PainExam Podcast Show 

Episode Title: Exploring PRP and BMAC in Pain Managemen 

Host:   David Rosenblum, MD  
        Release Date:    November 27, 2024  

 Episode Overview: 
In this episode of the PainExam Podcast, Dr. David Rosenblum, a New York-based pain physician, examines the latest research surrounding Platelet-Rich Plasma (PRP) and Bone Marrow Aspirate Concentrate (BMAC) in pain management for the knee, shoulder, and spine. Dr. Rosenblum reviews several key studies, providing insights into the efficacy of these regenerative treatments and their implications for clinical practice.

Featured Studies: 

1.  A Comparison of Functional Outcomes in Rotator Cuff Repairs Using Adjunctive Bone Marrow Aspirate Concentrate vs. Bone Marrow Aspirate Concentrate With Platelet-Rich Plasma: A Systematic Review and Meta-Analysis**  
   -     Authors:       Seth J. Spicer, Sara Soliman, Robert Malek, Mitchell Kaplan, Jensen Clark, Nicholas Averell, Brandon Goodwin, Richard Jermyn  
   -  Published in:  Cureus. 2024 Aug 23;16(8):e67594. doi: 10.7759/cureus.67594  
   -  Summary: This systematic review evaluates the outcomes of rotator cuff repairs (RCR) using BMAC alone versus BMAC combined with PRP. The analysis included three studies and found no significant difference in functional outcomes between the two groups, suggesting that BMAC alone may be adequate, potentially reducing costs and resource use.

2.        Bone Marrow Aspirate Concentrate Versus Platelet-Rich Plasma for Treating Knee Osteoarthritis: A One-Year Non-Randomized Retrospective Comparative Study        
   -  Authors: Abed El-Hakim El-Kadiry, Carlos Lumbao, Natasha Salame, Moutih Rafei, Riam Shammaa  
   -  Published in:  BMC Musculoskeletal Disorders, 2022.  
   -  Summary:   This study compared the effectiveness of intra-articular BMAC and PRP injections in patients with knee osteoarthritis (OA). Results indicated that patients receiving BMAC experienced significant improvements in pain and functionality scores over 12 months, while the PRP group showed nonsignificant improvements. BMAC was found to be more effective than PRP in managing knee OA symptoms.

3.  Patients With Knee Osteoarthritis Who Receive Platelet-Rich Plasma or Bone Marrow Aspirate Concentrate Injections Have Better Outcomes Than Patients Who Receive Hyaluronic Acid: Systematic Review and Meta-analysis**  
   -     Authors:  John W. Belk, Joseph J. Lim, Carson Keeter, Patrick C. McCulloch, Darby A. Houck, Eric C. McCarty, Rachel M. Frank, Matthew J. Kraeutler  
   -       Published in:   World Journal of Stem Cells, 2021.  
   -    Summary:  This systematic review assessed the efficacy of PRP and BMAC compared to hyaluronic acid (HA) injections for knee OA. The findings demonstrated that both PRP and BMAC led to significantly better patient-reported outcomes (PROs) compared to HA, with no significant differences between PRP and BMAC in terms of effectiveness.

4.          Platelet-Rich Plasma vs Bone Marrow Aspirate Concentrate: An Overview of Mechanisms of Action and Orthobiologic Synergistic Effects         
   - Authors: José Fábio Santos Duarte Lana, Lucas Furtado da Fonseca, Rafael da Rocha Macedo, Tomas Mosaner, William Murrell, Ashok Kumar, Joseph Purita, Marco Antonio Percope de Andrade  
   -  Published in:  World Journal of Stem Cells, 2021.  
   - **Summary:** This overview discusses the mechanisms of action for PRP and BMAC and their potential synergistic effects in musculoskeletal healing. The authors highlight that while both therapies show promise, further research is needed to standardize treatment protocols and fully understand their combined effects on healing processes.

5.  PRP and BMAC for Musculoskeletal Conditions via Biomaterial Carriers*   
   -   Authors:       Fabio S. M. Yamaguchi, Shahin Shams, Eduardo A. Silva, Roberta S. Stilhano  
   -   Published in:** International Journal of Molecular Sciences, 2019.  
   -     Summary:  This review focuses on the use of biomaterial carriers in conjunction with PRP and BMAC to enhance regenerative processes for musculoskeletal injuries. The authors emphasize the growing interest in these therapies as alternatives for treating cartilage, muscle, and bone injuries, and discuss the various biomaterials used in clinical trials.

