Short Term Analgesic Effects of 5% Dextrose Epidural Injections for Chronic Low Back Pain: A Randomized Controlled Trial

Demonstrating the effectiveness of intra-articular prolotherapy combined with peri-articular perineural injection in knee osteoarthritis: a randomized controlled trial

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.

Isometric vs Isotonic Core Stabilization Exercises to Improve Pain and Disability in Patients with Non-specific Chronic Low Back Pain: A Randomized Controlled Trial

Background

Non-specific chronic low back pain (NSCLBP) is a prevalent condition that affects 90% of individuals experiencing low back pain. Core stabilization exercises (CSE) stand out as the most commonly employed therapeutic approach for managing NSCLBP. Nevertheless, there remains uncertainty regarding the superior effectiveness between isometric (ISOM) and isotonic (ISOT) types of CSE in the treatment of NSCLBP.

Objectives

The primary objective of this study was to compare the efficacy of ISOM and ISOT exercises concerning pain and disability in patients with NSCLBP. Additionally, the study aimed to assess the effectiveness of both ISOM and ISOT in comparison to no intervention concerning these variables in these patients.

Methods

This study was a randomized controlled trial that involved 41 men and women experiencing NSCLBP. Participants were randomly allocated to three groups: ISOM CSE (n = 13), ISOT CSE (n = 14), and a waitlist control (n = 14). The exercise training was administered for 40 - 60 minutes three times a week over a period of up to 8 weeks. Pain (assessed using the Visual Analog Scale or VAS) and disability (evaluated through the Oswestry Disability Index or ODI) variables were measured before and after the interventions.

Results

Based on the results, there was no significant difference between the 2 exercise groups (ISOM and ISOT) regarding pain and disability. However, the ISOM group demonstrated numerically better results than the ISOT group. Both the ISOM and ISOT groups exhibited a significant decrease in pain levels, with the VAS score decreasing from 5.5 to 2.7 for ISOM and from 5.8 to 3.7 for ISOT, as compared to the control group (P < 0.001 and P = 0.001, respectively). Additionally, the average disability showed a significant improvement in both the ISOM (ODI score from 17 to 11) and ISOT (ODI score from 15.4 to 11) groups compared to the control group (P < 0.001).

Conclusions

Both ISOM and ISOT methods are effective in alleviating pain and disability in patients with NSCLBP. However, there is no significant difference in the benefits between them. Numerically, ISOM exercises were found to be superior. Further studies are needed to obtain a more accurate answer regarding their superiority.

A comparative analysis of prolotherapy efficacy in patients with knee osteoarthritis across varied dextrose concentrations

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.

Ultrasound-guided nerve hydrodissection of cervical nerve roots for cervical radicular pain in patients with mild and moderate to severe stenosis: a retrospective cohort study

Because fascial entrapment neuropathy can occur in multiple locations, ultrasound-guided nerve hydrodissection has become a key component of the treatment of cervical radicular pain. In this paper, we propose a combination of injectates used for nerve hydrodissection of the cervical nerve roots and compare the clinical outcomes of this treatment among patients with different severities of stenosis. This is a retrospective cohort study designed to compare outcomes between patients with mild stenosis and moderate to severe stenosis. Forty-four patients with mild cervical stenosis and 30 patients with moderate to severe cervical stenosis were consecutively enrolled into two groups. A 10-mL mixture in a single level consisting of 5% in Dextrose, 0.2% lidocaine (Xylocaine), and 4 mg betamethasone (Rinderon) was used for nerve roots hydrodissection. The two groups were compared with regard to their numeric rating scales (NRS) of pain, proportion of patients who exhibited a favorable outcome (a reduction of pain ≥ 50%), duration of patient exhibited a favorable outcome, and occurrence of serious complications and minor side effects. The follow-up period ranged from 3 to 20 months. The NRS of both groups improved significantly by 1 week, 1 month, 3 months, and final follow-up after the initial injection. Differences in the groups' NRS, proportion of patients who exhibited a favorable outcome, duration of patient exhibited a favorable outcome, and occurrence of serious complications and minor side effects were nonsignificant. There were 4 patients (5.4%) experienced dizziness in that resolved without further treatment. Ultrasound-guided nerve hydrodissection of cervical nerve roots is a safe procedure that reduces pain associated with cervical radicular pain, even in patients with moderate to severe stenosis.

