NYT: Stem Cell Treatments Flourish Despite Evidence

[drusso]

he identifies the problem fairly quickly in the article:

https://regenexx.com/blog/what-level-of-evidence-do-physicians-believe-they-need-to-use-orthobiologics/

"90% of physicians actually using orthobiologics don’t believe they need level 1 evidence to use the stuff. That’s in direct contradiction to the university talking heads that show up in these stories. Why the disconnect? I suspect that our quote above applies. If you’re in the trenches treating patients you have a different view about evidence than someone who lives in an Ivory Tower."

Interestingly, these findings EXACTLY how plastic surgeons and aesthetic physicians feels out their treatments.

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[lonelobo]

When Stem Cells start getting results like this get back to me...

 

[drusso]

When Stem Cells start getting results like this get back to me...
View attachment 264888

But, where is the level 1 evidence to support that treatment?

 

[lonelobo]

I thought your argument was they did treatments like you, not supported by good evidence?
My point is with them for $5000 you get the above and with your treatment $5000 gets the pt a placebo effect for his arthritic knee

 

[drusso]

I thought your argument was they did treatments like you, not supported by good evidence?
My point is with them for $5000 you get the above and with your treatment $5000 gets the pt a placebo effect for his arthritic knee

Here you go...works in knees and breasts.


J Clin Med. 2019 Apr 12;8(4). pii: E504. doi: 10.3390/jcm8040504.
Engineered Fat Graft Enhanced with Adipose-Derived Stromal Vascular Fraction Cells for Regenerative Medicine: Clinical, Histological and Instrumental Evaluation in Breast Reconstruction.
Gentile P1, Casella D2,3, Palma E4,5, Calabrese C6,7.
Author information

Abstract
The areas in which Stromal Vascular Fraction cells (SVFs) have been used include radiotherapy based tissue damage after mastectomy, breast augmentation, calvarial defects, Crohn's fistulas, and damaged skeletal muscle. Currently, the authors present their experience using regenerative cell therapy in breast reconstruction. The goal of this study was to evaluate the safety and efficacy of the use of Engineered Fat Graft Enhanced with Adipose-derived Stromal Vascular Fraction cells (EF-e-A) in breast reconstruction. 121 patients that were affected by the outcomes of breast oncoplastic surgery were treated with EF-e-A, comparing the results with the control group (n = 50) treated with not enhanced fat graft (EF-ne-A). The preoperative evaluation included a complete clinical examination, a photographic assessment, biopsy, magnetic resonance (MRI) of the soft tissue, and ultrasound (US). Postoperative follow-up took place at two, seven, 15, 21, 36 weeks, and then annually. In 72.8% (n = 88) of breast reconstruction treated with EF-e-A, we observed a restoration of the breast contour and an increase of 12.8 mm in the three-dimensional volume after 12 weeks, which was only observed in 27.3% (n = 33) of patients in the control group that was treated with EF-ne-A. Transplanted fat tissue reabsorption was analyzed with instrumental MRI and US. Volumetric persistence in the study group was higher (70.8%) than that in the control group (41.4%) (p < 0.0001 vs. control group). The use of EF-e-A was safe and effective in this series of treated cases.
KEYWORDS:
ASCs; Adipose-derived stem cells; Breast augmentation fat graft; Engineered fat graft

 

[Ducttape]

study 1 - GIGO. but not if it involves PRP, in which case it is "gold standard"...

study 2 - poor study. doing 3 injections on PRP patient but only 1 on the non-PRP arm leads to bias.

study 3 - no data printed. how they reached the conclusions is nebulous. these conclusions (and the study 2) are interesting in that there doesn't appear to be actual "healing" involved - no improvement of cartilage damage or increase in cartilage thickness.

so subjective decrease in pain. but no obvious improvement on MRI....

 

[Ferrismonk]

study 3 - no data printed. how they reached the conclusions is nebulous. these conclusions (and the study 2) are interesting in that there doesn't appear to be actual "healing" involved - no improvement of cartilage damage or increase in cartilage thickness.

so subjective decrease in pain. but no obvious improvement on MRI....

Like steroid injections?

 

[Ducttape]

exactly.
but there are other risks associated with steroids, and more historical data...

 

[drusso]

study 1 - GIGO. but not if it involves PRP, in which case it is "gold standard"...

study 2 - poor study. doing 3 injections on PRP patient but only 1 on the non-PRP arm leads to bias.

study 3 - no data printed. how they reached the conclusions is nebulous. these conclusions (and the study 2) are interesting in that there doesn't appear to be actual "healing" involved - no improvement of cartilage damage or increase in cartilage thickness.

so subjective decrease in pain. but no obvious improvement on MRI....

It might be true that PRP is just a pain treatment. Maybe no tissue healing effects at all...


