Episode Transcript
[00:00:00] Speaker A: Foreign.
[00:00:11] Speaker B: Welcome to the Comeback with Boomerang Healthcare, your podcast for relief, recovery and restoration.
[00:00:18] Speaker C: I'm Dr. Peter Abaci And I'm Dr. Sarah Guzet. As doctors, we know healing isn't just about treatment. It's about having the right tools, mindset, and support to move you forward.
[00:00:30] Speaker B: You can have pain, you might be injured or even hurting on the inside, but with all that you've got going on, you can still have a really great life. And that is what we are here for. This is the Comeback. Let's get started.
[00:00:46] Speaker C: Fantastic. Super excited to have with us today Dr. David Suarez.
He is a provider with Boomerang Healthcare. Welcome to the show, Dr. Suarez.
[00:00:59] Speaker A: Thank you. Thanks for having me. I'm excited. Longtime listener, first time caller.
[00:01:05] Speaker C: We love it. We love it. Why don't we start off by having you tell us a little bit about yourself?
[00:01:10] Speaker A: Sure, absolutely. That sounds great. So, yeah, so thanks again for inviting me on.
Well, I guess this is one of those questions where I never know how far back to start.
I'll just go with.
I was actually born and raised in Colombia, so I'm a native Spanish speaker. Moved here when I was 11.
You know, the college in LA. Did medical school a little bit later in life at ucsf. Did my residency in PMNR at Stanford here in the Bay Area.
Then I did a fellowship in interventional spine, sports and regenerative medicine, which obviously is what we are going to discuss today.
And I did that in Napa at the Boder Clinic.
And I've been working in private practice ever since for about eight years, first in San Francisco, and then I joined what used to be comprehensive Spine and Sports center in 2021, then Boomerang and, you know, 2022 or so.
And I'm married, have a couple kids, you know, living this, the suburban life. And, and then here I am today.
[00:02:14] Speaker B: You know, Dr. Suarez, when we were chatting before we started, I could just feel your enthusiasm for regenerative medicine, the whole field and specialty, which is really a new and growing specialty. Maybe tell us a little bit about how you got interested, what got you into it, how you ended up doing a whole fellowship.
[00:02:36] Speaker A: Absolutely.
So, yes, you're correct. I, I'm definitely very excited and I, and I do take some pride in, in feeling like I, I get to talk about it, I get to do it, I get to spread the knowledge about regenerative medicine. And my first exposure to it was in, in residency at Stanford.
And we might get into this a little bit later, but, you know, I would say the principal study about platelet rich plasma came out of stanford, you know, 2006, Dr. Mishra. And I believe, you know, because of that and probably, you know, just general interest that there was, you know, quite a bit of discussion about regenerative medicine at Stanford during my residency, and I got to participate in some procedures, the, you know, some couple athletes, and it just became interesting with a couple of the attendings that I was working with.
And just fortuitously I happened to get the opportunity to do a fellowship that was heavily involved with regenerative medicine as well with, with Dr. Marco Boder, and that kind of solidified the whole thing. I loved being able to offer something that was, you know, something a little bit, a little bit different than sort of your usual, you know, corticosteroid injection as far as procedures are concerned. And it, it became something that I, that I really enjoyed doing, that I saw a lot of good results with and, and, and something that I knew that I wanted to be able to offer to, to, to my patients as, as a treatment option.
[00:04:15] Speaker C: Fantastic. And I'm, I'm curious, you know, as you're going through your training and your fellowships and be exposed to a variety of interventions, was there any particular patient or case, whether it be your own that you came across or one that maybe you got to shadow, that really kind of struck a chord for you, and you just kind of like clicked and felt like it was your calling and you're like, yes, this is definitely my cup of tea and this is where I'm going. Anything in particular stand out for you?
[00:04:42] Speaker A: You know, it probably. I mean, there, there, there have been many patients that, that I still recall being sort of giving me extra satisfaction as far as the, the success that, that we achieved.
Whether it was because they were able to return to a certain level of function that they didn't have before, or whether it was because perhaps the result was, you know, unexpected and, and the improvement was even greater than I thought I might be able to achieve. But it was probably more of a cumulative effect. And really, in my fellowship, I would say, because that's really when I had the greatest exposure and, and, and the, you know, from, from treating a high school athlete's ankle to treating, you know, a famous member of, you know, of, of a rock band, and just seeing the improvement that, that it provided as well as the sort of the, the opportunity to, to have an alternative to just basically saying, well, you know, you can either do steroid or do surgery. It was sort of a. Well, you know, there are more things that we can potentially try, but yeah, I mean, there certainly, you know, I mean, one such patient, I would say, was someone who had a rotator cuff tear that really seemed like there was no other choice except surgery just because of the size of it. And he had had a bad experience with surgery in the other shoulder, and he was just not going to have surgery on, on, on, on his, on, on the one that, that had not been surgically repaired yet.
