This article will cover information on Prolotherapy including general questions on Prolotherapy treatments, side effects and research
- Prolotherapy is a regenerative injection treatment used to repair incomplete healing of the ligament and tendons.
- Prolotherapy is considered a viable alternative to surgery, as an option to pain medications and anti-inflammatory injections such as cortisone and other steroidal injections in instances of joint instability and osteoarthritis.
- Prolotherapy is considered a safe, affordable option that allows the patient to keep working and/or training during treatment.
Quick jumps to
- What is in Prolotherapy Injections?
- Prolotherapy Treatment Goals
- The effectiveness of Prolotherapy
- Questions about Prolotherapy injections at the time of treatment
- Prolotherapy Side effects and risks
- Prolotherapy for knee pain
- Prolotherapy for back pain
- Prolotherapy for Hip Pain
- Prolotherapy for shoulder pain
Chronic pain from joint instability involve strains and sprains to tendons and ligaments and resulting cartilage deterioration. Because ligaments and tendons generally have a poor blood supply, the body’s ability to repair these damaged connective tissues is compromised and the onset of osteoarthritis and joint degeneration begins.
This is where comprehensive Prolotherapy comes in – pain is coming from joint instability – joint instability is coming from weakened and damaged ligaments and tendons as well as deteriorated cartilage. Comprehensive Prolotherapy through a series of injections REBUILDS the joints from within.
When cartilage is degenerated, the force to the bone is greater and uneven and arthritis develops. Since cartilage decreases the force inside the joint, it becomes obvious that as cartilage deteriorates as we age, other structures are going to have to bear this force. Since tendons move the joints and ligaments stabilize the joints, it is primarily these soft tissue structures that are involved. Because ligaments stabilize the joints, a weakening of these structures causes a further force to the bones of the joints. This increased force hastens the arthritic process.
The primary ingredient in Prolotherapy injections used at Caring Medical is dextrose, a corn extract. How does a corn extract accelerate healing?
When a joint becomes injured, the cells in that area burst and release dextrose and trigger an influx of inflammatory cells, initiating the wound-healing system to the specific area.
In this basic Prolotherapy injection solutions, we also use an alkaline extract of the pitcher plant called Sarapin. Almost all pain issues have some kind of nerve component, which Sarapin helps to relieve. In our experience, Sarapin enhances the healing effects of injection treatments and has an excellent safety profile. It is one of the few materials found in the Physicians’ Desk Reference that has no known side effect. Also in the basic solution, to help ease the pain of the injection procedure, as well as provide pain relief to the area, procaine or lidocaine is added in very small quantities. Often, this helps to ease the pain right away after the procedure, but is used in such a small amount to not cause any adverse effect to the joint repair/wound healing cascade.
When a stronger inflammatory reaction is desired, additional natural ingredients can be used in the dextrose-based injections. These can include mineral additives, such as zinc or manganese. Another common Prolotherapy additive includes fatty acids, which increase the inflammatory effect. Lastly, certain hormones, including human growth hormone or testosterone, can be helpful for triggering localized repair of damaged tissue.
In research histologic studies of ligaments and tendons following Prolotherapy injections have shown an enhanced inflammatory healing reaction involving fibroblastic and capillary proliferation, along with growth factor stimulation.1-3
Animal research has documented that Prolotherapy-injected ligaments have an increased ligament mass, extracellular matrix, thickness and junction strength with bone.4-8
Prolotherapy is given to the articular ligaments of the entire spine, pelvis and peripheral joints to tighten unstable joints. Case series have documented the efficacy of Prolotherapy for ligament injuries of the sacroiliac joint 9-11, low back 12,13, neck 14,15, shoulder 16, elbow 17, knee 18,19, temporomandibular joint 20,21 and other articulations 22.
