Kenneth Dean Reeves

Hyperosmolar dextrose injection for recalcitrant Osgood-Schlatter disease.

OBJECTIVE: To examine the potential of dextrose injection versus lidocaine injection versus supervised usual care to reduce sport alteration and sport-related symptoms in adolescent athletes with Osgood-Schlatter disease. PATIENTS AND METHODS: Girls aged 9 to 15 and boys aged 10 to 17 were randomly assigned to either therapist-supervised usual care or double-blind injection of 1% lidocaine solution with or without 12.5% dextrose. Injections were administered monthly for 3 months. All subjects were then offered dextrose injections monthly as needed. Unaltered sport (Nirschl Pain Phase Scale < 4) and asymptomatic sport (Nirschl Pain Phase Scale = 0) were the threshold goals. RESULTS: Sixty-five knees in 54 athletes were treated. Compared with usual care at 3 months, unaltered sport was more common in both dextrose-treated (21 of 21 vs 13 of 22; P = .001) and lidocaine-treated (20 of 22 vs 13 of 22; P = .034) knees, and asymptomatic sport was more frequent in dextrose-treated knees than either lidocaine-treated (14 of 21 vs 5 of 22; P = .006) or usual-care–treated (14 of 21 vs 3 of 22; P < .001) knees. At 1 year, asymptomatic sport was more common in dextrose-treated knees than knees treated with only lidocaine (32 of 38 vs 6 of 13; P = .024) or only usual care (32 of 38 vs 2 of 14; P < .0001). CONCLUSIONS: Our results suggest superior symptom-reduction efficacy of injection therapy over usual care in the treatment of Osgood-Schlatter disease in adolescents. A significant component of the effect seems to be associated with the dextrose component of a dextrose/lidocaine solution. Dextrose injection over the apophysis and patellar tendon origin was safe and well tolerated and resulted in more rapid and frequent achievement of unaltered sport and asymptomatic sport than usual care.

Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: A systematic review and meta-analysis

Hypertonic dextrose injections (prolotherapy) is an emerging treatment for symptomatic knee osteoarthritis (OA) but its efficacy is uncertain. We conducted a systematic review with meta-analysis to synthesize clinical evidence on the effect of prolotherapy for knee OA. Fifteen electronic databases were searched from their inception to September 2015. The primary outcome of interest was score change on the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Three randomized controlled trials (RCTs) of moderate risk of bias and one quasi–randomized trial were included, with data from a total of 258 patients. In the meta-analysis of two eligible studies, prolotherapy is superior to exercise alone by a standardized mean difference (SMD) of 0.81 (95% CI: 0.18 to 1.45, p = 0.012), 0.78 (95% CI: 0.25 to 1.30, p = 0.001) and 0.62 (95% CI: 0.04 to 1.20, p = 0.035) on the WOMAC composite scale; and WOMAC function and pain subscale scores respectively. Moderate heterogeneity exists in all cases. Overall, prolotherapy conferred a positive and significant beneficial effect in the treatment of knee OA. Adequately powered, longer-term trials with uniform end points are needed to better elucidate the efficacy of prolotherapy.

Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis

Dextrose injection is reported to improve knee osteoarthritis (KOA)−related clinical outcomes, but its effect on articular cartilage is unknown. A chondrogenic effect of dextrose injection has been proposed.

Dextrose Prolotherapy: A Narrative Review of Basic Science, Clinical Research, and Best Treatment Recommendations

Prolotherapy involves the injection of nonbiologic solutions, typically at soft tissue attachments and within joint spaces, to reduce pain and improve function in painful musculoskeletal conditions. A variety of solutions have been used; dextrose prolotherapy is the most rigorously studied and is the focus of this review. Although the mechanism of action is not clearly known, it is likely to be multifactorial. Data on effectiveness for temporomandibular dysfunction are promising but insufficient for recommendations. Research on the mechanism of action and clinical effects of dextrose prolotherapy are under way.

