Could there be a benefit to sugar?

Prolotherapy, a treatment for chronic joint and muscle pain that involves injecting patients with dextrose, a form of sugar. Photo / 123RF

Imagine this: At your next doctor's appointment, instead of advising you to avoid sugar, your physician proposes treating you with sugar. That scenario may not be too sweet to be true. Prolotherapy, a treatment for chronic joint and muscle pain that involves injecting patients with dextrose, a form of sugar, is becoming increasingly popular, even though evidence supporting its efficacy is limited.

What is prolotherapy?

Prolotherapy is the injection of a non-active substance, most often dextrose, into an injured tissue to stimulate inflammation and trigger the body's natural healing response. The "prolo" in its name comes from claims that the therapy induces proliferation of new cells in injured tissue. Practitioners inject the substance multiple times during each treatment session at sites where tendons and ligaments attach to bones, areas that are considered to have relatively poor blood supplies.

It used to be thought that chronic tendon injuries were caused by inflammation, an out-of-control response by the body attempting to heal itself. These injuries were commonly referred to as tendinitis, the suffix "itis" meaning "inflammation."

Prolotherapy touts inflammation as the cure, not the problem. Current understanding is that tendinitis is caused by repetitive motion. Biopsies of chronically sore tendons show a breakdown of the tissues and an absence of the repairing cells typically associated with inflammation. Today many doctors use the terms "tendinosis" - a nonspecific condition involving the tendon - or "tendinopathy" - a disease or disorder involving the tendon - to describe this process instead of "tendinitis."

Ali Safayan, who specialises in integrative medicine, uses prolotherapy at his primary-care practice in Washington. (Integrative medicine combines, or integrates, conventional medicine with alternative medicine.)

"We are using dextrose as a decoy," Safayan says. "In an effort to get the dextrose out of the area, the body floods the area with serum, which has a number of healing factors and materials that are necessary for tissue repair. Essentially we trick the body into using healing factors already present in serum in higher concentrations."

Does it work?

Evidence suggests it may be effective for some parts of the body and not effective for others. Safayan most commonly uses prolotherapy to treat arthritis and chronic injuries to tendons and ligaments in the shoulders, hips, knees, neck and lower back.

Limited but encouraging evidence exists in support of prolotherapy for treating chronic tendon and ligament injuries caused by overuse. A small study published in the Clinical Journal of Sports Medicine demonstrated decreased pain and increased strength in patients who received prolotherapy for lateral epicondylosis, commonly known as tennis elbow. Other small studies have also shown promising results for treating chronic injuries in the Achilles tendon, the foot and the hip, as well as arthritis in the knee and finger.

Evidence for treating low back pain with prolotherapy is inconclusive. In 2010, a Cochrane review article, considered the gold standard of medical evidence, looked at the combined results of five studies and did not find sufficient evidence that prolotherapy alone is an effective treatment for chronic low back pain.

However, in a position statement on prolotherapy for back pain, the American Association of Orthopaedic Medicine called the treatment "a safe, cost effective and efficacious therapy that can provide pain relief and return of function for many patients."

An overall theme in prolotherapy research is the lack of good evidence demonstrating its efficacy as only a few high-quality studies have been conducted. More research needs to be done before its effectiveness can be proved or disproved.

Some physicians are skeptical, including Steven Novella, an assistant professor of neurology at the Yale School of Medicine and the founder of the Web site Science-Based Medicine. "It seems that the practice and promotion of prolotherapy greatly exceeds what is justified by this preliminary research," he says. "I would recommend caution to anyone considering this therapy, and certainly I would not believe the hype."

How much does it cost?

Safayan's practice generally charges US$250 to $350 per prolotherapy session; on average, patients undergo four to six sessions done at intervals of two to six weeks. Costs may be higher if a doctor uses imaging techniques such as ultrasound to guide the injections.

The Centers for Medicare and Medicaid Services and the Veterans Administration have reviewed the evidence for prolotherapy and recommended against third-party compensation. Most insurers consider the evidence of prolotherapy's effectiveness inadequate and will not pay for it, meaning the patient must bear the costs out of pocket.

What are the risks?

Prolotherapy is a low-risk procedure that can be performed only by a physician. You may experience some soreness and bruising in the injected area, but it generally resolves within 24 to 48 hours. Infection and bleeding are possible complications, but they are very rare.

All patients have at least some mild discomfort during the procedure. Safayan uses a topical numbing cream before injecting and estimates that 90 per cent of patients tolerate the procedure well without further anesthetic; the other 10 per cent require lidocaine injections before the dextrose treatments.

Is it right for me?

Prolotherapy can be a safe, reasonable option for people with chronic pain who want to avoid or delay invasive surgery. Many patients seek out providers who perform the procedure after more common treatments such as corticosteroid injections have failed. Keep in mind that you need to be willing to pay for the procedures yourself and endure the discomfort of an injection and that prolotherapy is often combined with physical or occupational therapy.

"It's safe and it's effective," Safayan says. "I tell my patients that prolotherapy is a bit like prayer. It can't hurt, and it probably will help."

Corey Carson is a senior resident at the Georgetown University/Providence Hospital Family Medicine Residency in Washington. He does not practice prolotherapy or any alternative medicine.