53. Adeel Khan, MD: Orthobiologics, Sports Medicine & Building Muscle for Longevity

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Our guest today joins us from just north of the US border from Toronto, Canada. His name is Dr. Adil Khan, and he is an expert in musculoskeletal medicine, pain medicine and regenerative medicine. He specializes in interventional orthopedics using orthobiologics with x-ray and ultrasound guidance to treat patients. He is one of the few sports physicians in Canada that holds membership with the Spine Intervention Society. He was the first doctor in Canada to perform intra-Auseous PRP. He is presented at the Orthobiologics Institute, the world's largest regenerative sports medicine conference. He has treated a wide range of patients from celebrities, top professional athletes and Olympic gold medalists. He has a special interest in using interventional procedures to treat weightlifting injuries as well as chronic neck and back pain. Dr. Khan also teaches medical students and residents and is an assistant adjunct clinical professor at McMaster University and the University of Toronto. So in this episode, we delve into Dr. Khan's journey. How did he really get into sports medicine? How did he find his love to use orthobiologics to treat procedures like I mentioned with neck pain, back pain, which so many of us have in this world? We then delve into his love for weightlifting and fitness and we get his principles as to why this may be a huge driver for great longevity. All right, without further ado, here's Dr. Khan. All right, hey everyone. Welcome back to Medicine Redefined. Today we got guest Dr. Adil Khan up from Canada. Hey, man, it's been awesome to now kind of put our face on the screens and chat here. I know we've been connected through Instagram for a bit. So it's awesome to kind of do this and delve into your expertise with sports medicine, orthobiologics, hormone replacement therapy, and kind of talk about the differences between the US system in Canada. But first off, man, how are you? I'm tired, but I'm here, but that's a life of a doctor and with newborns though. Yeah, man. Well, congratulations on the newborn and yeah, absolutely, man. I think we both can relate here with how tired it can be, especially with everything you're doing, man. You're pulling a lot of weight like ultimately just talking about in the gym and then you're definitely active and you're treating a lot of high profile people, man. So I'm sure the stress is on, but I'm glad to hear that you're doing well and thanks again for making the time to come on here. So I want to delve into your roots and kind of the beginnings. So you're obviously a sports medicine doctor, but there's a combination between medicine and fitness in order to do that. So take us through your journey, right? Why did you choose medicine? When did you choose it? And then how did fitness kind of play a role throughout your life? Yeah, I think that's exactly what you said. I was actually a personal trainer before I went into medicine and then so that's what really inspired me to want to help other people. And then the big thing for me was like, I was really into the preventative model because I was like, okay, there's all these lifestyle diseases and as a personal trainer, I can impact these people so much because I can actually, if they move better, sometimes they can even reverse or control their diabetes. They can prevent heart disease and a lot of lifestyle diseases. So I knew kind of from that setting that that's where I wanted to go, some sort of like holistic type of medicine. Why I got into personal training? Probably my cousin was a huge influence on that. He was a personal trainer and just being around him. And then just having that kind of, I guess, mentor seeing someone who's doing that, that's what got me into that whole world of fitness. And then just kind of like I just fell in love with it. I started, you know, I kind of started like everyone. I just wanted to get bigger biceps and bigger breasts and whatever. But when you're 19, you're just kind of like, I want to do it for fun and I want to do it to look good. But then it becomes, it becomes so much more as you become older. It's not just about looks like I could care less about the looks anymore. It's just more about like obviously longevity and health. But the other thing is it's for me, it's a mental stress and for me, it's almost a form of meditation now. It just becomes like a place where I can release like stress and just focus on myself and just do what I got to do. Combining that now into medicine is where there's so much opportunity because for me as a natural bodybuilder, I saw like, you know, all the musculoskeletal conditions these guys deal with. And so I kind of use that opportunity to build my brand, I guess, into that market more than anything else. And then, and then I guess I was the only one really, only medical sports doctor who's like that. So it just kind of took off from there because there wasn't many sports doctors who kind of lift the weight I do and train the way I do. And so a lot of bodybuilders just resonate with that. And then I also got lucky because I got mentored by Dr. Gallia, who's the pioneer of PRP. He was the first one in the world to do it back in 96 and he did for like Tiger Woods and all sorts of people. And so because of him, he's like the OG OG. So I got trained by him. And so I'm lucky because I have all these expertise now. And yeah, and I feel like just, I'm in a unique position because of my combination of fitness and health background and combined that with medicine. I can bring a skill set that not many people have. Yeah, it gives you instant credibility, right? Because if you're speaking the same language, as your patients, the high profile, but a bodybuilder is people in the space of sport of fitness, whatever it might be. If they walk into the clinic and they know, or rather if they follow you on Instagram or social media and they see what you can do, they're like, okay, this guy gets it. He must get it, right? And so I think that that automatically brings people inside the tribe and they feel much more comfortable disclosing some of the information that we always talk about how history is the most important thing. And I think that I've heard you talk about this and some of the other shows that you've been on is that, you know, getting that, getting that history is so critical. But also, you know, when you're asking about, hey, what medications are you taking? What other substance might you be using? If they feel like you speak the same language, they might be more open with that information. And that information could, the one key piece could change the trajectory of the treatment, right? Speaking of the same language, though, were there, I mean, to now you're treating a lot of people in sports medicine people with injuries, right? Did you have any injuries, you know, in the space of bodybuilding, in the space of, like, you know, growing up, did you have a serious injuries, a minor aches and pains there? No, I guess I've been blessed in that way. I have, I've been unblessed with us, you know, the Desi genetics, but that takes a lot of hard work to overcome it. I'm sure you guys can appreciate that too. But non-daisies don't understand, because they, you know, they're non-daisies, so they just don't get it. Putting on muscle, and there's actually been research on this, so there's actually a study that is very interesting. So they had a bunch of groups where they've different ethnic groups, and they put them into a calorie surplus, and basically they didn't have them doing resistance training. So they're basically just seeing how much fat they can put on, and how much of it will actually go into muscle. And so, you know, the African-American put on the least fat, and he somehow put on muscle, you know, though he was barely, he wasn't working out. And then the brown person put on the most fat, and put on no muscle, so that just shows you our genetics, susceptibility. Yeah, you're clearly an outlier. I need to find that study and just wave it around as a walk around, and people accuse me of getting older and, you know, all those things. That is amazing. And for those who aren't familiar with the vernacular, Desi's, the South Asian population really secluded to probably, well, three countries, I would say Bangladesh, Pakistan, and India, right? But anyways, coming back to the Canadian system, right? So that's where you grew up. That's where you got most of your education. Your path to medicine isn't the same, right? For us, it's undergrad four years, four years of medicine, and then we got residency that's anywhere from three to eight years, depending on what you're doing, potentially a fellowship. It's a very long road, a preposterous amount of student loans. Yours is a little bit different, right? For those who might not be familiar, can you lay out that, like, what's the education system like? Yeah, I kind of took a shortcut because you guys have to do five years, right? Or four years of desiatry to get to where you're at. Desiatry is four years, right? Yeah. Plus the fellowships are basically five years, yeah. So I basically, I did family medicine as my primary training, but I kind of knew I didn't want to do family. And so I did what we have something called change of scope in Canada or Ontario, which basically means you can add additional skill sets to it if you do supervised training. And so one of those trainings is sports medicine and one of those is interventional pain. So I did those two and so it allowed me to build those procedural skill sets under supervision and then eventually I got my own designation. And then the biggest thing was the regenerative medicine stuff because working with Tony Gallia, he's the only one really doing it properly and we'll get to what properly means later. But in Canada, there's a lot of guys doing PRP, but most of them are just copycats of Tony because he was, you know, he started it all and they just kind of copied him but they didn't really do it the right way. And so having his expertise in terms of regenerative medicine and then getting good mentors for interventional spine made a big difference because I had doctor, his name is Michael Goldfeld, but he's what you call a spinologist, I guess, that's what they call them in Europe. And basically there are anesthesiologists who do two years of interventional pain training. So he did seven years of training to get to where he's at. And so I learned a lot from him in terms of interventional spine and the procedural and technical stuff. And yeah, so that's because a lot of people always ask me, like, oh, you're so young, like, how are you? Like, you know, how are you doing this type of thing, especially where I'm out in my career? So I kind of got took a shortcut in that sense, I guess, because most people would have to do at