The Science Behind PRP Outcomes: Dr. Aneesh Garg, DO, CAQ and AJ Patton of BTI

Transcript

A conversation between Dr. Garg and AJ Patton of BTI. The caption export does not identify speakers reliably, so turns are separated but not labeled beyond the host’s opening.

Hook: same knee, same day, six weeks versus six months 0:04

Dr. Garg: Welcome to the Regen Doc podcast powered by DynamicAthlete.com. I’m your host Dr. Aneesh Garg. I’m Yale trained, Andrews trained, and a two sport US national team doctor here to help you make sense of regenerative medicine. Two patients get PRP in the same knee on the same day in the same city. One of them is back on the trail in six weeks. The other one in six months. Today we get into why and it has almost nothing to do with luck. Let’s get into it. Our guest today is AJ Patton. AJ is a director of US sales and operations for Biotechnology Institute of Spain and their regenerative platform Enderit PRGF. AJ has worked in the regenerative medicine space for the past 15 years and BTI has been pioneering research for over 30 years. Today we’ll be talking about regenerative medicine in general and the science behind it behind improving the patient outcomes. AJ, thank you for your time. Welcome to the show.

So great to be here. Thanks for having me.

AJ Patton’s path from spine hardware to PRP, and what he no longer believes 1:10

Yeah, let’s get into it. I mean, this is fascinating. You spent 15 years getting into in this space and you’re with a company that’s research researching this for double that amount of time. What pulls you into the regenerative medicine space in the first place?

Yeah. So, uh, my journey in the medical device world has been pretty interesting. I actually started out in the spine space selling spine hardware and spending a lot of time in the O mostly doing a lot of pedicle screws, plates, rods, um, spacers, those types of things. a little bit into the biologic space and that lifestyle was a little bit of a challenge for me. I had two small kids and uh spending all night in the O or all night in sterile processing putting trays back together and things was just uh

it wasn’t consistent with the life I wanted to have at home. So really looked at transitioning my career into something that was a little bit more clinic-based so that I could have uh better hours at home with my family and had the great opportunity to help launch a a product that was pretty pioneering in the PRP space about 15 years ago. Uh it was actually the distributor for the entire Rocky Mountain region, seven different states. And uh we we grew that platform. That one wound up getting licensed to one of the the big orthopedic companies. I did some consulting for them for a while, but then I discovered that there’s a lot of other really good regenerative medicine companies out there, not only in the US, but also globally. And so I’ve been working with them since uh since that licensing happened. And uh yeah, just just love the space and and love the technology, love uh all of the science behind the the treatments and really how it’s growing and becoming more and more mainstream as uh as we go. I mean, you know, one of the things we tal and we’ll get into this in terms of there are misconceptions about regenerative medicine, right? People think some people think it works. Some people think it doesn’t work. Some people think it’s all the same. We’re going to get into why it’s not all the same. But the big thing, what did you believe about PRP when you started that you no longer believe?

H gee, there’s there’s a lot of things, right? It’s been a big learning curve over the last 15 years. So, um the the thing that caught my attention the most was just the regenerative potential, right? Um, initially when I got into the space, uh, I did not know that the system that I was working with was considered the best at the time. I thought all PRP was the same. And I’d imagine that there’s probably a lot of patients out there that feel the same way. PRP is a PRP is a PRP.

As I’ve uh, as I’ve lived and worked in that space for the last last 15 years, nothing could be more inaccurate, right? There is such a broad spectrum of formulations and quality of uh delivery and and things like that that there’s so many variables that you really want to consider that uh you really got to get locked in on on all of those to have a really really good uh experience as a patient. Yeah. I mean I think that’s that you lead right into it. I mean, what’s the biggest misconception that you run into from doctors, not patients, but from doctors in terms of in the regenerative medicine space?

Yeah. Yeah. Doctors are an interesting breed. Not to be uh not to be rude, but a lot of times it’s the, you know, it’s it’s who has the the latest shiny object, right? Um what’s the latest thing? What’s the what’s the cool marketing that’s out there? And uh there’s a lot of science behind it, but a lot of the companies in this space have a lot bigger marketing teams than they do research teams to develop the science. And so a lot of a lot of the noise that’s generated in this space comes from really creative and really good marketing, not necessarily really good science.

Yeah. I mean, I think I agree with you. I mean I think from a colleague perspective you know doctors and physicians in that regard I think one of the biggest misconceptions is they rely on this older data that may not actually be up to date or continuing with the what’s going on. There’s a lot of misconception in terms of like you said that all PRP is the same or because my one patient didn’t get better, PRP doesn’t work or regenerative medicine doesn’t work. Right? It’s the same thing. I mean, it’s akin to somebody saying, “Hey, I had ACL surgery and I blew out my knee a year later. ACL surgeries don’t work.”

Pretty fair, right? I mean, if you’re going to if you’re going to surmise that,

then surgery doesn’t work in that reg. And don’t clip this where you just I’m making say that I’m saying surgery doesn’t work. I’m just giving you an example to this where I you know you can’t make that assumption. It’s case by case and if you’re doing it for the right reason, right? Why do you think this mis misconception has lasted so long?

Um because there’s such a wide variability of of products and systems out there. So, not only what’s being done on the on the back table in the creation of the PRP, but also how and where it’s injected, right? Um, a lot of what happens in this space that pe, you know, there’s there’s physicians that aren’t really dialed in as far as what’s in the syringe,

right? And there certainly are physicians out there that aren’t very dialed in as far as where to put it, how much to to put in certain locations, and just that entire injection uh process. So, when you combine those two things, it’s um you got to be really specific and you got to be really detailed and you got to really really know what you’re doing because if you want to if you want to maximize uh the best outcomes for the patient, you need to take into consideration all of those variables and make sure that it’s really dialed in. And the nice thing about it is the science is getting uh more and more refined to where people uh who are in working in this space are getting more dialed in as far as what to inject, where to inject it, and ideally how to inject it.

