Is PRP the best option for treatment of connective tissue damage overall?
As mentioned above, PRP is the strongest agent available to trigger the connective tissue healing process, due to its ability to harness both the white blood cell mechanism (which is the mechanism targeted by traditional Prolotherapy solutions), and its ability to trigger the platelet mechanism. In addition, for whatever benefit may be obtained, the stem cell mechanism is also brought into play with PRP.
The most important factor in patient outcome, when using PRP or other Prolotherapy solutions, though, is not the strength of the agent: the most important factors in clinical outcome are where the agent is used, and how long treatment is continued. What does this mean? Most people will respond will to any agent that is commonly used to trigger connective tissue healing. The elements that is often ‘missing’ from treatment when using ‘healing triggering’ via PRP, Prolotherapy, stem cell treatments, or treatments employing ‘growth factors’ derived from the placenta or from other sources are 1.) proper diagnosis of ALL of the symptom sources; and 2.) thorough and complete treatment of all of these pain sources. This is THE REASON for the wide range of results obtained by individual physicians, and in the research literature, when using PRP or Prolotherapy, and WHY THE MEDICAL LITERATURE ON USE OF PRP IS SO UNCONVINCING AS TO THE EFFECTIVENESS OF THIS TREATMENT. I would simply state the obvious: the results that an individual patient receives from treatment for relief of pain is directly proportional to the number of pain-causing structures which are correctly identified and thoroughly and completely treated. This begs the question of why common sense is so uncommon?
At Prolotherapy Nashville we have a unique advantage when it comes to treating patients with musculoskeletal pain. Medical researchers, as they clearly state in current research papers on Prolotherapy and PRP, have NO IDEA what is causing pain in connective tissue, and they have NO IDEA how PRP, or Prolotherapy, work to eliminate such symptoms, though they observe this phenomenon(See video presentations in the ‘For Healthcare Professionals’ section). While the cause of such symptoms was thought, since the 1950’s, to be primarily an inflammation (hence such terms as arthritis, or ‘joint inflammation; or tendonitis, or ‘tendon-inflammation’), it has now been convincingly demonstrated by medical research that inflammation plays NO ROLE in such symptoms. But researchers have yet to scientifically validate any other mechanism by which such pain is caused. And in fact all other recent theories have been disproven by researchers—except one. This theory of connective tissue/joint pain was proposed by Dr. Johnson in a paper published in a medical journal in 2009. It remains the only plausible theory of the cause of such pain. And using diagnostic and treatment strategies built upon this theory, Prolotherapy Nashville has been able to obtain clinical results which have been carefully studies, and presented in national physician meetings, which are superior to any published or reported results for such conditions.
The strategy that this understanding has lead Dr. Johnson to adopt is very simple to understand, if somewhat more complex to perform.
First: identify all symptom causing structures using a combination of palpation to identify tender connective tissue structures that are clinically important, and ‘symptom subtraction’—observing which symptoms ‘disappear’ when local anesthetic containing Prolotherapy and PRP solutions are injected into particular structures. If, after initial treatment, some of the symptoms persist, then additional connective tissue sources are sought, and usually found. The alternative is that a component of the symptoms are from a ‘non-connective tissue source’, like a nerve pinch. What has been truly amazing to Dr. Johnson is the rarity of occurrence of such ‘non-connective tissue sources, even though they have frequently been ‘diagnosed’—and incorrectly so—by other practitioners. If the symptoms which brought a patient to our door completely ‘disappear’ following treatment, what does this tell us about where symptoms are, and are not coming from? This is the simple manner in which correct diagnosis and thorough treatment is assured.
Then, there is the issue of completing the treatment. If one understands the correlation between the factor which initiates the pain—which is loss of tensile strength, due failure to replace broken collagen molecules in a connective tissue structure, with that loss sufficient to produce abnormal stretching in the structure under load—and the cause of the pain and tenderness associated with such structures—which is stretch-induced small fiber nerve damage in the microscopic nerves which inhabit each of these connective structures in large numbers—then one is armed with an understanding that will allow us to know when to cease treatment with assurance that the problem has been properly remedied. How do we know that treatment is ‘finished’? When tenderness is no longer present in the treated structures. Why is this such an important finding? Because if there is no tenderness, there are no longer damaged nerve fibers in a structure. This means that the structure is no longer stretching abnormally under typical body loads, and is therefore adequately healed.
Why is there confusion about when to stop treatment? There are two reasons for this. First, as structures strengthen, there is often a phase where symptoms are intermittent. They are gone for the moment, but with physical or other stress, they will return. In such structures, tenderness remains. So, cessation of tenderness is the only endpoint of treatment that assures that symptoms will not recur in the near future.
However, most physicians are not aware of what percentage of the symptoms are due to healable connective tissue damage—as they still subscribe to the idea that some percentage of the patient’s symptoms are due to the bulging disc, the scar tissue, or whatever. So these physicians expect that the patient will not become symptom-free with treatment, and are completely satisfied when the patient experiences a 50% or 70% symptom reduction. In fact, they are delighted, and so, often, is the patient, since these results are better than any previously obtained with treatment. So, due the physician uncertainty about the actual cause of symptoms, the physician is often reluctant to pursue treatment beyond a certain point.
