Cutting-Edge Pain Relief Without Surgery with Dr. John Pitts (Ep 113)

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Dr. Linda Bluestein: [00:00:00] Welcome back, Every Bendy Body, to the Bendy Bodies podcast with your host and founder, Dr. Linda Bluestein, the hypermobility MD. Today we are having a great conversation with Dr. John Pitts. I know that you are going to love this conversation. I personally have had prolotherapy and PRP, and I have wondered, with a lot of my nagging aches and pains that I have, should I consider getting more injections?

Or should I just wait it out until it's so bad that I need surgery? What, what should we do? This is not my area of expertise. I am an anesthesiologist. I have done pain management, of course, but I do not do these procedures. So I didn't really know a whole lot about them. So I really wanted to talk to Dr.

Pitts. Dr. Pitts [00:01:00] completed a residency in physical medicine and rehabilitation at Emory University in Atlanta, Georgia. He came to Colorado as a fellow to learn more about regenerative medicine and interventional orthopedics, as well as further develop his skills in fluoroscopic guided procedures, diagnostic ultrasound, and interventional ultrasound.

Dr. Pitts has been involved in research and development regarding regenerative procedures and post operative procedures. Procedural Rehabilitation. He is the current fellowship director at the Centeno Schultz Clinic and has interests in nutrition, supplements, and complementary and alternative medicine.

He has written a nutrition guide, Nutrition 2. 0, 21st Century Guide to Nutrition and Health. He is also the main editor of the Atlas of Interventional Orthopedics, the first full textbook on the new field of interventional orthopedics to educate physicians on why and how to perform these injection procedures.

I am so excited to chat with Dr. Pitts today. This is a super important topic for [00:02:00] people who have joint hypermobility and connective tissue disorders like the Ehlers Danlos syndromes. As always, this information is for educational purposes only and is not a substitute for personalized medical advice. Be sure to stick around until the very end so you don't miss any of our special hypermobility hacks and let's get started.

Well I am so excited to chat with Dr. Pitts today. I know so many people have been just really eager to hear this conversation about regenerative medicine. And for the purposes of the conversation today, we're really going to focus on the hypermobile EDS and HSD population. And in fact, we're not really going to make a distinction between the two because that would be a whole other conversation, right?

So we're going to kind of lump that population together. Um, but I want to start out by asking you. Can you define regenerative medicine for us, and why is this such an important topic for people that have these conditions? 

Dr. Pitts: Absolutely. So, uh, when I think of regenerative medicine, I think of doctors doing something to [00:03:00] patients that help them to heal themselves.

So, in traditional musculoskeletal medicine, we think of doctors doing pain management. This is doctors giving patients drugs and medicines, injecting medicines, or performing procedures that help the patient out of pain, but they don't actually address the underlying issues that caused their problem or dysfunction in the first place.

With regenerative medicine, we're trying to restore function, improve tissue healing, so that patient has better function and less pain because they're getting better, not just because we gave them drugs to help with their pain. 

Dr. Linda Bluestein: I love that. So you're really dealing with the root cause then, rather than just covering it up.

Dr. Pitts: Absolutely. We're trying to address all the root causes, biomechanical issues, structural issues that contribute to dysfunction that leads to pain. Uh, so if we address those, we're going to get better and longer lasting relief than if we just do pain management. And we're going to have far less potential side effects because we traditionally don't use many drugs and medications for this.

Dr. Linda Bluestein: Okay. Fantastic. And in terms of evaluating patients, how do you [00:04:00] evaluate the typical, um, you know, again, this conversation really is focused on EDS and HSD. How do you evaluate those patients? And is that evaluation different from patients that don't have those conditions? 

Dr. Pitts: Yes, absolutely. So every patient that comes in our clinic is going to get a full, basically hour long type evaluation where it's face to face, hands on exam.

So we're going to take a detailed history to find out what that patient's, uh, problems are, the symptoms that they're having. Uh, we're going to do a detailed physical exam so we can figure out which structures hurt. Uh, we're going to do ultrasound examination on many parts of this. Uh, we're going to look at any imaging films or if we don't have any imaging, we can request imaging, uh, from what we see on the film.

history and physical exam, put all that together like a detective, uh, to fit pieces of the puzzle together to know what's going on with that patient. For EDS patients, we're going to also add in a Biden score, you know, just to see if they have, uh, how hyper mobile they may be. Uh, and we're going to be aware that, you know, in patients with EDS, All their joints are going to [00:05:00] be hypermobile.

So if we're looking for excess mobility from their natural, we're going to really be comparing side to side differences. And it's also going to make a difference as far as what we recommend for treatment because we treat people with hypermobility a little bit different than the normal population that doesn't have EDS.

Dr. Linda Bluestein: Okay, and what percentage of your patients do have EDS or HSD, do you think? 

Dr. Pitts: I would estimate probably about 10%. You know, obviously, EDS is, uh, low in the population, but we tend to see a higher number of EDS patients because all EDS patients have muscle skeletal problems and pain and joint problems, etc.

So we're going to see a higher number of those patients in our practice. 

Dr. Linda Bluestein: And when we talk about regenerative medicine, or I know you also refer to it as, you know, Uh, non interventional orthopedics or interventional orthopedics. Okay. So you often refer to it as interventional orthopedics or when we're talking about regenerative medicine.

Can you explain to me what the different procedure types are for that? [00:06:00] 

Dr. Pitts: Yeah, absolutely. So we kind of kinded to, uh, Cardiovascular surgery and interventional cardiology. So if you had major heart problems in the past, you had to have an open heart surgery to address those problems. But now with new technology, it's more interventional cardiac procedures.

They can just go through a vein or artery in your leg or wrist and perform those same procedures. So similarly in orthopedics, you know, orthopedics is doing surgery. Cutting out body parts, fusing body parts, doing major surgery, we're trying to address those issues with just injections, basically. And what we inject is, uh, mostly substances, substances will be called orthobiologics.

These are basically substances, again, that help your body heal itself. Things like prototherapy, PRP, bone marrow concentrate contained in stem cells, adipose graft, et cetera. And the goal of all these things is, again, try to get the body to do what it naturally does, but just kind of enhance that healing function for areas that don't have enough stem cells in the area, don't have enough healing capacity for the [00:07:00] injury that's there.

Dr. Linda Bluestein: Okay. So those are the different types of procedures. What are the advantages and disadvantages of, of each of those? And I know that could probably be like a multi hour conversation right there, right, like going into each one, but just, you know, if you can just kind of give us that 10, 000 foot view in terms of maybe a little more detail about how prolotherapy is different from PRP and of course, I think an important conversation is, you know, stem cell injections and, and that.

You know, bone marrow concentrate, how those are different, if they are different, um, and why these things are important for people to understand. I think that's really important for them to know what the options are. So they can really be thinking through these things carefully. 

Dr. Pitts: Right, absolutely. So that is certainly a broad question.

We're going to keep it as general, but try to get as much detail in there as possible. So I think it's helpful first to just kind of compare it to the traditional pain treatments out there. So if you think somebody comes in with pain, they might do a steroid injection into a joint. [00:08:00] Steroids, you know, help reduce inflammation and help pain, but they actually can break down tissues.

Any of these substances, as far as PRP, uh, prolotherapy, bone marrow concentrate, stem cells, there's no destruction. It's basically taking parts of your own body and transplanting it or using a substance that helps stimulate healing in your own body, so it's safe. So that's one of the advantages of these procedures.

They don't have inherent risks themselves. There's only the risk of the injections, which again, are much less risk than surgery. If we think about That's kind of the easiest, most basic form of injection based therapy that we can do. Uh, this is basically injecting a sugar solution that's hypertonic. It creates a little, uh, osmotic stress on the cells.

