Prolotherapy in practice
Prolotherapy is a non-surgical treatment used to increase tendon and ligament strength and relieve arthritic changes. In humans, it is commonly used in Olympic sports medicine, as well as for the non-surgical treatment of rotator cuff injury, knee problems, and degenerative back and arthritic diseases. Prolotherapy is also becoming a more common practice in veterinary medicine for treating lameness. However, I have found it to be useful in a variety of other cases.
I have been using dextrose prolotherapy in my practice since it was introduced to me by Dr. Carvel Tiekart at the AHVMA conference in 2006.1 Regenerative injection therapy is a newer name that reflects the most common theory as to the treatment’s effects. The injection of a substance into a joint or at ligament/tendon attachments causes a controlled injury with a subsequent healing cascade. This results in the production of new collagen, thus tightening the joint and decreasing pain. I believe that each component of the dextrose solution carries with it specific properties that come together in a healing we are only just learning the intricacies of. This healing process continues over a course of six to eight weeks, so if another treatment is needed, I wait until after the six-week recheck to decide.
Recently, I have also incorporated plasma therapy, using the same technique, for intervertebral and arthritic joints. The platelets in the plasma contain stem cells that can differentiate to create a healing cascade in degenerative joints. For chronic or specialized cases, I use a combination of dextrose and plasma techniques on the same patient, often using the dextrose for torn knee ligament injuries, and plasma to relieve the associated lower back and/or hip arthritis that often accompanies the degenerative knee problem. I have also found success in using the dextrose solution for the tendons and ligaments of a weak knee with a mild-moderate drawer sign, and using the plasma solution on the arthritic cartilaginous bone surfaces. I also used a combination of therapies in a case of refractive seizures. I tend to use the dextrose solution for primary tendon/ligament issues, and the plasma in areas of arthritic change.
Technique is paramount
Knowing your anatomy is critical for needle placement. The needle and solution must come in contact with the origin, and I often also tag the insertion, of the tendon or ligament where it connects to the bone, and follow the tendon to the muscle body and the ligament to its attachments. Always pull back on the syringe when you are working near blood vessels. Often, the tendon or ligament will give a very quiet, but palpable and audible, pop sound as you penetrate it. This is my indication that I am in the right spot; then I follow it to its insertion, injecting multiple drops of solution as I go. Once I have found my point of contact, I will walk the needle, injecting as I go, as far as possible before retracting and starting a new puncture. Plasma injections are not walked through like dextrose injections, but are rather given in several small injections onto cartilage surfaces and into joints.
I treat the main tendons (patellar in the knee, biceps in the shoulder/elbow, brachiocephalic in the neck and shoulder) and also the respective surrounding collateral ligaments. I finish with local corresponding acupuncture points – for example, GB34 at the knee; TH14, LI15, SI9 at the shoulder; SI8 at the elbow; sometimes TH5 and TH4 for foreleg lameness completion; and GB29, GB30, and BL54 at the hip. I have used 25ge x 1.5” needles in very large dogs, but a 28ge x 1.5” needle for medium and large dogs, and a 30ge x 1” needle for small dogs and cats gives me a better outcome with less pain and more rapid improvement post-procedure. In my opinion, it is worth finding the right-sized needle.
My basic solution is made up of 50% dextrose, sterile water, and 2% lidocaine (without epinephrine). I have used procaine in the past, with the goal of better breaking down scar tissue, but it needs to be compounded, has a shorter shelf life, and doesn’t seem to really make a difference.
I use a short-acting injectable anesthetic. The procedure itself tends to only take ten to 20 minutes. For a large dog, I will often use 15cc to 20cc of dextrose solution, for a medium dog 10cc to 15 cc, and for a small dog or cat 5cc to 10cc. The quantity of plasma I use often depends on how much I get from the patient. I aim for 1cc to 3cc for a medium dog with one joint to treat, and 6cc for a large dog with multiple joints needing treatment (each vertebra is a joint). I prefer to draw fresh whole blood into a red top tube, let it clot, spin down and separate.
In our area, we are endemic for Lyme disease and anaplasmosis. I always test for these tick-borne diseases prior to the procedure. Previously undiagnosed anaplasma has led to severe bruising in the area post-procedure.
Examples of use in practice
Shortly after Dr. Tiekart’s lecture, I was working with a three-year-old Shiba Inu named Tiko who was starting to fail at the pole weaves as he advanced in agility. That summer, I attended a rehabilitation conference at which Dr. Christine Zink discussed how to recognize tendon laxity, primarily in the biceps. Tiko was being seen by a veterinary rehabilitator and was prescribed hobbles, much to my client’s dismay. Putting the two conference ideas together, I called the client and asked if we could try prolotherapy on Tiko’s shoulders. We did all four joints — shoulders and knees. Tiko went on and won his grand champion Mach title in agility that fall. I was impressed and motivated.