And, most physicians are now aware of the connection between tenderness in a structure, and its capacity to cause symptoms. This is because most physicians, even those who treat with Prolotherapy or PRP, do not understand the actual mechanism by which symptoms are being produced. Many, if not most, of these physicians persist in trying to use imaging studies to identify sites of damage, and to the extent to which they do examine, and do use tenderness to identify structures that they treat, they are often less than thorough, to say the least. If a physician treats only a fraction of the pain-causing structures, what kind of results can we expect? How many of their patients could possibly become symptom-free following treatment?
This is why it is so crucial at an initial visit at Prolotherapy Nashville that we accurately, precisely, scientifically determine what percentage of the patient’s symptoms are and are notcoming from connective tissue, and why our expertise at finding sources of pain that may be some distance from where symptoms are being perceived by the patient, and our understanding of the variety of symptoms which may be produced by such connective tissue/nerve damage is so vitally important. If we can make any or all symptoms ‘go away’ at the initial visit, we can make such symptoms abate long-term if we can successfully trigger connective tissue healing. We have had literally hundreds of patients, perhaps into the thousands, comment that they have either ‘never been examined’ at all, despite multiple physician evaluations, or that they have ‘never been examined there before, despite seeing other Prolotherapists, even skilled and well-reputed ones. In other words, the key to best results is correct, complete, and thorough diagnosis of the symptom sources.
This correct diagnosis will allow us to continue treatment in all clinically relevant structures until they stop causing symptoms indefinitely—which is, again, the point that they cease to be tender. While most patients at Prolotherapy Nashville DO complete a course of treatment, what do you think happens to those who cease treatment before the above endpoint is achieved? We have observed a high likelihood that symptoms will ‘recur’ over the six to 18 months, although taking such patients from ‘where they are’ to ‘completed’ is usually a simple process and relatively brief once they return to the office. If we pursue a strategy of completing treatment in all of our patients, does it make sense why over half of our patients become symptom free in treated areas, and why over 90% become over 80% symptom free? And why doesn’t everyone that we treat get 100% symptom-free? Because most cease treatment at the point that other areas in their body are more troublesome—their bad knee has become their good knee, for example—and they are no longer activity-limited in any way.
In light of the above, what is the best agent to use to trigger the body’s healing processes? First and foremost, the best thing to use to trigger healing is whatever the physician puts in every place that really needs to be treated, and whatever he/she uses to the limits of its potential to treat the damage. There are some limits on the effectiveness of traditional Prolotherapy solutions, and around 10% of people simply do not respond to any of these solutions. PRP, in contrast, will work in any patient with a functioning healing system. However, not all patients have a functioning healing system.
Here, again, is a place where understanding the underlying mechanisms in play, or not, can lead to differing patient outcomes. In Dr. Johnson’s practice, in patients who do not respond as expected to PRP, he also evaluates various factors known to impair the connective tissue healing system per se. Often factors are found which can be adjusted, with the result that ‘non-responders’ convert to ‘responders’, and good clinical outcomes are obtained.
In Dr. Johnson’s practice, 80% of patients are managed throughout treatment with Dextrose solution only. The remaining 20% receive PRP (16%), and/or modification of the Dextrose solution with various agents. Why this particular overall treatment strategy? Dr. Johnson believes in using the least expensive agent which will be effective in a given situation for most patients. On the other hand, PRP is the strongest available agent, and in situations where speed of result, and travel costs (Dr. Johnson has seen patients from almost every state in the US, and from several foreign countries) make the cost of treatment relatively less important, then use of the strongest, though more expensive, agent makes good sense. One of the most important, and often missing, elements in medical care is to thoroughly understand all of the factors—medical, personal, and financial—that impact an individual. At Prolotherapy Nashville every attempt is made to listen to each patient’s personal considerations and priorities, in order to craft an individualized approach to each patient that maximizes treatment result, and offers the optimal patient experience and financial impact for each person.
One further thought: the most expensive treatment is one that does not work, even if ‘insurance pays for it’. In fact, has anyone noticed that correlation between the lengthy list of medical tests and unsuccessful treatments for musculoskeletal pain (which are a significant part of this country’s overall medical expenses: Chronic Pain cost—$635 Billion per year; Back Pain $85 Billion per year; and Knee and Hip replacement $17 Billion per year—just these three issues cost US taxpayers and insurance premium payers 3/4 of a Trillion Dollars per year!!!—while a large percentage of these patients would respond successfully to PRP/Prolotherapy…), and sharply rising insurance premiums? If everyone were pursuing a relatively inexpensive and highly effective approach to these conditions—see our overall treatment results at Prolotherapy Nashville—even if the cost is ‘out of pocket’, how much of an impact would this have when it comes time to write those Medical Insurance premium and tax checks?