What is Prolotherapy Treatment for Chronic Back Pain?

Prolotherapy treatment for back pain includes injecting a medicated solution into the tendon, ligament, and/or joint space of the painful region in the upper or lower back. The solution typically contains a sugar (glucose) or irritant, combined with an anesthetic and saline, that is carefully injected into the degenerated and sore tissue(s) with the goal of initiating new inflammation in the area and promoting healing.

2 Main Prolotherapy Injection Sites in the Back

Most often, prolotherapy injections for back pain are given in the ligaments, which are tough and resilient tissues that connect bone to bone, and in the joint spaces. The two primary injection sites in the lower back include:

1. The key ligaments of the lower back that bear a great deal of stress on a daily basis, including the iliolumbar, supraspinous, interspinous, lumbosacral, sacral, and sacroiliac ligaments.¹Devika Roy GT, Walker V. Ultrasound guided dextrose prolotherapy and platelet rich plasma therapy in chronic low back pain: three case reports. Int J Phys Med Rehabil. 2013;01(06). These ligaments insert into the²Rabago D, Slattengren A, Zgierska A. Prolotherapy in primary care practice. Primary Care: Clinics in Office Practice. 2010;37(1):65-80.:
   • Spinous processes: the bony projection off the posterior (back) of a vertebra
   • Sacrum: the triangular-shaped bone at the bottom of the spine made up of 5 fused vertebrae
   • Ilium: the butterfly-shaped hip bone
2. The sacroiliac (SI) joint which connects the spine and the hip¹Devika Roy GT, Walker V. Ultrasound guided dextrose prolotherapy and platelet rich plasma therapy in chronic low back pain: three case reports. Int J Phys Med Rehabil. 2013;01(06).

Prolotherapy typically involves a series of injections delivered to these target tissues every 2 to 6 weeks over the course of several months.²Rabago D, Slattengren A, Zgierska A. Prolotherapy in primary care practice. Primary Care: Clinics in Office Practice. 2010;37(1):65-80.

Step-by-Step Prolotherapy Injection Procedure

A prolotherapy injection treatment is a minimally invasive procedure that is performed at a doctor’s office, surgical center, or hospital. Patients usually return home the same day. The entire session may take 15 minutes to an hour depending on the area being treated and the level of expertise of the treating physician.

1. Preparing for prolotherapy

   Discussing the complete list of current and past medications, such as the use of blood thinners and antibiotics, may help the doctor determine if the body needs time to normalize from the effects of these medications. Some of these medications may need to be stopped a few days before the injection procedure to avoid complications, such as excessive bleeding. Every institution requires the doctor and patient to have a thorough discussion, and some institutions require patients to sign a consent form before the procedure as an agreement that the possible benefits and potential risks have been discussed with the doctor.

2. The prolotherapy injection

   The prolotherapy injection is usually given while the patient lies on his or her stomach.¹Devika Roy GT, Walker V. Ultrasound guided dextrose prolotherapy and platelet rich plasma therapy in chronic low back pain: three case reports. Int J Phys Med Rehabil. 2013;01(06).

   A feeling of pressure may be experienced while the medication is injected into the tissue(s) or joint space. The addition of an anesthetic (numbing medication) to the prolotherapy agent typically minimizes any injection-related pain or discomfort.

   • The skin over the injection site is marked and cleaned with an antiseptic solution.¹Devika Roy GT, Walker V. Ultrasound guided dextrose prolotherapy and platelet rich plasma therapy in chronic low back pain: three case reports. Int J Phys Med Rehabil. 2013;01(06).
   • Ultrasound guidance is used to locate the accurate vertebral level, lumbar ligament, and/or spinal joint where the injection will be delivered.1 Ultrasound-guided injections allow the practitioner to visualize the needle in real-time as it enters the body and navigates to the treatment location.
   • A needle is inserted into the intended injection site and guided using ultrasound.¹Devika Roy GT, Walker V. Ultrasound guided dextrose prolotherapy and platelet rich plasma therapy in chronic low back pain: three case reports. Int J Phys Med Rehabil. 2013;01(06).

• Conscious sedation using relaxation medication is rarely needed or used but may be given to ease the patient’s anxiety.
• The size of the spinal needle is pragmatically determined and varies by the target tissue (ligament/joint/tendon). The smallest needle that can reach the target tissue is typically chosen to minimize needle trauma and injection-related pain.³Rabago D, Nourani B. Prolotherapy for Osteoarthritis and Tendinopathy: a Descriptive Review. Curr Rheumatol Rep. 2017 Jun;19(6):34. doi: 10.1007/s11926-017-0659-3. PMID: 28484944.

3. Monitoring and recovery after prolotherapy

   If conscious sedation was utilized, the patient may be monitored immediately after the injection in a recovery room for about 30 minutes to an hour, where vital signs are continuously checked.

   Light soreness or discomfort at the injection site may be treated with ice packs. Over-the-counter pain-relieving medication, such as acetaminophen, may be recommended for treating pain and soreness. Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) are usually avoided, as they can delay the healing process.²Rabago D, Slattengren A, Zgierska A. Prolotherapy in primary care practice. Primary Care: Clinics in Office Practice. 2010;37(1):65-80. It is advisable to avoid strenuous physical activities on the same day as the procedure. Daily activities may be resumed under the guidance of the treating physician.

It is considered important to follow up with the next dose of prolotherapy injection as recommended by the physician to ensure adequate tissue healing and recovery takes place, and to achieve the desired effects.