Inventor, author, and scientist, Dr. John Jaquish lectures on Osteogenic Loading therapy, its effects, its limitations, and the future of osteoporosis treatment without drugs.
Full Transcript
Edwin Lee: Dr. Jaquish has this interesting device that he has developed, and he had a really fresh eye to look at it, because he didn't come through the traditional medical background. His background was in software development and he got an MBA. He'll tell this story about his mother developing osteoporosis. But he got into biomedical science, and he's going to be talking about this osteogenic loading. And he's developed this new invention that can actually ... Has helped his mother in terms of reversing osteoporosis without medications. I'm excited to hear his lecture today. And in addition, he's very active in terms of; he's an artist. He's shown me some beautiful pictures he's done, and in addition, he likes to ski, and he's a cat lover, and his cat's called Mr. T. Let's give a nice warm applause to Dr. Jaquish.
Dr. John Jaquish: Thank you. Thanks for sticking around. I know it's nearing the end of the day, and the weather at the pool is getting better and better. Somebody just scrambled out and said they have an appointment at a zip line, which sounds pretty fun. I'd like to be on a zip line right now, also. Okay, so I'm going to talk about osteogenic loading and a specific device that was developed for putting a load on bone in an axial format along the axis. But this device is particularly important to this audience because, in age management, we can suppress myostatin, we can increase the levels of anabolic hormones in the body, can change growth hormones. But without the proper load being put on the body, the body cannot adapt. And when I speak to patients, I don't see patients; I'm a researcher. But when I go to, let's say, a retirement community that uses this technology, I developed when I speak to these patients, and they say, "Well, I take calcium." You've all heard this before, "I do this, or I do that."
And I say to these people who are not at all medical professionals; I say, "Okay, you see a weightlifter, and they take excessive amounts of protein, and they lift weights." And everyone nods, and they say, "Yeah." Imagine if they just took the protein and didn't lift the weights. Would they become great athletes? No. The same is true with bone, and I'm going to talk about some muscle interactions also how we can put greater force on muscle, tendons, ligaments, and bone to have an adaptation that hasn't been seen yet. I'm going to talk about bone; I'm going to talk about the risk factors of osteoporosis. I will go quickly through that because we're all very familiar. Talk about the new technology and how it applies to age management, as well as what type of practices may be able to take advantage of said technology.
So, quick bone review, we have a cortical and trabecular bone. We have an osteoblastic function, cells that pull in minerals and build a greater architecture around them if they sense the proper amount of load. We know what an osteoporotic bone looks like and what a healthy bone is. We show these to patients and get them to understand a little bit better why a bone becomes weaker. Global impact, 200 million worldwide have been diagnosed with osteoporosis. That's going to increase as people in developing countries, as physicians in developing countries, can test to a higher degree. I've been talking to the Chinese government, and some officials in the Chinese government and the Indian government about how they're just now able to take advantage of DEXA and some sonogram technologies to diagnose, and their diagnoses are much poorer than those in the Western world. Cultural, dietary, and many different factors play into that, so the burden is tremendous.
50-year-old woman has a similar lifetime risk of dying from a fracture than from breast cancer. That's something that patients need to understand. Very frequently, when a DEXA scan is prescribed, patients won't comply; they won't have it done. They'd rather not know; they don't feel sick, and they don't feel like there's anything wrong with them, so they'll put it off. And they don't realize that having a hip fracture in your 70s or your 80s could be a life-ending experience. As I was saying, the rates in the Asian countries of diagnosis are incredible. That's the takeaway from that image.
We know about some risk factors. Most know that there's a genetic component, but there are also some that patients aren't aware of—eating disorders. I have a great relationship with an eating disorder specialist in Chicago, and she's seen thousands of patients over the last 40 years of her practice and explains to me how she's never had a patient that did not have osteoporosis, did not have a T-score of lower than negative two, and some of these are even teenagers.
And, of course, smoking, alcohol, and low dietary calcium. We reach peak bone mass when we're younger. Now, it's important to point out, and this is what I was talking about at the beginning of the lecture, when we are younger, we're able to put greater forces on our bodies. And when we're older, no matter if we suppress myostatin, no matter if we have a hormonal advantage because of age management therapies, still not going to put the same amount of force on the musculoskeletal system that we would when we're younger. That's what we're going to talk about next, how to accomplish that objective.