 Key Takeaways: 
- The efficacy of BMAC compared to PRP in various orthopedic applications.
- Insights into the mechanisms of action and potential synergistic effects of PRP and BMAC.
- The importance of research in optimizing treatment protocols for knee osteoarthritis and other musculoskeletal conditions.

   Upcoming Events: 
Visit        NRAPpain.org  to learn about the virtual pain fellowship and other educational resources. Additionally, check out our live courses designed for healthcare professionals looking to enhance their skills in pain management and regenerative therapies.

 Listen to the Episode:  
Join Dr. Rosenblum as he provides expert analysis on these studies and discusses the implications for pain management and regenerative medicine.

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        Disclaimer  
The content of this podcast is for informational purposes only and does not constitute medical advice. Always consult with a qualified healthcare provider for any medical concerns.

Exploring the Efficacy of Autologous Platelet Leukocyte Rich Plasma Injections in Chronic Low Back Pain & Understanding Degenerative Lumbar Spinal Stenosis

 Host David Rosenblum, MD

 Episode Date: October 25, 2024

In this episode, Dr. David Rosenblum discusses two significant studies related to chronic low back pain and degenerative lumbar conditions. The first study focuses on the use of autologous platelet leukocyte rich plasma (PLRP) injections for treating atrophied lumbar multifidus muscles, while the second study investigates the correlation between muscle atrophy and the severity of degenerative lumbar spinal stenosis (DLSS).

 Featured Article 1: 
- Effect of Autologous Platelet Leukocyte Rich Plasma Injections on Atrophied Lumbar Multifidus Muscle in Low Back Pain Patients with Monosegmental Degenerative Disc Disease
- **Authors:** Mohamed Hussein, Tamer Hussein
 

 Key Points Discussed 
1. Background:  Correlation between lumbar multifidus muscle dysfunction and chronic low back pain.
2.  Study Overview: 115 patients treated with weekly PLRP injections for six weeks, followed for 24 months.
3.  Outcome Measures:  Significant improvements in NRS and ODI scores, with high patient satisfaction.
4. Conclusions: PLRP injections into the atrophied multifidus muscle are safe and effective for managing chronic low back pain.

 Featured Article 2: 
-   Degenerative Lumbar Spinal Stenosis
 Authors:*  Gen Xia, Xueru Li, Yanbing Shang, Bin Fu, Feng Jiang, Huan Liu, Yongdong Qiao

 Key Points Discussed 
1. Background:  DLSS is a common condition in older adults, often leading to muscle atrophy and disability.
2. Study Overview: A retrospective analysis involving 232 patients to investigate the correlation between muscle atrophy and spinal stenosis severity.
3.  Results: 
   - Significant differences in the ratio of fat-free multifidus muscle cross-sectional area between stenotic and non-stenotic segments.
   - A strong positive correlation was found between multifidus atrophy and the severity of spinal stenosis.
   - The atrophy was more pronounced on symptomatic sides of the spine compared to contralateral sides.
4.  Conclusions:  The findings suggest that more severe spinal stenosis is associated with greater muscle atrophy, emphasizing the importance of addressing muscle health in DLSS patients.

 Discussion: 
Dr. Rosenblum provides insights into how these studies inform clinical practices for treating chronic low back pain and managing degenerative conditions. He emphasizes the need for comprehensive treatment strategies that consider both muscle health and spinal integrity which may be achieved via peripheral nerve stimulation of the medial branch nerve and multifidus muscle or PRP injection in to the multifidus muscle.

 Closing Remarks: 
Listeners are encouraged to stay informed about innovative treatment options and the importance of muscle assessment in managing spinal disorders.

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**Disclaimer:** The information presented in this podcast is for educational purposes only and should not be considered medical advice. Always consult a healthcare professional for medical concerns.

References

Xia, G., Li, X., Shang, Y. et al. Correlation between severity of spinal stenosis and multifidus atrophy in degenerative lumbar spinal stenosis. BMC Musculoskelet Disord 22, 536 (2021). https://doi.org/10.1186/s12891-021-04411-5

Hussein M, Hussein T. Effect of autologous platelet leukocyte rich plasma injections on atrophied lumbar multifidus muscle in low back pain patients with monosegmental degenerative disc disease. SICOT J. 2016 Mar 22;2:12. doi: 10.1051/sicotj/2016002. PMID: 27163101; PMCID: PMC4849261.

Dr. Rosenblum reviews the benefits of Scrambler Therapy for CRPS and Neuropathic Pain State. 

