Latest / The Driven Athlete / THROWBACK - Spine Health and Regenerative Medicine w/ Dr. James Ghattas | Ep 83

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THROWBACK - Spine Health and Regenerative Medicine w/ Dr. James Ghattas | Ep 83 · The Driven Athlete

• 0:00
  Speaker 1: If you're a driven, active person who wants to reach and pursue a higher quality life with some ambition, then guess what this podcast is for you.
• 0:08
  Speaker 1: This is the Driven Athlete Podcast.
• 0:10
  Speaker 1: What's up?
• 0:12
  Speaker 1: Y'all?
• 0:12
  Speaker 1: It's your man, dr Kyle.
• 0:13
  Speaker 1: Welcome back to the Driven Athlete Podcast.
• 0:15
  Speaker 1: We've got a really cool guest, dr Gaddis.
• 0:17
  Speaker 1: Dr James Gaddis, thank you for coming in, man.
• 0:19
  Speaker 1: I know you're a busy dude from your practice, so thank you for coming in, dude.
• 0:25
  Speaker 1: Thanks for having me um the uh.
• 0:26
  Speaker 1: So tell us more about um your practice, regenics, right where you're at and what y'all do mainly yeah, so it's a uh.
• 0:34
  Speaker 2: The practice is called palm beach regenerative sport and spine.
• 0:37
  Speaker 2: Okay, and within my practice I offer regenics, musculoskeletal care and Regenexx is basically a network of physicians that perform essentially regenerative orthopedics.
• 0:48
  Speaker 2: We use biologics, your own biologics, like PRP, super concentrated platelets and bone marrow concentrate and a host of other things, to sort of address any sort of musculoskeletal condition, from the top of your spine all the way down to the smallest bone in your toe.
• 1:05
  Speaker 2: Um, it's all injection-based treatments under image guidance, x-ray guidance, ultrasound guidance, um, and really it's, it's more than just, you know, injections to fix a joint or something like that.
• 1:20
  Speaker 2: It's a different sort of approach to musculoskeletal care to address that massive gap in between conservative care which is what insurance companies like to call it and surgery, and we know now that a lot of surgeries there are many surgeries that are absolutely necessary- and there are a lot of surgeries that might not be necessary but are overutilized because of a lack of options, essentially, and we're starting to discover now that their outcomes aren't really any better than high quality or just doing nothing, and if they can find some high quality therapy, they might do better than getting surgery.
• 1:55
  Speaker 2: So I occupy that space in between, cool.
• 1:59
  Speaker 1: So you find yourself.
• 2:00
  Speaker 1: A lot of the treatments that you all do are enriched uh.
• 2:04
  Speaker 1: Platelet injections right prp bone marrow, dense uh injections right like bone, utilize the bone marrow yeah, contents yeah and then um uh stem cells that's so.
• 2:19
  Speaker 2: Yes, I'll kind of start from our shopping list of things that we use perfect from the most simple, which, by the way, I forgot to answer your question earlier.
• 2:27
  Speaker 2: So, we're just down the street, okay, we're on palm beach, lakes, boulevard, uh and village right next to renegades okay, yep you ever been to renegades?
• 2:34
  Speaker 1: fun place.
• 2:34
  Speaker 1: Yeah, yeah, yeah, get your country dance on, yeah exactly, um.
• 2:38
  Speaker 2: so our sort of armamentarium of tools, from the very most simple, is prolotherapy.
• 2:43
  Speaker 2: Prolotherapy is sort of like the godfather of regenerative orthopedics.
• 2:47
  Speaker 2: It's just concentrated sugar water and we use that to treat simple conditions like tendinitis, tennis, elbow, any type of ligament laxity.
• 2:59
  Speaker 2: We can use prolotherapy as a simple option.
• 3:01
  Speaker 2: It acts as a mild irritant to the tissue and causes proliferation of cells that are important for ligament growth and ligament health, things like fibroblasts and it lays down a lot of collagen and so on.
• 3:14
  Speaker 1: Okay, so it stimulates fibroblast activity to lay down new collagen by creating a little bit of irritation on purpose within the articular, Well within tissues within the ligaments themselves.
• 3:26
  Speaker 2: So let's say you have like a lax MCL and you're getting a lot of nevalgus.
• 3:30
  Speaker 2: We'll inject it into the MCL and it doubles in the sense that you have the proliferation because of the inflammatory reaction.
• 3:36
  Speaker 2: But it also acts as an osmotic, meaning it's concentrated, so it kind of draws fluid out of the tissue and tightens the tissue up.
• 3:43
  Speaker 2: There some debate about how true that is, but you still, you know, improve ligament health by using that.
• 3:50
  Speaker 2: So that's our most simple option.
• 3:52
  Speaker 2: The next most common thing we use is called super concentrated platelets, which is actually sort of one step past prp.
• 3:59
  Speaker 2: Okay, meaning um.
• 4:01
  Speaker 2: Prp is basically you take whole blood, you spin it down, you get rid of the red blood cells and what you're left with is plasma full of platelets we call it platelet-rich plasma and that's usually about one and a half times the concentration of the platelets.
• 4:16
  Speaker 2: That's just floating around in your blood as is, which is useful.
• 4:19
  Speaker 2: But we take it one step further by taking that plasma and concentrating it even more, and then from there we have, like this dense pellet of just you know, several billion platelets, and then we can use whatever leftover plasma there is to tailor the concentration of PRP Okay, which is important because some tissues require higher concentrations of PRP than others, which, by the way, let me know if I'm getting two in the yeah, no, I love this um, yeah, so we're able to concentrate the pr or I should say scp, super concentrated platelets.
• 4:53
  Speaker 2: Okay, um, to different concentrations depending on what I'm treating, meaning you know, ligaments and tendons.
• 4:58
  Speaker 2: I can usually five to seven x concentrated is good, but if we're treating, let's say, you know, a herniated disc in the lumbar spine, you need 20x and you know that requires a lot of blood to get to that 20x concentration, but it matters um, so that's scp.
• 5:14
  Speaker 2: And then we typically use those for mild to moderate conditions and most most spinal conditions.
• 5:21
  Speaker 2: Okay, um, beyond that we enter into the realm of bone marrow concentrate, and that's where the word stem cell sort of fits okay I don't like to say stem cells alone, because that implies a whole nother process.
• 5:36
  Speaker 2: That is not, you know, not fda approved in the us right now and certain facilities can do it correctly overseas and so on.
• 5:46
  Speaker 2: But as far as what we can do in the US with your stem cells is, we can get your bone marrow.
• 5:51
  Speaker 2: Very similar to what they do in the hospital for, you know, cancer patients and so on.
• 5:55
  Speaker 2: They aspirate bone marrow from the pelvis, from the big iliac crest on the side there.
• 6:00
  Speaker 2: From there we take anywhere from 60 to 90, in some, some cases, over 100 cc's of bone marrow and we can concentrate that down and take specifically the white uh, the white cells or the buffy coat.
• 6:14
  Speaker 2: The buffy coat has all the stem cells essentially.
• 6:18
  Speaker 2: So let's say, out of a 90 cc bone marrow concentrate draw, I'll probably get three or four ccs of concentrated what we call mesenchymal stromal cells.
• 6:33
  Speaker 2: They used to be called mesenchymal stem cells, now they're called stromal cells okay yeah, think of them as like stem cells with a college degree okay, meaning they used to be pluripotent.
• 6:42
  Speaker 2: Like they, they could become anything.
• 6:44
  Speaker 2: And then, because of where they are, they essentially have differentiated into some sort of musculoskeletal tissue.
• 6:51
  Speaker 2: They're either going to turn into ligament, tendon, cartilage, bone or muscle and, depending where you inject them, they sort of learn from their environment that you've injected them into.
• 7:01
  Speaker 2: What kind of cell they turn into and they follow suit, exactly, exactly environment that you've injected them into, what what kind of cell right turn into and they follow suit.
• 7:08
  Speaker 2: Yeah, exactly, exactly.
• 7:08
  Speaker 2: So out of you know, out of a 90 cc bone marrow, you get maybe four ccs of concentrated bone marrow cells.
• 7:13
  Speaker 2: And then out of that four ccs you might have, like you know, several hundred million or a few billion stromal cells, mscs, uh, and within that there's like maybe 100,000 actual true stem cells.
• 7:26
  Speaker 2: Yeah, so you do have a small concentration of your true stem cells inside your bone marrow, but it's a small number.
