Reddit CCI - Q and A

[00:00:02]Hi, it's Dark Centenno. Uh, thanks so much for joining me this morning at our new 9:00 am Mountain time on Sundays.

[00:00:10]Uh, that's 11 a.m. Eastern time, obviously 8:00 a.m. Pacific time. So, today I thought I'd do something a little different. You know, normally I get on here and sort of give a short lecture about a topic and then uh lots and lots of Q&A.

[00:00:26]This time I thought, you know, I'd just review Reddit. Um because you know sometimes as a busy doctor with a lot going on I you know do shorter answers on Reddit. Now listen I I check the Reddit sub for RPCL. If you don't know about that that's a a sub I have on Reddit where I answer patient questions about CCI the PCL procedure and other things. And I check that quite a bit. Uh having said that, because I'm super busy, sometimes I can just throw in a couple sentences as an answer. Um so I thought I'd use this opportunity uh to go through and try to provide some deeper answers to some of the questions here and then obviously still opening up to questions uh online. So what does that mean? I'll probably spend 10 minutes or so going over the uh questions on Reddit and then I'll switch into live Q&A mode. Um so if you have questions just put them in the comments no matter where you are and I'll see them on my end. Uh, and the sooner you get into your questions, the better because usually what ends up happening here is I can't get to all the questions. And because I can't get to all the questions, uh, that's kind of a bummer. I always feel bad if there's 10 or 20 questions at the end of all this.

[00:01:53]So, just try to get those in uh, early.

[00:01:55]All you do is just put your question in the comments either on Facebook or YouTube.

[00:02:02]So again, if you're just joining us, the focus here is just to spend a little time going through the Reddit sub, introducing everyone to the Reddit sub if you don't know about it, and then giving some deeper answers to some interesting questions uh that are sitting on Reddit. And then we'll go into our live Q&A mode. So again, uh if you're just joining us, go ahead and put your questions uh in the comments and I'll get to those. The sooner you get them in, the better.

[00:02:31]So, uh, let's see. Let's start going through this. This is the Reddit sub.

[00:02:35]Uh, it's RPICL or RPICL on Reddit. Uh, there's a welcome post here. Uh, the welcome post goes into all sorts of stuff. Um, it introduces me, gives our website, it gives the YouTube channel, the CCI guide and workbook link, uh, link to my book on CCI, uh, a link to an app I created to answer patient questions, an app I created to track and learn about the clinical outcomes of the PICL procedure, my scientific publications, a short information sheet on CCI to educate physicians, So bottom line is as I get new stuff uh to help patients, I I generally put it into that welcome post. Uh there's also rules for the EPICL proono program for those in financial need. Uh we do one of those procedures every month where we do it for free. uh those are focused on patients who are at higher need levels um financially as well as uh optimizing for someone who we think is going to do really well with a PICL procedure.

[00:03:52]So let's go through the these here and see what's interesting. This is a good one here. I like this one this morning from key seaworthiness uh about PCL versus posteriors. Um, I thought this was a really good one. So, it says if the patient has had several PCL's, what would be a deciding factor if a patient just needs posteriors and is done with PCL? So, we find ourselves in this situation quite a bit, right?

[00:04:17]There's some instability we see on flexion extension upright MRI or there's some uh instability we see on DMX. And then ultimately at some point we have to ask the question is that person fully stable now after a couple of PCLs and should we just be focusing on some posterior injections injecting structures that are bothering someone and to understand this question and its answer. You need to conceptualize this as sort of two big components right there's the instability component which then drives the injured structure component. the injured structure component, upper neck joints, nerves, all that stuff is what causes the symptoms and drives the symptoms.

[00:05:05]The instability piece um can also drive the symptoms, but you know there are times when we fix the instability piece and the symptoms are still there. Why is that? That's because the structures are still damaged or vice versa. There are times that we don't fix the instability piece and the symptoms are much better.

[00:05:26]Why is that? Because we're fixing the structures causing the symptoms. So, uh, in this particular case of where we get to that place, let's say we're three PCL's in and we're scratching our head saying, should we do another PCL?

[00:05:39]There's a couple things we can do. Uh the first most obvious one would be if that person is holding now in upper cervical chiropractic for let's say they started out holding only a week now they're holding for 6 months to a year then we're probably only going to do one more PCL or not do another PCL. Um or we can recheck a DMX.

[00:06:03]We can recheck an upright MRI and try to look at the metrics, the movementbased metrics that would change and try to see if those have normalized. And that's another way to decide. And then finally, a third way to decide would be if that person is just able to do a lot more functionally without a flare up. So let's say they started bedbound, but now they can do most things functionally without flaring up. That's also another hint that we may be close to ending up the stability portion and maybe trying to pick up a few small little problems that we see here and there.

[00:06:43]Um, okay. So, that's the first question I thought was super interesting on the Reddit sub. Uh, let's try to get something else here.

[00:06:58]So, this is an interesting one here.

[00:07:01]Steroid drops. Um, because this is a problem or this is a question I often get. Uh, I have posterior PRP in a week with you guys. I have scleritis of the eye and I'm supposed to take steroid eye drops. Is it okay if I block my duct when taking them?

