Joint Rejuvenation: Prolotherapy, Regenerative Injection Technique (R.I.T.)

Eliminate chronic pain.

Prolotherapy, R.I.T.

PROLOTHERAPY, also known as Regenerative Injection Therapy (RIT), facilitates the body’s own healing mechanisms to repair damaged tendons and ligaments. With this minimally invasive technique, damaged areas are injected with a solution that causes a nominal amount of irritation. In response to this irritation, the body begins to repair itself, strengthening weakened tissue and stimulating new growth.

"Not many physicians are aware of Prolotherapy... but I was also a patient who benefited from Prolotherapy. My intractable pain was not intractable and I was remarkably improved ..... I saw so many patients cured that I could not help but become a “believer” in Prolotherapy. The nice thing about Prolotherapy, if properly done, is that it cannot do any harm.”

Dr. C. Everett Koop – former U.S. Surgeon General on the benefits of Prolotherapy

Ligament laxity and tendinosis

Ligaments and tendons are the flexible structures that connect muscles and bones. They allow us to move freely, but become damaged if they are overstretched. When you twist or strain a tendon or ligament too much, the area becomes inflamed, and the healing process is initiated. Normally the structure is completely repaired, but if the healing process is incomplete, tendons and ligaments may remain stretched or weakened – like a rubber band that has lost its elasticity. This can cause chronic joint pain, and uncomfortable tightening of the surrounding muscles.

Ligaments and tendons are comprised of bundles of fibers, much like a rope. These fibers are made of collagen. When one of these structures is chronically damaged, they can lose up to 40% of their collagen fibers, leaving the remaining fibers in disarray. A freshly injured tendon is referred to as tendonitis; the “itis” means that healing inflammation is present. But tendons that never heal properly result in a condition called tendinosis or tendinopathy, in which the inflammation necessary to repair the site is absent. Therefore, pain of tendinosis is not due to inflammation, but to the process of degeneration.

You may have chronic ligament or tendon damage if you experience any of the following symptoms:

Numbness or a “pins-and-needles” feeling
Muscle tightness or spasms
Pain or tenderness when pressure is applied
An unstable, “loose” feeling in the affected joint
Pain worse upon initial movement, then better when movement is repeated

Inflammation — the body’s healing mechanism

Inflammation may seem like a problem, but it’s actually the body’s solution for healing damaged ligaments and tendons. It occurs in three stages: acute inflammation, granulation, and remodeling.

Stage One: Acute Inflammation - This initial stage, lasting about one hundred hours, begins at the time of injury. When the ligament is damaged, its contents spill at the site of the wound, attracting white blood cells called leukocytes that clean the area and prevent infection. Chemicals are released, instructing certain cells to activate and certain others to de-activate in order to facilitate healing.
Stage Two: Granulation (Tissue Repair) - The leukocytes secrete hormones that attract cells called macrophages. Macrophages are crucial to the healing process, performing a variety of functions. They break down and digest damaged molecules, and release hormones and chemicals that attract new cells to the injury site. These specialized cells, called fibroblasts, are responsible for the production of new ligaments, and they immediately begin producing new collagen – the main component of ligament and tendon fibers. This phase lasts anywhere from ten days to two weeks; during that time, the influx of new cells and the formation of new blood vessels in the damaged area can lead to a thickness or “full” feeling.
Stage Three: Ligament Remodeling (Wound Contraction) - Now that new collagen has been created, it begins arranging into fibers, which wind around each other like a rope. During this process the fibers begin to contract, becoming shorter and tighter. Excess water is squeezed out, causing further shrinkage. As the millions of collagen fibers collectively shrink, the ends of the loosened ligament are pulled together, tightening and strengthening it. In this phase, it’s very important to gently exercise the affected joint; movement causes the collagen fibers to align themselves properly. Even though this is the final stage in the healing process, the tissue won’t be fully strengthened for several months, so ask your doctor for recommendations regarding how much activity is safe.

