PLATELET RICH PLASMA – PRP
1. What is Platelet Rich Plasma?
Platelet Rich Plasma, or PRP, is a concentrated solution of a patient’s own white blood cells, platelets, and stem cells used to trigger the body’s healing system.
2. How does PRP work?
PRP triggers healing in two ways. First, it utilizes the body’s two major sources of growth factors (white blood cells and platelets), which are the chemicals that trigger the body’s connective tissue healing system. This is the six-week cycle of healing that most people are familiar with following major surgery. (Link to connective tissue healing and paper on CTDS). The connective tissue healing system (think ‘following surgical incision or sprained ankle’) primarily makes new collagen molecules to replace those torn due to accident, or cut by a surgeon’s knife. Most of the time, PRP is used to trigger healing to tighten, toughen, and shorten tendons and ligaments that have unhealed damage, which causes pain, joint cartilage loss, disc degeneration, and other problems.
The second mechanism involves stem cells that are present in the mixture. The Harvest system that I use provides about 120,000 stem cells per treatment. Stem cells are cells that are capable of ‘differentiating’ into other body cells, such as chondrocytes, or cells that make new articular cartilage (which lines joint surfaces). It should be emphasized that stem cells play no meaningful role in production of new collagen in ligaments and tendons. Healing and strengthening in ligaments and tendons is produced by the connective tissue healing system, not the stem-cell system.
3. How much experience does Dr. Johnson have using PRP?
Dr. Johnson was the third physician in the country to begin using PRP for musculoskeletal treatment, in 2005. Since then, he has treated many professional athletes in a variety of sports (including players from several NFL and MLB teams), Olympic athletes, and high level amateur athletes, as well as many patients who have had total joint replacement and other Orthopedic operative procedures recommended, and who have had a variety of other musculoskeletal problems. Dr. Johnson has innovated and improved techniques for successful use of PRP, and his results, and the techniques which produce those results have been presented in several national physician meetings in the last five years. While a number of physicians, including Orthopedic surgeons, Sports surgeons, and Spine surgeons have begun to use Platelet Rich Plasma in the last few years, the results from the ‘Orthopedic Approach’ to use of PRP, as shown by several research studies, does not produce results equivalent to the results that Dr. Johnson has obtained, and presented in national physician meetings. One of his recent teaching sessions focused on the difference between his approach and the ‘typical’ Orthopedic approach to use of PRP, the different outcomes that these two approaches produce, and why there is this difference in outcome. (See one of these presentations in the ‘For Healthcare Professionals’ section.)
4. What problems does PRP effectively treat?
PRP and other Prolotherapy solutions can be used essentially interchangeably to treat conditions characterized by ligament and tendon damage, cartilage loss, and bony changes (often termed ‘osteoarthritis’). Any condition, and any structure, that can be treated by Prolotherapy can also be effectively treated using PRP. (See ‘What Can Prolotherapy Treat)
**JOINT PAIN: It can be used for joint pains where no imaging abnormality (like ‘bone on bone’) is noted, and it can be used for people with severe changes on imaging studies (bone on bone, etc.).
**NECK AND LOW BACK PAIN: It can also be used to treat spinal ligament damage that often leads, in addition to back or neck pain, to disc degeneration and bony changes. Often epidural steroid injection, radio-frequency nerve ablation, and spinal fusion are recommended by Orthopedic and Spine surgeons for such problems.
**SPORTS INJURIES: It can be used to treat sports injuries of all types. It has been used successfully to treat many sports- related conditions for which Orthopedic surgeons recommend surgery, such as rotator cuff tears, labrum and meniscus tears, tendon damage (such as could undergo Tommy John surgery). It can be very effective for almost any ongoing pain noted during activity in feet, ankles, knees, hips, backs, shoulders, elbows, wrists, hands and thumbs, and necks. This would include things diagnosed in any area or structure as arthritis, sprain, strain, or tear. This would include sprains, strains, and tears of muscles, as well as ligaments and tendons. One very exciting aspect of PRP treatment of athletes is seeing them be able to resume full activity in a much shorter time than would be possible with any other treatment strategy. This is particularly true with professional athletes ‘in season’. Treatment under Dr. Johnson’s care has gotten several professionals ‘back on the field’ in such a way when treatment, even with PRP, by the ‘team doctor’ was not producing the desired ‘rapid’ results. This difference in results largely stems from the tendency of the Orthopedic physicians to target their treatment using imaging studies only. In other words, they only treat what they ‘see’ on films as damaged. Dr. Johnson uses a different targeting strategy for treatment that identifies all of the damaged, symptom-causing structures, including the ones that do not ‘show up’ on films, but which are producing pain and functional limitation.
