Platelet-Rich Plasma Therapy for Arthritis

Foreign. Talk about arthritis, living with arthritis, even reversing arthritis, things that you can do, maybe a little bit about the incidence. How often is arthritis does a crisis occur in different types of arthritis? So there's various different types of arthritis. I'm going to focus on degenerative joint disease or osteoarthritis. This is the one that occurs typically with age or injury, even with obesity, might have increased incidence of arthritis osteoarthritis. There are many other types of autoimmune and we're going to talk about osteoarthritis today. It's the most common and it's estimated that direct medical costs related to osteoarthritis right around $76 billion a year in terms of surgery and physical therapy and everything. And then about that much again, another 75 billion or so in lost production, maybe, you know, missing work or not doing as many activities you did before retiring early. And real issue is when somebody has arthritis of a single joint, most common one being the knee, it decreases their activity level, which has a big impact on mortality or longevity. In fact, it's estimated that if you have a single joint arthritis and don't do something to address it, you shorten your lifespan by about 1.8 years if you're normal weight. And if you're overweight or obese, it's more like three and a half years. And it's mostly due to decreased mobility. So a good example is that as we get older, we need to increase our physical activity, walking, taking walks, strolling, riding bicycles, not decrease it. But if you have limitations because of arthritis, you're more likely to be inactive or less active, which is probably the principal reason your lifespan is shortened. Other studies have shown that arthritis symptomatic osteoarthritis associated with minor or major depression, poor sleep and weight gain. So these are all considerable considerations right now with the big push towards losing weight with the GLP1 agonists such as Mangerno, Wegovy, Zepbound, Ozempic, we're having people that have maybe had less activity because of the weight and other weights down and they have some damage to their joints and they want to get active again. We got to look at what are the options besides surgery. Now, surgery, the common surgery is called an arthroplasty total joint replacement. And an issue with that is that there's a longevity on these replacements and the second time around is not so good. So the success rate for a joint replacement is, is estimated 15 to 20 years before it Needs to be replaced. And when you replace the joint, the second time has a high failure rate. You know, infections getting loose, having some kind of need for a repeated operation, maybe even incapacitating somebody. So we want to put our surgery replacement off as long as possible. And what can we do in the meantime? Now, do drugs work? No. I mean there's some evidence that glucosamine, chondroitin may give some benefit, collagen may give some benefit. Very limited on non steroidal and inflammatory drugs. Basically just managing the pain. They don't do anything for the disease itself. Injections that are currently covered by insurance, such as steroids or hyaluronic acids, let's talk about those. So steroid injections do improve knee symptoms in the short term, but they lead to a sooner onset of needing a knee replacement because the arthritis is there. The steroids decrease the plane and inflammation from it, but also thins out the tissue and the cartilage gets thinner faster. So the use of steroid actually hastens the time at which you'll be worse. So this is a situation where the drug is actually worse than the disease because it makes it worse faster. So I'm not an advocate of using steroids at all, even though that had been the only option we had, let's say 30 years ago. Then there's something called hyaluronic acid or hyalurons. And these are something that's, it's akin to the fillers that we use in our practice cosmetically, but it's a non cost linked, say lubricant of the joint. When it gets injected in the joint, they usually do three treatments. You get some improvement for a few months. Pretty expensive, no long term effects. And it doesn't actually heal the joint, but it does give some symptomatic relief teeth. So what can we do past that? Well, back in 2017, I wrote a book on stem cells and I'm not going to talk about stem cells today, that's for another subject. I'm going to talk about platelet rich plasma and platelet rich fibrin for osteoarthritis. So platelet rich plasma and platelet rich fibrin for osteoarthritis. So briefly, the platelet rich plasma and fibrin, I'm going to use those together because there's some confusion of what they mean. And I'll give you a brief overview with the differences. Not much, but the platelet rich plasma or platelet rich fibrin is a blood component. So we draw your blood Typically like a bio tube similar that you'd get in your doctor's office for a blood count or a chemistry test. Typically one or two or three or four vials are drawn and it's put