The effect of dextrose prolotherapy versus placebo/other non-surgical treatments on pain in chronic plantar fasciitis: a systematic review and meta-analysis of clinical trials

BACKGROUND

Prolotherapy is the injection of a small volume of sclerosing or irritant solutions into an injured tissue. We aimed to investigate the effect of dextrose prolotherapy (DPT) versus placebo/other non-surgical treatments on pain in chronic plantar fasciitis.

METHODS

We searched seven electronic databases (PubMed/MEDLINE, Web of Science, EMBASE, Scopus, ProQuest, CENTRAL, PEDro) from inception to December 31, 2021 with no language restriction for publications comparing the effect of DPT with placebo/other non-surgical treatments in patients with chronic plantar fasciitis. Our primary outcome was pain and the secondary outcomes were foot function and plantar fascia thickness. The risk of bias was assessed using the Cochrane Collaboration's tool.

RESULTS

Overall, eight studies with a total of 449 patients were included in the meta-analysis. All the included studies reported short-term pain. A large effect size (dppc2 = -0.97, 95% confidence interval [CI] -1.84 to -0.10) was observed favoring the use of DPT to reduce pain in patients with chronic plantar fasciitis in the short-term. The results for foot function improvement (dppc2 = -1.28, 95% CI -2.49 to -0.07) and plantar fascia thickness reduction (dppc2 = -1.02, 95% CI -1.99 to -0.05) in the short-term were also in favor of DPT.

CONCLUSIONS

Since almost all the included studies had high risk of bias and multiple trials lacked long-term follow-ups, further high-quality research is required to determine the long-term effects of DPT vs placebo/other non-surgical interventions.

Is Low-Dose Dextrose Prolotherapy as Effective as High-Dose Dextrose Prolotherapy in the Treatment of Lateral Epicondylitis? A Double-Blind, Ultrasound Guided, Randomized Controlled Study

OBJECTIVES

To investigate the effects of prolotherapy (PrT) on pain, functionality, clinical improvement and to compare the 5% low and 15% high dose dextrose PrT in chronic lateral epicondylitis.

DESIGN

A double-blind, parallel groups, randomized controlled study.

SETTINGS

Outpatient Clinic.

PARTICIPANTS

Sixty patients (N=60), aged 44.30±10.31 years old, with chronic lateral epicondylitis were allocated randomly into 3 groups.

INTERVENTIONS

To Group 1 5% dextrose PrT, to Group 2 15% dextrose PrT, to Group 3 0.9% saline injections were done at 3 times (weeks 0, 3, 6), to the entheses of forearm extensors and annular ligament.

MAIN OUTCOME MEASURES

The primary outcomes were handgrip strength, visual analog scale-rest (VAS-R), visual analog scale-activity (VAS-A), pressure-pain threshold, and Quick Disability of the Arm, Shoulder and Hand (Q-DASH). The secondary outcomes were clinical improvement (Disease Global Assessment Questionnaire), side effects, and complications. Primary outcomes were collected at baseline week 0, week 3, and 12. Secondary outcomes were collected at weeks 3 and 12.

RESULTS

In Group 2, VAS-A and VAS-R (at week 3), handgrip strength and pressure-pain threshold (at week 12) were significantly different than other groups (P<.05). In Groups 1 and 2, there was a difference in primary outcomes at week 12 than baseline (P<.05). In Group 3, there was no difference in VAS-R, VAS-A, and handgrip strength at weeks 3 and 12 than baseline (P>.05).

CONCLUSION

In chronic lateral epicondylitis, 5% and 15% dextrose PrT is more effective in pain, handgrip strength, functionality, and clinical improvement than %0.9 saline. There was no difference in functionality, clinical improvement, side effects, and complications between the PrT groups. 15% dextrose PrT was more effective in handgrip strength and pressure-pain threshold at week 12 and pain at week 3. We recommend 15% dextrose PrT based on this study.

