Most individuals have a tendency to make New Year's resolutions based on superficial personal aesthetics which subsequently vaporize in the month of January after the health clubs, fitness centers, diet centers and other entities have capitalized on our insecurities and holiday indiscretions. Why not turn the tables and focus on making resolutions for your practice that can simultaneously get it fatter and fit?
Think about what you have neglected for your practice that would make it really shine. We, in the field of regenerative orthopedic medicine fly in the face of current medical dogma on a daily basis. Big Pharma, orthopedic surgeons, endocrinologists, to name a few, are usually not our best friends. Marketing to our colleagues, though informative, is a low yield event. To my knowledge, Domino sugar has never come to our rescue and supported research on prolotherapy. So who can we turn to?
The patients get it! We treat them. They get better. They tell others and the word of mouth spreads. But this takes time … a lot of time. So how can you shorten that time period? How do you create those win–win situations? How do you get them to want you and what you have to offer? It's all about helping potential patients see and feel the benefit of our treatments. You see, like it or not, we are all sales persons more or less; some more and some less. We are selling a cash based treatment and people are inherently cost conscious; most solely want what their insurance company will pay for and that's it. We offer a revolutionary product. Our treatments can change patient's lives! So what?
I've made a lot of mistakes and spent a lot of money over the years in "advertising" and "marketing". I've been in radio ads and magazine ads. People generally don't want to be pitched. I've given talks to the wrong groups of doctors. I've gone to doctors offices and provided lunches (you really get to empathize with the drug reps on this one). This reminds me of one of my favorite Dan Hicks songs, "How can I love you when you won't go away". Earlier this year, my practice worked the Pittsburgh Marathon pre–race two– day event that yielded not a single referral. Live and Learn. Well, I'm still alive and still learning my lessons.
I remember years ago when Ken Knott mentioned advertising in gay male publications/ community. Why, I asked? Ken's reply was simple and to the point. These are people who are invested in their health, fitness and appearance. They are a natural audience for the treatments that we provide. In essence consider your ideal patient and their related interests.
Recently, I contacted a local TV station to promote the concept of a story about stem cell treatments. It resulted in a professional four minute segment that was personal and to the point. It featured one of my patients undergoing a bone marrow harvest and having stem cells implanted in his knee. He was a near 60 year old athlete who didn't want to have a knee replacement. His testimonial though not flashy was believable, the audience could relate to him. The response to that segment was overwhelming!
This was a no brainer and yet prior to doing this piece, I didn't see it. People truly don't want to undergo total joint replacements and will chose a viable alternative if they think it's legitimate alternative, more often than not.
It's the personal touch that sells! Get testimonials on your website. Make your website appealing to the patient. Mayo has pointed this out time and time again. Can I, as your potential patient, find myself and my condition on your website and can you potentially solve my problems? If so then I'm yours. Obviously, this is an oversimplification yet it illustrates a powerful concept. So skip the ads, gimmicks, and concentrate on the media and your website. Put yourself in front of patients who potentially will benefit from the treatment that you provide. Find your audience and they will find you.
We provide life enhancing treatments. We heal patients! It's time that they find us based on the benefits of our care. Explore ways to get your message across in a simple and straightforward manner. Help them see and consider the effective alternatives that you provide. Create that win–win situation for you and your patient. May you get healthier and your practice fatten up in the coming year!
"Your fences need to be horse–high, pig–tight and bull–strong."
"Keep skunks and bankers at a distance."
"Life is simpler when you plow around the stump."
"A bumble bee is considerably faster than a John Deere tractor."
"Words that soak into your ears are whispered … not yelled."
"Meanness don't just happen overnight."
"Forgive your enemies; it messes up their heads."
"Do not corner something that you know is meaner than you."
"It don't take a very big person to carry a grudge."
"You cannot unsay a cruel word."
"Every path has a few puddles."
"When you wallow with pigs, expect to get dirty."
"The best sermons are lived, not preached."
"Most of the stuff people worry about, ain't never gonna happen anyway."
"Don't judge folks by their relatives."
"Remember that silence is sometimes the best answer."
"Live a good and honorable life, then when you get older and think back, you'll enjoy it a second time."
"Don't interfere with somethin' that ain't bothering you none."
"Timing has a lot to do with the outcome of a rain dance."
