I came upon the subject of prolotherapy almost a year ago when I was still in school studying occupational therapy. I had a patient with subluxation of the shoulder – a common side effect in stroke where the weight of the arm without appropriate muscle tone pulls the shoulder joint out of alignment – and my preceptor and I were looking for exercises or activities that this patient could do after discharge from the hospital. As a first step, I did a Google search for “treatment shoulder subluxation” and the first page I saw was for prolotherapy: blind to its limitations and better than everything else ever. That’s a formula for win! Right?
What is prolotherapy
Prolotherapy, in a nutshell, is the practice of injecting an irritant solution (usually containing dextrose, cod liver oil, phenol, glycerine, or lidocaine) into ligaments and joints to induce an inflammatory response that’s supposed to tighten the joint and stimulate tissue growth. Prolotherapy was originally popularized by Gustav Hemwall for ankle, knee, elbow, and lower back pain. Notice that none of these are complex joints (hips, shoulder) – more on that later. But what’s good for one thing is, of course, good for everything else. Right?
Prolotherapy is available in some naturopathy clinics (for example), but so far is not considered a mainstream treatment for joint pain. It is notable that although the concept of injecting irritants for healing has been researched since the 1950s, there have been no significant advances since the early 90s – around the time that the main proponent of the therapy retired. As a result, prolotherapy is not covered by most health insurance companies.
According to the wiki for prolotherapy, there are some clinical trials underway. As for available publications, searches for “prolotherapy subluxation”, “prolotherapy shoulder”, and “prolotherapy stroke” on PubMed each returned no results. A search for “prolotherapy” returned 61 results (18 of which were reviews). Most articles were about lower back pain, a few were about other topics – mostly epicondylitis, groin pain, foot pain, and chronic pain. None were about ball-socket joints (hip and shoulder), which is significant because these 360-degree joints may not respond to prolotherapy in the same way as other joints due to the complex arrangement and number of ligaments. Based on what was available on PubMed, prolotherapy studies so far are of poor clinical quality (missing control groups, lacking appropriate variable control, using other therapies in conjunction, etc.) and results tended to get less promising as study design improved.
I also searched Cochrane Reviews and found two results. Both focused on lower back pain and the results weren’t thrilling. One described conflicting evidence due to clinical heterogeneity and the presence of co-interventions, concluding that prolotherapy was not effective as a lone treatment. The other (a more general review of injection therapy) concluded that there was insufficient evidence to support the use of injection therapy for back pain. So even the intended use of the therapy (back pain) is questionably effective, leading me to seriously question extrapolating to other conditions like shoulder subluxation.
In sum, the research regarding prolotherapy for shoulder pain is nil and, in my opinion, it’s inappropriate to promote prolotherapy for shoulders without researching that specific application. In fact the only “evidence” I could find regarding shoulder pain were testimonials from pro-prolotherapy sites. But that doesn’t stop them from making some fantastic claims.
The attractive public websites accessible via Google (I discuss the top results below), assure me that prolotherapy is awesome. Caring Medical (Illinois, USA) is #1 after a search for “shoulder subluxation”. Vancouver’s “Dr.” Hal Brown (who isn’t on this list of prolotherapy “doctors” – the only Canadian listed is a different naturopath) appears in the top 10 for “prolotherapy”.
Remember how I just demonstrated that research on shoulders and hips was lacking and there was some research on various joint pain conditions, but that most research focused on back pain? It may surprise you to find out, then, that according to these sites, prolotherapy is 85% effective in the treatment of everything:
Hip pain [??], knee pain, ankle pain, foot pain, wrist pain, elbow pain, shoulder pain [??], headaches [how?], TMJ (jaw) pain, post-injury/trauma pain, fibromyalgia, myofascial conditions, sports injuries, loose joints, tendonitis, post fracture treatment, rib pain, and more. In fact any joint, ligament or muscle tendon in the body that is experiencing pain can be treated with prolotherapy. [ref] I also saw carpal tunnel syndrome [makes no sense given that median nerve pain is caused by compression under the transverse carpal ligament], osteoarthritis, migraines, RSD pain, sciatica, herniated discs, degenerated discs, degenerated joints, chondromalacia patellae, Osgood-Schlatter disease, ligament sprains, plantar fasciitis, back pain, neck pain, hand pain, finger pain, and toe pain. [ref] Also arthritis. [ref]
That is unprecedented versatility. Or we could consider the research and conclude responsibly that these benefits are greatly exaggerated and the risks are overly downplayed. The promotional websites ignore other treatments or describe them incorrectly (including some scare-mongering about surgery). These claims are irresponsible and not objective.
