Learn the in’s and outs of the following procedures, answer patient questions and make appropriate referrals: PRP, radiofrequency ablation, stem cells, kyphoplasty, epidural steroid injections. Regenerative Medicine Dr. Brian Rich, MD
Dr. Brian Rich, MD started in Family Medicine but always had a passion for orthopedics. Back in 2007 the options were limited for certain injuries: it was either operable or not. Once regenerative medicine started to show up he decided to specialize in these non-surgical methods for pain control.
First thing we do on the interview is define all the non-surgical approaches out there for spine and extremity joint pain. If we aren’t all on the same page, confusion can happen.
PRP (platelet rich plasma) – growth factors in platelet and injecting it in injured areas with guidance.
Stem Cells- signaling cells are actually what are injected not mesenchymal stem cells but the signaling cells ‘call’ the stem cells to go to the injured area… again with ultrasound guidance, not just guessing with palpation. Dr. Kaplan, PhD from Case Western is the father of regenerative medicine and mesenchymal signaling cells. Dr. Kaplan usually lectures at the TOBY Conference (National Regenerative Medicine Conference
Radiofrequency Ablation- with good guidance system you can ablate the sensory nerve to that painful spinal facet joint (basal vertebral nerve in a few years), shoulder, hip, foot or knee joint. During the interview he goes into detail about the risk, and how long the procedure lasts. RFA is for the older population and is not a fix but a functional improvement.
Kyphoplasty for Compression Fractures: Compression fractures are generally unstable and painful and over time the comorbidity is a high risk downward spiral. Ignore the 2009 New England Journal of Medicine that says otherwise, it’s been proven wrong. The vertebral body has lots of nerve plexus and so plumbing it back to its near normal height has huge benefits for the patient.
Peripheral Nerve or Spinal Cord Stimulation- These procedures are electrical units embedded into the nerve supply to reduce pain. Spinal cord stimulation “battery is implanted” while the peripheral nerve stimulation units have a device you “wear and plug in.” This procedure neuromodulators and desensitizes the pain
Epidural Steroid Injections- disc compression with radicular pain are the types of patients that should get this. Fifty percent reduction in pain for 6 months via up to 3 shots is considered a success. Remember it’s still an off label use.
Dr. Rich will discuss when, why, risk factors and benefits of each procedure mentioned.
When would you use peripheral nerve stimulation versus the radiofrequency ablation RFA? Genicular nerve, clunial nerve for example.
Which nerve is the most common for cervicogenic headaches?
When would you use bone marrow concentrate instead of plasma and why is it so important to have a good ultra-sonographer helping you. Should you use
If you do have to have a full blown surgery to repair a shoulder, can you get a shot of PRP before they sew you up to improve the results? Dr. Philippe Hernigou in France started this procedure. Differences of PRP in France and USA, it will surprise you.
Dr. Rich warns us about the ‘drive thru’ clinics where you can just show up and get injected without ever having your own blood spun down and concentrated. Why are amniotic stem cells so popular? Should you fly to another country and use someone else’s placenta stem cells for your injections?
Why is guided needle insertion so important vs just blinded or palpating?
Why is regenerative medicine not really regulated by the FDA? Which is also why the Orthobiologics Consortium was created for ethical procedures of regenerative medicine?
Why doesn’t Dr. Rich charge the maximum going rate? With only a few years of data on these therapies and with varying degrees of success length, I think it’s wise that he is more conservative in how he explains the benefits to the patients.
What are the criteria for compression fracture kyphoplasty? We describe some patients that are atypical but still get results.
What are pulmonary and cardiac PRP injections?
Mesenchymal signaling cell injections do cause pain in the area that already hurts, but that’s a good thing, why is that?
When should you refer to a regenerative medicine specialist?
Why does Dr. Brian Rich choose not to do very many epidural steroid injections, ESI? When should you do ESI and when not?
We even discuss a little about insurance, cash rates and changes over the past few years.
Dr. Brian Rich, MD first did family medicine and then transitioned into a sports medicine residency at the University of Oklahoma at Tulsa. He then did his fellowship in interventional pain with a focus on fluoroscopic guided procedures and musculoskeletral ultrasound guided procedures. He was one of the first physicians to part of the Orthobiologics Consortium which is an ethics group for responsible use of PRP and Stem Cells. He also does a lot of radiofrequency ablation “RFA”, neuromodulation of both spinal and peripheral nerves (like the knee and shoulder), and kyphoplasty for compression fractures. Between the three clinics he also spends a lot of time as a faculty member at OU.
www.acellortho.com aCELLerated Interventional Orthopedics: 3 locations in Oklahoma
He is most active on LinkedIn.
Show notes can be found at www.adoctorsperspective.net/95 here you can also find links to things mentioned and a full transcript of the show.
Justin Trosclair 0:03
Episode 95 guidelines for PRP RFA stem cells neuro modulation I'm your host Dr. Justin trust clear and today we're Dr. Brian rich perspective
2017 and 2018 podcast Awards Nominated host as we get a behind the curtain look at all types of doctors and guests specialties. Let's hear
a doctor's perspective.
Justin Trosclair 0:31
Thanks for tuning in. Episode 100 is coming up. We're gonna have new music that day. And actually you get to preview it at the end of this episode. Well, today we have a Dr. Brian rich MD three practices in Oklahoma. He specializes in non surgical as well as regenerative medicine. If you had questions about what exactly is PRP versus stem cells, what is no radio frequency ablation Kibo plus the epidural steroid injections, any of those types of questions he is going to answer him today. How why would you do it? Who's a good referral? What's the risk? What's the benefit? What should you look out for it to not do all those types of questions are going to be answered really excited even drop some names of some of the head honchos in this field regenerative medicine, so that you can look up more papers on PubMed, I guarantee you, you're going to learn something today. So let's get into it. Show Notes can be found at a doctor's perspective, net slash nine, five, let's go hashtag behind the curtain.
Live from China and Oklahoma. Today on the show. We have a doctor who did family medicine, then sports medicine residency at the University of Oklahoma, Tulsa, then decided to get his fellowship and interventional pain. So he's super skilled and for us to be guided procedures, musculoskeletal ultrasound guided procedures. And he's one of the original physicians as part of the ortho biologics Consortium, which are the group that deals with the ethics on PRP and themselves. Welcome to the show. Dr. Brian rich.
Thank you. Thanks for having me.
Justin Trosclair 2:05
Absolutely. Well, I'm excited to have you on seems to be at least in chiropractic land, PRP stem cells stuff is getting really popular. Then you got your radio frequency specialty that go along with that. So big thing you know, what, give us a little bit of the background on how do you end up you know, you're a sports guy for sure endurance athlete, I believe. And then it seems like you kind of made me want to a roundabout way to to get into the to the pain. Talk about that before we jump into everything else.
