Is it true everyone living in the north should take vitamin supplements? What if I am very healthy, very active, and participate in outdoor sports activities like golf, tennis, and hiking? How do I know what I really need?

Current studies have provided convincing evidence that most people (children and adults) in the United States are Vitamin D deficient. You wouldn’t think athletes with their strong bones and muscles would need any Vitamin D supplementation. But they do.

According to a group of researchers from Marshall University School of Medicine in West Virginia, there are sports health benefits to taking Vitamin D supplements. Some of those benefits actually come in the form of prevention. That is — preventing the musculoskeletal events that can occur when someone is Vitamin D deficient (e.g., bone fractures, musculoskeletal pain, frequent illness).

People living in certain (Northern) regions of the globe don’t receive enough of the essential sun rays. This is especially true if they compound the problem by using sunscreen. And obesity has also reduced the amount of Vitamin D available in the body because it is a fat-soluble vitamin. This means fat cells store the vitamin rather than allowing the body to use those essential substances.

Because very little Vitamin D comes from natural food sources, some products like cereals and milk are Vitamin D fortified. But even with these dietary sources, most everyone is still Vitamin D deficient and in need of supplementation. Athletes and sports participants (indoor and outdoor athletes) are no exception.

To clarify a bit more, indoor athletes do need more Vitamin D supplementation than outdoor sports participants. But outdoor athletes must be aware of seasonal differences in sun exposure and supplement accordingly. Outdoor athletes should have their blood tested in early autumn to adjust for seasonal differences in sun exposure.

There is no extra advantage of having a blood value of more than 50 ng/mL of vitamin stores in the body. Differences in skin pigmentation must be taken into consideration. African Americans (and other dark-skinned individuals) need up to ten times more sun exposure to reach the same levels of Vitamin D in the body compared with Caucasian or light-skinned athletes.

If your blood test shows you are Vitamin D deficient (less than 30 ng/mL of 25(OH)D — the measure used to assess blood levels), then you may be advised to take 50,000 IU of Vitamin D3 each week for eight weeks or until blood tests show a steady level of at least 25(OH)D.

It is clear that the effects of too-low levels of Vitamin D include severe muscle weakness, loss of muscle tone, generalized body pain, increased falls, and bone deformities. Athletes who have enough Vitamin D have fewer colds and flus. And they may have the added benefit of faster recovery from inflammation after bouts of overtraining.

Sunshine is still nature’s perfect solution to strong muscles, teeth, and bones. Adequate exposure to ultraviolet rays that stimulate production of Vitamin D in the body avoid any excess accumulation or toxicity in the body. That’s because the body has special feedback loop to prevent this negative effect. Although these are published guidelines for athletes and sports participants, it is still best to ask your primary care physician to guide you through this process.

How reliable are animal studies when checking out something that is going to be used on humans? I ask this because my surgeon wants to inject my own blood plasma into my elbow for a true golfer’s elbow. But when I went on-line, most of the studies using this blood injection therapy have been on animals. So I’m a little less than enthusiastic to try this new treatment. What can you tell me?

As you have probably already found out from your own look into this treatment, platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems (in humans!). Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

It has been used for years after plastic surgery and surgery on the mouth, jaw, and neck. It seems to promote bone graft healing. Researchers have found a way to combine this substance with other chemicals to make it into a putty or gel that can be painted on a surgical site to speed up healing.

Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems, but gaining popularity quickly.

Research has been done on both animals and humans. Animal studies give researchers a place to start until the technique is determined to be safe and effective. Then trials with humans take place. So, although some studies have been done using an animal model, there are just as many using humans to evaluate this treatment.

So far, human studies have shown varied results — some clinical studies report decreased pain and improved use of the arm after PRP. Others show no improvement and the patients actually end up having surgery.

Why the difference and contradictory results? Experts speculate that different systems used to make the product may have something to do with it. Not all products are considered the same or “equal.” The best formula with the exact ratio of blood products (white blood cells and platelets) hasn’t been determined yet. In fact, it’s likely that different conditions (e.g., Achilles tendinitis, tennis elbow, golfer’s elbow) may respond better to one batch of platelet concentration compared to another.

This is where animal studies come in again — to help refine the current treatment techniques. For example, right now veterinarians at Cornell University in New York are using horses to investigate the effect of various platelet to white blood count ratios. They prepared and analyzed the results on healing for four different concentrations of platelet:white blood cells.

They found that the high levels of white blood cells (the leukocytes) caused increased inflammation. This was true no matter what platelet to leukocyte ratio used. Inflammation will delay or slow healing with the possibility of more scar tissue. At least from an animal model, it looks like reducing the amount of leukocytes in platelet-rich plasma (PRP) therapy might help stimulate the best healing response with the least amount of scar tissue. Increasing the amount of platelets does not counteract the inflammatory effect of the leukocytes.

I’ve been thinking about have a PRP injection into my elbow to help heal a bad case of tennis elbow. When I looked on-line I found your Patient Guide to Platelet-Rich Plasma Treatment. I work in a lab in a hospital so I know that preparations of this type are not all equal. How do I know I’ll be getting the exact right mix for my problem?

You are exactly right to suggest not all injections of platelet-rich plasma (PRP) are the same. And you bring up a second challenging factor in using PRP for tendon problems: knowing how much to inject and providing the exact right ratio of leukocytes (white blood cells) to platelets.

As you know from reading our Patient Guide to Platelet-Rich Plasma (PRP) Treatment, PRP refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

Researchers are investigating what is the best “recipe” for this product. There are looking to see if there is some amount of platelets and white blood cells that will give the best results. Right now, the exact ratio for optimum outcomes is unknown.

To aid in that research, veterinarians from Cornell University in New York are doing some studies using blood and tendon tissue from horses to investigate the effect of various platelet to white blood count ratios. They prepared and analyzed the results on healing for four different concentrations of platelet:white blood cells.

