Episode 75: Bone Up on OA – Osteoarthritis

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Welcome to Supplementing Health, a podcast presented by Advanced Orthomolecular Research. We are all about applying evidence based and effective dietary lifestyle and natural health product strategies for your optimal health. In each episode, we will feature very engaging clinicians and experts from the world of functional and naturopathic medicine to help achieve our mission to empower people to lead their best lives naturally.
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[01:10] Cassy Price: Hello and thank you for tuning into Supplementing Health. Today I am joined by Dr. Lev Kalika, chiropractic doctor to discuss early and late stages of osteoarthritis as well as new ways to treat the condition with non-invasive regenerative technology. Dr. Kalika has been working to revolutionise physical medicine and rehabilitation and sports medicine along with athletic performance since 1998. Welcome Dr. Kalika, thank you so much for joining me today.

[01:35] Dr. Lev Kalika: Thank you for inviting me. How are you today?

[01:37] Cassy Price: Really good thanks. How are you?

[01:40] Dr. Lev Kalika: Good.

[01:41] Cassy Price: So, sports medicine and injury rehab has been your calling since you were playing sports as a teenager, in particular soccer. Would you mind sharing a little bit about how your own history and your own injury led you into this practice?

[01:57] Dr. Lev Kalika: So, I sustained two injuries during my early teenage years. I was brought to the United States as a teenager when I was nineteen. One injury I had was a chest pain and I kept seeing the cardiologist and no one was able to diagnose anything or help me and then by accident I actually physically got into an accident and my medical doctor sent me to see a chiropractor and the chiropractor within two visits actually alleviated my chest pain and that is how I realised that maybe this was an interesting profession. Even going back to the Soviet Union, we didn’t have any chiropractors but we did have medical doctors who did manual theory and this is how my interest started. Even before then I injured my ankle. I played soccer in a professional junior soccer team in my hometown in Ukraine and I injured my ankle back in 1987, we didn’t have an MRIs back then, neither here or in the Soviet Union, so it was an X-Ray and they didn’t see any bone fracture so they said it was probably an ankle sprain and they didn’t recommend much rehab or diagnosis. Then I began having this concurring and repetitive ankle sprains and my ankle became permanently unstable. So, that injury led me to quit playing soccer and bottling that injury for years to come which eventually led to some of my back pain as the transfer up the kinetic chain led me to get interested in rehabilitation and that is how I discovered the Czech School of Rehabilitation which I went to in 1997.

[03:58] Dr. Lev Kalika: Back then world leading rehabilitation practitioners, Dr. Karel Lewit MPD, PHD and Vladimir Janda who the whole world knows as a new area of rehabilitation. I spent two years in multiple hospitals with these two grands and one day Karel Lewit took me by the hand and literally brought me to Pavel Koler who back then he said was a rising star and she he learned everything from me and now you can see our rising star. Right now, Pavel Koler is one of the top sports medicine rehabilitation practitioners in the world with a whole school foundation called DNS for Dynamic Neuromuscular Stabilisation. According to Koler it is a very famous approach today practiced by thousands of practitioners all over the world trained by multiple top elite athletes and that is how my journey actually began.

[04:54] Cassy Price: It is very interesting. Now, you have incorporated more ‘alternative’ medicine methods into your practice than what traditional chiropractic had to offer. Where does that passion for improving patient care and incorporating some of these newer methodologies come from for you?

[05:14] Dr. Lev Kalika: So, I literally basically when I do is very far away from chiropractic because once I met Karel Lewit, I realised that actually the way it happened is my uncle who is a very famous Soviet neurologist while I was going to chiropractors school sent me literature in Russian. As I started to read it I realised that it takes me three days to do just one chapter. That is when I went to see Karel Lewit. Once I went and worked with Karel Lewit, I realised that rehabilitations tie in not just about manipulation of the joints but really a very, very, broad topic where manipulation is only one very small component and working with someone like Lewit and Young, they really exposed me to all different methodologies. It really broadened my horizons. Right about 1999 or around 2000 I accidently discovered shockwaves and shockwaves are a technological regenerative treatment. I went to a conference in Italy, it was in Salerno in the south of Italy. There was a world conference on extra corporeal shockwave there and the professor Markus Gleitz , a German orthoptic from Luxemburg, and I asked him if I could visit his clinic. He invited me so I went there for three days and I was astonished how modern the way he practiced. It was like something out of a sci-fi movie where he would walk into the room and as soon as he crossed the door the nurse was by him, the light would show up and the left of the room there would be a screen where the MRI, X-Rays, and patient history really magnified on this huge screen it was immediately lit up.