I definitely did. I actually started off in family medicine that's a little secret Not a lot of people now, I started out as a just basic Family Medicine in a residency that was guided and geared towards orthopedics and sports medicine. And I was destined to do sports medicine fellowship for the day I walked in the door. As a family medicine residents Matter of fact, my first day is it today medicine resident, I was already doing an orthopedic procedures. So it was pretty quick, but moved on from that. And then did my sports medicine fellowship in Tulsa, which covered quite a bit of different teams at all levels from the pro college all the way down to high school and just really fell in love with taking care of what begins race and be a part of that fellowship, there was some interventional pain associated with it. What I didn't like much about the treatment process was there wasn't really many options as far as treatment, and this is back in 2007. So we didn't really do much we died did a lot of diagnosing. And if there was ever an issue or something you need to be fixed, it was really it was either surgical or not, it was not surgical, a lot of times it meant the patient didn't get better. So where we are today, and interventional pain, and really with regenerative medicine, which some of the early people that started out in regenerative medicine before me, we're really doing PRP, all the way back in 2005. And you know, even before that, a lot of guys will tell you that they've been doing regenerative medicine for a long time with prolotherapy. And that's true. That's true, you don't want to forget about that. But that's really where I am today. I mean, I'm really excited about what I do today, because I actually feel like I'm actually helping people non surgically, I think that we truly have a non surgical option to treat things. I mean, I get it in situations where something require surgery. But today, I feel like we've got a lot of options now they keep patients from having an app server.
Justin Trosclair 4:40
Well, this will be fun to have a conversation a little bit later in the show about the opioid crisis, failed back surgeries. And why aren't maybe more people being referred to people like yourself in different areas of the country versus just going underneath the knife. Like if it's protocol to try out all these different options first, then you can finally get the surgery or if it's still allowed to just skip and then do something more invasive. So but let's let's do a little bit of definitions. It's good to be all on the same page when we're talking about this stuff. PRP stem cell things, radiofrequency ablation, even neural modulation vertebroplasty, if you could take a minute and kind of give us a little bit of the doctor terms also little a person, most of the audience is going to be doctors. But what are we talking about here so that we know we're not getting confused?
Sure, everything there you just mentioned is non surgical approaches to to try to treat an individual or city or situational problem. And every one of those things all combined, you know, really is almost two or three days of lecturing to explain it. But after that, I'll go through a pretty quick realistically starting off with PRP, PRP, platelet rich plasma. And what we're doing there and is you're taking the sort of the super concentrated part of the platelets that's being spun down from a centrifuge and you're really deriving the growth factors from the platelets play, let's have a lot of growth factors, a lot of plasma proteins that are growth factors, and you're rejecting it are injecting it into an area that is damaged or injured. Ideally, you're injecting into an area under specific guidance, so you know where you're going. You're not injecting these things blind life so to speak, you're putting in a specific area. So that means you've had to diagnose that area. Same thing with stem cells just a little bit more concentrated. Now, here's going to be the war that everybody's going to hear from stem cells were not injecting stem cells for injecting signaling cells is bringing the stem cells to the area to that area. That's Dr. Kaplan PhD to Case Western who was really the father of Regenerative Medicine has a really good lecture that he gives just about every year at Toby which is the National all regenerative medicine conference talking about MSC are not mesenchymal stem cells are now called mesenchymal signaling selves. And he'll tell you, he hates that because he's the one that came up with mesenchymal stem cells. So there.
So those are those two things. Ideally, you're injecting those into targeted area under guidance. And then you're talking about radio frequency, which is really taken off. If you're following good guidelines and diagnosing getting good doing good blocks, getting good results with your blocks, identifying the area, you could take a radio frequency probe and put it at that area under really good guidance and good and good control. And and sort of help you know, normally a blight, that nerve that's causing the pain now you're not fixing the problem, but you're improving function. This is going to be an option for patients that are a little bit older. We're doing it a lot and spine, whether its neck, thoracic, lumbar, or even cycle. Also, we're doing on it nice, we're doing it and hips. Were doing it actually in the Baxters nerve in the foot. So it's really getting a lot now we're actually we're getting ready to start really even moving. The next thing that you're going to hear about here the next two or three years, this is a little bit of a fast forward you're going to hear about it in the base of a ticket or nerve and the vertebral body with where the pain is really thought to generate. And so that's that's on that's on the horizon
type of glasses. vertebroplasty augmentation is essentially the same mindset of the base of the TiVo nerve that causes a pain in the vertebral body. You get over to Bill fracture. It's unstable. It's very painful. The data definitely documents that there's a downward spiral and morbidity in a patients lives to ban do not believe the 2009 New England Journal of Medicine paper that says that there's really no benefit that's been very much disproven. With that being said, you know, you're basically stabilizing that vertebral body and you have a nerve Plexus inside that receiver body that's very rich and nerve supply that's causing that pain. So I think I went through most of them there for you. I think I've lived through them pretty fast. But that's that's all you just mentioned, including peripheral nerve stimulation, which is one of my favorite things. I wanted to do a lot of peripheral nerve stimulation, which is new. And then of course, spinal cord stimulation. So neuro modulation, whether it's spinal cord stimulation, or peripheral nerve stimulation is definitely the one of the fastest growing areas of interventional pain medicine or management rather, because there's so much we can do with it. And this is this plays right into my wheelhouse, because I do come from an orthopedic background and I do and I focus a lot on musculoskeletal medicine as well as floral guided so I do a lot of peripheral as well as spinal cord stimulation as well. So that's
Justin Trosclair 9:55
true when would you use a peripheral nerve versus the radiation frequency?
That's a really good question.
And that question that question is is definitely answered.
Based on the patient best way I can answer that is just really kind of taken to the patient encounter the issue so if you're thinking peripheral you're thinking a specific area like like a generic it or nerve Aranda knee or something along those lines you're thinking that you're thinking of upload Neil nerve around the hip, you're thinking those types of things that you're thinking of peripheral nerve stimulator, think of a specific nerve, you need to be targeting a specific nerve. If you can target that nerve. You can stimulate it, and that's those are not my words. Those are Dr. Andrea trust God's word so I just stole that from the pain. Well, it's going to neuro modulate the pain it's going to try to desensitize the pain I give you an example. I had a 95 year old patient that I just did a peripheral nerve stimulator was super scapular and our non operable shoulder nobody would do so surgery on and because there really wasn't a surgery for him. He was having an intense pain like his lifestyle wasn't great. Because his shoulder was it just in painting that's all I cared about. We did a super scapular
peripheral nerve similar that's the latest picture I've put up on on LinkedIn and I was playing with from a 10 to one and he was caught you know and so he he can't get his part we're getting ready to do I'm going to do is perform here next week. We just finished his trial but that's that's the second one of those I've done in a couple of weeks. So I do a lot of them but radiofrequency ablation, you can't radio frequency of blade, the super scapular nerve, you can you you can read, you know, read do radiofrequency ablation in a generic one over the knee, hip and some of those areas. But if I have someone that the interesting cases are the ones where someone has knee pain, and we've seen patients where we have failed back surgery syndrome, but we also should come up would fail total knee arthroplasty syndrome and Rialto hip arthroplasty syndrome. So now we have someone that's had a replacement, and they're painting go away and now what so now there was PT surgeon is a little upset because now they're they don't they don't they can't do a steroid injection anymore, which was kind of all their go to, and they send them to me and generally I'll look at it and you know, it's it's a neuropathic pain problem. So you can a blight that and they may get good relief, or you could offer them a trial of a peripheral nerve stimulator first before you'd normally destruct or destroy anything and see if they like that and then you give them the option. Do you care about having a simulator in or do you want to just drive inflation and go on with your life and come back a year year and a half later and do it again and go from there so I give it I sort of throw it back to them and give them the lifestyle choice options and really kind of explained both options
Justin Trosclair 12:58
All right, so I'm hearing ready for see it's pretty much you're not going to do motor nerves This is better for like purely sensational nurses like the
you never you never have like a modern urban right? You'll never ever ever doing motor nerves radiofrequency ablation ever
Justin Trosclair 13:14
Good. Good. Because the ones on the preset joints in the spine, those you know this the recurrent laryngeal, it's not really doing a lot except indicating like,
it's basically it's a medium branch coming off the dorsal primary Ramos, which is purely sensory, okay, so that's in the spine. Now, that's the then when you get down in the sacraments, the lateral branch, but all the way up to the neck, you know, all the way up to the third occipital nerve, which is the one that causes cervical gigantic headaches really bad. So you have somebody that younger has, you know, cervical genetic headaches, tension headaches, if you will, and they don't get, they don't get relief, but they don't get preset joint mediated relief, you know, then you can go that around, you know, you got you have some of your younger patients that have preset pain, you don't want you don't want to be thinking about radiofrequency ablation in a younger patient, like, you know, 20 to 30, maybe even 40 or talking about patients that are in their 50s, 60s, 70s
with bad the set joint hypertrophy, you you know, even in your area, you know, you can do manipulation there and it's just not getting any better. And that's because the neuropathy of the nerve, those joints are so sensitive, and it's just it really you just you're fighting a losing battle. Those are the those are the bread and butter spine radiofrequency ablation patients and there are a ton of them. You can a lot of a lot of these patients have been operated on. So now that's now you got failed back surgery syndrome. On top of it, they've had a fusion there preset joints, or even worse off, and those are the bread and butter and then you flip over into the knees where you have somebody was really bad osteoarthritis. Maybe they're not a really good candidate. And I mean, I've put I have one patient I put up on LinkedIn that had two knee replacements in the same name. Oh, can we we put DNS and her and her pain, you know from attended one and she was a young small rancher that was very active, and now she's out. going again. So you know, these are the things that we have to start talking to patients about or start talking to people about our are what are we fixing what we're doing surgery, if you're fixed, something that only surgery could fix? I get it Have at it. But if you if you're fixing something with surgery, that's not really like yes, that's not really the best option. So
Justin Trosclair 15:31
it with the with the RF It sounds like you said it kind of can come back because the nerves are able to regenerate.
