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Options for Pain Besides Anti Inflammatory medications

no anti inflammatory meds
https://youtu.be/BMqRXITaLrM

Options for Pain Besides Anti Inflammatory medications
Topics discussed:Anti inflammatory medications, side effects, why you should minimize.
Other options.Supplement options.Regenerative medicine options.Disease modifying medication options.


Hello, this is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. Welcome to our weekly educational meeting that is live, it’s August 17th, 2020, welcome everyone. On this broadcast I tried to go over either questions that I’ve gotten from patients in the last week or that my own team has, from either their own sort of questions or things that they’re hearing from patients and sometimes also just frequently asked questions that I get about musculoskeletal health and wellness and so today what I’d like to talk about is anti-inflammatory medications, nonsteroidal anti-inflammatory medication why you want to avoid them other options and I think smart ways about how we can tell if someone’s improving sometimes by how they’re using less anti-inflammatory medications.

So anti-inflammatory medications have been around since roughly the 1960s the more commonly used one since then and they have gone from being prescription based medications to essentially over-the-counter medications and they can include things as routine as Ibuprofen Advil, Aleve to things that are more prescribed like celebrex, diclofenac and even other prior meds that have been taken off the market, including things like Vioxx and they’re used so routinely by people for aches and pains that there’s a relative normalization that people have when it comes to using these medications and because of that, they feel like it’s downright low risk or no risk and the problem is that that is not correct, just because it’s sold over-the-counter, just because it’s utilized super frequently does not mean that it’s actually low risk or no risk and so there are a number of potential side effects that you should be aware of and that includes things such as stomach ulcers, kidney damage, liver damage and even increasing the rates of heart disease. So these are medications that have potential issues in the past when there really weren’t other good treatment options, frankly for various inflammatory arthritis conditions, nonsteroidal anti-inflammatory medications were considered revolutionary. That was however, I mean, 40 to 50 years ago if not longer than that and so in this day and age, when we have a lot of other treatment options, we should be utilizing, maximizing those options in order to really do better because the potential side effects when you sort of weigh risks, benefits and then consider other options you need to realize that these kinds of medications, while they may provide pain relief, they don’t really fix what your underlying problem is and the problem with that is you may be getting some degree of pain relief, but not only are you not correcting longterm issue, but you’re actually increasing the risk of longterm issues as well so considering all that you need to have other options.

The other thing is that the way that I look at it for my patients who are telling me that they’re stuck taking nonsteroidal anti-inflammatory medications long term is that whatever the condition is that we’re treating is obviously not being adequately controlled or treated and it’s a signal to me that we need to be doing more than just having you take that kind of pain medication that kind of anti-inflammatory medication and it’s a signal to me that I need to be digging deeper, looking further into what the problem is in order to make sure that you are being adequately treated.

So what are other potential options? Anytime you have a musculoskeletal issue, arthritis, tendonitis, back pain injuries that’s causing pain, functional limitations, you know, reduction in your normal activities or exercise, you absolutely should be considering physical therapy and some over-the-counter supplements. So physical therapy is that’s a no brainer, quite frankly, if you have an injury or if you have a abnormal motor pattern, exercise pattern, movement pattern, physical therapy is very helpful to help correct that, improve that and optimize that so 100% you should definitely be doing that.

The kind of over-the-ounter supplements that I recommend and, you know, I hear a lot of things that patients are taking, a lot of them without really very good evidence of whether they work or not, but a lot of them do seem to provide patients pain relief, the three big ones that I generally recommend however, which do have decent evidence of efficacy in arthritis and tendonitis patients would include glucosamine, curcumin as well as omega-3. So glucosamine which has been around for many years has decent evidence that it can help with wear and tear arthritis, wear and tear arthritis is in particular for knees, there’s evidence that glucosamine can help in 50% of people that take it. Number two, omega-3, omega-3 is a anti-inflammatory that you can get from fish oil, flaxseed oil those are the two big sources and there’s decent evidence that it can help with pain and even functional limitations in inflammatory arthritis conditions such as Rheumatoid arthritis. So I think it’s a good low risk anti-inflammatory medication and lastly is curcumin, which you get in turmeric, turmeric’s been around for, I mean, centuries, if not thousands of years utilize medicinally for all that time as well. There’s actually been some evidence that curcumin can actually provide similar degree of pain relief as anti-inflammatory medications for wear and tear arthritis. So again, a great low risk option that I think can provide pain relief and certainly preferable over anti-inflammatory medications may not be as strong, but it’s low risk, gives benefit and is definitely preferable on a longterm basis glucosamine, omega-3 and curcumin.

