Dr. Patel joins Dr. Sharma on the Preventive Medicine Podcast to explain orthobiologics: treatments like prolotherapy, PRP and stem cells that help start the body’s own healing. They talk about what preventive medicine really means (“adding life to our years”), how to stay active while lowering your risk of injury, and where regenerative treatments fit in a long-term plan for joint and spine health.
Welcome back, everyone, to a brand new episode of the Preventive Medicine Podcast. I’m your host, Dr. Ragav Sharma. We have another incredible guest on today. We’ve just had incredible guest after incredible guest, and I’m excited to get into this one.
This is Dr. Shounuck Patel. He’s actually a fellow CCOM alum, so Chicago College of Osteopathic Medicine. We went to the same school. He’s doing stuff very similar to what I want to be doing in the future as far as interventional spine and musculoskeletal medicine, being a master diagnostician of whatever’s going on within the body.
He did his training at the world-renowned OSS fellowship. He’s a master instructor for the Interventional Orthobiologics Foundation. I tripped over “orthobiologics” so many times in prepping for this. I still do.
He’s an internationally renowned speaker for both ultrasound education and orthobiologics. He’s an associate clinical professor at two medical schools in the Southern California region, and he is currently the founder of the Patel Center for Functional Regeneration in Newport Beach.
I can say I’ve been with him for a morning there, and he absolutely loves to teach. So if you want to learn more about some of this stuff, he has great content on his Instagram and YouTube. I’ll link it in the show notes below. It’s Regen Dr. Patel.
But Dr. Patel, welcome to the show.
Thank you very much. It is an absolute pleasure, and I appreciate you inviting me on. This is exciting. I’m always excited to teach, and you’ve been such a fantastic person that I’ve known over the past couple of years. I’m excited to see what you do in the future, but happy to be here.
Definitely. All right, let’s get into it.
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All right, let’s get into this podcast. We are talking about orthobiologics today.
Before we get into anything, Dr. Patel, what are orthobiologics?
Great question. Orthobiologics. Well, we used to think of it as purely things like stem cells and PRP. Orthobiologics refer to different things that are injected to stimulate some level of a healing cascade in our body.
That can range from things like prolotherapy, or dextrose sugar water injections, that have a history of several decades of research, all the way through to what’s become very popular right now, such as platelet-rich plasma.
So all of these fall under the umbrella of orthobiologics.
So as we come to orthobiologics, we think of stem cells. Those can have healing properties, as well as some people think of them preventively.
Before we get any further, the number one question I like to ask my guests, because this is the Preventive Medicine Podcast, is what does preventive medicine mean to you?
Preventative medicine. You can say it both ways. I argued over which way to say that for so long, and also the title of the podcast. I was kind of stuck much shorter.
It’s a debate in and of itself.
But ultimately, what that means to me is we think a lot about medicine and adding years to our lives. But I think of it as adding life to our years. And that’s really what it comes down to.
How do we prevent things from getting worse? There are things that unfortunately are degenerative by nature, but how can we best optimize our lives moving forward as we age? That’s what I think of it as.
Definitely. So, as far as where that takes you from adding life to our years, where does that leave you as far as what kind of stuff are we adding? Are we adding injury-free stuff? What are we adding here?
Well, point blank, it’s impossible to not have pain throughout your life. It’s impossible to not have an injury in one way, shape, or form.
You can argue if you’re completely sedentary, well, you’re going to prevent yourself from having specific musculoskeletal injuries. But then you’re going to have a slew of other issues that you’re going to have as well.
Ultimately, I think it’s a matter of how do we live our lives the way that we want to live it to the best of our ability and in as much of an injury-free way as possible.
I love that you mentioned that because oftentimes I think a recurring theme on this podcast is not that we’re just trying to prevent things outright and not even take risks, but it’s about mitigating risk so that we can still live the life that you want and just focus on doing what you can in your control to minimize the risk of injuries.
So, as far as regenerative medicine, what role does that play in there? Is that something that’s used preventively, or is that only used as a treatment?
Usually when people think about it and when that comes up in context, it’ll be, for example, I’m in a patient room and a patient has knee pain, and we’re talking about options to treat that. We’ve gone down the route of injections and PRP comes up. Is that the only context in which orthobiologics are discussed?
Yeah, I think that’s a very common context that orthobiologics are discussed in, in the treatment of situations.
The realistic thing that we have to recognize is that orthobiologics are not just an alternative for a corticosteroid injection. I think that’s the common misconception that we see.
If somebody has an injury or a pain condition, how do we treat that pain? How do we provide some pain relief?
When we talk about pain management, that’s where things like corticosteroid injections, radiofrequency ablation, and things along those lines benefit by reducing pain.
But the way in which orthobiologics work is certainly by improving or modulating pain, by improving or modulating inflammation. But also, there is the real potential of structural changes, improvement of tissue, and the real possibility of slowing down or preventing the progress of degenerative disease.
So this isn’t something that’s necessarily used for what we would call primary prevention, as in someone’s not going to come into the clinic and be like, “Hey, inject all of my joints. I want to prevent any sort of damage to them.” Is that correct?
Well, people will come into the office asking for that. Now, I don’t think we’re at that level that it’s ethical, in my opinion, to do something like that if somebody has zero pain.
But we also have to think about what does pain mean?
For example, I’m working with some physical therapists that are involved with the NFL and the combine and all that, and working with some agencies that are investing a significant amount of money into their athletes.
We see, especially recently within the last couple of years, how many different repetitive hamstring strains and Achilles tears are occurring without any specific traumas that are causing them.
We recognize that a lot of this is overuse. A lot of this is overspecialization from an early age. But all of it is also associated with ignoring certain signs.
So “no pain, no gain” and “Mamba mentality” may also be detrimental to a certain regard if we’re not paying attention to the subtle signs that things are going on.
We’re going to be looking at things like imaging studies, ultrasound, physical examination, etc., to see if we can catch subtle signs of things that are going on before they become more prevalent.
And if we have some subtle symptoms associated with those subtle signs, the advantages of things like orthobiologics is that we don’t have the negative side effects associated with corticosteroids.
So potentially using certain orthobiologics in somewhat of a preventative manner is something that we’re looking into actively right now.
Now, a couple things to point off of that.
Number one, this poster, if you’re watching YouTube, literally right here is a Mamba Mentality poster. You can’t see it on this camera, but right here it says Mamba Mentality.
Secondly, you mentioned athletes in there, and I think you mentioned the use case of prevention for athletes as far as those little niggles or whatever you want to call them in an Achilles that you might find on ultrasound that are not really symptomatic, quote unquote.
But what about the regular person? Is this something that can be used for, let’s say, I’m not an elite athlete. Could this be useful for me if I’m out trail running and I want to prevent my knee from getting worse?
In theory, potentially. Practically, I tell my patients all the time, I’m not going to be sticking a needle in you if you have zero symptoms associated with it.
We all know the literature that shows that if you scan X amount of MRIs of X amount of body parts, you’re going to find something.
And realistically, that is very, very true. Some of those things are completely normal things that happen as we get older. Having disc degeneration is like saying you got wrinkles. There’s always going to be things that we see on imaging.
That being said, if there are things that we see on imaging that correlate with signs or symptoms, either subjectively or objectively on physical exam, those are the type of scenarios that we may want to pay attention to.
A perfect example of this, and this is something that comes up in my clinic all the time, is, “I’ve had my back go out before, and every couple years I’m deadlifting and all of a sudden my back spasms for a week. It calms down and I’m perfectly fine.”
“All right, it was just a pulled muscle. Not a big deal.”
But is it?
What I see very frequently is these patients coming back to me some amount of time later with now knee pain, with now this, with that.
So we have to take a step back and look at that a little bit more in depth.
If somebody’s having their back go out, your back muscles, your paraspinals, are strong things that aren’t going to be tearing with just little activities.
But what commonly happens is an annular tear in the disc. And if that annular tear calms down, it’s not inflamed anymore, it could still be causing some chemical irritation periodically.
And if we don’t do a thorough physical exam and see, all right, they have some dural tension, they have proximal and distal L5-S1 weakness, they have these patterns that something is going on, well, now we’re going to have patellofemoral maltracking because the butt muscles aren’t firing properly.
Or now we’re going to have a hip issue because of the asymmetries of muscles.
So if we start paying attention rather than saying, “All right, no pain, no gain,” and if we’re seeing little patterns of stuff that are going on, even if we’re not in active symptoms at that juncture, that may be an area for us to be able to intervene sooner than later.
Definitely.
So, I want to dive into your mentality a little bit there as far as that treatment approach.
I think as far as most commonly in musculoskeletal medicine, if someone keeps coming in every three to four years, not really a big deal. You’re not going to be thinking about these little annular tears that you might be able to treat or do something about.
How did you come to start thinking about those little things and those little details that you can maybe try and prevent something else in the future?
Yeah, that’s a good question. And realistically, you’re right.
When people come to our clinics saying, “Hey, I have these little things here and there,” we’re not thinking like this because we’re trained to think reactively.
We’re trained to think, you know, our tools in our tool belt include things like epidural steroid injections. But we’re not going to do an epidural steroid injection if you’re not in significant pain, right?
That’s morally and ethically inappropriate because corticosteroids have significant side effects associated with them.
But the way that I came across this was partially because of the people that I trained under.
Respect to a lot of the forefathers of orthobiologics that I had an opportunity to train under, such as Jerry Malanga, the late Jerry Malanga, Chris Centeno, and others.
I got to understand that we have to look at the whole picture. By looking at the whole picture, we can recognize patterns of things that are going on.
Too many times I started seeing patients that came to me with a knee condition that just happened to happen without any specific injury that caused it.
But why?
Taking a step back and looking at it, there were X, Y, and Z other things that were a part of the picture that painted the story over the course of their lives.
Plantar fascia tear unilaterally, attributed to just wearing heels. Well, you’re only wearing heels on one side. What caused that to occur?
Upper limb issues, lateral epicondylosis in the absence of specific injuries, things like that.
We have to start thinking about the why. And that’s what caused me to start looking at what we can actually try to be proactive about.
Definitely. I want to put myself in a patient’s shoes for just a second here.
You mentioned one of the reasons that you’re using and thinking proactively is the use of orthobiologics and potentially making things better and making sure that they don’t happen in the future or again.
But you mentioned in there that corticosteroids have significant side effects.
And I’m thinking, if I’m a patient, I’m going in to see not yourself, but anyone else. Usually in the toolkit, there are mostly things with corticosteroids. Usually people are not talking about orthobiologics.
Is there a risk to those as far as preventive medicine-wise? Because we’re thinking we want to prevent things. If a patient gets a corticosteroid injection, are they risking future injury? Is that what you’re saying here?
Depending on the situation.
Corticosteroid injections, I don’t want to say that I’m demonizing them entirely. Maybe NSAIDs, but not corticosteroids. We’ll get to NSAIDs in a second.
Corticosteroids, there is a time and place for everything. Period.
Corticosteroid injections, the most literature in support of it, let’s say for a low back and a radiculopathy, is if you’re a young, single-level radiculopathy with a single-level disc protrusion that is more acute, then yeah, there’s a very reasonable time and place to do a corticosteroid injection.
However, as time goes on, and if you’ve done two, three, four epidural steroid injections over time and we’re getting more and more limited benefit, you have to recognize that it has its limitations.
Now, as we get older, corticosteroid injections have been demonstrated to increase osteoporosis and fracture in osteoporotic patients and have effects of increasing blood pressure and increasing blood sugar.
So we have to start recognizing that repetitive injections of corticosteroids is really where the downside is.
Even with several years of research that has repeatedly shown that repeated corticosteroid injections into the knees can increase cartilage damage and increased degeneration, there are real side effects associated with it.
Now, a single corticosteroid injection in somebody that has a hot joint or a hot radiculopathy, where otherwise the pain is getting in the way of their exercise and their movement, well, yeah, that’s a very reasonable strategy to use a steroid injection.
Yeah, I think I align with you really well there because the use of those corticosteroids, you’re not necessarily preventing anything, but you’re treating that pain. By treating that pain, you’re allowing the patient to re-engage in their exercise program, re-engage in the activities that they like doing, maybe re-engage and hang out with their friends that they weren’t able to do before.
And then all of a sudden, that provides all those tenets of preventive medicine that we talk about so much on this podcast.
And that’s kind of where that comes in.
On that note, the way that I use corticosteroids now is sparingly, admittedly. However, the way that I’ll use it is to allow a patient to then do X, Y, and Z.
Whether it’s, “I need to get through my daughter’s wedding this weekend,” or whether it’s, “The pain is getting in the way of me actually firing my muscles in physical therapy,” let’s do that.
Now, we have to also be very diligent on explaining to patients that, look, you’re going to get pain-free, but that doesn’t mean we’re not doing anything for yourself.
You have to then follow up with the appropriate exercise, the nutrition, getting the body moving correctly, connecting all those dots.
If you’re just going to do the corticosteroid injection, again, then you’re going to fall into that pattern of injections every three to four months.
Exactly. 100% agree with you there.
You mentioned NSAIDs and that you were jokingly demonizing them. What’s going on with that?
NSAIDs, you know, it is a very interesting category of medication that I think again has its time and place.
I think it could be a very applicable medication for autoimmune pro-inflammatory conditions.
However, it’s one of those things that’s popped like candy, and since it’s over-the-counter, a lot of people don’t even think of them as medications, and it’s honestly just overused across the board.
There are slews of side effects associated with it, everywhere from GI to cardiovascular.
But what we don’t oftentimes think about in mainstream medicine is the negative effects that NSAIDs have on healing.
There’s ample evidence at this juncture that suggests that it could interfere with healing, and not only just healing in general by being anti-inflammatory, but also potentially even with things like collagen synthesis.
So we have to recognize that there’s probably more negatives than positives when it comes to NSAIDs for most applications.
Now, again, certain situations notwithstanding.
Sure. So we’ve mentioned corticosteroids here. We mentioned NSAIDs. And obviously you use a fair amount of orthobiologics.
What does your day-to-day look like? Are you just using PRP as an orthobiologic?
First off, I guess can you explain what PRP is and then kind of where these orthobiologics come from? Are we just buying them from somewhere, or where are they coming from?
Great question.
The treatments that I do in my office are almost all autologous, coming from a patient’s own body.
I will use dextrose prolotherapy, which I could explain briefly as well, which is a concentration of sugar water.
Other than that, I’ll use a patient’s own blood growth factors, PRP, and a few different variations of that.
I’ll use a patient’s own bone marrow or bone marrow aspirate concentrate, BMAC, which contains stem cells but also contains a slew of other things, including growth factors, platelets, and anti-inflammatory proteins.
And then I’ll use a patient’s own fat, which what we create is called microfragmented adipose tissue, which is basically a tissue transfer or graft that we use. It also contains living stem cells.
However, it is used for more structural support for patients.
These things work in different ways across the board.
The dextrose prolotherapy, the sugar water, the way that it works and the way I explain it to patients is that that sugar water actually causes a little bit of irritation at the structures where it’s injected.
That irritation causes a little microscopic apoptosis, or small cell death. It tricks the body into thinking that there’s a new injury there. And then the body sends its blood growth factors to start the healing cascade.
There is evidence that suggests that the healing cascade is propagated by this. And it’s used really well for milder conditions, as well as conditions where there’s injury to vascular structures like ligaments.
Up the chain from that, I use platelet-rich plasma.
The dextrose, the sugar water prolotherapy, tricks the body. The body sends over its blood platelets, and that’s what starts the cascade.
So platelets, when you cut yourself, are the thing that stops the bleeding, right? And then the platelets, after they form a clot, slowly release these growth factors that cause inflammation and then take inflammation away and again propagate the healing process.
Part of that inflammation calls over macrophages to get rid of the damaged tissue, calling over your local stem cells because we have stem cells throughout our body.
The stem cells are the general contractors of the construction site. That’s how healing takes place.
So we could take your blood and make a high concentration of those blood platelets. That’s called platelet-rich plasma.
Basically, that is exponentially stronger than prolotherapy.
And then when we use our cell therapies like bone marrow and fat, that’s ultimately going to be exponentially stronger than your PRP.
All right. So you said stem cell in there, and stem cells unfortunately started to get a little bit of a bad rap in places, especially kind of in the preventive medicine world, because you have these people that are biohackers who are kind of using them as this panacea for trying to reverse aging, for doing all kinds of funky stuff.
There’s even some of my own colleagues that go down to these different countries like Colombia or wherever that have these stem cell clinics, and they just kind of get infusions of stem cells.
Is that something that there’s any merit to, or is that just absolutely woo-woo?
There’s probably somewhere in between.
But until I see research that’s robust enough, I fall more into the camp that thinks of it as woo-woo.
And look, I think there’s some people doing some legitimate things with allogeneic stem cell products, particularly outside of the country.
I’m hoping to get involved with some legitimate research in which we’re using some allogeneic products outside of the country and looking at the potential benefits of these products.
However, we have to recognize what these things can and cannot do so far and what the literature is and is not showing.
There is a lot of promise with some of these treatments, and that promise starts with animal models and basic science research.
However, because of that promise, there’s a lot that have started making that into hype, and there’s a tremendous amount of hype surrounding stem cell treatments and a variety of other biologic treatments in the setting of longevity.
Longevity is a beautiful word, and it means a lot to a lot of different people.
I have patients and colleagues that are knee-deep in the longevity space, some of which is really promising. Some of which seems really, really fantastic.
However, I still am not convinced by a lot of the research that is available at this juncture.
Again, there’s a lot of promise, but for some of these things, until I see safety studies that say that it’s all right for me to put an IV and flush your system with stem cells from another body source, I’d be concerned about negative potential side effects down the line.
Personally, I’m not quite getting involved with that yet because I don’t want to be a part of a future mesothelioma ad.
That’s really what it comes down to.
We have to recognize that there are potential actual risks associated with these things that we want to kind of pause and take a break despite what some celebrities may be doing.
Yeah. You’re going to end up on an ad like, “Have you or a loved one been affected by allogeneic stem cells? Contact blah blah blah.”
I also, every time I hear the word longevity, I start kind of rolling my eyes at this time because I think it’s kind of negatively co-opted what preventive medicine is supposed to be.
Because it takes, like you said, a lot of this promising research and just kind of puts it out there as this panacea for others to spend a lot of money on at this time.
And you have mostly wealthy people that go to do these things, and then you have regular folk or people who don’t have as many resources who are like, “Oh man, of course they have the best treatment out there.”
Do you think that there’s close promise to this? Is this something that we’re going to see in our lifetimes as far as getting these treatments, or is this not there yet?
To a certain extent, yeah. And I think there’s some things that are going in that direction.
However, what do we also mean by longevity? Are we talking about just increasing our lifespan? Are we talking about truly preventing disease? Are we talking about regrowing a lost limb? Or are we talking about reversing osteoarthritis?
What exactly are we talking about here?
I think that very likely in our lifespan we’re going to be able to halt the progress of degenerative conditions such as arthritis.
I think that we’re going to be able to potentially cause some regrowth of tissues such as discs, cartilage, and things along those lines. I think those are very, very realistic things.
Are we going to be able to, again, panacea prevent all diseases in our lifespan? That seems a little bit more hokey to me to think about.
Especially with things that we still don’t know can benefit one thing, let alone all things.
Right now, IV stem cells, for example, some of it makes sense to me if you have a cardiac or pulmonary condition, right? Because when you’re throwing something in your IV, the majority of those cells are going to end up in the heart and the lungs.
Even a decade ago, I had a patient with end-stage CHF end up getting some crazy IV treatment somewhere out of the country, and he had a substantial improvement of his symptoms objectively.
There’s something to be said about that.
But anytime somebody’s getting some treatment just for longevity as a whole, I still don’t 100% know what that means, let alone I can’t support it.
For sure.
So, it sounds like there’s some promise for some of these treatments within the next several years to decades, maybe, as far as improving things.
Now, my biggest gripe with orthobiologics is that because it’s considered quote-unquote experimental, it’s not something that is typically going to be reimbursed by the healthcare system in the United States.
All these insurance companies, they’re not paying for PRP, they’re not paying for BMAC, they’re not paying for any of this.
So my gripe is always, is this something that you obviously I’m asking someone who does this a lot, so a little bit of a devil’s advocate here, but is this something that patients should be asking for?
Is there enough evidence to say, “Hey, I want PRP. I think it’s going to help,” because this is something that people are putting a lot of times pretty significant investment into these products.
Do you think we’re there yet at a pretty broad basis, or we wouldn’t go that far yet?
For certain things, I think we’re definitely there.
For example, I’m involved with a consensus statement that should hopefully be coming out for AAPM&R in regards to PRP for knee osteoarthritis.
There is a substantial amount of research in support of PRP for knee osteoarthritis, particularly mild to moderate knee osteoarthritis, better than corticosteroids, better than hyaluronic acid, with more research in support of it than both of those, as well as saline and other treatments.
There’s evidence to suggest that it could slow down the progress of degeneration and slow down the timeframe to necessity for knee replacement.
Right now, there’s more recent research recognizing that the type of PRP matters and the quantity of delivered platelets matters.
We’re getting more and more nuanced into recognizing this, but the evidence is very clear for osteoarthritis of the knee.
Okay, very clear.
And there are some insurers that have started to cover it. So there’s definitely movement in the positive direction with that.
Now, there’s level-one evidence for lateral epicondylitis. There’s level-one evidence for gluteus medius tendinopathy, and a variety of things have growing research in support of it.
It’s only a matter of time for us to recognize that this is truly a better alternative and completely different from a corticosteroid injection.
So I think that when it comes to things like knee osteoarthritis, 100%, patients should be inquiring about it.
It also does matter who they’re inquiring to and, to a certain extent, the knowledge base that that person may have.
Pretty much everybody should be able to inject inside of a knee. But depending on the condition, not all PRP is created equal, and not all ways of delivering the orthobiologic are created equal.
So we also have to recognize that there are nuances that are still in that.
It’s important to go to somebody that knows what they’re doing.
Definitely.
So I guess, to summarize this, if a patient is thinking about orthobiologic treatment, what do you think they should start with?
Let’s say, in general, we’re talking hips, knees, shoulders. What kind of things should they be thinking about regenerative medicine for?
If anyone’s lucky enough to be listening to this podcast or thinking about orthobiologics in general, thinking about preventive medicine in general, and if you’re lucky enough to get in front of your knee osteoarthritis, hip osteoarthritis, whatever it may be, while things are still in that mild to moderate category instead of once you’ve already done a corticosteroid injection and you’ve had only X amount of benefit for X amount of time, then that’s the type of circumstance where we need to start thinking about orthobiologics and being more proactive about it.
In that setting, in that mild to moderate category, PRP could be a very reasonable approach.
There was a study done for knee osteoarthritis in which PRP was pitted against corticosteroid, and they were found to have equal benefit.
So people in my world were saying, “Oh, another study that shows that PRP doesn’t work.”
But in reality, that type of PRP that was used for that study was actually a very low-concentration, poor-quality PRP, and it had the same benefit as a corticosteroid injection without a lot of the downsides.
Without the downsides, right?
So even getting a bad PRP injection will still be potentially as good as a corticosteroid injection without the downsides.
And if you get a better quality treatment, then you’re expecting better and longer-term results.
Yeah, on a personal level I can say in residency you’re not exposed to orthobiologics that much, just because academic centers typically don’t have that much capability or access to it unless you’re on the cutting edge of that research.
But as time goes on, I’m kind of realizing more and more, even throughout fellowship, the utility of them, especially in the right patient population.
I even excluded it in my main research study for residency because it was better than corticosteroid and hyaluronic acid, and I wanted to compare the treatment effects of typical injections versus patient beliefs.
So if PRP was proven to be better, then I wanted to exclude it because then patient belief is not necessarily as equivalent as the rest of them.
So definitely becoming more of a believer in it.
And it’s changing in the academic centers too. There are more and more people doing PRP in the academic centers.
So there is a shift in that direction.
Particularly since the world of regenerative medicine started being recognized as an academic rank by the Mayo Clinic in 2020, there has been a shift in the positive trajectory as far as orthobiologic research in academic settings is concerned.
Definitely. I’m really excited for orthobiologics, for regenerative medicine, and the future of it, to kind of learn more about it throughout my fellowship, which I’ll be getting a lot of exposure.
But Dr. Patel, the last question I have for you as we wrap things up is, if a patient comes to you, let’s say you’re about to leave for the day or about to leave for lunch, you have two minutes, and they ask you, “How do I get healthy?” What do you tell them?
Move.
Movement is key.
That could be as simple as walking. That could be as simple as shadow boxing. That could be as simple as just waking up five minutes earlier so you can do some stretching in the morning.
But depending on the scenario, movement is absolutely key.
One of my mentors, Dr. Ferman, said, “Motion is the lotion.”
I think that’s probably one of, if not the most important things that you can do for your body.
Very well said.
Well, Dr. Patel, it’s been an absolute honor to have you on the show. Thank you so much for coming on, and have a great rest of your day.
Thank you very much. It has been an absolute pleasure.
Recorded at the Patel Center in Newport Beach, this episode follows the host on the day of her own treatment with Dr. Patel. He explains functional regenerative medicine, the knee, back and neck conditions he treats most often, and why patients over 60 can still benefit from biologics made from their own blood, bone marrow or fat.
Welcome back to another episode of Menopause Unscripted. I am on the road today and, as you’ll see during this episode, you join me for a procedure for myself. I’m down in Newport Beach with my good friend, Dr. Patel, who does functional regenerative medicine. Can you please explain to our audience a bit about what you do and what that means?
Sure, absolutely. Well, first of all, thanks so much for having me on this. Always great talking to you. It’s been a few years since we last talked.
We last saw each other. I think we talk almost every day.
That’s true. That’s true. But yeah, my background is, I’m a specialist in physical medicine and rehabilitation, sports medicine, and pain management. But I’ve been in the regenerative medicine world for the past 10-plus years, with my first exposure 16 or 17 years ago.
Regenerative medicine ultimately means using your own body’s biologics to try to cause some level of improvement of symptoms, whether it’s pain, injury to musculoskeletal structures, or things along those lines.
In my background, I’m an osteopath, so I’m a DO rather than an MD. In our tenets, we believe that the body has the innate ability to heal itself and that structure and function are interrelated.
Based on those thought processes, I started practicing what I call functional orthopedics, or essentially looking at the whole system when we’re trying to treat a specific injury or pain concern. In doing so, we tend to have longer-term, better benefits and ultimately get long-term benefit for symptoms that could be lingering for a long time otherwise.
What would you say are the top few things, maybe three or four things, that you treat? What do you see most commonly here?
Most commonly, I mean, everybody’s got knee pain and back pain.
Literally everybody.
Yeah. So knees and low backs are probably the most common things that I treat in general. I treat a lot of spine, so a lot of low back conditions and a lot of neck conditions. Because of the nature of my practice, I see a lot of more complex situations.
I’ll see patients that have had chronic pain, multiple injuries. I see patients that have more complex scenarios like EDS or hypermobility spectrum.
Along those lines, we see patients that have had either surgeries in the past or they’re in a situation where they’re trying to avoid surgery. So those are kind of a lot of the scenarios that we see in general.
What’s the age range? What’s the youngest person, the oldest person? What would you say is the average that you see?
Well, the youngest patient that I’ve seen in office was like two years old.
Wow.
But that was not for a procedure. That was more just for an evaluation.
The youngest patient that I’ve treated with a biologic treatment was 12 years old.
Okay.
And the oldest was over 90.
Got it. So a pretty wide spectrum in terms of the ages of patients that we’ve seen, but most people are in their 20s to 60s.
I see things like acute injuries, sports injuries, things along those lines, all the way to more degenerative conditions like osteoarthritis.
So, let me ask you about the older population. You’re using biologics, meaning that you’re using something from a person’s own body. And by the way, my right arm is like a total dead arm right now. If you’re wondering why I’m very animated with just my left, it’s because I can’t move my right. Okay, so just forgive me.
Remember, you’re here for my procedure today, too, which already happened. And I didn’t totally take that into account, to be honest. We’re going to videotape this part after I had the procedure, so I like bent my neck. My right arm doesn’t move. So just bear with me here. I did not account for this clearly.
Anyways, for the older population, we’re using a person’s body’s own things with the biologics, right? So somebody who is older and, for our population, postmenopausal, can you still use things like that? Do they have enough of that to work, or do you have to get it from somebody else?
Absolutely. That’s a great question, and it’s a question that comes up really across the board with older patients, whether they’re females or males. The question is always, “Are my cells old enough or young enough in order to provide benefit?”
Well, there’s a few different types of biologics that we use. We use a patient’s own blood growth factors called PRP, or platelet-rich plasma.
Okay.
Or we can use a patient’s own cells from their own bone marrow or from their own fat. These are tissues that contain what you may have heard of as stem cells.
Okay.
The thought process in the past has been that your stem cells are not vibrant enough as we get older in order to try to provide any kind of substantial healing. However, in the absence of any medical conditions that are truly preventing healing from taking place, if you’re cut at an older age, you’re still going to bleed.
Sure.
And you’re still going to clot.
Okay.
And you’re still going to heal when we have injuries. Now, the healing trajectory and the pathway may be a little bit different, but healing still can occur.
So, interestingly, we have not seen a dramatic change in the amount of improvement we see with patients using orthobiologic procedures as you get older. It actually depends more so on the specific condition or body region.
Okay.
So, for example, low backs and knees could still do really, really well. Hip joints, after a certain age, we tend to get less outcomes.
Is there a reason why?
We still don’t know, but it’s kind of that the hip joint in general, across the board, not just with orthobiologics, has a lot of challenges associated with it.
I think part of that has to do with the multidirectional movement of the hip joint, the fact that it’s a weight-bearing joint, that we put a lot of weight into it, and the fact that a lot of things upstream or downstream can contribute to hip issues.
So, if we’re looking at the hip in isolation and not paying attention to the low back, for example, then we may be missing a piece of the puzzle, and that might be why we don’t get as good results.
Okay.
But that’s why when I see a patient with hip issues, I’m looking at their knees, their ankle, their foot. I’m looking at their low back.
Sure.
Because if we look at the whole picture, we could still get really good outcomes even at older ages.
And just treating something maybe that’s above or below to help the thing that’s in the middle.
Absolutely. And we see that a lot with not only the hip joint, but with the pelvic floor in general.
Sure.
Because a lot of times there’s pelvic floor dysfunctions that have to do with muscles not firing appropriately. But those muscles may not be firing appropriately because of issues in the hip joint. It could be firing inappropriately because of a pinched nerve or disc tear in the low back or a variety of different things.
And if we look at it as the whole picture, we tend to get better outcomes.
I feel like you read my mind because I was just going to ask, like, from the hip because it connects into the pelvis. This is our model here.
Okay.
Right here, this is where the hip connects into the pelvis. And just for everyone, this is not the top of your hip. So right here, where we taught little girls to put our hands on our hips, not our hip, top of our pelvis. If you didn’t know that, you learned something today.
The hip’s actually way down here. So pelvic floor sits in this area. Not these little guys, which we don’t really know what they are, to be honest, but down in this area. But hip, pelvis, spine.
So, in terms of the vertebrae, which vertebrae and which nerves coming out of the low back go to the pelvic floor? Can you tell us? So, if someone saw an MRI and they were wondering if it was correlated, maybe they’d have some clue that they could be related.
Yeah. So, what’s interesting is there are a few nerves that go specifically to the pelvic floor. On the other hand, there’s several nerves that are indirectly involved as well.
So, when we talk about the nerves of the low back and spine that go to the pelvic floor, we’re talking about usually the sacral nerve roots.
Okay?
So your S1, S2, S3, S4 nerve roots, which are all the way at the very bottom of the spine, at the bottom of the sacrum.
And these nerves typically aren’t necessarily damaged in the absence of specific traumas.
Okay?
Because these nerve roots are very low down in the sacrum, they’re not directly susceptible to injury to things like discs, like when you have a disc herniation or disc bulge. That’s not necessarily completely pressing on the S3 or S4 nerves.
Now, the S1 nerve can get irritated and that can cause symptoms into the pelvic floor, but we can see irritation to other nerves like the L5 nerve, even a little higher, cause symptoms into the pelvic floor as well.
So the L5 and S1 nerves are very intimately involved with a lot of the muscles that go across the buttock and make up the bottom of the buttock area, which is intimately involved with the pelvic floor. And if those muscles are not firing properly, then that can cause asymmetries and dysfunction of the pelvic floor as well.
So commonly, people are coming into physical therapy for sciatica, and I’m assuming you see that a lot as well.
Yeah.
Word finding also not the best. Does sciatica contribute to pelvic floor dysfunctions that you see here in clinic?
So it’s a good question. First, we have to define the word sciatica, right? Because sciatica means a lot of things to a lot of different people, just like hip means a lot of things to a lot of different people.
Sciatica refers to irritation to the sciatic nerve, which comes from the low back.
The different nerve roots in the low back come together and form the sciatic nerve that comes through this area here and then down the back of the buttock, past the sit bone, and then down the legs.
When we talk about sciatica or irritation to the sciatic nerve, that could happen at several different areas. It can happen at the sit bone region from what we call femoroacetabular impingement or, sorry, ischial impingement, when there’s pressure on the nerve from where these two bones can come and pinch. That irritation to the sciatic nerve there can cause symptoms down the thigh or down the leg.
But a lot of times when people talk about sciatica, they’re talking about butt pain.
Yeah.
And butt pain can come from a lot of different sources. The root of the sciatic nerve back in the low back, irritation to these nerves can cause pain in the butt and can also cause pain to go down the legs.
So, there’s a lot of different things that sciatica could mean. And it really comes down to the appropriate physical exam to try to figure out where the root cause of the pain is.
Is it the back? Is it the actual butt? Is it the hip?
Yep.
Downstream somewhere else.
Absolutely. Because butt pain, if you’re referring to sciatica and referring to butt pain, that could be coming from the hip joint, that could be coming from the slew of muscles that go across the buttock. That could be coming from nerve irritation, that could be coming from a variety of different things.
And even if there’s pain in the butt that’s coming from muscles, that could even be rooted in nerve irritation in the low back because the nerves are the electrical wiring that send signals to the butt muscles.
Sure.
So, if the nerves aren’t firing properly, the butt muscles don’t fire properly and then that can cause an issue there.
And that could just feed directly into the pelvic floor as well.
That’s exactly right.
So that butt pain could then cause incontinence potentially or contribute to it.
Absolutely. Because if there’s a dysfunction or an imbalance of musculature, then there’s a trickle-down effect and different muscles start acting in inappropriate ways, which can then cause a slew of symptoms.
So upstream or downstream, you can affect things like urinary stress incontinence.
But do you ever do PRP specifically to the pelvic floor? Is that something that you do here in clinic?
It’s a good question. I don’t do PRP to the pelvic floor, orthobiologics to the pelvic floor directly myself, although there are people that do.
I have a close colleague out in the Washington, DC area.
That’s not exactly close locally.
That’s fair. Close personal colleague, friend of mine, who is across the nation from us that does PRP for the pelvic floor and is getting great results.