I mean, I think your point’s really well taken. I mean, I think if you if you want to know about this, there’s plenty of research and data out there that shows that this works.

If you are kind of like, well, I don’t know if this fits what I’m doing. Mhm.

So, I don’t really want to make the effort to go look for these things. Pretty easy to be like, “It doesn’t work.”

Right. There’s not enough data for it because I didn’t look for it.

Yeah.

Right. And it’s kind of the same thing of, you know, it’s it’s sort of this um blind negligence for it where you’re like, well, I’m just gonna look the other way. And, you know, there’s not enough data that I’ve found because I really haven’t put much effort into it. So, you know, I think I think your point’s really well taken there. So let’s start at the beginning here.

Sure.

What is actually in the syringe: anticoagulant, the blood draw, red cells, leukocytes, platelets 8:23

When we draw a patient’s blood and spin it, what are the components that we’re separating and which of these actually matter?

Yeah. So um one component that really matters that’s actually not part of the patient’s blood is the anti-coagulant that’s used, right? And the amount of anti-coagulant that is used. Uh there’s a couple different ones out there that are very very common in PRP systems. sodium citrate and ACDA. Uh both of them do a great job of keeping the blood from coagulating while everything’s being processed, but sodium citrate has a little bit uh higher comfort factor once it’s injected into the patient. ACDA has a tendency to sting a little bit more. So providers, if they’re using an ACDA system, need to be able to prepare their patients accordingly and say, “Hey, this might sting a little bit.” Y

but then once uh once it’s once the blood is drawn and again we we need to be careful when we’re drawing the blood that we’re not damaging any of the cell components in the blood, right? We want to keep all of those cellular components as intact as possible. Um couple different ways to do that. biggest uh biggest mistake that I see with some of the systems out there is when they’re doing massive blood draws and they’re either doing it in a in a high volume syringe or a high volume vacuut tainer just because the amount of pressure that those cells are subjected to when they’re coming out of the butterfly needle or out of the needle into the syringe into the vacuutainer will have a tendency to lice or tear apart those cells. Anytime there’s cell debris in an injectate, it’s going to cause an inflammatory response, right? So, so you know, we need to look at the the anti-coagulant that’s used. We need to look at the process for the blood draw to make sure that we’re keeping the the blood components as intact as possible, but then we need to be using a system that ideally separates those components, right? because there’s parts of blood that are great and provide a ton of healing capability and there’s parts of the blood that you really want to avoid and injectate. So the ideal system would eliminate all ariththroytes. We don’t want any red blood cells in there. Where it gets a little bit um I don’t want to say controversial, we’ll just say up for discussion is luccoytes. Right. Right. Because there are papers out there that say having a high luccoy content is great. There’s papers out there that say having a low luccoy content out there is is great. And there are papers out there that saying having no luccoytes are great. Whatever the philosophy is behind that, you need to be prepared for how it’s going to behave once it’s injected into the patient. But the biggest and the most important piece of any type of injection when we’re talking about blood-based therapies is the plasma and the platelets that are included in the blood. And the platelets are the they they’re really the workhorse when it comes to regenerative therapies because the platelets are are basically the the vessels that carry all of those proteins, growth factors, healing agents that we want to deliver to that injury site or that disease site so that they can actually do their job and repair or um regenerate that tissue.

Yeah. I mean I mean you know that’s well said. I mean, when we we draw this out, we talk about whole blood

and then here are the components we don’t want. Here are the components we do want and out of these components that we do want, here’s how we break them down. So, I mean, that’s great. And I think, you know,

Activation and preparing the host: sleep, nutrition, EMTT, shockwave, the gardening analogy 12:05

some people ask about activation, right? And so, activated PRP and some protocols activate it, some don’t. You know, what’s happening biologically at that moment from an activation standpoint and how does that impact the injection?

Yeah. So, we’re big believers in activation. We’ve done a lot of studies uh on activated and non-activated. Uh one of our big studies that we reference pretty often is actually a metaanalysis. So, 14 different studies, almost 1300 patients uh all with grade two, grade three nesteoarthritis. And the the data on that is what we base uh is kind of the foundation of why we base um our system being a fully activated system. Because when you look at pain scores and functional scores with activated versus nonactivated PRP systems, it’s pretty con it’s pretty compelling evidence that activated outperforms non-activated when you look at that study and that metaanalysis studies.

Yeah. So really just, you know, for those of you out there that aren’t familiar with activation, it’s just a process by which we force the platelets to release all of their growth factor content. Those platelets are are going to be suspended in the plasma. So if you add an activator, it’s usually done in vitro or in the syringe so that we force those platelets to release growth factors into the plasma. they remain in that liquid and then that liquid can be injected at the injury or the disease site something like that. So, um, big big believer in activation just because we’re saving the body a step and, uh, most most PRP systems that are injecting whole platelets and relying on spontaneous activation are only getting a partial activation of the platelets. And then do you I mean that’s a really good explanation of activation component versus non-activation. Are you a proponent of creating a better environment prior to these injections versus injecting them I guess sort of cold if you will right in terms of is this something that that is there value to that in your opinion or you know when you’re when you’re dealing with this from an international standpoint what’s your take on something like that? Yeah, we uh we always believe in optimizing the patient for uh for regeneration and repair. So it could be anything from, you know, cutting back on alcohol consumption, smoking, recreational drug use,

any of those types of things. Um there’s certain dietary things that that patients can do to increase their platelet count, things like that. So yeah, we always try to encourage our providers to have that discussion with their patients before they receive any type of PRP or regenerative medicine treatment.