So those really conservative options, physical therapy, exercises, altering some of your activities, over-the-counter supplements is not enough then if you’re still kind of hooked onto anti- inflammatory medications, then I would recommend escalating to the next level of treatment and what that treatment is depends on what is really the cause of your problem. The issue with anti-inflammatory meds is that they don’t treat the cause of your problems if you have, let’s say a wear and tear arthritis or tendonitis issue, then the next step would be an injection option, again, I don’t recommend steroid injections cause it’s not the right longterm option, but rather a regenerative medicine treatment options such as platelet-rich plasma, bone marrow aspirate stem cells is really the next appropriate treatment option to consider treating your arthritis, tendinitis and pain. Number one, it will actually do a better job in terms of longer term management or for that isse compared to anti-inflammatory med. Number two, it’ll actually be safer for the joint, the tendon, the ligament, it’ll strengthen those tissues as well, which is another reason why it helps with pain relief and functional improvement also.
On the other end, if your issue is more of an inflammatory arthritis conditions, such as Rheumatoid arthritis, Psoriatic arthritis or Ankylosing spondylitis, I would strongly recommend if you have significant active inflammation throughout your body, to then utilize a medication such as, a disease modifying treatment, a biologic treatment that will actually treat the condition at its source and what’s really causing the inflammation and problem rather than just taking more and more anti-inflammatory meds. Now, there are some people where medication may be an issue because they have other medical problems and number one, understand that your physician should be nuanced enough to be able to choose a treatment that’s going to be low risk in your case. In some settings, if someone cannot tolerate those kinds of medications, rather than being stuck on those kinds of anti-inflammatory meds, like Ibuprofen, Advil, Meloxicam, you can then consider some of the regenerative medicine treatment options that have more of an anti-inflammatory angle to them and so in all cases, these are the options that you should be considering for chronic musculoskeletal pain rather than chronic anti-inflammatory medications and really the reason is because you should always be thinking longterm, longterm in terms of benefit and longterm in terms of potential risks and when you weigh all those together, you realize that chronic, Ibuprofen, Advil, Diclofenac anti-inflammatory meds is not right way to go.
Another interesting thing is that for patients who are on those kinds of medications long term, anytime we’re trying to figure out how well is somebody doing from treatment for their musculoskeletal condition. You’re always looking for objective evidence, whether that’s objective evidence that inflammation is down in a joint or a patient telling you, hey, my pain level is down or hey, my functional improvement is better or my range of motion is better I’m able to do activity X, which I was not able to do six months ago those are somewhat objective options. Things like pain scores can be subjective of course, but there are definitely disease activity scores and ways to get more objective measurements from that. But another, I think interesting objective way is, has a person reduced their pain medication? Have they reduced their ingestion of anti-inflammatory medications? That’s another, I think clever and nuanced way to tell if someone is actually improving, because the goal is to get you off those kinds of medications.

So anti-inflammatory medications, not the way you want to go longterm for treating arthritis, tendinitis, injuries and back pain definitely plenty of other better options. If you’re stuck on those kinds of meds, make sure you’re maximizing things like over-the-counter supplements and physical therapy. If that’s not enough then make sure you’ve looked into regenerative medicine treatment options or medications for inflammatory arthritis conditions and lastly, if you’re not getting that kind of opinion, make sure you find a trusted physician who will keep you on track to make sure you’re being optimized in terms of your musculoskeletal health. Thank you for your time until we reconnect and again, I do a live session Mondays and Wednesdays until the next time have a good day and live well, bye bye.


Live Weekly educational meeting for the team at Chicago Arthritis and Regenerative Medicine where we discuss the basics of what we do for arthritis, tendinitis, injuries, and back pain. 
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***For evaluation and treatment at Chicago Arthritis and Regenerative Medicine:
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MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.

About this video
In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses Options for Pain Besides Anti Inflammatory medications.

Restarting Sports and Exercise during Covid

Weekly Live- 20200819- Pic YT

Returning to sports and exercise during Covid19.

Restarting your normal exercise routine is important for your health. While many people are focused on the covid risk aspects, this video/blog focuses on your musculoskeletal issues that may arise when restarting exercise, and optimizing your health and wellness.


Hello, this is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. It’s August 19th, 2020. Welcome to our weekly live broadcast. I’m excited to have everyone here. I hope everyone is having a great day, great week. It’s really, we’re kinda, we’re still in the middle of summer, but we’re starting to wind down and it’s August 19th. Before I start, I would be remiss if I did not say happy birthday to my mother. I won’t mention how old she is. She is still incredibly youthful and young looking, and happy birthday to her.

So around this time of year, there is so much going on from a sports standpoint, whether that is the US Open Tennis, football season is starting. And right now, obviously with COVID, you even have baseball and the NBA sort of in full swing and hockey as well. In particular, I am a huge football fan. I grew up in Western New York. And so I am a Buffalo Bills fan, and very excited about their season this year. The NFL has a number of interesting things that they’re trying to do in terms of dealing with COVID, stuff I’m not going to really talk about today, but just a whole enterprise of trying to manage their whole COVID protection prevention kind of program is mind boggling, quite frankly, and given all the circumstances, it’s probably the best that they can do if they’re trying to play. They even have some interesting ways that they’re trying to protect players while they’re actually playing with a special type of mask that they’re going to wear now. It’s a lot of interesting stuff that kind of connects public health and sports together. But it kinda makes me think about how for the rest of us as we start to reincorporate physical activity, things that you should be thinking about.

In my case, I happen to play tennis. I also swim. All stuff that I have not been really able to do in any significant degree in the last few months during COVID, but it’s stuff that I’m starting to look forward to reincorporating relatively soon in hopefully a safe and low risk manner. And over the summer, I mean, the things I’ve been doing to stay physically active have included a lot of body weight related exercises, spinning as well at home. And so things that are keeping me physically active, but as I try to reincorporate certain activities that are a bit more sports specific in particular for me overhead activity, including tennis and swimming, there are a number of things that you should be thinking about when it comes back to reincorporating physical activity.

So first and foremost, you need have a really clear on a sense for where your own physical vulnerabilities, weakness, injuries are. If you already know that, fantastic. You’re ahead of the game. If you don’t know that in any significant degree, probably worthwhile assessing yourself. For that kind of assessment, physical therapy tends to be really good. Most physicians don’t typically do a really dedicated exam to properly kinda figure that aspect out, but you really want to be kinda checked out head to toe to get a sense for where you have asymmetry, weakness, imbalances, instability, maybe some chronic inflammation signs. Those are the kinda things you want to be aware of because it’ll affect how you start to reincorporate physical activity. And what’s interesting is if you have, let’s say a shoulder issue, you need to know if you also may have some issues in the neck, whether it’s arthritic issue, instability issue, posture related issue, maybe some weaknesses from one set of muscles to another set of muscles. You want to be aware of that because that’s how you’re going to protect yourself and actually get better as well. So first and foremost, assessing yourself.