• 7:33
  Speaker 1: Right.
• 7:35
  Speaker 2: Up until about 2009, it was possible to isolate those few stem cells, analyze them and then culture them, grow them out, and so then you could expand, or what we call culture.
• 7:50
  Speaker 2: Expand those stem cells to several billion, and now you could store them and have them for later.
• 7:55
  Speaker 2: But in 2009, the FDA ruled that that was called more than minimal manipulation.
• 8:02
  Speaker 2: There's basically these laws surrounding what you can do with human tissue, and minimal manipulation is one of these.
• 8:10
  Speaker 2: So basically, you can't change the chemical properties or grow things without it being considered a new drug, and a new drug requires phase one, two, three.
• 8:19
  Speaker 1: FDA trials.
• 8:19
  Speaker 1: It's a several billion dollar industry.
• 8:21
  Speaker 2: So those facilities that were able to do that sort of moved offshore.
• 8:25
  Speaker 2: For example, regenexx has a university-style lab in the Grand Cayman Islands where they do this.
• 8:33
  Speaker 2: They basically culture your stem cells, expand them, store them so you can use them for years and years and years later.
• 8:40
  Speaker 2: As soon as I get the chance, I'm going to go out there and do that before I turn 40, get some pre-40 stem cells.
• 8:45
  Speaker 2: But going back to the US, and what I do essentially in clinic is we isolate bone marrow, we concentrate it down and then from that we can inject that back into more severe, severe arthritic conditions like bone on bone.
• 9:01
  Speaker 2: Arthritis is a commonly used one bone death, avascular necrosis of the hip, things like that.
• 9:06
  Speaker 2: We can inject it into the bone and it essentially halts the progression of of arthritis.
• 9:11
  Speaker 1: Yeah, Pretty good success rates.
• 9:13
  Speaker 1: That's really cool.
• 9:13
  Speaker 1: That's awesome.
• 9:14
  Speaker 1: Um for SCP um super condensed platelets, super concentrated super concentrated plates Close enough, yeah, yeah For herniated discs?
• 9:23
  Speaker 1: Um, and then I was also going to ask about tendinosis, like maybe a golfer's or tennis elbow or something like that.
• 9:29
  Speaker 1: Is there super common like what they call like recalcitrant development or progress for like healing?
• 9:36
  Speaker 1: Um, what's for hernia discs?
• 9:38
  Speaker 1: What's the mechanism?
• 9:40
  Speaker 2: So it depends on what kind of disc you're you're treating.
• 9:43
  Speaker 2: So let's say a disc that has a little tear in the outside of the disc an annular tear.
• 9:50
  Speaker 2: We know that if you just pump that disc full of super concentrated platelets they might just leak out of that tear.
• 9:57
  Speaker 2: So what you have to do is decide, okay, where is this tear and what's the best way for me to approach it?
• 10:03
  Speaker 2: Because you really want to put those platelets right in that tear, because those platelets will stick and aggregate and then they sort of open up from there.
• 10:14
  Speaker 2: So let's say you have a disc tear that's sort of out laterally on the side, it actually makes more sense not to even go into the disc but to just, with the needle under x-ray guidance, just go right up to that little tear and park the needle right in front of the tear and deposit your platelets there.
• 10:28
  Speaker 2: Very few cc's.
• 10:29
  Speaker 2: If you're dealing with a disc that's a little bit more degenerated, um, or is, you know, bulging, then it makes more sense to sort of go into the disc itself, um, and from there you have to sort of decide first.
• 10:43
  Speaker 2: You know, is this the disc that's bothering the person, cause usually there's more than one disc.
• 10:48
  Speaker 1: Yeah.
• 10:48
  Speaker 2: So you do what's called a discogram.
• 10:50
  Speaker 2: So we basically guide the needle in there.
• 10:52
  Speaker 2: The patient is awake, um, and we inject a small volume of a combination of antibiotics and, uh, contrast.
• 11:00
  Speaker 2: Contrast agent basically shows a dark on an x-ray.
• 11:02
  Speaker 1: so we can see it.
• 11:03
  Speaker 2: And we try and provoke that disc.
• 11:05
  Speaker 2: We fill it up a little bit and then we ask the patient does that reproduce the same pain that you have?
• 11:11
  Speaker 2: And a lot of times they'll say no, that's something different.
• 11:14
  Speaker 2: And so you sort of have to look and maybe it's not the disc that you expected, maybe it's a different one.
• 11:18
  Speaker 2: So you know, of course, correct.
• 11:20
  Speaker 2: Once you sort of reproduce that pain, then that's when we inject about, you know, three to four cc's, depending on the disc, of that highly concentrated prp uh, and it has your white blood cells in it, so we call it leukocyte rich prp, gotcha.
• 11:38
  Speaker 2: And that's more of a protective factor because the discs are prone to getting infected.
• 11:47
  Speaker 2: They oftentimes are colonized with a certain type of bacteria, and so you want to have your white blood cells in there to sort of manage that party, right, yeah totally.
• 11:57
  Speaker 2: Yeah, so again, it really depends on the disc.
• 12:00
  Speaker 2: If you're dealing with an annular tear, which is usually the most painful, you want to get as close to that tear as possible.
• 12:06
  Speaker 2: Um, there is a device by the late great dr greg lutz, uh, who recently passed away.
• 12:13
  Speaker 2: Um, it's like a catheter that basically kind of curves around.
• 12:17
  Speaker 2: So you enter the disc and then you introduce this catheter, it curves around and you can direct it right to that little tear and you just deposit your platelets right there interesting, which is amazing.
• 12:25
  Speaker 2: It's amazing device or you just fill up the disc itself.
• 12:28
  Speaker 1: Yeah, interesting, um, and then the platelets will be in there, they'll aggregate, proliferate and then help scar down and heal up the tear.
• 12:38
  Speaker 2: Essentially, yeah that that's the goal.
• 12:40
  Speaker 2: So, um, there's a lot of studies that show that the more that degenerated the disc is, the more likely those platelets are just going to immediately leak out.
• 12:47
  Speaker 2: So if you have a completely desiccated or degenerated disc, then you sort of have to decide is it worth injecting the disc and putting the patient at that risk, or do you want to do a more aggressive treatment and use culture expanded stem cells?
• 13:01
  Speaker 2: And use culture expanded stem cells, which those have been shown to improve very degenerated and desiccated discs, because they sort of they have these receptors on them, called CD19 receptors, that they stick to whatever surface that they're injected on.
• 13:16
  Speaker 2: They stick within like three minutes.
• 13:18
  Speaker 1: Cool yeah, so a lot better stick rate.
• 13:21
  Speaker 2: A lot better stick rate.
• 13:22
  Speaker 2: Yeah, exactly.
• 13:23
  Speaker 1: And for a patient like that, how many rounds of those injections?
• 13:26
  Speaker 1: Let's say it's like a very degenerative disc and they're having referred pain right Back pain.
• 13:32
  Speaker 1: Yeah, they got an image.
• 13:33
  Speaker 1: Looks bad.
• 13:34
  Speaker 1: Do this right.
• 13:36
  Speaker 1: How many rounds of that?
• 13:39
  Speaker 2: So, and then re-image like in six months and they'd see an improvement, or eight months oftentimes we will let re-imaging like let the patient decide if they want re-imaging or not, because we don't typically when it's.
• 13:50
  Speaker 2: It's definitely nice to have somebody come back with a post-injection mri and it like looks beautiful yeah, generate like see everybody, look, look exactly but more often than not the disc will look exactly the same.
• 14:01
  Speaker 2: On the mri you might have some you resolution of some tears and whatnot which we can see.
• 14:05
  Speaker 2: We actually published a study on this out in Colorado where we did pre and post MRI studies of intradiscal injections of annular tears.
• 14:11
  Speaker 2: It required a lot of sort of MRI software programming to be able to determine the grayscale difference on these different discs.
• 14:22
  Speaker 1: But, anyways.
• 14:24
  Speaker 2: yeah, sometimes you'll get image resolution of the disc.
• 14:27
  Speaker 2: That's always good, but more often than not the patient's symptoms will improve and their disc looks exactly the same.
• 14:34
  Speaker 2: You don't want to go into the disc.
• 14:35
  Speaker 2: That often it is a risky procedure.
• 14:38
  Speaker 1: So the disc looks very, very similar, but their symptoms are a lot better.