• What is Scrambler Therapy?
• Efficacy of Scrambler Therapy for Neuropathic Pain 
• Mechanism of action of Scrambler Therapy
• Regenerative Pain Management Course
• PainExam Board Prep
• NRAP Academy Private Tutorials for Ultrasound Guidance and Regenerative Medicine

ST was introduced as a chronic pain relief method in 2003. That same year, Giuseppe Marineo published findings from a small clinical trial involving 11 terminal cancer patients suffering from drug-resistant chronic visceral pain, with all participants showing positive responses and significant reductions in pain scores. In a subsequent trial involving 226 patients with neuropathic pain, 80% reported a 50% reduction in pain. Since then, numerous case reports and studies have documented the use of ST for various pain types.

Evidence from these reports suggests that ST is effective for managing both acute and chronic pain from different causes. For instance, a child with acute mixed pain, resistant to pharmacological treatment, experienced significant relief after four ST sessions, with pain levels dropping from 5/10 to 0/10. Additionally, a 52-year-old woman with burning pain from her foot to knee, stemming from a right medullary acute hemorrhage and suffering for 12 years, reported immediate relief after ST. Her pain score decreased from 9/10 to 3/10 on the first day, and to 0/10 by the second day, remaining below 1 on the Visual Analog Scale (VAS) throughout the 10-day treatment period.

In terms of chronic pain, literature includes a case where a patient with shoulder joint pain and limited range of motion saw significant pain reduction and increased mobility after 10 sessions of ST. ST has shown considerable promise in treating severe pain conditions that are typically difficult to manage, such as complex regional pain syndrome and pain related to HIV.

Despite the encouraging results from these case studies, higher-quality evidence is necessary to establish the efficacy of ST, which could be obtained through extensive clinical trials, particularly focusing on chronic pain. Besides the aforementioned studies by Marineo and Sabato et al, additional trials have indicated that ST is an effective treatment for various chronic pain conditions, including low back pain, postherpetic pain, and neuropathic pain. For instance, a prospective study on chronic low back pain patients showed a significant decrease in VAS scores from 8.12 to 3.63 after six treatment days. Another trial involving 10 patients with postherpetic pain reported a drop in the average Numeric Rating Scale (NRS-11) score from 7.64 to 1.46 at baseline and 0.42 to 0.89 after one month, with benefits persisting at two and three months.

ST has also demonstrated significant potential in treating neuropathic pain. In a prospective study of 45 patients with neuropathic pain lasting over three months, 28 experienced a decrease in Douleur Neuropathique en 4 questions (DN4) pain scores, with four patients stopping treatment early due to complete pain resolution. The mean baseline DN4 score dropped from 5.67 to 2.82 by the end of treatment. A pilot randomized trial involving 52 patients found that 21 out of 26 in the intervention group achieved complete pain relief.

While the findings from these studies, along with others that have been systematically analyzed, suggest strong evidence for the efficacy of ST, a definitive conclusion regarding its effectiveness has not yet been reached. A systematic review by Majithia et al concluded that while studies generally indicate ST results in pain reduction with lasting benefits, there are still gaps in the evidence.

This article aims to evaluate the research needs surrounding ST for cancer pain management. While Majithia et al focused on chronic pain across various conditions and noted specific evidence limitations, this study will concentrate on the effectiveness of ST for cancer-related pain. The objective is to identify gaps in the existing literature and provide recommendations for future research through a systematic review. We will specifically analyze the types and levels of evidence supporting the use of ST in managing cancer pain and determine what studies are necessary to enhance the evidence base.

References 

Majithia, N., Smith, T.J., Coyne, P.J. et al. Scrambler Therapy for the management of chronic pain. Support Care Cancer 24, 2807–2814 (2016). https://doi.org/10.1007/s00520-016-3177-3

Mohamed, Mohamed S. I.1; Alkahlout, Lama1; Elgamal, Salma1; Mohiuddin, Amna1; Al-sayed, Talal1; Al-Marri, Hamad1; Zahid, Fatima1; Martínez-Magallanes, Daniela2; Fregni, Felipe2; Doi, Suhail A. R.1; Abdallah, Abdallah M.3; Musa, Omran A.H.1,4; Khan, Muhammad Naseem1; Babu, Giridhara R.1,*. Efficacy of scrambler therapy in chronic neuropathic pain: pairwise and dose-response meta-analysis. Brain Network and Modulation 3(3):p 63-70, Jul–Sep 2024. | DOI: 10.4103/BNM.BNM_20_24

Kashyap, Komal, and Sushma Bhatnagar. "Evidence for the efficacy of scrambler therapy for cancer pain: a systematic review." Pain Physician 23.4 (2020): 349.