And basically he came to me and he said, I want to try anything, anything you got. So we actually did bone marrow stem cell injections into, into this rotary cuff tear that was a little bit larger than, you know, than typically I, I target and, and I let him know realistic expectations. And we followed it over time. And actually on the ultrasound, we could see the change of, you know, some of the fibers, which, which was pretty impressive. And he, his function improved significantly. And so, I mean, but there, there are definitely dozens of patients like that that I still remember that that had this great result. And I've had PRP on my body four times. So I've, you know, I, I, I'm, I'm one of those patients that certainly helped solidify my, sort of my opinion of the whole thing.
[00:07:08] Speaker B: Okay, you open that box.
Where did you get injected?
Do, do tell, doctor. Dr. Suarez.
[00:07:16] Speaker A: Yes, yes. So three of the four have been on my shoulders.
And then I did one at the first carpometacarpal joint.
And so first one was, I want to say, eight years ago into, into one shoulder. And one of the, so in my fellowship, there were three of us that, that were fellows at that time, and one of the other fellows did the injection my shoulder, and it was fantastic. I had really good results. I, you know, I didn't, I didn't have sort of a severe, severe injury. It was, you know, fairly mild, but it was, it was perfect. It was the perfect kind of treatment for that. So I had great results. And then I kind of tweaked both shoulders a few years later. And so of course, I, I immediately had my medical assistant. This is when I was now in, in, in private practice, and I had my medical assistant help me inject my own shoulders. So, so we did that.
And, and then, and then I happened to also, I had, I have some issues with this joint. So I said, you know what? We have a little bit of leftover. Let's, let's try that joint. And I would say I'm, I'm about, you know, three, three for four. Um, about 75% success rate in my own body. Which actually sort of goes along with what I've seen as far as success rate kind of across the board with, you know, with, with, with prp, I would say.
[00:08:44] Speaker C: Oh, wow.
[00:08:44] Speaker B: You know, it's interesting, I was gonna say, Sarah and I, we've been doing this podcast for about a year and a half and it seems like just about every guest that we've had who's been in healthcare, medical professional, has had issues that we're talking about.
It's really fascinating when you say Sarah.
[00:09:04] Speaker C: Oh, absolutely. It reminds me of the old adage, right, that what is it, pain is going to happen but suffering is optional. Right. It's part of the aging process. And so I am curious, you know, what exactly falls under regenerative medicine and what conditions can we treat? So for, you know, the non medical trained listeners, including my, myself, who you know, aren't quite as familiar with regenerative medicine, I think so many, I've heard so many procedures and interventions fall under it, whether it be prolotherapy, prp, like we're talking about stem cell, would love to learn more about, about this field and the different interventions and what it's ideal for.
[00:09:49] Speaker A: Yeah, absolutely. So I would say, I mean in general, regenerative medicine is anything that's going to encourage some level of inflammatory response that then leads to repair of some injury.
And yeah, specifically you mentioned some of the things that fall under that category. I would say prolotherapy, which is an injection usually with, with some sort of irritant. I would say most of us use dextrose as the, as the irritant solution and platelet rich plasma stem cell treatments, whether it's bone marrow or adipose stem cells are the two that I would say are commonly used when we're talking about cells from one's own body.
And then there are things like exosomes, which are, you know, the tiny little sort of messaging sort of envelopes or bubbles that, that cells use to communicate with each other.
And there are some of the umbilical and amniotic fluid products that you know, that are out there that fall into that category as well. Now not all of those are things that I use and not all of them are things that I think, you know, should be considered with the same level of interest.
But in general, that's the grouping of Regina medicine.
[00:11:17] Speaker B: So maybe break it down a little bit.
As far as I'm a patient, I come see you, I've hurt my shoulder, I'm interested in regenerative medicine.
Am I talking to you about PRP specifically or talk me through the process.
[00:11:40] Speaker A: Sure, absolutely. So, yeah, I would say a few factors would go into that discussion and let's say, yeah, let's say you have a shoulder injury and the first thing would be it depends what treatment you've had so far and how severe your injury is.
So if we were to rank how robust the regenerative response is from all the treatments I mentioned, I would say prolotherapy provides the sort of, the least robust treatment. It's sort of a, I use prolotherapy as a sort of a, a touch up if someone has a kind of a myofascial, you know, muscle, tendon, ligament strain that, you know, maybe just isn't going away. And we need to address perhaps your, the entirety of your shoulder. Right. Let's say you just have, you know, the, the, the rotator cuff is tight and the trapezius muscles are. All the muscles around the shoulder just, you know, are not quite, you know, 100% normal, but there's really no injury to your rotator cuff. Your labrum is okay. Everything is okay. Then maybe we go down the path of some prolotherapy to encourage some, you know, some soft tissue healing.
