PROLOTHERAPY FAQs
SYMPTOMS
Following a Prolotherapy treatment, people experience a wide variety of symptom change, and discomfort from their own healing system. The sensation of aching and fullness from the injections themselves are gone in a few minutes. Some people feel ‘better’ in the days following treatment. Most feel their usual range of symptoms.
Any ‘uptick’ in symptoms the next day is actually due to the patient’s own healing system. We are creating the equivalent of a ‘sprained ankle’ in the treated area. A sprain hurts worse the next day and the day after than the day of the accident. This is due to the chemicals that are released by the healing process. These often cause pain in addition to that of the actual injury. People do not always feel ‘more pain’ following treatment, but if they do, this is good evidence that their healing system is ‘triggering’ with the chemical combination that was injected, and this is a good thing. This system may also be triggering effectively if no additional pain is felt. At times, the ‘immune flare’ felt after treatment continues more than a couple of days, sometimes even for a month. This is very uncommon, and it usually happens only once during a course of treatment when we see it, but sometimes people return for their one-month followup having ‘felt worse’ the whole month. This seems to happen because the immune system has a more enthusiastic response than usual, and this will often result in a larger ‘improvement’ than usual once the immune response ‘calms down’. We can add some additional Sarapin at the next treatment in the Proloferant solution. This will usually shut down the ‘discomfort-causing’ process.
Complications following Prolotherapy treatment are, fortunately, extremely rare. But any medical intervention is capable of causing a complication. Issues which might occur in the treated area were discussed at the initial visit, and made available in writing. While these events are extremely uncommon, it is important to identify any potential problem as soon as possible. Of course, if there is any ‘unusual’ severe pain, or redness and swelling in a treated area, or fever noted following a treatment, please call the office and let us know. Infections are extremely rare following this treatment, but they are a possibility, and the sooner they are identified and treated, the better. If the ribcage or thorax was treated and there is any trouble breathing noted, call the office immediately and go to the nearest emergency room. If the spinal area was treated and there is a new and severe headache noted, that is worse when upright but which gets better when supine, call the office.
What everyone wants to see, obviously, is ‘improvement’ in symptoms—something changing that is ‘outside’ their usual range of symptoms. In addition to feeling ‘less pain’, or being ‘more active before the pain starts’, this can mean ‘sleeping better’, better range of motion, more strength or stability, fewer referred symptoms or headaches…basically any change that is noted during the month after the first treatment is important to bring to our attention. Most of the new collagen is made during the second two week period after a treatment, so often this is when improvement is noted. It is not uncommon to hear people report feeling better during the first ten days, then having their ‘usual’ symptoms recur during the fourth week, just before seeing us again. This pattern also means that the healing system is ‘triggering’.
It is also important for us to know if ‘nothing at all changed in any way’. This means that the chemical mixture did NOT trigger the person’s healing system, and we will need to alter that mixture going forward. This does NOT mean that Prolotherapy per se will not ‘work’, just that we either need a new chemical mix to adequately stimulate their system, or even on occasion that their healing system is functioning so poorly that we need to diagnose and remedy a systemic problem before we can obtain the desired results.
One of the defining characteristics of connective tissue related pain is that it fluctuates widely, in intensity and in location (if multiple sources are present). People who have this problem are already very familiar with these fluctuations. This symptom variation is often a prominent part of the treatment course as well. People will note improvement in symptoms at times, then they will note bad days, bad week, and occasionally a bad month, during a several month course of treatment. People are encouraged when symptoms are improving, but we often get calls and comments when the symptoms flare up again ‘wondering if this stuff is really working’. The most important determinant of the success of this treatment is whether or not the healing system is ‘triggering’. We focus on symptom changes over the first treatment or two, to determine whether this is happening or not. Even subtle changes in symptoms can mean that the patient is getting a very acceptable clinical response. And if they are not, we begin trying different solutions, and/or move to evaluation of the healing system per se.
For most people, their ‘baseline’ symptoms have been fluctuating in a certain ‘range’ of good days and bad days. During the course of treatment, they will begin to have more ‘good’ days, fewer ‘bad’ days. It may take more activity to ‘cause’ the worst pains. Recovery from a symptom flare after increased activity may be much ‘faster’. Sleep may improve. People may begin to feel more energetic as their burden of pain begins to lift. Stability in joints may be noticeably better. Range of motion and flexibility may improve. Headaches and other referred symptoms may begin to wane, or to disappear. Toward the very end of the course, symptoms may even be ‘intermittent’—there may be days that are entirely symptom free. At the next visit we will examine carefully to see if there are any remaining markedly tender structures. If there are, these should be treated, but if there are prolonged symptom-free intervals, the course is almost complete.
One of the most important things I have learned in treating the thousands of patients we have seen, is that if we can noticeably improve symptoms at any point, we are triggering healing. If we are triggering healing, the symptom fluctuations along the course of treatment do NOT mean that the patient is ‘going backward’, or the the treatment has ‘stopped working’. Instead, tensile strength in these structures will eventually increase to the point that the ‘stretch’ will stop, the nerve damage will heal, the tenderness will resolve, and all other symptoms will resolve. But, until healing is COMPLETED, symptoms can vary widely and ‘upticks’ can be ‘as bad as the patient has ever had’. Envision an individual connective tissue structure that is ‘non-loadbearing’ as that cable that ‘stretches’ under load. The healing system is building wires back into the cable progressively. But, as long as the cable is capable of stretching under load, until the job of strengthening is fully completed, the remaining ‘stretch’ is very capable of yanking on damaged nerve fibers, or damaging new ones, and causing symptoms that are just as bad as the patient has ‘ever felt’. This is annoying to the patient, but it does not mean that the treatment ‘is not working’, and that it ‘will not fix the problem’: it simply means that the patient triggered the ‘strain gauge’ in a few structures, loaded them until they stretched, aggravated some nerves, and paid the price…just like they were doing before treatment started.
CONDITIONS TREATED
Injury scenarios…sports, work, recreation, wear and tear, accidents, and any other situation where abnormal forces are applied to the body and pain results. Virtually all of these situations involve symptomatic, and healable, connective tissue damage, which can include damage to menicsus, labrum, tendons (like the rotator cuff tendons and may others), ligaments (like the ACL, sacroiliac, and many others), fascia and periosteum (like ‘shin splints’). Almost any ongoing muscle malfunction more than six weeks after an initial injury, though felt ‘in the muscle’, and usually associated with tightness of the muscle or spasm, is actually due to nearby tendon or ligament damage. Many sports injuries for which arthroscopic surgery, elbow surgery, and ankle surgery is recommended can be successfully treated without surgery.