Without question nerves, sensory nerves, peripheral nerves, peripheral nerves regenerate. So an aura is not forever. I have seen some RF cases that have gone out for for four years, which when I saw that patient, he wanted another RF, I was like, Oh, here we go. If I don't get this guy to four years, he's gonna which you know, generally, I mean, know, they can come back as short as nine months. And they they can go out to two years, but the average is about a year to 18 months.
Justin Trosclair 16:07
Did they grow back with scar tissue towards harder to get the same results?
Yeah, I can and and you know, and then so, you know, you you have to be somewhat mindful of that when you're doing a revision, the revisions are a little bit harder. But But what I typically see in my hands when I'm doing a revision on somebody, if it's not patient, I did initially, I follow pretty strict guidelines and do MRF and the way that was taught, so this national standard, and I get a pretty good lesion on it. So I use my results are usually pretty good.
Justin Trosclair 16:39
Not if you start with RF, maybe you do say two three round, let's say two rounds, and you're like, Man, it's coming back, it didn't last as long. Now what I'm only 57 adapt, what can you do a PS
depends on where it is. And I have done that with a patient. I did that with a patient Where were you know, some RF says there was a patient that one I was telling you about what the total You know, when you have a total You know, you're the Jamaican or nerves do not necessarily live in the same spot where they're supposed to live around the knee. And I've actually taken this particular patient when and identified or Jamaican on our vendor ultrasound went into the or dinner RF right at that spot, came back and RF still was refractory didn't work. And then we ended up going to p amp s on her. And she got complete really so you know, you have to you know, not everybody's the same, you had to figure out what's going to work for them. But where we are now with minimally invasive or interventional medicine, we're thinking about things to fix the problem, because you're right, which you kind of alluded to earlier on the guy that people send patients to get them off their opioids, or they can't prescribe them anymore.
Justin Trosclair 17:50
The penis Do you have like a little like a little 10s unit? Or is it the size of like a pacemaker? Can you feel it inside you? Is it battery replaceable.
So therefore, on our simulator that I use, the company that I that I typically use the their stimulator is, is completely buried, it's only the whole stimulator itself is is Ali. And what what you do is you where you put like let's say a word, let's say you're talking about that need you have you have to you have you like with just depends on where the block worked on the patient where the block was the most effective, whether generic, I don't, I don't always I don't put all of them in, I'll put them in where the where the mono neuropathy is where the pain is, whether that's one lead or two leads. But let's say we have somebody that's had inferior, medial and spirit mediagenic and in our bottom drop these and we're going to put a simulator on that side, the lead itself just go straight in, you bury it, and you and then and then you then it's just the lead, it's got a battery associate inside the lead. And then you were a very small little, something smaller than an iPhone that's really paper thin and you put it you could put like in a knee brace or something like that, where for eight to 10 hours a day, that gives you the stimulation that you need to help with your pain. You don't have to wear it at night. So you just you just put it on the top so there's not the generator buried underneath the scan, like you would see in a spinal cord stimulator. Now on the spot simulator, yes, you in mountain, you could use the same company for the for the for the US with peripheral but most have a generator that you barrier skin, but peripherals not like that.
Justin Trosclair 19:30
So the patient doesn't feel it. So you you can ask somebody, maybe we're in this little brace underneath their pants, you would never know. And they're able to kind of do what they're doing.
Yeah, correct. And like in a super scapular obviously that's up on the shoulder you would so you would so that little battery into our so that little generator into like a T shirt, they were the Shirley's patients, you know, you're talking about a non surgical shoulder and somebody who's older, you know, you're not, you're not talking about somebody that's going to, you know, that's going to be out, you know, throwing shock, but or something like that. So, you know, they're going to wear that it's going to give them the relief they need and they go on about their day and you were talking about something that option that they don't take any medication for it takes care of their problem.
Justin Trosclair 20:10
So let's jump into maybe the younger crowd were 20 to 20 to 50. Sounds like the most of the we're talking about is kind of like the older crowd. So we're young, we're athletic. We bluer or a meniscus out, maybe our shoulder just has some chronic pain from weightlifting, injury, something like that. Are we talking PRP for this type of stuff.