History of Prolotherapy

Believe it or not, Prolotherapy is not a new technique; similar methods have been traced back to ancient Greek times. It was also used in late 19th-century France to treat hernias. Today’s Prolotherapy techniques were developed in the 1930s, primarily by Ohio surgeon G.S. Hackett, M.D. Hackett named the procedure Prolotherapy because the tissue produced during the healing process was healthy tissue, not scar tissue; “prolo” indicates the proliferation and growth of new cells and fibers. The term Regenerative Injection Therapy (RIT) is newer, and was coined to more accurately describe what the treatment is.

Scientific and Clinical Evidence

Since the inception of Prolotherapy, numerous studies on both animals and humans have confirmed its benefits. In one of the most notable, Gustav Hemwall, M.D. – a protégé of Dr. Hackett who treated over ten thousand patients with Prolotherapy, including former U.S. Surgeon General Dr. C. Everett Koop – presented a survey of 2,007 Prolotherapy patients. The results: more than 99% of patients who completed Prolotherapy treatments showed improvement and relief from chronic pain. These results echoed the initial findings of Dr. Hackett, and repeated studies throughout the years have all yielded similar outcomes.

Overcoming fears

Many people cringe at the mere thought of injections, but the fear of the Prolotherapy procedure is often worse than the procedure itself. It is typically very well tolerated, even by the most needle-shy patients, and the end result – lasting relief from chronic pain – is well worth any minor discomfort encountered along the way. Most patients say they would gladly do it again.

Summary

When you injure a ligament or tendon, your body naturally heals with inflammation, which results in the formation of new collagen and strengthening of the joint. But sometimes that process is unable to complete itself, causing pain, numbness, joint instability and muscle spasms. Prolotherapy or Regenerative Injection Therapy (RIT) is a safe and effective way to induce inflammation, stimulating the body to begin its own healing process. While the technique can be uncomfortable, Prolotherapy’s response rate is approximately 80-90%, with at least 75% of cases seeing permanent repair.

Prolotherapy FAQ’s

Why didn’t my body heal the first time?

There are many reasons why the injured tendon or ligament may not have healed itself entirely. It may not have been adequately protected, or not given long enough to heal before regular activity resumed. Smoking or diseases such as diabetes can be a contributing factor. The use of non-steroidal anti-inflammatory medications (NSAID's) such as aspirin and ibuprofen can suppress inflammation, hindering the healing process. In fact, research is increasingly finding that the use of NSAID's causes even repaired ligaments and tendons to be weak, and may even directly cause ligament laxity and tendinopathy.

How prolotherapy works?

Now that you’ve learned how the damage and rejuvenation of ligaments and tendons works, you can better understand how Prolotherapy stimulates inflammation in a controlled manner. Prolotherapy involves the injection of proliferants – solutions that directly or indirectly irritate the injured area to stimulate healing inflammation and re-growth. There are a number of ways to irritate tissue, and all proliferants fall under one of four categories:

Osmotic shock agents - These leech water from the cells around the injection site, irritating tissue in the same manner that lemon juice would on an open wound. The most common osmotic shock agent is dextrose (sugar) and glycerin, diluted with pain-relieving Novocain®.
Chemical irritants - These directly irritate the tissue; phenol, a distant relative of alcohol, is most commonly used in combination with dextrose and glycerin (a solution called “P2G”).
Chemotactic activators - These “switch on” the cells responsible for causing inflammation. The most common chemotactic activator is sodium morrhuate, which is derived from cod liver oil – so if you have an allergy or sensitivity to shellfish, be sure to tell your physician.
Mechanical irritants - Pumice, a powder of finely ground rock, is sometimes used; its grittiness causes irritation.

All proliferants are mixed with anesthetic, which aids in relieving pain both during the procedure and for a few hours afterward. Additionally, the skin and underlying tissue is usually numbed to further minimize discomfort. Though you may experience pain, swelling, heat and redness as a result of the injections, the amount varies from person to person, and the discomfort is an important sign that the healing process has begun.

