DOC TALK WITH DR. GIRLING AND DR. PALOMERA: WHAT TYPE OF INJECTIONS DO YOU OFFER?
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BELOW DR. GIRLING AND DR. PALOMERA ANSWER:
WHAT TYPE OF INJECTIONS DO YOU OFFER?
Dr. Palomera: So you take care of a lot of wear and tear arthritis, you still do a lot of trauma, as well. Especially when you have a new referral. Let's talk hip and knee, particularly about those who come to you, potentially surgical candidates, that haven't had a lot of care. What kind of injections do you offer them? Are you able to do that?
Dr. Girling: Sure. We do a lot of injections in the clinic, not because we like sticking people with a needle, but because there's a lot of utility to it. I think the advertisements folks listen to on the radio and read about on the internet are full of really bad information. And by bad, I don't even mean that they're not telling you the right thing, I think it's very misleading. And I think that it creates a lot of confusion, like fear because of friends and relatives, that can be dangerous.
There's three categories of injections that we tend to use. The one that I use most frequently, because a lot of times I'm seeing patients with an issue that's post traumatic that's more severe, or somebody that we're trying to differentiate from surgery, the one I'm gonna focus on initially is the steroid shot. The steroid shot has two components, it's got a numbing agent and then it's got the actual steroid. The numbing agent is going to numb the joint itself, give you some immediate relief, and that's diagnostic for me. If I do an injection in a joint, it feels a whole lot better right away, at least I know we're in the right right area, we're treating the right thing. The second part of that is going to be the steroid. That's whenever you're starting to get some anti-inflammatory benefit that lasts a lot longer, brings down the inflammation and helps reduce the pain, not because it's numbing it but it’s actually helping improve the joint itself. So that way, you can get that longer term relief, but there's downsides. Steroid itself used too frequently, I mean, it raises your blood sugar, could start to damage the cartilage, as seen in animal models, at least. So we're hesitant to use that as a long term solution, but it's nice acutely.
From your standpoint, you'll do a lot more than I do like biologics and the viscous supplement type injections, talk more about those.
Dr. Palomera: The viscosupplementation injections have been around now for years. I've been in practice 21 years, so they've been around my entire career, at least. Viscosupplementations work well with arthritis of the knee. Everywhere else is not covered by insurance, a big reason being that the effects are very 50/50. The injection seems to work very well on the knee and has a high high success rate. And again, it’s covered by insurance, which is which is a good thing for all of us who are paying a premium. Even people that are very, very severely injured, tend to do well on these injections.
These injections are typically from rooster comb or rooster crests, so a lot of people will come in and ask for or say, "Hey, tell me about your chicken injection shot.” There's a couple of synthetics on the market, but you will hear the terms 'rooster comb,' 'Liquid Gel,' 'liquid cartilage' used. We do a significant number of those and those help, but they eventually stop working—that’s when we would get somebody like you involved. It's time for a replacement and so forth. But there are some patients that are injecting themselves every year, year and a half. I've been injecting for 15 years, and I've done real well.
Dr. Girling: And the one thing I always caution folks about is, don't get sucked into a cycle where you feel like it's not working, but you're still doing a shot. That’s one thing that kills me, folks will be, “You know, Doc I only got a week or two of relief out of this." These things need to give you at least six months of good quality relief or it's not worth doing. It's not magic. This isn't a time machine.
Dr. Palomera: We always try to consult our patients that we will probably hit a point where the Injections don't work as well as they used to they stop working completely. At that point, we've got to talk about alternatives. We're not going to push you into any surgery or anything, but we're going to be very honest that we're moving on instead of having you live with the pain.
Dr. Girling: Now we have biologics, PRP, amniotic. Talk a little bit about what you've seen with those and when you use them.
Dr. Palomera: Yeah, so biologics for us include PRP and cell injections, specifically, cells derived from the from amnion. The proper term is amnion cell, but I think the media has run away with the term stem cell. Although what we found is we can't prove there's stem cells in it.
PRP is platelet rich plasma, I get asked all the time, whose plasma are you using? We're using yours. In fact, just very quickly, whenever you come in for a PRP injection, we draw your blood. You do not have to be fasting. In fact, quite the opposite. We want you to be well hydrated with no anti-inflammatories for about three days. We draw your blood spin it for about 10 to 15 minutes—we keep the plasma and throw away the red blood cells and the white blood cells because we don't think they're quite as effective. Then, we inject the plasma right back into the knee during the same visit. We are not doctoring up that plasma to make all the proteins and growth factors that help you with inflammation, or anything like that. We think that these, these injections, PRP are great anti-inflammatories. People definitely feel that within as many as three injections, but typically one to two, they feel a lot better and they tend to last for a long time.
Amniotic injections work in quite the same way. If your own PRP has good stuff to help you feel better and aid in function, we think amniotic cell has a lot more of the good stuff. And it's basically several proteins that are mostly growth factors, things that help fight inflammation. I can't promise that it regrows anything, but what we know is that people feel better and more functional for a long time. The only downside is that these are not covered by insurance and are still being studied by the FDA. Because they are not considered a new medicine, we are allowed to use them. They're labeled a cash pay product. They're under a cash pay price list so that's something that any of us can talk to you about, if you're interested. I make it part of my discussion to let patients choose their type of injection, rehab, medications, supplements so forth. When they have arthritis, literally of any joint, I make it part of the discussion, and try to bring up all the pros and cons.
Dr. Girling: Please don't fall for the marketing on these things. That's what kills me. We see the videos too, the ones in between TV or sports segments. The ones where someone shows up, they get an injection and, magically, it looks like they're 20 years old. It's because they put a 20 year olds knee on the X ray. I'm sorry, that's not the same patient—it just doesn't happen, but these are really nice products.
The literature right now goes back and forth about whether or not they work or don't work.That's where I think the whole art of being a physician comes into play. We've done thousands, you've done far more than I have, thousands and thousands and thousands of these and we talk to our patients after and I promise they wouldn't come back if these things didn't work. But part of it is how we use them. Again, we don't use these as a silver bullet magically fixing everybody, but it's worth trying in most patients. We have a lot of success with all these different products. I see better results with the biologics, but again, they're not covered by the insurance. So if the hyaluronic acid product, the visco products, are going to be the one that's covered, we'd still rather use your insurance, but know that these cash pay products are available. And the nice part of cash pay products is we can do at the same time we see. We don't have to get approval. That's less time that you're taking off at work, less jumping through the hoops, and with insurance premiums being higher and higher every year sometimes it actually ends up being a cheaper option. But it's not something that we're just going to keep throwing at you even if it's not working.
Dr. Palomera: Yeah, one more thing I promise everybody in any injury we treat or any pain we treated is that we're going to go over the options for you. Not necessarily what worked for your neighbor or your friend but what is unique to you. And I will always give you options with the pros and cons and then we decide from there.
Dr. Girling: For sure.