Now you're flipping the script completely, you're changing your turn, you're going from the back of the book to the front of the book, and you're talking about nothing but Regenerative Medicine at that point, you want to be thinking about regenerative medicine, you want to be thinking about diagnosing it accurately precisely. What's the problem? What's the real problem? You know, one thing that's nice about ultrasound and you know, and I'm the training that I've had with the ultrasound and I mean, I've I've been using it for a long time is it's like a dynamic Mr. is you take a shoulder like you just said you you can you can basically with a good mosquito skill ultra send out a Naga refer, can look at that and say, hey, look, you know, your problem. Your issue right here is your soup scapular and your subscapularis, you got a partial tear in there, I can access that. And I can either do it with bone marrow concentrate, which is stronger than PRP, and I can get that and I can hit that really well. Or we could do PRP or do prolotherapy. So you're a lot of options. And that's what you want to be thinking about. I spent you know, I mean, if you've got a really bad complete retracted rotator cuff tear, your choice it is what it is, unfortunately, and I mean, it's there, you can't you can't grow space. And so if you have something that's like 50% non retracted, you know, and of course we can talk about all that but Dhabi for his an orthopedic surgeon at a Dallas is doing a lot is doing a really cool study on partial rotator cuff tears and treatment would just bone marrow concentrate, regenerative medicine, and then you know, you can get seen a lot of results in that you see that with shoulders, maybe knee like you said, maybe a disc, you know, somebody you want to put you to somebody who's younger, you know, they've got a partial, like an annular tear with a dispute. You know, a lot of people including myself, or doing PRP injections in the disc, Greg, let's really kind of started this out of New York and he still uses PRP is the one day I said, Greg, you know, why don't you use? Why don't you use bone marrow concentrated stronger? And his response was, I mean, you know, smartest guys in the world always had the best responses. He's like, because PRP works, watch change. So, you know, you're just like, okay, you know, I mean, and so you can't go against that, you know, he's right, you know, and so there's, there's that and but yeah, you want to be thinking more of the regenerative medicine,
Justin Trosclair 22:51
Jackie said if you have a spot where you're in a shoulder, man, you gotta you just got to get in there and have a big surgery. Is it common to say Hey, Doc, you right before you're finished throwing a bunch of PRP so that while it's healing, it's got the regenerative cells in there
very common, very common matter as a matter of fact that that actually is paid for by insurance companies
Justin Trosclair 23:15
in that scenario.
Yeah, and that scenario, yes, it is paid for whereas avoiding surgery and keeping somebody to go in here we we backwards,
Justin Trosclair 23:25
we back with me?
Wait, wait, you have this conversation forever. That's I whoever makes these decisions on on payment. But but that procedure, yes, that's very common. A lot of orthopedic surgeon been doing that for a long time. Dr. Hundred Yo, out of France really kind of started that several, several several years ago. If you're interested in regenerative medicine, anybody listens at your general medicine? You know, I mean, basically those two names Dr. Kaplan and Dr. Hart ago are the two guys if you just go Google them, you're going to get a good head start in regenerative medicine there ever talking at any talk or anywhere else just stop and listen. So those two guys really that you know, they're trying to go really started that with doing entry that he's doing, you know, it consular regenerative medicine, where he's just going straight into the femoral condo for us, you know, Croesus you know, a vascular necrosis go straight into condos injecting stem cells in and in France, they can't concentrate it. So, you can't you have to, you have to draw out a ton of concentrate, you have to draw it a dummy, he may have to do you know, a or not and, you know, aspirants on each side,
in the pelvis, whereas in the United States, we could do one, maybe two, when get about 12 cc's of highly concentrated, mesenchymal, you know, sell So, or you can do spat depending on whatever to your direction you choose to go, but,
Justin Trosclair 24:53
boy, they would not practice in France, like, let's just go to the next country, take a train over because this is a that'd be a lot more invasive and painful.
Well, you know, it's funny, too, but I mean, it is and they doing and they've been doing it for a bit longer. And they've got good data on it for people like that, that you know, you you you you often wonder you think got it, they can let them concentrate what they get. Can you imagine what they're getting? And in the United States, FDA will not let you grow it. So that's why you see some of these clinics in the Caymans or Bahamas and stuff like that, or Mexico, you fly a United States, you grow your own mesenchymal stem cells and and then and then you get a really high concentrate, you inject that back in. So maybe that'll change eventually. Who knows. But you know, the data, I think, has to support everything. And that's really where it's all driven. All right,
Justin Trosclair 25:46
let's talk about the negative first. Well, I don't know if there's that many negative towards it's always a surgery or anything can go wrong, I guess. But we were talking PRP, it seems to me it's like, this is the option for the sports crowd. I'm a chiropractor losses there, listen to this, you know, we're seeing a lot of these younger people, if you don't hit the right spot, if even if you do hit the right spot, are there any bad results that could happen? Something that we should be mindful of it? Because once you you know, once you inject it, and it's like, oh, no, what's injected, I can't go back. And it's like a surgery, you can only do surgery one time, you know, there's
no challenging, I think the negatives, there, there, there are some absolute negatives that you were kind of mentioning there. And there's some relative negatives in there. Me first of all, I mean, let's just take the United States, for example, you know, you're you're driving down the road, you see a billboard that says, you know, come will regrow your knees, all you gotta do is come in and give us $10,000 and you're in good shape, and somebody walks in and they never draw anything, they never take any of your any of your blood, they just walk in, and they just they inject what looks to me like blood into your name, your name, sure where it came from. And then oh, by the way, we had a little bit left over, we're going to start it and give it to you that way. Well, you know, that's become really popular, and that became popular because of marketing, you know, really good marketing. And so every really got everyone's attention. And that's really kind of the amniotic cord blood mentality, where we're going to give you all these the stem cells, the only problem is they're not alive, you know, and they're, and they're not yours. So you have to really ask yourself, do you want someone else's, you know, concentrate injected in your body, you know, you have no idea really where that comes from. That's what that's sort of a relative negative, an absolute negative, or the summit likely the case that we saw down in Florida recently, where a clinic decided they were going to inject some antibiotic cord blood and someone's macula to try to try to treat macular degeneration. And what they did is just made them fully on blind. And so I mean, yeah, then that's then of course, the carrying on to that is someone doing something, to try to do some type of Regenerative Medicine treatment, because someone's going to walk in and pay it for it. And that's really where the ortho biologics consortium comes from. It's an ortho ethics consortium of physicians that are doing it ethically and then really that the broad strokes of that is dumb practice outside your treatment area, or your practice your training area and and do whatever it is that you're doing, do it and with precise guidance as much as possible. So I'm orthopedics and interventional pain, anything that I do, if it's a disc, I'm going to do it under floor asked me and make sure I go to the right part of the disc, if it's a shoulder, I'm gonna do it under, you know, I'm gonna do that ultra sound and with maybe with some guidance with with flora, but but mostly ultrasound, and then and then various areas. You know, I've had patients come in and said they had cystic fibrosis and COPD, pulmonary fibrosis, and, you know, there's some clinics that are doing stem cells to try to treat that cannot do that. I said, I'm not a pulmonologist. And so, you know, I get it, I'd be interested to hear the data on that. But, but those are really the negatives. You know, I think, I think if you're, you're doing any kind of Regenerative Medicine, treatment, you know, the real leery of the people just over marketing, you have to market song to get get, you know, for people to know about who you are. But I think any physician is taken care of you is going to have some position with some street cred that has some background, it's just need to do patients, people need a little bit of research on who they're who their who's injecting these things into.
Justin Trosclair 29:36
I'm hearing, make sure somebody is taking your own blood, and then you're having to reschedule maybe a week or so out to get reinjected, that's the step one. Well, yeah, I gotta do is sit down and get injected, that's probably not going to be your blood.
That's right. And so, if you but see that, let me let me clarify that. So when in the United States, you can, the FDA, this is really interesting. The reason why regenerative medicine is not regulated, is because there is a part of regulation that they've already regulated by, and I can't remember off the top of my head, so I'm going to bundle this, but they regulate one agency is regulated regenerative medicine, and you can't have two different agencies regulating the same area. So physicians can take blood, spin it down, get the concentrate, take
bone marrow, concentrate, spin it down, get the concentrate, and then reinjected back into someone where they deem necessary as long as they do it in one sitting and do it right there. So that's in the States. Now, if you take if so if I go to Mexico, give them my blood or give them a bone marrow concentrate, they come back in two weeks, and they grew it and made it hyper concentrated. That's that's another thing. What I'm saying is, is that be real careful, getting somebody injected into you, that's not you. Okay, it's that that's the big thing.
