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Sports Medicine with Rahul Desai, MD

by Deanna Mutzel, DC

24 comments

 
Mike Mutzel: I would just like to ask folks. How do you get into musculoskeletal radiology and all the interventional things? What got you interested in that?

Dr. Rahul Desai: I always like technology. I kind of like toys and computers and all those types of things. I think I trended towards that in medical school. I always thought I was going to be an orthopedic surgeon. During my fourth year, I started to do more rotations, and then realized that I didn’t really like the OR that much. I stopped some different things, and just kind of fell in love with radiology, so that’s why I started radiology. I’m already liking kind of sports and musculoskeletal issues, and I got more involved in MSK radiology as I went through, and I found out when I finished my radiology residency that there were musculoskeletal fellowships where you could do a lot of interventional procedures like spine injections, joint injections, and have a clinical advantage as kind of interventional MSK. Fellowships – there are about six really good ones in the country. So, I applied for that most likely enough to get into that Washington University. My practice has kind of morphed since I came out to Portland, where somebody’s sending me to do a procedure that I actually see 20 patients a day. So, 11 in the clinic, then we see and work them up, treat them with medications, prescribe imaging studies, and also do therapies when appropriate. So, I really have become much more of a clinician. That’s why I’ve been introduced to Xymogen through one of our other practitioners, and really turn out to myself and utilize these techniques and procedures.

Mike Mutzel: That would be Jeff, right?

Dr. Rahul Desai: Yep.

Mike Mutzel: He’s a great guy. I’ve known him for… that’s why I met you guys. He’s very progressive, very integrative, and stuff like that, which is really awesome. Going back to the MSK residency and so forth, back then – I mean, not that that was long for you – but it seems like PRP, stem cells and all these different things were probably not being utilized at that time. Is that right?

Dr. Rahul Desai: Yeah. I will go through a little bit of that in my talk today, but when I was training, the mainstay for injection therapies was anesthetic and corticosteroid. We’re utilizing those and we always say a diagnostic and then cross our fingers potentially therapeutic injection, but really, those therapies – we’re trying to cover up inflammation – reduce inflammation, reduce pain – and then we’re hoping that in a tincture of time, we have other things to try to resolve the issues. Not really until I started practicing, and even then, maybe about a year or two into it was I introduced to initially PRP, and some of the discussion – prolotherapy have been out there for a long time – but then utilizing PRP and then stem cell. We saw that it was actually helping to heal patients. That’s when we really had to change our approach – change our paradigm to look at it systemically as well because we were noticing that patients got better. But if they were diabetic, if they were a smoker, if they had other co-morbidities or they’re just simply overweight, maybe not vitamin deficiency, hormonal deficiencies, but they were getting better. So, by using adjuncts to supplement those deficits that we’re seeing that our therapies – PRP and stem cell and those types of things – we’re working even better. We’re getting better results and happy patients.

Mike Mutzel: Wow.

Dr. Rahul Desai: Definitely a big change.

Mike Mutzel: How was it used in your field? Is it like kind of a fringe and you’re a little out there or is it becoming more and more mainstream as more of your colleagues are understanding that the patient and everything plays a critical role in recovery of joint and musculoskeletal dysfunction?

Dr. Rahul Desai: Yeah, I think initially, there was a lot of skepticism. There was definitely nay fairs especially within the orthopedic community, neurocologic community, and those that may not have forward thinking or just haven’t been exposed. They read their standard journals and that wasn’t really getting much press, or they’re back in the day GSM and have an article – I think they’re just one of the big journals to have a PRP study that really kind of concluded, but the study just wasn’t confirmed very well. It has deficits and the way that they were selecting the patients and also with the treatment and what they were doing, lack of emerging guidance and similar things. They didn’t have good outcomes, and so when that large study came out, a lot in the medical community said, “Okay, that doesn’t work. Next.” I think there was definitely some skepticism, but because I’m a radiologist, I was able to follow up a lot of our studies, so I wanted to see as well because patients were getting better clinically. When we started to repeat MRIs for free – because insurance is not going to pay for someone to come back and get a rescan because they’re feeling better – but they were feeling better and so we would sneak them on the scanner next to the company I was working with, and we were seeing over and over and over again that the torn tendon and the heel tendon and torn tissue, heel tissue, disc herniation, no herniation, and so we were seeing this over and over, and just proved to ourselves that this was working. Slowly or the past five years, more and more research and data has come out that is corroborating these stories of healing and we’re seeing it become more and more mainstream, and now you see these stem cell therapies and JBJS. The orthopedic community is now onboard. Now, if you go to – probably, I’d say 25/30% of the orthopedic practices in Oregon City and Portland, they have PRP as an adjunct. It may not be there go-to, but they definitely will have it as a potential therapy because patients are asking for it and they’re hearing family members getting better, and the spouse gets the treatment and has a lot of improvement. So, people want that minimally invasive type of therapy that’s relatively cost-effective if you look at the grand scheme of things. So, it’s definitely become much more mainstream. I think it will continue to do so, and I think that the anti-aging community and the progressive health community have definitely adopted it. If not, I think those practitioners should look at this as a definite adjunct in the clinical cabinet.

Mike Mutzel: That’s amazing. Now, is it mostly popular on the West Coast or is it expanding nationwide – PRP and stem cells and so forth?

Dr. Rahul Desai: I think it seems to be definitely coastal. My fraternity brother actually has to fly out here to get this PRP with the stem cell therapy. The meniscal tear – it was non-mechanical. He even had medium swelling and pain, but no walking, no significant mechanical symptoms, and all he was offered in Columbus, Ohio was meniscectomy and fluoroscopy. When we look around there and there’s a couple of people that are dabbling in PRP, but never used to doing stem cells – for that type of issue, we really need to kind of step up the game and do the stem cell therapy, so we actually have to fly up here to get a bone marrow lipoaspiration. And then one of my other cousins, who’s a nephrologist in Cleveland, just called me last week had the same issue – put together ACR instructions. He’s starting to have arthritic change in the knee and wants a stem cell therapy. I’ve looked in Cleveland and Ohio – I’m just having a hard time finding someone. So, if anybody online here listening has some connections, please let me know. So, I think the center of the country seems to have a little bit of deficit. In the Downtown Texas, there are several providers that are doing high-level work, and Florida. So, the south seems to have some options definitely in some of the coast – California and then on the East Coast – there are more options.

Mike Mutzel: Now, what would someone look for in terms of looking on the website or LinkedIn or after doing some Google searches for someone like yourself as really on the cutting edge and more integrative and look at the whole body. Is there some integrative musculoskeletal group that people can look for? What would you suggest?

Dr. Rahul Desai: Yes, one thing obviously – look at their website and see what they’re doing. One of the things, I think, is – maybe I’m a bit biased about this – but if they are just tied to one particular therapy and that’s all they’re promoting, and then I think maybe they’re using that same hammer for all the different nails or issues that they see. If they have different options available – because we still use corticosteroid; we still use hyaluronic acid when appropriate – I mean, there’s stem cell and PRP and amniotic membrane. There’s a whole host of different things out there that could be appropriate for the right patient. One is do they have a normal interim of different things that they’re offering. Two – how long have they been providing these types of services. I think imaging and correct diagnosis is huge because when you’re doing especially for tendon and soft-tissue injuries – some of these tears, as we’ll see on the discussion, are two- or three-millimeter tears. They’re very small; they’re very difficult to localize. And one of the things that has given PRP a bad name in the past and is still in continuous use in our community are doctors that are doing it and saying, “Okay, do you have pain in this area?” and they’re just injecting into a shoulder region and then hoping that those stuff get somewhere or doing a bursa injection or something like that, but they’re really not affecting the change that they could, and often times patients won’t feel better. They may have increased pain because of the localized inflammation from the PRP, but we’re not affecting the change into the areas that we need. So, I do think that the skill practitioner that is using all the tools that are available to them to implement this technology is really important.

