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Prolotherapy

Prolotherapy is a treatment technique used for chronic myofascial pain, back pain, osteoarthritis, or sports injury. It involves repeated injections of dextrose solution or other irritating substances into the joint, tendon, or painful tissue in order to provoke a regenerative tissue response. Similar techniques have been used for about a century, but the first formal publication describing prolotherapy dates back to 1956, by Dr. George Hackett. He wrote:

Within the attachment of weakened ligaments and tendons to bone, the sensory nerves become overstimulated by abnormal tension to become not only the origin of specific local pain, but also definite areas of referred pain throughout the body to as far as the head, fingers and toes from specific relaxed ligaments and tendons.

Prolotherapy. A treatment to permanently strengthen the “weld” of disabled ligaments and tendons to bone by stimulating the production of new bone and fibrous tissue cells has been developed.

Initially the concept, referred to a sclerotherapy, was that the injections formed scar tissue to stabilize the joint, tendon, or ligament. The newer concept, called prolotherapy, is that the injections provoke the proliferation of tissue, allowing for limited regeneration.

The exact response to the injections is not currently known, and so explanations of mechanism remain speculative. The notion that injecting an irritant would cause a positive proliferation of tissue resulting in improved function seems implausible. This is not enough to condemn the treatment — something is physically happening and it is possible that a useful local phenomenon is occurring. It’s possible, for example, that even without tissue regeneration, there can be a decrease in local pain or inflammation.

Therefore speculative explanations as to how prolotherapy might work are insufficient to recommend the treatment, but neither does low plausibility rule out an effect. In this case clinical evidence is critical.

It has been almost 60 years since Hackett’s first edition describing prolotherapy. In that time prolotherapy has remained on the fringe, without sufficient high-quality clinical research to clearly establish its effectiveness. This is always a red flag for me. Why is the clinical research lacking over such a long period of time? Either researchers have been unable to obtain positive results with rigorous trials, or those using prolotherapy are insufficiently interested in testing whether or not the treatment actually works.

The clinical research is divided into various indications, the substances that are injected, and the specific techniques used. A thorough review of every possible application is beyond the scope of this article, so let me focus on a few of the more common uses.

Chronic low back pain

Back pain is probably not the most favorable clinical application, because it is frequently complex with multiple facets, defying any single treatment. However, if prolotherapy were providing any effect in reducing pain or improving stability it should be detectable with careful clinical trials.

A 2007 systematic review of the literature concluded:

There is conflicting evidence regarding the efficacy of prolotherapy injections for patients with chronic low-back pain. When used alone, prolotherapy is not an effective treatment for chronic low-back pain. When combined with spinal manipulation, exercise, and other co-interventions, prolotherapy may improve chronic low-back pain and disability. Conclusions are confounded by clinical heterogeneity amongst studies and by the presence of co-interventions.

In other words, when prolotherapy can be isolated as a variable, it provided no specific benefit to back pain. When combined with other treatments known to be effective, there was a benefit. Such results are most consistent with there being no specific benefit from prolotherapy in back pain. A 2009 follow-up review concluded that there was still insufficient evidence to conclude the therapy works for back pain. There do not appear to be any rigorous studies of prolotherapy in back pain since that review.

Knee osteoarthritis

The literature for knee osteoarthritis (KOA) is a bit better than for back pain. Unfortunately, the only reviews I can find date back to 2004 or earlier. This review by Kim et al. found that the studies to date were small and of limited quality, not allowing for any firm conclusion.

A 2013 study of 90 subjects found improvement with dextrose prolotherapy over saline injections or at-home exercise. These results are positive, but still preliminary. A 2012 study of 36 subjects showed similar results. Another 2013 study, while also showing symptomatic benefit, measured cartilage volume (CV) by MRI scan and found no difference between the prolotherapy and saline groups — both continued to lose CV at the same rate over the course of the study. Other studies I found were small, prospective, or unblinded.

My summary of this research is that — preliminary clinic research comparing dextrose prolotherapy to saline injections or exercise shows a consistent symptomatic benefit, but no change in objective outcomes, like cartilage volume. This research, however, should be considered preliminary. Larger rigorous trials are needed to definitively address the issue of efficacy.

Other musculoskeletal indications

A 2005 systematic review of prolotherapy for soft tissue and musculoskeletal injuries concluded:

There are limited high-quality data supporting the use of prolotherapy in the treatment of musculoskeletal pain or sport-related soft tissue injuries. Positive results compared with controls have been reported in nonrandomized and randomized controlled trials. Further investigation with high-quality randomized controlled trials with noninjection control arms in studies specific to sport-related and musculoskeletal conditions is necessary to determine the efficacy of prolotherapy.

By now this language should be familiar — it is the description of preliminary clinical research.

Conclusion

Prolotherapy is a treatment that has been around for a long time, but still lacks definitive clinical evidence for efficacy. The plausibility of an effect is dubious, but not impossible. It does not appear to work for back pain. The best evidence exists for knee osteoarthritis, but even here the evidence is still preliminary. At best we can say that these results warrant further research.

It should be noted that the current level of evidence is completely compatible with the null hypothesis — that there is no specific effect from prolotherapy. Researcher bias, p-hacking, publication bias, mixing variables, and placebo effects can all conspire together to create the impression of a positive effect where none exists. Most of the time, encouraging preliminary research such as exists for prolotherapy is not supported by later rigorous clinical research.

Further, it seems that the practice and promotion of prolotherapy greatly exceeds what is justified by this preliminary research. I would recommend caution to anyone considering this therapy, and certainly I would not believe the hype. Proponents should conduct the type of double-blind placebo-controlled trials that can definitely determine whether or not prolotherapy has any specific effect.

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141 thoughts on “Prolotherapy

  1. goodnightirene says:

    So, who is offering this therapy? I wouldn’t think most altie practitioners are allowed to be injecting anything, nor would mainstream orthos do it (?), so who is left but MD’s who do other airy-fairy stuff?

    1. TwistBarbie says:

      My friend received this treatment through the Mayo clinic. I’m not sure what they were attempting to treat but I’m assuming it was her “fibromyalgia”. It didn’t work but then again she claims nothing works for any of her myriad ailments except worryingly high doses of narcotics and benzodiazapines.

      1. Windriven says:

        I have always questioned whether fibromyalgia is a disease or a drug seeking behavior. An oncologist friend insists that I shouldn’t be skeptical and that patients should be taken at their word. But I remain unconvinced. SBM has mentioned fibromyalgia several times including a pretty good look at fibromyalgia and CAM. But nothing I have read includes a definite embrace or rejection of the diagnosis. Perhaps there simply isn’t enough information to make a firm conclusion. I will just say, and this is entirely anecdotal, that those I have known who claim fibromyalgia have unfailingly been the same people who generally whine, slack, and drug-seek.

        1. MTDoc says:

          I think of fibromyalgia as a syndrome, and a not very well defined one at that. I can remember when we called it fibromyositis, but they had to change the name when they couldn’t find any inflammation. I did see claims to this from drug seekers, but they did not remain in my practice very long. For those who did appear to suffer from chronic, more or less generalized pain, I was extremely hesitant to employ long term opiates. Yet I always wondered if the problem wasn’t really “in their head”, not in the sense they were neurotics, but perhaps from an endorphin deficiency, or some neural inability to use it properly. In other words, a constitutional “low pain threshold”. Has anyone tried a vigorous exercise program for this, assuming you could get compliance?

          1. Andrey Pavlov says:

            I think you are correct MTDoc. It is a “real” thing… just what that “thing” is, we haven’t figured out quite yet. And just like many such syndromes, we are probably capturing false positives and multiple distinct pathologies manifesting as a similar syndrome.

            The fact that many drug seekers claim to have fibromyalgia is not an indication that there is no such condition, but that nebulous pain syndromes are haven for drug seekers.

            I seem to recall there once was a study on tai-chi (basically slow movement exercise) having benefit in fibromyalgia. It went a little overboard on the mystical aspects of it, but I see no reason why appropriate exercise (which for this may be a slow-movement type) wouldn’t at least ameliorate symptoms a bit. I don’t have the reference handy though.

            1. MTDoc says:

              Thanks for your thoughts. If the low endorphin hypothesis holds any water at all, then exercise should help, possibly the more the better. My “no pain, no gain” friends obviously have plenty of pain, but rather than complain, wear it like a badge of courage. Even with knee and hip replacements. Even so, I always felt endogenous opiate replacement, though perhaps rational, was a slippery slope I’d rather not take. Still, I had a few patients with chronic pain, not necessarily fibromyalgia, that could be managed long term on low dose opiates without tolerance or cheating problems. Very few.

              1. MTDoc says:

                That should read exogenous opiates. I’ve dictated so long, I’ve forgotten how to spell!

              2. Andrey Pavlov says:

                There is also obviously a contextualization of the pain. Which is a huge aspect of literally every aspect of pain (and not to digress too much, but no doubt a large part of why placebos tend to show large effect sizes for pain, particularly acupuncture and other theatrical placebos). I’m sure everyone has heard the term “it’s a good sore” after someone has worked out. I just said it myself very recently. I’m back on the bike after much too long a hiatus and going to bed say how wonderful it is to be sore and ache all over.

                Take that exact same feeling and have it be a result of nothing intentional and during times when you need to function or when life is stressful and frustrating and that “good” pain can become very bad indeed.

                Part of the problem that is inextricable with pain treatment is that treating pain validates the pain as existing (which is good and bad). In the context of a pain that has been ongoing and disruptive to life that validates the disruption. From there any number of myriad motivators can lead to chronicity. At some point circumstances may change and the person truly wishes to break out of it. Well, for ages up until then they had been doing “something” and that something didn’t “work” for whatever reason. Doing more of it cannot contextualize properly and, coupled with conditioning nocebo effects, render them ineffective. In comes something – anything – that the person can buy into and break them out of the cycle by subconsciously giving them permission to do so. I would be willing to bet – and there are case reports and anecdotes – that if that “something” had been acupuncture or other CAM for ages and then the person tried actual medicine one would find the regular medicine works. But that isn’t sexy and newsworthy, nor particularly interesting to study.

                All of this to say that yes, pain is real regardless of whether there is an external or even internal cause for it. Pain is what the brain is telling you, regardless of whether there is a signal external to the brain or not. And all pain should be treated. It is just a question of how to best approach it and proper contextualization is crucial.

              3. Windriven says:

                @Andrey

                “All of this to say that yes, pain is real regardless of whether there is an external or even internal cause for it. Pain is what the brain is telling you, regardless of whether there is a signal external to the brain or not. And all pain should be treated.”

                Yup. I think I buy that. Phantom limb pain comes to mind. Also trigeminal neuropathy, though that seems to be better understood than fibromyalgia.

              4. Andrey Pavlov says:

                Phantom limb pain comes to mind.

                There are even case reports of pain in supernumerary limbs. Wrap your mind around that one.

