Regenerative Medicine Treatment in FL

An individual begins as a single cell organism, made up of the combination of an egg and a sperm. That one cell will divide over and over again. Eventually, those cells will become different things: bone, nerve, blood, skin, and so forth. Cells that can grow into anything are called stem cells, but even these cells have different potencies. In other words, they have different abilities to become anything, almost anything, and a bunch of things. See the difference?

Totipotent cells have the most differentiation potential: they can become anything. They occur extremely early in the development of the organism. Pluripotent cells are slightly more limited, in that they can differentiate into one of three germ layers: the endoderm, ectoderm, and mesoderm. These are the embryonic stem cells. Multipotent cells differentiate into a variety of cells within a certain category. For example, a multipotent blood cell could become a red blood cell or a white blood cell, but it could not become a neuron or a bone. Injected stem cells are of the multipotent type.

Previously, people believed that stem cells would become the substance into which they were injected. That is, if stem cells were injected into the knee, they became joint fluid and cartilage. If they were injected into the discs, they became nucleus pulposus (the juicy center). We have since learned that this isn’t the primary method of action; this only occurs to a limited degree. The stem cells and PRP coordinate and stimulate the innate healing ability within the body. As we age, this innate ability declines. Consider that we don’t need to inject children with these therapies because the children have enough healing ability on their own! We also don’t find profound success in treating 90 year olds because there isn’t much innate healing ability there.

Osteoarthritis is the most common cause of chronic joint pain. Osteoarthritis involves the entire joint, including the nearby muscles, underlying bone, ligaments, and connective tissue. In osteoarthritis, the supportive tissue called cartilage degenerates, leading to inflammation and pain. This type of arthritis is common in shoulders, hips, knees, hands, and feet. Patients will often complain of joint stiffness, throbbing, and swelling. In spite of the fact that there is no cure for osteoarthritis, regenerative medicine might be very helpful as the “next revolution in medicine”. Regenerative medicine therapies such as Platelet Rich Plasma (PRP) and stem cell therapy are part of a new generation of treatments that have been proven to be safe, effective, and long-lasting.

Stem cells can also treat the pain of degenerative disc disease.

Current medical therapies work reasonably well, but there are pitfalls. In the treatment of pain, we commonly choose anti-inflammatories, opiates, and steroid injections. But…

• Anti-inflammatories are associated with gastrointestinal problems (like ulcers and reflux) and kidney damage.
• Opiates are habit-forming and can cause short-term memory loss, hormonal changes, and constipation. In the long-term, these medicines can worsen pain, and they are associated with many overdose deaths.
• Steroids, and the local anesthetics (numbing medicine) used with them, will eventually break down joints.

Ultimately, surgery is often recommended. Even after a surgical, anatomic correction, pain may still persist. The need for surgery can be greatly reduced by treating injured tissues before the damage progresses. Because the goal of regenerative therapy is to heal the pain and not just block it, it could prove to have lasting results.

However, researchers and physician scientists are always searching for newer, better therapies. Today, those therapies include the use of platelet-rich plasma (PRP) and adult autologous or allogenic stem cells. Several top-tier athletes have used these therapies, and they have credited the treatment with a speedier return to competition. Regenerative medicine procedures are ideal for individuals who face ailments such as:

• tendonitis,
• ACL injuries,
• arthritis of the knee, hip, or shoulder,
• rotator cuff tears, tennis elbow, hip bursitis, patellar tendon injury, plantar faciitis, and achilles tendon injury.

There are two ways to get the stem cells. First, we take them from the patient. People typically have a good concentration of easily accessible stem cells in our bone marrow. The best access point is the iliac crest of the pelvis. Unfortunately, as we age, we have fewer and fewer of our own stem cells circulating. This partially explains why we don’t heal as well as we get older. It also means that using our own stem cells (if we don’t have that many anyway) may not be a great idea. It might be better to use donated (allogenic) tissue, which is the second way to get the stem cells.

High concentrations of stem cells are found in placental tissues and amniotic fluid. These stem cells are taken from tissues acquired from living, healthy donors after full term pregnancy and at a scheduled Cesarean section. Another source is the baby’s umbilical cord blood. This is collected at delivery, as well. The tissues mentioned above are minimally processed and preserved to maintain the natural properties of the tissues. Both clinical and scientific studies show that these tissues support soft tissue repair, reduce inflammation, and minimize scar tissue formation. These tissues include a number of structural proteins, growth factors, and cytokines, which promote cellular proliferation, new collagen formation, and reduce inflammation.

