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Fu Y, Du Y, Li J, Xi Y, Ji W, Li T. Demonstrating the effectiveness of intra-articular prolotherapy combined with peri-articular perineural injection in knee osteoarthritis: a randomized controlled trial. J Orthop Surg Res 2024; 19:279. [PMID: 38705988 PMCID: PMC11071214 DOI: 10.1186/s13018-024-04762-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 04/21/2024] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND This study aimed to compare the efficacy of intra-articular prolotherapy (IG) combined with peri-articular perineural injection (PG) in the management of knee osteoarthritis (KOA). METHODS A total of 60 patients with the diagnosis of KOA were included in this double-blinded randomized controlled clinical trials. The inclusion criteria were as follow: (1) 48-80 years old; (2) the diagnose of KOA; (3) the grade 2 and 3 of the Kellgern-Lawrence grading scale; (4) the pain, crepitation, and knee joint stiffness continuing for 3 months at least. The main exclusion criteria were as follow: (1) any infection involving the knee skin; (2) history of any Influencing factors of disease. All patients were divided into three groups and received either IG, PG and I + PG under the ultrasound guidance and the 2, 4 and 8 weeks follow-up data of patients were available. (IG n = 20 or PG n = 20, I + PG n = 20). Visual Analogue Scale (VAS), The Western Ontario McMaster University Osteoarthritis Index (WOMAC) and the pressure pain threshold (PPT) were used as outcome measures at baseline, 2, 4 and 8 weeks. RESULTS There were no statistically significant differences in terms of age, sex, BMI, duration of current condition and baseline assessments of pain intensity, WOMAC scores and PPT. After treatment, the improvement of VAS activity, WOMAC and PPT values was showed compared with pre-treatment in all groups (p < 0.05). At 4 and 8 weeks after treatment, the VAS and WOMAC scores of the I + PG were significantly lower than those of the PG or IG, and the difference was statistically significant (p < 0.05). The PPT values of PG and I + PG were significantly improved compared to IG at 2, 4, and 8 weeks after treatment. CONCLUSION The ultrasound guided I + PG of 5% glucose seem to be more effective to alleviate pain and improve knee joint function than single therapy in short term. Clinical rehabilitators could clinically try this combination of I + PG to improve clinical symptoms in patients with KOA.
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Affiliation(s)
- Yiling Fu
- Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Yukun Du
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jianyi Li
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yongming Xi
- The Affiliated Hospital of Qingdao University, Qingdao, China.
| | - Wenbin Ji
- Qilu Hospital of Shandong University (Qingdao), Qingdao, China.
| | - Tieshan Li
- The Affiliated Hospital of Qingdao University, Qingdao, China.
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Öztürk MU, Baygutalp F. A comparative analysis of prolotherapy efficacy in patients with knee osteoarthritis across varied dextrose concentrations. Clin Rheumatol 2023; 42:3321-3331. [PMID: 37540383 DOI: 10.1007/s10067-023-06723-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/01/2023] [Accepted: 07/25/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE To compare the effectiveness of prolotherapy with dextrose concentrations of 5%, 10%, and 20% in patients diagnosed with knee osteoarthritis. METHODS This study was planned as a prospective, randomized controlled interventional trial. Prolotherapy at 5% dextrose concentration in group 1, 10% in group 2, and 20% in group 3 was applied to the knee intra-articularly and periarticularly at 0, 3, and 6 weeks, and a home exercise program was given. Group 4 received a home exercise program. All groups received hotpack therapy at weeks 0, 3, and 6. Outcome measures included the visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), knee range of motion, timed up and go test, and Short Form-36. RESULTS A total of 128 patients were divided into 4 groups. At the 6th and 12th weeks, VAS scores were significantly lower in groups 2 and 3 than in group 4 (p < 0.05). At the 12th week, the WOMAC pain score was significantly lower in group 3 than in group 4, and WOMAC physical function and WOMAC total scores were significantly lower in groups 1, 2, and 3 than in group 4 (p < 0.05). Week 6 active and passive knee flexion and week 12 passive knee flexion were significantly higher in group 3 than in group 4 (p < 0.05). CONCLUSIONS Although no significant difference was observed among the dextrose prolotherapy groups, higher dextrose concentrations demonstrated a greater improvement compared to the control group. Therefore, the use of 20% dextrose is recommended due to its significant superiority. Long-term follow-up and placebo-controlled studies are needed. TRIAL REGISTRATION ClinicalTrial.gov Identifier: NCT05537077, registration date: 09.03.2022, retrospectively registered. Key Points • The utilization of dextrose prolotherapy has gained popularity in the management of osteoarthritis, aiming to harness its regenerative and proliferative properties. However, the comparative efficacy of various concentrations of dextrose prolotherapy in treating knee osteoarthritis remains unexplored in the literature. This study aimed to address this gap by comparing different concentrations of dextrose prolotherapy in the treatment of knee osteoarthritis. The findings revealed no statistically significant difference among the various concentrations of dextrose prolotherapy for knee osteoarthritis treatment.
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Affiliation(s)
- Muhammet Uğur Öztürk
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Atatürk University, Erzurum, Turkey.
| | - Fatih Baygutalp
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Atatürk University, Erzurum, Turkey
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Yildiz KM, Guler H, Ogut H, Yildizgoren MT, Turhanoglu AD. A comparison between hypertonic dextrose prolotherapy and conventional physiotherapy in patients with knee osteoarthritis. MEDICINE INTERNATIONAL 2023; 3:45. [PMID: 37745156 PMCID: PMC10514571 DOI: 10.3892/mi.2023.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023]
Abstract
The aim of the present study was to compare the efficacy of hypertonic dextrose prolotherapy (HDP) with conventional physiotherapy (CPT) in improving symptoms in females with knee osteoarthritis (OA). The present study included 60 patients with a diagnosis of knee OA. The patients were randomly assigned to the HDP (n=30) and CPT (n=30) groups. The patients in the HDP group were treated with a dextrose injection into the knee joint (25% dextrose) and around the knee (15% dextrose) in two sessions for 1 month, while those in the CPT group received a hot pack, transcutaneous electrical nerve stimulation and therapeutic ultrasound in five sessions a week for 4 weeks. Prior to commencing the treatment, and at 1 and 3 months post-treatment, all the patients were evaluated using the visual analog scale (VAS), Western Ontario and McMaster Osteoarthritis Index (WOMAC), the goniometric measurement of active knee range of motion (ROM), a 50-m walking test and isokinetic knee muscle strength measurements. There were no statistically significant differences between the two groups as regards the demographic characteristics at pre-treatment (P>0.05). However, at 1 and 3 months post-treatment, the scores of all the outcome parameters were significantly improved in the HDP group compared with the CPT group (P<0.05 for all). In both groups, a significant improvement was observed in the VAS scores, WOMAC total values and ROM following the treatments, with the greatest improvement observed in the HDP group (P<0.001). The isokinetic quadriceps peak torque measurements were increased in both groups following treatment. All the scores exhibited a statistically significant improvement in the HDP group at both 1 and 3 months post-treatment. On the whole, the results of the present study demonstrate that both HDP and CPT are effective treatment modalities to relieve pain, and increase functionality and strength in patients with knee OA. However, greater improvements in pain and functionality can be achieved with prolotherapy.
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Affiliation(s)
- Kamil Mursit Yildiz
- Department of Physical Medicine and Rehabilitation, Medical School, Hatay Mustafa Kemal University, Antakya, Hatay, 31001, Turkey
| | - Hayal Guler
- Department of Physical Medicine and Rehabilitation, Medical School, Hatay Mustafa Kemal University, Antakya, Hatay, 31001, Turkey
| | - Halil Ogut
- Department of Physical Medicine and Rehabilitation, Medical School, Hatay Mustafa Kemal University, Antakya, Hatay, 31001, Turkey
| | | | - Ayse Dicle Turhanoglu
- Department of Physical Medicine and Rehabilitation, Medical School, Hatay Mustafa Kemal University, Antakya, Hatay, 31001, Turkey
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Smith KM, Massey BJ, Young JL, Rhon DI. What are the unsupervised exercise adherence rates in clinical trials for knee osteoarthritis? A systematic review. Braz J Phys Ther 2023; 27:100533. [PMID: 37597491 PMCID: PMC10462806 DOI: 10.1016/j.bjpt.2023.100533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/11/2023] [Accepted: 08/04/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND Exercise is an effective intervention for knee osteoarthritis (OA), and unsupervised exercise programs should be a common adjunct to most treatments. However, it is unknown if current clinical trials are capturing information regarding adherence. OBJECTIVE To summarize the extent and quality of reporting of unsupervised exercise adherence in clinical trials for knee OA. METHODS Reviewers searched five databases (PubMed, CINAHL, Medline (OVID), EMBASE and Cochrane). Randomized controlled trials where participants with knee OA engaged in an unsupervised exercise program were included. The extent to which exercise adherence was monitored and reported was assessed and findings were subgrouped according to method for tracking adherence. The types of adherence measurement categories were synthesized. A quality assessment was completed using the Physiotherapy Evidence Database (PEDro) scores. RESULTS Of 3622 abstracts screened, 176 studies met criteria for inclusion. PEDro scores for study quality ranged from two to ten (mean=6.3). Exercise adherence data was reported in 72 (40.9%) studies. Twenty-six (14.8%) studies only mentioned collection of adherence. Adherence rates ranged from 3.7 to 100% in trials that reported adherence. For 18 studies (10.2%) that tracked acceptable adherence, there was no clear superiority in treatment effect based on adherence rates. CONCLUSIONS Clinical trials for knee OA do not consistently collect or report adherence with unsupervised exercise programs. Slightly more than half of the studies reported collecting adherence data while only 40.9% reported findings with substantial heterogeneity in tracking methodology. The clinical relevance of these programs cannot be properly contextualized without this information.
