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Regenerative Medicine Treatment Options

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In this webinar replay, Dr. Siddharth Tambar from Chicago Arthritis and Regenerative Medicine reviews regenerative treatment options in details and answers audience questions.

Credit: Chicago Arthritis

Video Transcript:

Hello, everyone – this is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. Welcome to our webinar today on regenerative medicine treatments. As I’m talking, I’ve got a little bit of material, maybe about 20 25 minutes of stuff to discuss. Please enter in your your questions. A lot of the questions I’ll probably cover during the talk, but I will certainly leave time in the middle and also at the end of the talk as well to go through any questions you may have.

So what will we discuss today so number one you’ll learn about what are the best available: non-surgical treatments for arthritis and tendonitis and injuries and back pain that do not require surgery. What is legitimate and not legitimate in the field of regenerative medicine? So you can choose the best physicians in clinics for your own treatments if needed. So the big question is: what would you do if your pain was controlled? How would your life improve?

What exercises? Would you restart? What activities with family and friends? Would you participate in so who am I? My name is Siddharth Tambar physician here in Chicago at Chicago Arthritis and Regenerative Medicine, specialists in rheumatology, also specialists in image, guided musculoskeletal injections in practice since 2008 involved in regenerative medicine since 2008, as well and involved in the Regenexx Network, which is the largest network of Physicians, that are working together in regenerative medicine and that since 2012 for the last 10 years, so my journey through general medicine, really started with my own shoulder, I used to play fairly high level tennis when I was younger, as I picked it back up as an Adult in my mid 30s or early 30s, I noticed that starting to have some shoulder issues and around the same time, I started to learn diagnostic muscle scale ultrasound, which allowed me to look at tendon ligament injuries in a very different way and made me realize that A lot of the traditional treatments that we were using were really ignoring what was causing pain and what the problems were, and it sent me down the trajectory of looking for other options for not only treating myself but also treating patients as well.

So the traditional care model for joint issues or tendon issues is very insufficient uh. That’s whether you’re talking about arthritis, joint pains, tendinitis, sprains and strains back pain, it’s really focused on just masking the pain and waiting for eventual surgery. The equivalent of that would be, if you had diabetes, would be if, instead of treating the diabetes you’re just waiting to have your first stroke, it’s not how people would treat diabetes at this time, and you know we should do a better job when it comes to Treating arthritis and tendonitis so main problems with traditional care, it doesn’t fix the problem, pain medications do have side effects as well. Traditional injections, including steroid injections and nerve block injections, have a lot of side effects as well that you need to be aware of and careful of, because they’re not really treating the source of your problem surgery can be appropriate in in some patients. It’s definitely overused.

It’s definitely higher risk than non-surgical processes. It can accelerate the arthritis process in terms of common arthroscopy surgeries that are done for shoulder and knees. It can lead to more instability. Many routine surgeries that are still done are not proven to be more effective than just physical therapy or sham surgery, and really for those of us involved in general medicine. There’s a strong feeling that eventually 80 of what’s being handled surgically right now should be able to be handled non-surgically in the future, so in searching for better options.

Looking for treatments that are low risk with minimal side effects, but actually improve the cause of the problem and can actually give you longer term improvement, so imagine reducing your pain and getting back to the activities you care about without surgery or pain medications. So regenerative medicine is the process of using your body’s own cells to treat your musculoskeletal issues. So, if you think about how the body, normally heals after an injury, take something as small as a paper paper cut on your finger, what you have are platelets that infiltrate the area. They release growth factors which stimulate your local stem cells and recruit other cells and growth factors as well, which then causes inflammation, which then causes a slow cellular repair process. This works really well in tissues that have good blood supply and tissues that do not have good blood supply.

That includes tendons, cartilage, ligaments discs, labrum and meniscus. These do not heal as well on their own, so regenerative medicine is the process of using your own cells. To coordinate that normal healing process and to do so using very um, focused image guidance to do that, so there are challenges when it comes to finding a reserve medicine physician which I’ll talk about. So there are a number of things you should be thinking about number one: are they appropriately trained? So is your physician appropriately trained the musculoskeletal conditions or are they trained in something else and sort of jumping into this as well?

That’s a problem. You want to work with someone who’s really just focused on musculoskeletal conditions. Number two two: are they appropriately focused? I see other physicians who dabble in this kind of practice and the problem is they’re not very focused and thus not really experienced and when I say appropriately focus you can think about this in other ways as well. An orthopedic surgeon is very skilled in surgery and in the musculoskeletal system, but they’re not as skilled or practiced when it comes to using image, guidance, x-rays and ultrasound to do these sort of non-surgical treatments.

On the other hand, you may have a lot of pain, clinic doctors who are appropriately trained in terms of musculoskeletal system conditions, as well as image guidance of treatments, but they’re not focused on the right treatments. Instead, they’re using steroid injections, nerve block injections, really damaging tissue. Long term, that’s not the right person to be doing regenerative medicine either you need someone who really is focused properly in these treatments. So, in addition, are they do they really understand that regenerative medicine actually works? Do they understand how prolotherapy works when it comes to treating the soft tissue structures I’ll talk about that a little bit later?