Many painful conditions of the spine for which fusion is recommended. (read Dr. Johnson’s personal story)
Skeletal abnormalities that put additional ‘stress’ on certain Connective Tissue structures (scoliosis, hip socket malformations, etc.) produce symptoms that are almost always arising from connective tissue structures which do not ‘show up’ on imaging. This cause of pain is commonly overlooked during ‘standard’ evaluations.
‘Degenerative’ conditions involving discs, cartilage, and bony structures almost always involve ligament damage and ‘looseness’ as the cause of damage/ ‘degeneration’ of the structures. This ligament damage is generally the cause of ALL of the symptoms that are usually ‘diagnosed’ as being due to the ‘degeneration’. This includes the condition that is generally called ‘osteo-arthritis’, and includes situations termed ‘bone on bone’ based on imaging studies. In almost all of these situations, the connective tissue structures are where the pain is actually coming from, and healing this damage results in excellent long term results.
Any condition with an ‘itis’ as the last four letters. Tendonitis, bursitis, costo-chondritis, epicondylitis, osteo-arthritis, plantar fasciitis, tenosynovitis. Almost any condition which for which people experience transient symptom relief with an anti-inflammatory medication or corticosteroid can be resolved long-term by Prolotherapy treatment. Virtually any condition associated with ongoing or intermittent muscle malfunction—spasm, ‘trigger points’, and tightness, or weakness, loss of range of motion and pain with activity—is being caused by small-fiber, stretch-induced nerve damage in one or more connective tissue structures. If you cannot ‘stay in adjustment’ following Chiropractic care, this is in all likelihood due to healable connective tissue damage. Virtually any painful condition which would be treated with epidural steroid administration, radio-frequency nerve ablation, or physical therapy is also treatable with Prolotherapy with a very high, long-term success rate.
‘Undiagnosed chronic pain’ is often actually caused by the connective tissue damage mechanism described above (read about Connective Tissue Damage and Pain). It is easy, and inexpensive, to determine whether or not unhealed connective tissue damage is playing a role in a patient’s symptoms.
Post-operative pain is commonly arising from connective tissue, and this phenomenon is not usually diagnosed by surgeons or other practitioners. This pain is commonly ‘diagnosed’ as due to ‘scar tissue’, ‘a nerve pinch at another level’, ‘another disc that is symptomatic’, etc. It is certainly worth ruling out unhealed connective tissue damage as the cause of such pain before proceeding with ANY other intervention.
Almost all work-related and trauma-related pain in necks, backs, and joints is caused by healable connective tissue damage.
Almost all ‘postpartum’ back pain and coccyx pain, and pelvic floor dysfunction and pain are arising from connective tissue structures which respond to Prolotherapy with a high success rate.
Many headaches, migraine and other types, can be improved or cured by Prolotherapy, particularly when there is a history of neck trauma or ongoing neck symptoms.
This list is only partial, but will give you some idea of the many ‘faces’ of unhealed connective tissue damage, and the versatility of this treatment in addressing the many possible presentations of this pathology.
Joints and Areas
Head and occiput, TMJ, many facial pains and headaches, cervical pain and spasm, pain across the top of the shoulders, shoulder blades, and between the shoulder blades, (often incorrectly called ‘trigger points’), thoracic spine and costa-transverse joint (where ribs and vertebrae join), shoulder pain, including rotator cuff tears and labrum tears, symptoms radiating into shoulders, arms, and hands diagnosed as due to nerve pinch in the neck or disc problem in the neck (most of these symptoms are actually arising from the ligament structure, though an actual ruptured disc with visible nerve root compression, resulting in profound symptoms in the upper extremity, IS a surgical problem), elbow pain, including ‘golfer’s’ and ‘tennis’ elbow, ligament injuries for which ‘Tommy John’ operations are recommended, forearm, wrist, thumb (including ‘arthritis), hand, and finger symptoms (if you have been told that you have ‘carpal tunnel’, but have a ‘negative’ nerve conduction velocity test, you may well have symptoms arising from connective tissue), lumbar spine (including many situations where various disc problems, spinal stenosis, spondylolisthesis, sciatica, and arthritis are diagnosed), sacroiliac joint/ligament, and ligaments of the posterior and anterior pelvis (all of which are commonly associated with muscle malfunction—‘back locking up’, ‘pelvic tilt’, spasm, weakness, or limp), hip pain (with or without imaging evidence of cartilage loss or labrum tear, particularly when a ‘nerve pinch in the spine’ has been proposed as a cause, and an epidural steroid injection has been proposed as treatment), thigh and ilieotibial tract pain, hamstring and ‘groin muscle’ ‘pulls and tears’ that produce ongoing or recurrent symptoms, knee pain, with or without an ‘x-ray’ diagnosis (including cartilage loss, meniscal tears, ligament and tendon injuries), ‘Baker’s Cyst’, ’jumper’s knee’, foot and ankle pain (including that proposed to be due to ‘bone on bone’, ‘scar tissue’, ‘bone spurs’ plantar fasciitis, or ‘Morton’s Neuroma’,achilles tendon pain, and pain associated with bunions. This is a partial list of conditions and previous ‘diagnoses’ in patients who had symptoms successfully treated in our office. A complete list would be longer than you want to take the time to read. Bottom line: connective tissue damage is a common, and commonly mis-diagnosed, cause of moderate to severe body pain and dysfunction. Ruling this cause out before major Orthopedic and spine operations might be a good idea.
Structures:
Ligaments: a partial tear noted on films, or tenderness and pain not associated with imaging findings. Prolotherapy cannot treat a completely severed ligament or one that is completely torn from its attachment to the bone. One ‘asterisk’ is that ACL damage may be misdiagnosed as a ‘complete transsection’ on film when it is in fact only a partial tear. The ACL has a complex shape and it is often not seen in its entirety even when it is completely normal on MRI. We have seen several patients who had a ‘complete ACL tear’ read on film who had successful treatment with Prolotherapy. Ligament damage in the low back and neck often produces muscle malfunctions which may be interpreted as the ‘primary pathology’ and treated with massage and Chiropractic treatment for long periods, with transient improvement, but eventual recurrence, of symptoms. Any ‘ongoing’ muscle malfunction generally represents ligament and/or tendon damage. And what about the allegation made by some healthcare professionals that ‘ligaments do not heal’ due to a poor blood supply. This assertion is made by people who do not watch such healing occur on a daily basis in large numbers of people based on their misconception of how the healing system ‘works’.
