An Introduction to Regenerative Therapies

An Introduction to Regenerative Therapies
By Dr. Lisa Barr

Prolotherapy: Of the host of regenerative therapies, Prolotherapy is considered by most to be the “original” regenerative solution and for many years was our “go to solution.” Prolotherapy solution consists of a concentrated solution of sugar water and local anesthetics, as well as other substances that when injected stimulates a very localized inflammatory response that signals the body to heal itself. This solution also promotes tightening of lax connective tissue often seen in chronic or recurrent sprains and degenerative conditions. By improving joint stability, we can reduce abnormal loading forces around the joints and avoid activating “alarm cells” called mechanoreceptors which cause more pain and result in abnormal compensatory movement patterns. Over time, the domino effect of joint instability can result in irreparable changes to the bone structure of the joint, often leaving surgery as the only treatment option. Thus, Prolotherapy provides a unique service to the body and will be around for a long time to come.

PRP Injections: PRP (platelet rich plasma), on the other hand, is a newer technique that was originally used by dentists in the 1990s to help with implant dentistry. Later, large animal veterinarians used PRP to keep performance horses functioning at their best. PRP is all natural in that we obtain the solution by drawing a patient’s own blood, then concentrating the platelets and special proteins call growth factors in a special centrifuge. We then take this solution and under direct ultrasound or x-ray guidance, inject it into the damaged or degenerated tissue. This promotes a natural healing cascade of seemingly invisible cellular changes that, over time, heals the body. The healing process takes time and PRP injections (with or without the addition of Prolotherapy) takes 3-6 months. To optimize healing, we encourage our patients to modify their exercises in an effort to address some of the compensatory changes that have occurred in their bodies in response to the laxity and pain.

The growth factors also include a number of signal proteins that regulate the inflammatory process and facilitate natural wound healing and tissue regeneration by proliferating myoblasts (cells that form skeletal muscle). Pure PRP is distinguished from regular PRP by the absence of red blood cells and neutrophils, as well as by the sheer concentration of the platelets and growth factors contained in each sample. In this case, the old adage “more is better” is likely to hold true in so far as the number to platelets and growth factors are concerned. The irony is that Prolotherapy and PRP both work by the same mechanism- stimulating inflammatory and proliferative responses, thereby acting as signals to the cells and catalysts for tissue regeneration. Therefore, it appears clear that the addition of actual stem cells, be it fat derived or obtained by bone marrow aspiration, may only be necessary in select patients who have more severe muscle and tendon tears, cartilage loss and significant arthritis, as well as those who fail to respond to PRP and Prolotherapy injections.

Adult Stem cells can be obtained from subcutaneous fat and bone marrow. For the most part, stem cells are considered “non-committed progenitor cells” of the musculoskeletal system and also have an active role in the repair of connective tissue. In next month’s article I will review more information about stem cells themselves.

Statins: Side Effects & Possible Solutions

By Lisa Barr, M.D.

Since their introduction, the number of prescriptions for the cholesterol lowering family of drugs referred to as statins has grown to 100 million per year.  Recent studies suggest that up to 20% of people taking statins develop muscle pain.  This equates to 1.5 million or more people taking statins each year who experience muscle related side effects.  The exact cause for the muscle symptoms induced by the statins is not known.

Symptoms of statin induced myopathy include: painful muscles, inflamed muscles, muscle breakdown, elevated levels of the muscle enzyme Creatine Kinase (CK), muscle weakness, nighttime muscle cramps, tendon pain and fatigue.  These symptoms can affect many areas of the body and mimic other disorders of the musculoskeletal system.  The term myopathy implies any type of muscle related problem.  Studies show that even without the elevation of CK levels, muscle biopsies have shown inflammation and microscopic muscle damage in some people taking statins.

Interestingly, one small study pointed to Vitamin D deficiency as a secondary factor that causes muscle pain and suggested that by correcting the Vitamin D deficiency,  symptoms of muscle pain improved.  The use of COQ10 to treat or avoid these side effects has been shown to be equivocal at best.

There are basically two (2) different categories of statins; simvastatin (Zocor) and atorvastatin (Lipitor), which are more commonly associated with myalgia, and the water soluble statins such as pravastatins (Pravachol) and fluvastatin (Lescol), which are less likely to cause muscle pain and potential drug to drug interactions.

In general the risk factors for myopathy include: female gender, advanced age, kidney or liver disease, diabetes, EtOH use and drug interactions.  It is also advised to avoid prolonged vigorous exercise as this may predispose for statin related muscle pain.

