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K. Dean Reeves, M.D. Clinical Associate Professor Physical Medicine and Rehabilitation
Emphasis on Research in Use of Prolotherapy (Also called Regenerative Injection Therapy) ReevesOffice @ gmail.com Office Email DeanReevesMD @ gmail.com Personal email
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ABSTRACT Topol GA, Reeves KD: Regenerative injection of elite athletes with career-altering chronic groin pain who fail conservative treatment: a consecutive case series. Am J Phys Med Rehabil 2008;87; – . Objective: To obtain multisport and long-term outcome data from the use of regenerative injection therapy on career-threatened athletes. Design: Consecutive enrollment of elite performance-limited athletes with chronic groin/abdominal pain who failed a conservative treatment trial. The treatment consisted of monthly injections of 12.5% dextrose in 0.5% lidocaine in abdominal and adductor attachments on the pubis. Injection of the nociceptive source was confirmed by repetition of resistive testing 5 mins after injection. Results: Seventy-five athletes were enrolled. Seventy-two athletes (39 rugby, 29 soccer, and 4 other) completed the minimum two-treatment protocol. Their data revealed a mean groin pain history of 11 (3–60) mos. Average number of treatments received was 3 (1–6). Individual paired t tests for Visual Analog Scale (VAS) of pain with sport (VAS Pain) and Nirschl pain phase scale measured at 0 and an average of 26 (6–73) mos indicated VAS Pain improvement of 82% (P <10 10 ). and Nirschl pain phase scale improvement of 78% (P <10 10 ). Six athletes did not improve following regenerative injection therapy treatment, and the remaining 66 returned to unrestricted sport. Return to unrestricted sport occurred in an average of 3 (1–5) mos. Conclusions: Athletes returned to full elite-level performance in a timely and sustainable manner after regenerative injection therapy using dextrose. Key Words: Growth Substances, Osteitis Pubis, Glucose, Tendonitis, Groin, Proliferating, Tendons, Sports Medicine, Athletic Injuries, Sports Hernia
25 consecutive patients with chronic low back pain localized to the SI joint region (posterior superior iliac spine) and positive on examination test for sacroiliac laxity/pain source were treated with 3 injections at 6 week intervals using 17% dextrose with CT guidance in the ligament and specifically not inside the joint itself. 12 month followup data revealed that the SI laxity maneuver score improved from a mean of 7.2 to 2.2 at 1 years (p < .001), the Quebec Pain Disability Scale improved from 57.7 to 39.5 (p = .002), the Roland Morris Back Pain Questionnaire improved from 13.3 to 7.2 (p = .001) and the Roland Morris Multi Form Questionnaire improved from 146.5 to 108.6 to 12 months. (P = .016) Cusi M; Saunders J; Hungerford B; Wisbey-Roth T; Lucas P; Wilson S. The use of prolotherapy in the sacro-iliac joint. [E pub ahead of print] Br J Sports Med (England), Published On line Apr 9 2008, doi:10.1136/bjsm.2007.042044.
Other comments: The clinical history requirements to determine SI source of pain and mechanical dysfunction were the following:1. Localized and/or radiating low back or buttock pain in the vicinity of the posterior superior iliac spine, 2. Worse pain on loading positions such as standing, sitting, walking or negotiating stairs, and 3. 6 months of pain. 9 physical exam factors were looked at and scored to determine candidacy with maximum score of 9 and minimum score not mentioned. The diagnosis had to be made independently by a SEM physician (MC, JS) and a physiotherapist (BH, TWR) involved in the study. The minimum number was not mentioned. The tests were the sacroiliac joint (SIJ) glide test (antero-posterior and vertical arm, with and without self bracing) [11], posterior pelvic pain provocation test (PPPP) [12], active straight leg raise (ASLR) [13-15] with and without self bracing and external manual compression and stork support (Gillett) test [16]. A score of one was given for each positive finding. Clinical tests were therefore not graded. Maximum score was nine. Exercise program apparently continued that patient had performed with no sustainable benefit. The amount injected was unclear with 0.8 ml was injected under CT guidance, but several injections along the ligament noted and a volume of 4 ml of approximately 17% dextrose in bupivicaine. It is not clear if the study was truly consecutive. There were no controls. 