Cellular Prolotherapy – Stem Cell Therapy and Platelet Rich Plasma Therapy
As regenerative medicine advances, Prolotherapy practitioners are taking notice of which methods can be incorporated into dextrose Prolotherapy treatments to help direct a person’s own stem cells and/or growth factors into the exact places where healing needs to take place within a joint. This is called Autologous (From your own cells) Prolotherapy, or Cellular Prolotherapy. In our office, we utilize Platelet Rich Plasma (PRP) Prolotherapy, which involves concentrating platelets/growth factors found in the blood and injecting them directly into the joint. We also offer Stem Cell Therapy or Stem Cell Prolotherapy using a person’s own bone marrow and/or fat cells, which are collected and injected during the same day procedure. With any Cellular Prolotherapy procedure done in our office, patients also receive dextrose Prolotherapy to the surrounding joint attachments, in order to ensure the area of pain and instability is comprehensively treated.
Finding the source of your joint pain is crucial in Prolotherapy
The greatest stresses to the ligaments and tendons are where they attach to the bone, the fibro-osseous junction. The most sensitive structures that produce pain are the periosteum (covering of the bone) and the ligaments. It is important to note that in the scale of pain sensitivity (which part of the body hurts more when injured), research notes that the periosteum ranks first, followed by ligaments, tendons, fascia (the connective tissue that surrounds muscle), and finally muscle.
This is where the Prolotherapy injections occur and help eliminate the chronic pain of many conditions including arthritis, mechanical low back pain, Degenerative Disc Disease, cartilage injury, and, of course, sports injuries.
A discussion of Prolotherapy as non-surgical option
Most of the joints in the body are synovial joints, or freely movable joints. These joints function as a result of the unique properties of the articular cartilage that covers and protects the ends of the bones. If the cartilage is damaged or removed, so is the functioning of the joint, which suffers as bone rubs against bone instead of cartilage over cartilage.
Surgery can be broadly classified into open repair, in which a surgical incision is made for direct access and visualization of the injury site, and closed, or arthroscopic, repair, in which a miniature camera is used to look into the joint through a small hole, and specially designed tools are used to repair the tissue. Surgery almost always involves the removal of bone, ligaments and tendons. Many different types of surgery are common, including:
- rotator cuff surgery: arthroscopic surgery to clean scar tissue and damage to the joint surfaces, as well as repair the tear of the rotator cuff
- hip replacement: replacement of the joint in which the diseased bone tissue and cartilage is removed from the hip joint, replacing the head of the femur (the ball) and the acetabulum (the socket) with new, artificial parts; the healthy parts of the joint are left intact. Learn more about Prolotherapy as a hip replacement alternative.
- knee surgery, also called arthroscopy: although intended to “explore” the knee joint to determine the cause of the problem, it usually involves some scraping, burning and/or cutting of valuable cartilage
- laminectomy: the most common back surgery, which involves the surgical removal of the posterior arch of a vertebra; results in problems similar to those of a discetomy (see below)
- lumbar spinal fusion: fuses vertebrae together, which often leads to ligament laxity and spinal instability as other parts of the spine attempt to compensate for this new, rigid section
- ankle fusion: similar to a spinal fusion, it fuses the shinbone to the talus, immobilizing an area to eliminate pain, but often leading to more pain due to ligament laxity and compensation in other areas and joints
- discectomy: a disc is removed to alleviate lower back pain; this often results in more back pain as the surgery causes ligament laxity and instability of the spine
Reasons patients avoid surgery:
- Surgery is traumatic; it puts stress on the body and could cause the individual to feel less confident using the surgerized limb.
- Surgery irreversibly alters the individual’s anatomy.
- Surgery potentially involves all kinds of complications.
- Surgery can lead to long-term arthritis due to the removal of significant tissue that is needed to help the body bear weight, such as cartilage, meniscus and disc tissue.
- Rehabilitation is much longer after surgery than for more conservative measures, such as Prolotherapy.
- Surgery does not always resolve the pain, which either means it did not address the cause of the pain, or that it caused another problem.
The ideal Prolotherapy candidate has the following:
- Pain originating from a ligament or tendon
- Strong immune system
- Willingness to improve and receive follow-up visits
- Healthy diet
- Positive mental outlook
What are the goals of Prolotherapy treatments?
