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How Does Prolotherapy Work?

The switch that turns on your body‘s healing system is a group of chemicals that live in your white blood cells and your platelets. There are sixteen different chemicals shared between white cells and platelets, which are collectively called ’growth factors‘. In order to trigger your body‘s strongest healing system, the ’acute injury‘ system, these growth factors must be dumped in large quantity from platelets and/or white blood cells. Over the last few decades, forty or so chemicals have been identified that will prompt this growth factor outpouring, and thus fully trigger the healing system. Prolotherapy is the art of delivering the correct one of these, in the right place, in the right way.

Fools your body into thinking it has just sustained a major injury - by using a concentrated sugar solution.

Read Dr. Johnson's article regarding Connective Tissue Damage Syndrome

Prolotherapy treats unhealed damage in ligaments, tendons, and cartilage. Ligaments are structures that hold two bones together. Tendons connect a muscle to a bone. Cartilage is the surface coating within a joint that allows bones to glide smoothly against one another as the joint moves. What happens if these structures are damaged? Your body has very powerful healing mechanisms to completely heal such damage. But these healing
mechanisms do not always work perfectly, or heal completely.

Your healing mechanism is very time-limited. I am also a surgeon. If I make an incision on your abdomen, a healing process is initiated that heals that incision. That process lasts for six weeks, and consists of several types of cells performing several functions. The cell that we are most interested in is called a ’fibroblast‘. This cell makes collagen fibers, which are the raw material that your body uses to make new connective tissue (including ligament and tendon tissue). When an injury occurs, a chemical signal is sent out the activates fibroblasts in the area, and brings new fibroblasts into the area. These fibroblasts first proliferate (make lots of new fibroblast cells), then all these cells start making new collagen. (The name ’Prolotherapy‘ was coined by Dr. George Hackett as a shortened form of ’Fibroproliferative Therapy‘, which had been used to describe this process). After being activated by injury, fibroblasts will make new collagen fibers for 42-43 days. Then, leaving a skeleton crew around to respond to the next injury, the remaining cells die.

So, if you have an injury, you have six weeks to heal your injured ligaments and tendons. What happens if those structures do not heal completely? After six weeks, you have virtually all of the healing you are going to get. There is a much slower motion ’wear and tear‘ healing response that can do a little more on a gradual basis. Consider that a ligament is like a small cable holding two bones together. Those bones can move, but their movement is limited by the ligament. Ligaments are strong, tough tissues that can, and do, bear a lot of weight and force. Picture a cable that has been cut and frayed. Now apply the maximum force that this cable is designed to bear. First, the cable will stretch. Then it will break. Your body has something called ’nerves‘, and ligaments and tendons are richly supplied with nerve fibers. Those nerves will tell you is you are putting enough force on a damaged structure to risk breaking it. The nerve tells you this by using something called ’pain‘. You may be familiar with this phenomenon. Though you will stop short of breaking it, as you apply force to this damaged structure, it will continue to stretch until it looks like an overstretched rubber band. If you have a ligament that has lost, say, 25% of it‘s cross sectional area, what happens?

First, you get pain. Your body knows that this structure is damaged. It creates a type of inflammatory response in the ligament that is your body‘s way of telling you ’this part is damaged, do not overuse it‘. In addition to the pain you feel with simply stretching the structure, you get more pain. Pain with movement, sometimes pain at rest. Sometimes the pain is severe. Some people refer to these painful areas as ’trigger points‘. Sometime more colorful language is used. The net effect is pain in a joint or an
area, such as neck or back, that recurs or is constant.

Often the pain that a patient perceives is some distance from the actual pathology. This phenomenon, called ’referred pain‘, is commonly seen with damaged ligaments. Unhealed damage in the Lumbar, Lumbosacral, Ileolumbar, Sacrospinous, and Sacrotuberous ligaments can actually be felt as pain going down the leg to a certain point, even to the bottom of the feet. Pain arising from the pubic arch muscle insertions can be felt near the back of the knee. Pain arising from the cervical vertebrae can be felt in the shoulder, elbow, or forearm. There are many other pain referral patterns from ligament and tendon damage. Therefore, it takes training and experience to find the origin of these pains.

Secondly, you get joint instability. The ligament has a job to do, which is to let the bones move to a point, but only to a point. What if the ligament is stretched? The bones move farther than they are supposed to. The bones then do things they are not supposed to do. If two bones bang against each other, they activate the bone healing cells, called osteoblasts. These cells respond by making new bone, which we call bone spurs, osteophytes, arthritis, etc. You have disks between your vertebrae which are supposed to act as shock absorbers, and to allow your vertebrae to rotate slightly against each other. What do you think will happen to your disks if your ligaments are too loose, and allow your vertebrae to over-rotate, or to apply shearing forces on the disks? Could your disks degrade, or even rupture? Yes, they can.