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Affiliation(s)
- Kristin M Smith
- Science Program in Physical Therapy, Bellin College, Green Bay, WI, USA.
| | - B James Massey
- Science Program in Physical Therapy, Bellin College, Green Bay, WI, USA; Department of Physical Therapy, Wingate University, Wingate, NC, USA
| | - Jodi L Young
- Science Program in Physical Therapy, Bellin College, Green Bay, WI, USA
| | - Daniel I Rhon
- Science Program in Physical Therapy, Bellin College, Green Bay, WI, USA; Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Liao CD, Chen HC, Huang MH, Liou TH, Lin CL, Huang SW. Comparative Efficacy of Intra-Articular Injection, Physical Therapy, and Combined Treatments on Pain, Function, and Sarcopenia Indices in Knee Osteoarthritis: A Network Meta-Analysis of Randomized Controlled Trials. Int J Mol Sci 2023; 24:ijms24076078. [PMID: 37047058 PMCID: PMC10094194 DOI: 10.3390/ijms24076078] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
Knee osteoarthritis (KOA) is associated with a high risk of sarcopenia. Both intra-articular injections (IAIs) and physical therapy (PT) exert benefits in KOA. This network meta-analysis (NMA) study aimed to identify comparative efficacy among the combined treatments (IAI+PT) in patients with KOA. Seven electronic databases were systematically searched from inception until January 2023 for randomized controlled trials (RCTs) reporting the effects of IAI+PT vs. IAI or PT alone in patients with KOA. All RCTs which had treatment arms of IAI agents (autologous conditioned serum, botulinum neurotoxin type A, corticosteroids, dextrose prolotherapy (DxTP), hyaluronic acid, mesenchymal stem cells (MSC), ozone, platelet-rich plasma, plasma rich in growth factor, and stromal vascular fraction of adipose tissue) in combination with PT (exercise therapy, physical agent modalities (electrotherapy, shockwave therapy, thermal therapy), and physical activity training) were included in this NMA. A control arm receiving placebo IAI or usual care, without any other IAI or PT, was used as the reference group. The selected RCTs were analyzed through a frequentist method of NMA. The main outcomes included pain, global function (GF), and walking capability (WC). Meta-regression analyses were performed to explore potential moderators of the treatment efficacy. We included 80 RCTs (6934 patients) for analyses. Among the ten identified IAI+PT regimens, DxTP plus PT was the most optimal treatment for pain reduction (standard mean difference (SMD) = -2.54) and global function restoration (SMD = 2.28), whereas MSC plus PT was the most effective for enhancing WC recovery (SMD = 2.54). More severe KOA was associated with greater changes in pain (β = -2.52) and WC (β = 2.16) scores. Combined IAI+PT treatments afford more benefits than do their corresponding monotherapies in patients with KOA; however, treatment efficacy is moderated by disease severity.
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Affiliation(s)
- Chun-De Liao
- International Ph.D. Program in Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei 110301, Taiwan
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235041, Taiwan
| | - Hung-Chou Chen
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235041, Taiwan
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan
| | - Mao-Hua Huang
- Department of Biochemistry, University of Washington, Seattle, WA 98015, USA
| | - Tsan-Hon Liou
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235041, Taiwan
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan
| | - Che-Li Lin
- Department of Orthopedic Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Shih-Wei Huang
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235041, Taiwan
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan
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Medin Ceylan C, Sahbaz T, Cigdem Karacay B. Demonstrating the effectiveness of Platelet Rich Plasma and Prolotherapy treatments in knee osteoarthritis. Ir J Med Sci 2023; 192:193-198. [PMID: 36166187 DOI: 10.1007/s11845-022-03168-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 09/19/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Platelet-rich plasma(PRP) and prolotherapy(PRL) are regenerative treatment approaches in the knee osteoarthritis (KOA). AIM To see how efficient PRP and PRL are in treating KOA. METHODS A total of 108 patients with a diagnosis of KOA who received either PRL, PRP, or exercise therapy and whose 3-month follow-up data were available were included in this retrospective study (PRL n = 35 or PRP n = 35, exercise n = 38). Visual Analogue Scale(VAS) and The Western Ontario McMaster University Osteoarthritis Index(WOMAC) were used as outcome measures at baseline, 1 month, and 3 months. RESULTS There were no statistically significant differences between the three groups in terms of demographic parameters, baseline assessments of pain intensity, or WOMAC scores. At the first and third months, all groups showed a substantial improvement in the VAS activity, resting and WOMAC values as compared to before treatment(p < 0.05). When the groups were compared, the VAS activity, resting, and WOMAC values in PRP and PRL improved significantly in the first and third months compared to the exercise group. At one month, there was a statistically significant improvement in VAS activity and WOMAC pain and total scores compared to PRP and PRL, but this improvement was not significant at 3 months. CONCLUSION Pain and disability were significantly improved with PRL and PRP compared with exercise therapy. Although PRP is more effective than PRL in the first month after treatment, PRL may be preferred due to its low cost, long-term efficacy, and low complication rates due to the periarticular application.
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Affiliation(s)
- Cansın Medin Ceylan
- Department of Physical Medicine and Rehabilitation, Istanbul Physical Medicine and Rehabilitation Training and Research Hospital, Kocasinan Merkez Mah. Karadeniz Cad.No 48, 34147, Bahcelievler, Istanbul, Turkey.
| | - Tugba Sahbaz
- Department of Physical Medicine and Rehabilitation, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Basak Cigdem Karacay
- Department of Physical Medicine and Rehabilitation, Ahi Evran University Medicine Faculty, Kırşehir, Turkey
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Dextrose Prolotherapy for Symptomatic Grade IV Knee Osteoarthritis: A Pilot Study of Early and Longer-Term Analgesia and Pain-Specific Cytokine Concentrations. Clin Pract 2022; 12:926-938. [PMID: 36412676 PMCID: PMC9680458 DOI: 10.3390/clinpract12060097] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Neurocytokines may upregulate or downregulate neuropathic pain. We hypothesized that dextrose (D-glucose) injections for therapeutic purposes (dextrose prolotherapy: DPT) in painful knee osteoarthritis (KOA) would favorably affect synovial-fluid neurocytokine concentrations. Methods: Twenty participants with grade IV symptomatic KOA received synovial-fluid aspiration followed by dextrose or simulated dextrose injections, followed by the reverse after one week. All participants then received open-label dextrose injections monthly for 6 months, with serial assessments of walking pain at 20 min for 9 months, as well as synovial-neurocytokine-concentration measurements (calcitonin gene-related peptide, substance P (SP), and neuropeptide Y (NPY)) at one week and three months. Results: Clinically important analgesia was observed at 20 min and for 9 months post dextrose injection. One -week synovial-fluid SP concentration rose by 111% (p = 0.028 within groups and p = 0.07 between groups) in the dextrose-injected knees compared to synovial-fluid aspiration only. Three-month synovial-fluid NPY concentration dropped substantially (65%; p < 0.001) after open-label dextrose injection in all knees. Conclusions: Prompt and medium-term analgesia after intra-articular dextrose injection in KOA was accompanied by potentially favorable changes in synovial-fluid neurocytokines SP and NPY, respectively, although these changes were isolated. Including neurocytokines in future assessments of DPT to elucidate mechanisms of action is recommended.
