ARTICLE IN PRESS
Archives of Physical Medicine and Rehabilitation
journal homepage: www.archives-pmr.org
Archives of Physical Medicine and Rehabilitation 2023;000: 1
LETTER TO THE EDITOR
Response to Letter to of those solutions during the injection. If we had applied local
anesthetics to the 15% dextrose group so that there would be no
the Editor: Low-Dose painful injection, we could have caused a bias between the groups.
Dextrose Prolotherapy Therefore, further randomized controlled trials involving an
as Effective as High- adequate number of patients and extended follow-up periods are
Dose Dextrose necessary to reveal which dose has more effects on prolotherapy
in lateral epicondylitis treatment.
Prolotherapy in the
Treatment of Lateral Yıldız Gonca Dogru Ciftci, MD
Epicondylitis? A Department of Physical Medicine and Rehabilitation
Double-Blind, Sisli Etfal Hamidiye Research Hospital
Istanbul Turkey
Ultrasound Guided,
Randomized Controlled Figen Tuncay, MD, PhD
Study Fatmanur Aybala Kocak, MD, PhD
Department of Physical Medicine and Rehabilitation
Kirsehir Ahi Evran University Faculty of Medicine
Kirsehir Turkey
In lateral epicondylitis, angiofibroblastic hyperplasia and poor scar
tissue occur in response to recurring microtrauma in the tendon, Mehmet Okcu, MD
and consequently, complete healing does not take place. In vitro Department of Physical Medicine and Rehabilitation
studies using 50% dextrose as a proliferant have shown that expo- Marmara University Faculty of Medicine
sure of tenocytes to dextrose elicited an inflammatory response Istanbul Turkey
through the upregulation of proinflammatory markers, including
interleukin 8, cyclooxygenase 2, and prostaglandin 2, and downre- Disclosures: none.
gulation of anti-inflammatory marker growth factor b.1 Hyper-
tonic dextrose generates trophic effects on the tendon, such as
increased fibroblast proliferation and increased collagen produc-
tion, and extracellular matrix in treated tendons. However, accord- References
ing to the results of our study, although 5% dextrose is effective in 1. Ekwueme EC, Mohiuddin M, Yarborough JA, et al. Prolotherapy indu-
pain, 15% dextrose is more effective in resting and activity pain, ces an inflammatory response in human tenocytes in vitro. Clin Orthop
hand grip strength, and pressure pain threshold.2 Although the 5% Relat Res 2017;475:2117–27.
dextrose neuromodulation effect decreases pain levels, it should 2. Ciftci YGD, Tuncay F, Kocak FA, Okcu M. Is low-dose dextrose prolo-
not be forgotten that our aim in lateral epicondylitis treatment is therapy as effective as high-dose dextrose prolotherapy in the treatment
not just pain control. Prolotherapy is a treatment method in which of lateral epicondylitis? A double-blind, ultrasound guided, randomized
controlled study. Arch Phys Med Rehabil 2023;104:179–87.
we aim to activate the remodeling process by activating collagen
3. Levin S. Tensegrity-the new biomechanics. In: Hutson MA, Ellis RM,
synthesis in potentially affected weak tendons and ligaments.3,4
eds. Textbook of musculoskeletal medicine, Oxford: Oxford University
We agree that 15% dextrose injections are more painful than Press; 2006:69–80.
5% dextrose and saline when we apply them in clinical practice. 4. Hackett G. Ligament and tendon relaxation (skeletal disability) treated
We wanted to address that when planning the study, but we did by prolotherapy (fibro-osseous proliferation): treated by prolotherapy
not observe a significant pain difference. The reason for this result (fibroosseous proliferation). Springfield: Charles C. Thomas; 2014.
may be the amount of solution injected (1 mL). We did not con-
sider adding local anesthetic to the solutions to compare the pain https://doi.org/10.1016/j.apmr.2023.03.007
0003-9993/$36 - see front matter Ó 2023 by the American Congress of Rehabilitation Medicine.
