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11 Articles in Volume 15, Issue #4
Biofeedback: Information for Pain Management
False-Positive Screen for Marijuana
Hypnosis: Tool for Pain Management
Managing Headaches in Children and Adolescents
National Pain Strategy—A Positive Step Forward
Neuropathy in HIV Patients: Pain Management Concerns
Novel Treatment Device for Phantom-Limb Pain
Pain in Children
Pain Studies Program Emphasizes Pain Education as a Public Health Imperative
Targeting a Saboteur of Surgical Outcomes: Pain Catastrophizing
The History of Prolotherapy

The History of Prolotherapy

Prolotherapy is an injection therapy that involves the stimulation and regeneration of tissue through the use of stimulant solutions.

Prolotherapy, a pain therapy that involves the stimulation of the inflammatory healing/regenerative cascade through the injection of stimulant solutions, has a long history dating back to ancient times.

The earliest form of prolotherapy was used by the Egyptians to treat lame animals by “branding” or hot iron cautery in the 18th dynasty of Amenhotep III circa 1350 BC. The first recorded use of prolotherapy in humans was circa 400 BC by Hippocrates, who used a hot poker in the axilla to repair a dislocated shoulder.

In 1835, Alfred A.L.M. Velpeau, MD,1 considered the father of prolotherapy, injected a patient with an iodine solution to treat a hernia. Circa 1880, Rene Leriche, MD, injected ligaments with procaine demonstrating a pain pattern from ligament laxity and injury.2

From the 1830s to the early 1920s, hernias were the primary condition treated via prolotherapy. Then, in 1926, the first organization for injection therapy was born, the American Society of Herniologists, whose members performed procedures for hernias, varicose veins, and hemorrhoids.

Prolotherapy in the 1930s-1950s

Modern day prolotherapy owes its origins to the innovation of Earl Gedney, DO, an osteopathic physician and surgeon.3,4 In the early 1930s, Gedney caught his thumb in a surgical suite doors, stretching the joint and causing severe pain and instability. After being told by his colleagues that nothing could be done for his condition and that his surgical career was over, Dr. Gedney did his own research and decided to “be his own doctor.” He knew some members of the American Society of Herniologists who used irritating solutions to repair hernias, and extrapolated this knowledge to inject his injured thumb.5

In 1937, Dr. Gedney published “The hypermobile joint,” the first known article about injection therapy (then called “sclerotherapy”) in the medical literature.6 The 1937 article gave a preliminary protocol and 2 case reports—one of a patient with knee pain and another with low back pain—both successfully treated with this method. Dr. Gedney followed up this paper with a presentation at the February 1938 meeting of the Osteopathic Clinical Society of Philadelphia, outlining the technique.7

The 1930s proved to be an explosive time for injection therapy because of the intense histologic research being conducted by Rice, Matson, Harris, White, Biskind, and Manoil.8,9 These researchers showed that collagen was being regenerated at the injection site and that there were specific and reproducible cellular events that accounted for the positive outcomes from injection therapy.

During the 1940s and mid 1950s, there was a proliferation of articles about the use of prolotherapy for musculoskeletal system other than hernias.10-12 In the mid 1950s, Dr. Hackett observed that following injection therapy “…the junction of ligament and bone resulted in profuse proliferation of new tissue at this union.” Hence, Dr. Hackett termed the injection procedure, proliferation, which he later renamed prolotherapy, with ‘prolo’ referring to proliferation, or growth, of tissue.11

At the end of the 1950s, Dr. Hackett presented his research at national conferences and provided insight to the concept that ligament laxity and enthesopathies are the underlying pathophysiology of chronic pain patterns. Later, Dr. Leedy headed a lecture team of Gedney, Shuman, Willman, Greenbaum, Bumpus, Koudele, and Smith that formed through the Chicago Osteopathic College to present their research findings and lectures.13

Into the 1980s

The solutions used then (and now) were primarily dextrose-based, although other formulas are used and can be effective.14 Prolotherapy is practiced by physicians in the United States and worldwide, and has been shown to be effective in treating many musculoskeletal conditions, including tendinopathies, ligament sprains, back and neck pain, tennis/golfer’s elbow, ankle pain, joint laxity and instability, plantar fasciitis, shoulder, knee, and other joint pain.15

There have been many papers written and published that have advanced the understanding and knowledge of, and outcomes associated with, prolotherapy. For example, in his paper on joint stabilization, Dr. Hackett made the cognitive leap that proliferation included the 3 stages of healing—inflammation, granulation, and maturation—and that ligament laxity causes pain.11

In 1983, Liu et al demonstrated that 5% morrhuate sodium produced collagen at the sites in which it was injected.16 In 1985, Maynard et al showed that the morphologic and biochemical effects of morrhuate initiated the injury-repair sequence in tendons and ligaments.17 Double-blinded experiments by Klein et al and Ongley et al have contributed substantially by using the scientific method with statistically significant results (P <.001, <.004 and <.001) showing the effectiveness of prolotherapy compared to controls.18,19

There were several other researchers who made significant contributions that have helped advance the field. Kent Pomeroy, MD, contributed to improved scientific study design methods as well as data in the important areas of outcome studies,20 Dorman contributed surveys of patients, and Faber, Mooney, Leedy, Schultz, Hauser, Dorman and Montgomery wrote editorials in this area. Dr. Faber’s unique contribution was to eloquently explain prolotherapy to the patients on a large scale through many papers and books, especially Biological Reconstruction and Pain, Pain Go Away.21

What’s in a Name?

