The Business of Orthobiologics Podcast
Hi! My name is Ariana DeMers and I am an orthopedic surgeon and regenerative medicine expert. I have successfully integrated Orthobiologics into my busy practice and I wanted to share my experience. Integrating orthobiologics in your busy orthopedic or sports medicine practice is the most effective way to get more time in your life while improving your patients care. If you are looking to add PRP to your practice and you don’t know how to start, this show examines how to take these important steps in your practice. If you want to also make more money in less time, have happier patients and enjoy your life, then join me in The Business of Orthobiologics podcast.
The Business of Orthobiologics Podcast
How Nutrition, Sleep, and Metabolic Health Impact PRP Results | Conversations in Regen Episode 16
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Seeing uneven PRP results even when your injections are technically sound? [Learn what to do before PRP injection to consistently improve outcomes.]
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In this episode, Dr. Ariana DeMers, the Queen of Business Orthobiologic, is joined by Dr. Ashu Goyle—double board-certified in anesthesiology and pain management—for a deep clinical conversation on why patient optimization is the missing variable in many PRP cases. Together, they unpack how nutrition, sleep, metabolic health, and lifestyle factors directly influence platelet function, growth factor release, and tissue repair in orthobiologics and regenerative medicine.
Rather than focusing on technique alone, this discussion explores what to do before a PRP injection to create a biologic environment that supports healing. Topics include inflammatory load, insulin resistance, protein intake, vitamin deficiencies, sleep architecture, stress physiology, and why “prehab” is essential for predictable PRP outcomes. Dr. Goyle shares real-world protocols from his regenerative practice, while Dr. Ariana connects these principles to reproducible clinical results and long-term patient trust.
This episode is essential for physicians who want better PRP results, fewer failed cases, and a more systems-based approach to regenerative care that treats the patient—not just the pathology.
Building a successful cash-based orthobiologic practice is not a single decision. It is a series of the right decisions made in the right order. The Business of Orthobiologics offers three distinct programs designed to meet physicians at different stages of readiness — whether you are just beginning to explore PRP, ready to build a full practice system, or committed to going all-in on a comprehensive transformation.
Learn More here: https://thebusinessoforthobiologics.com/programs-explanation
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I always start my orthobiologic procedures with a prehabilitation phase. And the conversation starts with letting people know that they are the pharmacy that's creating the drug that I'm gonna be injecting back into their body. People aren't buying your procedure, Goyle. They're buying the outcome. And that really sunk home with me. I was like, oh my gosh, I need to set up a practice based on the outcome. People are buying an outcome. That's what they're spending their money on.
SPEAKER_01Welcome to Conversations in Regenerative Medicine. I'm so excited to bring my friend Dr. Ashu Goyle with us today. He is an awesome person, first of all, which is my favorite part. And we're gonna be talking about regenerative medicine, some controversial topics, cutting-edge insights that is shaping the future of interventional orthobiologics. And then we're gonna be talking a little bit more about how we can help you to have a thriving orthobiologic practice yourself. So for those of you who don't know me, I'm Dr. Ariana DeMers. I'm a board certified fellowship trained orthopedic and sports medicine surgeon and regenerative medicine infinitor. I have successfully moved my rural orthopedics practice away from insurance and focusing on cash-based injection-based procedures. I am obsessed about educating and training in both orthobiologics and ultrasound, and I am passionate about helping doctors incorporate orthobiologics seamlessly into your practice. So I wanted to introduce Dr. Goyle. This is Dr. Ashley Goyle. He is double board certified in anesthesiology and pain management. He's a fellowship trained at Cleveland Clinic under leaders in pain medicine and specializes in regenerative and interventional therapies. He is a functional medicine trained through the Institute for Functional Medicine, and he emphasizes pre-injection optimization and whole patient outcomes. And he's got greater than 15 years of expertise in clinical practice in Scottsdale, Arizona. So, Dr. Gwill, welcome, welcome, welcome. I'm so happy to have you here today, and I'm so excited. So, welcome to Conversations in Region.
SPEAKER_00Thank you so much. It's a pleasure to be here, Ariana.
SPEAKER_01Yeah, so everybody, thanks for joining me. Clearly, we're gonna hear from internationally renowned experts in regenerative medicine, including Dr. Ashley Goyle. We're gonna explore some controversial topics in orthobiologics and regenerative medicine. And today we're gonna gain some actionable insights into that you can implement in your practice tomorrow. And then we're gonna have a live Q ⁇ A session with Dr. Goyle to get your burning questions answered. So super excited. I want to just kind of remind everybody where we stand in the world, right? So my belief is that the biologics will be first-line treatment for musculoskeletal care in the next five years. But here's the deal the train is leaving the station, and if you are not actively offering these treatments to your patients, you are definitely gonna be missing the train. So you gotta get on the train for sure. The other part is many of you may be looking for successful integration into for orthobiologics into your practice, but it's hard. You know, we know orthobiologics is the best treatment for our patients, but how do we become successful? And I hope Ashu will be helping us kind of enlighten us on the steps to take to have a really thriving orthobiologic practice. But maybe you've tried some things, and maybe you say, gosh, I don't know. I don't know the science, I don't know the technique, I don't know cash business, I didn't learn marketing, I don't know how to do sales. Gosh, I don't want to be that used car salesman. And maybe you thought, maybe I'm just not good at business, but it's not our fault. We did not learn this in school. This is an apprenticeship, this is on-the-job training. And so we learn it through the school of hard knocks and from our colleagues who are doing it right. And really, maybe some of you are just figuring out how it is that we can be successful and capitalize on a six billion, yes, a billion dollar ortho biologics market. So I think we deserve more. Some of you may be asking, why is it so hard to actually integrate into your practice? So if you will, please just pop in the chat what you're struggling with most. So maybe we can go ahead and get those questions answered and get you on the road to offering orthobiologics within your practice. So the question is how do you win at this, right? I know we're talking about the science today, but we also need to consider how we talk about this with our patients so we all can win. And obviously, we need a system. Now, we're not gonna go over all of this today, but we are gonna get a little bit further down the road in this journey to be wildly successful in your orthobiological practice. So we need a system. So we're gonna start with orthobiologic knowledge, and so Dr. Goyle, at this point, we're gonna get down into business. We have questions for you, my friend. So, our first question is how do patients' nutritional status influence a platelet function, growth factor release, or healing capacity? And what deficiencies do you see most often?