Send to




Sports Health. 2019 May 28:1941738119834972. doi: 10.1177/1941738119834972. [Epub ahead of print]
Impact of Platelet-Rich Plasma Use on Pain in Orthopaedic Surgery: A Systematic Review and Meta-analysis.
Johal H1, Khan M1, Yung SP2, Dhillon MS3, Fu FF4, Bedi A5, Bhandari M1.
Author information

Abstract
CONTEXT:
Amid extensive debate, evidence surrounding the use of platelet-rich plasma (PRP) for musculoskeletal injuries has rapidly proliferated, and an overall assessment of efficacy of PRP across orthopaedic indications is required.
OBJECTIVES:
(1) Does PRP improve patient-reported pain in musculoskeletal conditions? and (2) Do PRP characteristics influence its treatment effect?
DATA SOURCES:
MEDLINE, EMBASE, Cochrane, CINAHL, SPORTDiscus, and Web of Science libraries were searched through February 8, 2017. Additional studies were identified from reviews, trial registries, and recent conferences.
STUDY SELECTION:
All English-language randomized trials comparing platelet-rich therapy with a control in patients 18 years or older with musculoskeletal bone, cartilage, or soft tissue injuries treated either conservatively or surgically were included. Substudies of previously reported trials or abstracts and conference proceedings that lacked sufficient information to generate estimates of effect for the primary outcome were excluded.
STUDY DESIGN:
Systematic review and meta-analysis.
LEVEL OF EVIDENCE:
Level 1.
DATA EXTRACTION:
All data were reviewed and extracted independently by 3 reviewers. Agreement was high between reviewers with regard to included studies.
RESULTS:
A total of 78 randomized controlled trials (5308 patients) were included. A standardized mean difference (SMD) of 0.5 was established as the minimum for a clinically significant reduction in pain. A reduction in pain was associated with PRP at 3 months (SMD, -0.34; 95% CI, -0.48 to -0.20) and sustained until 1 year (SMD, -0.60; 95% CI, -0.81 to -0.39). Low- to moderate-quality evidence supports a reduction in pain for lateral epicondylitis (SMD, -0.69; 95% CI, -1.15 to -0.23) and knee osteoarthritis (SMD, -0.91; 95% CI, -1.41 to -0.41) at 1 year. PRP characteristics did not influence results.
CONCLUSION:
PRP leads to a reduction in pain; however, evidence for clinically significant efficacy is limited. Available evidence supports the use of PRP in the management of lateral epicondylitis as well as knee osteoarthritis.
KEYWORDS:
arthritis; growth factor; orthopaedics; platelet-rich plasma; regenerative medicine; sports medicine

 

[Gauss]

Employers Are Steering Workers Toward Controversial Stem Cell Therapies

Regenexx, which runs a string of clinics, says stem cell injections can save employers a lot of money, but critics say there’s no proof.

time.com

 

[drusso]

Employers Are Steering Workers Toward Controversial Stem Cell Therapies

Regenexx, which runs a string of clinics, says stem cell injections can save employers a lot of money, but critics say there’s no proof.

time.com

My experience with corporate self-insured insurance products has been positive.

 

[lobelsteve]

My experience with corporate self-insured insurance products has been positive.

Clinically or financially positive.

 

[drusso]

Clinically or financially positive.

Both. Easier to deal with self-insured health plans than large commercial insurers. More physician and patient friendly.

https://regenexx.com/blog/kaiser-and-regenexx/

 

[SommeRiver]

Both. Easier to deal with self-insured health plans than large commercial insurers. More physician and patient friendly.

https://regenexx.com/blog/kaiser-and-regenexx/

That blog entry is a choke slam.

 

[Doctodd]

Employers Are Steering Workers Toward Controversial Stem Cell Therapies

Regenexx, which runs a string of clinics, says stem cell injections can save employers a lot of money, but critics say there’s no proof.

time.com

pretty one sided to put it lightly.....why didnt they report Harvard and Mayo and Cleveland Clinic are performing PRP and stem cell procedures? They cite Anthem and Aetna denying the procedures because not medically necessary as proof? Just like that the big bad insurance company is the good guy. And they picked one "trapeze" artist as failing a knee stem cell/prp procedure, yet subsequently had TWO knee surgeries? lmao

 

[epidural man]

Some weird bias against PRP here...

It's way better than steroid.

It isn't harmful.

Sheesh. What else do you want? You say you want evidence? Why? Nothing else in pain medicine has great evidence, except functional restoration pain programs.

 

[epidural man]

This is a true statment by the article: "But there is no clear evidence that these treatments work.." The evidence that does exist is not clear.

But let US be clear...there IS evidence (albeit poor).

So that makes this statement completely ridiculous -

"I believe strongly that it isn’t ethical to charge patients for unproven therapies like these and raise what are likely to be false hopes,” said Paul S. Knoepfler,

It doesn't raise false hopes. To say the hope is completely false, is to say that we know the answer which is that there is no benefit.

We do not know that answer - so hope isn't false, rather, it isn't clear. It may be a long shot - but that is what hope is.

 

[Ducttape]

the poor good evidence is "balanced" by the evidence - which seems equally poor - against benefit.

unlike other past treatments, there has not been good supposedly unequivocal evidence to suggest that these treatments worked previously.

what we have in "standard pain treatment" are older procedures that at one point in time thought to have good evidence showing benefit. this evidence later was for the most part refuted...

case in point are epidurals, with them being standard of care based on evidence - in the 1950s... or LSBs or stellates... or celiacs for noncancer pain...


the problem now is that there is data on both sides, and there exists financial renumeration on the side of the procedure, by the person who is advertising and doing the procedure. this is an unfortunate bias that taints PRP and stem cell therapy...

until we have Level 1 evidence through research.

