Stem Cell Therapy for Ultrarunners with Dr. Vass and Khoshal | Koopcast Episode 67

trail and ultra runners what is going on what's happening welcome to another episode of the KoopCast as always i'm your humble host coach Jason Koop and this episode of the podcast is all about regenerative medicine and i know all of you injured runners out there are going to be listening to this with a very keen interest because let's face it injuries suck and oftentimes they can be really stubborn and even more often they can be very complicated to solve in a traditional type of sports medicine or orthopedic setting which lends people to look to alternatives such as prp injections or stem cell therapy as a way to get over their injury so on the podcast today i have doctors voss and koshal from the rocky mountain regenerative medicine center in boulder colorado to cut through a lot of this clutter and demystify all of these different types of regenerative medicine that you could potentially encounter and use to to possibly i'm going to emphasize that word possibly help you in your injury recovery as always i have no financial entanglement entanglements or conflicts of interest with these two i just really appreciate what they do and i have seen athletes have great outcomes with them all right here we go i'm going to get right out of the way let's get right into it

with this episode all about regenerative medicine i've always felt that you guys's practice is like located in the in the perfect location near boulder you guys you're both laughing at this because you know where i'm going with it because there are a lot there are a lot of endurance athletes which is what we're going to spend the majority of the time talking about but there's also a lot of other types of athletes and the thread that holds them all together and for whatever reason boulder brings this out in people who live there is they all take their athletic endeavors to the extreme and doesn't matter whether they're an endurance athlete or they're a combat sports athlete or whatever they they get soup like super into it and because of that they get hurt inevitably and i've always made this joke whenever i bring uh people on the podcast from boulder that if you just like stand outside the whole foods in the middle of boulder there on pearl street it's a pretty good chance that half the people walking through the doors have either qualified for kona or qualified for the boston marathon like more probably more than half it'd probably be 80 so you guys that have a practice in rehabilitating athletes or rehabilitating injured athletes to try to get them to you know perform better or in like the perfect the perfect location to do that whether it's regenerative medicine or physical therapy or even like you know acupuncture or anything like that any of those tools that that have been used in an athletic setting

always go off really well in boulder because the population is really tuned to it so before we get too far into it like kind of describe your you guys's practice and specifically the types of athletes that you see come come in the door and what problems you're trying to help them solve yeah um i mean the whole it's luck it's just pure luck that we're here because it's where we both just kind of ended up choosing to live um but you're right and it's just it goes beyond the athletes it's people in general here are pretty health conscious and so although we do a lot of injury you know treatment we i would say we do just as much general wellness health and anti-aging um and so it's uh you know it's been it's been a good yeah we it's just a lot you know we've been lucky and fortunate so we count our you know count ourselves lucky there but you know we spend a lot of time helping people um optimize their health in general particularly um and this we we work with kids as young as you know college level nc double nc double a level athletes all the way up to you know professional you know professional athletes retired athletes and then and then we have a lot of clients who you know who are kind of like like us who were you know we were athletes in high school and

college profession kind of got in the way and then you know maybe you backslid a little bit on what you thought you're you know you're either athletic or just general wellness should and ought to be and then kind of want to get back into okay let's get back on track and so we do a lot of a lot of all of that um injury recovery with with regenerative and traditional techniques um but the important thing about that is that these regenerative techniques like when people talk about stem cells p or p ozone whatever whatever whatever the regenerative modality is it works better if the physiology is optimized and with athletes usually that's an easier thing to do because they're already you know most of them are either all the way there or 80 or 90 percent of the way there but when these techniques don't work it's usually because the underlying physiology isn't primed to run with these techniques and so the general wellness i think is is just as important as you know the stem cell therapy or the prp because they go they go hand in hand and when we see people fail treatments it's usually you know it's usually because either the treatment wasn't used appropriately meaning they have an injury or a problem and somebody's applying you know prp where that's not really the right treatment modality or they're using you know bone marrow

where the candidate really isn't a good bone marrow candidate they should be using either an allergenic or their own banked product or an adipose you know so there's there's a wide range of treatments they work better if you're optimized and um you know we do all of it and so you're right we're kind of lucky we landed in the right spot well one of the things i want to talk about is how the athlete can discern amongst all of these different treatment options because it's it's hard for them to navigate the space because it's not it doesn't have as long-standing roots as traditional like orthopedic type of type of medicine but when we before we like before we get into that a lot of athletes are going to think of a stem cell treatment or a prp treatment which are the most commonly i would say those are the ones that people are the most familiar with there's a sense out there that these are treatments that are reserved when they've exhausted a traditional rehabilitation pathway they've gone to their physical therapist they've gone to somebody in an orthopedic setting they've tried rest they tried all of these they were the rice method right which is now another acronym which we won't kind of get into they've tried all of these different ways of getting back in the game and they have all failed to a certain point and so then they make the leap hey i'm going to get a prp injection or hey i'm going to use some sort of stem cell treatment is that the way that athletes

should be looking at it or should some of these uh should some of these regenerative therapies be more in the chronological order of like the traditional treatment options that athletes look at yeah definitely i'm actually i'm actually i'll jump on that because i'm writing an article about that right now because we get that a lot and you know so so what i'd say is for athletes this is this is kind of the traditional approach rest ice and sets physical therapy maybe some dry needling you know that's stage one if that doesn't work then you get a steroid shot and or hyaluronic acid depending on the issue that's sort of like stage two and then stage three is surgery and that's right those are your options right that's you go to any orthopedist you go to any traditional sports medicine person that's their menu of treatment options in my mind um ozone should be in that you know rest ice ozone elevation um prp if if anybody who's ordered who's who's offered a steroid shot should at least consider prp because prp if it's done right um you know and step in if you think i'm you know um prp if you're offered a steroid shot if your practitioner doesn't do prp or they tell you oh there's no evidence it's not going to work like just think about it in the back of your mind because they're probably most people just aren't familiar and a lot of the people who are doing prp

um are doing it as kind of a bait and switch you know they offer it because they know there's demand but they don't really believe in it do you know what i mean yeah and they're like they'll have it on their website and you know they they don't have sort of the experience to say oh yeah this prp should should take care of this or no this is beyond prp or no you don't even need prp for this you can you can go to an you could go to ozone for that so it's ozone prp then then when you kind of fall in that trap of you know you're considering surgery because you're not getting better but surgery isn't like absolutely essential right so like you you snap your ac like i just tore my acl to you know i had surgery two months ago like you have a complete acl tear you need surgery right none of these therapies are good like when you need surgery you need it but rotator cuffs are good and elbows like you know tommy john surgery i think is it's obsolete regenerative therapy should completely replace that procedure um you know most meniscus surgeries probably not necessary uh you know partial or even high grade rotator cuff tears regenerative therapies you know those people who are stuck in you know they're beyond the steroid shot and they're like their surgeon's like yeah you know we can do surgery but let's wait you know let's wait a while and then they find themselves sitting there waiting six eight twelve weeks you know they get back into it and it you know what i mean and

