|
Journal of Prolotherapy.
2009;2:76-88.
A Retrospective
Study on Hackett-Hemwall Dextrose Prolotherapy for
Chronic Hip Pain at an Outpatient Charity Clinic in
Rural Illinois
Ross A. Hauser, MD & Marion A. Hauser, MS, RD
abstract
Objective: To investigate the outcomes of
patients undergoing Hackett-Hemwall dextrose
Prolotherapy treatment for chronic hip pain.
Design: Sixty-one patients,
representing 94 hips who had been in pain an average of
63 months, were treated quarterly with
Hackett-Hemwall
dextrose Prolotherapy. This included a subset of 20
patients who were told by their medical doctor(s) that
there were no other treatment options for their pain and
a subset of eight patients who were told by their
doctor(s) that surgery was their only option. Patients
were contacted an average of 19 months following their
last
Prolotherapy session and asked questions regarding
their levels of pain, physical and psychological
symptoms and activities of daily living, before and
after their last Prolotherapy treatment.
Results: In these 94 hips, pain levels
decreased from 7.0 to 2.4 after Prolotherapy; 89%
experienced more than 50% of pain relief with
Prolotherapy; more than 84% showed improvements in
walking and exercise ability, anxiety, depression and
overall disability; 54% were able to completely stop
taking pain medications. The decrease in pain reached
statistical significance at the p<.0001 for the 94 hips,
including the subset of patients who were told there was
no other treatment options for their pain and those who
were told surgery was their only treatment option.
Conclusion: In this retrospective study
on the use of Hackett-Hemwall dextrose Prolotherapy,
patients who presented with over five years of
unresolved hip pain were shown to improve their pain,
stiffness, range of motion, and quality of life measures
even 19 months subsequent to their last Prolotherapy
session. This pilot study shows that Prolotherapy is a
treatment that should be considered and further studied
for people suffering with unresolved hip pain.
introduction
Chronic hip pain is a common condition resulting in over
383,000
hip replacements annually in the United States
and the number is increasing every year.1
The high rates of wear and tear, attributable to normal
use of the hip, can result in long term problems. This
makes sense when one considers that patients move their
hips at least one million times per year during
activities of daily living.2,3
Population-based surveys of patients who have arthritis
of the hip document a large untapped need for these
procedures, suggesting that the rates of total hip
arthroplasty will likely increase in the future.4
Not everyone who is a candidate for a new hip will
choose this option, as the operation has inherent risks
including poor outcome, osteolysis and need for
revision, deep vein thrombosis and limited life span.5,6
Because of the limited response of chronic hip pain to
other traditional therapies, many people are turning to
alternative therapies, including Prolotherapy, for pain
control.7,8
Prolotherapy is becoming a widespread form of pain
management in both complementary and allopathic
medicine.9
Its primary use is in the pain management associated
with tendinopathies and ligament sprains in peripheral
joints.10-12
It is also being used in the treatment of spine and
joint degenerative arthritis.13-14
Prolotherapy has long been used for chronic low back
pain arising from the sacroiliac joints and as an
alternative to surgery.15-19
Prolotherapy has been shown in low back studies to
improve pain levels and range of motion.20-21
In doubleblinded human studies the evidence on the
effectiveness of Prolotherapy has been considered
promising but mixed.22-25
George
S. Hackett, MD, coined the term Prolotherapy.26
As he described it, “The treatment consists of the
injection of a solution within the relaxed ligament and
tendon which will stimulate the production of new
fibrous tissue and bone cells that will strengthen the
‘weld’ of fibrous tissue and bone to stabilize the
articulation and permanently eliminate the disability.”27
Animal studies have shown that Prolotherapy induces the
production of new collagen by stimulating the normal
inflammatory reaction.28,29
In addition, animal studies have shown improvements in
ligament and tendon diameter and strength.30-31
While Prolotherapy has been used for chronic hip pain,
no study has been published to date to show its
effectiveness for this condition.32
To evaluate the effectiveness of Hackett-Hemwall
dextrose Prolotherapy, not just on hip pain but on
quality of life measures, as well as its ability to
reduce or eliminate the need or other medical therapies
including total hip replacement this observational study
was undertaken.