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Poliwoda S, Noor N, Mousa B, Sarwary Z, Noss B, Urits I, Viswanath O, Behara R, Ulicny K, Howe A, Mychaskiw G, Kaye AD. A comprehensive review of intraarticular knee injection therapy, geniculate injections, and peripheral nerve stimulation for knee pain in clinical practice. Orthop Rev (Pavia) 2022; 14:38676. [DOI: 10.52965/001c.38676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The knee is the most common joint in adults associated with morbidity. Many pathologies are associated with knee damage, such as gout or rheumathoid arthritis, but the primary condition is osteoarthritis (OA). Not only can osteoarthritis cause significant pain, but it also can result in signficant disability as well. Treatment for this condition varies, starting off with oral analgesics and physical therapy to surgical total knee replacmenet. In the gamut of this various treatments, a conservative approach has included intra articular steroid injections. With time, researchers and clinicians determined that other components injected to the knee may additionally provide relief of this condition. In this investigation, we describe different types of knee injections such as platelet-rich plasma (PRP), hyaluronic acid, stem cells, and prolotherapy. Additionally, we describe the role of geniculate knee injections, radiofrequency, and periopheral nerve stimulation. These treatments should be considered for patients with knee pain refractory to conservative therapies.
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Affiliation(s)
| | | | - Bakir Mousa
- University of Arizona, College of Medicine-Phoenix
| | | | | | - Ivan Urits
- Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Omar Viswanath
- Creighton University School of Medicine, University of Arizona College of Medicine
| | - Raju Behara
- Louisiana State University Health Sciences Center – Shreveport
| | - Kenneth Ulicny
- Louisiana State University Health Sciences Center – Shreveport
| | - Austin Howe
- Louisiana State University Health Sciences Center – Shreveport
| | | | - Alan D. Kaye
- Louisiana State University Health Sciences Center – Shreveport
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Zhao AT, Caballero CJ, Nguyen LT, Vienne HC, Lee C, Kaye AD. A Comprehensive Update of Prolotherapy in the Management of Osteoarthritis of the Knee. Orthop Rev (Pavia) 2022; 14:33921. [PMID: 35769650 PMCID: PMC9235417 DOI: 10.52965/001c.33921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 01/12/2022] [Indexed: 12/07/2023] Open
Abstract
This is a comprehensive review of the literature focusing on the use of prolotherapy in the treatment of osteoarthritis of the knee. It covers the background, efficacy, and advantages of prolotherapy in the management of osteoarthritis symptoms and then covers the existing evidence of the use of prolotherapy for this purpose. Current treatments for osteoarthritis of the knee are numerous, yet patients continue to endorse chronic pain and poor quality of life. Prolotherapy is a treatment that has been inadequately studied with poor sample sizes and lack of standardization between trials. However, in recent years the literature on prolotherapy in the treatment of knee osteoarthritis has grown. Although there is still a lack of homogeneity, trials have shown that dextrose prolotherapy, autologous conditioned serum, hyaluronic injections, and normal saline administered either intra- or peri-articularly are comparable in reducing pain scores to other primary treatment options. The mechanism of action for prolotherapy is still unclear, but researchers have found that prolotherapy plays some role in cartilage growth or chondrogenesis and has been shown to have improved radiographic outcomes. Prolotherapy appears to be a safe treatment alternative that has been shown to improve stiffness, pain, function, and quality of life in osteoarthritis of the knee. Knee osteoarthritis is remarkably prevalent in the United States and is one of the most common causes of disability in the elderly population. Although there are many treatment options, patients continue to live with chronic pain which can incur high costs for patients. A safe, long-term, and effective solution has not yet been identified. Prolotherapy has been shown to be a safe option for improving pain, function, and quality of life as effectively as other treatment options.
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Affiliation(s)
- Alex Tang Zhao
- Georgetown University School of Medicine, Washington, DC
| | | | - Linh T Nguyen
- Louisiana State University School of Medicine Shreveport, Shreveport, LA
| | - Hunter C Vienne
- Louisiana State University School of Medicine Shreveport, Shreveport, LA
| | - Christopher Lee
- Department of Internal Medicine, Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, AZ
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA
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Meta-analysis of clinical trials focusing on hypertonic dextrose prolotherapy (HDP) for knee osteoarthritis. Aging Clin Exp Res 2022; 34:715-724. [PMID: 34449061 DOI: 10.1007/s40520-021-01963-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 08/14/2021] [Indexed: 10/20/2022]
Abstract
Hypertonic dextrose prolotherapy (HDP) is an injection of a concentrated dextrose solution for the purpose of local treatment of musculoskeletal pain and possible enhancement of repair mechanisms. This systematic review and meta-analysis examines the clinical utility of HDP injection for treatment of knee osteoarthritis (OA). Randomized controlled trials (RCTs) utilizing HDP to treat knee OA were retrieved from MEDLINE, EMBASE, and Cochrane Library (CENTRAL). Identification and inclusion of RCTs utilizing intra-articular and extra-articular administration of HDP vs administration of other injectate or physical therapy as control for knee OA were included. Primary clinical outcomes were changes in knee WOMAC, pain and function score. Secondary outcomes were adverse events related to HDP. For continuous outcomes with same or different measurements, we calculated, respectively the weighted mean difference (WMD) or the standardized mean difference (SMD), respectively. Results were pooled using DerSimonian and Laird random effect models across the included studies and heterogeneity between studies was estimated using the I2 index. Five studies comprising a total of 319 treated patients met inclusion criteria and were included in the final analysis. At a mean of 22.8 weeks follow-up, HDP treatment significantly improved total WOMAC score (WMD = 13.77, 95% CI: 6.75-20.78; p < 0.001; I2 = 90%), pain (SMD = 1.33, 95% CI: 0.49-2.17; p < 0.001; I2 = 91%) and knee function (SMD = 1.30, 95% CI: 0.45-2.14; p < 0.001; I2 = 91%) compared with control group. There were no severe adverse events related to dextrose injection reported in all the included studies. HDP is a promising treatment for knee OA with a reasonable safety profile. Further research in mechanism of HDP activity and long-term follow-up study will be needed for exploring this novel therapy modality.
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11
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Chiou HJ. Ultrasound-guided pain management for chronic musculoskeletal pain. J Med Ultrasound 2022; 30:165-168. [DOI: 10.4103/jmu.jmu_1_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 12/20/2021] [Indexed: 11/04/2022] Open
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Johnston E, Kou Y, Junge J, Chen L, Kochan A, Johnston M, Rabago D. Hypertonic Dextrose Stimulates Chondrogenic Cells to Deposit Collagen and Proliferate. Cartilage 2021; 13:213S-224S. [PMID: 34109827 PMCID: PMC8804764 DOI: 10.1177/19476035211014572] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Hypertonic dextrose (HD) injections (prolotherapy) for osteoarthritis are reported to reduce pain. Cartilage regeneration is hypothesized as a mechanism. This in vitro study identifies an HD concentration that stimulates chondrogenic cells to increase metabolic activity and assesses whether this concentration affects collagen deposition and proliferation. DESIGN ATDC5 chondrogenic cells were cultured in normoglycemic DMEM/F12 medium, treated with concentrations of HD (4-400 mM), and assessed with PrestoBlue. Advanced light microscopy was used to conduct live imaging of collagen deposition through second harmonic generation microscopy (SHG) and proliferation via 2-photon excitation microscopy. Proliferation was additionally assessed with hemocytometer counts. RESULTS A linear regression model found that, relative to the 4 mM baseline control, cells treated with 200 mM had a higher mean absorbance (P = 0.023) and cells treated with 250 mM were trending toward a higher mean absorbance (P = 0.076). Polynomial regression interpolated 240 mM as producing the highest average absorbance. Hemocytometer counts validated 250 mM as stimulating proliferation compared with the 4 mM control (P < 0.01). A concentration of 250 mM HD led to an increase in collagen deposition compared with that observed in control (P < 0.05). This HD concentration also led to increases in proliferation of ATDC5 cells relative to that of control (P < 0.001). CONCLUSIONS A 250 mM HD solution appears to be associated with increased metabolic activity of chondrocytes, increased collagen deposition, and increased chondrocyte proliferation. These results support clinical prolotherapy research suggesting that intra-articular HD joint injections reduce knee pain. Further study of HD and cellular processes is warranted.
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Affiliation(s)
| | - Yi Kou
- Molecular and Computational Biology,
Department of Biological Sciences, University of Southern California, Los Angeles,
CA, USA
| | - Jason Junge
- Imaging Services, Advanced Light
Microscopy Core, Translational Imaging Center, University of Southern California,
Los Angeles, CA, USA
| | - Lin Chen
- Department of Chemistry and Biological
Sciences, University of Southern California, Los Angeles, CA, USA
| | | | | | - David Rabago
- Department of Family and Community
Medicine, Penn State College of Medicine, Hershey, PA, USA,David Rabago, Department of Family and
Community Medicine, Penn State College of Medicine, 500 University Drive, P.O.