A little more fracture data. If anybody wants to go over the details of fracture data, I can go over that at the end of the lecture. We know what a T-score is. Some patients don't understand standard deviation, so I don't know what the standard of explaining that is, but below negative two is bad. That's about everybody nodding; that's about what you tell your patients, right? Right now, some medications can treat osteoporosis, bisphosphonates being the primary category. These have some terrible implications for irregular fractures. Though they may make a DEXA scan look better, the fracture data doesn't necessarily track along with these bone density gains, as seen on the DEXA, which has made DEXA a little more questionable and has made bisphosphonate therapy more questionable.
Now, there has always been a recommendation for exercise with bone. This was mentioned several times in the previous lecture. That was mostly based on the work of Dr. Julius Wolff in 1892. In 1892 Dr. Wolff wrote his paper, Mechanotransduction of bone, so placing heavy loads on the bone and causing an adaptation. Now, what Dr. Wolff did was have individuals go through high-impact experiences. One of the experiences was dropping sandbags onto people. Now obviously, in 1892, human ethics boards were not what they are today. Many different experiments were run, but the practicality of that type of activity is just not there.
Here are some ACSM recommendations. And now we're looking at a way to stimulate what Dr. Wolff described in his Mechanotransduction paper in 1892, looking at a way to trigger this in the body without the risk. The benefit of high impact without the risk of high impact. This is an osteogenic loading device. It's an exercise for bone and fracture prevention. It's compressive force through bone along the axis. As the bone is compressed, the osteogenic effect takes place; minerals get absorbed into the bone to calcify.
Again, Dr. Julius Wolff, more than 100 years ago, this was discovered. Now this can be a reality. Now, how does it work? Users are placed in an optimal biomechanical position. When everyone in this room trips and falls, you go fall, you're going to put your hands in front of you, you're not going to put them right in front of your face when you hit the ground, and you're not going to lock your elbows either. Your reflexes know that you're about right here. So, 120-degree angle of inclusion in the joint. Does that make sense, everyone? 120 degrees. If you jump up and land, you can have anybody do this, an elderly person, a healthy person. The angle of inclusion behind the knee is 120 degrees. Our reflexes know where we are most powerful.
Now, by isolating these positions and allowing for self-compression of bone in these positions, we can deliver many magnitudes of force to the human body that would never be acceptable in a fitness or training environment. So, the loading is self-imposed. In these positions of impact, patients are placing a load on their bodies, so the regulatory mechanism is their comfort. We are all wired with a safety system, our comfort. If there's a hot stove in front of me and I put my hand near it, I can feel the heat and know when to pull my hand away. This is not how we exercise. The way this device works, it works with the central nervous system as the mechanism of regulation.
When the compression takes place, there's a neuromusculoskeletal stimulus that triggers the response in density. So, mineral uptake in bone has a myofibril effect on muscular tissue, so the question will come up, "Will women grow bigger muscles from this?" No, they will get stronger muscles from this. They will get harder muscles from this. The size is not a component. So, very high power-to-weight ratio. Suppose you think of what happens to a gymnast when they hit the ground. Gymnasts are very lightweight; they're very lean, and they're very powerful. They have the highest power-to-weight ratio of any athlete. As bone adaptations take place, increases in forces are applied over time with comfort.
Now, so we know that compressing bone from end to end is the trigger for osteogenic loading experiences. Now, this is a very important graphic, probably the most important in the lecture. This is a 57-year-old postmenopausal woman. She is placing a load through her lower extremities. She weighs 120 pounds, and she is in the top graphic, not putting any load through her lower extremities. In the bottom graphic, she's placing ten times her body weight through her lower extremities. Think about that. Think about your body weight; multiply that by 10. That's how much force she's putting through her legs. Now, she is engaging this force through a neuromuscular process. She's engaging more motor neurons and larger spindles than potentially ever before in her life. And she's compressing bone.
And we know this because the seat and the press pad that you see in that picture they're not moving. But you see the angle of inclusion behind her knee. You see that drop-down. You see the knee moving, so that change in angle is from compression of joints and bone under ten times body weight. Now, she recruited all of the force to engage in this herself, so it's a self-compressive movement. The actual apparatus, the osteogenic loading apparatus, is not applying this force. She's applying this force.
There are four movements, upper extremities and lower extremities. There's a core movement for the ribcage and pelvis. And then the last one's called the vertical lift. It's actually like the top of a deadlift, but the elderly people didn't care for the word dead. So we changed it to vertical, which seemed a little more positive. Four movements put axial loading through every long bone in the body and encourage this osteogenic loading effect.
