Saturday, 7 July 2012

Prolotherapy: the illusion of effectiveness

Many of my blogs have a recurring theme: an intervention that sounds great (biologically plausible), has great early results, but on rigorous scientific testing is shown to be ineffective. Prolotherapy does not fit that mould, because I don’t even buy the biological argument in the first place. Prolotherapy involves the injection of irritant solutions in order to strengthen tissues and relieve pain. That makes about as much sense as homeopathy, or being struck on the head to relieve a headache.

Searching prolotherapy in the medical literature doesn’t get you far. There is a Cochrane review from 2010 that shows it to be ineffective on its own for back pain. When I searched for individual research articles, I found 75 articles in Medline. Of these, there were 8 randomised trials. Some of these compared prolotherapy to corticosteroid injections, giving it the illusion of effectiveness; here’s how. For each of these studies, the two treatments showed similar treatment effects. The conclusion was that prolotherapy was as good as corticosteroid injections. While technically correct, the illusion lies in the implication, or underlying assumption, that both treatments are effective. The conclusion does not tell us whether either treatment is more effective than placebo. Most of the placebo studies (here, here and here) show prolotherapy to be ineffective or barely effective. The placebo studies for corticosteroid injections aren’t much better and will be the subject of a future blog post.

Comparing one treatment to another is commonly done, and often leads to this illusion of effectiveness, because both treatments make use of the placebo effect. We conclude that both treatments are equally effective, without considering the equally valid conclusion that both treatments are equally ineffective. This is the problem with so called Comparative Effectiveness Research: even the title is misleading, because it assumes an effect, and by excluding comparisons with an inactive control (placebo), comparative studies often ask the wrong question.

79 comments:

  1. Hi Dr. Skeptic,

    The biological mechanism does sound a bit dubious, nevertheless interesting (getting kicked in the shins repeatedly is supposed to create microfractures and strengthen the bones right?)

    What do you think of this small double-blinded study: The efficacy of prolotherapy for lateral epicondylosis: a pilot study
    http://www.ncbi.nlm.nih.gov/pubmed/18469566

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    1. Thanks DavidM,
      Nice little study: randomised, allocation concealment, blinded patients and outcome assessors, well described outcome. Only 10 patients in each group but they found a difference. Alone, it looks good, so I would like to see it repeated, or to see the full study.
      Lateral epicondylitis is a funny one. Lots of treatments have gone down on that diagnosis by looking good in early trials and then failing on the final hurdle. Pulsed ultrasound, and even surgery. Sounds like fuel for a few more blog posts.

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    2. Hi Dr Skeptic,
      You are assuming that everyone who knows a secret has to publish it in a journal. There are many doctors who do not even know the technique for infilteration, who have published tons of literature. Then there are doctors who get more than 90 % success, who have never written a single article. I have astounding results for my patients with both corticosteroids and prolotherapy and PRP. But I do not believe I should share my trade secrets with anyone else. You can call me selfish, and I may be okay with that......These skills have a steep learning curve, infact it took me 5 years to perfect my skills, and I am still learning. I sure do not want competition, and others learning the same skills, so why would I want to publish an article....

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    3. Where would medicine be now if the discoverer of every great breakthrough kept it to themself? If you have developed a technique that helps people, I urge you to demonstrate that effectiveness in an unbiased, reliable way (scientific testing and publication) otherwise we (literally) cannot rely on those results.
      Corticosteroids? PRP? All pretty much shown to be ineffective with rigorous testing. Just like blood letting, which (apparently) worked wonders for many practitioners for thousands of year, only to fail when it was finally put to the test, much to the surprise of those using that therapy.
      Magicians keep secrets, not doctors.

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    4. Gorgeously stated, and a stinging backhand, Dr. Skeptic.

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  2. I've had prolotherapy for hip joint pain and instability. It works. The literature review might be inconclusive - but then you're not a prolotherapist are you? You're not someone who has suffered chronic pain either? So how does anyone review the literature and conclude what is a good or bad study?

    It's not coincidence that the doctors who get results with prolotherapy are the ones who themselves had pain and sought help. Talk to them about the studies which have been done to date and you quickly learn that why prolotherapy can be ineffective. For example, lower back pain does not heal up - well, did they check the pubis symphysis? Did they look at other drivers of lower back instability? No - they don't, because then that doesn't become a controlled study. Which is the problem with modern medicine. You get a doctor for specific parts of the body - but few are smart enough to consider the whole.

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    1. Thanks for commenting, however ...
      If pain improves after treatment, which it usually does, it does not necessarily mean that the treatment caused the improvement. That is why we use placebos as comparison, and also why placebos appear to "work" so often. Also, unless the hip is dysplastic and subluxing or dislocating, I think the diagnosis of 'hip instability' is questionable, and, if present, is unlikely to benefit from injections of anything.
      Also, I do not accept that me having chronic pain can alter the perception of the literature, or the effectiveness of any treatment. This is a common complaint from patients if I explain to them that surgery (for example) is not likely to help them. "But I am in pain" is the complaint. I explain that the presence or severity of that pain does not make an ineffective treatment effective.
      How does one review the literature and reach conclusions? By critical appraisal, a scientific, rational way of assessing the scientific merit of research. Certainly, there can bias in reviewers, but there can also be bias in researchers whereby researchers tend to see what they want to see.
      The objective evidence for a specific effect from prolotherapy is weak, at best. Being in pain and wanting it to work does not change that.

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    2. i agree with your opinion.. we have a story of three blind people went to see an elephant..each one described elaphant differently. this guy is not a prolotherapist nor he had taken the treatment nor he has a proper refersance.
      the literature he pointed to the links saying here here and here are actually saying that proolotherapy is effective in majority of cases.

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  3. I think if you suffered from chronic pain for 20 years, saw numerous doctors in numerous fields in different countries and cities and then had prolotherapy you might just change your tune.

    Readying a study on paper is never the same as the real thing.

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    1. Thanks,

      I think you are saying that prolotherapy is effective. If it is effective, then the length of time one has had pain, and the number of doctors seen previously is not very relevant to the effectiveness, only to the sense of relief for the individual.

      Many of the treatments referred to in my blog make most people feel better afterwards. Some call that effective. I call it perceived effectiveness and distinguish it from specific effectiveness, which is the effectiveness beyond that of placebo.

      There are many reasons why treatments often seem to work in 70 (+/-10) % of cases, and the only way that we can reliably test for specific effectiveness is through scientific enquiry (which accounts for such things as confounding, natural history, regression to the mean, concomitant treatments, and the placebo effect).