        2. Windriven says:

          Thanks to you both. One last question based on MTDoc’s hypothesis: if I took a good hit of naloxone, would I then experience something very like fibromyalgia or am I misunderstanding the receptors proposed to be involved?

          1. MTDoc says:

            That’s an interesting question. The answer I believe is no. The reason, we were taught 40 years ago, you can see how current I am, is that naloxone also acts like an opiate. This, of course, is a rationalization of the observed, and in no way a scientific explanation. Perhaps we have acquired some additional information on this since 1975.

            1. CHotel says:

              I believe that naloxone (along with naltrexone) is a pure antagonist with no agonistic action, as opposed to mixed agents like nalbuphine.

              1. MTDoc says:

                Thank you for the clarification. I guess I was thinking of nalline. There have sure been a lot of new agents in this class since I’ve retired. And it’s twice as confusing trying to remember generic as well as brand names for each one. I note, however, that there seems to be a trend toward learning just the generic name now days.

          2. CHotel says:

            Not necessarily. It would almost definitely decrease your pain tolerance while in your system, but it wouldn’t necessarily induce any pain. It doesn’t affect all opioid receptors, mainly has mu-receptor activity while having low affinity for kappa and delta receptors (though it is active there), so you’d still have active endogenous opioids floating around to some degree. Something would still have to cause the pain, which is one reason why there is likely a muscle/connective tissue component to the syndrome as well. Go for a hike until you get a little sore all over, then take a shot of narcan, that would probably be a more accurate representation of the syndrome from what I understand of it.

            I believe that it is likely a real condition, but I also hold very little hope that we’ll fully understand the pathophysiology of it due to its being co-opted by drug seekers. It may even be a multitude of conditions with similar presentation, since it is likely a diagnosis of exclusion, which would explain why there are so many proposed causes and treatments with little consensus.

            1. Windriven says:

              Thanks to you and MTDoc. I am at an age (well north of 28, let’s just say) where I have the usual array of aches and pains that accompany an active life. I may self-experiment with this, though your point about reduced antagonism to delta and kappa receptors is taken.

              I’m not sure why I have such conviction that this is a bogus condition, but I do. I’d have good cause to reassess if my n=1 experiment tended to support MTDoc’s interesting hypothesis.

              1. brewandferment says:

                Hi Windriven,

                There was an article published recently (Jun 13) in Pain Medicine that described some imaging that revealed an excess of sensory fibers surrounding capillary shunts in fibromyalgia patients. Here’s a link to a news summary with the relevant details if you’re interested. I don’t follow it closely so I don’t know if the results have been replicated or anything else, but it seems to be a definitive difference. Whether those differences have the significance to fibromyalgia that they are suspected to have, I’m not a medical professional and can’t begin to assess.

                http://americannewsreport.com/nationalpainreport/researchers-claim-breakthrough-in-fibromyalgia-study-8820525.html

              2. Windriven says:

                Interesting story, Brew. Thanks.

                Andrey, I took MTDoc to suggest that a dearth of endogenous opiods might have a role – though the story that BrewandFerment linked suggests a different mechanism. I was going to dick around with some narcan to see if shutting down response to my endogenous opioids would result in pain similar to that reported by fibromyalgia sufferers.

                I’ve always had a weird interest in off-kilter physiologic responses. A good friend, an anesthesiologist named Dale Harpold, was going to do a halothane induction on me. It is supposed to be a bizarre experience as your sensoria click off one by one starting with vision. As I recall, hearing is supposed to be the last to go. Sadly, Dale screwed his twin Moody into the ground returning to Biloxi one night and we never did it. Really bright guy. A little crazy too. Drove a Corvette with Mississippi plate “ZZ Doc”

              3. cloudskimmer says:

                An aside not relevant to the topic: Sorry to hear about your friend. I was trying to locate the accident report, and would like more details if possible, such as the date and location. You mentioned Biloxi, but if it occurred several miles away, it would be filed under the nearest town. You mention a “twin Moody” but I know of no such aircraft. There is a Mooney, but they never made a twin-engine airplane. Sorry to bother you with this, but it may make for a nice change from trying to reason with Dr.(?) Rodriguez. The location for this is wrong, but there’s no reply tag under the relevant note.

              4. Windriven says:

                @cloudskimmer

                Dale crashed in the mid to late 80s and it was definitely at one of the airfields in the immediate neighborhood of Biloxi. It would have been a small airfield because, as I remember the story, one had to key the mike on the radio at some certain frequency to turn on the runway lights. Dale apparently clipped a tree coming in late at night and the crash wasn’t found until the next morning.

                I’m sorry but I’m not a pilot or aircraft aficionado so the details are sketchy. I believe the ‘twin’ was a two seater and Moody, Mooney, whatever, I’ll take your word for it. He was being recruited by some little flyspeck hospital – as I recall it was in the neighborhood of Ft. Walton Beach, FL and was returning from there as I remember it. I don’t recall where he went to medical school but he did his residency at Ochsner in New Orleans. Do let me know if you find anything interesting. He was a terrific guy.

              5. Andrey Pavlov says:

                Andrey, I took MTDoc to suggest that a dearth of endogenous opiods might have a role – though the story that BrewandFerment linked suggests a different mechanism.

                As I had said above, with nebulous syndromes like these we are most likely to be capturing different etiologies that manifest similarly enough that we can’t discriminate between them (as well as false positives and drug seekers to make things extra fun and challenging), much like mild-to-moderate depression.

                I was going to dick around with some narcan to see if shutting down response to my endogenous opioids would result in pain similar to that reported by fibromyalgia sufferers.

                Well… if you’ve got access and are willing to experience some pain for science… sure. I’d be curious to read about your experience.

                That said, there will be subtle differences between a receptor issue model of FM (which is what narcan would be simulating) vs an endogenous opioid deficiency model. In the former up-regulating EO production would have little effect (and the latter is obvious). Since narcan is a reversible antagonist it is conceivable that you could up-regulate EO production and overcome some of the effects. I doubt that this would manifest itself noticeable clinically and could be overcome by increasing the dosage. However, there is still going to be a signal transduction difference between narcan induced receptor failure and an FM model wherein there is a chronic down-regulation of receptors and also an FM model where the number of receptors is normal but their function is impaired. And, of course, an even larger difference with an FM model of increased nociceptive fibers like B&F mentioned and yet again for a model that posits increased sensitivity mediated by increase substance P production (or possibly increased receptor affinity to substance P).

                So you can see why FM can very easily be capturing multiple etiologies and why it can be hard to really get to the bottom of it because differences are subjective and difficult to characterize making detailed study even more difficult.

                So as long as you realize the limited perspective narcan will give you, go for it. I’d be interested on your thoughts of the experience. But it will necessarily have a strong positive predictive power for you but a poor negative predictive power (meaning if you feel what you think you need to feel it will be [rightfully] very convincing, but if you don’t it shouldn’t convince you of the negative).

                I’ve always had a weird interest in off-kilter physiologic responses.

                Lets just say that altering consciousness is an interesting experience indeed. And that apparently my memory formation can be impaired, but it takes a LOT to put me down. I had an EGD done once and it took them 16mg of midazolam to sedate me enough. I remember the first 8mg.

                as I recall it was in the neighborhood of Ft. Walton Beach, FL and was returning from there as I remember it. I don’t recall where he went to medical school but he did his residency at Ochsner in New Orleans

                I am also sorry to hear about your friend. As you may imagine I have frequented many of the same spots you mention. I’ll try and remember to ask my friends in gas over at Ochsner if they knew him when I start up next month.

              6. Windriven says:

                @cloudskimmer

                I found it. NTSB MIA88FA127. He crashed at Fernandina Beach not in Biloxi (actually, his home airport was nearby Gulfport). In a final indignity the initial report misspelled his last name as Harrold rather than Harpold.

            2. Andrey Pavlov says:

              I am not an expert on this, but to my knowledge CHotel is correct. It does affect kappa and delta opioid receptors but has a much lower affinity. It does not affect endogenous opioids at all. So it would not induce pain but it would prevent the ability to endogenously reduce induced pain. Meaning that if I punch you in the arm after I give you nalaxone it will hurt hurt more than it normally would. However, the main effect would be that it would hurt longer than it normally would.

              There is also some indirect evidence of this in some trials with septic patients. Administration of nalaxone increases their blood pressure. I am not super familiar with that literature and it is pretty small, but it seems that this is thought to be because the pain response is heightening and pain causes the increase in BP. Which renders it horribly unethical to use as a pressor.

              1. CHotel says:

                I’m not as familiar with the sepsis literature either, have just heard of the proposed use in passing conversations, though I really should try to find the articles and read them. I sincerely hope the patients were unconscious, or else as you say the ethics of it would be potentially abhorrent (still sketchy if they were out of it but perhaps slightly more acceptable)

              2. Andrey Pavlov says:

                I sincerely hope the patients were unconscious, or else as you say the ethics of it would be potentially abhorrent (still sketchy if they were out of it but perhaps slightly more acceptable)

                I think it is a non-starter regardless. Besides the fact that a pain response (elevated BP) means pain perception (even if it is at a very dimmed and dull level) we also have evidence to support the idea that painful stimuli during traumatic experiences can sensitize to pain for months or even years after the event. One topic that pops out in my head is post-thoracotomy pain syndrome. These people cannot have appropriate anesthesia (since you only do emergent thoracotomies in the most dire of circumstances) and if the survive many of them have a chronic pain syndrome in their chests. Other data is post-surgical data (including thoracotomies) showing that pre-medicating surgical incision sites with local anesthetic and giving pre-incision IV acetaminophen both decrease pain after surgery, even when the patient is under general anesthesia.

                I cannot think of an ethically valid way to argue that sensitizing a patient to pain (even if that is not ultimately the direct causal mechanism of increasing BP, it is still a known and expected effect) is justifiable short of imminent death and a last ditch effort. Even if they were well sedated, we could expect it to increase their post-recovery pain and perhaps even trigger lasting hyperalgesia.

        3. Anon says:

          But is it only whiners who have fibro, or only whiners who talk about it all the time? If you studied a reasonable segment of the whole population, you might find quite a few folks who have been diagnosed but manage it and don’t talk about it much. Yes, exercise helps if done carefully. There are quite a few of us who manage perfectly well with exercise and non-narcotic pain relievers. (Yes, I did go through a whiny stage. Most people do, healthy or otherwise.)

          I wish I could have access to narcotics, maybe two or three doses a month, just for the really bad nights. That’ll never happen, so life goes on. There’s too much else to do to spend much time worrying about it.