I mean, it’s the same thing, right? Sleep optimization or like just little things like that. You know, people ask me and they say, “What what can I do?” I mean, in broad strokes, get really good sleep,

eat really nutritionally valuable foods,

and stay hydrated.

Yep.

I mean, the basic tenants there, right? You can get into vitamins, you can get into these other things, but again, right, like if if your body is not ready for the injection to receive it, is it the PRP that didn’t work or was the host just not ready for it?

Right? I mean, I think there’s and that’s kind of these other things that I think not all PRP is the same. So you look at that component, but if you’re coming in and your joint is super hot or like inflamed and you’re really sore, I mean, I think you have to be optimized. I think more people probably don’t understand or appreciate that component of it versus, you know, we use this example a lot like in terms of um so I think the big thing is what people may not understand that you need to sort of create a better host environment. We use a lot of EMTT and shockwave in in our practice in terms of how do you prepare a joint or a tendon or ligament or whatever you’re trying to do prior to these injections. And the big thing is the example I use is when you go gardening, do you just throw seeds on the ground

or do you take time to till the soil and prepare it and have a really good environment and then on top of that,

you know, and then if your seeds are bad, then it’s not good either, right? The PRP is not great or or the delivery and all that other stuff. And then also the postcare too, right? And I think that’s that’s kind of it. But you know, let’s talk about research.

Yeah. Sure.

Why one PRP study says it works and another says no better than saline 16:49

When a patient goes online and a PRP study says it works beautifully and another one says it’s no better than saline,

how do you reconcile those two papers and what should people be looking at when there’s such a difference in studies?

Yeah. Well, right now I think at last count there’s about 40 different commercially available PRP systems in the US. That means that they’ve been um cleared by the FDA for use and uh physicians can use them. Uh there’s also some other systems that um that providers kind of do on their own, kind of the the made from scratch type PRP systems. So 40 commercially available plus who knows how many more of the of the systems that providers do on their own. And when you look at research out there, you need to understand that there’s a lot of variables out there that aren’t necessarily um disclosed in the initial abstract or the summary or the conclusion that you read on those papers. So, while it may look like one PRP system works incredibly well for knee osteoarthritis and there’s another PRP system that doesn’t work as well for knee osteoarthritis, is it that PRP doesn’t work or is it that they’re just drastically different systems out there? Right. And I think that it it really needs to be um really need to focus on kind of the methods that are used, the systems that are used. And again, there’s a lot of different variables out there. There’s platelet concentration dose. There’s uh luccoyite content. There’s activated versus non-activated. There’s the potential for, you know, ariththroytes uh or or cell licing in there that anytime there’s a different um different components in the syringe, it’s going to behave differently in the patient. And so just because there’s a PRP system out there or a study out there that says that PRP didn’t work, I would say that it’s probably one of the more inferior systems that isn’t being optimized in the syringe and uh you know is is um carries the least regenerative potential for the patient. So

I think that’s a really good point. If you’re in your car and you’re hearing about this and you go to a doctor and says, you know, PRP doesn’t work and they say, “Well, you know, I have a lot of studies that show that PRP doesn’t work.” Either you read the headlines and it just says PRP doesn’t work. And then when you get into the details of it and you say, “Well, they took out 10 cc’s of blood.

They spun it once at a low rate. They didn’t use ultrasound to the injection. their platelet concentration or their dose wasn’t optimal. And then you’re like, well, wait a minute.

It didn’t work.

Okay, so our producer Trent here, you know, big strong guy and we talk about uh protein powder. If the proper dosing is two big scoops of protein powder

and you take a little teaspoon

and then you know you don’t have any muscles, you don’t feel like it’s working. Are you going to say protein powder just doesn’t work? I mean it’s akin to the same thing, right? Like if you’re if you’re not optimizing that component, then how can you say it doesn’t work? If you’re if you look at these different metrics that you that you talk about that these different variables and then the study just said the big sexy headline says PRP doesn’t work.

And I don’t think that’s fair, right? And so if you want to gravitate towards that, if it’s good for you in that space to say that PRP doesn’t work, then you’ll grab that

that article and you’ll neglect the other ones that say, “Look, they took more volume. they did this, they optimized this potential and you say regenerative potential and that’s exactly what it is, right? Where if they take that amount and do it right,

it works. It really works especially as you kind of go through it. So if you could standardize one thing tomorrow, what would it be in the regenerative medicine space? uh for PRP systems for me it would be luccoy free and fully activated

because that makes it much more predictable once it’s injected into the patient.

