Month: September 2022

Can platelet-rich plasma (PRP) help with pain?

Absolutely.

Your body is designed to heal itself. When you get sick, your immune system goes into defense mode to kill invading microbes. When you stop smoking, your lungs begin to repair themselves. If you get a cut, your blood clots in order to stop the bleeding.  These are all processes that involve the body’s natural immunity and regeneration.

Platelet-rich plasma (PRP) injections attempt to utilize many of these same protective and regenerative pathways to help heal damaged tissue. This can in turn help with your pain.

Let’s break it down even further.

What is platelet-rich plasma (PRP)?

Your blood is mostly a liquid known as plasma. It is also made up of red blood cells, white blood cells, and platelets. Platelets are responsible for clotting blood, slowing, and eventually stopping bleeding. In addition to helping with clotting, platelets also stimulate growth factors that support regeneration or healing.

Platelet-rich plasma is just what the name suggests—plasma enriched with at least 5-10 times more platelets than what is normally present in the blood.

In order for platelet-rich plasma to help with pain, it is usually injected at the site of injury. To prepare PRP injections, a blood sample is taken from you and placed into a centrifuge. The centrifuge is used to concentrate the platelets and separate them from other blood cells. The concentrated platelets are then re-injected directly into the injured site or tissue, such as a tendon or knee. Oftentimes, we will use advanced imaging like ultrasound to guide the injection where it needs to go.

How does PRP work?

While we are not 100% certain how PRP exactly works, we are fairly certain that the increased concentration of platelets in the PRP help to stimulate growth factors. These growth factors then activate and accelerate the healing process. By injecting PRP into an area that is injured, we are counting on the body’s own growth factors to stimulate and regenerate damaged or lost tissue.

What exactly are PRP injections used for?

PRP therapy has been used to treat a variety of musculoskeletal conditions from chronic arthritis to ligament or tendon strains. If you’ve ever had an injury or debilitating condition then you know that it can certainly take a while to heal. PRP injections can help boost the healing process with less pain and with a quicker return to normal activities.

Do PRP injections work?

Research supports the use of PRP for sports-related injuries such as those that can occur to the tendons and ligaments. PRP may also help with arthritis but further research is needed to classify which types of arthritis PRP is most effective at treating. As with any newer treatments, further studies are still needed to help us better understand things like how much, how often, and at what concentration PRP injections are most effective for different musculoskeletal conditions.

What are the side effects of PRP injections?

When performed properly, PRP injections generally do not pose severe side effects. Because PRP injections are made from your own plasma, there is very minimal chance that you’ll have an allergic reaction. Like many injections, you may have a sore arm or bruise at the site of the injection. Also, like with any injection, there is always the risk of infection at the injection site.

PRP injections can certainly help with your pain and are relatively safe when done correctly. Make sure you consult with a physician who is knowledgeable in providing these injections to ensure that you get the best outcome.

Dr. Sergio Guiteau is a physician who has certifications in Aesthetic Medicine and is board certified in Family Practice and Sports Medicine. He specializes in Anti-Aging Medicine and blogs on rhm.sys.mybluehost.me/website_d5adaba3/blog

Millions of Americans suffer from knee pain secondary to arthritis. Knowing your options for how to best treat arthritis knee pain is key in helping to alleviate your pain and to prevent it from coming back.

Arthritis, also known as osteoarthritis (OA), is the degeneration of cartilage that helps our joints glide smoothly against each other. This cartilage can break down from trauma, autoimmune conditions, or wear and tear over time. The effects of this degeneration are what lead to the pain and sometimes swelling that we see in osteoarthritis.

So what are your best options for treating knee arthritis?

There are many options for treating knee OA that range from conservative to more invasive. Generally, most medical practitioners will start with the most conservative options and will get more aggressive with treating your OA pain as each successive option works less and less.

For this review, we will start with the least invasive options and continue on to more invasive options as we move forward.

 1) Heat/Cold Therapy:

We have all used ice and or heat for one injury or another. The use of temperature to treat pain has been around for thousands of years. For those suffering from knee pain secondary to arthritis, this method is often overlooked. Studies have shown that using ice and/or heat can certainly relieve pain due to OA in the short term. If your pain is secondary to an acute flare-up, heat/cold therapy may be all you need.

There haven’t been any robust studies demonstrating how much and how often you can apply heat or ice to treat OA pain. When it comes to ice however the general rule of thumb is 30 minutes on and 30 minutes off. I would advise using a barrier material to prevent damage to your skin from the direct use of ice.