[00:07:18]Is it the only thing that is going to treat this? Would I need to reschedule?

[00:07:22]Would I forfeit my deposit?

[00:07:24]So ultimately here there's a few layers.

[00:07:27]The first layer is the steroid layer, right? Uh let's unpack that a little bit. So steroids are powerful anti-inflammatories. They can be incredibly effective in reducing inflammation, but they have a negative side effect of uh sort of blocking healing. And we know that because there's lots of studies that show that stero steroid use, and we're talking cortico or anti-inflammatory steroids, not bodybuilder steroids, that steroid use can kill off bones, cause osteoporosis, um can really, really, really reduce someone's ability to heal after, let's say, uh a major injury and more importantly dramatically increase the risk for infection. ction in that patient who's getting steroids. Now, having said that, here steroid eye drops are sort of an a level down. Um, you're not going to get as much into the system as you would in other ways. Um, so if we're focusing here on something like a PICL where we're relying on mezenymal stem cells in the bone marrow to do the healing, then I would say you'd probably want to postpone this or we'd have to have a heart-to-heart on whether or not this might block the messenal stem cells from doing what they're supposed to do and healing those ligaments. However, we do have some early data that shows that PRP injections are not as impacted by steroid use. In fact, they tend to rescue the body's um lack of healing by steroids. So, if this is just a steroid posterior or I'm sorry, if this is just a posterior injection with PRP and uh platelet based stuff as it says here, then I don't think there's an issue. I would play through on the steroids given these clinical uh given this clinical situation.

[00:09:34]Then I'll take one more and then we got some questions that are accumulating. Uh so let's see here.

[00:09:52]Yeah, I like this one from two days ago.

[00:09:55]Uh, desperate comfort 582. Returning to contact sports after PICL ligament healing and reinjury risk. Uh, because this is the question I get a lot, right?

[00:10:04]What can I do after this? Now, I'm not usually getting the question, hey, can I return to boxing or can I return to hang gliding after uh a PCL procedure? But I do get the general question of hey um what can I do and what can't I do after this kind of procedure. So the question is hello Dr. Centenno I have a question regarding long-term outcomes of PCL procedure specifically concerning high impact activities. Once the PCL process is complete the new tissue is fully matured. How does the tensional strength of this newly generated ligament tissue compare to the original healthy ligament? For an athlete looking to return to high contact sports like boxing, how prone is this regenerated tissue to reinjury or stretching due to the forces of the sport? So this is a little bit extreme, but maybe the answer is also the less extreme questions. Um so when it comes to returning to well let's go back a little bit. If we start with a concept of how strong is this tissue, the best way I can answer that is through our ACL ligament healing research. We did a randomized control trial where we injected damaged uh knee ACL ligaments with the same bone marrow concentrate mix that we're using for PCL. That's a ligament we can follow um really nicely on MRI. That's a ligament I can also follow on clinical exam. I can actually test it in the knee to see if it's firming up. and we got really good results there. And long-term it looks like those patients were able to return to really full activities. Now, none of them were professional athletes.

[00:11:42]They were all sort of weekend warriors, so no one's going back to playing in the NFL. Uh but it is important to note that they returned. So, the answer is the ligament is probably pretty strong if it responds. The problem that we have though with CCI is that we have a lot of muscle atrophy that happens. We have a lot of damaged structures that occur. So assuming we got good healing of the ligament, assuming we got uh those muscles strong again and assuming you were able to we were able to get those structures, let's say upper cervical facetses 90% healed, the answer would be theoretically yes. But I would always have the concern that we're not getting 100% fix here. In the same way that you would look at um fusion, right?

[00:12:43]I don't think there's any responsible surgeon that would say after a C1C2 fusion, you can go back to boxing.

[00:12:50]Uh they're not going to stop you, but they're also going to say that's probably not the best idea. So, my answer has got to be the same. That's probably not the best idea. We have had people return to higher impact things like jiu-jitsu grappling.

[00:13:05]Um but that person also modified what it is they did. So at the end of the day for this particular question uh ligament tissue fairly robust more stuff to rehab including the surrounding stabilizing muscles and assuming we get a good fix of the other damaged structures and I think within reason returning to sports is something that you can do but direct contact to the head sports probably not a great idea. Okay. uh really just trying to give us some time to get some good questions on the board. We got some good questions on the board. So, uh I'm just going to give another shout out before I go to those questions. The RPICL sub. Um there's really two of these that I recommend. This is for questions to me directly on Reddit. It's RPICL and I check it all the time. I answer a lot uh as many people know. The other way is there's a CCI uh Facebook group uh run by Dan uh Seamrad and uh that's a patient only one. I don't participate in that one on purpose because I wanted and he wanted sort of a patient safe space.

[00:14:19]So if you can go there uh to get your uh to get your patient to patient questions answered uh then that's a good spot. If you're trying to ask me a question, then this is a a a good spot. Okay, let's go to some other questions. Let me remove that, change this up a little bit, and we will go to our first question here, live question. So, first live question.