What I mean by that is if uh fully activated piece platelets release all of their growth factors. So fully activated 100% of the platelets release 100% of their growth factors 100% of the time every patient every time. If you use an activator similar like a calcium chloride or something like that, it will also interact with some of the other components in the plasma, specifically the fibbrinogen, cause the fibbrinogen to form some long fibbrin strands. And then when they inject when it’s injected into the injury site, it will actually have a nice little matrix for all of those growth factors to live. And then the body as it resorbs that fibbrin matrix will be releasing those growth factors into that surrounding tissue. Now ideally it’s injected at the injury site so that those growth factors are in uh are being distributed into that injured tissue. sometime you know that that’s another that’s another discussion about injection technique

right

but the thing about it is that even if it’s a PRP that is activated if there’s a lot of luccoytes present what’s going to wind up happening is that it’s going to degrade that matrix a lot faster so just to land the plane on that so if it’s luccoyfree and fully activated you’ll get a timerelease dose of 8 to 10 days pretty typical right if it’s a fully activated uh PRP where there are luccoytes present. It’s only going to have a time release for about a day and a half to two days. So that’s one of the things that you know depending on what’s actually in the syringe will determine how well it behaves inside of the patient and it’s up to the providers to know exactly what’s going to happen, you know, on the back table in the preparation, but also how it’s going to behave once it’s injected into the patient.

Who is injecting and where: the acupuncturist story, poke and hope, ultrasound guidance 23:24

Yeah. I mean, that’s really smart. I mean I think you know leads into what we talk about from a delivery and the part that nobody talks about here right and so the provider that’s doing it

the physician that’s doing this what’s their experience what’s their you know what’s their track record with this

we had somebody locally here AJ and I’ll tell you this we talked about this before we kind of got going that there was somebody here locally who their background ground is in acupuncture.

Mhm.

And a patient walked in and said, “You know, I had PRP done by my acupuncturist.” And I said, “Oh, really?” They said, “Yep.” They took blood, you know, they spun it and they injected it back in and they said it was PRP. I said, “All right, well, how much blood did they take out? How many times they spin it?

What did they what was their end volume? Did they use an ultrasound?”

And she was like, “You know, I don’t know. uh they didn’t use an ultrasound and I said okay well where did they put it and she said well they just put it where I told them it hurt and I said okay what was your diagnosis

what was the problem and they said elbow pain I said all right where in the elbow she said you know like just on the outside of it

and I said okay so now we have an acupuncturist that’s doing PRP here locally in this area so you tell me you want to go to an acupuncturist to go get PRP P or do you want somebody that has had experience doing this and teaches this?

Yeah.

And if people don’t think about that, I got PRP and guess what? Do you think your PRP worked?

Yeah. They’re probably going to be one of those patients that walks away terribly disappointed

and saying PRP doesn’t work.

Yeah. Exactly.

And so preparation’s half the story here. The other half’s delivery.

How much does injection accuracy change outcomes? Yeah. So, I get I get asked all the time by friends that know I’m in the business and stuff like that. They’re like, “Hey, you know, I’m I’m having knee pain. I need to go see a doc. You know, I would really rather get injections than surgery. What question should I ask?”

And the first question I tell them to ask is if they use any type of imaging guidance.

Yeah.

Most common is ultrasound. Depending on where the injection is in the body, you might need to use some fluoroscopy or live X-ray or something like that. But if it’s not imageguided, it’s a lot of poke and hope.

AJ, you know what we say on our podcast, like if they’re not going to use ultrasound, just grab your stuff and just walk out.

Agreed. We we’re in alignment 100%. Yeah. Yeah.

It’s it’s really fascinating. Yeah, we had we had one uh person, you know, um I use a click pen, but you know the pen caps that people sort of just like to chew on sometimes. And so we had a patient with who had PRP elsewhere uh done. And I said, “Okay, like walk me through that process.” And he said, “Yeah, he like literally just grabbed the the cap of the needle with his teeth and just like took it out that way like you were chewing on a pen cap and he injected it into it was another elbow.” and and the patient said, “Aren’t you going to use ultrasound?” And so this physician, this one happened to be an orthopedic surgeon, said, “Oh, no. I know where I’m going. I know where to put it. I don’t need an ultrasound.” There’s plenty of data out there that shows even when you think you know where you’re going, you don’t know where you’re going. And I I mean, if you’re paying money for regenerative potential, don’t you want to know that it’s going into the right place and that you can confirm it visually?

Yeah. We actually have a study that talks about imageguided versus landmark, which is just kind of I I know where it goes,

right? And the interesting thing is that uh hitting the injection site when you’re using landmark guidance and this is across a pretty large end of doctors is about 25%.

If you’re only hitting the mark 25% of the time,

right,

you’re not doing you’re not benefiting your patients like you should be. Yeah.

Especially when you have tools Yeah. that can help you hit your mark 99.9% of the time.

If you have those tools at hand, why not use them because you’ll have better outcomes.

Yeah. I mean, I think I think it’s part of the the challenge here of people trying to get into the regenerative medicine game and here big air quotes on that.

When I go lecture um across the country, people come up to me and say, “Well, how do I get into this?

What do I do here?” And I said, ‘Okay, like, um, do you walk up to an orthopedic surgeon and say, ‘How do I get in the orthopedic surgery business? You know, do you walk up to an OBGYN doctor and say, “What do I do to catch babies here?

Do I just get some sticky gloves? What do I need here?”

Yeah,

there’s training involved here, right? And I think and I think part of it is where understanding that component of why you’re doing what you’re doing. You know, we we’ve talked about this, you know, before we got going was we do a lot of PRP, we do a lot of bone marrow, we do a lot of ad post, and you’re trying to choose why you’re using this versus that and having an understanding of what you’re really trying to do and sort of work backwards. If your if your mission is to say, I have to do X number of PRPs in a month to make this money, I don’t know if you should be doing it anymore because your goals are misaligned for what’s in front of you, the the person in front of you. And so, and I think that’s a big big challenge here, right? Is the financial component versus the outcome component, right? And we talk about like these are we’re in the outcomes business.

That’s what really matters, right? I mean, walk me through that a little bit in terms of outcomes and why that’s sort of the metric that you’re looking at.