Box 850, Hershey, PA 17033, USA.
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Williams C, Jerome M, Fausel C, Dodson E, Stemper I, Centeno C. Regenerative Injection Treatments Utilizing Platelet Products and Prolotherapy for Cervical Spine Pain: A Functional Spinal Unit Approach. Cureus 2021; 13:e18608. [PMID: 34659923 PMCID: PMC8500543 DOI: 10.7759/cureus.18608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 11/19/2022] Open
Abstract
Background The increasing burden of musculoskeletal disorders combined with the high utilization of opiates and the relatively limited ability of traditional approaches to satisfactorily address many of these conditions has spurred an increased interest in alternative treatments such as regenerative medicine therapies. Evidence is growing to support the use of regenerative injection treatments, including prolotherapy, platelet-rich plasma (PRP), platelet lysate (PL), and mesenchymal stromal cells. This study aims to offer a proof of concept via a case series of patients with neck pain treated using a functional spinal unit (FSU) model with combination prolotherapy, PRP, and PL injections. Methodology A chart review identified patients with neck pain treated with a combination of cervical injections using concentrated platelets and prolotherapy. Results A total of 14 patients met the inclusion criteria. The average decrease in the Numeric Pain Score was 2.8 (p = 0.002). The mean decrease in the Functional Rating Index was 27.3 (p = 0.004) at 24 months. Two patients had mild adverse reactions. Conclusions This case series demonstrates basic safety and clinically significant improvements in patients treated for neck pain with autologous concentrated platelet products and prolotherapy utilizing an FSU treatment protocol. Additional clinical studies are warranted with a larger patient sample size and longer follow-up periods.
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Affiliation(s)
- Christopher Williams
- Physical Medicine and Rehabilitation, Interventional Orthopedics and Regenerative Medicine, Interventional Orthopedics of Atlanta, Atlanta, USA
| | - Mairin Jerome
- Physical Medicine and Rehabilitation, Regenerative SportsCare Institute, New York, USA
| | - Chaz Fausel
- Physical Medicine and Rehabilitation, Advanced Regenerative Health, Denver, USA
| | - Ehren Dodson
- Research and Development, Regenexx, LLC, Des Moines, USA
| | - Ian Stemper
- Research and Development, Regenexx, LLC, Des Moines, USA
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Sit RWS, Wu RWK, Rabago D, Reeves KD, Chan DCC, Yip BHK, Chung VCH, Wong SYS. Efficacy of Intra-Articular Hypertonic Dextrose (Prolotherapy) for Knee Osteoarthritis: A Randomized Controlled Trial. Ann Fam Med 2020; 18:235-242. [PMID: 32393559 PMCID: PMC7214004 DOI: 10.1370/afm.2520] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/23/2019] [Accepted: 11/04/2019] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To test the efficacy of intra-articular hypertonic dextrose prolotherapy (DPT) vs normal saline (NS) injection for knee osteoarthritis (KOA). METHODS A single-center, parallel-group, blinded, randomized controlled trial was conducted at a university primary care clinic in Hong Kong. Patients with KOA (n = 76) were randomly allocated (1:1) to DPT or NS groups for injections at weeks 0, 4, 8, and 16. The primary outcome was the Western Ontario McMaster University Osteoarthritis Index (WOMAC; 0-100 points) pain score. The secondary outcomes were the WOMAC composite, function and stiffness scores; objectively assessed physical function test results; visual analogue scale (VAS) for knee pain; and EuroQol-5D score. All outcomes were evaluated at baseline and at 16, 26, and 52 weeks using linear mixed model. RESULTS Randomization produced similar groups. The WOMAC pain score at 52 weeks showed a difference-in-difference estimate of -10.34 (95% CI, -19.20 to -1.49, P = 0.022) points. A similar favorable effect was shown on the difference-in-difference estimate on WOMAC function score of -9.55 (95% CI, -17.72 to -1.39, P = 0.022), WOMAC composite score of -9.65 (95% CI, -17.77 to -1.53, P = 0.020), VAS pain intensity score of -10.98 (95% CI, -21.36 to -0.61, P = 0.038), and EuroQol-5D VAS score of 8.64 (95% CI, 1.36 to 5.92, P = 0.020). No adverse events were reported. CONCLUSION Intra-articular dextrose prolotherapy injections reduced pain, improved function and quality of life in patients with KOA compared with blinded saline injections. The procedure is straightforward and safe; the adherence and satisfaction were high.
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Affiliation(s)
- Regina Wing Shan Sit
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong
| | - Ricky Wing Keung Wu
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong
| | - David Rabago
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kenneth Dean Reeves
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, Kansas
| | - Dicken Cheong Chun Chan
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong
| | - Benjamin Hon Kei Yip
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong
| | - Vincent Chi Ho Chung
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong
| | - Samuel Yeung Shan Wong
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong
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Sert AT, Sen EI, Esmaeilzadeh S, Ozcan E. The Effects of Dextrose Prolotherapy in Symptomatic Knee Osteoarthritis: A Randomized Controlled Study. J Altern Complement Med 2020; 26:409-417. [PMID: 32223554 DOI: 10.1089/acm.2019.0335] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective: To investigate the effects of dextrose prolotherapy in patients with knee osteoarthritis (KOA). Design: A prospective, randomized-controlled interventional trial. Setting: An outpatient pain medicine clinic. Participants: The study included 66 patients aged 40-70 years with chronic knee pain refractory to conservative therapy and diagnosed as grade II or III KOA according to the Kellgren-Lawrence classification. The patients were assigned to dextrose prolotherapy group (PG; n = 22), saline group (SG; n = 22), or control group (CG; n = 22). Interventions: The intra- and extra-articular dextrose prolotherapy and saline injections were administered to the PG and SG, respectively, at 0, 3, and 6 weeks. The patients were blinded to their injection group status. A home-based exercise program was prescribed for all patients in all three groups. Outcome measures: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, activity pain, stiffness severity measured using a visual analog scale (VAS), and the health-related quality of life (HRQoL) scores measured using the Short Form-36 (SF-36) subscales were recorded at the baseline, 6-week, and 18-week follow-ups. Results: The WOMAC-pain and VAS-activity pain scores decreased significantly in the PG compared to the SG (p = 0.002 and p < 0.001, respectively) and CG (p < 0.001 and p < 0.001, respectively) at 18 weeks. The WOMAC-stiffness scores decreased in the PG compared to the CG at 18 weeks (p < 0.001). The WOMAC physical functioning scores were improved in the PG compared to the CG at 18 weeks (p < 0.001). The physical component scores of the HRQoL were significantly improved in the PG compared to the CG at 18 weeks (p = 0.016), but the mental component scores of the HRQoL showed no significant differences. Conclusions: These findings suggest that dextrose prolotherapy is effective at reducing pain and improving the functional status and quality of life in patients with KOA.
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Affiliation(s)
- Alketa T Sert
- Department of Physical Medicine and Rehabilitation, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Ekin I Sen
- Department of Physical Medicine and Rehabilitation, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Sina Esmaeilzadeh
- Department of Physical Medicine and Rehabilitation, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Emel Ozcan
- Department of Physical Medicine and Rehabilitation, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
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Procedural Treatments for Knee Osteoarthritis: A Review of Current Injectable Therapies. Pain Res Manag 2020; 2020:3873098. [PMID: 32148599 PMCID: PMC7049418 DOI: 10.1155/2020/3873098] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 12/18/2019] [Accepted: 01/22/2020] [Indexed: 12/13/2022]
Abstract
Knee osteoarthritis is a common painful degenerative condition affecting the aging Canadian population. In addition to pain and disability, osteoarthritis is associated with depression, comorbid conditions such as diabetes, and increased caregiver burden. It is predicted to cost the Canadian healthcare system $7.6 billion dollars by 2031. Despite its high cost and prevalence, controversy persists in the medical community regarding optimal therapies to treat knee osteoarthritis. A variety of medications like nonsteroidal anti-inflammatories and opioids can cause severe side effects with limited benefits. Total knee arthroplasty, although a definitive management, comes with risk such as postoperative infections, revisions, and chronic pain. Newer injectable therapies are gaining attention as alternatives to medications because of a safer side effect profile and are much less invasive than a joint replacement. Platelet-rich plasma is beginning to replace the more common injectable therapies of intra-articular corticosteroids and hyaluronic acid, but larger trials are needed to confirm this effect. Small studies have examined prolotherapy and stem cell therapy and demonstrate some benefits. Trials involving genicular nerve block procedures have been successful. As treatments evolve, injectable therapies may offer a safe and effective pathway for patients suffering from knee osteoarthritis.