 

[drusso]

the poor good evidence is "balanced" by the evidence - which seems equally poor - against benefit.

unlike other past treatments, there has not been good supposedly unequivocal evidence to suggest that these treatments worked previously.

what we have in "standard pain treatment" are older procedures that at one point in time thought to have good evidence showing benefit. this evidence later was for the most part refuted...

case in point are epidurals, with them being standard of care based on evidence - in the 1950s... or LSBs or stellates... or celiacs for noncancer pain...


the problem now is that there is data on both sides, and there exists financial renumeration on the side of the procedure, by the person who is advertising and doing the procedure. this is an unfortunate bias that taints PRP and stem cell therapy...

until we have Level 1 evidence through research.

Sports Health. 2019 May 28:1941738119834972. doi: 10.1177/1941738119834972. [Epub ahead of print]
Impact of Platelet-Rich Plasma Use on Pain in Orthopaedic Surgery: A Systematic Review and Meta-analysis.
Johal H1, Khan M1, Yung SP2, Dhillon MS3, Fu FF4, Bedi A5, Bhandari M1.
Author information

Abstract
CONTEXT:
Amid extensive debate, evidence surrounding the use of platelet-rich plasma (PRP) for musculoskeletal injuries has rapidly proliferated, and an overall assessment of efficacy of PRP across orthopaedic indications is required.
OBJECTIVES:
(1) Does PRP improve patient-reported pain in musculoskeletal conditions? and (2) Do PRP characteristics influence its treatment effect?
DATA SOURCES:
MEDLINE, EMBASE, Cochrane, CINAHL, SPORTDiscus, and Web of Science libraries were searched through February 8, 2017. Additional studies were identified from reviews, trial registries, and recent conferences.
STUDY SELECTION:
All English-language randomized trials comparing platelet-rich therapy with a control in patients 18 years or older with musculoskeletal bone, cartilage, or soft tissue injuries treated either conservatively or surgically were included. Substudies of previously reported trials or abstracts and conference proceedings that lacked sufficient information to generate estimates of effect for the primary outcome were excluded.
STUDY DESIGN:
Systematic review and meta-analysis.

LEVEL OF EVIDENCE:
Level 1.

DATA EXTRACTION:
All data were reviewed and extracted independently by 3 reviewers. Agreement was high between reviewers with regard to included studies.
RESULTS:
A total of 78 randomized controlled trials (5308 patients) were included. A standardized mean difference (SMD) of 0.5 was established as the minimum for a clinically significant reduction in pain. A reduction in pain was associated with PRP at 3 months (SMD, -0.34; 95% CI, -0.48 to -0.20) and sustained until 1 year (SMD, -0.60; 95% CI, -0.81 to -0.39). Low- to moderate-quality evidence supports a reduction in pain for lateral epicondylitis (SMD, -0.69; 95% CI, -1.15 to -0.23) and knee osteoarthritis (SMD, -0.91; 95% CI, -1.41 to -0.41) at 1year. PRP characteristics did not influence results.

CONCLUSION:
PRP leads to a reduction in pain; however, evidence for clinically significant efficacy is limited. Available evidence supports the use of PRP in the management of lateral epicondylitis as well as knee osteoarthritis.
KEYWORDS:
arthritis; growth factor; orthopaedics; platelet-rich plasma; regenerative medicine; sports medicine

 

[deleted993114]

Some weird bias against PRP here...

It's way better than steroid.

It isn't harmful.

Sheesh. What else do you want? You say you want evidence? Why? Nothing else in pain medicine has great evidence, except functional restoration pain programs.

Stimulators and cervical rf have randomized, double blinded, prospective studies showing efficacy.

The placebo response is higher with higher cost treatments. We did PRP in the mid 90s at the behest of Rick Derby, who encouraged us all to try it. We did so, and it had less then impressive results, thus it was abandoned.

Everything old is new again- particularly when it generates $5K a pop.

I wish PRP worked, as it would be a nice option to have. However, given the paucity of evidence, if one is going to offer such treatments, one should state that it is considered "experimental" and offer it at a reasonable price ($500), instead of ripping people off with $5-$8K treatments. When we did PRP, we charged about $450. It was pretty damn easy to spin down the blood and get the plasma. Thus, these massive charges are simply taking advantage of a desperate group of people and makes those practicing PRP look greedy to other docs.

 

[drusso]

Stimulators and cervical rf have randomized, double blinded, prospective studies showing efficacy.

The placebo response is higher with higher cost treatments. We did PRP in the mid 90s at the behest of Rick Derby, who encouraged us all to try it. We did so, and it had less then impressive results, thus it was abandoned.

Everything old is new again- particularly when it generates $5K a pop.

Not your grandfather's PRP...

Curr Pharm Biotechnol. 2019 Jun 19. doi: 10.2174/1389201020666190619111118. [Epub ahead of print]
Anti-Inflammatory Effects of Novel Standardized Platelet Rich Plasma Releasates on Knee Osteoarthritic Chondrocytes and Cartilage in Vitro.
Gato-Calvo L1, Hermida-Gomez T1, Ruiz Romero C1, Burguera EF1, Blanco FJ1.
Author information