**AUTOMOBILE ACCIDENTS, FALLS, AND OTHER ACCIDENTS AND INJURIES: Pain following any trauma, whether anything is ‘seen’ on imaging studies or not, is generally due to unhealed connective tissue damage. This damage, as in the typical ‘whiplash’ injury, often does not ‘show up’ on imaging studies, and may remain undiagnosed, or may be misdiagnosed as a ‘nerve pinch’, a ‘bulging disc’, or as some kind of inflammation. The key to successful treatment in this group of people is to diagnose the source of the pain accurately and completely. In almost all people, all of the pain is emanating from unhealed damage in connective tissue structures. Although such damage does not ‘show up’ on imaging studies, it is very easy to accurately locate on physical examination. When correctly diagnosed, such problems respond in a very high percentage of people to repeating the healing cycle several times using either PRP or other Prolotherapy solutions.
CHRONIC PAIN: Many patients who present to Dr. Johnson’s office have significant pain that has been undiagnosed, or mis-diagnosed. Current diagnostic approaches, based upon emphasizing imaging studies, and not understanding the role that unhealed connective tissue damage may be playing, and not being trained how to diagnose such damage, often leads to patients being accused of having some character issue as the underlying cause of their ‘problem’, or of having an improper motive for seeking medical care. Or their ‘ condition’ has been assigned a cause, like a bulging disc, bone spur, or other entity ‘seen’ on an imaging study, or ‘inferred’, like scar tissue or nerve pinches or inflammation, that has not ‘responded’ to treatments based upon such ‘diagnoses’. If tenderness can be found in connective tissue structures that correlates to the patient’s location of symptoms, then these chronic painful conditions will respond with a very high degree of success to PRP administration, or to other Prolotherapy solutions, regardless of previous diagnoses. The one exception is in the case of an auto- immune disorder, like rheumatoid arthritis, that has been documented by laboratory testing, not simply assumed to be present by a Rheumatologist despite the fact that the tests are ‘normal’. In patients with chronic pain, including patients diagnosed as having ‘Fibromyalgia’, PRP, and traditional Prolotherapy, provides a high percentage of success, particularly when combined with diagnosis and treatment of the underlying problem with ‘maintenance connective tissue healing’ that caused the problem in the first place (links).
5. What are the advantages of Platelet Rich Plasma versus other Prolotherapy solutions?
The other Prolotherapy solutions act on white blood cells, getting them to release the ‘growth factors’ which trigger the connective tissue healing system. Platelet Rich Plasma also utilizes the other source of these chemical, the platelets, to add to add additional ‘triggering chemicals’, which generally provides overall a ‘stronger’ healing response. Also, if the white blood cell part of this mechanism is ‘unavailable’ due to necessary use of corticosteroids or other immunosuppressants (such as for immunosuppression following organ transplant), then the healing system can still be triggered via the platelet mechanism. Secondly, the addition of the stem cells to the equations makes it more likely that more cartilage can be produced. While Dextrose Prolotherapy has been shown to grow cartilage in a majority of knees treated in a research study, this effect is likely more pronounced when using PRP. PRP is overall the ‘strongest’ connective tissue healing trigger that we have.
6. What are the disadvantages of Platelet Rich Plasma?
COST: First, PRP adds to the cost of treatment. Selecting this treatment option adds $500.00 to the cost of a treatment. For this reason, we often try less expensive options first, and they are often effective, even in more ‘extreme’ situations (such as ‘bone on bone’ knees and hips).