One reason this type of research is even needed comes from previous studies that showed a “Goldilocks effect” of platelet-rich plasma treatment. It has been observed that too low or too high a concentration of platelets yields inferior results or poor outcomes. This study is an effort to find the “just right” concentration of these two important ingredients in the platelet-rich plasma (PRP) treatment.

The hypothesis (theory) of these researchers was that having a product with reduced leukocyte (white blood cell) count or one with increased platelets would give the best results. Their specific task was to find out which combination of these two products gave the best results. They started with three groups that had the same amount of platelets but different levels of leukocytes (low, medium, and high). A fourth group with high platelets and high leukocytes was also included.

They found that the high levels of white blood cells (the leukocytes) caused increased inflammation. This was true no matter what platelet to leukocyte ratio used. Inflammation will delay or slow healing with the possibility of more scar tissue. At least from an animal model, it looks like reducing the amount of leukocytes in platelet-rich plasma (PRP) therapy might help stimulate the best healing response with the least amount of scar tissue. On the other hand, increasing the amount of platelets does not counteract the inflammatory effect of the leukocytes.

Of course, this was just one set of differing concentration ratios and in animals with normal tendon tissue. More studies are needed to further define the optimum blend in humans and for different conditions.

And as someone who is familiar with lab procedures, you know it will be important to compare different preparations created with different systems. Different centrifugal speeds, varied plasma volumes, and number of spins could each have a unique impact on the final product. If there is a possibility of a superior product, patients and surgeons will want to know.

I suffered my first gout attack about six months ago. After the second attack yesterday, my doctor gave me a prescription for colchicine. But my father (who also has gout) told me he’s never heard of this drug. Should I really be taking it? Should my father find out about it? Maybe HE should be taking it, too.

The treatment of gout is not always the same from one person to the next. What stays the same is the preventive steps patients are encouraged to take. For example, patients are reminded not to drink alcohol (beer or liquor) or eat foods with purines in them (e.g., red meat, sea food).

It is important to stay hydrated as dehydration is a risk factor for acute flare-ups. The use of diuretics for any reason (control blood pressure, weight loss) can contribute to dehydration. Patients must be aware of these facts and act accordingly.

Medications such as antiinflammatories, corticosteroids, colchicine, or interleukin 1 inhibitors may be prescribed. The choice of medication depends on the patient’s age, severity of the gout attack, and other health factors such as the presence of diabetes and kidney function.

Older adults are at greater risk for heart problems so some of the medications may not be appropriate for them. Anyone who has gastrointestinal problems or who is already taking antiinflammatory medications may do better with one of the newer medications (e.g., colchicine).

If you have a history of cardiovascular disease, a history of gastrointestinal bleeding, or if you are already taking nonsteroidal antiinflammatory drugs (NSAIDs), then colchicine is the alternative medication choice for acute gout flare-ups. If none of these things describes your situation, then feel free to call your doctor and ask him about the choice of colchicine. Your father can also ask his physician the same question for himself.

When should someone with gout have the fluid taken out of the joint and sent to the lab? I’ve never had this done but someone else I know has. Just wondering why there’s a difference in how we are treated when we both have the same problem.

Anyone who has ever suffered an attack of gout knows just how painful it can be. The red, tender, and swollen joint can be so painful that even the touch of a sock or sheet can be excruciating.

Painful joint symptoms associated with gout are caused by the deposit of uric acid crystals in the joint and in the surrounding soft tissues. The most typical pattern is an attack that affects the big toe but other joints such as the elbow, wrist, fingers, and even the shoulder can be involved.

Before starting treatment, the physician will make sure the problem isn’t a case of joint infection from cellulitis or septic arthritis. If there is any doubt about the diagnosis, a small amount of fluid can be drawn out of the joint. Using a syringe to collect synovial fluid from a joint is called an arthrocentesis.

The fluid will be analyzed in the lab in order to make the final diagnosis. If it’s really gout, there will be urate crystals seen under the microscope. Sometimes those crystals are visible around the painful joint so the lab test isn’t needed.

The decision to perform an arthrocentesis is based on the patient’s history, physical exam, other lab results, and possibly X-rays taken during the initial evaluation. But studies show that arthrocentesis isn’t needed if the patient has four out of eight clinical findings.

These are the things the physician looks for: only one joint affected (usually the big toe), no more than four joints involved, more than one episode of painful joint symptoms typical of gout, visible crystals called tophi around the affected joint, and hyperuricemia (high levels of uric acid in the blood).

Most of the time, if the problem is really gout, the clinical picture is clear. But the “gold standard” for a clear and definitive diagnosis remains the just of arthrocentesis (joint fluid analysis).

It seems like all of my friends (yes, we are all “Seniors”) are taking something for their joint pain they found on the Internet. I’ve been advised to take SAMe, glucosamine, fish oil, capaicin cream, and a ton of other stuff. Is there any scientific proof that any of these things really work?

Well, you are in luck. As it turns out, a physician from Australia recently published an article with the latest findings in this area. It was intended as an update for physicians on the use of nutraceuticals for joint disease. But the information is just as valuable for patients like yourself who need a little guidance in knowing what is proven effective. Here’s what we can tell you that might help you in your own search for evidence-based information.

The supplements recommended are slightly different depending on whether the underlying joint disease is osteoarthritis (OA) or rheumatoid arthritis (RA). Fish oil is the one supplement used for both conditions. As the name suggests, the oil comes from fish and contains omega-3 fatty acids. It is a natural anti-inflammatory that is not made by the human body.

Studies show that fish oil does decrease joint tenderness and morning stiffness. Patients taking fish oil have also been able to decrease the use of nonsteroidal antiinflammatory drugs (NSAIDs). Physician should let patients know it can take eight to 12 weeks for the full benefit of fish oil to kick in.

As with all drugs and supplements, fish oil can have adverse side effects for some people. These may include gastroesophageal reflux (GERD), diarrhea, headaches, and a lingering fish taste in the mouth or odor on the breath. Studies are still needed to see if fish oil can prevent or delay the progression of osteoarthritis (OA).

