#2)  Optimal Results Depend on Thorough Treatment

Symptom elimination by Prolotherapy treatment is directly proportional to the percentage of symptom-causing structures that are successfully identified and successfully treated.

Most evaluations by Orthopedic Surgeons and other ‘mainstream’ practitioners are based solely on imaging studies—MRI, CT, and X-rays, and are based on assumptions like ‘tenderness represents inflammation’, and ‘any symptom traveling down into a hip, leg, foot, arm or hand must be a ‘nerve pinch’.  Attempts at diagnosis based on these assumptions, and on imaging study results, often lead practitioners to overlook actual sources of joint, neck, and back pain.  It is no surprise, then, that patients who have been ‘diagnosed’ with this approach have ongoing pain after the ‘diagnosed’ problems are ‘treated’ with ‘standard techniques’ like cortisone or surgery.  Worse, many things ‘show up’ on films, like ‘bulging discs, bone spurs, scoliosis, and cartilage loss’, to which symptoms are incorrectly attributed.  This may lead to operative therapy that might offer only partial pain relief, or may be unnecessary, or may be completely mis-directed.  Many Prolotherapists only partially identify, and partially treat, the entirety of the symptom-causing structures, particularly if they also rely on ‘imaging studies’ to target their treatment.  They will then get ‘some’ relief of symptoms.  At Prolotherapy Nashville, we have developed simple and inexpensive techniques to identify virtually all pain-causing connective tissue structures, many of which are not identified on imaging of any kind.  We understand what it takes to ‘completely’ treat these structures to the point of minimal, or no, symptoms in a very high percentage of our patients.  These results are why we are asked to teach our techniques, and the understanding that produces those techniques, to other physicians.  These results are also why many patients have traveled considerable distances to see us.

#3)  Correct Diagnosis

Proper Diagnosis vs. Common Mis-diagnosis of pain sources:  tenderness in connective tissue, and symptoms arising from these structures are present due to stretch-induced small fiber nerve injury (injury of nerves within the ligaments and tendons themselves).

 The nerve impulses produced by this stretch-induced damage in turn cause pain, tenderness, muscle malfunctions (tension, spasm, trigger point formation, or weakness), and referred symptoms that may be ‘somatic’ (aching, burning, numbness and tingling, etc.) or ‘autonomic’ (migraine headaches, voiding dysfunction, etc.)

Symptoms coming from connective tissue do so because enough collagen molecules are broken, and not replaced by the healing system, so that the ligament or tendon begins to stretch abnormally under normal body ‘loads’.  The nerve fibers that ‘live in’ these structures do not have the ability to ‘stretch’ (like fiberoptic cables:  you stretch, you damage).  Therefore, loss of tensile strength in these connective tissue structures leads to onset of symptoms, due to stretch-induced small fiber nerve damage.  The way to remedy this problem is to get the body’s healing system to graft more collagen molecules back into the structure(s) in question, stop the stretch, and allow the nerves to heal.  In brief, this is ‘what is wrong’ and ‘how Prolotherapy works’.  Most physician training (Orthopedic Surgery, Family Medicine, Rheumatology, Neurology and Neurosurgery, etc.) does not make the physicians aware that connective tissue (ligaments, tendons, fascia, periosteum) are capable of causing, for the most part, any local symptoms, much less symptoms that ‘travel’, from, say, the Sacroiliac ligament down to the hip, or leg; or from the cervical ligaments to the arm and hand; nor that migraines are often caused by ‘damaged connective tissue’ triggers in the occiput or upper cervical area.   Physicians who are unaware of these possibilities must then ‘attribute’ these symptoms to something else…usually something seen on films, like a bulging disc, or to an inflammation or to a ‘nerve pinch’ when they cannot ‘see’ anything on films…  Physicians are taught that ‘arthritis’ symptoms are the result of inflammation that ‘eats’ the joint, producing ‘bone on bone’.  They are not aware that the joint damage that they identify on films is actually produced by ligament damage, and resulting ‘looseness’ of the joint, that allows the cartilage to ‘rub off’, and which also leads to the bony changes due to resulting abnormal impact forces at the bone ends.  The medical research community has been saying very loudly for the last fifteen years that tender, painful tendons, previously diagnosed as being ‘tendonitis’, or ‘tendon inflammation’, are NOT in fact an inflammatory condition of any kind.  ‘Tendonitis’ does not exist.  This is an established scientific fact.  However, practitioners continue to ‘diagnose’ these tender, symptomatic structures as some kind of ‘itis’—-tendonitis, bursitis, arthritis, plantar fasciitis, etc.—and continue to try to ‘anti-inflame’ them with medications like Advil and Celebrex, or corticosteroids.  If you do not understand the role that unhealed connective tissue damage plays in producing these, and other, symptoms, you will not know what to look for, or how to look for it, to make a correct diagnosis.  You will either either hear that ‘the films are normal’, so there is ‘nothing wrong’, and you get the blank look, or even the suspicious look, from the provider—-it is either a character problem, or you are perhaps a drug seeker.  Or, there is ‘something seen’ on the films and you are told that you have all manner of skeletal abnormalities, disc bulges, cartilage loss, labral or meniscal tear, or whatever.  Which you have, if you see them on films.  But these findings are only a ‘part of  the story’ of why you are hurting, and/or why your joints are falling apart.  Current ‘medical training’ results in most of our patients having their actual pain sources only partially diagnosed, or misdiagnosed, or missed altogether on previous evaluations.  Dr. Johnson wrote the paper that characterizes the symptoms that arise from connective tissue, the mechanism by which these symptoms are produced, the best way to evaluate these symptoms, and the most logical and effective way to treat them. [Click To Read: “Connective Tissue Damage Syndrome”  by Dr. Johnson]

