Regenerative Injection Therapy
Regenerative Therapies are non-drug, cutting-edge therapies that promote the regeneration of healthy joints, muscle, tendons and ligaments.
Prolotherapy and Platelet-rich Plasma
A very effective therapy to regenerate healthy joint tissues, such as cartilage, tendons and ligaments. The end result is improved range of motion and mobility and reduction of pain. Used with knee pain, low back pain, elbow pain, shoulder pain and neck pain.
Restoring full performance and function following injury in the shortest time possible is the primary goal in sports medicine and rehabilitative medicine. Yet an even better goal is full healing of connective tissue to normal strength and therefore a truly durable recovery. Ligaments and tendons are poorly vascularized and when injured take longer to heal than most other tissues. Incomplete healing after injury is common. Healing can be interfered with by smoking, stress, medications, lack of sleep, and poor nutrition. Inflammation is a necessary part of soft tissue healing and the use of anti-inflammatory medication has been questioned as it has been shown to impair healing in some studies (O’Connor JP, Lysz T. Drugs Today, 2008).
Regenerative injection therapy (RIT or prolotherapy) is the injection of growth factors or growth factor production stimulants to promote regeneration of normal tissue (Reeves KD. in Pain Management. 2006). Open-label trials have been uniformly positive in outcome, but double-blind trials have been hampered by a needling control that is not a true placebo. Serial musculoskeletal ultrasound imaging offers a means to follow treatment response to RIT.
RIT has been used successfully to treat a large variety of musculoskeletal conditions, including back pain, groin and knee injuries, plantar fasciitis, foot and ankle pain, rotator cuff tendonitis/tendonosis, epicondylitis, TMJ dysfunction, and osteoarthritis. Treatment intervals vary; typically, treatment is repeated every 2-4 weeks until resolution for 4-6 treatments, each treatment involving multiple injections to a particular area or areas. The injections produce only mild pain. Improvement is most commonly noticed by the second or third treatment.
RIT is a durable solution rather than a palliative measure, and should be considered prior to the use of long-term medication or surgery in appropriate patients.
C.Everett Koop, MD, former U.S. Surgeon General, wrote the foreward to Prolo Your Pain Away, by Dr. Ross Hauser. He stated: “Not many physicians are aware of prolotherapy….one wonders why this is so. In my opinion, it is because medical folks are skeptical and prolotherapy, unless you have tried it and proven its worth, seems to be too easy a solution to a series of complicated problems….that have been notoriously difficult to treat….another reason is the simplicity of the therapy….Another very practical reason is that many insurance companies do not pay for prolotherapy, largely because their medical advisors do not understand it, have not practiced it, and therefore do not recommend it…I think it has to be admitted that those in the medical profession, once they have departed from their formal training and have established themselves in practice, are not the most open to innovative and new ideas.”
The definition of RIT/prolotherapy has evolved over the past 15 years from focusing on the injection of inflammatory solutions (e.g. dextrose) to induce growth to the injection of growth factors or growth factor production stimulants to promote regeneration (Reeves KD in Physiatric Procedures in Clinical Practice, 1995). The principle of regenerative injections is most widely practiced in the treatment of anemia due to chronic renal failure or myelosuppressive chemotherapeutic agents with the use of erythrocyte growth factor (erythropoietin) to cause red blood cell proliferation, as well as in preparation for acute blood loss during surgical procedures.
It is well accepted that growth factors work in coordination and cooperation with each other. Insulin-like growth factor-1 (IGF-1) stimulates fibroblast migration and proliferation and increases collagen production. Transforming growth factor beta (TGF-beta) regulates cell migration and collagen binding tendencies. Vascular endothelial growth factor (VEGF) is involved in angiogenesis. Platelet-derived growth factor (PDGF) stimulates IGF-1 production and tissue remodeling. Basic fibroblast growth factor (bFGF) regulates cell migration and proliferation and stimulates angiogenesis. Several growth factors increase the breaking energy of a healing tendon, including IGF-1, TGF-beta, and PDGF. Since growth factors are expressed within 10 days after tendon injury, RIT is ideally performed within this timeframe to minimize the healing time, although it can be used years after the initial problem began, as long as the patient is healthy.
The primary solutions used clinically for RIT have been dextrose 12.5% to 25%, combined with procaine. Dextrose has been shown to cause proliferation of renal fibroblasts in vitro, tighten loose anterior cruciate ligaments, and to be safe and probably effective in two double-blind studies in patients with osteoarthritis (Topol GA et al Arch Phys Med Rehabil 2005;86(4). Research has been hampered by limited funding for such an inexpensive solution; differences in injection techniques; design flaws such as treatments simultaneous to injection and the inclusion of patients who are receiving compensation for disability; and lack of placebo control owing to the therapeutic benefit of needling and microhemorrhage.
Platelet-rich Plasma
Over the last few years, autologous platelet-rich plasma (PRP) has been incorporated into RIT as a means of injecting multiple growth factors simultaneously and to stimulate further growth factor production by cells that are exposed to the solution. Blood is obtained through venipuncture, centrifuged and platelets harvested and injected into the injured or degenerated area/s. Providing multiple growth factors through injecting PRP more closely simulates natural healing. Microscopic evidence of proliferation, measurable mechanical improvement in animal studies, and improved function in tennis elbow has been demonstrated (Tsubone T et al. Ann Plast Surg 2004;53(4). Experience with PRP has generally shown that fewer treatments are necessary for restoration of full structure and function than with dextrose injections. Although PRP is more expensive, the fewer number of treatments mean that ultimately the cost is not significantly more than RIT with dextrose.
The chief forces driving RIT toward common usage are its low cost, ability to actually tighten loose connective tissue, its beneficial effects on joints, its potential for widespread use in athletics to truly repair overuse injuries, and the use of musculoskeletal ultrasound to objectively document healing. It is likely that this will be the century for RIT in sports and rehabilitative medicine.
Trigger Point Therapy
Relieves acute muscle spasms and tenderness. Used with tension and migraine headaches, back pain, shoulder pain, and neck pain.