Viewpoint - A new musculoskeletal therapy

Dr Peter Skew considers prolotherapy as an alternative treatment to osteoarthritis of the knee.

Prolotherapy may be used to treat osteoarthritis of the knee
Prolotherapy may be used to treat osteoarthritis of the knee

Options for treating osteoarthritis of the knee may appear to be steroid injections or surgery. As we know, steroid injections for this indication have no long-term benefits.

Weight loss and analgesia may not offer long-term improvement, which leaves surgery or nothing. This does not amount to choice in the NHS.

As a GPSI in musculoskeletal medicine, I have known about sclerosants, more recently rechristened prolotherapy, for 30 years and viscosupplementation since it was first marketed some 20 years ago. I have used both and settled on prolotherapy for a range of conditions including osteoarthritis of the knee.

A review noted that two randomised controlled trials on osteoarthritis reported decreased pain, increased range of motion, and increased patellofemoral cartilage thickness after prolotherapy.1

The patients I started using prolotherapy on were those too old or infirm to consider surgery and those with strong desires to avoid surgery. In these severe and delicate patients, early results were very encouraging.

What is prolotherapy?
Prolotherapy (proliferative injection therapy) involves injecting a non-pharmacological and non-active irritant solution into the body, generally in the region of tendons or ligaments for the purpose of strengthening weakened connective tissue and alleviating musculoskeletal pain.

Prolotherapy works by stimulating an inflammatory response, which in turn triggers the growth of new ligament and tendon tissue.

The ligaments and tendons produced after prolotherapy are similar to normal tissues, except they are thicker, stronger and contain fibres of varying thickness, testifying to the new and ongoing creation of tissue.

A range of proliferants is being used: dextrose 10-20%, phenol-glycerine-glucose (P2G), platelet-rich plasma (PRP), autologous blood and others. Dextrose is the most easily found and very safe.

Prolotherapy may be used for a range of other indications including: achilles tendinosis, anterior cruciate ligament, medial collateral ligament and lateral collateral ligament laxity, tennis and golfer's elbow, groin pain, low back pain, patellar tendinosis, plantar fasciitis and acromioclavicular arthritis.

Current use
A straw poll among members of the British Institute of Musculoskeletal Medicine revealed at least 13 members using prolotherapy in the NHS and 10 using viscosupplementation. At least five others use the techniques in the private sector.

From my experience, the technique is safe and patient friendly. The cost is minimal and in many patients it has bought them time to finish work and retire or lose weight before a knee replacement has been carried out.

In older patients, where surgery is not an option, even small benefits in strength, flexibility and pain levels are justified.

Clinical trials
Double-blind clinical trials are difficult to design for prolotherapy because the alternatives are typically surgery or physical therapy. Finding funding for such trials is also difficult.

The references box includes a selection of research published in the past three years demonstrating the range of conditions considered suitable and the distribution around the world of this technique being used. A variety of medical disciplines are represented.

One group in the south-west of England is trialling dextrose in osteoarthritis of the knee and the technique appears to be widely used in sports medicine, but I have no knowledge of ongoing formal trials.

Data from clinical trials would be of great use in this emerging area.

  • Dr Skew is a GPSI in Clacton-on-Sea, Essex
  • Declaration of interest: none

References

1. Rabago D, Best TM, Beamsley M, Patterson J. A systematic review of prolotherapy for chronic musculoskeletal pain. Clin J Sport Med 2005 Sep; 15(5): 376-80.

Further reading

  • Borg-Stein J, Zaremski JL, Hanford MA. New concepts in the assessment and treatment of regional musculoskeletal pain and sports injury. Phys Med Rehabil 2009; 1(8): 744-54.
  • Cusi M, Saunders J, Hungerford B et al. The use of prolotherapy in the sacroiliac joint. Br J Sports Med (England), 2010; 44(2): 100-4.
  • Scarpone M, Rabago DP, Zgierska A et al. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med (US), 2008; 8(3): 248-54.

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