Orthobiologics: Are We Overpromising PRP Or Under-Educating Patients? | Conversations in Regen Ep.11

Orthobiologics: are we overpromising PRP or under-educating patients sparks a vital discussion.

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Why do patients still default to steroids despite emerging regenerative medicine options? Are we failing in patient education, or is healthcare lacking transparency around informed decision making? And how do we balance patient needs with shared decision making in healthcare so that treatments like platelet rich plasma therapy (PRP) are presented realistically rather than as miracle cures?

In this fireside chat with Dr. Ariana Demers and Dr. Paul Tortland, we dive into the heart of orthobiologics, regenerative medicine, and the nuances of patient informed decision making. We explore how patient education in healthcare impacts choices, why transparency in healthcare is critical, and how both physicians and patients can work together through shared decision making in healthcare to avoid overpromising outcomes while still embracing innovation. From the ethics of steroid injections to the role of prp treatment in musculoskeletal care, this conversation unpacks the importance of educating patients about their real options. We also address how orthobiologics and regenerative medicine orthopedics could change long-term outcomes when combined with honest discussions about risks, limitations, and potential benefits.

Throughout the discussion, you’ll hear why orthobiologics—including platelet rich plasma therapy, prolotherapy, bone marrow concentrate, and micro-fragmented fat (MFAT)—require careful framing in patient conversations. We question whether physicians are under-educating patients or whether marketing has outpaced science, creating confusion and mistrust. By grounding the conversation in informed decision making in healthcare, Dr. Tortland and Dr. Demers provide insight into the real-world integration of regenerative treatments, highlighting the importance of educating patients about not just what orthobiologics can do, but also what they cannot. Viewers can expect open dialogue on ethical concerns, insurance barriers, and how patient informed decision making leads to better outcomes.

If you’re a clinician, patient, or someone curious about the evolving role of regenerative medicine, this video will help you understand the delicate balance between innovation and expectation. You’ll also discover why patient education in healthcare is not optional—it’s essential for guiding choices in a cash-based model where insurance rarely covers treatments like PRP. By the end, you’ll see how transparency in healthcare and a partnership approach can empower patients to make informed decisions about orthobiologics without false hope, while still accessing potential benefits of regenerative medicine orthopedics.

Building a successful cash-based orthobiologic practice is not a single decision. It is a series of the right decisions made in the right order. The Business of Orthobiologics offers three distinct programs designed to meet physicians at different stages of readiness — whether you are just beginning to explore PRP, ready to build a full practice system, or committed to going all-in on a comprehensive transformation.

Learn More here: https://thebusinessoforthobiologics.com/programs-explanation 

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Transcript

SPEAKER_01 0:00

I heard one scientist once uh say that science advances one funeral at a time. The key. The dose makes the poison.

SPEAKER_00 0:09

When I look at the research about how chondro toxic it is, I'm like, oh my gosh, to how many total joints did I hasten? I sure as heck would rather exhaust every single safe, low-risk opportunity to avoid knee replacement before we go down that path.

SPEAKER_01 0:29

It would be unethical for me to take your money.

SPEAKER_00 0:47

And this is a fun conversation where we get to cover cutting-edge insights on how we're shaping the future of interventional orthobiologics. And so welcome everybody. I absolutely want to welcome Dr. Paul Tortland to the stage. We're so glad to have you. Woohoo! Woohoo! And so Dr. Paul Tortland is a board-certified specialist in regenerative medicine and sports medicine. He treats patients both in the New England Stem Cell Institute in Glastonbury, Connecticut, as well as Jupiter, Florida. And really, he has a diverse background, and he is the master of burning the candle at both ends and in the middle, if you will. So he earned his degree from the New England College of Osteopathic Medicine in Biddeford, Maine. And he really has been a leader in the field for a while and not afraid to get his hands dirty in sussing out the what's real and what's not. So that's one of the reasons I invited you to this show, because really this is gonna be a little different. So thanks for joining. We're gonna hear from experts in regenerative medicine, but this is more like a fireside chat where we pull back the curtain, get rid of all of the fluff. This is not CME, and we can talk kind of candidly about what the heck is going on, and some maybe some more controversial topics, and hopefully gain some actionable insights that you can put into your practice immediately. And of course, we're gonna have a live QA session, so get everybody's questions answered. And it doesn't have to be the questions that are the topic, but if that works, we can actually talk about that too. For those of you who don't know me, I'm Dr. Ariana Demurs. I am a board-certified fellowship-trained sports medicine orthopedic surgeon, and I am obsessed with regenerative medicine. I always tell people I'm a recovering orthopedic surgeon for all of those people who are wondering. Yes, I still do surgery, unfortunately, but we're working on that. And I have successfully moved my rural practice, yes, town of 20,000 patients away from commercial insurance. And I focus on direct care for my patients. And then my biggest passion is helping physicians to incorporate orthobiologics in their practice seamlessly. And so without further ado, I am going to put out a bold statement that I believe orthobiologic treatments will be the first-line treatment for musculoskeletal care in the next five years. I sure hope so. And what I also know is successful integration of orthobiologics is hard sometimes. And the we wonder why this is difficult. And we know orthobiologics is a really great treatment for our patients, but how do we actually become successful? And maybe you've tried some things, but you don't know all of the science. And maybe you're wondering about the technique, or wondering about the business, the cash-based part, the marketing, the sales. And maybe you just thought it was, I'm not good at this business thing. But honestly, it's not our fault. We did not learn this in school. And so maybe some of you are struggling on how to be successful and capitalize on this four billion dollar orthobiologics market out there, right? How do we all get a piece of that? And maybe some of us are thinking we deserve more. Why is this so hard? And so, if I would love if you can just put in the chat what you're struggling with most in your current orthobiologics offerings so that we can talk a little bit about what's going on. So, how do we win, right? How do we win this conundrum? And while we are talking about the science today, we also need to consider how we talk about this with our patients so that we all win. And honestly, we need a system. And now we're not gonna go over all of this today. We're gonna go a little bit further down this journey to be wildly successful in our orthobiologics practice. And so we're gonna start with the orthobiologics knowledge today. So, Paul, if we can, we're gonna get down to business. So while we are talking about PRP, we're actually talking about the big elephant in the room, which is why are steroids still the gold standard? And are they still ethically justifiable in patient care when orthobiologics and PRP are available and well? So what I I just really want to know like, why is it that this is still used as the gold standard? What are your thoughts on either where this came from or how it is that we can kick steroids out of this crowning glory spot as the gold standard?