Yeah. Well, it back to what you had said earlier. It’s an interesting space, right? because a lot of providers now are fighting the battles with the Medicare and the insurance companies and reimbursements and you know they’re basically getting pay cuts every year for a lot of the procedures that they’ve been doing.

So there’s a natural desire to move towards more of a cash pay business where they don’t have to deal with the claims and the reimbursements and things like that. Now, um there’s certainly a lot of a lot of good actors and good doctors in there, but there’s also a lot of people that are just looking for an easy bach, right? Right. And so, uh as a as a patient, it’s a little bit hard to know who the who the great provider is that is interested in the outcomes and who the provider is that’s just looking for a box. So, it uh it’s an interesting space and it’s a little bit of a buyer beware market right now. just because there is such this large migration from providers who were doing insurance and Medicare reimburseed practices into cashbased practices. So that that’s a big challenge as consumers. And then the next part that you had talked about was outcomes, right?

I mean ultimately that’s that’s what we’re looking for, right? Again, there’s a bunch of different systems out there. It’s not like there’s going to be one magic ticket where you have to nail it down to one system that’s going to work. If you find a provider that really understands the anatomy and more important the physiology of what’s going on there and they understand the system and what they’re delivering, whether it be PRP, whether it be atapost, whether it be bone marrow, and how they expect it to function in patients, you’re going to maximize your chances for a great outcome. Unfortunately, in the regenerative medicine space, there’s no golden ticket that works 100% of the time. You could have the best physician and the best product and absolutely be dialed in with everything associated with your condition and there’s still going to be a small percentage of patients that are going to be non-responsive. But as a consumer, you need to be smart with how you are spending your health care dollars in this space by making sure that you are using a provider that really really knows what they’re doing and they’re using a system that has been very very well researched and well vetted and that the provider knows knows how to place that regenerative injection at the exact spot and the exact volume that you need it.

Diagnosis first, candidacy, saying no, and the real cost of injury 32:24

Right? I mean, it goes back to a couple things here. I mean, the most paramount thing is, are you getting the diagnosis correct?

Mhm.

I mean, you think that’s a given, right? But like, if you if you’re trying to fix your refrigerator,

Yeah.

because you think that’s broken, but it’s the microwave that’s beeping.

If you fix the refrigerator, it’s still not going to solve your problem.

Yeah. I think that’s the challenge in terms of you know if you are not looking at an image be it an MRI

or fluoroscopy or or we use dynamic ultrasound in our office right so we can I can tell you I’m say like there’s a big hole there right I’m going to show you your other side that looks normal and then I’m going to show you the other side there’s a big hole there

yes or no

right I mean somebody that has no ultrasound experience

we we had a we had a guy come in uh two daughters, one was like seven and one was five. And I showed them a hamstring, the one side that was normal.

And then I showed them the other side of their father. And I said, “Okay, you tell me what’s wrong here.”

Children and they’re like, “Oh, yeah. I see like that one’s got this little black spot in there and that other one it didn’t have.” But I said, “Yeah, that’s the tear.”

Yeah.

That’s in your father’s hamstring.

Yeah. And so that’s and if you’re going to use guidance for that, that’s where that value comes into play here, right? Like if you know what’s going on and you’re able to do that, and I think that’s a that’s a huge thing. The other thing that I would tell people, and you make kind of a good point about this in terms of just this value, I want you to ask anybody that’s doing regenerative medicine, and I don’t think we’ve actually talked about this on any of the podcasts. So AJ, thank you for being here and and and reminding me of this. Ask them, tell me a time when you’ve said, “No, this isn’t going to work.”

Not everybody’s a candidate. Look, we run over a 90% hit rate, success rate. We feel like over 90% of our time, our patients are successful when we do it. That’s a monster number to put up in the regenerative medicine space. And a lot of it has to do with how we prep it, what we do during, what we do after, and kind of that the gardening analogy that we talked about.

There are times you have to tell somebody that they’re not a candidate for what you’re doing.

They may need surgery. They may just need physical therapy. They may need something else. But you have to be able to it can’t be a 100% of the time that everybody that walks in your door is getting a regenerative medicine procedure.

Yeah.

It’s just not feasible, right? And so that’s a that’s a question I would ask our listeners, anybody else listening to this, just ask whoever obviously the questions of, you know, do you use ultrasound? You know, what’s your experience with it? What are your outcomes? All that other stuff. But just ask them, “Hey, what’s a time you told somebody that this wasn’t working?” Right? I say this a lot. I mean, I earlier this week, I told this person that they needed to go get surgery, and I said, “To the financial detriment of this clinic,

I am telling you, don’t do this.

It’s not going to be in your best interest.” And I think, let’s talk about insurance. I mean, it’s the same thing that insurance companies are not there for your best interest. They’re are privately held companies. They make money like everybody else. They beholden to their stockholders like everybody else. You don’t get mad at McDonald’s for making money. You don’t get mad at Microsoft for making money.

Yeah.

The insurance companies are designed to make money, right? I mean, I don’t I don’t love it because it’s in a sensitive space. So kind of walk me through a little bit about this this gap that between the care that you get with insurance

and then the care that you get outside of insurance and what sort of that difference of place.

Yeah. So in insurance companies like you said are designed to make money, right? So they want to maximize the amount of premium that they take in,

right?

And they want to minimize the amount of payments that they send out. But they also have to they also have to take care of the patients for anything that is medically necessary. Right. If if you have a broken leg and the only way to repair the leg is to you know interoperative surgically. Yeah. Go

ahead. What they deem medically necessary. Good point. Right. Okay.