But I would say if you have a more specific injury, let's say you do have rotator cuff tendinosis, so some irritation, you know, micro damage of, of that, of that tendon, of one of those tendons or some, a little bit of wear wearing out of the labrum. Right. The, for, for the non medical listeners, the little membrane inside your, you know, your shoulder joint that helps it function.
Then we start to talk about, okay, let's, let's step it up a little bit and then let's actually inject something that will hopefully restart the body's own repair mechanisms to some degree and help heal again to some degree, that tendon or that labrum or that structure that just your body didn't quite do a good enough job of repairing to a level that would allow you to have no pain or minimal pain.
And on that spectrum, let's say that you actually had, you know, a little bit of a bigger tear in your rotator cuff or some, some wearing out some degeneration of the joint that perhaps might benefit from a little bit of a stronger treatment. Then I might consider something like, like stem cell treatments, like a stem cell injection.
[00:14:13] Speaker B: So we're talking partial tear. Can't raise my arm all the way.
I'm a good candidate for prp.
[00:14:22] Speaker A: So. Well, it depends, right? Like everything right Maybe, Maybe. Right.
[00:14:26] Speaker C: I mean, for our friend Dr. Suarez, just so I know. And then I'll call you later.
We'll call you later.
[00:14:37] Speaker A: So, you know, I mean, if, if I would say, you know, you've tried physical therapy, perhaps you tried a steroid injection or not.
And, and, and your tear, it's partial, but it's not, let's say a 2 centimeter tear with retraction. Right. The tendon is still, still, you know, attached and just has, has a, you know, small defect within it versus something where, where, you know, where, where this structurally has changed locations then. Yeah, I, I would say, I would say you are a good candidate to try something like platelet rich plasma to be injected into the defect of the tendon and around the tendon and then coupling that with, of course, you know, a multidisciplinary approach, then rehab the shoulder. Right. I think that's, that's a key to everything that we do.
So following that up with, with physical therapy and you know, slow advancement of activity and seeing if that is sufficient to improve that, that pain and function, which is, you know, the main goal. And, and those are the two things that, you know, in the literature, those are the two things that, that really we, we measure or that have been measured with regenerative medicine. And those are kind of the outcomes that have been shown to improve, you know, more than anything else.
[00:15:52] Speaker C: I'm so glad that you referenced the research because I have a follow up question for you. I've personally treated a lot of patients who have had it done on the rotator cuff and I'm seeing it now more and more use at different joints and different locations. So can you talk a little bit about that, about where else we're seeing promise and benefit, um, or if it is indicated for only certain joints. I would love your input on that.
[00:16:18] Speaker A: Sure. Yeah, absolutely. So, so I would say the, the studies have shown benefit in some tendons. So the, the very first one, as I mentioned in 2006, you know, Mishra studied the, the, the tendons of the elbow for, you know, epicondylitis or, you know, tennis elbows. And, and it was the first time that it showed that it was that it provided efficient improvement and successful improvement of pain and function, even when compared with something like corticosteroid. So, so that has been kind of the marquee tendon. The marquee structure has been, has been those, those tendons of the elbow from, you know, from 2006, over the years, the, the other structures that have shown where regenerative Medicine has shown promise. And when I say that I really mostly platelet rich plasma, I would say then, you know, PRP has been the most studied out of, out of all the regenerative medicine treatments.
And it has shown improvement in knee osteoarthritis.
It has shown improvement in the rotator cuff.
And not as much research or literature out there, but there were a couple studies that showed that the patellar tendon, the gluteal tendons of the lateral hip and, and, and, and small Achilles tears that those had studies that showed that, okay, there, there, there was improvement, you know, compared to, to other treatments.
I will say there's certainly still a gap in the literature when it comes to regenerative medicine. And, and we're still, I think the field is still trying to solidify some of the conclusions.
There's still studies out there that show, you know, what, it's no different than placebo when it comes to, you know, many of the structures that we use it for.
It certainly, I would say, you know, as far as, you know, has it been shown that it's, that it's a safe treatment that has potential? Absolutely.
And we kind of use our judgment, you know, just, you know, patient by patient, you know, tear, tear, tear by tear, you know, degeneration by degeneration, whatever it is. We, we just have to really, you know, look at, okay, could this patient really benefit? And, and you know, each patient is different.
I would say that something that we're still working on as far as the literature is really standardizing how it is that we're doing these studies and what we're measuring.
