Prolotherapy is a unique, time-tested injection method used to treat chronic pain. It is defined by Webster's Third New International Dictionary as "the rehabilitation of an incompetent structure, such as ligaments or tendons, by the induced proliferation of new cells."

Pain from auto accidents, athletic injuries, and overuse injuries often arise from injury to the soft tissues in the body. These soft tissues which include ligaments, muscles, tendons and joint capsules are also called "connective tissues" because they connect to bones, thereby supporting the bony skeleton. Prolotherapy causes these connections to be repaired, rebuilt and strengthened. It is for this reason that prolotherapy has also been called ligament reconstructive therapy or stimulated ligament repair.

Common injuries include:

These constitute soft tissue injuries which can often become chronically painful. Normally, these injured muscles, tendons, and ligaments go through a repair and healing process which takes about four to six weeks. But, what happens when the low back pain, neck pain, and headaches from a whiplash injury, just will not get better? Or, the athletic injury that continues to cause nagging pain and is preventing you from staying active, especially keeping you from the sport you enjoy the most?

What about the pain where you cannot pinpoint a specific injury, but think it may be due to some repetitive tasks at work, or from overdoing it while working around the home. Anti-inflammatory and pain-killer drugs are often given to treat these injuries, but they may actually slow or stop this healing process. Are you really suffering from a drug deficiency?

When rest and pain medications fail, and usually they do because they only mask or cover up the underlying problem, other types of treatment are often tried. One method of treating these kinds of injuries is a specific flexibility and strengthening program, tailored to the individual and the areas of weakness. A physical therapist can administer therapeutic treatment, teach an exercise program, and provide the education to the individual to allow them to follow their program at home, giving them independence in their recovery.

Another type of treatment is manual therapy, in which a therapist uses his hands to break up or release adhesions, muscle spasms and restricted fascia (connective tissue). Acupuncture may only give temporary relief. Chiropractic treatments consisting of high velocity spinal adjustments may weaken the joints more and worsen the condition when they are done too often or for too long.

In a significant number of cases, despite a reasonable treatment plan and consistent effort from the individual, residual pain and dysfunction may persist. Chronic pain is often quite disabling and may affect job performance, recreational activities and activities of daily living. Along the way a doctor may state that "you just have to live with it... there is nothing you can do about it" or say that surgery is the only option. That news is frustrating and discouraging!

Although you may not have heard about prolotherapy until now, it has been around for more than sixty years and treatment results have been amazing. Up to 85-90% of patients have received good-to-excellent results in pain relief and improved function. Just as importantly, pain medications can be greatly reduced or even eliminated. This is good news, because pain medications can be costly and have potentially serious side effects. But, the best part of all is that prolotherapy produces long-lasting relief...naturally.

Most other types of treatment provide only temporary relief. Prolotherapy is an alternative to surgery in many cases, thereby avoiding disfiguring scars and lengthy rehabilitation. George Hackett, M.D., a prolotherapy pioneer, proved that strengthening connective tissue relieves soft tissue pain and a research study in the respected medical journal, Lancet, demonstrated the effectiveness of prolotherapy.

Prolotherapy works on a very simple principle: injecting the prolotherapy solution at the sites of pain and weakness stimulates the body's own healing mechanism to repair and rebuild injured tissue into a stronger, more supportive, less painful tissue than it was before.

When injuries to the connective tissues (ligaments, tendons, and muscles) occur, the normal healing process may be incomplete, due to poor blood supply or lack of proper treatment. For this reason, ligaments heal very slowly. Damaged ligaments are like loose hinges on a door, allowing bones in the joint to swing out of alignment causing pain, muscle spasms, and eventually arthritis, if left untreated. The attachment sites or anchor points of ligament to bone are the weak links. Connective tissue cells called fibroblasts are deficient, as seen under microscope. This deficiency of fibroblasts leads to loose ligaments and weakened tissues. As a result, the normal supportive function of the ligaments which was present prior to injury is lost. Therefore, joint stability is reduced.

Small pain fibers in these damaged ligaments transmit pain impulses to the brain when stretched. Through a subconcious reflex, the surrounding muscles go into a tight and painful spasm in an attempt to stabilize the joint. This causes the region to feel tight, stiff, achy, burning, tingling, numb, fatigued, and painful. The individual will often notice painful knots in the affected muscles.

