Is Dextrose Prolotherapy Superior To Corticosteroid Injection In Patients With Chronic Lateral Epicondylitis?: A Randomized Clinical Trial

In the Treatment of Lateral Epicondylitis by Percutaneous Perforation, Injectables Have No Added Value

BACKGROUND

No single injection therapy has been proven to be superior in the treatment of lateral epicondylitis. In most studies, the injection technique is not standardized, which makes it challenging to compare outcomes.

QUESTIONS/PURPOSES

(1) Does injection with autologous blood, dextrose, or needle perforation only at the extensor carpi radialis brevis tendon origin produce better VAS pain scores during provocation testing at 5 months of follow-up? (2) Which percutaneous technique resulted in better secondary outcome measures: VAS during rest and activity, VAS during maximum grip, Oxford elbow score (OES), QuickDASH, Patient-related Tennis Elbow Evaluation (PRTEE), or EuroQol-5D (EQ-5D)?

METHODS

In this multicenter, randomized controlled trial performed from November 2015 to January 2020, 166 patients with lateral epicondylitis were included and assigned to one of the three treatment groups: autologous blood, dextrose, or perforation only. Complete follow-up data were available for the primary outcome measures at the 5-month follow-up interval for 77% (127 of 166) of patients. Injections of the extensor carpi radialis brevis tendon were conducted in an accurate and standardized way. The three groups did not differ in terms of key variables such as age, gender, duration of symptoms, smoking habits, pain medication, and physiotherapy use. Data were collected at baseline and 8 weeks, 5 months, and 1 year after treatment and compared among the groups. The primary endpoint was the VAS pain score with provocation at 5 months. Our secondary study outcomes were VAS pain scores during rest, after activity, and after maximum grip strength; functional recovery; and quality of life. Therefore, we report the VAS pain score (0 to 100, with higher scores representing more-severe pain, minimum clinically important difference [MCID] 10), OES (0 to 48, with higher scores representing more satisfactory joint function, MCID 10), QuickDASH (0 to 100, with higher scores representing more severe disability, MCID 5.3), PRTEE (0 to 100, with higher scores representing more pain or more disability, MCID 20), EQ-5D/QALY (EQ-5D sumscore 0 to 1, with the maximum score of 1 representing the best health state, MCID 0.04), and EQ-5D VAS (0 to 100, with higher scores representing the best health status, MCID 8). For analysis, one-way analysis of variance and a linear mixed-model analysis were used. The analyses were performed according to the intention-to-treat principle. Four patients from the perforation group opted to crossover to autologous blood after 5 months.

RESULTS

No injection therapy proved to be superior to any other in terms of VAS pain scores during the provocation test at 5 months of follow-up (VAS for perforation: 25 ± 31; autologous blood: 26 ± 27; dextrose: 29 ± 32; p = 0.35). For the secondary outcomes, only a clinically important difference was found for the QuickDASH score. Both the perforation-only group (-8 [98% CI -4 to -12]) and autologous blood (-7 points [98% CI -3 to -11]) had improved QuickDASH scores over time compared with the dextrose group (MCID 5.3; p < 0.01). For the other outcomes, no clinically important differences were found.

CONCLUSION

There is no benefit to injectable autologous blood and dextrose over perforation alone to treat lateral epicondylitis, and they are therefore not indicated for this condition.

LEVEL OF EVIDENCE

Level I, therapeutic study.

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.