least five years to be where I'm at, to just to start out, not to mention building your own brand and name and all that stuff. I'm really happy. One of us brown people are getting the young comments. Let me tell you about a patient interaction I had today. You know, full disclosure, I'm 32 years old. I had a patient who was treating for my facial pain constantly and, you know, I told her, I was like, hey, listen, like, you know, we're the same age and these are kind of the expectations. She just looked at me and she goes, oh, you look so much older than I do. And I was like, well, thank you very much. Thank you very much for that. But anyways, hey, the chain compliment though, because you're so wise and, you know, so much. Appreciate that. Appreciate the same there, man. The changes go, what is that time for you when you decide, hey, you want to add another skill set? Like, you have to do a six months a year of supervestory. It's basically like two, it's two years of sports met and one year of interventional pain, basically. Wow. I agree. Yeah. It's like a little resident being similar. Yeah. Yeah. Awesome. Awesome. Regented medicine. Right. That's the latest thing than the most of your practices in our agenda, but do you still do any family medicine? Or is it primarily? No. I'm exclusively almost regenerative now. Like, I don't even, I barely do cortisol and stuff. I only do it for like, percitis and that's it pretty much. Okay. So let's start with this. Right. We had Dr. Melanga come and talk. And we talked about one of his favorite things to, you know, Dr. Melanga, well, is, you know, where it's really matter, right? And this term, regenerative medicine is somewhat of a misnomer, right? So maybe just in your, in your mind and how you have this conversation with, with folks is, you know, what does that term regenerative medicine mean to you? Some of the, one of the terms that we use is orthobiologics. Is that what you guys using up in Dr. Galea's clinic as well and really throughout Canada as well? Or do you have a better term for it? Yeah. That's the term we prefer to is orthobiologics, just because that's basically a term for just saying the substances that promote healing, right? And so there's natural, there's, so there's lots of, like, there's hyaluronic acid as well, right? And so the reason I don't like regenerative medicine and I don't like stem cells either is because there's too many doctors who just use those words to lure people. And I do use the word, I mean, I guess they use the word myself too, but like, I don't like it when the problem is a lot of people have to kind of use it for marketing to kind of give this false promise that we can regrow new tissue when, in reality, you can't really regrow new tissue unless you're using what's called induced pluripotence stem cells, right? And you're using 3D bio printer scaffolds and you're actually seeding those into those scaffolds. So that's a way to do it, but that's still in clinical trials in the States and can there's no one even doing that yet. So true regenerative medicines around the corner, but what we're doing right now is more, like you said, orthobiologics is more cellular signaling and changing the environment to promote healing. So you talk about cellular signaling, right, through various different mechanisms, PRP being one of them, what common ailments are you treating, right, for the people that are trying to understand regenerative orthobiologics and what that all means, what's the typical patient population you work with, who's coming in, and what exactly are you doing? Well, we have such a wide range because I've treated a 96 year old Korean man who just wanted to be able to walk and I've treated Olympic gold medalists and World Champion power lifters and World Champion, you know, so I've treated a 14 year old elite gymnast who was in the Olympics, like, so I have a huge range and I think the biggest thing though by far is definitely osteoarthritis, like I think that's hands down and the reason for that and even chronic tendonosis we know now is it's an inflammatory condition. And so what we're targeting in cellular pathways is inflammation. So the big problem with regular PRP is it's not actually that anti-inflammatory. It's somewhat anti-inflammatory, but it's more growth factors, right, as it has lots of TGF beta, IGF1, and other growths have actors that promote healing, but it doesn't have much of inhibitors, especially it doesn't have much in terms of what are called tint tissue inhibitor metaloprotienases and they target what are called MMPs and MMPs are pro-inflammatory cytokines that break down cartilage. And the other one that's pretty big, well known is IL-1, IL-1 is also another pro-inflammatory cytokine that can lead to degradation of cartilage and it's been linked to chronic tendonosis as well. And so those were the inflammatory pathways that we're trying to target and loss of research has been done on that in the last decade. And so there's a guy named Peter Whaling in Germany who came out with something called orthokine or Regenokine. Joel Rogan actually went to get that done because he probably didn't know about it. I don't think he knows Tony, that's why. But if he knew about Tony, he would have come to us. But anyway, he went there because he got orthokine done and they've just done a better job marketing than we have. We only came out two years ago, but basically what orthokine, the reason why it's so popular amongst the people around the league people like Michael Jordan went there, Kobe Bryant went there, I mean, the reason they go there is because it's targeting IL-1. It's IRAP as it's known in the colloquial term, I guess. But basically by targeting IL-1, you're targeting one of the main inflammatory mediators of chronic tendonosis, chronic pain and osteoarthritis. So it's a big game changer from regular PRP. So then cyto-rich takes a step further in that it also has high levels of tympus. So cyto-rich is our second generation plasma injection and so that's a big difference between cyto-rich and orthokine or Regenokine. And so that's, and it's all about chronic inflammation and that's really the root cause of so many different diseases, not just chronic musculoskeletal conditions, but obviously like, you know, even heart disease, cancer, stroke, diabetes, dementia, they've all been linked to chronic inflammation in some sense. So you know, I've heard you talk about this concept of cyto-rich, actually, you first saw Dr. John Barardi post it and I think he got treated by one of your colleagues. I forget who was or the other brown person is in your clinic, I think. But he... Rinse one, probably. That's right. That's right. That names everything's about. And so, and I was like, oh, cyto-rich is interesting because I think the terminology we use in the states is a bit different, right? And so we typically will refer to them with leukocytes or neutrophils and that kind of stuff like that. What would be the analogous terminology for at least what folks are using? I know you're familiar with the regentex folks, the Toby folks you said you presented there. How would cyto-rich compare to that? Well, it's... So the way to break it up is accellular. So it's actually an accellular plasma injection. So there's no cells in there. So it's more like a platelet lysate. So I think that's the way to kind of look at it because platelet lysate is the thing and leukocytes has obviously promoted that and they're with what they do. And as you guys know, the lysates is basically when they actually release all the anti-inflammatory cytokines. And there's different ways to do that. So you can freeze it, you can mechanically lysate, you can incubate it. So what we do is we actually incubate ours. So that's what we have and we have patterns on that for how we do it and stuff. And I think the regentex guys, they were freezing it, I believe before, but I'm not sure if they're still doing that. But also mechanically lysate, we use a special filter to light the platelets. And so what that does is it basically just releases all the anti-inflammatory cytokines, all the goodies, sort of speak inside of the platelets and immediately releases them into the area that you're injecting into. You know, so I've kind of been removed from this base a little bit. We're talking about newborns. That'll be, I have one myself and that's the fastest way to stay away from keeping up with literature, right? But... Yeah. At least, I was reading a recent paper at the American Medical Society Sports Medicine, right? That's our parent academy. They came up with a position statement not too long ago talking about just the regulations and what the evidence, the state of the evidence is for different types of pathologies, right? You talked about osteoarthritis, which is probably the most prevalent thing worldwide. Neostrathritis used to be specific. But focus on tenopathy for a second, right? The evidence, at least from my understanding, for lateral epiconolopathy is probably the strongest, right? Specifically, what we say is leukocyte rich, right? But from what you're, at least from what I'm hearing is saying, we're trying to take all that out. We know that leukocytes are going to be inflammatory, but here we're taking all the cells out. Like, how do you kind of look at that? Or I have actually haven't looked at a lot of the literature focusing particularly on the lysates or cyto-rich as you're referring to? Yeah, and that's... And I think you have to look at it from a mechanistic perspective and it does this make sense. You don't want to... Why would you be injecting cells or something that's pro-inflammatory into where you want to reduce inflammation, especially in the osteoarthritis and the joint? And we know in joints, when you actually inject the red plasma, which is a leukocyte rich, it can actually... The cells there can actually cause inflammation over time and actually lead to more wear and tear. So, I'm not a big fan of that from that perspective. I think the problem is, like, it's probably Tony's fault, too. He's been kind of reclusive for the last decade or so, and ever since he got... I'm sure... I don't know if you guys heard, but, like, it was back in 2010 when he treated Tiger Woods, Alex, with you guys, and a few other top US athletes, but he didn't have his US medical license at the time, so that it was in the media all over the world, and he eventually got suspended. And he kind of just disappeared for 10 years from the spotlight, and now he's kind of back with cyto-rich. And I'm kind of his protege, I guess, I'll just speak, and I'm his spokesman. But he... He understands PR people better than anyone else in the world, for sure, because he's been researching for 30 years. And the problem is, these guys, a lot of these guys just don't... Like, I'm not really sure why they're promoting leukocyte-rich for something that, even mechanistically, if you look at