← Rena Malik, MD Podcast
Rena Malik, MD Podcast
Moment: Vibration Plates, PRP & More: What REALLY Helps Your Joints? Ft. Leading Orthopedic Surgeon
00:20:54
In this episode, Rena Malik and Dr. Vonda Wright explore ways to prevent joint degeneration and promote musculoskeletal health. They cover essential factors like exercise, weight management, and innovative treatments such as PRP therapy, offering listeners practical guidance for maintaining healthy joints as they age.
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- [00:00]
A
What can people do to prevent joint degeneration?
- [00:03]
B
Yeah, so let's define a joint. A joint is just where two bones come together. The ones we think about most are our shoulder joint, our knee, our hip, especially in midlife women and men. So when two bones come together, bones are actually pretty fragile. And so every bone is coated on the end with a layer of cartilage. Cartilage is, is white, it's glistening, it's smoother than ice. It has a coefficient of friction that's less than ice. So it's so smooth you don't even perceive it moving in your joints until it starts to break down. Cartilage itself is a matrix with some few scattered cartilage cells in it. So it's mostly scaffolding. And the thing that makes it healthy is joint fluid. Joint fluid that is not filled with inflammatory cytokines. Joints are healthy when the cartilage do not hasn't been worn down like a food grater. Why would the cartilage matrix be worn down? Well, there's so many reasons. It could be due to high steroid use. Maybe you had asthma, maybe you had cancer and have to high steroids, that's really bad for cartilage. Maybe.
- [01:14]
A
Or you abuse steroids.
- [01:15]
B
Or you abuse steroids. How about that? Anabolic steroids. Or maybe you were pre ozempic and carrying around a couple hundred extra pounds. Joints bear 7 to 10 times body weight, so imagine 100 extra pounds. It's like a thousand extra pounds of pressure across a very delicate structure. And in the laboratory, when you want to damage cartilage, you drop a marble on it. It's very sensitive. And so maybe it was due to wear and tear of weight, maybe it's due to trauma. Athletes twist and bend and bang and we get one sheet of cartilage on every bone for our entire life. Once it's gone, it, it can repair with a patch, but it will never be the healthy cartilage we have again. So these are all reasons why people end up with joint degradation, aka arthritis. Before 50 men have more arthritis than women. A higher incidence of arthritis after 50 women will have can have a rapid progression in their arthritis. In fact, get this. There was a paper published in 1925, a hundred years ago by a researcher named Noble, documenting the arthritis of menopause. A hundred years ago.
- [02:41]
A
That's insane.
- [02:42]
B
Someone started asking, why do all these women in menopause have so much more arthritis? Well, it's because every musculoskeletal tissue, tendon, ligament, muscle, bone, fat, muscle derived Stem cells, they all are cousins, and they all have estrogen alpha and beta receptors. So if estrogen is not sitting in the receptor on the cartilage matrix, it cannot maintain its integrity as well. And therefore, lo and behold, we have a rapid progression of arthritis in women in midlife. Of course, during a time when they're putting on weight that they never wanted to have. And so we have that added pressure. Maybe they're still not eating because they're trying to diet their way to feeling better. Maybe they hurt so much because of arthralgia that they're not exercising. Because becoming strong and moving your joints is one of the cures for joint pain. But it's counterintuitive. If it hurts, don't move it. Not true. All the reasons that all of a sudden women in midlife have this rapid progression in arthritis, and then it slows them down and it just one thing leads to the next.
- [03:52]
A
Is it inevitable? I mean, because we're living longer, Is it inevitable that you will have joint pain and joint issues as you age?
- [04:00]
B
I think it's common, but not inevitable. And I think it goes in degrees. I mean, I. I think having an ache and pain once in a while, maybe that's inevitable. Having pain that's so debilitating, they have to sit in a chair. I don't think that's inevitable. But it cannot start when we're 60 or 70. We have to be mindful from a very younger age and do all the things that we've talked about in terms of keeping. For instance, let's talk about the knees. When people come to me with knee pain, I never just address their knee. We always. One of the steps in my plan for them is always to become strong as a bull. The muscle support above and below the knee has a critical effect on the impact that the knee sees. So they're always very surprised when I'm like, we're sending you to physical therapy and then we're getting you in a gym because we are going to get you strong as a bull and your knees will benefit. So to answer your question, I don't think debilitating joint pain is inevitable, but we have to start early on all the things we talked about. Will we have aches and pain as we age? Yeah, but not so much that they make us sit in a chair usually.