Mike Mutzel: Right.

Dr. Rahul Desai: I’d say look at – if they’re going to do Google searches on those types of things – musculoskeletal injuries, PRP. You can look up BMAC (Bone Marrow Aspirate Concentrate), stem cell, injection therapy, lipoaspiration (which is the fat stem cells). So, those are the types of keywords or passwords that one would look up in the area, and then you just kind of have to look at their credentials and make sure they’re well-trained in that specific field. We have a lot of training every five years of radiology. We have another year of interventional fellowship in musculoskeletal radiology. There’s a lot of training that goes into just the anatomical component of that to find those diagnosis, and then there are six years of clinical medicine. I’ve surrounded myself with these because I know there were definitely gaps on the clinical side. My partner’s a physiatrist. We do a lot of back and forth when I have a difficulty with a physical exam finding or some issue that he was integrative there. We work with Jeff on the integrative medicine, the functional medicine, anti-aging. I think that someone who has that broad scope to approach the patient – not just simply giving them an injection and, “Okay, we’ll see you on a couple of months.” We try to make a comprehensive… We work very closely with a physical therapist. I think this is another huge component because we’re putting these growth factors and these stem cells in tissue. That’s just the beginning. We’re initiating a healing cascade, but we really need the physical therapy – the augmentation – I like the term “biomechanical signaling.” So basically, it tells these tissues what to do. If you put everything there but if you just don’t do anything, the likelihood of them getting better is pretty low, but if you’re able to get them to a skilled practitioner that understands that, “Okay, this is their functional deficit. We need to work on the e-centric exercises to lower that achilles or we need to do this and do it in a progressive manner to stimulate those cells to heal and to build new type I collagen in those particular tissue planes. That’s where they’re going to get the most benefit.

Mike Mutzel: That’s amazing. I could talk about this all day long. We have a lot of people on now, so we’ll go ahead and get going. Thanks for joining us, everyone. This is Mike Mutzel and Bettina Newman here. We’re talking with Dr. Rahul Desai of the RestorePDX Clinic in Portland, Oregon. He’s going to get through an excellent presentation. I’ve reviewed these slides. As you can tell, he’s very knowledgeable on the subject. A little bit about his background – he’s musculoskeletal radiologist specializing in interventional joint and spine medicine. He completed his undergraduate degree at Ohio State University. He already told me he’s a Buckeyes fan, and he attended medical school at University of Toledo in Ohio and then went on to his residency program at Washington University in Saint Louis. Dr. Desai, thank you so much for preparing this presentation and joining us tonight. Let’s go ahead and just dive in to your PowerPoint here.

Dr. Rahul Desai: I’m going to scroll through. This is a little bit different presentation. I have a PowerPoint view on my desktop, but we’ll kind of scroll through the presentation. I just wanted to start off with an overview of the new regenerative medicine and therapies. Obviously, this is the bad news. Everyone on this phone call or webinar – we’re all getting older. We have degenerating and failing joints, organs, and tissues. It proves a huge cost to society, quality of life issues, and it’s something that with the baby boomer generations – we’re seeing more and more at the forefront. There’s a discussion especially with the Obama care and other things providing quality care and providing at a cost that is tolerable to our society. One thing that we can look at is kind of the current technologies. They’re amazing if we look back 100 years before and what we’re doing now. We do heart, liver, kidney transplants, pacemakers and joint replacements. They are wonderful technologies, but they are extremely expensive. And thinking about our society as it grows – the aging population – it’s almost unsustainable practice of doing these things especially as we’re going to have patients that are living longer and longer. We have a very active aging population especially what we see in the musculoskeletal world is that while it’s wonderful for the heart and lungs when people are staying healthy, their joints are falling apart, and we’re combatting this in multiple ways, and we want to obviously weigh their BMI or nutritional hormonal status and a lot of things that some of my partners are doing. And then on our side, we’re kind of putting off the fires locally as far as the joints and stuffed tissues. And so, we can take the page from the salamanders and the starfish that there is a possibility to regenerate. As you can see, they’re missing a limb, and then they’re able to grow that back. They’re able to grow their tails back and even the eyes. So, how does that happen? What are we looking at? Can we translate their abilities into our human medicine? This kind of sends us around in regenerative medicine. And something that I’ve gotten during the past three years – one of the things that we look at – we can break them up into two main groups. Tissue engineering where we’re actually engineering tissue and beginning to replace tissues and urinary bladders and kidneys. That field is an advancement in medicine, and what we have gotten into is more of the injectable or stem-cell types of therapies. These are some pictures. This is from Wake Forest University where they’re doing tissue engineering and basically taking these bioscaffolds from the allograft tissue or composite material or from other species and then implanting cells that are sent down. On this ear, it’s going to be basic epithelium, but as we’re getting more and more advanced, we’re going to be able to do entire organs. So, that’s one part of it.

And what we have focused on in my practice are injectable cell technologies, so things like PRP, stem cells, amniotic membrane drive growth factors. Those are the things that we’re injecting into tissues. In our practice, this is a very small part this, and we’re doing musculoskeletal care – so joints, tendons, ligaments, muscles, soft tissues, we’re doing some work on the spine, disc, and facet joints, injured nerves or sciatica. This is happening all over medicine for pancreatic tissues, for your skin and dermatology, for hair loss. And so there’s a wide scope – these types of technology.

I think for me the other thing that has really benefited our practice and allowed us to really provide a high level of service and efficiency is ultrasound guidance because with ultrasound imaging, you’re really able to put the needle and these growth factors and these stem cells in the right area. We use MRI quite a bit for determining where injuries are throughout the body, and then when we do find deficits or injuries, then we utilize different technologies to deliver that material – that could be fluoroscopy, that could be CAT scan, it could be a CT fluoroscopy as well or ultrasound. For a lot of the soft tissue, we use ultrasound.

This kind of combining of different areas of the imaging and then utilizing these growth factors has really provided, for me, a paradigm shift, and that happened several years ago. There’s one case that kind of illustrate what have been building and what kind of took me off my path from just a musculoskeletal that did a lot of reading of images and some injection therapy to somebody that really was motivated to this type of medicine where they think that we could heal patients. Some of my colleagues, we talked about some of issues with being on that leading edge or cutting edge. When I saw this change of scope of our practice where we can really affect a change. This is the American Buddhist. I make them qualify for some of that exuberance.