        4. mouse says:

          @windriven – A few thoughts on Fibromyalgia. I know a few folks with FM. My neighbor has it along with bipolar and possible RA (positive RF, but incomplete picture). A former co-worker has FM along with diabetes. A number of folks in rheumatic disease forums that I have joined have FM co-existing with Lupus, Rheumatoid Arthritis, Sjogren Syndrome and Scleroderma. Apparently people with inflammatory connective tissue diseases (and other auto-immune diseases?) have a higher risk of having FM than the typical population. Many of these disease can effect the nervous system, but they can also disrupt sleep. Sleep disruption seems to be highly is associated with FM. There seems to be some thought that sleep cycle disruption is causing a neuro/endocrine problem. Some FM seems to be associated with other pain conditions (like migraine) there is another thought that central sensitization is at play.

          Regardless, I can’t remember any of these folks saying they take narcotic pain medication for their FM. Primarily they seem to take anti- seizure medications like gabapentin or anti-depressants, particularly the ones that help with sleep. (It seems that anti-depressants are being used more in pain conditions even without depression. I know a couple of people with migraines who also take anti-depressants as a preventative.) I don’t think either of those are “fun” drugs, so I doubt that drug seeking is the point in these folks.

          Neither of the people that I know personally with FM are whiny slackers, although my neighbor is a kinda anxious person, she’s very pleasant and helpful. (She used to be reclusive, unfriendly, I think that was before getting treatment for the bipolar) The former co-worker was one of those folks that you could rely on getting things done with a minimum of fuss. (N=2)

          The folks on the CTD forums seem to be a pretty broad personality range, although often with more severe disease, as you see in most medical condition forums. But, I don’t know them in person, so -shrug-.

          1. Windriven says:

            Thanks, mouse. You and the others who have engaged me on this have given good reasons for me to reconsider my skepticism about fibromyalgia.

            1. Laurenak says:

              This will only be anecdotal but I just wanted to let you know that Fibromyalgia is definitely very real and debilitating and not just drug seeking behaviour. I was diagnosed during my third year of university studying an applied science degree in speech pathology, was very active at the gym and was the healthiest I’d been in years. The pain slowly crept through my body until it was hard to get out of bed in the morning due to the crippling pain and fatigue yet I still completed my degree with a distinction average and currently work full time in a private practise with a large caseload of children. Thankfully I found a decent rheumatologist (after a year of misdiagnoses, MRIs, surgery and various medications) who started me on Cymbalta (an antidepressant) and it has done wonders for the pain. I have never taken opiates and hopefully never will but I still battle every day with this condition. While I’m sure there are whiners and drug seekers out there (just with any chronic condition), there are many more of us who suffer quietly. Just wanted to share my experience.

              1. Andrey Pavlov says:

                Thank you for sharing Laurenak. What you say comports with my own knowledge and thoughts on the matter. I hope you continue to manage your condition with aplomb.

              2. WilliamLawrenceUtridge says:

                Fibromyalgia, chronic fatigue syndrome and whatever is actually causing chronic Lyme disease aren’t quite the “next great frontier” of medicine, but would certainly benefit from a strong research program. These diagnoses will probably always exist in some form or another but it would be nice to hive out and clarify some of the mixed causes that get dumped into the same bucket.

                Laurenak, kudos for being willing to attempt a treatment that so many consider insulting, and I hope one day they can find a way to get you off of it permanently.

              3. Interrobang says:

                I have a FM diagnosis as well, but what’s up with me may be something to do with adult sequelae to spastic cerebral palsy, which is not well-studied (dammit). I don’t take narcotics. Low-dose amytryptaline worked for me for a while, but then failed more or less completely, and now I take pregabalin, which is working well. I find Ativan works well for breakthrough pain, but getting it can be a challenge.

                I absolutely assure everyone reading that I do not just have a low pain tolerance, as I’ve had the good fortune to have to deal with gall bladder attacks (including an acute one that lasted eight hours before I gave up waiting for it to pass and went to the hospital), dislocated kneecaps, and an impingement in my right shoulder.

                On really bad days, the pain feels like the total-body ache one gets with the onset of influenza. On bad days, it just feels like arthritis pain displaced into the entheses of certain joints. I have osteoarthritis in some joints already (since my late 20s), so I’m very familiar with the feeling. I do suffer from some of the cognitive effects at times (and I do mean suffer; I’ve already got CP — my brain is the only thing keeping me employed), and it particularly bugs me that my short-term and working memory, already bad since approximately ever, is now pretty much nonexistent.

                I don’t presume to know what causes these symptoms, but I’d really rather not have them.

        5. AniCle says:

          I began having symptoms of fibromyalgia at the age of 3. This was in the 1960s. At the time, I was diagnosed as having had an arthritic reaction to impurities in a polio vaccine.

          My muscle pain comes and goes. Before I knew I had fibromyalgia, I considered myself fortunate not to have anything more serious that whatever it was that caused me intermittent pain. On rare occasions, the pain has been severe enough to make me weep.

          Over time, I began to experience other symptoms of fibromyalgia, like brain fog, digestive complaints and insomnia. I didn’t see a rheumatologist until I was over 30. At that time, I was finally diagnosed with fibromyalgia. Once I knew just what it was that fibromyalgia had been doing to my body–that these problems couldn’t be resolved, because of the underlying condition–I didn’t feel so lucky anymore.

        6. Dr Jeremy Greenwood (GP) says:

          I find it a really useful diagnosis. The self help advice is excellent and in my experience people, having been given this physical diagnosis and prognosis, do very well and get on with their lives. They don’t lose the pain, but over all they get very much better; and this is a population of chronically disabled people who have been a problem to themselves and their doctors often for many years.
          This is fully compatible with the placebo effect, especially as I quite passionately believe in the diagnosis, but as it only involves a low dose of amitriptyline and self help who cares? I would normally check TSH and antinuclear antibodies, among other things, before making the diagnosis.

    2. Catherine says:

      A friend’s daughter has undergone this for knee pain. It was offered by a mainstream ortho, and only after other treatments including physical therapy were not successful. My friend is, herself, a research scientist and not given to woo or airy-fairy stuff. She felt the doc was very upfront about chances for it being effective, stressing that it was equally likely to work as not to work, but was worth trying. The daughter had injured her knee years in school sports and was on a constant (daily) dose of anti-inflammatory drugs. The prolotherapy was part of the effort to get her off of what was beginning to look like a life time of taking daily pain medication.

      1. Windriven says:

        Did it work for your friend’s daughter?

        1. WilliamLawrenceUtridge says:

          Anecdote…

          1. Windriven says:

            Just casually interested. Anecdotes still provide information for n=1.

            1. WilliamLawrenceUtridge says:

              Burn the witch!

              Or more accurately – others don’t get to use anecdote to support their claims, neither do we. I know you know this, I’m more flagging this in general. If I’m going to give shit to Steve Rodrigues for his idiotic use of anecdotes, I’m going to spread a little around elsewhere too. One must be unstintingly even-handed in these things, for from such practices integrity comes.

              1. mouse says:

                Except Windriven didn’t have a claim…nothing wrong with asking for information. It’s the conclusions you draw from the information that matter.

              2. Windriven says:

                Echoing mouse, I’ve no dog in this fight. I wan’t going to use the information in any particular way but dangling threads annoy me like truncated plot lines in poorly written mysteries.

              3. Catherine says:

                Applogies — both for sharing an anecdote and for leaving it incomplete. I thought the interesting part was that the doc offering it was essentially saying, “well we tried everything else — this might not work either.”

        2. Catherine says:

          The jury is out. It “worked” in the sense that going through it meant no NSAIDs for the duration of the treatment, and so she was able to get off of pain meds. Did that just reset her pain threshhold? Did she simply need 6 more months more rest after physical therapy? Who knows?
          It didn’t work in the sense that she’s no longer an athlete. No running, twisting, jumping, etc. But they didn’t expect her to ever return to being as good as new. Getting through a normal day without throwing down a handful of OTC drugs was their goal, and that is what they were able to accomplish.

          1. Windriven says:

            Thanks for the update. Best of luck to her.

      2. Why a CAM does not work or live up to expectation, I answered this in another blog.

        I would like to address these failures in therapy. Vital data from a CAM provider:
        Acupuncture, Prolo, Bio, massage, dry needling are all not same like comparing a car to a 4 wheel truck. People and even some the therapy as a single concept like “car” and will not venture off road thru the muck. Gee, the tools and ideology of this therapy will also limit its effectiveness. The provider education and experience dependent.

        Pain can grow in size + density, can spread and seed local areas and metastasis up or down the spine. In this sense, the pain acts like a cancer and sometimes I refer to it as a “Pain Cancer.” Just like a cancer this “Pain Cancer” will evolve into 5 stages and will not respond well to weak and imprecise therapy. It is important to know which stage a patient is in, so you will understand if a higher intensity of therapy is needed. The only persons who can tell you if the therapy is effective are the patients who have the pain. So in a one on one session with a CAM provider the sources of the pain are uncovered and treated.

        This is a list, in increasing order, of the density of pain and the intensity + invasiveness of the CAMs needed for the treatment to be effective;
        0 => No treatment except Wellness and Balance.
        1 => Massage, Active Tissues Release, yoga etc.
        2 => Chiropractors and Acupuncture (who know pain points and muscle release).
        3 => Myofascial Acupuncture, GunnIMS plus all of 1-2.
        4 => Travell/Simons injections, wet/dry needling etc. plus 1-3.
        5 => Rachlin-Gunn-T/S IMS with hypodermics plus 1-3.

        Botox, Biopuncture, Glucose and Neural injections are Traditional Medicine concept that is less effective that the above due spending less time, effort and points used. The provider chooses theses points whereas in the above CAMs the patient is the only person who can tell the provider where to apply the therapy.

        It may take 3-13 visits to recombobulate a joint. In deep seeded case it may take years or dozens of visits

        1. WilliamLawrenceUtridge says:

          Why a CAM does not work or live up to expectation, I answered this in another blog.

          Why not link to that blog, so I can tell you why you are wrong? Why even mention it if you’re not going to link to it?

          As for why CAM doesn’t work – it’s because most of it is nonsense based on premises that are factually untrue. We don’t know which is which because CAM practitioners are too busy fleecing desperate or even merely worried patients to bother testing it, paying attention to the scientific evidence, or even educate themselves on what a kidney is.

          I would like to address these failures in therapy. Vital data from a CAM provider:
          Acupuncture, Prolo, Bio, massage, dry needling are all not same like comparing a car to a 4 wheel truck. People and even some the therapy as a single concept like “car” and will not venture off road thru the muck. Gee, the tools and ideology of this therapy will also limit its effectiveness. The provider education and experience dependent.

          Sure, that’s true – experience matters; which is why tests of things like acupuncture modulate the practitioner’s experience or rely on “expert” practitioners with extensive experience. Generally scientific studies will not be based on random people off the street who are given a pamphlet – they use experienced practitioners. Given this fact, can you explain why CAM still fails to show any benefits? Can you explain why acupuncture, prolotherapy and dry needling all lack good evidence of efficacy?