- Function Is the patient’s ability to function in activities of daily living improved? Is the patient able to perform previously painful activities without pain? Is the person able to do things that he/she could not do prior to Prolotherapy?Patients are typically advised to continue to receive Prolotherapy treatments until able to stably perform that certain function pain and cracking-free. For example, if a patient can now climb two flights of stairs without knee pain after Prolotherapy, whereas prior to the Prolotherapy this would cause excruciating pain, then we know that Prolotherapy is helping improve function.
- Strength Ligament and tendon injury may cause muscle strength to decline. When a person receives Prolotherapy, one of the noticeable effects of the treatment is that strength improves in the injected areas.
- Pain Pain is one of the most common reasons patients receive Prolotherapy. Thus, a noticeable decrease in pain shows the benefit of successful Prolotherapy.
- Stiffness Patients commonly experience stiffness upon morning rising or after performing a certain activity. This stiffness is commonly felt in the lower back or neck, but could involve any area of the body. A great sign that Prolotherapy is working is that stiffness has subsided. Once Prolotherapy helps stabilize the area involved, the muscles no longer have to provide this stability so they relax. Once they relax, the stiffness subsides.
- Physical Examination An experienced Prolotherapy doctor should be able to assess whether the Prolotherapy is working by simple physical examination. The physician can also listen for crepitation or crunching in the joints which can often be audibly heard by moving the joint. The joint that doesn’t crunch is also improving. X-rays and MRIs are poor indicators that Prolotherapy is working, the reason being that most ligaments do not show up well on these tests. Some improvements from Prolotherapy can be seen with x-rays and MRI’s, but it isn’t always necessary or advantageous to rely solely on those indicators due to their high incidence of inaccuracies.
The effectiveness of Prolotherapy does depend upon the technique of the individual doctor, as well as the overall health and dedication of the patient to encourage the healing process after each treatment. For the patient who has localized areas of pain or the person who has had a recent injury from an accident, Prolotherapy is a very effective treatment to strengthen those specific areas and eliminate the pain. Realize, however, that Prolotherapy starts the growth of new healthy, strong tissue. Your body–your own immune system–grows the tissue. For the person who has terrible digestion, chronic fatigue, irritable bowel; and a host of other chronic nutritional, hormonal, allergic problems, these deficiencies and illnesses should be corrected so the body will be able to respond to Prolotherapy.
As with other medical procedures, Prolotherapy is a specialty. If you are looking into Prolotherapy, you first want to make sure that the Prolotherapy doctor in experienced in the Comprehensive Prolotherapy procedure and has successfully treated cases like yours. Someone who receives Prolotherapy does so with the hope of achieving complete pain relief.
In our office, it is common for us to get various referrals from other Prolotherapy doctors and have some of their patients see us.
Questions about Prolotherapy injections at the time of treatment
To achieve a curative result with Prolotherapy, doctors should take a comprehensive approach, this will include multiple injections at each session, and enough treatment to:
- Stimulate all the structures that are injured to heal.
- Use enough solution per structure to induce a sufficient healing reaction.
- Use a strong enough solution per structure to induce a sufficient healing reaction.
- Help the person obtain maximum health if their health is not good.
- Assist the person in getting off medications, supplements, or traditional hormones (like birth control pills) that inhibit healing.
Patient comfort during the Prolotherapy procedure is of course a great concern. Some people have many Prolotherapy injections and experience little discomfort, while others receive a few shots and experience more discomfort.
Caring Medical has many options to help patients lessen or eliminate the pain of the injections
We are asked by every patient: Do the injections hurt? This depends on the condition and a person’s own pain tolerance. Most people surprise themselves at how well they do during a treatment because it is over in a matter of minutes, less time than sitting through a teeth cleaning at the dentist. In fact, most patients tolerate the procedure well enough by deep breathing or squeezing a stress ball.
What are the options for providing a “painless” Prolotherapy procedure?