#4) Adequate Course of Treatment

Even with ‘healing triggering’ (Prolotherapy, PRP, Stem Cells), as it is used by Orthopedic surgeons, and many Prolotherapy physicians, many patients only receive partial relief.  Is this because there are ‘other pain causes’ that healing cannot successfully address, or is this because a potentially effective treatment is being inadequately employed?  We have found that more than 90% of patients who come to our office with joint, neck, and back pain can have symptoms completely, or almost completely, relieved using Prolotherapy.   We have simple techniques to rule out ‘other pain sources’ with a high degree of certainty.  It is surprising how infrequently patients actually have such ‘other pain sources’—like nerve pinches—despite what they have been told by other practitioners about what is ‘causing’ their pain.  We also understand that, to get the results patients want, it is imperative to offer thorough treatment and a complete course of treatment. Structures need to be ‘load bearing’ (non-tender) with the patient engaging in the desired level of activity before treatment is ‘complete’.  (read more)

Completing a course of treatment:  There are two issues under this subheading that lead to people receiving incomplete treatment.  The first is being SATISFIED TOO QUICKLY, the second is being DISSATISFIED TOO QUICKLY.

WHAT IS ‘COMPLETE TREATMENT’?

How do we know when a structure has had ‘enough’ treatment.  Very simply.  The structure is no longer tender (no remaining stretch-induced nerve damage, meaning there is no longer any ‘abnormal stretching’ with use, because enough collagen molecules have been added to the structure by the patient’s own healing system, stimulated by Prolotherapy, to make it ).  This is the endpoint for treatment of any and all structures contributing to the patient’s presenting complaint.  At this point, we may cease treatment with confidence that the patient’s symptoms will not recur unless there is re-injury or unless the patient has a healing system problem (read more about healing system problems).

SATISFIED TOO QUICKLY…

Many patients have gotten modest results from prior ‘mainstream’ treatments.  When they get 50% or 80% symptom reduction using Prolotherapy, they are so happy (and a  bit reluctant to continue receiving treatments that are somewhat uncomfortable and expensive), that they wander off.  These people will often have their symptoms recur in a few months, because their structures, though better, are still ‘non-loadbearing’, and continuing to use them will cause re-accumulation of small fiber nerve damage.  These people will than be on the phone to the office saying, “I thought you said these results were supposed to last a long time.”  These results do ‘last a long time’, if the structures are fully healed, if you do not re-injure the structures, and if your healing system is doing proper maintenance repair work.  While there is no requirement or obligation to continue treatment at any point, we do want patients to clearly understand why we recommend continuing treatment until symptoms and tenderness cease.

