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Dextrose Prolotherapy Injections for Chronic Ankle Pain

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Dextrose Prolotherapy Injections for Chronic Ankle Pain Prolotherapy Dextrose Prolotherapy Injections for Chronic Ankle Pain In this retrospective observational study of chronic unresolved ankle pain, Hackett-Hemwall dextrose prolotherapy helped promote a measurable decrease in the pain and stiffness of the treated joints and improvement in clinically-relevant parameters. In this continuing series, Dr. Hauser reports on patients treated for unresolved ankle pain at a volunteer charity clinic having limited resources and personnel between 2000 to 2005. Treatment consisted of injecting a dextrose solution at specific ankle sites to stimulate healing of ligaments, tendons and joints. Patients—including those who were told by prior doctors that ‘nothing more could be done’ or that ‘surgery was the only option’—responded favorably to treatment as demonstrated by reports of reduced pain levels, increased range of motion, extended ability to exercise, reduced depression, reduced anxiety, and a reduction in medications needed. —Donna Alderman, DO By Ross A. Hauser, MD; Marion A. Hauser, MS, RD; and Joe Cukla, BA, LPN nkle sprains, especially of the lat- ankle instability end up with arthritic an- at pain levels, but we also reported on a eral ligaments, are extremely com- kles.7 Long term residual symptoms from host of quality of life measures that are Amon injuries in the general and ankle sprains that do not heal can result important to those with chronic ankle athletic populations. Approximately in ongoing problems including pain, stiff- problems. 25,000 people sprain their ankles daily.1 ness, limited range of motion and the in- Sprains constitute 85% of all ankle in- ability to exercise or walk long distances. PATIENTS AND METHODS juries and, of these, 85% are inversion Options such as medications, physical Framework and setting sprains.2 Sprains of the lateral ankle com- therapy, steroid shots, bracing and sur- In October 1994, the primary authors plex make up 38-45% of all injuries in gery typically leave the patient with resid- (R.H., M.H.) started a Christian charity sports.3,4 The recurrence rate for lateral ual symptoms.8 While the response to medical clinic called Beulah Land Natur- ankle sprains has been reported to be as acute ankle sprains is usually quick; treat- al Medicine Clinic in an impoverished high as 80%.5 Up to 40% of individuals ment for chronic ankle pain has had lim- area in southern Illinois at which the pri- have residual ankle symptoms due to ited success. According to a 1999 review, mary treatment modality offered was chronic instability.6 A 2005 study from the there are more than 20 different delayed University of Bassel in Switzerland found surgical procedures available for chronic that 70% to 80% of patients with chronic ankle pain and instability. While most of these procedures are reconstructive in na- TABLE 1. Patient Characteristics ture, none really restore true anatomy.9,10 Prior to Prolotherapy Because of this, many patients with chron- ic pain, including ankle pain, are open to alternative treatments. One of the treat- Ankle patients n=19 ments they are receiving is prolotherapy Percentage of female patients 63% since more physicians are getting trained 11 Percentage of male patients 37% to perform it. Prolotherapy for ankle lig- ament injuries has even been mentioned Average age of ankle patients 52 in the Mayo Clinic Health Newsletter.12 Average years of pain 3.3 While prolotherapy has been used for Average number of MD’s seen 3.3 decades to treat ankle injuries and chron- Average number of ic ankle pain, no specific studies on the pharmaceutical drugs 1.0 results of prolotherapy on patients with chronic ankle pain have been done.13 Be- No other treatment options available 63% cause of this, we decided to measure the Surgery only treatment response of patients who received dex- FIGURE 1. Typical prolotherapy injection sites option available 11% trose prolotherapy. Not only did we look for Hackett-Hemwall prolotherapy of the ankle 70 Practical PAIN MANAGEMENT, January/February 2010 ©2010 PPM Communications, Inc. Prolotherapy Hackett-Hemwall dextrose prolotherapy for pain control. Dex- tailed with an emphasis on the effect prolotherapy had on their trose was selected as the main ingredient in the prolotherapy ankle pain, stiffness, and quality of life. Specifically, patients were solution because it is the most common proliferant used in pro- asked questions concerning years of pain, pain intensity, stiff- lotherapy, is readily available, inexpensive (compared to other ness, number of physicians seen and medications taken, quality proliferants), and has a high degree of safety.14 The clinic met of life concerns, psychological factors, and whether the response every three months until July 2005. All treatments were provid- to