- Lidocaine cream for the skin. This is applied shortly before treatment and helps to reduce the pain when the needle pierces the skin. The needle piercing through the skin is generally the most painful part of the procedure.
- Pre-medication for anxiety and pain may be prescribed to help you relax and dull the pain from the treatment.
- Local anesthetic may be injected around the area prior to starting the treatment.
- Nitrous gas is an available option.
- Relaxing aromatic and topical essential oils are pleasant options for those who prefer a more natural approach.
- Sometimes squeezing a stress ball or deep breathing is all that is needed.
- Conscious sedation is an option for select cases in the Florida office location.
For those requiring Prolotherapy injections in many areas at one time or in delicate areas, some form of nitrous, sedation, or other medication is often suggested, such as with Ehlers-Danlos patients, or in cases where the pain of the condition itself already an excruciating “10 out of 10,” such as in cases of Chronic Regional Pain Syndrome. After treating thousands of patients who claim how much they “hate needles” (rest assured, these patients make it through just fine), it is good to remember that the goal of the treatment outcome should outweigh any hesitancy about the discomfort during the procedure, especially when there are now better options than ever to reduce procedural pain.
Most of our patients receive Prolotherapy without the help of medication and do just fine!
Prolotherapy Side effects and risks
- Bleeding in the area
- Bruising in the area
- Increased pain
- Joint effusion
- Nerve injury
- Puncture of a lung
- Spinal headache
- Tendon/ligament injury
Because Prolotherapy causes inflammation, the person will often note some bruising, pain, stiffness and swelling in the area after receiving Prolotherapy. Typically this lasts 1 to 7 days. On rare occasions it lasts longer. Lasting longer is not necessarily bad, some people just inflame more easily. Since the treatment works by inflammation, lingering pain after Prolotherapy can be a sign of healing. If the pain is severe after Prolotherapy, then call the office where the Prolotherapy was done. Prolotherapy should not cause excessive, severe pain. Severe pain after Prolotherapy, especially accompanied by a fever, could indicate an infection. Infection after Prolotherapy is the most serious risk that we have seen.
The risk of infection after Prolotherapy is between 1 and 1000 to 1 and 10,000 procedures. The most common infection with Prolotherapy is an infection in the skin. This type of infection typically responds to an antibiotic taken by mouth. If a joint or blood infection results, then intravenous antibiotics will typically be needed for six weeks.
Since some of the risks with Prolotherapy relate to the actual technique done, it is important to go to a clinic with a lot of experience.
Prolotherapy for knee pain
Research conducted by our team members at Caring Medical and independent investigators have found Prolotherapy to be an effective non-surgical treatment for various knee pathologies and degeneration.
In June 2015, doctors from the University of Wisconsin continued their research into Prolotherapy. They found Prolotherapy resulted in safe, significant, progressive improvement of knee pain, function and stiffness scores among most participants and continued as such at follow up an average of 2.5 years after initial treatment.
They concluded Prolotherapy may be an appropriate therapy for patients with unresponsive knee osteoarthritis. 23
Caring Medical doctors investigated Prolotherapy in patients with unresolved knee pain at a charity clinic in rural Illinois. Eighty patients, representing a total of 119 knees, were treated every three months with Prolotherapy. On average, 15 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment. The results of this study showed that patients had:
- Statistically significant decline in their level of pain, stiffness, crunching sensation, and improvement in their range of motion with Prolotherapy.
- More than 82% showed improvements in walking ability, medication usage, athletic ability, anxiety, depression, and overall disability with Prolotherapy.