in a centrifuge and it's spun. And the top portion, which is the yellow portion, you see a tube of blood spun. There's red on the bottom and kind of yellowish on the top, more clear. We take that yellow, more clear stuff off the top so I can be completely clear. There's platelets in it and white blood cells, but it's like kind of a yellowish golden turbid fluid. And that's a platelet rich plasma or platelet rich fibri that has healing tissues in it, which is predominantly a platelets, maybe the white blood cells as well. And we want the platelets to be injected into certain tissues to give off growth factors. Now just a brief discussion about what's platelet rich plasma and which platelet rich fibrin. We can use the terms interchangeably, it's kind of like a generic word. Platelet rich plasma typically means that the platelets have been more or less paralyzed by an additive or chemical in the tube, most notably something like sodium citrate. And that keeps the platelets from giving off the growth factors and clott, so it can be handled easier. But then right before we inject it, we may add an additive, another additive to reverse the anticoagulant. Therefore the platelets can go ahead and give off their growth factors and then that makes platelet rich plasma into what we call platelet rich fibrin to actually clot up. That term is not used so much platelet rich fibrin until recent years. Because now we have a way to actually draw the blood without additive using special types of tubes and a special type of centrifuge to get liquid platelet rich fibrinogens that's stable at room temperature for about 20 minutes and stable in a refrigerator for about 40 minutes. And that's what we're using now that we're not adding the additives that might impair the ability for the platelets to give off their growth factors. So let's talk about the growth factors associated with PRF or activated prp. So number one is platelet derived growth factor. Platelet derived growth factor, PDGF is a factor that causes cells to come into the area, that causes migration of healing cells and tissue cells to where the platelets were at. Let's imagine what platelets the first place you get a cut on your arm and it clots up and it heals up and then there's a scar and eventually you maybe can't see the scar at all. That's because your platelets recruited cells in the region, skin cells and fibroblasts and myofibroblasts and dermal cells to come into the area and fix it. So it's a strong healing growth factor. Platelet derived growth factor causes migration of cells, in this case into the joint, into the knee. Then there's vegf, vascular endothelial growth factor that stimulates the growth of circulation. Now the cartilage, low circulation in the region. Now there's really no circulation inside the cartilage. But this getting to the cartilage, it's got a low vascular bed where the cartilage has to have some nourishment and that's diminished in arthritis. And the vegf, which is vascular endothelial growth factor from platelets, aid circulation growth to the area so it can start feeding the cells that have migrated into the area. So platelet drive growth factor migrates cells in vegf, helps nourishment those cells. And last one is TGF beta, transforming growth factor beta. And that causes cells to duplicate. It does other things as well. But one of the, for the case of arthritis, it causes these cells to duplicate. We want to get cells to migrate in, in this case, mesenchymal stem cells, your own stem cells, we want to feed them with blood VEGF and we want them to grow and turn into new cartilage TGF beta. So those are the three principal growth factors to help aid the healing of tissue in the knee. Now, stem cells work in a similar fashion, different but similar fashion. We can use stem cells along with PRF or PRP activated. We're talking today about PRF and PRP activated because it's very practical, not very expensive, and it's FDA approved and everything. So what do the studies tell us? Well, there's been clinical studies on PRP or PRF for decades. I was the first patient in our clinic that got PRP treatment. So back in 2009 or so, I injured my shoulder and I had a rotator cuff tear. The subscapularis was, was torn about 70% and was a disability. It was hard for me to do surgery and stuff. It hurt when I would throw things and it limited my, my mobility, really impacted my life. And I was scheduled to have a surgery by a, by a orthopedic surgeon that specialized in the shoulder. Dr. Nicholas Shock, he's a friend of Mine evaluated me and said, you know, we'll do this surgery, shorten your biceps tendon, you'll have a scar along your shoulder, and you'll be functionally normal. Recovery about six or eight weeks. I was like, I was responsible for clinic. I was doing surgery. I didn't want to be out eight weeks. And I read about Stars and Athlet getting PRP into their tendons and joints. And it was a new thing at the time. There was kits to make it. So I went and bought the equipment. The first equipment I bought was called the Harvest Technologies Kit, one of