It is also important for patients to understand that people do not ‘partially respond’ to Prolotherapy.  They are either capable of fully responding (if their symptoms are due to unhealed connective tissue damage and if we can get their healing system to trigger), or they do not respond at all.  If patients are not responding, it is either because their healing system is not ‘triggering’ with the initial proliferate choice, and other options need to be tried, or, if all options have been tried without response, it is because their healing system is so impaired that no stimulus can produce the necessary amount of collagen production.  We see this situation in less than 5% of our patients.  In a significant percentage of these ‘non-responders’, medical evaluation can uncover the cause of healing system impairment, and they will convert to ‘responder’.  For the rest, unfortunately ‘healing’ has not been the topic of much medical research.  This is because the medical community does not identify most problems we successfully treat as being due to ‘lack of healing’.   They therefore do not recognize the connection between this healing system and joint damage, or structure pain.  Because of this lack of research, there is still much we do not know about how the healing system works, what goes wrong with it, and how to trouble-shoot problems.

DISSATISFIED TOO QUICKLY…

Given the number of things people are told about ‘where their symptoms are coming from’ by reputable and respected practitioners, like ‘bulging discs, bone spurs, scar tissue, nerve pinches, etc., etc., etc.’:   if they are not getting rapid results from Prolotherapy, the question naturally arises, “Is there actually another pain source that Prolotherapy cannot treat, or will this treatment in all likelihood lead to the desired outcome?”  In fact, most Orthopedic physicians do not ‘not do Prolotherapy’  primarily because they think Prolotherapy ‘does not work’.  They do not ‘do Prolotherapy’ because, based on their ideas about ‘what is wrong’, this treatment simply makes no sense. Why treat an ‘inflamed joint’—‘arthritis’—with something designed to trigger healing, after all… We have developed strategies that are very good at sorting out whether patients have sources of symptoms OTHER THAN connective tissue damage.  Those strategies are one of the cornerstones of our treatment approach, and I have a high degree of confidence in these diagnostic strategies.  But my confidence may not be initially shared by the patient.

Even when my evaluation, and the patient’s response to the first treatment or two, suggests that they will ultimately respond fully to treatment, people can still be confused due to ‘all the things they have been told’ about what is wrong.  When I started doing this practice full time ten years ago, it quickly became evident that people with these painful problems, in addition to simply not being yet ‘cured’ with the comparatively safe, and highly effective treatments that are available through triggering ‘healing’, were also often frustrated, confused, skeptical and angry based on prior encounters with multiple practitioners, who had offered conflicting opinions, ineffective therapies, and even questioned the motives and integrity of people who clearly had a ‘physical’ problem which had evaded proper diagnosis by those practitioners.  This is why we take so much time to attempt to explain why symptoms are present, based on the results of a patient’s individual evaluation, and what to expect during the course of treatment.

Aside from natural curiosity, this diagnostic ‘confusion’ in individual patients, in the medical literature and in the practitioner community, was the impetus for me to attempt to understand the actual causes of connective tissue pain—what is ‘wrong’ and ‘why’ Prolotherapy works.  This effort lead to developing a theoretical model for the cause of connective tissue related symptoms that lead, in turn, to the development of a highly successful strategy for treating these symptoms, which I termed the Connective Tissue Damage Syndrome.   This theoretical model explains virtually every clinical observation about both the problem, and the treatment.  It is worth noting that there is, in all of medical literature, no other satisfactory explanation for these phenomena.  Unless you correctly understand a problem, you will likely not do a very good job of correcting the problem…you may get lucky, but more likely you will become yet another ‘part of the problem’.

A large percentage of our patients have had multiple prior attempts at therapy, including corticosteroids, nerve ablations, operations (fusions, joint replacements, meniscus or labrum ‘repair’, ‘cartilage’ procedures, etc.), anti-depressants, narcotics, implanted pain control elector-stimulators, physical therapy, chiropractic therapy, acupuncture, etc.  And they often have additional unwanted effects from these previous treatments.  This is the group in which 90% plus get 80% or more symptom relief, and over half get complete relief of symptoms.  Around half our our knee patients have been told that they need an operation.  In other words, in this patient population, a HUGE percentage of patients have a HUGE percentage of their symptoms coming from a source that has generally NOT been correctly identified or treated prior to their coming to our office, but which DOES respond to the patient’s own healing system when that system is properly stimulated.

