Discussion

Principle Findings

The results of this retrospective, uncontrolled, observational study, show that Prolotherapy helps decrease pain and improve the quality of life of patients with chronic hip pain. Decreases in pain and stiffness and improvements in range of motion reached statistical significance even in patients whose medical doctors said there were no other treatment options for their hip pain or that surgery was their only option. Ninety-five percent of patients stated their pain was better after Prolotherapy. Over 70% said the improvements in their pain, crunching and stiffness since their last Prolotherapy session have very much continued (75% or greater). Eighty-nine percent of patients stated Prolotherapy relieved them of at least 50% of their pain. Fifty-nine percent received greater than 75% pain relief. Only two patients had less than 25% of their pain relieved with Prolotherapy.

More than 82% showed improvements in walking ability, exercise ability, anxiety, depression, sleep and overall disability with Prolotherapy. Eighty-five percent of patients who were on medications were able to cut their medication usage by 50% or more after Prolotherapy. They were able to lessen additional pain management care by 50% or more in 69% of cases. Ninety-eight percent said that dextrose Prolotherapy changed their life for the better. (See Table 3.)

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 of patients with unresolved hip pain to the Hackett-Hemwall technique of dextrose Prolotherapy at a charity medical clinic. Clear strengths of the study are the numerous quality of life parameters that were studied. Quality of life issues such as walking ability, stiffness, range of motion, activities of daily living, athletic (exercise) ability, dependency on others, work ability, sleep, anxiety and depression—in addition to pain level—are important factors affecting the person with chronic hip pain. Decreases in medication usage and additional pain management care were also documented. The improvement in such a large number of hips who were treated solely by Prolotherapy is likely to have resulted from the treatment. Many of the above parameters are objective with progress noted in the increased ability to walk, exercise, work and the need for less medications or other pain therapies.

The quality of the cases treated in this study is notable. The average person in this study experienced unresolved hip pain for over five years and saw over three physicians prior to Prolotherapy treatment. Twenty-eight (46%) of the patients were either told by their doctor(s) that there were no other treatment options for their pain or that surgery was their only option. So clearly this patient population represented chronic unresponsive hip pain. A follow-up time of nineteen months since their last treatment session provided a measure of the long-lasting effect of this modality.

Because this was a charity medical clinic with limited resources and personnel, the only therapy that was offered was Prolotherapy given every three months. In private practice, the Hackett-Hemwall technique of dextrose Prolotherapy is typically given every four to six weeks. If a patient is not improving or has poor healing ability, the Prolotherapy solutions may be changed and strengthened or the patient is advised about additional measures to improve their overall health. This can include advice on diet, supplements, exercise, weight loss, changes in medications, additional blood tests, and/or other medical care. Patients are typically weaned immediately off of anti-inflammatory and narcotic medications that inhibit the inflammatory response that is needed to achieve a healing effect from Prolotherapy. Since none of these were done in this study, the results of this study are expected to be the least optimum level of success achievable with Hackett-Hemwall dextrose Prolotherapy. This makes the results even more impressive.

A shortcoming of our study is the subjective nature of some of the evaluated parameters. Subjective parameters of this sort included pain, stiffness, anxiety, depression and disability levels. The results relied on the answers to questions by the patients. Another shortcoming is that any additional pain management care that they may have been receiving was not controlled. What was documented was the change in pain levels with Prolotherapy. There was also a lack of X-ray and MRI correlation for diagnosis and response to treatment. A lack of physical examination documentation in the patients’ charts made categorization of the patients into various diagnostic parameters impossible.

