Dr. Ice

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It’s Friday night and I feel like getting people riled up. My dentist has RA and bad elbow pain. Has gone to multiple docs and they have said to live with it, including her rheummie..big shocker there. I’m sure they drained her whole body of blood for analysis and found one slightly abnormal value and then either told her she had fibro or that she should live with it or offered her a biologic in their own glorious way with their wonderful bedside manner/personality.

She asked if I had any ideas for her. I’m thinking about trying prp. For all those who don’t have interest in ripping me a new dingus for even bringing this up, anyone have any experience with this?

To anyone who is going to ask me if she’s been ruled out for or treated for lateral/medial epicondylitis yadda yadda please don’t waste your time...

It’s elbow pain related to HER JOINT
 

SSdoc33

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It’s Friday night and I feel like getting people riled up. My dentist has RA and bad elbow pain. Has gone to multiple docs and they have said to live with it, including her rheummie..big shocker there. I’m sure they drained her whole body of blood for analysis and found one slightly abnormal value and then either told her she had fibro or that she should live with it or offered her a biologic in their own glorious way with their wonderful bedside manner/personality.

She asked if I had any ideas for her. I’m thinking about trying prp. For all those who don’t have interest in ripping me a new dingus for even bringing this up, anyone have any experience with this?

To anyone who is going to ask me if she’s been ruled out for or treated for lateral/medial epicondylitis yadda yadda please don’t waste your time...

It’s elbow pain related to HER JOINT

I cant speak to benefits of elbow joint PRP, but elbow replacements only last 8-10 years. Id consider PRP if i were the dentist.
 
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bedrock

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It’s Friday night and I feel like getting people riled up. My dentist has RA and bad elbow pain. Has gone to multiple docs and they have said to live with it, including her rheummie..big shocker there. I’m sure they drained her whole body of blood for analysis and found one slightly abnormal value and then either told her she had fibro or that she should live with it or offered her a biologic in their own glorious way with their wonderful bedside manner/personality.

She asked if I had any ideas for her. I’m thinking about trying prp. For all those who don’t have interest in ripping me a new dingus for even bringing this up, anyone have any experience with this?

To anyone who is going to ask me if she’s been ruled out for or treated for lateral/medial epicondylitis yadda yadda please don’t waste your time...

It’s elbow pain related to HER JOINT

Completely reasonable to try PRP. It works better for mild-moderate OA than severe OA which is what this sounds like. However their are no good alternatives. Elbow arthroplasties are terrible and he couldn't be dentist afterwards due to the poor function after those operations.
 
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ragnathor

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Only billing trigger point or tendon injection. Have a full lab so no charge for phlebotomy or centrifuge.

Really? If so that is quite generous.

We don't offer it, but from the prices I've seen I could send some patients for medical tourism PRP in GA and they'd still be coming out ahead after trip costs.
 
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Orin

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It’s elbow pain related to HER JOINT

I would try to see if you can RF ablate the articular branches to the joint then. I haven't seen any reports of it though.

Here are your anatomical targets.
These guys are in Atlanta if that's an option


I'm not sure I believe in PRP/biologics in end-stage RA, but sure. Give it a shot before you RF anything.

The nerves are probably easier to stimulate as well if you just want to capture them in the region where you might do an axillary brachial plexus block.
 
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I agree that peripheral nerve stim could be reasonable. I would probably consider infraclavicular approach.
 
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I would consider placing the lead in the area where one would perform an infraclavicular brachial plexus block. At this level the brachial plexus is at the level of the cords and in theory you could stimulate all 3 cords with one lead. I suppose since the lead would be at the level of the cords, calling this "peripheral nerve" stim isn't entirely accurate in pure terminology. I could have called it "brachial plexus stimulation."
 

painfree23

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I would consider placing the lead in the area where one would perform an infraclavicular brachial plexus block. At this level the brachial plexus is at the level of the cords and in theory you could stimulate all 3 cords with one lead. I suppose since the lead would be at the level of the cords, calling this "peripheral nerve" stim isn't entirely accurate in pure terminology. I could have called it "brachial plexus stimulation."
14g tuoy going infraclavicular??
 
