H3 Prolotherapy

h3-prolotherapy

This article will cover information on Prolotherapy including general questions on Prolotherapy treatments, side effects, research, reviews and medical studies.

Download our Prolotherapy brochure

Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments.

Prolotherapy leads to pain cure

In our opinion, based on research and clinical results, H3 Prolotherapy is superior to many other treatments in curing chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle. This is why it is the Caring Medical treatment method of choice.

Before we continue, would you like to ask our team a question about your pain or injury?

The basic mechanism of Prolotherapy is simple.

  • Prolotherapy solutions are injected into your painful areas to begin a reparative action.
  • The injections create a localized inflammation triggering the immune system to create the building blocks of ligaments, tendons, cartilage, and bone.
  • H3 Prolotherapy, through a series of injections, REBUILDS the joints from within.

Prolotherapy patient information in brief

Prolotherapy InfographicProlotherapy involves using a safe and simple base solution containing dextrose as the primary proliferant, along with an anesthetic (procaine), that is given into and around the entire painful/injured area (many injections vs only a few injections.)

This basic Prolotherapy solution used for over 70 years includes the above mentioned hypertonic dextrose (1­2.5% concentration) along with an anesthetic.

In our office, we often include other natural substances, such as Sarapin. The dextrose makes the solution more concentrated than blood (hypertonic), acting as a strong proliferant. Sarapin is used to treat nerve irritation and, in our experience, acts as a proliferant. Sarapin is an extract of the pitcher plant and is one of the few materials listed in the Physicians’ Desk Reference that has no known side effects. Procaine is an anesthetic that helps reinforce the diagnosis because the patient will experience immediate pain relief after the Prolotherapy injections.

The current Prolotherapy technique described here has been administered by Dr. Hemwall and our clinic to thousands of patients, administering millions of injections over the years.

Benefits:

  • Many body parts can be treated at the same visit, which is convenient and cost-effective for patients who have multiple painful joints or more complex chronic pain, or for patients who travel to us from out of the region or country.
  • In our aggressive comprehensive Prolotherapy approach, we may add additional proliferants, this may be bone marrow or adipose derived stem cells and blood platelets as used in PRP (Platelet Rich Plasma Therapy). Most treatments are given every four to six weeks to allow time for growth of the new connective tissues.

We are often asked how many treatments are needed?

This is dependent upon the person’s overall health status, the extent of the condition, injury, tear, or arthritis. In our clinical experience, as well as in our research, we find the number of treatments that help a person attain their goal averages 3 to 6 visits.

Because we treat a wide variety of cases, from young athletes with acute injuries to the elderly who have suffered through numerous surgeries and decades of anti-inflammatory pain medication, we work to tailor the treatment plans to the patients’ individual goals and needs.

While most patients have the goal of becoming pain-free and having increased stability and mobility in the joint, their activity goals must also be taken into consideration.

High level athletes may have more aggressive treatment needs than a retiree who does not desire to do a lot of activity. Thus, it is imperative to seek a practitioner who not only practices a thorough technique and has access to all types of solutions, but also who understands sports medicine and rehabilitation for patients to do between treatments.

What is Prolotherapy? Prolotherapy patient information in detail

  • Prolotherapy is a regenerative injection treatment used to repair incomplete healing of the ligament and tendons.
    • The major cause of degenerative arthritis and chronic pain is joint instability which involves ligament injury. Injured ligaments need to be correctly treated in order to fully restore joint stability. Prolotherapy treats and rebuilds ligaments.
  • 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 given without the use of narcotic medications, anti-inflammatory medications, and steroid solutions, as these inhibit healing.
  • The Prolotherapy procedure is considered a safe, affordable option that allows the patient to keep working and/or training during treatment.
    • It is typically best to treat all or most of the ligaments of an unstable joint if that joint or its surrounding structures are painful. Multiple joints and structures can be treated with each visit.
  • The treatments are generally given every four to six weeks to allow sufficient time for new collagen growth. Most commonly in our office, most patients receive monthly treatments, but in certain urgent healing situations, they can be given up to weekly.
  • 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 (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.

