Allingham Blog

PRP

PRPIntroductionPlatelet rich plasma (PRP) is rapidly rising as a source of growth factors to help in many clinical situations. Only an absolute basic few principles are reviewed here.DisclaimersThe big disclaimer in this walk through of PRP today is that it is ultra minimal.There are distributors and scientific reviews that are much more comprehensive than this. But this should give you a good overview to start out on understanding a safe treatment option available to you instead of so many dangerous surgeries and dirty medicines for so many things.DiscussionPRP, platelet rich plasma from you, contains platelets. Platelets are little sacks of growth factors, similar to cells, but contain no nuclear material - - no nuclei at all.So if there is no nucleus in a platelet, it contains all of these growth factors, but doesn’t know exactly what to do with them. The platelet instinctively goes to areas of inflammation and wounds to help heal wounds and resolve inflammation.But it must get instructions there. Cells that are healthy locally can give it instructions. The wound has ailing cells that can give it instructions. And stem cells are probably the best “computers” in the body that can give platelets instructions.So I guess that’s one of the big take-home’s: PRP works best if there is an abundance of high-quality stem cells nearby. Conversely, PRP doesn’t work well if there’s not many stem cells. One situation in which there are not many stem cells is aging. As we age, our stem cell numbers and quality decreases. So the extrapolation is, you guessed it: PRP does not work well in the elderly.So, if an elderly person is considering PRP for its many indications, many of which are reviewed below (and I know that’s why you’re probably reading this) (so, we’re almost there!), then that elderly person might higher prioritize getting some stem cells on board first.Another situation where PRP won’t work by itself no matter how many times you try it (John Wall) is in the joint which is highly nonvascular, so often times doesn’t contain many stem cells. Such an athlete might consider getting stem cells first which will last in their body 30 months including deployments directly into a knee… And then administer some PRP if you want. But many scientific journals are pointing to the fact that all things like knees need is stem cells alone without the PRP. But that’s another subject.So I’ll repeat this first big principal and all its repercussions: PRP requires stem cells to work. PRP will work better in young people than elderly. PRP will work better in people who have received stem cells recently. PRP will work better in people who receive stem cells concurrently, although many argue that the stem cells alone would suffice in that setting. PRP won’t work in avascular areas where there are not many stem cells like joints.PRP is obtained using PRP kits provided by many distributors in the US and Canada. PRP is extracted from venous blood - - just a regular blood draw folks. So when we talk about giving you PRP, we are giving you back platelets we pulled out of you, same day, usually same hour.Different PRP kits very in quality, and I’m not saying it isn’t always high-quality and safe. It pretty much is. PRP kits vary in how much white cells that they contain as if it was a strength, and I’m not saying that it always isn’t. And PRP varies in platelet concentration. And PRP kits vary in terms of whether they are activated or not.A source of some confusion to the novice, PRP also varies in activated versus non-activated. This is a much more important distinction you must understand - - and it’s easy. Activated PRP (activated for their prime function to help a damaged area of tissue) means that the platelets have been exposed to calcium salts such as in an active wound where cells are exploding and dumping out calcium salts. If platelets are exposed to calcium, they start working, and quickly - - they start getting sticky, leading to the formation of a fibrin clot - - and that’s what a wound needs. The other thing that happens when the platelet start getting sticky and Jell-O like instead of free-flowing is that they stay around. That is, they don’t migrate off.So. Activation when it comes to PRP means formation of fiber matrix. So some people would rather not worry about that fiber matrix with the PRP they are using. And they use other scaffolding or matrix sources, some of them allogenic, a term that literally means from a non-homologous source, i.e., from someone else.Some clinical situations have enough inflammation and activity from cell death that the platelets will be activated when they get into the body part. In those situations, they don’t need to be activated. The body will activate them. What do you like it or not, that activated PRP will stick around in that area.In other clinical situations, there is no cell break down, and you want the PRP to stick around. So you have to activate that PRP before administering it. Usually exposing it to a calcium salt like calcium chloride or cost include gluconate activates the PRP. The PRP is deployed; the PRP sticks around that area.And yet other clinical situations, there is no cell break down and you DON’T want the PRP to stick around locally. You were interested it and it defusing a little further away. Growth factors to encourage hair regeneration require this.So two more big principles. 