Varying Speed and Intensity of treatment for Arthritis/Tendinitis

When treating arthritis and tendinitis it’s key knowing when to pause, when to move forward with treatment cautiously, and when to move more aggressively.

-Hip arthritis
-Knee/Back degenerative joint disease
-Rotator cuff tendinitis

Hello, everyone, this is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. Welcome to our weekly live broadcast. It’s August 12th, 2020. I hope everyone is doing well and is healthy and safe. So on this broadcast I’m focused on discussing professional issues, relevant issues related to medicine, musculoskeletal health. At Chicago Arthritis and Regenerative Medicine we’re focused on evaluation and treatment of arthritis, tendonitis, injuries, back pain, utilizing the most up-to-date current non-surgical treatments that are available and doing so in low-risk, holistic ways to kind of maximize your pain, function, and quality of life.

So something I’ve been thinking about recently is speed, quickness. Speed in terms of life, speed in terms of medicine as well. And I’ll talk about the medical professional aspect in a moment, but first and foremost, speed in terms of life. It seems like life is just moving so fast right now. I was thinking about this recently that, as someone who grew up in the 80s and 90s, there was a relative consistency to life, where you didn’t expect the world to be dramatically changing every single day. And right now we live in a world where things are adapting so fast. Every single day there’s sort of new news and new noise, and that is challenging to sort of keep up with for a lot of people. In fact, even every week on a medical level things are changing. As an example, the states that are considered relative higher risk from an Illinois standpoint where you need to quarantine if you come back from one of those states. It used to be 22 states, overnight it dropped to 19 states. Maybe that’s based on some additional numbers that have come from those states, maybe that’s based on, who knows? Public health or some other issues or some local legislators who have to travel to those states. I’m not really sure, but even on a medical level, we keep on getting input about what is new and what do we understand about COVID happening on a day-to-day basis, sometimes a week-to-week basis, that it’s a lot of change and speed. It’s happening quickly. From my own personal standpoint, the way that I try to look at it is what are the key principles that I truly believe in in terms of life, values that I have in life? And now how do we apply that to every level of my life? Whether that’s personally, relationships, professionally, anything else as well. And then adapting to the situation, but still relying on those principles, because I know those principles and values are, you know, they will last the length of time. They are things like gratitude, integrity, things like that. A few other things as well that I’ll probably discuss in the future, but speed in life.

In medicine it’s interesting, because there’s different ways to think about speed. There’s obviously things like what is acute that needs really dramatic sort of up, immediate real-time sort of changes and care? And then there’s obviously things that are more chronic and subacute, where maybe you can take a little bit more time to think about it. There’s a difference in terms of speed and urgency that you need, but I think there’s even speed and a difference in terms of how quickly and aggressively you wanna treat things based on what are people’s individual goals for treatment, their individual issues when it comes to their medical health as well? And you can be relatively smart with these kind of things. On Monday I talked about how medicine, while 80% of it can be algorithmic, that extra 20% about being personalized goes a long way to making a difference in terms of outcome. And to me, speed plays into that. So you need to know, as a physician, you need to know when to pause, you need to know when to maybe slow down or treat mildly, and then you need to know when to be a bit more aggressive and treat a little bit more quickly or with more strength. And I’ve got some examples for each one of those.
The one for treating mildly or slowly, since I’m using this speed sort of metaphor, an example would be a patient who I saw recently who has knee and back osteoarthritis, moderate level osteoarthritis, and she’s someone where she’s gone through the tradition non-surgical options, meaning physical therapy, activity modification, and some knee bracing, and she’s still having pain and so she’s coming to me sort of has her first line what’s the next step kind of treatment option? And we talked about, well, you know, you could utilize something like platelet-rich plasma, you could utilize something like bone marrow-derived stem cells, why would you choose one over the other? In her case, her real goal was, can you improve my pain? Can you improve my function? And so we talked about as a first line option in her case, as someone who’s really never had any other kind of injection option is why don’t we try platelet-rich plasma for her lower back and both of her knees? And in her case, she did really well, meaning she’s two months out from treatment. Her right knee and lower back are totally pain free. Her left knee, she’s basically 70 to 80% better. She’s enthusiastic and excited about her result and she’s able to go back to work. She works as a machine operator at some kind of bakery. And she’s able to work basically 12 hours at a time now, which is essential for her from a work standpoint, from an income standpoint. And that would be a great result. That is a great result in her case. But the key here was to realize it’s okay to treat in a milder fashion, in a slower fashion, because our goals here are, they kind of meet what her expectations are and she understands that we’re utilizing something milder and if need be, we can escalate to something stronger. And fortunately in her case we don’t have to do that.

