Episode 25 - Regenerative Spine & Orthopedic Medicine with Dr. John Lesher
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Episode Summary
From Kim Kardashian getting a vampire facial to Hines Ward's extraordinary knee recovery in the weeks leading up to the 2009 Super Bowl, regenerative medicine has gained a tremendous amount of interest in both the lay population and the scientific community. This medical-assisted self-healing process has helped athletes including Tiger Woods, Kobe Bryant and other high-profile celebrities not only overcome injuries but increase their recovery times.
On this special one-year anniversary episode of Back Talk Doc, Dr. Lakhia welcomes Dr. John Lesher to discuss regenerative spine and orthopedic medicine, including the use of platelet-rich plasma (PRP) injections and stem-cell therapy. Dr. Lesher is board certified in physical medicine and rehabilitation with subspecialty certifications in sports medicine, electrodiagnostic medicine, and certification in musculoskeletal ultrasound.
Dr. Lesher shares his experience and knowledge in regenerative spine and orthopedic medicine from a personal and professional perspective. Given his background in athletics, he also discusses regenerative medicine and its applications in the sports arena.
Highlights from the episode:
Resources mentioned on this episode:
For more information on Dr. Sanjiv Lakhia’s practice, visit backtalk.com
If you enjoyed this episode of Back Talk Doc, check out our episode Introduction to Spinal Artificial Disc Replacement Surgery with Dr. Dom Coric.
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
From Kim Kardashian getting a vampire facial to Hines Ward's extraordinary knee recovery in the weeks leading up to the 2009 Super Bowl, regenerative medicine has gained a tremendous amount of interest in both the lay population and the scientific community. This medical-assisted self-healing process has helped athletes including Tiger Woods, Kobe Bryant and other high-profile celebrities not only overcome injuries but increase their recovery times.
On this special one-year anniversary episode of Back Talk Doc, Dr. Lakhia welcomes Dr. John Lesher to discuss regenerative spine and orthopedic medicine, including the use of platelet-rich plasma (PRP) injections and stem-cell therapy. Dr. Lesher is board certified in physical medicine and rehabilitation with subspecialty certifications in sports medicine, electrodiagnostic medicine, and certification in musculoskeletal ultrasound.
Dr. Lesher shares his experience and knowledge in regenerative spine and orthopedic medicine from a personal and professional perspective. Given his background in athletics, he also discusses regenerative medicine and its applications in the sports arena.
Highlights from the episode:
- What we mean when we say “regenerative medicine” (8:32)
- Examples of medical-assisted self-healing (9:47)
- Stem Cells 101 (14:01)
- Joint arthritis: the difference between corticosteroid injections vs stem cells or PRP (20:22)
- Effectiveness of regenerative medicine options: joints and tendons (23:34)
- The role for regenerative medicine in spine care (32:45)
- The future of regenerative medicine (43:26)
- Dr. John Lesher’s personal health tips (46:19)
- Dr. John Lesher’s podcast recommendations (48:03)
Resources mentioned on this episode:
- Prospective study of disc repair with allogeneic chondrocytes presented at the 2012 Joint Spine Section Meeting by Coric D, Pettine K, Sumich A, Boltes MO
- Mesoblast Study by Mesoblast the regenerative medicine company
- Cell-based therapy for spinal disc regeneration by Coric D.
- Clinical Study to Evaluate the Safety and Preliminary Efficacy of IDCT, a Cell Therapy to Treat Moderate, Symptomatic Lumbar Degenerative Disc Disease by Silverman L, Coric D, Foley K,
- British Journal of Sports Medicine
- Outside podcast
- The Peter Attia Drive Podcast
- The People's Pharmacy
For more information on Dr. Sanjiv Lakhia’s practice, visit backtalk.com
If you enjoyed this episode of Back Talk Doc, check out our episode Introduction to Spinal Artificial Disc Replacement Surgery with Dr. Dom Coric.
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Sponsor: 00:00
This podcast is sponsored by our partner QxMD. QxMD builds mobile solutions that drive evidence-based medicine in clinical practice. Check out Read for easy access to research personalized for you and Calculate for over 500 easy-to-use decision support tools. Try them today at QxMD.com/apps. Again, that is QxMD.com/apps.
Intro: 00:31
Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health. Brought to you by Carolina Neurosurgery & Spine Associates, where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 01:05
Greetings wherever you are and whoever you are. Thank you for tuning in to this episode of Back Talk Doc. I want to start today with a bit of gratitude. By the time I think this episode posts, we will hit our one-year anniversary of the podcast, and this will be our 25th episode. And it's just been an amazing experience for me. I want to thank so many people who have supported this endeavor. First, I'd like to thank Rob Ingalls at Lawpods. He's the producer for the show. He's helped guide us through how to put together a professionally sounding podcast. And it's just been a pleasure to work with him and his company. I'd also want to give thanks to my organization at Carolina Neurosurgery & Spine Associates. I think I work at the premier neurosurgery and spine practice in the country, and I have just wonderful support from the partnership here and administration.
Sanjiv Lakhia: 01:59
I also want to thank you the listeners and all the patients. We've received tremendous feedback about the episodes, in particular the quality of the content. We've done a really good job. I've really focused on bringing to you all who are listening, actionable information to help you with your decision-making process. With that being said, I'm very excited. We've also obtained our first... as you've heard in the intro, our first sponsorship with QxMD. QxMD has a mission to spread health information to health professionals across the world, and I'm excited to be a part of that, helping to communicate their message. So without further ado, today's episode is on a topic I've been really wanting to dive into deep, and it's just taken us some time to get some schedules together. Today we're going to be talking about regenerative spine and orthopedic medicine with Dr. John Lesher. Dr. Lesher is one of my partners here at the group.
Sanjiv Lakhia: 02:55
And in my opinion, he's one of the top physiatrist in the region if not the country. His level of expertise and knowledge about the topic today and spine and sports medicine in general is just fantastic. And that's just not me. I think if you surveyed our partnership, you would find unanimous support for that opinion. John, welcome to the show today.
John Lesher: 03:16
Thanks for having me Sanjiv. I think the podcast has been awesome.
Sanjiv Lakhia: 03:20
Yeah. It's been a lot of fun and I think today's topic there's going to be many people interested to hear what you have to say. Let me go ahead and introduce you to the listeners. John obtained his undergraduate at Boston College, and then he did a combined MD/MPH program at Tulane and ultimately went through internship and residency at the University of Washington in Seattle. He has a fellowship training in musculoskeletal medicine and interventional spine at Washington University in St. Louis, and he's board certified in physical medicine and rehabilitation with subspecialty certifications in sports medicine, electrodiagnostic medicine, and certification in musculoskeletal ultrasound. So what that means listeners is he's a lot smarter than me. So take some notes today, I think he's going to enlighten us. John, why don't you introduce yourself to the people who aren't familiar with your work? You have your practice up in the Huntersville Concord area around Charlotte, North Carolina. Talk to the listeners a little bit about your path to physiatry and in particular, your growing interest in regenerative medicine.
John Lesher: 04:23
Sure. My interest in physiatry started actually before I went to medical school. I did a yearlong internship at Princeton University... I'm not even sure if they have this anymore, but it was geared towards people that were interested in going to medical school. And I lived and literally worked and lived in Princeton's health infirmary. And during that time I worked with a sports medicine doctor. He was trained as an internist, and so he was not an orthopedic surgeon, but he exposed me a lot to sports medicine. I worked with their teams. And so that was I think my initial interest in musculoskeletal care. In medical school, I really thought I'd lean towards a surgical subspecialty, but in my mid 20s, I really didn't enjoy that dirty four-letter word called call, C-A-L-L. I knew if I didn't enjoy it in my mid 20s, I wouldn't like it much better when I was in my mid 50s.
John Lesher: 05:23
That's held true, even though I'm not that old yet. But during medical school, I kind of gravitated towards the musculoskeletal side of things and sought out exposure to physical medicine and rehab. Where I went to medical school, we did not have a department of PM&R, but I did work with a physiatrist to sports medicine, boarded and focused and he gave me some great recommendation. Did a couple of elective courses in my senior year and then decided the specialty is for me and then the rest is history. You've mentioned that the podcast is now one year old, which I think is great. This month for me, the end of October is my 13th year here at Carolina Neurosurgery & Spine Associates. So it's been great. Each year is a kind of learning and growing years. There's always new challenges, which makes it fun.
John Lesher: 06:15
As far as my practice set up goes, clearly I see plenty of patients with spine but I also see a good percentage of patients that I treat with shoulder issues, hip issues, and knee issues. I did quite a bit of foot and ankle care in my fellowship. I don't really do that much now. And then I do supplement my practice with quite a lot of electro-diagnostic tests and then ultrasound too. So I use ultrasound in my practice to diagnose soft tissue and joint issues like rotator cuff tears, or lateral tendon tears. And I also use it to evaluate peripheral nerves. So it's a great complimentary test to the nerve study. So when I test nerves with a nerve study, we can also evaluate them. It's a good, well-rounded clinic. I've really enjoyed it.
Sanjiv Lakhia: 07:06
Yeah. And you do have some training in sports medicine as well, were you into athletics growing up and into college?
John Lesher: 07:14
I've always enjoyed sports my entire life. I never played at the division one level. I played basketball and volleyball in high school and then played at the club level volleyball when I was at Boston College. Which was great because the club level what's serious about it, we traveled to different tournament's and nationally, but you didn't have the day in, day out grind all the time with higher level training. So it was a lot of fun. My jumping days, unfortunately, are behind me. And maybe we can talk a little bit more about that as we get into the topic today.
