Neural Prolotherapy

A novel, effective and minimally invasive treatment for common sports and spine injuries.

Neural prolotherapy (NPT) involves precise injections of glucose using a tiny needle just below the skin in the region of a patient’s pain. The physician targets tender points and/or trigger points typically associated with inflamed superficial nerves in the region of pain and injury. Based on publications to date and almost a decade of collected case reports, NPT offers a success rate of greater than 80% for diagnoses including tendon, ligament, nerve, mechanical impingement and muscle pain conditions.

The technique of NPT was developed by sports-medicine physician John Lyftogt, MD in New Zealand. Practicing at the internationally-renowned Commonwealth Games sport medicine clinic in Christchurch, Dr. Lyftogt has been using NPT since 2003. He was originally trained by Margaret Taylor, MD from Australia, in classic prolotherapy, he then discovered a novel modification to the classic technique which has revolutionized the field of regenerative injection therapies. As opposed to classic prolotherapy, Dr. Lyftogt discovered that superficial injections near the nerves in the painful area were just as effective, if not more effective than the classic technique of deeper injections. The superficial technique also produced results in much less time and with minimal risk because such short, thin needles are used. Dr. Lyftogt trained the first group of ten doctors in NPT in 2009. Dr. Lee Wolfer was amongst the first doctors in the world trained in this technique and is one of the leading clinicians in this technique in the world. Dr. Wolfer has gone on to both lecture and teach at national and international NPT conferences. In 2013, she reviewed presented an international lecture, reviewing all the studies to date on NPT. Dr. Wolfer’s success with Regenerative Injection Therapies (RIT) was prominently featured in Timothy Ferriss’ book, “The 4-Hour Body: An Uncommon Guide to Rapid Body Transformation.” Dr. Wolfer used a combination of NPT (injections with glucose) and Biopuncture (injections with Traumeel/Arnica) to cure Tim Ferriss’ 6 year history of shoulder pain and as well as treat his chronic Achilles pain.

Research

Initially, Dr. Lyftogt’s focused much of his research on Achilles tendon pain (including tendinosis and partial tears). After treating more than 400 Achilles tendons, he has a success rate of greater than 90%. Mostly recently, his technique was used in the randomized-controlled trial by Michael Yelland, MD. (Yelland, MJ, Sweeting JR, Lyftogt JA et al. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: A randomized trial. British Journal of Sports Medicine, 2011). Researchers found that NPT combined with eccentric Achilles strengthening exercises showed statistical and clinical superiority in terms of rapid relief of pain and return to normal function versus usual care. For treatment of Achilles tendinosis, two year follow up studies have shown success rates 80% and higher. The neural prolotherapy protocol has been successfully adapted to treat “tennis/golfer’s” elbows, shoulder problems (rotator cuff tears, impingement, bursitis, tendinopathy), neck/back pain, hip pain (including femoral acetabular impingement), knee pain (patellar “tendonitis”, arthritis) and nerve pain/sciatica. Many patients and doctors prefer this technique to classical prolotherapy because it is less invasive. Some doctors use a combination of both techniques depending on the patient’s problem. If a patient also has arthritis in a joint, medication may also be placed inside the joint.

How Neural Prolotherapy work?

Because neural prolotherapy does not target tendons, ligaments, or joints, the question had to be asked – what causes sometimes dramatic decline in pain levels even after a few treatments. The current hypothesis is that glucose acts via the TRPV1 receptors (the main pain receptor responsible for pain in humans/mammals) located on the tiny nerves next to every tendon, ligament and joint. Every region of the body has small superficial nerves which are responsible for maintaining the health of the local tissues as well as giving branches to inside of joints. These nerves can secrete either pro- or anti-inflammatory local chemicals to promote healing or cause inflammation in the adjoining tissues. This local nerve inflammation is known as “neurogenic inflammation” differs from conventional inflammation in that it does not typically respond to anti-inflammatories (i.e. Advil/Aleve or cortisone injections) or cortisone injections – in terms of a longterm treatment success. It is clear from one randomized-controlled trial, clinical observations on more than 4000 patients and six published case series that NPT can effectively treat a wide range of orthopedic conditions, naturally. In Europe, many physicians are also using a similar technique with injectable botanical and mineral formulas to treat inflammation (known as Biopuncture with Traumeel/Arnica). These botanical agents also exert a positive regulatory effect on the release of local inflammatory messengers.