• 14:43
  Speaker 2: Yeah, most often that's the case.
• 14:44
  Speaker 2: Sometimes you get this beautiful post injection MRI where the bulge is resolved and the annular tear is resolved.
• 14:51
  Speaker 1: So, if that looks the same, where do you like?
• 14:53
  Speaker 1: What are your thoughts on like?
• 14:54
  Speaker 1: What was the symptom reduction from?
• 14:57
  Speaker 2: A lot of times it's leakage of the inner contents of the disc.
• 15:03
  Speaker 2: Um, that has a lot of inflammatory cytokines in it.
• 15:06
  Speaker 2: There's a nerve that sort of encompasses the disc called the sinovertebral nerve.
• 15:12
  Speaker 2: You don't see that nerve in like neurology textbooks.
• 15:15
  Speaker 2: It's hilarious.
• 15:16
  Speaker 2: You just kind of skip over that and find out about it later.
• 15:18
  Speaker 2: So you can definitely have irritation of that sinovertebral nerve because of the inflammatory cytokines that leak out of a degenerated disc.
• 15:25
  Speaker 2: And oftentimes those same inflammatory cytokines can irritate the nerve roots and that's where you get not radiculopathy meaning like you know down symptoms of a nerve but you get radiculitis.
• 15:37
  Speaker 2: So hypersensitivity, pain and sort of tingling and things like that.
• 15:41
  Speaker 2: So that tells me that, oh, there's something's irritating the nerve but not compressing the nerve necessarily so by injecting platelets, you're hopefully stopping that leakage and reducing that inflammatory reaction.
• 15:53
  Speaker 1: Right, right Totally, and then with tendinosis, right Degenerative tendon progressions.
• 16:00
  Speaker 1: Do you do a lot with that?
• 16:01
  Speaker 1: With that too?
• 16:02
  Speaker 2: Yeah, that's like our bread and butter a golfer's elbow, tennis elbow?
• 16:05
  Speaker 1: yeah, a lot of stuff, a lot of achilles, yeah and achilles you can do some pretty cool stuff.
• 16:10
  Speaker 2: But basically you know a lot of times an mri you know you get somebody with tennis elbow will look at an mri and if there's no obvious tear there it doesn't really tell me 100 that there's no tear.
• 16:21
  Speaker 2: So oftentimes when we're treating with PRP I will sort of explore with the needle meaning.
• 16:30
  Speaker 2: I'll introduce the needle into the tendon and I'll gently test with some pressure and if there's resistance, then I know that that is an intact tendon.
• 16:39
  Speaker 2: There's no tear there.
• 16:40
  Speaker 2: But sometimes you put a little volume of fluid and a tear that it was hiding now all of a sudden opens up.
• 16:46
  Speaker 2: You could see it hiding inside.
• 16:47
  Speaker 2: You would have never seen that on an on an mri um, and so we'll sort of, when you see that you want to like fenestrate the tendon, you want to increase the surface area of that tear so that these platelets can aggregate open.
• 16:59
  Speaker 1: yeah, interesting, yeah, that's really cool.
• 17:02
  Speaker 1: I mean chronic lingering tennis elbow and golfer's elbow.
• 17:07
  Speaker 1: It's like I battled that recently, like where the last maybe 10 months, probably maybe eight months, oh yeah, just lingering.
• 17:15
  Speaker 2: Um.
• 17:15
  Speaker 1: I'll needle myself like dry needling myself and stuff, but, um, man, it can it.
• 17:18
  Speaker 1: It's uh, it's annoying, it is, you know, like a lingering tennis elbow or achilles tendonitis, like a lot of patients stumped.
• 17:26
  Speaker 1: You know what I mean.
• 17:27
  Speaker 2: Yeah, um, that's good, though one thing that I would add to that is um, you know, when somebody has a chronic tendon issue, it's worth looking outside the tendon.
• 17:38
  Speaker 2: You've got to wonder why, like you know why is this guy having this recurring tendon issue?
• 17:41
  Speaker 2: right exactly, and so a lot of times, especially especially with people who have well, yeah, let's say, tennis elbow or golfer's elbow.
• 17:47
  Speaker 2: I'll look upstream.
• 17:48
  Speaker 2: I'll look at the shoulder mechanics.
• 17:50
  Speaker 2: I'll see if their arm is, you know, tends to be pronated.
• 17:53
  Speaker 2: I'll look at any cervical issues.
• 17:55
  Speaker 2: There might be a subclinical radiculitis there, you know.
• 17:58
  Speaker 2: If they're having a golfer's elbow, well that's your sort of T1 dermatome.
• 18:05
  Speaker 2: So I'm looking at C8, T1 nerve roots to see if there's any issues there.
• 18:08
  Speaker 2: Is there any forward head position?
• 18:11
  Speaker 2: Is there any irritation of the facet joints in that?
• 18:14
  Speaker 1: area.
• 18:14
  Speaker 2: Yeah, totally so I'll likely treat that whole kinetic chain.
• 18:16
  Speaker 2: So we'll do platelet epidurals at those levels.
• 18:19
  Speaker 2: We'll treat the ligaments, we'll treat the joints and then we'll treat wherever the actual tendonosis is.
• 18:26
  Speaker 1: Sure, that's awesome, I think, something that separates like a person like yourself in orthopedics you know what I mean and I'm like that's what of course like as a sports physical therapist.
• 18:33
  Speaker 1: Like we're not going to do PRP injections, although dry needling can be helpful totally but anyway, we definitely like when we got to look at the scapula you know, on the shoulder Cause, like if I've always under the impression some mentors described it like a tendon at this point is the victim.
• 18:46
  Speaker 1: If it's overwhelmed and like chronically a tendonitis problem.
• 18:50
  Speaker 1: You know what I mean.
• 18:50
  Speaker 1: It's like usually it's because that thing is a victim and it's overworked and over required because of compensation issues elsewhere, and especially like a full body movement, like swing, like a tennis player right or even um, there's got to be other conversations elsewhere.
• 19:05
  Speaker 1: That's maybe like what's leading to the tendon getting lit up and overwhelmed in the first place, like we have to address those things, and then that'll actually follow suit, versus, like, just treating the tendon like this.
• 19:14
  Speaker 1: Um, it's just a, you know, a tertiary problem yeah, it's a very like kind of binoculars view.
• 19:19
  Speaker 1: Exactly, yeah, which is honestly that exactly right.
• 19:22
  Speaker 2: there is why I left pain management, because I was in pain management initially and I was like I need something more.
• 19:29
  Speaker 1: Like we're missing something.
• 19:30
  Speaker 1: You know I was going to ask, so tell us more.
• 19:32
  Speaker 1: All right, A little more background story.
• 19:35
  Speaker 1: Originally, where are you from?
• 19:37
  Speaker 1: Yeah, and then where'd you go to med school?
• 19:38
  Speaker 1: And I know you were in Colorado doing a lot of neural research, right?
• 19:46
  Speaker 1: Yeah, yeah, yeah.
• 19:47
  Speaker 1: So you know I like long walks on the beach.
• 19:48
  Speaker 2: Yeah, yeah, yeah, my folks are actually from Egypt, first generation Americans.
• 19:52
  Speaker 2: So I grew up in like the woods in Georgia.
• 19:54
  Speaker 1: Okay, where in?
• 19:55
  Speaker 2: Georgia Marietta, like outside of Atlanta.
• 19:57
  Speaker 1: Okay, yeah, Because we took we as a family Thanksgiving trips up in northern Georgia.
• 20:02
  Speaker 2: Oh nice.
• 20:02
  Speaker 2: Like Blue Ridge Mountains area yeah, yeah, yeah yeah.
• 20:05
  Speaker 1: So we passed through Atlanta and go to like Helen or what's it?
• 20:08
  Speaker 1: Dahlonega, Dahlonega, yeah, yeah.
• 20:09
  Speaker 2: They got one of the roller coasters at Six Flags up there.
• 20:12
  Speaker 2: It's called the Dahlonega Mine Train.
• 20:14
  Speaker 1: Oh, really that's cool.
• 20:24
  Speaker 1: No, we love it up there, man, we want you know it's a beautiful, it's beautiful yeah yeah, beautiful forest, um.
• 20:29
  Speaker 2: So yeah, grew up there, moved down to fort lauderdale in like 2003, uh.