Sanjiv Lakhia: 07:47
Well, I think that's actually important that you have a little bit of background in athletics from a personal perspective. Because when you dive into the field of regenerative medicine, a lot of the applications are in the sports arena. Not all of them, but certainly many of them. So it sounds like on a day-to-day basis, you have a wide variety of cases that come through your office. Let's dive into today's topic, which is the regenerative orthopedics and spine care. And there is a lot out there, John. You and I both know that you cannot turn the radio on, at least in the Greater Charlotte area without one or two commercials for a regenerative medicine clinic. And listeners of our podcast are both from a consumer or patient side and also professional side. So why don't we start with almost a definition or your description of what exactly regenerative medicine means for those who aren't familiar with the concept?
John Lesher: 08:41
Yes. When I think of regenerative medicine, actually it's pictures that usually come to mind, I think of a human ear or a human nose being grown in a Petri dish. That's what I normally think of when I hear this. But clearly that's not the case. And the description I like to give, I actually learned at a conference. And I forget who said it. There was a physician who was lecturing on regenerative medicine and they referred it to the name MASH. And MASH again, when I think of MASH, I usually think of the television series from the '70s, which stands for Mobile Army Surgical Hospital. Clearly that doesn't apply to regenerative medicine, but the new meaning, which I really liked is described as Medical-Assisted Self-Healing. So we're providing medicines. And usually when we think of regenerative medicines, we usually think of biological-type treatments that are either taken from the patient or other patients and then placed into the body to help the body heal itself. So the simple way to think of it is medical-assisted self-healing.
Sanjiv Lakhia: 09:47
Maybe give a few examples of what that means.
John Lesher: 09:51
So, one of the areas of regenerative medicine that has gained a tremendous amount of interest in both the lay population and the scientific community is what we call platelet-rich plasma. And so platelets are a component of our blood primarily used in clotting and wound healing. And so we can essentially draw blood and then concentrate the different components, primarily the platelets, get them to a level that we are interested in and then place them in the body, in certain areas of injuries to help with healing. So instead of taking a pill or in taking a laboratory-made medicine out of a vial and placing it in the body, here we are taking a patient's own biological fluid, concentrating it, and then putting it back in the body.
Sanjiv Lakhia: 10:46
And historically, I remember hearing about PRP, geez, at least maybe 15 years ago. I mean, this stuff has been around a while, has it not?
John Lesher: 10:56
Platelet-rich plasma or platelets in general, they've been used in the veterinary sciences, gosh, since the '80s and '90s. And they were being used to treat musculoskeletal injuries in dogs as well as horses and showing good results. And then as literature began to grow with those uses, primarily maxillofacial specialists were using it in jaw surgeries. That kind of further grew and developed and orthopedic doctors were using platelets to help with bone fusion or bone grafting. That really began in the early 2000s. But really what kind of put... What's interesting is when you really look back at the history, what really put platelet-rich plasma or platelet-based therapies on the map especially with regards to the lay population is Hines Ward's injury before the 2009 Super Bowl. Now I'm from the Philadelphia area, so I'm more partial to the Eagles. But long story short, I still respect the Steelers.
John Lesher: 12:01
And so he injured his knee, specifically his medial collateral ligament a few weeks before the Super Bowl. He was definitely going to play in the Super Bowl and not sit out. He sought out care and had platelets injected to that ligament of his knee and then played in the Super Bowl. And I believe, I think he won the MVP that year. And so that was 2009. So roughly it's 11 years ago. And PRP was gaining momentum at that time, but that really kind of led to this massive explosion and interest in the regenerative field. So he was very much a very prominent person who had it done, and then that was followed by Tiger Woods having it done, the late Kobe Bryant and then that leads to celebrities, Kim Kardashian getting a vampire facial and all different types of uses. So again, when you look at the history, I think that injection or the treatment that Hines Ward received before the Super Bowl was instrumental in the explosion of this field.
Sanjiv Lakhia: 13:04
Yeah. And I bring that up just to illustrate these procedures in general are not reimbursed through insurance plans and they're considered experimental. But experimental doesn't necessarily mean brand new. And I think number one, the basic science behind the idea of regenerative orthopedics has been around a long time, even going back to the prolotherapy days injecting dextrose water. And it's still being used. Think you do a little bit of that in your patient clinic as well. And that's been discussed for quite a long time. I remember even at osteopathic medical school, we were learning about that as well. So there are though some more modern kind of techniques and you hear all sorts of things now between PRP and then there's stem cells and amniotic tissue. Or you'll go online and you'll hear that Dave Asprey's getting stem cell injections in every joint of his body, every vertebral segment, every orthopedic joint.
Sanjiv Lakhia: 13:58
Ben Greenfield has done it and made it real popular. So for those who, again are somewhat new to this field, can you give a basic overview? I know each one of these topics could... We could go on for an hour on each individual topic, but maybe just breaking down a little bit of the differences between the types of stem... Let's start with stem cells because that's extremely popular. I think most people who are listening to the podcast today have heard about stem cells and are probably wondering what is that and is that something for me?
John Lesher: 14:26
Yeah. So I like to say, "Stem cell 101," just to kind of clear up or better understand this concept. So when we think of stem cells, a lot of people will think of a zygote. So a sperm meeting and egg gives rise to a zygote and the beginning of human life as we know it. And so those types of cells are what we call totipotent. So that's the very beginning when sperm meets the egg and cell division happens, those cells that further develop can really give rise to all types of tissues in fetal development. Those are not... Let me repeat. Those are not the cells that we are using when we talk about stem cells for orthopedic conditions. As the embryo grows and gets bigger, the stem cells then become pluripotent, and they can then give rise to different or most tissues, but not all tissues.
John Lesher: 15:25
So when we think of stem cells or adult stem cells for use again in orthopedic or spine conditions, these are again adult stem cells and they are multipotent. So that means that they can give rise to a limited number of tissues. There's a lot of specialized vocabulary with this, but what you will hear most commonly is the term MSC, which stands for mesenchymal stem cell. And that is an adult stem cell. There is a very famous cell biologist named Arnold Caplan who's essentially studied MSCs or mesenchymal stem cells his whole career. And he actually likes to call them medicinal signaling cells and is kind of moving away from using the term stem cell when referring to MSCs. And so just a little bit of biology or cell biology in regards to these types of MSCs. So the MSC is also called a pericyte.
John Lesher: 16:33
And so a pericyte is essentially a cell that hangs out on blood vessels all throughout our body. They're essentially just kind of hanging out in all of our tissues, surveying what's going on in our body. And say an injury happens at one part of the body near the blood vessel, an injury happens, that activates this pericyte or MSC essentially to leave the blood vessel, travel to that injury site, and then essentially it becomes the glorified MSC or medicinal signaling cells. It will kind of regulate the immune system at the site of the injury and also kind of send out a variety of different signals to try to get the injured tissue to respond to healing and essentially improving itself. So a lot of different terms there. But I like to tell my patients that I think there's a lot of misunderstood vocabulary about stem cells.
John Lesher: 17:38
These are technically medicinal signaling cells that hang out on blood vessels, they go to the sites of injury and then they orchestrate or kind of act as the job site boss saying, "Hey. We're going to tone up or tone down the immune response to this injury. And I'm also going to send out signals to get the cells in the area to try to start healing themselves and creating a repair to the injury." I hope that kind of clarifies some of the misunderstanding there. The use of stem cells with regards to orthopedic or musculoskeletal conditions really focuses on bone marrow aspirates. So what they're doing with regards to bone marrow aspirate, also called BMAC, which just stands for bone marrow aspirate concentrate, is essentially we tap into bone marrow and withdrawal the bone marrow cells. Essentially, that's a concentrate. Additionally, this is also done in fat tissue, also called adipose-derived stem cells or ADSC.
John Lesher: 18:44
We target the bone marrow as well as the fat tissues because these are sites in our body that are known to have higher quantities of these adult stem cells or MSCs. Additionally, there are stem cells found in fetal products of the placenta, the amnion, the chorion as well as the umbilical cord, and those are done as well. But really when it comes to stem cells from those tissues, that is not currently really being done in the U.S. Those tissues can create or lead to growth factors, but not really stem cells. Another thing that I also try to get across to patients when it comes to stem cell usage is, currently in the United States, we are only allowed as providers or physicians to what we call minimally manipulate the stem cells. So we can take cells from the bone marrow or cells from fatty tissue, essentially clean them or concentrate them and then place them in the injury sites that we're most interested in.
John Lesher: 19:48
Based on FDA rules, we cannot take those cells and grow them or expand them. So long story short, we can't take the cells, put them in essentially nutritional medium, and then essentially put them in an incubator and expand them. That is not allowed in the U.S. It is allowed in other countries, but we cannot do that currently under FDA regulations.
Sanjiv Lakhia: 20:13
Yeah. That's an excellent overview I think of just explaining what actually a stem cell is and kind of where it starts from and how it can be used clinically. Touch real briefly though on really a difference... So if a patient comes in and let's say they have an arthritic knee, what's the difference in terms of what's going on in the body when you inject corticosteroid in the knee versus let's say something like stem cells or PRP?
John Lesher: 20:39
That's a great question. So when it comes to joint arthritis, there's this balancing act going on inside the joint at the cellular level. So in a normal joint, without arthritis, there's kind of this nicely regulated system of an anabolic and catabolic process. So in a normal joint there's substances being produced that are healthy for the joints, that's what we call anabolic, then there's also catabolic processes where substances are being broken down. And when the joint is healthy and happy, these kind of sequences or pathways are essentially in check. They're being nicely weighed out against one another. When arthritis sets in, those catabolic processes or those breakdown processes take over. So they are essentially the growth or the building of good substances in the joint is starting to decline and things are starting to break down.
John Lesher: 21:41
So stem cells or I'll say MSC or medicinal signaling cells or things like platelet-rich plasma, when we put those into the joint, those are trying to further strengthen the anabolic process or the buildup process of good materials for the joint and limit the catabolic or breakdown processes. So we look at the stem cells or platelets as ways to try to build the joint up and limit the breakdown of the joint. Conversely, when you take a steroid and put it in the joint, it's essentially a much stronger catabolic trigger. So a steroid substance like triamcinolone or Kenalog, probably one of the more common steroids we inject into joints in all parts of the body, goes into the joint and leads to essentially cartilage damage or cartilage cells or what we call chondrocytes. And we know that those types of medicines, steroids that is, lead to chondrocyte death.
