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SUGAR-COATED NERVES: THE PSEUDO-SCIENCE OF NEURAL PROLOTHERAPY


It’s not often I have guest bloggers on Healthskills, but today I post an important article by Dr John Quintner, who writes about prolotherapy. If you haven’t heard of it, it involves being injected with a substance that creates local inflammation. Read on – it’s not something I’ll be doing any time soon.

The human understanding when it has once adopted an opinion draws all things else to support and agree with it. And though there be a greater number and weight of instances to be found on the other side, yet these it either neglects or despises, or else – by some distinction sets aside and rejects, in order that by this great and pernicious determination the authority of its former conclusion may remain inviolate.

[Francis Bacon (1620) from Novum Organum, Book 1, Aphorism XLVI.]

 

Introduction

The latest fads from the shadowy world of pseudo-science have always been quick to take off. For those who are keen on approaching pain sufferers with their sharp needles, the invention of Neural Prolotherapy by Dr John Lyftogt, of Christchurch in New Zealand, must have come as a godsend. A quick search on the Internet reveals that this invention is being taken seriously by a number of health practitioners who one might have expected to have known better than to accept it so uncritically.

 

The claims for Neural Prolotherapy

“Prolo-” is short for proliferation and derives from the Latin “to regenerate or rebuild”. Prolotherapy with injectable substances that are being acclaimed as growth factors is now the subject of intensive research. But Dr Lyftogt favours hypertonic sugar injections.

 

Here are some remarkable extracts from his website (http://www.doctorliftoff.co.nz/):

 

After the success of Neural Prolotherapy with Achilles tendonitis other persistent painful conditions of the neck, back, shoulders, elbows, wrists, knees, ankles and feet have been effectively treated by targeting the local inflamed superficial nerves with micro-injections of low dose Glucose.”

 

Comment: there have been no properly conducted clinical trials of Neural Prolotherapy.

 

“More recently Dr Lyftogt has developed effective neural prolotherapy treatment protocols for Migraine. ‘Fibromyalgia,’ CRPS, compartment syndrome and other difficult to treat persistent painful conditions.”

 

Comment: Again, no clinical trials have been conducted. The evidence is purely anecdotal and subject to all forms of bias.

 

“Neural prolotherapy is an effective novel and evolving treatment for non-malignant persistent pain, based on sound neuroscientific principles.”

 

“Subcutaneous prolotherapy with a series of percutaneous near nerve injections has been shown to be an effective treatment for a variety of recalcitrant painful conditions caused by prolonged neurogenic inflammation.”

 

Comment: This is the logical fallacy called circular argument: the conclusion is assumed before the evidence is presented. Dr Lyftogt offers no evidence that these conditions are associated with “prolonged neurogenic inflammation”.

 

The “sound neuroscientific principles”

Dr Lyftogt targets the “guilty” superficial nerves by injecting 5% Mannitol or 5% dextrose and thereby claims to modulate the neurogenic inflammation that he believes is responsible for “neuropathic pain”. He refers to the work of a highly regarded authority:

 

“Quintessential to the working hypothesis that subcutaneous prolotherapy treats prolonged pathological neurogenic inflammation is the work by Douglas W Zochodne from the Neuroscientific Research Unit at Calgary University.” [1]

 

When contacted by the author, Professor Zochodne replied: I can indicate that I have no interest in it, have not endorsed it or plan to endorse it and am disappointed our work would be quoted for something without evidence.

 

But there is more!

 

“The author hypothesizes that subcutaneous prolotherapy injections of hypertonic glucose and 0.1% lignocaine induce apoptosis of proliferating peptidergic noceffectors (i.e. SP and CGRP) and neovessels by reducing VEGF (vascular endothelial growth factor) levels and restoring “effective repair processes” with reduction of pain.” [2]

 

Comment: In this author’s opinion, this is pure speculation.

 

On his website and in a recent email to Associate-Professor Geoff Bove, a world leader in experimental studies of nervi nervorum (“the nerves of the nerves”), Dr Lyftogt claims that his injections target specific receptors (TRPV1) present on the nervi nervorum.

 

“The very small nerve fibers, innervating the nerve trunk, identified as unmyelinated C-fibers or ‘Nervi Nervorum’ are responsible for pain and swelling of the protective sheath of the nerve trunk. This was already demonstrated 125 years ago by Professor John Marshall from London and called neuralgia. It is now called ‘neurogenic inflammation’.”

 

Comment: Dr Marshall was in fact advocating “nerve stretching” in his Bradshaw Lecture given in London. Fortunately, this form of treatment has long been abandoned as being both ineffective and potentially dangerous.

 

Dr Bove made the following personal response to Dr Lyftogt in relation to his facile incrimination of the nervi nervorum:

 

“Dextrose does not do anything to TRPV1 receptors, and it is certainly not selective for abnormal ones (and there is no knowledge that those exist). You are not targeting nervi nervorum other than in your mind; they are few and far between on the small peripheral nerves, and maybe nonexistent. 

Regardless, you have nothing to offer regarding the injected dextrose reducing their function and thus reducing neurogenic inflammation, or reducing neurogenic inflammation at all. 

 

The bottom line

According to Dr Lyftogt: “The growing scientific evidence supporting the view that neuropathic pain syndromes are caused by unremitting peripheral neurogenic inflammation involving the autonomic and sensory nerves may lead to renewed interest in prolotherapy and neural therapy as these treatments are effective and seem to target the PNS.” [3]

 

However, Dr Lyftogt has yet to demonstrate the presence of the unremitting (enhanced) neurogenic inflammation that he claims to have identified and treated with his sugar injectates.