SPEAKER_01 6:24

A valid question, and the answer, of course, is nuanced, because there are several facets, multiple facets to this answer. First of all, where did this come from? Well, obviously, steroids have been around for eons and they've been used for eons, and as a result, medicine for advanced, as advanced as it is, moves very, very slowly. I heard one scientist once say that science advances one funeral at a time. In other words, it's only as the old guard and the old ideas pass away do new ideas start to get introduced. And very slowly at that, because steroids have been used for so long and they've been incorporated as part of a mainstream treatment strategy, people are very hesitant to abandon it. I remember my dad once said, don't dump the one that you came to the dance with. So steroids is what we grew up using. Now, part of the nuance with steroids is it's not an all-or-none thing. And even though I'm a huge proponent of regenerative medicine, I've been doing prolotherapy since 1995. I was the first in New England to do PRP starting in 2007, and the first in New England to start doing bone marrow and adipose in 2008. I still think that there may be a role, and heretics, don't come out on me. I think there may still be a role for steroids. Here's the key the dose makes the poison. So, for example, we now know that nanogram doses of steroid can actually enhance stem cell differentiation along chondrogenic lines. So to say all steroids are bad is not really a responsible position to take. The question is, is there a role for steroids? And if so, what is that role under what context? So I will use steroids very judiciously as part of a diagnostic workup. So if I'm wondering if somebody's hip pain is actually coming from inside their hip joint, I will use steroids in the joint. But here's the key. I will use 75 to 80% less steroid than the typical physician uses. So for example, the typical dose into a large joint is going to be 1 to 1.5 cc's of steroid. I might use 0.2 or 0.25, which is a very small amount. It's amazing how little you need to actually control inflammation and not cause damage in the process. So I think there still may be a role. The question is, how does that fit in the algorithm for regenerative medicine? Now to answer your question, is steroid use ethically justified? Well, you know, that's a great question. Who's to say what's ethical, what's moral? We do know that steroids are very toxic to the cartilage and they're toxic to soft tissue. But again, the dose makes the poison. So how much are we using and in what context? So the answer, as I said, is quite a bit more nuanced. And I'm gonna stop there and see what your response is to that.

SPEAKER_00 9:26

Yeah, absolutely. So you're not wrong. Uh, and honestly, I use nanogram dose dexamathasone for my diagnostic and therapeutic injections. And honestly, part of that is because the insurance companies don't say, well, what's the dose? They just say, What did you use? And I said, Well, I use dexamethasone, of course. And so that helps my patients, and I do a ton of diagnostic and therapeutic injections, and I do a lot of it with prolotherapy. And so I do also use steroids on occasion. I tell my patients it's for emergency-only use. If we're going to be celebrating the 50th wedding anniversary and you can't walk down the aisle, well, maybe we're gonna take that risk that we're gonna damage the cartilage in the future, and we're willing to take that risk. But what I really struggle with is the fact that when I talk to my patients about the risk of cortisone, and they say, well, no one ever talked to me about the actual risks, and I'm guilty of this myself historically, right? We just we just injected cortisone willy-nilly everywhere. And now when I look at the research about how chondro toxic it is, I'm like, oh my gosh, to how many total joints did I hasten? And I I have still a little bit of guilt about that. And I want to say we didn't know, but I think maybe we turned a blind eye because we didn't have better tools. What are your thoughts on that?

SPEAKER_01 11:10

Yeah, so that's a really great question. And I do discuss the risks with my patients, but again, I couch it with a little more nuanced discussion. For example, I say one drink is not going to give you cirrhosis of the liver. Okay? Now we know that alcohol is toxic, but is one drink going to cause cirrhosis of the liver? No, but if you drink a lot, you're going to cause some serious damage. I kind of look at steroids the same way. A low-dose single injection is most likely not harmful in the long term. And I would challenge anybody to show me the research that shows that a single corticosteroid injection into a joint results in significant measurable long-term damage. We do have data that shows that repeat serial injections will do that. There was a study that was published a few years ago where they injected a knee four times a year for two years, and the control group got sterolsaline injections. And at the end of two years, the group that got the serial corticosteroid injections had demonstrably less cartilage volume. So clear evidence that the corticosteroids, as a result of their chondrotoxicity, resulted in cartilage loss. We don't have that data for a single corticosteroid injection. In fact, I did a literature search before a few days ago in preparation for this. I could not find one single study or even a number of studies that were in consensus on what the optimum dose was for corticosteroids or what the optimum dosing frequency is. And it's incredible because we've had this medication for what, almost a hundred years, and we still don't know what the optimum dosing is. We do what we've always been done because that's the way it's always been done. But is that the right way? So I think we need to take a step back and not be so dogmatic, but look at this from a little bit more nuanced perspective.

SPEAKER_00 13:04

Yeah, absolutely. Absolutely. I appreciate that. And I think that you're exactly right. Coming up through the medical system, I think we have been quite dogmatic. And you we always did what our trainers did. This was a way that we learn how to do it. Oh, well, I saw my trainer do it, and that's how I do it, and well, what evidence? Um that's just how we learned, right? I take this topic not tongue in cheek, but ultimately to say, if we're going to use it, we have to be clear on risk, and we have to be clear on dose, and we have to be clear on that there are maybe better options. There's a lot of studies that have been shown to have better outcomes versus corticosteroids, you know, with H A and PRP at all time points. And so I think a lot of the people who maybe are proponents of corticosteroids are like, oh, well, it it works fast. And in the the US culture, we love our drive-thru McDonald's right now. Right.

SPEAKER_01 14:23

We like our 30, we like our 30-minute sitcoms and we want everything done yesterday, right?

SPEAKER_00 14:28

Exactly, exactly. And so this does lead me to another question. So we still have questions about corticosteroids. And my question is, is that rapid pain relief worth the potential for long-term damage? Or are how do we rectify or how are you rectifying this risk of damage when we're like when someone's in your clinic going, I'm dying, like I have really bad pain. Can you help me now? What how do you kind of look at that and talk to your patients about options that they have that may not be as chondro toxic?