"If you find yourself in a hole, the first thing to do is stop diggin'."
"Sometimes you get, and sometimes you get got."
"The biggest troublemaker you'll probably ever have to deal with, watches you from the mirror every mornin'."
"Always drink upstream from the herd."
"Good judgment comes from experience, and a lotta that comes from bad judgment."
"Lettin' the cat outta the bag is a whole lot easier than puttin' it back in."
"If you get to thinkin' you're a person of some influence, try orderin' somebody else's dog around."
"Live simply, love generously, care deeply, Speak kindly, and leave the rest to God."
"Don't pick a fight with an old man. If he is too old to fight, he'll just kill you."
One of the major goals of the AAOM is to educate physicians in the art of Prolotherapy. There are many factors involved in administering prolotherapy including knowing the anatomy, the proper approach, the intensity of the treatment, which solution to use, the patients tolerance for the procedure and the likelihood of their healing based on the overall health and the severity of the injury being treated. The balancing of these considerations is what constitutes the "art" of prolotherapy.
With the goal of teaching the science and art of prolotherapy in mind the AAOM has sponsored workshops in Lima, Peru and in Ciudad Guzman, Cancun, and Guadalajara in Mexico over the last few years.vEach workshop has consisted of 5 or 6 instructors, which are among the most experienced and knowledgeable prolotherapists in the AAOM working with students in a ratio of 1:4 which has resulted in an excellent learning experience for the students.
The most recent of our workshops was held November 3–8, 2013 at the Hospital Civil in Guadalajara, Mexico with the assistance of the Department of Physical Medicine and Rehabilitation headed by Dr. Jesus Gonzales and his residents. Andrew Kochan was Director of the Clinic and of the educational program and introduced several innovations with regards to the teaching program and the organization of the clinic. The program started on November 3 with a day of little lecture and a lot of student practice drawing on each other the surface anatomy of the relevant joints we were going to be injecting the next day in clinic.
Each clinic day started with a lecture on a particular joint by one of the instructors. Each instructor was designated the expert for a particular joint or body part for the week. If a patient showed up with a particular joint issue they would be triaged to that instructor. The students were divided into groups of 4 and would rotate together between instructors each half day. Thus, the students would hopefully be exposed to the same area/ joint 3 or 4 times in a row and thus would get reinforcement for what they were learning. The instructors Paul Lieber, Jonathan Fenton, Neal Kirschen, Wahid Burad, Miguel Zurate and Andrew Kochan did a wonderful job supporting this new system and made it work well. The students were very happy with the quality of teaching and what they got out of the program feeling that they could go home and implement some of what was taught. We were able to see about 700 patients and treat almost 800 joints during this week. The patients were scheduled to be followed in the PM&R outpatient clinic by the resident physicians in 4 to 6 weeks. It will be interesting to get feedback from them next year when we return.
The AAOM is determined to give students the best educational experience possible. We will continue to evolve our new Prolotherapy Education Curriculum (PEC) over the coming months. The PEC along with our hands–on training programs will be integrated into a standardized, sequential, graduated series of learning experiences – starting with the basic introductory course (Prolo 101), and proceeding to intermediate (200), advanced (300), and Master/Expert (400) levels courses. We believe once completed and implemented the PEC will give each student of Prolotherapy a progressive and experiential learning exposure second to no other. Come to the AAOM 2014 Conference in Clearwater and experience Prolotherapy 101: A Primer the first time the AAOM will be offering the new curriculum! Prolotherapy 101: A Primer will be offered on Wednesday, April 9, 2014 and it will be under the direction of Tommy Bond, MD and will include the Masters for teachers; Tom Ravin, MD, Ken Knott, MD, Carl Osborn MD and Mayo Friedlis, MD. We are looking forward to continuing the AAOM educational evolution during the coming years.
Today, one American develops Alzheimer's disease every 68 seconds. Alzheimer's disease is the 6th leading cause of death in the United States overall and the 5th leading cause of death for those aged 65 and older. It is the only cause of death among the top 10 in America without a way to prevent it, cure it or even slow its progression. In light of this, research is paramount. Two recently published studies revealed some exciting information.
Ground–breaking research from Oxford University revealed that B vitamin supplements STOP Alzheimer's brain shrinkage! The Medial Temporal Lobe, the lobe that degenerates in Alzheimer's patients, virtually stops shrinking in people taking B vitamins.