Let me also stress that every practitioner that a patient has seen prior to coming to our office is, in all likelihood,  well trained, well intended, competent, and caring.  The question is not one of other practitioners doing ‘less than their best’.  The question is simply what they are trained to think.  If you are not aware that connective tissue is capable of producing certain set of symptoms, if you have not ‘heard of’ that possibility, you will attribute patients’ symptoms to things you have heard of…  For a presentation in a national gathering of Prolotherapy physicians, I made a slide of the ‘diagnoses’ that had been given to my patients by previous practitioners that I knew with certainty to be incorrect….because I had completely corrected the actual problem.  In less than 15 minutes I made a list of over 100 such incorrect diagnoses from memory, without even looking at a chart.  This is the current state of ‘mainstream medicine’ when dealing with musculoskeletal pain.

Which is why I walked away from a career as a prominent and respected surgeon in my community to devote myself full time to this discipline.  I completely respect surgeons.  I am one.  But people of integrity can have differing opinions.  And based on my own 25 year back pain history, and the complete discrepancy between an imaging-study based Orthopedic diagnosis, and the actual diagnosis, which lead to a cure…and based upon my wife’s severe back and neck pain following a motor vehicle accident that ‘eluded’ diagnosis despite MRI, CT, and 4 limb nerve conduction studies, but which was quickly diagnosed and completely remedied using the diagnostic and treatment techniques of Prolotherapy, and now also based on closely observing thousands of other people with similar disorders, I have developed a strong opinion about ‘what is wrong’, and ‘what needs to be done’.  I became a Prolotherapist because this is a job that needs doing…

But how does this translate into individuals becoming ‘dissatisfied too quickly’?  Because what I tell patients, after evaluation, is perhaps the fifth, or tenth, different idea they have heard about their problem.   If we treat them once or twice, and they are noting a 10 or 15% change in their symptoms, which is very common among complete responders, the patients at times feel like they are not making the progress that THEY expect, in the timeframe that THEY expect.  And despite my confidence in the outcome, having seen over 4000 patients, this individual has no idea what to expect or how confident that THEY can reasonably be in the outcome of this treatment, particularly in light of the confusion up to this point about ‘what is wrong’ and their experience of trying other things that also got them a ‘little better’,  but did not produce good long term results.

This confusion is compounded by the confusion on the internet, and in medical literature, on the topic of Prolotherapy.  You have a lot of people with little training, including researchers, doing a completely inadequate treatment course, getting marginal results, and causing people, reasonably, to ‘question’ Prolotherapy as a treatment per se.  And people are reasonably lead to question how devoted they should be to a course of this treatment if they are not seeing rapid results.  This is completely understandable.   A large part of our job is to align patient expectations with what we can reasonably expect our body to do…in light of the rather large variation in the pace of response seen across the population.  A properly performed course of Prolotherapy often involves a variety of adjustments to get the best results most quickly and most economically.   And it requires that patients go through the actual process, and try to understand that process, rather than being frustrated by the difference between that process and their expectations.

So, optimal results depend on correct diagnosis and adequate treatment.  Before someone will complete the treatment, they must have some degree of confidence in the diagnosis.  And, before I will offer a course of treatment, I must have a high degree of confidence in the diagnosis.  I will make a point of discussing any uncertainties or questions I have about a given patient’s situation with the patient, and detail how those questions and uncertainties can be sorted out. We will direct patients toward the appropriate practitioner if other, non-connective tissue, symptom sources are noted.  But we will also recommend, with a high degree of confidence, that patients continue a course of treatment that has a high likelihood of ultimate success.  Again, this understanding of outcomes is based on taking a close look at the results that we have actually obtained in our office in such situations.

#5) Identifying and Correcting Healing System Problems
I you actually have ‘unhealed connective tissue damage’ (instead of ‘arthritis’, ‘tendonitis’, ‘sciatica’, ‘fibromyalgia’, etc.), then your healing system becomes an important part of the equation. ‘Unhealed damage’ is a result of ‘over-injury’, ‘under-healing’, or both. Particularly if you have multiple sites of pain, or have had multiple Orthopedic operations, you likely have a problem with your ‘maintenance healing system’. Your body is supposed to be repairing your daily damage and injuries on an ongoing basis, and it may not be doing so.