Abstract
BACKGROUND:
Platelet Rich Plasma (PRP) has recently emerged as a potential treatment for osteoarthritis (OA), but composition heterogeneity hampers comparison among studies, with the result that definite conclusions on its efficacy have not been reached.
OBJECTIVES:
1) To develop a novel methodology to prepare a series of standardized PRP releasates (PRP-Rs) with known absolute plateletconcentrations, and 2) To evaluate the influence of this standardization parameter on the anti-inflammatory properties of these PRP-Rs in an in vitro and an ex vivo model of OA.
METHODS:
A series of PRPs was prepared using the absolute platelet concentration as the standardization parameter. Doses of platelets ranged from 0% (platelet poor plasma, PPP) to 1.5·105 platelets/μl. PRPs were then activated with CaCl2 to obtain releasates (PRP-R). Chondrocytes were stimulated with 10% of each PRP-R in serum-free culture medium for 72 h to assess proliferation and viability. Cells were co-stimulated with interleukin (IL)-1β (5 ng/ml) and 10% of each PRP-R for 48 h to determine the effects on gene expression, secretion and intra-cellular content of common markers associated with inflammation, catabolism and oxidative stress in OA. OA cartilage explants were co-stimulated with IL-1β (5 ng/ml) and 10% of either PRP-R with 0.75·105 platelets/μl or PRP-R with 1.5·105 platelets/μl for 21 days to assess matrix inflammatory degradation.
RESULTS:
Chondrocyte viability was not affected, and proliferation was dose-dependently increased. The gene expression of all pro-inflammatory mediators was significantly and dose-independently reduced, except for that of IL-1β and IL-8. Immunoblotting corroborated this effect for inducible NO synthase (NOS2). Secreted matrix metalloproteinase-13 (MMP-13) was reduced to almost basal levels by the PRP-R from PPP. Increasing platelet dosage led to progressive loss to this anti-catabolic ability. Safranin O and toluidine blue stains supported the beneficial effect of low platelet dosage on cartilage matrix preservation.
CONCLUSION:
We have developed a methodology to prepare PRP releasates using the absolute platelet concentration as the standardization parameter. Using this approach, the composition of the resulting PRP derived product is independent of the donor initial basal platelet count, thereby allowing the evaluation of its effects objectively and reproducibly. In our OA models, PRP-Rs showed anti-inflammatory, anti-oxidant and anti-catabolic properties. Platelet enrichment could favor chondrocyte proliferation but is not necessary for the above effects and could even be counter-productive.
Copyright© Bentham Science Publishers; For any queries, please email at [email protected].
KEYWORDS:
Platelet rich plasma; chondrocytes.; inflammation; knee; osteoarthritis; standardization

 

[Dr. Ice]

Stimulators and cervical rf have randomized, double blinded, prospective studies showing efficacy.

The placebo response is higher with higher cost treatments. We did PRP in the mid 90s at the behest of Rick Derby, who encouraged us all to try it. We did so, and it had less then impressive results, thus it was abandoned.

Everything old is new again- particularly when it generates $5K a pop.

I wish PRP worked, as it would be a nice option to have. However, given the paucity of evidence, if one is going to offer such treatments, one should state that it is considered "experimental" and offer it at a reasonable price ($500), instead of ripping people off with $5-$8K treatments. When we did PRP, we charged about $450. It was pretty damn easy to spin down the blood and get the plasma. Thus, these massive charges are simply taking advantage of a desperate group of people and makes those practicing PRP look greedy to other docs.

Who charges 5k for prp..that’s just evil.

 

[drusso]

Who charges 5k for prp..that’s just evil.

Same people who charge $20K for a knee scope.

 

[deleted993114]

Who charges 5k for prp..that’s just evil.

That seems to be the going rate. The presentations of this "breakthrough" treatment at meetings is just embarrassing. We lived through IDET, decompressor, nucleoplasty, and prolotherapy- now this.

Even though I think it is ineffective (it was in the past), I have thought about offering it for $500 a pop to derail the financial locomotive of the local charlatans. If you are saving someone $4500, at least you are doing a financial public service, in the absence of any medical benefit.

Perhaps this may be the best solution. If you make PRP so it is just barely profitable, a lot of the enthusiasm will wane and they will move on to something else that makes more money. In a cash only procedure, this is certainly possible and is probably the answer. These guys are driven by cash and when there is no cash in it anymore, they will drop it like a hot potato.

 

[Orin]

The magic beans have the same thing going for them that fusions/discectomies do: face validity
We may get there eventually, but the basic science protocols and the clinical protocols are not congruent. There may be a signal in the noise and thus I do think it's a safer/better placebo than steroid injections, but I haven't tried to get started doing it yet due to the patient costs.

 

[drusso]

The magic beans have the same thing going for them that fusions/discectomies do: face validity
We may get there eventually, but the basic science protocols and the clinical protocols are not congruent. There may be a signal in the noise and thus I do think it's a safer/better placebo than steroid injections, but I haven't tried to get started doing it yet due to the patient costs.

Placebo PRP injections will beat real unnecessary surgery in any economic/clinical analysis.

 

[lobelsteve]

Not your grandfather's PRP...

Curr Pharm Biotechnol. 2019 Jun 19. doi: 10.2174/1389201020666190619111118. [Epub ahead of print]
Anti-Inflammatory Effects of Novel Standardized Platelet Rich Plasma Releasates on Knee Osteoarthritic Chondrocytes and Cartilage in Vitro.
Gato-Calvo L1, Hermida-Gomez T1, Ruiz Romero C1, Burguera EF1, Blanco FJ1.
Author information

