Fearless cardiologist author, Dr Aseem Malhotra, busts myths and shares Pioppi health secrets

One of the most influential cardiologists in Britain and a world leading expert in the prevention, diagnosis and treatment of heart disease, Dr Aseem Malhotra is a brave advocate for public health initiatives. An award-winning NHS cardiologist, Dr Malhotra has successfully motivated leading academics, the media and politicians to make sugar reduction a health priority in the UK. His academic publications can be found in the BMJ and BJSM (see links below) and he is prominent in mainstream media. He recently published what is already a best-seller, “the Pioppi Diet: A 21 day lifestyle plan”.

For more BJSM (British Journal of Sports Medicine) podcasts click here: BJSM Podcasts

Genicular Nerve Radiofrequency Ablation for Select Patients with Persistent Pain

An option for difficult-to-treat chronic knee pain

By Michael Schaefer, MD, and Robert Bolash, MD

Chronic knee pain is often a challenging condition to treat. Pharmacologic interventions commonly fail to provide adequate relief and can be limited by adverse effects. Corticosteroid injections provide only temporary relief, while hyaluronate injections are expensive and controversial. Newer “regenerative” injection treatments such as stem cells and platelet-rich plasma are still considered experimental and are often not covered by insurance. Surgical interventions for joint preservation are limited, and total joint replacement is often not an option for young or obese patients. Even after arthroplasty, unremitting knee pain continues to afflict some patients.

Radiofrequency ablation for genicular nerves (GNRFA) is a relatively new and lesser-known treatment option that is proving effective for certain patients. A randomized controlled trial demonstrated significant improvement with GNRFA throughout the 12-week follow-up period. At Cleveland Clinic, we consider patients for GNRFA who have failed or are excluded from other treatment modalities. The process begins with a diagnostic genicular nerve block.

Diagnostic Process

Genicular nerve blocks can be performed under fluoroscopic or ultrasound guidance. Nerves are targeted adjacent to the periosteum on the medial aspect of the tibia, and at both the medial and lateral aspects of the femur at the junctions of the shaft and the epicondyle.

Under fluoroscopic guidance, we approach the target by introducing a spinal needle from either an anteroposterior or lateral entry point with the final position residing adjacent to the bone. After negative aspiration, some physicians elect to administer contrast to exclude vascular uptake, avoiding a false negative result. To conclude the procedure, 2 mL of local anesthetic is deposited on each of the superolateral, superomedial and inferomedial genicular nerves.

While GNRFA performed under fluoroscopic-guided requires a procedure room, the ultrasound-guided procedure can be performed conveniently in the outpatient clinic setting without radiation exposure. In addition, two recent studies suggest ultrasound guidance improves accuracy of the diagnostic block by localizing arteries and soft tissues adjacent to the nerves. Again, all three genicular nerves are routinely injected – the superomedial, superolateral and inferomedial branches. Other branches have been reported to innervate the knee, but they are not suspected to carry as much nociceptive output from the joint, so injecting them may be less effective. In patients who report pain only on the medial side of the knee, the physician may choose to inject only the medial-sided nerves.

When to Proceed to Therapeutic Ablation

If the diagnostic injection produces at least 50 percent pain relief on a numeric rating score reduction, the patient is deemed a candidate for GNRFA. Exclusions include systemic or local infection and electrical devices implanted in the region of the radiofrequency ablation. Additional vigilance is required in the presence of anatomic deformities or implantable cardiac rhythm devices when considering GNRFA because of the potential for a defibrillator to interpret radiofrequency as a shockable dysrhythmia. GNRFA can successfully be performed with arthroplasty or with other orthopaedic hardware in place.

The GNRFA procedure is typically performed with local anesthetic, although moderate IV sedation may be offered. Either ultrasound or fluoroscopic guidance may be used. Following local anesthetic infiltration, a radiofrequency cannula is guided in proximity to the locations of each nerve. Sensory stimulation can be used to confirm accurate placement. Motor stimulation is also performed to ensure the absence of adjacent motor fibers.