Once this side effect is recognized and the statin is discontinued, symptoms can persist for up to three (3) months.  A recent article published by researchers from Johns Hopkins described a possible auto-immune reaction in patients with persistent muscle pain.

If you think you or someone you know may have these types of symptoms, we encourage you to bring this to your physician’s attention.



APM Spine and Sports Physicians are named “Top Docs” in Hampton Roads Magazine

APM Spine and Sports Physicians is pleased to announce that Dr. Lisa B. Barr, Dr. Scott I. Horn, and Dr. David L. Levi have been named “Top Docs” in the September 2013 issue of Hampton Roads Magazine based on the results of surveys sent out to physicians in the Hampton Roads area.

Hampton Roads Magazine, in partnered with Consumers’ Checkbook, sent surveys to physicians currently practicing in the Hampton Roads region.   They were asked  a simple question—who would you call if you or a loved one needed medical care? Each physician was asked to recommend one or two doctors in more than 35 specialties. The 2013 survey received approximately 226 doctor nominations. Those who received the most votes in each specialty were listed as Top Docs for 2013.

For more information about the selection process, visit Hampton Roads Magazine 2013



The Faces of Pain

By Bonnie Nock D.O., APM Spine & Sports Physicians

Pain is one of the most common reasons in the United States for a visit to the doctor.  Pain is hard to define for most people, but is felt to be an unpleasant sensation.  The International Association for the Study of Pain uses the definition:  “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. “  Pain is a major symptom in many medical conditions and can interfere with a person’s quality of life and general functioning.  But pain also is an important component of our body’s defense system.  The pain mechanism allows us to remove ourselves from dangerous situations in order to prevent further damage and promotes healing as we protect the injured part.

When a patient visits a doctor about their pain, unless the source is obvious the physician has to try to determine the cause of their complaint based on the symptoms and length of time the pain has been present.  Physicians are trained to look at pain as acute versus chronic and then try to determine the source based on the patient’s description of their discomfort.  Acute pain is part of a rapid warning system of the central nervous system to detect and minimize physical harm and is generally transitory lasting only until the stimulus or underlying damage has been healed.  In most cases the cause is apparent and symptoms resolve within a few months.  Chronic pain, symptoms lasting greater than six months, generally serves no biologic function and is not a symptom of a disease but is generally felt to be a disease itself.

Once a time course has been determined then your physician will ask you to describe your symptoms as a way to determine the source and cause of your pain.  Pain is broken down into two distinct categories-nociceptive and non-nociceptive.  In nociceptive pain specific receptors are activated.  These receptors sense temperature, stretch, vibration, inflammation and chemicals.  These nociceptors are the nerves which sense and respond to the parts of the body which suffer damage.  They signal tissue irritation, impending injury or actual injury to the brain.  The pain is typically well localized, constant and described as throbbing, aching or sharp.  A subset of nociceptive is visceral pain.  It involves the internal organs of the body and tends to be episodic, poorly localized and frequently referred to distant areas.  An example of this is the shoulder, arm and jaw pain that someone complains of when they are having a heart attack.  Nociceptive pain is usually time limited with the pain resolving when the tissue damage heals.  Examples include sprains, bone fractures, burns, bruises, inflammation, obstructions and myofascial pain.  Arthritis is an exception to the general rules in that it is recurrent and not time limited.  Nociceptive pain tends to be responsive to a wide variety of medications including anti-inflammatories, narcotics, anti-seizure and antidepressants.    Non-nociceptive pain is not related to any specific receptor and occurs within the nervous system.  It is the result of an injury or malfunction in the peripheral or central nervous system.  The pain is often triggered by an injury, but this may not cause actual damage to the nervous system.  The damage or malfunction causes a nerve to send abnormal signals to the brain.  The brain then interprets these impulses as pain.  Pain may persist for months or years beyond the apparent healing of any damaged tissues.  The pain signals no longer represent an alarm about ongoing or impending injury but demonstrate that the alarm system is malfunctioning.   Patients generally complain of numbness, tingling, burning, pins and needles, electric shocks and sensitivity to temperatures and touch.  Examples include post herpetic neuralgia (shingles), peripheral neuropathy, phantom limb pain (amputation of limb), fibromyalgia and nerve entrapments such as carpal tunnel syndrome.  Non-nociceptive pain is frequently chronic and tends to respond well to anti-seizure and antidepressant type medications but is less responsive to narcotic type medications.