- Ninety-six percent of patients felt Prolotherapy improved their life overall. 24
Other researchers have shown that Prolotherapy injections resulted in safe and substantial improvement in quality of life in knee osteoarthritis patients.25 Prolotherapy resulted in clinically meaningful sustained improvement of pain, function, and stiffness scores for knee osteoarthritis compared with blinded saline injections and at-home exercises.26 In other Caring Medical research, Dr. Hauser was able to document articular cartilage regeneration.27 In April 2016, researchers confirmed that Prolotherapy could regrow articular cartilage in the knee in a study of patients with an average age of 71 seventy-one.28
In patients with symptoms of anterior cruciate ligament laxity and weakness, intermittent Prolotherapy injections resulted in clinically and statistically significant improvement in pain, swelling, and knee range of motion.29
- More information
- Prolotherapy for osteoarthritis knee pain and surgery alternative
- Anterior Cruciate Ligament (ACL),
- Articular Cartilage Tears,
- Baker’s Cyst,
- Chondromalacia Patella
Prolotherapy and PRP (Platelet Rich Plasma) Injections for Knee Pain
Comprehensive Prolotherapy is an injection technique utilizing many healing factors. They can include or be used in conjunction with Dextrose, Blood Platelets, and stem cell injection therapy. The stem cells and blood platelets are drawn from the patient. In research, PRP by itself has been shown to be a remarkable treatment for knee osteoarthritis. However, other research points out that PRP’s effects may not be long lasting or beyond six months.30 At Caring Medical we developed comprehensive Prolotherapy and inject the supportive structures of the knee with dextrose Prolotherapy and other growth factors. Simply, while PRP can address and repair damaged cartilage, it is not addressing the ligament and tendon weakness that contributed to the cartilage deterioration. Comprehensive Prolotherapy seeks to repair the entire knee.
For a more detailed discussion on Platelet Rich Plasma Therapy for Osteoarthritis of the knee and bone on bone on our website.
Prolotherapy and Stem Cell Therapy for Knee Pain
In this study, Caring Medical doctors examined the use of a simple, cost-effective regenerative treatment using direct injection of bone marrow stem cells into osteoarthritic joints in combination with dextrose Prolotherapy. Seven patients with hip, knee or ankle osteoarthritis received two to seven treatments over a period of two to twelve months. All patients reported improvements with respect to pain, as well as gains in functionality and quality of life. Three patients, including two whose progress under other therapy had plateaued or reversed, achieved complete or near-complete symptomatic relief, and two additional patients achieved resumption of vigorous exercise.31 For a more comprehensive article please see Knee Osteoarthritis treated with Stem Cell Therapy on this website.
Prolotherapy for back pain
Caring Medical patients are often surprised to learn that Prolotherapy can heal most disc problems in neck and back. While we talk about Prolotherapy healing joint pain that results from ligament and tendon injuries, most people are unaware that disc problems results from ligament injuries or instability along the spine. Patients with degenerative disc disease,herniated discs, bulging discs, bone on bone, etc can all be healed with Prolotherapy.
Prolotherapy works to stabilize the ligaments of the spine allowing discs to get back into position and can even create space to a person who has lost space due to one or more degenerated disc. In Prolotherapy research from the doctors of Caring Medical, patients with more than four years of unresolved low back pain were shown to have had their pain improved, stiffness, range of motion, and quality of life measures even 12 months subsequent to their last Prolotherapy session. 32 More information can be found on these pages on our site Prolotherapy for Chronic Low Back Pain.33,34
Prolotherapy for shoulder pain
In published research from Caring Medical doctors, The optimal long-term, symptomatic therapy for chronic shoulder pain has not been established. Accordingly, we investigated the outcomes of patients undergoing Hackett-Hemwall dextrose Prolotherapy treatment for unresolved shoulder pain at a charity clinic in rural Illinois. We studied a sample of 94 patients with an average of 53 months of unresolved shoulder pain that were treated quarterly with Prolotherapy. An average of 20 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment. The results of this study showed that patients had a statistically significant decline in their level of pain, stiffness, and crunching sensations (crepitation). Prolotherapy, PRP, and Stem Cell Therapy have been used successfully in patients seeking alternatives to rotator cuff surgery. as well as patients with SLAP Lesions and Glenoid Labral Tears. Our treatments have also shown to be effective in helping patients who suffer from pain after shoulder surgery.