          Massage, of course, does work to resolve muscle knots, and just feels good. It also doesn’t penetrate the skin, making it universally a superior option in proof and safety over acupuncture.

          Pain can grow in size + density, can spread and seed local areas and metastasis up or down the spine. In this sense, the pain acts like a cancer and sometimes I refer to it as a “Pain Cancer.”

          Way to trivialize actual cancer there champ. Also, how do you know pain can grow and spread? And how do you address the fact that most people with back pain simply get better without any treatment?

          Just like a cancer this “Pain Cancer” will evolve into 5 stages and will not respond well to weak and imprecise therapy. It is important to know which stage a patient is in, so you will understand if a higher intensity of therapy is needed. The only persons who can tell you if the therapy is effective are the patients who have the pain. So in a one on one session with a CAM provider the sources of the pain are uncovered and treated.

          Have you validated this through reference to the scientific literature? Or did you just make it up? Because it seems like it’s a great way to move goalposts. “Oh, my acupuncture didn’t’ work? That’s because you are actually at stage 3, not stage 2. Now, you’ll need another ten rounds of treatment, but your insurance will cover it. You don’t have insurance? I give a discount for cash payments!”

          It may take 3-13 visits to recombobulate a joint. In deep seeded case it may take years or dozens of visits

          Convenient for you, it’s like an investment in your ability keep charging that patient until they die. No wonder you like chiropractors, you’ve got the same business model.

    3. Tazia Stagg says:

      A friend just asked me about this a couple weeks ago. Here’s a practice that offers it. http://www.rejuvenate-you.org/
      They also sell something else I’d never heard of called velvet elk antler (these three words can be arranged in almost any order) and other placebos.
      Here they are on YouTube.
      https://www.youtube.com/playlist?list=PLVqfyMlXOH2Fwr2AIa61f0zD42tUFKuOs
      The medical director trained in urology.

  2. chinomalon says:

    I’ve heard that not only the standard dextrose is been injected (which can be easily obtained in sterile vials), but in addition to the dextrose the patient’s own platelets are been added to the mix at the practitioners office which make me wonder specially on the safety of not subjecting that extracted blood and its components to a rigorous scientific process of ensuring a sterile mixture with no contaminants or unwanted by products.

    Besides seems like adding platelets to the mix has no scientifically proven or researched benefit that I know of. It seems it just makes the mix more “”glamorous”" to the public but at what cost? People are paying a lot for this injections with no apparent benefit, no insurance coverage and possible contamination.

    1. Andrey Pavlov says:

      Besides seems like adding platelets to the mix has no scientifically proven or researched benefit that I know of.

      While the data is lacking that actually has more scientific support and plausibility than injecting dextrose or other sclerosants. The idea being that the platelets contain growth factors and tissue stimulators that would actually induce cells in the injected area to proliferate, differentiate, and actually repair tissue.

      My feeling is that this will prove to be of some utility, but not nearly as much as people would hope. I also have a feeling it would be more useful in the earlier stages of injury.

      1. kaitch says:

        Another blogger has reviewed the literature on PRP injection before, his website is drskeptic.blogspot.com I think. Spoiler alert: it’s not effective

    2. Eldric IV says:

      I’ve heard that not only the standard dextrose is been injected (which can be easily obtained in sterile vials), but in addition to the dextrose the patient’s own platelets are been added to the mix at the practitioners office which make me wonder specially on the safety of not subjecting that extracted blood and its components to a rigorous scientific process of ensuring a sterile mixture with no contaminants or unwanted by products.

      I also worry about whether it is being carried out appropriately.

      USP 797 governs compounding of sterile products (which includes any transfer of sterile liquids from one container to another). It specifies minimum levels of air quality and cleanliness for any area used to compound sterile products.

      In the pharmacy, the simple act of reconstituting a lyophilized powder and adding it to a bag of normal saline is carried out in an ISO 5 hood (0.5mcm (smaller than a piece of dust) per cubic meter) in an ISO 7 or 8 room (logarithmic scale; for comparison, regular air is ISO 9, or 35,200,00 particles per cubic meter). This constitutes a low risk procedure. Compounding the same product at bedside is considered a high risk procedure.

      Now, instead of using a sealed vial of sterile water to reconstitute a sealed vial of lyophilized powder and adding it to a sealed bag of sterile normal saline, let’s take human blood, centrifuge and decant to extract the platelets, mix it with sterile dextrose, and inject it into a sterile site. I would classify that as high risk.

      1. Eldric IV says:

        Either I inadvertantly deleted a few words or part of my post disappeared. I bet it was my fault.

        It should say that ISO 5 means <3,520 particles of 0.5mcm or larger per cubic meter.

  3. Saynotoprolo says:

    In 2001, I was diagnosed with osteoarthritis of the hip by a doctor in the Chicago area who had probably administered far more prolotherapies than any other doctor, and had written a book on the subject. He made a number of claims, including the claim that 4-5 treatments would cure my OA. He also claimed that it was safe. After the second treatment, his injection just missed a nerve and induced a painful sciatica-like condition which made it impossible for me to sit for 3 weeks. A neurologist told me that if he had hit the nerve, I would have required hospitalization.

    Afterwards, I requested references from the doctor of individuals he had cured of OA. He claimed not to have any for OA of the hip. I asked for references from patients with OA of the knee, or any other type of OA that he had cured. He again said that he didn’t have any, even though he acknowledged that he had performed thousands of prolotherapies.

    In his book, he purported to show before and after images of the state of cartilage of a patient he had treated with prolotherapy. One image showed cartilage that was badly eroded, the other showed healthy cartilage. I asked for a reference for this patient. He claimed that he didn’t know where she was.

    He agreed to let me speak to two current patients whose OA he was treating with
    prolo. One of them had knee OA. She claimed she was getting some temporary pain relief, lasting 2-3 weeks, but was still limping and said that prolo could not cure OA. The other patient had had 16 treatments of prolo over a long period of time, perhaps more than a year, and was experiencing pain relief, but there was no reason to believe that it would continue once she stopped the prolo, or that it was regenerating her cartilage. Anyone who contemplates getting prolo should due their due diligence first. In 2001, I could not find anyone on the Internet who was claiming that prolotherapy worked for them.

    1. @Saynotoprolo
      I hope people understand this distinction! What you experienced is a possible complication of any injection of any type …. NOT just with Prolo. The treatment for this complication is a slightly different form of injection therapy. The Prolo MD may not know that. Apparently the neurologist did not know either and he used blaming instead.

      The main issue is why it works, or why it does not work and clarify for all to understand and publish in an ongoing basis for providers and for patients.

      All of these injection or needle therapies work:
      Prolo, Bio, Sugar, Alcohols, Platelet Rich Plasma, Neural, Travell Tp injects, GunnIMS, dry/wet needling and acupuncture all work under the same 2 step mechanism; Stimulation and muscle reboot.

      ref:
      Gunn, Simons/Travell, Rachlin, Baldry, Hackett, Lennard, Burke, DiFabio, Pybus, Helms, Acupuncture and countless articles on the subject.

      1. Andrey Pavlov says:

        Methinks SSR has a serious case of belenophilia.

        1. Windriven says:

          I’ve learned a new word! And YES that certainly seems to fit! (But why does the phrase needle dick keep coming to mind now?)

          1. Andrey Pavlov says:

            Haha, yes. Belenophilia is indeed quite apt. I don’t read 99% of his posts but from the random samples I do skim, he seems to be absolutely convinced that anything involving a needle must work.

            1. WilliamLawrenceUtridge says:

              He’s getting worse, he now seems to think that any therapy I consider stupid must be trustworthy:

              http://www.sciencebasedmedicine.org/vaccishield-pixie-dust-for-an-imaginary-threat/comment-page-1/#comment-238022

          2. Serge says:

            I’ve just really been enjoying this thread and then Mr Rodriguez comes along and p##ses all over my chips (that may be a little too English for some on this site, but I’ll be happy to explain).

            1. Lytrigian says:

              It’s a self-explanatory turn of phrase, I think.

              1. WilliamLawrenceUtridge says:

                Indeed, i think it universal to find the thought of one’s belov’d tv cop dramas to be micturated upon.

            2. Andrey Pavlov says:

              Those Brits and their piss. Took me a few months to figure out the proper usage of “taking the piss” in Australia.

              1. mouse says:

                Many years ago when I visited London for the summer I was confused that people in pubs kept referring to how pissed they were. I thought “My, the British sure do get irritable when they drink.” Finally – a light – pissed=drunk, not pissed=mad.

                Pee is such an all purpose expletive.

        2. WilliamLawrenceUtridge says:

          He doesn’t pique my interest.

        3. Thor says:

          Hah! Bullseye! How’d you find that? You three are a hoot (The Big Three)—
          chiming in with customary panache. SSR’s inanities certainly provide fodder for witty responses (although they’re really kind of scary).

          1. Andrey Pavlov says:

            Hah! Bullseye! How’d you find that? You three are a hoot (The Big Three)

            Which? The belenophilia? Because my fiance is deathly afraid of needles (I have literally never seen a human more afraid and with such a profound reaction to them) so years ago I learned about belenophobia. Made sense to me that there would be a -philia as well.

            As for the piss… I lived in Australia for 2 years. That is where I did my first 2 years of medical school.

      2. WilliamLawrenceUtridge says:

        Hi Steve,

        I’ve commented on most of these authors previously:

        http://www.sciencebasedmedicine.org/has-science-based-medicine-already-lost-to-pseudoscience/comment-page-1/#comment-199915

        To summarize – the books they wrote tend to be quite old. Almost none have published anything beyond books, meaning they have not subjected their ideas to the scrutiny of their scientific peers. They don’t seem to do research, merely cite one anecdote or unsupported assertion after another. Some are frankly lunatics who don’t come within spitting distance of real science. Citing them as authorities is about as useful as citing the Bible – if you trust it absolutely, it’s great. It’s just unconvincing if you want something beyond the word of the author.

  4. Canuklehead says:

    I ‘belive’ prolotherapy is useful if used for the correct conditions, I have seen some improvement in tennis elbow, golfers elbow, supraspinatus tendonitis, where the teno-osseous junction appears irritated (localised enthesis) I have not seen any decent research on the subject but it does seem to be espoused by some physical medicine practitioners especially those from the James Cyriax camp although he was mainly interested in Lumbar spine injections using P2G (phenol and glucose). I think it may warrant some research but it is likely it is useful for only select conditions. Just my observations.

  5. From the point of view of a 15 year clinical practitioner of Prolo and Injection Therapies.

    “The plausibility of an effect is dubious, but not impossible. It does not appear to work for back pain. ”

    Sorry these are NOT the correct conclusions probably due the the narrow scope of your research and some personal bias.

    If you like I can email you all of my references so you can get a true image of this therapy.

    For the new commenters or laypersons:
    This article is incomplete and needs much more work. I would professionally discount it ALL until there is broader look into the research be done and the conclusion be reconsidered.