After positive confirmation of sensory placement and negative motor testing, 2 mL of 2 percent lidocaine is administered adjacent to the nerve to mitigate pain associated with radiofrequency lesioning. Radiofrequency ablation is performed at a temperature of 70 C for 90 seconds.

Postprocedurally, patients remain ambulatory and often return to work on the subsequent day. A few days of localized soreness is expected following the procedure with typical final results realized within one week.

Pain Relief Can Be Long-lasting

While Choi showed that relief continued for 12 weeks, in our practice, we have seen many patients sustain even lengthier analgesia, at times approaching a year. The GNRFA may be repeated if symptoms return.

GNRFA is a suitable management option for a subset of patients with inadequate response to more conservative modalities and even for those with postsurgical refractory knee pain.

Dr. Schaefer is Director of Musculoskeletal Rehabilitation at Cleveland Clinic.

Dr. Bolash is an anesthesiologist and interventional pain management specialist in the departments of Pain Management and Evidence Based Pain Research.

Jun. 2, 2016 / Orthopaedics / Research

This article appeared in ConsultQD of the Cleveland Clinic

Genicular Nerve Radiofrequency Ablation for Select Patients with Persistent Pain

 

Letter to Our Patients

D O N A L D L A K A T O S H, M D
Orthopedic and Sports Rehabilitation

407 North Forest Park Blvd, Knoxville, Tennessee 37919 Tel: 865 577.1914 Fax: 865 577.1714

August 30, 2017

Dear Patients,

To begin, I want to thank you for the trust you have given me over the years as your physician. Taking care of you has been an honor for my staff and me.

I also want to let you know of some changes in my practice. As of September 6, 2017, my office will be relocating to 407 North Forest Park Blvd, in the Bearden area of Knoxville. My telephone number (865) 577-1914 and fax number (865) 577-1714 will remain the same. My Seymour and Fort Sanders West offices will be closing as of September 1, 2017.

Additionally, beginning January 1, 2018 my medical practice will no longer be participating in any insurance plans. What does this mean to you? I am still available to provide care, but it will be on a cash rather than insurance fee schedule. I will not be filing or participating with any insurance including Medicare.

A cash only model will enable me to provide care with greater efficiency and equal or lesser expense. I will be posting a fee schedule for services on my website, www.drlakatosh.com. Many of my services are currently not covered by insurance such as Regenerative Injection therapy, i.e., prolotherapy, PRP etc. This was a factor in making this transition in that I plan to focus more on Regenerative Medicine. Impairment ratings for the Department of Labor EEOICPA program will not be affected by this change.

This type of medical practice may not be for everyone. Because of this, I am providing a list of physicians who accept insurance from which you can choose. I will continue to be the custodian of your medical records. At your request, I can send your medical records to fellow physicians assisting in your care.

If you have questions or concerns please contact my office at 865 577-1914.

Sincerely,

Donald A. Lakatosh, M.D., FAAPMR
CAQ Sports Medicine

Whole Body Vibration Training (WBVT): It may be good to shake things up.

Whole Body Vibration Therapy is a passive exercise using vertical directional force against gravity. This creates what some refer to as “hyper gravity”.  Our body responds subconsciously to vibration frequencies of 23 Hz or higher by contracting muscles fibers. This is because the stretch receptors in our muscles and tendons are activated; they respond by rapidly contracting and relaxing every 2-3 seconds resulting in a near 100% activation of muscle fibers, a response that otherwise can only be achieved by extended weight training.  This in turn activates a cascade of physiological responses that can improve bone mass, circulation, and balance. There is also a release of hormones such as human growth hormone (HGH) and serotonin. The benefits include increased muscle tone, prevention of osteoporosis and improved balance to name a few.

Below is a list of potential benefits which are linked to a scientific article. I also linked to Dr. Mercola’s “Peak Fitness” which discusses Whole Body Vibration Therapy. Below are 2 videos demonstrating WBV; one on “The Doctors” and another on Advanced Whole Body Vibration Workout.