SPEAKER_01 15:14

Well, obviously, first of all, it's a great question. How do we interface with our patients and have this discussion? Partly because as regenerative medicine treatments, PRP, prolotherapy, MFAT, and bone marrow, they're not covered by insurance. And not all patients have the financial wherewithal to pay for those treatments. So, how do we have that discussion with patients about the risks and benefits of the alternatives, which in some cases certainly may be corticosteroids? And I have that honest discussion with patients. And I'll say we know now that, or now know, that corticosteroids are chondrotoxic and myotoxic. You really don't want to be injecting these if you can avoid it. However, if you use a low enough dose and you are using it judiciously, in other words, not doing the injections over and over and over again, then some immediate short-term relief for a particular purpose may be indicated. You indicated, okay, a wedding. I have patients who are going on trips to Europe, for example, and they say, I'm going to be walking around Europe for two weeks and I can't be in pain. Okay, I'll give you a modified, and for me, modified is 75% less of the steroid dose. I'll give you a modified injection to get you through your trip. But that's it. We're not going to keep doing this over and over because I don't want to run the risk of damaging your joint for the long term. By the way, I do have one exception to that rule, and that one exception is if a patient is imminently going to have that joint replaced, and I say imminently meaning within the next six to twelve months, my threshold for giving a corticosteroid injection is a lot lower because that joint's going to be replaced anyway. And knowing that I use significantly less steroid than the average physician does, my comfort level is a little bit higher doing it in those patients, as long as they don't get an injection within three months of their planned surgery as a surgeon. Okay? That's my one exception to doing a repeat injection. But I do have that discussion, and I think we're obligated as physicians, I think medical legally we're obligated, at least in my opinion, to discuss all of the appropriate alternatives with patients. So what I say to patients is you have this condition, and I'm going to break treatment options down into two broad categories, conventional medicine and alternative medicine. Conventional medicine are the treatments that are usually covered by insurance. Alternative medicine is everything else. And in the conventional medicine bucket are corticosteroid injections. But I discuss the risks of doing the steroid injection, and it's a decision that the patient and I make together in a partnership. Because really, I think the doctor-patient relationship is a partnership. I don't see it as a dictatorship, the doctor telling the patient, this is what you have to do. I want my patients to have complete buy-in with whatever it is that we decide to do. And I have patients who come in and they say, I absolutely categorically do not want cortisone injections. Fine, I'm on board with that. Other patients say, look, if you can give me a little bit of steroid just to get me over this quick hump, then let's do the PRP or the stem cells. I'm fine with that. I'm comfortable with that because now we have a rational treatment plan moving forward. Does that answer your question? Kind of a long-winded question.

SPEAKER_00 18:31

Yeah, absolutely. No, so number one, I love our audience because we just got called out. There was a publication in 2025 in radiology that showed that a single cortisone injection caused more progression of arthrosis at the two-year mark compared to saline injection, and HA showed less progression. And I am aware of that. And so that when I saw that research study come out, there starts to be even a single cortisone injection shows progression as compared to even saline. Right.

SPEAKER_01 19:08

But let me interject here. This is the same argument that we have with PRP. Not all PRP is the same, not all corticosteroids are the same.

SPEAKER_00 19:17

Right.

SPEAKER_01 19:17

So you can take that one paper, but you have to look at what the dose that was used in that paper. Was it a CC? Was it 40 milligrams of triumpcinolone? Was it 80 milligrams of triumsinolone?

SPEAKER_00 19:28

Right, right.

SPEAKER_01 19:29

What did they use? And if you recall at the very beginning of this webinar, I said the dose makes the poison. So you can't say all steroid use is bad. You have to look at it from a much more nuanced perspective. And that's why I said when I do these injections, I never use full-strength steroid. I'm typically using 25% of the normal dose or 75% less, and in some cases, even less than that. You alluded to nanogram dosing. That's a very, very different beast. And the same is true with PRP. We know that high-dose PRP works better than low dose PRP. So would you take a paper that said PRP didn't work and say, therefore, all PRP is bad, come to find out that the PRP that they used was a crappy low-dose PRP? No, you gotta look between the lines and read into these papers and not just spout this stuff off as dogma without getting into the weeds.

SPEAKER_00 20:22

Absolutely. I just wanted to call you out on that. That's just for fun. Yeah. No, it's okay. I can take it. I know you can, and that's why you're here. So my question: there's been some proponents of using other injectates such as dextrose, such as toridol, intra-articularly. What has been your experience with that?

SPEAKER_01 20:45

I have not used tordol in years, back in the day when I was using it, which has to be well over 20 years ago. I've been in practice 30 years now. About 20 years ago, I used it, and I really wasn't all that impressed with it. And so I just never jumped on board with it. I am a big fan of hyaluronic acid, but I never really gravitated towards the tordol. I tried it, I was unimpressed.

SPEAKER_00 21:07

Yeah.

SPEAKER_01 21:08

Your mile, your mileage may differ, but that was my experience.

SPEAKER_00 21:12

Yeah, yeah, I I hear you on that. So I think ultimately I use it, I would agree, it's plus-minus. I think that my experience is that prolotherapy probably works as good or better than the tortol by itself. And nanogram dose dexamethasone is I use it for the diagnostic and therapeutic with uh low dose either lidocaine or rapivacine. So I'm not even using it, I'm I'm using it to get paid and not for the steroid experience, because like you alluded to earlier, what we know about nanogram dose dexamethasone is that it may push chondrogenic improvement. Yeah. And so, number one, I feel really good about. Using it in a diagnostic and therapeutic injection that it's at least not harmful. And then I mix it with some dextrus, which we know we've used for 75 years with shockingly good results for what it is, right? Sugar water, man, people get better, they feel good. And so, yeah, that's kind of where I'm at from an injectate standpoint. And I do use cortisone rarely. I have one final question about this kind of rapid relief. I just came across this today. This is a guy with adhesive capsulitis, and he's really been struggling. And back in my whole rest of my career, everyone with adhesive capsulitis got a cortisone injection inter-articularly. Now I'm like tiptoeing. I'm like, oh shoot. And to make matters worse, he has about of adhesive capsulitis after a regenerative procedure. So now you're like, oh man, this person paid their good money. We uh were trying to regenerate or help heal or improve the state of affairs of your biologic situation. And now we have an adhesive capsulitis. What the heck do we do now? Right.