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İşik R, Karapolat H, Bayram KB, Uşan H, Tanıgör G, Atamaz Çalış F. Effects of Short Wave Diathermy Added on Dextrose Prolotherapy Injections in Osteoarthritis of the Knee. J Altern Complement Med 2020; 26:316-322. [PMID: 32017856 DOI: 10.1089/acm.2019.0341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Objective: To show the effects of short wave diathermy (SWD) added on prolotherapy injections in osteoarthritis (OA) of the knee on pain, physical functioning, and quality of life. Design: This is a single-blinded randomized controlled study. Setting: Physical Medicine and Rehabilitation Department of a university hospital. Subjects: Sixty-three patients with OA of the knee with Kellgren-Lawrence class 2 or 3 were included in the study. Methods: Patients were randomized into two groups, first being dextrose prolotherapy+SWD and the second being dextrose prolotherapy with sham SWD. Patients were injected with dextrose prolotherapy solutions in the beginning, third, and sixth week of the study, for a total of three times, and took 20 min of SWD after injection (true or sham). Outcome measures: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Visual Analogue Scale (VAS) for pain, and Short Form Health Survey (SF-36) were applied before, after (sixth week), and at the third month of treatment. Results: Both groups showed improvements in VAS, WOMAC, and SF-36 scores (p < 0.05). Between-group analyses showed no significant differences (p > 0.05). Conclusions: This study shows that prolotherapy is effective for pain, functionality, and quality of life in patients with OA of the knee. The effects of additional SWD require more evidence. More studies of higher quality are required to make a statement.
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Affiliation(s)
- Rıdvan İşik
- Physical Medicine and Rehabilitation Department, Ege University School of Medicine, İzmir, Turkey
| | - Hale Karapolat
- Physical Medicine and Rehabilitation Department, Ege University School of Medicine, İzmir, Turkey
| | - Korhan Barıs Bayram
- Physical Medicine and Rehabilitation Department, Ataturk Research and Training Hospital, İzmir Kâtip Çelebi University, İzmir, Turkey
| | - Hicran Uşan
- Physical Medicine and Rehabilitation Department, Ankara Ulus State Hospital, Ankara, Turkey
| | - Göksel Tanıgör
- Physical Medicine and Rehabilitation Department, Ege University School of Medicine, İzmir, Turkey
| | - Funda Atamaz Çalış
- Physical Medicine and Rehabilitation Department, Ege University School of Medicine, İzmir, Turkey
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Prolotherapy for Musculoskeletal Pain and Disability in Low- and Middle-Income Countries. Phys Med Rehabil Clin N Am 2019; 30:775-786. [DOI: 10.1016/j.pmr.2019.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Prolotherapy for knee osteoarthritis using hypertonic dextrose vs other interventional treatments: systematic review of clinical trials. Adv Rheumatol 2019; 59:39. [DOI: 10.1186/s42358-019-0083-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 08/07/2019] [Indexed: 12/31/2022] Open
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Rabago D, Kansariwala I, Marshall D, Nourani B, Stiffler-Joachim M, Heiderscheit B. Dextrose Prolotherapy for Symptomatic Knee Osteoarthritis: Feasibility, Acceptability, and Patient-Oriented Outcomes in a Pilot-Level Quality Improvement Project. J Altern Complement Med 2019; 25:406-412. [PMID: 30688517 DOI: 10.1089/acm.2018.0361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- David Rabago
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ina Kansariwala
- University of Wisconsin School of Medicine and Public Health Madison, WI
| | - David Marshall
- University of Wisconsin School of Medicine and Public Health Madison, WI
| | - Bobby Nourani
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Mikel Stiffler-Joachim
- UW Neuromuscular Biomechanics Laboratory, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Bryan Heiderscheit
- UW Neuromuscular Biomechanics Laboratory, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Borg-Stein J, Osoria HL, Hayano T. Regenerative Sports Medicine: Past, Present, and Future (Adapted From the PASSOR Legacy Award Presentation; AAPMR; October 2016). PM R 2018; 10:1083-1105. [PMID: 30031963 DOI: 10.1016/j.pmrj.2018.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 07/06/2018] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Joanne Borg-Stein
- Spaulding Newton Wellesley Rehab Hospital Rehabilitation Center, 65 Walnut St, Wellesley, MA 02481
| | | | - Todd Hayano
- Spaulding Rehabilitation Hospital, Charlestown, MA
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22
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Maniquis-Smigel L, Reeves KD, Rosen HJ, Lyftogt J, Graham-Coleman C, Cheng AL, Rabago D. Analgesic Effect and Potential Cumulative Benefit from Caudal Epidural D5W in Consecutive Participants with Chronic Low-Back and Buttock/Leg Pain. J Altern Complement Med 2018; 24:1189-1196. [PMID: 29883193 PMCID: PMC6308281 DOI: 10.1089/acm.2018.0085] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objectives: Chronic low-back pain (CLBP) participants in a prior controlled study reported short-term pain relief after caudal epidural injection of 5% dextrose (D5W). This study assessed whether repeated caudal epidural injections of D5W results in serial short-term diminution of CLBP and progressive long-term decrease in pain and disability. Design: Prospective uncontrolled study. Settings/Location: Outpatient pain clinic. Subjects: Adults with CLBP with radiation to gluteal or leg areas. Interventions: Caudal epidural injection of 10 mL of D5W (without anesthetic) every 2 weeks for four treatments and then as needed for 1 year. Outcome measures: Numerical Rating Scale (NRS, pain, 0–10 points), Oswestry Disability Index (ODI, disability, %), and fraction of participants with ≥50% reduction in NRS score. Analysis by intention to treat. Results: Participants (n = 32, 55 ± 9.8 years old, nine female) had moderate-to-severe CLBP (6.5 ± 1.2 NRS points) for 11.1 ± 10.8 years. They received 5.5 ± 2.9 caudal D5W injections through 12 months of follow-up. The data capture rate for analysis was 94% at 12 months for NRS and ODI outcome measures, with 6% carried forward by intention to treat. A consistent pattern of analgesia was demonstrated after D5W injection. Compared with baseline status, NRS and ODI scores improved by 3.4 ± 2.3 (52%) and 18.2 ± 16.4% (42%) points, respectively. The fraction of participants with 50% reduction in NRS-based pain was 21/32 (66%). Conclusion: Epidural D5W injection, in the absence of anesthetic, resulted in consistent postinjection analgesia and clinically significant improvement in pain and disability through 12 months for most participants. The consistent pattern postinjection analgesia suggests a potential sensorineural effect of dextrose on neurogenic pain.
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Affiliation(s)
- Liza Maniquis-Smigel
- Private Practice, Physical Medicine and Rehabilitation and Pain Management, Hilo and Honolulu, HI
| | - Kenneth Dean Reeves
- Department of Physical Medicine and Rehabilitation, University of Kansas, Kansas City, KS
| | | | - John Lyftogt
- Private Practice, Retired, Christchurch, New Zealand
| | | | - An-Lin Cheng
- Department of Biomedical and Health Informatics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO
| | - David Rabago
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Sit RWS, Wu RWK, Reeves KD, Rabago D, Chan DCC, Yip BHK, Chung VCH, Wong SYS. Efficacy of intra-articular hypertonic dextrose prolotherapy versus normal saline for knee osteoarthritis: a protocol for a triple-blinded randomized controlled trial. Altern Ther Health Med 2018; 18:157. [PMID: 29764447 PMCID: PMC5952445 DOI: 10.1186/s12906-018-2226-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 05/02/2018] [Indexed: 12/26/2022]
Abstract
Background Knee Osteoarthritis (KOA) is a very common condition with prevalence rising with age. It is a major contributor to global disability and has a large socioeconomic burden worldwide. Conservative therapies have marginal effectiveness, and surgery is reserved for severe symptomatic KOA. Dextrose Prolotherapy (DPT) is an evidence-based injection-based therapy for chronic musculoskeletal conditions including KOA. The standard “whole joint” injection method includes intra-articular injection and multiple extra-articular injections at soft tissue bony attachments. The procedure is painful and requires intensive procedural training often unavailable in conventional medical education, which potentially limits access. Intra-articular injection offers the possibility of a less painful, more accessible treatment. The aim of this project is to assess the clinical efficacy of intra-articular injection of DPT versus normal saline (NS) for KOA. Method Seventy-six participants with KOA will be recruited from the community. We will conduct a single center, parallel group, superiority randomized controlled trial comparing DPT and NS injections, with blinding of physician, participants, outcome assessors and statisticians. Each group will receive injections at week 0, 4, 8 and 16. The primary outcome will be the Western Ontario McMaster University Osteoarthritis Index pain scale (WOMAC), and secondary outcomes include WOMAC composite score, the WOMAC function and stiffness subscale, the Visual Analogue Score of pain, objective physical function tests (the 30 s chair stand, 40- m fast paced walk test, the Timed up and go test) and the EuroQol-5D (EQ-5D). All outcomes will be evaluated at baseline, and 16, 26 and 52 weeks. All analyses will be conducted on an intention-to-treat basis using linear mixed regression models. Discussion This paper presents the rationale, design, method and operational aspects of the trial. The findings will determine whether IA DPT, an inexpensive and simple injection, is a safe and effective non-surgical option for KOA. The results can be translated directly to clinical practice, with potentially substantial impact to patient care. Trial registration The trial (ChiCTR-IPC-15006617) is registered under Chinese Clinical Trials Registry on 17th June 2015.
