A Proloterapia é uma terapia biológica baseada em injeção para dor musculoesquelética crônica. Ela tem sido usada há aproximadamente 100 anos, no entanto, suas aplicações modernas remontam à década de 1950, quando os protocolos de injeção de prolotherapy foram formalizados por George Hackett, um cirurgião geral nos EUA, com base em sua experiência clínica de mais de 30 anos. Embora as técnicas de proloterapia e as soluções injetadas variem de acordo com a condição, gravidade clínica e preferências do profissional, um princípio fundamental é que um volume relativamente pequeno de uma solução irritante ou esclerosante é injetado em locais nas inserções dolorosas do ligamento e dos tendões e no espaço articular adjacente durante várias sessões de tratamento.

A substância utilizada na injeção é um agente irritante natural.

Exemplos incluem:

  • Açúcar (dextrose ou glicose) sozinho ou em combinação com glicerina e fenol
  • Morruato de sódio (um derivado purificado de óleo de fígado de bacalhau)

Durante os tratamentos de proloterapia para dor lombar crônica ou outros distúrbios, o agente é tipicamente usado com um anestésico local (lidocaína, procaína ou marcaina).

 A Proloterapia envolve uma série de injeções, variando de 4 a 8 sessões em média e dependendo da condição e do indivíduo a ser tratado. A série de injeção dura de 3 a 6 meses com injeções em intervalos de 2 a 3 semanas.

Até o momento, a proloterapia tem sido indicada como um tratamento complementar para dor lombar, osteoartrite e tendinopatia, cada uma das quais é uma causa significativa de dor e incapacidade, e é frequentemente refratária às melhores terapias padrão de tratamento.

 

Tabela: Força de evidência para proloterapia como um tratamento para condições musculoesqueléticas crônicas: Dor Lombar (LBP), Osteoartrite (OA) e Tendinopatia.

 Recomendação Clínica Chave sobre Proloterapia  Classificação de Evidência  Referências
 Lombalgia inespecífica: pode ser eficaz; resultados conflitantes em vários ECRs (Ensaios Clínicos Randomizados)  B 25 - 28
 Disfunção da articulação sacroilíaca: pode ser eficaz em pacientes com falha documentada de transferência de carga (incapacidade) na articulação sacroilíaca  B 34 
 Coccigodinia: pode ser eficaz com base em séries de casos prospectivas B 35
 Epicondilite lateral crônica: provavelmente eficaz com base em dados positivos fortes nestes ECRs pequenos A 6 , 7
 Tendinopatia de Aquiles: pode ser eficaz com base em séries de casos prospectivos de alta qualidade B 9
 Fasciite plantar: pode ser eficaz, com base em séries de casos prospectivos de alta qualidade B 60
Osteoartrite: pode ser eficaz para o joelho e OA de dedos, ECRs baseados em qualidade metodológica moderadamente forte B 17 , 61

 

Contraindicações absolutas à proloterapia são poucas e incluem infecções agudas, como celulite, abscesso local ou artrite séptica. Contra-indicações relativas incluem artrite gotosa aguda, fratura aguda e imunossupressão.

As injeções normalmente doem menos que a maioria das imunizações. A maioria dos pacientes tolera muito bem as injeções de proloterapia com apenas medidas tópicas e conservadoras.

 

 

 

 

 

Referências:

1. Hackett GS, Hemwall GA, Montgomery GA. Ligament and tendon relaxation treated by prolotherapy. 5. Oak Park: Gustav A. Hemwall; 1993.
2. Linetsky FS, FRafael M, Saberski L. Pain management with regenerative injection therapy (RIT) In: Weiner RS, editor. Pain Management. Boca Raton: CRC Press; 2002. pp. 381–402.
3. Matthews JH. Nonsurgical treatment of pain in lumbar spinal stenosis: Letter to the editor. Am Fam Physician. 1999;59(2):280–284. [PubMed]
4. Schnirring L. Are your patients asking about prolotherapy? Physician Sportsmed. 2000 August;28(8):15–17.
5. Dorman TA. Prolotherapy: A survey. The Journal of Orthopaedic Medicine. 1993;15(2):49–50.
6. Linetsky FS, Botwin K, Gorfin L, Jay GW. Regeneration injection therapy (RIT): Effectiveness and appropriate usage. Florida Academy of Pain Medicine. 2001.http://www.gracermedicalgroup.com/resources/articles/rf_file_0025.pdf.
7. Maxwell NJ, Ryan MB, Taunton JE, Gillies JH, Wong AD. Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study. Am J Roent. 2007;189(4):W215–220. [PubMed]
8. Scarpone M, Rabago D, Zgierska A, Arbogest J, Snell ED. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clinical J Sports Med. 2008;18:248–254. [PMC free article] [PubMed]
9. Rabago D, Best TM, Zgierska A, Zeisig E, Ryan M, Crane D. A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet rich plasma. BJSM. 2009 doi: 10.1136/bjsm.2008.052761. [PMC free article] [PubMed] [Cross Ref]
10. Liu YK, Tipton CM, Matthes RD, Bedford TG, Maynard JA, Walmer HC. An in-situ study of the influence of a sclerosing solution in rabbit medial collateral ligaments and its junction strength. Connective Tissue Research. 1983;11:95–102. [PubMed]
11. Maynard JA, Pedrini VA, Pedrini-Mille A, Romanus B, Ohlerking F. Morphological and biochemical effects of sodium morrhuate on tendons. Journal of Orthopaedic Research. 1985;3:236–248. [PubMed]
12. Banks A. A rationale for prolotherapy. Journal of Orthopaedic Medicine. 1991;13(3):54–59.
13. Hoksrud A, Ohberg L, Alfredson H, Bahr R. Ultrasound-guided sclerosis of neovessels in painful chronic patellar tendinopathy. Am J Sports Med. 2006;34:1738–1746. [PubMed]
14. Zeisig E, Fahlstrom M, Ohberg LHA. A 2-year sonographic follow-up after intratendinous injection therapy in patients with tennis elbow. Br J Sports Med. 2008 doi: 10.1136/bjsm.2008.049874. [PubMed][Cross Ref]
15. Kim SR, Stitik TP, Foye PM. Critical review of prolotherapy for osteoarthritis, low back pain, and other musculoskeletal conditions: a physiatric perspective. Journal of Physical Medicine and Rehabilitation. 2004;83(5):379–389. [PubMed]
16. Reeves KD, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Altern Ther Health M. 2000;6(2):68–80.[PubMed]
17. Jensen K, Rabago D, Best TM, Patterson JJ, Vanderby R. Early inflammatory response of knee ligaments to prolotherapy in a rat model. J Orthop Res. 2008;26:816–823. [PMC free article] [PubMed]
18. Aneja A, Spero G, Weinhold P, et al. Suture plication, thermal shrinkage and sclerosing agents. American Journal of Sports Medicine. 2005;33:1729–1734. [PubMed]
19. Jensen KT. PhD Dissertation: Healing response of knee ligaments to prolotherapy in a rat model.Madison: Biomedical Engineering, University of Wisconsin; 2006.
20. Rabago D, Best T, Beamsly M, Patterson J. A systematic review of prolotherapy for chronic musculoskeletal pain. Clinical J Sports Med. 2005;15(5):376–380. [PubMed]
21. Yelland M, Yeo M, Schluter P. Prolotherapy injections for chronic low back pain: results of a pilot comparative study. Austrailian Musculoskeletal Medicine. 2000;5(2):20–30.
22. Ernst E, Pittler MH, Stevinson C, White A. Randomised clinical trials: pragmatic or fastidious? Focus on Alternative and Complementary Therapies. 2001;63(3):179–180.
23. Wheeler AH. Pathophysiology of Chronic Back Pain. 2007.http://www.emedicine.com/neuro/topic516.htm.
24. Ongley MJ, Klein RG, Dorman TA, Eek BC, Hubert LJ. A new approach to the treatment of chronic low back pain. Lancet. 1987 July 18;2:143–146. [PubMed]
25. Klein RG, Eek BC, DeLong WB, Mooney V. A randomized double-blind trial of dextrose-glycerine-phenol injections for chronic, low back pain. J Spinal Disord. 1993;6(1):23–33. [PubMed]
26. Dechow E, Davies RK, Carr AJ, Thompson PW. A randomized, double-blind, placebo-controlled trial of sclerosing injections in patients with chronic low back pain. Rheumatology. 1999;38:1255–1259.[PubMed]