• 20:33
  Speaker 2: And then I went to high school pompano beach high school and it's actually there where I had a ap biology teacher who she was the one who sort of got me on the medicine track.
• 20:43
  Speaker 1: Cool.
• 20:44
  Speaker 2: She was a biology teacher.
• 20:44
  Speaker 1: What was her name?
• 20:45
  Speaker 2: Dr Sinkhornrat.
• 20:47
  Speaker 1: Okay, if she's out there, shout out.
• 20:49
  Speaker 1: Yeah, exactly, you are the reason, dianne Sinkhornrat, yeah.
• 20:53
  Speaker 2: She was great, that's cool.
• 20:54
  Speaker 2: I didn't know this at the time but her husband was like 15.
• 21:01
  Speaker 2: And she would show us all these cool techniques and these philosophies and all this stuff.
• 21:05
  Speaker 2: And I was just so intrigued that from that point I sort of decided, okay, I'm going to do this whole medicine thing.
• 21:11
  Speaker 2: It was a long and crazy road with college and all that stuff.
• 21:15
  Speaker 2: So I graduated high school, went to the University of Florida, go Gators, and got accepted into lake erie college of osteopathic medicine.
• 21:24
  Speaker 2: And before I did that I actually worked for a year down in miami doing, uh, research at a neurology clinic.
• 21:33
  Speaker 2: We were researching botox injections for upper and lower limb spasticity, for tbi and post stroke patients.
• 21:39
  Speaker 2: Um, it was like 11 simultaneous clinical trials.
• 21:44
  Speaker 2: It was crazy, wow.
• 21:46
  Speaker 2: But I learned a lot and I saw that and I was like, okay, neurology sort of is on my radar.
• 21:52
  Speaker 2: Went to med school, you know, did the whole first, second year, step one, step two just madness.
• 21:58
  Speaker 1: Insane yeah.
• 21:59
  Speaker 2: And then in that process I sort of decided I was actually really half and half between PM&R doing physical medicine rehab and neurology and I just was.
• 22:07
  Speaker 2: So I was very undecided and if you asked me to do it again I would still like have a hard time deciding which one.
• 22:13
  Speaker 2: But I ended up going to neurology because I really enjoyed neuroanatomy.
• 22:17
  Speaker 2: So I matched into a neurology residency.
• 22:18
  Speaker 2: I went to University of South Florida in Tampa and there you know it was bread and butter neurology.
• 22:24
  Speaker 2: You know stroke, epilepsy, dementia, movement disorders, parkinson's, things like that.
• 22:28
  Speaker 2: I was fortunate enough to go to a program that was very musculoskeletal focused and we had a pain management program in the neurology department.
• 22:38
  Speaker 1: Cool.
• 22:38
  Speaker 2: There's only one of two in the country that do that.
• 22:40
  Speaker 1: Yeah, really cool.
• 22:47
  Speaker 2: So went on to do pain management.
• 22:48
  Speaker 2: So I graduated that residency, did a pain management fellowship, worked in pain management for about a year like in private practice, and quickly realized I was like I don't know if I feel good about, you know, doing this for 40 more years or however many more years I would work because it was just, it was very dictated by insurance.
• 23:06
  Speaker 2: You are either strictly doing med, med management, um, and we all know what's, you know all the stuff surrounding med management, pain management, um, or you're doing just a lot of corticosteroid injections, and we all know that steroids are highly toxic to not only the tissue that you're injecting but like everything else in your body.
• 23:22
  Speaker 2: Or you're kind of being pushed these really higher level procedures like spinal cord stimulators and these like minimally invasive fusion devices, that kind of hedge on pseudo surgery.
• 23:34
  Speaker 2: And I just thought, you know, let me see if I can find something different.
• 23:39
  Speaker 1: Yeah.
• 23:40
  Speaker 2: And that's when I reached out to Regenexx out in Colorado.
• 23:44
  Speaker 2: I'd actually been following them for like several years and decided you know what, now's my chance.
• 23:50
  Speaker 2: So I reached out to them, inquired like how do I learn this stuff?
• 23:52
  Speaker 2: Blah, blah, blah.
• 23:53
  Speaker 2: And they were like well, we have a fellowship out here.
• 23:56
  Speaker 2: And I said get out of here.
• 23:57
  Speaker 1: Sweet.
• 23:58
  Speaker 2: Yeah, so I decided I wasn't married, I don't have kids.
• 24:03
  Speaker 1: I could afford to live in Colorado for a year.
• 24:04
  Speaker 1: Yeah, let's go Pick up and go.
• 24:06
  Speaker 2: Signed up.
• 24:06
  Speaker 2: You know they offered me.
• 24:08
  Speaker 2: The position which I discovered later was, like you know, not that easy to get and I had no clue, which was kind of nice.
• 24:14
  Speaker 1: Cool.
• 24:15
  Speaker 2: Went to Colorado for a year and everything about regenerative orthopedics, uh, and I learned all these like just the amount of procedural skill that came in with that fellowship was absolutely incredible.
• 24:27
  Speaker 2: I felt like I learned more in that year than I did for like the previous four years, it was great.
• 24:30
  Speaker 1: Cool.
• 24:31
  Speaker 2: Yeah, highly recommend, if anybody physicians out there, uh uh, fellows residents that are interested in pain management, sports medicine, musculoskeletal care management, sports medicine, musculoskeletal care, check them out.
• 24:40
  Speaker 2: Centeno Schultz Clinic.
• 24:41
  Speaker 2: They have a fellowship, one to two fellows a year.
• 24:44
  Speaker 2: Very worth it.
• 24:46
  Speaker 1: Cool yeah, that's awesome.
• 24:49
  Speaker 1: Real quick corticosteroid injections super common, handed out like candy.
• 24:54
  Speaker 1: What are your thoughts?
• 24:56
  Speaker 2: So in that year that I worked pain management which was only like nine months I counted it rough estimate I think I injected somewhere on the order of like 500 grams of corticosteroids into patients.
• 25:14
  Speaker 2: It's a lot of steroids, yeah.
• 25:17
  Speaker 2: And so you know, basically with every steroid injection it, you know, doubles your risk of getting a abascular necrosis, it increases your risk of osteoporosis, we all know.
• 25:26
  Speaker 2: It messes up your metabolism, blood sugar, it suppresses the hormone axis or your pituitary axis, ruins your sleep, the list goes on.
• 25:36
  Speaker 2: I mean, it's a miracle drug.
• 25:37
  Speaker 2: We used to use very, very high doses of steroids in neurology for people who had multiple sclerosis and NMO and all these devastating neurologic diseases, but outside of that it's overkill.
• 25:50
  Speaker 2: Routinely, we would inject 4 or 10 milligrams of dexamethasone into a patient and, to give you some perspective, we naturally produce these chemicals.
• 26:01
  Speaker 2: We naturally produce corticosteroids, but if our body's natural amount of steroids was about the height of, let's say, a matchbook, the amount of steroids that we give in your typical, just knee injection is the height of the Empire State Building.
• 26:14
  Speaker 2: It's a massive difference, yeah, and so, as you can imagine, I had no idea.
• 26:19
  Speaker 1: Yeah, it's a huge difference.
• 26:20
  Speaker 2: It's about six million times the dose.
• 26:23
  Speaker 1: Oh my gosh, a matchbook.
• 26:25
  Speaker 1: Yeah, yeah, I thought you were going to say like the ceiling.
• 26:28
  Speaker 2: I'd be like what.
• 26:29
  Speaker 1: The Empire State Building yeah.
• 26:33
  Speaker 2: Holy smokes.
• 26:33
  Speaker 2: And so basically, with repeated injections, you're just completely eliminating any possibility that that musculoskeletal tissue is going to ever regenerate on its own.
• 26:44
  Speaker 1: Yeah, it just helps to stimulate degenerative changes in the articular cartilage and the surrounding soft tissue musculoskeletal junction.
• 26:51
  Speaker 1: I've heard, and you tell me what your thoughts on this.
• 26:55
  Speaker 1: You have like one or two free tokens, yeah, and it's fine, not a big deal.
• 27:00
  Speaker 2: The old idiom is like you don't want more than three in a year, um per year, per year per year.
• 27:06
  Speaker 2: But that's just.
• 27:06
  Speaker 2: That's also somewhat dictated by what insurance will reimburse.
• 27:11
  Speaker 1: They're not going to reimburse I also imagine, like I mean, let's say, somebody's experiencing moderate knee discomfort at the age of 42, two a year until they're 80.
