Neuro-Prolotherapy

Perineural injection therapy(PIT) or neuroprolotherapy is a regenerative injection technique that addresses nerve pain from peripheral nerve entrapments. This technique was developed by Dr John Lyftogt in New Zealand about 15 years ago, and is now practiced in countries throughout the world. It involves the injection of 5% dextrose solution using a very small needle along the course of a nerve where a nerve entrapment may cause pain. These points are known as Valliex points, named after French physician Dr Valliex who discovered these points in the 1800s.

 

Common entrapment neuropathies are carpal tunnel syndrome and cubital tunnel syndrome. In carpal tunnel syndrome, the median nerve is entrapped in the canal in the wrist leading to the sensation of pain, numbness and tingling and if severe, weakness in the hand. Cubital tunnel involves entrapment of the ulnar nerve around the elbow. This can lead to much more significant hand weakness, pain and loss of function

 

Dr Lyftogt suspected that there may be additional nerve entrapments along the course of the nerve that can cause pain. Knowledge of anatomy and palpatory skills can help practitioners to identify these points and treat them with dextrose.​
 

How does dextrose work?

We do not know how or why Dextrose or glucose works at the site of a nerve. A simple explanation is that injections give the nerve needed energy to heal itself and to improve its function. Some studies show that receptors that are involved in pain such as TRVP1 and Subtance P may be down regulated with the addition of dextrose.

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In clinical practice, most people feel nearly immediate relief at entrapment points after injections. Dextrose is thought to modulate nerves and the injections have pain relieving effects.

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Are there studies on perineural injection therapy?

 

There are a number of studies on perineural injection therapy with 5% dextrose for a numerous conditions including carpal (1)  tunnel and cubital tunnel syndrome,(2)  patellofemoral syndrome,(3)  complex regional pain syndrome, knee osteoarthritis, shoulder pain, compartment syndrome, neuropathic pain syndromes including: post-herpetic neuralgia, trigeminal neuralgia, peripheral neuropathy. (4)

 

Randomized Control Trials:

Cubital Tunnel

A randomized control trial of 40 patients with ulnar neuropathy at the elbow were included in a study comparing normal saline and 5% dextrose with ultrasound guidance at 2 week intervals. Pts were evaluated on the VAS and Disabilities of the Arm and Shoulder questionnaire for disability as well as with EMG and NCS.​ Improvements in pain, disabilty and ulnar nerve cross sectional area were superior to those in the control group especailly and weeks 4 and 12

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Carpal Tunnel

A randomized control trial of 5% dextrose vs triamcinolone injection for caprla tunnel patients. Fifty-four participants with mild-to-moderate CTS were randomly divided into dextrose and steroid groups.  Compared with the steroid group, the dextrose group exhibited a significant reduction in pain and disability through the 4th to the 6th month (p < 0.01). (

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What is nerve hydrodissection?

Nerve hydro dissection is a a techinque in which dextrose solution is injected around a nerve to free it from the surrounding structures. This is usually done with ultrasound. On ultrasound the nerve is visualized and fluid is injected around it. This can be done for carpal tunnel and cubital tunnel syndromes.

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Is Perineural injection therapy FDA approved? Is it or covered by insurance?

 

Perineural injection therapy is not FDA approved and it is not covered by insurance. Its is considered and experimental technique, but has been practiced safely for many years. The ingredients for use are FDA approved.

 

What conditions can be treated with PIT?

Perineural injection therapy can be used to treat common entrapment neuropathies such as carpal abs cubital tunnel syndromes. It can also be used to treat any nerve entrapment of dysfunction along the course of a nerve such as:

 

1. Headaches

2. Neck pain

3. Low back pain

4. Thoracic outlet syndrome

5. Post operative pain syndromes

6. Pelvic pain

7. Peripheral neuropathies

8. Frozen shoulder and shoulder pain

9. Foot and able pain - tarsal tunnel

10. Pain after spine surgery

11. Carpal and Cubital tunnel

 

What are some common reasons for people to seek treatment with PIT?