      Studies should try to replicate real life, for example by selecting the appropriate patients, using appropriate doses and using appropriate tests of effectiveness. That way we can rely on the study to give us accurate information about the real effectiveness of any treatment.

      I would argue that scientific enquiry is how we get the best estimate of what "the real thing" is.

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    2. There is a difference between being a skeptic and real life experience. skeptics just talk out their rear. Prolotherapy works and until you have utilized it, to cure a chronic ligament condition, like me. Or other issues, you're still just talking out your rear. Keep enjoying being wrong though. I know you will. :)

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    3. Oh and always trust bloggers. ;)

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    4. Skeptics, certainly modern day skeptics, do the opposite of "talking out their rear". They have a questioning attitude, but base their assessments on science; they use reason and critical thinking to make more accurate and reliable assessments of claims, rather than relying on the bias of personal (subjective) experience.

      Don't trust me; trust science.

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    5. Don't trust me; trust science.(Dr.Skeptic)

      "There was a time when religion thought it could explain all the world, then came science, they both come up short." ;)

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    6. I disagree. Science has never stated that it can explain everything; it is a technique for understanding and explaining based on reason. If we could explain everything we could stop all research. If you do not use a system based on logic and reason in order to understand the world, that's your choice - you are not alone, that's for sure.

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    7. Hi Dr. Skeptic

      The joke was more a poke at just showing limitations. Obviously there are many more limitations with religion(lol). I am a Registered Massage Therapist and have worked closely with an MD who does prolotherapy. I will admit that the science may be lacking in regards to the effectiveness of prolo but in my experience the results are pretty substantial. I have personally witnessed amazing changes in people who tried pretty much everything else with minimal benefit. I have also personally had it done for 2 injuries. One with great success the other not so much(too painful, I didn't continue). I think its just a matter of time before science will show the mechanism behind these results. In the meantime, I keep praying. :)

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    8. Science is a religion. You can get most any answer you want if you take a selective enough pool especially if you are looking to prove that something doesn't work. If the poster has been in pain for 20 years and everything that science has to offer hasn't worked; then, the person suddenly experiences relief after receiving a treatment this is the placebo effect. This is the case where if the person was going to be magically healed by the placebo years ago. It is low level evidence but it is evidence nonetheless.

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  4. I have had numerous prolotherapy treatments on my shoulders, back, neck, and other parts of my body as well, and have chronicled the treatments at http://prolotherapydiary.com. I encourage you to visit to learn more about prolotherapy injections from the patient’s perspective.

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    1. Please see my comment above. People getting better after injections does not lead me to conclude that prolotherapy has any specific effect. People get better after almost any treatment you can find on the web, many of which have been shown to be no more effective than placebo.
      We need to avoid the raw human reaction of assigning cause-and-effect to every association we see and step into the (sometimes counter-intuitive) world of logic and rational thinking.

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    2. And I got worse after prolo and PRP. I wish I was joking.

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  5. Are you saying that a placebo study is perfect? How long is the effect of the placebo? If a person is to take a sugar pill and it last about 6 weeks vs. a person that takes a pill that last 1 year. wouldn't this indicate that the placebo effect is null? Besides there has been studies that suggest the placebo effect is fake. Studies have shown that the mind does heal the body. (example laughter) Several studies shows that stem cells regenerate tissue. So why would you conclude that do to lack of FDA studies would conclude that Prolotherapy is ineffective. just one article out of many that can be found. https://www.scientificamerican.com/article.cfm?id=study-finds-placebo-effec

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    1. Thanks for your comments. I hope I can address your points satisfactorily.

      No, I am not saying that placebo trials (in general, or any specific trial) are perfect. I would not say that any trial is perfect because there is no such thing as a perfect study. If I said that, I retract it. Science works on probabilities, likelihoods and uncertainties. Good scientific research can reduce uncertainty around certain probabilities but it cannot reduce the uncertainty to zero, especially in medicine where our ability to control the research environment is limited.

      We reduce uncertainties by removing or allowing for variables that may influence the outcome that we are studying, and this is where placebos come in. You suggest that the placebo effect is fake, and you are correct; allow me to explain. Placebos are, by definition, fake in that they are not “true” treatments. Also, by definition, placebos cannot have an effect, otherwise they wouldn’t be placebos.

      The term ‘placebo effect’ is misleading, which is why some discourage use of the term (see here: http://doctorskeptic.blogspot.com.au/2013/03/book-review-meaning-medicine-and.html). Unfortunately the term has stuck, but I am less interested in what we call it than I am in explaining it. People usually get better after any treatment. If that treatment happens to be placebo, it is often called a ‘placebo effect’, and if the treatment is a procedure we call it the ‘treatment effect’ – this is probably a leftover from our human tendency to read cause and effect into any association. In reality, the placebo has had no direct effect because it is a fake (as you point out). But the same can be true for the treatment: it may also be a fake, but because the patient got better, we don’t entertain that possibility.

      The problem is that there are many reasons why someone might improve after treatment: they might have improved anyway (for many reasons such as natural history, confounding, and regression to the mean), they might not have objectively improved but they feel better (perceived effect – again many reasons), or they might not have improved but we think they have (measurement bias). The best way (not perfect, but good) to tell if a treatment is working is to make everything else the same (every aspect of the treatment) except the actual specific drug, procedure or whatever, such that the patient and the person measuring their outcome has no idea of whether they actually received the real treatment.

      If a treatment and a placebo give the same results (“effect” if you like), then if the placebo is a ‘fake’ (which, by definition, it is), then the treatment must also be a fake. And often, that is the only way we can tell if a treatment is really effective.

      Regarding the timing of the effect, we need to choose what timing is important to us. If you have a treatment where the placebo group relapses after 6 weeks and the treatment group stays well for one year, then you have shown that the treatment is better than placebo. Studies should compare the results at the same time point, and preferably choose a clinically relevant time point as their primary outcome a priori.

      Stem cells are a good case in point. There are many studies showing stem cells doing amazing things in the lab and in animals. However, all of the clinical studies that have ever been done to date have not shown any clinical benefit of stem cell injections over placebo. That is why you need a placebo, because without it, most patient feel better after the stem cell injection and we attribute the improvement to the ‘stem cell effect’ – that is why stem cell clinics are booming in my country. If the patients were going to get better anyway, of if they just think they are better, then the stem cell injection is also a ‘fake' by the full definition: it is not providing a real effect and it is used to deceive patients. The only way of knowing this is to test it against a ‘control’, preferably a placebo.