SPEAKER_01 23:21

Yeah, yeah, exactly. And those are tough cases. Fortunately, I don't see that very commonly. I've only had one or two frozen shoulders following orthobiologics to the shoulder. But it's a great question. What do you do with those? One of the good answers to one of the good pieces of information in answer to that question is now that we've got more strategies such as energy medicine, shockwave, and class four laser, even hydrodilation of the joint to treat frozen shoulder, we do have other options other than going straight to the steroids. And by the way, there is some data that shows that even local anesthetics do have a very weak anti-inflammatory property to them. I have a couple of papers that show that. So just putting some anesthetic and doing a little hydrodilation, maybe combining that with shockwave and or laser, are reasonable things to try before taking out the cannons and howitzers of steroid.

SPEAKER_00 24:11

Yeah, I'm absolutely with you. Well, Paul, we still have more questions.

SPEAKER_01 24:16

Yeah, no, I'm here for the long haul. So fire away.

SPEAKER_00 24:20

So when we talk about insurance reimbursement, one of the things that people would say, oh, well, it's not, it's not covered. And so is that an unfair bias? That are things that are covered actually not as good for us? Like, how do we rectify that? How do we reconcile that what we know to be maybe the best option for treatment is maybe not the thing that is covered? And if you're not gonna offer things that aren't covered, is that actually maybe uh bordering on unethical from an offering standpoint?

SPEAKER_01 25:01

So that's a great question when it comes to the insurance world. And boy, that's a whole can of worms with that, because now you really get into the whole ethical issue of insurance companies denying payment for things that have been shown to be effective. For example, now there is more level one research that shows that PRP is effective for knee arthritis than for any other non-surgical treatment. And yet the insurance companies won't pay for it. They will pay for corticosteroid injections, which we know have the potential to do harm. So, how do you rectify that? Whether it's ethical not to offer these treatments, boy, I'm not an ethicist. I don't know that I want to venture into that. Each of you needs to make that decision on your own conscience, which is why I always tell patients these are all of the options that I think are available, even options that I don't perform or offer. I make the patient aware that these are the options. In terms of insurance biasing unfairly towards steroid use, I don't know that it's unfairly biasing, but it is a reality. I mean, if patients can get something covered, they may gravitate more towards that rather than paying out of pocket. That is, unless they're aware of the risks. And when they're made aware of the risk, sometimes that changes the tune. So you alluded to insurance companies not paying for regenerative medicine. That's a whole nother question which we can address. I actually did touch on that in a recent LinkedIn post, and I'd be happy to tell you if you want what I say to my patients. My patients always ask that question. Why will they pay for a knee replacement? Why will they pay for a steroid injection and they won't pay for prol therapy or PRP or stem cells? Why? When it works and it's safe.

SPEAKER_00 26:38

Yeah. And maybe you have a nicer way of saying it than I do. So I'd love to hear what you have to say because I'm happy to throw the insurance companies right under the bus.

SPEAKER_01 26:50

Well, here's my answer to them. Hopefully, this will be helpful to the audience. I first say, look, I'm not an apologist for the insurance companies. There's no love lost between me and them, but I have to put myself in their shoes. So follow me on this. Let's take knee replacements, for example. The insurance companies know two things dead to rights. They know exactly how many knee replacements are going to be performed year over year based on demographics and actuarial tables. Because of that, they know exactly what their financial liability is going to be because they know what the cost of a knee replacement is. So they can wrap their bean counterheads around what their financial liability is going to be. The second thing that they know is that the only people performing knee replacements are properly residency trained and board-certified surgeons. So, from an insurance perspective, there's at least a nominal level of safety that the people performing these procedures are properly trained and at least allegedly are doing it for the right reasons. Now, when it comes to orthobiologics and regenerative medicine, literally any Yahoo who has a license to wield the needle can run around claiming that they're doing regenerative medicine, irrespective of any lick of training at all. They don't need one iota of training to say that they're doing PRP. And they can do PRP for any reason under the sun. So now the insurance companies are looking at a completely unknown level of financial liability and a completely unknown level of risk because they can't vet the people who are doing these procedures, and they can't assure that the procedures are being done for the proper reasons. If I was an insurance company, absolutely no way would I pay for it under those circumstances. So when I say that to the patients, they get it. That rings with them because they now understand that, at least from my perspective, I'm looking out for their safety. And we don't want people doing these treatments who are improperly trained. And that's part of the patient education process also.

SPEAKER_00 28:49

Well, you're a whole lot more generous than I am because what I tell them is because they can't make money on it. That's your blood. You can't package up your blood and make an upcharge on it and make money on it. Just if you're wondering why things happen, follow the money.

SPEAKER_01 29:05

True, but the insurance companies don't make money on you doing procedures. They're paying out money for you doing procedures. So it's the pharmaceutical companies that aren't making any money. That's a different story. Now, you could argue that the pharmaceutical companies may be in cahoots with the insurance agencies. Just take a look at CVS and Aetna, for example. You know.

SPEAKER_00 29:25

Well, isn't that just called vertical integration, right?

SPEAKER_01 29:28

That's it. That's right. That's right. But I think that's where it gets really cloudy in terms of insurance reimbursement for these procedures. So and I have some patients who say to me, look, Doc, I'd love to get PRP, I'd love to get stem cells. I'm a retiree on a fixed income. I just don't have the money to do it. So I'm going to opt for a knee replacement. Okay, I get that.

unknown 29:46

You know?

SPEAKER_00 29:47

Yeah. Yeah. I mean, and I still do knee replacements. And I think one of the reasons that I started using regenerative medicine is because of my inability. And I think across the board, we're not good at identifying who's not going to do well with knee replacement because it's not 100%. It's not even 80% really. And it's hard to identify. I don't think we have the corner on the marker on how to identify who's going to do well and who's the 25% who aren't going to do well. And so I sure as heck would rather exhaust every single safe, low-risk opportunity to avoid knee replacement before we go down that path. And I say, hey, listen, you've got a one in four chance, you're not going to like it. And I can't predict with reasonable certainty who that's going to be. But if you're you're like miserable, okay, we're going to take that risk and say, all right, we have a 75% chance it's going to be good, 25% chance you don't like it, and you can't take it back. And you've tried every single other thing, and we all are on the same page. Fine, that's a very different thought process than well, you have grade two arthritis and we have no other treatment ideas, and so we're just gonna pop a knee in you. It's gonna be great until it's not, right?