- [05:19]
A
Right. Well, also, I mean, you can damage your joints from overuse, too. Right. So where is the balance then of. Obviously, you want to strengthen your muscles to maintain joint health and do all the other things we've talked about, but also avoid sort of, you know, really minimizing that. That joint fluid and space, that kind of that cushion there in the joints.
- [05:41]
B
You know what's interesting is there, there is clear literature that even the impact of running, long term, chronic running, does not speak speed up arthritis progression.
- [05:52]
A
Really?
- [05:52]
B
Running does not cause arthritis.
- [05:54]
A
Yes, that's good to know.
- [05:56]
B
Yes. Because that is a very common fallacy. Oh, you gotta stop running. Well, if you have trauma and your cartilage is damaged, then the repetitive nature of a thousand steps a mile can make you feel worse. But long term runners, running itself doesn't cause arthritis, probably for a lot of reasons, one of which is there tend to be lighter people. Right.
- [06:20]
A
So generally speaking, we don't need to worry about that if you're doing all the right things.
- [06:24]
B
If we're doing all the right things,
- [06:26]
A
you don't need to worry that you're actually like wearing out your joints.
- [06:29]
B
I would not know. I would not stop being mobile because of being afraid of wearing out your joints. Because what am I sentencing you to then? If I say, why don't you sit still and don't wear out your joints? I am sentencing you to sedentary death syndrome. We know that it's kind of like a societal mantra. Sitting will kill you. Well, smoking, it's like smoking.
- [06:51]
A
Yeah, Yeah. I want to talk about a couple things that are sort of novel and interesting and people are talking about them. What about vibration plates?
- [07:00]
B
So power plates, vibration plates. There is some small study data that it can stimulate impact and build bone density. Not as much as lifting, not as much as jumping. Vibratory plates are great for engaging the lymphatic system. They're great for involving your core strength in big compound lifts. Right. If your feet are firm on the ground and you're doing compound lifts, even though it's hard, it's not as hard as doing those squats, for instance, on a power plate, because then you must engage all your small muscles to stay upright. So there's. There's great value to it. Value alone in building bone is not as strong from a research perspective.
- [07:49]
A
Okay, and what about prp?
- [07:52]
B
So PRP is platelet rich plasma. We know that platelets, when you cut your leg shaving, platelets rush to the scene of the crime in your bloodstream and they plug the hole. But they're not just bricks in a wall. They're sacks full of variety of growth factors that your body use to initiate the healing cascade. So what we've learned, I started doing research on on platelet rich plasma. In 2000. In 2000 when I was in the lab. I know. And I would just draw my own blood, spin off my platelets because I had blood. Why not, right? Since that time, researchers have found that platelet rich plasma in a musculoskeletal system can be very effective for chronic tendon problems, for rotator cuff tears, for moderate arthritis, for tendon and ligaments, as I've said, like patellar tendonitis, tennis elbow, Achilles tendonitis. But it is dose dependent and you have to know how many platelets you're giving. So the current literature points to needing 10 billion platelets to mount an effective anti inflammatory and healing response. 10 billion. So that means wherever you're getting it done needs to have the ability to count, otherwise you don't know what you're getting and you don't know why it's not working. Right. And the science is evolving. But we do have enough papers to have meta analysis, meaning a lot of randomized control trials. Then you compare them all in a meta analysis analysis. When I first started using platelets clinically, we were doing 5 billion in three injections. Well, the data evolved. Now we know one injection of 10 billion is as effective. My patients get about 80% relief for more than a year, sometimes up to two years. So when we put the platelets into the knee joint for for instance, they burst, they release their growth factors, so start initiating an anti inflammatory cascade. And we believe that they call the stem cells from the synovium into the milieu to start working. Because to heal a tissue you need cells, you need scaffold and you need growth factors. So the platelets are providing growth factors, they're calling in the stels. And the knee has its own structure. Right. Are we to the end of the road with research knowing how everything works? Precisely. No, actually not. But does it offer an amazing option if we don't want to go do surgery, which most of my patients aren't looking for surgery and I've had great success with it. So I offer it generative.