Tendons: a partial tear noted on films, or tenderness and pain not associated with imaging findings. These injuries are often associated with spasm of the muscle served by the tendon, or with laxness of weakness of this muscle. A tendon that is completely severed or torn from its attachment to bone cannot be successfully treated with Prolotherapy.
Meniscus and Labrum (shoulder and hip): These are ‘fibro-cartilage’ structures, made of both collagen and cartilage. A tear can be ‘healed’ with a collagen bond, just like a cut in the skin, if the healing system is properly stimulated. Pain due to tearing of any of these structures can be eliminated with a high success rate by Prolotherapy, but there is one other element that is important to understand: these structures tore in the first place because there was abnormal movement of the bones in the joint. This means that the ligaments were stretchable and loose, which virtually always means that those ligaments are also a significant source of symptoms, and one that does not often ‘show up’ on films. This is why people often have pain following arthroscopy to ‘repair’ a damaged meniscus or labrum, and it is also why there is a high risk of ‘recurrent tearing’ of these structures—because the underlying situation that caused the tear to begin with has not been identified and successfully treated. I have treated dozens of patients with meniscal and labral tears over the last ten years. I am not aware of a single patient who has had a ‘new’ tear following treatment, nor has a patient, to my knowledge, required surgical treatment following Prolotherapy. This certainly could happen, but that it appears not to have happened suggests that Prolotherapy is an excellent treatment choice for these problems. In virtually all of these patients, there were multiple connective tissue structures, in addition to the ‘film-identified’ meniscal or labral tear, that required treatment.
TMJ: One of the first uses of Prolotherapy was in tempromandibular joint malfunction. Dr. George Schultz published a paper in the 1930’s after successfully treating a large group of such patients. The TMJ is also a ‘fibrocartilage’ structure, but it is usually the sole culprit causing symptoms in contrast to the situation detailed above for the meniscus and labrum, when other structures are almost always causing a portion of the symptoms.
Cartilage: Both Dextrose Prolotherapy and PRP have been shown to regrow cartilage in scientific studies. While this is the ‘main’ reason that a stem cell treatment is done, to address ‘bone on bone’, as mentioned above, the loss of cartilage is usually not the main source of symptoms—it is the ligament structure which allowed abnormal movement within the joint, ‘rubbing off’ the cartilage. If you make a shiny, and very expensive, new layer of cartilage, but do not address the issue that caused the cartilage to disappear in the first place (and no, this was not caused by ‘arthritis’, it was caused by mechanical forces), what do you think will happen in the next few years to your ‘new’ cartilage? We have looked out four years following treatment at some of our knees (in which knee replacement was recommended, so these were ‘severe arthritic’ knees when we started treatment). Absent a re-injury, this group of knees had fewer symptoms reported at four years than at one year following treatment. Meaning, our ‘different approach’ did address the dynamic that tore up these knees to begin with, which is the loose ligaments. Would this ‘different approach’ make a difference for you? Stem cells are an option to treat knees, hips, and other joints, to be sure. I am trained to offer this treatment. But I rarely do, because I do not need to do so to get the results that my patients desire—and receive, much more economically.
Muscle tears: the muscle cells are supported by a collagen meshwork. When a muscle is ‘torn’, this meshwork is also torn, and it must heal before the muscle can undergo heavy use. Prolotherapy can accelerate the healing process in current tears (in the case of sports injuries), and can generally address pain and dysfunction arising from prior tears. These ongoing ‘muscle tear’ symptoms are often also associated with undiagnosed tendon damage.
Fascia and periosteum: this covers a wide array of conditions, from fibromyalgia to shin splints to postpartum abdominal muscle laxity. These structures are also almost entirely made of collagen, and respond just like the ligaments and tendons. In essence, any situation where a combination of tenderness in connective tissue, and pain or muscle malfunction is seen, represents small fiber nerve damage within the connective tissue structure that is tender, and this can generally be rectified by triggering connective tissue healing (Prolotherapy).
Other Symptoms and Conditions:
One of the fascinating things about connective tissue damage that begs for explanation is its ability to produce ‘distant symptoms’. There is no explanation in the medical literature that explains how this might possible happen, except my paper on the Connective Tissue Damage Syndrome (Journal of Prolotherapy, Feb. 2009). It does make sense that damaged nerve fibers, firing impulses into the nervous system, might produce symptoms at a distance. These ‘distant symptoms’ include muscle malfunction (spasm, weakness, trigger point formation, abnormal tension, limping, and limited range of motion); somatic referred symptoms (burning, aching, throbbing, numbness, tingling) down legs and arms, on occasion to hands and feet; and autonomic referred symptoms, like migraine headaches, the Barre Lieou syndrome, voiding dysfunction, etc.
Barre-Lieou, headaches, ‘fibromyalgia’, ‘sciatica’, often cause has been previously misdiagnosed, or undiagnosed.
- Actual inflammatory disorders, like rheumatoid arthritis and other ‘collagen- vasular diseases’.
- Nerve damage/injury—stroke, severed or damaged nerve fibers following accident or surgery, or an actual neuropathy. Some numbness and tingling in hands and feet is incorrectly diagnosed as ‘neuropathy’ when it is in fact arising from stretch-induced nerve damage in ligaments and tendons. The nature and distribution of these ‘referred symptoms’ are easy to differentiate from an actual ‘neuropathy’ in the office.
- True ‘sciatica’, which is quite rare and which generally puts people in bed and on narcotics. The nature and distribution pattern of these symptoms can easily distinguish ‘true’ sciatica from referred connective tissue damage symptoms.
- Actual spinal stenosis. Actual spinal stenosis causes problems holding urine or feces, and causes numbness in a ‘stocking’ or ‘pantyhose’ distribution in the lower extremities (the entire foot, or the entire leg, instead of in part of the lower leg and foot, for instance), weakness that causes people to have trouble walking without falling, and muscle atrophy. If the problem is simply pain in the back and scattered symptoms down the leg or legs, then there may well be a connective tissue problem causing ALL of these symptoms.