However, I don’t personally do that in my clinic.
There are some other treatments also. There’s not a ton of research in support of it, but there are some treatments like using PRP directly at the urethra for incontinence issues there.
Okay.
I don’t do those in my office directly myself.
Makes sense.
So let’s kind of move into a different area. The stellate ganglion block that you did on me maybe an hour or so ago, and I’m functioning pretty well, guys. So yeah, it’s not terrible.
So when you watch that video, don’t get totally freaked out by the neck. But do you think that that kind of a treatment could potentially then help with incontinence issues? Because this is so much of what we deal with, and I know that we’re dealing with stress with that, and I’m going to have you explain what it is and trauma, but do you think that could then somehow feed into pelvic floor dysfunction?
It’s, I think, a great topic and it’s something important for us to be thinking about. I think that this is somewhat of an unexplored territory that we’re going to learn more about as time goes on.
But we know that the pelvic floor and issues like incontinence are intimately related with the autonomic nervous system.
What I tell patients all the time is there’s two types of nervous system in our body. There’s the somatic nervous system and the autonomic nervous system.
The somatic nervous system are the things that we’re consciously controlling, right? I’m going to make a fist or, in your situation, try to make a fist with that nerve block.
We’re getting there.
We’re getting there.
Oh my God. Okay.
Not yet.
So those are the conscious things that we’re controlling, and those are things like the peripheral nerves that I blocked in your situation.
But the subconscious, the things that we’re not necessarily directly controlling ourselves, are a part of the autonomic nervous system, or the automatic nervous system.
So that’s everything from our blood vessels, our heart, our GI tract, our pupils constricting and dilating. All of that is associated with the autonomic nervous system.
And that autonomic nervous system has two parts: the parasympathetic nervous system, which includes things like the vagus nerve, and the sympathetic nervous system, which is your fight-or-flight response system.
An imbalance of that can have a variety of effects throughout the body. So everything from heart issues like POTS or different types of tachycardia issues or heart beating fast, GI issues potentially linked to things like IBS, and genitourinary issues such as incontinence.
All of those things are controlled by the autonomic nervous system. So it’s not a far reach to think that disturbances of the autonomic nervous system can contribute to pelvic floor dysfunction and urinary incontinence.
Maybe we need to do a study on this together.
That would be interesting.
Joint task force.
That would be very interesting. And, you know, truth is there’s probably already some research on that that’s been done to a certain extent.
Again, this is a little bit outside of my realm of expertise because I’m more in the orthopedic space. But the autonomic nervous system is being researched more as we speak.
And one of the things that we’re seeing on that front is the stellate ganglion block. So the stellate ganglion block involves injecting at the front of the neck to calm down the sympathetic nervous system.
Okay. So if that sympathetic nervous system has become hypersensitized, that fight-or-flight response system has become hypersensitized, then the stellate ganglion block can help with calming that down.
And what would be things that could hypersensitize it, just for people who don’t know?
Absolutely. The most common things that we think about that increase that sympathetic nervous system are things like pain and things like trauma.
Okay?
So when we have pain, and particularly when we have repetitive injuries or repetitive pain, that can cause the system to get more sensitive.
And the other thing is trauma, whether that’s physical or psychological trauma.
So one of the mechanisms with how we think that PTSD works, or post-traumatic stress disorder, we think about things like somebody going off to war and seeing crazy things and being affected by that, right?
That is PTSD. We think that physiologically part of that may be that the sympathetic nervous system has become more and more and more sensitive.
Okay.
So that flight-or-fight response system with repetitive traumas causes the system to become more and more sensitive.
It’s kind of like you always have your dukes up, kind of like you just looked like.
That’s exactly. Always ready for it.
That’s exactly. And that’s what that hypervigilance is that we see very commonly with things like PTSD.
And if you’re tighter like that, then our muscles can’t work well, which I could see work feeding right into an incontinent situation. And sorry, I keep bringing that up, but just like for our audience, that’s one of the biggest problems.
Absolutely. I mean, the analogy that I use is that if you are making a muscle and you’re holding that muscle tight, well, guess what? The muscles are going to fatigue.
Yeah.
And they’re going to be painful.
They’re going to be painful.
And if they’re fatigued, they’re going to be weak.
Yeah.
Right. So ultimately, people carry their stressors in different areas. And two of the most common areas that we carry our stressors are in our neck and in our low back and pelvic floor.
Yeah.
And if there has been a physical trauma to those areas in one way, shape, or form, then we’re more susceptible for that area to become hypersensitized.
And I suppose that they could definitely be something from maybe a traumatic childbirth. And that could have been like 25 years ago, right? Or more, but it could linger.
It doesn’t have to be even a traumatic childbirth.
Sure. Which, by the way, traumatic and childbirth, I haven’t personally gone through it. However, I think that trauma and childbirth are, I mean, synonymous, right?
Childbirth is a traumatic experience even in the best of scenarios. There’s a lot of things that are taking place that can cause some sensitivity to the area in general.
Yeah. And then something we see in clinic a ton is people having the gynecological symptoms of menopause, so like GSM symptoms.
If they are super hypervigilant or they’ve had trauma in the past, those symptoms actually seem heightened for those people and their symptoms seem worse overall versus maybe somebody who hasn’t had those same experiences.
That’s really interesting. It makes sense.
Yeah. I mean, it’s all anecdotal, but I feel like these are things we could be doing research on to help the general populace. And whether we’re doing it or somebody else, maybe this conversation is for somebody to do it.
Yeah. I think it’s definitely something that merits more research and more attention.
I think there’s something to be said about our society, our management of stress.
Sure.
Whether that’s physical or psychological stress, our management of that. I mean, nine times out of ten, we’re not learning this when we’re kids, right?
No. And we’re not learning it in medical school, PT school, or anywhere.
Right. And realistically, the management of stress is a very important facet of a lot of different conditions, whether it’s pain, incontinence, I mean, shoot, even getting susceptible to repetitive injuries.
Because stress can affect not only, you know, psychologically our well-being, but can affect the way that we’re moving our bodies.
Absolutely. And causing repetitive injuries and then therefore cycling the trauma and stress all over again.
Absolutely. And then it’s a vicious cycle.
Yeah. 100%.
Let’s stop for one second. Will you mind stopping for just one sec? Ice.
Chronic inflammation is a key but often overlooked factor behind fatigue, weight resistance, hormonal imbalance, cardiovascular risk, and aging. In this expert discussion, Dr. Patel and Dr. Pearlman explain its root causes—such as metabolic dysfunction, stress, poor sleep, and gut health issues—and why it’s often missed in standard lab work. The session provides a clinically grounded approach to identifying and reducing inflammation through targeted lifestyle changes, nutrition, supplementation, and medical treatments, offering a clear, data-driven path to improving overall health and long-term wellness.
Hi everyone, welcome to the Prime Institute Podcast. I’m Dr. Michelle Pearlman, and today we’re diving into one of the most common complaints that I hear in my practice: joint pain, especially in midlife, and how it connects to weight, hormones, and aging.
To help unpack this, I’m joined by someone I’ve admired for a long time, Dr. Patel, a leader in nonsurgical, functional, and regenerative orthopedics at the Patel Center for Functional Regeneration. Dr. Patel, thank you so much for joining us.
Thank you so much for having me. It’s always a pleasure talking. So, maybe for our audience, if you can give us a quick snippet on where your practice is located and what is the typical patient that shows up to your clinic?
Sure, absolutely. My background first of all is in physical medicine and rehabilitation. I did my training in sports medicine and interventional pain management, but I’ve been doing almost exclusively regenerative medicine for almost 11 years now.
My practice is in Southern California. My main office location is in Newport Beach, and I also go up to LA, so kind of covering Southern California for the last 10-plus years, doing things like PRP, bone marrow, fat, and stem cell injections for a variety of different orthopedic conditions.
And I think what’s interesting is there are a couple of trending terms nowadays. AI is obviously one of them. Longevity is one of them. And regenerative medicine is one of them.
And I’m sure just like in Miami and in California, there’s also a lot of snake oil out there. So, just out of curiosity, how do you separate what you do in your practice with evidence-based medicine from some of the fluff and BS that’s out there, where everyone’s trying to sell who knows what in these concoctions?
Yeah. You know, the reality is that in the regenerative medicine space, there is no shortage of snake oil. And I think that has exploded over the course of the last several years.
In areas like Florida, where there’s been some recent laws that allow for more open usage of a variety of different regenerative medicine products, there’s a lot of people that are jumping on the hype bandwagon, and it’s kind of gotten a little bit ridiculous.
That being said, there’s a lot of very realistic research that is out there, very promising research for a lot of orthobiologic treatments, including things like PRP, as well as stem cell-type treatments coming from a patient’s own body, things like bone marrow and a patient’s own fat.
But there’s a lot of things that have some interesting potential research, but also a lot more hype than there is actually reality.
So, I like to really try to stay very, very evidence-based with my practice. I really stay on top of the research, and I’m involved with teaching other physicians how to do these regenerative medicine treatments.
In a part of teaching others, I think it’s really important to be realistic about what these things can and cannot do. We collect our data. We have a lab setup where we’re actually able to quantify how many cells, how many platelets we’re injecting, and we monitor that and see how patients are doing.
But I also want to make sure that, at the very least, there’s research and evidence and support of safety, let alone some sort of benefit in terms of efficacy, before I start doing treatments myself.
Yeah. So, I love that you make a really good point on transparency and setting expectations.
Just like when it comes to a lot of the patients I see, whether it’s for hormone replacement therapy or weight management, people often will think, “Oh, if I start estrogen, my whole life will change. If I start testosterone, I’m going to wake up at 5 in the morning and want to go to the gym.”
And I always ask them, “Were you ever that type of person?” Because if you were never that type of person, we’re not going to restore you to someone that you never were.
Without the foundation, without stress management, good nutrition, exercise, for instance, hormone replacement therapy is not going to fix everything. And I think the same with regenerative medicine. It’s not going to get someone to where they never were, but it can hopefully help restore function and reduce pain, I would imagine.
Absolutely. No, that’s a great point.
I think a phrase that I use for my patients quite frequently, which I think is very applicable to hormone replacement as much as it is to treating the musculoskeletal system, is that what we’re doing is really just a catalyst for what a patient is doing for themselves.
And I think that society as a whole, taking a step back and looking at society, people want a fix. People want that kind of magic bullet that’s going to get them to where they want to be.
But unfortunately, that’s not life. And that’s not the musculoskeletal system. That’s certainly not the whole endocrine system.
We have to recognize that if we can do things to give you a better opportunity for success, but without you putting your effort into it, then we’re not going to get there.
Yeah. I love that.
So, in my practice, especially with women in perimenopause and menopause, I’m seeing big shifts in body composition, loss of muscle mass, gaining of visceral fat, more stiffness, more inflammation.
From your orthopedic perspective, how does aging and hormonal changes impact the musculoskeletal system?
Big, big changes. And that’s something we’re starting to recognize more and more and more.
We used to think of the word sarcopenia or muscle loss as a disease, but in actuality, it’s kind of a part of aging.
I think what it comes down to is humans were never meant to live as long as we do. If you talk about things like cavemen and how things were back in the day, our lifespan was like 20 or 30 years old, right?
So, we’re now living four or five times past our intended lifespan, in which case we have to recognize that muscle loss is a part of it unless we do something about that.
I think that looking at your hormones, looking at strength training, that is one of, if not the most neglected parts of aging. Those are things that are really, really important parts of what we need to combat when we’re dealing with aging in general.
And one of the biggest things that I see, because I’m seeing patients that come to me for back pain, knee pain, whatever it may be, if we don’t have the strength to support our joints and our muscles, then we’re not going to get as good results.
But if we do pay attention to our bodies, I have a patient that’s 90 years old and snowboarding despite having ridiculous rotator cuff tears and back issues and this, that, and the other thing.
He’s staying in shape and moving appropriately and strengthening the muscles correctly, and then we do little biologics to keep things healthy and overall in a good position.
Hormones play a very big factor in that as we get older in general. Certainly in males as well, but particularly in females. So, it’s something that we need to look at from multiple perspectives.
Yeah. And I knew nothing about it. I was actually speaking in Boston recently at a joint and cartilage regenerative medicine conference, and I was talking about GI distress and athletes. I was on a panel talking about obesity and joint issues.
But I had the opportunity to listen to Dr. Vonda Wright talk about menopause and the hormonal changes that happen during the transition and the effect on the joints, and it was phenomenal.
She made some incredible points. She said most people age with frailty, but what if we could change the script and age with power?
More women develop osteoarthritis. I think men develop it earlier, but when women hit 50, that’s when women experience a lot of issues with arthritis.
And I think it’s a catch-22 when you have joint pain. I’m sure you see this in your patients. People don’t want to move.
So, how do you get someone to move who’s in so much pain? And if they do a hardcore exercise for two hours, that’s probably not the ideal solution versus 10 minutes of mobility every day.
I think as providers, we probably need to do a better job with exercise prescriptions instead of telling people you need to exercise more.
With some of my older patients, they overdo it and they tear a rotator cuff. So, how do some of those conversations look for you and your patients when someone comes in and they have arthritis issues? How do you go about exercise programming and getting them started?
Yeah. No, that’s a good question and a really good point.
The exercise prescription, first of all, exercise as medicine, is something that is a really, really a tenet of physiatry, or physical medicine and rehabilitation.
This is something that is kind of ingrained in our training: when we prescribe exercise, we have to do more than just saying, “Hey, go exercise.”
Because it’s really challenging for somebody, even if somebody is accustomed to exercising and has exercised their whole life, especially in the setting of injuries, it’s really hard to just get back into it without the propensity of reinjury or making things worse.
So, I rely heavily on physical therapists, and I think that’s something really, really important.
It’s a lot of times poo-pooed by patients, even when their concept of physical therapy. Unfortunately, there’s a lot of models that are out there where you go and you see the physical therapist for five minutes and then you’re given a handout and say, “All right, do these exercises,” while somebody may or may not be watching you.
Or they’re just focused on putting electrical stimulation and a variety of modalities when they’re not focused on the exercise.
But there are good physical therapists that can analyze how you’re moving and make sure that you’re moving in a correct fashion as you progress your exercises. That’s something that is worth its weight in gold when you have a particular injury or you’re trying to be proactive about your health.
Personal trainers can be of real benefit, but personal trainers are all over the place. You know, there’s personal trainers that are there just for, “It works for me, so it’ll work for you,” all the way up to those that are really, really educated and really fantastic.
When I see a patient coming in, though, I try to guide based off of the injury that’s involved and getting at least some level of fundamental motion, movement, and exercise.
Fundamentally, looking at things like the core, posture, activating certain muscles before we get into anything like more significant weight training. Because if we’re not able to move appropriately, then we will reinjure ourselves.
Now, that being said, kind of circling back to one thing that you said earlier, arthritis, osteoarthritis, is actually something that kind of starts in our 20s and 30s.
We have an ample amount of studies at this juncture looking at people that have zero symptoms, finding that there’s little arthritic changes that happen in the knees, in the spine, in the neck as early as 20 and 30 without any actual symptoms associated with it.
But what we see is when females get into their 50s, 60s, etc., and there are these hormonal fluctuations that are taking place, this then allows for a joint that has arthritis to then become irritated.
And those hormonal changes can also affect things like our ligaments and our soft tissues and our tendons. If these things are not firing appropriately or moving correctly, that’s when arthritis becomes a painful scenario.
So, the more we’re focused on our movement, our strengthening around our joints in an appropriate manner, then the less things like osteoarthritis become symptomatic.
If that makes sense.
Yeah, you make some interesting points. It’s if you X-ray everyone, you’re going to find a lot of arthritis and you have asymptomatic people. Then you also have people who have terrible symptoms and completely normal X-rays.
So, obviously, it’s the clinical correlation that matters.
One of the points you brought up is osteoarthritis, and one of the things I’ve learned more recently, specifically at that conference, is it’s an underlying inflammatory condition.
I think oftentimes we talk about osteoarthritis as just wear and tear, but if you’re 20, unless you’re a professional athlete, you shouldn’t have that much wear and tear by the age of 20.
Can you talk more about the pathophysiology of osteoarthritis, maybe some of the phenotypes?
It’s an interesting conversation because I actually just had a patient today talking to me about what are the phenotypes that are involved with osteoarthritis.
It’s a loaded question because it’s something that we still don’t know fully.
What’s interesting is that we see a bunch of different camps that are emerging at this juncture. You have your orthopedic wear-and-tear camp. You have your hormonal camp. You have your pro-inflammatory camp. You have your hypermobility camp.
There are these overlaps between these camps. I think that in medicine in general, we try to, as physicians, and partially because of the way that we’re trained, put people into a box and say that this is why something is happening.
This is the particular phenotype or this is the particular type of osteoarthritis that you have, when in reality it’s probably a combination of things.
The different types of conditions that osteoarthritis may have different phenotypes with are things like normal wear and tear, pro-inflammatory conditions, and that could be as overt as autoimmune conditions or inflammatory arthropathies like rheumatoid arthritis, Sjögren’s, and ankylosing spondylitis.
But also, you can have less overt pro-inflammatory conditions that are brought on by things like metabolic conditions, diabetes, high blood pressure, high cholesterol, etc., that kind of puts the body into a state that feeds inflammation.
A joint that has minimal wear and tear, it’s easier for that to get inflamed and irritated in those types of scenarios.
And then you have things that I think my practice has started to see more of: patients that have things like hypermobility.
I think that’s something that is underdiagnosed. It’s gaining a little bit too much hype at this juncture.
Are you referring to Ehlers-Danlos as one of the spectrums, as an extreme of that spectrum?
EDS, or Ehlers-Danlos. There are other conditions, Marfan syndrome, etc., that have connective tissue disorders genetically associated with them.
But aside from those extremes, I think that there are those that fall into this hypermobile spectrum that we can’t say is tied to a specific genetic condition at this juncture, but people that have just looser ligaments.
I see this commonly in everyone from young athletic females to older patients that have just been flexible their whole lives. Some people have been attracted to sports like gymnastics and yoga and things along those lines.
But all along the way, their joints have had excess mobility to them, which in the long term can increase the wear and tear.
But in the short term, and this is where we have those patients that have pain that don’t have a lot going on in their imaging, it’s because they don’t have a specific injury, but they just have excess mobility of the joint.
To circle that back to our conversation about strengthening as we get older, one of, if not the most important parts of treating a joint that is affected by something like hypermobility is strengthening the muscles around the joint.
So, as far as the different types of joint conditions that are involved in osteoarthritis, I actually don’t know if I truly believe in the different phenotypes.
I think we have different clusters of conditions that could then affect the joint.
Metabolic conditions, hypermobility, autoimmune conditions, these are the different things that happen to affect a joint whether it has osteoarthritis or not.
True or false: Do gymnasts have incredibly strong bones but terrible joints?
That’s what I heard because from all the impact, it helps with the bone density, but then also too much impact is too much impact on the joints. Is that fair to say? Do you think that could be true?
Yeah. So, I think that impact in general is good for joints. Correction: measured impact is good for joints.
I think that bones and joints thrive in the setting of repetitive impact in a controlled manner.
Where gymnasts get into a challenge is, again, chicken or the egg: is it a hypermobile patient that gets attracted to gymnastics, or is it gymnastics that makes somebody more hypermobile?
But ultimately, in the process, our ligaments get looser.
The way I describe ligaments to patients is that they’re those thick rubber bands that surround broccoli in the grocery store. They’re strong, they’re supportive, but there’s a little bit of a stretch to them, and that’s what’s connecting all of our bones together.
But if those rubber bands are a little bit looser, well, there’s going to be a little bit more jostling of those bones that take place.
So, in that setting, the repetitive impact, if we’re not accounting for that hypermobility or excess laxity, that’s when we’re getting into trouble.
Very interesting.
So, you mentioned pro-inflammatory states. One of those states that I see very often is with metabolic syndrome and high levels of visceral fat with obesity.
I know you do also some weight management. So, I’m just curious, how have the GLP-1s affected your patients coming in with joint pain?
If they’re able to lose weight, they’re able to lose visceral fat. We’re also seeing probably some anti-inflammatory effects of these GLP-1s.
So, curious what you’re seeing with your patients as far as pain reduction, whether or not they need more or less regenerative treatments, whether they respond better to regenerative treatments if they’re on these medications and losing weight.
Just wanted to pick your brain on that.
Yeah. No, I think that when it comes to GLP-1s, I think that they’re fantastic medications.
First and foremost, they fall into that category of peptides that have become so popular at this juncture as well, which is another…
Oh, yeah. And people ask me all the time, they’re like, “Oh, should I start peptides?” I’m like, “You’ve been on one for two years. This is like peptide.”
Exactly. Exactly. And that’s the most studied peptides with, you know, over time, right? And that’s why it’s a multimillion-dollar business at this juncture.
But the GLP-1s actually are fantastic. It seems like there’s more and more research showing the benefits of them, everything from cardiovascular to obviously weight loss.
We see there is an anti-inflammatory effect. It seems like there is an anti-inflammatory effect for this.
However, I have a lot of patients that are on GLP-1s that are still having symptoms.
So, I do think that there is a true benefit to being on GLP-1s to treating the musculoskeletal system, and I think that comes down to two very simple things.
One is that there seems to be this anti-inflammatory effect. But two, it’s the weight loss.
When you take weight off of a joint, it is invariably going to put less pressure on the joint. So, I think that plays a really, really big factor.
Whether it’s actually modulating the joint, is it actually affecting the negative environment of the joint, I don’t know the answer to that.
It seems like with myself and with my colleagues that we’ve discussed this, it seems like those on GLP-1s seem to be responding very well with orthobiologic treatments.
I think the verdict is still out at this juncture, and it’s still unclear as to why.
Is it truly just a physical thing, that again having less weight on the joints, or is there a true metabolic difference that’s occurring within the environment of the joint? I don’t know the answer to that.
Yeah. And I think that gets us into gut health. So, another topic at the conference I was at is emerging data looking at the gut microbiome and the effects in osteoarthritis, which I think is fascinating.
I mean, clearly they are two separate joints, but everything is connected.
And if we’re eating anti-inflammatory versus pro-inflammatory foods, if we have dysbiosis versus a healthy gut microbiome, what I never, and I hate the term “leaky gut.” I think most gastroenterologists kind of cringe when we hear that term because our gut is kind of always leaking. There’s always translocation of bacteria, blood, molecules.
But the reality is our gut, those tight junctions, can definitely get destroyed and you get more translocation of pathogenic bacteria, and then it infiltrates into the joint.
So, there’s so much emerging data looking at the gut microbiome, and I imagine there’s definitely some effects on GLP-1s. They are gut incretin hormones, and I imagine that there are some impacts on the gut microbiome that then translate into improvements in arthritis.
That’s a little bit of speculation, but there is data looking at the gut microbiome and osteoarthritis and joint health.
Is there data on the gut microbiome and GLP-1s currently?
I’d have to look into that. But I know the gut microbiome changes after gastric sleeves and Roux-en-Y gastric bypass. So, anatomical changes will alter that.
I’d have to look into the data with GLP-1s. I’m not sure, but I wouldn’t be surprised.
Yeah. I mean, I think that’s fascinating. There’s no doubt that our gut plays an influence on our whole body.
I see the type of foods that people are eating can and will influence people’s pain. Period.
For any time I’m doing a regenerative medicine treatment on any patient, leading up to and after the treatment, I strongly recommend an anti-inflammatory diet.
The most data for an anti-inflammatory diet that I’ve seen, and I’d love to hear your perspective on it, is things like a Mediterranean or green Mediterranean diet and things along those lines.
I do think on the side that there’s something to be said about genetics.
While I’ve had some patients that truly did have a decrease in their inflammatory markers with eating high-quality red meats on a high spectrum, and then on the other end of the spectrum being completely vegan and having immaculate inflammatory markers and things along those lines.
So, I do think that there’s some genetic component as to who does better on what type of diets, but that’s something that I think is very, very important that I discuss in depth with patients leading up to and after procedures.
Yeah, it’s so overlooked.
I think for a lot of providers, if they’re rushed in time, it’s like opening up Pandora’s box. As the patient’s walking out, it’s like, “Oh, by the way, try to eat healthier. I’ll see you back in a couple of months.”
It’s truly, as you know, the foundation. It should be one of the first things we start talking about with nutrition.
And if the provider is not well-versed in it, then there are a lot of resources out there that they can send patients.
I think patients just need to be guided on who are those credible resources, because there is a lot of stuff online that people can get very overwhelmed with.
But I remember there’s a lot of credible resources, but there’s a lot of misinformation out there, too.
Oh, yeah. When I had fractured my wrist during a cycling injury, I remember going to occupational therapy and I would chat with the therapist.
I would talk to her about nutrition. I actually had offered to put together a protocol for their patients where they would just have to scan a QR code and get access to a lot of anti-inflammatory resources, and it never went through.
I just don’t think they really, I don’t know, maybe they thought it was important and didn’t want to. It literally was going to be so easy to integrate it. Literally scan a QR code on your way out. It was a free resource, but nothing ever happened, unfortunately.
Can I get that QR code?
Yeah. [laughter]
But what’s interesting is the therapist would tell me, you know, they get patients that come in, one day it’s their elbow, the next day it’s the shoulder, the next day it’s the neck.
And she’s like, “It’s not a joint issue, it’s a systemic inflammatory issue.”
And unless they’re able to drop down that inflammation, even like the CRP or the ESR, it may be normal, but at a cellular level, there’s inflammation.
And one of the reasons why I eat healthy is when I was in medical school and I had high stress, I would eat tons of candy after a board exam and I’d wake up the next day and my neck felt horrible. I literally felt like I had fibromyalgia.
So, I experienced pain at a visceral level.
And I know when patients say, “Oh, I feel the pain after I eat candy,” oftentimes the physician looks at them like they’re crazy, but I felt it, so I believe it. I am a believer because I went through it.
So, it’s at a cellular level, inflammatory changes by the food that we consume on a daily basis. And people need to hear it over and over again.
They may not listen the first time around, but that’s why we have to keep reiterating it.
100%. I can’t agree with you more.
And you said a bunch of words that I need to comment on. Things like fibromyalgia. Does it exist or not?
I think that there’s probably true fibromyalgia that’s out there, but there’s probably a ton of patients that are affected by that inflammatory response of what they’re eating, what they’re putting into their body.
And then there’s also a strong correlation between the gut and the brain, and you mentioned that eating candy after being stressed at an exam and all that kind of stuff.
Stress plays a huge factor. And there’s an intimate connection between our management of stress as well as our nutrition.
There’s something truthfully to be said about the gut microbiome and how it’s affecting our management of stressors.
And ultimately, there’s an intimate connection between all that and the autonomic nervous system.
That’s been something that I’ve been delving into deeply over the course of the last few years: how much that dysautonomia, or the disruption of the autonomic nervous system, plays a factor into our gut health, but also into our musculoskeletal system and our perception of pain.
Yeah. And you mentioned stress, chronic stress, and cortisol is obviously a major stress hormone.
And at this conference, actually, one of the PhDs was talking about how low levels of chronic stress with cortisol levels that are never eradicated also lead to destruction of the joints.
And that cognitive behavioral therapy to help manage stress has a huge impact on pain and joint health, which is so incredible because you could go to all the orthopedic surgeons in the world.
You don’t fix all these impactful things in our life that affect us every second of the day, things will not get better.
But how do you get rid of stress? You can’t, right? That’s the challenge.
What do you tell your patients?
So, the thing is, stress in and of itself is not a bad thing, right? In life in general, and this is not talking about the gut, this is not talking about hormones, this is not talking about the musculoskeletal system, but in life in general, it’s not about what happens to us, it’s about how we react to it.
And we as a society don’t learn how to manage our stressors appropriately, period.
I’m sure there’s some outliers and there’s people that are raised correctly, and I love my parents dearly. But they sure as heck didn’t teach me how to deal with stress in appropriate ways all the time.
I think that’s something like we don’t learn how to eat correctly and we don’t learn how to manage our stressors correctly.
We don’t learn personal finance.
Those are the things that we should be learning in elementary school that we don’t learn enough of.
I think that cognitive behavioral therapy, trauma therapy, I think we have had traumas in our lives that we don’t address appropriately.
And then we find solace in the foods that we eat. We find solace in inappropriate relationships. We find solace in inappropriate habits with not doing exercise, etc.
And then these things kind of accumulate over time.
It’s become such a big part of my practice and just recognizing it that I very commonly recommend patients see various different talk therapists.
I even started doing these injection treatments called stellate ganglion blocks that help with resetting the sympathetic nervous system.
And I think that even in treating a musculoskeletal system, I might start with sending a patient to a nutritionist and a psychologist and considering stellate ganglion blocks even before addressing the musculoskeletal system in order for us to address the whole picture.
Are you checking cortisol levels periodically?
A lot of times patients will come to me having already had their lab work done.
Yeah. Challenging. I don’t have great people in the area that I regularly recommend seeing in order to manage their cortisol levels or endocrine dysfunctions.
That’s a need in the area, at least locally where I am right now.
Yeah. Well, I think the challenge is we would die without cortisol. So, unless someone has a pathologic issue where they’re hypersecreting it, if you have moderate levels, it may inform the patient that they are under chronic stress and this is why it’s important to do X, Y, and Z to lower those levels.
But it’s not like we’re just going to start a medication to block cortisol because they wouldn’t be able to survive without it.
So, I think data is important when people know what to do with it.
Just like the stool analysis for the gut microbiome. I don’t order it. If someone wants to know if they have dysbiosis, they will often come to me with a packet.
But the reality is it’s never going to tell me something I don’t know, right? I’m never going to recommend McDonald’s based on your gut microbiome.
It’s very clear: anti-inflammatory, high-fiber foods, lean protein, Mediterranean-style diet. It doesn’t really matter what the stool analysis tells me.
Those recommendations are going to stay pretty much the same, obviously with nuances based on personal preference and allergies and food intolerances.
Yeah. How do you deal with patients that have robust allergies?
Yeah, those are definitely some of my more challenging patients who are on more restrictive diets.
The problem is there’s no good testing out there. So, you have things like Everlywell and some of these food sensitivity tests that are checking for IgG proteins, but it’s not actually based on any sort of validated science.
So, it’s all about first identifying the allergy.
Well, if someone has a typical immediate allergy like a peanut allergy and they get anaphylaxis or hives, that’s pretty clear-cut. They obviously need to stay away from peanuts and have an EpiPen.
But for someone who has more nonspecific symptoms like bloating, those could be anywhere from non-IgE-mediated food allergies, and the skin prick test and blood work is only checking for IgE-mediated ones.
So, it’s not going to tell me if someone has a non-IgE-mediated food allergy. It could also just be a digestive issue.
Maybe it’s lactose intolerance, which is very common. It’s actually not a genetic problem. It’s actually normal to lose the lactase enzyme as we get older.
It’s not a survival advantage to steal another mammal’s milk. We’re the only mammal that does that and thinks it’s normal.
So, that’s not an allergy. That’s just a food intolerance.
And then I’ll tell people, “You don’t need to guzzle down milk,” but it doesn’t mean they have to stay away from all dairy. Not all dairy contains lactose.
So, that’s where there’s a lot of nuance.
Some people have celiac or non-celiac gluten sensitivity. You probably see some of those patients where they have joint pain after having gluten.
We need to make sure they don’t actually have celiac disease because that has ramifications as far as small bowel damage.
But as long as they don’t, they can choose whether or not they want to eat gluten. For some people, gluten can cause issues, not necessarily an allergy unless it’s a wheat allergy.
That’s more of an autoimmune condition.
So, not all things that cause people discomfort after eating are food allergies, and that’s where it gets a little bit complicated.
We have to figure out: does someone absolutely need to avoid it in a case like celiac or anaphylaxis, or is it that they have a little bit of bloating and they’ll survive and it’s not causing any intestinal damage?
But that’s where it can get a little bit complicated. People will feel it in their joints, and so it’s trying to figure out what plan is going to work for them.
As their body changes and they go through hormonal shifts, that’s going to change as well.
Whatever they could eat when they were 20 and 30 does not mean they’ll be able to slam down a pizza and maintain their weight and feel well at 50, 60, and 70.
So, very dynamic stuff.
Yeah. I’m curious because I see a lot in Southern California, as I’m sure it’s the same in Florida. There’s a lot of people that have dietary restrictions that aren’t necessarily based on things.
Yeah. And, you know, I see a lot of, you know, it used to be more. Actually, I feel like the trend is dying down of gluten intolerance.
But in the absence of something that’s as overt as celiac, when you have something like a gluten sensitivity or a lactose sensitivity, or nightshade sensitivity or an egg sensitivity, something that is a little bit pro-inflammatory, aside from something like an elimination diet, how else do you try to gauge that? Or is there a method?
It’s hard.
If someone were just eating eggs, it’s easy, right? They eat eggs, they don’t feel well.
The problem is nowadays our foods have a million ingredients. Even something as simple as a salad, I don’t know if they have Pure Vita in California, but if you get, let’s say, a big salad, it may have chickpeas, beans, carrots, cucumber, eggs, bacon. It literally has 30 different things.
We often think that more is better. But when someone has a food intolerance, it could be one. It could be five of those things.
It may have nothing to do with what they’re eating, but how fast they’re eating, how late they’re eating, how much they’re eating, are they talking when they’re eating, are they swallowing air when they’re eating?
So, for a lot of people who say, “I have symptoms whenever I eat anything,” it may be, okay, are you guzzling down fluid and using a straw and sucking down tons of air?
Or are they actually chewing their food? If they’re not chewing their food, they’re not allowing for proper digestion or absorption.
It has nothing to do with what they’re eating, but their dietary habits.
So, I’m actually developing an app. It’s in the App Store. It’s in its infant stages, called Bite MD, where you’re able to track what you’re eating and your dietary habits as well as your GI symptoms.
You can speak to an avatar and have conversations, and using AI and machine learning, it can give you feedback to say, “Okay, you know, it’s common for onions to cause you bloating, but it looks like it’s not the onions in the seasoning. Looking at all the patterns, it’s probably the garlic.”
Just looking at pattern recognition to help guide people as opposed to saying, “Go on a low-FODMAP diet and cut out X, Y, and Z.”
The goal is not to be super restrictive if we can at least avoid that, mainly because then people aren’t getting the protein, which is obviously incredibly important for muscle and bone strength.
So, we want to make sure people are getting adequate fiber, adequate protein. Those are the main things.
If they want to be on a restrictive diet, that’s fine, but we do need to make sure they’re getting their adequate nutrients and promoting healthy gut microbiomes, bone, and muscle.
Yeah. No, I think that’s really cool. I’d love to know more about that app because that sounds really great.
What I try to do with my patients, especially when we’re trying to optimize for a procedure, is we get somewhat restricted, but it’s impossible to completely control something unless we dig deeper.
And I think an app like this could be really, really helpful for most patients because it’s otherwise really challenging, and it could be some nuanced things that are making a big difference in terms of inflammation and pain.