This was the case that really changed the scope of what we can do. I have been doing PRP or platelet-rich plasma injections in the soft tissues for about two or three months prior to this patient coming in. We were lucky enough to treat some pretty high-profile patients and athletes in the beginning, and it got some notoriety in our medical community. So, this particular patient actually came from the same doctor that we had received some patients from and had really good success with PRP with image guidance. They had an achilles tear this 43-year-old school teacher, and they came in with severe pain; it was a few months old, it happened acutely, and it was a severe tear. This is an MRI, and we’re looking at the status image of the foot. The forefront is out here. This is the heel and the calcanea. This is the tibia. This is the achilles tendon and it really should look like this – a dark thin band that comes down here. All of these white here – all these disruptive fibers – that’s the tear. So, it should look dark and much thinner than this. And those are the refractive fibers. When I saw this patient, this was about a 70% tear. I told them, “This is probably a surgical intervention. You need to go to a fit medical surgeon and I think that if you try something that tears it completely, we’re looking at a much longer recovery. For whatever reasons you wanted to do the PRP…” She said she’s a school teacher, have a few months off. She said, “I really need to get this therapy. I can’t afford a surgery and that much time off.” So, we did the PRP injection. “Let’s see if it helps. There are no guarantees.” This is the tear in the ultrasound or at least part of it, and this is the needle placement of the material filling in that tendon. If you look here, this white line represents the front of the tendon, and this is the back of the tendon looking at it from the side. So, the front and back. In this slide, we’ll see that the tear is occupied much more here, but here we see it there. This is the placement of the needle; this is the 25-gauge or the 22-gauge needle placed into the tendon. That’s a nice thing – you can see how well it’s illuminated with this. And then there’s the delivery of the PRP which fills in that rupture gap.

This is the imaging that we had, but we followed this out. These obviously were the free images that we wanted to do to see how things were healing. There was the tear. There was the normal part of the tendon. This is the axial down the ball of the tendon. You can see here where most of that is torn, so that’s about a 70% tear of this tendon. This is after one PRP. The patient came in, got one injection, left with a band-aid – I think we had them booted for a week after each therapy. We can start to see this little sneaky way building so there’s something going on here, and pain levels suddenly become reduced. We did one more injection therapy at this time. We took her out of her boot because she’s got a lot of swelling around there. That’s all we do know. But you see how the tear has become smaller and smaller. This was 150 and a half and then she came back in complete resolution of her pain and had virtually a completely healed tendon. This is something that through all my years of musculoskeletal technology that I have not seen before. It was pretty dramatic process that really turns the way I thought about things.

Mike Mutzel: That’s amazing.

Dr. Rahul Desai: Yeah. That’s when I run around the imaging center and showed all the radiologists, “Take a look at this. This is unbelievable that we are able to affect a change with a simple injection.” They circumvented a major surgery, tens and thousands of dollars’ worth of surgical bills, cost of insurance, and then all the physical therapy. We did do a lot of physical therapies as well, but downtime away from work, all these things will all be aberrated because of this type of therapy.

Mike Mutzel: I don’t think you mentioned about how she tear it…

Dr. Rahul Desai: Walking.

Mike Mutzel: Oh, wow. Okay.

Dr. Rahul Desai: She was just…

Mike Mutzel: Overused?

Dr. Rahul Desai: Yeah, overused. But this wasn’t a super active person. This wasn’t some high-level athlete or somebody that has overused… I think she’d take walks in the neighborhood and it had bothered her a little bit, but it wasn’t super symptomatic. But obviously, it had been tendinopathic before it tore. Normal healthy tendons don’t tear. This has been going on for quite some time. Interestingly, looking back with the patient now with the type of practice that we have, we would’ve tried a lot more other interventions and they still did very well, but that patient’s BMI was probably 35 to 40, and there was some other issues that were going on that we could’ve treated as well that wasn’t the scope of our practice at that time.

Mike Mutzel: Sure. That’s awesome.

Dr. Rahul Desai: So, the PRP preparation. It’s pretty straightforward and simple. We use only FDA-approved kits, so PRP or platelet-rich plasma is FDA-approved for certain uses – for wound healing, for orthodontics – and there are some other things that it is applied for. It’s been utilized for 30 years for safe product, and the safety profile has been vented out very carefully. The preparation is fairly simple. You put an IV and draw 30-60 and sometimes, you do more. One of our kits that we use can draw up to 180 cc of the patient’s blood. You put it into a specialized centrifuge, which does the work, and then you’re able to draw out the buffy code or platelet-rich layer. The systems are standardized. Some of them have a dual-spin cycle that shows a very standardized collection and concentration of the PRP. So, we do like to use the FDA-approved kits, but we’re using them off label. So, we are using them for indications that aren’t FDA-approved, and some of those are considered experimental. The thing that we looked at when we started doing that was the safety profile. You know what? We’re doing harm; we’re potentially putting patients at risk, and then looking through all the data and now, looking back over the course of the last five years and over 15,000 injections. Knock on wood – we never made anybody worse. It definitely hurt after the procedure for a little while. We haven’t fixed everybody, but the vast majority – 70-80% of our patients have done very well. I think that it’s an extremely safe product to use if done correctly.

So, what we’re doing with the PRP is basically augmenting this normal healing cascade. So, normal wound healing. Wound means any soft tissue – a tendon tear, a fracture. There are three main components: one is inflammation, second is proliferation, and then remodeling. You can see here in times where that sits. Where we, with PRP, are going to be able to augment this healing cascade are tissues that are in this chronic inflammatory state and kind of stuck here, or tears or issues that are not healing. We’re able to stimulate or restimulate this, cause some localize inflammation by the liver and the platelets, they degranulate and release alpha-granules. We’ll try a ton of growth factors and they attract the stem cell… They attract and stimulate that initial part of healing. That goes on in a few days to a couple of weeks to proliferation basically laying down the scaffolding for those tissues to come in – for cellular material to come in and start that process. And then this remodeling or maturation process goes on for months to years. And that’s where we see – if we look at those MRIs – that kind of early stage where we saw a sneaky stage that things are going on, but it looks disorganized. We’re not really sure what’s happening, but that’s kind of this inflammation, proliferation phase, and then when it starts to get organized, we see that change. There are a couple of other examples that I have that we’ll really see how that progresses, and often times, the patients are feeling better here in this early phase, but if you scan them, it kind of looks junky, and over time, that becomes more mature and more remodeled and more kind of native tissue.

So, it’s a new paradigm in degenerative disease where we’re replacing or regenerating cells, tissues and organs to restore normal function. We first saw this in the regenerative medicine tag in the early 90s. And there’s a future prognostication in all the advancements that we’re seeing in medicine, and that we’re not applying upon simply symptom management, but trying to affect the change on the actual source of the disease process. Now, we’re seeing this $850 billion in health care costs – indirect and expenditures, lost wages. We’re looking for treatment alternatives for musculoskeletal conditions, and then PRP came to the forefront with Hines Ward in 2008/2009 Superbowl where they treated him, and he actually won the MVP. They did not think he was going to be able to play when they treated him with the PRP injection, and now it’s kind of gained notoriety in all different dermatologic fields and they’re using it for vampire facelifts, etc. All the basic tendons are the same when you’re putting this material – these powerful growth factors into tissue and hoping that they provide the healing effect.

For pain management and sports medicine – we use this for joints, tendons, ligaments, and muscle tears – both acute and chronic. We’ve actually been doing a lot more with spine. We tried epidural therapies, which has been amazing for acute and subacute disc herniation and sciatica. So instead of using corticosteroids, which will mask the inflammation and reduce the inflammation and take away the pain for a while, we’re trying to heal those tissues and we’re seeing some amazing results that are durable. That’s the big difference from all those types of therapies. Patients do come back for more injections, but you’re not doing them any favors with the soft tissues. If the desired result is a surgery, that’s a really good way to get there.

So the safety profile – we talked about the 30 years of experience. Raised horses – I think the veterinarians have a huge step-up on us as far as experience. They’ve been using this for a long time and there’s no placebo effect that goes on question with the raised horses. Additionally, orthodontics has been using it for gum healing and wound healing. So, there’s a lot of data out there as far as the efficacy.