[00:14:47]So-called uh case so-called comprehensive regen joint includes both intraarticular and extra articular ligament and tendon attachments. Uh when do you do yours? Are you injecting all the extra articular attachments?

[00:15:03]Yeah, Casey. And so, if we're talking about what we would call the functional spinal unit, a functional spinal unit is made up of a couple things, right?

[00:15:14]You've got the actual joint there. In that case, that'd be the facet joint.

[00:15:20]You've got a disc up front. You've got the ligaments that surround all of that.

[00:15:25]And then you've got the muscles that come with the attachments. Now, you could also kind of throw in the joint capsules, but as I've said before, if someone's talking to you about injecting facet joint capsules, that's a dead giveaway for someone who doesn't really have the experience to do this right. Uh because to do this right, you have to get into the facet joint. And that's something that you can only really do very well under fluoroscopy with contrast confirmation. you can do it kind of okay under ultrasound but you're not sure if you're in the joint uh in the same way you are using fluoroscopy with contrast and uh so but the answer is yes so when we inject uh and we look at let's say treating facet joints in one of our CCI patients we are doing intraarticular inside the joint we're confirming that with contrast we're doing the facet capsule on the way out of the joint uh and we are also then injecting into those tendons on the way out of the joint. Realize that once you're in the joint, which is your deepest structure, you can inject on the way out and get all of that stuff. Then we're also adding in the associated ligaments and oftent times treating an irritated nerve at that level and every once in a while treating the disc itself. So yes, a very comprehensive plan bigger than the prolo shotgun plan that I think you're you're talking about.

[00:16:58]Uh Casey, any pharmacologic treatment that works for central or peripheral sensitization that you use or could use?

[00:17:06]Yeah. So if you're talking about central sensitization, let's unpack what that is. Central sensitization means that a little bit of stimulus causes a big amount of pain. So for example, let's say a centrally sensitized patient goes for a massage.

[00:17:23]God, that blows things up for weeks for them. Uh that doesn't do that for someone who doesn't have central sensitization. Now, are there medications that you can take for that?

[00:17:34]You can. The best one I have seen is Lica or Pregablin. Uh Lica tends to calm that storm. The problem is the storm's still there. All LA is doing is kind of suppressing the wind speeds, if you will. it's not really treating anything.

[00:17:49]Uh so therefore, it's going to be a lifetime med. If you want to fix central sensitization, you got to fix the thing that's starting the fire uh of the central sensitization. And that would be finding those structures, the facet joints, the instability, the irritated nerves, and treating those. But in a centrally sensitized patient, it's a less is more dance to try to make sure you're not really causing too much havoc as you go.

[00:18:16]Um, Caseian, does Vegas nerve misbehavior contribute to central peripheral peripheral sensitization?

[00:18:26]You know, that's an interesting one, Caseian. Uh, I can't say that I've seen great literature on that. I mean, the Vegas nerve has a lot of functions and some functions are still being found.

[00:18:40]Um, so let's see here.

[00:18:46]I'm interested in that one as well.

[00:19:08]So, uh, I will use Jiren of AI from time to time. Uh, let me share that that screen there. But I probably use different prompts than you guys use. Uh, so it's it's probably a good thing to to show you.

[00:19:39]Okay. So, uh does the Vegas nerve have a role in central sensitization site peer-reviewed medical literature? So, I I you know always try to make sure that if I'm using something like chat pt claude etc that I hold its feet to the fire and it has to actually site literature that I can go back and check to make sure it's telling me the right things. Um so the answer here is yes.

[00:20:04]Vegas nerve appears to modulate several processes involving central sensitization although evidence that veagal dysfunction is a primary cause of central sensitization in humans remains limited. Yeah. So I think the answer is mechanistically it could make sense uh but we don't have much human evidence to show that that's the case. And you can see here it's cited various uh studies for me. So I can then go and and follow through in this study and make sure it's really talking about what it is it says.

[00:20:36]So that way I I don't get into the situation of it leading me down a primrose path that that makes uh no medical sense or or common sense.

[00:20:48]Uh Ver helloenno since PL1 six months ago my headaches and dizziness have improved but neck pain is worse particularly left sub oipital area. What could explain this? I'm still avoiding all my triggers as much as possible.

[00:21:01]Thank you. Yeah, Vero, in my experience, when something like that happens, it's usually uh what I call the activity conundrum. And so, what does that mean?

[00:21:12]The activity conundrum means that uh when you start getting rid of things like headaches and dizziness, especially dizziness and imbalance, what's the first thing that happens? Right? You do a little bit more um because you're not dizzy all the time. and you don't have a headache all the time and that little bit more might be 20 30% more. It might even be stuff that you don't even notice. Uh but that then drives another symptom and aggravates that other symptom. So that's probably what's going on is that activity conundrum. Fixing one or two things causes the person to get more active and as they get more active the other things start to complain. Um, and also realize that there's also another conundrum that that I've talked about in the past, and that is the um uh the pain focus fallacy, and and that is that we we tend to focus on our biggest symptoms. So, if headaches and dizziness were your biggest symptoms, that's kind of your focus. All of your mental energy goes into headaches and dizziness, headaches and dizziness all day. But when those calm down, you start to notice other things that were probably there, but you didn't have the mental energy to notice them. Um, and I've seen that throughout my practice.