We know that stem cells show more promise than PRP. They are the “seeds”, whereas PRP is the “fertilizer.” For a likely better outcome, stem cells are the recommended option. When comparing stem cells, there are no head-to-head studies. Essentially, it comes down to your preference. Here are some things to consider about each option:

• Bone marrow
  Since it comes from you, there is no infection risk. It is the use of your own body’s cells and growth factors. There is also no need to separately draw blood to make PRP. However, older patients don’t have as many stem cells in their bone marrow, so this option may be suboptimal. Also, it requires that the physician aspirate it from your hip (which isn’t usually as bad as people think!).
• Amniotic tissue
  This is taken from a healthy, screened, donated placenta. Due to legal issues, the tissue bank cannot report the number of stem cells, but it is said to be high. Additionally, there are quite a bit of growth factors included in the product. However, it must be ordered, so this will increase the cost of the therapy. Also, a higher cost will be incurred if you choose to mix this with your own PRP (arguably improving the clinical outcome), versus the option of mixing it with saline, for your injection.
• Umbilical cord blood
  This is also taken from a healthy, screened donor. This product contains very high concentrations of stem cells. However, it also must be ordered, which will increase the cost of the injection. And, you must again decide whether to mix it with your own PRP, at a higher cost, or simply in saline.
• Adipose (fat) tissue
  This is taken from the abdomen in a liposuction procedure. This option is not mentioned elsewhere because we do not offer it. Presently, the FDA has taken the position that the product is not “minimally processed”, so it should not be used in this way. Regardless, many clinics still offer it. We choose to defer for now.

Regenerative therapies are superior to our standard therapies. However, they are not perfect, and they are not miracles. The therapies may have to be repeated in the future, and there is no guarantee of success. Severe disease will not usually respond very well. Furthermore, patients at an advanced age will not have the good response a younger person would likely have. As we age, we have fewer stem cells of our own. Therefore, there is less natural healing for the injected stem cell to coordinate. Still, it is appealing to use a natural, anabolic (building up) therapy instead of our more common catabolic (breaking down) therapies.

• Intradiscal and intra-articular facet infiltrations with plasma rich in growth factors reduce pain in patients with chronic low back pain
  
• Cancer risk is not increased in patients treated for orthopaedic diseases with autologous bone marrow cell concentrate
• senchymal stem cells for cartilage repair in osteoarthritis.
• A systematic review of the use of platelet-rich plasma in sports medicine as a new treatment for tendon and ligament injuries.
• Evaluation of the effects of platelet-rich plasma (PRP) therapy involved in the healing of sports related soft tissue injuries.
• Efficacy of autologous bone marrow concentrate for knee osteoarthritis with and without adipose graft
• Intra-articular knee implantation of autologous bone marrow-derived mesenchymal stromal cells in rheumatoid arthritis patients with knee involvement: Results of a randomized, triple-blind, placebo-controlled phase 1/2 clinical trial.
• Intra-articular injections of expanded mesenchymal stem cells with and without addition of platelet-rich plasma are safe and effective for knee osteoarthritis.
• Early Clinical Outcomes of Intra-Articular Injections of Bone Marrow Aspirate Concentrate for the Treatment of Early Osteoarthritis of the Hip, and Knee: A Cohort Study.
• Effects of bone marrow aspirate concentrate and platelet-rich plasma on patients with partial tear of the rotator cuff tendon.
• Prospective, Randomized, Blinded, Comparative Study of injectable micronized dehydrated amniotic/chorionic membrane allograft for plantar fasciitis—a feasibility study
• Intra-articular injection of micronized dehydrated human amnion/chorion membrane attenuates osteoarthritis development
• Clinical Use of Amniotic Fluid in Osteoarthritis: A Source of Cell Therapy – Niranjan Bhattacharya

• The Role of Exosomes in Regenerative Medicine
• Therapeutic Utility of Exosomes
• Therapeutic Applications of MSC Exosomes
• UC derived MSCs extracellular vesicles can safely ameliorate the progression of chronic kidney disease
• SC Derived Exosomes as a Potential Alternative in Orthopedic
• PRP Exosomes Revolution Ross 2017
• PRP Exosomes Exo and Amnio Powerpoint
• Mesenchymal stem cell-derived exosomes as a new therapeutic strategy for liver diseases
• PRP Exosomes Contraindications Preoperative Labs Protocols
• Mesenchymal stem cell-derived exosomes as a new therapeutic strategy for liver diseases
• Mesenchymal Stem Cell Exosomes – Dr. Spiel

A: Autologous means that cells come from the patient. An autologous stem cell treatment involves the use of taking a patient’s stem cells from his or her bone marrow found in the hip. The bone marrow is centrifuged, which concentrates the regenerative products. Then, this is injected into the target area.

Allogenic means that the treatment comes from another human. In this case, we commonly use umbilical cord blood donated at a healthy baby delivery. The lab collects the product, tests it for infection, and sends it to us. Note that we do not offer adipose-derived (fat-derived) stem cells, as the FDA does not consider the process (351) used to handle these as “minimally manipulated”.

A: Exosomes are very small vesicles that have been discovered to be involved in cellular communication. Since we understand regenerative therapy to be a “signaling” therapy, the use of substances that are involved in cellular communication is quite helpful. We believe exosomes have strong signaling potential. Exosomes are derived from umbilical cord blood.

A: Stem cell therapy is one of the most fascinating areas of medicine. Many doctors have recognized that this therapy has the potential to treat various diseases and ailments by producing healthy new cells and tissue in the patient’s body. Stem cell therapy is an excellent pain treatment because it promotes regeneration of wounds and tissue damage after an ailment or an injury.

Our physicians at Advanced Pain Medical Center will discuss with you the conditions that can be treated by this type of therapy.