I like this slide. I think this is kind of what PRP or the platelet-rich plasma represents to me. It’s kind of a gateway drug, and it’s something that is a precursor to the future technologies that we’re going to see. Some of those things that we’re talking about – we’re using them now today – are stem cells. They’re unspecialized; they’re replicable; they have a long life; they can divide and renew; and they can become other cell types, so they can differentiate to different types of cells based on the environment that they’ve putted. So, that’s what we’re using. We’re not in this country unless you have a specialized IRP. We can only do minimum manipulation to these stem cells. We can only keep them outside the body for eight hours or less, and so we really just concentrate them for fat-derived. We’re able to take out some of the oils and then inject them back into the tissues. So, we’re not going to get the usual adult stem cells. So, we don’t have the illegal or ethical issues that we have with embryonic stem cells. There’s another type – the induced pluripotent was just kind of a hard one. We’re just taking stem cells from the patients and injecting them to areas of injury.

One of the ways to differentiate – why would you use PRP versus stem cell? We get this question quite a bit. PRP is what I like from the two. It’s kind of a mortar. This is soft tissue, and it’s breaking down. If you look here, we have a hole in the soft tissue; you have a tear in the tendon; you have a tear in the muscle; you have some mild arthritis that’s going on in the joint. But your basic building blocks are still around, but we need to put them all back together. We need rebuild the wall. That’s what PRP fits in well, so it’s kind of a mortar. We have the bricks; we just need that glue to stick everything together. It’s minimally invasive. It’s definitely cheaper. It’s less painful, and it works very well in certain issues. So, that’s where we use PRP, and that’s kind of our frontline therapy.

Now, when we get into the stem cells, we have this wall that’s beat up. The bricks are broken. We really need some help. And when we look at those things – these are areas that are more advanced – if we’re looking at the more advanced arthritis; if we’re looking at this meniscal tear that’s non-mechanical – labral tears on the hip, labral tears in the shoulder. Those things, which were usually in the past we’ve always thought required surgical intervention, could be treated with these stem cells, and we’re seeing just fantastic results within a week or two where patients are coming back and are having complete symptom resolution with very little time off, few days of pain, and a band-aid – few band-aids when they leave here. So, it’s a pretty amazing technology.

The stem cell therapy is what we’re doing now. We’re trying to – for most patients – we had a couple of patients that were so lean that we couldn’t draw out the fat, but we do a combination of the lipoaspiration, so we don’t need a fancy machine. It’s just a syringe. I use ultrasound to guide my cannula. I like to go under the surface fascia or that superficial fascia layer to get the deep fat. It provides less side effects for dimpling and other cosmetic issues. But we only need about 20 cc of fat, and then we do a bone marrow aspirate. I use fluoroscopy for this, then we drive a 13-gauge needle into the bone marrow and we get about 60 cc of bone marrow aspirate, and we spin those down until we obtain a concentrate of both the fat and lipoaspirate. We put that together and make a slurry and then inject it into soft tissues – in these joints and tendons – those that we feel that are appropriate for the stem-cell types of therapy. So, that’s the stem cell therapy. It’s a little bit more invasive. It’s more costly. You’re recharged anywhere between, I think, 2,500 and 3,504 stem cell therapies, and we do use skilled nursing care; we do IV sedation. We want the patients to feel comfortable. There’s also the post-care. Most of the time, it’s been very interesting. We’ve probably done over 75 getting close to 100 times of these therapies, and the areas of harvesting are the least of the patient’s complaints. It’s unheard off for the patients to complain of pain in these areas. It’s actually where we’re injecting that really takes their mind for a couple of days. I think that’s indicative of how powerful this combination of tissues are because they have a lot of pain and inflammation in that region for two to three days. We cover them with narcotic pain medication usually because it’s something that’s require. We stay away from anti-inflammatories around this perioperative course.

Something else that we’ve seen that we’ve been using with some success is the amniotic membranes. Basically, it has the same growth factors in PRP, and it’s the membrane between the mother and the child or fetus. The interesting part about that membrane is that it’s HLA antigen-free. So, we have all these growth factors that are supporting the placenta and the baby, but you don’t have any antigens, so you don’t have to worry about rejection or any issues with rejection when you’re injecting this. It’s been used for 12,000 applications in wound healing and ophthalmology. That’s something that’s interesting because they can derive these. They micronize it; so they break it up as small particles, and you would be able to basically reinject this in the tissue. What is really interesting on this is that it has a five-year shelf life. You don’t have to refrigerate it, and you can reconstitute it like a botox or the other injectable and injectives with a really quick process. You don’t have to draw a blood. And sometimes, getting blood from patients is very difficult.  There’s a lot of the PRP and the stem cell – you can see how intensive it is especially this gateway drug that it’s telling us these things are working, but there are other things out there such as this amniotic membrane that can potentially heal and heal much more quickly.

Mike, are there any questions? Should we take any questions? We’re going to go on to some cases at this point. I don’t know if you have any discussion points that could be addressed.

Okay, so I’m going to get into some cases. You there?

Mike Mutzel: Sorry, I had the mute on. Well, let’s get through a couple more slides and then I will ask you a few questions because they’re coming in. Thanks.

Dr. Rahul Desai: So, tendon and ligament injury – this is kind of the basic premise that I want you to think about when you see these slides, and we’re going to look at a lot of tendon and ligament because I think it’s very easy to see; it’s very black and white and very clear. But basically, you have this degenerating tissue and it’s like this raid rope. This is the native tissue that’s very tough twined. We want to see this reversed. We want to go from here where we are now – this tendinopathy or pain issue or tear – and get back to this healthier tissue.

So, if you look – this is the patient. Well, this is actually a study. This one was best poster last year at AAOS – orthopedic society meeting. This is, I think, very telling on the power of PRP in regenerative medicine injections not only how well it works, but think about the cost-effectiveness to our society. This is PRP and RCT (rotator cuff tear). They were PRP injections into the rotator cuff tendinopathy and partial thickness tears versus corticosteroid. They had 204 patients; they did a 50/50 split. I really liked how they did their studies – very simple outcomes. They looked at one-year follow-up, and of the three months of the one-year follow-up, the three-month follow-up showed statistically significant improvement of PRP compared with steroid injections where this processes. What was really telling was in this one-year follow-up, 102 patients – three of those patients in the PRP cohort had undergone surgery for recalcitrant pain for rotator cuff repair. In the steroid group – 48 patients. So, huge difference in numbers going from the PRP to corticosteroid, and that’s what we’re seeing in the clinics. The patients are having less pain; they’re having increased function; and it’s done at a very low cost. If you can look at this, we were saving 50% of the surgeries that would be required. We take 3 versus 48. So, it’s a pretty amazing result from that study, and I think we’re seeing this clinically.

So, the systemic effects of PRP just to show how powerful it is. This is a PRP; this is not even a stem cell, which I feel is a significant step-up in efficacy and in power. This is from Amy Wasterlain from Stanford, and basically, I wanted you to see what the systemic effects were of the PRP injection. It was amazing that it was a trigger for circulating growth factors, and it was very powerful in activating biological pathways. There’s significant elevation of serum IGF-1, VEGF, and beta-FGF, so much so that patients are getting more athletes, and they were looking at this on how it would affect high-level athletes and issues with WADA or World Anti-Doping Agency. A simple injection, periarticular injection, soft-tissue injection with PRP was stimulating elevations in serum concentrations of these growth factors, so much so that it would trigger a positive response to substance-abused exam and possibly cause the banning of a competitive athlete that wasn’t using these illegal pads. That’s how amazing it is, and we’ve seen that some of our patients that we’ve done PRP or stem cell – some of the other issues actually improve as well systemically. It’s something that we’ve seen with rheumatoid patients and steroids, that it works in a similar manner, but actually trying to heal the tissues.