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    2. The placebo does have an effect mentally this is my point. There are studies that show mentally a person can heal him or her self. If given a sugar pill lets say that does no more than provide sugar and a person was told that it would fix there ailment. Then that person's problem to some extent would be fixed mentally. Just as a person that is in good spirits would heal faster than a person that is not in good spirits. Prolotherapy would do much better if there were set times in which they would call a placebo effective but they cannot because at time the body is able to totally heal the problem due to mental exertion. In a case of broken bones lost cartilage one would think that based on the countless studies done on Stem cells that a serum produced with bone marrow or fat stem cells would help in repairing these problems. look at this person below me he is telling use that after many other treatments that have been proven to help his situation to no avail his problems still exist. 4 years is a good amount of time to suggest that a placebo would be ineffective. I just cannot not see how you can discredit so easily a therapy that is being supported by so many that have tried multiple ways to solve there issues. the fact there is not enough clinical trials to prove one way or another is no reason to discredit hundreds of people that have proven that this type of therapy does work. 25 years is more than enough time for a body to heal. Evidence should prove that after 25 years of pain trying several treatments none of them working then trying another treatment and things start to get better. then the last treatment should be understood to be the one that works for those type of ailments. it would be kind of silly to say that well your body decided to heal after 25 years by itself. I do apologize for not staying to the point in this whole reply. just so many reasons why I think you can be wrong. I understand where you are coming from but still have a problem with agree totally with what your saying. no need to reply to this I understand your position. I would hate for you to repeat yourself. thank you for taking the time to reply to my questions and statements.

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    3. Thanks, and I appreciate your comments.

      I think there is a difference between "healing" and "feeling better". I think in cases where you use the term "heal", you may be referring to cases where the person felt better. There may be no evidence of tissues actually healing. In that case, then yes, it does not surprise me that people can feel better after many years and after many treatments.
      Regarding popular support, this does not provide evidence of physical healing, only of many people feeling better. Almost any treatment can achieve this if it applied widely enough. Religion would be an extreme example: in general it can make people feel better and there are many cases of near-miraculous improvements with prayer/blessings etc. The extent of public support for religion and its ability to make people feel better does not provide proof of 'healing', or proof of an advantage over alternative treatments.

      I agree that I should not discount 'felling better' and the power of some treatments to provide this, but I think we should not assume that the improvement was due to some physical improvement in the underlying pathology.

      Thanks for contributing.

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  6. I have to say my my point too, I have suffered for over 25 years, from all kind of inflammations to many joints, knees, elbows, shoulders, lower back and so on. I have professionally practiced, Horse riding, kickboxing/Thaiboxing, jUJITSU, and many other sports intensively. I have caused myself many repeated injuries and inflammations, some became chronic and i have learned to live with them. I have lived in 7 different countries over the same period of time, Morocco, France, Italy, Switzerland, South Africa, Dubai and finally America. I have not been able to train my legs with weights for 20 years, every time I would attempt to start squats my knees tendonitis would flare up again, I gave up hope to be able to train my legs and all I could do is run a bit and train my legs doing cycling. I have seen so many doctors in so many different countries and I have tried all sorts of therapy out there including cortisone injections... all to no avail! Well, until the day I found out about Prolotherapy on the internet and out of desperation I decided to try even if deep in my mind I knew there would be no chance for me. I was wrong... dead wrong. After three months of treating my knees I restarted training my legs, for 1 month it was all great, then 2, 3, 4, 5, and no pain... I started doing leg presses with 300/350 pounds, squats with a 100/140 pounds. Now it has been 4 years and still going strong. A friend of mine who is a sports doctor said it's only mental, he does not believe that it's Prolotherapy that helped me heal my heels... I have to disagree completely, because regular doctors are like the religious fanatics, they only believe in their religion and refuse whatever is not in line with their academic learning.

    Sorry, but for me, it worked perfectly, and my case is quite strong! I know it can't work for every one, but it does work better than many other traditional or academic therapies.

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    1. Thanks, and if that picture is of you, then you seem to be doing very well.

      There are many cases of seemingly incredible improvements in hopeless cases for all sorts of treatments, including ones that cannot possibly have any direct effect, like homeopathy. Unfortunately, cases like yours provide a low level of scientific evidence. If it was really so dramatically effective, (in other words, if your improvement was really directly due to the prolotherapy) that effect would be easily shown in simple controlled trials. As for many treatments in my blog, they appear to be very effective (even 97% effective for tennis elbow) but when you put them to the test, they fail.

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  7. Dr Skeptic

    I believe in being skeptical about everything, challenging authority, and being cautious, but prolotherapy definitely works. I tore my serratus anterior and a few other scapular muscles lifting weights a few years back. I tried to to continue to workout a few months after the intial injury, but my shoulder felt very unstable because the musclar injury did not fully recover. I had 3 rounds of prolotherapy in my serratus anterior and I could feel my neuromusclar control over that muscle coming back after the first injection, more muscle density after the second (it felt grizzled and strained after the injury), and I regained 100% function in it after the third. Yes, I would say it is quite effective.

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    1. Thanks for your comment and I am glad that your condition improved. However, when assessing the true effectiveness of any treatment, we must use the most reliable evidence available, in order to reduce the likelihood of error (biases). As I have stated previously, many treatment "work" in that people get better afterwards - that is what kept blood-letting in the medical armamentarium for two thousand years and maintains much of conventional and alternative medicine today. Time after time, however, these treatments fail under scientific testing that is designed to reduce error and prove cause and effect, such as placebo trials.

      For example, it is unusual for a patient with a muscle tear to not recover good function eventually. If you had gone to a chiropractor or acupuncturist (etc. etc.) you may have attributed your improvement to their treatment, rather than the prolotherapy.

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  8. Doctors sometimes have huge egos and have the intellect to prove or disprove any point they want through pure verbosity without true substance. I would suggest that anyone reading this thread to take this Dr. Skeptic's opinion with a grain of salt. Seems to me like prolotherapy is very effective in most cases.

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  9. Anecdotal evidence can be very tricky and cannot be accepted from a scientific pov. However the "perceived" benefits from prolotherapy seems overwhelmingly positive for a selected sample size. Patients who gravitate to this are most often ones who have tried several other options without much relief. Patients whose conditions improved have a "don't knock it till you've tried it" approach, which seems fair.
    I'm about to embark on a prolotherapy session for a persistent baker's cyst which has become worse over the last few months. After several unsatisfactory visits with multiple OS, I am cautiously optimistic about prolotherapy.