the basic science literature, is actually a inflammatory condition, right? It makes sense to inject leukocyte-rich into a potential... We use it for chronic muscle tears, because you actually want to promote inflammation in there, right? And you want it to heal, and you want cells in there. But for inflammatory conditions, you actually... You want something that's accellular, and just going to be purely anti-inflammatory. If it's purely chronic tendinosis, but a lot of times it's not, right? A lot of times it's actually chronic tearing, and there's tendinosis, right? And so what we do is we use a regular PRP or leukocyte-rich, what I call it, or we use... Or sometimes... We'll actually use leukocyte-poor PRP with cells to go into the tear directly, and then we'll use our cyto-rich to bathe around the tendon to reduce inflammation. So that way you're reducing inflammation on the tendon sheath, but then you're promoting healing of those tears inside of the tendon. So we can actually target specific PRPs for a problem that way, and I do that for spine as well. So, for spine, like you don't want to put any cells in the spinal canal, like spinal cord, or nut block, or into the epidural space. And so that's why platelet lysate as well. It's well studied for that, and used, and also Regenokine is also been studied for that. So we use cyto-rich as well for spine, because we use it around the nerves to decrease inflammation, and then we use it for arthritis to decrease inflammation around there. But then we use the regular standard PRP or PRGF into the muscle tears and into the ligaments to heal those areas. So that way you can make a much more specific targeted approach. Yeah, I mean, I love that, right? I mean, I've heard you talk about this in the concept of precision medicine, right? Which is kind of what a lot of medicine is getting into, right? More and more. So, you bring up a lot of interesting points there, right? I think I've had some of these conversations with folks who, at least, in the States are kind of at the forefront, right? You've talked about some of those people on the West Coast, up in Colorado, right? And they talk about, for those reasons, that you just mentioned, that why they do choose to use leukocyte poor, right? I think that from the cyto-rich, from what you described is maybe taking it one step further, and you also mentioned using leukocyte poor. At the same time, you know, the folks who are non-believers, I put that in quotes, you know, they'll say, well, okay, well, what is the evidence point, right? And if the evidence and the randomized control trials, which is kind of, again, quote unquote, gold standard, it drives what's going to cover, right? And pairs are going to pay for it. And they're going to say, well, most of the evidence says that leukocyte rich is better, right? Mechanistically, the beautiful explanation that you gave, it's like, okay, we should be using, we should not be involving leukocytes or neutrophils and all that kind of good stuff. I mean, how do you have that conversation when people throw this? Well, the literature supports leukocyte rich is better, like, what do you say to that? I'm asking selfishly because I don't have an answer. Yeah, no, it's, I mean, there are some patients who do their research and definitely do say those type of things, but then I essentially just give them the same talk I gave you, and then just like, oh, that makes sense. And they don't really question it after that. It's more of, I think it's a bias of the literature too, and perhaps the lack of standardization, right? A lot of people, I think, who maybe are doing those studies, don't have, as well as the first in PRP, and so they're just kind of doing the studies for the, for doing it for, like, just, I feel like some of them just doing it to almost disprove that PRP doesn't work, you know what I mean? And then, because if they, if some of these studies are really poorly designed, like, I've seen a lot of them, where I'm just like, why would you ever use that type of PRP for this type of thing? You know what I mean? It almost doesn't make sense. It's almost like these guys don't know anything about PRP, but someone just told them to, like, just go study it, and like, they're just getting funding and then just doing it. And so, from your data perspective, so what we're doing is we're using Salesforce or CRM, and building a data base of, like, our own data, and then I know, I know Rijank's has the same thing, and I know Steve Sampson, who's with Arthur Healing, and Toby, he does the same thing. So we all have our databases with lots of data. Definitely, we all need to definitely publish more stuff, like, I think, that's a big gap, for sure, because right now, it is a lot of gruelism, I guess, so to speak, saying this person is the best, so this person is the best. And we need more objective data, for sure. And I think, I know we're working on, we have a 5,000 patient trial going on with the US with Cedar Ridge, right now. So that'll be helpful, obviously, for NeoA, and that's a big sample size. But we definitely need more data for, like, a lot of the tenant opportunities, and spine and stuff like that. You know, at the same time, I think a lot of these interventions are also, at least my practice, for the most part, are patients who've tried everything. Like, they've tried Cortezone, they've tried Physio, they've tried all of conservative management, and they don't want to say, you want surgery, someone can even try surgery, or they didn't work, or they weren't paying again after. And so, you don't have many options left, either. And I think the big thing in medicine is we have to look at number needed to treat versus number need to harm, right? Which is essentially fancy-wasting benefits versus risk. And so, the reality is, PRP has very low risk, especially ACE cellular PRP, and because leukocyte rich actually hurts like hell, I don't know if they're being injected, but it hurts a lot, and it's very uncomfortable for the patient. So, I don't, if I can cause at least harm in that perspective too, then I'd rather do that, especially if the results are just as good, if not better. And then the other thing is, for these patients, where even if they're concerned surgery, or if they're being surgery actually has pretty poor evidence for most things, there's a big mental analysis that came out last year about that. Yeah, yeah, it's a bit easier than a meal. Yeah, exactly. So, there's only a handful of things that actually had decent evidence for. So, would you rather have your knee cut into for a meniscus, or maybe try PRP, which is way less harmful, but maybe it doesn't have many studies, it has a few couple of studies on it, but it has way less risk of, you know, downtime complications, all that other stuff. So, I think that's the way I usually explain to patients, and almost everyone would rather try the PRP than surgery. Yeah, and I do want to point out that the study that you're talking about is, it looked at, I think, the 10 of the most common elective procedures. I don't want somebody to listen to this, be like, well, listen, I had an acute, you know, thermal neck fracture. Yeah, yeah, no, no fractures. Of course, of course. Of course, doctors are the best at acute, like, there's no one better than orthopedic surgeons when it comes to fractures, that could hand sound, right? We're just always talking about, whenever we're talking about gaps in the medical system, we're talking about chronic issues, right? And that's... Yeah, no, it opens up this kind of worry, and I kind of do want to go down, because I think, you know, one of the issues is, again, I was lucky that I exposed to the world of orthobiologics in medical school, right? And Dr. Malin goes to one of the folks who exposed me to that, because I had some time to spend with him, and then from there, I went to interventional orthopedics foundation conferences every year, Toby, as well, attend that, to really get to learn from the best of the best, right? And these conversations keep coming up, but then the challenge becomes when we go back to the regular world where people aren't dabbling it, I shouldn't say more than dabbling, there aren't... this isn't part of their routine practice, they're not diving deep into the literature like you are, they're not understanding the mechanisms. And then they'll be quick to dismiss, that, hey, listen, that doesn't work, or we don't have evidence, or people are charging whatever amount of money that you want. I mean, we know that you can charge... there's a really good paper, I think it was the... it was 2016, I remember reading an abstract in the American orthopedics, one of their journals, that there's just a wide variety of costs that people can charge for PRP anywhere from $400 to like $3,000. And it doesn't even make sense, right? And you've talked to this before, is that you guys actually look in, you're actually getting the cell count, and how important that is. So coming back to your point about methodologies, and Dr. Malanga brought this up last time is, you know, you'll look at some of these studies, and people haven't even commented on, you know, what percentage or what the cell count is, and if it's even appropriate. So if it didn't work, how could you say if it didn't work, if you didn't even take the medication, right? They're not trying. That's why I'm saying, half of the PRP literature is garbage, because they're not trying. And I'm just like, this doesn't mean anything to me, because I know, but how can a regular doctor discern that? If you're not an expert in PRP, how are they going to possibly know that the studies BS? And then a patient has zero eye away. So like I saw a physio today posted about something about like, oh, PRP doesn't work or something, so I just called him out on his BS bit. Because he's quoting some study that just nonsense, nonsensical. Like they're using the wrong type of PRP. Some of the studies you don't even do them with image guidance. So it's just like, like, what are you doing? Like it's the, which the lack of image guidance is a really wealth concept to me. I know you guys use ultrasound guidance, and you're, do you use fluoroscopy for your spine stuff? Yeah. Yeah. Yeah. Yeah. I need to talk to you too. I use fluoroscopy. Okay. Talk a little bit more about this interesting concept. I know it sounds like you're becoming more and more passionate about this. What is exactly for those who don't know? And when is it indicated? Yeah. So essentially for severe osteoarthritis, moderate to severe, because we know the evidence for regular PRP's only mild to moderate. So after that, you're kind of stuck limited with your options. Like, yeah, you can do stem cell injections. I put those in quotations because they're not really stem cell injections, right? They're just essentially anti-inflammatory signals. Everything's inflammation. And so, and so if you, if you