    1. Eldric IV says:

      If you like I can email you all of my references so you can get a true image of this therapy.

      ref:
      Gunn, Simons/Travell, Rachlin, Baldry, Hackett, Lennard, Burke, DiFabio, Pybus, Helms, Acupuncture and countless articles on the subject.

      Or you could try posting the references on this weird blog comment contraption that displays words you type. Similar to how the author provides links to the studies he reviews. And preferably actual references (you know, “author, title, journal, year” or even just PMID, to save you the trouble of making links via HTML) and not as you “reference” above.

      1. 1. Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin [Hardcover] C. Chan Gunn MD OBC CM DSc(hon) PhD (Author)
        http://www.amazon.com/Gunn-Approach-Treatment-Chronic-Pain/dp/0443054223/ref=sr_1_1?ie=UTF8&qid=1355779325&sr=8-1&keywords=chan+gunn

        2. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual (2-Volume Set) [Hardcover] David G. Simons (Author), Janet G. Travell (Author), Lois S. Simons (Author), Barbara D. Cummings (Author)
        http://www.amazon.com/Travell-Simons-Myofascial-Pain-Dysfunction/dp/0683307711/ref=sr_1_1?s=books&ie=UTF8&qid=1355779391&sr=1-1&keywords=travell%2C+md+vol+1

        3. Myofascial Pain and Fibromyalgia: Trigger Point Management [Hardcover]
        Edward S. Rachlin MD FACS (Author), Isabel Rachlin PT (Author), Isabel Rachlin (Author)
        http://www.amazon.com/Myofascial-Pain-Fibromyalgia-Trigger-Management/dp/0323011551/ref=sr_1_2?s=books&ie=UTF8&qid=1355779432&sr=1-2&keywords=rachlin%2C+md

        4. Ligament and Tendon Relaxation (Skeletal Disability : Treated By Prolotherapy) [Hardcover] George S. Hackett (Author)
        http://www.amazon.com/Ligament-Tendon-Relaxation-Skeletal-Disability/dp/039805066X/ref=sr_1_1?ie=UTF8&qid=1355958020&sr=8-1&keywords=ligament+and+tendon+relaxation

        5. Pain Procedures in Clinical Practice, 2e by Ted A. Lennard MD, David G Vivian MM BS FAFMM, Stevan DOW Walkowski and Aneesh K. Singla MD MPH (Mar 15, 2000)

        6. Backache from Occiput to Coccyx Hardcover – January 1, 1964
        by Gerald L. Burke (Author)

        7. Intraneural Injections for Rheumatoid Arthritis and Osteoarthritis & Control of Pain in Arthritis
        of the Knee by DiFabio and Pybus
        http://arthritistrust.org/books-and-pamphlets/

        8. Healing through Trigger Point Therapy: A Guide to Fibromyalgia, Myofascial Pain and Dysfunction by Devin J. Starlanyl, John Sharkey and Amanda Williams (Aug 27, 2013)

        9. Myofascial Pain and Fibromyalgia Syndromes: A Clinical Guide to Diagnosis and Management, 1e by Peter E. Baldry MB FRCP (May 4, 2001)

        1. WilliamLawrenceUtridge says:

          Please see my comments on these authors here:

          http://www.sciencebasedmedicine.org/has-science-based-medicine-already-lost-to-pseudoscience/comment-page-1/#comment-199915

          Please point out any i missed and i will address them.

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        Skootsky SA, Jaeger B, Oye RK. Prevalence of myofascial pain in general internal medicine practice. West J Med 1989; 151(2):157-60.
        Fricton JR, Kroening R, Haley D, Siegert R. Myofascial pain syndrome of the head and neck: a review of clinical characteristics of 164 patients. Oral Surg Oral Med Oral Pathol 1985; 60(6):615-23.
        Gerwin RD. A study of 96 subjects examined for both fibromyalgia and myofascial pain. J Musculoskeletal Pain 1995; 3 (suppl. 1):121-5.
        Fernandez-de-Las-Penas C, onso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA. Myofascial trigger points and their relationship to headache clinical parameters in chronic tension-type headache. Headache 2006; 46(8):1264-72.
        Fernandez-de-Las-Penas C, onso-Blanco C, Miangolarra JC. Myofascial trigger points in subjects presenting with mechanical neck pain: A blinded, controlled study. Man Ther 2006; .
        Ardic F, Gokharman D, Atsu S, Guner S, Yilmaz M, Yorgancioglu R. The comprehensive evaluation of temporomandibular disorders seen in rheumatoid arthritis. Aust Dent J 2006; 51(1):23-8.
        Hwang M, Kang YK, Kim DH. Referred pain pattern of the pronator quadratus muscle. Pain 2005; 116(3):238-42.
        Treaster D, Marras WS, Burr D, Sheedy JE, Hart D. Myofascial trigger point development from visual and postural stressors during computer work. J Electromyogr Kinesiol 2005; .
        Simons DG. Myofascial pain caused by trigger points. In: Mense S, Simons DG, Russel IJ, editors. Muscle Pain: Understanding its Nature, Diagnosis, and Treatment. First ed. Philadelphia: Lippincott Williams & Wilkins; 2001. 205-88.
        Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual. Baltimore: Williams & Wilkins; 1983.
        Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician 2002; 65(4):653-60.
        Graven-Nielsen T, Arendt-Nielsen L. Peripheral and central sensitization in musculoskeletal pain disorders: an experimental approach. Curr Rheumatol Rep 2002; 4(4):313-21.
        Arendt-Nielsen L, Graven-Nielsen T. Central sensitization in fibromyalgia and other musculoskeletal disorders. Curr Pain Headache Rep 2003; 7(5):355-61.
        Borg-Stein J. Cervical myofascial pain and headache. Curr Pain Headache Rep 2002; 6(4):324-30.
        Gerwin RD. Myofascial pain syndromes in the upper extremity. J Hand Ther 1997; 10(2):130-6.
        Travell J, Simons D. Myofascial Pain and Dysfunction: The trigger point manual, Volume 2. Baltimore: Williams & Wilkins; 1992.
        Rivner MH. The neurophysiology of myofascial pain syndrome. Curr Pain Headache Rep 2001; 5(5):432-40.
        Borg-Stein J, Simons DG. Focused review: myofascial pain. Arch Phys Med Rehabil 2002; 83(3 Suppl 1):S40-S49.
        Rudin NJ. Evaluation of treatments for myofascial pain syndrome and fibromyalgia. Curr Pain Headache Rep 2003; 7(6):433-42.
        Hong C-Z. Considerations and Recommendations Regarding Myofascial Trigger Point Injection. J Musculoskeletal Pain 1994; 2(1):29-59.
        Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil 1994; 73(4):256-63.
        Huang KC. Acupuncture: the past and the present. New York: Vantage, 1996.
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        Ernst E, White AR, eds. Acupuncture: a scientific appraisal. Oxford: Butterworth Heinemann, 1999.
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        1. MadisonMD says:

          Gee, SSR, you pasted this list before.

          WLU actually read your copypasta list and had this critique. In brief, none of your references provide evidence for your assertions. You had nor response.

          All you demonstrate by repeating this is:
          (1) You are impervious to critique and lack self criticism and awareness. (You did not respond to WLU’s critique.)
          (2) You will engage in deceit by attempting to flood a conversation with a large number of irrelevant citations to overwhelm. (Before I thought you were just too lazy to read them, but now that WLU pointed out the truth, basing claims on them clearly indicates deceit).

          Instead of using such methods to try to trick the reader, you should provide the single citation that provides the best evidence for your claims. Why don’t you do this? Oh, that’s right, because you are just trying to trick us into believing what you already “know” is the truth…

          1. Harriet Hall says:

            It’s useless asking him for evidence, because he has his own idiosyncratic concept of evidence, just as he has his own idiosyncratic definition of acupuncture. To him, evidence means “I tried it on a patient and the patient said he felt better, and there are books written by people who also used it.”

            1. Windriven says:

              “I tried it on a patient and the patient said he felt better”

              Again, I will direct everyone’s attention to Dr. Rodrigues’s less than stellar patient ratings. I will be the first to admit that these are fraught with bias, but it is striking to me that most of the other internists in his immediate area of Dallas have many more and much higher ratings.

              Perhaps the only person Steve is actually fooling into feeling better is himself.

              1. Flattery will get you nowhere.

                If you like I have a few testimonials. Gee just google my name on youtube. Have fun!

                OH you only believe the less than stellar ratings.
                Cherry pickering is very scientific evidence based.

              2. WilliamLawrenceUtridge says:

                Flattery will get you nowhere.

                He’s not flattering you, he’s calling you an idiot. I point this out because it’s pretty clear you are not very good at reading comprehension. But you’re great at ignoring logic and reason.

                If you like I have a few testimonials. Gee just google my name on youtube. Have fun!

                Do you make a point of gathering testimonials from the people who think you suck? How do we know you aren’t deleting the testimonials of the people who think you are a terrible doctor?

                OH you only believe the less than stellar ratings.
                Cherry pickering is very scientific evidence based.

                Testimonials and patient satisfaction aren’t scientific justifications for much, which is why I rarely comment on them. Instead I’ll ask you my usual question – what is your scientific justification for the treatment modalities you use? Because you consistently fail to link to any pubmed-indexed journals that support your treatments, and in the rare time you do, they are pretty irrelevant.

              3. Windriven says:

                “Cherry pickering is very scientific evidence based.”

                Yes Steve, I agree. You’ll note that I explicitly stated:

                ” I will be the first to admit that these are fraught with bias” just as are your “testimonials.” See, that’s exactly how quackery works. A few patients get better on their own or convince themselves that they feel better and the quack touts this as proof of efficacy.

                That is why scientists do carefully blinded studies. We all like to fool ourselves. So scientists have built a structure that makes fooling ourselves more difficult.

                I’d suggest that you try it but you and I both know that you aren’t up to it.

          2. WilliamLawrenceUtridge says:

            Not quite true – one paper (Hong, 1994) did provide preliminary evidence of a possible effect. The rest were worthless nonsense. I also analyzed his list of authors in a previous comment (see here), and his recycling both means I will have to keep both links handy to avoid having to find them again and again.

      3. We can discuss any of them when you are ready.

        1. WilliamLawrenceUtridge says:

          I already discussed the second turdpile of references here, you never replied to that comment (but you did repeatedly whine that nobody ever read your references – so I made sure to post in that link after every whine to be sure you had a chance to reply to my analysis).

          I also addressed a couple months ago your list of authors which you essentially duplicate above here. My expansion here is to note that many are old. I mean Hackett is from 1958 – anyone using treatments or relying on knowledge from 1958 is basically committing medical malpractice as far as I can tell. What has stayed so reliable in medicine that 56-year-old books are relevant?