Local Corticosteroid Injection Versus Dry Needling in the Treatment of Lateral Epicondylitis

Background Lateral epicondylitis (LE) is an inflammation or micro-tearing of the tendons that join the forearm muscles on the lateral aspect of the elbow. Primary treatment of LE includes rest from offending activity and corticosteroid therapy for pain control. Dry needling (DN) is a relatively new therapy for LE. This study examined the results of DN therapy with corticosteroid injection. We aimed to compare pain relief and improvements in functional disability of LE patients treated via DN and corticosteroid injection in a tertiary care center. Methodology A prospective randomized control study was conducted among 54 patients in the Orthopaedics Department of R L Jalappa Hospital from January 2022 to May 2022. Patients received either DN or injectable corticosteroid therapy, and treatment groups were randomized using single-blinded randomization with sealed envelopes. Patients were evaluated using the Patient-Related Tennis Elbow Evaluation (PRTEE) score before the intervention and four and eight weeks after the intervention. Results A total of 54 patients were included in the final analysis. The mean age in the DN group was 43.96 ± 8.15 years and 44.74 ± 8.33 years in the corticosteroid group. In the DN group, 17 (62.96%) patients were male, and in the corticosteroid group, 16 (59.26%) patients were male. The differences in the PRTEE score at the fourth and eighth-week follow-up with baseline value (pre-injection) were statistically significant (p < 0.001). Conclusions DN is a low-cost, minimally invasive, and low-risk therapy whereas corticosteroid therapy is costly and produces systemic side effects in the long term. In this study, during the last follow-up visit, the PRTEE score improved in the DN group compared to the corticosteroid group.

Exploring the clinical efficacy of different nonsurgical rehabilitation interventions for humeral lateral epicondylitis: A protocol for network meta-analysis

BACKGROUND

Lateral epicondylitis is a common musculoskeletal disorder characterized by the decreased grip and upper limb strength and pain in the lateral aspect of the elbow joint. At present, shock wave, corticosteroid injection, platelet-rich plasma injection, and Dextrose prolotherapy therapy nonsurgical rehabilitation treatment methods are commonly used in clinical. However, the conclusions of studies comparing treatment efficacy between them are controversial, with most studies focusing on limited comparisons and a lack of direct and indirect comparisons between them, making it difficult to have a clearer and more comprehensive understanding of the efficacy between them.

PURPOSE

To comprehensively compare the effectiveness of shockwave, corticosteroid injection, platelet-rich plasma injection, and Dextrose prolotherapy therapy for the treatment of external humeral lateral epicondylitis using a reticulo-meta-analysis.

METHODS

Randomized controlled trials on the effectiveness of shock wave, corticosteroid injection, platelet-rich plasma injection, and Dextrose prolotherapy therapy for the treatment of external humeral lateral epicondylitis were searched in PubMed, The Cochrane Library, CNKI, and Wan-Fang databases for the period January 1, 2016 to January 1, 2021 for each database. Two investigators independently screened the literature, extracted data according to inclusion and exclusion criteria, and evaluated the quality of the literature in parallel. Statistical analyses were performed using Stata 14.0 software to compare differences in efficacy between treatment measures using ratio and 95% confidence interval as effect indicators and to rank efficacy.

RESULTS

Nine randomized controlled trials with a total of 289 patients with external humeral lateral epicondylitis were included, involving 4 nonsurgical rehabilitation measures and 6 intervention options. Quadrilateral ring to test the inconsistency of each closed-loop study finding, and the results show that the inconsistency factor was bounded at 1.65, with lower 95% confidence interval of 0.47 and 2.84 for both, which in summary indicates that the formation between the treatment measures in this study indicates that each closed-loop inconsistency was good. The SUCRA curve showed that platelet-rich plasma injection + shockwave was the first treatment with an area under the curve of 86.9%. Six treatment measures were ranked as follows: platelet-rich plasma injection + shockwave > platelet-rich plasma injection > shockwave > corticosteroid > corticosteroid + shockwave > prolotherapy.

CONCLUSIONS

It is believed that in the course of clinical practice, platelet-rich plasma injection combined with shockwave therapy can be preferred for patients with humeral epicondylitis.

Effects of splinting and three injection therapies (corticosteroid, autologous blood and prolotherapy) on pain, grip strength, and functionality in patients with lateral epicondylitis

Objectives

This study aims to compare the efficacy of the wrist splint and the injection of corticosteroid, autologous blood, and hypertonic dextrose in the treatment of lateral epicondylitis (LE).