SPEAKER_00Ariana, that's a fantastic question. I always start my orthobiologic procedures with a prehabilitation phase, right? And the conversation starts with letting people know that they are the pharmacy that's creating the drug that I'm gonna be injecting back into their body. So I tell them, please make me a good drug so we can have a good outcome. And I start with food. Food is foundation, right? So nutrition is everything. I tell people everything you put in your mouth is gonna make up every cell in your body. So if you're putting bad stuff in, you're gonna have bad cells, you're gonna have bad platelets, you're gonna have bad growth factors. So I stress the importance of nutrition. And so nutrition can affect PRP through two main levers. First, it can change the quality of the platelets themselves, how readily they activate, what they release, and how they interact with immune and endothelial systems. I tell my clients that patients aren't all about clotting, they actively secrete the growth factors that are going to help tissues repair. They participate in inflammatory signaling that's incredibly important. And, you know, in states like insulin resistance and diabetes, you can have measurably altered effects of the platelets. So it's all about nutrition optimization in the very beginning. And that's how you make the healthy platelets, right? Number two, it's creating the environment with into which we're injecting these platelets. So the terrain is what I like to call it. So I tell patients, make me a healthy terrain if we're injecting in your knee. We want to have healthy collagen, you know, appropriate angiogenesis, immune function, oxidative stress, and basically improve the patient's ability to heal and repair tissue. And that's all through nutrition. So we focus on an anti-inflammatory diet, you know, foods that are colorful, rich in polyphenols, omegas, you know, protein is incredibly important. I tell my patients, look, protein is one of the most important building blocks of our tissues. So we need to have adequate protein intake. So typically start there as far as nutrition, and that's how I see it affecting platelet factor or platelet function and growth factor release and healing capacity. The most common deficiencies I would say I would see regular vitamin D deficiency. So I don't know if people are routinely checking vitamin D levels, but that is something that I do. I'm blessed to have referrals from a lot of concierge, physicians, and functional medicine specialists. So my patients are 99.9% of the time are coming to me with recent labs and they have a vitamin D level. Most of the time they're optimized, but I would say that is the most common deficiency I'm seeing clinically. And like we talked about protein intake. A lot of people aren't meeting their protein intake needs. You know, there has been a strong push in the anti-aging and longevity community to focus on protein and muscle-centric medicine, which is incredibly important. And all those can optimize outcomes with orthobiologics. So that's also part of my prehabilitation is increasing protein intake. Obviously, we have to look at kidney function, so we want to make sure it's safe for the person. I always supplement with vitamin C also. I don't know if it's a deficiency necessarily, but it's something that I include in my pre-procedure protocol. Tell patients to, you know, if they're not eating an adequate amount of fruits or vegetables, then to supplement with vitamin C, like a high quality vitamin C, anywhere from two to five grams daily. A lot of times clients will come into the office pre-procedure and we'll do an IV hydration with a Myers cocktail and then do a high dose of vitamin C and sometimes even glutathione for the antioxidant effect. Zinc is also a deficiency we see quite often. A lot of the concierge physicians and functional medicine specialists I see are ordering zinc panels as well, or zinc as part of their panels, and so we'll see zinc insufficiency. So sometimes I'll supplement with a zinc supplement. And then just overall metabolic health and a metabolic improvement is incredibly important. So if someone has insulin resistance or if they're type 2 diabetic, we want to optimize them metabolically before we even have this conversation about the actual procedure. I'll give you an example. I saw someone in early December who came to me with a foot and ankle issue, and he wanted bone marrow stem cells in his in his ankle. He had some pretty advanced osteoarthritic changes. He had done PRP in the past, didn't have a positive response, likely due to the advanced nature of his issue. But he saw another provider literally the week before, had the consult, and he was scheduled for his procedure the day after he saw me. This was unbeknownst to me during the time of our consultation. At the very end, when we went over his medical history, he told me he was diabetic, had a hemoglobin A1C most recently a few weeks ago with 7.1. We immediately stopped the discussion. I'm saying, you're not a candidate for biologics right now. You're not metabolically optimized. Your bone marrow stem cells, your MSCs, your matophiletic stem cells aren't going to aggregate appropriately. They're not going to release their exosomes and peptides and growth factors, and we need to optimize you. And that's when he told me, well, I saw this other pain clinic and they had me schedule tomorrow for a bone marrow stem cell procedure in my ankle with no optimization. Now, maybe he would have had a good outcome, but at least in my practice, I believe that my outcomes are pretty good. I track all my outcomes through data biologics, as I know you do as well, as most of us do who specialize in this field. And at six months, I have a 95% patient reported satisfaction rate. And that comes from this pre-optimization protocol. You know, it's really getting to know the patients and then understanding their physiology and metabolic health before you even really have a deep discussion of the procedure.
SPEAKER_01That's amazing. So we've talked about this. I also do a lot of pre-optimization. Now I have a couple of questions. You know, how long are you pre-optimizing before your patients are able to have, you know, their injections? Are you rechecking labs? Are like how what walk me through a typical experience for your patient?
SPEAKER_00Yeah, that's a great question. So it just really depends on the patient themselves and what procedure we're doing. So if it's a bigger spine case, I like them optimized at least two to four weeks before we do the actual procedure. And that tends to work out fine for my schedule, it's booked out about four weeks anyway for these procedures. So, you know, it's usually a minimum of two to four weeks of the anti-inflammatory diet, all the nutrition and metabolic health. We'll get into some other of the pre-procedure protocol modalities I like to incorporate. But as far as the nutrition part of it, at least two weeks. You know, with supplements like vitamin D, if they're low, then I usually just have them start supplementing with a high dose vitamin C, maybe 10,000 I use daily for at least two to four weeks, and then we'll do their procedure and then I'll have them re-check their vitamin D afterwards just to make sure they're not super therapeutic on that level. But you know, I'm not routinely rechecking labs unless there's a need to. We are definitely going to recheck labs in three months. So I think that was a wake-up call for him because he was really sold on having this procedure done, but he wanted to get a few different opinions. And when he heard, you know, my pre-procedure protocol and the fact that I wouldn't do this procedure on it with the hemoglobin A1C of 7.1, I think it was really eye-opening for him. And he understood the importance of really improving his overall health before he does these biologic procedures again because I told him, You're the pharmacy that's making me the drug that I'm going to be injecting back into your body. So please make it good. And so, yeah, but as far as typically anywhere from two to four weeks, like I said, a lot of my clients who are coming to me, they're from functional medicine practitioners who have optimized, you know, gut health, hormone health, and they're coming to me relatively healthy.