it kind of twinges again whether it's an ankle or knee this is where those are the people that the regenerative the regenerative therapies could really move the needle for them to help avoid surgery and and that's you know alpha 2 macroglobin and the range of stem cell therapies so that's kind of how i think about it does that yeah absolutely absolutely so you meant you mentioned you mentioned therapy that hardly any of the listeners are going to be uh familiar with and that's ozone therapy can you can we just put a pin in the dialogue really quick and can you describe can you describe that i don't know if we're going to spend a lot of time on it but i want people to understand this as a treatment option do you want to go ahead um yeah so ozone is really just ozone gas and um it's not widely used or and most medical practitioners are not familiar with it at all most of the research and the literature comes from um soviet era and and russian experience it's it's also widely used in cuba and in italy so so most of the research and there's more uh coming out of spain now so there's you know there's people who are skeptical about this thing they hear that and they're like forget it but but ozone ozone does have you know good regenerative capacity and capabilities and we've used it in great success um systemically for you know issues that are not typically um you know injury or athlete related um but for viral illness for example um and uh so there's other systemic things like chronic lyme chronic fatigue

again things that kind of fall through the cracks that traditional medicine doesn't have a treatment for right ozone can help boost regenerative capacity that allows people to live a more normal life um ozone can also be used as a localized injection into a joint around a ligament or we've used it with great success in the neck and back so these are people who i started using it for people who came to us for stem cell therapy with their back but they're so bad that they're just hunched over they can barely move and you know going in with a needle directly into those inflamed areas could be you know i don't want to say you know make you worse but but it can be a really rough road so we would use ozone to try to calm kind of calm the flare down as a pre as you know sort of like the preamble to doing stem cells and a lot of those people just ended up getting so much better that they didn't even need stem cell therapy so again it depends on the physiology it depends on how your body responds to oxidative stress but it can be used locally and and it has been looked at for things like uh cartilage regeneration regeneration soft tissue regeneration in in ligaments and tendons so in my view it's it's the least potent you know you have some degenerative therapies you have prolotherapy i think is on sort of like that's the the entry level that then you have ozone and then you have prp as sort of the you know sort of the next more potent intervention and so there's certainly things that are beyond

ozone but it's it's it's way cheaper it's if it's done properly it's very safe and we've seen really you know like i said with our back pain people sometimes kind of remarkable results and you can deploy that in several different ways which i think is something if if if the listeners are unfamiliar with ozone therapy they're not going to be familiar with the ways that it can be used but even with people who have some sort of exposure to it they're not even aware of the different ways that they that ozone can do can can be utilized just run through them like really quick just to kind of like paint a really broad brush stroke with it sure i mean you can use it topically you know cold sores fungal skin infections um as an anti-aging as part of an anti-aging regimen um it can be used um as a shot like a you know getting um uh like an intramuscular shot of ozone to help boost your your systemic um uh regenerative capacities it can be used intravenously um and it can also be used as as a direct localized injection actually into joints or or into or around ligament soft tissue tears yeah almost like a steroidal injection at that point yeah exactly so you mentioned so you mentioned the sequence of events and this is all the the fact that i don't see this as much has always been really fascinating to me you mentioned the sequence of events that athletes normally go through in a

traditional setup where they go see their physical therapist and they go into an orthopedic setting physical therapy doesn't work then they're offered some sort of injection and then they're recommended to surgery right that's a very prototypical pathway why don't we see some of the therapy options that you two specialize in interjected into that timeline like what is prohibiting that from happening on a larger scale than we see it now i mean i i almost i view it as almost non-existent like i have to introduce that to my athletes along logical time courses when i feel that they are and i'm not an expert in it and it's always been kind of flabbergasting to me that there's that there's not more of that out there that will go through that pathway that you just kind of described so what what's prohibiting that i think that's multifactorial and and i'd say that there's two in my view there's two main issues one is that the early adopters were viewed as snake oil salesmen right right it often came from either you know chiropractors naturopathic doctors fringe traditional medical practitioners and so the establishment looks at that and automatically they get kind of they're like well that's those people we don't consider them real you know what i mean it's not part of the medical establishment yeah and so there's there's this sort of stigma that builds up it's like oh only these only these

wackos do that stuff right and then the early research that that these people and and so there are some pioneers who who really tried to establish the the data that you know evidence-based doctors want to see the problem is that they don't these doctors don't have the setup that you know the big universities have you know we've both worked in academic settings where you're meeting once a month discussing the research you're going over the you know your your your methodologies how you're going to set up the trial the inclusion criteria the statistics it's it's like a there's a plan that goes on with a team of people that these small practices like we just even our practice currently like we're involved in generating research but we do not have the power that a true academic institution has we just don't you know there's a you know people who are funded to be the statisticians to tell you well if you want to power your study properly you got to do this and you got to do that and and that's beyond most physicians expertise you need somebody who does that and so the the literature that was put out initially most people looked at and said well this is garbage this isn't this isn't real literature we we won't like look at this as true evidence because the studies are are not considered I done done ideally right so there's a stigma the early research isn't perfect and then in my view the third issue

is none of these therapies are patentable this how do you move the needle in medicine you need the kind of money that and backing that um will not get into something to to support something that they aren't looking to recoup with patent protection so you will in my view and we've talked about this a lot you will see these therapies be rolled out when there's a proprietary cell line okay so that's what all the all the private industry is working on is they're trying to like you know particular cardiomyocyte progenitor stem cell none none of those avenues have really worked well as of yet because and so maybe there's a third prong is that there's a fundamental misunderstanding about how these therapies work because they've dismissed it because they they think it's a joke they haven't really looked at the research and they think stem cells work in a way that they don't actually work and so that's that's the long answer i i really i really appreciate that because the athletes that are listening to this they will recognize a lot of that criticism and i think the the biggest arrow in the in the criticism is going to be well it's not research backed or it hasn't been validated compared to all of these other more traditional therapies have been looked at and extensively and so yeah sorry to interrupt you

but what i say there is what there's a fundamental misunderstanding from the general population and even physicians themselves about okay what is evidence-based what is back so like take steroid injections it's never been fda approved for many of the indications that it's considered to be a standard of care therapy for it's just something that we all were taught to do through medical school and residency and so that's kind of like that's what we do but if you actually like try to go back and look at look at research for steroid injections like there there are a lot of things that we do okay here's another great example um you know acl repair like i just like i just had my acl redone i'm sure a lot of people out there have had that done go look for any fda approval process or randomized double blinded placebo controlled trials for acl grafts there's some stuff out there right but it's just the standard of care right and there there are many many things including down to things that happen all the time for example you have a urinary tract infection your doctor puts you on five days of of antibiotics that there's no you know versus seven versus two weeks versus five a lot of that's based on the original penicillin studies that were done you know in the 40s with pneumonia right right which is you