John Lesher: 22:48 It may feel good to get a steroid injection, and I do plenty of them in my clinic, but when you look at it on the cellular level, we are actually doing the cells of the joint relative harm. So just something to keep in mind. And that can also be said for most anesthetic or numbing medicines that we put in the joint. Those are typically going to have more of a catabolic or break down effect on the chondrocytes or the cells in the joint.
Sanjiv Lakhia: 23:18
Thank you for that. I think that's going to clear up a lot for people who are trying to understand the differences. Let's dive in a little bit into the whole question of does this stuff work? And in preparation for our interview, you did send me some articles. And I just want to open the floor up a little bit for you to provide the listeners with your overall broad view on the clinical efficacy or effectiveness of the different regenerative medicine options out there as people try and make decisions about investing their time and money into these procedures.
John Lesher: 23:51
This is a great question. And so we've already talked about how long these treatments have been available. The greatest amount of literature on clinical uses for regenerative treatments is really in the platelet realm. So at this point, there is strong and growing evidence that platelet usage can be beneficial for knee osteoarthritis, especially patients that have mild to moderate knee arthritis. If patients are in the severe category, that's really not being shown. So when it comes to joint arthritis, primarily in the knee, there is very good evidence that platelet-rich plasma, especially out to one year... So when you do a treatment, you want to measure how long does it last in patients? And most of the studies that have been done in the knee joint follow these patients out to one year, some cases in two years, and they are usually comparing the treatment to the standard of care.
John Lesher: 24:53
So in the knee, it's very common for us to inject either steroid or hyaluronic acid. Hyaluronic acid is a fancy name for essentially a large molecule of sugar and protein that holds on to water. And it's a component of the matrix or the environment that our cells live in. So those treatments, namely steroids and hyaluronic acid are regularly injected into knee joints for arthritis. And when we follow them over the long-term, we know that steroids provide a great response typically from anywhere from one month to three months. Hyaluronic acid can be longer than that and variable.
John Lesher: 25:34
And then when you compare them to the platelets, namely, if you compare a hyaluronic injection to a platelet injection and follow those folks out to a year, again, with patients that have mild to moderate knee arthritis, there is numerous studies that show that PRP typically will do better than the hyaluronic acid. And this literature is coming... What I think is really interesting and it's something that makes me pay more attention is when you see this literature being done and published in the orthopedic surgery journals. It's one thing... The way publishing works is very specialty-specific, but when you see these non-surgical studies being published in surgical journals, that usually kind of gets my attention. And the studies are being done by orthopedic surgeons. Because I think they say, "Hey. There's a need here." The current treatments that we have, namely steroids, hyaluronic acid, they're not creating the greatest amount of benefits here. So I'm going on a long-winded answer here.
John Lesher: 26:37
But the first step for mild to moderate arthritis... And again, this is for folks or patients that have done rehab for their joints that aren't improving. I really think platelets is a very good place to start. When we talk about stem cells, there was a study published earlier this year out of the Andrews Institute in Florida, and it compared essentially those patients again with mild to moderate knee arthritis, and they had one group receive platelets, one injection of platelets, and they had one group receive an injection of bone marrow aspirate [inaudible 00:27:11] or BMAC or stem cells.
John Lesher: 27:13
And again, they followed those patients out to one year. And they found that the patients had similar responses. So to me, that was actually one of the very few studies that has done a head-to-head comparison of very popular or very well tilted or awfully or highly marketed treatments, and they followed these patients out to a year and both had the same response. Now experts in regenerative medicine say, "Oh gosh. They need to follow them out to two years because the stem cell will show better results at two years." And my answer to that is that very well may be, but we don't know. We know that platelets are easily acquired through a blood draw, bone marrow aspirate requires a little bit more involved procedure of harvesting the cells from bone. Platelets are typically much cheaper to do, bone marrow aspirate is more expensive. So when it comes to patients with mild to moderate arthritis, and they're asking me about, "Gosh, what are regenerative options here? And I've already failed a good course of physical therapy, I've already had steroid shots, I've already had hyaluronic acid," those are the studies I'm going to tell them about.
John Lesher: 28:26
So that's from the joint perspective. When we look at tendons and we talk about regenerative treatments, the greatest or actually one of the first studies came out of Stanford in 2006, and it looked at putting platelets in the tendons of the lateral elbow or the side of the elbow commonly called tennis elbow or we have numerous names for it and lateral epicondylitis or lateral epicondylalgia. But long story short, it's tendon pain on the lateral elbow. This orthopedist surgeon looked at injecting platelets in 2006 and then followed these patients. And he found good results. And so when it comes to tendon usage, the lateral elbow, as well as the lateral hip have shown to do very well with platelet treatments.
John Lesher: 29:15
Other tendons have been studied as well, namely the Achilles tendon, the plantar fascia which is the tendons on the plantar surface of our foot are also tendons that are looked at, in addition to the patellar tendon which is the tendon in the front of our knees. There's also additional studies done on those tendons, but not nearly as robust as the tendon studies done for the lateral elbow and the lateral hip. When we specifically look at the lateral elbow and the lateral hip, those patients do very well with platelet treatments out to one to two years. And again, that's comparing a group of patients that receives platelet treatment for those tendons compared to a group of patients that receive a corticosteroid injection around those tendons. When you go to conferences addressing this, a lot of the experts will say, "In the tendons, I'm almost always going to start with platelets because there's such good evidence."
John Lesher: 30:12
Going to a stem cell treatment for tendon pathology usually is only going to happen after the patient has failed a course of platelet therapy and they're really not considered for surgical repair. The literature or research on the use of stem cells in different tendons is still very early and emerging. It is being done, I'm not here to say that... But the studies the long-term studies of tendon use are still pretty much in their infancy. Does that give a pretty good description of joint use versus tendon use? And then we can also talk about spine use as well.
Sanjiv Lakhia: 30:51
Yeah. I think that's great. And that mirrors my clinical experience. I've had some really terrific outcomes using platelets for gluteus medius and minimus tendinopathies, tendon tears. And the patients they can be in a lot of pain and the outcomes are really excellent for that. One point I would make though, this stuff only works if you get it in the right spot. So it's critical that you have whoever's performing the procedure that they have training and in the utilization of some form of guidance, preferably, particularly for the tendinopathies, so ultrasound guidance. Because there certainly are... There are groups of practitioners across the country who are doing these procedures blinded. And I think if you're a patient or even a referring physician, well, that's one key question to ask is, "Will I have this procedure done with some sort of imaging guidance to ensure accuracy in delivery of the material?"
John Lesher: 31:43
I think that's such a great point Sanjiv. I mean, one of the things that I... When I'm asked about regenerative treatments from patients that live maybe out of town or not in my practice area, they say, "What should I be looking for?" And the first thing I'll tell them is, you clearly want to find a physician who's board certified. And again, when it comes to sports medicine or musculoskeletal care or pain care, that could be a family medicine who's board certified, a PM&R physiatrist who's board certified, an anesthesiologist or a orthopedic surgeon who's board certified. You clearly want to have board certification. Ideally you want to have some type of sub-specialty certification, whether that's sports medicine or pain management, and you definitely want to have that provider be very well skilled in image guidance, either ultrasound usage or fluoroscopy, which is fancy word for x-ray guidance. Those are just two of the basic requirements to look for when you're looking to seek out these kinds of treatments.
Sanjiv Lakhia: 32:45
Okay. So let's transition then and pivot into our world which is predominantly spine care. You and I both know, and I've talked about this on previous podcasts, the microenvironment of the bone disc bone segment in the spine is much different than let's say the knee, hip or shoulder. So help us understand kind of your thoughts on the role for regenerative medicine in spine and where you think there are opportunities right now and where you see kind of the studies, where they've been and evolved over the last decade and where they might be heading.
John Lesher: 33:18
When I think of regenerative treatments aimed at the spine, I think of namely first off the disc, the lumbar disc. And it makes me think of the movie with Matthew Damon, I think it was called... Was it The Martian? Was that what it-
Sanjiv Lakhia: 33:32
Yeah. He's been in one-
John Lesher: 33:32
Was that what it was called?
Sanjiv Lakhia: 33:35
He's been in one. Yeah.
John Lesher: 33:37
Yeah. I think the name of the movie is The Martian. Why I think of that is, in that movie, he's essentially on Mars in this most barren landscape and I think he tries to grow or trying to start a colony that has a greenhouse. So he's going to this essentially desolate and barren land, and he's trying to thrive and survive. And so when I think of the adult lumbar disc, I think of Mars because we're going into this harsh, harsh environment and trying to tell cells in that environment kind of, "Wake up. We need you to start doing your job better. We need you to start making these proteins that will make the disc stronger." So it's not an easy task. But when you look at regenerative care and you look at it namely addressing the spine, there's I think one study when it comes to addressing the sacroiliac joint, one study when it comes to addressing the facet joints which are just the... I like to say the knuckle joints of our spine.
John Lesher: 34:40
And then most of the studies are based on disc usage. And when you look at preclinical studies, namely studies that are done in animals, studies that are done in the lab, the results are really impressive. They're able to get stem cells to grow and rejuvenate that are native to the disc. When we actually do these types of studies in humans, the responses or the results are really in development, or they're not as promising as what we see in the lab or in animals. Our group or Carolina Neurosurgery and Spine, really this has been spearheaded by Dr. Dom Coric. He's really kept our group involved in intradiscal regenerative treatments or essentially studies really for the past 10 years. So one of the first regenerative studies we were involved in was called the NuQu Study. And this looked at placing juvenile or very young chondrocytes... Again, chondrocytes is just a fancy word for cartilage cells because that's what a lot of our disc is. The spinal disc is made of cartilage.