SPEAKER_01Nice. Now, what's your rule of thumb for protein intake for optimizing the terrain, if you will?
SPEAKER_00So I just, you know, there's been a push towards high protein, you know. I think it's got to be what you can handle and what you can tolerate, right? So I'll go through diet with patients. That's part of our intake form. I asked them what they eat for breakfast routinely, what they eat for lunch, what they eat for dinner, what their snacking is like, you know, and if they do the 80-20 rule, which is kind of what I how I live 80%, I'm pretty much hardcore on it, you know, eating clean and healthy, 20% I'm normal. So, but I asked them what that 20% looks like, because that 20% could totally ruin that 80%. And so I don't have a hard set grams per day. It really just depends on the person. If I mean if they're obviously if they're working out and lifting weights regularly, I want them to increase their protein intake. If they're frail and elderly, I want them to increase their protein intake. I don't see a lot of frail elderly people, even my 87-year-olds are in really good shape. But that's probably Scottsdale, Arizona, too. It's a place to be active and stay healthy. But the RDA, I think, is really insufficient. So I don't go by those guidelines whatsoever. Um, but you know, on average, I tell people in the morning 30 to 40 grams per day, or sorry, 30 to 40 grams per serving in the morning, you know, kind of wake up and get that that your metabolic engine revved up. Then again, 30 to 40, maybe 50 grams at uh lunchtime and then another 50 to 60 grams at dinner.
SPEAKER_01Yeah, yeah, that I mean that's a lot, right? I struggle, uh, and I kind of my minimum for my patients is one gram per kilogram of ideal body weight, right? Um, and what that gets you is very, very that's the minimum, bare minimum every day. And I really want to push that to like 1.5 per kilogram of body weight. But that even in small women, that's a hundred grams of protein every day. And you know, in busy humans, we are underproteined for sure. For sure. Uh so do you uh c recommend supplementation with protein powders or shakes or any any bars or anything to kind of bump that up a little bit?
SPEAKER_00Sure. I mean, the problem with the protein bars is they're highly processed, there's a lot of bad stuff in them. It's hard to find like really good clean bars. Some of the protein powders, the cleaner ones, taste terrible. So it's a challenge, but I mean, some protein is better than no protein. So I tell people, you know, do what you can. If protein shakes work for you, do that. You know, if you're doing one a day, maybe bump it up to two a day pre-procedure just to get that metabolic engine running and get you know the cells, the substrates they need to function at a high level. And then definitely post-procedure. I mean, I tell people the post-procedure protocol is equally as important as the pre-procedure protocol.
SPEAKER_01Amazing.
SPEAKER_00Amazing.
SPEAKER_01Well, I have more questions for you. So, yeah, do you see value in short-term fasting protocols before PRP? Have anybody doing intermittent fasting or fasting the day of the procedure? Have you have you gotten into that? I I know this is quite quite controversial.
SPEAKER_00Yeah, you know, it is, and I don't I don't typically have that conversation with my clients unless they're athletes. A lot of my professional athletes will do a 72-hour fast because that's just what they do, it's part of their routine. You know, we know that with with the prolonged fast, you get that autophagy, you get the cellular repair signaling kicked in, and you know, can be profoundly anti-inflammatory. For me, you know, I did my anesthesia residency at the clinic, and we would go easily 20 hours without eating. So I've conditioned myself to do long fast. It works well for me. I do so 90% of my cases I do under sedation. So I'm doing a lot of bone marrow aspara concentrate. I do big spine cases, and for these procedures, I have patients come fasting because we're gonna give them some kind of sedation. So typically I have them stop eating from dinner the night before. So, and these two cases are typically done first first thing in the morning. So it usually it's about a 12-hour fast by the time they come in. By the time they eat food, it's about 16 hours. So I'm not I'm not really recommending fasting necessarily, but for the ones that do do it, I have seen I can say I've seen better outcomes, but those are also some of my professional athletes, like running backs and wide receivers that I've taken care of that have done these 72-hour fasts, and but they've got super genes anyway. I mean, you know, they've got they've got super cells. But yeah, routinely I'm not doing that. I think there could be benefit to it. But if someone's metabolically healthy, I think short fasting is optional. If they're insulin resistant or inflamed, or if they have like visceral adiposity, I would say maybe a 12 to 16 hour overnight fast would be reasonable or time-restricted eating for seven to 14 days because that can improve the biologic environment without any medications or supplements.
SPEAKER_01Great.
SPEAKER_00What about you?
SPEAKER_01Yeah, so I struggle with this because there's there's conflicting reports from an intermittent fasting standpoint, from uh a lifestyle boost, from a metabolic health boost. Yes, we we use this to enhance autophagy. For those of you, like I'm sure we all know what autophagy is, but some people would say uh that it's it's a good way to clean out the bad cells, and that you shouldn't use intermittent fasting all the time, right? But use it as a tool to kind of do a cellular clean out. So I'm not I I'm conflicted if we're gonna be doing a cellular clean out right before we're doing a cellular building procedure, right? There are some discussions that maybe it makes the PRP better. There are some discussions that when you fast the lipid content in your blood is less problematic. So I'm I'm conflicted. I don't require it. If they're already doing intermittent fasting and those kinds of things, I say, you know, more power to you, but I'm not requiring it.
SPEAKER_00Okay. Yeah, I think that you know, with my sedation guidelines, fasting is a part of it.
SPEAKER_01Yeah.
SPEAKER_00So they're coming fasting anyway. But to your point about the lipids, you can see when patients have like a high fat meal and you spin their PRP, it's the pla it's just gross and cloudy.
SPEAKER_01Yeah, the light P Mickey are like, oh no, you must have gone through the McDonald's drive-thru. What the heck's going on, buddy?
SPEAKER_00Yeah, yeah. No, that's yeah, that's that's a that's a deal breaker right there.