Justin Trosclair 31:01
Now, and if they don't do guided, it just means that may not be very effective, because they missed the spot that actually should have been done.
Yeah, some of these people are some of these patients are going and paying 510 thousand dollars to do is do procedures. First of all, I don't charge that number one. And I mean, I that's just not fair, you know, you know? Because I mean, it's just not I mean, it's, that's the enemy, you know, and I'm going to use Don Buford, again, it goes, why am I going to charge somebody something that costs more than a total hip replacement that I only have two or three years of data benefit. And that's the point. And I flipped that back around saying, so if you're we're injecting disk, and we only know for for sets, because we can do for set injections to try to help regenerate them. And we only have about two years of data. I mean, that's, I mean, I've done some RS that lasted longer than two years, and they then that an insurance paid for that. And that being said, you know, the, the big some of these patients are going in and they're getting and they're paying a lot of money and there and, and there, and they have some ideas drawn all this stuff, concentrated this down. And they're injecting it back in and I've actually asked people so okay, where'd you injected into? Well, I injected the shoulder, okay, and the rotator cuff? Well, they were the rotator cuff. Well, and the as well, how do you know, and when there's a really good study that was put out not too long ago, that showed what a blind injection look like, were they were they were they put a needle in and then under ultra setting and put and then the doctor who was really good, but the old they said, Where is it and the doctor said, Well, this is where it is. And then he put the ultrasound down, it was nowhere near it. And, and the majority of the time it was in the answer fat pad and the knee. And then there was that same study where they did the same thing where they were going under, under direct guidance with like, an otter scope. And it wasn't even was it was worse and and there are office based off of Scotland procedures. Now you can use it that if you're not a good ultrasound guy, there's an ultrasound, there's I mean, you just you just need to have good guy, and you have to put them in under precise guidance. And that's really where the individual orthopedics foundation really has their credence. And that's that's a that's a, that there's anybody that's an inner that, you know, calls themselves at some level individual individual repeat exposition understands what that is.
Justin Trosclair 33:17
So I'm hearing some of these doctors are probably being cheap, and being lazy, by not purchasing the equipment necessary, and maybe hiring someone that they're not good at it to be like, yeah, Doc, you're in the spot that you said you wanted to be in. So if you're going to do it, it's like, go find someone like yourself, who's going to spend the extra time money energy to do it right, and not just halfway do
it. Right. And I'm and I'm not so much of an in your face type position. I mean, I do it my way, I try to do it the best way possible, somebody comes up with even better way, I'm going to see it. And if they can prove to me that this is where it needs to be. But under something like an ultrasound, I could find the lesion. That's where the lesion is I wouldn't that need. Exactly. And I've actually had some some discussions with some physicians where we sat and talked about it. And we went on a little bit about it. And I said, Look, I get it, you know, you have good confidence and knowing where you think that needle is, I'm telling you data proves that some of the best physicians are not where they where they think they are. But that's you and me, I'm just going to make sure I put it in the right spot. it as a
Justin Trosclair 34:29
as a chiropractor, smile, because we have our own people with your studies were like, you know, they're painting the back like what you think you are on that l three, I'd give my firstborn. You like Dude, you're on l one. And they're like, wow, gosh, you know, we only focus on one area 30 years and you still can't pick the exact location and I
don't want to throw a certain group people under the bus but I get more time all the time but there's there's back in some of the guys were doing some some you know, guided injections when they were doing Paulo you know that they did everything the patient's standpoint and they would draw out like the bones and then they would start palpitating all this stuff. Well, I mean, I get it from a patient standpoint, but you have somebody that may be like an Oklahoma, you know, a lot of people live in Oklahoma, they like to eat You know, I'm working and sometimes palpitations not easy. And we used to call non ultrasound or non floral guy procedures blind it and and so then the didn't know that same group of people, they wanted to change it from blind to alternative how patient guided, I'm like, you're just put me Okay, it's still blah. So you don't know where you are. If you can't see where you are up on the screen. You're you don't know where you are. And that's that's how I feel about it. And then I'll throw in one more caveat, if you can point to the screen, and you know where you are, and you have a patient sitting right there. And I can say that is your need that is right where they're going. Had patient knows that they walk out of the room that they just think when exactly where it's supposed to go.
Justin Trosclair 36:02
placebo just jumped in there from the patient's viewpoint. And that's not necessarily a bad thing, either, whenever like, I'm convinced now that this is going to work because I can see exactly where he's about the score that
you're going to have to get greater than 37%. That's the placebo number 37% of people think that everything works for them, you know if you tell them but just but at any rate, most all my patients I show them like even after an interventional pain procedure is shown their pictures if I do a casual classy, and somebody has shown their picture, and when I'm doing an ultrasound on somebody, I'm explaining to them what I'm looking at. So they understand what they're looking at. Because I know the more engaged they are and knowing what's going on. When I give them their options or tell them what we need to do. It's not you know, it's not a hard explanation. Patients should be skeptical, they should question. But when you can show it to them. It's the takes a lot of questioning out of it. I want to switch gears just for a second.
Justin Trosclair 36:58
You know where I work? We do. It's so funny. Sometimes, you know, the 30 year old with some mild headaches, they don't refer to us, but they'll give us the 84 year old who's got a scoliosis to compression fractures. And they're like, hey, go chiropractor. Good luck.
Justin Trosclair 37:15
let's see what we can do. But once it's healed, it's been there for 10 years, that's it is capacity when you're putting the bones team in in there is that more of a fresh fracture only? Or what's the criteria for that? You
just described it Oklahoma Standard back. You know,
when I go when I go to conferences, sometimes there weren't a cadaver lab or doing something someone will get some of those. It has some scoliosis and oh my god, I'm like, I mean that to me, I'm like, that just looks normal. But yeah, you have somebody you just I mean, let's describe when we describe how you want, you got, you know, 75 year old, you know, five foot 190 pound woman who was on the map resolve for 2530 years, and she's got a big Chi Fatah comp, and she's got back pain and never gets better. You know, and and it just hurts, it hurts, it hurts and you do an X ray. And it looks like all of our virtual bodies look like disc, when there was a receiver bodies, and you're asking yourself, oh my god, you know. So the, one of my really good mentors believes I have several mentors that I rely on that I talked to all the time. And then if they probably tell me all the time, I'm not your mentor you you're very well. But I still like to call my mentors because I just like to but
the mentality is that you do not treat a vertebral compression fracture that is not acute or shows on to the demon on an MRI. The only problem is, is that you're leaving a lot of people out and I may take a I may get roasted on this. But you know, I've got I've got some people to back me up on this. But if you have somebody that has an old chronic compression fracture, and you paid that area, and it still hurts, and you've done everything around that vertebral body, whether you you've done said joint, you've done our app, and it still hurts. And we're not to the point where we can't do the base of a TiVo nerve radiofrequency ablation yet, because it's not approved. The best treatment of choice for that patient is do vertebral augmentation. And then What's also nice about that, is to re establish the vertebral body height with a really good material, you know, augmentation and that's what you know, there's a downward spiraling morbidity with chronic compression fractures. And I mean, it's just you see it, and I mean, you've literally see it and I mean, I've had patients that were admitted to the hospital and never taken pain medicine in their entire life. And we're in the hospital on you know, morphine pumps and PCA Pomson, I come in, I do a compression kind of capacity and that and I repair the appropriate levels. They walk out in hospital, and they they they have they probably don't take anything more than a Tylenol after that. So it's pretty dramatic when you get them like that. But then you get the gray areas, the ones that chronic, the ones that you just described become in there very osteopenia. And now they want you to do a manipulation and they got like seven compression fractures like oh, yeah, sure. Yeah.
