Hackett-Hemwall Dextrose Prolotherapy for Unresolved Elbow Pain
Chronic elbow pain is a common condition affecting 15% of the population at any one time.1 Lateral epicondylitis (tennis elbow) is the most common form of elbow pain and the most common reason patients with elbow pain come to a physician’s office.2 It is usually an overuse injury. Elbow injuries in sports with overhead or repetitive arm actions are frequent and often severe. Epicondylitis is an acute injury that results in inflammation and is usually the result of large valgus forces with medial distraction and lateral compression. Epicondylosis develops over a longer period of time from repetitive forces and results in structural changes in the tendon.3 Other diagnoses for elbow pain include olecranon bursitis, biceps tendinitis, ulna and radial collateral ligament sprain, and degenerative arthritis.
The typical treatment for elbow conditions is conservative and includes oral NSAIDs, physical therapy, botulinum injections, pulsed low-intensity ultrasound, repetitive low energy shock wave therapy, corticosteroid injections, bracing, ergo-nomic modification of work stations, and rest.4,5,6,7,8,9,10,11 Although these therapies are prescribed, convincing evidence to support their use is lacking.12 It appears the longer the condition persists, the more it becomes resistant to traditional therapies. It has been documented that prolonged symptoms and relapses are frequently observed after having many conservative treatments. In one survey analysis, the elbow complaint resolved in 13% of the patients at three months and in 34% at 12 months.13 Because of the limited response to traditional therapies,14,15 many patients with chronic elbow pain are turning to alternative therapies such as prolotherapy—including platelet rich plasma (PRP) prolotherapy injections.16,17
George S. Hackett, MD coined the term prolotherapy.18 As he described it, “The treatment consists of the injection of a solution within the relaxed ligament and tendon which will stimulate the production of new fibrous tissue and bone cells that will strengthen the ‘weld’ of fibrous tissue and bone to stabilize the articulation and permanently eliminate the disability.”19 Animal studies have shown that prolotherapy induces the production of new collagen by stimulating the normal inflammatory reaction.20,21 In addition, animal studies have shown improvements in ligament and tendon diameter and strength.22,23
Prolotherapy is becoming a widespread form of pain management in both complementary and allopathic medicine. Prolotherapy is commonly used for unresolved elbow pain.24,25 In double-blinded human studies, the evidence on the effectiveness of prolotherapy has been considered promising but mixed.26,27,28 More studies need to be done utilizing larger groups with validated clinical and diagnostic measures to show its effectiveness.
While the normal proliferant used in prolotherapy is dextrose-based, PRP prolotherapy is gaining in popularity. In PRP prolotherapy, a concentrated amount of one’s own platelets which contain growth factors are injected into the injured tissue to promote and speed up the body’s natural healing process.32 There have been numerous studies and papers written regarding use of platelet rich plasma (PRP) therapy to induce healing of elbow injuries—specifically for epicondylitis.29, 30,31
While prolotherapy has a long history of use with chronic elbow problems, no study to date using dextrose as the proliferant has been documented. This observational pilot study was undertaken to evaluate the effectiveness of Hackett-Hemwall dextrose prolotherapy not just on unresolved elbow pain but on quality of life measures and its ability to reduce or eliminate the need for pain medications.
Patients and Methods
Framework and setting
The primary authors of this paper started a Christian medical clinic called Beulah Land Natural Medicine Clinic in an impoverished area in southern Illinois. Hackett-Hemwall dextrose prolotherapy was the primary modality of treatment offered for pain control at the clinic. All treatments were given free of charge and the clinic was staffed by volunteer MDs, RNs, MAs and administrative staff. The clinic met every three months from October, 1994 through July, 2005.
Patients who received prolotherapy for their unresolved elbow pain in the years 2000 to 2005 were called by telephone and interviewed by a data collector (D.P.) who had no prior knowledge of prolotherapy. General inclusion criteria were an age of at least 18 years, having an unresolved elbow pain condition that typically responds to prolotherapy, and a willingness to undergo at least four prolotherapy sessions (unless the pain remitted with fewer prolotherapy sessions). Typical elbow conditions that respond to prolotherapy include medial and lateral epicondylitis or tendinosis, bicepital tendinitis, elbow osteoarthritis, as well as elbow ligament sprains. Patients not included in this study were those who were thought to have ulnar nerve entrapment.
The Hackett-Hemwall technique of prolotherapy was used. Each patient received 20 to 30 injections of a 15% dextrose and 0.2% lidocaine solution. Dextrose was selected as the main ingredient in the prolotherapy solution since it is readily available, inexpensive (compared to other proliferants), has a high safety profile and is the most common proliferant used in prolotherapy. A total of 15 to 30cc of solution was used per elbow. Injections were given into and around the areas on the elbow that were painful and/or tender to touch. The typical spots injected, each with 0.5 to 1cc of solution, can be seen in Figures 1a and 1b. Tender areas injected included the epicondyles and ligament attachments around the elbows. In general, the most tender spots were basically ¾ inch from the medial and lateral epicondyle where the various ligament attachments are located. These elbow ligaments were the primary focus of the treatment (see Figure 2). The patients were asked to reduce the amount of, or eliminate, the pain medications they were taking.
D.P. was the sole person obtaining the patient information during the telephone interviews. The patients were asked a series of questions about their pain and various symptoms before starting prolotherapy. Their response to prolotherapy was also detailed with an emphasis on the effect prolotherapy had on their elbow pain, stiffness, and quality of life. Specifically, patients were asked questions concerning years of pain, pain intensity, stiffness, number of physicians seen and medications taken, quality of life concerns, psychological factors, and whether the response to prolotherapy continued after the prolotherapy sessions stopped.