Number two is technique. I think having had some time off from physical activity, like formal sports related physical activity, that’s a great chance to kinda reevaluate technique related issues so that you are optimizing and putting yourself in the best position to not only function at a high level in that physical activity, but that you’re also doing things at their most optimal sort of technique so that you’re putting yourself at lower risk as well. So this is really relevant for me for a couple of reasons. Number one, as a tennis player, I do have some very mild rotator cuff tendinopathy in my shoulder. That’s something I’ve had probably since I was a teenager because it’s something that I first recognized about 12 years ago when I started using musculoskeletal ultrasound to look at joints and tendons. And that’s important because, well, why do I have a little bit of rotator cuff tendinopathy? Understanding sort of how I may have a little bit of asymmetry right to left, how my posture might be a little bit off, how my technique might be throwing things off as well. That’s stuff that I need to work on. And in my case, I made a really pretty strong effort a few years ago to really correct some technique related issues when it comes to serving and that’s kind of an ongoing process and something that I should always be thinking about. Another example of that for me was when I reincorporated swimming, I went out of my way to take some time to improve my technique, partly because it’s much harder to reincorporate an activity like that compared to when you’re a teenager. But number two, I know that having a mild shoulder issue, that can be something that can be at risk as I start to incorporate other types of overhead activity. So improving technique, a huge part of getting back into physical activity even if you are an amateur athlete. You don’t need to be a professional level athlete to be working on your technique. If you’re someone that does an activity once, twice per week, or even a couple of times per month, you should be thinking about technique obsessively. That’s how you protect yourself.

Then as you start to reincorporate physical activity, if you ever have any sort of an injury, pain, anything that seems off, I would recommend instead of just grinning and bearing it, which is what most people do, which is what we all do realistically, that you should be looking in terms of getting evaluated sooner rather than later. And the reason why is because if you have something at an early stage that can be improved upon, improve it. Do what you can so it doesn’t become something worse. It always strikes me as incredible that when it comes to things like diabetes and blood pressure in the past, nobody did anything about it until they actually had a heart disease or a stroke. But now it’s common medical wisdom that you need to do something about it. Diet, exercise, maybe medication, to treat that in an early stage so that you don’t have those kinds of bad consequences, like heart attacks and kidney failure. Well, it’s the same thing when it comes to your joints. If you have a little bit of knee pain, rather than sitting on it and just grinning and bearing it, icing it after playing or taking some anti-inflammatory meds, you really should be evaluating what’s going on here. Do I have a problem here? Is there something I can fix? Is there something with my back, my knee, my ankle? Like what’s going on here that needs to be corrected so I can actually fix this? My own brother who has started playing tennis pretty aggressively in his early 40s routinely tells me that he’s got pain in his elbow, or his shoulders, or his back, and he’s icing himself down after playing. And routinely I tell him “You really need to get that checked out because that’s probably not a good thing if you’re just icing yourself down and taking anti-inflammatory meds. That’s really not the right way to be treating this. Figure out what’s going on and fix it, or at least put yourself in the most optimal position so that you don’t need to deal with this chronically or that it gets worse.

So evaluation early makes sense. You want to get evaluated by somebody who knows what they’re doing here. Realistically, the vast majority of physicians don’t know how to evaluate musculoskeletal issues properly or competently. That’s a problem because they may be focused on other problems like diabetes, blood pressure, when you really should be focused on how to handle this in a more competent way. One issue if you’re seeing a surgeon for these kind of issues rather than someone who’s got expertise on a nonsurgical end, is that they’re looking at it from the lens of how bad is this? Does it need surgery now? It’s very likely if you have something early, you may have something that can be treated non-surgically early on so that you don’t need to be thinking about surgery. So you need someone who knows what they’re doing. They need to be able to do a proper examination.

In my own clinic, diagnostic musculoskeletal ultrasound for a lot of those types of injuries, whether it’s arthritis, tendonitis, or injuries is very helpful in terms of figuring out why do you have pain? Is there instability? Is something that’s developing? A really great way at very quickly making a diagnosis. If you have a overuse injury, the reality is that X-rays, they’ll show you some arthritic issues, but they’re not going to necessarily, they’re not going to show any of the soft tissue issues. And frequently you don’t need an actual MRI, but an ultrasound can help make that diagnosis. So your physician should be able to do that if they’ve got that expertise to help make that kind of diagnosis for you quickly.

And then making some changes early on so that you can improve things, whether it’s getting back into the right kinda strengthening exercises, correcting technique as well. Something that I’m very well aware of is that for my own shoulder, if I’m not doing the right kind of upper back kind of exercises, scapula stabilizing exercises, I’m putting my shoulder at risk longterm as well. So that’s stuff I need to be focused on chronically. And certainly if you have an injury or developing problem as you reincorporate your athletic activities, make sure that you’re doing the right kind of rehab or exercises to strengthen the muscles and put yourself in the best position to be protected. And then if you’re not getting better with that basic kind of approach, then consider a regenerative medicine treatment sooner rather than later.