SIZE OF POTENTIAL TREATMENT: Secondly, following processing and concentration, we end up with about 13cc’s of solution to inject. While this is a sufficient quantity to treat many conditions, we also have a quite a few patients who have conditions which need more, often much more, solution to administer a thorough and complete treatment. In these situations, PRP is used in the ‘worst, most damaged’ structures, and Dextrose is used in the other structures. In fact, Dextrose is used in ALL of the structures, including ones that will be treated with PRP. This is done for two reasons: first, to ‘pre-numb’ the structures to be treated with PRP, as PRP is quite uncomfortable if injected into an ‘un-numbed’ structure; secondly, because the Dextrose in all likelihood improves growth factor release in the injected white blood cells, just as it does in the white blood cells that reside in the injected areas. In addition, if the size of a ‘thorough and complete’ treatment exceeds the size attainable with PRP, then the remainder of the structures are treated with Dextrose only.
7. Platelet Rich Plasma versus Stem Cells
How does PRP compare to a stem cell treatment? First, one must be very clear about what is needed to ‘fix’ a given problem, and this is where some of the common diagnostic misconceptions in the medical community come into play. For instance, in a knee that has significant loss of cartilage (bone on bone), are the symptoms actually due to ‘bone ends rubbing together’, and to an inflammation (arthritis), or are the symptoms in knees where cartilage loss is noted primarily coming from the ligaments and tendons around the knee, and is the cartilage loss due to mechanical abrasion due to ‘loose ligaments’? (link to Connective Tissue Damage Syndrome paper).
A pure Stem Cell treatment ONLY grows new tissue, like cartilage. It DOES NOT add new collagen to ligaments and tendons, which is the way that pain and joint instability are successfully treated and resolved. Research studies have clearly shown that addressing ‘bone on bone’ knees by simply treating the cartilage surface and trying to grow new cartilage, does not give as good, or as enduring, symptom relief as treating the ligament and tendon structures in conjunction with treating the joint surface. Dr. Johnson is personally convinced that a significant percent of the symptoms in such knees, and other joints, are in fact coming from stretch-induced small fiber nerve damage in the damaged ligaments and tendons, NOT from the cartilage loss, and our treatment strategy targets both issues. He is also convinced that the loss of cartilage is in fact due to ‘loose’ ligaments, which are in turn caused by a lack of collagen molecules in these ligaments (unhealed damage). So, stem cell treatments address only one of the two major causes of joint pain in ‘bone on bone’ joints, and probably the more minor of the two causes, while PRP addresses both causes. The excellent results obtained by basing our treatment strategy on thoroughly treating both causes of pain in patients in whom total joint replacement has been recommended, lends supports this idea.
While stem cell treatments do produce good clinical results in patients with ‘large joint’ cartilage loss (knee, hip, shoulder), there are two concerns about using this treatment strategy: First, THE COST. If equivalent, much less better, results can be obtained by using a treatment strategy that is a fraction of the cost, why not fully explore the much less expensive option? Secondly, in a situation where cartilage has been lost, and the primary effort is to provide a nice, shiny new layer of cartilage, one must also ask what is likely to happen to this new, expensive layer of cartilage going forward? I would gently suggest that in all likelihood, the same thing will happen to this new layer that happened to the original cartilage. Unless the ligament laxity that caused the initial cartilage loss is successfully addressed, results will likely not be long-lived. Dr.Johnson would simply point out that he has not seen a single patient with significant cartilage loss (and over five hundred of his patients have fallen into this category) who does not also have demonstrable ligament laxity of the anterior cruciate ligament, and likely other ligaments. It is emphasized that most Orthopedic surgeons and other physicians who offer stem cell treatment, and PRP treatment, are apparently not aware of the role of the ligaments in causing either pain or cartilage loss (they assign the cause of the damage and the pain to an inflammatory process called ‘arthritis’…which has largely been discounted by recent research), and their treatment strategy—simply inserting either stem cells or PRP in the joint capsule, in conjunction with treatment with anti- inflammatory medication—reflects the belief that all of the symptoms are arising from a combination of cartilage loss and joint inflammation. This treatment strategy would be likely to produce results with far less than 100% relief of symptoms—which research studies clearly confirm—and the results that are produced will probably diminish over time— which research studies also confirm.
