Regenerative Interventional
Functional Orthopedic
Medicine
What are the Patient OptionsPhillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
Disclaimer
Stockholder of Canopy Growers
Associate of CTFO
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
2 What are treatment options for OA
(Osteoarthritis)
3 What are treatment options for MSK
pain and disability
What Causes Musculoskeletal Pain
bull Trauma
ndash Falls
ndash Injuries
ndash MVA
bull Overuse Repetitive
motion
bull Postural imbalance
strain
Rapid Onset Insidious Onset
4
Symptoms amp Types of Pain
bull Sharp
bull Severe
bull Ache
bull Burn
bull Dull
bull Acute
bull Chronic
Symptoms Types
5
Types of Pain
bull Falls
ndash Fractures
ndash Dislocations
bull Injuries
ndash Work Related
Hobby
ndash Strain Sprain
bull MVA
bull Overuse Repetitive motion
ndash Inflammatory
bull Bursitis
bull Tendonitis
ndash Non-Inflammatory
bull Tendonosis
bull Postural imbalance strain
ndash Kyphosis
ndash Lordosis
Acute Chronic
6
Form Follows Function or Deformity Delineates Dysfunction
SANS ndash Christopher Centeno MD
Tensegrity
Biotensegrity
ndash Buckyball
Form Follows Function or Deformity Delineates Dysfunction
BIOTENSEGRITY
Buckyball BuckminsterfullereneOrganism approach states everything is
in balance even at the cellular level
Form Follows Function or Deformity Delineates Dysfunction
bullBIOTENSEGRITY a unifying theory of biological architecture with
applications to osteopathic practice education and research-- to identify the mechanical causes of disease and to understand the bodys structure-function relationship at all size scales in the human body
bullAt the cellular level allows the cell to mechanically sense its environment and convert mechanical signals into biochemical changes
bullApplied to principles of osteopathic medicine biotensegrity provides a conceptual understanding of the hierarchical organization of the human body and explains the bodys ability to adapt to change
bullExplains how mechanical forces applied during osteopathic manipulative treatment could lead to effects at the cellular level providing a platform for future research on the mechanisms of action of osteopathic manipulative treatment
Swanson RL 2nd1 J Am Osteopath Assoc 2013 Jan113(1)34-52
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY DEFINITION (Buckminster Fuller 1975)
ldquoSynergeticsrdquo and the relation between continuous tension elements and
its continuous compression elements which are responsible for a structure
as follows
ldquoThe word tensegrity is an invention it is a contraction of tensional
integrity Tensegrity describes a structural‐relationship principle in which
structural shape is guaranteed by the finitely closed comprehensively
continuous tensional behaviors of the system and not by the discontinuous
and exclusively local compressional member behaviors
Tensegrity provides the ability to yield increasingly without ultimately
breaking or coming asunder
The integrity of the whole structure is invested in the finitely closed
tensional‐embracement network and the compressions are local islandsrdquowwwosteopathic-researchcompaper_pdfPfluegerpdf
Form Follows Function or Deformity Delineates Dysfunction
Myofascial system on macroscopic scale behaves like
a tensegrity structure
TENSEGRITY
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
Abnormal forces and environment2 What are treatment options for OA (Osteoarthritis)3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Disclaimer
Stockholder of Canopy Growers
Associate of CTFO
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
2 What are treatment options for OA
(Osteoarthritis)
3 What are treatment options for MSK
pain and disability
What Causes Musculoskeletal Pain
bull Trauma
ndash Falls
ndash Injuries
ndash MVA
bull Overuse Repetitive
motion
bull Postural imbalance
strain
Rapid Onset Insidious Onset
4
Symptoms amp Types of Pain
bull Sharp
bull Severe
bull Ache
bull Burn
bull Dull
bull Acute
bull Chronic
Symptoms Types
5
Types of Pain
bull Falls
ndash Fractures
ndash Dislocations
bull Injuries
ndash Work Related
Hobby
ndash Strain Sprain
bull MVA
bull Overuse Repetitive motion
ndash Inflammatory
bull Bursitis
bull Tendonitis
ndash Non-Inflammatory
bull Tendonosis
bull Postural imbalance strain
ndash Kyphosis
ndash Lordosis
Acute Chronic
6
Form Follows Function or Deformity Delineates Dysfunction
SANS ndash Christopher Centeno MD
Tensegrity
Biotensegrity
ndash Buckyball
Form Follows Function or Deformity Delineates Dysfunction
BIOTENSEGRITY
Buckyball BuckminsterfullereneOrganism approach states everything is
in balance even at the cellular level
Form Follows Function or Deformity Delineates Dysfunction
bullBIOTENSEGRITY a unifying theory of biological architecture with
applications to osteopathic practice education and research-- to identify the mechanical causes of disease and to understand the bodys structure-function relationship at all size scales in the human body
bullAt the cellular level allows the cell to mechanically sense its environment and convert mechanical signals into biochemical changes
bullApplied to principles of osteopathic medicine biotensegrity provides a conceptual understanding of the hierarchical organization of the human body and explains the bodys ability to adapt to change
bullExplains how mechanical forces applied during osteopathic manipulative treatment could lead to effects at the cellular level providing a platform for future research on the mechanisms of action of osteopathic manipulative treatment
Swanson RL 2nd1 J Am Osteopath Assoc 2013 Jan113(1)34-52
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY DEFINITION (Buckminster Fuller 1975)
ldquoSynergeticsrdquo and the relation between continuous tension elements and
its continuous compression elements which are responsible for a structure
as follows
ldquoThe word tensegrity is an invention it is a contraction of tensional
integrity Tensegrity describes a structural‐relationship principle in which
structural shape is guaranteed by the finitely closed comprehensively
continuous tensional behaviors of the system and not by the discontinuous
and exclusively local compressional member behaviors
Tensegrity provides the ability to yield increasingly without ultimately
breaking or coming asunder
The integrity of the whole structure is invested in the finitely closed
tensional‐embracement network and the compressions are local islandsrdquowwwosteopathic-researchcompaper_pdfPfluegerpdf
Form Follows Function or Deformity Delineates Dysfunction
Myofascial system on macroscopic scale behaves like
a tensegrity structure
TENSEGRITY
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