As for other supplements used for OA, glucosamine and chondroitin top the list. These can be taken separately or combined together to aid in the formation of joint cartilage. They may also help prevent inflammation and the breakdown of joint cartilage. Studies done so far support the long-term use of these supplements. Patients taking them for at least one (up to three) years have fewer joint replacements compared with patients receiving a placebo (sugar pill).

Another popular supplement taken by seniors for joint pain is SAMe, which stands for S-adenosylmethionine. Now you can see why the name SAMe is preferred! Each cell of the body creates its own SAMe. In the joint, it thickens and protects cartilage while also preventing joint pain. Taking SAMe as a supplement seems to improve joint pain and function.

In the treatment of rheumatoid arthritis (RA), many patients find relief with capsaicin. Capsaicin contains an enzyme that gives chili its “heat.” Used as a cream rubbed over and around a painful joint, it creates irritation of the skin. This, in turn, activates nerve fibers in the skin. The end-result is to distract the brain-body from recognizing joint pain.

Thunder god vine is a Chinese herb that can be taken as a pill or applied as a skin cream. Unlike some of the other supplements taken for joint pain that must be taken for months to years to be beneficial, thunder god vine provides pain relief and decreased joint swelling in the first 10 to 14 days. There are some potential adverse side effects though such as anemia, kidney problems, headache, hair loss, upset stomach, and even male infertility.

Of course, there are many more other supplements on the market. But this gives you an idea of what is known about the most commonly used and readily available supplements. As always, don’t take any over-the-counter products (whether medications or supplements) without first consulting with your doctor. That way you can benefit the most in as safe a way as possible.

The guy at our local vitamin shop has advised me against taking glucosamine for my arthritis. I have allergies to shellfish and these supplements are evidently made from the shells of shellfish. Are these pills really helpful? Does having an allergy to shellfish really mean I should avoid them?

Glucosamine is a sugar the body produces naturally that is needed for good cellular structure of joint cartilage. It helps keep the cartilage able to attract water and thus stay hydrated. Good hydration of the cartilage cells creates the positive pressure needed to stand up under load and pressure.

This is particularly helpful at the knee where most of the load from the ground up is transferred from the foot to the knee. And, of course, the knee is the joint that seems to give out first for many people who develop degenerative osteoarthritis.

Many of the glucosamine products on the market do have ground up shells from shellfish in them. Most of the allergic reactions to shellfish are to the flesh of the animal inside the shell rather than to the shell itself. People who are allergic to shellfish may be able to take preparations of glucosamine made from shellfish without any problems. But you should only do this under the supervision of a physician in conjunction with a pharmacist who understands the product being taken (or considered).

There are some glucosamine products made from vegetable sources that do not contain shells or any part of shellfish. You can consult with your pharmacist about these as well. The downside is that most of these alternative glucosamine products contain corn. There is some concern about modified genetically grown corn and the effect of these corn-based products on our DNA.

There are some other products available that may be of interest to you in the search for ways to naturally alleviated joint pain. For example, fish oil is one supplement used for both osteoarthritis (OA) and rheumatoid arthritis (RA). As the name suggests, the oil comes from fish and contains omega-3 fatty acids. It is a natural anti-inflammatory that is not made by the human body.

Studies show that fish oil does decrease joint tenderness and morning stiffness. Patients taking fish oil have also been able to decrease the use of nonsteroidal antiinflammatory drugs (NSAIDs). Physician should let patients know it can take eight to 12 weeks for the full benefit of fish oil to kick in.

As with all drugs and supplements, fish oil can have adverse side effects for some people. These may include gastroesophageal reflux (GERD), diarrhea, headaches, and a lingering fish taste in the mouth or odor on the breath. Studies are still needed to see if fish oil can prevent or delay the progression of osteoarthritis (OA).

Another popular supplement taken for joint pain is SAMe, which stands for S-adenosylmethionine. Now you can see why the name SAMe is preferred! Each cell of the body creates its own SAMe. In the joint, it thickens and protects cartilage while also preventing joint pain. Taking SAMe as a supplement seems to improve pain and function.

In the treatment of rheumatoid arthritis (RA), many patients find relief with capsaicin. Capsaicin contains an enzyme that gives chili its “heat.” Used as a cream rubbed over and around a painful joint, it creates irritation of the skin. This, in turn, activates nerve fibers in the skin. The end-result is to distract the brain-body from recognizing joint pain.

Thunder god vine is a Chinese herb that can be taken as a pill or applied as a skin cream. Unlike some of the other supplements taken for joint pain that must be taken for months to years to be beneficial, thunder god vine provides pain relief and decreased joint swelling in the first 10 to 14 days. There are some potential adverse side effects though such as anemia, kidney problems, headache, hair loss, upset stomach, and even male infertility.

It’s always a good idea to be an informed consumer when searching out products like any of these. Be sure and consult with a pharmacist and your primary care doctor or orthopedic physician. They may have some specific recommendations for you given your current, age, health, past medical history, and so on.

I am not an athlete and I’m heading toward middle age (I’m 43 years old) but I seem to have developed the kind of tendon problems athletes deal with. In fact, the doctor calls it tendinopathy, which is the same term I’ve heard applied to some of my favorite athletes. How does a guy like me get a problem like this?

Tendinopathy is a term used to describe a collection of symptoms such as pain, swelling, and impaired movement. The cause may not be an athletic injury but it is usually associated with overuse or repetitive motions. The everyday, average adult like yourself who develops these symptoms should take a look at your daily household or work activities. Perhaps there are some activities or actions you repeat more often than you realize that could contribute to this problem.

There’s another consideration in middle-aged and older adults that has nothing to do with overuse, repetitive motion, trauma, or athletic activities. And that is a medical condition that affects tendons. such as diabetes, medications, or even high cholesterol and atherosclerosis. Since you are seeing a physician for this problem, you can always ask if any of these could be contributing factors in your case.

If there is not an underlying medical problem, then treatment can be as simple as activity modification and an exercise program for you. Studies show that eccentric exercise has the ability to enhance tendon repair. During an eccentric muscle contraction, the muscle and its tendon starts in a shortened position and then lengthen as the body part moves.