27. Yelland M, Glasziou P, Bogduk N, Schluter P, McKernon M. Prolotherapy injections, saline injections, and exercises for chronic low back pain: a randomized trial. Spine. 2004;29(1):9–16. [PubMed]
28. Yelland MJ, Del Mar C, Pirozo S, Schoene ML. Prolotherapy injections for chronic low back pain: A systematic review. Spine. 2004;29:2126–2133. [PubMed]
29. Bellamy N, Carr A, Dougados M, Shea B, Wells G. Towards a definition of “difference” in osteoarthritis. J Rheumatology. 2001;28(2):427–430. [PubMed]
30. Redelmeier DA, Guyatt GH, Goldstein RS. Assessing the minimal important difference in symptoms: A comparison of two techniques. J Clin Epidemiol. 1996;49:1215–1219. [PubMed]
31. Wells GA, Tugwell P, Kraag GR, Baker PR, Groh J, Redelmeier DA. Minimum important difference between patients with rheumatoid arthritis: the patient’s perspective. Journal of Rheumatology. 1993;20:557–560. [PubMed]
32. Loeser JD. Point of view. Spine. 2004;29(1):16.
33. Reeves KD, Klein RG, DeLong WB. Letter to the editor. Spine. 2004;29(16):1839–1840. [PubMed]
34. Cusi M, Saunders J, Hungerford B, Wisbey-Roth B, Lucas P, Wilson S. The use of prolotherapy in the sacro-iliac joint. Br J Sports Med. 2008 doi: 10.1136/bjsm.2007.042044. [PubMed] [Cross Ref]
35. Khan SA, Kumar A, Varshney MK, Trikha V, Yadav CS. Dextrose prolotherapy for recalcitrant coccygodynia. J Orthop Surg. 2008;16:27–29. [PubMed]
36. Farrar JT, Young JP, LaMoreaux L, Werth JL, Poole M. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical rating scale. Pain. 2001;94:149–158. [PubMed]
37. Miller MR, Mathews RS, Reeves KD. Treatment of painful advanced internal lumbar disc derangement with intradiscal injection of hypertonic dextrose. Pain Physician. 2006;9:115–121. [PubMed]
38. Khan KM, Cook JL, Kannus P, Maffuli N, Bonar SF. Time to abandon the ‘tendinitis’ myth. BMJ. 2002;324:626–627. [PMC free article] [PubMed]
39. Bongers PM. The cost of shoulder pain at work. Variation in work tasks and good job opportunities are essential for prevention. BMJ. 2001;322:64–65. [PMC free article] [PubMed]
40. Wilson JJ, Best TM. Common overuse tendon problems: a review and recommendations for treatment. Am Fam Physician. 2005;72:811–818. [PubMed]
41. Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of tendinopathies. Update and implications for clinical management. Sports Med. 1999;27:393–408. [PubMed]
42. Puddu G, Ippolito E, Postacchini FA. classification of Achilles tendon disease. Am J Sports Med. 1976;4:145–150. [PubMed]
43. Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of lateral epicondylitis. Am Fam Physician. 2007;76:843–848. 849–850, 853. [PubMed]
44. Verhar J. Tennis elbow: anatomical, epidemiological and therapeutic aspects. Int Orthop. 1994;18:263–267. [PubMed]
45. Hamilton P. The prevalence of humeral epicondylitis: a survey in general practice. J R Coll Gen Pract. 1986;36:464–465. [PMC free article] [PubMed]
46. Kivi P. The etiology and conservative treatment of lateral epicondylitis. Scand J Rehabil Med. 1983;15:37–41. [PubMed]
47. Gabel GT. Acute and chronic tendinopathies at the elbow. Curr Opin Rheumatol. 1999;11:138–148.[PubMed]
48. Ono Y, Nakamura R, Shimaoka M, Hattori Y, Ichihara G. Epicondylitis among cooks in nursery schools. Occup Environ Med. 1998;55:172–179. [PMC free article] [PubMed]
49. Ritz BR. Humeral epicondylitis among gas and waterworks employees. Scand J Work Environ Health. 1995;21:478–486. [PubMed]
50. Buchbinder R, Green S, White M, Barnsley L, Smidt N, Assendelft WJ. Shock wave therapy for lateral elbow pain. The Cochrane Collaboration. 2005;3 [PubMed]
51. Smidt N, van der Windt DA, Assendelft WJ, Deville WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002;359:657–662. [PubMed]
52. Struijs PA, Smidt N, Arola H, Dijk CNv, Buchbinder R, Assendelft WJ. Orthotic devices for the treatment of tennis elbow. The Cochrane Collaboration. 2005;3 [PubMed]
53. Kvist M. Achilles tendon injuries in athletes. Sports Med. 1994;18:173–2001. [PubMed]
54. Zeisig E, Ohberg L, Alfredson H. Extensor origin vascularity related to pain in patients with tennis elbow. Knee Surg Sports Traumatol Arthrosc. 2006;14:659–663. [PubMed]
