There is obviously a time and place for surgery. However, it is nice to go over all of your options, especially the noninvasive ones, before having a major surgery done. Dr. Fawad Mian is a neurologist who specializes in regenerative medicine and sleep disorders. Within the field of neurology, we see a lot of other common things which you would typically see, such as headaches, neck pain, back pain, dizziness, memory problems, epilepsy, and memory disorders. Dr. Mian finds it a wonderful opportunity to try to help people who normally can’t get helped very well over a long period of time because there’s only so much medication that can go around and try to help make these people feel better. Dr. Mian goes over some regenerative musculoskeletal procedures that could possibly save people from major surgeries and get their lives back without having to go under the knife.
Dr. Fawad Mian is a Neurologist at West Orange, New Jersey. He specializes in regenerative medicine and sleep disorders. In this episode, we will go over some regenerative musculoskeletal procedures that could possibly save people from major surgeries and get their lives back without having to go under the knife. There is a time and place for surgery, however, it is nice to go over all of your options, especially the noninvasive ones before having a major surgery done. Please welcome, Dr. Fawad Mian.
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Regenerative Musculoskeletal with Dr. Fawad Mian
On this episode, we have Dr. Fawad Mian. He is a Neurologist, a Regenerative Medicine Specialist, a Sleep Disorder Specialist. I am lucky enough to have him in this same exact building as me here in West Orange. It’s a pleasure to have him here. Dr. Mian, how are you doing?
I’m great, Kevin. How are you?
Dr. Mian, where are you from originally?
All over the place. The first eight years of my life, I was in New Jersey but then my family moved away to North Carolina. I grew up in the High Point area, a town in North Carolina. I went to school in Chapel Hill. My family members came back up to the Northeast. My brother is an attorney in New York. My family migrated back to the New Jersey area. I’ve been doing some training in and out in the area.
Do you miss it down South in North Carolina?
Taxes are lower and it’s much warmer.
Dr. Mian, how did you get onto the path you’re on now of medicine? What made you pick that field?
EM 66 | Regenerative Musculoskeletal Procedures Regenerative Medicine Procedures: There’s only so much medication that can go around and try to help make these people feel better.
With neurology, I used to see patients who had strokes in the hospital. I found it fascinating how people had these weaknesses or these deficits in their body and how well it could match up on the MRI, how some of the patients were getting much better over time. I thought this was a wonderful opportunity to try to help these people who normally can’t get help very well over a long period of time. Within the field of neurology, not only do we see strokes, but we see a lot of other common things which you would typically see. For instance, you might see people with headaches, neck pain, back pain, dizziness, memory problems, epilepsy, memory disorders.
There are a lot of those that we see on a day-to-day basis. These are things that a lot of people suffer from time-to-time. One of the things that I did notice is that I saw a lot of patients with chronic pain and I found it difficult to treat some of these patients. There’s only so much medication that can go around and try to help make these people feel better. I was also having some problems with myself. For instance, I was having an Achilles issue that started out with some plantar fasciitis and it wasn’t getting any better.
I’ve got some cortisone shots and thought everything was fine. I went for a run a few weeks later on the treadmill, then I noticed that my Achilles hurt. I thought I would bounce back from it quickly. As the weeks and months went on, it didn’t get any better. I went to the podiatrist. The podiatrist said, “We’ll try some laser therapy or try some shockwave therapy.” After all of that failed, he was like, “We need to shave the bone down.” I was concerned given that I’ve already been through surgeries in the past at a younger age. I’ve had a jaw surgery, a knee surgery, which I found out years later that it didn’t work so well.
Given the limited options with what I had, I started looking into other things that could potentially heal. That was when I stumbled upon the origin of the medical field. It was something that I had never heard of. I didn’t understand what prolotherapy was, what platelet-rich plasma was, what stem cells were. I tried to learn more and more about this stuff. I went to conferences, started talking to other colleagues, and had self-treatment as well. After I had the treatment, I felt much better. After I had a few rounds of platelet-rich plasma, I felt significantly better. I just did a session on myself and the pain has been completely gone.
You injected it in the Achilles?
In the Achilles tendon, yeah. I found it very effective for that. Since then, I’ve had plenty of patients coming by who have suffered from chronic pain, who have failed physical therapy, acupuncture, trigger point injections with cortisone, medications, some chiropractic work here and there and we’ve been able to fix them.