A daily program over a period of six weeks’ time results in good outcomes with pain relief, improved function, and without adverse effects. Though time-consuming this exercise approach can be successful. When supervised by a physical therapist, motivation and compliance improve. The risk of reinjury is also less.

Heavy, slow eccentric load may work better than static stretching or fast eccentric load. Combining static stretching with slow eccentric movements has been shown to be very helpful in a few studies. More studies are needed to pinpoint the most effective way to introduce and progress eccentric exercise. But for now, the research consistently shows the positive benefit of exercise as a first-line of treatment for tendinopathy.

I am 16-years old and the captain of both the girls’ volleyball and soccer teams at my high school. Lately, I’ve been having tendon problems. First it was my elbow, now it’s my knee. My parents don’t want me to have the steroid injections that have been recommended. And I certainly don’t want to miss out on my senior year if I opt for surgery. What can I do to get through this problem quickly?

Tendon repair can be tricky business. When the process gets interrupted for any reason, the tendon may get stuck in a lose-lose situation. Too much inflammation (and even sometimes not enough inflammation) can result in a process that produces a problem we call tendinosis or tendinopathy.

Tendinopathy refers to any tendon that has been damaged in some way but is no longer in the acute inflammatory phase, which would be called a tendinitis. Examination of tendon tissue in patients who have had chronic pain over months and sometimes even years shows scarring and fibrosis but no active fluid, swelling, or white blood cells at the site needed for healing.

What can be done to kick the tendon out of this no-win situation and back into a healing strategy? Treatment efforts are many and varied. The latest idea being tried is called platelet-rich plasma or blood injection therapy.

The patient’s own blood is drawn and processed to collect the platelets. Then those platelets (suspended in a solution of the blood’s plasma) are injected into the damaged tendon. Platelets have lots of growth factors that get to work stimulating the repair process once again. This hasn’t been studied on children or teens so it’s not a very likely option for you.

Another approach tried has been shockwave therapy (SWT). Pulsations (vibrations) from this treatment create a mini-trauma to the tissues. The hope is to restart the healing process. Low-intensity ultrasound has also been used in the same way.

The old standby: corticosteroid injections are still used but there are more and more doubts about using this treatment. Steroid injections may have a short-term benefit but nothing that lasts. The negative effects on the tendon reduces tendon strength. Tendon rupture may not be worth the initial pain relief provided.

Surgery to clean the area up and restore blood supply to the tendon has some positive benefits. Mid-term results show significant pain relief and improved function after three years. Nerves that have grown inside the scar tissue can be one cause of the persistent pain experienced with some tendinopathies. The surgeon can try using a motorized shaver or radiofrequency to destroy these nerves. It sounds like you aren’t interested in this treatment approach right now.

Any of the treatment approaches mentioned so far have potential complications and limited favorable results. Studies are not conclusive yet to suggest one treatment rises above all others as the best. That brings us to the next possibility: exercise. There is very little cost involved, no postoperative complications to deal with, and the potential for proper tendon repair.

The downside of exercise as a treatment for tendinopathy is the patient’s own patience and cooperation. It does take time for consistent exercise to support the body’s innate ability to heal itself. But studies show that eccentric exercise has the ability to enhance tendon repair and even cause the nerve to pull back from the tendon.

During an eccentric muscle contraction, the muscle and its tendon starts in a shortened position and then lengthen as the body part moves. A daily program over a period of six weeks’ time results in good outcomes with pain relief, improved function, and without adverse effects.

Though time-consuming this exercise approach can be successful. For faster results, you may want to consult with a physical therapist.l When supervised by a physical therapist, motivation and compliance improve. The risk of reinjury is also less.

Heavy, slow eccentric load may work better than static stretching or fast eccentric load. Combining static stretching with slow eccentric movements has been shown to be very helpful in a few studies. More studies are needed to pinpoint the most effective way to introduce and progress eccentric exercise. But for now, the research consistently shows the positive benefit of exercise as a first-line of treatment for tendinopathy.

Maybe I’m being a bit obsessive compulsive but that is my nature. I’m investigating the use of platelet-rich plasma to treat a chronic tendon problem I have. So far, I understand the concept and the procedure. But now I find there are dozens of “kits” the surgeon can choose from to actually do the blood draw and make the injection. How do they know which one to choose? Should I investigate further?

From your personal research, you have probably discovered that Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as nine times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

And as you have found out, there are at least 16 different collection kits available on the market for this procedure. They are not all the same and the differences may make affect results of studies trying to determine the effectiveness and long-lasting benefit of this treatment. In a recent article you may find of interest, orthopedic surgeons from Northwestern University School of Medicine in Chicago discuss the contents and preparation of these platelet-rich plasma kits.

The injectable substance is created by first drawing the patient’s own blood and putting it in a special machine called a centrifuge. The centrifuge spins around at a fast rate and separates the various component parts of blood based on density and weight. The heavier red blood cells sink to the bottom faster than the lighter white blood cells and platelets.

Depending on how the blood sample is processed, the final amount of platelets and platelet-rich plasma can vary considerably. Some kits include an activator to speed up the process of clot formation (healing) but there is a potential downside. Adding an activator (e.g., calcium chloride or thrombin) can decrease how long the growth factors released by the platelets are available.

There is some research that has shown activators aren’t really needed. PRP preparations with and without activators have the same effectiveness. But other differences in PRP injections may make a difference and that is an area for future studies. Large, prospective, and randomized trials are needed to compare results using different PRP kits for each individual problem treated.

More and more studies are showing promising results using PRP for musculoskeletal problems. The focus turns now to preparation and classification of commercially available PRP preparation systems. Some kits are categorized according to the amount of platelets in the final sample. Others look at fibrin (clotting substance) and leukocyte (white blood cell) content. The presence (or absence) of an activator further classifies these products.

The authors of this article provided a table reviewing all 16 kits from the perspective of six key areas. Each system is named and described according to blood volume drawn, final PRP volume, and final platelet concentration (compared with whole blood). Whether or not an activator is added is noted (along with which activator is included). And finally, the white blood cell concentration and amount of fibrinogen are listed for consideration.