know you mentioned that to people and it's not okay there has been other research since then but a lot of these knee-jerk like oh you've got pneumonia you need 10 days of antibiotics that is literally um sort of a knee-jerk reaction that has been passed down from physician to physician to physician to physician that's not evidence-based that doesn't have any fda approval or you know approval otherwise and and a lot of these particularly a lot of medical recommendations are done by consensus right do you see what i'm saying so so traditional medicine loves to point the finger and says well that's not evidence-based but they don't like to look at the things that they do that are really just consensus-based and it's just a pattern of habit and we're trained we're trained to be skeptical in things that we're we're not like new things that we're not familiar with but people don't look at what they do the same way they that they've been taught to do the same way they look at new things and if i could just add like that's not a trivial point that that boss just made the way that we do things in traditional medicine each time we do it it becomes easier and it becomes easier to pass on to the next generation of doctors and the steroid injections that that boss alluded to that i'm sure your audience is familiar with and they've gotten them in the past and probably have scheduled appointments for more steroid injections that that's really not a trivial i mean that happens all the time it's been

shown to not only um not do anything in the long run steroid injections they've been proven to be harmful right but yet how often do people get their shoulders injected with steroids i had a patient in the er whose shoulder she was elderly uh multiple dislocations would come out of socket routinely and it was because she had so many steroids injected into her shoulder over the years that had become very lax and and easily dislocated another good example is meniscus repair a lot of your audience have probably had a meniscectomy where they go in and shave off a piece of the meniscus in the knee to in theory alleviate the pain that's been studied up and down and and in one of the studies they compared it to a placebo a sham procedure where patients went in got admitted to the hospital half of them got a sham procedure uh incisions and everything i know and the other half underwent meniscectomies and they followed those individuals i believe it was two years or five years and there was no difference in outcome in terms of pain or what have you and but that's just the way things have always been done people still do meniscectomies it's one of the most common knee procedures in the u.s um so to to boss's point where and we're not by the way before we're not here to to not traditional medicine both boss and i are steeped in that world we still work in the er we are from from that world we we come to this with these opinions not as boss alluded to as outsiders as

chiropractors chiropractors or or naturopaths or what have you we're medical doctors both of us mds u.s trained we still practice in that world we're we're discussing limitations within quote-unquote traditional medicine as practitioners within that world not necessarily as outsiders and we're telling you there's limitations there if you have a knee replacement it's not a permanent solution there's there's a life to that prosthetic that just went in if you have some sort of other surgery uh if you're an athlete especially there's pros and cons to it and um and there's certainly a role for surgery there's definitely a role for physical therapy um but i i think it i think the the audience and anybody should go into that with the same degree of um of of um skepticism skepticism is a great word yeah skepticism as as they would view some of the some of the treatment modalities that voss has been discussing stem cells prp ozone etc okay so let's go over the treatment modalities and i really i really appreciate that point of clarification that you guys are coming from this having first been and still medical doctors traditionally trained u.s trained medical doctors who also practice this these types of these types of therapies i'm going to kind of turn the floor over to you to determine the sequence of of types of therapies that we talk about because you know them better and i think that you know which

ones are going to be more readily identifiable or kind of more heavy hitters in an endurance perspective but what i want to try to illuminate is really three facets the first of which is just describe how and why the therapy works and what it actually like looks like because a lot of people hear these words get thrown around and they don't know whether they're going to get an injection or a topical or a pill or whatever i mean they don't even know the route of administration right that's the first thing second thing and i think which would be interesting for the listeners to hear is what is the state of the research you guys alluded to it earlier and you know it the best what what does that look like within that therapy and the third one is and you can lump this actually into the like the first part if you want to lead with it is what are the common athletic scenarios that you see come into your door where you look at and you go yeah this person is a good candidate for this type of this type of procedure so what do you what do you guys want to start out with you want to like paper rock scissors for it or you know where you want to go i mean so you want the range of therapies um i just want to make sure i don't miss anything yeah yeah yeah three is you know the common scenarios and what i would add to the common scenarios are scenarios that people aren't even aware of like the uncommon scenarios which are actually should be common scenarios where these things could be used and are not okay let's change that to the effective scenarios then as opposed to common ones what you guys think would

be the most effective scenarios but let's just do one by one and like i said if we get through one of these we start to talk about this for three hours that's totally fine we can bring you back on that's version right so we talked about ozone we talked about prp we talked a little bit about alpha 2 macroglobulin and then and then we get into the range of stem cell therapies and stem cell therapy is not just one thing there's there's a wide range of stem cell therapies bone marrow is sort of the one you know that's been around the longest it's also in my opinion the least potent one of the least potent then you have allergenics which are stem cells which have been harvested from somebody else's body usually from some form of um you know placental tissue it's not embryonic tissue it's placental tissue these are people who know they're donating their placentas the amniotic fluid and the umbilical cords for harvesting of stem cells the same way you know cadavers you know like acl grafts are taken from cadavers or people will donate an organ to be used by somebody else so their stem cells that are somebody else's stem cells that are available to be used there's adipose which is your own fat which can be processed for stem cells and is in my opinion way more potent than bone marrow um and there's you know good good research backing for that um and then you have um banking of your own stem cells you can bank either your own bone marrow or your own fat um the benefit to that one is is at least

currently you can culture expand those um which is where one of the limitations one of the big limitations of bone marrow why why that is often unsuccessful for people and then they get frustrated because they spent a lot of money and they didn't get the result they want but that kind of anyway we can get into why you know people who are doing that shouldn't be doing bone marrow on those people but it's because they don't they don't they don't have experience with these other ones yeah um then then there's exosome therapy and exosome therapy isn't what i would consider we call it a stem cell therapy just so people kind of have a familiarity with it but the the exosome is is how your stem cells heal the damaged tissue and this gets into the fundamental misunderstanding that most doctors have of how stem cells work i would even say the most well-known practitioners in the stem cell field continue to propagate myths about how stem cells work and none of this is new this research has been done you know five six years ago so whether they continue to propagate it because that's just kind of the common understanding and they don't want to try to you know because when you tell people no they don't actually you know that stem cell i put in there isn't turning into new ligament or new cartilage that's kind of a hard thing for people to understand but the stem cells affect healing through exosomal communication and so now you can actually grow stem cells in culture and just harvest the business end of the stem cell the part of the stem cell that's actually

causing the healing and concentrate that and give that as a localized injection or systemic infusion and so that's the range of therapies okay so we're going to first talk about stem cells and before we get into the weeds too much and into where those different stem cells are coming from and that's what you're alluding to you can take it from the bone marrow you take it from the adipose tissue and all these different sites we're gonna we're going to have to describe and i'm going back to my undergraduate genetics days right now we are going to have to describe why stem cells can be used in a treatment setting like what like fundamentally 101 you go back to you know college days and things like that sure how would you describe that to a patient come in what is this what like what is the stem cell and what is it going to do in an injury setting yeah um who wants to play professor well you know well actually i i had i i wasn't planning on doing this but um this is much there's a way to do this can i share my screen oh go ahead yeah there's going to be let me let me let me find my so i gave a pre well we gave a presentation for um brain injury um because we have a research study going for for brain injury that that we're actively early patients in and um you know we were invited to a conference and we presented our data and and we you know for the first time really forced ourselves to okay say