How do you feel about the cortisone injections overall? Is there a time and place for them?
With the cortisone, there’s a time and a place for it. I can use it around nerves because it is a good anti-inflammatory or in people who have tenosynovitis. For those people who have autoimmune diseases and have tenosynovitis, which is inflammation within the compartments around the wrist and the feet, it tends to work well. What steroids do is it can weaken the tissue around it. They’ll weaken the bone. If you inject steroids into a knee or into a shoulder, over time, you’ll see that there’s destruction of the bone and of the ligaments. When I take my ultrasound machine and look at where things were injected, it can clearly see them.
Years ago, I was having some AC joint issues. Again, I had gone to the orthopedic doctor and a few cortisone injections. It provided a bit of temporary relief. I tried some physical therapy a bit, but I still had this nagging shoulder pain. I had to do a prolotherapy on it. Several times it would help clear the ligament but when I put the ultrasound on the AC joint, it looked horrible. It looked like a dog was chewing on my bone. That’s how destructive it was. It didn’t look like a normal AC joint anymore and that was just with one or two steroid injections. Those patients who were getting injections in their knees or their shoulders repetitively, you can imagine what’s happening to their joints. They are going to have surgery because there’s not much of a joint left afterward. Even though it gives them that relief and even if that is paid for by the insurance company, it’s not something that I would advocate.
What year was it when you started to look into prolotherapy and platelet-rich plasma? When did it really start to come on the scene?
When I was having issues, it was around 2011, 2012 when I started looking into this stuff. Platelet-rich plasma has been around for a very long time. Dentists use it to try to help heal a tissue. In surgeries, these are used around the country. It started getting more attraction, particularly with athletes. For instance, you’ll hear about high profile basketball players, baseball players in the NBA, NFL, getting these injections. It was Hines Ward of the Pittsburgh Steelers who had a PRP. He was able to get an injection and then play at the Super Bowl a few weeks later. He was able to recover and was able to play. It has been around and it’s becoming more and more in the forefront in terms of regenerative medicine.
EM 66 | Regenerative Musculoskeletal Procedures Regenerative Musculoskeletal Procedures: Prolotherapy in and of itself has been around since the 1920s.
Prolotherapy in and of itself has been around since the 1920s. It was designed by a surgeon who found that they could create a localized inflammation and damage which would help heal certain tissues and ligaments. He had a lot of success with this. One of his disciples was Gus Hemwall. You may have heard of Hackett Hemwall Foundation, now is the Hackett Hemwall Patterson Foundation. In this foundation, they had trained prolotherapists since the ’60s, ’70s, ’80s, up until now they’re still doing it. I’ve got my training from there as well. I did some training down in Honduras. It was a wonderful experience and I gained a tremendous amount of knowledge. We injected a lot of patients who got better very quickly, and that involves a dextrose-based solution, which is a very simple solution. It is injecting salt water, sugar and a little bit of anesthetic so it’s not very toxic at all to the body.
How does the salt water, sugar and solution heal the tissue and the ligaments?
It creates a localized inflammatory response by causing a little bit of cell destruction, but it’s like a controlled fire. It signals the body to say, “We need to get some other guys down here to try to help heal this area.” There are a couple of different phases of healing. There is the inflammatory phase, the proliferative phase, and the remodeling phase. In the inflammatory phase is what you get initially after you have the injection. You’re going to feel inflamed, sore, a little swollen. You may not be very happy for those few days that you have it because you’re in more pain than you were. Over time after the inflammatory phase subsides, after a couple of days or about a week, you’ll have more of the proliferative phase. That’s when you start getting other cells involved such as fibroblasts, macrophages, and other cells to try to help heal that tissue.
As time goes along, with a little bit of strengthening and other exercises, the body’s going to try to help remodel that tissue to how it was previously. When you look at some of the other spectrums within regenerative medicine, which includes stem cells and PRP, we’ll see that the tissue is being replaced over time. There’s even been some success with increasing a cartilage and other things that would be lost. We’re seeing that more and more with some of the stem cells that are being done and that may be a bone marrow or fat. There is amniotic too although some of the data on that may not be the greatest in the world, but that’s what we’re seeing.
What is platelet-rich plasma therapy?