Examples of bold, unsupported, misleading statements:
- Prolotherapy offers the most curative results in treating chronic pain” and “Nearly all pain conditions can be successfully treated with Prolotherapy” following some deviously-worded and, in some cases, incorrect information about pain treatments in general. [ref]
- Another standard practice of modern medicine is to inject steroids or to prescribe anti-inflammatory medications. However, in the long run, these treatments do more damage than good. … Plus, long-term use of these drugs can lead to other sources of chronic pain, allergies and leaky gut syndrome.[ref]
- When all else fails, patients who experience chronic pain as a result of shoulder subluxation may be referred to a surgeon. Unfortunately, surgery often makes the problem worse. [ref]
- A better approach is to strengthen the ligamentous and shoulder capsular structures with Prolotherapy. In fact, shoulder subluxation or instability is one of the easiest conditions to treat with Prolotherapy. … The safest and most effective natural medicine treatment for repairing tendon, ligament and cartilage damage is Prolotherapy. … Prolotherapy offers the most curative results in treating chronic pain. It effectively eliminates pain because it attacks the source: the fibro-osseous junction, an area rich in sensory nerves. What’s more, the tissue strengthening and pain relief stimulated by Prolotherapy is permanent! [ref]
I find it telling that, rather than provide a list of peer-reviewed references to support their rather bold statements, they poison the well for other treatments, exaggerate their own benefits, and link to case reports and testimonials rather than peer-reviewed research. They have no basis upon which to make such bold claims for the treatment of shoulder pain – because there’s no research to support them. The mere possibility of effectiveness absolutely does not justify misleading people about other available therapies or exaggerating the supposed benefits of prolotherapy.
Why this is irresponsible
Caring Medical (as an example) charges $250 per shoulder for each treatment – given every 2-6 weeks until symptoms improve. Charging people huge sums of money for case-”supported” try-out treatments used to be called snake oil. Now it’s offered in health clinics. Apparently the thinking is “prolotherapy kinda works for X, so why not everything else?” This lazy science the only way I can explain these unsupported claims without assuming skulduggery.
Using a therapy for everything despite lacking research ignores basic anatomy and the differences between the types of joints. Consider the difficulty associated with injecting substances into the many tiny ligaments (of which some may be lax and some not – how do they test this?) of a ball-socket joint like the shoulder vs. a hinge joint like the elbow – these differences are important and need independent research, not assumptions:
Exaggerations confuse “consumers” about medical treatments, how science works, and how medical treatments are investigated and tested (e.g., the meaning and significance of clinical trials). It’s hard enough for patients to sift through all of the medical information relevant to their situation, let alone to pick out objective options when people are trying to sell them something. Irresponsible claims can cause strife where there needn’t be if grand promises of relief fail to come true.
I suppose the allure of being the sole proprietors of “the” treatment for X is hard for some people to resist. But when we’re talking about people’s health (and in the case of athletes, their jobs too) and pain, we’d better be sure. Their zeal wastes my time as a professional and has the potential to affect patient care if they are convincing enough to fool people who do not have the necessary training to interpret the science.
It’s hard for professionals to sift through the chaff with their limited time and large caseloads. We do it, of course, because it’s our job to ensure patient safety and a high quality of care, but it does add needless stress. It’s much easier to evaluate the merits of a treatment when the information about it is honest and supported by evidence.
If prolotherapy has weight to it, great, but those who promote prolotherapy don’t say “this a treatment that is currently gathering evidence that might work for you and here are our sources so far”, they say “traditional treatments will hurt you so you should do this”. Evidence? What’s that? I take issue with these misleading methods because these therapies are expensive, carry unacknowledged risks (infection, etc), and are not science-based.
Generally, and especially in medicine, if something sounds too good to be true (promoted vociferously without objectively acknowledging caveats), it probably is. There are always pros and cons that need to be considered – maybe sometimes more of one than the other, but both must be verified carefully with evidence. Ignoring information for the sake of promotion is not responsible medicine – so I must conclude that prolotherapy is not responsible medicine.
I won’t recommend an invasive treatment on a patient that at worst could cause harm and at best could do nothing when there are other available science-based methods. If there’s no evidence either way, I’ll try something low risk, but in this case there are acceptable alternatives. Given the current evidence, I would not recommend prolotherapy for shoulder subluxation, nor should anyone else until there is research to back it up.
*The opinions in this article reflect that of the author only and do not necessarily represent the views of employers, regulatory bodies, or professional associations. The author strives to promote science-based health care in all fields and advocates for a client’s right to honesty.