This has been in research for 17 years, as was mentioned when I was brought up here. Thank you, by the way. I started this research because my mother was diagnosed with osteoporosis. I'll just tell you the story. She came home, and this was when I was in college. She comes home, and she says, "I'm going to die." And she's very dramatic, so I've heard that before. So, like, "Okay, why?" She says, "Well, my doctor told me I have osteoporosis." And I said, "Okay, that's a real thing. Let me look into it." I was 20 years old. Maybe some of you have 20-year-old children; you know your 20-year-olds absolutely everything, right? So, I guess I was no different. I started looking at osteoblastic function and researching really how to trigger an osteoblast to build a greater architecture around itself.
And what I ended up looking at was completely unguided. I was a business major, and it was completely unguided research. And I think I came to a fresh perspective and made the decision that we could compress bone with a specific apparatus as long as the force called upon was self-regulatory. It took me a few years to get the device right, and I initially built the device in my garage and treated my mother. She went from a T-score of negative 2.2 to negative 1.8 in six months, and 18 months later, when she got her next DEXA scan, she was negative 0.2. So, went from, in about two years, went from osteoporotic to healthy bone. She still yells at me for putting my socks on the floor or whatever.
Individuals who do this increase their force production very quickly. It's a stimulus that the body typically doesn't get, even with athletic individuals, because the loading events are so high. Now, this is true of the upper extremities also. Individuals place four or five times their body weight on their upper extremities, maybe in the beginning six to seven times, and build up to 10 to 15 times their body weight in the lower extremities. Of all, I tell most patients to look for three times the body weight loading of the spine. I know that seems like a lot, but in the proper position, the human body is capable of adapting to this very specific position to an incredible degree. It's also an FDA registration class one device. And the registration number is right there, 890.1575.
Okay, so this is one of the cases in the study that was published about the apparatus in Osteoporosis International. This is just one of the patients. This is the pre-scan, this is the post-scan, showing a 7.7 increase in spine bone density. That happened to be the average of the entire study, a 7.7 increase over one year in the spine. That is many multiples the result that you would see with any existing intervention. That would normally take years or be considered not possible. This is from Osteoporosis International. Sorry, 7% in the hip and 7.7 in the spine with triple the amount of time standard of care doesn't match what the osteogenic loading is doing.
Also, some research presented at the European Sports Science Congress in Barcelona using force-specific movements showed increases in force production. So, adaptations in an individual's ability to produce force and muscular size do not necessarily change what muscular power does; muscular hardness does. Because this is an event, and some of you tried it in the other room over the past few days. In this experience, where you're delivering multiple body weights to the musculoskeletal system, you're not going to fatigue with the fuel system of the muscle. It's a very different experience from any type of resistance training. When you lift weights, you run out of ATP, then glycogen, then creatine phosphate. None of that happens here—a completely different mechanism. We are going to structural fatigue of the muscle cell. That's very important. Instead of fuel fatigue, structural fatigue, so the body always responds. An adaptation is always specific to the imposed demand, so the adaptation is a structural adaptation. Protein synthesis occurs, and we have new myofibrils.
We're starting some studies in China to look at hemoglobin A1C changes as a result of new myofibrils because, as we know, new myofibrils mean an upregulation of glucose. Ongoing research I mentioned, so we have Bloomsburg, Hadassah University in Israel, in China, and the University of Wyoming. And now, when it comes to your patients, everyone in this room needs to look at data to know that their patient is getting better. But having data that means something to the patient is very important because if they don't know that they're getting a great experience, are they going to be happy? Are they going to stay patients? Probably not. Just a show of hands, how many of you have had a patient that you've been improving and they were unable to see the improvement? Okay, almost everybody.
Here we drive the data through a report that gets automatically emailed to the patient so they get to see the improvements in their force production. Now, force production is a term used in neurological testing, but for our purposes, it is a measure of bone performance. When this particular individual began in the leg press movement, about 700 pounds was the first loading instance. And this individual has built up to 1,318 pounds. This is a 60-year-old female that did this particular report. They see a visual representation of what they're doing, and they see the improvement. They get very emotionally tied to this, which encourages incredible compliance. In the initial test group, which was the subject of the book that I wrote called Osteogenic Loading, I don't have a copy for everybody, but I have one, hang on.