Abstract
BACKGROUND:
Platelet Rich Plasma (PRP) has recently emerged as a potential treatment for osteoarthritis (OA), but composition heterogeneity hampers comparison among studies, with the result that definite conclusions on its efficacy have not been reached.
OBJECTIVES:
1) To develop a novel methodology to prepare a series of standardized PRP releasates (PRP-Rs) with known absolute plateletconcentrations, and 2) To evaluate the influence of this standardization parameter on the anti-inflammatory properties of these PRP-Rs in an in vitro and an ex vivo model of OA.
METHODS:
A series of PRPs was prepared using the absolute platelet concentration as the standardization parameter. Doses of platelets ranged from 0% (platelet poor plasma, PPP) to 1.5·105 platelets/μl. PRPs were then activated with CaCl2 to obtain releasates (PRP-R). Chondrocytes were stimulated with 10% of each PRP-R in serum-free culture medium for 72 h to assess proliferation and viability. Cells were co-stimulated with interleukin (IL)-1β (5 ng/ml) and 10% of each PRP-R for 48 h to determine the effects on gene expression, secretion and intra-cellular content of common markers associated with inflammation, catabolism and oxidative stress in OA. OA cartilage explants were co-stimulated with IL-1β (5 ng/ml) and 10% of either PRP-R with 0.75·105 platelets/μl or PRP-R with 1.5·105 platelets/μl for 21 days to assess matrix inflammatory degradation.
RESULTS:
Chondrocyte viability was not affected, and proliferation was dose-dependently increased. The gene expression of all pro-inflammatory mediators was significantly and dose-independently reduced, except for that of IL-1β and IL-8. Immunoblotting corroborated this effect for inducible NO synthase (NOS2). Secreted matrix metalloproteinase-13 (MMP-13) was reduced to almost basal levels by the PRP-R from PPP. Increasing platelet dosage led to progressive loss to this anti-catabolic ability. Safranin O and toluidine blue stains supported the beneficial effect of low platelet dosage on cartilage matrix preservation.
CONCLUSION:
We have developed a methodology to prepare PRP releasates using the absolute platelet concentration as the standardization parameter. Using this approach, the composition of the resulting PRP derived product is independent of the donor initial basal platelet count, thereby allowing the evaluation of its effects objectively and reproducibly. In our OA models, PRP-Rs showed anti-inflammatory, anti-oxidant and anti-catabolic properties. Platelet enrichment could favor chondrocyte proliferation but is not necessary for the above effects and could even be counter-productive.
Copyright© Bentham Science Publishers; For any queries, please email at [email protected].
KEYWORDS:
Platelet rich plasma; chondrocytes.; inflammation; knee; osteoarthritis; standardization

View attachment 269407

I’m uncertain what figure 2 is dealing with this study. The study seems to be about how they make their magic gout and the slide is of Womack scores not mentioned in the methodology.

 

[drusso]

I’m uncertain what figure 2 is dealing with this study. The study seems to be about how they make their magic gout and the slide is of Womack scores not mentioned in the methodology.

Different study. Method below. My point is that, like all things, technology has progressed since Rick Derby's misadventures in the 1990's... and, FWIW, IDET got screwed by bad luck. That treatment really worked...in properly selected patients...

 

[lobelsteve]

IDET worked for the Saal brothers. And I mean they got millions before it blew up.
It was fun to do, but did not do more than melt some tissue. Seal a meal for discs.

 

[drusso]

IDET worked for the Saal brothers. And I mean they got millions before it blew up.
It was fun to do, but did not do more than melt some tissue. Seal a meal for discs.

Are you still doing your L3 gray rami cummunicans block? I think it also denervated posterior annular branches of the sinuvertebral nerve. I'm pretty certain I did last commercially paid case in my state "back in the day."

 

[Dr. Ice]

That seems to be the going rate. The presentations of this "breakthrough" treatment at meetings is just embarrassing. We lived through IDET, decompressor, nucleoplasty, and prolotherapy- now this.

Even though I think it is ineffective (it was in the past), I have thought about offering it for $500 a pop to derail the financial locomotive of the local charlatans. If you are saving someone $4500, at least you are doing a financial public service, in the absence of any medical benefit.

Perhaps this may be the best solution. If you make PRP so it is just barely profitable, a lot of the enthusiasm will wane and they will move on to something else that makes more money. In a cash only procedure, this is certainly possible and is probably the answer. These guys are driven by cash and when there is no cash in it anymore, they will drop it like a hot potato.

I didn’t realize we were talking about intradiscal prp..I could see where the 5k would come for if the procedure is done in an asc and if the patient is also paying for the discogram component as well as CS if they are getting it...but still seems like a lot. If I do tendon sheath prp my fee is just slightly north of 450 but not much...

 

[lonelobo]

From 2017 Medical News today

Fast facts about platelet-rich plasma therapy:

• Doctors use PRP to encourage healing and to reduce inflammation.
• A doctor doing a PRP injection will first draw blood from the person being treated.
• The costs for PRP injections can range from $500 to $2,000, according to Scientific American.

These were joint injections

 

[TheIllusionist]

When Stem Cells start getting results like this get back to me...
View attachment 264888

Honestly, I like em natty. Small shapely breasts have their own unique appeal.

 

[lobelsteve]

Are you still doing your L3 gray rami cummunicans block? I think it also denervated posterior annular branches of the sinuvertebral nerve. I'm pretty certain I did last commercially paid case in my state "back in the day."

View attachment 269424

L2, only occasionally. RFs never seem to last more than 6 months and would put success rate after single block at 50%. Separates from placebo, but not enough to account for my recollection bias.

 

[Doctodd]

Mayo, Cleveland, Harvard etc are all doing PRP and regenerative medicine. And advertising for it as well.

 

[VA Hopeful Dr]

Mayo, Cleveland, Harvard etc are all doing PRP and regenerative medicine. And avdertising for it as well.