Patients and
Methods
Framework and Setting
In October 1994, the primary authors started a Christian
charity medical clinic called Beulah Land Natural
Medicine Clinic in an impoverished area in southern
Illinois. The primary treatment modality offered was
Hackett-Hemwall dextrose Prolotherapy for pain control.
Dextrose was selected as the main ingredient in the
Prolotherapy solution because it is the most common
proliferant used in Prolotherapy, is readily available,
is inexpensive compared to other proliferants, and has a
high safety profile. The clinic met every three months
until July 2005. All treatments were given free of
charge.
Patient Criteria
General inclusion criterion were an age of at least 18
years, having an unresolved hip pain condition greater
than six months that typically responds to Prolotherapy,
and a willingness to undergo at least four Prolotherapy
sessions, unless the pain remitted with less number of
Prolotherapy sessions.
Interventions
The Hackett-Hemwall technique of dextrose
Prolotherapy was used. Each patient received 40 to 60
injections of a 15% dextrose, 0.2% lidocaine solution
with a total of 50 to 60cc of solution used per hip.
Each patient was given an intraarticular injection of 5
to 10cc of solution via the lateral or posterior
approach. Injections were given at the bony attachments
of the following structures around the hips including:
the greater trochanter, intertrochanteric crest, neck of
femur and dorsal ilium; ischiofemoral and ilofemoral
ligaments; tensor fasica lata; and gluteus medius,
pyriformis, gemellus superior, quadrates femoris,
obturator internus, gemellus inferior and vastus lateral
muscles. These typical tender spots each injected with
0.5 to 1cc of solution, can be seen in Figure 1.
No other therapies were used. As much as the pain would
allow, the patients were asked to reduce or stop other
pain medications and therapies they were using.
Figure 1. Typical injection sites for
Hackett-Hemwall dextrose Prolotherapy of the hip.
Statistical Analysis
For the analysis, patient percentages of the various
responses were calculated using Microsoft Excel by an
independent computer consultant (D.G.), who also had no
previous knowledge of Prolotherapy. These responses,
gathered from patients before Prolotherapy, were then
compared with the responses to the same questions after
Prolotherapy. The patient percentages were also
calculated for patients who answered yes to either of
the following two questions: Before starting
Prolotherapy it was the consensus of my medical
doctor(s) that there were no other treatment options
that he or she knew of to get rid of my chronic pain?
and Before starting Prolotherapy my only other
treatment option was surgery. A matched sample
paired t-test was used to determine if there were
statistically significant improvements in the before and
after Prolotherapy measurements for pain, stiffness, and
range of motion in the above three groups (total hips
and two subgroups above).
Patient
characteristics
Complete data was obtained on 61 patients representing
94 hips. Of the 61 patients, 72% (44) were female and
28% (17) were male. The average age of the patients was
62 years-old. Patients reported an average of five
years, three months of pain. Fifty-four percent had pain
longer than four years and 39% had pain longer than six
years. The average patient saw three doctors before
receiving Prolotherapy. Twelve percent saw six or more
doctors and another 22% saw four or five doctors for
their chronic hip pain. The average patient was taking
1.1 pain medications. Thirteen percent stated that the
consensus of their doctor(s) was that surgery was the
only answer to their pain problem, and 33% of patients
were told by their doctor(s) that there were no other
treatment options for their chronic pain. (See Table
1.)
|
Table 1.
Patient Characteristics at Baseline. |
|
Total number of
patients treated |
|
|
Total number of
hips treated |
|
|
Average age of
patients |
|
|
Percent of male
patients |
|
|
Percent of female
patients |
|
|
Number of prior
physicians seen |
|
|
Average years of
pain |
|
|
Informed surgery
only treatment option |
|
|
Informed no other
treatment option for their chronic hip pain |
|
|
Average number of
pharmaceutical drugs taken for pain |
|
Treatment Outcomes
Patients received an average of 4.7 Prolotherapy
treatments per hip. The average time of follow-up after
their last Prolotherapy session was 19 months.
Pain, Crunching Sensation, Stiffness.