Yeah. So, let’s get practical.
If someone’s struggling with knee, hip, or back pain and they’re in midlife, they’re dealing with metabolic changes, what are some of the first steps that you want people to work on when it comes to protecting their joint health, minimizing pain, and hopefully preventing or slowing down progression?
Yeah. I mean, I think there’s some fundamental things that I recommend to all patients.
Number one is the appropriate exercise. And if they’re coming with a specific injury, then starting with physical therapy is the thing that I recommend the most.
What I say to all my patients in regards to that is that physical therapy does not mean massage or chiropractic treatment or electrical stimulation or acupuncture, all of which can be perfectly fine for symptom management.
But when I say physical therapy, I mean guided, progressive strengthening exercises to get you moving as appropriately as possible.
So, that’s number one, first and foremost.
Number two is the appropriate nutrition. And again, from the most basic standpoint, it’s eliminating processed sugars. It’s eliminating or decreasing processed meats. It’s getting more clean with that.
It’s multicolored vegetables. Hydration, hydration, hydration.
Now, again, if there’s more nuanced issues, if there are sensitivities, etc., then that needs to be dug into. But at the very basics, it’s an anti-inflammatory diet.
And then number three is making sure we’re paying attention to our triggers.
That could be musculoskeletal triggers, but it could also be psychological triggers.
So, circling back to things like stress and paying attention to the things.
By that I mean if we’re having a really crappy day at work, we’re very, very sleep-deprived, and we’ve been eating crappy, well, that’s not the day to try to do your PR in a run or in a weightlifting thing.
Because that is the time that you’re going to be the straw that broke the camel’s back, so to speak.
So, paying attention to our system ends up being a really important part of managing symptoms and also preventing injury.
Yeah. Love it. Listening to our body. So critical. So critical. So easy to neglect, though.
Yeah. So easy.
So, for the clinicians listening to this, when should they consider referring a patient to someone like you for regenerative orthopedic care?
Yeah. So, this is challenging. It also depends on the system that you’re in.
Traditional orthopedic care for musculoskeletal injuries in the insurance-based system is NSAIDs, pain medications, if you’re lucky, physical therapy, otherwise corticosteroid injections, and then surgery.
The problem with that system is that NSAIDs and pain medications are overutilized, physical therapy is underutilized, and corticosteroid injections and surgery are overutilized.
So, if you find a patient that is not responding to any of those things, then before going down the route of repeated corticosteroid injections that are ultimately going to cause the situation to be worse, whether worsening arthritis or causing soft tissue injuries because it causes destruction of the joint.
Correct.
Correct. Steroids over time.
Correct.
And then do you see joint injections, do those have systemic effects, let’s say, on potentially lowering bone density?
100%. There’s data that suggests that a single corticosteroid injection in a perimenopausal female will cause an increased risk of osteoporotic fracture. Period.
I’ve had patients that had a single steroid injection and then ended up with a compression fracture in their spine.
Now, that’s on an extreme, but it does occur.
I’ve seen patients with a single corticosteroid injection significantly increase their blood pressure, significantly increase their blood sugar.
So, there’s no doubt that there is an endocrine effect with the use of corticosteroids, and especially repetitively.
That’s a systemic effect, but there’s research now that shows that repetitive corticosteroid injections into joints will cause osteoarthritis to worsen, cartilage to decrease in size, etc.
So, it’s a very overutilized medication.
The challenging thing from a clinician standpoint is that people will come for their knee pain and get a cortisone injection in their knee, but, oh yeah, a month ago they also had a cortisone injection in their shoulder, or they were using an inhaler, or they had all this other stuff.
And it’s overutilized throughout medicine in general.
But the same thing could be said for NSAIDs, and NSAIDs have a metabolic effect on patients as well.
There is data that shows that NSAIDs can interfere with healing, can cause issues on the metabolic spectrum in general, and are popped like candy by patients left and right.
So, these are the things that need to be controlled for.
And if you see patients that are falling into a pattern of repetitive NSAID use or repetitive corticosteroid use, that’s when we need to divert and come to see someone like myself before going down the route of something like an irreversible surgery that may or may not even be appropriate.
Yeah. And there’s data to support negative effects taking NSAIDs prior to exercise.
And obviously, they give me job security because of the peptic ulcers and whatnot.
[laughter]
So, I think the challenge is when patients are writhing in pain and they’re desperate for a solution, and NSAIDs can be very helpful for pain control as well as corticosteroid injections.
And the reality is, even if it may not be the best decision, they will always find someone who will say yes and do it.
So, it comes back and, don’t get me wrong—
Yeah.
And don’t get me wrong, they’re very appropriate for certain circumstances.
Yeah.
But the second that we’re using these things repetitively, then we got to pause.
At what point are we just putting on a Band-Aid for short-term pain relief that’s causing ultimately long-term harm?
Yeah. I mean, the same thing for opioids, right? They’re—they have a purpose.
If you had a major surgery, well, yeah, maybe you need some opioids post-procedure in order to alleviate some of the postsurgical pain.
But these are overutilized and can actually have a negative effect on the system as well.
Yeah. Even the endocrine system with opioids.
Yeah. Yeah. My sister uses a powerful statement often. She says it’s like putting a Band-Aid on a bullet wound.
Yeah. Absolutely. Usually, you know, just a temporizing effect.
Yeah. Yeah. Absolutely.
I think you and I are in such an amazing space with what we do because we have our own practices. We can use evidence to inform our decisions, but we can also skirt that line of innovation because we’re not bogged down and slowed down, shall we say, by the typical insurance model that tends to dictate how we should be delivering health care.
So, things are evolving so rapidly in the orthobiologic space and the weight management space and the cardiometabolic space and the hormone space. It is all interconnected.
I think we’re both probably very excited as to what the next couple of decades are going to look like.
It’s probably going to put a bunch of surgeons out of business. I mean, that’s what we’re seeing with the GLP-1s. A lot of bariatric surgeons are now doing more general surgery.
And I think that’s great. Why is first-line therapy surgery? We should be exhausting all noninvasive methods before we operate.
And I think finally, when it comes to joint health, gut health, weight management, I think we were so behind the ball.
Absolutely. I 100% agree.
And realistically, surgery is always going to be necessary for specific conditions and specific scenarios. There is no doubt that it’s necessary.
But now we can surgically address really only what’s necessary, get better outcomes from the surgeries that are done, and then prevent irreversible long-term changes in people’s physical bodies and physiologies by doing things that are less invasive.
I think that’s the future.
And there’s a lot, a lot, a lot of promise with the things that both of us are doing.
Ultimately, even in conjunction, I think that the more we hit things from multiple angles, the better results that we get across the board.
Yeah. Love it.
I tell people all the time, I’m not a jack of all trades.
I think that’s the other thing, understanding what is our niche? What are we good at?
And then obviously finding other really good people who are really good at what they do.
You’re not a physical therapist, you’re not doing acupuncture, you’re not a dietitian. You’re doing what you know, and then you’ve created that other internal referral network.
So, you send people to the top subspecialists for whatever else they need to augment what you’re providing.
That’s exactly right. That’s exactly right.
And even on things like the weight management side of things, I don’t do as much as I’ve created a program to be able to do it.
We don’t do a ton of GLP-1 management or anything along those lines.
But we do, even with our program, get people moving appropriately so they don’t have the weight loss, or sorry, the sarcopenia or muscle loss that could be associated with things if people are just throwing medications at you.
My practice is ultimately about the niche of getting you functional.
The majority of that is using orthobiologics, but we’re only as good as the team that we surround ourselves with.
I think that’s something really important for clinicians in general to recognize: there is no single magic bullet to anything.
But if we collaborate with other like-minded individuals, and if a patient takes that step to be proactive about their care and to helm that ship, then we’ll ultimately get the best outcomes moving forward.
Love that.
Well, this was such a powerful conversation. The message is clear. Joint pain is not just about your joints. It’s about hormones, muscle, weight, metabolism, gut health, and aging all interacting together.
So, Dr. Patel, thank you so much for your expertise today.
Thank you for having me. This is absolutely wonderful, and I’d love to come back in the future and talk some more.
In this episode, Dhru and Dr. Patel discuss the current state of pain management, the opioid crisis, and the integrative and regenerative therapies Dr. Patel is using to help his patients address chronic pain. They discuss how platelet rich plasma therapy (PRP) and stem cell therapy can amplify your body’s own ability to heal, and when it’s a realistic option for pain. They also talk about the importance of addressing the root cause when it comes to the treatment of pain, as well as the role nutrition plays in regenerative medicine.
Hi everyone, Dhru Purohit here from the Broken Brain Podcast. Today, we’re interviewing my dear friend, Dr. Shounuck Patel, as part of our series on pain and addiction. We’re talking to Dr. Patel about his toolbox of regenerative medicine and some of the tools in it, including stem cell therapy and PRP (or platelet-rich plasma), as options to potentially address and get to the root of pain. Stay tuned.
Welcome to the Broken Brain Podcast, where we dive deep into the topics of neuroplasticity, epigenetics, mindfulness, mindset, and functional medicine, with the goal of helping you understand how your brain is not broken. I’m your host, Dhru Purohit, and each week my team and I will bring on a new guest who we think can help you improve your brain health, feel better, and live more.
This week’s guest is my dear friend, Dr. Shounuck Patel. He’s here to talk to us as part of our series on pain and addiction, and the role that regenerative medicine and therapies like stem cell therapy can play in getting to the root of these areas. Dr. Shounuck Patel, thank you for being here.
Thank you so much for having me, Dhru.
A little bit about your bio: Dr. Shounuck Patel is an interventional and functional orthopedic specialist with offices in Los Angeles and Orange County, California. He has a clinical interest in the biomechanical etiology of musculoskeletal injuries and pain conditions, and the holistic treatment of the whole-body continuum with innovative orthobiologic treatments, osteopathic manipulation, and therapeutic exercise.
Dr. Patel is board-certified in sports medicine, board-certified in physical medicine and rehabilitation, and fellowship-trained in interventional pain management. Dr. Patel lectures at medical conferences around the nation, is a clinical assistant professor at Western University and Touro University Colleges of Osteopathic Medicine, and is an expert instructor for the Interventional Orthopedics Foundation, where he teaches other physicians how to do advanced stem cell treatments and orthobiologic procedures.
In addition to numerous publications, including journals and book chapters, Dr. Patel is the illustrator—I want to hear more about that—and co-author of the recently published Atlas of Musculoskeletal Ultrasound Cross-Sectional Anatomy. That’s a handful, but we’re glad to have you here. Basically, all that just tells me you know what you’re talking about! Thank you for being here, I super appreciate it.
Thank you so much, Dhru, for having me. Honestly, this is amazing, what you’re doing here, and I’m just glad to contribute.
And we go way back.
Way back!
First of all, shout out to our friend Nirav, who we met through.
Absolutely.
Before we go into all things pain management, stem cells, and the landscape of pain that’s out there, two stories I want you to tell. True or false: You were in a breakdancing group with our friend Nirav?
That is true.
So you’re the breakdancing, hip-hop doctor?
Former breakdancing, yeah. I mean, even back then I was hurting, so I stopped doing that a while ago.
One other story related to this conversation here: We have a mutual friend, Chris. He got into a really bad surfing accident, injured his spine, and was in pain for quite some time. Then Nirav recommended that he come and see you. Take it from there—what kind of injury did Chris have, and what did you do for him to get him better?
Chris had a fairly typical injury that a lot of us face. A lot of us are working desk jobs, spending time sitting for long periods of time all day.
All day! Especially if you’re an entrepreneur. Chris is a financial advisor—incredible guy.
Absolutely. Sitting at a computer, sitting at a computer, right? But then on the weekends, what do we like to do? We like to have some fun, we like to surf, we like to work out, we like to go and do things. But that “weekend warrior” type of mentality is what predisposes us to injuries, right? We sit for long hours and then we play.
Naturally, a lot of times people have injuries to their back. Especially young folks doing higher levels of activity can injure things like their discs. The discs in the back are the shock absorbers, kind of like water balloons completely filled with jelly. These discs can get tears in them, or these discs can bulge. Actually, none of that has to equal pain, but in certain circumstances, they can irritate nerves and cause pain. When that occurs, we need to be proactive in treatment.
Ultimately, I did a treatment for him using growth factors from his own blood. I did injections throughout various areas in his spine, and he did a regimen of physical therapy to really strengthen the muscles around his spine. He did fantastic.
I texted him before this interview and asked, “Hey, can I tell your story? I’ll keep your name out of it.” He said, “No, use my name, because I’m a walking billboard for these approaches and regenerative medicine.” Of course, he’s a huge fan of yours and recommends you all the time.
We’re going to talk more specifically about what that treatment was and what it means to use growth factors from your own body, because these are all part of the emerging landscape in this category of regenerative medicine. Can you break it down really quickly? What do you classify as regenerative medicine? Then I want to talk about where the need comes from in the state of pain that we’re in in America.
First, regenerative medicine. Regenerative medicine is actually an interesting term; quite frankly, it’s a bit of a misnomer. The term “regenerative medicine” came from the fact that we’re using your own body’s growth factors and your own body’s stem cells to try to heal various tissues. We used to think that’s how things worked, but quite frankly, we’re now able to use your body’s biologics to improve the natural environment of an area—not necessarily regrowing joints or reversing the clock of time, but more like helping your body do what it normally would do.
Correct. Absolutely.
So the “regenerative medicine” term is kind of a misnomer in the orthopedic world, at least as far as pain management is concerned. There is real regenerative medicine going on in the bench lab/research world, where people are working with embryonic stem cells to try to grow organs and things along those lines, but that’s still very much in the research world.
Yeah, the way I see the work that you’re doing now is kind of the way people used to think of chiropractic when it first came out. They were like, “This is bogus, what is chiropractic?” If you look at the history of being a chiropractor, there was so much skepticism. At one point in time, insurance didn’t cover it, and then obviously more research came out. Now insurance knows that if you want to save somebody from spinal surgery years later after a car accident, one of the best things you can do is send them to chiropractic and other physical rehabilitation.
According to a 2016 CDC survey, an estimated 50 million Americans suffer from chronic pain, and 19.6 million Americans had high-impact chronic pain—meaning that the pain limited at least one major life activity. Give us the landscape of pain today, not just in America, but around the world.
Pain is an interesting thing. Looking at those numbers, the statistics are staggering. The amount of people in pain is tremendous; some would argue that chronic pain is itself an epidemic. But really, if you look at it, there are multiple epidemics in one.
The Gallup poll company put out a report in April of this year comparing a 2018 survey to 2017. Worldwide, they surveyed people and asked, “Yesterday, how did you feel in terms of anxiety, worry, anger, and pain?” It was staggering that one-third of people across the world said they were in pain. In the US, around 50% of people said they were stressed, anxious, or worried. I think that goes hand in hand. We’ve seen in the literature that stress and anxiety go hand in hand with pain, and that’s a vicious cycle pervading society at this point.
But there’s more to pain. The opioid epidemic is another issue that’s gained a lot of media attention, and we can certainly talk about that. But another epidemic that’s really overlooked is the mismanagement of pain. The way traditional medicine is set up right now, people go through an algorithmic approach to pain and aren’t getting to the root of the issue in terms of what’s causing the pain. Instead, people end up just treating the pain itself. So that’s really the broad landscape of what pain management is like right now.
Getting to the root of the pain—that’s really the work that you do. Tell us about your background before we jump into some of these innovative and emerging treatments that are resources people could seek out. I want to set a little bit of your background first. You are a Doctor of Osteopathic Medicine (DO). A lot of people are confused—my brother-in-law is a DO. Explain osteopathic medicine, and let’s start from there.
Sure. A DO is one of the two types of fully licensed physicians in the US; there are MDs and DOs. A Doctor of Osteopathic Medicine goes through the same four years of medical school education as an MD, but in addition, there are two major factors that set us apart.
Number one, in theory, we have four core tenets that look at the body as a whole, look at the body’s ability to heal itself, and look at how proper treatment should take all of that into account. Of course, there are MDs who look holistically at patients as well, but this is at the base of what it is to be an osteopath.
It was part of your training! Versus if you’re an MD like Dr. Hyman or someone else, you kind of had to seek it out and learn it separately from your medical training.
Absolutely. Don’t get me wrong, there are a lot of MDs I consider more osteopathic than DOs, and vice versa. But that is an innate part of our training. The other big difference is we learn osteopathic manipulation—similar to chiropractic and some physical therapy modalities—really getting our hands on patients, both in diagnosis and in treatment. So that’s really what sets DOs apart from MDs. As far as postgraduate education is concerned, both MDs and DOs do residency training, and some opt to do fellowship training in various subspecialties.
Take us on the journey of what brought you into specializing in pain.
In med school, I was originally interested in psychiatry. I was really interested in the mind, and particularly how the mind affects the body. But when I learned about osteopathic manipulative medicine, I got really interested in the musculoskeletal system and the body itself. So I was torn between the mind and the body.
That’s when I learned about my specialty: Physical Medicine and Rehabilitation (PM&R). It’s a specialty focused on function, treating everyone from stroke and spinal cord injury patients to amputees, post-orthopedic surgery patients, sports medicine, and pain medicine. That field really attracted me because it combined psychology, physical treatment, and a great view of pain: pain happens, injuries happen, surgeries happen, but let me talk about function. Let’s talk about getting people moving better and living their lives the way they want to.
Since then, I did a fellowship in sports medicine and interventional pain management. Ultimately, at every step of the way, I had exposure to this emerging field of regenerative medicine, which combined all the things going on in my training up until that point.
What was the process of you looking into this? I’m sure you didn’t really get taught much about stem cell therapy in school, right?
Yeah, we get taught about stem cells conceptually and theoretically. When you talk about stem cells, more often than not, people think about embryonic stem cells. At immaculate conception, when you’re made into a baby, those embryonic cells turn into everything. So everybody is hooked on the word “stem cell,” and that’s where my initial knowledge came from in med school. We didn’t learn about the emerging sciences that use various cells from the body to promote healing and function, or how to practically use and implement them for patients in an office setting.
When you started looking at regenerative medicine, what were some of the experiences you were having, either with patients or your own curiosity, that made you seek out solutions beyond what you were taught in med school?
To answer that, we have to look back at traditional pain management. The way we were taught in medical school and residency is that, oftentimes when dealing with pain, we’re dealing with the symptom, not the cause. We deal with pain using medications, cortisone injections, and ultimately surgery. But that wasn’t dealing with the root cause. If someone had an injury, more often than not, we were dealing with the after-effects rather than what caused it.
Physical Medicine and Rehabilitation focused on dealing with the underlying issue to a certain extent, because we sent patients to physical therapy and got people moving properly. But when tissues weren’t healing, we were kind of relegated to saying, “Hey, surgery is the next line.” I thought there was such a gap in between those things, and when I heard about people doing regenerative medicine, that really fascinated me.
Now, that’s evolved over the years. We used to think that we inject these stem cells and we’re regrowing joints, reversing arthritis, or regrowing damaged tissues. But we realize now that’s actually not the case.
So what is the case?
The interesting thing with stem cells is that they actually work to signal the environment around the area. Mesenchymal stem cells refer to the type of stem cells we use from bone marrow or other tissues. That line of stem cells is more differentiated down the route of bone, tendon, muscle, and orthopedic-type tissues. If you think of embryonic stem cells as being able to turn into anything, mesenchymal stem cells are more specific.
The founder of that term, a brilliant physician named Dr. Arnold Kaplan, named them mesenchymal stem cells because in a lab setting, we were able to differentiate them into bone, muscle, tendon, etc. But he found out that in the body, they’re actually not differentiating—they’re signaling the local environment! They signal the local stem cells to tell them, “Hey, wake up, do your job.”
This is so profound that over the past few years, Dr. Kaplan has recommended that instead of calling them mesenchymal stem cells, we call them “medicinal signaling cells”—not even calling them stem cells, because they’re not changing into these structures, but rather changing the environment and talking to the area that’s in pain.
This is how the industry’s understanding of stem cells has changed! It’s more that these injected stem cells act like a hype man, hype woman, or cheerleader to say, “Here’s what we need to do.” The body sometimes does it on its own, but in the case of regenerative medicine and stem cells, you’re encouraging the process to happen.
That’s right. If you have an injury, bump your arm, or get a cut, the local environment reacts. The local stem cells living in that area are attracted to that region and start the healing process. The local environment actually goes into inflammation first. People demonize the word “inflammation,” but it’s actually a good thing initially. It should come, and then it should go as part of the healing process.
The way I describe inflammation is like demolition day of a home reconstruction. If you want to get a new kitchen cabinet in there, you’ve got to get rid of the old kitchen cabinet first to lay down the new blocks, tile, or cabinets. But when people get stuck in inflammation—whether because of nutrition, body predisposition, or biomechanics (like walking funny and constantly irritating a joint, or having joint degeneration)—the local stem cells aren’t able to get that joint out of inflammation. Then you get stuck in chronic inflammation.
Absolutely, whether it’s whole-body or localized, depending on what the person is dealing with.
Going back to my analogy, you’re no longer just taking off the old kitchen cabinets; now you’re taking off the drywall. You’re getting more damage in an area when you’re stuck in that position.
Since we’re on the topic of stem cells, let’s stay there for a second. What are typically some of the things people come in to see you for? Because you’re not just a stem cell doctor—you work with a lot of different components of pain management to help people get to the root cause. Sometimes you do that with an anti-inflammatory diet and supplements, along with recommending lifestyle changes, stretching, physical therapy, etc. But what are the things people come to you for where stem cells become a possibility in your toolbox?
That’s a great question. People come to me with all sorts of orthopedic pain conditions, whether an ACL tear in their knee, a rotator cuff issue, or back pain going on for years. We treat the whole gamut. But when patients come to me, they’ve heard of stem cells. Unfortunately, the word “stem cells” is being thrown around left and right. There are people truly capitalizing on the sexiness of the word “stem cell” and the appeal of regrowing or regenerating, and taking advantage of patients. There are a lot of patients in pain or dealing with conditions who are desperate, and people are preying on that desperation.
Anytime an emerging industry grows, whether it’s cannabis, CBD, or other stuff, there are always people who flock there who may not understand the full spectrum or haven’t gone through the training, so they use marketing to get people’s attention.
That’s absolutely right. For better or worse, the marketing brings eyes and attention to the field as a whole, making people realize it’s an opportunity. On the other hand, the marketing takes patients away from legitimate treatments toward false hopes and beliefs. That’s why education is so important, and I appreciate you having me on the podcast to go down that journey.
Absolutely!
What’s interesting is that people are using the word “stem cell” and claiming they can do things not shown in the research or literature. A whole industry has grown out of this. That’s really what we’re trying to educate the public about: there are legitimate treatments available, but they’re vastly different from what people are claiming.
Let’s make it super practical. What are some injuries or conditions where stem cells are potentially one of the modalities to tap into, and when are they not? For example, I came to you because a family member was going through cancer for the second time. She had breast cancer, and after being cancer-free for a long time, through a chiropractic appointment, she found out she had growth on her spine. That was putting her in debilitating 10-out-of-10 pain because the tumors were putting pressure on a nerve. I came to you and asked, “Is my aunt a candidate for stem cells?” You said, “Listen, stem cells aren’t really anything nerve-related in this context.” Can you expand on that?
We can treat nerves, but we can’t treat cancer. That’s what it comes down to: whether we’re treating the pain or the cause of the pain. In this case, it was the tumor causing pressure on the nerve. Nothing was wrong with the nerve itself; it was caught between a rock and a hard place. Theoretically, we can try to calm down the irritation to the nerve, but since the nerve is continuously being irritated by the tumor, there’s nothing we can do about that.
More importantly, we don’t know how biologic treatments (like stem cells or growth factors from blood) negatively or positively affect a tumor. Does it increase growth? There’s not enough research yet, especially when something is active. We have data showing that for people in remission after a tumor (surgically removed, chemotherapy, or radiation), it is theoretically safe to do biologic treatments. We have enough data saying these treatments aren’t causing new cancer, but we don’t know how it affects ongoing cancer. So that’s something we tread carefully with and avoid until we know it’s safe.
That was a good example of when stem cells cannot be used. What are examples of what stem cells can be used for?
First, let me step away from using the word “stem cells.” I talked about calling them medicinal signaling cells, but I like the word “orthobiologics” because it refers to a spectrum of things: stem cells, growth factors from blood called PRP, and various other things that help with orthopedic conditions. The typical patients I see have arthritis—knee arthritis, back arthritis, shoulder or neck arthritis—and acute injuries like ACL tears, rotator cuff tears, or disc bulges causing nerve irritation in the low back or neck. Those are the types of things we treat.
I don’t use stem cells for all these patients because sometimes it’s not necessary. Sometimes we can get away with using growth factors from the blood (PRP), which is what I did for your friend Chris for his surfing back injury. He didn’t need stem cells, because just because we have a tool doesn’t mean we need to use it! We need to stratify which patients require what type of orthobiologics, and he did really well without stem cells.
How do you choose? When would someone use PRP (platelet-rich plasma), and when would they use stem cells? Of course, they have to see a physician to get properly diagnosed, but big picture, how do you categorize them?
The big picture question is, “When can this be an option for me?” When a patient has an injury or long-lasting pain, in traditional medicine, they’ve often gone through pain medications, steroid injections, and are facing surgery—like a knee replacement or spine surgery. Unless there are circumstances where surgery is absolutely necessary, when they’re in that gray zone, that’s where orthobiologics come into view.
If you have knee arthritis and have been told, “We can keep doing cortisone injections or you can have a knee replacement,” that’s a circumstance where you may want to see a physician specializing in orthobiologics to ask what options are available. The field is expanding. For ACL tears, traditionally the treatment for an active person or athlete is ACL repair surgery. But recovery from ACL repair surgery takes a year or longer; papers show you may not return to full sport for two years. ACL surgery sets you up for arthritis and, believe it or not, an ACL tear in the other knee. Now we’ve found that for partial-thickness ACL tears and even some full-thickness ACL tears, we’re able to heal the ligament using growth factors from blood and stem cells from bone marrow. Pretty remarkable stuff! We’ve had publications on that front as well.
If you have an injury where you’re suspicious that pain medications or cortisone injections are being thrown at you, or if you’re facing surgery, those are times to step back and ask if orthobiologics are a potential option.
In the case of knee surgery, you don’t just get knee surgery and then return completely to normal, right?
Knee surgery is a funny thing. You have two general categories: arthroscopic surgery (using scopes to clean out the knee) and knee replacement (removing the bone and replacing it with hardware when arthritis is very bad). Both are necessary in specific situations, but statistically, it’s ridiculous how much they are done—sometimes for reasons that aren’t necessary.
Arthroscopic surgery is done for milder conditions like meniscus tears (the shock absorber in the knee) or milder arthritis. But research shows that for degenerative conditions, arthroscopic surgery has no better outcomes than fake surgery, where they just poke holes in the knee and wash out the inflammation with saline water!
The placebo effect of surgery!
It may be placebo, or just that washing out the inflammation makes you feel better. Removing a torn meniscus or frayed cartilage removes structural tissue and predisposes you to worsening arthritis down the road. What if we can change the negative environment of the joint without removing structural tissues, strengthening them with biologics from your own body instead? Knee replacement surgery is an ultimate option, but up to 40% of people still continue to have pain afterwards.
A lot of people! That can lead to a lifelong dependency on pain management drugs. At the annual functional medicine conference, a doctor mentioned that pain is like a smoke detector—it’s trying to tell you something is wrong. If you’re left with pain, your body is saying something isn’t working. If you don’t address it, it could lead to a bigger issue later on. Anyone who has had a family member on long-term pain medication knows the body adjusts, requiring more medication to manage the same injury.
It’s a great analogy and a great point. Opioids change what pain is. There are two broad categories of pain: nociceptive pain (when you have an injury, twist your knee, or a disc bulge irritates a nerve) where pain fibers signal damage. When that becomes chronic, it’s no longer just that there’s damage—the signals get screwed up and your nervous system adapts in a maladaptive way. Opioids make your nervous system hypersensitive to pain.
The way I describe it is that your body is like a bank. With the initial injury, the bank got robbed, so the owner ups the security system. You don’t treat the root source of pain, so you get injured again, the bank gets robbed again, and security goes up again. Opioids change the way the security system works, so pretty soon a pigeon walks past the bank, the alarm goes off, and they shoot a nuclear bomb at it!
Exactly!
The pigeon isn’t robbing the bank, but the nervous system is so hypersensitive that even small actions signal damage instead of just bumping an elbow. That’s how opioids change the nervous system—it’s no longer nociceptive pain, but neurologic pain.
Super fascinating. This is a timely topic with all the lawsuits going on. We interviewed Dr. John Kelly, who talked about how the medical community was duped because studies showing a lack of addiction with opioids didn’t have real efficacy. Marketing buzz led to doctors prescribing and patients requesting them, creating an oversupply without proof of the implications.
The opioid crisis is multifactorial, and that is a huge part of it: not having appropriate data, but giving it to people suffering in pain. In America, we want a quick fix and we want to deal with pain now. Pain management became a huge source of income for pharmaceutical companies.
That’s not the only factor, though. A few years back, pain became one of the “vital signs,” alongside blood pressure and pulse. If a physician trying to get reimbursed didn’t check the box that they discussed pain with a patient, reimbursement went down. A physician seeing 30 patients a day needed a time-efficient way to deal with pain, so throwing medications at them became the system. We have to become the CEO of our health: listen to podcasts, read books, and advocate for ourselves.
Everyone goes through pain at some point. Understanding the approaches out there and being an advocate for yourself is key.
Absolutely. Ask why! If a doc gives you a prescription for a painkiller, why are you taking it? If that physician doesn’t have time to address it, take a step back and seek someone who can educate you.
Coming back to back and spine issues—what is the most frequent issue you see across the spectrum? Is it knees, backs, joints?
Backs and knees.
Backs are a big one. What actually happens during back or spinal surgery?
Spine surgery is a wide spectrum. It can be minimally invasive, interfering as little as possible to address the specific disc or area causing pain, numbness, or tingling. Or it can be as expansive as fusion surgery, where pieces of bone or disc are removed, causing instability, so hardware is used to fuse segments of the spine together.
Most ethical spine surgeons recommend surgery as an absolute last resort because it’s invasive, recovery is long, and there can be side effects. There’s a joke: “Doc, I’m still in pain after surgery, but the surgery was successful!” The fusion took place, but the patient is still in pain because other factors are involved. In fusion surgery, “adjacent segment disease” can occur: because those levels are fused, the levels above and below have to make up for that movement, leading to further degeneration. Surgery begets surgery.
When a patient comes in with back pain, what questions do you ask and what solutions do you look for using regenerative medicine?
When I see a patient, they’ve usually been through the ringer and are trying to avoid cortisone injections or surgery.
Briefly explain cortisone injections for those listening.
Cortisone is a corticosteroid that calms down inflammation in a region at a cellular level. It only lasts for a short period of time. If you don’t address the underlying issue, you repeatedly get cortisone. Research shows repeated cortisone injections in knees make arthritis worse. It also has side effects: changing hormones, causing lost periods, spiking blood sugar in diabetics, or causing spine fractures in elderly patients with osteoporosis. People use it like candy, but repeated patterns have detrimental long-term effects.
When a patient comes to me with back pain, I ask about nutrition, diet, supplements, and physical therapy. Many say they’ve done PT, but it was just massage and a handout of exercises. Have they done PT where someone works with them on moving properly? The stem cells and orthobiologics I use are just a catalyst to facilitate healing, but how you move and what you put in your body is where the real effect takes place.
I had a pitcher with a shoulder injury who had lingering pain after surgery. He came for a stem cell treatment, but I talked to him about nutrition (he had gained weight from depression about not playing). Before I even did the stem cell treatment, he lost 30 pounds, his pain improved, his mood changed, and he was eating healthy. After the stem cell treatment, his shoulder strength improved, but his long-term improvement came from his lifestyle changes.
We know inflammation starts in the gut. What are some key nutraceuticals/supplements you recommend in your practice for pain management?
I stratify whether a patient has an arthritic/degenerative condition or a nerve-related condition. For knee arthritis, three I like are fish oil (omega-3s), turmeric, and glucosamine chondroitin. Good quality is key. For nerve conditions, B vitamins (B6, B12) help. Turmeric also has research showing alpha-turmerones may benefit nerve stem cell health. For deep functional medicine, I send patients to functional medicine docs.
What is the landscape of literature and research available for stem cells and PRP?
There is a decent amount of research growing for orthobiologics. PRP has robust research for tennis elbow, knee arthritis, and hip tendinopathy. PRP stands for platelet-rich plasma. Platelets contain growth factors that decrease inflammation and call local stem cells to start healing. We draw normal blood, spin it down in a centrifuge, concentrate the platelets, and inject it into joints.
In the case of Chris, you used his own blood to treat his spine injury. What was that process like?
I created different varieties of PRP to treat different components of his spine. Instead of just finding one pain generator, we address the functional spinal unit: nerves, discs, ligaments, joints, and muscles. We use image guidance (x-ray or ultrasound) to inject those areas and provide strength to the region.
What is the timeline for PRP results?
Platelets work on a biological level, so it takes time. Cortisone works better short-term, but PRP has better long-term outcomes. Initial pain may increase due to temporary inflammation, but relief typically happens over 1 to 3 months. I follow up at 1–2 months. If progress plateaus, we may consider repeat injections, though there’s no set requirement for a series.
Is it a similar approach for stem cells?
Yes, depending on severity. For severe knee arthritis, we might do stem cells combined with PRP, and perhaps repeat PRP down the road since we aren’t regrowing a new joint. For acute injuries like an ACL tear in a young patient, one stem cell treatment may be enough.
What are proactive things people can do before pain becomes severe?
Be proactive early! People ignore low-grade recurring pain until their back goes out completely. Address biomechanics, movement, and minor injuries early through physical therapy or chiropractic care so it doesn’t build up over time.
Sitting at a desk all day puts a lot of pressure on the spine. I personally go to a chiropractor monthly as a proactive measure, and it helps immensely. Who should people consider seeing if pain is present but not severe?
Find a physical therapist or chiropractor focused on active recovery—teaching you how to help yourself rather than requiring 3 visits a week forever. Look for professionals who evaluate whole-body biomechanics, fascia, and movement patterns.
Does insurance cover PRP or stem cells?
Currently, they are mostly paid out-of-pocket. Some plans cover basic PRP like a single cortisone injection, but comprehensive orthobiologic treatments targeting the full functional unit usually aren’t covered.
Costs vary: PRP for one region generally ranges from $1,000 to $2,000 (more for complex spine procedures). Stem cell treatments in the US range between $4,000 and $10,000.
What resources or organizations can people look for to find trusted practitioners?
Look into the Interventional Orthopedics Foundation (IOF), the American Association of Orthopedic Medicine (AAOM), or networks like Regenexx. Look for clinics that collect and publish outcome data, and beware of red flags like claims of 100% success or promising to cure unrelated conditions like Alzheimer’s or diabetes with stem cells.