In regards to heat, there really is no limit as to how often you can use it. If it feels better with heat then you can use it liberally. If it doesn’t then you can stop using it. Just be sure not to leave a heating pad on overnight or while you are sleeping to prevent burn injuries.

2) Exercise:

Many studies have shown the benefits of exercise in helping to treat arthritis knee pain. The type of exercise and the duration will vary by individual. Whether it be physical therapy, leg strengthening, tai chi, or even swimming, the benefits of exercise cannot be ignored. Most people report some level of pain relief and improvement in function in the short term. Many studies show that if these exercises were part of a regular routine they would also result in an improvement in pain and function over the long term.

Not every modality of exercise will be beneficial to everyone. The type and duration of exercise must be tailored for you. What I recommend is that patients start by seeing a physical therapist or begin some low-impact activity (i.e. swimming, yoga, tai chi). As you progress through these activities for the first few weeks, keep in mind what works and what doesn’t. You should be able to complete the activity virtually pain-free. You also shouldn’t have any worsening in pain after the activity is completed.

By combining physical activity and a healthy diet, the hope is that you are not only making the muscles in your lower legs stronger but also losing any excess weight. Both leg strengthening and weight loss through exercise have been shown to contribute to pain relief from knee arthritis.

3) Knee Brace:

A knee brace is another often overlooked option for those suffering from knee pain secondary to arthritis. Specifically, the unloader knee brace has been clinically proven to decrease pain and increase functional mobility. They work by alleviating pressure in the area of your knee that has a loss in joint space from cartilage degeneration. They can be used daily to provide added support for your knee while also providing pain relief.

The unloader knee brace is custom-fitted to your type of arthritis and it may not be for everyone. Before getting one you should have imaging of your knee performed and speak to your doctor to know which type of unloader brace may be right for you. While some people complain of skin irritation from contact with the brace there are very few adverse effects from using an unloader knee brace.

4) Electrical Nerve Stimulation:

Transcutaneous electrical nerve stimulation (TENS) has been used to treat pain since the 1970s. While the evidence for its effectiveness in helping to treat arthritis knee pain has been mixed, it may still be worth trying. TENS works through a portable battery-operated device that delivers an electrical stimulation through the skin. This stimulation alters the sensation of pain that you notice at the central nervous system. The most serious side effects include local skin irritation, muscle soreness, and in very rare instances burn. You should always consult with your physician and ensure that you are using the proper machine settings before using a TENS apparatus.

 5) Acupuncture:

Evidence has been mixed to negative in regards to the effect of acupuncture in helping to treat arthritis knee pain. While acupuncture has been used for hundreds of years, there have been few scientific studies showing objective improvement in function with acupuncture. That being said, many people do experience a subjective improvement in pain. Before you decide to try acupuncture it’s important to make sure that the acupuncturist you use is certified to perform the procedure. They should also be using sterile equipment and technique to prevent infection. Acupuncture is commonly used in combination with the other modalities listed. If you are interested in learning more or even trying acupuncture contact our office for more information.

7) Topical Pain Medications:

There is strong evidence showing that topical medications can treat arthritis knee pain. In particular, topical Capsaicin or Menthol-based rubs (i.e. Bengay or Tigerbalm), as well as topical prescription anti-inflammatories (ie. Voltaren/Diclofenac gel), have been shown to improve knee pain. Capsaicin works as a counterirritant by directly causing a burning sensation at the skin. This modifies and can reduce the sensation of pain in the central nervous system when it is applied to a painful area.

Topical prescription antiinflammatories directly inhibit the pain signal locally. Because of the local effect of both of these topical medications, there is a low risk of systemic side effects. These options can be quite effective and their benefit can be enhanced when used with the other modalities discussed.

8) Supplements:

There are many supplement options for those with knee arthritis. Before trying any of these you should first understand that many of them may not work as well as you expect them too. Also, before starting any supplement you should always consult with your doctor.

Reviewing every supplement that has been used for knee arthritis would be beyond the scope of this article. However, a few supplements that have shown mixed to positive results include Fish-oil, Curcumin, Boswellia serrata extract, Glucosamine chondroitin, and Collagen hydrosylate. If you have any questions about which supplements might be right for you please contact our office.

9) Oral Pain Medications:

When it comes to oral pain medications for treating knee arthritis most doctors will prescribe either acetaminophen (Tylenol), non-steroidal antiinflammatories (i.e. Motrin, Aleve), or opioids (i.e. Oxycodone, Hydrocodone). All of these medications work by dulling signals along the neural pain pathway.