Again, simply putting stem cells into the knee capsule will have no effect on ligament length, strength, or symptom production, and to the extent that this ligament mechanism for symptoms remains unrecognized by the practitioner, the patient’s actual pain sources will remain untreated.
Let us hasten to add at this point that Dr. Johnson does stem cell treatments, and he does believe that they have a role in certain patients, particularly those in whom the connective tissue healing system is functioning poorly or is unavailable due to other medical conditions. But he also believes that PRP, and even Dextrose Prolotherapy, which does an excellent job of treating a very high percentage of these patients, would reasonably be ‘first line’ therapy, with stem cell treatment, or total joint replacement, reserved for the small percentage of these patients—less than 5%—that do not respond adequately to these ‘first line’ options.
8. What are the risks of Platelet Rich Plasma?
Fortunately, the risk/benefit ratio (potential of benefit versus the possibility of adverse events) for Platelet Rich Plasma is similar to Prolotherapy. While nothing is risk-free in medicine, both of these treatment options have an extremely low risk of adverse events. Platelet Rich Plasma per se has essentially no risk, since it is simply the patient’s own blood products concentrated, then given back to the patient. And the effect that is desired, triggering of connective tissue healing, is the most natural of body processes. There are rare occasions where PRP produces a ‘very enthusiastic’ triggering of the healing process, causing significant temporary symptom increases. Triggering of the connective tissue healing process produces some discomfort most of the time, as the chemicals released by the immune/healing system are irritating to the tissues, and particularly to the already-damaged nerve fibers in tissue that are already producing pain. So patients often feel some ‘uptick’ of symptoms in the first few days following treatment. But on rare occasions this becomes quite uncomfortable, and may prompt temporary administration of pain medication.
One of the risks of any ‘skin penetration’, by needle or surgery, is infection. One of the benefits of using Platelet Rich Plasma is that, in addition to triggering healing, it has been shown in research studies to be an outstanding antibiotic agent. While the risk of infection due to needle puncture is quite small, it would be expected that this risk would be further reduced if PRP is used.
9. Is PRP the best option for treatment of joint pain?
A strong case could be made that PRP is the best overall choice for treatment of most painful joint conditions (for everything except rheumatoid arthritis, gout, infections, or collagen-vascular diseases like psoriatic arthritis). This would include patients in whom total joint replacement has been recommended. This is because PRP addresses the most important cause of pain in most painful joints—the ligament and tendon structures—and also the most mentioned cause of joint pain, which is loss of cartilage. And it also addresses the most important unrecognized factor, which is the ligament laxity that is allowing abnormal abrasive forces within the joint to cause whatever cartilage damage is noted.
PRP is the most effective and powerful triggering strategy for the connective tissue healing system, which produces new collagen molecules to strengthen ligament and tendon structures, which when adequate additional strength is produced in ligaments and tendons will stop stretch induced small fiber nerve damage, which will then eliminate both tenderness and symptom production in these structures. And perhaps most important in the long run, in addition to resolving pain from these structures, returning these structures to adequate tensile strength and correct length corrects the dynamic that caused damage to the cartilage surfaces to begin with. As mentioned above, it has been shown that the growth factors released by the white cells are capable of growing new cartilage, and we know that stem cells are active in this regard.
So PRP, when administered based upon an understanding of the various factors involved in creating symptoms, cartilage loss, bony changes, and even Baker’s Cysts, can produce excellent results in this patient population. It is capable of addressing every factor that causes symptoms, and of reversing the factors that cause cartilage loss and bony changes. So PRP not only obtains excellent short term results, but the results obtained with PRP can reasonably be expected to be very long-lasting. We have found in our own patient population that, absent a specific re-injury, our knees treated with Platelet Rich Plasma have a higher percentage of being 100% pain free four years after treatment than one year after treatment. What does this mean? That we were able to reverse the factors that caused these knees to deteriorate, and the knees actually continued to repair themselves effectively ongoing, and further reduce symptoms.
10. 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(link to video presentation). 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 notcoming 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 not coming 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?