So this is relevant and sort of nuanced in a couple of ways. Number one is if you have a mild to moderate injury, you may be fine with just using your own platelets or prolotherapy. If you have something that’s a little bit more than that, then using your own bone marrow derived stem cells would be helpful. But on top of that, you have to also think about timing. If you’re someone who’s playing at a more competitive level where you have sort of a dedicated season, then understand that some of these treatments will actually sort of prevent you from doing that kind of physical level of activity for the first couple of weeks or so. So if you have something like platelet rich plasma, or your own bone marrow derived stem cells in the middle of season, you would have to expect that you’re really kinda shutting it down for the first two weeks in terms of that sort of sporting activity. And as you reincorporate that activity, you’d be starting at maybe 25-30% of your normal level of the next few weeks after that, and then slowly ramping up. So that may be something that’s better off if you’re willing to kinda take some time off, let’s say a month or so after treatment or something that’s outside of your normal competitive season. The other way to look at it is if you have a milder injury, that’s more of a soft tissue strain, you’re doing the right kind of physical therapy, you’re still having discomfort, you have something that doesn’t necessarily require platelet rich plasma or your own stem cells, then utilizing a treatment like neuro prolotherapy to reduce the pain, to reduce some of the neural agitation that’s causing the pain, myofascial related pain, is a great option to help shut down some of that pain quickly, keep you at a high level of function, as well as keep you physically active and keep you active during your actual sporting league season as well, during your competitive season as well. So there’s different sort of levels to how to approach that and treat that and with the right kind of approach, you can not only stay at a high level, you can recover from an injury. You can also kinda keep going at a high level even in the middle of your competitive season as well.

So exciting times for those of us who are trying to get back into physical activity, more sporting related activity, be smart about it in terms of assessing yourself before you get back into it, improving technique, making sure you get evaluated if you’re starting to develop pain or dysfunction as you kinda reincorporate things, and understanding how to incorporate some of the more modern regenerate medicine treatment options if needed when required.

Well, thank you very much. I hope everyone’s doing well. As a reminder, I’m doing this live every Monday and Wednesday. You can catch the replay as it’s been sort of edited and captioned after the next couple of days. And until our next broadcast, have a good day, and live well. Bye bye.


Chicago Arthritis and Regenerative Medicine Weekly Live broadcast.
Check us out live on Instagram, Facebook, or Youtube every Wednesday at 12:15pm cst.
Discussing relevant issues regarding state of the care for arthritis, tendinitis, injuries, and back pain.
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https://www.Facebook.com/ChicagoArthritis
https://www.Youtube.com/c/chicagoarthritis

***For more educational content:
Sign up for our email newsletter: https://www.chicagoarthritis.com/newsletter/
See our blog:https://www.chicagoarthritis.com/blog/
Listen to the Regenerative Medicine Report podcast: https://www.chicagoarthritis.com/regenerative-medicine-report/


***For evaluation and treatment at Chicago Arthritis and Regenerative Medicine:Determine if you are a Regenerative Medicine treatment candidate: https://www.chicagoarthritis.com/regenexx-candidate-form/
Contact us for more information or to schedule an appointment: https://www.chicagoarthritis.com/contact-us/


MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.
***About this video***In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses returning to sports and exercise during Covid.

Varying Speed and Intensity of treatment for Arthritis/Tendinitis

https://youtu.be/5Qv0f8sf-A0

Varying Speed and Intensity of treatment for Arthritis/Tendinitis

When treating arthritis and tendinitis it’s key knowing when to pause, when to move forward with treatment cautiously, and when to move more aggressively.

Cases:
-Hip arthritis
-Knee/Back degenerative joint disease
-Rotator cuff tendinitis


Hello, everyone, this is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. Welcome to our weekly live broadcast. It’s August 12th, 2020. I hope everyone is doing well and is healthy and safe. So on this broadcast I’m focused on discussing professional issues, relevant issues related to medicine, musculoskeletal health. At Chicago Arthritis and Regenerative Medicine we’re focused on evaluation and treatment of arthritis, tendonitis, injuries, back pain, utilizing the most up-to-date current non-surgical treatments that are available and doing so in low-risk, holistic ways to kind of maximize your pain, function, and quality of life.

So something I’ve been thinking about recently is speed, quickness. Speed in terms of life, speed in terms of medicine as well. And I’ll talk about the medical professional aspect in a moment, but first and foremost, speed in terms of life. It seems like life is just moving so fast right now. I was thinking about this recently that, as someone who grew up in the 80s and 90s, there was a relative consistency to life, where you didn’t expect the world to be dramatically changing every single day. And right now we live in a world where things are adapting so fast. Every single day there’s sort of new news and new noise, and that is challenging to sort of keep up with for a lot of people. In fact, even every week on a medical level things are changing. As an example, the states that are considered relative higher risk from an Illinois standpoint where you need to quarantine if you come back from one of those states. It used to be 22 states, overnight it dropped to 19 states. Maybe that’s based on some additional numbers that have come from those states, maybe that’s based on, who knows? Public health or some other issues or some local legislators who have to travel to those states. I’m not really sure, but even on a medical level, we keep on getting input about what is new and what do we understand about COVID happening on a day-to-day basis, sometimes a week-to-week basis, that it’s a lot of change and speed. It’s happening quickly. From my own personal standpoint, the way that I try to look at it is what are the key principles that I truly believe in in terms of life, values that I have in life? And now how do we apply that to every level of my life? Whether that’s personally, relationships, professionally, anything else as well. And then adapting to the situation, but still relying on those principles, because I know those principles and values are, you know, they will last the length of time. They are things like gratitude, integrity, things like that. A few other things as well that I’ll probably discuss in the future, but speed in life.

