What can you expect from your prolotherapy appointment? Here is an overview of the entire process...
Before Treatment: The Examination Process
When you are brought back to the examination room, Dr. Reeves will enter to take notes on your medical history. First, he will start with a history of your pain. He will ask about when your difficulties first began, so be prepared to tell him the sequence of what came first. He will ask about what diagnoses have been given, what types of specialists you have seen, and what testing has been done. If there are MRI scans, X-Rays, or other special testing, he will want to read a report, so if possible, bring a copy of the report when you are seen.
Next is the examination process. This typically consists of a general examination of the related sections of your nervous system, muscles, and joints. This is brief, but covers many areas. There are general findings that will sometimes be important for the specific problem for which you are being seen. Then you will be asked to put on a gown, still wearing your underclothing, for an examination related to the specific regions of the body that hurt.
Please be aware: This process of examination needs to be complete in order to be accurate and useful for determining how to treat -- and for estimating how fast or successful treatment will be. It is important to remember that this is not like a high-traffic general practitioner's office in which you must mention only one area of concern at a time. Instead, every area of pain should be mentioned so that examination can include everything. The areas are often related to each other and should not be treated in a piecemeal fashion.
Following that, the specific source(s) of every pain will be identified. One by one, specific examination techniques will be applied to "zero in" on those sources. The two methods of examination that perhaps will be the most unusual for you will be the nerve examination and ultrasound examination. The nerve examination utilizes manual (finger) pressure which is light and with just one finger over precise areas where small sensory nerves penetrate muscle and can contribute to pain. This is actually very common. The ultrasound examination uses the same sound waves used to see babies in the womb. High-quality ultrasound shows details of ligaments, tendons, and nerves in a way that is often better or different than MRI scans are capable of. Another advantage is that ultrasound allows your joints to be examined while in motion, which can provide even more information.
After the examination, a "map" of findings is made. If you are treated, this map will be re-checked at your next followup appointment.
During Treatment: How We Treat
Here are some pointers which will help you be prepared for your prolotherapy treatment...
1. It is best to use the restroom facilities before entering the room, as the treatment is meticulous and can last a while.
2. The areas to treat will be marked with a marker. Prior to your departure, these marks will be lightened using 91% alcohol, but there may be some marks that remain a few days.
3. Based on the number of treatable areas and their depth, we decide how to make the treatment as comfortable as possible. Our goal is to make treatment no more uncomfortable than the earlier examination was. This is done by oral pain medication, the use of as small needles as possible, and the injection of fluid as the needle enters, which pushes little nerves and sensitive structures out of the way. The fluid injection is very helpful.
4. Several different areas of your body may benefit from treatment...
A. Superficial nerve penetrator locations. This is where sensory nerves are diving down through holes in membranous layers called fascia, which line our muscles. Nerves can become irritated at those locations, and will produce pain chemicals (substance P included) that cause pain, and other chemicals (CGRP and nitric oxide) that can cause degenerative change and irritation of nearby joints, ligaments, and tendons. Injections here employ a small needle, delivering a 12.5% dextrose solution just under the skin. Dextrose helps with the healing of all soft tissue, which includes ligaments, tendons, and nerves. For more information on why superficial nerve penetrators are treated, see the articles in the section of this site titled "For Medical Professionals."
B. Deeper areas of nerve penetration. These fascial areas are stretched and separated using the dextrose solution. This both frees up deeper nerves and treats them at that location. This is often done using ultrasound to view the separation process for more accuracy.
C. Ligaments, which connect bones together. Joints cannot move properly without healthy ligaments. This is important, as an example, for a shoulder to move without rubbing the rotator cuff. Backs with weak ligaments may rotate, or feel loose or weak. Also, muscles may tighten up when ligaments are weak in a reflex attempt to protect the area; this is a reason for stiffness (muscles may also tighten when the aforementioned nerve penetrators are irritated).
D. Tendons, which connect muscles to bones. These are ropelike structures, very much like ligaments, and they cannot be strengthened by exercise. As an analogy, this treatment adds strands to an existing "rope" of a tendon.
5. We utilize mannitol cream to complement the prolotherapy and perineural injection treatments. You will be given a “cream application” map that will indicate areas of the body where application of the cream is recommended. An application of 4 times a day is best for active pain and twice a day for maintenance. We will go over that during your visit. Mannitol cream is not just a simple cream, but actually treats the superficial nerve causes of pain and can reduce the amount of injection treatments needed. We make up mannitol cream by the quart (in our office), and that can be diluted to make one gallon. Mannitol cream in these concentrations is patented, and we do not own that patent. However, as a researcher for this cream, I have been given permission to make it for my patients.