Clarify the legal landscape around stem cells in the US.
The primary FDA-compliant stem cell procedure in the US uses the patient’s own bone marrow (drawn from the back of the pelvis) in a same-day procedure. Umbilical cord blood or amniotic products sold in vials do not actually contain living stem cells after processing (gamma radiation or freeze-thaw), despite false claims by shady clinics. If it sounds too good to be true, it probably is.
Dr. Patel, thank you for coming on the podcast and breaking down the landscape of pain management and regenerative medicine. Where can people find you online?
On Instagram, I’m @stemcelldrpatel. Our website is www.healthlinkcenter.com, where we have blogs, articles, and outcome data available.
Dr. Patel, thank you for being here!
Thank you very much, Dhru. It was a pleasure.
An interview-style podcast designed to help you truly understand your brain and body. Hosted by medical doctor, Dr. Natasha Mehta, this podcast helps listeners dive deeper into topics across rehabilitation, wellness, fitness, nutrition, and more.
Dr. Natasha Mehta: Welcome to the Brain and Body Things podcast. I’m your host, Natasha Mehta. I’m a physical medicine and rehabilitation doctor, a medical doctor who specializes in optimizing quality of life despite pain or injury to the body. I treat conditions that require a combination of medicine, therapeutic exercise, and lifestyle modification. Through this lens, I’ve expanded my knowledge of health and wellness and am looking to share everything I’ve learned with you. This podcast and my website focus on the goal of helping you understand the brain and body in the simplest of terms. In my conversations with healthcare experts, we seek to provide actionable tips and tricks to enhance your lifestyle and optimize your life. Our guest this week is Dr. Shounuck Patel, here to talk to us about regenerative medicine for orthopedic injuries and pain conditions. I’m very excited about this conversation because this is definitely an area of medicine that has a lot of confusion and misinformation that he’s gonna clear up for us today. Dr. Patel is double board certified in sports medicine and physical medicine and rehabilitation, as well as fellowship trained in interventional pain management. He focuses his clinical practice on the use of exercise, nutrition, osteopathic manipulation, and natural therapies such as regenerative cell therapy. Dr. Patel earned his degrees across the nation. He was at George Washington University in Washington, DC, Drexel University in Philadelphia, and Midwestern University’s College of Osteopathic Medicine in Chicago. He then completed his residency at Kessler Institute for Rehabilitation in New Jersey, like I did, then went on to do a fellowship at the Orthopedic and Spine Specialist Hospital of Pennsylvania. He’s also completed an advanced regenerative medicine training with Regenexx and the Interventional Orthobiologics Foundation or IOF. This is a nonprofit for which he became a master instructor for other physicians and chair of the curriculum committee. Dr. Patel is an invited speaker and instructor for medical conferences across the world about this topic. I’m very honored to have him on the podcast to talk about all things regenerative for orthopedic and pain conditions. If you’d like to work with him, you can find him in Newport Beach, California. I’ll link his website and information in the show notes. Hi, Dr. Shounuck Patel. Thank you so much for joining me on Brain and Body Things podcast.
Dr. Patel: Thank you so much for inviting me on.
Dr. Natasha Mehta: So I have to be honest that normally when I invite guests on to the podcast, I know an extensive amount of information about the topic that they’ll be speaking, and I invited them because I want them, you know, to share a message along with me, and I sort of guide the conversation in the direction that I want. But in the case of regenerative medicine, it’s been years since I heard a lecture or, or read any of the literature on regenerative medicine and, you know, let alone know the practical implications of it. So I’m really excited to dive deeper into this with you. So can you share with the listeners a little bit about yourself and your practice?
Dr. Patel: Yeah, absolutely. Thank you. You know, it’s, it’s interesting. The, the world of regenerative medicine has exploded over the course of the last several years, but it is all over the place. My, my pathway was a little interesting in, in getting here as well. So my background, I’m a DO. While I was in medical school and doing my rotations, I had my first sampling, my, my first flavor of regenerative medicine when I was shadowing an osteopath that was doing osteopathic manipulation, but he started doing a lot of prolotherapy. And prolotherapy, and specifically this was in Manhattan, and he was treating a lot of, like, the New York City Ballet, a lot of hypermobile patients that were, you know, otherwise not getting sufficient care elsewhere, and I, I was really intrigued by the idea that we could do injections that can kind of, you know, push a body’s own ability to heal. And as a DO and with, with our osteopathic tenants kind of going along the lines that the body has the innate ability to heal, this really jived well with me, and it was something that then I sought out on every stage thereafter in terms of my education. So I did a residency in medicine and rehabilitation at Kessler, and while there had the opportunity to learn under some greats, including the late Jerry Malenga, who was obviously a, a force in the regenerative medicine field. And, you know, if, if you’re new to regenerative medicine, uh, if you, you know, look up Dr. Malenga on PubMed, you’ll see a slew of various different articles. He was really a force in both sports medicine and regenerative medicine, and having the opportunity to learn under him and others really, you know, pushed my interest forward.
Dr. Natasha Mehta: I’ll just add really quick for– sorry to interrupt you, that he did, he did pass this past year, and I think we should just… I do want to recognize that on, on this platform because he will be greatly, greatly missed.
Dr. Patel: Honestly, one of the smartest, most prolific people in, in not just the regenerative medicine space, but in the sports medicine space as well, and he’s, you know, he’s got a, a podcast that, that his, his fellows put on this last year. It’s, it’s both an absolute amazing podcast with, with gems of knowledge in sports medicine, and for those of us that have rotated with him and spent time with also kind of induces a little bit of PTSD ’cause- … you could, you could, you could hear him, you know, pimping the residents and fellows in the podcast, and it’s like, “Oh, man.” I, I started sweating even just now listening to it again.
Dr. Natasha Mehta: What is the– What’s the podcast called?
Dr. Patel: Oh, I don’t even… It’s called, like, Malenga Talks or something like that.
Dr. Natasha Mehta: Mm. I, I think you’re right. Yeah. I’ll, I’ll link it in the show notes, but yeah.
Dr. Patel: Yeah. It’s, it’s fantastic, you know, and some, some real gems. He’s one of those guys that would like, you know, “Oh yeah, this research from this year,” blip, and –
Dr. Natasha Mehta: Right
Dr. Patel: … kind of, you know, pull out some amazing knowledge. So that, that being said, you know, that, that really w- is what sparked my interest and fostered my interest in regenerative medicine. So I did my fellowship in interventional pain and sports medicine with Dr. Mike Furman and his crew in Pennsylvania, where we did a lot of spine procedures and a lot of peripheral procedures as well. And from there I joined the Regenexx network after fellowship, which is an international network that, that focuses on regenerative medicine treatments and From the Regenexx network blossomed a non-for-profit organization called Interventional Orthobiologics Foundation, which I’ve been, you know, teaching for for the last five years or so. So that’s, that’s really been my journey. Branched off and started my own practice March 2nd, 2020. And it’s been a roller coaster since then, but, but it’s been absolutely amazing.
Dr. Natasha Mehta: Well, and you know, you do mention that regenerative medicine is, is helping the body to heal and its innate ability to heal. I, I think that there is a misunderstanding in the public about what is quote unquote regenerative, so could you outline that a little bit further?
Dr. Patel: Yeah, you know, that’s, that’s a good question and, and, and interesting and nuanced point. I, I actually believe that the term regenerative medicine is a misnomer for the majority of the stuff that we do. The reality is so, so the, the concept of regenerative and, and the use of treatments to invoke the body’s healing process can actually be dated back to like Hippocrates, who used a, a hot poker in an axilla to try to treat some recurrent dislocations, right? To cause-
Dr. Natasha Mehta: Mm-hmm
Dr. Patel: … some scarring to occur. And, and that concept is what was carried on with, with regenerative medicine applications in the orthopedic space.
Dr. Natasha Mehta: Mm-hmm.
Dr. Patel: And things like prolotherapy have been around for decades upon decades at this juncture. But in 2020, Mayo Clinic adopted regenerative medicine as an academic rank. When we say regenerative medicine at this point, really it, it spans a spectrum. So it’s a spectrum from lab-based science all the way through to transitional medicine, all the way t- through to, you know, clinical practice. And really it, it, it’s a span of multiple specialties. So you got everything from growing ears on Petri dishes, which is like your true regenerative medicine, all the way through to what I do, which is more on the orthopedic clinical side, which really has only very limited circumstances where we get actual regeneration taking place. Most of the time it’s using a biologic substance to invoke some level of a process in the body, and that could be decreasing inflammation, that could be strengthening soft tissue structures like ligaments, tendons, et cetera. That could in some circumstance be healing of things like tendon tears, ligament tears, you know, things along those lines, getting nerves to function properly and getting muscles to, to act the way that they should be acting. But it’s not always regenerative. We used to think that like, all right, we’re gonna inject some stem cells into an area and regrow the knee, and unfortunately, there’s still a lot of folks that are kind of propagating that, that, that disinformation. The reality is that that’s not the case.
Dr. Natasha Mehta: That’s very helpful. And I think that a lot of these orthobiologics that you mentioned, like Prolo or PRP, they get incorrectly named stem cells. Like, oh, these are, these are stem cells. They’re coming from your body. And so I wanna dive a little bit more into that too. So what are the different orthobiologics that you use in the, yeah, orthopedic world?
Dr. Patel: Great, great question. I, I like to kind of separate out orthobiologics into kind of three broad categories. One category is something that’s like an extrinsic substance like prolotherapy. And with prolotherapy now, typically prolotherapy is using dextrose or sugar water as we describe to patients, and it historically it’s been really any injected substance that causes some level of irritation, tricks the body into thinking that there’s an acute issue going on, and then the body starts the healing process.
Dr. Natasha Mehta: Mm-hmm. Okay.
Dr. Patel: So dextrose at a hyperosmolar concentration causes a little bit of apoptosis at a cellular level, starts some inflammation. So this could be really beneficial for areas that have good blood supplies, so ligaments-
Dr. Natasha Mehta: Mm-hmm
Dr. Patel: … for example. So if somebody has chronic recurrent ankle sprains, then using dextrose injected along the ATFL, CFL, et cetera, can essentially trick the body into thinking it’s a new injury, right? That’s the concept behind prolotherapy or proliferative therapy. So that’s kind of one category. The other two categories are your autologous substances and your allogeneic substances. Your autologous substances include things like blood products, and there’s a laundry list of actual blood products, including PRP, which is probably the most famous or recognized at this point. Then you have other autologous products like bone marrow aspirate concentrate. You have adipose tissue graft or microfragmented adipose tissue, and then you have other things like getting the stem cells from these substances. Then there’s a whole allogeneic camp, things that are donated from other folks, right? And these are your umbilical, amniotic, embryonic, Wharton’s jelly, cord blood, all of those things that in the US, number one, don’t actually contain a substantial amount of living stem cells, if at all, and number two, are grossly illegal per the FDA-
Dr. Natasha Mehta: Mm-hmm
Dr. Patel: … unless in specific research circumstances. I have to mention this because that world has exploded over the course of the last several years to the point that there’s clinics left and right doing these stem cell treatments, injecting it locally, IV, inhaled, like let’s treat-
Dr. Natasha Mehta: What?
Dr. Patel: … the knee arthritis. Yeah, look, let’s treat your knee arthritis, and your long COVID, and your Alzheimer’s, and your kid’s Down sy- like it’s, it’s literally the Wild West.
Dr. Natasha Mehta: Oh my gosh.
Dr. Patel: And it, it wasn’t until just a couple years ago where a lot of this was highlighted in the media where there was like people that went blind from injections and people that were hospitalized with sepsis and-
Dr. Natasha Mehta: Mm-hmm
Dr. Patel: … and all this stuff kind of brought this to the forefront. There’s a, another good podcast called, uh- The Bad Batch, I think it’s called, that, that looks at one of these companies and, and all like the seedy underground of what, what this was doing. So like that whole world is like really what has, has dirtied the positive progress that we’re making in, in actual, you know, orthobiologics or regenerative medicine. So, you know, when, when somebody says that they’re thinking of getting stem cells or they had stem cells, the question is w- what exactly did they have? Now-
Dr. Natasha Mehta: Wow. I mean, so how would, how would the public know? Like, what is your advice to somebody for, for really discerning what they’re getting?
Dr. Patel: First rule is if it sounds too good to be true, it probably is, right? If, if you’re, if you’re thinking about going to a clinic, you were recommended them ’cause they’re the, you know, best thing since sliced bread, simply going to their website and seeing, all right, are they an orthopedic specialist, a physiatrist, pain management, sports medicine, orthopedic surgeon that is focused on doing these regenerative treatments within their lane of their specialty?
Dr. Natasha Mehta: Mm-hmm.
Dr. Patel: Or are they a plastic surgeon, urologist, whatever, trying to treat everything under the sun? So that’s, that’s the first thing, like the smell test of seeing, you know, what kind of claims are these people making on their websites. That, that should be like the litmus test of even like is this worth a call?
Dr. Natasha Mehta: Yeah.
Dr. Patel: Now, the other thing is looking at their training, and if somebody is using orthobiologics and that’s kind of their focus, that’s something that they’re trying to specialize in, and that they’ve had appropriate training to help them along the path, versus someone that’s like, “All right, I can inject inside of a joint, so I’m gonna get a centrifuge and start, you know, injecting X, Y, or Z.” There’s a vast difference when somebody’s actually like focused on what, what is it that they’re doing and how is it that they’re doing it. Those are the main things that I tell patients.
Dr. Natasha Mehta: Yeah, and I’m sorry to interrupt, but I would imagine that when it’s your field and you’re in that lane of orthobiologics, you are on top of the nonstop literature that, uh, is coming, right? Like I, I just think that this is a new field still, and, and there’s a lot we still don’t know. But before we go there, can– I just want to back up really quickly.
Dr. Patel: Yeah.
Dr. Natasha Mehta: So when I think of– when I think about stem cells, like how I learned in residency from Dr. Malenka, I think about adipose tissue and bone marrow. Is it safe to say that if someone is not getting the quote unquote “stem cell” from the adipose tissue or bone marrow and they’re getting it from something else, that maybe I should beware of that?
Dr. Patel: That’s, that’s a good point. Yeah. So first and foremost, even those treatments using bone marrow and adipose tissue, are they a stem cell treatment? I’m gonna just throw that out there. We’ll co- we’ll circle back to that. But yes. So, you know, blanket statement, if somebody says that they’re gonna do a stem cell treatment and they’re taking it off the shelf and they’re gonna be injecting billions and billions of– It’s crazy, like people people will say like, “Yeah, you know, I’m gonna get a hundred billion cells that are injected from whatever thing that they were, were getting.” And it, it doesn’t matter what they say in terms of how many billion cells. The, the, the reality is that these subs- these substances that are off the shelf have been– a lot of them have been independently t- studied to show that they have little to no actual living stem cells. And, and, and more importantly, they’re also illegal per the FDA.
Dr. Natasha Mehta: Yeah.
Dr. Patel: But, but more importantly, these particular substances have not been studied to show safety, let alone efficacy. So that’s an important thing, right? So to know where these things are coming from, if somebody’s planning on using stem cells that are donated because, you know, a embryo has richer supply of stem cells, I mean, that’s a fact, but that’s a bait and switch, right? So we, we have to recognize that.
Dr. Natasha Mehta: Yeah. No, that’s very helpful. And ag- and I guess I didn’t say this when, when I was watching the procedures in residency, it was from the o– it came from the own patient, the, the patient’s, uh, adipose tissue or, or bone marrow. So, so in the research, I guess, where– From what I understand or what I’ve heard is that we still are– there’s still a ways to go when it comes to determining what products in the injectate are actually helpful. Correct me if I’m wrong, and then, and then tell me where we are with that.
Dr. Patel: Great. Yeah. So that’s, that’s a very intricate question, but that actually– You know, it’s like having a plant in the audience. That brings me back to the, the question that I threw out there in terms of like, you know, what is a stem cell and, and, you know, are these bone marrow and adipose tissues really stem cell treatments? So bone marrow aspirate concentrate and adipose tissue are areas where we can get rich supply of these MSCs. These MSCs, Arnie Caplan back in nineteen ninety-one called these mesenchymal stem cells, and they were labeled as stem cells because when they take those cells and put them into the lab, you can take them down the different lineages of things like tendon, muscle, et cetera, right?
Dr. Natasha Mehta: Mm-hmm.
Dr. Patel: But in vivo in humans, it was actually found that these do not actually differentiate down these different lineages. So this is where we started to diverge from the concept of, all right, being able to inject bone marrow and regrow a joint versus a biologic or paracrine effect that could take place in the, in the region. These cells, Arnie Caplan, the, the f- the, the, the person that coined the term mesenchymal stem cells, backtracked, went on a rampage on lectures, you know, publications, et cetera, saying we should not be calling these stem cells.
Dr. Natasha Mehta: Oh.
Dr. Patel: But we should be calling these medicinal signaling cells.
Dr. Natasha Mehta: Okay.
Dr. Patel: Right? He still wanted to call it MSC, so he could still stick with the thing he named, right? But he called it medicinal signaling cells because they’re not regrowing tissue, but-
Dr. Natasha Mehta: Mm-hmm
Dr. Patel: … but talking to the local environment by way of the exosomes, packets of information that these cells are communicating with the local environment to which they are injected. We’re now having a biologic, a true biologic effect in that region, but not regenerative in nature. And then taking that a step further, bone marrow aspirate concentrate, for example, contains a ton of platelets, contains more than just MSCs, but also hematopoietic stem cells, or HSCs, right? Contains loose, strongly anti-inflammatory proteins like A2M, IRAP, interleukin receptor antagonist protein, things along those lines that all really are a milieu when we’re injecting that in, right?
Dr. Natasha Mehta: Mm-hmm.
Dr. Patel: We’re not isolating out the stem cells when we’re injecting it, and for that reason, the, the stem cell treatments that are legal in the US really aren’t stem cell treatments. They’re, you know, cell therapy or, or, or a tissue transfer-
Dr. Natasha Mehta: Mm-hmm
Dr. Patel: … of bone marrow aspirate concentrate or adipose graft, not technically a stem cell treatment. So it’s, it’s, it’s semantics to a certain extent, but it’s important, you know?
Dr. Natasha Mehta: It’s very important. I think those are very important distinctions, and one of the main things that I do when I work with patients is I set expectations, and if the expectation is that the stem cell… the, excuse me, the stem cell is going to regrow my meniscus-
Dr. Patel: Yep. Then what?
Dr. Natasha Mehta: And, and it doesn’t happen, right?
Dr. Patel: Right. Right, right. Now, what’s interesting is that, you know, I, I tell patients this all the time: We are not going to be able to give you a teenager’s knee again.
Dr. Natasha Mehta: Mm-hmm.
Dr. Patel: Or we are not going to be able to give you, you know, the spine of when you were a baby.
Dr. Natasha Mehta: Right.
Dr. Patel: But what we can try to do is strengthen structures.
Dr. Natasha Mehta: Mm-hmm.
Dr. Patel: What we can try to do is improve the negative environment of the joint. What we can try to do is, is slow down the progress of degeneration, but it’s also not just the biologic that we’d be injecting. It is your nutrition. It is-
Dr. Natasha Mehta: Mm-hmm
Dr. Patel: … your exercise. It is your ability to move appropriately. That’s the stuff that is the long-term solution, period. As I tell people, I could, I could throw stem cells until the cows come home. If we’re not moving appropriately, it’s just gonna continue to get aggravated, right? So that’s– And that’s something that I think is really important, and we’re still just wading into that territory as far as, you know, the, the orthobiologic space is concerned because w- everybody’s so fascinated about the thing that we’re injecting and, you know, the quality of the injectate and all of those kind of things, which are all absolutely important, but if we don’t take a step back and look at the whole picture and recognize that, that treating the knee is only gonna be a component of the whole biopsychosocial model of pain, right? We, we have to look at that whole picture, and that’s, and that’s something that I really try to push onto, you know, patients and, and those that I educate.
Dr. Natasha Mehta: I love that, you know, looking at the forest, but for this podcast, I’d like to focus a little bit more on these trees.
Dr. Patel: On the trees. Yeah, absolutely.
Dr. Natasha Mehta: And I, I, you know, I, I r- and for people who listen t-to many of my podcasts, I, I, I… that is a huge message that I’m trying to spread, that it’s not about this one thing. It’s about the combination of things. So all right. What are the orthobiologic treatments that you offer in your practice that you feel like have the most evidence to support its use, and, and what are the differences?
Dr. Patel: Sure. So the, the most research by and far is on PRP, and PRP specifically for knee osteoarthritis by and large has the most research. For those in the audience that don’t know what PRP is, I’m gonna, I’m gonna explain it the way that I explain it to patients. Platelet-rich plasma. Platelets are what clot the blood when you cut yourself, right? Those platelets then release growth factors that cause inflammation and then take inflammation away. Inflammation is the first part of healing. Part of that inflammation is because those platelet growth factors also have a chemotactic effect. They’re calling over other cells to the area, so they call over your macrophages to get rid of the damaged tissue. They call over your local stem cells, which then come and then conduct the rest of the healing process. So we’re able to take your blood and make a high concentration of those blood platelets. That’s called platelet-rich plasma. But not all PRP is created equal, and this is something that’s important as far as the literature’s concerned. PRP does not equal PRP does not equal PRP. We now recognize there’s literature dating back for a decade that looks at different kits that can create PRP and shows that, that different kits have different concentration of platelets, different concentration of red blood cells, different concentration of white blood cells, different concentrations of growth factors, and, and that is why the research for PRP is so heterogeneous, and that’s why if you look at any meta-analysis for PRP versus whatever for any joint or any condition, you’ll see ultimately that there’s some research that shows benefit, and there’s some research that doesn’t. That being said, by and large, PRP for knee osteoarthritis shows benefit, and when compared to corticosteroids, for example, corticosteroids has a better benefit in the short term, generally speaking, not just for knees, but really across the board, but then in the middle to long term, PRP tends to have better benefit. The quality does matter, though. So there was a recent paper that looked at PRP versus corticosteroids for knee arthritis, and the outcomes ultimately were that at the six-month mark, PRP and corticosteroid had the same outcomes.
Dr. Natasha Mehta: Mm-hmm.
Dr. Patel: So what we dig into, uh, though, was that the kit that was used for that PRP actually had a really, really low concentration platelet. Generally speaking, we say that over four times concentrations of platelets tends to be what’s considered platelet-rich plasma, and more, more recently, we’re actually digging into actual platelet counts, so over five billion, over 10 billion. We’re looking at actually the number of platelets that define better benefit. But this, you know, particular kit was perhaps making one to two times baseline concentration of platelets over normal blood, so it was really a low quality, low concentration platelets that ended up having the same benefit as corticosteroid at the six-month mark. So the people in my world were like, “Ah, another bad study showing poor quality PRP.” But I was like, “This is a great study, ’cause it’s showing that even bad PRP has the same benefit as steroid,” which, which we know has a negative effect for cartilage, especially when repeated inside joints, right? So that being said, there’s nearly 40 randomized control trials for PRP versus corticosteroid, hyaluronic acid, saline, placebo for knee osteoarthritis, and by and large, the majority of studies do show benefit of PRP over these other substances. So that’s where the, the most robust research is. There’s also level one evidence for lateral epicondylosis, gluteal tendinopathy, scant leaf for plantar fascia. Then there’s level two evidence for things like intradiscal, um, and facet joints and-
Dr. Natasha Mehta: Mm-hmm
Dr. Patel: … other tendinopathies, things along those lines, and then it goes to level three and beyond from there. So that’s… As far as the research is concerned, you know, PRP for knee osteoarthritis, pretty solid.
Dr. Natasha Mehta: Mm-hmm. And prolotherapy, you– do you do that in your office as well?
Dr. Patel: Yeah. So I, I do do prolotherapy. The literature for that is actually older, and there’s a, there’s a decent spread of literature actually for, for prolotherapy, and there’s some interesting research. Again, knee osteoarthritis is where we see the mo- but prolotherapy for mild to moderate knee osteoarthritis, and interestingly, some papers that even look at more severe osteoarthritis for the knee have shown prolotherapy to be of benefit. That being said, I, I, I find prolotherapy to be of benefit more so for milder ligament conditions. Again, kind of going back to the concept that it’s, it’s addressing a vascular structure, tricking the body into thinking it’s healing itself, and then the body does its own thing. It, it requires vasculature in order to do so appropriately. Prolotherapy more for mild to moderate conditions across the board. PRP still is kind of my mainstay, and I use different types of PRPs for the different structures that we’re treating based off of what we’re gradually seeing more of in the literature. I do use bone marrow aspirate and, and adipose tissue, but the literature is, you know, most for PRP, then for bone marrow, then for adipose tissue, um, although things are growing on both of those ends.
Dr. Natasha Mehta: Has PRP ever been compared to MSCs?
Dr. Patel: Yes, but only a little bit so. There was a recent paper that looked at bone marrow versus adipose tissue and found similar– sorry, PRP versus adipose tissue, and actually found similar benefit interestingly. But I, I think the– where the research is going to get a little bit nuanced here is that I think the real benefit from PRP or from any orthobiologic is going to be beyond just treating the pain generator. And we see now there’s a few– there’s a couple papers, for example, on treating the whole functional spinal unit for cervical spine and for lumbar spine.
Dr. Natasha Mehta: Oh, okay.
Dr. Patel: So the, the, the direction we’re going on into with orthobiologics is if somebody has a radiculopathy, for example, and has a nerve that’s being irritated by, let’s say, an L5-S1 disc protrusion, it’s– in my opinion, it’s n- I don’t know how frequent it is that we’re seeing someone that just has a small disc protrusion that’s causing the nerve irritation. More often than not, we’re seeing patients that have a disc protrusion, that have some osteoarthritis, that have some spondylolisthesis, that have multifidi atrophy, that have a variety of different things that are going on that are ultimately functionally contributing to the radiculopathy. So the direction we’re going now is with, with using orthobiologics to multiple different structures in order to strengthen tissues, in order to address the nerve that’s irritated, but also to address the facet arthropathy, address the ligament laxity, et cetera, right? And there’s one paper that actually demonstrated this in knee osteoarthritis, looking at injecting just intra-articular with PRP versus injecting intra-articular and the extra-articular ligaments, pes anserine tendons, et cetera, and those patients had better benefit than just injecting inside the joint. So that also makes it freaking challenging- … when it comes to, like, a randomized control trial, right? Because in an RCT, you want to be able to pinpoint the one variable that you’re trying to change and see what’s better, A or B. And while we’re seeing that in specific circumstances, I think for the vast majority of our patient population, we have to take that research and then apply that as a whole system to the patient.
Dr. Natasha Mehta: Well, and you mentioned the biopsychosocial factors too, and I think we can bring that back in here. Like, in research, in this type of research, I mean, how do you control for things like activity modification or therapy, doing your therapeutic exercises outside of therapy, diet, all those things that we already know from other research and pain that contributes to pain and function?
Dr. Patel: I mean, that’s, that’s why in orthopedics and pain, in regenerative medicine, there’s not a ton of great level one evidence, period, right? And, and what do we consider a, a good quality outcome in that level one evidence? Typically, it’s greater than fifty percent improvement in symptoms, right? What about the rest? Y-you know, so that’s, that’s where we have to get really into the nitty-gritty here. It’s important, don’t get me wrong, it’s important for us to look at the research and understand what is better for what circumstances. But when really applying this to our patient population, I think a fifty percent outcome or fifty percent benefit is not a great outcome, right? And if, and if somebody is, is looking to get back to doing what they wanna do in their life, we really have to look at the whole picture.
Dr. Natasha Mehta: Mm-hmm. I think in our world, I’m I’m lumping myself in with you now. In our world-
Dr. Patel: Yeah
Dr. Natasha Mehta: … I feel that we have to critically appraise our literature differently than perhaps other specialties that have more funding for their research. Like for example, cardiology, who have extensive, extensive guidelines based on randomized controlled trials. I mean, I was talking to Dr. He- Dr. Heidi Prather about joint pain, and, you know, she mentions that an NIH grant that was denied because the reason for figuring out this clinical question that she had wasn’t necessarily li- life-threatening. It was life-changing though for a lot of people, quality of life changing. Do you have any comments about that or, or personal experience with that?
Dr. Patel: Yeah. You know, I, I, I think it comes down to is, is what is our focus? You know, in medicine in general, the majority of medicine where a lot of funds are, are given are, are things that are life-threatening or things that are significantly debilitating. And, and things like pain ends up being such a nuanced and intricate and also simultaneously vague set of symptoms that, that can certainly be debilitating, but since we can’t visualize it, ends up being a real challenge when it comes to being able to throw funds at it, right?
Dr. Natasha Mehta: Mm-hmm.
Dr. Patel: So now that said, on the other end of the spectrum, I, I, I think that we shouldn’t be focusing on the pain, and this is, and this is the physiatrist in me talking here, that we really should be s- shifting the vernacular to be focused more on function. Because the reality is that pain is pain, and, and if, if we have pain or if we don’t have pain, if we’re not able to do the things that we want to do, that really ends up being, you know, life. Because pain as we get older is kind of a reality, right? But it’s what we do with it and how we, we deal with it. And, and pain is really a biopsychosocial thing, right? You know-
Dr. Natasha Mehta: Mm
Dr. Patel: … how, how many of us have increased neck pain when we’ve been stressed because we have X, Y, and Z going on, right? And vice versa. So by the way, if you haven’t figured this out already, I go on tangents, and I- … I end up talking quite a bit in circles, and I forgot where the question was, so there you go. That’s it.
Dr. Natasha Mehta: I, I think that was… I think that, that definitely answers the question. I think the, I think the field, and let’s talk, uh, uh, the field of regenerative medicine might get some heat because it does not… it’s not clear. And I, I think that we just have to look at it with a different lens, and we– it’s just gonna be hard to do these controlled studies because there’s so many factors when it comes to pain alone that are outside of our control, if that makes sense.
Dr. Patel: Yeah. No, I, I, I agree, and I think that, I think we need to continue to do studies, but there’s two different ways in which studies can be done. And I think that we overemphasize the, the RCT, the randomized control trial, which I still think is an important factor of regenerative medicine research, but I think we underestimate or undervalue or whatever the, the case series. So case serieses is case- … series-
Dr. Natasha Mehta: Many cases-
Dr. Patel: Many cases are, are, are more applicable to real life, and because once, once you see patients that have similar patterns of things and are able to apply a single or set of treatments to that patient and get outcomes, that’s valuable information. Even though those patients may have little variables that are different in one way, shape, or form, the fact that we’re able to get a set of patients that have similar enough conditions in going in the right direction is, is really, really valuable, and that’s kind of like bottom-up research versus the top-down research of a randomized controlled trial.
Dr. Natasha Mehta: Yeah.
Dr. Patel: You need both. You need both. And, and simultaneously, we need to know, all right, like what concentration of platelets is better for knee osteoarthritis, and is a, concentration A better than concentration B in RCT, right? Still very valuable information, but applying that to, to symptom sets ends up being like the focus that I think that, that regenerative medicine and really, you know, all of orthopedic medicine should be going in general. But to kind of piggyback on that and talk about where regenerative medicine finds its place, I think one of the problems with regenerative medicine is people are thinking of regenerative medicine as an alternative to corticosteroid injection or as an alternative to a pain management procedure like radiofrequency ablation or whatever, when in actuality, pain management is not an intermediary between conservative therapies like physical therapy and surgery. Like we kind of have put that in that intermediate space, right? You do physical therapy. If it doesn’t work, then you’re gonna get pain management procedures, and if that doesn’t work, you get surgery. But in actuality, pain management procedures are literally just managing pain to allow you to actually do the physical therapy to avoid the surgery, right? Regenerative medicine is truly an intermediary, so we’re kind of developing or pushing forward the nomenclature of interventional orthopedics, where we can actually help not only the pain, but also help the biology, the inflammation, the structure in some situations, and actually try to avoid surgery more long-term than just a palliative pain management procedure.
Dr. Natasha Mehta: Do you always pair your interventional orthopedic procedures with therapy?
Dr. Patel: 100%.
Dr. Natasha Mehta: Mm-hmm.
Dr. Patel: And I’ll take it a step further that I don’t… I, I tell patients this all the time. I think that what I’m doing really is just a catalyst- For what they’re doing. It, it, it is not to reduce the pain to allow you to do something, it is to help you do something more functionally. So I, I set patients up through prehab leading up to the procedure and then the rehab afterwards. I think that that is a crucial part of this. And leading up to the procedure, we talk about nutrition, we talk about weight management, we talk about all the things to get the soil as fertile as possible for when I plant seeds.
Dr. Natasha Mehta: So I, I wanted to bring up the topic of insurance. Why are these not covered by insurance?
Dr. Patel: Great question. That just goes back to the heterogeneity of what these substances are, right? So a, a brief story, and I don’t know all the details of this, but from what I am understanding, PRP for knee osteoarthritis started getting covered by Kaiser here in California last year or the year before. From what I’m told, it is no longer covered.
Dr. Natasha Mehta: Hmm.
Dr. Patel: Why? Why? So PRP started getting covered by a large hospital system, said large hospital system gets the most economic way of creating that PRP, a kit that is known to not have great concentration of platelets that it’s spitting out. Said hospital system o- only allows for X amount of reimbursement, so we’re not doing multiple injections to the whole functional unit, you’re just treating it as if it’s a corticosteroid injection with or without even image guidance.
Dr. Natasha Mehta: Mm-hmm.
Dr. Patel: Said hospital system has PRP with crappy results.
Dr. Natasha Mehta: Yeah.
Dr. Patel: So-
Dr. Natasha Mehta: Yeah
Dr. Patel: … now the rumor is that they’re gonna be studying it now with their crappy PRP kits, and guess what they’re gonna find out? Yeah, we shouldn’t be covering these with insurance. Therein lies the problem. Beautiful, eloquently done study was published in the American Journal of Sports Medicine, 2019, looking at PRP versus saline for interstitial rotator cuff tears.
Dr. Natasha Mehta: Mm-hmm.
Dr. Patel: The outcomes, no difference, right? But again, the concentration of that PRP was anywhere between .7 to 1.2 times concentration of baseline PRP. So it basically showed that platelet poor plasma is the same as saline for an interstitial rotator cuff tear.
Dr. Natasha Mehta: Yeah.
Dr. Patel: Beautifully done. Great randomized control trial, eloquent, strong N, published in a largely known journal, and then the conclusion supports no insurance reimbursement. So it’s the heterogeneity of it, and it’s a lot of us trying to police ourselves at this juncture that, that makes this an important distincting factor when it comes to insurance reimbursement.
Dr. Natasha Mehta: Yeah. I think that there is obviously something there. There’s obviously something here, uh, like, with what you’re doing in your practice and your outcomes and your cases, that it would be doing the general public a disservice really if we didn’t start moving in the direction of, of insurance coverage for these procedures.
Dr. Patel: I, I think it’s important. I really do. That being said, I almost feel like insurance reimbursement should somehow be tied, like, pre-approved specific distributors or dis- specific kits or, or, or, or something.