[00:22:31]Um, and some patients will realize it.

[00:22:34]They'll say, you know what, my my headache is much better, but I think I'm noticing my neck more because I'm not focusing all day on my headache. So, that's another thing that could be.

[00:22:48]Uh JS, hi Dexenno, is it harder recovering from PCL versus PRP? Do both strengthen strengthen ligaments? Can both help improve the neck curvature? Um yeah, I would I would say that any bone marrow stem cell procedure, which PCL is, is going to be is going to cause more inflammation afterwards than lucasite poor PRP. And what what do I mean by that? Lucasy poor PRP is kind of the amber PRP uh versus the red PRP. and it doesn't have many white and red blood cells. So, it tends not to be as uh inflammatory. It tends to cause less swelling. Uh bumar concentrate does have a lot of white and red blood cells and so it tends to be pretty pro-inflammatory.

[00:23:42]Now, red PRP can also be pro-inflammatory, but amber PRP, the kind we use, lucasy poor or white blood cell pore, tends to be much less so. So if you were going to look at those two things really any two procedures where it's the same procedure and you used bone marrow concentrate for one versus PRP for the other in general the PRP only with a lucasite poor amber PRP are going to have less of an inflammatory flare up than the patients that got the bone concentrate. So yeah, uh PCL bone marrow procedure, uh posterior PRP, not a bone marrow procedure, there's going to be a difference for that reason.

[00:24:25]Uh Vero, generally how long after nerve hydro dissection could we expect to feel symptom relief? If we're just looking at that one variable, that one variable being uh the nerve hydro dissection, I think you're talking about symptom relief along the lines of one to two months. Now you could get a more immediate hit because there's a tiny bit of nanogram dose anti-inflammatory and that tiny dose of nanogram anti-inflammatory can really uh reduce swelling around the nerve. But if we're really relying on the growth factor effect of the growth factors in the platelet lysate that are helping the nerve that's going to take longer to really move the needle and that's going to be mostly nerve growth factor and vascular endothelial growth factor. So for example, for the second one, VEGFP or vascular endothelial growth factor, what we tend to see is that is one that builds new blood vessels around the nerve, which is great, but it takes a couple weeks to really construct those new uh blood vessels. Uh hey everyone, before I go on, please like uh wherever you are because that's how other patients find this. If you like the idea that I'm a physician that, you know, donates a part of my Sunday uh and my busy weekend to to really get after patient questions.

[00:25:49]Uh if you like this, then other patients can find it. And if they can find it, they can join in and and ask qu questions themselves. So, pay it forward to other patients by by liking wherever you are.

[00:26:03]Caseium, I'm finding it difficult to find a place that will do upright flexion extension MRIs. Any suggestions?

[00:26:10]Yeah, Kase, that's a very specific machine. Um, there's a couple on the market. Uh, Phonar, uh, is one, uh, F O N A R. Another one, uh, is SEO, but it's not a regular MRI place. This is a place that decided to buy an upright MRI specifically and deal with all the trade-offs that go with that.

[00:26:34]Right? On the one hand, an upright MRI is better for certain types of things, uh, like this flexion extension imaging, and it's better because it's weightbearing, but it doesn't have the resolution of a closed bore MRI. So, these are going to be specialized uh, MRI center. So, you'd have to search upright MRI first because that's going to be a unique machine. And then once you find a unique machine, you got to make sure they can do flexion extension. uh images because not all of them do flexion extension images but they're not easy to find. So for instance in a larger well let's say a midsize city like Denver we would have I think only one upright MRI here. In a large city you might have two or three and in a small town zero. So there may be some driving involved. Now realize another option is just to go and get a DMX if you haven't had one done. Uh if there's not one locally at Centenno Schultz. So that's another option there as well. Um I'm a doctor. I got to check my phone. So I apologize guys.

[00:27:46]Okay. Sorry about that. Trying to make sure it wasn't a patient. Uh JS, if instability can cause gut issues via the vagus nerve, can fixing gut issues reverse symptoms of CCI or does one need to fix the CCI to correct gut issues?

[00:28:03]Yeah. So if we go backwards a little bit on that, right, I think what you're saying is that CCI can irritate the vagus nerve. Irritate the vagus nerve can cause gastroparesis that can cause gut issues. Uh now it doesn't then follow that going backwards would do much of anything right because the CCI pre-existed the gut problem. Uh now is it possible we may find at some point some magic connection between the two where it goes a little bit back the other way but it wouldn't make sense that it goes all the way back the other way. Um so CCI causes vag nerve issues.

[00:28:43]Vegas nerve issues then lead to gastroparesis, but you're probably not going back the other way.