• 27:21
  Speaker 1: You know what I mean?
• 27:22
  Speaker 1: Yeah, that's kind of a lot.
• 27:23
  Speaker 2: Yeah, yeah.
• 27:24
  Speaker 2: And think about patients that come in in their mid to late 30s for a steroid injection and now in their mind, okay, that's the fix.
• 27:31
  Speaker 2: Yeah, got it Perfect.
• 27:32
  Speaker 2: And so, cumulatively, over the years, they're going to get a lot of steroids.
• 27:37
  Speaker 1: A lot of things happen in addition, like you were saying all the hormones especially too.
• 27:41
  Speaker 1: There's been plenty of patients that I've met, talked with in the past, like in passing and other workshops or seminars and things, and they're like, yeah, at the beginning of the season I'll get an injection, before I leave I'll get an injection, and it helps maintain where I'm at and manages my knee pain, my back pain, I'm good, yeah, now by all means I don't want to live like that you know, that's just me but yeah, now there's.
• 28:04
  Speaker 2: There's definitely instances in which, like a steroid injection is, you know, somebody comes in with acute, you know, discogenic pain.
• 28:12
  Speaker 2: They got a bulging, bulging I don't hate it.
• 28:13
  Speaker 2: If you put platelets there, they're gonna flare up like 10 times much so yeah sometimes steroid injections are indicated totally, totally, but there's always a but.
• 28:22
  Speaker 2: You still don't really need to use that high of a dose.
• 28:25
  Speaker 2: For instance, in our clinic we use I call it low-dose dexamethasone.
• 28:30
  Speaker 2: It's about a millionth of the dose of your standard injection.
• 28:33
  Speaker 2: Oh, one millionth.
• 28:35
  Speaker 1: One millionth.
• 28:35
  Speaker 1: It still sounds great, one millionth, yeah, yeah.
• 28:37
  Speaker 2: It's 400 nanograms as opposed to milligrams.
• 28:40
  Speaker 2: So it's 400 nanograms as opposed to milligrams.
• 28:41
  Speaker 2: So nanograms is like 10 to the negative six, I think yeah yeah, and we use that because that's a lot closer to your physiologic level.
• 28:46
  Speaker 2: If you place that directly next to what you're trying to treat, then you're going to have the right amount of anti-inflammatory reaction.
• 28:55
  Speaker 2: The volume of the fluid sort of pushes away those inflammatory cytokines.
• 28:58
  Speaker 2: And there's a study out of England I, I believe that showed that these physiologic doses of corticosteroids actually promote uh, tenocyte and synoviocyte proliferation.
• 29:11
  Speaker 2: So it's like, oh okay, well, you're getting kind of the best of both worlds yeah, yeah.
• 29:15
  Speaker 1: So I would say, like I assume the synovium for synovial fluid is that you're talking about.
• 29:21
  Speaker 2: Yeah, yeah, so look, these are the cells that make up the joint capsule and then they line the inside of the joint capsule and they make synovial fluid.
• 29:28
  Speaker 2: Yeah, got it.
• 29:29
  Speaker 1: It's pretty, that's awesome yeah, um, okay, sorry, continue where we were at we were talking about.
• 29:34
  Speaker 1: Uh, oh, man, I forgot the train of thought we were before I brought up the corticosteroid question.
• 29:40
  Speaker 2: Oh, what were we talking?
• 29:41
  Speaker 1: about that, about that you were at, you finished up your fellowship oh this guy.
• 29:43
  Speaker 2: Oh, yeah, yeah, yeah, okay, yeah, finished up your fellowship.
• 29:45
  Speaker 1: It was a one-year fellowship, one-year fellowship, and then that's when you moved back to, moved back here.
• 29:50
  Speaker 2: Yeah, so you know, there was a lot of decision-making process in that.
• 29:54
  Speaker 2: While I was in move, you know, I had some.
• 30:08
  Speaker 2: I actually had some really really good opportunities to work with some like amazing doctors, people that I looked up to for years and, uh, he's actually out in Sarasota, he's got some locations in Sarasota and Tampa, um.
• 30:13
  Speaker 2: But at the same time, you know, I'd been away from South Florida since 2008.
• 30:19
  Speaker 2: And you know, I was just kind of felt like I needed to get closer to my family again.
• 30:24
  Speaker 2: At the same time, my fiancee, you know, she had the same feeling.
• 30:28
  Speaker 2: She's like well, you know, it's been a long time, let's move back to family.
• 30:32
  Speaker 2: So my folks live down in fort lauderdale and her folks live, and well, her mom lives in, uh, jupiter, oh nice uh and so we sort of split the difference and moved to west palm yeah and I was, like you know, I spoke to my older brother and I spoke to a lot of people that I really look up to about, hey, you know, what do you think about opening up a practice and taking the leap?
• 30:50
  Speaker 2: You know totally, and, um, yeah, you just, at some point you gotta just close your eyes and do it, pull the trigger and write a bullet.
• 30:59
  Speaker 1: You know, yeah, and it's calculated, you know exactly, it's been a roller coaster, awesome.
• 31:03
  Speaker 2: We I moved down here in january um and opened up like four weeks ago so that six months of just you know that grueling startup process.
• 31:13
  Speaker 2: But I learned a lot, you know.
• 31:15
  Speaker 2: You look back you're like, oh wow, I really did quite a bit to get this thing open.
• 31:18
  Speaker 1: Yeah, I um man, entrepreneurship, I'm a.
• 31:21
  Speaker 1: I love entrepreneurship stuff like, yeah, I'm a nerd when it comes to that I mean, yeah, you're a perfect example, totally reinvigorated my career and like this outlook on life and perspective.
• 31:30
  Speaker 1: I'm like this makes sense yeah, exactly okay, so tell me about these books all right.
• 31:34
  Speaker 2: So those books are authored by a doctor named chris centeno and, uh, he basically him and his partners sort of started experimenting with orthobiologics for orthopedic problems back in like the early 2000s okay, and they were the first ones to do culture, expanded stem cells into vertebral discs and show improvement, so they were kind of like the godfathers of this, more or less.
• 32:00
  Speaker 2: There's definitely people that precede them, um, and so dr centeno sort of put these books together as a as a manual for patients, but it does get a little bit in depth so it's not like for the right person to be cool when integrating.
• 32:17
  Speaker 2: Yeah it's a medium read.
• 32:18
  Speaker 2: It's not a light.
• 32:19
  Speaker 2: But basically what we do is we go through our diagnostic method, which is called the SANS method.
• 32:25
  Speaker 2: Sans stands for um, symmetry, articulation, neuromuscular, uh, connection and stability, and so we evaluate all those things when, when we're addressing a problem, um, so we talk about the sans method in there, we talk about the, the differences, and you know the types of orthobiologics that we offer, the differences and what we offer and what is commonly found out just in the industry or just wherever.
• 32:53
  Speaker 2: you know, prp, that you can get, and, or stem cells that you get in mexico, and things like that.
• 32:58
  Speaker 2: So a lot of distinction there, um, and then we break it down into the different books.
• 33:04
  Speaker 2: Basically, as you can see, there's shoulder 2.0, this is how we approach shoulder issues.
• 33:08
  Speaker 1: Y'all can't see we got shoulder 2.0, how you can avoid invasive shoulder surgery, orthopedics 2.0, which I imagine is like a-.
• 33:15
  Speaker 2: Yeah, that's like the encompassing, yeah.
• 33:17
  Speaker 1: How to avoid back pain the spine owner's manual.
• 33:20
  Speaker 2: Spine owner's manual.
• 33:21
  Speaker 1: yeah, and then how to avoid game-changing invasive knee surgeries.
• 33:24
  Speaker 1: To stay active as you age, the knee owner's manual, the knee owner's manual.
• 33:29
  Speaker 1: Yeah yeah, we have ankle owner's manual and elbow and all the fun stuff.
• 33:34
  Speaker 1: They're all around ankle.
• 33:35
  Speaker 1: I own a shoulder.
• 33:35
  Speaker 1: I got two of them pickable.
• 33:36
  Speaker 1: Yeah, cool.
• 33:37
  Speaker 1: No, I have to agree, that's really cool to read them they're all um online for free downloadable on my website.
• 33:41
  Speaker 2: I think a really cool thing is like.
• 33:42
  Speaker 1: It seems like in my but I mean ultimately right.
