Joint Regeneration…Prolotherapy and Beyond | Huber Personalized Medicine

Author: Dr. Anthony Bianco

Joint Regeneration…Prolotherapy and Beyond

In modern medicine the idea of regenerating joints is a science of the future. The advent of stem cells has a promising outlook; however, current regulations in the U.S. have a limit on the ability to utilize this advancing technology. The answer for joint and muscle pain in our current medical state starts with conservative interventions including anti-inflammatories and pain medicine, bracing and physical therapy. The next level of care offers minimally invasive methods such as corticosteroid injections, hyaluronic acid injection (knee osteoarthritis), radiofrequency denervation, and nerve stimulation devices among others. If the treatments are not effective in significantly reducing pain and improving function, there are typically only two options remaining. One being a surgical procedure and the other goes down the path of chronic pain management typically utilizing prescription medicines.

For the aging population, athletes and in general for the standard movement patterns of the human population, musculoskeletal injury is a part of life with an estimated 8.6 million yearly events from sports and recreation alone. Trauma, repetitive motion and poor postural maintenance can lead to injury of joints, bones, ligaments, tendons, cartilage and the entirety of the myofascial system. The body is fully capable of healing itself; however, many people have lifestyle influences that impede one to accomplish this. If injuries are not addressed through a holistic lens, the development of arthritis or insufficient connective tissue can occur. Over 30 million Americans have osteoarthritis, and many are looking for other options available for treating underlying factors. Manual medicine including Osteopathic, Chiropractic, physical therapy and massage therapy are commonly employed to help with increasing joint mobility and myofascial suppleness. Similarly, acupuncture, trigger point injection, dry needling and supplements are used as complementary treatment. One area of growing interest involves addressing underlying structural integrity through regenerative joint injections, specifically prolotherapy.

Prolotherapy is a nonsurgical injection technique typically using hypertonic solution of dextrose, a form of glucose, with the intention of mimicking the natural healing process. The use of both a mechanical (needle) and chemical (dextrose) stimulus, activates the immune system and inflammatory pathway to promote tissue repair and growth. This treatment is most commonly used for degenerative joints and pathologic ligaments and tendons. Animal studies have shown increased ligament diameter and strength, healing of cartilage defects and reduced joint laxity. Clinical trials in humans have shown clinically and statistically significant benefits with at least 6-12 months or longer data points. Specific evidenced-based studies have evaluated the effects on Osgood-Schlatter disease, temporomandibular joint dysfunction, Achilles tendinosis, lateral epicondylitis, patellar tendinopathy, chronic shoulder pain, plantar fasciitis, knee osteoarthritis, ACL laxity, finger osteoarthritis, sacroiliac joint pain, neck pain, low back pain and myofascial pain syndrome. With an understanding of the physiologic mechanism of this technique, it would be apparent that all joints of the body would attain benefit from this treatment with a skilled practitioner. Optimal outcomes can be expected by ensuring other influential factors are considered.

The actual procedure can take anywhere from 20-60 minutes depending on location and extent of injury and pain. The injections are targeted to the appropriate areas based on anatomical knowledge and palpation. Pain during treatment is mitigated using a topical anesthetic and ice if desired. In general, a series of three sessions is recommended to obtain the appropriate repair and growth response with intervals of 2-6 weeks. Depending on the extent of degeneration and tissue insufficiency, additional sessions maybe indicated. Recovery time varies person-to-person, but most can return the same day to regular routine. Avoidance of moderate to intense activity should be avoided for the first week as well as avoiding anti-inflammatory medications and supplements. The utilization of platelet-rich plasma (self-blood) is an additional option. On a similar note, stem cells have been a promising area for these injections; however, current U.S. regulations have inhibited this modality.

How does one optimize outcomes for this treatment? First, a structural assessment and treatment plan is important to ensure that an unbalanced movement pattern or postural alignment is not part of the underlying etiology. Working with an Osteopath, Chiropractor or other movement or manual medicine specialist is important. Another item necessary to achieve desired outcomes includes working with an integrative practitioner who has a solid foundation in nutrition, hormone interplay and inflammatory conditions. From a very general standpoint, the foods we eat can have a good or bad effect on our digestive tract and ultimately immune system. This can be difficult to uncover but can be started at home with an elimination nutrition plan. Some nutrients key for ligament and tendon repair include vitamin C for collagen, B vitamin as cofactors, essential fatty acids for hormone signaling and certain proteins like proline, lysine and L-carnitine as basic building blocks. Hormones play a key role in the ability of our body repair itself. For instance, T3, the active thyroid hormone has direct influence on genetic factors that control for differentiation of appropriate cells during muscle fiber development and regeneration. On a similar note, testosterone, in men and women, is a necessary androgen with the protective effect of mitigating inflammatory cartilage degradation . The body has the tremendous ability for self-healing and working with a holistic practitioner can optimize this system.

References:

Centers for Disease Control and Prevention. Osteoarthritis. Accessed 2018 Aug
Chou R, Huffman LH. Guidelines for the evaluation and management of low back pain evidence review. American Pain Society
Da Silva JA, Larbre JP, Spector TD, Perry LA, Scott DL, Willoughby DA. Protective effects of androgens against inflammation induced cartilage degradation in male rodents. Ann Rheum Dis. 1993 Apr, 52(4):285-91
Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A systematic review of dextrose prolotherapy for chronic musculoskeletal pain. Clinical Medicine Insights. 2016:9 139-159
Ravin, Cantieri, Pasquarello. Principles of Prolotherapy. American Academy of Musculoskeletal Medicine. 2008
Reeves KD. Prolotherapy: basic science, clinical studies, and technique.
Salvatore D, Simonides WS, Dentice M, Zavacki AM, Larsen PR. Thyroid hormones and skeletal muscle – new insights and potential implications. Nat Rev Endocrinol. 2014 Apr, 10(4):206-14
Sheu Y, Chen LH, Hedegaard H. Sports- and Recreation-related Injury Episodes in the United States, 2011–2014. Department of Health and Human Services. National Health Statistics Report Number 99, 2016 Nov

Regenerative Joint Therapy Highlights:

Main therapeutic options:

Dextrose Prolotherapy
Platelet-Rich Plasma
Stem Cells (future technology)

Addresses the underlying problem

Stimulates the self-healing ability of the body

Minimally invasive = minimal complications

Short recovery time (same day for some)

Prolotherapy is a nonsurgical injection treatment which mimics the body’s natural healing process. The use of a mechanical and chemical stimulus activates the immune system and inflammatory pathway to promote tissue repair and growth. It is most commonly used for degenerative joints and insufficient ligaments and tendons.

Animal studies have shown increased ligament diameter and strength, healing of cartilage defects and reduced joint laxity. Clinical trials in humans have shown clinically and statistically significant benefits for Osgood-Schlatter disease, temporomandibular joint dysfunction, Achilles tendinosis, lateral epicondylitis, patellar tendinopathy, chronic shoulder pain, plantar fasciitis, knee osteoarthritis, ACL laxity, finger osteoarthritis, sacroiliac joint pain, neck pain, low back pain and myofascial pain syndrome. Other areas and joints in the body are likely to have good outcomes with the knowledge of the physiologic function and of the therapy.

The treatment is minimally invasive and conducted as an in-office procedure. An initial consult is necessary to assess for other contributing factors (posture, nutrition, hormones) and will include an Osteopathic exam with manual medicine intervention as indicated. Additionally, the utilization of platelet-rich plasma (self-blood) can be an option based on nature of injury and previous interventions. Similarly, stem cells have a place in this field; however, current U.S. regulations limit the availability of this modality, but may be a future option.