Platelet-rich plasma therapy is we take blood out of you, spin it down, get the growth factors, and the platelets will the degranulate or release their growth factors. When they do that, they create an environment for your body to try to heal. Like when you cut yourself and bleed, what happens is that the platelets will degranulate or release these cytokines or release these other growth factors to try to help heal that area. You’ll start forming a little bit of a plug and then, there’s going to be a little bit of temporary scarring, but the tissue will heal. What we do with patients is we will take the blood, spin it down a few times and get the platelets and the growth factors concentrated, then we inject it back into the tissue. This may be the ligaments, tendons, or cartilaginous areas too as well.
We’re finding a lot of success with this. We’re finding patients healing very well, particularly after about four to six weeks. Some people a little bit longer because everybody’s healing can be different. I myself, having gone through it, am a little bit of a slow healer and there are different things that need to be done to try to help you heal better. When you get injected after a few weeks you might feel, “I feel a little bit better, but I still don’t feel that great.” About four weeks to eight weeks later, after about two months, you realize, “This is not hurting anymore. I can start doing stuff again.” It’s amazing how you feel after you get some of these injections.
That sounds like you need to space out the appointments a little bit too because it does take some time. How often do you recommend patients come in and then for the follow-up visit? How long would that be from their first initial injection?
From the initial injection, what I’d like to do is see patients in about a four to a six-week interval. That’ll give me a good assessment to see where they’re going. For some folks who are healing well, and I see them at the sixth-week mark. They say, “I feel much better. I’m 80% to 90% better.” “Could we do maybe a little bit more the next session to try to help you?” If that’s fine, we’ll get them treated. We’ll also get them into a little bit of therapy to help the functional movement of the joint or the area that’s being treated. If I have them come back another four to six weeks later and they’re fine, then, we don’t need to see them at that point.
For some folks who are still having some issues in trying to heal, we’ll have them come back at about the sixth week mark. Those people who are healing much slower, I’ll have them come back every two months. The key with this is a lot of patience. Some people in this day and age, as you know everything is social media, Facebook. We want the instant gratification of everything. We want the instant results and that’s not going to happen with this. This is something that’s simply going to take time. It’s not going to be like the cortisone where you feel like, “I feel great after a day but then two or three weeks later, I feel awful. I’m bearing all this crunching now where it was injected.”
Dr. Mian, what is the stem cell component shots to this?
This is something that we’re going to try to add by the end of the year. With stem cells, it’s something that you use from your own body. A lot of people don’t like to hear about stem cells, they freak out because they think they’re getting it from babies who have been aborted, which is not the case. It’s not with the things that we’re trying to do. With the stem cells, there are two main varieties. One is going to be the bone marrow. We have to harvest some of the bone marrow out from a bony area. That’s done in the lower back area, around the pelvic area to help minimize pain and discomfort. Then there’s also fat. A fat has a lot of stem cells in it too as well.
These stem cells are unique in the sense that they can differentiate into any type of cell. You can imagine if somebody has a large defect in a tissue, a tendon or a piece of cartilage, these things can regrow, which is what we want to do, rather than putting metal and screws in. Bone marrow entails extracting your stem cells out, which is going to be a little more invasive than getting blood out. However afterward we’re still concentrating and getting it down to where we get the most significant growth factors and then we’re doing the same thing that we do with any other type of injection. The only difference is how we’re getting it out and it doesn’t change how we’re applying the injections.
Although that might sound a little invasive, it’s a better alternative to begin with than somebody cutting you open and that’s the most invasive as you can get.
I’ve been somebody who’s gone through several surgeries. I’ve seen both sides of the spectrum, so I know what it’s like to go through surgery. I know what it’s like to have surgical complications. I know what it’s like to have hardware in them and it’s not fun. I have patients who think to themselves, “Maybe surgery is the better route to go,” then I’ll have patients come in who have had surgeries on their neck and their lower back. They’re telling me, “I wish I never had this done.” Sometimes at that point, they’re very difficult to treat because we’re dealing with a lot of hardware and screws which is hard to get around those things to try to help heal those areas.
There’s a time and place for surgery. I broke my elbow bad one time. I needed to get a couple of pins and everything there, but you also have to think to yourself, if you got neck surgery, you only got one neck. If you haven’t explored all the options yet, maybe you should rethink because there are alternatives out there now and it’s only getting better. Dr. Mian, who is a candidate for prolotherapy, PRP, stem cells? When do you think is the best time to do that? What conditions do you find it’s working well for?