• 33:45
  Speaker 1: Our perspectives and beliefs shape our world and like what we are the lens in which we perceive everything.
• 33:50
  Speaker 1: But as a biased conservative therapist, you know what I mean.
• 33:54
  Speaker 1: It seems like medicine's going this route less allopathic and like if someone has and someone decides that they want the awareness of like is there other methods besides just allopathic?
• 34:06
  Speaker 1: Take this med, you're good for life.
• 34:08
  Speaker 1: Take synthroid for your hypothyroidism, you're good forever like is there an option like what is this?
• 34:14
  Speaker 1: I was just told, but is there another way?
• 34:15
  Speaker 1: Right?
• 34:16
  Speaker 1: Or like type 2 diabetes, right, totally reversible right um or just, and also joint pain um orthopedics yeah, a huge one.
• 34:23
  Speaker 1: You know huge industry but anyway, uh, it seems like it's going that route, which is really cool, um, and I love it, you know, I think it's really interesting.
• 34:31
  Speaker 2: Yeah, I think patients are sort of waking up to the fact that what your insurance company tells you to do is not necessarily your only option.
• 34:39
  Speaker 2: And there are a lot of really smart minds out there and there are a lot of you know.
• 34:42
  Speaker 2: There's a lot of data coming out supporting all this, so it's definitely worth.
• 34:47
  Speaker 2: It's interesting.
• 34:48
  Speaker 2: I will say this.
• 34:53
  Speaker 2: I don't know how much time we have, but I'll say this Buyer beware, because this isn't FDA approved it is FDA regulated, but it's not FDA approved, which means that people can offer whatever they want, and oftentimes they make a lot of claims and those claims can basically be based on on on nothing, and so you might find yourself paying thousands and thousands of dollars for some miracle stem cell treatment, but in reality, we don't really know what you're getting.
• 35:25
  Speaker 1: Interesting, just like supplements.
• 35:26
  Speaker 2: Just like supplements.
• 35:27
  Speaker 2: Yeah, so I would always say you know if, if you're interested in you know non-surgical orthopedics or regenerative orthopedics.
• 35:34
  Speaker 2: There's four questions you should be asking.
• 35:36
  Speaker 2: Number one is where is this product coming from?
• 35:40
  Speaker 2: Right, is it coming from you or is it coming off the shelf?
• 35:43
  Speaker 2: So it should be coming from you.
• 35:44
  Speaker 2: Anything that's coming off the shelf essentially had to have gone through some sort of sterilizing or processing process, which means that there's no living cells in there, and we've proven that time and time again.
• 35:54
  Speaker 2: There's no such thing as living stem cells in one of these like off the shelf umbilical cord.
• 35:58
  Speaker 2: Placental Wharton's jelly stem cells, um, but they're not useless.
• 36:04
  Speaker 2: I mean, they still have good growth factors in them, so they can.
• 36:06
  Speaker 2: They have about the same effect as like PRP, essentially.
• 36:09
  Speaker 2: So where is it coming from?
• 36:10
  Speaker 2: It should be coming from you, number two, um.
• 36:18
  Speaker 2: What is it being injected into, you know?
• 36:19
  Speaker 2: Are they just doing a blind injection into the joint and hoping that it miraculously fix your joints?
• 36:21
  Speaker 2: Probably not the best.
• 36:22
  Speaker 2: You need to evaluate the entire kinetic chain.
• 36:25
  Speaker 2: You need to look at all the different structures.
• 36:26
  Speaker 2: You need to look at ligament tendon, you know meniscus.
• 36:29
  Speaker 2: You need to look at the neuromuscular connection.
• 36:31
  Speaker 2: You need to look at upstream issues.
• 36:33
  Speaker 2: So that's important.
• 36:35
  Speaker 2: Number two what's the dose?
• 36:36
  Speaker 2: The majority of your sort of off-the-shelf kind of bedside PRP kits will only concentrate your PRP to like maybe twice, which barely meets the actual definition of PRP.
• 36:49
  Speaker 2: So it's important that you get the right concentration because it matters what you're injecting.
• 36:51
  Speaker 2: It also matters depending on the age, which barely meets the actual definition of PRP.
• 36:52
  Speaker 2: So it's important that you get the right concentration because it matters what you're injecting.
• 36:55
  Speaker 2: It also matters depending on the age.
• 36:56
  Speaker 2: So the older you get, the higher concentration you need essentially.
• 36:59
  Speaker 2: And number four is who is injecting it?
• 37:02
  Speaker 2: You know there are a lot of very skilled nurse practitioners and medical assistants and things like that out there, but in order to provide the level of treatment or level of injection that I would offer, you need to be a board certified physician, having gone through fellowship training.
• 37:20
  Speaker 2: I mean, I went through two different fellowships to get to where I'm at.
• 37:25
  Speaker 1: So there's a different skill level.
• 37:27
  Speaker 2: Yeah, and you got to know all the risks that go along with what you're doing and you got to know how to mitigate potential complications and disasters.
• 37:33
  Speaker 2: You got to know all the risks that go along with what you're doing and you've got to know how to mitigate potential complications and disasters.
• 37:35
  Speaker 2: You've got to know how this fits in with a lot of other medical disorders.
• 37:38
  Speaker 2: It's not a one-size-all treatment and not everybody can just go get a bone marrow aspiration or draw 60 tubes of blood and so on, so you definitely need a medical professional behind it Interesting.
• 37:48
  Speaker 1: Yeah, that's a good point.
• 37:49
  Speaker 1: When you arrived here, you're talking about a patient that you just had.
• 37:52
  Speaker 1: That was super interesting, right.
• 37:54
  Speaker 2: Yeah, tell us about what was going on.
• 37:56
  Speaker 1: Yeah, so she Typical client, of course.
• 37:57
  Speaker 1: Yeah, so de-identified.
• 37:59
  Speaker 2: So she, you know, middle-aged, very active.
• 38:03
  Speaker 2: She's a distance runner.
• 38:04
  Speaker 2: You know her favorite activity is to go run for like 15 plus miles, which that's impressive.
• 38:10
  Speaker 1: Cool yeah, I think what was interesting is like it seems like healthcare.
• 38:15
  Speaker 1: You know practitioners like ourselves.
• 38:16
  Speaker 1: We hear that story and immediately, at least my head, is like awesome.
• 38:21
  Speaker 2: Yeah, I get excited Versus like all right.
• 38:23
  Speaker 2: Well, you're battling knee and hip pain.
• 38:25
  Speaker 1: Maybe you should stop running because it's bad for you.
• 38:27
  Speaker 1: Yeah, it's like people like that are tired of going to, people that are like just don't do that anymore.
• 38:31
  Speaker 1: Why don't you just rest ice and take Advil?
• 38:34
  Speaker 2: Like problem solved.
• 38:34
  Speaker 2: Oh Advil, don't get me started on Advil Like man like?
• 38:38
  Speaker 1: what about?
• 38:38
  Speaker 1: Like?
• 38:38
  Speaker 1: How can we enable this person there has to be something going on and like longevity wise.
• 38:53
  Speaker 2: How can we enable and?
• 38:54
  Speaker 1: empower this person to like continue what they're doing, and what strategies and stuff can we implement to allow this?
• 38:55
  Speaker 1: Let's high five and assist versus like resist and then just tell them to stop, like, oh it hurts, oh, don't do that.
• 38:57
  Speaker 1: Yeah, problem solved.
• 38:57
  Speaker 1: Yeah, oh my gosh, yeah, I mean anyway, that's a conversation I have a lot of patients.
• 39:00
  Speaker 2: It's like you know, there's no cure for arthritis and we're not going to fix or cure the issue.
• 39:05
  Speaker 2: But the goal here is to give your body the tools it needs to sort of get you back to what it whatever it is you were doing and simultaneously try to address what it was that got you there.
• 39:16
  Speaker 2: You know, so that's for example, I never do injections without also making sure that that person is getting high quality physical therapy.
• 39:23
  Speaker 2: Never Because I can inject all I want, but unless the body is being taught how to avoid that injury again.
• 39:31
  Speaker 2: Or you know the tissue is actually taught how to avoid that injury again, or you know the tissue is actually getting the physical stimulus in order to know how to heal.
• 39:36
  Speaker 1: Yeah, it's just it's not really gonna come back, you're not gonna get the best results, yeah, so you have to couple both of them, yeah yeah, cool, okay.