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Alternatives to Biologics in Management of Knee Osteoarthritis: A Systematic Review. Sports Med Arthrosc Rev 2018; 26:79-85. [PMID: 29722769 DOI: 10.1097/jsa.0000000000000190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Knee osteoarthritis (KOA) is a common condition encountered by physicians. KOA is addressed by a wide array of modalities including a number of nonbiological treatments. METHODS PubMed, ISI Web of Science, and SPORTDiscus were searched for level 1 to 4 studies published from inception to August 2017. RESULTS A total of 18 studies were evaluated and results demonstrated moderate supporting evidence for prolotherapy and limited evidence for botulinum toxin type A, sodium bicarbonate and calcium gluconate, and low-molecular weight fraction of 5% human serum albumin. Evidence for local anesthetic agents was conflicting. CONCLUSION There is moderate supportive evidence for the effectiveness of prolotherapy in improving pain and function in both, short-term and long-term. Limited supporting evidence found for botulinum toxin type A, sodium bicarbonate and calcium gluconate, and low-molecular weight fraction of 5% human serum albumin in improving pain and function. There is conflicting evidence for the use of local anesthetic agents in patients with KOA.
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Rabago D, Nourani B. Prolotherapy for Osteoarthritis and Tendinopathy: a Descriptive Review. Curr Rheumatol Rep 2018; 19:34. [PMID: 28484944 DOI: 10.1007/s11926-017-0659-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Osteoarthritis and overuse tendinopathy are common chronic conditions of high societal and patient burden. The precise etiology of pain and disability in both conditions is multifactorial and not well understood. Patients are often refractory to conservative therapy. The development of new therapeutic options in both conditions is a public health priority. Prolotherapy is an injection-based outpatient regenerative therapy for chronic musculoskeletal conditions, including osteoarthritis and tendinopathy. The authors reviewed the basic science and clinical literature associated with prolotherapy for these conditions. RECENT FINDINGS Systematic review, including meta-analysis, and randomized controlled trials suggest that prolotherapy may be associated with symptom improvement in mild to moderate symptomatic knee osteoarthritis and overuse tendinopathy. Although the mechanism of action is not well understood and is likely multifactorial, a growing body of literature suggests that prolotherapy for knee osteoarthritis may be appropriate for the treatment of symptoms associated with knee osteoarthritis in carefully selected patients who are refractory to conservative therapy and deserves further basic and clinical science investigation for the treatment of osteoarthritis and tendinopathy.
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Affiliation(s)
- David Rabago
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53715, USA.
| | - Bobby Nourani
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53715, USA
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27
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Musculoskeletal Injuries and Regenerative Medicine in the Elderly Patient. Phys Med Rehabil Clin N Am 2017; 28:777-794. [DOI: 10.1016/j.pmr.2017.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Hassan F, Trebinjac S, Murrell WD, Maffulli N. The effectiveness of prolotherapy in treating knee osteoarthritis in adults: a systematic review. Br Med Bull 2017; 122:91-108. [PMID: 28334196 DOI: 10.1093/bmb/ldx006] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 02/10/2017] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Osteoarthritis (OA) often leads to symptoms such as pain, stiffness and decreased function. OA is treated with a wide range of modalities, both conservatively and surgically. Prolotherapy has been used to treat various musculoskeletal problems and has shown some promise. SOURCES OF DATA Searches of the electronic databases, PubMed, ISI web of science, PEDro and SPORTDiscus, were conducted for all Level 1-4 studies published from inception through to December 2016. AREAS OF AGREEMENT Ten studies were evaluated and results show significant improvement in scores for pain, function and range of motion, both in the short term and long term. Patient satisfaction was also high in these patients (82%). AREAS OF CONTROVERSY Meta-analysis was not possible due to heterogeneity of outcome measures and populations. GROWING POINTS Moderate evidence suggests that prolotherapy is safe and can help achieve significant symptomatic control in individuals with OA. AREAS FOR DEVELOPING RESEARCH Future research should focus on larger sample size, standardization of treatment protocol and basic science evidence.
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Affiliation(s)
- Fadi Hassan
- Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, B75 7RR, UK
| | - Suad Trebinjac
- Dubai Physiotherapy & Rehabilitation Center, Al Garhoud Private Hospital, Al Garhoud, United Arab Emirates
| | - William D Murrell
- Deparment of Orthopaedic Sports Medicine, Dr Humeira Badsha Medical Center, Dubai, United Arab Emirates.,Department of Orthopaedics, Rehabilitation and Podiatry, Ft. Belvoir Community Hospital, Ft. Belvoir, VA, USA
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Dentistry, Salerno, Italy.,Queen Mary University of London, Barts and the London School of Medicine and Dentistry Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England
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Proliferative injection therapy for osteoarthritis: a systematic review. INTERNATIONAL ORTHOPAEDICS 2017; 41:671-679. [PMID: 28190092 DOI: 10.1007/s00264-017-3422-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 01/27/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE To systematically analyse randomised controlled trials (RCTs) about efficacy and safety of proliferative injection therapy (prolotherapy) for treatment of osteoarthritis (OA). METHODS CENTRAL, Embase and MEDLINE were searched. Two reviewers independently conducted screening and data extraction. RCTs were assessed with the Cochrane risk of bias tool. Type of treatment, study design, dosing, efficacy outcomes and safety outcomes were analysed. The protocol was registered in PROSPERO (CRD42016035258). RESULTS Seven RCTs were included, with 393 participants aged 40-75 years and mean OA pain duration from three months to eight years. Follow-up was 12 weeks to 12 months. Studies analysed OA of the knee joint (n = 5), first carpometacarpal joint (n = 1) and finger joints (n = 1). Various types of prolotherapy were used; dextrose was the most commonly used irritant agent. All studies concluded that prolotherapy was effective treatment for OA. No serious adverse events were reported. The studies had considerable methodological limitations. DISCUSSION Limited evidence from low-quality studies indicates a beneficial effect of prolotherapy for OA management. The number of participants in these studies was too small to provide reliable evidence. CONCLUSIONS Current data from trials about prolotherapy for OA should be considered preliminary, and future high-quality trials on this topic are warranted.
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Maniquis-Smigel L, Dean Reeves K, Jeffrey Rosen H, Lyftogt J, Graham-Coleman C, Cheng AL, Rabago D. Short Term Analgesic Effects of 5% Dextrose Epidural Injections for Chronic Low Back Pain: A Randomized Controlled Trial. Anesth Pain Med 2016; 7:e42550. [PMID: 28920043 PMCID: PMC5554430 DOI: 10.5812/aapm.42550] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 11/09/2016] [Accepted: 11/25/2016] [Indexed: 12/15/2022] Open
Abstract
Background Hypertonic dextrose injection (prolotherapy) is reported to reduce pain including non-surgical chronic low back pain (CLBP), and subcutaneous injection of 5% dextrose is reported to reduce neurogenic pain, hyperalgesia and allodynia. The mechanism in both cases is unclear, though a direct effect of dextrose on neurogenic pain has been proposed. This study assessed the short-term analgesic effects of epidural 5% dextrose injection compared with saline for non-surgical CLBP. Methods Randomized double-blind (injector, participant) controlled trial. Adults with moderate-to-severe non-surgical low back pain with radiation to gluteal or leg areas for at least 6 months received a single epidurogram-confirmed epidural injection of 10 mL of 5% dextrose or 0.9% saline using a published vertical caudal injection technique. The primary outcome was change in a numerical rating scale (NRS, 0 - 10 points) pain score between baseline and 15 minutes; and 2, 4, and 48 hours and 2 weeks post-injection. The secondary outcome was percentage of participants achieving 50% or more pain improvement at 4 hours. Results and Conclusions No baseline differences existed between groups; 35 participants (54 ± 10.7 years old; 11 female) with moderate-to-severe CLBP (6.7 ± 1.3 points) for 10.6 ± 10.5 years. Dextrose participants reported greater NRS pain score change at 15 minutes (4.4 ± 1.7 vs 2.4 ± 2.8 points; P = 0.015), 2 hours (4.6 ± 1.9 vs 1.8 ± 2.8 points; P = 0.001), 4 hours (4.6 ± 2.0 vs 1.4 ± 2.3 points; P < 0.001), and 48 hours (3.0 ± 2.3 vs 1.0 ± 2.1 points; P = 0.012), but not at 2 weeks (2.1 ± 2.9 vs 1.2 ± 2.4 points; P = 0.217). Eighty four percent (16/19) of dextrose recipients and 19% (3/16) of saline recipients reported ≥ 50% pain reduction at 4 hours (P < 0.001). These findings suggest a neurogenic effect of 5% dextrose on pain at the dorsal root level; waning pain control at 2 weeks suggests the need to assess the effect of serial dextrose epidural injections in a long-term study with robust outcome assessment.
