Prolotherapy consent form

Prolotherapy consent form


What is prolotherapy? Prolotherapy is a medical treatment which involves injecting certain drugs into injured or diseased tissues with the potential to cause these local tissues to proliferate and, therefore, to heal.

What is injected and where? Usually, a solution of dextrose (a kind of sugar), and local anesthetic in water is injected at the junction between tendons or ligaments, which have no blood vessels, and the periosteum, which is the blood vessel rich membrane which covers the bone. This causes inflammation, which brings blood vessels from the periosteum into the tendons and ligaments, thus allowing the proliferation of new connective tissue. This tissue is composed of collagen, which is the same substance that tendons and ligaments are made of. Tendons and ligaments can be made up to 40% thicker and stronger with prolotherapy.

What medical conditions does it treat? Medical studies have found prolotherapy to be a first or second line treatment for a variety of musculoskeletal disorders.

  • Headaches, temporomandibular joint (TMJ) pain
  • Pain in the neck, back, or lower back, particularly the sacroiliac joint
  • Pains in the ligaments and tendons around the joints, ligament or tendon tears
  • Rotator cuff problems of the shoulder
  • Tennis elbow, golfer’s elbow
  • Osteoarthritis of the wrist or fingers, carpal tunnel syndrome
  • Osteoarthritis of the hips, knees, ankles, feet and toes. Morton’s neuroma.
  • Plantar fasciitis, Achilles tendinitis.
What are the risks? Prolotherapy injections can be painful. Following the injections you may have pain in the area for anywhere from one day to two weeks. This is because of the inflammation that is induced by prolotherapy. You will be given painkillers specifically to deal with the problem, and you can use Tylenol (acetaminophen). You must not take any anti-inflammatory medication such as aspirin, ibuprofen, Advil, Motrin, or other NSAIDs. These would prevent the inflammation process which helps heal the ligaments and tendons. Occasionally the needle punctures a blood vessel, which causes bruising, or a nerve, which can send a brief, burning sensation down the limb, or, very rarely, the lung (when the chest area is injected). This may cause chest pain and shortness of breath. Call Dr. Bertrand or your doctor if this happens. Do not use prolotherapy if you are allergic to corn or to local anesthetic. If a joint is injected, there is a 1/10,000 chance of infection. If you experience increased pain in the joint, swelling, redness or heat, see Dr. Bertrand or your doctor as soon as possible. Prolotherapy does not work for everyone. Some people need as many as five treatments prior to experiencing results, and may need as many as 12 prolotherapy sessions.

What are the benefits? Better than 75% of people given prolotherapy state that their pain has disappeared or is much better, after anywhere from one to six treatments. These treatments are given every two to six weeks. Studies have shown prolotherapy can increase the thickness of the knee cartilage by 65% 2 in cases of arthritis of the knee, and it has been shown to cause dramatic pain reduction in arthritis of the wrists and fingers, as well as iliolumbar ligament and sacroiliac joint pain.

What are the costs? Prolotherapy is not covered by MSP. Some extended benefit plans will cover a portion of your costs. Each prolotherapy session costs between $50 and $300 depending on the area being treated. You will need, on average, one to four injection sessions.

I have read and understand this consent form and agree to be treated with prolotherapy.



Signed __________________________________        Date____________