Mike Mutzel: There was a good question that actually came in along those lines. Someone was asking about autoimmunity and how do stem cells help with say, joint dysfunction and RA or something like that. Have you had any experience with that clinically at this point?

Dr. Rahul Desai: We have not had a lot of RA patients. I do have more of kind of a national network where we have a think tag that’s been brought up. Most of the time, what I’ve seen with RA patients and patients that have autoimmune disorders or inflammatory conditions is that it has not been as effective. I think that one of the main issues is that increasing that inflammatory cascade initially. They have a lot of pain and discomfort from that, and it’s not coming down to tolerable levels, so they have a lot of pain afterwards. And now it may work out that later on, they’re seeing benefits from that, I don’t think we got that feedback that it’s been that helpful. So definitely, there’s an autoimmune inflammatory disorder that we’ve stayed away from the PRP or stem cell so far. Again, for our patients – it’s not a large segment of our patient population. We’ve usually stocked with corticosteroids and then for patients that have like ankylosing spondylitis or something that’s pretty advanced – those patients will send them to local rheumatologists and they’ve done very well with some of the systemic PRPs or if they’re concerned with some of those other medications, then we’ve tried a more natural version of those things where I send them to Jeff, our nurse practitioner.

Mike Mutzel: Right.

Dr. Rahul Desai: We are able to help a lot of those patients with more cutting edge alternatives. I think that’s a very good question. Currently, we’re probably standing away. I think there is data coming out that we could potentially even change the constituency of our PRP. I was talking about the different kits that are out there. There are some kits where you can actually reduce the amount of red blood cells, neutrophils and white blood cells that are in the PRP mixture – the concentrate – that can reduce that initial inflammatory response. So, there is some thinking that right now, we’re utilizing those for periarticular type of injections, spine and epidural injections, but we’re taking out some of that pro-inflammatory – those issues that we’re seeing with increased neutrophil concentration and RBCs, and so that has been a discussion, but we don’t have any significant feedback yet of utilizing those types of injections for patients with systemic inflammatory conditions.

Mike Mutzel: Sure. That makes sense. With the musculoskeletal issue, you’re addressing the core issue with some sort of damage with the autoimmunity. There are other systemic contributory factors, so just improving the joint locally or what have you may not get to the underlying cause, which would need to be addressed from an integrative standpoint. Is that what I hear you saying?

Dr. Rahul Desai: Yeah.

Mike Mutzel: Awesome.

Dr. Rahul Desai: There is control with that, and there are some other issues that are more degenerative and mechanical in nature. We could address that with some of those other interventions that patients have done so well that we haven’t really needed these types of things. We’ve diagnosed patients that come in with low-back pain and it turns out to be a side joint and ankylosing spondylitis, and so is the symptom off. That’s kind of a different treatment pathway that they go on.

Mike Mutzel: Right. Now, while we’re on this slide about the systemic effects of PRP, I get this question a lot typically particularly from women with hair loss of the scalp. I know there are some advertisements for PRP and stem cells, and I think they call it, “ACell” for hair loss. Any comments there from your feedback or colleagues?

Dr. Rahul Desai: It’s mixed. Locally, there is a doctor that was doing quite a bit of that and not seeing great response, so he actually stopped. We have talked with other folks out there that have been doing a little bit more advance of therapy. There’s a plastic surgeon that has some experience with utilizing the adipose stem cells mixed with the PRP and sometimes, the ACell, and then injecting that into the scalp, and they’ve had some good response. I think he’s working out with a doctor out of Italy and Milan. There have been kind of mixed reports for that, but it’s something that overall, I don’t think there’s any definitive data and I haven’t seen anything that’s really convincing that’s helpful. My wife’s a dermatologist, and I’ve talked to her about this. She’s actually a specialist in hair loss and she had alopecia areata, and she’s a bit skeptical. But again, we spoke about that initially; I think that this is so cutting edge, and differences in technique, differences in how often you do it, and what exactly are you putting in there, and patient selection. All those things make such a big difference. But I’m talking to people doing it and seeing doing it benefit, I think there is some promise there. But right now, I don’t think… and we haven’t been doing that as far as taking PRP and doing like a dermapen. I just haven’t heard real positive and convincing evidence. There’s an international PRP and stem cell conference coming up a few weeks that will be done in Las Vegas, so I’m interested to talk to more people about it. I myself suffer from male-pattern baldness, so I would love if it worked.

Mike Mutzel: Right.

Dr. Rahul Desai: So I’ll ask my wife, “Please inject me. I think it’s pretty safe,” and so far, no go.

Mike Mutzel: Got you. Interesting.

Dr. Rahul Desai: I would be showing a couple of cases. Mike, should I move on?

Mike Mutzel: Yeah, let’s move on. Good to go.

Dr. Rahul Desai: So, calcific tendinitis and partial thickness rotator cuff tear. This is an interesting case of a 42-year-old male drummer. He came in with six months of right shoulder pain, had been treated with anti-inflammatories, physical therapy, acupuncture, chiropractic care, and when he came in, he had a tendonitis and some calcium deposits. When we looked at his initial study – this is the rotator cuff; that’s the chromium, and this is the cuff coming over. The cuff should be nice and dark. We’re going to go over the tendon imaging. It’s very simple – the dark is good; this bright stuff is bad. These are small micro-tears, and edema and fluid in there. This dark glove here is a big piece of calcium, and that’s caused overall inflammation and degradation of the tendon. We did a couple of therapies with the – basically we’re going and washing out the calcium and put cortisone in. Patients still had significant pain in that calcium; just getting a little bit less, but really wasn’t going away. We changed over to a growth factor injection. We used the amniotic membrane. This was the progression; this was 9/2012, 11/2012, and 1/2013. You can notice that the morphology of the tendon where you can see here it’s irregular; there’s punctate calcification and there are small micro-tears. This is a follow-up after one injection, and this starts to become a little bit more homogeneous. You lose the calcium, you start to see that the tendons are looking a little bit better, and here is that end results – you go from these very irregular heterogeneous appearance to these various wood veneer type I collagen appearance and they had resolution of their pain. This is a little blow-up on that and you can see the organization of that tissue, and so what I want you to go back to is this slide as we are going from this to this. And now, over the course of several months – it’s not intermediate – but three to four months to bypass the surgical intervention and go from degenerating tissue that this is going on. If we don’t do anything, likelihood is going on to a tear and surgery. By doing this injection and infusion of these growth factors, and then intense physical therapy – we say we’ve already been undergoing with this and not getting any better because the augmentation of the growth factors that provided basically a neo-tendon, so we were able to reverse time in some ways and go from this degenerating tendon to this new one.