In fairness, Mayo is also doing acupuncture, Harvard has a chiropractic department, and the Cleveland Clinic offers Reiki.

 

[Orin]

Mayo, Cleveland, Harvard etc are all doing PRP and regenerative medicine. And avdertising for it as well.

The ivory tower can't sustain itself only with ego and hot air

 

[drusso]

In fairness, Mayo is also doing acupuncture, Harvard has a chiropractic department, and the Cleveland Clinic offers Reiki.

Columbia's PM&R department even added Regen Med to its name...and Visco does PRP injections.

Rehabilitation and Regenerative Medicine

Since our founding in 1952, the Department of Rehabilitation and Regenerative Medicine at CUIMC has driven numerous innovations in rehabilitation medicine.

www.cumc.columbia.edu

Rehabilitation and Regenerative Medicine

Since our founding in 1952, the Department of Rehabilitation and Regenerative Medicine at CUIMC has driven numerous innovations in rehabilitation medicine.

www.cumc.columbia.edu

 

[Ducttape]

Does an academic pain department performing a procedure provide implicit approval for said procedures? Or are these departments also trying to be financially profitable?

FWIW, your GIGO study - as you have pointed out from Cochrane articles before - states

Low- to moderate-quality evidence supports a reduction in pain for lateral epicondylitis and knee osteoarthritis. PRP characteristics did not influence results.

CONCLUSION:
PRP leads to a reduction in pain; however, evidence for clinically significant efficacy is limited.[\quote]

 

[drusso]

Does an academic pain department performing a procedure provide implicit approval for said procedures? Or are these departments also trying to be financially profitable?

FWIW, your GIGO study - as you have pointed out from Cochrane articles before - states

I've been doing a few post-op rotator cuffs...

J Orthop Surg Res. 2019 Jun 20;14(1):183. doi: 10.1186/s13018-019-1207-9.
Is platelet-rich plasma an ideal biomaterial for arthroscopic rotator cuff repair? A systematic review and meta-analysis of randomized controlled trials.
Han C1, Na Y1, Zhu Y2, Kong L1, Eerdun T1, Yang X3, Ren Y4.
Author information

Abstract
BACKGROUND:
Recently, many authors have reported the effects of platelet-rich plasma (PRP) on rotator cuff repair. Whether PRP treatment during arthroscopic rotator cuff repair improves tendon healing rates or restores full function remains unknown. The purpose of this meta-analysis was to evaluate the clinical improvement and radiological outcomes of PRP treatment in patients undergoing arthroscopic rotator cuff repair.
METHODS:
PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched. The study included only level 1 or 2 randomized controlled trials (RCTs) that compared the injection of platelet-rich plasma or platelet-rich fibrin matrix. The methodological quality of the trials was assessed using the Cochrane Handbook for Systematic Reviews of Interventions, 5.3. Continuous variables were analysed using the weighted mean difference, and categorical variables were assessed using relative risks. P < 0.05 was considered statistically significant.
RESULTS:
The meta-analysis revealed a lower retear rate following PRP treatment than that following the control method (mean difference, 1.10; 95% CI, 1.03 to 1.18; P = 0.004). Constant shoulder scores improved with PRP (mean difference, 2.31; 95% CI, 1.02 to 3.61; P = 0.0005). PRP treatment also resulted in higher UCLA scores (mean difference, 0.98; 95% CI, 0.27 to 1.69; P = 0.007), and simple shoulder test scores were improved (mean difference, 0.43; 95% CI, 0.11 to 0.75; P = 0.008). Finally, lower visual analogue scale scores were observed with PRP augmentation (mean difference, - 0.35; 95% CI, - 0.57 to - 0.13; P = 0.002).
CONCLUSIONS:
The current systematic review and meta-analysis reveals that PRP treatment with arthroscopic repair of rotator cuff tears decreases the retear rate and improves the clinical outcomes.
SYSTEMATIC REVIEW REGISTRATION:
PROSPERO CRD42016048416.
KEYWORDS:
Arthroscopic; Meta-analysis; Platelet-rich plasma; Rotator cuff

 

[VA Hopeful Dr]

Columbia's PM&R department even added Regen Med to its name...and Visco does PRP injections.

Rehabilitation and Regenerative Medicine

Since our founding in 1952, the Department of Rehabilitation and Regenerative Medicine at CUIMC has driven numerous innovations in rehabilitation medicine.

www.cumc.columbia.edu

Rehabilitation and Regenerative Medicine

Since our founding in 1952, the Department of Rehabilitation and Regenerative Medicine at CUIMC has driven numerous innovations in rehabilitation medicine.

www.cumc.columbia.edu

I don't know enough to comment on PRP (and no clue who Visco is), just pointing out the appeal to authority fallacy and a few very obvious and public examples of it.

 

[blockstar]

Columbia's PM&R department even added Regen Med to its name...and Visco does PRP injections.

Rehabilitation and Regenerative Medicine

Since our founding in 1952, the Department of Rehabilitation and Regenerative Medicine at CUIMC has driven numerous innovations in rehabilitation medicine.

www.cumc.columbia.edu

Rehabilitation and Regenerative Medicine

Since our founding in 1952, the Department of Rehabilitation and Regenerative Medicine at CUIMC has driven numerous innovations in rehabilitation medicine.

www.cumc.columbia.edu

I wonder if this is same PMR doc of same name who has a ROM scam in South Florida billing 2k a pop to have a tech put numbers in a computer algorithm on PI patients. Cant imagine it could be.