like listen most people don't understand how stem cells work let's let's try to make it as simple as possible so i have a presentation that that answers that question and i'm gonna i'm gonna find it here and then try to screen share um so while while you're queuing this up i'll queue the listeners up a little bit uh there'll be a youtube version of this where you can actually go and like visually see the presentation if you want to skip on over there but for the podcast listeners which are going to be the majority of the listeners i think between you and i we will do our best to audibly describe what is visually going on which is always a challenge but we'll let me share my screen now so this is how most people including doctors who do stem cell therapy think stem cell therapy works is you have a stem cell and you put it into an area of injury and and it will turn into and replace the dan so chondrocytes type of bone these can you know can turn into soft tissues like tenocytes tendon cells cartilage cells and so most people think okay you take stem cells and you put it in a knee there's cartilage damage there the stem cells turn into new cartilage and that's the narrative that's been told to everybody by even the most famous stem cell doctors but this is not how they work okay stem cells aren't healing tissue that way that's not how they work really in your body they they have the ability to turn into new tissue but that's not actually what they're doing when they're healing tissue damage that's really important by the way because if you have a very rudimentary genetics

background the the 30 000 foot view of stem cell therapy is just that you put in stem cells and they can turn into anything and that's not the case this is why so so the applications for this therapy go well beyond far far beyond what most people are used to thinking about these therapies for which are for injury right because what stem cells do is is they seek out cell dysfunction and and and they help heal that tissue in a way that enables that tissue those cells in that damaged area to divide and heal the injury themselves so so how does you know most people are thinking about okay you have damaged cells cells divide and by cell division you you can you can replenish an area of damage and so what stem cells do is they help facilitate that process and the question is how um so this is where we get into okay how do stem cells actually work so stem cells live all over your body they're in your bone marrow but most of your stem cells are actually in your peripheral tissue so this is this this is a study you can pull this up online if you want to this is just showing that this red cell this is a capillary bed arterial branching into capillaries that's what this green tissue is this red cell is is is what we call pericyte p-e-r-i-cite not parasite pericyte as in it hangs around the blood vessels and they're in all the tissues of your body brain heart skin you name it you have parasites there these are stem cells these are mesenchymal stem cells

you can actually see this one has tendrils that kind of wrap around the blood vessel like an octopus and what it does is it dangles little thermometers into the blood vessels looking for markers of inflammation which are basically markers of injury um when they sense uh an area of injury they move into the blood vessel use the blood vessel like a road get to the site of injury and help help affect the change that's necessary for healing and so they're like the foreman in the cleanup and repair process of your body that's what your stem cells do um this is what it looks like in kind of a cartoon like picture blood vessel um mesenchymal stem cells or pericytes hanging out on the blood vessels waiting for your body signal of of an injury and that could be an acute injury like a tear or a break or that could be wear and tear injury like grinding down of cartilage it's they all all these processes work the same way i'm going to show you in in live tissue what this looks like so this is canine tissue this is skin this is a poor dog that has been poked by a needle this is a blood vessel and if you watch this you're going to see what happens is that stem cells are migrating out of the blood vessel so so there's one here there's another they highlight some of them but there's others there's another one here there's another one here there's another one here another one here another one here so there are dozens and dozens and dozens of these parasites that respond to a single pinprick

right right and what they do is they migrate into this area and they help affect the healing process in a way that enables your body to heal that injury now we're looking at a pinprick here under microscope but this works the same for all any type of injury um we got this from um one of our mentors who's at ucla and dr voss let me let me stop you really quick so what's what's on your screen right now the podcast listeners uh are not going to be able to to see i'm just going to visually describe it a little bit so what it's showing is is under a microscope um an area of skin with a blood vessel underneath it which is a capillary and stem cells migrating in mass into the area of where this pinprick is that's what i wanted to get out of it is they're leaving the blood vessel to go to the injured site yes they're responding to chemical signals from that injury itself that's what i wanted to get out as well as why why are they leaving the blood vessels you get to the injury you get acute inflammation the acute inflammation is sort of the call for help the stem cells the pericytes that live within the air the area that can hear that call for help use the blood vessels to migrate into that area so that they can initiate the healing process got it and it's a chemical the hearing is a chemical signal yeah it's a it's a protein cytokine interleukin uh chemical it's like a localized hormonal signal

okay perfect that's a great description of it thank you very much and so this is anytime you injure your body this is how your body heals okay now how do they do that so now i'm going into kind of a cartoon version of i'm going to move where where we are on the screen um so you can see this so this is the cells living the pericytes living on on the um blood vessels you have a cell that's damaged whether that's cartilage that's been ground down because you're running or whether it's a a tenocyte or a tendon cell that's sending out markers of inflammation from a partial tear or complete tear whatever the injury is those cells send out a distress signal those tendrils that the stem cells have dropped into the circuit circulatory system here are looking for those markers of inflammation when they sense them they transmigrate into the blood vessel through the blood vessel to the site of injury okay once they're at the site of injury they do an assessment of the damage once that once they've done that assessment they there are a couple of different pathways that that could then you know there are a number of different things that could happen but what happens in the healing process is the stem cell sees what this cell needs to help affect the most reasonable and quick healing response and and what it does is it gives that to this cell specifically by releasing exosomes

which give the cell what it needs to help heal more effectively so it's an amplification process yes and and so so what what happens is when when cells are damaged um we we could get really deep in the weeds here but i'm trying to keep it simple please do because you're going to blow my brain if you get any further and so so so when you get you know let's try to make a take a simple example you know you you know car drives through a wall okay um there's some bricks you're going to be able to salvage there's you're gonna you're probably going to need some new material you might need some new brick you might need some mortar some concrete you might need some extra workmen to help you know build a scaffold and move this stuff around but the stem cell is the one that helps navigate this process for the damaged tissue once it once a cell is damaged its ability to divide is often impaired and therefore healing is often impaired some of those cells think that they're not able to divide as much as as they shorter could and there's a safety mechanism in there um because once their cell is damaged it's like ah you know i'm damaged i don't want to go on to become disease maybe i just need to apoptose and like just i need to die and and be done with it but you know but the reality is a lot of those cells are actually healthy and they could continue to divide to heal to heal the damaged area the stem

