Discussion |
PRINCIPLE FINDINGS
Hackett-Hemwall dextrose prolotherapy treatments have produced statistically significant improvements in wrist pain, stiffness, and quality of life measurements in this unique patient population as concluded from this retrospective, uncontrolled, observational study. More specifically, Hackett-Hemwall dextrose prolotherapy for chronic wrist pain resulted in 61% of patients achieving greater than 75% pain relief; with 90% achieving 50% or more pain relief. Pain and quality of life improvements were reported in 100% of the patients after receiving prolotherapy for their wrist pain. Substantial improvements in other quality of life areas including stiffness, range of motion, depression, anxiety, sleep, exercise ability, and medication usage was also reported in this prolotherapy study.
Data analysis for the nineteen patients (61%) in the “no other treatment options available” subgroup or the “surgery was their only option” subgroups showed notable improvements in pain, stiffness, and exercise ability with Hackett-Hemwall dextrose prolotherapy.
STUDY STRENGTHS AND WEAKNESSES
This study admittedly does not compare to a clinical trial under controlled conditions. As a retrospective study, we are examining the response of patients with unresolved wrist pain to the Hackett-Hemwall technique of dextrose prolotherapy at a volunteer medical clinic. Noticeable strengths of the study relate to the number of parameters studied which are vital to helping patients with wrist pain again achieve the ability to function in their daily lives. Parameters such as range of motion, stiffness, athletic (exercise) ability, sleep, anxiety, depression, use of pain medication, in addition to pain level, are important factors affecting the person with unresolved wrist pain. The improvement in such a large number of variables treated solely by prolotherapy is likely to have resulted from the prolotherapy, rather than by chance. So while there is no medical test to document pain improvement or the progress with prolotherapy, an increased ability to exercise, sleep, and use less medications are objective changes that are noted.
Nineteen patients (61%) were either told by their MDs that no other treatment option for their pain was available or that surgery was their only option. Clearly this patient population represented chronic unresponsive pain. An average follow-up period of twenty-two months since their last prolotherapy session, along with the fact that 100% of the patients reported lasting improvements in their wrist pain, indicated that the changes were due to the prolotherapy treatments.
Because this was a volunteer free medical clinic with limited resources and personnel, the only therapy that was used was prolotherapy. The prolotherapy treatments could only be given every three months. In private practice, the Hackett-Hemwall technique of dextrose prolotherapy is typically given every four to six weeks. In a patient who is not progressing as desired and/or who has poor healing ability, the prolotherapy solutions may be changed and strengthened. The patient may also be advised on additional measures to improve their overall health and may include advice on diet, supplements, exercise, weight loss, changes in medications, additional blood tests, and/or other medical care. Private patients are immediately weaned off anti-inflammatory and narcotic medications that inhibit the inflammatory response needed to produce a healing effect from prolotherapy. Since this was not done at this clinic, the results of this study are an indication of the minimum level of success with Hackett- Hemwall dextrose prolotherapy. This makes the results even that much 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, and depression levels. The results relied on the answers to questions by the patients. X-ray and MRI correlation for diagnosis and response to treatment was also lacking. Limited physical examination documentation in the patients’ charts made categorization of the patients into various diagnostic categories impossible.
INTERPRETATION OF FINDINGS
Hackett-Hemwall dextrose prolotherapy was shown to be very effective in eliminating pain, stiffness and improving the quality of life in this group of patients with unresolved wrist pain. This included the subgroup of patients told that no other treatment options were available or that surgery was their only option. Current conventional therapies for unresolved wrist pain include medical treatment with analgesics, non-steroidal antiinflammatory drugs, anti-depressant medications, steroid injections, trigger point injections, muscle strengthening exercises, bracing, physiotherapy, rest, massage therapy, manipulation, acupuncture, education, and counseling. The results of such therapies are typically short term and often leave the patients with unresolved pain. When these treatments fail, the surgical procedure most often recommended for those with chronic unresponsive wrist pain is wrist arthrodesis.22 Wrist arthropathy occurs most often in the scapholunate joint from resultant scapholunate ligament injury and resultant instability.23 A common finding associated with the development of wrist arthropathy is carpus instability or laxity of the intercarpal ligaments. Typically trauma to the carpal ligaments results in abnormal joint reaction forces with each movement of the wrist. The process produces degeneration of the articular cartilage, resulting in radiocarpal arthritis, selective intercarpal arthritis, or pancarpal arthritis, depending on the initial injury and subsequent healing. Wrist degenerative arthritis is nearly identical to arthropathy in other joints, including the hip and knee. The principle problem is loss of articular cartilage between the carpal bones and/or the metacarpal and distal radius. Surgery is indicated for wrist arthritis when disabling pain emerges despite non-operative treatment.
While wrist arthrodesis can result in a high degree of patient satisfaction, limitations of wrist motion are a certainty.24 With access to medical information on the Internet, people with chronic wrist pain are searching for alternatives to surgery and traditional therapies that have not proven to be effective. One of the treatments that chronic wrist pain patients are learning about and trying instead of surgery is prolotherapy.25,26
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 percent, ligament thickness by 27 percent and the ligament-bone junction strength by 28 percent.27 In human studies on prolotherapy, biopsies performed after the completion of prolotherapy showed statistically significant increases in tendon and ligament collagen fiber and diameter of 60 percent.28,29
One explanation for the lack of response of chronic wrist pain sufferers to traditional conservative therapies is that their underlying problem, ligament laxity, is not being addressed. Ligaments are notorious for not healing.30,31 Ligament injury has been implicated as one of the major causes of degenerative osteoarthritis in joints, not just the wrist.32-36 Typically in the early stages of wrist arthritis, the problems are mainly caused by carpal instability from ligament injury.37,38 Prolotherapy has been shown to decrease pain by stimulating tissue repair in degenerated tissues such as ligaments and tendons.39-43
Traditional surgical treatments aim to rectify the anatomic position and to correct the carpal instability to prevent degeneration of the wrist. Presumably, the same occurs with prolotherapy to the wrist. The goal of the prolotherapy treatment is to eliminate pain and prevent further degeneration by stimulating the injured ligament(s) to heal. If the arthritic process has progressed, prolotherapy helps to stabilize the unstable joints. Unlike wrist fusion, however, prolotherapy for chronic wrist pain, as indicated in this study, helps improve range of motion, not diminish it. Because this subgroup study population of only five patients that looked to prolotherapy as an alternative to a surgery had great results with prolotherapy, further research is warranted into using prolotherapy as an option to wrist surgeries such as arthrodesis.
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