          But hey, you want to discuss – let’s discuss! Why are old books, written by authors who never subjected their practices to peer review, reliable sources of information? Why didn’t they publish their clinical trials? Did they conduct clinical trials? Why are clinical trials with adequate randomization superior to assertions based on clinical experience?

          Inquiring minds want to know!

          1. NONE of what you said is relevant to ALL of the concepts in ALL of the articles. You can not pick and choose … or your conclusions will be incomplete.

            Actually without any clinical experience using ALL the techniques, I would reserve my opinions. I makes one look as though they are here to support a personal agenda and not trying to uncover the scientific evidence and truth.

            Actually does anyone have any experience with the use of needles? prolo? biopuncture? acupuncture? dry needling? Adjustments? spray and stretch?

            1. MadisonMD says:

              Hey, SSR. Look here. Nothing you say is relevant to ALL the concepts in ALL the articles there. You do not have experience in all the practices in those articles. So what? Perhaps that means you should reserve judgment and refrain from practicing medicine?

              Now that we’ve dispensed with such tomfoolery, which article in particular would you like us to take a second look at and what point did WLU miss in that article?

              1. @MadisonMD
                Assumptions are not wise.

                I use all of those options in the office to help patients in chronic complex pain. They all work beautifully when done appropriately.

                There are course out there for those who wish to learn.

              2. Windriven says:

                @Madison

                Note that Rodrigues makes no effort whatsoever to answer your simple question. This is clearly not an accidental oversight but a willful avoidance.

                One has no choice but to conclude that Dr. Rodrigues’ approach to his patients similarly avoids the elements of medicine that he finds uncomfortable or difficult to grasp.

                Chilling.

              3. WilliamLawrenceUtridge says:

                I use all of those options in the office to help patients in chronic complex pain. They all work beautifully when done appropriately.

                There are course out there for those who wish to learn.

                You didn’t answer Madison’s question, which was “what article wasn’t accurately summarized”. Please respond.

                Which of the options do you use that are scientifically justified? Which ones are based purely on your clinical experience? Most of the contributors are happy to learn – but not from clinical experience. So all you have to do is provide the scientific references that justify your beliefs and treatments, and we’ll come around.

              4. Is it wise or ethical to deny a therapy to someone who suffers in constant pain that is safe, still practiced around the world, effective, nontoxic and never disproven–that has been used effectively for thousands of years?
                –that has been used effectively for the last 100 years?
                –just because of a belief system?
                –just because modern scientists can not uncover a mechanism of action?
                –just to help promote and prove Quintner, McKay and Ingraham have not wasted their time refuting TrPs or Gunn/Travell/Simons.

                The human body has not changed much in the past few dozen millennia so those tools are still valid. I hope that you all are not subjecting your PAIN patients to all Traditional Pain Care Medicine without alternatives! At this point in time, CAM providers would considered that a VICTIMISING, SHORT SIGHTED and BENIGN NEGLECTFUL standard of care. For now, you all are safe from malpractice, but in the future those souls will have a voice in court!

              5. WilliamLawrenceUtridge says:

                Is it wise or ethical to deny a therapy to someone who suffers in constant pain that is safe, still practiced around the world, effective, nontoxic and never disproven–that has been used effectively for thousands of years?

                The thing is – if it was effective a thousand years ago (and bear in mind – acupuncture a thousand years ago was completely different from today’s practices, they did not use filiform steel needles but instead relied on bloodletting knives) then it should still be effective now in controlled trials. But consistently, “real” acupuncture and “fake” acupuncture, even nonpenetrating acupuncture, have the same results. Why do you think that is? Is it ethical to charge patients and subject them to the risks of nerve damage, bleeding and lung puncture for something that doesn’t seem to work better than placebo? Would you be comfortable with GSK selling a drug that causes bleeding, nerve damange and pneumothorax purely on the basis of it “never being disproven”?

                And of course, the specific tenets of acupuncture have been tested and most are irrelevant; it doesn’t matter where you needle, it doesn’t matter whether you penetrate the skin, and it doesn’t matter whether you use needles at all, but it does matter that your customer thinks they are getting real acupuncture. So much for “not being disproven”.

                –that has been used effectively for the last 100 years?

                I thought it was thousands of years old?

                –just because of a belief system?
                –just because modern scientists can not uncover a mechanism of action?
                –just to help promote and prove Quintner, McKay and Ingraham have not wasted their time refuting TrPs or Gunn/Travell/Simons.

                You’re rather missing the point, and the evidence. Scientists and doctors are not opposing acupuncture for it’s lack of mechanism, or because of a belief system, or to promote competing authors. Scientists and doctors (and the contributors to this blog) reject acupuncture because it consistently shows that it is nothing but a theatrical placebo. It’s not prejudice, it’s that acupuncture is inert – a point you never seem to recognize. You go on and on about prejudice, smear people who disagree with you by accusing them of being paid shills, and proclaim your clinical experience – but you never actually look at the evidence against acupuncture. Why is that?

                The human body has not changed much in the past few dozen millennia so those tools are still valid. I hope that you all are not subjecting your PAIN patients to all Traditional Pain Care Medicine without alternatives! At this point in time, CAM providers would considered that a VICTIMISING, SHORT SIGHTED and BENIGN NEGLECTFUL standard of care. For now, you all are safe from malpractice, but in the future those souls will have a voice in court!

                The human body has not changed, but medicine has. By asking for proof of efficacy, it has improved lives, lengthened lives and prevented childhood deaths – something which acupuncture didn’t seem to do despite “thousands of years” of history. Why do you think that is?

                If acupuncture actually works – prove it in controlled trials. Compare it to meaningful placebos and active conditions. Break it down into its basic units to determine which are essential and which are useless. Test it! If it’s as effective as you claim – why doesn’t it pass testing? Can you explain that simple fact?

            2. WilliamLawrenceUtridge says:

              NONE of what you said is relevant to ALL of the concepts in ALL of the articles. You can not pick and choose … or your conclusions will be incomplete.

              Well at least you no longer pretend I didn’t analyze your sources.

              My actual review of the sources you provided was to look at the sources and say whether they supported your claim that acupuncture was a valid treatment for triggerpoints. Only one source you provided was an actual experimental trial that tested this question – the rest simply assumed that it worked or were completely irrelevant (my favourite section being “history”; how the history of acupuncture is relevant to the efficacy of acupuncture, I’m not clear on).

              You are the one picking and choosing, in that you are taking a very specific (though surprisingly irrelevant) list of sources and ignoring the much, much larger list of null results and even the short list of Cochrane reviews that find acupuncture indistinguishable from pretending to do acupuncture. Your statement doesn’t make any sense and just tries to distract from your failure yet again to show any familiarity with the scientific evidence.

              Actually without any clinical experience using ALL the techniques, I would reserve my opinions. I makes one look as though they are here to support a personal agenda and not trying to uncover the scientific evidence and truth.

              It certainly looks like you are trying to support a personal agenda of “never having to read a scientific paper”. Medicine based purely on “clinical experience” is dangerous because it subjects patients to unknown risks for uncertain benefits. Just ask Kim Ribble-Orr or Roh Tae-woo. Bloodletters had thousands of years of clinical experience, but none of that experience demonstrated they were killing people.

              Actually does anyone have any experience with the use of needles? prolo? biopuncture? acupuncture? dry needling? Adjustments? spray and stretch?

              Why does it matter? Personal experience is deceptive, which is why scientific testing is so important.

              Also, I had some acupuncture for ankle pain, and it didn’t help. So there, some direct experience. Please stop promoting acupuncture.

              1. OK, Gee you’ve convinced me that you are biased and short sighted.

                You can let the discussion with me as it relates to acupuncture and TrPs go.

                I will interject for those who you attempt to persuade with your incomplete conclusions. I’m sure they will not have a vendetta.

              2. WilliamLawrenceUtridge says:

                OK, Gee you’ve convinced me that you are biased and short sighted.

                Why? Because I asked for evidence and you never provided any?

                You know what’s short-sighted and selfish? Demanding the ability to charge unproven medical treatments. Over the short term, you make a profit. Over the long term, you are either depriving people of effective medical care (if it works) or wasting the time and money of desperate people (if it doesn’t). So just fucking test it already.

                But no – you’re right; I’m biased and short sighted because I don’t charge people for unproven medical treatments and require evidence before endorsing them.

                You can let the discussion with me as it relates to acupuncture and TrPs go.As long as you keep saying stupid things and making claims without referencing any meaningful and relevant scientific literature, I’ll still be here. You’re free to go elsewhere if you don’t like me constantly pointing out how deceptive and lazy your comments are.

                I will interject for those who you attempt to persuade with your incomplete conclusions. I’m sure they will not have a vendetta.

                So…anybody who disagrees with you has an agenda or vendetta, but anybody who makes claims and charges people for unproven medical treatment should be left alone to exploit freely adminster them to their customers without any care to evidence?

                How would you feel if Pfizer demanded the right to sell drugs to the public with similar lack of restrictions and inattention to the scientific literature? Why is it OK for you to insist that shoving needles thorugh the skin is safe and effective but if Ian Read were to do this for their new drug dickfallofimaub, you’d shit your pants?

                Hypocrite.

    2. Serge says:

      Aaaaagh! Again!

    3. WilliamLawrenceUtridge says:

      From the point of view of a 15 year clinical practitioner of Prolo and Injection Therapies.

      The thing is – there were bloodletters who practiced for four, even five times that long, and they were convinced of their conclusions. The also opposed vaccination for smallpox.

      Duration of clinical experience is not worth much if your clinical experience has no touchstone with the empirical literature. Clinical experience is like all experiences – deceptive, and constructed by the mind to justify current beliefs and actions. It’s not reliable in isolation.

      Sorry these are NOT the correct conclusions probably due the the narrow scope of your research and some personal bias.

      Did you see the part where Dr. Novella cited numerous systematic reviews and discussed the scientific literature? What scientific literature did he, and the authors of the systematic reviews, miss? You should forward it to them so they can revisit their conclusions.

      If you like I can email you all of my references so you can get a true image of this therapy.

      Why not just pop in your pubmed-indexed citations here? Why take it offline? The scientific literature benefits tremendously from public exposure and scrutiny – when you “take something offline” it restricts the audience, meaning you don’t get as many minds looking at the evidence and assessing its validity. Real scientists are happy to be public, it’s only frauds and pseudoscientists that try to restrict commentary.

      For the new commenters or laypersons:
      This article is incomplete and needs much more work. I would professionally discount it ALL until there is broader look into the research be done and the conclusion be reconsidered.

      Well Steve, why not submit a guest post? Since you’ve got such a brilliant grasp of the scientific literature, why not demonstrate it through a superior post on prolotherapy that draws upon the primary literature in a way that Dr. Novella did not? Because since you cite no actual scientific literature, we must basically trust your competence in order for your word (the only thing you provide) to be worthwhile. And you give very little indication of competence, merely bluff and a complete lack of understanding of both the scientific literature and the myriad ways the mind can deceive.