This might be a good place to continue your investigation. But ask your surgeon what he/she uses and how the choice is made. It’s very likely your surgeon has already researched this very thing and can offer you considerable more information to help explain this aspect of the procedure.

Are there any safety issues with blood injection plasma for tendon tears? I’m planning to have this treatment but thought I’d do a little checking on the Internet before actually going through with it.

Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as nine times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

It has been used for years after plastic surgery and surgery on the mouth, jaw, and neck. It seems to promote bone graft healing. Researchers have found a way to combine this substance with other chemicals to make it into a putty or gel that can be painted on a surgical site to speed up healing.

Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems, but gaining popularity quickly.

The injectable substance is created by first drawing the patient’s own blood and putting it in a special machine called a centrifuge. The centrifuge spins around at a fast rate and separates the various component parts of blood based on density and weight. The heavier red blood cells sink to the bottom faster than the lighter white blood cells and platelets.

There are at least 16 different collection kits available on the market for platelet-rich plasma (PRP). They are not all the same and the differences may make affect results of studies trying to determine the effectiveness and long-lasting benefit of this treatment.

Depending on how the blood sample is processed, the final amount of platelets and platelet-rich plasma can vary considerably. Large, prospective, and randomized trials are needed to compare results using different PRP kits for each individual problem treated.

Safety is an area of concern and potential study. Since the product comes from the patient’s own blood, there is little risk involved. Rejection is not an issue. Local skin reactions, inflammation, and pain have been reported.

The positive benefits of speeding up healing are actually only part of the effectiveness of PRP. At least one study has shown that PRP increases the body’s ability to fight off staph infections and E. coli. The antimicrobial action of PRP is an added bonus to the patient.

I’m doing a little research for the orthopedic surgeon I work for. She uses platelet-rich plasma treatments for some carefully selected patients. We have recently found out that the lab where the samples are collected is reporting different blood (platelet and white blood cell) counts. I have the task to find out more about this. Is this happening everywhere? Are there any studies to help us investigate this further ourselves?

There was a recent study published from the University of Connecticut that reported platelet-rich plasma differs according to preparation methods and human variability. This isn’t the first study of its kind but the authors do compare their results with other similar studies already published.

The platelet-rich plasma therapy has been around long enough now to start studying it more carefully. Researchers have found that the platelet-rich plasma preparation varies significantly from sample to sample. That means patients aren’t always getting the same amount of platelets and growth factors. This has been shown to be true from one treatment to the next and even from one patient to the next. The question you asked then comes up: why the differences?

To find out, researchers from the University of Connecticut sampled blood from eight people on three separate occasions (baseline or first blood draw, fourteen days later, one month later). Each sample was analyzed for each patient at each of those time periods.

They used three different lab techniques to harvest the platelets: 1) a single-spin technique (referred to as LP), 2) an alternative single-spin method (the HP method, and 3) a double-spin (DS) technique. Each technique is carefully described for the reader including the number of minutes spun and the revolutions per minute.

In all cases, the HP (alternative single-spin separation method) gave the best results with the highest percentage of white blood cells and platelets. The one-step LP method far outperformed the other two methods.

There were clear differences in outcomes not only with the differing techniques used but also for the different times the samples were taken for each individual. The next question naturally arises: why would platelet levels and white blood cell levels vary over time for the same person? The authors suggest age could make a difference. Or there could be a physiologic reason why these variations exist that we just don’t know about yet.

What the study does show is that the method of separation when obtaining platelet-rich plasma makes a difference in the number of white blood cells and platelets collected. Physicians may want to take this fact into consideration when selecting the method used.

For example, it might be helpful to choose the method that matches the intended use of the plasma. One thing to keep in mind is the fact that too many white blood cells can actually cause an overreaction in the tissues.

And too much inflammation at certain points in the healing process may not be a good idea. Perhaps the double spin method would work best. Likewise, there may be times and situations where increased antibacterial and an increased immune response would be helpful. In those cases, the single-spin method might be the most useful.

We hope that helps you get started in exploring this topic. It may be helpful to read this study in addition to the studies mentioned in the article against which they compared their results. You may recognize contributing factors in your own situation based on what these other researchers report.

I’m reading various articles on-line about platelet-rich plasma therapy. I’ve had several key players on my basketball team get these treatments. I’m trying to figure out if they really work well enough to insist other injured players get the same treatment. I’m having some difficulty understanding what is meant when studies are deemed “low-quality” or “moderate evidence.” Help?

Any time a new treatment technique is tried approval depends on how well it works, long the effects last, and the balance between risks and benefits. Risks usually include problems during the procedure and complications after the treatment. One of the new treatments for orthopedic conditions currently being investigated is platelet-rich plasma or blood injection therapy.

Platelet-rich plasma (PRP) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets.

Once activated in response to an injury, platelets release active proteins and growth factors. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

In a recently published article, researchers from the Center for Evidence-Based Orthopaedics at McMaster University in Canada report on the efficacy (benefits) of platelet-rich plasma use for a variety of orthopedic conditions.

In that study, the authors provide a very nice summary describing how studies are evaluated for quality of evidence. For example, randomized, controlled trials are usually the highest quality. Randomized means patients are placed in different groups by random draw.

No one in the study knows what treatment they are actually receiving. Some patients will be randomly placed in the control group. This group receives an injection but the treatment is a placebo — usually a saline solution. In a double-blind study, even the physicians giving the treatments don’t know what treatment each patient is getting.

Studies are “downgraded” in quality when there is a lack of blinding, large numbers of patients are lost during the follow-up, or there is an early stop of the study for any reason. Studies can be upgraded or downgraded depending on how well matched the subjects are in terms of age and similarities or differences in the physical condition being studied. Quality of evidence can also be downgraded if there are large discrepancies between studies. And the quality of evidence can be graded as high, moderate, low, or very low.