cell sort of gives the permission to this cell says no you know what you're not cancer you're not disease you're fine you it sort of it's like the magic wand it grants them the ability to divide beyond the ability that that cell thought it could so then what happens so you get it you get an assessment by the stem cell you get exosomal communication exosomes work the same way neurotransmitters work across the synapse one cell releases a chemical signal the other cell senses it and the other cell takes action based on what that communication was so exosomes are really how stem cells talk to damaged cells those cells those cells then with the exosomal communication go on to divide in a way that can repair the damage this stem cell when it's done with this job will go back to the blood vessel to wait for the next area of damage so that's how stem cells work so is the way to think about this that the stem cells are facilitating healthy cell growth and healthy cell division versus they just become exactly healthy cells because that's the that's the that's the narrative that has been put out there in the stem cell world and it's completely wrong and the research been there for years but people just i don't know why they keep propagating this stuff and it's either because they haven't read the

research that they should have read meaning they don't really know what they're doing which i think is unfortunately the case for a lot of people who do this um because they they just take the narrative that makes sense to them but they haven't read the research i mean this has been done you know it's it's literally half a decade ago that this has been clearly demonstrated in the literature well i think it's just an easier it's just an easier narrative to say oh well this type of cell can become anything right i mean it's almost like a disney story right you could become anything you want because it's not because it's not defined yet then to understand the process that you just described of which there's going to be some listeners out there that still are not like connecting it and that's fine you know and what i'd say is this is this is exactly what you know why are doctors skeptical you know we're all skeptical to new things different things this is not the paradigm that and so i think some of the people that are propagating this sort of myth of how stem cells work might be doing it because they're like you know what trying to explain this to people is just going to confuse more people and it's too complicated and so we're going to stick with the narrative that that's simple and that's more easily understood but i feel like they're doing a disservice because these therapies can be used to help other dysregulated cells in almost any system whether that's the immune system whether that's

the neurologic system you know so there's implications for autoimmune disease anyway you know so like i said we could go down the rabbit hole yep okay that's how that's how stem cells work okay so we've got this mechanism of action that we've kind of kind of painted the second step in this and i i think this is this is going to be really important for the listeners and i'm sure you've gone through it a gazillion times can you give an overview of what the state of the research is in terms of athletic outcomes we can go down all different paths on health outcomes and things like that but we've got an athletic audience they're going to want to know is stem cell treatment right for me because of this dysfunction or this dysfunction or this injury what does the research actually say about it at the moment in time that we're recording this which is january 15th 2021 yeah um here's here's what i would say i would say that stem cell therapy can be an effective treatment for many many many different problems the problem comes in is that when you have a paucity of literature so so what does the literature do it gives the physicians a playbook it's like a recipe you know oh you you have partial acl tear you know you might be able to rehabilitate with conservative measures and avoid surgery you have complete acl tear you need surgery it gives them a cookbook for what to do

with particular problems when there's a lack of research what what you have and and you know i would argue that yeah are are there many areas that need more research for stem cell therapy yeah absolutely i would never you know i would agree with that but then what you have to rely on is the clinical judgment of the person using the therapy and their experience with it and this is true not just with stem cell therapy but with everything from your regular doctor to your sports medicine doc to orthopedist and so um there's good literature for knees there's good literature for shoulders there's good literature for elbows because those those have been the most commonly studied areas and good literature in terms of like patient outcomes or if they've compared it to a traditional you know a traditional surgical type of outcome because that's what i want to get into is like okay we know we know we can do surgery we know we can do this we know we can do that when we compare it to this alternative treatment yeah what is it what is it what does that research actually tell us yeah so so there's not enough of that but what does exist has some pretty i think important um things to to keep in mind most of these injections most of the research has been on prp because that's kind of the easiest the most the people are more familiar with it compared to steroid injections and there and i would say the

results are mixed there are some studies that show no benefit there are some studies that show benefit and so this is where the doctors who who haven't really taken the time to look at it say there's not enough research it's unproven the reality is that there are many different types of prp right and most of the literature hasn't really delineated a clear definition on what pr what the prp is that they're using and so it's a little bit like doing a study of comparing steroids to to an antibiotic where you haven't specified are you using azithromycin or are you using amoxicillin or are you using something totally different you're using aminoglycoside you know so there's some antibiotics work great in some situations and some don't and the the research on prp is such that because the definition has has been so vague and has been so um not uniform let's stick to stem cells right now like you we're going to move into prp a little bit but like let's focus on the research that's that is very specific to to stem cells and just as a just as a note for you guys and also for the listeners in the show notes will be any literature that i can find and also any literature that you can send over my way after we finish recording so if they want to access this they're more than free to go and do their own

research and you'd be surprised after i release these things sometimes i get requests left right and center for this kind of stuff so let's stick to the stem cell side and and try to kind of like encapsulate what the what the research current the picture that the research currently so most most of the research in stem cells comes from bone marrow and adipose derived stem cell therapies most of it's in knees there's other stuff um and and stem cell therapy for moderate moderate osteoarthritis you know i think should be a standard of care you know consideration it's not that it's right for everybody but there's good literature to support that um there's a lot of application now there there's a lot of applications where um that haven't been studied that well and so and this is where people are like well you know i've you know there's some shoulder osteoarthritis there's good literature for rotator cuff injuries in stem cells um and what's what is what is lacking is comparing the different types of stem cell therapy within the range of these you know like okay so we're talking about knee osteoarthritis and bone marrow but remember what i said is bone marrow is the least potent in my opinion of you know allergenic bone marrow are about on the same lines in terms of potency so just because you know there are some studies that show that bone marrow isn't effective for

severe osteoarthritis doesn't mean that adipose isn't now there's there's a we we're part of a group that has a huge database for adipose derived stem cell therapy that has very good results but that's not blinded and and so therefore it's it's not ideal and this gets back to what we said originally is like listen we have clinics like ours trying to build a body of literature but what you really need are the big dogs to get in there and and sort out all these details well i think so let's let's put a pin in that really quick yeah one of the things that is underappreciated when we're talking about the research in this specific area is how hard it is to sham control a trial you touched on it really briefly earlier you have to create the incisions and do everything that you would normally do except the actual procedure that's not easy that's not like a caffeine placebo controlled trial where you just give them a sugar pill it's way more invasive and technical in nature and because of that the research lags a lot in terms of the total volume of trials and literature and research that can get produced well and and i can't i can't underscore enough the importance of the patent issue because people aren't going to and and trust me we've we've tried to secure funding for for studies

like that and it's it's i don't want to say it's impossible it's very very difficult even from you know the places where you know government funded nih darpa barter you know you know the idea is that okay if it's not you know patent related that should be that should be industry you know private private industry is doing that research but the reality is you know universities are just as hooked into that process looking for patent right right and and and it was you know they it didn't used to be that way that changed about 20 years ago that universities were able to capture revenue on patents that they helped to develop and the and i think that was you know there's good argument for why that should happen because it used to be the universities and these this public funding would do all the the fund foundational even up the you know the the first story of research and then industry would come in and take all the profit and they're like this isn't this isn't fair so we should have you know part we should have you know we should get a piece of that pie but what it's done is it's shifted everybody's focus away from just general science basic research for the sake of doing it toward the patent right okay let's let's let's get back to our pathway here so we've got this mechanism of action for stem cells you went over some of the research and the general conclusion to that is is that you feel that it should be in line with the