1. PRP should be activated to keep locally (not for hair) (not for the P shot) (not for the O shot). In all of the situations, you don’t want to keep the PRP local. You want it to spread to the surrounding tissues. 2. If there is inflammation, you will want the PRP to stick around. But the bar is inflammation will activate the PRP, so it doesn’t need to be activated.Whether or not to activate the PRP that’s about to be used as important because as soon as you activated before deployment, you have a ticking clock. The stuff thickens very quickly, and it makes it harder and harder to administer by the minute after activation has been done outside the body in those situations that require it.And there is another distinguishing feature of PRP types. You can have a high density concentration, or you can have a low density concentration of platelets. Depending on how the PRP is mixed. Not all that significant as far as I can tell. After all, when you get your blood drawn for your PRP, your quantity of platelets is going to vary day to day depending on so many factors. Luck of the draw really. Ha. Pun intended.Indications for PRPJoints, Tendons, LigamentsHair, Skin problemsSexual function, so for the Penis it’s the P shot. The O shot in womenInflamed joints, arthritis, the situations benefit from PRP. But many argue that when it comes to joints, all you really need is stem cells. I’m going defer discussion on this.Hair. You might think with no inflammation or active wound, we might want to activate the PRP before deployment. But, no. The PRP should not be activated and that’s so it can spread around. It will activate in the body soon enough. The deployment is extremely superficial, just a couple of millimeters. And it’s leading to great things. Again, stem cells will be required for the PRP to help a man or woman regenerate hair or prevent hair loss. So, strongly consider investing in stem cells first, then PRP second if you are trying to regenerate tissue is the alopecia arena.The P shot with PRP, done in conjunction with shockwave therapy, is dramatically helping erectile dysfunction, as well as Peyronie’s disease and other more rare indications. The P shot, which is actually several shots along the shaft and glans of the penis, in conjunction with an increase vascularity treated with shockwave therapy, is leading to maximizing penile function not only severely impaired men, but even in fairly normal men. The results have been spectacular. We are just beginning to see the safe care effects in this strong indication for PRP.The “O” shot with PRP, which is actually two shots, one to the Skinners gland, and one elsewhere (different discussion on that) is helping with dyspareunia and lichen sclerosis, two serious conditions which affect women’s sexual health. But it is also helping much more healthy women increase general pubis color (consistent with increasing blood vessels there), thus leading to increased sensitivity during intercourse. So... Exciting advances in both of these arenas, in the highly unfortunate clinically ill, as well as the nearly healthy trying to optimize or improve an already fairly healthy sexual system. PRP is truly helping a lot of couples.ConclusionSo we begin to see a general principle that recurs again and again in all considerations of regenerative medicine. It is that you need growth factors from things like PRP, and you need guiding computer-like agents - - things like stem cells, and you need a matrix or scaffolding on which regeneration (some still call it healing, but that’s probably not entirely correct) can occur.PRP, so rich in platelets required for the traditional clotting of wounds, is going to be filled with growth factors. That’s really all they bring to the table. Pretty simple.And if you want your PRP growth factors to remain in the area of the deployment sustained for days instead of hours, you think of activating the PRP before deployment. If you in contrast prefer that the PRP defuse to the surrounding tissues for your particular application like hair maintenance and regeneration, you avoid pre-activation, so as to allow PRP to diffuse, and then the fiber matrix is created by the body later when it activates the PRP in a slower fashion allowing spread to more remote areas from the site of deployment.Stay well,David Allingham, MD