John Lesher: 35:52
And so one of the first studies our group was involved in was injecting these cells into the disc. Just one kind of point of clarification, our group has been involved in FDA-approved studies looking at placing stem cells in discs. All of the studies that we've been involved in have involved culturing these cells. So essentially the cells that we are injected have been cultured and multiplied and then placed in the disc and they have all been under FDA-approved studies. So these aren't patients coming in off the street saying, "Hey. I want to pay this amount of money. Will you inject me with stem cells?" All of our group's involvement has been involved with essentially studies of looking at how effective is this treatment. So sorry for the detour there, but I think that's really an important point.
John Lesher: 36:46
So when you look at the NuQu Study, are those chondrocytes, a phase I and phase II studies were done and they compared how do these groups of patients that get these juvenile chondrocytes in the disk compare to a control group that just gets saline injected into the group or... Pardon me. Into the disc. Saline is just salt water. And then they followed these patients for one to two years and they found that both groups did good, but these stem cell or juvenile chondrocytes group did not have superior results. So the study did not go past that. So it was encouraging like, "Gosh, the patients did well," but they didn't beat or significantly outperform a group that just received saline in the cell. And so it brings up a good point. Should we consider saline the most basic regenerative treatment out there? You touched a little bit on prolotherapy which is usually injecting dextrose or sugar solution into different tissues, but saline is even more simple than that.
John Lesher: 37:44
And these cells, I don't know whether it's due to a washout effect, so we inject saline into a disc that is in a deteriorating state, it's in that catabolic breakdown state and the saline, whether it washes some of those breakdown products way or jump-starts other cells, is doing something. So long story short with that first trial, the study treatment did not do better than saline, and it was put on hold. The second study, which is a totally different study that our group was involved in is called the Mesoblast Study. And again, it was using stem cells, namely bone-derived stem cells. So these cells were taken from bone marrow from donors, they were cleansed and essentially looked at for very specific types of cells once those cells were isolated. And the thought here is they were isolating cells that would be most beneficial in that harsh discal environment.
John Lesher: 38:43
They took those cells and then they multiplied them, and then once they got a significant amount, they were injecting them into discs as well. So this study very similar to the first NuQu Study, but different types of cells were being injected. And then the control groups were set up. One group received a higher concentration of stem cells, a second group received a lower concentration of stem cells. And then there was two controls. One control again had the saline being injected into the disc, and one control had hyaluronic acid. One thing to bring up is hyaluronic acid, like I said, is this large molecule that holds on to sugars or... Pardon me. It's a large molecule of sugar and protein that holds on to water. And that molecule was also injected as kind of a support mechanism or what we call a scaffold mechanism with the stem cells.
John Lesher: 39:37
So in the patients that were getting the stem cells, they were also being injected with hyaluronic acid. So I look at that as that when Matt Damon's on Mars, he has that greenhouse to help support him. The hyaluronic acid is that kind of supportive structure to the cells to kind of help get them started in this harsh environment. So again, a lot of detail there. But this Mesoblast Study was more involved, there was two treatment arms and then two control arms, and then they followed those patients out to one or two years. This study essentially went out to... It finished phase II and then it went to phase III. Phase III stops about... Don't quote me on this, but I think one or two years I think it's been completed. There have not been any officially published studies on it and I don't know why.
John Lesher: 40:24
Usually if the results are incredibly promising, there is essentially rush to market, rush to presses about this. So I think along the same lines as the first study is that the stem cells did not have this overwhelming response or benefit compared to the control studies of the hyaluronic acid or the saline group. Again, we're all still waiting for the studies to be officially published. Phase II trial results were discussed at meetings, but to my knowledge, phase III has not been formally discussed. So that was the second round of studies that our group was involved in. Now, the third round is through a company called DiscGenics. In this study, we are using lumbar spine disc-specific cells. So essentially these disc cells are coming from disc donors. We're isolating certain disc cells and then also culturally expanding them. And then we are injecting those types of discs into the cells and then following those patients out for one to two years.
John Lesher: 41:27
In this study there is again, two concentrations of cells, a higher concentration as well as a lower concentration, and there's also a control group as well of a saline as well. So phase II just stopped with regards to this trial. The results are being looked at and then potentially planning for phase III. So I think we'll put a link in the podcast about more information about this DiscGenics study as well. So to kind of sum it up, this is clearly a work in progress. Our group is very involved in stem cell treatments, but as of now, the evidence is not showing overwhelming treatment effects. My thought here is that in the future, as we understand the biology better, as we understand ways to support these cells in such a harsh environment improves, hopefully this will lead to better improvement of the disc tissue that's degenerating.
Sanjiv Lakhia: 42:26
And we touched on this a little bit when I did my interview with Dr. Coric. And if you haven't had a chance to hear that you should. I think it was our 19th episode, we talked a lot about the artificial disc and he spoke about the difference in outcome between the cervical area and the lumbar area. And I think the same challenges that they face in that arena we're facing in the regenerative arena. And it's multiple things. It's poor nutrition, poor blood supply to the disc and multiple biomechanical factors that play a role in lumbar disc disease, and the list can go on and on. So I'm like you. I'm cautiously optimistic, but I'm being realistic right now, at least when I recommend to patients how they should kind of take things slowly when they're looking at these potential treatment options that are out there in the market, particularly for lumbar disc disease.
Sanjiv Lakhia: 43:14
So I think that was a fabulous breakdown of this topic of regenerative medicine. I had a few other questions but I think we kind of covered some of this stuff already in terms of the differences with steroid injections. Before we just close out with a few personal questions, leave the listeners with your thoughts about where the future's heading with this from... I think a couple of things people want to know. Number one, is this really going to be kind of a standard of care treatment down the road for orthopedic and spine care? And then number two, do you ever foresee a situation where insurance companies, private payers will actually cover these services or will this continue to be an option for those... for a self pay basis?
John Lesher: 43:56
Sure. I think as far as what does the future hold, the literature so far with regards to joint treatments, primarily the knee and because there's such a huge demand for it based on how many Americans have knee arthritis and our population that's aging, I really think in the next few years, hopefully within five years, insurance companies are going to start at least paying for platelet-rich plasma. I know some workers' compensation industries do pay for it and I believe... Don't quote me on this. I think the VA may actually reimburse for platelet treatments. But I really think for the use of platelets with regards to knee arthritis, I do think that is on the near horizon. As far as tendon treatments, like I said, I think that would maybe second in line, just primarily with regards to the lateral elbow or the lateral hip, because there's good studies that support it.
John Lesher: 44:50 The spine, I think as you alluded to, I like to say... When I think of the future of the spine, I think it will continue to improve as we understand the biology better, but we do need to be a little bit cautious in making broad recommendations for these treatments in the disc or around the spine, because the data is really still very much in its nascent stages. There's the television show on HBO called Curb Your Enthusiasm. And when I think of the spine, that saying, it really comes to mind. I really think over the next 20 years, regenerative medicine type treatments or biologic treatments are going to become more and more common. As we understand more about inflammatory markers and patient's genomic makeup, that will also help guide us in trying to figure out what type of biologic treatments will best fit them.
John Lesher: 45:42
It's very much a work in progress, but I really think over the next decade or two decades, we're going to be seeing more and more of this. This is clearly not going away. I mean, based on our aging population, based on the prevalence of arthritis and based on essentially the finite number of surgeons we have to replace these joints, we need to figure out ways to treat it non-operatively.
Sanjiv Lakhia: 46:06
I think what goes hand in hand with regenerative medicine is the concept of lifestyle medicine and living a very healthy life in terms of your diet, exercise, and nutrition. So let's kind of close out the interview today... I know you're really big into fitness. Why don't you share with the listeners, maybe one or two of your top kind of personal health tips?
John Lesher: 46:28
My first tell health tip is very simple, but it can tell you a lot about how your overall cardiovascular or just generalized fitness is. It's three words. It's called... Or it's take the stairs. If you get out of breath after two or three flights of stairs, that's a very easy litmus test that you need to start working more on your general physical conditioning and physical fitness. It's very simple. In addition to that, when you go shopping, I mean, I know we're talking about these topics in the time of COVID so people aren't going out to the grocery stores willy-nilly or shopping centers. But when you go to a shopping store or any place where you're purchasing goods, park far away in the parking lot and walk in. If you get out of breath going into the store, you need to take a closer look at your physical conditioning and physical fitness. So I try not to get too specific and too labored in those recommendations. It's just a very easy litmus test, a very easy test to see how does your body feel with that?
Sanjiv Lakhia: 47:31
Yeah. So integrating movement into your lifestyle, you don't always have to have 30 to 60 minute block of time to exercise. I like that quite a bit. In fact, I laughed a little bit because recently I was in Nashville and I found myself on a hike up Mount Pisgah and I really had no idea what I was getting into. And 5,000 feet later, I really understood where my cardiac fitness was. I was motivated because as I was going up and considering quitting, there were several people probably twice my age who were coming back down smiling. So I think I've got some room for improvement there. And then what about some tools? I know you shared a little bit with me some apps and some books and things. What are some of your favorites that people might want to check out?
John Lesher: 48:11
Sure. I am a big podcaster. So like I said before Sanjiv , I think what you're doing is just absolutely phenomenal. I get a lot of my CME through podcasts on my way to work or to and from, I'll just be running errands and whatnot. Some of my favorite podcasts for more medical-specific information and advice, I really like BJSM that stands for the British Journal of Sports Medicine. I really like their interviews. They interview all types of providers. So those could be non-operative sports medicine docs, orthopedic surgeons, physiatrists, nutritionists, psychologists, public policy experts. So I really think they do a wonderful job of interviewing a broad array of different medical providers. So great information. And I think the lay public would benefit from listening to it as well.