The, a big thing over the years has been platelet concentration. And you know, the, there's so many studies that just haven't standardized that. Right. How many, how many million platelets, you know, per milliliter. And you know, what are we, how, how sort of concentrated is, is the platelet mixture that we're injecting. And if we can standardize that, then it's harder to come up with those conclusions to kind of, you know, across the board.
But we take the information we get and then we also use our own anecdotal experience and personal experience and we can make some conclusion about that, I would say.
[00:19:33] Speaker B: So talk me through this a little bit again.
I'm going to get the PRP done. I walk in the office, you're going to draw blood, you're going to put it in a centrifuge and then what happens next?
[00:19:48] Speaker A: Sure, sure. You mean, you mean your friend is gonna do this?
Yes. So yeah, you come in, you know, we usually have folks come in, you know, an hour, an hour early before their appointment time because that's about how long it would take. So yeah, they come in.
The blood draw. The blood draw takes place depending on the kits that get used.
You're, you know, you're drawing probably, you know, 60 mls of blood. So you know, it's a decent, a decent amount.
So 60ml of blood get drawn usually and from that then we concentrate the platelets. It's, we use a centrifuge. We, we centrifuge it twice. First the, the red blood cells come out, then the white blood cells come out and then we end up with what we call leukocyte poor platelet rich plasmas. So, so it's, everything has been taken out except the platelets which are, you know, as, as we didn't go into this but you know, one of the three cells in, in, in the blood, of course, um, and the, the platelets end up as this sort of like a residue at the bottom of the tube. So we leave behind 4, 5, 6 mls of plasma.
The, you know, the, the, the little liquid in the blood and we dilute it in that plasma, which is why it's called platelet rich plasma. And that takes about 45 minutes or so to do that process which just gets done in the office. It's fairly simple.
Again, depending on the kits that you have, you know, it can be pretty, pretty self contained, sterile process that gets done. And once we get our, let's call it, 6 ML of PRP, bring the patient back into the room. I do all my injections with ultrasound guidance so you know, put them in the room where my ultrasound is and we go to work into, you know, injecting the, the different amounts into the different structures of, of that shoulder and whether, you know, we're putting, you know, two mls in the subacromial space and one milliliter inside the tendon and maybe there's a little bit of arthritis in the shoulder. So we throw, you know, a couple of mls in the joint itself and that process, you know, takes about 30 minutes or so.
And, and then the recovery begins, which is kind of a whole other thing. Right, that there's definitely a kind of a recommended process as well as some, some expectations that I make sure I go over with every patient, like how much pain you're going to have and things like that.
[00:22:20] Speaker C: Yeah, I, you read my line there. I, you know, my friend has questions about that Tell me about the journey to recovery. Do they walk out feeling great that day and is it behind them or what does that look like? And what is your timeline for, you know, and the prognosis for, for their recovery? And what do they typically see as far as increased function?
[00:22:43] Speaker A: Yes, yes. So they, they don't walk out, you know, feeling great, unfortunately, but it's, you know, but it's a, it's a, it's a, it's a labor of love. So the, the, the platelets, or really any, any of the regenerative medicine treatments are going to very quickly create inflammation and pain. Essentially. It's, you know, it's going to irritate that area. Even, even the prolotherapy, just the dextrose, patients will feel irritated. The area will feel like, oh, gosh, something, something happens, something doesn't feel right. The platelets, certainly immediately within, within, you know, within a few minutes, they start to create kind of a, a very throbby ache that can turn into pretty achy pain.
People have different pain thresholds, but I've had a wide spectrum of response where patients have told me I was in so much pain, I couldn't sleep for a night or two.
I was a little irritated, but I was fine. But, yeah, essentially immediately that day, it's going to increase the pain response in, in the body part that gets injured. You know, there, there are all these factors that get released. I mean, cytokines and chemokines and growth factors and all, all the things that the body uses to try to heal things when, when it gets injured initially, the platelets basically get, you know, we, we trick the body into thinking, oh, you just got injured again, and that's why you have a million platelets in your tendons. So here we go. And then, and it restarts that process. It feels like you got injured again for, you know, anywhere from two to five days. I would say, you know, I'd say day one and two are possibly the, the most painful.
And then it starts to subside five days later, let's call it. Everything goes back to sort of its baseline level of pain. So whatever pain the patient had before we did the prp, that pain returns to that, to that same degree.
And on average, I would say, six weeks later, is when patients start to notice that there is some positive improvement taking place. And, and it starts slowly, and then it builds up slowly over the course of, let's say, three to four months on average.
You know, the responses are different. I've had patients that three or four weeks later come in and tell me I'm already 50% better. That's certainly not the expectation. That's certainly well ahead of. Of time. I've had patients that, three months later, they finally come in and tell me I am actually finally feeling better.
So, yeah, there's, there's definitely a range, but usually I have people not do rehab activity for about two weeks after the injection.