25 patients were mentioned but only 19 had 3 month followup data gathered and the body of the paper was not clear why the 3 month followup point was not reached in all cases. The authors make the point that previous studies on treatment of back pain with proliferant injection did not consider a specific clinical diagnosis. In contrast, if injury to specific structures, such as ligaments or fascia, can be related to a specific clinical presentation and subsequent loss of function associated with pain, the potential for measuring outcome with repeatable physical exam measures may be present. Standardization of those examination measures may be important Here is the abstract: Cusi M; Saunders J; Hungerford B; Wisbey-Roth T; Lucas P; Wilson S. The use of prolotherapy in the sacro-iliac joint. [E pub ahead of print] Br J Sports Med (England), Published On line Apr 9 2008, doi:10.1136/bjsm.2007.042044. ABSTRACT: OBJECTIVE: To determine whether prolotherapy is effective in the treatment of deficient load transfer of the SIJ. DESIGN: A prospective descriptive study. SETTING: Authors' private practice. PARTICIPANTS: 25 patients who consented to treatment and attended for at least one follow up visit and assessment. STUDY PERIOD: :From April 2004 to July 2007. INTERVENTION: Three injections of hypertonic dextrose solution into the dorsal interosseous ligament of the affected SIJ, under CT control, six weeks apart. MAIN OUTCOME MEASURES: Quebec Back Pain Disability Scale, Roland Morris 24, Roland Morris 24 Multiform questionnaires and clinical examination by two authors independently. Clinical tests include active straight leg raise, sacroiliac joint glide, Stork (Gillet), stance phase and posterior pelvic pain provocation tests. RESULTS: All patients included in this study attended for at least one follow up visit at 3, 12 or 24 months. The number of patients at follow up decreased at 12 and 24 months. Functional questionnaires demonstrated significant improvements for those followed up at 3, 12 and 24 months (p < 0.05). Clinical scores showed significant improvement from commencement to three, 12 and 24 months (p < 0.001). CONCLUSIONS: This descriptive study of prolotherapy in private practice has shown positive clinical outcomes for the 76% of patients who attended the 3 months and 12 months' follow up visits and for the 32% of patients who attended follow up visits at 24 months. Similar results were found in the Questionnaires (Q, RM and RMM) at 3, 12 and 24 months. The findings of this study warrant further research. Trial registration Written informed consent was obtained from all participants in the trial. This was conducted as a practice quality assurance project, and as such did not require ethics approval or trial registration.
ABSTRACT: PURPOSE. To present the results of dextrose prolotherapy undertaken for chronic non-responding coccygodynia in 37 patients. METHODS. 14 men and 23 women (mean age, 36 years) with chronic coccygodynia not responding to conservative treatment for more than 6 months were included. 27 of them had received local steroid injections. A visual analogue score (VAS) was recorded for all patients before and after injection of 8 ml of 25% dextrose and 2 ml of 2% lignocaine into the coccyx. In 8 patients with a VAS of more than 4 after the second injection, a third injection was given 4 weeks later. RESULTS. The mean VAS before prolotherapy was 8.5. It was 3.4 after the first injection and 2.5 after the second injection. Minimal or no improvement was noted in 7 patients; the remaining 30 patients had good pain relief. CONCLUSION. Dextrose prolothearpy is an effective treatment option in patients with chronic, recalcitrant coccygodynia and should be used before undergoing coccygectomy. Randomised studies are needed to compare prolotherapy with local steroid injections or coccygectomies. Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
Note that this study, although involving high concentration (Hypertonic) dextrose, was not intended in its conception as a study of prolotherapy, but primarily because a prolonged nerve blocking effect (neurolysis) of markedly hypertonic solutions was propsoed. Improvement in these patients was too quick (hours to days) to be explained on the basis of regeneration effects on the disc. The durability of improvement was potentially related however to regeneraive effects of the intradiscal dextrose. Note also that this study was only for severe degenerative discs (discs with severe tears) and is a pilot study, meaning much more work needs to be done to determine what solutions are best for direct disc injection. The great majority of the time disc treatment is not necessary because prolotherapy for supportive structure will eliminate or improve pain sufficiently. This study examined only patients with particularly severe discs in patients not responsive to prolotherapy of supportive structures. Therefore results in unscreened patients without prolotherapy on other spinal structures first, may not be comparable. To view this study click here: DiscInjectionStudy06.pdf Here is the abstract:Background: Degenerative discs are thought to produce nerve root pain either mechanically or chemically. Particularly in the case of advanced degenerative disc disease, this clinical entity has often proven to be symptomatically