Shock Wave Therapy

Shock Wave TherapyIntroductionShock wave therapy (SWT) or therapeutic ultrasound therapy or acoustic energy transference therapy is reviewed briefly here.DisclaimersThis discussion is for educational purposes only. Please have all care administered by a well trained physician excited about doing a team approach with you the patient and them.Humble opinion is kept to a minimum, I promise. Some ranting and raving.DiscussionSWT has been around as a physical therapy modality for 20 years. Probably its most established indication is plantar fasciitis. Professional athletes in respected organizations like the NBA plagued by such have received SWT for such indications with great success for many many years.More and more uses have been found for it, and new uses are discovered every day. Anything with soft tissue damage may benefit from it. Clinicians try it, it works, and they continue doing so privately. Formal research funding for prospective research has been limited for two reasons. One, it’s completely safe. So there’s no danger to research in turns of lack of safety. Two, there is a lack of funding for research trials, largely coming from big Pharma, because big Pharma has no interest in it. There’s nothing they can patent, so they don’t invest a single dollar. Not only does it not help them, it is likely to hurt their markets if they accidentally prove that it works. So... They stay clear of it. Academic institutions like universities have pursued a great deal of peer reviewed studies that justify its worth fortunately. So we salute sports and health minded pro American institutions like Duke, the Ivy leagues, Texas, California, Virginia... Thanks to them, it’s here to stay.IndicationsPhysical therapy for all soft tissue damageErectile dysfunctionFemale incontinence syndromesFemale sexuality, increases sensitivity, increases pinkness, increases orgasmPlantar fasciitisCelluliteBody sculptingAfter other noninvasive body sculpting lipolysis techniquesAfter surgical liposuctionPost surgery (in general)Aesthetics (in general)Delayed granulomas following surgery, indicated or electiveSome of these indications, only a single 20-30 minute therapy is necessary to fully resolve the problem. In others, 10-20 such therapies may be required.Physiology, pathophysiologyEdema from damage tissue increases lymphatic drainage, driving up blood flow.Repeated use of SWT leads to collagen production and blood vessel production.So, SWT increases the vasculature of the area providing for this increased need.Tissue damage leads to traffic jams. SWT leads to increased roadway production.SWT works by bubble formation. That bubble bombardment stimulates angiogenesis, blood vessel production.So:Most if not all of these clinical indications mentioned above are nicely complemented by concurrent use of PRP, platelet rich plasma, as an adjunct to provide growth factors. Stem cells as an adjunct can augment PRPs ability to help SWT, especially if the patient is low in their supply, i.e., the elderly.ConclusionThese beneficial outcomes are consistent. You combine that with spectacular safety, and you find that SWT is a terrific therapy choice whenever there is some sort of soft tissue damage involved with the medical condition you are trying to treat.

 

Stay well,

David Allingham, MD

Electromagnetic Body Sculpting

Electromagnetic Body Sculpting

IntroductionElectromagnetic body sculpting is the latest modality for transferring energy into the subcutaneous fat to burn fat for the purpose of aesthetic body contouring.Pros and cons reviewed here.

DisclaimersHumble opinion for the purposes of learning here.The big disclaimer would be to discourage anyone from generating a body sculpting treatment plan without a physician.Also, make no attempt to achieve these results with anything you might buy at Brookstone or the like.And, as exciting as electromagnetic body sculpting is, as with any body sculpting treatment plan, dual therapy with multiple modalities is always encouraged. And proceeding in a team approach, you and your physician, always produces the best results. You must find a physician that favors a team approach to this health care.