Dr. Natasha Mehta: Mm-hmm.
Dr. Patel: You know, the same way that there’s different reimbursement for different hyaluronic acid companies, right? So I, I, I think that there, there needs to be something along those lines in order to make it more, more reasonable.
Dr. Natasha Mehta: That’s interesting. So getting, like, getting that industry, control of industry, which can be hard, right? When, like, that business model intersects with healthcare.
Dr. Patel: And, and that’s, that’s… Well, that’s the reality of all of insurance-based healthcare, right?
Dr. Natasha Mehta: Yeah.
Dr. Patel: You know? And-
Dr. Natasha Mehta: Yeah
Dr. Patel: … that, that’s what makes it challenging too, because I, I… So I’m, I’m not against corticosteroid injections. I’m not against, you know, I’m, I’m not against any of these more conventional treatments, and I think that they have their time and place, but the way the model is set up is for failure, right? You see a patient for 15, 20 minutes, you see them for their knee, and you have time to do a corticosteroid injection. You may not even have– you don’t get further reimbursement for ultrasound guidance, right? You are going to just put, set them up as a cog in the wheel, and we don’t have time to go through the education, the rehab, the, the nutrition, all of that stuff. So then they come back in three, four months for their next injection, and then their next injection, and that just constantly makes the cartilage loss worse, and then you’re set up for your knee replacement. The issue was their butt wasn’t strong. You know? Like, it’s-
Dr. Natasha Mehta: Yeah
Dr. Patel: … it– But, but that’s the way that the system is.
Dr. Natasha Mehta: Yeah. I mean, we could go on and on about the system, and so I think I’ll stop us there.
Dr. Patel: Yeah. Yeah, yeah, fair enough. Fair enough.
Dr. Natasha Mehta: Really, I, I mean, yeah, I could go on and on. Okay, so my podcast theme question is, what do you do to take care of your brain and body?
Dr. Patel: Not enough, admittedly. I have a five-year-old and a three-year-old, and so they suck up all of my post-work time. But honestly, they are what I use to take care of my brain and body. I, I make it a point to come home and spend time with them and be present with them, and I think that’s kind of my sense of meditation, is actually being there with them 100%, and I absolutely freaking love it. And, and not to mention that they love to be carried and thrown around, so that’s, that, that’s where my exercise comes into play.
Dr. Natasha Mehta: Yeah. Yeah.
Dr. Patel: But yeah, no, I, I need to take care of myself more, admittedly, but I’m opening up an office in a month. I’m hoping that once that craziness settles down, I’m gonna be able to focus a little bit more on the things that I’ve historically liked, which are things like meditation and working out and, you know, spending time to, you know, play outside. But that’s, that’s, that’s the game, that’s the game plan.
Dr. Natasha Mehta: Yeah. Yeah. Well, social connection is definitely so, so important, and the thing-
Dr. Patel: Yeah
Dr. Natasha Mehta: … I think more people are talking about now, especially on the heels of the pandemic. Well, I don’t know. I, I feel like we’re on the heels, but maybe not.
Dr. Patel: The never-ending heels.
Dr. Natasha Mehta: The never-ending heels of this pandemic. So thank you so, so much for your time.
Dr. Patel: Absolutely.
Dr. Natasha Mehta: I will share how people can find you, your website, and all those different things. Are you on social media?
Dr. Patel: I am on social media at Regen Dr. Patel, R-E-G-E-N D-R P-A-T-E-L, on all platforms. And yeah, no, thank, thank you so much. This has been an absolute pleasure. I really enjoyed this, and I’m looking forward to all the great things that you’re putting out.
Dr. Natasha Mehta: Oh, wow. Well, I appreciate it. Thank you.
Dr. Patel: Of course. Thank you.
Dr. Natasha Mehta: Thank you for tuning in to this podcast about all things brain and body. Please rate, subscribe, and review on whatever platform you prefer to tune into your podcasts. Also, feel free to share this podcast on any platform. This podcast is for general information and educational purposes only. The information provided in this podcast is meant to better help you understand your health, but does not serve as a replacement for medical services or care. No doctor-patient relationship is formed. The content of this podcast does not constitute the practice of medicine, including the giving of medical advice. Curious about more brain and body things? Find me on Instagram, TikTok, or Twitter at Dr. Natasha Mehta and let me know what you’d like to hear about.
Robert Watkins, MD, orthopedic surgeon to professional athletes and creator of the Back Doctor App, debates Dr Shounuck Patel on the research, cost, utility and risks of stem therapy for back and neck pain.
Dr. Watkins: This is Dr. Robert Watkins, orthopedic spine surgeon to professional athletes and creator of the Back Doctor app. So, uh, we’re trying to double stream at the same time. Um, Shounuck Patel and Rob Watkins. It’s our first F- Facebook Live. We’re new to this. We’ve set it up. We’re ready to roll. We’re podcasting at the same time, so look at us. We’re hot and fresh. And so we appreciate you joining us on a Wednesday night, 7:30. What we’re gonna talk about is the stem cell madness that’s taken over the world. You know, we’ve got a lot of patients, friends, and family, even ourselves, that are interested in stem cells and wanna know, are they gonna work? What’s the utility? What are the risks? What’s the safety? And if you go on the internet, uh, even on TV, anywhere, there’s marketing for stem cells all over the place, and where’s the validity and where’s the truth in it? And so I appreciate you coming today.
Dr. Patel: Absolutely.
Dr. Watkins: The, uh, you know, this is the first time we’ve actually met in person, and we’re gonna go at it tonight. We’re gonna, we’re gonna get, uh, heated, and we both have the same goal. We just wanna help people and find out where the truth is. And the story about us getting together is great. The, um… In fact, it was Bode Daniels, the chiropractor for the Rams, I take care of the Rams, and we were talking on the sideline about stem cells, and he recommended you. He said you had a lot of experience. He had seen good results with patients that you had done-
Dr. Patel: Sure
Dr. Watkins: … different injections on, procedures on. And, uh, so I invited you to our conference, which we’re due on June 1st, for physical therapists, athletic trainers down in the Marina in Playa del Rey. We have, like, 300 people show up, and it’s a great conference, so I appreciate you, you know, coming to speak.
Dr. Patel: Absolutely.
Dr. Watkins: And then I put out a podcast last week on, you know, hunting for stem cells and stem cell madness and where is the truth, and I love it. You actually listened to it- … and you wrote me an email and told me where I was wrong, all these things, you know, and what… And so I said, “Well, let’s do a podcast together,” and you said, “Sure.” And then I called him yesterday and I said, “Hey, let’s Facebook Live it.” You know, you ever done that? He goes, “No, but let’s do it.” So I love your enthusiasm, you know?
Dr. Patel: Absolutely. Absolutely.
Dr. Watkins: There’s all these cool mediums. I have an app and podcast channel, and it’s just so cool that we can… you can hit a play, create this content, and we can share information. You know, one of the things that I realize more and more is, you know, we’ve got 10 years of training, 15 years in practice. You know, the cumulative amount of knowledge we know about these subjects is so valuable to people, our friends and family and patients. You know, they don’t know anything-
Dr. Patel: Yeah
Dr. Watkins: … about the whole basis for it and how are they making decisions on their life that affect them forever. And, and us being able to just hit play and talk and put some information out there is so cool.
Dr. Patel: Yeah.
Dr. Watkins: And it’s so, so fascinating.
Dr. Patel: Now, what I love about this is that we can be real, you know?
Dr. Watkins: Yeah, right.
Dr. Patel: We can, we can just talk.
Dr. Watkins: Right.
Dr. Patel: And we can talk about what we do and what works, what doesn’t work, and how people can learn about it.
Dr. Watkins: Yeah.
Dr. Patel: So that’s fantastic.
Dr. Watkins: And, and join the journey with us.
Dr. Patel: Yeah.
Dr. Watkins: You know, we sometimes, we give lectures, write chapters, textbooks, where you have to kinda have the definitive answer and… Well, we don’t have the answer yet. We’re working it out, so-
Dr. Patel: That’s right
Dr. Watkins: … wel- welcome to our brains and our worlds, and as we’re sorting this out, and, uh, we’ll see what makes the most sense, and we- we’ll find out what we think is really safe to do. So why don’t you go ahead and introduce yourself.
Dr. Patel: Sure.
Dr. Watkins: Tell everybody who you are.
Dr. Patel: So my name is Shounuck Patel. Um, I am an interventional physiatrist, uh, right here in Beverly Hills. Uh, my background is in what’s called physical medicine rehabilitation, which is non-operative orthopedic medicine, for all intents and purposes. I did a fellowship in sports medicine and interventional pain management, um, and I have been working in the regenerative medicine space for over four years now, uh, as a part of the Regenexx network, uh, which is really an international network, uh, that has been doing research and development in, uh, stem cells and other orthobiologics for over a decade at this juncture. Um, you know, Regenexx has published nearly 50% of the world’s data on, uh, bone marrow-aspirated stem cells for orthopedic conditions. Um, and we’ve basically been continuing to collect our data and, and base our procedures off of that because, as you know, data is king.
Dr. Watkins: Yeah. Yeah. And it’s hard to come by.
Dr. Patel: It’s hard.
Dr. Watkins: And it’s, and it’s hard. You know, I, I hold new products to a high standard. Uh, where’s the data? Where’s the randomized controlled studies, you know?
Dr. Patel: Yeah.
Dr. Watkins: The reality is they’re hard to get. It’s hard to get 1,000 patients, treat 500, do a sham procedure on the other 500 to prove a difference-
Dr. Patel: Yeah
Dr. Watkins: … when placebo effect has a 30% success rate-
Dr. Patel: Yeah
Dr. Watkins: … just from telling somebody you did something to them.
Dr. Patel: Absolutely.
Dr. Watkins: So it’s hard to get the data. And that was-
Dr. Patel: And that’s the hard thing is, you know, with, with randomized control trials, right? That data is hard to come by when it comes to anything musculoskeletal, right?
Dr. Watkins: Yeah.
Dr. Patel: Anything surgical, anything physical therapy, anything, you know, or definitely anything orthobiologic, it’s just hard to come by. So, you know, that’s what it comes down to, what we’re talking about is, is it’s the practice of medicine, right?
Dr. Watkins: Yeah.
Dr. Patel: We’re, we’re constantly learning and, and moving forward.
Dr. Watkins: Yeah. The, uh… So an introduction for me. I’m, uh, Robert Watkins. I’m the fourth. I work with my dad. We’ve worked together for 16 years here in Marina del Rey. We take care of a lot of athletes. We take care of most of the local teams, the Rams, and Dodgers, and Clippers and, and, uh, USC, the athletic department, and the Kings. And so we take care of a lot of athletes, but 95% of our patients are just normal people age 18 to 90 who are in pain. So back and neck pain, we do spine surgery, but I also do injections. I actually trained for Eng- trained in England for a year, where I had to do all the epidurals and facet injections-
Dr. Patel: Nice
Dr. Watkins: … at the end of the day.
Dr. Patel: Yeah.
Dr. Watkins: You know, it was part of my job. And so when I came back to America, I kept doing the injections. So I still do epidurals, and, uh, lumbar and thoracic. I don’t do the cervical ones. But, um- And I’ll tell you m- my basic approach, especially taking care of the athletes, but everybody right now, I still inject cortisone or pr- d- uh, Depomedrol, you know, prednisone. An, an anti-inflammatory steroid works. It’s been around for 50 years. It’s a g- it’s the best anti-inflammatory in the world. You know, anybody who’s ever has pain and takes some prednisone knows it treats the pain better than anything. And the injections we know are reliable, and they work. And so that’s what I do on all the athletes I treat because we gotta get them back as fast as possible with the most proven track record, safest thing, so we’re gonna inject that. Plus, most of the athletes are men and women who are 18 to 25 years old, and their body can handle some steroid.
Dr. Patel: Yeah.
Dr. Watkins: And it’s not that big of a deal to… It’s really low risk, but, you know, but there’s always risk. But, but anyway, it has the most reliable chance of getting them back to be able to train, do their rehab, do their core stabilization exercises, and, uh, and it’s most reliable, so that’s what I use. But at the same time, uh, I’ve got a lot of athletes that are interested in stem cells. You know, they got people talking at them from every angle, stem cells, PRP-
Dr. Patel: Yeah
Dr. Watkins: … Regenekine, Orthokine, you know, all these different products. And there’s some real validity to if these natural biologic products that come from your own blood, for one thing, that’s some of them, um, are safe and effective, well, and if they come from you, well, they can be better for you than the steroids ’cause we know steroids have a bad effect on the body long-term.
Dr. Patel: Yeah.
Dr. Watkins: If you inject them in joints, they can be bad. They can erode cartilage. I do epidurals mainly, which aren’t in a joint. They’re just in a space around the nerves, so they’ve never really been shown to be destructive.
Dr. Patel: Right.
Dr. Watkins: You know, you can have four to six epidurals in a year for, like, three years, and they’re really shown to have that, that real negative effect.
Dr. Patel: That said-
Dr. Watkins: Go ahead
Dr. Patel: … that said… Sorry. I’m coming from the viewpoint that I, I’ve done epidural steroid injections. Um, I, I treat more than just the spine. I treat, uh, peripheral joints as well. I used to do cortisone injections into joints. Um, and I think that there’s a, there’s a time and place for it, right? With, with everything in medicine.
Dr. Watkins: Yeah.
Dr. Patel: Um, I think there’s a time and place for an epidural steroid injection. If someone has a, a, a young radiculopathy or sciatica-type sys- uh, symptoms, um, because of a disc herniation or a disc bulge at single level with no other things going on, yeah, you’re right. You know, an epidural steroid injection might be enough in combination with the appropriate physical therapy training, et cetera. But once you start getting older, the truth is the risk of cortisone is there. Um, you know, a single cortisone injection can increase the risk of osteoporotic fractures in females, right? Um, you know, when, when you talk about things like diabetes, I, I’ve personally witnessed patients that went into the 400s with their blood sugars after a single epidural injection.
Dr. Watkins: Yeah. Mm-hmm.
Dr. Patel: All right? So these are real things. We’ve, we’ve seen post-menopausal females get their period back, and, and pre-menopausal females lose their periods, right?
Dr. Watkins: Yeah.
Dr. Patel: So, so these, these cortisone, especially at the high doses that a lot of folks use these epidural steroid injections with-
Dr. Watkins: Yeah
Dr. Patel: … that, there’s risks associated with it. Now-
Dr. Watkins: Yeah
Dr. Patel: … what’s interesting is there’s, there’s some studies that show that lower doses of cortisone do the same thing as the higher doses-
Dr. Watkins: Right
Dr. Patel: … for epidurals.
Dr. Watkins: Right.
Dr. Patel: But for some reason, you know, everybody’s using those high, high doses, so.
Dr. Watkins: Right.
Dr. Patel: But like you said, you know, if, if there is an opportunity to have something that is more natural provide the s- shoot, if it’s the same exact benefit as the cortisone injection, but it is natural, then, then it has less of the side effects, then that’s kind of a win.
Dr. Watkins: Yeah.
Dr. Patel: Now, what’s interesting is looking at our data, um, with, with Regenexx, um, and this is at least, uh, this is just, um, uh, data looking at patients retrospectively. So looking at patients that had previously had epidural steroid injections, uh, versus patients that had what we call epidural platelet lysate, uh, which is growth factors from the blood similar to PRP.
Dr. Watkins: Mm-hmm.
Dr. Patel: Um, essentially, the patients that had the epidural platelet lysate had significant improvement in their symptoms for a longer period of time than those with epidural steroid injections. So we know the steroid injections only last for a few months, right?
Dr. Watkins: Right.
Dr. Patel: So if we can have this last a little bit longer, then that’s a win.
Dr. Watkins: Yeah. So are there any patients that, like you mentioned, if somebody has a, an acute disc herniation, a fresh disc herniation hitting their nerve, causing sciatica, the pain’s agonizing or going down their arm, and where you said prednisone is pretty effective, is there any of those hot, fresh cases that you would do the, uh, PRP type of injection-
Dr. Patel: Not necessarily
Dr. Watkins: … instead?
Dr. Patel: Not necessarily.
Dr. Watkins: Yeah.
Dr. Patel: And quite frankly, that’s just not my patient population.
Dr. Watkins: Yeah.
Dr. Patel: Um, the, the couple times that I’ve seen patients that had hot radiculopathy, I’ve actually injected epidural steroids.
Dr. Watkins: Yeah.
Dr. Patel: Um, I have given oral, uh, prednisone, oral steroids, um, because if it’s hot, if it’s something new, you know, that might not necessarily be a situation where a, an orthobiologic would be of benefit. But when things have been going on for a while, right? If you have a disc herniation or a disc bulge that’s causing pressure on a nerve that’s been going on for a long time, God knows you’re gonna have changes to your facet joints in the back. You’re gonna have changes to the ligaments. You’re gonna have, you know, your small little muscles, your multifidi are gonna atrophy. So there’s, there’s the whole system that gets involved as time progresses, and this kinda goes back to the surgical literature of, of, of Punjabi and White and, and treating the f- the functional spinal unit, right?
Dr. Watkins: Right.
Dr. Patel: We wanna treat that whole picture rather than just, just treating that radiculopathy.
Dr. Watkins: Right. So how do you decide between the PRP type of injection versus stem cell injection?
Dr. Patel: That’s a great question, and that’s a question that we get all the time ’cause a lot of, lot of patients come to me looking for stem cells, right?
Dr. Watkins: Yeah.
Dr. Patel: Um, it really comes down to is w- what are we treating? Um, so most of the time for spine conditions, I’m actually using PRP and, and platelet lysate.
Dr. Watkins: Mm-hmm.
Dr. Patel: Um, why is that? Most of the time people are coming with, you know, sciatica, pain running down their leg, or pain coming from their disc, or pain coming from their facet joints. Um, although people argue what c- causes pain most frequently, right?
Dr. Watkins: Yeah.
Dr. Patel: That could be another discussion entirely.
Dr. Watkins: Right.
Dr. Patel: Um, but ultimately, using your own PRP, your own platelet lysate, can be enough to improve pain, improve the strength of some of the soft tissue structures, and calm down the inflammation or irritation of the nerves.
Dr. Watkins: Right.
Dr. Patel: What’s interesting is, um-
Dr. Watkins: You know, there’s a paper, what, five years ago, looking at epidural steroid injections- Mm-hmm … for spinal stenosis or, or narrowing of where the nerves are traveling, right? They could be multifactorial. It could be caused by disc herniations, uh, facet arthritis, uh, kinking of the ligaments. Yeah. Um, and the, the study showed that epidural steroids had the same effect essentially as epidural lidocaine, just numbing solution in the epidural space for people that have stenosis. Right. So what if we can have something that’s injectable that can strengthen the ligament and take pressure off of the nerves? What if we can strengthen some of the muscles back there? What if we can put something into the epidural space that actually may reduce the disc herniation a little bit? That’s a stretch. There’s a- You know that’s a stretch. No. I, I, I normally would agree with you. Now, again, this is on a, on a case-by-case basis, but I’ve had patients that have had reductions of disc herniations, um- Well, y- of course, everybody has. Of course. The faith healer has. Of course. Your priest has. Of course. Of course. And the reason why is because 15% of disc herniations resorb completely on their own with no treatment whatsoever. Absolutely. Absolutely. And, and that’s one of the downsides of any treatment out there, K- But what happens- You know, any treatment can say they claim credit because- But what… And 50% of the… So 15%, they resorb completely. Your body recognizes it’s not being used- Yeah … dissolves it with enzymes, gone. 50% of the time it gets a little bit smaller because the spinal fluid, every time your heart beats, it pulsates up against the disc herniation- Yeah … and backs it off kind of like water against a rock. So any treatment can say, “Oh yeah, look, we did it. We claimed it.” Correct. Yeah. And that’s why I don’t treat those acute cases as much. Uh-huh. Right? Because what happens if you have a 49-year-old female who is an athletic, um, personal trainer and, and group fitness instructor who has been dealing with radicular pain and weakness going on because of a large disc herniation at L5-S1 for years, despite physical therapy, despite epidural steroid injections, despite doing appropriate core strengthening exercises, and on repeat MRI that disc herniation- Yeah … is still there, right? Yeah. Right, right. So that’s- But th- but then you do this PRP type of treatment. What’s it called again? Uh, PRP and platelet lysate. Lysate? Yeah. So you do the lysate treatment and, and a stable disc bulge for four to five years gets smaller? Correct. That’s pretty… Okay, that’s impressive. And that’s correct. I mean, and- Let me, let me also- Let me see it. Let me see the picture. It’s on my Instagram at stemcelldrpatel. Nice. I have the before and after of the… Now- Yeah … it’s not completely gone. Right. Right? But- And I, I gotta check the quality of the MRI. Sometimes the MRI- Absolutely … is done a little different places- Yeah … or it looks a little different. Yeah, and I’m, I’m a stickler on before and after imaging. Um- Yeah … and I, I think that’s really important, right? Because- Yeah … oftentimes we see these publications of case reports that have an image that’s completely different than from before and after. Yeah, right. And I’m like, you know what? That’s not showing anything, right? Right. Unless it’s a different person. Right. Exactly. Yeah. Exactly. Um, but no, we’ve had some cases like that. Yeah. All right. Now, this isn’t a panacea, right? Yeah. Right. This isn’t something that’s gonna heal everybody, like, you know, the, the hand of God, right? Um, but this is something that’s an alternative for someone that doesn’t want surgery. Let me ask you another question. I, I don’t wanna get too technical, but- Yeah … I know I got some spine patients out there who kinda know what, you know, and doctors and everybody else, it mentioned… And I looked at that site, the, you know, about the, the, uh, PRP lysate. Mm-hmm. S- and it talked about strengthening the ligament, which, you know, the interspinous ligament, strengthening that or the, or the ligamentum flavum, which is buckled in, strengthening that, I don’t think that’s gonna change stenosis anyway. Stenosis develops because the disc degenerates. It loses height. It bulges out. Everything loses height, and the ligament buckles in. So str- it can be strong as a rock, but it’s still in that position. So in order to really change the stenosis, you gotta jack it open, which requires a fusion, or you have to do a microscopic laminotomy where we go in and just take out the ligament, which gets rid of it. But actually strengthening it, I don’t believe that’s going to increase height back in the disc and, and, and unbuckle the ligamentum flavum. So you’re, you’re right with a little asterisk at the end of that statement. Yeah. Um, it won’t strengthen the disc. Um, there’s nothing that we know, and this, and kind of side… go back to the stem cell ta- uh, talk from before, there’s people that are s- injecting stem cells into discs, and I do that for specific situations. Yeah. But we’re not regenerating the disc. We’re not growing the height of the disc. Yeah. That just doesn’t happen. Yeah. So you’re absolutely correct with that. Right. What else is causing that kinking of the ligamentum flavum, right? What’s attached to that ligamentum flavum- Yeah … more superficially? You have your interspinous ligament, your supraspinous ligament, you have your thoracolumbar fascia that’s all tying into that. What if, what if- Yeah. … what if we can strengthen those things? Now- Yeah, yeah … I honestly, I, I was doing it- Yeah, yeah … um, because I was seeing the results, but I don’t often do a, a before and after MRI for my stenotic patients- Yeah … because I just assumed that it wasn’t getting better, right? Right. Even though the patients were symptomatically improving, I wasn’t getting those after MRIs. Yeah. So I had this patient, um, three and a half years ago, um, this patient, uh, that came to me, he had previously had an orthobiologic treatment for, uh, uh, stenosis and radicular symptoms. Those radicular symptoms improved, but when he came and saw me, he had back pain, and he had weakness in his legs. Yeah. Okay? And I identified that his weakness was because he had severe stenosis at the L4-5 area- Mm-hmm … because of disc herniation, because of ligamentum flavum hypertrophy, because of arthritis and, and the joints getting larger, right? Yeah. Um, he was very, very obese, and he was like, “You know what? I just wanna start moving again.” I said, “Okay, look, we, we can try this.” Yeah. So I treated the functional spinal unit, the epidural space. I treated the facet joints. I treated the ligamentum flavum, the interspinous ligament, the supraspinous ligaments, all the things that are coming and attaching to that, that ligamentum flavum. Yeah. And he had- You injected all of them. I injected all of them. Yeah. All right. Okay? So with, with PRP, with platelet lysate, a combination of those various things. Yeah.
Dr. Patel: He had improvement-
Dr. Watkins: Yeah
Dr. Patel: … of his stenotic symptoms. His cramping in his legs improved, his weakness improved.
Dr. Watkins: Yeah.
Dr. Patel: He was able to get back to working out, he was exercising, he lost weight, he was happy.
Dr. Watkins: Right.
Dr. Patel: Okay. Then last year, I get a call from him saying, “Hey, Doc. My leg symptoms are still gone-
Dr. Watkins: Yeah
Dr. Patel: … but I’m having a lot more back pain. Oh, by the way, I stopped working out.”
Dr. Watkins: Yeah.
Dr. Patel: “Over the few, last few months, I’ve gained back 30, so 40 pounds,” or whatever it is.
Dr. Watkins: Right.
Dr. Patel: “I have this back pain.” I said, “All right, let’s get a new MRI.” So we got a new MRI, and at the L4-5 level, he had auto-fused.
Dr. Watkins: Right.
Dr. Patel: Right? His facet arthritis was rip-roaring pain.
Dr. Watkins: The one you injected.
Dr. Patel: Yeah. So, no, I didn’t inject the disc. No, I didn’t inject the disc. Um, but, uh, so-
Dr. Watkins: So was the purpose to auto-fuse the segment?
Dr. Patel: No, no, no, no. I, I didn’t-
Dr. Watkins: Is this a new fusion technique?
Dr. Patel: No, no, no. The, the point is-
Dr. Watkins: Yeah
Dr. Patel: … his facet joints were gnarly and arthritic.
Dr. Watkins: Yeah.
Dr. Patel: Right?
Dr. Watkins: Yeah.
Dr. Patel: He had gained a significant amount of weight, put pressure into that area.
Dr. Watkins: Yeah.
Dr. Patel: His ligamentum flavum hypertrophy had actually reduced.
Dr. Watkins: Yeah. All right. All right.
Dr. Patel: His stenosis was actually a little bit improved. Was it great? No, it was still an ugly picture.
Dr. Watkins: Right.
Dr. Patel: But he no longer had those symptoms.
Dr. Watkins: Well, an interesting part about the auto-fusion is if you stop the motion, it, when you do a fusion, you put in screws and rods, you stop the motion across the disc and the joints, and that has been historically a classic way to treat the stenosis-
Dr. Patel: Right
Dr. Watkins: … because you stop the motion, it stops the symptoms. Whether the ligamentum flavum that had hypertrophied in was buckled in, and some of the, ’cause bone spurs can resorb. You know, you get a big bone spur on your knuckle, it gets big, and, and that’s the bone spurs, how your knuckle gets bigger as you get older. If you stop the motion and fuse it, the bone spurs will resorb. So the bone spurs might have resorbed in the facet joints, which allowed the stenosis to resorb. But-
Dr. Patel: May- well, I mean, the facet joints were, looked worse-
Dr. Watkins: Yeah. No
Dr. Patel: … to be fair. To be fair.
Dr. Watkins: Right, right?
Dr. Patel: There are mo- but, but they stiffened up.
Dr. Watkins: Yeah.
Dr. Patel: So the, so the extra overgrowth resorbed. And, and I realize we may be getting a little detailed here. I hope that we’re not losing everybody with these technical terms, but-
Dr. Watkins: Little bit. All the people signing in have all dropped off.
Dr. Patel: Yeah, no.
Dr. Watkins: They’re like, “Ah, screw it,” you know? Tell us about, tell, tell us about how they work. Tell, tell us how they’re gonna save their, save our life. But these are interesting, you know, for us, these are the things that matter.
Dr. Patel: Yeah.
Dr. Watkins: When you talk about injecting a spine for back, you know, everybody has back pain. Over 50% of Americans have back pain, even more than that, in the, in, at some point in their lives. It’s the number-one cause for loss of work, loss of productivity, pain and suffering, divorce-
Dr. Patel: Yeah
Dr. Watkins: … can’t play with your kids, everything, loss of your job as an athlete-
Dr. Patel: Yep
Dr. Watkins: … is back pain, and then neck pain. You know, those are the first two. So the important part is, when we talk about back pain, you talk about doing an injection for back pain, well, what are you gonna inject? ‘Cause you have a disc. In fact, let me grab this thing.
Dr. Patel: He got scared and left.
Dr. Watkins: Yeah. Ow. But look what we got laying around.
Dr. Patel: Yeah.
Dr. Watkins: So you have a disc, which is 80% of all the weight-bearing. All the action occurs in the disc. So when people hurt their back, it’s m- usually the disc. That’s where all the biomechanical activity-
Dr. Patel: When they’re young
Dr. Watkins: … is occurring. When they’re young, but, you know.
Dr. Patel: Arguably, that’s a part of the mechanics over time.
Dr. Watkins: Yeah. All right.
Dr. Patel: No doubt.
Dr. Watkins: It, it can fade out. It can fade out.
Dr. Patel: Yeah.
Dr. Watkins: Number two is facet joints. That’s where the motion occurs in the back. Well, for every disc in the front, you got two facet joints, and they move. They can get, they can be a source of pain, you know, but usually, in my experience, people with disabling facet joint pain is, like, 5% of my practice. I just don’t see them that disabling. Yeah, it can be sore and hurt, but that’s, and that’s just my gestalt and, and tests I’ve done. Then the other thing is you got nerves coming out. At every level, you got a nerve coming out. You get a pinched nerve, that can cause back pain and then go down the leg. So one of the fundament- one of the most difficult things about treating the spine is, what are you gonna treat? What are you fusing? What are you replacing? What are you injecting? What are you focused on? And so the injections, uh, we’ll review this for everybody, you can inject the disc, you can stick a needle in the disc, inject the disc, and hope the disc regenerates. And you mentioned, as of now, nobody’s seen a disc height res- you know, increase of any significance.
Dr. Patel: I’m saying, yeah.
Dr. Watkins: And that’s a stretch, you know? To get it to come back to height, once it’s collapsed down, it’s probably gonna stay about like that.
Dr. Patel: Yep.
Dr. Watkins: And the hard part about that is o- you know, once it’s really mechanically collapsed, injecting is not gonna do much. Well, that means you gotta inject them when they’re big and plump and more normal biomechanically. Well, that’s very early in the degenerative process, so if you’re gonna stick a needle and inject a lot of discs that are big and plump, you’re gonna be sticking needles in a lot of relatively healthy discs, which may cause trauma to the disc by puncturing it. Whatever you inject in there better not cause an infection-
Dr. Patel: Right
Dr. Watkins: … and it better help. And then, and then another component of that is, well, how long is it gonna last? ‘Cause the disc is acidic. It has no blood supply. It has no oxygen supply. Most things you’re gonna inject in there are just gonna die, and so that’s part of the difficulty is you only, you only-
Dr. Patel: And, and that’s, that’s an important thing about the disc, right?
Dr. Watkins: Mm-hmm.
Dr. Patel: So we know, uh, through studies looking at, uh, what’s called provocative discography, right? Putting x-ray dye into the disc and, and seeing what that disc tear looks like, seeing if that causes somebody’s pain. Uh, we actually know that, that those kind of procedures cause discs to degenerate more.
Dr. Watkins: Right.
Dr. Patel: Right?
Dr. Watkins: By traumatizing the disc by injecting it.
Dr. Patel: That’s right.
Dr. Watkins: Yeah.
Dr. Patel: So, so the question is, should we be injecting discs as frequently as some folks are?
Dr. Watkins: Right.
Dr. Patel: And there are some people that are doing stem cell treatments across the country, across the world, um, that inject every single disc that walks through their door.
Dr. Watkins: Right.
Dr. Patel: Is that an appropriate thing to do? I, the, the question is, is what is the stem cells doing? What are the stem cells doing, right?
Dr. Watkins: Yeah.
Dr. Patel: Um, are they actually protecting the disc? Um, and, and the answer is we don’t know.
Dr. Watkins: Yeah.
Dr. Patel: Um, so I’ve seen patients that personally have gone over to other docs and had multiple discs injected, and they developed worse pain.
Dr. Watkins: Yeah.
Dr. Patel: Right?
Dr. Watkins: Right.
Dr. Patel: So we gotta be careful with that.
Dr. Watkins: Oh, right.
Dr. Patel: What would be an indication to inject a disc is if somebody has a young, healthy, plump disc that has a tear that’s causing pain.
Dr. Watkins: Yeah.
Dr. Patel: Okay? Now, that might be an indication to actually inject the disc, because ultimately, there is some studies, there are some studies that suggest that injecting PRP, there’s a couple randomized control trials, um, there are several, uh, case reports, um, a case series of injecting PRP into the disc, as well as injecting stem cells. There’s, uh, at least one, uh, randomized control trial and several case report studies, um, of injecting stem cells into the disc with benefit, um, even in comparison to, uh, placebo. So the truth is that for certain specific situations- Injecting the disc with a biologic could be a good thing.
Dr. Watkins: Right.
Dr. Patel: Now, should we be injecting everybody?
Dr. Watkins: Yeah, and that’s the hard part where I talk about the studies. To really get a study to prove it works, you gotta have 500 patients. Half get… Everybody gets a needle injected into the disc. Half get injected the biologic or the stem cell, the product. The other half get nothing injected-
Dr. Patel: Right
Dr. Watkins: … or maybe a little saline.
Dr. Patel: Right.
Dr. Watkins: So that means half, 250 people are gonna get a needle stuck in their disc and no treatment.
Dr. Patel: Right.
Dr. Watkins: And you may be traumatizing the disc. That’s why that study is never really gonna be done, and as a, as a scientist and a doctor, we want the data. Well, you’re never gonna really get that data. Plus, the cost of that study would be, like, 5 to $10 million.
Dr. Patel: And, and-
Dr. Watkins: And who’s gonna pay for that?
Dr. Patel: … putting that aside-
Dr. Watkins: Yeah
Dr. Patel: … is that, you know, if you’re just doing a study of injecting the disc, you’re missing the rest of the functional spinal unit.
Dr. Watkins: Right.
Dr. Patel: Right? If you’re doing a study to just inject the facet joint or just… There’s a, a study looking at PRP injected into the multifidi.
Dr. Watkins: Right.
Dr. Patel: Right? But you’re avoiding everything else that’s a part of the picture, and that’s what’s inherently difficult. Um, you know, we can do these studies. We can do these cases, and that’s why I think cases, believe it or not, um, cases are the, the bottom of the totem pole when it comes to, uh, actually seeing, uh, um, some validity-
Dr. Watkins: Yeah
Dr. Patel: … seeing some scientific scrutiny, right?
Dr. Watkins: Right.
Dr. Patel: Um, but the truth is cases give us a lot of information because we can see when, when an individual patient, and you apply information from other, um, actual randomized control studies-
Dr. Watkins: Yeah
Dr. Patel: … and apply that to an individual patient, how does that patient do? I think that’s why case reports are actually really important.