  6. TBruce says:

    It reminds me of deep tissue massage in that the idea is to cause breakdown and irritation to the painful tissue with subsequent regeneration and (hopefully) relief of symptoms. I don’t know how effective deep tissue massage is, although it’s very commonly used by athletes. However, a lot of scientifically dubious stuff is used by athletes.

    1. @TBurce
      The major primary cause of chronic pain is in the muscles and associated connective tissues … so the treatment of this should be focused at the muscles. Any therapy aimed at other structures would be treating the secondary problem which would be less effective, misguided and erroneous.

      The “why” massage works is based to activation of the natural healing cascade. (Not so scientifically dubious)

      1. WilliamLawrenceUtridge says:

        If you are so confident of this, can you please provide pubmed-indexed sources and other peer-reviewed publications to support this belief? Thanks!

        1. “pubmed-indexed sources”
          So this is where you all worship and where the words are all sacred and holy?

          1. WilliamLawrenceUtridge says:

            No, pubmed-indexed journal have passed a minimum threshold of quality that indicates they are worth at least considering and therefore not the absolute worst scum-sucking gutter journals.

            Using the words “sacred” and “holy” shows that you miss the point. “Sacred” and “holy” and “worship” for that matter, are religious terms that require faith for belief.

            Science and peer-reviewed articles do not require faith, since they are evidence-based and empirical. Scientists and those familiar with science will change their minds with sufficient adequate evidence. Nobody believes you because you consistently fail to provide it. Just long lists of irrelevant references, 30-year-old books and your own experience which, ironically given your statement, you demand we believe in like it were holy writ.

            All we ask is that you show us evidence, reliable, replicable evidence, that indicates acupuncture does what you claim it does – and that indicates why the mountain of existing evidence for acupuncture is consistently negative as you control for more aspects of the treatment.

            Why do you see this as unreasonable, given the expense and risks of acupuncture? Why is it so hard for you to provide or even appreciate the need for good evidence beyond your immediate experience?

  7. Ed Whitney says:

    One big problem with prolo is that it has irritant properties and its purported mechanism of action involves inflammation with release of cytokines and recruitment of fibroblasts ; this means that you cannot use NSAIDs to treat the resultant pain because this would block the inflammatory response. I asked a prolo practitioner about this and he suggested that you may need to use opioids to treat the post-procedure pain. Sounds like a drawback to the procedure.

    1. Andrey Pavlov says:

      Ed, it seems to me the solution is to take acetaminophen. It is not an anti-inflammatory and can help with the pain/soreness.

      1. Ed Whitney says:

        I had thought the same thing, but apparently acetaminophen sometimes does not provide sufficient analgesia. This conversation took place in the 1990s and perhaps the injected solution has changed since then, but the aftermath of some injections was quite painful.

        The S-I joint seems to invite a number of interventions born of desperation. Prolo seemed like one of them.

    2. If you consider Gunn/Cannon 2 step metallic needle theory, the prolo “chemical” would be invalid. (actually any chemical)

      The action of the needle is all that is needed to active the purported mechanism of action involves inflammation with release of cytokines and recruitment of fibroblasts == so called healing cascade.

      The needle depolarizes the muscle and allow the contracted muscle fibers to release and relax. (a tense muscle will not heal well)

      This is called GunnIMS and or Medical Acupuncture.

      THE BEST TOOL AND MEDICINE IN MEDICINE!!

      1. WilliamLawrenceUtridge says:

        If you consider Gunn/Cannon 2 step metallic needle theory, the prolo “chemical” would be invalid. (actually any chemical)

        The action of the needle is all that is needed to active the purported mechanism of action involves inflammation with release of cytokines and recruitment of fibroblasts == so called healing cascade.

        What peer-reviewed journal articles support this – specifically that needlling leads to a healing cascade, and the ultimate question, that it results in outcomes superior to current care? I’ll even accept animal studies as preliminary.

        The needle depolarizes the muscle and allow the contracted muscle fibers to release and relax. (a tense muscle will not heal well)

        Wouldn’t simply contracting and relaxing (i.e. moving) the muscle work just as well under this rather simplistic approach? Or a TENS unit? Or, for that matter, a simple massage? Why penetrate the skin? And, of course, what justifies this scientifically, where are your citations?

        THE BEST TOOL AND MEDICINE IN MEDICINE!!

        Really? Better than, say, vaccination, or dietary advice, or antibiotics, or exercise, or sanitation, nutritional advice, toxicology, food safety? Because even assuming it works (and you’ve yet to support that it does), it’s still only helping with muscle and perhaps joint pains. And while muscle and joint pain is indeed important, it’s pretty far from the most serious problem in medicuine.

  8. agitato says:

    Very informative blog entry Dr. Novella. Until now I had never heard of prolotherapy. I assumed it was because I live in Canada and maybe the treatment hadn’t yet wound its way north. Unfortunately, The Google proved me wrong. There it is, one of the services listed at a naturopathic clinic in the Nation’s Capital right under Biopuncture which I’d never heard of either. “Biopuncture involves the injection of biological substances into skin or into muscles for the purpose of stimulating the body’s own healing process and a return to normal function. This is often referred to as auto regulation.” Auto regulation? Often?

    And…I learned that Skeptic North has also written about prolotherapy:
    http: //www.skepticnorth.com/2010/01/prolotherapy/

    But the good news is no provincial health plan pays for it.

    Also, thanks to you “Kaitsch” for the link to http://doctorskeptic.blogspot.com. An interesting site. I note he has Science Based Medicine as a recommended link.

    1. “But the good news is no provincial health plan pays for it.”

      This is why Medicare is going to fail with 800,000 joint replacements per year … no alternatives. The present system can not support this malpractice much longer.

      Expand your search, If you find articles in various other locations and ask questions of providers and patients you will find that the articles can not grasp the complexity of pain and pain therapies.

      1. WilliamLawrenceUtridge says:

        This is why Medicare is going to fail with 800,000 joint replacements per year … no alternatives. The present system can not support this malpractice much longer.

        Where is your evidence that 800,000 joint replacements are all caused by muscle knots? How will muscle knots help someone whose cartilage is worn away and their joint consists of two bones rubbing directly on each other? Doesn’t it basically come down to the fact that you’ve seen some patients (far less than 800,000 I would expect) who are dissatisfied with their joint pain? How many patients do you see who are satisfied with their joint replacements?

        And, of course, what evidence do you have that your approach permanently and safely elminates joint pain?

        Expand your search, If you find articles in various other locations and ask questions of providers and patients you will find that the articles can not grasp the complexity of pain and pain therapies.

        Can you point us to any scientific, peer-reviewed articles that support your personal pain management approach? How do you know it works better than, say, joint replacement, or watchful waiting, or massage, or NSAIDS?

      2. Windriven says:

        “This is why Medicare is going to fail with 800,000 joint replacements per year … no alternatives.”

        Provide us with scientific evidence that acupuncture is a safe and effective – and cost-effective – treatment for conditions that are typically treated with joint replacement surgery and I will be the first to lobby for a change in Medicare coverage. But even your often wasteful Uncle Sugar is clear-eyed enough not to fall for pure quackery.

  9. Dr Jeremy Greenwood (GP) says:

    I managed to refer someone for prolotherapy to a specialist centre some years ago for ‘chronic spinal instability’, previously diagnosed by a consultant. This was shortly after I did the Cyriax course.
    It didn’t work.
    wrt Cyriax (orthopaedic medicine): I find the injections really useful, but the manipulations only useful were I to work in private practice (they work a short time and then need to be done again lol). With1 exception: I have seen 2 people with acute sacroiliac joint dysfunction (as defined by Cyriax) in 20 years and in each case the manipulation was both miraculous and permanent (though a chaperone is recommended).

    1. @Dr Jeremy Greenwood
      If this therapy does not work … the primary reasons are time, effort and technique.
      Time — I will see these folks once a week x 6 to be certain of the problem. A back pain may not be in the lower back – it maybe in the quadratus, gluts or hams. That is why acupuncture needles augment/complement the entire procedure. Pain is not where you think it is!
      Effort — If you are timid with the needles, size and or depth the results will be less than optimal.
      Tech — lots of intramuscular stimulation is vital.

      See my prior post on Gunn/Cannon if you wish to help your patients.
      Need help? See Travell/Rachlin/Hackett textbooks

      1. WilliamLawrenceUtridge says:

        See my reply here.

  10. If you are respectable researchers with open minds, free of agendas and in search for the truth.

    Borg-Stein J, Iaccarino MA.2014. Myofascial Pain Syndrome Treatments. Phys Med Rehabil Clin N Am. 25(2):357-374.

    1. WilliamLawrenceUtridge says:

      Actually, I would read that if I had access to it. Unfortunately it’s not available through a generic search.

        1. WilliamLawrenceUtridge says:

          Do you know what an abstract is? Because that’s all I can see; I have requested a copy from the first author and look forward to reviewing it.

          Also, congratulations on providing your very first meaningful and substantive citation. This is the first step in engaging with the scientific literature. Naturally, merely dropping a citation doesn’t mean all of your claims are correct. Considering it took you months to provide any pubmed-indexed citations, and that list was mostly irrelevant, I think I’ll not hold my breath about the citation you provide above. Further, secondary sources like this one require analysis of the quality of the primary sources.

          Not to mention, one must always ask “who disagrees”? Because if you only cite people who agree with you, and never look at or for dissenting literature, you’re basically just asking for an echo chamber, not science.

          So – I look forward to seeing what evidence Borg-Stein and Iaccarino discuss. Thank you for bringing this to my attention.

          But it forces me to ask – this is dated March, 2014, mere months ago. What were you basing your clinical practices on before it was published?

          1. Harriet Hall says:

            Don’t bother. You can tell from the abstract that it is simply a review listing what treatments are being used, not a controlled study showing that they work.

            1. WilliamLawrenceUtridge says:

              Oh, I still want to read it. I suspect that this incredibly recent review article will demonstrate that the theory is based solely on unreviewed books with few-to-no discussion of primary sources. And if that is the case, I really, really, really want to rub steve’s face in it and add to my list of his failures to understand science.

              If anyone can forward me a copy, I would be most grateful.

              And hell, I might learn something, which is something I always enjoy.

              1. Texts are a wealth of knowledge and wisdom that we in clinical medicine use to complement and compensate for the failures of SBM.

                If you are not in the clinics and don’t care about how patients feel, you would have no idea or concept. Sorry dude, you can not envision any of these concepts.

                lol my spelling needs work and your logic is flawed … I’d rather have the spelling problem.

              2. WilliamLawrenceUtridge says:

                Texts are a wealth of knowledge and wisdom that we in clinical medicine use to complement and compensate for the failures of SBM.