And they release growth factors that help heal the areas. They notice that as a damage. So it's basically like, uh, Creating an ankle sprain, for instance, uh, when you have a first ankle sprain, you get some swelling, uh, a little pain, recruiting blood flow to the area. So it just kind of stimulates a healing response in your body.

That's very mild, but can work really, [00:09:00] really well for minor injuries. So if you've got minor ligament injuries. That can work really well, but what we find in the EDS population, many of those EDS patients actually respond a little better to prolotherapy for ligaments as opposed to PRP for ligaments, so just for those particular substances, so we've noticed that difference with, uh, EDS patients.

Now we go up the ladder to PRP. which is much stronger than prolotherapy. So if you're akin to, if prolotherapy will fix this one problem with three to four procedures, PRP may be able to handle that same problem in one to two procedures, or even help problems that prolotherapy can't help at all. And PRP again stands for platelet rich plasma.

This is basically taking out your blood, concentrating the platelets, which are little cell fragments that have growth factors in them. They're involved in wound healing. We can concentrate those platelets and directly place them into damaged tissues. So PRP at this point has, uh, much better evidence than most of orthopedic surgery as a whole field.

We've got three dozen studies showing that PRP [00:10:00] helps for knee arthritis in randomized controlled trials. We've got randomized control trials showing it helps on pretty much most areas in the body right now. Uh, we publish these data every year and so that's a really great tool to help with mild to moderate musculoskeletal type problems.

If we go up a little further from there, then we get into bone marrow concentrate that contains stem cells. And I specifically word it that way just to be accurate. So just saying stem cells, you know, is, is sexy and fancy, but that's not the correct terminology. So basically with a bone marrow concentrate, we're taking bone marrow out the iliac crest.

Typically that's kind of the back of the hip bone. We're concentrating the cells out of there. That's where all your blood cells are, uh, are made. So, we have a lot of progenitor cells, or cells that turn into other cells. And a small number of those cells in the bone marrow are what we call mesenchymal stem cells.

And these cells can turn into a lot of different tissue types and involved in the healing response. These cells are found all throughout your [00:11:00] body. And so if you didn't have stem cells, you would pass away very quickly because these cells help repair damaged tissue in all your, um, all your joints and tissues.

And so basically we're just concentrating those cells, the stem cells, the other cells in the bone marrow that can also be helpful for healing. There's also PRP in the bone marrow that we can get. And all of that helps a person heal, and that's even stronger than PRP. So for more moderate to severe problems, we may choose a bone marrow concentrate procedure.

Um, another procedure that's done in the U S that has stem cells as well, it's called an adipose graft basically, or micronized adipose tissue. So, Fat tissue has stem cells in it, uh, has those mesenchymal stem cells in it as well. Um, so you can take fat tissue, um, you can break it down a little bit and you can inject that tissue into damaged structures as well to get some stem cells from the fat to repair tissues.

That doesn't have as much evidence as bone marrow cells, but it does have great evidence that it can help with things like knee arthritis and rotator cuff [00:12:00] tears. So that's a reasonable option as well. The other type of so called stem cell treatments, um, we can get into more detail if you want, but you know, those are things that either are not allowed in the U.

1. or some things are really scammy that sound like stem cells that you have to be careful to avoid. 

Dr. Linda Bluestein: I think that's a really important thing and we're definitely going to get into later what people should be looking for when they are thinking about whether or not to have one of these procedures because I'm sure there's some critically important questions that people should be asking when they are making that kind of a decision.

So let's talk about that. We'll talk about that like in the second half of the conversation. Um, so, but thank you for laying that out so well, that was really, really helpful. So in terms of each of those procedures, are there contraindications to To each of those? 

Dr. Pitts: Absolutely. There's no procedure or medical procedure on earth that, uh, is right for everybody.

Okay. Again, these procedures are very safe, so it's not very many things as, uh, preclude you from treatment. But one is, you know, do you have the right diagnosis? You know, [00:13:00] so, you know, what is the diagnosis? So we want to have a clear muscle skull or problem that we think can be helped by these treatments.

Uh, patients, uh, we typically get in the patient to heal themselves. So patients need to be healthy themselves. So if they have a lot of medical conditions or they can't tolerate procedures. Or if they have some severe nerve issues that are going on, you know, things like this, we might stop and say, Hey, we don't think you're necessarily candid for this.

Or if their problem is something that you need surgery for. It's just too severe a problem for any of these treatments to be able to help. And so every patient goes through a candidacy with our clinic, where we say, Hey, you're a great patient. Very good candidate for this treatment, or you know, you're a so so candidate, or you know, this may help but not sure, or you know what, this is not an appropriate treatment for you.

Um, you should go this other route. So definitely not everybody is a candidate for these treatments, um, but if you have a, a musculoskeletal problem that doesn't need surgery, and I emphasize need, not just surgery being an option, then likely you're a candidate if otherwise healthy and you don't have any medical conditions that would [00:14:00] preclude you from being able to undergo procedures.

Dr. Linda Bluestein: Okay, that makes sense. And then in terms of timing and when people, you know, are making that decision to go ahead or not go ahead, you know, sometimes people wait until things are really, really severe and other people are, you know, kind of more inclined to treat something when it's more of a nuisance or, you know, how do you decide when it's the right time?

Do you, do you ever tell people, Why don't you, you know, come back, but it's a little early for this or, you know, sometimes there's probably people where you're like, Oh, I wish you'd come sooner. How do people know from a timing standpoint when is the right time? 

Dr. Pitts: Absolutely. So I think the sooner the better to get evaluated.

Okay. If you have a lingering problem that hasn't gone away after maybe a month or two of trying conservative therapies, that's the time to go see a specialist doctor like myself. PM& R trained, non surgical interventionist or non surgical musculoskeletal doctor like PM& R, interventional pain, sports medicine, etc.

That's the time to see the doctor because at least then you can get a diagnosis. You can maybe get some [00:15:00] directed physical therapy, etc. So not everybody that has a problem is going to need treatment right away. So typically if you have an acute injury, you want to give your body about 4 8 weeks to see if it heals itself because most things are going to present themselves, hey, after 4 6 weeks, you're going to know.

if you're getting better or not. At that point, if you're not getting better, that's a good time to see us to seek treatment. Even if you saw us right after an injury, we would probably say, Hey, this is what I think's going on. Doesn't need surgery or does need surgery. Um, this is type of therapy I think you should try.

Um, and then do these other modalities. If that doesn't help, then you might want to consider one of these treatments that we're, that we offer. 

Dr. Linda Bluestein: Okay. And I'm thinking of a family member who's dealing with an injury right now. And I'm thinking of, so I've had PRP actually, um, into my, uh, TMJ joint. I've, I've had PRP a couple of times.

I've had prolotherapy a number of times, uh, not here, but I've, but that was before I moved to Colorado. Is there. Can you do these in [00:16:00] really, really small joints in the body? Like I'm thinking of a family member who actually has a, uh, a rock climbing, uh, flexor tendon injury. 

Dr. Pitts: Yeah. I mean, just yesterday, uh, treated just this little small, uh, DIP joint in the finger, also that same kind of joint in the toe.

Uh, we do treat those little tendons there. So, um, our clinic, we can treat the entire muscle skeletal system basically. So in any given day. You might see us injecting head to toe, TMJs, neck, low back, toe joints, knee joints, ankles, elbows, all of that. So yes, we can treat those, uh, small joints. And then you mentioned also before, um, you know, some patients that wait, wait too long, you know?

Yeah. As there, there's a point where sometimes you can wait too long. Typically that doesn't mean that this can't help. It usually just means it's not going to help as much as it could have when you got this earlier. Sometimes you do wait too long. Like if you got, you know, severe deformities or severe arthritis in the hip, particularly, um, that has gone way past where it should, then we can't help and [00:17:00] the only option at that point is surgery that's likely to help.