Abnormal forces and environment2 What are treatment options for OA (Osteoarthritis)3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
2 What are treatment options for OA
(Osteoarthritis)
3 What are treatment options for MSK
pain and disability
What Causes Musculoskeletal Pain
bull Trauma
ndash Falls
ndash Injuries
ndash MVA
bull Overuse Repetitive
motion
bull Postural imbalance
strain
Rapid Onset Insidious Onset
4
Symptoms amp Types of Pain
bull Sharp
bull Severe
bull Ache
bull Burn
bull Dull
bull Acute
bull Chronic
Symptoms Types
5
Types of Pain
bull Falls
ndash Fractures
ndash Dislocations
bull Injuries
ndash Work Related
Hobby
ndash Strain Sprain
bull MVA
bull Overuse Repetitive motion
ndash Inflammatory
bull Bursitis
bull Tendonitis
ndash Non-Inflammatory
bull Tendonosis
bull Postural imbalance strain
ndash Kyphosis
ndash Lordosis
Acute Chronic
6
Form Follows Function or Deformity Delineates Dysfunction
SANS ndash Christopher Centeno MD
Tensegrity
Biotensegrity
ndash Buckyball
Form Follows Function or Deformity Delineates Dysfunction
BIOTENSEGRITY
Buckyball BuckminsterfullereneOrganism approach states everything is
in balance even at the cellular level
Form Follows Function or Deformity Delineates Dysfunction
bullBIOTENSEGRITY a unifying theory of biological architecture with
applications to osteopathic practice education and research-- to identify the mechanical causes of disease and to understand the bodys structure-function relationship at all size scales in the human body
bullAt the cellular level allows the cell to mechanically sense its environment and convert mechanical signals into biochemical changes
bullApplied to principles of osteopathic medicine biotensegrity provides a conceptual understanding of the hierarchical organization of the human body and explains the bodys ability to adapt to change
bullExplains how mechanical forces applied during osteopathic manipulative treatment could lead to effects at the cellular level providing a platform for future research on the mechanisms of action of osteopathic manipulative treatment
Swanson RL 2nd1 J Am Osteopath Assoc 2013 Jan113(1)34-52
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY DEFINITION (Buckminster Fuller 1975)
ldquoSynergeticsrdquo and the relation between continuous tension elements and
its continuous compression elements which are responsible for a structure
as follows
ldquoThe word tensegrity is an invention it is a contraction of tensional
integrity Tensegrity describes a structural‐relationship principle in which
structural shape is guaranteed by the finitely closed comprehensively
continuous tensional behaviors of the system and not by the discontinuous
and exclusively local compressional member behaviors
Tensegrity provides the ability to yield increasingly without ultimately
breaking or coming asunder
The integrity of the whole structure is invested in the finitely closed
tensional‐embracement network and the compressions are local islandsrdquowwwosteopathic-researchcompaper_pdfPfluegerpdf
Form Follows Function or Deformity Delineates Dysfunction
Myofascial system on macroscopic scale behaves like
a tensegrity structure
TENSEGRITY
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
Abnormal forces and environment2 What are treatment options for OA (Osteoarthritis)3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
What Causes Musculoskeletal Pain
bull Trauma
ndash Falls
ndash Injuries
ndash MVA
bull Overuse Repetitive
motion
bull Postural imbalance
strain
Rapid Onset Insidious Onset
4
Symptoms amp Types of Pain
bull Sharp
bull Severe
bull Ache
bull Burn
bull Dull
bull Acute
bull Chronic
Symptoms Types
5
Types of Pain
bull Falls
ndash Fractures
ndash Dislocations
bull Injuries
ndash Work Related
Hobby
ndash Strain Sprain
bull MVA
bull Overuse Repetitive motion
ndash Inflammatory
bull Bursitis
bull Tendonitis
ndash Non-Inflammatory
bull Tendonosis
bull Postural imbalance strain
ndash Kyphosis
ndash Lordosis
Acute Chronic
6
Form Follows Function or Deformity Delineates Dysfunction
SANS ndash Christopher Centeno MD
Tensegrity
Biotensegrity
ndash Buckyball
Form Follows Function or Deformity Delineates Dysfunction
BIOTENSEGRITY
Buckyball BuckminsterfullereneOrganism approach states everything is
in balance even at the cellular level
Form Follows Function or Deformity Delineates Dysfunction
bullBIOTENSEGRITY a unifying theory of biological architecture with
applications to osteopathic practice education and research-- to identify the mechanical causes of disease and to understand the bodys structure-function relationship at all size scales in the human body
bullAt the cellular level allows the cell to mechanically sense its environment and convert mechanical signals into biochemical changes
bullApplied to principles of osteopathic medicine biotensegrity provides a conceptual understanding of the hierarchical organization of the human body and explains the bodys ability to adapt to change
bullExplains how mechanical forces applied during osteopathic manipulative treatment could lead to effects at the cellular level providing a platform for future research on the mechanisms of action of osteopathic manipulative treatment
Swanson RL 2nd1 J Am Osteopath Assoc 2013 Jan113(1)34-52
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY DEFINITION (Buckminster Fuller 1975)
ldquoSynergeticsrdquo and the relation between continuous tension elements and
its continuous compression elements which are responsible for a structure
as follows
ldquoThe word tensegrity is an invention it is a contraction of tensional
integrity Tensegrity describes a structural‐relationship principle in which
structural shape is guaranteed by the finitely closed comprehensively
continuous tensional behaviors of the system and not by the discontinuous
and exclusively local compressional member behaviors
Tensegrity provides the ability to yield increasingly without ultimately
breaking or coming asunder
The integrity of the whole structure is invested in the finitely closed
tensional‐embracement network and the compressions are local islandsrdquowwwosteopathic-researchcompaper_pdfPfluegerpdf
Form Follows Function or Deformity Delineates Dysfunction
Myofascial system on macroscopic scale behaves like
a tensegrity structure
TENSEGRITY
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
Abnormal forces and environment2 What are treatment options for OA (Osteoarthritis)3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Symptoms amp Types of Pain
bull Sharp
bull Severe
bull Ache
bull Burn
bull Dull
bull Acute
bull Chronic
Symptoms Types
5
Types of Pain
bull Falls
ndash Fractures
ndash Dislocations
bull Injuries
ndash Work Related
Hobby
ndash Strain Sprain
bull MVA
bull Overuse Repetitive motion
ndash Inflammatory
bull Bursitis
bull Tendonitis