The supplement group received B vitamin supplementation which included 800 mg folic acid, 20 mg B6, and 500 mg B12. The researchers used MRI technology to map the brain before, during and after the 2 year study period.
The researchers stated, "This is the first treatment that has been shown to potentially arrest Alzheimer's related brain shrinkage."
The findings were published in the Proceedings of the National Academy of Sciences of the USA.(1)
In light of these findings, a study published in the December 11, 2013 issue of JAMA,(2) becomes increasingly pertinent. Kaiser Permanente Division of Research, conducted a case&nash;control study in which they found the use of acid inhibiting medications (PPIs) for 2 or more years may lead to a vitamin B12 deficiency.
Another study, spanning 35 years, comes from Cardiff University. Wales, in the United Kingdom.
Researchers found five factors that were integral to helping avoid disease as we age. They were regular exercise, not smoking, low body weight, healthy diet and low alcohol intake. People who following four of these had a 60% decline in dementia rates and cognitive decline rates. However, exercise had the single biggest influence on dementia levels. The research was published in the PLOS One journal. (3)
This study adds to the growing body of evidence demonstrating that what is good for your heart is also good for your brain. It also demonstrates just how much of our health and wellness is in our own hands.
(1) Preventing Alzheimer's disease–related gray matter atrophy by B–vitamin treatment.
Gwenaëlle Douaud, Helga Refsum, Celeste A. de Jager, Robin Jacoby, Thomas E. Nichols, Stephen M.
Smith, A. David Smith
Proc Natl Acad Sci U S A. 2013 June 4; 110(23): 9523–9528. Published online 2013 May 20. doi: 10.1073/pnas.1301816110
(2) Proton Pump Inhibitor and Histamine 2 Receptor Antagonist Use and Vitamin B12 Deficiency Jameson R. Lam, MPH1; Jennifer L. Schneider, MPH1; Wei Zhao, MPH1; Douglas A. Corley, MD, PhD1. JAMA. 2013;310(22):2435-2442. doi:10.1001/jama.2013.280490.
(3) Healthy Lifestyles Reduce the Incidence of Chronic Diseases and Dementia: Evidence from the Caerphilly Cohort Study. Peter Elwood, Julieta Galante, Janet Pickering, Stephen Palmer, Antony Bayer, Yoav Ben–Shlomo, Marcus Longley, John Gallacher Research Article | published 09 Dec 2013 | PLOS ONE 10.1371/journal.pone.0081877
Background: The presence of high blood flow in the structurally abnormal and painful regions of tendinosis, but not in the normal pain–free tendons, was recently confirmed by colour Doppler (CD) ultrasound (US). Biopsies from the regions with high blood flow demonstrated the presence of sympathetic and sensitive nerve fibres juxtapositioned to neovessels. Grey–scale US and CD are reliable methods used to evaluate structural homogeneity, thickness, and blood flow in the peripheral tendons. The aim of this study was to utilize CD to qualitatively evaluate for the presence of abnormal high blood flow in paravertebral tissues after whiplash injuries in patients with chronic neck pain.
Methods: Twenty patients with chronic neck pain after whiplash–associated disorder (WAD) and 20 pain–free control subjects were included in the study. The same experienced radiologist performed all grey–scale US and CD examinations.
Results: More regions with high blood flow were observed in the patient group than in the control group. At all levels, the high blood flow pattern was detected at the enthesis of the spinous processes and bilaterally juxtapositioned to the facet joints.
Implications: These findings document increased blood–flow/neovascularisation at insertions of neck muscles which may indicate that there are pathological neovascularisation with accomanying pain– and sympathetic nerves, similar to what has been found in Achilles–tendinosis. These findings promise that similar treatments that now is successful with Achilles tendinosis, may be effective in the WAD–painful muscle insertions of the neck.
Conclusion: All regions identified by the patients as painful and tender corresponded to the positive high blood flow found during the CD examination.
Platelet Rich Plasma (PRP) has been used extensively in the fields of reconstructive cardiovascular surgery, plastic surgery, spine surgery, oral and maxillofacial surgery, podiatric surgery, advanced wound care and is now being introduced to pulmonary care. PRP is defined as a sequestration and concentration of platelets within the plasma fraction of autologous blood. The philosophy behind the use of PRP is the deliverance of high concentrations of growth factors and cytokines to enhance the healing process.