Dr. Linda Bluestein: And in terms of other, I, I asked people if they had questions for this conversation, which was great, because I got lots of great questions. And, you know, we, we, we know that people try various different things as they are pursuing relief of their musculoskeletal pain, right? So, uh, steroid injections, NSAIDs, non steroidal anti inflammatory drugs.

People asked, well, what are the pros and cons, basically, of getting a steroid injection or being on NSAIDs long term? And I know you wrote your excellent book about nutrition and supplements, and so can you just kind of give us a little, again, 10, 000 foot view about, you know, kind of alternatives that people might be trying and which ones are You know, good idea.

Which ones have maybe more side effects than people are aware of? 

Dr. Pitts: Yes, absolutely. So, you know, me personally, I haven't taken an NSAID since I was probably in my 20s. So, I'm, I'm, uh, we're prone to be against medicines for the most part because there's no such thing as a medicine that, uh, doesn't have [00:18:00] potential side effects.

If you take NSAIDs here and there, are they going to kill you? Probably not. But NSAIDs can, uh, increase your risk for GI bleeding. Kidney problems, liver problems, actually inhibit platelets, so it doesn't work well with PRP. So that can inhibit your healing mechanisms as well, um, actually can increase chronic pain.

You can actually get addicted to NSAIDs as well. So they come with a host of negative side effects. Steroids have all those same side effects and even more. They can cause severe bone loss, they can alter your sugars, they can alter your hormone levels. So, these medicines do not come without some serious risk.

And we see some of the complications and risks from these medicines. So, when all possible, we want to try to avoid that. And one of my biggest pet peeves is that patients will get packs of oral steroids just for musculoskeletal pain. And in my personal opinion, I think that's inappropriate. I've never in my life prescribed that for anybody with musculoskeletal pain.

Now, if you have a rheumatological condition, autoimmune condition, problems breathing, allergic reaction, totally appropriate, but not just for [00:19:00] pain. And so alternatives to those things, one, a great one would be turmeric or turmeric, curcumin. This has studies that show it can be as effective as NSAIDs for pain relief, but it kind of more.

Stimulates your natural anti inflammatory response instead of completely shutting it down. So it's safer. Turmeric does still have some risk at higher doses, far less than NSAIDs. It can cause gallbladder stones or kidney stones or if you have those conditions, may make that worse. But for the most part, it's pretty safe.

Some people can have some GI upset, etc. Um, you know, Tylenol is one of those medicines that Uh, it's okay as far as healing is concerned, still can have effects on the liver and kidney. Of course, if you take too much, that can be dangerous, but at least it doesn't impact the healing. So we prefer that over insets when it's appropriate or when it can help.

Um, and then there's other supplements like glucosamine and chondroitin have good evidence that that can help with some mild arthritic, arthritic pain. Um, you know, it's not going to be a home run, but Hey, if it helps five, 10, 15%, you know, that's a win. And then there's other supplements that have [00:20:00] plus or minus evidence like Boswell or.

You know, um, different things, bromelain, charred cherry juice, et cetera. Who knows, that stuff can help out a little bit, but having a overall healthy diet, you know, full of like whole foods, you know, vegetables, fruits, um, if you do meet the expensive grass fed, good kind, you know, so having a good healthy diet, less processed foods is anti inflammatory as well.

And actually some form of movement and exercise, physical activity is actually good for reducing inflammation also. 

Dr. Linda Bluestein: Well, that's, I feel like that was like a little mini master course in, you know, the, the multimodal, uh, pain approach. So I think there's probably some people who might've just heard you say addicted to NSAIDs who are like, what?

Kind of freaking out. And I, and I have had patients like this, young patients sometimes. And what they're doing is they, in fact, I interviewed, uh, a former professional ballet dancer who worked for both the Royal ballet and American ballet theater. And she was the winner of Prix de Lausanne, which [00:21:00] is, uh, for any dancers out there listening to this, they're going to know this is a huge international ballet competition.

So this, this woman was very, very high level. And, uh, this is, uh, Bonnie Southgate Moore. And she talks about how to get through all of that. She was taking hardcore prescription NSAIDs. And I can say this because she said it on the podcast. So, uh, can you explain a little bit when you said addicted to NSAIDs, you know, because of course when people hear addicted, they often think of opioids, right?

So can you explain a little bit more about what you mean by that and why that's important? 

Dr. Pitts: Right. So, uh, I think we all know somebody who's maybe tries to be as active as they can, but they can't do anything unless they pop Advil or leave first. Like they can't function throughout their day. If they miss a day, they're kind of completely shut down.

And so when you rely on any kind of pain medicine for a long period of time, your body would kind of get used to that and that becomes your new baseline. So now you're more susceptible to things that maybe shouldn't hurt, or maybe would cause you a little bit of pain. They cause [00:22:00] you increased pain. So you kind of get some dependence or reliance on those medicines the longer you take those.

And it happens with NSAIDs, it happens with opioids. You know, it's not quite the, you know, severe opioid addiction and opioids, you know, are more likely to cause, you know, death and all kind of, you know, drug seeking behaviors, but it's still an addiction and you still get hooked on these medicines and, you know, people can't function without them, which, you know, you get to a really bad spot then because, you know, those medicines will come up with side effects sooner or later.

Dr. Linda Bluestein: Yeah, it can be life threatening, right? I mean, if you end up with Kidney failure or you end up with a GI bleed or something like that. I mean, it really can be life threatening. So, so that really is important. And they can also interfere with tissue healing too, right? Absolutely. And, and steroids as well.

Okay. So, um, I have one more question before we go to a, we go to a break. So a lot of the people who have, Hypermobile EDS and HSD have mass cell activation syndrome. So they have massed cells that degranulate easily. So they might have like allergic type phenomenon and, uh, signs of [00:23:00] inflammation. And, you know, these conditions are not super well recognized by, you know, most Uh, practitioners, but when they're having procedures, especially if they're going to have any kind of, you know, um, contrast dye or exposed to different drugs.

Cause I know for some of these procedures you sedate people, right? Correct. So, so, um, are you familiar with those conditions and, and if so, is there anything different that you do in terms of preparing those patients for these procedures? 

Dr. Pitts: Yes, we have several, uh, EDS patients that have mast cell activation.

I most commonly see it in those patients that have cranial cervical instability. I believe there's some sort of link where, um, when you have some irritation to some of the cranial nerves or the base of the brain, um, that can impact mast cell because we've seen, when we treat those patients, They, the mast cell activation problem gets better as well.

So, some patients, you know, they kind of know a little bit already what kind of triggers them and maybe what helps them. Some patients we might give a prophylactic Benadryl. Some patients know certain medicines that bother them. [00:24:00] I've got one patient who, you know, she's, allergic to all kind of medicines.

And so what we'll do, we'll give her a little test of medicine that we might inject in her skin or give her to try to see if it causes any allergic reaction. So we can pick and choose what medicines we know that we can use for that type of procedure. Uh, most patients don't have a problem with sedation with that.

Um, so it's not usually a big deal, but if it is, you know, it's different medicines we can use for the sedation. So we can eliminate one if we have to. So we can make accommodations for that. 

Dr. Linda Bluestein: That's, that's fantastic. We are going to take a quick break and when we come back, we are going to talk about upper cervical instability.

So we'll be back soon.

So we're back with Dr. Pitts and really excited to talk about upper cervical instability because this is obviously such a huge problem for, for people Hypermobile, EDS, NHSD, and other types of Ehlers Danlos, of course. So can you talk a little bit about what upper cervical instability is [00:25:00] and what procedures might be considered for those conditions?