Yeah. As as consumers, we might not always agree with the insurance companies, but uh the the regenerative medicine space is interesting because it makes patients a lot smarter with their health care dollars. Yeah. Right.

So use use the leg as an example, right? Suppose you had to go you broke a leg, you had to go in for some imaging, they wanted to do X-ray, MRI, things like that. Most patients that have commercial insurance will just go wherever their doctor tells them to go,

right?

But what they don’t realize is there there might be an imaging center, you know, a few miles away that’s half the price, but they don’t really care because it’s the insurance company that’s paying it. They have the same co-pay or the same deductible or whatever regardless. So, we’re in an interesting space as there’s this huge trend towards more regenerative therapies, which are more cash pay, that it’s making consumers a lot smarter with the way that they spend their dollars. And I think overall that’s a great thing for the market because a lot of our health care system, especially the insurance coverage part of the health care system is a little bit broken and it’s in a it’s in a spiral to uh to just continue to get more and more expensive and provide less and less coverage. As consumers get smarter with their health health care dollars, it’s going to uh it’s going to help to move the system in the right direction to where it becomes more efficient and delivers better quality care for those patients. I mean, if you look at the ability to spend your money and make a decision on where you want to go

and what kind of product do you want, I’ve said this before where it’s the commoditization of PRP that is a big problem. Mhm.

If you if your first question to any place that does PRP or utilizes that, if your first question is how much does it cost? I think you’re looking at this wrong. I’m not saying that cost is a is not a variable. Don’t get me wrong. It can’t be the first thing. And here’s why. It is akin to you saying, “I’m going to go to the grocery store and I’m going to go get a gallon of milk. I’m gonna get some bananas. I’ll get a PRP and I’ll get a loaf of bread.

You start to look at and be like, well, all right, how much is this PRP? All right. Well, let me look at this. You think it’s the same, right? The apples to oranges comparison, right? The same premise. It goes back to the studies.

You’re not comparing this PRP and this PRP and seeing which one works and which one doesn’t. This one is a significantly inferior system that wasn’t placed right and this one is a superior system placed properly and it shows that it works.

So if you’re commoditizing your health because they don’t know any better, right? People don’t know what questions, that’s why they listen to this podcast. That’s why, you know, there’s, you know, there’s information here in terms of what am I supposed to ask so I can get to the answer here. So, I mean, we have people that fly in to come see us, that’ll drive four hours to come see us or whatever because they value that piece of it, right? And I think, you know, let’s talk about the real cost of injury there. People out there that are hurt, you’re paying either way. Mhm.

Either you pay with your money to get it fixed or you pay with your time or you pay with your inability to play with your kids

or inabil inability to play with your grandchildren or you can’t work out, you can’t do the things that you want to do. So what’s the cost of that? What’s more valuable to you?

And I think that’s what people have to answer. So the the season that um an athlete misses or a parent misses coaching, doing something a year that people are rehabbing, how do you frame it in terms of that tradeoff where somebody tells you, “Hey, this is too expensive.”

How would you tackle that? What’s your thoughts on that?

Yeah. Well, you laid it out pretty well, right? Um the adjustments to your lifestyle Yeah. have a cost. the adjustments to your functionality, whether it’s a knee, a hip, a shoulder, an elbow, you know, any any number of things, have a cost. And, you know, are you really willing to give those things up for um, you know, saving a few bucks, right? And then you also need to look at the long term, right? If you have if you have some type of a chronic condition, it’s probably not going to get better on its own

or it would have gotten better by now.

Exactly. That’s exactly where I was going. And and so um a lot of those things aren’t going to resolve themselves. So you can either pay a little bit now

or a lot later. And if you pay a lot later, you’re also going to be suffering along the way.

Yeah. So avoid the suffering. Figure out what the best way to treat that right now is. And like you were saying, you know, it might not be an injection. It might be rest. It might be physical therapy. It might be just holding off on these one or two activities that aggravate that for a week or a month or whatever it is. And it might repair itself, right? But what what you need to do is is find somebody that really knows what they’re doing and get expert advice from somebody who has treated patients with that same condition and knows the best uh protocol for getting you better.

I mean, look, it’s really fascinating. I mean, and it could be a lot of upfront money, too. So, not, you know, we don’t want to downplay it. Sometimes it’s it’s pretty it can be pretty costly. I mean I think it’s cost is variable and um dependent on the person right I mean and I think it’s it’s different for everybody but you know people come and see us they come to dynamic athlete they come and see me in terms of what’s your most valuable resource it’s your time

people come to see us to buy back time do I get three months of no pain or less pain I’ve been having this for years, multiple years. So then what if what if we took 12 weeks to get you back and you know, three months

and you’ve been having two years of pain. We’ve now bought back 21 months of painfree living.

You tell me what the value is on that, right? I mean, when we talk about this. So

yeah, I I can actually give you a personal example for that. I uh I play in the mountains a lot in the wintertime and uh I do things that my age probably would uh suggest I shouldn’t do and uh was snowboarding was a year ago Christmas and went off a jump because my kids like to see their dad go off jumps.

Sure.

Uh they like to see me land jumps too but uh actually came down a little bit awkward and had a slight miniscal tear in my right knee. It’s called a bucket handle tear. And went and saw a close personal friend, orthopedic doctor, orthopedic surgeon.