Efficacy comparison between ultrasound-guided injections of 5% dextrose with corticosteroids in carpal tunnel syndrome patients

BACKGROUND

There is no standard guideline for treating mild to moderate carpal tunnel syndrome (CTS). 5% dextrose perineural injection has been a potential and innovative treatment with long-term effects for CTS; however, there is few published randomized clinical trial comparing the efficacy of 5% dextrose perineural injection versus corticosteroid injection in treating CTS.

MATERIALS AND METHODS

In this double-blinded randomized active-controlled trial, we randomly allocated 1 session of either 2 cc 5% dextrose or 1 cc methylprednisolone acetate mixed with 1 cc normal saline in 36 patients with mild to moderate CTS of single or both their wrists. The baseline VAS, BCTQ, electrophysiological studies, and sonography assessment of median nerve CSA were carried out at the baseline and 1-month and 3-month follow-ups, as well as recording demographic variables.

RESULTS

A statistically significant decreasing trend in VAS (P < 0.0001), BCTQ-ss (P < 0.0001), median nerve CSA (P = 0.05), SNAP-PL (P < 0.0001), and CMAP-OL (P = 0.048) in both methylprednisolone and 5% dextrose groups was observed. No significant difference was observed in slope of the trend of studied parameters, including VAS (P = 0.95), BCTQ-ss (P = 0.88), BCTQ-F (P = 0.34), median nerve CSA (P = 0.321), SNAP-PL (P = 0.9), CMAP-OL (P = 0.799), SNAP-amplitude (P = 0.798), and CMAP-amplitude (P = 0.584).

CONCLUSION

5% dextrose perineural injection is an effective and safe treatment for mild to moderate CTS, in comparison with the short-term results attained from corticosteroids. Further randomized clinical trials with longer follow-up periods are warranted.

Dextrose Prolotherapy for Symptomatic Grade IV Knee Osteoarthritis: A Pilot Study of Early and Longer-Term Analgesia and Pain-Specific Cytokine Concentrations

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.

Isotonic Glucose Injections for Postherpetic Neuralgia in the Elderly

Postherpetic neuralgia (PHN) is a painful condition which is difficult to treat, especially among the elderly. This clinical case describes the treatment of an 88-year-old patient with PHN who continued to suffer from pain for several months despite oral and transdermal pain treatment. Multiple intradermal glucose 5% injections allowed her to discontinue her pain medication regimen after four sessions. The improvement was sustained at the four-month follow-up after the last procedure. A fifth session was performed because of a flaring up of the pain.

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

BACKGROUND

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

A Novel Somatic Treatment for Post-traumatic Stress Disorder: A Case Report of Hydrodissection of the Cervical Plexus Using 5% Dextrose

Despite years of standard treatments, a Marine veteran and former firefighter, disabled due to severe post-traumatic stress disorder (PTSD), worsened over ten weeks while receiving usual care. Bilateral injection of 10 mL of 5% dextrose in water using a 30-gauge needle just under the sternocleidomastoid muscle was performed at weeks 10, 12, 14, 16, and 18. Clinically important improvements were observed by 18 weeks on a 0-10 anxiety rating scale (57%), the PTSD checklist for civilians (41%), EuroQol overall quality of life scale (40%), and the Hospital Anxiety and Depression Scale (28%). Improvements were stable through 22 weeks. He reported symptomatic benefit on anxiety within 20 minutes of injection, suggesting a neurogenic mechanism, potentially related to a therapeutic effect on the nearby sympathetic trunk/superior sympathetic ganglion. Advantages of this procedure over stellate ganglion blockade include its safety (no lidocaine), bilateral treatment option, simplicity, and comfort.

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.