Dr. Pitts: Yeah, absolutely. So cranial cervical instability or instability in the upper neck ligaments is a pretty devastating condition. So everybody with EDS. You know, all your joints are hypermobile, you have pains everywhere, but you know, you can tolerate if maybe your ankle, your knee, or your hip bothers you a little bit, you can work around that a lot of times, but when your upper neck is unstable, it affects your brain and affects your mood and affects your nerves, it can give you headaches.

It really kind of just shuts down all parts of the body. So it's pretty, you know, pretty devastating disease to have. And so it was basically, if you have. Lacks ligaments in the upper part of the neck that cause either the base of the skull or the first and second cervical bones to move too much. Um, that's going to cause stress on different nerves of the spine, sometimes the base of the brain, sometimes the cranial nerves.

Sometimes that can impact a blood flow or venous outlet. So that's going to cause. a whole list of a myriad of different symptoms [00:26:00] depending on which area in particular is getting affected. We kind of have a little bit of a classification system based on where the instability is, um, and that will determine what type of treatment we offer.

So if we have some true cervical, cranial cervical instability at C1, C2 because the first bone slides over to the sides from Relation to the Second Bone, Suggesting Injury to the Alar Ligaments. We have a specialized procedure that Dr. Centeno and Dr. Schultz created called the PICL, Percutaneous Injection of the Cranial Cervical Ligaments.

It's a little mouthful. That's basically a novel procedure that we created here. It's only done here in Colorado. Where you actually inject through the back of the throat because that's the only way to safely get to those ligaments because they're in front of the spinal cord, can't come from the back and you can target those ligaments directly.

Also the transverse ligament, the apical ligaments, the AOL ligaments and other, uh, ligaments up in that area can be target with that procedure as well. If we just have some upper neck instability that is involving the supraspinous, [00:27:00] interspinous ligaments in the back, then that's an easier procedure where we can inject those ligaments from the back.

And then of course, a lot of times the joints are going to get some arthritis or wear and tear from having chronic instability, so those joints can be, uh, injected as well, typically from the backside also. So, uh, depends on what the specific problems are, that will determine what specific injection types we, we do.

But the big one, you know, For those main ligaments, alar, transverse, apical, et cetera, is that PICL procedure. 

Dr. Linda Bluestein: And, uh, I've heard people call that the pickle. 

Dr. Pitts: Yes. 

Dr. Linda Bluestein: Uh, so yeah, PICL is a little, uh, a little longer to say. So whether you're doing, I'm going to call it, do you mind if I call it the pickle? Is that okay?

Okay. So whether you're doing the pickle or you're doing another type of injection where you're doing that posterior approach that you described so well, what, what are you actually injecting for, for each of those or does it depend on the, on the patient? 

Dr. Pitts: Yes, it depends on the patient, uh, but you're specifically [00:28:00] targeting the ligaments that you believe to be damaged.

So, for any regenerative medicine orthobiologic treatment to work, it has to go exactly in the spot that's a problem. So, uh, if you have joint arthritis, for instance, you have to inject it inside the joint. If you have some ligament laxity in the supraspinous, interspinous ligaments, That's the P A O M, uh, the alar ligament, transverse ligament, etc.

You have to inject those ligaments directly. And anytime you're doing any injections, you want to make sure you have image guidance so you're sure that you're injecting to those ligaments correctly. So most of these injections are done on the fluoroscopic guidance or some ligaments are also done on the ultrasound guidance as well.

So whatever the targeted structures we think are either damaged or injured or contributing to pain, that would be the targets for injection. 

Dr. Linda Bluestein: And in terms of determining which ligament or ligaments, because I can imagine in some people, you're going to have multiple ligaments that are, that are problematic.

So how are you determining, because, you know, most people have had like a static MRI, so maybe they're laying down and everything actually [00:29:00] looks quite good. And we know that MRI only gives you a certain amount of information anyway. So how are you making your best. estimate, best evaluation. I know you've talked about like doing that detailed exam and things like that.

What is the most critical piece of data that you're looking for when you're determining what needs to be injected? 

Dr. Pitts: Yes, absolutely. Uh, you take all the information you have to make a full picture to determine what you're going to do. You don't just take imaging studies. You just don't take history. You just don't take exam.

You use all those tools to put them together because each one by themselves, has flaws. And so you're trying to reduce the chance of having an incorrect diagnosis by putting all that together. So, CCI is very frustrating for patients because if you go to most doctors, they're not trained to look for CCI.

If they think of upper neck instability, they think you have a hangman's fracture, you need emergent surgery, or everything's fine. There's no in between. But CCI is the in between. So, you have to take a detailed history to see the symptoms match, uh, do a detailed exam to see if, hey, the spots that you would expect to be tender or [00:30:00] sore or still loose on exam to match.

And then one of the best, uh, imaging studies to, that's most likely to get you to the diagnosis of CCI. It's a digital motion x ray. So these are movement based x rays where you can take a look at patients where they flex their head, rotate to the side, bend to the side, and take measurements to see how the bones move in relation to each other.

Uh, and DMX has some published data on what those measurements are so you can see if they're abnormal or not. Now, just having a DMX alone, again, Would not say, oh, we got to treat this, but if the symptoms and the physical exam match, that matches as well. Another good imaging modality is an upper cervical or upright MRI, uh, with flexion extension as well.

That can pick up a few things, um, that DMX can't, but, you know, DMX tends to pick up more things than that, uh, but static imaging is, uh, the least likely to pick up instability because like you said, that's a static image. Instability is dynamic. It relies on movement. So unless you see some really. Easy to tear in the ligament, which is very difficult to see [00:31:00] on an MRI, or you have some really grossly abnormal measurements that actually don't have enough evidence to support what's normal or not normal.

Um, you know, it's going to be more guessing or suggestive there rather than diagnostic. 

Dr. Linda Bluestein: And when it comes to working up people with upper cervical instability, we know that people who have Ehlers Danlos syndromes, in particular people who tend to have hypermobile Ehlers Danlos, it seems like there's this common co occurrence of tethered cord or Eagle syndrome where the styloid is compressing the jugular vein.

And, uh, tethered cord, you know, where they're, where the spinal cord, the end of the spinal cord is not moving freely in the CSF. So is there a potential risk if you tighten up the ligaments in the upper cervical spine and somebody has, for example, tethered cord, cause you know, we know it's all connected, right?

So, so are those things that, um, can impact outcomes? Are those things that, you know, you try to evaluate for before you, [00:32:00] procedures. 

Dr. Pitts: Yeah, absolutely. So it's very important to kind of realize what these terms mean and be careful with those diagnoses. Because a true tethered cord is, you know, something that you identify on the imaging study and MRI where you can see some tether in the cord or the cord terminates, you know, lower or higher than where it should.

And that's, that's a surgical procedure. Uh, you know, treatment. Now, most patients with EDS or that say they have tethered cord are really, uh, colt tethered cord is what they mean as a diagnosis. And basically what that means is we don't know if the cord is tethered or not. And the only way to know if it's tethered or not is to have an invasive surgery to de tether to see if that helps.

And so that's a much more invasive way. to figure out if that's the problem and that will have implications on the spine as well. So it's very rare that, you know, we're going to say, oh yeah, this patient has a colt tethered cord, um, you know, because there's no way to really prove that at all outside of surgery.

Um, same thing with, you know, Eagle syndrome is basically elongation of the styloid [00:33:00] process. That doesn't just happen randomly. That usually happens because you get an extra stress on your neck or your TMJ or on that, on that ligament there. Um, and that's going to create some extra bone. So whenever you see extra bone in the body, that's just a sign of instability.

That's your body's way of compensating for instability. So that's 4 percent of patients out there and out all normal patients out there that have elongated styloids. They don't have symptoms whatsoever. Um, so trying to figure out that maybe 4 percent of those 4 percent folks that actually have symptoms from that is really difficult.