When studies use different ways of measuring outcomes, it becomes more difficult to compare the results. When the outcomes are inconsistent among the participants (some get betters, others don’t or some get a little better while others are much better), then results are considered “imprecise” or “uninformative.”

Often, when researchers look over a body of evidence, there is a general lack of standardization among the studies reviewed. This means the way the studies were conducted was different enough to create problems in comparing results (like comparing apples to oranges — both fruit but different colors, tastes, and textures).

For example, studies can range in size from 10 to thousands of patients. Follow-up can be anywhere from hours to years. There can be differences in the way something like platelet-rich plasma is prepared among the studies. And the area of the body treated varies from shoulder to elbow, knee to lower leg, and spine.

Right now, there are some inconsistencies in study results so that PRP is not consistently being shown to be an effective treatment for bone and soft-tissue injuries. This may have more to do with the lack of standardization in study design and different way outcomes were measured. Based on current evidence, it is unclear that platelet-rich plasma is an effective treatment for orthopedic conditions.

High-quality studies are needed to identify best use of PRP (acute traumatic lesions, chronic conditions, degenerative diseases). It will be important to uncover risks of this treatment approach and weigh the benefits against the risks for each condition.

Future studies also need to have good design with high-grade evidence and measurable outcomes that can be compared from study to study. Follow-up should be long enough to tell if there is a long-term benefit to patients. And there needs to be a focus on the different results obtained based on various ways blood is processed to create platelet-rich plasma.

I have a question about the new blood injection therapy available for sports injuries. I understand they take the patient’s own blood and spin it down to get just the platelets. Then they inject those platelets into the injured area. But don’t platelet just cause blood to clot? How does this help the sprained ankle for example?

Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

It has been used for years after plastic surgery and surgery on the mouth, jaw, and neck. It seems to promote bone graft healing. Researchers have found a way to combine this substance with other chemicals to make it into a putty or gel that can be painted on a surgical site to speed up healing.

Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems such as ankle sprains or torn tendons, but gaining popularity quickly.

Platelets do circulate in the bloodstream ready and available for any cuts or wounds where clotting the blood is needed. Once activated in response to an injury, platelets also release active proteins and growth factors that assist with wound healing.

In fact, the tiny biologically active substances released when platelets are broken down help with the formation of new blood vessels to the damaged area and even new tissue. In theory, anyway, injecting additional platelets should dramatically increase (four to 15 times) the number of growth factors at the site of the injury.

We say “in theory” because results of studies in this area are in conflict (don’t agree) or simply show no benefit of using platelet-rich plasma injection over a placebo. In a recent meta-analysis, researchers from the Center for Evidence-Based Orthopaedics at McMaster University in Canada report on the efficacy (benefits) of platelet-rich plasma use for a variety of orthopedic conditions.

A meta-analysis means a large number of studies with small-to-medium numbers of participants are combined or pooled together. This method increases the n (number of patients involved) and allows for more meaningful statistical results. Sometimes smaller studies are high-quality but without the necessary number of patients involved, the results are limited in providing evidence that a treatment (such as PRP) is beneficial.

They found 895 articles on the subject but only 33 studies that qualified to be included. There was a general lack of standardization among the studies reviewed. In terms of pain control and improved function as a result of decreased pain, only six studies showed a benefit of the platelet-rich plasma (PRP) injection. One study even showed the control group had the best results. The remaining studies could not show a benefit of PRP over placebo.

The inability to conclude that PRP is an effective treatment for bone and soft-tissue injuries may have more to do with the lack of standardization in study design and different way outcomes were measured. As a result, the authors summarized by saying the evidence is unclear that platelet-rich plasma is an effective treatment for orthopedic conditions.

I am a physical therapist interested in platelet-rich plasma (PRP) treatment for sports injuries. Some of the more recent research suggests that the inflammatory process at the beginning of an injury should not be slowed down by using ice or taking antiinflammatory medications like ibuprofen. But what about the PRP treatment? Doesn’t that introduce an elevated number of white blood cells and growth factors? Doesn’t that heighten the inflammatory process?

You are right about the recent re-thinking on the use of antiinflammatory medications following acute injuries. Ice and ibuprofen have been the first line of treatment for swelling for a long time. And come to find out (as you suggest), this may not be helpful.

It has been determined that treatment should be geared toward reducing but not eliminating the swelling. The goal is to prevent an overreaction by the immune system but without stopping the inflammatory process.

Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

Platelets are part of the blood that circulate around the body ready to help with blood clotting should you have a cut, broken bone, injury that bleeds internally, or any other type of injury. Besides containing clotting factors, the platelets release growth factors that help start the healing sequence.

With a concentrated amount of platelets, larger quantities of these growth factors are released to stimulate a natural healing response. Plasma is the clear portion of the blood in which all the other blood particles such as platelets, red blood cells, and white blood cells travel.

Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems, but gaining popularity quickly.

In theory, blood injection therapy could be used in any area where a rapid healing response is desired such as the tendon-muscle junction, muscle injuries, torn ligaments, damaged joints, or inflamed tissue (e.g., plantar fasciitis).

Torn tendons and ligaments don’t always heal well because they have a poor blood supply. Connective tissues such as ligaments and tendons heal by filling in with scar tissue that doesn’t bear the brunt of large loads well. This increases the risk of re-injury.

Other available treatments for chronic tendon problems do not necessarily improve the tendon’s ability to heal in the same way that PRP does. And injections of PRP don’t have the side effects that can occur with steroid injections or long-term use of non-steroidal anti-inflammatory drugs (NSAIDs).

More recent studies have started to show that there is considerable variability in the number of platelets (with their growth factors) and white blood cells in samples of platelet-rich plasma. Some methods of preparation actually yield high levels of these substances while others produce much lower levels.

This information is helpful when considering what you have pointed out: too many white blood cells can cause an overreaction in the tissues. And too much inflammation at certain points in the healing process may not be a good idea.