resistant to peridural steroids, Intra-discalElectrothermoplasty (IDET) and direct surgical intervention. Exposure of irritated nerves to hypertonic dextrose is thought to have chemoneuromodulatory potential. Sustained pain reduction has been demonstrated in a pilot study involving injection of a combination of dextrose, glucosamine, chondroitin and dimethylsulfoxide into degenerative discs of patients with chronic low back pain of discogenic origin. Objective: To assess the effects of disc space injections of hypertonic dextrose in patients experiencing chronic advanced degenerative discogenic leg pain, with or without low back pain. Study Design: Prospective consecutive patient series. Methods: Patients with moderate to severe degenerative disc disease without herniation and with concordant pain reproduction with CT discography were included. All had failure of a physical therapy trial and substantial but temporary relief with two fl uoroscopically guided epidural steroid injections. Patients underwent bi-weekly disc space injection of a solution consisting of 50% dextrose and 0.25% Bupivacaine in the disc(s) found positive on discography. The study was performed in an out-patient surgery center in the United States. Outcome measures included an 11-scale numeric pain score (0-10). Results : Each patient was injected an average of 3.5 times. Overall, 43.4% of patients fell into the sustained improvement group with an average improvement in numeric pain scores of 71%, comparing pretreatment and 18 month measurements. Conclusion: The results suggest that intradiscal injection of hypertonic dextrose may have a place in the management of pain arising from advanced lumbar degenerative disc disease. Key Words: Degenerative disc disease, internal disc disruption, dextrose discogenic pain, discography
Dr. Wilkinson, a neurosurgeon, performed a single blind study assigning patients with low back pain to either phenol/glycerine or anesthetic injection and demonstrated a better pain reduction with phenol/glycerine injection. The injection sites were not clearly described in his study and the patients required periodic injection. However they were patients with prior lumbar surgery (86%) and all had been referred for further back surgery. Only 4 out of 35 continued to pursue that option, with 29 out of 35 preferring periodic injections. Again, even though lidocaine is clearly not a control intervention, this study provides randomized and blinded assignment evidence that low back treatment with proliferant is better than with lidocaine alone. Wilkinson HA Injection therapy for enthesopathies causing axial spine pain and the "failed back syndrome": a single blinded, randomized and cross-over study.: Pain Physician (United States), Apr 2005, 8(2) p167-73 ABSTRACT: BACKGROUND: Enthesopathies are a common cause of axial pain that is amenable to "minimally invasive" therapy. OBJECTIVE: To evaluate the effectiveness of injection therapy for enthesopathies. DESIGN: Single blinded, randomized, and cross-over study. METHODS: Thirty-five patients diagnosed as having painful enthesopathies as a major pain generator were studied. Of the patients studied, 86% of patients had undergone prior lumbar spine surgery and all were referred for neurosurgical evaluation for possible surgery. Patients were injected either with anesthetics alone or with anesthetics combined with phenol-glycerol proliferant prolotherapy. Outcomes were analyzed both clinically at the time of regular follow-ups, and by a series of multipart questionnaires. RESULTS: Patients received a total of 86 injections, 39 with local anesthetics, and 47 with prolotherapy. By clinical assessment patients obtained excellent to good relief of pain and tenderness after 80% of prolotherapy injections, but only 47% after anesthetics alone. By questionnaire, 66% reported excellent to good relief after prolotherapy vs. 34% after anesthetics alone. Patients reported improvement in work capacity and social functioning following both types of injections, but a greater reduction in focal pain intensity following prolotherapy injections. The mean and median durations of persistent relief were 2.4 and 1.75 months with prolotherapy vs. 1.8 and 0.75 months with anesthetics alone. Roughly 10% obtained greater than six months of relief from either injection. In the crossover portion of the study, patients reported that prolotherapy injections following initial anesthetic-only injections provided much better relief than that achieved after their anesthetic-only injections, and that anesthetic-only injections following initial prolotherapy injections failed to provide relief as good as that achieved after their prolotherapy. Subsequent to this study, only four of 35 patients required additional spine surgery, but 29 of the 35 patients requested additional injections. CONCLUSIONS: Injection therapy of painful enthesopathies can provide significant relief of axial pain and tenderness combined with functional improvement, even in "failed back syndrome" patients. Phenol-glycerol prolotherapy provides better and longer lasting relief than injection with anesthetics alone. Prolotherapy provides over six months of relief for some patients but generally provides relief for only a few months. However, most patients described good to excellent relief, felt that the injections had been beneficial, and requested additional injections for recurrent or residual focal pain. 5 Rockridge Rd. Wellesley Hills, MA 02481-1432, USA. hrldawlknsn@aol.com