Can they create a plan that is tailored for you important to understand most physicians in clinics that do regenerative medicine are taking basically a one-size-fits-all perspective, they’re they’re um locked into plant, whatever platform or format they use to prep their cells. That’s important because if you have let’s say knee arthritis that should be treated very differently in terms of your cells that you create. Then let’s say you have a lower back issue or if you have a rotator cuff issue, each one of those deserves a different type of platelet and and stem cell processing. And if you work in a place that is not as nuanced with that they’re going to give you a one-size-fits-all and then lastly again do they have the correct skills for the job, namely um? Do they not only understand the musculoskeletal skeletal system?

Do they understand how regenerative medicine works and do they have the imaging guidance and do they have the right focus again? Are they focused on these treatments or are they dabbling in it? Dabbling, never really works that well, so why regenerative medicine it treats the source of the problem, which is chronic instability and chronic inflammation it’s safer than surgery for sure it’s effective for most musculoskeletal conditions as well. So how does Virginia medicine work? There’s a number of different ways that it does.

If you take tissue, that’s been damaged again, the normal way that your body heals is by putting the right cells into that area, to start the normal inflammation healing process and so in tissue, that’s been either chronically damaged or too much damage by putting in your own Cells into that area, you’re, then being you’re, then being able to optimize the health of the tissue. That’s been damaged number two part of treating a entire joint. Is you need to treat not only that one area that’s damaged, but all the other supportive tissues? That’s what prolotherapy is, and you do that by treating let’s say someone who’s got knee arthritis. You want to treat not only the knee joint.

You want to treat the ligaments, the tendons, other soft tissue structures, even the bone and nerves as well. That goes a long way to actually make a big difference or how regenerative medicine works. Number three we reduce chronic inflammation number four. You can actually improve neuromuscular health by treating the nerves as well, which makes a big difference in terms of strength as well as pain and function. So a couple really basic, FAQ questions or frequently asked questions.

Is this legal simple answer is yes, while there is fluctuating guidance, that’s been coming from the FDA over the last two decades. The reality is that there’s, some very clear rules, number one. You have to use your own cells, not somebody else’s cells. Number two: the cells cannot be significantly altered or adjusted uh. What that really means is that they need to be processed the same day and then re-injected the same day, and they have to be used for orthopedic tissue, that that is considered acceptable by the FDA guidance.

If your physician is trying to use it for other organs or conditions, there’s very little little evidence that it works for these other conditions and really very much against FDA guidance. Common question I see is: if I’m older, should I use someone else’s cells and the simple answer is no: for the vast majority of orthopedic conditions, there’s very good evidence that using your own living cells is effective. There’s definitely risk when you use somebody else’s cells. Your body is not prepped for those other cells. In addition, there’s legality, there’s legal issues of using someone else’s living cells in the united states.

You can only use your own living cells in this country. Is there an age limit? Simple answer is no. The one exception is for hips, where age over 65 can be a problem, but for all of our other conditions, age does not make any difference and that’s based on not just my opinion. That’s based on the evidence of what we see in the published literature when it comes to using PRP and bone marrow stem cells.

Next question: what sort of doctor does these treatments? It should be a physician’s focus on musculoskeletal conditions if your doctor is doing age, management on the side, treating erectile dysfunction, treating high blood pressure and then jumping in to treat your your knee arthritis. Your lower back issues they’re not focused they’re dabbling, you don’t wanna deal with someone’s unfocused like that. Number two. They should be focused on non-surgical treatments. Orthopedic surgeons are good at surgery. They’re not trained in doing these kind of injection guided procedures under image guidance.

And then, lastly, you want a proper regenerative medicine expert, someone who understands a lot of the details of what we’re talking about today.

Can these treatments help if I’ve already had surgery? The simple answer is yes, but it really depends on what kind of surgery if you’ve had let’s say a routine arthroscopy, show an example of someone. Who’s had lower back surgery and in those kind of cases. Yes, these can still help. If you’ve had a joint replaced, then that’s a different story right now. Now you’ve got metal or plastic in the area and if you’ve got pain from the hardware that that has to be addressed by your surgeon. If you’ve got pain because you’ve got pinched nerve or some other issue that can still be treated though.

My general rules for orthopedic surgery is try to keep your own anatomy, avoid the routine arthroscopy surgeries that don’t have a lot of evidence or data that supports them. Avoid avoid surgeries that routinely cut out tissue. That leaves the joint chronically unstable and always consider a regenerative medicine treatment option if you’ve been recommended surgery. Okay, so a couple of key regime medicine concepts, we’re going to talk about stability is a big one. I mentioned the term prolotherapy.

It’s based on this idea from architecture called tensegrity. It’s this idea that if you take individual units that may be weak on their own, if you put them in close approximation and compress them, you have an overall unit. That’s much stronger an overall an overall structure, that’s stronger, so the concept in biologic tissues is that if you inject cells into those supportive soft tissue structures, you can strengthen them and can then lead to a stronger joint, a more stabilized joint, which then leads to less Damage in the joint long term, improved pain and better function as well. The keys here are to treat the layers and depth that are actually involved in a problem. Too often, I’ve seen other physicians, that’ll say, for example, let’s say someone’s got knee arthritis, they’re, injecting cells.