DiscussionBody sculpting by transferring energy non-surgically to burn fat is taking off. We have many modalities that produce energy transfer lipolysis including laser, heat, cryo-, and ultrasound, as well as the not completely non-invasive needle administration of chemicals that burn fat. All of these produce lipolysis secondary to fat burning. But while all of these produce the desired effect in that all of these burn fat, all of them have their pros and cons. Similarly, electromagnetic body sculpting has its advantages and disadvantages.Electro magnetic energy is transferred in electromagnetic body sculpting. Fairly expensive machine, it surfaced for the first time publicly this year, after extensive trials showing great success and safety.How does it work? You first need to understand the concept of supramaximal muscle contraction. The average person is able to contract their belly muscles or gluteal muscles about 20%. Olympic athletes, maybe 30%. With supramaximal contractions, electromagnetic body contouring technology can contract your muscle 95%. Now we’re talking! And it does so without a relaxation phase, so there is not a build up in lactic acid. Fascinating is that we are talking about the voluntary muscles here. But electromagnetic body sculpting techniques in current use are also helping to eliminate some visceral smooth muscle. That’s a deep burn, I’ll tell you what.Patients who describe how they feel after therapy say it’s not unlike the best workout they ever had - - times four hours. But this takes 30 minutes folks! (and in truth it’s much more!). Kind of makes you wonder what the Olympics is going to say about it.So. A brief review of advantages and disadvantages in a bit of a heads up fashion against other body sculpting modalities that have been available to us for years.Advantages. Of course, completely non-invasive. With no consumables, by the way. And... It’s effects are impressive, so that’s a big advantage over some modalities that have not stood the test of time.But perhaps the biggest advantage over essentially all of the other treatment modalities to eliminate fat burning is that it also increases muscle mass. And not only does it increase muscle mass by hypertrophy (Swelling of the muscle cells without actually increasing number of muscle cells), it actually leads to brand new muscle cells. So actually new muscle fibers come forward following this therapy. Fat elimination, plus increasing muscle mass? By hypertrophy and hyperplasia both? Patients (and doctors) are thrilled. All of the other modalities wish they could claim this. This one finally can.Disadvantages are few fortunately. Certainly, you cannot increase certain muscle mass areas like the pecs in an aging man or woman. The heart muscle lives under there; the risk is too great.Also, this modality, like many of the modalities, produces heat generation. Heat generation In the subcutaneous tissue leads to inflammation. Inflammation leads to swelling, and this in turn leads to induration. Such induration can compromise motion. So there is some down time. Of all the fat burning body sculpting modalities, only nonthermal ultasound fat destruction can make the claim that it produces no heat generation. But you can’t have everything!And perhaps another maybe not so subtle disadvantage: it’s brand new. I’m not the kind of physician that bandwagons. At least never too quickly. Let’s see what exciting testimonials its first year out brings, sure. But… What’s going to happen long term? It will take a few more years to figure out.As in all of its other cousin modalities, it’s tolerance seems to be excellent. The body seems to handle the increased fat load heading to the liver with no remarkable abnormality seen in bloodwork in all of these body sculpting patients to date. It’s certainly an increased fatty acid load. But our bodies have been handling such in stride for years. It’s called weight loss. And our bodies know what’s good for them. To give you completely reassurance, those increased fatty acid loads are indeed headed to the liver, and not to some blood vessel to clot off. Fat loss this way is safe, folks.

ConclusionPerhaps the best studied modality for body sculpting lipolysis pre-roll out to date, electromagnetic body contouring is now available if you want fat burning with muscle building. Investigators included CT, MRI, and ultrasound imaging in their pre-and post treatment studies In there before and after pictures. Patient satisfaction was tremendously high. Tolerance is good. And other than being slightly expensive, it’s limits are minimal. It’s first year out this year, it seems to be doing well. And it shows a lot of promise for the future.

Stay well,DAVID ALLINGHAM, M.D.