In some conditions the pain appears to be caused by a mixture of nociceptive and non-nociceptive factors.  A classic example of a mixed condition is chronic myofascial pain syndrome.  It is felt that myofascial pain syndrome is initially caused by a muscle injury that then causes a malfunction of the nervous system with development of continued abnormal muscle sensations and pain long after the muscle itself has healed.  The treatment for mixed type pain patterns are similar to those of the non-nociceptive group in that they respond to anti-seizure and antidepressant type medications and respond poorly to narcotics.

Spice Things Up this Spring

By Kathryn Bragg, PT

With the first blooms of spring and the promise of milder temperatures, we tend to transition our schedules from sedentary and almost exclusively indoor activities to more physically challenging outdoor sports and pastimes. However, no matter the season, most of us have set daily routines in which we perform the same types of repetitive activities at work, home and play. Spring offers an opportunity for new beginnings and fresh perspectives on the old routine, including breaking some possibly less than healthy habits.

Consider the fact that most of your life you have probably dressed in the same order, slept on the same side of the bed (maybe even in the same position), sat with the same posture in your car seat or office chair, have watched TV from in the same lounger, sat in the same dining room chair, and on and on. As a result of these repetitive habits, we develop muscle memories and patterns.

With the onset of  spring we resume yard work (most likely raking, digging, mowing) with the same motions, as well as sports that usually require  repetitive patterns (baseball, soccer, track, rowing), sometimes these patterns are sustained over time (such as in wind surfing, sailing, skiing or even fishing).  We become habituated, or in some cases develop bad habits (also known as compensatory movement patterns) ,that also develop muscle memories and patterns. 

Additionally, we primarily work and live in a counterclockwise world.  While most people think in terms of our living in a right- or left-handed world, what is even more impactful is the counterclockwise world in which we exist, causing us to become habituated to a consistent direction of movement in our homes, work and while at play. While shopping, you’ll notice most stores are set up in a counterclockwise traffic flow.  The circuit around a baseball field is counterclockwise. Most people run around a track in a counterclockwise direction. These are just a few of examples of how such patterns, of which we often are not even aware, can affect our muscle memories and patterns.

Anyone, with or without pain issues, needs to be aware that just by changing behaviors and trying to avoid habituation (same daily routines and recreational activities, and awareness of how our world is orientated), can bring healthy variety to our body.  Change the side of bed you sleep on, alternate the direction you walk in the neighborhood or on a track, change how you sit or move in your work environment, change the orientation of your computer screen or where you sit at meetings, and/or rearrange your office or home furnishings.

Variety is the “spice of life,” not only adding texture, depth, and escape from the mundane, but actually healthy in that it can help our bodies prevent habituation of patterns that can develop into dysfunction, often resulting in pain and/or injury.   So don’t be like Bill Murray in the movie  Ground Hog Day, continually stuck in the same routine. Spice things up this spring with some changes in your routine.

New Hope for Back Pain

By Dr. Scott Horn & Dr. David Levi of APM Spine & Sports Physicians

Low back pain affects 80% of Americans at one time or another throughout their lives.   In up to 50% of low back pain cases, the intervertebral  disc is involved. Discogenic pain is often initially experienced after a bending and twisting type of movement.  The pathophysiology is felt to be the development of a small tear or fissure in the outer ligamentous part of the intervertebral disc, the annulus fibrosis.  The individual typically experiences severe muscle spasms, feeling “locked up” and unable to flex the lower spine.  While symptoms usually abate within a few days, for the majority, subsequent similar episodes usually follow.  Too often, the pain can become chronic.

Most of the time, discogenic pain can be managed by a good physical therapy program and a motivated patient, but sometimes therapies, epidural injections, and medications are not enough.  As surgery is not usually the best option for discogenic pain, what other treatments are available?

Intradiscal injections are still somewhat controversial, as the medical literature is mixed in regards to outcomes, however, there does appear to be some promising treatments on the horizon.  The injection solution itself can vary widely from corticosteroids, platelet rich plasma, methylene blue, statins, glucosamine, dextrose, and even stem cells.

Intradiscal injections of corticosteroids in some studies have been shown to be helpful in discogenic pain that is also associated with certain changes to the bone surrounding the disc as seen on MRI. Corticosteroids injected into the disc itself may help limit some of the inflammatory cascade and subsequent cytokines produced by the annular tears which may be contributing to the pain.