Have one here. This was about the first 400 people who went through this therapy, and we noticed that over four years, 400 people, only 6% attrition because they liked it, felt good. They were encouraged by seeing the data. There's a huge psychological component when a patient can feel themselves improving or if they're so kinesthetically unaware, which is a lot of people. If they can't sense what's changing in their body, they can at least see on the data that they're improving. And that is tremendous.
This is the full performance report. This one is labeled, showing what's happening, and this is what a patient receives at the end of every session. And you see the performance increases; you also see normative data comparisons right on that chart. The age and gender cross-referenced with how many sessions the individual has done. For example, a 50-year-old female who has used this osteogenic loading technology, let's say, five times, is compared with other individuals who have used osteogenic loading for 50 years old and female five times. It's a server-based system where you're constantly being compared with people who are exactly like you.
The application of this in various locations, in age management, can be tremendous because we're able to get the benefit of the highest intensity and the highest impact level forces on the human body without the risk of injury. And for the age management physicians out there, as I've said, you can inhibit myostatin, and you can put them at a hormonal advantage, but some of them don't train with enough intensity to affect the body to a large degree. And you don't necessarily want to encourage that because even though they might have the hormones of a younger person, they still have the tendinous tissue, ligamentous tissue, and the recovery ability of somebody closer to their actual age. Here we can get this high-intensity explosive experience without the risk.
Some additional resources. International Osteoporosis Foundation, Osteoporosis Institute has several articles, this is more of a patient-focused website, and if patients have questions, I tell physicians that have one of these osteogenic loading devices to use the Osteoporosis Institute to educate their patients. National Osteoporosis Foundation. And, of course, if you would like to review some of the literature that I was touching upon today, you can get a copy of the book or email me at authors@osteogenic.org.
In summary, we looked at some perspectives on bone health and risk factors of osteoporosis. We looked at the new technology and how it applies to age management, and why this is important to this community. I'd like to open up for questions if there are any. Thank you.
Edwin Lee: That was a fantastic talk. I'm just curious, have you looked at women or men with scoliosis and put them on your device and have... I mean, people with deformities, significant kyphosis, and you try to load it. Have you noticed an increased rate of fracture, or has it helped them?
Dr. John Jaquish: Great question. There have been several users that have had ... Scoliosis and kyphotic curves; they behave very differently. We've seen kyphotic curves reverse, and in fact, the next book that I'm working on has several pre to post x-rays showing postural changes. This is without traction. This is without any other therapy, just loading the spine, forcing the tendinous ligamentous bone and the muscular tissue to realign the spine. With kyphotic curves, we've had great results. Scoliosis's not been studied; it's just been anecdotal. I've seen, and other physicians who've applied this in their practices, have seen somewhere between moderate and incredible results because the individual's central nervous system is aware of where their spine is. When they self-apply, the key here is the self-application of force. When they self-apply, their central nervous system is not going to let them put a force on the bone or tendons or ligaments that are going to create an injury.
Now, I say that with a caveat, which is you need to make sure that the individual is under control while they're doing this. All of the compressive movements are applied very slowly. The software is developed in a way where it discourages abrupt movement and encourages very slow movement. Using biofeedback as they're loading the spine, for example, the load on the spine is typically in the leg press and the vertical lift, mostly the vertical lift. And when they're doing the vertical lift, you just have the patient go much slower and ensure that they are comfortable through the loading experience. And as they're building the load, they're breathing; they're staying comfortable, and that way, the body can adapt and potentially improve the alignment of the spine.
Edwin Lee: One other quick question, what about patients who are already had multiple surgeries because of severe osteoporosis if they have rods? And just curious if you looked at that subset of patients.
Dr. John Jaquish: As the designer of the device, I don't ever tell a physician how to treat their patients. There are certain levels of osteoporosis and certain levels of kyphosis where an individual might want to start with just a few of the movements as opposed to all of them. In the spine movement, the individual grabs a bar and drops in a position with 120-degree angle, bends behind the knee and pulls the shoulders back as much as they can, and then creates upward force. Think of a deadlift-type movement, but just short of locking out. This is the most powerful portion of that movement. When they're in this position, there's a great level of comfort, so they can engage to a very high degree without necessarily challenging.