Healing system problems: If your symptoms and findings: pain in joints or regions, plus or minus joint changes (cartilage loss and bony changes), disc damage, meniscus and labrum tears, and other primary and secondary findings associated with unhealed connective tissue damage, are in fact due to UNHEALED DAMAGE in the ligament structures of the joint or area, which are NOT showing up on imaging studies, particularly when you have multiple painful areas, and when you have increasing numbers of such joints and areas over time, then your healing system per se becomes an important aspect of ‘the problem’. We strive to heal existing symptomatic damage, as well as to determine WHY you did not heal that damage in the first place.

You break and replace every collagen molecule in a given ligament or tendon, or, by extension, you completely replace every collagen molecule in every one of these structures in your entire body, about every seven years. You have a huge ‘turnover’ in these molecules, and your body has to keep up with the repair work. If it does not, eventually you will develop symptoms due to this lack of healing, and resulting gradual loss of tensile strength in connective tissue structures. All structures get progressively weaker. At a point, one structure after another ‘crosses the line’ to become ‘non-loadbearing’ (stretching abnormally under usual body loads), which produces ‘inside the structure’ nerve damage, which then produces tenderness and symptoms. (see How Your Healing System Works) (see What Causes Healing System Impairment)

People with healing system impairment are more ‘fragile’—more prone to hurt themselves doing things that they ‘should’ be able to do, like picking up a moderately heavy object. But their tissues are so weakened that symptomatic damage is easily produced, or worsened. These people usually become reluctant to exercise. We exercise—doing small, controlled amounts of ‘damage’—with the understanding that our healing system will not only ‘fix the damage’, but make us stronger. But people with healing system problems do not ‘fix their damage’ completely, much less get stronger. With exercise, they simply accumulate more unhealed damage. That is why some people get ‘worse’ with exercise, or with Physical Therapy. You cannot ‘exercise your way out’ of this problem.

If there might be a problem with maintenance connective tissue healing, we identify and treat certain issues, or we direct patients for evaluation to diagnose and to treat other conditions that keep the body from doing its own maintenance work. Prolotherapy will usually ‘work’ even if the healing system is not fully functional and in need of attention, but occasionally we will need to diagnose and rectify problems before Prolotherapy can be successfully used. The main point about healing system problems for most patients is their future: if this system is not working going forward, they may expect to have more ‘unhealed damage’ in the future…recurrence of pain in treated areas, and new areas and joints will likely become problems. A functional maintenance healing system is a vital factor promoting future quality of life.

#6)  Patient Experience

We strive to create the most positive possible experience during the treatment process.  We actually listen to you, and we do a careful physical examination.  We attempt to ensure that people understand their disease process, how the treatment works, what to expect from an individual treatment, and what to expect from the course of treatment.  There is a LARGE variation in rate of response to treatment, as well as large variations in the magnitude of damage among our patients.  We help people understand their individual response to treatment, and offer any adjustments to the treatment plan which might offer faster, or more economical, results.  We have innovated several approaches to help make this treatment as comfortable as possible.  The best experience of all, of course, is to ‘get your life back’, and be able to resume the activities that really matter to you.  We do all in our power to create THAT experience for you. 

Patient experience:  There are many You-Tube films of Prolotherapy treatment.  Some are, frankly a little scary.  We have gone to great lengths to innovate ways to improve people’s experience during this treatment.  While there is some inherent discomfort with any injection therapy, we use a powerful topical anesthetic combination that reduces the sensation of injection (and this is why it might seem that we are ‘leaving you’ in the exam room for lengthy periods.)  This topical anesthetic works best around 15-30 minutes after application, and is fully effective for more than an hour.  We try to time our treatment to minimize your discomfort.  (If you are in a hurry, please let us know and we will try to minimize your time in the office).  We also were the first Prolotherapists to use an electro-stimulation device to further minimize patient discomfort.  And there are things that our staff will do that further enhance your experience.  Many new patients, armed with You-Tube fueled mental images of a treatment that seems to resemble the shower scene from Psycho, arrive in the office wondering if they will survive the treatment.  Almost all leave with comments like, “gee, this was not as bad as I thought it would be…”.