have someone who doesn't want to get a knee replacement or a hip replacement, or they're too young, or they're maybe just contraindications or they can't do it for whatever reason, then their options are so limited, right? And so, so that's why I'm so excited about entrosias. Like, it's just an opportunity to help so many people who are suffering and pain and don't have an option. So the idea is that with osteoarthritis, as you guys know, it's not just a disease of the cartilage, but it's a disease of the subcondral bone, which is kind of the bone underneath the cartilage. And so we think of joints now more as like organ systems. We used to think of them as just like kind of inert, you know, they just move us around type of thing. But now we know that there's actually so many cellular signaling pathways that go around in those organ systems and they communicate. And so, what we do is we can target the subcondral bone with the PRP. So we can actually inject it directly into the bone. And that's where a lot of people have bone-a-demo or inflammation. And that's the main pain generator. So there's actually been studies on this saying that people who have narrowing, pain doesn't correlate with that. So you could have severe narrowing on x-plane x-rays, but you might not have much pain. But bone-a-demo on MRI correlates much higher with pain. So it is a big pain generator for a lot of people. And it's something we can target specifically with the PRP. So if I see someone who has an MRI and this shows specifically to have bone-a-demo that correlates with their pain, then I'm confident that I can treat it with the entrosias injection. And I've done it for many people. I'm publishing a bunch of case reports right now, because I'm only one in Canada doing it. And I've done it. And I'm pretty sure I was the first one in the world to do it for a few different, like I don't think I was publishing anything on a point. Like I did one guy. He was like a 35-year-old carpenter. He couldn't work because he was just iconic, like 9, 10 out of 10 pain because he had a previous fracture in that like in his fifth MTP when he was younger. And so it was like post-traumatic away. And then the surgeon was like, well, we could fuse it. And that's the only option. And then like he's just like, I don't want to fuse it. Like he's so young. And so we did the boat. We did the injection. And then he had like one out of 10 pain after two weeks and after six weeks, like zero to out of 10. And he's been fine since. And so like, there's just like incredible cases like that that I can just, you know, that literally had no other option. And if I wasn't doing this in Canada, like no one could help him. And like, so it's just cool to be able to help people like that. So that's what I'm passionate about it. I guess it's just cool to give that skill set and help people who otherwise would have no one to really help them. Now I love that. I mean, I think that is really important. And for those who don't know, MTPs, MetaTarza, Feline, Jill, join the suit. You're a little, I guess they're so the fifth, right? So pinky toe joint. I want to come back to MSCs and perinital drive products and a little bit. But I think that this might be a good segue to talk about just some of the the legalities and regulations, right? We maybe we did or didn't touch on. They're very loosely regulated. I think the FDA is really cracking down on at least in the States. I'm not really sure what the scope is in Canada. You are much more familiar with this. Could you highlight what the differences are in terms of regulations, both in the States and in Canada for those who might not be familiar? Yeah. So health Canada basically put a pause on all stem cell injections two years ago, or almost three years ago now. And the reason for that was because there's so many clinics doing, just like you guys are doing in the States, so wild, wild, less, right? There's people doing it. I heard in the States, there's even carols and natural paths doing it. So like, you know, there's just people, there's just no regulation. And even if there's regulation, maybe they're just not enforcing it enough. But the rule, so in Canada, they basically see no more stem cell injections period. So that means you can't take your bone marrow or your fat and inject into someone for any musculoskeletal condition. The only stem cells that are allowed here are bone marrow transplants, which are like, you know, which are very evident space and there's lots of good research for that. So that's the only thing that I think it's fair because it ruined it for people like me who are doing it properly. But there's so many bad people out there who are bad players who are just taking advantage of patients and selling them something that's not true. And the biggest thing I think people need to understand is that stem cells, when you take it from your body and you re-inject them, they are not re-growing new tissue. They're simply reducing inflammation. And the guy who coined the term mesenchymal stem cells, Dr. Arnold Kaplan from Case Western, said in a paper published in Nature about four years ago or five years now, that they should be renamed medicinal signaling cells, right? So MSCs, because they're sounding signals, it's all about paracrene secretion, which means sending signals to a local tissue that have stem cells in them and those stem cells are what's causing the regeneration ultimately. So when we have a tear in your shoulder and I inject it with PRP, the PRP only stays there for maybe a couple hours. No, sorry, not about it, like maybe a couple days. But what it does is it sends signals to your body's own immune system and it own stem cells to start regenerating. And so that's how it heals. And stem cell injections that you get do the same thing. They're not that stem cells themselves are causing engraftment or re-growing tissue is just sending cellular signals that promote that healing. So to get true regraftment or regeneration, it's like we need that regenerative medicine triad that we talk about, which are progenitor cells, growth factors, and a scaffold. So you need all three of those to actually get true regenerative medicine. We're getting there, so we're almost there. We're definitely going to be there in this decade. Like, I don't know if you guys know what organoids are, but organoids are like petri dish organs that they use to study pluripornous stem cells. So basically they can make livers, they can make, they're even doing for Parkinson's now, they're studying brain. And then basically they can make these different organoids and then they can put whatever pathology you want in there. So you can make a liver, you can make like, you know, liver cirrhosis, you can make dementia and then you can study in a petri dish and use stem cells to regenerate the damaged tissue. So that's how they're studying them. And so once you get, but now they're starting to clinical trials. They're doing their first clinical trial in Canada for Parkinson's disease using stem cells. So it's underway, but it's still a few years away. Yeah, dude. I mean, that's an awesome explanation and I really appreciate that. I think, you know, I keep coming back to this concept of, okay, so the, I guess I'll push you on this, because I want to get your perspective about the future holds, right? I mean, you have your pulse on this more so that either one of us, and I think that one of the issues becomes, as you alluded to, that the average doctor, quote, unquote, doesn't have the time to really sift through the literature like you have, maybe like even an eye have or darshas. And, and so what they have, what they're resorted to is they're just looking at the guidelines, right? And then the guidelines are based off, you know, randomized control trials and stuff like that would say, this works, this doesn't work, this doesn't work, this doesn't work, this works, right? And so if you're quickly going to look at it, you're like, well, no, doesn't work, doesn't work, doesn't work, okay, maybe it works for tennis elbow and lucaside riches, the only one, anybody who's not doing that, X, Y, and Z, reason, at least that's how the way it works here, right? Again, I'm very excited that we're still able to do, you know, bone marrow and, um, and adipose because I think, it, I really can't appreciate the, the bad actors who've ruined, or like, you know, one, one, a few bad apples who've ruined it for the batch, but at the same time, you know, the progress on science has to, has to happen, right? And so, um, what, what is your, um, if there's any optimism in terms of Canada and maybe some of the other countries who aren't making that progress or who've just said, okay, we're going to completely shut it off. How do you go get over that hump? How do you get back, get, get back to using MSCs in Canada or than that kind of stuff? Well, there was actually a big stem cell, I guess symposium that was in the Globe and Mail, which is like one of our big news media outlets. And they were talking about with a bunch of health regulators and stem cell biologists who do basic research. And they essentially said that they should remove the moratorium on stem cells within the next couple years. So it is going to go back the other way. They just want some more research before health Canada allows it again. So we're in the process. So I think, I think in the next five years, we'll be back, we'll be allowed to do so much more. And it's going to be really exciting to actually be in regenerative medicine in Canada and even US because there's just going to be so much research going on right now in this field. Um, so I think, I think the pendulum is going to swing the other way. It's just, it kind of swung too much one way, you know what I mean? And then now it's, now they're just, they're just going to have to go back and they're doing the research or making sure they have enough data. I think, I think when it comes to cellular medicine, like whenever you're using something that's cell base, you definitely want to make sure you have enough safety data because it's not like PRP where it's just harmless, right? It's the worst case. It doesn't work. But cellular stuff can, there's been people going blind in the, in the eye, there's been people growing tumors in the spine. So these are real things that happen to people in their case reports about them. So whatever, you know, you've got to be careful when injecting stem cells or cellular cell-based therapies into people. Um, so that's why I personally, I personally wouldn't feel comfortable doing them until there's more research from, for a lot of different conditions. Um, I think one application that I would be excited about and the reason why, you know, we're talking about the bi-thing earlier, I'm going to the bi to treat some folks. And the reason why I would like to establish a regenerative medicine center somewhere else outside of