In medicine it’s interesting, because there’s different ways to think about speed. There’s obviously things like what is acute that needs really dramatic sort of up, immediate real-time sort of changes and care? And then there’s obviously things that are more chronic and subacute, where maybe you can take a little bit more time to think about it. There’s a difference in terms of speed and urgency that you need, but I think there’s even speed and a difference in terms of how quickly and aggressively you wanna treat things based on what are people’s individual goals for treatment, their individual issues when it comes to their medical health as well? And you can be relatively smart with these kind of things. On Monday I talked about how medicine, while 80% of it can be algorithmic, that extra 20% about being personalized goes a long way to making a difference in terms of outcome. And to me, speed plays into that. So you need to know, as a physician, you need to know when to pause, you need to know when to maybe slow down or treat mildly, and then you need to know when to be a bit more aggressive and treat a little bit more quickly or with more strength. And I’ve got some examples for each one of those.
The one for treating mildly or slowly, since I’m using this speed sort of metaphor, an example would be a patient who I saw recently who has knee and back osteoarthritis, moderate level osteoarthritis, and she’s someone where she’s gone through the tradition non-surgical options, meaning physical therapy, activity modification, and some knee bracing, and she’s still having pain and so she’s coming to me sort of has her first line what’s the next step kind of treatment option? And we talked about, well, you know, you could utilize something like platelet-rich plasma, you could utilize something like bone marrow-derived stem cells, why would you choose one over the other? In her case, her real goal was, can you improve my pain? Can you improve my function? And so we talked about as a first line option in her case, as someone who’s really never had any other kind of injection option is why don’t we try platelet-rich plasma for her lower back and both of her knees? And in her case, she did really well, meaning she’s two months out from treatment. Her right knee and lower back are totally pain free. Her left knee, she’s basically 70 to 80% better. She’s enthusiastic and excited about her result and she’s able to go back to work. She works as a machine operator at some kind of bakery. And she’s able to work basically 12 hours at a time now, which is essential for her from a work standpoint, from an income standpoint. And that would be a great result. That is a great result in her case. But the key here was to realize it’s okay to treat in a milder fashion, in a slower fashion, because our goals here are, they kind of meet what her expectations are and she understands that we’re utilizing something milder and if need be, we can escalate to something stronger. And fortunately in her case we don’t have to do that.

A counter example to that would be a 60-year-old woman, very healthy, very physically active who came to me for hip pain. And in the course of doing her evaluation and imaging examination, all that kind of stuff, came to a diagnosis that she’s got more advanced hip osteoarthritis. And so what we know about hips is that if you have advanced hip arthritis, the chance of getting a good outcome from a regenerative treatment is currently considered challenging. And so my recommendation to her, because she was specifically coming asking about stem cell treatment for her hip, was I don’t think that’s the right option for you. I think you really should consider hip replacement surgery. And you know, she still wants to consider non-surgical options and what I’m guiding her is let’s pause for a second. You need to have a conversation with a hip surgeon, because that is the traditional and likely most appropriate option here. If you end up proceeding with something non-surgical, understand that even our strongest non-surgical option, like utilizing your own bone marrow stem cells, is that your chance of getting a 50% or better pain relief response is about a one in three chance. And we can have that conversation again, but let’s pause for a moment, consider the other surgical options before jumping into anything else I can help you out with. That’s a case where you need to pull the brakes and say, “Well, here’s what the evidence shows. You may be very healthy, you may be very physically active, but here’s realistically how you need to be guided.”
The last option is a younger person who I saw recently, a 25-year-old, he is competitive in Jiu-Jitsu and he basically has a left shoulder injury where he’s got some, a partial thickness tear of his rotator cuff, as well as a labral injury. And we talked about what are the options for treatment, platelets versus stem cells? He’d already failed some physical therapy and talking about what are his goals, and his goals are to get back to a high-level of Jiu-Jitsu where he can still compete and we talked about what are the chances of getting that result with just platelets verus going for bone marrow stem cells, and we ended up advocating for a stem cell treatment mainly because of his goals and expectations. In this case, I’m recommending going a little bit more aggressive, a little bit faster, because I think the speed of treatment here based on the goals that he wants would fit better with that kind of treatment approach. Something a little bit stronger and more aggressive. And the reason why he’ll likely do well is because, number one, we’re utilizing a cell type, his own stem cells that gives him that chance of getting that. Number two, we have sort of a common understanding in terms of aligned understanding of what are expectations for goals of what we can achieve. And then lastly, you know, the way that you wanna treat someone like this is you wanna treat it in a complete and thorough fashion. And that means hitting not only where he has an injury to the rotator cuff and to the labrum, but to understand that the reason why he has that is because he’s had some chronic instability in the shoulder due to some ligamentous strains in the past. Let’s properly treat that as well.

It gets back to the concept of biotensegrity, which is incredibly important in musculoskeletal health, where it’s, the basic understand is that if you take a larger unit, let’s say the shoulder, you have multiple pieces that are part of that. They are not directly attached, but when they’re close together and put under compression, that under that kind of setting, the strength of the whole unit is stronger than the individual pieces. And by treating not only the rotator cuff and the labrum that’s been inured, but by treating the ligaments that provide that support to create that kind of biotensegrity and stability, he’ll get a better response. And so aligning expectations, goals with the right cell type is going to get him the right kind of outcome.

You contrast that to someone where we had treated with just platelets, the knee and her back, where she has done great, and she’s done great because her expectations are a little bit different and she has a condition that can still respond very well to platelets. And understanding the platelets in her case are going to help with not only stability in the knee where she’s got some chronic degenerative issues and ligamentous injuries. She’s got some mild chronic inflammation and we’ll help treat that as well with platelets. And, because we’re also treating the back, we’re also addressing any kind of nerve-related neuromuscular issues that can affect not only the lower back but the knees as well, but it’ll get her to a higher level of physical activity and by doing that additional physical activity long-term, she’ll then be able to help support her knees and her back as well.

So speed makes a big difference in terms of knowing when to pause, knowing when to treat slowly and mildly and knowing when to treat a little bit quicker and a little bit more aggressively. I think that makes a difference in life. I think that makes a difference in medicine as well. Great, thank you for your time. Until next week, I hope everyone remains safe and healthy and as a reminder, I’m doing the live stream on Mondays and Wednesdays. And until our next broadcast, have a good day and live well.