They, I want them to obviously do some range of motion so that thing, things don't freeze up or anything. But, but two weeks of no, you know, no pt, no weightlifting, you know, nothing like that. And then after two weeks, the rehab process starts, if they're able to. Right. Not, not all of our patients are able to.
To have this sort of regimented rehab that occurs right after or anything like that. But, yeah, that's, that's the process.
[00:25:50] Speaker B: So, Dr. Suarez, it seems like if we're using the PRP to, to help the healing process, the sooner that we do the procedure from the onset of the injury, the more successful it's going to be. Does that sound correct or does the timeline not necessarily the case?
[00:26:13] Speaker A: Yes and no. I would say right after an injury, depending on the injury, I would rather see if the body can do its job and heal itself.
I think many of the injuries that we sustain, the body can and will take care of tendinosis, of tendon irritation, or they'll take care of, know, strain or sprain.
And, and the, the normal healing process that occurs will get patients back to that normal level of, you know, function that, that, that they want to get to.
If that process doesn't quite do its job, I would say, or, you know, sure, if, if we already know that an injury perhaps is something that, you know, historically doesn't quite get healed by the body on its own. Like, you know, I know that rotator cuff tears. You know, it's, you know, that tendon is difficult to heal on its own.
It, you know, could be beneficial to do regenerative medicine, you know, as soon as, as soon as we're able.
I kind of, you know, I'm. I take some care to not do unnecessary procedures if we don't have to.
So, so I, I don't kind of jump right to it. You know, if I see a patient that's a month out from. From a shoulder injury and we see that there is a, you know, small little tear, I, I don't say, let's just, let's just jump to it. I, I still prefer to go through, you know, our multidisciplinary multidisciplinary process and, and see if, if we can just get things better without, you know, without the additional, you know, minimal risk as it is of, of a blood draw, of injections, of increased pain. You know, it doesn't, it does, it does come at a cost, obviously.
And so I, you know, I tend to still give the body a little bit of time. Now, if we're saying, okay, whether it's, you know, six months or six years, you know, I've seen results even when injuries are remote, when, when things are years old, I've still seen improvement.
I can't say that I recall any studies out there that have tried to determine whether the age of the injury makes a difference in their response. And I could just be blanking, and there may be some that I've read and I just don't remember. So, so, so I can't say that I have a backup to that as far as, as far as the, the timeline for it. But I will say professional athletes, they tend to get this done. They don't. They. They don't, they don't have the luxury of waiting for the natural healing process. And an athlete's just, you know, if they're not getting surgery and they need to. Maximizing the, the recovery, they're getting it done within, you know, within days to try to, okay, let's get this healed and, and let's get you back on the field or on the court right away. So, you know, there's, there's something to that. Of course.
Yeah. So we'll see. We'll see.
[00:29:18] Speaker C: I was curious about that because as you were sharing that, I appreciate your attitude and acknowledgement of the body wants to heal itself and to give it an opportunity and to be, you know, conservative. And I think there's a lot of providers and clinics out there and that over promise, right. That it's a quick fix. And I think a big part of it is we see this culture where we see our favorite player get injured and show up again, like two games later. You're like, how is that even possible?
And I think it just kind of reinforces that immediate gratification and quick interventions. And I'm curious, what do you say to those patients? How do you handle those cases where they kind of come in and they, you know, they want what so and so got, you know, last season.
So could you speak a little to that?
[00:30:04] Speaker A: Yeah, absolutely. I mean, I think I tell them a lot of what, what I mentioned. Right. I mean, I think I educate and I explain the, the body's processes and how I expect things to go depending on the injury and the things that will be helpful, you know, kind of go through my whole spiel about, well, here are the treatment options and here's what we usually do. And, you know, we, we treat it conservatively, and if that doesn't help, then we turn to interventions and there, you know, we have some options when it comes to that. And then if nothing helps, then, you know, let's talk surgery. And I, it's, it's really about education, I would say, if, if people come in and tell me, okay, you know, I heard that you do regenerative medicine. I need, I need to do my knee right now. Well, okay, let's, you know, let's hold off. You know, do, do you have an mri? What's the injury?
You know, I mean, it's, it, it, it, it becomes a, you know, sort of a bit of a step by step process and just being, being, you know, detailed about explaining all of that, then I think patients tend to understand that, okay, let's, let's see if my injury is a good candidate for regenerative medicine. And maybe they never tried physical therapy. So. Okay, well, let's try a few weeks of physical therapy and see if you actually end up feeling much better. And we don't need to do that because maybe the tiny little tear you have actually doesn't cause any symptoms after you strengthen the muscles around the knee and then we don't have to do, you know, the, this, this procedure. So that's, that's usually how I handle it. You know, it doesn't work a hundred percent of the time. And there's still patients that will tell me, you know, what I'm, you know, I'm paying cash for this procedure.
