periarticular intradermal injections of dextrose 12% at 4 points around the knee (2.5 cc at each point). The second group underwent therapy with one intra-articular injection of triamcinolone (40 mg).

Results

Compared to pretreatment, both interventions caused significant improvement in pain (evaluated by VAS) and WOMAC (all its components) in 1 and 3 months postintervention (all with P-value < 0.005). In the first month, pain reduction was significantly better in corticosteroid group (P-Value 0.002 and 0.048 respectively). In third month post intervention, improvements in VAS and WOMAC components were significantly greater in prolotherapy group.

Conclusions

Both methods of corticosteroid and dextrose prolotherapy (combined intra and extraarticular technique) are effective on pain and function of patients with knee osteoarthritis. Compared to corticosteroid, prolotherapy method was associated with less pain reduction in short- term, but its effects were more persistent and in midterm examinations (3 months), it was more effective than corticosteroid.

A Case Series: Effect of Comorbidities on the Outcomes of Prolotherapy Injection for Frozen Shoulder Patients

Frozen shoulder (FS) is a disease caused by an inflammatory condition that causes severe pain and decreased range of motion by loss of glenohumeral mobility. Frozen Shoulder restricts daily life's functional aspect, increasing morbidity. Hypertension and diabetes mellitus are risk factors that make an FS poor prognosis during treatment because of the diabetes glycation process and hypertension-enhanced vascularization. Prolotherapy injects an irritant solution into the tendon, joints, ligaments, and joint spaces to release growth factors and collagen deposition, reducing pain, restoring joint stability, and increasing the quality of life. We report 3 cases of patients with confirmed FS. Patient A with no comorbidity, patient B with diabetes mellitus, and patient C with hypertension, with all patient's chief complaints of shoulder pain and limited ROM, and symptoms affected the general quality of daily life. This patient was provided injection with Prolotherapy treatment combined with physical therapy intervention. Patient A had significantly improved ROM to maximum after 6 weeks with relieved pain and improved shoulder function. Patients B and C showed increased ROM, still tiny, decreased pain, and improved shoulder function. In conclusion, prolotherapy demonstrated a beneficial effect in a patient with FS with comorbidities, although not to the maximum extent in patients without comorbidity.

Clinical efficacy of different shoulder joint drug injections for rotator cuff injuries: A network meta-analysis

BACKGROUND

Rotator cuff injury is a common clinical disorder of the musculoskeletal system. It is one of the most common causes of shoulder pain and shoulder joint dysfunction. Intra-articular injection therapy is one of the common conservative treatments for rotator cuff injury in clinical practice, but scholars have been controversial about the different drugs used for injection therapy and their clinical effectiveness, and there is no complete agreement on the choice of different injectables, and the existing original studies are mostly direct comparisons in 1 arm, lacking indirect comparisons, making it difficult to have a clear and comprehensive understanding.

OBJECTIVE

A network Meta-analysis was used to comprehensively compare the effectiveness of drug injection therapies for rotator cuff injuries.

METHODS

The PubMed, The Cochrane Library, EMbase, Chinese national knowledge infrastructure, Chinese BioMedical Literature on disc, China Science and Technology Journal Database, and Wan-Fang databases were searched for randomized controlled trials on the effectiveness of steroid injections for the comparative treatment of rotator cuff injury for the period April 19, 2013 to April 19, 2022 (the last decade). Two investigators independently screened the literature, extracted data according to inclusion and exclusion criteria, and evaluated the quality of the literature in parallel. Statistical analysis was performed using Stata 16.0 software to compare the differences in efficacy of each treatment measure and rank the efficacy using the ratio and 95% confidence interval (CI) as the effect indicator.

RESULTS

10 RCTs with a total of 861 patients with rotator cuff injury were included, involving 4 therapeutic measures: corticosteroid injection therapy (COR), platelet-rich plasma injection therapy (PRP), Hyaluronic acid injection therapy (HA), and prolotherapy therapy (PRO).Meta-analysis results showed that the ranking results of the 4 therapeutic measures were: corticosteroid injection + hyaluronic acid injection > platelet-rich plasma injection + corticosteroid injection > corticosteroid injection > platelet-rich plasma injection > PRO > platelet-rich plasma injection + hyaluronic acid injection > hyaluronic acid injection.

CONCLUSION

we recommend that corticosteroid injections combined with hyaluronic acid injections can be used for the non-surgical conservative clinical management of rotator cuff injuries.

Modified prolotherapy by 5% dextrose: Two years experiences of a traditional and complementary medicine practice center in Turkey

BACKGROUND

Prolotherapy (PrT) is an increasingly popular regenerative injection treatment for the management of musculoskeletal injuries. The diagnostic injection is a method for selecting suitable patients to apply PrT using subcutaneous 5% dextrose solution.

OBJECTIVE

The study aims to assess the PrT usage and modifications in the treatment of chronic low back pain and lumbar disc herniation and to define diagnostic injection procedure for PrT.

METHOD

Two thousand three hundred and eighty-two patients with low back pain or lumbar disc herniation were evaluated at the Traditional and Complementary Medicine Practice Center in Ankara, Turkey. Six hundred fifty-four patients were included in the study. Diagnostic injections were performed on all patients who were thought to be eligible candidates for PrT indications. A 4-or-6 week interval was allowed between treatment sessions.

RESULTS

Xix hundred and fifty-four patient treatments were completed. The Visual Analogue Scale (VAS) scores decreased to 5.1 ± 1.4 while 7.2 ± 1.1 before the diagnostic injection (p< 000.1). The VAS scores decreased from 7.2 ± 1.1 before the treatment to 0.9 ± 0.9 after 52 weeks of the treatment (p< 000.1). Thirty-four patients' treatments resulted in poor clinical results (5.2%), and 620 of the patients' pain improved (94.8%).