Perhaps the double spin method (which yields lower levels of platelets and white blood cells) would work best when a mild healing response is needed. Likewise, there may be times and situations where increased antibacterial and an increased immune response would be helpful. In those cases, the single-spin method might be the most useful. Physicians may want to take this fact into consideration when selecting the preparation method used to develop the platelet-rich plasma used in injection therapy.

Can you tell me a little about the kind of surgery they might do for psoriatic arthritis? I have pretty severe joint damage and I’m just starting to explore my options.

Treatment for psoriatic arthritis is individual and really a matter of medical management. In fact, it could be said that “it takes a village” to treat psoriatic arthritis. Dermatologists, rheumatologists, medical doctors, and physical therapists must work together to guide the patient and prevent as much damage as possible.

The specific treatment approach used is based on symptoms and severity of each person’s disease. It is recognized now that early aggressive treatment with medications to control the disease process is important. Medications typically prescribed include antiinflammatories and disease modifying antirheumatic drugs (DMARDs).

New drugs to treat psoriatic arthritis are being investigated by pharmaceutical companies. One of those new treatments is called biologic therapy. This approach uses special immune-blocking agents to stop the inflammatory process at different points in the cascade of events leading to the effects of this disease. Physicians who treat this condition generally agree that patients should explore all conservative options available before having surgery.

If there is severe joint destruction and damage, surgery may be needed to reduce pain and improve function. A variety of different surgical procedures can be used including debridement (cleaning the joint of thick tissue and debris), joint fusion, and joint replacement.

A major concern after surgery is skin infection. The skin lesions called psoriatic plaques often harbor bacteria that can lead to wound infections. Complications from infection can lead to further joint destruction and even systemic infection resulting in death.

Studies reporting the long-term results of surgical management of psoriatic arthritis are limited. In general, there appears to be some improvement in pain and function but stiffness and recurrent, progressive disease are common.

I’ve had psoriasis for a long time now. Thought I’d check in and see if there’s anything new. Give me a quick refresher, won’t you please?

There is a new review article out on psoriatic arthritis from surgeons from New York University Hospital for Joint Diseases. They bring us up-to-date on this condition with a good discussion of causes, symptoms, the diagnosis, and treatment. Complications of medical management and outcomes of treatment are also presented.

Psoriasis affects a small portion of the adult population in the United States (somewhere between 0.6 to less than five per cent). Men and women who develop psoriatic arthritis are usually in their 30s and 40s. Skin changes may appear first but some people notice joint pain, stiffness, and swelling before they break out.

The reason psoriatic arthritis occurs still remains somewhat of a mystery. There is a genetic link for some patients that is associated with trauma or infection. But exactly why the immune system goes haywire in this fashion is not clearly understood.

Studies show that there are actually five different types of psoriatic arthritis based on clinical presentation. In all cases, the hands are the main area affected but the toes, spine, and sacroiliac joints can also be involved. The different patterns are seen in which joints are affected, whether the condition is symmetric (affecting both hands at the same time), and the severity of the joint destruction.

There is still no special blood or lab test that can diagnose the problem. Most of the time, the diagnosis is made based on the physician’s examination and observations of the patient. Of course, X-rays clearly show joint erosion, damage, and deformities in the later stages of the disease. X-rays of the hands, feet, and spine are recommended to make sure all areas affected are identified and treated.

Treatment remains a matter of medical management. In fact, it could be said that “it takes a village” to treat psoriatic arthritis. Dermatologists, rheumatologists, medical doctors, and physical therapists must work together to guide the patient and prevent as much damage as possible.

The specific treatment approach used is individual and based on symptoms and severity of the disease. It is recognized now that early aggressive treatment with medications to control the disease process is important. Medications typically prescribed include antiinflammatories and disease modifying antirheumatic drugs (DMARDs).

New treatment called biologic treatment uses special immune-blocking agents to stop the inflammatory process at different points in the cascade of events leading to the effects of this disease. If there is severe joint destruction and damage, surgery may be needed to reduce pain and improve function. A variety of different surgical procedures can be used including debridement (cleaning the joint of thick tissue and debris), joint fusion, and joint replacement.

Studies reporting the long-term results of surgical management of psoriatic arthritis are limited. In general, there appears to be some improvement in pain and function but stiffness and recurrent, progressive disease are common. There is a need for more studies to report on the results of treatment to help guide physicians, surgeons, and patients in making the choice that will yield the best outcomes.

I just added a new word to my medical vocabulary: myofascial trigger point. Turns out that’s what’s been causing my neck and arm pain. A physical therapist figured this out and now I’m getting the right treatment for the problem. Can you tell me a little more about this condition?

Trigger points are defined as hyperirritable areas of tenderness in a muscle that when pressed or pinched can cause local and/or distant referred pain (e.g., someplace else down the arm or leg). Trigger points can be active (currently already causing pain) or latent (only painful when pressed or pinched).

Trigger points are common in the neck, upper trapezius, hip, back, and buttock regions. These are areas where muscles often contract without relaxing causing a build up of tension. Over time, the muscle itself forms a taut band of tight, static tissue instead of elastic, flexible muscle. In the center of this taut band is a pinpoint area that when stimulated can cause the pain of a trigger point.

Physical therapists often treat this problem using a variety of techniques that may be noninvasive or invasive. Noninvasive approaches include massage, stretching, and ultrasound. Invasive treatments include dry needling and corticosteroid injections. Dry needling refers to using needles to stimulate the trigger point without actually injecting any medication or other substances.

In a recent study, physical therapists from Tehran University of Medical Sciences in Iran used three different treatments for latent trigger points of the upper trapezius muscle. There were four total groups all together (phonophoresis, pressure release, ultrasound therapy, control group). Participants in each group were all women who had a positive trigger point of the upper trapezius.

Phonophoresis is a way to use ultrasound to push a topical corticosteroid (antiinflammatory ointment applied over the skin) through the skin into the muscle. Pressure release is the application of sustained pressure to the trigger point until pain is reduced.

Ultrasound therapy is the same as phonophoresis but without the corticosteroid cream — just the sound waves applied over the surface of the skin but directed down toward the bone. The sound bounces back off the bone and creates heat to the muscle tissue. Of course, the control group received no treatment but was measured before and after just the same.