                Wisdom is understanding the limits of your knowledge, which you do not seem to. Knowledge you lack completely, as you are totally unfamiliar with the scientific literature on acupuncture. The true failure is your failure to even know anything about the vast body of negative studies on acupuncture. For all your blather about patient care and respecting science, you’re still just using whatever you think to work, with no awareness of the flaws in clinical experience. And since you’ve run out of real arguments and never had any meaningful data, now you’re just showing up and mouthing vague platitudes.

                Tell me, what did you find most interesting in Borg-Stein and Iccarino’s paper? What finding most impressed you? What citations did they include, and what citations do you think they left out?

                If you are not in the clinics and don’t care about how patients feel, you would have no idea or concept. Sorry dude, you can not envision any of these concepts.

                To repeat yet again – clinical experience lies. Bloodletters swore they were healing patients, and if you know anything about the history of American medicine, the transition from bloodletting ignorant quacks to scientific medicine was a fraught and contested one, because doctors couldn’t bring themselves to abandon their needles and lancets. Why do you think your clinical experience is so much better than theirs? Why is it better than the orthopedic surgeons who swore knee cartilage debridement was safe and effective, based purely on their clinical experience?

                lol my spelling needs work and your logic is flawed … I’d rather have the spelling problem.

                Sadly you’ve got both. What logic have you employed? What logic have I used that is flawed? You keep claiming I make mistakes in reasoning – but you never provide an example beyond “well, you don’t believe my clinical experiences, which are totes awesome”.

            2. Disregarding data is not the way of a good scientist or practitioner.

  11. Where is Novella? He started this discussion!

    1. Windriven says:

      I suspect that Dr. Novella has better things to do with his time than engage with a science denialist and troll like you, Steve. Maybe he’s off getting a pedicure.

      1. NOvella and the other editors seems to using you guys as some sort of deflectors.

        1. WilliamLawrenceUtridge says:

          Nope, the other contributors are mostly practicing doctors (Dr. Hall is the exception), and Dr. Novella, in addition to his daily clinical duties, writes, reads and podcasts extensively on his other blogs and websites. He’s got way better things to do than argue with a repetitive, clueless fool, proudly braying his ignorance and lying about his knowledge of science.

          Rather than claiming some sort of self-aggrandizing conspiracy, why not refute my arguments or sources? Are you incapable of doing so, and are forced to try to distract everyone instead?

          1. See you are covering for him now!

            He has time, they all do!

            They are spread to thin trying to accomplish something other than the truth in science.

            Hmmm I wonder where they are?

            1. WilliamLawrenceUtridge says:

              See you are covering for him now!

              He has time, they all do!

              They are spread to thin trying to accomplish something other than the truth in science.

              Hmmm I wonder where they are?

              How is acknowleding a busy schedule “covering for him”. How do you know how much time he has?

              And why are you trying to cast vague aspersions on them? Why must you look for conspiracy or sinister motives rather than noting what I said – Dr. Novella has a personal blog, clinic duties, a website, and a very popular podcast. Why must you insist that you are so important that Dr. Novella must respond or there is some sort of nefarious plot afoot? Maybe he just doesn’t care about an evidence-free arrogant wannabe doctor like yourself?

            2. Sawyer says:

              I’ll throw out a wild guess that Dr. Novella easily puts in an 80 hour work week, and only gets paid for half those hours. If you can tell him how to more efficiently budget his time it’s probably worthy of a Nobel prize.

              SSR, if you seriously believe that he needs to be spending time responding to your idiotic screeds on a Sunday night rather than, say, spend a few hours with his family, then you aren’t just ignorant of science and medicine. You’re an asshole too.

  12. WilliamLawrenceUtridge says:

    If this therapy does not work … the primary reasons are time, effort and technique.

    Sounds like an awful lot of goalposts to move. So, if it doesn’t work – first you say it needs more time. If it still doesn’t work, then you say “not enough effort” (on whose part? And if you say “the patient’s”, then you’re very close to blaming the victim). And if it still doesn’t work, then finally you can blame technique. So how often do you fail to help a patient because of your shoddy technique?

    Time — I will see these folks once a week x 6 to be certain of the problem. A back pain may not be in the lower back – it maybe in the quadratus, gluts or hams. That is why acupuncture needles augment/complement the entire procedure. Pain is not where you think it is!

    that sounds very lucrative for you.

    Effort — If you are timid with the needles, size and or depth the results will be less than optimal.
    Tech — lots of intramuscular stimulation is vital.

    How do you reconcile this with the fact that studies have found nonpenetrating toothpicks to be as effective as actual needling?

    See my prior post on Gunn/Cannon if you wish to help your patients.
    Need help? See Travell/Rachlin/Hackett textbooks

    What primary studies do Travell, Rachlin and Hackett base their textbooks on? Because Rachlin at least I couldn’t find any clinical trial publications on pubmed. Could you please link to the primary studies they use to justify their recommendations?

    1. WilliamLawrenceUtridge says:

      In reply to this comment.

    2. You will need to get a copy for yourself.

      The concepts are too unfamiliar to understand them in a few pages.

      Once familiar they are very simplistic.

      1. Remember yall think I’m shallow so yall will be able to comprehend the data lickety–split.

        Be careful, it is like the red pill, truth of reality, which will get you out of many rabbit holes.

        1. WilliamLawrenceUtridge says:

          Your high-minded rhetoric is great and all – but all I want is a list of pubmed-indexed papers to support your assertions. Why have you been unable to accommodate such a simple request? Why do you keep dodging it, or dropping in spurious lists of papers you haven’t even read?

          It’s easy – just provide me the primary studies that you rely upon for your day-to-day clinical decision-making. Pubmed numbers are fine, or just weblinks. Empty assertions that I’m too stupid to understand them doesn’t make them magically appear.

          1. You guys think you can just read a few pages and “see” the therapy.
            That is not completely possible because a lot of my colleagues can not “see” what they are doing.

            Sorry the truth is a tough pill to swallow. You do not have the ability to understand because you do not wish to understand. First you have to have the need to see and then you have to trust the therapy and the trust the patients. Impossible for you all.

            Just because I have a few answers does not mean I know it all. Duh!

            I still have dozens of questions that need answering. I can not expect the people who got us in this situation to get us out due to profits and distractions.

            Hey don’t blame and shame me for your situations.

            I can write an article .. but you already have all of my data.

            1. WilliamLawrenceUtridge says:

              You guys think you can just read a few pages and “see” the therapy. That is not completely possible because a lot of my colleagues can not “see” what they are doing.

              I’m not asking to be able to “see” the therapy. I want to “see” the evidence-base supporting it. I’m not asking to be able to actually treat anybody – I just want to know what scientific evidence exists to demonstrate that it actually works. And it is increasingly obvious that there is zero such evidence, at least that you are aware of.

              Sorry the truth is a tough pill to swallow. You do not have the ability to understand because you do not wish to understand. First you have to have the need to see and then you have to trust the therapy and the trust the patients. Impossible for you all.

              If a treatment works, it should be possible to demonstrate this through clinical trials. This only requires “trust” that the researcher is not lying or committing blatant fraud. What I don’t “trust” is your familiarity with the evidence, mostly because you haven’t “provided” any.

              I don’t mind changing my mind, and I would love to have an effective therapy to point towards for low back pain, or joint pain, or muscle pain. All I ask is to see the evidence that supports it.

              Why are you unable to provide me with any such evidence?

              Just because I have a few answers does not mean I know it all. Duh!

              More accurately, you do not have any answers that I’ve seen, merely assertions that you can work miracles and that all other doctors are corrupt and greedy. May I point out that this is evidence of your own self-aggrandizement, not evidence that anything you do is effective.

              I still have dozens of questions that need answering. I can not expect the people who got us in this situation to get us out due to profits and distractions.

              Exactly what profits do you think are made on this site? You really think some nefarious company is paying everybody here to keep effective treatments out of the medical system?

              So far you haven’t really asked any questions beyond “who is paying you”, to which we have replied “nobody, now where is the evidence you claim to have but keep failing to provide?”

              Hey don’t blame and shame me for your situations.

              I’m blaming and shaming you for your situation – providing medical care with no evidence of efficacy.

              I can write an article .. but you already have all of my data.

              Really? Where is it? Because you’ve only provided long lists of irrelevant citations you apparently haven’t read, books published decades in the past, and a single review article – no primary studies whatsoever.

              You make a lot of claims, but you back none of them up. Why should anyone trust you?

            2. weing says:

              “That is not completely possible because a lot of my colleagues can not “see” what they are doing.”

              Are you sure it’s not all of your colleagues, including you?

        2. Windriven says:

          “Remember yall think I’m shallow so yall will be able to comprehend the data lickety–split.”

          No, for a long time I thought your were misguided, then I thought you were delusional. Now I just think you’re stupid.

          1. WilliamLawrenceUtridge says:

            That conclusion is becoming almost inescapable. It also illustrates the unfortunate tendency of the human mind regards cognitive dissonance. Rather than admitting his experience and ideas are based on flawed data and systematic bias, he has dug himself firmly into a deeper hole and now claims the problem is that we are all agents of a grand conspiracy to keep The Truth about CAM hidden.

            When faced with a choice of “I was wrong” versus “everyone else is actually evil“, the latter wins more often than not.

        3. Windriven says:

          Steve-

          Two things:

          1. Your schtick has gotten more than a little too stale. It is time for you to either participate in a science based discussion complete with citations of meaningful and relevant literature or to go away. If you choose neither, I will mount a campaign to have you banned. You chew up valuable time in a never ending game of whack-a-mole that adds absolutely nothing to the conversation.

          2. Write a guest post clearly laying out a science-based case for the flavors of acupuncture that you believe in. Again, I’ve no confidence that you can build an argument that would be publishable here, but it might help you to structure your own thinking on the issue. But who knows? If you write it and you wish, I will edit it for grammar, structure and punctuation.

          I’m not kidding about trying to get you banned if you don’t frame your arguments in a more meaningful form. We are all just tired of screwing around with your stream of consciousness blather.

  13. CJ says:

    I was a patient so all I can offer is my experience. If anecdotes upset you, don’t read further. Because I am not a medical expert, you will find no technical language here.

    I am a paraplegic. After decades of using improperly fitted manual wheelchairs, I developed severe pain in one shoulder. When it became so unbearable that I thought I might require surgery, my husband found and article written by Dr. C. Everett Koop on his positive experience receiving prolotherapy. I found a medical doctor whose specialty was treatment of pain. He gave me about 4 series of shots into my shoulder, spaced about a month apart. I believe he said the injections contained saline, glucose, and something for pain. Over the course of treatment, I gradually had less and less pain between treatments. However, it was not until I acquired a properly fitted chair that I had the most benefit. I am grateful that the prolotherapy helped as an intermediate step.

    1. WilliamLawrenceUtridge says:

      How do you know your shoulder didn’t simply get better over time, as pain often does when it’s at its worst, and hasn’t come back because you now have the appropriate wheelchair?

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