- [10:37]
A
Right. Like instead of an injection for pain, which is just relieving the pain or inflammatory markers, potentially it's actually creating a healing response.
- [10:46]
B
Well, let's compare that. Right. So I just told you that a dose of 10 billion platelets in my patients and in the literature has an 80% efficacy and relief of pain and can last durably. A steroid injection, which is the go to knee jerk reaction, which I rarely give in the literature, lasts three weeks and we don't really know it's three weeks. Three weeks. Now, some people get a six months out of it, but that is the exception, not the rule.
- [11:18]
A
Yeah.
- [11:19]
B
And so the only time I use steroid injections is when people do not want platelets or their joint is so damaged, it's bone on bone. We're just trying to buy some time getting them out of excruciating pain and then I'll do it because I'm not inhumane.
- [11:35]
A
Right? Yeah. And I think the interesting thing about PRP is one, there's definitely this lack of counting of platelets, you know, and two is it's a blood product. And so there's no. Right. You don't have to go through the same regulation as like a pharmaceutical injection. And so anybody can really give it. Anybody can.
- [11:53]
B
I brought that up. Right.
- [11:55]
A
Give it. And so I do worry and tell my patients as to. I think for. So people do use PRP for erectile dysfunction. However, the data is mixed and because I think we don't know the right amount of platelets. We don't know that. You know, there's still some, some things that need to be figured out. And so. Yeah. Could it work for the same reasons? Right. It's bringing growth factors and things like that. Yes, it could. I'm not convinced yet that I know exactly what to do. Right. And so I'm not offering it. But I think the issue is that, yeah, anybody can do it. Like anyone can give you PRP without really even necessarily being trained on it.
- [12:28]
B
Well, that's true. And so patients need to know who's treating them. Are they board certified doctors or licensed clinicians? At the very least board certified. There's a, you know, there's all kinds of letters after names out there. Lots of letters, lots of letters. And there are legitimate letters and there are letters that I don't really know where they came from. And I think if I don't know where they came from, that the public definitely doesn't know. So I, I just think people need to be careful, ask for the data, don't be sold.
- [13:01]
A
People are very good salespeople. We were just talking about this at lunch before we, before we started that we're not good at selling things.
- [13:09]
B
We're not, we're not taught in school. There's not to sell anything. Well, that's not our vision, that's not our mission. Doctors are not, not all doctors, but
- [13:20]
A
we are not certainly looking to sell anything. But yeah, I would say, look, if I was getting something injected in my joint, I would want it from an orthopedic surgeon or a PMNR physician.
- [13:29]
B
That's right.
- [13:29]
A
Someone who has a primary care sports medicine. Yes, primary care sports medicine. That's who I would look for. If I had something injected in my penis, I would go to a urologist. I don't have a penis, but you know what I mean. So, you know all those things. I think it's really important to bring that up because this is, this is one of the things that's not regulated and won't be and there's going to be more in the future. So it's really important now, especially in the time of social media, to be informed and to be. Look at who you're. Who's talking to you on the other end, really, really critically.
- [13:58]
B
I do you see this? I see a little bit of turn where audiences want to know what the qualifications are of the people speaking to them.
- [14:08]
A
I've always seen it, but I think now it's more so like, okay, just because you have the qualifications, they want a little more. They want to know, like, well, what does that even mean? Which is good. I think it's important for people to be. Be discerning. But also I see the other side of it where they just see someone who has a big following and is very eloquent and charming and they just say, well, this person said this.
- [14:32]
B
And, well, what's interesting. Oh, I'm. I'm glad you were. I'm gonna sound all hateful and spiteful. I'm not. But I see a real difference between the challenges that happen with female doctors and men online. Doctors are not who. Who. I don't think there's this much scrutiny, frankly. And I'm not trying to start anything on your podcast, but I observe it. I'm on there every day.