The Many Health Benefits of Whole Body Vibrational Training (Dr. Mercola)

 

10 Reasons to consider prolotherapy

1.      Promotes Natural Healing

2.      Minimal Recovery Time; days to weeks

3.      Usually takes 1 hour or less

4.      Much less complications than surgery or steroids

5.      Less expensive than surgery when factoring deductible and co-pay

6.      Does not require general anesthesia

7.      Minimally invasive. No incision or stitches

8.      Can treat more than 1 area in the same visit (i.e. knee and elbow)

9.      If effective, does not require repeated injections like steroids.

10.   Does not prevent future surgery if needed

Strike a Pose. It may help you run faster

I was recently listening to a podcast from the British Journal of Sports Medicine interviewing Dr. Jon Finnoff of the Mayo Clinic Sports Medicine Department discussing chronic exertional compartment syndrome, i.e. leg pain with activity. Dr. Finnoff mentioned modification of running technique, specifically the Pose Method as a treatment.

The Pose Method is a technique developed by Dr. Nicholas Romanov in 1977.  Dr. Romanov, an Olympic coach for the former Soviet Union, discovered that modifications in body position during an activity can improve performance.  The Pose Method has the body “posed” to optimize efficiency.  I became aware of the Pose Method some years ago when I developed chronic exertional leg pain affecting the anterior compartment, i.e. shin.  By modifying my running, utilizing the Pose Method, and transitioning from cushioned heeled shoes to a “minimalist” shoe resolved my symptoms.  This changed my stride from a hard heel strike to a mid-foot or forefoot strike increasing efficiency and decreasing the eccentric demands (work) of my shin muscles.  My symptoms resolved, and I now run pain free.

The Pose Method does require some coaching and understanding of the mechanics of the activity whether it be running, throwing or swimming.  Here is a link discussing the Pose Method which explains in some detail the theory, principle, and training techniques.

Here is Valerie Hunt’s Top 5 Tips for Learning the Pose Method

1.    Start by learning the Pose position.

2.    Practice falling.

3.    Learn to pull your foot properly.

4.    Change support between the Pose positions.

5.    Develop a rapid cadence.

If you are having some pain with your athletic activities such as running, consider the Pose Method.  Find someone who is trained in this method to help.  It is a 12-week program, but in the long-term be the key in decreasing injuries and improving performance.

Here is a of video showing how the Pose Method can improve running efficiency.

Are you in the Zone?

Several years ago, I had the pleasure of hearing Dr. Barry’s Sears, a world-renowned biochemist, speak about omega 3 fatty acids, inflammation and being  in “the Zone”.  His lecture has influenced the way I view diet, the treatment of inflammation, and illnesses such as arthritis and muscle pain.

Dr. Sears identifies specific chemicals in our body that increase and decrease inflammation and developed to an ingenuous way of using these to measure our body’s inflammatory state.

The key chemicals Dr. Sears chose to monitor are fats known as lipids and measure the ratio of Triglycerides (TG) to High Density Lipoprotein (HDL), the ratio of arachidonic acid (AA) to eicosapentaenoic acid (EPA) and the blood level of hemoglobin with glucose attached known as HgbA1c. Together these markers can tell how much inflammation is present in our body as well as monitor our body’s response to diet.

Below is information from Dr. Sears’ website  www.zonediet.com/the-zone-diet/

 

Clinical Marker Ideal Value What It Indicates
TG/HDL ratio
From your diet.
< 1 Level of insulin resistance in the liver.
AA/EPA ratio
From your diet & fish oil.
1.5-3 Level of diet-induced Inflammation in the body.
HbA1c
From your diet & polyphenols.
5% Level of Advanced Glycoslated Endproducts (AGE) tied to your blood glucose

 

AA/EPA Ratio Cellular Inflammation Future Wellness
1.5 to 3.0 Low Excellent
3.1 to 6.0 Moderate Good
6.1 to 15 Elevated Moderate
Greater than 15 High Poor

 

Benefits of being in the Zone include:

·        Losing excess body fat at the fastest possible rate

·        Maintaining wellness for a longer period of time

·        Performing better

·        Thinking faster

·        Slowing down the rate of aging

 

I welcome you to visit Dr. Sears website www.thezonediet.com to learn more and see if you are in the Zone.