SPEAKER_01 31:11

Or even worse, they say, Yeah, you're not ready for a knee replacement now. Just live with it until you're ready and then we'll replace it.

SPEAKER_00 31:17

Oh, yeah.

SPEAKER_01 31:18

That's terrible. That I think is unethical. Knowing what we know now, especially about orthobiologics for the knee, I think that's irresponsible.

SPEAKER_00 31:26

I'm gonna come at it from a little different perspective because, and this really goes to my next question is are we overpromising what PRP can do, or are we under-educating patients and physicians on what it can and cannot do? Because I will tell you, when I started out, and that was not that long ago, with orthobiologics, I was not well educated and not well versed in any of the literature that supported use for orthobiologics. And so there was this, and maybe it's dogma, right? Maybe it's groupthink of a very heterogeneous population of physicians, but I will tell you that it was it's not well taught and it's not well disseminated on the actual benefits and really robust amount of data out there to support the use of orthobiologics, and so when we say, Oh, just live with it, I I tell my patients the same thing. Why are we trying to push later, later, later in life? And I'm like, well, here's the deal. It's kind of a morbid reason, but we are trying to do only one joint replacement, and we know it only lasts about 20, 25 years on a good day, and so we're trying to predict when you're gonna die and then back it up 20 years and give you a knee replacement that you're gonna finally die with. And they're like, oh, that's terrible, but that's what we're doing, and that's why we're trying to push it off as far as possible. But you're right, the most recent data for orthobiologics shows that the sooner that we can get to a knee or a joint that has damage, the better the outcomes and the more high impact we can have in avoiding joint replacement at all, right?

SPEAKER_01 33:28

Correct, correct, correct.

SPEAKER_00 33:30

Yeah, I know.

SPEAKER_01 33:31

So, in answer to your question, are we overpromising or under-educating? I think the answer to that is both. Yes, I think the marketing, I think the marketing on PRP and bone marrow and adipose has far outpaced the science behind it. I do think that uh in some cases, the field in general tends to overpromise, and we certainly are under-educating. Now, what I do in my practice is I tell patients this is what these treatments can and can't do. I have patients who come in thinking that these treatments, and I'm lumping all orthobiologics, PRP, bone marrow, adipose, even prolotherapy and prolozone. Some patients come in thinking that these treatments are magically going to give them a new hip or a new knee, and they will avoid a joint replacement. And the first thing I tell them this this is not going to give you a new hip. It's not going to give you a new knee. The only way to get rid of arthritis in a joint is to replace the joint. That's it. You cannot reverse arthritis, you can't cure arthritis. Short of having a joint replacement, all we can do is manage it. Ideally, treat your pain, get your quality of life back, and ideally slow or halt further progression of the arthritis, which gets to your point, Ariana, about the sooner we treat, the better we are off. However, I'm a big analogy guy, so what I say to my patients is think of your joint, your arthritic joint, like your lawn. You get beautiful topsoil, you plant the grass seed, and you get a beautiful green Kentucky bluegrass lawn. You wouldn't step back and say, okay, I'm good for the next 20 years, I don't need to do anything. Of course that's not true. Now you don't need to replant the lawn every year. In other words, you don't need to do, say, a stem cell treatment every year, but you do need to fertilize that lawn in order to maintain the health of it. Because if you don't, all your hard work is going to go completely to waste and the weeds and the crabgrass are going to take it over. So the same I find true with orthobiologics. Eventually, these treatments wear out because at the end of the day, you still have an arthritic joint where you have inflammatory cytokines, tumor necrosis factor alpha, the interleukins, and the other inflammatory cytokines, want to keep flooding back into that joint and wreaking havoc. So, like your lawn fertilizer, which keeps the weeds and the crabgrass away, periodically we have to do an orthobiologics fertilizer or booster to keep that joint from deteriorating. And so I tell patients this is not a one-and-done. In most cases, you'll get maybe two to three years out of it, but we don't want that to last just two or three years. We want this to last for many years and ideally prevent you from having a joint replacement. So periodically, plan on having a PRP booster to keep the weeds and crabgrass away and maintain the health of your lawn. And some people say, hey, that's great. If all I need to do is get a PRP every one or two years, awesome. Other people say, look, I just want to be over and done with it. Okay, great, get your knee replaced. But it's an honest conversation with the patients about what these treatments can and can't do. I also tell them that it's not going to regrow cartilage if you have bone-on-bone. To take the grass seed analogy, you could take the best grass seed in the world. And if you throw it on your driveway, you ain't growing along. So, and patients resonate with that analogy. So they understand that you're not going to make a silk purse out of a sow's ear, but that doesn't mean that they can't get significant benefit in their quality of life and maybe spare them or at least delay the time until they need more definitive intervention like a joint replacement.

SPEAKER_00 37:06

Absolutely, absolutely. There's a lot in the chat about our biases. And honestly, I really, there's bias all over the place, right? People when I'm talking to orthopedic surgeons about their research that for to support use of orthobiologics, and I keep popping up all of the journals, and they're like, wait, that was in my journal? And I'm like, Yeah, here's the problem. It's confirmation bias, right? If you look at something that you don't know anything about and it's not in your realm and you don't use it, you're gonna go past it. You'd be like, yeah, whatever, I don't use that. Where's the journal article on polyethylene, you know, or some ridiculous thing, right? And so this confirmational bias, we're all at risk for. Just like when you think, oh, I need a red car, and then every car you see is red. You're like, oh my, what in the world is going on? It's because we filter out those things that we don't attend to or we're not interested in until it kind of slaps us in the face. And we're like, oh my gosh, this has been here the whole time. Holy cow. That's really fascinating.

SPEAKER_01 38:20

And we see that confirmation bias all the time. Orthopedic surgeons look at back pain and they say it's disc related, and the physicians look at back pain and they say it's facet-mediated, and the physical therapists look at back pain and they say your pelvis is out of alignment, and chiropractors look at back pain and they say it's a result of subluxations. Everybody's got their little telescope that they look at things through. And we're all guilty of the bias. And I am too, but at least I try to step back and I say to patients, I'm not anti-surgery. I'm surgery for the right reasons at the right time. My job is to present you with the information with which to make an informed decision. And then you decide which way is best for you. So I've had patients where I've said, you need a knee replacement, you need a hip replacement. It would be unethical for me to take your money. Other times I've said, look, you could go either way. This choice is up to you. So at least I try to present as much as I can within my own biases the wide panoply or palette of options to help the patients make an informed decision.