PainExam Podcast Episode: An In-Depth Look at Hydrogen-Rich Water for Chronic Inflammatory Pain

In a recent episode of the PainExam podcast, Dr. David Rosenblum delves into an intriguing study published in the journal Antioxidants, exploring the therapeutic potential of hydrogen-rich water (HRW) in alleviating chronic inflammatory pain and associated mood disorders in mice. The study, conducted by Santiago Coral-Pérez and colleagues from the Institut d’Investigació Biomèdica Sant Pau and Universitat Autònoma de Barcelona, presents compelling evidence supporting the analgesic, antidepressant, and anxiolytic effects of HRW.

Study Overview

The study investigates the efficacy of HRW in treating nociceptive responses and affective disorders associated with chronic inflammatory pain. Using a mouse model induced by the subplantar injection of complete Freund's adjuvant (CFA), the researchers evaluated the impact of HRW on several parameters:

1. Nociceptive Responses: Mechanical allodynia and thermal hyperalgesia.
2. Affective Disorders: Depressive-like behaviors (measured by Tail Suspension Test and Forced Swimming Test) and anxiety-like behaviors (assessed using Elevated Plus Maze and Open Field tests).
3. Biomarker Analysis: Levels of oxidative stress, inflammatory, and apoptotic markers in the paws and amygdala.

Key Findings

1. Analgesic Effects:

• Mechanical Allodynia and Thermal Hyperalgesia: The study found that both intraperitoneal and subplantar administration of HRW significantly reduced mechanical allodynia and thermal hyperalgesia in CFA-injected mice. Remarkably, the local (subplantar) administration showed greater effectiveness, achieving complete inhibition of nociceptive responses with just one day of treatment.

2. Antidepressant and Anxiolytic Effects:

• Depressive-like Behaviors: HRW treatment normalized the increased immobility times in both the Tail Suspension Test and Forced Swimming Test, indicating potent antidepressant properties.
• Anxiety-like Behaviors: HRW also reversed the anxiety-like behaviors in the Elevated Plus Maze and Open Field tests, showcasing its anxiolytic effects without impairing motor function.

3. Biochemical Pathways:

• The study highlighted the significant role of the Nrf2/HO-1-NQO1 pathway in mediating the analgesic effects of HRW. Inhibitors targeting this pathway reversed the pain-relieving actions of HRW, underscoring its pivotal role.
• Oxidative Stress and Inflammation: HRW treatment reduced the expression of oxidative (4-HNE), inflammatory (p-IKBα), and apoptotic (BAX) markers in both the paw and amygdala tissues, demonstrating its broad-spectrum protective effects.

Implications for Clinical Practice

Dr. Rosenblum emphasizes the potential of HRW as a novel therapeutic strategy for chronic inflammatory pain and its associated comorbidities. The study's findings suggest that HRW could offer a multifaceted approach, addressing both pain and mood disorders through its antioxidant, anti-inflammatory, and anti-apoptotic properties.

Conclusion

The episode concludes with a discussion on the broader implications of these findings for pain management, particularly in conditions where chronic inflammatory pain is prevalent. Dr. Rosenblum highlights the need for further clinical trials to validate these promising preclinical results and explore the potential of HRW in human subjects.

For more detailed insights into this study, including potential applications and future research directions, tune into the PainExam podcast with Dr. David Rosenblum.

For more information go to:

https://molecularhydrogeninstitute.org/links-mhi/

References

Coral-Pérez, S., Martínez-Martel, I., Martínez-Serrat, M., Batallé, G., Bai, X., Leite-Panissi, C. R., & Pol, O. (2022). Treatment with hydrogen-rich water improves the nociceptive and anxio-depressive-like behaviors associated with chronic inflammatory pain in mice. Antioxidants, 11(11), 2153.

Dr. Rosenblum serves at AMETD's 2024 Conference as faculty and discusses the safe and accurate usage of Ultrasound to Guide PRP injecitons

Discussed in this lecure:

Knee, Hip, Shoudler, Ligament and Tendon Targets, the ultrasound technique, the evidence for PRP and controversy.  Controversy with respect to the Achilles Tendon!

References 
https://rapm.bmj.com/content/rapm/early/2024/07/16/rapm-2024-105593.full.pdf

Disclaimer

Disclaimer: This Podcast, website and any content from NRAP Academy (NRAPpain.org) otherwise known as Qbazaar.com, LLC is  for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user’s own risk. Professionals should conduct their own fact finding, research, and due diligence to come to their own conclusions for treating patients. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.