Prolotherapy for Musculo-Skeletal Pain Management
Dr. Ricardo Al Khouri

What is prolotherapy ?

Prolotherapy is a conservative treatment for musculoskeletal pain affecting the neck, shoulders, elbows, back, knees, etc. It involves injecting 20% dextrose solution (concentrated sugar fluid) which is mixed with normal saline and local anesthetic into the tender points on bones. The rationale behind the procedure is that injecting the fluid would initiate an inflammatory reaction enhancing the regeneration of the soft tissue. Most  musculoskeletal pain comes from enthesis  the insertion of the muscles and ligaments on the bones and prolotherapy is directed at the spot.

Is prolotherapy like cortisone injections?

It is just the opposite. Steroid injections (such as cortisone) treat the inflammation while prolotherapy induces it and a recent steroid injection would switch prolotherapy off. if you have had one or more steroid injections to inn case of shoulder or hip pain “bursitis” supported by the clinical examination and ultrasound, Prolotherapy can be started 6-8 weeks after that.

Can prolotherapy be used to treat all types of musculoskeletal pain?

Definitely not. Prolotherapy is not suitable for inflammatory type of pain like in rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis etc. It is designed for chronic pain arising from sprain, ligament injury, osteo-arthritis and unexplained pain.

How many injections will the patient receive in each session?

It depends on the injury. It could be just one single injection in case of a single small joint pain or conditions like tennis or golfers’ elbow while it can go up to 20 injections for treating stiff neck and chronic low back pain. In general, the patient may need one to six sessions, three to four weeks apart.

Are the injections painful?

Generally speaking yes or, at least, unpleasant; The solution is an irritant and usually gives a burning pain when injected on a sore area; the local anesthetic in the solution is usually effective to kill the injection’s pain in a few minutes but the pain could come back in two hours and may stay for one to three days (in some rare cases the pain could get worse from seven to ten days) giving a bruised feeling. In some areas like the lower back of the skull which must be injected in almost all kinds of neck pain, a local anesthetic will be injected before prolotherapy; as it is a very sensitive area especially in chronic stiff and sore neck.

Can I have pain killers after the injections?

Yes, but not anti-inflammatory medications like Ibuprofen (Nurofen), Diclofenac (Voltaren), Meloxicam (Mobic and Mavalis), Naproxen (Naproxyn), Celecoxib (Celebrex) Ketoprofen (Orudis and Oruvail) etc.  Pain killers like Paracetamol (Panadol, Panamax, PanadolOsteo etc.) Codeine (Pnandeine Forte), Tramadol (Zydol, Tramahexal and Tramal) is convenient and stronger pain killers are needed very rarely unless you are already using a strong narcotic like Oxycontin or MS Contin.

What about the supplements?

The prescribed supplements are the building blocks for the new soft tissue prolotherapy is expected to build up and may cost AUD75 over two months. You can get them cheaper if you do not buy them from a chemist shop. The recommended supplements are:

1-    Glucosamine 1500 mg with Boron 3 mg (BIO Organics Glucosamine Forte 1500)

2-    Vitamin C 1000 mg ( Bio C 1000 mg) 

3-     Vitamin D 25 mcg (Ostelin)

4-   Zinc 30 mg (Zinc Plus with CO Factors “Magnesium 16 mg & Manganese 2 mg) 

The supplements are to be taken once a day at least 2-3 weeks before starting the treatment and through the period between the sessions.

What if a nerve is hit by the injections?

Hitting a nerve is an extremely rare complication due to the injection technique; but the needle size and the nature of the solution are safe and will not end in nerve damage. If a nerve is hit by mistake in some sensitive area, a sharp pain along the nerve will be felt for a few seconds. Generally speaking, prolotherapy injections can cause some complications like bruises, blood collection, local and general allergic reaction and infection but fortunately they are pretty rare.

How successful are the injections?

It really depends on the injury itself. They are very successful in case of neck stiffness and pain (>95%); while it is about 70-80% successful in case of shoulder and lower back pain; it may be slower when it comes to pure osteo-arthritic pain like in knees and ankles. Prolotherapy might not be effective at all in case of migraine with or without neck pain as the source or the trigger of the headache could be more complicated and vascular in nature. The mentioned percentages refer to the patients who got more than 50% relief from pain which should be encouraging for most patients.

Should I stop my physiotherapy while having the injections?

For a few days, yes. Physiotherapy is almost always recommended along with prolotherapy.

How much will it cost?

At this stage the price of the supplement is the only extra cost; all patients are being bulk-billed but extra charges may apply in the future.

What if I have needle-phobia?

If your phobia is significant such treatment would be impossible. But most patients would benefit well from a light sedation with a medication like Alprazolam (Xanax); a dose like 1 mg would be sufficient to calm you down enough to tolerate the needles. Do not hesitate to discuss this issue as there are effective options to treat this condition like psychotherapy and desensitization.

Can I drive after the injections?

Almost always, yes. If you are originally in too much pain, help in driving back would be a good idea.

Can I have the injections in more than one region at the same time?

Not really advised especially if you want to treat neck and lower back at the same time. Both shoulders could be done at one go but I do not prefer to inject more than 15-20 times in one session; a proper schedule is essential for a comfortable and successful treatment.