Patients and methods

A total of 120 patients (43 males, 77 females; mean age: 45.7±7.7 years; range, 18 to 65 years) diagnosed with LE between December 2013 and June 2015 were included in the study and randomized into four groups. The first group was administered 20 mg methylprednisolone acetate + 2 mL 2% prilocaine, the second group 2 mL venous blood + 0.5 mL prilocaine, and the third group 2 mL 30% dextrose + 0.5 mL prilocaine injections. A second injection was administered to the third group one month later. The fourth group was recommended to use only a wrist splint. Pre-treatment and post-treatment evaluations of the patients were carried out at one and six months by the Visual Analog Scale (VAS) in terms of pain, by Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire in terms of functional level, and by the Jamar dynamometer in terms of grip strength.

Results

In all groups, VAS values at one and six months after treatment were found to be lower in comparison to baseline. Except for the splint group, a significant improvement was observed in all three injection groups in terms of grip strength and PRTEE values at six months compared to the baseline values. In the comparison of the groups, no significant difference was observed in terms of improvement in VAS scores and grip strength. While corticosteroid injection was significantly effective in terms of PRTEE pain, function, and total scores only at one month, the autologous injection was effective in terms of PRTEE function and total scores at only six months after treatment. There were no significant differences for splint and prolotherapy groups in terms of PRTEE scores.

Conclusion

Corticosteroid injection, autologous blood injection, and prolotherapy are effective and safe long-term methods in LE treatment.

The effectiveness of dextrose prolotherapy in plantar fasciitis: A systemic review and meta-analysis

BACKGROUND

Dextrose prolotherapy (DPT) is considered to be a type of regenerative therapy and is widely used in various musculoskeletal disorders. Plantar fasciitis is a common cause of heel pain that affects the quality of life of many people. We aimed to evaluate the effectiveness and safety of DPT for plantar fasciitis.

METHODS

PubMed, Embase, and the Cochrane Library were searched from their respective inception dates to June 2021. Only randomized controlled trials comparing DPT and other interventions for plantar fasciitis were included in this review. Standardized mean differences (SMDs) with 95% confidence intervals were calculated for comparison. The outcome measurements included visual analog score, numeric rating scale, Foot Function index, Revised Foot Function index, American Orthopedic Foot and Ankle Score, and plantar fascia thickness. Post-treatment duration was classified as short-term (1-2 months), medium-term (3 months), or long-term (6 months).

RESULTS

Six studies with 388 adult patients diagnosed with plantar fasciitis were included for the meta-analysis. In terms of pain scores improvement, DPT was superior to placebo or exercise in the short-term (SMD: -1.163, 95%CI: -2.17 to -0.156) and the medium-term (SMD: -1.394, 95%CI: -2.702 to -0.085). DPT was inferior to corticosteroid injection in the short-term (SMD: 0.781, 95%CI: 0.41 to 1.152). For functional improvement, DPT was superior to placebo or exercise in the short-term (SMD: -1.51, 95%CI: -2.96 to -0.059), but inferior to corticosteroid injection (SMD: 0.526, 95%CI: 0.161 to 0.89) and extracorporeal shock wave therapy in the short-term (SMD: 0.484, 95%CI: 0.145 to 0.822). Randomized controlled trials showed a better pain improvement in the long-term for patients treated with DPT compared to corticosteroid (P = .002) and exercise control (P < .05). No significant differences were found between patients treated with DPT and patients treated with platelet-rich plasma.

CONCLUSION

Dextrose prolotherapy was a safe and effective treatment option for plantar fasciitis that may have long-term benefits for patients. The effects were comparable to extracorporeal shock wave therapy or platelet-rich plasma injection. Further studies with standardized protocols and long-term follow-up are needed to address potential biases.