Discussion

Principle Findings

The results of this prospective, non-controlled, pilot study show that Hackett-Hemwall dextrose Prolotherapy helps decrease pain and improve the quality of life of pain patients who have been told that they need surgery to resolve their musculoskeletal pain. Decreases in pain and stiffness reached statistical significance. On a scale of 0 to 10, the ending pain, stiffness, and crunching (crepitation) levels were 1.3, 2.5, and 1.5 respectively. Nine-one percent of participants received 50% or greater pain relief with Prolotherapy. Seventy-nine percent of patients felt they had enough current pain relief with Prolotherapy that they will never need surgery. Four (12%) of the patients received 50% or greater pain relief with Prolotherapy, but plan to receive additional Prolotherapy in order to avoid surgery. Three of the patients (9%) felt they will still need surgery. Additional noted improvements were seen overall in range of motion, walking ability, depressive and anxious symptoms, sleep and need for pain medication. One-hundred percent of patients recommended Prolotherapy to someone they know.

In regard to the three participants who ended up needing surgery; one had terrible shoulder pain especially with playing sports. He had failed physical therapy, cortisone injections, and medications for an intrasubstance tear of the supraspinatus tendon and impingement syndrome. He stated the two Prolotherapy treatments helped him 15%, but he was and is an active cricket player and decided on surgery. He is back to playing. Of interest is this participant at various times had five other body areas treated with Prolotherapy and responded 100%. The second patient who ended up needing surgery had osteoarthritis of the hip. He had six Prolotherapy treatments and felt he was 90% better in regard to pain from the Prolotherapy. He noted that he was sleeping and walking better since receiving Prolotherapy. Objectively, he had more range of motion with the Prolotherapy, but not enough for his activity level. He had a successful hip replacement. The third participant received two Prolotherapy treatments to her degenerated knee. She stated the Prolotherapy helped 50% with the pain but she was anxious to get back to dancing (her passion), and decided to get a total knee replacement. She is back to dancing.

While these three participants would be considered “failures” of Prolotherapy because they needed surgery, on closer examination it is clear that two of the patients did not receive the recommended number of treatments before stopping Prolotherapy. In the experience of the primary author (R.H.), patients who have been told by surgeons that surgery is their only option can often require at least six visits of Prolotherapy, especially if they have joint degeneration to the point of “bone on bone.” These three patients do demonstrate the challenge that doctors who utilize Prolotherapy face daily in active patients, that they want to get better quickly. While surgery is not a quick fix, Prolotherapy does require a patient to go to a doctor’s office and receive the treatment every month, sometimes for six months to a year. While this can be a stumbling block to some patients, for the patient who does not want to have surgery, surely this is a small inconvenience for a lifetime of pain relief.

Strengths and Limitations

Our study cannot be compared to a clinical trial in which an intervention is investigated under controlled conditions. Instead, it is aimed to document the response in a private medical practice of patients to Prolotherapy who have been told that surgery is needed to resolve their pain. Clear strengths of the study are the numerous quality of life parameters that were studied. Such quality of life issues as overall disability, walking ability, stiffness, range of motion, activities of daily living, sleep, anxiety and depression, in addition to pain level, are important factors affecting the person with pain. The statistically significant improvement in pain and stiffness levels, as well as improvements in quality of life measured, treated solely by Prolotherapy, even though subjective, is likely to have resulted from Prolotherapy.

Another strength of this study is that the study population received only Prolotherapy as a treatment for their pain; no other treatment modalities were used. While all 100% of patients were told by a medical doctor(s) that surgery was needed to resolve their pain, 91% were told by a medical doctor(s) that surgery was the only treatment option that would resolve their pain. This is further evidence that the amount of pain and disability suffered by these patients was significant. Patients with this caliber of pain and degeneration typically do not experience spontaneous pain improvement, so resolution of their symptoms most likely resulted from the Prolotherapy they received.

A weakness of this study is that there was not a control group. Also the study did not isolate one particular patient population in regard to diagnosis necessitating a specific type of surgery. The lack of X-ray or MRI correlation for diagnosis and response to treatment was also a limitation.

Interpretation of Findings

In 2004, there were 3.4 million operations on the musculoskeletal system necessitating and inpatient hospital stay.⁵⁸ While advances in technology and surgery are admirable; the cost of the surgeries is astronomical. In 2004 the estimated cost of performing spinal fusions was $17.6 billion and discectomy was $11.25 billion. While over a million hip and knee total joint replacements were performed in 2004 at a cost estimated at $30 billion, there are many reasons for people in chronic pain to forego surgery for their pain including risk with the procedure, lack of results, financial burden, inability to work while recovering, as well as personal preference toward natural healing techniques. While one can debate the efficacy of Prolotherapy versus surgery for specific medical diagnoses and symptoms, the cost comparison between the two is not debatable. Excluding the additional costs of rehabilitation, physiotherapy, repeat procedures, side effects, post-operative medications, and future medical problems caused by the surgeries, Prolotherapy is significantly less expensive than the commonly performed surgeries. (See Figures 6a & 6b.)

In the current study, conservatively 79% of the patients receiving Prolotherapy felt that Prolotherapy did resolve their painful condition to the point that they will not now, nor in the future, need the previously recommended surgical procedure. That number increases to 91% if you include the additional four patients who already had 50% or more pain relief with Prolotherapy and plan to get more Prolotherapy. Using a conservative number, such as 80% for the number of surgical procedures that would be eliminated with Prolotherapy, the cost savings if patients received Prolotherapy versus surgery are enormous. For instance, in the United States the number of knee replacements in the year 2015 is estimated to be 1.4 million. If 80% of these could be eliminated by patients receiving Prolotherapy now, the cost savings just in these surgeries alone would be $78 billion in the U.S. Imagine if 80% of the 4 million arthroscopies on the knee could be eliminated. This would save the U.S. health care system another $32 billion per year. If Prolotherapy could eliminate 80% of musculoskeletal surgeries in the United States, this procedure alone could make a tremendous dent on saving Medicare, private insurers, and patients money. (See Table 3.) This again does not include the money that is lost from lost productivity, and additional expenses that accompany surgery such as rehabilitation, physiotherapy, future procedures, medications, and disability (from continued pain).

When a person undergoes Prolotherapy, they often go right back to work after the appointment. There is no lost work productivity except the time it takes to go to the Prolotherapy appointment. After Prolotherapy, the person is instructed not to take narcotic or anti-inflammatory medications, as these decrease the healing with Prolotherapy. Normally no medications are needed after Prolotherapy. It is also quite common with Prolotherapy that no physiotherapy or other pain therapies are needed. Typically results with Prolotherapy are permanent. No future Prolotherapy is needed. These are reasons enough for patients to consider a Prolotherapy evaluation before undergoing a musculoskeletal surgery.