Only into the joint neglecting to treat all the other layers of tissue, whether it’s the ligaments, the tendons, the muscles the fascial layers, myofascial layers, the peripheral nerves in that area and sometimes even the bone. They’re. Only treating the joint they’re missing out an opportunity to really fully treat the joint. You need to treat all those layers and the depth of those layers and by doing that, what you get is progressive strengthening of that tissue over time, which then leads to longer lasting results. So this is an example of a gentleman who has chronic lower back pain.

He’s had surgery in the past the issue with lower back surgeries or spine surgeries in general is that if you’ve got compression of a nerve or nerve damage, spine surgery can be very helpful to take pressure off the nerve. If what you’re dealing with is more pain, the problem with with lower back surgery is that it’s not as good at actually treating pain. So pretty common is that you’ll see someone who’s had lower back surgery in the past and they still have pain years later and part of that is because they’re only treating one focal level and part of that is because, even if you treat one level there’s still The same amount of force going through that which then leads to pressure on those other segments and thus continued pain. So in this gentleman’s case, he’d had surgery in the past a laminectomy surgery times two still having pain. We ended up using platelets to treat his epidural space, the muscles facetunes and ligaments at an initial 30 improvement.

We then progressively moved on to using his own bone marrow stem cells, he’s currently at 75 improvement and still doing very well ortho orthobiologics. These are the biologic cells that we use for these treatments. Again, it uses a normal healing process and again important to use your own cells, not somebody else’s, so platelets platelet platelets are key when it comes to that initial response to an injury, recruiting other cells and stimulating your own stem cells. Utilizing inflammation to get that process going so there’s different types of platelet products and it’s important to recognize that which one you use depends on which area that you’re treating. If your physician only has a one-size-fits-all perspective, then they won’t understand that you need to use a platelet preparation, a different plate, platelet preparation.

If you’ve got a joint issue versus a tendon issue versus a muscle issue versus a ligament issue versus a nerve issue and even a bone issue, and if you don’t you’re not treating this correctly, you need that kind of nuance that, unfortunately, the vast majority of physicians, Who try to do these treatments are missing. They don’t quite have that nuance here. So this is a case study of using platelets. In somebody this was a 45 year old man he’s a um he’s an active cyclist, very active, had patellar tendonitis. He was falling with a sports medicine physician, just not getting better so referred to me to see if we could help him out with his knee issues.

So in his case we ended up using platelet-rich plasma. We did that two times and what that did for him is it um uh helped him to get back to his full capacity. He came back in three years later now, his other leg. He had a hamstring, tendinitis issue again used platelets again and now his pain was resolved and he’s back to activity on the right side. This is a picture of what that is, uh, that’s the kneecap.

This is the needle. This is all under ultrasound guidance. This is a tendon. The the key here is that you want to be so precise with your treatment. You want to be treating uh very definitively, only the pathologic tissue, not the other tissue that may be healthy, so in his case um number one.

He did very well with platelets it’s a great example of a tendonitis doing very well with platelet-rich plasma number two. It’s a good uh example of how repeat treatment can actually help people even more and then number three. It’s again a good example of how image guidance is really necessary here. The next type of orthobiology that we use are stem cells. So this is the main cell that drives tissue repair after an injury again use your own cells.

Not somebody else’s next understand that bone marrow derived stem cells are legal in the united states, fat or adipose derived stem cells are not legal in the U.S. You can use fat or adipose for structural support, but the way that it’s processed is considered illegal in the united states. So if you’re getting a stem cell treatment, you want to be getting your own bone marrow and you get that bone marrow from the back of the pelvic bone um. You do not need to be sedated for that.

Just a little bit of local anesthetic is more than good enough to control that kind of discomfort and that’s the right way to actually do a stem cell treatment. You may hear about other types of cells. You may hear about amniotic or umbilical cord cells. Physicians, who are offering those and calling those a live, stem cell treatment are not being honest, or they may not understand the difference. There are no living cells in those products and the reason why is that after they’ve been collected after birth, the only way that they can be utilized in the united states for FDA guidelines is that they need to go through a processing protocol.

That requires the tissue to be dissolved, pulverize become a powdered solution and then sit on the shelf waiting to be used by the physician for up to two years. There’s no living cells. On that when that’s been tested. You may also hear about physicians, who are using platelets or or bone marrow stem cells and injecting a via iv, there’s no evidence that that helps with orthopedic conditions. I would be very, very careful about any clinic, that’s offering that they probably don’t fully understand what they’re doing in terms of outcomes.

Even if you have an advanced degree of arthritis, it’s surprising how much pain and improvement and functional improvement can actually occur, and that occurs because number one you can reduce inflammation chronically. You can improve stability in the joint by treating all those soft tissue cells. You can get cells that have been chronically damaged and start getting them to start working better, which means that they start pumping out the healthy or correct types of proteins. And what i find is that in patients that have been chronically limited because of an issue, if you can stabilize that joint, improve the pain, slowly improve their function. The next thing you know, they’re doing a little bit more exercise, which means now their strength is starting to get a little bit better, which then helps with overall support of that joint.

