Orthobiologics and Shockwave Therapy Plus: Best Practices and Protocols, for Best Results.

Steven Sampson, D.O. Brice Blatz, MD, MS John Knab, M.D. Rowan Paul, M.D. Adam Tenforde Chris Centeno, M.D. Paul Tortland DO, FAOASM, CAQSM, RMSK Anne Truong MD Cutting Edge Laser Technologies

Mark Mollenkopf TOBI: The Orthobiologic Institute Sairam Atluri MD Sharon Reynolds-Kyle, DC Brett Brodbeck, DC, CFMP The Academy of Shockwave Excellence Lucio Zaghetto Giacomo Granozio Jillian Bennett, PT Thomas Stierle Tomas Nedelka Prof. Dr. Karsten Knobloch, FACS Gregory Mercure

Orthobiologics, shockwave therapy, EMTT, and laser therapy are increasingly popular for treating musculoskeletal conditions. Each treatment modality has its unique set of advantages regarding patient outcomes. Still, it is essential to understand how these treatments can be used synergistically to achieve optimal results. Combining the proper protocols and best practices from each treatment approach allows clinicians to create powerful combinations that provide superior patient care in treating MSK conditions.?

At The Orthobiologic Institute (TOBI) Conference in Las Vegas the weekend of June 9-11, it was inspiring to hear from many of the leaders in the field of stem cells, PRP, shockwave therapy, and photobiomodulation present the most up-to-date research and practical application of these powerful therapies to help reduce or eliminate pain in individuals and improve quality of life.

For context, it is currently estimated that 721 million dollars was spent on PRP alone, and it is projected that by the year 2030, it will be 1.94 billion in North America, an increase of 44%. This projected growth is remarkable. How could PRP, stem cells, and other advancements in the burgeoning field of orthobiologics surpass current estimates and experience even more significant exponential growth by 2030?

In searching Pubmed.gov, relatively few studies directly compare PRP or stem cell outcomes against shockwave therapy. However, the possible synergistic effect of combining orthobiologics with shockwave therapy to expedite healing outcomes for both the patient and the orthobiologic physician is virtually nonexistent.????

Similarly, just a few studies exist about extracorporeal magnetotransduction therapy (EMTT). Still, they have yet to research the possible impact of combining orthobiologics and EMTT to achieve even more excellent results for musculoskeletal pain and recovery from injuries, such as ligament tears. EMTT provides a high-powered magnetic pulse, which helps to properly charge cell membranes so that there is a healthy intake of healthy nutrients and expulsion of waste from the cell to increase health and healing at the cellular level.?

One key question: When would the application of EMTT be most effective to help the orthobiologic injection have the most favorable outcome in reducing pain while also increasing healing factors for soft tissue and within joints? One substantial potential benefit of adding EMTT to orthobiologic procedures is that EMTT has a field of about six inches of the depth-treatment zone, effectively traveling through bone, reducing inflammation, and augmenting healing at a profound level. There are areas in the body that EMTT can effectively reach, which are currently extremely difficult to reach or treat via injection. EMTT could have a positive effect even in those instances.?

Likewise, there are no studies I could find on Pubmed that combined or contrasted orthobiologics with MLS laser therapy. However, combining these two cutting-edge therapies has excellent healing potential to increase the positive outcomes that each treatment separately possesses.?

The MLS laser light penetrates about two inches into the tissue and jump-starts the healing process at the cellular level. Consider the concept of “preparing the soil” of the injured soft-tissue area that will receive orthobiologics, mimicking the light from the sun so that healthy cells and soft tissue proliferate and flourish.?

A fascinating presentation at TOBI by @Nelson Hager, MD, concerning the research on biomodulation, not only at Walter Reed Hospital and The Uniformed Services University but also in extensive collaboration with medical schools and universities, such as Harvard, Stanford, U of Washington, Mayo Clinic, and many other healthcare leaders in the field of regenerative medicine.?

Consider what may be a missing link(s) to maximize the powerful healing effect of orthobiologics while also planting the seeds of profound healing to musculoskeletal pain, injuries, and other ailments and diseases that may have yet to be contemplated.?

Investigating the results of combining orthobiologics with shockwave therapies, EMTT, Laser, and other leading medical devices, would collect the best possible results for both the patient receiving orthobiologics and the treating regenerative physician. The potential combinations are extensive. A comparison of orthobiologics treatment only with orthobiologics and either shockwave therapy, shockwave plus EMTT, or MLS laser by itself or in combination with orthobiologics could present more definitive conclusions on the most effective combinations.?

