PROLOTHERAPY IN THE MEDIA
You may have heard talk in the media recently about Phil Graham (an elite Australian rugby league player) having “sugar injections” following his pectoral muscle injury. Read here. I found it interesting to hear the Sydney Roosters team doctor, John Orchard, is using these injections, commonly know as ‘prolotherapy’, in an acute muscle tear case. This has lead the majority of athletes I have treated in the last few days to ask me “What’s with the sugar injections?”. So I hit the databases to look at the evidence for the use of ‘sugar injections’ or prolotherapy in an acute muscle tear.
WHAT IS PROLOTHERAPY?
Prolotherapy has been defined as an injection of growth factors or growth factor production stimulants to assist in the growth of normal cells or tissue (Reeves et al. 2007). The proliferant solution and technique varies across the clinical landscape. However, the most commonly reported proliferants include 10% to 15% dextrose (as in our reported ‘sugar’ injections), P2G (phenol, glycerin, glucose), and sodium morrhuate.
HOW DOES IT WORK?
The proliferant solution injected during prolotherapy is purported to work by creating a biological cascade of events that cause the increased release of pre-collagen growth factor (PGF). PGF encourages movement of fibroblasts into the injection area, which leads to increased secretion of collagen tissue. Interestingly, it is widely reported that this is a biological process that takes about 6 to 8 weeks (Reeves et al. 2007).
There are other, and more complex mechanisms through which prolotherapy is said to assist healing. However, these are beyond the scope of this blog, and I recommend further research and reading if you are interested.
WHAT THE RESEARCH SAYS
I could not find any clinical trials that have used prolotherapy in a population with acute muscle tears. There is some good evidence for use in a population with chronic muscular issues, specifically chronic groin pain (Topol et al. 2005), chronic LBP (Yelland et al. 2004) and knee OA (Reeves et al. 2000).
However, I did find a publication of “expert opinion”. The article was published in the British Journal of Sports Medicine entitled The early management of muscle strains in the elite athlete: best practice in a world with a limited evidence basis (Orchard et al. 2008). The expert panel reported that they successfully use injectional therapies, including prolotherapy, in the treatment of acute muscle strains. The panel discuss that these treatments are used only in the elite athlete population, when return to play timeframes are of upmost importance.
Interestingly, an author of this paper is Dr John Orchard. Sound familiar? That is correct, John Orchard is the Sydney Roosters Club doctor who has made the decision to inject the elite athlete in question, Phil Graham.
As previously suggested there is no sound evidence basis for the use of prolotherapy in an acute muscle strain population. However, this does not mean that prolotherapy is useless in this case. As sports physiotherapists we would consistently use ice and compression in this population, both of which lack sound evidence basis. I guess the proof will be in the pudding, as we all wait and see if Phil Graham recovers to potentially play in the NRL Grand Final.
Orchard JW, Best TM, Mueller-Wohlfahrt HW, Hunter G, Hamilton BH, Webborn N, Jaques R, Kenneally D, Budgett R, Phillips N, Becker C, Glasgow P. The early management of muscle strains in the elite athlete: best practice in a world with a limited evidence basis. Br J Sports Med 2008;42:158-159
Reeves KD, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Altern Ther Health Med 2000;6:68-74, 77-80.
Reeves KD. Prolotherapy: regenerative injection therapy. In: Waldman SD, editor. Pain management. Philadelphia: WB Saunders; 2007. p 1106-27.
Topol GA, Reeves KD, Hassanein K. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil 2005;86:697-702
Yelland MJ, Glasziou PP, Bogduk N, Schluter PJ, McKernon M. Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial. Spine 2004;29:9-16.
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