- [14:56]
A
Yeah.
- [14:57]
B
Observing who's. Who's being questioned and who isn't. So I don't think questioning is bad, frankly.
- [15:03]
A
I think questioning is good. I want to be questioned. I want people to call me. I've been wrong before, I'll be wrong again. Right. I'm certain I will. I'll misinterpret something. I'll. I'll not be. I'll, you know, I'll mess up.
- [15:14]
B
And it's the nature of medicine to do more research into change.
- [15:17]
A
Yes. And I think the other thing is how you present information. Right. It's. I think if you guys have listened to me for a while or you listen to even this conversation, we've not said things in absolutes unless they were truly absolute. And not harmful. Right. Like exercise is good for you. It's not harmful. Right. We can say that in absolutes. But there are certain things we're like, yes, there are some data on this. This is the data, this is what we know right now. And this is how we're practicing because of it. I think that's where you need to think there should be nuance because people are vying for your attention in such a way where if you say a negative, I just actually just heard this. If you say a negative thing, if your title is negative, if you start with a negative, people are like almost four times more likely to. It depends on the topic or how you're doing it. But they're significantly more likely to listen. And so it makes sense that people will find that pattern and say, oh, if I say someone didn't tell you this or you're doing this wrong or you know something, negative people pay attention. It's a survival instinct. Right. We want to know the things we
- [16:20]
B
should look at the bad. Yeah, yeah, that makes sense.
- [16:23]
A
You actually, on the prp, you did a study on this, you looked at using PRP before rotator cuff surgery and that it actually improved outcomes.
- [16:32]
B
It does, it does. And so why do we think that is? Well, it, it was observing data, it wasn't a causation study. But what we observed is that by adding an adequate dose of platelet rich plasma to a milieu where you have put the tissue back together. So what if the rotator cuff, this is the rotator cuff, this is the bone. What if the rotator cuff was still torn and I dumped platelet rich plasma in there? Well, actually there is an anti inflammatory pain relief effect of that, but it does nothing to the tissue. Cells don't jump. And so that paper showed that with repairing the tissue, so we have the structure, the scaffold, we've talked about adding the growth factors in the form of platelets bursting and expressing their growth factors helped the bone heal to the tendon better because that's the direction of healing. The bone sends out fibers to heal the tendon. And that was augmented by the addition of growth factors to the milieu. And so in a repair where some data shows that up to 40% of rotator cuff tears re tear, it's a lot. And it's not due to surgical technique. It's due to the fact that rotator cuffs have no blood supply and blood is key for bringing growth factors and cells to an area. Right. So in an event where 40 a surgical response that 40% of the time it can retear. The fact that we can simply add your own biologics back to the system and see better outcome. That's a bonus.
- [18:15]
A
That's a huge bonus. Do you foresee a future?
- [18:18]
B
Will this become standard of care in many sports practices? In elite sports practices, it is standard of care.
- [18:25]
A
Right.
- [18:25]
B
It's not a standard of care of everywhere, but almost everybody I know does it. Just because I come from a big academic center and those are the. The clinicians that I practice at that level, it might not be available in some small space without a centrifuge. Not because it can't be.
- [18:45]
A
Yeah.
- [18:45]
B
It's just not.
- [18:47]
A
Well, I mean, I. I don't know. I don't know. The orthopedic training. Is this something that everyone's trained on? In. In orthopedic training?
- [18:53]
B
You know what I would say in the big fellowships, they. They see it. Absolutely.
- [18:58]
A
Yeah. But maybe a general orthopedic surgeon who's, like, in a community taking care of everything would not necessarily see it.
- [19:03]
B
If you haven't done a fellowship in orthopedics, you can still go practice as a generalist, you might not have seen it, but if you've done a sports fellowship, you are likely to have seen it because it's a concentrated year of how to best take care of tendons, ligaments, bones, that kind of thing.
- [19:20]
A
If you guys like that clip with Dr. Vonda Wright, make sure to check out the full episode right here.