Medical Nutrition Therapy (MNT)

What Is Medical Nutrition Therapy (MNT)?

Medical Nutrition Therapy is a treatment based on nutrition that examines an individual’s nutritional status and nutritional needs. It may add or eliminate foods and/or nutrients to improve medical conditions such as diabetes, heart disease or gastrointestinal disorders. This may be accomplished by simply modifying a person’s diet or involving testing for nutritional deficiencies or sensitivities. The goal of Medical Nutrition Therapy (MNT) is to insure your body is getting the right “fuel” to maximize function.

Here are several articles that review Medical Nutrition Therapy:

The Evidence for the Effectiveness of MNT in Diabetes Mgn

Probiotics and Medical Nutrition Therapy

Example of the conditions treated with Medical Nutrition Therapy:

  • Celiac disease
  • Diabetes Mellitus, Type II
  • Overweight/Obesity
  • Crohn’s disease
  • Food allergies
  • Food intolerances
  • Gastroparesis (Slow Stomach Emptying)
  • Gastroesophageal reflux disease (GERD)
  • Inflammatory bowel disease
  • Ulcerative colitis

What to Expect from Medical Nutrition Therapy:

A medical nutrition therapy program will teach you what you eat is just as important as how you eat and how it makes you feel. Your therapy starts with a comprehensive nutrition assessment.

How it works:

A registered dietitian works with each client individually to create a realistic meal plan and determines appropriate lifestyle changes needed for a healthy lifestyle. Medical Nutrition Therapy is tailored to each client’s needs under the direction of the physician. Testing such as a Mediator Release Test (MRT®) or measuring of blood levels of vitamins and minerals may be considered.

Medical Nutrition Therapy is a tool to help you learn how to achieve a healthy lifestyle and feel better doing it.

“Let food be thy medicine and medicine be thy food”
                                                                        Hippocrates

Knee replacement? There are more options.

Knee osteoarthritis can be painful and disabling. Above age 50 years, 25% of Americans will experience symptomatic knee osteoarthritis. There are approximately 700,000 total knee replacement surgeries each year. It has become almost a right of passage as we age to have a joint replacement with the average cost being almost $50,000. There is also rehabilitation after surgery requiring weeks to months. This surgery is very successful, but there are alternatives.

Several factors predispose many of us to osteoarthritis.  Some risk factors we can control like weight and smoking. However, there are others we cannot control like genetics. Some of these are listed below. Knee osteoarthritis prevalence, risk factors 2011

Risk Factors:

  • Demographic characteristics and family history – Female, Increasing Age, Genetic, Family History.
  • Obesity and metabolic syndrome – Just one pound of weight gain causes 6 pounds of increased stress on the knee.
  • Nutritional and vitamin factors- Deficiency in Vitamins D, K2 and C may accelerate osteoarthritis.
  • Bone density and bone mass – Loss bone mass results in increased risk.
  • Smoking – Increased risk of painful osteoarthritis.
  • Other individual risk factors – Low birth weight, Pre-term birth

Things you can do:

There is no assurance that a knee replacement can be avoided, especially in advanced osteoarthritis, but hopefully, my list of alternative treatments will help reverse the progression of the disease before a knee replacement is necessary.

Metagenics Science Based Supplements: Now Available to Our Patients

Metagenics, a triple GMP-Certified medical nutrition company, has partnered with SPORTBLUE to make their products available directly to our patients.

  • Certified Gluten-Free
  • Over 100 vegetarian supplements
  • Science Base Products
  • Non-GMO ingredients

Ask Dr. Lakatosh or his staff what is the right supplement for you. There are supplements we recommend for effective healing of muscle, tendon, and ligament injuries. These supplements also help maximize the benefit of Regenerative Injection Therapy (RIT), such as Prolotherapy and Platelet Rich Plasma (PRP) injections.

Remember, though the supplements recommended are of the highest quality, they may interact with prescription medications or other herbs and supplements. Before beginning supplements make sure you discuss with Dr. Lakatosh or your provider.

Nutrition counseling will be a part of SPORTBLUE in the near future to help guide your choice of foods and supplements to maximize recovery and maintain health.