current standard of care one piece on the research that i want to visit that before we get on to like who are the candidates who should be looking at this type of therapy is is there any research to indicate that this type of therapy is contraindicated in any scenario yeah great great point um yeah there there always for any therapy there's nothing that's no risk right there's always risks involved with therapy the big risk that everybody you know and traditional people talk about is cancer risk you're taking a stem cell out of the body you're mucking around with it in a centrifuge whatever whatever you do and then you put it back in the body how do you know it's not going to turn into cancer fortunately for us that question has been answered so hernigue who's you know there are a lot of people who claim that they founded this type of therapy it was a french orthopedic surgeon who started doing this in the 80s with bone marrow he published his 30-year prospective trial on all the patients that he's done with bone marrow concentrate which is basically with bone marrow stem cells and he's got three or four thousand people in in that um in that group and they compared them to and again so it's not blinded yep but he compared it to the french population the people who got stem cells actually had a lower incidence of incidence of cancer compared to age and condition matched french population so and there's a lot of people didn't understand that and and he he doesn't make any claims that

it's cancer preventative that's not what i'm trying to say right but when you look at how stem cells work they find dysfunctional cells and either put the ones that are bad they pull them out of the system but the healthy ones they enable them to do more and so there's an argument that they might you know we can't make this statement based on the current literature but stem cells help your body heal it's possible that they could also be helping pulling bad players out out of the system that's not the only study that shows that there's we've got um good adipose derived stem cell data for that that's korean data that's almost a decade old the database we have is and that we contribute to is over 15 000 patients over seven years and has not shown uh an increase um incidence of cancer in the patients who have received adipose derived stem cell therapy so what i i personally feel like that that question is maybe not put to bed completely but it's it's about as put to bed as you can get like how much how much longer than you know 30 years of bone marrow data and about a decade of adipose data do you need to feel comfortable okay that data also shows that these therapies are safer in terms of infection risk and and other injury risk to similar type of uh of therapies so for example steroid shot

and it makes sense you get more infections with a steroid shot because it's an immunosuppressant right you get fewer infections and there are studies that have actually looked at surgical patients who gone standard of care surgery and standard of care surgery plus stem cells and you have fewer complications fewer infections so the broad answer is it's one of the safest medical procedures out there okay based on the literature as it currently exists all right i i would have been i i'm sure i would have gotten hammered in the comments if i didn't ask that question so that's why i threw it out there for you um okay let's move on to the third prong right these are the these are the people that are good that are good candidates for this and um just to i think this is this is going to be relevant in this answer i think the next thing we want to cover in this same type of sequence is prp you guys okay with that just from a familiar yeah yeah it's just my computers i need to plug it in it's running out no worries you know it's it's the same story people don't know the literature they haven't taken their time to look at it and there are no drug drugs hawking it to them yeah yeah yeah and so you know when you get somebody who says well there isn't enough research um that's sort of a doctor's you know and and they maybe they've looked at what they think is the body of research and to the in their opinion they believe that it's not adequate but um doctors have a hard time saying i don't know yeah yeah i'm not sure i have a hard time saying i don't know

doctors like we want to have an answer for people and and it's very easy to say there isn't enough research yeah when when you know what what you should consider what they're saying to you is i don't know yeah i don't know if it's actually a good option for you and unfortunately a lot of these therapies have been employed so for example somebody comes in and they're beyond prp they really need maybe they're even beyond stem cells they actually really do need surgery but the person doesn't have the experience enough to say the only the only regenerative procedure that they do is prp or bone marrow right or if they if you're only doing one and you're applying it in the wrong place it's not going to work yeah okay so let's get let's get back to this yeah the people that are candidates for stem for a stem cell treatment people injuries you got somebody coming in what like what what are you what are what presentation are you looking for that will tell you this person is a good candidate for this type of treatment sure no no sure um so one of the points that that voss had made earlier is is this the pericytes migrating to the site of injury once it arrives to the site of injury injury i'm sure some of those cells may change into the type of tissue that you want it to change into but that's a vast minority a lot of times what it's doing is recruiting other cells to that same

area um you know voss made the analogy of the car that went through the wall and and then you know you have a foreman sort of putting the team together and materials together to try to rebuild some rendition of that wall that wall that is remade is not going to be a perfect replica of what was destroyed uh but it's going to be as close as as possible so what you want to do from a biological standpoint if you're the injured party um is is to try to maximize the um the environment for that repair to occur and this is probably not going to be a huge problem for some of your your audience or it might be but some of the things that you want to avoid is metabolic derangements that are going to counteract the repair process so what am i talking about well one of the most common things in the u.s are or is metabolic syndrome or pre-diabetes or diabetes you know the person not taking care of their health um and and there being uh a a surplus of what are called senescent cells these are cells that are not quite dead but they're damaged and they're not contributing in a favorable way to the to the to that particular environment so say we're repairing the knee for example but you know at the same time the individual is a diabetic maybe they have some other medical issues that are and they're on a bunch of medications that are counteracting some of some of the repair some of the repair process but they've got to be

healthy is what you're getting at right they've got to be a healthy person in order to take advantage of the treatment yeah especially for example if you're doing you know if you're doing a knee procedure on somebody meanwhile the individual is vastly overweight they're weighing 300 400 pounds it's probably not going to do where they're not going to do well right they're not going to do well but in the case of your audience they may not be overweight but they might be itching to get back into the game right and so we have some patients that are that are uh a little stir crazy especially in the covid environment they want to get back out there and do their ultra marathon or what have you and you have to kind of uh discourage them from getting back and training hard too quickly post-procedure um but let's let's like you're skipping to the post-procedure like when they initially come in we yeah we're going to rule out like there's nobody listening to this podcast it's three or four hundred pounds and if there is like we'll there's they're very few and far in between they're ultra marathon runners to the analogy that that boss made is is if there's too much there so in the case of a knee for example you've got a complete acl there boss is talking about um his acl there and how he required repair so if you've got excessive damage to that area where there's a complete through and through acl tear and on top of that maybe some time has passed you kind of try to top it out as much as possible the more that injured tissue is unused the more it atropies and so the ends of the damage acl may start to actually pull apart because of atrophy the the ends of that tendon may pull apart