Prolotherapy research for hip pain
In the Journal of Prolotherapy we sought to show how Prolotherapy could provide high levels of patient outcome satisfaction while avoiding hip surgery. Here is what we reported:
- We examined Sixty-one patients, representing 94 hips, who had been in pain an average of 63 months We treated these patients quarterly with Hackett-Hemwall dextrose Prolotherapy.
- This included a subset of 20 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of eight patients who were told by their doctor(s) that surgery was their only option.
Patients were contacted an average of 19 months following their last Prolotherapy session and asked questions regarding their levels of pain, physical and psychological symptoms and activities of daily living, before and after their last Prolotherapy treatment.
Results: In these 94 hips,
- pain levels decreased from 7.0 to 2.4 after Prolotherapy;
- 89% experienced more than 50% of pain relief with Prolotherapy;
- more than 84% showed improvements in walking and exercise ability, anxiety, depression and overall disability;
- 54% were able to completely stop taking pain medications.
The results confirm that Prolotherapy is a treatment that should be highly considered for people suffering with chronic hip pain.35
Can Prolotherapy help you?
1. Maynard J. Morphological and biomechanical effects of sodium morrhuate on tendons. Journal of Orthopaedic Research. 1985;3:236-248.
2. Hackett G. Joint stabilization: An experimental, histologic study with comments on the clinical application in ligament proliferation. American Journal of Surgery. 1955;89:968-973.
3. Kim HJ, Kim SH, Yun DH. The effects of anti-inflammatory drugs on histologic findings of the experimental prolotherapy model. Journal of the Korean Academy of Rehabilitation Medicine. 2006;30:378-384.
4. Liu Y. An in situ of the influence of a sclerosing solution in rabbit medial collateral ligaments and its junction strength. Connective Tissue Research. 1983;2:95-102.
5. Jensen KT, Rabago DP, Best TM. Response of knee ligaments to prolotherapy in a rat injury model. American Journal of Sports Medicine. 2008;36:1347-1357.
6. Klein R. Proliferant injections for low back pain: histologic changes of injected ligaments and objective measures of lumbar spine mobility before and after treatment. Journal of Neurology, Orthopedic Medicine and Surgery. 1989;10:141-144.
7. Harman R, et al. A retrospective review of 62 cases of suspensory ligament injury in sport horses treated with adipose-derived stem and regenerative cell therapy. Proceedings of the Veterinarian Orthopedic Society, 2006.
8. Dahlgren LA. Use of adipose derived stem cells in tendon and ligament injuries. American College of Veterinarian Surgery Symposium on Equine Small Animal Proceedings. 2006;150-151.
9. Hackett, G. Shearing injury to the sacroiliac joint. Journal of the International College of Surgeons. 1954;22:631-642.
10. Lee JD, Lee DW, J CW. Effects of intraarticular prolotherapy on sacroiliac joint pain. Korean Journal of Pain. 2009;229-233.
11. Cusi M, Saunders J, Hungerford B. The use of prolotherapy in the sacroiliac joint. British Journal of Sports Medicine. 2010;44:100-104.
12. Hackett G. Back pain following trauma and disease-Prolotherapy. Military Medicine. 1961;July:517-525.
13. Hackett, G. Low back pain. The British Journal of Physical Medicine. 1956;19:25-35.
14. Hooper RA, Frizzell JB, Faris P. Case series on chronic whiplash related neck pain treated with intraarticular zygapophysial joint regeneration injection therapy. Pain Physician. 2007;10:313-318.
15. Centeno CJ, Elliott J, Elkins WL. Fluoroscopically guided cervical prolotherapy for instability with blinded pre and post radiographic reading. Pain Physician. 2005;8:67-72.
16. Jo D, Ryu K, Yang S. The effects of Prolotherapy on shoulder pain. Korean Journal of Anesthesiology. 2004;46:589-592.
17. Hauser R, Hauser M, Holian P. Hackett-Hemwall Dextrose Prolotherapy for unresolved elbow pain. Practical Pain Management. 2009;October:14-26.
18. Kim JM. The effect of prolotherapy for osteoarthritis of the knee. Journal of the Korean Academy of Rehabilitation Medicine. 2002;26:445-448.