- Joint damage so severe that, not just the cartilage, but the bones of the joint surface are badly damaged. This is an indication for a joint replacement.
HEALING SYSTEM
We identify healing system problems commonly in patients who have:
a.) extensive, body-wide pain and tenderness (often ‘diagnosed’ as having ‘fibromyalgia’, ‘lab-normal’ rheumatoid arthritis, or other ‘collagen-vascular’ diseases with ‘normal’ laboratory tests, or ‘multi-site connective tissue symptoms without a trauma history’(‘fibromyalgia-type symptoms that are scattered around the body, but not ‘everywhere’), or a history of multiple Orthopedic operations, or widespread ‘degenerative disease’ in discs, cartilage, and other joint structures.
b.) early recurrence of symptoms (in the first year or two) in a structure that was completely treated with Prolotherapy in the absence of an injury.
Because the medical community, for the most part, does not identify your aches and pains, and tissue damage that is visible on imaging studies, as due primarily to a ‘lack of healing’. Current medical ‘teaching’ emphasizes that these problems are due to ‘inflammation’ (aka ‘osteoarthritis’—in which pain and joint destruction has been shown by medical researchers to NOT be due to an actual inflammation), or to ‘degenerative disease’ (which acknowledges ‘unhealed damage’, but does not focus any attention on the healing system per se as a possible factor in causing this evident progressive ‘damage’—-which is a remarkable display of lack of common sense….I know, don’t get me started…). Or, your symptoms are due to disc bulges, nerve pinches, ‘primary nerve malfunction’ (fibromyalgia), scar tissue, bone spurs, or myriad ‘other things’…except unhealed connective tissue damage leading to stretch-induced small fiber nerve damage inside particular connective tissue structures, which are easily located because they are quite tender to touch. Again, we are back to the ‘diagnostic question’… And reiterating the fact that, even in the absence of injury, you break and replace every molecule in every ligament and tendon about ever seven years, so your body has to do a LOT of ‘healing’ (collagen production) on a daily basis. You do not need a research study, just common sense, to predict what would happen if this maintenance collagen production system is NOT functioning properly. And, we get to see what happens in the lives of a large number of our patients when problems in this system ARE identified and rectified, which is a phenomenon that most physicians DO NOT have the opportunity to see.
Again, let us briefly review how this system works. Fibroblasts make collagen. They do not make collagen unless they are told to do so. The ‘telling’ consists of a group of chemicals called ‘growth factors’(40 some-odd chemicals that act in concert, and which are housed in White Blood Cells (WBS’s) and in platelets). So, anything that impairs WBC function, or ‘distracts’ the WBC’s can effect this maintenance healing. Four things exert a powerful enough effect on WBC function to significantly effect healing in our patient population: a.) chronic infections—Hep B, C, D; Lyme disease; various other systemic viral infections; systemic candidiasis; and chronic bacterial infections. b.) significant food allergies/leaky gut syndrome. c.) Frequent use of NSAID’s (Advil, Aleve, Mobic, Celebrex, etc.) and corticosteroid medications (including those used to TREAT these painful problems, as well as post-transplant immunosuppression, treatment of auto-immune skin diseases, GI tract diseases, etc.). d.) Chemotherapy for malignancy. This effect generally wanes over time following cessation of treatment, but on occasion long term healing impairment effects are noted.
There are three hormones which exert significant effects on healing. The most important is Testosterone. Connective tissue healing is directly and strongly Testosterone dependent. This is unfortunate, because the testosterone levels in the general population have been trending strongly downward due to a vast array of environmental factors over the last 70 years—glyphosate (Roundup) directly affects Testosterone production, with permanent effect from limited exposure, hormonally active things to which we are exposed (birth-control pills which cannot be ‘filtered out of’ community water supplies, estrogenic properties of may common plastic products, including the flexible phthalates which line water bottles and are used extensively in hair-care products, for example)—which have produced in 50 year olds an average Testosterone level that is ONE THIRD the level in 1950. Today, the average 50 year old has a level of around 400. In 1950, that level was 1200, with an upper limit of ‘normal’ of 2400. We almost never see a level of 2400 even in teenagers today. So, is it any surprise that THEY were able to win the WWII, while today people are lining up in vast numbers to get joints replaced and backs and necks fused?
Testosterone levels that are below a certain threshold necessary for optimal connective tissue healing cause problems in both males and females. About 70% of females in our practice, including those diagnosed as having ‘fibromyalgia’, have a single factor responsible for ALL of their problem: a low testosterone level. A female needs a testosterone level in the upper 3/4 of the ‘normal female range’ for optimal healing. If this level is not present, this situation is easily remedied by topical bio-identical hormone replacement in most women. In men, the situation is complicated by the current ‘normal’ range when testosterone is tested by family doctors and others who are not aware of the shift in community levels. What does a ‘normal’ lab test mean? Is ‘normal’ a measure of the FUNCTION of what is being measured? No, it is not. It is a measure of statistics. Basically, for any laboratory test, 1000 levels are obtained from a random population. The middle 92% are deemed ‘normal’ (two standard deviations from the mean, in ‘statistical talk’), and the upper and lower 4% are called ‘abnormal’. This presupposes that only 4% of a population has a low enough level to effect function, and this correlates amazingly well with PHYSIOLOGIC FUNCTION in a large number of tests. But not all, and Testosterone is the poster child for this phenomenon. But your primary care physician, or even your Urologist, may not be aware of this. I am, because I am a Urologist who practices for 16 years in a hospital with a HUGE population of ‘heart patients’ (St. Thomas in Nashville), so I probably know more about Testosterone, and how it interacts with cardiovascular disease, for instance, than even the average Urologist. To restore optimal connective tissue healing in males, levels over 700 are generally required. Sometimes, over 1000. If you are 50 years old and your internist saw a Testosterone level of 1250, he would probably have a stroke. But, that is right in the middle of the ‘historical normal’ level. Question: what do you think your body is designed to ‘run best on’—a level in the middle of an ‘unmolested’ population’s levels, or a level right in the middle of a ‘depleted’ population?