[00:28:50]Uh, undercover sentinel, dear Dr. C, if ear infection and antibiotics, how long should I wait after completing antibiotics to do orthobiologics?

[00:28:59]Yeah, a lot really depends on what kind of antibiotics we're talking about. If we're talking about quinolone uh uh the fluxin type antibiotics, cyproloxisin uh those sorts of things, flloxxin, then you really should get that stuff out of your system for a good four to six weeks. Uh now most routine antibiotics, amoxicylin, augmentin, ariththramiin, zithramyosin or a zpack not a big deal with these procedures. So there you just want to make sure that you have actually solved the infection because you don't want to come in with some salt small latent infection for this kind of procedure. Um hey uh before I go to the next question guys uh like uh where you are uh if you want other patients to find this. We want to pay it forward to all the patients in the CCI community.

[00:29:52]So do me a favor and and like this where you're at right now.

[00:29:57]Uh Michael uh DMX uh showed overhang of 4.1 and 2.9 on autonomic dominant terrible symptoms of shakiness, jeriness, internal vibrations, anxiety. I can't get answers. It's possible DMX can explain symptoms.

[00:30:14]Yeah, Michael, it's possible. Um it tends to be more possible when there's a clear circumstantial connection. So what do I mean by that?

[00:30:26]Uh what I mean by that is if there's other circumstances that would point to the upper neck. So if you've got headaches that seem to be coming from your neck or you've got upper neck pain or uh you can point to the base of your skull and say, "Yeah, there's something going on right there." uh or if upper cervical chiropractic make a big difference in those symptoms or if wearing a cervical collar makes a big difference in those symptoms then we're moving down that pathway of saying yeah this certainly could be the neck uh so the CCI at C1C2 which it appears at least at least based on a little bit of information I'm being being given here is causing vagus nerve irritation and then that's leading to these symptoms uh that are autonomic dominant. Now you know there's no hard and fast rule there though, right? So there's other things that cause those symptoms. So if you don't have all those little circumstantial things to point in the right direction, then it becomes harder to make that connection. Then we usually go to a hands-on exam trying to see if the upper neck is involved to see if there's another way to make that connection. or we might ask you to try upper cervical chiropractic or we might ask you to try a collar test. So those are all things to think about.

[00:31:52]Undercover sentinel uh symptomatic fissures at L45 after a sudden stop in a vehicle. The fissurers were there before but now satic type pain with flexion and extension. Should I do BMAC at the disc or PRP?

[00:32:09]Um yeah. So I I would say first you got to find out whether or not those fissurers really just light spots on the disc on an MRI are causing symptoms. So if you're younger uh then those symptoms would be what we call discogenic. So that means that if you're sitting for too long you'll get a lot of back pain. uh and that's pretty pathnommonic meaning that's very linked.

[00:32:43]Now if you're older too much older than 50 or 55 then we get a little bit less concerned about pain coming from the disc. Now you could also have a chemical ridiculitis. So that would be that there's a tear in the disc and it's leaking out chemicals and pissing off the nerve causing the satic like pain.

[00:33:02]Uh, and that one there is no great diagnostic test for, but it's usually treated first by not going into the disc and doing from our standpoint platelet growth factors or platelet lysaid around the nerve or a transferinal epidural with platelet lysate. Uh, other pain doctors will use highdose steroids. That can be very powerful treatment, but it also has some significant downsides in inhibiting healing. Um, so I always say don't inject the disc until you need to inject the disc. And the reason why is there's a high risk of discitis. Now what's a high risk? The true risk of discitis is somewhere between one in several hundred and let's say one in 12 or 2400.

[00:33:50]But when it happens and it's a bacterial imbalance in the disc, it's a total mess. And what do I mean by a total mess? That means that you have to get IV antibiotics. That means that you probably need to get surgery. So, if you happen to be the one in a couple hundred, then you're kind of really screwed. Uh, and because of that high risk of discitis, I try to stay out of the disc. Uh, and only inject the disc if it's absolutely necessary. So that's what I would tell you is yes intradiscal PRP intradiscal bone marrow can be quite good between the two. I tend to like intradiscal PRP over intraiscal bone marrow. Having said that for most patients it's not needed and for most patients you don't need to expose them uh to that significant risk of discitis.

[00:34:43]Eduardo hydroxento after a pic1 getting 40% better. Will the second one treat the same exact ligaments or there could be variations to the ligaments treated nerves and amount of injection? Yeah, Eduardo, each time is certainly a separate incident. So each time as you as you may know uh comes with a hands-on exam. The hands-on exam uh is to try to pick the structures that we need to focus on. So for example, let's say someone comes in at first and they're tender on the right in the upper cervical facet joint 01 one two two three. So we're going to hit those structures but they're not on the left.

[00:35:24]Uh and there's some irritated nerves at the back of the head. Let's say greater occipital nerve. So we're going to treat those structures. But then they come in the second time, right? They're feeling 45% better. There's no teners in the facetses anymore. But there is still a problem with that nerve. And that particular day, there's another nerve back here. So, we'll focus on those nerves. So, each epic should come with an extensive hands-on exam so that you can make those fine adjustments on the go and not treat things that really don't need to be treated and focus on any new things that might be coming up for that patient.