Since then, I have used the dextrose technique on a large number of agility, sporting and pet dogs, ranging from five to 150 pounds. Most pets and owners were happy with the results after just one treatment, though a number of the agility and sporting dogs were given two treatments (“just to make sure they are as strong as possible”). In all cases, the increased thickness and spring of the patellar ligament was palpable at the six-week visit. I have also used this technique to tighten luxating patellae; however, unless it is a traumatic luxation, I haven’t seen prolotherapy alone eliminate it beyond a Grade 1 after four treatments. I have used dextrose prolotherapy treatments in two dogs with fixed knees, one congenital and one on an older rescue dog and with no clear cause. The young dog (20 weeks) had a full recovery. The rescue adult experienced what I see as an 80% recovery — still a little stiff, but almost fully flexible.
Movement post-procedure is imperative. For at least the first 48 hours, clients are instructed not to let the animal stay in one position for longer than two hours without a minimal 15-minute walk. They can sleep a full night. One of my few failures with prolotherapy involved a patient that traveled 2.5 hours for a treatment. The client was given direction to stop halfway home to walk the dog, which she did not do. When she got home, the dog was kenneled for the next eight hours with no walks.
Although most dogs (and the couple of cats I have treated for low lumbar arthritis) respond to one or at most two treatments, one case took almost six weeks to show improvement, though it finally did. The more cases I see, and the more I treat that are longstanding rural cases rather than on-the-spot agility cases, the more rounded my success curve becomes. Prolotherapy is still a vital part of my practice. It would benefit every practice, especially those with a large caseload of agility or performance dogs.
Ingredients to make a 15% solution
In a 10cc to 12cc syringe, draw up 1cc of 2% lidocaine (without epinephrine). Fill to 4cc with 50% dextrose, and to 10cc with sterile water (saline does not give the same results, in my experience). This is equivalent to 1cc lidocaine, 3cc 50%dextrose, and 6cc sterile water.
Where to get supplies
Plasma: from the animal you are treating – spin, separate, and draw up into a syringe.
Dextrose solution: veterinary supply distributors
Needles: we found 28ge x 1.5”, and 30ge x 1” at Air-Tite Products Co., Inc.
Case Report – treating seizures with prolotherapy
In February of 2016, I was presented with Tanner, a 97.6-pound six-year-old M/N German shepherd with a history of seizures. His owner, John, was referred to me by his human chiropractor. Tanner was experiencing full and often severe epileptic-type seizures approximately every three to five weeks since September of 2014. The primary clinic exam found no musculoskeletal or neurological abnormalities. Bloodwork showed a mildly elevated ALP. Tanner had been put on phenobarbital, potassium chloride and Keppa with no relief. Since the current medication regime did not affect the severity or frequency of Tanner’s seizures, John had removed him from all medications by the end of December. The seizures continued every two to four weeks when I met Tanner and John in February.
On exam, Tanner’s lumbar muscles from T10 to L3 were very tight. The nuchal ligament was also tight. He had normal biceps abduction angles, and thin and tight patellar ligaments. Dry needle acupuncture was initiated relative to the initial exam findings. I prescribed a Chinese formula for the seizures. We continued acupuncture and herbal formulas every month. While talking to John, I learned that three or four years prior to our meeting, Tanner had run into and flipped over a retaining wall, but little was thought of it since any obvious soreness was gone within a few days.
The severity of Tanner’s seizures lessened over the next three months, but they continued to occur. A radiograph showed a mild and quiet greenstick fracture line on the axis wing, mild occipital arthritic changes and inflammation. Tanner was anesthetized with a combination of ketamine and diazepam i.v. A solution of 15% dextrose was prepared, using 1cc of 2% lidocaine, 3cc of 50% dextrose, and 6cc of sterile water into solution. A 25ge x 1.5” sterile needle was put out for use. We also collected 3cc of plasma from Tanner. The dextrose solution was used in multiple taps at the nuchal ligament attachments on C2, along the nuchal ligament and its insertion, and the cervical vertebral ligament attachments. The plasma solution was used on the occipital protuberances where the arthritic changes were more evident, most cranial vertebral ligaments, and the C1 wings – especially noting the area of the greenstick fracture line to facilitate stem cell healing. Here I chose to use plasma in areas that not only needed more healing than strengthening, but also where I was working closely to the brain stem and spinal cord. Tanner was sent home with instructions for no collar, no neck pulls and neck ROM exercises using treats several times daily.
Tanner had a very minimal seizure two days post-procedure, but none at the normal three-week mark. Three months later, his owner reported there had been no seizures from May until August – a period of three months! Tanner had another mild seizure the end of August, so another prolotherapy session using the same protocol was set up for September 1. Tanner was again seizure-free until late November 2016 – almost another three months.
John had the carpets cleaned and that night Tanner seized. He was put on 97.2 mg of phenobarbital daily by his primary veterinarian, which has kept the seizures under control. As of July 2017, Tanner was seizure-free on a minimal dose of phenobarbital.
1Tiekert, Carvel G, DVM. “Prolotherapy treats pain by stimulating the body to repair damaged/loose ligaments”. IVC Journal, Summer 2015.