You know, would you, Would, would you do it? Am I, is it going to help me? And, you know, it's. We kind of make decisions about. Well, yeah, it would help you. And anywhere we, we kind of go from there.
[00:31:56] Speaker B: Dr. Suarez, you mentioned the knee. I've been seeing more and more articles published, you know, supporting PRP for knee injections above other options like cortisone injections, hyaluronic acid injections.
Is that what you're seeing? And what, what are your thoughts on that?
[00:32:16] Speaker A: Uh, yes. Yeah. So, I mean, I've seen, I'm sure I've seen the, the same articles that you have. And yes, it's, it's, it's showing a lot of promise. It's showing good results. As far as comparing it, yes, with Hyaluronic. Acid, coric steroid and placebo.
And it is what I've seen in practice over the years as well that, that it does have a pretty good chance of, of improving symptoms and improving function.
I would say a few years ago, before, before PRP was being shown as being as, as effective as it has been over the last few years, stem cells were actually the treatment that had had a couple of studies show that it could be beneficial for, for knee osteoarthritis, you know, mild to, you know, maybe mild, moderate knee osteoarthritis.
And I would say, you know, years ago that's, that was kind of my, my go to was to do bone marrow stem cells for knee osteoarthritis.
And but I think now, you know, in the spirit of okay, why you know, let's, let's go from sort of less involved and less invasive to more invasive. And in that kind of, in that, that process, I am considering more PRP for, for the knees and not so much the bone marrow stem cells, at least not initially.
[00:33:46] Speaker C: So for our listeners and potentially my friend, what are the common injuries and conditions that you do commonly see really successful outcomes with the interventions that you used?
[00:34:00] Speaker A: So I have seen good outcomes with rotator cuff issues in the shoulder, obviously epicondylitis at the elbow. So the, you know, the, the tennis elbow, the golf elbow.
And I've seen the, the knee osteoarthritis have good results.
I have seen Achilles, tiny, tiny Achilles tears and sort of, you know, tendinopathy that is non surgical. I've seen good results with that.
I have seen the glute tendons of the hip have good results.
I have even seen some really small meniscus tears respond well. As far as the, the improvement in function and pain, um, what else?
I would say overall there are other things that I, that I do.
So are there other structures that I have seen good results. I maybe just wouldn't put it in the, in the, you know, sort of majority good result category. But I've, I've done, you know, PRP for the cervical facet joints, for example, and I've had several patients with, with improvement done it in small joints of the, you know, of the wrist and hand and foot and ankle.
And even though the, you know, the literature isn't quite there that shows okay, you know, for the small joints of the foot and ankle, for example, it's, you know, there are a couple of studies that show that perioperatively it can provide some improvement. But you know, really Nothing that has been shown that if you do the, you know, the subtailor joint that, you know, your ankle pain is going to improve or some of the ligaments. But, you know, in my practice, I anecdotally, I actually have seen even good results into some of those, some of those small joints as well. So, you know, I would say it's. Yeah, again, case by case basis. But you know, overall, if I had to narrow it down, I would say the shoulder, the knee, the elbow are the three that just get the best result in, you know, it's kind of in an office setting. I know we haven't talked much about the spine and I actually did. I don't currently do too much regenerative medicine into the lumbar spine, I should say. So, you know, I'm not doing too much intradiscal PRP or intradiscal stem cell or those kinds of procedures into, into the lumbar discs. But that's another one where, you know, there is a lot of ongoing research about regenerative medicine into those intervertebral discs. That's, that's, you know, the discs continue to be an area where we just, you know, can't quite figure out how to make the discs better long term.
[00:36:47] Speaker C: It sounds like regardless of what our listeners or our friends might be, might be going through and hearing and experiencing, it might be worth talking to a provider about what's going on and seeing what interventions, if any, might be appropriate for them right now or maybe down the road.
And so I am curious though, because it does almost sound so good to be true. Right.
For the skeptics who might be listening, how do you help separate the providers and the interventions that may have fantastic marketing and lure individuals in.
How do you help patients navigate that?
[00:37:35] Speaker A: Yeah, I would say it is a question about taking a look at, taking a look at the, the procedure that that is being marketed or offered and whether the, the providers that might be marketing it or talking about it can discuss sort of the, you know, its efficacy and can in detail go over. Okay, you know, here, you know, some, some realistic expectations. So really, I mean, it really comes down to, I think asking those providers the right questions. If, if, if it's a sort of a provider type of meeting. If it's just sort of a, you know, we're looking online and you know, the clinic website says, you know, return to 100% function and you know, get back to running, you know, marathons with this procedure.