• 39:43
  Speaker 2: So yeah, lady coming in yeah, lady coming in endurance runner, endurance runner decides to change up her cadence or her stride.
• 39:49
  Speaker 2: Uh, one day and like halfway through her run, just intense anterior hip pain and groin pain, like searing groin pain, and ever since then she's had sitting intolerance.
• 40:00
  Speaker 2: She gets a lot of pain with internal rotation and inflection.
• 40:03
  Speaker 2: Uh, even with external rotation she started to get some kind of adductor type pain yeah, um so hip imping, so hip impingement hip impingement underlying.
• 40:11
  Speaker 1: FAI probably.
• 40:12
  Speaker 2: Right.
• 40:12
  Speaker 1: Somewhat.
• 40:13
  Speaker 2: Yeah and um, she came to my clinic, um, and we looked over her, her x-rays, and she actually has like grade three arthritis.
• 40:22
  Speaker 2: You know it was like pretty advanced Uh, but which goes to show you she was like asymptomatic all the way up to this point.
• 40:27
  Speaker 1: Super interesting, right, yeah, yeah.
• 40:30
  Speaker 2: Um so we did a physical exam.
• 40:32
  Speaker 2: Sure enough she had all the fai symptoms.
• 40:35
  Speaker 2: She also had some, you know uh, pain over the greater trochanteric bristis or all the glute muscles attached.
• 40:42
  Speaker 2: Um she was having some decreased multifidus activation on the back.
• 40:47
  Speaker 2: Um her pelvis was slightly posteriorly rotated on the right and sort of out flared and so she had some psoas tightness on that on that right side as well she had that.
• 40:56
  Speaker 1: Yeah, I love that because, like that's, yeah, totally s, the sij is super, yes, involved exactly.
• 41:03
  Speaker 1: I mean anyway, sorry through the ultrasound on.
• 41:05
  Speaker 2: I always ultrasound exam.
• 41:07
  Speaker 2: Um, just that's.
• 41:08
  Speaker 2: It's an extension of my physical exam.
• 41:10
  Speaker 2: So I put the ultrasound on and I was able to see that she had some bowing of the hip capsule which made me think that there's an effusion in there.
• 41:15
  Speaker 2: She had some degeneration of the anterior and superior labrum, some tendinopathy of the glute tendons at the GTB.
• 41:24
  Speaker 2: She had some tendinopathy at the iliac crest and then what else?
• 41:30
  Speaker 1: was there.
• 41:33
  Speaker 2: Oh, she had a little bit of hamstring tendinopathy as well and then she had this big old bursa of fluid underneath her psoas.
• 41:37
  Speaker 2: So there's definitely some irritation of the psoas that's going over the anterior hip there.
• 41:40
  Speaker 2: Um worked her up and then got her in for treatment, which was today, actually right before I came in and basically we did 10X concentrated platelets intraarticular into the hip and then we did 7X concentrated platelets into the anterior and posterior hip capsule, into the anterior and superior labrum, and then we use what's called PL-prolo or platelet lysate in prolotherapy.
• 42:10
  Speaker 2: Basically, we take PRP or super concentrated platelets, we freeze them, we break open the platelets, we pass them through a 200 micron filter and we get all the goodies without the thrombotic platelet factors, and then we take that and we mix it with prolo.
• 42:26
  Speaker 2: So you're basically taking prolotherapy and supercharging it with all the nutrients and growth factors from platelets.
• 42:30
  Speaker 1: Yeah, that's really interesting.
• 42:31
  Speaker 2: Yeah, Take and supercharging it with all the nutrients and growth factors from platelets.
• 42:33
  Speaker 2: Yeah, that's really interesting.
• 42:35
  Speaker 2: Yeah, take that and we inject that into the SI ligaments, sacrotubris, sacrospinous ligaments, and then, under fluoro, I did platelet lysate injections of the iliolumbar ligaments, interspinous ligaments at L5 and S1.
• 42:47
  Speaker 2: , and then a transferaminal platelet epidural at S1 as well.
• 42:52
  Speaker 1: So really just addressing that whole kinetic chain that whole component, yeah, the lumbar down to hip, and then I'm actually sending her to you guys.
• 42:57
  Speaker 1: Cool, Well, I'd love to help her.
• 42:59
  Speaker 1: Yeah, yeah, Because I mean it's interesting, they're a different breed and we love working with endurance athletes because they're in the same boat of like no, this is what I do.
• 43:08
  Speaker 1: Like no, this is this is what I do.
• 43:10
  Speaker 2: Yeah, exactly Awesome, let's get it.
• 43:12
  Speaker 1: Yeah, um, but that like that, enthusiasm and buy-in always just helps outcomes.
• 43:17
  Speaker 1: You know, yeah, um.
• 43:24
  Speaker 1: Why not do the PRP injections like that all the time to avoid the thrombitic properties, like you were describing Thrombitic being like you want to describe thrombosis, like yeah, yeah.
• 43:32
  Speaker 2: So basically you know platelets they like to clot.
• 43:33
  Speaker 2: That's their main job.
• 43:34
  Speaker 2: They basically stick and then they break open and in some cases, like if I'm injecting into the epidural space or into the spinal column, I don't want there to be any sort of risk of clot.
• 43:43
  Speaker 2: It's a theoretical risk, but it's a risk nonetheless.
• 43:46
  Speaker 2: So we basically take those platelets, concentrate them, break them open and then filter out the goodies.
• 43:51
  Speaker 2: So we use platelet lysate in the spine just to reduce the risk of thrombosis or clotting.
• 43:56
  Speaker 2: But for ligaments, I mean, I could inject platelets in there and you still get a good response.
• 44:02
  Speaker 2: But sometimes you want to use prolotherapy and so I'm just essentially combining them.
• 44:10
  Speaker 2: And so if you take prolo, which is just dextrose, sugar, water, and then you combine it with PRP, what happens is that because the sugar is so concentrated, the dextrose is concentrated, it basically turns the platelets into like raisins and so they become dysfunctional.
• 44:26
  Speaker 2: They can't stick and they can't open up.
• 44:27
  Speaker 2: So you're basically destroying the PRP.
• 44:29
  Speaker 2: But if you just get rid of the platelet part and you take all the factors, the nutrients, from inside.
• 44:39
  Speaker 2: You can mix that with prolotherapy and there's there's no issue at all, basically.
• 44:41
  Speaker 1: So what that does is that lets me sort of volume expand, meaning I can treat more structures without having to take so much more blood, yeah, from the patient, yeah, yeah, so to combine the prolotherapy with that, it's's a like the prolotherapy is small, purposeful irritation of the joint of the structure play that's in there as the heroes that go in and solve the problem.
• 45:01
  Speaker 2: Yeah, Basically you just you're giving them all the nutrients they need to sort of regenerate Cool.
• 45:06
  Speaker 2: That's really interesting man, it's awesome.
• 45:07
  Speaker 1: I love that.
• 45:08
  Speaker 1: We'd love to help her See a lot of runners and stuff.
• 45:10
  Speaker 1: Yeah, cool man.
• 45:12
  Speaker 1: Well, I appreciate that.
• 45:13
  Speaker 1: So, all right.
• 45:13
  Speaker 1: Last question what would you say is like your wheelhouse.
• 45:16
  Speaker 1: My wheelhouse, ideal patient you guys crush home runs with these people.
• 45:22
  Speaker 2: Every patient's an ideal patient.
• 45:24
  Speaker 1: I mean honestly like I feel the same way of like yo.
• 45:26
  Speaker 1: It doesn't matter if they're just motivated and enthusiastic and they're ready to to want to see good outcomes and results, yeah, the fact that they're coming to me means that they're in the mindsets of I want to get better.
• 45:38
  Speaker 2: Not not just oh, fix this and let me get back to my life, yeah, um so my wheelhouse, I would say spinal conditions um, especially like cervical spine, so neck pain, so neck pain, headaches, shoulders, jaw pain, TMJ, things like that.
• 45:52
  Speaker 1: I love doing that and that's partially because of my neurology.
• 45:54
  Speaker 1: I was going to say that's a cool link, yeah right.
• 45:58
  Speaker 2: So I mean a lot of like when I was in residency.
• 46:01
  Speaker 2: I mean it was always just migraine until proven otherwise.
• 46:07
  Speaker 1: And now I'm discovering.