the early pioneers. And I had my ultrasound technician, who was a vascular technician, learn how to do musculoskeletal ultrasound, at least for the shoulder. And I brought in a friend of mine, another orthopedic doctor, Dr. Jim Kehoe, to inject the shoulder with PRP again. This was brand new at the time. And we injected it twice. We did it once, and I had functional improvement pretty much within a couple weeks. And a month later, it felt great. And on ultrasound, when he. He did the injection, he could see the frayed subscapularis tendon, you see where it was ripped and injected right into the tendon. We went to do it again. The tendon had already been healed. We injected anyways, because at the time, the protocol was do it twice. Really not the case anymore. But we did it a second time. The tendon was already healed, and it's been normal more than a decade later. No pain, no functional disability, no recurrence of injury, and no need for surgery. That was an arthritis, that was a rotator cuff injury. And that's what we were first using platelets for, was for repairing tendons and ligaments. And then we learned it also seems to help with arthritis. And this came about comparing the current modalities, which is steroids, steroid shot in the joint, hyaluronic acid, or hyaluronans, which is a lubricant in the joint, or prp. PRP activated PRF into the joint. We found was that they all worked for symptoms. The people getting the steroid had rapid relief of pain, but a rapid onset of deterioration of the joint. Okay, hyaluronic acids, hyaluronid. These lasted. You have to do three shots, and they got some clinical improvement, lasted a few months, and then they sort of fall off. But they got improvement clinically to some degree. And the PRP patients had the most benefit and the most durable benefit, lasting typically basically six months to a year. Now there was additional studies combining things Together like PRP plus hyaluronic acid, or we'll call it HA or HA alone or PRP alone. And the combination did slightly better. But the real mainstay was the PRP was leapfrogging ahead of any prior injectable. Again, we're not talking about stem cells. There's some regulation with stem cells that we can, we can still use stem cells, but I'm not talking about comparing it to stem cells. And there have been comparisons of PRP to stem cells, which I'll talk about in a little bit. So the PRP seems to work to improve symptoms pretty consistently. Like more than 80% of people have more than a 50% improvement of their joint pain and disability and functional disability with PRP injection. When it first was being done, we were doing it multiple times, three times. Now we find that we use a little bit more platelets. We don't have to do it so often. Might be more like six to nine months. So one study, I like to quote, was a study looking at severe arthritis. Now there's a grading system for arthritis. It goes one through four, with four being, you know, bone on bone, three being almost bone on bone, two one being more just arthritis, and zero being no arthritis. And there's functional scores and pain scores for that as well. And so we look at study done with people that were having three and four, so they were bone on bone arthritis. Most of the studies had been twos and threes. More minor arthritis showing improvement. What about more severe arthritis, which we didn't really think would likely work as well? Well, so as we got experience doing more minor arthritis, we started treating people sicker. And we found that they were working, working just as good, potentially the same. And a large study looking at what they called a survival rate, meaning survival of not needing surgeries. There was a group in the Philippines, looked at about 300 people that had debilitating arthritis that was scheduled for surgery. And they offered them PRP injections or prf, in this case injections. They used two tubes of blood, made a PRF PRP combination and injected the knee. And at two months, if they did not have a 50% improvement, they said, okay, go ahead. And with surgery. And if they didn't, if they had a better than 50% but less than 80%, they'd say, well, let's do it again at month six. And if they had more than 80%, they said, well, come in when your knee pain comes back. And they followed the patients for three years, long study. But you don't usually have three year studies kind of hard to do. What they found at the end of the study is the grade three and four arthritis. The majority of people, four out of five did not meet the criteria for surgery anymore. These were people that required surgery that three years later, four out of five of them did not meet the criteria for surgery. That's actually about the same as surgery. So surgery, when people have surgery, about 20% of people still have some functional problem after the surgery. This is 20% of people have problems that they wind up getting surgery or being candidates for surgery. The study didn't assess whether or not they actually had the surgeries where they're a candidate and a candidate would