Platelet-rich plasma (PRP) injections have shown very promising results in musculoskeletal injuries. Platelet-rich plasma is an autologous volume of plasma with a platelet concentration 3-8 times the concentration contained in whole blood. PRP contains many different growth factors and cytokines which stimulate the healing of bone and soft tissue and the platelets secrete  growth factors needed for all of the stages of tissue repair.  These factors increase collagen content, accelerate endothelial regeneration and promote angiogenesis. In addition to healing properties, the growth factors may also activate quiescent stem cells to further promote tissue repair.

To discover whether an intradiscal injection of PRP could promote healing and regeneration of annular tears in the disc and improve discogenic pain, a randomized placebo controlled trial of 36 patients is currently under way with promising preliminary data.  Significant improvement in function and pain from baseline to 8 weeks for the PRP group had been found, but no significant improvement for the control group.  In addition 5/6 (83%) of the control group went on to surgery but only 3/11 (27%) of the treatment group opted for surgery after the PRP injection. Is one of these intradiscal injection procedures going to be the cure for discogenic low back pain?  For now, we’ll have to wait and see.

For more information on available leading edge intradiscal injection procedures, please contact APM Spine & Sports Physicians at 757.422.2966 or visit online at

 Dr. Scott Horn is an interventional spine specialist and board certified in Physical Medicine and Rehabilitation. He serves as the International Spine Intervention Society representative to the American Medical Association’s committee on economic issues.
David Levi M.D. is certified by the American Board of Physical Medicine and Rehabilitation. He lectures extensively on back and neck pain and is an instructor for the North American Spine Society, teaching physicians spine injection techniques.



By Scott Burch, MS PT & Lisa Barr, MD

For many years, subtle hip issues went undetected in people. Now, with sophisticated imaging studies, new x-ray criteria and functional movement assessment tools, we can better identify a variety of anatomical and functional issues that underlie the degenerative cascade of changes in the hip that ultimately lead to osteoarthritis and hip replacement.

There are four major potential problem areas that can contribute to hip pain and accelerate arthritis. The first is the shape of the joint and how the ball and socket joint is oriented in the pelvis. The second area consists of the labrum and extensive capsular ligaments that confer stability to the hip joint. The third is the dynamic area which includes the “rotator cuff” muscles of the hip, the SI joint and the muscles in the front of the hip and pelvis, including the psoas muscle. The fourth area includes the nerves of the low back, pelvis and lower limb, which innervate these structures. We also know that subtle issues affecting other parts of the lower limbs, including the nerves and joints of the foot, ankle, and knee, as well as the low back, can impact the hip and can cause compensatory issues in the hip girdle. These ripple effects and resulting muscle imbalances affect gait and often come to the fore in our assessment of the hip.

Any of these dysfunctions dynamically contribute to hip impingement syndromes, of which there are two types:

Pincer type—occurs when the leading edge of the acetabular lip extends too far outward and pinches the neck of the femur.
Cam type—occurs when the femoral neck doesn’t have enough clearance for the acetabular lip and labrum

In addition to seeing these bony changes on x-ray, muscle imbalances are often identified during one legged standing and other functional activities.

We have recognized the following Dos and Don’ts for those suffering from hip impingement: DO:
1. Focus on the core and exercises to strengthen it.


1. Do clam shell exercises
2. Use a recumbent bike

 Pinpointing the root of problems with hip function usually leads to strategies
that will ward off that eventual hip replacement

—that’s something we can all “wag” about!




A new study published in American Journal of Sports Medicine demonstrates clear evidence that platelet-rich plasma (PRP) is more effective at relieving pain and improving function than a common injection treatment for osteoarthritis, hyaluronic acid (HA).  The researchers randomly assigned 120 patients to the PRP group or the HA group to receive 4 weekly injections.  Pain, stiffness, and function were assessed at 1, 2, and 6 months. The PRP treatment was superior to the HA group at each time point with sustained improvement at the final 6 month follow up.  The HA group had some improvement at 4 and 8 weeks but less than the PRP, and the benefits of the HA did not last until the 6 month follow up.  This is in contrast to the PRP group which showed significant improvement in pain and function which appears to be long lasting.

APM Spine and Sports Physicians offers platelet-rich plasma injections for knee arthritis as well as many other conditions.

David Levi, MD

Stay Motivated to Get Healthy in the New Year – By Scott Horn D.O.

It’s a familiar story.  You have some aches and pains here and there.  Perhaps you take medications or have sought out therapy or medical procedures to help address your issues. With the new year coming, you’ve asked, “what more can I do to help myself?” It seems “life” keeps getting in the way of completing your new year’s resolution to get on a healthier path.  How do you stay motivated?