EM 66 | Regenerative Musculoskeletal Procedures Regenerative Musculoskeletal Procedures: The candidates for these types of injections are people who are motivated to try to get better.
The candidates for these types of injections are people who are going to be motivated to try to get better, number one. I’m always looking for that in patients. If I have a patient come in who is extremely overweight or diabetic, smoker, has bad toxic habits, eats poorly, and then want to get these injections, I will talk them out of it. I’ll say, “Don’t get these injections. You will improve, but you’re not going to get to where you want to be unless you start changing these other habits.” What I want to see from people is that number one, are they going to change their diet and lifestyle? Number two, are they going to do the types of therapies and treatments that are needed to try to help improve those joints, ligaments, tendons? Those people do extremely well.
I look for people who are in chronic pain, who have failed a lot of other treatments. These are all about people who have gone through physical therapy, acupuncture or traditional chiropractic work, who have gone through previous surgeries as well. Although some surgery patients, we can’t treat very well because there’s simply too much hardware. The people who are better candidates for stem cells and PRP are people who have more significant defects, have more significant injuries. PRP works incredibly well on tendons.
That’s something I’ve also found out on myself in treating my Achilles tendon because prolotherapy, while it works, it doesn’t work quite as well as PRP does on tendons. When I’ve done that on tendons on different people, I found remarkable success, but when I did prolotherapy on tendons themselves, I did have some improvement but not as fast and not as robust. Stem cells are used when other treatments have failed at that point. We’re talking about degenerative joints which have far gone. There are large defects in tendons and that’s when we want to do that. There’s a certain protocol of doing certain things with the stem cells.
You personally would like to start them off with the PRP and prolotherapy, see how that goes and then if necessary, recommend the stem cell?
There are different prices for different things because these things are not covered by insurance, but to go to the most expensive thing at first is reckless because we want to say, “Can you get better?” I’m also happy if someone gets better. If I send the physical therapy and they get better, then that’s fine. They don’t need to go through all of this. If you’ve been through the whole gamut of things and you’re stuck, or you are saying, “I don’t want to do X, Y and Z,” that’s when we want to have a good conversation about some of these treatments.
Are there any limits to where you can and cannot inject these injections? Are there any red flags or areas that work better than others? I know you mentioned with the PRP works better with the tendons. If someone comes in and says, “My left hip has been killing me.” What is your assessment of where to inject and if they need it or not?
We’ve got to do a good comprehensive physical examination to see what the problem with the hip is? Is it an SI joint issue too as well? Is there any ligament laxity? Is there any problem in the foot which also can be impacting the hip? All these things are aligned together. If we don’t know things too well in terms of what’s affecting that hip, then injecting the hip by itself is not going to fix the problem. If we are able to isolate that the hip as the issue at that point, then we’ll test to see what areas are tender? What areas are lax? In the hip for instance, we can inject the joint, we can inject those running ligamentous capsule too as well. We can inject around the tendons that wrap around your backside as well as to try to help stabilize it as well as try to help stabilize an SI joint.
That’s an example if somebody who had a really bad hip. It’s not just putting juice into a hip, it’s not going to heal anything. It’s no different than if you go to the orthopedic doctor down the street who puts PRP into a knee and says, “You’ve got regenerative medicine.” That’s not what it is. It’s also very operator-driven. You’ve got to know where you’re going to put the needle, you’ve got to know how to examine the patient, you’ve got to know what things are going to help stabilize that joint. I give people a lot of injections, not just a single injection. It’s a lot of injections to help cover the whole capsule of the area that needs to be treated, to try to help heal that tissue or that joint very well.
Do your patients need to have a certain imaging done before you inject? Are there other tests that you do to know if they’re a candidate for this?
I will order an MRI if things are questionable. I want to make sure that if there is something that shouldn’t be there, we want to know before we stick needles anywhere that’s highly important. I use ultrasound to help diagnose certain things too, so I can look at joints, tendons, or ligaments in real time and be able to see is there any tendinous damage or cartilaginous damage. Are there any osteophytes anywhere that need to be treated?
How long are these procedures? It’s a little lengthier with the stem cells because you have to go in and take them. How long do these procedures usually take?