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No, I wouldn't do Stimwave. I would consider SPR Sprint. I don't know much about Bioness but I think the lead and introducer is smaller than Stimwave, too. I don't know much about Nalu. Of course Sprint is a temporary lead, but it could help at least figure out if it will help and consider repeated placements every year or whatever it comes to. Not a perfect solution, but I'm not sure any of us have found a perfect solution yet for this case.

If you are worried about the introducer in the infraclavicular area, you could consider Stimwave in the axillary brachial plexus area like Orin mentioned, but I would be a little less confident in getting the 3 nerves with one lead there.
 
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Orin

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No, I wouldn't do Stimwave. I would consider SPR Sprint. I don't know much about Bioness but I think the lead and introducer is smaller than Stimwave, too. I don't know much about Nalu. Of course Sprint is a temporary lead, but it could help at least figure out if it will help and consider repeated placements every year or whatever it comes to. Not a perfect solution, but I'm not sure any of us have found a perfect solution yet for this case.

If you are worried about the introducer in the infraclavicular area, you could consider Stimwave in the axillary brachial plexus area like Orin mentioned, but I would be a little less confident in getting the 3 nerves with one lead there.

You can do an infraclavicular approach to the brachial plexus just fine with any system. The SPR is the simplest for a 60 day trial that may prove sufficient for longer. It is limited in the programmability.

The axillary approach to the plexus would require at least two, if not three leads to cover the various nerves.

The needle isn't as scary if you know how to use an ultrasound, but you do you. The Stimwave system is compatible with the RX-2 Coude which has that blunt obturator to help around vessels. I have done a supraclavicular approach with it previously from a conventional approach. The Bioness introducer system uses a blunt probe which isn't going to pop into a vessel too easily, but you might need a few leads to play with.

I hesitate to stimulate plexuses where they are forming or where the nerves are very thick. To get complete coverage in these locations requires some sandwiching or accepting overstimulation of parts of things, but when the nerves are diverging it allows for parking in between things and balancing the stimulation across the fibers. SPR does seem to avoid that.
 
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You can do an infraclavicular approach to the brachial plexus just fine with any system. The SPR is the simplest for a 60 day trial that may prove sufficient for longer. It is limited in the programmability.

The axillary approach to the plexus would require at least two, if not three leads to cover the various nerves.

The needle isn't as scary if you know how to use an ultrasound, but you do you. The Stimwave system is compatible with the RX-2 Coude which has that blunt obturator to help around vessels. I have done a supraclavicular approach with it previously from a conventional approach. The Bioness introducer system uses a blunt probe which isn't going to pop into a vessel too easily, but you might need a few leads to play with.

I hesitate to stimulate plexuses where they are forming or where the nerves are very thick. To get complete coverage in these locations requires some sandwiching or accepting overstimulation of parts of things, but when the nerves are diverging it allows for parking in between things and balancing the stimulation across the fibers. SPR does seem to avoid that.
Are you doing much PNS for refractory joint pain? I’ve got plenty of patients for it but have been hesitant to dive in due to generally hearing negative things about the available PNS systems.
 
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oreosandsake

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PRP is not standardized and people are getting ripped off. $500-1500 depending on local practices.
Do no harm, and don't rob people on false hopes. Worth trying if conventional care not helping.


except there is a therapeutic dose... not sure how much blood you're pulling off, but 5 ml of blood with platelet count of 150-400k and even if you get every single one of those platelets doesn't really give you a lot of platelets. less important for tendons (fenestration itself proven to stimulate healing, or tendon scraping)
 

lobelsteve

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except there is a therapeutic dose... not sure how much blood you're pulling off, but 5 ml of blood with platelet count of 150-400k and even if you get every single one of those platelets doesn't really give you a lot of platelets. less important for tendons (fenestration itself proven to stimulate healing, or tendon scraping)
Drawing 30cc whole blood. Getting 3cc to inject.
 
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Ducttape

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interesting that drusso is not offering opinion.

fwiw, since drusso isn't posting, ill say that it seems that PRP would be significantly safer and less costly and less problematic than peripheral stimulator....
 

lobelsteve

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interesting that drusso is not offering opinion.

fwiw, since drusso isn't posting, ill say that it seems that PRP would be significantly safer and less costly and less problematic than peripheral stimulator....
People treating osteoarthritis with a stimulator are a bigger problem.
 
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