Safety, efficacy and research on common conventional treatments

Patients are asking their physicians for better new, safer, and effective treatments for common muscle, joint, tendon and ligament problems. Common over the counter and prescription NSAIDs (non-steroid anti-inflammatory medications) and steroid injections in fact may not help (particularly in the longterm) and may cause harm. In terms of safety, NSAIDs (i.e. Advil/Aleve) are known to be associated with increased risk of ulcers, acute kidney failure, gastrointestinal bleeding and death. All NSAIDs also just received a “black box” warning that they may cause heart attack or stroke, even if used regularly for a short time (2015). A recent 2010 study of Australian veterans taking various types of common anti-inflammatory medications had a significant increased mortality risk. Longterm use is associated with increased risk of gastrointestinal, cardiovascular and kidney complications. Also, increasingly, animal and human research is showing that use of NSAIDs interferes with the normal tissue repair process and ultimately weakens the tissue and increases the chances recurrent problems.

Treatment Protocol

Treatment typically involves 6-8 sessions of micro-injections just under the skin with a very small needle. (Similar to a tiny insulin needle). Additional treatment sessions are sometimes needed if a patient has had a prior surgery with active scar “neuromas.” Dr. Wolfer will also assess if any of a patient’s underlying medical problems or medications are interfering tissue healing. Modifications of lifestyle factors such as diet, exercise, sleep, stress reduction may be recommended. Some patients may also benefit from supplements to decrease inflammation and promote tissue healing.

Treatments are completed within 15 minutes. Side effects are mild, typically related to mild pain at the injection site, a small bruise or redness. Infection has not been reported using this subcutaneous technique. A small % of patients report a flare-up of their typical pain for a few days after treatment, but this typically abates as they improve over the course of multiple treatments. Deep tissue manual massage or with instruments is not recommended until the injection site is healed. Most patients return to their typical work-outs the same day or next day. More than 98% of patients tolerate the minimal discomfort associated with the injections without a problem. The occasional patient however who is needle phobic or quite pain sensitive may not be a good candidate. NPT is not covered by insurance, prices for treatment vary by state and physician experience.

Prolotherapy vs. Neural Prolotherapy

Classical prolotherapy was developed in the 1940s by an American trauma surgeon name George Hackett, using injections of Sylnasol, a sclerosing (scarring) agent commonly used at the time for shrinking varicose veins. He targeted ‘lax’ or ‘weak’ ligaments with these injections to make them stronger. Dr. Hackett reasoned that if ‘weak’ ligaments were the cause of most joint pain, strengthening them would relieve the pain. He published 16 articles and a textbook on his work. He claimed a greater than 80% success rate. A growing number of studies on Prolotherapy over the last 40 years have indicated good to excellent results for various orthopedic problems from this type of treatment. David Rabago, PhD, John Lyftogt, MD and their colleagues have published well-balanced reviews on prolotherapy. (Systematic review of prolotherapy for chronic musculoskeletal pain. Clin J Sports Medicine, 2005). Most recently, Dr. Rabago performed a randomized controlled trial using a series of injections of glucose into the knees of patients with mild to moderate arthritis. (Dextrose ‘glucose’ Prolotherapy for Knee Osteoarthritis. Annals of Internal Medicine, 2013). Patients who received glucose instead of saline had statistically significant improvement in pain, stiffness and function. MRI findings showed new cartilage growth. The authors believe that the glucose acted in an anti-inflammatory fashion on the nerves in and around the knees and which lessened pain, improved function and allowed new cartilage to growth.

Conclusion

Neural prolotherapy is an excellent non-surgical treatment to consider for common sports and orthopedic problems—as a first line treatment or when other conventional treatments have not responded. Dr. Wolfer will determine if you are a good candidate for this treatment.

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