mean that they had, you know, they still had significant symptoms and this was more advanced arthritis. Since that time, numerous other papers been done looking at all kinds of grades of arthritis 1 through 4 and find that it pretty consistently works. You don't need to do multiple treatments up front. And it's looking like you need probably about three treatments in a year, maybe two treatments in a year, and then maybe once a year after that for maintenance because you're still having the functional issue that's causing the arthritis in the first place. Maybe your knees slightly bent, it was like valgus or varus deformity, maybe running your activities that, that caused it in the first place are still going on. So you may have to do some maintenance. So we devised a method to kind of mitigate the need for surgery. Again, this is $150 billion a year healthcare waste that we could do very if we could save, you know, the country money and save you money and time and effort and surgery, or to prolong delay the surgery as long as possible. That'd be a huge, huge home run. So we have a program where you, you get a subscription model where you get your PRF treatments. Typically we expect, you know, two to three in the first year, then about one a year after that. And if you need more, you can get it done, but most people won't. Maybe, you know, one out of five potentially might because they're going to didn't respond as well, or they might decide, well, I'm just going to go ahead and have the surgery. This is an option for somebody that wants to get prf, doesn't want to have a huge cost associated. I've seen cost as much as fifteen hundred dollars per injection shouldn't cost that much. The newer technology, they've come way down in price. So what was costing us a really a small fortune to do PRP in the past is now relatively inexpensive. The technology of getting into the joint really really smooth. We use ultrasound. We have ultrasound technicians and mid levels and doctors TR trained on using ultrasound so we can get right in that joint so we can get precision. We're most experienced with the knees, but we've done pretty much most joints except the spine. And talk a little bit about spine in a later episode, how that can be managed because that's a little bit more tricky. There's many more, much more complexity to that joy where say the knee joint is this one big pocket that we can get right into and the PRP spreads all over. The PRP can be augmented with hyaluronic acid. And we're typically thinking the first time you just, just do the PRF alone, the PRP or PRF alone get some improvement of your symptoms. Then the second time when you you're feeling wanted to have a booster, add the HA at that time. And the reason is that the HA and PRF together delays the onset of relief. Now even though it gives you more durability and it works synergistically better than either one alone, you don't get as quick of a pain relief with the combination. At least that's what studies are showing us. But I think you should do it anyways, maybe once a year, once every other year to get that scaffold and that lubricant for the joint. And we're using a cross linked HA which is has not been prior available in America for the knee joints. And we're using a special sugar alcohol to keep them from breaking down so it lasts a long time, gives good long term relief. So it is a, is a novel way to do this. And again we're using ultrasound to get in the ultrasound joint, get in joints with a lot of precision. We draw your own blood. So the way it works is you get evaluated by one of our providers. Most of our patients have already had a diagnosis of alters of arthritis. Most of our patients have already had diagnosis of arthritis. So that's the case. You know, you don't necessarily need to bring your records. If you know that's what you have, we're going to go with that. If you're not sure, you might need to be worked up. We potentially could send you for X ray or refer you to somebody that can make the diagnosis. Because this is a treatment for osteoarthritis, it can be used to treat ligament conditions as well. We want to know, you know, what we're treating so we get it in the right area. So, for example, I use my example of having rotator cuff injury that is different than say shoulder arthritis, same joint, but when it's rotator cuff injury, we want to get rated into the cuff, right into that particular tendon. Whereas with the shoulder arthritis, we just want to get it in the shoulder joint. So there's some differences. So an X ray may be needed in some cases in the MRI with the shoulder to see which ligament is or which tendon is injured. And the you come in, we can do it the same day. We draw your blood and typically be a couple vials of blood, just like getting a blood test done. And the blood, the tubes are a special plastic type of tube that is hydrophobic, meaning that the blood doesn't want to stick to the walls. It's less likely to clot. We put in a special centrifuge that goes horizontal so that way these platelets can slide past the red