Another one – a 30-year-old male. As you can see, this is a relatively young patient worsening in infrapatellar knee pain. They had a basketball injury and had a small partial thickness tear that had undergone conservative measures. This is the initial MRI, and you’re going to see a pattern here. This is the quadriceps tendon here. This is the patella. This is the femur and the tibia here. You can see this nice dark tendon catching the bone. Here it doesn’t look the same, but there was the tear. And so, there’s a tendon on the side. There’s a partial thickness tear that caused severe pain. This patient was unable to walk with that pain and wanting some inflammatory medications and wanting us to put some narcotics because the pain was so bad. This is an ultrasound correlate. Here you see this bright area, and here’s this dark area on the tendon. As you can see here, this is called a figural pattern in ultrasound. These tight type-1 collagen fibers that are lined up. There’s the bone, and that’s the interface where this disease process was. Here’s the ultrasound guidance. You’ll see this dark area; that’s where we need to get to. This is the needle placed in here. We can actually see this dark void when we put the PRP, and that’s the bright stuff here – fills in this gap. So, needle placed into here and then placed another PRP. So, you can see how precise the 2mm/3mm region – half the size the injections are. This was five weeks after the injection – the patient has complete resolution of the pain about 95%. There is the focus on the tearing, and you can see it starts to darken and see these fibers forming. You can see that the tear was bright there, and now you can see those type-I collagen fibers filling in. The other thing that was interesting here is that you had a effusion. This is fluid in the suprapatellar recess, so it’s fluid in the knee because it was overall. The patient was in an inflamed state because of this triggering injury. After we fix this, the effusion resolved and there was much less fluid and overall pain in the knee. So, I think that we’re seeing that and that maybe some of the systemic effect that was discussed in that Stanford article. So another – going from this torn to fixed tendon.

This is a common extensor tendon, so epicondylitis, lateral epicondylitis, tennis elbow. This was a 34-year-old ranger, and they were cutting wood when he had the injury. This was a year out, so he had had an injury quite some time ago, failed conservative measures. They came in, he was a work comp from the forest services in local McKinley. He came in with a partial thickness tear. When we looked at this, he had a cortisone injection in the community that was non-guided, and I had requested that we do PRP because I thought that he could help fix this and not just covered it up with the injection. They refused – the work comp refused and asked me to do an injection guided and just put cortisone in the area. So, we did do a cortisone in the area, and you can see here – this is a post-steroid. It actually looks a bit bigger. So, that’s the initial, and we did the injection. Now, the patient had three months of wonderful pain relief after the cortisone injection. It felt good; it reduced inflammation, reduced the pain. He went on about his work and probably overused the tissue that wasn’t healing and came back in post-tear injection three months with worse pain and a slightly bigger tear. So, that’s what we’re seeing over and over again. At that point in time, he said, “I’m just going to pay for the PRP myself. I need them. This is not getting better.” We did the injection. Here was the ultrasound. You could see the tear right there. So, this is the bone interface right here, which is the bright part here. That’s the joint space the radio had. The needle – injecting the common extensor tendons. You can see the delivery of the material. And this was the post-injection appearance. So, we have this, and what was interesting as we talked about – this actually looks a little bit more inflamed; it’s brighter overall than the early study, and that was concerning us. It’s all a little bit worse and inflamed. It’s more like a tendinopathy. But the patient at this point was really wonderful – about 85% relief – and doing really well. And this is that proliferative phase when there’s all that cellular material in the area and that’s healing. That’s what it looks like. The patient clinically is doing fantastic. We did another injection and we followed up several months later. Now, you can see that the tear is basically gone and now, there’s that remodeled appearance. When we go through – this was scanned through the entire tendon origin, which shows basically a normal-looking tendon – and there’s some little bit of disorganization right in this area that I’ve been over in the next course, next year or two that we remodel. This is the appearance that we have – we have this small micro-tear here that’s propagating a little bit after the cortisone injection – and then we end after the regenerative types of injection. After the growth factors, we see this healed tendon.

This is another patient. I’m going to go through this quickly, so we’re going to have time to talk. We’re going to get the basic. This was a decathlete 18-month-old injury. This was the avulsion tear of this patellar tendon. You can see this small avulsion fracture there. There was a gap and a lot of reactive edema and soft tissue changes. The patient could not walk upstairs without pain. He was not training. He was wanting anti-depressants because his whole life had been turned upside down. He was No. 2 in the country in the masters level of decathletes who’s a pretty high-level athlete and had been taking away from the sport. There was the tear here. This is the ultrasound. This is the patella. This is the tendon – the superior surface and the deep surface – and you can kind of see this torn by the tendon, which represents this, and that’s a little avulsion fracture that’s dark line here that have been pulled off of the patella. This is the delivery of the PRP. This was the course of – this actually took us a year to completely lose all. We had three injections and you can see that over time, this area fills in with a more normal-looking tissue, and while we never may have this looking completely normal or may take years to reorganize and mature – we see that this gap, which is causing a lot of pain and inflammation, had been filled in. This patient won the national title the year following our therapy. So, we’re really excited to see about his results. He’s one of our early patients.

Another one – two years out – same type of injury, split tear. This was a two-year-old injury that patient had a lower quality MRI in an open scanner, and they said, “You don’t have a meniscal tear. You don’t have a fracture. Your ACL’s intact, and you’re good to go.” They missed this very subtle tear, but it has caused a lot of discomfort. The patient’s on disability by the time we saw her on some significant narcotics. We did one therapy. This was six weeks later, and the tendon completely resolved. It was completely healed. You can see the change from this bright linear tear to a completely normal-looking tendon. And so, that was pretty amazing.  We saw her six months later, she’d lost 35 pounds – exercising, back to work, and sends us a bunch of presents.

This was Delta Airline stewardess – almost a full-thickness tear at the common extensor tendon. This is coming off the bone here – extremely painful on disability. Not only that there was some instability – her joint was inflamed – so this is an effusion of the elbow joint. Not only was this causing pain locally, it was causing some regional effects as well, and that was the lateral epicondylitis and partial tear. This was six weeks later – one injection later – and you can see the fibers rebuilding. This is kind of a black-and-white proof that this type of technology does work. The other interesting thing is that effusion of the joint had completely resolved as well. So overall, not only we’re able to treat this focus of injury, but we’re providing a benefit to the local tissues and joints.

This is a full-thickness rotator cuff tear, which even now, I talk to some of the docs that work with us and they’re kind of trepidatious, but we talk about full-thickness rotator cuff tears especially the shoulders region, and they think it is not going to work. “Don’t send them the PRP. They need a surgery.” When I start to show them these cases, they slowly, I think, it all gained their confidence, but I think they’re still on offense. This is a full-thickness rotator cuff tear – pretty big defect. This was the ultrasound, and it should look like this. This is bone and here, the bone tendon interface. Between here and here, is the tendon coming over. This is deltoid and the muscular bursa sits on a very thin line right here, and then that’s superficial fat. We had a very big gap right here. That’s the tendon over here and a large tear.

This was a laborer. This patient lifted boxes between 50 and 100 pounds over head, was not able to lift their arm, and again, was one of the early patients that has needed to go to surgery. This is the full-thickness tear refute. It’s life worth that the imaging center that I worked at, and so we did the therapy. He came back after one PRP about five or six months later left with 50% reduction in pain. Here’s the tear; the delivery of the material with the needle. This was the progression; this was about a couple of months out and this was the year out. But basically, there are the new fibers. There’s the gap, there’s the full-thickness tear, some early changes, and then actually neo-tendon. That’s the ultrasound appearance. Here’s the MRI appearance. We have this tendon. The large fluid filled the gap. So, it’s some cellular material coming to the area that’s scaffolding building. And then here’s that neo-tendon in the same area. This patient – his wife actually now works for our clinic, and I talk to him all the time. He’s still one of the biggest proponents of PRP. He had two injections and complete resolution of full-thickness rotator cuff tear bypass surgery.