SPEAKER_00 39:21

Absolutely, absolutely. Well, you know, so this brings me to the next question, which is what is that next step? If you're looking to now we've let's just say we've convinced everybody that cortisone is not maybe the greatest option and the dose makes the poison, and maybe we have some other options. So, how do we start to be successful in our orthobiologics practice? And so we've talked about that orthobiologic knowledge. I think the next part is really trying to figure out um how we use this, how to attract the right patients. We have a practice launch system that I use, I teach, and I I want people to be a part of this, how to create that cash-based business, how to have high converting results, and honestly, how to have success, who the right patients are, who needs your help with orthobiologics, and who may be served better by surgical intervention. So if you want the fast track on all of that information, I'm gonna offer next week Bob Live, the business of orthobiologics. Everybody, come on down. It's gonna be great. It's at Toby. If anyone is going to Toby and uh wants to something else to do on Thursday, come on down. We're doing a full day of business training on how to integrate PRP seamlessly into your workflows, step-by-step roadmap for success. And so, really, that's what I wanted to offer you today. Obviously, that we have we can't do this for free, but we do think this is worth the investment. If this is something that you're interested in, this ticket is for the 21st. That's next week. So don't miss out. And if you're not going to Toby, you absolutely should. It's in Las Vegas, and it's two days of amazing education, international experts in the field, including regenerative medicine, cellular therapy, stem cell, culture expanded stem cell, energy medicine. So please, please, please don't miss the boat. And so I did want to open this up to the questions and the chats. So if you all who are there, oh my gosh, there's so many questions. I love it. So we'll look in the chat. There's and we'll get to this. You can also raise your hand. But we have a couple of questions, Paul. And what I want to know is Kyle was asking, do you prefer one treatment and see how you're doing, or do you prefer a treatment series? What are your thoughts on that?

SPEAKER_01 42:17

So again, all of these answers are not cookie-cutter. There's a little nuance. Let's take joints, for example, arthritic joints. We now know that the literature, or at least the literature, seems to strongly suggest that administering a minimum of 10 billion platelets seems to be the threshold at which we get the best results. Back when I started PRP in 2007, everything was a one-size-fits-all. And unfortunately, there are still practices that are doing PRP using a one-size-fits-all PRP product. In order to get 10 billion platelets into a joint, you've got two options. You either use a weak PRP and you have to administer multiple treatments, or you draw a lot of blood and concentrate that down to a small volume of PRP and administer one treatment. The more recent research suggests that a single treatment using a high dose PRP seems to work better than multiple treatments. It's certainly more cost-effective for the patient and induces less morbidity. So when it comes to the joints, it's typically one treatment, but that one treatment has to be a high dose that contains a minimum of 10 billion platelets. So I noticed in one of the questions in the chat, how much blood are you drawing? Typically, for me, for a single large joint, which is going to be knee, hip, or shoulder, we're drawing 120 cc's of blood, and I'm concentrating that down to four cc's. And by the way, Dr. Santeno had a very good blog a number of years ago talking about the difference between dose and concentration. And that's a big issue. So three cc's of a 20x PRP is not the same as 20 cc's of a 3x PRP. So there's this concept known as a gradient, a concentration gradient. And so a smaller volume of a higher concentration of platelets works much better than a large volume of a weak amount of platelets. So the only way you're going to get that is by drawing a lot of blood. Now one limitation of that is it limits how many joints you can treat at a time. If I'm treating two large joints, that's 240 cc's of blood that I'm drawing to get the maximum platelet dose into each joint. And I let patients know that. Now if it's something different, if I'm treating a tennis elbow or a rotator cuff, then a slightly lower concentration is needed. And typically still only one treatment is required. And I see how they do. And I tell them I want to give this a good two to three months. And the reason for that is biologically, the tendons require about a hundred days to synthesize the main structural proteins that make up the tendon. So I need to give the body enough time to respond before I consider injecting another dose. But then again, I'm using a higher concentration PRP, which I think now is the appropriate standard of care, if you can say that.

SPEAKER_00 45:11

I think we're getting to a point where we have pretty good scientific evidence that we at least know concentration in dose. And I'm gonna I'm gonna put my little pet peep out there that X is really just X. Please, please, please don't take offense. But honestly, we used to say, oh, it's 10x, it's 20x, it's 1 billion X. Of what?

SPEAKER_01 45:37

Right.

SPEAKER_00 45:37

And so if we don't know what we're starting with, then really it doesn't matter what we're ending with because we can't talk about dose. We can't talk about the absolute number. We can't talk about the constituents within the injectate. So I'm gonna say if we're not talking about dose, the X-fold concentration is maybe old news. Right.

SPEAKER_01 46:04

And the reason for that is let's say somebody has a baseline platelet concentration of 150,000. Well, 10x is gonna be 1.5 billion. Okay? Now let's say that somebody has a baseline platelet concentration of 300,000. Well, 5x is going to be 1.5 billion. So there you have a situation where a 10x is equivalent to a 5x. So that's why the X factor above baseline is completely meaningless if you don't know the baseline platelet count. So for those of you who don't have cell counters, I have a cell counter, we measure every PRP that we do and we document it in the chart. If you don't have a cell counter, at least get a baseline CBC within a reasonable time period before you do the PRP. And from that, you know what the patient's baseline platelet count is, and then you can figure out how much blood you're going to need to draw to get to the, let's say, the 10 billion platelet dose. If you don't have at least that foundational information, you're hazarding a guess because you don't know what the baseline platelet count is. So how do you make a meaningful determination on the appropriate dose for the patient? We know in medicine that oftentimes drugs are based on the weight of the patient. We certainly know that in pediatrics. So why do we think that a one-size PRP is going to work for every patient? We don't. You know that we need a higher concentration for older people than you do for younger people. You need more blood for people who have a lower platelet concentration than for people who have a higher platelet concentration. This is the direction that I think our field really, really needs to move into is quantifying these numbers and not just drawing a sample of blood that's standard across everything and injecting the same amount in every patient and expecting the same results. It doesn't work that way.