What about the risks of Testosterone replacement? That discussion is beyond the scope of this general essay, and should be conducted in person with anyone considering this treatment. However, in general, given the above, what ‘risk’ would there be of having a ‘natural’ hormone in levels that are in the ‘historical normal range’? Did people in the 1950’s have more prostate cancer? No. Did they die more commonly of cardiovascular diseases? Yes, but they also smoked much more than the current population, and they ate a diet that was pretty much designed to kill people at a young age. This is the part of the discussion that needs to happen in person, but there is evidence that a higher testosterone level is actually protective in terms of cardiovascular risk, while a high estrogen level poses the actual risk for both cardiovascular problems and malignancy. In some men, estrogen levels can be increased by giving Testosterone, so this factor may be important to examine. Again, if you are reading this, I am making NO recommendation regarding your personal treatment unless you are my patient and have been fully evaluated, and have had a course of treatment formally recommended. And even in these situations, this treatment, while a good idea in certain people, is not essential, but is an option that a patient may choose to pursue, or may choose not to pursue, at their discretion in light of the available facts and studies.
These are Thyroid Hormone and Human Growth Hormone. Thyroid hormone does not ‘directly’ affect the healing system like Testosterone does. It controls the ‘energy level’ in the WBC’s, and in all other cells. If the WBC’s have insufficient energy for optimal performance, they will use the energy they have to keep you alive and neglect connective tissue maintenance healing. If you have ‘cold’ hands and feet, if your ‘early morning’ temperature is less than 97.8 on a consistent basis, you might have a functionally low Thyroid Hormone level (regardless of having ‘normal’ values on blood testing). Thyroid Hormone testing is another place where ‘normal’ does not necessarily mean ‘fully functional’.
Human Growth Hormone (HGH) is released in deeper stages of sleep. If you have a severe sleep disorder, or if you have had irradiation of the pituitary gland for medical treatment, you might have a low HGH level, and this might effect your maintenance healing. This is a situation which should be diagnosed and treated by an Endocrinologist. The testing is a bit complicated, and the treatment is long-term and expensive, but may be necessary in rare situations to get the healing system working properly.
There are a variety of nutritional issues, toxicities, and other factors which can, more rarely, impair maintenance healing. I can check a Testosterone level, and start replacement if a patient desires. For all of the rest of the potential problems, including food allergy/sensitivity, Thyroid and other hormone issues, toxicity and nutrition, we refer to providers who have expertise in these realms. This is not your average ‘family doctor’ (though some of them may have such interests and expertise). It is often a challenge for people seeing us from other states to find practitioners in their area who can do a good job of performing such evaluations. And many of patients ‘regular doctors’ look at them like they are out of their minds when they start discussing the connection between their Testosterone or Thyroid function and their body aches and pains. Such things are not common knowledge based on current medical training. We are back, again, to the ‘diagnostic problem’. If your doctor tells you that ‘Testosterone cannot cause such problems’, fine. Ask them to tell you what DOES cause such problems, and ask them to use their understanding to fix the problem that they think you have. If they cannot fix your problem based on ‘their understanding’, then I am not sure I would take their ‘objections’ too seriously. The beauty of the concepts detailed above is that they DO work to fix real, and serious, problems in a high percentage of real people. Because of this, I am confident that this understanding of the basic disease process, the manner in which this process is reversed (symptoms cured), and the factors that ‘set up’ these problems to occur, are substantially correct.
TREATMENT
The staff will apply a powerful topical anesthetic to the areas which might be treated. We cleanse the skin thoroughly with a combination of Hibiclens and Alcohol. We put electrical stimulator electrodes in the vicinity of the treatment, and turn up the current to a level that is strong, but not uncomfortable. We then proceed with treatment.
The key is to insert proliferate solution in every symptom generating structure. At the end of the treatment, the patient may be ‘field tested’ to assess for additional symptom-generating structures that were not identified on the initial exam, or for structures which were not fully ‘soaked’ with proliferant and which need additional treatment.
Does the treatment hurt? Yes. But the problem that brings you to see us also hurts, often a lot. So most people who see us are already ‘handling’ quite a bit of pain and the treatment is not that much ‘worse’. We work very hard to minimize the discomfort and to make the patient as comfortable and as relaxed a possible during the process. We also see an interesting phenomenon in many people: as we inject the ‘spots’ where pain has actually been coming from (which are often different than what people have been ‘told’ is the source of their symptoms—the ‘spot’ is actually in the sacroiliac ligament instead of their ‘diagnosed’ lumber disc, for example), people will say, “There it is, that is THE spot..no one has ever found that before!” While treatment is uncomfortable, it is comforting to know that we can actually find your pain-causing structures…and generally resolve your pain.
Although my first Prolotherapy treatment was, for reasons we can discuss in person, more uncomfortable than most treatments I offer, still it was ‘comforting’ to me to feel the doctor ‘hit the spots’ where my pain had actually been coming from, after finding them on examination. That gave me great confidence that he was on the ‘right track’ with his treatment. People who have been treated by other Prolotherapists generally say that our treatment process is ‘more comfortable’ than their previous experience, in addition to being more thorough. Holley and I have had numerous structures treated with Prolotherapy over the last decade. We live very active lives, and are accumulating birthdays at an alarming rate…. We have paid very careful attention as we have been receiving treatments to adapt our techniques to minimize discomfort. You get to benefit from our extensive experience on ‘the other end of the needle’.
The endpoint of treatment is that a patient can return to full activity, doing the activities that they desire, symptom free. If we can trigger the healing system (which we can ultimately do in around 95% of people), and assuming that there are no other major sources of symptoms (which, even in our very broad and varied patient population, is very rare), then we can generally accomplish this. The endpoint of treatment for any given structure is that it becomes ‘load-bearing’, or ceases stretching abnormally under typical body loads. Therefore, the nerve fibers that had been chronically damaged heal, and cease to produce either tenderness or symptoms. Usually many structures are treated in a given patient. Some of these structures finish healing before others, so toward the end of the treatment course it is not uncommon for the treatment size to contract a bit. How do we know what to treat, and what we do not need to treat, at a given visit? We treat only tender structures. Those that have become non-tender can be left alone. We simply continue until we are finished, and this does not comply with any arbitrary ‘schedule’ or patient expectation. Healing systems produce widely varying amounts of collagen with stimulation—some large amounts leading to quick responses, others smaller amounts, leading to progress that can be ‘moderate’, ‘slow’, or ‘very slow’. If the pace of healing is not optimal, we will usually explore options to stimulate the system more strongly, and perhaps look at the healing system per se more carefully.