ndash Non-Inflammatory
bull Tendonosis
bull Postural imbalance strain
ndash Kyphosis
ndash Lordosis
Acute Chronic
6
Form Follows Function or Deformity Delineates Dysfunction
SANS ndash Christopher Centeno MD
Tensegrity
Biotensegrity
ndash Buckyball
Form Follows Function or Deformity Delineates Dysfunction
BIOTENSEGRITY
Buckyball BuckminsterfullereneOrganism approach states everything is
in balance even at the cellular level
Form Follows Function or Deformity Delineates Dysfunction
bullBIOTENSEGRITY a unifying theory of biological architecture with
applications to osteopathic practice education and research-- to identify the mechanical causes of disease and to understand the bodys structure-function relationship at all size scales in the human body
bullAt the cellular level allows the cell to mechanically sense its environment and convert mechanical signals into biochemical changes
bullApplied to principles of osteopathic medicine biotensegrity provides a conceptual understanding of the hierarchical organization of the human body and explains the bodys ability to adapt to change
bullExplains how mechanical forces applied during osteopathic manipulative treatment could lead to effects at the cellular level providing a platform for future research on the mechanisms of action of osteopathic manipulative treatment
Swanson RL 2nd1 J Am Osteopath Assoc 2013 Jan113(1)34-52
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY DEFINITION (Buckminster Fuller 1975)
ldquoSynergeticsrdquo and the relation between continuous tension elements and
its continuous compression elements which are responsible for a structure
as follows
ldquoThe word tensegrity is an invention it is a contraction of tensional
integrity Tensegrity describes a structural‐relationship principle in which
structural shape is guaranteed by the finitely closed comprehensively
continuous tensional behaviors of the system and not by the discontinuous
and exclusively local compressional member behaviors
Tensegrity provides the ability to yield increasingly without ultimately
breaking or coming asunder
The integrity of the whole structure is invested in the finitely closed
tensional‐embracement network and the compressions are local islandsrdquowwwosteopathic-researchcompaper_pdfPfluegerpdf
Form Follows Function or Deformity Delineates Dysfunction
Myofascial system on macroscopic scale behaves like
a tensegrity structure
TENSEGRITY
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
Abnormal forces and environment2 What are treatment options for OA (Osteoarthritis)3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Types of Pain
bull Falls
ndash Fractures
ndash Dislocations
bull Injuries
ndash Work Related
Hobby
ndash Strain Sprain
bull MVA
bull Overuse Repetitive motion
ndash Inflammatory
bull Bursitis
bull Tendonitis
ndash Non-Inflammatory
bull Tendonosis
bull Postural imbalance strain
ndash Kyphosis
ndash Lordosis
Acute Chronic
6
Form Follows Function or Deformity Delineates Dysfunction
SANS ndash Christopher Centeno MD
Tensegrity
Biotensegrity
ndash Buckyball
Form Follows Function or Deformity Delineates Dysfunction
BIOTENSEGRITY
Buckyball BuckminsterfullereneOrganism approach states everything is
in balance even at the cellular level
Form Follows Function or Deformity Delineates Dysfunction
bullBIOTENSEGRITY a unifying theory of biological architecture with
applications to osteopathic practice education and research-- to identify the mechanical causes of disease and to understand the bodys structure-function relationship at all size scales in the human body
bullAt the cellular level allows the cell to mechanically sense its environment and convert mechanical signals into biochemical changes
bullApplied to principles of osteopathic medicine biotensegrity provides a conceptual understanding of the hierarchical organization of the human body and explains the bodys ability to adapt to change
bullExplains how mechanical forces applied during osteopathic manipulative treatment could lead to effects at the cellular level providing a platform for future research on the mechanisms of action of osteopathic manipulative treatment
Swanson RL 2nd1 J Am Osteopath Assoc 2013 Jan113(1)34-52
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY DEFINITION (Buckminster Fuller 1975)
ldquoSynergeticsrdquo and the relation between continuous tension elements and
its continuous compression elements which are responsible for a structure
as follows
ldquoThe word tensegrity is an invention it is a contraction of tensional
integrity Tensegrity describes a structural‐relationship principle in which
structural shape is guaranteed by the finitely closed comprehensively
continuous tensional behaviors of the system and not by the discontinuous
and exclusively local compressional member behaviors
Tensegrity provides the ability to yield increasingly without ultimately
breaking or coming asunder
The integrity of the whole structure is invested in the finitely closed
tensional‐embracement network and the compressions are local islandsrdquowwwosteopathic-researchcompaper_pdfPfluegerpdf
Form Follows Function or Deformity Delineates Dysfunction
Myofascial system on macroscopic scale behaves like
a tensegrity structure
TENSEGRITY
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
Abnormal forces and environment2 What are treatment options for OA (Osteoarthritis)3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
SANS ndash Christopher Centeno MD
Tensegrity
Biotensegrity
ndash Buckyball
Form Follows Function or Deformity Delineates Dysfunction
BIOTENSEGRITY
Buckyball BuckminsterfullereneOrganism approach states everything is
in balance even at the cellular level
Form Follows Function or Deformity Delineates Dysfunction
bullBIOTENSEGRITY a unifying theory of biological architecture with
applications to osteopathic practice education and research-- to identify the mechanical causes of disease and to understand the bodys structure-function relationship at all size scales in the human body
bullAt the cellular level allows the cell to mechanically sense its environment and convert mechanical signals into biochemical changes
bullApplied to principles of osteopathic medicine biotensegrity provides a conceptual understanding of the hierarchical organization of the human body and explains the bodys ability to adapt to change
bullExplains how mechanical forces applied during osteopathic manipulative treatment could lead to effects at the cellular level providing a platform for future research on the mechanisms of action of osteopathic manipulative treatment
Swanson RL 2nd1 J Am Osteopath Assoc 2013 Jan113(1)34-52
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY DEFINITION (Buckminster Fuller 1975)