55. Alfredson H, Ohberg L. Sclerosing injections to areas of neovascularization reduce pain in chronic Achilles tendinopathy: a double-blind randomised trial. Knee Surg Sports Traumatol Arthrosc. 2005;13:338–344. [PubMed]
56. Holmich P, Uhrskou P, Ulnits L. Effectiveness of active physical training as treatment of long-standing adductor-related groin pain in athletes: a randomized controlled trial. Lancet. 1999;353:439–443.[PubMed]
57. Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with groin pain. Arch Phys Rehabil. 2005;86:697–702. [PubMed]
58. Buchbinder R. Plantar Fasciitis. N Engl J Med. 2004;350:2159–2166. [PubMed]
59. Taunton J, Ryan M, Clement D, McKenzie D, Lloyd-Smith D, Zumbo B. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36:95–101. [PMC free article] [PubMed]
60. Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database. 2003;3(CD000416) [PubMed]
61. Ryan MB, Wong AD, Gillies JH, Wong J, Taunton JE. Sonographically guided intratendinous injections of hyperosmolar dextrose/lidocaine: a pilot study for the treatment of chronic plantar fasciitis. Br J Sports Med. 2009;43:303–306. doi: 10.1136/bjsm.2008.050021. [PubMed] [Cross Ref]
62. Reeves KD, Hassanein K. Randomized, prospective, placebo-controlled double-blind study of dextrose prolotherapy for osteoarthritic thumb and finger (DIP,PIP, and Trapeziometacarpal) joints: evidence of clinical efficacy. J Altern Complem Med. 2000;6(4):311–320. [PubMed]
63. Rabago D. The efficacy of prolotherapy in osteoarthritic knee pain. NIH-NCCAM Grant, 1K23 AT001879–01; In Progress.
64. Reginster JY. The prevalence and burden of arthritis. Rheumatology. 2002;41(supp 1):3–6. [PubMed]
65. CDC. Prevalence and impact of chronic joint symptoms-seven states, 1996. MMWR. 1998;47:345–351. [PubMed]
66. CDC. Prevalence of disabilities and associated health conditions-United States, 1991–1992. MMWR. 1994;43:730–739. [PubMed]
67. Felson DT, Zhang Y. An update on the epidemiology of knee and hip osteoarthritis with a view to prevention. Arthritis & Rheumatism. 1998;41(8):1343–1355. [PubMed]
68. Wilson MG, Michet CJ, Ilstrup DM, Melton LJ. Ideopathic symptomatic osteoarthritis of the hip and knee: A population-based incidence study. Mayo Clic Proc. 1990;65:1214–1221. [PubMed]
69. Oliveria SA, Felson DT, Klein RA, Reed JI, Walker AM. Estrogen replacement therapy and the development of osteoarthritis. Epidemiology. 1996;7:415–419. [PubMed]
70. Levy E, Ferme A, Perocheau D, et al. Socioeconomic costs of osteoarthritis in France. Rev Rhum. 1993;60:63S–67S. [PubMed]
71. Felson DT, Lawarence RC, Hochberg MC, et al. Osteoarthritis: new insights, part 2: treatment approaches. Annals of Internal Medicine. 2000;133:726–737. [PubMed]
72. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee. Arthritis Rheum. 2000;43:1905–1915.[PubMed]
73. Samson DJ, Grant MD, Ratko TA, Bonnell CJ, Ziegler KM, Aronson N. Treatment of primary and secondary osteoarthritis of the knee. Agency for Healthcare Research and Quality: Evidence Report/Technology Assessment. 2007:151. [PMC free article] [PubMed]
74. Rabago D, Zgierska A, Mundt M, Kijowski R, DeLucia R, Longlais B. Efficacy of prolotherapy for knee osteoarthritis: Results of a prospective case series (poster presentation). North American Research Conference on Complementary and Integrative Medicine; 2009.
75. AbbottLabs. FDA indications for 50% dextrose. 2004. http://www.fda.gov/cder/foi/nda/98/19445-s4-s6.htm.
76. AbbottLabs. Approval Documentation for 25% Dextrose submitted to FDA. Abbott Laboratories; Online documentation]
77. Schneider RC, Williams JJ, Liss L. Fatality after injection of sclerosing agent to precipitate fibro-osseous proliferation. Journal of the American Medical Association. 1959 August 8;170(15):1768–1772.[PubMed]
78. Keplinger JE, Bucy PC. Paraplegia from treatment with sclerosing agents - report of a case. Journal of the American Medical Association. 1960;173(12):1333–1336. [PubMed]
79. Hunt WE, Baird WC. Complications following injection of sclerosing agent to precipitate fibro-osseous proliferation. Journal of Neurosurgery. 1961;18:461–465. [PubMed]
80. Dagenais S, Ogunseitan O, Haldeman S, Wooley JR, Newcomb RL. Side effects and adverse events related to intraligamentous injection of sclerosing solutions (prolotherapy) for back and neck pain: a survey of practitioners. Arch Phys Med Rehabil. 2006;87:909–913. [PubMed]

Dr Daniel Rezende ortopedista em Porto Seguro Bahia