Regenerative injection therapies (RIT) are a set of therapeutic tools that assist in the healing of non-contractile tissues; these include tendons, ligaments, cartilage, and bone. This method can be helpful in many orthopedic scenarios, including chronic pain associated with ligamentous injury, acute ligament tears, osteoarthritic degeneration, and delayed healing of fractures.
Pain, particularly if it is chronic in nature, not only inflicts personal debility but monetary costs in Canada are high. Estimates indicate that the health care system burdens $6 billion per year, and productivity related losses and sick days at over $37 billion per year (1,2). In Canada, chronic pain management expenses exceed that of cancer, heart disease, and HIV combined. Personal financial burdens are also worth mentioning. The Canadian STOP-PAIN Research Group reported that patients who are waiting to access conventional pain clinics will spend an average of $17,544 a year, which is mostly in the form of lost wages and alternative choices of treatment (1,3). As part of the personal cost in alternative choices and the healthcare system, it benefits long-term outcomes to provide options for reducing chronic pain.
Readily accessible regenerative injection therapies in British Columbia include dextrose prolotherapy (DP) and platelet-rich plasma injections (PRP). A third therapy not as readily accessible is stem cell injections, however, can be found being offered by practitioners in Vancouver, Kamloops, and Kelowna.
Dextrose Prolotherapy uses a hyperosmolar dextrose as the injected substance and is used as the proliferant.
Platelet-Rich Plasma (PRP)
PRP involves extracting growth factors and platelets from the patient’s own blood and this is used as the proliferant.
What to Expect During a Visit
During a clinical appointment, patients can expect an orthopedic exam by a practitioner to determine appropriate treatment sites. The technique itself will include an injection to those sites under ultrasound guidance and local anesthetic as an option. Besides the extraction process of PRP, which involves a blood draw, the injecting procedure is the same. Multiple visits are usually required to achieve desired outcomes of reduced or resolution of pain.
The procedure exploits the body’s own mechanism of healing to deliver the nutrients it needs for regeneration of the tissue. The injectable proliferant is placed in regions of injury, which stimulates an inflammatory cascade. This, in turn, increases blood flow and recruits cellular and growth factors to the area. The mechanistic physiology can be broken down into three stages of response. The first being inflammation which lasts for an average of 10 days. The cellular recruitment of platelets and white blood cells activates an inflammatory cascade. Cell proliferation and matrix deposition is the second phase, where the body brings fibroblasts, and collagen, and deposits extracellular matrix and stimulates angiogenesis to feed the surrounding tissue. This phase takes place from the first day to about 30 days after treatment. The last phase of matrix remodelling can last up to 300 days after treatment where the synthesis leads to increased tensile strength and a resolution of cellular activity and vascularity to the area. The overall result is a regeneration of aberrant non-contractile tissue in degenerated or injured ligaments, tendons, cartilage or bone.
Dextrose Prolotherapy has been shown to have more desirable long-term pain outcomes than control injections, corticosteroid injections, and exercise alone (4,5,6). Evidence shows that PRP is more effective than dextrose Prolotherapy and hyaluronic acid injections, a common treatment of osteoarthritis of the knee, in subjective pain scales. (7,8). Overall the effect of regenerative therapies is positive in terms of pain outcomes for associated ligamentous, tendon, bone, and osteoarthritic injuries. It is a viable option for those suffering from chronic pain to improve quality of life and furthermore can reduce the burden on conventional health systems and financial losses in personal and institutional settings.
About the Author:
1. Choiniere M, Dion D, Peng P, et al. The Canadian STOP-PAIN Project – Part 1: Who are the patients on the waitlists of multidisciplinary pain treatment facilities? Can J Anesth. 2010;57:539–48
2. Phillips CJ, Schopflocher D. The Economics of Chronic Pain. In: Rashiq S, Taenzer P, Schopflocher D, editors. Health Policy Perspectives on Chronic Pain. Weinheim: Wiley Press; 2008.
3. Guerriere D, Choiniere M, Dion D, et al. The Canadian STOP-PAIN Project – Part 2: What is the cost of pain for patients on the waitlists of multidisciplinary pain treatment facilities? Can J Anesth. 2010;57:549–58.
4. Hung C-Y, Hsiao M-Y, Chang K-V, Han D-S, Wang T-G. Comparative effectiveness of dextrose prolotherapy versus control injections and exercise in the management of osteoarthritis pain: a systematic review and meta-analysis. Journal of Pain Research. 2016;9:847-857. doi:10.2147/JPR.S118669.
5. Hauser, R. A., Lackner, J. B., Steilen-Matias, D., & Harris, D. K. (2016). A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain. Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders, 9, 139–159. http://doi.org/10.4137/CMAMD.S39160
6. Coombes, Brooke K., Leanne Bisset, and Bill Vicenzino. “Efficacy and Safety of Corticosteroid Injections and Other Injections for Management of Tendinopathy: A Systematic Review of Randomised Controlled Trials.” The Lancet 376.9754 (2010): 1751–1767. The Lancet. Web.
7. Rahimzadeh, Poupak et al. “The Effects of Injecting Intra-Articular Platelet-Rich Plasma or Prolotherapy on Pain Score and Function in Knee Osteoarthritis.” Clinical Interventions in Aging 13 (2018): 73–79. PMC. Web. 21 June 2018.
8. Cole, Brian J. et al. “Hyaluronic Acid Versus Platelet-Rich Plasma: A Prospective, Double-Blind Randomized Controlled Trial Comparing Clinical Outcomes and Effects on Intra-Articular Biology for the Treatment of Knee Osteoarthritis.” The American Journal of Sports Medicine 45.2 (2017): 339–346. The American Journal of Sports Medicine. Web.