These muscles become tight and painful as they try to compensate for the weak and damaged underlying tissue structures. The muscle spasms reduce blood flow, causing even more pain. Not only are these symptoms local, but they are often referred (transmitted) through nerve pathways into the legs and feet, arms and hands, and head (headaches). In other words, pain felt in the head, arms, or legs may be due to instability in the neck or back.

For example, weakness or injury to the ligaments in the neck may interfere with the sympathetic (automatic) nervous system, causing a group of symptoms called Barré-Lieou Syndrome. This syndrome consists of one or more of the following: dizziness, visual blurring, loss of balance, ringing in the ears, runny nose, salivation, trouble swallowing, hoarse voice, nausea, vomiting, nervousness and headaches. These symptoms are caused by instability in the neck and can be eliminated by prolotherapy.

Medications and other forms of passive treatment such as ultrasound, ice, heat, massage, acupuncture and manipulation may give minimal lasting benefits because the primary problem, the loose and injured ligaments, is not being addressed. Stretching and strengthening exercises usually can provide some relief from chronic pain, but this is often only temporary. When these exercises have failed to increase the support sufficiently to diminish pain and improve function, the chronic pain cycle ensues. Prolotherapy should be initiated as soon as possible, before the problem becomes wide-spread.

The most basic prolotherapy solution contains a naturally-occurring sugar (dextrose) derived from corn combined with an anesthetic (lidocaine). Other common natural substances can also be used effectively. This solution does not contain cortisone, which is known to decrease inflammation, but will also slow or stop the healing process. Acute pain may be relieved with cortisone, but repeated use causes a weakening of the tissues and chronic pain develops.

When the injured tissues are injected with small amounts of the prolotherapy solution, a reaction begins, starting a three-stage healing process. Prolotherapy initiates the first stage (Inflammation). Stages two (Fibroblastic) and three (Maturation) follow automatically.

In stage one, the body sends in special cells which help to clean up the debris, much like a cleanup crew at a construction site. These cells respond as if another injury has occurred resulting in a controlled inflammation and increased blood flow. This process takes a week.

In stage two, the body begins the process of repair and healing. This is accomplished by the addition of tissue repair cells called fibroblasts which are deificne in the injured tissue.

Fibroblasts increase in number at the sites of injection, and over the course of four to six weeks secrete a substance called collagen, which is a very strong and relatively inelastic substance and the most abundant protein in the body. The new collagen makes the ligaments thicker, denser and stronger, providing more support to your joints primarily where the ligaments anchor or attach to bone. The strength of the injected ligaments can increase up to 40% above normal. Stability is increased as pain and muscle spasm decrease.

In stage three, the newly formed tissue continues to mature for one to three years. If, during the three stages of the healing process, anti-inflammatory drugs, ice, compression and/or immobilization are used to reduce pain and inflammation, complete and normal healing will be inhibited. Most people are taught that inflammation is bad and don’t realize that, without inflammation, no healing will occur.

So, in essence, prolotherapy strengthens ligaments and decreases pain by stimulating the body's own repair and healing mechanism to go into action. There is no masking of pain, tissues heal naturally and become stronger, without the formation of scar tissue. It is for this reason that prolotherapy gives long-lasting relief measured in months to years.

Several treatments spaced apart by about four weeks are usually required to get the full benefit from prolotherapy. When a house is built, as each support is added the structure becomes more solid, giving more strength to the house. The same is true for joints. As each treatment strengthens the ligaments, more strength and support is added to the joint structure. No treatment other than prolotherapy is able to increase the strength and stability of joints.

Why Haven't You Heard of Prolotherapy?