Efficacy of hypertonic dextrose injection (prolotherapy) in temporomandibular joint dysfunction: a systematic review and meta-analysis

Hypertonic dextrose prolotherapy (DPT) has been reported to be effective for temporomandibular disorders (TMDs) in clinical trials but its overall efficacy is uncertain. To conduct a systematic review with meta-analysis of randomized controlled trials (RCTs) to synthesize evidence on the effectiveness of DPT for TMDs. Eleven electronic databases were searched from their inception to October, 2020. The primary outcome of interest was pain intensity. Secondary outcomes included maximum inter-incisal mouth opening (MIO) and disability score. Studies were graded by “Cochrane risk of bias 2” tool; if data could be pooled, a meta-analysis was performed. Ten RCTs (n = 336) with some to high risk of bias were included. In a meta-analysis of 5 RCTs, DPT was significantly superior to placebo injections in reducing TMJ pain at 12 weeks, with moderate effect size and low heterogeneity (Standardized Mean Difference: − 0.76; 95% CI − 1.19 to − 0.32, I² = 0%). No statistically significant differences were detected for changes in MIO and functional scores. In this systematic review and meta-analysis, evidence from low to moderate quality studies show that DPT conferred a large positive effect which met criteria for clinical relevance in the treatment of TMJ pain, compared with placebo injections.

Protocol registration at PROSPERO: CRD42020214305.

Prolotherapy for chronic low back pain: a review of literature

INTRODUCTION

Low back pain is common and imposes major societal burdens for patient suffering and costs. Prolotherapy injections are used for musculoskeletal conditions including tendinopathies, osteoarthritis and low back pain to enhance soft-tissue healing. This review aims to clarify the place of prolotherapy in chronic low back pain (CLBP).

SOURCES OF DATA

Using multiple databases, a systematic search was performed to identify studies detailing the use of prolotherapy to manage CLBP. A total of 12 articles was included in the present work.

AREAS OF AGREEMENT

Considering the level of evidence and the quality of the studies assessed using the modified Coleman Score, prolotherapy is an effective management modality for CLBP patients in whom conservative therapies failed.

AREAS OF CONTROVERSY

The presence of co-interventions and the clinical heterogeneity of the work contributes to confound the overall conclusions.

GROWING POINTS AND AREAS FOR RESEARCH

The analysis of the studies included in the review, using appropriate tools, showed how their quality has decreased over the years, reflecting the need for appropriately powered well planned and performed randomized control trials.

Effectiveness of Conservative Treatment According to Severity and Systemic Disease in Carpal Tunnel Syndrome: A Systematic Review

(1) Background: Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy in the upper extremity. Conservative treatment has been effective for mild and moderate idiopathic CTS. However, severe CTS and systemic conditions were an exclusion criterion from the studies. The aim of this study is to review the effectiveness of conservative treatment in patients with CTS regardless of the level of severity and the presence or not of systemic diseases in the last ten years. (2) Methods: Randomized controlled clinical trials that compared the effect of conservative treatment on the Boston questionnaire and pain were selected. PubMed, PEDro, Scopus, Cochrane, and Web of Science databases were used. PRISMA statement checklist was performed. (3) Results: 876 studies were recorded, 29 were selected. Pharmacology, Electrotherapy and Manual Therapy had benefits for CTS. Electrotherapy and manual therapy could be effective for severe CTS patients with a systemic condition in the short term, but there was a low percentage of these patients included in the studies. (4) Conclusion: Some pharmacological treatments, manual therapy and electrotherapy have shown benefits for handling CTS, although the most effective combination of techniques is unknown. It would be necessary to include patients with systemic conditions in the selection criteria for future studies.

Volume Matters in Ultrasound-Guided Perineural Dextrose Injection for Carpal Tunnel Syndrome: A Randomized, Double-Blinded, Three-Arm Trial