Platelets are colorless cell fragments, produced when the cytoplasm of bone marrow, termed megakaryocytes, fragment, and enter the circulation.1 Platelets do not contain a nucleus, but have organelles such as mitochondria and granules, with α granules containing more than 30 bioactive proteins that play an essential role in hemostasis and hard and soft tissue healing.2 Each platelet has approximately 50 to 80 α granules and platelet counts of 150,000 to 300,000/μL are considered normal in the human blood.2,3 PRP should achieve a three– to five fold increase in platelet concentration over baseline, and a PRP count of 1,000,000 μL is regarded as the benchmark for PRP.4 Alpha granules contain numerous proteins and peptides that aid in cellular migration and growth including platelet derived growth factor (PDGF), transforming growth factor (TGF–β), insulin–like growth factor (IGF), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), platelet factor 4, interleukin–1 (IL–1), platelet derived angiogeneis factor, platelet derived endothelial growth factor, epithelial cell growth factor, osteocalcin, osteonectin, fibrinogen, vitronectin, fibronectin, and thrombospondin.2,4 Exogenenous delivery of PRP after activation results in platelet aggregration and clotting after approximately 10 minutes.5 During this process, platelets are actively secreting proteins from α granules, and within 1 hour approximately 95% of the α granule contents have been secreted.5
The theory behind PRP is to increase the concentration of platelets to an injured site. During an acute injury, the addition of PRP increases the concentration of platelets over the baseline that is normally activated during the inflammatory phase.3 Chronic injuries occur when the inflammatory phase has ceased, the phase which platelet activation normally occurs. The addition of PRP to chronic injuries reintroduces activated platelets and restarts the inflammatory phase, leading to healing.3
The efficacy in using PRP has shown promise in many clinical aspects, including augmenting cartilaginous and tendinous/ligamentous injuries. In vitro studies have shown that PRP has the potential of increasing proteoglycan and collagen synthesis in chondrocytes.6 When discussing tendinous and ligamentous injuries, PRP is thought to reverse the effects of tendinopathy by stimulating revascularization and improving healing at the microscopic level.7
In addition to musculoskeletal injuries, clinical and experimental observations indicate that platelets are important and potentially essential for systemic and pulmonary vascular integrity. This is supported by the fact that thrombocytopenia occurs frequently in acute lung injuries and acute respiratory distress syndrome. Adhesive interactions with neutrophils, monocytes and other immune cells in pulmonary artery blood are influenced directly by platelet number. Other anatomic and functional evidence demonstrate that platelets deposit in the acutely injured lung but the exact contributions of platelets remain to be determined.8
This purpose of this study is to present a multitude of case studies of both acute and chronic injuries. The patients in these studies have exhausted conservative care options and sought out alternative treatment for their condition in attempt to avoid continued steroid/pharmacotherapy or surgical intervention.
Instances of epidural injections for the purpose of pain relief are widespread and effective, yet even under proper administration the procedure is not without risk. Well established risks include infection, paralysis, and headache indicative of a number of complications including spinal headache, hemorrhage, or hematoma [1,2,5,6,9]. Injected steroids have been documented to cause septic and aseptic meningitis as well as spinal cord embolisms wherein the steroid itself is the causative agent . In the case of pregnancy, steroids can prolong labor, lead to complications or even end in either fetal or maternal death; therefore, a need arises to find a safe alternative to steroid injections for pain management in pregnancy.
This paper presents an interesting pain management case wherein the patient being treated for cervical and lumbar pain became pregnant and thus became contraindicated for the corticosteroid injections under fluoroscopy as planned. Due to our clinical success using Platelet Rich Plasma (PRP) in place of steroids for joint and ligamentous and even spinal injuries this was a logical alternative choice . Blood has proven natural regenerative capabilities thus utilizing platelet rich plasma epidural injections was determined to be the most desirable method for treatment of her back pain during pregnancy.