So why doesn’t everyone with chronic pain, or at least your doctor, know about prolotherapy? It does seem strange since so many people have benefitted from prolotherapy. Several logical explanations come to mind:

1) Chronic pain is not well understood by most health care professionals and, therefore, is frustrating to treat. Thus, the comment, "There is not much you can do about it... you just have to live with it".
2) Prolotherapy is not taught in medical schools, so doctors are unfamiliar with it.
3) The technique of prolotherapy requires an in-depth knowledge of anatomy and the skill to place the injections accurately. It takes a great deal of study and training for a physician to become adept at the technique.
4) The procedure may take up to one hour of clinic time, and most busy clinics cannot afford to take this amount of time for one patient.
5) Many doctors and patients are looking for a "quick fix", but prolotherapy results do not occur overnight. The prolotherapy patient must be committed to the treatment because multiple sessions are usually required.
6) Pharmaceutical companies are not involved because there is no money in it for them. Prolotherapy solutions contain common and inexpensive substances. Drug companies cannot obtain patents for exclusive manufacturing rights, so there is no investment incentive, and, thus, no profit to be made.
7) Because there are very few doctors who perform prolotherapy, patients typically just accept the pain or have surgery. While surgery has its place, many patients and doctors are not aware that prolotherapy may relieve their pain and postpone or prevent the surgery they thought they needed.
8) Since prolotherapy is considered by most insurance companies to be "investigational" and "alternative", it is not usually covered.

What About the Procedure Itself?

 Prolotherapy is a very safe procedure when performed by a trained and highly skilled physician who has an in-depth knowledge of anatomy and experience using this injection technique. The use of needles involves risks, but complications from prolotherapy are rare. The solutions used have been shown to be safe and, as stated previously, do not contain cortisone.

The most common side effect is discomfort due to the injections, as well as temporary soreness, stiffness, and occasional bruising. Although injection discomfort cannot be eliminated, it is well-tolerated in most cases. If necessary, it can be reduced by the use of prescription oral medications for pain control and sedation taken prior to the treatment. Most patients prefer not to be sedated because it makes them feel groggy and because a driver is required to and from the appointment. Topical freeze sprays or anesthetic cream can also reduce needle discomfort.

Depending on the area treated and the number of injections, which is usually just a few for small areas or many for larger areas, one may return to usual activities the next day or two. The actual treatment may last anywhere from a few minutes if there is only one site of tenderness such as the elbow, to fifteen minutes, if a large region such as the back and neck are being treated together. The soreness following the injections is normal and gradually lessens over several days, as will any bruising that may occur.

Approved, prescribed drugs or plain Tylenol may be taken for this discomfort. However, no anti-inflammatory drugs may be taken during the treatment period because these will interfere with the healing process that prolotherapy initiates. A goal of prolotherapy is to get the patient off all pain medications. Specific natural supplements may be recommended to enhance healing and alleviate pain.

Can Prolotherapy Cure Everything?

Prolotherapy is not an overnight cure. It cannot “cure” every condition, nor always eliminate 100% of one's pain. There are some areas that the prolotherapist cannot safely reach with a needle. The vast majority of patients completely treated by prolotherapy (usually two to ten sessions) will receive at least 50% relief of their pain. Some even report complete resolution. These results are excellent, considering that chronic pain is exceedingly difficult to treat by any means.

When other treatments are combined, such as muscle therapy, physical therapy, electrotherapy, oral supplements, and exercise, results are enhanced. It is also important to know that prolotherapy only strengthens tissues. No structures are weakened and no scars are formed. Therefore, no bridges are burned.

A good history and a thorough examination are necessary to select the best candidates for prolotherapy. The motivation to want to get better and complete the necessary treatments is vital. Patience and time are important to reap benefits from prolotherapy. Chronic pain problems do not occur overnight and they do not heal that way either. If the pain is enough to affect one’s life, then prolotherapy may be indicated.

Individuals who smoke, drink excessively, have unhealthy lifestyles, lack fitness, are obese, have underlying diseases or are under stress may not heal as well, decreasing the effectiveness of treatment. It also should be noted that people who regularly take narcotic painkillers receive far less benefit from prolotherapy because these drugs suppress the body’s immune system. Tolerance, physical dependence and addiction are consequences of habitual narcotic use. Weaning off narcotics greatly improves the results of prolotherapy.

Frequently Asked Questions:
1) What is Prolotherapy and what does it treat?

Prolotherapy is an injection method which treats chronically painful conditions by stimulating the body's own healing process to repair injured soft tissues, such as ligaments, thereby stabilizing the joints. It involves the injection of a solution containing dextrose (corn extract) or other common substances, and lidocaine (anesthetic), into areas of injury. It may take as little as five minutes to complete a treatment although larger areas will take more time. The procedure is performed in the clinic.