CONCLUSION

PrT can be regarded as a safe way of providing a meaningful improvement in pain and musculoskeletal function compared to the initial status. Diagnostic injection is an easy way to eliminate patients and may become a favorite treatment modality. 5% dextrose is a more simple and painless solution for PrT and also has a high success.

Use of Behavior Change Techniques Alongside Exercise in the Management of Rotator Cuff-Related Shoulder Pain: A Scoping Review

OBJECTIVES

The aims of this scoping review were to: (1) determine the frequency and types of behavior change techniques (BCTs) and education utilized in trials investigating exercise interventions for rotator cuff related shoulder pain (RCRSP); (2) subcategorize the BCTs and education found in the trials to summarize all behavior change approaches reported by trials; and (3) compare the frequency, types, and subcategories of BCTs and education utilized in the clinical guidelines for managing RCRSP between the trials.

METHODS

Data sources included Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE, CINAHL Plus, Google Scholar and PubMed, which were searched from inception to June 2020. Trials assessing exercise interventions for RCRSP were included. Three authors independently determined eligibility and extracted data. The frequency and types of BCTs and education in the trials and clinical practice guidelines were reported and compared descriptively. Two authors assessed the content of the BCTs to develop subcategories.

RESULTS

Most trials reported including at least 1 type of BCT (89.2%), which was most commonly feedback and monitoring (78.5%). There were many different approaches to the BCTs and education; for example, feedback and monitoring was subcategorized into supervised exercise, exercise monitoring, and feedback through external aids, such as mirrors. Clinical guidelines recommend supervision, goal setting, activity modification, pain management recommendations, information about the condition, and exercise education.

CONCLUSION

Although over two-thirds of trials reported including a BCT alongside exercise interventions for RCRSP, the breadth of these interventions is limited (supervision is the only common one). Future trialists should consider using any type of BCT that may improve exercise adherence and outcomes.

IMPACT

The findings of this review have: (1) identified gaps in the literature; and (2) contributed to the design of future exercise interventions for RCRSP.

A Review of Laser Therapy and Low-Intensity Ultrasound for Chronic Pain States

PURPOSE OF REVIEW

Chronic pain management therapies have expanded quickly over the past decade. In particular, the use of laser therapy and ultrasound in the management of chronic pain has risen in recent years. Understanding the uses of these types of therapies can better equip chronic pain specialists for managing complicated chronic pain syndromes. The purpose of this review was to summarize the current literature regarding laser radiation and ultrasound therapy used for managing chronic pain syndromes.

RECENT FINDINGS

In summary, there is stronger evidence supporting the usage of laser therapy for managing chronic pain states compared to low-intensity ultrasound therapies. As a monotherapy, laser therapy has proven to be beneficial in managing chronic pain in patients with a variety of pain syndromes. On the other hand, LIUS has less clear benefits as a monotherapy with an uncertain, optimal delivery method established. Both laser therapy and low-intensity ultrasound have proven beneficial in managing various pain syndromes and can be effective interventions, in particular, when utilized in combination therapy.

Effect of Hypertonic Dextrose Injection on Pain and Shoulder Disability in Patients with Chronic Supraspinatus Tendinosis: A Randomized Double-Blind Controlled Study

OBJECTIVES

To investigate the effect of hypertonic dextrose injection on pain and disability in patients with chronic supraspinatus tendinosis. The secondary aim was to evaluate its effect on the tendon range of motion (ROM) and morphology.

DESIGN

Randomized double-blind placebo-controlled trial.

SETTING

Outpatient clinic.

PARTICIPANTS

Individuals (N=57) with symptomatic chronic supraspinatus tendinosis.

INTERVENTIONS

Participants were randomly administered ultrasound-guided injections of 20% hypertonic dextrose (study group, n=29) or 5% normal saline (control group, n=28).

MAIN OUTCOME MEASURES

The primary outcome measure was visual analog scale (VAS) scores for pain and Shoulder Pain and Disability Index (SPADI) scores. Secondary outcomes included the ROM and ultrasound examination findings of the supraspinatus tendon at baseline and at 2, 6, and 12 weeks postintervention.

RESULTS

The study group exhibited significant improvements in the VAS (mean difference [MD], -2.1; 95% confidence interval [CI], -2.7 to -1.4; P<.001) and SPADI (MD, -11.6; 95% CI, -16.5 to -6.7; P<.001) scores compared with baseline scores at week 2. However, the effect was not sustained to week 6. Flexion ROM increased at weeks 2 (MD, 14.1; 95% CI, 5.7-22.5; P<.001) and 6 (MD, 8.9; 95% CI, 2.4-15.4; P=.003) compared with baseline. The thickness of the supraspinatus tendon improved at weeks 6 (MD, .50; 95% CI, .26-.74; P<.001) and 12 (MD, .61; 95% CI, .37-.84; P<.001) compared with baseline. The ratio of histograms also improved at weeks 6 (MD, .19; 95% CI, .06-.32; P=.002) and 12 (MD, .26; 95% CI, .10-.41; P<.001) compared with baseline.

CONCLUSION

Hypertonic dextrose injection could provide short-term pain and disability relief in patients with chronic supraspinatus tendinosis. Ultrasound imaging at week 6 revealed changed tendon morphology.