Ultrasound in Body Sculpting - Lipolysis, But Also Angiogenesis

Ultrasound in Body Sculpting -Lipolysis, But Also AngiogenesisIntroductionThe health benefits of removing fat are widely known.Ultrasound as a modality to provide shockwave therapy using acoustics to eliminate tough to get at fat in the overweight and not particularly overweight is reviewed here.DisclosuresDon’t conduct any of these therapies on your own for yourself or your loved ones. Consult with a physician. A team approach with a physician who believes in a team approach, you and her, is the best approach.DiscussionNonsurgical body sculpting is here to stay.Results are exciting. But a 600% increase in body sculpting modalities in general in the past 20 years is only half the story. The really exciting thing is that slimmer and slimmer patients with excess fat finding it difficult to mobilize fat in certain body areas are joining in, and are super happy about the results they have seen from having entered into this care...Body contouring. By now, it is becoming more widely known that there are multiple nonsurgical, so non-invasive, energy transferring modalities that are being used to burn fat (lipolysis) in medical therapy generally known as body sculpting. Cryo-therapy is really gaining popularity. And laser therapy and heat therapy are also widely used. Electromagnetic therapy is also being used to impart an energy form into fat containing tissue to burn fat. It’s the newest kid on the block, and everybody’s waiting to see the pros and cons as it makes its debut this year.Slightly more invasive, needle therapy is also somewhat popular because it allows the physician to inject fat burning chemicals into very specific areas where lipolysis is desired. This therapy of course thus provides chemical burning. Obviously, there are a few downsides with needle therapy - pain, needles, chemical burning. In contrast, we can provide all of the other energy imparting body sculpting modalities noninvasively.Body sculpting is the term loosely used to describe destroying fat in areas where it has always been tough to destroy fat. These areas usually overlie muscle, so what is left is well-defined muscle, and the patients really dig it.In addition to cold, heat, and laser energy, there is yet another energy modality that can be transferred noninvasively to burn fat. And that’s acoustic energy; and it’s generated with ultrasound. Ultrasound at one range of settings is widely known for imaging techniques. Well, at other settings, it destroys fat. It also has been discovered to increase the vascularity in the tissues where it is applied, if the correct settings are used — but I’m getting ahead of myself. Fat burning properties of ultrasound or shock wave therapy first. In ultrasound therapy, acoustic waves are generated which are sent directly into the skin. Depending on the settings, scatter can be minimized or maximized, but depending on the effect you want to achieve, it is most safely exploited.If those waves produce bubbles of a certain size that cause a certain type of impact, blood vessel growth is stimulated and produced. At different settings, ultrasound acoustic, shockwave therapy actually destroy fat. So it brings both of those things to the table.And there’s another advantage to ultrasound. Unlike other modalities being used for non-surgical body sculpting, ultrasound produced fat destruction does not produce inflammation. With non-heat generating ultrasound techniques, there is no heat generated (clever name, right?). If there’s no heat generated, there’s no inflammation. If there’s no inflammation, there is less induration. If there is less induration, there is less downtime. If there is less downtime, the patient can continue to work out, critical for weight loss and staying in shape and toned, as everyone obviously knows. So the fat exodus is not only faster because of the increased vascularity allowing the body to rid itself of the dead fat quicker . There is less pain. And there is less downtime for the patient.So for two separate reasons, increased vascularity and decreased inflammation, ultrasound shockwave therapy produces faster body sculpting results that are nicely effective. Every patient can be excited about this.ConclusionMany nonsurgical modalities now exist to burn difficult to get at fat. Alternatively, ultrasound is yet another nonsurgical, thus noninvasive modality used for body sculpting to burn fat. But in addition to burning fat, it also increases the vascularity of that tissue, albeit at different settings. And it does all this non-thermally, without generating heat, so as to improve tolerance, increasing speed of response and recovery even more. This increased vascularity increases the speed of fat elimination after lipolysis. So, instead of leaving the fat in place for the body to deal with more slowly on its own with its limited vascularity, ultrasound’s increased vascularity eliminates the traffic jam.And the other big distinction of ultrasound acoustic shockwave therapy in comparison to other non-surgical body sculpting modalities, it is nonthermal so you don’t get the inflammation. So you don’t get the induration, you don’t get the swelling, you don’t get the pain. So the patient appreciates that! Plus sees results faster. (Note: this type of ultrasound, nonthermal, US care must be clearly distinguished from heat generating ultrasound which is also available today for lipolysis.)Most body sculpting conducted by physicians is being done in dual modality modes. To choose ultrasound as one of those paired modalities would seem wise.Stay well,David Allingham, MD