Canada, we're looking at other options is because if you can actually grow stem cells, what are called pluriponus stem cells, and actually culture them and get the viable number of regenerate cells, culture them for a couple weeks, and then inject them into a disk. For example, a generative disease, you can actually regrow the disk, then have like a significant height regain, you know, because there's been, there's been basic science data on that. Um, and I know, I know like someone like, uh, Centino, he's published some data on that too, from Regenix. And so, um, so I think that's exciting to actually regrow new tissue from that perspective, but, uh, until there's more research, like it's, it's hard to, you know, really stand behind it from that perspective. So I, because I know there's so many people doing in the States, and it's, uh, it's, it's, it's just kind of buyer beware right now, because you've got to just look out for those people who are just kind of selling you, um, it's almost like snake oil salesman, it's kind of a shame, because we're doctors, right? We're not supposed to be like, just in order to make money, hopefully, hopefully most people are doing it just because they want to help people, right? And you want to give always best available evidence. And I think what you were saying earlier about the guidelines, the best available evidence to me is, it's not a new replacement for someone who has advanced arthritis. There's been studies, you're looking at intraocys PRP in Europe and in Spain, they've been studying it for over a decade. So if you look at the data and you look at the data for knee replacement surgeries, to me, there's better data to support the intraocius as a next step for knee replacement. And it's also because of that paradigm we talked about is that how much harm versus benefit are you going to have, right? The benefit is potentially the same if not, you know, without the potential harms and risks that you have with surgery. Uh, so yes, you can be, you can be a robot and just look at guidelines, but then, you know, I'd rather just get a robot to replace you as a doctor because, you know, but that's what AI is going to do to replace those type of doctors. If you're just going to go by guidelines and nothing critically, and you value it with the evidence, then, you know, yeah, that's that you're not really doing your job. Yeah. Now, and we've talked about that at length before, how, how challenged that makes it to practice medicine. Um, at least enjoyable medicine, right? I mean, if you're just going to follow guidelines or algorithms, rather, um, it doesn't make it as much fun, right? Pilling detective. Um, follow up, although, uh, so my understanding, at least for PRP, right? So let's just take, um, you know, Kale grade four osteoarthritis. Um, that's kind of the bone and bone end state arthritis. I think we know, at least from what I know, that PRP may be not, you know, great indication for those folks, but you're saying IO is better. That's where that comes in. Yeah, I wouldn't even offer regular PRP or even side of rich for those, I don't even offer that side of rich can work from moderate to severe, but if they have an end stage like that, like the only way I'm going to treat them is if they have bone edema and MRI, but if they have no bone edema and there's no target. So if there's no target, then they have no choice but to get in the replacement. Um, at least, you know, what they're doing at, um, Washington University, um, just like, uh, they're doing 3D bio printing. So they can actually resurface a knee or resurface the hip using 3D bio printers. So they print a scaffold using polymer hydrogels and then they see that with medicine, then they grow the stem cells in lab and they see that with it. And then they can actually regrow cartilage and regrow new joints. So I think that's the future of, um, like organ transplantation for at least a knee and hip and stuff. Like I don't think, I think 10 years, they'll be very, uh, I think you'll, I think in 10 years, most people won't be getting joint replacement. So probably be getting stem cell transplantations and joint, those type of things. Interesting. So for your interalcius injections, are you doing them under X-ray, are you doing them under ultrasound? Yeah. I use both. I use, um, for most of them, I do them under floral, but sometimes I'll use ultrasound just, uh, uh, market first, but then the actual active life injection I'll do under, uh, floral, because then floor, you can see exactly how deep you're going and everything. Right. Awesome. So, uh, we talked a lot about a snake old salesman. No, this, I don't know if it's a good transition or not. Let's talk a little bit about perinatal drive products, right? Um, way, uh, and these are the products that people are saying, I'm the out of tissue drive products and stuff, and they were quite popular, uh, for a long time, right? Um, walk us through the history of that. What was so special about them over PRP, because PRP, as you mentioned, has been around for a long, long time, right? A few decades now. Why were I'm the out of tissue products so popular? And now they're officially completely banned, so people can't acquire them, but I still get patients coming. Yeah, I'm getting patients for follow-ups like now. And they're like, oh, last year, you know, my, my sister's friend had it done. And this is, and that's what I want. And I'm like, oh, listen, I can't get that for you. I'm sorry. And I wouldn't, wouldn't want to. Uh, but tell us a little bit about that. I think it's just a lure of anything that's, uh, embryonic has this magical power. That's why we store our, um, a bill, a billical cord stem cells too, right? That's why people, they ask that the hospital here when, you know, your babies are born now. So it is, it's just, and yeah, they are powerful agents potentially, but we, again, there isn't enough research on it. And we know that antibiotics, uh, you know, stem cells, they're barely any stem cells in there. The, the, what they were sending to you in a bio where it's like, basically, it's just, if there's been studies like, uh, looking at the fraction of it, it was mainly just protein. And it had a little bit of like, progenital cells, but it's just, you know, it's just a bio of like, some anti-inflammatory, like, you know, nonsense, basically, in my, in my opinion, like, it's not anything that's, um, really evidence-based. And, and then there's also risks with it too. I think there's been infections and other things that have happened with that stuff. So, um, so you've got to be careful with that. Optical type of product. I think, I think autologous is a way to go in general and regenerative medicine. And, um, like, that means taking it from people's own bodies. And that's, that's, and autologous, even in older people, it's going to be a possibility because of induced pluripotence themselves. Like, that's, that's kind of the way to do it. Yeah. And I alluded to the, you know, FDA cracking down hard. I think the, the two requirements that they've made it is, is, I think the, the word is they use homologous, but I think maybe the referring to autologous is what they're trying to get. And the second part is minimally manipulated, right? I think once you, and the minimally manipulated, like, defining what that means, that's the difficult part of it, right? So we talked about adipose, MSC's a little bit, right? There's one device where you kind of, should you aspirate from the stomach or, or, or, you know, um, post your thigh and that kind of stuff. And then you'll shake it through this device and you're breaking that up and you're trying to harvest the, this stromal vascular, is that stromal vascular? Am I, am I confusing that with? Yeah. S, S, S, yeah, stromal vascular vaccine. Yeah. Yeah. Yeah. So, so you'll get, and then you'll inject that back into and the scaffold that you're talking about, whether you're filling a defect like a meniscus or rotator cuff or whatever it might be. Uh, but again, coming back to what does minimum manipulation mean? And that's where the FDA can't go moderate every single physician, um, that is, are doing these procedures and say, Hey, are you doing it right? Are you not doing it right and putting a microscope? Um, that being said, though, uh, you know, if you're, I mean, one thing I'll caution is what they have come down very hard is that nobody should be doing these, um, for the reasons that you alluded to. One big one, like, there aren't any viable cells in there anymore. Who knows how long they've been on there for? There are other things, as you mentioned. Uh, but also the, the rule number one, coming back to doing a harm, right? Uh, and we know that this actually has done quite a bit of harm. And that was all up in the news a couple of years ago. Um, but for those folks, um, this is an important question, right? So, so for those folks, uh, maybe patients that are listening to it are interested in the kind of stuff, it is really challenging. They're not going to go and go to PubMed and read all the studies and try to sift through it. I mean, like we mentioned, even for clinicians and people who are trained in the sciences, um, it's hard to figure out what's right, what's not right. Um, for just the average person who's trying to figure out where to go, who to go, what are some basic check boxes that, uh, that need to meet for you to recommend a practitioner doing this? I have pretty high standards. So I, there's only, uh, maybe, there's only one one clinic in Canada that meets my standards, which is obviously us. And then in, in US there's maybe three or four. Um, so there's the basics, which is obviously using image guidance injections. And there's actually a lot of people in Canada doing it without image guidance. And I've had many patients go to other clinics and they, I was like, oh, did they use image guidance? They're like, no, they just kind of felt and injected here and I was like, oh my god. So I'm like, you didn't even have PRP. I don't know what you had. Like, yeah, you injected something, but I don't know where it went. So, uh, so then, that's definitely number one, most important. Um, the other number two would probably be standardization or measuring your cell count or having a scientist or someone to actually have a cell calendar to actually see what you're injecting. If they're just using generic, um, centrifuges, I mean, that's, that's fine up to a point, but you're not going to get the special mice service that you're going to get, um, at clinics that actually do that. So that just allows, like we're saying, precision medicine, when you actually have a cell counter and you can, you kind of formulate your own PRP, so target different things. And so I know, like the genics guys, like, I know they do that. I've been Colorado and Steve Sanson and California. He's really good with that type of stuff. He uses, he uses mainly