John Lesher: 49:04
Just to your point about hiking up in Nashville, I really like the Outside Podcast that's based on... It's either Outside or Outdoors. I always get them mixed up, but the magazine. They usually talk about a lot of physical fitness-type topics, whether it is hiking or whether it's water sports, whether it's experiencing a snake bite in the wilderness. That just kind of speaks to me because I like being outside as well. For deeper dive, real in-depth medical podcast... Again, this may be over the head of some of the lay population, but regardless give it a try. I really like The Drive by Dr. Peter Attia, I think his last name is spelled A-T-T-I-A, the guests that he has on his podcast. There is a free service and then a subscription service, I just use the free service, but he goes deep into a lot of topics where I just feel like I've learned... my knowledge has been taken to another level and I'll re-listen to it.
John Lesher: 49:59
So again, I really think that is a wealth of really good information. And then also closer to home, I think they are at either... I know they're in Raleigh. I want to say UNC, but if they're at Duke, heaven forbid I misspeak, but the People's Pharmacy, the Graedon's , it's a husband and wife and they talk about all types of medical treatments. Some are holistic, some are mainstream, and I think they do a great job of again interviewing a broad array, a great diversity of different providers and experts. So those are four podcasts I think we'll do most listeners really well.
Sanjiv Lakhia: 50:34
Great. We'll put links to those as well in the show notes. And hey buddy. I really appreciate the time you took today. This is a fascinating topic and I can't think of anyone better to break it down with than you. And you did a fabulous job with it. In fact, I think, let's see how the terrain evolves, but love to revisit this topic in a year or two and just kind of see what's changed.
John Lesher: 50:54
I think that's a great idea Sanjiv. Because, this field is changing so quickly. It really is. So I think that's a wonderful idea. And congratulations on the one year anniversary. I was glad I was part of it man.
Sanjiv Lakhia: 51:09
Yeah. Thank you. It's been great. So there you have it folks. Dr. John Lesher breaking down regenerative orthopedics, regenerative spine care. I hope you enjoyed it. And thanks for listening.
Outro: 51:23
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
This podcast is sponsored by our partner QxMD. QxMD builds mobile solutions that drive evidence-based medicine in clinical practice. Check out Read for easy access to research personalized for you and Calculate for over 500 easy-to-use decision support tools. Try them today at QxMD.com/apps. Again, that is QxMD.com/apps.
Intro: 00:31
Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health. Brought to you by Carolina Neurosurgery & Spine Associates, where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 01:05
Greetings wherever you are and whoever you are. Thank you for tuning in to this episode of Back Talk Doc. I want to start today with a bit of gratitude. By the time I think this episode posts, we will hit our one-year anniversary of the podcast, and this will be our 25th episode. And it's just been an amazing experience for me. I want to thank so many people who have supported this endeavor. First, I'd like to thank Rob Ingalls at Lawpods. He's the producer for the show. He's helped guide us through how to put together a professionally sounding podcast. And it's just been a pleasure to work with him and his company. I'd also want to give thanks to my organization at Carolina Neurosurgery & Spine Associates. I think I work at the premier neurosurgery and spine practice in the country, and I have just wonderful support from the partnership here and administration.
Sanjiv Lakhia: 01:59
I also want to thank you the listeners and all the patients. We've received tremendous feedback about the episodes, in particular the quality of the content. We've done a really good job. I've really focused on bringing to you all who are listening, actionable information to help you with your decision-making process. With that being said, I'm very excited. We've also obtained our first... as you've heard in the intro, our first sponsorship with QxMD. QxMD has a mission to spread health information to health professionals across the world, and I'm excited to be a part of that, helping to communicate their message. So without further ado, today's episode is on a topic I've been really wanting to dive into deep, and it's just taken us some time to get some schedules together. Today we're going to be talking about regenerative spine and orthopedic medicine with Dr. John Lesher. Dr. Lesher is one of my partners here at the group.
Sanjiv Lakhia: 02:55
And in my opinion, he's one of the top physiatrist in the region if not the country. His level of expertise and knowledge about the topic today and spine and sports medicine in general is just fantastic. And that's just not me. I think if you surveyed our partnership, you would find unanimous support for that opinion. John, welcome to the show today.
John Lesher: 03:16
Thanks for having me Sanjiv. I think the podcast has been awesome.
Sanjiv Lakhia: 03:20
Yeah. It's been a lot of fun and I think today's topic there's going to be many people interested to hear what you have to say. Let me go ahead and introduce you to the listeners. John obtained his undergraduate at Boston College, and then he did a combined MD/MPH program at Tulane and ultimately went through internship and residency at the University of Washington in Seattle. He has a fellowship training in musculoskeletal medicine and interventional spine at Washington University in St. Louis, and he's board certified in physical medicine and rehabilitation with subspecialty certifications in sports medicine, electrodiagnostic medicine, and certification in musculoskeletal ultrasound. So what that means listeners is he's a lot smarter than me. So take some notes today, I think he's going to enlighten us. John, why don't you introduce yourself to the people who aren't familiar with your work? You have your practice up in the Huntersville Concord area around Charlotte, North Carolina. Talk to the listeners a little bit about your path to physiatry and in particular, your growing interest in regenerative medicine.
John Lesher: 04:23
Sure. My interest in physiatry started actually before I went to medical school. I did a yearlong internship at Princeton University... I'm not even sure if they have this anymore, but it was geared towards people that were interested in going to medical school. And I lived and literally worked and lived in Princeton's health infirmary. And during that time I worked with a sports medicine doctor. He was trained as an internist, and so he was not an orthopedic surgeon, but he exposed me a lot to sports medicine. I worked with their teams. And so that was I think my initial interest in musculoskeletal care. In medical school, I really thought I'd lean towards a surgical subspecialty, but in my mid 20s, I really didn't enjoy that dirty four-letter word called call, C-A-L-L. I knew if I didn't enjoy it in my mid 20s, I wouldn't like it much better when I was in my mid 50s.
John Lesher: 05:23
That's held true, even though I'm not that old yet. But during medical school, I kind of gravitated towards the musculoskeletal side of things and sought out exposure to physical medicine and rehab. Where I went to medical school, we did not have a department of PM&R, but I did work with a physiatrist to sports medicine, boarded and focused and he gave me some great recommendation. Did a couple of elective courses in my senior year and then decided the specialty is for me and then the rest is history. You've mentioned that the podcast is now one year old, which I think is great. This month for me, the end of October is my 13th year here at Carolina Neurosurgery & Spine Associates. So it's been great. Each year is a kind of learning and growing years. There's always new challenges, which makes it fun.
John Lesher: 06:15
As far as my practice set up goes, clearly I see plenty of patients with spine but I also see a good percentage of patients that I treat with shoulder issues, hip issues, and knee issues. I did quite a bit of foot and ankle care in my fellowship. I don't really do that much now. And then I do supplement my practice with quite a lot of electro-diagnostic tests and then ultrasound too. So I use ultrasound in my practice to diagnose soft tissue and joint issues like rotator cuff tears, or lateral tendon tears. And I also use it to evaluate peripheral nerves. So it's a great complimentary test to the nerve study. So when I test nerves with a nerve study, we can also evaluate them. It's a good, well-rounded clinic. I've really enjoyed it.
Sanjiv Lakhia: 07:06
Yeah. And you do have some training in sports medicine as well, were you into athletics growing up and into college?
John Lesher: 07:14
I've always enjoyed sports my entire life. I never played at the division one level. I played basketball and volleyball in high school and then played at the club level volleyball when I was at Boston College. Which was great because the club level what's serious about it, we traveled to different tournament's and nationally, but you didn't have the day in, day out grind all the time with higher level training. So it was a lot of fun. My jumping days, unfortunately, are behind me. And maybe we can talk a little bit more about that as we get into the topic today.
Sanjiv Lakhia: 07:47
Well, I think that's actually important that you have a little bit of background in athletics from a personal perspective. Because when you dive into the field of regenerative medicine, a lot of the applications are in the sports arena. Not all of them, but certainly many of them. So it sounds like on a day-to-day basis, you have a wide variety of cases that come through your office. Let's dive into today's topic, which is the regenerative orthopedics and spine care. And there is a lot out there, John. You and I both know that you cannot turn the radio on, at least in the Greater Charlotte area without one or two commercials for a regenerative medicine clinic. And listeners of our podcast are both from a consumer or patient side and also professional side. So why don't we start with almost a definition or your description of what exactly regenerative medicine means for those who aren't familiar with the concept?
John Lesher: 08:41
Yes. When I think of regenerative medicine, actually it's pictures that usually come to mind, I think of a human ear or a human nose being grown in a Petri dish. That's what I normally think of when I hear this. But clearly that's not the case. And the description I like to give, I actually learned at a conference. And I forget who said it. There was a physician who was lecturing on regenerative medicine and they referred it to the name MASH. And MASH again, when I think of MASH, I usually think of the television series from the '70s, which stands for Mobile Army Surgical Hospital. Clearly that doesn't apply to regenerative medicine, but the new meaning, which I really liked is described as Medical-Assisted Self-Healing. So we're providing medicines. And usually when we think of regenerative medicines, we usually think of biological-type treatments that are either taken from the patient or other patients and then placed into the body to help the body heal itself. So the simple way to think of it is medical-assisted self-healing.
Sanjiv Lakhia: 09:47
Maybe give a few examples of what that means.
John Lesher: 09:51
So, one of the areas of regenerative medicine that has gained a tremendous amount of interest in both the lay population and the scientific community is what we call platelet-rich plasma. And so platelets are a component of our blood primarily used in clotting and wound healing. And so we can essentially draw blood and then concentrate the different components, primarily the platelets, get them to a level that we are interested in and then place them in the body, in certain areas of injuries to help with healing. So instead of taking a pill or in taking a laboratory-made medicine out of a vial and placing it in the body, here we are taking a patient's own biological fluid, concentrating it, and then putting it back in the body.