A Historical Analysis of Randomized Controlled Trials in the Management of Pain in Rotator Cuff Tears

The aim of this analysis was to assess the quality of reporting of randomized controlled trials (RCTs) relating to pain management in rotator cuff (RC) tears. This review evaluated the quality of the studies in the literature regarding this topic through the use of some factors and trends. The online databases used to search all RCTs on the topic of RC surgery were Medline, Scopus, CINAHL, EMBASE, and CENTRAL. This research was completed in September 2020. To assess the quality of reports, the Consolidated Standards of Reporting Trials (CONSORT) and the modified Coleman methodology score (MCMS) were used. From the research, 262 articles emerged. Finally, 79 studies were included in this historical analysis. There were no statistically significant changes in MCMS across trials that included or did not include a CONSORT diagram (p = 0.10). A statistically significant difference in MCMS was discovered between papers produced prior to 2009 and publications produced after 2015 (p = 0.03). There was no association between the number of checklist items for each article and the Coleman score. During the years there has been a significant increase in both quantity and quality of RCTs relating to pain in RC tears.

Periarticular Neurofascial Dextrose Prolotherapy Versus Physiotherapy for the Treatment of Chronic Rotator Cuff Tendinopathy: Randomized Clinical Trial

BACKGROUND/OBJECTIVE

Rotator cuff tendinopathy is a common cause of shoulder pain. We aimed to compare periarticular (neurofascial) dextrose prolotherapy versus physiotherapy for treatment of chronic rotator cuff tendinopathy in the short term.

METHODS

We carried out a randomized clinical trial with 2 arms at a university hospital. In total, 66 patients with chronic rotator cuff tendinopathy, proven by magnetic resonance imaging, were randomly allocated to 2 groups. The outcomes were change in shoulder pain intensity (primary) and disability (secondary) index using a questionnaire for Shoulder Pain and Disability Index. For physiotherapy, participants received superficial heat, transcutaneous electrical nerve stimulation, and pulsed ultrasound. Also, they carried out an exercise program, 10 sessions of 30 minutes for 3 weeks. For prolotherapy, we used 8 mL of 12.5% dextrose and 40 mg of 2% lidocaine. The mixture was injected 2 times with 1-week interval superficially around the shoulder joint and to tender points along the suprascapular nerve.

RESULTS

Neurofascial dextrose was more effective than physiotherapy for alleviating pain in 2 weeks (p < 0.001), and they were similar 3 months after the interventions (p = 0.055). For disability, dextrose was more effective than physiotherapy 2 weeks and 3 months (both p < 0.001) after the interventions. However, the changes in the physiotherapy group seemed to be more sustained.

CONCLUSIONS

Both interventions are effective for the short-term management of rotator cuff tendinopathy. However, prolotherapy is more successful as the initial treatment. Besides, the treatment time is much shorter for dextrose prolotherapy compared with physiotherapy.

Non-operative orthobiologic use for rotator cuff disorders and glenohumeral osteoarthritis: A systematic review

BACKGROUND

Shoulder pain from rotator cuff pathology and glenohumeral osteoarthritis is a common entity encountered in musculoskeletal practices. Orthobiologic agents are being increasingly used as a treatment option and understanding their safety and efficacy is necessary.

OBJECTIVE

To systematically evaluate the available evidence for orthobiologic use in rotator cuff and glenohumeral pathology.

METHODS

A systematic review was undertaken following PRISMA guidelines. Randomized clinical trials (RCTs) and prospective cohort studies evaluating non-operative treatment with prolotherapy, platelet-rich plasma (PRP), or medicinal signaling cells (MSCs) for rotator cuff pathology and glenohumeral osteoarthritis were included. Bias risk assessments used were the Cochrane tool and Newcastle-Ottawa score.

RESULTS

The search yielded 852 potential articles, of which 20 met the inclusion criteria with a breakdown of 5 prolotherapy, 13 PRP, and 2 MSC. Sixteen studies were RCTs and 4 were cohort studies. Six studies were deemed "low risk of bias or good quality". Efficacy results were mixed, and no serious adverse events were reported from orthobiologic treatment.

CONCLUSIONS

Orthobiologics offer a relatively safe management option with inconclusive evidence for or against its use for rotator cuff pathology. No studies on glenohumeral osteoarthritis met the inclusion criteria. Adoption of standardized preparation reporting and consistent use of functional outcome measures is imperative for future studies to consider.

Noninvasive management of soft tissue disorders of the shoulder: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration

OBJECTIVES

Objective of this study is to develop an evidence-based guideline for the noninvasive management of soft tissue disorders of the shoulder (shoulder pain), excluding major pathology.

METHODS

This guideline is based on high-quality evidence from seven systematic reviews. Multidisciplinary experts considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience is clinicians; target population is adults with shoulder pain.

RESULTS

When managing patients with shoulder pain, clinicians should (a) rule out major structural or other pathologies as the cause of shoulder pain and reassure patients about the benign and self-limited nature of most soft tissue shoulder pain; (b) develop a care plan in partnership with the patient; (c) for shoulder pain of any duration, consider low-level laser therapy; multimodal care (heat/cold, joint mobilization, and range of motion exercise); cervicothoracic spine manipulation and mobilization for shoulder pain when associated pain or restricted movement of the cervicothoracic spine; or thoracic spine manipulation; (d) for shoulder pain >3-month duration, consider stretching and/or strengthening exercises; laser acupuncture; or general physician care (information, advice, and pharmacological pain management if necessary); (e) for shoulder pain with calcific tendinitis on imaging, consider shock-wave therapy; (f) for shoulder pain of any duration, do not offer ultrasound; taping; interferential current therapy; diacutaneous fibrolysis; soft tissue massage; or cervicothoracic spine manipulation and mobilization as an adjunct to exercise (i.e., range of motion, strengthening and stretching exercise) for pain between the neck and the elbow at rest or during movement of the arm; (g) for shoulder pain >3-month duration, do not offer shock-wave therapy; and (h) should reassess the patient's status at each visit for worsening of symptoms or new physical, mental, or psychological symptoms, or satisfactory recovery.