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Affiliation(s)
| | - Kenneth Dean Reeves
- Private Practice PM&R and Pain Management, Roeland Park, Kansas, Past Clinical Assistant/Associate Professor (1986-2015) University of Kansas Department of PM&R, Kansas City, Kansas
- Corresponding author: Kenneth Dean Reeves, Private Practice PM&R and Pain Management, Roeland Park, Kansas, Past Clinical Assistant/Associate Professor (1986-2015) University of Kansas Department of PM&R, Kansas City, Kansas. Tel: +1-9133621600, Fax: +1-913362-4452, E-mail:
| | - Howard Jeffrey Rosen
- Private Practice Anesthesiology and Pain Management, Anaheim and Monterey, California, U.S.A
| | | | | | - An-Lin Cheng
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, 2411 Holmes Street, Kansas City, MO, 64108
| | - David Rabago
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, 1100 Delaplaine Court, Madison, Wisconsin, U.S A. 53715
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Hung CY, Hsiao MY, Chang KV, Han DS, Wang TG. Comparative effectiveness of dextrose prolotherapy versus control injections and exercise in the management of osteoarthritis pain: a systematic review and meta-analysis. J Pain Res 2016; 9:847-857. [PMID: 27799816 PMCID: PMC5079700 DOI: 10.2147/jpr.s118669] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Increasing evidence has supported the use of dextrose prolotherapy for patients with osteoarthritis. However, the real benefits may be affected by differences in injection protocols, comparative regimens, and evaluation scales. METHODS PubMed and Scopus were searched from the earliest record until February 2016. One single-arm study and five randomized controlled trials were included, comprising 326 participants. We estimated the effect sizes of pain reduction before and after serial dextrose injections and compared the values between dextrose prolotherapy, comparative regimens, and exercise 6 months after the initial injection. RESULTS Regarding the treatment arm using dextrose prolotherapy, the effect sizes compared with baseline were 0.65 (95% confidence interval [CI], 0.14-1.17), 0.84 (95% CI, 0.40-1.27), 0.85 (95% CI, 0.60-1.10), and 0.87 (95% CI, 0.53-1.21) after the first, second, third, and fourth or more injections, respectively. The overall effect of dextrose was better than control injections (effect size, 0.36; 95% CI, 0.10-0.63). Dextrose prolotherapy had a superior effect compared with local anesthesia (effect size, 0.38; 95% CI, 0.07-0.70) and exercise (effect size, 0.71; 95% CI, 0.30-1.11). There was an insignificant advantage of dextrose over corticosteroids (effect size, 0.31; 95% CI, -0.18 to 0.80) which was only estimated from one study. CONCLUSION Dextrose injections decreased pain in osteoarthritis patients but did not exhibit a positive dose-response relationship following serial injections. Dextrose prolotherapy was found to provide a better therapeutic effect than exercise, local anesthetics, and probably corticosteroids when patients were retested 6 months following the initial injection.
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Affiliation(s)
- Chen-Yu Hung
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan
| | - Ming-Yen Hsiao
- National Taiwan University College of Medicine, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan; National Taiwan University College of Medicine, Taipei, Taiwan
| | - Der-Sheng Han
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan; National Taiwan University College of Medicine, Taipei, Taiwan
| | - Tyng-Guey Wang
- National Taiwan University College of Medicine, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
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Rabago D, van Leuven L, Benes L, Fortney L, Slattengren A, Grettie J, Mundt M. Qualitative Assessment of Patients Receiving Prolotherapy for Knee Osteoarthritis in a Multimethod Study. J Altern Complement Med 2016; 22:983-989. [PMID: 27603001 DOI: 10.1089/acm.2016.0164] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Randomized and open-label studies assessing prolotherapy for knee osteoarthritis have found quantitative improvement on the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC) compared with baseline status and control therapies. This study assessed the qualitative response of participants receiving prolotherapy, an injection-based complementary treatment for symptomatic knee osteoarthritis (OA). DESIGN Qualitative study using semi-structured in-depth interviews at 52 weeks after enrollment; transcribed responses were discussed by coauthors to identify themes; disagreement was resolved by consensus. SETTING Outpatient. PARTICIPANTS Twenty-two participants treated with prolotherapy for symptomatic knee OA who were exited from three randomized and open-label studies. INTERVENTIONS Intra- and extra-articular hypertonic dextrose injection (prolotherapy). MAIN OUTCOME MEASURES Patient narrative and composite WOMAC questionnaire (0-100 points) scores. RESULTS Participants had baseline demographic and knee OA severity similar to those of participants in three prior intervention trials, as well as similar robust follow-up WOMAC score change (19.9 ± 12.6 points), suggesting a representative subsample. Seven themes were identified from participant narratives: (1) improvement in knee-specific quality of life (n = 18), (2) safety and comfort, (3) pretreatment counseling enhanced treatment adherence and optimism, (4) overall positive experience with prolotherapy, (5) limited response to prolotherapy (n = 4), (6) consistency with anecdotal clinical prolotherapy experience; and (7) functional improvement without pain reduction. CONCLUSIONS Most participants reported substantially improved knee-specific effects, resulting in improved quality of life and activities of daily living; four participants reported minimal or no effect. Clear, complete description of procedural rationale may enhance optimism about and adherence to treatment appointments.
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Affiliation(s)
- David Rabago
- 1 The Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health , Madison, WI
| | - Laura van Leuven
- 1 The Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health , Madison, WI
| | - Lane Benes
- 2 Department of Medicine, University of Chicago , Chicago, IL
| | - Luke Fortney
- 3 McKee Clinic Family Medicine , Meriter Unity Point Health, Madison, WI
| | - Andrew Slattengren
- 4 Department of Family Medicine and Community Health, Broadway Family Medicine Clinic, University of Minnesota Medical School , Minneapolis, MN
| | - Jessica Grettie
- 5 Wisconsin Center for Education Research, University of Wisconsin , Madison, WI
| | - Marlon Mundt
- 1 The Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health , Madison, WI
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Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2016; 9:139-59. [PMID: 27429562 PMCID: PMC4938120 DOI: 10.4137/cmamd.s39160] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 04/20/2016] [Accepted: 05/03/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of this study was to systematically review dextrose (d-glucose) prolotherapy efficacy in the treatment of chronic musculoskeletal pain. DATA SOURCES Electronic databases PubMed, Healthline, OmniMedicalSearch, Medscape, and EMBASE were searched from 1990 to January 2016. STUDY SELECTION Prospectively designed studies that used dextrose as the sole active prolotherapy constituent were selected. DATA EXTRACTION Two independent reviewers rated studies for quality of evidence using the Physiotherapy Evidence Database assessment scale for randomized controlled trials (RCTs) and the Downs and Black evaluation tool for non-RCTs, for level of evidence using a modified Sackett scale, and for clinically relevant pain score difference using minimal clinically important change criteria. Study population, methods, and results data were extracted and tabulated. DATA SYNTHESIS Fourteen RCTs, 1 case–control study, and 18 case series studies met the inclusion criteria and were evaluated. Pain conditions were clustered into tendinopathies, osteoarthritis (OA), spinal/pelvic, and myofascial pain. The RCTs were high-quality Level 1 evidence (Physiotherapy Evidence Database ≥8) and found dextrose injection superior to controls in Osgood–Schlatter disease, lateral epicondylitis of the elbow, traumatic rotator cuff injury, knee OA, finger OA, and myofascial pain; in biomechanical but not subjective measures in temporal mandibular joint; and comparable in a short-term RCT but superior in a long-term RCT in low back pain. Many observational studies were of high quality and reported consistent positive evidence in multiple studies of tendinopathies, knee OA, sacroiliac pain, and iliac crest pain that received RCT confirmation in separate studies. Eighteen studies combined patient self-rating (subjective) with psychometric, imaging, and/or biomechanical (objective) outcome measurement and found both positive subjective and objective outcomes in 16 studies and positive objective but not subjective outcomes in two studies. All 15 studies solely using subjective or psychometric measures reported positive findings. CONCLUSION Use of dextrose prolotherapy is supported for treatment of tendinopathies, knee and finger joint OA, and spinal/pelvic pain due to ligament dysfunction. Efficacy in acute pain, as first-line therapy, and in myofascial pain cannot be determined from the literature.