PRGF, which is spot, which I'm a, I'm a fine, I'm fine with that too because it's a lucocyc poor PRP. It's not painful to inject and it's well studied and, um, again, just very less chance. There's very low likelihood of any sort of harm with that. Um, and then I think the other thing is looking at their credentials in the sense that, uh, like, who are they treated? What have they done in terms of schooling and that kind of stuff? Like, you don't want an essay go to a naturopath or a chiropractor who's doing this because they thought it'd be fun, um, and just so they want to make some money. Uh, because a lot of people, you know, they're motivated by money, unfortunately, and, um, because like we talked about, it's not a really well-regulated space. There are a lot of naturopaths doing it. I just don't see why you would go to naturopath because you don't have a specialized training that we do, right? We have to go to school for years to do just, just to learn, like, just to learn ultrasound technique takes, it took me like two years. Like, it's, it's a really specialized thing, right? And so you have to really be proficient and skilled at it. I don't see how a naturopath can just pick it up. Like, there are naturopaths doing it all over and they just do it without image guidance. So I think, I think looking at the credentials, making sure they're like, you know, an actual medical doctor, uh, and have, ideally, some sort of specialized training and image guidance and that kind of stuff is really important. So I think those are probably the most important criteria to look at. I don't, I don't want to bash naturopaths as well. I don't know what, uh, what training is required to be an naturopath. Like, is there like a four year training? Does anybody know? It's like two years. Yeah, it's a four year. Yeah. Oh, yeah. I think, I think in the US, it's like, so oh, you might be right. It's four years. I think so. It's a two year curriculum, but they learn a lot more of the integrative holistic. So they don't go as far and depth as we do. You know, in physiology, pharmacology, they learn kind of very superficial from what I've read up on. They have an entrance exam. It's credited. But again, the, the depth is not there as much as we learn. And then their clinical rotations and stuff are a little bit more like specific, uh, than hours. So it's kind of like PA or an NP where they delve into like a special, a special scope early on, whereas we kind of, you know, have the interior general practice. And then we start to funnel it down. Do they have an entrance exam? Yeah. I'm not sure. I think you can do a residency. I think you can do like a year or two in a specific like field. I know some natural.pathics that do like oncology, like residency for a year. Um, but I don't, it's, again, I don't think it's as like in depth as, as, as what we do. And like, I don't know how much of the billing coding, you know, prescription, because it state to state is going to be different as well. I'll say this, man. I think, uh, I really appreciate your point where I disagree is, you know, I don't know if, uh, I think that the degree part is as long as it is legal within the scope of wherever country you're living in, like, it doesn't bother me as long as the intentions of the person are right. And they're actually doing the work. And they're actually doing it the right way, as I should what I should say, because I'll tell you, I graduate with a lot of physicians who have no business doing the injections that they're doing. I promise you, like, I've seen their work first. Yeah. Um, and they have the credential. They have the degrees, but God, I would never refer a patient to them. Um, by the same respect, you know, I wonder if somebody, I can, I think car practice schools for your, if they did become a car factor and they got, you know, advanced training, like, like you did, like, you know, scope training and they, they went to a couple of let's say, I, of course, is then did that. If legally, which I admit, I don't know what the legalities are, um, there are a lot to do that kind of stuff. Um, I wonder if that's as bad, you know, but, but it makes it challenging. And, uh, to be fair, the question I asked you, what are your baseline requirements at a superficial level? And that's the question you answered. So I, so I appreciate that. Um, to your point about the image guidance, I do want to ask about this follow, right? Cause I'm passionate about musculoskeletal ultrasound is what I spend a lot of my residency training and fellowship training doing. Um, I imagine that you have these conversations with your colleagues who are not using image guidance, right? When they're doing these procedures. Um, and I suspect they probably tell you, oh, I know that when I go through the portal and the knee, I'm injecting right, I know I'm getting there all the time, right? What's that conversation when you're in like with them? Cause I, I know the evidence that supports image guidance versus non-image guidance, what it says. But that person's like, no, no, no, I'm in there. I know I'm in there. Or maybe even orthopedic surgeon who actually do orthoscopie and no. Exactly. Yeah. Well, orthopedic surgeons are always like, uh, it's walking on eggshells when you're telling them that they're not doing something right. Cause they think, you know, they're, they're gods in the OR. But when it comes to injections, they're not so good. Uh, that's our specialty, right? Intervention, we're interventionists, like we're true, like we do, that's all we do. We play with needles and that's all we do all day, right? Image guidance injections. These guys are good at cutting, they're great at drilling all that stuff. But when it comes to injections, uh, it's it's own specialty and it should be treated as such. So I don't think it makes sense for someone who's not specialized in training in it to dabble into it on the side. I think you need a lot of experience, especially for spine, like you need a lot of experience and expertise to do that type of stuff. Um, so usually the way I phrase it, um, like what you said is basically most like 80% of orthopedic surgeons who did unguided injections missed a target. Like there was a study about that. And so for the shoulder. And so even experience or speak for just one minute. Was it glad to humor or like stuff? What was that? It was, uh, it was a, it was a, it was a, it was a, it was a tendon for like super-spinnated tendon. Okay. Okay. Yeah. Okay. Yeah. So glad to humor. I would think would be higher. I'm sure. Yeah. Like, I mean, lower, I mean, like low, like they would probably wouldn't miss it as much. But like tendons like are hard to get into, right? Especially if you're doing like this problem is a precision medicine. It hasn't, it hasn't changed, right? The concept basically was we can inject cortisone and you'll get better because, but the reality is cortisone I can inject you into your butt and it probably make your shoulder feel a little bit better because it has a systemic anti-inflammatory effect. And so you don't have to be that precise. You just kind of have to get it in the general area. Uh, but the orthobiologics it's all about precision. And like you have to, like when you have small tears that are in the super-spinnates are causing chronic shoulder pain. If you don't get the right target, the patient is not going to get better. And you have to find the right angle and you have to, you have to know how to use a probe and you have to know how to guide into there. So it's very precise and it's very different from what the traditional model of training was. And so I think the, unfortunately, the medicine field has still not evolved. At least on Canada, I don't know how it's in the States, but Canada, for the most part, majority people are doing it without image guidance and they're not even trained in image guidance. Um, and there's the, the college here is finally starting to regulate it because they've seen how much harm has been done and, and the Toronto star here did a huge investigation into all these pain clinics that were doing all these BS injections. So they kind of exposed all the cracks in the system. And so now that they're finally starting to make it a standard that you have to have image guidance and you have to save your pictures and all that stuff. You know, just like when you do, like I'm sure you know the Spine Intervention Society guidelines, like I said, like just like that, it should be the same guidelines for us, right? It should be like very precise, like, you know, high standards of care type of thing. Yeah, I mean, that warms my heart. It's really funny because over the last two years, uh, 2019 Journal of Journalism Medicine, I think the first author of Lens Drum, he publishes studies looking at viscous supplementation, right? Hyaluronic acid, um, ultrasound guided versus, um, blind injections. And what they documented over like over a six-year period, folks that, um, got palpation guided or blind injections were significantly more likely to go on for a knee replacement than folks who went ultrasound guidance, right? Take that for what it is. There was another study published in 2021. I think this one is in one of the arthroscopy journal, also AGSM, um, I'll find it and we'll link it and they, um, just compared, you know, um, for knee osteoarthritis, moderate to severe knee osteoarthritis, palpation guided versus ultrasound guidance, and significantly better effects for ultrasound guided. And ultimately, you know, it's, it's funny because when I told that to my co-founder, shout out to him, Ryan Meyer, when I tell them his response was like, yeah, he was tongue in cheek, but he's like, yeah, you know, all the surgeons that I've ever worked with are in the top 1%, so they never miss, you know, and he was joking about that. But, you know, every time I have this conversation, um, and then they'll say, oh, no, I'm in there because I've done 10,000, and I know I'm going into the subacromia bursa, but I just, I find that to be really, really interesting. I do want to call out my bias, though. I am a non-surgeon, and as Dr. Malanga said that, um, you know, we have to appreciate our biases. I think that, um, I'm curious to see if there's orthopedic literature that shows the, you know, the, the opposite side is true of if some palpation guided injections can be just as good as ultrasound guidance. I don't know. I'm not familiar with that, but, um, if somebody out there knows of it, please send it away. I think patients don't, like once they realize, would I rather have this procedure done with the camera guiding it or not? Like, I mean, it, from a patient perspective, they're just like, why would I not have, why would I not want my practitioner who's injecting something into me to see what they're doing? Like, it's just, it, it, to them, it makes a lot more sense. And, um, I think, yeah, I think orthopedic surgeons