SPEAKER_01So you're like, oh man, really? Absolutely, absolutely. Well, we have more questions for you, my friend. This has been great. I'll do my best, but we we still have more questions. So, you know, sleep and circadian rhythm stability are not usually discussed in regenerative medicine. Are you offering lifestyle interventions for these patients? And you know, what is the best way to harness the power of sleep to help patients heal?
SPEAKER_00Sleep is probably the most important aspect of the pre-procedure protocol, just because that's you know, during deep delta sleep, that's when most of our healing takes place, right? I can tell you for me, from you know, personally, sleep has been a struggle most of my life. I have sleep apnea, I wear a CPAP, I've got a high stress job, I worked a lot of hours. So I'm always looking for whatever sleep hacks I can find. But I have this conversation with all my clients, it's it's part of my intake form. Sleep hygiene is incredibly important, especially when people are dealing with any kind of pain, chronic pain. I don't see a lot of like fibromyalgia type of stuff anymore. That's not really my practice, it's mostly musculoskeletal and spine.
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SPEAKER_00But I mean I stress the importance of sleep, and a lot of people are having sleep issues. You know, some resort to drugs, which I think is not a good way to go about this. We know that people who take ambient aren't getting that deep delta wave sleep, so they're not getting the restorative sleep that they need. So I'll try other supplements for some people like L-theanine, magnesium L-3-8, phosphatylcerine. Some of these, some of these supplements can help just improve sleep architecture. You know, I tell them like one thing we want to do is kind of have a consistent sleep time and wake time. So I'll tell them if you you know, I ask them what their sleep schedule is like. I mean, my consults are an hour, so I have plenty of time to do this. But we'll go over sleep. I'll tell ask them when their sleep time is, and you know, whatever it is for them, I tell them I set it set a timer an hour before your sleep time, and that's when you get off the phone, you shut the TV off, you dim the lights, and you prepare your mind and your body for sleep, right? We want to shut off the LED lights if you can get like you know, you know, incondensive bulbs, just go back to the you know, old school lighting and create an environment where it's relaxing for you. Like I said, no TV. If you want to read a book, that's fine. But do it without an LED light, or if you all you have is LED light, try try blue blockers or some kind of glasses. But the the goal is to set a consistent sleep time and a consistent wake time. So I have them start with that. I tell them every morning when you wake up, get outside for 10 minutes, get direct sunlight, light exposure, take a walk if you want to, or you know, sit outside and drink your coffee in the morning. Just get that direct light because that helps reset your circadian rhythm. So, you know, I follow I listen to Andrew Huberman's podcast all the time and he stresses the importance of this. And, you know, I mean, there's a lot of science and data to support it. Plus, I mean, before we had artificial light, all we had was the sun, right? And uh, you know, I I bet if we go back to cavemen time, people didn't have these same slight of the same type of sleep issues that we do. So I tell them getting out in the morning, having natural light exposure for just as little as 10 minutes can be very beneficial. I've got a strict caffeine cutoff time as well. I tell people, look, the you know, the half-life of caffeine is around six hours or so. So for some people it's longer, for some people it's shorter. So at the latest, no caffeine afternoon. You know, ideally no caffeine after 10 a.m. So, you know, I I've been really good about that. It's taken me years, if not decades, decades of drinking coffee to get to the point where it's like, okay, 10 a.m., I'm just done drinking coffee, unless I'm on vacation or it's a weekend or something. But during the week, I I tell people between 10 and 12 is reasonable. And these are all easy things to do that cost no money, right? And and they're not drugs. And this is a good thing you can start to do, you know, ahead of time to prepare yourself for sleep. And then the big, you know, the other big thing is the nighttime hygiene, you know, no LED lights, bright overhead lights, you know, 60 to 90 minutes before, no screen time, no TV time. Just put your phone outside, you know. If you have a TV in the bedroom, make sure it's off. And I think those are things that we can all do that can help us improve sleep hygiene, because that's one of the most important, you know, factors in our healing.
SPEAKER_01Yeah, absolutely. I, you know, I I have this conversation with my patients all the time. And I I think one of the things that's that kind of sticks with them is good restorative sleep allows your growth hormone to be released, and that's those growth hormones that actually create tissue repair. And so if we're not able to get good restorative sleep, it blends that growth hormone production and it also then blends that healing, that reparative process that happens at nighttime.
SPEAKER_00Exactly. Yeah, that's a really, really good point. Yeah, I mean, like you said, cellular repair, growth hormone release, that's yeah, that's incredibly valuable.
SPEAKER_01Well, I have a question. Shocking, shocking. So if a clinician only had two weeks to prepare a patient for PRP, what is the minimum, like biggest bang for your box that you would say, okay, we got two weeks, what can we get done in two weeks?
SPEAKER_00Okay, the sleep techniques I just mentioned, we could do that. I would actually probably if sleep was an issue, I'd start them on L-theanine, hospital searing, and magnesium L-3-inate. I would just say, hey, look, start these right away because we only have two weeks to prepare, so we want to start optimizing your sleep hygiene. Food is foundational medicine, so strict anti-inflammatory whole food meals, protein with each meal, high fiber, remove added sugar, processed foods. For all my biologic procedures, I tell them no alcohol, uh, one or two weeks before the week of and the week after. So anywhere from three to four weeks, no alcohol. So two weeks to prepare it is cut out booze, it's not an option. It's a stem cell killer, it's pro-inflammatory, it's toxic to your brain, no benefit when it comes towards the biologics. And I've had people actually who tell me that, hey, they have two glasses of wine every night and they're not going to give it up. I'm like, you're probably not the best candidate, at least in my practice. I'm sure you'll find someone who'll do it for you and maybe you'll have a good outcome, great, but that's not what that's not a good fit for what I'm doing and for what I'm building in my practice. So that's incredibly important. You know, for if they have insulin resistance, then maybe do a longer fast, 12 to 14 hour intermittent fasting, may improve their insulin sensitivity. And then we talked about sleep, that's the most important thing. And then movement, just getting out and moving, zone two, 20 to 30 minutes, taking a walk. What's nice about that is it's easy to do and it doesn't add that recovery debt, right? So it's not strenuous. So they're not gonna be in a deficit over those two weeks, but they still get some exercise. Supplements, vitamin D if needed, vitamin C, zinc. We talked about all those antioxidants, glutathione, omegas. If it's not spine case, then I'll do some omegas as well. Just anything we can do to optimize cellular health and cellular function. I think you can do a lot in two weeks, though. You know, two weeks is I think is completely reasonable. And I've had I just had a person we did today who two weeks ago I met him and we got them all optimized within two weeks. And but that I also did some hyperbaric oxy therapy protocol. I mean, so I got a whole protocol for hyperbaric oxy therapy. I think that's one of the that's been one of the biggest game changers for my outcomes pre and post-procedures, incorporating hyperbaric oxy therapy. So that really optimizes the system, you know, from an MSc standpoint, growth factor standpoint, you know, reduces risk of infection, all that. So, but that's that's what I would do in the two weeks. I'm trying to think if there's anything else. I think those are the big things. Anything you can think of?