Sanjiv Lakhia: 10:46
And historically, I remember hearing about PRP, geez, at least maybe 15 years ago. I mean, this stuff has been around a while, has it not?
John Lesher: 10:56
Platelet-rich plasma or platelets in general, they've been used in the veterinary sciences, gosh, since the '80s and '90s. And they were being used to treat musculoskeletal injuries in dogs as well as horses and showing good results. And then as literature began to grow with those uses, primarily maxillofacial specialists were using it in jaw surgeries. That kind of further grew and developed and orthopedic doctors were using platelets to help with bone fusion or bone grafting. That really began in the early 2000s. But really what kind of put... What's interesting is when you really look back at the history, what really put platelet-rich plasma or platelet-based therapies on the map especially with regards to the lay population is Hines Ward's injury before the 2009 Super Bowl. Now I'm from the Philadelphia area, so I'm more partial to the Eagles. But long story short, I still respect the Steelers.
John Lesher: 12:01
And so he injured his knee, specifically his medial collateral ligament a few weeks before the Super Bowl. He was definitely going to play in the Super Bowl and not sit out. He sought out care and had platelets injected to that ligament of his knee and then played in the Super Bowl. And I believe, I think he won the MVP that year. And so that was 2009. So roughly it's 11 years ago. And PRP was gaining momentum at that time, but that really kind of led to this massive explosion and interest in the regenerative field. So he was very much a very prominent person who had it done, and then that was followed by Tiger Woods having it done, the late Kobe Bryant and then that leads to celebrities, Kim Kardashian getting a vampire facial and all different types of uses. So again, when you look at the history, I think that injection or the treatment that Hines Ward received before the Super Bowl was instrumental in the explosion of this field.
Sanjiv Lakhia: 13:04
Yeah. And I bring that up just to illustrate these procedures in general are not reimbursed through insurance plans and they're considered experimental. But experimental doesn't necessarily mean brand new. And I think number one, the basic science behind the idea of regenerative orthopedics has been around a long time, even going back to the prolotherapy days injecting dextrose water. And it's still being used. Think you do a little bit of that in your patient clinic as well. And that's been discussed for quite a long time. I remember even at osteopathic medical school, we were learning about that as well. So there are though some more modern kind of techniques and you hear all sorts of things now between PRP and then there's stem cells and amniotic tissue. Or you'll go online and you'll hear that Dave Asprey's getting stem cell injections in every joint of his body, every vertebral segment, every orthopedic joint.
Sanjiv Lakhia: 13:58
Ben Greenfield has done it and made it real popular. So for those who, again are somewhat new to this field, can you give a basic overview? I know each one of these topics could... We could go on for an hour on each individual topic, but maybe just breaking down a little bit of the differences between the types of stem... Let's start with stem cells because that's extremely popular. I think most people who are listening to the podcast today have heard about stem cells and are probably wondering what is that and is that something for me?
John Lesher: 14:26
Yeah. So I like to say, "Stem cell 101," just to kind of clear up or better understand this concept. So when we think of stem cells, a lot of people will think of a zygote. So a sperm meeting and egg gives rise to a zygote and the beginning of human life as we know it. And so those types of cells are what we call totipotent. So that's the very beginning when sperm meets the egg and cell division happens, those cells that further develop can really give rise to all types of tissues in fetal development. Those are not... Let me repeat. Those are not the cells that we are using when we talk about stem cells for orthopedic conditions. As the embryo grows and gets bigger, the stem cells then become pluripotent, and they can then give rise to different or most tissues, but not all tissues.
John Lesher: 15:25
So when we think of stem cells or adult stem cells for use again in orthopedic or spine conditions, these are again adult stem cells and they are multipotent. So that means that they can give rise to a limited number of tissues. There's a lot of specialized vocabulary with this, but what you will hear most commonly is the term MSC, which stands for mesenchymal stem cell. And that is an adult stem cell. There is a very famous cell biologist named Arnold Caplan who's essentially studied MSCs or mesenchymal stem cells his whole career. And he actually likes to call them medicinal signaling cells and is kind of moving away from using the term stem cell when referring to MSCs. And so just a little bit of biology or cell biology in regards to these types of MSCs. So the MSC is also called a pericyte.
John Lesher: 16:33
And so a pericyte is essentially a cell that hangs out on blood vessels all throughout our body. They're essentially just kind of hanging out in all of our tissues, surveying what's going on in our body. And say an injury happens at one part of the body near the blood vessel, an injury happens, that activates this pericyte or MSC essentially to leave the blood vessel, travel to that injury site, and then essentially it becomes the glorified MSC or medicinal signaling cells. It will kind of regulate the immune system at the site of the injury and also kind of send out a variety of different signals to try to get the injured tissue to respond to healing and essentially improving itself. So a lot of different terms there. But I like to tell my patients that I think there's a lot of misunderstood vocabulary about stem cells.
John Lesher: 17:38
These are technically medicinal signaling cells that hang out on blood vessels, they go to the sites of injury and then they orchestrate or kind of act as the job site boss saying, "Hey. We're going to tone up or tone down the immune response to this injury. And I'm also going to send out signals to get the cells in the area to try to start healing themselves and creating a repair to the injury." I hope that kind of clarifies some of the misunderstanding there. The use of stem cells with regards to orthopedic or musculoskeletal conditions really focuses on bone marrow aspirates. So what they're doing with regards to bone marrow aspirate, also called BMAC, which just stands for bone marrow aspirate concentrate, is essentially we tap into bone marrow and withdrawal the bone marrow cells. Essentially, that's a concentrate. Additionally, this is also done in fat tissue, also called adipose-derived stem cells or ADSC.
John Lesher: 18:44
We target the bone marrow as well as the fat tissues because these are sites in our body that are known to have higher quantities of these adult stem cells or MSCs. Additionally, there are stem cells found in fetal products of the placenta, the amnion, the chorion as well as the umbilical cord, and those are done as well. But really when it comes to stem cells from those tissues, that is not currently really being done in the U.S. Those tissues can create or lead to growth factors, but not really stem cells. Another thing that I also try to get across to patients when it comes to stem cell usage is, currently in the United States, we are only allowed as providers or physicians to what we call minimally manipulate the stem cells. So we can take cells from the bone marrow or cells from fatty tissue, essentially clean them or concentrate them and then place them in the injury sites that we're most interested in.
John Lesher: 19:48
Based on FDA rules, we cannot take those cells and grow them or expand them. So long story short, we can't take the cells, put them in essentially nutritional medium, and then essentially put them in an incubator and expand them. That is not allowed in the U.S. It is allowed in other countries, but we cannot do that currently under FDA regulations.
Sanjiv Lakhia: 20:13
Yeah. That's an excellent overview I think of just explaining what actually a stem cell is and kind of where it starts from and how it can be used clinically. Touch real briefly though on really a difference... So if a patient comes in and let's say they have an arthritic knee, what's the difference in terms of what's going on in the body when you inject corticosteroid in the knee versus let's say something like stem cells or PRP?
John Lesher: 20:39
That's a great question. So when it comes to joint arthritis, there's this balancing act going on inside the joint at the cellular level. So in a normal joint, without arthritis, there's kind of this nicely regulated system of an anabolic and catabolic process. So in a normal joint there's substances being produced that are healthy for the joints, that's what we call anabolic, then there's also catabolic processes where substances are being broken down. And when the joint is healthy and happy, these kind of sequences or pathways are essentially in check. They're being nicely weighed out against one another. When arthritis sets in, those catabolic processes or those breakdown processes take over. So they are essentially the growth or the building of good substances in the joint is starting to decline and things are starting to break down.
John Lesher: 21:41
So stem cells or I'll say MSC or medicinal signaling cells or things like platelet-rich plasma, when we put those into the joint, those are trying to further strengthen the anabolic process or the buildup process of good materials for the joint and limit the catabolic or breakdown processes. So we look at the stem cells or platelets as ways to try to build the joint up and limit the breakdown of the joint. Conversely, when you take a steroid and put it in the joint, it's essentially a much stronger catabolic trigger. So a steroid substance like triamcinolone or Kenalog, probably one of the more common steroids we inject into joints in all parts of the body, goes into the joint and leads to essentially cartilage damage or cartilage cells or what we call chondrocytes. And we know that those types of medicines, steroids that is, lead to chondrocyte death.
John Lesher: 22:48 It may feel good to get a steroid injection, and I do plenty of them in my clinic, but when you look at it on the cellular level, we are actually doing the cells of the joint relative harm. So just something to keep in mind. And that can also be said for most anesthetic or numbing medicines that we put in the joint. Those are typically going to have more of a catabolic or break down effect on the chondrocytes or the cells in the joint.
Sanjiv Lakhia: 23:18
Thank you for that. I think that's going to clear up a lot for people who are trying to understand the differences. Let's dive in a little bit into the whole question of does this stuff work? And in preparation for our interview, you did send me some articles. And I just want to open the floor up a little bit for you to provide the listeners with your overall broad view on the clinical efficacy or effectiveness of the different regenerative medicine options out there as people try and make decisions about investing their time and money into these procedures.
John Lesher: 23:51
This is a great question. And so we've already talked about how long these treatments have been available. The greatest amount of literature on clinical uses for regenerative treatments is really in the platelet realm. So at this point, there is strong and growing evidence that platelet usage can be beneficial for knee osteoarthritis, especially patients that have mild to moderate knee arthritis. If patients are in the severe category, that's really not being shown. So when it comes to joint arthritis, primarily in the knee, there is very good evidence that platelet-rich plasma, especially out to one year... So when you do a treatment, you want to measure how long does it last in patients? And most of the studies that have been done in the knee joint follow these patients out to one year, some cases in two years, and they are usually comparing the treatment to the standard of care.