As the field of orthobiologics grows and proliferates, if shockwave therapy, EMTT, and laser are going to add to the potential positive outcomes of PRP and stem cells, it may be beneficial to establish best practices and protocols for integrating SW, EMTT, and/or laser therapy.?

Many leading physicians have already integrated PRP and stem cells, along with shockwave therapy, with some also adding EMTT and laser therapy into their patients' treatment protocols. They have established best practices and protocols for their patients and have a strong foundation for combining these innovative therapies. As more physicians incorporate multiple therapies into their treatment plans and refer outside their own practice due to distance or not having shockwave therapy in their office, it is imperative that everyone, from patient to physician and clinic that offers shockwave therapy Plus, is clearly outlined to achieve the best possible outcome for both patient and the physician.?

The following is a general starting point for best practices and protocols, which I gleaned from attending conferences with CuraMedix, ISMST in Prague, The Academy of Shockwave Excellence, and most recently, TOBI. The ideal outcome would be for experts in orthobiologics, Shockwave Therapy, EMTT, Laser, and other healing devices to recommend the most effective dose, timing, and sequence, augmenting orthobiologic procedures.?

Professional input requested:

Please change, modify, or make any recommendations you might have; from that, an initial baseline of best practices and protocols might emerge.?

Best practices and protocols:

Before biologics:

Ideally, two weeks before orthobiologics, Incorporate one session per week of shockwave therapy, including radial shockwaves (RSW), to help normalize soft-tissue injury that may be affecting the surrounding injured area and lines of fascia. If available, the focused shockwave would be used more directly on the specific injury, whether it be muscle, tendon, ligament, or bone or around the affected or injured joint.

RSW, depending on the area and thickness of the injured tissue, concentrates on the most pronounced trigger points, adhesions, and scar tissue. It may take 500 plus pulses in each targeted area to begin the normalizing process at a discomfort level from 3 to 6; light to moderate discomfort is acceptable but never causes undue or unnecessary pain. Total pulses are about 2000, depending on the area and the extent of existing soft-tissue restrictions.

A focused shockwave (FSW) of approximately 1500 to 2000 pulses, again at a discomfort level of 3 to 6, is recommended in each of the critical areas of the musculotendinous junction (MTJ) or other vital areas of the injured tendons, ligaments, bony attachments, and in and around joints, as well as specific areas where the orthobiologics, PRP or stem cells, will be injected.?

A combination of RSW and FSW will dramatically jump-start the healing process, helping to normalize long-standing injured or damaged soft tissue or joints that will be better ready to create an ideal healing environment for orthobiologic treatment.?

.

Same-day:

On the same day as the orthobiologic procedure, my thought is to do another session just before the injection but half as much, and probably at half the previous intensity, maybe 500 to 1000 pulses of each RSW and FSW, at an easy discomfort level of 2 or 3, just enough to "prime the pump." Recommendations for this same-day orthobiologics injection are requested!?

Post-procedure:?

Week 1 after the orthobiologic injection, depending on how the patient feels after the procedure, tailor the number of pulses and the intensity level to reintroduce RSW and FSW to cover all areas previously addressed but at a reduced discomfort level of 2 to 4.?

Week 2, after orthobiologics, begin to increase the number of pulses and discomfort level, always to the patient’s tolerance while returning to the general shockwave pre-procedures and protocols.

Ideally, the individual receiving PRP and/or stem cells would receive five full sessions of shockwave therapy, not counting the very light and brief shockwave treatment immediately before the injection.

Additionally, the synergistic combination of orthobiologics with shockwave therapy, EMTT, and/or laser therapy could provide the most targeted healing outcome for the patient and the physician and profoundly benefit people with musculoskeletal pain. With this knowledge of treatment frequency and the combination of modalities, clinicians can expect better and faster patient results.

****************

I would like to offer you, the physician, the clinician, and the medical researcher, the venerable experts in the field of orthobiologics, the opportunity to have perhaps some of your patients that live in or near Cincinnati, Ohio, test some of your theories on how to best boost and amplify PRP and stem cell therapy, with a possible combination of shockwave therapy, EMTT, and/or laser therapy. Our clinic has the radial and focused shockwave, the EMTT, and the M6 laser, and we would be happy to discuss how we can assist your patients and your research.?

The vast possibilities and potential when combining Orthobiologics with Shockwave Therapy Plus are expansive.