Dr. Watkins: Yeah, they are, and, and what’s this say? Injections.
Dr. Patel: Oh, yeah, we have comments.
Dr. Watkins: Yeah, “Did ligamentum flavum injections reduce infolding, physical reduction, or anti-inflammatory effects?”
Dr. Patel: That’s a great question. Well, the question is what, what are the biologics doing, right?
Dr. Watkins: Right.
Dr. Patel: Um, so the… when we talk about-
Dr. Watkins: And, and let me ask you a question in terms of how I think about it. The injections that you’re doing, are they an anti-inflammatory like a steroid, or are they regenerative, where they’re actually getting discs to heal and to create something new, fountain of youth type of?
Dr. Patel: The answer is yes.
Dr. Watkins: Both? Is that a yes to both?
Dr. Patel: It, it’s actually yes and no, right?
Dr. Watkins: Yeah. Right.
Dr. Patel: Um, because, you know, look, first of all, let’s, let’s take a step back from-
Dr. Watkins: Yeah
Dr. Patel: … even answering this question. I apologize. You’re gonna have to-
Dr. Watkins: Yeah
Dr. Patel: … wait through this.
Dr. Watkins: Yeah.
Dr. Patel: Um, but, uh, what are the things that we are injecting?
Dr. Watkins: Yeah.
Dr. Patel: What are stem cells? What is PRP? What’s platelet lysate? So just starting with PRP, and this is the, this is the way that I describe it to patients, right? Um, so forgive all… forgive me for all the docs in the audience that, that want some more, uh, you know, higher level vocabulary here.
Dr. Watkins: Yeah.
Dr. Patel: PRP, when you cut yourself, platelets are the things that stop the bleeding.
Dr. Watkins: Yeah.
Dr. Patel: Right? Those platelets contain growth factors in them.
Dr. Watkins: Yeah.
Dr. Patel: And those growth factors are released over time, and those growth factors do different things. There are anti-inflammatory growth factors. There are pro-inflammatory growth factors.
Dr. Watkins: Right.
Dr. Patel: There are growth factors that do chemotaxis or bringing other cells to the area, including the local stem cells in the region.
Dr. Watkins: Right.
Dr. Patel: Important.
Dr. Watkins: Right.
Dr. Patel: Um, so as PRP, uh, PRP is a concentration of those blood platelets, and that concentration will then cause inflammation and then take inflammation away.
Dr. Watkins: Right.
Dr. Patel: That’s essentially how PRP works.
Dr. Watkins: Right.
Dr. Patel: And part of that response is calling the local stem cells. So why does it work in some situations and not in others? So we have studies now sh- comparing PRP to cortisone as well as PRP to hyaluronic acid for things like knee osteoarthritis.
Dr. Watkins: Right.
Dr. Patel: Uh, there’s actually several studies now that show that, that PRP has, uh, better outcomes than hyaluronic acid. There’s a couple that show that there’s equal outcomes.
Dr. Watkins: Right.
Dr. Patel: There’s different types of PRP, and that’s where the research gets all muddy, right?
Dr. Watkins: Right.
Dr. Patel: Um-
Dr. Watkins: How many different types of PRP do you think there are on the market right now?
Dr. Patel: Well, so hypothetically, first of all, there’s, there’s categories of PRP.
Dr. Watkins: How, how many in LA are, are being offered? 30?
Dr. Patel: Maybe more.
Dr. Watkins: Maybe 50. So when you say PRP, and you go to your doctor, “Give me some PRP,” there’s 50 different types out there right now.
Dr. Patel: And there’s different ways of administering the PRP, right?
Dr. Watkins: Right. Right.
Dr. Patel: You know, you can have blind injections of platelets into a knee joint where you need no image guidance, or you can have specific injection to specific parts of the knee joint, right?
Dr. Watkins: Right.
Dr. Patel: So there’s, there’s all these different layers on that.
Dr. Watkins: So back to the mechanism of the PRP.
Dr. Patel: Yeah.
Dr. Watkins: Um, it can… it induces this response of the host body, inflammatory and healing, and it, it, it, it heals tissue. It breaks down tissues. It starts the process.
Dr. Patel: Correct.
Dr. Watkins: And we’re basically assuming that because they’re your own platelets, and these are a natural thing that occurs when you injure your body, that it’s gonna stimulate a positive reaction of what should happen to get it to heal, and it may just be amplified ’cause you’re injecting more of the cells there to get it to happen.
Dr. Patel: The idea is that it is causing a reaction.
Dr. Watkins: Right.
Dr. Patel: Okay? So if it is a tissue that is injured, if it is a tissue that is stagnant and injured, right? We’re not talking about acute injuries that suddenly happened. We’re talking about something that’s been sitting around for a long time and, and no longer in a healing response. It’s going to be invoking a healing response that’s taking place there. Now, if we just inject PRP into a knee joint, um, what, what’s it gonna do?
Dr. Watkins: Yeah.
Dr. Patel: Right? Um, I believe that we need to not only inject PRP into the joint-
Dr. Watkins: Mm-hmm
Dr. Patel: … but also inject into various different structures that may be stretched, may be injured, may be, um, may be pulled, right? If, uh, the ligament is being stretched because of their mechanics, you wanna inject those ligaments, but you also wanna work on the mechanics.
Dr. Watkins: Right.
Dr. Patel: So strengthening the appropriate muscles and, you know, when we talk about the spine, strengthening the core muscles. You know, some folks have wonderful ways of teaching patients how to, uh… He’s got a, uh-
Dr. Watkins: Yeah, you got our app, by the way.
Dr. Patel: Yeah, yeah.
Dr. Watkins: The ba-
Dr. Patel: Little plug, right?
Dr. Watkins: … the Back Doctor app. That’s our app. Free in the App Store, Google Play Store. It’s got the whole rehab program on it.
Dr. Patel: But that is an important-
Dr. Watkins: Right
Dr. Patel: … important thing, right?
Dr. Watkins: It is. It’s huge.
Dr. Patel: Because the thing is, it, you know, we can-
Dr. Watkins: Mm-hmm
Dr. Patel: … inject all these various things that, that, that develop a reaction to tell the body to heal, but if your body’s not moving correctly, it’s not gonna heal the way that it should.
Dr. Watkins: Now, let me ask you about this principle. I kind of try and strip things down. I don’t take any supplements. I don’t take vitamins. I just try and eat fruits and vegetables, and I think my body has everything it needs to heal. And even my wife is into meditation and energy healing, and I’ve gone more down that path of, you know, yogis have lived till they’re 150 years old with no stem cell injections just by letting the body heal when it’s injured by the natural process. So doing an injection of PRP, all the stuff like that, assumes the body doesn’t have enough platelets and growth factors and stem cells there to heal itself. So d- so how do we know it needs more to heal?
Dr. Patel: Great question. Question isn’t, does the body have those things? It’s, does the body have those things at those specific areas?
Dr. Watkins: Yeah.
Dr. Patel: So a lot of times we’re talking about areas that don’t have appropriate blood flow, right?
Dr. Watkins: Right.
Dr. Patel: We’re talking about areas that are deficient in their local stem cells. Um, so for example, there are studies that now show that a rotator cuff tear in the shoulder, the local stem cells in that area aren’t working the way they should be, right?
Dr. Watkins: Right.
Dr. Patel: So, um, why is it the rotator cuff tear repair surgeries fail miserably a lot of times, right? Why is it that a study by Hernigou showed that, um, putting stem cells in a, in addition to a rotator cuff repair actually decreased the timeframe for recovery and improved, uh, uh, the healing rate, right?
Dr. Watkins: Right.
Dr. Patel: So, you know, it’s, it’s that local area that does not have great blood flow. It’s the local area that’s, that’s not working the way that should be. That’s where the biologics come into play.
Dr. Watkins: So tell us a bit about… The problem with case studies is you always have an example of how it works, and that’s all we have to go by. Tell me an example of when it doesn’t work.
Dr. Patel: The… Where it doesn’t work is when there’s, uh, mechanics that cannot be corrected. So, you know, for example, we’re talking about, uh, knee arthritis, right?
Dr. Watkins: Yeah.
Dr. Patel: If your knee joint normally works in this position-
Dr. Watkins: Right
Dr. Patel: … um, as we get older, uh, the majority of patients, their, their… this is the right knee, starts to bow outwards a little bit.
Dr. Watkins: Right.
Dr. Patel: But, uh, you know, a certain proportion bow inwards. If that bowing has gone past a certain point-
Dr. Watkins: Yeah
Dr. Patel: … that no matter what muscle strength that we put into the rehab, no matter what we do biologic-wise to try to strengthen the ligaments-
Dr. Watkins: Yeah
Dr. Patel: … you’re stuck in this position, it is what it is.
Dr. Watkins: Gotcha. And, and so it’s mechanically, which makes sense. Once you’re past a certain point, it’s not gonna do that. Um, what about-
Dr. Patel: That’s where surgery comes into play.
Dr. Watkins: Right. So for backs specifically-
Dr. Patel: Sure
Dr. Watkins: … and then I’ll try and branch out because I know I got people who are interested in their kids and parents and dementia and all these other conditions too, and-
Dr. Patel: Oh, we gotta talk about that.
Dr. Watkins: Yeah. The, uh… But, but for backs, ’cause I’m a back fiend, and, uh, the… Uh, so for backs specifically, somebody has back pain for three years, done all the PT, done our app religiously. Believe it or not, they’re still having some pain, and, you know, they’ve done everything, and, um, but they’re still having back pain. For three years, chronic back pain, what would you typically… what injection would you do? Are you gonna do a stem cell? Are you gonna do the PRP? Does it, does the cost matter? Is that a factor in the decision? And so therefore, you know, what, what would you do for a back pain? And you may explain if, if the cost matters, if, um… And then what are the sources that matter, and how long do you think each one lasts?
Dr. Patel: So that’s a, that’s a loaded question.
Dr. Watkins: Right.
Dr. Patel: It’s a…
Dr. Watkins: Right.
Dr. Patel: Um, so somebody comes to me with three years of back pain or-
Dr. Watkins: Yeah
Dr. Patel: … X amount of years of back pain. Question is, what’s causing it?
Dr. Watkins: Right.
Dr. Patel: Okay? What… And, and, you know-
Dr. Watkins: Let’s say they got, they got three discs that are dark. They’ve got some disc desiccation, a little bit of degeneration on the mirror, a little bit narrowed down, facet joints matching degeneration, without much stenosis really, kind of mild to moderate stenosis.
Dr. Patel: Sure. Yeah. Um, in that type of situation, the imaging-
Dr. Watkins: Yeah
Dr. Patel: … matters this much.
Dr. Watkins: Right.
Dr. Patel: Right? Because as we get older, right, greater the age of 30, greater than 30% of people have some sort of disc degeneration or disc bulge, even in the absence of pain.
Dr. Watkins: Their physical exam, they wake up, they’re stiff, it hurts, and then it loosens up after a hot shower. After 30 minutes, they can get through their day, but then towards the end, it starts to hurt some more, and that’s, that’s 80%-
Dr. Patel: Sure
Dr. Watkins: … of my patients. Yeah.
Dr. Patel: So no- … and that’s, that’s a lot of my patients too.
Dr. Watkins: Right.
Dr. Patel: We gotta take that to the next level, right?
Dr. Watkins: Yeah.
Dr. Patel: Um, I, I go very in depth with their, their physical examination to see, are we dealing with any subtle weakness that’s going on?
Dr. Watkins: No.
Dr. Patel: Right? It’s easy to say no. It’s easy to say no.
Dr. Watkins: I was like, “This is a hypothetical example.”
Dr. Patel: It’s easy to say no.
Dr. Watkins: Yeah. Right.
Dr. Patel: Um, but, you know, the truth is that a lot of people will have toe weakness-
Dr. Watkins: Yeah
Dr. Patel: … or-
Dr. Watkins: Right
Dr. Patel: … neural tension stretch, which shows-
Dr. Watkins: Right
Dr. Patel: … a sign that there’s some level of nerve irritation going on.
Dr. Watkins: Yeah. Right.
Dr. Patel: Or, or when we examine them, you know, their, their muscles are, are more taut on one side than the other.
Dr. Watkins: Yeah. Yeah.
Dr. Patel: Right? So are we dealing with a facet issue-
Dr. Watkins: Right
Dr. Patel: … which is your, your stiffness that gets better over time?
Dr. Watkins: Right.
Dr. Patel: Are we dealing with a disc issue if pain is worse with bending forward or with, with coughing or sneezing?
Dr. Watkins: Right.
Dr. Patel: Um, are we dealing with a subtle nerve irritation that might not be causing a rip-roaring pain down the leg?
Dr. Watkins: Yeah.
Dr. Patel: But what exactly is going on? Or is it a combination of it all? And-
Dr. Watkins: Combo
Dr. Patel: … and, and then in that combination-
Dr. Watkins: Right
Dr. Patel: … um, based off of my physical examination and the imaging and the whole picture as a whole-
Dr. Watkins: Yeah
Dr. Patel: … um, more often than not, I’m still using platelets as my first line.
Dr. Watkins: Uh-huh.
Dr. Patel: When I would use the stem cells is if the arthritis in the facet joints is very, very bad.
Dr. Watkins: Right.
Dr. Patel: If the disc has a specific tear in it.
Dr. Watkins: Okay.
Dr. Patel: Okay?
Dr. Watkins: You’re gonna inject the disc?
Dr. Patel: If it has a disc tear and if it is causing pain.
Dr. Watkins: Okay.
Dr. Patel: Now-
Dr. Watkins: All right
Dr. Patel: … but that is actually typically a younger population.
Dr. Watkins: Right.
Dr. Patel: Um, the younger patient, CrossFit athlete, or any athlete, right? Um, yeah, yeah, yeah. You know, I’ve had back pain for the past, uh, you know, on and off for the past five years. Uh-
Dr. Watkins: Yeah
Dr. Patel: … you know, I was squatting, and then I, my back spasmed, and it went out for two weeks.
Dr. Watkins: Right.
Dr. Patel: Uh, but I’ve never had back pain before, right?
Dr. Watkins: All right.
Dr. Patel: Um, that’s the type of that I would-
Dr. Watkins: I gotcha. That sounds pretty reasonable. And so, um, um, shifting from that, so you may try the PRP first and then try the stem cells. Is, is-
Dr. Patel: Depends.
Dr. Watkins: Yeah. Depends if, and you may, but you’ll inject facet joints or disc with stem cells.
Dr. Patel: Uh, if needed, yeah.
Dr. Watkins: What about, um, ozone?
Dr. Patel: Great question. Ozone.
Dr. Watkins: Yeah.
Dr. Patel: So for those of you that don’t know about ozone, um, ozone is from, from our atmosphere, right?
Dr. Watkins: Yeah.
Dr. Patel: Um, and it’s, it’s O3. It has-
Dr. Watkins: It’s natural. What could be wrong with it?
Dr. Patel: It has, there’s free radicals and yada yada. The truth is, we don’t know how it works 100%. Um, now I, I am not, admittedly, I am not up to date with the research with ozone.
Dr. Watkins: Yeah.
Dr. Patel: Um, that being said, um, I, I did, uh, several years ago, um, you know, publish a paper… not a paper, a poster on, on the use of a… it was, again, a case-
Dr. Watkins: Yeah
Dr. Patel: … of ozone used, uh, in conjunction with, uh, botulinum toxin for somebody that had torticollis.
Dr. Watkins: Right.
Dr. Patel: It was an interesting case. Um, but regardless, even then, and certainly now, I don’t think we have the knowledge as to what ozone does.
Dr. Watkins: Yeah.
Dr. Patel: Um, I’ve seen patients that have had improvement with ozone. When I say improvement… Let’s backtrack a little bit. With all my PRP cases, stem cell cases or whatnot, if somebody says they had improvement within the first week-
Dr. Watkins: Yeah
Dr. Patel: … placebo until proven otherwise.
Dr. Watkins: Right.
Dr. Patel: I don’t judge anybody until after the two, three-month mark or even further.
Dr. Watkins: Yeah.
Dr. Patel: Okay? Placebo is a true effect, but typically that effect tapers off and dips down after the two, three-month mark.
Dr. Watkins: Yeah.
Dr. Patel: Right? Um, rarely it does stay longer.
Dr. Watkins: Right.
Dr. Patel: So I’ve had ozone patients that had improvement that was long-term.
Dr. Watkins: Yeah.
Dr. Patel: I’ve also seen patients that were injected epidurally with ozone that developed rip-roaring radiculopathy.
Dr. Watkins: Hmm. Interesting.
Dr. Patel: So the truth is, I don’t know if and how it works.
Dr. Watkins: Yeah.
Dr. Patel: I have seen patients that benefited. I’ve seen patients that did really, really poorly with it.
Dr. Watkins: Is the PRP treatment that you do less expensive than the stem cell?
Dr. Patel: The PRP treatments that I do are less expensive.
Dr. Watkins: Do they… If, if somebody… If, if you thought somebody was a candidate for either one, um, and so you’re gonna inject the same type of biology, do you think that one lasts longer than the other?
Dr. Patel: Uh, yes, potentially. Again-
Dr. Watkins: Mm-hmm
Dr. Patel: … somewhat of a loaded question, right?
Dr. Watkins: Yeah, sure.
Dr. Patel: Because, um, if, if PRP is relying on the growth factors causing decreasing inflammation, relying somewhat on drawing the local stem cells to the area-
Dr. Watkins: Yeah
Dr. Patel: … right? What does the stem cell treatment do that the PRP doesn’t?
Dr. Watkins: Right.
Dr. Patel: The reason that I would use a stem cell treatment is if the local stem cells aren’t great.
Dr. Watkins: Mm-hmm.
Dr. Patel: Right? So if the arthritis in the region is very, very bad-
Dr. Watkins: Mm-hmm
Dr. Patel: … right? Uh, we see things like Modic changes in the spine that are suggestive of damage, so to speak, um, of the local area, the local milieu. Would that be a circumstance where stem cells are more appropriate? And I don’t know the-
Dr. Watkins: So you’re kind of looking for more degeneration-
Dr. Patel: Correct
Dr. Watkins: … but not so much that mechanically-
Dr. Patel: That’s exactly right
Dr. Watkins: … you’ve gone past… Well, that’s reasonable. The, um… And, uh, and the reason why I ask that is because part of my question originally was, you know, what’s… Everybody asks me about the injections. One, one of the big questions is, “Well, what’s the cost? How long is it gonna last?”
Dr. Patel: Yeah.
Dr. Watkins: “And therefore, is it worth it?” And that obviously depends on how much money you have, and, and how much pain you’re in and, and what’s the effect and, you know, um… And I know that’s really hard to quantitate.
Dr. Patel: Yeah.
Dr. Watkins: And so even though I’m trying to get you to answer- … the, uh… Yep.
Dr. Patel: So I have… I’ll give you an example. So- … I’ll give you, uh, two examples.
Dr. Watkins: Yeah.
Dr. Patel: Okay? Uh, both spine. Uh, one example of a relatively young patient, when I first saw him he was about 39 years old. This was four years ago.
Dr. Watkins: Yeah.
Dr. Patel: Um, he had two levels of disc herniations.
Dr. Watkins: Yeah.
Dr. Patel: Um, sorry, of, of disc tears.
Dr. Watkins: Yeah.
Dr. Patel: Um, and he had axial low back pain and pain going down his leg. And I talked to him, and I talked to him about both options, of doing PRP and platelet lysate-
Dr. Watkins: Yeah
Dr. Patel: … or doing stem cells. By the way, when I do stem cell treatments, I actually do a combination of PRP, platelet lysate, and stem cells.
Dr. Watkins: Uh-huh.
Dr. Patel: Right?
Dr. Watkins: Right.
Dr. Patel: So if I’m injecting the disc with stem cells-
Dr. Watkins: Yeah
Dr. Patel: … I’m still injecting the epidural space with platelet lysate to calm the inflammation of the nerves, et cetera.
Dr. Watkins: Yeah.
Dr. Patel: Okay? Um, but I presented both options, and he was like, “Look, I wanna be conservative.” I said, “Look, I’d do the same.”
Dr. Watkins: Yeah.
Dr. Patel: So we did PRP, um, into the, the s- the, the posterior elements, all the structures, to try to tighten things up and take pressure off of the disc.
Dr. Watkins: Yeah.
Dr. Patel: I did, I… platelet lysate into the epidural space, and he had improvement of his symptoms.
Dr. Watkins: Yeah.
Dr. Patel: Now, this was a guy that had failed epidural steroid injections-
Dr. Watkins: Right
Dr. Patel: … had done physical therapy, the whole nine.
Dr. Watkins: Right.
Dr. Patel: He had improvement, up to 90% improvement of his symptoms, and he was diligent with his home exercises afterwards.
Dr. Watkins: Yeah. Right.
Dr. Patel: This is a guy that I told, “Look, if we can’t get rid of the disc tears, then we may need to go into the disc.”
Dr. Watkins: Right.
Dr. Patel: He had improvement.
Dr. Watkins: Right.
Dr. Patel: Right? Other end of the spectrum, I had a female, um, single mother, wonderful. And this is an interesting story. Um, same type of situation: disc tears, pain going down her legs.
Dr. Watkins: Mm-hmm.
Dr. Patel: We did the conservative treatment first. She had resolution of the pain going down her legs.
Dr. Watkins: Mm-hmm.
Dr. Patel: She still had the disc-related pain.
Dr. Watkins: Yeah.
Dr. Patel: So then we decided to go into the disc and do the stem cells.
Dr. Watkins: Right.
Dr. Patel: She again had substantial improvement of her symptoms.
Dr. Watkins: Right.
Dr. Patel: This was three years ago now.
Dr. Watkins: Right.
Dr. Patel: I found out after the fact that she had actually done a GoFundMe account-
Dr. Watkins: Yeah
Dr. Patel: … for her treatment.
Dr. Watkins: Yeah.
Dr. Patel: It actually tore me apart.
Dr. Watkins: Yeah. Right.
Dr. Patel: I don’t like that, you know?
Dr. Watkins: Yeah. Right. Sure.
Dr. Patel: And, and, and I’ve… You know, my, my company gets mad at me a little bit ’cause I give-
Dr. Watkins: Right
Dr. Patel: … discounts when I need to, right?
Dr. Watkins: Right.
Dr. Patel: Because when patients need these treatments-
Dr. Watkins: Right
Dr. Patel: … and they want to avoid surgery-
Dr. Watkins: Yeah
Dr. Patel: … then, then, then what other options are there, right?
Dr. Watkins: True.
Dr. Patel: Um, and I’d rather them-
Dr. Watkins: She, she got the opportunity for other people to help her.
Dr. Patel: Yeah.
Dr. Watkins: So spread the love.
Dr. Patel: That’s it.
Dr. Watkins: Right.
Dr. Patel: Um, but the truth is she had benefit.
Dr. Watkins: Yeah. Right.
Dr. Patel: It… A year and a half later or something along those lines, um, she was pirouetting at a Christmas thing with her daughter-
Dr. Watkins: Right
Dr. Patel: … and, and she fell, and she had increased back pain.
Dr. Watkins: Yeah.
Dr. Patel: Did I do another treatment on her?
Dr. Watkins: No.
Dr. Patel: Not at first, actually.
Dr. Watkins: Right.
Dr. Patel: She actually did physical therapy, and she did fantastic.
Dr. Watkins: Yeah.
Dr. Patel: I ended up doing, like, trigger points on her, and she did great.
Dr. Watkins: Yeah.
Dr. Patel: It was… It’s, it’s one of those things that’s, that’s really fulfilling because her other option at that juncture … was a three-level fusion
Dr. Watkins: Yeah. No, there’s no question about that, and one of the, well, the hardest patients I have are people who come to me who want surgery. They’ve been in back pain for two to three years. They’re 28 years old. Their life sucks. They’re in agony. They can’t do anything, and they just say, “Look, do something,” and if I tell them, “I don’t think you should have a fusion…” Artificial disc replacements can work, but there are gonna be problems within the lumbar spine ’cause you’re only replacing the disc, not the facet joints and the nerves and-
Dr. Patel: The functional spinal unit.
Dr. Watkins: There you go. It comes back. All right, I’ll give you that one. The, uh, and, uh, and so I’ll say, “Look, don’t have surgery,” and those people are the hardest ones for me because I don’t have anything to offer them, you know? And we do the app. We, we gotta put them on the program. I got a podcast on everything I recommend to avoid pain, diet, meditation, massage, cardi, everything.
Dr. Patel: Which, by the way, I think is a huge, huge part of it.
Dr. Watkins: It is.
Dr. Patel: And that’s something that I talk to all my patients about-
Dr. Watkins: Yeah
Dr. Patel: … is, is the mind-
Dr. Watkins: Yeah
Dr. Patel: … and the nutrition.
Dr. Watkins: It’s huge.
Dr. Patel: That’s-
Dr. Watkins: It all, it, it all plays… But still, then people say to me, “I’ve done all that. I’ve… and I’m still in agony.” And so this middle ground, and that’s why I’m hunting for stem cells, is because I got a lot of people who fall into that middle ground, that I don’t think they should have surgery, but you wanna help them, and even help them some, to give them that jumpstart so then they can do the rehab and do all the physical therapy. And so I really respect that, that, that window. So let’s move on to three different types of stem cells. Uh, bone marrow aspirate, which is any orthopedist does. We do that all the time. Stick a needle into the, into the iliac crest into your pelvis. That’s where the body makes bone. You can suck out some stem cells from that, and we can… You know, that’s pretty basic accepted medical procedure. There’s fat cells, which a lot of plastic surgeons and dermatologists use ’cause they do that. They get the fat, and then they get the stem cells. They inject them back into people’s faces and extremities of every kind. And, uh, and then there’s umbilical cord stem cells, which are kind of a hot topic. And, and I’ll just say my kinda… For me, the umbilical stem cells, people say they’re young and fresh cells. Like, you don’t wanna take my cells. They’re already 47 years old. They’re already dying, you know? You want some fresh, new cells, so you gotta get the umbilical cells, you know, which makes somewhat sense, but then it’s from another person. So you’ve gotta process it where you don’t kill all the stem cells, but you also don’t get an infection, and you-
Dr. Patel: Therein lies the problem.
Dr. Watkins: Yeah. All right.
Dr. Patel: Yeah.
Dr. Watkins: That’s it. That’s a fundamental problem.
Dr. Patel: So, so that’s the fundamental-
Dr. Watkins: Yeah
Dr. Patel: … so let’s talk about those three.
Dr. Watkins: Yeah, right.
Dr. Patel: So bone marrow, uh, stem cells, when, when, when we talk about stem cells, first of all, what’s allowed in the US?
Dr. Watkins: Yeah.
Dr. Patel: That’s the first question.
Dr. Watkins: Right.
Dr. Patel: What’s legal?
Dr. Watkins: What’s legal, and what can you talk about, and much less, what can you put in print?
Dr. Patel: Yeah. Right. Right, right. That’s, that, that’s actually a great point- Right … because what you can put in print is, is anything, right?
Dr. Watkins: Yeah.
Dr. Patel: You can, you can say anything at this juncture.
Dr. Watkins: Yeah.
Dr. Patel: Um, whether that’s true or not is a different story.
Dr. Watkins: Yeah.
Dr. Patel: Um, the only stem cell treatment, the only true stem cell treatment that is allowed in the US-
Dr. Watkins: Yeah
Dr. Patel: … is from the bone marrow.
Dr. Watkins: Yeah. Okay. There you go.
Dr. Patel: Period.
Dr. Watkins: Yeah.
Dr. Patel: For, at, at least for orthopedic conditions.
Dr. Watkins: Right.
Dr. Patel: Right?
Dr. Watkins: ‘Cause it’s established. It’s been around a long time.
Dr. Patel: It’s, yep.
Dr. Watkins: Right.
Dr. Patel: It’s been around for a long time. Uh, it’s been used in many different ways. The FDA, um, which is, you know, kind of this hierarchy that, uh, that oversees this, uh, says that it needs to be autologous use, meaning that it’s coming from the same tissue back to the same tissue.
Dr. Watkins: Yeah.
Dr. Patel: Um, it-
Dr. Watkins: Same person. Same person.
Dr. Patel: Yeah. Right.
Dr. Watkins: Right, right, right.
Dr. Patel: And, and it needs to be, uh, less than minimally manipulated.
Dr. Watkins: Right.
Dr. Patel: So that is a very strong statement.
Dr. Watkins: Right.
Dr. Patel: And it is, it has been open to interpretation quite a bit, as, as has the autologous use.
Dr. Watkins: Right. What does manipulation mean? What’s minimal versus moderate?
Dr. Patel: Correct. Right. Um, but as far as the FDA is concerned, and this is as, as, as recently as last year and the year before-
Dr. Watkins: Yeah
Dr. Patel: … um, the D- FDA has said that s- getting stem cells from fat is actually illegal.
Dr. Watkins: Illegal?
Dr. Patel: Illegal.
Dr. Watkins: Huh.
Dr. Patel: So the way to get stem cells from fat is you need to create this stuff called SVF, or stromal vascular fraction.
Dr. Watkins: Yeah.
Dr. Patel: In order to create that, you need to digest the fat, which, with a chemical called collagenase.
Dr. Watkins: Yeah.
Dr. Patel: Um, supposedly there are some systems that can mechanically, and, and therefore less than minimal manipulation, right?
Dr. Watkins: Right.
Dr. Patel: Um, but the only standardized way of making SVF is through, uh, digestion, and that chemical digestion, per the FDA, is considered illegal.
Dr. Watkins: Yeah.
Dr. Patel: So that’s that. Now, are there people doing it? Yes.
Dr. Watkins: Right.
Dr. Patel: There’s actually been several clinics. Um, there’s actually clinics here in LA-
Dr. Watkins: Right
Dr. Patel: … um, that have been in scrutiny under the FDA. FDA sent letters to them. The FDA has shut down a lot of clinics across the country.
Dr. Watkins: Yeah.
Dr. Patel: Um, and it’s doing that more because, not because this SVF is dangerous or doesn’t work. The research in SVF is very, very low-
Dr. Watkins: Right
Dr. Patel: … but there is research internationally on it.
Dr. Watkins: Right.
Dr. Patel: The problem is that there’s a ton of clinics that take that SVF, and they’re saying, “Hey, we’re gonna inject your knee-
Dr. Watkins: Yeah
Dr. Patel: … but we’re also gonna inject it IV, and we’ll treat your knee and your Alzheimer’s all in one shot.”
Dr. Watkins: Right.
Dr. Patel: “We’re gonna treat your diabetes.”
Dr. Watkins: Right.
Dr. Patel: “We’re gonna treat your son’s autism.”
Dr. Watkins: Right.
Dr. Patel: You’re gonna… You know, all these crazy, bogus claims-
Dr. Watkins: Right
Dr. Patel: … that really are based on little to no research whatsoever.
Dr. Watkins: Right.
Dr. Patel: So that’s where SVF gets dangerous, and there’s not the long-term study of outcomes.
Dr. Watkins: Right. Although, in its defense, it’s probably safe ’cause you’re just taking your fat and putting it in, injecting it back in. So you inject your fat into your IV into your bloodstream. Your body just goes, “Yeah, whatever,” and pees it out basically.
Dr. Patel: Potentially. Yeah. Potentially. Right, right. But we don’t know what the chemical digestion is actually changing it. Yeah. You know? Right.
Dr. Watkins: Sure.
Dr. Patel: So we don’t know what’s going on there.
Dr. Watkins: And, and, and part of the principle is anything that’s powerful enough to treat Alzheimer’s, autism, back pain, spinal cord injuries, well, anything that’s powerful enough to do all that is probably gonna cause cancers ’cause it’s so powerful-
Dr. Patel: Potentially
Dr. Watkins: … it’s gonna make cells, and when’s it gonna stop? How’s it gonna know, “Okay, you’ve done your job. Now shut off and go home”? No, it’s gonna keep working and create all sorts of crazy things.
Dr. Patel: And, and whether or not that’s true, we just don’t know.
Dr. Watkins: Yeah.
Dr. Patel: Right? And, and-
Dr. Watkins: Right
Dr. Patel: … so, you know, as, as much as a lot of people in the regenerative medicine space are like, “Oh, FDA, we don’t like you,” truth is they’re looking out for our safety-
Dr. Watkins: Yeah
Dr. Patel: … to a certain extent, right?
Dr. Watkins: Right.
Dr. Patel: Um, so that’s, that’s a big thing with the SVF type of thing.
Dr. Watkins: Yeah.
Dr. Patel: So that, that’s not legal in the US and, and-
Dr. Watkins: Huh, that’s fascinating.
Dr. Patel: It’s interesting. But there-
Dr. Watkins: ‘Cause it’s done a lot
Dr. Patel: … there’s tons of folks that are still doing it
Dr. Watkins: … it’s just going all over the place.
Dr. Patel: Well-
Dr. Watkins: I was gonna go up the street and get an injection tonight, but-
Dr. Patel: Uh, truth is, FDA doesn’t have enough funds to, to shut everybody down.
Dr. Watkins: Very true.
Dr. Patel: Um, but there is a type of fat procedure that is legal.
Dr. Watkins: Yeah.
Dr. Patel: Um, and that’s micronized fat.
Dr. Watkins: Oh.
Dr. Patel: Um, and that’s taking fat and just mechanically emulsifying it and making it very, very small.
Dr. Watkins: Yeah.
Dr. Patel: Not liberating the stem cells from it-
Dr. Watkins: Yeah
Dr. Patel: … but just having the fat graft, and that, there is actually some interesting research-
Dr. Watkins: Yeah
Dr. Patel: … um, that is starting. It’s still fresh, but there’s some interesting research for things like knee osteoarthritis, rotator cuff-
Dr. Watkins: Yeah
Dr. Patel: … um, that, that, you know, areas where you might need to fill a gap, so to speak.
Dr. Watkins: Yeah.
Dr. Patel: Right? If you have a rotator cuff tear.
Dr. Watkins: Right.
Dr. Patel: Something like that might be of benefit.
Dr. Watkins: So tell me about the umbilical cord while we’re still on that.
Dr. Patel: Yeah.
Dr. Watkins: I mean, the, this sounds pretty legit, right?
Dr. Patel: Absolutely.
Dr. Watkins: These young, little-
Dr. Patel: I mean, who wouldn’t-
Dr. Watkins: … fertile things
Dr. Patel: … who wouldn’t want, you know-
Dr. Watkins: Right
Dr. Patel: … a, a baby embryo, right?
Dr. Watkins: Yeah.
Dr. Patel: BS. So it’s-
Dr. Watkins: Yeah? Really? Straight up?
Dr. Patel: So here’s the thing.
Dr. Watkins: Yeah.
Dr. Patel: Right? There has been now three, um, independent groups that have-
Dr. Watkins: Yeah
Dr. Patel: … looked at umbilical, amb-, uh, amniotic, uh, cord blood tissues.
Dr. Watkins: Right.