John Lesher: 24:53
So in the knee, it's very common for us to inject either steroid or hyaluronic acid. Hyaluronic acid is a fancy name for essentially a large molecule of sugar and protein that holds on to water. And it's a component of the matrix or the environment that our cells live in. So those treatments, namely steroids and hyaluronic acid are regularly injected into knee joints for arthritis. And when we follow them over the long-term, we know that steroids provide a great response typically from anywhere from one month to three months. Hyaluronic acid can be longer than that and variable.
John Lesher: 25:34
And then when you compare them to the platelets, namely, if you compare a hyaluronic injection to a platelet injection and follow those folks out to a year, again, with patients that have mild to moderate knee arthritis, there is numerous studies that show that PRP typically will do better than the hyaluronic acid. And this literature is coming... What I think is really interesting and it's something that makes me pay more attention is when you see this literature being done and published in the orthopedic surgery journals. It's one thing... The way publishing works is very specialty-specific, but when you see these non-surgical studies being published in surgical journals, that usually kind of gets my attention. And the studies are being done by orthopedic surgeons. Because I think they say, "Hey. There's a need here." The current treatments that we have, namely steroids, hyaluronic acid, they're not creating the greatest amount of benefits here. So I'm going on a long-winded answer here.
John Lesher: 26:37
But the first step for mild to moderate arthritis... And again, this is for folks or patients that have done rehab for their joints that aren't improving. I really think platelets is a very good place to start. When we talk about stem cells, there was a study published earlier this year out of the Andrews Institute in Florida, and it compared essentially those patients again with mild to moderate knee arthritis, and they had one group receive platelets, one injection of platelets, and they had one group receive an injection of bone marrow aspirate [inaudible 00:27:11] or BMAC or stem cells.
John Lesher: 27:13
And again, they followed those patients out to one year. And they found that the patients had similar responses. So to me, that was actually one of the very few studies that has done a head-to-head comparison of very popular or very well tilted or awfully or highly marketed treatments, and they followed these patients out to a year and both had the same response. Now experts in regenerative medicine say, "Oh gosh. They need to follow them out to two years because the stem cell will show better results at two years." And my answer to that is that very well may be, but we don't know. We know that platelets are easily acquired through a blood draw, bone marrow aspirate requires a little bit more involved procedure of harvesting the cells from bone. Platelets are typically much cheaper to do, bone marrow aspirate is more expensive. So when it comes to patients with mild to moderate arthritis, and they're asking me about, "Gosh, what are regenerative options here? And I've already failed a good course of physical therapy, I've already had steroid shots, I've already had hyaluronic acid," those are the studies I'm going to tell them about.
John Lesher: 28:26
So that's from the joint perspective. When we look at tendons and we talk about regenerative treatments, the greatest or actually one of the first studies came out of Stanford in 2006, and it looked at putting platelets in the tendons of the lateral elbow or the side of the elbow commonly called tennis elbow or we have numerous names for it and lateral epicondylitis or lateral epicondylalgia. But long story short, it's tendon pain on the lateral elbow. This orthopedist surgeon looked at injecting platelets in 2006 and then followed these patients. And he found good results. And so when it comes to tendon usage, the lateral elbow, as well as the lateral hip have shown to do very well with platelet treatments.
John Lesher: 29:15
Other tendons have been studied as well, namely the Achilles tendon, the plantar fascia which is the tendons on the plantar surface of our foot are also tendons that are looked at, in addition to the patellar tendon which is the tendon in the front of our knees. There's also additional studies done on those tendons, but not nearly as robust as the tendon studies done for the lateral elbow and the lateral hip. When we specifically look at the lateral elbow and the lateral hip, those patients do very well with platelet treatments out to one to two years. And again, that's comparing a group of patients that receives platelet treatment for those tendons compared to a group of patients that receive a corticosteroid injection around those tendons. When you go to conferences addressing this, a lot of the experts will say, "In the tendons, I'm almost always going to start with platelets because there's such good evidence."
John Lesher: 30:12
Going to a stem cell treatment for tendon pathology usually is only going to happen after the patient has failed a course of platelet therapy and they're really not considered for surgical repair. The literature or research on the use of stem cells in different tendons is still very early and emerging. It is being done, I'm not here to say that... But the studies the long-term studies of tendon use are still pretty much in their infancy. Does that give a pretty good description of joint use versus tendon use? And then we can also talk about spine use as well.
Sanjiv Lakhia: 30:51
Yeah. I think that's great. And that mirrors my clinical experience. I've had some really terrific outcomes using platelets for gluteus medius and minimus tendinopathies, tendon tears. And the patients they can be in a lot of pain and the outcomes are really excellent for that. One point I would make though, this stuff only works if you get it in the right spot. So it's critical that you have whoever's performing the procedure that they have training and in the utilization of some form of guidance, preferably, particularly for the tendinopathies, so ultrasound guidance. Because there certainly are... There are groups of practitioners across the country who are doing these procedures blinded. And I think if you're a patient or even a referring physician, well, that's one key question to ask is, "Will I have this procedure done with some sort of imaging guidance to ensure accuracy in delivery of the material?"
John Lesher: 31:43
I think that's such a great point Sanjiv. I mean, one of the things that I... When I'm asked about regenerative treatments from patients that live maybe out of town or not in my practice area, they say, "What should I be looking for?" And the first thing I'll tell them is, you clearly want to find a physician who's board certified. And again, when it comes to sports medicine or musculoskeletal care or pain care, that could be a family medicine who's board certified, a PM&R physiatrist who's board certified, an anesthesiologist or a orthopedic surgeon who's board certified. You clearly want to have board certification. Ideally you want to have some type of sub-specialty certification, whether that's sports medicine or pain management, and you definitely want to have that provider be very well skilled in image guidance, either ultrasound usage or fluoroscopy, which is fancy word for x-ray guidance. Those are just two of the basic requirements to look for when you're looking to seek out these kinds of treatments.
Sanjiv Lakhia: 32:45
Okay. So let's transition then and pivot into our world which is predominantly spine care. You and I both know, and I've talked about this on previous podcasts, the microenvironment of the bone disc bone segment in the spine is much different than let's say the knee, hip or shoulder. So help us understand kind of your thoughts on the role for regenerative medicine in spine and where you think there are opportunities right now and where you see kind of the studies, where they've been and evolved over the last decade and where they might be heading.
John Lesher: 33:18
When I think of regenerative treatments aimed at the spine, I think of namely first off the disc, the lumbar disc. And it makes me think of the movie with Matthew Damon, I think it was called... Was it The Martian? Was that what it-
Sanjiv Lakhia: 33:32
Yeah. He's been in one-
John Lesher: 33:32
Was that what it was called?
Sanjiv Lakhia: 33:35
He's been in one. Yeah.
John Lesher: 33:37
Yeah. I think the name of the movie is The Martian. Why I think of that is, in that movie, he's essentially on Mars in this most barren landscape and I think he tries to grow or trying to start a colony that has a greenhouse. So he's going to this essentially desolate and barren land, and he's trying to thrive and survive. And so when I think of the adult lumbar disc, I think of Mars because we're going into this harsh, harsh environment and trying to tell cells in that environment kind of, "Wake up. We need you to start doing your job better. We need you to start making these proteins that will make the disc stronger." So it's not an easy task. But when you look at regenerative care and you look at it namely addressing the spine, there's I think one study when it comes to addressing the sacroiliac joint, one study when it comes to addressing the facet joints which are just the... I like to say the knuckle joints of our spine.
John Lesher: 34:40
And then most of the studies are based on disc usage. And when you look at preclinical studies, namely studies that are done in animals, studies that are done in the lab, the results are really impressive. They're able to get stem cells to grow and rejuvenate that are native to the disc. When we actually do these types of studies in humans, the responses or the results are really in development, or they're not as promising as what we see in the lab or in animals. Our group or Carolina Neurosurgery and Spine, really this has been spearheaded by Dr. Dom Coric. He's really kept our group involved in intradiscal regenerative treatments or essentially studies really for the past 10 years. So one of the first regenerative studies we were involved in was called the NuQu Study. And this looked at placing juvenile or very young chondrocytes... Again, chondrocytes is just a fancy word for cartilage cells because that's what a lot of our disc is. The spinal disc is made of cartilage.
John Lesher: 35:52
And so one of the first studies our group was involved in was injecting these cells into the disc. Just one kind of point of clarification, our group has been involved in FDA-approved studies looking at placing stem cells in discs. All of the studies that we've been involved in have involved culturing these cells. So essentially the cells that we are injected have been cultured and multiplied and then placed in the disc and they have all been under FDA-approved studies. So these aren't patients coming in off the street saying, "Hey. I want to pay this amount of money. Will you inject me with stem cells?" All of our group's involvement has been involved with essentially studies of looking at how effective is this treatment. So sorry for the detour there, but I think that's really an important point.
John Lesher: 36:46
So when you look at the NuQu Study, are those chondrocytes, a phase I and phase II studies were done and they compared how do these groups of patients that get these juvenile chondrocytes in the disk compare to a control group that just gets saline injected into the group or... Pardon me. Into the disc. Saline is just salt water. And then they followed these patients for one to two years and they found that both groups did good, but these stem cell or juvenile chondrocytes group did not have superior results. So the study did not go past that. So it was encouraging like, "Gosh, the patients did well," but they didn't beat or significantly outperform a group that just received saline in the cell. And so it brings up a good point. Should we consider saline the most basic regenerative treatment out there? You touched a little bit on prolotherapy which is usually injecting dextrose or sugar solution into different tissues, but saline is even more simple than that.
John Lesher: 37:44
And these cells, I don't know whether it's due to a washout effect, so we inject saline into a disc that is in a deteriorating state, it's in that catabolic breakdown state and the saline, whether it washes some of those breakdown products way or jump-starts other cells, is doing something. So long story short with that first trial, the study treatment did not do better than saline, and it was put on hold. The second study, which is a totally different study that our group was involved in is called the Mesoblast Study. And again, it was using stem cells, namely bone-derived stem cells. So these cells were taken from bone marrow from donors, they were cleansed and essentially looked at for very specific types of cells once those cells were isolated. And the thought here is they were isolating cells that would be most beneficial in that harsh discal environment.