Studies have shown non-steroidal antiinflammatories (NSAIDS) to be most effective at treating arthritis pain. Acetaminophen is another great option as well. While studies show they may be inferior to NSAIDS, many patients who do not get relief from NSAIDS or cannot tolerate them, may find pain relief from acetaminophen.

Opioids are less commonly used for knee arthritis because of the high risk of addiction and the multitude of side effects. Your doctor may be more likely to use this as a short-term solution in the event that you will be having surgery. For those suffering from severe knee arthritis who may not be candidates for surgery, opioids may be a reasonable although less ideal option.

Before taking any of these medications it is important to speak with your doctor about the side effects. You also need to be honest about your medical history and medication/supplement use.

10) Corticosteroid Injections:

Steroid injections for knee pain can be an excellent option for those seeking short-term pain relief. Studies show that intra-articular steroids can provide improvement in pain and function for up to six weeks if not longer. When combined with other modalities, especially exercise, they can maximize pain relief and function.

These injections are only temporary and repeat injections have been shown to not be as effective. Multiple injections over time have been shown to actually increase joint degeneration and thus are not recommended.

Side effects from these injections can include worsening pain, bleeding, infection, localized skin irritation and in some instances skin discoloration. Make sure your provider is knowledgeable in how to perform this injection correctly to maximize the benefit you get from this procedure.

11) Hyaluronic Acid Injections:

Hyaluronic acid is a viscous polysaccharide found in connective tissue. Since the late 1990’s the FDA has approved Hyaluronic acid injections (more commonly known as gel injections or viscosupplementation) for the treatment of knee osteoarthritis. As of today, there are at least a dozen formulations on the market. While we aren’t 100% sure how they help with pain control, it is believed that they function by helping with joint viscosity. While more recent evidence has been mixed, evidence has shown that there is some improvement in both pain and function.

Your insurance will likely cover these injections and there is a very low risk of side effects when these injections are performed properly. Some uncommon side effects do however include increased pain, localized skin irritation, and infection. Make sure your provider is knowledgeable about how to perform these injections correctly to maximize the benefit you get from this procedure.

12) PRP injections:

Platelet-rich plasma (PRP) has traditionally been used for muscle and tendon injuries. More recent studies have shown some effectiveness in its ability to treat arthritis knee pain. PRP has been used for over 20 years and involves collecting your own blood and then separating out your body’s growth factors. This high concentration of growth factor can then be introduced into your knee joint. The theory behind this is that your joint will use these growth factors to begin the process of repairing some of the damaged cartilage. This may in turn help decrease your pain.

PRP has received FDA clearance but because of regulatory statutes it  has not been labeled as FDA approved. Because PRP is not a drug and involves a person’s own blood product, it is not clearly subject to FDA approval. However, the devices used to collect and harvest PRP should be FDA-approved. No studies have shown a reversal in joint arthritis with PRP use. That being said, studies have shown an improvement in pain over time. Generally, the more severe your arthritis the less effective PRP injections may work. As of this writing, insurance does not cover these injections. Therefore, it’s important that you choose a provider with experience in performing them so that you can maximize their benefit.

 13) Stem Cell injections:

The use of adult-derived stem cells to treat joint arthritis is part of a growing area of research. The FDA has not approved using your own adult stem cells or foreign stem cells for OA at this time. Any stem cell injection into your knee for OA is considered off-label and as of this writing is experimental.

The theory behind this injection is that once in your joint, these cells will communicate with your native tissue to begin the process of repairing the damaged cartilage that was lost. The regeneration of knee joint cartilage has only been seen in a few studies as it pertains to knee arthritis. However, studies do suggest that stem cells may alleviate arthritis pain. They may also alleviate your pain for a longer period of time than PRP or corticosteroid injections.

Despite the fact that early research has been promising, more high-quality studies need to be done to confirm whether or not stem cells improve cartilage degeneration from knee arthritis. Like PRP, stem cell injections are also not covered by your insurance. Side effects include increased pain, swelling, infection, and in rare instances tumor formation which has been seen when stem cells are injected into other parts of the body. If you are considering stem cell injections, finding a provider with expertise in both the harvesting and injection of stem cells will help to maximize your benefit and limit side effects from this procedure.