• 46:07
  Speaker 2: Oh well, there's more to it than this.
• 46:08
  Speaker 2: Yes, you can have migraine features, but we need to be looking at the neck, because if there's, any sort of instability if there's forward head, if there's loss of the curve of the neck, like you're going to get neurological dissonance.
• 46:17
  Speaker 1: Cervical genetic headaches yeah, absolutely.
• 46:19
  Speaker 1: Tmj referral totally.
• 46:20
  Speaker 1: We've been seeing some more TMJ patients, which is interesting.
• 46:24
  Speaker 1: What do you do for TMJ patients?
• 46:27
  Speaker 1: Internal mobs yeah, yeah, and if it's hypermobile or hypomobile either side and then dry needling is really effective into the joint underneath the, the in the joint, yeah, the lateral pterygoid masseter and then the temporalis muscles.
• 46:44
  Speaker 2: How do you get to the lateral pterygoids?
• 46:46
  Speaker 2: That's through the joint.
• 46:47
  Speaker 2: Yeah, I know.
• 46:47
  Speaker 2: Yeah, it's kind of scary.
• 46:48
  Speaker 1: Go through the temple like the sphenoid region and then just below the condyle, and then straight through, so you're going through the mouth, no right here straight through.
• 46:59
  Speaker 1: Take like a one-inch needle, nice.
• 47:01
  Speaker 1: Usually we use like the.
• 47:03
  Speaker 1: I think they're 15-millimeter length needles for the masseter, the temporalis and then the joint itself intraarticular, but then for the lateral p a lot of to reach it.
• 47:14
  Speaker 1: You get like a one inch needle and go straight through that's hardcore.
• 47:17
  Speaker 1: I like it, but it's interesting is like it really doesn't feel like people get freaked out.
• 47:21
  Speaker 1: You know, they're so tiny, you know what I mean.
• 47:22
  Speaker 1: Yeah, um, like the needles, but um, it's just, it's really effective.
• 47:26
  Speaker 1: Yeah, that's awesome.
• 47:28
  Speaker 1: Yeah, okay, and then you, stim, put the stimulation on it too.
• 47:31
  Speaker 2: I have a very good friend who she has bad.
• 47:34
  Speaker 2: You know bruxism.
• 47:35
  Speaker 2: She grinds like crazy and her masseters are just like rock solid.
• 47:38
  Speaker 2: Yeah, yeah, yeah, totally, and so I was trying to figure out.
• 47:41
  Speaker 2: You know, what do I do before we put Botox in there, basically, yeah, yeah, um, anyone who's getting like Botox for migraines.
• 47:50
  Speaker 2: You know, the typical protocol for migraine Botox is to, you know, obviously inject around the head, but they also inject into the neck muscles and that can actually cause a lot of problems down the road, because by weakening those, I mean, you know, by weakening that posterior chain, you get this more instability, yeah, so you know I decided that you know when I treat my migraine patients with Botox that I'm going to do the typical, you know, cranial injections, but just avoid the posterior.
• 48:18
  Speaker 1: We usually, I mean like from our head.
• 48:20
  Speaker 1: We don't do injections right, it's not our thing.
• 48:21
  Speaker 1: But for fixing headaches it's like, how can we help improve this?
• 48:25
  Speaker 1: We definitely consider upper cervical, suboccipital cervical, genic headaches.
• 48:30
  Speaker 1: Tmj is definitely on this too, and then not our realm right, but if something's bruxing at night, clenching, clearly there's some kind of anxiety, psych there's.
• 48:41
  Speaker 1: We can't neglect, there's a psychological component to a pain experience.
• 48:43
  Speaker 1: You can't separate the mind from the body.
• 48:44
  Speaker 1: But that's also something that we can't neglect and be like that's something I would dive into right, not me, but like that's something I would investigate on your end and I do have some mental health professionals that would recommend totally but that's something that I'm like we can't neglect.
• 48:58
  Speaker 1: That either.
• 48:58
  Speaker 1: You know what I mean.
• 48:59
  Speaker 2: Yeah.
• 48:59
  Speaker 1: It's a delicate dance of a conversation.
• 49:01
  Speaker 1: Of course we're not.
• 49:03
  Speaker 1: You know we want to validate and, like you know, do the things.
• 49:06
  Speaker 1: We can't separate the mind from the body or neglect.
• 49:10
  Speaker 1: There's a psychological component to pain too, something I don't want to leave any stone unturned.
• 49:15
  Speaker 2: Having those resources is invaluable.
• 49:17
  Speaker 2: To be able to say to recognize okay, there is a significant sort of psychosocial component to this.
• 49:22
  Speaker 2: We need to address it.
• 49:24
  Speaker 2: The biopsychosocial model, exactly.
• 49:25
  Speaker 2: So to be able to send them out is good.
• 49:28
  Speaker 1: Yeah, it's not what we do, but.
• 49:29
  Speaker 2: Yeah, it's not what we do.
• 49:30
  Speaker 2: I want to help you with biomechanics, pain for sure strengthening stuff.
• 49:34
  Speaker 1: But I do know people that do and if you're interested we'll reach out or we'll give you the information if you want.
• 49:42
  Speaker 1: But anyway, sorry, go ahead.
• 49:44
  Speaker 2: Migraines and Botox.
• 49:45
  Speaker 2: Yeah, basically, if I do Botox for migraines, I treat appropriately, but I just avoid the posterior cervical chain because it's it might help your migraines but you're going to eventually get cervical problems and maybe cervicogenic headaches down the road.
• 49:58
  Speaker 2: It's important thing yeah, yeah totally, but other than that I mean going back to the wheelhouse.
• 50:02
  Speaker 2: Like you know, I my favorite thing is treating spine.
• 50:05
  Speaker 2: I love being with the c-arm fluoroscopy just hitting facets, transferaminal, getting the ligaments multifidus just getting the whole functional spinal unit.
• 50:13
  Speaker 2: which man, I could talk about functional spinal unit for like hours, functional spinal unit.
• 50:17
  Speaker 1: Yeah, exactly.
• 50:19
  Speaker 2: And then so that's like my favorite.
• 50:21
  Speaker 2: My least favorite is ankles.
• 50:24
  Speaker 2: Ankles are tough, they're very tough, very tough.
• 50:28
  Speaker 2: They're hard to.
• 50:28
  Speaker 2: I mean they Very tough.
• 50:30
  Speaker 2: They're hard to.
• 50:30
  Speaker 2: I mean they're very painful when they're in pain.
• 50:33
  Speaker 2: Anatomically they can be very, very challenging.
• 50:34
  Speaker 2: Yeah, but if you get it right yeah, if you get it right, you can really change someone's life.
• 50:39
  Speaker 1: Cool yeah, a lot of moving parts, oh yeah.
• 50:41
  Speaker 2: A lot of force, like a lot of weight and tension, and you know it's a very tough joint.
• 50:46
  Speaker 1: Yeah, totally, all right, man, alright, man, well, dude, thanks for coming in, we'll have to do another round.
• 50:51
  Speaker 2: I'm down the street, man, just let me know.
• 50:52
  Speaker 1: Talk about all the other stuff we can nerd out on you know which is cool but thanks for coming in.
• 50:57
  Speaker 1: If people want to reach out, what's the best way to reach you?
• 51:00
  Speaker 2: well, two ways.
• 51:01
  Speaker 2: You can find me on Instagram, docregen d-o-c-r-e-g-e-n, or you can go to my website, palmbeachregencom.
• 51:08
  Speaker 2: Or, if you are listening and you are like in Alaska or something like that, go to regeneratecom R E G E N E X X and find a regenerate provider in your network.
• 51:19
  Speaker 2: There's about 120 of us around the world.
• 51:20
  Speaker 2: Oh cool, that's interesting.
• 51:22
  Speaker 1: I had to chat with them too, like you know some kind of that's awesome.
• 51:26
  Speaker 1: Yeah, Cool man.
• 51:27
  Speaker 1: Well, we'll get round two on the books soon and if y'all have any questions, we're always open to questions, opinions, comments.
• 51:34
  Speaker 1: Concerns conflicting opinions totally, and if you have any questions as a patient, definitely reach out.
• 51:38
  Speaker 1: We love to chat and share some insights, if we can help.
• 51:40
  Speaker 1: The best way to reach us is team at athleterccom or our phone number at 561-898725.
• 51:49
  Speaker 1: And we'll catch y'all next time.