And then they just get into a good cycle, a positive cycle where they’re feeling better and better can we improve x-ray and MRI images if you’ve got advanced arthritis? No, if you have a physician who’s, showing you an x-ray of advanced arthritis and showing how they can make that look differently, that’s not legitimate! You! You want to really run away from that kind of clinic that that’s not accurate. If you have a tendon or ligament hair, that’s small, then that can still actually improve not only clinically in terms of your symptoms, but also on imaging.

If you have swelling in a joint or in the bone that can improve. If you have a condition called a vascular necrosis that can improve as well so great question i hear all the time is: can we treat bone on bone arthritis um? To begin with, i would say if your physician is using the term bone on bone arthritis, which is a term that’s maybe 70 years old. It’s number one, not an accurate term. If you have, let’s say advanced arthritis of the knee and your and your surgeon tells you you’ve got bone on bone arthritis, and yet you can still flex your knee almost the entire way.

You don’t really have bone on bone arthritis right. It’s unfortunately, a throwaway term that a lot of physicians use that is not really accurate. Arthritis is a biologic condition. It’s not just a condition that you can look on a x-ray image. It’s not a picture, it’s a biologic condition and so the treatments that we utilize for that ortho biologic treatments, platelets stem cells can help because it’s a biologic condition in particular if your range of motion is good and still intact.

So the caveats of this are number one. If you have advanced hip arthritis, it’s a different situation, it’s more challenging. I generally recommend those patients go for surgery, but for advanced, knee or lower back arthritis that still responds very well to treatment. In addition, expectations, i would kind of always temper your expectations. If you’ve got a more advanced condition, we can improve pain and function.

Improving imaging is, however, unlikely. So it’s a case of you know: can we actually improve tendon ligament injuries, so this is an ACL case. If you’ve got a partial thickness, tear definitely for full thickness tears, some of them can actually be treated with these treatments. So this is an example of a 28 year old man he’s a butcher. He stands for hours on end.

He plays volleyball during the summers. In an ACL chair, I saw him a few years ago. At that time we ended up using his own bone marrow cells within three months. Symptoms were resolved, no pain and he’s restarting, no more dynamic activity. The picture on the right is an important one to understand.

This is the knee. This is a knee cap. It’s the thigh bone. This is shin bone. This is the needle here and deep inside.

What’s lighting up here is the ACL anterior cruciate ligament? You cannot inject that blindly. You really need to do that under very high level, x-ray guidance, so in this case I’m injecting his ACL, and this is what he gets three months later. He has not only significant pain, relief, functional improvement activity resumption, but on the left side is his MRI of his ACL before treatment. So I’m going to show you a couple spots here.

This is the bottom of his ACL. It’s intact, the middle of his ACL on the top of his ACL are very hard to distinguish they’re very hazy. The radiologist has read this out as likely a full thickness tear picture on the right same ACL. Now. What you see three months later is a very linear structure, one that’s very clean and essentially normal.

Looking and that’s been read out as prior ACL tear has resolved so great case of where he had not only great clinical outcome, but imaging outcome as well. It’s an example of a gentleman who is a general contractor for 30 plus years 35 years. He came to me. He does a lot of overhead activity as part of his job and he now has chronic pain in his shoulder. It’s an ultrasound example of where, after stem cell and PRP treatment, he goes from a full thickness stair to one that’s no longer torn so the ultrasound on the left um.

This is his tendon. This is the gap in the tendon. This big gap in the tendon is a tear in the tendon. This is three months later. This is the tendon again and that prior gap in the tendon has been filled in right.

That that makes a big difference. That’s not only improvement in pain. It’s also improvement in improvement in uh function as well, so he’s actually doing quite well function as well as in imaging as well. So I have colleagues who really think that, because of their experience, just by palpating the skin, they can target where they need to inject. Somebody and um, you know when you start to learn about ultrasound and x-ray guidance to do these kind of procedures.

You realize um how how nonsensical that is you you can’t. You cannot inject these structures blindly and for my colleagues who say that you know I think, they’re really just guessing where they’re placing the needle and, if you’re injecting steroids. You know it’s not as big of a deal because steroids are fat soluble. You can inject somebody’s toe and their headache will feel better, but when you’re injecting somebody’s cells, whether that is um, platelets or bone marrow, when you’re, injecting it in a very targeted fashion, you’re, injecting it into a one millimeter by one millimeter spot. Otherwise, you’re not going to get the response, you have to be that precise and if you’re, you could only be that precise with ultrasound and x-ray diamonds so ultrasound on the left.

This is an individual’s rotator cuff. This is a very small tear. This is a needle and that’s the needle tip, injecting into that very small tear. This is a magnified image. This is like a 10x magnified image, and so that spot is very small.

You cannot do that blindly. The image on the right. This is somewhat it’s another. Shoulder example um, who this is the humerus. This is the glenoid.