Short Term Analgesic Effects of 5% Dextrose Epidural Injections for Chronic Low Back Pain: A Randomized Controlled Trial

Background Hypertonic dextrose injection (prolotherapy) is reported to reduce pain including non-surgical chronic low back pain (CLBP), and subcutaneous injection of 5% dextrose is reported to reduce neurogenic pain, hyperalgesia and allodynia. The mechanism in both cases is unclear, though a direct effect of dextrose on neurogenic pain has been proposed. This study assessed the short-term analgesic effects of epidural 5% dextrose injection compared with saline for non-surgical CLBP. Methods Randomized double-blind (injector, participant) controlled trial. Adults with moderate-to-severe non-surgical low back pain with radiation to gluteal or leg areas for at least 6 months received a single epidurogram-confirmed epidural injection of 10 mL of 5% dextrose or 0.9% saline using a published vertical caudal injection technique. The primary outcome was change in a numerical rating scale (NRS, 0 - 10 points) pain score between baseline and 15 minutes; and 2, 4, and 48 hours and 2 weeks post-injection. The secondary outcome was percentage of participants achieving 50% or more pain improvement at 4 hours. Results and Conclusions No baseline differences existed between groups; 35 participants (54 ± 10.7 years old; 11 female) with moderate-to-severe CLBP (6.7 ± 1.3 points) for 10.6 ± 10.5 years. Dextrose participants reported greater NRS pain score change at 15 minutes (4.4 ± 1.7 vs 2.4 ± 2.8 points; P = 0.015), 2 hours (4.6 ± 1.9 vs 1.8 ± 2.8 points; P = 0.001), 4 hours (4.6 ± 2.0 vs 1.4 ± 2.3 points; P < 0.001), and 48 hours (3.0 ± 2.3 vs 1.0 ± 2.1 points; P = 0.012), but not at 2 weeks (2.1 ± 2.9 vs 1.2 ± 2.4 points; P = 0.217). Eighty four percent (16/19) of dextrose recipients and 19% (3/16) of saline recipients reported ≥ 50% pain reduction at 4 hours (P < 0.001). These findings suggest a neurogenic effect of 5% dextrose on pain at the dorsal root level; waning pain control at 2 weeks suggests the need to assess the effect of serial dextrose epidural injections in a long-term study with robust outcome assessment.

Vertical Small-Needle Caudal Epidural Injection Technique

Background Anecdotal evidence suggests that a vertical small-needle injection method enters the caudal epidural space with comparable efficacy to cephalad-directed methods, with less intravascular injection. Objectives Assess the success rate of vertical caudal epidural injection using epidurography and the frequency of intravascular injection using a vertical small-needle approach. Patients and Methods Participants had chronic generalized non-surgical low back pain and either gluteal and/or leg pain and were enrolled in a simultaneous clinical trial assessing the analgesic effect of 5% dextrose epidural injection. A 25 gauge 3.7 cm hypodermic needle was placed at the sacral hiatus using a fingertip-guided vertical technique without imaging assistance, followed by fluoroscopic epidurography. Minimal needle redirection was allowed up to 10 degrees from the vertical plane if the initial epidurogram showed an extradural pattern, followed by repeat epidurography. Results First needle placement without imaging resulted in blood return in 1/199 participants and positive epidurography in 179/199 (90%). Minimal needle repositioning resulted in a positive epidurogram in the remaining 19 attempts. No intravascular injection patterns were observed. Conclusions This compares favorably to published success rates of fluoroscopically-guided technique and was well tolerated. Vertical caudal epidural injection may be suitable for combination with ultrasound-guided methods with Doppler flow monitoring.

Clinical effectiveness of patella mobilisation therapy versus a waiting list control for knee osteoarthritis: a protocol for a pragmatic randomised clinical trial

Introduction Knee osteoarthritis (KOA) is a common, disabling and costly medical condition. The patellofemoral joint is a critical source of pain in individuals with KOA, and coexistence of patellofemoral osteoarthritis (PFOA) and tibiofemoral osteoarthritis (TFOA) is sometimes observed. The identification of subgroups with PFOA and customised interventions to correct underlying pathomechanics is beneficial for individuals with KOA. This study aims to evaluate whether a clinic-based patella mobilisation therapy (PMT) leads to significant improvement in pain, physical function and quality of life of individuals with KOA. Methods and analysis A total of 208 participants with coexistence of PFOA and TFOA will be recruited. A pragmatic randomised clinical trial will be conducted, and participants will be randomised into the PMT and waiting list groups. For the PMT group, three manual mobilisation sessions, along with home-based vastus medialis oblique muscle exercise, will be conducted at 2-month intervals. The waiting list group will continue to receive their usual care, and as an incentive the waiting list group will be offered PMT after the study period is over. The primary outcome is the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale, and secondary outcomes include the WOMAC function and stiffness subscales, scores for objective physical function tests (the 30 s chair stand, 40-metre fast-paced walk test, the Timed Up and Go Test), and the EuroQol-5D scores. All outcomes will be evaluated at baseline and 6 months using intention-to-treat and incorporating covariate analysis. Ethics and dissemination Ethics approval has been obtained (CREC no: 2014.379). Results of the trial will be submitted for publication in a peer-reviewed journal. Trial registration number ChiCTR-IPC-15006618; Pre-results.