SPEAKER_01Yeah, do you do you talk with your patients about mindfulness, about stress reduction? Do you have any conversation about that as all?
SPEAKER_00Yeah, yeah. Actually, I'm glad you brought that up. Yeah, I mean, I've been meditating. I'm I I tell all my clients I'm a big meditator. That's something I've been doing for years now. And not everyone can meditate, but I I ask them to find what brings them peace and joy and stillness. And if you can do that for, you know, 10 to 20 minutes a day, sometimes twice a day, whether it's just listening to music, whether it's listening to an audiobook, or just doing some breath work, absolutely. I mean, we're we're in a world where we're so high stressed, we're always in a sympathetic overdrive state. And I think we're we're starting to realize the importance of balancing our nervous system and sympathetic and parasympathetic tone. So, you know, with mindfulness, stress reduction techniques, there are you know, red light therapy beds that can help with this as well, just getting exposure to red light therapy. There's something really cool called the Amortal Chamber. I don't know if you're familiar with this thing, but it's it's got vibroacoustic technology, it's got pemp, it's got red light therapy, it's got brainwave entrainment, it's got like 10 different modalities all in one, but it's all designed to rev up your parasympathetic nervous system and tone down your sympathetic nervous system. So we have a few of those here in Scottsdale. So I do refer to a wellness facility that has that for people who are. I got a lot of type A people, executives, high functioning, super stressed out people. And I'm like, look, you know, the healthier you are going into this, including your mindset, is incredibly important, the better your outcomes are gonna be. And even before procedure, I'd love to have one in my office if I could. Maybe someday I will, but they're a little costly. But you know, 30 minutes in that chamber, I've tried it myself, and it's pretty profound. I mean, something magic happens in that place.
SPEAKER_01So I gotta check that place out.
SPEAKER_00That sounds so cool, so cool. But yeah, incredibly important. You know, there's an app called Insight Timer, and so I I refer a lot of my clients to the Insight Timer. It's free, and there's hundreds of thousands of free meditations on there. You know, as some are religious, some are non-religious, and again, some are pre woo-woo, some are like completely just breathe with me and you know, feel your heart rate and count your heart rate and solve numbers. And there's something for everyone on there, and it's free. So I tell people, you know, just download the app, find something you like, and work with it. Start off with five minutes a day and then work your way back up, work your way up to maybe 20 minutes, ideally twice a day if you can do that. But anything to help support our parasympathetic nervous system and get back into that healing state.
SPEAKER_01Amazing, amazing. Such uh a wealth of knowledge. So you've dropped like a massive science bomb on us. So thank you so much. You know, we've done that first step, which is with the biologic knowledge. And so, what's the next step? Clearly, you know, you have to have our practice launch system, and that's where we find the right patients, create a cash-based business, high converting consults so that patients just want to say yes, and then clearly putting it all together for success, right? So if you want the fast track, you can come join me in Clearwater, Florida, the business of the Biologics Express course on Saturday, and then a cadaver course on Sunday to learn advanced technologies. The best part, there's no fee, there's no registration. So if you want to scan those dates for this next quarter, that would be amazing, and we can see everybody live. And I want you to scan this QR code and discover what your next step should be. Whether this is do you need more capital, or do you have clinical confidence, or do you have problems with your workflow? What about you know, non-compete clauses? Is that something that is holding you back? So this is just a quick quiz to create, are we pushing as a pathway for implementing or the biologics successfully in your practice? So ultimately, we are having a virtual summit, and so we haven't released the registration yet. So this is the wait list. If you're interested in a deep dive virtual summit, please scan the QR code just to get on the wait list. But this brings us to the QA session. So, Dr. Goyle, thank you so much for the massive knowledge bomb. So the question is, is there any advice for protocols in PRP with patients with a stage two kidney disease? Um and they have unfortunately meniscus terra neoway and angry oA. So is there anything that you would specifically do for kidney disease to kind of optimize? Maybe they can't take as much protein in. Is there what is there anything else that you'd be like, hmm, let's let's see what would we would be doing?
SPEAKER_00You know, the only thing I'd be cautious of is the protein intake, and that's really it. I mean, obviously NSAIDs are not part of my pre-procedure protocol. I have them discontinue NSAIDs a few weeks before, and most likely we stake two kidney disease and not taking NSAIDs anyway. So I really wouldn't change much other than really monitor the protein intake. Yeah. What are you thinking?
SPEAKER_01Yeah, I I wouldn't change anything either. Clearly, you know, for my pre-optimization, I do get basic labs. You know, we check a hemoglobin A1C, we get a vitamin D level, we check a thyroid, just to make sure that we're not surprised because those are things that are modifiable, and if not checked, can really tank your results. So, you know, we just want to make sure that anything that's modifiable, we can things that aren't modifiable, we're not gonna get too crazy about. We're just gonna try to optimize the human best method that we know how from you know sleep, stress, nutrition, anti-inflammatory diet, all of those things. And so, yeah, stage two kidney disease and stage two kidney diseases. I wouldn't get too crazy on it.
SPEAKER_00I agree.
SPEAKER_01All right. Um there's some recommendations for some pea protein mastevia, uh, which yep, I I agree. That's pretty nice. You know, there is a fine balance though of processed foods or ultra-processed foods versus whole foods. Do you have a specific program that you recommend or just like, hey, do you have a proprietary program that you use for your patients?