It’s all part of the shoulder joint. This is the needle here, and this is the shoulder joint there’s a little bit of contrast in there under x-ray to make sure we’re hitting the right spot, and this other triangular structure is a labrum. We injected that as well and again, you can really only do that kind of position, precision with proper image guidance. These are pictures I showed before the one on the left is a patellar tendinitis case. The one on the right is a ACL case again all cases where you really need that precision.

It’s an example of a vascular, necrosis case. A vascular necrosis means that you have essentially dying bone and if the bone dies it can collapse and lead to worse arthritis and get very bad. So you need to treat that very early and aggressively, and so using your own bone marrow stem cells. You can do very well if this is targeted under x-ray guidance. It’s an example of a 41 year old man on the screen he’s a chef.

He stands on his feet for 12 13 hours at a time he came to me because he had a vascular necrosis in his ankle. We treated him and he is several years out now and doing really well picture on the left. This is the ankle joint right here. This um white uptake right here – that is a vascular necrosis three months later that vascular necrosis is gone. The fluid is gone and he’s doing fantastic so that that’s essentially curing his avascular necrosis, which is an exciting thing, because that really prevents him from significantly worse problems.

Long term regenerative, medicine treatments offer safe and effective solutions for your pain, [, Music, ]. So some common questions that i get is this too good to be true, so there’s evidence behind these treatments since the mid 1990s, Philip Hernandez, a orthopedic surgeon in France, who’s been doing his treatments since then, so he has data going back 25, 27 years. The Regenexx Network there’s data going back to 2005 I hear a lot of physicians who are interested in these kind of treatments. Who don’t have experience will say things like well, these treatments they’re low risk they may help, but i don’t know if it’s going to make a difference or too new. The reality is they’re.

Not new they’ve been around for a couple decades. My personal experience goes back to 2008. I think if you’re inexperienced and new to the field, it seems new. This is a rapidly developing field, but it’s not new. If you’re experienced you’ve had time doing this, you realize that there’s right and wrong ways to do this, and if you follow the right ways, you can get patients with good results to get good results, important of expectations that are grounded in reality and evidence-based medicine, though, If you’re getting pie in the eye expectations, that’s not accurate either right.

You want to have expectations from your physician that are very conservative, that that are appropriate as well. So how long the results last again there’s data in the Regenexx Network that goes 15 years now. At this point, Philip Hernandez experience, it goes over 20 years. What I tell people again is think conservatively, if you have a chronic condition, expect that somewhere down the line, it may be a few years. Where repeat, treatment would be helpful to keep that initial treatment.

Improving the best way to maintain results after treatment are to improve your biomechanics with physical therapy, continuing exercise afterwards taking the appropriate supplements, so we know help with inflammation arthritis and, lastly, repeating treatment if needed is additive to that initial treatment cost somebody asked about cost. So these are not routinely covered by insurance. There are some exceptions: the Regenexx corporate plan uh there’s a website up there. If your insurance, if your company is self-insured, they can add the Regenexx benefits to their benefits plan where, whereupon it’s then covered as any other kind of insured procedure, if not the general cost in the united states you’ll see this is that PRP roughly is five hundred Dollars and up and and bone marrow stencil teams are eighty five hundred dollars an hour. The keys to determine value are number one.

Is your physician and clinic a true regenerative medicine expert? Are they focused on this? Do they know what they’re doing are they dabbling or are they an actual expert number two: are you receiving a real stem cell treatment via your own bone marrow, or are you getting an amniotic or umbilical cord treatment? That is not any living cell? You have to be very careful there and lastly understand that these are in-office procedures.

You do not need to be hospitalized or go through a surgery center. If you do you’ll end up racking up more facility fees, and you can avoid that as well. So, a little bit more, just in brief, our approach of Chicago arthritis from our drive medicine focus on non-surgical treatments for your arthritis and eyes, injuries and back pain, always starting evaluation by saying, what’s the big picture in terms of inflammation instability, asymmetry, neurologic issues trying to Originally correct with low risk interventions, exercise and supplements. Most of the patients that come to us have already tried multiple things. It’s rare that we get someone who’s really never tried anything for for their issues.

If conservative treatments are not working, then we talk about retired medicine treatments number one using the best available treatment options for from your own body, a plan that specifically is tailored to your condition, needs with platelet and stem cell preps. That are very specific to your to your needs and then delivering cells using very precise, high level image guidance as well. I think these should be the bare minimum. The bare minimum should be very high in terms of what what you should expect from your physician from these kind of treatments. So I see there have been a few questions that have come up and I’ll start to go through those uh.

But if you have any questions or that you’d like to ask us in the future or if you want to know how to get evaluated three different ways, you can go to the website, you can email us at admin, Chicago or you can even just Call us at 773-348-7171, okay, great. So let’s see these questions all right question about I’m an orthopedic surgeon, I’m not I’m a rheumatologist, I’m also um an expert in image, guided injections, as I mentioned before, the uh. The challenge for orthopedic surgeons is that they don’t have the right sort of um training, with image guidance or with regenerative medicine, so they’re they’re, usually actually not the right people to do these treatments they’re experts in surgery, which is very different than these kind of treatments.