Chicago Arthritis and Regenerative Medicine Weekly Live broadcast.
Check us out live on Instagram, Facebook, or Youtube every Wednesday at 12:15pm cst.
Discussing relevant issues regarding state of the care for arthritis, tendinitis, injuries, and back pain.
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https://www.Youtube.com/c/chicagoarthritis

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***For evaluation and treatment at Chicago Arthritis and Regenerative Medicine:
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MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.

About this video
In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses changing treatment intensity for arthritis, tendinitis, back pain, and injuries.

 

Uncertainty in Life and Medicine

dealing with uncertainty
img
Weekly Live broadcast replay 20200805

Uncertainty in life and medicine.

Strategies and examples
-Focus on what you can control.
-Accepting uncertainty.
-Focus on your big principles.
-Trusted sources

Also covered a new study showing treatment with canakinumab a il1 blocking medication can possibly help prevent progression of osteoarthritis.
Discussion on how IRAP, PRP, and Bone marrow derived cells can do so as well without medication risks.

Chicago Arthritis and Regenerative Medicine Weekly Live broadcast.
Check us out live on Instagram, Facebook, or Youtube every Wednesday at 12:15pm cst.
Discussing relevant issues regarding state of the care for arthritis, tendinitis, injuries, and back pain.
https://www.Instagram.com/ChicagoArthritis
https://www.Facebook.com/ChicagoArthritis
https://www.Youtube.com/c/chicagoarthritis


