Jack of All Trades, Master of None: PRP and Stem Cell Procedures

POSTED ON 6/25/2018 IN Regenerative Medicine Education BY Chris Centeno

My mother has some great old-school sayings. In fact, I find myself using a few around my kids and usually get a blank stare. One of those is "Jack of all trades, master of none." This one struck a chord this morning when discussing a patient who had tried PRP at another clinic that had failed. She was amazed by what she received at our clinic and how it was so dramatically different. This is despite both of these treatments being called PRP (platelet-rich plasma) by the doctor. Hence, when I heard this story, my mom's Jack of all trades saying popped into my head. Let me explain.

Jack of All Trades

What my mother meant by this phrase was that if you try to be all things to all people, you will, at best, deliver low-quality service in any one area. Conversely, if you specialize and focus your efforts, you can achieve mastery. This is exactly what we see happening in regen med right now. I see countless ads for "Jack of all trades" clinics that usually deliver low-quality care. These fall into the following categories:

  1. Cosmetics and Stem Cells! These clinics specialize in cosmetic care. They understand things like LASER skin treatments and Botox or perhaps facial fat grafts. However, the train comes off the rails (another one of my mom's) when they decide that there's gold in them thar hills and begin to offer musculoskeletal PRP and stem cell therapy. While they might be expert in delivering a PRP vampire facelift, they wouldn't even have a clue about how to diagnose what's wrong with a knee or a hip.
  2. From Hormones to Knee Arthritis! These are physicians who usually have reinvented themselves. They may be trained in cardiology or emergency medicine, but they take some courses and begin offering age-management medicine. They then begin offering stem cell treatments for knee arthritis but know just enough about this area to be dangerous.
  3. The Chiro Miracle Cure! These are chiropractic offices that have added a physician assistant (PA) or nurse to add services like weight loss, age management, or cosmetics. They then add a new "service line," which involves claiming miracle cures can be had by injecting dead amniotic tissue and claiming that this has live and functional stem cells. They also often charge "all the market will bear," which is thousands to tens of thousands of dollars per procedure.
  4. Botox for Orthos! I'll never forget speaking to an orthopedic surgeon about what we do, who concluded that since cosmetic dermatologists could offer cash Botox procedures to boost their bottom lines that he, too, could offer stem cell procedures to do the same. I hung up the phone. Hence, these are orthopedic-surgery practices that will offer patients PRP or stem cells when they show interest, but know very little about the topic.
  5. We Do PRP Too! This is usually a medical clinic that may specialize in something like pain management and interventional spine. They know how to perform steroid epidurals and radiofrequency, but then take a weekend course on how to use PRP. They also know enough about the topic to be dangerous.

The patient above was initially treated at the last type of clinic, a local interventional spine clinic that began recently offering PRP.

Master of None

My patient has knee arthritis, but other issues as well. This clinic just placed her into the "knee arthritis" bucket and performed a simple intra-articular knee injection. This is what she got from the pain management clinic:

  1. A bad injection. Since the provider had never really been trained how to use imaging guidance to inject a knee, my patient got injected into the painful medial fat pad. She compared the pain to labor. This injection took a few seconds.
  2. Red PRP from a bedside machine. The provider who performed the procedure didn't know that bloody PRP would cause a massive inflammatory response in the joint.

She had severe pain and no benefits, despite being charged top dollar. What she got from us:

  1. Precise ultrasound and fluoroscopy-guided injections. These were not only into the joint but also into the ligaments that hold the meniscus in place, as it was slipping out of the joint. This procedure took 30 minutes of careful numbing and targeting of these structures. She had very little pain.
  2. High-dose amber PRP. We didn't use a puny little bedside machine to create a weak platelet cocktail, but a state-of-the-art lab to create high-dose PRP that contained about four times as many platelets per ml compared to her first injection.

What+Where+How

As I've written before, if you're going to spend your hard-earned cash on a PRP or stem cell procedure, make sure it's not an afterthought used to drive income in a practice that doesn't specialize in this area. The provider needs to be able to answer these questions:

  1. What will be injected? Meaning if the answer is just "PRP" then that's not good enough. What type and why? What dose of platelets and why?
  2. Where will it be injected and why? While a few of our injections are just in the joint, most target specific structures. For this patient, I spent a full 30 minutes examining her knees and reviewing her MRIs to make the decision about which structures to target. So the provider must be able to tell you exactly where the stuff will go in the joint. In this case, I targeted the meniscus, the coronal ligaments that hold the meniscus in place, and the midline fibers of the ACL/PCL complex where the meniscal root takes its origin.
  3. How will it be injected? In this patient, I used both fluoroscopy (real-time X-ray guidance) to target the midline ACL fibers as well as ultrasound imaging to target the meniscus and coronal ligaments. Your average orthopedic surgeon, pain management doctor, or PA/nurse wouldn't have a clue how these injections are performed. To find providers who do know how to do this type of sophisticated injection, see the Interventional Orthopedics Foundation. At Regenexx, we won't accept any other coursework out there.

The upshot? What this patient got on the first go-around was a poorly done injection of weak PRP destined to cause her knee to blow up. Why? Her provider was a "Jack of all trades and master of none." She was astounded at the differences once she found a clinic that truly specialized in this area of medicine and advanced interventional orthopedics. As I always say, buyer beware!

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