Potential Implications of Findings

While the exact cause of chronic hip pain is still debated, this study did show that the Hackett-Hemwall technique of dextrose Prolotherapy improves not only pain and stiffness levels of those with chronic hip pain but also a host of other quality of life measures. Current conventional therapies for unresolved hip pain include medical treatment with analgesics, non-steroidal antiinflammatory drugs, anti-depressant medications, steroid shots, trigger point injections, muscle strengthening exercises, physiotherapy, weight loss, rest, massage therapy, manipulation, orthotics, surgical treatments including total hip replacement, multidisciplinary group rehabilitation, education and counseling. The results of such therapies often leave the patients with residual pain.^33-35 Because of this many patients with chronic hip pain are searching for alternative treatments for their pain.^36,37 This is especially true for those who have been told they need a hip replacement in the future. They realize that total hip replacement surgeries carry with them significant risk including prosthesis failure, sciatic nerve injury, infection, post-op blood clot and potential for continued pain.^38,39 For younger clients especially those under the age of 50, the notion of a second more complicated revision hip replacement in the future is not a very appealing prospect.⁴⁰ Six to 12 months after a hip joint replacement, pivoting or twisting on the involved leg should be avoided. As there are over 120 hip replacement systems, the hip replacement market is driving more and more conservative surgeries.⁴¹ Despite much fanfare, there is little scientific evidence of the purported advantages of minimally invasive joint replacement and hip resurfacing over conventional joint replacement.⁴² One of the treatments that chronic hip pain patients are trying instead of surgery is Prolotherapy.⁴³ Prolotherapy is the injection of a solution for the purpose of tightening and strengthening weak tendons, ligaments or joint capsules. Prolotherapy works by stimulating the body to repair these soft tissue structures. It starts and accelerates the inflammatory healing cascade by which fibroblasts proliferate. Fibroblasts are the cells through which collagen is made and by which ligaments and tendons repair. Prolotherapy has been shown in one double-blinded animal study in a six-week period to increase ligament mass by 44%, ligament thickness by 27% and the ligament-bone junction strength by 28%.⁴⁴ In human studies on Prolotherapy, biopsies performed after the completion of Prolotherapy showed significant increases in collagen fiber and ligament diameter of 60%.^45,46 This is significant since degenerative osteoarthritis has been in many cases known to be caused by joint instability caused by ligament injury.⁴⁷ Thus, Prolotherapy has the potential to stop the degenerative joint disease process and some preliminary and anecdotal evidence shows that in some cases it can reverse it.^48,49 (See Figure 11.)

For most cases of chronic hip pain, the cause of the pain is presumed to be cartilage degeneration. Because the average person moves his/her hip one million times per year during activities of daily living, it is no wonder that over time this wear and tear can begin to break down the joint.⁵⁰ Besides the pain and disability that degenerative arthritis causes, there is a tremendous cost. About 20% of the costs result from ambulatory care services and up to one third from pain medications. Forty-five percent of costs are hospital charges, as an estimated 400,000 people each year undergo a hip replacement alone.⁵¹ The average hospital costs in Chicago per hip replacement is over $45,000 each. Surgeon and prosthesis costs are between $15,000-18,000 with total costs per hip including hospital stay, surgeons fee, MRI and X-ray studies and post-operation rehabilitation being over $75,000.^52,53 Compare those figures to the average cost per Prolotherapy treatment to the hip of $300 to $400.⁵⁴ (See Table 4.) If, as in this study, the average person receives four to five Prolotherapy sessions to complete therapy, the total cost of Prolotherapy for a chronic hip patient would be on the order of $1500 to $3000. Thus, each person who received Prolotherapy instead of a hip replacement would, at minimum, save the health care system on the order of $72,000. These costs do not include patients whose hip replacements fail or need to be revised. This also does not include the lifetime cost savings in medication and ancillary pain management usage, as well-as the cost savings for patients who would not need a hip replacement because of the Prolotherapy treatment received. It has been shown that hip pain is the major predictor of radiographic hip osteoarthritis that progresses to eventual hip replacement.⁵⁵ If this group of patients were to receive Prolotherapy at the start of their pain, prior to significant radiographic hip osteoarthritis, the potential cost savings would be tremendous if these patients were to no longer need a hip replacement. Thus, the actual costs savings over a lifetime with Hackett-Hemwall dextrose Prolotherapy in patients with unresolved hip pain would most likely be well in excess of $100,000 per hip patient. If this occurred for 250,000 patients per year, the cost savings to the United States health care system could potentially be over 25 billion dollars per year. Future studies should be done to determine if indeed Prolotherapy can keep chronic hip pain sufferers from needing total hip replacements.