blood cells a little bit easier. You have way more red blood cells than white or platelet cells. White blood cells are platelet cells, and some people say platelets aren't. Cells are actually fragments. So they're for all intents and purposes a cell. Even though they don't have a nucleus anyways, they're little balls, the red blood cells and get to the top, they're lighter, less dense, and the red blood cells fall to the bottom. So that's how we separate them out. Then we put it into a little cooling device to give us a little bit more working time so we can get you prepared. We sterilize the knee or prep the skin and you can get a little numbing shot. We get the ultrasound and find the area that we're going to eject from. And then the knee is the most common area we treat. We go right above the knee. There's a little space above the patella that has, that's contiguous with the joint. And we typically inject there. It's called supra patellar approach. Shoulders typically done to the back. Hips done from the front. Ankles and wrists are done a little bit different. These are all done with ultrasound guidance. And after your skin is numbed up, you really don't feel the needle in. There's a little discomfort with it, but it's almost none. The injection gets put into the knee joint and needles pulled out and you're done. That's it. Now there might be some tightness feeling in your knee. It might be a little inflamed afterwards, but it's typically not much of anything. And typically you Feel better pretty quickly within a month. And it peaks typically between month two and month six of improvement. There are heaven studies showing there's some growth of cartilage. Again, the joint space is getting better. Better particularly doing repeated treatments. And it's not necessarily one and done like a knee replacement where you've actually cut the joint out and put in a new metal joint that's going to last 10 or 15 years or 15, 20 years or like a ceramic joint, there's going to be continued wear and tear. So this might be something you plan to do periodically. And we're thinking that most common pattern seems to be doing it two to three times in the first year and then about once a year after that. You can even do genetic testing to see what joints are at risk for arthritis. So my genetic test tests show that I would have risk for hip arthritis. I'm sorry, first I strike that my genital have risk for knee arthritis. The reason hips led in my mind is I have a little hip pain that turns out to be related to something called neuralgia paresthetica. It's a pinched nerve and my pinched femoral lateral femoral cutaneous nerve, which we've treated. But I'm at risk for knee arthritis. So I've done some things over the past 10 years to keep from getting arthritis. So starting out, I did what's called extracorporeal shockwave therapy and photobiomodulation and did X rays and rechecked the X rays six years later. And there. There's no degradation of the joint whatsoever. Nothing. When I started getting a little bit of. A little bit of discomfort my knees that would occur after, say running upstairs or maybe a long bike ride. More than an hour or like dancing at a Christmas party and you just feel kind of hot the next day. Not hurt. And that's really the earliest form of arthritis. You know, really not clinically arthritis yet. The X ray to show maybe a little narrowing of the joint space, but no gnarly appearance to the bone. Bone. And I've done PRP twice to my knees. Once in 20 and once in 23. Now I plan to do it every year just for prevention. And I'm not a symptomatic person to any degree, but I know the telltale signs I've got the genetic risk for knee arthritis. My mom had both her knees replaced when she was relatively young. She wasn't much older than I am now. She got her knees replaced. And I don't want to get to that point where the knees are looking bad. So there's even like a model where somebody can find out what joints are at risk and when they start having. Having minor symptoms, get ahead of it. And going back to a personal story, I did my last PRP injection right about a year and a half ago, and my knees have felt great. But we had a Christmas party a couple weeks ago recording this. In December 24, we had a Christmas party and I was dancing and the next day my knees felt kind of hot. And I hadn't had that in about a year and a half. And then the next day or maybe the next week, I noticed when I ran up the stairs to work. I always take the stairs. We're in the third floor in my main office in Shelley. And around the stairs, my knees feel little, little hot afterwards. Not bad, but a little bit hot. So I'm scheduling myself for another prp. That's just a sign that I'm getting a little inflammation. Genetics and my age, this is continued. But doing a shot once a year, I'm getting my blood drawn, separating it out, putting it in a joint. Good preventative medicine. So this can go anywhere from preventative medicine to treatment. Now, there's not been big studies on preventative medicine. I'd been no studies in preventive medicine