And he’s like, “Oh yeah, need to need to operate on that. Need to operate on that. Need to operate on that.” I was like, “Hey, I’m in the PRP business. I can’t go straight to surgery. I have to at least try my product.” He’s like, “Okay, let’s try your product. Let’s do it.” If I looked at what it would have cost me from a lifestyle perspective to have that surgery, I would have been out weeks and weeks. I would have been on crutches. I would have been, you know, at least a week off of work from the surgery, things like that. Uh, versus having a series of PRP injections in my knee, actually intraminiscal. And what wound up happening is that the PRP injections healed it. Right.

Right. So again, just being a smart consumer of of your health care dollars and like you had said your health care time.

Right.

Right. And so I have I have the luxury of being in the business and know a lot about the studies and things like that and how injuries like mine can be resolved with regenerative therapies instead of surgery. But yeah, I I look at the outcome that I had and I’m I’m so happy I did the PRP injections. Now, from a cost perspective, I had to pay out of pocket. It cost me more to have the series of PRP injections in my knee, actual cash out of my own wallet, than it would have cost me to have the surgery, right? Just because my insurance would have paid for all the surgery. So, from from a pure dollar standpoint, it was more expensive. From a lifestyle perspective, it was such a good decision. I mean, also impacting your future. So, if they, you know, you know, at a certain age, you can’t repair that meniscus.

So, they’re going to take it out.

And so, you know what that does?

That arthritis train starts to now leave the station, you know, and and so the downstream effect of some of these things. So, last question before we get into a little rapid fire. Um,

sure.

The future of combinations, rapid fire, and the label versus the protocol 46:39

Where do you think this is field’s going? Where do you think five years out, what changes about regenerative medicine, the way that sports and orthopedics is practiced? What changes in the future here?

Yeah, I um there’s so many pioneers doing so much great research in the space right now. Uh really figuring out exactly how all of the the proteins, the growth factors, the healing agents work together in combination. um you know starting about 10 maybe even 12 years ago there was a big buzz about stem cells we haven’t really gotten into that but uh I think there’s a lot of future in stem cells and exoomes not excited about it currently I personally wouldn’t go that direction right now but the scientists that are working on all of the signaling mechanisms with that once we get the signaling figured out with stem cells with exes zones and and other, you know, similar type products. Um, that’s going to be a really exciting time because there’s going to be there’s going to be some amazing things that we’re going to be able to do in the regenerative medicine space, especially with, you know, there’s a huge trend right now with with peptides and a lot of those types of things as we figure out how how to do the signaling and what peptides to use and what amino acids are out there and how all of those different proteins or protein fragments um interact with one another. It’s going to be unbelievable some of the things that we’re going to be able to do. I mean, I’ll I’ll be able to snowboard into my 60s instead of uh instead of having to quit here in the next few years.

No, I I mean, I agree with you. I mean, I really think every day you just you see advancements,

right? And people pushing the envelope on things and making sure it’s done in a safe way. And I think that’s really a big thing is

for me making sure that things are done in a really safe way

and and almost having a reason for why you’re doing it. And and I think it goes back to having a really good understanding of what it is, what are you trying to treat, how can we get there, and then going from there rather than just sort of this shotgun approach to things, right? And so

earlier you had mentioned shockwave therapy and we didn’t really get into the combination therapy idea

but love the idea of using shockwave with PRP.

Yeah.

Works unbelievably well. And the nice part about that is that shockwave on its own very very effective. Tons of great studies out there. PRP on its own very very effective. Tons of great studies out there as long as you have a good provider, good injector, good system. But the idea that when you combine those two, you can actually have outcomes that are better than either one of them individually is exciting. And I only bring that up because we’re talking about what the future’s going to be. I think the future is really going to be what those magical combinations are. We just need to get the science caught up to figure out what they are. It might be shockwave and atapost followed by PRP followed by some other, you know, uh, peptide regimen or something like that. I’m just making that up. Don’t follow that advice. That was just a hypothetical. But, but once we get that figured out, there’s going to be some really, really cool stuff that happens with people. I mean, look, you know, I just I feel like uh you know, the listeners are going to think I paid you to say that, but uh you know, we we run shockwave with our biologics pretty much standard

and the rationale is again sort of, you know, how do you how do you take care of that environment? And so I think that’s super important. I think that’s really why our success rate is so high is because again, we try to dial in and really get to those different factors and say, okay, like have we checked this box off? Have we checked this off? Are we good here? Do we have this here? Okay, then let’s go. Right. And then then we kind of go from there. So, no, that’s a really good one to end on. Um, I got five questions here.

Okay, let’s do it.

Real quick, just short answers. You tell me what comes to mind here and we’ll and we’ll send everybody off on these five. So, uh, one thing patients get wrong about PRP.

Well, we talked about that a little bit before that they’re that they’re all the same and that all PRP and all PRP systems are equal. all our PRP doctors are equal, all that. It’s a it’s a wide range. Um, the analogy that I use a lot when I’m when I’m out selling is it’s like steak, right? Steak is a very broad general term. You could have the most amazing Wagu type or Kobe beef type steak, super premium, and you could have the most gristly, nasty steak there is. Both of them are considered stakes, but there’s a huge spectrum out there as far as the quality and the delivery and the way it’s prepared and things like that. So,

yeah, you know, I mean, that’s a really good example. My parents are vegetarian, so anybody listening can uh can email me a vegetarian uh correlary to that and then also our vegan friends uh can do the same. So, yeah, I wholeheartedly agree. And then if any steak place wants to sponsor us too, we can do that too. Um, so one thing that doctors get wrong about PRP,

um, again, we talked about that a little bit as well, there’s, um, you know, the the last rep in the office or the last conference they went to or the last webinar that they were on.