need to get over the fact that, um, that, they can just admit they don't have the training and they can refer to someone else with an injection. Like, I don't, it's not a, it's not a ego thing who cares. Like, just get the patient better. That's what it's about. Yeah. Well, the difficult part here in the States is, right? So for the non-surgeon folks, they'll tell me it's a time-based issue, right? This comes back to our conversation with Peter Valenzuela as the business of medicine is driving the practice of medicine, right? It's putting on an ultrasound and saving the pictures takes more time. And so it's frustrating for us three here. Uh, but this is just the, uh, I don't have an answer to that one. Yeah. And that's the, I mean, that's the systemic issue of the whole medical system. It's just, it's time-based and based off, you know, the more you see, the more you make type of thing and just kind of a nonsense system. But that's another discussion, I guess. Yeah. So, do you know, I mean, we touch on orthobiologics and depth here. Um, and I know you're not just like a needle junkie. Uh, you're very well versed in the world of functional integrated, you know, lifestyle medicine and those topics. And as we touch on precision medicine, there's obviously this other leg, right, that we look at labs, um, and try to, you know, figure out labs, especially maybe some of those that might be, quote, unquote, strange, right, that are not on your normal panel. You're obviously working with a lot of, you know, top athletes, bodybuilders, um, active members. Are there any specific labs that you're looking at, right? So when you're thinking about PRP orthobiologics, what are their adjunct kind of treatments labs? Are you looking at, um, when you look at the holistic viewpoint? Well, I think we can talk about what would be ideal scenario and what I actually do. So an ideal scenario, ideal world, you would, uh, yeah, because in an ideal world, you would actually have them, you know, come in, uh, ideally three to six months before injection, you would do a full blood work and you would like kind of look at inflammatory markers, look at every, just like kind of like general panel of everything. Make sure they're generally healthy. Like, they're not having like, uh, just because you don't, if they have lots of inflammation in the body, it's just, you know, the injections may not necessarily work as well, um, especially the standard PRP because you're not standard, you're not necessarily removing all the, and you're not promoting the anti-inflammatory effect like you are with the second generation PRP's. And so, um, so if they're not that healthy, like, I wouldn't maybe want them to, if I the blood work comes back and they have high cholesterol, they have diabetes and they, inflammatory markers are through the roof and that kind of stuff. Then I'd be like, you know, let's hold off on PRP for three months. Let's get you to see this nutritionist work, you know, work on exercise, legs down and then we can come back and revisit it. That would be the ideal thing to do. Um, it's, but the reality is most patients come to me and they're, you know, they're going to paint for so long. They just want to get treated ASAP and they don't care. Uh, and so, so what I do in those days, in, for those patients, what I check are hormones, at least, to see if there's something maybe that is impairing their recovery, uh, because we know that if you're, if you're to testosterone and your growth hormone levels are suboptimal, it can definitely impair recovery. So the way we check that is free to testosterone by available and then IGF1 and IGF BP3, which are markers for growth hormone. And so if they have deficiencies in those, that may actually not only increase the risk of injuries, but it could even, for some patients, they can explain why they're keeping injured and then once you get those levels to a good range, it feels so much better to recover better to sleep better, all that stuff. And then it just makes the outcomes much better too. I've had many patients where even like some patients with chronic pain, like you just put them on growth hormone and all the pain goes away because they're, they've had like no growth hormone. And like they, they just never, no one ever checked it. Tony, Tony wrote a whole book about growth hormone. So that's why I'm well versed in it too. And he, he did for tight, like he used to optimize levels a little bit for people and that's what he has controversial as well. But um, the reality is it makes a big difference, right? Like for where, we're just, we're not necessarily talking about professional athletes because obviously there's, um, you know, with performance enhancing and stuff that might cause an issue, but just for regular folks, it's something, if you optimize, it can make a big difference. Yeah, I was going to ask, in the population of the bodybuilders, is there anything that you get worried about that they might be taking that would get in the way of doing any type of orthobiologic procedure, any type of supplements or steroids? Uh, yeah. Ask anti, yeah, anti-assurgeons, um, specifically because they, like, um, like there's noble decks and there's, um, anesthozole and like a bunch of, they're actually serms, which are used breast cancer, but the reason they use them is because they don't want their estrogen to build up in their system when they're on a cycle. And the problem is what happens those anti-assurgeons actually increase your risk of tendon ruptures and they can affect tendon healing as well. Uh, so it's been like, uh, in vitro studies on that type of stuff. So that's, that's the type of thing that I would, I usually caught like, I'm like, you know, the, and that's, that's actually a lot of times where you see a lot of tears and a lot of ruptures is close to a show for bodybuilders because they're getting shredded and they're taking these high doses steroids, but they're also taking high doses of anti-assurgeon and they're, and they're in a calorie deficit. So the body's just like primed to be injured. Gotcha. Very cool. Go for it all. So wait, so this is maybe a common misconception. So it's actually the rheumatized inhibitors that make it more susceptible to tendon ruptures, not the testosterone. Yeah, interesting. Yeah, yeah, exactly. Yeah. Cool. Well, I know you're also very interested in fitness and weightlifting, as we talked about, right? Tell us about why muscle is so important for longevity and that conversation that you have with your patients. Yeah, I say like muscles like the body armor, like real body armor. Yeah, just that. It protects you from so many, it protects you not, it protects you from so many diseases because of what's called myokines. We talked about cytokines earlier, but myokines are like the cellular signals that go throughout your body from the muscle and they actually reduce inflammation and they help protect you from, we know from heart disease, cancer, diabetes. And similarly, if you have too much fat, they release something called dipokines. And those are dipokines or pro-inflammatory cytokines that, you know, lead to, especially visceral adiposity, which is like the fat around your organs, that's very, and that's very pro-inflammatory and increases risk of so many different diseases. So, yes, muscle looks nice, but it's not just about aesthetics, it's actually pretty much, it's an organ of longevity, right? It's essentially what you need to live a good, long, functional, healthy life. And there's no compromise, there's no way around it anymore, like you have to just say suck it up and you have to learn to put on muscle. Whether you want to do that through gym or, you know, through resistance, like, there's, I mean, swimming, cycling, or resistance training. The problem is, you need a periodized training program. And like, the reality is, most people don't know how to do that. And most people just kind of show up and just do some 1980s thought-y building workout and just get in and get out. And I've seen, I had this intensivist who was like, it was like a smarts intensivist I ever met in my life. And he was like doing this, like, 1980s routine. And I was like, it's so odd. Like, why are these intelligent doctors training like, like 1980s bodybuilders? Like, this doesn't make it, but it's just they penetrated the mass market, right? With their supplements and with their influence and everything. And so there's so much evidence now with actual strength science, but it's just run by bodybuilders. Like, I love bodybuilders. I work with them all the time. I treat them all the time. But, and I'm part of a few muscles, like I work with them, but at the same time, what they preach is not based on evidence. It's a bro science, right? It's all, it's just, and like, periodized training. There's a certain way to do it, which is science space. And that can lead to so much faster strength gains and put in a muscle. It's not that hard if you know how to do it properly. But the reality is most people don't. And I think, I think that, I think that's why I'm working with a startup company called Exalt. And we're just that we're trying to make fitness accessible to the average person because it's just we need it. We're using scalable technology to do that. And so that's, I think that's really what the future needs because everyone needs a coach, I think. It's just too hard. Otherwise, take us through a song. What's the technology? What's your goal with that? So there's two components to it. One is a health dashboard to track data over time. Okay. And then apply machine learning to apply machine learning to that to better help predict health outcomes eventually. And then the other is there's mobility assessment, which again, we're using machine learning to assess people's movement patterns. So there's something called the functional movement screen FMS, which is like kind of like a standard for movement screen, but it's not bad. Well, I mean, it's like 50% accurate, but there's nothing great. There's nothing great to predict injury risk, right? That's reality. And so what we want to do is we want to use machine learning and our data to assess people's movement. And hopefully over time as we get lots of data, we can over years, we can hopefully start to predict injury risk better. But the movement assessment is basically a camera AI technology that can help at least a trainer to assess movement because it's so subjective otherwise. Yeah. Cool. Very cool. And so the idea is that we're just we're doing at the biggest thing is we're doing at the fraction of the cost if you're wondering what's so different about is it's 15 minutes sessions. So it's short sessions, but it's it's it allows people to get a trainer and a coach for $1,000 a year versus if you're paying a trainer, you have to pay $3,000 for like three months, right? And that's who can afford that? The average income in the US is