prolotherapy continued after the treatment sessions stopped. ed at no cost to the patients. Analysis Patients The patients’ responses to the telephone questionnaire were Patients who received prolotherapy for their unresolved ankle gathered and analyzed before prolotherapy and then compared pain in the years 2004 to 2005 at the charity clinic were called with the responses to the same questions after prolotherapy. The by telephone and interviewed by a data collector (D.P.) who had responses were also analyzed in a subset of patients who an- no prior knowledge of prolotherapy. General inclusion criteria swered “yes” to the following statement: “Before starting pro- were an age of at least 18 years, possessing unresolved ankle lotherapy it was the consensus of my MD(s) that there were no pain that typically responds to prolotherapy, and an ability to other treatment options that he or she knew of to get rid of my undergo at least four prolotherapy sessions, unless the pain re- chronic ankle pain.” mitted with fewer prolotherapy sessions. Typical ankle condi- tions that respond to prolotherapy include ankle instability, Patient characteristics ankle ligament sprain, and ankle degenerative arthritis. Complete data was obtained on a total of 19 ankle patients who met the inclusion criteria. Of these, 63% (12) were female and Interventions 37% (7) were male. The average age of the patients was 52 years The Hackett-Hemwall technique of prolotherapy was used to old. Patients reported an average of 3.3 years (40 months) of treat each ankle. Each patient received 20 to 30 injections of a pain and on average saw 3.3 MDs before receiving prolothera- 15% dextrose, 0.2% lidocaine solution with a total of 15 to 30 cc py. The average patient was taking 1.0 pain medication. Sixty- of solution used per ankle. Injections were given into and around three percent (12) stated that the consensus of their medical the areas on the ankle that were painful and/or tender to touch. doctor(s) was that there were no other treatment options for The typical areas injected, each with 0.5 to 1 cc of solution, can their chronic pain. Eleven percent (2) stated that the only other be seen in Figure 1. Tender areas injected were on the lateral treatment option for their chronic ankle pain was surgery (see and medial malleolus, talus, calcaneus, and into and around the Table 1). tibiotalar joint. The tender areas of the attachments of the del- toid, anterior and posterior talofibular, and calcaneofibular lig- Treatment outcomes aments were also injected. As much as their pain would allow, Patients received an average of 4.4 prolotherapy treatments per the patients were asked to cut down or stop the pain medica- ankle. The average time of follow-up after their last prolother- tions they were taking. apy session was twenty-one months. Patients were asked to rate their pain and stiffness levels on a Outcomes scale of 1 to 10 on a visual analog scale (VAS) with 1 being no D.P. was the sole person obtaining the patient follow-up assess- pain/stiffness and 10 being severe crippling pain/stiffness. The ment information during the telephone interviews approximate- 19 ankles had an average starting pain level of 7.9 and stiffness ly 21 months after they were treated. They were asked a series of 5.4. Ending pain and stiffness levels were 1.6 and 1.5 respec- of questions about their pain and various symptoms before start- tively (see Figures 2a and 2b). Ninety-five percent reported a ing prolotherapy. Their response to prolotherapy was also de- starting pain level of 6 or greater, while none had a starting pain Pain Level Before and After Prolotherapy Stiffness Level Before and After Prolotherapy 20 20 18 18 16 16 Before prolo Before prolo 14 14 After prolo After prolo 12 12 10 10 8 8 6 6 4 4 Number of patients 2 Number of patients 2 0 0 12345678910 12345678910 Pain Level Pain Level FIGURE 2a. Pain levels before and after receiving Hackett-Hemwall pro- FIGURE 2b. Stiffness levels before and after receiving Hackett-Hemwall lotherapy in 19 patients with unresolved ankle pain. prolotherapy in 19 patients with unresolved ankle pain. Practical PAIN MANAGEMENT, January/February 2010 71 ©2010 PPM Communications, Inc. Prolotherapy Figure 5). Percent Reporting 50% or Greater Pain Relief Prior to prolotherapy, 47% of patients 100% expressed feelings of depression and anx- 90 iety. After prolotherapy, only 5% ex- 80 pressed depressed feelings and 16% anx- iety (see Figure 6 and Figure 7). In regard 70 to sleep, 79% of patients felt pain inter- 60 rupted their sleep. After prolotherapy, 50 74% experienced improvements in their 40 sleeping ability. 30 To a simple yes or no question, “Has prolotherapy changed your life for the Percent of patients Percent 20 10 better,” all of the patients treated an- swered “yes.” One hundred percent of pa- 0 12345678910 tients knew someone who had received Starting level of pain prolotherapy.
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