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    1. Thanks again. I agree about doctor's egos, and about the effectiveness of prolotherapy. Most things that are done to patients, whether mainstream medicine or alternative, are effective. My argument is that many are little better than placebo. Some don't mind this - "as long as it is perceived to work, what is the problem?" I can only think of 3 things wrong with that:
      1. Cost: I don't want to pay for it. The opportunity cost must be considered.
      2. Deceit: we either fool the patients or fool ourselves, and such unscientific use fails to distinguish science-based medicine from non-science based practitioners.
      3. Potential harm: although this varies greatly between interventions.

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    2. I am so confused about your responses. If someone is in chronic pain, you are saying that a placebo could be as effective as prolotherapy? So when prolotherapy actually works for someone who has been in pain for months or years, you're saying that it could have been just as effective to trick them into feeling better? Wouldn't chronic pain suggest an actual health problem rather than your mind tricking you into being in pain?

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    3. Why would chronic pain be more likely to indicate a physical cause than acute pain? I would argue the opposite: acute pain is nearly always due to a direct physical cause, whereas chronic pain almost always has a strong psychosocial component, which is why it persists long after the physical trigger has been removed.
      Don't be confused by the placebo effect. It is not a trick, sometimes it is just natural history but it is certainly more complicated that a simple trick. The only thing we know from placebo studies is whether or not the treatment works better than placebo, we can only speculate how the placebo works. All we can say if the treatment is the same as placebo, is that it has no direct effect.

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  10. Glad to have found this balanced pro/con discussion without degenerating into a flame war. Thanks to the author and contributors for both points of view. I'm a recovering addict and don't want to go under the knife again for a second acl surgery, mostly because of the pills afterward and secondarily the cost (lame insurance). Have been reading a lot of information regarding this treatment and will likely give it a try. I haven't found anything yet regarding age of the patient (I'm 51) and the likelihood of effective treatment given that constraint but will keep searching. Thanks!

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  11. I've had shoulder pain (work-related) for almost 3 years. I tried physiotherapy, electro-stimulation, accupuncture, massage therapy, chiropractic sessions and nothing worked. I had 3 prolotherapy injections and have experienced a considerable improvement since I started 3 months ago. When you've had persistent cramps and pain in your shoulder that just won't go away and then you get sugar water injections in your back and it works, quite frankly, I don't care if it's the placebo effect or not. I'm now without pain now and that's what's more important to me than what your studies say or don't say...

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    1. Thanks. I actually agree with you. Patients don't care how they get better, as long as they feel better. If you are happy to accept that it is due to placebo, natural history or whatever, that is better than trying to explain it away with biological plausibility.
      My main problem with medicine is that much of it relies on non-specific effects, and doctors and the public do not realise that. They hold medicine to be higher than alternative therapies, but do not apply the same high scientific standards to their own practices.
      Most people get better after the treatments listed in my blogs. I never say that people do not improve with these treatments. Its just that most of them are no more effective than placebo so we shouldn't fool ourselves with biological mechanisms.

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  12. Here's something. I found Dr. Skeptic through another treatment that I was trying to check out. I'm a full Skeptic as well and yes anyone who believes for no reason, whether it's a treatment or gods or some other bs...yeah, you get the point.

    The point is to have information out there in places like this so we don't get sucked into to believing in bs treatments or Zeus or that Jesus was the sorry son of god, an only child. with one father in heaven and no mother..

    However, any time I've ripped my body apart I use Prolo to put it back together. The last time I had frozen shoulder I went to our team physios and after 1 week of intensive treatment I could move my arm only an extra 2-3 inches... they said it would take another 6 months.

    After one shot of Prolo I could move my arm at least ten inches from my body. After the next shot I could raise it almost parallel with my shoulder and then after the next one I could raise it above my shoulder...

    Point being - to be an athlete, there's a little more involved than having good grades in college biology courses like these pastie mother fucker doctors and the thing is when you see 99.9 percent of these doctors and they look like pieces of shit - they probably are -- these are the people you didn't hang out with in highschool...the joke on cops are that they eat donuts which is a joke, but actually it's true in most cases... but for doctor's we've seen them... and now for the first time in their life have a bit of money (good for them)...but now they try to reflect on things outside of what they are as a person... it's a bit strange. Either be there or get the fuck out.

    So if you're actually really DOING something (unlike 99 percent of doctors) Prolo might fix you - however I don't know - it might be any injection into the target area that works... doesn't have to be sugar, it could probably be anything - because if the injection misses the target area, nothing happens. So the nature of injection into problem areas worked for me, whatever was injected.

    I don't know how it treats other pain - I only had in my shoulder and knees and fixed them as well...

    where's facebook profile so I link this?

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  13. Is it possible that the problem with proving prolotherapy's effectiveness is that it's difficult to evaluate ligament laxity with diagnostic imaging? I have had good results with treatments to my chronically sprained ankle. The improvement in stability is undeniable when using previous hypermobility of the joint to track progress.

    Any thoughts?

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    1. Hutch1363, the problem with proving prolotherapy's effectiveness is more likely to be related to its lack of effectiveness. If it were very effective, it would be easy to prove.

      Regarding single case reports of improvement, there are probably more people who have claimed similar improvements in health from using prayer than using prolotherapy, it doesn't prove much, particularly when these case reports are pitted against placebo controlled randomised, blinded trials.

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  14. I don’t know how some people say that they felt improvement and almost no pain after one prolo treatment. I have a shoulder tendonitis case that started almost 11 months ago. I have lifted weights for the last 15 years and never had an injury cause I’ve been always careful and follow the correct forms to exercise. I tried prolotherpay cause I didn’t want to stop exercising completely. Dr. Fields in Santa Monica gave me 3 treatments and every time I felt worst and worst. How is possible that some people say that they had almost no pain after the first treatment when after my first one I couldn’t even raise my arm for days, even driving was difficult. The pain got so bad that I had to quit the treatment, besides I researched about it and if you do not get any relief after the 3rd or 4th treatment is better to stop completely. Dr. Peter Fields is supposed to be one of the best on prolotherapy out there but to be honest he just ripped me off, $300 the first consultation plus $375 each prolo session.

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    1. Thanks. I don't think it was anything the doctor did - it is likely that the injections were given correctly. Prolotherapy is meant to cause local irritation - that is the theory behind the mechanism for effect. But why do some people feel better and some people feel worse? Because we are dealing with conditions that fluctuate, and causing a disturbance in the region. That is why case reports and observational data are so limited. When dealing with subjective outcomes for a fluctuating condition, the best test for effectiveness is a placebo controlled experimental study. Individual reports of feeling worse or feeling better do not carry enough weight in such cases. The limited placebo controlled RCT evidence we have for prolotherapy is not very convincing.