2) How many injections are required?

This depends on the condition and the size of the area that needs to be treated. If there is only a small area of injury and tenderness, a few injections may be all that will be required. Large regions such as the lower back, upper back or neck regions usually require 20 injections or more because each site of tenderness needs to be treated to receive maximal benefit. The volume of each injection is small, between 1/2-1cc (ml).

3) Do the injections hurt?

The use of a needle is always accompanied by some discomfort. It varies from patient to patient, but is generally well-tolerated
because the needles are short and slender, similar to acupuncture needles. The most important thing a patient can do is to stay very relaxed by not tensing the muscles and focusing on smooth breathing. Patients who undergo prolotherapy may be given the option of receiving prescriptions for oral pain medication and sedation to help minimize discomfort. If sedation is used for the procedure, a friend or relative is required to drive you to and from your appointment. Prescription anesthetic cream to reduce skin sensation is another option. Each option can be discussed with the physician prior to scheduling the first treatment.

4) Are there any risks?

Anytime a needle is used to penetrate the skin into the deeper tissues, there is always the chance that inadvertent puncture of
arteries, nerves, spinal fluid or lung tissue may occur. Complications from needle penetration are rare and are greatly minimized by the skill of the trained prolotherapist. The solutions used in prolotherapy are very safe and the amounts used are well within manufacturer's guidelines. However, since prolotherapy is a procedure with some risk to the patient, all patients are asked to read and sign a consent and waiver form prior to the procedure.

5) Should I eat before I come?

A light, easily-digested meal and plenty of water are recommended about 1-2 hours prior to the procedure. Water improves cell hydration and lessens the discomfort of the injections, while food diminishes the likelihood of dizziness. Patients report even less discomfort when they drink water right up to the time of the injections.

6) How many treatments are needed?

Plan on at least four to six treatments for a given area. A few patients respond quickly to just a treatment or two, but most patients will not. Some patients who respond slowly may need 10 or more treatments and stronger solutions may be used to improve the
response. The longer the problem has existed, and the more severe and widespread it is, the more treatments will be needed to stabilize the joints. After the first session, successive treatments follow at monthly intervals. Reassessment of structural healing usually occurs at the fourth session to determine if more treatments are necessary or desired. Staying on a consistent schedule of treatments will decrease the chance that early benefits are lost.

7) When will benefit from the injections occur?

Prolotherapy does not result in immediate relief of pain. Some patients report improvement in as little as two weeks following injections, but it is not expected that any significant relief will be obtained until four to six weeks. Some patients report significant improvement in their symptoms following their first two treatments. Others may not receive much benefit at all until they have had further treatment. As ligament strength and joint stability improve, results become more noticeable. Improvement may continue for up to 3 years after the last prolotherapy treatment.

8) What can I take for the pain during recovery?

Typically, post-injection stiffness and soreness can be expected and is necessary for healing to begin. This lasts only a few days. Heat usually soothes the soreness, but ice should be avoided since it slows healing. No anti-inflammatory (NSAIDs) medications may be used once treatment begins because they interfere withthe healing process that the prolotherapy injections created. An exception to this is for those who take a baby aspirin each day for their heart. Regular use of narcotic drugs should be avoided because they inhibit the immune system. Tylenol may be used for a short period of time. If you are not sure whether a medication you are taking interferes with your prolotherapy treatment, bring it to our attention. Remember that you are not suffering from a painkiller deficiency. On the other hand, specific supplements to assist the healing process are recommended and available at the clinic.

9) Should I exercise following Prolotherapy? What should I avoid doing?

Controlled exercise and mobilization of the treated area promotes tissue healing and results in faster recovery from the treatment. For this reason, I encourage movement and exercise as soon as possible following prolotherapy. The amount will depend on your level of fitness and on how many areas were treated. Frequent high-velocity chiropractic adjustments should be avoided because they do not allow the joints treated with prolotherapy to stabilize. Massage and other similar therapies are compatible with prolotherapy.

10) When should I return to work?

In most cases, depending on your job, you may return to work the same day as your treatment. If, however, your job places a great deal of stress on the area treated, if you were sedated for the procedure, or if you have significant post-injection discomfort, you should not return to work the same day.