Patients were asked to rate their pain, crunching
sensation and stiffness on a scale of 1 to 10 with 1
being no pain/crunching/stiffness and 10 being severe
crippling pain/crunching/stiffness. The 61, representing
94 hips had an average starting pain level of 7.0,
crunching sensation of 2.0 and stiffness of 4.4. Their
average ending pain, crunching and stiffness levels were
2.4, 1.2, and 2.0 respectively. Fiftyfour percent had a
starting pain level of eight or greater, while only 5%
had a starting pain level of three or less, whereas
after Prolotherapy only 2% had a pain level of eight or
greater while 77% had a pain level of three or less. (See
Figure 2.)
Figure 2. Starting and ending
pain, stiffness, and cruching levels before and after
receiving
Hackett-Hemwall dextrose Prolotherapy in 61 patients (94
hips) with unresolved hip pain.
Data Collection
Patients who received Prolotherapy for their
chronic hip pain in the years 2001 to 2005 were called
by telephone and interviewed by an independent data
collector (D.P.) who had no prior knowledge of
Prolotherapy. D.P. was the sole person obtaining the
patient information during the telephone interviews. The
patients were asked a series of detailed questions about
their pain and previous treatments before starting
Prolotherapy. Their response to Prolotherapy treatments
was also documented in detail with an emphasis on the
effect the treatments had on their need for subsequent
pain treatments and their quality of life. Specifically,
patients were asked questions concerning years of pain,
pain intensity, overall disability, number of physicians
seen, medications taken, stiffness, walking and exercise
ability, activities of daily living, quality of life
concerns, psychological factors and whether the response
to Prolotherapy continued after their last Prolotherapy
session.
Range of
Motion.
Patients were asked to rate their range of motion on a
scale of 1 to 7 with 1 being no motion, 2 through 5 were
fractions of normal motion, 6 was normal motion, and 7
was excessive motion. The average starting range of
motion was 4.3 and ending range of motion was 5.1.
Before Prolotherapy 30% had very limited motion (49% or
less of normal motion), this decreased to only five
percent after Prolotherapy. Prior to Prolotherapy only
36% had 75% or greater of normal range of motion but
this improved to 75% after Prolotherapy. (See Figure
3.)
Pain
Medication Utilization.
Sixty percent discontinued pain medications altogether
after Prolotherapy. In all, 75% of patients on
medications at the start of Prolotherapy were able to
decrease them by 75% or more after Prolotherapy. None of
the patients had to increase pain medication usage after
stopping Prolotherapy. Before Prolotherapy the average
patient was taking 1.1 pain medications but this
decreased to 0.3 medications after Prolotherapy. Before
Prolotherapy 23% of patients were on two or more pain
medications, but this decreased to 2% after
Prolotherapy. Sixty-nine percent of clients using
additional pain management therapies before Prolotherapy
were able to decrease them by 75% or more after
treatment.
Walking
Ability.
Before Prolotherapy, 59% of patients experienced
compromised walking ability, but this decreased to 39%
after Prolotherapy. Specifically, 38% could walk three
blocks or less before Prolotherapy, but this decreased
to 10% after Prolotherapy. While 27% of patients could
walk less than one block before Prolotherapy, all could
walk greater than that distance after Prolotherapy. (See
Figure 4.)
Exercise and
Athletic Ability. In regard to exercise or
athletic ability prior to Prolotherapy, 30% reported
totally compromised ability (couldn’t do any athletics),
seven percent ranked it as severely compromised (less
than 10 minutes), 23% ranked it as very compromised
(less than 30 minutes) and a total of 84% ranked it as
at least somewhat compromised. After treatments, 80% of
patients were able to do 30 or more minutes of exercise
with 40% not being compromised at all. (See Figure
5.)
Disability.
In regard to quality of life issues prior to receiving
treatment, 40% had an overall disability of at least 50%
(could only do about half of the tasks they wanted to).
This decreased to 11% after Prolotherapy. Sixty-seven
percent noted they had at least a 25% overall disability
prior to treatments and this decreased to 24% after.
Before receiving Prolotherapy, five of the patients were
dependent on someone for activities of daily living
(dressing self and additional general self care). All
five regained complete independence after Prolotherapy.
Before Prolotherapy 11% considered themselves completely
disabled in regards to their work situation, but this
decreased to seven percent after Prolotherapy.
Depression and
Anxiety. Prior to Prolotherapy, 46% of patients
had feelings of depression and 52% had feelings of
anxiety. After treatments, only 13% had depressed
feelings and 21% had feelings of anxiety.