– Hello, everyone. This is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. This is our weekly live, live broadcast. Welcome, it is August 5th, 2020. On this broadcast, essentially I’m discussing topics and professional aspects that are relevant and interesting to me. Here at Chicago Arthritis and Regenerative Medicine, we are focused on evaluation and treatment of arthritis, tendonitis, injuries, and back pain with a real focus on utilizing nonsurgical treatments and the most up-to-date and interesting treatments that are currently available to treat not only pain and improve function, but to really treat the root cause of what’s driving these conditions. So there’s two topics I’m talking about today. The bigger one is uncertainty because I think that is just huge right now. But before that, I wanted to briefly go over a recent article that was published in the articles, on the Annals of Internal Medicine yesterday. It’s sort of a hot-off-the-press sort of topic that I think is interesting that I want to give a very brief but relevant commentary on. So essentially the title of the article is Effects of Interleukin-1B Inhibition on Incident Hip and Knee Replacement. It’s a ridiculous name, but it’s being sort of presented as, hey, finally, a medication that will prevent the progression of osteoarthritis and relevant because we have other treatments for things like rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, where medication will actually prevent the progression of those conditions. And we don’t really have a medication for osteoarthritis that can do the same thing. So in this study, they looked at a medication called canakinumab, which specifically blocks a molecule called interleukin-1B, and it’s currently approved for rheumatoid arthritis. Canakinumab is approved for systemic juvenile rheumatoid arthritis or juvenile idiopathic arthritis. And it’s also approved for a very small subset of some other inflammatory conditions called caps CAPS, C-A-P-S. And in this study, they actually looked at patients that in a bigger study, they looked at the patients who have had a history of heart disease and have mildly elevated inflammation levels. And they wanted to know if utilizing this medication would prevent other heart disease. So this followup sort of subset of this study was to look at 1,000 of those patients. And they wanted to see if the patients who are on this medication would actually, it would actually do anything else from a osteoarthritis standpoint. And they found that for patients who are on this medication, as compared to patients who were just taking placebo, they had a much lower rate of progressing to knee replacement surgery or total hip replacement surgery. And so it’s presented as, wow, look at this, finally a medication that is disease-modifying for osteoarthritis. And it’s interesting. It’s very early. There still needs to be much larger studies and more dedicated studies from the osteoarthritis standpoint. And the whole point is that it’s blocking this molecule called interleukin-1. And that’s interesting because here is possibly a biologic way to actually prevent the progression of osteoarthritis. Super interesting. And it’s curious that the medication can do it, but it’s worthwhile understanding that this sort of medication has potential risks, and there may be other treatment options, and I’ll discuss that, that can do the same thing. So the potential risks of this kind of medication are, the main one is infection risk, that it increased the risk of infection. And that’s significant because you need to balance the risk of infection with the possible benefit of what this treatment is trying to do. And you’d have to be careful about suddenly utilizing this in a wide spectrum and like millions of people who’ve had osteoarthritis, especially if there’s some other treatment options that are lower risk. So the options that are lower risk are to utilize your own blood platelets and bone marrow graft stem cells to actually treat osteoarthritis. And the reason why is because those same treatments from your own blood and body and bone marrow do actually block interleukin-1 receptor antagonist protein. So it does the same effect, but because you’re utilizing your own cells, you don’t have that same risk of infection, that same risk of allergic reaction. And anytime you’re measuring risks and benefits, you need to say, what are the potential risks? And can I get the same benefit in a lower-risk fashion? And in this case, you possibly can. Now there’s no head-to-head trials of saying, utilizing your own cells versus this medication. That’s still very early. But it’s worthwhile understanding that while there may be some benefit here to this medication, you can get a similar, if not same effect, in a much lower-risk fashion utilizing your own cells right now. And so my sort of hot-take or initial take is very interesting that there there’s maybe some progress on looking for disease-modifying medications for osteoarthritis. It’s always good to have additional options, but understand that there’s existing options that already work in that same kind of mechanism where we know it’s definitely safer. Okay, so the bigger topic for the day I wanted to discuss is the concept of uncertainty, obviously with a focus on the medical side and a focus on musculoskeletal health and stuff like that. But uncertainty is the topic of the day. It’s just too big of a topic to ignore. I mean, I can’t just talk about joint and tendon issues and not sort of address what are the things everyone’s thinking about, uncertainty, meaning uncertainty with COVID, uncertainty with what are people doing if they want to go back to the gym, uncertainty when it comes to sending your own kid back to school. Obviously, my wife and I are thinking about that a lot in terms of what’s right for our own family and our own child in terms of going back to school, knowing that most schools really don’t, don’t know how to address this. I mean, this is a once-in-every-couple-100-years kind of event. And obviously the modern school system is not exactly made for that once-in-a-several-lifetime event. And there are a number of things that I think about when it comes to uncertainty and obviously seeing patients, and they’re all going through those same issues and thinking about those same concerns. Here’s kind of how I think about it. There’s sort of four different things that I’m going to give examples of of how to address kind of each one of these. But, you need to focus on what you can actually do something about. You need to be able to accept uncertainty, focusing on big principles, and you need to know what are trusted sources. And the examples I’m going to discuss are going to involve COVID-19, in addition, uncertainty in everyday decision-making, as a physician how I look at some of the uncertainty associated with musculoskeletal conditions, whether it’s things like inflammatory arthritis or even routine things like lower-back or knee issues, and how you think about imaging findings as well. Because uncertainty is present in all of these things. So first and foremost, I think it’s so essential to focus on what you can actually control. As an example, so we’re starting to realize that post COVID infection, there’s likely some chronic inflammatory issues that may be present a few months later, and obviously a lot of people are still symptomatic. We’re starting to see some of those patients. And there was a small study that came out of Germany a couple of weeks ago where they found that even two to three months after the initial infection, that a significant number of people in this small study still had evidence of inflammation around the heart, objective inflammation, either lab tests, MRI evidence. And that was regardless of how severe their COVID infection was, whether it was mild, moderate, or severe. So relevant because that same inflammation can be present in other parts of the body as well. And so I’ve had certainly one patient in particular recently who came in with all sorts of pain symptoms and fatigue symptoms after she’d had a COVID infection diagnosed a couple months ago. And it’s challenging because you’re looking for objective evidence of active inflammation that needs to be treated. And in her case, while she has slightly elevated labs, her imaging and exam don’t really show that. And so you’re in that sort of gray zone about, you want to treat this appropriately because this is likely related to her prior COVID infection, meaning the immune system is still revved up. She’s not any longer infected, but her immune system is still revved up and still causing inflammation. And yet how aggressively do you treat this is not clear. In addition, we’re not even sure what the full scope of post-COVID will be, how long does that last, and what’s the right way to handle that. There’s a lot of uncertainty to that. And for that individual that’s dealing with that, that’s super difficult and obviously very challenging when you’re being told that, listen, you have likely something, but we need to be realistic with how we’re going to treat this. And we need to be realistic to understand that there’s a lot of uncertainty here and that there isn’t really definitive guidance as to how to treat this. So let’s focus on what you can control, meaning here’s someone who’s had to pull back in a lot of exercise activity because of symptoms. Well, that will not only perpetuate her pain. It’s obviously affecting her sort of overall emotional and mental wellness as well if she went from doing significant physical activity five days out of the week and now doing none. Well, let’s get back into some physical therapy. Let’s let them start to kind of promote some of that kind of muscle firing, load bearing, get you back into doing some low-impact exercise. They can use some modalities like electrical stimulation, massage, maybe dry needling, just to help with pain as well. Let’s get back into something like that. There’s something that you can do something about. Let’s make sure you’re doing the right stuff from a nutrition standpoint, from a supplement standpoint. Optimize what you can control. It may not be 100% in terms of controlling your symptoms, but let’s at least maximize what we can control on your own without having to resort to medication, stronger treatment options as well. Focus on what you can control. Number two is focusing on big principles. So every single day, right, when I see patients, there’s uncertainty in terms of diagnosis, in terms of treatment options, in terms of what’s the next right step. And a lot of times, you just have to rely on what are your big principle understanding for the overall condition, the way the body works, in order to help make some decisions. So, as an example, inflammatory arthritis, early rheumatoid arthritis, is it really meet the criteria, does it not meet the criteria? You sometimes don’t get exact definitive diagnoses in medicine. And a lot of times, you need to use your best clinical judgment based on what you understand and have seen in the past, based on subtle findings that you might see on exam. For me, utilizing musculoskeletal ultrasound to find some subtle findings to help really push somebody into the right diagnostic criteria, it goes a long way. But a lot of times it is, in times of uncertainty, you still need to find and utilize those big principles, that if somebody has inflammation, their ultrasound findings will tend to look like this as opposed to degenerative arthritis and may look like that. That’s a big principle that helps to guide me in terms of my decision making. And that goes a long way to helping to make a right decision. Another example would be, I mean, knee and lower back degenerative arthritis is endemic. Like 70% of the population will have one of those issues or, if not higher, in their lifetime. And a lot of times people come in with pain symptoms, and their imaging may show a lot of findings. Their X-ray may show advanced arthritis in their knee, or their MRI may show tons of different things. And clinically you realize that not all of that correlates with their pain or their symptoms. And you have to utilize good principles of exam, understanding of the pathology, to really help guide people. As an example, the example I love to give for hips where it can be a little bit confusing is for my own mother. She’d had chronic hip pain for decades, and she’s had some imaging of the hip that actually showed some degree of wear-and-tear arthritis. But after a proper examination and figuring it out, it turned out her pain was really coming more from her SI joint, and her SI joint doesn’t have a ton of imaging findings. But clinically, based on my clinical experience, exam, and even treatment, we figured out that her pain was really coming from the SI joint. And focusing treatment on that has got a humongous way to treating her hip pain. And so even though her imaging may have said one thing, clinical understanding of how pathology works and how a condition presents, those big principles, helped to guide me in terms of making the right kind of medical decision and treatment decision in her case and in other cases as well. I think that same kind of concept applies to big principles in life as well. So, as an example, deciding, you know, what sort of activities do you put your kid back into, you don’t need to make reactive, scared decisions. You do need to make sensible, commonsense ones, things that are based on your own prior experience and principles that you live by. Apply those to the challenges and uncertainty of the day. It’s not going to be 100%, but it’ll at least help guide you to make the right kind of decisions that are going to respect your own beliefs and do the best that you can for your own family. Focus on big principles I think is a huge one in times of uncertainty because that’s how you stay on the right path. The third one is really accepting that uncertainty is, that is what life is. And it’s hard because right now, we went from a world that we were used to. And now there’s a humongous amount of uncertainty about what is happening in the fall for kids’ schooling, uncertainty in terms of what can you do for the normal kind of events in your life, going to weddings, going to the gym, going to restaurants, meeting friends, all that kind of stuff. And yet I think it’s important to understand that as human beings, we’re literally built for this kind of uncertainty. If you go far enough back in anyone’s family lineage, you’ll find people who went through a high degree of chaos, uncertainty, and troubled times. And the reality is that, as hard as right now is, there’ve been times in human history where people, our own family members, have had to go through things that are dramatically worse. We are built for this physically, mentally, emotionally. It’s hard, but we are really built for this, to be hardy and adaptable, to take these kind of things on. And I think that that understanding of uncertainty that that’s what life is, is helpful for not only on an individual level, but understand that even on a macro level, in terms of how science works, how medicine works, that uncertainty is part of the process. And so it’s frustrating for a lot of people to hear the CDC give guidance, one thing, or doctors saying one thing about maybe this medication works, maybe do this, maybe wear masks, don’t wear masks. And then later on, they change it up. But the reality is that’s how science and that’s how medicine works. It works based on understanding to the best of your ability what is going on now, and as more information comes in, to then adapt and change to what the new information is. That’s literally how science works. And while it may be unsettling for people to hear that, the reality is that uncertainty is part of the strength of the system, that it adapts to what the new information is. It considers what it already understands, but then adds on and layers on that new information. And the better people understand that that’s how science works, that’s how medicine works, it’s not static, it’s dynamic, it’s learning, it’s growing and understanding, I think people will feel a little bit better in terms of the advice and guidance that they’re hearing from authorities and their physicians. The last thing is you need to have trusted sources. You need to be really clear what people, organizations, news sources can you trust and that you should rely on. We live in a world where it’s great to have so much information, but there’s just so much noise. It’s overwhelming to hear the discordance in terms of what people are thinking and talking about. You need to be able to judge who you trust so well. That’s no different than how it was pre-COVID. It’s just now there’s so much noise. You really need to be very clear what physician do you trust. What higher authority organizations on a medical level do you trust? What policy organizations and other sources do you trust? Understand that they may not always be right. I think one way that you know you’re dealing with a legitimate organization or person is, are they willing to admit when they’re wrong, and when they’ve made a mistake. When can they admit that my prior belief and understanding was this way, and as information has adapted and changed, now I’m thinking this. That sort of humility is very important. And understand that when it comes to things like science and medicine, you really should trust science, scientists and doctors who are actually experts in their field of study rather than trusting necessarily political sources, other news sources, but actually trusting people who are experts at what they’re doing. So, expertise is helpful, but a sense of being humble and humility when they’re expressing that, and a dynamic process of adjusting that information as things go along because the reality is circumstances change in life. Understanding changes as well, and you know a trusted source is on it when their opinions slowly adjust over time, not someone who’s changing every week or every day what they’re recommending, but somebody who, as they gather more information, can give you more updated, sensible understanding of what you should be thinking and doing. So to me, those are the big things. Uncertainty is difficult at this time, but the same rules apply pre-COVID as they do right now. Understand that there are things that you can focus on, and that’s what you should really be focused on, the things that you can control. Number two, having a big picture understanding of how you approach life and relying on those when times are more difficult. Number three, accepting that uncertainty is part of how life is. And then lastly, making sure you have good trusted sources that can guide you during this process as well. Until next week, I appreciate your time. As a reminder, we do this twice per week, Mondays and Wednesdays. Until the next time, have a good day, be well, live well, bye bye.