[00:36:01]Undercover Sentinel, have you found issues with Hashimoto and Graves coexisting when performing orthobiologics? You know, we haven't.

[00:36:11]We've certainly had Hashimoto's and Graves patients, but we haven't seen any particular issues there to date. Um, hey, do me a favor. Uh, like this wherever you are, uh, simply because that helps us be able to, uh, expose this to other patients. That's how the the YouTube and the Facebook algorithms work. So, if you're liking this, other patients can find it. And that's how you pay pay it forward in the CCI community to to your fellow patients.

[00:36:44]What do you do to heal from depression other than fixing CCI? Yeah, that's a great question, right? I think what it brings up is that you we have CCI. Uh we have uh depression. Uh people can get depressed when they're in chronic pain all the time. When they don't see any hope in their life, when all of a sudden everything that they always wanted to do gets taken away from them uh through CCI. Now obviously the first part is fixing the CCI, but that depression could go deep enough where it needs to be treated separately on top of fixing the CCI. So this brings up an important point. Um you can tip into a very serious chemical depression and that may need to be treated with medications or extensive counseling and reframing of what's going on. So very important concept here to understand that we do have patients that get into such severe chemical depressions because of the circumstances surrounding CCI. Then then and then we fix the CCI and all of a sudden they need other help.

[00:38:00]Uh Var further to the return of sports question after PCL what about returning to ice skating meaning spinning and jumping which puts G forces stress on the neck. Now Ver that's an interesting question because if you got strong enough I think it could do that but the biggest problem right is always the falls. So, for example, let's compare two two different kinds of ice skating. One where you're the flyer, uh, the gal being pushed up in the air, and the other where you are, you know, just a single participant. I think you're probably safer as that single participant. Now, you may have falls, but at least your falls aren't going to be unexpected.

[00:38:45]as the flyer, you can have an unexpected fall that you can't brace for. So, you know, the participant would be better.

[00:38:52]Now, is it perfect? Probably not.

[00:38:55]Certainly better than hockey getting checked or stuff like that. Uh so you'd have to make sure that that person didn't have any more instability that that person got really strong uh in their supporting neck muscles and then they were no longer living in a functional box and that activity didn't cause them any problems and there would still be caveats but it's it's probably okay to do.

[00:39:22]Uh, Undercover Sentinel. Um, can I do orthobiologics for CCI if I'm undergoing TMJ treatment? I used a CVS night guard that shifted my teeth causing significant pain. TMJ has been added now. It was not there before the night guard.

[00:39:40]Yeah. So, not a problem to do orthobiologics for CCI if you're undergoing TMJ treatment. Um, usually those things go go hand and glove.

[00:39:51]Uh M. Purple. Do AC joint separations that shift the joint permanently typically cause arthritis later?

[00:40:01]Um yes, they do. Uh so that's a pretty common one. Uh let's unpack that a bit.

[00:40:08]An AC joint separation means that where the clavicle attaches to the acromian, there's some ligaments there that hold those two things together. And that's the AC joint right here.

[00:40:21]And if that gets torn apart or pulled apart or stretched and there's instability happening in that joint, instability plus time equals arthritis.

[00:40:31]So that's an important concept, right?

[00:40:33]Instability plus time equals arthritis.

[00:40:35]Whether it's that joint, the AC joint in the shoulder or whether it's the facet joints in the neck with with CCI uh GRT Dr. Centenno for someone who has facet joint pain around C45 and C56. If I get posterior PRP by your clinic, can the PRP tighten the facet joint capsules? In general, can PRP tighten ligaments?

[00:41:00]Um, PRP can tighten ligaments and the facet joint capsules are easily treated uh when we're treating the lower cervical facets. So, yes to all of that.

[00:41:15]And purple is patellofhemeral syndrome due to patellar tendon being loose or unbalanced or more due to poor alignment stemming from structural issues like fat flat feet. Yeah, usually uh patellofhemeral syndrome stems from a misalignment issue or a weakness issue.

[00:41:34]From the misalignment standpoint, it can come from the ground up. That would be the flat feet you're talking about. It can also come from the hip down which would be let's say a weak hip that's allowing the knee to come inward and as that knee comes inward the patella wants to stay in the middle and then you get the groove of the patella banging against the patella and that causes patellofhemeral syndrome. uh you can also have muscle imbalances and weaknesses in either of those areas including the quad muscles that can lead to that same type of issue. So the answer to your question is usually the structural issues and poor alignment, not necessarily a patellar tendon that's too loose or too tight.

[00:42:28]Uh, Carol Yates in advance by Elizabeth Sans. Is there an age requirement for the PICL procedure? My niece is all the symptoms you mentioned, but she's only 12 years old.