Okay, what is the bone marrow protocol? You mentioned, I’m not exactly sure what you’re asking, but the way that you um get your own stem cells. It comes from your own bone marrow, and so you do a bone marrow aspiration from the back of the hip bone. We take out it’s done under just local anesthetic. Our average patient tells us that discomfort is roughly a 3 out of 10 We then prep that same day into a high concentration of your own bone marrow cells.

We then re-inject that, on that same day as well, okay, somebody asked about insurance coverage. We talked about that, usually not um, hsa and flex accounts. Right I mean you have to obviously ask your your uh, the administrator that handles that, but those kind of accounts are made to handle these kind of elective um uh costs as well, and so they they should be covered under that that’s actually a good option. If you have that available, do you become less dependent on meds and supplements meds for sure, right, like our goal, is to get you off pain, medications uh. If you’ve been on it for many many years that can be hard part of our treatment protocol is.

We need you off any anti-inflammatory medications, including ibuprofen, Advil or Aleve – that’s hard for people originally because they’re so used to it. But what I like is you can gauge a person’s expect. You can gauge a person’s improvement initially by. Are they back to their baseline, um kind of life or activity level, despite being off the pain medications and then progressively, as they get better without the pain medications? That’s a really great sign so that that’s what we’re looking for for sure in terms of supplements.

I think supplements are additive, they’re not necessary, but i think they are additive in that they can help with inflammation in different ways, and so i i do still encourage people to take supplements but trying to get them off pain, medications for sure, okay, somebody asking about Son-In-Law in a serious accident hardware, in his lower leg and no cartilage, is there a non-singular treatment to relieve his pain and increase functionality yeah. So it there’s a lot of details that need to be figured out there right number one is um number one is what areas are actually problematic meaning are we talking about an ankle or knee that that’s painful uh? If so, is there any hardware already in the joint or is it just hardware, that’s in the bone? If the joint itself is still not replaced or there’s no hardware in it, then that can still be treated. Alternatively, if he’s got chronic pain in the leg, because he’s got a pinched nerve in the lower back again that can be treated as well.

Also, so for sure I mean I would definitely look into that, especially if he’s already gone through surgery. What is the Regenexx stem cell protocol right, so um Regenexx, again network of physicians? Not just in this country, there’s actually sites around the world, uh we’re sort of loosely affiliated, but we use all the same uh. We use all all the same protocols in terms of treatment in terms of lab prep and quality control, as well now for the stem cell protocol. There’s a three-step protocol that we utilize for all of our patients that that’s been in use since 2005.

You’re welcome. I appreciate the uh. Thank you. How long is the procedure is a piece patient under local anesthesia? Okay.

So how long is the procedure depends on what procedure we’re talking about if you’re getting platelet-rich plasma? There’s an initial blood draw in the morning you’re in the office for probably about 30 minutes and then there’s a re-injection of tissue in the afternoon uh that can take anywhere from 20 minutes to an hour depending on what area and what structures need to be treated. Uh we do routinely use local anesthetic, of course, to numb up the area we will uh occasionally use sedation, we’ll have an anesthesiologist sedate patients in in cases where we think that’s more appropriate, but that’s that’s not routine, but local anesthesia, all the time. Of course. Okay.

Somebody asking about pain of retrieval: you must be talking about bone marrow. It is not as bad as you as you think it is people tell us it’s about three out of ten. I I think you have to understand, there’s a difference between a bone marrow aspiration for a cancer patient versus a bone marrow aspiration for what we’re doing here, bone marrow aspiration for a cancer patient you’re talking about somebody who is already very ill um. They may have lost a lot of weight, a lot of muscle, again they’re suffering from a systemic, very severe disorder to severe condition. They may already be getting chemotherapy or radiation.

A lot of their normal reserves are down. I think even the setting of that, whether it’s an interventional radiology or in the hospital, it’s just a more stressful setting um for these kind of procedures, which are elective. Where um, you know, if you do, if you do this enough, patients really shouldn’t be that uncomfortable with this. I think if your physician is maybe not as well experienced with this, then then um, then there may be more discomfort just because they’re, not as they just don’t have the skill set. At that point we have requirements.

You know I routinely recommend physical therapy after treatment. Just because I think it’s low risk and I think a good physical therapist is worth their weight in gold, and I think they can get you back to your activity levels very fast back to normal work. Slash play um part of it depends on. What’s your normal. Are you talking about what is your new normal for the last few years?

You know, hopefully we can get you better than that. Are you talking about your your normal from when you were 18 years old and now you’re 50 years old? You know like we can’t. We can’t turn back the clock. We can’t reverse time like that, but we can certainly get people to a higher level.

What i normally tell people is expect from a timing. Standpoint is um first couple days after treatment, expect more inflammation and discomfort than stiffness for about another week or two, and then really more noticing significant improvement at the one month mark and then improving for several months afterwards for platelets that improvement. I normally see that around up to three months to six months, there are studies out there saying even longer than that for bone marrow. I always say give it at least six months up to 12 months to see how well you’re doing as well. How long will it last again the the the evidence out there?