Dr. Patel: Uh, one of which including Cornell, a lab out of Cornell.
Dr. Watkins: Right.
Dr. Patel: One publication that was just recently done in a national publication-
Dr. Watkins: Yeah
Dr. Patel: … um, that shows that these umbilical, embryonic, uh, placental products-
Dr. Watkins: Yeah
Dr. Patel: … don’t contain any living stem cells.
Dr. Watkins: Right, or minimal.
Dr. Patel: Or minimal. Or minimal.
Dr. Watkins: ‘Cause not zero.
Dr. Patel: It, potentially zero.
Dr. Watkins: But, but, but-
Dr. Patel: Some of these products-
Dr. Watkins: … but are much less than you think, or what, what they propose they have.
Dr. Patel: And, and the issue is-
Dr. Watkins: Yeah
Dr. Patel: … right, the process in which you’re-
Dr. Watkins: Yeah
Dr. Patel: … you know, some of these are gamma radiated to, to make them-
Dr. Watkins: Yeah
Dr. Patel: … safe. Some of them are, are shock thawed and-
Dr. Watkins: Yeah
Dr. Patel: … frozen, right? All of this process is gonna kill the stem cells.
Dr. Watkins: Let me tell you a quick story. I had this older gentleman who’s, lives in LA, who came in, and this guy’s, like, 80. Comes in, he’s having neck pain. He goes, “I couldn’t get in touch with you. I couldn’t get an off- appointment with you fast enough, you know? And I was having pain, so I went to my local guy, and he injected some stem cells in me. And, you know, I thought… I just went to bed. My wife, in the middle of the night, thought something didn’t seem right, calls 911.” They take him to the hospital. He gets diagnosed with sepsis. He had an infection in his whole bloodstream, was, could’ve died in his bed that night, and his wife just thought something didn’t seem right. And the thing I’ve learned as a doctor is if the wife or husband, usually wives, though, they’re more perceptive-
Dr. Patel: Yes. Yeah, to be fair
Dr. Watkins: … if the wife ever goes, “Somethi- he doesn’t seem right. Something doesn’t seem right. Something’s wrong. You better drag that man to the hospital and do some tests on him,” and that’s exactly what happened. And that company was LivOn. I don’t think I’m bad-mouthing anybody. It’s just a fact. It’s a factual story.
Dr. Patel: Yeah.
Dr. Watkins: Got shut down by the FDA. It was in the LA Times. Oh, I had read about it in the LA Times-
Dr. Patel: No, actually-
Dr. Watkins: … literally three days before, and this guy walks in, I said, “What was the company?” He goes, “Oh, I think it was this LivOn thing.” I go, “You’re one of the cases.”
Dr. Patel: Yeah.
Dr. Watkins: So it happens.
Dr. Patel: And you know what’s crazy? LivOn did not get shut down.
Dr. Watkins: Oh, oh, they didn’t?
Dr. Patel: No. I, I think they made a… Like, a week later-
Dr. Watkins: Uh-huh
Dr. Patel: … they miraculously made another product. Um-
Dr. Watkins: Yeah
Dr. Patel: … so you know-
Dr. Watkins: All right.
Dr. Patel: A- and I, I don’t know the situation. Look-
Dr. Watkins: We are not blaspheming LivOn.
Dr. Patel: Yeah.
Dr. Watkins: We don’t know anything about them. It’s just a story.
Dr. Patel: Interesting. And, and this is, you know, this is stuff that’s, that’s on the news.
Dr. Watkins: Yeah.
Dr. Patel: And, and-
Dr. Watkins: Right
Dr. Patel: … it’s, it’s well-known. Um, you know, The New York Times, everybody’s picked up the, the story about these, these, like, you know, at the time it was 12, but now I think it’s, like, 16 or 17 patients that-
Dr. Watkins: Right
Dr. Patel: … were hospitalized with this scrupulous stem cell treatment.
Dr. Watkins: Right.
Dr. Patel: And I’m like, you know, I wanna write this letter to the editor here saying, can you just put a little, you know, caret and say fake stem cell treatment because-
Dr. Watkins: Yeah. All right
Dr. Patel: … it’s not living stem cells.
Dr. Watkins: So you’re not the umbilical one. All right.
Dr. Patel: No.
Dr. Watkins: I, that’ll be my next guest. Just the guy doing the umbilical, and then he’ll say-
Dr. Patel: But this-
Dr. Watkins: Then he’ll come out and say, “Oh, they’re amazing,” you know, all this kinda stuff.
Dr. Patel: Look, the, the truth is-
Dr. Watkins: Yeah
Dr. Patel: … what, what’s in them, and why do they work, right?
Dr. Watkins: Right.
Dr. Patel: There, there are growth factors that are in them.
Dr. Watkins: Yeah.
Dr. Patel: Um, and there is, uh, something. There’s a milieu. There’s a-
Dr. Watkins: Right. They say there’s the juice. It’s all those growth factors, everything goes with it, that stimulates the body to come and heal, uh, the cells.
Dr. Patel: And so what research is on that?
Dr. Watkins: Let me ask you one other question about that, is what about, uh, uh, people who have saved their child’s or their umbilical cord, the child’s umbilical cord, the c- the combo, I don’t even know who. Who does it belong to?
Dr. Patel: Yeah.
Dr. Watkins: The mom or the child?
Dr. Patel: Yeah.
Dr. Watkins: But they saved it, and they got it frozen away. What do you think of that? Do you think it’s worth saving? Is it worth paying the 100 bucks a month to keep it frozen?
Dr. Patel: You know what, that’s a great que- and this is, this is a very, uh, very topical question for me-
Dr. Watkins: Yeah
Dr. Patel: … because, um, I just had a, a baby girl-
Dr. Watkins: Yeah. Congratulations
Dr. Patel: … a month ago. Thank you.
Dr. Watkins: Right, I know. Taking the night off.
Dr. Patel: Thank you.
Dr. Watkins: Yeah.
Dr. Patel: I’m gonna get in trouble, but yeah.
Dr. Watkins: Yeah. Right.
Dr. Patel: Uh, so no, I had a baby girl a month ago, and I have a two-year-old, uh-
Dr. Watkins: Yeah
Dr. Patel: … less than two-year-old boy.
Dr. Watkins: Yeah.
Dr. Patel: Um, so for my son, we saved his, uh, cord blood and-
Dr. Watkins: Yeah
Dr. Patel: … cord tissue.
Dr. Watkins: Yeah.
Dr. Patel: Um, currently, the only use for that is if he develops a, uh, cancer-
Dr. Watkins: Right
Dr. Patel: … and particularly a cancer that needs to have his bone marrow irradiated or-
Dr. Watkins: Uh-huh
Dr. Patel: … or, or taken away. Instead of having to find a bone marrow donor that matches him-
Dr. Watkins: Yeah
Dr. Patel: … he’ll have his own banked.
Dr. Watkins: Really?
Dr. Patel: That’s, that’s-
Dr. Watkins: That’s pretty useful. I mean, what are the, what are the odds anyway?
Dr. Patel: I mean, the odds are low. Um-
Dr. Watkins: Do you know, have you any idea what the actual number is?
Dr. Patel: I actually don’t know.
Dr. Watkins: I wonder what it’s… It’s probably one in a million.
Dr. Patel: Yeah. Some… I have no idea.
Dr. Watkins: I don’t know. I don’t know either. But, but, but that’s, at least there’s something. We know there’s something, and that’s today. 30, 40 years-
Dr. Patel: Yep
Dr. Watkins: … so did you do it for both or just your son?
Dr. Patel: Nope. So I j- And, and here’s the thing, you know-
Dr. Watkins: Right
Dr. Patel: … I didn’t do it for my daughter.
Dr. Watkins: The girl looked tougher.
Dr. Patel: It, that…
Dr. Watkins: Yeah. So, you know, yeah, right.
Dr. Patel: She takes after her mom, so she is.
Dr. Watkins: Yeah. Right. Right.
Dr. Patel: Uh, no, but the truth is, I don’t know what these companies are doing with-
Dr. Watkins: Yeah
Dr. Patel: … with the product, um, with, with the product, right? With these cells.
Dr. Watkins: Yeah.
Dr. Patel: Because ultimately, all these companies that are out there that are making all these, uh, you know, cord and, and amniotic and all these tissues-
Dr. Watkins: Yeah
Dr. Patel: … they’re getting these products from somewhere.
Dr. Watkins: Yeah.
Dr. Patel: Um, and a lot of them are public banks. You know, if you check off that banks, uh, off that slip saying that-
Dr. Watkins: Yeah
Dr. Patel: … you know, what you’re li- you’re willing to sell it to, uh, or send it to, uh, research or whatnot-
Dr. Watkins: Yeah
Dr. Patel: … and that, that, that’s might be where it’s going-
Dr. Watkins: Right
Dr. Patel: … um, which is interesting. Um, and the truth is, we don’t know where our technology using our own biologics-
Dr. Watkins: Right
Dr. Patel: … is gonna go 10 years from now.
Dr. Watkins: Right. But why didn’t you do it for your daughter?
Dr. Patel: Just for that reason.
Dr. Watkins: Yeah.
Dr. Patel: You know? Um, w- with the way things are going right now-
Dr. Watkins: Yeah, you don’t think you’ll need it.
Dr. Patel: I don’t know if I’m gonna need it.
Dr. Watkins: Yeah, I gotcha.
Dr. Patel: Now I’m still paying yearly for my son just because-
Dr. Watkins: Yeah
Dr. Patel: … I’ve already spent money. Now I’m like-
Dr. Watkins: Right
Dr. Patel: … shoot, you know?
Dr. Watkins: Right. Yeah, that’s an interesting call. For me, I’ve, I’ve, I just said forget it. My kids are 11 and 13, and so it was, it was a m- but they asked, and I, I just thought it, I thought it was like somebody trying to sell me some insurance on my rental car. I was like, “Nah, forget it.”
Dr. Patel: Yeah.
Dr. Watkins: I’m not paying. And thr- I kicked them out. My wife was like, “Who was that?” I’m like, “Ah, nothing. Don’t worry about it.” You know, but…
Dr. Patel: Yeah, no, it’s interesting. Um, but that, that world, when you talk about the Wild West of stem cells-
Dr. Watkins: Yeah
Dr. Patel: … that’s the world.
Dr. Watkins: Oh, it’s huge.
Dr. Patel: It’s, you know, and-
Dr. Watkins: It’s a big market
Dr. Patel: … the hard thing is, um, with these stem cell treatments, really if you’re going to somebody, um, the… you should be going to somebody that’s a specialist in it.
Dr. Watkins: Yeah.
Dr. Patel: Um, unfortunately, a lot of the amniotic, umbilical, et cetera, a lot of these are, are clinics, whether they’re run by physicians or chiropractors or whatnot, they might have a nurse practitioner that’s doing an injection, um, that is not properly trained.
Dr. Watkins: Right.
Dr. Patel: Um, so I think it was just last week, Dean Cain-
Dr. Watkins: Uh-huh
Dr. Patel: … uh, Superman-
Dr. Watkins: Yeah
Dr. Patel: … um, had a video that was just, uh, you know, put online last week and an article associated with it saying that he got this stem cell treatment for his knee.
Dr. Watkins: Yeah.
Dr. Patel: And the video shows-
Dr. Watkins: Yeah
Dr. Patel: … a nurse practitioner doing an injection without any image guidance up here-
Dr. Watkins: Yeah
Dr. Patel: … for his knee joint when his knee-
Dr. Watkins: Right.
Dr. Patel: And I’m like, first of all, where’s the injection?
Dr. Watkins: I watched a couple videos on YouTube where it’s a doctor-
Dr. Patel: You know?
Dr. Watkins: … doctor doing some procedure, and you’re like, “Whoa.”
Dr. Patel: Yeah.
Dr. Watkins: And, you know, and they’re like, “Oh, I’m injecting the inner sp- the spinous…” And you’re like-
Dr. Patel: Yeah
Dr. Watkins: … “That’s not even a real structure.”
Dr. Patel: Right, right.
Dr. Watkins: But yeah.
Dr. Patel: And, and the poor guy, like in the video, he starts doubling over because it’s painful. I’m like, I don’t know what’s going on, but this wasn’t right, you know?
Dr. Watkins: Right. Right.
Dr. Patel: Um…
Dr. Watkins: So, and then the, uh, last group is the bone marrow stem cells, and that’s what you do. And, um, and so why do those work?
Dr. Patel: So bone marrow stem cells have-
Dr. Watkins: Yeah
Dr. Patel: … the, have the most research overall for-
Dr. Watkins: Yeah
Dr. Patel: … orthopedic conditions.
Dr. Watkins: Yeah.
Dr. Patel: Um, and when we talk about bone marrow stem cells, there’s stuff even in the bone marrow stem cell world that we can and cannot do in the US.
Dr. Watkins: Yeah.
Dr. Patel: So we can’t grow the stem cells out in culture-
Dr. Watkins: Mm-hmm
Dr. Patel: … um, in the US.
Dr. Watkins: Right.
Dr. Patel: Um, we have to have a same day, same procedure type of situation.
Dr. Watkins: Now, you can send them off, and they can store them for the person potentially for later. You can freeze them and store them?
Dr. Patel: There, there is- … there’s a gray zone there. Uh-
Dr. Watkins: Cut the mic.
Dr. Patel: That’s… Uh, no, there’s, there’s a gray zone there.
Dr. Watkins: Yeah.
Dr. Patel: And I think that’s by state by state regulation.
Dr. Watkins: Oh, is it? Okay.
Dr. Patel: Um, I think. Um-
Dr. Watkins: All right
Dr. Patel: … I think. Um…
Dr. Watkins: All right, but regardless, you can take them out, m- minimally manipulate them-
Dr. Patel: Yep
Dr. Watkins: … and inject them back in.
Dr. Patel: Correct.
Dr. Watkins: Yeah.
Dr. Patel: Um, so as, you know, as long as you’re manually pipetting, manually centrifuging-
Dr. Watkins: Yeah
Dr. Patel: … um, there’s a lot of kits that are available that could do this kind of stuff.
Dr. Watkins: Yeah.
Dr. Patel: We use our, our own lab setup where we manually do things ourselves.
Dr. Watkins: Yeah.
Dr. Patel: Um, that is perfectly legit.
Dr. Watkins: Yeah.
Dr. Patel: Um, and that’s where all the research is. Not all, but that’s where a majority of the research is for orthopedic conditions.
Dr. Watkins: Right. Now, what’s the downside? Do you believe these cells will be old? You’re taking them out of some old person, injecting them back into the same old person?
Dr. Patel: Uh, the downside is pain.
Dr. Watkins: Uh-huh.
Dr. Patel: Uh, because-
Dr. Watkins: Right
Dr. Patel: … the stem cells cause a significant inflammation first-
Dr. Watkins: Uh-huh
Dr. Patel: … before taking the inflammation away. Beyond that, there’s actually some, some published research that shows, or published data that shows, um, that, that the stem cell treatments are fairly safe.
Dr. Watkins: Yeah.
Dr. Patel: Um, there was a study a couple years ago, 2016, uh, by the, the founder of Regenexx, as well as folks from Mayo Clinic and, and others, uh, that came together, pooled data, and said that the bone marrow stem cell procedures, um, and I believe some fat was included in that study too-
Dr. Watkins: Yeah
Dr. Patel: … um, w- has, has, uh, no significant adverse effects. Now, the data was only carried out for just over two years on average.
Dr. Watkins: Right.
Dr. Patel: So it’s still fairly young, fairly fresh.
Dr. Watkins: Yeah.
Dr. Patel: Looking at our Regenexx data over years, we don’t have any major adverse effects that are associated with it.
Dr. Watkins: What about… You know, so one of the things about stem cells is they’re very early cells that are pluripotent, multipotent. They can become other types of cells. So you’re taking the cells out of the bone marrow, which you would think are more predisposed to become bone, and you’re injecting them, hoping that they become disc or cartilage. Um, I’ve heard of a case that, where it was injected into a knee, and muscle formed in the knee joint because the cell doesn’t necessarily know what it’s supposed to become, and it became a muscle cell. You, you heard any cases like that?
Dr. Patel: Um, kind of.
Dr. Watkins: Yeah.
Dr. Patel: In the cultured stem cell world-
Dr. Watkins: Yeah
Dr. Patel: … um, that there’s some case reports on that front.
Dr. Watkins: Yeah.
Dr. Patel: And, and that’s why p- perhaps why it’s not as-
Dr. Watkins: When you say cultured stem cell, you mean the umbilical?
Dr. Patel: No, no, cultured bone marrow stem cells. So when you take the bone marrow out-
Dr. Watkins: Process it
Dr. Patel: … you grow it, grow it out over time.
Dr. Watkins: Gotcha, and then put it back in.
Dr. Patel: Correct.
Dr. Watkins: Okay.
Dr. Patel: Um, now with Regenexx, uh, we actually have a facility in the Cayman Islands I haven’t gone to ’cause, you know, Caymans is too far away from us.
Dr. Watkins: Yeah.
Dr. Patel: Um, but-
Dr. Watkins: Sounds nice.
Dr. Patel: It… I know. Um, but they, they do cultured stem cell procedures there, and, and looking at their outcome data-
Dr. Watkins: Yeah
Dr. Patel: … over time is, again, there’s no, uh, adverse events in terms of tumor growth. And why is that?
Dr. Watkins: Yeah.
Dr. Patel: So first of all, the same day stem cell treatments, now this is gonna get deep. What are the stem cells actually doing?
Dr. Watkins: Yeah.
Dr. Patel: Right? We used to think we take the stem cells from the bone marrow, we inject it into the disc, the joint, et cetera, and it’s gonna change into disc cells.
Dr. Watkins: Yeah.
Dr. Patel: Or it’s gonna change into the cartilage in the knee joint.
Dr. Watkins: Right.
Dr. Patel: Or it’s gonna change into this. It’s gonna ch- That’s not how it works.
Dr. Watkins: Yeah.
Dr. Patel: We realized that, that stem cells in the lab setting-
Dr. Watkins: Yeah
Dr. Patel: … can change down these different lines.
Dr. Watkins: Right.
Dr. Patel: But not actually in humans.
Dr. Watkins: Yeah.
Dr. Patel: So the, the founder of what’s called the mesenchymal stem cell, or MSC-
Dr. Watkins: Yeah
Dr. Patel: … Arnie Caplan, 1991-
Dr. Watkins: Yeah
Dr. Patel: … named, uh, that the MSC.
Dr. Watkins: Yeah.
Dr. Patel: Actually over the course of the last few years has said-
Dr. Watkins: So instead of calling them stem cells, call them additional marking cells? Or-
Dr. Patel: You know what? That MSC or medicinal signaling cells.
Dr. Watkins: Signal cells.
Dr. Patel: Still call it an MSC, right?
Dr. Watkins: Bring it out of the cells.
Dr. Patel: Signal cells.
Dr. Watkins: That’s good. Really confusing.
Dr. Patel: Um, so what happens is-
Dr. Watkins: Yeah
Dr. Patel: … you know, when we talk about stem cells, people think about pluripotent stem cells, and that’s where people get worried about cancer growth.
Dr. Watkins: Right.
Dr. Patel: Pluripotent are the embryonic stem cells that could change literally into anything.
Dr. Watkins: Right.
Dr. Patel: Okay? They can change into all these different lines, including bone stem cells or mesenchymal stem cells-
Dr. Watkins: Yeah
Dr. Patel: … you know, uh, nerve cells-
Dr. Watkins: Right
Dr. Patel: … hematopoietic cells going into blood, blood cells.
Dr. Watkins: Yeah.
Dr. Patel: Um, so that’s the pluripotent embryonic stem cell that is technically not legal in the US. And that is not in these umbilical products that are available on market.
Dr. Watkins: Right.
Dr. Patel: Okay? Um, the stem cells from the bone marrow, the primary stem cells in the bone marrow-
Dr. Watkins: Yeah
Dr. Patel: … that we’re s- interested in are the-
Dr. Watkins: Yeah
Dr. Patel: … mesenchymal stem cells-
Dr. Watkins: Right
Dr. Patel: … or now what we call the m- medicinal signaling cells.
Dr. Watkins: Yeah.
Dr. Patel: There’s other stem cells in the bone marrow, hematopoietic stem cells that turn into blood and et cetera.
Dr. Watkins: Right.
Dr. Patel: Um, there’s other stuff in the bone marrow.
Dr. Watkins: Yeah.
Dr. Patel: There’s growth factors, there’s blood, there’s platelets.
Dr. Watkins: Right.
Dr. Patel: There’s these things called exosomes, packets of information, all this stuff.
Dr. Watkins: And so the, the point is those stem cells are not becoming necessarily disc cells. They’re triggering the body to come and heal-
Dr. Patel: That’s right
Dr. Watkins: … wake up the stem cells that are already there potentially-
Dr. Patel: Boom
Dr. Watkins: … to get them going.
Dr. Patel: That’s, that’s the thought process behind it. And, and, and that’s how it works. And, and we don’t even know if it’s just the MSCs or if it’s the MSCs in combination with all the other stuff that’s-
Dr. Watkins: Right
Dr. Patel: … in there-
Dr. Watkins: All the other juice
Dr. Patel: … that’s, that’s changing that environment.
Dr. Watkins: Right. All right.
Dr. Patel: So.
Dr. Watkins: All right. The, um… Yeah, it’s interesting. I think one of the things about doing bone marrow is you kinda gotta know how to do it, and you gotta have the setup and, you know, not cause too much pain doing it. One of the, the things about the umbilical stem cells, why they are popular in certain clinical settings and o- offices, is ’cause they come in a packet and they’re frozen. And you can have a freezer, and they’re in a packet, and you take ’em out and inject ’em, which is a lot… It doesn’t cause pain the… of, of harvesting the cells out of the person’s hip, and it’s a lot easier and faster. And so, you know, and I think about stuff like that as you… ‘Cause I know in my world, what treatments do I do, well, they gotta make sense. You know? They gotta… I’m not, I’m not gonna go down to… I’m not going over the c- state lines to get the product or to do it, you know? It’s gotta be here. It’s gotta be controlled. At the hospital, I can do a bone marrow aspirate ’cause it’s an orthopedic procedure I have privileges for, so I’m more likely to do that. Although, do the umbilical ones, you know, we use fresh frozen allograft. We use allograft-type products from cadavers-
Dr. Patel: Yeah
Dr. Watkins: … that are over in the hospital in the freezer right now, so we do that, too. Um, but, but that’s-
Dr. Patel: I use allograft for specific situations, too.
Dr. Watkins: Yeah, the… And, and, and that’s part of it, is, you know, when you, when you’re going to somebody who’s gonna do a certain type of procedure, you kinda wanna know, are you doing this procedure ’cause this is all you can do or do do, or is it because you really think it’s the best? And what’s your rationale behind it? And, um, so… And that, and that… So all those work. Again, it’s like the, the plastic surgeons are gonna do, uh, do fat cells ’cause they’re sucking ’em out all the time. They got ’em. They got, they got ’em laying around all over the office. They can inject them in anybody. But, um, mild divergence.
Dr. Patel: Yeah.
Dr. Watkins: The, uh… So, uh, anything else you wanna say about that?
Dr. Patel: No, I think, I think we kinda covered the ba-
Dr. Watkins: Yeah.
Dr. Patel: Oh, the, the one thing that I was trying to say was, um, that, that if somebody is doing an injection-
Dr. Watkins: Yeah
Dr. Patel: … and, and on their website is saying that they, uh, treat the knee arthritis, and the back pain, and Alzheimer’s, and your, you know, uh, baldness, and, and all this stuff-
Dr. Watkins: If it treats everything-
Dr. Patel: Mm
Dr. Watkins: … it’s a little… I’m, I’m wary, too. We’re just-
Dr. Patel: It’s suspect.
Dr. Watkins: It is suspect. That being said, because stem cells are a primordial, basic cell that exists in all humans, it can become everything, they may be the cell that can cure everything. That is the theory. That is the potential. I mean, of, of any cell that could do it, it would be it.
Dr. Patel: But that cell is not allowed in the US.
Dr. Watkins: Yeah.
Dr. Patel: So you’d have to go outside of the country, where there are risks of other things happening.
Dr. Watkins: I actually read Riordan’s book, who’s in Panama, has a whole clinic in Panama.
Dr. Patel: Yeah.
Dr. Watkins: Interesting book, but he had every condition you could think of and three examples of every condition and how it had, had saved people. Spinal cord injuries, injecting them into the spinal cord, getting the spinal cord to regenerate, um, which happens naturally. Most people who have a spinal cord injury regain one or two levels of motor function, which is… can be really vital. That happens. We, we know that happens already.
Dr. Patel: Mm-hmm.
Dr. Watkins: So did, did it happen because of the stem cells? We don’t know. But my, my point about just what you said, it was an interesting book. I mean, smart man, lot of data, lot of research, and, and I, I, I respect people who are on the cutting edge doing these things. At the same time, well, just what you said, it treats every condition, and all the examples, three examples of every condition, and how it cured all three of them. And that’s kinda my point, and what I ask, too, as a doctor, is kinda like, “Okay, so I know you don’t have the randomized controlled data to show this or that. You have some examples of how it works. Well, tell me some examples of when it doesn’t work.”
Dr. Patel: Yeah.
Dr. Watkins: Because we know that they gotta exist.
Dr. Patel: Yeah.
Dr. Watkins: And so it’s kinda like, just don’t tell me the good.
Dr. Patel: Absolutely.
Dr. Watkins: As, especially as a surgeon, I’ve been in practice 16 years. When I go to conferences with other surgeons, I don’t wanna hear about how great this product is. I wanna hear the complications-
Dr. Patel: Yeah
Dr. Watkins: … and when it doesn’t work. Tell me the bad stuff, because then, for one, then I’ll believe you, and number two, I’ll know how to not… of how to avoid that, and that’s what, you know, really matters. And so-
Dr. Patel: And that’s where the data counts, right?
Dr. Watkins: Yeah.
Dr. Patel: And not, not only the data that’s published, but your own personal data. And this is to all you docs that are doing regen med or really anything out there. Collect your own data to see what’s working and what’s not, you know? Um, the truth is, it doesn’t work for everybody, and there’s a lot of docs out there that say, “Oh, this treatment will work for 90% of patients.” You know, I’ve seen this advertised on websites, “Stem cell treatment, 90% better in all patients.” I’m like, “That’s bogus.”
Dr. Watkins: Yeah.
Dr. Patel: We have our data published that’s on our, on our website.
Dr. Watkins: Yeah.
Dr. Patel: Um, on the Regenexx website, you can see what, uh, nationally, all the data that’s accumulated, and you can see that our numbers are greater than 50%.
Dr. Watkins: Yeah.
Dr. Patel: So that’s nowhere close to 90%, right?
Dr. Watkins: Yeah.
Dr. Patel: So we need to know what works, but we also need to know what doesn’t work.
Dr. Watkins: Yeah, totally. Well, it’s been great, you know? Um, and I’ve really enjoyed it, and I really-
Dr. Patel: It’s been fun.
Dr. Watkins: It was a lot of fun. We’ll do this every Wednesday. What do you think? We’ll have some pizza. I promised you margaritas originally.
Dr. Patel: I did. Oh, yeah, that’s right.
Dr. Watkins: Then I re- I realized I gotta operate tomorrow- … so we’re gonna have to, we’re gonna have to hold off on those. But I hope this has been helpful to everybody. And, um, the, uh… Basically what we can do is Facebook either one of us, you know, questions, um, and we can answer ’em. That way we can do a-
Dr. Patel: Yeah
Dr. Watkins: … follow-up. You know, I might Facebook Live your lecture on June 1st.
Dr. Patel: Yeah, sure.
Dr. Watkins: And we can do that.
Dr. Patel: Absolutely.
Dr. Watkins: And you guys can watch more. And, and I’ll come up with some, um, more que- I’ll read some data and really grill ’em, uh, on the post, uh, thing there in front.
Dr. Patel: Yeah.
Dr. Watkins: The, uh… And, um, you can contact me at watkinsspine.com is our webpage. My email is robertwatkinsmd@yahoo. You can email me. You wanna tell them your info?
Dr. Patel: Yeah. So my info, uh, our website is www.healthlinkcenter.com. Um, my Instagram is @stemcelldrpatel. Um, my email address is dr*****@**************er.com. Um, so you can reach us at, at any of those. Um, we have a, we have an education center that, that helps patients navigate this whole world of stem cells.
Dr. Watkins: Yeah.
Dr. Patel: Um, so that… You can email them at in**@**************er.com.
Dr. Watkins: Cool.
Dr. Patel: Um, and, and they’d be more than happy to, you know, give you information about, you know, our, our outcomes, our data, um, and, and really clearing up some of the stuff that’s, that’s really, uh, a myth out there.
Dr. Watkins: Cool. All right, guys, thanks a lot. Thanks for joining us.
Dr. Patel: Thanks so much.
Dr. Watkins: Have a good night.
Dr. Patel: And thanks for having me.
Dr. Watkins: Yeah, man, it was fun.
Dr. Patel: Appreciate it.
If you’ve heard of PRP (platelet-rich therapy), or prolotherapy, or even stem cell therapy you’ll want to listen to this episode as Dr. Shounuck Patel, DO discusses what they are, and what to look for when seeking a provider. Are these therapies right for you?
Announcer: Welcome to the Stay Healthy Los Angeles podcast, aimed at helping you live an active, healthy, and enjoyable life in and around Los Angeles. Brought to you by Core By Design Clinical Pilates. And now, here’s your host, physical therapist, Emma Green.
Emma Green: So on today’s podcast, I have Dr. Shounuck Patel, who, uh, i- is a specialist in regenerative medicine and interventional orthopedics in Los Angeles and Orange County. So thanks for joining me today, Dr. Patel.
Dr. Patel: Thank you so much for having me, Emma.
Emma Green: Oh, you’re welcome. It’s great to speak with you. So, um, we, we met at a conference a couple of months ago, and, uh, you were, you were speaking at the conference, and I was very interested in the topic that you were discussing. Um, and, and I know it can be of benefit to a lot of people, which is why I really wanted to get you on the podcast and s- and talk to you about this because I think we really need to kind of spread the word. So, um, if you’d like to start by telling me a little bit about your background.
Dr. Patel: Yeah, absolutely. Um, so I am a DO, a doctor of osteopathic medicine. Um, I did residency training in physical medicine and rehabilitation, and I did a fellowship in sports medicine and interventional pain management. A little bit early on in my career, uh, actually when I was in medical school, I had learned a little bit about regenerative medicine and things like prolotherapy and, and using a patient’s own blood, PRP, uh, to treat various conditions. So I kind of, um, sought that out on every step of my training, was really looking, uh, to learn more about that. Um, so when I finished my training, I had the opportunity to, um, learn more, um, and start working with, uh, international network called Regenexx, and I have been doing regenerative medicine, uh, interventional orthopedics for the last four and a half years now.
Emma Green: Okay, that’s great. So, so regenerative medicine, what re- what really is that? What does that term mean?
Dr. Patel: Yeah. Actually, you know, I, I have a love-hate relationship with the term- … regenerative medicine. Um, quite frankly, there is regenerative medicine, and then there’s regenerative medicine. So-
Emma Green: Okay, you’re gonna explain the difference, right?
Dr. Patel: So when we, when we talk about true regenerative medicine, there’s a lot of research that’s being done, um, right now for the last several years, um, uh, with using, uh, what it– what’s called pluripotent stem cells or induced pluripotent stem cells, um, and, and actually regrowing tissue. Um, you know, you may have heard of things like, you know, regrowing organs in a lab setting and things along those lines. Um, that’s, that’s what I call true regenerative medicine, um, that’s still very, very much so on the research front, essentially. Um-
Emma Green: Yeah
Dr. Patel: … then there’s this, then there’s this kinda world of regenerative medicine that has gained in popularity over the past several years on the clinical side. Um, and, and I use kinda air quotes when I talk about this because in a lot of senses, it’s not always actually regenerating tissue, um, but oftentimes improving structures, uh, improving the, the way structures function, uh, trying to prevent degeneration from getting worse, things along those lines. And my specific interest in this field is, is with orthopedics, with musculoskeletal medicine.
Emma Green: Okay. And so what drew you to this particular, um, branch of medicine? What made you so interested in it?
Dr. Patel: That’s, that’s a, a little bit of a long rollercoaster of a story. Um, but ultimately, uh, I was, I was always interested in musculoskeletal medicine. Um, I’m, uh, somewhat of an artist. I’ve drawn since I was a little kid, so I’ve always been interested in the musculoskeletal side of things. Um, and when I started delving into medical school, I decided to be a doctor of osteopathic medicine because I really loved some of the tenets that, you know, osteopathy, um, really focuses on treating the whole individual, um, you know, treating all aspects of the person. Um, and really, you know, osteopathy believes in the fact the body has its innate ability to heal itself.
Emma Green: Mm-hmm.
Dr. Patel: Um, so as I was learning more about that, I fell upon, you know, some folks that were using, um, simple things like your body’s own platelet growth factors, um, or even things like sugar water for prolotherapy and getting the body to heal, uh, without using, uh, surgery or more invasive treatments. So that’s really what attracted me to it. You know, I was interested in the musculoskeletal world as, um, um, as a baseline, and then I, I really got attracted to the body’s ability to heal itself.
Emma Green: Yeah. Sounds good.
Dr. Patel: Yeah.
Emma Green: So you’ve mentioned the term prolotherapy. What does that term mean to the average person on the street? How can you explain that to them?
Dr. Patel: Sure. Um, so we talk about kind of the field of regenerative medicine as a whole. It, it, uh, on the clinical side, it started with this concept of prolotherapy. Um-
Emma Green: Right
Dr. Patel: … prolotherapy stands for proliferative therapy, and the idea is that when we have some chronic injury going on, usually it’s a ligament type injury, whether that ligament’s been sprained… Think of your ankle, right? If you sprained your ankle as a kid, and then you’ve sprained it again, and you’ve sprained it again, you, you know, the ankle itself can be fairly loose. The ligaments are generally loose in that setting. But the body’s not registering that as a new injury. That’s kinda this chronic stagnant thing that there’s no healing taking place there. Um, so the concept was made that if we inject something that can actually cause irritation to those structures, um, can that trick the body into thinking, “All right, there’s a new injury here. We should heal this.” Right? So, um, prolotherapy, uh, what, what we use typically at this juncture is dextrose, which is a type of sugar water. And at the concentration of that sugar water, it actually causes some localized inflammation, some localized irritation, really some micro- microscopic cell death, um, that causes, you know, this tiny bit of damage, and then the body’s like, “All right, we need to send growth factors there. We need to sell– send the local stem cells to that area. We need to cause that healing to take place.” So that’s kind of the concept behind prolotherapy. It’s, it’s been around for decades, um, and there’s been people that inject various different solutions. Um, the traditional prolotherapy has been used without any image guidance, um, with, with palpation, um, and there’s been this kind of whole school of training, um, by these docs named Hackett and Hemwall, um, who really, um, uh, uh, grew this school of, of being able to palpate, um, or press on somebody’s body and say, “Okay, these are the structures that we need to inject.” Um, more, more recently, with the advent of things like ultrasound and fluoroscopy X-ray guidance, we now use precise image guidance to see and, and inject s- specific structures.