  1. Make a plan, but anticipate problems. It has been shown in some psychology studies that if you target potential pitfalls and plan to troubleshoot them before setting a goal, you will be more successful. For example, you might say, “The weather forecast is bad, but I’m planning to go for a jog.” You can then work around potential problems using if-then statements, “If it rains, then I’ll go to the gym and use the treadmill rather than skip exercising altogether.”
  2. Channel your desire. A person’s drive is often based on what one believes about their abilities, not on how objectively talented they are.  Studies have shown that people who have a strong sense of self-efficacy (that is, the belief that they can accomplish what they set out to do) perform better than those who don’t.
  3. Don’t go overboard.  When your sights are too ambitious, they can backfire, burn you out and actually become demotivating. Instead of aiming unrealistically high, set goals that are a stretch, but not an overreach.  But it is important to work toward them every day. Continually taking small steps will not only help hold your interest in what you’re trying to achieve, but will also ensure that you move slowly, but surely, toward your goal.
  4. Go public with it. Instead of keeping your intentions to yourself, make them known to many. Other people can help reinforce your behavior.
  5. Lean on a support crew when struggling. Think of the friends and family who truly want to see you succeed. Enlisting those with whom you have authentic relationships is key when your motivation begins to wane. Psychologists say that you should choose people who may have seen you fail in the past and who know how much success means to you.
  6. Make yourself a priority. Put your needs first, even when it feels utterly selfish. You will derail your progress if you sacrifice yourself for others in order to please them (such as eating a cupcake that a co-worker baked, even though you’re on a diet).
  7. Challenge yourself―and change things up. It’s hard to remain enthusiastic when everything stays the same.
  8. Keep on learning. To refuel your efforts, focus on enjoying the process of getting to the goal, rather than just eyeing the finish line.
  9. Remember the deeper meaning. You’re more likely to realize a goal when it has true personal significance to you. When the process isn’t a pleasant one, it helps to recall that personal meaning. Not all dedicated gym-goers love working out, but because they have a deep desire to be healthy, they exercise week after week.

New personalized pharmacogenetic medicine testing service available only at APM

We are pleased to announce another first for APM Spine and Sports and Hampton Roads.  Effective January 1, 2013, we will be the first and only Spine and Sports medicine practice to offer our patients a new cutting edge tool to assess the truths encoded in your genes.  Sounds a little bit like sci-fi doesn’t it?  It really is very simple.  Each of us has a unique way that our liver enzymes function.  This is very important since our livers perform the most essential function of metabolizing the medications we take and detoxifying our bodies.   Everyone has a unique “finger print” of enzymatic function in their liver that determines how and if they can metabolize certain drugs.  This unique pattern of enzyme function determines if you will respond to a certain medication or not.  It can tell us if you will metabolize the drug slowly or quickly or even at all.  Previously, this type of sophisticated genetic testing was only available in big academic centers and was cost prohibitive.  This new test is obtained by taking swabs of saliva from inside your gums and sending the DNA specimen to the lab for analysis.  Typically we have the results back within 10-14 days.   The cost of this testing is usually covered by commercial health insurance, as well as Medicare and Champus, and is billed directly to the insurance company.  We have been advised that our patients will have copays similar to other outpatient lab testing.  After the results return, we set up a consultative appointment exclusively to discuss the test results and the implications the results have on each patient’s prescribing history.  This information is shared with the patient and their other medical professionals, thereby improving safety, efficacy and cost effectiveness across the board.

By using the detailed clinical information derived from this pharmacogenetic test, we can now determine which drug will be the best fit for you.  The test provides both genotypic and phenotypic information about the ten different enzyme systems in the liver and these details can dramatically influence a patient’s treatment options.   This takes a lot of the guesswork out of determining which is the best medication to select for each patient.  By using this information, medication side effects, lost time from work and potential hazardous drug interactions are minimized and efficacy is maximized early in the treatment process.  People get better faster with less risk.   Another benefit of this test is that we can also identify medications you may be taking from other physicians that may not be ideal for your specific genetic make up.  We can then consult with your other physicians and advise them of this information so that they can help you select the best medication options for you.

By working closely with the detailed analysis provided by this unique genetic test, we can select the best pain medication, muscle relaxer, antidepressant, etc., just for you.   Currently this technology is being used in cardiology to help determine the best anti-coagulant option for patients with cardio-vascular disease.  We are excited to bring this same level of specificity to our patients.