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  15. I have shoulder injuries, mess of a hip replacement, knee issue and ankle...

    I had a series of dextros in right shoulder 4 yrs ago and got a great 3 yrs of relief....and I didn't go to Fields or Darrow.... My integrative rheumy does Prolo and I plan to get more in my knee and shoulder again.

    What does CURE......certainly not those steroids and surgeries.....death yes....

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  16. Nice entry, Dr Skeptic. And very thoughtful rebuttals to some of the comments.
    I never ceased to be baffled by people who just can’t understand that anecdotes and personal experience are virtually worthless when it comes to figuring out what really works; what’s worth actually implementing as a recommended treatment. I have no problem with people throwing their own money away at something they are convinced works even if it doesn’t, but it makes me nervous that insurance and government healthcare might start to fund unproven/disproved treatments like prolo.

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    1. Thanks. I agree with your points. However, I am not very surprised that people tend to rely on personal experience, because that is how we evolved and it is "natural" to us. Being scientific and objective is often difficult.

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  17. A true skeptic remains skeptical, but still considers results in context. You seem to have a clear bias against prolotherapy. Most research that passes through the FDA is done by drug companies. They get through because they have money. There are plenty of conditions for which it has plenty of evidence (Grade A level for Tennis Elbow, see Rabago). It is minimally invasive, alleviates the pain and repairs the underlying condition. Yet even for this, because there is no cash and no lobby behind it, the FDA does not approve it. We have to remember why. These are dextrose and water injections; there is no money to be made by a drug company, so the only research being done is by University researchers. Meanwhile, the FDA and insurance companies have no problem with corticosteroids, which degenerate joints over time. This is perverse. You clearly are behind in your research and you're choosing to ignore the context and unique nature of prolotherapy. I have attached a slightly more recent review: http://www.drreeves.com/Articles/A-Clinical-Review

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    1. This is important...administering prolotherapy is a helluva lot of work. My MD worked hard for 2 hours administering the injections...and she was passionate in helping me. Most MDs will not work that hard and long on a patient...It is just not cost effective. There needs to be a study on that...!

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  18. And to address a few points you made, even minimally invasive if they involve needles, it does not take a genius to realize that any time you involve anything surgical you no longer have a "placebo" option, ever which is why there are not RCTs truly for surgery ever, and that’s why steroids don’t hold up for it and why there are no surgical RCTs, so it’s crazy that we expect RCTs for prolo when nothing else surgical requires it – with needling and surgical any treatment is treatment and cannot be done in a RCT. Especially, consider the theory and mechanism behind prolotherapy -- part of the action and mechanism is the needle itself, the connection of the needle with the bone and connective tissue to cause inflammation and scarring. This is why there is a procedure that you may know called "dry needling". What insurance will give people who have loose ligaments and pain like mine are: steroids, physical therapy, surgery, or nothing. These are the appropriate controls against which prolotherapy is tested and against which it has held up quite well. And you try to say that it has come out the same as corticosteroids, but that's only in short term. In double-blind studies where they follow them longer, prolotherapy comes out far on top of the steroids, which is a significant effect -- and when patients don't know they've been given prolo vs. a steroid and end up doing better, that is not a placebo effect, it shows that prolo is superior. But most importantly there are loads of us (and far more common in women) who have hypermobility and Ehlers Danlos Syndrome -- true joint connectivity disorders that when they end up leading to injury, subluxations, and dislocations, end up in extreme pain, and we're told there's nothing anyone can do -- we're told we need to keep our joints strong and stabilized, but no one can give any of us suggestions on how to adequately stabilize and strengthen around a joint that dislocates every single, especially when the pain comes with nausea and convulsive vomiting as a reaction. When performed correctly in the connective tissues surrounding a weak joint that's been popped into place, prolo does what it purports to do: the peppering of the needles along with the inflammatory agent (dextrose or sodium morrhuate), causes the tissues surrounding the joint to inflame. The tissues begin to tighten, and they hold into place, which greatly reduces the pain as compared to pre-treatment dislocations. I am not sure what a skeptics would suggest for joint laxity and chronic dislocations throughout the body, but I never found a good suggestion before prolo. This isn't psychosomatic: Ultrasounds, x-rays, physical exams always confirm that I can point right to my dislocated joints pre-treatment, and they confirm that everything is solid and in place after treatment. My one hope for the sake of those of us with no other options is that you stop your crusade against a procedure that is cheap, safe, and extremely effective, and saves us from a lifetime of hell and disability.

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    1. Thanks for your comments.
      Due to the bias in published literature and individual studies that tends to overestimate the effectiveness of treatments, I demand strong, consistent associations and high level evidence before I will believe a true effect exists. I apply this rule to all treatments, not just prolotherapy. You call this a bias, I call it an allowance for an existing bias. My default position is that of the null hypothesis: that treatments do not work unless the evidence makes the null hypothesis untenable. History is full of treatments that appeared to be effective until put to more rigid tests (see most of my posts).
      I disagree that placebo RCTs of surgery (and therefore prolotherapy) are not possible. My blog has a whole section on them and many posts demanding that more be done. You mention tennis elbow, where prolo and surgery have good results, but in the only sham (placebo) study of surgery, it was ineffective.
      You also state that if a comparative study of prolo vs steroids shows prolo to be better, that it is not the placebo effect. I disagree, because more invasive and painful procedures have stronger placebo effects.
      Much of the rest of your post covers the theoretical mechanism of action (joint stability etc.). I can't argue with these statements. Like I often say, one can put forward a theoretical mechanism for anything; I am only interested in whether it works, not on how it might.
      Prolotherapy may work but at the moment the evidence for it is weak and open to bias. Blinded sham studies would give us a better measure of the true effectiveness. I am not willing to believe that it is effective without the support of this evidence.

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  19. What's lacking in sense isn't prolotherapy, it is the fact that you don't offer any substantive argument against the modality. To assert "that makes just about as much sense as doing X to make Y happen . . ." is just a bad argument from analogy, as your conclusion lacks any deductive or empirical basis, or any basis for that matter, besides a faulty intuition.

    Anyhow, here are documented cases of a complete ACL tear and a full thickness achilles tendon tear for you, all performed by reputable doctors in good standing, with accompanying imaging studies, to boot.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2929023/

    http://www.prolotherapy.com/Lazzara_Repair%20of%20complete%20achilles%20rupture%20by%20prolotherapy_2007.pdf

    Does this not count as "medical literature"? Or perhaps your search was not nearly as extensive as you're implying?