with osteoarthritis, because there's no way to do a study like that. You can't follow people long enough. Like in my case was a year and half a half before I noticed anything again, not even what I would call pain. They just felt kind of hot. So we have to make that might be a little bit of a. Of a leap of faith. And we call evidence based medicine, where there's plenty of evidence and you have a, you know, some faith that it's going to help, because I know in my case, clinically it did. We're probably going to focus mostly on people that have symptoms. But as the symptoms get more advanced, we used to think it was, you know, kind of a long shot and we go right to stem cells or surgery. And now we're realizing, based on clinical studies, maybe not give it a try. About four out of five people will still respond with severe arthritis. Again, three, grade three and four. That's as high as it gets. Bone on bone. Arthritis is still going to respond. And somebody could choose to do stem cells as an alternative. I would do PRP with it. Prf, PRF or PRP with it. And I certainly would give PRF a shot to see how it does. It kind of precondition, the knees. The. I said I talk about back just a little bit on a meal, talk about that in a later episode. But the back is difficult because there's so much interconnection between these, the bones in the lumbar spine or the cervical spine, which are the ones that most commonly become deranged. But people are doing what's called paraspinal injection, where this doing injections in the area with PRP or stem cells. And they're seeing, because of these properties of the cell migration, cell proliferation, blood vessel proliferation, are getting some clinical response. So I'm not really keen on that idea yet. I'm still studying it, I'm still looking at what's being done. I know this is being done in clinics and other countries and in America. I'd say the jury's still out. But that might be some option in the future for people with spinal disease when we can't really get into all the joints quite as easily. It's much more complex, more risky, but can we do something simpler? But the low hanging fruit is the knees, the hips, the wrists. These are the 95% of arthritis in America. We know that women over 60 have arthritis, symptomatic arthritis, 50% more than men. So men around 18% have symptomatic arthritis that are men between 60 and 69. And women is about 35, 36%. So rate about double at 60 to 65, about 50% more overall if we look at all ages, women have arthritis about 15%, men about 10%. But as we get older, the rates, you know, go up. And typically in postmenopausal period, people that are overweight weight have more arthritis than people of normal weight. People that have been athletes have more arthritis than non athletic people. However, activity is a slight prevention arthritis because you're more likely to be fit and not, not as heavy. And one of the keys are for longevity. If we want to live a healthy life and not be debilitated in our final years, we've got to be fit. And to be fit, we've got to be mobile. And to be mobile, you're only as good as your worst joint, only as good as your worst joints. You've got a bad joint. I would get on that and get it resolved. Surgery is no longer the first step. I mean, it was never really the first step. They would do steroid injection injections and ha, which really were kind of kicking the can down the road in case of steroids, probably accelerating the time that you had deterioration. So I'd say those are certainly options they cover by your Insurance PRP and PRF is not covered by insurance. Stem cells are not covered by insurance, probably won't be anytime soon. But now this cost has really come down dramatically in terms of the cost of doing these joint injections. And the real take home message to this is that you have an option. You have an option that is, you know, the insurance companies might say it's experimental and they're not going to cover it. But this is being beyond experimental phase. There's been tens of thousands of people in clinical studies, hundreds of thousands of people been treated, tens of thousands of people in clinical studies treated successfully with arthritis and PRP or prf, tens of thousands successfully treated. Don't need a whole lot more experiments. What stops insurance companies from covering these things are the lack of big pharma being the contributor to the supposed drug. This comes out of your own blood. So there's no big pharma company involved. So there's nobody pushing for insurance companies to cover it. This is a standalone procedure. So the drug companies are not going to be there to persuade insurance companies to cover the drug. They do for These drugs called HA's, the hyaluronic acids they do for steroids. But there's no hero for the prp. So this is something that will be paid out of pocket. I think it's a question of what do you love more, your health and your life or your possessions? If it's your health and your life, then you can pay the nominal cost of cost for doing a PRP or PRF and joint injections