[00:42:39]Yeah. So, uh, the answer to that question is that we want the patient to be skeletally mature. Now, the good news is girls tend to become skeletal mature quicker than boys. So, uh, the answer is yes. uh we can do a 12 or a 13y old if that 12 or 13y old is done growing or is skeletally mature. Now if they're not then that could be problematic because we don't know the effects of treating those upper cervical ligaments on overall height or growth or how that growth spurt could affect that treatment. So we do need the patient to be skeleton mature. The good news is there are skeletally mature 12-year-old girls out there. That tends to happen more commonly than in boys who tend to mature later.

[00:43:30]Undercover uh Sentinel uh your interview with Dr. Rosa. Awesome for diagnosing treatment but funds limited. Would love to go to you first. I never had AO in my life. I I am not aligned. Okay to do orthobiologics without alignment. Yes, it's okay to do orthobiologics without having an upper cervical chiropractor.

[00:43:52]Uh we mostly want you to continue with an upper cervical chiropractor only if you are um having that done and it really really helps you. So there's not a requirement to have to do that.

[00:44:11]GRT can your clinic PRP help knee issue poster corner ligament mild injuries and meniscus injuries.

[00:44:18]Yeah, we treat those issues all the time in clinic. Obviously, these days since I'm only in clinic two days a week, my focus is very much on the PCL procedure, but you can uh get PRP done in the knee.

[00:44:31]Uh we can treat uh the posterior I think you're talking about posterior lateral corner issues. Uh we can treat those with PRP or other types of treatments as well. Those are all imageguided procedures. There's a first hands-on exam, review of imaging, getting to the targets, and then getting the stuff specifically at that target.

[00:44:53]Uh, Cara, is there a way to operate on arthritis at C23? Do you operate on that? Um, that's possible, Carara. If the arthritis at C23 is causing problems, but you got to be careful there. If you've just got some isolated arthritis at C23, then you have to ask why is the first question. Uh so the why could be C C23 isn't unstable. If C23 is unstable, then C23 is going to need to be uh treated. Now, um, you know, the next component of that would be treating the ligaments to try to stabilize C23 at the same time as treating that C23 arthritis with something like PRP.

[00:45:39]Uh, as far as operating on the C23 joint, you would only want to do that if that joint was so big that it was crushing a nerve and then you have to shave off pieces to give the nerve room.

[00:45:52]That's going to be pretty darn rare at C23. Probably one in a hundred patients who would state that their C23 arthritis that was found on their MRI would be in that situation. So the vast majority of people are going to be in a situation where you got to get to the why, fix the why, and then treat the joint. And those are usually injectionbased treatments, not surgery.

[00:46:18]Eduardo uh doc uh how can I find my stem cell number during epi sales given in discharge paperwork? Yeah, we don't measure stem cell number as much as total nucleated cell count. The total nucleated cell count or TNCC uh is usually provided in the paperwork.

[00:46:34]You may just want to ask staff where that is located or just ask them to get you the number. Uh the number isn't really associated with a good or bad outcome. uh but some patients like to track it and then there's a fraction of that number that's the total cells there's a fraction of that number that would represent the messenal stem cells now uh it's theoretically possible to get to the exact stem cell number that would require flowcytometry which we have but it's a very expensive technology we use it only for research purposes um or post hoc you can determine it a little cheap more cheaply by doing a CFU analysis but that takes a couple weeks to grow out the cells. So again, not practical for day-to-day dosing. So what we provide is that immediate total nucleated cell number.

[00:47:23]HRS any D3 serum level you recommend maintaining from a bone marrow stem cell count perspective?

[00:47:30]Yeah, I think just normal uh vitamin D3 levels would be fine. If you want to take supplements, you know, most supplements, as you probably know, are in the 2,000 to 5,000 range. So maybe total supplementation, uh, depending on the part of the country you live in the winter, might be five or 10,000, uh, units of D3. If you're in a place that doesn't get much sun in the winter, uh dropping that supplementation during the summer, if you're outdoors a lot, obviously if you spend all day indoors, then you got to keep that same level of supplementation going. That's because uh your body makes a lot of vitamin D when it's out in the sun. So, you have to sort of flex the amount you're taking based on that.

[00:48:21]Uh same thing about serum levels regarding DHA EPA. Do you recommend taking a fish oil supplement over just an ALA supplement like flax seed? Also omega6 small amounts from bone marrow MSC standpoint. Yes, I think fish oil uh is great. I think it can help a lot of things. You do need to stop that a week before the procedure because it does have a tendency to cause more bleeding uh if you don't stop it. But it's a very good thing to take and I would go more the DHA EPA route uh that you mentioned.

[00:48:55]Uh you don't need serum levels but focusing on supplements that have high DHA EPA levels.

[00:49:05]Uh is the EPICL far better than the previous version?

[00:49:10]Yeah, I would say I don't think we know that yet with regard to outcomes, but I would say in general what I see. Yes.

[00:49:18]Um, and I would say in general based on the circumstantial evidence of uh what we can inject. Yes. So yes, I think the epic is far better than the old PCL procedure in many different ways.

[00:49:34]Everything from the mouthpiece allowing us to treat more different kinds of patients.