A counter example to that would be a 60-year-old woman, very healthy, very physically active who came to me for hip pain. And in the course of doing her evaluation and imaging examination, all that kind of stuff, came to a diagnosis that she’s got more advanced hip osteoarthritis. And so what we know about hips is that if you have advanced hip arthritis, the chance of getting a good outcome from a regenerative treatment is currently considered challenging. And so my recommendation to her, because she was specifically coming asking about stem cell treatment for her hip, was I don’t think that’s the right option for you. I think you really should consider hip replacement surgery. And you know, she still wants to consider non-surgical options and what I’m guiding her is let’s pause for a second. You need to have a conversation with a hip surgeon, because that is the traditional and likely most appropriate option here. If you end up proceeding with something non-surgical, understand that even our strongest non-surgical option, like utilizing your own bone marrow stem cells, is that your chance of getting a 50% or better pain relief response is about a one in three chance. And we can have that conversation again, but let’s pause for a moment, consider the other surgical options before jumping into anything else I can help you out with. That’s a case where you need to pull the brakes and say, “Well, here’s what the evidence shows. You may be very healthy, you may be very physically active, but here’s realistically how you need to be guided.”
The last option is a younger person who I saw recently, a 25-year-old, he is competitive in Jiu-Jitsu and he basically has a left shoulder injury where he’s got some, a partial thickness tear of his rotator cuff, as well as a labral injury. And we talked about what are the options for treatment, platelets versus stem cells? He’d already failed some physical therapy and talking about what are his goals, and his goals are to get back to a high-level of Jiu-Jitsu where he can still compete and we talked about what are the chances of getting that result with just platelets verus going for bone marrow stem cells, and we ended up advocating for a stem cell treatment mainly because of his goals and expectations. In this case, I’m recommending going a little bit more aggressive, a little bit faster, because I think the speed of treatment here based on the goals that he wants would fit better with that kind of treatment approach. Something a little bit stronger and more aggressive. And the reason why he’ll likely do well is because, number one, we’re utilizing a cell type, his own stem cells that gives him that chance of getting that. Number two, we have sort of a common understanding in terms of aligned understanding of what are expectations for goals of what we can achieve. And then lastly, you know, the way that you wanna treat someone like this is you wanna treat it in a complete and thorough fashion. And that means hitting not only where he has an injury to the rotator cuff and to the labrum, but to understand that the reason why he has that is because he’s had some chronic instability in the shoulder due to some ligamentous strains in the past. Let’s properly treat that as well.

It gets back to the concept of biotensegrity, which is incredibly important in musculoskeletal health, where it’s, the basic understand is that if you take a larger unit, let’s say the shoulder, you have multiple pieces that are part of that. They are not directly attached, but when they’re close together and put under compression, that under that kind of setting, the strength of the whole unit is stronger than the individual pieces. And by treating not only the rotator cuff and the labrum that’s been inured, but by treating the ligaments that provide that support to create that kind of biotensegrity and stability, he’ll get a better response. And so aligning expectations, goals with the right cell type is going to get him the right kind of outcome.

You contrast that to someone where we had treated with just platelets, the knee and her back, where she has done great, and she’s done great because her expectations are a little bit different and she has a condition that can still respond very well to platelets. And understanding the platelets in her case are going to help with not only stability in the knee where she’s got some chronic degenerative issues and ligamentous injuries. She’s got some mild chronic inflammation and we’ll help treat that as well with platelets. And, because we’re also treating the back, we’re also addressing any kind of nerve-related neuromuscular issues that can affect not only the lower back but the knees as well, but it’ll get her to a higher level of physical activity and by doing that additional physical activity long-term, she’ll then be able to help support her knees and her back as well.

So speed makes a big difference in terms of knowing when to pause, knowing when to treat slowly and mildly and knowing when to treat a little bit quicker and a little bit more aggressively. I think that makes a difference in life. I think that makes a difference in medicine as well. Great, thank you for your time. Until next week, I hope everyone remains safe and healthy and as a reminder, I’m doing the live stream on Mondays and Wednesdays. And until our next broadcast, have a good day and live well.

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About this video
In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses changing treatment intensity for arthritis, tendinitis, back pain, and injuries.