Physical therapy, intra-articular dextrose prolotherapy, botulinum neurotoxin, and hyaluronic acid for knee osteoarthritis: randomized clinical trial

Abstract

This study aimed to compare the efficacy of four treatments in the management of knee osteoarthritis. We carried out a randomized clinical trial with four study arms in an outpatient Department of Physical Medicine and Rehabilitation at a University Hospital. In total, 120 patients with knee osteoarthritis ≥50 years of age were randomly allocated to four groups. The primary outcome was knee pain in visual analog scale and the secondary outcome was the Knee Injury and Osteoarthritis Outcome Score. The exercise was prescribed daily for all participants throughout the study. For physical therapy (group 1), participants received superficial heat, transcutaneous electrical nerve stimulation and pulsed ultrasound. We administered a single intra-articular injection of botulinum neurotoxin type A (group 2) and three injections of hyaluronic acid (group 3) or 20% dextrose (group 4) to patients in the corresponding groups. Mixed analysis of variance showed that there was statistically significant difference between the groups in pain (P < 0.001), and Knee Injury and Osteoarthritis Outcome Score (P < 0.001). Pairwise between- and within-group comparisons showed that botulinum neurotoxin and dextrose prolotherapy were the most, and hyaluronic acid was the least efficient treatments for controlling pain and recovering function in patients. An intra-articular injection of botulinum toxin type A or dextrose prolotherapy is effective first-line treatments. In the next place stands physical therapy particularly if the patient is not willing to continue regular exercise programs. Our study was not very supportive of intra-articular injection of hyaluronic acid as an effective treatment of knee osteoarthritis.

Dextrose prolotherapy in knee osteoarthritis: A systematic review and meta-analysis

“…The five intercurrent studies have had relatively large participant numbers, with most findings favoring dextrose prolotherapy, but have also discussed other injectable and conventional treatments. 16,17,20,25,26 Results from our systematic review indicated that most authors favored intra-articular injections with a three-injection regime. Half of the studies used dextrose solutions of less than 20%, while the rest used dextrose solutions of between 20% and 25%.…”

“…Physical therapy and intra-articular dextrose prolotherapy resulted in a significant decrease in pain and all the various KOOS subscales three months post-intervention. 17 However, the effect size of physical therapy on stiffness was larger compared to dextrose prolotherapy, whereas the effect size of physical therapy on physical function for daily living was smaller.…”

“…Both intra-articular botulinum toxin and intra-articular dextrose prolotherapy resulted in a significant decrease in pain three months post-intervention. 17 Using the Knee Injury and Osteoarthritis Outcome Score (KOOS) as an outcome measure, dextrose prolotherapy resulted in a significant improvement in symptoms other than pain, physical function for daily living, and for sports activities at three months. Patients in the intra-articular botulinum toxin arm reported significant improvement in the preceding domains apart from stiffness.…”

“…11 Our systematic review has included two studies that compared dextrose prolotherapy against intra-articular hyaluronic acid; however, we did not find any studies comparing dextrose prolotherapy against intra-articular corticosteroids. 17,26 From this systematic review, many questions regarding the periprocedural characteristics of dextrose prolotherapy remain unanswered. These include injection sites, the optimal concentration of dextrose, the number of injections, and the interval between injections.…”

Therapeutic Effects of Intra-articular Botulinum Neurotoxin Versus Physical Therapy in Knee Osteoarthritis

“…and invasive treatment options for KOA have been investigated. Platelet-rich plasma (PRP) (5,6), prolotherapy (7,8) have currently shown ideal outcomes. Hyaluronic acid, PRP, and prolotherapy require multiple injections that increase the risk of joint infections (9,10).…”