There are some other things that kind of bypass this sports hernia, which we’re seeing a lot in some of the high-level athletes. We have a soccer team in town and it’s a pain at the aponeurotic synthesis, and basically where the six-pack adductor abdominus attaches aponeurotic synthesis and also the adductor tendons. We get these tears, and there’s a lot of going pain. We see it in the runners as well. A very common misdiagnosis is a hernia. This is a therapy that doesn’t have a great surgical intervention – relatively poor outcomes – and we’ve had some patients. This one was a pretty significant tear, severe pain in the groin. Periostin was getting stripped off the bone here and they had a large tear that should be more like this side. This is the right side. You have this tear here. This is after a couple of PRP treatments. That stripped periostin is healing and that tear is significantly smaller, and we’re getting that more normal rope-like appearance that’s getting more look like the opposite side – the asymptomatic side. This patient at this time at this image had a complete resolution of the pain. And I think that the morphology is following the clinical patterns, so I hope that they are able to get complete resolution.

Here’s the tear. Here’s the aponeurotic synthesis that periostin was stripping. There’s the tear now filling in the neo-tendon, and there is that periostin.

Anyway, just wanted to finish up with that slide. I think Mike’s going to be taking over here.

Mike Mutzel: Yeah, that’s amazing. Great job, Dr. Desai! That’s a lot of good information. Quite a few questions came up regarding the spine and herniated discs. Can you talk about that a little bit while I’m working with these slides?

Dr. Rahul Desai: Sure. So, where we have had very good success – we’re kind of testing out some different things, but we have been using PRP as a replacement or substitute for corticosteroids. One, we usually try the corticosteroids first because the insurance will pay for it. I always say it’s kind of a diagnostic and potentially therapeutic injection. But if it’s something that’s short-term – it’s working, but it’s not durable – we might try a couple, but at a certain point we may be doing more harm to the patient than good by injecting corticosteroids into the epidural space. I’m a pretty firm believer on that especially over the long term. So, we’re trying to find replacements and one of those was PRP. We’ve seen probably the best success with that with disc herniations that are relatively acute to subacute – something within six/eight months – and then when you do the MRI, you see kind of a bright –  you can see a brighter disc. That’s kind of an extrusion. We’ve seen those heal over time, but often times, that’s over 18 months or two years to a slow progression with a disc gets resort. We’ve had a couple of patients, and we had the MRIs. I wish I have had them in here, but I can give that maybe to Jeff as he’s going to be a presenter again. But we have those disc extrusions resolved within a matter of weeks with PRP injections. So, I think that what you saw today with tendons was valid with other parts of the body that are basically accelerating the healing process. So whatever mechanisms that is that those disc herniations are being resolved, the macrophages are coming and healing it up, and we’re able to kind of stimulate that process with the PRP, and we’ve seen that completely resolved and the sciatic pains completely reduced. We’ve been using this to some regular low-back pains sciatica with successes not as higher rate and we’ve even had it with failed backs syndrome – so, patients that have had lower back surgery – and it’s kind of the step that we use before spinal cord stimulation. They’ve had the surgery; they’ve had continued low-back pain and sciatic symptoms, and there’s really no other alternative that we’ve used PRP as a trial, and I’d say that 40-50% of the patients that we’ve tried on had a wonderful relief that’s durable. They may not have a complete relief, but a tremendous reduction that’s tolerable. We’re in a place where they’re very happy with that, and we’ve circumvented an implantable device forever. I think it’s a powerful tool. We’re still learning how to use it.

Mike Mutzel: That’s amazing. Let’s talk about turnaround times. You mentioned after a couple of weeks. I know my wife had PRP on her achilles and she was in a boot like you mentioned in that one patient of yours. Some people are asking like turnaround times at a case – let’s say you’re a high-performance athlete or even weekend warrior or even when you’re out for a month or two – what do you recommend for your patients?

Dr. Rahul Desai: It really depends on the disease process that we’re treating. We look at the scope of the injury – some of the injuries that we saw here. So, there’s  a spectrum. If it’s a mild tendinosis, obviously, you’re going to expect a much shorter recovery time on the matter of weeks. If it’s a significant tear, then we’re going to talk about a much longer or projected course. The other thing is that everybody’s healing ability is different. That’s one of the reasons that probably an in-season athlete that needs to get back on the field right away or they’re going to lose their position, this may not be the ideal treatment for them especially if they have a more advanced process. They can try and can help to reduce some of the pain over time, but what we have seen, more often than not, is that they have increased pain for several days, and then they need to get back to playing before they even have the chance to heal. So the in-season athlete – I don’t think this is the best type of therapy unless you can really sit them and allow them to heal. Now for the off-season, I think it’s a wonderful type of therapy. We see that very commonly right after the end of the season that we see the athletes, we get them on a program, so we’re going to try to fit it. Maybe we don’t need two or three injections, but we’re going to try to fit in three injections. My usual course of therapy is that I’ll do – I think this might help explain a little bit – when I do these therapies, it’s out-of-pocket expense. So, it’s something that I want to be conscious out. I don’t want to feel like I’m charging them all this money and doing all these injections close together. The other thing is that I think it really does take time for that healing cascade to kick in. So, if you do too many injections too close together – I know that there are some folks out there that are doing it every couple of weeks; I just don’t think they’re getting enough time for that healing cascade to cycle through. So, my therapy – my regimen is we do an injection and we follow up in about six weeks. I tell the patient to expect pain increase for up to two weeks and then I want them to start physical therapy if they’re doing well at about 10 days to two weeks. So, you do the therapy – they kind of have the relative rest. Sometimes, I immobilize them for a couple of days with relative rest, get to the physical therapy for about two weeks, and then I see them at six weeks. If I see anything around 25% – partially subjective – but 25% in improvement of decreased pain from baseline – decreased pain, increased functionality – that they have less pain; after use, they recover faster – those kinds of things that I look for – then we can consider another injection depending on how they’re doing. If they come in at six weeks and say, “I’m having 40% improvement, but every week I’m feeling 10% better.” I let her ride and say, “Okay, we’ll see you in another few weeks.” So, I’ll give her another follow-up. If they continue to improve – and we’ve seen this that one injection heals that – but we just have to follow it up and make sure that they’re getting better. If they have a benefit and they plateau – usually I’ll say plateau for a week or two – that’s where we’ll go back in there and kind of reenergize the tissue by doing another one. And that’s where we started with the decathlete – that was three injections – and he would kind of… He could walk upstairs without pain. We did an injection, he had severe pain after the injection, and then after a few weeks, he was able to walk up the stairs without pain. He started jogging, he started to have pain – the injecting begun. I have that same kind of course. He was able to jog without pain, but then he started splinting in pain, and the last phase for him was ballistics where he was doing pole vaulting and those types of things. We did one last therapy, and that’s where he was able to get together with that. So sometimes, we just have to take two steps forwards and one step back. I’d like to give the patient’s body to heal instead of jumping back in there and be too aggressive with the injection therapies.

Mike Mutzel: Sure. You bring up a good point – some questions came in on the age on which PRP would be beneficial for the patient because we’re kind of relying on the body’s natural ability from what it sounds like to me to help improve and restore your joint and function. Is there an upper limit or age window where people tend to function best or recover best or have a best outcome with PRP?