You know, all these companies out there are for-profit companies and they’re trying to make sales, right? and they’re always going to say they’re the best and they’re always going to have a list of reasons why.

Sure.

And so there’s a little bit of uh what I would call a a credibility validation gap

that providers really need to dig into. They need they need to do more spend more time on the science than the marketing.

Yeah, a great point. All right. The number three, the most important variable in the entire preparation process. uh preparation process is how well you separate the platelets from the other components. Basically, it’s um it’s it’s probably as much if not more about what you throw in the trash than it is what you keep because you could take you could have the best injector in the world. You could have them injected at the at the best spot in the world, but I or best spot for your condition, but if it’s a if it’s a terribly prepared product, in other words, there’s a there’s a bunch of trash in there, you’re not going to have a good outcome. So, so you know, make sure that make sure that the right things are going in the trash.

I mean, I agree with you there. How about a paper that clinicians should read in this space? Do you have a have an article that you like? Yeah, there’s a great one that came out. I’ll get you the link to it. I apologize. I can’t remember the the author, but uh he he goes in and he breaks down all the different variables with PRP systems and how each of those variables can impact patient outcomes, patient experience, everything like that. I’ll get you the link to it, but it’s really good. He he dives into everything from the anti-coagulants that we talked about to platelet dose or platelet concentration, luccoytes, um whether we’re removing any of the platelet poor plasma because there’s a lot of really valuable proteins that are contained in the plasma that you don’t want to pull those out. Um you know, ultrasound guided injections, things like that. So, I’ll get you a copy of that. Yeah, we can put a link to that in the in the um podcast episode in the notes there. So, we can do that. All right, last one here. Most underrated application of this technology, this regenerative medicine space.

So, we uh our formulation is a little bit different in that it’s luccoyfree that it allows us to inject in places that other systems that have luccoytes present cannot inject. And so two of the areas that we really really shine with that that you would never want to inject a luccoy poor luccoyer rich PRP are interosius injections especially for moderate to severe knee osteoarthritis patients that aren’t great candidates for uh knee replacement surgeries uh and by interosius I just mean injecting into the bone right

so if you’re injecting into the bone you don’t want to create any type of inflammatory response because there’s not really anywhere for the inflammation to show and it can be an incredibly painful procedure. If it’s an anti-inflammatory product, i.e. a PRP that doesn’t have luccoytes, unbelievably good outcomes. We actually have a study that we um that we started 15 years ago about prolonging knee replacement surgery. And uh we actually still have two patients that have made it 15 years without having a knee replacement surgery just by having annual injections. And by interosius when we’re talking about knee it would be an interarticular injection. So we do an injection in the joint. Right?

Then we we do an injection at the top of the tibia. Right? So that’s kind of your shin bone.

Um it’s called the tibial plateau. Do it there. And then at the at the far end of the femur, it’s called the femoral condiles. There’s two of them. Depending on where the condition um is more prevalent, we do injections there. And the nice part about that is that you’re treating the entire joint space instead of just the the internal compartment of the joint. So, that’s one of the big ones. I’m going to I’m going to expand on this and do a second one as well. Uh we’ve done a ton of research on intraural injections as well. And again, not all PRPs are designed to be injected into the nerve, but we do a lot of work with uh with physicians who treat UFC fighters.

Y

and a lot of times, especially the guys that lose, wind up having a lot of nerve damage, especially in their neck, kind of that nerve plexus that runs through their shoulder. And after fights, they’ll have a lot of numbness and weakness in their arms. And by doing injections directly into that nerve plexus, we’ve actually been able to help them recover a lot faster and get their strike force and and fighting ability back. Get them get them back on the mat in the ring and the octagon.

I mean, I think I think those are super valuable. I’m excited to sort of see, you know, we talked about shockwave and we didn’t mention EMTT. You know, so we have this debate whether or not you’re going to need introsius injections if you’re able to actually pinpoint with a shockwave and be able to get deep into that into that bone space and then being able to utilize it. There’s really good stuff EMTT is really good with nerves the potential of combining them with PRP in that that space. And if you guys are thinking about you know what AJ was saying is absolutely correct think about rungs on a ladder. So that top rung is that femoral condile, that middle rung is intraarticular, and that bottom rung is that tibial plateau that he’s talking about where you’re taking care of that whole section there. So that’s really big. Uh AJ, I can’t thank you enough. I wish we had more time here. This has been super fun. I mean, if there’s anything you want to plug, you want to you want to tell people where to find you, what to do, you know, certainly um you know, let us know where how do people find you and and read more about and what you’re doing and and all the cool stuff that you’re up to.

Yeah. Uh my my product is called Enderet PRGF. Um I’ll give you a link to the website so you can put it on the show notes and stuff like that. But uh yeah, been been around for 30 years. tons of science behind the product and continually pushing the envelope on ways that we can do um treat injuries and disease states with regenerative therapies as opposed to surgery. So, I mean this is great. I mean, if there’s one thing that I want, you know, typically I tell people, here are some things to sort of walk away with that the label on your treatment doesn’t tell you what you you’re getting.

Mhm.

The protocol does. and ask what’s in it,

who’s delivering it. Ask what the plan is when the needle comes out. If you’re dealing with something that hasn’t healed and and you’re trying different options, just go to DynamicAthlete.com, read about the stuff that we’re talking about here. See if it resonates with you. Ask the right questions when you walk in there. be the most informed consumer you can be when you’re trying to spend your health care dollars on your care to get back faster. So, we’ll see you guys next time. Thanks so much.