because of lack of use if that makes sense so that would be a scenario where you don't want to use stem cell because it has a low probability of of repair and that that individual might be more of a surgical candidate rather than a stem cell candidate does that yeah so what so what i'm hearing is is they have to kind of almost be in the middle of the bell curve of the damage in order for this treatment to be particularly effective and so are you determining that with imaging exactly we have a lot of our patients undergo in fact everybody that i see if if i suspect some sort of a soft tissue injury whether it's a meniscal tear acl tear um a shoulder injury a rotator cuff injury a label tear i have them undergo an mri we take a look at the mri images together and assess the extent of the injury and again stem cell like any other therapy right you have a probability of something working really well probability of a therapeutic intervention not working so well the the chances of stem cells working working well to repair an injury diminishes the the longer that's that's gone on since since the time of injury because of that atrophy effect and uh and also if it's a complete through and through tear so it works well if it's a partial tear partial label tear partial acl tear partial meniscal tear rather than a complete tear if it's if it's a relatively new injury instead of an injury that's years and years

old there's some caveats to that you know like with knee degeneration that's something that tends to be partial rather than complete it tends to occur over years rather than suddenly so there's always caveats but um if it's if it's not a complete tear and if a significant amount of time hasn't surpassed since the time of injury those individuals tend to be better candidates for for stem cells let me take a little bit of a leap on the on the presentation though of this because an athlete that's out there running around unless they have been through the scenario before they're not going to know whether they're on a low the low end of the damage spectrum a partial tear and something like an acl or a labrum or maybe they maybe they do know if there's a complete tear if they're kind of that aware but even in that case i mean you guys have seen the labral images right you you scanned a hundred you know a hundred runners out there every single one of them is going to have some degree of labral tear but what i'm hearing from you first and foremost is as i've mentioned or as i described earlier it's kind of a bell curve right they've got to be in the middle of that spectrum somewhere but the way that that might present for somebody who's unaware of like looking at imaging or anything like that is they would be moderately compromised in the type of activity that they are doing if they weren't running so much or weren't doing so much swimming or weren't doing so much of whatever endurance activity that they're doing we're talking about ultra runners here they might not notice that level of dysfunction but because of the level of activity and the intensity that they're doing that

activity and the expectations that they have that go along with that activity typically we perceive dysfunction in through a much more magnified lens that makes sense as opposed to what is actually is as opposed to what is actually there is that a reasonable description of that from a patient's point of view um i guess here's what i would say about my experience with ultra runners and and and you know endurance athletes in general we're endurance athletes are conditioned to to to pain okay endurance athletes are way more likely to run you know ultra runners are way more likely to run on a knee that's somebody else would say has 10 out of 10 pain and they'd say tell me about it kind of it kind of aches when i'm done with my you know kind of aches when i'm when i'm done with my whatever with my training and so um i don't know if that's i'm i'm contradicting what you said or no you're saying the exact same thing but but um but what i would say is if you want to avoid surgery and you want to avoid long-term disability don't ignore it don't because if you wait too long eventually what we're saying is your only option will end up being surgery and you don't want that to happen and this is a hard thing to do for people when they're like

man this these these therapies aren't covered by insurance and they could be really expensive but but here's here's what i would say to you and this is where i think traditional medicine is falling down on the ball here is that if you intervene early or midway in your degenerative process you can extend the life of your knees your low back your shoulders your elbows for years and these therapies if you're lucky might enable you to completely avoid replacement surgery or repair surgery or at a minimum what koshal was alluding to earlier once you replace i mean once you replace a knee forget it you're not your doctor's going to say you're done you're done running you're not doing an ultra again because they know if you do that that prosthesis is going to wear out in two years so so you want to get it before it's too big of a problem now the one caveat to this that i'll say is that this is where banking could be really really effective for your type of listener because banking your stem cells is expensive up front but what it does is it brings the cost of therapies after that initial banking procedure down into range that most people could can afford to do it you know not without blinking an eye but but have the budget to do it on you know um you know i would say like most you know upper middle class people can afford to bank and that's how being able to do these

therapies repetitively with your bank cells in a much more cost-effective fashion is how you stave off the long-term problems that that end careers and but we we don't want to come across as as it for this to come across as a sales pitch like it look if you and and i completely agree with boss the ultra marathon community especially so accustomed to pain that any other patient would describe their discomfort as 10 out of 10 as he said and we'd be like meh i keep going i'm only gonna do 28 miles instead of 30 miles this weekend and we're not saying like look come in for stem cell but i think they should get an mri if they feel some element of discomfort and they really have to get a little introspective and and and determine for themselves if that's real pain or not it does it's it's a really inexpensive thing to to get most insurance plans will cover it and even if they don't i think it's even out of out of pocket is fairly affordable get an mri whether you go to an orthopedist for surgery or to a regenerative specialist for stem cell or some other biological therapy they're going to probably want an mri it's very helpful and just for your own information it's very helpful to assess the extent of your damage just in case something changes five six years down the line at least you have a baseline to compare it to so so get an mri um and take a look and you can answer you know the therapeutic questions down the line so okay yeah i mean i don't i don't want to be hot yeah i don't want to come off

like but so the reason why i brought up repetitive injections is you know we're saying that okay you have grade four osteoarthritis you've which basically means like you've got no cartilage left you're bone on bone right most people would say you're you know you're beyond regenerative therapy you need a replacement um in people who are able to do repetitive stem cell injections in severe cases can see improvement in symptoms you're you're probably you're most likely never going to get a nice healthy cartilage bed again and you can stave off symptoms in that scenario but now you're just you're like putting your finger you know the dam is like is about to rupture and you're you're like you're trying to keep it together so you can eke out another year running before knee replacement start before you get there right is the point and if you start before if you start when you have moderate disease you your your ability to stave off the inevitable which is we're all going to end up if we live long enough with bone on bone joints and you know the joints we use most regularly particularly in ultra marathon you know hips and knees are gonna are gonna go first and low back and so start early um you can stave off the kind of medical intervention that prevents you from doing what you really love doing before we move off the stem cell uh topic what does that banking process

look like and how frequently are you getting the injections during the course of treatment yeah so banking it's it would you know you come in and we do a procedure where we harvest cells whether it's from your bone marrow or we preferentially would steer people to fat um there are some scenarios where bone marrow might be of benefit you know but that's anyway we you know we would harvest it we send it to the cell bank the cell bank then expands your cells and freezes them and holds them there for you and so you don't have to use them immediately most people do because they come in when there's a problem and in the course of you know discussing okay what are your options well if you're going to do stem cells you might as well add you know relatively nominal costs on top of that to bank because then the next time you have an issue you're it's going to be it brings it down in the range of almost a prp intervention to get your own stem cells right that those stem cells can be thawed and regrown so if you use up all you know usually we'll grow out like 70 million cells in seven you know so that's like seven doses 10 million of your own cells each dose when you get down to two they'll thaw a vial and grow more and so it's not it's not an infinite amount of cells eventually those cells will stop culturing but you've kind of bought you bought yourself years of intervention with your own stem cells and so how frequently are those are the interventions where you're re-injecting the stem cells that have been grown so that depends on the scenario so for