 

[deleted993114]

Different study. Method below. My point is that, like all things, technology has progressed since Rick Derby's misadventures in the 1990's... and, FWIW, IDET got screwed by bad luck. That treatment really worked...in properly selected patients...

View attachment 269421

Technology?

PRP is still platelet rich plasma obtained from humans, right? And it is still injected into facet joints, knees, medial and lateral epicondyles, and lumbar discs, right?

I heard the same arguments when IDET didn't work-
a. you are doing it incorrectly
b. your patient selection is wrong
c. 20 % improvement is something

Let's face it- unless humans have changed significantly in the last 25 years, PRP then is the same PRP now. Additionally, the PRP was placed in the same areas used today. Result- below 50% improvement in "selected" patients, thus everyone stopped doing it.

Granted, Derby injected some weird things in some odd places with marginal evidence to support treatments......................................... but he also did some very legitimate treatments and was no fool. PRP was considered in the same vein as the other "snake oils" being advocated, but was at least tried................. and failed. It was about the same time we learned that using a bunch of botox in the cervical paraspinous muscles made people worse, not better, but actually helped some people with headaches. This "mistake" convinced everyone (that boondoggle was advocated by Ferrante, who is also a smart guy) that strengthening the extensor muscles, rather than weakening them, was the right course of action, thus that focus in PT today for cervical spondylosis.

Now what exactly what compounds do you think is in PRP that results in long term pain relief or "regeneration" that those areas would not receive by their normal blood supply? Which ones? What about the effect of just plain old plasma? What is it about platelets in particular that is so appealing? Why not just create trauma in that area, induce bleeding, and then let their own blood do the trick?

Why is bruising then not therapeutic? There is extravasation of blood (and plenty of plasma with platelets) into such an area and one would then presume this would be therapeutic. Why not just traumatize the area and let the patient's own blood supply the "platelet rich plasma"? I've done some cervical medial branch blocks which has resulted in bruising on the patient's neck- why were they not better as a result of that?

When you operate on someone, you stir up plenty of bleeding, for which you obtain hemostasis before closing. Why are not those patients all better in those areas? They were, after all, treated with "plasma" (their own blood), but it doesn't seem to help them. Why don't people who sustain intra-abdominal bleeding (say from a bleeding artery) not feel just dandy from all that plasma they received?

Why, when do epidural blood patches for dural punctures, does the patient not report improvement of their axial, spondylitic pain? There is a bunch of platelets in that 15-20ccs (I mean, a whole bunch)- why doesn't that fix their back pain?

If a little of something is "good", how do we know that a lot more is better? How many platelets is enough?

Why not, if you believe that PRP is effective, try to isolate which (of the hundreds of compounds) is performing the "magic" of PRP? Is there any "magic" at all?

 

[Doctodd]

welcome to the board.....maybe cuz the rbc's cause scarring and adhesions? Also, I havent researched, it but isnt PRP proven effective in horses?

 

[deleted993114]

welcome to the board.....maybe cuz the rbc's cause scarring and adhesions? Also, I havent researched, it but isnt PRP proven effective in horses?

So is glucosamine chondroitin-= however, it is ineffective in humans.

RBCs are not the cells and means by which scarring occurs.

Just think about the above considerations for a few moments. If PRP is so great, we should just be inducing bleeding into all the structures we want to treat- after all, we are introducing lots of plasma with platelets into the area.

For total joint procedures, we should be able to skip the hardware and just muck about in the joint space, close, then they would be all better. Think of the savings in hardware and time in the procedure. The same for a herniated disc- don't bother removing the disc or heaven forbid opening the neural foramina, just take a few bites here and there with rongeurs, let it bleed, then you are done!

However, history and experience shows us that this is not true. This has become the problem with pain management- there has been wholesale adoption of techniques and methods with very little, if any, basic science to back it up. This has led in the past to a number of failed endeavors, all of which have had their supporters who swear by its efficacy, only to find later with actual studies that the treatment is ineffective.

Look before you leap. Again, I think that perhaps the best way to deal with this issue (as you simply cannot speak rationally to the people who support this treatment) is to offer it at such a cheap price that they lose their zeal and interest in the treatment. I would offer that if the charges for PRP were essentially the same as a steroid injection, we would see this treatment fade fairly quickly. The enthusiasm for these procedures seems to be directly related to its relative reimbursement for the provider.

 

[drusso]

Technology?

PRP is still platelet rich plasma obtained from humans, right? And it is still injected into facet joints, knees, medial and lateral epicondyles, and lumbar discs, right?

I heard the same arguments when IDET didn't work-
a. you are doing it incorrectly
b. your patient selection is wrong
c. 20 % improvement is something

Let's face it- unless humans have changed significantly in the last 25 years, PRP then is the same PRP now. Additionally, the PRP was placed in the same areas used today. Result- below 50% improvement in "selected" patients, thus everyone stopped doing it.

Granted, Derby injected some weird things in some odd places with marginal evidence to support treatments......................................... but he also did some very legitimate treatments and was no fool. PRP was considered in the same vein as the other "snake oils" being advocated, but was at least tried................. and failed. It was about the same time we learned that using a bunch of botox in the cervical paraspinous muscles made people worse, not better, but actually helped some people with headaches. This "mistake" convinced everyone (that boondoggle was advocated by Ferrante, who is also a smart guy) that strengthening the extensor muscles, rather than weakening them, was the right course of action, thus that focus in PT today for cervical spondylosis.