 

Conclusion

The question as to the efficacy of Neural Prolotherapy, as practiced and taught around the world by Dr Lyftogt, is outside the scope of this article. There are no published trials upon which to base any firm conclusions.

 

Anecdotally, there may be face validity for this treatment but to date there has been no discussion of placebo effect, observer bias, expectation bias, reversion to the mean of the conditions being treated etc.

 

But what is abundantly clear is that published animal experimental research by leading neurobiologists Professor Douglas Zochodne and Associate-Professor Geoffrey Bove does NOT in any way support Dr Lyftogt’s hypothesis. This should be the end of the story but I suspect that the aphorism by Francis Bacon is as true today as it was over 400 years ago. All we can do is hope that good science will triumph over its rival.

 

Author: Dr John Quintner, Physician in Rheumatology and Pain Medicine

Dr Quintner accepts full responsibility for the content and opinions expressed in this article.

 

References

1. Lyftogt J. Subcutaneous prolotherapy treatment of refractory knee, shoulder and lateral elbow pain. Australasian Musculoskeletal Medicine November, 2007: 83-85.

 

2. Lyftogt J. Prolotherapy for recalcitrant lumbago. Australasian Musculoskeletal Medicine May 2008: 18-20.

 

3. Lyftogt J. Pain conundrums: which hypothesis? Australasian Musculoskeletal Medicine November 2008: 72-7

12 comments

  1. Great post – timely given the fast-growing interest in this technique in British Columbia Canada.
    An expert says they know what is wrong, confidently explains it and tells the patient about this intervention that will make the problem better. Then the expert sticks needles into the skin, potentially convincing the person the problem has been been effectively treated. Patient improves. This of course does not prove the theoretical premise of the intervention!
    Like acupuncture, and IMS, we need to look at the expert ritual as a huge factor in clinical success, and experimental success. Some suggest we need to also look at the reality that the skin is vastly intertwined with other systems. Sticking needles in the dermis has the capacity to do so much more than provide an access to inflammatory processes.
    Added to one of the key points of this blog – where’s the evidence that the pain is related to an inflammatory process.
    This pain paradigm of – if it hurts there must be inflammation – is so difficult to change.

    1. The clinical ritual: so incredibly powerful. Includes the context in which the ritual is performed such as the certificates on the wall, the prefix to the name, the value on the invoice. It’s powerful not just because it influences the patient, but because it is almost invisible to the one conducting the ritual.

  2. There is yet another dimension that seems relevant to this discussion:

    “The contrast between the endless variety of ‘orthodox’ medicine – with a multitude of different remedies for the multitude of different diseases – and the monotony of the remedies offered by alternative practitioners, has never been sufficiently remarked upon … What is more, exponents of one particular brand of alternative therapy have little time for purveyors of other non-orthodox alternatives. The closed-mindedness orthodox practitioners are accused of is very much alive and well in the ranks of alternative practitioners.” (p. 304) from: Raymond Tallis. Hippocratic Oaths: Medicine and its Discontents, 2004.

  3. So let me get this straight – this guy is going around the world injecting people with no proof to show that it works? Why is this allowed to happen?

  4. Can I just add that I had this treatment in the UK around 18 months ago. I’d suffered with terrible back pain for months. It would wipe me out and render me immobile for one day per week – it was unbearable and ruining my life. I have two small children. I went to see a specialist and he recommended these back injections. Admitedly he didn’t give it the name ‘prolotherapy’ but that’s what it was. I had 3 injections in total (v painful) over the course of about 5 weeks. My bupa cover wouldn’t pay for anymore so that’s where it stopped. However – the back pain did go away – that terrible pain that took my breath away. I can’t describe it. I’m not mad, I don’t believe this was a placebo. I’d had accupuncture already that hadn’t helped. I know I have a deep curve in my spine so my posture isn’t good and I should do pilates etc. This did work though. I just thought I’d put my own perspective in here as I for one am so grateful that I had this treatment.

    1. Hi Biddyk I’m glad you’ve had a good result from your intervention – as Scott said, there are some interesting case studies but lots of potential bias, so the scientific basis for the therapy is not yet demonstrated. This doesn’t mean that individuals might benefit – just that there’s no good reason to extend the treatment more broadly without careful scrutiny of the proposed mechanisms and careful evaluation of the outcomes.

  5. There isn’t no proof Carol, but it is limited. He has some interesting case studies, but there is lots of possible bias involved in these studies. further studies are planned. As Dr Quintner points out, the science certainly needs improving.

    On the plus side, it is a very low risk procedure, but that In itself is not an excuse to bypass the need for better data

  6. A very well thought out article
    It is at the case study level of evidence only except for caudal injections where a RCT showed benefit over saline. Not published yet but presented at a conference.
    The explanation for its mechanism is doubtful, as John points out

    Can it still be trialled in practice – I think so but under certain conditions only.

  7. That is good news Biddyk and one shared by many other people. There are also people who get no benefit and rarely people who suffer complications. You sound like you might have been treated with traditional prolotherapy which is more painful than the neuroprolotherapy

  8. I’ve used John Lyftogt’s injection’s 4 different complaints, years apart. Usually 4 to 6 sessions of injections for a complaint. If you had bad pain from the injections it wasn’t neuroprolotherapy. Surgeons and other Doctors run this down as for $500- $600 YOU CAN BE FIXED AND THEY LOSE A $5000- $10000 OPERATIONS.

    1. I’m so pleased you found something to help you. While I can understand your cynicism regarding medics promoting more expensive solutions, in this case Dr Quintner is a rheumatologist, not a surgeon, and both of us promote self management rather than external interventions.

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