There's no diagnostic test for that. Typically, you know, all these things are related to the instability. If you help the instability, that does help. Now we'll say I've had one patient that, um, we did a pickle on, um, and. It actually helped his neck a great deal. He also had a lot of lower, uh, lumbar symptoms.

And then he just noticed those a little bit more. So he did undergo a tethered cord surgery, and it did help with the lower leg symptoms, but then it made his CCI worse. So even in that [00:34:00] case where, yeah, he did have some occult tethered cord, that surgery did help him, still has some negative consequences.

And then for that one patient, I've seen multiple patients who've had tethered cord surgery before coming to us, and a lot of those patients are often worse. Not better after that surgery. So again, it's one of those things that, you know, it's a riskier procedure to kind of figure out if you have that or not.

Dr. Linda Bluestein: Yeah. I have patients like that too, where they, they might have abnormal neurodynamic testing of the bladder, which of course can come from a lot of other things besides, uh, you know, having a tethered cord. So like you said, if you have a colt tethered cord, you can't prove that. I mean, by definition, you're not seeing evidence of it on the MRI.

So it's really, really tricky if they have that. And then of course, there's a lot happening between here and here. And so is that from cervical instability? Is that from, you know, Eagle syndrome? I have so many people that have been diagnosed with CSF leak and Eagle syndrome and cervical, like, [00:35:00] like that, like the list just goes on and on.

And it's like, there's a different surgery or different intervention for each of these. And do you really have all of those different things or do so many of the symptoms overlap that it's just really, really difficult to sort out what's the driver of. A lot of those other processes. So it sounds like if I'm hearing you correctly, that you're saying that even if someone did have an occult tethered cord to undergo the pickle, which is going to be less invasive first.

And then, okay, so maybe you are going to end up deciding to pursue tethered cord surgery after that, if it does worsen things, um, you know, when you have a, when you have a tethered cord surgery, you have to have, I'm an anesthesiologist, so you're going to have a general anesthetic. They're going to have to manipulate your airway.

So if you have an unstable cervical spine. That's a problem right there too. So if you don't have the pickle first or, or some other way of stabilizing your upper cervical spine, now you're having a surgery where not only are they inducing a general anesthetic and doing endotracheal intubation, but now they're also turning you prone, [00:36:00] incurs obviously risk because now you've been paralyzed and so you have extra laxity.

in your musculoskeletal system. We're very careful when we turn people prone, but things can happen, right? So. 

Dr. Pitts: Yeah, absolutely. Great point. So, um, I've have, I have so many patients that have developed CCI symptoms just from undergoing maybe another surgery, gallbladder remove or anything, um, because the intubation or the, the staff wasn't aware of that problem.

Um, and they, or they didn't take extra care. Intubation went, you know, a little bit rougher. And they develop problems because of just having surgery in general. So in all of medicine, you kind of want to go, you know, risk benefit. You want to do the least likely, I mean, least risky, most likely to help procedure first and then work your way up the invasiveness ladder.

So the first step, if you have. You start with conservative things, medicines, physical therapy, et cetera, all those type of, you know, modalities that help you try to, you know, exercise and mobilize, et cetera. Work on [00:37:00] your posture alignment, maybe some gentle A. O. chiropractic, et cetera. Um, and if that doesn't work, you know, then you can go up.

to maybe some injections, injections like PRP or platelet lysate, epidurals around those lower nerves if you think it's tethered cord. Treating some of the upper neck joints or ligaments from posterior if we think those are contributing. Uh, then PICL procedure. Um, and then, you know, if all that has failed or didn't get you where you need to be and you still have symptoms that maybe would be ego syndrome or, you know, internal jugular vein compression or tethered cord, then you have those surgeries as a, as a last resort.

Dr. Linda Bluestein: Yeah. No, I totally, I totally agree. So in terms of, uh, pickle versus fusion, do you have patients sometimes that come to you where they definitely have upper cervical instability, but it's so significant that you say, you know what, I think you're a candidate for, for, uh, fusion surgery. And, you know, this is not an appropriate situation for a pickle or is [00:38:00] that, does that not usually happen?

Dr. Pitts: Yes, absolutely that can happen. So, um, it doesn't happen as often because most of those patients very clearly need surgery so they don't get to us in the first place. So they tend to have surgery. Um, but yes, we do see patients that do have either just severe disability where they can't, we don't think they can undergo a procedure.

So if they had this cranial cervical incivility going on for so long, it's gotten so severe. Uh, maybe patients have some cranial settling. Where, you know, those that may be a little bit more difficult to treat with a PICOT procedure. Um, or, you know, they just have some really bad instability and they're just on the verge of emergent surgery.

Yes. We would definitely tell patients, yes, you need to have surgery, but otherwise, you know, uh, we give them the risk and benefits. Uh, and PICL is likely a procedure that could be helpful or something that's worth trying if they don't have any emergent red flags or they're able to tolerate this procedure or they don't have any other medical things that would preclude them from treatment, okay?

And then, you know, based on our, our research and our evidence, probably about 7 in 10, 70 [00:39:00] percent of the patients that undergo PICL procedures who otherwise may have been a candidate for cervical fusion wind up avoiding that invasive surgery or avoiding other types of treatments that they seek out.

Dr. Linda Bluestein: Okay, and let's talk about what happens after these procedures. So what kind of precautions do people need to take and what is the typical course like? 

Dr. Pitts: Yeah, now you can imagine this is going to vary patient to patient. So let's just give a couple of generic examples. So if it's a relatively healthy patient with a newer injury or newer symptoms, uh, you know, and they're pretty functional in life, their recovery is going to be much quicker.

So you know, after all these procedures, you're going to have quite a bit of soreness and pain. That's typically just for a few days up to the week afterwards. You know, it's going to listen to your body. You're just going to feel things out. You're going to take it a little bit easier as you start to calm down and get better.

In general, whatever you could do before the procedure, you should be able to do, um, shortly afterwards. Within a few days or a week or two, uh, at most for most [00:40:00] patients. Uh, again, as long as it doesn't hurt or flare up symptoms. Um, so things that you couldn't do before that were, or that would flare up symptoms, that's going to take longer until your body's healing up.

So, typically, most people are getting the biggest improvements between three to six months. Even before that, you can start to get some little improvements. So, as you get better, you can do a little bit more. It's basically listening to your body. Now, patients who've had this longer, more debilitated, maybe can't work.

Some patients are lying in bed for 20 hours a day. They can't even be upright for a period of time. They're probably going to have a little bit tougher recovery. So, that little bit of flare up of pain and dysfunction can Could be a little, you know, very life altering and traumatic for them for those first week or two, et cetera.

Okay. And then there's a handful of patients who nothing happened. They feel like nothing was going on. There's a handful of patients who get a prolonged flare up where they may be a little sore or worse off for a couple of months before they start to turn the corner and get better. So it's a range, but most people, you know, flare it up for [00:41:00] about a few days to a week or two.

Dr. Linda Bluestein: Okay. And I know people are dying to hear about data. And outcomes and what you're seeing in terms of results. And I have to say, so I, I met you a month ago, something like that. I've lived in Colorado for two years and this, and I finally, I had enough patients that either had, had seen you guys, or, you know, I obviously had heard of you a long time ago.

Um, but I really wanted to come and see what was it that you were doing. And I was so impressed when I went on the tour and, um, You showed me the lab and just, I was just like, wow. And then you started telling me about that you have a PhD on staff, right? Like I want to hear about that. So, so this is so important that people are aware of what kind of outcomes, obviously you can't, you can't make a perfect prediction for any one person, but it seems like you're doing a really good job of collecting data and looking at short term outcomes, long term outcomes.