like 35,000 USD, right? Single. And so you know what I mean? So like it's not it doesn't make sense to the pricing makes no sense just for rich people. Exactly, man. Especially for trying to make systemic change, right? I mean, we know chronic disease and obesity and all that is through the roof here in the US and globally, honestly. Yeah. Cool, man. So I wanted to ask you about longevity, right? Because I've been listening to Davidson Claire and I wanted to get your take on this, right? Like, how do you balance out kind of, well, first of all, the take that Davidson Claire has, right? Is limited. He's now like anti-proteid, limiting kind of the protein side of things. So we have muscle in one side that kind of, right, helps with longevity. But then you have this other side with like caloric restriction and fasting. What is your end goal here? When you look at kind of your health and fitness and longevity, kind of what's your take on what you want to do? I know it's a little. Yeah. They always talk about the empty. No, I know they always talk about the empty or pathway. Right. You know, it might increase. I think, I think the reality is you have to like, this is where basic scientists like Davidson Claire and maybe clinicians like us can help to elucidate some of the discrepancies. And I think the reality is you have to look at function. You have to look at quality of life and you have to look at functional impairment. Yeah. The reality is if you don't have sufficient muscle and protein, you're going to lose that as you age. And you're going to lose it really fast. And there's been large meta-analysis, like there's one's done at Tufts University looking at grip strength as a predictor of mortality. So like people who, and that's just grip strength. So imagine if you actually did a real assessment of like measuring someone's leg strength, like leg press or squats or something functional, dynamic. Like imagine how much you could actually gauge in terms of like longevity there. So muscle, muscle is the ultimate longevity tool. And I'd rather have muscle and look good than be a skinny guy and live longer, I guess. Like I don't like, I don't know. Like to me, it's more important to be like, I want to look good and I want to feel good. Like that and muscle allows you to do that. So whatever, whatever basic science stuff that they're talking about or like some of the data on, I mean, maybe maybe I would live a few years longer if I didn't eat as much or if I was a calorie restriction and I was fasting every day, maybe, but I don't know. Like I feel like there's not enough to say that. And they're on a counterpoint to that. Like there hasn't been enough data on muscle, right? And that's where there's a lot of research heading that way now, because people are trying to realize, oh wait, they're like, oh, muscle is not just some stupid thing to look good. It actually is a organ complex organ system, they're sending all these cellular signals. So now we realize that. So it's like, that's why they're finally studying it. So there's so much research in this field. Like I think, I think I can almost guarantee you even like 10 years will be like, oh, maybe we were wrong about this whole calorie restriction for muscles, actually, they're both important. So I like, I can almost guarantee that it just makes sense from a functional perspective too. Like what? Like think about how many people like lose their quality of life because they just don't have enough muscle, right? Or they didn't move enough. And think about how many injuries we treat because it's double as short, right? If you're trained too much or if you're trained too little, it can cause issues. You got to find that sweet spot. And if you do that, if you do that, that's how you age, age gracefully. No, absolutely. I agree with you. Go to the No. So, Darshan, I haven't listened to exactly what you're talking about. But I think the point of clarification, I mean, are they saying that too much muscle is going to be detrimental to longevity? Or is it the, because caloric, you could have caloric restriction for a long time. I mean, that's the holy grail, right? If you, I don't know how easy it's going to be to put on muscle when you're in caloric restriction or in a deficit phase. But like what are they saying exactly? So I think more, more from the growth hormone perspective is what he's kind of looking at, right? And he's saying, if you're going to be caloricly restrictive, right? So I'm looking at the perspective of if somebody wants to put on a lot of muscle, likely they're not intermittent fasting, right? You're probably going to be more sometimes at a caloric surplus or you're going to be doing more things that are anti-emptor pathway, doing what Davidson Claire is kind of thinking about. And so for him, you know, balancing out, working out with doing this caloric restriction, now becoming a vegetarian, you know, I think sometimes it's like a tug of war balance, right? As you kind of mentioned. So for me, I think, like you said, all I think the mechanistic pathways sound great, but a deal like you said, what it might add a year to, like we're not even sure how much, right? So a lot of it sounds great to the ear. Yeah, and the big irony, the irony is, the irony is that he's looking at one pathway. There's seven cellular stiggling pathways of aging. I can't remember all seven of them, but there's like protein turnover, telomere links, mitochondrial dysfunction, insulin resistance, and like, so there's all these paths, there's seven that have been well identified in the literature. And so he's looking at like I got like maybe telomere or something, but but the reality is exercise is the only tool that can activate all seven cellular pathways and have beneficial effects on them. That's why there's something called exercise mimetics or drugs that are trying to mimic the exercise effect. But it's, I can always get into you, they'll never find that because it's too complicated. And there's just too many pathways that are getting activated by exercise and that have too many beneficial effects. So you got to, you know, you got to learn to like exercise properly. Not just exercise has become such a catch-all term that it's just almost just like telling people to exercise because it doesn't mean anything. Like you have to actually, you have to actually like specify, you know, what kind of exercise, how to move, like what to move, and that kind of stuff. So there's so much more to it. Exactly. So Peter Tia kind of breaks down into four categories of movement, right? So stability, strength, and all you can correct here. I think it's anaerobic and then aerobic exercise, right? And so he's kind of working on all four of those pillars, right? And I think when people think about weightlifting or fitness, they might just be thinking of that one route, but you know, how do we diversify? And I think that's the key. When you talk about functionality, I mean, hey, we're all getting older. Healthcare's getting better, right? So we're we're living longer. We're aging, but at the same time, we need to become functional to play with our great-grandkids or, you know, further on. So I totally agree with your perspective on that. Yeah. Well guys, Adele, I know we've taken more of your time than we actually requested. So I do apologize for that, but at the same time, I actually have like another hundred questions. Darcy just asked me if I had anything else else. I guess I have so much more. But maybe we'll save it for a part two, hopefully someday. I, a couple of questions just to round it up is, you know, where can our listeners find you if they want to get a hold of you? What's the best way to connect with your men? Yeah, I'm pretty active on Instagram. So at dr.acon, aka.n, don't DM me though. Email if you want to contact me because my email is on there, but people never listen. I get wait. I just can't. Yeah, but it is what it is. Do you you said on some other that there was somebody who responds to 130 emails a day and that's your goal? Is that true? That sounds like a nightmare to me. That doesn't sound now. Yeah, that was actually an orthopedic, orthopedic surgeon Brian Cole out of Chicago. Yeah, I know he, I listened to him on a podcast and he, uh, he, he says he gets about 100 emails a day and 130 and he responds to all them. Well, so I was like, if you can do that, I can do, I'll respond to all my emails, but DMs are just like, there's just so many. And there's also like some of them just like adds a nonsense. So I just, I just can't go through all them, you know? Yeah, it sounds like a pretty good filter right there. People don't have that. You know, the barrier of getting to the computer and sending an email is just too much nowadays. Um, last and perhaps the most important question, it's kind of the mission of the show, man, is how do we, how do we add the health back and health care? We connect with other people more. Connection is the key that we're missing. It's called the Rosetta effect and it was studied in an Italian population where they, even though they ate like crap, they smoked and all this, that they still live longer because they had connection. So I think that's the biggest thing is, uh, and that's what I'm trying to do with my social media and all that stuff too is just, yeah, just reach more people and help. Absolutely. Well, you're appreciate it. So thanks for coming on. Yeah, thanks. Thanks so much for hanging around through this episode. Dr. Gil Khan is an awesome resource and he's got a lot of cool things coming up and he has an awesome vision when it comes to orthobiologics and sports medicine and weightlifting. And so if you're interested in what he's doing and you want to follow his journey, I highly recommend following his Instagram. He posts a lot of great content and it's not only just about sports medicine. He posts a lot about just general health and fitness and how we can do our best every single day to become the best versions of ourselves. Now, if you want another perspective when it comes to PRP, regenerative medicine, orthobiologics, and sports medicine, you can check out episode 14 of this podcast with Dr. Gerald Malanga, who is one of the fathers of orthobiologics in the US. Now, if you're enjoying this episode and you think somebody else would enjoy it as well, please share it with them. Please take the time to subscribe and also rate and review this podcast if you feel like you're getting value out of it. And as always, everything in this podcast is for educational purposes only. It does not constitute to practice some medicine and we are not providing medical advice. No physician, patient, relationship is formed and anything discussed in this podcast is not representative use of our employers. We recommend that you see the guidance of your personal physician regarding any specific health related issues. We'll see you next week with a lessons learned.