SPEAKER_00 47:52

Absolutely. Now, this this is a really good question because we've been harping on dose so much. What's the dosing for the laser after PRP? We keep saying dose. What are we talking about here?

SPEAKER_01 48:05

So yeah, it's a great question. I am admittedly fairly new to the laser world. Ariana, you may have more experience with it than I do. I've been using Shockwave longer than I have for laser. What I've been doing is particularly for my soft tissue PRPs, so Achilles, planar fascia, tennis elbow, rotator cough, blah, blah, blah. I am applying a laser immediately after I inject the PRP. That same visit. Either the laser gets rolled into the exam room or the patient is brought into our energy room. We have an exam room that's dedicated to energy medicine where we do all our shockwaves and lasers. One way or the other, that patient is getting that laser immediately after application of the PRP, and then ideally once a week for the next three to four weeks. And that's based on some data that came out recently. Maybe Ariana, it was you. Somebody reported on their data biologics registry that administering laser immediately after PRP showed a significantly better outcome than the PRP by itself.

SPEAKER_00 49:07

Yeah. So I'll share what we have from our data biologics. Um, and it's always so interesting because this is just extrapolated from the stuff that when I started, I was just making it up, honestly. I was like, okay, and it had to do with the financial reasons because I was like, okay, I got this laser. I know that I think it's gonna do well. My colleagues are like, oh man, if you put laser with your PRP, the patients are gonna do better. And I'm like, all right, let's go. This is gonna be an easy thing. Everyone's gonna want it, right? There's really good data that it makes wounds heal 30% faster, all these things. And then I put it in pride practice, and I'm like, hmm, this is not working as well as I would have thought. And so it's the necessity of it. I was like, shoot, man, I'm gonna just put my laser with all of my ortho biologics, and everyone's gonna get it because it's gonna help them with pain-swelling inflammation after the procedures, and then we're gonna monitor our data. And what we found was that it did accelerate that inflammatory phase, and at that six-month mark, we did have better results, and we didn't change any other parts of our protocol. And so, yeah, that it that was part of what we talked about, but honestly, that wasn't scientific. I didn't set out to do that, I just collected my data on the back end and I was like, oh, cool. This did this was helpful. But uh ultimately, some of our watchers are saying we should probably follow these outcome measures when we do this in our clinic. And this is something that you can follow in, I know for data biologics, you can do this independently. This is an independent thing that you can monitor patient-reported outcomes, that your validated patient-reported outcomes. So, Kyle, you are exactly right. We should and we do follow this for outcome measures in our clinic.

SPEAKER_01 51:01

We do, we do data biologics also, and I encourage all of you who are doing orthobiologics, if you're not using data biologics, at least choose some registry or some way to track your outcomes. That's the only way we're going to get the data. And it's also the only way we're going to be able to be honest with our patients about what the data shows in terms of how people are responding to these treatments. We don't want to be pulling numbers out of thin air. We want to have the data to back up what we're saying. And the only way we're going to do that is by using some type of registry.

SPEAKER_00 51:32

Yeah. So I know you talked, I tell this people all the time, you don't have to buy the registry, but you do have to put all the data in a spreadsheet and use the PROs. So a lot of times the registries are way easier and they do the work for you, which is way better. There's a question about combining PRP and prolo therapy in the same procedure time. Is this something that you're doing, or are you doing an either-or? Can you share your great question?

SPEAKER_01 51:58

It's an either-or. And the reason that I never combine prolo therapy with PRP is very simple. You're diluting the platelets. PRP is all about the platelet dose and having that dose in a certain volume of solution, which goes back to the chemotactic gradient that I referred to a few moments ago. If you're adding prolo therapy to your platelet solution, all you're doing is diluting the platelets and you're reducing the chemotactic gradient. So I really don't think you're adding anything, you're actually taking away. This is also, by the way, I'm going to go a little bit afield. This is also why I don't routinely combine more than two orthobiologics at one time. I know there's some people who combine M fat and bone marrow and PRP. Well, the issue with that is most of the time you're injecting into a confined space where you've got a limited amount of volume that you can put stuff into. Everything that you add, you have to use less of the more stuff that you add. So now you are diluting your orthobiologic, the more things you put in there. Having said that, every time that I do either a BMA or an MFAT procedure, I always add a small amount of ultra-high concentrate PRP. And the reason I do that is there are some studies that show that the PRP helps activate the stem cells, but I never combine bone marrow, MFAT, and PRP all at the same time, and I never combine any of those with prolotherapy. The main reason that I use prolotherapy is more for patient cost. Not everybody can afford PRP. Prolotherapy has been around since the 1950s. I've been doing it for 30 years. It works, it works well. It takes more treatments to get there, but it's more cost effective because dextrose is cheap and it's time effective because you don't have to draw and spin blood. Having said that, my experience is that one PRP treatment is roughly equivalent to about two or three prolo therapy treatments. So I tell patients, pick your poison. The one place, by the way, where I do prolotherapy almost exclusively is on the cervical spine. I found that PRP to the cervical spine just hurts like the dickens. Lumbar spine, different story. Thoracic spine, different story. But cervical spine, it's just miserable to have PRP done when you're doing it properly with a good concentrate PRP. Prolotherapy, on the other hand, people seem to tolerate that really well. And I much more enjoy doing the prolotherapy, and the patients much prefer to have it done.

SPEAKER_00 54:25

Yeah. So I think there's some great comments and questions about intra-articular PRP with prolotherapy in the periarticular space, which is a great use of PRP and prolotherapy. I think that I call my prolotherapy PRP light. So, like if I they can't afford it, I'm like, all right, well, prolotherapy is gonna get you 40-50% there, and we'll see how you do. I think it's low risk.

SPEAKER_01 54:55

Yeah, and that's a different story. So I thought the question was: are you combining prolotherapy with PRP in the same solution into a joint or into a tendon or ligament? Completely different story if you're putting PRP or bone marrow or fat into a joint and then using prolotherapy to treat the extra articular structures. Absolutely, that's a great way to go. When I'm treating a really broad area like an entire lumbosacral complex, I can't draw and process enough blood to make PRP for all of those areas. So I'll hit the really key areas with the PRP and then the secondary areas with the prolotherapy. By the way, don't overlook the platelet pore plasma. So if you see on MRI that they've got atrophy of the deep multifidus fibers, I'll use the platelet pore plasma to treat those deep multifidous fibers to help regenerate them. And I'll also use that for treating the platelet pore plasma for treating mid-substance muscle tears, muscle injuries. The platelet pore plasma works great. So there's a lot of good biologic properties in the platelet poor plasma. So don't overlook that.