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    1. Thanks for your comment. The two links you provide are to case reports: one of an ACL tear and one of an Achilles tear, both treated with prolotherapy and both with good outcomes. I DO count this as medical literature, as it is published in a medical journal, but I do not count this as good evidence supporting the effectiveness of prolotherapy. In order to show effectiveness, it must be tested in a scientific experiment against an alternative, preferably a placebo, preferably with randomisation and preferably with blinding.

      A single case report may be hypothesis generating and interesting, but it is not evidence of effectiveness. My practice is to treat all Achilles ruptures without surgery (or prolotherapy, or anything else). The natural healing rate is very good with Achilles tears. If I had given my patients prolotherapy injections, prolotherapy would have unfairly claimed credit for the repairs.

      I am not arguing from analogy, I am asking for unbiased experimental studies to proof effectiveness. Case reports do not provide such evidence - I can find just as many case reports of healing after homeopathy and even prayer, than after prolotherapy.

      You should also note that the burden of proof lies on you. I do not have to offer proof against prolotherapy. Until then, the null hypothesis remains true.

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  20. I have read with much interest the ideas put forward by both sides, but it appears that Dr. Skeptic might have missed the point of medicine completely.
    The dear doctor does not appreciate that one of the objectives of medicine should be to "do no harm"

    Now when one considers that prolotherapy does not do any harm (other than to the wallet as some would claim ) then it meets this objective.
    ( This firstly is more than can be said for so many so called effective treatments)

    A second objective of medicine should be to improve the quality of life of the recipient of the treatment.
    Now it does not matter if the quality of life improvement comes about by placebo or by some physiological phenomena that is not yet understood by the medical 'industry' The fact remains that for, far too many to be ignored, the improvement in the quality of life experienced after treatment with prolotherpy could only be ignored by a fool or someone with a vested interest in ignoring the improvement.
    I put it to Dr. Skeptic that if one wants to discredit prolotherapy then one should arrange to have prolotherapy proven to be nothing more than a scam.
    I would gamble that based on statistical analysis of improvements in pain levels (1-10) at follow-up after different methods of treatment that prolotherapy would rank as good, if not better than any other method of treatment that anyone would like to add to the list.
    By all means...If one wants to discredit a method of treatment then they should put their money where their mouth is or not tear down a procedure that has given relief from agony for so many.

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    1. Thanks, But rather than missing the point, a driving force behind my message is that we should do no harm - that the burden of proof is on those who intervene, and that the default position should be to abstain from treatment in the absence of good evidence. The main point of prolotherapy, however, is to do harm. The rationale behind this treatment is to cause local harm to the tissues in order to provoke an inflammatory response. It also costs, as there is both a direct financial cost and an opportunity cost.

      I disagree that “it does not matter if the quality of life improvement comes about by placebo”. Apart from the direct and indirect costs, there are other objections to using the placebo effect which, I agree, is used by doctors as well as alternative medicine providers. Placebo is, by definition, a sham - it involves deception. An “open-label” placebo can be used, but then you are lessening the effect, which is not what we want. Using placebo also removes the only real barrier between medicine and alternative medicine - a reliance on scientific foundation. Ignoring the science means that real progress is unlikely. Another problem with placebos is that are often associated with harm (even routine, ineffective steroid injections have a risk of infection and underlying tendon damage). The final problem with placebos is that their effectiveness is only due to perception, and is therefore limited, unreliable and short-lived.

      If you are happy to rely on placebo interventions, be aware of the costs and risk of harm. To me, it is a backward step that takes us to back to the days of blood letting and faith healing. Real progress cannot come of it.

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  21. Doctor, I'm with you on this one. Prolotherapy seems a little too easy a solution for the types of ailments it supposedly can help. Except for the anecdotal evidence, and the ever-possible placebo effect, this procedure just seems like bad science to me.
    I think many of the posters here are either prolo practitioners taking offense to your sensible observations, or folks who've gotten that good old placebo effect. Amazing how defensive people can get just because they are convinced something "works" for them, and you dare to question it from an actual scientific perspective.
    I have read up on prolotherapy, and if I really thought it might work, I would be first in line to get it for my chronic neck issues.

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    1. I guess you and Dr Sceptic have been sponsored by big pharmaceutical companies for posting your negative comments here. And obviously you would recommend pain killers or even other expensive medicine instead of prolotherapy. You both don’t see how many people have left their positive comments here! You persistently telling us that prolotherapy is fake. I wish you both suffer from the same pain as we do and I wish you good luck with treatment of that pain with pharmaceutical expensive drugs! And I would love to see your comments after that!

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    2. Thank you for your kind wishes. They have come true, in that I have chronic back pain, but choose to live with it and cope very well and don't use pharmaceutical. You are also wrong about me being sponsored.
      As far as the number of positive posts, I am not aware of good evidence that popularity is correlated with effectiveness - look at homeopathy.

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  22. Thank you for this article and your thoughtful responses! I have a really stretchy ankle, and this past weekend my massage therapist (don't judge; massages feel AWESOME!) recommended prolotherapy. I quizzed her repeatedly on the practitioner she was recommending, making sure he was a legit Medical Doctor, and not a "doctor." When I got home I looked him up on my state's medical board and he has no complaints. Hmm... Then I googled the therapy itself, but me being me, added "skeptic" to my google search (my other favorite add-ons are "woo" and "scam"). Lo and behold, total woo. Reading this saved me a lot of money and, it seems, time & pain. I'll just slap on the ankle brace she also recommended and move along with my day. Thank you!!

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    1. Dude, you should have gotten the prolotherapy instead of the ankle brace.