14) Surgery:

When all of the above options for knee arthritis have been exhausted then it is time to talk to an orthopedic surgeon about surgical options. Generally, the options for knee arthritis involve either knee replacement or some form of knee resurfacing. Debridement of the knee joint, where worn cartilage is either shaved down or removed, has for the most part fallen out of favor. However, It may still be an option for a very select group of patients.

If you find that you have tried all of your non-surgical options, then speaking to a surgeon who you trust may be the best option to help reduce your pain. I recommend seeing someone who both specializes in joint replacements and who has experience in replacement of knee joints in particular. For questions regarding surgeons we recommend here in Florida please contact our office.

Dr. Sergio Guiteau is a physician who has certifications in Aesthetic Medicine and is board certified in Family Practice and Sports Medicine. He specializes in Anti-Aging Medicine and blogs on rhm.sys.mybluehost.me/website_d5adaba3/blog

I’ve been very fortunate throughout my medical career to be able to work with some of the premier athletes of our time. Treating these professional athletes has been an amazing experience.

The people who compete at the highest levels of their sport are among the most driven and focused individuals I have come across. Unlike the average patient, professional athletes are proactive when it comes to their health. They also tend to be more knowledgeable about their health than their doctors.

However, treating professional athletes isn’t always easy and it comes with its fair share of drawbacks. Being able to navigate the tightrope between doing what’s best for a professional athlete while also helping them perform while sick or injured can be tough. Things can get even more difficult when you factor in agents, team management, media, advertisers, friends, family, and the millions of dollars that can oftentimes be at stake.

Despite this difficulty I have learned a few things along the way that have helped me immensely.

Do

Give VIP treatment:

The same is true when it comes to professional athletes. Because of the nature of who they are and what they do, they will expect better accommodations. While this doesn’t mean sacrificing the care of other patients, it will mean sacrificing your time and energy for their accommodations. I regularly miss meals and work off-hours to accommodate my patients who are professional athletes. While I certainly can’t do this for every patient, when it comes to professional athletes it’s sometimes a necessity. Your ability to treat them in a timely fashion can make a difference of millions of dollars for the organizations they play for, the people those organizations employ, and the athlete themselves. If you’re not able to make decisions or treat them when they need to be treated, they will quickly find someone else who can.

Work with their expectations:

Many athletes want to play and they want to play despite injuries. As a physician, my job is to help them return to the court or field quickly and in the safest way possible. To do this you have to be 100% honest with what your expectations are versus what their expectations are. If an athlete wants to play next week and it isn’t possible, their expectations have to be re-oriented to what’s safe. We’ve all seen stories of athletes who returned too soon and compromised their long term careers. Professional athletes are highly competitive individuals and many want to play at all costs. Working with their expectations can be difficult. Learning how to do it in a way that maximizes a working relationship with them is key.

Keep the lines of communication open:

When you’re treating a professional athlete you’re not just working with the player but oftentimes you’re also working with family, close friends, the agent, the team, other team doctors, and trainers. Navigating through the myriad of opinions and expectations can be tough. There are times when the athlete wants to play but the agent disagrees. Other times the athlete doesn’t want to play and the team disagrees. Or sometimes the athlete wants to play and the team wants him/her to play but the family disagrees. Recognizing everyone’s concerns and viewpoints while doing what’s best for the athlete can be a challenge. Being available for the athlete and his/her immediate circle will help mitigate this challenge.

I personally ensure that the athlete and the people who they allow to have access to their medical information, have a direct line of communication to me whether it be via phone or email. Being available for questions or medical advice goes a long way towards gaining their trust. It  will also hopefully help foster a positive working relationship.

Respect boundaries:

There is nothing wrong with being friendly with your patients, whether they be athletes or otherwise. However, it’s usually not a good idea to treat your professional relationship with them as an out of office friendship. This can lead to situations where patients may try to take advantage of your working relationship because of your friendship. I’ve seen situations where physicians who develop a friendship with patients begin receiving personal calls or requests. This includes things like signatures for medical exemption forms, controlled substances, or other medications that may not be indicated. Keeping the relationship with the athlete professional can help continue to ensure that you’re objectively looking out for their best interest without them having to expect anything in return.

Go above and beyond:

Professional athletes are used to dedicating themselves 100% to their craft. Many of them rarely have days off and it’s not uncommon for them to expect the same from the people they work with. As a physician, it ‘s expected that you go above and beyond for patients who are professional athletes. Treating them can sometimes mean staying late, getting to the office or training room early, answering calls off-hour, or sacrificing your time for theirs. The ability to go above and beyond for their care is part of what keeps them performing at an elite level. While it may often go unrecognized, their success is in many ways directly tied to your ability to be there when they need care.