Small Needle Vertical Caudal Epidural Injection Method: Success Rate and Safety Profile

Objective(s): To assess the efficacy of concurrent dextrose prolotherapy and physical therapy in reducing pain and reversing degenerative changes in participants with painful rotator cuff tendinopathy. Design: Randomized double-bind controlled trial. Setting: Outpatient pain medicine practice. Participants: Chronic shoulder pain and ultrasound-confirmed rotator cuff tendinopathy. Interventions: Delayed treatment control period, followed by concurrent physical therapy (six sessions) and three monthly solution-and-depthconcealed (participant, evaluator) or solution-concealed (injector) injections of normal saline/0.1% lidocaine either above (Superfic-Saline) or onto painful entheses (Enth-Saline), or onto entheses with 25% dextrose included (Enth-Dex). Main Outcome Measure(s): Primary: 0-10 Visual Analog Score (VAS) for pain, 0-10 Ultrasound Pathology Rating Scale (USPRS) and a 0-10 satisfaction score. Results: No baseline differences between groups in demographics or duration of delayed treatment control period (3.5 2.1months; pZ.920). The 74 participants had moderate to severe shoulder pain (7.0 2.0) for 7.6 9.6 years. Only 7 participants were both confident and correct about their group assignment with no difference between groups. Each group significantly outperformed their delayed treatment control at short term (3 month) followup. At 9 month follow-up 59 percent of Enth-Dex participants maintained a 2.8 improvement in VAS pain(twice the MCID) compared to Enth-Saline (35%;pZ.088) and Superfic-Saline (27%;pZ.017), and Enth-Dex participants’ satisfaction was 6.7 3.2 (10Z completely satisfied) compared to Enth-Saline (4.7 4.1;pZ.079) and Superfic-Saline (3.9 3.1;pZ.003) participants. USPRS findings were not different between groups (p Z .734). Conclusions: Concurrent physical therapy and dextrose prolotherapy resulted in superior long term pain improvement and satisfaction in chronically painful rotator cuff tendinopathy in comparison with physical therapy and a superficial saline control injection, with intermediate results for entheses injection with saline. These differences could not be attributed to a regenerative effect.

Concurrent Dextrose Prolotherapy and Physical Therapy in Painful Rotator Cuff Tendinopathy: A Randomized Controlled Trial

Objective(s): To assess the efficacy of concurrent dextrose prolotherapy and physical therapy in reducing pain and reversing degenerative changes in participants with painful rotator cuff tendinopathy. Design: Randomized double-bind controlled trial. Setting: Outpatient pain medicine practice. Participants: Chronic shoulder pain and ultrasound-confirmed rotator cuff tendinopathy. Interventions: Delayed treatment control period, followed by concurrent physical therapy (six sessions) and three monthly solution-and-depthconcealed (participant, evaluator) or solution-concealed (injector) injections of normal saline/0.1% lidocaine either above (Superfic-Saline) or onto painful entheses (Enth-Saline), or onto entheses with 25% dextrose included (Enth-Dex). Main Outcome Measure(s): Primary: 0-10 Visual Analog Score (VAS) for pain, 0-10 Ultrasound Pathology Rating Scale (USPRS) and a 0-10 satisfaction score. Results: No baseline differences between groups in demographics or duration of delayed treatment control period (3.5 2.1months; pZ.920). The 74 participants had moderate to severe shoulder pain (7.0 2.0) for 7.6 9.6 years. Only 7 participants were both confident and correct about their group assignment with no difference between groups. Each group significantly outperformed their delayed treatment control at short term (3 month) followup. At 9 month follow-up 59 percent of Enth-Dex participants maintained a 2.8 improvement in VAS pain(twice the MCID) compared to Enth-Saline (35%;pZ.088) and Superfic-Saline (27%;pZ.017), and Enth-Dex participants’ satisfaction was 6.7 3.2 (10Z completely satisfied) compared to Enth-Saline (4.7 4.1;pZ.079) and Superfic-Saline (3.9 3.1;pZ.003) participants. USPRS findings were not different between groups (p Z .734). Conclusions: Concurrent physical therapy and dextrose prolotherapy resulted in superior long term pain improvement and satisfaction in chronically painful rotator cuff tendinopathy in comparison with physical therapy and a superficial saline control injection, with intermediate results for entheses injection with saline. These differences could not be attributed to a regenerative effect.