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  23. I am both a former student of quantitative methods ~ and really do appreciate methodology ~ but I have noticed a potential flaw of logic in how the quantitative methodology is used ~ that is ... the CONCLUSION one reaches from the evidence gathered. GIVEN the paucity, as Dr. Skeptic notes, of the gold standard of study, that is to say, double-blind, multi-center, with adequate N's participating (points of data measurement), can ANY (caps lock here for emphasis - not yelling) reasonable conclusion ~ pro OR negative ~ about a phenomenon be safely stated? In other words, at best one can say, "There is ignorance as to whether this is safe and effective BECAUSE the evidentiary threshold has not been met. We cannot state we know a negative until the threshold for knowledge is met." In other words, the conclusion that the hypothesis Ho has not been debunked (sugar pill better than prolotherapy) is NOT the same conclusion as "We know that sugar pill is the same as prolotherapy." ALL we can say is that there is insufficient data to determine the status of prolotherapy treatment. Full stop. This is not a moot point, because there is, in my well lived experience dealing with MDs, the consistent apparent glaring tendency for the conclusion "I really don't know one way or another" to morph into "No! There is no causal connection," when in reality, all there is is ignorance! In general, from the 1,300 studies I have read concerning spine surgery, only one made the gold standard. hahaha. Yeah. So maybe we just stop treating people who have severed spinal cords ~ sorry folks, there is no study that holds strictly that spinal cord surgery is better than placebo ~ so ... go home and pretend your spinal cord is not severed. Yet ... that IS what the quantitative method, when STRICTLY applied, would say to do!! THAT is the reason why we cannot really claim to be quantitative. We have to ADMIT that the quantitative methods we ARE accepting, here and elsewhere, are a sham in the first place. A SHAM. THere has got to be a rethink of how we evaluate things. Full stop. Either we are all in with quantitative methods and not a single patient gets treated for anything (we then can sue for reimbursement of all insurance premiums, too ~ let's be fair) OR we stop with this sham and ask, "IS the PUBLIC being served by a system that uses SHAM application of data and quantitative methods?"

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    1. Wow. How will you determine if the public is being served? By asking them if they feel better? The bottom line is that we need rational, reliable methods to answer questions about the physical world. We use the scientific method to do that. This has given us strong evidence to support many treatments that we currently perform.
      Your question is about what we do with so-called 'negative' studies, that fail to reject the null hypothesis. You state that doctors assume that it doesn't work - I find the opposite, that when there is a lack of evidence, doctors continue to treat. The default position should be the null hypothesis. The burden of proof is on the proponents of the treatment.
      Regarding your reference to spine surgery, we don't operate on severed spinal cords, because surgery is not effective is restoring the nerves. We do lots of operations on spines and many of them are ineffective or harmful, and have been shown to be so in studies. We SHOULD be rejecting spine surgery in many cases, but doctors continue to treat in the hope / belief that the treatment is effective - the opposite of what you are claiming.

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  24. HI I just read a study. Would have to find it again but it was not measuring subjective pain levels with Prolotherapy but the actual cellular changes to the ligaments and surrounding tissues. I may be off on some of the details but they found that collagen was greatly increased and ligament fibers were thickened and tighter. This was studied in rabbits. If I can find the study I'll post it.

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    1. Please don't. Changes in collagen (or anything else) in a rabbit are so far removed from patient symptoms that it is only worthy of speculation as to any connection between them. It is easier to test whether these things work by asking patients if they got better, and choosing an appropriate comparator to control for confounding and placebo effects. If you do anything to any animal (including humans) and look at them closely afterwards, you will see changes. Our problem is jumping to conclusions and establishing causal links between those changes and the clinical effectiveness of the intervention. This is bad science and is one of the many problems I address in this blog.

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  25. I have read this blog, and the counter discussions with interest. I am a specialist obstetrician/gynaecologist - and sometimes see patients with a physiotherapist with chronic pelvic pain in 'post vaginal mesh pain'.

    The fact that I actually searched for 'prilotherapy and scam' with in the same reference acknowledges a fear of practicing/or recommending a potentially fringe therapy.

    However - if all former therapies / surgery/ steroids /botox / psychotherapy/ neuromodulators fails and pelvic floor and musculoskeletal physical therapy identifies a musculoskeletal system as a potential contributor to pain and plateus' in its effectiveness, all that is left is fringe therapy.

    Not withstanding the mechanism of action if any - a concern that I have if I see a positive outcome following such injection therapy is - what component of package of care was responsible.

    (A package of care meaning - that a Doctor and physio review the patient together, have more frequent assessments, the psychological benefits (and improvements in sleep hygiene, initiation of inhibitory descending pain fibres, whether or not the improvement was going to happen as part of the natural history of the condition, whether it was the physiotherapy at the time, the dry needling of the needle, the volume effect of the injection or the contents of the injection..)

    I also wonder, when patients say that previous therapies failed (ie sacroneuromodulation, botox injection etc) - whether it really failed - or that their current recollection was that it failed at the time.

    Notwithstanding recall bias, and assuming that previously the disease process was static - if one was confident that the resolution of symptoms was attributal to a placebo effect alone - why did this placebo effect not take place with the earlier interventions.

    Sadly - such knowledge that influences ones personal clinical decisions is not easily entered into peer reviewed scientific literature. The best I think that can help is that detailed accounts are published in the form of case reports, and that all case reports are submitted whether successful or not (to avoid 'publication bias').

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    1. Thanks. You certainly raise some good points. I agree that recall is very unreliable. I disagree though, about your point that if all treatments have failed, we must try fringe therapies. I often see people for whom treatments have failed, and further treatment is not always the answer. Often reassurance and introducing the idea that they can live with this problem and still function and enjoy life is all that is needed to make them satisfied. I see it all the time with osteoarthritis of the knee. Most people go away happy and are glad to get off the medical merry-go-round.

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  26. As a PM&R specialist, I do believe that Prolo *by itself* will not yield the best results.

    However if you are going to be skeptic, it is my humble belief that you should've shared the complete truth about Cochrane's conlusion on the Prolo and chronic low-back pain review: "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."

    Function dictates how the body deposits collagen and elastin fibers during repair. It is only logical that after the induced inflammation of ligaments and tendons with prolo, the proliferative phase should be protected and guided by proper exercise prescription. Which is what the new evidence is pointing to.

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    1. Thanks. Although please note that everything mentioned in my blog sounds logical or biologically plausible and was associated with "promising" evidence that was "pointing to" an effect. Or my favourite line: "emerging evidence".

      The Cochrane review is correct: it may work.

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  27. My wife had her meniscus almost gone and her MD advised her that both knee replacement was inevitable. In 2011 she started prolo treatments. She ran her first triathlon in 2015. I run and bike also and her knees are better than mine. You may say that this is a placebo effect but a placebo will not last 5 years.He also treated a chronic plantar fasciitis And it did not return.
    My Dad was 84 with chronic back pain, he went for all the medical help that was available with no relief. Doctors said he was to old for surgery. He went to the same prolo doctor and had relief after two injections.The Prolo Dr. told him not to lift over 50 pounds and he felt well enough to replace a hot water heater by himself and re injured it. It took 4 treatments to get relief then. It never got 100 percent better but he is now 86 and still mows and does garden work and I seen him riding a bike. So anyone says prolo does not work is truly pessimistic about any kind of new treatments that they don't understand.