Cellulite

Cellulite   Introduction   What affects 95% of all women (over puberty) and 10% of all men? Cellulite.   Nonsurgical treatment options today I review here.   Disclaimer   Nonsurgical yes. But at the same time, not you - should be guiding his care. Do not try to simulate any of this care with any Brookstone gadgets from your local mall.   Yes, you should consider it. In a team wise approach with a physician you can trust.   Having said that, the physician you team up with should be able to accept a strong working partnership with you that allows both you and him to guide your care.   Discussion   And here’s your pneumonic, right up front. “The three F’s“ - Fat, Fiber, Fitness. Or fit’nass, like my more vulgar Beverly Hills counterparts like to say. Because it’s all about the derrière “in the end”? (sorry I couldn’t resist). But I’ll save that for... The end. Okay, okay... Enough. I’m a get myself in trouble.      1. Fat. For the fat component… There’s always liposuction. That has complications. Not just the classic fat embolus concern, but other surgical complications. Edema? Yeah. And it hurts more. And it’s more expensive. And the results aren’t always that great, not that even, there can be dimpling, there’s wound care, and there is a variability in the surgical teams you have across the land.   So, what has taken off for the past 10 years in the world of body sculpting are various nonsurgical modalities that produce lipolysis, death of the fat cells. These range from injecting chemicals into fatty areas that destroy fat (needles); to completely noninvasive nonsurgical options like laser, heat, and cold therapy.   And the brand new kid on the block, electromagnetic, high impulse, therapy that not only kills fat cells, but also increases muscle cells in size AND NUMBER. Very exciting. Olympic athletes train 30% of their muscle most the time. This fat killing, first ever muscle augmenting nonsurgical body sculpting modality works out muscle 100%! Crazy. But it’s new. And that in my mind is about the only thing working against it. Let’s see what the next year or two shows...   So. Non-surgical, fat killing modalities. Too good to be true? No. And clearly cheaper. Arguably safer, no doubt. And nicely effective. And you don’t have to miss any work. No downtime at all really. You don’t even have to stop working out, which will help one of the “F’s” below.     2. Fiber. There are these nasty, tenacious fibers that occur around dimpling areas of fat from some prior trauma and what not that must be broken up. Unfortunately, often require surgery, or at least needling techniques that take some time and training to master. Probably little if any ways of getting around that.   Fibrous bands from some long ago forgotten injury that must be dealt with... Versus skin laxity... Which should be dealt with differently. Versus some important blood vessel you don’t want to damage! The world of the plastic surgeon! Gentle retraction on the skin by the hand of a trained surgeon produces difference effects, allowing them to distinguish between these important different things. Hence on to the right kind of surgery...   But wait! There IS a non-surgical modality doctors can use to break up fibrous bands in dimpling cellulite. Shockwave therapy (SWT) provided by acoustic ultrasound machines can indeed break up some banding underneath the tissue of the skin if done aggressively enough. So, no needles. No surgery. And you can get rid of those fibrous bands over time — with a little persistence. And ultrasound SWT.   And another nice advantage to shockwave, ultrasound, acoustic therapy like this is that it increases new blood vessels in that area! Bonus! So, whatever fat has been destroyed by the non-invasive fat killing modalities mentioned above can have a faster, smoother exit from the subcutaneous tissue because of new increased vasculature. Rather than just wait for the body to rid the fat that has been killed by one of the nonsurgical modalities above by it’s regular pokey, slow rate (something the body doesn’t ever seem to want to do; am I right ladies?), ultrasound therapy increases vascularity in whatever tissue it is aimed at so the fat loss is faster. Faster fat elimination. That always sounds good.     3. Fitness. The doctor does his part with the other two “F’s”. Here’s where the patient has to do her part. Here, I have to sell the cellulite patient on eating better than they ever have done before, exercising, non-impact of course (biking, not motorbiking —swimming, yeah you have to get wet, or kayaking, just kidding, but an option). Okay, okay, I’ll be nice. Anyway... I’m not sure why, if it’s the increased teamwork the genuinely interested physician fosters with his or her fat conscious patient, or maybe it’s increased investment the patient has finally made into their temple… But, bit by bit, the body sculpting patient tends to start doing the right thing! Really going to that gym they joined months ago, genuinely eating less because they are actually following calorie counts finally...   (That’s right. The only way to genuinely eat less is to do calorie counts. I’ve spent time with people who swear they don’t eat much at all. They have no clue. To eat less, or less enough to make a difference anyway, you must do your calorie counts! Then... Stick to what you discover for 1 to 3 months, make a change downwards 10% if you are not losing weight. Etc. Easy.)   Conclusion   So, now it’s time to do your Internet search for the modality of your choice! Aesthetics are important! And if you don’t think so, think about self-esteem. And don’t forget about eating less and exercising more.   Stay well, David Allingham, MD