We track progress with several questions on the patient follow-up form, and with a follow-up pain and symptom diagram. These are extremely helpful in caring for you, for decision making that allows us to render the best care possible. We would greatly appreciate it if you would take these questions seriously and give the best answer you can. Symptoms fluctuate, we understand…but your ‘guesstimate’ answers are surprisingly helpful to us. The fundamental question at each visit is, ‘more of same’, or ‘change course in some way’.
The issue that is most disconcerting to patients during treatment courses is the occasional ‘bad’ day or week that occurs just when the patient ‘thought they were getting better’. We spend A LOT of time discussing whether or not the treatment is ‘working’ in light of these symptom variations. The issue is not that WE do not know the answer to that question…the problem is that what the patient is ‘feeling’ does not match what they ‘expect’ to feel if the treatment is ‘working’. If a person understands the concept of ‘load bearing’ and ‘non-loadbearing’ structures, and realizes that, at any point, if enough force is applied to any of these structures to ‘trip the strain gauge’ (stretch the structure to the point that damaged nerve fibers are yanked, or further damaged), then symptoms MAY WELL be as ‘bad’ as they have ever felt, even though they are very close to being completely healed. If patients ‘get this’ concept, and understand that this is normal and, frankly, expected as patients become more active as they are feeling ‘better’, then much anxiety can be avoided. A more detailed discussion of symptoms during treatment will follow in a few paragraphs.
Some people have a large array of painful and symptomatic structures. One reason that people from all over the country seek us out is that we get excellent results with ‘larger’ issues. Our treatments are more precise, and can therefore cover more geography (we do not treat structures that do NOT need to be treated, as opposed to many practitioners ‘template’ approach—where they treat the same set of structures in every back, neck, shoulder, etc.), and we have developed ways to get patients through treatments that are ‘larger volume’ treatments, so that we can cumulatively treat a multitude of structures successfully in a finite amount of time. If you have this kind of problem, the discussion about overall treatment strategy will be quite detailed and take into account physical, logistical, and financial issues.
Whether we are treating half the body, or ongoing pain in a single structure, we can give patients a general idea of the length of the process, particularly after seeing the ‘trajectory’ of healing after a few treatments. But pace of healing and magnitude of injury are unique in each patient, and this process simply requires that our patients have patience.
One of the defining characteristics of connective tissue related pain is that it fluctuates widely, in intensity and in location (if multiple sources are present). People who have this problem are already very familiar with these fluctuations. This symptom variation is often a prominent part of the treatment course as well. People will note improvement in symptoms at times, then they will note bad days, bad week, and occasionally a bad month, during a several month course of treatment. People are encouraged when symptoms are improving, but we often get calls and comments when the symptoms flare up again ‘wondering if this stuff is really working’. The most important determinant of the success of this treatment is whether or not the healing system is ‘triggering’. We focus on symptom changes over the first treatment or two, to determine whether this is happening or not. Even subtle changes in symptoms can mean that the patient is getting a very acceptable clinical response. And if they are not, we begin trying different solutions, and/or move to evaluation of the healing system per se.
For most people, their ‘baseline’ symptoms have been fluctuating in a certain ‘range’ of good days and bad days. During the course of treatment, they will begin to have more ‘good’ days, fewer ‘bad’ days. It may take more activity to ‘cause’ the worst pains. Recovery from a symptom flare after increased activity may be much ‘faster’. Sleep may improve. People may begin to feel more energetic as their burden of pain begins to lift. Stability in joints may be noticeably better. Range of motion and flexibility may improve. Headaches and other referred symptoms may begin to wane, or to disappear. Toward the very end of the course, symptoms may even be ‘intermittent’—there may be days that are entirely symptom free. At the next visit we will examine carefully to see if there are any remaining markedly tender structures. If there are, these should be treated, but if there are prolonged symptom-free intervals, the course is almost complete.
One of the most important things I have learned in treating the thousands of patients we have seen, is that if we can noticeably improve symptoms at any point, we are triggering healing. If we are triggering healing, the symptom fluctuations along the course of treatment do NOT mean that the patient is ‘going backward’, or the the treatment has ‘stopped working’. Instead, tensile strength in these structures will eventually increase to the point that the ‘stretch’ will stop, the nerve damage will heal, the tenderness will resolve, and all other symptoms will resolve. But, until healing is COMPLETED, symptoms can vary widely and ‘upticks’ can be ‘as bad as the patient has ever had’. Envision an individual connective tissue structure that is ‘non-loadbearing’ as that cable that ‘stretches’ under load. The healing system is building wires back into the cable progressively. But, as long as the cable is capable of stretching under load, until the job of strengthening is fully completed, the remaining ‘stretch’ is very capable of yanking on damaged nerve fibers, or damaging new ones, and causing symptoms that are just as bad as the patient has ‘ever felt’. This is annoying to the patient, but it does not mean that the treatment ‘is not working’, and that it ‘will not fix the problem’: it simply means that the patient triggered the ‘strain gauge’ in a few structures, loaded them until they stretched, aggravated some nerves, and paid the price…just like they were doing before treatment started.
There is wide variation in the number of treatments required to fully heal structures in a given patient. The variables are the extent of the injury, the strength of response to a given Proliferant solution, and the capacity of the individual’s healing system when maximally stimulated. Most people can heal most injuries in four to six treatments on average, but some people heal VERY QUICKLY—one or two treatments—and some people heal VERY SLOWLY, needing eight, or ten, or more treatments to heal significant injuries. We will try different strategies when ‘slower’ responses are noted to improve the pace of healing as much as possible. But some patients simply have a modest response to any strength stimulus, and there is no arbitrary ‘limit’ to how many treatments may be needed, or given.