Does Prolotherapy work? The research starts here:

For patients who are looking into Prolotherapy, please understand that this is a specialty procedure with technique and experience being a key component. What we present on our website is based on our experience and research and does not apply to all practitioners or injection therapies.

In July 2016, doctors at Caring Medical published findings on the effectiveness of Prolotherapy treatments in the medical journal: Clinical Insights: Arthritis and Musculoskeletal Disorders, here are the summary highlights:

Our doctors reviewed 32 studies on dextrose prolotherapy for chronic musculoskeletal pain. The following conclusions are made:

Overall, Prolotherapy has been demonstrated to be efficacious and should be considered as a treatment for pain and dysfunction associated with chronic musculoskeletal conditions, particularly tendinopathies and osteoarthritis.

Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain. Clinical Medicine Insights Arthritis and Musculoskeletal Disorders. [Google Scholar]

 

The Biology of Prolotherapy

 

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.4-6

Animal research has documented that Prolotherapy-injected ligaments have an increased ligament mass, extracellular matrix, thickness and junction strength with bone.7-11

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 12-14, low back 15-16, neck 17-18, shoulder 19, elbow 20, knee 21-22 temporomandibular joint 23,24 and other articulations 25.

A discussion of Prolotherapy as a 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.

Am I a Candidate? The ideal Prolotherapy candidate has the following:

  1. Pain originating from a ligament or tendon
  2. Strong immune system
  3. Ability to perform recommended rehab exercises and complete the treatment series
  4. Healthy diet
  5. Positive mental outlook

Prolotherapy treatment goals

What are the goals of H3 Prolotherapy treatments?

  • Better 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? Patients are typically advised to continue to receive Prolotherapy treatments until able to stably perform that certain function without pain or instability symptoms. 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.
  • Increased 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.
  • Alleviate pain: The most common reason patients receive Prolotherapy is to resolve pain by repairing the pain-causing structures. Thus, a noticeable decrease in pain shows the benefit of successful Prolotherapy.
  • Eliminate stiffness, swelling, and spasms: Most patients with chronic pain complain of stiffness, swelling, and/or muscle spasms. These are natural responses by the body to protect injured or unstable joints. Patients commonly experience these symptoms after performing a certain activity.  A great sign that Prolotherapy is working is that stiffness, swelling, and muscle spasms have 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 and spasms subside. Same with joint swelling: as stability improves, the joint will not chronically swell.
  • Improved physical examination findings: An experienced Prolotherapy provider should be able to assess whether the treatment is working by simple physical examination. He or she 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. Static 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, which are used more in surgical cases. Musculoskeletal ultrasound is a much better tool for Prolotherapists because it can correlate other physical exam findings with ligament laxity and joint instability. Digital Motion X-ray also has advantages over static X-ray and MRI because it allows the patient and provider to see instability when the joint/spine is in motion, as well as improvement with the treatment series.

Questions about Prolotherapy injections at the time of treatment

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.

What are the options for providing a “painless” Prolotherapy procedure?

  • Anesthetic spray 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 or a nerve block may be used 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

Prolotherapy Side effects and risks

  • Bleeding in the area 
  • Bruising in the area
  • Increased pain
  • Infection
  • Joint effusion
  • Nerve injury
  • Puncture of a lung
  • Spinal headache
  • Stiffness
  • Swelling
  • 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 or solutions used, it is important to go to a clinic with a lot of experience and one who has researched the best options for various types of pain, versus just utilizing the same ingredients for every patient.

Prolotherapy for Knee Pain

View our main page about 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.

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. 26

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:

  • A 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. 27

Other researchers have shown that Prolotherapy injections resulted in safe and substantial improvement in the quality of life in knee osteoarthritis patients.28 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.29 In other Caring Medical research, Dr. Hauser was able to document articular cartilage regeneration.30  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.31

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.32

This was confirmed by September 2016 research from the Universities of Wisconsin, Chicago, and Minnesota which found “Most (Prolotherapy) participants reported substantially improved knee-specific effects, resulting in improved quality of life and activities of daily living.”36

More information can be found in these articles:

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 cells. The stem cells and blood platelets are drawn from you 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.33 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:

Prolotherapy and Stem Cells for Knee Pain

Bone marrow derived stem cells

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.34 

For a more comprehensive article please see: The stem cell alternative to knee replacement

Prolotherapy for Back Pain

View our main page about 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 for 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.35 More information can be found on these pages on our site Prolotherapy for Chronic Low Back Pain.