 

Most people who try this therapy have already failed conventional treatment and are seeking other options, or they are trying to explore different treatments prior to having more invasive treatments such as surgery, spinal cord stimulator placement or other more permanent procedures.

 

Persistent pain despite conventional treatment

 

1. Knee pain after total knee replacement

2. Back pain after surgery when re-operation is not warranted, or other treatments have not been successful

3. Pain after shoulder surgery that is not resolving with physical therapy

4. Persistent nerve pain after surgery such as hernia surgery

5. Neuopathic pain syndromes such as diabetic peripheral neuropathy

6.Thoracic outlet syndrome not yet ready for surgery, not a candidate surgery

7. Plexopathies

8. Complex regional pain syndrome

9. Nerve entrapment

10. Peripheral neuropathy

11. Scapular winging

12. Persistent neck pain despite multiple trigger point injections

13. Occipital neuralgia and chronic severe headaches

 

Is it worth trying?

Yes, Neuroprolotherapy is worth trying. While studies are promising, there are many people who have had benefit from these treatments with minimal risk. Most people seeking alternative pain management have tried many other conventional treatments and have not had success or would like to improve their pain control and function. Neuroprolotherapy provides another alterative to pain management. One of the significant advantages this kind of therapy provides is that is does not use medications. We hope that this kind of therapy is neuroregenenerative and that it can ultimately help nerves to function better, leading to improved long term function without the use of medications.

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How many treatments will I need?

Injections typically have to be repeated every 1-2 weeks for 8 to 10 sessions.

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How much does PIT cost?

Cost range from $80 - $150 depending on the complexity and areas treated with no ultrasound guidance. 

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Who might benefit from PIT or neuroprolotherapy?

Perineural injection therapy can be used for many conditions. Typically people are seeking alternatives when they have failed other treatments such as triggers points, nerve blocks, epidurals or other kinds of steroids injections

 

What PIT cannot treat

Perineural injection cannot treat severe entrapment syndrome that requires surgery. If you have loss of motor function surgical treatment by is necessary.

 

If you have mild symptoms or you have tried and failed conventional treatments or surgery are seeking alternative treatments, perineural injection therapy may be an option.

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Summary of Dextrose therapy from AAPM&R

A summary of dextrose therapy for chronic pain can be found here from AAPM&R

https://now.aapmr.org/therapeutic-injection-of-dextrose-prolotherapy-perineural-injection-therapy-and-hydrodissection/

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1. Yung-Tsan Wu MD, Ming-Jen Ke MD, Tsung-Yen Ho MD, Tsung-Ying Li MD, Yu-Ping Shen MD, Liang-Cheng Chen MD, MS Randomized double-blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients  Annals of Neurology Volume 84, Issue 4 p. 601-610

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​2 Basak Mansiz-Kaplan, Baris Nacir, Secil Pervane-Vural, Olcay Tosun-Meric, Burcu Duyur-Cakit, Hakan Genc,
Effect of Perineural Dextrose Injection on Ulnar Neuropathy at the Elbow: A Randomized, Controlled, Double-Blind Study,
Archives of Physical Medicine and Rehabilitation, Volume 103, Issue 11

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3. Neal BS, Bartholomew C, Barton CJ, Morrissey D, Lack SD. Six Treatments Have Positive Effects at 3 Months for People With Patellofemoral Pain: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther. 2022 Nov;52(11):750-768. doi: 10.2519/jospt.2022.11359. Epub 2022 Sep 7. PMID: 36070427.

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4. Neal BS, Bartholomew C, Barton CJ, Morrissey D, Lack SD. Six Treatments Have Positive Effects at 3 Months for People With Patellofemoral Pain: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther. 2022 Nov;52(11):750-768. doi: 10.2519/jospt.2022.11359. Epub 2022 Sep 7. PMID: 36070427.