Metabolic Optimization Before Orthobiologic Therapies (MOBOT): A Narrative Review

Abstract

Context:

The efficacy of orthobiologic therapies, such as platelet-rich plasma (PRP) and concentrated bone marrow aspirate (cBMA), is influenced by not only the biologic product but also the patient’s systemic biological milieu. Emerging preclinical and clinical evidence suggests that modifiable metabolic factors, including obesity, insulin resistance, chronic low-grade inflammation, inflammaging, sarcopenia, dysbiosis, poor sleep, and lifestyle behaviors such as smoking and alcohol use, can impair tissue regeneration and reduce the effectiveness of orthobiologics.

Evidence Acquisition:

A structured approach guided article selection. Searches in PubMed, Embase, and Scopus through July 2025 were supplemented by reference checking. Terms included “metabolic optimization,” “obesity,” “insulin resistance,” “inflammation,” “sarcopenia,” “dysbiosis,” “sleep,” “orthobiologics,” “PRP,” and “bone marrow aspirate.” Preclinical and clinical studies, mechanistic reviews, and meta-analyses assessing the impact of metabolic factors on musculoskeletal regeneration and orthobiologic outcomes were included. Only English-language articles relevant to mechanisms, clinical implications, or patient optimization were considered.

Study Design:

Narrative review.

Level of Evidence:

Level 5.

Results:

Evidence-based strategies to optimize metabolic health include targeted exercise, nutritional optimization, pharmacologic interventions, sleep regulation, microbiome support, and behavioral counseling for tobacco and alcohol cessation. While clinical evidence remains limited and of low methodological rigor, preclinical and available clinical studies support the plausibility, safety, and potential efficacy of these interventions. Optimizing metabolic factors can enhance tissue responsiveness, reduce interpatient variability, and improve orthobiologic therapy outcomes.

Conclusion:

Optimizing metabolic health before orthobiologic therapy improves the biological environment and regenerative outcomes. Screening and managing factors such as insulin resistance, chronic inflammation, and poor sleep are essential. Further randomized controlled trials and biomarker-guided studies are needed to validate strategies and personalize interventions.

Strength-of-Recommendation Taxonomy (SORT):

C: Supported mostly by preclinical and indirect clinical evidence.