CONCLUSIONS

Our evidence-based guideline provides recommendations for non-invasive management of shoulder pain. The impact of the guideline in clinical practice requires further evaluation.

SIGNIFICANCE

Shoulder pain of any duration can be effectively treated with laser therapy, multimodal care (i.e., heat/cold, joint mobilization, range of motion exercise), or cervicothoracic manipulation and mobilization. Shoulder pain (>3 months) can be effectively treated with exercises, laser acupuncture, or general physician care (information, advice, and pharmacological pain management if necessary).

Comparison of the Effectiveness of Ultrasound-Guided Prolotherapy in Supraspinatus Tendon with Ultrasound-Guided Corticosteroid Injection of Subacromial Subdeltoid Bursa in Rotator Cuff-Related Shoulder Pain: A Clinical Trial Study

Background

Shoulder pain is the third most common type of musculoskeletal disorder and rotator cuff (RC) tendinopathy is the most frequent diagnosis. Ultrasound is the most preferable guidance tool for diagnostic and interventional purposes. The aim of this study is to compare the effectiveness of the prolotherapy injection with corticosteroid injection in patients with RC dysfunction.

Materials and Methods

Thirty to sixty-five-year-old patients with chronic RC disease were divided into two groups. Ultrasound-guided dextrose prolotherapy of supraspinatus tendon was done for one group and ultrasound-guided corticosteroid injection in the subacromial bursa was done for the other groups. Visual analog scale (VAS) and Shoulder Pain and Disability Index (SPADI) were evaluated for both groups at baseline, 3 and 12 weeks after injections.

Results

Thirty-three patients were included in the result. Both the groups showed significant improvement in VAS and SPADI scores in 3 and 12 weeks after injections compared with preinjection times with no difference between two groups neither in 3 weeks nor in 12 weeks after injections.

Conclusion

Both ultrasound-guided dextrose prolotherapy and CS injections are effective in the management of RC-related shoulder pain in both short-term and long-term with neither being superior to the other. Therefore, prolotherapy may be a safe alternative therapy instead of corticosteroid injection due to lack of its side effects.

High-Intensity Shoulder Abduction Exercise in Subacromial Pain Syndrome

Subacromial pain syndrome (SAPS) defined as pain of nontraumatic origin localized around the acromion, is a debilitating, common, and often chronic condition. Among many proposed underlying causes of SAPS, hypoperfusion and hypoxic conditions in and around the tendons may be an intrinsic cause of SAPS.

PURPOSE

This study aimed to determine if adding high-intensity aerobic interval training (HIIT) of the rotator cuff to usual care was feasible in SAPS and improved shoulder endurance more than usual care alone, as well as to examine the influence on shoulder pain and disability and the response of tendinous microcirculation after HIIT.

METHODS

Twenty-one subjects with chronic SAPS were randomized to two groups: experimental group (EG; n = 13) receiving HIIT in addition to treatment as usual and control group (CG; n = 8) receiving treatment as usual. Before and after 8 wk of exercise therapy, endurance performance was assessed by an incremental abduction exercise of the arm to exhaustion (TTE). Pain and disability was assessed by the shoulder pain and disability index (SPADI). Contrast-enhanced ultrasound of the musculus supraspinatus and tendon was utilized to indicate tendon blood flow.

RESULTS

Endurance in the TTE test improved by an estimated 233 s more on average in EG than in CG (P = 0.001; 95% confidence interval, 102 to 363). The SPADI score was reduced 22 points more on average in EG (P = 0.017; 95% confidence interval, -40 to -5). The change from pretest to posttest was significant in EG for both TTE test and SPADI improvement (P < 0.001). EG also experienced less pain during exercise after the intervention compared with CG (P < 0.001). Contrast-enhanced ultrasound indicated an increase in tendinous blood flow in EG (P = 0.019).

CONCLUSIONS

HIIT rotator cuff exercise seems to be a feasible intervention in SAPS, increasing endurance performance more than usual care alone.

Prolotherapy for the patients with chronic musculoskeletal pain: systematic review and meta-analysis

Background

Prolotherapy, which stimulates the healing of loosened ligaments and tendons, is a cost-effective and safe treatment modality for chronic musculoskeletal pain. Its benefits may be affected by injection protocols, comparative regimens, and evaluation scales. The aim of this study was to determine the effectiveness of dextrose prolotherapy as a long-term treatment for chronic musculoskeletal pain.

Methods

Medline, Embase, Cochrane Central, KoreaMed, and KMbase databases were searched for studies published up to March 2019. We included randomized controlled trials which compared the effect of dextrose prolotherapy with that of other therapies such as exercise, saline, platelet-rich plasma, and steroid injection. The primary outcome was pain score change during daily life.

Results

Ten studies involving 750 participants were included in the final analysis. Pain scores from 6 months to 1 year after dextrose prolotherapy were significantly reduced compared to saline injection (standardized mean difference [SMD] –0.44; 95% confidence interval [CI] –0.76 to –0.11, P = 0.008) and exercise (SMD –0.42; 95% CI –0.77 to –0.07, P = 0.02). Prolotherapy yielded results similar to platelet-rich plasma or steroid injection, that it showed no significant difference in pain score.

Conclusions

Dextrose prolotherapy is more effective in the treatment of chronic pain compared to saline injection or exercise. Its effect was comparable to that of platelet-rich plasma or steroid injection. Adequately powered, homogeneous, and longer-term trials are needed to better elucidate the efficacy of prolotherapy.