19. Reeves KD, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Alternative Therapies. 2000;6:68-79.
20. Hakala RV. Prolotherapy in the Treatment of TMD. The Journal of Craniomandibular Practice. 2005;23:1-6.
21. Schultz, L. A treatment of subluxation of the temporomandibular joint. Journal of the American Medical Association. September 25, 1937.
22. Reeves KD, Topol GA, Fullerton BD. Evidence-based regenerative injection therapy (prolotherapy) in sports medicine. In Seidenberg PH, Beutler PI. (Eds). The Sports Medicine Resource Manual. Saunders (Elsevier); 2008:611-619.
23. Rabago D, Mundt M, Zgierska A, Grettie J. Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis: Long term outcomes. Complement Ther Med. 2015 Jun;23(3):388-95. doi: 10.1016/j.ctim.2015.04.003. Epub 2015 Apr 8.
24. Hauser RA, Hauser MA. A Retrospective Study on Dextrose Prolotherapy for Unresolved Knee Pain at an Outpatient Charity Clinic in Rural Illinois Journal of Prolotherapy. 2009;1(1):11-21.
25. Rabago D et al. Association between disease-specific quality of life and magnetic resonance imaging outcomes in a clinical trial of prolotherapy for knee osteoarthritis. Arch Phys Med Rehabil. 2013 Nov;94(11):2075-82. doi: 10.1016/j.apmr.2013.06.025. Epub 2013 Jul 10.
26. Rabago D. et al. Dextrose prolotherapy for knee osteoarthritis: a randomized controlled trial. Ann Fam Med. 2013 May-Jun;11(3):229-37. doi: 10.1370/afm.1504.
27. Hauser RA. The Regeneration of Articular Cartilage with Prolotherapy. Journal of Prolotherapy. 2009;1:39-44.
28. Topol GA, Podesta LA, Reeves KD, Giraldo MM, Johnson LL, Grasso R, Jamín A, Tom Clark DC, Rabago D. The Chondrogenic Effect of Intra-articular Hypertonic-dextrose (prolotherapy) in Severe Knee Osteoarthritis. PM R. 2016 Apr 4. pii: S1934-1482(16)30054-5. doi: 10.1016/j.pmrj.2016.03.008.
29. Reeves KD, Hassanein KM. Long-term effects of dextrose prolotherapy for anterior cruciate ligament laxity. Altern Ther Health Med. 2003 May-Jun;9(3):58-62.
30. Khoshbin A, Leroux T, Wasserstein D, Marks P, Theodoropoulos J, Ogilvie-Harris D, Gandhi R, Takhar K, Lum G, Chahal J. The efficacy of platelet-rich plasma in the treatment of symptomatic knee osteoarthritis: a systematic review with quantitative synthesis. Arthroscopy. 2013 Dec;29(12):2037-48. doi: 10.1016/j.arthro.2013.09.006.
31. Stem Cell Therapy and Prolotherapy research Hauser RA, Orlofsky A. Regenerative injection therapy with whole bone marrow aspirate for degenerative joint disease: a case series. Clin Med Insights Arthritis Musculoskelet Disord. 2013 Sep 4;6:65-72. doi:11.4137/CMAMD.S10951. eCollection 2013.
32. Hauser RA, Hauser MA Dextrose Prolotherapy for Unresolved Low Back Pain: A Retrospective Case Series Study Journal of Prolotherapy. 2009;3:145-155.
33. Hauser RA, Hauser MA Dextrose Prolotherapy for Unresolved Low Back Pain: A Retrospective Case Series Study Journal of Prolotherapy. 2009;3:145-155.
34. Low back pain research: Steindler A, Luck JV. Differential diagnosis of pain low in the back JAMA. 1938;110(2):106-113. doi:10.1001/jama.1938.02790020020007.
35. Hauser R, Hauser M, A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Hip Pain at an Outpatient Charity Clinic in Rural Illinois. Journal of Prolotherapy. 2009;2:76-88.