Sleep. Seventy-two percent of patients
reported their pain interrupted their sleep prior to
Prolotherapy treatments and 71% subsequently experienced
improvements in their sleeping ability.
Quality of Life. To a simple yes or no
question: Has Prolotherapy changed your life for the
better? 98% of patients treated answered “yes.” In
quantifying the response:
|
• |
Seventy-five
percent felt their life was at least very much
better from Prolotherapy. |
|
• |
Sixty percent
stated that the results from Prolotherapy have
very much continued (>75%) to this day. |
|
• |
Ninety-eight
percent felt that they still have some benefits
from the Prolotherapy they received. |
When patients experiencing some regression were asked, “Are
there reasons besides the Prolotherapy effect wearing
off that are causing some return of my pain/disability?”
81% answered “yes.” The patients noted the reasons for
some of their returning pain were:
|
• |
stopped
Prolotherapy treatments too soon (before pain
completely gone) – 50% |
|
• |
re-injury –
12% |
|
• |
new area of
pain – 14% |
|
• |
had increased
life stressors – 10% |
|
• |
had other
explanations for the pain – 14% |
Of the patients whose pain recurred after Prolotherapy
was stopped, 80% were planning on receiving additional
Prolotherapy treatments.
Patient Satisfaction. Eighty-five
percent of patients knew someone who had received and
benefited from Prolotherapy. In fact, seventy-five
percent came to receive their first Prolotherapy session
because of the recommendation of a friend. Eighty-nine
percent of patients treated considered the Prolotherapy
treatment to be very successful (greater than 50% pain
relief). (See Figure 6.) Ninety-seven percent
noted the Prolotherapy was at least somewhat successful
(greater than 25% pain relief). All 100% noted some
benefit in their pain with treatment. None indicated
that the Prolotherapy treatments made them worse.
Ninety-five percent have recommended Prolotherapy to
someone.
Subgroup Analysis
Patient percentages were also calculated for patients
who answered “yes” to either of the following two
statements:
1. “Before starting Prolotherapy it was the consensus of
my medical doctor(s) that there were no other treatment
options that he/she knew to get rid of my chronic pain.”
and
2. “Before starting Prolotherapy my only other treatment
option was surgery.”
“No Other Treatment Options” Subgroup. Twenty
patients had been told by their doctors that there were
no other treatment options for their pain prior to
presenting for Prolotherapy. As a group they suffered
with pain on average 69 months, saw 3.2 physicians and
were on 1.5 medications for pain. Sixty percent of these
patients had pain longer than six years. In analyzing
these patients, they had a starting average pain level
of 8.1 and after Prolotherapy 3.1. Prior to
Prolotherapy, 65% of the patients rated their pain as a
level eight or higher and none rated it a three or less.
After Prolotherapy none rated it an eight or higher and
70% rated it a three or less. (See Figure 7.)
Starting levels of
stiffness and crunching levels were 5.9 and 3.1 and
ending levels of 2.7 and 1.4, respectively. In regard to
range of motion, prior to Prolotherapy only 33% had 75%
or greater normal range of motion, but this increased to
75% after Prolotherapy. As a group, prior to
Prolotherapy, 60% noted in regards to activities of
daily living, they could not do at least 50% of the
tasks they wanted to do. This decreased to 15% after
Prolotherapy. Twenty percent of patients before
Prolotherapy could walk one block or less, but all could
walk over a block after Prolotherapy. Only 35% percent
said they were not compromised in regard to walking
before Prolotherapy, but this increased to 60% after
Prolotherapy. Before Prolotherapy 30% could not exercise
at all, whereas after Prolotherapy this was down to
three percent. Only five percent ranked their exercise
ability as not compromised before Prolotherapy, but
after Prolotherapy 67% rated it as not compromised. (See
Figure 8.) For those patients on pain medication,
80% were able to decrease them by 50% or more after
treatments. Twenty-five percent of patients on pain
medications were able to stop taking them after
Prolotherapy. Eighty-five percent were able to decrease
their need for additional pain therapies by 50% or more.
Eighty percent of these
patients noted the Prolotherapy treatment gave them
greater than 50% pain relief with 50% of them receiving
75% or greater pain relief. In response to the question
Has Prolotherapy changed your life for the better? 100%
answered “yes.” All 100% have recommended Prolotherapy
to someone else. (See Table 2.)