What is better for rotator cuff tendinopathy: dextrose prolotherapy, platelet-rich plasma, or corticosteroid injections? A randomized controlled study

Background

Rotator cuff tendinopathy (RCT) is a leading cause of shoulder pain and disability. Management is mainly conservative, but the limited ability of tendons to regenerate is the main cause of unsatisfactory results. So, we conducted our study to compare the efficacy of deep prolotherapy (glucose 25%), platelet-rich plasma (PRP), and betamethasone corticosteroid for treatment of RCT to find the most effective one based on clinical, functional, and radiological assessment.

Results

Regarding visual analog scale (VAS), it was significantly (p < 0.001) improved after injection among group 1 (prolotherapy group) and group 3 (steroid group) patients, while no significant improvement was noted among group 2 (PRP group) (p = 0.212) patients. The Western Ontario Rotator Cuff (WORC) Index significantly improved among the studied groups (p < 0.001, p = 0.049, and p < 0.001, respectively) after injection. Regarding the range of motion (ROM), a significant improvement (p = 0.029) was achieved in group 1 after injection but no significant improvements were noted among group 2 and 3 patients (p = 0.529 and 0.121, respectively). There was a significant improvement among group 1 and 2 patients (p < 0.001 and p = 0.020, respectively) regarding the grade of tendon lesions but no improvement occurred among group 3 patients (p = 0.470).

Conclusion

Prolotherapy injections improve shoulder ROM, VAS, WORC index, and rotator cuff tendon healing while PRP injections improve WORC index and tendon healing but steroid injection has no effect on healing.

Trial registration

PACTR202005610509496. Retrospective registration on May 25, 2020, Pan African Clinical Trial Registry.

A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

Injection Therapy in Patients with Lateral Epicondylalgia: Hyaluronic Acid or Dextrose Prolotherapy? A Single-Blind, Randomized Clinical Trial

Objective: To compare the effects of hyaluronic acid (HA) and dextrose prolotherapy (DPT) injections in patients with chronic lateral epicondylalgia (LE). Materials and Methods: Thirty-two patients with at least 6 months of signs and symptoms of LE were randomly allocated into two groups: an HA group (n = 16) and a DPT group (n = 16). HA injection was performed as a single dose of 30 mg/2 mL 1500 kDa high-molecular-weight preparation (baseline). DPT injection was administered with 15% dextrose solution in three doses (baseline, third week, and sixth week). Severity of pain using the visual analog scale score, grip strength with a hand dynamometer, and physical function as determined by the Quick-Disabilities of the Arm, Shoulder, and Hand (Q-DASH) score were determined. Results: DPT was favored over HA for improvements from 0 to 12 weeks for pain with activity (4.81 ± 1.2 vs. 3.18 ± 2.3; p = 0.04), pain at night (5.1 ± 1.9 vs. 4.1 ± 2.2; p = 0.03), and pain at rest (3.8 ± 2.09 vs. 2.7 ± 1.7; p = 0.04). Q-DASH scores improved significantly more from 0 to 12 weeks in the DPT group (43.5 ± 17.6 vs. 28.4 ± 13.4; p = 0.04). No between-group improvement was observed for grip pain (7.3 ± 6.4 vs. 4.8 ± 3.2; p = 0.38). Conclusions: HA and DPT injections were both effective in reducing pain and increasing grip strength and function in patients with chronic LE. DPT injection was more effective in the short term than HA injection, in terms of pain relief and functional outcome. The study was registered at ClinicalTrials.gov under the identifier number NCT04395417.

Subacromial corticosteroid injection versus subcutaneous 5% dextrose in patients with chronic rotator cuff tendinopathy: A short-term randomized clinical trial

Aim

The aim of this study is to compare subcutaneous 5% dextrose versus subacromial corticosteroid injection for the treatment of chronic rotator cuff tendinopathy.

Methods

We carried out a randomized clinical trial with two parallel groups at a university hospital. Overall, 57 (32 women) were included in two groups of corticosteroid (n = 29) and dextrose (n = 28). The mean pain score was 6.6 (1.0). We used a visual analog scale for pain and goniometry for the range of motion. The measurements were repeated 1 month after the interventions. For corticosteroid, a single injection of triamcinolone and 1% lidocaine, and for dextrose, a mixture of 5% dextrose and 2% lidocaine three times weekly were prescribed.

Results

Both interventions were effective in decreasing pain compared to the baseline (both p < 0.001). The difference in pain between the two groups was nearly significant 1-month post-intervention (p = 0.052). The comparison of the two groups in considerable pain reduction (≥2.8) was in favor of dextrose (p = 0.046). The differences in the range of motion were not conclusive. None of the participants reported an important adverse effect.

Conclusion

The 5% dextrose treatment is at least as effective as corticosteroid for reducing pain in patients with rotator cuff tendinopathy.

Treatment of Osteoarthritis Secondary to Developmental Dysplasia of the Hip with Prolotherapy Injection versus a Supervised Progressive Exercise Control

Background

Osteoarthritis secondary to developmental dysplasia of the hip (DDH) is one of the major causes of hip pain and disability. The aim of the study was to compare the effectiveness of prolotherapy (PrT) injections versus exercise protocol for the treatment of DDH.

Material/Methods

There were 46 hips of 41 patients who had osteoarthritis secondary to DDH included in this study. Patients were divided into 2 groups: treated with PrT (PrT group; n=20) and exercise (control group; n=21). Clinical outcomes were evaluated with visual analog scale for pain (VAS) and Harris hip score (HHS) at baseline, 3 weeks, 3 months, 6 months, and a minimum of 1-year follow-up. In PrT group clinical results were also compared in Crowe type I–IV hips.