There is data that shows that people have an enduring response for 10 plus years in some cases um. I tell people think more conservatively, which means, if you’ve got something, that’s chronic, that you’ve been dealing with for years, expect that you may need a repeat treatment somewhere down the line earlier than that that might be in five years. It might be in a year. Just depends on the person ongoing visits after procedure. Well, frankly, i think for musculoskeletal care, if you’re only getting a procedure and then you know uh a shake of the hand and you know call us if there’s a problem, i i don’t think that’s really appropriate medical care.

What we normally do is we stay in touch um at around the one week mark one month mark and then every three months or so for the first year to make sure people are back on track. Um, okay, there’s more billing questions, follow-up included in price. You know there there’s there’s a cost for procedures and there’s a cost for follow-ups. You know this. This is not like surgery where they have global fees and things like that.

That’s that’s a different kind of scenario with moderate arthritis in the hip, which treatment is recommended. Great question: so, if you’ve got moderate osteoarthritis, i would recommend using your own bone marrow stem cells. Um platelets can work as well. Um for moderate, hip osteoarthritis, but stem cells are more reliable. Hips are such that you have to be um appropriately aggressive if you’re doing platelets.

You should expect that it’s going to take a few treatments to get the ideal outcome, and so I think bone marrow tends to be stronger in that case is stem cell the best option to repair hip cartilage um number one. If you have chronic arthritis, that’s causing cartilage wear you’re, not going to be able to change what the cartilage looks like on your x-ray or MRI, not based on the current imaging there’s some evidence actually that you can get the cartilage to look healthier on MRI. Some of the more experimental MRI research grade – MRI images, I’m still very hesitant to tell patients that you can repair hip cartilage. I think that cartilage can be healthier but to say that you’re, repairing it. You have to be very careful about using that, because you’re not going to be able to fill in a huge gap of cartilage with any treatment that’s available right now, but stem cells are definitely a better option for for hip arthritis, stronger option than just platelets.

Okay. Do these treatments help cartilage thinning versus cartilage tears? Yes, absolutely i mean cartilage thinning. That is what osteoarthritis degenerative arthritis is. So absolutely how effective will this be for the thumb and wrist area great question um.

I find uh surprisingly that people do quite well with treatment and part of the trick is treating all the related structures. So as an example, if you’ve got um arthritis of the thumb uh, which we’ve seen a lot of people nowadays because we’re all texting, uh we’re all typing at work, we’re all stressing our hands in different ways, and we have done in the past. But the keys to treating that area are treating the joint itself, the ligaments as well, and then even the nerve as well. If you do that, people then do pretty well actually specifically glenoid versus labrum. Okay, I’m not exactly sure.

I think this may be in relation to your question about treating thinning of the cartilage and certainly treating shoulder. Osteoarthritis is certainly a common thing that we treat for sure. Okay, getting back to the thumb and the risk asking PRP or stem cells depends on the degree of damage. It’s such a small joint. I find that platelets sometimes are good enough as a first line, treatment and and on occasion, like less common, we’ll end up using stem cells for that certain medical insurance is acceptable right.

So if there are roughly 500 companies in the country right now that have the Regenexx corporate plan under their benefits package, if that’s the case, then these procedures are covered. Traditional insurance does not every once in a while you’ll find a workers comp plan that may cover this. It’s less certain. The Regenexx corporate plan is a lot more definitive in terms of what they cover and very clear that they make it very clear: who’s. The right candidate, or not, if you have the option of doing that, I’d strongly, recommend it it’s good for not only the employer and the company itself in terms of reducing their surgical costs.

It’s such a great option for their employees, patients as well, because it really gives them access to these kind of treatments in a very affordable manner. Okay. Somebody next question: i have chronic pain in my shoulder, lower back hips and both knees osteoarthritis. How long does it take the procedure? Um?

It depends on what you’re treating it’s. It’s um number one. You can only treat so many places at one time. I think if somebody has osteoarthritis in multiple joints, sometimes separating the procedure into two separate days makes a lot more sense. Uh number one.

I think that is um more comfortable for the patient. I mean where none of us want to be a pin, cushion and number two. I think if you want to get the right kind, the right quantity, uh of cells, you want to make sure that you’re treating the right number of joints. At the same time, too, many joints can be a problem. Are you accepting payment plan?

Yes, we work with care credit, there’s, definitely payment plan options. Okay, thank you look forward to meeting you, sir. Do you inject rear neck ligaments with PRP what levels and what specific ligaments can you reach great question? I personally do not treat the neck the cervical spine. I treat the lower back for the neck and we’re referring to a couple of my other colleagues to me.

It’s a great example of if you’re an expert in one thing make sure you stay in your lane. I have colleagues who are experts in other areas and I defer to them when it comes to the neck, but i can tell you that they um they can go right up to the upper cervical levels and they can get pretty deep in terms of hitting The ligaments that are most critical for next stability um. So if you do have instability the neck, that is certainly an option, not one that i treat but um. I do have colleagues who are skilled to know how to do that so within the Regenexx Network. There’s definitely folks who can help you out.