Now, when it comes to hardware installed in the body, that's a potential challenge. There have been many people with pins, screws, and joint replacements. Now, bone is flexible. The hardware installed in the body is not flexible. We have patients saying, "I can feel the screws in my tibia," for example. There's one particular guy I know the bone is bending; the bone is being distorted. However, if there's an osteogenic effect around that screw, what's happening? You're increasing the strength of the bone around the screw because that's receiving load also. We've never had anyone complain of any complications and only had good results with that. Yes?
Speaker: Question about, say, we have a fragile 90-year-old woman who might have an undetected hairline fracture, and you put her on that. Have you seen any worsening of that kind of fracture? I realize over the long term; it's going to get stronger, but?
Dr. John Jaquish: That has happened several times, and the osteogenic loading device has been able to help the practitioner diagnose a hairline fracture. Because at times, just an example, there was a guy in his 40s who had a hairline fracture in his wrist, and every time he would go to load the upper extremities, he would just say there was a pain in his right hand. And so I said, "I think you need an x-ray." And he had a hairline fracture. The periosteum knows the sort of funny anecdote I give to the practitioners, "The central nervous system will know the patient better than you will ever know the patient. If you let that be the regulatory mechanism, the central nervous system can show you things about that individual that they may be unaware of, so."
Speaker: So, you have a consent form, sort of a disclaimer for that?
Dr. John Jaquish: Yeah, it's almost like a generic fitness-type consent form. I am aware that I can exercise. I got it.
Speaker: One more question. One of the things as we age is we begin to become less coordinated, and our balance worsens. Have you looked at the effect of this particular device on balance itself?
Dr. John Jaquish: Repeat that question one more time.
Speaker: One of the things as we age is our sense of balance-
Dr. John Jaquish: Yes.
Speaker:... worsens. Have you looked at all the results of your patient?
Dr. John Jaquish: Great question. The power that the human body has is increased by this. You need to be strong before you can be balanced. A lot of patients who have poor balance don't have the strength to do balance training. Now, many practitioners pair this technology with whole-body vibration platforms. So, they increase the power in the muscle, they increase the bone density with the osteogenic loading apparatus, and then they'll use a whole body vibration platform to destabilize the body to get reflexes firing to rebalance. That's a dynamite combination, and very many locations that have this also use whole-body vibration for fall prevention purposes.
Speaker: What if a person has lumbar spine disease wherein he has a compression of a nerve? He could be asymptomatic but has radiculopathy. Does this aggravate radiculopathy?
Dr. John Jaquish: From what we've seen, it doesn't because the position that the spine is placed in is the position that the individual would absorb impact. If you stood up on the table right now and jumped off, I don't want you to do that, but if you did and you went to land on the ground, your reflexes would pull your shoulders back before you hit the ground. It's a reflex. When placed in the optimal position, there is the least pressure on nerves. Now, if one of those nerves is hot, is they're in acute pain, or if they get to the point where they're touching one of those nerves, in the movement, they would have a neural inhibitory moment. They would sense the discomfort, and they actually wouldn't be able to continue because the central nervous system would just start shutting those muscles off. But again, it's self-regulatory.
Speaker: How is this machine different than the person doing squats against gravity?
Dr. John Jaquish: It's multiples of body weight of loading. When someone does a squat, typically ... You saw the image of that woman I pointed out as the most important graphic in the presentation—a 57-year-old woman placing ten times her body weight through her lower extremity. You won't find many people attempting that, including professional athletes that would even attempt something like that.
Speaker: So, she's pushing the machine, she's pushing the resistance?
Dr. John Jaquish: She's pushing against two fixed points. The seat and the pad do not move. The reason there was movement in the joint was from compression of the joint and bone.
Speaker: Okay, thank you.
Dr. John Jaquish: Thanks.
Speaker: What is the effect on the tendon and ligament strength with everything going on here too?
Dr. John Jaquish: You already know the answer to that question. Okay, so Benjamin and Ralphs 1999 did a study. It was a little bit like what Dr. Julius Wolff did in 1892, looking at the compression of joints and what the adaptation to that compression was. And what they found was the same thing that Dr. Wolff found was that when you compress the joint, the joint capsule starts building fibrocartilage, which pulls in minerals. Very similar to Wolff's law, so it pulls in minerals and increases fibrocartilage. When we see a dysfunctional joint, the strength of that joint becomes greater. Now, that dysfunction, let's say bone on bone in the knee, we have that all over the place. We see the pain drop, and this is because of what Benjamin and Ralphs found in the compression of joints. The tendinous ligamentous tissue that supports the joint, the joint capsule, is becoming stronger and supporting the joint better.