Results

Between group analysis revealed no significant between group differences at baseline. Dextrose injection recipients out performed exercise controls for VAS pain change score at 6 months (−4.6±2.6 versus −2.8±2.5; P=0.016), and 12 months (−4.5±2.4 versus −2.9±2.5; P=0.017) and for HHS at 6 months (24.2±14.0 versus 14.8±12.4; P=0.007) and 12 months (24.3±13.4 versus 16.5±11.3; P=0.018).

Conclusions

To our best knowledge, this study is the first regarding the effects of an injection method in the treatment of osteoarthritis secondary to DDH. According to our study, PrT is superior to exercises. PrT could provide significant improvement for clinical outcomes in DDH and might delay surgery.

Effectiveness of Dextrose Prolotherapy for Rotator Cuff Tendinopathy: A Systematic Review

OBJECTIVE

To systematically review and evaluate the efficacy and complication profile of prolotherapy using hyperosmolar dextrose solution injection for rotator cuff tendinopathy.

LITERATURE SURVEY

MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials (from inception to 1 July, 2019).

METHODOLOGY

A comprehensive search was completed to identify randomized controlled trials addressing prolotherapy using hyperosmolar dextrose solution for rotator cuff tendinopathy. Two reviewers independently screened the titles, abstracts, and full texts, and then extracted data from eligible studies. All reported outcome measures and complications were analyzed descriptively.

SYNTHESIS

Five studies satisfied inclusion criteria. Included studies analyzed a total of 272 participants with a final follow-up ranging from 6 weeks to 12 months. Prolotherapy differed greatly among studies. Two studies used a multisite enthesis injection protocol while the other three used ultrasound-guided protocols. Two of the studies used an intrasubstance supraspinatus injection and three used a supraspinatus enthesis injection. Control groups consisted of nonoperative rehabilitation including physical therapy and medical management in three studies, supraspinatus saline enthesis injection in one study, and corticosteroid injection in one study. There was statistically significant improvement in pain intensity with multisite injection protocols compared to physical therapy and medical management in both studies. Ultrasound-guided supraspinatus injection trials did not find any statistically significant difference in pain intensity, range of motion, strength, function, or ultrasound characteristics compared to controls of enthesis saline injection or corticosteroid. The complication rate was low, with only 6/272 participants experiencing adverse events consisting of transient increase in pain for 1 to 2 days postintervention.

CONCLUSIONS

Prolotherapy with hyperosmolar dextrose solution is a potentially effective adjuvant intervention to physical therapy for patients with rotator cuff tendinopathy ranging from tendinosis to partial-thickness and small full-thickness tears. Further studies are necessary to determine effects in subpopulations as well as optimal technique including dextrose concentration, volume, and location.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part I, shoulder

BACKGROUND

Image-guided interventional procedures around the shoulder are commonly performed in clinical practice, although evidence regarding their effectiveness is scarce. We report the results of a Delphi method review of evidence on literature published on image-guided interventional procedures around the shoulder with a list of clinical indications.

METHODS

Forty-five experts in image-guided musculoskeletal procedures from the ESSR participated in a consensus study using the Delphic method. Peer-reviewed papers regarding interventional procedures around the shoulder up to September 2018 were scored according to the Oxford Centre for Evidence-based Medicine levels of evidence. Statements on clinical indications were constructed. Consensus was considered as strong if more than 95% of experts agreed and as broad if more than 80% agreed.

RESULTS

A total of 20 statements were drafted, and 5 reached the highest level of evidence. There were 10 statements about tendon procedures, 6 about intra-articular procedures, and 4 about intrabursal injections. Strong consensus was obtained in 16 of them (80%), while 4 received broad consensus (20%).

CONCLUSIONS

Literature evidence on image-guided interventional procedures around the shoulder is limited. A strong consensus has been reached for 80% of statements. The ESSR recommends further research to potentially influence treatment options, patient outcomes, and social impact.

KEY POINTS

• Expert consensus produced a list of 20 evidence-based statements on clinical indications of image-guided interventional procedures around the shoulder. • The highest level of evidence was reached for five statements. • Strong consensus was obtained for 16 statements (80%), while 4 received broad consensus (20%).

Comparison of Platelet Rich Plasma and Prolotherapy in the Management of Osteochondral Lesions of the Talus: A Retrospective Cohort Study

BACKGROUND Osteochondral lesions of talus (OLT) are among the most common ankle problems. Platelet-rich plasma (PRP) and prolotherapy (PrT) are 2 successful injection-based techniques for treatment of chronic musculoskeletal problems. The aim of the present study was to compare PRP and PrT injections for the management of OLT. MATERIAL AND METHODS This was a retrospective cohort study of 49 patients with OLT symptoms of more than 6 months who had been refractory to 3 months of treatment using conservative methods. The patients were divided into 2 groups: PrT injections (PrT group, n=27) or PRP injections (PRP group, n=22). The patients were given 3 injections of 4 mL solution into periarticular and intra-articular ankle joint spaces. After treatment, patients were evaluated via Visual Analogue Scale (VAS), American Orthopedic Foot and Ankle Society Score (AOFAS), and Ankle Osteoarthritis Scale (AOS) at baseline and 21-, 90-, 180-, and 360-day follow-up periods. RESULTS Both PRP and PrT treatments resulted in greater improvement in pain and ankle functions at follow-up periods extending to 1 year (P<0.001) and there was no difference between the groups for the outcomes at follow-up periods (P>0.05). Excellent or good outcomes were reported by 88.8% of the patients in PrT group and 90.9% of the patients in PRP group. CONCLUSIONS Both PRP and PrT are efficient and safe methods in treatment of OLT. PrT offers advantages of less cost and minimal invasiveness.