The practice of re–administering autologous blood with platelets and growth factors concentrated by centrifugation as a means of managing pain and accelerating healing is spreading. While being met with the skepticism that science necessitates, pain relief and accelerated healing have been documented in dental medicine, sports medicine, orthopedic medicine, and wound care, while pilot studies are being conducted in neurological and cardiovascular fields [3,4,7,8,10,11]. Even studies comparing PRP to corticosteroid injections for the purpose of pain management show PRP to be a safe and effective means of treatment . Despite the controversy surrounding the efficacy of platelet rich plasma, providing the patient with autologous blood under sterile conditions without sedation was a safe and fast way to provide her with significant pain relief during pregnancy.
MC is a 35 year old female who had her initial consultation on July 11th, 2011. The patient's initial complaints were of neck pain with headaches and radiation of symptoms to the parascapular area and upper extremities. She also presented with low back pain and lower extremity radiation of symptoms. This pain has been ongoing since a motor vehicle collision on March 3rd 2011. The patient was pregnant at the time of the accident and experienced temporary contractions following the accident without other pregnancy complications. She was unable to seek conventional therapies for her pain due to the pregnancy.
Upon her initial visit at the office, the patient stated that her pain was worse with sitting or standing. Her exam revealed spinous process tenderness to the cervical, thoracic, and lumbar spine with palpable muscle spasms and limited range of motion due to pain. The risks and benefits of treatment were explained and the patient received a cervical steroid injection on the same day as her initial visit with no complications. She had 3 days of relief before her neck pain returned. A repeat steroid injection was given on July 26th 2011, with little short term relief. Afterward, the patient was referred to physical therapy where she received 6 months of treatment with no long term relief of her pain. When returning back to the office in January 2012 the patient received occasional cervical or lumbar steroid injections with no more than a few weeks of relief before her pain returned.
On June 27th 2012 she returned to the office complaining of neck pain and stating that she was currently 10 weeks pregnant. After considering her pain management options she agreed to a cervical Platelet Rich Plasma (PRP) epidural catheter injection. The procedure was scheduled for July 24th 2012. During the procedure, a Tuohy epidural needle was advanced into the epidural space. An epidural catheter was then used to inject 9cc of platelet rich plasma with 18cc of platelet poor plasma targeting C4 through C6 bilaterally. PRP was also administered as cervical paraspinous trigger point injections using a fan–type distribution. The patient tolerated the procedure well and was able to be sent home after a short recovery.
A follow up call was placed the day after her PRP injection where she stated that she had a 50% improvement in her pain and was only experiencing pain at the injection site. On her one week follow up visit, she reported that her symptoms were still improving and that she was pleased with the results of the PRP injections verses the steroid injections. The patient requested another PRP injection to manage her low back pain which was scheduled for 8/20/12 and the patient reported that her lumbar pain resolved for 3 months after the procedure. Soon after, the patient delivered a healthy child with no adverse effects from the treatment.
This case study suggests that PRP injections are a safe and effective alternative treatment option for pain management of pregnant women. Pain management for pregnancy is limited due to the adverse effects that certain medications and treatment options such as corticosteroids can have on the developing fetus. PRP can possibly be used as an option to treat many other ailments that arise as a direct result of the pregnancy. Further studies are necessary to confirm the efficacy of pain management via PRP injection during pregnancy that was observed in this case.
Visit the Journal of Anatomy to read about Anatomy of the Anaterolateral Ligament of the Knee Read the article
Sports, Spine and Beyond – Latest Advances in Regenerative
Clearwater, Florida April 9–12, 2014
The AAOM annual meeting is not just the same–old topics that you can hear at every other medical conference. If you want "out of the box, cutting edge" thinking and information, come to the AAOM – you will not find this type of program and the camaraderie to share ideas anyplace else.
The field of Orthopedic Medicine is exploding! Though this explosion is quite positive for our burgeoning field, it is important to be able to navigate around the technological advances, to avoid the pitfalls and be able to get what you need to enhance your patients and your practice. To that end, I've worked to combine topics from the not so traditional Interventional Pain Medicine, Sports Medicine and Regenerative Orthopedic Medicine. We will also explore advances in Manual Medicine, Nutrition, Physical Examination and Physical Therapy. We will have several workshops that include Musculoskeletal Ultrasound, Stem Cell Extraction from Adipose, Prolotherapy 101 – A Primer, Bioidentical Hormone Replacement Therapy, to name a few. The goal of this conference is to bring you state of the art techniques and technologies that can help our patients now.