Ultrasound-guided perineural dextrose injection (PDI) has been reported effective for carpal tunnel syndrome (CTS). Higher volume of injectate may reduce adhesion of median nerve from other tissues, but volume-dependent effects of PDI in CTS remain unknown. We aimed to investigate whether PDI with different injectate volumes had different effects for CTS participants. In this randomized, double-blinded, three-arm trial, 63 wrists diagnosed with CTS were randomized into three groups that received ultrasound-guided PDI with either 1, 2 or 4 ml of 5% dextrose water. All participants finished this study. Primary outcome as visual analog scale (VAS) and secondary outcomes including Boston Carpal Tunnel Questionnaire (BCTQ), Disability of the Arm, Shoulder and Hand score (QuickDASH), electrophysiological studies and cross-sectional area (CSA) of the median nerve at carpal tunnel inlet were assessed before and after PDI at the 1st, 4th, 12th and 24th weeks. For within-group analysis, all three groups (21 participants, each) revealed significant improvement from baseline in VAS, BCTQ and QuickDASH at the 1st, 4th, 12th and 24th weeks. For between-group analysis, 4 ml-group yielded better VAS reduction at the 4th and 12th weeks as well as improvement of BCTQ and QuickDASH at the 1st, 4th, and 12th weeks, compared to other groups. No significant between-group differences were observed in electrophysiological studies or median nerve CSA at any follow-up time points. There were no severe complications in this trial, and transient minor adverse effects occurred equally in the three groups. In conclusion, ultrasound-guided PDI with 4 ml of 5% dextrose provided better efficacy than with 1 and 2 ml based on symptom relief and functional improvement for CTS at the 1st, 4th, and 12th week post-injection, with no reports of severe adverse effects. There was no significant difference between the three groups at the 24th-week post-injection follow-up.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT03598322.

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

BACKGROUND Osteoarthritis secondary to developmental dysplasia of the hip (DDH) is one of the major causes of hip pain and disability. The aim of the study was to compare the effectiveness of prolotherapy (PrT) injections versus exercise protocol for the treatment of DDH. MATERIAL AND METHODS There were 46 hips of 41 patients who had osteoarthritis secondary to DDH included in this study. Patients were divided into 2 groups: treated with PrT (PrT group; n=20) and exercise (control group; n=21). Clinical outcomes were evaluated with visual analog scale for pain (VAS) and Harris hip score (HHS) at baseline, 3 weeks, 3 months, 6 months, and a minimum of 1-year follow-up. In PrT group clinical results were also compared in Crowe type I-IV hips. RESULTS Between group analysis revealed no significant between group differences at baseline. Dextrose injection recipients out performed exercise controls for VAS pain change score at 6 months (-4.6±2.6 versus -2.8±2.5; P=0.016), and 12 months (-4.5±2.4 versus -2.9±2.5; P=0.017) and for HHS at 6 months (24.2±14.0 versus 14.8±12.4; P=0.007) and 12 months (24.3±13.4 versus 16.5±11.3; P=0.018). CONCLUSIONS To our best knowledge, this study is the first regarding the effects of an injection method in the treatment of osteoarthritis secondary to DDH. According to our study, PrT is superior to exercises. PrT could provide significant improvement for clinical outcomes in DDH and might delay surgery.

Periarticular hypertonic dextrose vs intraarticular hyaluronic acid injections: a comparison of two minimally invasive techniques in the treatment of symptomatic knee osteoarthritis

Background

Knee osteoarthritis (KOA) is the most prevailing form of joint disease. Despite the importance of minimally invasive therapeutic methods of KOA, there is a lack of evidence to compare intraarticular hyaluronic acid injection vs traditional dextrose prolotherapy.

Objective

The aim was to compare the therapeutic effects of prolotherapy with hypertonic dextrose vs hyaluronic acid on function and pain in KOA cases.

Materials and methods

One hundred and four KOA patients were enrolled and randomly assigned into two groups, each containing 52 patients. The hyaluronic acid (HA) group were treated by 2.5 mL of hyaluronic acid intraarticulary, and the hypertonic dextrose (HD) group received 10 mL of 12.5% dextrose periarticulary. Injections were repeated three times with 1-week intervals. Pain intensity, measured by visual analog scale, and knee function, scaled by the Western Ontario and McMaster university arthritis index scores were compared between the two groups before and 3 months after intervention. Pain and function of the knee improved significantly (P<0.001) in all patients. However, significantly more symptom relief was found in the HA over the HD group. Prolotherapy with hypertonic dextrose and intraarticular injection of hyaluronic acid results in the same pain reduction and symptom relief as a noninvasive therapeutic method of KOA.

Conclusion

These results recommended intraarticular hyaluronic acid rather than prolotherapy by hypertonic dextrose for KOA symptoms relief.

