Am Fam Physician. 2021 Apr 1;103(7):395.
Original Article: Chronic Musculoskeletal Pain: Nonpharmacologic, Noninvasive Treatments
Issue Date: October 15, 2020
Available at: https://www.aafp.org/afp/2020/1015/p465.html
To the Editor: We appreciate the article on therapeutic options for chronic musculoskeletal pain by Dr. Flynn. We want to highlight prolotherapy, an injection-based modality for chronic pain with protocols targeting intra- and extra-articular pain-generating tissue. Prolotherapy is supported by a growing body of literature reporting effectiveness for several chronic pain conditions, particularly knee osteoarthritis.
Prolotherapy dates from at least 1937 (then called sclerotherapy because of the observation that early, more caustic solutions caused scarring).1 Small volumes of a therapeutic solution, typically dextrose, are injected within the affected joint and at the bony attachments of tender tendons and ligaments around the joint. Injections are typically given monthly over three to six sessions. The mechanism of action is unclear; inflammatory and nerve-specific effects are hypothesized.2
A rigorous randomized clinical trial assessed the effectiveness of prolotherapy for knee osteoarthritis.3 One year after treatment, participants receiving prolotherapy reported statistically significant and clinically important improvements on a validated questionnaire compared with participants in two different control groups (blinded injection and at-home exercise). These findings have been corroborated in other clinical trials.4 Data from some have been subjected to systematic review and meta-analysis, with positive results.5 Satisfaction with prolotherapy in these studies was high, and there were no adverse events.
The prolotherapy protocol is appropriate for outpatient family medicine but requires training not typically available in residency and fellowship programs. Two nonprofit professional organizations offer such training: the Hackett Hemwall Patterson Foundation (https://hhpfoundation.org/education/conferences/clinical-conference-october/) and the International Association for Regenerative Therapy (https://www.iart.org/About). These sibling organizations offer CME-eligible training through academic conference and service-learning activities in collaboration with the University of Wisconsin.6
Although more studies are needed to better understand prolotherapy's mechanism of action and clinical utility at the system level, existing literature supports considering prolotherapy in carefully selected patients with symptomatic knee osteoarthritis refractory to other care modalities.
David Rabago, MD
Hershey, Pa.
Brian Ralston, MD
Berwyn, Ill.
Email: brian.ralston@lumc.edu
Annette Zaharoff, MD
San Antonio, Tex.
Author disclosure: Dr. Rabago is past president of the Hackett Hemwall Patterson Foundation. Dr. Ralston is the president of the Hackett Hemwall Patterson Foundation. Dr. Zaharoff is the president of the International Association for Regenerative Therapy and serves on the board of directors for the Hackett Hem-wall Patterson Foundation.
1. Schultz LW. A treatment for subluxation of the temporomandibular joint. JAMA. 1937;109(13):1032–1035....
2. Rabago D, Slattengren A, Zgierska A. Prolotherapy in primary care. Prim Care. 2010;37(1):65–80.
3. Rabago D, Patterson JJ, Mundt M, et al. Dextrose prolotherapy for knee osteoarthritis: a randomized controlled trial [published correction appears in Ann Fam Med. 2013;11(5):480]. Ann Fam Med. 2013;11(3):229–237.
4. Hassan F, Trebinjac S, Murrell WD, et al. The effectiveness of prolotherapy in treating knee osteoarthritis in adults; a systematic review. Br Med Bull. 2017;122:91–108.
5. Sit RW, Chung VC, Reeves KD, et al. Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: a systematic review and meta-analysis [published correction appears in Sci Rep. 2017;7:45879]. Sci Rep. 2016;6:25247.
6. Rabago D, Reeves KD, Doherty MP, et al. Prolotherapy for musculoskeletal pain and disability in low- and middle-income countries. Phys Med Rehabil Clin N Am. 2019;30(4):775–786.
In Reply: Thank you for your letter in response to my review of nonpharmacologic, noninvasive therapies for chronic musculoskeletal pain. Prolotherapy was outside the scope of the article, which did not include the evaluation of injection therapies. I agree that in a small number of clinical trials of knee osteoarthritis involving small sample sizes, study participants who received prolotherapy experienced small treatment effects compared with control participants. However, it is noteworthy that due to the limited quality of these studies, the 2019 American College of Rheumatology osteoarthritis treatment guidelines conditionally recommended against the use of prolotherapy for knee or hip osteoarthritis.1
Diane M. Flynn, MD, MPH
Tacoma, Wash.
Email: diane.m.flynn4.civ@mail.mil
Author disclosure: No relevant financial affiliations.
1. Kolasinski S, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2020;72(2):149–162.
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