With prolotherapy, we have to make salt solutions, so that’s not going to take too long. People can be in and out quickly. With a platelet-rich plasma, what we have to do is have somebody come in at least an hour earlier than their appointment, so in that way, we can take their blood out, spin it down a few times and concentrate things. With stem cells, we have to harvest the tissue and then process it too, so that might take a few hours. The injection process itself isn’t that long. For some people, it could be done in ten minutes. If it’s a more complex area, it might take fifteen, twenty minutes max. A lot of times it never has to go that long because I’ve been doing this long enough where it’s not as complicated as we need to be. As we add some other modalities of treatment and other ways to help with the injection, we’re going to try to help pinpoint things even better and try to help make the treatments better than what they are.
What’s your protocol for after an injection? Do you recommend people take it easy for X amount of days because you have these athletes that want to return right away? If it’s mild, a little tendinitis or something, do you recommend people to rest after an injection?
EM 66 | Regenerative Musculoskeletal Procedures Regenerative Musculoskeletal Procedures: In order to heal better, nutrition is important, but then also the functionality of that joint, ligament, and tendon is also important.
For the first four days or so, I’d like them to rest. If I’m injecting a shoulder, for instance, I would want them to be in a sling, so we want to help those fibers heal. I want to brace people for at least for a few days with whatever is being injected so that those fibers will help heal. For the first week, really to try to take it easy. Over the next few weeks, we’re going to start increasing the range of motion. After about a three-week mark, which is the typical healing phase for most people anyway although it’s not the norm for everybody, we’ll start getting them into a little bit of therapy.
Whether that be NeuroKinetic Therapy, physical therapy, ART or whatever it may be. We’ll get them into that because we want to help things move better than what they are. In order to heal better, nutrition is important. The functionality of that joint, ligament and tendon is also important. Those are the people who are getting the best outcomes. In general, we would have them do therapy of some sort at least for a few weeks before we reassess them in about the six to eight-week mark.
For people who have trouble sleeping or with sleeping disorders, what do you do for those patients?
It depends on what the patient is coming from or what the issue is. With sleep disorders, there’s a wide variety of different things. When people think of sleep issues it’s, “I can’t fall asleep at night,” which is insomnia. Insomnia is a difficult condition to treat. I always find that nine times out of ten, the issue is more up in the head or some other medical condition, not so much something else. It involves a lot of behavioral strategies, sleep hygiene strategies and sometimes even some cognitive behavioral therapy to help break certain habits.
What are some behavioral therapies that somebody can cope with if they’re having insomnia?
There’s something called stimulus control. A lot of people will try to go to bed and they can’t fall asleep. They’ll stare at the ceiling and watch TV, get on their phone, tablet, whatever lights up though that they get on. One of the things I tell them is, number one, stay away from electronic devices for at least two hours prior to bedtime. When we had Superstorm Sandy in 2012, I had a few insomniacs at that time and they were bad. Nothing was working for them. Lo and behold, when all the lights went out, they were falling asleep at 8:00 or 9:00 at night. That’s the power of how these devices we’re looking at.
The other important thing too is not staying in bed. If you can’t fall asleep, don’t count sheep. Don’t look at your phone, don’t go eat, don’t clean, don’t do work. Get up out of the room, go to another room, pick up a book, a magazine, start reading. You can read something mundane. It doesn’t have to be anything that’s exciting or stimulating, but once you start feeling sleepy, try to go back to bed. If you can’t fall asleep after a little bit, get up out of the room. Do the same thing again. The whole point is trying to help break that pattern. It’s no different than Pavlov’s dog. You may have heard of back in psychology between the dog, the bell, the food. That’s the same exact thing.
Dr. Mian, where are you located and where can people find you on the internet?
We’re located in West Orange, in the same building as you are. We’re one floor down. 155 Prospect Avenue, West Orange, New Jersey. Our office number is (973) 928-3288. I encourage anybody with any neurological issues, chronic pain issues or sleep issues to give us a call so we can assess whether or not we can help you. In a lot of cases, we can help a lot of folks.
What is one piece of advice you have taken with you over the years that have stuck with you and helped you out that you would like to share with the audience?
The thing that’s stuck with me is perseverance. Persevere no matter how difficult things are, no matter what you’re going through, no matter how bleak things looked like, whether it be physically, mentally, or socially. Keep plugging away and keep working at it. If you work harder and you start working a bit smarter with whatever it is, eventually success will find you.
Thank you so much, Dr. Mian. It was a pleasure having you. I would love to have you on another time and maybe once you get the stem cells, we could have you back and we’ll see how that’s going.
I would love to be back.
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