ldquoSynergeticsrdquo and the relation between continuous tension elements and
its continuous compression elements which are responsible for a structure
as follows
ldquoThe word tensegrity is an invention it is a contraction of tensional
integrity Tensegrity describes a structural‐relationship principle in which
structural shape is guaranteed by the finitely closed comprehensively
continuous tensional behaviors of the system and not by the discontinuous
and exclusively local compressional member behaviors
Tensegrity provides the ability to yield increasingly without ultimately
breaking or coming asunder
The integrity of the whole structure is invested in the finitely closed
tensional‐embracement network and the compressions are local islandsrdquowwwosteopathic-researchcompaper_pdfPfluegerpdf
Form Follows Function or Deformity Delineates Dysfunction
Myofascial system on macroscopic scale behaves like
a tensegrity structure
TENSEGRITY
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
Abnormal forces and environment2 What are treatment options for OA (Osteoarthritis)3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
BIOTENSEGRITY
Buckyball BuckminsterfullereneOrganism approach states everything is
in balance even at the cellular level
Form Follows Function or Deformity Delineates Dysfunction
bullBIOTENSEGRITY a unifying theory of biological architecture with
applications to osteopathic practice education and research-- to identify the mechanical causes of disease and to understand the bodys structure-function relationship at all size scales in the human body
bullAt the cellular level allows the cell to mechanically sense its environment and convert mechanical signals into biochemical changes
bullApplied to principles of osteopathic medicine biotensegrity provides a conceptual understanding of the hierarchical organization of the human body and explains the bodys ability to adapt to change
bullExplains how mechanical forces applied during osteopathic manipulative treatment could lead to effects at the cellular level providing a platform for future research on the mechanisms of action of osteopathic manipulative treatment
Swanson RL 2nd1 J Am Osteopath Assoc 2013 Jan113(1)34-52
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY DEFINITION (Buckminster Fuller 1975)
ldquoSynergeticsrdquo and the relation between continuous tension elements and
its continuous compression elements which are responsible for a structure
as follows
ldquoThe word tensegrity is an invention it is a contraction of tensional
integrity Tensegrity describes a structural‐relationship principle in which
structural shape is guaranteed by the finitely closed comprehensively
continuous tensional behaviors of the system and not by the discontinuous
and exclusively local compressional member behaviors
Tensegrity provides the ability to yield increasingly without ultimately
breaking or coming asunder
The integrity of the whole structure is invested in the finitely closed
tensional‐embracement network and the compressions are local islandsrdquowwwosteopathic-researchcompaper_pdfPfluegerpdf
Form Follows Function or Deformity Delineates Dysfunction
Myofascial system on macroscopic scale behaves like
a tensegrity structure
TENSEGRITY
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
Abnormal forces and environment2 What are treatment options for OA (Osteoarthritis)3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
bullBIOTENSEGRITY a unifying theory of biological architecture with
applications to osteopathic practice education and research-- to identify the mechanical causes of disease and to understand the bodys structure-function relationship at all size scales in the human body
bullAt the cellular level allows the cell to mechanically sense its environment and convert mechanical signals into biochemical changes
bullApplied to principles of osteopathic medicine biotensegrity provides a conceptual understanding of the hierarchical organization of the human body and explains the bodys ability to adapt to change
bullExplains how mechanical forces applied during osteopathic manipulative treatment could lead to effects at the cellular level providing a platform for future research on the mechanisms of action of osteopathic manipulative treatment
Swanson RL 2nd1 J Am Osteopath Assoc 2013 Jan113(1)34-52
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY DEFINITION (Buckminster Fuller 1975)
ldquoSynergeticsrdquo and the relation between continuous tension elements and
its continuous compression elements which are responsible for a structure
as follows
ldquoThe word tensegrity is an invention it is a contraction of tensional
integrity Tensegrity describes a structural‐relationship principle in which
structural shape is guaranteed by the finitely closed comprehensively
continuous tensional behaviors of the system and not by the discontinuous
and exclusively local compressional member behaviors
Tensegrity provides the ability to yield increasingly without ultimately
breaking or coming asunder
The integrity of the whole structure is invested in the finitely closed
tensional‐embracement network and the compressions are local islandsrdquowwwosteopathic-researchcompaper_pdfPfluegerpdf
Form Follows Function or Deformity Delineates Dysfunction
Myofascial system on macroscopic scale behaves like
a tensegrity structure
TENSEGRITY
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
Abnormal forces and environment2 What are treatment options for OA (Osteoarthritis)3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY DEFINITION (Buckminster Fuller 1975)
ldquoSynergeticsrdquo and the relation between continuous tension elements and
its continuous compression elements which are responsible for a structure
as follows
ldquoThe word tensegrity is an invention it is a contraction of tensional
integrity Tensegrity describes a structural‐relationship principle in which
structural shape is guaranteed by the finitely closed comprehensively
continuous tensional behaviors of the system and not by the discontinuous
and exclusively local compressional member behaviors
Tensegrity provides the ability to yield increasingly without ultimately
breaking or coming asunder
The integrity of the whole structure is invested in the finitely closed
tensional‐embracement network and the compressions are local islandsrdquowwwosteopathic-researchcompaper_pdfPfluegerpdf
Form Follows Function or Deformity Delineates Dysfunction
Myofascial system on macroscopic scale behaves like
a tensegrity structure
TENSEGRITY
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
Abnormal forces and environment2 What are treatment options for OA (Osteoarthritis)3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