Know your athlete:

Every athlete approaches their medical care and physical conditioning differently. Some athletes prefer to be in the training room constantly for exercises, rehab, stretching, massages, etc. Others prefer a more hands-off approach and will rarely seek out help unless it’s needed. I have some athletes who reach out to me almost weekly for advice on health, nutrition, exercises, training regimens, etc. Others are comfortable doing their own research and probably take everything I say with a grain of salt. Knowing what an athlete needs to perform his or her best is key when it comes to tailoring how you deliver their care. To maximize their recovery and performance it’s important to provide and communicate their care in a way that they can relate to so that they can best utilize your care to their advantage.

Don’t

Treat them like a celebrity:

Asking a professional athlete for autographs, selfies, or other perks/favors is probably the quickest way to never work with them again. When a player comes to you for help, the last thing he/she wants is for you to ask them for something in return. A trusting relationship means treating them like a patient and not as a celebrity. Many of them are already bombarded daily with requests for interviews, autographs, photos, or the like. In order to build trust with that individual they first have to feel comfortable around you. I have personally seen employees get fired on the spot for asking for these things. As a physician, asking a professional athlete for something can easily hamper the relationship and their ability to trust in your advice and medical recommendations.

Be the team’s physician:

While your job may be the team’s physician you don’t want to be seen as the physician that works for the team. Your primary responsibility is to care for the athlete to the best of your ability while doing no harm. The wants and needs of the team and those who operate the business of the team come secondary. Most professional athletes understand the business of the sport that they play. They are hypersensitive to decisions that are made from people they see as “from the team”. If you are in any way perceived as making a decision that is in the best interest of the team instead of the athlete, you will lose that athlete’s trust as well as the trust of other members of the team.

Violate HIPAA:

This one should be a no brainer. However, you would be surprised how easy it can be to violate HIPAA laws in a professional athletic setting. HIPAA privacy laws regulate the disclosure of patient health information. Under these laws disclosing patient health information without their consent can be a federal offense. A professional athletes health is constantly being evaluated by media, opposing teams, family, friends, trainers, etc. Because of this, violating HIPAA can easily be just an inadvertent slip of the tongue away.

I once had a player from another team ask me what I thought about my patient’s rolled ankle. Divulging any details without explicit consent from the athlete himself would have been a clear violation of HIPAA privacy laws. I always make it a habit to ask the athlete who they would like me to disclose medical information with. I also always try to have them present when I am discussing their personal health information with others.

Talk in absolutes:

Professional athletes LOVE absolutes. I wish I had a dollar for every time I heard questions like, when will I be back? Or how long until I get better? Or when can I go back to practice? The reality is that doctors aren’t fortune tellers. All we can do is estimate outcomes based on our medical knowledge and experience. I never tell an athlete when something will happen. Instead, I let them know when something is likely to happen. A lot of athletes hate it, but they will hate it even more if I give them an absolute timetable and it doesn’t happen the way I guaranteed.

I’ve seen many cases where athletes are considering surgery in the offseason. They’re then told that if they get the surgery they can be back by the start of the next season. If they are still in rehab when the season starts the athlete is now stuck wondering why their recovery is taking so long. Now they’re unhappy and their trust in you might be in question. I never talk in absolutes. It avoids a lot of headache and disappointment down the road.

Be easily offended:

Working in the world of professional sports means dealing with some pretty intense situations. At this level of athletic care you’re working with highly competitive individuals. They’re often under immense pressure to perform on a stage where millions of dollars are involved. Tensions can run high and frustrations can run even higher. Having thick skin is a necessity to work in this environment whether you’re a team physician or in any way involved in the world of professional sports. Most of the scenarios we see are not life or death decisions. However, careers and livelihoods are often at stake not just for the professional athlete but for their family/friends, as well as team management, trainers, and staff. Being able to function in this environment will mean not taking things personally and focusing on positive outcomes instead of the setbacks that will eventually happen.

Eat before the players:

I’ll let NBA Hall of Famer Paul Pierce explain this one. In short just don’t do it

https://www.thescore.com/nba/news/1090936

Dr. Sergio Guiteau is a physician who has certifications in Aesthetic Medicine and is board certified in Family Practice and Sports Medicine. He specializes in Anti-Aging Medicine and blogs on rhm.sys.mybluehost.me/website_d5adaba3/blog