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MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.

***About this video***
In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses dealing with uncertainty in life and medicine.

Inflammation in Joints and Tendons

img

Inflammation in Joints and Tendons
Weekly Education Replay 20200803
Inflammation
-What is inflammation?
-Inflammation in the musculoskeletal system.
-Cases
Tendinitis
Inflammatory arthritis
Post Covid19 symptoms

Content- Weekly Education
Live Weekly educational meeting for the team at Chicago Arthritis and Regenerative Medicine where we discuss the basics of what we do for arthritis, tendinitis, injuries, and back pain.
Watch live on FB/IG/Youtube every monday.
https://www.Instagram.com/ChicagoArthritis
https://www.Facebook.com/ChicagoArthritis
https://www.youtube.com/c/chicagoarthritis

***For more educational content:
Sign up for our email newsletter:

Subscribe to our Newsletter

See our blog:

Chicago Arthritis Blog

Listen to the Regenerative Medicine Report podcast:
https://www.chicagoarthritis.com/regenerative-medicine-report/

***For evaluation and treatment at Chicago Arthritis and Regenerative Medicine:
Determine if you are a Regenerative Medicine treatment candidate:

Candidate Form

Contact us for more information or to schedule an appointment:
https://www.chicagoarthritis.com/contact-us/

MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.

***About this video***
In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses inflammation in the joints and tendons.