TENSEGRITY DEFINITION (Buckminster Fuller 1975)
ldquoSynergeticsrdquo and the relation between continuous tension elements and
its continuous compression elements which are responsible for a structure
as follows
ldquoThe word tensegrity is an invention it is a contraction of tensional
integrity Tensegrity describes a structural‐relationship principle in which
structural shape is guaranteed by the finitely closed comprehensively
continuous tensional behaviors of the system and not by the discontinuous
and exclusively local compressional member behaviors
Tensegrity provides the ability to yield increasingly without ultimately
breaking or coming asunder
The integrity of the whole structure is invested in the finitely closed
tensional‐embracement network and the compressions are local islandsrdquowwwosteopathic-researchcompaper_pdfPfluegerpdf
Form Follows Function or Deformity Delineates Dysfunction
Myofascial system on macroscopic scale behaves like
a tensegrity structure
TENSEGRITY
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
Abnormal forces and environment2 What are treatment options for OA (Osteoarthritis)3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
Myofascial system on macroscopic scale behaves like
a tensegrity structure
TENSEGRITY
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
Abnormal forces and environment2 What are treatment options for OA (Osteoarthritis)3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal)
pain and disability
Abnormal forces and environment2 What are treatment options for OA (Osteoarthritis)3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
(Osteoarthritis)3 What are treatment options for MSK pain and disability
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
What are the Regenerative Interventional Orthopedic
Functional Medicine options
1st Body AlignmentBalance PTEgoscue OMM Adjustment CBD steroids
1) VISCOSUPPLEMENTATION INJECTION
2) Prolotherapy
3) PRP (Platelet Rich Plasma)
4) STEM CELLBiologic Therapy
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
What are Treatment Options for Musculoskeletal Pain
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary and
Alternative
17
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Pain ManagementPharmaceuticals
bull Acetaminophens
bull NSAIDS
ndash Oral
bull Increased GI Side Effects
ndash Topical
bull Decreased GI Side Effects
bull zolpidem (Ambien)
bull amitriptyline
bull trazodone
bull gabapentin (Neurontin)
Analgesia Anti-Inflammatory Sedative Other
18
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Pain ManagementPharmaceuticals
bull NSAIDS
ndash Topical Studies of diclofenac ibuprofen amp ketoprofen
ndash Less Plasma concentrations
ndash Increased Meniscus and Cartilage concentrations
bull Do NOT want this
1 C Rolf et al Intra-articular absorption and distribution of ketoprofen after topical plaster application and oral intake in 100 patients undergoing knee arthroscopy Rheumatology 1999 38 564-567
2 CA Heyneman et al Oral versus topical NSAIDs in rheumatic diseases A comparison Drugs 2000 60 555-574
3 J Radermacher et al Diclofenac concentrations in synovial fluid and plasma after cutaneous application in inflammatory and degenerative joint disease British Journal of Clinical Pharmacology 1991 31 537-541
Anti-Inflammatory
19
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
What about CBD Few contraindications ndash similar as CYP450 enzyme pathway Philpott ldquoAttenuation of early phase inflammation by cannabidiol prevents pain
and nerve damage in rat osteoarthritisrdquo Pain 2017 Dec NIH Database
ldquoShowed 1st time local CBD administration inhibited pain amp peripheral sensitization in
established OA Topical treatment with CBD reduced leukocyte trafficking and joint
hyperemia during the early stages of MIA (Joint irritant) By attenuating this initial
inflammatory response with CBD end-stage OA pain and peripheral neuropathy were
abrogated Thus CBD may be a safe therapeutic to treat OA pain locally as well as
block the acute inflammatory flares that drive disease progression and joint
neuropathyrdquo
Hammell ldquoTransdermal cannabidiol reduces inflammation and pain-related
behaviors in a rat model of arthritisrdquo Eur J Pain 2016 NIH Database
ldquoThese studies demonstrate topical applied CBD has long-lasting therapeutic effects wo
psychoactive side-effects Thus topical CBD has potential as effective treatment of
arthritic symptomatology At present one in five (21) adults worldwide are diagnosed
with some form of arthritis by their physicians (Helmick et al 2008) The data
presented suggest transdermal CBD is a good candidate for developing improved
therapies for these debilitating diseaserdquo
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) Blake DR ldquoPreliminary assessment of the efficacy tolerability and safety of a
cannabis-based medicine - nabiximols in the treatment of pain caused by rheumatoid arthritisrdquo Rheumatology (Oxford) 2006 NIH Database
ldquoThe 1st ever controlled trial of a CBM (Cannabis Based Medicine) in RA a significant
analgesic effect was observed and disease activity was significantly suppressed
following nabiximols (Sativex) treatment While the differences are small and variable
across the population they represent benefits of clinical relevance and show the
need for more detailed investigation in this indicationrdquo
CBD Oil Should You Try It for Arthritis Symptoms
httpswwwarthritisorgliving-with-arthritistreatmentsnaturalsupplements-
herbscannabidiol-oilphp
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
CBD (Continued) The Health Effects of Cannabis and Cannabinoids The Current State
of Evidence and Recommendations for Research The committee reached nearly 100 research conclusions based on
consideration of more than 10000 research articles The committee found three medical applications for cannabis use
supported by conclusive evidence1 In adults with chemotherapy induced nausea and vomiting oral cannabinoids are effective antiemetics2 In adults with chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms3 In adults with multiple sclerosis (MS) related spasticity short term use of oral cannabinoids improves patient-reported spasticity symptoms For these conditions the effects of cannabinoids are modest for all
other conditions evaluated there is inadequate information to assess their effects
httpwwwnationalacademiesorghmd~mediaFilesReport20Files2017Cannabis-Health-EffectsCannabis-public-release-slidespdf
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
1) What about Steroid Injections Steroids if individual will NOT out live their joint or body part (PZ)
Juumlni P Intra-articular corticosteroid for knee osteoarthritis Cochrane Database Syst Rev Oct 2015