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Affiliation(s)
- Ross A Hauser
- Caring Medical Regenerative Medicine Clinics, Oak Park, IL, USA
| | | | | | - David K Harris
- Center for Healing and Regenerative Medicine, Austin, TX, USA
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Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: A systematic review and meta-analysis. Sci Rep 2016; 6:25247. [PMID: 27146849 PMCID: PMC4857084 DOI: 10.1038/srep25247] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 04/13/2016] [Indexed: 12/15/2022] Open
Abstract
Hypertonic dextrose injections (prolotherapy) is an emerging treatment for symptomatic knee osteoarthritis (OA) but its efficacy is uncertain. We conducted a systematic review with meta-analysis to synthesize clinical evidence on the effect of prolotherapy for knee OA. Fifteen electronic databases were searched from their inception to September 2015. The primary outcome of interest was score change on the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Three randomized controlled trials (RCTs) of moderate risk of bias and one quasi-randomized trial were included, with data from a total of 258 patients. In the meta-analysis of two eligible studies, prolotherapy is superior to exercise alone by a standardized mean difference (SMD) of 0.81 (95% CI: 0.18 to 1.45, p = 0.012), 0.78 (95% CI: 0.25 to 1.30, p = 0.001) and 0.62 (95% CI: 0.04 to 1.20, p = 0.035) on the WOMAC composite scale; and WOMAC function and pain subscale scores respectively. Moderate heterogeneity exists in all cases. Overall, prolotherapy conferred a positive and significant beneficial effect in the treatment of knee OA. Adequately powered, longer-term trials with uniform end points are needed to better elucidate the efficacy of prolotherapy.
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Topol GA, Podesta LA, Reeves KD, Giraldo MM, Johnson LL, Grasso R, Jamín A, Clark T, Rabago D. Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis. PM R 2016; 8:1072-1082. [PMID: 27058744 DOI: 10.1016/j.pmrj.2016.03.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 03/24/2016] [Accepted: 03/25/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Dextrose injection is reported to improve knee osteoarthritis (KOA)-related clinical outcomes, but its effect on articular cartilage is unknown. A chondrogenic effect of dextrose injection has been proposed. OBJECTIVE To assess biological and clinical effects of intra-articular hypertonic dextrose injections (prolotherapy) in painful KOA. DESIGN Case series with blinded arthroscopic evaluation before and after treatment. SETTING Physical medicine and day surgery practice. PARTICIPANTS Symptomatic KOA for at least 6 months, arthroscopy-confirmed medial compartment exposed subchondral bone, and temporary pain relief with intra-articular lidocaine injection. INTERVENTION Four to 6 monthly 10-mL intra-articular injections with 12.5% dextrose. MAIN OUTCOME MEASURES Visual cartilage growth assessment of 9 standardized medial condyle zones in each of 6 participants by 3 arthroscopy readers masked to pre-/postinjection status (total 54 zones evaluated per reader); biopsy of a cartilage growth area posttreatment, evaluated using hematoxylin and eosin and Safranin-O stains, quantitative polarized light microscopy, and immunohistologic cartilage typing; self-reported knee specific quality of life using the Western Ontario McMaster University Osteoarthritis Index (WOMAC, 0-100 points). RESULTS Six participants (1 female and 5 male) with median age of 71 years, WOMAC composite score of 57.5 points, and a 9-year pain duration received a median of 6 dextrose injections and follow-up arthroscopy at 7.75 months (range 4.5-9.5 months). In 19 of 54 zone comparisons, all 3 readers agreed that the posttreatment zone showed cartilage growth compared with the pretreatment zone. Biopsy specimens showed metabolically active cartilage with variable cellular organization, fiber parallelism, and cartilage typing patterns consistent with fibro- and hyaline-like cartilage. Compared with baseline status, the median WOMAC score improved 13 points (P = .013). Self-limited soreness after methylene blue instillation was noted. CONCLUSIONS Positive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA, suggesting disease-modifying effects and the need for confirmation in controlled studies. Minimally invasive arthroscopy (single-compartment, single-portal) enabled collection of robust intra-articular data. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Gastón Andrés Topol
- Department of Physical Medicine and Rehabilitation, National University of Rosario, Rosario, Argentina(∗)
| | | | - Kenneth Dean Reeves
- Private Practice Physical Medicine and Rehabilitation, Roeland Park, Kansas City, KS 66205; Department of PM&R, University of Kansas Medical Center, Kansas City, KS(‡).
| | | | - Lanny L Johnson
- Department of Radiology, College of Human Medicine, Michigan State University, East Lansing, MI; Department of Orthopaedic Surgery, Michigan State University, East Lansing, MI(‖)
| | - Raul Grasso
- Deceased; previously private practice anatamopathology consultation, Rosario, Argentina; Provincial Hospital Domingo Funes, Santa Maria de Punilla, Argentina(¶)
| | - Alexis Jamín
- Department of Radiology, Hospital Emergencia Clemente Alvarez, Rosario, Argentina(#)
| | - Tom Clark
- Private practice ultrasonographic training, Vista, CA(∗∗)
| | - David Rabago
- Department of Family Medicine and Community Health, University of Wisconsin, School of Medicine and Public Health, Madison, WI(††)
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Nourani B, Rabago D. Prolotherapy for Knee Osteoarthritis: A Descriptive Review. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2016. [DOI: 10.1007/s40141-016-0111-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Rabago D, Mundt M, Zgierska A, Grettie J. Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis: Long term outcomes. Complement Ther Med 2015; 23:388-95. [DOI: 10.1016/j.ctim.2015.04.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 11/26/2014] [Accepted: 04/01/2015] [Indexed: 12/13/2022] Open
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Bertrand H, Kyriazis M, Reeves KD, Lyftogt J, Rabago D. Topical Mannitol Reduces Capsaicin-Induced Pain: Results of a Pilot-Level, Double-Blind, Randomized Controlled Trial. PM R 2015; 7:1111-1117. [PMID: 25978942 DOI: 10.1016/j.pmrj.2015.05.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 05/01/2015] [Accepted: 05/02/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Capsaicin specifically activates, and then gradually exhausts, the transient receptor potential vanilloid type 1 (TRPV1) receptor, a key receptor in neuropathic pain. Activation of the TRPV-1 receptor is accompanied by burning pain. A natural substance or medication that can reduce the burning pain resulting from capsaicin application may have therapeutic potential in neuropathic pain. OBJECTIVE To assess the pain-relieving effects of a mannitol-containing cream in a capsaicin-based pain model. DESIGN Randomized, placebo-controlled, double-blind clinical trial. SETTING Outpatient pain clinic. PARTICIPANTS Twenty-five adults with pain-free lips. METHODS Capsaicin .075% cream was applied to both halves of each participant's upper lip, inducing pain via stimulation of the transient receptor potential vanilloid 1 (TRPV1, capsaicin) receptor, then removed after 5 minutes or when participants reported a burning pain of 8/10, whichever came first. A cream containing mannitol and the same cream without mannitol (control) were then immediately applied, 1 on each side of the lip, in an allocation-masked manner. OUTCOME MEASURES Participants self-recorded a numeric rating scale (NRS, 0-10) pain score for each side of the lip per minute for 10 minutes. A t-test was performed to evaluate the pain score change from baseline between each side of the lip at each recording. Area under the curve (AUC) analysis was used to determine the overall difference between groups. RESULTS Participants reached a capsaicin-induced pain level of 7.8 ± 1.0 points in 3.3 ± 1.6 minutes that was equal on both sides of the lip. Both groups reported progressive diminution of pain over the 10-minute study period. However, participants reported significantly reduced pain scores on the mannitol cream half-lip compared to control at 3 through 10 minutes (P < .05) and in AUC analysis (P < .001). CONCLUSIONS Mannitol cream reduced self-reported pain scores in a capsaicin pain model more rapidly than a control cream, potentially via a TRPV1 receptor effect.
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Affiliation(s)
| | - Marylene Kyriazis
- University of British Columbia, Faculty of Pharmaceutical Sciences, North Vancouver, BC, Canada
| | - K Dean Reeves
- Department of Physical Medicine and Rehabilitation, University of Kansas, Kansas City, KS
| | - John Lyftogt
- Private Practice Sports Medicine, retired, Cass Bass, Lyttelton, New Zealand
| | - David Rabago
- Department of Family Medicine, University of Wisconsin, Madison, WI
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