[07:32] Dr. Lev Kalika: He was going to that wall to that screen and the nurse was telling him the history of the patient and the patient was sitting on a bed on the right. He would examine those films, walk to the patient, and ask some questions and then he would take an ultrasound so he can take a look himself. Once I saw that I was really literally completely surprised how efficient his practice was and I asked him why the ultrasound if you have the MRI and the X-Ray and everything. He said “I want to see the lesion with my own eyes because the X-Ray and MRI is a static image. Once you see the patient in the movement where they bend the knee, and the patient can pinpoint where the pain is I have more precise diagnosis than the X-Ray and MRIs.” That behoved me to learn ultrasound. It took me more than ten years to be where I am with the ultrasonography and the diagnostic skills of ultrasonography is a constantly developing science where every three to five years the physicians accomplish new accepting not independent strategies but more into the resolution of the image. Once we get those machines or resolutions with the better resolution, we are able to see much more details so the anatomies is being revised of revisited and you constantly are updating your knowledge. Right now, I use the best machine which is Aplio 800 by Canon and there are only two machines like this is New York, one with me and one with the bone cancer institute. The resolution on the other dozen visible on this category allow me to provide precise diagnosis in staging. That was the one component of why I always want to get the better kit and improve patient care because I worked with Karel Lewit who is foundational in thinking.

[10:01] Dr. Lev Kalika: The other aspect which was shockwaves which led me to ultrasound. The third aspect was about 2007 I met Professor Christopher Powers from USC. He is a famous gate analysis practitioner. He is one of the most famous running doctors and a scientist who has done multiple studies and he helped return to sports. Back then, the beginning of 2000, the motion analysis technology was taking its beginning and I have got so interested into that that I went on a road of paper and that allowed me to get a grant and that grant served me a foundational down payment for a computer system called CAREN, Computer Assistant Rehabilitation Environment. CAREN is a collection of different hardware and software and methods in Israel or produced in Holland. CAREN stands for Computer Assistant Rehabilitation Environment and it is made up of a six degree motion platform that is instrumented with two force blades. The force blades are measuring instruments of your ground reaction forces. On top of that system, we have twelve motion analysis cameras, infrared cameras, that register your movement and give you a breakdown of joint angles and all of that is in front of a six metre 180-degree virtual reality screen. So, on top of all of this hardware, there is software that combines all of these and reads the human movement and gives you a good analysis on the fly. So, practicing with that system lead me to delve into biomechanics to help me develop my skills in analysing motion from a movement analysis perspective.

[12:16] Dr. Lev Kalika: Of course, human movement is much more complex and detailed than the gate analysis shows but knowing human movement from this perspective and studying with all of these scientists it moves me to believe that I need some way of objectifying patient diagnosis and patient movement so I can test and retest. The way I practice today combines motion analysis, very intricate clinic examination, multiple regenerative technology such as extra corporeal shockwave therapy that focus on radio machines. A new addition to the practice is ENTT, Electromagnetic Transaction Therapy. It is a new technology which has a regenerative effect to the cells which is the best anti-inflammatory remedy today. It is better than any steroid injections. We are seeing tremendous results. On top of that I also study with Professor Rostyslav Bubnov from Ukraine who is one of the pioneers of ultrasound-guided dry needle work. Doing that also allows me to very quickly assess if the pain coming from myofascial perspective in the degree because it is so precise that if it doesn’t work in one or two sessions then you know that the myofascial pain is secondary to some other problem. I try to be very comprehensive in my examine because as professor Lewit once said “rehabilitation can be time consuming and time should not be lost.” So, what I see in my practice it is very frequent that patients are lost in rehabilitation because rehabilitation has done either for the wrong diagnosis or the physical therapist often times are trading compensations. The most difficult time in rehabilitation is for physical therapist to arrive at the diagnosis, that is the link of what starts everything. Discerning whether the problem is functional or structural and on a more complex level what is the interaction between the structural problem and the functional problem. In a nutshell if you are satisfied with that answer that summarises all of my practice and the areas of my studying and research and clinical practice.

[14:59] Cassy Price: Awesome. Do you notice a difference in European acceptance of cutting-edge technology and North American or are there differences as far as how they are used in practice between the two countries?

[15:14] Dr. Lev Kalika: There is certainly differences. The difference are multiple. One aspect of the difference is that Europeans don’t have FDA they have their version of it but it is much more amenable. It is allowing technologies to progress faster than FDA because we are a medical society and the health care driven by pharmacy and by drugs and surgery. European healthcare is mostly social so the surgeons don’t make as much money. It is a different system. An ever-true European surgeon is the one who doesn’t only operate but also does pain management and understands manual therapy, can take an ultrasound machine. It is much more comprehensive medical approach. Of course, I don’t want to say we don’t have our advantages over them, but they have their advantages, and we have our advantages. Their system is not driven by quotes and therefore the technology there most of the technology which are not pharmaceutical really comes from Europe. We develop mostly surgical and pharmaceutical technologies in the States today.