So the thing is, and I just did one of these on Thursday, or just yesterday, patient came in is actually seen the local chiropractor, chiropractor did an X ray, outline, the vertebral body, this L one was extremely compressed. He came to me and he said, my, you know, my pain started there about six months ago, and it's never gone away, I post on it still painful. Mr. I did not show any edema. We repaired it and they're gone. And he's doing extremely well. And so there you go. And now that kind of goes against the standard, or the or the or the common belief, but you know, we're I think we're going to change that mentality pretty soon. If you have that level. And those types of levels and stuff like that, then, you know, you need to, you know, somewhat repair it
Justin Trosclair 40:59
was last resort, what else are you going to do? I mean, this person needs help. And that if that's the last thing available things like try it, and it's working. I mean, that's all right. Well, but the research gets up a little bit, I tell
the patients I say look, here's the thing, it was like when in that and and that patient right there that you just described it, this patient wasn't so common, it would be a different thing. This was an outlier be a different thing. These patients would either extremely common there is this thing is extremely common, especially in rural parts of Oklahoma where I practice. And they don't you know, they're not even even in Oklahoma City and Tulsa, Dallas, and you know, I don't care where you are Houston, wherever, you know, it's still common. And I always tell the patients as they look, you are tender there, you are painful there. That is where it hurts. I'm pushing Ronald where it hurts. If we didn't ever repair that, and we don't repair that, then and we do everything else, and you're still in pain that we did all these other things when we know that that still could be causing you pain, so why not? Why not fix that? And so I'm getting away. I've kind of gotten away from the normal IBM The only gold standard measurement on window repair one notch repair,
Justin Trosclair 42:04
why are you in three small towns instead of just the big city?
So really good question. So I'm in I'm in for people that don't know that I'm in Lawton, Oklahoma, which is south western Oklahoma. I'm also out just a little further west and McAllister. And in Salazar, I'm actually in other places that I still go to and it'll surrounding areas. But what I've done and what I've learned is, there's I start when I finished my fellowship, and I when I did, I did sports medicine. So when I started out, I did not complete the traditional interventional pain management fellowship. And when I decided that I wanted us initially started out doing musculoskeletal medicine, focus mostly on on ultrasound, and slowly but surely asked, gravitated over towards doing more interventional pain. So I went back and did get retrained and more training through American Board of interventional pain positions where I'm bored eligible, and I'm also involved in the world is to the pain. And what I when I got started, I started out in the rural parts of Oklahoma, because I just wanted to start a little slow. And what happened was, it was like trying to drink water out of a fire hose. I mean, it just, I mean, there was just an enormous amount of patience. And you know, and I set up shop and enlightened especially everybody that walked in that door they said we're so happy to hear you We're glad you're here we don't have anybody like you You do everything you do every procedure and I want to tell them that I do everybody more procedures that people in Oklahoma City and Tulsa do so. And I mean, I just think it's it's there's not many people around sort of the big fish in a small pond. And I love the referrals. And you know, I love the feedback and and I just stuck with it. And one of my big big mentors is in Oklahoma City, and he's trained me alive done and I've learned a lot from a I just didn't want to go real close to him and and and be as competition I think it was fair. So that's that's kind of a long answer. But it just really is this kind of you know, I am where where I got busy the quickest,
Justin Trosclair 44:07
and no, you got time. So just curious, real quick. I've heard a story I was listened to a podcast, I want to say like Mel Gibson and his dad, they had some really bad issues. They fruit a panel. And they got like, placenta courses, you know, placenta, stuff like that. They're not like harvesting aborted babies or anything. It's just they talked like these ladies, they have a certain thing that they're looking for. And he's like, dude, the results for himself and his dad is not allowed on America. Do you know what I'm kind of talking
talking about really core to my cord blood. And it's kind of again, that's that's not you know, that's not their own, that's someone else's. And then the mindset is, okay, so when you when you're taking placenta blood, the placenta blood is thought or a Gora cord blood itself is thought to be extremely rich, and growth factors. And so they're taking extremely, very rich growth factors. Now, here's the thing.
The best way I can explain this is, is when you go up some when you go up to 100 people in a room and you say, Who wants a pizza, and 50% of the room, say pepperoni 10% say the 10% say cheese. And everybody else said
small group say I want mine with pineapple, which still understand that but you know, they, they, they but my point is they're they're all getting the same thing. They're just getting it differently if you if you went you and and that's sort of where someone's trying to describe our approach is better than your approach. But they can't, they can't answer to that. I mean, they don't have back that up and prove it. I mean, you No one can tell you that if you didn't go down and concentrate or grow your own growth factors and grow your own bone marrow concentrate that it wouldn't be better and no, and there's not any physician in this world that can that can validate one is better than the other without data. So and that's, that's a, you know, you would have to what you have to do, and you'd have to look at what they were injecting what it was, what the cell counts were, and all of those things. And, you know, Kristen, Tonto out in Colorado and some of the other guys and you know, I guys like like, Don, they're looking at cell counts, they're not, they're not just injecting so they're actually counting the cell and seeing what you're getting. And so you know, that's where you you some things like in placenta blood and things like that you have no idea what you're getting. Now, this would be a crazy question. So just bear with me, if it's the most dumbest thing here, you have a kid, you've got your own blood, you and your wives blood right there. If you took that and split it down and just injected into an IV and somebody wherever that blood goes, couldn't have a benefit. Like why don't why don't we just doing full body, you meet with your own blood, you spend it down, you concentrating it? Why don't we just inject it and wherever it goes, it lands and lands and gets better, you, you you pull his blood out of the highest growth factor concentrating person in the world, spin it down, get the highest, the richest, the most extreme and growth factors, you start an IV injected into a vein, it's going to go through the right side of the heart to the lungs and stop. It'll never, it'll never cross the alveoli. That's the mentality of doing pulmonary stem cell treatments and things of that nature. And that's where that goes that comes from is the nurse injecting it into the blood. Now, a really good friend of mine who's a cell biologists who who lectures all the time on the regenerative medicine market is is that why would you take something and concentrated and then reap injected back into your body and and concentrated
did? And he's rush? You know, it's like, He's right. He said, that's like taking really good. It's like taking really strong tea and putting in a glass of wine wiki.
Justin Trosclair 48:01
You got it's just that.
So again, you know, I think the question that you posed, and the thought that you pose has started a lot of theories in in research. And so what you do is you take that theory and you take it and you go, and you go look at it from a research standpoint. And the people that have done some of the best Regenerative Medicine Research really in the world again, our our vets are take care of horses, because they do you know, you know what, I'm telling you, there's people that own thoroughbreds, that race on it is the race around the world, they spent a lot of money on those horses. And so something happens to them, they want to do the best thing possible. And the interesting thing is, is that when you're harvesting, bone marrow concentrate from a horse, you take it from the sternum, why they're standing up. I've seen that procedure done. And I asked myself, I can't imagine doing that on a regular patient. First of all, you wouldn't. But that's where the richest area of bone marrow concentrator are really signaling sales come from is in the sternum. You can't do that human but you can horse because the sternum is extremely thick and a horse. But yeah, so that's it.