SPEAKER_00I don't. No, I I basically let most like I said, most people are coming to me from functional medicine doctors and concierge medical doctors who have their clients pretty teed up. So you know, I just tell them just be mindful of of your protein intake and and do what works for you.
SPEAKER_01Yeah. I've been using the the whole 30 diet. That I I I get 'em a little book and I give it to them and it's got recipes and it walks them through day by day. It's not you know the end all be all, but if you have if they're like, I don't even know where to start, I'm like, great, you know what, we got a book for that.
SPEAKER_00Yeah. Yeah, I guess you know, a few years ago, you know, Nikki, she she loves to cook and she created an anti-inflammatory meal plan. And sometimes if I have a person who's completely naive in the food realm and they're like, oh, you know, yeah, I eat healthy, I go to in and out twice, two or three times a week, and you know, I get the the what's it called? The uh the burger without the bun. What do they call it?
SPEAKER_01Was it animal cell or like Yeah, no one of those, exactly.
SPEAKER_00That's not right.
SPEAKER_01I don't know, I don't get those, but I don't either.
SPEAKER_00I don't either. But no, but we we do have an anti-inflammatory meal plan. It's pretty basic, pretty generic. It's easy though. They're all like 20-minute meals, simple ingredients, not you know, not they're not gonna break the bank or anything like that. So pretty much anyone can afford them, but they're good and healthy, and it's a good place to start. We tell I tell people, look, you know, if you don't eat this way, start with just one meal, one or two meals a week, and then work this into your diet. And before you know it, people like I had a woman, she was a she's a high-powered federal attorney. She came in to see me from Washington, D.C. This was in 2023, and uh she had about 40 pounds to lose, right? She was a little overweight, she had knee pain and and hip pain. We were gonna do a combination of PRP and protein concentrate for her. And I gave her the anti-inflammatory diet, she saw it, and this was in August. She's like, give me three months. She's like, I'm gonna go on this diet and clean up my eating, and I'll come back in December and then we'll do my procedure. I'm like, great. She's like, is that a good plan? I'm like, yes, because the healthier I tell people the healthier you are going into this, the better your alcohol is gonna be. She came back, she lost her 40 pounds, her knee pain went away, her hip pain was a lot better. We still did the PRP because she's like, oh, you know, it's chondro protective. She understood all the science behind it. So we're like, we did it more prophylactically in her knees, but also to get relief. So we did that. I just got a message from her earlier in 2025. She texted me and said, Hey, by the way, knees and hips are doing great. Uh I've kept the weight off. She's like, Your PRP was fantastic, but your wife's recipes were life-changing. She's like, My husband is eating anti-inflammatory foods. She's like, I got my sister and her family eating anti-inflammatory foods, and they're the healthiest they've been in years.
SPEAKER_01So awesome.
SPEAKER_00Yeah.
SPEAKER_01I you know, isn't that I I swear, that's like part of the best part about what we get to do is, you know, it's sometimes the little stuff, the the ability to take the time to be like, hey, listen, we gotta change the way you're eating.
SPEAKER_00Yeah.
SPEAKER_01And here's how. And I'm gonna empower you on how to do it, right? It's so awesome.
SPEAKER_00But Ariana, especially with these biologic procedures, you know, my issue with all the studies that are out there is no one is taking into consideration the prehabilitation, right? They're just taking random people off the street. We're gonna do PRP in one knee or saline or we're gonna do this and see what happens, right? And even in some of those people who I'm sure are very metabolically unhealthy, we're seeing a positive response. But imagine if we optimize people ahead of time and then do these procedures. Like, I want to see those studies. I mean, no one's gonna do that. I mean, that's a that's a crazy study, and it's not a it's not a good representation of our patient population, but you know, I think that I think that's that could be a fatal flaw in a lot of these studies, and why we're seeing some studies that show no difference between PRP versus saline or whatever the placebo is in in those studies. We know pay we know platelet concentration makes a difference. There's some controversy about platelet count and platelet dosing, but we know that's a factor for sure. But could it be prehabilitation? Could it be that the patients weren't optimized, and that's why your study failed.
SPEAKER_01Yeah, I you know, I think you're so right. You're right that nobody's gonna study food, like nutrition. Like there that's not a return on investment that has somebody's gonna be like, ooh, that's a money-making deal. But I believe in it wholeheartedly, and just like you, it's instrumental in my protocols. Like we they don't get out of the clinic without getting nutrition and sleep and all of the things optimized. So now there's a question here about ozone therapy. Um, what about ozone therapy pre-PRP to help with PRP success? Can we give PRP and ozone in the same joint and at the same time? Do you have any experience with ozone?
SPEAKER_00I I do not. I know that ozone can be profoundly anti-inflammatory inside a joint. I've got colleagues and some of my friends who are doing ozone inside joints and they're seeing great results. I'm seeing them do ozone in infradiscal as well. And, you know, it's antibacterial, it's got so many potential positive properties. I just don't know enough about it to comfortably do it in my in my patient population. So I'm not anti-ozone. I'd like to see more data and I'd like to, you know, hear from more of my, you know, esteemed colleagues in the community who are using it regularly to really understand it before I would do it. I don't know if you can combine them together. I don't see why not. I don't think ozone is toxic to platelets.
SPEAKER_01Yeah, again, I'm not uh using ozone or prozone at this point. My mentor, Jerry Malenga, was a big proponent. So uh he's a pretty smart guy. So I I think that if I had to, you know, go one way or the other, I would say, yeah, I think it's absolutely reasonable. I just don't have the bandwidth to put it into practice in my current practice, but you're you're exactly right. There's a question about your hyperbaric protocol and and what the ATA pressure is.