And of course we could probably talk about this for. A couple of hours, right? So, so in a nutshell, because I know we're [00:42:00] talking about multiple different procedures, we're talking about different parts of the body, um, can you just give us a, again, a 10, 000 foot overview of what you're seeing for results?

Dr. Pitts: Absolutely. So, you know, when we started, we were the first, clinic in the world to inject stem cells orthopedic use back in 2005. Since that time, we've been tracking patients in the registry. So we send surveys out to patient one month, three months, six months, every year, uh, for the duration of their treatments to collect data.

And so with the CCI patients and PICOT procedures, no different. Um, Dr. Centeno just, uh, kind of collected some data because we had enough EDS patients to compare to the, uh, non EDS population. We had about 40 EDS patients compared to close to 200. You know, non EDS patients, and the outcomes were pretty similar.

There was no difference in outcomes. Now, just on our own intuition, you know, we think people with EDS may need a little bit more treatments or they're more likely to, you know, can easily re injure themselves because all your ligaments are loose. So we can make ligaments [00:43:00] stronger than a baseline. We can get them back to the baseline where you were functional and not having as much pain or problems.

But it can take less to injure those ligaments if you have EDS. But based on the data, the outcomes are very similar. Uh, and that holds true for probably most procedures, though we haven't compared those with EDS and non EDS directly. For most procedures, you know, obviously it varies from procedure to procedure, but most of these things help out 70 to 80 percent of folks.

And we tend to see, you know, Worst patients, because we know, we see patients that are coming from all over the world. They've tried everything else. We're not getting the home run patients a lot where, Hey, I just had an injury a month ago and I found out about you guys and I want to get this evaluated.

You know, those are probably 90 plus percent, you know, you're knocking that out the park. Um, but we see all kinds of levels of severity of patients and, you know, the majority of folks are getting much better. And what we would classify as getting much better, we basically ask patients, What percentage improved do you think you are from your baseline?

For So if most patients say they're greater than 50 percent improved as far as their pain and function, they can do [00:44:00] more things, they're happy, they're not worried about these issues as much, they've avoided surgeries that they otherwise would have had, you know, that's a success. So one example of avoiding surgery is like knee replacement.

So patients with severe knee arthritis, so of all our knee patients we've tracked tens of thousands, only about 13 percent of those have gone on knee replacement. To have knee replacement so far in the data. So 87 percent avoid a knee surgery at least is pretty remarkable. 

Dr. Linda Bluestein: That's amazing. So, uh, knowing a few people who are probably in that category that you just talked about, not necessarily with EDS, how, how far out does that data go?

So when you're saying only 13 percent needed knee replacement, are you talking about that you have data that shows that five years out, three years out, a couple of years out? 

Dr. Pitts: Yeah, so that's data collected from every patient since 2005. So some of those patients, you know, some patients are going to fall off after some years.

But you have long term data for some patients for maybe 5 to 9 years. Um, so [00:45:00] that's a collection of patients with long term and the short term data, you know, all together. Okay? Based on the evidence that we have, uh, from our internal data, uh, Stem cell procedures for the knee, for example, or joints in general, can help out for 2 to 7 years at a time.

And then at that point, if it helped a lot, you can always repeat. Uh, if we add in intraosseous or bone injections when you have severe arthritis, um, that published data is 5 to 15 years of benefit from stem cell procedures for severe arthritis. If we're talking about, you know, non EDS patients that just have a ligament or tendon problem, those things can be fixed, and you're fine, unless, you Some other issue comes up.

So for instance, rotator cuff tears. We've, uh, completed randomized controlled trial, 50 patients comparing bone marrow concentrate injections with stem cells versus exercise, and the average improvement is about 89%. And you see both subjective and objective, uh, changes on ultrasound and MRI, and you know, those patients, those ligaments or tendons are healed unless you re injure them.

Um, and [00:46:00] 89 percent overall improvement for anything orthopedics is, is Darn near a miracle. 

Dr. Linda Bluestein: Yeah. Yeah. Exactly. So, um, I'm also remembering when I was here last time and I watched you do some procedures, one of the procedures that you were doing, and I think it's okay to say that it was on a physician because you know, that, that still leaves a, a large pool of people.

It's not like people are going to identify who that was, but it was somebody that was coming back for their second knee. And you had already done their other knee some five years plus earlier. So, um, again, I was, I, that, that was a very, I really enjoyed getting to observe some of those procedures. And of course, that's what we're going to do this afternoon too.

So pretty psyched about that. Are there certain factors that you have identified here at your clinic that are predictive of better or less good outcomes? And does something like osteoporosis make a difference? 

Dr. Pitts: Uh, yeah, so there's definitely factors that can contribute to the success of the procedure. Uh, some of that we kind of speculate, some of that is based on, uh, evidence.

So, uh, and a lot of [00:47:00] this data is based on, you know, knee arthritis, um, because that's kind of the most common problem we treat, but kind of, probably translates across, uh, with arthritis. So, um, when things are mild to moderate, PRP works great for, for arthritis in general. Things get more moderate to severe, Bone Marrow Concentrate works better.

Uh, when patients have had prior surgeries, especially meniscectomies, most of them still do better, but there are going to be patients that don't do as well because you can't get that removed meniscus tissue back. So prior surgeries are sometimes a big deal as far as, uh, outcomes depending on what the, what the issue is.

Um, of course if you have some deformities, Cause you're not going to correct deformities with any injections. Sometimes that can play a negative role in outcomes as well. And then like things like ligaments or tendons, if you have a complete tear where the tissues are retracted, then you're not going to be able to get those ends back, those are the things that need surgery and can't be helped.

Uh, we suspect, you know, your nutrition, your diet, your overall health, that plays a huge role. Uh, if you have [00:48:00] diabetes or metabolic syndrome, which lots of Americans have that can have an impact on your success as well, um, haven't found actually obesity be a big contributor to some of the data that we suspect.

But I still suspect again, if you have obesity with metabolic syndrome, that's going to, uh, alter the chance of success as well. And then we've studied lots of different medicines. Uh, or notice different medicines that patients were on when we were growing stem cells out that had a negative effect on stem cells.

So certain drug classes have a negative effect on outcomes as well such as statin drugs, some blood pressure medicines, of course steroids and NSAID medicines like that, uh, some prostate medicines actually or hair loss medicines. So some things like that can have an impact too. So if there's anything that we can stop, as far as medicines that we think can have a negative impact on, on, uh, stem cells and healing, we'll tell the patient to do that as well.

Dr. Linda Bluestein: Okay. So that just blew my mind, um, about the statins. So a lot of people are on statins, right. And obviously on [00:49:00] antihypertensives as well. But if we just talk about the statins for a second, is that certain statins or pretty much all of them, because I would imagine. That's a pretty common medication class.

Dr. Pitts: Yes, it tends to be all the statins, yes. Now again, these are things that, you know, you have to weigh the risk and benefits. So, uh, for most patients, you know, if you have a, you know, just taking statins for a high cholesterol, you don't have a family history, you haven't had a heart attack or stroke, Most doctors are going to be okay and say, Hey, yes, you can come off your statin for a week or two before and after these procedures.

No big deal. Now, if you've had some cardiovascular issues or you have some familiar, uh, hypercholesterolemia, then, you know, maybe your doctors might say, no, you better stay on that, or you can only come off for a few days. And again, these are just risks. It's not a guarantee you're going to fail. You just, you know, we're just trying to stack the deck in your favor.

So we always got to weigh risks and benefits. It's not always going to be. 100 percent perfect. Nobody's perfect. So we just try to do the best we can and give you the best chance of success as possible. 

Dr. Linda Bluestein: Yeah, no, we know nothing is, nothing [00:50:00] is a hundred percent, but I think that, uh, especially if there's small things that we can do, we should absolutely be doing those to try to improve our outcomes for sure.