Now what exactly what compounds do you think is in PRP that results in long term pain relief or "regeneration" that those areas would not receive by their normal blood supply? Which ones? What about the effect of just plain old plasma? What is it about platelets in particular that is so appealing? Why not just create trauma in that area, induce bleeding, and then let their own blood do the trick?

Why is bruising then not therapeutic? There is extravasation of blood (and plenty of plasma with platelets) into such an area and one would then presume this would be therapeutic. Why not just traumatize the area and let the patient's own blood supply the "platelet rich plasma"? I've done some cervical medial branch blocks which has resulted in bruising on the patient's neck- why were they not better as a result of that?

When you operate on someone, you stir up plenty of bleeding, for which you obtain hemostasis before closing. Why are not those patients all better in those areas? They were, after all, treated with "plasma" (their own blood), but it doesn't seem to help them. Why don't people who sustain intra-abdominal bleeding (say from a bleeding artery) not feel just dandy from all that plasma they received?

Why, when do epidural blood patches for dural punctures, does the patient not report improvement of their axial, spondylitic pain? There is a bunch of platelets in that 15-20ccs (I mean, a whole bunch)- why doesn't that fix their back pain?

If a little of something is "good", how do we know that a lot more is better? How many platelets is enough?

Why not, if you believe that PRP is effective, try to isolate which (of the hundreds of compounds) is performing the "magic" of PRP? Is there any "magic" at all?

Of course human biology is the same, but a few things have changed since the 1990's:

a) concentrations/concentrating ability--newer protocols emphasize higher concentrations of platelets over baseline.
b) recognition that not all PRP is the same--leukocyte-poor versus leukocyte-rich
c) application of MSK US to target specific structures.
d) much more evolved and nuanced understanding of wound care biology, tissue healing, and platelet/growth factor biology.
e) I've long argued that epidural blood patches ARE a regenerative therapy intervention and not recognized as such.
f) groups are finally getting to the issue of "dose" by doing baseline hematograms and comparing them to hematograms after concentrating.

I lament the hype in a lot of regenerative medicine. There is nothing new under the sun. PRP has been used for decades in burn medicine, dermatology, wound care, and equine-veterinary. What is novel is applying it to MSK/orthopedic conditions.

The field must deal with the equity and health disparity issues around the deployment of this technology: It's either a broad disruptor to standard MSK care or a cash-only niche service line for the rich who can afford it. The field barely has the capacity to advance a research agenda (no pharma deep pockets) let alone the capacity to do the heavy lifting on the health policy side (my interest).

IOF is the SIS/ISIS of Regen Med...great group to check out and learn from:

Home - Interventional Orthopedics Foundation

interventionalorthopedics.org

 

[Doctodd]

So is glucosamine chondroitin-= however, it is ineffective in humans.

RBCs are not the cells and means by which scarring occurs.

Just think about the above considerations for a few moments. If PRP is so great, we should just be inducing bleeding into all the structures we want to treat- after all, we are introducing lots of plasma with platelets into the area.

For total joint procedures, we should be able to skip the hardware and just muck about in the joint space, close, then they would be all better. Think of the savings in hardware and time in the procedure. The same for a herniated disc- don't bother removing the disc or heaven forbid opening the neural foramina, just take a few bites here and there with rongeurs, let it bleed, then you are done!

However, history and experience shows us that this is not true. This has become the problem with pain management- there has been wholesale adoption of techniques and methods with very little, if any, basic science to back it up. This has led in the past to a number of failed endeavors, all of which have had their supporters who swear by its efficacy, only to find later with actual studies that the treatment is ineffective.

Look before you leap. Again, I think that perhaps the best way to deal with this issue (as you simply cannot speak rationally to the people who support this treatment) is to offer it at such a cheap price that they lose their zeal and interest in the treatment. I would offer that if the charges for PRP were essentially the same as a steroid injection, we would see this treatment fade fairly quickly. The enthusiasm for these procedures seems to be directly related to its relative reimbursement for the provider.

Good points....as was said about concentration and equine treatment.

I frequently perform PRP for free and would favor it over steroid injections even if all other things were equal. The adverse effects of corticosteroids are well known. I won’t ask you what you think of prolotherapy.

 

[lobelsteve]

California Stem Cells -- Will California Voters Be Stem-Cell Suckered Again? | National Review

 

[drusso]

California Stem Cells -- Will California Voters Be Stem-Cell Suckered Again? | National Review

"Big Cell" Boondoggle...just like Big Pharma, Big Hospital, Big Tobacco...liberals love Big Cell.

"California is in worse shape now than it was in 2004. Thousands of people are living in tents on the streets of San Francisco and Los Angeles. There is an epidemic of human feces and used hypodermic needles fouling the streets of San Francisco, so bad there is even a map to warn people where the excrement can be found. Victor Davis Hanson has sadly documented the plunge, calling California the USA’s “first Third World state.”

 

[epidural man]

I wonder if we will ever have good answers in the chronic pain realm.

Think about this. Ten patients have shoulder pain, all with rotator cuff tears. One patient hurts because of a nociceptive and inflamed bursa, and the other have pain because of moms with fibro, they tend to catastrophize everything, business is failing, and some just found out their son wants to transition. Now add a treatment that is legit and works for inflamed bursa extremely well. Would we every be able to figure that out? I doubt it.