Prolotherapy in the Academy: Results of a National Cross-Sectional Mixed Methods Survey

CONTEXT: Prolotherapy (PrT) is a non-opioid injection-based therapy for chronic pain. Patient-oriented evidence supporting PrT is growing. PrT has historically been taught in mentored clinical settings and medical conferences, not in academic training programs. Anecdotally, the use and teaching of PrT is growing; this trend is unassessed, limiting understanding of its use and rationale for further research.

OBJECTIVE We conducted a survey to identify the rate and characteristics of academic PrT use and teaching in the U.S., and the rationales for adopting or not adopting PrT.

STUDY DESIGN Mixed methods cross-sectional survey. A 21-item mixed-methods paper survey was developed by co-authors in collaboration with a university-based survey center.

POPULATION/SETTING The survey was mailed in three waves to program directors of the Accreditation Council for Graduate Medical Education (ACGME) resident and fellowship programs in 11 specialties (including Family Medicine and Sports Medicine) that treat chronic pain.

OUTCOMES Primary outcomes were rate and rationale of PrT use and teaching. Secondary outcomes were indications for PrT use and rate of ultrasound guidance for PrT injections.

RESULTS: We received 854 responses from 1792 mailed surveys (47.6%). 24.7% (211) of programs reported PrT use; 13.9% (119) of programs reported PrT teaching. Osteopathic programs were most likely to include PrT training (73.3%; 11), followed by PM&R residencies (40.0%; 18) and Sports Medicine fellowships (31.5%; 45). 8.5% (31) of Family Medicine programs reported that they include PrT in residency training. The top 3 anatomical regions treated were the knee (79.1%; 91), shoulder (74.8%; 86), and elbow (69.6%; 80). 81.5% (97) of programs training PrT teach the use of ultrasound guidance. Qualitative analysis revealed mixed perceptions of the evidence base, effectiveness, and resource limitations associated with use and non-use of PrT.

CONCLUSIONS: In this first study to assess the use and teaching of PrT for chronic pain in ACGME accredited training programs, a substantial minority reported use and teaching. Adopters reported that PrT is a valuable, effective, evidence-based treatment option for chronic pain. Ultrasound is used by most programs to guide injections. Osteopathic, PM&R and Sports Medicine programs were most likely to be adopters. Non-adopters cited concerns about evidence and effectiveness, resource restrictions, and limited awareness.