1. Stiffness or soreness: 1-10 days after treatment.

2. Flare of pain: Although this is not an indication of a problem, we still would like to know if this lasts more than several days.

3. Discomfort with injection: Local anesthetic may be utilized to decrease the discomfort with injection. Patients can request an anesthetic.

4. Worsening of pain: Pain level may increase and decrease. Tissue healing begins in days but the strength of tissue may not increase until two months. Two treatments (or a time span of 4 months) may be needed before benefit is noted.

5. Small or large nerve irritation: Needle contact can irritate nerves, creating a burning sensation. Dextrose is healthy for nerves, but if burning or weakness is noted after injection medication may be recommended. Nerve irritation is not known to be permanent outside the spinal cord.

6. Infection: This is a concern with large joint injections. The risk is considerably less than with surgery but infections are nevertheless possible.

7. Allergy: Serious allergies have not occurred in this office with agents in current use. Notify Dr. Nourani directly if you have any known allergies to the active ingredients

8. Serious bleeding: This can occur if you are on Coumadin, Lovenox, or other blood thinners. You must be able to stop the blood thinners (check with your doctor to be sure this is acceptable) a few days before treatment, or the treatment will need to be modified to decrease risk, or canceled.

9. Lack of improvement: The advantage of prolotherapy is its effectiveness and high likelihood of improvement in four sessions. Thus, if you do not improve after two treatments, we would like to hear from you 1-2 weeks before your scheduled third session. There may be a cause for lack of improvement that we need to identify before considering further treatment.

10. Risk of overdoing activity: Avoid heavy or repetitive activity for three days after deeper prolotherapy. If you feel markedly better, do not greatly increase activity. Many fitness experts recommend that you should increase your activity by no more than 10% per week. We normally advise you not to do things that cause pain. If an exception is needed, please notify Dr. Nourani.

11. Risk of injection over the chest; Pneumothorax aka lung puncture: This is very rare, but will cause pain with breathing and may require a chest tube to be inserted and/or some time in the hospital. This is typically noticed within the first hour after injection.

12. Risk of injection of the spine; Spinal Headache: This is rare but will interfere with sitting for up to 5 days; bed rest will be required. You will need help during the period when sitting is limited so that symptoms do not persist.

The financial risk of complications: If you need hospitalization or other treatment, and are uninsured or underinsured, the cost can be considerable.

MEDICATIONS USED

May include anesthetics (i.e., lidocaine, procaine, ropivacaine), dextrose, glycerine, sodium morrhuate, vitamin B12, normal saline, sterile water, ozone, steroid, magnesium chloride, ascorbic acid, testosterone. Additionally, the patient's own blood products will be used for PRP injections.

ALTERNATIVES TO REGENERATIVE/PROLIFERATIVE INJECTIONS

1. Doing nothing

2. Surgical intervention

3. Injection with steroids

4. Medication(s)

5. Physical therapy or other physical modalities such as acupuncture or manipulation.

You must communicate to Dr. Nourani if you experience one of the following: 

1. Pain with a deep breath that is increasing

2. Head pain when sitting that goes away when lying down 

3. A Warm or red joint that is becoming more and more difficult to bear weight on.

* I understand that it is Dr. Nourani's opinion that I would benefit from Prolotherapy Regenerative Injections. Although it is not widely accepted in the general medical community, several clinical trials have been published which have shown that it is safe and effective and can produce significant improvement in many patients' pain problems.

* No guarantee can be made to me regarding the success of Proliferant Therapy for my problem.

* I understand that insurance companies consider Proliferant Therapy experimental and do not pay for this treatment. Payment is due at the time of treatment unless other payment arrangements have been made.

By signing this form I confirm I have read and understand all the material provided and I had all my questions answered.