[00:49:39]uh to the fact that we've got better targeting of some of the critical structures like the accessory ligament and the tight bundle of the AAR ligament. Uh it's just advanced a lot from those two time points from PCL to EPICL.

[00:49:59]Uh HRS, uh do you plan to update the before MRI results on your website and your blog stuff written by you not generic stuff?

[00:50:08]Not sure what you mean by that question.

[00:50:10]So, I'm not really uh clear on what question is being asked. Maybe if you could reask it, I'll try to prioritize it. We got sort of the last eight minutes here. Um uh Nava, hello Dr. C. Happy Sunday. At a PI sale in April about a month ago, someone did some acupuncture in my ear and was kind of pressing on my head. if I had new symptoms like nausea, headaches, dizziness, just feeling really bad all of a sudden. I've never had these things before. I consulted my physician in the clinic and asked if he thinks it's worth trying an AO even though I've never been. He said he doesn't think it would cause more damage. Do you think it's a good idea?

[00:50:49]Yav, I don't know your specific clinical situation. In general, uh patients can always try AO chiropractic. Uh there's no reason not to try it. uh it tends to work well with CCI patients and if you suspect that maybe what happened kind of pushed you out of alignment then I think it's reasonable to try. Now, sometimes we tell patients no after these procedures because we don't want to add in another variable to try to see if it's the AO that's pissing things off, for example, or if that person's in a flare. But given your specific scenario or a scenario like the one you describe where someone gets some force on their head and they feel like they're out of alignment, it's not unreasonable.

[00:51:40]Caleb, so I do have CCI. However, I've been told uh that inflamed fascia, damaged fascia, etc. can make it feel worse in order to actually showing up on imaging. Can you recommend PRP to heal fascia, fascial release exercises?

[00:51:54]Um, yeah, Caleb, you can always try trying to you can always try to treat the fascia with PRP. Those are ultrasound guided uh injections into the fascia. I think they can be very helpful. So, I don't think there's any reason uh not to try something like that. Um so, yeah, I I think give it a shot. Do I think it's going to treat the internal ligament component of the CCI?

[00:52:18]I don't. But it may help symptoms and it may be one of the variables that needs to be closed in on, right? There may be some CCI plus some fascial issues. So, you know, go ahead and and give it a shot. uh but I don't think it's going to fix the internal ligament issue more sort of the uh the issues around the instability.

[00:52:42]Nava also do you know if mold can affect healing of PCL?

[00:52:47]You know I don't Nava but we don't have any information on that. We have some general circumstantial evidence that mold can cause an inflammatory response.

[00:52:54]We've got very little hard clinical data that it impacts healing. Um, I think you know the doctors that treat mold related illnesses would say yes. Um, so I would say likely, but I don't really have a lot of evidence to back that up.

[00:53:14]Let's see here.

[00:53:17]Uh, James, can a long-term misalignment of C1 over many years cause cervical damage?

[00:53:26]Yeah. Yeah. So I think what you're saying it we got to get unpack that a little bit to get in what's causing the misalignment right is the misalignment due to instability then absolutely. If the misalignment is due to something like a side bend in the spine scoliosis then sure you can see some one-sided damage in the facet joints etc. So listen at the end of the day I would say um yes um but it's important to understand what's causing the misalignment.

[00:53:57]Undercover Sentinel. If I'm at my worst point now with metabolic syndrome, hormone issues, per menopause, sleep apnea, osteopenic, can I do BMC now or bear to wait? How long to wait?

[00:54:08]Um, I don't think waiting is going to help. Uh, you might consider getting hormone replacement therapy. That would be the the first thing I would do is look at biioidentical hormone replacement therapy. And it's important to note what that is and what that isn't. Uh what that is is someone that does blood tests several times a year.

[00:54:30]They manage your hor hormones. They bring those up to younger levels and they're looking at progesterone, estrogen, and testosterone in a woman.

[00:54:40]What it's not is going to your OB and they give you a little progesterone cream or an estrogen pill to take and they never check your levels again. that is not biioidentical hormone replacement therapy. So, if you're doing the first kind, um that would be a good thing to try. You know, close out that variable and then consider getting treated. Uh if that's not something you're willing to do, then nothing's going to change three years from now versus now. Um you're still going to have those same challenges. Are they going to be major challenges? That's going to depend on on what's going on with that specific person.

[00:55:20]Uh Jessica, can CCI cause an elevated right hemidi diaphragm if most my issues are right side? Example, my right SCM down to my shoulder causes most of my issues. A CT this week for something else and it was noted.

[00:55:38]Yeah, it's possible, Jessica, but um and and I have a patient right now that has uh a similar issue. So, I would say yes, we can see that happen due to CCI, but there obviously could be other causes.

[00:55:54]Okay, guys. Well, I'm going to wrap up here uh because I've got some things to do later today. Uh and I want to thank everyone for all the great questions. As I say, there are no bad questions. We all learn through hearing the answers to someone else's questions. So, thank you so much. I really appreciate you. I'm in gratitude that you join me here every single Sunday. Uh so thanks for for joining and I will see you uh next Sunday with another topic. Uh thanks so much. Thank you.