Most people are familiar with the ‘healing cycle’ noted after a major operation. Most people resume ‘full activity’ beginning one month after such a procedure, because this is when the production of collagen molecules, used to heal the wounds, is almost completed. With this ‘healing cycle’, 15% of collagen is made during the first two weeks, 85% during the second two week period following surgery, or injury. Therefore, at one month following a treatment, I can tell what has been accomplished, and what is yet to be accomplished, by treatment. This is why the month interval is generally chosen. Can treatments be given more frequently? Yes. If there is a seven day wait after a treatment, subsequent treatment produces a ‘full’ reaction and a second ‘healing cycle’ that is layered on top of the initial one. If you wait less than seven days following a treatment, the responses ‘blend’ and there is less than a full response to the second treatment. We often have athletes who are preparing for a season, or a competition, or we have people traveling from great distance at great cost, who will get treatments at 7 day intervals. And there is no ill effect from delaying treatment more than a month. Each treatment is a self-contained, independent event, which produces a certain amount of strengthening of structures. One treatment does not ‘depend’ on a former treatment in any way, so there is no clinical problem that results from delaying subsequent treatment. It just takes longer to complete the process.
One principle has become evident: if healing is not ‘completed’, and if a non-loadbearing (tender) structure remains—even though it is ‘stronger’ and the patient ‘feels better’, what do you think will happen over time? Will continuing to use this ‘vulnerable’ structure lead to re-accumulation of small fiber nerve damage? Will this vulnerable structure be more susceptible to further injury? Will this patient be back on the phone to us at some point saying ‘I thought you said this treatment was supposed to produce ‘lasting results’…? Probably.
On the other hand, when people ‘complete’ treatment, and the treated structures are strong enough to handle typical loads, these structures continue to be symptom free unless a.) re-injured or b.) the patient’s ‘maintenance healing system’ is not working. How do we know that we have reached this point? The treated structures cease to cause any of the symptoms for which the patient sought treatment, AND these structures are FREE OF TENDERNESS. Toward the end of the treatment course, symptoms may be INTERMITTENT (meaning you might not have any for a week or two), but some of the structures are still tender, and they are waiting to punish you if you pull on them in just the ‘right’ way. Toward the end of a course of treatment, some structures will become non-tender (load-bearing) before others. We do not treat these structures, only the ones that continue to be tender. And, from this point, very soon all structures will become non-tender. This is one of the principles that ‘makes sense’ in light of understanding the actual mechanism of the pain, and the treatment. And this is one of the main reasons that we have so many 100% ‘pain free’ patients following our treatments…who STAY pain free.
Injury scenarios…sports, work, recreation, wear and tear, accidents, and any other situation where abnormal forces are applied to the body and pain results. Virtually all of these situations involve symptomatic, and healable, connective tissue damage, which can include damage to menicsus, labrum, tendons (like the rotator cuff tendons and may others), ligaments (like the ACL, sacroiliac, and many others), fascia and periosteum (like ‘shin splints’). Almost any ongoing muscle malfunction more than six weeks after an initial injury, though felt ‘in the muscle’, and usually associated with tightness of the muscle or spasm, is actually due to nearby tendon or ligament damage. Many sports injuries for which arthroscopic surgery, elbow surgery, and ankle surgery is recommended can be successfully treated without surgery.
Many painful conditions of the spine for which fusion is recommended. (read Dr. Johnson’s personal story)
Skeletal abnormalities that put additional ‘stress’ on certain Connective Tissue structures (scoliosis, hip socket malformations, etc.) produce symptoms that are almost always arising from connective tissue structures which do not ‘show up’ on imaging. This cause of pain is commonly overlooked during ‘standard’ evaluations.
‘Degenerative’ conditions involving discs, cartilage, and bony structures almost always involve ligament damage and ‘looseness’ as the cause of damage/ ‘degeneration’ of the structures. This ligament damage is generally the cause of ALL of the symptoms that are usually ‘diagnosed’ as being due to the ‘degeneration’. This includes the condition that is generally called ‘osteo-arthritis’, and includes situations termed ‘bone on bone’ based on imaging studies. In almost all of these situations, the connective tissue structures are where the pain is actually coming from, and healing this damage results in excellent long term results.
Any condition with an ‘itis’ as the last four letters. Tendonitis, bursitis, costo-chondritis, epicondylitis, osteo-arthritis, plantar fasciitis, tenosynovitis. Almost any condition which for which people experience transient symptom relief with an anti-inflammatory medication or corticosteroid can be resolved long-term by Prolotherapy treatment. Virtually any condition associated with ongoing or intermittent muscle malfunction—spasm, ‘trigger points’, and tightness, or weakness, loss of range of motion and pain with activity—is being caused by small-fiber, stretch-induced nerve damage in one or more connective tissue structures. If you cannot ‘stay in adjustment’ following Chiropractic care, this is in all likelihood due to healable connective tissue damage. Virtually any painful condition which would be treated with epidural steroid administration, radio-frequency nerve ablation, or physical therapy is also treatable with Prolotherapy with a very high, long-term success rate.
‘Undiagnosed chronic pain’ is often actually caused by the connective tissue damage mechanism described above (read about Connective Tissue Damage and Pain). It is easy, and inexpensive, to determine whether or not unhealed connective tissue damage is playing a role in a patient’s symptoms.
Post-operative pain is commonly arising from connective tissue, and this phenomenon is not usually diagnosed by surgeons or other practitioners. This pain is commonly ‘diagnosed’ as due to ‘scar tissue’, ‘a nerve pinch at another level’, ‘another disc that is symptomatic’, etc. It is certainly worth ruling out unhealed connective tissue damage as the cause of such pain before proceeding with ANY other intervention.
Almost all work-related and trauma-related pain in necks, backs, and joints is caused by healable connective tissue damage.
Almost all ‘postpartum’ back pain and coccyx pain, and pelvic floor dysfunction and pain are arising from connective tissue structures which respond to Prolotherapy with a high success rate.
Many headaches, migraine and other types, can be improved or cured by Prolotherapy, particularly when there is a history of neck trauma or ongoing neck symptoms.
This list is only partial, but will give you some idea of the many ‘faces’ of unhealed connective tissue damage, and the versatility of this treatment in addressing the many possible presentations of this pathology.
AFTER TREATMENT
Following a Prolotherapy treatment, people experience a wide variety of symptom change, and discomfort from their own healing system. The sensation of aching and fullness from the injections themselves are gone in a few minutes. Some people feel ‘better’ in the days following treatment. Most feel their usual range of symptoms.