“Surgery is the
Only Treatment Option” Subgroup. This group
represents 13% of the patients (eight in number). As a
group they saw on average 4.2 physicians and were taking
1.8 pain medications prior to Prolotherapy. They had
pain for an average of 44 months. Initial average pain
level was 8.4, which decreased to 2.4 after
Prolotherapy. Eighty-eight percent had a pain level of
eight or more before Prolotherapy. None had a pain level
under a seven before Prolotherapy. After Prolotherapy,
all had a pain level of five or less with 63% of them
having no pain. (See Figure 9.)
On average, 19 months
after their last Prolotherapy treatment, as a group they
stated that 100% of their improvement in daily pain had
continued. Before Prolotherapy their starting stiffness
and crunching levels were 4.0 and 1.8 respectively,
whereas the ending stiffness and crunching levels were
2.0 and 1.2. Sixty-two percent stated they had greater
than 75% pain relief and a full 100% (eight of eight)
had 50% or greater pain relief with Prolotherapy. In
regard to range of motion, before Prolotherapy 89% of
the patients had 74% or less of normal motion, whereas
after Prolotherapy, 75% had 75% or greater of normal
motion. Fifty percent had normal range of motion. (See
Figure 10.)
Before Prolotherapy 87%
noted an overall disability of 25% or greater, but this
decreased to 13% after Prolotherapy. Sixty-two percent
could walk one block or less before Prolotherapy, but
all of these patients could walk greater than one block
after Prolotherapy. All 100% could only exercise 30
minutes or less before Prolotherapy, but after
Prolotherapy 74% could exercise more than 30 minutes per
day. Before Prolotherapy, 100% were taking pain
medications, but after Prolotherapy 75% were taking no
medications. Since their last Prolotherapy treatment 75%
(six of eight) are still not on any pain medications and
the other two patients are just on one medication. All
100% said that Prolotherapy changed their life for the
better.
Statistical Analysis
A matched sample paired t-test was used to calculate the
difference in responses between the before and after
measures for pain, stiffness and range of motion for the
94 hips, including the subgroup of twenty patients who
before starting Prolotherapy were told there were no
other treatment options and the eight patients told by
their medical doctor(s) there was no other treatment
option but surgery. Using the paired t-test, all p
values for pain for all subgroups reached statistical
significance at the p<.0001 level. For the 94 hips, the
p values for pain, stiffness, and range of motion all
showed statistically significant improvements at the
p<.0001 level.
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.
Conclusions
The Hackett-Hemwall technique of dextrose Prolotherapy
used on patients who presented with over five years of
unresolved hip pain were shown in this retrospective
pilot study to improve their quality of life even 19
months subsequent from their last Prolotherapy session.
The 61 patients with 94 hips treated reported
significantly less pain, stiffness, crunching sensation,
disability, depressed and anxious thoughts, medication
and other pain therapy usage, as well as improved
walking ability, range of motion, sleep, exercise
ability, and activities of daily living. This included
patients who were told there were no other treatment
options for their pain or that surgery was their only
option. The results confirm that Prolotherapy is a
treatment that should be highly considered for people
suffering with chronic hip pain. Future studies will be
needed to confirm this pilot study and to document if
Prolotherapy can keep chronic hip pain sufferers from
needing hip surgeries including hip replacements.
Acknowledgements
Doug Puller (D.P.), independent data collector.
Dave Gruen (D.G.) independent data analyst from
www.bolderimage.com.
bibliography
1. Kurtz S.
Prevalence of primary and revision total hip and knee
arthroplasty in the United States from 1990 through 2002.
J Bone Joint Surg Am. 2005 Jul;87(7):1487-97.
2. Kim S.
Changes in surgical loads and economic burden of hip and
knee replacements in the US: 1997-2004. Arthritis
Rheum. 2008 Apr 15;59(4):481-8.
3. Lee K, et al.
Current state and future of joint replacements in the
hip and knee. Expert Rev Med Devices. 2008
May;5(3):383-93.
4. Agency for Healthcare Research and Quality (AHRQ).
Agency News and Notes:
Musculoskeletal
procedures account for over 10 percent of all hospital
care in the United States.