Justin Trosclair 49:12
Is there any, a lot of people have heart issues? So you when you said that I'm thinking, would that be something that could benefit and probably the resources in there, if it just go straight to your heart and lungs? Well, there's a lot of people that have heart problems. It could be a good thing. So I was listening, you could
I was listed hematologist, one type talk a little bit about blood typing and things like that, from regenerative medicine. You know, I I actually, you know, I live actually in Irving, Texas, and I fly up and do so I'm a pilot to so actually fly to my clinic. And, and I was listening to a guy, UT Southwestern who's a hematologist said, you know, it's interesting, we spend a lot of time typing, we spend a lot of time typing in and bone marrow, transplants to buy and things of that nature. But it's interesting, you can go into some clinic and middle of Dallas, and somebody can inject anybody's blood and you have no idea whether it's compatible or not. The mindset is dead. It's been frozen, all the antibodies are taken off of it, which is true, but we're still not typing it, we're still not checking it. So it's hard to say I mean, it's you know, when you're when you're pumping that in and it goes into the heart, it just pumps through, it has to hit its target. So you have to think about the kinesiology of Regenerative Medicine, if you will, you're putting something in an area where the bone marrow will will segue, you get signal that that's where growth factors need to go and heal that. So that's when like, let's take a rotator cuff, let's say somebody has a partial rotator cuff tear, and you inject highly highly concentrated mesenchymal signaling sales in that area, then the bone marrow will then release it signals to the bone marrow to come to that area to heal it. Now it's going to hurt and there's a really good friend of mine that used to in that area that does regenerative medicine and consecutive Paul to Portland and he always says you have to embrace the pain
because if you think about it, whenever you're regenerating something in your healing something you're you're bringing growth factors that area are also bringing inflammatory cells so it hurts and that's one of the reasons why they do it. They are the go home message after you have a procedure for Regenerative Medicine. Don't go home and take an anti inflammatory because you bought the healing effects of of what you're doing. But yeah, the pros, so will hurt Yeah, they're prolotherapy guys, the guys have done a lot of prolotherapy for a long time I've done some growth there but not I'm talking to the guys have done it for 2030 years. their, their way of knowing if it's working, which is sort of a low in form of Regenerative Medicine, their way of know it's working, is if you come back and you're in pain, more pain, because you got more you have more inflammation come to that area.
Justin Trosclair 51:50
chiropractor physical therapy, I'm assuming that's probably where you get a lot of referrals, I hope in that triple dynamic me you them. When should we referred to you? And when do you see a patient first and say you know what, you should go try something else before you come to me.
So I think you have to look at what what I do. Specifically what I do is is is pretty absolutely I don't do a lot epidural steroid injections, I don't do a lot of yes, I do some I mean, I do them for to get the guidelines kind of you know, worn it if you have ridiculous pain disc compression, and it's you're getting shooting pain down your leg and it's hurting, then you could be a good candidate for an e si if you you know, something along those lines. That's, that's, that's that procedure. But things like is somebody with radio frequency somebody with a compression fracture, have somebody with, you know, the pain or chronic pain, they don't want surgery that really hurts. Those are the kinds of patients that I really need to see. And then there's the specialty things like, you know, somebody who's got chronic regional pain syndrome, some type of bad peripheral neuropathy, maybe they're diabetic, really bad for property, and it's not good, better, we can talk about a stimulator. And it really just reverse engineering. What are the proceed one of the things that I do, which I do just about every procedure and think about what it is that I do, and think what that is an indication for and that's when you refer it.
My goal, like any physical therapist, like any chiropractor is trying to keep my commandments surgery. When somebody has surgery, I mean, I would feel really bad as a specialist that there was a diagnosis of fail back starter syndrome named after what I do. And I get it to a certain extent when we have patients and those situations, you know, until I completely get it, I didn't give everybody is with the mindset of working together. And just saying and calling it the phone I have guys, I have a few chiropractors and lot and then some and McAllister and Salus on other areas, you know, they're just shoot me a text and say, Hey, I got this patient, you know, is this something you see, and I think when you get a relationship with somebody who does interventional pain management are all the things that I do if you can get that relationship with that person where you can just ask them and say, Hey, I don't know if this is your thing, or not. But if somebody is not getting better with what I'm doing, whether you're doing, you know why you guys might, which is bad SI joint pain, they come in for an SI joint manipulation, they get off the table, and they're raising you up on their Christmas list your number one on their Christmas list for that year, they come in every four or five, six months, whatever said that that's your patient until it doesn't work. But if it keeps if you do it, it never gets better. They come back, you come back a week later, we just never gets better. That's when you start thinking about Okay, let's let's kick this up and see if there's somebody
Justin Trosclair 54:40
you know, like me, they can take care of it. Should we recommend what like what you do before an epidural? Because the studies that we see as the stuff that we hear is like Sometimes it works, sometimes it doesn't. But you can get almost the same results from manipulation based on some of these studies out there, you know, so you don't it's kind of like flipping a coin she went this route versus you go that route? Should we try to avoid this steroid injections and just kind of do more like a PRP or is it come down to like finances a little bit?