Dextrose injections for failed back surgery syndrome: a consecutive case series

PURPOSE

Patients with chronic low back pain, who do not respond to conservative treatment methods, generally undergo surgical revision operations, and sometimes an undesirable condition called failed back surgery syndrome (FBSS) may be inevitable. Hereby, dextrose is one of the regenerative methods that has gained popularity in the treatment of many musculoskeletal problems, and we aimed to present and evaluate the outcomes of 5% dextrose for the treatment of FBSS.

METHODS

It has been designed as a consecutive case series. A total of 79 patients with FBSS, who had minimum 6 months of symptoms and did not respond to 3 months of conservative methods between May 2014 and March 2016, participated in the study. Prolotherapy injections were applied in posterior and lateral approaches. Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were used for the pre- and post-treatment evaluations. Patient satisfaction was assessed with using a 5-point Likert scale by phone contacting.

RESULTS

There was statistically significant difference between repeated VAS and ODI measurements.

CONCLUSIONS

These results may be the first step giving a lead to an undiscovered field. This treatment method should be kept in mind for FBSS patients before giving a decision of revision surgery. These slides can be retrieved under Electronic Supplementary Material.

Rotator Cuff-Related Shoulder Pain: To Inject or Not to Inject?

The most common source of shoulder pain is thought to involve the tendons of the rotator cuff and associated structures around the subacromial space. A generic diagnostic term has been suggested, rotator cuff-related shoulder pain (RCRSP), which is an overarching clinical term that includes a number of conditions, such as subacromial impingement syndrome, subacromial pain syndrome, and rotator cuff tendinopathy. The management of RCRSP may include exercise, surgery, or injection therapy. Those who perform or recommend injection therapy for RCRSP have a duty of care to provide advice on the expected benefits and outcomes, as well as the potential risks and associated harms. Clinicians also need to consider what medication to inject, where to inject it, and how to inject it. The aim of this Viewpoint is to discuss these issues. J Orthop Sports Phys Ther 2019;49(5):289-293. doi:10.2519/jospt.2019.0607.

Prolotherapy: Potential for the Treatment of Chronic Wounds?

Significance: Chronic skin ulcers, including venous, diabetic, and pressure ulcers, constitute a major health care burden, affecting 2-6 million people in the United States alone, with projected increases in incidence owing to the aging population and rising epidemic of diabetes. The ulcers are often accompanied by pain. Standard of care fails to heal ∼50% of diabetic foot ulcers and 25% of venous leg ulcers. Even advanced therapies do not heal >60%. Thus there is an unmet need for novel therapies that promote healing and also address the concomitant pain issue. Recent Advances: Prolotherapy involves injection of small amounts of an irritant material to the site of degenerated or painful joints, ligaments, and tendons. Multiple irritants are reported to be efficacious, but the focus here is on dextrose prolotherapy. In vitro and in vivo studies support translation to clinical use. Concentrations as low as 5% dextrose have resulted in production of growth factors that have critical roles in repair. Numerous clinical trials report pro-reparative effects of dextrose prolotherapy in joint diseases, tendon, and ligament damage, and for painful musculoskeletal issues. However, most of the studies have limitations that result in low-quality evidence. Critical Issues: The preclinical data support a role for dextrose prolotherapy in promoting tissue repair that is required for healing chronic wounds and ameliorating the associated pain. Critical issues include provision of evidence of efficacy in human chronic wounds. Another potential obstacle is limitation of reimbursement by third-party payers for a therapy with as yet limited evidence. Future Directions: Preclinical studies in models of chronic wounds would support clinical translation. As dextrose prolotherapy has some mechanistic similarities to already approved honey therapies, it may have a shortened pathway for clinical translation. The gold standard for widespread adoption would be a well-designed clinical trial.

Ultrasound-Guided Prolotherapy for Acromial Enthesopathy and Acromioclavicular Joint Arthropathy: A Single-Arm Prospective Study

OBJECTIVES

Prolotherapy is an injection-based complementary treatment for various musculoskeletal diseases. The aim of this study was to evaluate the therapeutic efficacy of ultrasound-guided prolotherapy in the treatment of acromial enthesopathy and acromioclavicular joint arthropathy.

METHODS

Thirty-one patients with chronic moderate-to-severe shoulder pain were recruited from September 2015 to September 2017. Ultrasound-guided prolotherapy was performed by injecting 10 mL of a 15% dextrose solution into the acromial enthesis of the deltoid or acromioclavicular joint capsule aseptically. Prolotherapy was given in 2 sessions separated by a 1-month interval. The pretreatment-to-posttreatment change in the pain visual analog scale (VAS) score was recorded as the primary outcome. The mean follow-up duration was 61.8 days. A paired t test was used to assess the difference in pretreatment and posttreatment VAS scores. A univariate logistic regression analysis was conducted to identify the demographic variables associated with substantial pain reduction after the intervention. Substantial pain reduction was defined as a posttreatment VAS score of 3 or less.

RESULTS

Twenty of the 31 patients reported substantial pain reduction without adverse effects after the intervention. The mean VAS score reduction ± SD was 4.3 ± 2.6 (pretreatment, 6.8 ± 1.5; posttreatment, 2.5 ± 2.1; P < .01).

CONCLUSIONS

Ultrasound-guided prolotherapy with a 15% dextrose solution is an effective and safe therapeutic option for moderate-to-severe acromial enthesopathy and acromioclavicular joint arthropathy.

The effectiveness of prolotherapy on failed rotator cuff repair surgery

Objectives

The aim of the present study was to investigate the effectiveness of prolotherapy injections in the treatment of failed rotator cuff repair surgery.