5. Freedman KB. A meta-analysis of thromboembolic
prophylaxis for elective total hip arthroplasty. Paper
presented at: Ninth Annual Meeting of the American
Association of Hip and Knee Surgeons; November
12-14,1999; Dallas, Texas.
6. Elfick A. Variation in the wear rate during the life
of a total hip arthroplasty: A simulator and retrieval
study. J Arthroplasty. 2000;379:34-40.
7. Alternative treatments: Dealing with chronic pain.
Mayo Clinic
Health Letter. April 2005. 23(4).
8. Lennard T. Pain Procedures in Clinical Practice. 2nd
ed. Philadelphia, PA: Hanley & Belfus, Inc.;2000.
9. Lennard T. Physiatric Procedures in Clinical
Practice. Philadelphia, PA: Hanley & Belfus, Inc.;1995.
10. Hackett G, et al. Ligament and Tendon Relaxation
Treated by Prolotherapy. 5th ed. Oak Park, IL: Gustav A.
Hemwall;1992.
11. Reeves KD. Prolotherapy: Present and future
applications in soft tissue pain and disability. Phys
Med Rehabil Clin N Am. 1995;6:917-926.
12. Ongley M. Ligament instability of knees: a new
approach to treatment. Manual Med. 1988;3:152-154.
13. Hackett G.
Prolotherapy in whiplash and low back
pain Postgrad Med. 1960;27:214-219.
14. Kayfetz D. Occipital-cervical (whiplash) injuries
treated by Prolotherapy. Med Trial Tech Quarterly. June
1963:9-29.
15. Merriman J. Prolotherapy versus operative fusion in
the treatment of joint instability of the spine and
pelvis. J Inter Coll of Surg. 1964;42:150-159.
16. Hackett G. Shearing injury to the sacroiliac joint.
J Inter Coll Surg. 1954;22:631-639.
17. Hackett G. Referred pain and sciatica in diagnosis
of low back disability. J Am Med Assoc.
1957;163:183-185.
18. Hackett G. Ligament and Tendon Relaxation Treated by
Prolotherapy. Springfield, IL: Charles C. Thomas, 1958.
19. Hackett G. Joint stabilization: An experimental,
histologic study with comments on the clinical
application in ligament proliferation. Am J Surg.
1955;89:968-973.
20. Ongley M, et al.
A New Approach to
the Treatment of Chronic Low Back Pain.
Lancet. July 1987:143-147.
21. Echow E. A randomized, double-blind,
placebo-controlled trial of sclerosing injections in
patients with chronic low back pain. Rheumatology.
1999;38(12):1255-9.
22. Klein RG, et al. A randomized double-blind trial of
dextroseglycerine-phenol injections for chronic low back
pain. J Spinal Dis. 1993;6(1):23-33.
23. Klein RG, et al. Proliferative injection for low
back pain: Histologic changes of injected ligaments and
objective measurements of lumbar spine mobility before
and after treatment. J Neuro & Orthop Med & Surg. July
1989;10(2).
24. Yelland MJ.
Prolotherapy injections, saline injections and exercises
for chronic low back pain: a randomized trial.
2004;29(1):9-16.
25. Dagenais S.
Intraligamentous
injection of sclerosing solutions (Prolotherapy) for
spinal pain: a critical review of literature.
Spine J. 2005;5:310-328.
26. Hackett G. Referral pain and sciatica in diagnosis
of low back disability. J Am Med Assoc.
1957;163:183-185.
27. Hackett G.
Ligament and Tendon Relaxation Treated by Prolotherapy.
3rd ed. Springfield, IL: Charles C. Thomas, 1958.
28. Schwarz R. Prolotherapy:
A literature review
and retrospective study. J Neuro, Orthop Med
& Surg. 1991;12:220-229.
29. Schmidt H. Effect of growth factors on proliferation
of fibroblasts from the medial collateral and anterior
cruciate ligaments. J Orthop Res. 1995;13:184-190.
30. Liu Y.
An in-situ study of the influence of a sclerosing
solution in rabbit medial collateral ligaments and its
junction strength. Connect Tissue Res.
1983;2:95-102.
31. Maynard J.
Morphological and
biomechanical effects of sodium morrhuate on tendons.
J Orthop Res. 1985;3:236-248.