Yep you’re, welcome. Okay. Are there any particular kits in the market you use for the separation of stem cells and our PRP, whereas the collection of sample re-injection interval, okay, so um? It’s a question from a physician. This is a um uh.

I guess the simple way to put it is I don’t use a particular kit what we use. We use the intellectual property that Regenexx provides us and in that intellectual property we essentially prep cells in a lab-based setting. So you use centrifuges, but we’re not using a particular kit. The issue with kits is that they generally give you just a one size fits all product. There may be ways to sort of adjust that on the back end, but your you you’re put into a little bit more of a box in that regard, and so that’s not that’s not the direction.

I go. Um uh the direction, the direction that we use uh, the lab-based format – gives us maximum ability to do this. What is the collection of sample re-injection intervals? So how long does it take? So the one downside to doing this in the lab setting is that it is much more manually exhaustive.

It takes more staff time lab time, training of staff to make sure that they’re appropriately skilled in terms of doing these kind of lab techniques uh. So for us it’ll take us a couple hours if you’re doing a um sort of kit-based method that can take. You know that can take 30 minutes. It can take less than that. Um.

But again you you. You have the convenience of that. That aspect to it, but you lose the nuance and um ability to um professionally deliver a wider range of treatments. How many sessions it depends on the patient right. So what we generically tell people for platelets for PRP, we’ll tell patients expect treatment on day one and let’s see what happens over the next several months and generically expect anywhere from one to three treatments based on how you respond over the next two years.

I don’t like to tell people expect you’re going to definitely get this number of treatments, because I don’t think that’s accurate. I think each person is a little bit different people heal a bit differently. What i prefer to do as treatment on day one. Let’s see how you progress over the next three months and then decide what to do stem cells. I would give it more like 12 months to see how well they do.

There may be some cases where you do it at the six month mark, but normally give it 12 months. Okay, so insurance question is it covered by Medicare nope? As i mentioned, while office visits, evaluation imaging physical therapy bracing, all that is covered by insurance, including Medicare. These procedures are not the government does not quite um does not quite know how to handle this. At this point, there’s a limb of the government that treats active military duty folks, who it’s called Tricare. Tricare will cover platelet-rich plasma for some indications, not all indications.

Medicare does not cover it at all, unfortunately, for lower back PRP ligament treatment. What’s spacing at time between treatments are optimal yeah. That’s it’s a great question. I’ve seen people do this every month. I think that’s too much.

I really that’s too much when you think about how platelets work and the normal healing inflammation cascade works. You really should be giving it at least two to three months. I think I actually tend to give it like up to three months. I just like to let people slowly progressively get better at the same time they start doing their own core exercises hip exercises that helps as well, and so I think you have to give a little bit more time than just one month. Yeah well you’re welcome everyone.

I appreciate the thanks and the gratitude um any other questions before we call it a day. Wonderful. Well, if there are any other questions. Okay, there is one more question: yes, okay, uh, I’m waiting, um uh, as I wait on that. If there you have any other questions or you need to contact us again, you can do so at any of our contact.

Um points, whether that is um, a website, email phone number, any of our social channels as well. Okay, great question: my brother has a hip labrum tear, do you diagnose it and how is it treated, fascinating question? Uh hip labrum tears are probably over diagnosed and that’s and in large part, because MRIs are so good at detecting problems, and the problem is that a lot of times you may see a little bit of fraying of the labrum on MRI, but a person’s actual problem Is not related to that? It may be related to instability around the hip. It may be more related to the ligaments, or you may find that somebody has a little bit of fraying of the labrum or tear in the labrum, but they’ve also got hip arthritis, in which case the labrum is not the problem.

It’s the overall degenerative process going on so and then every once in a while, you do have somebody who actually their problem is actually just a hip label, tear um and in that case um. How do you diagnose it? Partly by um uh how’s, a person’s exam like do they have some classic uh symptoms that they describe as well. Examination findings catching clicking findings like that uh and then an MRI in particular, MR arthrogram, is really your diet. Your kind of gold standard way of diagnosing hip labrum tear in terms of treatment i find platelets, are generally the first line treatment for hip label tears, the exception would be if they have more arthritis, in which case bone marrow stem cells would be appropriate great.

Well, i appreciate everyone’s time today. One last question: sorry um uh yep. We do see ankle issues as well, um, whether it’s ankle arthritis or tendonitis. Absolutely that’s a very common area that we treat as well um. Okay uh is the webinar available for off uh offline.

Viewing, yes, it will be uh, we’ll put it up on our youtube channel and um. You should, via email, get a notification of the uh, the link to re-watch it as well. Wonderful! Well, thank you, everyone for your time today. I understand, um just one last question somebody’s saying they were approved for a very specific procedure for the neck, but it’s only being done in Colorado, you’re right.

It’s maybe not the most convenient thing, but um they’re, the ones who are most focused on it. At this time, and so um, you want to get it done by the guys, uh or gals, who know what they’re doing uh, and so I would definitely stick with it that way. Okay, wonderful! Thank you! Everyone for your time and uh best of luck and uh.

Look forward to talking and communicating the future have a good day and live well. Bye-Bye

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