Unclear if clinically important benefits of intra-articular corticosteroids after one to six weeks effects decrease over time and no evidence that an effect remains six months after a corticosteroid injection
Wernecke C The Effect of Intra-articular Corticosteroids on Articular Cartilage A Systematic Review Orthop J Sports Med Apr 2015
Corticosteroids have a time- and dose-dependent effect on articular cartilage with detrimental effects at high doses and durations
Bellamy N Intraarticular corticosteroid for treatment of osteoarthritis of the knee Cochrane Database Syst Rev Apr 2006
Longer term benefits have not been confirmed based on the RevMan analysis The response to HA products appears more durable
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
2) What about Viscosupplementation
Injection (AMSSM Position Statement)
Knee OA with viscosupplementation injection [hyaluronic acid
(HA)] vs steroid [intra-articular corticosteroid (IAS)] vs
placebo [intra-articular placebo (IAP)] treatment effect using
Outcome Measures in Rheumatoid Arthritis Clinical Trialsndash
Osteoarthritis Research Society International (OMERACT-
OARSI) criteria
Systematic literature search relevant articles 1960 to August 2014
in the MEDLINE EMBASE and Cochrane CENTRAL using a
network meta-analysis (NMA) of relevant literature determine a
benefit from HA vs IAS vs IAP
11 articles met inclusion criteria from the search strategy
Subjects receiving HA were 15 and 11 more likely to
respond to treatment by the OMERACT-OARSI criteria than
those receiving IAS or IAP respectively (P lt 005 for both)
Recommends HA for the appropriate patients with knee OA
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
3) What is Prolotherapy
Nonsurgical treatment
Strengthen and tighten the ligaments and tendons that hold
bones and muscles in place
Series of injections stimulate bodys natural healing
response
Restores proper joint alignment and relieves pressure on
sensitive tissues
Dramatic and lasting pain relief
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Work
Injections of a mildly irritating solution into the painful area
Diluted anesthetic solution triggers the bodys natural healing response
and causes the proliferation of new collagen fibers which are the building
blocks of ligaments and tendons
Tissue growth continues the ligaments and tendons become thicker and
stronger regaining their ability to stabilize the joint and take the pressure
off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows
down
Sometimes one treatment is enough to achieve complete pain relief but it
usually takes several treatments administered at 3-5 weeks apart to
produce sufficient collagen growth to relieve pain and restore normal
function
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Injection Relieve Chronic Pain
Addresses pain at the source weakness in the ligaments and tendons
Ligaments and tendons are tough fibrous bands of tissue that connect
bone to bone or bone to muscle
Stabilizers of the musculoskeletal system
As long as they are strong and taut they keep bones joints and
muscles in place allowing for pain-free smooth movement
When ligaments and tendons become injured weak or lax these other
structures become unstable and move out of position
Resulting misalignment impinges on nerves and blood vessels
damaging tissues and causing pain
Lasting relief can only be obtained by restoring the proper alignment to
these structures and taking the pressure off sensitive tissues
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
How Does Prolotherapy Compare to Drug Therapy
Most common NSAIDs
NSAIDs relieve joint pain by countering inflammation and pain
Inflammation is the first stage of your bodys healing process these
drugs may hinder recovery
NSAIDs notorious for GI side effects and destroy cartilage
NSAIDs do not address underlying laxity of ligaments and tendons
which is the source of chronic pain
More severe or chronic musculoskeletal pain corticosteroids used next
Also counter inflammation and suppress immune function
increasing susceptibility to infection and interfering with healing
Long-term use associated with increased risk HTN osteoporosis AVN
and destroy cartilage
Prolotherapy does not mask pain
Corrects underlying problem
Extremely safe therapy has none of the risks of NSAIDs and
corticosteroids and its only side effect is mild discomfort during the
first few days of healing
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
What Conditions Can be Treated With Prolotherapy
Partial List
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
LANDMARK RESEARCH STUDIES
656 pts chronic low back pain treated with Prolotherapy
Ave pain duration prior to treatment 45 yrs up to 65 yrs
Half of pts had undergone back surgery wo success
82 pts considered themselves cured
Hackett G Ligament and Tendon Relaxation Treated by Prolotherapy 3rd edition
Springfield IL Charles C Thomas 1958
81 pts chronic low back pain randomly assigned either Prolotherapy or injections of
saline (an inactive placebo)
6 mths after treatment 875 those who had received Prolotherapy rated as gt50
improved compared to 39 of those in the placebo group
About 4x as many patients in the Prolotherapy group were completely free of
disability as in the placebo group
Ongley M Klein R Dorman T Eek B Hubert L A New Approach to the
Treatment of Chronic Low Back Pain Lancet 19872143-146
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Hackett GS et al Back pain following trauma and disease Military
Medicine July 1961 517-525
Faber WJ amp Walker M Pain Pain Go Away Mountain View CA ISHI Press
International 1990
Ko G A new old treatment for chronic back pain Natural Med J 1998
Jul1(6)12-17
Hauser RA Punishing the pain Treating chronic pain with Prolotherapy
Rehab Manag 199912(2)26-28 30
Practical Pain Management October 2007
Kim WM A randomized controlled trial of intra-articular Prolotherapy
versus steroid injection for sacroiliac joint pain
J Altern Complement Med Dec 2010
Rabago Dextrose Prolotherapy Knee OA Randomized Controlled
Trial Ann Fam Med MayJune 2013
Bertrand H Reeves KD Bennett CJ Bicknell S Cheng AL Dextrose
Prolotherapy versus Control Injections in Painful Rotator Cuff
Tendinopathy Arch Phys Med Rehabil 2015 Aug 21
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES Rabago Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis
Long term outcomes Comp Therapies in Medicine June 2015
Background Dextrose injection is reported to improve knee osteoarthritis (KOA)related clinical outcomes but its effect on articular cartilage is unknown A chondrogenic effect of dextrose injection has been proposed