SPEAKER_00Yeah, usually anywhere from 2.0 to 2.4 atmospheres, usually a minimum of 60 minutes. It really depends on what people can tolerate. Not everyone is a candidate for hyperbaric oxy therapy. I do require that they go to a true medical grade hyperbaric chamber, so that's 100% auction under pressure. No face masks, no nasal cannula. These are these are true hospital grade chambers, individualized. You know, they're the kind of chambers you're not taking your phone into, you're not taking your book into, no perfume, no lotion. I'm very fortunate to have probably one of the one of my favorite people, Dr. Carrie Burdenko at Benissaire Health. She has a very amazing concierge internal medicine practice, and she has a very, very fine-tuned, high-level hyperbaric program, and that's where I send most of the majority of my clients to. So I know they're going to be safe, and the protocols there are up to standard and bar, and they're just amazing. So, anyway, so the to answer the question 2.0 to 2.4 atmospheres for anywhere from 60 minutes up to two hours. Some clients I send down there and they just love it and they become lifers and they just keep on going. I mean, I'm one of those people. I do hyperbaric usually once a week, twice a week if I'm lucky, just depending on my schedule. But for my pre-procedure protocol, it's two to two point four atmospheres. And that's based on some data. I can find the study. If anyone wants to email me, I'm sure we'll put up my email and my contact information. But there was a study showing that hyperbaric oxy therapy, 100% oxygen at 2.0 atmospheres, increases MSC release from the bone marrow into circulation by 8 to 20%. So typically I'll have people if they'll do a couple of sessions before the procedure. So we'll do hyperbaric oxy therapy, like if the procedure is a Wednesday, they'll do hyperbaric Monday and Tuesday. Wednesday, if the procedures in the morning, they'll go in the afternoon. And the rationale for that is if I'm doing PRP or even anytime I do bone air, I'm doing PRP also. We know that PRP releases platelet-drive growth factor BB, which is a homing signal for MSCs. So the rationale is we do the procedure, we have the release of these growth factors, specifically platelet-drive growth factor BB. You go into hyperbaric, there's an 8 to 20% increase in circulating MSCs from your bone marrow. Those MSCs are going to get attracted to that platelet-drive growth factor BB, which we've concentrated to a very high level and put it into we've delivered to injured tissues. So they'll do hyperbaric immediately after, and then the next two days, it's usually a series of 10, five the week of, five the week after.
SPEAKER_01Gotcha. Yeah, that that is a uh really robust protocol.
SPEAKER_00It is, you know, it helps tremendously with the post procedural and pain and discomfort as well. Yeah.
SPEAKER_01Man, I don't even have a hyperbaric chamber in near me. So unfortunately, that as you know. I live in the sticks.
SPEAKER_00Well, like I say, it's a nice to do, it's not a need to do. Yeah, I offer that. I'm like, if you can do this and it works for you, hallelujah. But if not, we're still gonna do well.
SPEAKER_01So, yeah. What about vagus nerve stimulators? I was just talking with one of my patients today about this. You know, is the science there for that parasympathetic tone for vagus nerve stimulators versus mindfulness and deep breathing?
SPEAKER_00Yeah, great question. I do not have that data. So I have people who use these vagus nerve stimulators. There are so many in the market right now. I don't know, you know, there's Pulsetto, there's the True Vaga devices that Dr. Churchill mentioned. I don't know what the differences are. I don't know if one is better than the other. I don't know if one has been studied more than the other. I just I don't have that data. So instead of buying a device, I tell people just breathe, you know. It's yeah, breathe and use your lungs. Use your lungs, exactly. And yeah, practice mindfulness. But yeah, so I I I can't answer that question.
SPEAKER_01Gotcha. Gotcha. So, you know, there is some questions. The the everyone's talking about the sleep supplements, the L-3-9, phosphatyl serine, and MAG3N8. Yeah, yeah, those are the ones. I think these are all pretty standard and uh you know high-quality brands, of course. Uh, you don't want to go to Costco and get the the the the the full 5,000 pills for three dollars, but or Amazon.
SPEAKER_00And I always tell people with supplements make sure they're CGMP certified. Yeah, or NSF certified.
SPEAKER_01Yes, absolutely, you are absolutely right. Um, and you know, patients come to me and they're like, Well, what about this? I'm like, do you don't see the seal? Do you don't see the certification, do you? So at least that's exactly right. Uh there's a question Do you recommend PRP as a preventative measure? For example, in elite athletes, or for patients who've had meniscus surgery and at a higher risk later in life for OA? And then the other there's another question that are you are you offering a series of injections, or is this uh usually uh a single injection protocol that you're using?
SPEAKER_00Yeah, for for 90 say 99% of what I do is a single procedure. So I'm just doing high dose, like for a mild to moderate neo a, I'm doing 120cc blood draw. If it's more advanced, I'm doing BMAC, intraosseus, and you know, so for PRP, it's usually just a high dose PRP single shot. I always use protein concentrate, A2M, IRAP, so I always concentrate the PPP down. And I found that I mean I don't think I've I don't know if I've ever done a series to be honest with you. I think it's always just been high dose, high dose PRP. And like I said, with more advanced cases like for NeoA, I'm doing B Mac and I'm going into osseus as well as intra-articular.
SPEAKER_01So yeah, yeah, absolutely. Oh, can you repeat those supplement certifications again?
SPEAKER_00Oh C GMP, so current good manufacturing processes, and then NSF is is a sports one, the nationals. I forget what it stands for. Yes, thank you. Yeah, exactly. NSF, and is in Nancy, S isn't Sam, F isn't Frank.
SPEAKER_01Awesome. Well, this has been phenomenal. I do have one last question for you. We've talked a lot about PRP, we've talked a lot about prehab and lifestyle. I want to jump into the business side for just a little bit. Number one, if you can share with everybody kind of your journey to, you know, your current state. I think you've done a phenomenal job. And so that is if you can just kind of give them a snapshot because you've been at it for a while and you were a standard anesthesia pain physician with a very, very high volume insurance practice, and now you're not, right? And how much better is that, right?
SPEAKER_00What a journey.
SPEAKER_01Yeah. And then my biggest question, and you can use your journey to kind of maybe share your answer, but what based on your journey, what was that like turning point where you were like, oh man, what do you think one decision or one mindset or one piece of advice that you could offer these participants that has the opportunity to be a game changer, to be a life changer, and really be that departure point towards success.