It's, I would say with, with, with anything, right. Nothing.
If it sounds Too good to be true. It. It might be. And, and it, It's. It takes a little bit of, of discussion with, with the providers, and it would be beneficial to, to have providers really go over, okay, injury and give options as far as, you know, okay, what other, what other things can be done. And if, if those kinds of things are discussed. And I usually say people can feel pretty good that, that they are getting a treatment that is being considered in the grand scheme of things and not just someone that is saying, okay, you know, here's, here's what I do. I do regenerative medicine. So we're doing regenerative medicine.
And in, I guess from, from a different perspective, personally, I find that the treatments that are autologous, so the cells that come from the patient's own body, I find to have better potential and they are, have been obviously better studied compared to perhaps some of the clinics or marketing where they're discussing things like, oh, you know, umbilical and amniotic fluid and, you know, these are you know, just the, you know, baby cells that will cure everything that you have. And I'm very leery of those kinds of treatments. And I tend to ask a lot more questions when it comes to those kinds of products, where it comes from, how it's been treated.
And, and so those are good questions to ask if the discussion turns into not just platelets and stem cells from one's own body, but instead some of these other products.
Some of those other products also have additional rules as far as the FDA and legality and all kinds of things that, that make it even a little bit more complex and possibly harder to navigate, both for providers and for patients. So, you know, it's, it's difficult. I've had patients that have gone to other countries to get treatments that they can't get here because they're not legal here. We can't, you know, we can't do certain things and, you know, to some degree for a good reason. Right.
But anyway, so, yeah, just. It's about getting all the information and getting a feel for the sort of the honesty and the care that the provider has taken into actually evaluating the injury and the options for it. I would say, when do you pivot
[00:41:09] Speaker B: from doing prp, which I think we're seeing getting approved more and more by payers and insurance companies, to using stem cells? What's the, what causes the shift clinically for you and what does that look like for the patient as far as coverage goes or cost?
[00:41:29] Speaker A: Sure, sure. So I, if, if I am, if If I've done a platelet rich plasma injection and an injury that seemed to be a good fit for PRP and it didn't quite respond as I expected and Perhaps there was 20% improvement and we are discussing well do we repeat the prp, see if we get a little bit more or is this something that could benefit? So that's, that's one scenario in which let's say there is a, there is a small rotator cuff tear or knee osteoarthritis that perhaps is on that threshold of what we've seen responds well to prp, then I pivot to bone marrow stem cell treatments. If we didn't get the response with prp, if the injury, for example, if it's a rotator cuff tear that is half a centimeter, something like that, I might, depending on the patient, I might suggest actually doing bone marrow stem cell treatment and skipping the PRP if there's just more tissue that we really need to fill in or try to repair or kind of improve it. The, the function of as far as costs and, and everything else that is associated with that.
So, so yes, you're right. As far as prp, we are seeing more payers coverage I would say namely workers compensation, which I know is you know, obviously a big part of, of our practice.
They are, they are certainly the rates of, of you know, authorization. I even, you know, personally I, I have seen more and more being authorized for, for, for my own patients.
However, that is about the only payer that will cover it. No other payer will. Medicare doesn't pay for PRP commercial insurance. None of them pay for PRP personal injury of course, but that's a whole different set of payer relationship.
So similarly, bone marrow stem cells, none of those pairs cover bone marrow stem cell treatments either. And I will say I don't trying to remember if I have ever had a bone marrow stem cell treatment covered by workers comp. And my memory is failing me.
Maybe one. But it's, it's also a less common treatment that I, that I usually, you know, I'm not recommending that all the time.
Um, but cost is more with, with the bone marrow stem cell treatment.
What is required? I can kind of briefly cover that. If we're going to do a bone marrow stem cell injection, first we have to get the bone marrow and that, that is, that is a whole other procedure that that needs to be done. Um, it is common. I mean there, you know, there are other pro. Types of, of specialties that obviously have to test the bone Marrow, like oncologists and hematologists and so forth. Right. The. They have to go in there and get that marrow. So getting the marrow, it's. Is kind of its whole, you know, other thing that I do.
[00:44:40] Speaker B: You, you prefer the bone marrow to the adipose tissue?
[00:44:44] Speaker A: I do, I do. I find that it's a.
Probably an easier sort of aspiration or, you know, sort of extraction procedure for me. It's, you know, it's, it's a needle, granted, a pretty good sized needle, but it's, it's, you know, it's a needle into the bone, which, you know, happens for other things in medicine rather than a essentially liposuction procedure, which is, you know, what it, what it looks like when you're getting it from the adipose cells. Right? It's, you know, it's the, you know, it's the little suction and you're, you're, you're, you're combing through that adipose tissue in the, you know, in the abdomen and the stomach and you're trying to get that fat to go into the collecting system and so forth.
