Prolotherapy in the Academy: A Mixed Methods Survey Study

Context: Safe, effective treatment for chronic pain is needed. Prolotherapy is an injection-based complementary and integrative therapy supported by emerging peer-reviewed evidence. It is anecdotally used in clinical care, yet it is not part of medical society practice guidelines. It is unclear how many medical training programs practice and teach prolotherapy, limiting research and clinical optimization. Objective: To assess the use and teaching of prolotherapy in U.S. medical training programs (residencies and fellowships) in specialties that treat chronic pain. Design and Analysis: A mixed-methods, 21-item cross-sectional anonymized survey was sent to directors of the Accreditation Council for Graduate Medical Education (ACGME) residency and fellowship programs in 11 specialties treating chronic pain. Analysis was by descriptive statistics, ANOVA, and qualitative inductive content analysis. Results: From 1852 mailed surveys, we received 854 responses (46.1%). Two-hundred eleven (24.7%) programs reported prolotherapy use, and 119 (13.9%) reported prolotherapy-focused education. Prolotherapy use was most frequently reported by Osteopathic Manipulative Medicine/Neuromusculoskeletal Medicine (OMM/NMM) and Physical Medicine and Rehabilitation (PM&R) residencies and by Sports Medicine and Musculoskeletal Radiology fellowships. Prolotherapy-focused teaching was most frequently provided by OMM/NMM and PM&R residencies and Sports Medicine Fellowships. Among the 119 programs teaching prolotherapy, educational efforts most commonly addressed knee (91; 76.5%), shoulder (86; 72.3%), and elbow (80; 67.2%) pathology, and most (97; 81.5%) include ultrasound guidance at least some of the time. Qualitative analysis revealed mixed perspectives about the use and teaching of prolotherapy. Non-adopters cited limited peer-reviewed evidence and awareness, while adopters noted supportive evidence, a favorable safety profile, and appreciation of alternative treatment options. Conclusions: This is the first study to assess the practice and teaching of prolotherapy for chronic pain in U.S. ACGME-accredited medical training programs. Prolotherapy appears to be used and taught by a substantial minority of responding programs; results should be interpreted with caution due to potential self-selection bias. Findings suggest more research about the use and training, and the efficacy and effectiveness, of prolotherapy is warranted.