Prolotherapy for Shoulder Pain

View our main page about 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.

Doctors at the University of British Columbia, University of Kansas, and the University of Missouri-Kansas City published joint research that found: In participants with painful rotator cuff tendinopathy who receive physical therapy and Prolotherapy, treatments resulted in superior long-term pain improvement and patient satisfaction. “Prolotherapy may improve on the standard care of painful rotator cuff tendinopathy for certain patients.”37

Prolotherapy for hip pain

View our main page about Prolotherapy 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 from chronic hip pain.38

Published research on Prolotherapy:

Dr. Ross Hauser and our team have published a number of research papers, case studies, and scientific editorials in the Journal of Prolotherapy, including articles on Prolotherapy as an alternative to surgery; Prolotherapy for chronic back pain; cartilage regeneration in knees; Stem cell therapy for degenerative joint disease; Prolotherapy as for meniscus tears, and many, many more.

Our Prolotherapy research papers, case studies, & scientific editorials:


4. Maynard J. Morphological and biomechanical effects of sodium morrhuate on tendons. Journal of Orthopaedic Research. 1985;3:236-248.  [PubMed] [Google Scholar]
5. 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.
6. 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.
7. 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. [PubMed] [Google Scholar]
8. 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. [PubMed] [Google Scholar]
9. 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. [AAOM Citation]
10. 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.
11. 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.
12. Hackett, G. Shearing injury to the sacroiliac joint. Journal of the International College of Surgeons. 1954;22:631-642.
13. Lee JD, Lee DW, J CW. Effects of intraarticular prolotherapy on sacroiliac joint pain. Korean Journal of Pain. 2009;229-233.[PubMed Citation]
14. Cusi M, Saunders J, Hungerford B. The use of prolotherapy in the sacroiliac joint. British Journal of Sports Medicine. 2010;44:100-104. [PubMed Citation]
15. Hackett G. Back pain following trauma and disease-Prolotherapy. Military Medicine. 1961;July:517-525.
16. Hackett, G. Low back pain. The British Journal of Physical Medicine. 1956;19:25-35.
17. 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.[PubMed Citation]
18. 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.[PubMed Citation]
19. Jo D, Ryu K, Yang S. The effects of Prolotherapy on shoulder pain. Korean Journal of Anesthesiology. 2004;46:589-592.
20. Hauser R, Hauser M, Holian P. Hackett-Hemwall Dextrose Prolotherapy for unresolved elbow pain. Practical Pain Management. 2009;October:14-26. [PPM Citation]
21. Kim JM. The effect of prolotherapy for osteoarthritis of the knee. Journal of the Korean Academy of Rehabilitation Medicine. 2002;26:445-448.
22. 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.
23. Hakala RV. Prolotherapy in the Treatment of TMD. The Journal of Craniomandibular Practice. 2005;23:1-6.
24. Schultz, L. A treatment of subluxation of the temporomandibular joint. Journal of the American Medical Association. September 25, 1937.
25. 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.
26. 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.
27. 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.
28. 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.
29. 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.
30. Hauser RA. The Regeneration of Articular Cartilage with Prolotherapy. Journal of Prolotherapy. 2009;1:39-44.
31. 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. Steindler A, Luck JV. Differential diagnosis of pain low in the back  JAMA. 1938;110(2):106-113.
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.
36. Rabago D, van Leuven L, Benes L, Fortney L, Slattengren A, Grettie J, Mundt M. Qualitative Assessment of Patients Receiving Prolotherapy for Knee Osteoarthritis in a Multimethod Study. J Altern Complement Med. 2016 Sep 7.
37. Bertrand H, Reeves KD, Bennett CJ, Bicknell S, Cheng AL. Dextrose Prolotherapy Versus Control Injections in Painful Rotator Cuff Tendinopathy. Arch Phys Med Rehabil. 2016 Jan;97(1):17-25.

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