[16:42] Cassy Price: Okay, so, for osteoarthritis it is a condition that affects several people and so I think a lot of people think of it from more of a pain management standpoint than a regenerative standpoint so what are some of the things or new technologies that you have come across that get you most excited when it comes to that regenerative piece for osteoarthritis?

[17:07] Dr. Lev Kalika: Well, in the past we were thinking as a scientific community where we were classifying osteoarthritis as a cartilage disease based on overload and the degeneration of the cartilage and within the less decade with a lot of advances in molecular bioscience so we now understand that the osteoarthritis is really a multifactorial disease that doesn’t normally involve cartilage but actually involves multiple tissues such as muscles, tendons, ligaments, subchondral bone, even the fat around the joint, therefore inflammation has a major component that we now understand drives the osteoarthritis and the pain form osteoarthritis isn’t really driven by the cartilage but really driven by multiple and very intricate system and cascade of the events that occur during inflammatory stage. In the past we have been using shockwaves and it was only working for some of the patients with early-stage osteoarthritis and in the past decade PRP, platelet-rich plasma, was developing which initially was a really poor outcome and has sort of advanced today and has had some decent results in the regeneration of arthritic joints. The newest technology like I just mentioned before we see amazing results. It is called EMTT, electromagnetic transaction therapy. It is so new that literally there are only like ten machines in the whole US and we see fantastic results with osteoarthritis however as the technology is so new we really don’t have rigid perimeters as to how much to use, when to use so we just follow basic protocols and I think in years to come as it happened with PRP, and PRP still in its early days even though it has been at least over ten years of development the biggest disadvantage of platelet-rich plasma injections is that human blood is so individual we don’t know how Joe is different from Jack.

[19:49] Dr. Lev Kalika: So, Joe may need a different amount. Maybe Joe will need leukocyte four and Jack will need leukocytes six and that is where we don’t know how to change it according to individual people. That is the problem we have with PRP. It does have some results but still the science, a lot of the studies say it has no effect and the other studies say it does and so we are still being influenced with EMTT clinically I see fantastic results but still it takes years for research to catch up with clinicians. I think the most advanced treatment is to catch the arthritis early, to change the lifestyle, to change your movement, to use regenerative therapies in all parameters because it is just a mystery of biomolecules that evolve with arthritis that no one technology or treatment will physically help everyone. So, I think we still need a comprehensive approach are this time.

[21:07] Cassy Price: So, what are some of the dietary changes or supplements that you recommend for patients when they are making those switches after to try and prevent additional degradation of the joints?

[21:19] Dr. Lev Kalika: So, of course we know that people who are overweight are more prone to osteoarthritis, so we strongly recommend to keep the weight down. This is one parameter and one thing that I work with my patients is to try to minimise the weight or optimise the weight as I would say. The second one is optimising their diet. So, we know that since inflammation is the biggest problem with osteoarthritis we know that gut microbiome is very important so dietary changes that improve your gut microbiome and an anti-inflammatory diet with taking supplements for example like Boswellia or Curcumin are really the things that I would recommend in more complexity since I say to patients that I am not a dietitian. I am not a doctor who works with anthropology issues and with more complex patients if they don’t get results by trying simple recommendations I send them to other practitioners who focus on this. So, these are the changes that I recommend from a dietary perspective. The other changes I think that often times is the patient movement. Movement creates muscle atrophy. When we don’t move we don’t load our joints and this creates a vicious circle. Physical therapy and optimising movement and loading the joint is what I recommend.

[23:17] Dr. Lev Kalika: Often it is very individual. Often it is to find the right way to load and load within parameters which don’t cause the patient pain and find optimal joint modification or deloading machines like for example we have a machine from Italy which you can program. It has artificial intelligence and if you know that the joint problem like let’s say within the knees happen within 140-degrees we can deload that as they are going through the motion. Using different movement optimisation through kinetic change, using some proper pain medication, maybe sending to pain management in some stages, or using EMTT to find a balance within movement and pain. We can decrease pain because pain is often the biggest obstacle in rehabilitation process. If something hurts the patient doesn’t move, he doesn’t’ like to do PT and often times physical therapist try to optimise the movement, but it just doesn’t happen with patients with osteoarthritis. That has been my experience that it is a struggle to lull the patient and continue physical therapy because patients rally get discouraged. I think the EMTT is really an amazing alternative too because it doesn’t only regenerate and decrease inflammation, it is also a great pain modulation technology because it really kind of deceives the human nervous system and shuts off these signalling pathways for pain and sometimes we use shockwaves for inhibition, depending on the tissues that are at stake with that particular arthritic joint. So, really working on pain allows the patient to move the join, improve muscle strength, and move on. So, I would say those three components are really paramount.