Dextrose: Participants: Twenty-two rugby and 2 soccer players with chronic groin pain that prevented full sports participation and who were non- responsive both to therapy and to a graded reintroduction into sports activity. Intervention: Monthly injection of 12.5% dextrose and 0.5% lidocaine in thigh adductor origins, suprapubic abdominal insertions, and symphysis pubis, depending on palpation tenderness. Injections were given until complete resolution of pain or lack of improvement for 2 consecutive treatments. Main Outcome Measures: Visual analogue scale (VAS) for pain with sports and the Nirschl Pain Phase Scale (NPPS), a measure of functional impairment from pain. Results: The final data collection point was 6-32 months after treatment (mean, 17mo). A mean of 2.8 treatments were given. The mean reduction in pain during sports , as measured by the VAS, improved from 6.3 +/- 1.4 to 1.0 +/- 2.4 (P < .001), and the mean reduction NPPS score improved from 5.3 +/- 0.7 to 0.8 +/- 1.9 (P < .001). Twenty of 24 patients had no pain and 22 of 24 were unrestricted with sports at final data collection. Conclusions: Dextrose prolotherapy showed marked efficacy for chronic groin pain in this group of elite rugby and soccer athletes.
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Dextrose:
Topol et al 2008. Dextrose Injection for Groin Pain and Sports Hernia in Elite
Athletes Dextrose 12.5%
injection returns 66/72 elite rugby and soccer players to full sport who
were prevented from high level
Dextrose:
Cusi et al 2008: Dextrose injection markedly improves laxity testing of the SI
joint. 
Dextrose:
Khan et al 2008. Dextrose injection for chronic pain after coccyx
fracture. Treatment of coccygodynia after fracture
was the subject of a consecutive patient study recently published in the Journal
of Orthopedic Surgery. 30 out of 37 patients with chronic non-responding
coccygodynia responded to 2 injections of 20% dextrose. The recommendation was a
trial of dextrose prolotherapy prior to proceeding to coccygectomy. Khan
SA; Kumar A; Varshney MK; Trikha V; Yadav CS: Dextrose prolotherapy for
recalcitrant coccygodynia [In Process Citation] J Orthop Surg (Hong Kong)
(China), Apr 2008, 16(1) p27-9. 
PRP:
Mishra et al 2006. Treatment of tennis elbow. 141 consecutive patients with elbow
epicondylar pain. All failed a standardized physical therapy protocol and a
variety of other nonoperative treatments. Either PRP injection of bupivicaine
with 15 in the active group and 5 in the control group. Only 8 week followup
with 60% improvement versus 16% in control. (Non blinded control). At 6 months
81% improvement. (All patients included) and at 12 months minimum 93%
improvement. Blinding did not occur at IRB request, accounting in part of the
very small control group. All had pain over medial or lateral epicondyle (14/15
lateral) and pain at the elbow with resistance of either resisted flexion or
extension respectively. The number of patients that were able to be contacted
was not mentioned. Nevertheless results were impressive. Noted is that a blinded
clinical trial was approved and status of this is not clear.
MIshra A, Pavelko T. Treatment of chronic elbow
tendinosis with buffered platelet-rich plasma. American
Journal of Sports Medicine Dec 2006 Volume 34: 1774-1778 
Dextrose:
Miller et al 2006: Treatment of severely degenerative discs. 25% dextrose
injected in severely degenerative lumbar discs (too severe for IDET) with
multiple tears reduced pain in a durable manner. Effects were quick enough
to suggest a neurolytic mechanism via hypertonicity or other (IE neovessel)
mechanisms. Miller MR, Mathews RS, Reeves KD.
Treatment of painful advanced internal disc derangement with intradiscal
injection of hypertonic dextrose. Pain Physician 2006 9:115-121.
Topol
et al 2005. Injection for Groin Pain and Sports Hernia in Elite Athletes Dextrose
12.5% injection returns 22/24 elite rugby and soccer players to full sport who
were prevented from high level play by chronic groin pain. This involved
treatment of abdominal muscle weakness, adductor sprain and osteitis pubis. Topol GA, Reeves
KD, Hassanein K. Efficacy of Dextrose Prolotherapy in Elite Male Kicking-Sport
Athletes With Chronic Groin Pain. Archives Phys Med Rehabil, 2005;86:697-702.
(Reprint available by request at