example say you came in with with a 90 you know rotator cuff tear one stem cell shot will probably make you better but probably isn't going to get you you know totally pain-free back to 100 percent now if you had 50 60 percent you know rotator cuff tear one p or p or stem cell shot depending on your physiologic you know body makeup will probably get you there 90 percent you might need two or three to get you where you want to be right and so for most people with without banking that's just totally cost prohibitive but you bank you can now address those higher grade injuries that sort of get on sort of the fringe of the bell curve you know so we're talking about okay there's this meat of the bell curve which are it's not too bad you catch it early you catch it right after it happened but you start getting farther out on the bell curve the farther out it doesn't mean that regenerative therapies aren't an option at all it might mean you need a series of injections so it depends on depends on the injury and then what i'd say is there's utility here for um just recovery in general so for example after i did my acl surgery i got 30 million in my own cells i just did them iv and i'm two months out and i'm i'm almost back to full activity where it normally takes somewhere between six and 12 months to get back to full activity so you know i didn't plan on that i

wouldn't you know i wouldn't have done a stem cell procedure after well actually i probably would have because i have easier access to it which all just does it for me and it's way cheaper because i do it for myself at cost right but but for most people they're like yeah i don't know i just had surgery like am i the expense of a stem cell procedure am i really going to add that on top of everything but once you're banked why not yeah do you see what i'm saying no i totally get i totally get and then and then there's and then there's a performance enhancement component to that too i'm so glad that you mentioned that because there's going to be somebody out there that says hey i've heard that you can use stem cells in it as an ergogenic aid well they'd be right because they help repair damage so you you go run 110 miles guess what you've done you've done a lot of damage and you can do it when you're 20 and bounce back in no time but when you're 40 you know it takes a little bit longer to bounce back from that and you know what i mean it's they're not used in this way because traditional stem cell therapy is so expensive most people wouldn't it's not in their realm of like oh i'm just going to go do a seven thousand dollar procedure six thousand dollar ten thousand dollar you know what i mean like right most people like i could know most people can't do that but you bank now for you know like around

around a grand you can just order up 10 million of your own cells and stick them in iv and let them go where they're going to go to help heal whatever you damaged i don't have literature for that but i have personal experience with that and i'll tell you you know i'm 47 and i'm a competitive athlete it helps me recover more quickly and it could there be a placebo component there yeah of course of course there could be um but i'll tell you we've done enough enough professional and high level athletes that um i believe it is my personal belief that it is a it is a performance enhancer and it's not a drug because it's your own cells but it helps you recover more quickly but there are yeah i don't want to get into the weeds too much on this but there are and it would be it would it would be unprofessional of me not to mention that although it is not considered a performance enhancing drug there are still wada considerations that athletes need to take into account if they're thinking about this i don't know is all is ultra running water is it in some very limited circumstances there will be some form of doping control at ultra marathon very very very limited but i always make the blanket statement just to cover my ass for somebody that's going to say oh you're encouraging athletes to do this or no and and what i'd say is like take for example i think actually bodybuilding has the right approach

here so we have clients who are bodybuilders um you know i'm talking like muscle you know men and women and and they have two categories they they they have an advanced category and a non-enhanced category and and if you want to compete and now are there people you know competing in the non-enhanced category who who are who shouldn't be you know that you know that's a whole nother issue but but like the nfl like they don't they want all their players on performance enhancers they don't test anybody yeah that's another whole deal but you know what i mean and so and so there's some sports where there's there's an ethical you know there's sort of like okay we're not usada sanction but there's an you know there's an ethical thing there that they they don't want to cross listen we have a lot of we have a lot of professional athletes who who are what a sanction and you know you know we're familiar with that and i'm not trying to encourage somebody to break the rules but even if you even if you're an athlete and you solder what a sanction events and you sustain an injury you can still use a regenerative therapy to help heal as long as it's done appropriate correct correct yeah you have to you have to dot your i's and cross your t's and so in you know i don't know what the ethos in ultra marathoning is in terms of like you know so for example a common one which is more common is like you know guys my age they start you know their testosterone's waning and it's like well do i start testosterone or not and then

if they're gonna be they're like well i don't want to be you know i don't be i don't want to be doping right even though they're not professionals they're just you know the rowing crew or they're running or you know what i mean they're they're doing something that isn't you know not when triathletes are usually you know they're sanctions so they're usually pretty tight and narrow and there's an ethos there that that they at least in my experience they really don't want to break the rules right um and so anyway we have experience with that and can help you navigate it if even if you have a question be like hey i was just injured but i gotta do this can i do whatever bp can i try peptide is that you know i'm glad we brushed on it because it is an emerging area of performance certainly but also with this culture of like biohacking that's going on right now it kind of gets lumped in it kind of gets lumped into that because it's cutting edge not to call you guys biohackers or anything like that because there's there's some stigma that's associated with it but i want to i want i definitely did want to brush on it because somebody out there would have said oh well this could be considered a performance enhancing drug and i think both you and i are really well aware of where those lines are i think it is like no question in my mind it helps you recover quicker what do most performance enhancers do yeah you know what i mean i will um so as another service to the listeners i will put the specific water rule in the show notes as well so they can once again go

ahead and uh go ahead and look it up it has to do with the total volume of injectable stuff substance that you're putting in i think it's 50 cc's right now they just changed the rules so i'm gonna have to go and refresh my yeah but they're they're easy to look up so it's anybody can go find it um okay anyway so we did this really big deep dive in stem cells i think we're gonna have to put a pin in it there because i know you guys have patience to go see yeah you have an open invitation to come back on this podcast at a future point in time and we'll nerd out on prp injections next because i think that's kind of like the next one of the heavy hitters there will you take will you take me up on that offer yeah okay so we'll schedule that off offline i knew this was going to happen i knew we were going to go down the rabbit hole i appreciate both of you guys's time on this i'm going to put links in the show notes to everything where they can find you where they can find your clinic but before we let you guys go you guys have any parting thoughts on where people can find you or where they can just learn more about these types of therapies yeah thanks for that by the way yeah thanks our website is rmrm.com and we have i mean the information constantly is getting renewed so i'm not sure what's up there i think we have information about stem cells and prp covid covid's up there now i'm sure and our emails are there if you've got any questions feel free to write to us cool all right thanks you

guys i really appreciate you guys time yeah thank you and there you have it folks there you go much thanks to drs bosch and koshal for coming on the podcast today really appreciate your insights and this is just an area that i cannot emphasize it's just really fascinating to me and also one i can't quite figure out i've had athletes that have that have had different types of regenerative therapies and some of them have had absolutely great outcomes even despite them going through a traditional orthopedic setting and not really being able to put a finger on what is actually causing their injury and i've had other athletes that have gone in for prp injections or stem cell therapy and really noticed no difference so it's an area that is once again really mystifying and something that i hope that we can shed a lot of light on in the future for those of you that are interested in dr voss's and koshal's practice links to that are in the show notes i also have links to the show notes for all the wada and usada compliant stuff that we mentioned throughout the podcast that's it for the for today folks appreciate the heck out of each and every one of you and we will see you out on the trails you