Rise of the Organizations

Over the years, there have been various organizations for sclerosing. In addition to the American Society of Herniologists, the Sclerotherapy College and the Osteopathic College of Joint Sclerotherapy joined to form the American Osteopathic Academy of Sclerotherapy (AOAS) in the mid-1950s.

In 1961, Drs. Hackett and Hemwall founded the Prolotherapy Association, which later became the parent chapter of the American Association of Orthopedic Medicine (AAOM). The AAOM was founded by Dr. Kent Pomeroy in 1984. In 1996, the AOAS was re-structured to form The American College of Osteopathic Pain Management and Sclerotherapy (ACOPMS), which subsequently changed to The American College of Osteopathic Sclerotherapeutic Pain Management (ACOSPM). Today’s major organization for practitioners in the field is the American Osteopathic Association of Prolotherapy Regenerative Medicine.

There is significant politics amongst various specialty colleges within the American Osteopathic Association (AOA) wanting to lay claim to various terms such as sclerotherapy, pain management, etc—thus, the many name changes. The current president (2014) is Richard Hull, DO, conference chairman and president elect is Arden Andersen, DO, and the vice president is Gerald Harris, DO, executive director is Linda Pavina.

Prolotherapy Today

Prolotherapy is fundamentally the same as it has always been, the stimulation of the inflammatory healing/regenerative cascade through the placement of stimulant solutions via injection at the enthesis and/or disrupted tissue junction. By any other name, it is still prolotherapy.

Over time, what has evolved is the selection of solutions to be injected. This is, in part, because of what is being manufactured and, in part, because certain solutions have been shown to be successful. Sodium morrhuate, for example, is no longer available commercially, so a replacement had to be found. Many practitioners have opted to use platelet rich plasma (PRP), which comes out of the Buffy coat from centrifuged blood. It is an excellent stimulant, readily available, and an autologous product so it confers potentially less risk of allergic reactions and many endogenous growth/stimulatory factors. Some practitioners have termed their use of PRP for prolotherapy as “PRP Therapy,” leaving the impression that this is somehow a different or more advanced treatment than prolotherapy. It’s still prolotherapy using PRP as the injectable solution.

Another substance that has gained notoriety is “stem cells” in the injectable solution—in this case, stem cells derived from subcutaneous fat or bone marrow of adults. Some clinicians combine the PRP with “stem cell mixes,” whereas others just use the stem cell mixes. Again, some practitioners/organizations term their therapy “stem cell therapy,” hoping to differentiate themselves from prolotherapists, when, in fact, the therapy is still prolotherapy, using stem cell mix as the injectable solution.

What patients, and even many practitioners, miss is that the solution used is secondary to the placement of the solution. If the solution is not placed where there is injury/disruption that is specifically correlated to the patient’s pain, success will elude the patient and the doctor. Excellent results, as good as with PRP or stem cell solutions, can be derived from proper placement using very basic solutions of glucose, hypertonic saline, B-complex vitamins, vitamin C, and/or pumice.

The benefit of PRP and/or stem cell solutions is that fewer injections sessions may be needed to get the desired results. Holding all else equal, it is possible that with PRP and stem cell solutions, 1 or 2 sessions might correct the problem, whereas 6 to 10 sessions might be needed with standard solutions. This seems to be most evident in hip and knee injections, where we no longer have easy access to human growth hormone as in the past.

Regardless of the injectable solutions used, the patient’s innate ability to heal must be considered. This means the practitioner must consider the patient’s systemic medical issues, diet and lifestyle, nutritional status, and hormone balance. Ideally, patients would on a dairy-free diet, because dairy products are highly inflammatory; would be taking a therapeutic multivitamin and mineral supplement, such as Optimal Daily Allowance from O’Brien Pharmacy (given a 5-star rating by NutriSearch: Comparative Guide to Nutritional Supplements) because therapeutic levels of nutrition are needed for optimal connective tissue healing and appropriate bio-identical hormone replacement therapy (physiologically appropriate) because hormones drive every metabolic process in the body; as well as appropriate exercise. There really are only 2 reasons patients fail prolotherapy: inappropriate placement of the injectable solution and inadequate innate ability of the patient to heal. Correct these 2 issues, and prolotherapy simply gets results.

Last updated on: May 11, 2015
Continue Reading:
Advances in Regenerative Medicine: High-density Platelet-rich Plasma and Stem Cell Prolotherapy For Musculoskeletal Pain

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