[25:39] Cassy Price: So, I know you said you use ultrasound technology in your assessment portion, but do you also use it for dry needling because I heard ultrasound-guided dry needling can be very effective for certain joint conditions?

[25:56] Dr. Lev Kalika: Yes, so, Id like to if the time is involved and most of the time by the time that the patient reaches some osteoarthritis obviously the disfunction of the movement involves all of the joints and the body because the body works as one, as you know we have all of these myofascial chains that transfer the body and interacts so obviously disfunction in the body it is not moving as a whole so when for instance when it moves through the spine I think ultrasound-guided dry needle is super effective for unblocking the movement in the spine and optimising the movement in the spine and rib joint. It is particularly effective. I would say it is almost like a miracle for people with shoulder pain. I once had a patient with shoulder osteoarthritis who came back crying after a dry needle session because he said for three years he wasn’t able to lift his arm and in just a few sessions we were able to give him that movement back even though he had large osteokines and synovitis in the joint and it is off for the grid for the hips, not so much for the knee and ankle. I guess it is case by case but I think dry needle ultrasound is really important. One problem I see with patients when we do an ultrasound-guided dry needling, patients really react to what their friends got relief from and what they read online. In my mind as a clinician I always look at what is more important because the joint, the nerve, and the pain really govern the muscles. So, yes of course in the beginning of the dysfunction it is the muscles which causes the problem but once you have some problem in the tendon, in the joint, the nerve, or the pain, that is what needs to be addressed. I always try to say that I don’t want to do dry needle work for you because I see a tendonopic I see edema in the joint, I want to address the components which govern and direct the muscles first. When we heal the tendons, decrease the inflammation in the joints, then maybe we work with nerves and pain, then the dry needling provided long lasting changes. If we don’t we get successful relief and patients feel better but the problems come back because the more important structures are not being fixed. That is my look at dry needle and how I use it.

[28:48] Cassy Price: Makes sense. So, have you utilised stem cell therapy in your practice?

[28:53] Dr. Lev Kalika: I don’t utilise stem cells because I haven’t seen much effect from stem cells. I do refer my patients for platelet-rich plasma injections and I work in conjunction with administrative doctors and in more complex cases where I see the problem is really, for example, I have an adoptive tendinopathy and it is hard to get rid of in a middle age person and if that adoptive tendinopathy evulsion or has really sever changes I don’t think any of my methodologies will work alone. Neither PRP will heal it but if we combine PRP with shockwave and EMTT not only in my clinical experience but there are multiple studies to prove that combining these regenerative therapies really allows better outcomes for patients. In a more severe cases we try to combine different regenerative treatments and PRP would be not my number one option to go to but would be something that I would try to combine in a more advanced stages and try to help with what I have in my toolbox.

[30:20] Cassy Price: Okay. So, from all of your years of experience are there any myths or misinformation around osteoarthritis that you wish you could dispel?

[30:29] Dr. Lev Kalika: Well, I think I mentioned one, it is that people think it is all about joint cartilage because in the past patients would come in, still people come in, and they say, “I have bone on bone.” This bone-on-bone phrase has stuck because it is very simple and it resonates but the interesting thing would be that we found out that it is not the cartilage, the cartilage doesn’t have pain receptors. It is the bone underneath which we would call subungual bone. So, I have really experienced that myself with my own patients that during EMTT people have less stage of osteoarthritis they lose pain because it is the inflammation that drives the pain and if we try the joint they have no pain. Doctors who treat osteoarthritis know for years that we have patients that have severe osteoarthritis and have no pain. They have bone on bone, but they have no pain. I think the patients that have bone on bone and have no pain are the patients that are able to control this inflammation and so I think this bone-on-bone overload and loss of cartilage is a myth. It is not a myth it is just looking at osteoarthritis through a very narrow prism rather than looking at the bigger and fullest picture. I think people need to realise that it is a lot more than bone on bone.

[32:05] Cassy Price: Okay. Awesome. So, if any of our listeners wanted to work with you, how could they go about getting a hold of you?

[32:12] Dr. Lev Kalika: They can reach me on the email. It is [email protected] or they can call us at 917-817-5289 or 212-308-9595.

[32:33] Cassy Price: Fantastic well thank you so much for taking the time to share your knowledge with us.

[32:38] Dr. Lev Kalika: Thank you so much for having me.

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