Before treatment, the physical therapist measured each woman’s pain level, pain pressure threshold (PPT), and neck range of motion. These same measurements were taken after treatment and compared for each group. Pain pressure threshold was measured using a special device called a dual inclinometer. Pressure was applied to the trigger point until pain was created. The amount of pressure required to elicit pain was recorded as the pain pressure threshold.

The results showed that the women in all three treatment groups had decreased pain, decreased pain pressure thresholds, and improved neck motion. The control group stayed the same without improvement in any area.

The phonophoresis and pressure release techniques yielded better results than the ultrasound. Phonophoresis outperformed pressure release. The mechanisms by which these treatments work to reduce the effects of trigger points aren’t entirely clear yet.

Some experts suggest the increase in blood flow to the area from phonophoresis helps clear out substances in the area that cause pain. Pressure release may help by lengthening the muscle fibers themselves. Once the pressure is removed, there is a release of antipain hormones (e.g., endorphins, enkephalins), thus blocking pain and making it possible to move once again. Ultrasound may not have been as effective as phonophoresis or pressure release because a pulsed form of ultrasound was used that does not generate any heat to improve circulation.

The authors concluded that phonophoresis and pressure release are both good treatment techniques to relieve the pain and loss of motion caused by trigger points of the upper trapezius muscle. Both treatment approaches are safe and effective providing relief of painful symptoms without adverse effects.

My brother has this annoying habit of coming up behind me and pinching the muscle above my shoulder. He says it’s the “Vulcan death grip.” I can believe that because it is incredibly painful. Brings me to my knees every time. What is he really pinching and what can I do to stay relaxed and unresponsive to this technique?

Star Trek lovers are familiar with the “Vulcan nerve pinch”, a technique used by Dr. Spock to cause someone to lose consciousness. The technique was to pinch a pressure point at the base of the victim’s neck but in fact, it’s likely the pinch was in fact a trigger point (TrP) of the upper trapezius muscle. The upper trapezius muscle is the muscle along the top of the shoulder at the base of the neck (where the neck and shoulder meet).

Trigger points are defined as hyperirritable areas of tenderness in a muscle that when pressed or pinched can cause local and/or distant referred pain (e.g., someplace else down the arm). Trigger points can be active (currently already causing pain) or latent (only painful when pressed or pinched).

Physical therapists often treat this problem using a variety of techniques that may be noninvasive or invasive. Noninvasive approaches include massage, stretching, and ultrasound. Invasive treatments include dry needling and corticosteroid injections. Dry needling refers to using needles to stimulate the trigger point without actually injecting any medication or other substances.

Two other techniques that have been shown to work well include phonophoresis and pressure release. Phonophoresis is a way to use ultrasound to push a topical corticosteroid (antiinflammatory ointment applied over the skin) through the skin into the muscle. Pressure release is the application of sustained pressure to the trigger point until pain is reduced.

Some experts suggest the increase in blood flow to the area from phonophoresis helps clear out substances in the area that cause pain. Pressure release may help by lengthening the muscle fibers themselves. Once the pressure is removed, there is a release of antipain hormones (e.g., endorphins, enkephalins), thus blocking pain and making it possible to move once again.

Whether you are the victim of the Vulcan nerve pinch or simply a neck pain sufferer from trigger points of the upper trapezius muscle, ask a physical therapist to apply either or both of these treatment techniques. Experience the safe and effective relief of painful symptoms without adverse effects that phonophoresis and/or pressure release have to offer.

What ever happened to stem cell research? I thought this was going to be the miracle cure for all diseases including arthritic joints. I’m definitely interested!

Stem cell research originally got stymied by lack of approval and funding from the White House (under former President Bush’s administration). But now under the Obama plan, approval of stem cell research has moved ahead. Funding is still always what holds back any scientific or medical research.

Some of the newer ideas involving tissue engineering (like using stem cells and growth factors in healing) appear to have lots of potential for clinical application. But they have not produced the kind of positive results expected. The reason for this disconnect isn’t clear yet but it is something scientists are paying attention to and exploring further.

Here’s what we know so far. First, when it comes to using stem cell therapy during surgery to reattach a torn tendon to the bone, it looks like more research is needed. Before this treatment can be successful, scientists must find ways to signal stem cells to form the different cells needed at the insertion site. The goal is to find ways to use the patient’s own stem cells (rather than injecting donor stem cells from someone else) to form what is needed at the specific site of injury.

The results of studies so far suggest that this transition site from tendon to bone is very complex. In normal anatomy, joint stability, and movement, there is a load transfer from tendon to bone. Tendon and bone are two uniquely different types of tissue. One type of stem cell may not be enough to accomplish the task of restoring normal anatomy and function. Some cells must be formed of stiffer collagen fibers for bone while other cells remain soft and flexible to form tendons.

In the area of osteoarthritis research, researchers continue to focus on understanding what happens to the joint cartilage in the formation of osteoarthritis. Scientists have been able to identify key molecules involved in the process. Applying this information to mice has resulted in decreased osteoarthritis.

Right now, various types of growth factors are being tested in the treatment of joint pain from early osteoarthritic changes. It has been discovered that when osteogenic (bone) protein is combined with insulin-like growth factor joint regeneration is possible.

Other biologic therapies for the regeneration of tissue such as joint cartilage currently under investigation include autologous conditioned (blood) serum and bone marrow concentrate. Autologous refers to the body’s own cells. Any time autologous sources of cells can be used, it is considered an advantage both in terms of (lower) cost and (easy) administration.

Most of these ideas are still being investigated in the laboratory and are not yet fully available to the public at large. Your orthopedic surgeon will be the first one to let you know when new, innovative treatment is available.

In the meantime, studies do show that strengthening and flexibility exercises are still the best way to control joint flare ups from osteoarthritis. If you are interested in a specific program of supervised exercises for this problem, see a physical therapist. The therapist can get you headed in the right direction and help keep you on track for the best possible outcome with conservative (nonoperative) care.