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    1. Thanks, but unfortunately case reports do not provide strong evidence of a causal association. My father is also 84 ad was hospitalised with severe back pain. A series of steroid injections and he eventually recovered and has been fine for years, but I strongly doubt that the injections had anything to do with it, let alone his continued health beyond the life of the injected substance. Similarly, plantar fasciitis is a self-limiting condition. I don't see my self as pessimistic, just realistic. I do see others as optimistic in that they are too ready to attribute causation to associations that they see, prefering this observational evidence to rigorous comparative trials.

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    2. Who did the prolo? I have meniscus tear in right knee and had arthroscopy to both knees but got worst. I'm interested in prolo, if I could get relief as I'm no hurry to have metal or plastic in my 59yrs old body, after years of sports... Thks eva.erl57@gmail.com

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  28. I am 42. I had a very major click (sense of dislocation when fully bending my knee) for about TEN MONTHS. It was diagnosed as meniscus tear. Before suggested surgery I opted for PRP. One injection and LESS THAN TWO WEEKS later the click and instability in my knee was gone and surgery avoided all together. MY TESTIMONY: close to a miracle!

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    1. Close, but no cigar. There are similar stories of after treatment with stem cells, homeopathy, prolotherapy, goanna oil and meditation. Unfortunately, single case reports do provide strong evidence.

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  29. I started receiving prolotherapy for whiplash and other related injuries. I have had $2000 of treatments to my upper cervicals lower cervicals and thoracic areas and shoulder. I can tell you that it definitely works. You must give it time. Everyone wants a quick fix. No such thing with prolo. But if you are fully 'in', you will be rewarded. The treatments I had were spread out over a long period of time from 2013 to 2016. The longer the time less treatments I need. Before prolo I was homebound. I could not lift 10 pounds without lingering pain and problems lasting for months. The pain was horrible. I wanted to die. The laxity in my neck was also disconcerting. I had constant weird parasthesia down both arms. I am better. I know some PT will come in and discount my experience but I don't care. PT couldn't help. Drugs couldn't help, so there.

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    1. If you gave PT a chance for 3 years like you did for prolotherapy, who's to say you wouldn't have a similar good outcome. You say PT couldn't help, that is often because they think PT will help in a matter of weeks. You gave prolotherapy years to work; doesn't seem like an effective treatment at all.

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  30. Dr. Skeptic. I just wanted to applaud your continued patience with people commenting about how effective this or that treatment was for them. You continue to explain to them the trap of anecdotal evidence, and it seems like people just are not getting it. Just wanted to say I have tried every single treatment possible for chronic tendon pain. The only thing to ever work was consistent physiotherapy over years. We somehow give muscles and bones many months to heal, but expect tendons, ligaments and joints to feel better within days or weeks. I haven't quite figured out why this is the case.

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    1. Yes, but like I pointed out in a recent post on my own tennis elbow (http://doctorskeptic.blogspot.com.au/2017/01/dont-treat-me-im-doctor.html), many conditions are self limiting and will resolve in 1-2 years. If you were getting NSAIDs or prolo or PT or whatever, your tendency would be to attribute your improvement to that treatment. But this does not prove cause and effect.

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    2. Yes totally agree with you, if someone for example began meditating, and they got better, they would attribute it to meditation. But when discussing bones, muscles and tendons which are load bearing components of our bodies; there is solid scientific evidence showing that overloading, and underloading cause negative tissue adaptation. So an appropriate loading intervention for a long duration has merit. But like you said, it does not prove cause and effect. However I would like to add, the evidence for exercise interventions in tendinopathies are much higher than other treatments such as taping, bracing, shockwave, injections, NSAIDs, etc. Also Exercise interventions do not carry the risks of treatments such as prolotherapy, and can be done by the patient for free at home.

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    3. seems to me that this situation just keeps going back and forth forever. patients say it has worked for them, you Dr. Skeptic say there is no scientific evidence to back this up, can all these people who feel better really be wrong. what works for one may not work for another, doesn't mean they are wrong. I have suffered from back pain for 20 years have tried all the so called scientific treatments and nothing so am going to try prolo, as my doctor said to me try it and if it works for you great!! it is always easier to criticize something than to have an open mind. As with anything someone has to go first.

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    4. TO answer our question: yes, it is possible that these people are wrong. We have believed in all sorts of non-effective therapies for thousands of years - look at blood letting. Read my book for a more detailed discussion (Surgery, the Ultimate Placebo).
      I have no problem with you trying it, as long as others are not forced to pay for it (insurance premiums taxes etc). If we are to support treatments only because some people feel better afterwards, we would support anything you could think of and more. There would be no point in ever evaluating treatments because all you would need is some people who said they felt better afterwards. Every treatment for the common cold would get approved.

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  31. I raced motorcross for years and suffered from a severe right ac joint separation in a crash and had an acromioplasty and ac resection from a neer 3 clavicle where the bursa was removed and ten years later the biceps tendon was frayed. The resulting instability also lead to severe neck pain. I tried everything under the sun. 2 years of physical therapy later I decided on prp prolo mixed with hgh to both shoulders as the instability was creating unrelenting trigger points to stabilize the joints. I never thought it was possible to get my life back and can now workout, ride and even do push-ups. No pain and zero instability. Try doing that with an ac joint that moves all around. It's rock solid so tell me how is that possible? I have had various other successful injections as well. The problem I see here is that there is a high level of ignorance and lack of acceptance that regenerative medicine is the future. It's so early that doctors cannot even agree on protocols for treatment so I understand the lack of appropriate and consistent data. I am so thankful that there are knowledgeable people who can think outside the box to resolve my problems. If all of medicine thought like you there would be many more suffering and there would be no progress as we would be stuck with cortisone pt and surgery. I suggest you get prolo in one form or another and try it. Don't fight it. Maybe you won't have to live in pain any longer and you can apologize to the people on this board whom you ran in circles with defending your blog title. Maybe it's time you move forward and learn something from someone whom has a successful regenerative practice. Ask questions. There is so little we understand about the human body that regardless of what you were taught ignorance will always be present. We fight against what we don't understand.

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    1. Thanks. I am always asking questions and thinking beyond what is currently discussed and accepted. I am just less swayed by low level evidence and don't rush to approve or use things because people say it "works for them". If all doctors did that, we would end up where we are now, with a large proportion of medical treatment useless and money and time wasted. We are scientific. It shouldn't be too much to ask to have treatments undergo high quality tests before widespread uptake. If they really are great treatments, they should pass such tests easily.

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