to your joint. What determines success? Well, there's probably a lot of factors but proper patient selection. Somebody has a significant derangement on their knee, it's substantially crooked. You know, like somebody has severe bow leg or inverted legs where the knees kind of cocked in a little bit more issues with that, having mechanical disturbance. That's not going to get a lot of results. Could it help with pain? But you're probably need to do it more often and it will never probably, you know, go away. But that's, you know, still could be an earlier step before surgery. But that's probably patient selection. Your knees really crooked and it's bent, not as likely to be a good success. Other limitations are, you know, using the proper prp. Now there's different kits out there, have different amounts and this has been debated ad nauseam. It doesn't seem to matter a whole lot. We were using. I went to our lab years ago and took the various kits there and then made it on my own. I Could make as much platelets on my own as I could through the various kits. So they're pretty similar. But the big breakthrough in the past few years has been making true PRF without an additive. And that's has a theoretical advantage of not having the anticoagulant and then the pro coagulant affecting the release of growth factors from the platelets. Not sure that really matters a lot. It certainly does decomplicate the process makes it a lot less expensive, a lot easier to do. Is it better? Maybe. Dr. Muren who wrote several papers on this, over 100 and a couple books on it, he's persuading that this is a better solution. No real studies showing that are inhuman legs, comparing it to the older fashioned one. But he's done, you know, different experiments to prove that it likely is better. I think say that's not the biggest issue. The biggest issue is deciding to do it. Very, very low risk, you know, drawing of blood, low risk. You can get a bruise injecting into the joint. Very low risk of causing an infection. It's extremely unlikely it can occur, but it's extremely unlikely. I think the way we were doing it in the past had a little bit more risk because we were handling the stuff a little bit more. Now this is really kind of an almost completely closed system. So very low risk. Just like getting an injection of a steroid or HA in your joint. Not much risk and risk of making it worse. None is. It's not occurred. So we know that consistently improves the biggest risk. As you do it, you spend the money for it. And you're one of those people, one out of five people with severe arthritis that did not get more than 50% improvement. That that's the inherent risk and that that can happen. So that can happen. You want to go a place like us and guarantees it potentially. So PRP PRF almost interchangeable. Most time we were activating the PRP to make a PRF where it's now using straight PRF stem cells still stolen option. Hyaluronic acid still an option. Steroids. I'd say stop, stop with the steroids for arthritis. It's just, just a bad idea. That's maybe old school. Does give pain relief but it's not appropriate in 20, 24 and 20. First option. First line therapy. I tried that first. You want to have mobility and getting back to this longevity thing. I really think now a lot. You know, I'm in my 60s and I think about having a long healthy life ahead of me. And one of the Keys is being fit, being active. So predictors of longevity, there's a lot of them, obviously genetics and different things, but big predictors are how active are you. The more active you are, the more activity you're capable of, the longer and healthier you will live. So not just longer, long life associated with longer health. Spirits span is key. So we talk about longevity, we're really referring to having a long period of time where you're doing just fine, might be on some medications, but you're able to take care of yourself. You would take walks, play with your grandkids. Got two grandkids now. I hope to have more in the future and stay active for them. And I, like I said, my personal experience. I had the shoulder issue which I treated with PRP back in 2011. I've treated my knees with various therapies because I have genetic risk and not. I'm not symptomatic of any degree. But I'm going to do a PRP PRF injection injection in the next month or so as I'm starting to feel something again. It's been a couple years since the last. About a year and a half since I last did it. And this might be something you can just do to kind of maintain your health. Just like, you know, exercising and dieting and taking care of yourself and reading and meditating and walking. We take care of our skin, we do skin care, take care of our bodies, we put on deodorant, we brush our teeth and maybe we got to take care of our joints. There's an option for you now doesn't be done that often. I think the first year, two or three times and about once a year after that. And good luck and you're as healthy as your worst joint. So if you have a joint that's bothering you, let's look at a high options. Thank you.