Other problems can occur as a result of loose, incompetent ligaments and tendons. Muscle spasms are common, particularly in the back and neck. Migraine headaches can be triggered by cervical spine trigger points. A type of autonomic nervous system dysfunction called Barre-Lieou Syndrome, which involves headaches, blurred vision, ringing in the ears, sinus problems, abnormal tearing, and other symptoms, can be caused by abnormal mobility in the cervical vertebrae. In addition to ligaments, the
shoulder is held together with a group of four tendons called the ’rotator cuff‘. If these tendons are damaged, pain and shoulder instability can result. Localized pain and spasm is often caused by damaged points of attachment of back and neck muscles to vertebrae, ribs, scapula, shoulder structures, and the base of the skull.

How do we harness the body‘s healing mechanism with Prolotherapy? Consider the damaged ligament we were discussing earlier. If a proliferant solution consisting of concentrated dextrose (sugar) is injected at the point of unhealed injury, it fools the body into thinking that a major injury has just occurred. The immune cells in the area send out a chemical signal that activates local fibroblasts and summons new fibroblasts to the area. These fibroblasts proliferate, then start making new collagen fibers. Interestingly, instead of just making ’scar tissue‘, these cells make new tissue that is identical to the tissue that was damaged - ligament, tendon, etc. In fact, electron microscopy has shown that the tissue that is made is actually very ’high quality‘, like a marathon runner‘s instead of like that of the usual weekend warrior. The healing cycle is just like that described relative to the surgical incision (above), in that it lasts six weeks. The vast majority of the new collagen is made between week two and week four. Thus, at a month, you have a good idea how much healing has occurred, and how much still needs to occur. Depending on how much of a defect there is to heal, and how fast and effectively a given person‘s healing system works, it may take several cycles to completely heal the structure to full tensile strength and load bearing capacity. But, when the structure does become fully load bearing, the pain stops. Permanently.

Then another useful mechanism comes into play. If I make an incision on your abdomen that is six inches long, it will be six inches long a month later. But at three months it will be five and a half inches long, and at six months it will be five inches long. When new fibrous tissue is made, it is somewhat soft and pliable. The ’making‘ process stops at six weeks, but over the next few months that new tissue chemically matures, toughens, strengthens, AND SHORTENS. Consider the ’stretched out rubber band‘ ligament. It needs to be stronger. It also needs to be shorter. Over several months Prolotherapy treatments not only strengthen, they shorten these ligaments. This stabilizes joints, and stops the problems caused by abnormal joint mobility (disk degradation, Barre-Lieou Syndrome, muscle spasms, development of additional bony arthritis deformity, etc.)

So far, we have been looking at what happens when a single structure is damaged. But these structures are tough. It takes a lot to damage one. And we do not just have a few tendons and ligaments. We have hundreds of these structures. After a wreck, a fall, a sports injury, or years of hard work and wear and tear, we usually have a number of unhealed, injured structures. Often the worst pain-generating structures are sending out pain at, say, a level of 7 out of 10 (we often grade pain on a 1-to-10 scale). You
can only feel so much pain, so you literally are not able to feel the areas that are sending out pain at level 3 or 4. If we just treat the worst areas, and stop pain there, you will suddenly start feeling ’new pain‘ in other areas. It was there all along, you just didn‘t know it. But I can find those areas on physical exam. They will be tender to moderate pressure, even if they are not noticed otherwise by the patient at this time.

Damaged structures are carefully mapped. A treatment plan will be developed that encompasses all damaged, pain-generating structures in an area. If there are multiple joints and areas involved, treatment will be prioritized.

A proper Prolotherapy treatment will treat all the pain-generating structures in the area in question. The less-damaged areas may heal with a treatment or two, the more damaged areas may take four or six treatments. As areas heal, fewer points need to be treated.

During the course of treatment people experience different things. Pain levels may fluctuate (usually with intermittent significant relief of pain) before they finally resolve. The first thing some people report is feeling ’stronger‘ in an area even though they still have pain. As treatment progresses, people may be pain free for considerable periods, then note some recurrence. If you consider what is happening at the structural level, our damaged cable (ligament or tendon) is gradually rebuilding. It hurt initially because it was not capable of full weight-bearing. Your body knows this, and creates the low level inflammatory process that is your body‘s way of saying ’This is a damaged structure. Do not put full weight on it or you will damage it further.‘ As this structure heals, it begins to cross the threshold and become capable of full load bearing. Then, once it is fully healed, it possesses full strength. During this healing process, pain becomes intermittent, then ceases altogether. You can imagine this process played out in an area with multiple structures that are damaged to varying degrees. Ultimately, when the most severely damaged areas are healed, the area becomes pain-free. That means that the pain that has plagued people in their neck, or shoulder, or back, or hip, or knee, or other joint for months, or years, is gone.

Will the pain come back? I am often asked this question. Pain in a structure exists because that structure is damaged. You took a normal structure initially and damaged it enough to be considering treatment. When that structure is returned to ’normal‘, it will not cause pain. If you damage it again, it will hurt again. For many people, the process of healing also involves learning to avoid the damaging activities that got them here in the first place. At Prolotherapy Nashville, our goal is to return you to full activity without pain. We also will offer recommendations to keep you from doing further damage, when appropriate, so that you can take better care of yourself in the future.

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