Holley and I lead very active lives, and have our own injuries and aches and pains to deal with.  We have both been treated in a variety of joints and areas over the last decade, in addition to our original major issues.  We have paid particular attention during these treatments to any ways that we might improve care of our patients, and we have learned a lot from being ‘on the other end of the needle’.  You get to benefit from our experience.

When was the last time a physician or a medical staff person actually listened to you?  They too often seem to be pre-occupied looking at your imaging study, looking at your lab tests, and trying to fit you into some kind of pre-determined box.  Then, they try to treat you based on their ‘scientific’, ‘best-practices’ approach for the ‘disease in the box’.  ‘Standardized’ and ‘Individualized’ are not synonyms.   If their treatment is not successful, somehow it is your fault….  This is because most physicians are not trained to properly diagnose some of the most common problems that physicians see—joint pain, chronic connective tissue symptoms, neck pain, back pain, even ‘arthritis’.  They are doing the best that they can in the absence of that understanding, but your problem is not being successfully resolved.  Often, people are told that they just have to ‘live with’ their problem.  Our experience shows that this may not necessarily be true…

We have had dozens of patients in tears, saying things like, “so I am not crazy after all….” when we can explain to them what is actually wrong.  We had a prominent area Psychologist, after listening to an explanation of the connective tissue source of his wife’s symptoms, say the following at the end of the office visit:  “During the course of my professional career, I had over a hundred patients referred to me purely for the purpose of pointing out to them that their ‘symptoms’ had a psychological cause—basically, that they were ‘nuts’.   I bet, almost to a one, that this is what those people had…”.  How tragic.  There are psychosomatic problems.  There are things seen on films that are properly diagnosed and effectively treated by ‘mainstream’ medicine.  But most of our patients have ‘been through the system’ and have not gotten the help they need.

It has amazed me how many of these patients have problems which can be successfully diagnosed, and effectively treated, if you understand what the Connective Tissue Damage Syndrome looks like and know how to diagnose the presence of unhealed damage.  The experience we most want to create for our patients is getting their life back.  One of the most frustrating things to me, personally, about this whole issue is how little is known, among the general public and among the practitioner community, about this disease process and how easy it is in most cases to cure.   What you are reading is a part of our attempt to remedy that particular problem.

#7)  Prayer has been shown to improve clinical outcomes.

We understand that people have many different beliefs about ‘spiritual things’, and we respect everyone’s right to their own opinion.  We will offer to pray with our patients, if they desire that we do so.  We do this for two reasons:  based on our own Christian beliefs, this makes perfect sense on several levels.  Secondly, prayer has been shown in scientific studies to improve patient outcomes. 

Appreciating the Giver of Life and the Great Healer:  Our bodies are far too complex and well designed to be a collection of cosmic accidents and random events.  Our body is created much more ‘intelligently’ than most people, even most medical practitioners and scientists, fully appreciate.  As a Prolotherapist, I work with the body’s healing mechanisms, within the confines of that design, and the results of this strategy, both short and long term, exceed most ‘standard’ therapies, such as burning nerves, replacing body parts, giving potentially toxic and harmful chemicals.  We acknowledge the beauty of the design, and offer thanks to the Designer.  Prayer has been shown in medical studies to improve patient outcomes.  In the interest of obtaining the best outcomes for our patients, we offer to pray with our patients if they so desire.

Severe, activity limiting pain is the intersection of the physical/structural, the emotional, and the spiritual.  People often have huge personal issues related to the physical problems for which they are seeking treatment.  Our concern for people, and our prayers, are not necessarily confined to the physical treatment per se.  In fact, given some of the problems that our patients are confronting, it is hard to imagine their coping successfully without resources to draw on that far exceed their own.  Further, the set of conceptual realities that have been revealed to humans by God are the only point of integration that make essentially anything, good or bad, that happens to us make any sense.  If we are simply a collection of random accidents and improbable chemical combinations, then literally nothing in all of life matters at all…   I think something inside each of us argues against that.