Design Case series with blinded arthroscopic evaluation before and after treatment Participants 65 symptomatic KOA for at least 6 months arthroscopy-confirmed medial compartment exposed subchondral bone and temporary pain relief with intra-articular lidocaine injection
Intervention 4 to 6 monthly 10-mL intra-articular injections with 125 dextrose
Conclusions Prolotherapy resulted in safe significant progressive improvement of knee pain function and stiffness scores among most participants through a mean follow-up of 25 years and may be an appropriate therapy for patients with knee OA refractory to other conservative care
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Form Follows Function or Deformity Delineates Dysfunction
REFERENCES
Topol etal Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis Am Academy Phys Med Rehabil
March 2016
Intervention and outcome measures
bull6 participants received 3ndash5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC 0ndash100 points) at baseline 12 26 52 weeks and 25 years
Conclusions
bullPositive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies Minimally invasive arthroscopy (single-compartment single-portal) enabled collection of robust intra-articular data
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
4) PRP (Concentrated Platelets) =Platelet Rich Plasma
How Does PRP Injection Work
Injections of concentrated platelets with growth factors and low or high leukocyte concentrations into the damaged area
Triggers and provides the bodys natural healing response and causes the proliferation of new tissue of ligaments tendons or chondral surface
Tissue growth continues the ligaments and tendons become thicker and stronger regaining their ability to stabilize the joint and take the pressure off sensitive nerve endings
Pain subsides range of motion returns and cartilage degeneration slows down halts or reverses
Sometimes one treatment is enough to achieve complete pain relief but it usually takes 3 treatments administered at 3-5 weeks apart to produce sufficient tissue growth to relieve pain and restore normal function
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
vs
Machine vs Man Machine processes autologous blood to create PRP
Preparations with sufficient platelet concentrations
Less expensive
Bed-side process
Laboratory procedures to create a platelet concentrate by hand
Preparations that can be higher concentrations
More expensive
Requires Lab set-up maintenance and Quality Control
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Concentrated platelets promote healing
High Concentration PRP
Low Concentration PRP
Leukocyte Poor (Low)
ndash PRP may be better
for joints ie OA
Leukocyte Rich (High)
ndash PRP may be better
for Ligaments and
Tendons
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
5) What are
the different
types of Stem
Cells
Adult Stem Cells
NOT
Pluripotent
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Whatrsquos an MSC
bull Mesenchymal stem cell
bull Present in adipose and orthopedic tissues like bone periosteum synovial tissue cartilage bone marrow muscle ligaments and tendon
bull Can differentiate into all orthopedic tissues and orchestrate repair of same
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Two Different Types of Bone Marrow Stem Cell Processes
Bone MarrowNucleated Cell
IsolationThe stem cell fraction
of bone marrow is isolated via a
centrifuge and re-injected the same day
Bone Marrow Mesenchymal Stem
Cell CultureThe stem cells themselves are isolated and cultured
to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is
different than the mix of cells produced by same
day procedures
Simple Adipose Graft
The fat is separated from the oil and
liquid and the fat is injected (however the stem cells are still trapped in the
fat and are not concentrated)
Stromal Vascular
Fraction (SVF)The fat is separated and then chemically digested to release
the stem cell fraction which is
then concentrated
Adipose Mesenchymal
Stem Cell CultureThe stem cells are
isolated and cultured to greater numbers over a few weeks This produces
a ldquopurerdquo population of stem cells which is different
than the mix of cells produced by same day
procedures
Three Different Types of Fat Stem Cell Processes
Sam
e D
ay
Sam
e D
ay
Sam
e D
ay
Ad
van
ced
Ad
van
ced
DrugNeeds FDA Approval
DrugNeeds FDA Approval
DrugNeeds FDA Approval
TissueNo FDA Approval
TissueNo FDA Approval
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Bone MarrowStem Cells
AdiposeStemCells
6
AmnioticFluid
Stem Cells
PubMed search of US National Library of Medicine on 52316
bone marrow derived stem cells cartilage repair
adipose derived stem cells cartilage repair
amniotic fluid derived stem cells cartilage repair
synovial fluid derived stem cells cartilage repair
umbilical cord blood derived stem cells cartilage repair
embryonic stem cells cartilage repair
SynovialFluid
Stem Cells
CordStem Cells
109
EmbryonicStem Cells
362
163
17 25
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
SVFAdipose Stromal Vascular Fraction
AmnioticFluidStemCells
PubMed search of US National Library of Medicine on 6142016 knee bone marrow mesenchymal stem cells human knee bone marrow mesenchymal stem cells complications safety autologous bone marrow mesenchymal stem cells cartilage repair osteonecrosis stem cells outcome osteonecrosis mononuclear cells osteonecrosis gangji bone marrow nucleated osteoarthritis stromal vascular fraction osteoarthritis stromal vascular fraction osteonecrosis Pak J[Author] stromal vascular fraction fracture amniotic fluid stem cells osteoarthritis amniotic fluid stem cells osteonecrosis amniotic fluid stem cells fracture synovial fluid stem cells osteoarthritis synovial fluid stem cells osteonecrosis synovial fluid stem cells fracture cord stem cells osteoarthritis cord stem cells osteonecrosis cord stem cells fracture embryonic stem cells osteoarthritis embryonic stem cells osteonecrosis embryonic stem cells fracture
FDA Trials Data or Review Articles httpwwwosiristxcomprod_chondrogenphp httpwwwncbinlmnihgovpmcarticlesPMC2964482pdfSCI2010-410170pdf
SynovialFluidStemCells
CordStemCells
EmbryonicStemCells
BoneMarrow
NucleatedCells
1106
48 0 01 011
SVF wPRP
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
US National Library of Medicine Search searched 5916 using terms ldquoadipose bone marrow mesenchymal stem cell chondrogenesisrdquo End date of search was 42015 Only papers showing head to head quantitative chondrogenesis considered
Bone Marrow Stem Cells
Fatty Tissue(Adipose Stem Cells)
16 papers
3 papers
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Procedure History Latest Registry Data14
2372 Patients
3012 Procedures
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Cells collected from one of several sources (bone