32. Hauser R, et al.
Prolo Your Pain Away! 3rd ed. Beulah Land Press, Oak
Park, IL. 2007.
33. Cleveland Clinic total hip arthroplasty orthopedic
surgery outcomes 2006, pp. 10-11.
34. Ottawa Panel evidence-based clinical practice
guidelines for therapeutic exercises and manual therapy
in the management of osteoarthritis. Phys Ther.
2005;85:907-71.
35. Roddy E. Evidence-based recommendations for the role
of exercise in the management of osteoarthritis of the
hip or kneethe MOVE consensus. Rheumatology.
2005;44:67-71.
36. Garfinkel M. Yoga as a complementary therapy.
Geriatr Aging. 2006;9:190-194.
37. Pavelka K.
Glucosamine sulfate prevents total joint
replacement in the long-term follow-up of knee
osteoarthritis patients. American College of
Rheumatology 2004 meeting; October 16-21, 2004; San
Antonio, TX; presentation 251, poster board 252.
38. Garellick G. Life expectancy and cost utility after
total hip replacement. Clin Orthop Relat Res.
1998;346:141-151.
39. Schmale G. Early failure of revision total hip
arthroplasty with cemented precoated femoral components:
comparison with uncemented components at 2 to 8 years. J
Arthroplasty. 2000; Septmeber;15(6):718-729.
40. Lieberman J. The efficacy of prophylaxis with
low-dose warfarin for prevention of pulmonary embolism
following total hip arthroplasty. J Bone Joint Surg Am.
1997;79:319-325.
41. Dorr L, et al.
Causes of and treatment protocol for
instability of total hip replacement. Clin Orthop Relat
Res. 1998;355:144-151.
42. American Association of Hip and Knee Surgeons.
Minimally invasive & small incision joint replacement
surgery: what patients should consider. Available at:
www.aahks.org//web/pdf/MIS_patients.pdf. Accessed
December 11, 2008.
43. Reeves K. Prolotherapy: Basic science, clinical
studies and technique. In: Lennard TA, ed. Pain
Procedures in Clinical Practice. 2nd ed. Philadelphia,
PA: Hanley and Belfus; 2000:172-190.
44. Alderman, D. Prolotherapy for knee pain. Pract Pain
Manage. July/Aug 2007, pp. 70-79.
45. Reeves KD, et al.
Randomized
prospective double-blind placebocontrolled study of
dextrose Prolotherapy for knee osteoarthritis with or
without ACL laxity. Altern Ther. March
2000;6(2):68-80.
46. Hauser R, et al. Standard clinical X-ray studies
document cartilage regeneration in five degenerated
knees after Prolotherapy. Journal of Prolotherapy.
2009;1:22-27.
47. Alderman D. Prolotherapy for knee pain. Pract Pain
Manage. July/August 2007, pp.70-79.
48. Bennett LD, et al. Meniscal and articular cartilage
changes in knee osteoarthritis: a cross sectional
double-contrast macrographic study. Rheumatology.
2002;41:917-923.
49. Brandt KD. Transection of the anterior cruciate
ligament in the dog: a model of osteoarthritis. Semin
Arthritis Rheum. 1991;21(3 Suppl 2):22-32.
50. Fleming BC, et al.
Ligament injury, reconstruction
and osteoarthritis. Curr Opin Orthop. 2005
Oct;16(5):354-362.
51. HCUPnet, Healthcare Cost and Utilization Project.
Agency for Healthcare Research and Quality, Rockville,
MD. Available at: www.ahrq.gov/data/hcup/hcupnet.htm.
(accessed 2/08/2008)
52. HCUP Databases (Nationwide Inpatient Sample).
Healthcare Cost and Utilization Project (HCUP). Agency
for Healthcare Research and Quality, 1999-2003.
Available at: www.hcupnet.ahrq.gov/HCUP. Accessed
December 11, 2008.
53. Illinois Hospital Price Survey Report: 2000.
Provided by Illinois Health Care Cost Containment
Council
54. Charges for Prolotherapy at Caring Medical and
Rehabilitation Services, Oak Park, IL for 2007.
55. Lane N.
Progression of radiographic hip
osteoarthritis over eight years in a community sample of
elderly white women. Arthritis Rheum. May
2004;50(5):1477-1486.
|