So. When you are doing procedures in the cervical spine, getting back to that for a minute before we wrap up, there are, of course, very, very critical structures in the neck. So are there life threatening complications that, that can occur? What, um, what's the frequency of those? And what are the kind of things, because that's going to lead into, what are the questions that people should be asking when they are deciding what You know, maybe they're at a clinic or they're talking to a specific doctor and they're trying to decide, do I let this particular person do this particular procedure on me?

And I know you guys are the only ones that do the pickle, but there's, there's other procedures that people are doing in the cervical spine. So yeah, if we can start with the cervical spine and if there's any life threatening complications there, and then go into the questions that people should be asking.

Dr. Pitts: Yeah, absolutely. So we we're fortunate. We've never had any life, [00:51:00] uh, life threatening or severe adverse outcomes like that when any of these kind of cervical procedures, but the risks are there. So, especially for, you know, C01, C12 facet joint injections, because of vertebral artery runs close to those. So if you don't know how to perform those procedures and you're very comfortable with those type of procedures, that can be a bit, big risk of causing stroke, uh, causing some, uh, neurologic injury or damage if you inject, you know, the wrong substances into those arteries.

So again, with us. We use fluoroscopic guidance. We have this special program on our fluoroscopic machine called DSA. Um, and so we can, uh, we can look and make sure that we're not getting any vascular uptake before we do the injection. So if we notice that we can make adjustments. Um, and for the most part, we try to avoid that in the first place by kind of knowing how to do these procedures, but you have to do.

Lots of these procedures to kind of be comfortable with that. And unfortunately, these are not common procedures for most clinics because most clinics, again, are [00:52:00] pain management. And so for joints, you're looking, you don't, they don't even inject joints mostly anymore. They just block the nerves that go to the joints, medial branch blocks, so they can do a radiofrequency ablation.

But you can't do that for these upper joints. So not a lot of doctors are trained or experienced to have those type of procedures. So only the doctors here have, uh, you know, we know, have a ton of experience with that. We've trained a couple of doctors that have some experience in that. I don't know how much they do now.

And then I'm sure there are a handful of doctors out there to have this experience. So you need to ask the doctor, Hey, how often do you treat these 0 1 1 2 joints? You know, are you using fluoroscopic guidance? Do you have digital subtraction angiography or DSA on your. On your program, uh, in case you think you're getting vascular uptake, how many of these you do, uh, on a basis, you know, those are the type of questions you want to ask for that type of procedure, obviously with the pickle procedure, you know, biggest risk is infection.

If you get infection around the spinal cord or something like that. That can be very devastating. Again, we've never had any major complications, uh, like [00:53:00] that with these procedures. So, um, you know, there are risks with every procedure, but injections tend to be far, far less risky than any surgeries. Um, and again, the invasiveness of injections, you know, can incur a different risk depending on where that is.

Dr. Linda Bluestein: Okay, so it sounds like some of the key questions to ask are the person's experience, how many of whatever type of injection that they're going to be doing on you, how many of those have they, have they done, what kind of imaging are they going to be using. Now, now I'm bringing this back to like the kind of general, uh, procedures.

So you want to ask, how many? You want to ask, uh, what kind of imaging they're going to use? Some of the procedures I know you do under sedation. And I think some places might have that ability. I know here you actually have a nurse anesthetist that comes in for the pickles, um, which is, which is great. Uh, what other questions should people be asking when they're trying to decide their, you know, they're in Montana and they're, they're talking to a doctor and maybe, maybe it's, you know, more simply probotherapy and they're trying to decide whether or not to, to pursue [00:54:00] that.

Dr. Pitts: Yeah, absolutely. Great question. So, in general, if you're thinking about doing a regenerative medicine orthobiologic procedure, what should you look for in a clinic? So, who? Who is doing the procedure? Is it a nurse practitioner, a PA, or is it a physician? And if it is a physician, what is their training? Are they a muscle skeletal physician?

You don't want an ER doctor, a pulmonologist, cardiologist. Doing your musculoskeletal medicine just like you don't want me doing your cardiology. So you want to make sure it's a doctor trained in musculoskeletal medicine, most typically PM& R doctor, anesthesia, pain, or sports medicine, you know, some type of interventional radiology, some type of doctor that deals with these type of problems.

You don't want a nurse practitioner, PA, um, you don't want this done in the chiropractor's office if there are no MDs there. Um, so that's, that's one. Big thing. And then, so what, what do they, what do they have the options for injection? Prolotherapy, PRP, bone marrow concentrate with stem cells. There's a host of questions you can ask about that because just saying PRP is very generic.

What are the [00:55:00] concentration? How much blood, uh, do you tend to take? Uh, do you have leukocytes or white blood cells in the PRP? These are questions to ask. What concentration do you have? Prolotherapy you use, if you're doing stem cells, is it coming from bone marrow, adipose, et cetera. They mention things about exosomes and, uh, birth tissue stem cells here in the U.

1. All that stuff is more scammy and, uh, not allowed, so you got to be careful. Um, and then, you know, how are they doing the procedure? Are they using ultrasound, x ray guidance, et cetera? Um, and then, you know, when is it appropriate to do the procedure? So if every single patient that has a credit card is a candidate for treatment, then you Uh, that's not appropriate.

So there should be cases we can ask, Hey, when would I not be a candidate? What type of patients would not be a candidate for this type of procedure? So that's very important, um, as well. So those are some of the big ones, uh, think of top of my head. 

Dr. Linda Bluestein: Yeah, those are great points. And, and I, my husband's a surgeon and I, I tell people all the time when it comes to [00:56:00] getting a surgical consult, make sure that they're not, you know, Operating on everyone who walks through the door and that they are selective in who they operate on because then you're by far the most likely to have a better outcome than somebody who's not discriminating like that.

So, yeah, those are great, great questions. And somebody did ask, What, if anything, are you doing here at your clinic to improve access and affordability? I know that, you know, I think a lot of people don't realize how much is involved in these procedures. I know when I came here like a month ago or whenever it was, and I, First of all, I, I saw the door at the front and I thought, oh, I thought it would be bigger, but then you took me on a tour and I was like, oh, this is a huge place.

It's just from the outside. It didn't look that big. Um, but I think people don't necessarily realize how expensive it is to offer these procedures and especially in the right way. You know, it's really hard, like you just said about, you know, You know, I've seen places where they, they do, uh, teach a PA or a nurse practitioner how to do some prolotherapy, but that person, you [00:57:00] know, didn't go through the kind of training that you went through.

Um, and, and so can you just talk about that a little bit in terms of access and affordability? 

Dr. Pitts: Yes, absolutely. So, um, you know, for us, um, we always try to do the least expensive, least invasive, safest thing that we think is most likely to help the patient. So not everybody walks through the door, Oh, you need stem cells, you know, Hey, you might just need physical therapy.

Let's try that. Or, Hey, we think for this problem, prolotherapy has a great chance of helping, et cetera. So try to limit costs in that matter. Um, and then, uh, with our overarching company, Regenexx that, you know, Dr. Centeno and Schultz founded, um, we're going out to and companies that self insure their employees, um, because they're going to be a little bit more focused on the cost of preventive care than big insurance companies.

So they know that orthopedics tends to be their biggest healthcare spend. So orthopedic surgery is very expensive, much more expensive than, than what we do. And so based on our data and research, we can say these companies probably 70 [00:58:00] percent of their orthopedic surgery costs. And what we do is much cheaper.

So they're, they're getting on board with that. So we have more than 2000 companies, maybe more than 10 million people without the U S that have that type of coverage for our procedures. So if they have a problem that otherwise would have led to surgery and they failed physical therapy, conservative measures, and possibly, you know, some type of injection that was a pain management injection, then they actually have coverage for PRP and bone marrow concentrate procedures through only our Regenexx doctors.

