Dextrose Prolotherapy for Unresolved Wrist Pain
The wrist is a very complex structure and is composed of eight small bones which are connected by ligaments. When these structures are injured, pain may result along with the inability to use the hand and/or the upper extremity - including the shoulder. Obviously, most people would consider use of the hands an essential function, thus properly treating the wrist pain/injury can greatly affect a patient's quality of life. The articulation afforded the hand and the upper extremity by the wrist is essential for mobility, strength, and dexterity that most patients need to function in their daily lives.
Interestingly enough, primary care physicians frequently see patients in their offices with complaints of wrist pain. The causes of wrist pain are typically related to overuse, as well as repetitive and high impact injuries that may be work or sports related. These injuries often start as an acute tendonitis or ligament sprain and, if not effectively treated, can result in chronic pain due to the formation of degenerative arthritis. Symptoms are frequently gradual at first - with mild aching but full range of motion - and then typically progress to more acute pain along with impaired movement of the hand and upper extremity. Approximately one person in seven (13.6%) of the U.S. population has degenerative wrist arthritis.1
Typical treatments for unresolved wrist pain, including degenerative arthritis, are conservative in nature. These treatments include rest, physical therapy, NSAIDs, splinting, cortisone injections, and ergonomic modification of work stations. Though these treatments are commonly prescribed, they often produce only temporary results. Objective proof to support the use of these treatments is lacking.2,3 When the pain does not remit - especially pain related to carpal instability - the patient is then often referred to a surgeon to assess for surgery. Surgery is usually arthroscopy or a fusion.4 As surgery can be fraught with complications - such as plate tenderness, nonunion, distal radioulnar joint pain or dysfunction, persistent unexplained pain, and carpal tunnel syndrome - patients often look for other options.5 However, because traditional wrist pain therapies often do not result in positive remission of symptoms, many patients are turning to alternative therapies such as prolotherapy to achieve positive outcomes.6
Prolotherapy, an injection therapy that stimulates the body to repair weak/injured areas of the body, is fast developing into a recognized form of pain management in both the complimentary and allopathic medicine fields. Its primary use has been related to the pain management associated with tendinopathies and ligament sprains in peripheral joints.7,8 Prolotherapy is also effectively used in the treatment of spine and joint degenerative arthritis.9,10 In double blind human studies, the evidence to support the effectiveness of prolotherapy has been considered encouraging but varied.11-14
George S. Hackett, MD coined the term prolotherapy and was one of the originating prolotherapy pioneers back in the 1940s. Hackett wrote, "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."15
Animal studies have shown that prolotherapy stimulates the production of new collagen by initiating the normal inflammatory reaction.16,17 Animal studies have also revealed ligament and tendon diameter and strength improvements with prolotherapy.18-20 While prolotherapy is commonly taught and used for unresolved wrist pain,21 no study has been done to date related to effectiveness. This observational study's purpose was to evaluate the effectiveness of Hackett-Hemwall dextrose prolotherapy - not only on unresolved wrist 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
In October 1994, the primary authors of this study opened a Christian charity clinic called Beulah Land Natural Medicine Clinic located in an impoverished area of rural southern Illinois. An all volunteer staff composed of MDs, RNs, clinical assistants, and administrative staff ran the clinic every three months until July, 2005. Hackett-Hemwall dextrose prolotherapy was utilized as the treatment of choice. Dextrose was selected because it is the most common proliferant used in prolotherapy. The patients traveled from many different areas of the country to receive prolotherapy - primarily from Kentucky, Missouri, and Illinois. The patients were seen and treated free of charge.
Patients who received prolotherapy for their unresolved wrist pain in the years 2000 to 2005 were called by telephone and interviewed by an independent data collector (D.P.) who had no prior prolotherapy knowledge. General inclusion criteria were the following: at least 18 years of age, presence of an unresolved wrist 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 wrist conditions that responded to prolotherapy included carpal instability, tendinopathy, ligament sprain, and wrist degenerative arthritis. Patients who were thought to have median nerve entrapment were not included.
The 31 wrist pain patients each received prolotherapy for their painful condition using the Hackett-Hemwall technique of prolotherapy. Each patient received 20 to 30 injections of a 15% dextrose, 0.2% lidocaine solution with a total of 15 to 30cc of solution used per wrist. Injections were given into and around the painful and/or tender-to-touch areas of the wrist. Figure 1 outlines the typical injection sites where 0.5 to 1cc of solution were given. Tender areas injected included the carpal bones, as well as ligament and tendon attachments in the wrist. The patients were asked to reduce or eliminate pain medications as much as the pain would allow.
Only one person (D.P.) conducted the telephone interviews and obtained patient data. The patients were asked a series of questions related to pain and various symptoms before starting prolotherapy. Their response to prolotherapy was also detailed with an emphasis on the effect prolotherapy had on their wrist pain, stiffness, and quality of life. Data collection consisted of questions concerning years of pain, pain intensity, stiffness, number of physicians seen, medications taken, quality of life concerns, psychological factors and whether the response to prolotherapy continued after the prolotherapy sessions ended.