SPEAKER_00You know, so that's a great question, Ariana. And there's there's a lot, there's a lot to that answer. I'm gonna try to keep it as succinct as possible. So I'll talk briefly about my journey. So I finished my anesthesia residency in 2006 at Cleveland Clinic, then did my pain fellowship there. Very heavily interventional based. I did a ton of pumps, stems, narcotic management. I learned to block every nerve from C2 all the way down to the big toe. If there's a nerve down there, I could probably stick a needle in it and block it. So from 2007 to 2017, 10 years of private practice, very high volume. I was a bit with a bit large anesthesia and pain group. You know, it was it was routine to do anywhere from 35 to 50 procedures in my procedure day. I was doing that on average two to three times per week. It was very high volume. I loved it. I mean, I was doing great. I thought I was doing great work, got top doc, voted by my peers multiple years in a row in Scottsdale and Phoenix. And then in 2017, I went to Briggsby's pain conference in Napa. He has a big pain conference there every year. So Nikki and I went together thinking we're gonna have this relaxing getaway, drink some wine, go get some good food, connect with colleagues, I'll get my CMEs. Well, the first day was a pre-conference symposium dedicated to regenerative medicine. And my good friend now, who's one of my mentor and colleague, George Chang Chan, was moderating that entire day. And it was in that one day I learned that epidural steroid injections and steroids in general are toxic and they're destroying tissue, that radio frequency ablation procedures denervate not only the joint, but they also denurvate the multifidae muscle and lead to fat atrophy of the multifidae muscle. I learned how to read an MRI that day from a whole new perspective. I learned that everything I taught, I was taught was basically symptom management. And that, you know, when I was at Cleveland Clinic, they were teaching me root cause, root cause is a hernated disc. Well, no, root cause is all the events that led to the hernated disc. That's what I learned in that one day, and it was mind-blowing for me. So in 2017 is when I began my regenerative medicine journey. You know, I sought out the leaders in the field and said, hey, I'm gonna come shadow you. I just want to sit there, I just want to be a sponge. And, you know, George was kind enough to let me shadow him multiple times. I learned a lot from that guy, especially over those next few years. So in 2021, I started my own practice, Introgators Bind, Pain, and Wellness. It was insurance-based, and I was trying to incorporate orthobiologics at the same time, had no clue what I was doing. Fast forward to October 2023 when you and I were both at a mastermind together, Mavericks, with Matt Gallagley, who's absolutely brilliant, and I wouldn't be doing here doing what I am now without his foundational work to get me there, which was a lot of mindset work. But I realized how how much I was drowning. So my practice, I had started in June of 2021, by October 2023. I put my financials up in front of a group of strangers at this conference, at this mastermind, and Matt Globely, the person who put on this mastermind, eviscerated our financials in front of everyone and basically told me my practice is in the ICU. It's on full life support, they're doing chest compressions. If we don't turn this around in six months, the bank is going to take our life insurance policy, our car, and our home. So it was that bad. We were drowning so bad. Because I was trying to, I was trying to deliver concierge-level service with insurance-based medicine and try to fit orthobiologics in there somewhere. It was a complete disaster. So Matt helped me shift my mindset and realize that, and this this is to answer your question, what's the one thing that that really catapulted me into my current success mindset or otherwise? Was changing from building my practice around procedures and start building it around the outcome. You know, he was really, he's he he he drilled this home. He's like, people aren't buying your procedure, Goyle. They're buying the outcome. And that really sunk home with me. I was like, oh my gosh, I need to set up a practice that's based on the outcome, right? And that's what I did. And I got it. It took me a while. Like, you know, Nikki was my wife was a part of our mastermind too, because she's the business and brains behind everything. But it really took me understanding what he meant, you know, build a practice around the outcome. And that's where all my passion for holistic medicine, nutrition, movement, mindset, all that came into play. And that's how I created these protocols, right? With the anti-inflammatory lifestyle, the prehabilitation. And then everything changed. And then over the next two years, I weaned off insurance. And as of January 1st this year, I'm 100% insurance free. It's amazing. Like literally, I did four procedures yesterday, and it was a fantastic day. Better than any of my 25 to 30 procedure days I was doing in insurance. Today I saw eight people, great connection, great conversation. But that's what that's what it is now. And it's it's tremendous and it's extraordinary. But it really came down to that one piece of information and just like, hey man, build your practice around the outcome. People are buying an outcome, that's what they're spending their money on.
SPEAKER_01Yes, awesome. Well, thank you so much for sharing your journey and sharing all of your knowledge. You know, I know that we have gained so much. And really, thanks for spending time with us, everybody. We are at the top of the hour. And so, Dr. Goyle, thank you so much. Uh, you know, if anyone wants to contact me at the business of orthobiologics or info at the business of ortho biologics, and we're all going to hashtag make money monday, right? Uh so it's it's all about the passion and the money will follow. If you build your practice around the outcomes, the patients want what you're doing, they want great outcomes. And and so you don't have to mortgage your soul, you just have to give great outcomes and you get to connect with your patients in a profound way. So, everyone who has joined us, thank you so much for your time. It's been an amazing journey, and this is great. So, if there's any other questions, you are I think we got them all. Did you sell that? Yes. Did you offer, did you start offering one-hour appointments for cash while you were doing insurance for others?
SPEAKER_00I did, yeah. As I started weaning off insurance, for example, like the one of the first insurances we dropped that was they're evil was Cigna. Yeah, they're horrible. So we dropped Cigna, and so my my former Cigna patients who still wanted to see me, or if if new consults were coming in that had Cigna, all my new consults for cash pay patients are an hour, all my follow-ups are 30 minutes. So if they were insurance-based, it was 30 minutes and 15-minute follow-ups, because that's the only way you can do it. And you know, because I tried it the other way. I tried the one-hour consults with insurance. I did that for I tried doing that for two years and until Matt eviscerated my financials in front of you and your husband.
SPEAKER_01You put your practicing life in the ICU, yeah.
SPEAKER_00Yeah, he did.
SPEAKER_01He yeah, so well, you can't do it from a financial standpoint. You can only care for insurance-based patients for seven minutes before you make money. Unfortunately, right? That's not that that's what the insurance has set as the bar. If you want to spend the time, it's a cash-based world. And and patients are willing to pay for it. And they they clearly say all the time, oh my gosh, I've never had a doctor spend this much time with me. And that's correct, because there that is an insurance-based experience. What we provide, and I'm sure what you provide, you you have an amazing concierge experience, is a completely different experience, and it's transformative. And so if you're looking for transformation as a patient, then you get to go see Dr. Goyle. So thanks so much everybody for joining us, and you're a wealth of knowledge. Thank you so much again.