Emma Green: Okay. So whe-when should somebody be considering prolotherapy? What would be, uh, somebody who would really benefit from this type of technique?
Dr. Patel: Yeah. I think prolotherapy could be beneficial for, um, a few different things. First of all, the, the research shows that prolotherapy can be beneficial for certain types of back pain conditions. Um, you know, when you talk about the sacroiliac joint as being a, a culprit in terms of back pain. Um, also, you know, various ligament injuries, like the, the ankle sprain that I talked about. Um, mostly injuries or irritation, low-grade injury or irritation to ligament structures can be addressed with prolotherapy. Um, prolotherapy has its pros and cons, though. Um, you know, specifically that prolotherapy, it, it’s, it’s very early down the chain of healing, meaning we’re causing a little irritation that’s tricking the body into sending the platelet growth factors, which then call the stem cells to the area. So it’s very, very, um, you know, uh, early in the treatment kind of, um, protocol. So it’s, it’s good for structures that have milder issues. Um, it’s also good for structures that have good adequate blood supply, um, because if we can’t– if we don’t have good blood supply to these structures, we can cause irritation as much as we want to, but the body’s not gonna be able to send the healing platelet growth factors or stem cells or whatever to that area.
Emma Green: So therefore, that reason, would, would that… would prolotherapy be something that could be used in something like tennis elbow, where it’s a tendon that is causing the issue?
Dr. Patel: Potentially. Uh, potentially. So tennis elbow, you’re right, is a tendon, it’s not a ligament, um, that’s causing the issue. It’s, um, you know, it’s the outside of the elbow, the tendon that comes from the wrist extension, people whipping their wrist playing backhand tennis poorly, right?
Emma Green: Right.
Dr. Patel: Um, but, but really that, that is not, uh… People use the word lateral epicondylitis, meaning inflammation of that area, but it’s typically not an inflammation, more of a, a tendinopathy or irritation to the tendon or disorganization of the tendon. So theoretically, the prolotherapy could, uh, be beneficial for that. It really comes to the extent of the damage to that tendon. Um, and, and with prolotherapy in general, since it is kind of, uh, a, a lighter weapon to use, so to speak, sometimes it takes multiple sessions over time in order to get good outcomes.
Emma Green: Okay.
Dr. Patel: Um, so for s- for something like tennis elbow, um, there’s actually some pretty good solid, uh, research, uh, level one research that z- uh, recommends PRP and a specific type of PRP, um, for, uh, that, that tendinopathy that occurs there.
Emma Green: Okay. So the first question I have to ask is, what does PRP stand for?
Dr. Patel: Um, so PRP stands for platelet-rich plasma. Um, and platelets, uh, this is, this is how I describe it to all my patients, so if any of my patients are listening, this is-
Emma Green: Yeah. Right
Dr. Patel: … this is repetitive for you. Um, but when you cut yourself, um, the platelets are the thing that stops the bleeding, right?
Emma Green: Right.
Dr. Patel: Those platelets then, uh, release growth factors after they form the clot, and they release growth factors over time. They actually release some growth factors that cause inflammation, and then they release more growth factors that then decrease inflammation. So there are both pro and anti-inflammatory growth factors in platelets.
Emma Green: Right.
Dr. Patel: Um, and there’s also what are called chemotactic growth factors. So these are growth factors that call local stem cells and other cells to the area. So if you think about it, we have stem cells throughout our body, um, in all of our blood vessels and in our bones, in our fat. There are stem cells of various types that live in these areas. Um, so the platelets actually will call those to the region of injury. So that actually is what, you know, kind of, uh, uh, causes the healing to take place, so to speak. So when you cut yourself, it’s the platelets that are kind of starting that healing process. So we’re able to take your blood and concentrate those platelets into a high, high concentration, and that’s called platelet-rich plasma. Um, and that’s, you know, when, when you talk about PRP and you talk about people that are doing it-
Emma Green: Mm-hmm
Dr. Patel: … it’s all over the place as to what that PRP may mean in terms of-
Emma Green: Right
Dr. Patel: … what’s in it, uh, the concentration of the platelets, whether there’s red blood cells, white blood cells. Various different stuff is in the platelets, and that’s why not all PRP is c- uh, i- is, is created equally. Um, but different PRPs may be more beneficial than others for specific circumstances.
Emma Green: This is one of the big things that I really learned from you at the conference is for, for, for me as, as a healthcare professional, obviously I’ve heard of PRP. I have a, a basic understanding of what it can be used for. I had no idea that not all PRP was the same. You know?
Dr. Patel: Yeah.
Emma Green: I had no idea that there were different concentrations and different cells in there. That, that was completely new to me. And so then that, that then takes me onto the fact that this must be so confusing for patients who are looking for answers to their questions when they can’t even compare one type of PRP to another because there, there’s such a discrepancy.
Dr. Patel: Yeah.
Emma Green: How, how do you… how do you explain that to patients? How do, how do they go about trying to navigate this, this area to find what they specifically need? So confusing.
Dr. Patel: You know, honestly, it is confusing. And, and quite frankly, it is confusing still to a lot of us that are in this field, you know?
Emma Green: Right.
Dr. Patel: Because the truth is, um, we’re still learning. And, and-
Emma Green: Right
Dr. Patel: … this is, this is inherently the problem, right? Because PRP is not currently covered by insurance, so-
Emma Green: Right
Dr. Patel: … a lot of folks, um, see this as an… a lot of clinics see this as an opportunity to do something, uh, for patients, but they– if they’re not specializing in this field, then they’re not figuring out the exact nuances of what works for what condition, and that’s when their, our outcomes actually plummet. Um, so, you know, if the average person that’s doing a PRP, average physician that’s doing PRP injections might not even know what type of PRP they’re injecting because they are, you know, just ordered X specific kit, and that produces, you know, whatever product, and that might not be appropriate for all things that they could be considering. So that’s, that’s also why the research is so all over the place when it comes to PRP. There’s some areas like, um, you know, tennis elbow, um, that we have some pretty robust research showing that, uh, that, that a high concentration of PRP, uh, with no red blood cells but with white blood cells might be beneficial for true tendinopathy. Um, but, you know, looking at our internal data, if that tendinopathy becomes a tear, then we might wanna take those white blood cells out completely. So we’re still kind of formulating what is precisely beneficial for s- for exact situations. And from the patient’s point of view, that’s, that’s really hard to interpret.
Emma Green: Yeah.
Dr. Patel: Um, the biggest piece of advice that I have for somebody is if, if you have a, an orthopedic condition, um, it might not be the best idea to go to your, your general practitioner that’s just doing PRP on the side, right?
Emma Green: Right.
Dr. Patel: It, it might not be a good idea to go to your plastic surgeon that’s doing PRP for the face and, “Oh, yeah, I can also treat your knee,” right? So that’s the kind of thing that, that we need to start considering when we’re doing these type of procedures. Um, I actually think it’s a good thing, and, uh, and, and people are gonna be mad at me right now, but I think it’s a good thing that it’s not currently covered by insurance because then I think people would start doing it for everything and anything and not using the correct techniques, using incorrect PRP, and, and then I think patients would suffer in the long run.
Emma Green: I think that what– the, the, the sentence you just said there, that is just phenomenal for, for patients to take that from somebody who is a specialist in doing this particular technique. You know, everybody really needs to hear that. It’s, it’s so true. Um, you know, I, I get a lot of people coming to me and saying, you know, “What do you think about PRP?” And I can give them my limited knowledge. But really, whenever we’re considering any of these types of invasive procedures, we need to be seeing the specialist.
Dr. Patel: Yeah.
Emma Green: And you need to be seeing the specialist who is doing these procedures all the time, and it’s not just the, “Oh, I… And, and by the way, I do this as well.”
Dr. Patel: Yeah.
Emma Green: It’s– that’s crucial. So the, yeah, that’s immensely helpful for sure.
Dr. Patel: And, and in addition to that, not only doing these procedures all the time, but also collecting data. You know? Saying, “Are these procedures working?” Right?
Emma Green: Right. Looking at the outcomes.
Dr. Patel: I see some websites out there that are like, you know, “Ninety-five percent of my patients get better.” And I’m like, that’s probably bogus because, you know, we, we track our data, and we put that data available on our websites for people to see. And for some body parts, we’re happy when over fifty percent of people get benefit, right? Because realistically, everybody’s different.
Emma Green: Yeah.
Dr. Patel: And everybody has multiple different issues that are going on, and not everybody’s going to respond to the same treatment.
Emma Green: Right.
Dr. Patel: So we’re still in that learning process, and the only way we can learn and grow is if we’re collecting the data. So, you know, if you’re shopping around for these type of docs, it’s, one, important to make sure that they’re specializing in this and, and two, making sure that they’re collecting their data, that they’re analyzing it, that they’re publishing it. All of that stuff is really important.
Emma Green: Yeah, absolutely. So we- we talked about tennis elbow a little bit and with regards to a change in PRP becoming, uh, a more popular option. Now, sort of in the olden days, it used to be the, the cortisone shots that typically-
Dr. Patel: Yeah
Emma Green: … people would get for tennis elbow, and I know that it’s-
Dr. Patel: Yeah
Emma Green: … still going on out there. What’s your view on that?
Dr. Patel: So I think, uh, cortisone is an amazing and horrible medication all in one. Um, so there are specific instances where I think cortisone injections are perfectly fine. Um, but there are more and more instances where we’re realizing that it actually can do more harm than good. Um-
Emma Green: Can you give me some examples?
Dr. Patel: Absolutely. Um, so if somebody has sciatica, and that person is young, otherwise healthy with no other medical issues, has an isolated disc bulge that’s irritating a nerve, and it’s rip-roaring just freshly started, then perhaps a cortisone injection might be appropriate to calm down the inflammation of the nerve, decrease the pain, and then allow us to do the appropriate physical therapy to strengthen the core and take pressure off of the area, et cetera, et cetera. However, that’s a very, very limited population of people that, that, that present to us with nerve irritation or back pain, et cetera. Um-
Emma Green: Right. So with no other existing factors, right? That’s-
Dr. Patel: Exactly
Emma Green: … the, the key thing. Yeah.
Dr. Patel: And that’s the key thing, right? Most times when we see someone with a nerve irritation, they’ve got arthritis. They’ve got ligaments that are loose. They’ve got muscles that are a- atrophied or not working properly, right? So all of those things need to be addressed, and that’s why cortisone injections epidurally for those type of multifactorial conditions aren’t the greatest. They only work for a couple months at a time. Um-
Emma Green: Right
Dr. Patel: … right? You’re happy if you get three, four months of benefit, then you have to repeat the injection and repeat the injection. Now, the problem with repeating the injections is especially if as we’re getting older, especially if we have other medical conditions like, uh, diabetes, these, these cortisone injections can actually make all those conditions a heck of a lot worse. Um, you know, a single cortisone injection can make your blood sugar skyrocket. Um-
Emma Green: Right
Dr. Patel: … single cortisone injection in a post-menopausal female can cause osteoporotic fractures, right? Um, so these are important factors to consider as when we’re thinking about cortisone injections. Now, for tendons like tennis elbow, at this point, it seems like cortisone injections should not be done, period.
Emma Green: Right.
Dr. Patel: Um, because ultimately the cortisone, um, a steroid can actually damage the tendon-
Emma Green: Mm-hmm
Dr. Patel: … um, par- particularly if it’s injected within the tendon. Um, and we, we don’t see it as much with, uh, tennis elbow, but I’ve seen cases, multiple cases at this point, patients that have, uh, biceps tendon, uh, irritation or tendinopathy in their shoulder, um, and they get an injection of cortisone without image guidance, so not exactly knowing where it’s going.
Emma Green: Right.
Dr. Patel: And then that biceps tendon ruptures. Um, and we’ve, we’ve seen that in other areas. Um, I have seen it in the, in the tennis elbow in the past, but not, not as commonly. Um, but-
Emma Green: Okay
Dr. Patel: … but this is, this is stuff to consider. This-
Emma Green: Yeah
Dr. Patel: … the cortisone has side effects associated with it. So if you’re going to get a cortisone injection in, in and around tendons, then ultrasound guidance needs to be there in order to make sure that we’re doing things in a safe manner. Um, but quite frankly, those are the type of situations that, you know, if we have an, a better alternative like PRP, um, or like other things like bone marrow stem cells, um, then, then is that a better option to actually improve the pain and potentially provide some healing there? Um, and I think in the right hands with the right approach with image guidance, that that is an option.
Emma Green: So you, you just mentioned stem cells there. So there’s so many different varieties of these injectables. It used to just be cortisone shot, and that was it.
Dr. Patel: Yeah.
Emma Green: And now there’s PRP, and there’s prolotherapy, and there’s stem cells, and there’s so many different things. So what, what is stem cells? What, what does that involve, and what can that help?
Dr. Patel: So stem cells are the new kids on the block, so to speak. Um-
Emma Green: Right
Dr. Patel: … they’ve still been around for, uh, a couple decades, at least in the, in the lab setting. Um, the, the stem cells that what I’m discussing are what are called mesenchymal stem cells, um, and, and quite frankly, that’s a misnomer as well. Um, basically, if you think about what’s, what are, what are stem cells, um, stem cells, uh, when we think about stem cells, most people think about what are called pluripotent stem cells, meaning that they can change into anything.
Emma Green: Right.
Dr. Patel: And that’s the little guys that are in your embryos, right?
Emma Green: Yeah.
Dr. Patel: When, when your fetus is and your body is changing, right, we, we, we go from semen and, and egg to, to all of a sudden we’re proliferating all the way to hands and feet and all that kind of stuff, right?
Emma Green: Yeah.
Dr. Patel: So those cells can literally change into anything. What they do is they go down specific lines. So there’s the line called the mesenchymal stem cell that could change into bone, muscle, uh, uh, tendon, all of those structures. There are, uh, hematopoietic stem cells that go down the bloodlines. There’s, uh, there’s, um, various different essentially stem cells, neuroendocrine stem cells that go down to the nerves and the endocrine organs, and all these kind of different, um, types of stem cells that occur.
Emma Green: Okay.
Dr. Patel: So the mesenchymal stem cells are what we use for orthopedic conditions. Um, but there’s actually a lot of research that’s, that’s mixed in terms of whether these are actually stem cells or not. Um, we are able to get these stem cells from a few different sources. Uh, bone marrow is the most prevalent, easiest to get, uh, source of stem cells. The other area that people get these stem cells from very commonly is the adipose, is the fat. Um, but the way that we are able to extract those stem cells, um, we have to follow certain guidelines. So the FDA, um, says what is and is not allowed, um, in terms of how we’re able to get these stem cells. So from the bone marrow, we take that bone marrow out. We use a centrifuge to kind of get the different layers, and from that, we can extract the layers of stem cells. Um, and that is perfectly allowed by the FDA.
Emma Green: Great.
Dr. Patel: Uh, what is not allowed with the bone marrow stem cells is if we take those stem cells and then grow them over multiple days or grow them over multiple weeks, that culturing of the stem cells is not allowed by the FDA. That’s considered more than minimal manipulation, and that is illegal. So there are some circumstances in, in, uh, research settings where folks are able to do that, but that is purely in a research setting. Um, there are some facilities that go, uh, out of the country in order to do these type of treatments as well. Um, some have actually been shown to be safe, um, but it’s, it’s kind of outside of the US at that juncture.
Emma Green: Okay.
Dr. Patel: Now, in order to actually get stem cells from fat, the only way to do that is to chemically digest the fat, um, and that chemical digestion of the fat to liberate the stem cells, that’s considered more than minimal manipulation by the FDA.
Emma Green: Wow.
Dr. Patel: That’s considered creating a drug, and therefore, the FDA calls that illegal.
Emma Green: Wow.
Dr. Patel: So there are still a lot of clinics that are actually doing this, and this is called SVF or stromal vascular fraction. Um, and the FDA is actually starting to, to shut down a lot of these clinics. Um, it has wr- written letters. Uh, it’s been in the news. It’s been in the media.
Emma Green: Wow.
Dr. Patel: Um, because quite frankly, the research is not as good for SVF as it is for bone marrow aspirate concentrate. Um, and a lot of these clinics are taking SVF, and they’re not only injecting orthopedic things, but they’re also injecting it IV to treat somebody’s Alzheimer’s or their multiple sclerosis or their diabetes or whatever under the sun, and they’re really not doing evidence-based medicine. Um, they’re, they’re loosely basing things off of, uh, very, very early research-
Emma Green: Mm-hmm
Dr. Patel: … and quite frankly, taking advantage of patients. So-
Emma Green: Yeah
Dr. Patel: … we don’t know if it’s even safe. It may be, and shoot, it may be beneficial, but we just don’t know at this juncture.
Emma Green: Right.
Dr. Patel: Um, and because that has exploded with something that is a chemical digestion that the FDA considers a drug, they’re saying that that’s illegal. Now-
Emma Green: Yeah
Dr. Patel: … there are other treatments from the fat that are legal, um, but it’s not technically a stem cell treatment, where you take the fat and you kind of pulverize it or micronize it, and that is considered a fat graft. Um, and, and there are some folks that are doing that, and that is legal, um, per the FDA currently. Um, and, and, and there is some growing research in that that looks like it may be promising for certain orthopedic conditions.
Emma Green: So like what? What, what are they doing with that fat graft? Where are they putting it?
Dr. Patel: Um, so, uh, there is some research so far, uh, for things like rotator cuff tears, um, even for knee osteoarthritis. Um, it seems like there is some, some growing literature in, in some various different orthopedic conditions. Um, right now I’m kind of, you know, trying to figure out the per– the, the application that’s most, uh, appropriate for that.
Emma Green: Yeah.
Dr. Patel: Um, so I’ve trained how to do those type of procedures, but I haven’t started doing them yet because I, I wanna make sure that I’m doing it for the right cases.
Emma Green: Sounds good. And again, are not covered by insurance.
Dr. Patel: Yeah. The… None, none of these treatments are covered by insurance because, you know, as I mentioned with the PRP, with PRP being all over the place-
Emma Green: Right
Dr. Patel: … um, but PRP being around for years-
Emma Green: Yeah
Dr. Patel: … um, stem cells, whether it’s adipose graft or if it’s bone marrow stem cells, um, that’s still, like I said before, the new kid on the block, right?
Emma Green: Mm-hmm.
Dr. Patel: So it’s, it’s… the… still the research is still growing in that arena.
Emma Green: Okay. Um, so with regards to stem cells, um, you’re, you’re using stem cells. You are doing the bone marrow graft, and you’re using stem cells. Are, are you using them in spinal conditions? What are you using them for?
Dr. Patel: Yeah. So I, I use stem cells for, um, a f- uh, several different types of conditions. Um, as far as the spine is concerned, um, more often than not, I’m using a patient’s own blood growth factors, PRP and, and, uh, and-
Emma Green: Okay
Dr. Patel: … derivatives of PRP. Um, but there are specific spine conditions that I will use a pat- a patient’s own bone marrow aspirate concentrate or the bone marrow stem cells, and the two major things are if there’s more advanced joint arthritis, um, or if there is a tear inside their disk within specific parameters. So, um, the, the disk, uh, is, is, uh, not always a culprit when it comes to pain. Y- Disk bulges happen very commonly and have no pain associated with it. But sometimes a tear occurs in the disk, and that can cause a lot of issues. Um, and, um, there is a little bit of research that suggests that stem cells and even PRP, uh, into the disk directly may actually be able to help the inflammation and pain associated with that. Um, now none of these treatments are reversing disk degeneration.
Emma Green: Right.
Dr. Patel: Um, but improving the pain associated with the disk tear may actually in fact be possible. Um, same thing with the arthritis. We can’t reverse the arthritis. We can’t reverse the degeneration in that joint, but we may be able to provide some stability. We may be able to improve the pain, and we may be able to try to prevent that arthritis from getting worse.
Emma Green: Right. Yeah. Is it, is it a procedure that could be done if somebody has had a spinal surgery in the past, say somebody has a fusion? Are, are they still able to benefit from some of these injectables?
Dr. Patel: Yeah. So, you know, anytime any surgery is done, whether it’s spinal or otherwise, it kind of puts a little bit of a monkey wrench into the situation, right? Uh, the, the anatomy is inherently, uh, altered.
Emma Green: Mm-hmm.
Dr. Patel: Um, so we’re not gonna get as reproducible, as great results as, uh, as somebody that has had no surgery. Um, but it, but it is still possible. In fact, I’ve treated a lot of patients that have had prior surgeries and with, with some fairly significant benefit. So with a, a spine surgery, for example, a fusion, um, what we oftentimes see, uh, I’ll see a couple different varieties, either somebody that has had a fusion but still continues to have nerve irritation or some residual nerve irritation from the same area that the fusion has taken place-
Emma Green: Mm-hmm
Dr. Patel: … whether there’s scar tissue there or whether the nerve damage is kind of, uh, too bad, um, that had occurred. Um, and in those circumstances, using your blood platelet growth factors may actually be really beneficial. Um, I had a, uh, great patient, and I, I could share you the, the pictures on Instagram. I’m working on cell… uh, on, on publishing the case. Um, but essentially, uh, this patient had, um, uh, a motor vehicle accident, had a neck injury, had a fusion of two levels of his neck, had improvement of his symptoms down his arms, was doing really well, um, then had a re-injury to the neck. Um, the nerve became damaged. He had to have a repeat surgery, um, but he still had nerve damage. The muscles were still very atrophied or, or, uh, decreased in size, and he had z-zero strength in certain muscles. Um, and we were, were able to inject, uh, uh, in the epidural space, the space that surrounds the nerves. Um, and once he started to get some sensation down into the arm, we actually injected directly into the muscles, and we were able to regrow the muscles at a more rapid pace than the normal healing would be expected.
Emma Green: Wow.
Dr. Patel: So, um, it was pretty remarkable case. Not all cases are like that, right?
Emma Green: Yeah.
Dr. Patel: Um, you know, it– a lot of factors were for us in that situation. Um, he did some intensive physical therapy, which was really, really necessary. Um, it was also a relatively, uh, recent injury, um, and, and I think that, you know, it wasn’t this chronic nerve injury for years and years and years, right?
Emma Green: Yeah. Yeah.
Dr. Patel: Um, but, you know, those are the type of situations post-operatively we can help. Now, with fusions, people also get things like adjacent segment disease when you start to develop arthritis changes above and below. Uh, the ligaments can get looser above and below. The joints can get irritated. The disc can get irritated. Those are things that we can certainly treat as well. Um, but those also can be challenging in certain circumstances.
Emma Green: Yeah. It, it seems like from what you’re saying, a, a lot of the, um, the best results come from when these, um, injuries are most acute. So when, when-
Dr. Patel: That’s true to say
Emma Green: … to get the, the best result, you’re looking at sort of, uh, the acute injuries. But, I mean, what about people who have chronic pain? I mean, there, there are people out there who have suffered for years, and they’ve tried everything under the sun, and, you know, a lot of them are now looking at some of these new procedures and wondering, “Is that something that can help me?” What’s your, what’s your experience with those types of patients?
Dr. Patel: Yeah. Actually, most of my patients fall into the chronic pain category. Um, and, and I think this is where I, I wanna differentiate regenerative medicine and regenerative medicine again.
Emma Green: Okay. Yeah.
Dr. Patel: Because when it’s, when it’s more of an acute injury, I think we have a better chance of causing healing to take place.
Emma Green: Right.
Dr. Patel: Um, whether it’s nerve damage or whether it’s, um, you know, an ACL tear in the knee, um, you know, some partial and some full thickness, uh, ACL tears, we can actually get them to heal without surgery. Um, but if that’s a tear that took place thirty years ago and there’s a ton of scar tissue that’s already grown there, um, then that’s not something that I think is realistic as far as true regeneration is o- is, is to occur.
Emma Green: Makes sense.
Dr. Patel: Um, but on the other hand, um, can we improve pain? You know, can we improve the negative environment of the joint? Um, and, and the answer to that is, is most likely yes in a lot of situations. So, you know, when we have a chronic condition… Let’s talk about knee arthritis, right? Um, people get hung up on the idea that your cartilage is decreased with knee arthritis, um, but there’s argument i-i as to whether the cartilage itself is actually the pain generator or not. Um, you know, we see a lot of patients that have no cartilage and have no pain associated with it, right?
Emma Green: Yeah. Absolutely.
Dr. Patel: So the question is, what’s causing the pain? And oftentimes, when the cartilage is worn off, um, and we’re putting abnormal pressure into the joint, so we have– if we have abnormal mechanics for whatever reason, um, and we’re putting abnormal pressure into the joint, then, then there’s excess pressure that takes place onto the bone where the cartilage is decreased, and over time that bone reacts to that excess pressure. Sometimes that bone can become this kind of chronic bruised state, and ultimately what that is is that the local stem cells that live in the area are not working the way that they should be. So the local stem cells, when we think about what happens with an injury, right? If you twist your knee or if you twist your ankle and that swelling that occurs, that’s all the local stem cells and, and other cells, macrophages, all these things coming to the area to, to clean out the, the damaged tissue and s- lay down the foundation for healing, right? So that’s inflammation. That’s healthy inflammation. Um, and that should come, but then that should go. And what regulates that process partially is most likely the local stem cells that live in that area. So if the local stem cells aren’t great, and we have that in a, in a joint that has more chronic and severe arthritis, then when you do put abnormal pressure into the joint and it gets inflamed or irritated, the local environment can’t fight that inflammation. So instead of that inflammation coming and going, it comes and stays. And, uh, I, I, again, sorry to all the patients of mine that are listening and hearing this again, but I, I say inflammation is like the demolition day of a home reconstruction. Um, you know, we’re taking off the, the damaged kitchen cabinets in order to lay down new kitchen cabinets, um, but it should come and go, and if you get stuck in inflammation, now you’re not only taking off the kitchen cabinets, but you’re taking off the drywall too, right? So that chronic inflammation actually then makes the degeneration worse. So theoretically, the stem cells in this setting actually don’t work as stem cells. Um, and this is not true regeneration that’s occurring. They’re not actually regrowing tissues, so to speak. Um, but what they’re working or how they’re working is what’s called a paracrine effect. So the-
Emma Green: Wow
Dr. Patel: … these, these stem cells actually communicate with the local environment. They actually help activate the local stem cells and, and get that local environment to fight off the inflammation in an appropriate manner. So the, this is, this is such a hotly debated topic within my world that, that the person that actually named mesenchymal stem cells is a doctor by the name of Arnie Kaplan. He’s actually since then said, “I don’t wanna call it mesenchymal stem cells anymore.” He wants to call it medicinal signaling cells because they’re not actually acting like stem cells. So I think that that is the situation for these chronic su- you know, conditions. When we’re injecting your fresh stem cells to the area, it’s a chemical effect. It’s what’s called the paracrine effect. That’s how we can actually get improvement of pain and function in that region. When it’s more of an acute injury, we might actually have true regeneration occurring in that area. Um, so that’s kind of the debate right now. Are, are these MSCs working as stem cells or signaling cells? And the answer is probably a combination of both.
Emma Green: Right. Yeah. That, that’s– But really it, it kind of kicks off the body’s own natural process that has been going on, right?
Dr. Patel: That’s, that’s exactly right.
Emma Green: Yeah.
Dr. Patel: Exactly.
Emma Green: That’s so interesting. So is anything that patients should do before they get to the point of considering injectables? Because after all, it is an invasive procedure. What, what should they be doing beforehand? What should they be considering before they get to the point where they’re thinking, “Okay, now I need to go with these injectables”?
Dr. Patel: Th- that’s a great question. And, and to, to answer that question is, basically I– when I see my patients, I talk to them from multiple angles. Um, you know, the, the truth is it is an invasive procedure, but it’s a heck of a lot at less invasive than a surgery, right?
Emma Green: Absolutely.
Dr. Patel: But more importantly than the invasiveness is, is, is how is it gonna work? Um, and to me, if our body is not moving correctly, um, if our nutrition, our internal environment is not good, then we’re setting ourselves up for a disaster with these interventional procedures, with these, these biologic procedures, right? So I can put stem cells till the cows come home into a joint that has arthritis or whatever it may be, but if we’re walking at a weird angle, if we’re not activating our butt muscles so every step we take our knee is moving inwards, then, then it’s not gonna work, right?
Emma Green: Yeah.
Dr. Patel: So when we do these stem cell treatments, and again, this is why we have to go to, you know, a specialist, I, I’m not just injecting into the joint, I’m injecting into the ligaments. I wanna strengthen those ligaments, provide stability to the area, inject various tendons, all these structures in order to provide stability and get the body moving correctly. But if we’re not doing the work to rehab and to prehab the joint, then we’re not gonna get the best results. So when I see a patient, if they haven’t had physical therapy, if they haven’t been paying attention to their nutrition, that’s the kind of stuff that I talk about leading up to any procedure that we may or may not do.
Emma Green: Okay.
Dr. Patel: And, and the truth is, most of these conditions, as you know, most of these conditions respond to physical therapy and nutrition alone, and patients are able to get better overall, you know?
Emma Green: Right.
Dr. Patel: Um, what, what I do is really just a catalyst, and I’ve said this in, in other talks and interviews before, really what I’m doing is just a piece of the puzzle. It’s really the, the exercise and, and taking care of your body that’s the main thing.
Emma Green: Right. Absolutely. So if somebody is looking for that magic fix, they’re looking for the magic pill, the magic injection, the magic wand, it’s not there, right?
Dr. Patel: It’s not there. And, and that’s, that’s the hard thing, right? Because there are people that are promising it. Um, and-
Emma Green: Yeah
Dr. Patel: … and that’s, that’s, that’s what I wanna kind of spread is that there is a lot of people that are promising that magic pill. They’re promising that, you know, “You don’t gotta do any work. We’ll do this, and you’ll regrow your, your knee,” right? But that’s just not true. So-
Emma Green: Yeah
Dr. Patel: … um, we gotta hit things from multiple angles, and, and I think that’s important.
Emma Green: So how do people go about researching? If, if they, they have been through physical therapy, they have been- So, uh, their, their nutrition is good, and they’re, they’re thinking about, you know, “This is the next step. I don’t want to be considering surgery. I maybe do want to be considering some kind of a, a in- injectable procedure.” How do they go about researching who to go to?
Dr. Patel: This is a hard question, um, because, as I mentioned before, there’s a lot of good folks doing this. There’s a lot of, uh, not so good folks doing this. Um, I, I think that there are a few organizations-
Emma Green: Mm-hmm
Dr. Patel: … uh, that are worth, um, you know, looking into. Um, I, I, uh, full disclosure, I teach for, uh, the Interventional Orthopedics Foundation. Um, that is an organization that’s a non-for-profit, um, and we basically teach other docs how to do these type of procedures. Um, so the, the Interventional Orthopedics Foundation website does have, uh, a list of people that have taken the various different courses that we offer. Um, so that’s one resource for sure.
Emma Green: Yeah, if you let me have the link afterwards, I’ll pop it in the show notes, and then people can click straight through.
Dr. Patel: Absolutely. Um, and then there’s a few other organizations. Um, the American Academy of Orthopedic Medicine, um, is another organization that focuses on regenerative medicine, um, procedures. Um, uh, there, there’s a network called Regenexx that I am a part of, um, that, uh, treats, uh, trains physicians how to do these specific types of procedures and specific protocols. Um, so there’s a few different resources that are available. Um, Google could be our friend or our foe.
Emma Green: Dr. Google.
Dr. Patel: Um, I think, uh, I think Google’s actually a valuable resource. We just have to be smart in terms of how we use it. Um, so, you know, looking up stem cells in whatever state or city that you’re in is perfectly fine, but looking at that website and seeing, you know, are they offering every type of treatment under the sun for every condition under the sun, right?
Emma Green: Right.
Dr. Patel: Are they making claims like they’re gonna regrow cartilage and, and heal 100% of their patients?
Emma Green: Right.
Dr. Patel: Um, you know, what’s the training of the physician that are doing the treatments?
Emma Green: Yeah.
Dr. Patel: Um, there, there are a lot of clinics that are chiropractic clinics-
Emma Green: Absolutely
Dr. Patel: … that have a nurse doing the injections, and that does not have any additional training on image-guided procedures-
Emma Green: Yeah
Dr. Patel: … for a specific area. So it’s, it’s some scary stuff sometimes, but, you know, that’s the kind of stuff that you can find or, or look out for.
Emma Green: How can people find out more about you?
Dr. Patel: Sure. So, uh, a few different resources. Uh, I’m on social media, on, uh, Instagram, Facebook, Twitter, all under the handle @stemcelldrpatel. Uh, my company website is, uh, www.healthlinkumcenter.com, and I, we can give you that information-
Emma Green: On the show notes, yeah
Dr. Patel: … as well. And yeah, we can, you know, make sure that you have my contact information and everything.
Emma Green: Yeah, for sure. Sounds good. Um, so we’ve pretty much come to the end, um, of the show, and I do have a couple of, of last-minute questions that I would like to ask you.
Dr. Patel: Absolutely.
Emma Green: What is your favorite book?
Dr. Patel: Oof. Favorite book. Um, Life of Pi.
Emma Green: Oh, okay. Okay. Okay. I’ve not even seen the movie, but …
Dr. Patel: I haven’t seen the movie. I haven’t seen the movie, but the, the book was fantastic. Um-
Emma Green: Okay
Dr. Patel: … I, I-
Emma Green: We’ll accept that
Dr. Patel: … it, my second favorite is gonna have to be, like, a random textbook, so it’s… I think that’s all you’re gonna get for now.
Emma Green: And what, what are your hobbies?
Dr. Patel: Um, right now it seems like my only hobby is playing with my two-year-old and my four-month-old. Um, but-
Emma Green: Hands full, that’s for sure.
Dr. Patel: Hands full, a little bit. Um, I, I do like photography, drawing, snowboarding. Um, and I, I, I miss more activities than I do.
Emma Green: And is there anything I should have asked and didn’t?
Dr. Patel: I think you were really comprehensive.
Emma Green: Okay.
Dr. Patel: This has been a lot of fun.
Emma Green: Great. Thanks so much. You know, I really appreciate you joining me for this. It’s really given me a lot of food for thought. You’ve, you’ve given some great advice for people there. It’s such a confusing area for a lot of people. Uh, and I think just listening back to everything that you mentioned, all the different things, that’s gonna be immensely helpful for a number of people. So thank you so much for your time today, Dr. Patel.
Dr. Patel: Absolutely. No problem. It was, uh, it was my pleasure.
Emma Green: Thank you. Thanks so much.
Dr. Patel: Thanks. Have a good one.
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In this very special episode, Dr. Patel debunks the most popular and uncommon myths regarding Stem Cells and Exosomes. During this episode, we cover everything from FDA guidelines and research, the best source of stem cells, how people are getting scammed by “sales” men and more.