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

OBJECTIVE

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

LITERATURE SURVEY

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

METHODOLOGY

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

SYNTHESIS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Treatment of Temporomandibular Dysfunction With Hypertonic Dextrose Injection (Prolotherapy): A Randomized Controlled Trial With Long-term Partial Crossover

OBJECTIVE

To assess the efficacy and longer-term effectiveness of dextrose prolotherapy injections in participants with temporomandibular dysfunction.

PATIENTS AND METHODS

A randomized controlled trial with masked allocation was conducted from January 14, 2013, through December 19, 2015. Forty-two participants (with 54 joints) meeting temporomandibular dysfunction criteria were randomized (1:1) to 3 monthly intra-articular injections (20% dextrose/0.2% lidocaine or 0.2% lidocaine) followed by as-needed dextrose/0.2% lidocaine injections through 1 year. Primary and secondary outcome measures included a 0 to 10 Numerical Rating Scale score for facial pain and jaw dysfunction; maximal interincisal opening (MIO) measured in millimeters, percentage of joints with 50% or more change (improvement) in pain and function, and satisfaction.

RESULTS

Randomization produced a control group with more female participants (P=.03), longer pain duration (P=.01), and less MIO (P=.01). Upon 3-month analysis, including pertinent covariates, dextrose group participants reported decreased jaw pain (4.3±2.9 points vs 1.8±2.7 points; P=.02), jaw dysfunction (3.5±2.8 points vs 1.0±2.1 points; P=.008), and improved MIO (1.5±4.1 mm vs -1.8±5.1 mm; P=.006). Control group participants received dextrose injections beginning at 3 months. No between-group differences were noted at 12 months; pooled data suggested that jaw pain, jaw function, and MIO improved by 5.2±2.7 points (68%), 4.1±2.8 points (64%), and 2.1±5.5 mm, respectively. Pain and dysfunction improved by at least 50% in 38 of 54 (70%) and 39 of 54 (72%) jaws, respectively.

CONCLUSION

Intra-articular dextrose injection (prolotherapy) resulted in substantial improvement in jaw pain, function, and MIO compared with masked control injection at 3 months; clinical improvements endured to 12 months. Satisfaction was high.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01706172.

Prolotherapy: Potential for the Treatment of Chronic Wounds?

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

Analgesic Effect and Potential Cumulative Benefit from Caudal Epidural D5W in Consecutive Participants with Chronic Low-Back and Buttock/Leg Pain

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.

Transition from Deep Regional Blocks toward Deep Nerve Hydrodissection in the Upper Body and Torso: Method Description and Results from a Retrospective Chart Review of the Analgesic Effect of 5% Dextrose Water as the Primary Hydrodissection Injectate to Enhance Safety

Deep nerve hydrodissection uses fluid injection under pressure to purposely separate nerves from areas of suspected fascial compression, which are increasingly viewed as potential perpetuating factors in recalcitrant neuropathic pain/complex regional pain. The usage of 5% dextrose water (D5W) as a primary injectate for hydrodissection, with or without low dose anesthetic, could limit anesthetic-related toxicity. An analgesic effect of 5% dextrose water (D5W) upon perineural injection in patients with chronic neuropathic pain has recently been described. Here we describe ultrasound-guided methods for hydrodissection of deep nerve structures in the upper torso, including the stellate ganglion, brachial plexus, cervical nerve roots, and paravertebral spaces. We retrospectively reviewed the outcomes of 100 hydrodissection treatments in 26 consecutive cases with a neuropathic pain duration of 16 ± 12.2 months and the mean Numeric Pain Rating Scale (NPRS) 0-10 pain level of 8.3 ± 1.3. The mean percentage of analgesia during each treatment session involving D5W injection without anesthetic was 88.1%  ±  9.8%. The pretreatment Numeric Pain Rating Scale score of 8.3 ± 1.3 improved to 1.9 ± 0.9 at 2 months after the last treatment. Patients received 3.8 ± 2.6 treatments over 9.7 ± 7.8 months from the first treatment to the 2-month posttreatment follow-up. Pain improvement exceeded 50% in all cases and 75% in half. Our results confirm the analgesic effect of D5W injection and suggest that hydrodissection using D5W provides cumulative pain reduction.