11) What are the chances I will get better? Get worse? How long will it last?

Statistics indicate that 85-90% of all patients treated with prolotherapy receive at least a 50% benefit when treated between two and ten times. There is no evidence of a condition becoming permanently worse from receiving prolotherapy treatments. Also, because actual healing occurs with prolotherapy, it is anticipated that long-lasting or even permanent relief of one's pain can take place. If an area is re-injured, prolotherapy treatments may be necessary in the future.

12) Will my insurance cover prolotherapy?

In most cases it will not be covered, as it still is considered by insurance companies to be an “investigational” or “alternative” type of treatment. We will discuss your particular situation regarding insurance coverage of prolotherapy and the fees involved before you proceed with treatment.

Instructions Prior to Treatment

  1. Stop taking all anti-inflammatory medications, including:
    Naprosyn * Ibuprofen * Aleve * Cortisone-like drugs * Relafen * Motrin * Advil * Aspirin products
    (except for baby aspirin taken for the heart)
  2. IMPORTANT:
    Please tell us in advance if you are taking blood thinners (e.g. Coumadin) or if you have allergies to fish, corn,
    sugar, anesthetics, or pain-killers.
  3. Eat a light meal one to two hours prior to your appointment, and drink up to the time of your treatment.
  4. If you are to be sedated with oral medications, they need to be taken about 2 hours before your appointment and you will need
    to have someone drive you to and from your appointment.

Instructions Following Treatment

  1. DO NOT take anti-inflammatory medications after the injections. These drugs will interfere with the healing process that the
    injected solution stimulates.
  2. You may take Tylenol or other approved medications for relief of injection pain following treatment. You should start taking the recommended daily supplements beginning the day of your treatment
  3. You may use heat for soreness (heating pad, warm moist towel, hot shower or bath). However, refrain from the use of ice during the first week. Bruises that occur are normal and will gradually disappear.
  4. After the injected anesthetic has worn off (usually in a few hours), you may have a temporary increase in stiffness and pain. Not only is this expected, but it is also necessary to signal the start of the healing process. This should last only one to three days. Some patients experience episodes of pain during the first two to three weeks after treatment. This is normal and should not alarm you. Drinking water following treatment will decrease pain and improve cell function.
  5. Depending on your job and the area treated, you may be advised to reduce your activities after treatment, but as a rule, you are encouraged to return to your usual activities as soon as you feel able.
  6. The injections you received did not contain any cortisone or steroid medications. Instead, they may contain some of the following substances: dextrose (corn extract), morrhuate sodium (refined cod liver oil), zinc, calcium, lidocaine, and/or sarapin anesthetics), and sterile water.
  7. Prolotherapy injections are intended to provide you with long-lasting relief of your pain. In many cases your pain will be greatly diminished and not return unless you re-injure yourself. An average of four to six treatment sessions, performed monthly, are usually required to adequately treat the problem. More treatments are necessary for difficult problems. Each
    treatment builds on the previous one and too much time between treatment may slow improvement. Complete relief of pain cannot be guaranteed.
  8. Pain relief is usually first noticed at about two to six weeks following the injections. Joint strength and stability will increase with each treatment and continues for up to one and a half years after the last treatment. The process of healing, increased joint strength, and pain relief is gradual and patience is required to realize the benefits of prolotherapy.
  9. You should resume your previous activities as soon as they are tolerated. Avoid high stress on the areas treated. You are encouraged to exercise to strengthen areas of weakness and for general fitness. The more active and fit you are, the quicker your recovery will be. A physical therapy / exercise program may be prescribed, if indicated, when appropriate.
  10. If you have any problems following the treatment, an increase in your pain or wish to ask questions about prolotherapy, please let us know so we can serve you better.
  11. You will be asked to periodically provide a progress note to update and track your progress and current status.

In Summary

Prolotherapy is an effective treatment for a multitude of conditions. There is no other treatment that replaces prolotherapy for strengthening weakened ligaments. It works by stimulating the body's own healing process at the sites of injection. Healing occurs slowly but surely, and naturally. Multiple treatments are usually necessary to achieve maximum joint stability and long-lasting relief from pain. The goals of prolotherapy are to decrease pain and to improve the person’s overall ability to function at work, at home, and during usual activities.