marrow aspirate adipose)
IV blood sample taken to isolate
PRP
MSC Procedure (Autologous Orthopedics Only)
Injected same day
MSCrsquos isolated by
lab bedside
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
How do Various Biologic Therapies for Knee OA Stack up
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Knee OA-MSCs vs PRP
Update Biological Therapies Knee OA Curr Rev Musculoskeletal Medicine
Sept 2014
Biological therapies increasingly are being sought as alternatives for treating
OA Studies using these therapies show great promise for patients with mild
to moderate knee OA further research on biological therapies for knee OA is
needed to assess the risks and benefits and especially to understand the
mechanism of action as well as long-term outcomes
Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior
Outcomes Compared Other Therapies in Treatment of Knee Osteoarthritis A
Systematic Review of Overlapping Meta-analyses J Arthroscopic and
Related Surgery Nov 2015 (Level IV systematic review of Level II-IV
studies)
IA-PRP is a viable treatment for knee OA and has the potential to lead to
symptomatic relief for up to 12 months IA-PRP offers better
symptomatic relief to patients with early knee degenerative changes
and its use should be considered in patients with knee OA
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Treatment with Autologous conditioned serum (ACS) and physiotherapy produced a rapid decline in pain which was sustained for the entire two years of the study This was accompanied by a large improvement in WOMAC scores at two years These results confirm that ACS combined with physiotherapy is an effective treatment for OA of the knee Plos One December 2015
Treatment of Osteoarthritis of the Knee with a Combination of Autologous Conditioned Serum amp Physiotherapy A Two-Year Observational Study
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
When used for orthopedic injuries whatrsquos the target tissue for PRP
bull Human Mesenchymal Stem Cells can differentiate and effect repair in cartilage bone muscle ligament and tendon
bull As a result the big question is how your PRP prompts the bodyrsquos resident MSCrsquos to proliferate
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Summary
bull In 60 ndash 70+ YO Patient Hand made PRP may be better to stimulate orthopedic repair cells (MSCs) better than bed side PRP (in one study)
bull No studies comparing PRP to Prolotherapy to HA
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Conclusionsbull Based on the published research for orthopedic
conditions bone marrow stem cellsgtgtadipose stem cellsgtgtPRPgtgtProlotherapy
ndash Cost
1) BMAC $5000 ndash 20000
2) ASC $3000 ndash 5000
3) PRP $500-1000
4) Prolotherapy Some Insurance Cover
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Conclusions
bull Stem cell procedure helps patients with knee OA (outcome data) if cost not an issue
Consider ldquoArthritis in the Militaryrdquondash A Lifetime Of Disability for the rest of his or her life
require arthritis-related health care paid for by US taxpayers in the form of doctor visits medications procedures and physical therapy
ndash Average annual health care expenditures for a disabled veteran are $7450
ndash Lifetime care cost anticipated at $976172
wwwarthritisorgadvocate
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
ConclusionsldquoArthritis in the Militaryrdquo (continued)bull Cost Example Based on a US Army soldier diagnosed with post-traumatic OA at age 24
(two years after a traumatic injury) who is discharged and requires knee replacement surgery in his or her thirties (Amounts will vary in individual situations including the kind of treatment surgery required number of dependents etc)
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA
I Viscosupplementation
II Prolotherapy
III PRP
IV MSC3 What are treatment options for MSK pain and disability
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
How Is Musculoskeletal Pain Treated
bull Pharmaceutical
bull Manipulation
bull Physical Therapy
bull Acupuncture
bull Dietary
bull Herbal
bull Homeopathic
bull Massage
bull Mind-Body Therapy
TraditionalComplementary
and Alternative
56
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Pain ManagementDietary
bull Decreasing dietary fat
intake ampor eating plant
foods that contain anti-
inflammatory agents
ease pain by limiting
inflammation
bull Raw vegetarian diet
bull Weight reduction
Daily Doses
bull Glucosamine sulfate
ndash 1500 mg
bull Chondroitin sulfate
ndash 1500 mg
bull MSM
ndash 800 mg
bull Omega-3 Fish oils
ndash 1500 mg EPA
Macronutrients Supplements
57
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Pain ManagementEnergy Based
bull Activate the self-healing processes of an individual and therefore reduce pain
bull Does not require actual physical contact they do involve close physical proximity between practitioner and patient
Therapeutic Touch amp Reiki Healing
58
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Pain ManagementHerbal
Daily Doses
bull Boswellia Serrata Extract 1200 mg
bull Curcumin Extract (Turmeric) 1200 mg
bull Cayenne 360-2400 mg
bull Devilrsquos Claw 1530 mg
bull Feverfew 85-125 mg
bull Ginger 1200 mg
bull White Willow Bark (Salicin) 360-720 mg59
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Pain Management CBD
60
What is a good starting dose
Start low and go slow (I donrsquot Rx THC)
Usual starting dose of CBD is 1-5mgkg in
1-2 divided doses up to 10-20mgkg
Different delivery methods have different
onset and duration times ndash be aware (oral
ingested delayed vs sublingual faster
acting)
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Conservative Therapybull Body AlignmentBalance (PTEgoscue) OMM DC
Adjustment
bull Inj TxPRP Substitute for ldquosteroidrdquo epidural nerve
ligament tendon muscle and joint injections
bull Repair Heal joint surface ligaments tendon muscle and
nerve injurydamage
Achilles Injury
Arthritis
Back pain
Carpal Tunnel
Fibromyalgia
Headaches
Knee pain
Ligament sprains
Neck pain
ldquoSciaticardquo
Shoulder pain
Spondylolisthesis
Sports injuries
Tendinitis
Tennis Elbow
Unresolved whiplash injuries
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Regenerative Interventional
Functional Orthopedic Medicine1 What causersquos MSK (Musculoskeletal) pain and disability
2 What are treatment options for OA (Osteoarthritis)
3 What are treatment options for MSK
pain and disability
Conservative Therapy
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom
Thank you for your time and
care of patients
Phillip Zinni III DO FAOASM MS ATC
Past-President
American Osteopathic Academy of Sports Medicine
National Medical Director
The Industrial Athlete
209-324-2255
JockOccDocHotmailcom