Dr. Rahul Desai: We have seen improvement all over the board. Some of the most spectacular cases have been older patients. The patient that I was talking about that had the disc extrusion was late 60s, and did tremendously well. Overall I think for soft tissue injuries, probably the younger you are the better chance that you’re going to have to heal, but I think it’s also a part of the status of the tissue. If you’re dealing with an advanced process with a large tear, it really doesn’t matter if you’re younger or older, that’s going to be harder to heal. If you catch something earlier on, arthritic process or a tear (any of those) – we catch it earlier on and if the patient is relatively healthy, I think they’ll all do fairly well the earlier that you can catch it, and that’ why I think about now looking at the system and just focusing on that particular issue is that if we can optimize the patient’s health, and sometimes you have to do that before you do the therapy. If you need a hands-on interventions to have them stop smoking or improve their metabolic function or other things, then I think there are different supplements that we can utilize. I am lucky that I have Jeff with me; I just kind of send the patients to him and he handles that. I’d like to get them tuned up and when we do, we did one patient, a high-level athlete golfer, that had moderate hip osteoarthritis with severe pain. That was a constant pain at baseline sitting, doing anything. That’s been by 18 months. It had been on and off before and now it’s just become constant. They have given the hip replacement’s the way to go by the surgical team. I had Jeff look at him and we started some supplementation program. We put him on some IV therapies. It took us six weeks to get him ready for the therapy. After that, we did the stem cell therapy and that’s been a few weeks, and he’s had tremendous improvement from baseline. He still has a little bit of discomfort, but from where he was the last 18 months, it’s been dramatic and it’s only been a few weeks. Not only age is important, but I think the status. The age is a number – I’m preaching to the choir on that one. I really think that where we can get these patients to an overall health status is really going to affect the type of change that we can facilitate with these types of therapies.

Mike Mutzel: That makes a lot of sense.

Dr. Rahul Desai: One of the early patients that we’ve seen were some of these MMA fighters, and that triggered my interest in looking at hormonal therapies and other things because I knew these guys were on HGH and higher levels of testosterone, and actually, one of them that we treated had a very high level and got in trouble from his knee. All of them may be on the news, but I’ve never seen anybody heal that fast. Still to this day, those guys – one, they’re super fit, but I really think the other part is that this augmentation of hormones and just kind of the health optimization really changes the outcome because we’re using our own immune system with these types of therapies to heal, and if you can optimize that. I think that those studies will come out in the future – maybe we take them to super therapeutic levels. This is kind of theoretical, but what would happen if we have that patient that was a school teacher that we could take to super therapeutic level of whatever hormone or mineral or vitamin that it needs to help heal that for that short period of time. I’m not saying keep them on that forever, but for that short period of time, we were trying to allow that body to heal that tissue. What can we do to augment that? I think that’s exciting to me to see what kind of research is done in the future to see what kind of interventions that we can utilize and optimize with kind of a collaborative therapy.

Mike Mutzel: Sure. That’s awesome. In addition to MMA, CrossFit’s really big here on the West Coast and in Portland as well. Have you run into any stories with CrossFit athletes with either knees or back or any joints issues?

Dr. Rahul Desai: Oh, yeah. Sometimes, I feel bad for them when they come, but they kind of keeping us in business.

Mike Mutzel: Right.

Dr. Rahul Desai: There are so many accidents and traumas. The big thing is that a lot of times, the patients just aren’t ready for that type of rigorous activity. Some of them obviously, we’ve seen them there and there, and they have built up slowly to perform at that level and they can do it. Still, there’s a certain limit. I think that a lot of patients came in a tore the triceps and tendons when they’re trying to lift a tire. It was way too heavy, and they came back on them and basically hyper-extended both elbows and the hip. That went to surgical intervention, began similar types of therapies. If it’s not that bad, we’ve been able to treat with PRP. That community loves it – one, because it’s minimal downtimes, not a surgery; and two, they wanted to get their functionality back. It’s not just a matter of “take the pain away,” but they wanted to be back in the gym, they wanted to be back in doing the things they love to do. We’ve had some patients that are bodybuilders. Same type of thing – they’ve injured themselves, they want that tissue to heal, and this provides a really nice mechanism to do that. So, I think those types of communities – even just basic things – osteoarthritis community is huge here in Portland. Biking community – those people – they’re kind of type A; they’re really athletic, they’re really driven, they’re really pushed – and often times, they come into our clinic seeking this type of therapy. When they find this on the internet, they know what they want, and they want to find somebody that’s knowledgeable about how to implement that process.

Mike Mutzel: That’s sounds great. Now, what are the costs associated with PRP in your therapies?

Dr. Rahul Desai: The basic injection that we charge is around $725. You’re going to think that you’re going to pay for the kit, which ranges from a couple of $100 and up. At the time of processing, you have to have someone or a nurse to draw the blood. There’s time spinning it down. We do use sedation for most of the soft-tissue therapies, so there’s a time involved in that – money involved in that. And then also, in delivering the injections with the guidance, so you have to cover the cost of the ultrasound and those types of things. It’s not a huge profit margin. Here in Portland, there’s definitely competition. In other markets – you look at LA market and the various places, they’re charging quite a bit more for that. There are different ways to augment that, too. We use the adelite system here, which increases the anti-inflammatory proteins theoretically, so we try to augment ours the best of our ability. We do add HGH – a very small amount into some of the injection therapies, the stem cell therapies and intra-articular injections. There are some studies that demonstrated the benefits of HGH intra-articular with cartilage issues – cartilage wear and tear.

Mike Mutzel: Nice. That’s great.

Dr. Rahul Desai: One of the things that you can look into this is that PRP is very different from steroid, but we’re trying to limit the exposure, so we want to do like one issue and diagnose that particular problem. It’s just sometimes patients will have multiple problems – epicondylitis, patellar tendinitis and other issues. It’s cost-effective to treat both areas at the same time because you’re drawing that blood, you’re using the FDA-approved device and kit that’s available, and so we do have kind of an adjustment. We’re going do two areas. It’s going to be a little bit more expensive, but it’s not double. We’ve taken a lot of time and process a lot of cost there. Sometimes, my partner teases me. He’s a physiatry-trained interventional spine guide, but he says I’m like the thin-man syndrome where I was kind of lubricating all these different areas with PRP, but that’s a little bit augmentation.

With the stem cell, I think we’ve said before that it’s anywhere between $3,000 and $4,000 with the fat and the bone marrow.

Mike Mutzel: Right. And that’s a little bit more invasive and time involved.

Dr. Rahul Desai: With the PRP, we’ve probably set up the patients – we want them to have realistic expectations, so I’d like to say anywhere between – before an issue, I try to gauge how many. That’s just one; it’s from experience, but how many injections. But I always try to – depending on most of the things that we see – two to three injections is what I’d recommend that you can expect that many. Now, if we get to a point that we don’t need that many, wonderful. If you’ve treated one or two and we’re done, and that’s fantastic. At least, setting them up that it’s a process. It’s not a one and done. It’s not pixie dust that we can sprinkle over and then suddenly you’re going to feel…

Mike Mutzel: Yeah, I like that.

Dr. Rahul Desai: You have to get there by as well as the therapy. If you’re going to have to push it, we’re going to need some rejuvenated tissues and some of that works on you.

Mike Mutzel: That makes sense. Dr. Desai, it’s been a lot of fun to talk with you. Thanks so much for this awesome information. As we close up, I just want to highlight a couple of new things that we have here for everyone. The SynovX Recovery – we are featuring a new chondroitin sulfate from Spain. It’s 100% purified material, which is unique in the market place; most companies are selling 85% purified. So, a lot of great research on this ingredient, and we wrapped it into the SynovX Recovery, and also the SynovX DJD. We do have the Hyal-Joint material, which is from the rooster comb. Again, a lot of great research from our friends of Bioiberica in Spain. So, really science-based products that you have researched on the ingredients and what they do in humans and a great way to nutritionally support your joints and tendons and ligaments. Thanks so much for joining us and hope you all have a great evening. Dr. Desai, thanks again.

Dr. Rahul Desai: Thank you. Thanks Mike for having me. Good night.

Mike Mutzel: You’re welcome. Take care.

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