So that's one way we're helping. Uh, large. Insurance companies, you know, they just think about, uh, not paying for anything, giving you the hard time, you know, they'll wait till you get dropped insurance, switch jobs and get on Medicare, et cetera. So they're going to take much, much longer to come around. And then now with some of the high deductible insurance plans that people have, a lot of times what we offer is not really more expensive than their traditional care, because we got epidurals or other pain management injections and you had to pay out of pocket for those.

Those are about the same cost of sometimes [00:59:00] more than what we do here. as well. So, um, you know, costs can vary, um, but we try to be consistent with that, you know, and so be aware of that. So we're not just trying to give patients the most expensive procedure, we're trying to give them the most appropriate procedure for their problem.

And of course, all our doctors, the musculoskeletal doctors, all board certified, all have undergone fellowship training in this area, do this all day, every day. We've got, you know, Four procedure rooms up there with fancy C arms, ultrasound equipment, you know, all the crash cart, cause we do sedation. Uh, we've got a full staff of team members to help you out downstairs.

We've got a full lab, you know, run by a lab manager that has to meet, you know, um, protocols for, for operating with, you know, all this, you know, centrifuge and staffing and air vents to make sure everything is safe and reducing the risk of infection. We've got a university, you know, million dollar style lab where it's run by a PhD and we do PhD clinical research.

So, um, you know, we're putting in a lot of effort and resources to make [01:00:00] sure you're getting the very best care and outcomes as possible, uh, and trying to make that as affordable as we can. 

Dr. Linda Bluestein: Yeah, no, that's, that's really, really good. And I think that, um, the insurance question is a, is a really interesting, and that's such a, it's such an interesting approach.

Cause I've, I've thought that so often that, you know, insurance companies, it's crazy what they'll, what they'll pay for, but they won't pay for some of the preventative things. And, and I had to buy insurance on the marketplace and it's, it's pretty much, you know, just catastrophic coverage. Yeah, that, that's really all that it is.

Um, okay. So I like to end every episode with a hypermobility hack. And. You've already given us, of course, so much great information, but do you have a hack that you can share with us for people that are hypermobile? 

Dr. Pitts: Yes, absolutely. Strip training, you know, so people are hypermobile, you have instability in your ligaments so that, uh, you have to compensate that.

You know, compensate for that with some muscular strength. So, you know, if you hypermobile, you can do all kinds of fancy party tricks, but you might [01:01:00] not want to, you want to make sure that you have good mobility, which means full strength throughout your range of motion, able to move your joints with your muscles being active and focus more on strength training rather than a lot of stretching.

So that's very important. And with strength training, you definitely want to get enough protein to help build muscles. I think that's super important. And then from our side of things, if you do have these nagging, you know, joint pains or problems, get those addressed earlier because a lot of times, you know, maybe if it's just some instability and if you're younger, you know, when you're younger with hypermobility, um, you know, your joints haven't worn out quite as quick as you got enough stem cells and repair mechanisms that you haven't broken down your joints yet.

So if you're having some early problem, you know, you might get be helped with just some simple prolotherapy injections to the ligaments around a joint or an issue. Um, and you know, that'll save you more procedures or more arthritis and problems down the road. 

Dr. Linda Bluestein: That I think is a really good point because it seems like it's not uncommon for one thing to set someone off.

And [01:02:00] then, like you said, I, I do have patients that spend 20 hours a day in bed because they have so much persistent pain and some of them are really young. And of course it can be. Multifactorial, they can end up with dysautonomia and other reasons why they're in bed, but it can start out as a musculoskeletal thing.

Then they're in bed. Well, then of course their autonomic nervous system doesn't function properly because they're in bed. Like when they were trying to do studies on astronauts, what did they do? It's very expensive to send people into space, but instead they took young people and put them in bed because that was a good way to stimulate or simulate, excuse me, not being exposed to gravity, right?

So that was a great way to study that. So, so, so Dr. Pitts, it was so great chatting with you. I'm so grateful to you for sharing this information. Um, before we wrap up, I just have, uh, two final questions. Um, the first one is what are you up to these days in terms of, uh, any special projects you're working on, anything that you're researching, anything that you're really excited about, and also where can people learn more about you and about the clinic?

Dr. Pitts: [01:03:00] Absolutely. First, thank you for having me. Quite an honor. It's a pleasure talking with you. Um, you know, some of my focus as far as research of just submitted a paper on treating discogenic pain in the neck. So cervical intradiscal. So we have a lot of evidence that actually PRP, bone marrow concentrates, stem cells can help discogenic pain in the low back.

Um, but the cervical region is a little bit more, you know, tougher area. So kind of developed a procedure to treat those discs and, um, we're getting pretty good outcomes. So just submitted a paper on that. Um, another thing that's probably relevant to this community as well with hypermobility is that, uh, the ligament teres in the hip, um, is a, is a big ligament that's often missed, overlooked, and that can contribute to instability that leads to hip labral tears, uh, and so I've developed a procedure to kind of treat that ligament as well, um, so kind of working on, uh, teaching that and, uh, perfecting that, um, and so that's a, that's a big one because a lot of people with hip labral tears, hip labral surgery, And I'm sure you don't see many patients, oh yeah, that hip [01:04:00] labral surgery went really well.

And the reason is because you have to think again of the underlying biomechanics. Typically, the hip is unstable either from a ligament standpoint or butt muscle standpoint or low back issues that cause that hip to move abnormally and that leads to the tear in the labrum that you see. But just, Taking out the labrum or trying to repair it doesn't always work because then you create more instability just by having surgery.

So working on that hip instability is a big passion of mine as well. Um, and then people can find out about me right at, um, you know, cincinnoshultz. com and, you know, um, I'm on the doctor's page there. Um, so all my info is on there. 

Dr. Linda Bluestein: Okay, great. Well, it was such a pleasure chatting with you. I learned a lot.

Uh, I'm sure that the listeners and viewers will have learned a lot as well. And, uh, so thank you again for taking the time to share your vast knowledge with us and, uh, your incredible wisdom. So thank you. 

Dr. Pitts: Thanks for having me. Appreciate it. Thanks.

Dr. Linda Bluestein: [01:05:00] Oh my gosh. That was such a great conversation with Dr. Pitts. Um, I'm sure that you went. Learned a lot because I know I sure did. Field of regenerative medicine is such an exciting one, but there's so much confusion. And I feel like it was just really important to talk to somebody who has a lot of experience and a lot of knowledge and could, could help.

Give us, again, that 10, 000 foot view of so many things that we need to be aware of. And I particularly want you to pay attention to those questions that he shared with you in terms of what you should be asking if you're evaluating, um, a clinic or a specialist that might be doing a procedure on you, because that's extremely, extremely important.

So make sure that you ask those questions that he shared. Thank you for listening to this week's episode of the Bendy Bodies podcast. I hope you found it empowering and informative. If you loved what you learned, please Follow the Bendy Bodies podcast on your favorite podcast player and subscribe on YouTube at Bendy Bodies podcast.

Visit [01:06:00] bendybodies.com to access transcripts, show notes, or leave us a message. Help us spread the word about joint hypermobility and related disorders by leaving a review and sharing the podcast. If you'd like to meet with me one on one, please check out the available options on my services page at hypermobilitymd.

com. You can also find me, Dr. Linda Bluestein, on Instagram, Facebook. Twitter, or LinkedIn, all with the handle HypermobilityMD. You can find human content, my producing team at human content pods on TikTok and Instagram. To learn about the Bendy Bodies program, disclaimer and ethics policy, submission verification and licensing terms, and HIPAA release terms, or to reach out with any questions, please visit bendybodiespodcast.com. Bendy Bodies Podcast is a human content production. Thank you for being a part of our community and we'll catch you next time on the Bendy Bodies Podcast.