The History of Prolotherapy
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.