SPEAKER_00 55:59

Yeah, absolutely. Wow, you just blew up the comment section.

SPEAKER_01 56:03

Um I'm not afraid to poke the bear.

SPEAKER_00 56:06

Well, there's some conversation about using lysate in the cervical spine, and that there's not as much discomfort that they're experiencing as practitioners when they're using lysate in the cervical spine. And I would agree to a certain extent. There's also some discussions about Endra to PRGF is a leukocyte-free and uses citrate as an anticoagulant. So I think there are nuances, especially when we're using spine-based procedures and especially the PPP, the platelet pore plasma. Though I think I used to throw it out, and now I'm like, oh my gosh, liquid gold, please don't throw it out. And what we found is when we can concentrate that, we can get a significant number concentration of A2M, IL1RA, and we can scavenge about 1.5 billion additional platelets in that PPP. And so, like, don't overlook that section of the blood stack as part of our treatment. Um, and I agree that the muscle actually we prefer platelet poor plasma for treatment of muscle injuries, and that platelet rich plasma underperforms platelet poor plasma when we're talking about muscle injuries.

SPEAKER_01 57:28

Exactly. Exactly. And that was a great suggestion, by the way, to use platelet release aid or platelet lysate for those most sensitive areas like the cervical spine. One of my issues is when I treat the cervical spine, I treat pretty comprehensively. I'm treating the facet capsules, I'm also treating the deep multifidus, I'm treating the interspinous and supraspinous ligaments, I'm treating the suboccipital attachments. So it's very common for me to use as much as 24 to 30 cc of solution in the cervical spine. It's hard to get that much platelet release aid when you're doing that type of comprehensive treatment. And I'm treating people who have tried and failed other PRP treatments by other providers who are not as skilled. So for me, it tends to be a volume issue when it comes to that. But if you're treating a very focal or localized area, I think the platelet release aid or platelet lysate is a great idea. Obviously, you're going to do that if you're treating certain spine conditions, like if you're doing transforamenal epidurals in the spine, using the platelet release aid or lysate is absolutely a must. I also tend to use platelet release aid or lysate, and those, by the way, are two different things. They're variations on a theme. But I will use that when I'm doing hydrodissection around nerves because I find that PRP around nerves really hurts, but the lysate or release aid doesn't anywhere near as much. So I prefer that when I'm like doing a hydrodissection of the carpal tunnel.

SPEAKER_00 58:48

Yeah, absolutely. I think that's uh really good sound recommendations. I think we'll wrap this up. We've gone way over and you've been wildly popular. So that thank you so much for sharing all of your knowledge. That was so fun. Um, and then the last piece I would say is floro or ultrasound or both for these treatments, either joints, C spine, lumbar spine. How do you determine what you're using?

SPEAKER_01 59:16

So I'm really glad that you asked that question because this goes way back to uh a point that you made about the how to get started in regenerative medicine. Very frequently I have clinicians, doctors coming to me saying, I really want to get started in regenerative medicine. How do I learn how to do PRP? How do I learn how to do bone marrow? How do I learn how to do fat? My answer is always the same. Learn how to inject under ultrasound guidance. Become the absolute best that you can be in guiding a needle under ultrasound. Because if you can't do that, it doesn't matter a hill of beans what's in your syringe, because you won't be able to A, identify the pathology, and B, guide a needle accurately to that spot. So absolutely take as many courses as you can afford to take on ultrasound and don't think that a weekend two-day course is going to get the job done, okay? It is not. You really need to dedicate the time and effort to get good at ultrasound in order to be able to do these properly. Now, to answer your direct question, fluoro versus ultrasound. For me, I use fluoro in the following circumstances. If I'm doing anything transferaminal, epidural, I will use fluoro. And if I'm doing anything intraosseous, I just had two intraosseo cases today. I'm a firm believer that you need to see where that needle goes. I know there are people who are doing intraosseous injections under ultrasound. I just don't buy it because you can't see where that needle is going safely. So I have a C arm and I will use fluoro under those circumstances. There's one other circumstance where I will use fluoro in a joint, and that is somebody who's got a severely arthritic ankle. Sometimes it's really hard to guarantee that that needle is in an arthritic ankle joint. When I do it under fluoro and I put a little touch of contrast to confirm that I'm in the joint, now my comfort level is rock solid, that my orthobiologic is going to go in there. Oh, and by the way, the same is true for sacraliac joint injections. Yes, there are people out there saying you can inject the SI joint under ultrasound, and that is true. However, you absolutely positively 100% cannot prove that you are in the sacraliac joint without fluoroscopy and contrast. So you can guide the needle to the SI joint under ultrasound, which is what I do to save time and radiation exposure, but I will use the floral at the end to confirm that that needle is actually in the joint. For everything else, I use ultrasound. And other than the lift-off perineural injections, every single injection that I perform is always done under ultrasound guidance.

SPEAKER_00 1:01:47

Yep. Me too. You know, I'm a huge proponent of ultrasound, and I've been doing it a long time. A shout out to Don Buford. I took first took his course, his weekend course, way back in the day. Um, and that had that started my journey. And then we took I took all of the IOF courses, Toby courses, any course I could find on.

SPEAKER_01 1:02:11

And that's what you have to do. Yeah, that's what you have to do.

SPEAKER_00 1:02:14

Yep. So thank you so much, Pop. I'm gonna have to have you back on. This was phenomenal.

SPEAKER_01 1:02:19

I would be honored. It was a blast.

SPEAKER_00 1:02:21

Thank you so much. Everyone else, thank you so much for all of your great, great, great questions. Please come to Vegas next weekend. Come to the business of orthobiologics, come to Toby, come to IOF, come to Orthosono. These are all great. We'd love to have everybody.

SPEAKER_01 1:02:38

And we're gonna be at Toby next week, so we look forward to seeing you. I know Don Buford's gonna be there, Arian's gonna be there, I'll be there. Anyone who's anybody in regenerative medicine is gonna be there. So awesome.

SPEAKER_00 1:02:50

Thanks so much, everybody.