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The New Age of Prolotherapy

In addition to traditional prolotherapy, platelet-rich plasma and stem cells are also available to enhance healing of musculoskeletal injuries and mitigation of pain.
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Is PRP “Blood Doping”?
The answer to this question is unclear and the subject of controversy. Under current rules of the World Anti-Doping Agency (WADA) for Olympic athletes, PRP is prohibited via the “intramuscular” route with other routes of administration requiring a Therapeutic Use Exemption.94 This WADA prohibition is based chiefly on the concern with the release of IGF-1 by activated platelets, although the type of IGF-1 released by platelets has too short a half-life to provide an athletic advantage, is the wrong isoform to create skeletal hypertrophy, and levels are subtherapeutic and therefore do not produce a systemic anabolic effect.95 A Consensus Meeting on the topic is planned for Spring 2010 by the Medical & Scientific Commission of the International Olympic Committee.96 Hopefully these restrictions will be lifted. While WADA regulates Olympic athletes, it does not have jurisdiction over professional sports leagues in the United States and PRP is not addressed specifically on any banned substances lists by those various leagues.

Related article: Stem Cell Prolotherapy: The Next Horizon

Musculoskeletal Ultrasound
Musculoskeletal ultrasound has been used by physicians, especially rheumatologists, in Europe for many years. Various machines exist, many are portable, and image quality has improved by light years in the past decade. Introduced to the U.S. within the last few years, musculoskeletal ultrasound allows high resolution, real time imaging of articular and periarticular—structures such as ligament, tendons, and cartilage, including tears and tendonosis—and can be used in the office setting to give quick answers and is also highly acceptable to patients.97 However, there are limitations, with one of the chief being the time it takes to learn. As stated by Dr. Rosenquist, an anesthesiologist at the University of Iowa, “It’s not something you pick up after staying at a Holiday Inn Express.”98 There is a high degree of operator variability with the technique, lack of standardization and a long learning curve.97 Musculoskeletal ultrasound is more common in Europe than the U.S. and in some European countries is part of physician training.97 The European Society of Musculoskeletal Radiology has established technical guidelines, protocols and hands-on training since 1994.99 In the U.S., there is growing demand for training in this emerging field and there are more and more courses being offered each year by various institutions.

Many prolotherapists produce spectacular results while being “low tech” without the use or necessity of musculoskeletal ultrasound. And imaging does not, nor should it, supplant the physician’s “common sense.” Imaging studies are notoriously unreliable in terms of musculoskeletal pain, with multiple studies showing a high percentage of abnormal scans in asymptomatic individuals100-103 and thus should always be correlated to the patient history and area of complaint. However, when imaging equipment is used—especially where testing can be addressed specifically to an area of complaint, along with dynamic (motion) analysis—these ultrasound studies can add useful additional information for the physician. However, a physician should avoid using it as the sole source of diagnosis but always take a good history and physical and have an understanding of the cause of a patients problem first before using imaging as a confirmation. Use of ultrasound guidance for injections may or may not be needed, depending on the specific problem being treated. Some of the PRP studies cited above did not use ultrasound guidance86 yet still obtained excellent results for the participants. Knowledge of anatomy and good technique goes a long way in the prolotherapy world and only administering injections with ultrasound guidance may limit the treatment scope, especially in a case of tendonosis where there is no discrete lesion. However, when indicated—as in the case of a discrete tear or effusion—the ability to visualize an injection under guidance, or the use of ultrasound to confirm a diagnosis, can be satisfying for the patient as well as the physician. Ultrasound can also help to objectively document change in tissue which otherwise would be purely subjective .

Marx and Garg write: “Surgeons do not heal tissue; they merely place it where nature can heal it.”25 With advances in science we are able to offer our patients safe, effective alternatives to surgery. Traditional prolotherapy, platelet rich plasma, and now stem cell therapy are available to enhance healing of musculoskeletal injuries and pain, along with musculoskeletal ultrasound for added diagnostic acumen. Yet, in spite of all these wonderful technological advances, there may still be times when the “low tech” approach is more practical. Technology is just a tool and should never become an obsession or violate common sense. Treating the patient in front of you and understanding what options are available for his or her condition will always be the foundation of good patient care, new age or old.

Last updated on: May 11, 2015