6. A specific frequency of further treatment will be recommended. For elite athletes with pending obligations, a one- to four-week frequency can be considered. Our goal, however, is to allow full time for natural healing, which can decrease the treatment frequency needed. We recommend a two- to three-session trial, typically at two-month intervals. Our treatments are quite comprehensive; we do not need more than 2-3 treatments to determine if your condition will respond to prolotherapy. After that period, our goal is to taper (as soon as possible) to 3-12 months intervals, or more infrequently as needed.
After Treatment: What to Expect
Most patients have a variety of questions about what to expect after treatment. Dr. Reeves has compiled these questions, and his answers, into this helpful handout. Below are some additional post-treatment instructions.
How you feel after treatment depends on how much of your pain is from nerves outside of ligaments and tendons versus how much from nerves inside ligaments and tendons. If you pain is from nerves outside of ligaments and tendons, you typically feel improvements for 4-48 hours due to a calming or “re-setting” of the nerves. Then pain recurs. Nerves outside of ligaments and tendons may need 3 treatments to begin holding the effects of treatment, although nerves may partially reset much quicker. Nerves in ligaments and tendons respond much slower, over 8 weeks or more, because the ligaments or tendons may need to heal themselves before the nerve can respond. As the ligament or tendon repairs, pressure can be taken off the nerve. Nerves inside ligaments and tendons may need 2 treatments to begin holding the effects of treatments. Since treatments are often spaced at 2 month intervals to allow time for healing, it can be 4 months or more before changes are seen. The important takeaway message here is that we generally expect improvements by 2 healing cycles or 4 months but many patients see improvement more quickly than that.
Exercising is encouraged, but please do not over-do it. Pay attention to what your body tells you. If it hurts, take a break! Do not push yourself just because you feel better (you may pay for it later). Use either ice or heat to help calm pain or spasms.
Additional injuries will make healing more difficult. We notice several common sources of falls in those with significant chronic pain -- and stairs are one of the most common. Thus, for any of our patients with significant pain we recommend the following: when going up or down stairs, do not alternate feet. Take one step at a time. Always hold on to at least one handrail when using stairs, watch for obstructions on steps, and do not carry things in both hands.
Feeling better or worse: Sometimes breaking a pain cycle can help quickly, especially if you feel supported by the fluid of injection. Therefore you may feel better after the post-injection soreness wears off. However, many nerves are not going to quit firing until the ligaments and tendons become strong enough that the nerves are taken off "stretch" -- and that takes time. In this office we attempt to avoid missing anything during a treatment session so that 6 weeks after the 2nd treatment is usually enough time to determine benefit.
Dr. Reeves uses the Hackett approach to prolotherapy, which is typically very comprehensive. For this reason, areas are rarely missed in treatment and two trial treatments are usually enough to determine if the treatment will be beneficial. Exceptions include athletes that are actively engaging in contact sports or high force activity during treatment periods. Typically those areas which have hurt less over months or years resolve first, and we then taper out treatment as the more stubborn areas start responding. There are those conditions in which all cartilage has been lost already in a joint (such as the knee) and in which wear and tear of everyday living may require a treatment every 3-4 months, but our goal is always to restore tissue enough towards "normal" that repeat visits are only recommended following trauma or some unusual event.
It is very important to realize that prolotherapy is a diagnostic as well as a therapeutic treatment. This means that if prolotherapy does not help it may very well be that there is an undiagnosed problem that needs to be identified. Therefore, be sure to check with Dr. Reeves or your prolotherapy practitioner about this possibility in the event additional testing is needed. Surgery is not needed often in patients receiving prolotherapy, but occasionally it is and referrals from your prolotherapy physician can often save a lot of time in obtaining surgery when it is truly necessary. For those few patients who need surgery, prolotherapy prepares them by addressing other pain problems unrelated to the need for surgery, simplifying decision making by the surgeon, and typically allowing a smoother recovery from surgery.
Typically patients do not need narcotic pain medication after treatment except, perhaps, that evening of the treatment, or the next day. Patients typically receive a prescription for a limited amount of post-injection pain medication. Pain flares lasting more than a week should be reported to us. We may need to see you back in the office to review the situation rather than just covering up a pain flare with medication.
For those patients already taking chronic narcotics, Dr. Reeves will not take over prescribing and refilling them for you. We only prescribe a limited amount to take on top of the chronic medication already being taken. This clinic focuses on pain elimination and reduction, not pain management. Dr. Reeves has a colleague specializing in pain management if needed or desired by our patients. However, elimination or reduction of pain sources is the purpose of Dr. Reeves' approach.
Please feel free to contact our office with any questions.
If there are further questions about how we treat that you want to ask before treatment, feel free to call the office at (913) 362-1600, or come in ready to ask.
It is, of course, difficult to make specific comments before the examination, since so much examination is needed to decide on the specific treatment need.