John Lesher: 38:43
They took those cells and then they multiplied them, and then once they got a significant amount, they were injecting them into discs as well. So this study very similar to the first NuQu Study, but different types of cells were being injected. And then the control groups were set up. One group received a higher concentration of stem cells, a second group received a lower concentration of stem cells. And then there was two controls. One control again had the saline being injected into the disc, and one control had hyaluronic acid. One thing to bring up is hyaluronic acid, like I said, is this large molecule that holds on to sugars or... Pardon me. It's a large molecule of sugar and protein that holds on to water. And that molecule was also injected as kind of a support mechanism or what we call a scaffold mechanism with the stem cells.
John Lesher: 39:37
So in the patients that were getting the stem cells, they were also being injected with hyaluronic acid. So I look at that as that when Matt Damon's on Mars, he has that greenhouse to help support him. The hyaluronic acid is that kind of supportive structure to the cells to kind of help get them started in this harsh environment. So again, a lot of detail there. But this Mesoblast Study was more involved, there was two treatment arms and then two control arms, and then they followed those patients out to one or two years. This study essentially went out to... It finished phase II and then it went to phase III. Phase III stops about... Don't quote me on this, but I think one or two years I think it's been completed. There have not been any officially published studies on it and I don't know why.
John Lesher: 40:24
Usually if the results are incredibly promising, there is essentially rush to market, rush to presses about this. So I think along the same lines as the first study is that the stem cells did not have this overwhelming response or benefit compared to the control studies of the hyaluronic acid or the saline group. Again, we're all still waiting for the studies to be officially published. Phase II trial results were discussed at meetings, but to my knowledge, phase III has not been formally discussed. So that was the second round of studies that our group was involved in. Now, the third round is through a company called DiscGenics. In this study, we are using lumbar spine disc-specific cells. So essentially these disc cells are coming from disc donors. We're isolating certain disc cells and then also culturally expanding them. And then we are injecting those types of discs into the cells and then following those patients out for one to two years.
John Lesher: 41:27
In this study there is again, two concentrations of cells, a higher concentration as well as a lower concentration, and there's also a control group as well of a saline as well. So phase II just stopped with regards to this trial. The results are being looked at and then potentially planning for phase III. So I think we'll put a link in the podcast about more information about this DiscGenics study as well. So to kind of sum it up, this is clearly a work in progress. Our group is very involved in stem cell treatments, but as of now, the evidence is not showing overwhelming treatment effects. My thought here is that in the future, as we understand the biology better, as we understand ways to support these cells in such a harsh environment improves, hopefully this will lead to better improvement of the disc tissue that's degenerating.
Sanjiv Lakhia: 42:26
And we touched on this a little bit when I did my interview with Dr. Coric. And if you haven't had a chance to hear that you should. I think it was our 19th episode, we talked a lot about the artificial disc and he spoke about the difference in outcome between the cervical area and the lumbar area. And I think the same challenges that they face in that arena we're facing in the regenerative arena. And it's multiple things. It's poor nutrition, poor blood supply to the disc and multiple biomechanical factors that play a role in lumbar disc disease, and the list can go on and on. So I'm like you. I'm cautiously optimistic, but I'm being realistic right now, at least when I recommend to patients how they should kind of take things slowly when they're looking at these potential treatment options that are out there in the market, particularly for lumbar disc disease.
Sanjiv Lakhia: 43:14
So I think that was a fabulous breakdown of this topic of regenerative medicine. I had a few other questions but I think we kind of covered some of this stuff already in terms of the differences with steroid injections. Before we just close out with a few personal questions, leave the listeners with your thoughts about where the future's heading with this from... I think a couple of things people want to know. Number one, is this really going to be kind of a standard of care treatment down the road for orthopedic and spine care? And then number two, do you ever foresee a situation where insurance companies, private payers will actually cover these services or will this continue to be an option for those... for a self pay basis?
John Lesher: 43:56
Sure. I think as far as what does the future hold, the literature so far with regards to joint treatments, primarily the knee and because there's such a huge demand for it based on how many Americans have knee arthritis and our population that's aging, I really think in the next few years, hopefully within five years, insurance companies are going to start at least paying for platelet-rich plasma. I know some workers' compensation industries do pay for it and I believe... Don't quote me on this. I think the VA may actually reimburse for platelet treatments. But I really think for the use of platelets with regards to knee arthritis, I do think that is on the near horizon. As far as tendon treatments, like I said, I think that would maybe second in line, just primarily with regards to the lateral elbow or the lateral hip, because there's good studies that support it.
John Lesher: 44:50 The spine, I think as you alluded to, I like to say... When I think of the future of the spine, I think it will continue to improve as we understand the biology better, but we do need to be a little bit cautious in making broad recommendations for these treatments in the disc or around the spine, because the data is really still very much in its nascent stages. There's the television show on HBO called Curb Your Enthusiasm. And when I think of the spine, that saying, it really comes to mind. I really think over the next 20 years, regenerative medicine type treatments or biologic treatments are going to become more and more common. As we understand more about inflammatory markers and patient's genomic makeup, that will also help guide us in trying to figure out what type of biologic treatments will best fit them.
John Lesher: 45:42
It's very much a work in progress, but I really think over the next decade or two decades, we're going to be seeing more and more of this. This is clearly not going away. I mean, based on our aging population, based on the prevalence of arthritis and based on essentially the finite number of surgeons we have to replace these joints, we need to figure out ways to treat it non-operatively.
Sanjiv Lakhia: 46:06
I think what goes hand in hand with regenerative medicine is the concept of lifestyle medicine and living a very healthy life in terms of your diet, exercise, and nutrition. So let's kind of close out the interview today... I know you're really big into fitness. Why don't you share with the listeners, maybe one or two of your top kind of personal health tips?
John Lesher: 46:28
My first tell health tip is very simple, but it can tell you a lot about how your overall cardiovascular or just generalized fitness is. It's three words. It's called... Or it's take the stairs. If you get out of breath after two or three flights of stairs, that's a very easy litmus test that you need to start working more on your general physical conditioning and physical fitness. It's very simple. In addition to that, when you go shopping, I mean, I know we're talking about these topics in the time of COVID so people aren't going out to the grocery stores willy-nilly or shopping centers. But when you go to a shopping store or any place where you're purchasing goods, park far away in the parking lot and walk in. If you get out of breath going into the store, you need to take a closer look at your physical conditioning and physical fitness. So I try not to get too specific and too labored in those recommendations. It's just a very easy litmus test, a very easy test to see how does your body feel with that?
Sanjiv Lakhia: 47:31
Yeah. So integrating movement into your lifestyle, you don't always have to have 30 to 60 minute block of time to exercise. I like that quite a bit. In fact, I laughed a little bit because recently I was in Nashville and I found myself on a hike up Mount Pisgah and I really had no idea what I was getting into. And 5,000 feet later, I really understood where my cardiac fitness was. I was motivated because as I was going up and considering quitting, there were several people probably twice my age who were coming back down smiling. So I think I've got some room for improvement there. And then what about some tools? I know you shared a little bit with me some apps and some books and things. What are some of your favorites that people might want to check out?
John Lesher: 48:11
Sure. I am a big podcaster. So like I said before Sanjiv , I think what you're doing is just absolutely phenomenal. I get a lot of my CME through podcasts on my way to work or to and from, I'll just be running errands and whatnot. Some of my favorite podcasts for more medical-specific information and advice, I really like BJSM that stands for the British Journal of Sports Medicine. I really like their interviews. They interview all types of providers. So those could be non-operative sports medicine docs, orthopedic surgeons, physiatrists, nutritionists, psychologists, public policy experts. So I really think they do a wonderful job of interviewing a broad array of different medical providers. So great information. And I think the lay public would benefit from listening to it as well.
John Lesher: 49:04
Just to your point about hiking up in Nashville, I really like the Outside Podcast that's based on... It's either Outside or Outdoors. I always get them mixed up, but the magazine. They usually talk about a lot of physical fitness-type topics, whether it is hiking or whether it's water sports, whether it's experiencing a snake bite in the wilderness. That just kind of speaks to me because I like being outside as well. For deeper dive, real in-depth medical podcast... Again, this may be over the head of some of the lay population, but regardless give it a try. I really like The Drive by Dr. Peter Attia, I think his last name is spelled A-T-T-I-A, the guests that he has on his podcast. There is a free service and then a subscription service, I just use the free service, but he goes deep into a lot of topics where I just feel like I've learned... my knowledge has been taken to another level and I'll re-listen to it.
John Lesher: 49:59
So again, I really think that is a wealth of really good information. And then also closer to home, I think they are at either... I know they're in Raleigh. I want to say UNC, but if they're at Duke, heaven forbid I misspeak, but the People's Pharmacy, the Graedon's , it's a husband and wife and they talk about all types of medical treatments. Some are holistic, some are mainstream, and I think they do a great job of again interviewing a broad array, a great diversity of different providers and experts. So those are four podcasts I think we'll do most listeners really well.
Sanjiv Lakhia: 50:34
Great. We'll put links to those as well in the show notes. And hey buddy. I really appreciate the time you took today. This is a fascinating topic and I can't think of anyone better to break it down with than you. And you did a fabulous job with it. In fact, I think, let's see how the terrain evolves, but love to revisit this topic in a year or two and just kind of see what's changed.
John Lesher: 50:54
I think that's a great idea Sanjiv. Because, this field is changing so quickly. It really is. So I think that's a wonderful idea. And congratulations on the one year anniversary. I was glad I was part of it man.
Sanjiv Lakhia: 51:09
Yeah. Thank you. It's been great. So there you have it folks. Dr. John Lesher breaking down regenerative orthopedics, regenerative spine care. I hope you enjoyed it. And thanks for listening.
Outro: 51:23
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.