Is Prolotherapy risky?

Any medical treatment carries a certain degree of risk, but complications from Prolotherapy are exceedingly rare. Since the intent of Prolotherapy is to cause inflammation, pain at the injection site can – and should – be expected. You may find the injections slightly painful due to the sensitive nature of the placement site, but anesthetic will help alleviate any discomfort. As with any injection, there is the slight risk of infection or nerve damage, which are uncommon. There may be a bit of temporary bruising at the injection site.

Hope for osteoarthritis?

Osteoarthritis is a common form of arthritis caused by wear and tear. Layers of cartilage that protect the surface of the joints wear down, collapsing the space and loosening the ligaments responsible for stabilization. Conventional medicine dictates that osteoarthritis should be treated with the use of anti-inflammatory drugs (NSAID's) and cortisol injections, which only treat the pain and not the underlying cause. But in 2000, two double blind, placebo-controlled Prolotherapy studies were conducted on osteoarthritic joints of the hands and knees. The patients receiving Prolotherapy saw significant improvements in pain levels, swelling, and range of motion. Most impressively, independent analysis of the studies’ x-rays showed that the joints of the untreated group had worsened over the twelve-month study, while the joints of the group treated with Prolotherapy showed a re-growth of cartilage.

What should I do before the procedure?

Since anti-inflammatory medications (ibuprofen, Motrin, Aleve, etc.) are known to hinder the healing process, they should be stopped before Prolotherapy (Tylenol is still acceptable, since it isn’t an anti-inflammatory). Tell your doctor if you have a chronic disease such as diabetes, or a thyroid or hormonal condition.

How many treatments will it take?

The number varies, and depends on the patient’s specific issues. Side effects and risks do not change, whether you need one treatment or twenty. Each treatment session consists of anywhere from one to fifteen or more injections, depending upon your diagnosis.

How often are treatments given?

The majority of patients require between two and six sets of injections, spaced 2-6 weeks apart. (Treatments are never given more frequently than every two weeks.) Treatments are stopped when the patient shows at least an 80-90% improvement; reaches a “plateau” at which treatments seem to stop helping; or simply reaches a point where he or she feels that further treatments are unnecessary.

Are there any special post-injection instructions?

As previously noted, you should preferably discontinue the use of anti-inflammatory medications during the course of treatment. If you must use them, you should avoid doing so for three days prior to the procedure, and for ten days after receiving the injections. Wobenzyme and damp heat can provide relief for any discomfort you encounter as a result of the treatments. Avoid over-activity, taking special care not to exert the treated area so that the new fibers are able to strengthen. Gentle, rhythmic movement of the area may be encouraged; your doctor will provide you with recommendations.

When will I see pain relief?

Again, it depends on the patient. The amount of collagen growth required to provide joint stabilization is highly variable. Most patients will not see much improvement on the first or second treatments, but some amount of improvement should be evident after the third treatment – so don’t be discouraged if you don’t have immediate pain relief. It is important to receive the full-recommended course of Prolotherapy for complete healing.

Will my insurance cover Prolotherapy?

Despite its safety and decades of scientifically documented success, Prolotherapy unfortunately falls under the “experimental” category according to most insurance companies, and is therefore not generally covered.

If it’s such a great procedure, why don’t more doctors use it?

Though it has taken quite a long time for modern medicine to acknowledge the success of alternative treatments, the medical field is finally recognizing many of these as legitimate healing methods. Until recently, many effective therapies have been overlooked by conventional medicine – and Prolotherapy is one of those. It isn’t currently taught in traditional medical schools, but increasingly more physicians are becoming aware of its existence and training in its use. As it becomes more widespread, and as more studies prove its effectiveness, it will become a more accepted practice – and will likely, at some point, be covered by insurance.

This information was adapted from Valley Sports Physicians & Orthopedic Medicine, Avon, CT 06001