Any ‘uptick’ in symptoms the next day is actually due to the patient’s own healing system. We are creating the equivalent of a ‘sprained ankle’ in the treated area. A sprain hurts worse the next day and the day after than the day of the accident. This is due to the chemicals that are released by the healing process. These often cause pain in addition to that of the actual injury. People do not always feel ‘more pain’ following treatment, but if they do, this is good evidence that their healing system is ‘triggering’ with the chemical combination that was injected, and this is a good thing. This system may also be triggering effectively if no additional pain is felt. At times, the ‘immune flare’ felt after treatment continues more than a couple of days, sometimes even for a month. This is very uncommon, and it usually happens only once during a course of treatment when we see it, but sometimes people return for their one-month followup having ‘felt worse’ the whole month. This seems to happen because the immune system has a more enthusiastic response than usual, and this will often result in a larger ‘improvement’ than usual once the immune response ‘calms down’. We can add some additional Sarapin at the next treatment in the Proloferant solution. This will usually shut down the ‘discomfort-causing’ process.
Complications following Prolotherapy treatment are, fortunately, extremely rare. But any medical intervention is capable of causing a complication. Issues which might occur in the treated area were discussed at the initial visit, and made available in writing. While these events are extremely uncommon, it is important to identify any potential problem as soon as possible. Of course, if there is any ‘unusual’ severe pain, or redness and swelling in a treated area, or fever noted following a treatment, please call the office and let us know. Infections are extremely rare following this treatment, but they are a possibility, and the sooner they are identified and treated, the better. If the ribcage or thorax was treated and there is any trouble breathing noted, call the office immediately and go to the nearest emergency room. If the spinal area was treated and there is a new and severe headache noted, that is worse when upright but which gets better when supine, call the office.
What everyone wants to see, obviously, is ‘improvement’ in symptoms—something changing that is ‘outside’ their usual range of symptoms. In addition to feeling ‘less pain’, or being ‘more active before the pain starts’, this can mean ‘sleeping better’, better range of motion, more strength or stability, fewer referred symptoms or headaches…basically any change that is noted during the month after the first treatment is important to bring to our attention. Most of the new collagen is made during the second two week period after a treatment, so often this is when improvement is noted. It is not uncommon to hear people report feeling better during the first ten days, then having their ‘usual’ symptoms recur during the fourth week, just before seeing us again. This pattern also means that the healing system is ‘triggering’.
It is also important for us to know if ‘nothing at all changed in any way’. This means that the chemical mixture did NOT trigger the person’s healing system, and we will need to alter that mixture going forward. This does NOT mean that Prolotherapy per se will not ‘work’, just that we either need a new chemical mix to adequately stimulate their system, or even on occasion that their healing system is functioning so poorly that we need to diagnose and remedy a systemic problem before we can obtain the desired results.
Because of the above, we recommend that, even when you feel ‘better’ (and especially when you feel ‘better’), you do not launch into all the projects you have had ‘on hold’ because you felt too bad to do them. You are not as vulnerable, but you are still vulnerable when it comes to creating pain flare-ups. As you feel better, SLOWLY, GRADUALLY increase your activity level. Count on about three months to return to 100% load and activity, once you are beginning to feel ‘a lot better’, not three weeks. If you are involved in recreational weight training, we recommend that you drop your resistance on treated structures to about 40% of what you are capable of lifting, and up the reps. Ideally, stay in 30-50 rep range for resistance. You will feel, initially, like this is a waste of time. But you may be surprised by how effective a workout this can produce. We have had a number of people, including elite athletes, shift to this pattern and away from super-loading structures after finding out how effective this ‘high rep’ strategy can be.
ACTIVITY
Because of the above, we recommend that, even when you feel ‘better’ (and especially when you feel ‘better’), you do not launch into all the projects you have had ‘on hold’ because you felt too bad to do them. You are not as vulnerable, but you are still vulnerable when it comes to creating pain flare-ups. As you feel better, SLOWLY, GRADUALLY increase your activity level. Count on about three months to return to 100% load and activity, once you are beginning to feel ‘a lot better’, not three weeks. If you are involved in recreational weight training, we recommend that you drop your resistance on treated structures to about 40% of what you are capable of lifting, and up the reps. Ideally, stay in 30-50 rep range for resistance. You will feel, initially, like this is a waste of time. But you may be surprised by how effective a workout this can produce. We have had a number of people, including elite athletes, shift to this pattern and away from super-loading structures after finding out how effective this ‘high rep’ strategy can be.
We do want you using the treated structures, as opposed to keeping them immobile and staying ‘off’ them during a course of treatment. Anything that increases blood flow and activity will, in general, promote healing. This includes moderate activity, massage, heating the area with any form of heat, including infrared treatments and ‘cold laser’ treatments, and may include some Chiropractic treatments (being careful to avoid ‘high velocity’ manipulation!). Physical Therapy may be a useful addition, keeping in mind that the premise of Physical Therapy does NOT recognize the reality of vulnerable connective tissue and connective tissue damage. They focus, instead, on the muscles and muscle function. They try to ‘exercise you out of’ the problem by improving muscle strength, balance, and flexibility. If Physical Therapy makes you feel better, all good. If you ‘walk in, crawl out’, if the ‘treatment’ causes increased pain, then it would reasonably be avoided. These ‘increased pains’ seem not to lead to ‘increased healing’ in our patient population.
Oddly, though, I do not mind if you are a little ‘over active’ and you make your symptoms get worse. This almost never means that you have ‘set yourself back’ in the treatment course. This just tells us that we are ‘not there yet’. The goal of treatment is that you are pain free AT YOUR DESIRED LEVEL OF ACTIVITY, not that you are pain-free sitting on the couch watching Dr. Oz. The only way we know whether your structures are strong enough to handle your life is by using them. We can continue to ‘upsize’ these structures to handle any load, from ultimate frisbee to MLB pitching, from jogging to Olympic level running, from puttering around in the garage to playing linebacker in the NFL. So, we DO want you to gradually increase your activity level as you feel ‘better’ during treatment, just use some common sense in light of what is going on in our structures. This is another place where understanding the actual mechanism of the pain-causing process, and how the treatment ‘works’, helps us craft the best strategy, while maintaining peace of mind. The endpoint of treatment is that, with the desired level of activity, structures are free of tenderness and symptoms. This means that the collagen content of the individual structures is now adequate to ‘hold’ any load applied to the structure without any abnormal ‘stretching’ which would damage the indwelling nerve supply. In plain English, healing is now complete.