I prefer to basically just go into the, the, the iliac crest, you know, into the pelvis and, and get the, the marrow that way. And I would say over the years it's, you know, it's become a, a much less painful procedure than I think maybe earlier on. We keep discovering ways to, to really anesthetize the, you know, so sort of the areas around the bone so that, you know, we minimize the discomfort of, of getting the bone marrow. But, you know, the, the fact that it is that extra procedure does increase the time, the materials, the cost, and therefore it does affect authorization. I would say when it comes to the, To. To essentially to workers comp. Which is, you know, they're the ones that are authorizing regenerative medicine at the moment.
[00:46:27] Speaker C: It sounds like quite a commitment in regards to, you know, especially for the bone marrow, like essentially two procedures to completely do the entire process. And so I'm, I'm curious how you talk to patients about the, the commitment and, and honestly the, the value for them, because oftentimes they are paying for this out of pocket.
Um, and so I'm, I'm curious about that.
[00:46:54] Speaker A: Yeah, absolutely. I think we just have to be realistic about expectations and, and, and, and really share, to the best of our knowledge, sort of a. The, the possible outcome from the procedure. Whether that is, you know, the sharing that the research or anecdotally, you know, 65% of patients will have significant improvement or 70% or 50% or 80%. And, and, you know, really, you know, being upfront about that and that there is a chance that perhaps it won't give them significant improvement, that the improvement might be very mild.
And the, the, you know, of course, going over the, the, the procedures themselves, I know I made it sound like it's, you know, something, you know, sort of brutal, but I mean, it's a common thing that, you know, it's, you know, it's a little uncomfortable to go through, but, but, you know, we do it sterilly, we do it safely. We, you know, we try to minimize pain. And of course, I am also very honest about that and very honest about the. Mostly about the pain that people will feel after regenerative medicine. I certainly stress that. But.
And then we do kind of a cost benefit analysis about, okay, you know, what, what do they want to get back to doing and what options do they have? Um, if it's something that is just not surgical and they've tried everything else, there's, you know, there's definitely some value to, okay, well, let's, let's exhaust all treatments. Even if, even if there is a, you know, 30% chance that it won't work. Well, 70% is pretty good.
If, if it's going to get them to do X, Y or Z that they are not able to do, or if they have a contraindication to surgery or if they just purely, you know, will not, they do not want to go through that process. And you know, we kind of go through expectations and what that means and the possible outcomes and, and whether that makes sense for, for the patient to, to do the procedure and pay them money if they're paying for out of pocket. And, and we go from there.
[00:49:04] Speaker B: Dr. Suarez, this has been so interesting, so informative, and I think there's so many people who are interested in this topic, in this subject for themselves or family members, for people who are interested in consulting with you and diving into this more and seeing if it's right for them.
How do they find you?
[00:49:27] Speaker A: Oh, gosh. Well, on, on our website, you know, the, the, the, the Boomerang Healthcare or BHC website.
Um, and I work in the East. I didn't mention this initially, but I, I work in Walnut Creek in Oakland and in Concord for a little bit longer, but really it's going to be Walnut Creek in Oakland where I do all of these procedures, whether it's prolotherapy, prp, bone marrow, stem cell treatments. It's all done. It's all done in the office and I do it at both offices. So, um, yeah, looking me up on, on the website is probably the easiest way. I am sure there are emails and phone numbers that I don't know that we could share with folks that want to get a hold of us and a hold of me, but just give them Sarah's email.
[00:50:14] Speaker B: That's fine.
[00:50:17] Speaker C: Well, my friend will be emailing him, so. Yes.
But such a wealth of information. Thank you so much for being here today, Doctor, for us. We really appreciate all your, all your time. Any closing words of wisdom for our listeners before we sign off?
[00:50:35] Speaker A: I mean, I would say it's, it's, it's, it's certainly something that, that should be discussed in a lot of injuries. I, it's, I think it's worth taking a look at regenerative medicine for a lot of the musculoskeletal injuries that, that our patient population has. And it's, you know, I, I think results can be very positive and for the right patient. And I would, I would certainly encourage at least considering it for, for a lot, for a lot of the injuries that, that we sustain. So.
[00:51:10] Speaker C: Yeah.
[00:51:10] Speaker A: And I'm happy to, you know, happy to answer any questions at any time.
[00:51:15] Speaker C: Fantastic. Well, thanks again, Dr. Suarez, and thank you everyone for tuning in and joining us today on the Comeback with Boomerang Healthcare. We're grateful to if you've enjoyed today's episode, be sure to subscribe so you never miss an update. You can always follow us on social media for more tips, information and inspiration. Until next time, keep moving forward. Your comeback is just getting started.