Speaker: How fast have you seen this improve? Is it a direct correlation to bone density as well, or is it happening faster? What have you found?
Dr. John Jaquish: I don't know if I'd call it a correlation. It's correlated because they both respond to the same stimulus. But I don't know if the machine is the bone gets denser, and then the tendons and ligaments get denser, or vice versa. I wouldn't say. Now, much more research has gone into osteogenic bloating and osteogenic effects on increasing bone density, but tendons and ligaments are of great importance also. I think it's just because the research is heavier on bone. We know more about bone. But I believe it's the same stimulus is stimulating both, and both adaptations are happening at the same time.
Speaker: Gotcha. One more quick question. Osgood-Schlatter Disease in Kids. Have you worked with kids, and is there any effect on that?
Dr. John Jaquish: It is safe for children to use because we are putting people in positions where they would go through high impact. Children go through high impact anyway. So, we are putting them in an environment where the high-impact experience is controlled and has a greater level of safety, so children adapt wonderfully.
Speaker: Thank you.
Dr. John Jaquish: Yeah, thanks. Yes?
Speaker: People who have had a prosthesis in their hip, let's say-
Dr. John Jaquish: Yes.
Speaker ... typically they've had osteopenia or worse. And now, with the prosthesis, there's the issue of the alloy on the wear surfaces, most particularly the cobalt-chromium alloy that has been used in recent years. And the wear of that throws off ions into the body and creates metal toxicity. With your device and that of the whole-body vibration technique that together you said is the most effective way to do it, do you have any evidence or knowledge about the extent to which that metal toxicity issue is increased, particularly by the whole-body vibration where you presumably are creating a minute but constant wear condition on the ball and socket joint in the prosthesis?
**Dr. John Jaquish:** Yeah, I only caught about half of that, and I'm sorry, I was trying hard to figure it out. Are you talking about joint replacements? And I caught joint replacements or prostheses and then whole-body vibrations. That's all I got.
Speaker: Do I need to speak louder? Is that-
Dr. John Jaquish: Yes, that would be great.
Speaker: My apologies.
Dr. John Jaquish: It's all right.
Speaker: That was a long-winded question, but I'll try to summarize it again. Where you have a prosthesis-
Dr. John Jaquish: Yes.
Speaker:... in the hip where there is a wear surface issue that has been shown in recent years to have developed.
Dr. John Jaquish: I see.
Speaker: That is creating metal ions that are going into the body, creating metal toxicity basically, simply. And so that comes from wear. And so, the whole issue of worn surfaces on prostheses is a current topic needing more research and development. As you may know, there are recalls on the prosthesis of that exact issue. There's a large incident of that in England where a particular device was used, et cetera, so it's well known. Now the theory would be that several people had a hip replacement, perhaps due to a fracture, who had osteoporosis or osteopenia, whatever, and therefore need to continue to build strength back, bone density, bone strength, whatever. The question is, does your device and that of combining it with whole-body vibration, which you indicated is a great combination and creates greater results-
Dr. John Jaquish: Yes.
Speaker ... possibly going to increase additional wear and therefore greater metal toxicity issues in the body?
Dr. John Jaquish: I've never seen anything that would indicate that that would happen. I was rapidly wearing out the joint with either whole-body vibration or osteogenic loading. It could be a possibility. I don't believe it's been studied, but there are, I think, over ... I don't know how many whole-body vibration platforms are being used out there, but I know Power Plate specifically, there's 155,000 in circulation, and I've never heard of that. And they're typically used in long-term care, in fall prevention programs. Several care centers in the United Kingdom use them for fall prevention. Many of these people have joint replacements, never heard about that.
The same with osteogenic loading. Here in the United States, there are over 200 locations, and all of them have joint replacements. When a joint replacement is engineered, it's designed to accept very high impact. Now, maybe in some of the early ones that used more metals as opposed to ceramics, that was an issue. And it's possible that various therapies could accelerate the wear of those processes contributing to toxicity.
But now I believe that replacements are better. They are made from materials that aren't going to dissolve, and I don't believe these therapy interventions would have any implications with that. But that's a great concern. Someone should study that, for sure. Thank you.
Anything else? I'll be at the back to answer questions, and if anybody wants a copy of the research, I've got a stack of papers, and I'll be handing them out in the back. Thank you very much.