Patients and methods

Between May 2014 and March 2016, a total of 15 patients (5 males, 10 females; mean age 49.4±10.7 years; range, 33 to 71 years) with failed rotator cuff repair surgery who had at least six months of complaints and were refractory to at least of three months of conservative methods were included. Ultrasound-guided prolotherapy injections were performed under aseptic conditions, and the patients were instructed to carry out a home-based exercise program. Clinical assessment of shoulder function was performed using a visual analog scale (VAS) for pain, Shoulder Pain and Disability Index (SPADI), Western Ontario Rotator Cuff (WORC) Index, patient satisfaction and shoulder range of motion. All patients were examined at baseline, at Week 3, 6, and 12 and at the final follow-up visit.

Results

The intra-group comparison showed that the patients achieved significant improvements at all time points, compared to baseline as measured by VAS, SPADI, WORC index, and shoulder range of motion (p<0.001). Twelve patients (80%) reported excellent or good outcomes.

Conclusion

Our study results show that prolotherapy is effective in the treatment of patients with failed rotator cuff repair surgery with significant improvements in the shoulder functions and pain relief.

Myths and Facts of In-Office Regenerative Procedures for Tendinopathy

Tendinopathy carries a large burden of musculoskeletal disorders seen in both athletes and aging population. Treatment is often challenging, and progression to chronic tendinopathy is common. Physical therapy, nonsteroidal anti-inflammatory drugs, and corticosteroid injections have been the mainstay of treatment but are not optimal given that most tendon disorders seem to involve degenerative changes in addition to inflammation. The field of regenerative medicine has taken the forefront, and various treatments have been developed and explored including prolotherapy, platelet rich plasma, stem cells, and percutaneous ultrasonic tenotomy. However, high-quality research with standardized protocols and consistent controls for proper evaluation of treatment efficacy is currently needed. This will make it possible to provide recommendations on appropriate treatment options for tendinopathy.

Regenerative Sports Medicine: Past, Present, and Future (Adapted From the PASSOR Legacy Award Presentation; AAPMR; October 2016)

Regenerative medicine has shown dramatic expanse and evolution in the past decade. Within that milieu, physiatrists are taking an active role in research, clinical care delivery, and education. The purpose of this review is to provide a balance among evidence, theory, experience, clinical trends, and the foreseeable future. We focus on the literature that reports the research with the best methodology in each practice area, recognizing that the level of evidence varies substantially among different treatment modalities and conditions. The following elements are included: an overview of the evolution of currently available regenerative techniques, evidence base for each available modality (prolotherapy, platelet rich plasma, bone marrow aspirate concentrate and stem cells, adipose-derived stem cells, and amniotic tissue products), general principles in the application of these treatments, and discussion and a vision of what lies ahead. We expect that practitioners will use this review to facilitate clinical decision making and to provide a core knowledge base to assist when counseling patients. LEVEL OF EVIDENCE: IV.

Injection Therapies for Rotator Cuff Disease

Rotator cuff disease affects a large proportion of the overall population and encompasses a wide spectrum of pathologies, including subacromial impingement, rotator cuff tendinopathy or tear, and calcific tendinitis. Various injection therapies have been used for the treatment of rotator cuff disease, including corticosteroid, prolotherapy, platelet-rich plasma, stem cells, and ultrasound-guided barbotage for calcific tendinitis. However, the existing evidence for these therapies remains controversial or sparse. Ultimately, improved understanding of the underlying structural and compositional deficiencies of the injured rotator cuff tissue is needed to identify the biological needs that can potentially be targeted with injection therapies.

Ultrasound-Guided Prolotherapy with Polydeoxyribonucleotide for Painful Rotator Cuff Tendinopathy

Background

Rotator cuff tendinopathy is a primary cause of shoulder pain and dysfunction. Several effective nonsurgical treatment methods have been described for chronic rotator cuff tendinopathy. Prolotherapy with polydeoxyribonucleotide (PDRN), which consists of active deoxyribonucleotide polymers that stimulate tissue repair, is a nonsurgical regenerative injection that may be a viable treatment option. The objective of this study was to assess the efficacy of PDRN in the treatment of chronic rotator cuff tendinopathy.

Method

The records of patients with chronic rotator cuff tendinopathy (n=131) were reviewed retrospectively, and the patients treated with PDRN prolotherapy (n=32) were selected. We measured the main outcome of the shoulder pain and disability index score on a numerical rating scale of average shoulder pain.

Results

Compared with baseline data, significant improvements in the shoulder pain and disability index and pain visual analog scale scores were demonstrated at one week after the end of treatment, and at one month and three months later.

Conclusions

PDRN prolotherapy may improve the conservative treatment of painful rotator cuff tendinopathy for a specific subset of patients.

Management of Rotator Cuff Injuries in the Elite Athlete

PURPOSE OF REVIEW

Rotator cuff injuries are a common cause of pain and dysfunction for the elite athlete and can result in time loss from participation. This review highlights the current management of these injuries.

RECENT FINDINGS

Conservative management of rotator cuff injuries continues to be the "gold standard" in the elite athlete. This includes a comprehensive rehabilitation program, anti-inflammatories, and corticosteroid injections. Newer treatment techniques such as intramuscular dry needling and the use of biologics such as platelet-rich plasma and stem cells demonstrate early promising results; however, these modalities require further investigation to determine their effectiveness. Rotator cuff injuries can range from contusions and tendinopathy to full-thickness tears. A comprehensive evaluation is needed to determine the extent of injury and appropriate plan of care. Management strategies can range from rehabilitation to operative intervention and are guided by the size of the tear, time of season, sport, performance limitations, and presence of concomitant pathology.