Well obviously find is those are going to play a role because PRP is not covered by insurance. But you know, you know, the indication for any aside, you know, Nikolai bogged down by category, in 2012, put out a really good paper on indications and the point of doing the si si is really are beneficial somebody who has ridiculous pain with or what I obviously don't see it on MRI, but they got ridiculous shooting pain is very specific. And then you inject that area. And with a series of three of those injections, the gold standard of improvement is if you get 50% pain relief for six months or more. It doesn't sound great. But you know, taking somebody from attend to a five, maybe great taking somebody from a five to two or from a to afford and there it is. But if you don't have ridiculous pain, and you don't have it on MRI and you don't have it symptom, ology you don't have no physical exam. Do it an ESRI on somebody and there's a lot ritual pain guys that will consider as well let's just do an e si si p get better, like I'm going to tell you if you've got degenerative joint disease that upset and you got to journey, this is a you got just a Jared a change of you and jack, you know, 10 milligrams of deca drawn in somebody and it reduces their information, they're going to feel better. for about a week or two, they're going to feel better because you just pumped a bunch of steroids. You didn't pump it in, you know for what it's point or what it's what it's meant for. And remember this an asi, the use of steroids and the size of off label use. It's not an indication for steroids. It's all
Justin Trosclair 56:39
what are your feelings about that? I mean, it's off label and that that's not like a violation of some sort. I mean, obviously not somebody
comes to me they're younger person and I get it, I get this, you know, we get this slide, these are the majority that I'll do any si on. So if somebody comes to me and and they have discrimination is putting is causing nerve root compression, and they're in pain, and they are trying to see they can avoid surgery. And the goal is okay, we're going to do an asi, whether we do a transfer Emily or inner laminar however, we're going to do it. And we're going to try to see if we can decompress that disk. With the steroids. I always put a little bit a lot of kid in there to do the nerve root block to make sure I'm in the right area. And they get benefit. And they get a great amount of benefit. And they don't have surgery great. But if somebody comes in this is this is real common if somebody comes in, and they're little bit older, and they got preset joined the general to change. And you know, they're a little hesitant about one to come in and see me because they've quote unquote, had all these injections that never worked. And I'm trying to explain to him, Well, I'm not doing those injections, I'm going to try to diagnose a different problem because this is where your problem is. That's when he really gets under my skin because that means that somebody was just doing a bunch of psi just to kind of crank them out. And there's a lot of people out there that do epidural steroid injections, not a lot of them are interventional pain Doc, there's a fair amount of that are interventional pain doctors. And that's just kind of an egg, you know, some of them will do them just to try to prove some I need surgery. And sometimes that procedure gets abused a lot. If you follow that guideline and that procedure fairly closely for the points. I mean, if if you got pretty good reasoning for why you do it, and you can justify, I think is a good procedure. But if you're doing it just to say well no one else nothing else we're so let's try this even though you don't have the indication for it. I disagree with doing it for that purpose. I like
Justin Trosclair 58:35
that, like I always saw like guidelines. That was one thing that I like about the medical profession as you've had so much trials and errors, and this is the best practices and you can actually do that. Do you want to be an insurance
if they started covering this? I mean, would you do the PRP, the radio frequency
Justin Trosclair 58:55
all neuro modulation right frequency, rather's peripheral, whether it's spinal cord stimulator, all that, you know, all that is covered by insurance, regenerative medicine, whether it's PRP or stem cells are not covered by insurance. You know,
and again, and we kind of were talking about it earlier, if somebody comes in and they have an issue, let's say someone who's younger, they got a disc, or they got a preset, or they got something along those lines, and I'm thinking, Hey, you know, you would be a good candidate for a PRP injection or something along those lines out, you know, I'll I'll say, but it's not covered by insurance. And what I do is I mean, I, I like I said, I try to gauge the patient, I don't try to, I'm not trying to just hit on as hard as I can. I mean, that's, you know, that's not you know, you you see people trying to market for Regenerative Medicine. And I think when you say you're trying to increase your revenue for your practice, that's not the mentality to have, and you're doing regenerative medicine, you need to thank come up with us ways to make people better. That didn't work in other areas. Okay. I like that. I don't like let me find, let me show you how you can make $10,000 more a month in your practice. That's not the right idea.
Justin Trosclair 1:00:11
If it is expensive, we all have high deductibles these days, maybe you might need two or three shots that year, you know, hey, I paid for one out of pocket practically. But then the next one in the next area. Now insurance is covering it. This is a great thing. I'm out of pain, more people are being helped. And let's face it, you'll be busy as well. And you end up making more money anyway. So it's tasty that
insurance has gotten really interesting. You know, lately, you know, I'll tell you it's, you know, United States, everyone really is everyone. It just just loses their mind over nationalized healthcare. Now, granted, you got to be able to pay for it. So I mean, you look at England can like some of these places, they have nationalized medicine and you know, some some of those guys, they can't pay for it. So that's problem if you have nationalized healthcare, and all sudden you can't pay for like so security can't pay for it country basically, and things like that. That's a big issue. But you have somebody has private insurance. And you know, I mean, I had a I had a patient at a really good candidate, a really good patient, they wanted a peripheral nerve stimulator, and he has an insurance payer that wouldn't cover it. And he's paying out of pocket for, and I'm telling you, it's a lot more expensive than what a bone marrow concentrate, or a PRP injection would have cost him, not from me, but from the but from the manufacturer, and they're cutting him a really good deal when they're selling it to him. And with that being said, I mean, in some of these deductibles that people have five and $7,000 deductible is my question is, why am I mean, it's almost like you're not even having insurance at that point. I mean, you're already paying, you know, you're paying $400 a month more just to just for your deductible, and you're paying in, you're probably still paying other eight $900 a month ratio insurance has gotten really, really difficult from a from a player standpoint. So and, and really, from a provider standpoint, too, but I don't know where that's going to go. But I try to have that conversation with people. And I just, I don't try to think of insurance as a barrier for what I present to them as the best option for them. I probably would have considered that 10 years ago, but today, I don't think that way. Because Because so much of these policies are are out of whack for lack of a better word.
Justin Trosclair 1:02:24
Yeah. Well, how can people get in touch with you, your website, all that type stuff.
So you can get in touch with it a cell ortho.com It's a c e Ll ortho calm, and that has my main office number. Of course, obviously, you can always get in touch with me on LinkedIn or like the ways most people get in touch with me and stuff like that. I'm usually pretty responsive on LinkedIn. And the but yeah, that's that's usually the easiest way I'm on Facebook as well. But and I try to stay pretty active on on that but but generally speaking, you know, the numbers through the the, you know, all the, you know, my email addresses on on my website, if you need to contact me directly got a question about a things that we talked about today, I want to know a little bit more I do a lot of teaching. So I like doing that. And so and I answer a lot of people's questions that you know, some of the stuff I put up on LinkedIn. Some people ask me how, what a prostitute how to do how to do that, I usually try to hit them back, you know, give them because I mean, I don't I think it's important to do things correctly. And right. So if somebody is interested in and how doing something I have no
Justin Trosclair 1:03:32
problems answer and that anything that we didn't cover that you want to talk about real quick.
Now, I think you really, I think you really hit on it. You know, it's, I think the only thing I would probably say, extra is this is a really exciting time for interventional pain management. You know, regenerative medicine, neuro modulation, doing things minimally invasive, is really where things are headed. And it's really growing. My biggest thing is, is that, you know, I think we're finally getting away from just operating on everybody. And you know, and I think finding other all options and alternatives to doing that is a really nice thing to do. And that's really what we should be thinking about.
Justin Trosclair 1:04:16
Dr. Brian rich, great episode. Thank you so much for spending the hour with us and enlighten us educating us and figuring out helping us to figure out what PRP is what neuro modulation is, and when we should refer really big thank you for that you got
it was good talking to you and join it.
Justin Trosclair 1:04:36
Didn't want to take a second say thank you so much for listening to the show. If you haven't left a review on your favorite listening app, please go ahead and do that. One thing I've realized, I'm putting out a lot of links all over Instagram, Facebook, this podcast itself, and if you ever change the link are shut the website down. All those links are now gone and dead. So I just want you to know, if you're listening to some of these episodes, I mentioned a link and it's going to head on over to a doctor's perspective. net, you're probably going to find that thing you're looking for on the top menu, search around and I'm sure you'll find it all the books that you find their acupuncture Boca no needles, the free chapters, you can download the 360 degree health from exercises stretches financial health, what is Chiropractic and the free chapters are for their t shirts, resources. And we even have a financial support site now. It's just a doctor's perspective. NET slash support. There's one time support, there's monthly support, go ahead over there and check it out. Something that I'm offering right now, with the needless acupuncture. If you buy the book, you also get the electric acupuncture pin for free as a bonus. And that electric acupuncture pin helps you not only stimulate the points stronger, that helps you to locate the points as well. So that's a huge plus. And then with the today's choices, tomorrow's health book, I'm offering a bonus of a one hour one on one coaching session. Go along with the purchase of that book. Actually, there's three different bonus packages if you had to a doctor's perspective net slash no needles as getting close to the end of the year. Are y'all ready for the 2018 Top 10 I mean it is too early right now but it's going to be here before you know it that will be available for download later on just like the 2017 is now. You just heard a great guest implement one thing make your practice and personal life as best as it can be.
Transcribed by https://otter.ai